Airway Obstruction Caused by Iron Pill Aspiration: An Interventional Pulmonology Approach to Prevent Surgery.

Iron Pill Aspiration (IPA) is a challenging medical condition that requires prompt management to prevent detrimental outcomes. One of the most serious complications of IPA is airway inflammation which commonly leads to severe obstruction. Airway complications may require surgical intervention including the resection of the affected lung. Prompt recognition and management of IPA can reduce the risk of airway complications and may prevent the need of a surgical intervention. Bronchoscopic management entails the use of flexible and rigid bronchoscopes along with balloon bronchoplasty, ablation of the inflammatory tissue causing obstruction and airway stenting. In this report, we describe a case of severe airway obstruction secondary to iron pill aspiration with favourable outcome following bronchoscopic multimodalities intervention including temporary airway stenting.

Esophago-pulmonary fistula manifesting as recurrent pneumonias and migrating mediastinal calcifications.

A 43-year old man presented with recurrent pneumonias, episodes of hemoptysis and an enlarging right lower lobe mass. A clear diagnosis was not previously established in spite of multiple radiological evaluations and biopsies. Meticulous review of his CT imaging showed that he had subcarinal calcification on his prior CT scans, which had decreased in size and now multiple new small areas of calcifications were seen in the right lower lobe lesion. An esophago-pulmonary fistula due to migration of mediastinal calcifications was suspected which was identified on careful review of the CT chest and confirmed by esophagogastroduodenoscopy. Patient had surgical repair with complete recovery.

Anesthesia for Advanced Bronchoscopic Procedures: State-of-the-Art Review.

The bronchoscopic procedures have seen a remarkable increase in both numbers and complexity. Although many anesthesia providers have kept pace with the challenge, the practice is varied and frequently suboptimal. Shared airway during bronchoscopy poses unique challenges. The available reviews have tried to address this lacuna; however, these have frequently dealt with the technical aspects of bronchoscopy than anesthetic challenges. The present review provides evidence-based management insights into anesthesia for bronchoscopy-both flexible and rigid. A systematic approach toward pre-procedural evaluation and risk stratification is presented. The possible anatomical and physiological factors that can influence the outcomes are discussed. Pharmacological principles guiding sedation levels and appropriate selection of sedatives form the crux of safe anesthetic management. The newer and safer drugs that can have potential role in anesthesia for bronchoscopy in the near future are discussed. Ventilatory strategies during bronchoscopy for prevention of hypoxia and hypercarbia are emphasized.

Endobronchial biopsies on aspirin and prasugrel.

Patients are generally required to stop antiplatelet therapy prior to elective invasive procedures. Some patients receive dual antiplatelet therapy for recent vascular procedures such as drug-eluting coronary stenting, and early discontinuation of antiplatelet agents could lead to a significant risk of stent thrombosis. Most bronchoscopic procedures are performed on patients using Aspirin but not on those using Clopidogrel or Prasugrel. In this report, we describe a unique case of a patient with a recent placement of drug-eluting stents, who required endobronchial biopsies for evaluation of lung cancer recurrence. The procedure was performed successfully and safely with no complications.

Endobronchial ultrasonography with transbronchial needle aspiration to sample a solitary substernal thyroid nodule: a new approach.

Sampling of solitary thyroid nodules (STNs) is a common procedure performed for cytological diagnosis. The easiest and safest method is ultrasound guided fine needle aspiration biopsy (US-FNAB). This technique is usually performed under local anaesthesia in an office setting. In contrast, sampling a substernal STN could prove to be more difficult and problematic, and sometimes requires more invasive procedures. We describe a case of substernal thyroid nodule, where malignancy was excluded using endobronchial ultrasonography with transbronchial fine needle aspiration (EBUS-TBNA). We emphasise the feasibility and safety of EBUS-TBNA in sampling retrosternal thyroid nodules. In appropriate settings, this procedure can help avoid more invasive testing, and subsequently decrease the cost and complications.

The use of a PleurX catheter in the management of recurrent benign pleural effusion: a concise review.

