[Current possibilities in the treatment of severe stenosis of the large airways].
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Airway Obstruction↗
Biomedical subjects
H G Colt
Publications and source records attributed to H G Colt.
Endoscopic management of bronchial stenosis after double lung transplantation.
Double lung transplantation with bilateral bronchial sutures is an increasingly popular therapeutic alternative for endstage, bilateral, septic pulmonary disease; however, surgical outcome has been hampered by mechanical complications at the level of the airway anastomoses. In our institution, therefore, the protocol for surveillance includes frequent flexible fiberoptic and rigid bronchoscopy under general anesthesia in all patients. Since 1988, there were 24 double lung transplantations (mean age, 19 yr) performed at the University of Marseille Hospitals using bilateral sutures without omental wrapping. Nineteen patients had cystic fibrosis; of the ten individuals (53 percent) with cystic fibrosis who ultimately developed bronchial stenosis, six required therapeutic endoscopic intervention including dilatation or Nd:YAG laser resection. Five patients required endobronchial silicone stents. Statistically significant risk factors for postsurgical airway narrowing included young age (mean, 14.3 yr vs 24.0 yr in patients without stenosis) and prolonged mechanical ventilation prior to transplant (all five patients ventilated before surgery developed stenosis). Results of interventional bronchoscopy were good, and an excellent level of physical activity was maintained in most patients. A team familiar with all aspects of therapeutic bronchoscopy is essential to ensure proper management of airway complications in patients after lung transplantation.
Adolescent↗
Safety of interventional rigid bronchoscopy using intravenous anesthesia and spontaneous assisted ventilation. A prospective study.
STUDY OBJECTIVE: To investigate the safety of total intravenous anesthesia and spontaneous assisted ventilation during interventional rigid bronchoscopy (IRB). DESIGN: Prospective, noncomparative study. SETTING: A university hospital thoracic endoscopy and laser center. PATIENTS: Eighty-three patients underwent a total of 124 procedures (including Nd:Yag laser therapy, stent insertions, transbronchial biopsies/bronchoalveolar lavages (TBB/BALs) in transplant patients and others). Results of preanesthesia consultation, endoscopic and anesthesia intervention, perioperative complications, and time spent in recovery room were recorded prospectively. RESULTS: Respiratory complications occurred in 22 procedures (18 percent) and included severe intraoperative or postoperative oxyhemoglobin desaturations (19 cases), bronchospasms/laryngospasms (two cases), and one recurrent pneumothorax. These complications were mostly related to the endobronchial surgical procedure. Respiratory complications occurred more frequently in patients with American Society of Anesthesiologists (ASA) 3 and 4 status (p < 0.005) and in patients with a karnofsky Performance Scale (KPS) below 70 (p < 0.05). No cardiac complications were noted, although 13 patients had significant underlying heart disease. Propofol was used in 121 procedures. Etomidate was used 15 times for induction and three times for both induction and maintenance in patients with ASA status 4 or low blood pressure before induction. CONCLUSION: Total intravenous anesthesia and spontaneous assisted ventilation is a well-suited technique for IRB. Severe hypoxemia, however, may occur in approximately 15 percent of patients. This complication is usually related to the procedure itself and is easy to reverse. Propofol is well tolerated in the majority of patients but it must be used with care in patients with poor functional or cardiovascular status.
Adolescent↗
Hypoxemia vs sleep fragmentation as cause of excessive daytime sleepiness in obstructive sleep apnea.
To determine the effects of intermittent hypoxemia on daytime sleepiness in the clinical setting of obstructive sleep apnea syndrome, we enrolled seven patients in a prospective, randomized, crossover study. We had two experimental conditions with NCPAP treatment as follow: (1) to correct apneas, sleep fragmentation, and hypoxemia; and (2) to correct apneas and sleep fragmentation and at the same time, induce intermittent hypoxemia. The outcome variable, daytime sleepiness, was measured objectively with the multiple sleep latency test following completion of baseline and each treatment condition. Compared with sleep latencies in the untreated condition, both experimental treatment arms prolonged sleep latencies (p less than 0.05). We found no statistically significant differences between mean MSLT scores obtained after NCPAP treatment under hypoxemic and nonhypoxemic conditions. In summary, two nights of intermittent nocturnal hypoxemia during NCPAP treatment for OSAS did not diminish the objective improvement in daytime somnolence seen with NCPAP treatment in the absence of nocturnal hypoxemia. Results lend further support to the hypothesis relating excessive daytime sleepiness to sleep fragmentation.
Adult↗
[Lasers and endoprosthesis in bronchopneumology].
