Prasoon Jain

American College of Chest Physicians Consensus Statement on the Use of Topical Anesthesia, Analgesia, and Sedation During Flexible Bronchoscopy in Adult Patients

BACKGROUND Optimal performance of bronchoscopy requires patients comfort, physicians ease of execution, and minimal risk. There is currently a wide variation in the use of topical anesthesia, analgesia, and sedation during bronchoscopy. METHODS A panel of experts was convened by the American College of Chest Physicians Interventional/Chest Diagnostic Network. A literature search was conducted on MEDLINE from 1969 to 2009, and consensus was reached by the panel members after a comprehensive review of the data. Randomized controlled trials and prospective studies were given highest priority in building the consensus. RESULTS In the absence of contraindications, topical anesthesia, analgesia, and sedation are suggested in all patients undergoing bronchoscopy because of enhanced patient tolerance and satisfaction. Robust data suggest that anticholinergic agents, when administered prebronchoscopy, do not produce a clinically meaningful effect, and their use is discouraged. Lidocaine is the preferred topical anesthetic for bronchoscopy, given its short half life and wide margin of safety. The use of a combination of benzodiazepines and opiates is suggested because of their synergistic effects on patient tolerance during the procedure and the added antitussive properties of opioids. Propofol is an effective agent for sedation in bronchoscopy and can achieve similar sedation, amnesia, and patient tolerance when compared with the combined administration of benzodiazepines and opiates. CONCLUSIONS We suggest that all physicians performing bronchoscopy consider using topical anesthesia, analgesic and sedative agents, when feasible. The existing body of literature supports the safety and effectiveness of this approach when the proper agents are used in an appropriately selected patient population.

Airway complications of esophageal self-expandable metallic stent

The primary therapeutic objective in patients with advanced esophageal cancer is to relieve symptomatic dysphagia. Traditionally, palliative radiotherapy, chemotherapy, and periodic bougie dilation have been used for this purpose. Rapid palliation is possible with placement of a plastic esophageal prosthesis. However, such devices are associated with a high rate of complications such as migration, esophageal perforation, and aspiration pneumonia.1 In recent years, self-expandable metallic stent (SEMS) have been used to relieve esophageal obstruction. Although complications are less frequent with SEMS as compared with conventional plastic stents,2 we have seen two patients who developed severe tracheobronchial complications after SEMS placement.

Clinical management of asthma in the 1990s : Current therapy and new directions

SummaryAsthma is a serious global health problem affecting nearly 100 million people worldwide. Its rising prevalence and associated morbidity and mortality are of increasing concern. Traditionally, symptomatic control of bronchoconstriction with β2 agonists and theophylline has been the mainstay of therapy. However, during recent years, inflammation has been recognised as the predominant cause of reversible airway obstruction and airway hyperreactivity. As a result, the emphasis in treatment has shifted to the early use of inhaled corticosteroids to control airway inflammation. β2 agonists are best used on an as-needed basis for the relief of acute bronchoconstriction and for the prevention of exercise-induced asthma. Sustained release theophylline or an inhaled long-acting β2 agonist may effectively control nocturnal symptoms. Preliminary studies involving agents active in the 5-lipoxygenase pathway as preventive therapy are encouraging. Further studies are needed to define their role in the management of asthma.

Transbronchial Lung Biopsy

Transbronchial Lung biopsy (TBBx) also known as “Bronchoscopic Lung Biopsy” is one of the most important sampling procedures performed during flexible bronchoscopy. In majority of cases, TBBx is performed under conscious sedation in an outpatient setting. TBBx is performed for obtaining tissue specimen from peripheral lung masses and focal or diffuse lung infiltrates. The technique is useful in patients with suspected lung cancer, fungal and mycobacterial lung infections, unexplained infiltrates in immunocompromised hosts and in patients with suspected pulmonary sarcoidosis, lymphangitic carcinomatosis, and in selected cases of pulmonary Langerhan’s cell histiocytosis, lymphangioleiomyomatosis, and cryptogenic organizing pneumonia. TBBx also plays important role in assessment of rejection and infectious complications following lung transplantation.

Diseases of Central Airways: An Overview

Central airways are involved in a variety of neoplastic and non-neoplastic disorders and cause non-specific symptoms such as cough, expectoration, dyspnea, wheezing, and hemoptysis. In the absence of distinctive clinical features, many of these patients are misdiagnosed as asthma or chronic obstructive pulmonary disease (COPD) for months to years before the underlying pathology is identified. Failure to diagnose the disease process in early stages can lead to progressive respiratory symptoms and respiratory failure in some patients. A high index of suspicion is essential for early diagnosis. A detailed clinical evaluation can provide useful clues, but advanced radiological imaging and bronchoscopy are often needed for diagnosis. Spirometry has a low sensitivity, but an abnormal flow volume loop is an important indicator of central airway pathology. Multidetector computed tomography (MDCT) of chest is the most useful radiological test. Multiplanar reconstruction of CT data provides additional useful information in selected cases. There should be low threshold to perform bronchoscopy in patients suspected to have central airway disorders. Apart from the direct endoscopic examination, biopsy and culture material obtained during bronchoscopy are very helpful in establishing the diagnosis. The treatment of central airway diseases depends on underlying diagnosis and may include close observation, medical treatments such as antimicrobial agents, systemic corticosteroids, immunosuppressive medications and biologic agents, interventional bronchoscopy procedures, and airway surgery. An early diagnosis is essential for optimal outcome. Due to the complex nature of the disease processes, need for multispecialty involvement, and high demand for equipment and expertise, an early referral to a center that specializes in advanced airway disorders is highly recommended.