Effect of fibreoptic bronchoscopy on pulmonary function.

Several studies have shown that after fibreoptic bronchoscopy there may be a deterioration in lung function but it is not known whether this is due to the premedication, the topical anaesthetic, or the obstruction produced by the bronchoscope. The effects of each part of the procedure on spirometric measurements were studied in patients with lung disease and in normal non-smokers. Measurements were made after premedication (papaveretum and atropine) in seven patients and after topical anaesthesia of the bronchial tree (340 mg lignocaine) with and without the bronchoscope in the trachea in 21 patients and 10 control subjects. Premedication had no effect. In the normal subjects lignocaine produced significant falls in FEV1, forced vital capacity (FVC), peak expiratory flow (PEF), and peak inspiratory flow (PIF), and insertion of the bronchoscope caused further falls that were also significant. In the patients, however, although anaesthesia produced significant falls in FEV1, FVC, PEF, and PIF of similar magnitude to those found in the normal subjects, there was no further important decrease when the bronchoscope was inserted. It is concluded that the major effect of bronchoscopy on lung function is due to topical lignocaine in the airways, and in patients with lung disease (excluding asthma or a central obstructing carcinoma) the insertion of the bronchoscope causes little additional obstruction.     

Experience with Ultraflex expandable metallic stents in the management of endobronchial pathology

BACKGROUND: Experience with Ultraflex expandable metallic stents (Micro-invasive, Boston Scientific, Watertown, MA) in the management of endobronchial pathologies leading to airway compromise is reported. METHODS: Between January 1999 and August 2000, twenty-eight expandable metallic stents were inserted into 25 patients (7 men and 18 women; median age, 65 years) who presented with respiratory distress. Each patient had comorbid medical conditions or end-stage malignancy that precluded formal surgical repair. Seventeen patients had intrinsic airway obstruction, 5 had extrinsic compression, 2 had a tracheal tear, and 1 had a tracheoesophageal fistula. Stents were inserted through a bronchoscope under direct vision. Eighteen patients received tracheal stents alone (1 of these patients received two tracheal stents), and 5 patients received bronchial stents only. Two patients received a tracheal and a bronchial stent. Twenty-one stents were covered and seven were uncovered. RESULTS: All patients had successful stents with restoration of airway patency and closure of tracheal defects. One patient developed a respiratory infection early after the operation. Follow-up bronchoscopy confirmed satisfactory stent position in each patient. Late complications included sputum retention, halitosis, and granulation tissue formation. CONCLUSIONS: Ultraflex expandable metallic stents should be considered in the management of airway compromise in selected patients for whom formal surgical repair is inappropriate or contraindicated.     

EXPANDABLE METALLIC BILIARY STENTS

Eighteen expandable metallic biliary stents were inserted in patients with malignant (16 patients) or benign (two patients) biliary strictures. Four were the Gianturco-Rosch biliary Z-stents and the remaining 14 were the Wallstent. The stents were delivered through either the endoscopic transpapillary (10 patients), percutaneous transhepatic (five patients) or combined percutaneous-endoscopic (three patients) route. No failure in implantation was encountered. Bile drainage was successful in all patients. Stent occlusions were observed in four patients with hilar obstruction due to tumour overgrowth above the stents at 30–67 days (mean 47.75 days) after insertion. The occlusions were drained percutaneously (two patients) or endoscopically (two patients). Migration of stent did not occur. After a median follow-up period of 170.5 days (range 57–731 days), 11 patients were still alive and free of jaundice. The median patency period of the stents for common bile duct and hilar obstruction was 288.5 days (range 117–731 days) and 61.5 days (range 30–188 days), respectively. The overall median patency period was 165 days. It is concluded that expandable metallic biliary stent is a useful adjunct to the treatment of malignant biliary obstructions with a better result in distal obstruction.     

