Recomendaciones para la realización de intervenciones pulmonares durante la pandemia COVID-19 / Recommendations for performing interventions during the COVID-19 pandemic

Coronavirus infection (SARS-CoV-2), is a pandemic disease declared by the World Health Organization (WHO). This disease reports a high risk of contagion, especially by the transmission of aerosols in health care workers. In this scenario, aerosol exposure is increased in various procedures related to the airway, lungs, and pleural space. For this reason, it is important to have recommendations that reduce the risk of exposure and infection with COVID-19. In this document, a team of international specialists in interventional pulmonology elaborated a series of recommendations, based on the available evidence to define the risk stratification, diagnostic methods and technical considerations on procedures such as bronchoscopy, tracheostomy, and pleural procedures among others. As well as the precautions to reduce the risk of contagion when carrying out pulmonary interventions.

Como interpretar una revisión sistemática con comparaciones múltiples o network metaanálisis / How to interpret systematic reviews with multiple comparisons or network meta-analysis

Systematic reviews evaluating multiple interventions can be useful in different clinical situations. However, some concerns arise when more than two interventions are compared and there is a paucity of good quality randomized clinical trials. A novel statistical method based on indirect comparisons, called network meta-analysis (NMA), can be a useful approach to find a clinical answer when multiple interventions are evaluated for the same outcome or comparator. The aim of this review is to describe the main characteristics and provide a user guide for a critical analysis of NMA focusing on its three main domains, namely homogeneity, transitivity and consistency.

Sedation for bronchoscopy: current practices in Latin America / Sedação na broncoscopia: práticas atuais na América Latina

ABSTRACT Objective: To evaluate current practices in sedation for bronchoscopy in Latin America. Methods: This was an anonymous survey of select members of the Latin American Thoracic Association. The questionnaire, made available online from November of 2015 through February of 2016, was designed to collect data on demographic characteristics; type of facility (public or private); type/volume of bronchoscopies; type of sedation; and type of professional administering the sedation. Results: We received 338 completed questionnaires from 19 countries; 250 respondents (74.0%) were male. The mean respondent age was 36.0 ± 10.5 years. Of the 338 respondents, 304 (89.9%) were pulmonologists; 169 (50.0%) worked at public facilities; and 152 (45.0%) worked at teaching facilities. All of the respondents performed diagnostic fiberoptic bronchoscopy, 206 (60.9%) performed therapeutic fiberoptic bronchoscopy, 125 (37.0%) performed rigid bronchoscopy, 37 (10.9%) performed endobronchial ultrasound, and 3 (0.9%) performed laser therapy/thermoplasty/cryotherapy. Sedation for bronchoscopy was employed by 324 respondents (95.6%). Of the 338 respondents, 103 (30.5%) and 96 (28.4%) stated, respectively, that such sedation should "usually" and "never" be administered by a bronchoscopist; 324 (95.9%) supported training bronchoscopists in sedation. Sedation administered by a bronchoscopist was reported by 113 respondents, conscious sedation being employed by 109 (96.2%). The use of benzodiazepines, propofol, and opiates was reported, respectively, by 252 (74.6%), 179 (52.9%), and 132 (39.0%) of the 338 respondents. Deep sedation and general anesthesia were more common at private facilities. Conclusions: The consensus seems to be that a well-trained bronchoscopist can safely administer sedation for bronchoscopy. However, approximately 40% of bronchoscopists do not do so regularly.

RESUMO Objetivo: Avaliar as práticas atuais de sedação na broncoscopia na América Latina. Métodos: Trata-se de um inquérito realizado de forma anônima com membros selecionados da Associação Latino-Americana de Tórax. O questionário, disponibilizado on-line entre novembro de 2015 e fevereiro de 2016, foi desenvolvido para coletar dados sobre características demográficas, tipo de serviço (público ou privado), tipo/volume de broncoscopias, tipo de sedação e tipo de profissional que administra a sedação. Resultados: Recebemos 338 questionários preenchidos de 19 países; 250 entrevistados (74,0%) eram do sexo masculino. A média de idade dos entrevistados foi de 36,0 ± 10,5 anos. Dos 338 entrevistados, 304 (89,9%) eram pneumologistas; 169 (50,0%) trabalhavam em estabelecimentos públicos; e 152 (45,0%) trabalhavam em instituições educacionais. Todos os entrevistados realizavam fibrobroncoscopia diagnóstica, 206 (60,9%) realizavam fibrobroncoscopia terapêutica, 125 (37,0%) realizavam broncoscopia rígida, 37 (10,9%) realizavam ultrassom endobrônquico, e 3 (0,9%) realizavam terapia a laser/termoplastia/crioterapia. A sedação na broncoscopia foi empregada por 324 entrevistados (95,6%). Dos 338 entrevistados, 103 (30,5%) e 96 (28,4%) afirmaram, respectivamente, que a sedação "geralmente" e "nunca" deveria ser administrada por um broncoscopista; 324 (95,9%) apoiavam o treinamento de broncoscopistas em sedação. A sedação era administrada por um broncoscopista segundo 113 entrevistados, sendo a sedação consciente empregada por 109 (96,2%). O uso de benzodiazepínicos, propofol e opiáceos foi relatado, respectivamente, por 252 (74,6%), 179 (52,9%) e 132 (39,0%) dos 338 entrevistados. Sedação profunda e anestesia geral eram mais comuns em serviços privados. Conclusões: O consenso foi de que um broncoscopista bem treinado poderia administrar com segurança a sedação na broncoscopia. No entanto, aproximadamente 40% dos broncoscopistas não o fazem regularmente.

