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[The significance of bronchoscopic findings as a prognostic factor in inoperable adenocarcinoma of the lung].

The clinical value of bronchoscopic findings as a prognostic factor has been studied in 136 cases with an inoperable adenocarcinoma of the lung. The survival time in 107 cases with pathological bronchoscopic findings was significantly shorter than in 29 cases without pathological bronchoscopic findings. In the three subtypes of bronchoscopic findings, classified according to the tumor proliferation pattern, i.e. polypoid type, submucosal type and exposing type, the exposing type proved to have the worst prognosis. In addition, our study suggests that the level of infiltrated bronchus is related to the survival time. The more central the tumor infiltration, the worse the prognosis.

Adenocarcinoma↗

Relation between bronchoscopic findings and tumor size of roentgenographically occult bronchogenic squamous cell carcinoma.

A total of 105 lesions in 98 patients with roentgenographically occult bronchogenic squamous cell carcinoma were examined. The relationship of bronchoscopic findings to the depth of invasion into the bronchial wall and the length of longitudinal extension along the bronchus was documented. From viewpoints of the degree of difficulty of bronchoscopic detection and with reference to the height of the lesions, the bronchoscopic findings were classified into three categories: remarkable, minute, and hidden. Of the 105 lesions, 55 (52%) were remarkable, 27 (26%) were minute, and the remaining 23 (22%) were hidden. Of the 23 hidden lesions, 12 were within and 11 were beyond the range of endoscopic visibility. The maximal depth of bronchial invasion (mean +/- standard error) was 3.07 +/- 0.40 mm in the category designated remarkable and 1.62 +/- 0.47 mm in the category designated minute. The depth was 0.93 +/- 0.36 mm in the hidden lesions within the range of endoscopic visibility and 0.78 +/- 0.21 mm in the hidden lesions beyond the range of endoscopic visibility. The maximal length of longitudinal extension along the bronchus was 19.6 +/- 1.5 mm in the remarkable lesions, 9.9 +/- 1.4 mm in the minute lesions, 5.5 +/- 1.0 mm in the hidden lesions within the range of endoscopic visibility, and 8.6 +/- 2.1 mm in the hidden lesions beyond the range of endoscopic visibility. It is useful for predicting the depth of invasion to classify bronchoscopic findings into these three categories for the study of roentgenographically occult bronchogenic squamous cell carcinomas.

Aged↗

[Contamination of flexible fiberoptic bronchoscopes with Mycobacterium chelonae linked to an automated endoscope disinfection machine--on the relationship between the presence of the organism in the intestinal tract and contamination of disinfection machine, and a case of gallbladder and bile duct infection with M. chelonae].

In 1993, thirteen strains (8.7%) of M. chelonae were isolated from bronchoalveolar lavage fluid (BALF) obtained by bronchoscopy of 150 patients in Tachikawa-sogo (T) hospital, where the same automated disinfection machine was commonly used for cleaning, sterilization and disinfection of fiberbronchoscope and fibercolonoscope except 3 bronchoscopes disinfected by gas sterilization. Since January 1994, manual cleaning and sterilization has been applied for bronchoscope, and thereafter no strain of M. chelonae was isolated from BALF of 55 patients in the T hospital. While only one strain (3%) of M. chelonae was isolated from BALF of 33 patients in Ota (O) hospital, but many strains of M. chelonae were isolated from intestinal fluid obtained by fibercolonoscopy of the patients. Manual method of cleaning and disinfection was performed for both bronchoscopes and colonoscopes in the O hospital from the beginning. Based on these results, it was suggested that M. chelonae are commonly present in the colon (intestine) of normal persons. Thus colonoendscope may be often contaminated with the organism and subsequently the automated disinfecting machine may also be contaminated with the organism which is resist and against usual disinfection procedure, and resulted in bronchoscope contamination. If the presence of M. chelonae in intestinal tract is not rare, bile duct may be naturally infected with the organism. A case of cholecystitis and cholangitis caused by M. chelonae, which has not been reported previously, was found in the T hospital.

Aged↗

[Two cases of metastatic lung cancer examined by bronchoscopic cytology].

