Apnoeic oxygenation using transnasal humidified rapid-insufflation ventilatory exchange during rigid bronchoscopy: a report of four cases

General anaesthesia with a muscle relaxant is usually performed for rigid bronchoscopy (RB), but ventilation is challenging due to large amounts of leakage. Optiflow™ supplies 100% humidified, warmed oxygen at a rate of up to 70 l/min and this high flow rate may overcome the leakage problem. This case report describes four patients that were scheduled for RB. The lung lesions were all located below the carina, so a bronchial tube was inserted under general anaesthesia. Once a large amount of leakage was confirmed by manual ventilation, Optiflow™ was connected to the bronchial tube (flow rate, 70 l/min). All of the ports of the bronchoscopy were left open to prevent the risk of outlet obstruction. Oxygenation was well maintained with stable vital signs throughout the procedures, which took up to 34 min without airway intervention. There were no occurrences of cardiac arrhythmia or changes in the electrocardiograms. Respiratory acidosis recovered after emergence, which was confirmed by arterial blood gas analysis in all cases. Apnoeic oxygenation using Optiflow™ was applied successfully during RB. Applying Optiflow™ could make cases of difficult ventilation during RB much easier for the anaesthetist. Larger studies need to demonstrate the efficacy and safety of this technique.

Laryngeal mask combined with bronchial tube achieves one-lung ventilation for transthoracic oesophagectomy

Laryngeal mask combined with bronchial blocker provides an alternative for lung isolation but lacks adequate access to the non-dependent lung. Substituting the blocker with a bronchial tube may overcome this limitation. In this report, a #4.5 cuffed bronchial tube was introduced into the non-dependent lung through a second-generation laryngeal mask for transthoracic oesophagectomy. During the 2.5-hour thoracotomy, one-lung ventilation was achieved by isolating the left lung with the bronchial tube and ventilating the right lung via the laryngeal mask, using volume-control mode (7 mL/kg × 12/min) with PIP21–23 cm H2O, pH 7.36 and PaCO2 38.3. Prior to thoracotomy closure, suction and reinflation of the left lung were performed through the bronchial tube. Bronchoscopy via the laryngeal mask revealed no injury to the airway after removal of the bronchial tube. The case shows that laryngeal mask combined with bronchial intubation provides one-lung ventilation with access to the isolated lung.

Technique of pressurized intrathoracic aerosol chemotherapy (PITAC) for malignant pleural effusion

ObjectivesMalignant pleural effusion (MPE) is a devastating evolution of several malignancies. Pressurized intrathoracic aerosol chemotherapy (PITAC) might be a novel therapy option in MPE.MethodsPITAC is considered for patients with MPE with a performance status <2 and without other metastatic sites. General anesthesia is administered and a double-lumen bronchial tube is inserted. The patient is placed in a lateral decubitus position, and the operation is performed after ipsilateral lung exclusion. Two 12-mm balloon trocars are inserted—one in the seventh intercostal space in the mid-axillary line and one in the fifth intercostal space in the anterior axillary line. Extent of pleural disease and volume of MPE are documented. MPE is removed and parietal pleural biopsy are performed. An intrathoracic pressure of 12 mmHg CO2 is established, and a combination of Cisplatin (10.5 mg/m2 in a total volume of 150 cc NaCl 0.9%) and Doxorubicin (2.1 mg/m2 in a total volume of 50 cc NaCl 0.9%) are aerosolized via nebulizer in the pleural cavity. Vital signs and nebulization are remote-controlled. After 30 min, the remaining toxic aerosol is exhausted using a closed surgical smoke evacuation system. A 24Fr chest tube is inserted in postero-apical position with continuous negative pressure of 20 cm H2O. When needed, PITAC may be repeated every six weeks in alternate with systemic chemotherapy.ResultsIn our hands, the technique above has shown to be feasible and safe.ConclusionsFurther studies are needed to assess the potential symptomatic and oncological benefits of PITAC in MPE.

P111 ROBOTIC-ASSISTED REPAIR OF IATROGENIC LEFT BRONCHUS PERFORATION DURING RAMIE – A CASE REPORT

Background Iatrogenic bronchial injury during an esophageal surgery is a severe complication. Hence, immediate treatment is necessary to avoid further pulmonary complications and death. We present a case of an intraoperative bronchial injury caused by a bronchial tube cuff during a full robotic-assisted Ivor-Lewis esophagectomy (RAMIE). Case report A 64-year old patient with adenocarcinoma of the distal esophagus was planned for a RAMIE after completing neoadjuvant radiochemotherapy. Before beginning the thoracic phase, the anesthesist reported an airway leakage during the ventilation. During the transthoracic robotic assisted esophagectomy a perforation of the left main bronchus caused by the cuff of the double-lumen tube was found. Due to the diameter of the defect (1/2 inch) direct suturing was not possible. Therefore, we used a stalked pericardial patch to robotically oversew the perforation. The precise agility using the robotic DaVinci system was very useful treating this perforation minimally- invasively during the RAMIE without conversion. The rest of the surgery including the gastric pull-up and intrathoracic anastomosis was carried out without further complication. The patient had a normal postoperative course and showed no signs of any pulmonary restrictions or any other morbidity. The patient was discharged fully enteralised and in good conditions at the 9th postoperative day. The histopathological stage was ypT3, N2(4/21), L0, V0, Pn0, R0 (stage IIIB in 7th UICC). Conclusion This case report points out the great possibilities of robotic surgery dealing with unexpected complications during complex operations. Robot-assisted complex suturing is a great advantage in robot-assisted minimally invasive surgery, especially during sewing a pericardium-flap onto the left bronchus perforation during an esophagectomy.

