Aerosol Generation During Bronchoscopy.

BACKGROUND: Bronchoscopy is an aerosol-generating procedure and can place the health care providers at risk for exposure to viral pathogens. The pattern of aerosol generation during  different aspects of bronchoscopy are poorly understood. The goal of this study is to characterize the pattern of aerosol generation during flexible and rigid bronchoscopy performed under moderate sedation or general anesthesia (GA). The inhalable mass concentration of aerosol generated during the procedures was measured continuously. METHODS: The aerosol concentration in the endoscopy room at baseline and while the procedures were performed was measured. Procedures included flexible bronchoscopies with moderate sedation, flexible bronchoscopies performed through endotracheal tube under GA and rigid bronchoscopies under GA. Changes from the baseline were measured continuously during the bronchoscopy. RESULTS: Measurements obtained during the procedure were compared with the baseline reading. For flexible bronchoscopy under moderate sedation, the inhalable aerosol fraction was significantly higher (P=0.036) during atomization of lidocaine. For Flexible bronchoscopy through endotracheal tube, inhalable aerosol fraction was significantly higher (P<0.001) during intubation and extubation. For rigid bronchoscopy done under GA with jet ventilation, inhalable aerosol fraction was significantly higher during both the bronchoscopy (P=0.01) and recovery (P=0.012). CONCLUSION: Elevated levels of aerosol were generated during all aspects of bronchoscopy. However, atomization of lidocaine, intubation, extubation, and recovery generated the most aerosol.

Planning for End of Life.

BACKGROUND: Oncology provider discussions of treatment options, outcomes of treatment, and end of life planning are essential to care for patients with advanced malignancies. Studies have shown that despite this, many patients do not have adequate care planning, including end of life planning. It is thought that the accessibility of information outside of clinical encounters and individual factors and/or beliefs may influence the patient's perception of disease. AIMS: The objective of this study was to evaluate if patient understanding of treatment goals matched the provider and if there were areas of discrepancy. If a discrepancy was found, the survey inquired further into more specific aspects. METHODS: A questionnaire-based survey was performed at a cancer hospital outpatient clinic. 100 consecutive and consenting patients who had stage IV non-curable lung, gastrointestinal (GI), or other cancer were included in the study. Patients must have had at least 2 visits with their oncologist. RESULTS: 40 patients reported their disease might be curable and 60 reported their disease was not curable. Patients who reported their disease was not curable were more likely to be 65 years or older (P-value: 0.055). They were more likely to report that their doctor discussed the possibility of their cancer getting worse (78.3% VS 55%; P-value 0.024), that their doctor discussed end of life plans (58.3% VS 30%; P- value: 0.01), and that they had appointed a health care decision-maker (86.7% VS 62.5%; P-value: 0.01). 65% of patients who thought their disease might be curable reported that their doctor said it might be curable, compared with only 6.7% of patients who thought their disease was not curable (p < 0.001). Or, equivalently, 35% of patients who thought their disease might be curable reported that their doctor's opinion was that it was not curable, compared with 93% of patients who thought their disease was not curable (p < 0.001). Patients who had lung cancer were more likely to believe their cancer was not curable than patients with gastrointestinal or other cancer, though the difference was not statistically significant (p = 0.165). Patients who said their disease might be curable selected as possible reasons that a miracle (50%) or alternative medicine (66.7%) would get rid of the cancer, or said their family wanted them to believe the cancer would go away (16.7%) or that another doctor said it would (4.2%). Patients who said their disease might be curable said they did so due to alternative medications, another doctor, or their family. Restricting to the 70 patients who reported their doctors telling them their disease was not curable, 20% of them still said that they personally felt their disease might be curable. Patients below 65 years of age were more likely to disagree with the doctor in this case (P-value: 0.047). CONCLUSION: This survey of patients diagnosed with stage IV cancer shows that a significant number of patients had misunderstandings of the treatment and curability of their disease. Findings suggest that a notable proportion kept these beliefs even after being told by treating physicians that their disease is not curable.

Core needle biopsy with endobronchial ultrasonography: single center experience with 100 cases.

INTRODUCTION: Adequate sampling by endobronchial ultrasound (EBUS)-transbronchial needle aspiration to meet the demands of precision medicine or histologic evaluation is challenging. There is increasing demand for core biopsy specimens with advances in therapy. Franseen enodoscopic ultrasound needles have shown promising results in gastroenterology application for obtaining core biopsies and same design has recently been extended for pulmonary use. We evaluated Franseen needles with EBUS to assess its utility, safety and ability to provide core biopsy specimens. MATERIALS AND METHODS: Retrospective analysis of our database at the University of Utah of patients undergoing EBUS with a Franseen needle was performed to ascertain the performance characteristics of this needle in the first 100 patients after its implementation. Medical records were also reviewed to identify any immediate procedure-related complications. RESULTS: One hundred seventy locations were sampled in 100 patients. A total of 152 lymph nodes and 18 masses were sampled. Core biopsies, as per pathology report, were seen in 87% of patients. A clinically concordant pathological diagnosis was established in 97% of patients. Diagnostic yield for granulomatous lymphadenopathy was 95.6% (22 of 23). No patient-related adverse events were noted. CONCLUSION: The Franseen needle evaluated in this study can safely procure core tissue samples during EBUS bronchoscopy that are adequate for histopathological diagnosis in benign and malignant lesions. Its ability to provide adequate tissue in patients with granulomatous inflammation is encouraging.

Respiratory Complication in Liver Disease.

Cirrhosis, the twelfth leading cause of death, accounts for 1.1% of all deaths in the United States. Although there are multiple pulmonary complications associated with liver disease, the most important complications that cause significant morbidity and mortality are hepatopulmonary syndrome, hepatic hydrothorax, and portopulmonary hypertension. Patients with cirrhosis who complain of dyspnea should be evaluated for these complications. This article reviews these complications.