Background and Objective: The purpose of this study was to evaluate the relationship between the wall structure assessed by using endobronchial ultrasonography (EBUS) and bronchial hyperresponsiveness in patients with asthma.Methods: Twenty-four patients with stable asthma and 11 individuals without asthma were studied. EBUS was performed with a radial 20-MHz ultrasonic probe inserted into the intermediate bronchus undergoing flexible bronchoscopy to assess the airway wall structure. The percentage of airway wall thickness {WT%; defined as [(ideal outer diameter-ideal luminal diameter)/ideal outer diameter] x 100} was determined by EBUS. We measured bronchial hyperresponsiveness to methacholine [the provocative concentration of methacholine causing a decrease of 20% or more in forced expiratory volume in 1 s (PC20)].Results: Percentage wall thickness measured by EBUS was significantly greater in patients with asthma than that in subjects without asthma (P<0.01). The evaluation of the laminar structure using EBUS indicated that the thickness of the second layer in patients with asthma was greater than that in subjects without asthma (P<0.05). PC20 was negatively correlated with the thickness of the second layer (r=0.52, P<0.01) but was not significantly correlated with other layers in patients with asthma.Conclusions: The evaluation of the bronchial mural structure using EBUS might be advantageous for assessing the relationship between airway wall remodeling and bronchial hyperresponsiveness.
Crohn disease (CD) is a multisystem disease with a variety of intestinal and extraintestinal manifestations. Many forms of pulmonary involvement have been described with CD. In this bronchoscopic image, we present a case of tracheobronchial involvement in CD with uncommon findings on both bronchoscopic and histopathologic examinations. We also discuss the correlation of these unusual findings with the pathology of the disease.
Background: Children with chronic lung diseases are vulnerable to develop bacterial colonization of their distal airways. The aim of this study was to assess role of flexible bronchoscopy to determine distal airway microbial colonization and inflammation in children with chronic lung diseases compared with conventional methods.Methods: Bronchoalveolar lavage fluid (BALF), sputum, and blood samples were collected from 10 healthy and 30 children with chronic lung diseases. All samples were subjected to microbiologic assessment, cytology assessment, and biochemical assessment of Lactic dehydrogenase enzyme and alkaline phosphatase enzyme levels as indicators for inflammation.Results: Distal airway bacterial colonization by potentially pathogenic microorganisms was detected in 73% of the children with chronic lung diseases. The most common organism was Staphylococcus aureus followed by Escherichia coli, Pseudomonas aeruginosa, and Citrobacter freundii. BALF analysis was superior to sputum (odds ratio=5.5; 95% confidence interval: 1.6-19.7, P=0.004) and blood samples (odds ratio=38.5; 95% confidence interval: 6.4-302, P=0.0001) analyses as they missed detection of many organisms. Antibiogram analysis revealed that most of Gram-negative organisms were highly sensitive to imipenem, tobramycin, ceftriaxone, Garamycin, and amikacin. Most of Gram-positive organisms were highly sensitive to vancomycin, Dalacin, and oxacillin. All patients visualized to have ongoing distal airways inflammation, even when not colonized, had higher levels of inflammatory markers and cellular loads in comparison to the controls.Conclusions: BALF sampling is a safe, technically simple procedure in children and has a significant diagnostic value compared with sputum or blood markers for distal airways bacterial colonization and inflammation.
Silicone stents are the preferred treatment for benign airway narrowing because they are easy to remove. Since Dumon described his dedicated airway silicone stent in 1990, it has been the treatment of choice for patients with benign airway narrowing. However, they have the disadvantage of potential dislodgment that may make them more difficult to seat or may result in migration. We describe our experience with a patient who required surgical retrieval of a Dumon stent that was placed 9 years earlier.
Endobronchial metastases from nonpulmonary tumors are very uncommon and sarcomas are especially unusual. Few primary mammary sarcomas have been reported and metastatic disease at the initial presentation is exceptional. We report an unusual case of complete airway obstruction resulting from distant metastasis of a primary breast sarcoma. A healthy 33-year-old woman, life-long nonsmoker, developed cough and progressive shortness of breath. A chest x-ray revealed a right upper lobe atelectasis with an approximately 6 cm in diameter round lesion as confirmed by a computerized tomography scan. A complete right lung atelectasis developed in 24 hours. Flexible bronchoscopy revealed a polypoid lesion completely occluding the right main bronchus. The tumor was endoscopically excised using endobronchial electrosurgery, initially. Pathologic diagnosis demonstrated undifferentiated sarcoma. A right upper lobectomy was performed and the surgical specimen confirmed diagnosis of synovial sarcoma. Physical examination disclosed a hard lump in the right breast and in the left mammary gland; the latter was proven to be synovial sarcoma. A whole body positron emission tomography scan was also performed which did not show any other sites of metastasis. Metastatic soft-tissue sarcoma should be included in the differential diagnosis of endobronchial metastases.
