Diagnostic and Therapeutic Role of Electrocautery Snare Use in Endobronchial Polypoid Lesions.

INTRODUCTION: Electrocautery with a snare probe offers a tool for the treatment of endobronchial polyps. The aim of this study was to demonstrate the efficacy of the snare probe in patients undergoing rigid bronchoscopy due to central airway obstruction. METHODS: This retrospective descriptive study included patients who underwent rigid bronchoscopy with an electrocautery snare probe for the diagnosis and/or treatment of endobronchial polyps in an interventional pulmonology unit. RESULTS: The mean age of the 47 patients (38 men) with endobronchial polypoid lesions was 61.5 years. Six lesions (12.8%) were located in the trachea, 6 (12.8%) in the right main bronchus, 11 (23.4%) in the left main bronchus, and 24 (51.1%) in the lobar bronchi. Twenty-eight lesions (59.5%) were malignant. Prior to the procedure, 6 (12.8%) patients had grade 1 obstruction, 6 (12.8%) had grade 2 obstruction, 15 (31.9%) had grade 3 obstruction, and 20 (42.6%) had grade 4 obstruction. In terms of airway obstruction after the procedure, grade 1 was present in 46 (97.9%) patients and grade 2 was present in 1 (2.1%) patient. No major complication developed in 93.6% of the patients. During a mean follow-up period of 48 months, 85.1% of the patients did not experience recurrence. CONCLUSION: Our results demonstrate that the snare probe can be used to effectively and reliably establish airway patency in patients with central airway obstruction due to endobronchial polypoid lesions.

Tracheobronchial stent sizing and deployment practices airway stenting practices around the world: a survey study.

BACKGROUND: Tracheobronchial stents types, uses, techniques for deployment and extraction have practice variations around the world. METHODS: We collected responses by sending an online survey of 8 questions to world interventional bronchology member societies and social media groups. RESULTS: There were 269 respondents from 47 countries. Europe had 97 respondents from 22 countries. There were 8 respondents from Australia, 7 from Africa (3 countries) and 7 from 4 countries in South America (SA). North America (NA) had 72 respondents from 3 countries. Asia had 78 respondents from 14 countries. For stent placements 15% [41] used fiberoptic bronchoscope (FB) only. Rigid bronchoscopy (RB) was solely utilized by 38% [102]. Forty-six percent [123] used a combination of RB and FB (P value <0.00001). For stent extraction 13% [19] used FB alone, 57% [85] used RB, and 36% [54] used a combination of RB and FB (P value <0.00001). Placement of stents were 50.5% [135] only by direct visualization. Twenty-three percent [61] always used fluoroscopic guidance. Twenty-six-point-five percent [71] used fluoroscopy in certain cases (P value <0.00001). Sixty percent [162] decided stent sizing by measurements of stenotic and non-stenotic areas on radiology. Twelve percent [32] respondents used sizing devices. Sixty-five percent [177] used a ruler and bronchoscope to measure stenotic areas. Thirty-eight percent [104] used visual estimation and experience. Seven percent [19] used serial balloon dilatation size. To prevent clogging of stents, 22% [59] prescribed mucolytics. Seventy-three percent [195] nebulized saline, 26% [70] had Mucomyst Nebulization, 24% [65] Nebulized bronchodilators and other methods 11% [30] were advised. Covered self-expandable metal stents (SEMS) 44% was the commonest type of stent used around the world. Silicone stents 37%, Y stents 15%, uncovered SEMS 12%, Montgomery T tube 5% followed. Polyflex stents 3% and custom-made stents 3% were least used. Biodegradable stents were used by 7.5%, and not used by 92.5%. CONCLUSIONS: Tracheobronchial stent practice norms have slowly evolved, but its practice variations lack uniformity, and have sparse evidence-based studies for its direction.

A new electrocardiographic parameter associated with sudden cardiac death in pulmonary sarcoidosis.

