Diagnostic Bronchoscopy Research Articles

Incidence and Nature of Respiratory Events in Patients Undergoing Bronchoscopy Under Conscious Sedation.

During diagnostic bronchoscopies, conscious sedation improves patient tolerance, but it can contribute to hypercapnia and hypoxia by various mechanisms including depression of ventilatory drive. This prospective study was undertaken to determine the frequency of respiratory events and associated oxygen desaturations during bronchoscopy with conscious sedation. The Nox-T3 monitoring system was placed before starting the bronchoscopy and remained in place for 30 minutes following the procedure. The primary endpoint was the occurrence of obstructive and central apneic events during bronchoscopy under conscious sedation. Obstructive events (apnea and hypopnea) occurred in 100% of patients (n=31), and central apneas occurred in 58% of patients (n=18) during the procedure with a median of 9 and 2 events per patient, respectively. During recovery, a significant proportion of patients had detectable obstructive (86%) and central (36%) events. Higher body mass index was associated with oxygen desaturation to <90% and with the need for escalation of care. Furthermore, a conscious sedation regimen that included propofol was significantly associated with central apneic events. Respiratory events are common during and immediately postprocedure after conscious sedation for bronchoscopy. Most events are obstructive, and the use of propofol predisposes to central apneas during the procedure. Both types of events are associated with a higher body mass index. Oxygen desaturation to <90% triggers escalation of care. A further prospective study will be required to determine the clinical significance of these apneic events and whether alleviating these events will improve the safety and outcomes of bronchoscopic procedures performed under conscious sedation.

Should We Start With Navigation or Endobronchial Ultrasound Bronchoscopy?: Insights From Monte Carlo Simulations

Should We Start With Navigation or Endobronchial Ultrasound Bronchoscopy?: Insights From Monte Carlo Simulations

РОЛЬ ИММУНОЛОГИЧЕСКИХ ФАКТОРОВ В НЕБЛАГОПРИЯТНОМ ИСХОДЕ ХРОНИЧЕСКОЙ ОБСТРУКТИВНОЙ БОЛЕЗНИ ЛЕГКИХ

Aim. The aim of the research was to study the role of immunological mechanisms in the unfavorable outcome of chronic obstructive pulmonary disease (COPD). Material and methods. The research included 116 patients hospitalized in 2005-2006 in the pulmonology department of patients with the exacerbation of mild and moderate COPD. Research protocol: general clinical and special (immunological) methods of examination were performed in patients with COPD. Instrumental research methods included: spirography, ECG, EchoCG, fibrobronchoscopy, chest X-ray. After diagnostic bronchoscopy, bronchoalveolar fluid (BAF) was taken for cytological and immunological examination. On the first and second days of inpatient treatment, patients underwent immunological studies: immunophenotyping of mononuclear cells (MNC), assessment of phagocytic activity of leukocytes (latex test, nitroblue tetrazolium (NBT) test) in blood and BAF, determination of the content of immunoglobulins in blood serum and BAF, study of cytokine levels in blood serum, BAF and MNC culture supernatant under conditions of their spontaneous production and activation in the mitogen-stimulated (phytohemagglutinin "Difco" 5 mg/ml) proliferation. Statistical data processing was carried out using the Statistica 10.0 program. In 2020, the long-term survival of COPD patients was assessed. The cohort of patients was divided into two groups. Survivors were included in the first group (n=44), and patients who died by 2020 were included in the other group (n=72). The retrospective comparison of the studied indicators was determined at the time of COPD exacerbation in 2005- 2006 in these patient groups. Results and discussion. In the surviving patients, the BAF cytogram was distinguished by the higher macrophage content and the increased number of NBT-positive cells in this population with the reduced neutrophil content in both blood and BAF. The deceased had elevated levels of IgM and IgA in the blood serum and BAF. The results of the study of cytokine production in MNC cultures in vitro indicate that the ratio of IFN-γ/IL-4 in the conditions of spontaneous cytokine production was higher in the deceased compared with the indicators of the surviving patients. This fact indicates the polarization of the immune response of the deceased in the direction of the cell type mediated by Th1 cells, which is confirmed by the peculiarities of the BAF cytokine profile in the deceased – the significant increase in the value of IFN-γ/IL-4 relative to the indicators in the survivors. Conclusion. The unfavorable outcome of COPD is associated with the increase in the number of neutrophil cells in BAF, in the blood, with the predominance of Th1-type activation of adaptive immunity at the local level and activation of both cellular and humoral mechanisms of adaptive immunity at the systemic level. The increased activity of innate immunity in COPD exacerbation, manifested by the increase in the number and metabolic activity of macrophages, is associated with the long-term survival of patients.