Therapeutic bronchoscopy is widely used in the management of central airway obstruction. Although various endobronchial methods are available for endoluminal lesions, it is difficult to establish complete patency when a submucosal process is present. We present a new technique of using a resector balloon that can be applied for both endoluminal and submucosal lesions. We successfully used resector balloon in 29 cases for submucosal tumoral obstruction from central airway neoplasms. We suggest that submucosal lesions can be safely and easily removed to establish adequate central airway patency with a new technique using "resector balloon.'' Larger multi-center trials are warranted.
A long-standing undiagnosed denture in the bronchus is not unknown, yet it is rare. We report a case in which a denture was lodged in the left main bronchus for 15 years. Bronchial asthma and other misleading factors delayed the diagnosis. Hemoptysis warranted bronchoscopy, which led to the diagnosis of foreign body aspiration and its removal.
Endobronchial amyloidosis consists of fibrillar proteins deposition along the airway walls, being a rare and potentially fatal condition. It is an uncommon localized form of amyloidosis with no universally accepted treatment. The authors perform a review of amyloidosis pathogenesis, clinical features of endobronchial amyloidosis, its diagnosis, and treatment options.
Bronchopleural and alveolopleural fistulae from surgical and nonsurgical causes present unique management issues. A myriad of strategies have been employed to diminish airflow through the fistulous tracts. Frequently, treatment approaches need to be individually tailored on the basis of fistula size and location and to limit morbidity associated with treatment options. In unstable patients, a combination or staging of minimally invasive and surgical approaches may be necessary. Unfortunately, necessary resources may not be readily available for emergent intervention in all cases. We describe a novel approach of predeployment length modification of a self-expanding metallic airway stent. Deployment of this modified stent completely abrogated airflow through the intractable alveolopleural fistula that caused profound respiratory failure.
Early morbidity and mortality after lung transplantation is frequently related to airway anastomotic complications. The anastomotic complications have been attributed to the lack of blood flow to the donor tracheobronchial tree in the first few hours to days after the transplantation. The establishment of systemic circulation to the airway anastomosis via bronchial artery revascularization has been shown to minimize the anastomotic complications and may also postpone the incidence of bronchiolitis obliterans syndrome. We report a case of successful bronchial artery revascularization with tracheal anastomosis in en bloc double lung transplantation.
Tracheobronchopathia osteochondroplastica (TO) is a rare benign disorder characterized by multiple cartilaginous or osseous submucosal nodules that project into the tracheobronchial lumen. The etiology of TO is unknown. Even though there are oblique references to the association between TO and malignancy, there is no convincing evidence of a relationship. Bronchoscopy is the only technique that firmly establishes the diagnosis of TO. However, even after the bronchoscopic examination, TO has been misdiagnosed. We report the case of a patient with a suspected tumoral infiltration of the trachea and 2 failed bronchoscopies. The final diagnosis was TO and small cell lung cancer. TO was the cause for a difficult transbronchial needle aspiration from mediastinal lymph nodes.
Background: Biologic lung volume reduction ( BLVR) is an experimental endobronchial treatment for advanced emphysema that reduces lung volume by remodeling damaged areas of hyperinflated lung. This article summarizes the first experience using BLVR to treat unilateral bullous disease.Methods: A 67-year-old man with very severe chronic obstructive pulmonary disease owing to advanced emphysema underwent BLVR at 8 right upper lobe (RUL) subsegmental sites during 2-treatment sessions 6 weeks apart. Response to therapy was assessed 6 weeks after initial treatment, and 6 and 12 weeks after the second treatment.Results: Six weeks after initial BLVR treatment at 4 subsegments, small improvements in spirometry, dyspnea [Modified Medical Research Council Dyspnea (MRCD) score= -1U change], and a 6-minute walk distance (6MWD=+ 76m change) were observed. Improvements at 6 and 12 weeks after repeat treatment in FEV1 (+ 20.0%, + 22.1%), FVC (+ 33.1%, + 27.6%), DLco (+ 6.4%, + 6.3%), RV/ TLC ratio (- 9.8%, - 5.1%), MRCD (- 1U, - 1 U), 6MWD (79 m, 77 m), and St George's Respiratory Questionnaire score ( total score= -5.9 U, - 2.2 U) were observed. Quantitative analysis of computed tomography imaging demonstrated a 357mL reduction in RUL lung volume, and corresponding increases in volumes of adjacent, less damaged areas of lung tissue.Conclusions: BLVR produced effective targeted lung volume reduction of a RUL bullous and improvements in spirometry, symptoms, exercise capacity, and diffusing capacity. This novel bronchoscopic technique may provide a safe alterative to bullectomy in selected patients.
