Foreign body removal using flexible bronchoscopy in terminal cancer: A case report

Rationale:Pulmonary foreign body aspiration is a serious medical problem. The risk of foreign body aspiration into the airways increases considerably in patients with end stage cancer with reduced consciousness and impaired airway reflexes. However, few studies have reported on foreign body aspiration in the airways in patients with terminal cancer or receiving end-of-life care. Herein, we report the use of flexible bronchoscopy in patients with end-of-life cancer with pulmonary aspiration.Patient concerns:A 71-year-old man with neuroendocrine carcinoma was admitted to a palliative care unit for end-of-life care. He accidentally aspirated implant teeth into the airway with decreased consciousness and death rattle.Diagnosis:On chest x-ray, the foreign material was observed in the left main bronchus.Interventions:Despite concerns regarding the use of bronchoscopy given the deterioration of the overall organ function, flexible bronchoscopy was performed.Outcomes:Eventually, the foreign body was removed using a basket in the nasal cavity without major complications. The patient died comfortably after 7 days.Lessons:The possibility of patients in the palliative care unit with reduced consciousness and death rattle to aspirate foreign bodies into the airways must be carefully considered. Flexible bronchoscopy should be considered to carefully remove aspirated foreign bodies in the airway without any side effects, even in patients with terminal cancer or receiving end-of-life care.     

Broncholith removal using the YAG laser

An 85-year-old woman presented with a broncholith in the intermediate bronchus that could not be extracted with either flexible or rigid bronchoscopes. A YAG laser was used to fragment this broncholith so that it could be removed in pieces through a bronchoscope. Chemical composition and morphology of the broncholith were determined. Fragmentation of the large, impacted broncholith with the laser eliminated the necessity for a thoracotomy in this elderly woman.     

Electromagnetic navigation during flexible bronchoscopy

BACKGROUND: Flexible bronchoscopy is routinely utilized in the diagnosis and treatment of various lung diseases. Nondiagnostic bronchoscopy leads to more invasive interventions, such as transthoracic needle aspiration, mediastinoscopy or even thoracotomy. Electromagnetic navigation is a novel technology that facilitates approaching peripheral lung lesions, which are difficult to sample by conventional means. The navigation system involves creating an electromagnetic field around the chest and localizing an endoscopic tool using a microsensor overlaid upon previously acquired CT images. OBJECTIVES: To determine the practicality, accuracy and safety of real-time electromagnetic navigation, coupled with previously acquired 3D CT images, in locating artificially created peripheral lung lesions in a swine model. METHODS: Peripheral lung lesions were created in four swine models by insertion of a metal tube (1 x 10 mm) via a transthoracic approach. An electromagnetic field was created by placing the animal on an electromagnetic location board. A position sensor incorporated into the distal tip of a dedicated tool was used to navigate to the various target lesions. Information gathered in real time during bronchoscopy was presented on a monitor simultaneously by displaying previously acquired CT images. Upon reaching the target lesion, biopsies were performed and the functionality and safety of the superDimension/Bronchus System was observed and documented. RESULTS: The registration accuracy expressed by the fiducial target registration error, expressing both the registration quality and the stability of fiducial (registration) points, was 4.5 mm on average. No adverse effects, such as pneumothorax or internal bleeding, were encountered in any of the animals in this study. CONCLUSIONS: Real-time electromagnetic positioning technology coupled with previously acquired CT images is an accurate technology added to standard bronchoscopy to assist in reaching peripheral lung lesions and performing biopsies.     

The air apparent: a rare complication during flexible bronchoscopy

Flexible bronchoscopy is a common and safe outpatient procedure, with complications arising in less than 1% of cases. The case presented herein details the occurrence of pneumomediastinum, pneumopericardium, pneumoperitoneum, interstitial lung emphysema and subcutaneous emphysema during flexible bronchoscopy. Although these complications have been reported individually in various circumstances, they have not been reported concomitantly in this setting. Recovery was rapid and complete, requiring only supplemental oxygen and monitoring. After a literature and chart review, the authors postulate that the complications were not a direct result of bronchoscopy but rather the simple act of placing an oxygen delivery cannula in a patient with possible prior trauma to the site.     

