© 2002 American Thoracic Society
Serendipity Times TwoFiberoptic Bronchoscopy Becomes a Medical ProcedureMount Sinai Medical Center, Miami Beach, and Non-Invasive Monitoring Systems, Inc., North Bay Village, Florida Correspondence and requests for reprints should be addressed to Marvin A. Sackner, M.D., Chairman, Board of Directors, Non-Invasive Monitoring Systems, Inc., 1666 Kennedy Causeway, Suite 400, North Bay Village, FL 33141. E-mail: artchive{at}msn.com In early 1970, I was asked to comment on an article dealing with pulmonary function after rigid bronchoscopy that was to be presented during the annual meeting of The American Broncho-Esophagological Association at the Hollywood Beach Hotel. When the day arrived, I realized that I did not have precise directions to the hotel and decided to leave earlier from Miami Beach, where I lived, than the expected time to drive to Hollywood Beach. I arrived early and entered the conference room during a presentation that immediately preceded the one on which I was scheduled to comment. I slipped into a chair in the darkened room. I viewed a remarkable series of color photographs of segmental and smaller airways while listening to a Japanese physician describing them in halting English. It was an amazing serendipitous experience akin to seeing a great work of art for the first time. The speaker was Dr. S. Ikeda, the inventor of the Olympus flexible bronchofiberscope. He was showing images of distal airways obtained after passing it through a rigid bronchoscope. I became excited thinking about the applications that this new technique, which I was learning about for the first time, would bring to the diagnosis of diseases within airways beyond the reach of the rigid bronchoscope. After I discussed the pulmonary function article at the meeting, I went to the Olympus booth and asked the salesman if he could present the instrument before our thoracic surgeons after the meeting ended. He agreed, and I called an afternoon meeting of the surgeons, along with my associates and trainees in pulmonary disease the next day. The salesman showed the same slides as Dr. Ikeda and also brought an instrument for demonstration. However, the surgeons did not see much advantage to the technique over rigid bronchoscopy. This was an unexpected defeat, but at that moment, I could not think of any alternatives. In most institutions at that time, thoracic surgeons and/or otolaryngologists were permitted to carry out bronchoscopies. Pulmonary physicians rarely had that privilege, and when they did, it was generally confined to tuberculosis sanatoriums. I felt that the bronchofiberscope could revolutionize the practice of pulmonary medicine but did not know how to promote its use. In the fall of 1970, I came up with a scheme for putting the bronchofiberscope into the hands of the pulmonary physician for observations in intubated patients on mechanical ventilators. With another serendipitous event came my recognition of the obstructive sleep apnea syndrome for the first time in America. I hit on a means to insert this instrument without prior insertion of a rigid bronchoscope. Our publication of the transnasal insertion for the bronchofiberscope in May 1971 was the first article to describe the use of this instrument in the practice of pulmonary medicine (1). The path to this first publication was complex. It involved serendipity and understanding that most good ideas in medicine flow from observations made of patients whom a physician cares for in clinical practice. The solution to medical problems is generally easy; precise identification of the problem is often difficult. In my experience, it is the identification of the problem that forms the basis for conception of an invention not its solution. I came up with the first use of bronchofiberoscopy without inserting it through a rigid bronchoscope by reflecting on airway management of patients supported by mechanical ventilators. At that time, there was heated debate about the length of time an endotracheal tube could safely be left in place and when to perform tracheostomy. I reasoned that the endotracheal tube was analogous to a bronchoscope as an entry to the airways, and by inserting the bronchofiberscope through a slit of a latex membrane on a T-tube adapter to the endotracheal tube, it would be possible to visualize safely the trachea under the cuff and check for damage. I sold this idea to the surgeons who thought the information would help in management of long-term ventilator-dependent postoperative chest and cardiac patients. I purchased a fiberoptic bronchoscope out of research funds, and we were in business. Together with my fellows, we went into the animal laboratory to test this hypothesis and confirmed the safety of this means of exploring the airways. Furthermore, we gained skills in manipulating the fiberoptic bronchoscope in the airways. This study of cuff damage was subsequently published (2). In March 1970, Dr. Edward Michaelson paid me a visit. He had been a medical student rotating through my laboratory and now was a Major at Wilford Hall at Lackland Air Force Base in Texas. He told me about a perplexing case that he had treated: a young, obese man with daytime hypersomnolence, intermittent apneas during sleep, and congestive heart failure. These features partially responded to weight-reduction therapy and diuretics but on discharge the patient gained weight and became overtly symptomatic. The apneas completely ceased with placement of an