Novel Robotic-Assisted Cryobiopsy for Peripheral Pulmonary Lesions.

PURPOSE: Tissue acquisition in lung cancer is vital for multiple reasons. Primary reasons reported for molecular testing failure in lung cancer biopsy specimens include insufficient amount of tumor cells provided and inadequate tissue quality. Robotic bronchoscopy is a new tool enabling peripheral pulmonary lesion sampling; however, diagnostic yield remains imperfect possibly due to the location of nodules adjacent to or outside of the airway. The 1.1-mm cryoprobe is a novel diagnostic tool and accesses tissue in a 360-degree manner, thus potentially sampling eccentric/adjacent lesions. This study examines the diagnostic yield of the cryoprobe compared to standard needle aspiration and forceps biopsy. It additionally evaluates yield for molecular markers in cases of lung cancer. METHODS: This is a retrospective analysis of 112 patients with 120 peripheral pulmonary lesions biopsied via robotic bronchoscopy using needle aspirate, forceps, and cryobiopsy. RESULTS: The overall diagnostic yield was 90%. Nearly 18% of diagnoses were made exclusively from the cryobiopsy sample. Molecular analysis was adequate on all cryobiopsy samples sent. Digital imaging software confirmed an increase in quantity and quality of samples taken via cryobiopsy compared to needle aspirate and traditional forceps biopsy. CONCLUSION: Using the 1.1-mm cryoprobe to biopsy PPN combined with the Ion robotic bronchoscopy system is safe, feasible, and provides more diagnostic tissue than needle aspirates or traditional forceps biopsies. The combination of cryobiopsy with robotic-assisted bronchoscopy increased diagnostic yield, likely due to its 360-degree tissue acquisition which is beneficial when targeting extraluminal lesions adjacent to the airway.

Pre-Procedural COVID-19 Nasopharyngeal Swab Has Good Concordance with Bronchoalveolar Lavage in Patients at Low Risk for Viral Infection.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has drastically affected hospital and operating room (OR) workflow around the world as well as trainee education. Many institutions have instituted mandatory preoperative SARS-CoV-2 PCR nasopharyngeal swab (NS) testing in patients who are low risk for COVID-19 prior to elective cases. This method, however, is challenging as the sensitivity, specificity, and overall reliability of testing remains unclear. OBJECTIVES: The objective of this study was to assess the concordance of a negative NS in low risk preoperative patients with lower airway bronchoalveolar lavage (BAL) specimens obtained from the same patients. METHODS: We prospectively sent intraoperative lower airway BAL samples collected within 48 h of a negative mandatory preoperative NS for SARS-CoV-2 PCR testing. All adult patients undergoing a scheduled bronchoscopic procedure for any reason were enrolled, including elective and nonelective cases. RESULTS: One-hundred eighty-nine patients were included. All BAL specimens were negative for SARS-CoV-2 indicative of 100% concordance between testing modalities. CONCLUSIONS: These results are promising and suggest that preoperative nasopharyngeal SARS-CoV-2 testing provides adequate screening to rule out active COVID-19 infection prior to OR cases in a population characterized as low risk by negative symptom screening. This information can be used for both pre-procedural screening and when reintroducing trainees into the workforce.

Percutaneous Tracheostomy.

Tracheostomy is a commonly performed surgical procedure in intensive care units (ICUs). Over the past three decades, there has been a substantial body of evidence to suggest percutaneous tracheostomy (PT) is at least as safe as surgical tracheostomy (ST) in the hands of trained clinicians. In most institutions, PT is more readily performed at bedside than ST in the ICU; hence, PT is an attractive alternative to ST in the ICU. Bedside PT generates significant cost savings by eliminating operating room and anesthesia charges. Bronchoscopy is commonly used as a visual aid during PT. Ultrasound (US)-guided PT is gaining popularity. It can be used as an adjunct or alternative to bronchoscopic-guided PT, especially in hospitals where access to bronchoscopy remains fairly limited and US is more widely available. There are many benefits in converting translaryngeal intubation to tracheostomy. It is widely accepted that tracheostomy is preferred if there is an anticipation of prolonged need for an artificial airway. The timing of this conversion from translaryngeal intubation to tracheostomy remains a subject of controversy. Limited data are available regarding the safety of PT on patients who are on dual antiplatelet therapy or active anticoagulation. Given the heterogeneity of PT techniques, adequate training and experience with the technique, coupled with careful planning are essential in minimizing any potential complication.

Pneumothorax ex-vacuo or "trapped lung" in the setting of hepatic hydrothorax.

BACKGROUND: Hepatic hydrothorax is a major pulmonary complication of liver disease occurring in up to 5-10% of patients with cirrhosis. CASE PRESENTATION: We report four observations of the development of pneumothorax ex-vacuo or trapped lung in the setting of hepatic hydrothorax. The diagnosis of trapped lung was made based on the presence of a hydropneumothorax after evacuation of a longstanding hepatic hydrothorax with failure of the lung to re-expand after chest tube placement in three of the four cases. Two patients underwent surgical decortication with one subsequent death from post-operative bleeding. The other two patients remarkably had spontaneous improvement of their "trapped lung" without surgical intervention. CONCLUSIONS: While pneumothorax ex-vacuo is a known phenomenon in malignant effusions, to our knowledge, it has never been described in association with hepatic hydrothoraces. The pathophysiology of this phenomenon remains unclear but could be related to chronic inflammation with development of a fibrous layer along the visceral pleura.

