John C. McDougall

Management of malignant airway obstruction: Clinical and dosimetric considerations using an iridium-192 afterloading technique in conjunction with the neodymium-YAG laser

Fourteen patients with malignant airway obstruction have had 21 placements of a flexible nylon catheter for afterloading Iridium-192 using the flexible fiberoptic bronchoscope. Prescribed therapy was completed in 13 patients (18 courses). All patients had prior full-dose external irradiation, and no effective surgical or chemotherapeutic options remained. While many have had a trial of neodymium-YAG (yttrium-aluminum-garnet) laser therapy alone, eight patients received laser treatment one to three weeks prior to planned brachytherapy to provide immediate relief of symptoms and/or facilitate access and safe catheter placement. Most patients (64%) had recurrent squamous cell lung cancer. A dose of 3000 cGy is currently specified to 5 mm and 10 mm in the bronchus and trachea, respectively. Nine of the 13 treated patients have had follow-up bronchoscopy at approximately three months post-treatment with improvement documented in seven and progression in two patients. One patient was clinically improved without follow-up bronchoscopy, and three patients have had insufficient follow-up. A single patient treated with laser and 6000 rad at 5 mm developed a bronchoesophageal fistula. No other complication has been observed. The technique is simple and safe with the use of laser therapy when needed and appears to offer effective palliation in most patients even when standard therapy is exhausted.

Airway foreign bodies in adults

The objective of this study was to evaluate the efficacy of flexible bronchoscopy in the management of tracheobronchial foreign bodies (TFB) in adults (≥16 y) from 1990 through 2002. TFB was defined as the presence of any foreign object below the vocal cords. Patients with gastric aspiration or regurgitation were excluded. We reviewed Mayo Clinic Rochesters medical data retrieval system to obtain information on patients with TFBs. Data abstracted included demographics, clinical symptoms, physical examination findings, bronchoscopic techniques used for extraction, success rates, and complications. A total of 65 adults with TFB aspiration were identified. There were 44 males (68%) and 21 females (32%) with a mean age of 60.8 years. A recognized predisposition to aspiration was evident in 35 patients (54%). The right lower lobe was the most common site for lodgment of aspirated TFB (24 of 65 patients; 37%), followed by the bronchus intermedius in 14 patients (22%), trachea in 7 (11%), left main stem bronchus in 7 (11%), and other locations in the rest. The most common symptom was cough (58 of 65 patients; 89%). The most common finding on physical examination was wheezing, seen in 20 patients (31%). Chest radiographs were obtained in 59 patients (91%) and were abnormal in 54 (92%). TFB was seen or its presence was suggested on the chest radiograph in 19 patients (32%). TFBs extracted included dental pieces in 14 patients (22%), nuts in 12 (18%), corn kernels in 7 (11%), vegetable matter in 7 (11%), bones in 6 (9%), plastic pieces in 4 (6%), pills in 2 (3%), and one each of the following: meat, nail, laryngeal polyp, folded drinking straw, broken piece of an endotracheal tube, broken piece of a voice prosthesis, tracheostomy cleaning brush, foil, surgical staple, surgical pledget, balloon fragment, sunflower seed, and a sewing needle. The flexible bronchoscope was used in 61 of the 65 patients (94%) and was successful in 54 of these patients (89%). Flexible bronchoscopy was unsuccessful in 7 patients, 6 of whom underwent successful TFB extraction by rigid bronchoscopy. One patient required a thoracotomy for the removal of a TFB in the right lower lobe. Complications from bronchoscopy were minimal and consisted of minor bleeding in 3 patients. Flexible bronchoscopic procedures were successful in the extraction of 89% of tracheobronchial foreign bodies in adults. Our experience also indicates that flexible bronchoscopic removal of TFBs in adults can be safely performed with minimal complications.

