Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort Study.

BACKGROUND: The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused more than 210 000 deaths worldwide. However, little is known about the causes of death and the virus's pathologic features. OBJECTIVE: To validate and compare clinical findings with data from medical autopsy, virtual autopsy, and virologic tests. DESIGN: Prospective cohort study. SETTING: Autopsies performed at a single academic medical center, as mandated by the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of COVID-19. PATIENTS: The first 12 consecutive COVID-19-positive deaths. MEASUREMENTS: Complete autopsy, including postmortem computed tomography and histopathologic and virologic analysis, was performed. Clinical data and medical course were evaluated. RESULTS: Median patient age was 73 years (range, 52 to 87 years), 75% of patients were male, and death occurred in the hospital (n = 10) or outpatient sector (n = 2). Coronary heart disease and asthma or chronic obstructive pulmonary disease were the most common comorbid conditions (50% and 25%, respectively). Autopsy revealed deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death; pulmonary embolism was the direct cause of death in 4 patients. Postmortem computed tomography revealed reticular infiltration of the lungs with severe bilateral, dense consolidation, whereas histomorphologically diffuse alveolar damage was seen in 8 patients. In all patients, SARS-CoV-2 RNA was detected in the lung at high concentrations; viremia in 6 of 10 and 5 of 12 patients demonstrated high viral RNA titers in the liver, kidney, or heart. LIMITATION: Limited sample size. CONCLUSION: The high incidence of thromboembolic events suggests an important role of COVID-19-induced coagulopathy. Further studies are needed to investigate the molecular mechanism and overall clinical incidence of COVID-19-related death, as well as possible therapeutic interventions to reduce it. PRIMARY FUNDING SOURCE: University Medical Center Hamburg-Eppendorf.

Work of Breathing in Fixed and Pressure Relief Continuous Positive Airway Pressure (C-Flex™): A post hoc Analysis.

BACKGROUND: Expiratory pressure relief continuous positive airway pressure (pressure relief CPAP; C-Flex™) causes increases in inspiratory duty cycle and shortening of expiratory time. It has been suggested that these changes are caused by an increase in work of breathing. OBJECTIVES: We studied the effects of C-Flex on work of breathing and intrinsic positive end-expiratory pressure as compared to fixed CPAP. METHODS: Work of breathing was analyzed in 24 patients with obstructive sleep apnea during treatment with fixed CPAP and C-Flex with 3 different pressure relief settings in a randomized order during rapid-eye-movement (REM) and non-REM sleep. Work of breathing was assessed on a breath-by-breath basis using a piezoelectric esophageal pressure catheter and a pneumotachograph for measuring airflow. RESULTS: We found there was no increase in inspiratory work of breathing observed using C-Flex compared to fixed CPAP. Instead, we found a linear decrease in inspiratory work of breathing with increasing pressure relief, with a mean difference of 1.22 J/min between CPAP and maximum pressure release (C-Flex 3; 90% of the value with nasal CPAP); however, the decrease was not statistically significant. The decrease in inspiratory work of breathing associated with C-Flex has a significant inverse correlation with BMI. CONCLUSIONS: The C-Flex technology does not change work of breathing but shows a tendency towards a reduction of inspiratory work of breathing in patients with a lower BMI using higher C-Flex. The effect is probably caused by diminishing airway resistance generated by the positive end-expiratory pressure. Our findings may lead to additional fields of application of the C-Flex technology, such as chronic obstructive pulmonary disease or muscular dystrophy.

Clinical features of critically ill patients with Shiga toxin-induced hemolytic uremic syndrome.