Bronchial fenestration improves expiratory flow in emphysematous human lungs

BACKGROUND: The crippling effects of emphysema are due in part to dynamic hyperinflation, resulting in altered respiratory mechanics, an increased work of breathing, and a pervasive sense of dyspnea. Because of the extensive collateral ventilation present in emphysematous lungs, we hypothesize that placement of stents between pulmonary parenchyma and large airways could effectively improve expiratory flow, thus reducing dynamic hyperinflation. METHODS: Twelve human emphysematous lungs, removed at the time of lung transplantation, were placed in an airtight ventilation chamber with the bronchus attached to a tube traversing the chamber wall, and attached to a pneumotachometer. The chamber was evacuated to -10 cm H2O pressure for lung inflation. A forced expiratory maneuver was simulated by rapidly pressurizing the chamber to 20 cm H2O, while the expiratory volume was continuously recorded. A flexible bronchoscope was then inserted into the airway and a radiofrequency catheter (Broncus Technologies) was used to create a passage through the wall of three separate segmental bronchi into the adjacent lung parenchyma. An expandable stent, 1.5 cm in length and 3 mm in diameter, was then inserted through each passage. Expiratory volumes were then remeasured as above. In six experiments, two additional stents were then inserted and forced expiratory volumes again determined. RESULTS: The forced expiratory volume in 1 second (FEV1) increased from 245 +/- 107 mL at baseline to 447 +/- 199 mL after placement of three bronchopulmonary stents (p < 0.001). With two additional stents, the FEV1 increased to 666 +/- 284 mL (p < 0.001). CONCLUSIONS: Creation of extra-anatomic bronchopulmonary passages is a potential therapeutic option for emphysematous patients with marked hyperinflation and severe homogeneous pulmonary destruction.     

Sequential silastic and expandable metal stenting for tracheobronchial strictures.

The risks and limitations of surgical resection and reconstruction for tracheobronchial strictures demand consideration of other therapeutic options that can alleviate the distressing symptoms of tracheobronchial obstruction. One alternative is to stent the obstructive lesion until surgical advances allow primary reconstruction or replacement of the critically diseased airway or until an ideal endoprosthesis is found. The latter requires uniformity in the distribution of expansile force, conformability and stability within the tracheobronchial tree, and ease of placement. Here we report our experience with the placement of expandable metal stents (Wall-stent) used in conjunction with our Silastic (Dow Corning) endobronchial stents in 5 patients with recurrent tracheal or bronchial strictures. The major site of obstruction was the trachea in 1 patient and a main bronchus or both bronchi in 4 patients. Three patients had a benign bronchial stricture (anastomotic stricture in 2, idiopathic polychondritis in 1), and 2 patients had an obstructive airway neoplasm. Placement of the stents was performed under rigid bronchoscopic guidance. We had no complications from our technique of stenting. There has been no evidence of restenosis or occlusion within the stented segment of airway. The complementary use of expandable metal and Silastic endobronchial stents provided symptomatic and functional improvement in our patients during follow-up ranging from 5 to 24 months.     

Anaesthesia and tracheobronchial stenting for central airway obstruction in adults

In the last decade, stents suitable for the management of tracheobronchialstenoses and obstruction have evolved from bulky prosthesesrequiring tracheal resection to small devices that are self-expandingand can be inserted using fibreoptic techniques. The experiencebase for this review is more than 100 patients between 1989and 2001 who have been anaesthetized for stent insertion. Earlycases required rigid bronchoscopy for the routine of insertion.Anaesthetic techniques have evolved from those that were designedand developed for laser surgery in the central airways. Theadvent of modern devices now extends the variety of anaestheticmanagement techniques that can be used. But the original one,based on the requirement for use of a rigid bronchoscope, isbest for dealing with complications and extracting problem stents.The most frequent complication of the processes of stent insertionhas been respiratory failure because of carbon dioxide retention,consequent on obstruction with secretions in the area of thecarina. The nature of central airway problems suggests thatanaesthesia induction, management and teaching should not befounded on the conventional model-base of upper airway obstruction. Br J Anaesth 2003; 90: 367–74     

Airway stenting.

