Tunneled Pleural Catheter for the Treatment of Malignant Pleural Effusion: A Systematic Review and Meta-analysis.

Tunneled pleural catheter (TPC) has been widely used to control malignant pleural effusion (MPE); however, it is still not clear whether it is more effective than chemical pleurodesis. We performed a systematic review with meta-analysis to evaluate success and complication rate of TPC as compared with chemical pleurodesis in the management of MPE. PubMed, EMBASE, Cochrane central register of controlled trials, and MEDLINE were searched for English-language studies of clinical controlled trials comparing TPC with chemical pleurodesis until May 2014. Overall success and complication rate were evaluated. Relative risks (RRs) were estimated using random-effects model, and statistical heterogeneity was assessed using I test. Three trials involving 307 patients with MPE were included. The success rate was comparable between TPC and chemical pleurodesis group when all studies included in the analysis (RR, 0.8; 95% confidence interval, 0.53-1.19; P = 0.27). TPC had slightly higher complication rate but was not statistically significant (RR, 2; 95% confidence interval, 0.91-4.4; P = 0.09). Current evidence suggests that TPC and chemical pleurodesis are both effective treatment for recurrent MPE with similar success and complication rate. Further randomized controlled trials are needed to compare TPC with other therapies in patients with MPE.

A 24-Hour Postintensive Care Unit Transition-of-Care Model Shortens Hospital Stay.

BACKGROUND: Patients discharged early from the medical intensive care unit (MICU) are at risk of deterioration, MICU readmission, and increased mortality. An earlier discharge to a medical ward is desirable to reduce costs but it may adversely affect outcomes. To address this problem, a new model for the MICU transition of care was implemented at our academic center: The MICU team continued to manage all patients transferred from the MICU to the medical ward for at least 24 hours. METHODS: Data were collected for all MICU patients admitted 1 year before and 1 year after the intervention. Hospital length of stay (LOS) after transfer from the MICU, readmission rate, and mortality rate were compared before and after the intervention. A nonparsimonious propensity model based on 30 factors was used to identify matched preintervention and postintervention cohorts. RESULTS: A total of 618 of the 848 patients admitted to the MICU were transferred to medical ward during the year prior to the implementation of the new model, and 600 of the 883 patients were transferred during the following year. Pre- and postintervention cohorts were well matched (n = 483 patients in each group). Poisson regression analysis showed a decrease in the hospital LOS after MICU transfer by 1.17 days (P < .001) without a significant change in adjusted mortality (lower by 1.9%, P = .181) and MICU readmission rates (lower by 2%, P = .264). CONCLUSION: A new model for the post-MICU transition of care, with the MICU team continuing to manage all patients transferred to the medical ward for at least 24 hours, significantly decreased duration of hospital stay after MICU transfer without affecting MICU readmission and mortality rate. The implementation of this model may lower medical costs and make transition of care safer without adverse outcomes.

Rigid bronchoscopy.

The purpose of this article is to provide an introduction to rigid bronchoscopy (RB). We will briefly discuss its history, evolution, and resurgence while we highlight its versatility and usefulness for today's interventional pulmonologist and thoracic surgeon. Despite being one of the earliest pulmonary procedures described, RB is still an important technique. Advances in thoracic medicine have made this skill critical for a fully functional interventional pulmonary program. If the interventional pulmonologist of this century is to be successful, he or she should be facile in this technique. Despite the availability of RB for decades, the invention of flexible bronchoscopy in 1966 led to a significant downturn in its usage. The growth of the interventional pulmonology field brought RB back into the spot light. Apart from the historic role of RB in treatment of central airway lesions and mechanical debulking of endobronchial lesions, RB is the key instrument that can adapt modern therapeutic tools such as laser, argon plasma coagulation, electrocautery, cryotherapy, and stent deployment. Performing RB requires proper preprocedure preparation, exceptional understanding of upper airway anatomy, specific hand-eye coordination, and open communication between the bronchoscopist and the anesthesiologist. These skills can be primarily learned and maintained with repetition. This article will review information relevant to this technique and lay a foundation to be built upon for years to come.

Predictors and Outcomes of Extracorporeal Membrane Oxygenation in COVID-19 Patients With ARDS: A Propensity-Matched Analysis of National Inpatient Sample.

