Self expectoration of a forgotten foreign body
Ashish K. Prakash, A. Jaiswal, Roopanshi Jain, B. Datta
Department of Respiratory and Sleep Medicine, Medanta -The Medicity. Gurugram, Haryana. India. E-mail: ashishsinhadoctor@gmail.com, akp_vpci@yahoo.com
Background: Foreign body and its bronchoscopic removal has always been fascinating for interventional pulmonologist. Inhaled inert foreign bodies surviving in lungs for several years is rarely seen. We report a case of a forgotten foreign body that got self expectorated after several years, while patient was on antibiotics and inhaled bronchodilators.
Case: A 20-year-old female student was referred to the Pulmonary Department for chronic cough. HRCT chest showed localised bronchiectasis and mucus impaction in right lower lobe. A bronchoscopy was planned. Patient continued the bronchodilator treatment. After around one month of regular bronchodilators, patient expectorated one plastic tip of pen with a bout of cough. She came to our OPD and showed that tip of pen. She recalled that she had inhaled one tip of a pen in her childhood nearly 13-14 years back and couldn’t tell to her parents because of fear. HRCT after expectoration showed improvement in ?Mucus impaction but residual dilatation of bronchus was persisting. We concluded this case as a forgotten foreign body in bronchus leading to bronchiectasis.
Conclusion: The history of bronchial asthma is always to be rechecked and all patients who received ATT need not had tuberculosis. Localized bronchiectasis, especially in right lower lobe should be evaluated and if needed bronchoscopy should be done after trial of bronchodilators.
Endobronchial ultrasound–guided transbronchial needle aspiration under conscious sedation for undiagnosed mediastinal lymphnodes
A. Mehta Asmita, Paul Tisa, Perathur Arvind, Archana George, K. Akhilesh, Nithya Haridas
Amrita Institute of Medical Sciences, Kochi, Kerala, India. E-mail: asmitamehta790@gmail.com
Background: Patients with mediastinal lymphadenopathy (ML) are a common presentation to a pulmonologists. Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is established as an alternative to mediastinoscopy in patients with lung cancer.
Objective: To determine the efficacy and health care costs of EBUSTBNA as an alternative initial investigation to mediastinoscopy in patients with isolated IML.
Methods: Prospective single centre single-arm study of 350 consecutive patients with ML from our centre between Julyr 2018 and August 2021. All patients underwent EBUS-TBNA. EBUS was done under conscious sedation. Rapid Onsite Evaluation (ROSE) was done for all the patients. If EBUS-TBNA did not provide a diagnosis, then participants underwent mediastinoscopy or videoassisted thoracoscopy.
Results: Out of 350 patients 28 were lost for follow up and were excluded from the study. Total 322 patients were included in the final analysis. EBUS was able to detect 164 out of 180 malignancy and 96 out of 102 patients with granuloma correctly. EBUS-TBNA has 88% yields in the current procedure. Out of 62 patients with reactive lymphnodes, 40 were true reactive. Sensitivity and negative predictive value of EBUS-TBNA in patients with malignancy were 92% (95% CI, 87–95%) and 71% (95% CI, 61–80%); while the same for granulomatous inflammation were 94 (95% CI 88-99) and 87 (95% CI 75-93) respectively.
Conclusion: EBUS under conscious sedation had yield of 88% and for diagnosing malignancy as well as granulomatous inflammation. No major complications and majority of procedures were done on day care.
Role of bronchoscopy to determine the etiology of non resolving pneumonia in a tertiary care institute
V. Ch S. Sai Snigdha Sri Veeramalla, A. Ayyappa
Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. E-mail: v.sniggu@gmail.com
Background: Non resolving pneumonia is one of the common clinical problems encountered. FOB is one of the most useful procedure in the evaluation of patients with non resolving pneumonia. This study is to establish the etiology of non resolving pneumonia by using FOB
Methods: A Prospective observational study was conducted in department of Pulmonary Medicine, Andhra medical college, Visakhapatnam which included 52 patients of non resolving pneumonia. All patients were subjected to bronchoscopy and samples sent for cytology, microbiological analysis, HPE.
Results: Out of 52 patients, etiological diagnosis was made in 94.2% (n=49) of patients. Infections (59.61%) were the most common cause followed by malignancy (26.92%).Combined etiology was noted in 7.69%. Among the infectious causes, Gram negative pyogenic bacterial infection was diagnosed in 32.69% (n=17). Tuberculosis was diagnosed in 19.23% (n=10) and fungal infection was diagnosed in 7.69% (n=4), Squamous cell variety is the predominant type of malignancy. BAL fluid cytology revealed malignancy in 9.61% (n=5) of patients. FOB guided Brush cytology revealed malignancy in 11.53% (n=6) of patients. No major complications were encountered during FOB in my study.
Conclusion: Bronchoscopy has a definitive role (Yield 94%) in the diagnosis of Non resolving pneumonia. Infectious etiology including tuberculosis (60%) is the most common cause of non resolving pneumonia.
Malignant central airway obstruction: A case of metastatic squamous cell carcinoma of trachea masquerading as COPD
K. K. Krishnanand, V. Nookaraju, Y. Gayathri Devi, B. Padmaja
Department of Pulmonary Medicine, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. E-mail: krishnanandkk@gmail.com
Background: Malignant central airway obstruction (MCAO) can develop due to compression of central airways from intraluminal malignancy, metastatic disease, or extrinsic compression from a nearby malignancy. MCAO presents very late in the disease course, and hold very grave prognosis and a limited life expectancy if untreated.
Case Study: A 56-year male patient, presented with complaints of breathlessness, hoarseness of voice and wheeze for 4 month more during night time and on lying down. Patient was treated as COPD from a private clinic for 4 months. Patient had a smoking history of 10 cigarettes per day for the past 15 years. On examination he was having stridor with Spo2 of 90% on room air. Routine blood and sputum investigations were within normal limits. Chest x ray showed superior mediastinal widening. CECT chest showed a large mediastinal mass encasing trachea with anterior mediastinal lymphadenopathy with liver secondaries. Bronchoscopy done showed left vocal cord palsy with a shiny vascular mass in trachea. Tracheal mass biopsy showed squamous cell carcinoma. Patient was referred to higher center in view of surgical evaluation. But patient expired before the procedure took place.
Discussion: Current management of MCAO includes a multidisciplinary approach with minimally invasive bronchoscopic palliative interventions like mechanical or thermal ablation or stent placement, as surgery may not be an option anymore due to advanced disease.
Conclusion: Primary lung cancers or metastatic diseases can present with MCAO which may mimic COPD. There are many minimally invasive palliative bronchoscopic interventions which can be lifesaving even in advanced stages.
The missing tooth-a peculiar case of post-obstructive pneumonia
Aakansha Sarda, Anil Sontakke, B. O. Tayade, Gopal Agrawal
NKPSIMS and Lata Mangeshkar Hospital and Research Centre, Nagpur, Maharashtra, India. E-mail: sarda.aakanksha@gmail.com
Introduction: Aspiration of foreign body in adult is rare. The presentation is mostly insidious, without history of choking and are mostly diagnosed by clinical presentation which may be acute/chronic. Often the diagnosis is delayed due to wide range of differential diagnosis- unresolving infective pneumonia, obstructive pneumonia secondary to inflammatory disorder/neoplasm.
Case Report: 50-year-old male, came complaining of cough with expectoration since 1 year, blood tinged sputum since 5-6 days and loss of weight around 5 kg. He had no other medical illness. Chest Xray done was suggestive of consolidation in right basal zone with dense radio opacity in right hilar region. After antibiotic course when no radiological improvement was seen, further detailed history revealed past history of trauma when he had multiple mandibular fractures with loss of a tooth. Patient was posted for bronchoscopy-suggestive of impacted tooth in right lower lobe bronchus. It was not retrievable by dormia basket, so with the help of three prong forceps the tooth was removed. After procedure his cough resolved.
