Insertion Of Bronchoscope Research Articles

Diagnosis of peripheral pulmonary lesions using a bronchoscope insertion guidance system combined with endobronchial ultrasonography with a guide sheath

We developed a bronchoscope insertion guidance system that produces virtual images by extracting the bronchi by automatic threshold adjustment, and searching for the bronchial route to the determined target. We used this system in combination with a thin bronchoscope and endobronchial ultrasonography with a guide sheath (EBUS-GS), and evaluated its practicability, usefulness and safety. The subjects were 31 patients with 32 peripheral pulmonary lesions. Computed tomography (CT) data were transferred into this system, and virtual bronchial images were automatically produced by setting the lesion as the target. While virtual images with the target were displayed for comparison with real images by the system, a thin bronchoscope was advanced to the target bronchus. Transbronchial biopsy (TBB) was then performed by EBUS-GS. The system automatically produced virtual images to a median of fifth- (third- to seventh-) order bronchi. In all patients, the thin bronchoscope could be guided along the planned route, and observation to a median of fifth- (third- to seventh-) order bronchi was possible. Thirty lesions (93.8%) were successfully visualized by EBUS, and 27 (84.4%) could be pathologically diagnosed. In lesions < or =30mm in size, the EBUS visualization yield was 91.7% (22/24), and the diagnostic yield was 79.2% (19/24). The median total examination time was 22.3 (9.8-41.5) min. In summary, using the bronchoscope insertion guidance system, virtual images can be readily produced, and the bronchoscope can be successfully guided to the target. This method is promising as a routine examination method in the biopsy of peripheral pulmonary lesions.

Diameter of paediatric sized flexible bronchoscopes: When size matters

A flexible bronchoscope typically gets its designated size from the diameter of the distal tip but this is not the maximum diameter of the insertion tube. The aim of this study was to determine the size and site of the maximum diameter of flexible bronchoscope insertion tubes and to compare standard bronchofiberscopes with newer bronchovideoscopes. We assessed 10 bronchoscopes ranging from 2.2 to 4.9 mm external diameter (Olympus, Tokyo, Japan) using an electronic digital caliper. Investigators were blinded to the type and model of each scope. The median, minimum and maximum diameters of the bronchoscopes were calculated and the measured diameters were compared with the stated diameters of the distal tip and insertion tube. The maximum and median measured diameters were wider than the stated diameter of the distal tip in all the scopes. The maximum discrepancy between the measured and stated diameters ranged from 0.19 mm (6.7%) to 0.66 mm (22.2%) with a mean of 0.41 mm (14.0%). There was no difference between bronchofiberscopes and bronchovideoscopes. The maximum diameter of the distal tip and insertion tube of pediatric sized flexible bronchoscopes is significantly greater than the manufacturer's specifications. This may impact on the choice of bronchoscope selected for procedures in children.

