Ascedio Jose Rodrigues

Bronchoscopic techniques for removal of foreign bodies in children's airways.

The management of airway foreign bodies (AFB) can be a dramatic situation in the emergency treatment of children and different techniques have been used to improve the therapeutic success and minimize risks.

Broncoscopia flexível como primeira opção para a remoção de corpo estranho das vias aéreas em adultos

OBJECTIVE To determine the success rate of flexible bronchoscopy as the first-choice method of removing foreign bodies from the airways of adults. METHODS This was a retrospective study of all adult patients (over 18 years of age) with foreign body aspiration submitted to bronchoscopy between January of 2009 and January of 2011 at the University of São Paulo School of Medicine Hospital das Clínicas, located in São Paulo, Brazil. RESULTS The study sample comprised 40 adult patients, with a mean age of 52 years (range, 18-88 years). The median time of permanence of the foreign body in the airway was 15 days (range, 12 h to 10 years). All of the patients first underwent diagnostic flexible bronchoscopy. Foreign bodies were successfully removed with flexible bronchoscopy in 33 (82.5%) of the patients. In 1 patient, a metal object lodged in the distal bronchial tree required the use of fluoroscopy. Six patients (15%) required rigid bronchoscopy due to tracheal foreign body-induced dyspnea, in 2, and because the foreign body was too large for the flexible forceps, in 4. Bronchoscopy failed in 1 patient, who therefore required surgical bronchotomy. CONCLUSIONS Although rigid bronchoscopy is considered the gold standard for the removal of foreign bodies from the airways, our experience showed that flexible bronchoscopy can be safely and effectively used in the diagnosis and treatment of stable adult patients.

Broncoscopia no diagnóstico de tuberculose pulmonar em pacientes com baciloscopia de escarro negativa

OBJECTIVE To evaluate the diagnostic accuracy of bronchoscopy in patients with clinical or radiological suspicion of tuberculosis who were unable to produce sputum or with negative sputum smear microscopy results. METHODS A prospective cross-sectional study involving 286 patients under clinical or radiological suspicion of having pulmonary tuberculosis and submitted to bronchoscopy-BAL and transbronchial biopsy (TBB). The BAL specimens were submitted to direct testing and culture for AFB and fungi, whereas the TBB specimens were submitted to histopathological examination. RESULTS Of the 286 patients studied, 225 (79%) were diagnosed on the basis of bronchoscopic findings, as follows: pulmonary tuberculosis, in 127 (44%); nonspecific chronic inflammation, in 51 (18%); pneumocystis, fungal infections, or nocardiosis, in 20 (7%); bronchiolitis obliterans organizing pneumonia, alveolites, or pneumoconiosis, in 14 (5%); lung or metastatic neoplasms, in 7 (2%); and nontuberculous mycobacterium infections, in 6 (2%). For the diagnosis of tuberculosis, BAL showed a sensitivity and a specificity of 60% and 100%, respectively. Adding the TBB findings significantly increased this sensitivity (to 84%), as did adding the post-bronchoscopy sputum smear microscopy results (total sensitivity, 94%). Minor post-procedure complications occurred in 5.6% of the cases. CONCLUSIONS Bronchoscopy is a reliable method for the diagnosis of pulmonary tuberculosis, with low complication rates. The combination of TBB and BAL increases the sensitivity of the method and facilitates the differential diagnosis with other diseases.

Estado atual e aplicabilidade clínica da punção aspirativa por agulha guiada por ultrassom endobrônquico

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has played a key role in the diagnosis of mediastinal, paratracheal, and peribronchial lesions, as well as in lymph node staging for lung cancer. Despite its minimally invasive character, EBUS-TBNA has demonstrated a diagnostic yield comparable with that of established surgical methods. It has therefore gained credibility and has become a routine procedure at various referral centers. A successful EBUS-TBNA procedure requires careful planning, which includes a thorough review of the radiological imaging and special care during specimen collection and preparation, as well as technical expertise, experience with the procedure itself, and knowledge of the potential complications inherent to the procedure. The most common indications for EBUS-TBNA include lymph node staging for lung cancer and the diagnostic investigation of mediastinal/hilar masses and lymph node enlargement. Recently, tumor biomarkers in malignant samples collected during the EBUS-TBNA procedure have begun to be identified, and this molecular analysis has proven to be absolutely feasible. The EBUS-TBNA procedure has yet to be included on the Brazilian Medical Association list of medical procedures approved for reimbursement. The EBUS-TBNA procedure has shown to be a safe and accurate tool for lung cancer staging/restaging, as well as for the diagnosis of mediastinal, paratracheal, and peribronchial lesions/lymph node enlargement

Ressecção minimamente invasiva por broncoscopia de tumores brônquicos benignos

OBJECTIVE Primary benign tumors of the trachea and main bronchi are uncommon. Interventional bronchoscopy allows the diagnosis and the treatment of some of these lesions. METHODS We reviewed four cases endoscopically treated at our institution. RESULTS Two patients had hamartoma, and two patients had endobronchial lipoma. In all of the cases, the interventional technique for the resection was the use of a polypectomy snare and electrocautery. The only complication reported was one episode of bronchospasm. CONCLUSIONS Minimally invasive bronchoscopic resection is a safe, effective method for treating selected benign tumors of the main airway and has a low complication rate.