Aplicaciones de la impresión 3D en la vía aérea central / Airway tridimensional printing

Tridimensional printing is becoming relevant in medicine, specially in surgical and interventional specialties. We review the technical aspects and clinical application of airway tridimensional printing. Using this technique, simulation models for bronchoscopy and models for diagnostic and therapeutic procedures such as stent design, tracheal reconstruction and airway models can be created.

Utilidad de la crio-tecnología para uso diagnóstico y terapéutico en neumología intervencionista: crio-biopsia pulmonar transbronquial y crioterapia / Transbronchial cryobiopsies and cryotherapy in lung diseases

Bronchoscopy cryoprobes are used for palliative treatment of endobronchial obstructions caused by tumors and removal of granulation tissue or foreign bodies. Currently this technology is also used for diagnosis of diffuse interstitial lung disease (ILD). The multidisciplinary team that establishes the clinical, radiological and histopathological correlation in ILD, decides about performing a surgical lung biopsy when the characteristics of the interstitial disease are not similar to Idiopathic Pulmonary Fibrosis (IPF). Although surgical lung biopsy is the gold standard for diagnosis, treatment, and prognosis, transbronchial cryo-biopsy has a high diagnostic yield, low morbidity and mortality rate, low rate of complications and lower cost. It is the diagnostic method of choice in ILD when it is available. Technological improvements with greater freezing power and tensile strength of the cryo probes, allow their use in cryotherapy and cryo-recanalization for occlusive airway tumors.

Utilidad del ultrasonido endobronquial para el diagnóstico y etapificación del cáncer pulmonar / Endobronchial ultrasound-guided transbronchial needle aspiration

In the last years, several techniques have been developed to obtain a prompt diagnosis or rule out lung cancer. Endobronchial ultrasound- guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high diagnostic yield for mediastinal and central pulmonary lesions. This procedure is especially useful for lung cancer diagnosis and mediastinal staging. Two different types of EBUS are currently available: Radial EBUS and lineal EBUS. Each one has technical differences together with a range of clinical indications. The aim of this review is to discuss about EBUS-TBNA and its current clinical indications, evidence about the accuracy of the procedure for lung cancer diagnosis and staging, and evaluation of the pathological and molecular studies (EGFR, ALK, and ROS1) obtained through EBUS-TBNA and rapid on-site evaluation (ROSE).

Reducción de volumen pulmonar endoscópica en enfisema pulmonar avanzado: Casos clínicos / Endoscopic lung volume reduction in advanced pulmonary emphysema: initial experience in Chile

Chronic obstructive pulmonary disease (COPD) has no curative treatment, and in moderate to advanced stages, functional parameters and quality of life are affected. Lung volume reduction improves respiratory parameters and quality of life of these patients. Endoscopic lung volume reduction is a minimally invasive procedure that uses endobronchial valves or coils. Valves are unidirectional, blocking the air from entering the target lobe during inspiration, allowing the exit of air and secretions during expiration. Complete fissure and absence of collateral ventilation are needed for an adequate functioning of endobronchial valves. Endobronchial coils cause mechanical retraction of the lung parenchyma. We report two patients who underwent endoscopic lung volume reduction by endobronchial valves. One patient was on continuous positive pressure non-invasive ventilation due to his severe emphysema.

Aplicaciones torácicas del ultrasonido / A review on thoracic ultrasound

The use of thoracic ultrasound as a diagnostic tool in the emergency department, intensive care unit or in patients with pulmonary diseases is increasing steadily. It is used to guide percutaneous tracheostomies, to assess pleural effusions, to rule out pneumothorax, and to guide the placement of endovascular and pleural catheters. It is also useful in the assessment of patients with dyspnea. The aim of this review is to provide the practical and technical basics for the use of this diagnostic tool among internists and specialists in pulmonary diseases.

