Management of airway complications following lung transplantation: first interventional bronchoscopy report from Türkiye.

Background/aim: Lung transplantation is the treatment of last resort for many chronic lung diseases. Airway complications (AC) following lung transplantation, such as bronchial stenosis, dehiscence, malacia, and fistula, account for frequent hospital admissions, additional treatment costs, decreased quality of life, and reduced survival rates. Beyond surgical and medical preventive efforts, interventional bronchoscopy (IB) can be used in the management of these complications. The aim of the study is to evaluate the efficacy of IB on the management of AC following lung transplantation. Materials and methods: A retrospective analysis was done using the data of lung transplant patients with AC referred to the interventional pulmonology unit between December 2012 and December 2019. Results: From a total of 116 lung transplants, the data of 14/116 (12%) patients and 14/220 (6.3%) anastomoses in the same lung transplant group with AC requiring IB were analyzed. In these 14 patients, the diseases leading to lung transplantation were interstitial lung diseases (ILD) (50.0%), bronchiectasis (28.6%), pulmonary arterial hypertension (PAH) (7.1%), chronic obstructive pulmonary disease (COPD) (7.1%), and COPD + bronchiectasis (7.1%). Airway stenosis was the most common airway complication, and it developed mostly in the right bronchial system.The 14 patients underwent 27 total sessions of IB with an average of 2-3 per patient. Airway patency was successfully achieved in 74.1% of the procedures. Mechanical dilatation with a balloon and/or a rigid tube was the most preferred procedure (81.5%). Permanent airway patency was achieved in eight (57.4%) patients. No early complications were encountered (0%). The late complication rate was 48.1%. The most frequent late complication was restenosis, which cannot be directly attributed to IB. Conclusion: IB is safe to perform on lung transplant patients with AC. It has low procedural complication rates and can be performed repeatedly. Because of the high rate of restenosis, interventional pulmonologists should find out treatment modalities with lower rates of restenosis.

Pulmonary Physician Consultancy in Emergency Services in Turkiye (PuPCEST) - a cross-sectional multicenter study.

Pulmonology is one of the branches that frequently receive consultation requests from the emergency department. Pulmonology consultation (PC) is requested from almost all clinical branches due to the diagnosis and treatment of any respiratory condition, preoperative evaluation, or postoperative pulmonary problems. The aim of our study was to describe the profile of the pulmonology consultations received from emergency departments in Turkiye. A total of 32 centers from Turkiye (the PuPCEST Study Group) were included to the study. The demographic, clinical, laboratory and radiological data of the consulted cases were examined. The final result of the consultation and the justification of the consultation by the consulting pulmonologist were recorded. We identified 1712 patients, 64% of which applied to the emergency department by themselves and 41.4% were women. Eighty-five percent of the patients had a previously diagnosed disease. Dyspnea was the reason for consultation in 34.7% of the cases. The leading radiological finding was consolidation (13%). Exacerbation of preexisting lung disease was present in 39% of patients. The most commonly established diagnoses by pulmonologists were chronic obstructive pulmonary disease (19%) and pneumonia (12%). While 35% of the patients were discharged, 35% were interned into the chest diseases ward. The majority of patients were hospitalized and treated conservatively. It may be suggested that most of the applications would be evaluated in the pulmonology outpatient clinic which may result in a decrease in emergency department visits/consultations. Thus, improvements in the reorganization of the pulmonology outpatient clinics and follow-up visits may positively contribute emergency admission rates.

A rare case: Endobronchial solitary mixed papilloma.

Endobronchial solitary papillomas are extremely rare lung neoplasms originating from the bronchial surface epithelium. They often present with cough or recurrent hemoptysis. These tumors are benign, but they should be followed closely because they may even have a low probability of malignant transformation features. It should be kept in mind that malignancy may develop especially if the patient is a smoker. Although the etiology is not known for certain, it is thought to be caused by human papillomavirus in some cases. A 43-year-old male patient was admitted with a complaint of chronic cough. Rigid bronchoscopy was performed for diagnostic and therapeutic purposes after imaging techniques revealed a lesion obstructing the lumen of the right main bronchus. The pathology result was reported as mixed bronchial papilloma. We aimed to present our case because of its rarity and to indicate that chronic cough must be further evaluated.

