- Email: [email protected]
Bronchoscopy
Tuesday, October 28, 1997 ARDS/Lung Injury, continued -5, -3, 0 (initiation of tr eatm ent), +3, +5, + 7, + 10, and + 14 of MPT . Plasma IL-lO levels wer e measur ed using ELISA methodo logy. We analyzed changes in IL -lO levels over time in relation to improvements in LIS, final outcom e, and response to MPT . Re sults: On day 1 of ARDS , plasma IL- lO levels we re higher in patie nts with shock (28 1:!:: 43 vs 53:!::33; p < O.OOOl) and septic shock (352:!::5 1 vs 68 :!:: 29; p=0.OO2). In th e early ph ase of ARDS, plasma IL-lO levels were significantly higher on days 3 (9 1:!:: 39 vs 44 :!:: 27; p = 0.045) and 5 (l 06 :!::38 vs 34:!::28; p = 0.012) in pa tients who spontaneous ly improved LIS, while those failing to improve LIS had a significant redu ction by day 3 (P = 0.04) and 5 (P = 0.002). MPT was associated with a significant (P = 0.04) increase in plasma IL-I0 levels by day 3-5 of treatment , and this increase was sustained over tim e. Con cl us io ns : Th ese findings suggest th at endoge nous lL-lO may have a role in modu lating resolution of pulm onary inflammation in ARDS and th at MPT increases circulating l L-lO levels. Clinical Implications: lL-lO is import ant in the resolution of ARDS and can be increased with pro longed MPT . Supp ort ed by Gene ral Clinical Research Ce nter Grant MOlR ROO211 and a gran t from the Schering Plough Research Institute. PROSP E CTIVE ANALYSIS O F A KE TOCO NAZO LE PRA CTICE GUIDELINE IM PLEMENTATION FOR ADULT RESPIRAT ORY DISTR E SS SYND ROME PROPHYLAXI S Tasnim Sinuff, JC Pet er son , S Caldwe ll, D Cook, H Fuller-McMaster University, Hamilton , Ontario, Can ada Pu rpose: (I ) To de velop an evide nce-base d practice guide lme (PG) base d on two rigorou s randomized controlled trials (RCTs) suggesting Ad ult Respiratory Distress Syndrome (ARDS) preven tion with ketoconazole, (2) To determine whe the r a ketoconazole PG impleme ntation for ARDS prophylaxis changes its utilization for, and incidence of ARDS. (3) To document physicians ' views on the utility of ketoconazole in ARD S prophylaxis, both pre- and po st- PG implementation . Me thods : A ketoconazole PG for ARDS proph ylaxis was developed, disseminated, and implemented, the n studied prospectively at St. Josep h's Hospital Intensive Ca re Unit (lCU ) bet ween Novembe r 1996 and June 1997. House staff, attending ph ysicians, and nur ses received standa rdized ed ucational sessions. Patients wer e exclude d if age less tha n 18 yea rs, pr egnant, cirrhotic, history of hepatitis, hep atic failure , elevated liver enzymes grea ter th an twi ce norm al, or ARD S on admission. McM aster IC U was the control. Th e study had a power of 95% and alph a 1% to detect a 20% differen ce in ARD S developm ent with ket oconazole prophylaxis. House staff and atte nding physicians at the study hospit al completed quest ionnaires regarding ket oconazole in ARDS prophylaxis. Re sults: A priori, staff physicians' views: 100% aware of priorketoconazole studies for ARDS prophylaxis, 86% believed in utility, 72% thought it should be a standard ord er. To date, resu lts from 40 patient s (20 per hospital) reveal that use of keto conazole is 57% compared to 5% (p< 0.000 l) , with ARDS incid ence 7% and 33% (p <0.05) in the stu dy and control hospitals, respect ively. Hou se staff views: 60% aware of prio r studi es pr e- PG implem ent ation ; after rotation 75% believed th ey had increased their use of ketoconazole (p= NS). Conclusions: (l ) Impl ementation of an evidence- base d PG significantly increased ketoconazole use . (2) ARD S incidence decreased concurrently (p<0.0.5 ). (3) House staff percepti on of incr eased ket ocon azole use was reflected in actual pr escript ion patterns. Clinical Implica tions: E ffective implemen tation of a practice guideline in th e IC U may enhance th e utilization of a th erapeu tic measure. TRANSFORM ING G ROWTH FACTO R-AL PHA: RO LE OF ALTERED PRODUCTION, ACTIVATION AND BI NDING IN REPAIR OF LUNG INJURY Georges S Yacoub, A Maju mdar, and BA Dubaybo-Pulmonary/C ritical Ca re Med ., VAMC and Wayne State University Schoo l of Medicine, Detroit, MI
Me thods : Lung injury. Unilateral lung injury was induced in rats by left sided intratra cheal instillation of paraqu at. Total Tyr -K and EG F-R Tyr-K activity. Tyr-K activi~ of immu noprecipitated lung EGF-R was measured in the presence of 3 P-ATP by autoradio graphy and den sitomet ry after SDS-PAGE separation of ph osphorylated immunoprecipitates before and after incubation with T GF-o:. Total Tyr-K activity was measured by 32p_ATP incorporation. Recept or Ident ification. 96-well plates were coated with lung homogenates and EGF -R levels were quanti fied using a direct ELI SA. TGF -a Levels. Similarly, TGF- a levels in lung homogenates were quanti fied using a direct ELISA. Statistical Analysis. Student's t-test with p <0.05. Re sults: Total Tyr -K activity increased with a measur ed peak dem onstrated on day 3 after injury . Patt ern of expression of EG F-R was similar, and EGF -R Tyr -K activity doub led as early as day 1 in the injur ed group, with a peak (4 times control) det ected on day 3 afte r injury. Incubation of T GF - 0: with these homogenat es in vitro resulted in furth er activation of EGF-R Tyr-K (maximal on day 3). TGF-o: levels were redu ced on day 1 after injury with gradual increas e subsequ ently. Co ncl usions: EGF-R expression, its Tyr-K activity and responsivene ss to TGF - 0: . increase during th e early ph ases of repair follmving fibrotic lun g injury. Th e concomitant increase in cell proliferative activity and the eventua l developm ent of fibrosis indicate th at TGF - 0: and its receptor may play a mechanistic role in pathogenesis of pulmonary fibrosis. Th e different patterns in changes in TGF-a and its receptors suggest that th ey are indep endent ly regulated .
Bronchoscopy IS C HEST X-RAY NEEDED ROUTINE LY AFTER EVERY TRANSBR O NCHIAL LUNG BI OPSY (TBL B)? Getachew M Afre, MD ; EA Hamda, MD ; W Davis, MD , FCCP; S Hassan, MD, FCC P- Howard University Hospital, Dep artm ent of Med icine, Division of Pulmonary and Critical Care Med icine, Washington, DC Purpose : A chest x-ray is routin ely ordered afte r every TBLB to look for the occurr ence of pn eu moth orax. In this study, a re trospec tive analysis of medical record s was conducted to determin e the need for ches t x-ray after every TBLB . Me thods : Th e medical reco rds of all 130 patient s who und erwent fibro bro nchoscoy between June 1995 and Septe mbe r 1996 were reviewed . Out of th ese, the chart s and chest x-ray results of those patient s who were subjec ted to TBLB were scrutinized for the occurrence of pn eumotho rax as a complication of th e procedure . Re sults: Transbronchial lung biopsies were done on 29 of the 130 patients. Ther e were 17 males and 12 females. Th e mean age was 56 years with SD of 15; th e youngest being 27 and the olde st 83. The commonest indic ation for bronchoscopy was suspicion of malignancy (48%), followed by PCP (27%) and Sarcoidosis (10%). One patient developed asymptomatic pn eum oth orax th at did not requ ire any intervent ion. Conclus io n : This review as well as pr evious rep orts from our instit ution and other cente rs, have dem onstrat ed th at th e incidence of pneumoth orax afte r TBLB is low. Th er efore, routinely obtaining chest x-ray after each procedure may not be necessary. Clinical Implicati o n: Minimizing unnecessary investigations will help reduce health care cost. D IAG NOSTI C AND COST E FFICACY OF POST-BR O NCHOSCOPIC RADIOGRAPHIC EVALUATION James H Hen derson II MD , Carlos Morales MD, David Thornton MD , Den nis Lawlor MD FCCP , Stephen Derd ak DO FCCP- Wilford Hall Med ical Center, Lackland AF B, TX
Purpose: Previous work demonstrated th at transformi ng growth factor alph a (TGF-a ) overexpression in a tran sgenic mouse model is associated with lung fibros is. T GF-o: is a ligand for Epid er mal Growth Factor Receptor (EG F-R) which possesses tyrosine kinase (Tyr-K ) activity. It is unclear to what exten t EGF-R activation plays a role in lung fibrosis. Th e purpose of this study is to investigate changes in the pro duction ofTGF-a and EGF -R and their potential role in modulating the fibrot ic response.
