Overuse of small chest drains for pleural effusions: a retrospective practice review.

PURPOSE: Small-bore drains (≤ 16 Fr) are used in many centers to manage all pleural effusions. The goal of this study was to determine the proportion of avoidable chest drains and associated complications when a strategy of routine chest drain insertion is in place. DESIGN/METHODOLOGY/APPROACH: We retrospectively reviewed consecutive pleural procedures performed in the Radiology Department of the McGill University Health Centre over one year (August 2015-July 2016). Drain insertion was the default drainage strategy. An interdisciplinary workgroup established criteria for drain insertion, namely: pneumothorax, pleural infection (confirmed/highly suspected), massive effusion (more than 2/3 of hemithorax with severe dyspnea /hypoxemia), effusions in ventilated patients and hemothorax. Drains inserted without any of these criteria were deemed potentially avoidable. FINDINGS: A total of 288 procedures performed in 205 patients were reviewed: 249 (86.5%) drain insertions and 39 (13.5%) thoracenteses. Out of 249 chest drains, 113 (45.4%) were placed in the absence of drain insertion criteria and were deemed potentially avoidable. Of those, 33.6% were inserted for malignant effusions (without subsequent pleurodesis) and 34.5% for transudative effusions (median drainage duration of 2 and 4 days, respectively). Major complications were seen in 21.5% of all procedures. Pneumothorax requiring intervention (2.1%), bleeding (0.7%) and organ puncture or drain misplacement (2%) only occurred with drain insertion. Narcotics were prescribed more frequently following drain insertion vs. thoracentesis (27.1% vs. 9.1%, p = 0.03). ORIGINALITY/VALUE: Routine use of chest drains for pleural effusions leads to avoidable drain insertions in a large proportion of cases and causes unnecessary harms.

Feasibility of using the nasal route for linear endobronchial ultrasound.

PURPOSE: Linear endobronchial ultrasound (EBUS) is a safe and accurate diagnostic test for mediastinal adenopathy. Its feasibility through the nasal route has not been reported. The objective of this study was to document the feasibility of linear EBUS using the nasal route and compare its accuracy and safety with the oral route. METHODS: A retrospective analysis of consecutive subjects who underwent an EBUS procedure under conscious sedation at our center was conducted. Nasal insertion of the bronchoscope was attempted in all subjects; the oral route was used in case of failed nasal insertion. Characteristics of the procedure and the diagnostic accuracy of EBUS were compared between the two insertion routes. RESULTS: From May to October 2012, 209 subjects underwent an EBUS. Complete data were available for 196 subjects. Nasal insertion of the EBUS bronchoscope was possible in 73.5 %. There was no difference between the two insertion routes in the location and number of stations sampled per subject. Procedure duration and complications (epistaxis, bronchial bleeding, desaturation, and pneumothorax) were similar between the two groups (2.1 % for nasal group vs 1.9 % for oral group). Minor epistaxis occurred in one subject in the nasal group. Comparing the nasal and oral groups, rates of adequate specimens were similar (90.5 vs 88.9 %, respectively; p = 0.68), and proportions of diagnostic specimens were not statistically different (51.4 vs 42.3 %, respectively; p = 0.26). CONCLUSION: Linear EBUS can be performed safely and with high accuracy via the nasal route. Controlled studies are required to determine which insertion route provides best patient comfort.

Healthcare utilization and health-related quality of life of adult survivors of preterm birth complicated by bronchopulmonary dysplasia.

