Perception versus reality: the measuring of pleural fluid pH in the United States.

BACKGROUND: Pleural fluid pH measured by a blood gas analyzer is the only recommended method of pH measurement to guide management for patients with parapneumonic pleural effusions. Not all hospitals use blood gas analyzers for pleural fluid pH determination and it is unknown if physicians are aware of this problem. OBJECTIVE: To determine if a discrepancy exists between the modality used for measuring pleural fluid pH and how physicians believe it is measured. METHODS: We surveyed pulmonologists randomly across the USA by e-mail inquiring how they thought pleural fluid pH was measured at their laboratory. We then independently contacted the laboratory and asked how pleural fluid pH was actually measured. RESULTS: Two hundred and sixty-seven pulmonologists completed the survey. Eighty-six percent of the pulmonologists use pleural fluid pH to manage complicated parapneumonic effusions. Forty-three percent did not recognize blood gas analyzer solely as the most accurate and validated method. Thirty-nine percent of the physicians who use pleural pH to manage effusions and believe that blood gas analyzers are the most accurate were wrong in their assumption that their laboratory was using this tool for pleural pH measurement. CONCLUSIONS: Whether it is due to inaccurate knowledge or a perception of how pleural fluid pH is tested, a significant number of pulmonologists, when treating complicated parapneumonic effusions, may be making management decisions based on erroneous information.

Conventional and endobronchial ultrasound-guided transbronchial needle aspiration: complementary procedures.

OBJECTIVE: The diagnosis of mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are on the rise. Most reports have demonstrated high yields with EBUS-TBNA and superiority of this procedure over conventional TBNA (cTBNA), but the relative roles of these procedures remain undefined. We present a comprehensive comparison of EBUS-TBNA to cTBNA. METHODS: We reviewed all of the bronchoscopies performed at our medical center from January 2009 through December 2010. We collected data on 82 EBUS-TBNAs and 209 cTBNAs performed. A cost analysis was subsequently performed. RESULTS: EBUS-TBNA was performed more often in patients with known prior cancer and suspicion of recurrence or staging compared with cTBNA (42% vs 18%, P < 0.001). cTBNA was more likely to be performed in patients suspected of having malignancy and needing diagnostic specimens (70% vs 46%, P = 0.009). The overall yield in which a diagnostic specimen or lymphoid tissue was obtained was not different in each group: EBUS 84% vs cTBNA 86% (P = 0.75). The cancer yield was 57% in cTBNAs compared with 44% in EBUS-TBNAs (P < 0.0001), with EBUS-TBNA more often targeting smaller nodes (mean 15 ± 7 mm vs 21 ± 11 mm; P < 0.0001) and paratracheal sites (67% vs 49%, P = 0.003). Per-procedure cost using a Medicare scale was higher for EBUS than it was for cTBNA ($1195 vs $808; P < 0.001). CONCLUSIONS: EBUS-TBNA and cTBNA are complementary bronchoscopic procedures, and the appropriate diagnostic modality can be selected in a cost-effective manner based upon the primary indication for TBNA, lymph node size, and lymph node location.

Reproducibility of the 6-minute walk test for ambulatory oxygen prescription.

BACKGROUND: Ambulatory oxygen is frequently prescribed for patients with chronic obstructive pulmonary disease (COPD) who have oxygen desaturation

Prevalence of flexible bronchoscopic removal of foreign bodies in the advanced elderly.

OBJECTIVES: to define the likelihood and establish the overall safety and effectiveness of flexible bronchoscopy in the removal of foreign bodies in the advanced elderly compared to those younger. DESIGN: a retrospective case-control analysis. SETTING: tertiary care academic hospital. POPULATION: 7,089 adults (age >18 years), including 949 (15%) advanced elderly (age >75 years), who underwent flexible bronchoscopy between January 1995 and June 2007. MEASUREMENTS: in those patients with foreign body aspiration (FBA) (n = 20), a comparison of multiple clinical characteristics based on defined age groups (group 1, age <75 years and group 2, age >75 years) was performed. RESULTS: FBA requiring bronchoscopic removal was greater than three and a half times more likely in patients aged >75 years compared to those younger (OR 3.78, CI 1.4-10: P <0.05). Flexible bronchoscopy was 87.5% effective in the removal of foreign bodies in the advanced elderly and associated with no increase in adverse events. CONCLUSION: bronchoscopic removal of foreign bodies is more likely in the advanced elderly when compared to those younger. This implies that this population may be most at risk. Flexible bronchoscopy is a safe and effective initial diagnostic and therapeutic approach in this age group.