Pneumomediastino espontâneo associado a lesões laríngeas e úlceras traqueais na dermatomiosite

We described a 41-year-old woman with dermatomyositis, interstitial lung disease, and cutaneous vasculopathy who developed a pneumomediastinum. The routine bronchoscopy investigation found pale lesions in the larynx, that extended to the tracheobronchial tree, and deep ulcers in the membranous wall of the trachea. The histopathology examination revealed an inflammatory process that was diagnosed secondary to the vasculitis, but no infections. Superior and inferior airway lesions in the same patient with dermatomyositis is a very rare condition. The association of dermatomyositis with deep mucosal ulcers and pneumomediastinum is not clear, but a bronchoscopic examination should be used to improve evaluation.We described a 41-year-old woman with dermatomyositis, interstitial lung disease, and cutaneous vasculopathy who developed a pneumomediastinum. The routine bronchoscopy investigation found pale lesions in the larynx, that extended to the tracheobronchial tree, and deep ulcers in the membranous wall of the trachea. The histopathology examination revealed an inflammatory process that was diagnosed secondary to the vasculitis, but no infections. Superior and inferior airway lesions in the same patient with dermatomyositis is a very rare condition. The association of dermatomyositis with deep mucosal ulcers and pneumomediastinum is not clear, but a bronchoscopic examination should be used to improve evaluation.

Comprometimento da árvore respiratória na granulomatose de Wegener

INTRODUCAO: A granulomatose de Wegener (GW) e uma forma de vasculite sistemica que envolve primariamente as vias aereas superiores e inferiores e os rins. As manifestacoes mais frequentes nas vias aereas sao estenose subglotica e inflamacoes, estenoses da traqueia e dos bronquios. A visualizacao endoscopica das vias aereas e a melhor ferramenta para avaliacao, diagnostico e manejo dessas alteracoes. OBJETIVOS: Descrever as alteracoes endoscopicas encontradas na mucosa das vias aereas de um grupo de pacientes com GW submetido a broncoscopia no Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo (HC-FMUSP) e relatar as intervencoes terapeuticas broncoscopicas utilizadas em alguns casos. METODOS: Foram estudados 15 pacientes com diagnostico de GW provenientes do Ambulatorio de Vasculites da Disciplina de Pneumologia do HC-FMUSP, encaminhados para a realizacao de broncoscopia no servico de Endoscopia Respiratoria do HC-FMUSP no periodo de 2003 a 2007. RESULTADOS: Dos 15 pacientes avaliados, 11 eram mulheres (73,33%) com idade media de 34 ± 11,5 anos. Foram encontradas alteracoes das vias aereas em 80% dos pacientes, e o achado endoscopico mais frequente foi estenose subglotica (n = 6). Realizou-se broncoscopia terapeutica em tres pacientes com estenose subglotica e em outros tres com estenose bronquica, todos apresentando bons resultados. CONCLUSAO: A broncoscopia permite diagnostico, acompanhamento e tratamento das lesoes de vias aereas na GW, constituindo-se um recurso terapeutico pouco invasivo em casos selecionados.

Intubação de via aérea difícil com broncoscópio flexível

BACKGROUND AND OBJECTIVE To describe the efficacy and safety of a flexible bronchoscopy intubation (FBI) protocol in patients with difficult airway. METHOD We reviewed the medical records of patients diagnosed with difficult airway who underwent flexible bronchoscopy intubation under spontaneous ventilation and sedation with midazolam and fentanyl from March 2009 to December 2010. RESULTS The study enrolled 102 patients, 69 (67.7%) men and 33 (32.3%) women, with a mean age of 44 years. FBI was performed in 59 patients (57.8%) with expected difficult airway in the operating room, in 39 patients (38.2%) in the Intensive Care Unit (ICU), and in 4 patients (3.9%) in the emergency room. Cough, decrease in transient oxygen saturation, and difficult progression of the cannula through the larynx were the main complications, but these factors did not prevent intubation. CONCLUSION FBI according to the conscious sedation protocol with midazolam and fentanyl is effective and safe in the management of patients with difficult airway.

Difficult Airway Intubation with Flexible Bronchoscope

BACKGROUND AND OBJECTIVE To describe the efficacy and safety of a flexible bronchoscopy intubation (FBI) protocol in patients with difficult airway. METHOD We reviewed the medical records of patients diagnosed with difficult airway who underwent flexible bronchoscopy intubation under spontaneous ventilation and sedation with midazolam and fentanyl from March 2009 to December 2010. RESULTS The study enrolled 102 patients, 69 (67.7%) men and 33 (32.3%) women, with a mean age of 44 years. FBI was performed in 59 patients (57.8%) with expected difficult airway in the operating room, in 39 patients (38.2%) in the Intensive Care Unit (ICU), and in 4 patients (3.9%) in the emergency room. Cough, decrease in transient oxygen saturation, and difficult progression of the cannula through the larynx were the main complications, but these factors did not prevent intubation. CONCLUSION FBI according to the conscious sedation protocol with midazolam and fentanyl is effective and safe in the management of patients with difficult airway.

Endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer staging: early experience in Brazil,

Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, safe and accurate method for collecting samples from mediastinal and hilar lymph nodes. This study focused on the initial results obtained with EBUS-TBNA for lung cancer and lymph node staging at three teaching hospitals in Brazil. Methods: This was a retrospective analysis of patients diagnosed with lung cancer and submitted to EBUS-TBNA for mediastinal lymph node staging. The EBUS-TBNA procedures, which involved the use of an EBUS scope, an ultrasound processor, and a compatible, disposable 22 G needle, were performed while the patients were under general anesthesia. Results: Between January of 2011 and January of 2014, 149 patients underwent EBUS-TBNA for lymph node staging. The mean age was 66 ± 12 years, and 58% were male. A total of 407 lymph nodes were sampled by EBUS-TBNA. The most common types of lung neoplasm were adenocarcinoma (in 67%) and squamous cell carcinoma (in 24%). For lung cancer staging, EBUS-TBNA was found to have a sensitivity of 96%, a specificity of 100%, and a negative predictive value of 85%. Conclusions: We found EBUS-TBNA to be a safe and accurate method for lymph node staging in lung cancer patients.