AIM: This study aims to characterize the impact of preterm birth, respiratory distress syndrome and bronchopulmonary dysplasia on quality of life and healthcare utilization in adulthood. METHODS: A mail survey on quality of life and respiratory health was sent to a list of potential subjects identified using the databases of the Régie de l'asssurance maladie du Québec. Four groups of adults born between 1987 and 1993 were compared: (i) preterm with bronchopulmonary dysplasia, (ii) preterm with respiratory distress syndrome, (iii) preterm without respiratory complications and (iv) term controls. As a complement, data from the governmental healthcare administrative databases were extracted for responders. RESULTS: Although the groups differed in their use of healthcare services and prescription drugs, no clinically significant difference was observed for Saint George's Respiratory Questionnaire (SGRQ), SF-36v2 and Medical Research Council (MRC) Dyspnea Scale scores. However, compared to term subjects, bronchopulmonary dysplasia subjects were less likely to access higher education and more likely to be either invalid or unemployed. CONCLUSION: Compared to term subjects, subjects with a history of prematurity and respiratory distress syndrome or bronchopulmonary dysplasia had similar health-related quality of life and respiratory symptoms despite greater use of healthcare services and prescription drugs.

Impact of a Pleural Care Program on the Management of Patients With Malignant Pleural Effusions.

BACKGROUND: Malignant pleural effusions (MPEs) are common and associated with a poor prognosis. Yet, many patients face suboptimal management characterized by repeated, nondefinitive therapeutic procedures and potentially avoidable hospital admissions. METHODS: We conducted a retrospective comparison of patients who underwent a definitive palliative intervention for MPE (indwelling pleural catheter or pleurodesis) at our center, before and after the implementation of a pleural care program. Targeted interventions included staff education, establishment of formal pleural drainage policies, a pleural clinic with weekday walk-in capacity, and a rapid access pathway for oncology patients. Outcomes assessed were the proportion of emergency room (ER) presentations, hospitalizations, number of nondefinitive pleural procedures, and time-to-definitive palliative procedure. RESULTS: A total of 144 patients were included: 69 in the preintervention group and 75 in the postintervention group. Although there was no difference in the proportion of ER presentations before and after interventions (43.5% vs. 38.7%, P =0.56), hospital admissions declined significantly (47.8% vs. 24.0%, P =0.003). The proportion of patients undergoing chest drain insertion decreased significantly (46.4% vs. 13.3%, P <0.001), with a stable low number of nondefinitive procedures per patient (1.6±1.1 vs. 1.3±0.9, P =0.32). A 7-day decrease in median time from presentation-to-definitive palliative procedure ( P =0.05) was observed. CONCLUSION: A targeted pleural care program improved MPE palliation through reduction in hospitalizations and chest drain use, and shorter time-to-definitive palliation, despite failing to reduce ER presentations.

Reduction of Chest Drain Overuse Through Implementation of a Pleural Drainage Order Set.

BACKGROUND AND OBJECTIVES: Small chest drains are used in many centers as the default drainage strategy for various pleural effusions. This can lead to drain overuse, which may be harmful. This study aimed to reduce chest drain overuse. METHODS: We studied consecutive pleural procedures performed in the radiology department before (August 1, 2015, to July 31, 2016) and after intervention (September 1, 2019, to January 31, 2020). Chest drains were deemed indicated or not based on criteria established by a local interdisciplinary work group. The intervention consisted of a pleural drainage order set embedded in electronic medical records. It included indications for chest drain insertion, prespecified drain sizes for each indication, fluid analyses, and postprocedure radiography orders. Overall chest drain use and proportion of nonindicated drains were the outcomes of interest. RESULTS: We reviewed a total of 288 procedures (pre-intervention) and 155 procedures (post-intervention) (thoracentesis and drains). Order-set implementation led to a reduction in drain use (86.5% vs 54.8% of all procedures, P < .001) and reduction in drain insertions in the absence of an indication (from 45.4% to 29.4% of drains, P = .01). The need for repeat procedures did not increase after order-set implementation (22.0% pre vs 17.7% post, P = .40). Complication rates and length of hospital stay did not differ significantly after the intervention. More pleural infections were treated with drain sizes of 12Fr and greater (31 vs 70%, P < .001) after order-set deployment, and direct procedural costs were reduced by 27 CAN$ per procedure. CONCLUSION: Implementation of a pleural drainage order-set reduced chest drain use, improved procedure selection according to clinical needs, and reduced direct procedural costs. In institutions where small chest drains are used as the default drainage strategy for pleural effusions, this order set can reduce chest drain overuse.

