Advances and Controversies in Thoracentesis and Medical Thoracoscopy.

Pleural effusions are common and associated with high morbidity and mortality. Whereas thoracentesis can assist in achieving a diagnosis or therapy, advances in education and in the technique may prevent morbidity associated with the procedure. Medical thoracoscopy is often useful for undiagnosed effusions, as well as for therapeutic purposes. There is much enthusiasm about techniques for biopsies that extend beyond forceps. These include biopsies using a diathermic knife as well as cryoprobes. Similarly, adhesiolysis or other techniques to improve therapy in multiloculated effusions using medical thoracoscopy are contested. This review attempts to synthesize recent advances and controversies in thoracentesis and medical thoracoscopy as clinicians head into the next decade of treatment.

Indwelling Pleural Catheter Placement for Nonmalignant Pleural Effusions.

Pleural effusions account for significant symptoms and morbidity. Recent studies demonstrate a high mortality in patients with "benign" pleural effusions, now better characterized as nonmalignant pleural effusions (NMPEs) based on their prognosis. The most common nonmalignant clinical conditions with recurrent pleural effusions are congestive heart failure and hepatic hydrothorax, although many other diseases exist in isolation or as comorbid conditions. When conventional therapy fails, thoracentesis is often performed for relief of dyspnea. Many times, however, the effusions recur despite maximal medical therapy. Placement of tunneled or indwelling pleural catheters provides an effective therapeutic strategy for recurrent NMPEs when other medical therapy fails.

Lung Endothelial MicroRNA-1 Regulates Tumor Growth and Angiogenesis.

RATIONALE: Vascular endothelial growth factor down-regulates microRNA-1 (miR-1) in the lung endothelium, and endothelial cells play a critical role in tumor progression and angiogenesis. OBJECTIVES: To examine the clinical significance of miR-1 in non-small cell lung cancer (NSCLC) and its specific role in tumor endothelium. METHODS: miR-1 levels were measured by Taqman assay. Endothelial cells were isolated by magnetic sorting. We used vascular endothelial cadherin promoter to create a vascular-specific miR-1 lentiviral vector and an inducible transgenic mouse. KRASG12D mut/Trp53-/- (KP) mice, lung-specific vascular endothelial growth factor transgenic mice, Lewis lung carcinoma xenografts, and primary endothelial cells were used to test the effects of miR-1. MEASUREMENTS AND MAIN RESULTS: In two cohorts of patients with NSCLC, miR-1 levels were lower in tumors than the cancer-free tissue. Tumor miR-1 levels correlated with the overall survival of patients with NSCLC. miR-1 levels were also lower in endothelial cells isolated from NSCLC tumors and tumor-bearing lungs of KP mouse model. We examined the significance of lower miR-1 levels by testing the effects of vascular-specific miR-1 overexpression. Vector-mediated delivery or transgenic overexpression of miR-1 in endothelial cells decreased tumor burden in KP mice, reduced the growth and vascularity of Lewis lung carcinoma xenografts, and decreased tracheal angiogenesis in vascular endothelial growth factor transgenic mice. In endothelial cells, miR-1 level was regulated through phosphoinositide 3-kinase and specifically controlled proliferation, de novo DNA synthesis, and ERK1/2 activation. Myeloproliferative leukemia oncogene was targeted by miR-1 in the lung endothelium and regulated tumor growth and angiogenesis. CONCLUSIONS: Endothelial miR-1 is down-regulated in NSCLC tumors and controls tumor progression and angiogenesis.

Randomized Trial of Pleural Fluid Drainage Frequency in Patients with Malignant Pleural Effusions. The ASAP Trial.