Perceptions vs. reality: measuring of pleural fluid pH in North Carolina.

BACKGROUND: Pleural fluid pH anaerobically handled and measured by a blood gas analyzer (BGA) is used to define a pleural space infection as complicated and predict the life expectancy of patients with malignant pleural effusions. Pleural fluid pH can also be measured by other less accurate methods. It is unknown whether physicians who use pleural fluid pH measurements are aware of the method used by their laboratories. METHODS: We surveyed 90 pulmonary physicians in North Carolina about their use of pleural fluid pH and their hospital laboratory's approach (pH indicator stick, pH meter, or BGA). We then contacted their hospital laboratories to determine the actual method of pH measurement. RESULTS: Twenty-eight (31%) pulmonologists in 11 North Carolina hospitals responded on their use of pleural fluid pH. Of the 20 pulmonologists who order pleural fluid pH, 90% reported that their hospital measures pleural fluid pH via BGA, but the majority (72%) were inaccurate. Only two of 11 hospitals reported that they measure pleural fluid pH with a BGA. CONCLUSION: Almost two-thirds of the chest physicians that order pleural fluid pH to help manage pleural effusions were using information that is not substantiated by the literature and, despite previous reports, hospitals still use suboptimal methods to measure pleural fluid pH. Further information is needed concerning the barriers to physicians and laboratory practices concerning the use of BGA for the measurement of pleural fluid pH.

The Magnitude of Postconvulsive Leukocytosis Mirrors the Severity of Periconvulsive Respiratory Compromise: A Single Center Retrospective Study.

Background: Generalized epileptic convulsions frequently exhibit transient respiratory symptoms and non-infectious leukocytosis. While these peri-ictal effects appear to arise independently from one another, the possibility that they stem from a common ictal pathophysiological response has yet to be explored. We aimed to investigate whether peri-ictal respiratory symptoms and postictal leukocytosis coexist. Methods: We performed a single center retrospective chart review of 446 patients brought to our emergency department between January 1, 2017 and August 23, 2018 for the care of generalized epileptic convulsions with or without status epilepticus. We included 152 patients who were stratified based on the presence (PeCRC+) or absence (PeCRC-) of overt periconvulsive respiratory compromise (PeCRC). In addition, patients were stratified based on the presence or absence of postconvulsive leukocytosis (PoCL), defined as an initial postconvulsive white blood cell (WBC) count ≥ 11,000 cells/mm3. Triage vital signs, and chest x ray (CXR) abnormalities were also examined. Results: Overt PeCRC was observed in 31.6% of patients, 43% of whom required emergent endotracheal intubations. PoCL was observed in 37.5% of patients, and was more likely to occur in PeCRC+ than in PeCRC- patients (79.2 vs. 18.2%; OR = 17.0; 95% CI = 7.2-40.9; p < 0.001). Notably, the magnitude of PoCL was proportional to the severity of PeCRC, as the postconvulsive WBC count demonstrated a negative correlation with triage hemoglobin oxygen saturation (R = -0.22; p < 0.01; CI = -0.48 to -0.07). Moreover, a receiver operating characteristic analysis of the WBC count's performance as predictor of endotracheal intubation reached a significant area under the curve value of 0.81 (95% CI = 0.71-0.90; p < 0.001). Finally, PeCRC+ patients demonstrated frequent CXR abnormalities, and their postconvulsive WBC counts correlated directly with triage heart rate (R = 0.53; p < 0.001). Conclusion: Our data support the existence of an ictal pathophysiological response, which induces proportional degrees of PoCL and PeCRC. We suggest this response is at least partially propelled by systemic catecholamines.

Pulmonary extramedullary hematopoiesis.

Extramedullary hematopoiesis (EMH) is the formation and development of blood cells outside of the bone marrow. Of particular interest to chest physicians and radiologists is the occurrence of EMH in the lungs and pleura. There have been several reports of patients presenting with pulmonary EMH published in the literature and the majority are due to a secondary process, such as myeloproliferative disorders, hemolytic anemias, hereditary spherocytosis, and Gaucher disease. We present a case report of pulmonary EMH and a review of the literature concentrating on the etiology, clinical presentation, pathophysiology, diagnosis, and therapy for this uncommon disorder.

Endobronchial ultrasound in the evaluation of lung cancer: a practical review and cost analysis for the practicing pulmonologist.