An 82-year-old man presented with cough and wheeze. Chest x-ray and computed tomography of the chest revealed a right upper lobe mass that occupied the middle lung field when the patient was in upright position and moved cephalad when he was supine. At bronchoscopy, there was a significant narrowing of the right main bronchus, which totally disappeared when the patient assumed a sitting posture. At thoracotomy, the right upper lobe had no pleural adhesion, and lobectomy was performed. Pathologic examination showed tuberculosis in the lung parenchyma and also endobronchial tuberculosis.
Background: Flexible bronchoscopy is a widely used diagnostic and research tool in pulmonary medicine. As evolving techniques and technology continue to influence practice trends, it is opportune for a survey on bronchoscopy practice in Singapore.Methods: A 30-question survey related to bronchoscopy, training, and physician demographics was sent to every pulmonologist in Singapore.Results: Twenty-eight completed questionnaires out of 41 were returned giving a response of 68%. Twenty-three pulmonologists (82%) practiced in academic institution, and 5 (18%) in private practice. All pulmonologists were <= 50 years of age, and had been performing bronchoscopy for >= 5 years. All received training in flexible bronchoscopy, 9 (32%) in rigid bronchoscopy, 8 (29%) in Nd-YAG laser, 7 (25%) in brachytherapy, 6 (21%) in stent placement, 4 (14%) in electrosurgery, and 2 (7%) in endobronchial ultrasonography. The number of procedures/y performed by pulmonologists in private practice was <= 10, which was in contrast to >= 50 by those in academic institutions (P < 0.05). Chest radiograph was considered important, and most pulmonologists preferred pethidine, midazolam, or both. Majority believed guidelines were necessary, at least 50 bronchoscopies to achieve competence and 10 per year to maintain the skill.Conclusions: Results from this survey provide information that is important for the development of national guidelines pertaining to bronchoscopy practice and training in Singapore. Such guidelines will serve to help national bodies design and implement programs that assure competency in bronchoscopy.
Background: Transthoracic needle aspiration (TTNA) and core needle biopsy (CNB) are performed by a pulmonologist or an interventional radiologist (IR). Very few pulmonary fellowship programs offer training in TTNA/CBN. We compared the yield and complications of TTNA/CNB when performed by pulmonologist versus IR.Method: This was a retrospective analysis of patients that underwent TTNA/CNB from 2003 to 2007 at our institution. Procedures were performed by either, any of 5 pulmonary fellows under the supervision of any of 4 pulmonologists or by a single IR.Results: Thirty-five patients were included, 19 in the pulmonary and 16 in the IR group. There were no differences in yield (P=0.28) or complications (P=0.31) between the groups. The overall diagnostic yield was 63% for pulmonary versus 69% for IR. Malignancy was the most common diagnosis (70%). CNB was used by pulmonary in 21% compared with 50% of IR cases. The yield was higher when TTNA was combined with CBN (75% vs. 61% for TTNA alone). An on-site pathologist was present only during the pulmonary cases.Conclusions: The overall yield and complications were similar in both groups. Combining TTNA and CBN provides higher yield than TTNA alone. Obtaining expertise in CNB is of the outmost importance to maximize yield and decrease need for more invasive procedures. Pulmonary fellowship programs should continue to offer training in TTNA/CNB with an onsite pathologist where available, to achieve diagnostic yield comparable with the interventional radiologist. Those programs should develop a system to maintain proficiency for the faculty.
