Combined use of a Total Control Introducer and a hyperangulated video laryngoscope to place a left-sided double lumen endotracheal tube in a patient with a history of difficult laryngoscopy

We describe the use of a Total Control Introducer (TCI) in combination with video laryngoscopy (VL) to place a left-sided double-lumen endotracheal tube (DLT) in a patient with a history of difficult laryngoscopy undergoing video-assisted thoracoscopic surgery (VATS). VL was used to obtain visualisation of the glottis and a TCI articulating introducer was used to dynamically navigate the airway and access the trachea. A 39 French DLT was subsequently passed over the TCI shaft and into the trachea under indirect visualisation. The TCI shaft was removed and the DLT was gently guided into the left main bronchus. Successful endobronchial intubation was confirmed with capnography, auscultation and fibreoptic bronchoscopy. We propose that the combined use of VL and a TCI can facilitate placement of a DLT in a patient with a known difficult airway who may otherwise be limited to a bronchial blocker placement for lung isolation during VATS.

Registry of Primary Lung Tumours in Ain Shams Hospitals

Background Bronchogenic carcinoma is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. This growth can spread beyond the lung by the process of metastasis into nearby tissue or other parts of the body. Most cancers that start in the lung, known as primary lung cancers, are carcinomas, The two main types are small-cell lung carcinoma (SCLC) and non- small-cell lung carcinoma (NSCLC). Aim of the Study Register cases of primary lung tumors presented to Ain shams university hospital during period from June 2018 to June 2019 and to follow up their response to different lines of treatment and to assess delay time between diagnosis and start of treatment. Patients and Methods This study is an observational, analytical and retrospective study, conducted upon 95 cases of primary lung tumor cases presented to Ain Shams University Hospital _oncology chest clinic. Results The main age of our studied population ranging from 17 to 66 years old in cases diagnosed as small cell lung cancer (SCLC), from 30 to 81 years old in cases diagnosed as non small cell lung cancer(NSCLC), eight out of nine cases diagnosed as SCLC were males, sixty six out of 86 NSCLC cases were males, about 66.7% of SCLC cases & 57% of NSCLC were smokers, forty four percent of SCLC presented with performance score 2, while 48.8% of NSCLC presented with performance score 1, Out of 86 cases of non small cell lung cancer 54 were adenocarcinoma, 27 were squamous cell carcinoma, 4 cases were large cell lung cancer and 1 case was mucoepidermoid carcinoma. Dyspnea was the main symptom in SCLC cases (6 cases out of 8). Fibreoptic bronchoscopy was the diagnostic tool in 33.3% of SCLC cases, 29.1% of NSCLC cases. In non small cell lung cancer, US guided biopsy took the second hand after fibreoptic bronchoscopy by 25.6%, Most of cases were stage 4, 77.8% in small cell carcinoma, 80.2% in non small cell lung cancer. SCLC received Gemcitabine/carboplatin in 33.3% of cases, 22.2% of cases received palliative radiotherapy as first line treatment.11.1% of them received definitive radiotherapy as second line treatment.In NSCLC, 25.6% of cases treated with Gemcitabine/carboplatin, 17.4% received palliative radiotherapy.In NSCLC 36% of cases presented with dyspnea then chest pain 22%.The relation between delay time and prognosis as regard disease progression is non significant similar to the relation between delay time from definitive diagnosis to start of treatment)and stage at time of diagnosis. Unlikely, the inverse relation between delay time and ECOG(Eastern Cooperative Oncology Group Performance status) in both small and non small cell lung cancer. Conclusion The relation between delay time and prognosis is non significant similar to the relation between delay time and stage at time of diagnosis. Unlikely, the inverse relation between delay time and ECOG in both small and non small cell lung cancer.