Bronchoalveolar lavage lymphocytosis in hypersensitivity pneumonitis: a retrospective cohort analysis with elimination of incorporation bias

BackgroundRecent studies support the diagnostic role of bronchoalveolar lavage lymphocytosis (BALL) in patients with suspected hypersensitivity pneumonitis (HP). Our study aim was to determine the spectrum of BALL findings with elimination of incorporation bias in non-fibrotic and fibrotic patients and assess correlates of positive BALL cut-off and BALL association with long-term outcomes in those with fibrotic disease (f-HP).MethodsA single-center retrospective cohort study was pursued of patients undergoing diagnostic bronchoscopy for interstitial lung disease. Strict study enrollment was based on recent ATS/JRS/ALAT diagnostic guidance meeting ‘moderate’ or higher diagnostic confidence. BALL findings were assessed in both fibrotic and non-fibrotic HP patients with regression and survival analysis pursued for correlates of positive BALL cut-off and long-term outcome.ResultsA total of 148 patients (88 fibrotic and 60 non-fibrotic) meeting moderate or higher diagnostic confidence were included. Median BALL in f-HP was 15% compared to 19% in non-fibrotic patients, with only 28% of f-HP meeting diagnostic cut-off (≥ 30%) compared to 41% of non-fibrotic. For f-HP, centrilobular nodules on computed tomography was positively correlated with a diagnostic BALL (OR 4.07; p = 0.018) while honeycombing was negatively correlated (OR 6.9 × e−8; p = 0.001). Higher BALL was also associated with lower all-cause mortality (HR 0.98; p = 0.015).ConclusionWith elimination of incorporation bias, most patients with well-described HP did not meet diagnostic BALL thresholds. Higher BALL was associated with better long-term survival in those with fibrosis, but its diagnostic role may be more additive than characteristic or distinguishing.

Effect of Bronchoscopist-Directed Sedation and Other Factors on Patient Comfort during Diagnostic Flexible Bronchoscopy.

Background The factors affecting patient comfort during flexible bronchoscopy are not sufficiently addressed in resource-limited countries, and a need to devise strategies to improve patient experience is felt. The present study was undertaken to assess the effect of sedation and other factors on patient comfort during flexible bronchoscopy. Methods A total of 374 patients, aged ≥18 years undergoing flexible bronchoscopy, were enrolled in this prospective, single-center, cross-sectional study. The baseline clinical data of sedation and nonsedation groups were recorded. Anxiety level was assessed using Visual Analog Scale (VAS). Postprocedure VAS score (primary outcome measure) assessed the discomfort related to flexible bronchoscopy. Patient-reported willingness for a repeat procedure and occurrence of adverse events were used as secondary outcome measures. Based on the median of VAS score, the study population was divided into low discomfort and high discomfort groups, and the factors affecting comfort levels in these two groups were noted. Results Postprocedural VAS score (median (Q1, Q3)) for sedation and nonsedation groups was 20 (15, 30) and 25 (20, 40), respectively (<0.001). Willingness for a repeat procedure was significantly more in the sedation group (p=0.002). In the low and high discomfort groups, the preprocedural anxiety level (median (Q1, Q3)) was 20 (10, 25) and 30 (20, 40), respectively (p < 0.001). Conclusion Bronchoscopist-directed sedation significantly reduces patient discomfort and increases their willingness for a repeat procedure. Midazolam-fentanyl combination and lower prebronchoscopy anxiety are associated with lower discomfort levels during flexible bronchoscopy. This study is registered with the Clinical Trial Registry of India (CTRI/2018/11/016328).