During the past decade lasers, especially the Neodymium: Yttrium-Aluminum-Garnet (Nd: YAG), have transformed interventional bronchoscopy. Recent improvements of tracheobronchial prostheses have further increased the therapeutic possibilities of endoscopy. Tracheobronchial obstruction by intraluminal tumeur, stenosis, or extrinsic compression can now be palliated successfully. The future of therapeutic bronchoscopy is bright. New techniques of optic spectroscopy will allow improved detection of laser induced tissue fluorescence. Refinements of laser technology and development of visualisation systems such as endoscopic echography and electronic videoendoscopy will lead to improved diagnostic and therapeutic capabilities.
Anesthesia, General↗
On septicemia in an adult with cystic fibrosis: neutrophil function and serum chemoattractant activity.
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Adult↗
Fiberoptic bronchoscopy without premedication. A retrospective study.
The objective of this study was to determine if flexible FOB could be performed safely without premedication other than topical anesthesia. A total of 281 procedures performed during a 12-month period at a VA medical center were reviewed. Ninety-one procedures performed without premedication were compared with 190 procedures performed with premedication. Complications occurred in 5 percent of patients in each group. Statistical analysis revealed no significant differences in age, spirometry, P(A-a)O2 or SaO2 between both groups. Despite the proven safety of outpatient FOB without sedation, many bronchoscopists administer complicated premedication regimens and employ ambulatory surgery beds or recovery rooms to monitor patients before and after procedures. These results support a simplified approach to routine FOB which would include no premedications and greater use of outpatient facilities resulting in decreased expenditures without compromising patient care, safety or comfort.
Adult↗
Attitudes of patients and physicians regarding physician dress and demeanor in the emergency department.
To compare the opinions of patients and physicians regarding physician dress and demeanor in the emergency department, we conducted a cross-sectional survey of 190 ED patients and 129 medical specialists, family practitioners, surgeons, and emergency physicians in a community hospital. Seventy-three percent of physicians and 43% of patients thought that physical appearance influenced patient opinion of medical care. Forty-nine percent of patients believed emergency physicians should wear white coats, but only 18% disliked scrub suits. Patients were more tolerant of casual dress than were physicians. Both groups disliked excessive jewelry, prominent ruffles or ribbons, long fingernails, blue jeans, and sandals. Opinions and practices of emergency physicians were similar to those of other medical specialists. Most physicians (96%) addressed patients by surname or title, but 43% of patients preferred being called by their first names. The age, gender, income, and education of patients did not influence how they wished to be addressed. Larger studies are needed to assess the influence of age, sex, race, and depth of feeling regarding first-name address and physician attire in the ED.
Attitude↗
Drug-induced illness as a cause for admission to a community hospital.
To assess the rate of occurrence of drug-induced illness as a cause for admission to the general medicine service of a community hospital, charts were reviewed retrospectively of all patients admitted to the service over two randomly selected one-month periods. Statistical analysis was performed on patients over and under the age of 65, and on iatrogenic and noniatrogenic admissions. Twenty-three of 244 patients (9.4%) were admitted with drug-induced illness. Patients with drug-induced illness had 5.7 medications as compared to 3.2 medications per patient admitted for other reasons (P less than .05). A single drug was responsible for 61% of all drug-induced illness admissions. Aspirin and other nonsteroidal anti-inflammatory agents were most often implicated. Eighteen of 155 elderly patients (11.7%) were admitted with drug-induced illness. These patients were on an average of 6.3 medications as compared with 3.8 medications per elderly patient admitted for other causes (P less than .005). Polypharmacy and a preponderantly elderly population may explain the substantial number of admissions caused by adverse drug reactions. Further research to assess the role of patient age and the number and type of medications involved in the event of drug-induced illness requires standardization of definition and diagnostic criteria.
Adult↗
Cholesterol emboli after cardiac catheterization. Eight cases and a review of the literature.
Cholesterol embolization is a puzzling event that may be increasingly iatrogenic in origin. Diagnosis is difficult and requires a high index of suspicion, an appropriate clinical picture, and usually, confirmation by biopsy. Certain laboratory abnormalities may be helpful; the elevated sedimentation rate and relative eosinophilia found in our patients concurs with other cases reported in the literature. Prognosis is related to the extent of systemic involvement, but renal disease is particularly threatening and gangrene and infection can be lethal. Multiple therapeutic regimens have been generally unsuccessful in altering the course of the disease process. The most significant impact on the disease can be made by its prevention. Cholesterol emboli occur spontaneously, but also after invasive aortic procedures such as diagnostic angiography or cardiovascular surgery. In addition, cardiac catheterization and percutaneous transluminal coronary angioplasty have the potential for arterial trauma and consequent cholesterol embolization. Although the apparent increasing numbers of cholesterol emboli may be a reflection of the increased use of arterial invasive procedures, they are being performed on an older, more severely ill population, with other risk factors for the development of embolic phenomena, i.e., age, smoking history, diabetes mellitus, hypertension, and peripheral vascular disease. Our observed cases and review of the literature do not furnish information concerning the comparative incidences of embolization as related to the suggested etiologies. Careful documentation of the clinical situation preceding the event, the type of procedure, the site of arterial entry, and the duration, difficulty, and extent of the intravascular invasion (i.e., above or below the left subclavian artery) are necessary for this purpose. Such data should help to develop guidelines for patient and procedure selection in order to minimize the possibility of cholesterol embolization.