Diagnostic Value of Bronchoalveolar Lavage Examination in Sputum Negative Patients for AFB in Suspected Pulmonary Tuberculosis

Background: Pulmonary tuberculosis (PTB) is one of the most common infections worldwide, more commonly among the developing countries like Bangladesh. So its early detection and prompt treatment was a challenge and the burden of diagnostic challenge was higher if the patients smear negative for Acid Fast Bacilli (AFB). Objective: Evaluate the diagnostic value of Bronchoalveolar lavage (BAL) for diagnosis of suspected Pulmonary Tuberculosis (PTB) whose sputum for AFB smear neagtive. Materials and Methods: A cross-sectional observational reserach was undertaken where 50 patients were included on the basis of specific inclusion and exclusion criteria. All patients who had negative smear for AFB but highly suspected for PTB underwent fibreoptic bronchoscopy to collect Bronchoalveolar lavage (BAL) fluid for diagnostic testing in the form of BAL for AFB and mycobacterial culture in Lowenstein Jensen medium. Results: The Male predominacy 29 (58%) was obserevd among the smear negative PTB patients. Clinically more than seventy percent (72%) presents with fever then cough with sputum and haemoptysis 62% and 32% respectively. Radiological cavitation 33 (66%) was the most common x-ray findings. After analysis of BAL for AFB about 31 (62%) patient found positive and on culture about mycobacterial growth found in 29 (58%) patients. Conclusion: Bronchoalveolar lavage had a superior diagnostic value in patients with smear negative suspected pulmonary tuberculosis. KYAMC Journal.2021;12(02): 84-87

1033 Endobronchial Sclerotic Neurofibroma: A Case Report of a Very Rare Benign Tumour

Introduction Endobronchial neurofibromas are exceedingly rare benign lesions most commonly originating at the trachea. Primary pulmonary tumours of neurogenic origin such as peripheral nerve sheath tumours (PNSTs) are extremely rare, accounting for less than 0.2% of all lung tumours. Intrathoracic PNSTs are usually benign and are commonly found in the posterior mediastinum as schwannomas with female preponderance. We present the first reported occurrence of the sclerotic variant of endobronchial neurofibroma and the approach used in its definitive investigation and management. Case Report A 69-year-old Caucasian male with a 66 pack-year smoking history and a background of alcohol induced liver cirrhosis, peripheral vascular disease and dilated cardiomyopathy presented with dyspnoea and fatigue with severe normocytic anaemia. Computed Tomography (CT) chest, abdomen and pelvis revealed an indeterminate nodule at the secondary carina projecting into the bronchus intermedius (BI). Fibreoptic bronchoscopy showed a polypoid lesion with a vascular appearance. Under general anaesthetic, combined fibreoptic and rigid bronchoscopy was used to remove the lesion with rigid forceps. Gross histological appearance showed an 8x6x5mm pedunculated lesion with a 2mm diameter short stalk and histology of a sclerotic neurofibroma with fibroblasts and collagen, positively staining for S100 and LP10. This patient is due for follow up in 6-month with a CT chest to ensure no tumour recurrence. Conclusions Endobronchial neurofibromas appear highly vascular and demand extra caution at bronchoscopic intervention. Prompt, experienced thoracic surgical and intervention pulmonology input should always be sought. Combined approach of fibreoptic and rigid bronchoscopy allows better control of potential bleeding and the airway.

Inhibition of Stress and Spontaneous Respiration: Efficacy and Safety of Monitored Anaesthesia Care by Remifentanil in Fibreoptic Bronchoscopy for Patients with Severe Tracheal Stenosis

