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INTRODUCTION: Pulmonary infections, such as tuberculosis, can result in numerous pleural complications including empyemas, pneumothoraces with broncho-pleural fistulas, and persistent air leak (PAL). While definitive surgical interventions are often initially considered, management of these complications can be particularly challenging if a patient has an active infection and is not a surgical candidate. CASE PRESENTATION: Autologous blood patch pleurodesis and endobronchial valve placement have both been described in remedying PALs effectively and safely. PALs due to broncho-pleural fistulas in active pulmonary disease are rare, and we present two such cases that were managed with autologous blood patch pleurodesis and endobronchial valves. CONCLUSION: The two cases presented illustrate the complexities of PAL management and discuss the treatment options that can be applied to individual patients.
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Fístula Brônquica , Pleurodese , Humanos , Pleurodese/métodos , Masculino , Fístula Brônquica/terapia , Fístula Brônquica/etiologia , Fístula Brônquica/cirurgia , Pneumotórax/terapia , Pneumotórax/etiologia , Tuberculose Pulmonar/complicações , Tuberculose Pulmonar/terapia , Pessoa de Meia-Idade , Feminino , Adulto , Transfusão de Sangue Autóloga/métodosRESUMO
Carcinoma cuniculatum is a rare variant of well-differentiated squamous cell carcinoma. To date, there are less than 30 cases of esophageal carcinoma cuniculatum reported. It is frequently a diagnostic challenge: A definitive diagnosis typically cannot be made before esophagectomy. We present a uniquely aggressive case of esophageal carcinoma cuniculatum complicated by a bronchoesophageal fistula and successfully palliated with dual esophageal and endobronchial stenting.
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PURPOSE: Lung cancer screening (LCS) results in earlier detection of malignancy and decreases mortality but requires access to care to benefit. We assessed factors associated with timing of lung cancer diagnosis in the absence of systematic LCS in an urban safety net hospital. PATIENTS AND METHODS: Retrospective chart review was performed of patients with pathologic diagnosis and/or staging of lung cancer at our institution between 2015 and 2018. Patient socio-demographics, disease characteristics, factors associated with access to medical care, and time point and process by which the patient accessed care were collected and analyzed. RESULTS: In total, 223 patients were identified with median age of 63 years and 57.8% male predominance. Racial distribution was 22.9%, 20.2%, 17.1%, and 9.4% for Black, White, Asian, and Hispanic, respectively. Stage at diagnosis was 8.1%, 4.5%, 17.0%, and 60.5% for stages I, II, III, and IV, respectively. Medicaid (59.6%) and Medicare/Medicaid (17.1%) were the most common insurance types, while 16.1% had no insurance. A majority (54.3%) had no established primary care provider (PCP), and only 17.9% had an in-network PCP. Patients without PCPs were more likely to have diagnostic evaluation initiated from Emergency Department or Urgent Care settings (95.0% vs 50.1%, P < .01) and present with later stage disease (92.7% vs 77.8%, P < .01). Of the 83 patients that met age and smoking history LCS criteria, only 33.7% (12.6% of total) also had an in-network PCP. CONCLUSION: Absence of established PCPs is associated with later stage presentation of lung cancer and may limit system- level benefits of LCS implementation.
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Detecção Precoce de Câncer , Neoplasias Pulmonares , Idoso , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Neoplasias Pulmonares/diagnóstico , Masculino , Medicare , Pessoa de Meia-Idade , Estudos Retrospectivos , Provedores de Redes de Segurança , Estados UnidosRESUMO
Unilateral mainstem obstruction is an uncommon cause of dyspnea in the clinic setting. However, it is identifiable on spirometry as the "two-compartment phenomenon," in which the expiratory and/or inspiratory flow is decreased, followed by a further rapid decrease, resulting in a flattened end-expiratory or end-inspiratory tail, respectively. This case report outlines a 48-year-old woman with prior subglottic stenosis who presented with recurrent dyspnea. On spirometry, she had the characteristic finding of a flattened end-expiratory tail and was confirmed on imaging to have a left-sided unilateral mainstem bronchial obstruction. Her symptoms improved following a bronchoscopic intervention, and her spirometry pattern returned to normal. Though there are numerous known causes of unilateral mainstem obstruction, the workup for this patient was unrevealing, raising the possibility of idiopathic causes of this disease process. This is a unique case of idiopathic subglottic stenosis and left-sided unilateral mainstem bronchial obstruction occurring in the same patient.
