Managing Known Difficult Airways in Obstetric Patients Using a Flexible Bronchoscope and IRRIS: A Case-Illustrated Guide for Nonexpert Anesthesiologists, without Surgical Backup

Pregnancy is associated with anatomical and physiological changes leading to potential difficult airway management. Some pregnant women have known difficult airways and cannot be intubated even with a hyperangulated videolaryngoscope. If neuraxial techniques are also impossible, awake tracheal intubation with a flexible bronchoscope may be one of the few available options to avoid more invasive techniques. The Infrared Red Intubation System (IRRIS) may help nonexpert anesthesiologists in such situations and may enhance the chance of successful intubation increasing safety for the mother and the fetus, especially in hospitals without the ear, nose, and throat surgical backup.

Pre-emptive veno-venous ECMO in advanced tracheal malignancy prior to tracheal stenting

Extracorporeal membrane oxygenation (ECMO) is helpful in providing ventilatory support when other conventional methods of ventilation fail. We report a case of successful management of advanced tracheal malignancy with impeding airway obstruction where veno-venous ECMO (VV-ECMO) was instituted prior to performing critical endotracheal procedure. After securing the VV-ECMO through right jugular vein and left femoral vein under local anaesthesia, the tracheal stent placement was conducted under flexible bronchoscope and fluoroscope control. Oxygenation and carbon dioxide levels were maintained by the ECMO. VV-ECMO is a useful adjunct in the management of subglottic difficult airway obstruction due to complex tracheal pathology where conventional ventilation may not be possible or adequate.

Natural nasal–esophageal fiberscopy in the COVID-19 pandemic—preventing sneezing without anesthesia: a case report

Background We are laryngologists. We observe natural phonatory and swallowing functions in clinical examinations with a trans-nasal laryngeal fiberscope (TNLF). Before each observation, we use epinephrine to enlarge and smooth the common nasal meatus (bottom of nostril) and then insert a wet swab inside the nose, as in taking a swab culture in the nasopharynx. During the current COVID-19 pandemic situation, this careful technique prevents any complications, including nasal bleeding, painfulness, and induced sneezing. Here, we introduce our routine to observe esophageal movement in swallowing in a natural (sitting) position without anesthesia. Case presentation The case was a 70-year-old female who complained that something was stuck in her esophagus; there was a strange sensation below the larynx and pharynx. After enlarging and smoothing the common nasal meatus, we inserted the TNLF (slim type ⌀2.9 mm fiberscope, VNL8-J10, PENTAX Medical, Tokyo, Japan.) in the normal way. We then observed the phonatory and swallowing movements of the vocal folds. As usual, to not interfere with natural movements, we used no anesthesia. We found no pathological condition in the pyriform sinus. We asked the patient to swallow the fiberscope. During the swallow, we pushed the TNLF and inserted the tip a bit deeper, which made the fiberscope easily enter the esophagus, like in the insertion of a nasogastric tube. We then asked the patient to swallow a sip of water or saliva to clear and enlarge the lumen of the esophagus. This made it possible to observe the esophagus easily without any air supply. With tone enhancement scan, the esophagus was found to be completely normal except for glycogenic acanthosis. Conclusions The advantage of this examination is that it is easily able to perform without anesthesia and with the patient in sitting position. It is quick and minimally invasive, enabling observation the physiologically natural swallowing. It is also possible to observe without anesthesia down to the level of the esophagogastric junction using with a thin type flexible bronchoscope. In the future, gastric fiberscopes might be thinner, even with narrow band imaging (NBI) function. Before that time, physicians should remember to just insert along the bottom of the nose.

Bronchoscopic evaluation of children less than 5 years old with stridor

Background: Stridor is a harsh, vibratory sound with variable pitch which is caused by partial obstruction of airway that results in turbulent airflow. It is mainly due to anatomic deformities in the infantile age group. However, various acquired conditions affecting upper airway may also cause stridor. Here, we evaluated 87 cases of stridor using Flexible bronchoscope in order to determine the cause of stridor. Objective: To determine the clinical characteristics, Flexible bronchoscopy findings and clinical correlation in children admitted in our hospital with complains of stridor. Design: Retrospective observational study. Setting: Single center study conducted in Amrut medical foundation. 87 children aged less than 5 years with a clinical complains of stridor were included in the study and Flexible bronchoscopy was performed. The findings were analyzed and results were reported. Results: A total of 87 children with stridor were enrolled in the study and Flexible Bronchoscopy was performed in them. Of these, 68 children had an abnormal bronchoscopy finding. Laryngomalacia was the commonest cause of stridor observed followed by subglottic stenosis and tracheomalacia. Cough was the commonest presenting symptom associated with stridor and tachypnea was the commonest clinical sign observed in these children. Conclusion: Flexible bronchoscopy plays an important role in diagnosing the exact cause of stridor in pediatric age group. Key words: Stridor, Flexible Bronchoscopy, Laryngomalacia.