Secondary pulmonary malignancies requiring interventional bronchoscopic procedures.

BACKGROUND: In this study, we aimed to share our singlecenter experience and to investigate the effect of interventional bronchoscopic procedures on secondary pulmonary malignancies in terms of complications, success, and survival rates. METHODS: A total of 83 patients (42 males, 41 females; mean age: 57.8±15.2 years; range, 18 to 94 years) with secondary pulmonary malignancies who underwent interventional bronchoscopic procedures between January 2009 and December 2019 were retrospectively reviewed. Data including demographic and clinical characteristics of the patients, complications, and success and survival rates were recorded. RESULTS: The most common secondary pulmonary malignancies were kidney and thyroid tumors with the complaints of cough, shortness of breath, and hemoptysis. The mean duration before the diagnosis was 34.7±52.8 (range, 0.1 to 219.3) months, and the mean survival after the diagnosis were 10±13.1 (range, 0.2 to 44.4) months. A total of 92% of the patients had an airway obstruction of >50% and the interventional bronchoscopic procedures such as argon plasma coagulation, laser, cryo, and mechanical resection were successful in achieving airway patency. Laser application was found to significantly improve survival (p=0.015). Acute complication rate was 8.4% and mortality rate was 0%. CONCLUSION: In patients with tracheobronchial lesions due to secondary pulmonary malignancies, interventional bronchoscopic procedures, regardless of the stage of the disease, provide rapid palliation in life-threatening symptoms such as dyspnea and hemoptysis due to airway obstruction, prolonging patient"s survival and gain time for additional treatments to take effect for primary disease.

Transbronchial cryobiopsy for diagnosing parenchymal lung diseases: real-life experience from a tertiary referral center.

BACKGROUND AND OBJECTIVES: Transbronchial cryobiopsy (cryo-TBB) is increasingly being used in the diagnosis of diffuse parenchymal lung diseases (DPLD). Varying diagnostic success and complication rates have been reported. Herein we report our experience with cryo-TBB, focusing on diagnostic yield, factors affecting diagnosis, and safety. METHODS: This retrospective study was conducted in a tertiary referral chest diseases hospital. Data regarding the patients, procedures, complication rates, diagnostic yield, and the final diagnosis made by a multidisciplinary committee at all diagnosis stages were evaluated. RESULTS: We recruited 147 patients with suspected DPLD. The definitive diagnosis was made pathologically in 98 of 147 patients (66.6%) and using a multidisciplinary approach in 109 of 147 (74.1%) cases. The number of samples had a significant effect on diagnostic success. Histopathologic diagnostic yield and diagnostic yield with a multidisciplinary committee after a single biopsy were 50%, and histopathological diagnostic yield and diagnostic yield with multidisciplinary committee increased to 71.4% and 85.7%, respectively, with a second biopsy (p = 0.034). The incidence of mild-to-moderate hemorrhage was 31.9%; no severe hemorrhage occurred. Pneumothorax rate was 15.6%, and the mortality rate was 0.68%. CONCLUSIONS: Cryo-TBB has sufficient diagnostic yield in the context of a multidisciplinary diagnosis with acceptable complication rates. Performing at least 2 biopsies and from at least 2 segments increases diagnostic success.

