Severe cardiac complication as coronary artery spasm during bronchoscopy: a case report.

Background: Bronchoscopy is widely used in clinical diagnosis and treatment of respiratory diseases. Although it is generally safe, cardiac complications such as acute myocardial ischemia and arrhythmia can also occur in patients especially with comorbidities and in elderly ones. Acute malignant coronary vasospasm as a severe cardiac complication can occur during bronchoscopy. It is essential to observe the occurrence of complications and provide early curing. Case Description: We presented a case of a 52-year-old man who experienced chest pain, dyspnea and even shock during bronchoscopy. Electrocardiogram (ECG) showed an acute muti-leads ST-segment elevation and declined to baseline soon after emergent medication treatment including antithrombotic, expansion of coronary artery and fluid replenishment myocardial infarction. Coronary artery spasm was considered according to the clinical symptom and ECG characteristics. Subsequent coronary angiogram which showed normal coronary artery also supported the diagnosis of coronary artery spasm. The symptom of the patient was discovered timely and was treated successfully with good prognosis. Conclusions: Bronchoscopy is the main and important method of diagnosis and treatment for respiratory diseases. Coronary artery spasm as a serious cardiac complication should be paid more attention during bronchoscopy. Timely and appropriate treatment may lead to better clinical results. Multidisciplinary cooperation plays a key role in the whole therapy. The potential triggers of coronary artery spasm during bronchoscopy mainly include low oxygen, hypersensitivity reactions and chronic inflammatory.

Pneumothorax following rigid bronchoscopy for foreign body removal in a child: A case report.

INTRODUCTION: Rigid bronchoscopy is an effective tool for the management of pediatric airway foreign bodies. However, it is not exempt from complications that can be fatal, such as pneumothorax. CASE PRESENTATION: A 20-month-old child was admitted to our department after inhaling a foreign body (peanut). Immediately after removal of this foreign body, the child presented with a pre-arrest state with right auscultatory silence. Pneumothorax was suspected and aspirated, and cardiopulmonary resuscitation was performed. After 3 days in the intensive care unit (ICU), the child was discharged. CLINICAL DISCUSSION: Inhalation of foreign bodies is frequent during the first 3 years of life. Its management relies on rigid bronchoscopy. However, this procedure is not devoid of risks, which can be fatal. CONCLUSION: Our case illustrates a rare complication of rigid bronchoscopy in pediatric population and highlights the importance of prompt diagnosis and management.

Artificial intelligence for automatic and objective assessment of competencies in flexible bronchoscopy.

Background: Bronchoscopy is a challenging technical procedure, and assessment of competence currently relies on expert raters. Human rating is time consuming and prone to rater bias. The aim of this study was to evaluate if a bronchial segment identification system based on artificial intelligence (AI) could automatically, instantly, and objectively assess competencies in flexible bronchoscopy in a valid way. Methods: Participants were recruited at the Clinical Skills Zone of the European Respiratory Society Annual Conference in Milan, 9th-13th September 2023. The participants performed one full diagnostic bronchoscopy in a simulated setting and were rated immediately by the AI according to its four outcome measures: diagnostic completeness (DC), structured progress (SP), procedure time (PT), and mean intersegmental time (MIT). The procedures were video-recorded and rated after the conference by two blinded, expert raters using a previously validated assessment tool with nine items regarding anatomy and dexterity. Results: Fifty-two participants from six different continents were included. All four outcome measures of the AI correlated significantly with the experts' anatomy-ratings (Pearson's correlation coefficient, P value): DC (r=0.47, P<0.001), SP (r=0.57, P<0.001), PT (r=-0.32, P=0.02), and MIT (r=-0.55, P<0.001) and also with the experts' dexterity-ratings: DC (r=0.38, P=0.006), SP (r=0.53, P<0.001), PT (r=-0.34, P=0.014), and MIT (r=-0.47, P<0.001). Conclusions: The study provides initial validity evidence for AI-based immediate and automatic assessment of anatomical and navigational competencies in flexible bronchoscopy. SP provided stronger correlations with human experts' ratings than the traditional DC.

Tracheobronchial injury after blunt thoracic trauma-lessons to learn in diagnosis, treatment, and postoperative care: a case series.