Diagnosis: Post obstructive pneumonitis.
Discussion: Tooth impaction most commonly occurs in trauma leading to delayed complications. Post obstructive pneumonia is mostly poly-microbial. Both antibiotic coverage and removal of foreign body is important in it’s management.
Conclusion: This case helps us in knowing the importance of detailed history, interpreting imaging correctly and making proper diagnosis in recurrent pneumonia patient, which is important in our current health care system. The importance of bronchoscopy as diagnostic and therapeutic tool in cases of foreign body aspiration.
Management of respiratory distress post esophageal stenting
Ashish Kumar Prakash, Sandeep Mittal, Bornali Datta, Anand Jaiswal
E-mail: akp_vpci@yahoo.com
Background: Tracheoesophageal fistula (TOF) is considered as a commonly occurring complication with esophageal or bronchial carcinoma. About 5-15% of patients develop tracheoesophageal fistula due to esophageal carcinoma. Esophageal stenting is generally used as an attempt to manage TOF We reported a case of respiratory distress post esophageal stenting. It is a case of ruptured esophageal stent.
Case Presentation: This is a case of 43-year-old male who was a known case of CA esophagus (Squamous cell carcinoma). The patient received chemotherapy/radiation and developed tracheoesophageal fistula. The patient complains of coughing for 4-5 months. He started having difficulty in drinking water and he was shown in a local hospital where upper GI endoscopy and biopsy were done followed by PET scan.Thenupper GI endoscopy was performed which revealed trachea-esophageal fistula. Subsequently patient was advised for esophageal and tracheal stenting. The esophageal stenting was performed and the patients was advised to take liquid diet. At our centre, fibreoptic bronchoscopy was performed which showed esophageal stent rupturing the trachea which leads to protruded trachea. This was corrected by placing the tracheal stent and the fluoroscopy was performed post tracheal stenting. No leakage was observed in the fluoroscopy. The patient was discharged to home and regular follow-up with respiratory medicine and gastroenterology was advised.
Conclusion: Tracheal stent is good option for palliative management of tracheoesophageal fistula in CA oesophagus.It has shown to ameliorate the quality of life in patients with tracheoesophageal fistula and alleviate their symptoms of dyspnea and dysphagia.
A study to evaluate the role of medical thoracoscopy in undiagnosed exudative pleural effusion
M. T. Chandramouli, Y. Sunil Kumar, V. Rajesh, B. H. Giridhar
Department of Pulmonary Medicine, K S Hegde Medical Academy, Mangalore, Karnataka, India. E-mail: mouli.aims@gmail.com
Background: Unexplained exudative pleural effusion is a diagnostic challenge. Thoracoscopy or Pleuroscopy is a minimally invasive procedure that has a diagnostic value in patients with exudative pleural effusion.
Objective: This work aimed to study the outcomes of medical thoracoscopy in undiagnosed exudative pleural effusion.
Methods: A retrospective observational study was performed on clinical data of consecutive patients with undiagnosed exudative pleural effusion who had undergone thoracoscopy at a tertiary care center between July 2019 to October 2021.
Results: The mean age was 50± 2.3 (range 25–75) years and 13(59%) were males. Pleural malignancy was diagnosed in 59.09% (13/22) of patients, tuberculosis in 18.18% (4/22) of patients, fibrotic pleurisy in 9.09% (2/22) of patients, and non-specific inflammation in 13.3% (3/22) of patients. Among the pleural malignancies, metastatic adenocarcinoma was found in 53.84% (7/13) of patients, malignant mesothelioma in 23.07% (3/13) of patients, synovial sarcoma in 7.69% (1/13) of patients, and poorly differentiated in 15.38% of patients. There were no major complications, only one patient had a minor complication.
Conclusion: Medical thoracoscopy is a minimally invasive, safe, and effective tool in the diagnosis of undiagnosed exudative pleural effusion with a high diagnostic yield and minimal complication rate.
Bronchoscopic management of tracheobronchial mucormycosis
Santhakumar Subramanian, T. H. Deepak, Venugopal Jagannathan
Department of Interventional Pulmonology, Kovai Medical Centre and Hospital, Coimbatore, Tamil Nadu, India. E-mail: drskumar.chest@gmail.com
Introduction: Mucormycosis is a catastrophic, opportunistic infection with a high mortality rate. Incidence of Pulmonary mucormycosis has gone up in the post covid-19 era. Treatment includes combined surgical and medical therapy. Mucormycosis involving major airway is difficult to treat because, the surgical options are limited. We present a case series of tracheobronchial mucormycosis, managed by combined bronchoscopic interventions and medical therapy.
Case Series: Case 1: 30 years old diabetic female presented with stridor. Bronchoscopy showed mass lesion arising from carina extending to lower trachea causing obstruction. Biopsy revealed Mucormycosis. The lesion was completely debulked by using rigid bronchoscopy, cryoprobe, electrosurgical knife. Intravenous amphotericin was for 6 weeks. Follow-up bronchoscopy showed no recurrence. Case 2: 45 years old diabetic male who had Covid-19 recently, presented with cough. Bronchoscopy revealed near-total occlusion left main bronchus by fleshy lesion destroying medial wall and communicating with the mediastinum. Lesion was removed by bronchoscopic methods and intra-lesional amphotericin was injected in multiple sittings along with intravenous amphotericin therapy followed by oral posaconazole. Follow-up bronchoscopy showed complete healing of left main bronchus. Case 3: 25-year-old diabetic male, presented with stridor. Bronchoscopy revealed complete destruction of the upper trachea by necrotic infection extending to paratracheal tissue on right side. Silicon tracheal stent was placed to stabilize trachea and patient was continued on intra-lesional and intravenous amphotericin therapy. Interim bronchoscopy in after 2 weeks showed partial healing of the lesion however patient missed for follow up after 3 weeks of amphotericin therapy.
Conclusion: Surgical options for tracheobronchial mucormycosis are limited. Bronchoscopic methods may be tried to treat the disease locally along with intravenous amphotericin therapy when Surgical options are exhausted.
Transbronchial Cryo lung biopsy using supraglottic airway
Santhakumar Subramanian, Venugopal Jaganathan, Sangita Sharma Mehta, Ramesh Varatharajan
E-mail: drskumar.chest@gmail.com
Background and Objective: Transbronchial lung cryo biopsy (TLCB) is a novel technique of sampling lung tissue for pathological diagnosis. It is generally done under general anaesthesia in operating room with rigid bronchoscopy or endotracheal tube. We have attempted doing cryo lung biopsy in our routine bronchoscopy suite with supraglottic airway instead of rigid bronchoscope, under moderate to deep sedation.
Methods: We have performed transbronchial cryo lung biopsy with supraglottic airway in moderate sedation and spontaneous breathing, with a prophylactic balloon in place to control bleeding, with a freezing time of 4 seconds, targeting the most peripheral lung, in our routine bronchoscopy suite as a day care procedure and analysed the yield, safety and other aspects of this technique.
Results: We have done cryo lung biopsy in 59 (27 females) patients with mean age of 52 years. A definitive pathological diagnosis was made in 84% (n=50) of patients. The complications were mild to moderate bleeding in 96% (n=57) of the patients and pneumothorax in 4% (n=2) of patients. There was no severe bleeding or mortality. Mean procedure duration were 36 minutes.
Conclusion: our technique of cryo lung biopsy seems to be a safe, minimally invasive and cost - effective day-care procedure.
