Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis.

AIMS: Patients with acute pulmonary embolism (PE) at low risk for short-term death are candidates for home treatment or short-hospital stay. We aimed at determining whether the assessment of right ventricle dysfunction (RVD) or elevated troponin improves identification of low-risk patients over clinical models alone. METHODS AND RESULTS: Individual patient data meta-analysis of studies assessing the relationship between RVD or elevated troponin and short-term mortality in patients with acute PE at low risk for death based on clinical models (Pulmonary Embolism Severity Index, simplified Pulmonary Embolism Severity Index or Hestia). The primary study outcome was short-term death defined as death occurring in hospital or within 30 days. Individual data of 5010 low-risk patients from 18 studies were pooled. Short-term mortality was 0.7% [95% confidence interval (CI) 0.4-1.3]. RVD at echocardiography, computed tomography or B-type natriuretic peptide (BNP)/N-terminal pro BNP (NT-proBNP) was associated with increased risk for short-term death (1.5 vs. 0.3%; OR 4.81, 95% CI 1.98-11.68), death within 3 months (1.6 vs. 0.4%; OR 4.03, 95% CI 2.01-8.08), and PE-related death (1.1 vs. 0.04%; OR 22.9, 95% CI 2.89-181). Elevated troponin was associated with short-term death (OR 2.78, 95% CI 1.06-7.26) and death within 3 months (OR 3.68, 95% CI 1.75-7.74). CONCLUSION: RVD assessed by echocardiography, computed tomography, or elevated BNP/NT-proBNP levels and increased troponin are associated with short-term death in patients with acute PE at low risk based on clinical models. RVD assessment, mainly by BNP/NT-proBNP or echocardiography, should be considered to improve identification of low-risk patients that may be candidates for outpatient management or short hospital stay.

What Have We Learned About Transmission of Coronavirus Disease-2019: Implications for Pulmonary Function Testing and Pulmonary Procedures.

Because of the potential for high aerosol transmission during pulmonary function testing and pulmonary procedures, performing these tests and procedures must be considered carefully during the coronavirus disease-2019 (COVID-19) pandemic. Much has been learned about the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by aerosols and the potential for such transmission through pulmonary function tests and pulmonary procedures, and subsequently preventative practices have been enhanced and developed to reduce the risk of transmission of virus to patients and personnel. This article reviews what is known about the potential for transmission of SARS-CoV-2 during pulmonary function testing and pulmonary procedures and the recommended mitigation steps to prevent the spread of COVID-19.

Reduced risk of breast cancer recurrence in patients using ACE inhibitors, ARBs, and/or statins.

BACKGROUND: Epidemiologic and biochemical evidence suggest a role of statins and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) as anti-neoplastic agents. This study was designed to evaluate the association between the use of these agents and the risk of breast cancer recurrence. METHODS: We reviewed the medical records of patients treated for stage II/III breast cancer between 1999 and 2005. Statin and ACE-inhibitors/ARB users were defined as patients who took these medications for at least 6 months in no evidence of disease (NED) stage after the initial diagnosis. The primary outcome was disease-free survival and the secondary was overall survival. The Kaplan-Meier and Cox proportional hazard models were used. RESULTS: A total of 703 patients were included. The median and maximal of follow up was 55 and 118 months, respectively. A total of 168 patients used ACE-inhibitors/ARBs, 156 patients used statins, and 81 used both. Univariate analysis showed significant reduction in breast cancer recurrence among patients who used ACE-inhibitors/ARBs (hazard ratio (HR) = 0.57; 95% CI: 0.37-0.89; p = .013) or statins (HR = 0.43; 95% CI: 0.26-0.70; p < .001). After adjusting for multiple variables, the use of ACE-inhibitors/ARBs (HR = 0.49; 95% CI: 0.31-0.76; p = .002) and statins (HR = 0.40; 95% CI: 0.24-0.67; p < .001) remained significant and an additive effect was found on those who used both drugs (HR = 0.30 95% CI: 0.15-0.61; p = .001). No association was found regarding overall survival. CONCLUSIONS: The use of ACE-inhibitors/ARBs, statins, and the combination of both were all associated with a reduced risk of breast cancer recurrence. This observation should prompt further exploration.