Objective To determine the effective concentration of target-controlled infusion (TCI) of remifentanil used to inhibit stress during the treatment of severe tracheal stenosis with fibreoptic bronchoscopy and to evaluate the safety of the monitored anaesthesia care (MAC) by remifentanil.Methods A study of 60 patients with severe tracheal stenosis who underwent diagnostic and therapeutic fibreoptic bronchoscopy at Shanghai Pulmonary Hospital affiliated with Tongji University was performed. Dexmedetomidine was initially administered at a bolus dose (0.8 mcg/kg), followed by a 0.5 mcg/(kg·h) continuous infusion. Remifentanil was administered by TCI. When the target concentration was reached, the nasopharyngeal airway was inserted, and then oxygen was supplied by a connected anaesthesia machine. The effective concentration of remifentanil was titrated by the improved sequential method, and 30 patients were included. The EC95 of remifentanil was set as the plasma target concentration to evaluate the safety of the MAC, and another 30 patients were included. Remedy measures: Propofol (10-20 mg) was injected intravenously. The primary outcome measures were the cough score and the incidence and severity of hypoxemia. The tolerance score for nasopharyngeal airway placement, Ramsay sedation score, haemodynamic changes, satisfaction score, patients’ 24 h recall score, patients’ willingness to re-receive the procedure, and related adverse events were recorded.Results On the basis of sedation with dexmedetomidine, the EC95 of remifentanil for inhibiting the stress response in fibreoptic bronchoscopy performed on patients with severe tracheal stenosis was 2.710 ng/ml (95% CI, 2.471-4.473 ng/ml), and the EC50 was 2.243 ng/ml (95% CI, 2.061-2.446 ng/ml). Among the 30 patients who received an EC95 of remifentanil as the target concentration, 1 patient was remedied by injecting propofol; the tolerance score for insertion of the nasopharyngeal airway was 2, the score of Ramsay sedation was 3, and the cough score was 1. The incidence of respiratory depression was 50%, the incidence of hypoxemia was 20%, and 86.7% of patients with respiratory depression returned to normal by awakening. One patient returned to normal by mask-assisted ventilation, and another returned to normal by laryngeal mask mechanical ventilation. The satisfaction score of the operator was 9, the satisfaction score of the anaesthesiologist was 8, the satisfaction score of the patients was 10, the score of the patients' 24 h operative recall was 1, the rate of patient willingness to re-accept the procedure was 93.3%, the incidence of throat pain at 30 min after the end of the operation was 16.7%, and the circulation was stable during the operation. No pruritus, nausea, vomiting or other related adverse reactions were reported.Conclusion MAC using TCI of remifentanil can effectively inhibit the stress response to fibreoptic bronchoscopy in patients with severe tracheal stenosis while maintaining spontaneous breathing. The patients are safe and comfortable and express high satisfaction, making this method worthy of clinical application.Trial registration Registration date : 12/02/2021, Registration number: ChiCTR2100043380.

Detection and diagnosis of large airway collapse: a systematic review

Large airway collapse (LAC) is a frequently encountered clinical problem, caused by tracheobronchomalacia +/- excessive dynamic airway collapse, yet there are currently no universally accepted diagnostic criteria. We systematically reviewed studies reporting a diagnostic approach to LAC in healthy adults and patients, to compare diagnostic modalities and criteria used. Electronic databases were searched for relevant studies between 1989 and 2019. Studies that reported a diagnostic approach using computed tomography (CT), magnetic resonance imaging, or flexible fibreoptic bronchoscopy were included. Random effects meta-analyses were performed to estimate the prevalence of LAC in healthy subjects and in patients with chronic obstructive airway diseases. We included 41 studies, describing 10,071 subjects (47% female), and mean (+/- sd) age 59±9 years. Most studies (n=35) reported CT findings and only 3 studies report bronchoscopic findings. The most reported diagnostic criterion was a ≥50% reduction in tracheal or main bronchi calibre at end-expiration on dynamic expiratory CT. Meta-analyses of relevant studies found that 17% (95% CI: 0–61%) of healthy subjects and 27% (95% CI: 11–46%) of patients with chronic airways disease were classified as having LAC, using this threshold. The most reported approach to diagnose LAC utilises CT diagnostics and at a threshold used by most clinicians (i.e., ≥50%) may classify a considerable proportion of healthy individuals as being abnormal and LAC in a quarter of patients with chronic airways disease. Future work should focus on establishing more precise diagnostic criteria for LAC, relating this to relevant physiological and disease sequalae.

