Management of post-intubation tracheal stenoses using the endoscopic approach.

BACKGROUND AND AIM: Tracheal stenosis is a common complication of intubation with or without subsequent tracheotomy whose management remains poorly defined. Over 600 post-intubation tracheal stenoses have been treated in our centre since 1982: the aim of this study was to determine the safety and efficacy of our endoscopic approach. METHODS: This retrospective study includes 113 new cases treated between 1998 and 2001. We chose this period to have a standardised technique and a significant number of cases with a sufficiently long follow up (28-78 months). Forty patients who did not meet the criteria for "true stenosis" (granulomas, pseudoglottic stenosis, etc.) were excluded from the study. RESULTS: 73 patients (50+/-21 years) entered the study: 13 (18%) web-like and 60 (82%) complex stenoses. Most web-like stenoses were successfully treated with Laser Assisted Mechanical Dilation (LAMD) alone; among complex stenoses LAMD was sufficient to treat 13 patients (22%), whereas 47 patients (78%) required stent placement: 22 had their stent removed after one year and did not require any further therapy, 13 inoperable patients required permanent stent and 12 were referred to surgery after failure of multiple endoscopic treatments. No permanent complications secondary to endoscopic treatment were observed. 48 patients (66%) obtained a stable, good result with the endoscopic procedure, 13 (18%) required a permanent stent while 12 patients (16%) were referred to surgery. CONCLUSIONS: Our results indicate that the endoscopic treatment of post-intubation tracheal stenoses performed in an expert setting can be considered a safe first-line therapy, leaving some selected cases and the relapsing stenoses, for surgical resection.

Cardiac arrest due to ventricular fibrillation as a complication occurRing during rigid bronchoscopic laser therapy.

Laser bronchoscopy is a usually well tolerated procedure for the treatment of obstructive lesions on the tracheobronchial tree, with a very low morbidity and mortality rate. Cardiovascular complications, including atrial and ventricular arrhythmias, and myocardial ischemia, have only rarely been reported during laser bronchoscopy. Cardiac arrhythmias during such a procedure are usually well tolerated but occasionally may be life threatening. Here we report a case of a young, female patient affected by Pulmonary Tuberculosis with a cicatricial stenosis of the left main bronchus who developed an episode of prolonged cardiac arrest due to ventricular fibrillation (and no signs of acute myocardial ischemia) during rigid broncoscopic laser-therapy. Underlying Coronary Artery Disease and other cardiac abnormalities were also excluded by subsequent cardiovascular examination. The clinical implications are also discussed.

Acute respiratory acidosis does not increase plasma potassium in normokalaemic anaesthetized patients. A controlled randomized trial.

BACKGROUND AND OBJECTIVE: Few and conflicting data are available regarding the changes of plasma potassium concentration during acute respiratory acidosis in human beings. This study compares the acute changes in plasma potassium concentration in acutely hypercapnic patients and in non-hypercapnic patients during general anaesthesia. METHODS: Thirty-three patients undergoing interventional rigid bronchoscopy were studied. Ventilation of the lungs was randomly conducted using either spontaneous-assisted ventilation or intermittent negative-pressure ventilation. All patients received the same anaesthetic protocol. Arterial blood gases and osmolality, and plasma concentrations of glucose, sodium, potassium and chloride were measured. RESULTS: Intraoperatively, PaCO2 was higher during spontaneous-assisted ventilation than during intermittent negative-pressure ventilation (9 +/- 1.8 vs. 5.4 +/- 1.2 kPa, P < 0.001) and the pH was also lower during spontaneous-assisted ventilation than during intermittent negative-pressure ventilation (7.24 +/- 0.07 vs. 7.4 +/- 0.08, P < 0.001). Plasma potassium concentration remained similar in both groups (3.8 +/- 0.2 mmol L(-1) with spontaneous-assisted ventilation vs. 3.7 +/- 0.4 mmol L(-1) with intermittent negative-pressure ventilation). CONCLUSION: Acute respiratory acidosis does not affect plasma potassium concentration.

Negative pressure ventilation vs external high-frequency oscillation during rigid bronchoscopy. A controlled randomized trial.