Artificial intelligence in pulmonary medicine: computer vision, predictive model and COVID-19.

Artificial intelligence (AI) is transforming healthcare delivery. The digital revolution in medicine and healthcare information is prompting a staggering growth of data intertwined with elements from many digital sources such as genomics, medical imaging and electronic health records. Such massive growth has sparked the development of an increasing number of AI-based applications that can be deployed in clinical practice. Pulmonary specialists who are familiar with the principles of AI and its applications will be empowered and prepared to seize future practice and research opportunities. The goal of this review is to provide pulmonary specialists and other readers with information pertinent to the use of AI in pulmonary medicine. First, we describe the concept of AI and some of the requisites of machine learning and deep learning. Next, we review some of the literature relevant to the use of computer vision in medical imaging, predictive modelling with machine learning, and the use of AI for battling the novel severe acute respiratory syndrome-coronavirus-2 pandemic. We close our review with a discussion of limitations and challenges pertaining to the further incorporation of AI into clinical pulmonary practice.

Management of tracheo-oesophageal fistula in adults.

Tracheo-oesophageal fistula (TOF) is a pathological connection between the trachea and the oesophagus that is associated with various underlying conditions including malignancies, infections, inhalation injuries and traumatic damage. As the condition spans multiple organ systems with varying aetiologies and acuities, TOF poses unique diagnostic and management challenges to pulmonologists, gastroenterologists and thoracic surgeons alike. Although stents have been a cornerstone in the management of TOF, there exists a large gap in our understanding of their efficacy and precise methodology, making stenting procedure both art and science. TOFs relating to underlying oesophageal or tracheal malignancies require advanced understanding of the airway and digestive tract anatomy, dimensions of the fistula, stent characteristics and types, and the interplay between the oesophageal stent and the airway stent if dual stenting procedure is elected. In this review article, we review the most up-to-date data on risk factors, clinical manifestations, diagnostic approaches, management methods and prognosis. Consequently, this article serves to evaluate current therapeutic strategies and the future directions in the areas of 3D-printed stents, over-the-scope clipping systems, tissue matrices and atrial septal closure devices.

Role of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration in the Diagnosis and Management of Mediastinal Cyst.

BACKGROUND: Foregut cysts account for >50% of cystic lesions in the mediastinum, of which bronchogenic cysts are most common. Surgical resection is the most definitive approach for its diagnosis and treatment. A recent systematic review, however, suggests that endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has a role in the management of bronchogenic cyst. We report our experience with EBUS-TBNA in the diagnosis and management of bronchogenic cysts. METHODS: Medical records of patients with evidence of mediastinal cysts who underwent EBUS-TBNA between 2008 and 2016 were reviewed.The primary aims of this study were to assess EBUS-TBNA diagnostic yield of peri-bronchial cysts and their specific type/origin and to determine its short-term and long-term drainage efficacy. RESULTS: A total of 26 patients met the inclusion criteria. The cytopathology diagnosis was compatible with bronchogenic cyst in 4 cases, pleural-pericardial cyst in 3 cases, and 19 were indeterminate cysts. Successful long-term treatment occurred in 5.5% of the subjects. One patient developed inflammatory pericarditis after EBUS-TBNA. CONCLUSION: Diagnostic and therapeutic yield of EBUS-TBNA for mediastinal cysts is limited and surgical resection remains the treatment of choice.

Design and Implementation of a Peer-Reviewed Medical Education Video Competition: The Best of American Thoracic Society Video Lecture Series.

