Bronchoscope-assisted Tritube® placement for resection of sequential tracheal stenosis.

Symptomatic tracheal stenosis is a rare but significant complication of long-term tracheal intubation and mechanical ventilation. Airway management for tracheal resection in severe tracheal stenosis, especially sequential stenoses, requires multidisciplinary planning. A valuable method of airway management is the insertion of a small-bore, cuffed tracheal tube (Tritube®, Ventinova Medical B.V., Eindhoven, The Netherlands) in combination with flow-controlled ventilation. In this case, a patient with tracheal stenosis following prolonged ventilation required resection of the stenosed tissue. A Tritube was placed via a J-tipped guidewire inserted through the working channel of a bronchoscope. Bronchoscopic cuff visualisation along the tube in severe stenosis is impossible because of the outer diameter of the tracheal tube. In this case, we therefore estimated the position of the tube tip based on the distance from the vocal cords to the carina measured on pre-operative computed tomography imaging. During completion of the dorsal tracheal anastomosis, cross field ventilation using a conventional tracheal tube had to be started due to impeded ventilation caused by the Tritube protruding distal to the carina. In severe sequential tracheal stenosis, a small-bore tracheal tube can safely be placed by guidance with a J-tipped guidewire. However, it is important to plan a backup method of ventilation, such as cross field ventilation, prior to commencing a critical procedure.

[Recommendations for Performing Bronchoscopy in Times of the COVID-19 Pandemic - Update 12/2020]. / Empfehlungen zur Durchführung einer Bronchoskopie in Zeiten der COVID-19-Pandemie: Update 12/2020.

The SARS-CoV-19 pandemic continues to be globally related with significant morbidity and mortality, making protective measures to prevent transmission of the virus still necessary. Healthcare employees are exposed to a higher risk of infection and this is particularly true when performing aerosol-generating procedures such as bronchoscopy.Since the publication of recommendations for performing a bronchoscopy in the times of COVID-19 more than six months ago, the risk situation has not changed significantly, but due to the considerable gain in knowledge in the meantime, an update of the recommendations was necessary.The updated recommendations include the reduction of aerosol formation, the personal protection of the people involved in the procedure, as well as measures to better organize the processes in the endoscopy suite in order to perform bronchoscopic procedures securely even in times of COVID-19.

[Recommendations for Performing Bronchoscopy in Times of the COVID-19 Pandemic]. / Empfehlungen zur Durchführung einer Bronchoskopie in Zeiten der COVID-19-Pandemie.

COVID-19, caused by coronavirus SARS-CoV-2 is a new and ongoing infectious disease affecting healthcare systems worldwide. Healthcare worker are at high risk for COIVD-19 and many have been infected or even died in countries severely affected by COVID-19 like China or Italy. Bronchoscopy causes cough and aerosol production and has to be considered a significant risk for the staff to get infected. Particular recommendations should guide to prevent spreading COVID-19 and to protect healthcare worker when performing a bronchoscopy.

The effect of intraparenchymal blood patching on the rate of pneumothorax in patients undergoing percutaneous CT-guided core biopsy of the lung.

PURPOSE: To assess the effect of intraparenchymal blood patching (IBP) as well as tumor- and operator-related risk factors on the rate of pneumothoraxes after percutaneous CT-guided core needle biopsy of the lung. MATERIALS AND METHODS: We performed a retrospective analysis of 868 CT-guided lung biopsies that were conducted at our institution between 2003 and 2018, of which 419 (48%) received an IBP. Outcome variable included the rates of pneumothorax and chest tube placement, as well as lesion size (<3 cm versus ≥3 cm long axis diameter), lesion depth (≤2 cm, >2-4 cm, >4-5 cm and >5 cm distance to the pleura), location within the lungs (upper lobe, lower lobe, middle lobe), needle caliber (13 G, 15 G, 17 G, 19 G), number of samples taken (1-3 versus ≥4 samples), and experience of the performing physician. RESULTS: The rate of pneumothorax was significantly (p < 0.05) lower in the group with IBP (10.7%) compared to the group without IBP (15.4%). The number of post-interventional chest tube placements was also lower in the IBP group (3.1% vs. 5.8%) but not statistically significant. The lesion size correlated negatively with the rate of pneumothoraxes, whereas in both groups (±IBP) lesions ≥ 3 cm showed a significantly lower rate of pneumothorax (p < 0.05). With increasing lesion depth, the pneumothorax rate increased with (p < 0.01) and without (p < 0.001) IBP. The rate of pneumothorax was significantly lower (p < 0.05) for 17 G needles with IBP, but not for other calibers. For biopsies in the lower lobe, the pneumothorax rate reduced significantly (p < 0.001) with IBP. In case of ≥4 tissue samples, the pneumothorax rate was significantly lower with IBP (p < 0.01). For experienced operators, the overall pneumothorax rate was significantly lower compared to less experienced operators (p < 0001). CONCLUSIONS: IBP significantly reduces the rate of pneumothorax following CT-guided lung biopsies in particular for lesions located deeper in the lungs, when ≥4 samples are taken, when samples are taken by less-experienced operators, and when sampling from the lower lobes.

