Pulmonary hemorrhage and air embolism complicating transbronchial biopsy in pulmonary amyloidosis

The spectrum of pulmonary amyloidosis

Amyloidosis is a disease caused by misfolded proteins that deposit in the extracellular matrix as fibrils, resulting in the dysfunction of the involved organ. The lung is a common target of Amyloidosis, but pulmonary amyloidosis is uncommonly diagnosed since it is rarely symptomatic. Diagnosis of pulmonary amyloidosis is usually made in the setting of systemic amyloidosis, however in cases of localized pulmonary disease, surgical or transbronchial tissue biopsy might be indicated. Pulmonary amyloidosis can be present in a variety of discrete entities. Diffuse Alveolar septal amyloidosis is the most common type and is usually associated with systemic AL amyloidosis. Depending on the degree of the interstitial involvement, it may affect alveolar gas exchange and cause respiratory symptoms. Localized pulmonary Amyloidosis can present as Nodular, Cystic or Tracheobronchial Amyloidosis which may cause symptoms of airway obstruction and large airway stenosis. Pleural effusions, mediastinal lymphadenopathy and pulmonary hypertension has also been reported. Treatment of all types of pulmonary amyloidosis depends on the type of precursor protein, organ involvement and distribution of the disease. Most of the cases are asymptomatic and require only close monitoring. Diffuse alveolar septal amyloidosis treatment follows the treatment of underlying systemic amyloidosis. Tracheobronchial amyloidosis is usually treated with bronchoscopic interventions including debulking and stenting or with external beam radiation. Long-term prognosis of pulmonary amyloidosis usually depends on the type of lung involvement and other organ function.

Differential diagnoses of calcified nodules in pulmonary amyloidosis: A case report

Pulmonary amyloidosis should be included in the differential diagnosis of calcified lung nodules, and more careful preparation for bleeding should be taken when performing bronchoscopy. While management does not require aggressive treatment, follow‐up is necessary to monitor for multiple myeloma and malignant lymphoma

Systemic arterial gas embolism (SAGE) as a complication of bronchoscopic lung biopsy: a case report and systematic literature review

Background

Systemic arterial gas embolism (SAGE) is a rare yet serious and underrecognized complication of bronchoscopic procedures. A recent case of presumed SAGE after transbronchial needle aspiration prompted a systematic literature review of SAGE after biopsy procedures during flexible bronchoscopy.

Methods

We performed a systematic database search for case reports and case series pertaining to SAGE after bronchoscopic lung biopsy; reports or series involving only bronchoscopic laser therapy or argon plasma coagulation (APC) were excluded. Patient data were extracted directly from published reports.

Results

A total of 29 unique patient reports were assessed for patient demographics, specifics of the procedure, clinical manifestations, diagnostic findings, and clinical outcomes. Cases of SAGE occurred after multiple types of bronchoscopic biopsy and under both positive and negative pressure ventilation. The most common clinical findings were neurologic, followed by cardiac manifestations; temporal patterns included acute onset of cardiac or neurologic emergencies immediately after biopsy, or delayed awakening post-procedure. There was a high mortality rate among cases (28%), with residual neurologic deficits also common (24%).

Discussion

SAGE is an underrecognized but severe adverse effect of bronchoscopic lung biopsy, which often presents with acute coronary or cerebral ischemia or delayed awakening from sedation. It is important for all physicians who perform bronchoscopic biopsies to be aware of the clinical manifestations and therapeutic management of SAGE in order to mitigate morbidity and mortality among patients undergoing these procedures.

Cerebral air embolism complicating transbronchial lung biopsy: A case report

BACKGROUND

In this case report we describe an extremely rare case of cerebral air embolism following transbronchial lung biopsy (TBLB). Only a few cases of this rare complication were described previously. Every bronchologist should recognize this severe adverse event. Prompt recognition of this complication is mandatory in order to initiate supportive measures and consider hyperbaric oxygen therapy.

CASE SUMMARY

In this case report we describe an extremely rare case of cerebral air embolism following TBLB. Only a few cases of this rare complication were described previously. Our patient had an incidental finding of lung tumour and pulmonary emphysema. Cerebral air embolism developed during bronchoscopy procedure, immediately after the third trans-bronchial lung biopsy sample and caused cerebral ischaemia of the right hemisphere and severe left-sided hemiplegia. Despite timely initiation of hyperbaric oxygen therapy hemiplegia didn´t resolve and the patient died several weeks later. Cerebral air embolism is an extremely rare complication of TBLB. This condition should be considered in case the patient remains unresponsive or presents with acute neurological symptoms in the post-intervention period since early recognition, diagnosis and hyperbaric oxygen therapy initiation are key factors determining the patient´s outcome.