BACKGROUND: Video is an increasingly popular medium for consuming online content, and video-based education is effective for knowledge acquisition and development of technical skills. Despite the increased interest in and use of video in medical education, there remains a need to develop accurate and trusted collections of peer-reviewed videos for medical learners. OBJECTIVE: We developed the first professional society-based, open-access library of crowd-sourced and peer-reviewed educational videos for medical learners and health care providers. METHODS: A comprehensive peer-review process of medical education videos was designed, implemented, reviewed, and modified using a plan-do-study-act approach to ensure optimal accuracy and effective pedagogy, while emphasizing modern teaching methods and brevity. The number of submissions and views were tracked as metrics of interest and engagement of medical learners and educators. RESULTS: The Best of American Thoracic Society Video Lecture Series (BAVLS) was launched in 2016. Total video submissions for 2016, 2017, and 2018 were 26, 55, and 52, respectively. Revisions to the video peer-review process were made after each submission cycle. By 2017, the total views of BAVLS videos on www.thoracic.org and YouTube were 9100 and 17 499, respectively. By 2018, total views were 77 720 and 152 941, respectively. BAVLS has achieved global reach, with views from 89 countries. CONCLUSIONS: The growth in submissions, content diversity, and viewership of BAVLS is a result of an intentional and evolving review process that emphasizes creativity and innovation in video-based pedagogy. BAVLS can serve as an example for developing institutional or society-based video platforms.

Predictive Variables for Failure in Administration of Intrapleural Tissue Plasminogen Activator/Deoxyribonuclease in Patients With Complicated Parapneumonic Effusions/Empyema.

BACKGROUND: Combined intrapleural therapy with tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) has been shown to reduce the need for surgical intervention for complicated pleural effusion/empyema (CPE/empyema). For patients in whom tPA/DNase is likely to fail, however, receipt of this therapy may simply delay the inevitable. The goal of this study was to identify risk factors for failure of combined intrapleural therapy. METHODS: We performed a retrospective chart review of patients who received intrapleural tPA/DNase for the treatment of CPE/empyema. Clinical variables included demographic data, radiographic parameters at time of diagnosis, and results from pleural fluid analysis. We used gradient boosted trees-an ensemble machine learning technique, with hyperparameter tuning to mitigate overfitting-to rank the importance of 19 candidate clinical variables with respect to their ability to predict failure of tPA/DNase therapy. RESULTS: We identified 84 patients who received intrapleural tPA/DNase for the treatment of complicated pleural effusions/empyema over a 5-year period. Resolution of CPE/empyema with intrapleural tPA/DNase was achieved in two-thirds of the patients (n = 57). Of the 19 candidate predictors of tPA/DNase failure, the presence of pleural thickening was found to be the most important (48% relative importance), followed by the presence of an abscess or necrotizing pneumonia (24%), the pleural protein level (6%), and the presence of loculated effusion (4%). CONCLUSIONS: Our analysis found that the presence of pleural thickening and the presence of an abscess/necrotizing pneumonia helps to triage patients in whom combined intrapleural therapy is likely to fail. The results warrant further study and validation in a prospective multicenter study.

Diagnostic Yield and Safety of Bronchoscopist-directed Moderate Sedation With a Bolus Dose Administration of Propofol During Endobronchial Ultrasound Bronchoscopy.

BACKGROUND: The propofol use for moderate sedation (MS) during endobronchial ultrasound (EBUS) bronchoscopy is primarily restricted for use by an anesthesiologist because of safety concerns. The goals of this study were to demonstrate the safety and the diagnostic yield of the use of propofol by bronchoscopists and trained endoscopy nurses during EBUS bronchoscopy without intubation. METHODS: We tested a bolus propofol administration protocol targeting MS for EBUS bronchoscopy. A fixed initial dose of 40 mg of propofol along with a fixed 50 mcg fentanyl dose were administered. Sedation assessment was performed every 2 minutes, and repeated bolus doses of propofol were given to maintain MS under the direction of the bronchoscopist. RESULTS: A total of 122 subjects underwent EBUS bronchoscopy with a goal of MS from August 2015 to April 2017. In total, 110 subjects who underwent convex EBUS bronchoscopy under MS with propofol were included in the analysis. Median procedure duration was 57 minutes (range, 15 to 97 min). Deep sedation and agitation-related delay were occurred in 14 and 21 subjects, respectively. Hemodynamic instability and hypoxemia occurred in 23 subjects. However, there was no need for vasopressors or artificial airway placement. Median of total propofol dose per case was 560 mg. Diagnostic yield for malignancy and granuloma was 68%, and a median of 4 lymph node stations were sampled per subject. All specimens with adenocarcinoma were sufficient for genetic marker analysis. There were no major sedation-related complications. CONCLUSION: A bolus administration of propofol during EBUS bronchoscopy provided excellent adequacy of sedation and well tolerance safety profile.