Recurrent pleural effusion (RPE) can be encountered in various benign conditions such as inflammatory, infectious, or other systemic diseases (e.g., congestive heart failure (CHF), hepatic hydrothorax, post lung transplants, post coronary artery bypass graft (CABG) surgery, and chronic exudative pleurisy). Each condition is treated based on its unique pathophysiologic characteristics, and medical management is successful in the majority of patients. In rare circumstances, pleural effusions are rapidly recurring despite optimal medical therapy and patients have frequent hospitalisations that require repeated thoracenteses. Other than medical therapy and repeat thoracentesis, treatment options are limited to chest tube placement and chemical pleurodesis or, rarely, surgical pleurodesis. We conducted a literature review using PubMed and Google Scholar, finding 33 articles that were relevant to our topic over the last 30 years. In patients with recurrent benign pleural effusion that is refractory to medical management, the PleurX catheter seems to be a useful tool in relieving respiratory symptoms, decreasing the rate of hospitalisation and achieving pleurodesis.

Unusual presentation of pneumocystis pneumonia in an immunocompetent patient diagnosed by open lung biopsy.

Pneumocystis pneumonia (PCP) is the most common opportunistic infection in acquired immune deficiency syndrome (AIDS) patients. It is a fungal infection with Pneumocystis jiroveci which can be isolated from bronchoalveolar lavage of healthy subjects. The infection occurs mainly in HIV patients; with CD4 lymphocyte count drop to less than 200 cells/µL. PCP has been reported in non-HIV patients with other risk factors such as immunosuppressive medications, malignancies, and other inflammatory conditions. PCP has been rarely reported in immunocompetent subjects. However, in most of these patients, PCP occurred after a period of acute illness with bacterial pneumonia and antibiotic therapy. In this report, we describe a case of PCP in an immunocompetent patient with nonreactive HIV and no immunosuppressive risk factors. The patient had large pulmonary nodules discovered incidentally on chest film as preoperative evaluation for hip surgery. Bronchoalveolar lavage, transbronchial biopsies (TBB), and computed tomography (CT) guided needle biopsy were all negative for P. jiroveci. PCP diagnosis was made after open lung biopsy and wedge resection. To our knowledge, this is the first case of PCP in immunocompetent patient with negative BAL, TBB and CT guided biopsy. The diagnosis of PCP required open lung biopsy and the patient recovered without complications.

Intraoperative electromagnetic navigation bronchoscopy (IENB) to localize peripheral lung lesions: A new technique in the pediatric oncology population.

BACKGROUND: The utility, diagnostic yield and accuracy of lung biopsies in pediatric oncology patients are variable. Here we describe our preliminary results using intraoperative electromagnetic navigation bronchoscopy (IENB) for peripheral lung lesions to increase the surgical yield and accuracy in pediatric oncology patients. METHODS: From May 2018 until October 2020 all surgical lung biopsies on pediatric oncology patients were performed using IENB technology. IENB and tattooing with methylene blue dye, Indocyanine green dye or both followed by Video-assisted Thoracoscopic Surgery (VATS) was performed in the same setting. Data were collected retrospectively. Data points included diagnosis, technical success, pathologic diagnosis and alteration in treatment management and complications. RESULTS: A total of 10 biopsy procedures were performed on 8 patients during the study. The youngest patient was 7 years old. All had successful IENB with tattooing. All biopsies were diagnostic. No procedures were converted to open. There were no technical failures or procedure complications. One patient had a total of 11 biopsies, 6 from the right lung and 5 from the left, performed at 2 separate procedures. Another had 2 biopsies, one from the right lung and one from the left performed at the same operation. In 7 of the 8 patients treatment changes were made based on results of their biopsy. CONCLUSION: Here we present the first described experience of IENB and tattooing of peripheral lung lesions in the pediatric population. We have shown that IENB for peripheral lung lesion localization is a safe and effective technique in pediatric oncology.

The clinical characteristics, treatments and prognosis of post-esophagectomy airway fistula: a multicenter cohort study.

