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Occlusion balloons: (a) The assistant is firmly gripping the Fogarty Balloon catheter with his right hand at its proximal exit from the laryngeal mask airway which he also stabilizes with his left hand. The operator maneuvers the bronchoscope through the laryngeal mask airway. (b) An Arndt endobronchial blocker is advanced through the blocker port of the Arndt Multiport Adapter, and a fiber-optic bronchoscope is introduced through its fiber-optic port. The occlusion balloon is secured by tightening the blocker port of the Arndt Multiport Adapter
Source publication
Background:
Intubation with either an endotracheal tube or a rigid bronchoscope is generally preferred to provide airway protection as well as to manage unpredictable complications during transbronchial lung cryobiopsy (TBLC). The laryngeal mask airway has been described as a safe and convenient tool for airway control during bronchoscopy.
Aims a...
Contexts in source publication
Context 1
... snare was disengaged from the Fogarty catheter and was pulled out of the bronchoscope. The catheter was secured firmly throughout the procedure by the assistant at the entry port of the LMA to prevent its dislodgment following biopsy extraction [ Figure 1a]. An Arndt blocker when chosen was advanced through the blocker port of the Arndt Multiport Adapter, and a fiber-optic bronchoscope was introduced through its fiber-optic port. ...
Context 2
... guide loop is loosened, releasing the OB from the bronchoscope, where it remains in place. The OB is secured by tightening the blocker port of the Arndt Multiport Adapter [14] [ Figure 1b]. ...
Context 3
... that reason, we used a therapeutic bronchoscope with its wider working channel that could also manage intraoperative bleeding more efficiently than a thin bronchoscope. We did not find any difficulty in maneuvering a 5.9-mm OD bronchoscope alongside the occlusion balloon through the LMA, due to its wide internal diameter [ Figure 1]. ...
Context 4
... the OB displacement [18] or malfunction [38] is anecdotally reported and has not been observed in the studies [13,14] including ours in which LMA was used, but one has to be always mindful of occurrence of this complication. We observed that the Arndt blocker can be soundly secured by tightening it at the balloon port and the Fogarty catheter by an assistant operator who grips it firmly at its exit from the LMA [ Figure 1], which is likely to minimise the risk of displacement of OB following biopsy extraction. However, we believe that RB must be a definitive backup in case of a massive bleed during the procedure with blocker malfunction. ...
Citations
... 59 Due to the anticipated higher bleeding risk based on the TBLC data in ILD, 66 rigid bronchoscope, endotracheal tube (ETT) and an endobronchial blocker have generally been used to provide airway protection in case of unpredictable bleeding for TBLC of PPLs. [67][68][69][70] Nevertheless, the use of rigid bronchoscope or ETT is time-consuming and resource intensive, which could be a hindrance for the widespread adoption of this diagnostic modality at majority of centers with a lack of rigid bronchoscopy expertise and intubation skills. 71,72 Plus, the presence of an endobronchial blocker during TBLC may be detrimental for the diagnosis of PPLs because it interferes with bronchoscope manipulation and prevents the devices such as r-EBUS, GS, and the cryoprobe guiding into the correct bronchus route toward the targeted PPLs. ...
... Transbronchial lung cryobiopsy (TBLC) is a minimally invasive technique alternative to surgical lung biopsy (SLB) in the diagnosis of DPLD [5,6]. The diagnostic yield of TBLC has been found to be high (pooled estimate of 83% (95% confidence interval [CI], 73-94), however, complication rates vary in a wide range (pooled estimates for pneumothorax and moderate/severe bleeding were 12% (95% CI, [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] and 39% (95% CI, 3-76), respectively) [7]. TBLC is recommended in a specific group of DPLD patients where the integration of clinical and high-resolution computed tomography (HRCT) features is not sufficient to make a definitive diagnosis. ...