Resection of giant endobronchial hamartoma by electrocautery and cryotherapy via flexible bronchoscopy

Endobronchial hamartoma is a rare tumor which is 3-10% of all hamartomas. We presented a case of endobronchial hamartoma that was resected and ablated with electrocautery and cryotherapy by fiberoptic bronchoscopy. A 71-year-old male, presented with progressive dyspnea on exertion, chest pain and hemoptysis. Chest computed tomography (CT) scan of the patient revealed a mass lesion mostly obliterating tracheal lumen and left main bronchus. An initial bronchoscopy showed a large polypoid lesion within the left mainstem bronchus. Polypoid lesion protrudes to the right with respiration. Interventional bronchoscopy with snare probe of the electrocautery resected the polyp in 4 pieces followed by cryotherapy of the base. Pathology of the resected lesion diagnosed as bronchial hamartoma with fibrovascular component. Control bronchoscopy applied 10 days later revealed patency of all airways. The majority of hamartomas is parenchymal and is often located in the periphery of the lung, unlike our patient who had a more central lesion. Where a firm diagnosis is made preoperatively, surgical removal may not be necessary unless symptoms are present, or tumor expansion is noted. Our case demonstrates resection of an endobronchial hamartoma by snare probe of the electrocautery and with cryotherapy. Electrocautery and cryotherapy may present an alternative therapy for resection of selected benign endobronchial benign tumors.     

Management of hypoxemia during flexible bronchoscopy

Under controlled conditions, FB is a safe procedure that has few significant adverse events. Significant hypoxemia may sometimes occur during FB despite the use of supplemental oxygen. UAO has been shown to be the dominant cause of hypoxemia during FB, and this is successfully managed with nasopharyngeal tube insertion. Other strategies that may need to be implemented include oxygen supplementation with intratracheal catheter, administration of sedation reversal medication, removal of the bronchoscope, bag-and-mask ventilation, and, rarely, endotracheal intubation and ventilation. Access to an anesthetist, availability of propofol, backup rigid bronchoscopy, and fluoroscopy are optional but desirable components in the bronchoscopy suite.     

Sedative drug requirements during flexible bronchoscopy

BACKGROUND: There is a paucity of data comparing doses of sedative medication during bronchoscopy in immunosuppressed and non-immunosuppressed patients. OBJECTIVES: The aim of this study was to define the sedative medication doses used in specific patient groups during bronchoscopy. METHODS: Bronchoscopy was performed under local anesthesia, sedation with intermittent boluses of intravenous midazolam and intravenous hydrocodone 5 mg. Two hundred and thirty-nine consecutive bronchoalveolar lavage procedures were included. Procedures in non-immunosuppressed patients were classified as controls (n = 91). Procedures in immunosuppressed patients who received midazolam consisted of stem cell transplant (34), solid organ transplant (25), chemotherapy (33), HIV with drug abuse (10), HIV (5), prednisone (17) and immunosuppression for other diseases (12). Intravenous propofol was administered during 12 procedures due to inability to achieve optimal sedation with midazolam in a previous bronchoscopy (stem cell transplant recipient 1, lung transplant for cystic fibrosis 5) and during the same bronchoscopy due to inadequate sedation with a high dose of midazolam--renal transplant recipient 1, drug abuse (HIV 1, renal transplant recipient 1), bronchoscopy combined with gastroscopy (2) and a hypoxemic patient (1). The mean dose of propofol administered was 2.8 +/- 1.3 mg/kg. RESULTS: Midazolam requirement was significantly higher in patients with stem cell transplantation (0.09 +/- 0.05 mg/kg) compared with controls (0.06 +/- 0.03 mg/kg; p = 0.0002). In the HIV patients with drug abuse (0.12 +/- 0.10 mg/kg), there was a tendency for the need of a higher dose of midazolam compared with the control group (p = 0.0754). CONCLUSION: Stem cell transplant recipients and selected HIV patients with drug abuse need higher doses of midazolam for bronchoscopy.     

