Standardized Definitions of Bleeding After Transbronchial Lung Biopsy: A Delphi Consensus Statement From the Nashville Working Group.

BACKGROUND: Transbronchial lung biopsies are commonly performed for a variety of indications. Although generally well tolerated, complications such as bleeding do occur. Description of bleeding severity is crucial both clinically and in research trials; to date, there is no validated scale that is widely accepted for this purpose. Can a simple, reproducible tool for categorizing the severity of bleeding after transbronchial biopsy be created? METHODS: Using the modified Delphi method, an international group of bronchoscopists sought to create a new scale tailored to assess bleeding severity among patients undergoing flexible bronchoscopy with transbronchial lung biopsies. Cessation criteria were specified a priori and included reaching > 80% consensus among the experts or three rounds, whichever occurred first. RESULTS: Thirty-six expert bronchoscopists from eight countries, both in academic and community practice settings, participated in the creation of the scale. After the live meeting, two iterations were made. The second and final scale was vetted by all 36 participants, with a weighted average of 4.47/5; 53% were satisfied, and 47% were very satisfied. The panel reached a consensus and proposes the Nashville Bleeding Scale. CONCLUSIONS: The use of a simplified airway bleeding scale that can be applied at bedside is an important, necessary tool for categorizing the severity of bleeding. Uniformity in reporting clinically significant airway bleeding during bronchoscopic procedures will improve the quality of the information derived and could lead to standardization of management. In addition to transbronchial biopsies, this scale could also be applied to other bronchoscopic procedures, such as endobronchial biopsy or endobronchial ultrasound-guided needle aspiration.

Broncholithiasis secondary to pulmonary actinomycosis.

We report a case of broncholithiasis secondary to pulmonary actinomycosis. Broncholithiasis has occasionally been reported in association with actinomycosis, but it is unclear if actinomycosis leads to lymph node calcification with subsequent erosion into the airway, producing a broncholith, or if an existing generic broncholith is secondarily colonized with Actinomyces. The patient had post-obstruction pneumonia, and computed tomography showed calcified nodules obstructing the bronchus intermedius and distal necrotizing pneumonia. The nodules included sulfur granules containing Gram-positive branching filamentous organisms consistent with Actinomyces. The finding of Actinomyces throughout the broncholith is strong evidence that the etiology of the broncholithiasis was a primary pulmonary Actinomyces infection.