Multicentre European study for the treatment of advanced emphysema with bronchial valves

This multicentre, blinded, sham-controlled study was performed to assess the safety and effectiveness of bronchial valve therapy using a bilateral upper lobe treatment approach without the goal of lobar atelectasis. Patients with upper lobe predominant severe emphysema were randomised to bronchoscopy with (n = 37) or without (n = 36) IBV Valves for a 3-month blinded phase. A positive responder was defined as having both a ≥ 4-point improvement in St George's Respiratory Questionnaire (SGRQ) and a lobar volume shift as measured by quantitative computed tomography. At 3 months, there were eight (24%) positive responders in the treated group versus none (0%) in the control group (p = 0.002). Also, there was a significant shift in volume in the treated group from the upper lobes (mean ± SD -7.3 ± 9.0%) to the non-treated lobes (6.7 ± 14.5%), with minimal change in the control group (p<0.05). Mean SGRQ total score improved in both groups (treatment: -4.3 ± 16.2; control: -3.6 ± 10.7). The procedure and devices were well tolerated and there were no differences in adverse events reported in the treatment and control groups. Treatment with bronchial valves without complete lobar occlusion in both upper lobes was safe, but not effective in the majority of patients.     

Nd:YAG laser bronchoscopy. A five-year experience with 1,396 applications in 1,000 patients

We treated 1,000 patients with the Nd:YAG laser. The rigid bronchoscope was used in 1,280 (92 percent) of the treatments, with patients almost always under general anesthesia; 116 (8 percent) treatments were performed with the flexible fiberoptic bronchoscope alone, with the use of local anesthesia. In almost all cases of benign tumors and in many carcinoid tumors, the treatment was curative. In genuine nonmalignant tracheal stenoses, laser therapy was curative in 34 out of 81 cases. In malignant tumors, the laser improved airway gauge 92 percent of the time. Cumulative survival was 50 percent (+/- 3 percent) at six months and 26 percent (+/- 3 percent) at one year. Following palliative laser therapy, eight patients with bronchogenic carcinoma appearing to be inoperable did have surgery and ten underwent less extensive surgery than expected. Results confirm the usefulness and safety of this relatively new method in the treatment of obstructive lesions of the tracheobronchial tree.     

Acute respiratory acidosis does not increase plasma potassium in normokalaemic anaesthetized patients. A controlled randomized trial.

BACKGROUND AND OBJECTIVE: Few and conflicting data are available regarding the changes of plasma potassium concentration during acute respiratory acidosis in human beings. This study compares the acute changes in plasma potassium concentration in acutely hypercapnic patients and in non-hypercapnic patients during general anaesthesia. METHODS: Thirty-three patients undergoing interventional rigid bronchoscopy were studied. Ventilation of the lungs was randomly conducted using either spontaneous-assisted ventilation or intermittent negative-pressure ventilation. All patients received the same anaesthetic protocol. Arterial blood gases and osmolality, and plasma concentrations of glucose, sodium, potassium and chloride were measured. RESULTS: Intraoperatively, PaCO2 was higher during spontaneous-assisted ventilation than during intermittent negative-pressure ventilation (9 +/- 1.8 vs. 5.4 +/- 1.2 kPa, P < 0.001) and the pH was also lower during spontaneous-assisted ventilation than during intermittent negative-pressure ventilation (7.24 +/- 0.07 vs. 7.4 +/- 0.08, P < 0.001). Plasma potassium concentration remained similar in both groups (3.8 +/- 0.2 mmol L(-1) with spontaneous-assisted ventilation vs. 3.7 +/- 0.4 mmol L(-1) with intermittent negative-pressure ventilation). CONCLUSION: Acute respiratory acidosis does not affect plasma potassium concentration.     

Endoscopic management of laryngo-tracheobronchial amyloidosis: a series of 32 patients

