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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 54-58

Clinical profile and diagnosis of tracheal bronchus among patients undergoing fiberoptic bronchoscopy in a tertiary level health facility


1 Department of Pulmonary Medicine, DM Wayanad Institute of Medical Sciences, Wayanad, Kerala, India
2 Department of Internal Medicine, DM Wayanad Institute of Medical Sciences, Wayanad, Kerala, India

Date of Submission07-Jul-2021
Date of Acceptance24-Aug-2021
Date of Web Publication17-May-2022

Correspondence Address:
Dr. Sanjeev Shivashankaran
Department of Pulmonary Medicine, DM Wayanad Institute of Medical Sciences, Wayanad, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jalh.jalh_17_21

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  Abstract 


Background: Tracheobronchial anomalies are rare clinical entities and often asymptomatic in nature. Some patients may experience symptoms such as cough, recurrent pneumonia, or hemoptysis. Tracheal bronchus is one of the rarer forms of tracheobronchial anomalies, which may be seen during routine bronchoscopy. Knowledge and understanding of tracheal bronchus is important for diagnosing symptomatic patients and performing certain procedures, including bronchoscopy and endotracheal intubation. Objective: The objective is to study the clinical profile, diagnosis, and management of tracheal bronchus detected during routine bronchoscopy in a tertiary care setting. Methods: This study was a retrospective analysis of hospital data of patients undergoing fiberoptic bronchoscopy for 2 years in a tertiary care setting. Results: There were 150 bronchoscopies performed during the period. A total of 42 anomalies were detected in 35 (23.33%) patients. Three patients had tracheal bronchus (2%). Conclusions: This retrospective study evaluated the presence of tracheal bronchus among patients who underwent bronchoscopy in a tertiary care hospital in Kerala, India. This study revealed that tracheal bronchus was present in 2% of all bronchoscopies done during that period.

Keywords: Supernumerary bronchus, tracheal bronchus, tracheobronchial anomalies


How to cite this article:
Shivashankaran S, Prakash SM, Shyvin K S, Kesavan S, Chetambath R. Clinical profile and diagnosis of tracheal bronchus among patients undergoing fiberoptic bronchoscopy in a tertiary level health facility. J Adv Lung Health 2022;2:54-8

How to cite this URL:
Shivashankaran S, Prakash SM, Shyvin K S, Kesavan S, Chetambath R. Clinical profile and diagnosis of tracheal bronchus among patients undergoing fiberoptic bronchoscopy in a tertiary level health facility. J Adv Lung Health [serial online] 2022 [cited 2022 Jul 6];2:54-8. Available from: http://www.jalh.com/text.asp?2022/2/2/54/345374




  Introduction Top


Several congenital branching anomalies affecting the trachea, main bronchi, and intermediate bronchus have been reported, all of which can be recognized by bronchoscopy or by chest computed tomography (CT). These anomalies are often overlooked. Variations in the pattern of bronchial tree are, for the most part, due to displacement of segmental and subsegmental bronchi. The main embryonic hypothesis for congenital bronchial anomalies is reduction, migration, and selection theories.[1] It is estimated that the incidence of trachea–bronchial anomalies ranges from 1% and 12%.[2],[3],[4] Most important tracheobronchial anomalies or variations are tracheal bronchus, accessory cardiac bronchus, bronchial diverticula, absent bronchus, and supernumerary bronchus. Tracheal bronchus is a rare anomaly with a prevalence of 0.1%–2% for right tracheal bronchus and 0.3%–1% for left tracheal bronchus.[5] In general, these variations are a rare clinical entity owing to the fact that most of these anomalies are asymptomatic in nature and escape detection. However, these anomalies can be responsible for pulmonary symptoms such as dyspnea, recurrent pneumonia, and hemoptysis. These anomalies may cause inconveniences during procedures, such endotracheal intubation and bronchoscopy. It is essential that these anomalies are recognized before lung resection to avoid complications, especially when video-assisted thoracoscopic surgery is performed. This study evaluated the demographics, clinical profile, diagnosis, and management of tracheal bronchus in patients undergoing fiberoptic bronchoscopy in a tertiary care hospital during a period of 2 years.

