Severity of Atelectasis during Bronchoscopy: Descriptions of a New Grading System (AtelectasisSeverity Scoring System-"ASSESS") and At-Risk-Lung Zones.

Atelectasis during bronchoscopy under general anesthesia is very common and can have a detrimental effect on navigational and diagnostic outcomes. While the intraprocedural incidence and anatomic location have been previously described, the severity of atelectasis has not. We reviewed chest CT images of patients who developed atelectasis in the VESPA trial (Ventilatory Strategy to Prevent Atelectasis). By drawing boundaries at the posterior chest wall (A), the anterior aspect of the vertebral body (C), and mid-way between these two lines (B), we delineated at-risk lung zones 1, 2, and 3 (from posterior to anterior). An Atelectasis Severity Score System ("ASSESS") was created, classifying atelectasis as "mild" (zone 1), "moderate" (zones 1-2), and "severe" (zones 1-2-3). A total of 43 patients who developed atelectasis were included in this study. A total of 32 patients were in the control arm, and 11 were in the VESPA arm; 20 patients (47%) had mild atelectasis, 20 (47%) had moderate atelectasis, and 3 (6%) had severe atelectasis. A higher BMI was associated with increased odds (1.5 per 1 unit change; 95% CI, 1.10-2.04) (p = 0.0098), and VESPA was associated with decreased odds (0.05; 95% CI, 0.01-0.47) (p = 0.0080) of developing moderate to severe atelectasis. ASSESS is a simple method used to categorize intra-bronchoscopy atelectasis, which allows for a qualitative description of this phenomenon to be developed. In the VESPA trial, a higher BMI was not only associated with increased incidence but also increased severity of atelectasis, while VESPA had the opposite effect. Preventive strategies should be strongly considered in patients with risk factors for atelectasis who have lesions located in zones 1 and 2, but not in zone 3.

Outcomes of Pleural Space Infections in Patients With Indwelling Pleural Catheters for Active Malignancies.

BACKGROUND: Pleural infections related to indwelling pleural catheters (IPCs) are an uncommon clinical problem. However, management decisions can be complex for patients with active malignancies due to their comorbidities and limited life expectancies. There are limited studies on the management of IPC-related infections, including whether to remove the IPC or use intrapleural fibrinolytics. METHODS: We conducted a retrospective cohort study of patients with active malignancies and IPC-related empyemas at our institution between January 1, 2005 and May 31, 2021. The primary outcome was to evaluate clinical outcomes in patients with malignant pleural effusions and IPC-related empyemas treated with intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) compared with those treated with tPA alone or no intrapleural fibrinolytic therapy. The secondary outcome evaluated was the incidence of bleeding complications. RESULTS: We identified 69 patients with a malignant pleural effusion and an IPC-related empyema. Twenty patients received tPA/DNase, 9 received tPA alone, and 40 were managed without fibrinolytics. Those treated with fibrinolytics were more likely to have their IPCs removed as part of the initial management strategy ( P =0.004). The rate of surgical intervention and mortality attributable to the empyema were not significantly different between treatment groups. There were no bleeding events in any group. CONCLUSION: In patients with IPC-related empyemas, we did not find significant differences in the rates of surgical intervention, empyema-related mortality, or bleeding complications in those treated with intrapleural tPA/DNase, tPA alone, or no fibrinolytics. More patients who received intrapleural fibrinolytics had their IPCs removed, which may have been due to selection bias.

Airway stenting for central airway obstruction: a review.

Central airway obstruction is a serious complication of various diseases, most often malignancy. Malignant etiologies include primary lung cancer as most common though metastases from various other cancers can obstruct the airways as well. Benign etiologies include inflammatory or fibrotic changes due to prior airway interventions (e.g., endotracheal intubation or tracheostomy) or specific autoimmune conditions. Different interventional modalities exist including various electrosurgical or mechanical debulking tools, though these are sometimes insufficient or contraindicated for the purpose of restoration of airway patency. The placement of stents is thus needed in certain particularly complex or refractory cases. Airway stenting requires careful patient selection and stent selection along with a thorough knowledge of relevant anatomy and procedural technique. Indeed, certain clinical presentations are better suited for stent placement and more likely to achieve a symptomatic benefit. Moreover, a variety of stents exist with each having different attributes that may better fit specific conditions. Complications must be managed properly as well. These include stent migration, granulation tissue formation, and stent-related infection which can have clinically significant consequences. In this review, we will discuss airway stenting for central airway obstruction with regard to these various subject areas as well as conclude with discussion of future research directions.

Clinical Risk Factors for Death in Patients With Empyema and Active Malignancy.