Granulomatous tracheo-bronchitis from Crohn's disease.

Tracheo-bronchitis is an uncommon but important extra-intestinal manifestation of Crohn's disease. Our case demonstrates radiological and bronchoscopic evidence of tracheo-bronchitis secondary to Crohn's disease with pathology-proven granulomatous inflammation. This case highlights the importance of investigating airway involvement in patients with Crohn's disease and new respiratory symptoms.

Real-World Outcomes of Patients With Advanced Non-small Cell Lung Cancer Treated With Anti-PD1 Therapy on the Basis of PD-L1 Results in EBUS-TBNA vs Histological Specimens.

BACKGROUND: Programmed death-ligand 1 (PD-L1) testing is feasible in most specimens acquired using endobronchial ultrasound-guided needle aspiration (EBUS-TBNA). RESEARCH QUESTION: Are the outcomes of patients with advanced non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICI) on the basis of PD-L1 expression in EBUS-TBNA samples significantly different from those of patients who are treated on the basis of PD-L1 expression in histological samples? STUDY DESIGN AND METHODS: Patients treated with pembrolizumab or nivolumab between June 2016 and 2019 were included. Patient characteristics, PD-L1 expression, line of treatment, response (Response Evaluation Criteria in Solid Tumors [RECIST] criteria), and vital status (May 14, 2020) were recorded. Progression-free survival (PFS) and overall survival (OS) were assessed, and hazard ratios (HR) estimated. RESULTS: A total of 145 patients were treated with pembrolizumab or nivolumab on the basis of PD-L1 expression in EBUS-TBNA (31.7%) or histological (68.3%) samples. Most had metastatic disease, with a predominance of adenocarcinomas (64.1%). First-line pembrolizumab was administered to 61 patients with tumor proportion score ≥50% in EBUS-TBNA (n = 16) or histology samples (n = 45). Median OS and PFS of patients who received first-line pembrolizumab on the basis of PD-L1 results in EBUS-TBNA vs histology samples were not significantly different (OS 25.8 months vs not reached, respectively; HR, 0.82 [95% CI, 0.34-1.95], P = .651). Similarly, the median OS and PFS of patients who received subsequent lines of treatment on the basis of PD-L1 results in EBUS-TBNA vs histological samples were not significantly different (including after adjustment for PD-L1 expression). INTERPRETATION: These findings suggest that PD-L1 results in EBUS-TBNA samples can guide ICI therapy, with treatment outcomes being comparable to those of patients in whom PD-L1 expression was assessed in histological specimens.

Bronchoscopic tissue yield for advanced molecular testing: are we getting enough?

The treatment of advanced lung cancer has become increasingly personalized over the past decade as a result of the improved understanding of tumor molecular biology and anti-tumor immunity. An adequate tumor sample is central to targetable mutation analysis, and immunologic profiling. The majority of lung cancer patients currently present at an advanced disease stage, so that diagnosis and staging are largely based on small biopsy and cytology specimens. Flexible bronchoscopy techniques play a prominent role in the acquisition of these diagnostic specimens. This narrative review summarizes the available evidence with regards to the role of various conventional and advanced flexible bronchoscopy techniques in acquiring sufficient tissue for mutation analysis and programmed death-ligand 1 (PD-L1) testing.

Intractable pleural effusion in Kaposi sarcoma following antiretroviral therapy in a Caucasian female infected with HIV.

We report the case of a 57-year-old Caucasian woman with AIDS-related disseminated Kaposi sarcoma (KS) characterised by the combination of several unusual features. The chylous nature of the pleural effusions, the documented parietal pleural involvement at thoracoscopy and the marked clinical worsening through an immune reconstitution syndrome following antiretroviral therapy initiation represent several rare situations that occurred in the same female patient. In addition, the use of indwelling pleural catheters for dyspnoea palliation also represents a rare therapeutic intervention. This case is a reminder of the possibility of AIDS-related pleural KS, now uncommon in the era of antiretroviral therapy.