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Background: The impact of the coronavirus disease (COVID-19) pandemic extends beyond the realms of patient care and healthcare resource use to include medical education; however, the repercussions of COVID-19 on the quality of training and trainee perceptions have yet to be explored. Objective: The purpose of this study was to determine the degree of interventional pulmonology (IP) fellows' involvement in the care of COVID-19 and its impact on fellows' clinical education, procedure skills, and postgraduation employment search. Methods: An internet-based survey was validated and distributed among IP fellows in North American fellowship training programs. Results: Of 40 eligible fellows, 38 (95%) completed the survey. A majority of fellows (76%) reported involvement in the care of patients with COVID-19. Fellows training in the Northeast United States reported involvement in the care of a higher number of patients with COVID-19 than in other regions (median, 30 [interquartile range, 20-50] vs. 10 [5-13], respectively; P < 0.01). Fifty-two percent of fellows reported redeployment outside IP during COVID-19, mostly into intensive care units. IP procedure volume decreased by 21% during COVID-19 compared with pre-COVID-19 volume. This decrease was mainly accounted for by a reduction in bronchoscopies. A majority of fellows (82%) reported retainment of outpatient clinics during COVID-19 with the transition from face-to-face to telehealth-predominant format. Continuation of academic and research activities during COVID-19 was reported by 86% and 82% of fellows, respectively. After graduation, all fellows reported having secured employment positions. Conclusion: Although IP fellows were extensively involved in the care of patients with COVID-19, most IP programs retained educational activities through the COVID-19 outbreak. The impact of the decrease in procedure volume on trainee competency would be best addressed individually within each training program. These data may assist in focusing efforts regarding the education of medical trainees during the current and future healthcare crises.
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BACKGROUND: While the efficacy of Indwelling pleural catheters for palliation of malignant pleural effusions is supported by relatively robust evidence, there is less clarity surrounding the postinsertion management. METHODS: The Trustworthy Consensus-Based Statement approach was utilized to develop unbiased, scientifically valid guidance for the management of patients with malignant effusions treated with indwelling pleural catheters. A comprehensive electronic database search of PubMed was performed based on a priori crafted PICO questions (Population/Intervention/Comparator/Outcomes paradigm). Manual searches of the literature were performed to identify additional relevant literature. Dual screenings at the title, abstract, and full-text levels were performed. Identified studies were then assessed for quality based on a combination of validated tools. Appropriateness for data pooling and formation of evidence-based recommendations was assessed using predetermined criteria. All panel members participated in development of the final recommendations utilizing the modified Delphi technique. RESULTS: A total of 7 studies were identified for formal quality assessment, all of which were deemed to have a high risk of bias. There was insufficient evidence to allow for data pooling and formation of any evidence-based recommendations. Panel consensus resulted in 11 ungraded consensus-based recommendations. CONCLUSION: This manuscript was developed to provide clinicians with guidance on the management of patients with indwelling pleural catheters placed for palliation of malignant pleural effusions. Through a systematic and rigorous process, management suggestions were developed based on the best available evidence with augmentation by expert opinion when necessary. In addition, these guidelines highlight important gaps in knowledge which require further study.
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Cateteres de Demora/estatística & dados numéricos , Medicina Baseada em Evidências/métodos , Cuidados Paliativos/métodos , Derrame Pleural Maligno/terapia , Guias de Prática Clínica como Assunto/normas , Cateteres de Demora/efeitos adversos , Ensaios Clínicos como Assunto , Consenso , Técnica Delphi , Humanos , Derrame Pleural Maligno/epidemiologia , Pleurodese/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/microbiologia , Pneumologia/organização & administração , Estudos Retrospectivos , Segurança , Sociedades Médicas/organização & administração , Resultado do Tratamento , Estados UnidosRESUMO
Pneumonia is among the leading causes of morbidity and mortality worldwide. Although Streptococcus pneumoniae is the most likely cause in most cases, the variety of potential pathogens can make choosing a management strategy a complex endeavor. The setting in which pneumonia is acquired heavily influences diagnostic and therapeutic choices. Because the causative organism is typically unknown early on, timely administration of empiric antibiotics is a cornerstone of pneumonia management. Disease severity and rates of antibiotic resistance should be carefully considered when choosing an empiric regimen. When complications arise, further work-up and consultation with a pulmonary specialist may be necessary.