Lung cancer screening: detected nodules, what next?

Since the success of the NLST study, the incorporation of lung cancer screening programs into current academic programs has been growing. Center for Medicare and Medicaid Services have acknowledged the importance and potential impact of lung cancer screening by making it a reimbursable study. Based on Fleischner Society Guidelines, many nodules will require follow-up imaging. The remainder of those nodules will need tissue to appropriately make the diagnosis. The use of bronchoscopy with transbronchial biopsy has been a standard technique for many years, but as smaller nodules need to be assessed, more advanced tools, such as endobronchial ultrasound and electromagnetic navigation are now improving the yield on the diagnosis of these smaller peripheral nodules. As electromagnetic navigation and peripheral ultrasound are significant changes from practice only 10 years ago, further advancements in the technology, such as bronchoscopic robots and advanced optical imaging tools, that are becoming available, need to be assessed as to their possible incorporation into the evaluation of peripheral nodules. The ceiling to the diagnosis of these small lesions remains at 70-75%; techniques and tools need to be used to improve upon this to maximize the impact of lung cancer screening and minimize the risk to patients.

Past, present, and future of endobronchial laser photoresection.

Laser photoresection of central airway obstruction is a useful tool for an Interventional Pulmonologist (IP). Endobronchial therapy of the malignant airway obstruction is considered as a palliative measure or a bridge therapy to the definite treatment of cancer. Several ablative therapies such as electrocautery, argon plasma coagulation (APC), cryotherapy and laser photoresection exist in the armamentarium of IP to tackle such presentations. Besides Neodymium-Yttrium, Aluminum, Garnet (Nd:YAG) laser, there are several different types of laser that have been used by the pulmonologist with different coagulative and cutting properties. This chapter focuses on the historical perspective, current status, and potentials of lasers in the management of central airway lesions.

"Pills" and the air passages: a continuum.

Recently, we reported a number of key, common medications that affect the air passages in a variety of fashions. The purpose of this article is to provide a comprehensive review of the literature on the subject, including supportive articles published in languages other than English. The presented information was gathered by a review of the English literature, by cross referencing, and by communication with other interventional pulmonologists. We identified several additional medications causing either direct or systemic effects on the air passages. In this review, we update the clinical presentation, mechanism of injury, diagnosis, and management of the airway complications related to these medications.

Common Congenital Anomalies of the Central Airways in Adults.

The knowledge of airway anatomy is the most fundamental requirement of every bronchoscopist. There are numerous and frequent anatomic variations of the central airways making the examination unique for every individual. It is imperative for every bronchoscopist to be fully cognizant of the common congenital anomalies involving the central airways. Proper identification and reporting of these findings are a matter of the utmost importance, especially when surgical options in a patient with lung cancer or lung transplantation is under consideration. This article focuses on the congenital anomalies of central airway encountered among adults. Each of these anatomic variations has a characteristic appearance, yet requires bronchoscopic acumen for their identification. This review provides a comprehensive description of these anomalies and highlights their clinical implications.

Right ventricular echocardiographic parameters are associated with mortality after acute pulmonary embolism.