endotracheal tube and he subsequently did well with a fenestrated tracheostomy tube. Michaelson told me that the findings suggested upper airway obstruction but that the mechanism and site of the obstruction were unclear. I told him that I had never observed a similar presentation and could not provide any novel ideas. In April 1970, a few weeks after Michaelson's visit, I was paged by Dr. Zighelboim, the pulmonary fellow on call, while attending the Jai Lai matches at the Miami Fronton. Ordinarily, physicians were not paged there, so the calling of my name over the loudspeaker system jarred me, particularly as I was ahead on the bets. I picked up the telephone and spoke to Zighelboim who asked for advice in managing an obese patient who was stuporous and in respiratory acidosis. He and the attending anesthesiologist were unable to insert an endotracheal tube to establish an airway. He told me that attempts to ventilate the patient using a facemask and a volume-limited ventilator revealed no chest movements even with pressures of 60 cm H2O after a few unimpeded breaths. I immediately recalled Michaelson's patient and told him that I would rush to the hospital. I confirmed Zighelboim's findings and realized that this patient was another example of what would turn out to be the first cases of the obstructive sleep apnea syndrome reported in the American scientific literature (3). I subsequently learned that Gastaut and associates (4) had described the syndrome in 1966, although they took the tack that the findings were responsible for the Pickwickian syndrome. We successfully intubated the patient to bypass the upper airway obstruction, causing relief of respiratory acidosis. After treating his heart failure, we extubated him and confirmed the soft tissue site of upper airway obstruction with cinefluoroscopy. Once the cause was recognized, a nonsurgical solution to the upper airway obstruction became obvious. A soft latex nasopharyngeal airway was inserted at night, and by the next morning, the patient said he felt more rested on arising from sleep than he had felt in many years. While doing the study of damage to the trachea because of endotracheal cuff inflation, I realized the importance of suctioning secretions and that undirected, transnasal insertion of a suction catheter could not be relied on to enter the airways. Now that I had knowledge about the soft latex nasopharyngeal airway, it seemed that this device would be an ideal conduit for inserting suction catheters. To test this hypothesis, we set up an experiment using nasopharyngeal airways in both nostrils, one for a suction catheter and the other for a fiberoptic bronchoscope. We placed the fiberoptic bronchoscope above the vocal cords to see whether the nasopharyngeal airway directed the catheter through the vocal cords. We found that the distal tip of the airway was positioned just above the glottis and directed the suction catheter through the vocal cords in 83% of attempts in eight volunteers and two comatose patients. If the catheter directed through the nasopharyngeal airway entered the trachea so often, then the bronchofiberscope might take the same route. We began using the nasopharyngeal airway for inserting the bronchofiberscope for removal of bronchial secretions in nonintubated patients. This led to other uses that we listed in our first publication, such as selective aspiration of mucus plugs or abscesses, selective sputum cultures of the lower respiratory tract, visualization of tumors and foreign bodies, observation of tracheobronchial collapse and stenosis, and localization of hemoptysis. We wrote an article describing the transnasal insertion of the flexible fiberoptic bronchoscope with the applications to date and submitted it to the New England Journal of Medicine. I even called a member of the editorial board to alert him about the far-reaching potential of this new tool. The journal rejected the manuscript with the reviewers commenting that "the fiberoptic bronchoscope was an interesting diagnostic device but didn't offer much an advantage over rigid bronchoscopy equipped with mirrors to visualize distal airways, there was no control over the airways for bleeding problems, and the transnasal approach did not have any advantage over using rigid bronchoscopic insertion which in the reviewer's hands was a benign, comfortable procedure." After receiving this review, I decided that the medical world would have to be fed smaller doses of what I perceived would be a great advance in the practice of pulmonary medicine. Thus, we wrote the article on which this essay is based as a first step and then published a series of articles on clinical and research applications of fiberoptic bronchoscopy that culminated in a summary review of applications (5). I chose this article to emphasize that the medical community often meets new ideas with rejection and skepticism. If the idea has merit, persistence and parsing the message into smaller bites will generally lead to its acceptance. The investigator has to have equanimity, as defined by Sir William Osler: "Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity, and consume your own smoke with an extra draft of hard work, so that those about you may not be annoyed with the dust and soot of your complaints." Osler also stated, "One of the first essentials in securing a good-natured equanimity is not to expect too much of the people amongst whom you dwell" (6). REFERENCES
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