Excessive Dynamic Airway Collapse Severity Scoring System: A Call Out for an Overall Severity Determination.

BACKGROUND: Severe excessive dynamic airway collapse (EDAC) is defined as airway narrowing due to posterior wall protrusion into the airway lumen, >90%. We aimed to establish an overall severity score to assess severe EDAC and the need for subsequent intervention. METHODS: A retrospective study of patients who underwent dynamic bronchoscopy for evaluation of expiratory central airway collapse between January 2019 and July 2021. A numerical value was given to each tracheobronchial segmental collapse: 0 points (<70%), 1 point (70% to 79%), 2 points (80% to 89%), and 3 points (>90%) to be added for an overall EDAC severity score per patient. We compared the score among patients who underwent stent trials (severe EDAC) and those who did not. Based on the receiver operating characteristics curve, a cutoff total score to predict severe EDAC was calculated. RESULTS: One hundred fifty-eight patients were included. Patients were divided into severe (n = 60) and nonsevere (n = 98) EDAC. A cutoff of 9 as the total score had a sensitivity of 94% and a specificity of 74% to predict severe EDAC, based on an area under the curve 0.888 (95% CI: 0.84, 0.93; P < 0.001). CONCLUSION: Our EDAC Severity Scoring System was able to discern between severe and nonsevere EDAC by an overall score cutoff of 9, with high sensitivity and specificity for predicting severe disease and the need for further intervention, in our institution.

Robotic-assisted bronchoscopy versus CT-guided transthoracic biopsy for diagnosis of pulmonary nodules.

BACKGROUND AND OBJECTIVE: Currently, computed tomography-guided transthoracic biopsy (CTTB) is the most accurate diagnostic approach for pulmonary nodules suspected of malignancy. Traditional bronchoscopy has shown suboptimal diagnostic sensitivity, but the emergence of robotic-assisted bronchoscopy (RAB) has the potential to improve diagnostic accuracy, maximize diagnostic yield and complete mediastinal and hilar staging in a single procedure. We aim to assess the efficacy and diagnostic performance of RAB compared to CTTB for diagnosing pulmonary nodules suspected of lung cancer. METHODS: A multicenter retrospective review of consecutive patients who underwent RAB and CTTB for evaluating pulmonary nodules from January 2019 to March 2021 at Mayo Clinic Florida and Mayo Clinic Rochester, United States. Clinical and demographic information, nodule characteristics, outcomes and complications were compared between RAB and CTTB. RESULTS: A total of 225 patients were included: 113 in the RAB group and 112 in the CTTB group. Overall diagnostic yield was 87.6% for RAB and 88.4% for CTTB. For malignant disease, RAB had a sensitivity of 82.1% and a specificity of 100%, CTTB had a sensitivity of 88.5% and a specificity of 100%. Complication rate was significantly higher for CTTB compared to RAB (17% vs. 4.4%; p = 0.002). CONCLUSION: RAB, when available, can be as accurate as CTTB for sampling pulmonary nodules with similar or reduced complications and should be considered as a means for nodule biopsy, particularly when mediastinal staging is also clinically warranted.

Prevention of acute exacerbation of chronic obstructive pulmonary disease after bronchoscopic lung volume reduction with endobronchial valves.

INTRODUCTION: Bronchoscopic lung volume reduction (BLVR) with endobronchial valves (EBVs) has emerged as an important treatment method for patients with severe chronic obstructive pulmonary disease (COPD). Acute exacerbations of COPD (AECOPD) are a frequent complication following BLVR with EBV. However, there is no consensus on the prevention of AECOPD. OBJECTIVES: Our study aims to compare the outcomes of different prophylactic measures on the occurrence of AECOPD after BLVR with EBV. METHODS: We conducted a multicenter, retrospective study of patients who underwent BLVR with EBV at six different institutions. Emphasis was directed towards the specific practices aimed at preventing AECOPD: antibiotics, steroids, antibiotics plus steroids, or no prophylaxis. Subgroups were compared, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated. RESULTS: A total of 170 patients were reviewed. The rate of AECOPD was 21.2% for the full cohort. Patients who received prophylaxis had a significantly lower rate of AECOPD compared with those who did not (16.7% vs. 46.2%; p = 0.001). The rate was lowest in patients who received antibiotics alone (9.2%). There was no significant difference in the rate of AECOPD between patients who received steroids alone or antibiotics plus steroids, compared with the other subgroups. The OR for AECOPD was 4.3 (95% CI: 1.8-10.4; p = 0.001) for patients not receiving prophylaxis and 3.9 (95% CI: 1.5-10.1; p = 0.004) for prophylaxis other than antibiotics alone. CONCLUSIONS: Administration of antibiotics after BLVR with EBV was associated with a lower rate of AECOPD. This was not observed with the use of steroids or in combination with antibiotics.

Comparing diagnostic sensitivity of different needle sizes for lymph nodes suspected of lung cancer in endobronchial ultrasound transbronchial needle aspiration: Systematic review and meta-analysis.