STUDY OBJECTIVES: To compare the effectiveness of two modalities of external ventilation during rigid bronchoscopy: intermittent negative pressure ventilation (INPV) and external high-frequency oscillation (EHFO). DESIGN: Prospective, controlled, randomized, nonblinded study. SETTING: University-affiliated hospital. PATIENTS: Seventy patients undergoing interventional rigid bronchoscopy for tracheobronchial lesions were enrolled into the study. INTERVENTIONS: Mechanical ventilation was performed by INPV or EHFO. When pulse oximetry was < 90%, manually assisted ventilation was delivered. MEASUREMENTS AND RESULTS: Arterial blood gases were sampled preoperatively and intraoperatively. Most patients in both groups had normal intraoperative PaCO(2) (mean, 43. 6 +/- 11.8 mm Hg under EHFO and 37.4 +/- 8.2 mm Hg under INPV; p = 0.012), and acidemia occurred in 9 of 35 patients of EHFO group and in 2 of 35 patients of INPV group (p = 0.049). Hypercapnia (PaCO(2) > 50 mm Hg) was observed in 10 patients under EHFO and in 2 with INPV (p = 0.026). Intraoperative mean PaO(2) was similar (101.4 +/- 52.9 mm Hg with EHFO and 124.2 +/- 50.3 mm Hg with INPV; p = 0.07), but O(2) supply was different (3.5 +/- 2.3 L/min during INPV and 8.5 +/- 6.2 L/min during EHFO; p < 0.001). Intraoperative hypoxemia (PaO(2) < 60 mm Hg) occurred in five patients with EHFO and two with INPV (p = 0.426). Three EHFO patients required manually assisted ventilation (mean, 0.2 +/- 0.9), but no INPV patient did (p = 0.142). CONCLUSIONS: External negative pressure ventilation appears to be a suitable choice during rigid bronchoscopy: both EHFO and INPV ensure effective ventilation and comfortable operating conditions in the majority of patients. Some patients may receive inadequate ventilation with EHFO, developing respiratory acidosis and requiring manually assisted ventilation. In comparison with INPV, EHFO requires a higher fraction of inspired oxygen.

Breathing pattern and arterial blood gases during Nd-YAG laser photoresection of endobronchial lesions under general anesthesia: use of negative pressure ventilation: a preliminary study.

STUDY OBJECTIVE: To evaluate the efficacy of negative pressure ventilation (NPV) in avoiding or reducing apneas and related hypoxemia and respiratory acidosis during laser therapy (LT) of endobronchial lesions. DESIGN: A prospective, controlled, randomized study. SETTING: An operating theater of a respiratory endoscopy and laser therapy unit. POPULATION AND INTERVENTION: Twenty-seven consecutive patients referred to LT were entered into the study. Fourteen patients were randomly assigned to LT under general anesthesia and spontaneous assisted ventilation (control group) whereas in 13 cases, NPV by a poncho-wrap ventilator (NPV group) was added to the procedure. MEASUREMENTS AND RESULTS: The prevalence and the duration of apnea/hypopnea periods assessed by respiratory inductive plethysmography during LT were significantly reduced under NPV, compared to the control group. As compared to baseline, during LT, all control patients developed mild to severe hypercapnia (PaCO2 ranging from 55 to 76 mm Hg) and respiratory acidosis (pH from 7.33 to 7.19), whereas only three patients undergoing NPV (23%) developed hypercapnia (PaCO2 from 52 to 68 mm Hg) and related acidosis (pH from 7.29 to 7.21). Optimal oxygenation was achieved in all of the patients; nevertheless, patients under NPV needed a lower mean oxygen supply; five of them (38%) could be treated at a fraction of inspired oxygen of 0.21 for the whole procedure. CONCLUSION: NPV may be useful in reducing apneas during laser therapy under general anesthesia, thus reducing hypercapnia, related acidosis, and need of oxygen supplementation.

Endoscopic treatment of malignant airway obstructions in 2,008 patients.