CONCLUSION

Within this report, we conclude that air/gas embolism is an extremely rare complication after TBLB, which should be considered in case the patient remains unresponsive or presents with acute neurological symptoms in the post-intervention period after bronchoscopy. The current gold standard for diagnosis is computed tomography scan of the head. After recognition of this complication we suggest immediate hyperbaric oxygen therapy, if available.

Systemic AL amyloidosis presenting with diffuse alveolar septal involvement and respiratory failure: a case report and review of the literature

Background

Amyloidosis is the extracellular deposition of amyloid fibril protein in any tissue or organ. The clinical manifestations of pulmonary amyloidosis are variable and without specific symptoms. We report a rare case of diffuse alveolar septal amyloidosis which is an extremely rare pattern of involvement, with a very poor prognosis, to improve our understanding of the disease.

Case presentation

A 27-year-old man complained of shortness of breath and cyanosis. High-resolution computed tomography revealed diffuse ground-glass opacifications with interlobular septal thickening in both lungs. The immune-histochemistry showed monoclonal lambda light chains. This case also showed nephrotic syndrome and cardiac arrhythmia, suggesting an involvement of the kidney and the heart. Diagnosis: The diagnosis was finally established by tru-cut transthoracic sonar guided lung biopsy (TSLB), and histological examination revealed Congo red-positive amorphous eosinophilic deposits in the alveolar sept. Interventions: The patient was admitted to a respiratory intensive care unit and put on non-invasive ventilation, then discharged on domiciliary oxygen therapy, and started treatment with chemotherapy melphalan 2 mg daily plus prednisone 60 mg daily immediately after the result of histopathology. Outcomes: Three months after treatment, dyspnea and hypoxemia improved, and he continued treatment. The patient was in a good clinical condition after 10 months of follow-up, but he died suddenly.

Conclusion

As it is difficult to distinguish diffuse alveolar septal amyloidosis from other interstitial and granulomatous lung diseases because of their similar symptoms and imaging findings, thus, transthoracic sonar guided lung biopsy and histological examination is very important in the diagnosis of diffuse alveolar septal amyloidosis.

Management of Pulmonary Hemorrhage Complicating Pulmonary Thromboendarterectomy

Airway management during pulmonary thromboendarterectomy (PTE) can prove challenging, especially in the face of unexpected intraoperative pulmonary hemorrhage. Utilization of proper airway equipment on induction is crucial for the successful management of intraoperative pulmonary hemorrhage. Our case series describes the preoperative risk factors that can lead to intraoperative pulmonary hemorrhage, the preinduction airway equipment considerations for PTE, and the intraoperative management of pulmonary hemorrhage. We summarize the lessons learned at our institution from four cases of post perfusion pulmonary hemorrhage.

Air embolism following bronchoscopy with fine needle aspiration: An unexpected complication

Flexible fibreoptic bronchoscopy with fine needle aspiration is a common procedure, useful in the diagnosis and assessment of lung disease. There are known complications associated with such a procedure that are well documented in the literature. However, there are only four cases of air embolus following fine needle aspiration during bronchoscopy described in the literature. Due to the varying clinical manifestations of the complication, it remains underrecognized by the clinical community and was not described at all by the most recent British Thoracic society 2013 statement on bronchoscopy. The following two case reports describe incidences where air emboli ensued following bronchoscopy with fine needle aspiration. They examine four notable, and arguably avoidable, risk factors that can exacerbate an air embolus and offer guidance on both imaging and treatment for any physician faced with a corresponding clinical picture.

Cerebral Artery Gas Embolism Following Navigational Bronchoscopy

INTRODUCTION

Cerebral artery gas embolism (CAGE) is a rare but serious adverse event with potentially devastating neurologic sequelae. Bronchoscopy is a frequently performed procedure but with only a few reported cases of CAGE.

METHODS

We report the first documented case of CAGE associated with electromagnetic navigational bronchoscopy.

