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Otoscopy, rhinoscopy, and bronchoscopy are indispensable techniwues in ear, nose, and throat clinics and in diseases of the trachea and the bronchial tree. The quality of the instruments used in these techniques is of primary importance. The endoscopic procedures, the instruments used, and the indications for the examinations are discussed.
The reliability of self-reported smoking behaviour can vary and may result in bias if errors in misclassification vary with outcome. We examined whether self-report was an accurate measure of current smoking status in patients with malignant or non-malignant respiratory disease. Smoking behaviour was assessed by self-report and by analysis of whole blood for cotinine, a biomarker of exposure to cigarette smoke, in 166 patients attending a bronchoscopy clinic. Cotinine levels ranged from 2.5 to >400 ng ml(-1) blood and were higher in self-reported current smokers (173+/-123 ng ml(-1)) than in never smokers (3.7+/-8.7 ng ml(-1)) or ex-smokers (20.5+/-49.0 ng ml(-1)). Cotinine levels in self-reported current smokers increased with the numbers of cigarettes smoked (p=0.06), and levels in smokers and ex-smokers decreased with the reported length of time since the last cigarette (p=0.001). Using a cotinine level of 20 ng ml(-1) and self-report as the gold standard, the sensitivity and specificity for defining current smoking status were 90.2% and 82.4%, respectively. Out of a total of 125 self-reported current non-smokers, 23 (18.4%) had cotinine levels greater than 20 ng ml(-1). Smoking prevalence was significantly underestimated by self-report (24.7%) when compared with that defined using blood cotinine levels (36.1%: p<0.001). Misclassification of current smoking status was particularly high in ex-smokers, in patients without malignant respiratory disease, in men, and in those below the median age. Such differential misclassification may result in bias in studies examining associations between current smoking habits and disease risk.
Our experience with interventional bronchoscopic techniques in a University Hospital is described: in 93 patients during a 5-year period, 149 interventional procedures (i.e., Nd-YAG laser photoresection and/or airway stenting and/or balloon dilatation) have been performed. Laser resection was successful in relieving major symptoms (intractable dyspnea, hemoptysis or retro-obstructive complications) in 35/41 (85%) of malignant indications, and in 18/19 (94%) of benign obstructions. Major complications included one death (1.6%) early in the series, and major nonfatal hemorrhage in three patients (5%), all with malignant disease. In 31/35 (89%) of malignant central airway stenoses treated with stents, respiratory symptoms could be palliated successfully. Mean survival after stenting was 6 +/- 5.3 months. In 20/23 (87%) of benign tracheal stenoses, temporary or permanent stenting allowed for complete restoration of airway patency. The development of inexpensive and simplified insertion techniques for existing stents, and of a new (and even less expensive) type of tracheal stent has enabled the use of airway stenting in all categories of patients. Bronchoscopic balloon dilatation was helpful in the mechanical dilatation of stenoses, and in the unfolding of unopened stents. Finally, a plea for an organised referral system and for active collaboration between interventional bronchoscopy centers is made.
Between March and June 1988, Rhodotorula rubra was isolated from the bronchial washings of 30 of 56 (54%) patients undergoing bronchoscopy at a North Carolina community hospital. Pulmonary disease consistent with invasive fungal pneumonia was not apparent for any patient. Repeat sputum cultures were performed on 11 patients, none of whom were positive for R rubra. Investigation revealed fungal contamination of two brushes used to clean the bronchoscope channels and one positive sample of the tub water used to test the integrity of the bronchoscope prior to cleaning and disinfection. Control measures instituted were high-level disinfection of all equipment used to clean the bronchoscopes, including the brushes, complete air drying of the bronchoscopes before storing and storage of equipment in closed cabinets. An additional case one month after instituting these measures prompted the addition of a final 70% ethyl alcohol rinse of the bronchoscopes immediately prior to storage. Over a six-month period no additional cases have been identified. Despite published disinfection guidelines, pseudoepidemics and infections from contaminated equipment continue to appear. This pseudoepidemic investigation revealed a site for contaminating bronchoscopes that has not been previously reported, the inner cannula cleaning brushes. This emphasizes the need for stringent adherence to recommended cleaning and disinfection guidelines.
Mycobacterium gordonae and rapidly growing "atypical" mycobacteria including Mycobacterium chelonae are commonly found in tap water. This article describes a pseudo-outbreak of M chelonae infections related to bronchoscopy. Because patients may be treated and isolated unnecessarily when positive with acid-fast bacilli before the species are known, the financial burden for patients and hospitals may be great.