Background: Post-esophagectomy airway fistula (PEAF) is a serious complication after esophageal cancer resection. At present, the clinical characteristics, treatments and prognosis of PEAF patients remain inconclusive. We aimed to investigate these problems of patients with PEAF through a multi-center retrospective cohort study. Methods: We included consecutive patients who underwent esophagectomy for esophageal cancer in seven major Chinese esophageal cancer centers from January 2010 to December 2020. Based on the anatomic characteristics of PEAF patients, PEAFs were divided into Union type I (without digestive fistula) and Union type II [respiratory-digestive fistula (RDF)], and subtypes a and b (tracheal or bronchial fistulas), as well as L1 and L2 (same or different level of fistulas). The clinical characteristics, diagnoses, managements, and effects of the various types were retrospectively analyzed. Results: PEAF occurred in 85 of 26,608 patients (0.32%), including eight females and 77 males. There were 16 patients with type I and 69 with type II. The numbers of healings, non-healings, and deaths at discharge were 45 (52.9%), 20 (23.5%), and 20 (23.5%), respectively. Type Ib was common in type I, and type II L1 was common in type II. The healing rates of surgical, stent, and conservative treatments were 50%, 60%, and 50%, respectively. All type I patients treated with stent implantation were healed at discharge. The healing rates, mortality, and 3-year survival of type II L1 and type II L2 patients were 55.4% and 30.8%, 17.9% and 30.8%, and 34.3% and 15.4%, respectively. The 5-year survival rates of all PEAFs were 21.1%. Conclusions: PEAF is an infrequent and life-threatening complication after esophagectomy. Patients with different types of PEAF often have different inducements. In this study, we found that the healing rates of surgical and conservative treatments were similar, and stent implantation may have the potential to improve efficacy. Type II L2 patients were the most difficult to cure.

Thymoma calcification: is it clinically meaningful?

Among anterior mediastinal lesions, thymoma is the most common. Thymomas are tumors of thymic epithelial cell origin that are distinguished by inconsistent histological and biologic behavior. Chest imaging studies typically show a round or lobulated tumor in the anterior mediastinum. Calcifications in thymomas are classically punctuate or amorphous, positioned within the lesion. Chest computed tomography (CT) features suggesting higher risk thymoma consist of tumor heterogeneity, vascular involvement, lobulation, pulmonary nodules, lymphadenopathy, and pleural manifestations. Imaging findings have an imperfect ability to predict stage and prognosis for thymoma patients. Our objective is to highlight the clinical implications of thymoma calcifications on the diagnosis, clinical manifestation and prognosis. A pubmed and google search was performed using the following words: thymoma calcification, calcified thymus, mediastinal calcification, anterior mediastinal calcification, and calcified thymoma. After reviewing 370 articles, 32 eligible articles describing thymoma calcifications were found and included in this review. Although the presence of thymus calcifications was more common in patients with invasive thymomas, they were present in significant portion of non-invasive thymomas. The presence of calcifications was not a significant factor in differentiating between benign and malignant thymoma. As a result, the type, location, size or other characteristics of thymus gland calcifications were not relevant features in clinical and radiologic diagnosis of thymoma. The histopathological diagnosis is still the only possible way to confirm the neoplastic nature of thymoma. All types of thymomas should be evaluated and managed independently of the presence of calcifications.

The use of botox in the treatment of post cardiac surgery paradoxical vocal cord movement.

Paradoxical vocal cord movement (PVCM) is a laryngeal disorder characterised by paradoxical adduction of the vocal cords during inspiration, expiration, or both. In severe cases patients can present with acute respiratory failure requiring intubation and mechanical ventilation. Paradoxical vocal cord movement can be due to different conditions including central nervous system injury, conversion disorders, psychological stress, inhaled irritants, and true laryngeal dystonias. Paradoxical vocal cord movement has also been described in association with cardiac surgery. Most cases of mild PVCM are successfully treated with a combination of speech therapy, patient education, and psychotherapy. In severe cases, patients might require tracheostomy. We report a case of a 65 year-old man who developed severe PVCM post coronary artery bypass surgery requiring tracheostomy for six months. He was successfully treated with bronchoscopic injection of Botulinum toxin type A into his vocal cords. He was decannulated one week after the injection, and was doing well at six weeks follow up.