Extracorporeal membrane oxygenation (ECMO) is a significant treatment modality for COVID-19 patients on ventilators. The current data is limited for understanding the indicators and outcomes of ECMO in COVID-19 patients with acute respiratory distress syndrome (ARDS). The National Inpatient Sample (NIS) database from 2020 was queried in this study. Among 1,666,960 patients admitted with COVID-19, 99,785 (5.98%) patients developed ARDS, and 60,114 (60.2%) were placed on mechanical ventilation. Of these mechanically ventilated COVID-ARDS patients, 2580 (4.3%) were placed on ECMO. Patients with ECMO intervention had higher adjusted odds (aOR) of blood loss anemia (aOR 9.1, 95% CI: 6.16-13.5, propensity score-matched (PSM) 42% vs 5.4%, P < 0.001), major bleeding (aOR 3.79, 95% CI: 2.5-5.6, PSM 19.9% vs 5.9%, P < 0.001) and acute liver injury (aOR 1.7, 95% CI: 1.14-2.6 PSM 14% vs 6%, P = 0.009) compared to patients without ECMO intervention. However, in-hospital mortality, acute kidney injury, transfusions, acute MI, and cardiac arrest were insignificant. On subgroup analysis, patients placed on veno-arterial ECMO had higher odds of cardiogenic shock (aOR 13.4, CI 3.95-46, P < 0.0001), cardiac arrest (aOR 3.5, CI 1.45-8.47, P = 0.0057), acute congestive heart failure (aOR 4.18, CI 1.05-16.5, P = 0.042) and lower odds of major bleeding (aOR 0.26, CI 0.07-0.92). However, there was no significant difference in mortality, intracranial hemorrhage, and acute MI. Further studies are needed before considering COVID-19 ARDS patients for placement on ECMO.

Medical thoracoscopy in intensive care unit.

During the last decade, there has been a tremendous effort towards making procedures less invasive, which could reduce complications, decrease hospital stay and minimize overall health care cost. Medical thoracoscopy (MT) or pleuroscopy is a minimally invasive procedure commonly performed by interventional pulmonologist in United States. It has a favorable safety profile allowing access to the pleural cavity with a thoracoscope via a small chest wall incision to perform diagnostic or therapeutic interventions under direct visualization. MT allows the physician to perform pleural biopsy with high accuracy, drain loculated pleural effusion, guide chest tube placement and perform pleurodesis. As compared to video-assisted thoracoscopic surgery (VATS), MT is less invasive, does not require single lung ventilation, has a comparable diagnostic yield, and better tolerated in high-risk patients. MT can also be performed at bedside in critically ill patients. Although MT is generally safe, a multi-disciplinary discussion between the interventional pulmonologist, intensive care team, anesthesiologist and thoracic team is necessary to ensure best clinical practice as well as minimize complications for such high-risk patients. The purpose of this article is to review technique, diagnostic and therapeutic indications, as well as contraindications of performing bedside MT in intensive care unit. It aims to review both advantages and limitations of performing MT in intensive care unit.

3D printing for airway disease.

It has been 30 years since the first commercial three-dimensional (3D) printer was available on market. The technological advancement of 3D printing has far exceeded its implementation in medicine. The application of 3D printing technology has the potential of playing a major role within interventional pulmonology; specifically, in the management of complex airway disease. Tailoring management to the patient-specific anatomical malformation caused by benign or malignant disease is a major challenge faced by interventional pulmonologists. Such cases often require adjunctive therapeutic procedures with thermal therapies followed by dilation and airway stenting to maintain the patency of the airway. Airway-stent size matching is one key to reducing stent-related complications. A major barrier to matching is the expansion of the stent in two dimensions (fixed sizes in length and diameter) within the deformed airway. Additional challenges are created by the subjective oversizing of the stent to reduce the likelihood of migration. Improper sizing adversely affects the stability of the stent. The stent-airway mismatch can be complicated by airway erosion, perforation, or the formation of granulation tissue. Stents can migrate, fracture, obstruct, or become infected. The use of patient-specific 3D printed airway stents may be able to reduce the stent airway mismatch. These stents allow more precise stent-airway sizing and minimizes high-pressure points on distorted airway anatomy. In theory, this should reduce the incidence of the well-known complications of factory manufactured stents. In this article, the authors present the brief history of 3D printed stents, their consideration in select patients, processing steps for development, and future direction.

Endobronchial metastasis as an uncommon pattern of metastatic dissemination from small cell osteosarcoma.