Complex subglottic stenosis- bronchoscopic recanalization and decannulation
Santhakumar Subramanian, Venugopal Jaganathan, T. H. Deepak
Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India. E-mail: drskumar.chest@gmail.com
Background: Incidence of post tracheostomy tracheal stenosis is increasing because of increased practice of early tracheostomy and prolonged ventilation in the ICU. Though surgical resection and anastomosis is the defective treatment for complex tracheal stenosis, bronchoscopic recanalization and balloon dilatation is an option when surgery cannot be done either due to the location of the stenosis or due to patient refusal or unfitness. We present a case of grade 4 subglottic stenosis following prolonged ventilation in the ICU with a highly placed percutaneous tracheostomy. This patient has undergone bronchoscopic recanalization of the subglottis and upper trachea followed by successful decannulation of tracheostomy.
Case Report: 60-year-old female, who had failed decannulation of tracheostomy due to complete obstruction of subglottis by granulation, following a prolonged ventilation in the ICU with tracheostomy which was highly placed. She was referred from our ENT colleague, as the surgery was not an option due to the location of the lesion. She was Subjected for bronchoscopic recanalization using rigid bronchoscopy and multimodality approach with electro surgical knife, APC and balloon dilatation in two sittings. Post procedure, complete tracheal patency was achieved and she was successfully decannulated from tracheostomy.
Conclusion: Bronchoscopic recanalization may be successfully done in even in grade 4 subglottic stenosis when surgical options are exhausted.
Management of Broncho-Oesophageal fistula develop after Oesophageal stenting in a Case of Ca Oesophagus
Sumit Kumar Pahariya, Ashish Kumar Prakash, Roopanshi Jain, Anand Jaiswal
E-mail: spaharia88@gmail.com
Background: Tracheoesophageal fistula (TOF) is considered as a commonly occurring complication with oesophageal or bronchial carcinoma.About 5-15% of patients develop tracheoesophageal fistula due to oesophageal carcinoma.Oesophageal stenting is generally used as an attempt to manage TOF. We reported a case in which oesophageal stent has ruptured in the left main bronchus near carina leading to broncho-oesophageal fistula.
Case Presentation: 53 year old male diagnosed with metastatic squamous cell Ca oesophagus and referred to Medanta for chemo radiation.After few days patient develop cough which used to exaggerate during eating.Upper GI endoscopy was performed which revealed trachea-esophageal fistula for which eosophageal stenting was done.After few days patient develop respiratory distress,fibreoptic bronchoscopy was performed which showed oesophageal stent rupturing the left main bronchus which was corrected by placing the tracheal Y stent.
Discussion: Esophageal stents are considered to be useful in the treatment of tracheoesophageal fistula. In this case report patient developed respiratory distress post esophageal stenting.Bronchoscopy revealed the esophageal stent was ruptured leading to protruded in upper part of left main bronchus of trachea. This was corrected by placing Y shaped tracheal stent.Gastrograffin study shows no leakage after placement of tracheal stent however there is aspiration from pyriform fossa so patient was discharge on ryles tube feed.
Conclusion: racheal Y stent is good option for palliative management of broncho-oesophageal fistula in Ca Oesophagus if fistula is located in upper part of left main bronchus. It has shown to ameliorate the quality of life in patients and alleviate their symptoms of dyspnea and dysphagia.
Bronchus and the Pandora’s box
K. S. Sharath Chandra, B. H. Giridhar, M. T. Chandramouli
Department of Pulmonary Medicine, KSHEMA, Mangaluru, Karnataka, India. E-mail: sharathchandraks@gmail.com
Background:
• Pancreatico Pleural fistula is common, however Bronchial-Pancreatic fistula is a rare condition with fewer than 30 cases reported.
Case Study:
• 30 Year old male, manual labourer presented to ED with Breathlessness, Chest pain, Right shoulder pain, Fever and Cough *1 week
• CXR and USG- suggestive of right massive pleural effusion with calcified pancreas and intraductal calculus
• S. Amylase- 531 and S.Lipase- 1240 elevated
• Chest Xray - Right mid and lower zone homogenous opacity in with blunting of CP angle
• Sputum C/S : Klebshiella pneumoni
• Patient was treated with antibiotics, therapeutic pleural fluid aspiration, along with other supportive measures. Patient’s condition improved only to further worsen requiring ICU and NIV. Cough and expectoration increased. In view of worsened secretions, patient was taken up for bronchoscopy to clear secretions
• Mucoid secretions were noted in the right lower lobe bronchus. BAL showed significantly high levels of Amylase – suggesting of Bronchial Pancreatic fistula
• CT thorax was done which showed chronic calcific pancreatitis with the possibility of Broncho pancreatic fistula which explained the copious expectoration.
Final Diagnosis:
1. Bronchial Pancreatic fistula
2. Right lower Lobe Pneumonia with Pleural Effusion
3. Secondary to Chronic Pancreatitis.
Patient underwent MRCP and was advised Octreotide and Peri-pancreatic fluid drainage with pigtail catheter by the gastro surgeon.
Discussion:
• Bronchial Pancreatic fistula is an unusual examples of internal pancreatic fistulas
• If the secretions are contained in the retroperitoneum, -it burrows upwards along the diaphragmatic crura and escape into the thorax.
Conclusion:
• Pancreatico bronchial fistula is an extension of process that has already led to pancreatic duct rupture, peri pancreatic fluid collections and pancreatico pleural/bronchial fistulas
• These are unusual but should be included in the differential diagnosis of resistant pneumonias presenting with copious frothy sputum production and underlying pancreatitis
• The diagnosis is suggested by bronchoscopy and determination of amylase activity in BAL.
Diagnostic yield and safety of cryobiopsy in diffuse parenchymal lung diseases
Shubhra Srivastava
J. N. Medical College, AMU, Aligarh, Uttar Pradesh, India. E-mail: shubhrasrivastava62@gmail.com
Background: In many cases of diffuse parenchymal lung diseases, clinical and radiological features are not sufficient to make the diagnosis. Hence Surgical lung biopsy is frequently required but has significant morbidity and mortality and appreciable cost. Recently novel bronchoscopic technique “TRANSBRONCHIAL LUNG CRYOBIOPSY” has been developed and considered as first diagnostic approach, reserving SLB for those in which TBLC is inconclusive.
Methods: A prospective study was conducted on 50 patients suspected to have DPLDs basing on their symptoms and radiology from December 2019 to December 2021. A flexible video bronchoscope and 1.9 mm diameter nitrous oxide cooled flexible cryoprobe were used for biopsy procedure through rigid bronchoscope under general anaesthesia . H & E stained biopsies were reviewed by pathologist.
Results: Based on cryobiopsy samples, with a mean area of 58.2 mm2 (which is larger than traditional transbronchial lung biopsy sample), specific diagnosis was made in 34 of 50 patients [IPF (13), HP(7), NSIP(5), BOOP(2), RB-ILD(1), Malignancy(2), Wegener’s(1), LAM(1), TB(1), Sarcoidosis(1)] .16 patients have non-diagnostic results. The overall diagnostic yield was 68%. 2 patients (4%) had pneumothorax, 1 patient (2%) had hypoxia and in 32 patients (64%) mild to moderate bleeding occurred after TBLC. No severe bleeding and mortality observed.
Conclusion: In patients with suspected diffuse parenchymal lung diseases, bronchoscopic cryobiopsy is a better and minimally invasive approach to obtain lung tissue with high diagnostic yield and better safety profile.