Ancillary Therapies in the Management of Lung Cancer: Photodynamic Therapy, Laser Therapy, and Endobronchial Prosthetic Devices

Endoscopic therapy for cancer that involves the tracheobronchial tree is currently available for two distinct types of lesions: radiographically occult superficial squamous cell carcinoma and advanced malignant tumors that cause severe airway obstruction. Photodynamic therapy, which uses a photosensitizing agent, is effective for managing early superficial squamous cell carcinoma. Neodymium:yttrium-aluminum-garnet laser therapy has been effective in the palliative management of patients with advanced or recurrent malignant obstructive airway lesions, either alone or in combination with intraluminal radiation therapy. Most recently, endobronchial prosthetic devices (stents) have been used in patients with advanced airway obstruction. The use of each of these modalities in the management of lung cancer is reviewed.

Right ventricular assessment in patients presenting for lung transplantation

Chronic pulmonary disease is associated with varying degrees of cardiac dysfunction. Because of the potentially predominant effect of severe lung disease on right ventricular (RV) size and function, a reliable method to assess RV mechanics before and after lung transplantation may provide information of long-term significance and/or prognosis. Conventional invasive and non-invasive imaging methods have a number of limitations in evaluating RV function. Ultrafast computed tomographic (ultrafast CT) scanning has been shown to provide quantitative assessment of RV and left ventricular (LV) function in individuals with and without cardiac disease. Twenty-two patients presenting during evaluation for possible lung transplantation with end-stage pulmonary disease formed the basis of this study. There were 14 patients with chronic obstructive pulmonary disease and 8 with pulmonary fibrosis. Conventional transthoracic echocardiography and ultrafast CT were used for the assessment of RV and LV function. All patients had invasive assessment of right-sided hemodynamics and pulmonary function studies performed within 7–10 days of cardiac imaging. A qualitative assessment of RV size or function was possible in all but two patients by echocardiogram, but in 45%, the echo-cardiographic examination was described as suboptimal. In contrast, a quantitative assessment of ventricular volumes and systolic function was obtained in all patients by ultrafast CT. Pulmonary function parameters or hemodynamic measurements obtained during cardiac catheterization did not correlate with any assessment of RV function. We concluded that (1) ultrafast CT provides measurement of the RV and LV cavity dimension and systolic function; (2) invasive right-sided hemodynamics or pulmonary function studies do not predict RV function; and (3) echocardiography does not uniformly provide assessment of RV function in patients with chronic pulmonary disease.

Medical Management and Complications in the Lung Transplant Recipient

Lung transplantation has evolved as a viable therapy for patients with end-stage lung disease. Improvements in surgical techniques, avoidance of rejection by effective strategies of immunosuppression, and other aspects of medical management allow successful lung transplantation, with 1-year survivorship of 70 to 93%. In this review, we address the medical management of patients who have undergone lung transplantation. The immunosuppressive protocol used at Mayo Clinic Rochester is presented, along with a discussion of the mechanisms of action and potential complications associated with the various drugs used. The recognition and treatment of early graft dysfunction, infection, rejection, stenosis of the airway anastomosis, and posttransplantation lymphoproliferative disorder are also reviewed. Careful surveillance of patients after lung transplantation helps maintain graft function and facilitates identification, treatment, and potential avoidance of complications.

Monitoring and Analysis of Oxygenation and Ventilation During Rigid Bronchoscopic Neodymium-YAG Laser Resection of Airway Tumors

Neodymium-YAG (yttrium-aluminum-garnet) laser resection of obstructing and inoperable tumors of the large airways is used as palliative therapy to improve the quality of survival in patients by alleviating airway obstruction. Rapid changes in oxygenation and ventilation can occur during these procedures. In a study of 14 patients, transcutaneous oxygen (PtcO 2 ) and carbon dioxide (PtcCO 2 ) monitors responded slowly to these changes and frequently provided misleading values. Pulse oximetry (SNO 2 ) accurately reflected arterial oxygen saturation but did not indicate severe desaturation until arterial oxygen tension approached dangerously low values. Thus, we did not find PtcO 2 or PtcCO 2 monitoring to be clinically useful during neodymium-YAG laser resection of airway tumors through a rigid bronchoscope. SNO 2 was clinically useful and accurate; however, a large decrement in oxygenation may occur before changes in oxygen saturation ensue and are detected.