Phase Locking the Spin Precession in a Storage Ring.

This Letter reports the successful use of feedback from a spin polarization measurement to the revolution frequency of a 0.97 GeV/c bunched and polarized deuteron beam in the Cooler Synchrotron (COSY) storage ring in order to control both the precession rate (≈121 kHz) and the phase of the horizontal polarization component. Real time synchronization with a radio frequency (rf) solenoid made possible the rotation of the polarization out of the horizontal plane, yielding a demonstration of the feedback method to manipulate the polarization. In particular, the rotation rate shows a sinusoidal function of the horizontal polarization phase (relative to the rf solenoid), which was controlled to within a 1 standard deviation range of σ=0.21 rad. The minimum possible adjustment was 3.7 mHz out of a revolution frequency of 753 kHz, which changes the precession rate by 26 mrad/s. Such a capability meets a requirement for the use of storage rings to look for an intrinsic electric dipole moment of charged particles.

Bronchial Artery Embolization in Hemoptysis: 10-Year Survival and Recurrence-Free Survival in Benign and Malignant Etiologies - A Retrospective Study.

Purpose: The aim of the study was to evaluate safety, effectiveness, recurrence rate and 10-year survival after bronchial artery embolization (BAE) in benign and malignant etiologies. Methods: The retrospective study includes 100 BAE procedures in 88 patients. Underlying disease was classified as benign (n = 67) and malignant (n = 21) etiologies. Immediate bleeding control and procedure safety were evaluated in all patients. In 51 (58 %) patients, follow-up data with a median follow-up time of 1015 days (range, 494 to 3727 days) were acquired to assess overall survival, time-to-recurrence of bleeding and recurrence-free survival, using Kaplan-Maier estimates to compare differences between both subgroups. Results: Immediate bleeding control was achieved after 96/100 procedures (96 %), with a minor complication rate of 5.0 %. No major complications occurred. The overall survival was 74 % after 1 year and 59 % after 5 years and 10 years. There was a significant difference in survival between the malignant and benign groups (p < 0.0001). Survival was 90 %, 80 % and 76 % at 1 year, 3 years and 10 years, respectively, in the benign group and 18 % and 0 % at 1 year and 3 years, respectively in the malignant group. The median time to recurrence of bleeding and recurrence-free survival were 239 days and 94 % after 1 year and 87 % after 10 years in the benign group, compared to 66 days and 34 % after 1 year and 0 % after 3 years in the malignant group (p = 0.0107). Conclusion: BAE is a safe and highly effective treatment option in hemoptysis. However, the recurrence rate and survival are highly dependent on the underlying disease. Key Points: • BAE is a safe and highly effective treatment option in hemoptysis.• Recurrence rate and survival are strongly dependent on the underlying disease with significantly impaired results in patients with malignant diseases. • Coil embolization is an effective BAE treatment method. Nevertheless, it should be mentioned, that reinterventions can be impeded, if embolization is performed in the proximal part of bronchial arteries. Citation Format: • Syha R, Benz T, Hetzel J et al. Bronchial Artery Embolization in Hemoptysis: 10-Year Survival and Recurrence-Free Survival in Benign and Malignant Etiologies - A Retrospective Study. Fortschr Röntgenstr 2016; 188: 1061 - 1066.

How to Reach a Thousand-Second in-Plane Polarization Lifetime with 0.97-GeV/c Deuterons in a Storage Ring.

