Management of the challenging airway with the Bullard laryngoscope

The Bullard laryngoscope is a rigid fiber-optic device that offers a new approach to oral laryngoscopy. In this report, I present five cases illustrative of the use of the Bullard laryngoscope in patients with demonstrated or suspected difficult laryngoscopy and intubation.

Quantitation of solid-phase immunoassays using a fibre-optic reflectance spectrophotometer

A reflectance measuring instrument (fibre-optic spectrometer linked to a personal computer) which will quantitate the results of immunoassays that result in the deposition of a coloured chromophore on a membrane or other similar solid phase (SP) is described and the reflectance spectra of some chromophores which are commonly produced or used in SP immunoassays are presented. The instrument has been used in conjunction with silver-enhanced SP-immunogold capture assays to determine the concentrations in serum of IgG and of IgM rheumatoid factor (RF) and the results have been compared with those obtained by rate nephelometry and latex agglutination assays, respectively. It is concluded that fibre-optic reflectance photometry is an accurate and useful means of quantitating SP immunoassays in which coloured chromophores are produced and that the results obtained from such immunoassays are comparable to those given by established procedures.

External and internal rigid fixation

A 25-year-old labourer sustained submandibular and intra-oral injuries in an unusual industrial site accident. He fell from above onto steel reinforcing rods which were set in concrete and projecting two metres above the concrete floor. He was impaled by a rod which entered the mouth beneath the right side of the mandible and exited from the mouth passing upwards in front of the nose. The management of this patient is discussed with particular emphasis on the method of obtaining an airway for surgery. Due to the proximity of the rigidly embedded reinforcing rod to the nose, mouth and midline of the neck, an awake tracheostomy under local anaesthesia was conducted. The alternatives to this approach with their potential complications are discussed. In addition possible pre-, peri- and post-operative surgical complications for this case are outlined.

Bronchoscopy with bronchoalveolar lavage causes neutrophil recruitment to the lower respiratory tract

Bronchoscopy with bronchoalveolar lavage (BAL) is a technique now widely utilized for both clinical and investigational purposes. At times, it is useful to perform bronchoscopy with BAL in a serial fashion. However, previous work in animals indicates that bronchoscopy with BAL can cause lower respiratory tract inflammation. To determine if BAL also causes lower respiratory tract inflammation in humans, sequential bronchoscopy with BAL was performed in 30 human subjects. Inflammation was evaluated using a quantitative visual assessment of bronchitis and by BAL. BAL was performed by instilling and aspirating five 20-ml aliquots of saline in each of three areas of the lung. The fluid returned from the first aliquot from each site was pooled as the bronchial fraction, and that from the remaining four aliquots was pooled as the alveolar fraction. Each volunteer was restudied at 2, 7, 24 or 72 h. Findings at the second bronchoscopy with BAL included an elevation in visual signs of large airways inflammation, which was greatest at 24 h. Bronchial neutrophils increased significantly, with the greatest effect seen at 7 h (5.3 +/- 2.0 versus 59.5 +/- 11.0%, SEM). The effect was most pronounced in the area of the lung previously lavaged, but was also seen in lobes that had not received BAL at the first bronchoscopy. Alveolar neutrophils also increased, with the maximal effect also seen at 7 h. Visible bronchial inflammation, bronchial neutrophils, and alveolar neutrophils returned to the normal range by 72 h.(ABSTRACT TRUNCATED AT 250 WORDS)

A light-diffusing device for intraoperative photodynamic therapy in the peritoneal or pleural cavity

Light delivery to anatomic areas involved by tumor is critical for effective photodynamic therapy. The authors provide a detailed overview of a light-diffusing device which they have used for intraoperative illumination of the peritoneal and pleural cavities in patients with tumors involving the surfaces of these cavities. Their device represents an inexpensive modification of widely available endotracheal tubes. It has been used to deliver intraoperative photodynamic therapy in over 50 patients without episodes of device failure. When combined with a lipid-based, light-diffusing medium and on-line power/energy density monitoring, it allows homogeneous illumination of these complex surfaces.

The management of ingested foreign bodies in the upper digestive tract: a retrospective study of 49 cases

Forty-nine cases of accidental foreign body ingestion treated in our unit were reviewed. Fish bones were the commonest foreign body ingested by adults while coins and pins accounted for most cases in the paediatric age group. All except one patient had endoscopy performed, majority with flexible endoscope. Foreign bodies were detected and successfully removed endoscopically in 23 patients except one. In another 12 patients, foreign bodies were demonstrated by chest X-ray or Barium meal but at the time of endoscopy, they had passed beyond the reach of the endoscope. For the remaining 13 patients, despite having a history of foreign body ingestion and retrosternal pain, subsequent investigation failed to demonstrate the foreign bodies. Barium contrast studies were performed in 31 cases, with 5 false negative and 2 possible false positive findings. There were 2 serious complications related to foreign body ingestion, one had empyema thoracis and another died of massive bleeding due to esophageal carotid fistula.

Safety and possible efficacy of fiberoptic bronchoscopy with lavage in the management of refractory asthma with mucous impaction

Mucous impaction may be suspected in asthmatic exacerbation when, despite aggressive medical management, patients continue to produce sputum containing mucous plugs and exhibit prominent rhonchi and/or wheezes on chest auscultation. Spirometric measurements in this setting corroborate lack of improvement and reveal significant impairment in indices that may reflect small airways function (FEF25-75). We hypothesized that clearance of inspissated secretions by fiberoptic bronchoscopy with lavage (FOBwL) may promote or hasten the clinical improvement of such patients. Fifty-one therapeutic FOBwL were accomplished in 19 patients during 20 episodes of stabilized yet refractory asthma with mucous impaction. No significant complications were encountered. After FOBwL, spirometric measurements of FEV1, FEF25-75, and FVC increased significantly (P less than .01, paired t test), and correlated with relief of dyspnea and mobilization of secretions with cough. FOBwL can be safely performed in stabilized, refractory asthma, and with apparent efficacy. Further investigation is needed to document the therapeutic utility of FOBwL in refractory asthma.

