Diagnosis and Management of Malignant Pleural Effusion: A Decade in Review.

Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality. Treatment is mainly palliative, with symptomatic management achieved via effusion drainage and pleurodesis. Pleurodesis may be hastened by administering a sclerosing agent through a thoracostomy tube, thoracoscopy, or an indwelling pleural catheter (IPC). Over the last decade, several randomized controlled studies shaped the current management of MPE in favor of an outpatient-based approach with a notable increase in IPC usage. Patient preferences remain essential in choosing optimal therapy, especially when the lung is expandable. In this article, we reviewed the last 10 to 15 years of MPE literature with a particular focus on the diagnosis and evolving management.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA): Technical Updates and Pathological Yield.

Since the endobronchial ultrasound bronchoscope was introduced to clinical practice, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become the procedure of choice to sample hilar and mediastinal adenopathy. Multiple studies have been conducted in the last two decades to look at the different technical aspects of the procedure and their effects on the final cytopathological yield. In addition, newer modes of ultrasound scanning and newer tools with the potential to optimize the selection and sampling of the target lymph node have been introduced. These have the potential to reduce the number of passes, reduce the procedure time, and increase the diagnostic yield, especially in rare tumors and benign diseases. Herein, we review the latest updates related to the technical aspects of EBUS-TBNA and their effects on the final cytopathological yield in malignant and benign diseases.

Feasibility study: Proposed alternative to N95 respirator during the personal protective equipment shortage from COVID-19 pandemic.

INTRODUCTION: Having an adequate supply of personal protective equipment during the COVID-19 pandemic has been a constant challenge for hospitals across the United States. In the event of shortages, our assembled mask might offer noninferior protection compared to an N95 respirator. OBJECTIVE: To study the ability of an assembled mask to pass a quantitative fit testing. METHODS: We conducted a feasibility study at the Oklahoma City Veteran Affairs Health Care System. Volunteers were fitted with an assembled mask made of either a Hans Rudolph half-face mask or a Respironics Performax full-face mask, attached to an Iso-Gard HEPA light Filter 28022 through a Performax SE elbow hinge. Quantitative fit testing was conducted using the Occupation Safety and Health Administration fit testing protocol. The primary outcome was the percentage of participants who pass the quantitative fit test. Secondary outcomes included the overall fit factor (FF), average FF for different exercises, changes in pulse oximetry and end-tidal CO2 at 0 and 15 minutes, willingness to use the mask, and visibility assessment. RESULTS: Twenty participants completed the study, and all (100 percent) passed the quantitative fit testing. The overall FF had a geometric mean of 2,317 (range: 208-16,613) and a geometric standard deviation of 3.8. The lowest FF was recorded while the subjects were talking. Between time 0 and 15 minutes, there was no clinically significant change in pulse oximetry and end-tidal CO2 levels. Most participants reported "very good" visibility and were "highly likely" to use the Hans Rudolph half-face mask in the case of shortage. CONCLUSION: Our assembled respirator offers noninferior protection to N95 respirators in the setting of hypothetical protective equipment shortage.

Diagnosis and management of peripheral lung nodule.

A solitary pulmonary nodule (SPN) is a well-defined radiographic opacity up to 3 cm in diameter that is surrounded by unaltered aerated lung. Frequently, it is an incidental finding on chest radiographs and chest CT scans. Determining the probability of malignancy is the first step in the evaluation of SPN. This can be done by looking at specific risk factors and the rate of radiographic progression. Subsequent management is guided by the type of the nodule. Patients with solid nodules and low pretest probability can be followed radiographically; those with high probability, who are good surgical candidates, can be referred for surgical resection. When the pretest probability is in the intermediate range additional testing such as biopsy should be done. Various modalities are now available to obtain tissue diagnosis. These modalities differ in their yield and complication rate. Patients with SPN should be well informed of each approach's risks and benefits and should be able to make an informed decision regarding the different diagnostic and therapeutic modalities.

Fluid management in Acute Respiratory Distress Syndrome: A narrative review.

Acute Respiratory Distress Syndrome remains a major source of morbidity and mortality in the modern intensive care unit (ICU). Major advances in the understanding and management of this condition were made in the last two decades. The use of low tidal ventilation is a well-established therapy. Conservative fluid management is now another cornerstone of management. However, much remains to be understood in this arena. Assessing volume status in these patients may be challenging and the tools available to do so are far from perfect. Several dynamic measures including pulse pressures variation are used. Ultrasound of the lungs and the vascular system may also have a role. In addition, the type of fluid to administer when needed is still open to debate. Finally, supportive measures in these patients, early during their ICU stay and later after discharge continue to be crucial for survival and adequate recovery.

Pleural fluid glucose testing using a finger stick glucometer: a novel bedside test.