OBJECTIVE: In Spring 2011, an unprecedented outbreak of Shiga toxin-producing Escherichia coli serotype O104:H4-associated hemolytic uremic syndrome occurred in Northern Germany. The aim of this study was to describe the clinical characteristics, treatments, and outcomes of critically ill patients with Shiga toxin-producing E. coli-associated hemolytic uremic syndrome during this outbreak. DESIGN, SETTING, AND PATIENTS: Multicenter, retrospective, observational study of critically ill adult patients with Shiga toxin-producing E. coli-associated hemolytic uremic syndrome in six hospitals in Hamburg, Germany, between May 2011 and August 2011. MEASUREMENTS AND MAIN RESULTS: During the study period, 106 patients with Shiga toxin-producing E. coli-associated hemolytic uremic syndrome were admitted to eight ICUs. The median age was 40 years (range, 18-83) with a female:male ratio of 3:1. The median time from onset of clinical symptoms to hospital admission was 3 days and from hospital to ICU admission an additional 3 days. A total of 101 patients (95.3%) had acute renal failure and 78 (73.6%) required renal replacement therapy. Intubation and mechanical ventilation were required in 38 patients (35.8%) and noninvasive ventilation was required in 17 patients (16.0%). The median duration of invasive ventilation was 7 days (range, 1-32 days) and the median ICU stay was 10 days (range, 1-45 days). Fifty-one patients (48.1%) developed sepsis; of these 51 patients, 27 (25.4%) developed septic shock. Seventy patients (66.0%) developed severe neurological symptoms. Ninety-seven patients (91.5%) were treated with plasma exchange and 50 patients (47.2%) received eculizumab (monoclonal anti-C5 antibody). The mortality rate was 4.7%. Mild residual neurological symptoms were present in 21.7% of patients at ICU discharge, and no patient required renal replacement therapy 6 months after ICU admission. CONCLUSIONS: During the 2011 Shiga toxin-producing E. coli-associated hemolytic uremic syndrome outbreak in Germany, critical illness developed rapidly after hospital admission, often in young women. The infection was associated with severe neurological and renal symptoms, requiring mechanical ventilation and renal replacement therapy in a substantial proportion of patients. Overall, recovery was much better than expected.

Bronchoscopic long-term palliation of a recurrent atypical carcinoid tumor.

Bronchial carcinoid tumors account for 1-2% of all primary lung tumors and are separated into 2 subgroups: typical and atypical carcinoids. Atypical carcinoids as intermediate-grade malignancies can metastasize more frequently, thus exhibiting poorer prognosis than the low-grade typical carcinoid tumors. Surgical resection remains the mainstay of treatment for pulmonary carcinoids. Bronchoscopic treatment using ablation techniques is an effective alternative to surgery in selected patients with typical carcinoid tumors. However, evidence is lacking regarding the effect of bronchoscopic resection of atypical carcinoid tumor and its recurrences. We report the case of a 73-year-old male with frequent endobronchial recurrences of a previously surgically resected atypical carcinoid tumor successfully treated using Nd:YAG laser photoresection. Furthermore, the therapeutic and local staging aspects of the disease are discussed emphasizing the efficacy of bronchoscopic resection strategies and the value of novel bronchoscopic imaging techniques in detailed inspection of the structures of the bronchial wall.

Autofluorescence imaging videobronchoscopy improves assessment of tumor margins and affects therapeutic strategy in central lung cancer.

OBJECTIVE: Autofluorescence imaging (AFI) videobronchoscopy is a new endoscopic tool that improves visualization of neoplastic changes in the bronchial mucosa. The major aim of our study was to determine sensitivity and specificity of the technique in the assessment of tumor extent (margins). The secondary objective was to evaluate the possible effect of AFI on the change in therapeutic decisions of lung cancer treatment. METHODS: In this prospective trial, we enrolled 104 patients in whom we performed 624 targeted biopsies, 3 from the pathologically altered mucosa (red-brownish or magenta colored) and 3 from randomly picked normal areas. We were using the Olympus BF-F260 videobronchoscope and EVIS LUCERA system. White light videobronchoscopy (WLB) preceded AFI examination and biopsy collection. All biopsy specimens were examined by a pathologist blinded to bronchoscopy findings, and where applicable surgically resected specimens were examined. RESULTS: In 14.4% of the patients, AFI revealed a greater extent of the tumor than WLB, and in 11.5% that finding led to change in therapeutic decision (lesser or greater resection or avoidance of surgery). We found a significant correlation between tumor extent determined by AFI and changes in therapeutic decisions (P < 0.01). Sensitivity, specificity, positive predictive value and negative predictive value for AFI in the assessment of tumor extension were 93%, 92%, 92% and 93%, respectively. Corresponding results for WLB were 84%, 79%, 77% and 85%, respectively. Relative sensitivity of AFI is 1.11. CONCLUSIONS: Our results confirm that AFI videobronchoscopy significantly improves the assessment of central lung cancer extension and influences the therapeutic strategy. This technique has greater sensitivity and specificity, in assessment of tumor margins, than WLB alone.