We herein report two cases of metastatic lung cancer examined with bronchoscopic cytology. The first case involved a 43-year-old female, who had undergone low anterior resection of the rectum for rectal cancer three years earlier. Routine chest X-ray showed a nodular lesion in the left upper area. Bronchoscopic examination revealed a mass occluding the left upper bronchus. Simultaneous bronchoscopic biopsy and washing cytology were performed. The cytological specimen consisted of cell clusters with tall columnar epithelium arranged in a palisading manner. The cytological findings strongly suggested metastatic adenocarcinoma originating from the colorectal region. The patient died from respiratory failure. Autopsy confirmed metastatic deposit of adenocarcinoma in the lung. Histologically, the tumor invaded the overlying bronchial wall and was exposed in the lumen. The second case was an 80-year-old female, who had been diagnosed as gastric cancer by the endoscopic examination one year earlier. She had refused surgical treatment. Routine chest X-ray showed reticulonodular lesions disseminated throughout the bilateral lungs. Bronchial endoscopy presented edematous mucosa of the right lower bronchus. Brushing cytology as well as punch biopsy were taken. Cytological examination revealed atypical cells with increased N/C ratio and reduced cohesiveness. The lesion was diagnosed as metastatic adenocarcinoma of gastric origin from cytological findings and clinical history. The patient died from respiratory failure. Postmortem examination revealed cancer cells in the lymphatic channels of the bronchial wall. Our two cases indicate that bronchoscopic cytology is useful for estimating the origin of metastatic cancer.

Adenocarcinoma↗

The diagnostic effectiveness of the flexible bronchoscope in children.

Over a 5-year period 1,000 pulmonary endoscopic procedures (172 laryngoscopies, 828 bronchoscopies) were performed in children less than 10 years of age using flexible fiberoptic bronchoscopes, with sedation and topical anesthesia. An endoscopic diagnosis of direct relevance to the primary indication for the procedure was established in 76% of the cases; in an additional 15%, abnormalities relevant to a secondary indication were found. Findings were normal in 9% of the cases. The bronchoscope was most useful in the evaluation of patients who had stridor, atelectasis, persistent wheezing, or a suspected foreign body for which there was insufficient evidence to warrant open-tube bronchoscopy, and for patients who had tracheostomies. The high diagnostic yield and low complication rate strongly support the use of the flexible bronchoscope in the diagnostic evaluation of infants and children who have a variety of pulmonary problems.

Bronchi↗

A study of glutaraldehyde disinfection of fibreoptic bronchoscopes experimentally contaminated with Mycobacterium tuberculosis.

Mycobacteria are difficult to inactivate, and concern about the spread of tuberculosis at bronchoscopy has a major influence on infection control practices. Recommendations from the UK Department of Health are based largely on in-vitro mycobactericidal assays which do not take into account the particular conditions encountered in endoscopy units. In this applied study cleaning and disinfection methods were examined using five bronchoscopes that were heavily contaminated with a recent isolate of Mycobacterium tuberculosis in sputum. Cleaning reduced contamination by a mean 3.5 log(10) colony forming units (cfu) per ml; all bronchoscopes were free of detectable mycobacteria after 10 min in 2% alkaline glutaraldehyde (AG). It is recommended that all bronchoscopes be thoroughly pre-cleaned and disinfected in 2% AG for 20 min as part of a uniform policy of infection control.

Bronchoscopes↗

An outbreak of Serratia marcescens traced to a contaminated bronchoscope.

An outbreak of colonization and infection with Serratia marcescens in a surgical Intensive Care Unit is described. A case-control study pointed to a bronchoscope as the source of the epidemic strain, and cultures of washing effluent of the incriminated bronchoscope yielded S. marcescens. Discontinuation of the use of the instrument and the implementation of recommendations for future use of bronchoscopes ended the outbreak.

Adolescent↗

Clinical evaluation of bronchopulmonary lavage using the flexible fiberoptic bronchoscope.