Various airway pathologies may result in central airway obstruction. For patients who have benign and malignant disease, definitive surgical correction by tracheobronchial resection and reconstruction is preferred. Numerous patients, however, have unresectable airway lesions owing to the extent of disease or to medical or surgical contraindications. These patients can be palliated by several endoscopic strategies, including dilatation, core out of tumor, laser resection, endobronchial brachytherapy, or photodynamic therapy. Airway stenting with silicone or expandable metal stents provides reliable and durable palliation in 80% to 95% of properly selected patients. The major advantages of silicone stents are the ease of customization, repositioning, and removal, with the major drawbacks being stent migration or stent obstruction. Expandable metal stents have the advantage of ease of insertion, conformation to the airway, low inner-to-outer diameter ratio, and stent stability. These advantages, however, are offset by (1) the development of tumor ingrowth or of granulation at the end of the stent or through the interstices of the stent and (2) the difficulty or impossibility of stent repositioning or removal once it has been seated completely within the airway. Management of the patient who has central airway obstruction requires a thorough knowledge and consideration of the surgical and endoscopic management options and, usually, a multidisciplinary approach, with experienced thoracic surgical consultation to evaluate the potential for definitive surgical correction. The interventional bronchoscopist must consider the spectrum of endoscopic therapeutics fully. Most patients benefit from combining strategies in a flexible algorithm directed at optimizing patient outcomes. The benefits and risks of airway stenting must be considered in comparison with the other options for airway palliation. In refractory strictures, rapidly recurrent tumor, or extrinsic compression, endobronchial stenting likely will be necessary to achieve durable palliation of airway obstruction. The short- and long-term implications of airway stenting, including the complications of silicone versus expandable metal stents, should be considered thoroughly, while the physician bases treatment or procedure decisions on individual patient anatomy and expected natural history.     

Airway Stenting

Interventional pulmonology, otherwise known as airway stenting, has developed in the field of pulmonary medicine focused on using advanced bronchoscopic techniques to treat airway disorders. Tracheobronchial disorders can be caused by malignant or benign tumors, extrinsic compression, postintubation tracheal injuries, tracheobronchomalacia, or sequelae after tracheostomy. Tracheobronchial prostheses, known as airway stents, are used to palliate the effects of large airway obstruction. Specially designed stents are being used increasingly, not only in the airways, but also in the biliary tree, esophagus, urinary tract, and vascular system. There are two main types of airway stents currently available; tube stents made of silicone, and expandable metallic stents. Silicone stents are usually placed with the aid of a rigid bronchoscope while the patient is under general anesthesia. Unlike silicone stents, metal stents can be placed with a flexible bronchoscope. We examine the advantages and disadvantages of currently available stents and present our thoughts on the future development of airway stenting.     

Self-expandable metal stents for malignant dysphagia.

BACKGROUND: The use of self-expandable metal stents in relieving dysphagia for patients with incurable malignant oesophageal strictures was retrospectively evaluated. METHODS: Between September 1993 and August 1996, 66 male and 16 female patients with a median age of 72 years received self-expandable metal stents for malignant dysphagia. Six patients had concurrent tracheo-oesophageal fistulas. All patients were stented under sedation and stent insertion was performed under fluoroscopic guidance. RESULTS: Stent placement was successful in 80 patients (98%). There were seven early complications (inaccurate positioning (n = 3), migration (n = 1), incomplete expansion (n = 1), intractable pain (n = 1), and perforation (n = 1)). Two complications were lethal and three were treated endoscopically. Mean dysphagia grade improved from 3.2+/-0.7 to 1.8+/-0.9 (P < 0.05) after implantation. All tracheo-esophageal fistulas were successfully occluded. Upon a median follow-up of 8 weeks (range: 2-20 weeks), 30 complications developed in 21 patients (tumour overgrowth (n = 15), food bolus obstruction (n = 7), tumour ingrowth (n = 2), buckling of stent (n = 2), tracheo-esophageal fistula (n = 2), bleeding (n = 1), and gastric wall herniation through metal coils (n = 1)). Median survival was 13 weeks (range: 1-82 weeks). CONCLUSION: Self-expandable metal stents provide useful palliation in patients with incurable malignant dysphagia.     

