Influence of trainee involvement on procedural characteristics for linear endobronchial ultrasound.

BACKGROUND: Linear endobronchial ultrasound (EBUS) is a safe and effective method for the diagnostic sampling of mediastinal lymph nodes. However, there is a learning curve associated with the procedure and operator experience influences diagnostic yield. We sought to determine if trainee involvement during EBUS influences procedural characteristics, complication rate, and diagnostic yield. METHODS: We performed a retrospective analysis of 220 subjects who underwent an EBUS procedure at our center from December 2012 to June 2013. Procedures were performed by six different interventional pulmonologists with substantial experience with EBUS or by a trainee under their direct supervision. Procedural characteristics and complications were recorded. Diagnostic yield and specimen adequacy were compared between groups. RESULTS: EBUS was performed in 220 patients with a trainee involved (n = 116) or by staff physician alone (n = 104). Patient characteristics, and the number and size of lymph node stations sampled were similar. EBUS duration was longer (16.0 vs. 13.7 minutes; P = 0.002) and the total dose of lidocaine used was higher (322.3 vs. 304.2 mg; P = 0.045) when a trainee was involved. The rate of adequate specimens sampled was comparable between the groups (92.0 vs. 92.0%; P = 0.60). Diagnostic yield was lower when a trainee was involved in the EBUS procedure (52.6 vs. 68.3%; P = 0.02). CONCLUSION: Trainee involvement significantly increased EBUS duration and the dose of local anesthesia used for the procedure. Diagnostic yield was lower when a trainee was involved. Factors accounting for this difference in yield, despite adequate samples being obtained, warrant further investigation.

Evaluation of Pulmonary Nodules Using the Spyglass Direct Visualization System Combined With Radial Endobronchial Ultrasound: A Clinical Feasibility Study.

BACKGROUND: Sampling of peripheral pulmonary nodules with radial endobronchial ultrasound (p-EBUS) increases diagnostic yield of bronchoscopy. However, diagnostic yield is influenced by numerous factors. OBJECTIVE: We evaluated the use of SpyGlass, a one millimeter diameter optic fiber, to obtain images of the distal mucosa and of pulmonary lesions detected with p-EBUS to determine if visual aspect of the distal mucosa was predictive of diagnosis. METHODS: We prospectively recruited subjects investigated for peripheral nodules. Bronchoscopy was performed and p-EBUS was used to locate the lesion through a guide sheath. The Spyglass fiber was introduced in the sheath to obtain images of the distal bronchial mucosa. Tissue sampling was subsequently done. RESULTS: Fifteen patients were enrolled in the study. A final diagnosis of malignancy was confirmed in 80%. All lesions could be located using p-EBUS (100%). Diagnostic sensitivity for p-EBUS was 58.3%. Distal mucosa could be imaged with SpyGlass in 14/15 patients (93.3%). Mucosal appearance was described as abnormal in 7 out of the 15 subjects. Mean SpyGlass procedure time was 6.5 minutes. No direct complication was reported. CONCLUSION: Spyglass can be used in combination with p-EBUS to obtain images of the distal bronchial mucosa and peripheral pulmonary nodules. More patients will be needed to confirm whether mucosal appearance can be predictive of malignancy.

Randomized Trial Comparing Patient Comfort Between the Oral and Nasal Insertion Routes for Linear Endobronchial Ultrasound.

BACKGROUND: Linear endobronchial ultrasound (EBUS) is a safe and accurate sampling method for mediastinal adenopathy. The transnasal approach has been proposed to improve patient comfort, but no data compare the oral and nasal routes. The objective was to compare patient comfort during linear EBUS under conscious sedation between the oral and the nasal routes. METHODS: An open-label randomized study comparing the 2 insertion routes for linear EBUS was conducted. Standardized protocols for sedation and topical anesthesia were used. Primary outcome was subjects' comfort measured by a 10-point scale filled 2 hours after the procedure. Willingness to return for a repeat examination, procedural characteristics, complications, and diagnostic yields were also compared. RESULTS: A total of 220 subjects were randomized and allocated to the nasal (n=110) or oral (n=110) route. Twenty-seven subjects in the nasal group (24.5%) had a failed nasal insertion but were analyzed in the nasal group. Procedural characteristics were similar (EBUS duration, doses of sedatives and lidocaine, number of stations sampled, complications). There was no difference between the nasal and oral groups in subjects' comfort (8.3 vs. 8.3, respectively, P=0.99), overall patient satisfaction (8.9 vs. 9.1, respectively, P=0.34), subjects' willingness to return (96% vs. 97%, P=1.00), and physician-reported subject comfort. Rates of adequate specimens and diagnostic yields did not differ significantly between the groups. CONCLUSIONS: For linear EBUS, the nasal and oral approaches confer a similarly high degree of patient comfort with similar complication rates and diagnostic yield. Patient and physician preferences should dictate the route of insertion.