Diagnostic Value of Bronchoscopy for Peripheral Metastatic Lung Tumors.

Simple SummaryMetastatic lung tumors are relatively common, and their pathological diagnosis is crucial for determining the appropriate treatment strategy. Although bronchoscopy is one biopsy method, its role has not been established for peripheral metastatic lung tumors. The present study aimed to investigate the value of bronchoscopy, using radial endobronchial ultrasound for diagnosis. We analyzed 235 lesions consecutively, and the overall diagnostic yield was 76.6%, which was slightly higher than the reported cumulative sensitivity for general peripheral pulmonary lesions. There were no serious complications. The results demonstrated that bronchoscopy is a valuable technique for peripheral metastatic lung tumors that combines diagnostic accuracy and safety. Moreover, the higher diagnostic yield was associated with the large lesion size, inner location, and visibility on radiography. These findings should contribute to the selection of biopsy methods for metastatic lung tumors and improve the diagnostic yield.Although lungs are one of the most frequent sites of metastasis for malignant tumors, little has been reported about the value of bronchoscopy for lung metastases presenting with peripheral pulmonary lesions (PPLs). This retrospective cohort study investigated the diagnostic value of bronchoscopy for peripheral metastatic lung tumors. Consecutive patients who underwent diagnostic bronchoscopy with radial endobronchial ultrasound for PPLs and were finally diagnosed with metastatic lung tumors from April 2012 to March 2019 were included. We analyzed 235 PPLs, with a median size of 18.8 mm. The overall diagnostic yield was 76.6%. In a multivariable analysis, large lesion size (>20.0 mm vs. <20.0 mm: 87.6% vs. 67.7%, p = 0.043, OR = 2.26), inner location (inner 2/3 vs. outer 1/3: 84.8% vs. 69.1%, p = 0.004, OR = 2.79), and visibility on radiography (visible vs. invisible: 83.2% vs. 56.1%, p = 0.015, OR = 3.29) significantly affected the diagnostic yield. Although a positive bronchus sign tended to have a higher yield, no significant difference was observed (81.8% vs. 70.6%, p = 0.063). Only one case of lung abscess was observed, with no serious complications. In conclusion, bronchoscopy is a valuable technique for peripheral metastatic lung tumors, with good diagnostic accuracy and safety.

Diagnostic value of bronchoscopy in sputum-negative pulmonary tuberculosis patients and its correlation with clinicoradiological features.

CONTEXT:Tuberculosis (TB) remains endemic in Saudi Arabia. Little local data have been reported on bronchoscopic evaluation of sputum-negative pulmonary TB patients, which poses a significant diagnostic and therapeutic challenge.AIMS:To determine the diagnostic value of bronchoscopy and bronchoalveolar lavage (BAL) and its correlation with clinical and radiological features in sputum-negative, culture-confirmed pulmonary TB patients.METHODS:We performed a retrospective analysis of patients with definite or probable pulmonary TB with overall negative (smear and/or polymerase chain reaction [PCR]) or scanty sputum that had undergone bronchoscopy with BAL over a period of 5 years. Patients’ symptoms, radiological features, lung lobe lavaged, BAL acid-fast bacilli (AFB) stain, Mycobacterium TB (MTB)-PCR, and mycobacterial cultures were analyzed. Mycobacterial cultures (either sputum or BAL) were used as a reference standard.RESULTS:Out of 154 patients, 49 (32%) were overall sputum negative and underwent a diagnostic bronchoscopy. Dry cough and fever were the most common symptoms. Uncontrolled diabetes mellitus was the most frequent comorbidity identified in 15 (31%) patients. Fifty-nine percent of the patients had diffuse lung infiltrates, with consolidation being the most common abnormality (41%), followed by cavitation (39%). Right upper lobe was the most frequent lung lobe lavaged (31%), while transbronchial lung biopsies (TBLB) were obtained in 21 (43%). BAL mycobacterial culture and MTB PCR were positive in 35 (71%) and 23 (47%) patients, respectively. Combined BAL MTB PCR and TBLB provided rapid diagnosis in 28 (57%) patients.CONCLUSIONS:An overall diagnostic yield of 90% was achieved with combined use of BAL MTB PCR, culture, and histopathology. Upper lobe lavage and presence of cavities on chest imaging had a higher diagnostic yield.