Endobronchial metastasis (EBM) from extrapulmonary primary malignancy is a rare entity. Although the most common site of metastasis of osteosarcoma is the lungs, EBM remains a rare occurrence. Cough and dyspnea are the most common symptoms. A significant number of patients are asymptomatic, making the diagnosis without any radiographic imaging challenging. CT scan of the lung, along with bronchoscopy and biopsy, is the mainstay of diagnosis and staging. A 36-year-old man presented with small cell osteosarcoma of the left maxillary region and was treated with surgery and adjuvant chemotherapy. The patient presented 8 years later with axillary metastasis and was found to have lung metastasis on further workup. Bronchoscopy and biopsy proved an EBM that was debulked by hot snare technique. The patient was then started on chemotherapy for recurrent small cell osteosarcoma.

A systematic approach to the management of massive hemoptysis.

Massive hemoptysis is regarded as a potentially lethal condition that requires immediate attention, and prompt action. Although minor hemoptysis is frequently encountered by most clinicians, massive hemoptysis in far less frequent and most physicians are not prepared to manage this time-sensitive clinical presentation in a systematic and timely fashion. Critical initial steps in management need to be implemented in an expedited fashion, such that patients may have a chance at a more definitive treatment. In this article, we review the definition, vascular anatomy, etiology, diagnostic evaluation, epidemiology and prognostic markers of massive hemoptysis. A systematic approach to management, stabilization and treatment options is followed. An algorithm is proposed for the management of massive hemoptysis and the importance of a multidisciplinary approach is emphasized.

Initial experience of medical pleuroscopy via the peel-away introducer of the indwelling pleural catheter using a thin bronchoscope.

We present a case series describing a modified technique of combining medical Pleuroscopy (MP) and indwelling pleural catheter (IPC) placement for obtaining pleural biopsies and managing recurrent pleural effusions. The unique feature of this technique is the introduction of a thin bronchoscope through the peel-away introducer of IPC to obtain pleural biopsies thus avoiding a bigger incision followed by placement of IPC. This procedure was performed on nine patients in an outpatient setting. A regular flexible bronchoscopy forceps was used to obtain pleural biopsies in eight out of nine patients and only one patient could not tolerate the procedure due to marginal respiratory status. A diagnosis of malignancy was successfully obtained in six patients, one patient had biopsy findings of chronic inflammation and one patient had necrotic debris and rare atypical cells despite having visible pleural lesions. No procedure related patient complications were noted.

Vanishing Bronchus After Lung Transplantation: The Role of Sequential Airway Dilatations.

BACKGROUND: Airway complications after lung transplant play an important role in patient survival. Early recognition and treatment of these complications are necessary to help ensure that patients who receive lung transplants have good outcomes. CASE REPORT: A 61-year-old female with a history of pulmonary venous occlusive disease presented to our hospital for a double-lung transplant. Her postoperative course was complicated by severe primary graft dysfunction. Airway examination showed significant mucosal ischemia distal to the anastomosis bilaterally with diffuse narrowing of all distal bronchial segments. Repeat bronchoscopies with debridement of necrotic material and balloon dilatation of stenotic airways were performed to maintain airway patency. CONCLUSION: Post-lung transplant airway necrosis and stenosis mandate early identification and treatment. Repetitive bronchoscopies with sequential balloon dilatations are mandatory to prevent future airway stenosis and airway vanishing.

Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis.

BACKGROUND: The indwelling pleural catheter (IPC), which was initially introduced for the management of recurrent malignant effusions, could be a valuable management option for recurrent benign pleural effusion (BPE), replacing chemical pleurodesis. The purpose of this study is to analyze the efficacy and safety of IPC use in the management of refractory nonmalignant effusions. METHODS: We conducted a systematic review and meta-analysis on the published literature. Retrospective cohort studies, case series, and reports that used IPCs for the management of pleural effusion were included in the study. RESULTS: Thirteen studies were included in the analysis, with a total of 325 patients. Congestive heart failure (49.8%) was the most common cause of BPE requiring IPC placement. The estimated average rate of spontaneous pleurodesis was 51.3% (95% CI, 37.1%-65.6%). The estimated average rate of all complications was 17.2% (95% CI, 9.8%-24.5%) for the entire group. The estimated average rate of major complications included the following: empyema, 2.3% (95% CI, 0.0%-4.7%); loculation, 2.0% (95% CI, 0.0%-4.7%); dislodgement, 1.3% (95% CI, 0.0%-3.7%); leakage, 1.3% (95% CI, 0.0%-3.5%); and pneumothorax, 1.2% (95% CI, 0.0%-4.1%). The estimated average rate of minor complications included the following: skin infection, 2.7% (95% CI, 0.6%-4.9%); blockage and drainage failure, 1.1% (95% CI, 0.0%-3.5%); subcutaneous emphysema, 1.1% (95% CI, 0.0%-4.0%); and other, 2.5% (95% CI, 0.0%-5.2%). One death was directly related to IPC use. CONCLUSIONS: IPCs are an effective and viable option in the management of patients with refractory BPE. The quality of evidence to support IPC use for BPE remains low, and high-quality studies such as randomized controlled trials are needed.

