Medical Inspection – Health Blog

use of inappropriate instruments for bronchos­copy is a major potential pitfall. Flexible broncho­scopes at least partially obstruct the airway, and the instrument used should be small enough to allow adequate ventilation if possible. On the other hand, it is also possible to employ an instrument which is inappropriately small for the task at hand. The “ultra- thin” flexible bronchoscopes do not have suction channels, and it may therefore be very difficult to adequately visualize the airways with such an instru­ment if there are excessive secretions. The bronchos­copist must be certain that the appropriate structures have been adequately visualized.

A more insidious problem is the use of a flexible bronchoscope when a rigid instrument should be used instead. While in general I believe that the flexible instruments are superior for diagnostic purposes, there are several distinct situations in which use of the rigid bronchoscope may be essential to reach an accurate diagnosis. The rigid instrument approaches the glottis from the anterior aspect, and it is often difficult to adequately evaluate the anterior aspect of the glottis with a rigid instrument. On the other hand, the flexible instrument approaches the glottis (via the transnasal route) from the posterior aspect, and must be flexed anteriorly to view the glottis. Thus, it may be difficult to adequately evaluate the posterior aspect of the glottis with a flexible instrument. Therefore, the examination of a patient with suspected H-type tracheoesophageal fistula or a suspected laryngeal cleft is probably best performed with a rigid broncho­scope. The lens of the flexible bronchoscope is at the extreme distal end of the instrument; this makes it very difficult to manipulate the tissues under direct vision, as can be done with a rigid bronchoscope or laryngoscope. Vocal cord movement is most appropri­ately evaluated under topical anesthesia (and sedation) rather than general anesthesia, and the flexible instru­ments are usually adequate. However, if the vocal cords do not abduct, the problem may be either paralysis or interarytenoid fixation. These possibilities can best be distinguished with a rigid instrument, since the cords can be separated by the tip of the bronchoscope while their movement is observed through the telescope.

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Flexible bronchoscopy is an important diagnostic (and sometimes therapeutic) tool that is under­utilized in infants and children in many centers today. It is a relatively simple technique, but the unwary or inexperienced bronchoscopist can readily get into trouble, as there are many potential pitfalls. This article will review some of these pitfalls from the perspective of my own experience with more than 2,500 pediatric procedures over the past 16 years.

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Diagnosis: Benign intrapulmonary teratoma and ipsilateral cystic bronchiectasis

Intrathoracic teratomas almost always occur in the mediastinum, and only very rarely arise within the lung. By 1978, Holt et al^l found 13 histologically confirmed lung teratomata in the world literature. Since then, three have been added to the English, and one to the German literature. Seven tumors have been located in the left upper lobe, three in the right upper lobe, and six confined to the middle and lower lobes; in one, the exact intrapulmonary site was not listed. Eleven tumors have been malignant and six benign. In our patient, the tumor was benign and situated in the right upper lobe. Though extension into the mediastinum was demonstrated, histologic evidence of a primarily intrapulmonary location was convincing. Sections showed pancreatic tissue in direct continuity with bronchioles and cavities; further evi­dence of this included the presence of a tuft of hair protruding from the upper lobe bronchus on the resected specimen. Reported symptoms associated with pulmonary teratoma have been prolonged and have included cough, hemoptysis, chest pain and trichoptysis. Plain roentgenographs features are of a calcified mass, which may show peripheral translucent areas. In our patient, though calcification was seen, even in retrospect the mass was not discernible on the chest radiographs due to destruction of the contig­uous lung. CT appearances were more helpful, indi­cating a mass of complex structure containing punctate calcification and areas of high local fat content. CT also demonstrated the degree of mediastinal invasion and relationship of the tumor to vascular structures.

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A 31-year-old black nurse was most recently admitted for assessment of recurrent hemoptysis and se­vere bronchiectasis. The patient had been well to age 15, when she began suffering recurrent respiratory tract infections and fevers. At ages 20 and 22 years, partial right pneumonectomies were performed for recurring hemoptysis.