Hydroxychloroquine plus azithromycin and early hospital admission are beneficial in COVID-19 patients: Turkish experience with real-life data

Background/aim: New treatment regimens for COVID-19, which has threatened the world recently, continue to be investigated. Although some of the treatments are promising, it is thought to be early to state that there is definitive treatment. Experiences and treatment protocol studies from treatment centers are still important. The aim of this study is to evaluate factors affecting the treatment process of the first cases followed in our clinic. Materials and methods: The consecutive hospitalized patients with COVID-19 pneumonia were analyzed in this retrospective and cross-sectional study. Data were recorded from the electronic and written files of patients. Results: Eighty-three patients were evaluated. The median age was 50 ± 15 years. Forty-eight (57.8%) patients had one or more comorbidities. The most common comorbidity was hypertension. The most common symptom was cough in 58 patients (70%). The overall mortality was 15%, and 85% of the patients were discharged. The time between the onset of symptoms and hospitalization was statistically significantly longer in deceased patients (P = 0.039). Age, D-Dimer, troponin, CK, CK-MB, ferritin, procalcitonin, and neutrophil to lymphocyte ratio were statistically significantly higher in deceased patients than survivor patients. In subgroup analysis, in the patients receiving azithromycin plus hydroxychloroquine and other antibiotics plus hydroxychloroquine, the duration of hospitalization was shorter in the azithromycin group (P = 0.027). Conclusion: Early treatment and early admission to the hospital can be crucial for the better treatment process. Combination therapy with azithromycin may be preferred in the first treatment choice because it can shorten the length of hospital stay.

Real life results of coil treatment for bronchoscopic lung volume reduction in emphysema.

INTRODUCTION: The lung volume reduction coil treatment is a minimally invasive bronchoscopic treatment option for emphysema patients who suffer from severe hyperinflation. Previous studies have reported successful outcomes in selected cases using coil for bronchoscopic lung volume reduction (BLVR). Our aim is to determine the changes in respiratory function tests, perception of dyspnea and exercise capacities after 12 months in patients treated with endobronchial coil. MATERIALS AND METHODS: The data of patients with severe emphysema and treated with coils between 2014-2017 were evaluated retrospectively. Dynamic and static lung volume capacities at baseline and 12 months, modified Medical Research Council (mMRC) questionnaire and six-minute walk test (6-MWT) results were recorded. RESULT: BLVR was performed in thirty patients (one female, twenty-nine males). Five patients were treated bilaterally and twentyfive unilaterally. One patient died after 7 days and 4 patients died during follow-up. Five patients were lost to follow-up. A total of twenty patients with available data were included in the study. A statistically significant difference was found in mMRC results in pre-treatment and 12-month evaluations. There was no significant difference in FEV1, TLC and RV values at the end of 12 months. There was an increase of 18.9 meters (± 83.5 m) between the baseline and 12 months in 6-MWT. 45% of the patients improved their walking distance over 26 meters which is known as minimal clinically important difference (MCID). CONCLUSIONS: Although no significant changes were observed in pulmonary function tests and lung volumes, the increase in exercise capacity and decreased perception of dyspnea indicate the efficacy of endobronchial coil.

[Bronchiectasis in Turkey: Under the light of national publications]. / Ulusal yayinlar isiginda Türkiye'de bronsektazi.

In this review, we aimed to determine the etiopathogenesis, diagnosis and treatment of non-cystic fibrosis bronchiectasis in the light of scientific studies conducted in our country. For this purpose, Pubmed, Web of Science ve Ulakbim TR Dizin were searched and the publications available as of July 2019 were evaluated and the findings of these studies were summarized and presented.

The impact of co-existing comorbid diseases on long-term mortality in bronchoscopic lung volume reduction.

