Impact of structured curriculum with simulation on bronchoscopy.

BACKGROUND AND OBJECTIVE: Simulation enhances a physician's competency in procedural skills by accelerating ascent of the learning curve. Training programmes are moving away from the Halstedian model of 'see one, do one, teach one', also referred as medical apprenticeship. We aimed to determine if a 3-month structured bronchoscopy curriculum that incorporated simulator training could improve bronchoscopy competency among pulmonary medicine trainees. METHODS: We prospectively recruited trainees from hospitals with accredited pulmonary medicine programmes. Trainees from hospitals (A, B and C) were assigned to control group (CG) where they received training by traditional apprenticeship while trainees from hospital D were assigned to intervention group (IG) where they underwent 3-month structured curriculum that incorporated training with the bronchoscopy simulator. Two patient bronchoscopy procedures per trainee were recorded on video and scored independently by two expert bronchoscopists using the modified Bronchoscopy Skills and Tasks Assessment Tool (BSTAT) forms. A 25 multiple choice questions (MCQ) test was administered to all participants at the end of 3 months. RESULTS: Eighteen trainees participated; 10 in CG and eight in IG with equal female:male ratio. Competency assessed by modified BSTAT and MCQ tests was variable and not driven by volume as IG performed fewer patient bronchoscopies but demonstrated better BSTAT, airway anaesthesia and MCQ scores. Bronchoscopy simulator training was the only factor that correlated with better BSTAT (r = 0.80), MCQ (r = 0.85) and airway anaesthesia scores (r = 0.83), and accelerated the learning curve of IG trainees. CONCLUSION: An intensive 3-month structured bronchoscopy curriculum that incorporated simulator training led to improved cognitive and technical skill performance as compared with apprenticeship training.

Bedside pleural procedures by pulmonologists and non-pulmonologists: a 3-year safety audit.

BACKGROUND AND OBJECTIVE: Pleural procedures such as tube thoracostomy and chest aspirations are commonly performed and carry potential risks of visceral organ injury, pneumothorax and bleeding. In this context limited information exists on the complication rates when non-pulmonologists perform ultrasound-guided bedside pleural procedures. Bedside pleural procedures in our university hospital were audited to compare complication rates between pulmonologists and non-pulmonologists. METHODS: A combined safety approach using standardized training, pleural safety checklists and ultrasound-guidance was initially implemented in a ∼1000-bed academic medical centre. A prospective audit, over approximately 3.5 years, of all bedside pleural procedures excluding procedures done in operating theatres and radiological suites was then performed. RESULTS: Overall, 529 procedures (295 by pulmonologists; 234 by non-pulmonologists) for 443 patients were assessed. There were 16 (3.0%) procedure-related complications, all in separate patients. These included five iatrogenic pneumothoraces, four dry taps, four malpositioned chest tubes, two significant chest wall bleeds and one iatrogenic hemothorax. There were no differences in complication rates between pulmonologists and non-pulmonologists. Presence of chronic obstructive pulmonary disease (COPD) independently increased the risk of complications by nearly sevenfold. CONCLUSIONS: Results from this study support pleural procedural practice by both pulmonologists and non-pulmonologists in an academic medical centre setting. This is possible with a standard training program, pleural safety checklists and relatively high utilization rates of ultrasound guidance for pleural effusions. Nonetheless, additional vigilance is needed when patients with COPD undergo pleural procedures.

Drug-induced chylothorax as a rare pleural complication in dasatinib therapy for chronic myeloid leukaemia.

Chylothorax is a lymphatic chylous pleural effusion typically associated with traumatic (iatrogenic, non-iatrogenic) and non-traumatic (infections, malignancy, lymphatic disorders) aetiologies. Drug-induced chylothorax is uncommon and mostly reported in association with BCR-ABL tyrosine kinase inhibitor therapy.

Effect of a pleural checklist on patient safety in the ultrasound era.

BACKGROUND AND OBJECTIVE: Bedside ultrasound allows direct visualization of pleural collections for thoracentesis and tube thoracostomy. However, there is little information on patient safety improvement methods with this approach. The effect of a checklist on patient safety for bedside ultrasound-guided pleural procedures was evaluated. METHODS: A prospective study of ultrasound-guided pleural procedures from September 2007 to June 2010 was performed. Ultrasound guidance was routine practice for all patients under the institution's care and the freehand method was used. All operators took a half-day training session on basic thoracic ultrasound and were supervised by more experienced operators. A 14-item checklist was introduced in June 2009. It included systematic thoracic scanning and a safety audit. Clinical and safety data are described before (Phase I) and after (Phase II) the introduction of the checklist. RESULTS: There were 121 patients in Phase I (58.7 ± 18.9 years) and 134 patients in Phase II (60.2 ± 19.6 years). Complications occurred for 10 patients (8.3%) in Phase I (six dry taps, three pneumothoraces, one haemothorax) and for 2 patients (1.5%) in Phase II (one significant bleed, one malposition of chest tube) (P = 0.015). There were no procedure-related deaths. The use of the checklist alone was associated with fewer procedure-related complications. This was independent of thoracostomy rate, pleural effusion size and pleural fluid ultrasound appearance. CONCLUSIONS: A pleural checklist with systematic scanning and close supervision may further enhance safety of ultrasound-guided procedures. This may also help promote safety while trainees are learning to perform these procedures.