DIAGNOSTIC BRONCHOSCOPY FOR EVALUATION OF CONGENITAL STRIDOR:A CASE SERIES

Introduction: Stridor is a noise mechanically produced through partially occluded airway. Airway obstruction may be extrathoracic or intrathoracic. Stridor may be congenital or acquired. Timing in respiratory cycle determines anatomic location of lesion – inspiratory, biphasic, or expiratory. Gold standard for diagnosis is bronchoscopy which requires general anaesthesia in infants and small children. Major anaesthetic concerns are – possible difficult airway, sharing of an already compromised airway, airway oedema. Case Description: 40 infants, 0 - 6 months age, with history of noisy breathing suggestive of congenital stridor, planned for diagnostic rigid bronchoscopy with or without therapeutic procedure, over one year period. Preoperative treatment – humidified oxygen, nebulization, dexamethasone, antibiotics, anti-reflux medication. Not premedicated, standard monitors applied. Induction of anaesthesia with inhalational oxygen and sevoflurane or intravenous propofol, fentanyl 1 mcg/kg, dexamethasone 0.5 mg/kg. Topical lidocaine 2% sprayed at vocal cords. 100% oxygen with propofol infusion for maintenance with spontaneous ventilation via nasopharyngeal airway. Patients requiring surgical intervention intubated using microcuffed endotracheal tube. Patients observed post-operatively. If ventilation was inadequate, intubated to control airway during recovery, extubated on restoration of spontaneous ventilation. After surgical intervention, babies shifted to ICU for elective ventilation for 48 hours. Discussion: On bronchoscopy, laryngomalacia was the finding in majority of cases. Others had subglottic stenosis, tracheomalacia, vocal-cord paresis, laryngeal cyst. Out of 40 patients, 9 underwent therapeutic procedure and were electively ventilated, 26 resumed spontaneous breathing, 2 patients had delayed recovery and 2 had severe chest retractions and desaturations and they were managed accordingly. One baby aged 6 months diagnosed with grade III subglottic stenosis desaturatedand tracheostomy had to be done. Conclusion:Anaesthesia for rigid diagnostic bronchoscopy is a significant challenge. Rigid bronchoscopy under general anaesthesia requires multidisciplinary approach and close cooperation between all team members.

Rapid Progression of Neonatal Respiratory Distress from Laryngeal Cleft Type I: A Case Report

A one-month-old boy showed cyanosis and severe retraction on crying. He underwent diagnostic rigid bronchoscopy under general anesthesia, maintaining spontaneous ventilation. Rigid bronchoscopy revealed laryngeal cleft type I and excessive mucosa in the interarytenoid space that protruded into the subglottic area, very unusual findings in laryngeal cleft. His clinical condition quickly deteriorated and tracheotomy was performed to prevent complete airway obstruction in the few days until surgical repair of the cleft.

Airway nerve block versus nebulization by lignocaine during diagnostic flexible bronchoscopy under moderate sedation: A randomized controlled trial

ABSTRACT Background Flexible bronchoscopy is an important procedure for the diagnosis and management of patients with respiratory diseases. This study aimed to assess safety and effectiveness of local anesthetic nebulization versus airway nerve block for upper airway anesthesia during diagnostic fiberoptic bronchoscopy under moderate sedation. Methods This randomized, controlled trial enrolled 120 patients scheduled for diagnostic fiberoptic procedures. The patients received 5 ml of 10% lignocaine by air-driven jet nebulizer for 20 minutes (Group A, n = 60) or bilateral superior laryngeal nerve block and trans-tracheal instillation of 4 ml of 2% lignocaine along with viscous lignocaine gargles twice (Group B, n = 60). In the postoperative period, the patient tolerance was assessed. Results Both groups were comparable in all baseline characteristics. The pain score was significantly lower in the nerve block group. Cough and requiring lignocaine were significantly more frequent in the nebulization group. No significant differences between the studied groups regarding intraoperative and postoperative PaO2, PaCO2, heart rate and mean blood pressure except heart rate; were significantly higher in the nebulized group. PaO2 reductions at intraoperative and postoperative (compared with induction) were non-significantly higher in the nebulized group. PaCO2, heart rate and mean blood pressure elevations in intraoperative and postoperative (compared with induction) were higher in the nebulized group, and the differences were non-significant in heart rate only. Conclusion Airway nerve block was associated with reduced consumption of lignocaine and less cough episodes during the procedure compared to nebulized lignocaine.

