Pablo Álvarez-Maldonado

Narrow-band imaging bronchoscopy in tracheobronchial amyloidosis.

Primary tracheobronchial amyloidosis (TBA) is a rare disease characterized by extracellular focal or diffuse submucosal deposits of amyloid proteins. Various types of endobronchial lesions have been described in TBA when bronchoscopy is performed using white light. Narrow-band imaging bronchoscopy has been mainly employed for detecting preneoplastic and neoplastic endobronchial lesions as it provides more detailed images of the microvasculature reflective of an altered angiogenesis process. Here, we describe bronchoscopic findings with white light and narrow-band imaging in 2 patients presenting with central airway obstructive disease later confirmed as having primary TBA.

Tracheal ring fracture and pseudomembrane formation after percutaneous dilatational tracheostomy.

To the Editor: Various complications from percutaneous dilatational tracheostomy (PDT) have been reported in the literature. Tracheal ring fracture can take place while either using single or sequential dilators during the procedure.1 Fibrinous tracheal pseudomembranes can also appear in previously intubated patient.2 Recently, we encountered a case in which both tracheal ring fracture and pseudomembrane developed as a consequence of PDT. A 36-year-old woman with a history of diabetes mellitus and postpartum dilated cardiomyopathy was admitted to intensive care unit (ICU) with decompensated cardiac failure. She required intubation because of acute pulmonary edema. On day 6, she developed ventilatorassociated pneumonia and on the 11th day, she underwent bronchoscopy-guided PDT. The procedure was performed by a thoracic surgeon using a single dilator technique (Blue Rhino; Cook Critical Care Inc.). There were no immediate complications. Moreover, there were no unusual findings during the insertion of the dilator and the tracheostomy cannula as evidenced endoscopically. The patient was disconnected from mechanical ventilation and discharged from the ICU 4 days later. To safely remove the tracheostomy cannula, a flexible bronchoscopy was performed on day 18. A fibrinous tracheal pseudomembrane was found above the tracheal stoma (Fig. 1A). It was removed using argon plasma coagulation through the flexible bronchoscope. Concomitantly, a segment of tracheal cartilage protruding into the tracheal lumen was evidenced (Figs. 1B, C). The cartilage was removed with the help of Kelly’s forceps introduced through the tracheal stoma (Fig. 1D). The tracheostomy cannula was successfully removed and she remained asymptomatic at 15-day, 1month, and 6-month follow-up. PDT is a common and relatively safe procedure.2 Prolonged intubation remains the most common indication. Complications from PDT could be encountered perioperatively or during the early or late postoperative period. Tracheal ring fracture is a perioperative complication that could occur while using single or sequential dilators. It could be un-noticed, despite bronchoscopic guidance during tracheostomy. Its incidence range from 5% to 36%1 and its long-term significance remains poorly defined.3 Tracheal pseudomembranes may appear in previously intubated patients shortly after the extubation and is considered a potentially fatal complication from sudden airway obstruction if undetected and not managed in a timely manner.4 It is usually located at the site where the tracheal tube cuff comes in contact with the tracheal mucosa. It is composed mainly of fibrin and desquamated necrotic epithelium. It could be permanently removed with a rigid bronchoscope or by means of flexible bronchoscopy techniques.4–6 In the presented case, both pseudomembrane and tracheal ring fracture were evidenced during bronchoscopic inspection performed before the removal of the tracheostomy cannula. In the beginning, extraction of the pseudomembrane with forceps through the flexible bronchoscope was not feasible because of its firm adherence to the tracheal wall, and the argon plasma use of coagulation was required. Removal of the piece of cartilage was possible with the use of Kelly’s forceps introduced through the tracheal stoma. In conclusion, tracheal ring fracture and postintubation tracheal pseudomembranes are not infrequent complications of the PDT, the latter being potentially fatal if not detected and treated in timely fashion. Bronchoscopic examination should be performed before decannulation for early detection and prompt management of PDT complications.

Grupo de trabajo para la revisión, modificación y desarrollo de indicadores de calidad para unidades de cuidados intensivos respiratorios en México

These are times of transition in which healthcare delivery is capturing more attention and is clearly beginning to take an important position in patient care. The desire to improve patient safety has led to a series of initiatives aimed at implementing standard practices to improve quality in healthcare.1 Quality indicators are standardized measures for determining the appearance and intensity of a phenomenon or event.2 Intensive care units are not exempt from the application of an organizational model that can be measured from different angles and improved once areas of opportunity have been identified. One of the most important advances in the development of evidence-based quality indicators in intensive care has been made by the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), together with the Avedis Donabedian Foundation.2,3 SEMICYUC generated quality indicators that were adopted by intensive care units in Spain and by other international scientific societies, such as the European Society of Intensive Care Medicine and the Indian Society of Critical Care Medicine. The proposals included not only general indicators, but also quality of care indicators for specific patient populations, such as coronary artery patients, who are often treated in dedicated units. Specialized units catering for patients with particular characteristics require specifically adapted indicators and standards, some of which may have to be more rigid than others.4 The aim of this project is to draw up recommendations for monitoring quality in units that, due to the type of patient they specialize in, share common features and are termed collectively “respiratory intensive care units”. The initiative was launched by the heads of the intensive care units in the chest clinics of tertiary and fourthlevel hospitals in Mexico, namely (1) the Respiratory Intensive Care Unit of the Pulmonology and Thoracic Surgery of the Hospital General de México, (2) the Intensive Care Unit of the Instituto Nacional de Enfermedades Respiratorias (INER); (3) the Respiratory Intensive Care Unit of the Centro Médico Nacional “La Raza”, and (4) the Intensive Care Unit of the Department of Pulmonology and Intensive Care of the Hospital Universitario de Monterrey. The first meeting of Task Force members took place during the 39th Annual Meeting of the Mexican Association of Critical

Tracheal ulcers due to endotracheal tube cuff pressure.