Background Pleural infection is a common clinical problem resulting in prolonged hospitalization and increased mortality. In patients with active malignancy, management decisions are based on the need for further immunosuppressive therapies, the ability to tolerate surgery, and consideration of the limited life expectancy. Identifying patients at risk for death or poor outcomes is very important as it will guide care. Study design and methods This is a retrospective cohort study of all patients with active malignancy and empyema. The primary outcome was time to death from empyema at three months. The secondary outcome was surgery at 30 days. Standard Cox regression model and cause-specific hazard regression model were used to analyze the data. Results A total of 202 patients with active malignancy and empyema were included. The overall mortality rate at three months was 32.7%. On multivariable analysis, female gender and higher urea were associated with an increased risk of death from empyema at three months. The area under the curve (AUC) of the model was 0.70. The risk factors for surgery at 30 days included the presence of frank pus and postsurgical empyema. The AUC of the model was 0.76. Interpretation Patients with active malignancy and empyema have a high probability of death. In our model, the risk factors for death from empyema included female gender and higher urea.

Control of bleeding from intercostal artery laceration.

Laceration of an intercostal artery is a rare but potentially catastrophic complication of pleural procedures such as thoracentesis. Recognition of this problem often occurs late in the bleeding process, only after hemodynamic decompensation has occurred. Aggressive and emergent measures are usually undertaken such as angiographic embolization or thoracotomy. In our review of the literature, manual pressure over the pleural space is not described as an intervention in case reports or case series. We demonstrate the first video proof of the immediate success of direct pressure over an intercostal site as a simple, rapid, and effective method for definitively stopping intercostal arterial hemorrhage after a pleural procedure.

Ventilatory Strategy to Prevent Atelectasis During Bronchoscopy Under General Anesthesia: A Multicenter Randomized Controlled Trial (Ventilatory Strategy to Prevent Atelectasis -VESPA- Trial).

BACKGROUND: Atelectasis negatively influences peripheral bronchoscopy, increasing CT scan-body divergence, obscuring targets, and creating false-positive radial-probe endobronchial ultrasound (RP-EBUS) images. RESEARCH QUESTION: Can a ventilatory strategy reduce the incidence of atelectasis during bronchoscopy under general anesthesia? STUDY DESIGN AND METHODS: Randomized controlled study (1:1) in which patients undergoing bronchoscopy were randomized to receive standard ventilation (laryngeal mask airway, 100% Fio2, zero positive end-expiratory pressure [PEEP]) vs a ventilatory strategy to prevent atelectasis (VESPA) with endotracheal intubation followed by a recruitment maneuver, Fio2 titration (< 100%), and PEEP of 8 to 10 cm H2O. All patients underwent chest CT imaging and a survey for atelectasis with RP-EBUS bilaterally on bronchial segments 6, 9, and 10 after artificial airway insertion (time 1) and 20 to 30 min later (time 2). Chest CT scans were reviewed by a blinded chest radiologist. RP-EBUS images were assessed by three independent, blinded readers. The primary end point was the proportion of patients with any atelectasis (either unilateral or bilateral) at time 2 according to chest CT scan findings. RESULTS: Seventy-six patients were analyzed, 38 in each group. The proportion of patients with any atelectasis according to chest CT scan at time 2 was 84.2% (95% CI, 72.6%-95.8%) in the control group and 28.9% (95% CI, 15.4%-45.9%) in the VESPA group (P < .0001). The proportion of patients with bilateral atelectasis at time 2 was 71.1% (95% CI, 56.6%-85.5%) in the control group and 7.9% (95% CI, 1.7%-21.4%) in the VESPA group (P < .0001). At time 2, 3.84 ± 1.67 (mean ± SD) bronchial segments in the control group vs 1.21 ± 1.63 in the VESPA group were deemed atelectatic (P < .0001). No differences were found in the rate of complications. INTERPRETATION: VESPA significantly reduced the incidence of atelectasis, was well tolerated, and showed a sustained effect over time despite bronchoscopic nodal staging maneuvers. VESPA should be considered for bronchoscopy when atelectasis is to be avoided. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04311723; URL: www. CLINICALTRIALS: gov.

Predicting malignant pleural effusion during diagnostic pleuroscopy with biopsy: A prospective multicentre study.

