Safety and feasibility of ultrathin probe transbronchial lung cryobiopsy without balloon blocker via robotic bronchoscopy in the evaluation of peripheral lung lesions: a retrospective pilot study.

Ultrathin probe transbronchial lung cryobiopsy (UP-TBLC) via robotic bronchoscopy can be safely performed without prophylactic balloon blockade. UP-TBLC offers incremental diagnostic yields of ultrasonographic eccentric lesions. https://bit.ly/3YUEWx4.

Current Practices Supporting Rigid Bronchoscopy-An International Survey.

BACKGROUND: There are no guidelines for anesthesia or staff support needed during rigid bronchoscopy (RB). Identifying current practice patterns for RB pertinent to anesthesia, multidisciplinary teams, and algorithms of intra and post-procedural care may inform best practice recommendations. METHODS: Thirty-three-question survey created obtaining practice patterns for RB, disseminated via email to the members of the American Association of Bronchology and Interventional Pulmonology and the American College of Chest Physicians Interventional Chest Diagnostic Procedures Network. RESULTS: One hundred seventy-five clinicians participated. Presence of a dedicated interventional pulmonology (IP) suite correlated with having a dedicated multidisciplinary RB team ( P =0.0001) and predicted higher likelihood of implementing team-based algorithms for managing complications (39.4% vs. 23.5%, P =0.024). A dedicated anesthesiology team was associated with the increased use of high-frequency jet ventilation ( P =0.0033), higher likelihood of laryngeal mask airway use post-RB extubation ( P =0.0249), and perceived lower rates of postprocedural anesthesia adverse effects ( P =0.0170). Although total intravenous anesthesia was the most used technique during RB (94.29%), significant variability in the modes of ventilation and administration of muscle relaxants was reported. Higher comfort levels in performing RB are reported for both anesthesiologists ( P =0.0074) and interventional pulmonologists ( P =0.05) with the presence of dedicated anesthesia and RB supportive teams, respectively. CONCLUSION: Interventional bronchoscopists value dedicated services supporting RB. Multidisciplinary dedicated RB teams are more likely to implement protocols guiding management of intraprocedural complications. There are no preferred modes of ventilation during RB. These findings may guide future research on RB practices.

Safety and Efficacy of Manual Aspiration Via Small Bore Chest Tube in Facilitating the Outpatient Management of Transbronchial Biopsy-related Iatrogenic Pneumothorax.

BACKGROUND: Iatrogenic pneumothorax complicates transbronchial biopsies with a prevalence of 1% to 6%. Conventional treatment consists of inpatient management with chest tube drainage. While aspiration techniques have been investigated in the management of both primary spontaneous and transthoracic lung biopsy-induced pneumothorax, its role in the management of transbronchial biopsy-iatrogenic pneumothorax (TBBX-IP) is undefined. An appealing treatment alternative for TBBX-IP may exist in the placement of a small bore chest tube (SBCT) followed by a manual aspiration (MA) technique promoting earlier SBCT removal to facilitate outpatient management. To our knowledge, no study exists evaluating the efficacy of MA via a SBCT performed specifically for TBBX-IP. PATIENTS AND METHODS: Prospective evaluation of the efficacy of a protocolized pathway incorporating MA through a SBCT for the outpatient management of TBBX-IP. Primary outcome was the clinicoradiographic resolution of TBBX-IP avoiding hospitalizations. RESULTS: A total of 763 biopsies performed; 31 complicated by TBBX-IP, 18 qualified for intervention. Sixteen were outpatients, 2 inpatients. Thirteen (81.25%) of the 16 outpatients were successfully treated with MA via SBCT and did not require admission. Twelve (75%) of these 13 had SBCT removed, 1 patient was discharged with SBCT and removed in 24 hours. Of the 18 patients requiring intervention, 13 (72.2%) were successfully treated with MA via SBCT enabling removal of SBCT. No patient required reintervention. CONCLUSION: MA via SBCT represents a safe and viable management approach of TBBX-IP promoting earlier SBCT removal and decreased hospitalizations. Our results challenge conventional management of TBBX-IP warranting further investigation.

