Rigid bronchoscopic dilatation of postintubation tracheal stenosis.

BACKGROUND: Postintubation tracheal stenosis (PITS) occurs due to excessive pressure on the trachea by the cuff of the endotracheal tube which leads to local ischaemic necrosis of the tracheal cartilage and excessive growth of granulation tissue. The recognition of its aetiology and modifications in the design and management of endotracheal tubes have led to a diminished incidence of PITS. The management modalities that have been employed for the management of PITS include stenting, surgical resection and reconstruction, percutaneous dilatation, rigid bronchoscopic dilatation, fibreoptic assisted balloon dilatation and Nd:YAG (neodymium: yttritium-aluminum garnet) laser therapy with or without stenting. METHODS: Three female patients with a history of varying periods of endotracheal intubation after a period of acute respiratory failure who developed symptoms of tracheal stenosis 1-2 weeks post-extubationare presented. The mean age was 24 +/- 12.49 years (range = 14-38 years). RESULTS: All the three patients were successfully managed by frequent, rigid bronchoscopy and gradual dilatation until the resolution of the tracheal stenosis and the return of pulmonary function tests (PFT) to normal. CONCLUSIONS: Rigid bronchoscopic dilation in patients with PITS provides safe, effective tracheal dilatation and improved pulmonary function in the medium term.

Effect of intercostal nerve block with 0.5% bupivacaine on peak expiratory flow rate and arterial oxygen saturation in rib fractures.

BACKGROUND: This prospective study was undertaken to evaluate the efficiency of intercostal nerve block (ICNB) with 0.5% bupivacaine (Marcaine) for pain relief in patients with rib fractures and to correlate the degree of pain relief with changes in the peak expiratory flow rate (PEFR) and oxygen saturation (Sao2). METHODS: Twenty-one consecutive adult patients admitted with rib fractures associated with severe pain formed the basis of the study. Chest pain was scored on a four-point scale before ICNB, 1 hour after ICNB, and 24 hours after ICNB. Sao2 was measured before and immediately after ICNB. PEFR was measured before and immediately after ICNB. RESULTS: Pain score and PEFR before and after ICNB showed statistically significant differences (p = 0.0000, df = 20). There was a significant difference between Sao2 before and after ICNB. CONCLUSION: Significant increases in Sao2 and PEFR occur after ICNB with 0.5% bupivacaine, which also provides sustained analgesia, leading to improvement in respiratory mechanics.

Pulmonary aspergilloma simulating bronchogenic carcinoma.

When a pre-existing lung cavity is colonized by Aspergilius fumigatus, it forms a fungal ball (pulmonary aspergilloma) and the presenting symptom is usually haemoptysis that may be massive and often-times life threatening. The radiological finding is that of a ball-like structure within a lung cavitation and the typical air crescent around the ball both on plain radiography and CT scan of the chest. The present case is of a 50-year-old male who had a 25-year history of heavy smoking (40 cigarettes per day) and haemoptysis. Although the cavitating lesion, ball-like structure and the crescenteric rim of air were present on the radiographs, the possibility of bronchogenic carcinoma was held high in view. Flexible fibreoptic and transbronchial biopsies were negative for malignancy. Sputum and bronchoalveolar lavage examinations showed neither malignant cells nor fungal elements. Right thoracotomy, cavernostomy, removal of the fungal ball and obliteration of the cavity by suturing (capitonnage) were done with an uneventful postoperative period.

Ectopic chest tube insertions: diagnosis and strategies for prevention.

In the six-month period from October 1999 to March 2000, the authors carried out a prospective study of ectopic chest tube placements (ECTP) diagnosed at the Assir Central Hospital, Abha, Saudi Arabia. During the reference period, 63 chest tube placements were carried out in 44 patients while one patient was from a medium-sized general hospital within a neighbouring city. The grades of the surgeons who had performed the ECTP were: surgeon specialists based at peripheral hospitals--5 (83.3%), and surgical resident in training at the regional referral centre--1 (16.7%). Mean age = 29.7 years; M:F ratio = 2:1. A total of 6 cases of ECTP were found constituting 9.5% of all chest tube insertions mostly from small hospitals situated in the peripheral, non-urban areas. The diagnosis of ECTP was made on plain chest radiographs in 3 patients (50%) and on the CT scans of the chest in 3 patients (50%). The ECTP was into the lung (2 cases--33.3%), subdiaphragmatic. intraabdominal (3 cases--50%), and chest wall, subcutaneous (1 case--16.7%). Misdiagnosis and failure to carry out a finger exploration of the pleural cavity prior to the placement of the chest tube rather than the use of chest tubes with trocars was to blame. The incidence of ECTP (9.5%) is high and underlines the need for proper training in the methodology of chest tube insertion for junior surgical cadre.