RESULTS

A 61-year-old man with a left lower lobe nodule underwent electromagnetic navigational bronchoscopy. The target lesion underwent transbronchial biopsy, brushing and an end-procedure lavage. Following the procedure, he developed seizures, evidence of hypoxic injury and cerebral edema, and air emboli were seen on computed tomography imaging. He then underwent treatment with hyperbaric oxygen with a full and complete neurologic recovery. Review of other cases reported in the literature suggests improved neurologic outcomes with hyperbaric oxygen treatment.

CONCLUSIONS

Biopsy techniques performed during bronchoscopy and electromagnetic navigational bronchoscopy can result in CAGE. Comparison with other reported cases suggests improved neurologic outcomes in those treated with hyperbaric oxygen. Prompt recognition of this complication and timely treatment with hyperbaric oxygen are the cornerstones to recovery.

Transbronchial biopsies safely diagnose amyloid lung disease

BACKGROUND

Autopsy identifies lung involvement in 58-92% of patients with the most prevalent forms of systemic amyloidoses. In the absence of lung biopsies, amyloid lung disease often goes unrecognized. Report of a death following transbronchial biopsies in a patient with systemic amyloidosis cautioned against the procedure in this patient cohort. We reviewed our experience with transbronchial biopsies in patients with amyloidosis to determine the safety and utility of bronchoscopic lung biopsies.

METHODS

We identified patients referred to the Amyloidosis Center at Boston Medical Center with lung amyloidosis diagnosed by transbronchial lung biopsies (TBBX). Amyloid typing was determined by immunohistochemistry or mass spectrometry. Standard end organ assessments, including pulmonary function test (PFT) and chest tomography (CT) imaging, and extra-thoracic biopsies established the extent of disease.

RESULTS

Twenty-five (21.7%) of 115 patients with lung amyloidosis were diagnosed by TBBX. PFT classified 33.3% with restrictive physiology, 28.6% with obstructive disease, and 9.5% mixed physiology; 9.5% exhibited isolated diffusion defects while 19% had normal pulmonary testing. Two view chest or CT imaging identified focal opacities in 52% of cases and diffuse interstitial disease in 48%. Amyloid type and disease extent included 68% systemic AL disease, 16% localized (lung limited) AL disease, 12% ATTR disease, and 4% AA amyloidosis. Fluoroscopy was not used during biopsy. No procedure complications were reported.

CONCLUSIONS

Our case series of 25 patients supports the use of bronchoscopic transbronchial biopsies for diagnosis of parenchymal lung amyloidosis. Normal PFTs do not rule out the histologic presence of amyloid lung disease.

Usefulness of an angioplasty balloon as selective bronchial blockade device after transbronchial cryobiopsy

BACKGROUND AND OBJECTIVE

Transbronchial cryobiopsy (TBCB) is a technique in which frozen samples of lung are obtained using a probe inserted through a bronchoscope. We performed a retrospective study to assess the performance of the TBCB procedure complemented by segmental bronchial blockade using an angioplasty balloon, in terms of diagnostic yield and safety in diffuse parenchymal lung disease (DPLD).

METHODS

Data from 100 patients with suspected DPLD (clinical and radiological findings), who underwent TBCB in our institution to establish a definitive diagnosis, were reviewed. In our institution, TBCB is monitored with fluoroscopy and performed under general anaesthesia by a multidisciplinary team (an anaesthesiologist, a pulmonologist and an interventional radiologist). In each patient, four samples were collected using a 2.4-mm distal diameter cryoprobe. To control bleeding, the biopsied segmental bronchus was blocked with a 6-mm diameter angioplasty balloon, inserted over a 0.035-inch angled hydrophilic guidewire. After the cryoextraction, the balloon was inflated for 3 min intervals until bleeding stopped.

RESULTS

Overall, 98% of samples had diagnostic value. In 85% of cases, DPLD was confirmed, while in 7%, cancer was diagnosed. Complications were observed in 16% of the patients: 13 patients developed moderate haemorrhage, and 3 developed pneumothorax.

CONCLUSION

Transbronchial cryobiopsy had a high diagnostic yield for DPLD. Performing the procedure under fluoroscopy guidance and using angioplasty balloon for selective bronchial blockade achieved a low rate of iatrogenic complications directly associated with the technique.