Transitioning to Combined EBUS EUS-B FNA for Experienced EBUS Bronchoscopist.

Endobronchial ultrasound (EBUS) combined with trans-esophageal endoscopic ultrasound bronchoscope guided fine need aspirate (EUS-B FNA) of mediastinal lymph nodes is an established procedure for diagnosis. The main barrier to a combined EBUS EUS-B FNA approach is availability of trained and accredited pulmonologist who can perform procedure safely and confidently. To address this gap, we undertook a training program for experienced EBUS bronchoscopists to train, learn, and incorporate combined EBUS EUS-B FNA into their procedural practice. Thirty-two patients were selected based on CT and or PET findings. Four experienced bronchoscopists participated by reading through learning material, observing 5 cases before performing EUS-B FNA under direct supervision. Forty-one lymph nodes and 6 non-nodal lesions were sampled. EUSAT assessment was performed by supervisor. Learning curves were derived from assessment scores. We observed that learning curve tends to plateau when participant can perform 3 or more consecutive cases with EUSAT score above 50. There were no complications. Our experience suggests that there is relative ease in transition to combined EBUS EUS-B TBNA procedures for mediastinal lymphadenopathy and lung cancer diagnosis and staging for experienced bronchoscopist using a program which incorporates direct supervision, EUSAT assessment, and extension of EUS B FNA training into daily real-world practice.

Galactomannan testing of bronchoalveolar lavage fluid is useful for diagnosis of invasive pulmonary aspergillosis in hematology patients.

BACKGROUND: Invasive pulmonary aspergillosis (IPA) is a major cause of morbidity and mortality in patients with hematological malignancies in the setting of profound neutropenia and/or hematopoietic stem cell transplantation. Early diagnosis and therapy has been shown to improve outcomes, but reaching a definitive diagnosis quickly can be problematic. Recently, galactomannan testing of bronchoalveolar lavage (BAL) fluid has been investigated as a diagnostic test for IPA, but widespread experience and consensus on optical density (OD) cut-offs remain lacking. METHODS: We performed a prospective case-control study to determine an optimal BAL galactomannan OD cutoff for IPA in at-risk patients with hematological diagnoses. Cases were subjects with hematological diagnoses who met established definitions for proven or probable IPA. There were two control groups: subjects with hematological diagnoses who did not meet definitions for proven or probable IPA and subjects with non-hematological diagnoses who had no evidence of aspergillosis. Following bronchoscopy and BAL, galactomannan testing was performed using the Platelia Aspergillus seroassay in accordance with the manufacturer's instructions. RESULTS: There were 10 cases and 52 controls. Cases had higher BAL fluid galactomannan OD indices (median 4.1, range 1.1-7.7) compared with controls (median 0.3, range 0.1-1.1). ROC analysis demonstrated an optimum OD index cutoff of 1.1, with high specificity (98.1%) and sensitivity (100%) for diagnosing IPA. CONCLUSIONS: Our results also support BAL galactomannan testing as a reasonably safe test with higher sensitivity compared to serum galactomannan testing in at-risk patients with hematological diseases. A higher OD cutoff is necessary to avoid over-diagnosis of IPA, and a standardized method of collection should be established before results can be compared between centers.

Severe community-acquired Acinetobacter baumannii pneumonia: an emerging highly lethal infectious disease in the Asia-Pacific.