BACKGROUND: Pleural fluid glucose (PFG) has diagnostic and therapeutic implications for the management of pleural effusion. The literature examining point-of-care testing of PFG is limited, and no studies exist for the bedside measurement of PFG using a glucometer (B-PFG). In this study, we compared the accuracy of B-PFG measurement to standard in-lab measurement (Lab-PFG). METHODS: Patients undergoing thoracentesis or thoracostomy were enrolled. PFG was measured at the bedside with a finger stick blood glucometer (ACCU-CHEK® Inform II, Roche) and in the laboratory. Two consecutive measurements were taken using the glucometer, and their mean was compared to the glucose concentration measured in the laboratory. Pearson correlation coefficient and Bland-Altman Plot analysis were used to compare the two measurements. RESULTS: Sixty patients were included. Mean age was 64.1 years. Forty-nine patients had exudative effusions (41% malignant, 26% parapneumonic, and 33% others). There was a significant correlation between the B-PFG and the Lab-PFG (r=0.98, 95% CI of 0.97 to 0.99; P<0.0001). There was good agreement between the B-PFG and the Lab-PFG with a mean difference of 14.8 mg/dL [95% limit of agreement (LOA) of -2.2 to 31.8 mg/dL]. This agreement was even better at glucose values less than 80 mg/dL. CONCLUSIONS: PFG measured at the bedside with a glucometer closely correlates with the laboratory measurement. Further studies are needed prior to incorporating this test in clinical practice.

Bronchoscopic advances in the management of aerodigestive fistulas.

Malignant aerodigestive fistula (ADF) is an uncommon condition complicating thoracic malignancies. It results in increased morbidity and mortality and warrants therapeutic intervention. The management approach depends on symptoms, configuration, location, and extent of the fistula. This article will discuss the therapeutic considerations in the management of ADF.

Management of oral antiplatelet agents and anticoagulation therapy before bronchoscopy.

Although, bronchoscopy is a relatively safe procedure, small amount of bleeding in the airway can have serious consequences. Careful consideration of the risks of diagnostic and therapeutic bronchoscopic intervention can help minimize potential complications. With increasing number of patients using antiplatelet and anticoagulation therapies, strategies for minimizing thromboembolic and operative bleeding events need to be included in the risk and benefit analyses. Growing evidence suggests that aspirin is safe and does not increase bleeding during bronchoscopy. In addition, despite small studies reporting that it may be safe to perform bronchoscopic procedures that have low risk for bleeding such as endobronchial ultrasound with transbronchial needle aspiration on clopidogrel, it is still recommended to hold it for 7 days prior to performing elective bronchoscopy. It is recommended to hold vitamin K antagonist, as well as new oral anticoagulation agents prior to bronchoscopy. The timing for pre-procedural discontinuation of anticoagulation therapy and the decision to bridge depend on the agent used, the renal function and the thromboembolic risk. In this review article, we will discuss available data regarding management of anticoagulation and antiplatelet therapy as it applies to bronchoscopic procedures.

IVC Measurements in Critically Ill Patients with Acute Renal Failure.

OBJECTIVE: To determine whether the inferior vena cava (IVC) measurement by bedside ultrasound (US-IVC) predicts improvement in renal function in patients with acute kidney injury (AKI). DESIGN: Prospective observational study. SETTING: Medical intensive care unit. PATIENTS: 33 patients with AKI were included. INTERVENTION: US-IVC was done on admission. The patients' management was done by the primary teams, who were unaware of the US-IVC findings. Two groups of patients were identified. Group 1 included patients who were managed in concordance with their US-IVC (potential volume responders who had a positive fluid balance at 48 h after admission and potential volume nonresponders who had an even or negative fluid balance at 48 hours after admission). Group 2 included patients in whom the fluid management was discordant with their US-IVC. MEASUREMENTS AND MAIN RESULTS: At 48 hours, Group 1 patients had a greater improvement in creatinine [85% versus 31%, p = 0.0002], creatinine clearance (78 ± 93% versus 8 ± 64%, p = 0.002), and urine output (0.86 ± 0.54 versus 0.45 ± 0.36 ml/Kg/h, p = 0.03). CONCLUSION: In critically ill patients with AKI, concurrence of fluid therapy with IVC predicted fluid management, as assessed by bedside ultrasound, was associated with improved renal function at 48 hours. This trial is registered with ClinicalTrials.gov registration number: NCT02064244.

Review and Outcome of Prolonged Cardiopulmonary Resuscitation.