Narrow band imaging videobronchoscopy improves assessment of lung cancer extension and influences therapeutic strategy.

OBJECTIVE: Narrow band imaging (NBI) videobronchoscopy is a new technique aimed at lung cancer detection. This study investigated its sensitivity and specificity for evaluation of lung cancer extension and its possible influence on therapeutic decision, compared with white light videobronchoscopy. METHODS: In this prospective study, we evaluated 106 patients with suspected lung cancer. All patients were examined using EVIS LUCERA videoendoscopy system. In every patient, at least three biopsies were taken from places visualized as pathologic, surrounding primary tumor, and three biopsies from places that appeared normal. The overall number of biopsies performed in 106 patients was 636. RESULTS: The specificity and sensitivity of NBI in revealing greater lung cancer extension were 85.6% and 95%, respectively; positive and negative predictive values were 84% and 95.6%, respectively. Specificity and sensitivity were significantly better when compared with white light bronchoscopy alone (P < 0.01). NBI led to the change in therapeutic decision in 14 patients. There was statistically significant correlation between NBI assessment of tumor extension and change in therapeutic decision (P < 0.000). CONCLUSIONS: NBI showed significantly better specificity and sensitivity in the assessment of lung cancer extension. NBI proved that it might have potential influence on therapeutic decision, making it more accurate. The procedure is safe and easily deployed in everyday practice.

Vibration response imaging as a new tool for interventional-bronchoscopy outcome assessment: a prospective pilot study.

BACKGROUND: In many patients, the benefit of interventional bronchoscopy cannot be appropriately objectified. OBJECTIVES: We investigated a new technique, vibration response imaging (VRI), for breathing sound mapping to determine whether it could provide additional, valuable objective qualitative and quantitative information in central airway obstruction (CAO) and patient outcome following interventional bronchoscopy. METHODS: VRI images from 83 patients with suspected central airway stenosis and 25 healthy volunteers were evaluated by two raters blinded to the subjects' status. Qualitative and quantitative dynamic and static features were documented for the final assessment of images as normal or abnormal and changes after the intervention. As a secondary goal, stenosis location was also evaluated and compared to bronchoscopic findings. Treatment outcome analysis (improved vs. not improved) was performed by comparing baseline and follow-up images in 64 evaluations of interventional bronchoscopy. VRI measurements of treatment outcome were compared to standard tests, i.e. dyspnea score, pulmonary function testing (PFT, i.e. FEV(1), FVC and FEV(1)/FVC), chest X-ray/computed tomography and bronchoscopy, the latter being considered the gold standard). RESULTS: There was 95% (115/121) agreement between raters and clinical assessment in distinguishing between normal and abnormal images. The sensitivity and specificity of VRI were 97 and 88%, respectively. The accuracy of VRI in locating the pathology compared to bronchoscopy was 85% (17/20) for tracheal and 88% (51/58) for bronchial obstruction; overall accuracy was 83%. Correct detection of the affected side in bronchial obstructions was 88%. The overall accuracy of VRI in defining the outcome of interventional bronchoscopy was 84%. CONCLUSIONS: Obstruction location and procedure outcome were reliably identified according to specific patterns of lung images. VRI proved at least as good as standard tests in locating CAO and has the potential for becoming a valuable complementary tool in evaluating treatment outcome in patients with CAO. If our results are confirmed by further studies, VRI may replace PFT or imaging procedures in cases in which such tests cannot be performed or are not readily available at the time of the intervention.

Health-related quality of life in patients with narcolepsy.

