Improving Referral Patterns for Bronchoscopic Lung Volume Reduction: A Quality Improvement Initiative.

Bronchoscopic lung volume reduction (BLVR) is a minimally invasive treatment option for patients with severe emphysema and hyperinflation refractory to optimal medical care. This therapy is effective in improving functional status and quality of life, underscoring the importance of identifying potential procedure candidates. To our knowledge, scalable strategies to improve the referral of advanced lung disease patients are lacking. This quality improvement project aimed to increase identification and referral for BLVR in a large Veterans Affairs academic medical center. We show implementing case identification within a pulmonary function testing report, in conjunction with provider education, increased referral rates for BLVR. Because of the ubiquity of lung function testing, other advanced lung disease programs may consider adopting this strategy to improve patients' access to timely clinical evaluation and therapy.

Use of Mitomycin-C in Laryngotracheal Stenosis: A Focused Clinical Review.

BACKGROUND: Therapeutic options for managing laryngotracheal stenosis (LTS) are limited. Endoscopy is a minimally invasive approach to treating LTS, but carries a high risk of stenosis recurrence. Mitomycin C (MMC) is often used as an adjunct therapy to delay the time to symptomatic recurrence of LTS. This review synthesizes the current literature on the topic of MMC as an adjunct treatment strategy for LTS. METHODS: A focused literature search was carried out from PubMed on June 12, 2022 using the terms "mitomycin c AND stenosis" in all fields with no date limitations. Evidence-based recommendations relevant to the clinical application of MMC as an adjunct therapy for LTS were formulated. Three questions were addressed: 1) efficacy of MMC, 2) single versus multiple application(s) of MMC, and 3) safety of MMC. The evidence rating and recommendation strength were guided by the GRADE system. RESULTS: Twenty-nine studies were reviewed. The efficacy of MMC as an adjunct therapy for LTS varied across studies. Randomized controlled trials have not shown an outcome difference with MMC use, although methodologic flaws including underpowering were noted. A meta-analysis of observational studies with a comparator arm found the unadjusted probability of remaining symptom-free for > 1 year is greater with versus without MMC application (73% vs. 35%). Single versus multiple application(s) of MMC resulted in similar restenosis rates at long-term follow-up. Complications related to MMC use are rarely reported using conventional doses (0.4 mg/mL). Overall, the quality of evidence was low and the recommendation for intervention was weak. CONCLUSION: The role for MMC as an adjunct therapy in LTS is uncertain. While safe in its application, the efficacy of MMC in reducing stenosis recurrence remains a matter of debate. Large, prospective studies are needed to inform future recommendations.

Short-term Endoscopic Outcomes of Balloon and Rigid Bronchoplasty in the Management of Benign Subglottic and Tracheal Stenosis.

BACKGROUND: Endoscopic therapies are firmly established in the management algorithm of benign subglottic and tracheal stenosis (SGTS). The optimal dilation strategy, however, has yet to be elucidated. The objective of this study was to compare the efficacy and safety of balloon versus rigid bronchoplasty in the treatment of benign SGTS. METHODS: De novo cases of benign SGTS at our institution over a 9-year period were retrospectively identified. Patients were divided into 2 groups based on the initial dilation strategy of balloon or rigid bronchoplasty. Demographics, clinical findings, concurrent interventions, lesion characteristics, and complications were analyzed. Two reviewers independently assigned an index and follow-up endoscopic stenosis grade for each case. The mean stenosis grade at follow-up in both groups was then calculated and compared. RESULTS: Sixty-three patients with benign SGTS were included. Most stenoses in the rigid (80%) and balloon (63%) bronchoplasty groups were complex ( P =0.174). In addition, 94% (59/63) of index stenoses were classified as Cotton Myer Grade 3. At follow-up, no significant difference was found in the mean stenosis grade between dilation strategies (1.97 vs. 2.2, P =0.287). Furthermore, no procedural-related complications were observed in either group. CONCLUSION: Balloon and rigid bronchoplasty are safe and effective endoscopic tools in the early management of benign SGTS. A multimodality approach centered around mucosal sparing techniques remains vitally important to the overall and likely long-term success of treating this challenging disease entity.

Rapid On-site Evaluation Practice Variability Appraisal (ROSE PETAL) survey.