Amyloidosis involving the respiratory system: 5-year's experience of a multi-disciplinary group's activity

Amyloidosis may involve the respiratory system with different clinical-radiological-functional patterns which are not always easy to be recognized. A good level of knowledge of the disease, an active integration of the pulmonologist within a multidisciplinary setting and a high level of clinical suspicion are necessary for an early diagnosis of respiratory amyloidosis. The aim of this retrospective study was to evaluate the number and the patterns of amyloidosis involving the respiratory system. We searched the cases of amyloidosis among patients attending the multidisciplinary rare and diffuse lung disease outpatients' clinic of Pulmonology Unit of the Hospital of Arezzo from 2007 to 2012. Among the 298 patients evaluated during the study period, we identified three cases of amyloidosis with involvement of the respiratory system, associated or not with other extra-thoracic localizations, whose diagnosis was histo-pathologically confirmed after the pulmonologist, the radiologist, and the pathologist evaluation. Our experience of a multidisciplinary team confirms that intra-thoracic amyloidosis is an uncommon disorder, representing 1.0% of the cases of rare and diffuse lung diseases referred to our center. The diagnosis of the disease is not always easy and quick as the amyloidosis may involve different parts of the respiratory system (airways, pleura, parenchyma). It is therefore recommended to remind this orphan disease in the differential diagnosis of the wide clinical scenarios the pulmonologist may intercept in clinical practice.

Transbronchial lung biopsy: the pathologist's point of view

BACKGROUND AND AIMS

The efficacy of flexible cryoprobe in providing high-quality tissue specimens through bronchoscopy for making a diagnosis remains debatable. In this study, we have compared the diagnostic yield of cryoprobe with conventional sampling by forceps.

METHODS

Forty-one patients scheduled to undergo transbronchial lung biopsy (TBLB) in a pulmonary hospital in Tehran, Iran. Each patient underwent conventional TBLB and flexible cryoprobe TBLB (FCLB) sequentially. Specimen adequacy was defined by the presence of at least 50 alveolar spaces or a positive diagnostic yield. Adequacy of specimens, number and percentage of alveolar spaces without artifact, type of artifact, presence of bronchiolar structures and the diagnosis made based on the results of the two methods separately were compared.

RESULTS

The mean values of tissue section area obtained by forceps and cryoprobe were 6 mm(2) [standard deviation (SD) ± 6.7] and 22 mm(2) (SD ± 19.1), respectively (P < 0.001). Specimens were adequate in 26 cases of conventional TBLB and 40 cases of FCLB (P < 0.001). Of adequate specimens, 14 samples obtained by TBLB and 28 samples obtained via FCLB were diagnostic. A significant difference was also detected between diagnostic and non-diagnostic specimens (P = 0.04). Frequency of specimens with >75% artifact-free lung parenchyma was significantly higher in FCLB method.

CONCLUSION

FCLB method provides larger tissue samples with better quality compared with TBLB. Higher-quality specimens are associated with less artifact and higher diagnostic yield. Multisite randomized trials are required to improve our knowledge about the benefits and indications of TBLB with cryoprobe.

Diagnostic yield of transbronchial cryobiopsy in interstitial lung disease: a randomized trial

BACKGROUND AND OBJECTIVE

Transbronchial lung biopsy (TBLB) is required for evaluation in selected patients with interstitial lung disease (ILD). The diagnostic yield of histopathologic assessment is variable and is influenced by factors such as the size of samples and the presence of crush artefacts left by conventional biopsy forceps. We compared the diagnostic yield and safety of TBLB with cryoprobe sampling versus conventional forceps sampling.

METHODS

This randomized clinical trial analysed data for 77 patients undergoing TBLB for evaluation of ILD; patients were assigned to either a conventional-forceps group or a cryoprobe group. Two pathologists assessed the tissue samples and agreed on histopathologic diagnoses. We also compared the duration of procedures, complications and sample-quality variables.

RESULTS

The most frequent diagnosis observed in the cryoprobe group was non-specific interstitial pneumonia. Histopathologic diagnoses were identified in more cases in the cryoprobe group (74.4%) than in the conventional-forceps group (34.1%) (P < 0.001), and the diagnostic yield was higher in the cryoprobe group (51.3% vs 29.1% in the conventional forceps group; P = 0.038). A larger mean area of tissue was harvested by cryoprobe (14.7 ± 11 mm(2) ) than by conventional forceps (3.3 ± 4.1 mm(2)) (P < 0.001). More grade 2 bleeding (not statistically significant) occurred in the cryoprobe group (56.4%) than in the conventional-forceps group (34.2%). No differences in other complications were observed.