Utility of nasal application of lignocaine gel using cotton tip swab versus squirting with slip-tip syringe for transnasal fibreoptic bronchoscopy: a pilot randomised controlled trial

BackgroundDuring flexible fibreoptic bronchoscopy through the nasal route, anaesthesia of the nasal passage is achieved by lignocaine gel application by a slip-tip syringe or with the help of a cotton tip swab. No studies in existing literature have compared the two techniques in terms of efficacy.Methods137 consecutive patients undergoing bronchoalveolar lavage (BAL) were recruited over a 2-year period. The patients underwent BAL after nasal anaesthesia—either by slip-tip syringe or by cotton tip swab smeared with 2% lignocaine gel. Patients were monitored for intraprocedural epistaxis, discomfort and improvement in operator visibility of nasal passage.Results67 patients were randomised to cotton swab and 70 patients to the gel instillation group. There were no significant differences in terms of epistaxis, 29.9% in the cotton tip swab (95% CI 19.3% to 42.3%) versus 24.3% in the gel instillation group (95% CI 14.8% to 36%) or detection of nasal blocks, 7.5% in the cotton tip swab (95% CI 2.5% to 16.6%) versus 10% in the gel instillation group (95% CI 4.1% to 19.5%) in the two groups, although a significant difference was there in terms of visibility, 73.1% in the cotton tip swab (95% CI 60.9% to 83.2%) versus 42.9% in the gel instillation group (95% CI 31.1% to 55.3%). There was no difference in the mean pain score across the two groups either during the procedure or 1 hour after it. A short systematic review of existing literature on the topic has been provided for comparison.ConclusionApplication of 2% lignocaine gel by slip-tip syringe and cotton tip swab are equivalent in terms of observed and narrated pain experienced by patients, frequency of epistaxis and nasal blocks. Vision was better preserved in the cotton tip swab group.

Use of Video Laryngoscope in Sedated Spontaneously Breathing Patients with Predicted Difficult Tracheal Intubation and Impossibility of Using Fibreoptic Bronchoscopy

Intubation with a flexible fibrobronchoscope in an awake patient is frequently considered the technique of choice in patients with predicted difficult intubation. There are, however, situations in which the use of the fibrobronchoscope is not applicable, particularly due to problems attributable to the patient or to limited use of the instrument. In such situations, the video laryngoscope can be a useful alternative, as long as it is associated with adequate sedation of the patient. In fact, it ensures excellent viewing of the glottis, allowing for successful orotracheal intubation to be performed even in case of difficult airways, while keeping the patient spontaneously breathing throughout the procedure. From the data present in the literature, this technique seems to ensure a success rate and a safety profile similar to those obtained with the fibrobronchoscope, moreover, with greater ease of use by the anaesthesiologist. The main purpose of this work is to provide a valid and safe alternative to intubation with a fibrobronchoscope while awake in those patients with anticipated difficult airway management and in whom, for different reasons, fibrobronchoscope cannot be used.

Pneumocystis pneumonia causing cavitating lung nodules in an immunocompetent individual

Pneumocystis jirovecii pneumonia (PCP) is a potential life-threatening pulmonary infection which commonly manifests in immunosuppressed patients especially with HIV, with underlying malignancies, severe malnutrition as well as those on immunosuppressive treatments. There have been case reports of symptomatic PCP in individuals with a normally functioning immune system with typical clinical features and radiologic findings of bilateral and diffuse interstitial opacities. However, PCP in immunocompetent individuals presenting with lung nodules had been rarely reported. We report a 53-year-old immunocompetent gentleman who presented with subacute cough, progressive shortness of breath and radiographic findings of multiple lung nodules with central cavitation. The diagnosis of PCP was made by detection of PCP DNA PCR in bronchoalveolar lavage sample following fibreoptic bronchoscopy. This case also highlights the atypical radiographic findings of multiple cavitating lung nodules as a presentation of PCP in an immunocompetent patient.