Prevalence of Mycobacterium tuberculosis Infection in Suspected Patients in a Teaching Hospital in Northeastern Iran: A Cross-Sectional Study

Background: Mycobacterium tuberculosis is an infectious agent responsible for major health problems and a large number of mortalities. The prevalence of Mycobacterium tuberculosis infection varies across countries. Knowing the infection prevalence can aid in improving public health and reduce the associated costs. The aim of this study was to determine the prevalence of tuberculosis (TB) infection in suspected cases in Mashhad, Iran.Methods: All the clinical specimens suspected of TB infection were sent to a laboratory for diagnosis during -March 2017 to March 2018. The samples were analyzed microscopically using Ziehl–Neelsen staining, by polymerase chain reaction (PCR) to identify the Mycobacterium tuberculosis species using IS6110 primers, and the samples were also grown on Lowenstein–Jensen medium.Results: Of 2,755 clinical samples analyzed, 153 (5.55%) were identified as Mycobacterium tuberculosis-positive, of which 54.9% originated from females and 45.1% from males. The highest rate of infection was observed in spring, especially in May (15%). Most TB cases were found in patients in VIP (43.1%), thorax (17%), and internal (15%) wards. TB infection was mostly detected in bronchial tube (70%) and sputum (23.5%) samples. The most common positive smear was 1+ (36%). Of the 153 cases, (147) 96.1% were culture –positive and 2% were PCR-negative also 84.3% were smear –positive.Conclusion: The highest rate of infection occurred in spring, when the number of religious tourists entering the city was at its peak. Considering the sensitive location of this city, awareness regarding TB status can lead to improved health in the community and development of basic strategies to control and eliminate the transmission of this infection from Mashhad to other areas.

The study of consequences of acute injuries by agents of pulmonotoxic action

Цель исследования - изучение особенностей развития последствий острого поражения веществами пульмонотоксического действия. Методика. Исследование выполнено на 160 белых нелинейных крысах-самцах массой 180-220 г. Для оценки развития последствий острого поражения пульмонотоксикантами использовали модели отравления фосгеном, диоксидом азота и паракватом. Проводили оценку гравиметрических показателей легочной ткани и изменений толерантности к физической нагрузке по показателю продолжительности плавания «до отказа» с грузом 7% от массы тела животного. Также проводилась морфологическая оценка тяжести поражения ткани легких. Результаты. Установлено, что однократное поражение крыс пульмонотоксикантами в дозе 1LCt в остром периоде сопровождается развитием комплекса морфологических и функциональных изменений, характерных для токсического отека лёгких. У части животных наблюдалось выраженное снижение функциональных возможностей, патологоанатомическим субстратом которых являлось нарушение структуры легочной паренхимы с деструкцией и фиброзированием бронхов и сосудов, развитием выраженной панацинарной эмфиземы, которая в 35% случаев сочетается с хроническими гнойно-деструктивными изменениями в легочной ткани. Заключение. Частота развития необратимых последствий поражений веществами пульмонотоксического действия составила: 60% случаев при отравлении паракватом, 40 и 20% при поражении фосгеном и диоксидом азота соответственно. The purpose is to study features of an acute injury progression in case of poisoning by agents of pulmonotoxic action. Experimental work was done in a model of 160 white non-linear male rats weighing 180-220 g. For the assessment of an acute injury development after poisoning by agents of pulmonotoxic action the models of phosgene, nitrogen dioxide and paraquat poisoning were used. The assessment of gravimetric characteristics of lung tissue and changes of physical activity tolerance according to the rate of swimming duration to the full with 7%-load of body mass was carried out. The morphological assessment of severity of lung tissue injury was carried out as well. Results. It was found out that a single exposure of rats with pulmonotoxicants in 1LCt during its acute period was accompanied by the development of a range of morphological and functional changes which were typical for the course of toxic pulmonary edema. As a consequence of poisoning in a half of animals an evident decrease of functional abilities was observed. Pathologicoanatomic substrate of these abilities was the abnormality of lung parenchyma with destruction and bronchial tube and vessel fibrosis, that in 35% of cases matched with chronical purulent-destructive changes in lung tissue. Conclusion. The rate of consequences development after pulmonotoxic agents exposure was the following: 60% cases after paraquate exposure, 40% and 20% after phosgene and nitrogen dioxide respectively.

Successful Management of Pregnancy Complicated by Klippel-Trenaunay Syndrome Using MR Angiography-Based Evaluation

Klippel-Trenaunay syndrome (KTS) is a rare congenital disease, and extensive cutaneous hemangiomas and abnormal venous vessels are characteristic. In our case, to manage her pregnancy with KTS, whole-body MRA was performed before delivery. A 29-year-old woman was referred at 28 weeks because of prominent vulvovaginal varicosities due to KTS. At 35 weeks, hypertrophy and multiple venous varicosities of her leg as well as massive vulvovaginal varicosities became prominent with a normal coagulation profile. Systematic MRAs revealed hemangiomas and varicosities in the right leg, the lower abdomen, and the pubic region, while no obvious AVM was detected around the bronchial tube and spine. We decided to deliver her baby by cesarean section at 37 weeks under general anesthesia, and a healthy baby was delivered. No blood transfusion was required. Prophylaxis against thrombosis was performed after the operation. She was discharged with her baby. Her vulvovaginal varicosities shrunk considerably one month later.