Endo-bronchial application of glue in the management of hemoptysis
Rakesh K. Chawla, Arun Madan, Aditya K. Chawla
Department of Pulmonary Medicine, Critical Care and Sleep Medicine, Jaipur Golden Hospital, New Delhi, India. E-mail: rakeshchawla8888@gmail.com
Background: Hemoptysis from varied etiologies, often fails to respond to conservative therapy. The conventional managements of such a situation are Bronchial Artery Embolization (BAE) or thoracic surgery which is often not possible. Endoscopic application of glue may stand as a method of therapy in these circumstances.
Methods: 202 patients of hemoptysis were treated by video-bronchoscopy assisted endobronchial application of glue (n-butyl cyanoacrylate) with the help of polyethylene catheter being placed through the working channel. The details of the procedure and their 6 month follow up are presented.
Results: Immediate control of hemoptysis was achieved in 183 i.e. 90.59% of patients. 19 patients had a partial response, i.e., hemoptysis stopped and then recurred, endobronchial application of glue was repeated in them out of which 14 (6.9%) responded to the second procedure whereas 5 (2.47%) failed to show any response in spite of the repeated proced- ure. The complication rate was 0.49% in the form of glue migrating into the trachea. There was no mortality.
Conclusion: Endobronchial application of glue for hemoptysis can be an effective, economic and alternative therapy for mild to moderate hemoptysis.
Cracking a conundrum of dwindling lungs - Bedside bronchoscopy in ICUs
Archit Krishna Manohar, R. Saravanavasan, B. Rajesh Kumar, R. Prabhakaran
Department of Respiratory Medicine, Government Rajaji Hospital and Madurai Medical College, Madurai, Tamil Nadu, India. E-mail: architisd1@gmail.com
Background: Critically ill patients always keep the doctor on his/her toes. Clinical examination, blood parameters, chest X-rays are the commonly used diagnostic tools since patients cannot be shifted anywhere easily. Lung conditions like atelectasis and pneumonia are very common in ICU patients and a need for bronchoscopy arises when all other conservative measures fail to diagnose and treat the patient.
Case Study: This series describes 12 cases for whom bedside flexible fibre-optic bronchoscopy was done at various ICUs in Government Rajaji Hospital, Madurai. The most common indication for bronchoscopy was lung collapse alone (66.6%). Other indications included atelectasis with suspected foreign body (16.6%) and specimen acquisition (16.6%). 10 patients (83.3%) had lung atelectasis and 8 of them had mucus plugging the lumen and 2 patients had foreign bodies which were removed. Bronchial wash culture revealed no growth in four, Klebsiella pneumoniae in four, Pseudomonas aeruginosa and Staphylococcus aureus in two each. No procedure-related complications were noted. Among patients with collapse, complete lung expansion achieved in 3 cases (30%) and partial in 7 cases (70%), post-procedure.
Discussion: Lung atelectasis secondary to secretions is usually treated with mucolytics, bronchodilators and chest physiotherapy. If it is still persistent or involving a large part of the lung, bronchoscopic intervention may be warranted.
Conclusion: Bedside bronchoscopy serves as both a diagnostic and therapeutic tool in ICUs when other less invasive methods fail and help specimen acquisition from precise sites within the lungs. Aspirated foreign bodies are important causes of lung collapse and potentially rectifiable.
Utility of fiberoptic bronchoscopy in diagnosis of etiology of collapse of lung in a teritiary care hospital. Our experience
Katikam Sai Vikas Reddy, T. Priyanka, Bharath Kathi, G. Aruna
Department of Pulmonary Medicine, SVRRGGH, Tirupati, Andhra Pradesh, India. E-mail: saivikasreddy54@gmail.com
Background: Collapse of lung, is defined as loss of aeration, leading to loss of volume of lung. Collapse is not a disease, but an important sign that results from disease or abnormalities in the lung. It is necessary to use diagnostic tools such as fiberoptic bronchoscopy to get an accurate diagnosis of underlying cause in a patient presenting with collapse on chest radiograph or CT-Chest. We aim, to present bronchoscopic appearances and percentages for the various etiologies of collapse of lung.
Methods: From June 2021 to October 2021, Fiberoptic bronchoscopy was performed in 30 adult patients who had opacities on chest radiography in the form of collapse in department of Pulmonary Medicine SV Medical College Tirupati. Bronchoscopic aspirates, brushing and biopsy were taken. Patients with known lung cancer, sputum positive pulmonary TB, recent myocardial infarction, allergic diseases and blood dyscrasias were excluded.
Results: Fiberoptic bronchoscopy was diagnostic in 28 (93.3%) patients. Malignancy was diagnosed in 21 patients(70.0%), endobronchial tuberculosis in 4 patients (13.33%), pneumonia causing collapse in 1 patient (3.3%) , foreign body in 1 patient and post operative mucus plug in 1 patient (6.6%).
Conclusion: We conclude that fiberoptic bronchoscopy was found to be extremely useful in finding specific etiology of collapse of lung.
Tracheobronchopathia osteochondroplastica: A rare benign disease coexisting with malignant pleural effusion
Subhaprada Mishra, Pravati Dutta, Rekha Manjhi, Aurobindo Behera, Vimsar Burla, Sambalpur
E-mail: mishrasubhaprada123@gmail.com
Background: Tracheobronchopathia Osteochondroplastica (TO) is a rare benign disease of unknown etiology characterized by accumulation of calcium phosphate in the submucosa of large airways and benign proliferation of bone and cartilage resulting in nodular formation. Patients with TO can be either asymptomatic or have nonspecific respiratory symptoms. It is found incidentally. A few cases have been associated with lung cancer.
Case Study: A 56-year housewife presented with complaints of right side chestpain, dry cough, shortness of breath for 1 month. She has no comorbidity and no addiction.
Examination: Patient was conscious oriented with normal vitals. General examination was normal except presence of pallor. Respiratory examination revealed stony dull note on percussion and decrease breath sound on auscultation over right infrascapular, lower interscapular and infraaxillary area.
Investigations: Chest x-ray suggestive of right pleural effusion. ECG was normal.CECT thorax showed right middle lobe lung mass with right pleural effusion with mediastinal lymphadenopathy and irregular tracheal mucosa. Pleural fluid cytology showed presence of atypical cells suspecting malignant pleural effusion. Fibroptic bronchoscopy showed multiple nodules in the anterolateral walls of trachea and both main bronchi sparing the posterior part. Biopsy taken from the nodules showed osseous metaplasia without any evidence of malignancy. Thoracoscopy of right hemithorax showed multiple whitish nodules in visceral,parietal and diaphragmatic pleura. Biopsy of parietal pleura revealed invasive adenocarcinoma.
Discussion: TO is a rarely identified by bronchoscopy or chest CT with a reported incidence of approximately 0.3%.In our case the patient came for malignant pleural effusion and TO is found incidentally on CECT thorax and bronchoscopy while evaluating malignant pleural effusion.TO is not suspected as a differential diagnosis of malignant invasion of trachea. It can be easily misdiagnosed in the patients complicated with malignancy at the same time. There is no definitive therapy for TO, treatment is only symptomatic.
Conclusion: TO is rare benign idiopathic pulmonary condition with various presentations.it is diagnosed with bronchoscopy. In our case it is found incidentally where the clinical picture is clouded by the malignant pleural effusion.
Diagnostic utility of thoracoscopy in undiagnosed and misdiagnosed pleural effusion at a tertiary care centre
Gauri Goswami, Lalit Singh, Yatin Mehta, Pradeep Nirala
Department of Respiratory Medicine, SRMS, Bareilly, Uttar Pradesh, India. E-mail: gaurigoswami2014@gmail.com
Background: Pleural effusion results from accumulation of abnormal volumes (> 10-20) ml of fluid in pleural space. Significant number of cases of pleural effusion remains undiagnosed after simple diagnostic pleural aspiration. Thoracoscopy allows direct visual assessment of the pleura and subsequent biopsy of visually abnormal areas, hence maximising diagnostic yield.