... Hemorrhage was the most common (n = 10, 16.1%) complication in our study population. The overall complication rate was 2.76% and hemorrhage was 0.92% in a study which 326 TBLC procedures were evaluated [21]. Pneumothorax rates have been reported in a wide range from 0% to over 30% in studies [22]. ...
Background:
: Transbronchial lung cryobiopsy (TBLC) is a minimally invasive technique of the diagnosis of diffuse parenchymal lung diseases (DPLD). The aim of this study is to determine the clinical-radiological and histopathological characteristics of patients in whom cryobiopsy contributes to the diagnosis.
Methods:
: In this retrospective study, we searched for the medical records of patients who underwent TBLC from July 2015 to March 2020 at the pulmonology department of our university hospital clinic. Radiological images were evaluated by a chest radiologist experienced in DPLD. Prediagnosis was indicated by clinical-radiological findings. The final diagnosis was determined by the contribution of histopathological diagnosis. The agreement of pretest/posttest diagnosis and the diagnostic yield of TBLC were calculated.
Results:
Sixty-one patients with female predominance (59.0%) and current or ex-smoker (49.2%) made up the study population. We found the diagnostic yield of TBLC 88.5%. The most common radiological and clinical-radiological diagnosis was idiopathic pulmonary fibrosis (IPF) (n = 12, 19.6%) while the most common multidisciplinary final diagnosis was cryptogenic organizing pneumonia (COP) (n = 14, %22.9). The concordance of pre/posttests was significant (p < 0.001) with a kappa agreement = 0.485. The usual interstitial pneumonia (UIP) diagnosis was detected in six patients among 12 who were prediagnosed as IPF having also a suspicion of other DPLD by clinical-radiological evaluation (p < 0.001). After the contribution of TBLC, the multidisciplinary final diagnosis of 22(36.1) patients changed. The histopathological diagnosis in which the clinical-radiological diagnosis changed the most was nonspecific interstitial pneumonia (NSIP).
Discussion:
We found the overall diagnostic yield of TBLC high. The pretest clinical-radiological diagnosis was often compatible with the multidisciplinary final diagnosis. However, TBLC is useful for the confirmation of clinical radiological diagnosis as well as clinical entities such as NSIP which is difficult to diagnose clinical-radiological. We also suggest that TBLC should be considered in patients whose clinicopathological IPF diagnosis is not precise.
Background and objective:
Bronchoscopic transbronchial lung cryobiopsy (TBLC) is a guideline-endorsed alternative to surgical lung biopsy for tissue diagnosis in unclassifiable interstitial lung disease (ILD). The reported incidence of post-procedural bleeding has varied widely. We aimed to characterize the incidence, severity and risk factors for clinically significant bleeding following TBLC using an expert-consensus airway bleeding scale, in addition to other complications and diagnostic yield.
Methods:
A retrospective cohort study of consecutive adult outpatients with unclassifiable ILD who underwent TBLC following multidisciplinary discussion at a single centre in the UK between July 2016 and December 2021. TBLC was performed under general anaesthesia with fluoroscopic guidance and a prophylactic endobronchial balloon.
Results:
One hundred twenty-six patients underwent TBLC (68.3% male; mean age 62.7 years; FVC 86.2%; DLCO 54.5%). Significant bleeding requiring balloon blocker reinflation for >20 min, admission to ICU, packed red blood cell transfusion, bronchial artery embolization, resuscitation or procedural abandonment, occurred in 10 cases (7.9%). Significant bleeding was associated with traction bronchiectasis on HRCT (OR 7.1, CI 1.1-59.1, p = 0.042), a TBLC histological pattern of UIP (OR 4.0, CI 1.1-14, p = 0.046) and the presence of medium-large vessels on histology (OR 37.3, CI 6.5-212, p < 0.001). BMI ≥30 (p = 0.017) and traction bronchiectasis on HRCT (p = 0.025) were significant multivariate predictors of longer total bleeding time (p = 0.017). Pneumothorax occurred in nine cases (7.1%) and the 30-day mortality was 0%. Diagnostic yield was 80.6%.