Background: Tracheobronchial injury (TBI) is the subsuming term to describe rare and mostly traumatic damage to the tracheobronchial tree. Prehospital mortality is significant. TBI patients may face delayed diagnosis, challenging perioperative care, and prolonged recovery. The focus of this case series is to identify issues that represent common hurdles and potential problems in the diagnosis, treatment, and postoperative care of patients with TBI. Case Description: This is a single-center retrospective case-series study of four patients who experienced TBI following blunt thoracic trauma in the study period from January 1, 2020, to December 31, 2023. The mean age of the patients was 48 years, with patient age ranging from 24 to 59 years. One patient was female and the other three were male. Two patients sustained injuries to the main bronchi, while the others sustained injuries to more peripheral parts of the tracheobronchial tree. Three patients were secondary transfers to our hospital, while the other was a primary admission. All four patients underwent surgery for their TBI. The duration of hospitalization ranged from 10 to 60 days. The two patients with main stem bronchus injury required the longest hospitalization. The same two patients required extracorporeal membrane oxygenation therapy. We experienced no mortality, and all patients were discharged for post-hospital rehabilitation. Conclusions: TBI management requires a multidisciplinary and experienced team. One must be aware of the classic clinical presentation: dyspnea, soft tissue emphysema, and hemoptysis. Cases in which a history of trauma is associated with dyspnea and/or chest wall/mediastinal emphysema require early bronchoscopy as the diagnostic gold standard. The use of "Minimum-intensity projection" (MinIP) reconstructions can help identify TBI in computed tomography scans. Extracorporeal membrane oxygenation therapy is to be considered in selected cases. Surgical repair must focus on preventing parenchymal loss by reconstructing the bronchial defect while avoiding anatomical resection. Postoperative care should consider the possibility of bronchial denervation and its potential complications.

Preoperative localization of pulmonary nodules by electromagnetic navigation bronchoscopy combined with methylene blue injection.

Background: Electromagnetic navigation bronchoscopy (ENB) can help to accurately locate pulmonary nodules using a minimally invasive approach. This study sought to evaluate the clinical efficacy and safety of dye marking localization under the guidance of ENB followed by surgery. Methods: A retrospective analysis was performed of 61 patients who underwent ENB localization using methylene blue dye marking before surgery at Shanghai General Hospital from October 2021 to February 2022. The clinical efficacy and safety of ENB localization and the related factors affecting the navigation time of ENB location were analyzed. Results: ENB was performed on 170 pulmonary nodules in 61 patients with a median age of 60 [interquartile range (IQR), 18] years. The majority of patients (70.69%) had more than two pulmonary nodules. The median maximum nodule diameter was 10 (IQR, 8) mm, and 48.21% of the nodules were mixed ground-glass nodules. Median time for ENB navigation was 10.5 (IQR, 6) min. The navigation success rate was 92.96%, and the ENB location success rate was 95.89%. The rate of complications related to ENB localization was 1.64% (there was only one case of pulmonary hemorrhage). The multivariate analysis showed that the factors related to the navigation time included the node location (P=0.001) and location mode (P=0.04). Conclusions: ENB-guided methylene blue injection is an effective and safe tool for localizing and marking pulmonary nodules, and can be used to assist the diagnosis and treatment of early lung cancer. The node location and location mode had significant effects on navigation time.

Factors influencing management modifications following fiberoptic bronchoscopy in critically ill ICU patients.

Background: Fiberoptic bronchoscopy (FOB) has evolved into a crucial diagnostic and therapeutic procedure for respiratory tract conditions over the years. Despite its benefits, this approach poses increased risks to critically ill patients. This study aimed to identify clinical parameters that influence management modifications after FOB in the general intensive care unit (ICU) population, an area not extensively explored. Methods: In this retrospective study, critically ill adults admitted to a medical ICU in Bangkok, Thailand, who underwent FOB between January 2013 and December 2022 were enrolled. Clinical parameters, imaging findings, and indications were analyzed to identify factors associated with modifications in post-bronchoscopic management. Results: A total of 118 patients were reviewed and management modifications occurred in 69 patients (58.5%), in which antibiotic modification (78.3%) was the leading reason. Chronic steroid use and suspected interstitial lung disease were associated with management modifications after FOB, while alveolar infiltration on chest radiography was not. Although management modifications showed a trend toward lower mortality, statistical significance was not reached. Multivariate analysis identified chronic steroid use as the only independent factor [adjusted odds ratio (aOR): 2.26; 95% confidence interval (CI): 1.01-5.06; P=0.048]. Conclusions: Among critically ill patients, chronic steroid use was a predictor of management modifications after FOB and is likely to be beneficial.

