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Introduction: The aspiration of foreign bodies into the airway (AFB) is an important cause of death in children worldwide. The incidence is higher in children aged 1-2 years. The presentation and severity depends in the degree of airway obstruction. In the event of a compatible clinical history, a bronchoscopy evaluation is needed. Methods: Retrospective study. Included pediatric patients who underwent bronchoscopy for removal of AFB at the Service of Respiratory Endoscopy in the period from January 2014 until June 2020. We reviewed medical and bronchoscopy records, collected information about the equipment used, foreign body location and nature, age, sex, success rate and complications. Results: 40 pediatric patients were treated. Children under 3 years accounted for 51% of cases with a peak incidence between 1 to 2 years accounting for 35.5% of cases. The majority of the removals were done by a flexible bronchoscopy (90%), using a basket (47,5%) or a rat tooth forceps (35%). The overall removal success rate was 100%. Complications occurred in 3 cases (7.5%). No deaths were reported. Discussion: The bronchoscopic removal of AFB in children is a complex and demanding procedure with a high potential for complications. Historically, rigid bronchoscopy has been the gold standard for the treatment of pediatric foreign body inhalation, but several authors have described flexible bronchoscopy as a diagnostic and therapeutic method for the removal of AFB. Our results show that, in most cases, flexible bronchoscopy is a safe and effective for the removal of AFB.

The endobronchial ultrasound is a minimally invasive technique that simultaneously associates ultrasound and bronchoscopy, to visualize lung nodule or masses, airway wall, and structures adjacent to the tracheobronchial tree. Endobronchial ultrasound has been incorporated into clinical practice all over the world because of its low risk and high diagnostic yield in neoplastic and non-neoplastic disease. RESUMO A ultrassonografia endobrônquica é uma técnica minimamente invasiva que associa simultaneamente broncoscopia à ultrassonografia, com a finalidade de visualizar nódulos ou massas pulmonares, paredes das vias aéreas, e estruturas ao redor de toda a árvore traqueobrônquica. A ultrassonografia endobrônquica foi incorporada à prática clínica em todo o mundo devido a seu baixo risco e elevado rendimento diagnóstico em doenças neoplásicas e não neoplásicas.

OBJECTIVES Using a method developed for this study, the objective was to perform a quantitative analysis of glottic aperture during the respiratory cycle in subjects suspected of having inducible laryngeal obstruction (ILO) and to compare results to healthy individuals. Correlations between glottic aperture and spirometric parameters were assessed. METHODS Subjects with high clinical suspicion of ILO and atypical inspiratory findings in spirometry had the images of their laryngoscopy displayed alongside a respiratory flow chart and both were recorded simultaneously. This method allowed detailed analysis of the glottic aperture by measuring the angle of the anterior commissure during inspiration and expiration. Healthy volunteers who performed the same tests and agreed to provide data to this study were used as a control group. RESULTS All 15 subjects with ILO and 16 healthy participants were evaluated successfully using the proposed method. Measures of the anterior commissure angle in the ILO versus control group were significantly different in all observed parameters and just three ILO subjects had an anterior commissure closure greater than 50% during the respiratory cycle. Inspired volume (FIF50 ) and mid-vital capacity ratio (FEF50 /FIF50 ) had a significant correlation with glottic aperture parameters when considering the evaluation of the subjects all together. CONCLUSION The proposed method provided precise and quantitative analysis of glottic aperture during the respiratory cycle thus indicating that the usage of equipment that allows for such assessment should be encouraged. Also, the threshold of vocal cords closure accepted as indicative of ILO should be reconsidered, especially during the intercritical period of the disease. LEVEL OF EVIDENCE 4 Laryngoscope, 130:E349-E356, 2020.

A 66-year old female patient complained of sensation of a foreign body in her pharynx and of dry cough for the past 6 months. She denied dysphonia, dysphagia or dyspnea. Endoscopy was performed for suspected gastroesophageal reflux, and it showed several roundish, yellowish and well-limited lesions, in the posterior region of the larynx, adjacent to the arytenoid cartilages ( and ). A biopsy of the lesions was performed ( ), and the pathological examination revealed neoplasm with clear limits, composed [...]

Objective To describe indications, clinical outcomes and complications of flexible bronchoscopy. Methods A descriptive observational study of bronchoscopies performed at the endoscopy service of Hospital Israelita Albert Einstein . Demographic (age, gender and origin) and medical (indications and results of endoscopy and diagnostic tests, such as biopsy collection, lavage, cytology and culture) data were analyzed. Electronic medical records with incomplete data or reporting interventional procedures were excluded. Results Over a three-year period (2013 to 2016), a total of 1,949 bronchoscopies were performed by respiratory endoscopy team and anesthesia specialists of the hospital. The mean age of patients was 57.7±21.9 years (range of 3 days to 99 years), with prevalence of males (56.4%). The procedures were mostly (86.3%) elective and 30.7% were carried out in the intensive care unit. Major indications for bronchoscopy were infection or secretion (42.4%), followed by suspected neoplasm (10.8%). Endoscopic changes were reported in 91.9% of cases, with more than one change described in approximately 6.9% of patients. Positive results were obtained via direct testing or culture in 36.3% and 53.9% of 1,399 bronchoalveolar lavages, respectively. The overall diagnostic yield (bronchoalveolar lavage and biopsy) was 72.6%. Mild adverse event rate was 7.2%. The rate of severe adverse events requiring additional intervention was 0.5% (pneumothorax, 0.4%; severe bleeding with patient death, 0.1%). Conclusion Lower airway endoscopy is critical for respiratory disease assessment, diagnosis and treatment. Flexible bronchoscopy is associated with good diagnostic yield and minimal inherent risk.