Purpose : Standard of care for post-b ronchoscopy assessme nt of pn eu mothorax has long been conve ntional PA chest radiograph. We stu died the efficacy of using screen ing chest fluoroscopy in pa tients who required fluoroscopy as an aid in diagnosti c bronchoscopy for accuracy in identi fying postp rocedure pneum othorax when compare d to conventional chest x-ray. Me thods: All patient s from 1 Janu ary 1996 to 13 May 1997 und ergoing fluoroscopic guided tran sbron chial lun g biopsy were includ ed . Fluoroscopic screening was performed postbron choscopy by real tim e scanning
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Abstracts of Original Investigations, CHEST 1997-Poster Presentations
Tuesday, October 28, 1997 Bronchoscopy, continued of the entire biopsied hemithorax and paramediastinal and apcx of the contralateral hemithorax (additional scan time limited to 30 seconds or less). 1-2 hours posthron choscopy, a PA chest x-ray was also performed if fluoroscopy was unrevealing. The results were compared and a cost analysis performed. Results: 391 total bronchoscopies were performed during the evaluation period of which 184 were accompanied by fluoroscopic use. 2 pneumothoraces were identified by fluoroscopic use. 2 pneumothoraces were identified by fluoroscopy and were evacuated by pneumocath placement. 2 other pneu mothoraces were chronic in natur e and identified on both fluoroscopy and chest x-ray with no increase postprocedur e. The remaining 180 bronchoscopies were negative for pneumothorax by modes of evaluation. Only one delayed pneumotborax occurred during this study period. Postprocedure fluoroscopy and chest x-ray were normal in this patient. Estimated cost savings possible during this period by elimination of routine chest x-ray was $18,000. Conclusion: Fluoroscopic evaluation is efficacious in diagnosing postbroncoscopic pneu mothorax. No additional patient benefit was obtained with routine cbest x-ray. Both acute pneumoth oraces were clinically suspected at the time of the procedure. Significant cost savings can be obtained by eliminating routine postb ronchoscopic chest x-ray. Additional study is needed to assess the need for radiologic postbr onchoscopic evaluation in the asymptomatic patient. Funding: Wilford Hall Medical Center Pulmonary Research Fund.
cystic carcinoma, schwannoma, thyroid carcinoma, colon carcinoma, ovarian carcinoma, renal cell carcinoma, lung carcinoma); 4 had benign lesions. Tumor locations were: trachea (5), main bronchus (3), trachea and bronchus (2), larynx, trachea and bronchus (1); eight lesions were greater than 85% obstructive. Results: The LMA was inserted uneventfully in all patient s. Median procedure time was 50 minutes (range 20 to 365 minutes). Thr ee patient s had complications: transient stridor, lung atelectasis and myocardial ischemia. Symptomatic improve ment was excellent (6), good (3), fair 0), unimproved (1). Four patient s without excellent results underwent second treatment s. Results were excellent (1), good (2), unimproved (1). Conclusions: Patient s with tumors of the larynx, trachea, or mainstem bronchi, and in whom laser therapy is required, the LMA is an excellent device to safely and quickly secur e the airway. This device can provide controlled access to the entire airway including the laryns and upper trachea which cannot be visualized if an endotracheal tube is used. Clinical Implications: Endotracheal intubation with an orot racheal tube or rigid bronchoscope, the standard techniques for airway control when laser therapy of the airway is performed , is unnecessary if an LMA is used. Difficult airways can be more readily handled with an LMA than standard method s, and lesions of the larynx, trachea, and bronchi can be managed without an obstructed view that can occur with rigid bronchoscopy or endotracheal intubation.
LARYNGEAL MASK AIRWAY FACILITATED FIBEROPTIC BRONCHOSCOPY WITH BRONCHOALVEOLAR LAVAGE IN YOUNG CHILDREN Hari PR Bandla, MD , Donald E Smith, MD, Michael P Kiern an, MD-Tulane University School of Medicine, New Orleans, LA, USA Purpose: Diagnostic and therapeutic use of bronehoalveolar lavage (BAL) with flexible fiberoptic bronchoscopy (FOB) is increasing in children. Infants and young children with bord erline cardiopulmonary reserve are potentially at risk for complications via the traditional transnasal approach with sedation. Nonbronchoscopic suction cathete r lavage may not be effective for focal pathology. Passage of 3.5 mm pediatric FOB with suction channel requires 2:4.5-5 mm endotracheal tube which often is not suitable in children <4 yr old. The aim of the study is to assess the efficacy and safety of Laryngeal mask airway (LMA) facilitated FOB with BAL in infants and young children. Methods: 21 consecutive patients (pts) were observed. Procedures were done in the operating suite under general anesthesia plus torical anesthesia. Size 1-2.5 LMAs were used. A 3.5 mm FOB was used in al pts. Intra- and postoperative complications were recorded. Result" Mean age: 12.5 (2-48) months, mean weight: 8 (2.1-11.3) kg. 10/21 pts had significant pulmonary disease. LMA placement was difficult in 1 pt requirin g change from size 2 to 1. Two pts had laryngospasm and bronchospasm, 1 pt had transient O2 desaturation resolving with deepened anesthesia and positive pressure ventilation. LMA failed in one pt necessitating endotracheal intubation. BAL was successful in 20/21 pts. No serious complications occurred. Conclusions: GA via LMA facilitates safe FOB and BAL in young children. Clinical Implications: Improved airway management and provision of ventilatory support makes BAL via LMA safe, effective in pts with poor cardiopulmonary reserve. Support: Maternal Child Health Bureau MCJ-22Yl63. THE LARYNGEAL MASK AIRWAY: A VALUABLE ADJUNCT FOR LASER BRONCHOSCOPY OF OBSTRUCTIVE TUMORS Jonathan C Nesbitt, MD; DZ Ferson, MD; GL Walsh, MD; DS Schrump , MD ; SG Swisher, MD; KK Nesbitt, MD; JB Putnam-The University of Texas M D Anderson Cancer Center, Houston, Texas, USA Purpose: For patients with obstructive tracheobronchial tu mors, optimal control of the airway duri ng inspection and laser therapy remains a challenge. The laryngeal mask airway (LMA) can easily secure the airway and has qualities that provide easy access of the entire airway to facilitate laser treatment. Materials and Methods: Eleven patient s, 5 men and 6 women, underwent 16 laser bronchoscofY treatments for tracheal or mainstem bronchial lesions using genera anesthesia, the LMA, and a flexible fiberoptic bronchoscope, Seven patient s had malignant lesions (adenoid
DOES BRONCHOSCOPY ADD TO CHEST COMPUTER TO MOGRAPHY (CT) SCAN IN STAGING ESOPHAGEAL CANCER? Maher Bazarbashi*, Tarek Amin", Souki Bazarbashi*, MohamIj}ed Khalid*- * Departm ent of Medicine, + Departm ent of Surgery and Department of Oncology, King Faisal Specialist Hospital and Research Center , Hiyadh, Saudi Arabia Introduction: The lungs and thc airways are commonly invaded by esophageal cancer. Up to 12% of patients with squamous cell-type get broncho-eosophageal fistula. Objective: To examine the yield of conventional chest CT vs bronchoscopy in detecting bronchial tree involvemen t, ten patient s aged between 45-75 with proven diagnosis of esophageal cancer were studied by CT chest 0 cm cut) and bronchoscopy under local anesthesia with cytological examination of bronchial wash and bru sh. Results: Invasion Diagnosed hy Br
Tumor location
1 2 3 4 5 6 7 8 9 10
23 cm 19-23 23 cm 22 cm 38 cm 22-30 18 em 22-30 19-26 24-30
I
CT
Bronchoscopy
No No No No No No Yes No No No
No Yes No No No No No No No Yes
I
Cytology
+
+ +
Chest CT was not diagnOStiC of tracheal involvement in any case. Bronchoscopy and cytology proved invasion in 3/10 cases. Tumor that tends to invade is located HJ-30 cm from incisors. One patient had proven invasion by cytology with no mucosal abnormality. Conclusion: Bronchoscopy and cytology are useful in the workup of eosophageal carcinoma even if there is no visual evidence of mucosal changes. CT scan chest is less sensitive than bronchoscopy for airway invasion. CHEST / 112 / 3/ SEPTEMBER, 1997 SUPPLEMENT
595