Massive pneumomediastinum following orotracheal intubation in an emergency setting

We admitted in our intensive care unit, a 34-year old, Female patient from the emergency room, with a hypothesis of COVID-19 disease, who was intubated before transportation due to hypoxemic respiratory insufficiency. In physical examination the patient showed a massive subcutaneous emphysema. A computed tomography confirmed the hypothesis of pneumomediastinum/pneumothorax (Figure 1A). Refractory hypoxemia issued despite optimized mechanical ventilation, so we opted to submit the patient to Extracorporeal Membrane Oxygenation (ECMO). A diagnostic bronchoscopy showed an important laceration of the trachea (Figure 1B, black arrow, and Figure 1C), near the carina. Despite rare, tracheal lesion after intubation may have a dramatic outcome.

Robotic bronchoscopy and future directions of interventional pulmonology.

To describe the emerging field of robotic bronchoscopy within advanced diagnostic bronchoscopy. We review the literature available for these two novel platforms to highlight their differences and discuss the impact on future directions. There are two distinct technologies both known as robotic bronchoscopy. The Monarch robotic-assisted bronchoscopy is based on electromagnetic guidance whereas the Ion robotic-assisted bronchoscopy is founded on shape sensing technology. Although there is ongoing work to explore the capabilities of these systems, studies have shown that both are safe modalities. Furthermore, both hold promise to improve diagnostic yield and may eventually pave the way for therapeutic bronchoscopic ablation in the future. Although both platforms fall under the umbrella term of robotic-assisted bronchoscopy, the Monarch and Ion systems are quite unique in their technology. Thus far, both have demonstrated safety, and early data shows promising results for improved diagnostic yield compared to previously advanced bronchoscopy modalities, especially when combined with advanced confirmatory imaging. Future directions may include bronchoscopic ablation of peripheral lesions given the stability and reach of these platforms.

Modified high-flow nasal cannula oxygen therapy versus conventional oxygen therapy in patients undergoing bronchoscopy: a randomized clinical trial

BackgroundHypoxemia frequently occurs during bronchoscopy. High-flow nasal cannula (HFNC) oxygen therapy may be a feasible alternative to prevent the deterioration of gas exchange during bronchoscopy. With the convenience of clinical use in mind, we modified an HFNC using a single cannula. This clinical trial was designed to test the hypothesis that a modified HFNC would decrease the proportion of patients with a single moment of peripheral arterial oxygen saturation (SpO2) < 90% during bronchoscopy.MethodsIn this single-center, prospective randomized controlled trial, hospitalized patients in the respiratory department in need of diagnostic bronchoscopy were randomly assigned to a modified HFNC oxygen therapy group or a conventional oxygen therapy (COT) group. The primary outcome was the proportion of patients with a single moment of SpO2 < 90% during bronchoscopy.ResultsEight hundred and twelve patients were randomized to the modified HFNC (n = 406) or COT (n = 406) group. Twenty-four patients were unable to cooperate or comply with bronchoscopy. Thus, 788 patients were included in the analysis. The proportion of patients with a single moment of SpO2 < 90% during bronchoscopy in the modified HFNC group was significantly lower than that in the COT group (12.5% vs. 28.8%, p < 0.001). There were no significant differences in the fraction of inspired oxygen between the two groups. The lowest SpO2 during bronchoscopy and 5 min after bronchoscopy in the modified HFNC group was significantly higher than that in the COT group. Multivariate analysis showed that a baseline forced vital capacity (FVC) < 2.7 L (OR, 0.276; 95% CI, 0.083–0.919, p = 0.036) and a volume of fluid instilled > 60 ml (OR, 1.034; 95% CI, 1.002–1.067, p = 0.036) were independent risk factors for hypoxemia during bronchoscopy in the modified HFNC group.ConclusionsA modified HFNC could decrease the proportion of patients with a single moment of SpO2 < 90% during bronchoscopy. A lower baseline FVC and large-volume bronchoalveolar lavage may predict desaturation during bronchoscopy when using a modified HFNC.Trial registration ClinicalTrials. Gov: NCT02606188. Registered 17 November 2015.