The maximal duration of cardiopulmonary resuscitation (CPR) is unknown. We report a case of prolonged CPR. We have then reviewed all published cases with CPR duration equal to or more than 20 minutes. The objective was to determine the survival rate, the neurological outcome, and the characteristics of the survivors. Measurements and Main Results. The CPR data for 82 patients was reviewed. The median duration of CPR was 75 minutes. Patients mean age was 43 ± 21 years with no significant comorbidities. The main causes of the cardiac arrests were myocardial infarction (29%), hypothermia (21%), and pulmonary emboli (12%). 74% of the arrests were witnessed, with a mean latency to CPR of 2 ± 6 minutes and good quality chest compression provided in 96% of the cases. Adjunct therapy included extracorporeal membrane oxygenation (18%), thrombolysis (15.8%), and rewarming for hypothermia (19.5%). 83% were alive at 1 year, with full neurological recovery reported in 63 patients. Conclusion. Patients undergoing prolonged CPR can survive with good outcome. Young age, myocardial infarction, and potentially reversible causes of cardiac arrest such as hypothermia and pulmonary emboli predict a favorable result, especially when the arrest is witnessed and followed by prompt and good resuscitative efforts.

Bronchial responsiveness in patients with restrictive spirometry.

BACKGROUND: Improvement in PFT after bronchodilators is characteristic of obstructive airway diseases such as COPD. However, improvement in patients with restrictive pattern is occasionally seen. We aim to determine the clinical significance of a bronchodilator responsive restrictive defect. METHODS: Patients with restrictive spirometry and a bronchodilator study were identified at the University of Oklahoma and Oklahoma City VAMC between September 2003 and December 2009. Restriction was defined as a decreased FVC and FEV1, with normal FEV1/FVC. Responsiveness to bronchodilators was defined as an improvement in FEV1 and/or FVC of at least 12% and 200 mL. Patients with lung volume measurements had their clinical and radiographic records reviewed. RESULTS: Twenty-one patients were included in the study. Most were current or ex-smokers, with most being on bronchodilators. The average FVC and FEV1 were 65 ± 11% and 62 ± 10% of the predicted, respectively. Most patients (66%) had a normal TLC, averaging 90 ± 16% of the predicted. RV, RV/TLC, and the TLC-VA values strongly suggested an obstructive defect. CONCLUSIONS: Reversible restrictive pattern on spirometry appears to be a variant of obstructive lung disease in which early airway closure results in air trapping and low FVC. In symptomatic patients, a therapeutic trial of bronchodilators may be beneficial.

Dornase alpha compared to hypertonic saline for lung atelectasis in critically ill patients.

BACKGROUND: Despite the lack of randomized trials, nebulized Dornase alpha and hypertonic saline are used empirically to treat atelectasis in mechanically ventilated patients. Our objective was to determine the clinical and radiological efficacy of these medications as an adjunct to standard therapy in critically ill patients. METHODS: Mechanically ventilated patients with new onset (<48 h) lobar or multilobar atelectasis were randomized into three groups: nebulized Dornase alpha, hypertonic (7%) saline or normal saline every 12 h. All patients received standard therapy, including chest percussion therapy, kinetic therapy, and bronchodilators. The primary endpoint was the change in the daily chest X-ray atelectasis score. RESULTS: A total of 33 patients met the inclusion criteria and were randomized equally into the three groups. Patients in the Dornase alpha group showed a reduction of 2.18±1.33 points in the CXR score from baseline to day 7, whereas patients in the normal saline group had a reduction of 1.00±1.79 points, and patients in the hypertonic saline group showed a score reduction of 1.09±1.51 points. Pairwise comparison of the mean change of the CXR score showed no statistical difference between hypertonic saline, normal saline, and dornase alpha. Airway pressures as well as oxygenation, expressed as PaO(2)/F(I)O(2) and time to extubation also were similar among groups. During the study period the rate of extubation was 54% (6/11), 45% (5/11), and 63% (7/11) in the normal saline, hypertonic saline, and Dornase alpha groups, respectively (p=0.09). No treatment related complications were observed. CONCLUSIONS: There was no significant improvement in the chest X-ray atelectasis score in mechanically ventilated patients with new onset atelectasis who were nebulized with Dornase alpha twice a day. Hypertonic saline was no more effective than normal saline in this population. Larger randomized control trials are needed to confirm our results.

Optical coherence tomography as an adjunct to flexible bronchoscopy in the diagnosis of lung cancer: a pilot study.