The possible use of fluorescence bronchoscopy for localization of bronchogenic tumours at the carcinoma in situ stage has been investigated. The target lesion is 80 micrometer thick with a mass of 250 microgram, containing 250 pg of haematoporphyrin derivative. The injected haematoporphyrin-derivative is preferentially taken up or retained by a malignant tumour, and can be detected in small amounts by its red flourescence under illumination by violet light. Previous clincial trials were successful in detecting tumours, but the instrumentation was only marginally adequate, the fluorescent compound was not standardized and no measurements or calculation of sensitivity were made. In this work, a fibreoptic bronchoscope system with a 200 W mercury vapour lamp, special violet-transmitting light conductor, sharp cut-off blue and red filters and three-stage image intensifier tube was designed and assembled. Measurements in vitro indicate the design objectives were met, and test on tumours are in progress.
A microspray nozzle has been developed for the localized administration of solutions or suspensions to discrete pulmonary airway regions via bronchoscopy. Toxicants or tracer particles can be administered to single or multiple, specific lung airway segments. This permits studies of local-airway, whole-lung, and systemic responses to inhaled materials. The nozzle is fabricated by ultra-precision machining, has an overall length of 1 mm, and a diameter small enough to fit in the end of a 1.1-mm inner diameter, 1.2-mm outer diameter catheter. In vitro studies demonstrated the delivery efficiency for 99mTc solutions (98 +/- 1% SD) and for suspensions of 99mTc sulfur colloid or 3-mum 85Sr-labeled microspheres (55 +/- 15%). Photographic and gamma camera images of material deposited in the airways of Beagle dogs demonstrated in vivo that the deposition patterns are compact and uniform. The technique may also have therapeutic medical applications.
A technique for ventilating patients thorugh a catheter with nitrous oxide and oxygen utilizing the venturi principle is described for patients undergoing laryngoscopy or bronchoscopy. Arterial blood-gas measurements in 34 patients reveal that ventilation was adequate.
The use of the standard 4-mm cuffed endotracheal tube to deliver manually or mechanically interrupted jets of oxygen or nitrous oxide and oxygen into the trachea allowed bronchoscopy and other related procedures to be performed with advantage to the patient, the surgeon and the anawsthetist. This paper describes the equipment used and the advantages obtained.
One hundred and fifty patients were ventilated artificially during bronchoscopy using a Bird Mark 2 ventilator with either oxygen or a nitrous oxide in oxygen mixture as the driving gas. Satisfactory conditions for the examination were achieved. There was no significant deterioration in PaO2 or PaCO2.
Six patients with airway stenosis were submitted to bronchoscopy under general anaesthesia. Each was ventilated with a gas mixture of 50% oxygen and nitrogen using successively manual jet insufflation (JV) using the Sanders technique at 20 b.p.m., and high frequency jet ventilation (HFJV) at rates of 150, 300 and 500 b.p.m. The effects on alveolar ventilation were assessed by blood-gas analysis and the transcutaneous monitoring of carbon dioxide tension. It is concluded that HFJV achieves satisfactory operating conditions, and provides adequate gas exchanges up to a rate of 300 b.p.m. At the faster rate some degree of hypoxaemia and hypercarbia were noted. The correlation between PaCO2 and transcutaneous carbon dioxide tension was satisfactory.
Fibreoptic bronchoscopy was undertaken in 26 patients upon hospital admission, to assess if they were suffering from pulmonary lesions subsequent to the aspiration of gastric contents. In 24 of these patients erythematous lesions were observed (sensitivity of the procedure: 92.3%), mainly on the carina. Distal to the carina, the lesions were observed less frequently. The procedure caused no complications in any of the patients studied.
We have compared sedation for fibreoptic bronchoscopy provided by incremental doses of midazolam with that provided by a computer-controlled infusion of propofol. These two methods were compared in terms of operator and patient acceptability, anxiolysis, effects on systolic arterial pressure and oxygen saturation. Tests were made also of memory and motor reactions, before and 60 min after the end of the procedure. Acceptability to operators and patients was high in both groups. There were no significant differences between the groups in systemic arterial pressure or anxiolysis. Oxygen saturation decreased in both groups (propofol group median 83% (range 69-95%); midazolam group median 86% (range 77-95%)) (ns). The median recovery time was 5 min (range 5-10 min) in the propofol group and 10 min (range 5-40 min) in the midazolam group (P < 0.01). Memory and motor reaction times 60 min after the end of the procedure did not differ from baseline in the propofol group, but were significantly impaired in the midazolam group.
