While travelling abroad in 2006, the patient had an episode of acute respiratory distress of unknown aetiol-ogy (endoprosthesis obstruction or migration), which was managed by a large incision tracheostomy. This pro-cedure was technically difficult, since the endoprosthesis was still in place, and resulted in a major loss of tracheal and cutaneous tissue. Upon his return to France, a new, longer tracheal endoprosthesis was inserted (70 mm), in order to cover the tracheal and cutaneous gap as well as the subglottic, suprastomal stenosis.Figure 1 shows a cervical outside view of the endopros-thesis, which was implanted 37 months ago. Figure 2
<b><i>Background:</i></b> The management of airway bleeding is generally performed in an emergency to prevent hypoxemia and lung flooding. When the bleeding arises from peripheral lesions that are not visible endoscopically, bronchoscopic options have limited curative intents. Endobronchial embolization using silicone spigots (EESS) is a novel approach. <b><i>Objectives:</i></b> We analyzed the efficacy and safety of EESS in a retrospective study. <b><i>Methods:</i></b> We retrospectively reviewed charts of patients referred to our center for moderate hemoptysis (MH) who underwent EESS. Successful management is defined as immediate bleeding cessation. <b><i>Results:</i></b> From December 2008 to January 2012, 9 patients were treated with EESS in our endoscopy unit. The MH originated from the left upper lobe in 4 cases, the right upper lobe in 3 cases and the right middle lobe and left lower lobe in 1 case each. Thirteen spigots were inserted. The success rate was 78%. Of the 9 patients, 7 were referred to interventional radiology for bronchial artery embolization, with a success rate of 86%, and 2 were referred for thoracic surgery. One patient had EESS as definitive treatment; the silicone spigots were bronchoscopically removed after a median of 4 days in 6 of the remaining 8 patients. Only 2 patients had hemoptysis recurrence after a median follow-up of 107 days (ranging from 13 to 1,017 days). None of the patients died from hemoptysis. <b><i>Conclusion:</i></b> EESS is an original, temporary technique that requires only a flexible bronchoscope and biopsy forceps for placement and removal. EESS ensures airway protection while waiting for definitive management.
Medical thoracoscopy (MT) is the gold-standard to investigate unexplained pleural exudates. However, the major prerequisite is an easy pleural access obtained by creating an artificial pneumothorax at the beginning of the procedure which can be a challenge in case of pleural adhesions and make the procedure unsafe. The detection of pleural adhesions prior to MT is necessary. Nowadays chest ultrasonography (CUS) is considered the best procedure to detect pleural adhesions. However, this technique is not available in all countries where the assessment of the pleural cavity is only based on chest radiography. Therefore, we conducted this study to compare the performance of lateral decubitus chest radiography (LDCR) and CUS to predict pleural adhesions.LDCR and CUS were performed prior MT in consecutive patients presenting exudative pleural effusion to detect pleural adhesions. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for each pre thoracoscopy procedure were calculated.Data analysis for the sixty-six enrolled patients showed a higher superiority to detect pleural adhesions for CUS in comparison to LDCR for all the parameters analyzed.These results confirm that pre-MT CUS is the cornerstone to evaluate the access to the pleural cavity and justify educational program in this field in all centers which intends to develop interventional pulmonology.