CONCLUSIONS

TBLB by cryoprobe is safe and potentially useful in the diagnosis of ILD. Larger multisite randomized trials are required to confirm the potential benefits of this procedure. Clinical trial registration at ClinicalTrials.gov: NCT01064609.

Cerebral air embolism following transbronchial lung biopsy during flexible bronchoscopy

During a diagnostic flexible bronchoscopy an 84 year old patient suffered a sudden reduction in conscious level following a transbronchial lung biopsy. A subsequent computed tomography brain scan confirmed cerebral air emboli. The patient survived following a period of supportive treatment in the critical care unit. Transbronchial lung biopsy may cause disruption of vessels walls within the lung parenchyma. Increased airway pressure, caused by the patient exhaling against a bronchoscope wedged within a segmental bronchi, may subsequently force air bubbles through the vessel wall defects. This may explain the occurrence of air emboli. This is a rare report of air embolism complicating transbronchial lung biopsy and all bronchoscopists should aware of this potentially fatal complication.

Lung amyloid nodule detected by 99mTc-aprotinin scintigraphy

We present a case in which an amyloid lung nodule was diagnosed preoperatively by amyloid scintigraphy (99m)Tc-aprotinin. A 65-year-old man complained of marked weight loss (9 kg) over a period of 6 months. An abnormal shadow in the middle field of the right lung was detected on chest X-ray, corresponding to a 16-mm nodule in the right middle lobe on thoracic computed tomography (CT). Total protein and immunoglobulin G levels were elevated to 8.3 and 2245 mg/dl, respectively, but other blood tests including several tumor marker levels and Cryptococcus antibodies were all within normal range. Fluorodeoxyglucose positron emission tomography showed no uptake by the lung nodule, so lung amyloidosis was considered as differential diagnosis. To avoid risk of bleeding on bronchoscopy, noninvasive amyloid scintigraphy using (99m)Tc-aprotinin was first performed. A nodular, abnormal accumulation was observed in the right middle lung lobe. Diagnostic imaging strongly suggested amyloidosis, so video-assisted thoracic surgery was performed rather than bronchoscopy. Pathological samples showed positive staining with Congo red, and A-λ amyloidosis was diagnosed on the basis of immunostaining. Scintigraphy using (99m)Tc-aprotinin offers a useful, noninvasive method for assessing lung amyloidosis.

[Transbronchial lung biopsy using cryoprobes]

BACKGROUND AND OBJECTIVES

Transbronchial lung biopsy (TBLB) is a bronchoscopy procedure used to obtain peripheral lung tissue. Small size samples and artefacts lead to variable, and usually poor, diagnostic yield. The use of cryoprobes may enable larger size and better quality biopsy samples to be obtained. The purpose of this study was to evaluate the feasibility of TBLB with cryoprobes and analyse the histological quality of samples obtained.

PATIENTS AND METHODS

We selected 10 patients with interstitial lung disease who were suitable for TBLB. A cryoprobe (Erbokryo CA, Erbe, Germany) was introduced through the bronchoscope work channel. Then, under fluoroscopic control, the cryoprobe was placed in an area of the peripheral lung previously selected according to CT findings. A temperature of -89.5 degrees C was applied for 3s and the cryoprobe and bronchoscope were removed with the frozen lung sample attached to the probe. The procedure was performed under sedation and the patient was intubated to allow bronchoscope and cryoprobe removal. Safety, duration of the procedure and histological findings has been evaluated.

RESULTS

There were 10 patients (64+/-8 years, 6 males). Procedure length was 35 min. The specimen area was 9.5 mm2 (range 3 to 25 mm2) and the mean number of alveolar spaces was 29.62. No pneumothorax was registered. 6/10 patients had mild post-biopsy bleeding controlled with standard bronchoscopy measures.

CONCLUSIONS

The use of cryoprobes for TBLB may become an alternative technique to increase diagnostic yield.

