Therapeutic bronchoscopy for malignant central airway obstructions caused by non-bronchogenic cancers: Results from the EpiGETIF registry.

BACKGROUND AND OBJECTIVE: Little is known about malignant central airway obstruction (MCAO) complicating the metastatic spread of non-bronchogenic solid cancers (NBC) and their bronchoscopic management. This study aimed to describe the epidemiology of this population and determine prognostic factors before therapeutic bronchoscopy (TB). METHODS: In this multicenter study using the EpiGETIF registry, we analysed patients treated with TB for MCAO caused by NBC between January 2019 and December 2022. RESULTS: From a database of 2389 patients, 436 patients (18%) with MCAO and NBC were identified. After excluding patients with direct local invasion, 214 patients (8.9%) were analysed. The main primaries involved were kidney (17.8%), colon (16.4%), sarcoma (15.4%), thyroid (8.9%) and head and neck (7.9%) cancers. Most patients (63.8%) had already received one or more lines of systemic treatment. Obstructions were purely intrinsic in 58.2%, extrinsic in 11.1% and mixed in 30.8%. Mechanical debulking was used in 73.4% of cases, combined with thermal techniques in 25.6% of cases. Airway stenting was required in 38.4% of patients. Median survival after TB was 11.2 months, influenced by histology (p = 0.002), performance status (p = 0.019), initial hypoxia (HR 1.45 [1.01-2.18]), prior oncologic treatment received (HR 1.82 [1.28-2.56], p < 0.001) and assessment of success at the end of the procedure (HR 0.66 [0.44-0.99], p < 0.001). Complications rate was 8.8%, mostly mild, with no procedure-related mortality. CONCLUSION: TB for MCAO caused by a NBC metastasis provides rapid improvement of symptoms and prolonged survival. Patients should be promptly referred by medical oncologists for bronchoscopic management based on the prognostic factors identified.

Therapeutic bronchoscopy for malignant central airway obstruction: Introduction to the EpiGETIF registry.

BACKGROUND AND OBJECTIVE: EpiGETIF is a web-based, multicentre clinical database created in 2019 aiming for prospective collection of data regarding therapeutic rigid bronchoscopy (TB) for malignant central airway obstruction (MCAO). METHODS: Patients were enrolled into the registry from January 2019 to November 2022. Data were prospectively entered through a web-interface, using standardized definitions for each item. The objective of this first extraction of data was to describe the population and the techniques used among the included centres to target, facilitate and encourage further studies in TB. RESULTS: Overall, 2118 patients from 36 centres were included. Patients were on average 63.7 years old, mostly male and smokers. Most patients had a WHO score ≤2 (70.2%) and 39.6% required preoperative oxygen support, including mechanical ventilation in 6.7%. 62.4% had an already known histologic diagnosis but only 46.3% had received any oncologic treatment. Most tumours were bronchogenic (60.6%), causing mainly intrinsic or mixed obstruction (43.3% and 41.5%, respectively). Mechanical debulking was the most frequent technique (67.3%), while laser (9.8%) and cryo-recanalization (2.7%) use depended on local expertise. Stenting was required in 54.7%, silicone being the main type of stent used (55.3%). 96.3% of procedure results were considered at least partially successful, resulting in a mean 4.1 points decrease on the Borg scale of dyspnoea. Complications were noted in 10.9%. CONCLUSION: This study exposes a high volume of TB that could represent a good source of future studies given the dismal amount of data about the effects of TB in certain populations and situations.

Trans-bronchial lung cryobiopsy in patients at high-risk of complications.

BACKGROUND: The surgical lung biopsy (SLB) is the recommended sampling technique when the pathological analysis of the lung is required in the work-up of an interstitial lung disease (ILD) but trans-bronchial lung cryobiopsy (TBLC) is increasingly recognized as an alternative approach. As TBLCs have lower mortality and morbidity risks than SLB, this study aimed to investigate the safety of TBLCs in patients at higher risk of complications and for whom SLB was not considered as an alternative. METHOD: This prospective study was conducted in two hospitals in which TBLCs were performed in patients with body mass index (BMI) > 35, and/or older than 75 years, and/or with severely impaired lung function (FVC < 50% or DLCO < 30%), and/or systolic pulmonary artery pressure > 45 mmHg, and/or a clinically significant cardiac disease. Patients with any of these risk factors constituted the high-risk group. Clinical outcomes were compared with those obtained in patients without these risk factors (low-risk group). RESULTS: Ninety-six patients were included between April 2015 and April 2020, respectively 38 and 58 in the high-risk or the low-risk group. No statistically significant difference was observed between both groups in terms of severity and rate of bleeding, pneumothorax, or duration of hospital stay (p value ranging from 0.419 to 0.914). CONCLUSION: This preliminary study on a limited number of patients suggests that TBLC appears safe in those in whom lung biopsy is at high-risk of complications according to their age, BMI, lung impairment, and cardiac comorbidities.

