Endobronchial Ultrasound Elastography for Differentiating Benign and Malignant Lymph Nodes.

BACKGROUND: Endobronchial ultrasound elastography that provides information on tissue stiffness may help distinguish malignant from benign mediastinal and hilar lymph nodes. OBJECTIVES: In this prospective trial, we assessed the diagnostic value of elastographic images and the interobserver agreement in its evaluation. METHOD: Elastographic images from 77 lymph nodes in 65 patients were reviewed by 3 pneumologists. The elastographic image was classified based on the predominant colour: predominantly green, intermediary, and predominantly blue. With 2 or 3 interobserver matches, the corresponding elastographic image was correlated with the pathological result obtained from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and/or other invasive procedures. RESULTS: All 3 reviewers had agreement in classifying elastographic images in 45% (35/77). Overall, the interobserver agreement among the 3 readers for classifying elastographic pattern was found to be moderate (Fleiss Kappa index = 0.519; 95% CI = [0.427; 0.611]). On cytological/histological evaluation, 55 lymph nodes were malignant and 22 were benign. In classifying "green" as benign and "blue" as malignant, the sensitivity and specificity were 71% (95% CI = [54%; 85%]) and 67% (95%-CI = [35%; 90%]), respectively. CONCLUSIONS: Elastography will not replace invasive EBUS-TBNA due to a moderate interobserver agreement and insufficient sensitivity and specificity. However, elastography will, maybe, present an additional feature to identify malignant lymph nodes in the context of clinical, radiological, and cytological results.

Possible value of antifibrotic drugs in patients with progressive fibrosing non-IPF interstitial lung diseases.

BACKGROUND: Fibrosing, non-idiopathic pulmonary fibrosis (non-IPF) interstitial lung diseases (fILDs) are a heterogeneous group of diseases characterized by a different amount of inflammation and fibrosis. Therapy is currently based on corticosteroids and/or immunomodulators. However, response to these therapies is highly variable, sometimes without meaningful improvement, especially in more fibrosing forms. Pirfenidone and nintedanib have recently demonstrated to reduce functional decline in patients with IPF. However, their antifibrotic mechanism makes these two drugs an interesting approach for treatment of fibrosing ILDs other than IPF. OBJECTIVES: We here report our experience with antifibrotic drugs in fibrosing non-IPF ILDs patients having a progressive phenotype during immunosuppressive therapy. METHODS: Patients with a multidisciplinary team diagnosis of fibrosing non-IPF ILDs experiencing a progressive phenotype during treatment with corticosteroids and/or immunomodulators between October-2014 and January-2018 at our tertiary referral Center for ILDs were retrospectively analyzed. Antifibrotic therapy was administered after application with the respective health insurance company and after consent by the patient. Pulmonary-function-tests and follow-up visits were performed every 6 ± 1 months. RESULTS: Eleven patients were treated with antifibrotic drugs (8 males, mean age 62 ± 12.8 years, mean FVC% 62.8 ± 22.3, mean DLCO% 35.5 ± 10.7, median follow-up under antifibrotic treatment 11.1 months). Patients had a diagnosis of unclassifiable ILD in 6 cases, pleuroparenchymal fibroelastosis in 2 cases, idiopathic-NSIP in 1 case, asbestos-related ILD in 1 case and Hermansky-Pudlak syndrome in 1 case. Treatment before antifibrotics consisted of corticosteroids in all patients: 5 combined with Azathioprin, 1 with either methotrexate or cyclophosphamide (i.v.). Ten patients were treated with pirfenidone (2403 mg/die) and 1 with nintedanib (300 mg/die). Median FVC was 56, 56, 50%, at time points - 24, - 12, - 6 before initiation, 44% at time of initiation and 46.5% at 6 months after initiation of antifibrotic treatment. Antifibrotic treatment was generally well tolerated with a need of dose reduction in 2 cases (rash and nausea) and early termination in 3 cases. CONCLUSIONS: Antifibrotic treatment may be a valuable treatment option in patients with progressive fibrosing non-IPF ILD if currently no other treatment options exist. However, prospective, randomized clinical trials are urgently needed to assess the real impact of antifibrotic therapy in these patients.

Interventional pulmonology in chronic obstructive pulmonary disease.

PURPOSE OF REVIEW: Chronic obstructive pulmonary disease (COPD) and emphysema are widespread diseases associated with progressive dyspnea because of airflow limitation and hyperinflation. Fundamental therapeutic strategies consist of pulmonary rehabilitation, pharmacotherapy, long-term oxygen therapy, noninvasive ventilation, and surgical therapeutic approaches. RECENT FINDINGS: In the last 14 years, endoscopic therapeutic modalities emerged as a substantial part of severe COPD and emphysema treatment. Techniques of the endoscopic lung volume reduction (ELVR) aim at reduction of hyperinflation. Thereby, the reversible valve implantation of which the efficacy was confirmed in various randomized controlled trials (RCT) results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation. Nonblocking ELVR methods that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation and polymeric lung volume reduction both inducing inflammatory reaction. The nonblocking methods have been examined in only a few RCTs. The targeted lung denervation as a novel bronchoscopic therapy for COPD patients aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves. SUMMARY: The review summarizes the various endoscopic treatment approaches for managment of COPD and emphysema, their mechanism of action, their complications and the current available results of the most important RCTs.

Interventional therapy in patients with severe emphysema: evaluation of contraindications and their incidence.