We report our 13-year experience with endoscopic treatment of malignant obstructions of the airway by Nd:YAG laser, stents, and intraluminal brachytherapy in 2,008 patients. We performed 2,610 laser resections in 1,838 patients, 66 high dose rate brachytherapies, and we placed 393 tracheobronchial silicone stents in 306 patients. We used the rigid bronchoscope in 96% of the laser procedures and in all cases requiring stent placement; general anesthesia was given to 90% of these patients. Endobronchial radiotherapy was performed under local, anesthesia. In 93% of patients undergoing laser resection, we obtained an immediate patency of the airway with consequent improvement of quality of life. The median time between the first and second laser treatment was 102 days, being longer in the case of stent placement (when required) or in association with brachytherapy. Even if endoscopic treatment should be considered only for palliation, laser vaporization could be curative in case of in situ carcinoma. Since 1983, we have treated 23 such lesions in 17 patients and up to now, none has recurred. Finally, endoscopic resection may allow a better assessment of the true extent of the tumor, shifting to surgery patients originally considered to have inoperable disease or allowing lung-sparing operations (21 and 18 patients of our series, respectively). The total mortality rate was 0.4% (12 patients over 2,798 treatments; 2,710 Nd:YAG laser + 151 stents without laser + 37 brachytherapies without laser) in the first week after the procedures, and was mainly related to cardiovascular problems and respiratory failure. In conclusion, endoscopic resection of lung malignancies is rapid, effective, repeatable, and complementary to other treatments; although it should be considered only palliative, laser resection could be curative in patients with in situ carcinomas and early cancers. Laser, stents, and endoluminal brachytherapy should be available in all centers with major experience; a well-trained team is mandatory to plan the most appropriate treatment and manage any possible complication.

Clinical and bronchoscopic features of endobronchial tuberculosis.

Clinical and bronchoscopic features of endobronchial tuberculosis were retrospectively investigated in 24 patients. A barking cough was the most frequent chief complaint in 50% of patients. The typical apico-subclavian localization of pulmonary tuberculosis in adults was found in only 50% of patients; in one patient the lung fields were clear. Bronchoscopic features consisted of exudative lesions in 38% of cases, ulcerative lesions in 25%, granulomatous lesions in 25%, and ulcerative-granulomatous tumour-like lesions in 12%. In 12% of patients, a residual fibrotic stenosis was seen. It was concluded from our data that patients whose cough is barking and resistant to antitussive agents should be evaluated for endobronchial tuberculosis, and, therefore, the use of fibreoptic bronchoscopy is mandatory. We also conclude that diagnosis of endobronchial tuberculosis demands the use of corticosteroid therapy.

Nd:YAG laser bronchoscopy. A five-year experience with 1,396 applications in 1,000 patients.

We treated 1,000 patients with the Nd:YAG laser. The rigid bronchoscope was used in 1,280 (92 percent) of the treatments, with patients almost always under general anesthesia; 116 (8 percent) treatments were performed with the flexible fiberoptic bronchoscope alone, with the use of local anesthesia. In almost all cases of benign tumors and in many carcinoid tumors, the treatment was curative. In genuine nonmalignant tracheal stenoses, laser therapy was curative in 34 out of 81 cases. In malignant tumors, the laser improved airway gauge 92 percent of the time. Cumulative survival was 50 percent (+/- 3 percent) at six months and 26 percent (+/- 3 percent) at one year. Following palliative laser therapy, eight patients with bronchogenic carcinoma appearing to be inoperable did have surgery and ten underwent less extensive surgery than expected. Results confirm the usefulness and safety of this relatively new method in the treatment of obstructive lesions of the tracheobronchial tree.

[Symphyseal therapy with tetracycline in neoplastic pleurisy and spontaneous pneumothorax]. / La terapia sinfisaria con tetraciclina nelle pleuriti neoplastiche e nel pneumotorace spontaneo.

The treatment of 15 patients with neoplastic pleurisy and 25 with spontaneous pneumothorax occurring for the second time is described. All were given endopleural tetracycline therapy for symphyseal purposes. In the neoplastic pleurisy cases, the treatment reduced the number of thoracenteses required. In only 1 case did spontaneous pneumothorax recur a short time after treatment.