Letters to Editor

Tim Thomas Joseph, Lokvendra Singh Budania, Amrut K. Rao, Kush Ashokkumar Goyal Department of Anesthesiology, Kasturba Hospital, Kasturba Medical College, Manipal University, Manipal, Karnataka, India Address for correspondence: Dr. Kush Ashokkumar Goyal, Department of Anesthesiology, Kasturba Hospital, Kasturba Medical College, Manipal University, Manipal - 576 104, Karnataka, India. E-mail: [email protected]

REFERENCES

Figure 3: Self-expanding metal stents in situ in strictured lower 1/3rd of esophagus with no leak in Gastrograffin scan

esophagus continued and collection in the intercostal drain persisted. Hence, SEMS was considered. SEMS have been described for traumatic esophageal perforations and anastomotic leaks. [2] Improved survival rates, low mortality and morbidity have been documented. A clinical success rate of 63-100% has been found for perforations and anastomotic leaks.[3] However, it is associated with stent migration and ulceration. The mortality rate after surgical repair of iatrogenic perforation of esophagus and anastomotic leaks ranges from 12% to 50%, respectively.[4] Placement of such stents are not highly invasive and are not associated with significant perioperative risks.

1. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004;77:1475-83. 2. Salminen P, Gullichsen R, Laine S. Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks. Surg Endosc 2009;23:1526-30. 3. Eloubeidi MA, Lopes TL. Novel removable internally fully covered self-expanding metal esophageal stent: Feasibility, technique of removal, and tissue response in humans. Am J Gastroenterol 2009;104:1374-81. 4. Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt UT. Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents. Ann Thorac Surg 2006;81:467-72. Access this article online Quick Response Code:

Website: www.saudija.org

DOI: 10.4103/1658-354X.146339

Is there a role for therapeutic bronchoscopy in acute severe asthma? Sir, Provided clinical expertise, bronchoscopy is considered safe in ventilated non-asthmatic patients.[1,2] At present, however, data regarding outcomes and safety of bronchoscopy in ventilated adult patients with acute severe asthma (ASA) (formerly known as status asthmaticus) is limited to few and mostly old case reports.[3-6] Regarding a recent interesting publication in the Saudi Journal of Anesthesia on this topic by Khan et al.,[7] there are some relevant aspects that need reviewing: Saudi Journal of Anesthesia

· The sticky secretions in the asthmatic patient may be so viscous that they form casts of the smaller bronchi, known as Curshmann’s spirals. Together with edematous swelling of the submucosa, large agglomerations of mucus may obstruct segmental or even larger bronchi.[8] In intubated patients with ASA, severe bronchoconstriction, mucous plugging and air trapping make management challenging. This patients are at risk of profound hypoxemia, hemodynamic collapse and death.[9-11]

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· The National Asthma Education and Prevention Program guidelines sug gest that “per missive hypercapnia” or “controlled hypoventilation” should be utilized to reduce the risk of barotrauma.[12] · If neuromuscular blockade is attained during the bronchoscopy it will reduce patient-ventilator asynchronies, but there is a potential risk of induced myopathy.[9] · Based on intubated lung models, it has been shown that to maintain volume delivery and minimize autopositive end-expiratory pressure (PEEP) the inner diameter of the endotracheal tube should be more than 2.0-mm larger than the outer diameter of the bronchoscope.[13] · If bronchoscopy is performed, risk of complications is even higher. Adjustment of the ventilator settings by reducing airway pressures during the procedure may decrease alveolar ventilation and lead to hypoxemia, whereas keeping a target tidal volume may lead to barotrauma and hemodynamic instability from excess airway pressure and intrinsic PEEP.[11] Besides, it is known that bronchoalveolar lavage may worsen hypoxemia. [14] And, if thick secretions are to be removed, suction may be ineffective regardless of the scope’s working channel diameter. But there is more: It is important to time each pass with bronchoscope since time may go by without the bronchoscopist realizing it, so several rapid inspections and procedures would be preferred over a single long uninterrupted procedure.[11] All these factors should be accounted for when assessing risks of a bronchoscopy in patients with ASA. Khan et al.[7] in their study have reported about two intubated patients whose asthma is refractory to medical treatment and are subjected to bronchoscopy for suspected mucus plugs. The authors inform of a significant improvement in airway pressures and gas exchange after bronchial lavage in both patients and no significant immediate complications, which is a remarkable finding. However, there are a few comments we would like to make: · First, Case 1 had septic shock from unknown origin, but one wonders if pneumonia was the focus. Case 2 had community acquired pneumonia. In such cases, the patients’ mucous plugs might not be as sticky as those with ASA, so aspiration could be easier to perform. · Second, both patients required FiO2 of 100% for adequate oxygenation before the procedure. Then, one would expect worsening airway pressures and derangement of blood gases during the procedure, but data is missing. Vol. 9, Issue 1, January-March 2015