Tracheal papillomatosis: what do we know so far?

Tracheal papillomatosis (TP) is a benign condition characterized by papillomatous growth of the bronchial epithelium that involves the trachea. This abnormal growth is a result of infection with human papilloma virus (HPV). Two subtypes of HPV were found in most cases of TP, HPV-6 and HPV-11. TP, presents in two forms, the juvenile onset (JO) or adult onset (AO). The clinical presentation is typically nonspecific and it ranges from mild symptoms like cough to life-threatening conditions like upper airway obstruction. Treatment depends on the location of the papillomas and age of the patient and the plan of therapy is usually made on an individual basis. Treatment can range from observation with symptomatic control to specific medical therapy and multiple surgeries in case of recurrence or progressively worsening disease. The recent invention of HPV vaccine is expected to be the first step in eradicating respiratory papillomatosis.

The use of the PleurX catheter in the management of non-malignant pleural effusions.

PURPOSE: To evaluate the effectiveness of the PleurX catheter in the management of recurrent non-malignant pleural effusions. METHODS: All subjects who underwent a PleurX catheter placement between 2003 and 2009 were evaluated. General demographic data, time to pleurodesis, complications, and a satisfaction questionnaire were collected. The subjects were divided into two groups. Group I included patients with non-malignant effusions and group II included patients with malignant effusions. RESULTS: A total of 64 subjects were included in the final data analysis. A total of 23 subjects were included in group I and 41 subjects were included in group II. The diagnoses in group I included congestive heart failure (CHF; 13), hepatic hydrothorax (8), traumatic bloody (1), and idiopathic exudative (1). The diagnoses in group II included lung cancer (20), breast cancer (11), colon cancer (5), prostate cancer (2), B-cell lymphoma (2), and mesothelioma (1). The time to pleurodesis was 36 ± 12 days for group II compared to 110.8 ± 41 days for group I (p < 0.0001). The mean satisfaction score was similar in both groups (3.8 ± 0.4). Time to pleurodesis was significantly shorter in hepatic hydrothorax compared to CHF (73.6 ± 9 days vs. 113 ± 36 days, p = 0.006). There was one case of exit site infection in a patient with hepatic hydrothorax. Among subjects who were alive at 3 months after the catheter removal, none had recurrence of their pleural effusion. CONCLUSION: The Denver catheter was effective in achieving pleurodesis in non-malignant pleural effusions. The complication rate was low and patient satisfaction was high.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA): Technical Updates and Pathological Yield.

Since the endobronchial ultrasound bronchoscope was introduced to clinical practice, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become the procedure of choice to sample hilar and mediastinal adenopathy. Multiple studies have been conducted in the last two decades to look at the different technical aspects of the procedure and their effects on the final cytopathological yield. In addition, newer modes of ultrasound scanning and newer tools with the potential to optimize the selection and sampling of the target lymph node have been introduced. These have the potential to reduce the number of passes, reduce the procedure time, and increase the diagnostic yield, especially in rare tumors and benign diseases. Herein, we review the latest updates related to the technical aspects of EBUS-TBNA and their effects on the final cytopathological yield in malignant and benign diseases.

Hybrid stenting with silicone Y stents and metallic stents in the management of severe malignant airway stenosis and fistulas.

