Dear Editor,

Dr Toma and colleagues [1] describe interesting directions along which fibreoptic bronchoscopy may develop. The authors quite rightly state that rigid bronchoscopy has largely fallen within the domain of thoracic surgeons. Furthermore the techniques available until relatively recently were limited. I think it appropriate to ask the question “will this situation change�? In my opinion it already has. At St George’s Hospital we have a multidisciplinary team approach to investigate and treat patients with diverse large airway pathologies. There is input from specialists in cardiothoracic surgery, anaesthesia, medicine and intensive care and respiratory medicine. Our procedures are performed in a cardiothoracic theatre on a designated morning list. Theatre personnel involved include a consultant in cardiothoracic anaesthesia with SpRs in anaesthesia, a consultant in cardiothoracic medicine, SpRs in respiratory medicine and a research fellow. In addition there is full nursing and operating department assistant support.

We regularly receive referrals of patients with severe large airway compromise who present a challenging anaesthetic risk. We perform approximately 20 endobronchial intervention procedures (Nd Yag laser therapy, endobronchial stent deployment for benign and malignant diseases, dilatation techniques, foreign body retrieval, biopsies of proximal friable tumours and paediatric interventions e.g. localisation of tracheo oesophageal fistula in neonates) per month. Our trainees in respiratory medicine spend an initial period of three months in our unit. They gain excellent exposure to large airway intervention, receive training in rigid bronchoscopic deployment in a controlled environment and have exposure to the large number of interventions currently available.

We consistently receive positive feedback from our SpRs in respiratory medicine and indeed regularly welcome visitors from overseas. The use of an intra-operative video is a useful teaching tool and the work also provides an important forum for research. Our SpRs advise us that skills learnt in deployment of the rigid bronchoscope gives them extra confidence for their fibreoptic bronchoscopy work. Additionally the fact that there are cardiothoracic surgeons available in theatre provides an important opportunity to discuss patients with colleagues in thelight of the bronchoscopic appearances and in conjunction with radiology (available on PACS in theatre).

Over the past five years we have had no operative mortality. Two patients developed a pneumothorax which required intercostal chest drain deployment. Although bleeding was encountered occasionally it was always possible to secure haemostasis by endobronchial means including direct application of adrenalin on gauze using rigid forceps. We never cease to be amazed by the spectrum of referrals which we are privileged to receive. Indeed on last weeks list alone there was one patient with tracheal amyloid causing 90% obstruction who was treated using Nd Yag laser therapy, a patient with adenoid cystic carcinoma referred by our oncology colleagues also for tumour debulking using Nd Yag laser, dilatation of an airway stricture in a patient with Wegener’s granulomatosis, deployment of a right main bronchial stent in a patient with extrinsic airway compression as a consequence of achalasia of the oesophagus and removal of a right main bronchial lipoma which was obstructing the right main bronchus completely.

With increasing demand from trainees in respiratory medicine, thoracic surgery and anaesthesia to learn these techniques we arrange national study days for endobronchial intervention on a biannual basis.

I believe that there is a brave new world for interventional bronchoscopy but given our experience together with the very positive feedback from our trainees I believe that rigid bronchoscopy and large airway intervention should have an important and more prominent role among respiratory physicians in this new world.

Yours sincerely.

Dr Brendan Madden, MD, MSc, FRCP, FRCPI
Consultant Cardiothoracic and ITU Physician
Reader in Cardiothoracic Medicine

Reference

1. Toma TP, Geddes DM, Shah PL. Thorax 2005; 60:180–181