We describe a case series of seven patients that demonstrates the usefulness of rigid bronchoscopy in percutaneous tracheostomy. The technique was used in selected patients who had a previous tracheostomy, a difficult airway, high risk of bleeding, or a tracheal stent in place.
Concentrations of levofloxacin were measured in bronchial biopsies, alveolar macrophages (AM), epithelial lining fluid (ELF) and serum following a single oral dose. Concentrations were measured by a microbiological assay method. A total of 35 patients undergoing fibre-optic bronchoscopy were studied. Mean serum, AM, ELF and biopsy concentrations were as follows. 0.5 h: 4.73 mg/L, 19.1 mg/L, 4.74 mg/L and 4.3 mg/kg; 1 h: 6.6 mg/L, 32.5 mg/L, 10.8 mg/L and 8.3 mg/kg; 2 h: 4.9 mg/L, 41.9 mg/L, 9.0 mg/L and 6.5 mg/kg; 4 h: 4.1 mg/L, 27.7 mg/L, 10.9 mg/L and 6.0 mg/kg; and 6-8 h: 4.0 mg/L, 38.4 mg/L, 9.6 mg/L and 4.0 mg/kg respectively. Mean serum and AM concentrations at 12-24 h were 1.2 and 13.9 mg/L respectively (concentrations in biopsy and ELF were only measurable in three of the six patients). These concentrations exceed the MIC90s of the common respiratory pathogens, Haemophilus influenzae (0.015 mg/L), Moraxella catarrhalis (0.06 mg/L) and Streptococcus pneumoniae (1 mg/L) and suggest that levofloxacin should be efficacious in the treatment of community- and hospital-acquired respiratory infection.
The concentrations of clinafloxacin were measured in serum, bronchial mucosa, alveolar macrophages and epithelial lining fluid after single 200 mg oral doses of clinafloxacin had been administered to 15 subjects who were undergoing bronchoscopy. Concentrations were measured using a microbiological assay method. Mean concentrations in serum, bronchial mucosa, alveolar macrophages and epithelial lining fluid at a mean of 1.27 h post-dose were 1.54, 2.65, 15.60 and 2.71 mg/L respectively. These site concentrations exceeded the MIC90 for common respiratory pathogens and indicate that clinafloxacin is likely to be effective in the treatment of a wide range of respiratory tract infections.
The concentrations of moxifloxacin achieved after a single 400 mg dose were measured in serum, epithelial lining fluid (ELF), alveolar macrophages (AM) and bronchial mucosa (BM). Concentrations were determined using a microbiological assay. Nineteen patients undergoing fibre-optic bronchoscopy were studied. Mean serum, ELF, AM and BM concentrations at 2.2, 12 and 24 h were as follows: 2.2 h: 3.2 mg/L, 20.7 mg/L, 56.7 mg/L, 5.4 mg/kg; 12 h: 1.1 mg/L, 5.9 mg/L, 54.1 mg/L, 2.0 mg/kg; 24 h: 0.5 mg/L, 3.6 mg/L, 35.9 mg/L, 1.1 mg/kg, respectively. These concentrations exceed the MIC(90)s for common respiratory pathogens such as Streptococcus pneumoniae (0.25 mg/L), Haemophilus influenzae (0.03 mg/L), Moraxella catarrhalis (0.12 mg/L), Chlamydia pneumoniae (0.12 mg/L) and Mycoplasma pneumoniae (0. 12 mg/L) and indicate that moxifloxacin should be effective in the treatment of community-acquired, lower respiratory tract infections.
The concentrations of gatifloxacin achieved after a single 400 mg oral dose were measured in plasma, epithelial lining fluid (ELF), alveolar macrophages (AMs) and bronchial mucosa (BM) using a microbiological assay. Fourteen patients undergoing fibre-optic bronchoscopy were studied. Mean plasma, ELF, AMs and BM concentrations, respectively, at 2, 4 and 12 h were as follows: 2 h: 3.96 mg/L, 6.00 mg/L, 69.10 mg/L, 6.24 mg/kg; 4 h: 3.22 mg/L, 6.16 mg/L, 77.32 mg/L, 5.32 mg/kg; 12 h: 1.74 mg/L, 2.98 mg/L, 61.95 mg/L, 3.00 mg/kg. These concentrations exceed the MIC(90)s for common respiratory pathogens such as Streptococcus pneumoniae (0.5 mg/L), Haemophilus influenzae (0.013 mg/L), Moraxella catarrhalis (0.05 mg/L), Chlamydia pneumoniae (0.125 mg/L) and Mycoplasma pneumoniae (0.06 mg/L).