Cone-beam computed tomography-guided shape-sensing robotic bronchoscopy vs. electromagnetic navigation bronchoscopy for pulmonary nodules.

Background: Electromagnetic navigation bronchoscopy (ENB) and shape-sensing robotic-assisted bronchoscopy (ssRAB) are minimally invasive technologies for the diagnosis of pulmonary nodules. Cone-beam computed tomography (CBCT) has shown to increase diagnostic yield by allowing real-time confirmation of position of lesion and biopsy tool. There is a lack of comparative studies of such platforms using CBCT guidance to overcome computed tomography to body divergence. The aim of this study was to compare the diagnostic yield of ENB- and ssRAB-guided CBCT for biopsy of pulmonary nodules. Methods: We conducted a retrospective comparative study of consecutive patients undergoing ENB-CBCT and ssRAB-CBCT. Navigational success was defined as biopsy tool within lesion confirmed during CBCT. Diagnostic yield was assessed using two methods: (I) presence of malignancy or benign histological findings that lead to a specific diagnosis at the time of bronchoscopy, and (II) longitudinal follow-up of patients with nonspecific benign finding during bronchoscopy. Results: ENB-CBCT was used to biopsy 97 nodules and ssRAB-CBCT was used to biopsy 111 nodules. Median size of the lesion for the ENB-CBCT group was 16.5 mm [interquartile range (IQR), 12-22 mm] as compared to 12 mm (IQR, 9-16 mm) in the ssRAB-CBCT group (P<0.001). Navigational success was 70.1% in ENB-CBCT arm as compared to 83% in ssRAB-CBCT arm respectively (P=0.03). Diagnostic yield was 66% for ENB-CBCT and 89.2% for ssRAB-CBCT (P<0.001) following bronchoscopy; 79.4% for ENB-CBCT and 95.4% for ssRAB-CBCT (P<0.001) with longitudinal follow-up data respectively. Following multivariate regression analysis adjusting for the size of the lesion, distance from the pleura, presence of bronchus sign, number of CBCT spins, and number of nodules, the odds ratio for the diagnostic yield was 4.72 [95% confidence interval (CI): 2.05-10.85; P<0.001] in the ssRAB-CBCT group as compared with ENB-CBCT. The overall rate of adverse events was similar in both groups (P=0.77). Conclusions: ssRAB-CBCT showed increased navigational success and diagnostic yield as compared to ENB-CBCT for pulmonary nodule biopsies.

Complex Management of a Migrating Inhaled Metallic Foreign Body in a Child: A Multidisciplinary Success.

Foreign body (FB) inhalation in children is a common and potentially life-threatening occurrence encountered in pediatric emergency medicine. A wide range of clinical presentations including often delayed onset of symptoms make it challenging to identify and provide a timely diagnosis. This increases the risk of complications and leads to suboptimal outcomes. For instance, inhalation of sharp objects may lead to perforations and migrations to surrounding structures making it difficult to retrieve the FB as seen in this case. Additionally, the onset of symptoms can vary, making it difficult to diagnose based on a patient's history alone. An unusual case of an inhaled sharp metallic object (dental bur) in a 13-year-old boy that migrated from the left lower thorax to the right perihilar and finally to the gastric lumen is presented a week after the incident. A 13-year-old boy presented to the emergency department with mild symptoms. He was stable with normal chest findings. Previous rigid bronchoscopy failed to localize and remove the FB and the thoracotomy. A post-operative X-ray was done, and the migration of the FB to the right middle lobe was revealed. A flexible bronchoscopy was then performed, again with no positive results. It was finally the abdominopelvic CT scan followed by the gastroduodenal esophagoscopy that allowed us to visualize and remove the FB from the gastric lumen.  In this case, we review the literature to emphasize the diagnostic challenges of FB inhalation in children, focusing on key diagnostic clues that assist clinicians in managing this condition.

