Pulmonologist-led ultrasound guided lung biopsy safety and efficacy: a 4-year experience from a tertiary centre in Northern Malaysia.

INTRODUCTION: Ultrasound guided lung biopsy (USLB) is a minimally invasive diagnostic tool with short examination time and real-time monitoring conducted bedside for accurate diagnosis in order to provide the best treatment. However, it is not widely performed by pulmonologists. We aim to explicate the efficacy and safety of USLB led by pulmonologists. The objective of this study is to assess safety and efficacy of USLB performed by pulmonologists in an outpatient setting. MATERIALS AND METHODS: We retrospectively enrolled patients who underwent the procedure from January 2018 to April 2022. Under real time ultrasound (Hitachi Medical ProSound F37), thoracic lesions adjacent to the chest wall were sampled with a full-core biopsy needle (CT Core Single Action Biopsy Device, 18G × 15 cm, Vigeo, Italy). Chest x-ray was performed 30 minutes post procedure ruling out pneumothorax. Patients were discharged home 1-2 hours post biopsy. Data was analysed using Microsoft Excel 2010 and Statistical Package for Social Science (SPSS) Version 26. RESULTS: A total of 18 patients (14 males, 4 females) underwent USLB for lung tumours. Biopsies were histologically deemed adequate with an overall diagnostic yield of 77.8% (14/18). A total of 57% were positive for thoracic malignancy (21% squamous cell carcinoma, 21% adenocarcinoma, 15% small cell carcinoma) and another 43% were positive for extra thoracic malignancy (1 hepatocellular carcinoma, 2 DLBCL, 1 Hodgkin's lymphoma, 1 seminoma, 1 thymoma). Four patients had inconclusive results but managed to get positive results from surgical or lymph node biopsy (thymoma and adenocarcinoma). Statistical analysis showed more than two passes are needed to achieve a positive HPE yield (p value<0.05). There were nil complications to all the cases done. CONCLUSIONS: USLB can safely and effectively be performed by trained pulmonologists with excellent accuracy and low complication rate in outpatients.

[COPD : a still neglected condition]. / BPCO : une maladie encore négligée.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung disorder with a complex clinical picture. The diagnosis may be difficult at times, as COPD may develop insidiously and remain unnoticed for a long time. Therefore, general practitioners play a central role in early detection of disease. Suspected COPD may be confirmed by further investigations in collaboration with a pulmonologist. The most recent GOLD guideline defines three COPD risk groups (A-B-E) which should guide the personalized treatment concept. General practitioners are crucial for implementing non-pharmacological measures such as smoking cessation, regular exercise, vaccinations, and patient self-management education. However, this also underlines the challenges to implement the GOLD recommendations in daily practice.

La BPCO est une maladie hétérogène avec un tableau clinique complexe. Le diagnostic n'est pas toujours facile à évoquer, car elle peut se développer insidieusement et passer longtemps inaperçue. Les médecins de premier recours (MPR) jouent donc un rôle central dans le diagnostic précoce. La suspicion de BPCO peut être confirmée en collaboration avec un pneumologue par des examens fonctionnels respiratoires avant l'instauration d'un traitement médicamenteux. Les nouvelles recommandations GOLD, publiées en 2022 définissent trois groupes de risques pour la BPCO (A-B-E). Les MPR sont importants pour la mise en œuvre de mesures accompagnant le traitement (arrêt du tabac, activité physique régulière, vaccinations, éducation thérapeutique). Mais cela souligne également les exigences élevées de la mise en œuvre des recommandations GOLD dans la pratique quotidienne.*.

The yield and impact of pulmonologist-performed EUS-B-FNA of subdiaphragmatic lesions-an institutional experience.