“TO STUDY THE CLINICAL PROFILE AND UTILITY OF FIBER-OPTIC BRONCHOSCOPY IN SUSPECTED CASES OF NON RESOLVING PNEUMONIA IN IDENTIFYING ITS ETIOLOGY AT TERTIARY HEALTH CARE CENTRE”

Introduction- Non-resolving pneumonia is always a challenging clinical scenerio where Various diagnostic modalities are greatly required to reach the diagnosis. We aimed to study The role of beroptic bronchoscopy in non-resolving pneumonia along with the various comorbidities associated with the disease condition. Methodology- A prospective observative study in a tertiary care hospital was undertaken. A total of 40 patients diagnosed with non-resolving pneumonia were recruited for diagnostic beroptic bronchoscopy. Results- The overall diagnostic yield of beroptic bronchoscopy in non-resolving pneumonia was 87.5%. The causes of non-resolving pneumonia were Tuberculosis(22.5%), bacterial pneumonia(45%), malignancy(15%), fungal pneumonia(5%). 12.5% patients were undiagnosed. Patients had a signicant past history which also revealed associated comorbid conditions. Diabetes(14(33%)) and COPD(11(27.5%)) were leading comorbid conditions. Conclusion- Fiberoptic Bronchoscopy is a great utility tool in reaching the diagnosis in patients with non-resolving pneumonia.

Clinical usefulness of intermediate-dose dexmedetomidine (0.75 μg/kg) in flexible bronchoscopy - A prospective, randomized, double-blinded study.

BACKGROUND:Dexmedetomidine, although an effective drug for conscious sedation during flexible bronchoscopy, has occasional side effects on the cardiovascular system which need to be addressed.MATERIALS AND METHODS:Patients between 18 and 65 years, requiring diagnostic flexible bronchoscopy, found eligible, after screening, were randomized to either receive 0.75 μg/kg intravenous dexmedetomidine over 10 min or intravenous midazolam 0.035 mg/kg over 1 min. Composite score was used as the primary outcome measure. Additional parameters recorded were: Hemodynamic variables, oxygen saturation, Ramsay sedation score, for pain intensity and distress Numerical Rating Scale, number of rescue medication doses, ease of doing bronchoscopy, Visual Analog Scale score for cough and response of the patient 24 h after bronchoscopy.RESULTS:In each group, 24 patients were enrolled. The composite score was in the ideal category in 24 patients in dexmedetomidine group and 21 in midazolam group, at nasopharynx (P = 0.234). The corresponding values at the level of trachea were 23 and 16 (P = 0.023). In dexmedetomidine group, patient response after 24 h of bronchoscopy showed quality of sedation to be excellent in 0 subjects, good in 13, fair in 9 and poor in 2 and discomfort to be nil in 7, mild 10, moderate in 7 and severe in 0. The corresponding values in midazolam group for quality of sedation were 0, 4, 14, 6, and for discomfort 0, 10, 14, 0. The Visual Analog Scale (VAS) for cough revealed a mean score of 0.800 and 1.812 (P = 0.011) during and 2.092 and 3.542 (P = 0.016) 24 h after bronchoscopy in the respective study groups.CONCLUSION:Low-dose dexmedetomidine (0.75 μg/kg single dose) appears to provide better patient comfort and equivalent safety profile when compared with midazolam.

Advances in Diagnostic Bronchoscopy.