Objective To describe the results of endobronchial ultrasound-guided transbronchial needle aspiration in making diagnosis of mediastinal injuries associated to different causes. Methods A retrospective cross-sectional study of patients submitted to Endobronchial ultrasound-guided transbronchial needle aspiration at a private organization, between June 2013 and October 2016. All cases referred for collection of lymph nodes or peritracheal/peribronchial masses by endobronchial ultrasound-guided transbronchial needle aspiration, and evaluated through tomography or PET-CT were included. Interventional pulmonologists and thoracic surgeons with experience in the method did the procedures. Rapid on-site evaluation of fine needle aspiration was performed by an experienced pathologist. Material analysis included cytological smear and cytopathological analysis of paraffin-embedded cell blocks. Other specific analyses (immunocytochemistry, tests and cultures of infectious agents) were performed whenever necessary. Results We included 72 patients; 6 were excluded for presenting endobronchial lesions in which bronchoscopic biopsy could be performed, or intrathoracic lesions that were not accessible by endobronchial ultrasound-guided transbronchial needle aspiration. The mean age of 66 patients included for analysis was 61.17 years (±14.67 years), with a predominance of males (64%). Endobronchial ultrasound-guided transbronchial needle aspiration was definitive for diagnosis in 60 cases (91%). Three cases (4.5%) had inconclusive test results. There were no major complications related to the procedure. Conclusion Endobronchial ultrasound-guided transbronchial needle aspiration had a high diagnosis yield, with minimal morbidity, being an excellent option for diagnostic approach of patients with lymphadenopathy or intrathoracic lesions, and for neoplasm staging. RESUMO Objetivo Descrever os resultados da utilização de punção aspirativa por agulha guiada por ultrassom endobrônquico na definição do diagnóstico em casos de lesões mediastinais por diferentes causas. Métodos Estudo transversal retrospectivo de pacientes submetidos à punção aspirativa por agulha guiada por ultrassom endobrônquico em instituição privada, entre junho de 2013 e outubro de 2016. Foram incluídos todos os casos referenciados para coleta de materiais de linfonodos ou massas peritraqueais/peribrônquicas por punção aspirativa por agulha guiada por ultrassom endobrônquico, estudados com tomografia ou PET-CT. Os procedimentos foram realizados por pneumologistas intervencionistas e cirurgiões torácicos com experiência no método. Rapid on-site evaluation da punção aspirativa por agulha fina foi realizada por patologista experiente. A análise do material incluiu citologia dos esfregaços em lâminas e análise citopatológica do emblocado celular. Outras análises específicas (imunocitoquímica, pesquisas e culturas de agentes infecciosos) foram realizadas se necessárias. Resultados Foram incluídos 72 pacientes; destes, 6 foram excluídos por apresentarem lesões endobrônquicas passíveis de biópsia broncoscópica convencional ou lesões intratorácicas não acessíveis a punção aspirativa por agulha guiada por ultrassom endobrônquico. Assim, a média de idade dos 66 pacientes incluídos para análise foi 61,17 anos (±14,67 anos), com predomínio do sexo masculino (64%). A punção aspirativa por agulha guiada por ultrassom endobrônquico foi definitivo para o diagnóstico em 60 casos (91%). Três casos (4,5%) foram inconclusivos. Não houve complicações maiores relacionadas ao procedimento. Conclusão A punção aspirativa por agulha guiada por ultrassom endobrônquico teve elevado rendimento diagnóstico, com mínima morbidade, constituindo excelente opção na abordagem diagnóstica de pacientes com linfadenopatia ou lesões intratorácicas e no estadiamento de neoplasias.

Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, safe and accurate method for collecting samples from mediastinal and hilar lymph nodes. This study focused on the initial results obtained with EBUS-TBNA for lung cancer and lymph node staging at three teaching hospitals in Brazil. Methods: This was a retrospective analysis of patients diagnosed with lung cancer and submitted to EBUS-TBNA for mediastinal lymph node staging. The EBUS-TBNA procedures, which involved the use of an EBUS scope, an ultrasound processor, and a compatible, disposable 22 G needle, were performed while the patients were under general anesthesia. Results: Between January of 2011 and January of 2014, 149 patients underwent EBUS-TBNA for lymph node staging. The mean age was 66 ± 12 years, and 58% were male. A total of 407 lymph nodes were sampled by EBUS-TBNA. The most common types of lung neoplasm were adenocarcinoma (in 67%) and squamous cell carcinoma (in 24%). For lung cancer staging, EBUS-TBNA was found to have a sensitivity of 96%, a specificity of 100%, and a negative predictive value of 85%. Conclusions: We found EBUS-TBNA to be a safe and accurate method for lymph node staging in lung cancer patients. Objetivo: A endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA, punção aspirativa por agulha guiada por ultrassom endobrônquico) é um método seguro e preciso para a coleta de amostras de linfonodos mediastinais e hilares. O presente estudo teve por objetivo avaliar os resultados iniciais com EBUS-TBNA para o estadiamento linfonodal de câncer de pulmão em 3 hospitais acadêmicos no Brasil. Métodos: Análise retrospectiva de pacientes com neoplasia de pulmão diagnosticada e submetidos a EBUS-TBNA para estadiamento linfonodal mediastinal. Todos os procedimentos foram realizados sob anestesia geral. Utilizou-se um ecobroncoscópio, uma processadora de ultrassom e agulhas 22 G descartáveis e compatíveis com o ecobroncoscópio. Resultados: Entre janeiro de 2011 e janeiro de 2014, 149 pacientes foram submetidos ao estadiamento linfonodal com EBUS-TBNA. A média de idade foi 66 ± 12 anos, sendo 58% do sexo masculino. Um total de 407 linfonodos foram puncionados via EBUS-TBNA. Os tipos mais comuns de neoplasia brônquica foram adenocarcinoma (em 67%) e carcinoma escamoso (em 24%). Para o estadiamento da neoplasia, o EBUS-TBNA apresentou sensibilidade de 96%, especificidade de 100% e valor preditivo negativo de 85%. Conclusões: A EBUS-TBNA mostrou-se um método seguro e acurado no estadiamento linfonodal em pacientes com câncer de pulmão.