We observe a deuteron beam polarization lifetime near 1000 s in the horizontal plane of a magnetic storage ring (COSY). This long spin coherence time is maintained through a combination of beam bunching, electron cooling, sextupole field corrections, and the suppression of collective effects through beam current limits. This record lifetime is required for a storage ring search for an intrinsic electric dipole moment on the deuteron at a statistical sensitivity level approaching 10^{-29} e cm.

Cross-Sectional Survey on Bronchoscopy in Germany--The Current Status of Clinical Practice.

OBJECTIVES: Bronchoscopy is an integral part of pulmonary medicine. In recent years, a series of new technologies have evolved. It is to assume that significant changes have also occurred in clinical practice. We conducted a nationwide survey to evaluate the current status of care and to compare it with earlier reports. METHODS: A standard questionnaire was sent to 1875 institutions to assess the clinical practice of bronchoscopy in Germany with respect to general issues, education, sedation/anaesthesia and technical aspects. RESULTS: The returned questionnaires cover 301,965 bronchoscopies, performed by 2158 physicians over 12 months, making it the largest survey to date. The proportion of rigid bronchoscopies has decreased and amounts to 7.3% at present. Atropine as a premedication is hardly used any more. Sedation is routinely applied in 88% of flexible bronchoscopies, for which a combination of propofol and midazolam is preferred by most institutions (41.3%), followed by propofol monotherapy (28.3%). 74.4% of institutions accept aspirin for transbronchial biopsy, 8.1% dual platelet inhibition. 62.4% of all institutions perform airway recanalisation, favouring cryotherapy and argon plasma coagulation. 9.1% of bronchoscopies are supported by endobronchial ultrasound. CONCLUSION: Compared to preceding surveys, the experience of bronchoscopists, especially regarding interventional procedures, has increased. Endobronchial ultrasound has become a standard of care, as has patient sedation with propofol.

Impact of endobronchial coiling on segmental bronchial lumen in treated and untreated lung lobes: Correlation with changes in lung volume, clinical and pulmonary function tests.

OBJECTIVES: To assess the impact of endobronchial coiling on the segment bronchus cross-sectional area and volumes in patients with lung emphysema using quantitative chest-CT measurements. MATERIALS AND METHODS: Thirty patients (female = 15; median age = 65.36 years) received chest-CT before and after endobronchial coiling for lung volume reduction (LVR) between January 2010 and December 2014. Thin-slice (0.6 mm) non-enhanced image data sets were acquired both at end-inspiration and end-expiration using helical technique and 120 kV/100-150 mAs. Clinical response was defined as an increase in the walking distance (Six-minute walk test; 6MWT) after LVR-therapy. Additionally, pulmonary function test (PFT) measurements were used for clinical correlation. RESULTS: In the treated segmental bronchia, the cross-sectional lumen area showed significant reduction (p < 0.05) in inspiration and tendency towards enlargement in expiration (p > 0.05). In the ipsilateral lobes, the lumina showed no significant changes. In the contralateral lung, we found tendency towards increased cross-sectional area in inspiration (p = 0.06). Volumes of the treated segments correlated with the treated segmental bronchial lumina in expiration (r = 0.80, p < 0.001). Clinical correlation with changes in 6MWT/PFT showed a significant decrease of the inspiratory volume of the treated lobe in responders only. CONCLUSION: Endobronchial coiling causes significant decrease in the cross-sectional area of treated segment bronchi in inspiration and a slight increase in expiration accompanied by a volume reduction. KEY POINTS: • Endobronchial coiling has indirect impact on cross-sectional area of treated segment bronchi • Volume changes of treated lobes correlate with changes in bronchial cross-sectional area • Coil-induced effects reflect their stabilizing and stiffening impact on lung parenchyma • Endobronchial coiling reduces bronchial collapsing compensating the loss of elasticity.

New Method for a Continuous Determination of the Spin Tune in Storage Rings and Implications for Precision Experiments.