The increase in incidental discovery of pulmonary nodules has led to more urgent requirement of tissue diagnosis. The peripheral pulmonary nodules are especially challenging for clinicians. There are various modalities for diagnosis and tissue sampling of pulmonary lesions, but most of these modalities have their own limitations. This has led to the development of many advanced technical modalities, which have empowered pulmonologists to reach the periphery of the lung safely and effectively. These techniques include thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), and navigation bronchoscopy—including virtual navigation bronchoscopy (VNB) and electromagnetic navigation bronchoscopy (ENB). Recently, newer technologies—including robotic-assisted bronchoscopy (RAB), cone-beam CT (CBCT), and augmented fluoroscopy (AF)—have been introduced to aid in the navigation to peripheral pulmonary nodules. Technological advances will also enable more precise tissue sampling of smaller peripheral lung nodules for local ablative and other therapies of peripheral lung cancers in the future. However, we still need to overcome the CT-to-body divergence, among other limitations. In this review, our aim is to summarize the recent advances in diagnostic bronchoscopy technology.

1640 Stridor in An Infant with Double Aortic Arch

Abstract An eleven-month-old infant presented to our casualty with stridor that had been noticed by the parents a few weeks earlier and became increasingly evident lately. They did not recall a specific event when the infant “chocked”, but they denied any recent history of respiratory tract infection. The infant had no relevant medical or surgical history, and he was born full term with normal vaginal delivery. Examination of the infant showed moderate biphasic stridor with both suprasternal and intercostal recessions. Oxygen saturation on room air was 94% and temperature was 37.1°. Chest auscultation revealed bilateral equal air entry, though decreased, with transmitted stridor. No lung crepitations were appreciated. Suspicion of unwitnessed foreign body aspiration arose, and a decision of diagnostic rigid bronchoscopy was taken. Rigid bronchoscopy revealed no foreign body along the tracheobronchial tree, but evident circumferential constriction of the lower trachea was noted with tendency of the tracheal wall to collapse upon withdrawal of the bronchoscope. Following recovery, computed tomography with contrast of the neck and chest was done and a vascular ring, consisting of double aortic arch, was found compressing and narrowing the trachea. Further follow up over the following 6 months showed marked improvement of his distress, and active observation was continued. Conclusions Although foreign body aspiration is the commonest cause of stridor in infants and young children, external compression of the trachea, particularly with vascular rings, should be considered in children with otherwise unexplained stridor.

Missed foreign body inhalation for 15-years

&#x0D; Background:&#x0D; Foreign body inhalation is a life threating event in children and it is common in our country ,which is a daily practice of Thoracic .It can lead to morbidity even mortality in the hands of untrained or not well- trained doctors.&#x0D; Aim:&#x0D; Is to report a case of missed foreign body inhaled 15-years back, which is uncommonly reported in the literatures and to compare it with other studies reporting similar cases.&#x0D; Methods:&#x0D; The details, presentation, clinical findings, radiological appearance and the successful removal by a rigid bronchoscope under general anesthesia will be presented.&#x0D; Results:&#x0D; The successful removal of this long standing impacted foreign body (plastic whistle) using the rigid bronchoscope and the eventful outcome of patient’s clinical symptoms is elucidated.&#x0D; Conclusion:&#x0D; Refractory respiratory symptoms of long duration without improvement justify the need for diagnostic bronchoscopy which will offers the best chance of cure in missed foreign body inhalation.&#x0D;

Association between Anxiety, Depressive Symptoms, and Quality of Life in Patients Undergoing Diagnostic Flexible Video Bronchoscopy.