BACKGROUND: Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a safe and minimally invasive procedure for evaluating hilar and mediastinal lymph nodes. The reported sensitivity and specificity of EBUS-TBNA are 95% and 97%, respectively. A comparison of diagnostic sensitivity for lymph nodes suspected of lung cancer according to needle size in EBUS-TBNA is needed. OBJECTIVES: To compare the diagnostic sensitivity of the 19-G, 21-G, 22-G and 25-G needles for lymph nodes suspected of non-small cell lung cancer (NSCLC) using EBUS-TBNA. METHODS: A literature search from PubMed, EMBASE, LILACS, DOAJ and CENTRAL through October 2020 was performed by two reviewers. The extracted data were evaluated using STATA® and Open Meta Analyst software for meta-analysis with a binary method model to compare sensitivity, specificity and summary receiver operating characteristic curve for each needle size. RESULTS: Fourteen studies including 1296 participants were considered for the analysis. The overall sensitivity of EBUS-TBNA was 88.2% (95% CI 84%, 91%) and 93% (95% CI 88%, 95%) for the 19-G needle, 87.6% (95% CI 79.6%, 92.8%) for the 21-G needle and 85% (95% CI 80%, 88%) for the 22-G needle. The overall sensitivity of EBUS-TBNA for diagnosing NSCLC was 88.3% (95% CI, 81%, 93%) and 92.9% (95% CI, 85%, 97%) for the 19-G needle, 89.4% (95% CI 79.4%, 94.8%) for the 21-G needle and 82.1% (95% CI 66%, 91%) for the 22-G needle. CONCLUSION: The 19-G, 21-G and 22-G needles present a similarly high diagnostic sensitivity in EBUS-TBNA. The 19-G needle provided better sample adequacy for molecular and immunohistochemical testing, improving diagnostic yield in this subgroup.

Impact of Preoperative Testing on Patients Undergoing Ophthalmologic Surgery: A Retrospective Cohort Study.

OBJECTIVE: Routine medical testing is not recommended before cataract surgery, but no consensus exists about preoperative testing before general ophthalmologic surgery. We aimed to assess the impact of preoperative testing on patients undergoing ophthalmologic surgery by analyzing their surgical outcomes and complications. METHODS: We retrospectively reviewed electronic health records of patients who had preoperative evaluations before cataract or noncataract ophthalmologic surgery at a tertiary care center from January 1, 2015, through December 31, 2019. RESULTS: The cohort consisted of 2268 patients (1270 [56.0%] women). The most frequent ophthalmologic procedure was cataract extraction (n = 1450 [63.9%]). Laboratory tests results were available for 489 patients (33.7%) in the cataract group; of these, 275 results (56.2%) had abnormal values, and 18 patients (6.5%) required preoperative interventions. Preoperative test results were available for 772 out of 818 patients (94.4%) having noncataract procedures. Of these, 384 results (49.7%) had abnormal values, and 10 patients (2.6%) required additional intervention. No significant differences were observed for the rate of surgery cancellations between the cataract and noncataract patient groups (0.6% vs 1.0%; P = .24). Of the 12 patients (0.5%) who had complications, all had undergone preoperative testing. CONCLUSIONS: No differences in outcomes and complications were observed among patients who underwent cataract or noncataract surgery. It is reasonable to consider avoiding preoperative testing in patients undergoing ophthalmologic surgery.

Safety and Diagnostic Yield of Transthoracic Needle Aspiration of the Lung in Elderly Patients.

BACKGROUND: Pulmonary nodules in elderly patients are commonly encountered in clinical practice. Tissue sampling with image guided transthoracic needle aspiration is often performed but may be complicated by pneumothorax or bleeding. To understand the outcomes of transthoracic needle aspiration in the elderly, we retrospectively reviewed outcomes of patients age 75 or greater in a single tertiary center. METHODS: Four-hundred eleven patients age 75 or greater with a pulmonary nodule identified on computed tomography who underwent needle aspiration of the lung were studied. Diagnostic yield and procedural complications were assessed for each patient and subgroups analysis of those age 85 or greater was performed. RESULTS: Malignancy was confirmed in 70% of subjects and a benign diagnosis identified in 9%. Of the 411 patents, 203 (49.4%) experienced a complication; 150 patients (36.5%) developed a pneumothorax and 79 (19.2%) had bleeding. No patient required transfusion, experienced persistent air leak or massive hemoptysis, air embolism or death. Post procedural hospitalization was required in 36 patients (8.8%) with a median hospital stay of 2 days. No factors were identified to be associated with occurrence of a complication (all p ≥ 0.16) and complications were not increased in those 85 or greater. CONCLUSION: Our results suggest that in an elderly population, image guided needle aspiration of a pulmonary nodule provides diagnostic findings in most patients. Procedural complications following are not uncommon but the severity and long-term impact are limited. The occurrence of complications is similar in those age 75-84 and age 85 and older.

Endobronchial Extranodal Marginal Zone B-Cell Lymphoma with Plasmacytic Differentiation.

Endobronchial tumors (ET) are unusual and mostly malignant, presenting with non-specific symptoms that often delay appropriate diagnosis and treatment. Lymphomas in the airway represent less than 1% of pulmonary malignancies and require multidisciplinary approach for their management. We present a case of a 48-year-old male former smoker with a one-year history of recurrent respiratory infections and new-onset shortness of breath. Diagnostic tests included a chest computed tomography (CT) reporting the presence of an endobronchial mass and neck and cervical lymph node biopsies with inconclusive results. Bronchoscopy was successfully performed for tumor resection, improving the patient's respiratory symptoms. Histological analysis described an extranodal marginal zone B-cell lymphoma (ENMZL) with plasmacytic differentiation; a subtype of non-Hodgkin's lymphoma (NHL) in mucosa-associated lymphoid tissue (MALT), rarely found as an endobronchial growth. ET should be considered in the setting of persistent and worsening respiratory symptoms. ENMZL with plasmacytic differentiation is rarely found as an ET and diagnosis requires bronchoscopic intervention and extensive immunohistochemical analysis.