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We studied 82 consecutive patients admitted to the ICU with predominant tricyclic antidepressant overdose (mean plasma tricyclic level, 1,025 ng/ml) to determine the nature and incidence of respiratory complications. The [...]

Six cases of massive late bleeding following tracheostomy, diagnosed clinically as tracheal-innominate artery fistula, are presented. This entity is discussed from the point of view of causes, factors such as low placement of the tracheostomy tube below the third tracheal ring, utilization of a mobile ill-fitting tube with an anterior angulation of 90 degrees, use of high-pressure cuffs on metal tubes rather than high-volume low-pressure cuffs on plastic tubes, and hyperextension of the head. Suggested diagnostic measures include fiberoptic bronchoscopy and arteriography if there is enough time. If not, management involves digital compression of the innominate artery against the sternum through the tracheal stoma followed by immediate surgical intervention via median sternotomy, with ligation or resection, or both, of the innominate artery. Prognosis of tracheal-innominate artery fistula is poor, but aggressive management may save many patients.

Bronchial brushing was performed concomitantly with transnasal flexible fiberoptic bronchoscopy in 44 patients with localized peripheral pulmonary lesions and absence of visible bronchial abnormality down to subsegmental level. Fluoroscopic confirmation of brush placement was obtained. A diagnosis of malignancy was made by bronchial brushing in 12 of 23 patients (52 percent) proved to have neoplasm, although diagnostic accuracy rose to six of seven patients (86 percent) in the final quarter of the study. There was no relationship between diagnostic accuracy and tumor location. Diagnostic accuracy was highest for squamous cell carcinoma, intermediate for adenocarcinoma, and lowest for undifferentiated carcinoma. A diagnosis of tuberculosis was made in two of 21 patients found not to have malignancy, and bronchial brushing was the only procedure to yield diagnostic material in these two patients. There were no false-positive cytologic examinations and no complications. Fluoroscopic control of placement of the bronchial brush passed through the fiberoptic bronchoscope allows a single, highyield, diagnostic procedure to be performed with minimal risk to the patient In selected cases, thoracotomy may be avoided by this procedure.