Aim of the study

The aim is to study the demographic features, clinical profile, diagnosis, and management of tracheal bronchus among patients undergoing fiberoptic bronchoscopy in a tertiary care setting in Kerala.


  Methods Top


Our study was a retrospective study in which data of all patients who underwent fiberoptic bronchoscopy performed in the department of pulmonary medicine, of a teaching hospital for a period of 2 years, were collected and analyzed. Each bronchoscopic procedure was performed by a skilled pulmonologist. After prior explained consent for the procedure, bronchoscopy was performed using fiberoptic bronchoscope (Olympus BF1T 150). Clinical details, primary diagnosis, radiologic findings, and bronchoscopic findings from images and videos were studied. The total number of cases performed during the study period was 150. We analyzed major tracheobronchial variations in these 150 cases. The protocol for the research project has been approved by the institutional ethics committee. Data collected from bronchoscopy were documented in Microsoft Excel format. Statistical analysis was performed using IBM SPSS Modeler Version 16. Presence of tracheal bronchus and its percentage were recorded. Demographic details, clinical features, other diagnostic tests, and management offered were captured from the hospital records. Statistical significance for age and sex of the patients was calculated using Chi-square test.


  Results Top


Authors reviewed bronchoscopy reports of 150 patients comprising 110 males and 40 females. Major tracheobronchial variations were observed in 35 patients, contributing to a prevalence of 23.33% [Figure 1]. Multiple anomalies were present in the bronchial tree of 7 patients, making a total of 42 anomalies. Out of 110 male patients, 26 (23.6%) were found to have tracheobronchial anomalies, while among 40 females studied, 9 patients (22.5%) had anomalies [Table 1]. There were 109 patients aged >50 years and 41 patients aged ≤50 years. Among patients with age >50 years, 22.93% had tracheobronchial anomalies. 24.39% of the patients aged ≤50 years had tracheobronchial anomalies [Table 2]. Statistical significance for age and sex of the patients was calculated using Chi-square test. It was found that there was no statistical significance between these demographic variables and presence of anomalies. Tracheal bronchus was found in three patients [Table 3]. Tracheal bronchus constituted 2% of total bronchoscopy and 7.14% of all the anomalies detected in this series [Figure 2]. Among this, two patients were males and one was a female. All the three tracheal bronchi were seen on the right side. All the three patients had symptoms attributable to tracheal bronchus.
Figure 1: Diagram demonstrating the various tracheobronchial anomalies

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Figure 2: Diagram demonstrating the percentage of tracheal bronchus

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Figure 3: X-ray chest posteroanterior view showing homogenous opacity right upper zone in the paratracheal region

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Figure 4: Bronchoscopic visualization of tracheal bronchus. Necrotic material is seen in the lumen

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Figure 5: High-resolution computed tomography thorax axial window showing collapse consolidation of a subsegment of the right upper lobe. Tracheal bronchus can be traced

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Figure 6: X-ray chest posteroanterior view showing ill-defined opacity in the right paratracheal region

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Figure 7: Bronchoscopy showing right tracheal bronchus. Tracheal mucosa is congested and inflamed

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Figure 8: High-resolution computed tomography thorax showing bilateral nodular shadows. Tracheal bronchus is also seen

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Figure 9: Bronchoscopic picture showing right tracheal bronchus

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Table 1: Gender distribution of tracheobronchial anomalies

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Table 2: Age group distribution of tracheobronchial anomalies

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Table 3: Demography, clinical features, diagnosis, and management of tracheal bronchi in this series