A double-lumen tube technique for selective lobar isolation

EDITOR: A 72-yr-old female (height 162 cm, weight 55 kg) was admitted to our Intensive Care Unit (ICU) because of acute respiratory failure (PaO2/inspired O2 fraction (FiO2) 10.3 kPa). On admission, her trachea was intubated with a 7.5 mm inner diameter endotracheal tube (Portex, Kent, UK) and lungs mechanically ventilated in a pressure-regulated volume-controlled mode (Siemens 300C®, Berlin, Germany). Tidal volume was set at 380-400 mL, respiratory rate 20 breaths min−1, externally applied positive end-expiratory pressure (PEEP) 0 cmH2O. The achieved PaO2/FiO2 was 12 kPa. The patient was sedated with propofol (4 mg kg−1 h−1). The admission chest radiograph revealed diffuse, bilateral pulmonary infiltrates. She had no prior history of chronic inhalation of dusts causing inflammation and pulmonary fibrosis. Microbiological, serological and imaging investigations for patients with suspected interstitial lung disease [1] failed to establish a definitive, causal diagnosis. Thus, surgical lung biopsy [1-4] under selective lobar collapse [5] was decided. For selective left upper lobar collapse, the following technique was employed. (a) Determination of left mainstem bronchus length. A 3.4 mm fibreoptic bronchoscope was inserted through the original endotracheal tube; the upper incisor-to-carina distance (23.5 cm) was determined by subtracting the endotracheal tube connector-to-upper incisor length (part of endotracheal tube protruding from the patient's mouth) from the fibreoptic bronchoscope insertion length at the level of carina (endotracheal tube connector-to-carina); in a similar way, the upper incisor-to-left upper bronchus orifice distance (26.0 cm) was determined by subtracting the endotracheal tube connector-to-upper incisor length from the fibreoptic bronchoscope insertion length at the level of the left upper bronchus orifice; lastly, the difference of the aforementioned distances yielded the left mainstem bronchus length (2.5 cm). (b) LUL isolation. Additional propofol (1 mg kg−1), fentanyl (3 μg kg−1) and cisatracurium (0.2 mg kg−1) were given. Then the original endotracheal tube was replaced by a 37-FG, left-sided, double-lumen tube (BronchoCath®; Mallinckrodt Medical Inc., St. Louis, MO, USA); the double-lumen tube was inserted to the 28.0 cm mark at upper incisor level, and the inflation of both tracheal and bronchial cuffs resulted in the desired selective LUL isolation (Fig. 1).Figure 1: Selective isolation of the left upper lobe with the left-sided double-lumen tube inserted to the 28 cm mark.(c) Confirmation of LUL isolation. A fibreoptic bronchoscope inspection via the tracheal lumen of the double-lumen tube revealed the carina and both mainstem bronchial orifices; on inspection through the bronchial lumen only the segmental left lower bronchial orifices were visualized; on chest auscultation, with both double-lumen tube cuffs inflated, breath sounds were diminished solely over the left upper lobe. In the right lateral decubitus position, the desired double-lumen tube positioning was reconfirmed as above. Following left upper lobe collapse [5], an uneventful videothoracoscopic biopsy of the left upper lung was performed within 40 min. Intraprocedural ventilator settings were: FiO2, 1.0; tidal volume, 350-360 mL; respiratory rate, 23 breaths min−1; inspiratory time-to-total respiratory cycle time ratio 0.5; externally applied PEEP 0 cmH2O. Peak, plateau and mean airway pressures were 45-46, 28-30 and 8-9 cmH2O, respectively; intrinsic PEEP was 2 cmH2O. PaO2 was maintained ≥8 kPa throughout the procedure. In patients in respiratory failure with a short (≈2.5 cm) left mainstem bronchus [6], we recommend our selective left upper lung isolation technique for open lung biopsy. The left lower lobe can still be ventilated through the left endobronchial lumen of the double-lumen tube and the right lung is ventilated through the tracheal lumen. This is likely to minimize the risk of intraoperative hypoxaemia. S. D. Mentzelopoulos K. Rellos M. J. Tzoufi A. S. Michalopoulos Department of Intensive Care Medicine; Henry Dunant General Hospital; Athens, Greece E. P. Papageorgiou Department of Anaesthesiology; Henry Dunant General Hospital; Athens, Greece

Personal View: One way to reduce the overdraft

Student debt is at the forefront of most students' minds. Every student knows the joy of trying to persuade the bank manager to increase his or her overdraft limit. My housemates and I are no exception. A few weeks ago I found myself talking to my bank manager. He tried to be sympathetic, but I'm trying to increase my limit for the umpteenth time. Finally, we got round to the inevitable question, “How exactly do you plan to bring your overdraft back down to a manageable limit?” I stuttered a bit, and made a few excuses, but after putting the phone down I thought, “How am I going to pay this back?” I tend to view the overdraft as free money, but living at the limit of your overdraft is beginning to get dull. So how could I make money quickly, and with relatively little effort on my part? Insertion of a flexible bronchoscope (ANTONIA REEVE/ SPL) This is when we started to discuss taking part in research experiments. One …

The outcome after perinatal management of infants with potential airway obstruction

Masses in the head and neck are being detected prenatally with increasing frequency, necessitating the need for management of potential upper airway obstruction at delivery. Establishment of the airway at delivery and its maintenance thereafter are critical. This should optimally be performed with the baby still attached to the placental circulation. The importance of multidisciplinary team management, including a high risk obstetrician, neonatologist, pediatric otolaryngologist, pediatric thoracic surgeon, and an anesthetist, cannot be overemphasized. Endotracheal intubation is attempted first, if unsuccessful then is followed by insertion of a rigid bronchoscope. Tracheotomy should be reserved for airway obstructions, which are not amenable to endotracheal intubation or in babies in whom exchange from a bronchoscope to endotracheal tube cannot be safely performed. The management of six infants with prenatally diagnosed potential airway obstruction is presented. Morbidity and mortality still ultimately depend on the severity of the existent anomalies.

