Descripción de las intervenciones broncoscópicas en estenosis traqueales posterior a infección por COVID-19 / Description of Bronchoscopic Interventions in Post-COVID Tracheal Stenosis

Introducción: La infección por SARS-CoV-2 puede presentar síndrome de distrés res-piratorio agudo con requerimiento de ventilación mecánica prolongada y retraso en la realización de traqueostomía. Esto trae como consecuencia un incremento en casos de estenosis traqueal y la necesidad de métodos menos invasivos para su abordaje. Métodos: Estudio descriptivo de corte transversal, desde marzo 2020 hasta diciem-bre 2021 en el Hospital Universitario Nacional de Colombia, en adultos con estenosis traqueal postintubación asociado SARS-CoV-2. Se realizó análisis univariado entre los grupos con infección o no por SARS-CoV-2 como control, y reintervención, grado de estenosis, uso de inyección intramucosa con dexametasona intratraqueal o múltiples estenosis como desenlaces de importancia. Se usó test exacto de Fisher, t Student y Man-Whitney según la naturaleza de variables. Se consideró p estadísticamente significativo menor a 0.05.Resultados: Se identificaron 26 pacientes, 20 tenían COVID-19 y 6 no. Se encontraron diferencias en edad (p=0,002), epilepsia (p=0,007) y estenosis múltiple (p= 0,04). En 85% de los casos se utilizó láser blue más dilatación con balón pulmonar, en 35% inyección intramucosa con dexametasona intratraqueal y reintervención en 35%, sin diferencias significativas entre grupos. Conclusiones: Se observó un incremento tres veces mayor de pacientes con estenosis múltiple en el grupo de infección por COVID-19, así mismo se encontró que el método más utilizado en este grupo para la recanalización fue el uso de láser blue más dilatación con balón pulmonar y la innovación en el uso de inyección intramucosa.

Introduction: SARS-CoV-2 infection can lead to acute respiratory distress syndrome with a prolonged need for mechanical ventilation and delayed tracheostomy, resulting in an increase in cases of tracheal stenosis and the necessity for less invasive approaches.Methods: A descriptive cross-sectional study was conducted from March 2020 to December 2021 at the Hospital Universitario Nacional de Colombia, focusing on adults with post-intubation tracheal stenosis associated with SARS-CoV-2. Univariate analysis was performed between groups with or without SARS-CoV-2 infection as a control, considering reintervention, degree of stenosis, use of intratracheal steroids, or multiple stenoses as important outcomes. Fisher's exact test, Student's t-test, and Mann-Whit-ney test were employed based on the nature of variables. A p-value less than 0.05 was considered statistically significant.Results: A total of 26 patients were included, with 20 having COVID-19 and 6 without. Significant differences were found in age (p=0.002), epilepsy (p=0.007), and multiple stenosis (p=0.04). In 85% of cases, laser blue plus balloon pulmonary dilation was used, intratracheal dexamethasone in 35%, and reintervention in 35%, with no significant differences between groups.Conclusions: A threefold increase in subglottic stenosis was observed during the SARS-CoV-2 pandemic, with more instances of multiple stenosis and predominantly the use of laser blue plus balloon pulmonary dilation as a successful recanalization technique. There was a higher use of intratracheal dexamethasone in this group compared to oth-er pathologies causing tracheal stenosis.

Caracterización de pacientes con cáncer de pulmón en un servicio de neumología / Characterization of patients with lung cancer in a pneumology service i: en

Introducción: El cáncer de pulmón es un problema de salud pública a escala mundial y Cuba no está exenta de este. Objetivo: Caracterizar a los pacientes diagnosticados con cáncer de pulmón según variables clínicas, epidemiológicas y morfológicas. Métodos: Se realizó un estudio transversal, descriptivo y retrospectivo de los 145 adultos diagnosticados con cáncer de pulmón en el Servicio de Neumología del Hospital General Docente Dr. Juan Bruno Zayas Alfonso de Santiago de Cuba, desde enero del 2018 hasta diciembre del 2019. A tal efecto, en el procesamiento estadístico se emplearon como medidas de resumen el porcentaje y la media para variables cualitativas y cuantitativas, respectivamente; asimismo, se aplicaron el coeficiente kappa para establecer el grado de concordancia entre datos y la prueba de independencia de la Χ2 para identificar asociación significativa entre los criterios de interés seleccionados (con p<0,05). Resultados: Se obtuvo un predominio del sexo masculino (62,1 %) y el grupo etario de 65-75 años (37,9 %). Respecto a la variedad histológica, resultó más frecuente el carcinoma epidermoide (42,7 %). El pulmón derecho fue el más afectado, específicamente su lóbulo superior (33,8 %); del mismo modo, existieron alteraciones morfológicas, como la infiltración bronquial (100,0 %), la irregularidad y el edema de la mucosa (con 98,5 % en cada caso) y la inflamación con engrosamiento de la pared bronquial (90,3 %). Conclusiones: La determinación de las características clínicas, epidemiológicas y morfológicas relacionadas con el cáncer de pulmón permite efectuar el correcto seguimiento de los pacientes y aplicar un adecuado protocolo terapéutico.

Introduction: Lung cancer is a public health problem worldwide and Cuba is not exempt from it. Objective: Characterize patients diagnosed with lung cancer according to clinical, epidemiological and morphological variables. Methods: A cross-sectional, descriptive and retrospective study was carried out on 145 adults diagnosed with lung cancer in the Pneumology Service of Dr. Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba, from January, 2018 to December, 2019. For this purpose, in the statistical processing, the percentage and mean were used as summary measures for qualitative and quantitative variables, respectively; Likewise, there were applied the kappa coefficient to establish the degree of agreement between data and the Χ2 independence test to identify a significant association between the selected criteria of interest (with p<0.05). Results: There was a predominance of the male sex (62.1%) and the age group of 65-75 years (37.9%). Regarding the histological type, squamous cell carcinoma was more common (42.7%). The right lung was the most affected, specifically its upper lobe (33.8%); also, there were morphological alterations, such as bronchial infiltration (100.0%), mucosal irregularity and edema (with 98.5% in each case), and inflammation with bronchial wall thickening (90.3%). Conclusions: The determination of the clinical, epidemiological and morphological characteristics related to lung cancer makes it possible to carry out the correct follow-up of the patients and apply an appropriate therapeutic protocol.