To the Editor: The removal of self-expanding metallic stents (SEMS) is becoming a more common clinical challenge. Recently, Food and Drug Administration warnings have been issued to warn against the use of these prostheses unless no other options are tenable, specifically in nonmalignant diseases.1 The ease of implantation and other physical characteristics of the SEMS have, in some cases, led to its inappropriate use.2 Reported complications include stent fracture, migration, difficult repositioning, or removal after deployment owing to ingrowth with either tumor or granulation tissue.3–6 Particularly, in patients with benign diseases, long-term complications are as frequent as 25% to 50% requiring removal by 16 months.7,8 Stent-related granulation is particularly difficult to manage.9,10 The reported difficulties of stent removal or replacement present unique constellations of procedure complications, episodes of primary disease relapse, treatment failure, or even death.11 To facilitate endoscopic removal of SEMS, we adopted a new technique to help free the stent from its mucosal attachments with the following approach: first, we assess the patient for location of proposed stent removal. Fully epithelialized stents generally require multimodality techniques, including rigid bronchoscopy and thermal treatments, to clear the mucosa. In the event the stent is only partially epithelialized, a stent removal may be performed under conscious sedation. In all cases, the patients' airway is entered via the oral route. Using a flexible bronchoscope and endoscopic forceps, we meticulously attempt to pull wires free of the mucosa to create a narrow “surgical plane” along the full length of the stent such that a potential space between the airway wall and the stent can be created. Then, a controlled radial expansion balloon dilatation catheter (Boston Scientific, Boston, MA) is passed through the scope and placed between the airway mucosa and the outer surface of stent. The balloon size selected is slightly smaller than the stent diameter. The stent is then separated from the airway mucosa by controlled incremental expansion of the balloon. This procedure is repeated in different areas across the perimeter to free as much of the stent from the adherent airway mucosa as possible before attempting to pull the stent. Care needs to be taken if the stent completely collapses and causes obstruction of the involved airway, the balloon must be repositioned inside the lumen of the stent and the stent lumen restored. Third, opposing walls of the metallic stent or the silk suture, if present, is then grasped with alligator or rat-toothed forceps and a gentle continuous traction is applied to pull the stent out of the airway. The actual extraction can be performed with either flexible or rigid bronchoscopic instruments. This technique allowed for successful removal of the stent intact in most cases. We find that this technique is safer and cleaner than the described technique of grabbing and twisting the stent free of the mucosa with rigid instruments.12 Depending on several factors, most importantly the clinical stability of the patient and the degree to which the stent is incorporated into the airway wall, the described technique may be performed with conscious sedation without an endotracheal tube in an incompletely epithelialized stent. We hope this approach will be a useful addition to the few existing studies that have assessed the best methods of stent removal. Reyadh Salman, MD Michael S. Machuzak, MD Thomas R. Gildea, MD Department of Pulmonary Allergy, and Critical Care Medicine Cleveland Clinic, Cleveland, OH
Airway foreign bodies may be discovered after aspiration, or less commonly, after erosion into the airway. Surgical pledgets may erode into neighboring anatomic structures, often many years after the original surgery. In this case, we describe a patient who developed chronic symptoms of dyspnea and cough and then developed an acute pneumonia because of obstruction of her right mainstem bronchus from a pledget placed 7 years earlier to control a bleeding mediastinal arteriovenous malformation. She was treated successfully with antibiotics followed by bronchoscopic removal of the pledget.
Bronchoscopic finding for endobronchial vascular diseases warrants further investigations. A 54-year-old woman presented with a 3-cm bronchial artery aneurysm of the right perihilar area. Bronchoscopic examination of the right bronchial tree exhibited extensive and severe vascular engorgement along with some submucosal vessels displaying a beaded nonpulsatile bulging. Bronchial angiography revealed no hypervascularization in the bronchial wall, confirming a diagnosis of endobronchial varices with bronchial artery aneurysm. After excision of the bronchial artery aneurysm, submucosal varices markedly improved. This is the first report of bronchoscopic appearance of bulging endobronchial varices. Bronchial varices should be considered among the differential diagnoses for bronchoscopic vascular abnormalities.
Tracheal insufflation is useful during bronchoscopy to improve oxygenation. A 75-year-old woman developed seizure during bronchoscopy resulting in desaturation. Oxygen was insufflated into the trachea; however, jaw clenching and tongue swelling limited her ability to exhale resulting in bilateral pneumothoraces. Pneumothorax owing to insufflation has been reported in children and during mechanical ventilation, especially during targeted bronchial maneuver. Bronchoscopists need to be aware that seizure can compromise exhalation sufficiently to make insufflation dangerous.
Study Objective: Location of the tumor tissue within the metastatic lymph nodes from lung cancer should be determined to improve the results of endobronchial ultrasound-guided transbronchial needle aspiration.Methods: We histopathologically investigated 128 metastatic lymph nodes (LNs), that were less than or equal to 20mm in short axis, and classified these as follows. Type I was minimal invasive metastasis, including type Ia (marginal metastasis occupying < 25% of the LN) and type Ib (marginal invasive metastasis occupying < 50% of the LN). Type II was invasive metastasis occupying 50% to 90% of the LN and type III was advanced metastasis occupying > 90% of the LN.Results: Among 72 LNs with metastatic adenocarcinoma, types I, II, and III accounted for 32%, 6%, and 62%, respectively. Among 44 LNs with metastatic squamous cell carcinoma, types I, II, and III accounted for 27%, 27%, and 46%, respectively. Ten (22%) out of 45 nodes with adenocarcinoma and 6 (24%) out of 25 nodes with squamous cell carcinoma, greater than 5mm in short axis, were classified as types Ia and Ib. Types Ia and Ib LNs have no metastasis at the center.Conclusions: In about one-fifth to one-fourth of metastatic LNs, greater than equal to 5mm and less than or equal to 20mm in diameter, of adenocarcinoma and squamous cell carcinoma, these metastases can only be detected in biopsy specimens collected from the marginal area of the LN.