Methods: A retrospective study of all Thoracoscopic procedure performed with rigid and semi- rigid scope in patients admitted in Respiratory department of SRMS, Bareilly. Post-procedural diagnoses were obtained from the clinical records and using relevant hospital databases.
Results: A total of 40 patients underwent Thoracoscopy in time span of one year to diagnose a wide spectrum of benign and malignant conditions. The diagnosis of 23 malignant conditions - 13 Adeno Carcinoma, 3 Non – small cell carcinoma and 7 cases of other malignancies, along with 17 benign cases were made.
Conclusion: Thoracoscopy can be used as a diagnostic tool for investigation of various pathologies of undiagnosed pleural effusion. In our study the sensitivity of thoracoscopy was more than 90%.
A rare case report of endobronchial carcinoid
Shaik Shah Nawaz, A. Vinay Kumar, Akshai Kumar Duvva
Department of Pulmonary Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana, India. E-mail: shanu.shaik007@gmail.com
Background: Lung neuroendocrine tumours are an uncommon group of pulmonary neoplasms characterized by neuroendocrine differentiation and relatively indolent clinical behaviour. In view of it’s rarity and atypical presentation, delay in diagnosis and treatment are common.
Case Study: The patient reported in this case is a 46 year old female, presented with exertional dyspnoea since 2 months, cough with expectoration since 2 months and wheezing since 2 months. She is a non smoker. CT-scan showed briskly enhancing left main bronchus endoluminal mass extending into left lower lobe bronchus with internal calcifications. The detected soft tissue mass was bronchoscopically biopsied and histopathological diagnosis showed typical carcinoid. In line with importance of cancer treatment, early identification of neuroendocrine neoplasms is highly warranted.
Discussion: Based on histologic differentiation the World Health Organization/The International Association for the Study of Lung Cancer (WHO/IASLC) classifies pulmonary Carcinoid tumors into: Typical carcinoids (76–90%), less than 2 mitosis/2 mm2 and no necrosis; Atypical carcinoid, increased mitosis (2–10 mitosis/2 mm2) with confirmed necrosis.
Conclusion: Diagnosis of Lung carcinoids are although rare must be considered in patients having endobronchial mass. Surgical resection is the main stay of treatment for patients with no evidence of systemic metastasis.
Medical thoracoscopy for undiagnosed pleural effusions: Experience from a tertiary health care center in South India.
G. Anand Raja, P. Dhamodharan, Senthil Kumar, B. Rajesh Kumar, R. Hariprasad, R. Prabhakaran
Department of Respiratory Medicine, Madurai Medical College, Madurai, Tamil Nadu, India. E-mail: rgk.anand@gmail.com
Introduction: Medical thoracoscopy also known as Pleuroscopy is an effective method of diagnosing the cause of pleural effusion in any case of undiagnosed pleural effusion. Thoracoscopy has a sensitivity of 90% in detecting malignancy and has a sensitivity of 93% in diagnosing tubercular effusion. Medical thoracoscopy is done under local anesthesia and mild sedation and is relatively safe.
Objective: To describe the role of Thoracoscopy in undiagnosed pleural effusion.
Methods: Patients with moderate to massive pleural effusion who remain undiagnosed after an initial diagnostic thoracentesis are subjected to Medical thoracoscopy using Rigid thoracoscope (Wolff) and biopsy taken.
Results: 24 patients underwent medical thoracoscopy in our institution in the year 2021. Of these 24 patients, 16(66.6%) were males and 8(33.3%) females. Effusion was right sided in 12(50%) and left sided in 12(50%). Effusion was moderate in 9(37.5%) and massive in 15(62.5%). Thoracoscopic findings include mass (4%, n=1), nodules (71%,n=17), thickening (12.5%, n=3) and was normal in 3 (12.5%) patients. Most common findings were Adenocarcinoma (58.3%, n=14), Granulomatous inflammation (29.1%, n=7), Mesothelioma (8.3%, n=2) and was inconclusive in 1(4%) of patients.
Conclusion: The yield of medical thoracoscopy was 95.8% in our centre. The most common cause of Undiagnosed pleural effusion was Metastatic Adeno carcinoma followed by Granulomatous inflammation. Nodules in parietal pleura was the most common thoracoscopic finding. Thus, Thoracoscopy is the most effective procedure in diagnosing the etiology of undiagnosed pleural effusion.
Utilizing a hydrogel for persistant air lea: A Case Report of Novel Technique
Himanshu Saini
Department of Pulmonology, Max Superspeciality Hospital, New Delhi, India. E-mail: hsainiprivate@gmail.com
PAL (Persistant air leak) is defined as an air leak that lasts longer than 5–7 days secondary to bronchopleural fistula .A bronchopleural fistula (BPF) is a pathological connection between the main stem, lobar, or segmental bronchus and the pleural space. This tract permits sterile pleural space to be contaminated, leading to a high risk of pleural space infections. In effect, morbidity and mortality remain high for this condition. There are quite a number of bronchoscopic interventions proposed to combat BPF’s. Even so, no technique has been found superior for closure of BPF’s to date. We present a challenging case report introducing the use Hydrogel as a viable intervention for the termination of PAL. Hydrogel is a synthetic, absorbable polyethylene glycol (PEG) having hydrophilic properties. Specifically, hydrogel provided a watertight seal allowing for the dura more time to heal.Bronchoscopic administration of a synthetic hydrogel is an effective, nonsurgical, minimally invasive intervention for patients with persistent pulmonary air leaks secondary to broncho-pleural fistula.
Exudative pleural effusions-relationship between thoracoscopic findings and type of lesion
A. Lavanya, Venkateswara Reddy Tummuru
Department of Pulmonology, SVS Medical College and Hospital, Mahabubnagar, Telangana, India. E-mail: lavanyaagram5@gmail.com
Background: Thoracoscopy is gold standard diagnostic modality for evaluation of pleural pathology. In most of patients, cytobiochemical analysis of pleural fluid establishes etiology. In cases where etiology remains unclear, thoracoscopy becomes vital investigation modality.
Methods: This prospective observational study conducted at our hospital from July 2020 to July 2021 in 30 patients to establish the role of thoracoscopy in exudative pleural effusions.
RESULTS:
Type of lesion according to final diagnosis of cases studied.
| Type of lesion | Frequency |
|---|---|
| Metastatic adenocarcinoma | 20 |
| Malignant lymphoma | 1 |
| Metastatic squamous cell carcinoma | 1 |
| Tuberculosis | 8 |
73% were found to be malignant pleural effusions in which
• 91% metastatic adenocarcinoma
• 4.5% malignant lymphoma
• 4.5% metastatic squamous cell carcinoma.
27% - Tubercular pleural effusion.
Relation between thoracoscopic findings and type of lesion
Malignant pleural effusion showed higher percentage of nodules (77.2%), mass(36.3%), plaque(13.6%),adhesions(9%).
Tubercular pleural effusion showed higher percentage of nodules (62.5%), mass (25%), adhesions (12.5%).
Conclusion: In this study, 30 patients underwent thoracoscopy in which 22 showed malignant etiology and 8 tubercular etiology.11 out of 20 adenocarcinoma cases were thought to be squamous cell carcinoma in view of central mass lesion.However, biopsy proved adenocarcinoma.
Tracheal bronchus: Fiber optic bronchoscopy diagnosis in a symptomatic patient
Sandeep Kumar, Gunjan Soni, Manak Gujrani, Rajendra Saugat
Department of Respiratory Medicine, Sardar Patel Medical College, Bikaner, Rajasthan, India. Email: yogisandeep85@gmail.com
Background: The tracheal bronchus (TrB) is a rare congenital anomaly which occurs as a result of an additional tracheal out growth, more commonly from right wall of the trachea, above carina. Here, we are presenting a case of tracheal bronchus who presents with recurrent respiratory infections.