Criterios broncoscópicos, laboratoriales y anatomopatológicos de enfermedad de la vía aérea en pacientes diagnosticados con granulomatosis con poliangitis / Bronchoscopic, laboratory and anatomopathological criteria for airway disease in patients diagnosed with granulomatosis with polyangiitis

Introducción: los pacientes con granulomatosis con poliangitis (GPA) pueden presentar compromiso de la vía aérea superior (VAS) o inferior (VAI). Objetivos: describimos las manifestaciones endoscópicas de las vías respiratorias, los hallazgos histológicos y los anticuerpos anticitoplasma de neutrófilos (ANCA) en un grupo de pacientes con GPA. Métodos: estudio retrospectivo de historias clínicas de pacientes con GPA sometidos a broncoscopia entre 2012 y 2019. Se analizaron hallazgos de la vía aérea, biopsias y ANCA. Resultados: se incluyeron 40 pacientes, con una edad media de 46,92±17,61 años, predominantemente del sexo femenino (67,5%). Se observó afectación de la vía aérea en el 90% (n=36). El C-ANCA fue reactivo en el 63,9%, P-ANCA en el 25%, ANCA doblemente reactivo en el 8,33% y no reactivo en el 20%. Los hallazgos comunes en la vía aérea superior (VS) fueron sinusitis crónica (41,7%), destrucción del tabique nasal (16,7%); y en la vía aérea inferior (AI): estenosis traqueobronquial (38,9%), traqueobronquitis (25%). Los hallazgos más frecuentes de las biopsias broncoscópicas fueron proceso inflamatorio polimorfonuclear (61,9%) y necrosis geográfica (47,6%). Conclusión: la vía aérea está comprometida hasta en un 90% de los pacientes con GPA. ANCA no reactivos no descartan esta posibilidad. La sinusitis crónica y los procesos fibroestenóticos traqueobronquiales fueron los hallazgos endoscópicos más comunes. La vasculitis en biopsias se encontró en una minoría de casos.

Introduction: patients with granulomatosis with polyangiitis (GPA) may present upper airway (UA) and lower airway (LA) involvement. Objectives: we describe the endoscopic manifestations of the airways, histological findings from biopsied tissue and antineutrophilic cytoplasm antibody (ANCA) in a group of patients with GPA. Methods: retrospective study of medical records of patients with GPA undergoing bronchoscopy between 2012 and 2019. Airway findings, results of biopsies performed and ANCA results were analyzed. Results: 40 patients were included, with a mean age of 46.92±17.61 years and predominantly female (67.5%). Airway involvement was observed in 90% (n=36). The C-ANCA was reactive in 63.9%, P-ANCA in 25%, doubly reactive ANCA in 8.33% and non-reactive in 20%. The findings in upper airway (UA) were: chronic sinusitis (41.7%), destruction of the nasal septum (16.7%); and in lower airway (LA) were: tracheobronchial stenosis (38.9%) and tracheobronchitis (25%). The pathological findings most common of bronchoscopic biopsies were: polymorphonuclear inflammatory process (61.9%) and geographic necrosis (47.6%). Conclusion: the airway is involved in up to 90% of patients with GPA. Non-reactive ANCA does not rule out this possibility. Chronic sinusitis and tracheobronchial fibrostenotic processes were the most common endoscopic findings. Vasculitis in biopsies was found in a minority of cases.

Utilidad del lavado broncoalveolar para la detección microbiológica, y factores asociados, en receptores de trasplante de precursores hematopoyéticos: estudio de cohorte retrospectivo

Introducción: Las opacidades pulmonares en receptores de trasplante de precursores hematopoyéticos (TPH) representan un desafío diagnóstico y son una causa de morbimortalidad. Existen grandes discrepancias con respecto a la sensibilidad diagnóstica del lavado broncoalveolar (LBA), sus complicaciones, y los factores asociados a la identificación microbiológica. Objetivo: Conocer la utilidad del estudio microbiológico del LBA en el diagnóstico, modificación de la conducta médica y estimar las complicaciones y mortalidad asociada al procedimiento, en receptores de TPH con opacidades pulmonares. Pacientes y Métodos: Estudio de cohorte, retrospectivo, en adultos receptores de TPH a los que se les realizó una broncoscopía con LBA por presentar opacidades pulmonares, en el Hospital Italiano de Buenos Aires entre el 01/01/2011 y el 31/12/2020. Resultados: De los 189 procedimientos analizados, en 79 se logró un hallazgo microbiológico (41,8%) y 122 permitieron modificar la conducta médica (64,6%). En 11 casos se observaron complicaciones graves dentro de las 12 horas (5,8%) de efectuado el LBA. La mortalidad intrahospitalaria fue de 16,8% (N = 21/125). El valor de neutrófilos en sangre previo al LBA (p = 0,037) y la presencia de nódulos pulmonares como lesión tomográfica predominante (p = 0,029) se asociaron independientemente al hallazgo microbiològico global. Conclusiones: Nuestra investigación apoya la realización del LBA como herramienta diagnóstica en pacientes que reciben un TPH y presentan opacidades pulmonares.

Background: Lung opacities are a cause of morbimortality in bone marrow transplant patients, and represent a diagnostic challenge. There are large discrepancies regarding the diagnostic sensitivity of bronchoalveolar lavage (BAL), its complications, and the factors associated with microbiological detection. Aim: To know the usefulness of the microbiological study of BAL in the diagnosis, in the modification in medical behavior and to estimate the complications and associated mortality of this diagnostic procedure in patients transplanted with hematopoietic progenitor cells with pulmonary opacities. Methods: Retrospective cohort study in bone marrow transplant adult patients who underwent bronchoscopy with BAL due to lung opacities at Hospital Italiano de Buenos Aires between 01/01/2011 and 12/31/2020. Results: Of the 189 BAL analyzed, 79 presented a microbiological detection (41.8%) and 122 allowed to modify the medical behavior (64.6%). Severe complications were observed within 12 hours after the procedure in11 cases (5.8%). In-hospital mortality was 16,8% (N = 21/125). The value of blood neutrophils prior to bronchoalveolar lavage (p = 0.037) and the presence of pulmonary nodules as the predominant tomographic lesion (p = 0.029) were independently associated with global microbiological detection. Conclusion: Our research supports the performance of BAL as a diagnostic tool in bone marrow transplant patients with lung opacities.