Flexible bronchoscopy remains an important tool in the staging, diagnosis, and treatment of primary and metastatic lung malignancies. Endobronchial ultrasound is a new technology utilized with bronchoscopy that has been shown to identify bronchial wall invasion by malignant tumors, aid in the fine needle aspiration of peripheral lung lesions and mediastinal/hilar lymph nodes, and determine the course of treatment in patients with pulmonary carcinoma in situ. The decision to invest both time and money in this technology is determined by several factors such as the cost of the equipment, reimbursement for the procedure, availability of training, the number of bronchoscopies one performs in a year, and access to endoscopic ultrasound and mediastinoscopy. This article reviews the literature to determine the utility of endobronchial ultrasound in the management of patients with lung cancer and to provide information to practicing pulmonologists that may aid in determining whether and where this technology fits into their clinical armamentarium.

Survey of academic pulmonologists, oncologists, and infectious disease physicians on the role of bronchoscopy in managing hematopoietic stem cell transplantation patients with pulmonary infiltrates.

BACKGROUND: In the absence of evidence-based guidelines, there is potential for variability in the management of hematopoietic stem cell transplantation (HSCT) patients with pulmonary infiltrates. We decided to perform a nationwide survey of pulmonologists, oncologists, and infectious disease physicians on the role of bronchoscopy in managing HSCT patients. METHODS: An 18-question survey was prepared, and after being internally reviewed it was sent through electronic mail to all hematology oncology, pulmonary and critical care, and infectious disease fellowship programs in the United States. Both faculty and fellows from all training programs were asked to electronically fill out the survey. RESULTS: A total of 167 responses, representing 76 different institutions were collected (62 pulmonary, 49 oncology, 53 infectious disease). Pulmonologists felt that bronchoscopy was less likely to yield a positive result or change pharmacological therapy (P-value=0.02 and 0.02). With regard to timing for bronchoscopy in HSCT recipients, there was consensus between all the 3 groups that patients who are non-neutropenic and do not have cavitating infiltrates on chest computed tomography scan should receive bronchoscopy only after failure of empiric antimicrobial therapy. However, there was no agreement between the 3 groups on when neutropenic patients or those with cavitating lesions should receive bronchoscopy. CONCLUSIONS: In the absence of randomized clinical trials and evidence-based guidelines, disparities exist in the use of bronchoscopy in the management of infiltrates. These differences were observed within and between both specialties. This study reflects the need for further research to better define the role of bronchoscopy in these patients.

Use of microdebrider bronchoscopy for the treatment of endobronchial leiomyoma.

AIMS: Pulmonary leiomyomas are rare benign tumors that may cause symptoms when they spread endobronchially. Traditionally they were managed surgically or through interventional bronchoscopy with the aid of thermal modalities to assist in debulking of tumor. We report the novel use of microdebrider bronchoscopy to debulk an endobronchial leiomyoma in a symptomatic patient. METHOD/RESULTS: The microdebrider successfully débrided the endobronchial leiomyoma. CONCLUSION: This modality can be successfully employed when oxygenation is an issue, preventing use of thermal modalities. In addition, use of microdebrider not only reduced procedure time but also decreased the risk of airway fire and damage to adjacent normal tissue in our patient.

A prospective multicenter study of competency metrics and educational interventions in the learning of bronchoscopy among new pulmonary fellows.

BACKGROUND: Learning medical procedures relies predominantly on the apprenticeship model, and competency is established based on the number of performed procedures. Our study aimed to establish bronchoscopy competency metrics based on performance and enhanced learning with educational interventions. METHODS: We conducted a prospective study of the acquisition of bronchoscopy skills and cognitive knowledge in two successive cohorts of new pulmonary fellows between July 5, 2006, and June 30, 2008. At prespecified milestones, validated tools were used for testing: the Bronchoscopy Skills and Tasks Assessment Tool (BSTAT), an objective evaluation of bronchoscopy skills with scores ranging from 0 to 24, and written multiple-choice questions examinations. The first cohort received training in bronchoscopy as per the standards set by each institution, whereas the second cohort received educational interventions, including training in simulation bronchoscopy and an online bronchoscopy curriculum. RESULTS: There was significant variation among study participants in bronchoscopy skills at their 50th bronchoscopy, the minimum number previously set to achieve competency in bronchoscopy. An educational intervention of incorporating simulation bronchoscopy enhanced the speed of acquisition of bronchoscopy skills, as shown by the statistically significant improvement in mean BSTAT scores for seven of the eight milestone bronchoscopies (P < .05). The online curriculum did not improve the performance on the written tests; however, compliance of the learners with the curriculum was low. CONCLUSIONS: Performance-based competency metrics can be used to evaluate bronchoscopy skills. Educational interventions, such as simulation-based training, accelerated the acquisition of bronchoscopy skills among first-year pulmonary fellows as assessed by a validated objective assessment tool.