INTRODUCTION: Pulmonologists can biopsy structures below the diaphragm using the convex curvilinear ultrasound bronchoscope via the esophagus (EUS-B). The literature with respect to the value of EUS-B, rapid on-site evaluation, and final diagnostic yield for structures below the diaphragm is limited. We review our institutional experience. MATERIALS AND METHODS: Our database was queried retrospectively for EUS-B fine needle aspirations (FNAs) from 2013 to 2021. All procedures involving EUS-B-FNA of subdiaphragmatic structures were selected for analysis. The following data elements were collected for each patient: age, gender, clinical indication, sample site, on-site adequacy (OSA), preliminary and final diagnoses, and sufficiency of cell block for ancillary studies. RESULTS: A total of 75 subdiaphragmatic sites were biopsied in 74 patients. Of which, 87% of samples subjected to rapid on-site evaluation were deemed to contain adequate material (OSA+). There were no false-positive OSAs. Six cases remained nondiagnostic at the final diagnosis. The final diagnostic yield (with cell block) was 92% (69/75 cases). Cell block was sufficient for immunohistochemistry or special stains in all applicable cases (n = 36). Molecular testing was requested for 11 cases and successful in 10 (91%). Sampling of subdiaphragmatic sites changed the stage in 67% (38/57) of lung cancer patients. CONCLUSIONS: Pulmonologists can perform EUS-B-FNA of subdiaphragmatic sites with high OSA and final diagnostic yield when assisted by cytopathologists. Strong correlations exist between OSA, cell block adequacy, and subsequent capacity to perform ancillary testing. EUS-B below the diaphragm can make an important contribution to the diagnosis of lung cancer, nonpulmonary malignancies, and other diseases.

[An outline of pulmonary hemorrhage - A pulmonologists perspective]. / Eine Einführung in die pulmonale Hämorrhagie aus Sicht der Pneumologie.

Hemoptysis resembles a clinical emergency and necessitates a fast and well-coordinated diagnostic and therapeutic approach. While up to 50% of the underlying causes remain unidentified, the majority of cases in the western world can be attributed to respiratory infections and pulmonary neoplasm. While 10% of the patients present with massive, life-threatening hemoptysis, which require a timely airway protection in order to secure a sustained pulmonary gas-exchange, the vast majority presents with non-critical pulmonary bleeding events. Most critical pulmonary bleeding events arise from the bronchial circulation. An early chest imaging is key for identifying the bleeding cause and localization. While chest x-rays are widely implemented in the clinical work-flow and rapidly applicable, computed tomography and computed tomography angiography exhibit the highest diagnostic yield. Bronchoscopy can add diagnostic information especially in pathologies of the central airways, while offering multiple therapeutic options to maintain pulmonary gas exchange. The initial therapeutic regimen comprises early supportive care, but treatment of the underlying etiology is of prognostic relevance and avoids recurrent bleeding events. Bronchial arterial embolization usually is the therapy of choice in patients with massive hemoptysis, while definitive surgery is reserved for patients with refractory bleeding and complex pathologies.

Challenges in the diagnosis of idiopathic pulmonary fibrosis: the importance of a multidisciplinary approach.

INTRODUCTION: The diagnosis of Idiopathic pulmonary fibrosis (IPF) requires the careful exclusion of secondary causes of interstitial lung disease (ILD), and the collaboration among different specialists is considered paramount to establish a diagnosis with high diagnostic confidence. The multidisciplinary discussion (MDD) has assumed an increasing importance over the years in the different phases of the IPF diagnostic work-up. AREAS COVERED: The role of MDD in the diagnosis and management of IPF will be described. Practical insights will be provided into how and when to perform MDD based on the available scientific evidence. Current limitations and future perspectives will be discussed. EXPERT OPINION: In the absence of high diagnostic confidence, agreement between different specialists during MDD is recognized as a surrogate indicator of diagnostic accuracy. Often, despite a lengthy evaluation, the diagnosis remains unclassifiable in a significant percentage of patients. MDD therefore appears to be pivotal in attaining an accurate diagnosis of ILDs. The discussion among different specialists can also include other specialists, such as rheumatologists and thoracic surgeons, in addition to the core group of pulmonologists, radiologists, and pathologists. Such discussions can allow greater diagnostic accuracy and have important effects on management, pharmacologic therapies, and prognosis.

Comparison of chest X-ray interpretation by pediatric pulmonologists, pediatric radiologists, and pediatric residents in children with suspected foreign body aspiration-a retrospective cohort study.

