Conventional transbronchial needle aspiration: from acquisition to precision

Conventional transbronchial needle aspiration [C-TBNA] is a minimally invasive, safe, and cost-effective technique in evaluating mediastinal lymphadenopathy. Previously we reported that the skills for C-TBNA can be acquired from the books. We studied the learning curve for C-TBNA for a single bronchoscopist at a tertiary-care center where ultrasound technology remains difficult to acquire. We prospectively collected results of the first 99 consecutively performed C-TBNA between December 2009 and 2013. Patients were divided into 3 groups: [I]: First 33, [II]: Next 33 and [III]: Last 33. Results were categorized as malignant, non-malignant or non-diagnostic. Diagnostic yield [DY], sensitivity [SEN], specificity [SPE], positive and negative predictive values [PPV, NPV], and accuracy [ACC] were calculated to learn the learning curve for C-TBNA. Total 99 patients [M:F = 62:37], mean age 58.2 +/- 11.5 years, mean LN diameter 26.9 +/- 9.8 mm underwent C-TBNA. Sixty-nine patients had lymph nodes [LNs] >20 mm in diameter. Final diagnoses were established by C-TBNA in 44 [yield 44.4%], mediastinoscopy 47, transthoracic needle aspiration 5, endobronchial biopsy 2 and peripheral LN biopsy 1. C-TBNA was exclusively diagnostic in 35.4%. Group I: DY: 42.4%, 64.7% in malignancies, 19% in benign conditions [P = 0.008]. SEN, SPE, PPV, NPV, ACC = 70%, 100%, 100%, 66.6%, 78.7%, respectively. Group II: DY: 54.5% [36.4% exclusive], 88.2% in malignancies and 19% benign conditions [P = 0.000]. SEN, SPE, PPV, NPV, ACC=72%, 100%, 100%, 53.3%, 78.7%, respectively. Group III: DY: 36.3% [27% exclusive], 100% in malignancies and 16% in benign conditions. SEN, SPE, PPV, NPV, ACC = 92.3%, 100%, 100%, 95.2%, 97%, respectively. No difference was found in relation to LN size or location and TBNA yield. C-TBNA can be easily learned and the proficiency can be attained with <66 procedures. In selected patients, its exclusivity could exceed 35%

Transbronchial needle aspiration "by the books"

Training for advanced bronchoscopic procedures is acquired during the interventional pulmonology [IP] Fellowship. Unfortunately a number of such programs are small, limiting dissemination of formal training. We studied success of conventional transbronchial needle aspiration [C-TBNA] in the hands of physicians without formal IP training. A technique of C-TBNA was learned solely form the literature, videos and practicing on inanimate models at "Hands-On" courses. Conventional TBNA with 21 and /or 19 gauge Smooth Shot Needles [Olympus [Registered Sign], Japan] was performed on consecutive patients with undiagnosed mediastinal lymphadenopathy. Thirty-four patients [male 23], mean age 54.9 +/- 11.8 years underwent C-TBNA. Twenty- two patients had nodes larger than 20 mms. Suspected diagnoses were malignancy in 20 and nonmalignant conditions in 14. Final diagnoses were malignancy 17, sarcoidosis 4, reactive lymph 12, and tuberculosis 1. Final diagnosis was established by C-TBNA in 14 [11 malignancy, 3 sarcoidosis; yield 41.1%], mediastinoscopy in 14, transthoracic needle aspiration in 3, peripheral lymph node biopsies in 2 and by endobronchial biopsy in 1. Nodal size had an impact on outcome [P=0.000] while location did not [P=0.33]. C-TBNA was positive in 11/20 when malignancy was suspected [yield 55%], while 3/14 when benign diagnosis was suspected [yield 21.4%] [P=0.05]. Sensitivity, specificity, PPV, NPV, and diagnostic accuracy were 66.6%, 100%, 100%, 65% and 79.4%, respectively. There were no complications or scope damage. Conventional-TBNA can be learned by the books and by practicing on inanimate models without formal training and results similar to those published in the literature could be achieved

Pleural effusion following ventriculo-pleural shunt: case reports and review of the literature

Ventriculo-pleural shunt [VPLS] is an acceptable alternative in the management of hydrocephalus. Imbalance between the production and absorption of cerebrospinal fluid an lead to formation of pleural effusion in patient with VPLS and on occasion produce symptoms. Pleural effusion could be a transudate or a non-specific exudate. We report our experience with this modality in relation to formation of pleural effusion and review the literature to make recommendation for its management. Information related to patients' demographics, smoking history, prior pulmonary and occupational history, indication, duration and complications of the VPLS and their management was gathered to substantiate current recommendation with our experience

Cilazapril-induced pleural effusion: a case report and review of the literature

We describe an unusual case of lymphocytic pleural effusion associated with the use of cilazapril, a novel angiotensin-converting-enzyme inhibitor [ACEI]. An 80-year-old male was prescribed cilazapril for hypertension. He subsequently presented with right chest pain and dry cough. He was found to have a lymphocytic pleural effusion on thoracentesis. Extensive workup, including open pleural biopsy, failed to reveal the etiology of the effusion. However, soon after the withdrawal of cilazapril, his clinical symptoms improved and the effusion disappeared. ACEI-induced pleural effusion has only been rarely reported. Drug-induced pleural effusion should be considered when formulating the differential diagnosis in a patient receiving ACEI