Traqueotomía percutánea guiada por ultrasonografía en tiempo real. Revisión de la literatura / Literature Review. Real-time ultrasonography-guided percutaneous tracheotomy

La traqueotomía percutánea por dilatación es un procedimiento que se realiza en las unidades de paciente crítico, implica la disección roma de los tejidos pretraqueales, seguida de la dilatación de la tráquea sobre la guía y la inserción de la cánula traqueal mediante la técnica de Seldinger. En las últimas décadas, la evidencia sugiere que, en manos de médicos capacitados, es al menos tan segura como la traqueotomía quirúrgica, con similar incidencia de complicaciones. La selección adecuada de pacientes y el uso de herramientas de seguridad complementarias, como broncoscopio o ultrasonido, disminuyen las tasas de falla y complicaciones. Siendo contraindicaciones absolutas para traqueotomía percutánea por dilatación una anatomía anormal, tumor maligno en el sitio de traqueostomía, coagulopatías o vía aérea difícil. La guía mediante broncoscopia permite la evaluación de la profundidad del tubo endotraqueal, confirma la posición de la aguja en el eje de la tráquea y la adecuada inserción del cable guía y dilatador. Entre sus desventajas destacan que, el sitio de punción está sujeto a sesgo y no puede guiar con precisión la aguja en la penetración de la tráquea. La traqueotomía percutánea guiada por ultrasonido es una alternativa validada en unidades, donde no se cuente con broncoscopia. Es un método rápido, seguro, que permite la identificación de estructuras anatómicas, vasculatura cervical, permite identificar el sitio de la punción y guía la inserción de la aguja en la tráquea. Esta técnica presenta altas tasas de éxito al primer intento, reduciendo significativamente el número de punciones.

Percutaneous dilation tracheostomy is a procedure performed in critical patient units. It involves blunt dissection of the pretracheal tissues followed by dilation of the trachea over the guidewire and insertion of the tracheal cannula using the Seldinger technique. In recent decades, evidence suggests that in the hands of trained physicians it is at least as safe as surgical tracheostomy, with a similar incidence of complications. The proper selection of patients and the use of complementary safety tools such as bronchoscope or ultrasound reduce failure rates and complications. Being absolute contraindications for PDT abnormal anatomy, malignant tumor at the tracheostomy site, coagulopathies, or difficult to treat airway. Bronchoscopy guidance allows evaluation of the depth of the endotracheal tube, confirms the position of the needle in the axis of the trachea and the proper insertion of the guide wire and dilator. Among its disadvantages are that the puncture site is subject to slant and cannot accurately guide the needle into the trachea. In addition, it requires Critical Patient Units with bronchoscope and trained personnel. Ultrasound-guided percutaneous tracheotomy is a validated alternative in units where bronchoscopy is not available. It is a fast, safe method that allows the identification of anatomical structures, cervical vasculature, identifies the puncture site and guides the insertion of the needle into the trachea. With high first-attempt success rates, significantly reducing the number of punctures.

Neumonía lipoidea exógena crónica y sobreinfección por Mycobacterium tuberculosis / Chronic Exogenous Lipoid Pneumonia and Superinfection by Mycobacterium Tuberculosis

Introducción: la neumonía lipoidea exógena es una enfermedad pulmonar inflamatoria poco común, desencadenada por la inhalación o aspiración de material graso de origen animal, vegetal o mineral. El diagnóstico se establece a través de confirmación histo-patológica, por la presencia de macrófagos cargados de lípidos en muestras respirato-rias, asociado a las características clínicas específicas al momento de su presentación.Requiere de un alto nivel de sospecha y una adecuada anamnesis de los antecedentes exposicionales del paciente debido a que muchos casos son subdiagnosticados y trat-ados como neumonía adquirida en la comunidad, lo que retrasa su diagnóstico y mane-jo, sumado a la ausencia de guías disponibles para su tratamiento.Se han reportado pocos casos de sobreinfección por tuberculosis en pacientes con neu-monía lipoidea exógena crónica. Caso clínico: femenino 33 años, con antecedentes de exposición crónica a sustancias desinfectantes de características aceitosas sin protección de vía aérea, con cuadro de tos y dolor torácico. Conclusión: el diagnóstico temprano, asociado a tratamiento de soporte, general-mente conservador, favorece la mejoría clínica y radiológica, y de esta manera dis-minuye la morbimortalidad. (AU)

Introduction: exogenous lipoid pneumonia is a rare inflammatory lung disease, trigge-red by inhalation or aspiration of fatty material of animal, vegetable or mineral origin. The diagnosis is established through histological confirmation by the presence of lipid-laden macrophages in respiratory samples, associated with the specific clinical charac-teristics at the time of presentation. It requires a high level of suspicion and an adequate anamnesis of the patient's expo-sure history, since many cases are underdiagnosed and treated as community-acquired pneumonia, what delays its diagnosis and management, added to the absence of avai-lable guidelines for its treatment. Few cases of tuberculosis superinfection have been reported in patients with exoge-nous lipoid pneumonia.Clinical case: 33-year-old female, with a history of chronic exposure to oily disinfectant substances without airway protection, with symptoms of cough and chest pain.Conclusion: early diagnosis, associated with supportive treatment, generally conser-vative, favors clinical and radiological improvement, thus reducing morbidity and mor-tality. (AU)

Diagnostic performance of cryobiopsy guided by radial-probe EBUS with a guide sheath for peripheral pulmonary lesions / Desempenho diagnóstico da criobiópsia guiada por EBUS radial com bainha guia para lesões pulmonares periféricas