Programmed Death Ligand 1 Testing of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration Samples Acquired For the Diagnosis and Staging of Non-Small Cell Lung Cancer.

RATIONALE: Immunotherapy has become an integral part of management in patients with advanced non-small cell lung cancer (NSCLC). Programmed death ligand 1 (PD-L1) expression in at least 50% of tumor cells on histologic samples has been correlated with improved efficacy of the immune checkpoint inhibitor pembrolizumab. A limited number of studies have examined the suitability of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) specimens for assessment of PD-L1 status. OBJECTIVE: We sought to examine the feasibility and results of PD-L1 testing performed on EBUS-TBNA samples acquired for the diagnosis and staging of NSCLC. MATERIALS AND METHODS: Patients were identified from a prospectively maintained pathology database. Baseline characteristics were tabulated. Hematoxylin and eosin slides were reviewed to categorize cellularity between <100, 100 to 500, and >500 viable tumor cells. Samples were tested using Dako's PD-L1 IHC 22C3 pharmDx kit, with a minimum of 100 viable tumor cells. For patients in whom additional tissue samples were available, the results of PD-L1 testing were compared. RESULTS: PD-L1 testing was attempted on 120 EBUS-TBNA samples. The most common NSCLC subtype was adenocarcinoma (78%). Seventy-six specimens (63%) had a cellularity >500 tumor cells. Among 110 of 120 (92%) patients with an adequate endobronchial ultrasound (EBUS) sample, 53 of 110 (48.2%) had high PD-L1 expression, defined as a Tumor Proportion Score ≥50%. EBUS PD-L1 results were concordant with an available histologic sample in 14 of 18 patients (78%), with no false-negative results. CONCLUSION: PD-L1 testing was feasible in the majority of EBUS-TBNA samples acquired for the diagnosis and staging of NSCLC. Comparison of EBUS results with histologic samples revealed moderate concordance, with no false-negative results.

Influence of trainee involvement on procedural characteristics for linear endobronchial ultrasound.

BACKGROUND: Linear endobronchial ultrasound (EBUS) is a safe and effective method for the diagnostic sampling of mediastinal lymph nodes. However, there is a learning curve associated with the procedure and operator experience influences diagnostic yield. We sought to determine if trainee involvement during EBUS influences procedural characteristics, complication rate, and diagnostic yield. METHODS: We performed a retrospective analysis of 220 subjects who underwent an EBUS procedure at our center from December 2012 to June 2013. Procedures were performed by six different interventional pulmonologists with substantial experience with EBUS or by a trainee under their direct supervision. Procedural characteristics and complications were recorded. Diagnostic yield and specimen adequacy were compared between groups. RESULTS: EBUS was performed in 220 patients with a trainee involved (n = 116) or by staff physician alone (n = 104). Patient characteristics, and the number and size of lymph node stations sampled were similar. EBUS duration was longer (16.0 vs. 13.7 minutes; P = 0.002) and the total dose of lidocaine used was higher (322.3 vs. 304.2 mg; P = 0.045) when a trainee was involved. The rate of adequate specimens sampled was comparable between the groups (92.0 vs. 92.0%; P = 0.60). Diagnostic yield was lower when a trainee was involved in the EBUS procedure (52.6 vs. 68.3%; P = 0.02). CONCLUSION: Trainee involvement significantly increased EBUS duration and the dose of local anesthesia used for the procedure. Diagnostic yield was lower when a trainee was involved. Factors accounting for this difference in yield, despite adequate samples being obtained, warrant further investigation.

Randomized Trial Comparing Patient Comfort Between the Oral and Nasal Insertion Routes for Linear Endobronchial Ultrasound.