Background Tuberculosis(TB) remains a global public health concern.1 It is one of intrathoracic lymphadenopathy(ITLN) numerous causes and must be taken into account in differential diagnosis, especially in endemic countries.2 Diagnostic yield of EBUS-TBNA for mediastinal and hilar TB has been reported to be 80%.2 Aim To determine the prevalence of TB in patients with ITLN undergoing EBUS-TBNA and calculate diagnostic yield. Methods Retrospective study of all patients undergoing EBUS-TBNA for ITLN, from August/2011 to March/2017. Clinical, laboratorial, histopathological and radiological data were assessed. We considered for diagnosis by EBUS-TBNA all cases with TB confirmed and granulomatous lymph node with TB confirmation by other methods. Results 186 patients were included, mean age of 57 years (SD=14), 53.8% male. Granulomatous disease was diagnosed in 29% (n=54), 42.6% (n=23) with cancer diagnosis or suspicion at the time of procedure. Sarcoidosis was diagnosed in 15.6% (n=29), mycobacteriosis in 9.7% (n=18), fungal infection in 2.7% (n=5) and other granulomatosis in 1% (n=2). Mycobacteriosis was due to M.tuberculosis in 88.9% (n=16), M.kansasii in 5.55% (n=1) and M.avium in 5.55% (n=1). EBUS-TBNA established the diagnosis in 56.3% (n=9) of TB cases: 25% (n=4) caseous granuloma in cell block, 18.8% (n=3) positive acid-fast bacilli (AFB) and 12.5% (n=2) M.Tuberculosis in aspirated sample culture. In 37.5% (n=6) cell block from EBUS-TBNA showed granulomas but definite diagnosis was made by presence of caseous granuloma in biopsy (12.5%,n=2) or positive AFB (6.25%,n=1) in other organs, positive PCR of bronchoalveolar lavage in 6.25% (n=1) or pleural fluid in 6.25% (n=1), and sputum culture in 6.25% (n=1).One patient needed mediastinoscopy. 25% (n=4) of patients diagnosed with TB had cancer and 31.6% (n=5) was submitted to EBUS-TBNA for cancer suspicion. In our setting, the prevalence of TB was 8.6% and the diagnostic yield of EBUS-TBNA was 77.7%. Conclusions Our study showed granulomatosis in 29% of patients with TB as second most frequent cause.Brazil belongs to the five countries that collectively account for about 50% of the world TB cases1 and, despite lymphadenopathy is not a major form of TB, our study emphasises its importance in differential diagnosis of ITLN in endemic countries. EBUS-TBNA showed to be a useful diagnostic tool. References World Health Organisation. Global tuberculosis control: WHO report2016. http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf?ua=1 Li W, et al. Diagnostic value of convex probe endobronchial ultra sound-guided transbronchial needle aspiration in mediastinal tuberculous lymphadenitis: A systematic review and meta-analysis. Med Sci Monit2015, Jul 16;21:2064–72.

Background Lung cancer(LC) is the leading cause of worldwide cancer-related deaths and its accurate diagnosis and staging is crucial to guide appropriate treatment and prognosis. 1 EBUS-TBNA is a minimally invasive standard procedure for staging that has proven to be useful in diagnosis too, allowing a complete characterisation of the disease in a single procedure and, thus, decreasing time-to-treatment. 2 Aim To evaluate the role of EBUS-TBNA as initial technique for simultaneous diagnosis and staging in patients with suspected LC and calculate its sensitivity, specificity, positive and negative predictive values. Methods Retrospective study of all patients with suspected LC in computed tomography(CT) or positron-emission tomography(PET)/CT submitted to EBUS-TBNA for simultaneous diagnosis and staging, from September/2011 to February/2017.Results of EBUS-TBNA were compared to surgical ones, when patients were subsequently submitted to surgery, or to clinical and radiological follow-up. Results Patients included(n=62) had mean age of 68 years(SD=10) and 66.1% were male. Smoking history was present in 53.2% and history of extrathoracic malignant disease in 17.7%. Mean diameter of pulmonary lesions in CT or PET/CT was 37.2 mm(SD=21 mm) and in 64.5% of cases were associated to lymphadenopathy. 59.7%(n=48) of patients were diagnosed with LC, 77.1%(n=37) of them by EBUS-TBNA, 8.3(n=4) by other bronchoscopic methods at same time of EBUS and 14.6%(n=7) needed surgical biopsy. LC diagnosed by EBUS-TBNA were 59.5% adenocarcinoma, 16.2% squamous, 21.6% small cell and 2.7% carcinoid. In all of LC diagnosed by EBUS-TBNA, staging was achieved in the same procedure(8.1% N0, 5.4% N1, 67.6% N2 and 18.9% N3).EBUS-TBNA showed a sensitivity of 86%, specificity of 88.9%, PPV of 97.4% and PNV of 57.1% for simultaneous diagnosis and staging in our setting. Conclusions In our study EBUS-TBNA was useful to simplify the diagnosis and staging of LC, allowing both simultaneously in 77.1% of the patients and may be the preferred method for the initial approach after CT or PET/CT scan in this group of patients, in order to achieve faster diagnosis. References Navani N, et al . Lung-BOOST trial investigators. Lung cancer diagnosis and staging with endobronchial ultrasound-guided transbronchial needle aspiration compared with conventional approaches: An open-label, pragmatic, randomised controlled trial. Lancet RespirMed 2015, April;3(4):282–9. Steinhauser Motta JP, et al . Endobronchial ultrasound in real life: Primary diagnosis and mediastinal staging of lung cancer in patients submitted to thoracic surgery. BMC Pulm Med 2016, July 19;16(1):101.

JUSTIFICATIVA Y OBJETIVO: Describir un protocolo de intubacion con broncoscopio fl exible (FBI, de flexible bronchoscopy intubation) en pacientes con la via aerea dificil, su eficacia y seguridad. METODOS: Describir un protocolo de intubacion con broncoscopio fl exible (FBI, de flexible bronchoscopy intubation) en pacientes con la via aerea dificil, su efi cacia y se Se revisaron las historias clinicas de pacientes diagnosticados con via aerea dificil y que fueron sometidos a la broncoscopia fl exible para la intubacion bajo ventilacion espontanea y sedacion con midazolam y fentanilo, de marzo de 2009 a diciembre de 2010. RESULTADOS: Fueron seleccionados 102 pacientes, 69 (67,7%) hombres y 33 (32,3%) mujeres, con una edad promedio de 44 anos. En 59 pacientes con via aerea dificil prevista (57,8%) la FBI se hizo en un centro quirurgico; 39 (38,2%) ocurrieron en la Unidad de Cuidados Intensivos y cuatro casos (3,9%) en la sala de emergencia. La tos, la caida de saturacion de oxigeno transitoria y la difi cultad para insertar la canula a traves de la laringe, fueron las principales complicaciones del metodo, pero no impidieron la intubacion. CONCLUSIONES: La FBI, si secunda un protocolo de sedacion consciente con midazolam y fentanilo, es efi ciente y segura en el manejo de pacientes con via aerea dificil.

Resumen Justificativa y objetivo Describir un protocolo de intubacion con broncoscopio flexible (FBI, de flexible bronchoscopy intubation) en pacientes con la via aerea dificil, su eficacia y seguridad. Metodos: Se revisaron las historias clinicas de pacientes diagnosticados con via aerea dificil y que fueron sometidos a la broncoscopia flexible para la intubacion bajo ventilacion espontanea y sedacion con midazolam y fentanilo, de marzo de 2009 a diciembre de 2010. Resultados Fueron seleccionados 102 pacientes, 69 (67,7%) hombres y 33 (32,3%) mujeres, con una edad promedio de 44 anos. En 59 pacientes con via aerea dificil prevista (57,8%) la FBI se hizo en un centro quirurgico; 39 (38,2%) ocurrieron en la Unidad de Cuidados Intensivos y cuatro casos (3,9%) en la sala de emergencia. La tos, la caida de saturacion de oxigeno transitoria y la dificultad para insertar la canula a traves de la laringe, fueron las principales complicaciones del metodo, pero no impidieron la intubacion. Conclusiones La FBI, si secunda un protocolo de sedacion consciente con midazolam y fentanilo, es eficiente y segura en el manejo de pacientes con via aerea dificil.

