This document discusses bronchopleural fistula (BPF), which is an abnormal communication between the bronchial tree and pleural space that can occur after lung surgery or due to other non-operative causes. It presents classifications of air leaks, risk factors, clinical presentation, diagnosis, and treatment approaches for BPF. Treatment may involve drainage, antibiotics, ventilation strategies, bronchoscopic techniques, or surgical procedures depending on the size and location of the fistula. Anesthesia management for surgery aims to isolate the healthy lung and prevent complications from air loss through the fistula.
Despite modern anti-tuberculous chemotherapy, approximately 2% of all cases of pulmonary mycobacterial infection require surgical treatment.Therefore, surgical treatment of pulmonary mycobacterial disease is rarely necessary.Types of surgical procedures for PTB include: Collapse therapy, pulmonary resection, lung decortication, drainage procedures such as closed tube thoracostomy, rib resection and open window thoracotomy beside pulmonary resection+ collapse therapy (thoracoplasty). The decreasing morbidity and mortality of pulmonary resection for PTB is due to careful patient selection ( failure of chemotherapy, massive haemoptysis, BPF), improved anaesthetic techniques, stapling devices and better chemotherapy.The prognosis after successful resection is excellent ( 90% survive and remain disease free).
Interstitial lung disease is a general category that includes many different lung conditions. All interstitial lung diseases affect the interstitium, a part of the lungs' anatomic structure.
Some of the types of interstitial lung disease include:
Interstitial pneumonia: Bacteria, viruses, or fungi may infect the interstitium of the lung. A bacterium called Mycoplasma pneumonia is the most common cause.
Idiopathic pulmonary fibrosis : A chronic, progressive form of fibrosis (scarring) of the interstitium. Its cause is unknown.
Nonspecific interstitial pneumonitis: Interstitial lung disease that's often present with autoimmune conditions (such as rheumatoid arthritis or scleroderma).
Despite modern anti-tuberculous chemotherapy, approximately 2% of all cases of pulmonary mycobacterial infection require surgical treatment.Therefore, surgical treatment of pulmonary mycobacterial disease is rarely necessary.Types of surgical procedures for PTB include: Collapse therapy, pulmonary resection, lung decortication, drainage procedures such as closed tube thoracostomy, rib resection and open window thoracotomy beside pulmonary resection+ collapse therapy (thoracoplasty). The decreasing morbidity and mortality of pulmonary resection for PTB is due to careful patient selection ( failure of chemotherapy, massive haemoptysis, BPF), improved anaesthetic techniques, stapling devices and better chemotherapy.The prognosis after successful resection is excellent ( 90% survive and remain disease free).
Interstitial lung disease is a general category that includes many different lung conditions. All interstitial lung diseases affect the interstitium, a part of the lungs' anatomic structure.
Some of the types of interstitial lung disease include:
Interstitial pneumonia: Bacteria, viruses, or fungi may infect the interstitium of the lung. A bacterium called Mycoplasma pneumonia is the most common cause.
Idiopathic pulmonary fibrosis : A chronic, progressive form of fibrosis (scarring) of the interstitium. Its cause is unknown.
Nonspecific interstitial pneumonitis: Interstitial lung disease that's often present with autoimmune conditions (such as rheumatoid arthritis or scleroderma).
Here is a presentation about the double lung ventilation or independent lung ventilation
I hope it will be helpful
There are some videos in the presentation , here is the links :)
http://www.youtube.com/watch?v=w1cgx2AVC6k&list=UUUIWCsRV3siWB-jzBmNg6pA
http://www.youtube.com/watch?v=JZkOiy4PXxg&list=UUUIWCsRV3siWB-jzBmNg6pA
http://www.youtube.com/watch?v=mlS35eUUxqA&list=UUUIWCsRV3siWB-jzBmNg6pA
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. Communication
between bronchial tree
and pleural space
High morbidity and mortality
Prolonged hospital stay
No standard treatment guidelines or
consensus
Aetiology :
1.postoperative – 2/3
2.non-operative – 1/3
3. CLASSIFICATION OF AIR
LEAKS
Alveolopleural
fistula(APF):pulmonary-pleural
communication distal to segmental
bronchus, common after lung
resection except
pneumonectomy, heal conservatively.