Efficacy of high-flow nasal cannula in improving the view of the glottis during flexible bronchoscopy for tracheal intubation.

BACKGROUND: Flexible bronchoscopy for tracheal intubation is indicated in patients with difficult airways, but the upper airway is frequently obstructed in sedated or anaesthetised apnoeic patients. This makes it more difficult to locate the glottis through bronchoscopy, and increases the risk of hypoxaemia. Nasal high-flow oxygenation is useful to prevent hypoxaemia during airway management, but no studies have assessed if this method of oxygenation improves the bronchoscopic view of the glottis by preventing upper airway obstruction. METHODS: As a crossover design, we studied 20 anaesthetised apnoeic patients to assess if nasal high-flow oxygenation (60 L min-1) improves the view of the glottis during attempts at bronchoscopic intubation by widening the pharyngeal space. RESULTS: The pharyngeal space was wider with nasal high-flow oxygenation than without in 19 of 20 patients (95%; 95% confidence interval [CI]: 85-100%; P<0.0001), and bronchoscopic view of the glottis was better with high-flow oxygenation than without in 17 of 20 patients (85%; 95% CI: 69-100%, P<0.0001). The flexible bronchoscope was easily inserted into the trachea in all patients, and no complications including hypoxaemia were observed. CONCLUSIONS: Nasal high-flow oxygenation facilitates flexible bronchoscopy for tracheal intubation by widening the pharyngeal space and by improving the view of the glottis through the bronchoscope. Therefore, use of nasal high-flow oxygenation is useful in patients with difficult airways in whom flexible bronchoscopy for tracheal intubation is indicated.

A prospective observation study of the dynamic monitoring of transcutaneous arterial blood oxygen saturation and carbon dioxide during bronchoscopy.

BACKGROUND AND AIMS: Because bronchoscopy is an invasive procedure, sedatives and analgesics are commonly administered, which may suppress the patient's spontaneous breathing and can lead to hypoventilation and hypoxemia. Few reports exist on the dynamic monitoring of oxygenation and ventilation during bronchoscopy. This study aimed to prospectively monitor and evaluate oxygenation and ventilation during bronchoscopy using transcutaneous arterial blood oxygen saturation and carbon dioxide. METHODS: We included patients who required pathological diagnosis using fluoroscopic bronchoscopy at our hospital between March 2021 and April 2022. Midazolam was intravenously administered to all patients as a sedative during bronchoscopy, and fentanyl was administered in addition to midazolam when necessary. A transcutaneous blood gas monitor was used to measure dynamic changes, including arterial blood partial pressure of carbon dioxide (tcPCO2), transcutaneous arterial blood oxygen saturation (SpO2), pulse rate, and perfusion index during bronchoscopy. Quantitative data of tcPCO2 and SpO2 were presented as mean ± standard deviation (SD) (min-max), while the quantitative data of midazolam plus fentanyl and midazolam alone were compared. Similarly, data on sex, smoking history, and body mass index were compared. Subgroup comparisons of the difference (Δ value) between baseline tcPCO2 at the beginning of bronchoscopy and the maximum value of tcPCO2 during the examination were performed. RESULTS: Of the 117 included cases, consecutive measurements were performed in 113 cases, with a success rate of 96.6%. Transbronchial lung biopsy was performed in 100 cases, whereas transbronchial lung cryobiopsy was performed in 17 cases. Midazolam and fentanyl were used as anesthetics during bronchoscopy in 46 cases, whereas midazolam alone was used in 67 cases. The median Δ value in the midazolam plus fentanyl and midazolam alone groups was 8.10 and 4.00 mmHg, respectively, indicating a significant difference of p < 0.005. The mean ± standard deviation of tcPCO2 in the midazolam plus fentanyl and midazolam alone groups was 44.8 ± 7.83 and 40.6 ± 4.10 mmHg, respectively. The SpO2 in the midazolam plus fentanyl and midazolam alone groups was 94.4 ± 3.37 and 96.2 ± 2.61%, respectively, with a larger SD and greater variability in the midazolam plus fentanyl group. CONCLUSION: A transcutaneous blood gas monitor is non-invasive and can easily measure the dynamic transition of CO2. Furthermore, tcPCO2 can be used to evaluate the ventilatory status during bronchoscopy easily. A transcutaneous blood gas monitor may be useful to observe regarding respiratory depression during bronchoscopy, particularly when analgesics are used.

