A Novel Simulator for Teaching Endobronchial Ultrasound-guided Needle Biopsy.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become standard for the diagnosis of lung cancer, and there is an increasing need for procedural competence in trainees. We evaluate a low-cost, gelatin-based EBUS-TBNA training simulator to assess pulmonary fellows' baseline skills and facilitate procedural development. METHODS: A low-cost ($30) gelatin-based, high-fidelity simulator was created to represent the airways, major vessels, and lymph node stations essential to identify for EBUS-TBNA. Trainees had a baseline skills assessment using the simulator and were then provided a 1-hour didactic session on EBUS-TBNA and additional practice time with the simulator. Trainees then underwent a postsimulation skills assessment using a modified endobronchial ultrasound (EBUS)-Skills and Tasks Assessment Tool (STAT) performance assessment tool. Simulator fidelity and trainee procedural confidence was assessed using a 10-point scale. RESULTS: Ten fellows received training on the EBUS-TBNA simulator. First-year trainees scored the lowest on the 18-point performance scale with a mean score of 9, while third-year trainees scored highest with a mean score of 17.5. Mean 18-point performance score improvement after simulator training and didactics was 4.31 points for all trainees with the largest change in first-year trainees amounting to 8.25 points. First-year trainees experienced the greatest improvement in EBUS procedural confidence by a mean of 2.5 points on a 10-point confidence survey. CONCLUSION: A low-cost EBUS simulator effectively differentiated early and advanced learners based on graded procedural performance scores. Simulation-based practice significantly improved learners' procedural performance, and the degree of improvement correlated with learner inexperience. The simulation significantly increased early learner confidence in EBUS-TBNA technique.

The role of interventional pulmonology in pleural disease diagnosis and management.

PURPOSE OF REVIEW: Pleural disease guidelines have not been updated in a decade. Advances have been made in the diagnosis and management of pleural diseases since, with expanding evidence of the utility of medical thoracoscopy (MT) as a safe and effective tool. RECENT FINDINGS: Although thoracic ultrasound has improved early determination of pleural disease etiology, thoracentesis remains limited, and pleural tissue is necessary for the diagnosis of undifferentiated exudative pleural effusions. Medical thoracoscopy has been shown to be superior to traditional closed pleural biopsy, and recent literature is focused on which technique is best. A recent randomized controlled trial (RCT) found rigid mini-thoracoscopy was not superior to semirigid thoracoscopy. Meta-analyses have not found pleural cyrobiopsy to be superior to forceps biopsies. As a therapeutic tool, meta-analysis suggests MT as a possible first-line tool for the treatment of complicated parapneumonic effusions (CPE) and early empyema. A RCT comparing MT to intrapleural fibrinolytic therapy demonstrated that the former technique is safe, effective, and may shorten hospital length of stay in patients with CPE/empyema. SUMMARY: The implications of the recent findings in the medical literature are that medical thoracoscopy, particularly by trained Interventional Pulmonologists, will find an expanded role in future iteration of pleural disease guidelines.

Endobronchial Valve Placement for Persistent Air Leaks Secondary to Pulmonary Infections.

BACKGROUND: Pneumothoraces associated with infectious diseases have a higher rate of treatment failure and longer length of hospital stay than those associated with obstructive lung diseases and malignancy. Little is mentioned in the medical literature concerning the use of endobronchial 1-way valves in treating alveolar-pleural fistulae (APF) caused by pulmonary infections. METHODS: A 7-year, single-center, retrospective analysis of patients consented for exempted off-label use of the Olympus Spiration Implantable Endobronchial Valve system to control prolonged air leaks at the University of Cincinnati Medical Center. RESULTS: Nineteen consecutive patients had 22 separate APF events from pulmonary infections during which a total of 101 valves were placed over 23 procedures (average 4.4±2.8 valves per procedure). The average time from the first chest tube placement to valve placement was 23.4±20.8 days (range, 2 to 84 d). Chest tubes were successfully removed in 19 (86.4%) of 22 APF events without further intervention. In events not including chest tubes remaining solely for empyema treatment after cessation of air leak (n=14), the average time from valve placement to the removal of all chest tubes was 12.8±20.2 days (1 to 81 d). Thirty and ninety day all-cause mortality was 15.8%. On average, valves were removed 64.1±27.1 days (range, 38 to 135 d) after placement. CONCLUSION: Based on our institutional experience, endobronchial valves may be a treatment option for select patients with persistent air leaks caused by pulmonary infections. Further standardized and comparative studies are required to fully understand the risks and benefits of this treatment.

Desvenlafaxine-Induced Interstitial Pneumonitis: A Case Report.

A 52-year-old man developed interstitial pneumonitis during treatment with desvenlafaxine for major depressive disorder. The man received desvenlafaxine at 50 mg for symptoms of depression 4 years earlier. Six months after a dose increase to 100 mg, he developed bronchitic symptoms with mild, persistent dyspnea. Investigations revealed a restrictive pattern on pulmonary function testing, bilateral upper lobe reticular opacities with traction bronchiectasis on radiology imaging, and end-stage interstitial fibrosis with honeycomb changes consistent with chronic hypersensitivity pneumonitis on open lung biopsy. He was diagnosed with drug-induced interstitial pneumonitis. Desvenlafaxine was discontinued and the patient received prednisone and mycophenolate mofetil. The patient had subsequent stability in the progression of his pulmonary disease after 1 month. After 1 year of drug discontinuation and treatment, his disease process remained, but without major progression. A Naranjo assessment score of 4 was obtained, indicating a possible relationship between the patient's adverse drug reaction and his use of the suspect drug.

Improved transplant-free survival in patients with systemic sclerosis-associated pulmonary hypertension and interstitial lung disease.

OBJECTIVE: Survival in patients with systemic sclerosis (SSc)-associated pulmonary hypertension (PH) and interstitial lung disease (ILD) is poor. Evidence supporting the efficacy of aggressive pulmonary arterial hypertension (PAH)-targeted therapy in this population is limited. The aim of this study was to investigate transplant-free survival in patients with isolated SSc-related PAH or SSc-related PH-ILD who were treated with aggressive PAH-targeted therapy. METHODS: SSc patients with right-sided heart catheterization (RHC)-diagnosed precapillary PH (mean pulmonary artery pressure ≥25 mm Hg, pulmonary capillary wedge pressure ≤15 mm Hg, and pulmonary vascular resistance ≥240 dynes × second/cm(5) ) were included. Patients were classified as having ILD based on review of high-resolution computed tomography (CT) chest imaging and spirometry. The Kaplan-Meier method was applied and Cox proportional hazards models were constructed to analyze survival and identify predictive variables. RESULTS: Of 99 patients with SSc-related precapillary PH, 28% had SSc-related PAH and 72% had SSc-related PH-ILD. The 1- and 2-year survival estimates were, respectively, 72% and 59% in the SSc-related PH-ILD group versus 82% and 66% in the SSc-related PAH group (P = 0.5). Within 6 months of the diagnostic RHC, 24% of all patients were started on prostanoid therapy; an additional 24% were started on prostanoid therapy after 6 months. In the multivariate model, male sex (hazard ratio [HR] 0.7, P = 0.01) and prostanoid therapy initiation within 6 months of the RHC (HR 1.4, P = 0.01) were the only factors significantly associated with transplant-free survival, after accounting for the presence of ILD and severity of PH. CONCLUSION: In this study, survival of patients with SSc-related PH-ILD was modestly improved relative to historical series. While these findings may not be generalizable, improved survival may be due partly to aggressive PAH-targeted therapy.