Bronchoscopic NdYAG laser treatment in lung cancer, 30 years on: an institutional review

We review our 21-year experience in bronchoscopic NdYAG laser for lung cancer and the relevant literature. Patients totaling 1,159 received 2,235 bronchoscopic treatments. The pre-requisite for laser therapy was the presence of >50% obstruction of the bronchial lumen. We use the rigid bronchoscope, with the patient under general anaesthetic and application of laser in its non-contact mode. Two patients (0.17%) died following the procedure, and 4.8% had non-fatal complications. Four to 6 weeks after treatment there was a 48% increase in bronchial calibre and an increase of 27% (mean) in forced vital capacity and 15% (mean) in forced expiratory volume in one second, respectively. These paralleled symptomatic relief and chest X-ray improvement. Literature review indicated results similar to ours in those centres with high volume activity. Thirty years on, bronchoscopic YAG laser therapy of lung cancer still has an important role in palliation of patients with inoperable lung cancer, particularly those requiring immediate relief of bronchial obstruction.     

Laryngeal mask airway for ventilation during diagnostic and interventional fibreoptic bronchoscopy in children

BACKGROUND: The use of the flexible fibreoptic bronchoscope in infants and children has expanded to include both interventional and diagnostic bronchoscopy. The present report utilizes the laryngeal mask airway (LMATM) for ventilation and anaesthesia administration in children during fibreoptic bronchoscopy using an adult bronchoscope. METHODS: The technique was used in 10 children; their age ranged between 1.2 and 5 years. Six of these children had a history of foreign body aspiration and underwent interventional bronchoscopy, while four children underwent diagnostic bronchoscopy. Anaesthesia was induced by facemask using sevoflurane 6-8% followed by the insertion of a LMA size 2 or 2.5. A swivel adapter connected the proximal end of the LMA to the T-piece anaesthesia system. Anaesthesia was then maintained with spontaneous breathing of sevoflurane 2-4% in oxygen, delivered via the LMA. A flexible adult fibreoptic bronchoscope (outer diameter 4.9 mm) was inserted via the swivel adapter. RESULTS: The procedure could be accomplished successfully in the 10 patients. However, one child developed laryngospasm that was easily relieved by deepening the level of anaesthesia. In a second child hypoxia and hypercarbia occurred and were relieved by intermittent withdrawal of the fibreoptic bronchoscope. CONCLUSIONS: Laryngeal mask airway is a safe and effective adjunct to fibreoptic bronchoscopy under general anaesthesia in children. Its larger internal diameter compared with a tracheal tube permits the use of relatively large fibreoptic bronchoscope without a significant increase in airway resistance.     

Photodynamic therapy (PDT) for bronchial carcinoma with the use of rigid bronchoscope

Endoscopic PDT was undertaken in nine patients with inoperable bronchial cancer. Eight patients had advanced metastatic disease and one was unsuitablefor surgery on account of age, respiratory function and location of tumour. Patients were injected with Photofrin II (no. 7) or Polyhaematoporphyrin derivative (no. 2) at 2 mg kg⁻¹ of bodyweight before being irradiated 48 h later by 630 nm red light generated by a copper vapour laser (Oxford Lasers) for 200 J cm⁻¹ tumour tissue. Treatment was undertaken under general anaesthetic using a rigid bronchoscope for ventilating and suction purposes with the fibre optic instrument introduced through the rigid bronchoscope for localization of tumour and placement of the diffusing fibre. One patient died 2 months after treatment from carcinomatosis. One patient had total response with negative histology for 10 months. All other patients with substantial endobronchial obstructive lesions had partial response with significant reduction in percentage obstruction and improved pulmonary function. There have been no post-operative complications.     

Sequential brush biopsy and conventional biopsy: direct comparison of diagnostic sensitivity in lung malignancy.

One hundred and sixteen patients with suspected lung malignancy who were referred for bronchoscopy were examined using both the flexible fibreoptic bronchoscope and the rigid bronchoscope. Both instruments were used sequentially under the same general anaesthetic. Brush biopsies were obtained through the fibreoptic bronchoscope and conventional biopsies, for histological examination, through the rigid bronchoscope. Both specimens were taken from the same area. Eighty-two per cent of those in whom there was a final clinical diagnosis of malignancy were found to have abnormal cytology via the fibreoptic bronchoscope, while abnormal histology was found in 50% by means of the rigid bronchoscope. For those in whom malignancy was confirmed, 16.9% showed disagreement between the two methods in cell typing. Brush biopsy through the flexible fibreoptic bronchoscope under general anaesthesia is confirmed as a sensitive method for diagnosing lung malignancy.     