ABSTRACT Objective: Transbronchial lung cryobiopsy (TBCB) has developed rapidly and has become one of the research hotspots of lung biopsy technology. The present study sought to evaluate the efficacy of TBCB guided by radial-probe EBUS (RP-EBUS) and a guide sheath (GS) without fluoroscopy for peripheral pulmonary lesions. Methods: In this retrospective study, McNemar's test was used in order to compare TBCB and transbronchial forceps biopsy (TBFB) in terms of diagnostic performance. A multivariate logistic regression model was designed to explore the association between predictive variables and the diagnostic yield of TBCB. Results: A total of 168 patients underwent GS-guided RP-EBUS. Of those, 157 had lesions that were visible and 11 had lesions that were not. Of those 157 patients, 24 were excluded because of missing data or an unclear final diagnosis. Therefore, 133 patients underwent RP-EBUS-GS-guided TBFB and TBCB. The pooled diagnostic yield of RP-EBUS-GS-guided TBCB without fluoroscopy was 71.5% (103/144). In 133 patients, the diagnostic yield of TBCB was significantly higher than that of TBFB (77.4% vs. 59.4%; p < 0.05). Multivariate analysis indicated that lesion size and site were independently associated with the diagnostic yield of TBCB (OR = 2.8, p = 0.03 and OR = 4.1, p = 0.01, respectively), although cryoprobe size was not. There was no significant difference between the 1.1-mm cryoprobe and the 1.9-mm cryoprobe in terms of diagnostic performance (78.4% vs. 76.8%; p > 0.05). Conclusions: GS-guided RP-EBUS is regarded as a practical option for guiding cryobiopsy, although it may not be able to replace fluoroscopy. Peripheral pulmonary lesions not located in the upper lobes or larger than 30 mm are significantly associated with a higher diagnostic yield of cryobiopsy.

RESUMO Objetivo: A criobiópsia transbrônquica (CBTB) desenvolveu-se rapidamente e tornou-se um dos focos de pesquisa de tecnologia de biópsia pulmonar. O presente estudo buscou avaliar a eficácia da CBTB guiada por EBUS radial com bainha guia sem fluoroscopia no diagnóstico de lesões pulmonares periféricas. Métodos: Neste estudo retrospectivo, o teste de McNemar foi usado para comparar a CBTB e a biópsia transbrônquica com pinça (BTB) quanto ao desempenho diagnóstico. Um modelo de regressão logística multivariada foi criado para explorar a relação entre variáveis preditivas e o rendimento diagnóstico da CBTB. Resultados: Um total de 168 pacientes foram submetidos a EBUS radial com bainha guia. Destes, 157 apresentavam lesões que puderam ser visualizadas e 11 apresentavam lesões que não puderam ser visualizadas. Dos 157 pacientes, 24 foram excluídos em virtude de dados incompletos ou diagnóstico final incerto. Portanto, 133 pacientes foram submetidos a BTB e CBTB guiadas por EBUS radial com bainha guia. O rendimento diagnóstico combinado da CBTB guiada por EBUS radial com bainha guia foi de 71,5%. O rendimento diagnóstico da CBTB foi significativamente maior que o da BTB (77,4% vs. 59,4%; p < 0,05). A análise multivariada indicou que o tamanho e o local da lesão apresentaram relação independente com o rendimento diagnóstico da CBTB (OR = 2,8, p = 0,03 e OR = 4,1, p = 0,01, respectivamente); o tamanho da criossonda, por sua vez, não apresentou relação com o rendimento diagnóstico da CBTB. Não houve diferença significativa entre a criossonda de 1,1 mm e a de 1,9 mm no que tange ao desempenho diagnóstico (78,4% vs. 76,8%; p > 0,05). Conclusões: EBUS radial com bainha guia é uma opção prática para guiar a criobiópsia, embora talvez não possa substituir a fluoroscopia. Lesões pulmonares periféricas que não estejam nos lobos superiores ou que tenham mais de 30 mm apresentam relação significativa com maior rendimento diagnóstico da criobiópsia.

Predictive factors for improved diagnostic accuracy with the use of radial-probe EBUS / Fatores preditivos de maior precisão diagnóstica com EBUS com sonda radial

ABSTRACT Objective: To assess predictive factors for improved diagnostic accuracy with the use of radial-probe EBUS (RP-EBUS). Methods: This was a retrospective review of consecutive patients undergoing RP-EBUS between February of 2012 and January of 2020. Parameters including the presence of a bronchus sign on CT scans, the position of the radial EBUS probe, lesion size, lesion location, and lesion type were analyzed in relation to two defined outcomes (final diagnosis or no diagnosis). Univariate analysis was used in order to explore the individual effects of each parameter on diagnostic accuracy. Multivariate logistic regression was performed to identify significant predictors of diagnostic accuracy. Results: RP-EBUS was used for diagnostic purposes in 101 patients. The lesion was < 3 cm in size in 59 patients (58.4%) and predominantly solid in 60.3%. There was a positive correlation between radial EBUS probe position and diagnostic accuracy (p = 0.036), with 80.9% of the patients showing a bronchus sign on CT scans. Furthermore, 89% of the patients showed a bronchus sign on CT scans and a correlation with diagnostic accuracy (p = 0.030), with 65.8% of the lesions being located in the left/right upper lobe (p = 0.046). When the radial EBUS probe was within the target lesion, the diagnostic yield was = 80.8%. When the probe was adjacent to the lesion, the diagnostic yield was = 19.2%. A bronchus sign on CT scans was the only parameter that independently influenced diagnostic accuracy (adjusted OR, 3.20; 95% CI, 1.081-9.770; p = 0.036). Conclusions: A bronchus sign on CT scans is a powerful predictor of successful diagnosis by RP-EBUS.

RESUMO Objetivo: Avaliar fatores preditivos de maior precisão diagnóstica com EBUS com sonda radial. Métodos: Revisão retrospectiva de pacientes consecutivos submetidos a EBUS radial entre fevereiro de 2012 e janeiro de 2020. Parâmetros como a presença do sinal brônquico na TC, a posição da sonda radial de EBUS, o tamanho da lesão, a localização da lesão e o tipo de lesão foram analisados em relação a dois desfechos definidos (diagnóstico final ou sem diagnóstico). A análise univariada foi usada para explorar os efeitos individuais de cada parâmetro na precisão do diagnóstico. A regressão logística multivariada foi realizada para identificar preditores significativos de precisão diagnóstica. Resultados: O EBUS radial foi usado para fins diagnósticos em 101 pacientes. A lesão era < 3 cm em 59 pacientes (58,4%) e predominantemente sólida em 60,3%. Houve correlação positiva entre a posição da sonda radial de EBUS e a precisão do diagnóstico (p = 0,036), sendo que 80,9% dos pacientes apresentaram o sinal brônquico na TC. Além disso, 89% dos pacientes apresentaram o sinal brônquico na TC e correlação com a precisão do diagnóstico (p = 0,030), sendo que 65,8% das lesões localizavam-se no lobo superior esquerdo/direito (p = 0,046). Com a sonda radial de EBUS dentro da lesão-alvo, o rendimento diagnóstico foi de 80,8%. Com a sonda adjacente à lesão, o rendimento diagnóstico foi de 19,2%. O sinal brônquico na TC foi o único parâmetro que influenciou de forma independente a precisão do diagnóstico (OR ajustada = 3,20; IC95%: 1,081-9,770; p = 0,036). Conclusões: O sinal brônquico na TC é um poderoso preditor de diagnóstico bem-sucedido por meio de EBUS radial.