Thirty-three patients had segmental and lobar bronchopulmonary lavage using three types of flexible fiberoptic bronchoscopes. A maximum volume of 300 ml of normal saline solution at room temperature was used. Lavage was effective for removing large numbers of alveolar macrophages (mean, 17 million) and proteinaceous material (mean, 0.18 mg per milliliter) that helped enhance the antibacterial properties of the macrophages. Transient shunting (mean fall in partial pressure of arterial oxygen, 65 mm Hg) and alveolar filling that reverted to normal in 3 hours were noted. The procedure averaged 45 minutes and was as simple as bronchoscopy. The larger the internal diameter of the bronchoscope (> 2.6 mm) the better suited it was for lavage. Sequential segmental lavage seems to offer the advantages of simplicity and technical ease over isolated lobar lavage with a balloon-tipped bronchoscope. It also has the advantage of simplicity over whole-lung lavage.

Adolescent↗

A prospective randomized trial comparing the use of the flexible gastroscope versus the bronchoscope in the management of foreign body ingestion.

BACKGROUND: Foreign body ingestion is a common clinical problem in Hong Kong. Some recent reports have proposed the use of flexible nasoendoscopy for foreign body retrieval. The present study is a prospective randomized trial on the use of the flexible gastroscope and bronchoscope in the management of foreign body ingestion. METHODS: Two hundred sixteen patients older than 11 years were prospectively randomized to flexible endoscopic examination using either the gastroscope (108 patients) or the bronchoscope (108 patients). The duration of the procedure was noted. Patients were asked to assess their overall tolerance to the procedure on a scale of 1 (well tolerated) to 10 (unacceptable). RESULTS: A foreign body was retrieved in 68 patients (31.5%). There was no difference between the two groups in the foreign body retrieval rate, type of foreign body retrieved, duration of procedure, and tolerance level. In the group managed with the bronchoscope, however, three patients required the additional use of the gastroscope for foreign body retrieval at (for one patient) or below (for two patients) the cricopharyngeus. The patient's tolerance level was related only to the duration of procedure (rho = 0.386; p < 0.001). CONCLUSION: The use of the flexible gastroscope is recommended because of its efficacy, safety, and tolerability.

Adolescent↗

Disinfection of bronchoscopes, contaminated in vitro with Mycobacterium tuberculosis, Mycobacterium avium-intracellulare and Mycobacterium chelonae in sputum, using stabilized, buffered peracetic acid solution ('Nu-Cidex').

The efficacy of 0.35% stabilized buffered peracetic acid solution ('Nu-Cidex') against clinical isolates of Mycobacterium tuberculosis, Mycobacterium avium-intracellulare and Mycobacterium chelonae in homogenized sputum was tested. An in-use method, using an automated bronchoscope washing machine, showed that over 10 cycles, at a disinfectant contact time of 5 min, M. tuberculosis and M. chelonae were effectively eradicated from the bronchoscope, even in the absence of detergent and pre-cleaning. M. avium-intracellulare was not eradicated in only one of 10 cycles with contact times of 5 and 10 min, but numbers were reduced by > 7 log10 and > 5 log10, respectively. With detergent present, M. avium-intracellulare was successfully eradicated in all cycles at a contact time of 5 min or greater. The results demonstrate that peracetic acid is an effective mycobactericidal agent for use in the disinfection of bronchoscopes.

Bronchoscopes↗

Foreign body removal with the flexible fiberoptic bronchoscope.

Intrabronchial foreign bodies are occasionally encountered in adults but most available information in humans consists only of reports evaluating one or two cases. We surveyed our experience and found seven patients with intrabronchial foreign bodies who had been examined with the flexible fiberoptic bronchoscope, six of whom were managed successfully. Nine cases have been identified in the literature. Although there were no major complications in either our cases or those in the literature, several problems were identified which under other circumstances could have caused significant complications. We assessed all of these cases for situations which presented potential risk to the patient. These risks were grouped into the following problem categories: 1. selection of appropriate bronchoscope, 2. availability of appropriate instruments, 3. control of the foreign body, and 4. unexpected foreign bodies. Endoscopists planning to use the FFB in foreign body removal should be aware of the problems and hazards which may ensue if improperly managed, and should attempt to gain experience either in the animal laboratory or in models prior to approaching patients with foreign bodies with the flexible fiberoptic bronchoscope.

Adolescent↗

The present status of bronchoscopic Nd:YAG laser.