Ambulatory Iodopovidone Instillation Via Indwelling Pleural Catheters For Malignant Pleural Effusions.

Malignant pleural effusions' (MPEs) treatment goals focus on optimizing the quality of life and decreasing time spent in health care facilities in this patient population with limited life expectancy. Numerous pleural palliation options and combination of these exist and continue to undergo studies to identify safe, superior and ideally patient-centered care. We report a cohort of 13 patients with symptomatic MPE managed with iodopovidone intrapleural instillation via an indwelling pleural catheter (IPC) in the ambulatory setting. Successful complete pleurodesis was achieved in 10 of 13 (76.9%) patients at a median time of 5 days with IPC removal at a median of 16 days. Two patient obtained partial pleurodesis with IPC removal, 1 required IPC reinsertion due to symptom recurrence. Complications were limited to intraprocedural pain in 4 patients (31%). Iodopovidone pleurodesis via IPC may represent a safe, feasible, and effective ambulatory-based option for pleural palliation in MPE.

Protocolized Thoracic Ultrasonography in Transbronchial Lung Cryobiopsies: A Potential Role as an Exclusion Study for Pneumothorax.

BACKGROUND: Widespread implementation of transbronchial lung cryobiopsy (TBLCB) in the diagnostic approach to diffuse parenchymal lung disease has prompted a call for standardization of technique to optimize safety and diagnostic yield. Thoracic ultrasound (TUS) is proving effective in detecting postconventional transbronchial biopsy pneumothorax (PTX). However, TUS does not obviate the need for chest radiography (CXR) which quantifies and guides treatment of PTX. To our knowledge, this is the first experience evaluating TUS's reliability to rule-out PTX post-TBLCB in diffuse parenchymal lung disease. METHODS: Retrospective analysis of patients undergoing TBLCB. A standardized pre-TBLCB/post-TBLCB TUS was performed to detect the presence or absence of sliding lung (SL). TUS' findings were then compared with CXR performed at 1 hour after TBLCB. RESULTS: A total of 24 patients' records reviewed. In total, 21 of 24 patients had SL in all lung zones on TUS before and after TBLCB, with a negative CXR for PTX in all 21 patients. The negative predictive value was 100% (95% confidence interval, 84%-100%). Three patients did not have SL in all lung zones on TUS, of which 2 showed the absence of SL in all lung zones on both pre-TBLCB and post-TBLCB TUS, with negative CXR for PTX. 1 of the 3 showed SL in all zones pre-TBLCB and in only 2 zones post-TBLCB. CXR confirmed PTX in this 1 patient. CONCLUSION: Our study demonstrates a 100% negative predictive value for the exclusion of PTX via TUS' verification of SL. The practical value of TUS post-TBLCB may lie in its application as a rule-out study, thereby avoiding CXR.

Venous-Airway Fistula With Aspergilloma: A Case of an Implanted Catheter Gone Bad.

The implanted venous access catheter is commonly used in the treatment of oncology patients. Although common long-term complications of these devices, such as infection and thrombosis, have been widely reported, venous-airway fistula due to port placement is an extremely rare and poorly understood complication. We report a case of a 56-year-old woman with pancreatic adenocarcinoma whose implanted catheter was complicated by the development of an azygo-bronchial fistula with a concomitant aspergilloma. Herein is the first reported case of successful venous-airway fistula closure obtained through silicone stenting.

Awareness, Competencies, and Practice Patterns in Tracheobronchomalacia: A Survey of Pulmonologists.

