Advances in bronchoscopy--new and upcoming bronchoscopic methods at the dawn of the 21st century.

The last decade has seen the increasing application of bronchoscopic methods such as transbronchial needle aspiration in the staging of lung cancer as well as in the diagnosis of peripheral lung cancer, balloon dilatation using flexible bronchoscopy, development of new tracheobronchial stents to manage central airway obstruction, autofluorescence bronchoscopy for the early diagnosis of lung cancer and pediatric flexible bronchoscopy. There is also a better understanding in the mechanisms and management of hypoxemia during bronchoscopy such as upper airway obstruction. Recent developments include direct endobronchial ultrasound to increase the yield of transbronchial needle aspiration, high magnification bronchoscopy to assist in the diagnosis of early lung cancer and bronchoscopic lung volume reduction to gain the effects lung volume reduction surgery without the need for surgery in patients with severe emphysema. In this article the new and upcoming bronchoscopic techniques are discussed, which we believe will find a broader clinical application in the near future to manage patients in a better way.

Advances in bronchoscopy--therapeutic bronchoscopy.

The common indications for therapeutic bronchoscopy include relief of benign and malignant airway stenosis, in the intensive care unit, foreign body removal and management of hemoptysis. Debulking of airway tumors may be undertaken using techniques such as laser photoresection, electrocautery, cryotherapy, argon plasma coagulation or mechanically using rigid bronchoscopy. These techniques are often used in combination. Balloon dilatation and insertion of silicone or metallic airway stents can be undertaken to treat benign and malignant strictures or bronchomalacia. Airway stents maintain luminal patency by opposing extrinsic compressive forces or by providing internal support. Certain stent types may also physically prevent (Silicone and covered metallic stents) the encroachment of tumor tissue into the airways. Covered metallic airway stents are safe and effective in the management of malignant tracheoesophageal fistulae, reduce the risk of recurrent aspiration and provide enhanced quality of life by allowing resumption of oral nutrition. In this article, we present an overview of application and the current methods available to perform therapeutic bronchoscopy.

Obstructive sleep apnea: therapies other than CPAP.

Nasal application of continuous positive airway pressure (CPAP) is the standard form of therapy for treating obstructive sleep apnea (OSA). Common difficulties associated with CPAP therapy include sense of dryness in the mouth, rhinorrhea, nasal congestion and dryness, mask discomfort, claustrophobia, irritation from device noise, aerophagy, chest discomfort and partner's intolerance. Therefore, many patients are unable to or unwilling to comply with the use of CPAP. This article discusses the various non-CPAP approaches that have been investigated in the management of OSA, which include behavioral therapy (weight loss and positional therapy), pharmacological treatment, mandibular advancement techniques and surgery. However, none of these has been shown to be superior to CPAP. In clinical practice, only selected patients will benefit from therapies other than CPAP.

Lung transplantation: management and complications.

Lung transplantation has become an accepted treatment modality for end stage lung disease including emphysema, fibrosing alveolitis, cystic fibrosis, pulmonary hypertension and bronchiectasis. Despite the use of potent immunosuppressive drugs, acute rejection occurs frequently, especially in the first few weeks and months after transplantation. Bacterial, viral and fungal infections frequently occur in lung transplant recipients. Rapid diagnosis and adequate treatment of infections is needed. The side effects with the use of long term immunosuppressive agents includes renal toxicity, hypertension, neurotoxicity, hyperlipidemia, leucopoenia, hyperglycaemia, weight gain, osteoporosis and malignancy. However, obliterative bronchiolitis (OB) which is regarded as a chronic rejection process remains the dominant cause of morbidity and mortality in the long-term survivors of lung transplantation. This article focuses on the postoperative and long term management of lung transplant recipients.