Optimization of Subglottic View During Flexible Laryngoscopy With Patient Positioning.

OBJECTIVE: Determine the ideal head position to optimize visualization of the subglottis using flexible laryngoscopy. STUDY DESIGN: Prospective cohort study. SETTING: Outpatient multidisciplinary airway clinic at a tertiary care center. METHODS: Patients presenting to a multidisciplinary airway clinic undergoing nasoendoscopic airway examination were enrolled. Three head positions were utilized to examine the subglottis during laryngoscopy: "sniffing," chin tuck, and stooping positions. In-office reviewers and blinded clinician participants evaluated views of the airway based on Cormack-Lehane (CL) scale, airway grade (AG), and visual analog scale (VAS). Demographic data were obtained. Statistical analysis compared head positions and demographic data using Student's t test, analysis of variance, and Tukey's post hoc analysis. RESULTS: One hundred patients participated. No statistical differences existed among in-clinic or blinded reviewers for the CL score in any head position (p = .35, .5, respectively). For both AG and VAS, flexed and stooping positions were rated higher than the sniffing positions by both in-clinic and blinded reviewers (p < .01 for all analyses), but there was no statistical difference between these two positions (p = .28, .18, respectively). There was an inverse correlation between age and scores for AG and VAS in the flexed position for both sets of reviewers (p = .02, <.01 respectively), and a higher body mass index was significantly associated with the need to perform tracheoscopy for full airway evaluation (p < .01). CONCLUSION: Both flexion and stoop postures can be implemented by an experienced endoscopist in awake, transnasal flexible laryngoscopy to enhance visualization of the subglottic airway.

Aerosol Generation During Bronchoscopy.

BACKGROUND: Bronchoscopy is an aerosol-generating procedure and can place the health care providers at risk for exposure to viral pathogens. The pattern of aerosol generation during  different aspects of bronchoscopy are poorly understood. The goal of this study is to characterize the pattern of aerosol generation during flexible and rigid bronchoscopy performed under moderate sedation or general anesthesia (GA). The inhalable mass concentration of aerosol generated during the procedures was measured continuously. METHODS: The aerosol concentration in the endoscopy room at baseline and while the procedures were performed was measured. Procedures included flexible bronchoscopies with moderate sedation, flexible bronchoscopies performed through endotracheal tube under GA and rigid bronchoscopies under GA. Changes from the baseline were measured continuously during the bronchoscopy. RESULTS: Measurements obtained during the procedure were compared with the baseline reading. For flexible bronchoscopy under moderate sedation, the inhalable aerosol fraction was significantly higher (P=0.036) during atomization of lidocaine. For Flexible bronchoscopy through endotracheal tube, inhalable aerosol fraction was significantly higher (P<0.001) during intubation and extubation. For rigid bronchoscopy done under GA with jet ventilation, inhalable aerosol fraction was significantly higher during both the bronchoscopy (P=0.01) and recovery (P=0.012). CONCLUSION: Elevated levels of aerosol were generated during all aspects of bronchoscopy. However, atomization of lidocaine, intubation, extubation, and recovery generated the most aerosol.

Acute decompensation of patient following an outpatient CT-guided needle biopsy: A case report.

A 74-year-old female with history of type 2 diabetes, hypertension, and uterine adenocarcinoma presented for CT-guided lung biopsy that was ultimately complicated by an arterial air embolus requiring intensive care. Systemic air embolism is a very rare event but can be devastating. Prompt recognition can be difficult due to an often-vague presentation but is essential and should be considered upon rapid deterioration of a patient's status following high risk procedures. Hyperbaric oxygen therapy is preferred; however, if this is unavailable, additional treatments are predominately supportive care with 100% supplemental oxygen, rapid volume expansion, and ionotropic medications as needed.

Embolization of pulmonary artery aneurysms in a patient with Behçet's disease complicated by coil erosion into the airway.

Behçet's disease is an inflammatory vasculitis with the unique feature of pulmonary artery aneurysms. We describe a patient with Behçet's disease and pulmonary artery aneurysms who presented with massive hemoptysis treated by coil embolization. Although there was immediate resolution of hemoptysis and improvement in hemodynamic status, 2 months later the patient reported a refractory cough and feeling of foreign body in her throat. Imaging demonstrated partial coil migration into the bronchus and trachea. Although endovascular intervention is the first-line treatment for massive hemoptysis, in patients with Behçet's disease, active inflammation and chronic steroid use may increase the risk of coil erosion and migration.

Core needle biopsy with endobronchial ultrasonography: single center experience with 100 cases.

INTRODUCTION: Adequate sampling by endobronchial ultrasound (EBUS)-transbronchial needle aspiration to meet the demands of precision medicine or histologic evaluation is challenging. There is increasing demand for core biopsy specimens with advances in therapy. Franseen enodoscopic ultrasound needles have shown promising results in gastroenterology application for obtaining core biopsies and same design has recently been extended for pulmonary use. We evaluated Franseen needles with EBUS to assess its utility, safety and ability to provide core biopsy specimens. MATERIALS AND METHODS: Retrospective analysis of our database at the University of Utah of patients undergoing EBUS with a Franseen needle was performed to ascertain the performance characteristics of this needle in the first 100 patients after its implementation. Medical records were also reviewed to identify any immediate procedure-related complications. RESULTS: One hundred seventy locations were sampled in 100 patients. A total of 152 lymph nodes and 18 masses were sampled. Core biopsies, as per pathology report, were seen in 87% of patients. A clinically concordant pathological diagnosis was established in 97% of patients. Diagnostic yield for granulomatous lymphadenopathy was 95.6% (22 of 23). No patient-related adverse events were noted. CONCLUSION: The Franseen needle evaluated in this study can safely procure core tissue samples during EBUS bronchoscopy that are adequate for histopathological diagnosis in benign and malignant lesions. Its ability to provide adequate tissue in patients with granulomatous inflammation is encouraging.