Paulo Rogério Scordamaglio

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.

Tratamento endoscópico de fístulas da árvore traqueobrônquica com dispositivos para a correção de defeitos do septo interatrial: resultados preliminares

Fistulas in the tracheobronchial tree (bronchopleural and tracheoesophageal fistulas) have a multifactorial etiology and present a variable incidence in the literature. In general, the related morbidity and mortality are high. Once such a fistula has been diagnosed, surgical closure is formally indicated. However, the clinical status of affected patients is usually unfavorable, which precludes the use of additional, extensive surgical interventions. In addition, attempts at endoscopic closure of these fistulas have seldom been successful, especially when the fistula is large in diameter. We report the cases of three patients submitted to endoscopic closure of fistulas, two of which were larger than 10 mm in diameter, by means of the insertion of atrial septal defect occluders. The procedure was minimally invasive, and the initial results were positive. The results indicate that this is a promising technique for the resolution of tracheobronchial tree fistulas.

Endobronchial closure of total bronchopleural fistula with Occlutech Figulla ASD N device.

Bronchopleural fistula may be treated by medical, endoscopic, and surgical techniques, but large fistulas remain a challenge to be closed using endoscopic techniques. We describe the endoscopic closure of a bronchial total fistula with the Occlutech Figulla ASD N device (International Occlutech AB, Helsingborg, Sweden), originally designed for closure of an atrial septal defect. The procedure was conducted without general anesthesia or rigid bronchoscopy, bronchography, or radioscopy. An immediate reduction in the air leak was observed and also later on bronchoscopy, as the device was almost covered by granulation tissue. The endobronchial technique described seems to be safe and effective to manage large bronchopleural fistulas.

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.

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.

Bronchoscopic closure of tracheoesophageal fistulas.

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Minimally Invasive Closure of Bronchopleural Fistulas

We would like to congratulate Fruchter et al 1 for their ingenious, effective, and minimally invasive way of treating the very challenging condition of bronchopleural fi stulas as reported in a recent issue of CHEST (March 2011). However, because we were cited in their work, we must make a correction. The misunderstanding is that our fi rst publication was a case report of our fi rst patient (53-year-old man with a right upper lobectomy) using this method. 2 Later, Scordamaglio et al 3 published a review of our experience endoscopically treating airway fi stulas (two bronchopleural and one tracheoesophageal), which included this same patient. Since then, fi ve more fi stulas in four other patients have been treated, making a total of seven fi stulas treated in six patients (one patient with two fi stulas), with fi ve of them already closed. Although the technique used is similar to that in Fruchter et al, 1