Background and objective: To describe the efficacy and safety of a flexible bronchoscopy intubation (FBI) protocol in patients with difficult airway. Method: We reviewed the medical records of patients diagnosed with difficult airway who underwent flexible bronchoscopy intubation under spontaneous ventilation and sedation with midazolam and fentanyl from March 2009 to December 2010. Results: The study enrolled 102 patients, 69 (67.7%) men and 33 (32.3%) women, with a mean age of 44 years. FBI was performed in 59 patients (57.8%) with expected difficult airway in the operating room, in 39 patients (38.2%) in the Intensive Care Unit (ICU), and in 4 patients (3.9%) in the emergency room. Cough, decrease in transient oxygen saturation, and difficult progression of the cannula through the larynx were the main complications, but these factors did not prevent intubation. Conclusion: FBI according to the conscious sedation protocol with midazolam and fentanyl is effective and safe in the management of patients with difficult airway. Keywords: Bronchoscopy, Airway Management, Intubation Intratracheal, Deep Sedation

OBJETIVO: Determinar a taxa de sucesso da broncoscopia flexível como primeira opção na remoção de corpos estranhos das vias aéreas em adultos. MÉTODOS: Estudo retrospectivo de todos os pacientes adultos (acima de 18 anos) com aspiração de corpo estranho submetidos a broncoscopia no Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, em São Paulo (SP). RESULTADOS: A amostra foi constituída por 40 pacientes adultos, com média de idade de 52 anos (variação: 18-88 anos). A mediana do tempo de permanência do corpo estranho na via aérea foi de 15 dias (variação: 12 h a 10 anos). Todos os pacientes foram submetidos primeiramente a broncoscopia flexível diagnóstica. A retirada do corpo estranho por meio de broncoscopia flexível foi bem-sucedida em 33 dos pacientes (82,5%). Em 1 paciente, um objeto metálico alojado na árvore brônquica distal requereu o uso de fluoroscopia. Seis pacientes (15%) foram submetidos a broncoscopia rígida devido a dispneia induzida por corpo estranho traqueal, em 2, e porque o corpo estranho era muito grande para as pinças flexíveis, em 4. A broncoscopia falhou em apenas 1 paciente, que portanto necessitou de broncotomia. CONCLUSÕES: Embora a broncoscopia rígida seja considerada o padrão ouro na remoção de corpos estranhos na via aérea, nossa experiência mostrou que a broncoscopia flexível pode ser utilizada segura e eficientemente no diagnóstico e tratamento de pacientes adultos estáveis.

OBJETIVO: Tumores benignos primários da traqueia e dos brônquios principais são incomuns. A broncoscopia intervencionista permite o diagnóstico e o tratamento de algumas dessas lesões. MÉTODOS: Revisamos quatro casos tratados endoscopicamente em nossa instituição. RESULTADOS: Dois pacientes tinham hamartoma, e dois pacientes apresentaram lipoma endobrônquico. Em todos os casos, a técnica de intervenção para a ressecção foi o uso de alça de polipectomia e eletrocautério. A única complicação relatada foi um episódio de broncoespasmo. CONCLUSÕES: O tratamento broncoscópico minimamente invasivo é um método seguro e efetivo para o tratamento bem-sucedido de alguns tumores benignos da via aérea principal, com um baixo índice de complicações. OBJECTIVE: Primary benign tumors of the trachea and main bronchi are uncommon. Interventional bronchoscopy allows the diagnosis and the treatment of some of these lesions. METHODS: We reviewed four cases endoscopically treated at our institution. RESULTS: Two patients had hamartoma, and two patients had endobronchial lipoma. In all of the cases, the interventional technique for the resection was the use of a polypectomy snare and electrocautery. The only complication reported was one episode of bronchospasm. CONCLUSIONS: Minimally invasive bronchoscopic resection is a safe, effective method for treating selected benign tumors of the main airway and has a low complication rate.

Objectives/Hypothesis: Polysomnography (PSG) is the gold-standard method for diagnosing obstructive sleep apnea (OSA). However, the gap between demand and capacity in performing PSG is a major health-care problem. We sought to validate a short day-time induced sleep for the diagnosis of OSA. Study Design: Prospective diagnostic method validation. Methods: We studied 25 consecutive patients referred to the sleep laboratory and 15 healthy volunteers. All subjects were evaluated by means of full overnight PSG (Full-PSG) and short day-time induced-sleep PSG (Induced-PSG). Sleep was monitored during both procedures (Embla, 16 channels). Sleep was induced by slow intravenous drip infusion of midazolam. Results: The population studied (N = 40) was 60% male (mean age, 42 ± 10 years; body mass index, 29 ± 6.5 kg/m2). Sleep was successfully induced in all subjects, and no complications were observed (midazolam doses, 6.2 ± 3.8 mg; time of induced sleep 41.5 ± 18.9 minutes). The apnea-hypopnea index (AHI) and minimal oxygen saturation during Full-PSG versus Induced-PSG were similar: median AHI (with 25%–75% interquartile range) was 13 (3–35) events per hour versus 17 (4–36) events per hour, and median oxygen saturation was 84% (75–90) versus 85% (76–92); P =.89 and P =.53, respectively. The majority of the respiratory events during induced sleep were obstructive and similar to those observed during Full-PSG. AHI and lowest oxygen saturation during Induced-PSG correlated significantly with Full-PSG (r = 0.67 and r = 0.77, respectively). Sensitivity and specificity for the diagnosis of OSA (AHI > 15 events per hour) by Induced-PSG were 0.83 and 0.72, respectively. Conclusions: Induced-PSG by midazolam during the day is safe and correlates with Full-PSG; it therefore is a promising alternative method in the diagnosis of OSA.