Chest X-ray (CXR) is an important tool in the assessment of children with suspected foreign body aspiration (FBA), although it can falsely be interpreted as normal in one-third of the cases. The aim of this study is to evaluate the positive predictive value of CXR in children hospitalized with suspected FBA, when interpreted by three disciplines: pediatric pulmonology, pediatric radiology, and pediatric residents. This is a retrospective study that included children aged 0-18 years, admitted with suspected FBA, between 2009 and 2020 in one tertiary center. All patients underwent CXR and a flexible/rigid bronchoscopy for the definitive diagnosis of FBA, up to 1 week apart. Two physicians from each discipline interpreted the CXR, independently. Intra-raters' and inter-raters' agreements were assessed. Sensitivity, specificity, and area under the curve (AUC) were calculated for each discipline. Four hundred seventy-three children were included in the study, 175 (37%) with FBA and 298 (63%) without FBA on flexible/rigid bronchoscopy. The most common radiological findings, as interpreted by a pediatric pulmonologist, were unilateral hyperinflation (47%), radiopaque FB (37.6%), lobar atelectasis (10.3%), unilateral hyperinflation with atelectasis (3.4%), and lobar consolidation (1.7%). Intra-raters' agreement ranged from 0.744 (p < 0.001) among pediatric pulmonologists to 0.326 (p < 0.001) among pediatric radiologists. AUC for predicting FBA based on a CXR was 0.81, 0.77, and 0.7 when interpreted by pediatric pulmonologists, pediatric residents, and radiologists, respectively (p < 0.001). CONCLUSIONS: CXR has a high positive predictive value and independently predicts FBA in children; however, normal CXR should not rule out FBA. Predictability is variable among different disciplines. WHAT IS KNOWN: • Chest X-ray is an important tool in the assessment of children with suspected foreign body aspiration (FBA). • Chest X-ray can be interpreted as normal in one-third of the cases. WHAT IS NEW: • Chest X-ray independently predicts FBA in children, with a high positive predictive value. • The ability of chest x-ray to predict FBA in children differs between pediatric residents, pediatric radiologists, and pediatric pulmonologists.

Response to "The opinion of French pulmonologists and palliative care physicians on non-invasive ventilation during palliative sedation at end of life: a nationwide survey''.

We have several major concerns about this article [Guastella et al 2021]. Although it states that it is about palliative sedation, it is not. Rather, it is about the French Claeys Leonetti Law about Continuous Deep Sedation (CDS) at the end of life [Loi n°2016-87].

Reply to 'Response to "The opinion of French pulmonologists and palliative care physicians on non-invasive ventilation during palliative sedation at end of life: a nationwide survey'' '.

We read with interest the letter by Twycross and al on our article recently published in BMC Palliative Care. The authors suggest that the term palliative sedation has been used inappropriately and they consider that in the situation described the sedation was a procedural one rather than a continuous deep sedation. We strongly disagree with this point of view. In an end-of-life situation, the priorities are the patient's comfort, pain and anxiety. This type of sedation does not have the characteristics of procedural sedation described in anaesthesia. The French Clayes Leonetti law makes it possible to clarify the intention of the sedation in end-of-life situations.

Suspected Lung Cancer with Suspicious Liver Lesions: Diagnostic Yield and Safety of Same-Day Bronchoscopy and Liver Biopsy in the Hands of a Pulmonologist.

BACKGROUND: Bronchoscopy and endobronchial ultrasound (EBUS) are standard procedures for the diagnosis and staging of patients suspected of lung cancer. If the patient simultaneously presents with suspicious liver lesions, it is tradition to refer the patient to a radiologist for ultrasound-guided percutaneous liver biopsy. OBJECTIVE: The aim of this study was to investigate the results and complications when the pulmonologist performs all three procedures in the same setting. METHODS: We retrospectively identified patients who during 2018-2020 underwent invasive workup of suspected lung cancer and liver metastases with percutaneous liver lesion biopsy with or without same-day endoscopy (bronchoscopy and EBUS). We compared diagnostic yield and safety of liver lesion biopsy stratified by same-day endoscopy or not. RESULTS: In total, 89 patients were included, of whom 28 patients (31%) underwent same-day endoscopy. All liver lesion biopsies were fine-needle aspiration biopsies performed by experienced pulmonologists. No complications were reported, and overall diagnostic yield was 88%. The diagnostic yield was significantly lower in the same-day endoscopy group (71% vs. 95%), and undergoing endoscopy was significantly associated with having fewer liver lesions, higher prevalence of lung cancer, and lower overall prevalence of a malignant diagnosis. CONCLUSION: Liver biopsy in the same session as endoscopy during lung cancer workup was feasible and safe. Confounding by indication was present in our study.

Developing Cardiothoracic Surgical Critical Care Intensivists: A Case for Distinct Training.