UNLABELLED: Lung cancer is the leading cause of cancer-related deaths in the United States and the second most common type of cancer in both men and women. Optical coherence tomography (OCT) scanning can generate high-resolution cross-sectional images of complex, living tissues in real time. The objectives of this study were to determine the feasibility of using OCT imaging during flexible bronchoscopy and to preliminarily assess the ability of OCT imaging to distinguish an endobronchial malignancy from normal endobronchial mucosa. A Niris OCT probe was introduced into the airways of patients with an endobronchial mass during flexible bronchoscopy. An investigational device exemption was approved by the US Food and Drug Administration for the use of the OCT system in this study. Conventional OCT scans of an endobronchial mass and a control area of normal bronchial mucosa were performed to generate real-time images in each patient. Following OCT imaging, the same sites were biopsied for pathologic correlation. We report on the first five patients enrolled. A total of 60 OCT images with corresponding endobronchial biopsy specimens were obtained. The average procedure time was 29 min. The histopathologic diagnoses of the endobronchial masses included two small cell carcinomas, one squamous cell carcinoma, one adenocarcinoma, and one endobronchial schwannoma. Microstructures of normal bronchial mucosa, including epithelium and lamina propria, were identified with OCT imaging. OCT scan features of malignancy included loss of normal, identifiable microstructures and subepithelial "optical fracture" of tissues. All patients tolerated the endobronchial imaging well without complications. Preliminary results suggest that OCT imaging is a technically feasible adjunct to flexible bronchoscopy in the diagnosis of lung cancer. This is the first reported use of OCT to generate images of endobronchial neoplasms during flexible bronchoscopy in the United States. This technology may in the future provide a noninvasive "optical biopsy," which could potentially guide the bronchoscopist to areas for biopsy or even obviate the need for conventional lung biopsies. TRIAL REGISTRATION: clinicaltrials.gov; Identifier: NCT01039311.

Endobronchial nodules in a patient with rheumatoid arthritis.

We report the case of a patient with rheumatoid arthritis who presented with endobronchial nodules. Endobronchial biopsy showed a large B cell lymphoma. Non-Hodgkin lymphoma rarely involves the endobronchial tree, and is typically treated with systemic chemotherapy, but in this case additional treatment with argon plasma coagulation was used for local control of the disease.

The use of statins and lung function in current and former smokers.

BACKGROUND: Smokers are affected by a variety of inflammatory diseases, including COPD. Statins, 3-hydroxy-3-methyl-glutaryl-coenzyme-A reductase inhibitors, are used for their lipid-lowering characteristics but also appear to have antiinflammatory and immunomodulatory activities. We assessed their ability to preserve lung function in current and former smokers. METHODS: All smokers and ex-smokers seen at the Oklahoma City VA hospital in 2005 with abnormal baseline spirometry findings and two or more pulmonary function tests done 6 months apart were classified into obstructive and restrictive groups based on the initial PFT result. Statin use, annual decline in FEV(1) and FVC, and need for respiratory-related urgent care (emergency department or inpatient) were compared. RESULTS: Approximately one half, 215 of 418 patients, were receiving a statin. Compared to the control group, statin users had a lower decline in FEV(1) (- 0.005 +/- 0.20 L/yr vs 0.085 +/- 0.17 L/yr, p < 0.0001) and FVC (- 0.046 +/- 0.45 L/yr vs 0.135 +/- 0.32 L/yr, p < 0.0001) [mean +/- SD]. This difference remained significant irrespective of whether the patient had obstructive (n = 319), or restrictive (n = 99) disease, and regardless of whether the patient continued or stopped smoking. In patients with an obstructive spirometry finding, we found a lower incidence of respiratory-related urgent care in favor of the statin group (0.12 +/- 0.29 patient-years vs 0.19 +/- 0.32/patient-years; p = 0.02). CONCLUSION: In smokers and former smokers, statins are associated with a slower decline in pulmonary function, independent of the underlying lung disease. CLINICAL IMPLICATION: Prospective, randomized trials are needed to study the effect of statins on lung function.

Rounded atelectasis with atypical computed tomography findings.

Rounded atelectasis is atelectasis of the peripheral part of the lung, typically in contact with thickened pleura, featuring characteristic computed tomography findings. In this case, a 61-year-old man with history of asbestos exposure presented with a right-middle-lobe nodule on chest radiograph, with computed tomography findings suspicious for neoplasm. The patient underwent surgical resection, which revealed rounded atelectasis. Our case raises a question about the sensitivity of radiographic criteria used in identifying rounded atelectasis, and it emphasizes the need to keep rounded atelectasis in the differential diagnosis of a single pulmonary nodule in a patient with a history of asbestos exposure.

Hepatic hydrothorax.

A hepatic hydrothorax is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. The pleural effusion is derived from ascitic fluid that enters the chest because of the negative pressure within the pleural space via defects in the diaphragm. The peritoneal-to-pleural flow of fluid can be demonstrated by nuclear scanning, even when the ascites is not clinically apparent. The pleural fluid usually has the characteristics of a transudate. However, an occasional patient with hepatic hydrothorax will develop spontaneous bacterial pleuritis manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. Treatment of the hydrothorax is directed at the underlying liver disease but a dyspneic patient can obtain relief from a thoracentesis or paracentesis. When medical therapy fails, liver transplantation is the treatment of choice. Both transjugular intrahepatic portosystemic shunting and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality of these procedures are high because of the fragile nature of the patients.