RATIONALE: Patients with malignant pleural effusions have significant dyspnea and shortened life expectancy. Indwelling pleural catheters allow patients to drain pleural fluid at home and can lead to autopleurodesis. The optimal drainage frequency to achieve autopleurodesis and freedom from catheter has not been determined. OBJECTIVES: To determine whether an aggressive daily drainage strategy is superior to the current standard every other day drainage of pleural fluid in achieving autopleurodesis. METHODS: Patients were randomized to either an aggressive drainage (daily drainage; n = 73) or standard drainage (every other day drainage; n = 76) of pleural fluid via a tunneled pleural catheter. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the incidence of autopleurodesis following the placement of the indwelling pleural catheters. The rate of autopleurodesis, defined as complete or partial response based on symptomatic and radiographic changes, was greater in the aggressive drainage arm than the standard drainage arm (47% vs. 24%, respectively; P = 0.003). Median time to autopleurodesis was shorter in the aggressive arm (54 d; 95% confidence interval, 34-83) as compared with the standard arm (90 d; 95% confidence interval, 70 to nonestimable). Rate of adverse events, quality of life, and patient satisfaction were not significantly different between the two arms. CONCLUSIONS: Among patients with malignant pleural effusion, daily drainage of pleural fluid via an indwelling pleural catheter led to a higher rate of autopleurodesis and faster time to liberty from catheter. Clinical trial registered with www.clinicaltrials.gov (NCT 00978939).

Extracellular Mitochondrial DNA Is Generated by Fibroblasts and Predicts Death in Idiopathic Pulmonary Fibrosis.

RATIONALE: Idiopathic pulmonary fibrosis (IPF) involves the accumulation of α-smooth muscle actin-expressing myofibroblasts arising from interactions with soluble mediators such as transforming growth factor-ß1 (TGF-ß1) and mechanical influences such as local tissue stiffness. Whereas IPF fibroblasts are enriched for aerobic glycolysis and innate immune receptor activation, innate immune ligands related to mitochondrial injury, such as extracellular mitochondrial DNA (mtDNA), have not been identified in IPF. OBJECTIVES: We aimed to define an association between mtDNA and fibroblast responses in IPF. METHODS: We evaluated the response of normal human lung fibroblasts (NHLFs) to stimulation with mtDNA and determined whether the glycolytic reprogramming that occurs in response to TGF-ß1 stimulation and direct contact with stiff substrates, and spontaneously in IPF fibroblasts, is associated with excessive levels of mtDNA. We measured mtDNA concentrations in bronchoalveolar lavage (BAL) from subjects with and without IPF, as well as in plasma samples from two longitudinal IPF cohorts and demographically matched control subjects. MEASUREMENTS AND MAIN RESULTS: Exposure to mtDNA augments α-smooth muscle actin expression in NHLFs. The metabolic changes in NHLFs that are induced by interactions with TGF-ß1 or stiff hydrogels are accompanied by the accumulation of extracellular mtDNA. These findings replicate the spontaneous phenotype of IPF fibroblasts. mtDNA concentrations are increased in IPF BAL and plasma, and in the latter compartment, they display robust associations with disease progression and reduced event-free survival. CONCLUSIONS: These findings demonstrate a previously unrecognized and highly novel connection between metabolic reprogramming, mtDNA, fibroblast activation, and clinical outcomes that provides new insight into IPF.

Diagnostic Yield and Complications of Bronchoscopy for Peripheral Lung Lesions. Results of the AQuIRE Registry.

RATIONALE: Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy. OBJECTIVES: To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations. METHODS: We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions. MEASUREMENTS AND MAIN RESULTS: Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16). CONCLUSIONS: Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.

Pleural effusions as markers of mortality and disease severity: a state-of-the-art review.

PURPOSE OF REVIEW: Pleural effusions are common and are the result of various etiologies. Malignant pleural effusion (MPE) has a known high mortality, but there is also increasing evidence that patients with benign pleural effusions also have a poor prognosis. This review will discuss the most recent literature on mortality and prognostication in patients with pleural effusion. RECENT FINDINGS: Survival in patients with MPE is influenced by many factors, the most significant of which are underlying tumor type, performance score, and markers of systemic inflammation. Prognostic models have been developed for patients with both MPE and those with pleural infection to aid with treatment decision-making and patient counseling. Patients with benign pleural effusions may benefit from more definitive treatment of their pleural effusion as opposed to repeated thoracentesis. SUMMARY: Both benign and MPEs are associated with high mortality. Prognostic models and studies comparing treatment modality effect on survival will continue to guide management of these complex problems.

Mortality among patients with pleural effusion undergoing thoracentesis.