Cardiothoracic surgical critical care medicine is practiced by a diverse group of physicians including surgeons, anesthesiologists, pulmonologists, and cardiologists. With a wide array of specialties involved, the training of cardiothoracic surgical intensivists lacks standardization, creating significant variation in practice. Additionally, it results in siloed physicians who are less likely to collaborate and advocate for the cardiothoracic surgical critical care subspeciality. Moreover, the current model creates credentialing dilemmas, as experienced by some cardiothoracic surgeons. Through the lens of critical care anesthesiologists, this article addresses the shortcomings of the contemporary cardiothoracic surgical intensivist training standards. First, we describe the present state of practice, summarize past initiatives concerning specific training, outline why standardized education is needed, provide goals of such training standardization, and offer a list of desirable competencies that a trainee should develop to become a successful cardiothoracic surgical intensivist.

[The role of an interventional pulmonologist in the management of metastatic pleural effusions (MPE)]. / Place du pneumologue interventionnel dans la gestion des pleurésies métastatiques.

An interventional pulmonologist possesses expertise in minimally invasive diagnostic and therapeutic procedures involving the airways, lungs and pleura. A malignant pleural effusion (MPE), which occurs in 20% of cancer patients, can be a daunting diagnostic challenge insofar as the pleural cavity is a closed cavity. In these patients, treatment may consequently be delayed before a precise diagnosis can be given. In the meantime, an interventional pulmonologist is called upon to carry out a wide range of examinations in order to establish the etiological diagnosis and to treat the symptoms of an MPE patient. Classical medical thoracoscopy, also called "pleuroscopy", is the reference method in MPE diagnosis because it allows visualization of the pleural cavity, pleural biopsy under direct visual control, providing excellent diagnostic yield. Over the past decade, new diagnostic methods have emerged, such as ultrasound-guided biopsy, as well as different interventions, such as indwelling pleural catheters, aimed at improving the quality of life of MPE patients, for whom therapeutic options are limited. The objective of this review of the literature is to point out the role of the interventional pulmonologist in the management of MPE by detailing the various diagnostic and therapeutic methods he possesses at the present time.

Lung Cancer Screening in Community-Based Practice in Puerto Rico: A Survey of Puerto Rico Pulmonologists.

OBJECTIVE: Lung Cancer (LC) in Puerto Rico (PR) is the fifth most common malignancy (5.2%), the third most common among men (5.9%) and the fifth among women (4.6%), with a mortality of 11.3%. Despite current data demonstrating the importance and clinical value for lung cancer screening LDCT Screening among high risk patients remains low regardless of the potential to prevent thousands of lung cancer deaths per year. Due to significant disparities in health care in PR it is believed that LDCT use for lung cancer screening in PR is not been enforced in the private sector. METHODS: A self-administered anonymous survey was provided to a group of pulmonologists at the annual meeting of the PR Pneumology Society. The survey contained questions regarding characteristics of their practice and implementation of lung cancer screening. Provided information was tabulated in percentages. RESULTS: A total of 31 pulmonologists participated in the administration of the survey. Most participants had their medical practice in the metropolitan area (52%), which is the most populated area with best access to physicians and health care services. The sample from the north area comprised 19% of the subjects. All respondents were affiliated to health care institutions. As most of them served 1-3 health care centers (96%) with access to specialized equipment such as Chest CT. Most of the physicians (99%) had availability of chest CT scan within 1 hour from their practices and 97% were aware of the U.S. Preventive Services Task Force lung cancer screening recommendations. Their age range was 41 and over (55%). Despite the above there were discrepancies when asked about lung cancer screening implementation. Sixteen (16) percent did not perform lung cancer screening at all, and 77% that performed screening, reported limitations to it. CONCLUSION: This data suggests that although lung cancer screening has shown to reduce mortality and is recommended by the USPTF, it is not been conducted appropriately in PR. The main limitation identified was what the health insurance had to offer rather than lack of health insurance. Other factor to take in consideration is the lack of a comprehensive screening program for Lung Cancer anywhere in the island. In addition, costs associated with staff and implementation were noted as a significant barrier among the surveyed pulmonologists.

[Computed tomographic imaging in chronic obstructive pulmonary disease : What pulmonologists and thoracic surgeons want to know]. / Computertomographie bei chronisch-obstruktiver Lungenerkrankung : Was Pneumologen und Thoraxchirurgen wissen wollen.