BACKGROUND: To evaluate the health-related quality of life (HRQoL) in patients suffering from narcolepsy. METHODS: Subjects included 75 narcoleptic patients diagnosed at the Hephata Klinik, Germany, who met the International Classification of Sleep Disorders (ICSD) criteria for narcolepsy. A standardized telephone interview was used to inquire about the disease and its burdens to the patients. HRQoL was recorded using the 36-item short-form Medical Outcomes Study (SF-36) as well as the Euroqol (EQ-5D). Frequency and factors of influence on decreased HRQoL were evaluated by using bivariate and multivariate analyses. RESULTS: Patients with narcolepsy had considerably lower scores on all eight domains of the SF-36 compared to the general German population. In particular, scores were poor for the dimensions "physical role", "vitality", and "general health perception". Forty-eight percent of the patients reported problems in at least one of the EQ-5D items; most frequent were problems in the dimension "usual activity" (63.8%), "pain/discomfort" (61.7%) and "anxiety/depression" (41.1%). Difficulty maintaining "self-care" was documented only by 6.8%. The mean VAS score was 60.7%. Interestingly, signs and symptoms of narcolepsy, except for irresistible sleep episodes (p<0.03), had only a minor impact on HRQoL. Multivariate analyses confirmed a strong influence of employment status, living with a partner, excessive daytime sleepiness (EDS) and professional advancement. CONCLUSIONS: HRQoL is considerably reduced in patients, with narcolepsy affecting the different dimensions to various degrees. Factors other than clinical signs and symptoms are associated also with poor HRQoL. Measures should be taken to integrate those factors into healthcare guidelines in order to improve the quality of life in patients with narcolepsy.

Real-time electromagnetic navigation bronchoscopy to peripheral lung lesions using overlaid CT images: the first human study.

STUDY OBJECTIVES: To characterize the feasibility, accuracy, and safety of the superDimension/Bronchus system (SDBS) [superDimension, Ltd; Hertzliya, Israel] in navigating to previously unreachable peripheral lung lesions and obtaining biopsy specimens. DESIGN: Open-label, prospective, controlled clinical study. SETTING: Pulmonary institute of a university-affiliated municipal hospital. PATIENTS: Thirteen adult candidates for nonemergency bronchoscopy who gave informed consent to participate. INTERVENTIONS: The patients underwent flexible bronchoscopy using the SDBS, which is based on real-time CT-guided electromagnetic navigation and is capable of reaching peripheral lung masses beyond the reach of the bronchoscope. A position sensor was used to navigate to and sample the various target lesions for biopsy. MEASUREMENTS AND RESULTS: Three-dimensional chest CT was followed by SDBS methodology for marking anatomic landmarks and the target lesion on a virtual bronchoscopy screen and for sampling the lesion. The SDBS assisted in obtaining positive biopsy diagnoses in 9 of 13 cases (69%), with an average navigation accuracy of 5.7 mm. There were no SDBS-related adverse events. CONCLUSIONS: The SDBS is safe and effective in navigating to peripheral lung lesions located beyond the optic limits of a standard flexible bronchoscope.

Effect of routine clopidogrel use on bleeding complications after transbronchial biopsy in humans.

STUDY OBJECTIVES: Clopidogrel is often prescribed for primary or secondary prevention of cardiovascular disease and has been associated with unwanted bleeding events. After having shown that transbronchial biopsy can safely be performed in pigs receiving clopidogrel, we sought to determine whether routine clopidogrel use increases the risk of bleeding after transbronchial lung biopsy in humans. DESIGN: Prospective cohort study. PATIENTS AND INTERVENTIONS: Data were collected on 604 patients without underlying coagulation problems who underwent transbronchial lung biopsy over 13 months. Clopidogrel was not discontinued before biopsy in patients who were using it. Transbronchial biopsies were performed, and the incidence of bleeding and other complications among patients receiving clopidogrel was compared with that of other patients. RESULTS: The study was stopped early because the bleeding rate in the clopidogrel-only group (n = 18) was excessive (89% [16 of 18 patients] vs 3.4% [20 of 574 control subjects; p > 0.001] and also in the group receiving clopidogrel and aspirin (100% [12 of 12 patients] vs 3.4% among control subjects [p > 0.001]. Bleeding rates were significantly higher in the clopidogrel group for each degree of bleeding severity: mild (27% vs 1.5%), moderate (34% vs 1.5%), and severe (27% vs 0.3%; p > 0.001 for all comparisons). All 12 patients receiving both aspirin and clopidogrel had bleeding: moderate in 6 patients and severe in 6 patients. All bleeding was controlled by endoscopic means. There were no fatalities or need for blood transfusions in the patients enrolled in the trial. CONCLUSIONS: Clopidogrel use greatly increases the risk of bleeding after transbronchial lung biopsy in humans and therefore should be discontinued before bronchoscopy with biopsies. Aspirin exacerbates the effect of clopidogrel on bleeding.