The safety profile of a protocolized transbronchial cryobiopsy program utilizing a 2.4 mm cryoprobe for interstitial lung disease.

INTRODUCTION: Transbronchial lung cryobiopsy (TBLC) has emerged as a promising alternative to surgical lung biopsy for the diagnosis of interstitial lung disease. However, uncertainty remains regarding its overall complications due to a lack of procedural standardization including the size of cryoprobe utilized. METHODS: This is a prospective cohort study of a protocolized transbronchial cryobiopsy program utilizing a 2.4 mm cryoprobe. 201 consecutive subjects were enrolled at a single academic center. RESULTS: The average biopsy size was 106.2 ± 39.3 mm2. Complications included a total pneumothorax rate of 4.9% with 3.5% undergoing chest tube placement. Severe bleeding defined by the Nashville Working Group occurred in 0.5% of cases. There were no deaths at 30-days. DISCUSSION: A protocolized transbronchial cryobiopsy program utilizing a 2.4 mm cryoprobe in can achieve a high diagnostic yield with a favorable safety profile.

Long-term complications of artificial airways.

In summary, long-term complications of artificial airways are rare but important sequelae of artificial airways. Many of the potential long-term complications of translaryngeal intubation and tracheotomy are similar and overlapping. Although most patients who undergo these procedures tend to tolerate them without difficulties, significant morbidity and mortality may occur. Identifying the exact cause of the complication may not be possible at times, due to the multiple risk factors involved in the pathogenesis. It is hoped that understanding these potential complications will lead to a more vigilant preventive measures during the institution of long-term artificial airways and a judicious early search for the underlying pathology when a complication is suspected.

The successful use of inhaled nitric oxide in the management of severe hepatopulmonary syndrome after orthotopic liver transplantation.

Hepatopulmonary syndrome (HPS) is characterized by pulmonary vasodilation and subsequent hypoxemia in the setting of hepatic dysfunction. There is currently no pharmacologic intervention that has been shown to significantly affect outcomes and liver transplantation remains the mainstay of therapy. Unfortunately, patients undergoing liver transplantation are at high risk of significant hypoxemia and mortality in the early postoperative period. In the following case series, we present two cases of patients with severe HPS who underwent liver transplantation and experienced marked hypoxemia in the early postoperative period. In both cases, we successfully treated the patients with inhaled nitric oxide for their severe refractory life-threatening hypoxemia which led to immediate and dramatic improvements in their oxygenation. Although the use of inhaled nitric oxide in patients with HPS has been sporadically reported in pediatric literature and in animal studies, to our knowledge, our cases are the first recorded in adult patients.

Transition from hepatopulmonary syndrome to portopulmonary hypertension: a case series of 3 patients.

Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PPHTN) are the two major pulmonary vascular complications of liver disease. While HPS is characterized by low pulmonary vascular resistance, PPHTN is defined by the presence of elevated pulmonary vascular resistance. Given these seemingly opposing pathophysiologic mechanisms, these conditions were traditionally felt to be mutually exclusive. In this series, we present three patients with severe hepatopulmonary syndrome who had spontaneous resolution of their HPS with the subsequent development of PPHTN. To our knowledge, this is the largest case series presented of this phenomenon in nontransplanted patients. One proposed mechanism for the occurrence of this phenomenon involves dysregulation of the same vascular signaling pathway, which may lead to both pulmonary vascular dilatations and pulmonary arterial remodeling in the same patient. Another theory involves the possible differential binding of endothelin-1, a vasoactive signaling peptide that induces vasoconstriction when bound to receptor A and vasodilation when bound to receptor B. Although the mechanisms for this phenomenon remain unclear, it is important to be vigilant of this phenomenon as it may change the patient's overall treatment plan, especially in regard to appropriateness and timing of liver transplant.

Regression of recurrent respiratory papillomatosis with celecoxib and erlotinib combination therapy.

Recurrent respiratory papillomatosis (RRP) can be difficult to manage. Symptoms are related to recurrent tracheobronchial papillomas and are usually treated with bronchoscopic removal. Other modalities are added when the papilloma burden becomes too great or recurrence is too frequent, but with limited efficacy. We report a patient with progressive RRP that had become refractory to available therapy. Because papillomas overexpress epidermal growth factor receptor, along with increased expression of cyclooxygenase-2 and prostaglandin E2, it was reasoned that a combination therapy of erlotinib and celecoxib would be effective in controlling papilloma growth. After institutional approval and informed patient consent, this combination was initiated. There was a striking improvement in the number and appearance of respiratory tract papillomas, with elimination of the need for repeated papilloma removal. Pretreatment and posttreatment images document this response, and the improvement has now been maintained for nearly 2 years with effective therapy.