BACKGROUND AND OBJECTIVE: Patients with community-acquired Acinetobacter baumannii (AB) pneumonia have been reported from subtropical countries. We investigated the epidemiology, clinical and microbiological characteristics of community-acquired pneumonia (CAP) due to AB in Singapore. METHOD: A retrospective case series was performed over a 21-month period at two institutions. RESULTS: From 1 January 2007 to 30 September 2008, eight patients were diagnosed with CAP due to AB. Seven had bacteraemia and five were sputum culture-positive. The median age at presentation was 58.5 years (range 45-76 years). Five patients (71.4%) acquired the pneumonia in the warmer months of June to September. Presentation was acute, with a median duration of 2.5 days (range 1-7 days). The median Acute Physiology and Chronic Health Evaluation II score was 28.5 (range 6-36). Six patients presented with septic shock, lactic acidosis, acute kidney injury and respiratory failure, necessitating ICU care; five of these patients eventually died. All patients received empirical antibiotics, including third-generation cephalosporins, which were inactive against the organism. All isolates were susceptible to ampicillin/sulbactam, ciprofloxacin, co-trimoxazole, aminoglycosides and imipenem. CONCLUSIONS: Community-acquired AB pneumonia have a fulminant course. In a region endemic for melioidosis and severe community-acquired Klebsiella pneumoniae, the challenge lies in rapid identification and initiation of appropriate empirical antibiotics to improve the survival of patients with AB CAP.

Feasibility of using low-volume tissue samples for gene expression profiling of advanced non-small cell lung cancers.

PURPOSE: The majority of patients with non-small cell lung cancer (NSCLC) present at an advanced clinical stage, when surgery is not a recommended therapeutic option. In such cases, tissues for molecular research are usually limited to the low-volume samples obtained at the time of diagnosis, usually via fine-needle aspiration (FNA). We tested the feasibility of performing gene expression profiling of advanced NSCLCs using amplified RNA from lung FNAs. EXPERIMENTAL DESIGN AND RESULTS: A total of 46 FNAs was tested, of which 18 yielded RNA of sufficient quality for microarray analysis. Expression profiles of these 18 samples were compared with profiles of 17 pairs of tumor and normal lung tissues that had been surgically obtained. Using a variety of unsupervised and supervised analytical approaches, we found that the FNA profiles were highly distinct from the normal samples and similar to the tumor profiles. CONCLUSIONS: We conclude that when RNA amplification is successful, gene expression profiles from NSCLC FNAs can determine malignancy and suggest that with additional refinement and standardization of sample collection and RNA amplification protocols, it will be possible to conduct additional and more detailed molecular analysis of advanced NSCLC using lung FNAs.

A man with pleural effusion and ascites.

A male lifelong nonsmoker aged 58 years with no prior asbestos exposure complained of gradual worsening breathlessness over 3 months. This was associated with abdominal and leg swelling and a 2-kg weight loss. He had no fever, night sweats, hemoptysis, joint pain, rash, abdominal pain, chest pain, or orthopnea. The patient had no recent travel or contact with pulmonary TB. He had stage I left-side testicular seminoma treated with left-sided radical orchidectomy 10 years previous and recently received a diagnosis of Child's B alcoholic liver cirrhosis. His hepatitis B and C screen result was normal.

Role of clinical judgment in the application of a nucleic acid amplification test for the rapid diagnosis of pulmonary tuberculosis.

BACKGROUND: Several nucleic acid amplification (NAA) tests for Mycobacterium tuberculosis (MTB) have been licensed for the rapid diagnosis of active pulmonary tuberculosis (PTB) in respiratory secretions. There is uncertainty however regarding the practical application of these tests in clinical decision making. OBJECTIVE: To evaluate the utility of the COBAS AMPLICOR assay (Roche Diagnostics; Singapore) for MTB as applied by specialists for the rapid diagnosis of PTB in the routine clinical setting. DESIGN: A prospective study of consecutive patients suspected of PTB and tested with the AMPLICOR assay under the care of respiratory physicians. The final diagnosis was based on all relevant clinical information after at least 3 months of follow-up. Accuracy of the NAA test was compared with that of the initial expectant treatment. Expectant treatment was based on an integrated approach that incorporated clinical evaluation with results of direct smear and NAA tests. RESULTS: The incidence of PTB in 168 patients was 32%. The basis for expectant treatment of PTB was positive smear result in 47%, clinical suspicion in 26%, and positive AMPLICOR result in 23%. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the AMPLICOR test were 77%, 100%, 99%, 90%, and 93%, respectively. In comparison, they were 96%, 97%, 94%, 98%, and 97%, respectively, for the integrated clinical approach. CONCLUSIONS: In the rapid diagnosis of PTB, the clinical judgment of specialists augmented the utility of the NAA test: (1) specialists selected patients with high-to-moderate pretest probabilities, (2) they commenced treatment promptly on a positive NAA test result, and (3) they were willing to start treatment in some patients on the basis of high clinical suspicion despite negative smear and negative NAA test results.

Transbronchial needle aspiration: initial experience in routine diagnostic bronchoscopy.