Case Study: A 63-year old male presented with complaints of recurrent episodes of fever and cough with expectoration for 3-4 months. Chest X-ray revealed bilateral hilar opacity and HRCT showed bilateral hilar irregular hypodense lesions. Fiber optic bronchoscopy revealed a right tracheal bronchus arising 1 cm above carina. Right upper lobe bronchi had all three lobar branches, confirming that this was a supernumerary type of TrB. Thick secretions were present. Rest of the bronchoscopy was normal. BAL revealed pseudomonas. Patient was treated with i.v. antibiotics and referred to cardio-thoracic surgeon.
Discussion: TrB is an incidental finding during radiological investigation or bronchoscopy. Prevalence of right TrB is 0.1%–2% and of left TrB 0.3%–1%. It is a normal finding in pigs, so also called “bronchus suis” or “pig bronchus”. It can be classified into two types: Supernumerary, as an accessory bronchus, and Displaced when the entire upper lobe is supplied by this bronchus. It is usually asymptomatic but some people experience recurrent pneumonia, chronic bronchitis or bronchiectasis, probably due to narrowing at origin of TrB.
Conclusion: Patients who present with recurrent respiratory infections must be evaluated for rare congenital anomalies like TrB. Multidetector CT and bronchoscopy are valuable for identification of TrB.
Diagnostic yield of TBLB in focal and diffuse parenchymal lung diseases in tertiary care hospital in Maharashtra, India
M. S. Barthwal, Dundan Mehta, Harsha Elizabeth Meleth, Ashwin Ramesh
Department of Respiratory Medicine, Dr. D. Y. Patil Medical College, Pune, Maharashtra, India. E-mail: harshaelizabethmeleth@gmail.com
Background: Transbronchial Lung Biopsy is an important diagnostic modality in patients with focal or diffuse lung pathology.
Objectives: To determine the diagnostic yield of TBLB in focal and diffuse parenchymal lung diseases and correlate clinical and pathological data.
Methods: Retrospective study of 140 patients who were admitted in Dr. DY Patil Medical College over a period of 4 years underwent Transbronchial Lung biopsy. The clinical and pathological data was retrospectively analysed and correlated.
Results: The transbronchial lung biopsy performed on 140 patients had clinical diagnosis of Pulmonary tuberculosis 72.85% (n=102), Sarcoidosis 12.9%(n=18), Lung malignancy 13.57% (n=19), Interstitial Lung disease 12.85%(n=18), Community Acquired Pneumonia 7.85% (n=11), Metastasis 1.4% (n=2), Hodgkins Lymphoma 0.7% (n=1) and TBLB histopathological diagnosis yielded Caseating granuloma suggestive of tuberculosis in 20.7% (n=29), non caseating granuloma suggestive of Sarcoidosis 6.4% (n=9), Malignancy 6.4% (n=9) which included adenocarcinoma, squamous cell carcinoma, Bronchoalveolar carcinoma; Interstitial Lung Disease 4.28% (n=6), inflammatory cells suggestive of Community Acquired Pneumonia 2.85% (n=4). Diagnostic yield was obtained in 55/140 (39.28%) of the cases studied.
Conclusion: Concordance was observed between clinical diagnosis and histopathology obtained from TBLB. Transbronchial Lung biopsy is an important diagnostic modality with good yield for diagnosis of focal and diffuse parenchymal lung diseases.
Simultaneous vs sequential thoracoscopic management of bilateral primary spontaneous pneumothorax
Mohan Venkatesh Pulle, Sukhram Bishnoi, Harsh Vardhan Puri, Belal Bin Asaf, Arvind Kumar
Institute of Chest Surgery, Medanta – The Medicity, Gurguram, Haryana, India. E mail: mohanvenkateshpulle@gmail.com
Objectives: To report our experience and outcomes of thoracoscopic single staged vs thoracoscopic 2 staged (Interval) management of bilateral primary spontaneous pneumothorax.
Methods: To operate on Bilateral spontaneous pneumothorax in the same sitting (Single stage) and to weigh the advantages and disadvantages of the same as compared with interval (2 staged) surgery. There were 14 such cases of bilateral primary spontaneous pneumothorax over a period of 5 years. All patients were taken up for the surgery after thorough workup. Seven patients were operated in the same sitting and 5 patients were operated sequentially.
Results: Seven patients who were operated in same sitting were male, underwent VATS blebectomy and parietal pleurectomy on both sides in same sitting. Median hospital stay was 5 days. The Drain removal were on day 6 th postoperative day. Other 5 patients who underwent same surgery but in interval of 2 days respectively. The median age of patients in this was 25 years. The median hospital stay was 9 days. All drains were removed on 9th/10th postoperative day. There was no post-operative mortality. There was no prolonged air leak (All air leaks < 7days).
Conclusion: Simultaneous surgery for bilateral spontaneous primary pneumothorax is safe and cost-effective procedure, requires less hospital stay and early recovery. We recommend to operate such bilateral primary spontaneous pneumothorax in same sitting, whenever feasible. We recommend keeping ventilator pressures low while operating bilateral Primary spontaneous pneumothorax in single stage.
Diagnostic utility of EBUS- TBNA in lung cancer and granulomatous disease in tertiary care center
Kriti Sarin, Lalit Singh, Yatin Mehta
Department of Respiratory Medicine, SRMSIMS, Bhoji Pura, Uttar Pradesh, India. E-mail: kritisarin13@gmail.com
Background: Endobronchial ultrasound (EBUS) transbronchial needle aspiration (TBNA) is a minimally invasive diagnostic technique using fine needle aspiration under direct sonographic visualization for sampling of lung tissue and lymph nodes through the wall of the trachea and bronchi. It has a low rate of morbidity, and has demonstrated utility in the diagnosis of mediastinal lymphadenopathy secondary to malignancy, lymphoma, sarcoidosis and mycobacterial lymph node infection.
Methods: A retrospective study of all EBUS-guided TBNA procedures using convex probe that were performed at Department of Respiratory Medicine, Shri Ram Murti Smarak Institute Of Medical Sciences , Bareilly. Post-procedural diagnoses were obtained from the clinical records and using relevant hospital databases.
Results: A total of 50 patients underwent EBUS TBNA in time span of 2020-2021 to diagnose a wide spectrum of benign and malignant conditions. The main application was in the diagnosis and staging of malignant conditions 52% (26 ), and in the diagnosis of granulomatous conditions such as tuberculosis 30% (15) , sarcoidosis 4% (2) and others including reactive hyperplasia 10% (5) and no definite result 4% (2).
Conclusion: Good diagnostic accuracy and safety profiles were demonstrated for the procedure, supporting its application as a first line investigation in the diagnosis and/or staging of a range of malignant and benign conditions.
To study the outcome and complications of ultrasound guided biopsy for peripheral lung lesions-a cross sectional study
R. Parthiban, A. Mahilmaran, Rajeswari
Institute Thoracic Medicine, Madras Medical College, Chennai, Tamil Nadu, India. E-mail id- parthibanravi92@gmail.com
Background: Evaluation of the patients presented with lung mass lesions is challenging. For central lesions, bronchoscopy will be useful to find the pathology. For peripherally located lesions image guided biopsy will be useful to prove the histopathological variety of the lesion. Though CT guided biopsy remains standard of care for biopsy of lung mass lesions, it is costly and also associated with high degree of radiation exposure along with increased chances of developing complications like pneumothorax and hemorrhage. USG is being increasingly used bedside for the point of care diagnosis for the various chest pathologies.