In Japan, the first bronchoscopic Nd:YAG laser applied clinically was performed in our institute 10 years ago, and based on this decade of experience, the indications, effectiveness, and limitations were studied. Between 1980 and 1989, a total of 202 cases were treated by Nd:YAG laser in our institute. Among them, 94 (46.5%) cases were primary lung cancers, 10 (5.0%) cases were primary tracheal malignancies, 56 (27.7%) cases were metastatic tracheal tumors, 6 (3.0%) cases were benign tracheal tumors, and 36 (17.8%) cases were nontumorous tracheal lesions. The indications for Nd:YAG laser therapy were defined as emergency widening of airway, curative treatment, reduction of tumor size, nontumorous benign lesions, and hemostasis. The desired therapeutic effects were obtained in 55/58 (94.8%) for emergency airway widening, 22/27 (81.5%) for curative treatment, 69/88 (78.4%) for reduction of tumor size, and 48/68 (70.6%) for nontumorous benign lesions. While performing Nd:YAG laser treatment, some limitations, such as poor residual pulmonary function, tumor size, tumor depth, cartilage structure, granulation, and stricture length, were encountered. Since bronchoscopic Nd:YAG laser treatment has become a well-established therapeutic modality for tracheobroncheal lesions, areas to be addressed in the future are the training of bronchoscopic laser therapists and research on the extension of applications. To increase the range of clinical applications, it is hoped that makers of laser systems will provide tunable wavelength machines at reduced cost.

Bronchoscopes↗

Measurement of bronchodilatation using a superfine fibreoptic bronchoscope.

In this study, we report the development and accuracy of a direct technique to measure airway calibre using a superfine fibreoptic bronchoscope. Ten mongrel dogs were anaesthetized with pentobarbitone and the trachea intubated with a tracheal tube; the small lumen of the tube allowed passage of a superfine fibreoptic bronchoscope (od 2.2 mm). Bronchial cross-sectional area and airway pressure were recorded continuously and dynamic pulmonary compliance and airway resistance calculated. The dogs were allocated to one of two groups. In the first group (six dogs), bronchoconstriction was induced with histamine 10 micrograms kg-1 i.v. and 500 micrograms kg-1 h-1 c.i.v. Thirty minutes later, adrenaline 0-0.4 mg kg-1 was given i.v. Bronchial cross-sectional area, dynamic pulmonary compliance and airway resistance were assessed simultaneously. In the second group, 0.9% saline was given 30 min after placement of the superfine fibreoptic bronchoscope and 10 min later atropine 0.1 microgram kg-1 was administered. In the first group, histamine decreased mean percentage bronchial cross-sectional area by 49.2 (SD 11.5) %, reduced dynamic pulmonary compliance from 32.1 (12.6) to 22.3 (5.2) ml cm H2O-1 and increased airway resistance from 39.1 (11.6) to 57.2 (10.2) cm H2O litre-1 s-1. Adrenaline produced a dose-dependent increase in percentage bronchial cross-sectional area and dynamic pulmonary compliance to 119.4 (31.3)% and 27.4 (5.5) ml cm H2O-1, respectively, and a decrease in airway resistance to 43.9 (7.2) cm H2O litre-1 s-1. There were significant correlations between percentage bronchial cross-sectional area and dynamic pulmonary compliance (r = 0.720, P < 0.0001) and airway resistance (r = 0.727, P < 0.0001). Atropine 0.1 mg kg-1 increased basal bronchial cross-sectional area to 137.5 (16.9) %. These data indicate that adrenaline reversed histamine- and pentobarbitone-induced bronchoconstriction.

Airway Resistance↗

Diagnostic value of brush biopsy in suspected bronchial carcinoma with the use of the flexible fibre bronchoscope.