BACKGROUND: Tracheobronchomalacia (TBM) is a disorder of expiratory central airway collapse. TBM is separate from excessive dynamic airway collapse. Historically TBM has lacked a universally accepted definition. No consensus recommendations on evaluation and management exist. We suspect these unresolved issues contribute to deficits in pulmonologists' awareness and management of TBM. METHODS: We created a 20-question survey obtaining information about overall awareness, knowledge base, competencies, and practice patterns in managing TBM. The survey was disseminated via email by American College of Chest Physicians to members of their Interventional Chest Diagnostic Procedures Network. RESULTS: One hundred sixty-five clinicians participated in the survey. Seventy-seven percent of respondents chose the correct definition for TBM. Twenty-two percent of respondents never considered TBM in patients with cough, sputum production, dyspnea, and recurrent infections. Thirty-eight percent did not proceed with further evaluation of TBM if pulmonary function tests were normal. Eighteen percent use a classification system to describe the severity of TBM. Only 29% could identify TBM on bronchoscopy and only 39% identified TBM on computed tomography. Respondents that practice interventional pulmonology demonstrated a better knowledge base of TBM. CONCLUSION: This survey exposes deficits among pulmonologists in their ability to confidently and correctly diagnose and manage TBM. These deficits are not surprising as our understanding of this clinical entity is evolving. There exists a need for further education of pulmonologists about TBM and a need to promote collaborative efforts through research and expert consensus committees to progress our knowledge and management of this disease.

Stereotactic body radiotherapy (SBRT) for high-risk central pulmonary metastases.

BACKGROUND AND PURPOSE: Radiotherapy of central lung tumors carries a higher risk of treatment-related toxicity and local failure. In the era of aggressive oligometastic management the exploration of the proper dose-fractionation for metastatic central lung tumors is essential. MATERIALS AND METHODS: Patients diagnosed with high-risk metastatic lesions of the central pulmonary tree comprised this single-institutional retrospective analysis. "High-risk" central pulmonary lesions were defined as those with abutment and/or invasion of the mainstem bronchus. All patients were treated using the CyberKnife SBRT system in 5 fractions to a total dose of 35 or 40 Gy. RESULTS: Twenty patients were treated from 2008 to 2011 at Georgetown University Hospital. At a median follow up of 19 months, 1-year Kaplan-Meier local control and overall survival was 70 and 75 %, respectively. Late grade 2 or higher atelectasis was the most common treatment-related toxicity and was significantly associated with maximum dose to the mainstem bronchus. Gross endobronchial involvement was associated with significantly lower overall survival. CONCLUSIONS: Five-fraction SBRT to a total dose of 35 or 40 Gy appears to be a safe and effective management strategy for high-risk central pulmonary metastatic lesions, though care should be taken to limit the maximum point dose to the mainstem bronchus.

Plasma levels of retinoids, carotenoids and tocopherols in patients with mild obstructive sleep apnoea.

BACKGROUND AND OBJECTIVE: OSA is associated with increased incidence of cardiovascular diseases. Pathogenic mechanisms of vascular diseases include thickened vascular walls due to the increased number of smooth muscle cells (SMC). Retinoic acid (RA) suppresses the growth of SMC, and reduced retinoid levels are associated with vascular diseases. Oxidant signalling promotes SMC growth, thus antioxidant levels may also influence the development of cardiovascular diseases. The present study tested the hypothesis that plasmas from OSA patients contain altered levels of retinoids, carotenoids and tocopherols. METHODS: Plasma samples were taken before and after sleep from patients with OSA (mostly mild) without known cardiovascular diseases and from control subjects. Levels of retinoids, carotenoids and tocopherols were measured using sensitive gas chromatograph-mass spectrometry and high pressure liquid chromatography methods and total antioxidant capacity was assessed fluorometrically. RESULTS: Results showed that plasmas from patients with OSA had significantly lower retinyl palmitate and 9-cis RA compared with control subjects, while levels of retinol, all-trans RA and 13-cis RA were indifferent. All-transbeta-carotene and 9-cisbeta-carotene were also lower in OSA patients. Levels of all-trans RA and 13-cis RA in OSA patients were reduced after sleep compared with before sleep. OSA patients showed significantly higher delta-tocopherol compared with controls. Treatment of cultured human vascular SMC with post-sleep OSA patient plasmas promoted cell growth, but not in controls. CONCLUSIONS: Mild OSA exhibits altered levels of specific retinoids, carotenoids and tocopherols, which may be markers and/or mediators for the increased susceptibility of patients to vascular diseases.