Methods: It’s a study with 66 patients with peripherally located lung mass on CECT Chest were selected by consecutive sampling methods. USG guided transthoracic lung biopsy done by using coaxial system
Results: 1. Among 66 patients, diagnostic yield obtained in 62 patients. Which gives p- value of about 0.014 [<0.05 with 95% C.I lies between 0.611 to 1.000] which is statistically significant and gives the accuracy rate of 97.0% with Sensitivity- 98.4%, Specificity-75.0% 2. In my study only 3(4.5%) patients developed mild pneumothorax and 2(3%) patients developed hemoptysis following the procedure.
Conclusion: Peripherally placed mass lesions with size more than 5 cm and dense component, assessed by USG Imaging, gives good diagnostic yield with very minimal post procedural complications. Hence USG guided lung biopsy will be good alternative for peripheral lung lesions in the hands of chest physicians.
Endo-bronchial ultrasound-guided intra cardiac needle aspiration/biopsy: Pushing the Boundaries
Virender Pratibh Prasad, Chetan Rao Vaddepally, Venkata Nagarjuna Maturu
Department of Pulmonary Medicine, Yashoda Hospitals, Somajiguda, Hyderabad, India. E-mail: vpratibh712@yahoo.co.in
Background: Obtaining biopsy from intra-cardiac lesions, especially from the left heart is challenging, and the conventionally used methods are either invasive or involve significant risks. We report a case with suspected metastatic disease to heart, in whom EBUS guided trans-bronchial intra-cardiac needle aspiration (ICNA) was safely performed.
Case Study: A 25-year lady presented with headache, giddiness and exertional dyspnea for one-month. MRI brain showed multiple enhancing lesions, suspicious of metastases. PET-CT revealed 8.5 x7.0x10.8cm non FDG-avid cystic mass in left upper lobe. A large thrombus was noted extending from pulmonary veins into LA (SUV-Max:19.3). CT guided biopsy of LUL mass revealed necrosis with inflammatory cells. Coronal reconstruction of PET scan showed the LA thrombus abutting LMB. On EBUS the LA mass was visualized from LMB. Doppler was used to select appropriate area for biopsy and monitor for bleeding. Four passes were made using 21G-TBNA needle. ROSE confirmed presence of malignant cells. No intra/post procedural complications were encountered. HPE was suggestive of adenocarcinoma of pulmonary origin.
Discussion: Ours is the first case where trans bronchial sampling of LA mass was performed using EBUS. Procedure was safe and yielded adequate material for HPE, IHC and Molecular studies. EBUS-ICNA has several advantages over traditional trans-vascular sampling of LA lesions such as real-time visualization and targeting, avoiding damage to cardiac valves and eliminating use of fluoroscopy.
Conclusion: Trans Bronchial EBUS-ICNA is a novel technique for performing biopsy of intra atrial masses. It may be performed in cases where alternative routes of biopsy are not feasible or inconclusive.
Surgical outcomes of pneumonectomy for benign disease
Sukhram Bishnoi, Mohan Venkatesh Pulle, Harsh Vardhan Puri, Belal Bin Asaf, Arvind Kumar
Institute of Chest Surgery, Medanta – The Medicity, Gurguram, Haryana, India. E mail: dr_sukhs5@yahoo.com
Introduction: Pneumonectomy for benign disease is still considered to be a challenging procedure, with morbidity and mortality several times higher than pneumonectomy for a malignant condition. In this study, we aim to report the surgical outcomes of pneumonectomy for benign diseases operated at a high volume tertiary care centre.
Methods: This study is a retrospective analysis of prospectively maintained data of operated cases of pneumonectomy for benign diseases from March 2012 to June 2021 and includes data from 93 patients. An analysis of demographic characteristics and perioperative variables, including complications, was carried out. Postoperative morbidity and mortality were analysed.
Results: Patients’ age ranged from 12 to 58 years with a 38 to 55 male-female ratio. The mean operative time of pneumonectomy was 211 minutes (159 to 423 minutes) and the mean intraoperative blood loss of the procedures was 504 (100–1500) ml. The hospital stay ranged from 5 to 12 days (mean of 6.5 days). Over all Morbidity in our post pneumonectomy patients is7.52. % and mortality is 2.15 %. The median follow-up of 58 month with range of (6 to 104 months).
Conclusion: Pneumonectomy for patients with benign disease may be more difficult and challenging than malignant one but with proper patient selection and meticulous operative technique he post-operative morbidity and mortality can be kept under acceptable limits.
Is VATS feasible in bronchiectasis? A retrospective analysis from a dedicated chest surgery center in India
Sukhram Bishnoi, Mohan Venkatesh Pulle, Harsh Vardhan Puri, Belal Bin Asaf, Arvind Kumar
???, Institute of Chest Surgery. Medanta – The Medicity, Gurguram, Haryana, India. E mail: dr_sukhs5@yahoo.com
Introduction: Surgical resection is required in localised bronchiectasis in patients not responding to medical management. Traditionally open thoracotomy has been the preferred approach because of anticipated dense adhesions, enlarged stuck perivascular lymph nodes and high chance of bleeding. In recent years Video-assisted thoracic surgery has evolved as a valid alternative in properly selected cases. We herein report our experience with thoracoscopic management of bronchiectasis.
Patient and Methods: This study is a retrospective analysis of prospectively maintained data of 141 operated cases of bronchiectasis from March 2012 to June 2021. The patient records were thoroughly analysed for demography, clinical presentation, the procedure performed (open or VATS), post-operative complications and course during 6 months’ follow up.
Results: The patients were aged between 19 to 68 years with 97 (68.79) males and 44 (31.21) females. The average blood loss was 204 ml and the average operative duration was 134 minutes. Total 8 patients required conversion because of difficult hilar anatomy, however no emergency conversion was done. There was no operative mortality. The Median hospital stay was 5.5 days (range 3-15 days) and median chest tube removal was at 4.5 days (Range 2-11 days). Fourteen patients had prolonged air leak (>7 days). No other complication was noted in any of the patients. During follow up (Median 58-month, range of 6 to 96 months) 3 patients had recurrence of haemoptysis which was managed with angioembolization.
Conclusions: VATS lung resection is a safe, feasible, and effective treatment for bronchiectasis with low morbidity.
Flexible fiberoptic bronchoscopy: A safe and effective procedure for extraction of adult airway foreign bodies
Jeenam Shah, T. K. Jayalakshmi, Bhumika Madhav, Gokul Bathe
Department of Pulmonary Medicine, Apollo Hospitals, Navi Mumbai, Maharashtra, India. E-mail: gokulbathe@gmail.com
Background: Foreign body aspiration can be a life-threatening emergency. An accidental FB aspiration is relatively rare in adults than children. An aspirated solid or semisolid object may lodge in the larynx or trachea. Signs and symptoms are less severe when object passes beyond the carina. Patients often do not remember the event of choking or aspiration.
Case: A 25 year old male with no prior comorbidities presented to the OPD with complaints of cough and haemoptysis, since 4 days. History of binge alcohol intake 4 days prior to the episode. No any other significant past history. CTPA was done revealed a small hollow cone shaped intraluminal radio-density at origin of left posterior basal segmental bronchiole. Flexible v/s Rigid Bronchoscopy was planned. Flexible bronchoscopy was performed under sedation. FB identified at the left lower lobe posterior segment. It was conical in shape with a small distal opening. Fogarty catheter (4 Fr) was passed beyond the opening-inflated and FB was pulled out till the carina. Rat tooth forcep was used to pull out the FB. It was 2cm sized cone shaped pen cap. Check bronchoscopy was done and hemostasis was achieved. Post procedure patient condition improved and was discharged in hemodynamically stable condition.