Síndrome de Hamman (neumomediastino) posparto. Síntesis de la bibliografía y reporte de caso / Postpartum Hamman (pneumomediastinal) syndrome. Synthesis of the literature and case report

Resumen ANTECEDENTES: El síndrome de Hamman se caracteriza por la coexistencia de aire libre en el mediastino sin una causa identificable; también puede ser secundario a traumatismos, infecciones intratorácicas, procedimientos médicos como la esofagoscopia y broncoscopia. Su incidencia se estima entre 1 en 2000 y 1 en 100,000 embarazos. CASO CLÍNICO: Paciente de 18 años, con 65 kg de peso, 1.56 m de talla e IMC 26.74, correspondiente a sobrepeso, primigesta, sin antecedentes patológicos ni heredofamiliares relevantes, con evolución normal del embarazo. A las 39 semanas acudió a urgencias ginecológicas debido a contractilidad uterina y salida de líquido por la vagina. La finalización del embarazo fue por parto, con recién nacido vivo. En el puerperio mediato (30 horas después del parto) súbitamente tuvo disnea, ortopnea y dolor en la región infraclavicular, sensación de "burbujeo" en la parte anterior del tórax. La radiografía simple de tórax mostró aire libre en el mediastino y enfisema subcutáneo. La TAC de tórax evidenció múltiples burbujas de aire, con extensión del espacio perivertebral de predominio derecho. La conclusión diagnóstica fue: enfisema extenso subcutáneo en los espacios del cuello, con alcance al mediastino anterior, con extenso neumomediastino y cardiomegalia global. CONCLUSIONES: El síndrome de Hamman prevalece en primigestas jóvenes y tiene un curso benigno. El tratamiento debe ser conservador, con oxígeno y analgésicos.

Abstract BACKGROUND: Hamman's syndrome is characterized by the coexistence of free air in the mediastinum without an identifiable cause; it may also be secondary to trauma, intrathoracic infections, medical procedures such as oesophagoscopy and bronchoscopy. Its incidence is estimated to be between 1 in 2000 and 1 in 100,000 pregnancies. CLINICAL CASE: 18-year-old female patient, weight 65 kg, height 1.56 m and BMI 26.74, corresponding to overweight, primigravida, with no relevant pathological or heredofamilial history, with normal evolution of pregnancy. At 39 weeks, she attended the gynaecological emergency department due to uterine contractility and leakage of fluid from the vagina. The pregnancy was terminated by delivery, with a live newborn. In the immediate postpartum period (30 hours after delivery) she suddenly experienced dyspnoea, orthopnoea and pain in the infraclavicular region, with a sensation of "bubbling" in the anterior chest. Plain chest X-ray showed free air in the mediastinum and subcutaneous emphysema. Chest CT showed multiple air bubbles, with extension of the perivertebral space predominantly on the right. The diagnostic conclusion was: extensive subcutaneous emphysema in the neck spaces extending into the anterior mediastinum, with extensive pneumomediastinum and global cardiomegaly. CONCLUSIONS: Hamman syndrome is prevalent in young primigravidae and has a benign course. Treatment should be conservative, with oxygen and analgesics.

Aspergilosis pulmonar crónica necrotizante

Introducción: La aspergilosis crónica necrotizante es una enfermedad infrecuente que se caracteriza por ser un proceso destructivo y crónico en el parénquima pulmonar. Se clasifica en cavitaria, necrotizante y fibrosante. Objetivo: Presentar una paciente con aspergilosis crónica necrotizante, sus características clínicas, diagnósticas y procedimiento terapéutico empleado. Caso clínico: Paciente femenina de 20 años de edad con antecedentes de asma bronquial que hace 6 meses presenta tos con expectoración amarrilla; realizó varios ciclos de antibióticos con poca mejoría clínica, un mes atrás comenzó con fiebre de 38 ºC, falta de aire y hemoptisis. Se ingresó en la sala de neumología con la sospecha de tuberculosis pulmonar o micosis pulmonar. Se estableció el diagnóstico definitivo de aspergilosis crónica necrotizante, a través de la tinción de Grocott y ácido peryódico de Schiff, los esputos micológicos y la tomografía axial computarizada. Se instauró tratamiento con anfotericina B liofilizada, por 21 días y luego itraconazol por vía oral, por 3 meses; la evolución fue satisfactoria. Conclusiones: La sospecha clínica y la confirmación, tanto radiológica como micológica en todo paciente con manifestaciones clínicas de evolución insidiosa y escasa respuesta a los antibióticos, es fundamental para llegar al diagnóstico de aspergilosis pulmonar.

Introduction: Chronic necrotizing aspergillosis is a rare disease that is characterized by being a destructive and chronic process in the lung parenchyma. It is classified as cavitary, necrotizing and fibrosing. Objective: To present a patient with chronic necrotizing aspergillosis, her clinical and diagnostic characteristics and the therapeutic procedure used. Clinical case: A 20-year-old female patient with a history of bronchial asthma who had a cough with yellow expectoration 6 months ago; she underwent several cycles of antibiotics with little clinical improvement, a month ago she started with a fever of 38 ºC, shortness of breath and hemoptysis. She was admitted to the pulmonology ward with suspected pulmonary tuberculosis or pulmonary mycosis. The definitive diagnosis of chronic necrotizing aspergillosis was established through Grocott and Schiff periodic acid staining, mycological sputum, and computerized axial tomography. Treatment with lyophilized amphotericin B was established for 21 days and then oral itraconazole for 3 months; the evolution was satisfactory. Conclusions: Clinical suspicion and confirmation, both radiological and mycological in all patients with clinical manifestations of insidious evolution and poor response to antibiotics, is essential to reach the diagnosis of pulmonary aspergillosis.