BACKGROUND: Airway stenting is frequently used in the palliative treatment of patients with advanced tumor-induced airway stenosis and fistulas. However, there is paucity of studies regarding the use of airway stents in restoring patency. The aim of the study was to assess the efficacy and safety of hybrid silicon Y stents and covered self-expanding metal stents (SEMS) and in reestablishing patency in airway stenoses and fistulas. METHODS: This retrospective study included 31 patients between January 2016 to December 2019 with inoperable complex malignant airway stenoses and fistulas, managed with Silicone Y stents, and covered SEMS. The clinical details, clinical outcomes and complications up to 6 months were extracted from medical records. The improvement of performance was assessed based on modified British Medical Research Council (mMRC) dyspnea scores (t=6.892, P<0.001), Karnofsky Performance Scores (KPS) (t=-11.653, P<0.001), and performance status (PS) (t=3.503, P<0.001). RESULT: A total of 31 silicon Y stents and 35 covered SEMSs were inserted. Of the 31 patients (M:F 20:11; age: 54.64±9.57), 25/31 (80.6%) experienced immediate relief of symptoms following stent placement. Patients' mMRC dyspnea scores, KPS, and PS showed significant improvement following stenting. The mean duration of stent placement was 146.3±47.7 days, and 17/31 (55%) patients were alive at 6 months. No major complications related to hybrid stenting were observed during the follow-up period. CONCLUSIONS: Hybrid stenting is a feasible and safe palliative treatment for malignant airway stenosis and fistulas to improve quality of life and can be performed without major complications.

Endosonography with lymph node sampling for restaging the mediastinum in lung cancer: A systematic review and pooled data analysis.

BACKGROUND: Mediastinal restaging after induction treatment is still a difficult and controversial issue. We aimed to investigate the diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration for restaging the mediastinum after induction treatment in patients with lung cancer. METHODS: Embase and PubMed databases were searched from conception to March 2019. Data from relevant studies were analyzed to assess sensitivity and specificity of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration, and to fit the hierarchical summary receiver operating characteristic curves. RESULTS: A total of 10 studies consisting of 558 patients fulfilled the inclusion criteria. All patients were restaged by endobronchial ultrasound-guided transbronchial needle aspiration, endoscopic ultrasound-guided fine-needle aspiration, or both. Negative results were confirmed by subsequent surgical approaches. There were no complications reported during any endosonography approaches reviewed. The pooled sensitivities of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration were 65% (95% confidence interval [CI], 52-76) and 73% (95% CI, 52-87), respectively, and specificities were 99% (95% CI, 78-100) and 99% (95% CI, 90-100), respectively. The area under the hierarchical summary receiver operating characteristic curves were 0.85 (95% CI, 0.81-0.88) for endobronchial ultrasound-guided transbronchial needle aspiration and 0.99 (95% CI, 0.98-1) for endoscopic ultrasound-guided fine-needle aspiration. Moreover, for patients who received chemotherapy alone, the pooled sensitivity of endosonography with lymph node sampling for restaging was 66% (95% CI, 56-75), and specificity was 100% (95% CI, 34-100); for patients who received chemoradiotherapy, the results seemed similar with a sensitivity of 77% (95% CI, 47-92) and specificity of 99% (95% CI, 48-100). CONCLUSIONS: Endosonography with lymph node sampling is an accurate and safe technique for mediastinal restaging of lung cancer.

Role of bronchoscopy in management of central squamous cell lung carcinoma in situ.

Squamous cell carcinoma in situ (SCIS) is the pre-invasive stage of squamous cell carcinoma. Early detection and management of SCIS can prevent further progression. Although surgery and external beam radiation therapy are treatment options for SCIS, smaller lesions can be easily managed by bronchoscopic modalities like photodynamic therapy (PDT), cryotherapy, mechanical debulking with biopsy forceps, electrocautery and argon plasma coagulation (APC). Endobronchial brachytherapy (EBBT) and lasers may be judiciously utilized in selected cases. Although, previous studies of treatment modalities may have inadvertently included cases of invasive carcinomas, the advent of new technologies like radial probe endobronchial ultrasound (RP-EBUS) and optical coherence tomography (OCT) can help accurately determine the of depth of invasion. Superficial extent can also be better demarcated with techniques like auto-fluorescence bronchoscopy and narrow band imaging (NBI). New drugs for PDT with deeper penetration and less phototoxicity are being developed. These advances hopefully will allow us to perform superior clinical trials in future and improve our understanding of diagnosis and management of SCIS.