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The COVID-19 Pandemic has resulted in a high number of hospital admissions and some of those patients need ventilatory support in intensive care units. The viral pneumonia secondary to Sars-cov-2 infection may lead to acute respiratory distress syndrome (ARDS) and longer mechanical ventilation needs, resulting in a higher demand for tracheostomies. Due to the high aerosolization potential of such procedure, and the associated risks of staff and envoirenment contamination, it is necesseray to develop a specific standardization of the of the whole process involving tracheostomies. This manuscript aims to demonstrate the main steps of the standardization created by a tracheostomy team in a tertiary hospital dedicated to providing care for patients with COVID-19.

We aimed to test a new model of self-expanding tracheal stent so that it might be made available for clinical use. Using direct laryngoscopy, we placed polyurethane-coated, nitinol stents into the middle third of the trachea in 25 New Zealand rabbits. After a mean observation period of 26 days, we evaluated stent migration, degree of expansion, attachment, adherence, formation of granulation tissue, presence of inflammatory infiltrate, parietal involvement, and epithelial lining. The results showed complete radial expansion, little adherence to the tracheal mucosa, and low tissue attachment, as well as high rates of granuloma formation and stent migration. This new model proved to be biocompatible and showed a behavior similar to that of other stents on the market.

Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new method for the diagnosis and staging of mediastinal lymph nodes. The objective of this study was to evaluate the preliminary results obtained with EBUS-TBNA in the diagnosis of lesions and mediastinal lymph node staging., Methods: We evaluated patients with tumors or mediastinal adenopathy, diagnosed with or suspected of having lung cancer. The procedures were performed with the patients under sedation or under general anesthesia. Material was collected by EBUS-TBNA, after which it was prepared on slides, fixed in either absolute alcohol (for cytology) or formalin (for cell-block analysis)., Results: We included 50 patients (30 males). The mean age was 58.3 ± 13.5 years. We performed 201 biopsies of 81 lymph nodes or mediastinal masses (mean of 2.5 punctures/biopsy). The quantity of material was considered sufficient for cytology in 37 patients (74%), 21 (57%) of whom were thus diagnosed with malignancy. Of the remaining 16 patients, 1 was diagnosed with tuberculosis, 6 entered clinical follow-up, and 9 underwent further investigation (2 diagnosed with neoplasm-false-negative results). The yield was higher when the procedure was performed for diagnostic purposes, as well as being higher in patients with lesions in multiple stations and in biopsies involving the subcarinal lymph node station. One patient had endobronchial bleeding, which was resolved with local measures. There were no deaths among the patients evaluated., Conclusions: This preliminary experience shows that EBUS-TBNA is a safe procedure. Our diagnostic yield, although lower than that reported in the literature, was consistent with the learning curve for the method.

Suspension laryngoscopy is one of the most common otolaryngological procedures for the diagnosis and surgical approach to the larynx. However, most thoracic surgeons are not familiar with the procedure and seldom use it. The indications for its use are similar to those for that of rigid bronchoscopy (dilatation, endoprosthesis insertion, and tumor resection). It can be performed in children and adults. Suspension laryngoscopy is an alternative when rigid bronchoscopy is unavailable and is therefore a viable option for use at smaller facilities. In this communication, we describe the technique and the applications of suspension laryngoscopy in thoracic surgery.

Fistulas in the tracheobronchial tree (bronchopleural and tracheoesophageal fistulas) have a multifactorial etiology and present a variable incidence in the literature. In general, the related morbidity and mortality are high. Once such a fistula has been diagnosed, surgical closure is formally indicated. However, the clinical status of affected patients is usually unfavorable, which precludes the use of additional, extensive surgical interventions. In addition, attempts at endoscopic closure of these fistulas have seldom been successful, especially when the fistula is large in diameter. We report the cases of three patients submitted to endoscopic closure of fistulas, two of which were larger than 10 mm in diameter, by means of the insertion of atrial septal defect occluders. The procedure was minimally invasive, and the initial results were positive. The results indicate that this is a promising technique for the resolution of tracheobronchial tree fistulas.