Clinical characteristics of HIV-associated tracheobronchial Talaromyces marneffei infection in seven patients in Guangxi, China.

OBJECTIVES: Tracheobronchial Talaromyces marneffei (T. marneffei) infections among HIV-infected patients are rare. To improve understanding, we analyzed the clinical features, immune mechanisms, treatment, and prognosis of these patients. METHODS: We collected clinical information from HIV-positive patients with talaromycosis admitted to the Fourth People's Hospital of Nanning from January 2015 to June 2022. Patients who presented with culture and/or histopathological proof of tracheobronchial T. marneffei infection were included. RESULTS: A total of 108 patients with respiratory infections who underwent bronchoscopy were enrolled. Seven patients with tracheobronchial T. marneffei infection, all of whom were men with a median age of 48 years (range 39-50 years), were analyzed. Cough, sputum, fever, and weight loss were the most common symptoms. The total white blood cell count was normal or decreased, and all lymphocyte counts were decreased. All patients had reduced CD4+ T-cell counts, with values less than 50 cells/µL. The chest CT imaging signs included patchy signals or large areas of exudation, bronchial stenosis and occlusion. This was different from the lack of bronchial involvement. Endoscopically, the trachea and bronchial mucosa showed congestion, edema, surface attachment, nodules, lumen stenosis, obstruction, etc. T. marneffei spores were found via bronchial mucosal pathology in all 7 patients. Five patients were initially treated with intravenous infusion of amphotericin B for 2 weeks, followed by oral itraconazole capsules (200 mg) twice daily, and two patients were initially treated with itraconazole. Six patients were remission, and 1 died. CONCLUSIONS: The clinical features of trachea invasion and nontracheal invasion are not unique, but chest CT reveals manifestations such as masses, solid shadows, and bronchial stenosis/obstruction. Bronchoscopy should be performed if possible, and the presence or absence of trachea T. marneffei infection should be confirmed. Antiviral therapy combined with antifungal therapy can improve patient prognosis.

Diagnostic efficacy of cryobiopsy for peripheral pulmonary lesions with ground-glass opacity: a propensity score-matched analysis.

Background: Peripheral pulmonary lesions (PPLs) with ground-glass opacity (GGO) are generally difficult to diagnose via bronchoscopy. Cryobiopsy, a recently introduced technique, provides quantitatively and qualitatively superior tissues compared with conventional biopsy methods and can improve diagnostic outcomes. However, its diagnostic accuracy has not been specifically investigated. Therefore, this study aimed to determine whether the combined use of cryobiopsy improves the diagnostic yield for PPLs with GGO. Methods: Consecutive patients who underwent bronchoscopy combined with radial endobronchial ultrasound and virtual bronchoscopic navigation for PPLs with GGO were retrospectively reviewed between June 2014 and May 2020. Cryobiopsy was introduced at our institution in June 2017. Patients who underwent only conventional biopsy (forceps and/or needle aspiration) between June 2014 and May 2017 were classified as the conventional group, whereas those who underwent cryobiopsy with or without conventional biopsy between June 2017 and May 2020 were categorized as the "cryo" group. The diagnostic performance of the two groups was compared using propensity score-matched analysis. Results: Overall, 553 cases were identified, including 250 and 303 in the cryo and conventional groups, respectively. Propensity scoring was implemented to match lesion characteristics and intraprocedural findings, leading to the selection of 232 pairs of cases for each matched (m) group. The diagnostic yield in the m-cryo group was significantly higher than that in the m-conventional group [88.8% vs. 63.8%, odds ratio: 4.50 (95% confidence interval: 2.76-7.33), P<0.001]. Although the incidence of grade 2 and 3 bleeding in the m-cryo group was higher than that in the m-conventional group (40.5% vs. 8.6% and 2.6% vs. 0.4%, respectively; P<0.001), grade 4 bleeding was not reported. Conclusions: The combined use of cryobiopsy provides improved diagnostic yield for PPLs with GGO compared with conventional biopsy methods.