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Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/terapia , Pneumonia/diagnóstico , Pneumonia/terapia , Antibacterianos/administração & dosagem , Infecções Comunitárias Adquiridas/microbiologia , Infecções Comunitárias Adquiridas/fisiopatologia , Pneumonia Associada a Assistência à Saúde/diagnóstico , Pneumonia Associada a Assistência à Saúde/microbiologia , Pneumonia Associada a Assistência à Saúde/fisiopatologia , Pneumonia Associada a Assistência à Saúde/terapia , Humanos , Pneumonia/microbiologia , Pneumonia/fisiopatologia , Fatores de RiscoRESUMO
PURPOSE: Readmission after hospitalization for malignant pleural effusion (MPE) may represent gaps in the quality of health care delivery. The goal of this study was to determine the frequency of 30-day readmission for MPE and identify clinical factors associated with rehospitalization. PATIENTS AND METHODS: A retrospective cohort of adults hospitalized for MPE from 2009 to 2011 was analyzed using an administrative database. The primary outcome was all-cause 30-day readmission rate. Hierarchic mixed-effects logistic regression models were used to examine associations between patient- and hospital-level factors and 30-day readmission and assess variation in readmission rates across hospitals. RESULTS: The 7-, 14-, 30-, 60-, and 90-day readmission rates for MPE were 16.1%, 25.9%, 38.3%, 52.5%, and 63.8%, respectively. The most common primary diagnoses for 30-day readmission were MPE (69.5%) and other clinical issues related to malignancy (21.1%). Clinical factors associated with 30-day readmission were female sex (odds ratio [OR], 0.78; 95% CI, 0.63 to 0.95), greater number of medical comorbidities (OR, 1.51; 95% CI, 1.15 to 1.99), and having a do-not-resuscitate order (OR, 1.37; 95% CI, 1.03 to 1.84). Hospitals in the 90th percentile were only 1.1 times more likely to have a 30-day readmission for MPE than those in the lowest 10th percentile (40.9% v 37%). CONCLUSION: Readmission for MPE is common and frequently results from progression of malignancy. Readmission rates were similar across all hospitals, suggesting they are unlikely to be mutable using conventional approaches to reduce rehospitalizations. Instead, interventions may need to focus on addressing care planning at the end of life.
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Readmissão do Paciente/estatística & dados numéricos , Derrame Pleural Maligno/epidemiologia , Idoso , California/epidemiologia , Comorbidade , Feminino , Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Razão de Chances , Derrame Pleural Maligno/diagnóstico , Ordens quanto à Conduta (Ética Médica) , Estudos RetrospectivosRESUMO
Pulmonary inflammatory pseudotumor (PIP) is a rare benign tumor that represents less than one percent of all tumors found in the lungs. Despite the benign etiology, PIP can cause significant clinical problems due to its growth rate and potential to compromise adjacent pulmonary and thoracic structures. Complete surgical resection is the preferred therapy for PIP to prevent recurrence, however, this is not possible in some patients due to the size or location of the tumor. We present the case of an 18 year-old male presenting with PIP in the proximal left mainstem bronchus causing complete left lung collapse. Surgical resection was not possible due to tumor location, and therefore the patient was treated with corticosteroids with marked response. Corticosteroid use has for PIP has been described in few other situations, and this case demonstrates the potential for this therapeutic option in patients with PIP who have a contraindication to surgical resection.
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Chronic retention of aspirated foreign bodies is rare but can result in indolent systemic and respiratory symptoms. Bronchoscopy may show features of tissue reaction to the foreign body, including granulation tissue, endobronchial stenosis, strictures, edema, and airway distortion. The diagnosis of foreign body aspiration is often difficult to establish since some patients may not give a clear history of aspiration or may present late. In addition, patients may be misdiagnosed with chronic pneumonia, bronchitis, asthma, or malignancy. We present the case of a 42-year-old male who had a chronically retained piece of an aluminum beverage container in the left mainstem bronchus for 12 years. Careful history, radiographic evaluation, and bronchoscopic examination revealed the foreign body, which was successfully extracted by rigid bronchoscopy.