BPF: communication between a
mainstem, lobar or segmental
bronchus and the pleura lined
cavity, usually require surgical
intervention
4. 4.5%-20% after pneumonectomy and 0.5% after lobectomy
Predisposing factors:
1.h `Rt.pneumonectomy
2. Uncontrolled pleural/pulmonary infection
3. Preop. radiation,steroid,cirrhosis,diabetes
4. Uncorrected low serum albumin, anaemia
5. Malignancy
6. Contd.mechanical ventilation for more than 24h
7. H influenzae in sputum
8. Fever, high ESR
5. Main bronchus,intermdt bronchus has higher risk
compared to lobar bronchus
Long bronchial stump, residual tumour, excessive
peribronchial and paratracheal dissection-harmful
Routine coverage of stump with
omentum, intercostal muscle flap, pleural
flap, pericardial fat esp after right pneumonectomy
suggested
7. CLINICAL
PRESENTATION
o
o
o
o
o
Usually 7-15 days following a lung
resection
Early (1-7days ), intermediate ( 8-30 days )
and late ( more than 30 days )
As complication of pleuropulmonary
infection-any time during the course of the
illness
Early indicators: reappearance of
fever,increased cough with
purulent/serosanguinous sputum
Persistent bubbling from the chest drain
8. CLINICAL PRESENTATION (CONTD)
ACUTE: sudden onset of
dyspnoea,cough,expectoration of purulent
material,hypotension,subcutn.emphysema,shifting of
trachea and mediastinum.
SUBACUTE: insidious onset of
fever,malaise,wasting,minimally productive cough
CHRONIC: associated with infectious disease,minimal
mediastinal shift due to pleural and mediastinal
fibrosis,not life threatening,adequate gas exchange in
healthy lung
Systemic features of sepsis
10. ACUTE POST-PNEUMONECTOMY BPF
Day 22
Reappearance of air
OR a drop in airfluid level >1.5cm
Subcutaneous or
mediastinal
emphysema
Tension pneumothorax
& Pulmonary flooding
Mediastinal
shift
Contralateral lung
consolidation
from
transbronchial
spill
Radiographics 2006;26:1449-1468
11. DIAGNOSIS
CLINICAL
Persistent air leak: >24h after
development of pneumothorax
Exclude other causes of persistent air
leak:
1.an external air leak
2.extrathoracic location of side
holes
3.disconnections
12. DIAGNOSIS (CONTD.)
Plain x-rays may reveal following
features of BPF :
1.steady increase in intrapleural
airspace
2.appearance of a new air fluid level
(indicates level of the BPF)
4.development of tension
pneumothorax
5.drop in air fluid level exceeding
2cm (in absence of chest tube )
13. DIAGNOSIS CONTD.
Role of CT Scan: demonstrates
pneumothorax,pneumomediastinum,underlyin
g lung pathology
Demarcation of actual fistulous
communication
Role of FOB: can confirm and localise the
BPF
FOB and selective bronchography
Visualisation of continuous return of air
bubbles on bronchial wash
Selective instillation of methylene blue into
segmental bronchi: appears in chest
drain,sputum
14. FOB aided placement of balloon-tipped catheter
in selective airway: inflation of balloon eliminates
leak
Combined FOB and Capnography : polyurethane
catheter passed through br.scopic channel and
introduced into different bronchi
BPF suggested by loss of capnographic tracing:
affected bronchus communicates to atmosphere
through chest tube
16. Post pneumonectomy bronchopleural fistula, (A)
right hydropneumothorax, (B) FOB showed a possible fistulous
opening at the right bronchial stump, (C) methylene
Blue injected at the suspected site, (D) appearance of dye
in the pleural drainage system confirmed the diagnosis.
17. DIAGNOSIS (CONTD.)
Changes in gas concentration in pneumonectomy
cavity after inhalation of different conc. of O2,N2O
Ventilation scintigraphy using radioactive
gases, eg.
