A new endoscopic standardized grading system for macroscopic central airway complications following lung transplantation: the MDS classification.

OBJECTIVES: After lung transplant, between 9 and 13% of bronchial anastomoses develop complications severe enough to warrant therapeutic intervention. These complications include stenosis, dehiscence, granulation tissue, bronchomalacia and fistula. Most of these have already been included in a classification or another, but none of these have been universally accepted. Moreover, no grading system has integrated all of these complications. The Groupe Transplantation (GT) (Transplant Group), from the Société de Pneumologie de Langue Française (SPLF) [French Language Pulmonology Society], maintains a prospective national registry of lung transplants performed in France. The GT has mandated the Groupe d'Endoscopie de Langue Française (GELF), also from the SPLF, to develop an endoscopic classification, in order to describe the macroscopic aspect of the bronchial anastomoses, and downhill airways, using a standardized and exhaustive grading system. METHODS: An endoscopic classification that would take into account the three major aspects of the description of bronchial anastomoses was elaborated. The first parameter is the macroscopic aspect (M), the second, the diameter (D) of the anastomosis and the third, the sutures (S) of the anastomosis. This classification was then submitted to expert bronchoscopists from nine centres, responsible for lung transplants in France, for their opinion, using a five-item questionnaire, according to the Delphi methodology. RESULTS: After the first round of consultation, all experts (100%) agreed on Questions 1 and 4. Answers were positive for Questions 2 (59%), 3 (56.25%) and 5 (70%). A modified classification, incorporating propositions from the first round, was then submitted. This second round allowed a consensus to be reached between all experts: the MDS classification. Each parameter (M, D and S) can be classified from 0 to 3. For M and D, it is possible to determine the extent of abnormalities downhill from the anastomosis into four subgroups (a, b, c or d). For S, the localization of abnormalities can be divided between two subgroups (e and f). CONCLUSION: The MDS classification, established by a consensus of French experts in bronchoscopy, could represent a standardized, universally acceptable system to describe central airway complications after lung transplant.

Automatic administration of propofol and remifentanil guided by the bispectral index during rigid bronchoscopic procedures: a randomized trial.

BACKGROUND: Anesthesia for rigid bronchoscopic procedures is a demanding procedure. Automatic titration of propofol and remifentanil to maintain the bispectral index (BIS) within the recommended range (40-60) has been reported during routine surgical procedures. The aim of the present study was to evaluate its use during rigid bronchoscopy. METHODS: Patients were enrolled in a randomized study comparing manual target-controlled infusion of propofol and remifentanil (manual TCI group) with automatic titration guided by the BIS (dual-loop group). Categorical variables were compared by the Fisher's exact test, and continuous variables (median [interquartile range 25-75]) were compared by the Mann-Whitney test. RESULTS: Thirty-four patients were included in the manual TCI group and 33 were included in the dual-loop group. Baseline characteristics were well balanced between the groups. Intervention by the anesthesiologist in charge to modify propofol and/or remifentanil targets in the dual-loop group was not necessary. Percentage of time spent in the BIS interval (40-60) was similar in the manual TCI and dual-loop groups (69% [48-79] vs 70% [58-80], respectively). Durations of induction and of maintenance and propofol and remifentanil doses were also similar between groups, except for the amount of propofol needed for induction (P = 0.002). Time to tracheal extubation was also similar. No case of intraoperational awareness was detected. CONCLUSION: The present study could not establish the superiority of automatic system over manual adjustment for bronchoscopy. Further studies with a different design and a larger number of patients are required to establish the place of automatic delivery of anesthetic agents. This study was registered at ClinicalTrials.gov number, NCT00571181.

The management of bronchus intermedius complications after lung transplantation: a retrospective study.

BACKGROUND: Airway complications following lung transplantation remain a significant cause of morbidity and mortality. The management of bronchial complications in Bronchus Intermedius (BI) is challenging due to the location of right upper bronchus. The aim of this study was to analyze the results of BI Montgomery T-tube stent in a consecutive patients with lung transplantations. METHODS: Between January 2007 and December 2010, 132 lung transplantations were performed at Foch Hospital, Suresnes, France. All the patients who had BI Montgomery T-tube after lung transplantation were included in this retrospective study. The demographic and interventional data and also complications were recorded. RESULTS: Out of 132 lung transplant recipients, 12 patients (9 male and 3 female) were entered into this study. The indications for lung transplantation were: cystic fibrosis 8 (67%), emphysema 3 (25%), and idiopathic pulmonary fibrosis 1 (8%). Most of the patients (83%) had bilateral lung transplantation. The mean interval between lung transplantation and interventional bronchoscopy was 11.5 ± 9.8 (SD) months. There was bronchial stenosis at the level of BI in 7 patients (58.3%). The Montgomery T-tube number 10 was used in 9 patients (75%). There was statistically significant difference in Forced Expiratory Volume in one second (FEV1) before and after stent placement (p = 0.01). The most common complication after stent placement was migration (33%). CONCLUSION: BI complications after lung transplantation are still a significant problem. Stenosis or malacia following lung transplantation could be well managed with modified Montgomery T-tube.

Endoscopic successful management of tracheobronchomalacia with laser: apropos of a Mounier-Kuhn syndrome.

Mounier-Kuhn syndrome is a rare condition that combines tracheobronchomegaly (TBM) and severe tracheobronchomalacia. Symptoms can be severe with recurrent bronchopulmonary infections and cough-induced syncope. Therapeutic management is non-specific and limited to chest physiotherapy and antibiotics during infectious exacerbations. We report a case of Mounier-Kuhn syndrome that was successfully managed by treating the posterior collapse of the central airway with yttrium aluminum pevroskyte laser. Endoscopic aspects, respiratory symptoms, and lung function tests all improved and remained stable with a follow-up of 8 years. Laser, at low power settings, could be a new therapeutic option in selected cases of tracheobronchomalacia.