Chronic obstructive pulmonary disease (COPD) begins with chronic inflammation of the bronchial system and leads to the development of emphysema in many patients. COPD patients are characterized by reduced performance, dyspnea in the context of an obstructive respiratory disorder and increased susceptibility to infections. COPD has a major impact on public health, as it is very common and many patients die from it. The most important preventable cause of COPD is tobacco smoke inhalation, which is why consistent smoking cessation is the most important component of any COPD treatment. There is no causal therapy, but in severely symptomatic patients with advanced emphysema, respiratory mechanics can be improved by lung volume reduction if all conservative treatment options have been exhausted. Diagnostic imaging is of great importance in the care of COPD patients. This article summarizes which indications warrant the performance of computed tomography (CT) and what we should pay special attention to during image analysis in order to provide optimal advice to our clinical partners.

Genetic testing in interstitial lung disease: An international survey.

BACKGROUND AND OBJECTIVE: Genetic analysis is emerging for interstitial lung diseases (ILDs); however, ILD practices are not yet standardized. We surveyed patients', relatives' and pulmonologists' experiences and needs on genetic testing in ILD to evaluate the current situation and identify future needs. METHODS: A clinical epidemiologist (MT) together with members of the ERS taskforce and representatives of the European Idiopathic Pulmonary Fibrosis and related disorders Federation (EU-IPFF) patient organisation developed a survey for patients, relatives and pulmonologists. Online surveys consisted of questions on five main topics: awareness of hereditary ILD, the provision of information, genetic testing, screening of asymptomatic relatives and clinical impact of genetic analysis in ILD. RESULTS: Survey respondents consisted of 458 patients with ILD, 181 patients' relatives and 352 pulmonologists. Most respondents think genetic testing can be useful, particularly for explaining the cause of disease, predicting its course, determining risk for developing disease and the need to test relatives. Informing patients and relatives on genetic analysis is primarily performed by the pulmonologist, but 88% (218) of pulmonologists identify a need for more information and 96% (240) ask for guidelines on genetic testing in ILD. A third of the pulmonologists who would offer genetic testing currently do not offer a genetic test, primarily because they have limited access to genetic tests. Following genetic testing, 72% (171) of pulmonologists may change the diagnostic work-up and 57% (137) may change the therapeutic approach. CONCLUSION: This survey shows that there is wide support for implementation of genetic testing in ILD and a high need for information, guidelines and access to testing among patients, their relatives and pulmonologists.

Malignant Central Airway Obstruction: What's New?

Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.

Marked safety and high diagnostic yield of freehand ultrasound-guided core-needle biopsies performed by pulmonologists.

BACKGROUND: Adequate tissue sampling is fundamental for establishing a definitive diagnosis, assessing prognosis and tailoring therapy. Each of the methods for obtaining tissue (e.g., endoscopic, image guidance and surgical biopsies) results in a different diagnostic yield and complication rate profile. OBJECTIVES: Present feasibility, and assess safety and efficacy of freehand transthoracic ultrasound-guided core-needle biopsies (USGNB) of thoracic lesions performed by pulmonologist. METHODS: A retrospective analysis study of ultrasound-guided core-needle biopsies of thoracic lesions performed at the Pulmonary Institute of Rabin Medical Center was conducted from September 2020 to October 2021. All core-needle biopsies were performed under local anesthesia with guidance of Mindray TE7 2019 US system. Procedural variables including complications and pathological diagnostic yield were the primary end point. IRB 0671-21-RMC. RESULTS: In total 91 biopsy procedures were analyzed in38 females and 53 males, average age 71.1 years. Twenty-three (25.3%) cases were lung lesions, 7 (7.7%) - mediastinal, 13 (14.3%) - chest wall, 27 (29.7%) - pleural, and 21 (23.1%) supraclavicular lesions. Average lesion size was 51.6 mm, the largest in the mediastinum and the smallest in supraclavicular locations (97.7mm and 28.0 mm, respectively). Overall pathological diagnostic yield was 90%, highest success in chest wall (100%) and lowest in mediastinal biopsies (71.4%). We had only one complication -hemothorax resolved by chest tube drainage- accounting for only 1.1% complication rate. CONCLUSION: Safety and efficacy were demonstrated in freehand US-guided core-needle biopsy of thoracic lesions performed by pulmonologists. We suggest thoracic ultrasound and USG-CNB be part of training and clinical practice in interventional pulmonology.