Bryan Husta

Three-dimensional Modeled T-tube Design and Insertion in a Patient With Tracheal Dehiscence

A 68-year-old man with recurrent medullary thyroid cancer underwent cervical tracheal resection and reconstruction. His course was complicated by tracheal anastomotic dehiscence, right carotid blowout, and ultimately cervical tracheoplasty with AlloDerm. Given the complex vascular interventions and upper-airway anatomy, a custom-designed Montgomery T-tube was designed for him. Three-dimensional digital reconstruction of his upper airways was obtained from a CT scan. The T-tube was designed and fabricated based on the digital trachea model and was subsequently placed successfully. Follow-up CT scan and bronchoscopy confirmed placement and revealed no granulation tissue at 4 weeks. The patient was discharged to home with the ability to phonate. To our knowledge, this is the first demonstration of three-dimensional modeling of an upper-airway defect with subsequent T-tube design using engineering software. The success of this case demonstrates a possible avenue for personalized airway prosthesis design and manufacturing in the future.

Covered Balloon-Expanding Stents in Airway Stenosis

BACKGROUND The balloon-expanding stents are widely available but rarely described for use within the tracheobronchial tree. This report describes our experience with these stents in airway stenosis particularly as a lobar salvage therapy. METHODS This was a retrospective review of all records in which the balloon-expanding stents were used at a tertiary medical center. Ages, sex, location of stenosis, etiology of stenosis, stent size, duration of stent placement and associated interventions for airway stenosis were recorded. Patients self-reported respiratory symptoms, dyspnea scale, and radiographic imaging at baseline and after stent placement were also reported. RESULTS Twenty-one Atrium iCAST stents were inserted in 18 patients with malignant and benign airway disease. The median age was 69.5 years (interquartile range, 53.5 to 74). Most stents (n=20, 95%) were deployed in the lobar airways. There was a significant improvement in the modified Medical Research Council dyspnea scale from median of 3 to 2 (P<0.05). Self-reported respiratory symptoms improved in 14 patients (78%, P<0.05). Radiographic improvement post Atrium iCAST stent placement was achieved in 15 patients (83%). No deaths were related to airway stenting complications. Adverse events related to stents included migration (n=2, 9.5%), granulation tissue formation (n=2, 9.5%) and mucus plugging (n=1, 4.8%). CONCLUSIONS Lobar stenting with balloon-expanding metallic stents appears feasible, safe and improves symptoms as well as radiographic atelectasis in patients with lobar airway stenosis in this small case series. Larger studies are needed to confirm this observation and to address long-term safety.Background: The balloon-expanding stents are widely available but rarely described for use within the tracheobronchial tree. This report describes our experience with these stents in airway stenosis particularly as a lobar salvage therapy. Methods: This was a retrospective review of all records in which the balloon-expanding stents were used at a tertiary medical center. Ages, sex, location of stenosis, etiology of stenosis, stent size, duration of stent placement and associated interventions for airway stenosis were recorded. Patient’s self-reported respiratory symptoms, dyspnea scale, and radiographic imaging at baseline and after stent placement were also reported. Results: Twenty-one Atrium iCAST stents were inserted in 18 patients with malignant and benign airway disease. The median age was 69.5 years (interquartile range, 53.5 to 74). Most stents (n=20, 95%) were deployed in the lobar airways. There was a significant improvement in the modified Medical Research Council dyspnea scale from median of 3 to 2 (P<0.05). Self-reported respiratory symptoms improved in 14 patients (78%, P<0.05). Radiographic improvement post Atrium iCAST stent placement was achieved in 15 patients (83%). No deaths were related to airway stenting complications. Adverse events related to stents included migration (n=2, 9.5%), granulation tissue formation (n=2, 9.5%) and mucus plugging (n=1, 4.8%). Conclusions: Lobar stenting with balloon-expanding metallic stents appears feasible, safe and improves symptoms as well as radiographic atelectasis in patients with lobar airway stenosis in this small case series. Larger studies are needed to confirm this observation and to address long-term safety.

ASSOCIATION BETWEEN ASA CLASSIFICATION AND INCIDENCE OF ADVERSE EVENTS AMONG PATIENTS UNDERGOING BRONCHOSCOPY

METHODS: We conducted a retrospective cohort analysis at a university affiliated teaching hospital in an urban setting. A total of 946 rigid and flexible bronchoscopic procedures, done during December 2016 to February 2018, were analyzed. Of the 946, 45 had peri-procedural adverse events, which are defined as any bleeding from the respiratory system, pneumothorax, hypoxia (defined as greater than 5% drop in SpO2), methemoglobinemia, hemothorax, infection, subcutaneous emphysema, arrhythmia, and respiratory failure requiring intubation. All 45 cases were analyzed regardless of indication for the procedures and comorbid medical conditions. We examined the pre-procedurally determined ASA class of all 946 cases, and sought out a correlation between the ASA class and the incidence of the 45 adverse events.

TIME IS MONEY: OPERATING ROOM VS ENDOSCOPY FOR INTERVENTIONAL PULMONARY PROCEDURES

E D U C A T IO N R E S E A R C H A N D Q U A L IT Y PURPOSE: Interventional pulmonary (IP) procedures are fast becoming more accessible and a cornerstone in the management of multiple pulmonary diseases. They can be performed in the operating room (OR) vs Endoscopy suite (ES) depending on the center and availability. To our knowledge, there is no data comparing the delay in initiating the procedure between the 2 locations. We present a single center retrospective analysis comparing the time delay from scheduled procedure time in the OR vs the ES using the same staff.

Complication of antiquated tuberculosis treatment

In the early 20th century, the rapid spread of tuberculosis (TB) invited novel therapies for treatment. A surgical procedure known as plombage was one such method where lobes were forced to collapse by placing an inert object such as mineral oil, paraffin wax, gauze or Lucite (methyl methacylate) balls. The collapse would lead to isolation of TB infection and decrease aeration of the affected lung. Removal of these objects had initially been, usually after 24 months, however this fell out of favor after the patient had recovered without commonly seen late complications. Decades later, reports have been made illustrating complications such as migration and infection of the plombe as well as expanding oleothorax.