Tuesday, October 28, 1997 Bronchoscopy, continued CLINICAL EVALUATION OF THE VISION SCIENCES FLEXIBLE BRONCHOSCOPE & ENDOSHEATH SYSTEM John F Beamis, MD, FCCP , PM Mathur, MBBS, FCCP, H. Colt, MD, FCCP , J Harrell, MD, FCCP-Lahey Hitchcock Medical Center, Burlington, MA, IU Medical Center, Indianapolis, IN, UCSD Medical Center, San Diego, CA USA Purpose: A prototype fiberoptic bronchoscope system has been developed that utilizes a disposable sheath to cover and protect all working surfaces from contamination. The reusable part contains fiberoptic bundles, a steering mechanism and eyepiece. The working channel for suctionlbiopsy and the suction mechanism are incorporated in a disposable sheath which is removed after each use to provide each patient with a contamination-free endoscope . A prospective trial was performed to evaluate this new bronchoscope sheath system in the bronchoscopy services at thre e tertiary teaching hospitals. Methods: Clinical evaluations of the prototype bronchoscope system were performed by three bronchoscopy teams. Rating scales from I (poor) to 5 (excellent) were used to record evaluations of endoscope performance after each procedure . Parameters include image clarity, illumination, fogging, handle comfort, ease of passage and suctioning. Results: Performance ratings were greater than 4.0 (range 4.06-4.59) for each of the above categories except for handling comfort (mean 3.88± 0.70). Nineteen procedur es were evaluated. Conclusions: The prototype bronchoscope and Endosh eath System performed well in all parameters evaluated. The highest scores were obtained for image clarity (4.53) and illumination (4.59). Handling comfort was rated average, likely resulting from a need for adaptation to the "feel" of the new bronchoscope . Bronchoscopists felt that the new bronchoscope performed adequately for suctioning and in the use of accessory instrume nts. Clinical Implications: This bronchoscope has the potential to reduce scope downtime by eliminating routine high level disinfection between procedures. Exposure of staff to chemical germicides is also reduced . Scope degradation associated with repeated disinfection processes and working channel damage due to procedures such as TBNA are also eliminated. This new bronchoscope system promises to be complementary to existing bronchoscopy practices. PROFOUND PROLONGATION OF THE PROTHROMBIN TIME DOES NOT PREDISPOSE TO ENDOBRONCHIAL BLEEDING WITH BRONCHOSCOPIC LUNG BIOPSIES IN A PIG MODEL David A Brickey, DO, D Lawlor, MD, FCCP-Wilford Hall Medical Cente r, Lackland AFB, TX, USA Purpose: Endobronchial bleeding followingbronchoscopic lung biopsy can be a life-threatening complication. The ability of screening coagulation tests to predict clinical bleedin g is poor regardless of a patient's history of a coagulopathy. We used a pig mode\, administered escalating doses of warfarin, and repeated bronchoscopic biopsies to identify a level of coagulopathy that would predict serious bleeding. Methods: Anesthetized Yucatan mini-swine (Sus scrofa) initially underwent fiberoptic bronchoscopy (FOB) and transbronchial biopsies (TBBx) to establish a baseline bleeding risk. A P30 Olympus bronchoscope and Microinvasive 2.2 mm alligator forceps were used via a 7.5 mm endotracheal tube in an anesthetized animal with fluoroscopic guidance. Biopsy specimens were examined histologicallyto confirm alveolar tissue. Endobr onchial bleeding was graded as Significant if > 100 ml. Animals were then administered escalating doses of warfarin, starting at 0.08 mglKg, to prolong the prothrombin time (PT). Repeat TBBx was then perform ed and the amount of hemorrhage and complications was recorded. Results: Eighteen Yucatan mini-swine were enrolled in the study. Seventeen animals had bleeding :510 ml followingTBBx. One animal was noted to have 65 ml of endobronchial bleeding. Four deaths were recorded . The cause of death was anesthetic related in one, and spontaneous abdominal hemorrhage in the remaining three. There was no Significant hemorrh age at the TBBx sites. The study was terminated when no significant endobronchial bleeding was noted with INR's > 7. Concluslonss Despite profound prolongations of the PT (INR>7), Significant endobron chial bleeding did not develop in any animal. Three animals died from spontaneous abdominal hemorrhage. Clinical Implications: To date the Yucatan mini-swine coagulation system has not been found to differ from humans in applicability of INR system of measuring coagulopathy. PT prolongation alone poses no
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significant risk to endobronchial bleeding with FOB TBBxin a pig model. By extension, humans would be expected to also be at low risk of endobronchial bleeding despite isolated prothrombin prolongation. USE OF THE FLEXIBLE BRONCHOSCOPE TO REMOVE ENDOBRONCHIAL FOREIGN BODIES: THE CLEVELAND CLINIC EXPERIENCE A Dasgupta MD, P Jain MD, K Stelmach RRT, JK Stoller MD, AC Mehta MD-The Cleveland Clinic Foundation , Cleveland, Ohio Background: Airway foreign bodies (FB) can cause serious and at times, life-threatening complications. Although most authorities advocate rigid bronchoscopy (RB) to remove inhaled FB, we have amassed experience using the flexible bronchoscope (FFB) for FB removal and report this experience here. Methods: This study includes all adult patients who underwent FFB to remove airway FB in our department over the last 15 years. A retrospective chart review identified the following features: demographic profile, conditions that may have predisposed to FB aspiration, clinical presentation, chest roentgenogram findings, number , location and the type of FB removed, accessory instruments used to extract FB in each case, and complications. The procedure was considered successful if the FB was removed in its entirety thus averting need for rigid bronchoscopy. Results: Over 15 years, all 14 patients who presented to our department with FB underwent FFB and 25 foreign bodies were removed. Five patients had multiple FB in the airways. The mean age was57 years (range 27 to 87). Of the 25 FB, 56% were vegetable matter, 20% metallic objects and 8% dental amalgam. Substance abuse was the predisposing cause in 20%. Chest radiograph showed pneumonia in 20% and revealed the FB in 20%. Fourte en out of 25 (56%) FB were retrieved from the basilar segments of the lower lobes. Successful retrieval was achieved in 93% of patients (13/14) and for 96% of FB (24/25). Conscious sedation in the bronchoscopy suite was employed in 10/14 patients (71%), all with successful FB retrieval. In the remaining four patients, FB were removed in all but one via endotracheal tube using FFB . Three of these patients were intubated for respiratory failure. In the remaining patient both FFB and RB failed to retrieve the FB. For the 13 patients in whom FB retrieval was successful, a Fogarty catheter was used in 10 and Dormia basket in 4. Complications included one episode of transient lidocaine toxicityand one post bronchoscopic pneumonia. Conclusion: Our experience suggests that in adult patients, airway foreign bodies can be successfully removed using flexible bronchoscope under conscious sedation. Rigid bronchoscopy should be performed only when flexible bronchoscopy is unsuccessful. SEDATION WITH MIDAZOLAM DURING BRONCHOSCOPY: CLINICAL EFFECTIVENESS AND SIDE EFFECTS Shyam Ivaturi, MD, P Venkatachala, MD, F Butt, MD, H Amin, MD-Department of Medicine, Interfaith Medical Center, Brooklyn,NY Purpose: To clarify the safety profile of intravenous (iv) midazolam as sedation during bronchoscopy. Methods: 40 patients undergoing bronchoscopy were randomized into two groups. Group B (n = 20) received 1-2 mg of iv midazolam as premedic ation whereas group A (n= 20) did not. Average age of patients in the two groups were 47 and 46 years respectively. Mental status, pulse rate (PR), blood pressure (B.P) respiratory rate (RR) and arterial oxygen saturation (Sa0 2 ) by pulseoximetry were measured in all patients before the procedure, at the end of the procedure and at 2 hours thereafter. Results: There was no Significant difference in the PR (p> O.I) , RR or Sa02 in the two groups at baseline, end of the procedur e or 2 hours thereafter. The average mean arterial pressure (MAP) though higher in group B was not statisticallysignificant (p>0.10) and returned to baseline 2 hours after the procedure . The average duration of procedure in groups A and B for bronchoscopy with biopsy was 46 minutes and 31 minutes (p< 0.05) while that for bronchoscopy without biopsy was 26 minutes and 9.6 minutes (p< 0.05) respectively.8 patients in group A (40%) compared to none in group B demonstrat ed some degree of agitation. Conclusions: Administration of midazolam as premedication prior to bronchoscopy improved compliance and shortened the duration of the procedure without causing any significant respiratory or hemodynamic compromise .