Of the 1.5 million people diagnosed with pleural effusion in the USA annually, ~178 000 undergo thoracentesis. While it is known that malignant pleural effusion portends a poor prognosis, mortality of patients with nonmalignant effusions has not been well studied.This prospective cohort study evaluated 308 patients undergoing thoracentesis. Chart review was performed to obtain baseline characteristics. The aetiology of the effusions was determined using standardised criteria. Mortality was determined at 30 days and 1 year.247 unilateral and 61 bilateral thoracenteses were performed. Malignant effusion had the highest 30-day (37%) and 1-year (77%) mortality. There was substantial patient 30-day and 1-year mortality with effusions due to multiple benign aetiologies (29% and 55%), congestive heart failure (22% and 53%), and renal failure (14% and 57%, respectively). Patients with bilateral, relative to unilateral, pleural effusion were associated with higher risk of death at 30 days and 1 year (17% versus 47% (hazard ratio (HR) 2.58, 95% CI 1.44-4.63) and 36% versus 69% (HR 2.32, 95% CI 1.55-3.48), respectively).Patients undergoing thoracentesis for pleural effusion have high short- and long-term mortality. Patients with malignant effusion had the highest mortality followed by multiple benign aetiologies, congestive heart failure and renal failure. Bilateral pleural effusion is distinctly associated with high mortality.

Thoracentesis and the risks for bleeding: a new era.

PURPOSE OF REVIEW: Thoracentesis is a commonly performed procedure throughout the world. Convention dictates that patients should have laboratory values such as international normalized ratio (INR) and platelets corrected or medications that affect bleeding withheld prior to performing this procedure. By transfusing blood products or withholding medications, patients are exposed to risks that are different than but equally if not more significant than the risk of hemothorax from thoracentesis. This review highlights recent studies that suggest the parameters of performing thoracentesis should be less stringent than traditionally thought. RECENT FINDINGS: Although the safety of thoracentesis has improved with the use of ultrasound and other advancements, the number of patients on new medications that exert an influence on bleeding and those who have physiologic coagulation abnormalities continues to grow. Despite a 1991 study demonstrating the safety of thoracentesis in patients with an abnormal INR or low platelet count, transfusion of blood products to normalize laboratory values is commonplace. A number of studies within the past year address the safety of thoracentesis amidst INR and platelet abnormalities and in patients taking antiplatelet or other medications that affect a patient's bleeding potential. SUMMARY: Although large randomized studies do not exist, recent literature suggests that it is time to reevaluate the need to correct INR and platelet counts or to transfuse blood products or withhold medications prior to thoracentesis in patients felt to have a risk of possible bleeding.

Advanced diagnostic bronchoscopy using conscious sedation and the laryngeal nerve block: tolerability, thoroughness, and diagnostic yield.

PURPOSE: Although bronchoscopy has conventionally been performed using conscious sedation, advanced diagnostic techniques like endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), peripheral EBUS, and electromagnetic navigational bronchoscopy add to procedural complexity. The adaptation of these techniques by bronchoscopists of varied backgrounds is expanding. It is not clear how patients will tolerate these advanced procedures when they are performed using traditional conscious sedation. METHODS: We prospectively studied patients that underwent diagnostic bronchoscopic procedures using conscious sedation over a 1-year period. The primary outcome was patient tolerability measured with four questions soliciting subjective responses. Secondary outcomes included required dosage of medications, thoroughness of the procedure, diagnostic yield, and occurrence of complications. RESULTS: A total of 181 patients were enrolled. Compared to patients in whom conventional bronchoscopy with transbronchial biopsies were performed, there was no difference in patient tolerability using the advanced techniques. Although some of the advanced procedures added to the procedure time, the required amount of medication was within commonly accepted dosages. When EBUS-TBNA was performed, a mean of 2.8 lymph node stations per patient were sampled. A specific diagnosis was obtained in 55.9 % of patients who solely underwent EBUS-TBNA. The diagnostic yield increased to 75.7 % when a parenchymal abnormality prompted additional biopsies. One patient required sedation reversal. Complications were minimal. CONCLUSIONS: This study suggests that advanced diagnostic bronchoscopic procedures are well tolerated using conscious sedation with no compromise of thoroughness, diagnostic yield, or safety. This may be useful for bronchoscopists using these techniques who do not have ready access to general anesthesia.