BACKGROUND AND OBJECTIVE: Pleuroscopy with pleural biopsy has a high sensitivity for malignant pleural effusion (MPE). Because MPEs tend to recur, concurrent diagnosis and treatment of MPE during pleuroscopy is desired. However, proceeding directly to treatment at the time of pleuroscopy requires confidence in the on-site diagnosis. The study's primary objective was to create a predictive model to estimate the probability of MPE during pleuroscopy. METHODS: A prospective observational multicentre cohort study of consecutive patients undergoing pleuroscopy was conducted. We used a logistic regression model to evaluate the probability of MPE with relation to visual assessment, rapid on-site evaluation (ROSE) of touch preparation and presence of pleural nodules/masses on computed tomography (CT). To assess the model's prediction accuracy, a bootstrapped training/testing approach was utilized to estimate the cross-validated area under the receiver operating characteristic curve. RESULTS: Of the 201 patients included in the study, 103 had MPE. Logistic regression showed that higher level of malignancy on visual assessment is associated with higher odds of MPE (OR = 34.68, 95% CI = 9.17-131.14, p < 0.001). The logistic regression also showed that higher level of malignancy on ROSE of touch preparation is associated with higher odds of MPE (OR = 11.63, 95% CI = 3.85-35.16, p < 0.001). Presence of pleural nodules/masses on CT is associated with higher odds of MPE (OR = 6.61, 95% CI = 1.97-22.1, p = 0.002). A multivariable logistic regression model of final pathologic status with relation to visual assessment, ROSE of touch preparation and presence of pleural nodules/masses on CT had a cross-validated AUC of 0.94 (95% CI = 0.91-0.97). CONCLUSION: A prediction model using visual assessment, ROSE of touch preparation and CT scan findings demonstrated excellent predictive accuracy for MPE. Further validation studies are needed to confirm our findings.

Giant Cell Arteritis as an Uncommon Cause of Chronic Cough: A Case Report.

BACKGROUND Chronic cough is a common medical concern. Giant cell arteritis (GCA) is an uncommon cause of chronic cough and is not usually suspected since symptoms can be non-specific. We present a case of chronic cough due to GCA in which symptoms were subtle but imaging was remarkable and clearly disclosed the diagnosis. CASE REPORT A 71-year-old woman presented to the pulmonary clinic with a concern of worsening cough for 4 months. She had been treated with proton pump inhibitor, intranasal steroids, and antibiotics, without improvement. Other symptoms were an occasional headache for the prior 5 months, but this had resolved. She had a history of early-stage breast and thyroid cancers, both of which were treated surgically several years earlier and were in remission. Results of a physical examination including flexible video laryngoscopy of the upper airway were completely normal. Laboratory investigations showed normal blood chemistries and blood cell counts. Her C-reactive protein level was 1 mg/L (upper limit of normal <10) but her erythrocyte sedimentation level was 121 mm/hr (upper limit of normal <30). A positron emission tomography (PET) scan was performed as surveillance for her prior cancers. This showed diffuse tracer uptake in the aorta as well as bilateral common carotid, subclavian, and common iliac arteries, revealing GCA as the underlying diagnosis. CONCLUSIONS Giant cell arteritis is a rare cause of chronic cough. Other symptoms can be subtle or non-specific as in our case, and a high index of suspicion is needed to obtain a temporal artery biopsy. In these cases, imaging adjuncts can provide a non-invasive diagnosis.

Chronic Pleuritis and Recurrent Pleural Effusion After Atezolizumab for Small Cell Lung Cancer.

BACKGROUND As use of immune checkpoint inhibitors consistently grows, so does knowledge of immune-related adverse events. Pleural complications from PD-L1 inhibitors such as atezolizumab have never been reported. We describe the first reported case of biopsy-proven pleuritis manifesting as recurrent pleural effusion in a patient treated with atezolizumab. CASE REPORT A 66-year-old woman with history of extensive-stage small cell lung cancer presented with a new pleural effusion. She was previously treated with carboplatin, etoposide, and atezolizumab followed by atezolizumab maintenance, but this later was stopped due to pneumonitis. She had been on no systemic therapy for 6 months prior; radiation to the chest was completed 1 year earlier. Thoracentesis revealed an exudate with eosinophilia but no malignancy. She underwent medical thoracoscopy, which showed normal pleura with no evidence of radiation changes. Random pleural biopsies revealed only chronic pleuritis. Given normal-appearing pleura, radiation pleuritis was ruled out. It was felt that the chemotherapy had occurred too long ago to be a present cause of her pleuritis. As such, after extensive workup, the eosinophilic pleural effusion was felt to be due to pleuritis from atezolizumab. The effusion has ultimately recurred 5 times over 1 year, and cytology remains negative for malignancy. CONCLUSIONS Patients with prior cancer presenting with a new pleural effusion should undergo an extensive workup to evaluate for recurrence. When other causes have been ruled out, ongoing immune-related effects of immunotherapy should be considered. Pleural complications from PD-L1 inhibitors have not been reported; we present a possible case of chronic pleuritis and recurrent effusion due to atezolizumab.

Spontaneous resolution of Mycobacterium kansasii presenting as a spiculated lung mass.