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  Discussion Top


Tracheobronchial development begins early in fetal life. It is estimated that the prievalence of tracheobronchial anomalies ranges from 1% to 12%.[2],[3],[4] In this study, we retrospectively analyzed the bronchoscopy reports of 150 patients comprising 110 males and 40 females. Major tracheobronchial variations were observed in 35 patients, contributing to a total of 42 anomalies. Tracheobronchial anomalies detected constitute 23.33%. This is higher than the prevalence reported in various studies. This may be explained by the fact that population in this district constitutes many closed communities among tribes. Most congenital tracheobronchial anomalies are asymptomatic and are discovered incidentally. Authors observed tracheal bronchus in three patients (2%) on the right side, contributing to 7.14% of all anomalies. Mean age of the patients was 50.6. Among them, two patients were males and one was a female. Two patients presented with fever, cough with expectoration, and right upper lobe pneumonia. Third patients presented with fever, hypotension, hypoxemia, and bilateral bronchopneumonia. Tracheal bronchus was also associated with abnormal branching pattern of the bronchi. The term “tracheal bronchus” encompasses a variety of bronchial anomalies originating from the trachea or main bronchus and directed to the upper lobe territory.[6],[7] A prevalence of 0.1%–2% for right tracheal bronchus and 0.3%–1% for left tracheal bronchus has been reported.[5] This study is also in conformity with the above statistics. However, we could not detect any left-sided tracheal bronchus among our subjects. A bronchus abnormally originating directly from the trachea is exposed to additional risks during tracheal intubation, such as lobar or segmental atelectasis due to luminal occlusion by the tube or respiratory failure due to inadvertent intubation of the tracheal bronchus.[8],[9] Clinically tracheal bronchus may be associated with recurrent pneumonia, stridor, or respiratory distress in children.[10]


  Conclusions Top


Tracheal bronchus was seen in 2% of all bronchoscopies in this institute. All the three patients were symptomatic and tracheal bronchus could be attributed to their symptoms. Awareness of the presence of tracheal bronchus is important as it can cause difficulty in performing certain procedures, including bronchoscopy and endotracheal intubation.

Limitation

This is a hospital-based study and hence did not reflect the prevalence in the community.

Acknowledgment

Authors would like to thank the Dean and Medical Superintendent for permitting to use the hospital data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ghaye B, Szapiro D, Fanchamps JM, Dondelinger RF. Congenital bronchial abnormalities revisited. Radiographics 2001;21:105-19.  Back to cited text no. 1
    
2.
Lemoine JM, Gagnon A. Main modes of division and anatomical abnormalities of the trachea and bronchi. Bronches. 1952;2:409-21. [Google Scholar].  Back to cited text no. 2
    
3.
Laforet EG, Starkey GW, Scheff S. Anomalies of upper lobe bronchial distributions. J Thorac Cardiovasc Surg 1962;43:595-606.  Back to cited text no. 3
    
4.
Atwell SW. Major anomalies of the tracheobronchial tree: With a list of the minor anomalies. Dis Chest 1967;52:611-5.  Back to cited text no. 4
    
5.
Guillaume C, Baptist M, Elodie C. Tracheobronchial branching abnormalities: Lobe based classification scheme. Radiographics 2016;36:2.  Back to cited text no. 5
    
6.
Boyden EA. Segmental Anatomy of the Lungs. New York: McGraw-Hill; 1955.  Back to cited text no. 6
    
7.
Applegate KE, Goske MJ, Pierce G, Murphy D. Situs revisited: Imaging of the heterotaxy syndrome. Radiographics 1999;19:837-52; discussion 853-4.  Back to cited text no. 7
    
8.
Ming Z, Lin Z. Evaluation of tracheal bronchus in Chinese children using multidetector CT. Pediatr Radiol 2007;37:1230-4.  Back to cited text no. 8
    
9.
O'Sullivan BP, Frassica JJ, Rayder SM. Tracheal bronchus: A cause of prolonged atelectasis in intubated children. Chest 1998;113:537-40.  Back to cited text no. 9
    
10.
Panigada S, Sacco O, Girosi D, Tomà P, Rossi GA. Recurrent severe lower respiratory tract infections in a child with abnormal tracheal morphology. Pediatr Pulmonol 2009;44:192-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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