Tracheostomy Is Associated With a Decrease in Delirium and Sedation for Intubated COVID-19 Patients.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome can experience prolonged periods of ventilation, high incidence of delirium, and require high amounts of sedation. Tracheostomy has been associated with earlier ventilator liberation, decreased sedation needs, and lower rates of delirium but optimal timing of tracheostomy remains unknown. Is tracheostomy associated with lower sedation requirements and lower incidence of delirium in patients with COVID-19 that are intubated? METHODS: We retrospectively reviewed the first 32 patients at a large urban tertiary referral center that underwent tracheostomy for prolonged respiratory failure. We obtained Richmond Agitation Sedation-Scale scores and Confusion Assessment Method for Intensive Care Unit data along with amount(s) and type(s) of sedating medications given, in the 7 days before and after tracheostomy. Proportion of days delirious and sedating medications were compared in the 7 days before and after tracheostomy. RESULTS: There was a significant decrease in the amount of opioids and benzodiazepines in the 7-day period following tracheostomy. Opioid dosing decreased by 157.5 morphine equivalents (SD=339, P =0.01) and benzodiazepine dosing decreased by 18 mg lorazepam equivalents (SD=34, P =0.01). There was no significant difference in antipsychotic or other sedative-hyponotic drug doses. There was a significant decrease in the proportion of days of coma or delirium (mean decrease in proportion=0.16, SD=0.32, P =0.008) following tracheostomy. CONCLUSION: Tracheostomy was associated with a significant decrease amount of sedating medications and with a decrease in proportion of days delirious following tracheostomy.

Bleeding Risk With Combination Intrapleural Fibrinolytic and Enzyme Therapy in Pleural Infection: An International, Multicenter, Retrospective Cohort Study.

BACKGROUND: Combination intrapleural fibrinolytic and enzyme therapy (IET) has been established as a therapeutic option in pleural infection. Despite demonstrated efficacy, studies specifically designed and adequately powered to address complications are sparse. The safety profile, the effects of concurrent therapeutic anticoagulation, and the nature and extent of nonbleeding complications remain poorly defined. RESEARCH QUESTION: What is the bleeding complication risk associated with IET use in pleural infection? STUDY DESIGN AND METHODS: This was a multicenter, retrospective observational study conducted in 24 centers across the United States and the United Kingdom. Protocolized data collection for 1,851 patients treated with at least one dose of combination IET for pleural infection between January 2012 and May 2019 was undertaken. The primary outcome was the overall incidence of pleural bleeding defined using pre hoc criteria. RESULTS: Overall, pleural bleeding occurred in 76 of 1,833 patients (4.1%; 95% CI, 3.0%-5.0%). Using a half-dose regimen (tissue plasminogen activator, 5 mg) did not change this risk significantly (6/172 [3.5%]; P = .68). Therapeutic anticoagulation alongside IET was associated with increased bleeding rates (19/197 [9.6%]) compared with temporarily withholding anticoagulation before administration of IET (3/118 [2.6%]; P = .017). As well as systemic anticoagulation, increasing RAPID score, elevated serum urea, and platelets of < 100 × 109/L were associated with a significant increase in bleeding risk. However, only RAPID score and use of systemic anticoagulation were independently predictive. Apart from pain, non-bleeding complications were rare. INTERPRETATION: IET use in pleural infection confers a low overall bleeding risk. Increased rates of pleural bleeding are associated with concurrent use of anticoagulation but can be mitigated by withholding anticoagulation before IET. Concomitant administration of IET and therapeutic anticoagulation should be avoided. Parameters related to higher IET-related bleeding have been identified that may lead to altered risk thresholds for treatment.

Pleural Effusions in the Critically Ill and "At-Bleeding-Risk" Population.

Thoracentesis is a common bedside procedure, which has a low risk of complications when performed with thoracic ultrasound and by experienced operators. In critically ill or mechanically ventilated patients, or in patients with bleeding risks due to medications or other coagulopathies, the complication rate remains low. Drainage of pleural effusion in the intensive care unit has diagnostic and therapeutic utility, and perceived bleeding risks should be one part of an individualized and comprehensive risk-benefit analysis.