Effects of Bronchial Thermoplasty on Airway Smooth Muscle and Collagen Deposition in Asthma.

RATIONALE: The aim of bronchial thermoplasty is to improve asthma symptoms by reducing central airway smooth muscle mass. Up to now, the reduction of smooth muscle mass has been documented for only 1 group of 10 patients who had 15% or more of their pretreatment total bronchial biopsy area occupied by smooth muscle. OBJECTIVES: To evaluate the effects of bronchial thermoplasty on airway smooth muscle mass and airway collagen deposition in adult patients with asthma, regardless of pretreatment smooth muscle area. METHODS: Seventeen patients with asthma underwent bronchial thermoplasty over the course of three visits. At Visit 1, bronchial biopsies were taken from the lower lobe that was not treated during this session. At Visit 2 (3-14 wk after the first visit), all 17 patients underwent biopsy of the lower lobe treated during the first procedure. At Visit 3 (7-22 wk after the first visit), nine patients agreed to undergo biopsy of the same lower lobe. Histological and immunohistochemical analyses were performed on the biopsy specimens. MEASUREMENTS AND MAIN RESULTS: Bronchial thermoplasty decreased airway smooth muscle from 12.9 ± 1.2% of the total biopsy surface at Visit 1 to 4.6 ± 0.8% at Visit 2 (P < 0.0001). For the nine patients who underwent a third biopsy, mean airway smooth muscle area was 5.3 ± 1.3% at Visit 3 (P = 0.0008 compared with baseline). Bronchial thermoplasty also decreased Type I collagen deposition underneath the basement membrane from 6.8 ± 0.3 µm at Visit 1 to 4.3 ± 0.2 µm at Visit 2 (P < 0.0001) and to 4.4 ± 0.4 µm for nine patients at Visit 3 (P < 0.0001 compared with baseline). Over the course of 1 year after treatment, the doses of inhaled corticosteroid, the number of severe exacerbations, and asthma control all improved (P ≤ 0.02). CONCLUSIONS: For patients with severe asthma, bronchial thermoplasty reduced the smooth muscle mass of treated airway segments, regardless of the baseline level of muscle mass. Treatment also altered the deposition of collagen. At follow-up, bronchial thermoplasty improved asthma control; however, the limited number of subjects did not allow us to evaluate possible correlations between these improvements and the studied histological parameters. Further studies are needed to confirm these results and evaluate their persistence.

Importance of viral and bacterial infections in chronic obstructive pulmonary disease exacerbations.

BACKGROUND: Few studies have evaluated the contribution of both viruses and bacteria in acute exacerbation of chronic obstructive pulmonary disease (AECOPD). OBJECTIVES: This study estimated the burden of both types of pathogens among adults seeking care for an AECOPD during two consecutive winter seasons. STUDY DESIGN: Patients 50 years or older who consulted within 10 days of AECOPD onset were eligible. Clinical data were collected on a standardized questionnaire, and nasopharyngeal aspirates (NPA), paired sera, and non-induced sputum were collected. Polymerase chain reaction (PRC) assays were used to identify viral, atypical and bacterial pathogens in NPA specimen. RESULTS: Overall, 108 patients with AECOPD were included, 88% of patients were admitted and 2 patients (2%) received intensive care. A third of patients (31%) had evidence of a viral infection, 9% with influenza A, 7% RSV and 7% with PIV-3. One patient was positive for Mycoplasma pneumoniae. Bacterial pathogens were identified in 49% of patients with available sputum, most frequently Staphylococcus aureus, Pseudomonas aeruginosa, and Haemophilus influenzae. Among virus-infected patients, 14 (58%) also had bacteria in their sputum, but co-infected patients did not present with different symptoms than patients with single infections. CONCLUSIONS: These results suggest that influenza and RSV are frequent contributors of AECOPD, and that coinfection with bacteria does not appear to be more severe among virus-infected patients. Clinicians should be aware that AECOPD may be frequently triggered by viruses, and may consider antivirals and proper infection control measures in appropriate epidemiological setting.