INTRODUCTION: Esophageal cancer staging has been performed through bronchoscopy, computerized tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS). Whereas CT and PET scan provide assessments of distant metastasis, bronchoscopy importantly diagnoses tracheobronchial involvement, complementing chest CT findings. EUS is the most accurate examination for T and N staging but is technically limited when tumoral stenoses cannot be traversed. Endobronchial ultrasound (EBUS) appears to present greater accuracy than EUS, CT, and bronchoscopy for assessing tracheobronchial wall involvement. EBUS has been recently associated with EUS for esophageal cancer staging in our unit. OBJECTIVE: To compare EBUS findings in esophageal cancer patients without evident signs of tracheobronchial invasion on conventional bronchoscopy with EUS and CT. METHODS: Fourteen patients with esophageal cancer underwent CT, conventional bronchoscopy, EUS, and EBUS for preoperative staging. All patients underwent EBUS and EUS with an Olympus® MH-908 echoendoscope at 7.5 MHz. Seven patients were eligible for the study according to the inclusion criteria. RESULTS: The echoendoscope could not traverse tumoral esophageal stenosis to perform EUS in two patients, and invasion was effectively diagnosed by EBUS. In 4 (57%) of 7 patients EBUS revealed additional information to staging. In the remaining 3 cases the invasion findings were the same under both EUS and EBUS. CONCLUSION: EBUS showed signs of tracheobronchial invasion not observed by conventional bronchoscopy, adding information to staging in most of the cases when compared with CT and EUS.

A nasofaringoscopia com realização de Manobra de Müller é freqüentemente utilizada para determinar o local da obstrução na via aérea superior. No entanto, sua utilidade é controversa, uma vez que é realizada com o paciente acordado e pode não reproduzir os fenômenos obstrutivos que ocorrem durante o sono. OBJETIVOS: Comparar o grau de obstrução faríngea nas regiões retropalatal e retrolingual que ocorrem durante a manobra de Müller com aquelas que ocorrem durante o sono induzido. MATERIAL E MÉTODOS: Estudo prospectivo de 8 pacientes (3 homens e 5 mulheres) com idade (média ±desvio padrão) de 48,6 ± 9,2 anos de idade através de videonasofaringoscopia durante a manobra de Müller e durante o sono induzido por midazolam endovenoso. RESULTADOS: Observamos obstrução retropalatal similar durante a manobra de Müller e sono induzido (média + desvio padrão 3,13 + 0,99 e 2,75 + 0,46, respectivamente, p= 0,234). Em contraste, a obstrução retrolingual foi significantemente menor durante a manobra de Müller (média + desvio padrão 0,63 + 1,06 e 2,63 + 1,30, respectivamente, p= 0,005). CONCLUSÃO: O método do sono induzido foi seguro sob as condições de monitorização adotadas, tendo detectado maior ocorrência de colapso retrolingual do que a manobra de Müller.The use of nasopharyngoscopy during the application of intrathoracic pressure (Müller maneuver) is frequently employed to establish the site of upper airway obstruction. The Müller maneuver, however, is used when the patient is awake and therefore may not correlate with obstruction occurring during sleep. AIM: to compare the degree of pharyngeal obstruction in the retropalatal and retroglossal regions during the Müller maneuver versus induced sleep using nasopharyngoscopy. STUDY DESIGN: A prospective, case series study. MATERIAL AND METHODS: Eight patients (three males, five females), with a mean age of 48.6 +/- 9,2 year, underwent nasopharyngoscopy to assess airway anatomy and funciton during the Müller maneuver while awake and during sleep induced by drip infusion of Midazolam. RESULTS: Retropalatal obstruction was similar during the Müller maneuver and sleep (mean + standard deviation = 3.13 +/- 0.99 and 2.75 +/- 0.46, p= 0.234). Retroglossal obstruction was significantly lower during Müller maneuver compared to sleep (mean + standard deviation 0.63 +/- 1.06 and 2.63 +/- 1.30, respectively, p= 0.005). CONCLUSIONS: The sleep inducing method was safe under the monitored conditions of this study, and detected more retroglossal obstruction than the Müller maneuver.

Summary The use of nasopharyngoscopy during the application of intrathoracic pressure (Muller maneuver) is frequently employed to establish the site of upper airway obstruction. The Muller maneuver, however, is used when the patient is awake and therefore may not correlate with obstruction occurring during sleep. Aim: to compare the degree of pharyngeal obstruction in the retropalatal and retroglossal regions during the Muller maneuver versus induced sleep using nasopharyngoscopy. Study design: A prospective, case series study. Material and methods: Eight patients (three males, five females), with a mean age of 48.6 +/- 9,2 year, underwent nasopharyngoscopy to assess airway anatomy and funciton during the Muller maneuver while awake and during sleep induced by drip infusion of Midazolam. Results: Retropalatal obstruction was similar during the Muller maneuver and sleep (mean + standard deviation = 3.13 +/- 0.99 and 2.75 +/- 0.46, p= 0.234). Retroglossal obstruction was significantly lower during Muller maneuver compared to sleep (mean + standard deviation 0.63 +/- 1.06 and 2.63 +/- 1.30, respectively, p= 0.005). Conclusion: The sleep inducing method was safe under the monitored conditions of this study, and detected more retroglossal obstruction than the Muller maneuver.

A tosse, como mecanismo fisiológico, tem fundamental importância na remoção das secreções respiratórias, constituindo, assim, um dos mecanismos de defesa pulmonar. No entanto, os quadros de tosse crônica constituem uma das principais causas de procura por assistência médica no mundo, o que ressalta o significado da correta identificação e tratamento dos fatores desencadeantes e/ou perpetuadores. Dentre os vários fatores relacionados aos quadros de tosse crônica, alguns assumem papel de relevada importância, tais como o refluxo gastroesofágico, a rinorréia posterior ou a asma, já que, isolada ou conjuntamente, constituem cerca de 95% das causas. O passo fundamental para o sucesso terapêutico nos quadros de tosse crônica é uma abordagem diagnóstica racional, que investigue a tosse crônica de maneira progressiva, permitindo, assim, a instituição do tratamento de forma mais custo-efetiva. Para isso, a proposta de um algoritmo a ser seguido serve como base para essa investigação inicial. Cough is the main physiological mechanism responsible for the clearance of secretions from airways, acting as an important defense mechanism. However, the presentation of chronic cough is one of the most important causes for patients to seek medical attention all over the world, thus the significance of the correct recognition of all the factors related to the process of cough. Among those factors, some are of extreme importance, since they may be present in almost 95% of the cases: post-nasal drip syndrome, asthma and gastroesophageal reflux disease. The main step for a successful therapy for chronic cough is a rational and progressive diagnostic approach, narrowing the list of possible diagnosis and allowing the institution of a treatment with a better cost-effectiveness. The proposal of an algorithm focusing on the most common causes of chronic cough may be helpful in this initial approach.