BACKGROUND: There is limited information on the utility of certain echocardiographic measurements, such as right ventricular (RV) strain analysis, in predicting mortality in patients with acute pulmonary embolism (PE). METHODS: A total of 211 patients with acute PE admitted to a medical intensive care unit (ICU) were retrospectively identified. Echocardiographic variables were prospectively measured in this cohort. The focus was on ICU, hospital, and long-term mortality. RESULTS: The mean age was 61 ± 15 years. Median Acute Physiology and Chronic Health Evaluation IV and simplified Pulmonary Embolism Severity Index scores were 60 (interquartile range, 40-71) and 2 (interquartile range, 1-2), respectively. Thirty-eight patients (18%) died during the sentinel hospitalization (13% died in the ICU). A total of 61 patients (28.9%) died during a median follow-up period of 15 months (interquartile range, 5-26 months). The echocardiographic variables associated with long-term mortality (from PE diagnosis) were ratio of RV to left ventricular end-diastolic diameter (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.2-4.8), tricuspid annular plane systolic excursion (HR, 0.53; 95% CI, 0.31-0.92), and RV-right atrial gradient (HR, 1.02; 95% CI, 1.01-1.4). ICU mortality was associated with ratio of RV to LV end-diastolic diameter (HR, 4.4; 95% CI, 1.3-15), RV systolic pressure (HR, 1.03; 95% CI, 1.01-1.05), tricuspid annular plane systolic excursion (HR, 0.4; 95% CI, 0.18-0.9), and inferior vena cava collapsibility < 50% (HR, 4.3; 95% CI, 1.7-11). These variables remain significantly associated with mortality after adjusting by Acute Physiology and Chronic Health Evaluation IV score, Pulmonary Embolism Severity Index score, or the use of thrombolytic agents. RV strain parameters were not correlated with hospital or long-term mortality. CONCLUSIONS: Four simple parameters that measure different aspects of the right ventricle (ratio of RV to left ventricular end-diastolic diameter, RV systolic pressure, tricuspid annular plane systolic excursion, and inferior vena cava collapsibility) were independently associated with mortality in patients presenting with acute PE who were admitted to the ICU.

Cost-benefit analysis of hepatitis a vaccination in Thailand.

We constructed a decision model to simulate costs and benefits for persons in the context of hepatitis A prevention. Three strategies were compared: i) no intervention; ii) vaccination against hepatitis A without screening; iii) vaccination against hepatitis A for those susceptible after screening for anti-HAV. We divided the population into 3 age groups : 3-11 years, 12-18 years and 19-40 years. Data regarding the cost of treatment and vaccination were obtained from the King Chulalongkorn Memorial Hospital. Relevant probabilities were obtained from published literature and expert opinion. At the present incidence of hepatitis A infection, in all age groups examined, the net benefits of a universal no-intervention strategy were higher than those of either vaccination (intervention) strategy. The cost of vaccination without screening in the 3-11-year and 12-18-year groups would equal the benefit if the incidence rates amounted to approximately 138 and 212 infected individuals per 100,000, respectively, that of vaccination with screening at incidence rates of about 200 and 260 infected persons per 100,000, respectively. In the 19-40-year group, the cost incurred by vaccination either with or without screening would equal the benefit at an incidence rate above 450 infected individual per 100,000. For the benefits to outweigh the estimated vaccination costs at present the vaccine is still too expensive. The cost of vaccination without screening in the 3-11-year group would equal the benefit if the cost of vaccine was about 586 baht/2 doses (293 baht/dose), and about 500 baht/2 doses (250 baht/dose) in the 12-18-year group. Likewise, because of the cost of vaccine, it would not be cost-beneficial in the 19-40-year group both with and without screening, and neither would it be in the 3-11-year and 12-18-year groups including screening. According to current standards, under the conditions of the present study the benefit of hepatitis A vaccination administered to the general population between the age of 3 and 40 years in Thailand does not justify the expenses incurred. Major changes in hepatitis A incidence, anti-HAV seroprevalence, vaccine cost or the treatment outcome would be required to potentially render either intervention strategy cost beneficial.

Complex metallic stent removal: decade after deployment.

Endobronchial involvement is a relatively uncommon but well-described presentation in Granulomatosis with polyangiitis (GPA). Self-expandable metallic stents (SEMs) should be reserved for the malignant airway disorder to maintain airway patency, but have been used for benign disease in specific cases. We present a case of longstanding endobronchial GPA with recurrent bronchial stenosis. Three SEMs were deployed in the distal left main bronchus 10 years prior. Two were removed in the standard manner, but the remaining stent SEM was completely embedded in the bronchial mucosa making its removal extraordinarily difficult. We placed an oversized silicone stent inside the stent leading to necrosis of the mucosa allowing for a less formidable removal of the embedded stent. Another silicone stent was temporarily placed. SEMs removal can be extremely complicated and should only be performed by experienced bronchoscopists in an institution with sufficient resources.