Conclusion: In case of a hollow cylindrical/conical FB which is impacted in bronchus-fogarthy catheter can be used. It has a very small diameter (around 1.5mm for 4 Fr size) which can easily pass through distal small opening .Flexible bronchoscopy can help to remove such foreign body and avoid complex procedures which can further reduce morbidity and length of hospitalization.
Bronchoscopic treatment of post COVID post endotrachal intubation tracheal stenosis
Manish Aggarwal, Rajiv Goyal, Sruthi Mohan
Jaipur Golden Hospital, New Delhi, India. E-mail aggarmanish@gmail.com
Background: Covid 19 has rapidly spread to a worldwide pandemic. Approximately 3.5-4% patients requiring invasive ventilator support. One of the common & serious complication of prolonged intubation is post intubation tracheal stenosis (PITS). The incidence of tracheal stenosis following laryngotracheal intubation & tracheostomy has been said to range from 6%-21% and 0.6%-21%, respectively
Case Report: Here is a case report of 2 male patients who were postcovid,post intubation with significant tracheal stenosis in subglottic area. One among them had undergone multiple tracheal dilatation and bronchoplasty. Under conscious sedation, assessment of airway done with FOB. Adequate dilatation done with electrocautery, CRE balloon and length of stenosis measured. Under GA, Dumon stent of appropriate size was deployed with the help of rigid scope. In both cases, high stitch suturing taken in subglottic area with a 16G cannula and biopsy forceps to prevent migration of stent. Check bronchoscopy showed significant endoluminal patency with stent insitu.
Discussion: Central airway obstruction (CAO) can be due to malignant and nonmalignant etiology .Post intubation post tracheostomy stenosis is a common cause of nonmalignant CAO. Therapeutic approach includes balloon bronchoplasty, electrocautery / laser therapy, airway stents, and surgery. Better results are reported when bronchoplasty is followed by stenting as bronchoplasty often results in restenosis.
Conclusion: Patients with post Covid-19, post intubation tracheal stenosis who were surgically inoperable \ was effectively treated with bronchoscopic balloon dilation followed by silicon stenting.
The profile and outcomes of therapeutic bronchoscopic management of central airway obstruction due to malignant disease in a tertiary care center in southern India
Lakshminarayana Jasti, Balamugesh Thangakunam, Barney T. J. Isaac, Devasahayam J. Christopher
Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India. Email: jastilaxman@gmail.com
Background: Therapeutic bronchoscopy is performed to relieve central airway due to malignant disease, often with palliative intent. There is paucity of literature from India.
Methodology: We did a retrospective analysis of therapeutic bronchoscopies done for central airway obstruction (CAO) done under general anesthesia over a 12 years period. All relevant clinical, lab, radiology and procedural information was collected from the electronic medical records and analyzed.
Results: Seventy five patients underwent 97 procedures- 79% were elective and 21% emergency. The mean age was 43 years and 45 (60%) were males. The commonest malignancy was Carinoma lung 54(55%), followed by, esophageal in 12 (13%). Therapeutic procedures done were- debulking in 76 (78%) and stenting in 46 (47%) - 45% silicone & 54 % metallic. Forty seven percent were straight tracheal stents, 43 % Y-stents and 7% bronchial stents. Early complications were bleeding 17 (17%), desaturation 11 (10%), vocal cord injury 4 (4%), pneumothorax 6(6%), infection 7 (7%) and stent migration 1 (1%). There were 3 (3%) deaths on table or in the immediate post procedure period. Late complications included; stent migration 6 (6%) or stent block due to granulation or mucus plug 5(5%). After the procedure, patients experienced relief or substantial reduction of symptoms, often facilitating discharge from hospital. The median duration of hospital stay was 3.86 days. The overall, the procedure was deemed to be a successful in 85.5%, partially successful in 7% and failure in 3%.
Conclusion: Therapeutic bronchoscopy plays a useful role in managing life threatening CAO caused by malignancy, with substantial improvement of symptoms.
| Mass, n (%) | Nodule, n (%) | Plaque, n (%) | Adhesion, n (%) | |
|---|---|---|---|---|
| Metastatic adenocarcinoma (n=20) | 8 (40) | 15 (75) | 2 (10) | 2 (10) |
| Malignant lymphoma (n=1) | 1 (100) | |||
| Metastatic squamous cell carcinoma (n=1) | 1 (100) | 1 (100) | ||
| Tuberculosis (n=8) | 2 (25) | 5 (62.5) | 1 (12.5) | |
| Total (n=30) | 10 (33.3) | 12 (40) | 3 (10) | 3 (10) |
Role of fiberoptic bronchoscopy in patients presenting with hemoptysis
Dipanshu Jain, Anil Saxena, Suman Khangarot
Department of Respiratory Medicine, Government medical college, Kota, Rajasthan, India. dipanshu22@gmail.com
Introduction and Objectives: The coughing up of blood is termed hemoptysis. The material and amount produced varies from mere streaking of expectorated sputum to massive volumes of pure blood. Objectives of this study were to define the role of hemoptysis to study the BAL fluid analysis and to evaluate the diagnostic yield of bronchoscopy in patients presenting with hemoptysis.
Methodology: we studied 30 patients who presented with hemoptysis to the department of Respiratory Medicine, NMC Hospital Kota. All cases were interviewed, examined and investigated. Informed consent was taken and patients who met the exclusion criteria of our study were excluded from the procedure.
Results and Discussion: Gross bronchoscopic examination on 30 patients presenting with hemoptysis revealed congestion of the endobronchial lumen in (73.3%), ectasia in (40%), active bleeding /bleeding site was localized in (50%) patients. Analysis of BAL fluid came positive for malignant cytology in (13.3%), AFB in (10%), fungal elements in (13.3%) and bacterial culture in (10%).Forceps biopsy for histopathological examination came positive for squamous cell carcinoma in (10%) and adenocarcinoma in (6.7%) patients. Bronchoscopy resulted in definitive diagnosis in three-fourths of patients analysed in our study with a positive yield of (76.6%).
Conclusion: Fiberoptic bronchoscopy (FOB) Its an important and useful investigation in patients presenting with hemoptysis in determining the site of bleed and etiology of hemoptysis.
Diagnostic Efficacy of Bronchoalveolar Lavage Using Flexible Fibroptic Bronchoscopy
Dipanshu Jain, Anil Saxena, Suman Khangarot
Department of Respiratory Medicine, Government Medical College, Kota, Rajasthan, India. dipanshu22@gmail.com
Introduction: A prospective study conducted to assess the diagnostic capabilities of Bronchoalveolar lavage using a flexible fiberoptic bronchoscope in diagnosis of obscure lung pathologies.
Aim and Objectives:
1. To study the main indications for which the BAL analysis was being done
2. To find the yield of BAL using a flexible fibre optic bronchoscope, with regard to culture (pyogenic & fungal), gram stain, cytology & AFB.
3. To assess the impact of BAL findings on further management by assessing the outcomes.
Methodology: We studied 60 serial bronchoscopies with BAL in all age groups,
A reference group of 40 patients who refused the procedure/ were medically unfit to
undertake the procedure
Results and Discussion: In our study, we found that 38 of 60 patients returned a positive result in the study group as compared to only 10 out of 40 in the control group. BAL results were statistically superior to the Non BAL group (p value = 0.005).Also just 4 cases out of 60 experienced minor complications, which was easily reversible. Treatment outcomes were far superior in BAL group with 53.3 % patients making recovery as compared to only 15% in the Non BAL group.
Conclusions: Hence we opine that BAL using a FOB is a safe & reliable first line investigation.