Aim Emphysema is a lung disease in which alveolar capillary units are destroyed supporting tissue lost. Bronchoscopic lung volume reduction (BLVR) is a novel treatment for emphysema. Several comorbidities have been reported to coexist in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate comorbidities of patients with severe emphysema who underwent BLVR and association of these comorbidities with mortality. Methods Between January 2011 and December 2017 the records of severe emphysema patients who underwent endobronchial valve (EBV) or lung volume reduction coil (LVRC) placement were reviewed retrospectively. Results There were 37 patients who received EBV therapy and 29 received LVRC therapy. There were no significant differences in the demographic and clinical characteristics between two groups before the treatment. There were seven deaths (10.6%) over the period of twelve months following the BLVR treatment. All deaths occurred in patients with at least one comorbid condition. Mortality was increased in the presence of comorbidities (14.3% vs 0%, respectively; p=0.099), and it was significantly increased in the presence of multiple comorbidities (18.5% vs 0%; p=0.059). The mortality rate was higher (37.5% vs 10.5%) in the LVRC comparing to the EBV treatment group in the presence of multiple comorbid conditions, albeit not reaching statistical significance (p=0.099). Conclusion The presence of more than one comorbidity in patients who underwent the LVRC treatment are associated with significant increase of mortality. For patients with severe emphysema who have more than one comorbidity, EBV is a better choice than LVRC.

Is there any effect of smoking status on severity and mortality of hospitalized patients with COVID-19 pneumonia?

INTRODUCTION: The Severe Acute Respiratory Syndrome (SARS-CoV-2) virus, which emerged from China and spread all over the world, has affected the world in every aspect and will do so in the foreseeable future. This study was carried out to investigate the possible aggravating effect of smoking on the prognosis of patients with COVID-19 pneumonia presenting with pulmonary involvement. MATERIALS AND METHODS: 114 adult patients who received inpatient treatment in our clinic with the diagnosis of COVID-19 pneumonia between 11 March 2020 and 30 April 2020 were retrospectively included in the study; in particular, they were evaluated in terms of smoking history, severity of disease, need for NIMV and ICU admission, and mortality during their hospitalization. RESULT: The mean age of the 114 patients hospitalized with COVID-19 pneumonia was 51.14 ± 14.97 (range 16-81), and 77 (67.5%) were male. Of the patients, 19 (15.9%) were active smokers, 23 were ex-smokers (20.1%), 72 (63.1%) non-smokers. The effect of smoking on the severity of the disease, length of hospitalization, need for non-invasive mechanical ventilation (NIMV) and intensive care unit (ICU) admission and mortality were not statistically significant. CONCLUSIONS: The rate of active smoking in patients hospitalized with COVID- 19 is lower than the population average. In this study, no correlation was observed between smoking status and the severity, prognosis and mortality of the disease. Further studies with larger number of patients and case series are needed to better elucidate the relationship between smoking and COVID-19 and the pathophysiologic mechanisms of the effects of smoking on the natural history of COVID-19 pneumonia.

[Endobronchial metastases secondary to extrapulmonary malignancies]. / Ekstrapulmoner malignitelere bagli endobronsiyal metastazlar.

Although parenchymal, pleural and mediastinal lymph node locations of metastatic Lung cancer are frequently seen, they are rarely found endobronchially. Endobronchial metastases comprise a portion of central airway obstructions that are diagnosed and treated by interventional pulmonology. Interventional procedures for endobronchial metastases (EBM) can help us reach early diagnosis, or in advanced cases with respiratory symptoms, used palliatively.

What have we learned in interventional pulmonology in the past decade?

Background/aim: The increasing number of lung diseases and particularly pulmonary malignancies has intensified the need for diverse interventions in the field of interventional pulmonology. In recent years we have seen many new developments and expanding applications in the field of interventional pulmonology. This has resulted in an increased number and variety of performed procedures and differing approaches. The purpose of the present study is to provide information on patient characteristics, range of interventions, complication rates, and the evolving approach of an experienced center for interventional pulmonology. Materials and methods: We retrospectively examined the records of 1307 patients who underwent a total of 2029 interventional procedures in our interventional pulmonology department between January 2008 and December 2017. Results: About half of the interventional procedures (47.2%) were performed on patients with airway stenosis due to malignant disease. Among patients with benign airway stenosis, the most frequent reason for intervention was postintubation tracheal stenosis. The number of patients who developed complications was 81 (6.2%), and the most common complication was hemorrhage (n = 31, 2.99%); 94.9% (n = 1240) of interventional procedures were performed under general anesthesia, without complications or deaths associated with anesthesia. Only one death (0.076%) occurred in the perioperative period. A total of 18 patients (1.38%) died in the 30-day perioperative and postoperative period. None of the patients with benign airway stenosis died. Conclusion: Interventional bronchoscopy is an invasive but considerably safe and efficient procedure for selected cases and effective treatment modality for airway obstructions, massive hemoptysis, and foreign body aspiration. Interventional pulmonology is a field of pulmonary medicine that needs effort to progress and provide an opportunity to witness relevant developments, and increase the number of competent physicians and centers.