BACKGROUND: Rapid on-site evaluation (ROSE) is frequently used during diagnostic procedures in patients with or suspected to have lung cancer. There is variation in ROSE use among bronchoscopists, and discussion of ROSE results can have significant consequences for patients. This study was performed to define ROSE practice and result disclosure patterns among bronchoscopists. METHODS: This cross-sectional study was performed using an electronic survey disseminated to the members of the American Association for Bronchology and Interventional Pulmonology and the Society for Advanced Bronchoscopy. The questions centered around ROSE availability, utilization, barriers, and discussion of results with patients. RESULTS: There were 137 respondents. Most identified themselves as interventional pulmonologists (109, 80%); most respondents worked in an academic setting (71, 52%). Availability of ROSE was reported by 121 (88%) respondents. Time constraints (28%), availability of cytology (22%), and scheduling conflicts (20%) were the most reported barriers to ROSE use. Endobronchial ultrasound transbronchial needle aspiration (85%) and nonrobotic peripheral bronchoscopy (65%) were the most reported procedures that used ROSE. There was heterogeneity regarding discussion of ROSE results with the patient or their caregiver in the immediate postprocedure setting: yes - always (40, 33%), yes - sometimes (32, 26%), yes - rarely (18, 15%), or no (31, 26%). Thirty-eight respondents reported they believed ROSE was ≥90% concordant with final cytology results. CONCLUSIONS: The results confirmed the heterogeneity of practice patterns. Estimates of ROSE-final cytology concordance were lower than previously published concordance results. Notably, the discussion of ROSE results varied significantly.

Do Interviews Really Matter in Generating Programs and Applicants' Rank Lists for the Match?

OBJECTIVE: A paucity of data exists on the role of the interview day in programs and applicants' final rank list. The objective of our study was to investigate the impact interview day has on our programs and our interviewees' final rank list. METHODS: For the 2020 appointment year, our program used an Electronic Residency Application System Application Scoring Tool and Interview Scoring Tool to generate the preliminary rank list for our pulmonary and critical care fellowship applicants. The final rank list was decided after interviewers' discussion during the program's rank list meeting. We aimed to correlate the preliminary and final lists. We also surveyed applicants on the importance of interview day in generating their rank list. RESULTS: The final and the preliminary rank lists were strongly correlated (rs(47) = 0.87, P < 0.001). There was a stronger correlation between the final rank and the rank based on the application score (rs(47) = 0.84, P < 0.001) than the rank based on the interview score (rs(47) = 0.64, P < 0.001). For the postinterview survey, 48 applicants were surveyed-20 replied with a response rate of 42% and 18 respondents (90%) rated the interview experience as important or very important in their rank list decisions. CONCLUSIONS: The programs rank list correlated more with the candidates' written application than their interview day performance; however, interview experience greatly influenced the applicants' rank lists. In the coronavirus disease 2019 pandemic, in which all interviews are virtual, programs should make diligent efforts to construct virtual interview days, given their importance to applicants in generating their final rank list for the match.

Indeterminate pulmonary nodule in lung allograft characterized using dual-energy computed tomography.

Pulmonary nodules (PNs) arising in the lung transplant recipient pose a diagnostic challenge for providers. Conventional computed tomography (CT) has improved our ability to detect PNs in this population, but establishing a confident diagnosis with imaging alone remains difficult. Dual-energy spectral detector CT is a novel, emerging technology that provides insight into the radiographic behavior of PNs, and has potential in differentiating benign from malignant morphologies. Herein, we report a case of a PN in a lung transplant recipient whose initial diagnostic work-up was inconclusive, but then had the diagnosis rendered using a spectral detector CT.

Preoperative assessment of lung nodules and lobar function by spectral detector computed tomography.

Conventional computed tomography (CT) plays an important role in detection of lung nodules. However, further characterization is usually limited requiring additional imaging and invasive work up. Spectral Detector CT (SDCT) is an upcoming novel modality that not only allows morphological evaluation but also provides insight into prediction of malignant behavior of lung nodules. Additional quantification capabilities available from the same scan make it a more comprehensive imaging option in oncology patients. This is a first case report demonstrating the potential of single SDCT to provide necessary information for lung cancer diagnosis and preoperative planning, comparable to standard of care imaging.