Parasites of the air passages.

Parasitic infestations affect millions of the world's population. Global immigration and climate change have led to changes in the natural distribution of parasitic diseases far removed from endemic areas. A broad spectrum of helminthic and protozoal parasitic diseases frequently affects the respiratory system. The wide varieties of clinical and radiographic presentations of parasitic diseases make the diagnosis of this entity challenging. Pulmonologists need to become familiar with the epidemiology, clinical presentation, pathophysiologic characteristics, and bronchoscopic findings to provide proper management in a timely fashion. This review provides a comprehensive view of both helminthic and protozoal parasitic diseases that affect the respiratory system, especially the airways.

Inhibition of renin angiotensin axis may be associated with reduced risk of developing venous thromboembolism in patients with atherosclerotic disease.

BACKGROUND: Arterial and venous thrombosis may share common pathophysiology involving the activation of platelets and inflammatory mediators. A growing body of evidence suggests prothrombotic effect of renin angiotensin system (RAS) including vascular inflammation and platelet activation. We hypothesized that the use of angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) plays a role in protecting against venous thromboembolism (VTE) in patients atherosclerosis. METHODS: We conducted a retrospective study, reviewing 1,100 consecutive patients admitted to a teaching hospital with a diagnosis of either myocardial infarction or ischemic stroke from 2005 to 2010. Patients who had been treated with anticoagulation therapy before or after the first visit were excluded. The occurrence of VTE during the follow up period, risk factors for VTE on admission, and the use of ACEIs or ARBs during the follow up period were recorded. RESULTS: The mean age of the entire study population was 68.1 years. 52.0% of the patients were female and 76.5% were African American. 67.3% were on RAS inhibitors. The overall incidence of VTE was 9.7% (n = 107). Among the RAS inhibitor users, the incidence of VTE events was 9.0% (54/603) for the ACEI only users, 7.1% (8/113) for the ARB only users, and 0% (0/24) for the patients taking combination of ACEI and ARB. Among patients on RAS inhibitors, 8.4% (62/740) developed a VTE, compared with 12.5% (45/360) in the nonuser group [HR (hazard ratio), 0.58; 95% CI (confidence interval), 0.39-0.84; P<0.01]. Even after controlling for factors related to VTE (smoking, history of cancer, and immobilization, hormone use) and diabetes, the use of RAS inhibitors was still associated with a significantly lower risk of developing VTE (AHR, 0.59; 95% CI, 0.40-0.88; P = 0.01). CONCLUSIONS: The use of RAS inhibitors appears to be associated with a reduction in the risk of VTE.

Black bronchoscopy.

A presence of black pigmentation involving the endobronchial tree is not uncommon. It was first described in the literature in association with occupational exposure in the early 1940s. However, in 2003, Packham and Yeow formally used the term black bronchoscopy to describe endobronchial metastasis from a malignant melanoma. Hyperpigmentation of the airway, however, is associated with multiple etiologies such as congenital disease, inborn errors of metabolism, infections, environmental exposures, neoplasm, and iatrogenic causes. Although the majority of these conditions are benign, a proper diagnosis is important for optimal management. In this article, we review the etiology of black bronchoscopy and discuss its presentations and current management guidelines.

"Pills" and the air passages.

Aspiration of a medication in the airways in any form produces a variety of adverse effects, both local and systemic. Furthermore, specific reaction of the airways to each type of pill strongly affects the outcome. It is crucial for pulmonologists and emergency medicine specialists to acknowledge this clinical entity. In addition, airways have been increasingly used to deliver medications such as insulin and prostacycline. These aerosolized medications can also cause local as well as systemic side effects. We review the local and systemic reactions of these "pills" accessing the airways either by incidental aspiration or iatrogenic administration. We address clinical presentation, mechanism of injury, diagnosis, and management of complications of these pills in the air passages.