BACKGROUND: Linear endobronchial ultrasound (EBUS) is a safe and accurate sampling method for mediastinal adenopathy. The transnasal approach has been proposed to improve patient comfort, but no data compare the oral and nasal routes. The objective was to compare patient comfort during linear EBUS under conscious sedation between the oral and the nasal routes. METHODS: An open-label randomized study comparing the 2 insertion routes for linear EBUS was conducted. Standardized protocols for sedation and topical anesthesia were used. Primary outcome was subjects' comfort measured by a 10-point scale filled 2 hours after the procedure. Willingness to return for a repeat examination, procedural characteristics, complications, and diagnostic yields were also compared. RESULTS: A total of 220 subjects were randomized and allocated to the nasal (n=110) or oral (n=110) route. Twenty-seven subjects in the nasal group (24.5%) had a failed nasal insertion but were analyzed in the nasal group. Procedural characteristics were similar (EBUS duration, doses of sedatives and lidocaine, number of stations sampled, complications). There was no difference between the nasal and oral groups in subjects' comfort (8.3 vs. 8.3, respectively, P=0.99), overall patient satisfaction (8.9 vs. 9.1, respectively, P=0.34), subjects' willingness to return (96% vs. 97%, P=1.00), and physician-reported subject comfort. Rates of adequate specimens and diagnostic yields did not differ significantly between the groups. CONCLUSIONS: For linear EBUS, the nasal and oral approaches confer a similarly high degree of patient comfort with similar complication rates and diagnostic yield. Patient and physician preferences should dictate the route of insertion.

Diagnostic yield of non-guided flexible bronchoscopy for peripheral pulmonary neoplasia.

BACKGROUND: The role of conventional bronchoscopy for peripheral pulmonary neoplasia remains controversial. We aimed to assess the diagnostic yield and the added value of non-guided bronchial aspiration, bronchoalveolar lavage (BAL), and brushing for the diagnosis of pulmonary neoplasia not visible endoscopically. METHODS: We retrospectively assessed 207 consecutive patients with a final diagnosis of peripheral lung malignancy who underwent bronchoscopy with non-guided aspiration, brushing, and BAL as their initial evaluation. The influence of clinical and radiological factors on diagnostic yield was assessed using univariate logistic regression analyses. RESULTS: The overall sensitivity of non-guided bronchoscopy was 25.6%, whereas sensitivities for bronchial aspiration, BAL, and brushing were 14.2%, 11.6%, and 16.5%, respectively. Younger age, larger lesion, central/intermediate distance from the hilum, presence of a bronchus sign, and higher standardized uptake value (SUV) on positron emission tomography scan were predictors of a higher diagnostic yield. Conversely, forced expiratory volume in one second, fellow implication in the procedure, and tumor histology did not influence sensitivity. The overall sensitivity of bronshoscopy was >40% for tumors >4 cm, located in the central/intermediate thirds of the lung, showing a bronchus sign, with an SUV >12 or occurring in patients <50 years of age. Conversely, the sensitivity was <10% for tumors <2 cm, located peripherally or with an SUV <4. CONCLUSION: Neoplasia characteristics may help targeting situations in which conventional bronchoscopy could be used as the initial diagnostic procedure when advanced techniques are unavailable. However, advanced diagnostic tools should probably be proposed as the initial modality for the diagnosis of peripheral malignant lesions when available.

Optimizing tissue sampling for the diagnosis, subtyping, and molecular analysis of lung cancer.

Lung cancer has entered the era of personalized therapy with histologic subclassification and the presence of molecular biomarkers becoming increasingly important in therapeutic algorithms. At the same time, biopsy specimens are becoming increasingly smaller as diagnostic algorithms seek to establish diagnosis and stage with the least invasive techniques. Here, we review techniques used in the diagnosis of lung cancer including bronchoscopy, ultrasound-guided bronchoscopy, transthoracic needle biopsy, and thoracoscopy. In addition to discussing indications and complications, we focus our discussion on diagnostic yields and the feasibility of testing for molecular biomarkers such as epidermal growth factor receptor and anaplastic lymphoma kinase, emphasizing the importance of a sufficient tumor biopsy.