O suporte ventilatório artificial invasivo e não invasivo ao paciente crítico tem evoluído e inúmeras evidências têm surgido, podendo ter impacto na melhora da sobrevida e da qualidade do atendimento oferecido nas unidades de terapia intensiva no Brasil. Isto posto, a Associação de Medicina Intensiva Brasileira (AMIB) e a Sociedade Brasileira de Pneumologia e Tisiologia (SBPT) - representadas pelo seus Comitê de Ventilação Mecânica e Comissão de Terapia Intensiva, respectivamente, decidiram revisar a literatura e preparar recomendações sobre ventilação mecânica objetivando oferecer aos associados um documento orientador das melhores práticas da ventilação mecânica na beira do leito, baseado nas evidencias existentes, sobre os 29 subtemas selecionados como mais relevantes no assunto. O projeto envolveu etapas visando distribuir os subtemas relevantes ao assunto entre experts indicados por ambas as sociedades que tivessem publicações recentes no assunto e/ou atividades relevantes em ensino e pesquisa no Brasil na área de ventilação mecânica. Esses profissionais, divididos por subtemas em duplas, responsabilizaram-se por fazer revisão extensa da literatura mundial sobre cada subtema. Reuniram-se todos no Forum de Ventilação Mecânica na sede da AMIB em São Paulo, em 03 e 04 de agosto de 2013 para finalização conjunta do texto de cada subtema e apresentação, apreciação, discussão e aprovação em plenária pelos 58 participantes, permitindo a elaboração de um documento final. Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Extrinsic compression of the central airway is usually related to the presence of adjacent solid lesions, the most common being primary or secondary mediastinal tumors. Cystic lesions account for 12-30% of mediastinal masses and are usually benign and asymptomatic. Obstructive or compressive symptoms are extremely uncommon.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has played a key role in the diagnosis of mediastinal, paratracheal, and peribronchial lesions, as well as in lymph node staging for lung cancer. Despite its minimally invasive character, EBUS-TBNA has demonstrated a diagnostic yield comparable with that of established surgical methods. It has therefore gained credibility and has become a routine procedure at various referral centers. A successful EBUS-TBNA procedure requires careful planning, which includes a thorough review of the radiological imaging and special care during specimen collection and preparation, as well as technical expertise, experience with the procedure itself, and knowledge of the potential complications inherent to the procedure. The most common indications for EBUS-TBNA include lymph node staging for lung cancer and the diagnostic investigation of mediastinal/hilar masses and lymph node enlargement. Recently, tumor biomarkers in malignant samples collected during the EBUS-TBNA procedure have begun to be identified, and this molecular analysis has proven to be absolutely feasible. The EBUS-TBNA procedure has yet to be included on the Brazilian Medical Association list of medical procedures approved for reimbursement. The EBUS-TBNA procedure has shown to be a safe and accurate tool for lung cancer staging/restaging, as well as for the diagnosis of mediastinal, paratracheal, and peribronchial lesions/lymph node enlargement Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA, punção aspirativa por agulha guiada por ultrassom endobrônquico) tem desempenhado um papel fundamental no diagnóstico de lesões mediastinais, paratraqueais e peribrônquicas, assim como no estadiamento linfonodal da neoplasia pulmonar. Por se tratar de exame endoscópico minimamente invasivo cujo rendimento diagnóstico tem se mostrado comparável aos métodos cirúrgicos estabelecidos, o procedimento de EBUS-TBNA ganhou espaço rapidamente e já se encontra integrado à rotina de investigação em serviços de referência. Para a realização de EBUS-TBNA, é importante o planejamento prévio ao procedimento, que deve incluir uma análise minuciosa dos exames radiológicos e cuidado especial com a coleta e preparo do material, além do domínio da técnica e conhecimento de eventuais complicações inerentes ao procedimento. As principais indicações para a realização de EBUS-TBNA são o estadiamento linfonodal da neoplasia pulmonar e a investigação diagnóstica de massas e linfonodomegalias mediastinais ou hilares. Recentemente, iniciou-se a identificação de biomarcadores tumorais em amostras neoplásicas; essa análise molecular no material coletado durante o procedimento de EBUS-TBNA provou ser totalmente possível. Até o momento, o procedimento de EBUS-TBNA não consta nas tabelas de procedimentos médicos da Associação Médica Brasileira. O procedimento de EBUS-TBNA tem se mostrado seguro e eficaz no estadiamento e reestadiamento de neoplasia de pulmão e no esclarecimento diagnóstico de lesões ou linfonodomegalias mediastinais, paratraqueais e peribrônquicas.

INTRODUÇÃO: A granulomatose de Wegener (GW) é uma forma de vasculite sistêmica que envolve primariamente as vias aéreas superiores e inferiores e os rins. As manifestações mais frequentes nas vias aéreas são estenose subglótica e inflamações, estenoses da traqueia e dos brônquios. A visualização endoscópica das vias aéreas é a melhor ferramenta para avaliação, diagnóstico e manejo dessas alterações. OBJETIVOS: Descrever as alterações endoscópicas encontradas na mucosa das vias aéreas de um grupo de pacientes com GW submetido à broncoscopia no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP) e relatar as intervenções terapêuticas broncoscópicas utilizadas em alguns casos. MÉTODOS: Foram estudados 15 pacientes com diagnóstico de GW provenientes do Ambulatório de Vasculites da Disciplina de Pneumologia do HC-FMUSP, encaminhados para a realização de broncoscopia no serviço de Endoscopia Respiratória do HC-FMUSP no período de 2003 a 2007. RESULTADOS: Dos 15 pacientes avaliados, 11 eram mulheres (73,33%) com idade média de 34 ± 11,5 anos. Foram encontradas alterações das vias aéreas em 80% dos pacientes, e o achado endoscópico mais frequente foi estenose subglótica (n = 6). Realizou-se broncoscopia terapêutica em três pacientes com estenose subglótica e em outros três com estenose brônquica, todos apresentando bons resultados. CONCLUSÃO: A broncoscopia permite diagnóstico, acompanhamento e tratamento das lesões de vias aéreas na GW, constituindo-se um recurso terapêutico pouco invasivo em casos selecionados. INTRODUCTION: Wegener's granulomatosis (WG) is a form of systemic vasculitis that involves primarily the upper and lower airways and the kidneys. The most frequent airway manifestations include subglottic stenosis and inflammation, and tracheal and bronchial stenoses. The endoscopic visualization of the airways is the best tool for assessing, diagnosing and managing those changes. OBJECTIVES: To describe the endoscopic abnormalities found in the airway mucosa of a group of patients with WG undergoing bronchoscopy at Hospital das Clínicas of the Faculdade de Medicina, Universidade de São Paulo (HC-FMUSP), and to report the therapeutic bronchoscopic interventions used in some cases. METHODS: The study assessed 15 patients diagnosed with GW from the Vasculitis Outpatient Clinic of the Department of Pulmonology, HC-FMUSP, referred for bronchoscopy at the Service of Respiratory Endoscopy, HC-FMUSP, from 2003 to 2007. RESULTS: Fifteen patients were studied [11 females (73.33%)]; mean age, 34 ± 11.5 years. Airway changes were found in 80% of the patients, and the most frequent endoscopic finding was subglottic stenosis (n = 6). Therapeutic bronchoscopy was performed in three patients with subglottic stenosis and in other three patients with bronchial stenosis, all showing good results. CONCLUSION: Bronchoscopy allows for diagnosing, monitoring, and treating the airway lesions in WG, being a minimally invasive therapeutic option in selected cases.