Aged↗
Bilateral renal cell carcinoma.
Renal carcinoma is frequently detected incidentally during abdominal ultrasound studies or computed tomographic scanning. Although clinical studies report bilateral tumors in fewer than 4 percent of patients with renal carcinoma, an autopsy study has shown a much higher incidence. Various surgical approaches are available.
Carcinoma, Renal Cell↗
AIDS and cardiomyopathy.
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Acquired Immunodeficiency Syndrome↗
The perspective of junior medical residents.
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Attitude of Health Personnel↗
Double stents for carcinoma of the esophagus invading the tracheo-bronchial tree.
Extrinsic compression, neoplastic involvement of the trachea or left main bronchus, and esophago-airway fistula may cause airway obstruction and infection in patients with esophageal carcinoma. Further reduction of airway lumen may result from palliative treatment of dysphagia by radiation or esophageal stent insertion. In order to evaluate the extent of airway compromise, bronchoscopy was systematically performed in 39 consecutive patients with advanced carcinoma of the esophagus requiring esophageal endoprostheses. Airway obstruction observed in 10 patients (mean age, 60 years) resulted in the additional placement of a silicone stent in the trachea (five patients) or left main bronchus (five patients). Esophageal and airway procedures were performed under general anesthesia. All had squamous cell carcinoma of the middle third of the esophagus. Severe dyspnea at rest was documented in five patients prior to intervention. Esophago-tracheal fistula was present in five. Eight patients with associated, neoplastic invasion of the tracheo-bronchial tree required airway Nd:YAG laser therapy. The esophageal prosthesis contributed significantly to airway compromise in four patients. Symptomatic relief of dysphagia and dyspnea was obtained in all individuals. Mean survival was 121 days (range, 12 to 350 days). Complications were not serious, but included esophageal or tracheal stent migration in three patients.
Bronchial Diseases↗
Necrotizing tracheitis caused by Corynebacterium pseudodiphtheriticum: unique case and review.
The occasional pathogenicity of nondiphtheria corynebacteria in both immunocompetent and immunocompromised individuals is now well established. Previously described sites of infection include heart valves, wounds, urinary tract, and lungs. This report of necrotizing tracheitis caused by Corynebacterium pseudodiphtheriticum illustrates the widening spectrum of infections caused by these organisms. A 54-year-old man developed respiratory distress and symptoms of upper airway obstruction unresponsive to inhaled bronchodilators, systemic corticosteroids, or intravenous erythromycin. A spirometry flow-volume loop demonstrated fixed upper airway obstruction. Fiberoptic bronchoscopic examination revealed a circumferential inflammatory process partially occluding the tracheal lumen. Gram staining revealed gram-positive rods typical of corynebacteria, and cultures of tracheal tissue yielded C. pseudodiphtheriticum resistant to erythromycin and clindamycin. There was no clinical or laboratory evidence for exotoxin or cell-associated toxins. Treatment with intravenous penicillin resulted in resolution of the inflammatory process and eradication of the organisms, as assessed by subsequent cultures.
Airway Obstruction↗
Size matching in lung transplantation.
Volume concordance between donor lungs and the chest cavities of transplant recipients has important perioperative and postoperative implications. Between December 1987 and August 1991, 90 patients underwent lung transplantation in the Joint Marseilles-Montreal Lung Transplantation Program: 51 patients had double lung transplants, 19 patients had single lung transplants, and 20 patients had heart-lung transplants. There were 18 children (age range, 7 to 17 years) and 72 adults (age range, 18 to 58 years). Size matching was based on measurement of the submammary thoracic perimeter. Patient age (+/- 2 years) was also taken into consideration in children. Airway anastomoses were bronchial except for all heart-lung transplant patients and two double lung transplant patients, who had tracheal anastomoses. Occasional differences between donor and receiver bronchial diameters in children (greater donor size twice and smaller donor size once) required bronchoplasty in three instances. Healing was normal in these three instances, and no bronchial stenoses were noted. Performance of separate sutures rather than continuous running sutures on the cartilaginous anterior portion facilitated correction of airway diameter inequalities in adults. Excess volume was noted in three patients during closure of the thorax. In one patient, donor and recipient thoracic perimeters were similar. In two patients, however, donor size was greater by more than 20%. This was corrected by pneumoreduction with a surgical stapler. Lung size was decreased by 10% to 40% with use of this technique. Thoracic closure was facilitated and hemodynamic instability was thus corrected. No functional abnormalities were noted after surgery once the differences in lung size were corrected.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