Bronchoscopy is one of the basic invasive procedures in pulmonology accompanied by patients’ anxiety. This study aimed to find an association between predictors of state anxiety/depression and patient’s quality of life (QOL) with pulmonary symptoms undergoing diagnostic flexible video bronchoscopy (FVB). A total of 125 adult patients before FVB were included in a prospective observational study. The quality of life (QOL) was assessed by WHOQOL-BREF questionnaire, the depression possibility by the Beck’s Depression Inventory-II (BDI-II), and the anxiety level by Spielberger’s State-Trait Anxiety Inventory (STAI-S; STAI-T). Results show that the older patients and patients with more comorbidities showed a significantly higher anxiety level. The previous FVB under deep sedation significantly reduced state anxiety. A significantly positive association was found between the STAI score and total BDI-II score. More severe symptoms of anxiety were especially related to lower QOL (physical health, psychological and environmental domains) in patients. Statistically higher trait anxiety in lower social QOL domain scores was observed. Our findings show that high state and trait anxiety were associated with higher depression scores and lower quality of life in the elderly. It seems that the elderly and patients at risk of depression development require more attention in the clinical setting to minimize the anxiety accompanying the bronchoscopy.

BRONCHOPLEURAL FISTULA? ENDOBRONCHIAL VALVES TO THE RESCUE

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: Bronchopleural fistula (BPF) is a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space. Most commonly seen as a complication of lung resection surgery with morbidity ranging from 25%-71%. Treatment of BPF primarily is surgical closure but might but bronchoscopic interventions can be considered in certain cases. Here we present a case of endobronchial valves (EBVs) being used as a bridge to surgery. CASE PRESENTATION: A 60-year-old man presented muscle weakness, anterior mediastinal mass and respiratory failure requiring intubation. Diagnosis of myasthenic crisis was made and he underwent three rounds of plasmapheresis. Subsequently, video assisted thoracoscopy with resection of the thymoma was done but the surgery was complicated with need for right pneumonectomy. On post-operative day 6, patient developed right sided tension pneumothorax requiring a 28 Fr chest tube placement resulting in continuous grade IV air leak. Chest CT scan revealed a right hydropneumothorax (Fig 1). Diagnostic bronchoscopy on day 10, showed absence of right main stem bronchus along with a 4mm bronchopleural fistula (Fig 2). Cultures from the bronchoscopy grew methicillin sensitive staphylococcus aureus and he was started on appropriate antibiotics. He continued to have PAL along with significant tidal volume loss which led to failed weaning on the ventilator. Unfortunately, he was deemed not a surgical candidate due to his ventilator dependence from pneumonia and poor nutritional status. On day 14, we repeated bronchoscopy and fibrin sealant was applied through a guide sheath, down the working channel which reduced the air leak but still persisted. Next day, bronchoscopy with deployment of size 5 spiration endobronchial valves was performed (Fig 3) which led to cessation of air leak and on day 20, patient was successfully weaned off ventilator support. Patient was treated for the empyema for 4 weeks and chest tubes were thereafter removed. He was then discharged to subacute rehabilitation after 57 days of hospitalization and 8 weeks later underwent surgical closure. DISCUSSION: BPF diagnosis and management requires a multidisciplinary approach. Patients with poor cardiopulmonary status, the risks of general anesthesia and surgical intervention pose a challenge. A variety of bronchoscopic options like EBVs, stents, ASD closure devices and occlusive material can be considered, primarily as temporizing measures. EBVs allow retrograde passage of air and infected secretions while blocking anterograde airflow. This reduces or stops the air leak and promotes healing. Their use in our patient allowed for weaning from high levels of oxygen support and liberation from mechanical ventilation. CONCLUSIONS: EBV placement is a minimally invasive procedure which can be performed to help with PAL associated with small BPF (<5mm) when surgery is not an option. REFERENCE #1: M. Lois, M. Noppen, Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management, Chest 128 (2005) 3955–3965. REFERENCE #2: Giddings O, Kuhn J, Akulian J. Endobronchial valve placement for the treatment of bronchopleural fistula: a review of the current literature. Curr Opin Pulm Med. 2014 Jul;20(4):347-51. doi: 10.1097/MCP.0000000000000063. PMID: 24811833. REFERENCE #3: Mahajan AK, Verhoef P, Patel SB, Carr G, Kyle Hogarth D. Intrabronchial valves: a case series describing a minimally invasive approach to bronchopleural fistulas in medical intensive care unit patients. J Bronchology Interv Pulmonol. 2012;19(2):137-141. doi:10.1097/LBR.0b013e318251c897 DISCLOSURES: No relevant relationships by Tejaswi Nadig, source=Web Response