Tracheal injury is a well-known complication of endotracheal intubation. We present a case of a 73-year-old man who underwent craniotomy because of parenchymal hemorrhage involving the left hemisphere. After the surgical procedure, he was admitted to the intensive care unit. Bronchoscopy-guided percutaneous dilational tracheostomy was performed on day 8 of mechanical ventilation. During the procedure, tracheal ulcers were found affecting the anterior tracheal wall. The site of the lesions corresponded to the site where the endotracheal tube cuff was placed previously.

Primary Mediastinal Goiter Resected via Cervical Approach

Primary mediastinal goiter is a rare entity. In most cases their finding is incidental. Excision is mandatory because of the risk of compression of vital structures within the chest. We report the case of a primary posterior mediastinal goiter that was resected through a cervical approach. being discharged she received a thoracic surgery consultation for tumor resection. Two months after discharge she was hospitalized again for surgery. A cervical surgical approach with the intention to convert to thoracotomy was planned. Through a standard collar incision, digital exploration and tumor dissection was made that properly surround it in its entirety surface with no evidence of adherences to any intrathoracic structure. The goiter had its blood supply from a branch of esophageal arteries at its cranial edge, which was identified and ligated. The surgical specimen was then removed with a clamp getting scarce bleeding at the surgical bed. Hemostasis was verified leaving a closed drainage that was later withdrawn. The cervical thyroid gland was explored during surgery with no abnormalities found. There were no intraoperative or postoperative complications and the patient was discharged from the hospital three days after surgery. Macroscopically, a tumor of 10 × 5 × 2 cm, with a multi-nodular surface, covered by a thin, translucent full capsule, with reddish brown and yellowish areas was reported (Figure 3a). Its interior was multi- nodular, composed by light brown areas of granular consistency, hemorrhagic areas and yellowish colloid-appearance areas. Indurated consistency areas were not identified. Microscopically (Figure 3b), small follicles of thyroid tissue with no colloid plus dilated cysts with abundant colloid were identified. Foamy macrophages, some with hemosiderin in their cytoplasm were also reported. There were no findings suggestive of malignancy. Dysphagia and cough disappeared after surgery and the patient remained asymptomatic after 19 months of follow-up. Discussion PMG, also known as aberrant goiter or ectopic mediastinal goiter implies the presence of intra-thoracic thyroid tissue independent of the cervical thyroid gland; its vascular supply comes from intra- thoracic vessels and is considered a benign entity. Its localized primarily in the anterior mediastinum (85% of cases). The middle and posterior mediastinum are less frequent locations in 15% of cases (4). It is a rare condition. Due to thyroid gland migration during embryonic development (between the 3rd and the 8th weeks) the location of primary ectopic goiter may occur from the tongue

Proptosis during flexible bronchoscopy.

Bronchoscopy has been described as a safe procedure with a low rate of complications. We present a case of a 48-year-old woman who underwent flexible bronchoscopy for chronic cough. Immediately after the procedure, she developed proptosis of the left eye that required urgent attention. It resolved with medical treatment alone and the patient was discharged without any long-term complications.

Benign tracheal stenosis: a case series analysis.

Tracheal stenosis (TS) requires a precise diagnosis and an experienced operator in both endoscopic and surgical treatment. We describe a case series at a tertiary care teaching hospital. Twenty patients with TS and/or subglottic stenosis were included. All underwent flexible bronchoscopy (FB). Spirometry (SP) was obtained in 8 patients, and helical computed tomography with three-dimensional reconstruction (HCT3D) was obtained in 11 patients. All cases were graded by each modality on a scale of 1 to 3, and the findings were correlated among modalities. Mean follow-up was 11.1 months (range: 3 to 47 mo). Postintubation injury was the most frequent cause of stenosis in 16 patients (80%). Mean stenosis grade±SD was 2.0±0.92 for SP, 2.3±0.86 for FB, and 2.54±0.68 for HCT3D. A significant correlation was found between HCT3D and FB (r=0.76, P<0.01). There was no correlation between SP and FB (r=0.46, P=0.2) or between SP and HCT3D (r=0.68, P=0.13). Treatment was conservative in 8 patients. Eighteen tracheal dilatation procedures were performed in 7 patients (mean: 2.5 dilatations/patient, range: 1 to 6; mean free time between dilatations 109.7±81 d, range: 6 to 210 d). Tracheoplasty was carried out in 7 patients, with tracheal anastomosis in 4 patients and thyroid-tracheal anastomosis in 3 patients. Tracheostomy was required in 1 patient with scleroma. Neither complications nor mortality related to FB was reported. HCT3D has a good correlation with FB. Tracheal dilatation is a viable option for patients who are not surgical candidates and for those with restenosis of tracheal anastomosis.