Between June 1983 and December 2002, 32 patients were treated for primary localized laryngo-tracheobronchial amyloidosis (LTBA) at our institution. For enrollment in this retrospective study, at least one positive biopsy with Congo red stain and a diagnostic test battery excluding systemic or secondary amyloidosis were mandatory. The most common presenting symptom was dyspnea, which was observed in 75% of cases. Endoscopic appearance was described as submucosal plaques and nodules with a cobblestone appearance in 44% of patients, tumor-like in 28% and circumferential wall thickening in 28% of cases. Tracheobronchopatia osteochondroplastica was associated with LTBA in 22% of patients, both at the first treatment (four cases) or during follow-up examinations (three). Synchronous or metachronous disease in the larynx and tracheobronchial tree was observed in 47% of cases, while only one patient showed lung involvement with extensive amyloidosis of the trachea and bronchi. All but two patients were endoscopically treated. One of these was affected by a tracheal amyloidoma cured by endoscopic debulking and further tracheal resection-anastomosis. The other patient presented massive laryngo-pharyngeal involvement and was therefore treated by total laryngectomy. A total of 58 endoscopic procedures (range: 1-7; mean: two per patient) were carried out, 11 with CO2 laser (for supraglottic, glottic and selected subglottic lesions) and 47 with Nd:YAG laser (for the most part of subglottic lesions and amyloid deposits located in trachea and bronchi). Four patients required a tracheotomy and three necessitated a T-tube stent during management, which was subsequently removed in all cases. One patient was lost to follow-up, nine were endoscopically controlled elsewhere (Group A) and 22 were followed at our institution (Group B). In Group A, the patient with tracheal amyloidoma is asymptomatic and free of additional LTBA localizations 8 years after surgery. The remaining eight are asymptomatic, but with persistent endoscopic signs of amyloidosis. In Group B, five patients died: one from heart failure and another one from pneumonia 3 and 4 days after surgery, respectively. In one case death was from unrelated causes, and in the two remaining patients it was from respiratory failure due to uncontrolled bilateral bronchial amyloidosis in the subsequent 5 to 6 years. One patient is completely cured 5 years after surgery, and 16 are asymptomatic with persistence of LTBA.     

Negative pressure ventilation vs external high-frequency oscillation during rigid bronchoscopy. A controlled randomized trial

STUDY OBJECTIVES: To compare the effectiveness of two modalities of external ventilation during rigid bronchoscopy: intermittent negative pressure ventilation (INPV) and external high-frequency oscillation (EHFO). DESIGN: Prospective, controlled, randomized, nonblinded study. SETTING: University-affiliated hospital. PATIENTS: Seventy patients undergoing interventional rigid bronchoscopy for tracheobronchial lesions were enrolled into the study. INTERVENTIONS: Mechanical ventilation was performed by INPV or EHFO. When pulse oximetry was < 90%, manually assisted ventilation was delivered. Measurements and results: Arterial blood gases were sampled preoperatively and intraoperatively. Most patients in both groups had normal intraoperative PaCO(2) (mean, 43. 6 +/- 11.8 mm Hg under EHFO and 37.4 +/- 8.2 mm Hg under INPV; p = 0.012), and acidemia occurred in 9 of 35 patients of EHFO group and in 2 of 35 patients of INPV group (p = 0.049). Hypercapnia (PaCO(2) > 50 mm Hg) was observed in 10 patients under EHFO and in 2 with INPV (p = 0.026). Intraoperative mean PaO(2) was similar (101.4 +/- 52.9 mm Hg with EHFO and 124.2 +/- 50.3 mm Hg with INPV; p = 0.07), but O(2) supply was different (3.5 +/- 2.3 L/min during INPV and 8.5 +/- 6.2 L/min during EHFO; p < 0.001). Intraoperative hypoxemia (PaO(2) < 60 mm Hg) occurred in five patients with EHFO and two with INPV (p = 0.426). Three EHFO patients required manually assisted ventilation (mean, 0.2 +/- 0.9), but no INPV patient did (p = 0.142). CONCLUSIONS: External negative pressure ventilation appears to be a suitable choice during rigid bronchoscopy: both EHFO and INPV ensure effective ventilation and comfortable operating conditions in the majority of patients. Some patients may receive inadequate ventilation with EHFO, developing respiratory acidosis and requiring manually assisted ventilation. In comparison with INPV, EHFO requires a higher fraction of inspired oxygen.     

Idiopathic subglottic stenosis: management by endoscopic and open-neck surgery in a series of 30 patients

We describe our experience in the diagnosis and treatment of idiopathic subglottic stenosis (ISS), a rare pathological entity involving the subglottic larynx and the first tracheal rings and affecting virtually only females. Its diagnosis can be made only after the exclusion of all other known causes of subglottic stenosis. In a 17-year period, between January 1986 and June 2002, 30 patients were admitted and treated for ISS at the Department of Otolaryngology and/or the Center for Respiratory Endoscopy and Laser Therapy, the University of Brescia, Italy. Clinical, endoscopic and surgical records were retrospectively analyzed with particular emphasis on treatment (endoscopic versus open-neck procedures) and follow-up. Based on our experience, we can define endoscopic treatment by carbon dioxide or Nd:YAG laser-assisted dilatation and scar tissue resection with or without airway stenting as the treatment of choice for the initial management of ISS. After repeated endoscopic failures, open-neck surgery by laryngoplasty or laryngotracheal resection and anastomosis is strongly recommended, particularly for complex lesions longer than 1 cm.