Our eight years experience in postintubation/posttracheostomy tracheal stenosis.

INTRODUCTION: The most common cause of tracheal stenosis (TS) continues to be traumas according to the intubation and tracheostomy. Bronchoscopy is considered the gold standard for the detection and diagnosis of tracheobronchial pathology. There are several treatment options. We aimed to discuss our tracheal stenosis patients' treatment options, and their follow-up period. MATERIALS AND METHODS: Consecutive referred patients between 2009 and 2018 presenting with TS were reviewed for the study. Demographic characteristics, localization, length and degree of stenosis, treatment techniques, postoperative complications, and survival were recorded for all patients. RESULT: A total of 110 patients included. The mean age was 53.7 ± 16.7 (16-98 years) years. Of 110 patients, 54 (49.1%) were female. Most common type of stenosis was complex stenosis (74.5%). Mechanical dilatation was applied to all patients. Stenotic regions of 22 (20%) patients were cut with bronchoscopic scissor. Tracheal stents were inserted into trachea of 49 (44.5%) patients. During follow-up period; 36 of 110 (32.7%) patients had surgical resection. Six of 36 (16.7%) patients died during follow-up period (one of them died during surgery), 17 (47.2%) patients had total recovery after surgery. Thirteen of 36 (36.1%) patients had restenosis after surgery. CONCLUSIONS: Tracheal stenosis is a process seen after postintubation or posttracheostomy frequently and it has a wide range of management modalities. Although, it is believed that surgery is the most efficient technique in cases without medical contraindications, we determined that endoscopic interventions can be alternative therapeutic options for inoperable patients. Patients must be followed-up after interventional therapies because complications, and restenosis can usually be seen.

Airway stents: a retrospective evaluation of indications, results and complications in our 10-year experience.

INTRODUCTION: Tracheobronchial stents (TBS) are the principal modalities in the management of central airway obstruction with intrinsic tracheobronchial pathology and extrinsic airway compression. The aim of the study is to assess the indications, surveillance management, complications, and long-term outcomes of the TBS managed by rigid bronchoscopy (RB) in our 10-year experience. MATERIALS AND METHODS: The files of all patients who underwent stenting in two centers from November 2008 to September 2018 were reviewed for background data, type of disease, and indication for the placement of stents, symptoms, treatment, complications and outcome. RESULT: 305 patients were stented with 342 TBS. TBS were placed in both malignant (n= 223) and benign airway diseases (n= 82). The median length of stent stay was 88 (34-280) days in patients with malignancies and 775 (228-2085) days in benign diseases. There was no stent-related mortality. Mucostasis (19%) and granulation tissue formation (17%) were the most common stentrelated complications. Benign nature of the disease, tumors metastatic to tracheobronchial tree, lenght of stent stay, and shape of stent were associated with the development of complications. CONCLUSIONS: TBS offer a safe and effective therapy for patients with both benign and malign tracheobronchial pathologies.

General features of patients with Pulmonary Langerhans Cell Histiocytosis followed in our instution.