OBJETIVO: Avaliar a acurácia diagnóstica da broncoscopia em pacientes com suspeita clínica ou radiológica de tuberculose, com baciloscopia negativa ou incapazes de produzir escarro. MÉTODOS: Estudo transversal prospectivo de 286 pacientes com suspeita clínica/radiológica de tuberculose pulmonar e submetidos à broncoscopia - LBA e biópsia transbrônquica (BTB). As amostras de LBA foram testadas por pesquisas diretas e culturas de BAAR e de fungos, e as de BTB por exame histopatológico. RESULTADOS: Dos 286 pacientes estudados, a broncoscopia contribuiu para o diagnóstico em 225 (79%): tuberculose pulmonar em 127 (44%); inflamações crônicas inespecíficas em 51 (18%); pneumocistose, infecções fúngicas ou nocardiose em 20 (7%); bronquiolite obliterante com pneumonia em organização, alveolites ou pneumoconioses em 14 (5%); neoplasias pulmonares ou metastáticas em 7 (2%); e micobacterioses não tuberculosas em 6 (2%). Para o diagnóstico de tuberculose, o LBA mostrou sensibilidade e especificidade de 60% e 100% respectivamente, havendo um aumento importante da sensibilidade quando associado à biópsia (84%) e à baciloscopia após a broncoscopia (94%). Complicações controláveis decorrentes do procedimento ocorreram em 5,6% dos casos. CONCLUSÕES: A broncoscopia representa um método diagnóstico confiável para pacientes com tuberculose pulmonar, apresentando baixos índices de complicações. A associação de biópsia transbrônquica ao lavado broncoalveolar elevou a sensibilidade diagnóstica do método e permitiu o diagnóstico diferencial com outras doenças. OBJECTIVE: To evaluate the diagnostic accuracy of bronchoscopy in patients with clinical or radiological suspicion of tuberculosis who were unable to produce sputum or with negative sputum smear microscopy results. METHODS: A prospective cross-sectional study involving 286 patients under clinical or radiological suspicion of having pulmonary tuberculosis and submitted to bronchoscopy-BAL and transbronchial biopsy (TBB). The BAL specimens were submitted to direct testing and culture for AFB and fungi, whereas the TBB specimens were submitted to histopathological examination. RESULTS: Of the 286 patients studied, 225 (79%) were diagnosed on the basis of bronchoscopic findings, as follows: pulmonary tuberculosis, in 127 (44%); nonspecific chronic inflammation, in 51 (18%); pneumocystis, fungal infections, or nocardiosis, in 20 (7%); bronchiolitis obliterans organizing pneumonia, alveolites, or pneumoconiosis, in 14 (5%); lung or metastatic neoplasms, in 7 (2%); and nontuberculous mycobacterium infections, in 6 (2%). For the diagnosis of tuberculosis, BAL showed a sensitivity and a specificity of 60% and 100%, respectively. Adding the TBB findings significantly increased this sensitivity (to 84%), as did adding the post-bronchoscopy sputum smear microscopy results (total sensitivity, 94%). Minor post-procedure complications occurred in 5.6% of the cases. CONCLUSIONS: Bronchoscopy is a reliable method for the diagnosis of pulmonary tuberculosis, with low complication rates. The combination of TBB and BAL increases the sensitivity of the method and facilitates the differential diagnosis with other diseases.

To determine the success rate of flexible bronchoscopy as the first-choice method of removing foreign bodies from the airways of adults.This was a retrospective study of all adult patients (over 18 years of age) with foreign body aspiration submitted to bronchoscopy between January of 2009 and January of 2011 at the University of São Paulo School of Medicine Hospital das Clínicas, located in São Paulo, Brazil.The study sample comprised 40 adult patients, with a mean age of 52 years (range, 18-88 years). The median time of permanence of the foreign body in the airway was 15 days (range, 12 h to 10 years). All of the patients first underwent diagnostic flexible bronchoscopy. Foreign bodies were successfully removed with flexible bronchoscopy in 33 (82.5%) of the patients. In 1 patient, a metal object lodged in the distal bronchial tree required the use of fluoroscopy. Six patients (15%) required rigid bronchoscopy due to tracheal foreign body-induced dyspnea, in 2, and because the foreign body was too large for the flexible forceps, in 4. Bronchoscopy failed in 1 patient, who therefore required surgical bronchotomy.Although rigid bronchoscopy is considered the gold standard for the removal of foreign bodies from the airways, our experience showed that flexible bronchoscopy can be safely and effectively used in the diagnosis and treatment of stable adult patients.

To evaluate the diagnostic accuracy of bronchoscopy in patients with clinical or radiological suspicion of tuberculosis who were unable to produce sputum or with negative sputum smear microscopy results.A prospective cross-sectional study involving 286 patients under clinical or radiological suspicion of having pulmonary tuberculosis and submitted to bronchoscopy-BAL and transbronchial biopsy (TBB). The BAL specimens were submitted to direct testing and culture for AFB and fungi, whereas the TBB specimens were submitted to histopathological examination.Of the 286 patients studied, 225 (79%) were diagnosed on the basis of bronchoscopic findings, as follows: pulmonary tuberculosis, in 127 (44%); nonspecific chronic inflammation, in 51 (18%); pneumocystis, fungal infections, or nocardiosis, in 20 (7%); bronchiolitis obliterans organizing pneumonia, alveolites, or pneumoconiosis, in 14 (5%); lung or metastatic neoplasms, in 7 (2%); and nontuberculous mycobacterium infections, in 6 (2%). For the diagnosis of tuberculosis, BAL showed a sensitivity and a specificity of 60% and 100%, respectively. Adding the TBB findings significantly increased this sensitivity (to 84%), as did adding the post-bronchoscopy sputum smear microscopy results (total sensitivity, 94%). Minor post-procedure complications occurred in 5.6% of the cases.Bronchoscopy is a reliable method for the diagnosis of pulmonary tuberculosis, with low complication rates. The combination of TBB and BAL increases the sensitivity of the method and facilitates the differential diagnosis with other diseases.