BACKGROUND: Endoscopic and surgical interventions may be beneficial for selected patients with emphysema. Rates of treatment failure decrease when the predictors for successful therapy are known. The aim of the study was to evaluate the number of patients with severe emphysema who were not eligible for any intervention, and the reasons for their exclusion. METHODS: The study was a retrospective analysis of 231 consecutive patients with advanced emphysema who were considered for interventional therapy in 2016 at the Thoraxklinik, Heidelberg, Germany. The reasons for not receiving valve or coil therapy were assessed for all patients who did not receive any therapy. RESULTS: Of the 231 patients, 50% received an interventional therapy for lung volume reduction (LVR) (82% valve therapy, 6% coil therapy, 4.3% polymeric LVR or bronchial thermal vapour ablation, 4.3% total lung denervation, and 3.4% lung volume reduction surgery [LVRS]). A total of 115 patients did not undergo LVR. Out of these, valve or coil therapy was not performed due to one or more of the following reasons: incomplete fissure in 37% and 0%; missing target lobe in 31% and 30%; personal decision in 18% and 28%; pulmonary function test results in 8% and 15%; ventilatory failure in 4% and 4%; missing optimal standard medical care and/or continued nicotine abuse in 4% and 3%; general condition too good in less than 1% and 3%; cardiovascular comorbidities in 0% and 3%; age of patient in 0% and less than 1%. Both techniques were not performed due to one or more of the following reasons: solitary pulmonary nodule(s)/consolidation in 27%; bronchopathy in 7%; neoplasia in 2%; destroyed lung in 2%; prior LVRS in less than 1%. CONCLUSIONS: The main reason for not placing valves was an incomplete fissure and for coils a missing target lobe. Numerous additional contraindications that may exclude a patient from interventional emphysema therapy should be respected.

[Interventional Bronchoscopy: What is Possible and What Makes Sense?] / Interventionelle Bronchoskopie: was ist möglich und was ist sinnvoll?

Interventional bronchoscopy plays a significant role in the treatment of various pulmonary diseases. Different endoscopic therapeutic modalities are available for the management of central airway obstruction (CAO) that represent a common indication for interventional bronchoscopy. The latest development in the field of CAO management are biodegradable stents, that would maintain the airway patency over time, then gradually degrade and vanish from the airway. Other indications for interventional bronchoscopy are chronic obstructive pulmonary disease (COPD), emphysema, asthma and chronic bronchitis. Thereby, various techniques of endoscopic lung volume reduction (ELVR) that address at hyperinflation reduction extend the therapeutic spectrum of patients with severe emphysema. Targeted lung denervation that aims a persistent bronchodilation present an area of current research in the field of COPD and asthma. In patients with chronic bronchitis, cryospray therapy that is performed within clinical trials may reduce the amount of secretion.

New bacterial growth in bronchial secretions after bronchoscopic valve implantation.

Background: Bronchoscopic valve implantation is an established treatment in selected patients with severe lung emphysema. There is evidence in literature of increased bacterial colonization of various implants. So far, it is unclear if an increased bacterial colonization can also be observed after endoscopic valve therapy. Methods: Retrospective analysis of patients with examination of the bronchial secretions for presence or change of bacterial growth before and after valve implantation. Results: Overall, 144 patients who underwent bronchoscopic follow-up after valve implantation were included in this analysis. Prior to valve placement, only 7 out of 144 consecutive emphysema patients (5%) presented with evidence of bacterial colonization, whereas 137 patients (95%) showed no bacterial growth prior to valve placement. One hundred seven out of the 137 patients (78%) showed new bacterial growth after valve implantation. Almost 38% of the patients who presented with a new bacterial growth had evidence of Viridans streptococci, Rothia mucilaginousa and Neisseria species simultaneously, as bacterial colonization. Pathogenic bacterial growth was recorded for Staphylococcus aureus (18%), Pseudomonas aeruginosa (13%) and Stenotrophomonas maltophilia (9%) microorganisms. There was also a significant bacterial growth by Moraxella catarrhalis (26%) and anaerobic bacteria (23%), especially in patients with complete atelectasis after successful endoscopic lung volume reduction. For all of the 7 patients, the presented initial bacterial colonization showed a change in the flora after bronchoscopy valve implantation. Conclusion: In this study we observed an increased bacterial colonization in the long term after valve implantation. This finding needs further evaluation regarding its possible clinical relevance but should be taken into consideration in the follow-up of these patients.

Patients' perspectives on depression case management in general practice - a qualitative study.

OBJECTIVE: General practice-based case management is effective in improving symptoms, adherence, and the perceived process of care of patients living with major depression. The aim was to explore the patients' perceptions of practice-based depression case management, their satisfaction with it and how living with depression contextualizes case management. METHODS: This qualitative study was nested in a large cluster-randomized controlled trial on the effectiveness of case management for patients living with major depression. Case management was provided over 12 months by practice-based health care assistants, who monitored symptoms. We undertook semi-structured interviews with 41 patients, then transcribed and analysed them using qualitative content analysis. RESULTS: Patients described depression as the unfortunate situation, where loneliness and lack of energy lead to being unable to actively seek help. Case management was appreciated because of regular, proactive contact and support by health care assistants. It was crucial to patients that they could trust the health care assistant. Some patients complained that case management was undertaken too mechanically and lacked empathy. CONCLUSION: Patients living with depression may perceive practice-based case management as beneficial if carried out in a trustworthy and empathetic manner. PRACTICE IMPLICATIONS: General practices should ensure that depression case management is patient-centered and non-mechanical.