· Third, there is no information on endotracheal tube size, external diameter of the scope, diameter of the working channel and other procedural details. These data would give insight in such a risky process. So we ask: Is there a role for bronchoscopy in intubated patients with ASA? If such a procedure is undertaken there should be an ongoing monitoring to estimate the benefit to risk ratio on a constant bases: Airway pressures, tidal volume and hemodynamics and gas exchange. All this findings should be reported. Finally, the authors state that robust studies are warranted to explore the potential role of bronchoscopy and lavage in these patients. We think that such studies are unlikely to be performed given the low likelihood of bronchoscopic practices in intubated ASA patients. Even though, the outcomes of bronchial toilet reported by Khan et al. are quite impressive and possibly thought provoking for clinicians in charge of patients with ASA, caution and expertise are compelling in a high risk procedure and a life threatening situation. Javier Navarro-Esteva, Antonio M. Esquinas-Rodríguez1 Department of Pulmonary Medicine, Hospital Universitario Gran Canaria “Dr. Negrín”, Bco/La Ballena, Las Palmas de GC. 1Intensive Care Unit Department, Hospital Morales Meseguer, Murcia, Spain Address for correspondence: Dr. Javier Navarro-Esteva, Department of Pulmonary Medicine, Hospital Universitario Gran Canaria “Dr. Negrín”, Bco/ La Ballena, Las Palmas de GC, Spain. E-mail: [email protected]

REFERENCES 1. Lucena CM, Martínez-Olondris P, Badia JR, Xaubet A, Ferrer M, Torres A, et al. Fiberoptic bronchoscopy in a respiratory intensive care unit. Med Intensiva 2012;36:389-95. 2. Phua GC, Wahidi MM. ICU procedures of the critically ill. Respirology 2009;14:1092-7. 3. Zamanian M, Marini JJ. Pressure-flow signatures of centralairway mucus plugging. Crit Care Med 2006;34:223-6. 4. Walker PE, Marshall M. Bronchial lavage in status asthmaticus. Br Med J 1969;3:31-2. 5. Thompson HT, Pryor WJ, Hill J. Bronchial lavage in the treatment of obstructive lung disease. Thorax 1966;21: 557-9. 6. Shridharani M, Maxson TR. Pulmonary lavage in a patient in status asthmaticus receiving mechanical ventilation: A case report. Ann Allergy 1982;49:156-8. 7. Khan MF, Al Otair HA, Elgishy AF, Alzeer AH. Bronchoscopy as a rescue therapy in patients with status asthmaticus: Two case reports and review of literature. Saudi J Anaesth 2013;7:327-30. 8. Becker HD. Bronchoscopy for airway lesions. In: Wang KP, Mehta AC, Turner JF, editors. Flexible Bronchoscopy. 2nd ed. Malden, MA, USA: Blackwell Publishing; 2004. p. 71-88. 9. Elsayegh D, Saito S, Eden E, Shapiro J. Increasing severity of status asthmaticus in an urban medical intensive care unit. J Hosp Med 2008;3:206-11. 10. Peters JI, Stupka JE, Singh H, Rossrucker J, Angel LF, Melo J, et al. Status asthmaticus in the medical

Saudi Journal of Anesthesia

Letters to Editor intensive care unit: A 30-year experience. Respir Med 2012;106:344-8. 11. Bush A. Primum non nocere: How to cause chaos with a bronchoscope in the ICU. Chest 2009;135:2-4. 12. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Summary Report 2007. Available from: http:// www.nhlbi.nih.gov/guidelines/asthma. Last accessed: November 20th 2013. 13. Lawson RW, Peters JI, Shelledy DC. Effects of fiberoptic bronchoscopy during mechanical ventilation in a lung model. Chest 2000;118:824-31. 14. Bauer TT, Torres A, Ewig S, Hernández C, SanchezNieto JM, Xaubet A, et al. Effects of bronchoalveolar

lavage volume on arterial oxygenation in mechanically ventilated patients with pneumonia. Intensive Care Med 2001;27:384-93. Access this article online Quick Response Code:

Website: www.saudija.org

DOI: 10.4103/1658-354X.146341

A proposal for a new approach in the prevention of laryngospasm in children Sir, Laryngospasm is a potentially fatal complication of general anesthesia is more common in children (17.4/1000) than in adults (8.7/1000). The most frequent risky factors are: Infections of the upper airways, the young age of the child, the stimulation of the upper airway in insufficient depth of anesthesia (secretions, blood, pharyngeal aspiration, and extubation) and the inexperience of the anesthetist.[1] Laryngospasm can be defined as a glottic closure reflex secondary to a contraction of the laryngeal muscles. It may be complete or partial.

cuff insertion of the tracheal tube [Figure 1]. The distal orifice of this tube is used to inject the local anesthetic at the glottis. After surgery (without reducing the level of anesthesia) and after suction of the oropharynx, the child is placed in a semi-sitting position, to bring the axis of the trachea in the most upright position that allows homogeneous distribution of local anesthetic. We inject through the additional pilot tube the 2% lidocaine at a dose of 4 mg/kg. This first phase allows to anesthetize the glottic structures located above the cuff of the tracheal tube.

Complete is recognized at the extubation by inefficient chest movements, breathing silence, and no movement at the ball of the anesthetic circuit and unable to ventilate the child. Whereas partial laryngospasm is recognized by thoracic movements inefficient, stridor and respiratory effort mismatch between the child and the movements seen at the ball of the anesthesia circuit.[3] We propose a new approach in the prevention of laryngeal spasm, especially in children using a modified tracheal tube. Unlike conventional endotracheal tube, the new tube is provided with a second pilot tube other than the tube allowing to inflate the cuff which its path is located along the concave face of the endotracheal tube with a distal extremity which ends at the proximal region of the Saudi Journal of Anesthesia

Figure 1: The modified tracheal tube with tubulure to inject local anesthetic

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Is there a role for therapeutic bronchoscopy in acute severe asthma?

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