GM-CSF autoantibodies and neutrophil dysfunction in pulmonary alveolar proteinosis.

BACKGROUND: Increased mortality from infection in patients with pulmonary alveolar proteinosis occurs in association with high levels of autoantibodies against granulocyte-macrophage colony-stimulating factor (GM-CSF). We tested the hypothesis that neutrophil functions are impaired in patients with pulmonary alveolar proteinosis and that GM-CSF autoantibodies cause the dysfunction. METHODS: We studied 12 subjects with pulmonary alveolar proteinosis, 61 healthy control subjects, and 12 control subjects with either cystic fibrosis or end-stage liver disease. We also studied GM-CSF-/- mice and wild-type mice. We evaluated basal neutrophil functions, neutrophil functions after priming by GM-CSF to augment antimicrobial functions, and the effects of highly purified GM-CSF autoantibodies on neutrophil functions in vitro and in vivo. RESULTS: Neutrophils from subjects with pulmonary alveolar proteinosis had normal ultrastructure and differentiation markers but impaired basal functions and antimicrobial functions after GM-CSF priming. GM-CSF-/- mice also had reduced basal neutrophil functions, but functions after GM-CSF priming were unimpaired. The neutrophil dysfunction characteristic of pulmonary alveolar proteinosis was reproduced in a dose-dependent fashion in blood specimens from healthy control subjects after incubation with affinity-purified GM-CSF autoantibodies isolated from patients with pulmonary alveolar proteinosis. The injection of mouse GM-CSF antibodies into wild-type mice also caused neutrophil dysfunction. CONCLUSIONS: The antimicrobial functions of neutrophils are impaired in patients with pulmonary alveolar proteinosis, owing to the presence of GM-CSF autoantibodies. The effects of these autoantibodies show that GM-CSF is an essential regulator of neutrophil functions.

Physician Practice Patterns for Performing Thoracentesis in Patients Taking Anticoagulant Medications.

BACKGROUND: Patients undergoing thoracentesis often have comorbid conditions or take medications that potentially put them at higher bleeding risk. Direct oral anticoagulant (DOAC) use has also increased significantly. There are no published guidelines or consensus on when to perform thoracentesis in patients on anticoagulants. Recent studies support the safety of a more liberal approach for thoracentesis among patients with coagulopathy. METHODS: We conducted a survey to ascertain the practices of physicians regarding thoracentesis in patients with increased bleeding risk. The survey was administered to the email distribution lists of the American Association of Bronchology and Interventional Pulmonology and of the American Thoracic Society. RESULTS: The survey was completed by 256 attending physicians. Most of them were general pulmonologists practicing at academic medical centers. Most of them would perform a thoracentesis in patients receiving acetylsalicylic acid or prophylactic doses of unfractionated heparin or low molecular weight heparin (96%, 89%, and 88%, respectively). Half of the respondents would perform a thoracentesis in patients on antiplatelet medications (clopidogrel and ticagrelor, 51%; ticlopidine, 53%). A minority would perform thoracentesis in patients on direct oral anticoagulants or infused thrombin inhibitors (19% and 12%, respectively). The only subgroup that had a higher proclivity for performing thoracentesis without holding medications were attending physicians practicing for under 10 years. Relative to noninterventional pulmonologists, there were no significant differences in the responses of interventional pulmonologists. CONCLUSION: There was variation in the practice patterns of attending physicians in performing thoracentesis in patients with elevated bleeding risk. Further data and guidelines regarding the safety of thoracentesis in these patients are needed.

Improved Diagnostic Yield and Specimen Quality With Endobronchial Ultrasound-Guided Forceps Biopsies: A Retrospective Analysis.