Ultrasonografía bronquial con aspiración por aguja fina en el estudio lesiones adyacentes a la vía aérea central / Endobronchial ultrasound and fine needle aspiration for central airway lesions

Background: Endobronchial ultrasound-guided trans-bronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high diagnostic yield for lesions adjacent to the central airway. Aim: To describe the diagnostic yield of EBUS-TBNA for lesions suspicious of Non-Small Cell Lung Cancer (NSCLC). Material and Methods: Prospective study of 128 patients aged 25 to 87 years (56% males) undergoing EBUS-TBNA. Radiological features of the lesions were recorded by chest CT scan such as morphology, margins of the lesion, lesion size and location based on the International Association for the Study of Lung Cancer (IASLC) map. Definitive pathological results were evaluated. Results: The average size of lesions was 18.5 millimeter and; 68 cases were of less than 20 millimeters. Sensitivity was 96.7%, specificity 100%, and negative predictive value 93.3%. The most common histological diagnosis was adenocarcinoma. Conclusions: EBUS-TBNA is a useful diagnostic tool for NSCLC suspicious lesions adjacent to the central airway.

Lavado broncoalveolar y derrame pleural con hipereosinofilia: caso clínico y revisión de la literatura / Chronic eosinophilic pneumonia: report of one case

Chronic eosinophilic pneumonia (CEP) is uncommon and predominantly seen in women. More than 6% of eosinophils in peripheral blood and more than 25% in bronchoalveolar lavage are diagnostic criteria. Secondary causes of hypereosinophilic pneumonia must be ruled out. We report a 72-year-old non-smoker man presenting in the emergency room with a history of cough, fever, and moderate dyspnea. He was not taking any medication. A chest-X ray showed a left lower lobe (LLL) consolidation, and was started on broad-spectrum antibiotics with a presumptive diagnosis of pneumonia. There was no improvement after therapy. A chest CT scan showed increased LLL consolidation and new left upper lobe ground glass opacities as well as a moderate left pleural effusion. Flexible bronchoscopy was performed and bronchoalveolar lavage showed 95% eosinophils, and had negative cultures. No parasites were identified. Transbronchial biopsies demonstrated eosinophil accumulation in alveoli and interstitium and pleural fluid was composed by 85% eosinophils. With the diagnosis of CEP, systemic corticosteroids were used with favorable clinical and radiological response.

Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal staging in lung cancer / Rendimiento diagnóstico de la ultrasonografía endobronquial con aspiración transbronquial por aguja fina en el estudio de etapificación mediastínica en pacientes con cáncer pulmonar

OBJECTIVE: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic test with a high diagnostic yield for suspicious central pulmonary lesions and for mediastinal lymph node staging. The main objective of this study was to describe the diagnostic yield of EBUS-TBNA for mediastinal lymph node staging in patients with suspected lung cancer. METHODS: Prospective study of patients undergoing EBUS-TBNA for diagnosis. Patients ≥ 18 years of age were recruited between July of 2010 and August of 2013. We recorded demographic variables, radiological characteristics provided by axial CT of the chest, location of the lesion in the mediastinum as per the International Association for the Study of Lung Cancer classification, and definitive diagnostic result (EBUS with a diagnostic biopsy or a definitive diagnostic method). RESULTS: Our analysis included 354 biopsies, from 145 patients. Of those 145 patients, 54.48% were male. The mean age was 63.75 years. The mean lymph node size was 15.03 mm, and 90 lymph nodes were smaller than 10.0 mm. The EBUS-TBNA method showed a sensitivity of 91.17%, a specificity of 100.0%, and a negative predictive value of 92.9%. The most common histological diagnosis was adenocarcinoma. CONCLUSIONS: EBUS-TBNA is a diagnostic tool that yields satisfactory results in the staging of neoplastic mediastinal lesions. .

OBJETIVO: La ultrasonografía endobronquial con aspiración transbronquial por aguja fina (EBUS-TBNA, por sus siglas en inglés) es una alternativa mínimamente invasiva con un alto rendimiento diagnóstico para lesiones pulmonares centrales sospechosas de cáncer o para etapificación de linfonodos mediastínicos. El objetivo principal de este trabajo es describir el rendimiento de EBUS-TBNA como método de etapificación de linfonodos mediastínicos en pacientes con sospecha de cáncer pulmonar. MÉTODOS: Estudio prospectivo de pacientes sometidos a EBUS-TBNA como método diagnóstico. Se seleccionaron pacientes mayores de 18 años entre julio del 2010 y agosto del 2013. Se registraron variables demográficas, características radiológicas mediante TC axial de tórax, localización mediastínica según clasificación de la International Association for the Study of Lung Cancer y resultado diagnóstico definitivo (EBUS con biopsia diagnóstica o método diagnóstico definitivo). RESULTADOS: Se incluyeron 145 pacientes con un total de 354 biopsias. El 54,48% de los pacientes eran hombres, con edad promedio de 63,75 años. El tamaño promedio de los linfonodos fue de 15,03 mm, y 90 fueron menores de 10,0 mm. El rendimiento diagnóstico fue: sensibilidad, 91,17%; especificidad, 100,0%; y valor predictivo negativo, 92,9%. El diagnóstico histológico más frecuente fue adenocarcinoma. CONCLUSIONES: EBUS-TBNA es una herramienta diagnóstica con buenos resultados en el estudio de etapificación de lesiones neoplásicas en mediastino. .