INTRODUCTION: Pulmonary Langerhans Cell Histiocytosis (PLCH) is a rare disease affecting young smokers. It is more common between the ages of 20-40 and equals the male/female ratio. Lung biopsy is the most useful methods for diagnosis. The first treatment is to quit smoking. Corticosteroids or chemotherapeutic agents can be used in severe progressive cases despite of quiting smoking. The patients with PLCH followed in our clinic were assessed with general clinical features in the light of the literature. MATERIALS AND METHODS: We retrospectively evaluated patients with PLCH in our clinic between January 1999 and June 2017. RESULT: The female and male distribution of the 21 patients was 11/10. The average age was 35.04 ± 11.78 years. All patients were active smokers at the time of admission. The most common symptom was dyspnea. The most common finding in the pulmonary function tests was obstructive ventilatory defect. The DLCO value of the 70% patient in the carbonmonooxid diffusion test was below 80%. The most common pathologic findings detected in high-resolution chest tomography (HRCT) were cystic lesions involving bilateral upper and middle areas. There were 3 (14%) patients with pneumothorax at the time of admission and 6 (28.5%) patients with pneumothorax history before. The most common diagnostic method was open lung biopsy. All the patients quit cigarette after the diagnosis. There were 6 patients using steroid therapy, 1 patient receiving steroid and bosentan therapy, and 1 patient made pleurectomy due to recurrent pneumothorax. Lung transplantation was done to patient who received combined bosentan treatment with steroids. CONCLUSIONS: PLCH is a rare disease and should be considered in young, smokers with spontaneous pneumothorax and cystic lung disease in the differential diagnosis. As more diffusions are affected in patients, respiratory functions for follow-up should be evaluated with diffusion tests. It is essential to quit smoking in therapy.

[Postintubation tracheal stenosis]. / Postentübasyon trakeal stenoz.

Postintubation tracheal stenosis (PITS) is an iatrogenic complication seen increasingly often as the number of intensive care unit (ICU) bed multiply, the indications for endotracheal intubation expand and disease awareness rises. PITS has a clinical severity spectrum ranging from asymptomatic cases to patients requiring urgent interventional procedures. It should therefore always be considered in the differential diagnosis in patients with a history of intubation who present with the complaint of difficult breathing. The golden standart for diagnosis is fiberoptic/rigid bronchoscopy. Even though tracheal resection and end-to-end anastomosis (TRA) is the preferred traetment, in some selected cases and in the patients who are not candidates for surgery, bronchoscopic interventions can be life saving, temporizing until surgery is possible and even be curative.

The awareness of chest physicians about nutritional assessment in chronic obstructive pulmonary disease.

INTRODUCTION: The number of studies that target nonpharmacologic treatments for chronic obstructive pulmonary disease (COPD) are increasing because no existing pharmacologic treatment modality for COPD leads to significant improvement in lung function.Positive effects can be observed in patients with COPD using nutritional support alone or as an adjunct to exercise. In this study, we aimed to evaluate the awareness of chest physicians about the nutritional state of patients with COPD. MATERIALS AND METHODS: A questionnaire consisting of 15 multiple choice questions was conducted to 121 chest physicians. The questions were formed to evaluate the awareness of chest physicians on the patients' nutritional state and the importance of nutrition in COPD follow-up. RESULT: In total, of the 121 physicians, only 3 (2.5%) reported undertaking routine assessment for nutritional state of patients with COPD. The rates of physicians who routinely questioned patients about weight loss and loss of appetite were 56.2% (n= 68) and 51.2% (n= 62), respectively. Forty-five (37.2%) physicians said that they usually started nutritional support if they detected weight loss in patients with COPD. CONCLUSION: Although there is limited data on the benefits of nutritional supplementation for patients with COPD, some studies have suggested advantages of nutritional support against the progress of COPD. Our study showed that routine screening for malnutrition in patients with COPD is rare among chest physicians and this did not differ according to the hospitals in which they worked or from where they took their residency training. There is a need for further studies emphasizing the importance of nutritional state in the progress of COPD.