Objective: To analyze the outcomes of patients undergoing repair of congenital tracheal stenosis., Methods: This was a retrospective review of congenital tracheal stenosis patients treated between 2001 and 2007 at the University of São Paulo School of Medicine Hospital das Clínicas in São Paulo, Brazil., Results: Six boys and one girl (age at diagnosis ranging from 28 days to 3 years) were included. Five of the patients also had cardiac or major vessel malformations. The stenosis length was short in three patients, medium in one and long in three. The techniques used were pericardial patch tracheoplasty in three patients, resection and anastomosis in two, slide tracheoplasty in one and vascular ring correction in one. One patient died during surgery due to hypoxia and hemodynamic instability, and one died from septic shock on postoperative day 11. Other complications included pneumonia, arrhythmia, stenosis at the anastomosis level, residual stenosis, granuloma formation and malacia. The mean follow-up period was 31 months; four patients were cured, and one required the use of a T tube to maintain airway patency., Conclusions: Congenital tracheal stenosis is a curable disease. However, its repair is complex and is associated with high rates of morbidity and mortality.

Objective: To evaluate the Polyflex stent in terms of its efficacy, ease of implantation, and complications in patients with tracheobronchial affections., Methods: This was a prospective study, in which sixteen patients with inoperable tracheal stenosis secondary to orotracheal intubation (n = 12), neoplasia (n = 3), or Wegener's granulomatosis (n = 1) were monitored. Of these patients, eleven were women, and five were men. The mean age was 42.8 years (range, 21-72 years). Patients were submitted to implantation of a total of 21 Polyflex stents. All procedures were carried out in the operating room under general anesthesia, and the stents were implanted via suspension laryngoscopy using the stent applicator., Results: Stents were implanted and symptoms were resolved in all cases. The stents remained in place for a mean period of 7.45 months, ranging from 2 to 18 months. The complications observed in the immediate postoperative period were dysphonia (in two patients, 12.5%) and odynophagia (in two patients, 12.5%). Late complications were cough (in ten patients, 62.5%), migration (in seven patients, 43.75%), granuloma formation (in two patients, 12.5%), and pneumonia (in one patient, 6.25%)., Conclusion: The Polyflex stent is easily implanted, easily removed, well tolerated by patients and effective in resolving symptoms. However, its use is associated with a high rate of migration, especially in patients with post-orotracheal intubation stenosis.

This is a prospective study involving 300 persons with lung cancer admitted to the "Arnaldo Vieira de Carvalho" Cancer Institute (ICAVC). The intention of the survey was to detect delay in diagnosis after the initial symptoms. THe authors tried to identify causes of this delay and its implications. Patients were asked about the day that the symptoms started, medical care and specialists sought, number of physicians seen and their diagnosis, also examinations carried out and referrals. Results showed that 78% of cases were seen firstly by general practitioners and 69.6% looked for medical assistance at least 30 days after the clinical beginning of the disease. Chest X-rays could identify only 9 cases (3%) without symptoms. The most common clinical diagnoses were: pneumonia (20%), neoplasia (19%), bronchitis/emphysema (9.3%) and tuberculosis (8%). The number of first appointments seen by the Public Health Services and Contracted Private Hospital Network was 64.1% and the second appointment was 70%. Only 24 (8%) of the patients were referred to ICAVC just after their first appointment and 64.4% after the third. The time lost between the first appointment and the diagnosis was longer than 90 days in 55.7% of cases. These people needed to see 3 to 4 doctors (as an average) to obtain a positive diagnosis. The diagnostic techniques used more frequently were bronchoscopy (59.7%) and fine needle lung biopsy (18.4%) and the delay was 20 and 10 days on average, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors try to identify causes of delay in the diagnosis of lung cancer, such causes being liable for low survival rates in five years. With this in mind, they developed a prospective study involving 100 patients admitted to the "Arnaldo Vieira de Carvalho" Cancer Institute, who were asked as to the date symptoms started, medical care searched, first diagnostic impressions, and number of physicians seen till the moment of diagnosis. They observed that 73 patients looked for medical assistance up to the 30th day from the beginning of disease, and only in 10 occasions this interval was longer than 120 days. 46 patients had a confirmed diagnosis in less than 90 days after their first medical appointment, and in 41 cases the delay in diagnosis was longer than 4 months. Upon the first exam with the physician, neoplasia was suspected 25 times, but only 11 patients were immediately referred to the Cancer Institute. Of the remaining 89 patients, 57 were referred only after their third medical appointment. 80 patients were first seen by general practitioners and, on average, patients went to 3 or 4 physicians to obtain a definite diagnosis. The most commonly used method to identify neoplasia was bronchofibroscopy (67 cases), with an average of 20 days of delay for its performance. Lung biopsy using transparietal fine needle was the second most used (14 cases), with an average delay of 10 days. The authors conclude that delay in the diagnosis is mostly due to the inadequacy of medical services, delay in referrals and in the performance of subsidiary tests.(ABSTRACT TRUNCATED AT 250 WORDS)