Saviour tool now a foreign body

ABSTRACT

Foreign bodies are commonly seen in children, here presenting a case of a male adult with an impacted thumb pin in the left lower lobe bronchus. Extraction required fiber-optic bronchoscopy, failure of which led to thoracotomy with bronchotomy.

Warfarin-induced diffuse alveolar hemorrhage: Case report and a review of the literature

Diffuse alveolar hemorrhage (DAH) refers to the intra-alveolar accumulation of blood originating from the pulmonary microvasculature. This life-threatening condition is a medical emergency as patients often develop acute respiratory failure requiring invasive mechanical ventilation. This mandates for an early diagnosis with prompt and aggressive management strategies. A host of clinical disorders are known to cause DAH; however, warfarin-induced alveolar hemorrhage is a distinct clinical rarity. A search of the literature reveals few reports documenting this entity. A 27-year-old male presented with complaints of recent-onset hemoptysis and dyspnea. One month back, he was diagnosed with lower-limb deep-venous thrombosis and pulmonary embolism. He had been taking oral anticoagulants irregularly since then without monitoring of prothrombin time. Chest radiograph, done on presentation, revealed bilateral upper-lobe infiltrates, whereas computed tomography of the chest was suggestive of bilateral upper-lobe ground-glass opacities. Serial bronchoscopic alveolar lavage yielded samples which became progressively bloodier, whereas cytological evaluation of the sample revealed numerous alveolar macrophages with intracytoplasmic hemosiderin. A diagnosis of DAH due to warfarin was made, and the patient was administered Vitamin K followed by infusion of fresh frozen plasma. There was a marked clinical recovery, and the patient has been asymptomatic since then.

Is bronchoscopy always justified in diagnosis of haemoptysis?

INTRODUCTION

Fiber-optic bronchoscopy (FOB) is commonly performed in the first line in diagnostic process of haemoptysis. However, lots of evidences suggest that in haemoptysis FOB do not always provide additional, useful information to radiological diagnostics. Therefore, this study aimed to evaluate the validity of performing FOB as a method of choice in first line diagnostics of haemoptysis.

MATERIAL AND METHODS

Data comprised consecutively collected results from patients referred for FOB assessment for clinical purposes were retrospectively analysed. We included all examinations, which were performed due to haemoptysis as the only indication, excluding any other lung-related conditions.

RESULTS

114 patients were finally included to the study. The median age was 59 (IQR: 46-64.75). Active bleeding was visualized during examination of 13 (11.4%) patients. Patients with active bleeding did not differ significantly according to age: 59 (54-69) vs 59 (45-64) years; W = 532.5, p-value = 0.27, and gender: c2 = 1.68, p-value = 0.2. On the other hand, in 29 (25.44%) patients, FOB revealed no visible abnormalities. This subgroup of patients was significantly younger - 46 (34-62) years vs 60 (53-67) years; W = 782, p-value = 0.003.

CONCLUSION

Low number of visualized active bleeding sites suggest overuse of bronchoscopy in diagnosis of haemoptysis. Indications for this examination should be reconsidered especially in young patients with non-massive haemoptysis.

Comparison of Bronchoscopy-Guided and Real-Time Ultrasound-Guided Percutaneous Dilatational Tracheostomy: Safety, Complications, and Effectiveness in Critically Ill Patients

OBJECTIVE

To compare the efficacy, safety, and incidence of complications between fiber-optic bronchoscopy-guided percutaneous dilatational tracheostomy (FOB-PDT) and ultrasound-guided percutaneous dilatational tracheostomy (US-PDT) and to determine whether US-PDT is a viable alternative to FOB-PDT.

METHODS

This randomized prospective study was carried out in 80 patients who were randomly divided into US-PDT and FOB-PDT groups. Demographic data and Acute Physiology and Chronic Health Evaluation II (APACHE II), procedure duration, hemorrhage status, complications, procedure difficulty, displacement of entry location after US, and hemodynamic data were evaluated in both groups. Tracheal incision was performed with real-time US and a transverse probe position in the out-of-plane mode.

RESULTS

No significant differences were observed between the 2 groups in terms of demographic data, oral intubation time, APACHE II values, difficulty of the procedure, or the number of needle interventions ( P > .05). The mean hemorrhage ratio of the FOB-PDT group was significantly higher than that of the US-PDT group ( P < .05). The entry location was changed in 6 patients in the US-PDT group following neck examination with US. The mean duration of the procedure for the FOB-PDT group was significantly longer than that for the US-PDT group ( P < .05).

CONCLUSION

Ultrasound-guided percutaneous dilatational tracheostomy is a safe procedure for critically ill patients and has the advantages of a low complication rate, short duration of procedure, being informative with regard to neck anatomy, and facilitating prevention of vascular puncture. Thus, US-PDT can be used as an alternative to FOB-PDT.

Two Different Endoscopic Procedures Made Feasible by the Janus Mask in a High-Risk Patient

The Janus mask is a full face mask designed for providing noninvasive ventilation (NIV) during any kind of upper endoscopies (e.g., fiber-optic bronchoscopy, gastrointestinal endoscopy, and transesophageal echocardiography). Due to its unique conformation, its use can be considered for both elective and urgent endoscopic procedures in high-risk patients. In this case report, we present a patient with acute respiratory failure who underwent two consecutive different endoscopic procedures (fiber-optic bronchoscopy and gastrointestinal endoscopy) during continuous positive airway pressure support by means of this novel NIV mask, thus avoiding tracheal intubation and at the same time, improving his respiratory condition.