Clinical Implications: Use of midazolam as premedication may improve compliance and shorten the duration of bronchoscopy thereby Abstracts of Original Investigations, CHEST 1997-Poster Presentations
Tuesday, October 28, 1997 Bronchoscopy, continued improving the yield of the procedure. Concerns regarding hemodynamic and respiratory compromise may be minimized with appropriate monitoring. Before Procedure
PR MAP RR Sa02
After Procedure
2 Hours After Procedure
A
B
A
B
A
B
91.6 98.8 21.7 97.5
88.9 105 22.8 97.7
102.2 102.6 23.5 97.1
111.7 112.7 24.2 96.6
88 97 21 98
93 103 21 98
HOW DO PHYSICIANS, RESPIRATORY TECHNICIANS, AND PATIENTS RATE DISCOMFORT DURING FIBEROPTIC BRONCHOSCOPY? William Klebanskyj, I' Kupfer, D Small, E Dajczman, M Palayew, H Frank, N Wolkove, H Kreisman-Respiratory Medicine, Jewish General Hospital, McGill University, Montreal, Canada Purpose: To compare the perception of discomfort during bronchoscopy experienced by the patient (Pt) with that estimated by medical personnel (MDs, RTs). Methods: 264 Pts undergoing bronchoscopy from 94/4-96/11 completed a questionnaire immediately following the procedur e. They were pre-treated with either lorazepam , midazolam, or did not receive any pre-medication. As part of this questionnaire Pts, MDs and RTs rated the level of discomfort of the procedu re using a 10 cm. scale with O=no discomfort and lO=unbearable discomfort. Pts rated various components of the bronchoscopy as well as the procedur e as a whole. Results: Pt discomfort ratings by MDs and RTs showed excellent correlation (r= .78), however neither the rating by the MDs or RTs correlated as well with that rated by the pt (r = .45 Pt vs MD, r=.48 Pt vs RT). There was no relationship between Pt age, or length of procedur e and discomfort reported by the PI. There was no significant differen ce, (anova p=0.055) in the discomfort reported by those Pts pre-medicated with lorazepam (x= 4.3:!:2.8, n=111 ), midazolam (x= 3.6:!:2.4, n=40), and those who did not receive any pre-medication (x= 3.4:!:2.8, n=113), although there was a trend toward more discomfort following lorazepam. Pts who received lorazepam or midazolam were Significantly more anxious prior to bronchoscopy (x= 4.73, x= 5.9) than Pts without premedication (x= 3.15). Conclusions: MDs and RTs are unable to accurately estimate Pt discomfort during bronchoscopy. The use of pre-medications in this series may reflect pre procedu re Pt anxiety and thus account for the increased discomfort with use of lorazepam. Clinical Implications: Health care personnel should be aware that they may not appreciate the level of Pt discomfort during medical procedures such as bronchoscopy. Further studies which include Pts subjective evaluations are needed to deter mine the optimal pre-medication regimen. TRACHEOBRONCHIAL AMYLOIDOSIS: A SERIES OF FOUR PATIENTS WITH BRONCHOSCOPIC, SPIROMETRIC, RADIOLOGIC, AND PATHOLOGIC ANALYSIS David C Mares, MD, LS Broderick, MD, OW Cummings, MD, MD Benson, MD, PN Mathur, MBBS-Indiana University Medical Center, Indianapolis, Indiana, USA Purpose: Tracheobronchial amyloidosis represents an unusual form of isolated pulmonary amyloidosis with localized deposition of glycoproteins in the tracheobron chial tree. Our purpose is to better define this disease in its clinical, radiographic, spirometric, bronchoscopic and pathologic characteristics. Methods: Four patients with tracheobronchial amyloidosis were evaluated with chest radiography, helical computed tomography (CT) with tracheobronchial reconstruction bronchoscopy, and biopsy. Results: Patients with tracheobronchial amyloidosis usually present with obstructive phenom ena, atelectasis or recurrent pneumonia, but may have presentations mimicking asthma, CT scanning is effective in the assessment of submucosal plaques, but is augmented by the use of helical
CT airway reconstruction. Spirometry reveals patterns of obstruction. Bronchoscopy reveals submucosal plaque lesions that may be partially or completely occlusive. Endobronchial lesions seem to respond well to bronchoscopic Nd:YAG laser resection . Diagnosis is verified by positive congo red staining of histologic preparation s. Some preliminary data suggests that immunoglobulin light chain deposition may play an etiologic role in the disease process. Conclusions: This series demonstrates the modem evaluation of patients with tracheobronchialamyloidosis and possible therapeutic options. Clinical Implications: Tracheobron chial amyloidosis is unusual, may mimic other pulmonary diseases, may be evaluated with CT scanning, helical CT airway reconstru ction, or spirometry, and may be managed with bronchoscopic techniques for the removal of endobronchial tissue. MEDIASTINAL THIN NEEDLE BIOPSY: A 9·YEAR EXPERIENCE WITH 235 CASES Marjeta Tereelj-Zorman, I Kern, and M Jereb-Institute for Respiratory Diseases Golnik, Slovenia Purpose: Thin needle aspiration biopsy (TNAB) of mediastinal masses with radiological guidance and cytological evaluation has proven to be a reliable complementary method to fiberoptic bronchoscopic examination. The purpose of our review was to confirm the results on a large series and to define, if possible, the areas where the TNAB is complementary to fiberoptic bronchoscopy with transtr acheal and transbron chial biopsy. Material and Methods: In this, one of the largest series from a single institution, TNAB was performed on 235 patients with mediastinal mass. In all of them, previous work-up included bronchoscopy with transtra cheal and transbronchial biopsy which, however, failed to clarify the lesion. The TNAB needles were 22 gauge and 10-15 cm in length . Bidirectional fluoroscopy was used and the aspirates were stained according to Papanicolau or May-Griinwald-Giemsa. Results: Adequate material was obtained with a diagnosis achieved in 196 (83%) cases. Ther e were 39 (14%) false negative diagnosis, but there was no false positive diagnosis for cancer. Of these 235 patients, 60 cases had benign diagnosis, 114 of these lesions proved to be malignant mediastinal tumors, 61 patients the TNAB was performed as a part of the staging process for primary lung cancer. Conclusion: TNAB is reaffirmed as a reliable and sensitive diagnostic tool for mediastinal lesions, obviating the need for more aggressive and costly surgical approach in a sizable proport ion of theselatients . Clinical Implication: TNAB is a complementary an not a competitive method for the diagnosis of the mediastinal masses and for the staging process in lung cancer.