Conclusion:
TBLC has an acceptable safety profile in experienced hands. Radiological traction bronchiectasis and obesity increase the risk of significant bleeding following TBLC.
Purpose of Review
In recent years, supraglottic airway (SGA) devices have been used extensively intraoperatively and in non-operating room anesthesia (NORA) locations. Their use in laparoscopic surgery, non-supine positions, endoscopy, and bronchoscopy has become common place in anesthesia practices. The purpose of this review is to canvass the recent literature for an evidence-based approach for vetting SGA devices for use in anesthetic procedures traditionally performed with an endotracheal tube (ETT) and in NORA locations.
Recent Findings
We found considerable studies utilizing SGA devices in innovative and non-traditional ways. Recent literature discussed the use of second- and third-generation SGA devices in NORA locations including bronchoscopy and endoscopy suites and in operating rooms for laparoscopic surgeries. Some studies have also used SGA devices in non-supine surgeries which traditionally require ETTs.
Summary
The efficacy and safety of the SGA devices have been vetted in several clinical studies since their inception. This manuscript is focused on the evolution of SGA devices with anesthesia practice to meet the needs of the patient inside and outside the operating room. We hope this article will encourage practitioners to use SGA devices with more ease and comfort in the various, non-conventional clinical settings without compromising patient safety.
Background:
Diagnosis of interstitial lung disease (ILD) is based on multidisciplinary team discussion (MDD) with the incorporation of clinical, radiographical, and histopathologic information if available. We aim to evaluate the diagnostic yield and safety outcomes of transbronchial lung cryobiopsy (TBLC) in the diagnosis of ILD.
Methods:
We conducted a meta-analysis by comprehensive literature search to include all studies that evaluated the diagnostic yields and/or adverse events with TBLC in patients with ILD. We calculated the pooled event rates and their 95% confidence intervals (CIs) for the diagnostic yield by MDD, histopathologic diagnostic yield, and various clinical adverse events.
Results:
We included 68 articles (44 full texts and 24 abstracts) totaling 6386 patients with a mean age of 60.7±14.1 years and 56% men. The overall diagnostic yield of TBLC to achieve a definite or high-confidence diagnosis based on MDD was 82.3% (95% CI: 78.9%-85.2%) and histopathologic diagnosis of 72.5% (95% CI: 67.7%-76.9%). The overall rate of pneumothorax was 9.6% (95% CI: 7.9%-11%), while the rate of pneumothorax requiring drainage by a thoracostomy tube was 5.3% (95% CI: 4.1%-6.9%). The rate of moderate bleeding was 11.7% (95% CI: 9.1%-14.9%), while the rate of severe bleeding was 1.9% (95% CI: 1.4%-2.6%). The risk of mortality attributed to the procedure was 0.9% (95% CI: 0.7%-1.3%).
Conclusion:
Among patients with undiagnosed or unclassified ILD requiring tissue biopsy for diagnosis, transbronchial cryobiopsy represents a reliable alternative to surgical lung biopsy with decreased incidence of various clinical adverse events.
Purpose of review:
Anesthesia for pulmonological interventions is a demanding challenge. This article discusses recent innovations and the implications for periinterventional anesthetic management.
Recent findings:
Interventional pulmonology is a rapidly expanding specialty with very complex diagnostic and therapeutic approaches that include oncological staging, treatment of obstructive and restrictive lung diseases, recanalization of endobronchial obstructions, and retrieval of foreign bodies. With the development of advanced diagnostic and therapeutic interventions, the application is extended to critically ill patients. Current evidence focusing on the anesthetic techniques is presented here.
Summary:
The development of new pulmonological methods requires a tailored anesthesiological approach. Their specific impact must be taken into account to ensure patient safety, goal-oriented outcome diagnostics and -quality, successful interventions, and patient comfort.