Transdiaphragmatic amyloidoma

The term "amyloidoma" has been used to describe localized pulmonary nodular amyloidosis when it is a solitary lesion. Amyloidoma is an uncommon and infrequently reported cause of benign pulmonary lesions. We report the case of a 45-year-old man with hemoptysis, eosinophilia, and a large mass involving both lobes of the left lung, the chest wall, and, via extension through the diaphragm, the liver. Clinical suspicion of echinococcal cyst led to treatment via en bloc excision rather than attempting tissue biopsy for diagnosis. Complete resection of the isolated pulmonary amyloidoma was achieved with no evidence of recurrence.

Gas flow during bronchoscopic ablation therapy causes gas emboli to the heart: a comparative animal study

BACKGROUND

Thermal ablation is one of the most commonly used modalities to treat central airway obstruction. Both laser and argon plasma coagulation (APC) have been reported to cause gas emboli and cardiac arrest. We sought to determine whether bronchoscopic ablation therapy can result in systemic gas emboli, correlate their presence with the rate of gas flow, and establish whether a zero-flow (ZF) modality would result in the significant reduction or elimination of emboli.

METHODS

CO(2) laser delivered through a photonic bandgap fiber (PBF) and APC were applied in the trachea and mainstem bronchi of six anesthetized sheep at varying dosages and gas flow rates. Direct epicardial echocardiography was used to obtain a four-chamber view and detect gas emboli.

RESULTS

The presence of gas flow accompanying APC and the CO(2) laser with forward flow correlated significantly with the appearance of gas bubbles in the atria. A definite dose response was observed between the gas flow rate and the number of bubbles seen. When the CO(2) laser was delivered through a PBF with ZF to the trachea or bronchi, no bubbles were observed.

CONCLUSION

Bronchoscopic thermal ablation therapy using gas flow is associated with gas emboli in a dose-dependent fashion. The use of the flexible PBF with ZF is not associated with the development of gas emboli. Further study is required to determine whether a clinically safe threshold of gas emboli exists, and the relationships among the pathologic depth of tissue destruction, gas flow, pulse duration, and the development of gas emboli.

Three cases of the nodular pulmonary amyloidosis with a longterm observation

Longterm observation with chest radiograph and computed tomography (CT) scan was performed for pulmonary amyloidosis. There are few reports of primary pulmonary amyloidosis with a longterm observation. We encountered three cases of nodular pulmonary amyloidosis observed by intermittent chest radiograph or CT for 5 years or more. The patients were a 54-year-old man, and 67- and 68-year old women. For diagnosis, transbronchial biopsy and percutaneous lung biopsy were performed. Amyloid nodules grew slowly and two cases showed findings of cavity and calcification.

Fatal cerebral air embolism as a complication of transbronchoscopic lung biopsy: a case report

A rare complication of transbronchoscopic lung biopsy, namely a cerebral air embolism, is presented. The course of events following the embolic episode in the form of a fall in blood pressure, bradycardia and convulsions is documented, as is the presence of an air emboli on the CT scan of the brain with subsequent resorption of the emboli on the follow-up scan. The salient features of the case are the rarity of the complication and the excellent temporal depiction of imaging findings on CT scan demonstrated as resorption of air emboli and subsequent watershed territory infarcts.

Pathogenesis of systemic air embolism during bronchoscopic Nd:YAG laser operations

BACKGROUND

The occurrence of systemic air embolism during bronchoscopic neodymium:yttrium-aluminum garnet laser operations has been suspected. Here we describe its mechanism.

METHODS

Two patients with embolic cardiac and neurologic complications after bronchoscopic neodymium: yttrium-aluminum garnet laser tumor ablation are described. A subsequent third patient was monitored for intracardiac and aortic air by transesophageal echocardiography. A review of the literature and safety recommendations are discussed.

RESULTS

The appearance of systemic air emboli was related to the use of the laser fiber air coolant at high flow and resolved by decreasing the air flow. The presence of intracardiac and aortic air was associated with hypotension and inferior ischemic electrocardiographic changes.

CONCLUSIONS

Systemic air embolism during bronchoscopic laser operations is a potentially catastrophic complication and is related to the use of gas-cooled laser fibers and contact probes. We recommend using the noncontact mode whenever possible and maintaining the coaxial coolant air flow at the minimum level or using a fluid coolant if contact is necessary.