BACKGROUND: Transbronchial needle aspiration (TBNA) has been shown to be useful not only for the diagnosis and staging of lung cancer, its most widely studied indication, but also for many of other clinical indications. Despite this, it remains largely underutilized, mainly because of concerns with poor yield, safety, lack of experience of the bronchoscopist, and lack of cytopathological support. OBJECTIVE: To study the clinical utility and yield of TBNA as an adjunct to other conventional procedures in diagnostic bronchoscopy at a centre that was relatively inexperienced with this technique, but where there was availability of rapid on-site evaluation (ROSE). Most of the major indications for TBNA in both malignant as well as benign disease were included. SETTING: University Teaching Hospital naïve to the procedure. PATIENT AND METHODS: Forty-five consecutive patients who underwent TBNA as part of diagnostic bronchoscopy during a 2-year study period. RESULTS: TBNA gave a yield of 65% for evaluation of mediastinal disease, both benign and malignant. The overall diagnostic utility for all indications was 71% and there were no complications. CONCLUSIONS: We conclude that TBNA is a useful and safe adjunct to diagnostic bronchoscopy in routine clinical practice. It has a satisfactory yield even with an inexperienced team, if used with ROSE.

Mediastinal re-staging of non small-cell lung cancer.

Selected patients with non small-cell lung cancer (NSCLC) with mediastinal lymph node involvement may have a survival benefit from surgical resection, particularly if mediastinal nodal down-staging occurs after induction therapy and complete resection is achieved with lobectomy. Accurate re-staging of the mediastinum after induction therapy is therefore crucial in determining prognosis and subsequent treatment. Non-invasive imaging techniques usually require a confirmatory tissue sampling method to improve the accuracy of mediastinal re-staging. As in the initial staging of the mediastinum, minimally invasive endosonography-guided needle sampling techniques such as endobronchial ultrasound-guided fine-needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine-needle aspiration show promise in re-staging the mediastinum, though invasive surgical re-staging remains the gold standard. Despite a lower sensitivity in the mediastinal re-staging of NSCLC, EBUS-TBNA with or without EUS-FNA may still be the preferred initial mediastinal re-staging technique.

A review of current bronchoscopic interventions for obstructive airway diseases.

Obstructive diseases of the airway are a diverse group, although they share in common airway narrowing as a sequel to inflammation, which leads to increased work of breathing. Optimal treatment strategies for this heterogeneous group of asthma, chronic bronchitis and emphysema should be multidimensional and embrace pharmacological and nonpharmacological means as well as surgery in a highly select group of patients with emphysema. We review the current status of the bronchoscopic interventions that have been in development for the past decade with the objectives of providing better symptom control in asthma and palliation in individuals with emphysema who are otherwise poor candidates for lung volume reduction surgery.

Endoscopic mediastinal staging of lung cancer.

The advent of endoscopic ultrasound-guided sampling procedures such as endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has lead to significant advances in the mediastinal diagnosis and staging of lung cancer. These endoscopic techniques can be performed in the outpatient setting under conscious sedation and local anesthesia, in contrast to the surgical standard, mediastinoscopy (MS), which requires operating theatre time and general anesthesia. Proponents of mediastinoscopy have always emphasized the advantages of mediastinoscopy, namely its sensitivity even with a low prevalence of mediastinal metastases and its low false negative rate. Newer endoscopic techniques such as EBUS-TBNA are showing sensitivities exceeding that of mediastinoscopy, even in the setting of an equally low prevalence of mediastinal metastases. However, endoscopic techniques have double the false negative rate of mediastinoscopy. As the tracheobronchial route and esophageal route provide almost complete access to mediastinal lymph nodes, these endoscopic techniques are complementary rather than competing. When used in combination, it is possible mediastinoscopy may be superseded. The challenge however, is how best to select the appropriate endoscopic procedures to accurately stage lung cancer in the most cost-effective manner.

First endoscopic procedure for diagnosis and staging of mediastinal lymphadenopathy.

AIM: To compare a first diagnostic procedure of transbronchial needle aspiration (TBNA) with selection of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or TBNA for mediastinal lymphadenopathy. METHODS: Sixty-eight consecutive patients with mediastinal lymphadenopathy on computed tomography (CT), who required cytopathological diagnosis, were recruited. The first 34 underwent a sequential approach in which TBNA was performed first, followed by EUS-FNA if TBNA was unrevealing. The next 34 underwent a selective approach where either TBNA or EUS-FNA was selected as the first procedure based on the CT findings. RESULTS: The diagnostic yield of TBNA as the first diagnostic procedure in the sequential approach was 62%. In the selective approach, the diagnostic yield of the first procedure was 71%. There was no significant difference in the overall diagnostic yield, but there were significantly fewer combined procedures with the selective approach. CONCLUSION: Selecting either EUS-FNA or TBNA as the first diagnostic procedure achieved a comparable diagnostic yield with significantly fewer procedures than performing TBNA first in all patients.