Clinical Characteristics in Suspected Tracheobronchial Foreign Body Aspiration in Children

The objective of this study was to assess clinical characteristics of suspected tracheobronchial foreign body (TFB) aspiration in children to determine whether any singular feature of the history, physical examination, or radiologic evaluation would predict actual TFB aspiration. Chart review of all bronchoscopies was performed for the clinical suspicion of TFB aspiration in children younger than 16 years of age. Data extracted included history (witnessed event, choking his- tory), clinical symptoms, results of physical examination, and radiographic evaluation. A total of 94 children (62 boys and 32 girls; mean age, 46.5 ± 45.9 months) were evaluated for sus- pected TFB aspiration. Bronchoscopy identified TFB in 39 children (TFB group). Bronchoscopy did not identify TFB in 55 children (non-TFB group). Overall, 57 children (61%) had a witnessed aspiration. In the TFB group, 33 of 39 children (85%) had a witnessed event whereas in the non-TFB group 24 of 55 children (44%) were witnessed (odds ratio for TFB for a witnessed event was 7.1 (95% confidence interval, 2.7-21.3; p < 0.0001)). Of the 94 children, choking was observed in 53%. In the TFB group, 79% of children had a choking event whereas choking was observed in only 35% of children in the non-TFB group (odds ratio for TFB for choking was 7.3 (95% confidence interval, 2.9-20.1; p < 0.0001)). Other clinical symptoms such as dyspnea and cough were not helpful in dif- ferentiating the presence or absence of a TFB. No specific finding on physical examination was helpful at predicting the presence of a TFB. Radiographic findings were also unhelpful unless a radiopaque TFB was visualized. In children with sus- pected TFB aspiration, each of the two clinical features—a choking episode and witnessed aspiration—is seven times more likely in those with bronchoscopically identified TFB com- pared with those without TFB. Other clinical features and chest radiographs are less helpful in predicting the presence of TFB. Nevertheless, some negative bronchoscopies are necessary to exclude TFB in children with suspected TFB aspiration. Key Words: Bronchoscopy—Tracheobronchial foreign body— Choking—Aspiration—Children.

Hypersensitivity Pneumonitis Due to Dove Antigens in an Adolescent

Hypersensitivity pneumonitis is infrequently reported in children. This article describes a 15-year-old girl who presented with insidious onset of dyspnea and weight loss. A hamster and doves were housed in her bedroom. Chest radiographs showed bilateral nodular infiltrates. Pulmonary function tests showed a restrictive pattern with O2 desaturation at rest. The diagnosis was substantiated by the presence of precipitating antibody to dove serum and droppings and by clinical improvement, along with marked improvement in pulmonary function test, after the doves were removed from her environment. The importance of making an early diagnosis to prevent debilitating fibrotic lung disease is emphasized. A detailed environmental history is essential.

Fungal infection of the contralateral native lung after single-lung transplantation

We report a case of fungal infection in the native lung after single-lung transplantation that was effectively treated with itraconazole therapy. Infection in the contralateral native lung of single-lung transplant recipients is emerging as a potentially serious problem.

Lung transplantation : Selection of patients and analysis of outcome

Lung transplantation is an important option for patients with respiratory failure and limited life expectancy. Herein we review the current indications for and outcome after lung transplantation. These results are compared with the natural history of various respiratory diseases, estimated from available databases. Candidates for lung transplantation are generally younger than 60 years of age, have a limited life expectancy because of end-stage lung disease, and have no other major organ dysfunction. Single lung transplantation is performed most commonly for emphysema, pulmonary fibrosis, and pulmonary hypertension. Survival after single lung transplantation is approximately 70% at 1 year, 60% at 2 years, and 40% at 3 years. The median duration of survival for patients with end-stage lung diseases ranges from approximately 2 to 6 years, with wide variation based on the diagnosis and severity of illness. Currently, prolongation of the average survival has not been clearly substantiated after lung transplantation. Further evaluation of outcomes, functional status, and quality of life after lung transplantation is necessary.