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Palliative airway treatments are essential to improve quality and length of life in lung cancer patients with central airway obstruction. Rigid bronchoscopy has proved to be an excellent tool to provide airway access and control in this cohort of patients. The main indication for rigid bronchoscopy in adult bronchology remains central airway obstruction due to neoplastic or non-neoplastic disease. We routinely use negative pressure ventilation (NPV) under general anaesthesia to prevent intraoperative apnoea and respiratory acidosis. This procedure allows opioid sparing, a shorter recovery time and avoids manually assisted ventilation, thereby reducing the amount of oxygen needed, while maintaining optimal surgical conditions. The major indication for NPV rigid bronchoscopy at our institution has been airway obstruction by neoplastic tracheobronchial tissue, mainly treated by laser-assisted mechanical dissection. When strictly necessary, we use silicone stents for neoplastic or cicatricial strictures, reserving metal stents to cover tracheo-oesophageal fistulae. NPV rigid bronchoscopy is an excellent tool for the endoscopic treatment of locally advanced tumours of the lung, especially when patients have exhausted the conventional therapeutic resources. Laser-assisted mechanical resection and stent placement are the most effective procedures for preserving quality of life in patients with advanced stage cancer., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-thoracic Surgery. All rights reserved.)

Laser bronchoscopy is a usually well tolerated procedure for the treatment of obstructive lesions on the tracheobronchial tree, with a very low morbidity and mortality rate. Cardiovascular complications, including atrial and ventricular arrhythmias, and myocardial ischemia, have only rarely been reported during laser bronchoscopy. Cardiac arrhythmias during such a procedure are usually well tolerated but occasionally may be life threatening. Here we report a case of a young, female patient affected by Pulmonary Tuberculosis with a cicatricial stenosis of the left main bronchus who developed an episode of prolonged cardiac arrest due to ventricular fibrillation (and no signs of acute myocardial ischemia) during rigid broncoscopic laser-therapy. Underlying Coronary Artery Disease and other cardiac abnormalities were also excluded by subsequent cardiovascular examination. The clinical implications are also discussed.

Laser emits a light characterised by being monochromatic, phased and collimated. Since the beginning of the '80s the fibers ND-YAG laser, whose energy may be transmitted by quartz fibres, is the type principally used for therapeutic bronchoscopy. It may be used to coagulate or to vaporize endoluminal lesions. The effect looked for depends on the level of density of power selected. During rigid bronchoscopy, YAG laser is usually applied in the coagulation mode, with a weak liberation of energy. Further resection is then achieved mechanically with the rigid tube or forceps. For malignant lesions the laser has a palliative action in eliminating endoluminal tumour mass. Its use has overturned the management of progressive tracheal or bronchial asphyxia. Outside emergencies, its action can be combined with radio and chemotherapy. For benign lesions its action may be curative. The laser is however poorly adapted for extrinsic compression and for infiltrating lesions where other more appropriate endoscopic methods should be used.

Study Objective: To evaluate the efficacy of negative pressure ventilation (NPV) in avoiding or reducing apneas and related hypoxemia and respiratory acidosis during laser therapy (LT) of endobronchial lesions., Design: A prospective, controlled, randomized study., Setting: An operating theater of a respiratory endoscopy and laser therapy unit. POPULATION AND INTERVENTION: Twenty-seven consecutive patients referred to LT were entered into the study. Fourteen patients were randomly assigned to LT under general anesthesia and spontaneous assisted ventilation (control group) whereas in 13 cases, NPV by a poncho-wrap ventilator (NPV group) was added to the procedure., Measurements and Results: The prevalence and the duration of apnea/hypopnea periods assessed by respiratory inductive plethysmography during LT were significantly reduced under NPV, compared to the control group. As compared to baseline, during LT, all control patients developed mild to severe hypercapnia (PaCO2 ranging from 55 to 76 mm Hg) and respiratory acidosis (pH from 7.33 to 7.19), whereas only three patients undergoing NPV (23%) developed hypercapnia (PaCO2 from 52 to 68 mm Hg) and related acidosis (pH from 7.29 to 7.21). Optimal oxygenation was achieved in all of the patients; nevertheless, patients under NPV needed a lower mean oxygen supply; five of them (38%) could be treated at a fraction of inspired oxygen of 0.21 for the whole procedure., Conclusion: NPV may be useful in reducing apneas during laser therapy under general anesthesia, thus reducing hypercapnia, related acidosis, and need of oxygen supplementation.

We conducted a review of all the bronchoscopies performed at our institutions for benign tumors from 1980 to 1991 to determine the endoscopic characteristics of these lesions. We reviewed the charts, the endoscopic characteristics from our video records, and finally the pathologic findings of these cases. We tried to identify the effectiveness of laser resections in each group. Of a total of 3,937 patients, 185 (4.7%) were benign tumors. On these patients, 317 procedures were carried out. There were 3 myoblastomas, 53 papillomas, 1 adenoma, 8 chondromas, 4 fibromas, 45 hamartomas, 15 hamartochondromas, 6 lipomas, 19 angiomas, 5 leiomyomas, 4 schwannomas, 1 neurofibroma, and 21 amyloidomas. Results of laser resection were "very good" in 115 (62%) and "good" in 70 (38%). Complications were minimal: two mediastinal emphysemas, one pneumothorax, and one anesthesia-related cardiac arrest leading to the single death in this series. In general, benign tumors of the proximal endobronchial tree responded well to laser resection when their endoscopic appearance is recognized and prognosis known. Even when recurrent, repeated procedures can be performed easily with good results. This series is probably the largest in the world's literature about endoscopic recognition and the role of laser resection in patients presenting with benign endobronchial tumors.