Case Report: Unusual case of candy wrapper aspiration.

Foreign body (FB) aspiration is a life-threatening medical emergency that usually presents with a history of choking episodes, followed by cough and shortness of breath. However, when the signs and symptoms are subtle, they can be easily missed by the parents or the child, causing delays in the diagnosis and management, suspecting other respiratory illnesses. Here, we report an eight years old neurologically stable girl without a history of choking episodes, with only subtle respiratory symptoms, with a candy wrapper stuck in the left bronchus missed by X-ray and computer tomography (CT)- scan of the chest and diagnosed and removed by flexible bronchoscopy.

The patient was admitted, managed and discharged after ten days from Pediatric Ward of Kanti Children's hospital, Kathmandu, Nepal in January of 2024. Foreign body (FB) aspiration is a life-threatening medical emergency usually presenting with history of choking episode followed by repeated episodes of cough and shortness of breath. It usually occurs in children below 3 years of age. It is in older children and the risk of FB aspiration occurs if they are not fully conscious. Chest x-ray, CT scan of chest and rigid bronchoscopy are the investigations performed for the diagnosis of FB aspiration which usually occurs in the airway of the right side of the lung. We report an unusual case of candy wrapper aspiration in left bronchus in an 8-years-old girl who was fully conscious, without any choking episodes, with two subtle episodes of cough and breathing difficulty, which was diagnosed and removed by flexible bronchoscopy. Her x-ray and CT scan of chest were inconclusive. She was being treated as a case of bacterial pneumonia and was suspected and investigated for tuberculosis of the lungs because of prolonged duration of illness of one month. Hence, we suggest all children, including older ones who are fully conscious, with recurrent or prolonged cough or breathing difficulty, to be suspected of FB aspiration, even in the absence of choking episode, typical symptoms and signs of aspiration and atypical x-ray or CT scan of chest, which could be lifesaving.

A Rare Endobronchial Tumor in a Pediatric Patient.

A pediatric patient who presented with non-specific respiratory symptoms, including mild hemoptysis, wheezing, and eventual respiratory distress, was found to have a rare endobronchial inflammatory myofibroblastic tumor obstructing her right mainstem bronchus. It was diagnosed and initially debulked using bronchoscopy, which helped to stabilize the patient and eliminate the need for supplemental oxygen. The patient subsequently underwent successful removal of the residual tumor with parenchymal-sparing sleeve resection. This case highlights the importance of pursuing appropriate imaging along with diagnostic and therapeutic bronchoscopy for an endobronchial lesion to help manage pediatric patients with persistent respiratory symptoms.

Feasibility and Impact on Diagnosis of Peripheral Pulmonary Lesions under Real-Time Direct Vision by Iriscope®.

INTRODUCTION: Interventional pneumology plays a crucial role in the diagnosis of peripheral pulmonary lesions (PPLs), offering a minimally invasive approach with a low risk of complications. Iriscope® is a novel device that provides a direct and real-time image of PPLs. The objective of this study was to demonstrate the feasibility and impact of Iriscope® in diagnosing PPLs by analyzing its ability to directly visualize lesions and support accurate sampling during radial probe endobronchial ultrasound (rEBUS) and electromagnetic navigation bronchoscopy (ENB) combined with rEBUS. METHODS: A single-center prospective study was conducted from December 2022 to October 2023 on patients with suspicious PPLs. The diagnostic approach involved either rEBUS alone or in combination with ENB. In all cases, an additional novel technique called Iriscope® (Lys Medical, Charleroi, Belgium) was also applied. Iriscope® findings of each lesion were evaluated individually by three expert interventional pulmonologists. RESULTS: Seventy PPLs suspected of malignancy were included in the study. The PPLs underwent examination by ENB combined with rEBUS (55) or by rEBUS alone (15). Diagnosis was obtained in 68.6% (48/70) of cases. Iriscope® provided a direct, real-time view of 57.1% (40/70) of PPLs with a positive predictive value of 92.5% (37/40). This technique was able to visualize 72% (39/54) of malignant lesions, while only 6.1% (1/16) of benign lesions showed pathologic changes. The most common findings observed with Iriscope® were mucosal thickening and infiltration (92.5%), increased capillary vascularization (82%), pale or grayish mucosa (72.5%), obstruction with accumulation of secretions (50%), and cobblestone mucosa (15%). CONCLUSION: Iriscope® is a promising technique in the diagnostic process of PPLs, providing real-time pathologic imaging that facilitates accurate sampling. Further studies are needed to evaluate success rate of Iriscope-mediated repositioning and to establish predictive patterns for malignant or even benign diseases.