Cancer: Diagnosis THE RELIABLE NON-INVASIVE EXCLUSION OF MALIG NANCY IN SOLITARY PULMONARY NODULES USING A SOMATOSTATIN TYPE RECEPTOR BINDING PEPTIDE-P829 Jay Blum, H Handmaker, N Rinne, YM Baran, C Lutrin , H Abernathy-Arizona Institute of Nuclear Medicine, Cigna Healthcare of Arizona, Phoenix, Arizona and Diatide, Inc., Londonderry, New Hampshire Purpose: Many neoplasms including small cell and non-small cell lung cancers more densely express Somatostatin Type Receptors than granulomatous and other non-malignant processes. This study evaluated the utility of this phenomenon in the non-invasive differentiation of malignant and non-malignant solitary pulmonary nodules. Me thods: 1'829 is a unique low molecular weight somatostatin type receptor binding polypeptide. The radiopharmaceutical Techn etium Tc99m-P829 was utilized for scintigraphy including Single Photon Emission Computed Tomography. Seventeen individuals, 10 female, 7 male, mean age 55, with solitary pulmonary nodules of 1 centimeter or greater underwent simultaneous Comput ed Tomography and 1'829 Scintigraphy. Tissue diagnosis was then established by transthoracic needle biopsy or thoracotomy. Results: Ten patients demonstrated intense uptake in region of the pulmonary nodules seen on chest film. In nine subjects, the final diagn osis of malignancy was established. One patient had a granulomatous process CHEST / 112 /3/ SEPTEMBER, 1997 SUPPLEMENT
6 15
Me thods : Lung injury. Unilateral lung injury was induced in rats by left sided intratra cheal instillation of paraqu at. Total Tyr -K and EG F-R Tyr-K activity. Tyr-K activi~ of immu noprecipitated lung EGF-R was measured in the presence of 3 P-ATP by autoradio graphy and den sitomet ry after SDS-PAGE separation of ph osphorylated immunoprecipitates before and after incubation with T GF-o:. Total Tyr-K activity was measured by 32p_ATP incorporation. Recept or Ident ification. 96-well plates were coated with lung homogenates and EGF -R levels were quanti fied using a direct ELI SA. TGF -a Levels. Similarly, TGF- a levels in lung homogenates were quanti fied using a direct ELISA. Statistical Analysis. Student's t-test with p <0.05. Re sults: Total Tyr -K activity increased with a measur ed peak dem onstrated on day 3 after injury . Patt ern of expression of EG F-R was similar, and EGF -R Tyr -K activity doub led as early as day 1 in the injur ed group, with a peak (4 times control) det ected on day 3 afte r injury. Incubation of T GF - 0: with these homogenat es in vitro resulted in furth er activation of EGF-R Tyr-K (maximal on day 3). TGF-o: levels were redu ced on day 1 after injury with gradual increas e subsequ ently. Co ncl usions: EGF-R expression, its Tyr-K activity and responsivene ss to TGF - 0: . increase during th e early ph ases of repair follmving fibrotic lun g injury. Th e concomitant increase in cell proliferative activity and the eventua l developm ent of fibrosis indicate th at TGF - 0: and its receptor may play a mechanistic role in pathogenesis of pulmonary fibrosis. Th e different patterns in changes in TGF-a and its receptors suggest that th ey are indep endent ly regulated .
Bronchoscopy IS C HEST X-RAY NEEDED ROUTINE LY AFTER EVERY TRANSBR O NCHIAL LUNG BI OPSY (TBL B)? Getachew M Afre, MD ; EA Hamda, MD ; W Davis, MD , FCCP; S Hassan, MD, FCC P- Howard University Hospital, Dep artm ent of Med icine, Division of Pulmonary and Critical Care Med icine, Washington, DC Purpose : A chest x-ray is routin ely ordered afte r every TBLB to look for the occurr ence of pn eu moth orax. In this study, a re trospec tive analysis of medical record s was conducted to determin e the need for ches t x-ray after every TBLB . Me thods : Th e medical reco rds of all 130 patient s who und erwent fibro bro nchoscoy between June 1995 and Septe mbe r 1996 were reviewed . Out of th ese, the chart s and chest x-ray results of those patient s who were subjec ted to TBLB were scrutinized for the occurrence of pn eumotho rax as a complication of th e procedure . Re sults: Transbronchial lung biopsies were done on 29 of the 130 patients. Ther e were 17 males and 12 females. Th e mean age was 56 years with SD of 15; th e youngest being 27 and the olde st 83. The commonest indic ation for bronchoscopy was suspicion of malignancy (48%), followed by PCP (27%) and Sarcoidosis (10%). One patient developed asymptomatic pn eum oth orax th at did not requ ire any intervent ion. Conclus io n : This review as well as pr evious rep orts from our instit ution and other cente rs, have dem onstrat ed th at th e incidence of pneumoth orax afte r TBLB is low. Th er efore, routinely obtaining chest x-ray after each procedure may not be necessary. Clinical Implicati o n: Minimizing unnecessary investigations will help reduce health care cost. D IAG NOSTI C AND COST E FFICACY OF POST-BR O NCHOSCOPIC RADIOGRAPHIC EVALUATION James H Hen derson II MD , Carlos Morales MD, David Thornton MD , Den nis Lawlor MD FCCP , Stephen Derd ak DO FCCP- Wilford Hall Med ical Center, Lackland AF B, TX
Purpose: Previous work demonstrated th at transformi ng growth factor alph a (TGF-a ) overexpression in a tran sgenic mouse model is associated with lung fibros is. T GF-o: is a ligand for Epid er mal Growth Factor Receptor (EG F-R) which possesses tyrosine kinase (Tyr-K ) activity. It is unclear to what exten t EGF-R activation plays a role in lung fibrosis. Th e purpose of this study is to investigate changes in the pro duction ofTGF-a and EGF -R and their potential role in modulating the fibrot ic response.
Purpose : Standard of care for post-b ronchoscopy assessme nt of pn eu mothorax has long been conve ntional PA chest radiograph. We stu died the efficacy of using screen ing chest fluoroscopy in pa tients who required fluoroscopy as an aid in diagnosti c bronchoscopy for accuracy in identi fying postp rocedure pneum othorax when compare d to conventional chest x-ray. Me thods: All patient s from 1 Janu ary 1996 to 13 May 1997 und ergoing fluoroscopic guided tran sbron chial lun g biopsy were includ ed . Fluoroscopic screening was performed postbron choscopy by real tim e scanning
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Abstracts of Original Investigations, CHEST 1997-Poster Presentations
Tuesday, October 28, 1997 Bronchoscopy, continued of the entire biopsied hemithorax and paramediastinal and apcx of the contralateral hemithorax (additional scan time limited to 30 seconds or less). 1-2 hours posthron choscopy, a PA chest x-ray was also performed if fluoroscopy was unrevealing. The results were compared and a cost analysis performed. Results: 391 total bronchoscopies were performed during the evaluation period of which 184 were accompanied by fluoroscopic use. 2 pneumothoraces were identified by fluoroscopic use. 2 pneumothoraces were identified by fluoroscopy and were evacuated by pneumocath placement. 2 other pneu mothoraces were chronic in natur e and identified on both fluoroscopy and chest x-ray with no increase postprocedur e. The remaining 180 bronchoscopies were negative for pneumothorax by modes of evaluation. Only one delayed pneumotborax occurred during this study period. Postprocedure fluoroscopy and chest x-ray were normal in this patient. Estimated cost savings possible during this period by elimination of routine chest x-ray was $18,000. Conclusion: Fluoroscopic evaluation is efficacious in diagnosing postbroncoscopic pneu mothorax. No additional patient benefit was obtained with routine cbest x-ray. Both acute pneumoth oraces were clinically suspected at the time of the procedure. Significant cost savings can be obtained by eliminating routine postb ronchoscopic chest x-ray. Additional study is needed to assess the need for radiologic postbr onchoscopic evaluation in the asymptomatic patient. Funding: Wilford Hall Medical Center Pulmonary Research Fund.