Plasmocitoma traqueal: Una causa inusual de hemoptisis / Plasmacytoma of the Trachea: an Unusual Cause of Hemoptysis

RESUMEN Presentamos el caso de un paciente afectado por un mieloma múltiple refractario a diversas líneas de tratamiento, que ingresó por hemoptisis causada por la aparición de un plasmocitoma en la tráquea. El hallazgo se produjo por broncoscopia y el diagnós tico y tratamiento se realizó mediante técnicas endoscópicas, con muy buen resultado funcional. El caso es de interés por su escasa frecuencia, así como para dar a conocer a la comunidad este tipo de presentación atípica y su posible manejo.

ABSTRACT We present the case of a patient affected by multiple myeloma refractory to various lines of treatment who was admitted due to hemoptysis caused by the appearance of a plasmacytoma in the trachea. The finding was obtained from a bronchoscopy, and the diagnosis and treatment were made by means of endoscopic techniques, with a very good functional result. This case is of interest because it is unusual and also because it allows us to raise awareness among the community of this atypical presentation and possible managemen

Fuga gaseosa persistente posoperatoria / Posoperative Persistent Gas Leak

Introducción: La fuga gaseosa persistente es la complicación posoperatoria más frecuente en cirugía torácica. En la actualidad no hay estudios con suficiente evidencia científica que permitan establecer una norma para el tratamiento de esta complicación. Objetivo: Ofrecer una actualización de los factores predisponentes de la fuga gaseosa, así como las modalidades de tratamiento que han surgido en los últimos años. Métodos: Se realizó una revisión bibliográfica en bases de datos MEDLINE (PubMed), SciELO, así como Google académico. Se tuvieron en cuenta variables como tipo de resección pulmonar, tiempo quirúrgico, complicaciones posoperatorias, se emplearon las palabras claves en idioma español e inglés y se seleccionaron un total de 44 artículos publicados desde el 1998 hasta el 2020. Desarrollo: Aunque por lo general esta complicación se considera leve, puede llegar a tener una incidencia de un 46 por ciento, asociándose a un aumento en la estadía hospitalaria, con repercusión en el costo sanitario, así como incomodidad y morbilidad para el paciente. En dependencia del momento en que se presente y su localización el tratamiento incluirá diferentes alternativas que abarcan desde la conducta conservadora, hasta diferentes modalidades de pleurodesis, tratamiento endoscópico o quirúrgico. Conclusiones: La resolución de esta entidad se produce en la mayoría de los pacientes mediante el empleo de sonda pleural, mientras que en el resto se requerirán estrategias alternativas, siendo importante el conocimiento por parte de los cirujanos de su forma de prevención, así como de todas las opciones terapéuticas, para su adecuado empleo en base a su criterio o experiencia(AU)

Introduction: Persistent gas leak is the most common postoperative complication in thoracic surgery. Currently there are no studies with sufficient scientific evidence to establish a standard for the treatment of this complication. Objective: To offer an update of the predisposing factors of gas leak, as well as the treatment modalities that have emerged in recent years. Methods: A bibliographic review was carried out in MEDLINE (PubMed), SciELO databases, as well as in academic Google. Variables such as type of lung resection, surgical time, and postoperative complications were taken into account. The keywords in Spanish and English were used and a total of 44 articles published from 1998 to 2020 were selected. Discussion: Although this complication is generally considered mild, it can have 46 percent incidence, being associated with an extra time of the hospital stay, affecting health costs, as well as discomfort and morbidity for the patient. Depending on when it occurs and its location, the treatment will include different alternatives that range from conservative management, to different modalities of pleurodesis, endoscopic or surgical treatment. Conclusions: The resolution of this entity occurs in most patients through the use of a chest tube, while alternative strategies will be required for the rest. It is important for surgeons to know their form of prevention, as well as all the therapeutic options, for their proper use based on their criteria or experience(AU)

Bronquio cardíaco diagnosticado por estudio endoscópico / Cardiac bronchus diagnosed by endoscopic study

Introducción: El bronquio cardíaco es una anomalía congénita poco frecuente, con una incidencia de aproximadamente 0,1 por ciento. Consiste en un bronquio supernumerario que nace de la pared medial del bronquio principal derecho o del bronquio intermediario, opuesto al origen del bronquio para el lóbulo superior derecho y proximal al bronquio del segmento apical del lóbulo inferior derecho. Objetivo: Presentar el caso de un bronquio cardíaco diagnosticado por estudio endoscópico. Presentación del caso: Se presenta el caso de un paciente que ingresa en el servicio de Neumología del Hospital Clínico Quirúrgico Hermanos Ameijeiras por presentar tos, expectoración blanca, disnea a los grandes esfuerzos y una radiografía de tórax con una radiopacidad en el lóbulo superior izquierdo y que como hallazgo incidental durante la realización de la broncoscopia se detecta un bronquio cardíaco o supernumerario. Conclusiones: El bronquio cardíaco es una malformación congénita infrecuente que puede cursar de manera asintomática, cuyo diagnóstico definitivo es por broncoscopia(AU)

Introduction: The cardiac bronchus is a rare congenital anomaly, with an incidence of approximately 0.1 percent. It consists of a supernumerary bronchus that arises from the medial wall of the right main bronchus or the bronchus intermediary, opposite the origin of the bronchus for the right upper lobe and proximal to the bronchus of the apical segment of the right lower lobe. Objective: To report the case of a cardiac bronchus diagnosed by endoscopic study. Case report: We report the case of a patient who was admitted to the Pneumology service at Hermanos Ameijeiras Surgical Clinical Hospital due to cough, white expectoration, dyspnea on exertion and a chest X-ray with radiopacity in the upper lobe, and that as an incidental finding during the bronchoscopy, a cardiac or supernumerary bronchus was detected. Conclusions: Bronchus is an infrequent congenital malformation that can be asymptomatic, whose definitive diagnosis is by bronchoscopy(AU)

Cuerpo extraño de presentación tardía en bronquiotronco izquierdo. Caso clínico

RESUMEN Introducción: la introducción fortuita de un cuerpo extraño en las vías respiratorias es un accidente dramático que puede provocar complicaciones, aunque raro en los adultos, y sobre todo su presentación tardía, y en bronquio izquierdo. Caso clínico: se reporta el caso de un paciente de 71 años con un cuerpo extraño de presentación tardía en bronquiotronco izquierdo, que consultó por un cuadro de sepsis respiratoria, sin otros síntomas asociados, cuatro meses posteriores a referir haberse tragado un hueso de pollo, ocasión ésta en que el examen físico y los estudios radiológicos fueron negativos. Se realizó estudio con TAC de tórax y broncoscopia flexible evidenciándose una imagen sugerente de un cuerpo extraño en el bronquiotronco izquierdo. Discusión: después de realizar broncoscopia rígida y extracción de cuerpo extraño, presenta varias complicaciones, que requieren ingreso en terapia intensiva, la evolución clínica posterior fue favorable, con radiografía de tórax de control con adecuada reexpansión pulmonar y dándose de alta a los 55 días después del diagnóstico. Conclusiones: en presencia de un paciente con sepsis respiratoria después de un cuadro de broncoaspiración se debe tener en cuenta el diagnóstico de aspiración de un cuerpo extraño. La extracción del cuerpo extraño resulta la solución definitiva.