Pulmonary endoscopy - central to an interventional pulmonology program.

INTRODUCTION: Pulmonary endoscopy occupies a central role in Interventional Pulmonology and is frequently the mainstay of diagnosis of respiratory disease, in particular lung malignancy. Older techniques such as rigid bronchoscopy maintain an important role in central airway obstruction. Renewed interest in the peripheral pulmonary nodule is driving major advances in technologies to increase the diagnostic accuracy and advance new potential endoscopic therapeutic options. AREAS COVERED: This paper describes the role of pulmonary endoscopy, in particular ultrasound in the diagnosis and staging of lung malignancy. We will explore the recent expansion of ultrasound to include endoscopic ultrasound - bronchoscopy (EUS-B) and combined ultrasound (CUS) techniques. We will discuss in detail the advances in the workup of the peripheral pulmonary nodule.We performed a non-systematic, narrative review of the literature to summarize the evidence regarding the indications, diagnostic yield, and safety of current bronchoscopic sampling techniques. EXPERT OPINION: EBUS/EUS-B has revolutionized the diagnosis and staging of thoracic malignancy resulting in more accurate assessment of the mediastinum compared to mediastinoscopy alone, thus reducing the rate of futile thoracotomies. Although major advances in the assessment of the peripheral pulmonary nodule have been made, the role of endoscopy in this area requires further clarification and investigation.

Closure of a secondary tracheoesophageal fistula in severe pneumonia using an Amplatzer Duct Occluder II during invasive mechanical ventilation: A case report.

Key Clinical Message: Early and timely closure of secondary tracheoesophageal fistula (TEF) is crucial for critically ill patients. For those requiring invasive mechanical ventilation, the Amplatzer Duct Occluder II (ADO II) can be used as an emergency therapeutic option to rapidly close secondary TEF, providing opportunities for subsequent treatments. Abstract: Secondary tracheoesophageal fistula (TEF) is a life-threatening condition characterized by high mortality, high recurrence rates, and multiple complications. Reports on the management of secondary TEF in critically ill patients are limited due to the challenges in treatment and the lack of suitable therapeutic options. We report a case of secondary TEF in a 69-year-old male diagnosed with severe pneumonia, whose condition deteriorated rapidly following the onset of TEF. Despite invasive mechanical ventilation, maintaining blood oxygen saturation above 80% was unachievable due to the TEF. Bedside bronchoscopy revealed expansion TEF expansion caused by gastrointestinal fluid reflux and respiratory machine pressure. The TEF was urgently closed using an ADO II device during invasive mechanical ventilation to prevent further deterioration. After the patient's condition stabilized, the ADO II was replaced with a Y-shaped tracheal membrane-covered stent for further TEF management. The patient's condition improved, meeting the criteria for liberation from invasive mechanical ventilation, and bedside chest X-rays revealed a gradual resolution of pulmonary inflammation. Selecting appropriate treatment modalities for early and timely closure of secondary TEF is crucial for critically ill patients. ADO II can serve as a rescue therapy to achieve rapid closure of secondary TEF in critically ill patients requiring invasive mechanical ventilation support, providing opportunities and time for subsequent treatment.

The Bronchoalveolar Lavage Dilution Conundrum: An Updated View on a Long-Standing Problem.