BACKGROUND: Endobronchial ultrasound (EBUS) transbronchial needle aspiration (TBNA) has a high diagnostic yield when evaluating mediastinal and hilar lymphadenopathy (LAD). Having previously demonstrated the safety of EBUS-guided cautery-assisted transbronchial nodal forceps biopsy (ca-TBFB), we report disease-specific improvements in diagnostic yield and tissue acquisition when supplementing the EBUS-TBNA-based standard of care (SOC) with ca-TBFB. METHODS: We retrospectively reviewed 213 patients who sequentially underwent SOC and ca-TBFB during the same procedure. We determined 3 clinical scenarios of interest based on preprocedural imaging: isolated mediastinal/hilar LAD, LAD associated with a nodule or mass suspicious for malignancy, and LAD associated with parenchymal findings suggestive of sarcoidosis. Using validated methods, we assessed diagnostic yield on a per-patient basis and specimen quality on a per-node basis on the 136 patients meeting diagnostic criteria. RESULTS: Administration of disease-specific SOC with ca-TBFB yielded gains that varied by diagnosis. Diagnostic yields of SOC and its supplementation with ca-TBFB were 91.8% and 93.4% (P = .50) of the 61 patients diagnosed with solid-organ malignancy, 62.7% and 94.9% (P < .001) of the 59 patients diagnosed with sarcoidosis, and 62.5% and 93.8% (P = .042) of the 16 patients diagnosed with lymphoma, the. For each disease process, specimens obtained with ca-TBFB exhibited statistically higher quality. CONCLUSIONS: We suggest that relative to SOC, ca-TBFB improves diagnostic yield for sarcoidosis and lymphoma while providing uniformly better tissue quality and cellularity. We propose a protocol for use of this innovative technique.

The utility of bronchoscopy in immunocompromised patients: a review.

Bronchoscopy is an important tool for the diagnosis of pulmonary disorders in immunocompromised patients. The addition of biopsies to bronchoalveolar lavage improves the diagnostic yield of non-infectious etiologies, although the underlying etiology of the immunocompromised state must be considered and may be influential. Certain unknowns remain, including timing of bronchoscopy and its impact on medical management and mortality. The ongoing role of non-invasive testing for infectious complications prior to bronchoscopy also remains to be defined. This review addresses the role of bronchoscopy in immunocompromised states related to underlying hematologic malignancies, prescription drug use or chemotherapy, and other disorders that predispose patients to infectious or non-infectious pulmonary diseases.

Safety and Tolerability of Vacuum Versus Manual Drainage During Thoracentesis: A Randomized Trial.

BACKGROUND: Pleural effusions may be aspirated manually or via vacuum during thoracentesis. This study compares the safety, pain level, and time involved in these techniques. METHODS: We randomized 100 patients receiving ultrasound-guided unilateral thoracentesis in an academic medical center from December 2015 through September 2017 to either vacuum or manual drainage. Without using pleural manometry, the effusion was drained completely or until the development of refractory symptoms. Measurements included self-reported pain before and during the procedure (from 0 to 10), time for completion of drainage, and volume removed. Primary outcomes were rates of all-cause complications and of early termination of the procedure with secondary outcomes of change in pain score, drainage time, volume removed, and inverse rate of removal. RESULTS: Patient characteristics in the manual (n=49) and vacuum (n=51) groups were similar. Rate of all-cause complications was higher in the vacuum group (5 vs. 0; P=0.03): pneumothorax (n=3), surgically treated hemothorax with subsequent death (n=1) and reexpansion pulmonary edema causing respiratory failure (n=1), as was rate of early termination (8 vs. 1; P=0.018). The vacuum group exhibited greater pain during drainage (P<0.05), shorter drainage time (P<0.01), no association with volume removed (P>0.05), and lower inverse rate of removal (P≤0.01). CONCLUSION: Despite requiring less time, vacuum aspiration during thoracentesis was associated with higher rates of complication and of early termination of the procedure and greater pain. Although larger studies are needed, this pilot study suggests that manual aspiration provides greater safety and patient comfort.

Bronchoscopic lung volume reduction: recent updates.

Emphysema causes significant morbidity and mortality, incurring both financial and psychosocial costs. Alternatives to medical therapy and surgical lung volume reduction surgery (LVRS) have increased interest in bronchoscopic techniques. Bronchoscopic lung volume reduction (BLVR) is still in its infancy and additional trials and follow-up are critical. However, several new randomized clinical trials (RCTs) have demonstrated improvement in lung function, quality of life and exercise capacity in select patients receiving endobronchial valves and coil therapy. This article highlights recent data regarding bronchoscopic treatment of emphysema.