ABSTRACT Introduction: the fortuitous introduction of a foreign body in the respiratory tract is a dramatic accident that can cause complications, although rare in adults, and especially its late presentation, and in the left bronchus. Clinical case: we report the case of a 71-year-old patient with a late-onset foreign body in the left bronchial trunk, who consulted for respiratory sepsis, with no other associated symptoms, four months after reporting having swallowed a chicken bone. On which occasion the physical examination and radiological studies were negative. A CT scan of the chest and flexible bronchoscopy were performed, revealing an image suggestive of a foreign body in the left bronchial trunk. Discussion: after performing rigid bronchoscopy and extraction of a foreign body, he presented several complications, which required admission to intensive care, the subsequent clinical evolution was favorable, with a control chest X-ray with adequate lung re-expansion and being discharged 55 days later. of the diagnosis. Conclusions: in the presence of a patient with respiratory sepsis after a picture of bronchoaspiration, the diagnosis of aspiration of a foreign body should be taken into account. Extraction of the foreign body is the definitive solution.

RESUMO Introdução: a introdução fortuita de corpo estranho no trato respiratório é um acidente dramático que pode causar complicações, embora raras em adultos, e principalmente sua apresentação tardia, e no brônquio esquerdo. Caso clínico: relatamos o caso de um paciente de 71 anos com corpo estranho de início tardio no tronco brônquico esquerdo, que consultou por sepse respiratória, sem outros sintomas associados, quatro meses após relatar ter engolido osso de galinha. ocasião em que o exame físico e os estudos radiológicos foram negativos. Realizou-se TC de tórax e broncoscopia flexível, revelando imagem sugestiva de corpo estranho em tronco brônquico esquerdo. Discussão: após realização de broncoscopia rígida e extração de corpo estranho, apresentou diversas complicações, que exigiram internação em terapia intensiva, a evolução clínica posterior foi favorável, com radiografia de tórax de controle com reexpansão pulmonar adequada e alta hospitalar 55 dias depois do diagnóstico. Conclusões: na presença de um paciente com sepse respiratória após quadro de broncoaspiração, deve-se levar em consideração o diagnóstico de aspiração de corpo estranho. A extração do corpo estranho é a solução definitiva.

EBUS-TBNA versus mediastinoscopy for mediastinal staging of lung cancer: a cost-minimization analysis / EBUS-TBNA versus mediastinoscopia no estadiamento mediastinal do câncer de pulmão: análise de custo-minimização

ABSTRACT Objective: To assess cost differences between EBUS-TBNA and mediastinoscopy for mediastinal staging of non-small cell lung cancer (NSCLC). Methods: This was an economic evaluation study with a cost-minimization analysis. We used a decision analysis software program to construct a decision tree model to compare the downstream costs of mediastinoscopy, EBUS-TBNA without surgical confirmation of negative results, and EBUS-TBNA with surgical confirmation of negative results for the mediastinal staging of NSCLC. The study was conducted from the perspective of the Brazilian public health care system. Only direct medical costs were considered. Results are shown in Brazilian currency (Real; R$) and in International Dollars (I$). Results: For the base-case analysis, initial evaluation with EBUS-TBNA without surgical confirmation of negative results was found to be the least costly strategy (R$1,254/I$2,961) in comparison with mediastinoscopy (R$3,255/I$7,688) and EBUS-TBNA with surgical confirmation of negative results (R$3,688/I$8,711). The sensitivity analyses also showed that EBUS-TBNA without surgical confirmation of negative results was the least costly strategy. Mediastinoscopy would become the least costly strategy if the costs for hospital supplies for EBUS-TBNA increased by more than 300%. EBUS-TBNA with surgical confirmation of negative results, in comparison with mediastinoscopy, will be less costly if the prevalence of mediastinal lymph node metastasis is ≥ 38%. Conclusions: This study has demonstrated that EBUS-TBNA is the least costly strategy for invasive mediastinal staging of NSCLC in the Brazilian public health care system.

RESUMO Objetivo: Avaliar as diferenças de custo entre EBUS-TBNA e mediastinoscopia no estadiamento mediastinal do câncer de pulmão não pequenas células (CPNPC). Métodos: Estudo de avaliação econômica com análise de custo-minimização. Utilizamos um software de análise de decisão para a construção de um modelo de árvore de decisão para comparar os custos à jusante da mediastinoscopia, de EBUS-TBNA sem confirmação cirúrgica de resultados negativos e de EBUS-TBNA com confirmação cirúrgica de resultados negativos no estadiamento mediastinal do CPNPC. O estudo foi realizado sob a perspectiva do sistema público de saúde brasileiro. Foram considerados apenas os custos médicos diretos. Os resultados são apresentados em moeda brasileira (reais; R$) e em dólares internacionais (I$). Resultados: Na análise de caso base, a avaliação inicial com EBUS-TBNA sem confirmação cirúrgica de resultados negativos foi a estratégia menos dispendiosa (R$ 1.254/I$ 2.961) em comparação com a mediastinoscopia (R$ 3.255/I$ 7.688) e EBUS-TBNA com confirmação cirúrgica de resultados negativos (R$ 3.688/I$ 8.711). As análises de sensibilidade também mostraram que EBUS-TBNA sem confirmação cirúrgica de resultados negativos foi a estratégia menos dispendiosa. A mediastinoscopia se tornaria a estratégia menos dispendiosa se os custos com insumos hospitalares para a realização de EBUS-TBNA aumentassem mais de 300%. EBUS-TBNA com confirmação cirúrgica de resultados negativos, em comparação com a mediastinoscopia, será menos dispendiosa se a prevalência de metástase linfonodal mediastinal for ≥ 38%. Conclusões: Este estudo demonstrou que EBUS-TBNA é a estratégia menos dispendiosa para o estadiamento mediastinal invasivo do CPNPC no sistema público de saúde brasileiro.