[Tracheobronchial amyloidosis: apropos of 3 cases]

We report 3 cases of tracheobronchial amyloidosis starting with post-obstructive pneumonitis, suggesting underlying neoplasm. The diagnosis was by fiberoptic bronchoscopy. We also describe radiological findings and their usefulness, therapeutic options, and course of disease.

Gas Embolism: Part II. Arterial Gas Embolism and Decompression Sickness

Gas emboli syndromes are known to occur in many different settings, and they may result in life-threatening emergencies. Venous gas embolization was discussed previously in Part I of this review. Gas emboli that gain access to the arterial circulation or that result from exposures to decreased ambient pressures in the environment are discussed in Part II. The prevalence of arterial gas emboli and decompression sickness are likely not as high as for venous gas emboli. Most cases are preventable, and prompt treatment is frequently effective. Once present, gas bubbles generally distribute themselves throughout the body based on the relative blood flow at the time, thus making the nervous system, heart, lung, and skin the primary organ systems involved. Both mechanical and biophysical effects lead to intravascular and extracellular alterations that result in tissue injury. The clinical manifestations of these disorders are varied, and a high index of suspicion in the appropriate settings will aid health care providers in prompt recognition of these problems and allow timely intervention with specific therapy. Management of arterial gas emboli and decompression sickness is similar, with a focus on hyberbaric chamber therapy and intermittent hyperoxygenation. Recompression schedules in current use have withstood the test of time. Research continues to refine our understanding of these diseases and to optimize the treatment regimens available.

Pulmonary amyloidoma. Histologic proof yielded by transthoracic coaxial fine needle biopsy

Nodular pulmonary amyloidosis was diagnosed by percutaneous transthoracic fine needle biopsy specimen in an 88-year-old woman. Congo red staining should be performed whenever band-like hyalinized material is obtained on aspiration of a solitary nodule. Dense calcifications can occur in pulmonary amyloidomas. In selected cases, fine needle biopsy appears to be preferable to transbronchial forceps biopsy since the risk of a possibly life-threatening pulmonary hemorrhage may be lower.

Pulmonary diffuse alveolar septal amyloidosis--diagnosed by transbronchial lung biopsy

Diffuse alveolar septal involvement is a rare form of pulmonary amyloidosis. Antemortem diagnosis is unusual, and most of the reported cases were diagnosed at autopsy. It has recently been reported that transbronchial lung biopsy via a flexible fiberoptic bronchoscope was a relatively safe method to confirm diffuse alveolar septal amyloidosis. We report a case of pulmonary diffuse alveolar septal amyloidosis confirmed by transbronchial lung biopsy. The patient's chief complaints were dyspnea on exertion and epigastric pain aggravated over a one-year period, while a chest roentgenogram showed bilateral diffuse interstitial infiltration. This case also showed nephrotic syndrome, cardiac arrhythmia, congestive heart failure, a tingling sensation in both hands and multiple nodules in the gastrointestinal tracts, suggesting involvement of the kidney, heart, peripheral nerves and gastrointestinal tracts. We propose that when diffuse interstitial lung disease is present with systemic signs such as nephrotic syndrome or cardiac arrhythmia, amyloidosis should be considered as a possible diagnosis. Also, transbronchial lung biopsy may be a useful confirmative diagnostic tool.

Transbronchial biopsy without fluoroscopy: a five year experience in outpatients

Transbronchial biopsy is the technique of choice for obtaining tissue for histological diagnosis in many pulmonary disorders. The procedure has usually been carried out as an inpatient procedure with the use of fluoroscopy, though this policy has recently been questioned. This report concerns a five year experience of 174 transbronchial biopsies performed without fluoroscopy as an outpatient procedure in patients with interstitial lung disease or a suspicion of sarcoidosis. Chest radiography was carried out only if the patient developed symptoms. No major complications were encountered and the overall complication rate was low. Pneumothorax occurred in six patients (3.4%), only one of whom required intercostal intubation, and bleeding of more than 30 ml occurred in two patients. Histological diagnosis was obtained in 154 patients (88%). In the experience of this group transbronchial biopsy has been safe when carried out as an outpatient procedure without fluoroscopic guidance.

Pathogenesis of cerebral air embolism during neodymium-YAG laser photoresection

We describe a case of air embolism complicating neodymium-YAG laser resection of an endobronchial carcinoid tumor. A 27-year-old man experienced an acute neurologic syndrome during laser photoresection which responded to acute hyperbaric therapy.