133Xe that accumulate in pleural space within and
remain trapped in the pleural space in washout
study
High incidence of false negative results
Inhalation of radio-labelled aerosols with planar
and SPECT imaging: requires patient
cooperation, false positives occur, direct estimation
of size of BPF not possible
18. 1.The
largest(C): continued bubbling through
chest tube,least common,pts on
mech.ventilation
2.The 2nd largest(I): air leak only during
inspiration,pts on mech. ventilation with
large APF or small BPF
3.The 3rd largest(E): air leak only during
expiration,after lung surgery due to APF
4.The smallest(FE): air leak only during
forced expiration eg. coughing,common after
lung resection
Small leaks heal with underwater drains but
larger leaks may require suction
19. CONSEQUENCES OF BPF
Persistent pneumothorax: air escaping through
the BPF delays healing of the tract
Inadequate ventilation: significant loss of TV
Pendelluft: seen in early BPF when mediastinum
is mobile
V/Q mismatch
Infection of pleural space
Most common cause of death in BPF: aspiration
pneumonia and ARDS,tension pneumothorax
20. PROBLEMS WITH LARGE BPF IN ICU
Difficult to wean from ventilator
Inability to apply PEEP
Failure to expand the remaining lung
Hypoxia, hypercarbia
May need dual ventilation
May need HFV
High mortality: occurrence of BPF during
mechanical ventilation identifies pts. with high
mortality
21. TREATMENT OF BPF
Treatment options include: surgical
procedures,medical therapy,bronchoscopic- guided
placement of glue,coils,sealants etc
Initial treatment: control of life-threatening
conditions
Tension pneumothorax: urgent insertion of
chestdrain
Pulmonary flooding: immediate airway
control,postural drain with affected side down
Major bronchial stump dehiscence: immediate
resuture with reinforcement
22. TREATMENT (CONTD)
Aggressive management of underlying
comorbidities
Haemodynamically unstable pt. with varying
degrees of resp. failure
Superadded sepsis
Poor nutrition, hypoalbunaemia, anaemia
Unresolved empyema, underlying
tubercular/fungal infection
Poor candidates for a second surgical procedure
Need care in ICU setup
23. TREATMENT ( CONTD.)
o Drainage of pleural space with proper
antimicrobial coverage
o Enteral or parenteral nutrition
o Correction low albumin and haematocrit
o Mechanical ventilatory support if required
24. ROLE OF CHEST TUBE IN BPF
Indicated in all pts. with high flow BPF and
drainage of empyema
Add positive intrapleural pressure during expiration
to reduce air leak and maintain PEEP
Intermittent occlusion during inspiratory phase to
decrease BPF flow
Useful in patients with ARDS
Can function as foreign body and delay healing
Predispose to infection at insertion site and pleural
space
25. CHEST TUBE (CONTD.)
Loss
of tidal volume
Abnormal gas exchange
Inappropiate ventilator cycling
Tube should of sufficient diameter to allow
free drainage of air leak
Flow varies with 5th power of tube radius in
clinical situations due to turbulent flow of
moist air( Fanning equation )
Pleurodesis: sclerosing agent eg
bleomycin can be passed through tube
26. Air leaks may range from 1-16L/min
Loss of effective TV and PEEP, incomplete lung
expansion,CO2 retention, auto-triggering of
ventilator, severe hyperventilation
Excess use of sedatives, muscle relaxants
Goal: 1. keep airway pressure at or below critical
opening pressure of fistula
2.adequate pleural space decompression to allow
lung re-expansion
27. Increased chest tube suction increases flow through
BPF, so use least possible pressure or none at all
Limiting the amount of PEEP during ventilation
Limiting effective tidal volume
Shortening the inspiratory time
Reducing the respiratory rate
Reducing the proportion of minute volume supplied
by ventilator
Differential lung ventilation using a DLT
Independent lung ventilation using 2 ventilators
28. HIGH FREQUENCY VENTILATION IN BPF
Results are conflicting
More useful in pts. with normal lung
parenchyma and proximal BPF
Can be useful in pts. with massive air leak
Have been successfully used in pts. with
bilateral BPF
Less effective in pts. with bilaterally diseased
noncompliant lungs
Major handicap: doesn’t allow isolation of lungs
29. THERAPEUTIC BRONCHOSCOPY IN BPF
o Allows inspection of the stump
o Confirms location and size of the BPF
o Bronchoscopy aided application of sealant substance
can be tried
o Intrabronchial stents, valves,embolisation coils etc
have been used
o Suitable for small fistulas ( <5mm diam )
o Proximally located fistula-mainstem, lobar or
segmental bronchi are more suitable
o Useful alternative in patients not proper candidates
for surgery
30. SURGICAL PROCEDURES IN BPF
• Decortication of lung
• Revision of bronchial stump
• Closure of fistula with muscle flap
from intercostal space
• Thoracoplasty combined with pedicle
muscle flap to cover bronchial stump
• Resection of diseased chronically
infected lung segments
31. Experienced
thoracic anaesthesiologist
Problems in anaesthesia for BPF pts.:
1.Isolation of the healthy lung reqd.