[Intermediate care units and noninvasive ventilation]. / Intermediate-Care-Units und nichtinvasive Beatmung.

Intermediate care units (IMC) have been introduced to provide optimal patient management according to disease severity and to bridge the gap between intensive care (ICU) and general wards. Most patients that are referred to an IMC need monitoring and intensive analgetic treatment. Over the past years noninvasive ventilation (NIV) and weaning have emerged as important new forms of active treatment in the IMC. Most studies that have been published so far demonstrate that an IMC improves patient outcome and lowers costs, although randomized controlled trials are missing. NIV reduces mortality, the need for intubation as well as ICU and hospital length of stay in patients with chronic obstructive pulmonary disease (COPD) and other disorders that cause respiratory failure. In many cases NIV can be performed in the IMC, a fact that reduces the number of ICU admissions, lowers costs and improves patient care. The high prevalence of pulmonary diseases and NIV emphasizes the importance of pneumologists as directors of both ICU and IMC.

[Sleep apnea--treatment improves hypertension]. / Schlafapnoe--Behandlung verbessert Hypertonie.

Obstructive sleep apnea and arterial hypertension are frequent diseases, but they are also often overlooked. There is a causal relationship of sleep apnea and hypertension. Undiagnosed sleep apnea is probably the most important reason for "essential" hypertension. It is important to identify these patients. All hypertensive patients should be asked for snoring, breathing arrest and daytime sleepiness, neck circumference should be measured, and an ambulant sleep apnea monitoring should be performed, if necessary. Especially patients with refractory hypertension or non-dippers should be screened for sleep apnea and patients with sleep apnea should be examined for arterial hypertension. Continuous positive airway pressure (CPAP) can effectively lower blood pressure in the hypertensive sleep apnea patient. This is especially true for the obstructive sleep apnea patient with refractory hypertension. CPAP therapy is probably the best therapy for sleep apnea-induced nocturnal blood pressure rises.

Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea.

BACKGROUND: There is increasing evidence that obstructive sleep apnea (OSA) is an independent risk factor for arterial hypertension. Because there are no controlled studies showing a substantial effect of nasal continuous positive airway pressure (nCPAP) therapy on hypertension in OSA, the impact of treatment on cardiovascular sequelae has been questioned altogether. Therefore, we studied the effect of nCPAP on arterial hypertension in patients with OSA. METHODS AND RESULTS: Sixty consecutive patients with moderate to severe OSA were randomly assigned to either effective or subtherapeutic nCPAP for 9 weeks on average. Nocturnal polysomnography and continuous noninvasive blood pressure recording for 19 hours was performed before and with treatment. Thirty two patients, 16 in each group, completed the study. Apneas and hypopneas were reduced by approximately 95% and 50% in the therapeutic and subtherapeutic groups, respectively. Mean arterial blood pressure decreased by 9.9+/-11.4 mm Hg with effective nCPAP treatment, whereas no relevant change occurred with subtherapeutic nCPAP (P=0.01). Mean, diastolic, and systolic blood pressures all decreased significantly by approximately 10 mm Hg, both at night and during the day. CONCLUSIONS: Effective nCPAP treatment in patients with moderate to severe OSA leads to a substantial reduction in both day and night arterial blood pressure. The fact that a 50% reduction in the apnea-hypopnea index did not result in a decrease in blood pressure emphasizes the importance of highly effective treatment. The drop in mean blood pressure by 10 mm Hg would be predicted to reduce coronary heart disease event risk by 37% and stroke risk by 56%.

Endoscopic drainage of lung abscesses: technique and outcome.