A 68-year old woman with a long smoking history underwent lung cancer screening by low-dose computed tomography. This detected a 3.0 cm spiculated mass in the left upper lobe. Transbronchial biopsy revealed necrotizing granulomatous inflammation and cultures grew Mycobacterium kansasii. Given lack of symptoms and concerns over drug toxicity, the patient declined antimicrobial therapy and she was monitored radiographically. Serial CT scans at six and twenty-two months showed progressive resolution of the mass. We present the first report of Mycobacterium kansasii presenting as a solitary lung nodule that spontaneously resolved without treatment.

The (Hour)glass Half-Full: Modified Silicone Hourglass Stents for the Treatment of Central Airway Obstruction.

Central airway obstruction often presents with airway narrowing of differing internal diameters. Conventional straight stents do not fit these airways well and are prone to migration. We present a series of cases where hourglass-shaped silicone stents were customized intra-operatively to fit airway obstructions of both malignant and non-malignant etiologies and to improve patient performance status. Modified hourglass stents are a versatile tool to manage inoperable airway obstruction with unique anatomical characteristics.

Sending retirees to the frontlines?

Facing an unprecedented surge of patient volumes and acuity, institutions around the globe called for volunteer healthcare workers to aid in the effort against COVID-19. Specifically being sought out are retirees. But retired healthcare workers are taking on significant risk to themselves in answering these calls. Aside from the risks that come from being on the frontlines of the epidemic, they are also at risk due to their age and the comorbidities that often accompany age. If, for current or future COVID efforts, we as a society will be so bold as to exhort a vulnerable population to take on further risk, we must use much care and attention in how we involve them in this effort. Herein we describe the multifaceted nature of the risks that retired healthcare workers are taking by entering the COVID-19 workforce as well as suggest ways in which we might take advantage of their medical skills and altruism yet while optimizing caution and safety.

Incidence and Location of Atelectasis Developed During Bronchoscopy Under General Anesthesia: The I-LOCATE Trial.

BACKGROUND: Despite the many advances in peripheral bronchoscopy, its diagnostic yield remains suboptimal. With the use of cone-beam CT imaging we have found atelectasis mimicking lung tumors or obscuring them when using radial-probe endobronchial ultrasound (RP-EBUS), but its incidence remains unknown. RESEARCH QUESTION: What are the incidence, anatomic location, and risk factors for developing atelectasis during bronchoscopy under general anesthesia? STUDY DESIGN AND METHODS: We performed a prospective observational study in which patients undergoing peripheral bronchoscopy under general anesthesia were subject to an atelectasis survey carried out by RP-EBUS under fluoroscopic guidance. The following dependent segments were evaluated: right bronchus 2 (RB2), RB6, RB9, and RB10; and left bronchus 2 (LB2), LB6, LB9, and LB10. Images were categorized either as aerated lung ("snowstorm" pattern) or as having a nonaerated/atelectatic pattern. Categorization was performed by three independent readers. RESULTS: Fifty-seven patients were enrolled. The overall intraclass correlation agreement among readers was 0.82 (95% CI, 0.71-0.89). Median time from anesthesia induction to atelectasis survey was 33 min (range, 3-94 min). Fifty-one patients (89%; 95% CI, 78%-96%) had atelectasis in at least one of the eight evaluated segments, 45 patients (79%) had atelectasis in at least three, 41 patients (72%) had atelectasis in at least four, 33 patients (58%) had atelectasis in at least five, and 18 patients (32%) had atelectasis in at least six segments. Right and left B6, B9, and B10 segments showed atelectasis in > 50% of patients. BMI and time to atelectasis survey were associated with increased odds of having more atelectatic segments (BMI: OR, 1.13 per unit change; 95% CI, 1.034-1.235; P = .007; time to survey: OR, 1.064 per minute; 95% CI, 1.025-1.105; P = .001). INTERPRETATION: The incidence of atelectasis developing during bronchoscopy under general anesthesia in dependent lung zones is high, and the number of atelectatic segments is greater with higher BMI and with longer time under anesthesia. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT03523689; URL: www.clinicaltrials.gov.

A 55-Year-Old Man With Cough and Hematochezia.

CASE PRESENTATION: A 55-year-old man presented to the ED with a 3-week history of worsening cough and shortness of breath. He had blood-tinged sputum, fever, night sweats, and a 2.7 kg weight loss within the same period. For the past few days, he had taken amoxicillin-clavulanate for presumed sinusitis. Despite this, his symptoms persisted, prompting him to seek further evaluation. His medical history was significant for ulcerative colitis and he had some bloody diarrhea for the past few weeks. Medications included aspirin, mesalamine, multivitamins, folic acid, and herbal supplements including gingko biloba, ginseng, and turmeric-ginger. He never smoked and drank alcohol occasionally. Family history was notable for stroke and myocardial infarction.