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RATIONALE: This is the first multicenter randomized controlled trial to evaluate the effectiveness and safety of Zephyr Endobronchial Valve (EBV) in patients with little to no collateral ventilation out to 12 months. OBJECTIVES: To evaluate the effectiveness and safety of Zephyr EBV in heterogeneous emphysema with little to no collateral ventilation in the treated lobe. METHODS: Subjects were enrolled with a 2:1 randomization (EBV/standard of care [SoC]) at 24 sites. Primary outcome at 12 months was the ΔEBV-SoC of subjects with a post-bronchodilator FEV1 improvement from baseline of greater than or equal to 15%. Secondary endpoints included absolute changes in post-bronchodilator FEV1, 6-minute-walk distance, and St. George's Respiratory Questionnaire scores. MEASUREMENTS AND MAIN RESULTS: A total of 190 subjects (128 EBV and 62 SoC) were randomized. At 12 months, 47.7% EBV and 16.8% SoC subjects had a ΔFEV1 greater than or equal to 15% (P < 0.001). ΔEBV-SoC at 12 months was statistically and clinically significant: for FEV1, 0.106 L (P < 0.001); 6-minute-walk distance, +39.31 m (P = 0.002); and St. George's Respiratory Questionnaire, -7.05 points (P = 0.004). Significant ΔEBV-SoC were also observed in hyperinflation (residual volume, -522 ml; P < 0.001), modified Medical Research Council Dyspnea Scale (-0.8 points; P < 0.001), and the BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index (-1.2 points). Pneumothorax was the most common serious adverse event in the treatment period (procedure to 45 d), in 34/128 (26.6%) of EBV subjects. Four deaths occurred in the EBV group during this phase, and one each in the EBV and SoC groups between 46 days and 12 months. CONCLUSIONS: Zephyr EBV provides clinically meaningful benefits in lung function, exercise tolerance, dyspnea, and quality of life out to at least 12 months, with an acceptable safety profile in patients with little or no collateral ventilation in the target lobe. Clinical trial registered with www.clinicaltrials.gov (NCT 01796392).
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Brônquios/cirurgia , Próteses e Implantes , Enfisema Pulmonar/cirurgia , Broncoscopia , Desenho de Equipamento , Tolerância ao Exercício , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Resultado do TratamentoRESUMO
Current advances in guided bronchoscopy methods permit minimally invasive access to essentially any area of the lungs. This provides a potential means to treat patients with localized lung malignancies who might not otherwise tolerate conventional treatment, which commonly relies on surgical resection. Ablation methods have long been used for bronchoscopic treatment of central airway malignancies and percutaneous treatment of peripheral lung cancer. This article reviews ablation technologies being adapted for use with guided bronchoscopy and the current state of investigation for the treatment of peripheral lung malignancies.
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Broncoscopia/métodos , Neoplasias Pulmonares/diagnóstico por imagem , Humanos , Neoplasias Pulmonares/patologiaAssuntos
Falso Aneurisma , Aorta Torácica , Procedimentos Endovasculares/efeitos adversos , Hemoptise , Enxerto Vascular/efeitos adversos , Falso Aneurisma/diagnóstico , Falso Aneurisma/etiologia , Falso Aneurisma/fisiopatologia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/patologia , Aneurisma da Aorta Torácica/cirurgia , Broncoscopia/métodos , Angiografia por Tomografia Computadorizada/métodos , Diagnóstico Diferencial , Procedimentos Endovasculares/métodos , Feminino , Hemoptise/diagnóstico , Hemoptise/etiologia , Humanos , Pessoa de Meia-Idade , Administração dos Cuidados ao Paciente/métodos , Enxerto Vascular/métodosRESUMO
Localized tracheobronchial amyloidosis is a rare disease that results from submucosal deposition of insoluble amyloid proteins in the large airways. Amyloidosis affecting the larynx and subglottic space typically results in unilateral, nodular vocal cord infiltration. It rarely can present with bilateral vocal cord involvement and can progress to lifethreatening respiratory failure due to upper airway obstruction. In these patients, typical treatment modalities such as CO2 laser ablation are often ineffectual. Bronchiectasis is a predisposing risk factor associated with the secondary (AA) form of disease. We present a patient with the primary (AL) form of localized laryngotracheal amyloidosis with pre-existing bronchiectasis, and also review the existing literature on this disease.