In a 12-month period, brush biopsy through a fibreoptic bronchoscope was performed on 125 consecutive patients who were clinically or radiographically suspected of lung cancer. Of the patients, 62 appeared to have lung cancer. Cytological analysis of the brush-biopsy specimens was positive in 69%. A total of 58% had positive biopsy, and 58% had cancer cells in the bronchial secretion aspirated during the bronchoscopy. Thirty-five per cent had positive mediastinoscopy. When the methods of examination were combined, the diagnosis could be established in 90% of the patients. The study shows that brush biopsy and cytological analysis, in combination with the other methods of examination, increase the diagnostic sensitivity in bronchoscopically visible tumours. In bronchoscopically invisible tumours, brush cytological analysis, together with the study of bronchial secretion and fine-needle puncture, is the most effective diagnostic method. The diagnostic possibilities can presumably be further improved by the use of fluoroscopic control in two places during the bronchoscopy.

Adult↗

Flexible-bronchoscope biopsy of lung and bronchial wall in intrathoracic sarcoidosis.

1) Twenty of 25 patients (80%) with sarcoidosis had positive lung biopsies obtained by flexible-bronchoscope biopsy. 2) Three of the 5 negative biopsies were in patients with chronic sarcoidosis whose chest radiograph was unchanged for 1 yr or more. 3) Two insignificant pneumothoraces occurred as a complication of the bronchoscopic biopsy procedures. 4) Noncaseating epithelioid-cell granulomas found on fiberoptic bronchoscopic biopsy are no more specific for the diagnosis of sarcoidosis than similar findings in any other organ biopsy.

Biopsy↗

Recovery of the human immunodeficiency virus from fibreoptic bronchoscopes.

Ten bronchoscopes that had been used on patients with the acquired immunodeficiency syndrome were sampled to determine the nature and extent of microbial contamination. Samples were taken by irrigating the suction biopsy channel with modified viral transport medium and by swabbing the insertion tube. Sampling was repeated after they had been cleaned in detergent and after two minutes' disinfection in 2% alkaline glutaraldehyde. Before being cleaned the seven bronchoscopes tested by polymerase chain reaction were contaminated with the human immunodeficiency virus, though infectivity and antigen assays gave negative results. Other organisms identified were hepatitis B virus (1), commensal bacteria (9), and Pneumocystis carinii (4). Mean bacterial contamination was 2.27 log colony forming organisms per millilitre. Cleaning the bronchoscope before disinfection removed all detectable contaminants with a reduction in bacterial growth of up to 8 log colony forming units/ml.

Bronchoscopes↗

A new rigid bronchoscope for laser fiber application.

A new fiberoptic rigid bronchoscope system, designed especially for laser fiber delivery, provides the endoscopist with an excellent conduit for application of the flexible fiberoptic bronchoscope, while still allowing maintenance of adequate ventilation. This system is designed for treatment of benign and malignant obstructing tumors in the trachea and mainstem bronchi. The bronchoscope will be available in sizes ranging from 6 mm to 10 mm in diameter.

Bronchial Neoplasms↗

A pseudoepidemic of Mycobacterium chelonae infection caused by contamination of a fibreoptic bronchoscope suction channel.

An unusual increase in the frequency of isolation of Mycobacterium chelonae subspecies chelonae from specimens of bronchial washings was found between September and December 1992 in National Taiwan University Hospital. During this period, a total of 123 patients underwent fibreoptic bronchoscopy with an Olympus P20. Seventy six patients had bronchial washing for bacteriological study and cytological examination. Acid-fast bacilli were found in 21 patients, in 18 of whom Mycobacterium chelonae were isolated from bronchial washing cultures. Eight patients were treated as mycobacterial infected, because of the presence of unexplained pulmonary lesion, positive acid-fast stain and culture for Mycobacterium chelonae. Diagnosis of lung cancer was delayed in one patient because of the initial negative cytological study and positive bacterial culture. The fibreoptic bronchoscope was disinfected by automated washing machine (EW-20, Olympus) using 2.3% glutaraldehyde according to a standard protocol. From a survey to search for possible sources of contamination, they were identified at the suction channel of four different bronchoscopes. This episode proved to be a pseudoepidemic. The contamination was controlled by extensive suction and rinsing of the channel with 70% alcohol immediately after disinfection by the automated bronchoscope disinfection machine. This study shows that, despite using the disinfection machine, the suction channel could still be contaminated with Mycobacterium chelonae. This may cause diagnostic confusion and unnecessary antimycobacterial treatment.

Aged↗