Acromegaly and papillomatosis: difficult intubation and use of the airway exchange catheter

We describe the anaesthetic management of a patient with acromegaly scheduled for transsphenoidal resection of a pituitary tumour who was found at intubation to have coexisting laryngeal papillomatosis. Oral intubation was impossible using both direct and fibreoptic techniques. Nasal fibreoptic intubation was successful but precluded the transsphenoidal approach to surgery. A Cook Airway Exchange Catheter [Cook (UK) Ltd, Monroe House, Letchworth SG6 1LN] was used with a Negus bronchoscope to convert to oral intubation and allow completion of surgery without resort to tracheostomy.     

Anaesthetic management of infants requiring endobronchial argon laser surgery

Small infants with endobronchial lesions primarily due to traumatic suction catheter injuries are now undergoing argon laser surgery to remove obstructive tissue. Providing an anaesthetic for these infants can be challenging because of the small airways involved which must be shared by the anaesthetist and the surgeon. We have performed 30 argon laser endobronchial surgeries in nine infants. The lungs of the majority of patients were ventilated through a tracheostomy intraoperatively, while the surgeon passed the argon laser fibre through the suction port of a fibreoptic bronchoscope which was passed trans-nasally. Three infants were too small to allow passage of the fibreoptic bronchoscope past an artificial airway. In these patients surgery and ventilation were accomplished through a rigid bronchoscope. Three larger patients without tracheostomies were managed with a modified nasal airway for intraoperative ventilation in conjunction with the fibreoptic bronchoscope.     

Use of the laryngeal mask for fibrescope–aided tracheal intubation in an awake patient with a deviated larynx

I report a case in which fibrescope–aided awake tracheal intubation was achieved using a laryngeal mask, in a patient with a mediastinal goitre in whom tracheal intubation with both a laryngoscope and a fibreoptic bronchoscope had failed. The tumour extended to the upper part of the mediastinum. The larynx and the upper segment of the trachea were displaced by the tumour. Awake tracheal intubation with both a laryngoscope and a fibreoptic bronchoscope failed. The laryngeal mask was then inserted without difficulty. After a fibreoptic bronchoscope had been covered by a plastic tube, the combination was passed through the laryngeal mask into the trachea. The fibreoptic bronchoscope and the laryngeal mask were removed, and a reinforced endotracheal tube was then inserted over the plastic tube into the trachea. The time for tracheal intubation was about 70 s. The laryngeal mask may allow easier location of the laryngeal inlet with a fibreoptic bronchoscope, and this technique is a useful alternative to the conventional technique of tracheal intubation in the patient with a deviated larynx.     

Comparison of haemodynamic responses to orotracheal intubation with GlideScope videolaryngoscope and fibreoptic bronchoscope

BACKGROUND AND OBJECTIVE: The GlideScope videolaryngoscope is a newly developed laryngoscope for tracheal intubation recently introduced into clinical anaesthesia. In this randomised clinical study, we compared the haemodynamic responses to orotracheal intubation using a GlideScope videolaryngoscope and a fibreoptic bronchoscope. METHODS: Fifty-six adult patients, ASA I-II scheduled for elective plastic surgery under general anaesthesia requiring orotracheal intubation were randomly allocated to either the GlideScope videolaryngoscope group or the fibreoptic bronchoscope group. After a standard intravenous anaesthetic induction, orotracheal intubation was performed. Noninvasive blood pressure and heart rate were recorded before and after induction, at intubation and for 5 min after intubation at 1 min intervals. RESULTS: As compared with the post-induction values the orotracheal intubations using a fibreoptic bronchoscope and a GlideScope videolaryngoscope resulted in the significant increases in blood pressures which did not exceed their baseline values. In the two groups, heart rates at intubation and within 2 min after intubation were significantly higher than their baseline values. However, there were no significant differences in blood pressures and heart rates at all time points, their maximal values and maximal percent changes during the observation and the times required to reach their maximal values between the two groups. CONCLUSIONS: The orotracheal intubations using a fibreoptic bronchoscope and a GlideScope videolaryngoscope produce similar haemodynamic responses.     