cystic carcinoma, schwannoma, thyroid carcinoma, colon carcinoma, ovarian carcinoma, renal cell carcinoma, lung carcinoma); 4 had benign lesions. Tumor locations were: trachea (5), main bronchus (3), trachea and bronchus (2), larynx, trachea and bronchus (1); eight lesions were greater than 85% obstructive. Results: The LMA was inserted uneventfully in all patient s. Median procedure time was 50 minutes (range 20 to 365 minutes). Thr ee patient s had complications: transient stridor, lung atelectasis and myocardial ischemia. Symptomatic improve ment was excellent (6), good (3), fair 0), unimproved (1). Four patient s without excellent results underwent second treatment s. Results were excellent (1), good (2), unimproved (1). Conclusions: Patient s with tumors of the larynx, trachea, or mainstem bronchi, and in whom laser therapy is required, the LMA is an excellent device to safely and quickly secur e the airway. This device can provide controlled access to the entire airway including the laryns and upper trachea which cannot be visualized if an endotracheal tube is used. Clinical Implications: Endotracheal intubation with an orot racheal tube or rigid bronchoscope, the standard techniques for airway control when laser therapy of the airway is performed , is unnecessary if an LMA is used. Difficult airways can be more readily handled with an LMA than standard method s, and lesions of the larynx, trachea, and bronchi can be managed without an obstructed view that can occur with rigid bronchoscopy or endotracheal intubation.
LARYNGEAL MASK AIRWAY FACILITATED FIBEROPTIC BRONCHOSCOPY WITH BRONCHOALVEOLAR LAVAGE IN YOUNG CHILDREN Hari PR Bandla, MD , Donald E Smith, MD, Michael P Kiern an, MD-Tulane University School of Medicine, New Orleans, LA, USA Purpose: Diagnostic and therapeutic use of bronehoalveolar lavage (BAL) with flexible fiberoptic bronchoscopy (FOB) is increasing in children. Infants and young children with bord erline cardiopulmonary reserve are potentially at risk for complications via the traditional transnasal approach with sedation. Nonbronchoscopic suction cathete r lavage may not be effective for focal pathology. Passage of 3.5 mm pediatric FOB with suction channel requires 2:4.5-5 mm endotracheal tube which often is not suitable in children <4 yr old. The aim of the study is to assess the efficacy and safety of Laryngeal mask airway (LMA) facilitated FOB with BAL in infants and young children. Methods: 21 consecutive patients (pts) were observed. Procedures were done in the operating suite under general anesthesia plus torical anesthesia. Size 1-2.5 LMAs were used. A 3.5 mm FOB was used in al pts. Intra- and postoperative complications were recorded. Result" Mean age: 12.5 (2-48) months, mean weight: 8 (2.1-11.3) kg. 10/21 pts had significant pulmonary disease. LMA placement was difficult in 1 pt requirin g change from size 2 to 1. Two pts had laryngospasm and bronchospasm, 1 pt had transient O2 desaturation resolving with deepened anesthesia and positive pressure ventilation. LMA failed in one pt necessitating endotracheal intubation. BAL was successful in 20/21 pts. No serious complications occurred. Conclusions: GA via LMA facilitates safe FOB and BAL in young children. Clinical Implications: Improved airway management and provision of ventilatory support makes BAL via LMA safe, effective in pts with poor cardiopulmonary reserve. Support: Maternal Child Health Bureau MCJ-22Yl63. THE LARYNGEAL MASK AIRWAY: A VALUABLE ADJUNCT FOR LASER BRONCHOSCOPY OF OBSTRUCTIVE TUMORS Jonathan C Nesbitt, MD; DZ Ferson, MD; GL Walsh, MD; DS Schrump , MD ; SG Swisher, MD; KK Nesbitt, MD; JB Putnam-The University of Texas M D Anderson Cancer Center, Houston, Texas, USA Purpose: For patients with obstructive tracheobronchial tu mors, optimal control of the airway duri ng inspection and laser therapy remains a challenge. The laryngeal mask airway (LMA) can easily secure the airway and has qualities that provide easy access of the entire airway to facilitate laser treatment. Materials and Methods: Eleven patient s, 5 men and 6 women, underwent 16 laser bronchoscofY treatments for tracheal or mainstem bronchial lesions using genera anesthesia, the LMA, and a flexible fiberoptic bronchoscope, Seven patient s had malignant lesions (adenoid
DOES BRONCHOSCOPY ADD TO CHEST COMPUTER TO MOGRAPHY (CT) SCAN IN STAGING ESOPHAGEAL CANCER? Maher Bazarbashi*, Tarek Amin", Souki Bazarbashi*, MohamIj}ed Khalid*- * Departm ent of Medicine, + Departm ent of Surgery and Department of Oncology, King Faisal Specialist Hospital and Research Center , Hiyadh, Saudi Arabia Introduction: The lungs and thc airways are commonly invaded by esophageal cancer. Up to 12% of patients with squamous cell-type get broncho-eosophageal fistula. Objective: To examine the yield of conventional chest CT vs bronchoscopy in detecting bronchial tree involvemen t, ten patient s aged between 45-75 with proven diagnosis of esophageal cancer were studied by CT chest 0 cm cut) and bronchoscopy under local anesthesia with cytological examination of bronchial wash and bru sh. Results: Invasion Diagnosed hy Br
Tumor location
1 2 3 4 5 6 7 8 9 10
23 cm 19-23 23 cm 22 cm 38 cm 22-30 18 em 22-30 19-26 24-30
I
CT
Bronchoscopy
No No No No No No Yes No No No
No Yes No No No No No No No Yes
I
Cytology
+
+ +
Chest CT was not diagnOStiC of tracheal involvement in any case. Bronchoscopy and cytology proved invasion in 3/10 cases. Tumor that tends to invade is located HJ-30 cm from incisors. One patient had proven invasion by cytology with no mucosal abnormality. Conclusion: Bronchoscopy and cytology are useful in the workup of eosophageal carcinoma even if there is no visual evidence of mucosal changes. CT scan chest is less sensitive than bronchoscopy for airway invasion. CHEST / 112 / 3/ SEPTEMBER, 1997 SUPPLEMENT
595
Tuesday, October 28, 1997 Bronchoscopy, continued CLINICAL EVALUATION OF THE VISION SCIENCES FLEXIBLE BRONCHOSCOPE & ENDOSHEATH SYSTEM John F Beamis, MD, FCCP , PM Mathur, MBBS, FCCP, H. Colt, MD, FCCP , J Harrell, MD, FCCP-Lahey Hitchcock Medical Center, Burlington, MA, IU Medical Center, Indianapolis, IN, UCSD Medical Center, San Diego, CA USA Purpose: A prototype fiberoptic bronchoscope system has been developed that utilizes a disposable sheath to cover and protect all working surfaces from contamination. The reusable part contains fiberoptic bundles, a steering mechanism and eyepiece. The working channel for suctionlbiopsy and the suction mechanism are incorporated in a disposable sheath which is removed after each use to provide each patient with a contamination-free endoscope . A prospective trial was performed to evaluate this new bronchoscope sheath system in the bronchoscopy services at thre e tertiary teaching hospitals. Methods: Clinical evaluations of the prototype bronchoscope system were performed by three bronchoscopy teams. Rating scales from I (poor) to 5 (excellent) were used to record evaluations of endoscope performance after each procedure . Parameters include image clarity, illumination, fogging, handle comfort, ease of passage and suctioning. Results: Performance ratings were greater than 4.0 (range 4.06-4.59) for each of the above categories except for handling comfort (mean 3.88± 0.70). Nineteen procedur es were evaluated. Conclusions: The prototype bronchoscope and Endosh eath System performed well