Lesão inalatória confirmada por broncoscopia nos pacientes admitidos em uma UTI de queimados / Inhalation injury confirmed by bronchoscopy in patients admitted to a burns ICU

OBJETIVO: Verificar a incidência de lesão inalatória confirmada por broncoscopia em pacientes com queimaduras faciais e/ou histórico de exposição a fumaça em uma Unidade de Terapia Intensiva para Queimados. MÉTODO: Estudo transversal retrospectivo baseado em coleta de prontuários de pacientes internados entre agosto de 2015 e maio de 2020. Na análise estatística realizou-se a caracterização dos dados categóricos e contínuos, teste exato de Fisher, teste de Shapiro-Wilk e teste de Kruskal-Wallis sendo avaliados no software STATA® 14 com nível de significância de 5%. RESULTADOS: 82 pacientes com lesão inalatória foram classificados em grupos de nenhuma lesão/leve, moderada e grave, com incidência de 19,2 casos de lesão inalatória a cada 100 internações na unidade de terapia intensiva de queimados e tempo médio de internação de 35,6 dias; destes, 27 faleceram. Os pacientes com lesão grave ficaram por menor tempo em ventilação mecânica. CONCLUSÕES: A avaliação por broncoscopia no atendimento inicial imediato ou em até 24h da admissão do paciente com queimadura facial pode ser adotada para otimizar o diagnóstico e realizar a classificação da lesão inalatória aprimorando a visualização do prognóstico, o atendimento e tratamento a estes pacientes.

OBJECTIVE: To verify the incidence of inhalation injury confirmed by bronchoscopy in patients with facial burns and/or a history of exposure to smoke in a Burns Intensive Care Unit. METHODS: Retrospective cross-sectional study based on the collection of medical records of patients hospitalized between August 2015 and May 2020. In the statistical analysis the categorical and continuous data were characterized, Fisher's exact test, Shapiro-Wilk test, and Kruskal-Wallis test were evaluated in STATA® 14 software with a 5% significance level. RESULTS: 82 patients with inhalation injury were classified into groups of no/mild, moderate and severe injuries, with an incidence of 19.2 cases of inhalation injury for every 100 admissions in the intensive care unit for burns patients with an average length of stay of 35.6 days; of these 27 died. Patients with severe injuries were on mechanical ventilation for a shorter time. CONCLUSIONS: The bronchoscopy evaluation in the immediate initial care or within 24 hours of admission of patients with facial burns can be adopted to optimize the diagnosis and perform the classification of the inhalation injury improving the visualization of the prognosis, care and treatment of these patients.

Bronchoscopy simulation training in the post-pandemic world / Treinamento com simuladores de broncoscopia no mundo pós-pandemia

ABSTRACT Bronchoscopy is an important procedure to examine the airways. It is traditionally taught by having trainees perform it in humans. This carries risks, albeit rarely, and causes stress to trainees. The objective of this study was to review bronchoscopy simulators, as well as their use in and impact on medical education, presenting perspectives on the use of simulators in the post-pandemic world. This review was based on articles published in English in 2000-2021 and retrieved from any of the following databases: MEDLINE (PubMed), Embase, SciELO, and Google Scholar. Bronchoscopy simulators have improved markedly over time, allowing the teaching/learning process to take place in a risk-free environment. Bronchoscopy simulation training is an interesting option for the evaluation of the airways, especially in the coming years, with the COVID-19 pandemic highlighting the need for continuing medical education.

RESUMO A broncoscopia é um procedimento importante para examinar as vias aéreas. O treinamento tradicional consiste em realizar o procedimento em humanos. Isso traz riscos, embora apenas raramente, e causa estresse nos broncoscopistas em formação. O objetivo deste estudo foi realizar uma revisão da literatura a respeito de simuladores de broncoscopia e seu uso e impacto na educação médica, apresentando perspectivas acerca do uso de simuladores no mundo pós-pandemia. A revisão baseou-se em artigos publicados em inglês em 2000-2021 e recuperados a partir de buscas realizadas nos seguintes bancos de dados: MEDLINE (PubMed), Embase, SciELO e Google Acadêmico. Os simuladores de broncoscopia melhoraram muito ao longo dos anos, permitindo que o processo de ensino e aprendizagem ocorra em um ambiente livre de riscos. O treinamento com simuladores de broncoscopia é uma opção interessante para a avaliação das vias aéreas, principalmente nos próximos anos, já que a pandemia de COVID-19 ressaltou a necessidade de educação médica continuada.

Criptococosis diseminada en paciente inmunocompetente imitando un cáncer de pulmón metastásico / Disseminated cryptococcosis in an immunocompetent patient imitating metastatic lung cancer

El cáncer de pulmón es la principal causa de muerte en el mundo por cáncer, y en Colombia es la segunda. Su pronóstico es pobre cuando se ha documentado enfermedad metastásica en el sistema nervioso central. El diagnóstico se basa en el resultado definitivo de patología. Aunque los hallazgos imagenológicos pueden ser muy sugestivos de malignidad, hay reportes de otras enfermedades que pueden imitar cáncer, tales como infecciones o tumores benignos, los cuales pueden llevar a adoptar conductas terapéuticas inapropiadas. Las infecciones fúngicas como las producidas por Criptococcus neoformans, son capaces de generar lesiones que pueden imitar neoplasias. El objetivo de esta publicación es reportar el caso de un hombre a quien inicialmente se le sospechó un carcinoma pulmonar metastásico al sistema nervioso central, y finalmente se le diagnosticó una criptococosis diseminada posterior a su fallecimiento

Lung cancer is the leading cause of death from cancer in the world and the second in Colombia, its prognosis is bad when the diagnosis of metastatic disease in the central nervous system is documented. The diagnosis is based on the definitive pathologic result. Although the imaging findings can be highly suggestive of malignancy, there are reports of other conditions that can mimic lung cancer, such as infections or benign tumors, which can lead to inappropriate treatment. Fungal infections such as those caused by Criptococcus neoformans are capable of generating lesions that can mimic neoplasms. The objective of this article is to report the case of a man who was initially diagnosed with metastatic lung carcinoma to the central nervous system, and was finally diagnosed with disseminated cryptococcosis after his death