Mini-laparoscopy and fiber-optic lasers

The use of the Adair Verres needle and an optical catheter system has enabled us to perform both diagnostic and laser mini-laparoscopy. The prefix mini refers to the fact that the three incisions placed in the abdomen were 3 mm in diameter. There were no complications in our pilot series. Because initial inspections of the abdomen may localize abnormalities such as intestinal adhesions and may show the surgeon a safer approach to subsequent trocar placement, nothing is lost and much may be gained by routinely performing mini-laparoscopy. The picture produced on the video monitor is now of excellent quality and seems likely to improve. In the near future, a three-chip camera, which is able to produce even better resolution, will become available. The further development of 3-mm instrumentation promises additional expansion in operative capability. Although mini-laparoscopy will not replace conventional operative laparoscopy with the 10-mm telescope in the near future, a significant proportion of diagnostic and minimally to moderately involved operative procedures may be safely carried out by this method.

A new optical transducer for arterial pressure measurement

A new optical pressure transducer system (Viggo) has been assessed and compared with a standard P10 transducer (Spectramed) using a similar 20-gauge cannula, both in vitro in terms of linearity and frequency response and in vivo using an animal model. The linearity of the transducers was comparable; the resonant frequencies were 106 Hz and 75 Hz, respectively. However, the resonant frequency of the complete Spectramed system including 150-cm tubing was 11 Hz. The frequencies at which the output amplitude error exceeded 10% of the initial amplitude for the Viggo and for P10 with and without 150-cm tubing were 32 Hz, 24 Hz and 4 Hz, respectively. The principal advantage of the new transducer is that it is sufficiently compact to be mounted directly in the cannula at the wrist, so obviating the use of connecting tubing between the transducer and the cannula.

A low-cost fiber-optic strain gage system for biological applications

A new low-cost strain measurement system has been developed for the mechanical testing of biological soft tissues. The technique creates four spots of light on a tissue sample surface by piercing the tissue sample with two pairs of small light-conducting optical fibers (one pair for each axis of a biaxial stretch), terminated by high intensity infrared emitters. A large-area photodiode, located below the tissue sample, detects the light emitted from the two pairs of light-spots. Analog and digital circuitry analyze the current signal from the photodiode to determine the position of a light-spot in real time. Each infrared emitter is sequentially cycled "on" at a rate of 3 kHz and the resulting photodiode current signal, after being converted to a voltage signal, is held by an integrated circuit sample and hold amplifier. Analog differencing of pairs of light-spot voltage signals provides a final output proportional to the separation between coaxial light-spots.

Fiber-optic measurement of intracellular pH in intact rat liver using pH-sensitive dyes

The pH-sensitive fluorescent dye 1,3-dihydroxy-pyrene-6,8-disulfonic acid (DHPDS) was used to measure intracellular pH (pHi) from the surface fluorescence of the isolated perfused rat liver. Monochromatic light from a fluorometer was focused on the liver with a fiber optic, emitted light was collected with a second fiber bundle and returned to the spectrometer. To correct for changes in intracellular dye concentration, the excitation wavelength was changed between the pH-sensitive excitation peak wavelength and the isosbestic wavelength, then a ratio was computed between fluorescence intensities at these two wavelengths. Intracellular calibration of the dye was performed by clamping the intracellular to the extracellular pH with H+/K(+)-ionophore Nigericin. This method was used to monitor transient changes in intracellular pH caused either by addition and removal of NH4Cl or by changing perfusate CO2 and HCO3- concentrations while keeping their ratio constant. The effects of these maneuvers on bileflow were studied, too. Data obtained in the perfused liver were in good agreement with those obtained in isolated liver cells except that the steady-state pHi (7.46 +/- 0.02) was slightly higher than reported values. Measurements in livers of mutant TR- rats that are defective of dye secretion revealed similar pHi values, indicating that secretion of the dye into bile canaliculi did not affect measurements. The technique appears adequate to measure pHi in the liver and will allow to study pH regulatory mechanisms in the intact organ.

Endoscopic and videofluoroscopic evaluations of swallowing and aspiration

A new procedure for evaluating oropharyngeal dysphagia utilizing fiberoptic laryngoscopy was compared to the videofluoroscopy procedure. Twenty-one subjects were given both examinations within a 48-hour period. Results of the fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopy examinations were compared for presence or absence of abnormal events. Good agreement was found, especially for the finding of aspiration (90% agreement). The FEES was then measured against the videofluoroscopy study for sensitivity, specificity, positive predictive value, and negative predictive value. Sensitivity was 0.88 or greater for three of the four parameters measured. Specificity was lower overall, but was still 0.92 for detection of aspiration. It was concluded that the FEES is a valid and valuable tool for evaluating oropharyngeal dysphagia. Some specific patients and conditions that lend themselves to this procedure are discussed.

[The specificity of the peripheral blood changes in patients with gastric peptic ulcer]

Leucocytes were studied in 112 patients with ulcer disease of the stomach in comparison with periods of existence of an ulcer defect of the gastric mucosa. Methods of statistical analysis allowed to establish that the peripheral blood shows phasic changes in the absolute content of the leucocytes and their forms, pathogenetically related to the course of the reparative process.