Bronchoalveolar lavage (BAL) is used by researchers to study molecular interactions within healthy and diseased human lungs. However, the utility of BAL fluid measurements may be limited by difficulties accounting for dilution of the epithelial lining fluid (ELF) sampled and inconsistent collection techniques. The use of endogenous markers to estimate ELF dilution has been proposed as a potential method to normalize acellular molecule measurements in BAL fluid, but these markers are also imperfect and prone to inaccuracy. The focus of this report is to review factors that affect the interpretation of acellular molecule measurements in lung ELF and present original data comparing the performance of several BAL dilution markers during health and in a human endobronchial endotoxin challenge model of acute inflammation. Our findings suggest that incomplete ELF and lavage fluid mixing, flux of markers across the alveolar barrier, and lung inflammation are all possible factors that can affect marker performance. Accounting for these factors, we show that commonly used markers including urea, total protein, albumin, and immunoglobulin M are likely unreliable BAL dilution markers. In contrast, surfactant protein D, appears to be less affected by these factors and may be a more accurate and biologically plausible marker to improve the reproducibility of acellular BAL component measurements across individuals, during health and inflammatory states.

Fiberoptic bronchoscopy for the prevention of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials.

INTRODUCTION: Ventilator-associated pneumonia (VAP) causes increased time of mechanical ventilation (MV), prolonged intensive care unit (ICU) stay, and a higher mortality risk. The systematic review and meta-analysis aimed to compare the efficacies between fiberoptic bronchoscopy (FOB) and general sputum suction for the prevention of VAP in patients with invasive MV. METHODOLOGY: Relevant randomized controlled trials (RCTs) were obtained via a search of PubMed, Embase, Cochrane Library, Wanfang, and CNKI databases. A random-effects model was used to pool the results if significant heterogeneity was observed. Otherwise, a fixed-effects model was used. RESULTS: Sixteen RCTs were included. Compared to general sputum suction, sputum suction with FOB was associated with a significantly reduced risk of VAP (risk ratio [RR]: 0.56, 95% CI: 0.47 to 0.67, p < 0.001; I2 = 0%). Subgroup analyses showed that the combination of FOB-assisted sputum suction with bronchoalveolar lavage (BAL) further reduced the risk of VAP as compared to FOB-assisted sputum suction alone (p for subgroup difference = 0.04). In addition, FOB-assisted treatment was also associated with a reduced MV time (mean difference [MD]: -2.19 days, 95% CI: -2.69 to -1.68, p < 0.001; I2 = 18%), a shorter ICU stay (MD: 2.9 days, 95% CI: -3.68 to -2.13, p < 0.001; I2 = 34%), and a reduced mortality risk (RR: 0.46, 95% CI: 0.24 to 0.90, p = 0.02; I2 = 0%) in patients with invasive MV. CONCLUSIONS: FOB for sputum suction and BAL in patients with invasive MV is effective in reducing the incidence of VAP.

Unravelling the Impact of Foreign Bodies on Bronchiectasis: Insights From a Case Series Study.

Foreign body (FB) aspiration in adults is a rare yet critical event that can mimic chronic respiratory conditions such as asthma or bronchitis, often causing delays in diagnosis and treatment. This case series explores the presentations of four adult patients, each with a prolonged history of chronic cough, who were later discovered to have aspirated foreign bodies. Initial misdiagnoses and the limitations of high-resolution CT scans in detecting these foreign bodies contributed to delays in reaching an accurate diagnosis. Interestingly, three of the cases involved aspirated vegetative matter, which went undetected on imaging and was only identified through bronchoscopy. The fourth patient, a young adult male, had aspirated a safety pin, which led to empyema, a severe complication highlighting the risks associated with delayed diagnosis. A key finding in this series is the significant role of flexible bronchoscopy in both diagnosing and managing FB aspiration. In each case, flexible bronchoscopy, guided through a rigid bronchoscope, was instrumental in successfully removing the foreign bodies, even in complex cases involving vegetative material or sharp objects. This case series underscores the importance of considering FB aspiration in adults with unexplained chronic cough, especially when conventional imaging does not reveal a clear cause. The diagnosis of airway foreign body requires a thorough clinical history and assessment of risk factors, with bronchoscopy serving as a crucial diagnostic and therapeutic tool when CT scans are inconclusive and stressing the need for timely diagnosis and intervention to prevent severe complications and improve patient outcomes.