Topical lidocaine exaggerates laryngomalacia during flexible bronchoscopy

In 156 infants and children referred for flexible fiberoptic bronchoscopy (FFB) we examined the larynx before and after application of 2% lidocaine solution to see what effect topical anesthesia might have on laryngeal function. All patients received midazolam and nalbuphine intravenously. Using blinded, randomly re-recorded key segments of the original video recordings of bronchoscopy, we used an empirical scoring system (Table 2) to grade signs of laryngomalacia on a scale of 0 to 8 points before and after application of the lidocaine solution. This score was based on the magnitude of collapse of the arytenoids and folding of the epiglottis during inspiration. Topical lidocaine was more likely to result in an increase in signs of laryngomalacia than in a decrease in such signs (p < 0.0001). Younger patients were more likely to have signs of laryngomalacia before topical anesthesia (odds ratio, 1.83). In a group of 10 additional patients, selected for history and physical findings consistent with laryngomalacia, application of a normal saline solution had no effect on the laryngomalacia score, but application of 2% lidocaine solution to the larynx resulted in a significant increase in this score (p < 0.001). Thus, this study has clearly demonstrated that topical anesthesia in infants and children undergoing FFB exaggerates the findings commonly associated with laryngomalacia. Because overestimation of these findings might lead to unnecessary treatment, it is important to examine the larynx and contiguous structures before applying topical anesthesia.     

经脐软式内镜腹腔粘连松解术初步临床应用

目的探讨经脐软式内镜完成腹腔粘连松解术的可行性和安全性。方法对1例因子宫肌瘤子宫切除术后腹腔粘连腹痛入院患者,经脐开口（1．5cm）入腹腔,置入普通胃镜,经内镜送气系统送入CO2建立气腹。探查腹腔,见下腹正中刀VI处腹膜与肠管和大网膜粘连,下腹部粘连较重。经内镜活检通道,分别用IT刀和Hook刀贴腹壁至上而下分离粘连带。分离大部分粘连后,发现分离过的大网膜和肠管粘连创面有新鲜渗血,内镜寻找出血点困难。遂经左下腹部布置1个5mm鞘管,腹腔镜协助寻找出血点,但未见出血部位,后自行止血。腹腔镜协助完成残余粘连松解。脐部切口用可吸收线缝合1针,左下腹部小切口不缝合。结果手术过程耗时40min,术中少量出血。患者术后脐部切口微痛,无需处理。术后当天进食并下床活动,观察2d无异常出院。结论经脐软式内镜腹腔粘连松解术是安全可行的,但有效性还有待进一步证实。     

Foreign body removal by flexible fiberoptic bronchoscopy in infants and children

Rigid bronchoscopy is the preferred method for removal of foreign bodies lodged in the airways, but some studies found that flexible bronchoscopy can also achieve a high success rate. The aim of the present work was to report our experience in using flexible bronchoscopy for foreign body retrieval in infants and children. Reports of all bronchoscopies performed from 1994-2003 at a tertiary-level pediatric hospital in Mexico City were reviewed. Those with a final diagnosis of foreign body aspiration were analyzed. Of 2,376 bronchoscopies performed during the study period, 59 (2.5%) yielded a final diagnosis of foreign body aspiration: 28 lodged in the right bronchi, 15 in the left bronchi, and those remaining, in the larynx or trachea. Foreign bodies were organic in nature in 38 (64.4%), mainly peanuts, pumpkin seeds, and beans, while 21 (35.6%) were inorganic, mainly pen caps and pins. In 23 cases, flexible bronchoscopy was attempted as the initial therapeutic procedure. Among these latter patients, the procedure was successful in 21 (91.3%). Ages of these 21 patients ranged from 9 months to 16 years (median, 5 years). The only two patients in whom foreign bodies could not be removed through flexible bronchoscopy were males, 2 years of age, both with a peanut lodged in right main bronchus. In conclusion, flexible bronchoscopy must be taken into account as initial therapeutic method for foreign body removal in infants and children.     

Patient-oriented optimal depth of conscious sedation using midazolam during flexible bronchoscopy: A prospective open-labeled single-arm trial

Background

The British Thoracic Society guidelines for diagnostic flexible bronchoscopy (FB) in adults recommend that intravenous sedation should be offered to patients undergoing bronchoscopy. However, it is difficult to determine the adequate depth of sedation for each patient because of inter-individual variability.