Chest radiographs demonstrated extensive bronchi­ectasis in the right lung associated with fibrosis and volume loss. Punctate calcifications were noted in the right suprahilar and paratracheal regions where there was severe fibrotic and architectural distortion. An air space opacity was identified in the lingula with possi­ble underlying bronchiectasis. The remainder of the left lung appeared normal (Fig 1). Fiberoptic bron­choscopy revealed edematous granular mucosa with copious purulent secretions in all of the visualized right bronchial tree. No abnormality was identified in the left system.

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Other studies warrant brief discussion for the sake of completeness. In a retrospective analysis of 123 patients with spinal cord injury, Reines and Harris found that respiratory complications (atelectasis and pneumonia) occurred during the first month of hospi-talization in 35.7 percent of patients. Among a sub-group of 20 patients treated with the RRKTT, however, the pulmonary complication rate was only 10 percent, suggesting that continuous postural oscillation was beneficial in this regard. Quite similar results were obtained in an earlier, smaller retrospective study of therapy with the RRKTT for spinal cord injury victims. Other studies, however, do not support the findings presented here. For example, Torrington et al reported that postoperative chest percussion and postural drainage failed to affect the incidence of postoperative pulmonary complications after gastric bypass surgery. It is not clear why intermittent chest physiotherapy is apparently less effective than treat¬ment with an oscillating bed, although the more sustained treatment afforded by the latter approach may be important. We can only speculate about the possible mecha-nisms that account for the observed beneficial effects of continuous postural oscillation. Experimental data support the idea that immobility leads to the formation of edema in dependent portions of the lung. Other data suggest that pulmonary edema impairs clearance of bacteria from the lung. Thus, continuous postural oscillation may work by improving clearance of bacteria from the tracheobronchial tree by ameliorating the tendency toward edema formation in dependent lung zones. Regardless of the mechanisms involved, our results suggest that the routine use of oscillating beds can decrease the incidence of pulmonary sepsis in patients with serious injuries due to blunt trauma. Since previous studies as well as our own data suggest that the risk of LRTI is especially high in victims of major head trauma, kinetic therapy may be particularly beneficial in this population of patients. This may be true also for very badly injured patients (ISS >=35), since the present data showed that this population had an increased likelihood of developing LRTI in the SICU.

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We showed that continuous postural oscillation decreased the incidence of LRTI and pneumonia and shortened the median hospital stay for victims of nonpenetrating trauma. Patients in the control arm received standard nursing care, including turning from side to side every 2 h (although the efficacy of this effort to turn patients was sometimes compromised by the presence of skeletal traction devices). Although the mean ISS and APACHE-II scores were somewhat lower for the patients randomized to the study bed, the differences were small and not statistically signif-icant. It is unlikely, therefore, that differences between groups in severity of injury or physiologic derangement were responsible for the observed differences in incidence of LRTI and pneumonia. More patients with major head trauma were randomized to the control group, but it is unlikely that this can explain the observed effect of postural oscillation, since logistic regression analyses showed that treatment with a conventional hospital bed remained a significant risk factor for LRTI and pneumonia, even when severity of injury (ISS) and major head trauma were simultaneously considered in the model. Furthermore, when patients with and without major head trauma were analyzed separately, the conclusions were similar, although when LRTI was the outcome variable, the beneficial effect of the oscillating bed barely missed achieving statistical significance, possibly because of inadequate sample size.

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Since including patients who died early in their course might confound interpretation of LOS (in SICU and hospital) and duration of intubation, we analyzed these variables in two ways (ie, for all patients and for survivors only) (Table 2); LOS in the SICU was shorter for patients in the RRKTT group. The difference between groups for this variable approached statistical significance (p = 0.0645 and p = 0.0535, for all patients and survivors, respectively). Hospital LOS and dura¬tion of intubation were significantly shorter for patients in the RRKTT group.

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