Acute Airway Obstruction from Megaoesophagus Secondary to Achalasia Evaluated with Flexible Bronchoscope

A 94-year-old female presented to the emergency department with acute expiratory stridor. In the absence of an otorhinolaryngologist, an urgent laryngoscopy was performed using a flexible bronchoscope by an anaesthesiologist in the emergency department leading to a change in management. Subsequent radiographs confirmed severe tracheal compression from megaoesophagus secondary to achalasia as the cause of acute airway obstruction. Use of flexible bronchoscope as a diagnostic tool by an anaesthesiologist to evaluate a patient presenting with signs of acute airway obstruction may lead to a safer and more careful airway management planning. Suggestions are also made regarding establishment of emergency surgical airways when conventional approaches fail.

Transient maintenance of tracheal patency upon the insertion of a flexible bronchoscope in a patient with an anterior mediastinal mass: a case report

Background Patients with an anterior mediastinal mass are at risk of perioperative respiratory collapse. Case presentation A 74-year-old woman with a large anterior mediastinal mass that led to partial tracheal collapse (shortest diameter, 1.3 mm) was scheduled for tracheobronchial balloon dilation and stent placement under general anesthesia. Although veno-venous extracorporeal membrane oxygenation (V-V ECMO) had been established, maximum flow was limited to 1.6 L/min, and general anesthesia induction was followed by hypoxia probably due to inadequate ventilation. A flexible bronchoscope was inserted through the tracheal lumen that was being compressed by the anterior mass; this not only increased tracheal patency but also enabled positive pressure ventilation and resulted in recovery from hypoxia. Scheduled procedures were successfully performed without complications. Conclusion We describe a case wherein tracheal patency was transiently maintained by inserting a flexible bronchoscope in a patient with an anterior mediastinal mass.

The lung microbiota in Korean patients with non-tuberculous mycobacterial pulmonary disease

Background The microbiota of the lower respiratory tract in patients with non-tuberculous mycobacterial pulmonary disease (NTM-PD) has not been fully evaluated. We explored the role of the lung microbiota in NTM-PD by analyzing protected specimen brushing (PSB) and bronchial washing samples from patients with NTM-PD obtained using a flexible bronchoscope. Results Bronchial washing and PSB samples from the NTM-PD group tended to have fewer OTUs and lower Chao1 richness values compared with those from the control group. In both bronchial washing and PSB samples, beta diversity was significantly lower in the NTM-PD group than in the control group (P = 2.25E-6 and P = 4.13E-4, respectively). Principal component analysis showed that the PSBs and bronchial washings exhibited similar patterns within each group but differed between the two groups. The volcano plots indicated differences in several phyla and genera between the two groups. Conclusions The lower respiratory tract of patients with NTM-PD has a unique microbiota distribution that is low in richness/diversity.

Implementation of transbronchial lung cryobiopsy in a tertiary referral center for interstitial lung diseases: a cohort study on diagnostic yield, complications, and learning curves

Background Transbronchial lung cryobiopsy (TBLC) has been introduced as an alternative to surgical lung biopsy (SLB) in the diagnostics of interstitial lung diseases (ILD). Despite controversy on safety, TBLC is increasingly implemented in ILD centers with an apparent diagnostic yield comparable to SLB. The aim of this study was to assess TBLC implementation experiences from a tertiary Danish ILD center regarding diagnosis, complications, and learning curves for TBLC performance. Methods TBLC was prospectively performed in a cohort of patients with unclassifiable ILD based on a preceding multidisciplinary clinical and radiological revision. TBLC was performed as an outpatient procedure with the patients in general anesthesia using a flexible bronchoscope with 1.9 or 2.4 mm cryoprobes. Learning curves for TBLC performance were calculated using cumulated sum (CUSUM) scores for diagnostic yield, pneumothorax, and bleeding. Results From February 2017 to March 2020 141 patients (86 (61%) men, median age 69 years [IQR, 60–74 years]) had TBLC performed. A histological and confirmative diagnosis was made in 101 patients (75.2%) and 124 patients (87.9%, i.e. clinical diagnostic yield), respectively, in whom idiopathic interstitial pneumonias constituted the majority (67.3%) of the clinical diagnoses. We observed 2 deaths (1.4%) within 30 days of TBLC, but no procedure-related mortality or severe bleeding. Moderate bleeding occurred in 23 patients (16.3%), pneumothorax in 21 patients (14.9%) with only 14 patients (9.9%) requiring a pleural drain. Based on the CUSUM score analysis, the diagnostic yield obtained was satisfactory throughout the period. Conclusion This study reports experiences of outpatient TBLC implementation in a tertiary referral ILD center from the largest investigated TBLC cohort in Scandinavia The diagnostic yield and prevalence of complications obtained by TBLC from this single center study on unclassifiable ILD support outpatient TBLC as a valuable and safe alternative to SLB to diagnose ILD in well-selected patients. The learning curves for TBLC were acceptable in the hands of experienced bronchoscopists.