The introduction of heart, lung and heart-and-lung transplants, only recently performed in Italy, has presented the anesthetist with the problem of the anesthesiological treatment of newly transplanted patients whose number will increase over time. For some time our unit has used general anesthesia using spontaneous breathing for endotracheal and endobronchial laser therapy. This solution was adopted in the case of a patient who had undergone a heart-lung transplant using an "a domino" technique some 90 days earlier. The authors discuss the results of the anesthesiological technique used taking into account the particular hemodynamic and respiratory characteristics of these patients.

This study concerns the quantitative modifications of the prostaglandins, PGF alpha e PGE2, in the vitreous and in the lens following the application of Nd-Yag Laser. Five minutes after the Yag-laser treatment, an increase of PGF1 alpha concentration of PGE2 decreased in the lens and increased in the vitreous. These changes, similar to those occurring in the aqueous humor, may be related to the activation of specific enzymatic pathways of prostaglandin synthesis.

Anesthesia of the tracheobronchial (TB) pathways during laser therapy (LT) faces a variety of problems including analgesia and sedation in patients with respiratory difficulties or who continue to breathe spontaneously while the airways are occupied by operating instruments. During the course of the study, two methods of anesthesia were compared in 36 patients undergoing LT of the TB pathways. The first method (Group A, n = 16) involved the use of Diazepam as an hypnotic starter and Fentanyl as an opioid analgesic in continuous infusion. Propofol was used both as an inducer and as the main drug in the second method (Group B, n = 20) in order to reduce the opioid dose required. The following variables were studied: heart rate, systolic and diastolic blood pressure, blood gas analytic parameters, side-effects such as cough and intraoperative movement, and disturbances of heart rhythm and conduction; in addition, the duration of operations and the time taken to regain consciousness were recorded, together with the total dose of Fentanyl used. An improved hematosis was observed in patients treated with Propofol during the operation and on regaining consciousness, and the time taken to regain consciousness was significantly reduced. No significant differences were observed between the two groups with regard to cardiocirculatory variables or undesirable effects.

Anesthesia during Nd-YAG laser resection of the airways necessitates continuous O2 and CO2 monitoring. Although only partial, monitoring may be performed using a transcutaneous method utilising Clark's electrode to measure O2 and Stowe-Severinghaus' electrode to assess CO2 on the skin surface. The paper evaluates the advantages and limits of this form of monitoring during anesthesia in 85 patients undergoing laser resection of the airways. In conclusion, in spite of the fact that it is currently impossible to build up a complete picture of blood gas status from a single transcutaneous finding, the use of the transcutaneous method increases the level of safety of the operation as a whole.

The YAG laser is being used more often in cases of nonresectable bronchogenic cancer and in some cases is called on in lieu of surgery for tracheal stenosis. Patient safety hinges first on the endoscopist's technical skill and second on his understanding of the dangers involved in laser therapy. This report is based on experience gleaned from a 1,503 case series of endoscopic YAG laser treatments on 839 patients. These treatments were carried out by seven endoscopists in four teams using exactly the same equipment and techniques. In spite of the use of this high-risk technique in a high-risk patient population comprising a majority of major airways malignancy, the mortality rate was only 0.4 percent (six deaths: all in the postoperative period). We attribute this success to careful screening prior to resection, whenever possible, and above all to our methodology which not only emphasizes prevention but also enables rapid response.

We treated 1,000 patients with the Nd:YAG laser. The rigid bronchoscope was used in 1,280 (92 percent) of the treatments, with patients almost always under general anesthesia; 116 (8 percent) treatments were performed with the flexible fiberoptic bronchoscope alone, with the use of local anesthesia. In almost all cases of benign tumors and in many carcinoid tumors, the treatment was curative. In genuine nonmalignant tracheal stenoses, laser therapy was curative in 34 out of 81 cases. In malignant tumors, the laser improved airway gauge 92 percent of the time. Cumulative survival was 50 percent (+/- 3 percent) at six months and 26 percent (+/- 3 percent) at one year. Following palliative laser therapy, eight patients with bronchogenic carcinoma appearing to be inoperable did have surgery and ten underwent less extensive surgery than expected. Results confirm the usefulness and safety of this relatively new method in the treatment of obstructive lesions of the tracheobronchial tree.

172 patients affected by obstructive diseases (malignant or benign) of the trachea and/or main bronchi and admitted to the hospital for a laser treatment of the lesions, underwent radiological investigations. All patients underwent one or more of the following examinations: routine chest radiography, tomography of the trachea or bronchi, CT of the lungs and mediastinum with axial scans (eventually completed by frontal and sagittal reconstructions). The radiological approach was extremely useful for selecting cases which had to be treated by laser therapy; it permitted to get information about the lumen and the wall of the airways, and about their relationship with all surrounding structures. Moreover, the cases examined permitted the bronchologist to assert the value of the x-ray examinations, either for a correct evaluation of the respiratory situation immediately following the treatment, or for a long term follow-up on all those patients who were affected by recurrent lesions.