in all parameters evaluated. The highest scores were obtained for image clarity (4.53) and illumination (4.59). Handling comfort was rated average, likely resulting from a need for adaptation to the "feel" of the new bronchoscope . Bronchoscopists felt that the new bronchoscope performed adequately for suctioning and in the use of accessory instrume nts. Clinical Implications: This bronchoscope has the potential to reduce scope downtime by eliminating routine high level disinfection between procedures. Exposure of staff to chemical germicides is also reduced . Scope degradation associated with repeated disinfection processes and working channel damage due to procedures such as TBNA are also eliminated. This new bronchoscope system promises to be complementary to existing bronchoscopy practices. PROFOUND PROLONGATION OF THE PROTHROMBIN TIME DOES NOT PREDISPOSE TO ENDOBRONCHIAL BLEEDING WITH BRONCHOSCOPIC LUNG BIOPSIES IN A PIG MODEL David A Brickey, DO, D Lawlor, MD, FCCP-Wilford Hall Medical Cente r, Lackland AFB, TX, USA Purpose: Endobronchial bleeding followingbronchoscopic lung biopsy can be a life-threatening complication. The ability of screening coagulation tests to predict clinical bleedin g is poor regardless of a patient's history of a coagulopathy. We used a pig mode\, administered escalating doses of warfarin, and repeated bronchoscopic biopsies to identify a level of coagulopathy that would predict serious bleeding. Methods: Anesthetized Yucatan mini-swine (Sus scrofa) initially underwent fiberoptic bronchoscopy (FOB) and transbronchial biopsies (TBBx) to establish a baseline bleeding risk. A P30 Olympus bronchoscope and Microinvasive 2.2 mm alligator forceps were used via a 7.5 mm endotracheal tube in an anesthetized animal with fluoroscopic guidance. Biopsy specimens were examined histologicallyto confirm alveolar tissue. Endobr onchial bleeding was graded as Significant if > 100 ml. Animals were then administered escalating doses of warfarin, starting at 0.08 mglKg, to prolong the prothrombin time (PT). Repeat TBBx was then perform ed and the amount of hemorrhage and complications was recorded. Results: Eighteen Yucatan mini-swine were enrolled in the study. Seventeen animals had bleeding :510 ml followingTBBx. One animal was noted to have 65 ml of endobronchial bleeding. Four deaths were recorded . The cause of death was anesthetic related in one, and spontaneous abdominal hemorrhage in the remaining three. There was no Significant hemorrh age at the TBBx sites. The study was terminated when no significant endobronchial bleeding was noted with INR's > 7. Concluslonss Despite profound prolongations of the PT (INR>7), Significant endobron chial bleeding did not develop in any animal. Three animals died from spontaneous abdominal hemorrhage. Clinical Implications: To date the Yucatan mini-swine coagulation system has not been found to differ from humans in applicability of INR system of measuring coagulopathy. PT prolongation alone poses no
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significant risk to endobronchial bleeding with FOB TBBxin a pig model. By extension, humans would be expected to also be at low risk of endobronchial bleeding despite isolated prothrombin prolongation. USE OF THE FLEXIBLE BRONCHOSCOPE TO REMOVE ENDOBRONCHIAL FOREIGN BODIES: THE CLEVELAND CLINIC EXPERIENCE A Dasgupta MD, P Jain MD, K Stelmach RRT, JK Stoller MD, AC Mehta MD-The Cleveland Clinic Foundation , Cleveland, Ohio Background: Airway foreign bodies (FB) can cause serious and at times, life-threatening complications. Although most authorities advocate rigid bronchoscopy (RB) to remove inhaled FB, we have amassed experience using the flexible bronchoscope (FFB) for FB removal and report this experience here. Methods: This study includes all adult patients who underwent FFB to remove airway FB in our department over the last 15 years. A retrospective chart review identified the following features: demographic profile, conditions that may have predisposed to FB aspiration, clinical presentation, chest roentgenogram findings, number , location and the type of FB removed, accessory instruments used to extract FB in each case, and complications. The procedure was considered successful if the FB was removed in its entirety thus averting need for rigid bronchoscopy. Results: Over 15 years, all 14 patients who presented to our department with FB underwent FFB and 25 foreign bodies were removed. Five patients had multiple FB in the airways. The mean age was57 years (range 27 to 87). Of the 25 FB, 56% were vegetable matter, 20% metallic objects and 8% dental amalgam. Substance abuse was the predisposing cause in 20%. Chest radiograph showed pneumonia in 20% and revealed the FB in 20%. Fourte en out of 25 (56%) FB were retrieved from the basilar segments of the lower lobes. Successful retrieval was achieved in 93% of patients (13/14) and for 96% of FB (24/25). Conscious sedation in the bronchoscopy suite was employed in 10/14 patients (71%), all with successful FB retrieval. In the remaining four patients, FB were removed in all but one via endotracheal tube using FFB . Three of these patients were intubated for respiratory failure. In the remaining patient both FFB and RB failed to retrieve the FB. For the 13 patients in whom FB retrieval was successful, a Fogarty catheter was used in 10 and Dormia basket in 4. Complications included one episode of transient lidocaine toxicityand one post bronchoscopic pneumonia. Conclusion: Our experience suggests that in adult patients, airway foreign bodies can be successfully removed using flexible bronchoscope under conscious sedation. Rigid bronchoscopy should be performed only when flexible bronchoscopy is unsuccessful. SEDATION WITH MIDAZOLAM DURING BRONCHOSCOPY: CLINICAL EFFECTIVENESS AND SIDE EFFECTS Shyam Ivaturi, MD, P Venkatachala, MD, F Butt, MD, H Amin, MD-Department of Medicine, Interfaith Medical Center, Brooklyn,NY Purpose: To clarify the safety profile of intravenous (iv) midazolam as sedation during bronchoscopy. Methods: 40 patients undergoing bronchoscopy were randomized into two groups. Group B (n = 20) received 1-2 mg of iv midazolam as premedic ation whereas group A (n= 20) did not. Average age of patients in the two groups were 47 and 46 years respectively. Mental status, pulse rate (PR), blood pressure (B.P) respiratory rate (RR) and arterial oxygen saturation (Sa0 2 ) by pulseoximetry were measured in all patients before the procedure, at the end of the procedure and at 2 hours thereafter. Results: There was no Significant difference in the PR (p> O.I) , RR or Sa02 in the two groups at baseline, end of the procedur e or 2 hours thereafter. The average mean arterial pressure (MAP) though higher in group B was not statisticallysignificant (p>0.10) and returned to baseline 2 hours after the procedure . The average duration of procedure in groups A and B for bronchoscopy with biopsy was 46 minutes and 31 minutes (p< 0.05) while that for bronchoscopy without biopsy was 26 minutes and 9.6 minutes (p< 0.05) respectively.8 patients in group A (40%) compared to none in group B demonstrat ed some degree of agitation. Conclusions: Administration of midazolam as premedication prior to bronchoscopy improved compliance and shortened the duration of the procedure without causing any significant respiratory or hemodynamic compromise .