Rendimiento diagnóstico de la broncoscopia con biopsia transbronquial en el estudio de lesiones sugerentes de cáncer pulmonar / Bronchoscopy with transbronchial biopsy for the diagnosis of potentially malignant pulmonary lesions: experience in 261 patients

Background: Bronchoscopy is a minimally invasive procedure used for the diagnosis of lung cancer. Aim: To report our experience with bronchoscopy and transbronchial biopsies for the diagnosis of potentially malignant pulmonary lesions. Material and Methods: Revision of electronic records from patients who underwent transbronchial biopsies seeking for lung cancer. The diagnostic yield of the procedure was evaluated using pathology reports or a 24 months follow up. Results: 261 patients were included. Bronchoscopy was diagnostic in 65% of cases. Lesions mean diameter was 51 mm (range 9-120 mm). Diagnostic yield for lesions less than 30 mm was 59%, for lesions less than 35 mm was 61%, and for lesions over 40 mm was 69%. The presence of malignant lesions and their location in the superior or middle lobe were associated with a better predictive value of the procedure. TNM staging was IIIB/IV in 80% of the patient at the time of diagnosis. Conclusions: The diagnostic yield of bronchoscopy is influenced by the etiology and location of lung lesions.

Complicaciones asociadas a la broncoscopía flexible: análisis de registro post-procedimiento / Immediate complications following flexible bronchoscopy: Retrospective analysis of 1079 procedures

Background: Flexible bronchoscopy is a useful diagnostic tool with a relative low rate of complications. Aim: To analyze post procedure risk of complications after flexible bronchoscopy with transbronchial or bronchial biopsy. Material and Methods: The electronic database of a bronchoscopy unit at a general Hospital was analyzed. All procedures performed between 2009 and 2011 were reviewed and complications recorded. The primary outcome measure was the risk for complications de fined as the percentage of procedures complicated by hemorrhage, pneumothorax, desaturation < 80% and other complications. We used a logistic regression model to explore the association between each procedure characteristic and complication. Results: One thousand seventy nine procedures were included in the analysis. Eight percent had complications. Among these, the frequency of hemorrhage was 5.9% and pneumothorax was 0.3%. Factors associated with complications were exclusive use of topical anesthesia with an odds ratio (OR) of 1.72 (confidence intervals (CI): 1.04-2.86), regular or bad intolerance to the procedure with an OR 4.70 (CI: 3.00-7.38) and performing biopsies of the upper lobes with an OR of 1.76 (CI: 1.04-2.97). Conclusions: Exclusive use of topical anesthesia, performing biopsies of the upper lobes and procedure tolerance were risk factors associated with complications following bronchoscopic biopsies.

Falla de tratamiento en neumonía adquirida en la comunidad: coccidioidomicosis en un viajero / Treatment failure in community-adquired pneumonia: coccidioidomycosis in a traveler patient

Treatment failure in community-acquired pneumonia is defined as a clinical condition with inadequate response to antimicrobial therapy. Resistant and unusual microorganisms and noninfectious causes are responsible for treatment failure. Coccidioides immitis is a fungus that causes pneumonia in the northern hemisphere, especially in the United States and northern Mexico. We report a case of pulmonary coccidioidomycosis imported from Mexico to Chile. After a comprehensive study, histopathology was able to establish Coccidiodes immitis as the causative agent, achieving clinical and radiological improvement with antifungal therapy.

La neumonía de evolución tórpida son aquellas en que no se logra una respuesta clínica adecuada con el uso de terapia antimicrobiana. Existen múltiples causas a esta falta de respuesta: resistencia antimicrobiana, microorganismos no cubiertos o infecciones por microorganismos atípicos. Coccidioides immitis es un hongo causante de neumonía en el hemisferio norte, especialmente en E.U.A y norte de México. No existen reportes de casos pulmonares importados en Chile. Presentamos el caso de una mujer adulta con una neumonía que no respondió al tratamiento antimicrobiano habitual. Una vez realizado un estudio exhaustivo, se logró establecer mediante el estudio histopatológico la existencia de una coccidiodomicosis como entidad causal, logrando una respuesta clínica y radiológica favorable al tratamiento antifúngico.