Ureteral metal stents: a tale or a tool?

There are four types of ureteral metal stents: self expandable, balloon expandable, covered, and thermoexpandable shape-memory. Insertion of metal stents requires expertise with transurethral and percutaneous techniques. The stricture is traversed with the aid of a guidewire via a percutaneous nephrostomy, and the stenotic segment is dilated using a high-pressure balloon catheter. The stent is then inserted over the guidewire, such that the upper end bypasses the obstruction by at least 3 to 4 cm, while the lower end extends intravesically for 0.5 to 1 cm from the ureteral orifice. If necessary, two or more stents are placed in sequence, overlapping by at least 2 to 3 cm. Metal stents were initially used for the relief of end-stage malignant disease, and their role in the treatment of benign ureteral strictures is still undefined. Patients often complain of abdominal discomfort and mild pain after stent insertion, which soon resolve spontaneously. Hematuria usually stops after a few days and does not necessitate any treatment. Mild urothelial hyperplasia in the stent lumen is common but usually regresses after 4 to 6 weeks. Many authors suggest the use of a double-pigtail catheter for the first 4 to 6 weeks to avoid narrowing of the ureteral lumen. The influence of stents on ureteral peristalsis is a major but poorly documented issue. Encrustation is a significant problem that needs to be addressed. The characteristics of both the patient and the stent influence its likelihood. Migration of coated metal stents was seen in 81% of patients at our center. Virtual endoscopy has recently been introduced as a tool for the follow-up of patients with stented ureters. Further design development is necessary to obtain the ideal ureteral metal stent. In a recent study in female pigs, paclitaxel-eluting metal stents engendered less inflammation and hyperplasia of the surrounding tissues.     

Delayed massive hemoptysis after expandable bronchial stent placement

Patients with lung cancer often develop airway obstruction that necessitates palliative bronchoscopic interventions. Expandable metal stents are increasingly used for this indication. We report a case of fatal massive hemoptysis that occurred 1 week after uneventful bronchial stent placement. Previous treatment with external-beam radiotherapy, brachytherapy, and photodynamic therapy probably contributed to pulmonary artery-bronchial fistulization in this patient. This complication should be kept in mind when considering expandable airway stent insertion in heavily pretreated lung cancer patients.     

Adjuvant therapies using biliary stenting for malignant biliary obstruction

The aim of this study was to analyze the patency of expandable metallic stents in malignant biliary obstruction and to evaluate the efficacy of adjuvant therapy accompanied by biliary stenting. We analyzed 29 patients in whom bile duct stenting was performed for malignant biliary obstruction. Their types of disease were: hilar ductal carcinoma (n = 8), gallbladder carcinoma (n = 11), and pancreatic carcinoma (n = 10). Initially, 46 expandable metallic stents were placed in 29 patients. In 23 of the 29 patients, adjuvant therapy was administered. Seventeen patients underwent radiotherapy, and 16 patients received various systemic chemotherapies. In principle, hyperthermia was performed twice a week, simultaneously with radiotherapy. Patient survival and the probability of stent patency were calculated using actuarial life table analysis. There was no significant difference in stent patency among the patients according to type of disease. Hyperthermia did not influence the stent patency rate. The median stent patency time was significantly greater in the chemo-radiation group than in the no-adjuvant therapy group: 182 days versus 68 days, respectively (P = 0.017). Moreover, a significant increase was seen in the median survival time in the chemo-radiation group: 261 days versus 109 days (P = 0.0337). Complications occurred in 9 patients (31.0%). Stent occlusion occurred in 6 patients (20.7%), with all of these patients managed successfully using a transhepatically placed new expandable metallic stent, employing the stent-in-stent method. Stent migration occurred in 2 patients after radiotherapy. Adjuvant therapies such as radiotherapy and systemic chemotherapy, in combination with stent insertion, resulted in an increase in the patency period of expandable metallic stents and in increased patient survival time. Received: August 18, 2000 / Accepted: December 1, 2000