This study has been conducted by the Department of Microbiology and Department of Respiratory Medicine, Ganni Subba Lakshmi (GSL) Medical College, Rajahmundry, from February 2007 to May 2010. Our teaching hospital attached to the medical college has thousand beds and is a referral center for TB treatment in this area.
In this study we considered patients with suspected PT, that is, cough of more than two weeks. All the cases — new, old, and default, were considered. Both male and female patients were included. Patients who were not cooperative and children below 14 years were excluded from the study (getting sputum sample was difficult). First, smears were made with the sputum samples to detect AFB as per the Revised National Tuberculosis Control Program (RNTCP) guidelines.[3
] All smears positive for AFB cases were referred to the clinician for anti-tuberculosis treatment (ATT) and smears negative for AFB cases were preceded by FOB, and were then included in the study. Written informed consent was taken from all the individuals participating in the study, as also an endorsement from the Ethical Committee of the institute. An algorithm explains the exact procedures of this study .
The FOB was done by FUJINON-BRO YL2, Japan, transorally, TOPS was used to avoid contamination. The subject was kept fasting for three hours before the procedure. Syrup Codine phosphate 30 ml was given to suppress the cough. Injection Atropine 0.01mg/kg IM was given half an hour before the procedure. Midazolam was given IV, 0.05 mg/kg, as and when required. Bronchodilator, Salbutamol 1 ml + 1 ml normal saline was given via a nebulizer to all these subjects as they had bronchospasm earlier. The subjects were directed to rinse the oral cavity with 2 ml of Lidocaine jelly before the procedure and Lidocaine 2% was liberally used through the channel of FOB, not exceeding 200 mg in total.
Bronchial lavage from the affected segment, brush smear, and post scopy sputum were also collected for smear examination to detect AFB by Ziehl Neelsen (ZN) staining.
The main features of the study design were:
- The microbiologist picked up the correct portion of the bronchial lavage in the endoscopy room and the samples were examined immediately after ZN staining.
- The total Xylocaine used, on an average, was 3 ml from the vocal cords down to the bronchial tree.
- FOB was done through TOPS, patented by the senior author and manufactured by the Pran Clinic and Co., Rajahmundry, 2004 model. This was a mechanical devise to deliver the aerosol medicine for the symptomatic treatment of bronchial asthma. This was made of ethylene vinyl acetate copolymer. It was 10 cm in length, with a 10 mm internal diameter . There was a universal adapter in front, which had a straight part and an arched section that bent twice with angles of 110° and 150°. As per the Mallampati classification, the oropharynx could be classified into classes I, II, III, and IV, depending upon the patency of the oropharyngeal lumen. Classes III and IV were narrower. In such cases the TOPS was much more useful , as it lifted the uvula , and FOB or blind intubation could be done easily through TOPS. It also snugly fitted into the pharynx, the distal end being just above the epiglottis. The advantage of using this was avoidance of contamination with the oropharyngeal / nasal flora and easy passage of the scope. If there was bleeding, effective toileting could be done and intubation also could be achieved.
The highlight of the study is the use of the Trans Oro Pharyngeal Spacer (TOPS), which is an innovative product, by the senior author. It helps in easy passage of the tube, and bronchoscope bite is avoided. Adding to this, there have been no complaints of discomfort from the patients while passing the scope. As TOPS is the first of its kind no other references are available.