Polysomnography (PSG) is the gold-standard method for diagnosing obstructive sleep apnea (OSA). However, the gap between demand and capacity in performing PSG is a major health-care problem. We sought to validate a short day-time induced sleep for the diagnosis of OSA.Prospective diagnostic method validation.We studied 25 consecutive patients referred to the sleep laboratory and 15 healthy volunteers. All subjects were evaluated by means of full overnight PSG (Full-PSG) and short day-time induced-sleep PSG (Induced-PSG). Sleep was monitored during both procedures (Embla, 16 channels). Sleep was induced by slow intravenous drip infusion of midazolam.The population studied (N = 40) was 60% male (mean age, 42 ± 10 years; body mass index, 29 ± 6.5 kg/m(2)). Sleep was successfully induced in all subjects, and no complications were observed (midazolam doses, 6.2 ± 3.8 mg; time of induced sleep 41.5 ± 18.9 minutes). The apnea-hypopnea index (AHI) and minimal oxygen saturation during Full-PSG versus Induced-PSG were similar: median AHI (with 25%-75% interquartile range) was 13 (3-35) events per hour versus 17 (4-36) events per hour, and median oxygen saturation was 84% (75-90) versus 85% (76-92); P = .89 and P = .53, respectively. The majority of the respiratory events during induced sleep were obstructive and similar to those observed during Full-PSG. AHI and lowest oxygen saturation during Induced-PSG correlated significantly with Full-PSG (r = 0.67 and r = 0.77, respectively). Sensitivity and specificity for the diagnosis of OSA (AHI15 events per hour) by Induced-PSG were 0.83 and 0.72, respectively.Induced-PSG by midazolam during the day is safe and correlates with Full-PSG; it therefore is a promising alternative method in the diagnosis of OSA.

The management of airway foreign bodies (AFB) can be a dramatic situation in the emergency treatment of children and different techniques have been used to improve the therapeutic success and minimize risks.to describe the bronchoscopic techniques used in the treatment of AFB in children referred to the Service of Respiratory Endoscopy of HC-FMUSP.Retrospective analysis of 78 children who underwent bronchoscopy for foreign body removal, at our Service from February 2003 to April 2008.78 patients with an AFB, aged 08 months to 14 years, with 39 being organic and 39 inorganic foreign bodies. Nine foreign bodies were located in the central airway (four in the larynx and five in the trachea), 34 in the right bronchial tree and 33 in the left bronchial tree. There was bilateral aspiration in two cases. All patients were initially submitted to diagnostic flexible bronchoscopy. A rigid bronchoscope was used in 39 cases; a flexible bronchoscope in 23 and an association of techniques in 15 cases (rigid bronchoscopy, flexible bronchoscopy, suspension laryngoscopy, and fluoroscopy).Although the rigid bronchoscopy is considered the main tool for the removal of foreign bodies from airways, other useful techniques deserve attention as part of the medical training.The knowledge and association of different methods in pediatric bronchoscopy add the benefits of one method to another, minimizing the chances of therapeutic failure.

A nasofaringoscopia com realização de Manobra de Müller é freqüentemente utilizada para determinar o local da obstrução na via aérea superior. No entanto, sua utilidade é controversa, uma vez que é realizada com o paciente acordado e pode não reproduzir os fenômenos obstrutivos que ocorrem durante o sono. OBJETIVOS: Comparar o grau de obstrução faríngea nas regiões retropalatal e retrolingual que ocorrem durante a manobra de Müller com aquelas que ocorrem durante o sono induzido. MATERIAL E MÉTODOS: Estudo prospectivo de 8 pacientes (3 homens e 5 mulheres) com idade (média ±desvio padrão) de 48,6 ± 9,2 anos de idade através de videonasofaringoscopia durante a manobra de Müller e durante o sono induzido por midazolam endovenoso. RESULTADOS: Observamos obstrução retropalatal similar durante a manobra de Müller e sono induzido (média + desvio padrão 3,13 + 0,99 e 2,75 + 0,46, respectivamente, p= 0,234). Em contraste, a obstrução retrolingual foi significantemente menor durante a manobra de Müller (média + desvio padrão 0,63 + 1,06 e 2,63 + 1,30, respectivamente, p= 0,005). CONCLUSÃO: O método do sono induzido foi seguro sob as condições de monitorização adotadas, tendo detectado maior ocorrência de colapso retrolingual do que a manobra de Müller. The use of nasopharyngoscopy during the application of intrathoracic pressure (Müller maneuver) is frequently employed to establish the site of upper airway obstruction. The Müller maneuver, however, is used when the patient is awake and therefore may not correlate with obstruction occurring during sleep. AIM: to compare the degree of pharyngeal obstruction in the retropalatal and retroglossal regions during the Müller maneuver versus induced sleep using nasopharyngoscopy. STUDY DESIGN: A prospective, case series study. MATERIAL AND METHODS: Eight patients (three males, five females), with a mean age of 48.6 +/- 9,2 year, underwent nasopharyngoscopy to assess airway anatomy and funciton during the Müller maneuver while awake and during sleep induced by drip infusion of Midazolam. RESULTS: Retropalatal obstruction was similar during the Müller maneuver and sleep (mean + standard deviation = 3.13 +/- 0.99 and 2.75 +/- 0.46, p= 0.234). Retroglossal obstruction was significantly lower during Müller maneuver compared to sleep (mean + standard deviation 0.63 +/- 1.06 and 2.63 +/- 1.30, respectively, p= 0.005). CONCLUSIONS: The sleep inducing method was safe under the monitored conditions of this study, and detected more retroglossal obstruction than the Müller maneuver.

We described a 41-year-old woman with dermatomyositis, interstitial lung disease, and cutaneous vasculopathy who developed a pneumomediastinum. The routine bronchoscopy investigation found pale lesions in the larynx, that extended to the tracheobronchial tree, and deep ulcers in the membranous wall of the trachea. The histopathology examination revealed an inflammatory process that was diagnosed secondary to the vasculitis, but no infections. Superior and inferior airway lesions in the same patient with dermatomyositis is a very rare condition. The association of dermatomyositis with deep mucosal ulcers and pneumomediastinum is not clear, but a bronchoscopic examination should be used to improve evaluation.