BACKGROUND: Lung abscesses commonly respond well to antibiotic therapy. In patients in whom conventional therapy fails, either percutaneous catheter drainage or surgical resection are usually considered, but are frequently problematic. This study describes our experience with endoscopic lung abscess drainage in patients in whom antibiotic therapy fails. METHODS: Patients in whom antibiotic therapy for lung abscess (enlarging cavity or lack of improvement of clinical status) was unsuccessful were considered candidates if an airway connection to the cavity was present. Treatment decisions were made in a multidisciplinary chest conference. Pigtail catheters were placed via a guidewire approach into the cavities. The abscesses were flushed twice daily with gentamycin solution. If fungal infection was suspected, once-daily amphotericin B was added to the regimen. RESULTS: Forty-two patients, from January 2000 to May 2002 (17 woman and 25 men) were included in this study (mean age, 48.9 years). Catheter placement was successful in 38 patients and led to successful therapy after a mean of 6.2 days of treatment (range, 3 to 21 days). Two patients required transient ventilation after catheter placement; there were no other complications. CONCLUSIONS: Endoscopic lung abscess drainage in selected patients in whom antibiotic therapy fails is feasible and successful in experienced hands. This treatment represents an additional option for the chest physician other than percutaneous catheter drainage or surgical resection.

Effect of clopidogrel with and without aspirin on bleeding following transbronchial lung biopsy.

BACKGROUND: Clopidogrel, a potent inhibitor of platelet aggregation, is being commonly prescribed in the elderly population due to its benefits in patients with atherosclerotic diseases. It is currently unknown whether clopidogrel increases the risk of bleeding during invasive pulmonary procedures. METHODS: Pigs of the Yorkshire species were randomized to one of the following two arms: clopidogrel (75 mg/d) alone; or clopidogrel plus aspirin (75 mg/d and 325 mg/d, respectively). The animals underwent flexible bronchoscopy with transbronchial lung biopsies under fluoroscopic guidance at baseline and after 1 week of daily oral intake of their assigned drugs. The main outcome of the study was the quantity of blood collected through the bronchoscope following transbronchial lung biopsy (TBLB). RESULTS: Sixteen animals were enrolled in the study, with 8 animals randomized to each arm. No statistically significant difference was found in the average quantity of blood resulting from transbronchial lung biopsies between procedures performed at baseline and those performed after animals received either clopidogrel (mean [+/- SD] dose, 1.41 +/- 1.14 mL) or clopidogrel plus aspirin (mean dose, 1.75 +/- 1.28 mL; p = 0.42). CONCLUSIONS: Clopidogrel, with or without aspirin, does not increase bleeding complications after TBLB in healthy pigs.

The socioeconomic impact of narcolepsy.

STUDY OBJECTIVE: To evaluate the economic burden of patients suffering from narcolepsy. DESIGN: Cross-sectional study. PARTICIPANTS: 75 narcoleptic patients diagnosed at the Hephata Klinik, Germany, who met the International Classification of Sleep Disorders criteria for narcolepsy. MEASUREMENTS: A standardized telephone interview was used to inquire about the disease and its burden. In addition, health-related quality of life scales (SF-36 and EQ-5D) were mailed to the patients. Complete data were available for 75 patients. Direct and indirect costs were calculated from the societal perspective. All costs (mean +/- SD) were calculated in 2002 Euros (Euros). RESULTS: Total annual costs were Euros 14,790 +/- 16,180 (US-dollars 15,410) per patient. Direct costs were Euros 3,180 +/- 3,540 (US-dollars 3,310), which consisted of hospital costs (Euros 1,210 +/- 2,210; US-dollars 1,260), drug costs (narcolepsy medication: Euros 1,020 +/- 1,420; US-dollars 1,060), ambulatory care (Euros 90 +/- 90; US-dollars 40), and ambulatory diagnostics (Euros 20 +/- 30; US-dollars 20). More than 50% of the drug costs were due to the newer wake-promoting drugs. Total annual indirect costs amounted to Euros 11,390 +/- 15,740 (US-dollars 11,860) per patient and were mainly attributable to early retirement due to the disease. Narcolepsy was listed as being the cause of unemployment by 32 patients. In patients with sleep attacks, there was a significant correlation between early retirement and higher indirect costs compared to patients without these attacks. CONCLUSIONS: Narcolepsy causes a high socioeconomic burden, which is comparable to other chronic neurologic diseases, Indirect costs are considerably higher than direct costs. Measures should be taken to increase public awareness of this disease. Appropriate treatment must be provided in order to increase quality of life and to assist patients continuing in working life.