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Amiloidose/complicações , Bronquiectasia/complicações , Doenças da Laringe/complicações , Doenças da Traqueia/complicações , Prega Vocal/fisiopatologia , Adulto , Amiloidose/diagnóstico por imagem , Amiloidose/fisiopatologia , Bronquiectasia/diagnóstico por imagem , Bronquiectasia/fisiopatologia , Diagnóstico Diferencial , Humanos , Amiloidose de Cadeia Leve de Imunoglobulina , Doenças da Laringe/diagnóstico por imagem , Doenças da Laringe/fisiopatologia , Laringoscopia , Laringe/diagnóstico por imagem , Laringe/fisiopatologia , Masculino , Tomografia Computadorizada por Raios X , Traqueia/diagnóstico por imagem , Traqueia/fisiopatologia , Doenças da Traqueia/diagnóstico por imagem , Doenças da Traqueia/fisiopatologiaRESUMO
Mycobacterium tuberculosis disease is a common disease worldwide. Pleural visualization, however, is usually not required as the diagnosis can typically be made by less invasive methods. Thoracoscopic visualization typically reveals pleural erythema and studding with numerous small pleural tubercules and adhesions. We present images from a patient with less commonly seen large pleural nodules and plaques resulting from tuberculous pleuritis.
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Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Pleural/patologia , Idoso , Biópsia , Humanos , Masculino , Pleura/microbiologia , Pleura/patologia , Derrame Pleural/microbiologia , Derrame Pleural/patologia , Toracoscopia/métodosAssuntos
Hemoptise/induzido quimicamente , Éteres Metílicos/efeitos adversos , Alvéolos Pulmonares/efeitos dos fármacos , Administração por Inalação , Adulto , Anestésicos Inalatórios/administração & dosagem , Anestésicos Inalatórios/efeitos adversos , Broncoscopia , Diagnóstico Diferencial , Hemoptise/diagnóstico , Humanos , Masculino , Éteres Metílicos/administração & dosagem , Alvéolos Pulmonares/patologia , SevofluranoRESUMO
BACKGROUND: Since the introduction of the flexible bronchoscope over 50 years ago, bronchoscopists have seen vast improvement in the technology available for diagnostics and therapeutics in the bronchoscopy laboratory. We set forth to evaluate the latest evolution in flexible bronchoscopes with features designed to improve imaging and airway navigation. METHODS: The BF-Q190, BF-H190, and/or BF-1TH190 bronchoscopes were evaluated prospectively in 105 patients undergoing bronchoscopy from November 2010 to August 2011 at 2 tertiary care centers in the United States. Data collected from each procedure included method of insertion, airway images, and therapeutic interventions. At the completion of the study, 10 bronchoscopists were surveyed using a 7-point Likert scale to identify the perceived benefits of the design. RESULTS: Insertion methods included nasal, oral, laryngeal mask airway or endotracheal tube, and tracheostomy. Procedures performed included bronchoalveolar lavage, endobronchial biopsy or brushing, transbronchial biopsy, transbronchial needle aspiration or injection, peripheral navigation, and large airway therapeutic interventions. Survey of bronchoscopists revealed that when compared with current bronchoscopes, the features rated as having the most significant impact on functionality are the 210-degree tip angulation (average 2.4/3) and rotational capability of the insertion tube (average 2.4/3). CONCLUSIONS: The new-generation flexible bronchoscope offers improvement in image quality, magnification options, unique insertion tube rotation, and an increased 210-degree distal tip angulation over currently available flexible bronchoscopes. The bronchoscopes are an overall improvement to the current generation of bronchoscopes. The increased tip angulation and novel rotating insertion tube add the most to improvement in functionality.