Stent-in-Stent Technique for the Treatment of Proximal Bronchial Restenosis after Insertion of Metallic Stents: A Report of Two Cases.

Endoscopic treatment of a bronchial restenosis previously treated by insertion of a partially covered self-expandable metallic stent (SEMS) can be difficult. Classically, after recanalization of the bronchus, the stent is removed and replaced by a more adapted one. We report on two cases of proximal bronchial restenosis treated by insertion of an additional stent inside the lumen of the previously inserted stent using the stent-in-stent (SIS) technique. The indications for the initial stent were malignancy in Patient 1 and posttransplant bronchial stenosis in Patient 2. Restenosis occurred at the proximal end of the stent within months in both cases. Stent removal and insertion of a new stent were considered, but this option was discarded because of an excessive risk of bronchial perforation and preference towards an alternative approach. In both cases, a second customized SEMS was placed using the SIS technique after ablation of the proximal end stenosis of the stent by argon plasma coagulation and/or dilation with a balloon. Recanalization of the bronchus was achieved in both cases without complications. The SIS technique is a valuable alternative to removal of SEMS in case of proximal bronchial restenosis.

Successful management of congenital bronchial stenosis using an expandable stent.

Congenital bronchial stenosis is a very rare cause of neonatal dyspnea. Surgical management remains challenging in small children. We report successful implantation of a bronchial stent in a 3-month-old female infant presenting with congenital right bronchial stenosis and 18 months of follow-up. Use of stents in children remains controversial because of the problem of size mismatch as the child grows. Nevertheless, expandable stent implantation could be an interesting alternative to complex surgery for localized bronchial stenosis in neonates.

[Adult respiratory distress symptom during Plasmodium falciparum malaria]. / Syndrome de détresse respiratoire de l'adulte compliquant un accès palustre à Plasmodium falciparum.

INTRODUCTION: We present a typical case of adult respiratory distress syndrome (ARDS) occurring during infection with Plasmodium falciparum, in a nonimmune adult. The patient recovered after treatment. CASE: A 63-year-old man who had traveled in Kenya without malaria prophylaxis came to the hospital after 72 hours of fever on his return. On admission, the blood smear revealed severe P. falciparum parasitemia (45%), thrombopenia (4000/mm3), disseminated intravascular coagulation, and hepatic dysfunction. He was treated with intravenous quinine, and the initial course was favorable. On day 4, his parasitemia resolved, but he developed dyspnea with hypoxemia and required mechanical ventilation. Chest radiography showed bilateral diffuse infiltrate. Low central venous and pulmonary artery occlusion pressure confirmed ARDS. Bacteriological testing remained negative. Secondary course was favorable: he was extubated on day 10 and discharged on day 13. DISCUSSION: During the first five days of treatment for severe or multisystemic P. falciparum malaria, patients have a substantial risk of ARDS. This case illustrates the principal predisposing factors: severe parasitemia, hypoalbuminemia and fluid overload; hypoglycemia and lactic acidosis are also common. CONCLUSION: Physicians caring for patients with malaria must anticipate the possible onset of complications, including ARDS.

Emergency percutaneous tracheostomy in a severely burned patient with upper airway obstruction and circulatory arrest.

We report the life-saving use of Griggs percutaneous tracheostomy in an arrested patient with complex upper airway obstruction, as a result of burns, smoke injuries and iterative tracheal intubation attempts. The technique was performed blindly at bedside to treat an acute episode of failed ventilation and intubation and cardiac arrest in a patient with altered neck anatomy. The intervention salvaged the situation, leaving a definitive airway. The feasibility of using an emergency Griggs percutaneous tracheostomy versus cricothyroidotomy is suggested in selected cases.

The prognostic value of nutritional and inflammatory indices in critically ill patients with acute respiratory failure.

In critically ill patients suffering from acute respiratory failure, weaning from ventilatory assistance is a key survival factor in intensive care units (ICU). The aim of this study was to provide deeper insight into laboratory methods allowing improved monitoring of that critical period. Eighty-three ICU patients (mean age 63.9 years), classified according to the Second Acute Physiology and Chronic Health Evaluation criteria, were submitted to mechanical ventilation, antibiotherapy and nutritional support. Weaning attempts required degressive pressure support ventilation. The biological status of the patients was assessed by the serial measurement of inflammatory (C-reactive protein and alpha1-acid glycoprotein) and of nutritional (albumin and transthyretin) indicators whose aggregation yields a prognostic inflammatory and nutritional index (PINI). Statistical analyses compared ventilatory and biological data recorded on admission and at the time of extubation. Results showed that vital capacity and plasma concentrations of albumin and transthyretin rose, whereas rapid shallow breathing index, C-reactive protein and PINI values declined during the tested period. Persistent low transthyretin concentrations were predictive of lethality while increased values were associated with improved ventilatory performances. The PINI scoring formula worked as an independent predictor of the weaning trial outcome. The study underlined the value of the PINI system for the successful management of the weaning procedure.