Causes and predictors of 30-day readmissions in patients with cardiogenic shock requiring extracorporeal membrane oxygenation support.

BACKGROUND: Cardiogenic shock is associated with significant mortality, morbidity, and healthcare cost. Utilization of extracorporeal membrane oxygenation in cardiogenic shock has increased in the United States. We sought to identify the rates and predictors of hospital readmissions in patients with cardiogenic shock after weaning from extracorporeal membrane oxygenation. METHODS: Using the 2016 Nationwide Readmission Database, we identified all patients (⩾18 years) with cardiogenic shock (ICD-10 CM R57.0) that have been implanted with extracorporeal membrane oxygenation (ICD-10-PSC of 5A15223) and were discharged alive (January-November 2016). We explored the rates, causes, and predictors of all-cause readmissions within 30 days. RESULTS: Out of 69,040 admissions with cardiogenic shock, 1641 (2.4%) underwent extracorporeal membrane oxygenation (581 were implanted during or after cardiac surgery). A total of 734 (44.7%) patients of all extracorporeal membrane oxygenations survived to discharge, and 661 were available for analysis. Out of those, 158 (23.9%) were readmitted within 30 days of discharge. More than 50% of these readmissions happened within the first 11 days. Out of 158 patients who were readmitted, 12 (7.4%) died during the readmission hospitalization. Leading causes of readmission were cardiovascular (31.6%) (heart failure: 24.1%, arrhythmia: 20.6%, neurovascular: 10.3%, hypertension: 10.3%, and endocarditis: 6.8%), followed by complications of medical/device care (17.7%), infection (11.3%), and gastrointestinal/liver (10.1%) complications. Factors associated with readmissions include the following: discharge to skilled nursing facility or with home healthcare (odds ratio: 2.10; 95% confidence interval: 1.18-3.74), durable ventricular assisted device implantation, asthma, and chronic liver disease. CONCLUSION: Patients with cardiogenic shock who underwent extracorporeal membrane oxygenation had a readmission rate. Identifying patients at high risk of readmissions might help improve outcomes.

Comparison of specimen adequacy and diagnostic accuracy of a 25-gauge and 22-gauge needle in endobronchial ultrasound-guided transbronchial needle aspiration.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the preferred diagnostic modality for sampling mediastinal and hilar lymph nodes (LNs). The conventional needle used for sampling is either a 21-gauge (21G) or 22-gauge (22G). A 25-gauge (25G) needle has recently been introduced with little known regarding its efficacy. METHODS: A retrospective study was conducted on patients referred for EBUS-TBNA who had LNs sampled using a 25G or 22G needle. A propensity score matching analysis was performed. After matching the groups, each LN was assessed for adequacy and final diagnosis. Non-diagnostic and benign lymphoid specimens were compared with repeat biopsy findings or long-term clinical and radiological follow-up. RESULTS: A total of 158 LNs were included. An adequate sample was obtained in 92.4% (73/79) in the 25G group and 92.4% (73/79) in the 22G group (P=1). The 25G group diagnosed benign lymphoid tissue in 82.3% (65/79), granuloma in 7.6% (6/79) and malignancy in 2.5% (2/79). Six lymph nodes in the 25G group were non-diagnostic (7.6%). The 22G group diagnosed benign lymphoid tissue in 83.5% (66/79), granuloma in 3.8% (3/79) and malignancy in 5.1% (4/79). Six lymph nodes in the 22G group were non-diagnostic (7.6%). The sensitivity, specificity, negative predictive value (NPV) and diagnostic accuracy in the 25G group was 88.9% (95% CI, 51.8-99.7%), 100% (95% CI, 92.1-100%), 97.8% (95% CI, 87.6-99.7%) and 98.2% (95% CI, 90.1-100%), respectively. The sensitivity, specificity, NPV and diagnostic accuracy in the 22G group was 77.8% (95% CI, 40-97.2%), 100% (95% CI, 86.8-100%), 92.9% (95% CI, 79.3-97.8%) and 94.3% (95% CI, 80.8-99.3%), respectively. The 25G and 22G group were comparable in diagnostic accuracy (P=0.7). CONCLUSIONS: The 25G and 22G needle achieve comparable specimen adequacy and diagnostic accuracy in EBUS-TBNA.