2.Prevention of tension pneumothorax during
PPV
3.Inadequate ventilation due to loss of gas
through fistula
4.Significant intraoperative blood loss
5.Patient preparation may be suboptimal
6.Early extubation and avoidance of
postoperative PPV desirable
32. Assessment of possible loss of TV through the
fistula:
bubble flow through chest drain continous or
intermittent
Quantification of size of BPF: inhaled TV– exhaled
TV
Nonintubated pt.: tight fitting mask and fast
responding spirometer
Intubated pt.: direct attachment of spirometer to
ETT
Larger the leak,greater need to isolate BPF by lung
isolation
Devices: DLT,SLT,independent bronchial blocker
33. ANAESTHESIA FOR BPF (CONTD.)
DLT advantages:
1.most secure method of isolation
2.allows easy bilateral suction and ventilation
3.differential lung ventilation possible
DLT disadvantage: most difficult to place in awake patients
under topical anaesthesia of airway
SLT disadvantage:
1.doesnt allow easy suction or ventilation of affected
lung
2. not designed for endobronchial use
3.if placed in R mainstem bronchus will obstruct
orifice of RUL
34. ANAESTHESIA FOR BPF (CONTD.)
Bronchial blocker advantages:
1.can be deflated to suction or ventilate BPF lung
2.allows lobar isolation
Disadvantage: least secure method of lung isolation
Ability to deliver PPV must be assessed
Working chest drain prior to induction
SLT safe to use: if fistula small, chronic,uninfected
DLT best choice for PPV: if significant airleak present
Usual MV can be delivered to healthy lung,no loss
through fistula and no risk of contamination on
turning the pt.
35. ANAESTHESIA FOR BPF (CONTD.)
o Emergency situation: SLT can be used,provides
protection and ventilation to healthy lung
o Non pneumonectomy pt.: BB can be placed through
ETT into mainstem bronchus of affected side,less
stable,less protection to the healthy lung
o Post pneumonectomy pt.: BB is not an option due to
short length of bronchial stump available
o Anaesthetic management options include:
o
1.awake fibreoptic intubation with SLT,DLT or BB.
o Induction of GA after lung isolation is achieved
36. ANAESTHESIA FOR BPF (CONTD.)
Safest method but technically most difficult
Requires excellent pt. cooperation and thorough airway
topical anaesthesia
2.Induction of GA maintaining spont.ventilation using
deep inhalational anaesthesia
PPV avoided lungs are isolated
Breath holding and laryngospasm may nessecitate
unplanned use of PPV
Vigorous coughing in either technique may provoke
spillover into healthy lungs and reopen a fistula
Significant hypotension can occur in elderly,debilitated
pts.
37. 3.If airway is thought to be easy, rapid sequence
induction can be done avoiding PPV until lung
isolation.
Position for induction: head up position maintained
as long as possible with 30deg lateral tilt keeping
diseased lung down
Post pneumonectomy pts.; DLT or SLT placed under
direct vision with help of FOB for accurate
placement and avoiding injury to bronchial stump
Suction of chest tube to be avoided during
induction: to reduce loss of TV with PPV
38. Chest open, SLT used, excessive air leak: lungs packed
off and manual compression of fistula by surgeon
Rigid bronchoscope can be introduced under topical
anaesthesia of airways or inhalation anaesthesia:
observation of fistula, suction,positioning of
endobronchial tube or BB, jet ventilate the healthy lung
Extubation: as soon as feasible as neg. pr. ventilation is
best
Bronchial tree examined with FOB before extubation
39. ANAESTHESIA FOR BPF (CONTD.)
If postop ventilation is necessary
DLT is not changed
Thoracic epidural analgesia for post
operative analgesia
TEA has been used as sole
anaesthetic technique in BPF closure
in elderly debilitated pts.
40. REFERENCES
Sarkar P et al Diagnosis and Management
Bronchopleural Fistula Indian J Chest Allied
Sci 2010;52:97-104
Manuel L et al Bronchopleural Fistulas An
Overview of the Problem With Special Focus on
Endoscopic Mnagement CHEST 2005;128:39553965
Sanjay O P et al Management of Bronchopleural
Fistula. Core Topics in Thoracic Anaesthesia
Chapter 27,OUP 2009
Principles and Practice of Anaesthesia for
Thoracic Surgery.ed P Slinger 2011 Pg 467-71