The utility of endobronchial ultrasound-transbronchial needle aspiration in lymphoma.

BACKGROUND AND OBJECTIVES: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has a well-established role in the diagnosis and staging of lung cancer. This technology is also widely used for the diagnosis of mediastinal masses and cysts as well as other inflammatory disorders such as sarcoidosis. However, the utility of this procedure in the diagnosis and subclassification of lymphoproliferative disorders (LPDs) is not clear. We performed a systematic review to evaluate EBUS-TBNA use in LPDs. MATERIALS AND METHODS: PubMed, EMBASE, MEDLINE, Cochrane Library Plus, and ISI Web of Knowledge were searched for studies of clinical trials in English reporting diagnostic performance of EBUS-TBNA in lymphoma until September 2014. The overall sensitivity, negative predictive value (NPV), and diagnostic accuracy were evaluated. RESULTS: Six trials involving 346 patients with suspected lymphoma were included. The overall sensitivity, NPV, and diagnostic accuracy ranged 38%-91%, 83%-96.4%, and 91%-97%, respectively. Further invasive surgery was needed only in 13-43% of the patients. None of the studies included in the present review reported important complications. CONCLUSION: Current evidence suggests that EBUS-TBNA can be used as an initial evaluation for patients with suspected lymphoma. Additional surgical procedures may be necessary if a sample is inadequate or negative with high suspicion of lymphoma. Further multicenter trials are needed to evaluate the diagnostic yield of EBUS-TBNA in lymphoma patients.

Reporting of central airway obstruction on radiology reports and impact on bronchoscopic airway interventions and patient outcomes.

BACKGROUND: Central airway obstruction (CAO) is a serious condition that affects patients with both benign and malignant diseases. Timely recognition of CAO is crucial for prompt intervention aimed at improving the symptoms and quality of life of these patients. The aim of this study is to evaluate the formal radiology reporting of CAO and its impact on patients' outcomes. METHODS: The medical records of patients who underwent advanced therapeutic bronchoscopy for CAO from August 2013 to September 2014 were retrospectively reviewed. Three researchers each reviewed 14 of the 42 formal radiology reports that were performed at 16 different medical and radiology centers.Patient characteristics were reported as means, medians, and standard deviations for continuous variables, and as frequencies and relative frequencies for categorical variables. RESULTS: Out of 42 patients who underwent advanced bronchoscopy for planned therapeutic intervention, only 30 had radiology and pulmonology concordance about the airway findings of CAO. This is an agreement rate of 71.4% [95% confidence interval (CI): 56.7-83.3%] or a disagreement rate of 28.6% (95% CI: 16.7-43.3%). The radiology reports did not mention 31% of CAO on CT scans. The median time from CT imaging to bronchoscopy was significantly longer in patients with CAO not reported by the radiologists (21 versus 10 days; p = 0.011). Most patients improved postoperatively with no significant difference between the two groups. CONCLUSIONS: Findings of CAOs were not described in a significant proportion of radiology reports. This results in significant delay in bronchoscopic airway management.

Mediastinal mass diagnosed by endobronchial ultrasound as recurrent hepatocellular carcinoma in a post-liver transplantation patient.

OBJECTIVE: We presented a rare case of recurrent hepatocellular carcinoma after liver transplant manifested as an isolated mediastinal mass. METHODS: A 62-year-old man was referred for evaluation of atypical chest pain and abnormal finding of a computed tomography of the chest. He had history of chronic hepatitis C liver cirrhosis and hepatocellular carcinoma underwent orthotopic liver transplant as a curative treatment three years earlier. RESULTS: The computed tomography of the chest demonstrated paratracheal mediastinal lymphadenopathy. He subsequently underwent endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA). The right paratracheal lymph node station 4R was sampled. Rapid on-site cytology evaluation demonstrated recurrent metastatic hepatocellular carcinoma. CONCLUSION: Pulmonologist should be cognizant of diagnostic utility of EBUS-TBNA in this clinical setting as more transplant patients on immunosuppressive medications with enlarged mediastinal lymphadenopathy of unknown origin will be referred for further evaluation.