Endobronchial ultrasound reliably differentiates between airway infiltration and compression by tumor.

OBJECTIVE: A frequent problem in patients with intrathoracic malignancies neighboring central airways is the question of whether the airway wall is infiltrated by the tumor or if it is merely compressed. This distinction can often not be made with certainty with the help of chest CT alone, but frequently necessitates surgical biopsy or exploration. We prospectively studied the utility of endobronchial ultrasound (EBUS) in this clinical circumstance. METHODS AND PATIENTS: Between May 1999 and July 2000, 131 consecutive patients with central thoracic malignancies potentially involving the airways were enrolled into the study. Patients underwent chest CT followed by standard bronchoscopy together with EBUS and subsequent surgical evaluation. The bronchoscopists did not know the radiologist's interpretation of the chest CT before performing EBUS. The ability of chest CT and EBUS to distinguish between compression and infiltration was measured against the histologic results. RESULTS: One hundred five patients completed the trial by undergoing surgery. In 81 patients (77%), the CT scan was read as consistent with tumor invasion. EBUS only showed invasion in 49 cases (47%). Histology after surgery revealed a specificity of 100%, a sensitivity of 89%, and an accuracy of 94% for EBUS. Chest CT was far inferior, with a specificity of 28%, a sensitivity of 75%, and an accuracy of 51%. CONCLUSION: We conclude that EBUS is a highly accurate diagnostic tool and superior to chest CT in evaluating the question of airway involvement by central intrathoracic tumors. In the hands of experienced endoscopists, EBUS may become the procedure of choice for this question.

Ultrasound-guided transbronchial needle aspiration: an experience in 242 patients.

STUDY OBJECTIVES: Conventional transbronchial needle aspiration (TBNA) is a valuable procedure but remains underutilized. Recently, imaging guidance such as CT fluoroscopy has created considerable interest. As CT fluoroscopy is cumbersome and exposes patients and staff to radiation, we have examined the feasibility of endobronchial ultrasound (EBUS) in providing imaging support for TBNA. DESIGN: Prospective consecutive patient enrollment. SETTING: University-related tertiary referral centers for pulmonary diseases. RESULTS: From January 1999 to January 2000, 242 consecutive patients were entered into this prospective study (82 women and 160 men; mean age, 60.0 years). Indications for TBNA were diagnosis of enlarged lymph nodes and cancer staging. The average lymph node size was 1.7 cm (SD, 0.47; range, 0.8 to 4.3 cm). Target lymph nodes were visualized with EBUS, followed by TBNA in standard fashion. All targets could be visualized with EBUS. In 207 patients, the lymph nodes were successfully sampled (86%). This was independent of lymph node size and location. A firm diagnosis or cancer stage could be obtained in 172 patients (72%). There were no complications associated with the use of EBUS. CONCLUSION: EBUS is simply performed and if used for TBNA guidance affords an excellent yield independent of lymph node location. Randomized trials comparing standard TBNA and imaging-guided TBNA by CT fluoroscopy and EBUS are indicated.

Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial.

STUDY OBJECTIVE: Our group performed a randomized trial to assess whether the addition of endobronchial ultrasound (EBUS) guidance will lead to better results than standard transbronchial needle aspiration (TBNS). EBUS guidance seems to be beneficial in increasing the yield of TBNA but has not been proven to be superior to conventional procedures in a randomized trial. METHODS: Consecutive patients who were referred for TBNA were randomized to an EBUS-guided and a conventional TBNA arm. Patients with subcarinal lymph nodes were randomized and analyzed separately (group A) from all other stations (group B). A positive result was defined as either lymphocytes or a specific abnormality on cytology. RESULTS: Two hundred patients were examined (100 patients each in groups A and B). Half of the patients underwent EBUS-guided TBNA rather than conventional TBNA. In group A, the yield of conventional TBNA was 74% compared to 86% in the EBUS group (difference not significant). In group B, the overall yields were 58% and 84%, respectively. This difference was statistically highly significant (p < 0.001). The average number of passes was four. CONCLUSION: EBUS guidance significantly increases the yield of TBNA in all stations except in the subcarinal region. It should be considered to be a routine adjunct to TBNA. On-site cytology may be unnecessary, and the number of necessary needle passes required is low.