Comparative evaluation of TIVA with propofol-fentanyl and thiopental-sevoflurane anesthesia using laryngeal mask airway for diagnostic bronchoscopy.

Diagnostic bronchoscopy is performed under general anesthesia in our hospital. This study was designed to determine whether total intravenous anesthesia (TIVA) with propofol-fentanyl provides more stable hemodynamics using a laryngeal mask airway (LMA) for diagnostic bronchoscopy than thiopental-sevoflurane anesthesia. Sixty patients scheduled for diagnostic bronchoscopy were randomly assigned to two groups. TIVA with propofol-fentanyl was induced with intravenous fentanyl 2 μg·kg-1 and propofol 2 mg·kg-1 and maintained with continuous infusion of propofol with fentanyl. Thiopental-sevoflurane anesthesia was induced with thiopental 5 mg·kg-1 and maintained with N2O/O2/sevoflurane. Insertion of the LMA was facilitated with vecuronium 0.1 mg·kg-1 i.v. in both groups. Ventilation was controlled, and administration of propofol and sevoflurane was continued until the end of the procedure. The LMA was removed when the patient was able to open his or her mouth. During TIVA, the mean arterial pressure and rate pressure product decreased significantly from induction until 20 min after the start of the procedure, and they were maintained at around 70 mmHg and 7000, respectively, during the procedure. There were no significant differences in heart rate,[Formula: see text] and[Formula: see text]. In thiopental-sevoflurane anesthesia, the mean arterial pressure and rate pressure product decreased significantly after induction and increased significantly from insertion of the LMA until removal of the LMA. Heart rate increased significantly after insertion of the LMA, insertion of the bronchoscope, and removal of the LMA. There were no significant differences in[Formula: see text] and[Formula: see text]. TIVA with propofol-fentanyl in conjunction with an LMA performs better than thiopental-sevoflurane anesthesia for diagnostic bronchoscopy because of its superior maintenance of cardiovascular stability.

Nasal versus Oral Insertion of the Flexible Bronchoscope

Nasal versus Oral Insertion of the Flexible Bronchoscope

Nasal versus Oral Insertion of the Flexible Bronchoscope

Pulmonary/Critical Care Medicine, Baylor College of Medicine and Medical Intensive Care Unit, Ben Taub General Hospital; and The Methodist Hospital, VA Hospital and Ben Taub General Hospital, Houston, Texas, U.S.A.

Topical Nasal Anesthesia for Flexible Bronchoscopy: A Comparison of Four Methods in Normal Subjects and in Patients Undergoing Transnasal Bronchoscopy

We evaluated nasal anesthesia regimens by comparing, in seven normal men, four drug regimens: 1) 1 percent phenylephrine; 2) 4 percent lidocaine; 3) 1 percent phenylephrine + 4 percent lidocaine; and 4) 5 percent cocaine. After spraying each drug into the anterior nares, vasoconstriction, decongestion, and nasal anesthesia (measured as transnasal depth of nasogastric (NG) tube insertion before discomfort) were assessed. There were no significant differences in NG tube insertion depth between the regimens (p = 0.54). Insertion depth was significantly increased after 10 ml of 2 percent viscous lidocaine were sniffed (p less than 0.004), but again, differences between regimens were not significant (p = 0.051). One hundred bronchoscoped patients received one of the following sprayed into the nose: 1) placebo (P); 2) 1 percent phenylephrine + P; 3) 1 percent phenylephrine + 4 percent lidocaine; or 4) 5 percent cocaine + P. Each patient then sniffed viscous lidocaine. There were no significant differences between regimens for any of the following: 1) nasal resistance to bronchoscope insertion, 2) patient's nasal discomfort, or 3) bronchoscopist's perception of patient discomfort. We conclude that sprayed anesthetics contribute little to nasal anesthesia and any regimen appears acceptable when viscous lidocaine is used.