Self-expandable metallic (SEM) airway stents are an important approach to treating malignant central airway obstruction (CAO). Standard over-the-while (OTW) stent needs the guidance of a guide-wire. It should be implanted under flouroscopy or the guidance of bronchoscope visualization. In this study, we evaluated the operation time and safety between OTW stent and a novel through-the-scope (TTS) SEM airway stent.In this multi-center, randomized, parallel-group superiority study, malignant CAO patients were enrolled randomly assigned (2:1) to the TTS stent implantation group (TTS group) or the standard OTW stent group (OTW group) in six sites across China. The entire process of all surgical procedures was recorded by video. Primary endpoint was the operation time of the airway stent implantation and secondary endpoint was the success rate of the stent implantation as well as its efficacy and safety.From May 15, 2017, to December 30, 2018, 148 patients were enrolled from the six sites. We analyzed 134 patients (including 91 patients from the TTS group and 43 patients from the OTW group) according to the per-protocol set. There were no significant differences in the ages, genders, underlying diseases, and stenosis sites between the two groups. The operation time in the TTS group was significantly shorter than that in the OTW group (104±68 vs. 252±111 seconds, P<0.001). Compared to the OTW group, the efficacy of stent implantation (97.80% vs. 90.70%, P=0.093) and rate of first-time successful stent implantation (78.02% vs. 74.42%, P=0.668) were higher in the TTS group, but did not reach statistically significance. The rates of granulation (28.57% vs. 41.86%, P=0.128) and restenosis (15.38% vs. 30.23%, P=0.064) in the TTS group were slightly lower as compared with the OTW group without achieving statistical significance.The TTS stent implantation procedure time was significantly shorter than that of the OTW airway stent with similar efficacy and complications, which might reduce the risk and flexibility of stent implantation.Chinese Clinical Trial Registry ChiCTR-IOR-17011431.
Background: As the endobronchial valves (EBV) were successfully developed as treatment for severe emphysema, its main complication, pneumothorax, remained an important concern (prevalence reported as 26% in a recent published meta-analysis). Objective: To assess whether the placement of Zephyr endobronchial valves throughout 2 procedures instead of 1 minor the frequency of pneumothorax without lowering its benefits. Methods: This retrospective study was conducted in 15 pulmonology departments in France. All patients met the inclusion criteria defined by the expert panel on the Endoscopic Lung Volume Reduction (ELVR), updated in 2019. During the first procedure, all but the most proximal sub-segment of the targeted lobe were occluded. One month after, EBV were placed in the last subsegment. All patients were evaluated before and 3 months after the second procedure. Results: Between March 2018 and December 2019, 95 patients received EBV treatment. 12 patients (12.5%) presented a pneumothorax (3 after the 1st and 9 after the 2nd procedure). Beside pneumothorax, the main adverse event were exacerbation (21%) and pneumonia (5%). No death was reported. Significant improvements were found for FEV1 (14.6 ± 25.3%), RV (- 0.69 ± 2.1L), 6MWT (34.8 ± 45.9m), BODE Score (-1.41 ± 1.41pts), and mMRC scale (-0.85 ± 0.7pts). Our results are similar to the ones previously published with the usual 1 time procedure (Table 1). Conclusion: Placing EBV during 2 procedures instead of one led to a significant decrease of post treatment pneumothoraces. It did not increased the rate of other complications. It does not seem to alter the benefits of this therapy for severe emphysema.
ABSTRACT Background and objective Iatrogenic tracheal injury ( ITI ) is a rare yet severe complication of endotracheal tube ( ETT ) placement or tracheostomy. ITI is suspected in patients with clinical and/or radiographic signs or inefficient mechanical ventilation ( MV ) following these procedures. Bronchoscopy is used to establish a definitive diagnosis. Methods We conducted a retrospective, single‐centre chart review of 35 patients between 2004 and 2014. Depending on the nature and location of ITI and need for MV , patients were triaged to surgical repair, endoscopic management with airway stents or conservative treatment consisting of ETT or tracheotomy cannula ( TC ) placement distal to the wound and bronchoscopic surveillance. Results Three of the four patients (11.43%) presenting with tracheoesophageal fistula ( TEF ) underwent surgery. Seven patients (20%) who did not require MV underwent endoscopic surveillance. Of the 24 ventilated patients (68.57%), 7 with ITI in the lower trachea were treated with silicone Y‐stent ( ETT or TC was placed inside the stent) and 17 patients with ITI in the upper trachea were managed by placing ETT or TC cuff distal to the injury. Overall management success, defined as complete healing of the ITI , was seen in 88.57% of patients. Four patients (11.43%) died of non‐ ITI ‐related comorbidities. Conclusion Conservative management should be considered in non‐ventilated patients with ITI and when ITI is located in the upper trachea of ventilated patients where ETT or TC bypasses the injury. Airway stenting should be considered in ventilated patients with ITI located in the lower trachea. Surgery should be reserved for TEF and conservative and endoscopic management failure.