A new method to determine the spin tune is described and tested. In an ideal planar magnetic ring, the spin tune-defined as the number of spin precessions per turn-is given by ν(s)=γG (γ is the Lorentz factor, G the gyromagnetic anomaly). At 970 MeV/c, the deuteron spins coherently precess at a frequency of ≈120 kHz in the Cooler Synchrotron COSY. The spin tune is deduced from the up-down asymmetry of deuteron-carbon scattering. In a time interval of 2.6 s, the spin tune was determined with a precision of the order 10^{-8}, and to 1×10^{-10} for a continuous 100 s accelerator cycle. This renders the presented method a new precision tool for accelerator physics; controlling the spin motion of particles to high precision is mandatory, in particular, for the measurement of electric dipole moments of charged particles in a storage ring.

Fluticasone/formoterol dry powder versus budesonide/formoterol in adults and adolescents with uncontrolled or partly controlled asthma.

UNLABELLED: This 12-week study compared the efficacy and safety of a fixed combination of fluticasone propionate plus formoterol (FL/F) 250/12 µg b.i.d. administered via a dry powder inhaler (DPI) (Libbs Farmacêutica, Brazil) to a combination of budesonide plus formoterol (BD/F) 400/12 µg b.i.d. After a 2-week run-in period (in which all patients were treated exclusively with budesonide plus formoterol), patients aged 12-65 years of age (N = 196) with uncontrolled asthma were randomized into an actively-controlled, open-labeled, parallel-group, multicentre, phase III study. The primary objective was to demonstrate non-inferiority, measured by morning peak expiratory flow (mPEF). The non-inferiority was demonstrated. A statistically significant improvement from baseline was observed in both groups in terms of lung function, asthma control, and the use of rescue medication. FL/F demonstrated a statistical superiority to BD/F in terms of lung function (FEV(1)) (p = 0.01) and for asthma control (p = 0.02). Non-significant between-group differences were observed with regards to exacerbation rates and adverse events. In uncontrolled or partly controlled asthma patients, the use of a combination of fluticasone propionate plus formoterol via DPI for 12-weeks was non-inferior and showed improvements in FEV(1) and asthma control when compared to a combination of budesonide plus formoterol. ( CLINICAL TRIAL NUMBER: ISRCTN60408425).

Human metapneumovirus (HMPV) associated pulmonary infections in immunocompromised adults--initial CT findings, disease course and comparison to respiratory-syncytial-virus (RSV) induced pulmonary infections.

AIM: To describe computed tomography (CT)-imaging findings in human metapneumovirus (HMPV)-related pulmonary infection as well as their temporal course and to analyze resemblances/differences to pulmonary infection induced by the closely related respiratory-syncytial-virus (RSV) in immunocompromised patients. MATERIALS AND METHODS: Chest-CT-scans of 10 HMPV PCR-positive patients experiencing pulmonary symptoms were evaluated retrospectively with respect to imaging findings and their distribution and results were then compared with data acquired in 13 patients with RSV pulmonary infection. Subsequently, we analyzed the course of chest-findings in HMPV patients. RESULTS: In HMPV, 8/10 patients showed asymmetric pulmonary findings, whereas 13/13 patients with RSV-pneumonia presented more symmetrical bilateral pulmonary infiltrates. Image analysis yielded in HMPV patients following results: ground-glass-opacity (GGO) (n=6), parenchymal airspace consolidations (n=5), ill-defined nodular-like centrilobular opacities (n=9), bronchial wall thickening (n=8). In comparison, results in RSV patients were: GGO (n=10), parenchymal airspace consolidations (n=9), ill-defined nodular-like centrilobular opacities (n=10), bronchial wall thickening (n=4). In the course of the disease, signs of acute HMPV interstitial pneumonia regressed transforming temporarily in part into findings compatible with bronchitis/bronchiolitis. CONCLUSIONS: Early chest-CT findings in patients with HMPV-related pulmonary symptoms are compatible with asymmetric acute interstitial pneumonia accompanied by signs of bronchitis; the former transforming with time into bronchitis and bronchiolitis before they resolve. On the contrary, RSV-induced pulmonary infection exhibits mainly symmetric acute interstitial pneumonia.

[Endoscopic treatment for tumorous obstructions of the tracheobronchial system: a comparison of available techniques]. / Die endoskopische Therapie der Tumorobstruktion des Tracheobronchialsystems: eine Gegenüberstellung verfügbarer Techniken.