Clinical Implications: Use of midazolam as premedication may improve compliance and shorten the duration of bronchoscopy thereby Abstracts of Original Investigations, CHEST 1997-Poster Presentations
Tuesday, October 28, 1997 Bronchoscopy, continued improving the yield of the procedure. Concerns regarding hemodynamic and respiratory compromise may be minimized with appropriate monitoring. Before Procedure
PR MAP RR Sa02
After Procedure
2 Hours After Procedure
A
B
A
B
A
B
91.6 98.8 21.7 97.5
88.9 105 22.8 97.7
102.2 102.6 23.5 97.1
111.7 112.7 24.2 96.6
88 97 21 98
93 103 21 98
HOW DO PHYSICIANS, RESPIRATORY TECHNICIANS, AND PATIENTS RATE DISCOMFORT DURING FIBEROPTIC BRONCHOSCOPY? William Klebanskyj, I' Kupfer, D Small, E Dajczman, M Palayew, H Frank, N Wolkove, H Kreisman-Respiratory Medicine, Jewish General Hospital, McGill University, Montreal, Canada Purpose: To compare the perception of discomfort during bronchoscopy experienced by the patient (Pt) with that estimated by medical personnel (MDs, RTs). Methods: 264 Pts undergoing bronchoscopy from 94/4-96/11 completed a questionnaire immediately following the procedur e. They were pre-treated with either lorazepam , midazolam, or did not receive any pre-medication. As part of this questionnaire Pts, MDs and RTs rated the level of discomfort of the procedu re using a 10 cm. scale with O=no discomfort and lO=unbearable discomfort. Pts rated various components of the bronchoscopy as well as the procedur e as a whole. Results: Pt discomfort ratings by MDs and RTs showed excellent correlation (r= .78), however neither the rating by the MDs or RTs correlated as well with that rated by the pt (r = .45 Pt vs MD, r=.48 Pt vs RT). There was no relationship between Pt age, or length of procedur e and discomfort reported by the PI. There was no significant differen ce, (anova p=0.055) in the discomfort reported by those Pts pre-medicated with lorazepam (x= 4.3:!:2.8, n=111 ), midazolam (x= 3.6:!:2.4, n=40), and those who did not receive any pre-medication (x= 3.4:!:2.8, n=113), although there was a trend toward more discomfort following lorazepam. Pts who received lorazepam or midazolam were Significantly more anxious prior to bronchoscopy (x= 4.73, x= 5.9) than Pts without premedication (x= 3.15). Conclusions: MDs and RTs are unable to accurately estimate Pt discomfort during bronchoscopy. The use of pre-medications in this series may reflect pre procedu re Pt anxiety and thus account for the increased discomfort with use of lorazepam. Clinical Implications: Health care personnel should be aware that they may not appreciate the level of Pt discomfort during medical procedures such as bronchoscopy. Further studies which include Pts subjective evaluations are needed to deter mine the optimal pre-medication regimen. TRACHEOBRONCHIAL AMYLOIDOSIS: A SERIES OF FOUR PATIENTS WITH BRONCHOSCOPIC, SPIROMETRIC, RADIOLOGIC, AND PATHOLOGIC ANALYSIS David C Mares, MD, LS Broderick, MD, OW Cummings, MD, MD Benson, MD, PN Mathur, MBBS-Indiana University Medical Center, Indianapolis, Indiana, USA Purpose: Tracheobronchial amyloidosis represents an unusual form of isolated pulmonary amyloidosis with localized deposition of glycoproteins in the tracheobron chial tree. Our purpose is to better define this disease in its clinical, radiographic, spirometric, bronchoscopic and pathologic characteristics. Methods: Four patients with tracheobronchial amyloidosis were evaluated with chest radiography, helical computed tomography (CT) with tracheobronchial reconstruction bronchoscopy, and biopsy. Results: Patients with tracheobronchial amyloidosis usually present with obstructive phenom ena, atelectasis or recurrent pneumonia, but may have presentations mimicking asthma, CT scanning is effective in the assessment of submucosal plaques, but is augmented by the use of helical
CT airway reconstruction. Spirometry reveals patterns of obstruction. Bronchoscopy reveals submucosal plaque lesions that may be partially or completely occlusive. Endobronchial lesions seem to respond well to bronchoscopic Nd:YAG laser resection . Diagnosis is verified by positive congo red staining of histologic preparation s. Some preliminary data suggests that immunoglobulin light chain deposition may play an etiologic role in the disease process. Conclusions: This series demonstrates the modem evaluation of patients with tracheobronchialamyloidosis and possible therapeutic options. Clinical Implications: Tracheobron chial amyloidosis is unusual, may mimic other pulmonary diseases, may be evaluated with CT scanning, helical CT airway reconstru ction, or spirometry, and may be managed with bronchoscopic techniques for the removal of endobronchial tissue. MEDIASTINAL THIN NEEDLE BIOPSY: A 9·YEAR EXPERIENCE WITH 235 CASES Marjeta Tereelj-Zorman, I Kern, and M Jereb-Institute for Respiratory Diseases Golnik, Slovenia Purpose: Thin needle aspiration biopsy (TNAB) of mediastinal masses with radiological guidance and cytological evaluation has proven to be a reliable complementary method to fiberoptic bronchoscopic examination. The purpose of our review was to confirm the results on a large series and to define, if possible, the areas where the TNAB is complementary to fiberoptic bronchoscopy with transtr acheal and transbron chial biopsy. Material and Methods: In this, one of the largest series from a single institution, TNAB was performed on 235 patients with mediastinal mass. In all of them, previous work-up included bronchoscopy with transtra cheal and transbronchial biopsy which, however, failed to clarify the lesion. The TNAB needles were 22 gauge and 10-15 cm in length . Bidirectional fluoroscopy was used and the aspirates were stained according to Papanicolau or May-Griinwald-Giemsa. Results: Adequate material was obtained with a diagnosis achieved in 196 (83%) cases. Ther e were 39 (14%) false negative diagnosis, but there was no false positive diagnosis for cancer. Of these 235 patients, 60 cases had benign diagnosis, 114 of these lesions proved to be malignant mediastinal tumors, 61 patients the TNAB was performed as a part of the staging process for primary lung cancer. Conclusion: TNAB is reaffirmed as a reliable and sensitive diagnostic tool for mediastinal lesions, obviating the need for more aggressive and costly surgical approach in a sizable proport ion of theselatients . Clinical Implication: TNAB is a complementary an not a competitive method for the diagnosis of the mediastinal masses and for the staging process in lung cancer.
Cancer: Diagnosis THE RELIABLE NON-INVASIVE EXCLUSION OF MALIG NANCY IN SOLITARY PULMONARY NODULES USING A SOMATOSTATIN TYPE RECEPTOR BINDING PEPTIDE-P829 Jay Blum, H Handmaker, N Rinne, YM Baran, C Lutrin , H Abernathy-Arizona Institute of Nuclear Medicine, Cigna Healthcare of Arizona, Phoenix, Arizona and Diatide, Inc., Londonderry, New Hampshire Purpose: Many neoplasms including small cell and non-small cell lung cancers more densely express Somatostatin Type Receptors than granulomatous and other non-malignant processes. This study evaluated the utility of this phenomenon in the non-invasive differentiation of malignant and non-malignant solitary pulmonary nodules. Me thods: 1'829 is a unique low molecular weight somatostatin type receptor binding polypeptide. The radiopharmaceutical Techn etium Tc99m-P829 was utilized for scintigraphy including Single Photon Emission Computed Tomography. Seventeen individuals, 10 female, 7 male, mean age 55, with solitary pulmonary nodules of 1 centimeter or greater underwent simultaneous Comput ed Tomography and 1'829 Scintigraphy. Tissue diagnosis was then established by transthoracic needle biopsy or thoracotomy. Results: Ten patients demonstrated intense uptake in region of the pulmonary nodules seen on chest film. In nine subjects, the final diagn osis of malignancy was established. One patient had a granulomatous process CHEST / 112 /3/ SEPTEMBER, 1997 SUPPLEMENT
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