The role of sedation in endobronchial ultrasound-guided transbronchial needle aspiration: Systematic review.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in diagnosis and staging of mediastinal lymph node (LN) lesions in lung cancer. Adequate sedation is an important part of the procedure since it provides patient's comfort and potentially increases diagnostic yield. We aimed to compare deep sedation (DS) versus moderate sedation (MS) in patients undergoing EBUS-TBNA procedure. METHODS: PubMed, EMBASE, MEDLINE, and Cochrane Library were searched for English studies of clinical trials comparing the two different methods of sedations in EBUS-TBNA until December 2015. The overall diagnostic yield, LN size sampling, procedural time, complication, and safety were evaluated. RESULTS: Six studies with 3000 patients which compared two different modalities of sedation in patients performing EBUS-TBNA were included in the study. The overall diagnostic yield of DS method was 52.3%-100% and MS method was 46.1%-85.7%. The overall sensitivity of EBUS-TBNA of DS method was 98.15%-100% as compared with 80%-98.08% in MS method. The overall procedural times were 27.2-50.9 min and 20.6-44.1 min in DS and MS groups, respectively. The numbers of LN sampled were between 1.33-3.20 nodes and 1.36-2.80 nodes in DS and MS groups, respectively. The numbers of passes per LN were 3.21-3.70 passes in DS group as compared to 2.73-3.00 passes in MS group. The mean of LN size was indifferent between two groups. None of the studies included reported serious adverse events. CONCLUSIONS: Using MS in EBUS-TBNA has comparable diagnostic yield and safety profile to DS. The decision on the method of sedation for EBUS-TBNA should be individually selected based on operator experience, patient preference, as well as duration of the anticipated procedure.

Aspirin use and the risk of bleeding complications after therapeutic bronchoscopy.

BACKGROUND: Aspirin use has been shown to be safe for patients undergoing certain diagnostic bronchoscopy procedures such as transbronchial biopsies and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration. However, there are no studies documenting the safety of aspirin in patients undergoing therapeutic bronchoscopy. The aim of this study is to evaluate whether aspirin increases the risk of bleeding following therapeutic bronchoscopy. METHODS: This was a retrospective study to determine if there was a higher risk of bleeding in patients on aspirin undergoing therapeutic bronchoscopy compared with those not on aspirin. Patient characteristics were reported by cohort using the mean, median, and standard deviation for continuous variables, and using frequencies and relative frequencies for categorical variables. RESULTS: Of the 108 patients who had multimodality therapeutic bronchoscopy, 17 (15.7%) were taking aspirin and 91 (84.3%) were not on aspirin. Patients in the aspirin group were older than those in the no aspirin group (median age: 66 versus 60 years, p = 0.007). The treatment modalities were similar in both groups except that more patients in the no aspirin group were treated with argon plasma coagulation (APC) compared to the aspirin group (60.4% versus 29.4%, p = 0.031). The estimated blood loss (EBL) between the aspirin and no aspirin groups was not significantly different (mean: 6.0 versus 6.7 ml; median: 5.0 versus 5.0, p = 0.36). Overall, there was no difference in complications between both groups. CONCLUSION: Aspirin use was not associated with increased risk of bleeding or procedure-related complications after therapeutic bronchoscopy.

Recurrent Bronchogenic Cyst After Surgical Resection.

BACKGROUND: Bronchogenic cysts are rare congenital anomalies that are often solitary and rarely multiple. Most bronchogenic cysts are asymptomatic, and symptoms when present are usually the result of compression by the cyst on the surrounding structures. CASE REPORT: We report a case of recurrent bronchogenic cyst following a partial resection treated with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). CONCLUSION: EBUS-TBNA can provide instant decompression of the cyst and relieves the pressure on the surrounding structures.

A 60-year-old woman with cough, dyspnea, and atelectasis 19 years after liver transplant.

A 60-year-old black woman presented with nonproductive cough of 1-month duration. She had also experienced rapidly progressive dyspnea for 1 week and one bout of vomiting a day before presentation. Her symptoms had failed to improve with a course of amoxicillin-clavulanate. Her medical history was significant for diabetes mellitus and liver transplant 19 years earlier for hepatitis C cirrhosis, for which she was receiving tacrolimus and mycophenolate. She was a current smoker with 40 pack-years of smoking history.