Malignant central airway obstruction is a common problem in lung cancer. A symptomatic stenosis can often be treated successfully using endoscopy. Different approaches for recanalisation are available. The goal of treating exophytic obstruction is to remove the endobronchial tumour growth. Mechanic debulking, electrocautery/diathermy, argon plasma coagulation, laser resection and cryoextraction are techniques that can provide immediate relief. Cryotherapy, brachytherapy and photodynamic therapy show delayed recanalisation effects. Silicone or self-expanding metallic airway stents can be used for the treatment of airway obstruction due to extrinsic disease to restore and maintain airway patency.

Cryobiopsy increases the diagnostic yield of endobronchial biopsy: a multicentre trial.

Forceps, brushes or needles are currently the standard tools used during flexible bronchoscopy when diagnosing endobronchial malignancies. The new biopsy technique of cryobiopsy appears to provide better diagnostic samples. The aim of this study was to evaluate cryobiopsy over conventional endobronchial sampling. A total of 600 patients in eight centres with suspected endobronchial tumours were included in a prospective, randomised, single-blinded multicentre study. Patients were randomised to either sampling using forceps or the cryoprobe. After obtaining biopsy samples, a blinded histological evaluation was performed. According to the definitive clinical diagnosis, the diagnostic yield for malignancy was evaluated by a Chi-squared test. A total of 593 patients were randomised, of whom 563 had a final diagnosis of cancer. 281 patients were randomised to receive endobronchial biopsies using forceps and 282 had biopsies performed using a flexible cryoprobe. A definitive diagnosis was achieved in 85.1% of patients randomised to conventional forceps biopsy and 95.0% of patients who underwent cryobiopsy (p<0.001). Importantly, there was no difference in the incidence of significant bleeding. Endobronchial cryobiopsy is a safe technique with superior diagnostic yield in comparison with conventional forceps biopsy.

HRCT-features of Pneumocystis jiroveci pneumonia and their evolution before and after treatment in non-HIV immunocompromised patients.

OBJECTIVE: This study retrospectively analyzes the characteristics and kinetics of pulmonary changes in Pneumocystis jiroveci pneumonia (PJP) before and after treatment as depicted by thin-section-CT in HIV-negative patients. MATERIALS AND METHODS: Serial CT scans of 84 consecutive HIV-negative PJP patients were reviewed retrospectively encompassing a median follow-up of 76 (range, 37-506) days. Along with underlying disease and time span between the onset of symptoms and specific antimicrobial therapy, early and late pulmonary CT-findings were evaluated. RESULTS: Imaging findings at initial diagnosis differed from those in the posttherapeutic setting. In the acute (initial) PJP-phase, most frequent finding was symmetric, apically distributed ground glass opacities (GGO) with peripheral sparing 43% (n = 36). These initial changes resolved up to 1st follow-up-examination in 57% (n = 48), and finally in all except for two patients after a median period of 13 (mean 26, range 1-58) days following application of specific therapy. In 42% (n = 35) architectural distortions occurred, but they resolved after a median period of 27 (mean 60, range 11-302) days. Only in 9 patients, complete resolution could not be documented. Significant correlations of the underlying disease or the time span between the onset of symptoms and specific antibiotic therapy and morphologic kinetic could not be found. CONCLUSION: Thin-section CT-findings of PJP usually resolve soon after onset of specific therapy. Postinfectious fibrosis rarely occurs following PJP in HIV-negative patients.

[Recommendations for sedation during flexible bronchoscopy]. / Empfehlung zur Sedierung in der flexiblen Bronchoskopie.

Flexible bronchoscopy is a standard examination today and is conducted not only in nearly every hospital but also in privately owned practices. The vast majority of patients want sedation for this examination. Such a procedure is nearly always necessary in complex and interventional procedures, irrespective of the patient's wish. The recommendation at hand to use sedation measures for flexible bronchoscopy is based on the results of numerous clinical studies and also takes account of individual experiences in this area. The structural and procedural requirements and the requirements for staff training are defined and should describe the minimum standard when it comes to conducting a bronchoscopy under sedation. Furthermore the drugs recommended for sedation are discussed and their methods of application shown. Finally the recommendations also include suggestions for patient clarification, monitoring and discharge. They should provide the examiner with concrete operating options and therefore above all increase patient safety.