INTRODUCTION: The interval from the peak to the end of the electrocardiographic T wave (Tp-Te) may correspond to malignant ventricular arrhythmias. In this study we aimed to assess Tp-Te variability and investigate the transmural dispersion of repolarisation in pulmonary sarcoidosis disease without proofed cardiac involvement. MATERIAL AND METHODS: This was a retrospective case-control study that included patients who had a pathologic and radiologic diagnosis of sarcoidosis. All data of the patients' demographic features and electrocardiographs were analysed. RESULTS: We enrolled 78 patients with sarcoidosis and 54 healthy volunteers as controls in our study. Men comprised 36% of the sarcoidosis group and 27% of controls. The mean age in the sarcoidosis and control group was 45.4 ±8.7 years (range: 23-58 years) and 44.6 ±11.9 years (range: 21-73 years), respectively. There was no significant difference between the groups for age or sex (p = 0.654, p = 0.246, respectively). There was a significant increase in Tp-Te results in all precordial leads in the sarcoidosis group compared with the control group (p < 0.05). CONCLUSIONS: Pulmonary sarcoidosis is suspected to have cardiac involvement; therefore, we need to develop new approaches. We present strong evidence that Tp-Te intervals were increased in patients with pulmonary sarcoidosis, which suggests that there may be a link between sarcoidosis and ventricular arrhythmias without proofed cardiac involvement.

Malignant Melanoma Metastasis to the Thyroid Gland Causing Severe Central Airway Obstruction.

Metastasis of malignant melanoma to the thyroid gland causing airway obstruction is an extremely rare condition. In an 80-year-old woman who presented with painless swelling of the neck, a diagnosis of malignant melanoma metastasis to the thyroid gland with an unknown source was established. She received multiple radiotherapy sessions that resulted in occasional regression but not complete resolution. She was then referred for tracheal stenting owing to progressed dysphagia and dyspnea. Rigid bronchoscopy was performed, and a fully covered metal stent was placed to secure the open airway. Dyspnea improved immediately after stent insertion. The patient died at her residence because of a cerebrovascular event 2 weeks after the procedure. To the best of our knowledge, central airway obstruction due to malignant melanoma metastasis to the thyroid gland has been not reported in the literature. The approach for palliation of obstruction is similar to that of other malignant central airway obstructions.

Comparison of silicon and metallic bifurcated stents in patients with malignant airway lesions.

INTRODUCTION AND OBJECTIVE: Silicon and metallic are two types of stents in use. In this study, we compared complications and long-term survival among patients who received silicon or fully covered, bifurcated self-expandable metallic stents (SEMS) for a malignant tracheobronchial obstruction and/or tracheo/bronchial oesophageal fistulas. METHODS: Patients in whom Y-shaped stents were used from January 2013 to June 2017 in our interventional pulmonology unit were evaluated retrospectively from patient files. RESULTS: Of the 47 patients, 30 (23 males, 76.7%) were in the silicon stent group and 17 (14 males, 82.4%) were in the covered SEMS group. No differences between the groups were detected in ECOG status, pathological properties of the disease, radiotherapy or chemotherapy history before the procedure, symptoms at presentation, or comorbidities. The most common symptom was dyspnoea (96.7% and 100%), and the most common comorbidity was chronic obstructive pulmonary disease (26.7% and 23.5%). A total of 20 complications (42.6%) were seen, with no significant difference between the groups (silicon, 40%; SEMS, 47.1%; P = . 62). Mean survival was 164.51 ± 38.83 days for the silicon stent group and 254.45 ± 103.32 days for the SEMS group (P = .588). No differences were observed in 30-, 90- or 180-day mortality between the two groups (P = .966, .846 and .534, respectively). CONCLUSIONS: No significant differences in symptom palliation, insertion safety, complication rate or survival were detected between the two types of stent.

Use of interventional bronchoscopic treatment in small cell lung cancer.

AIMS: Small cell lung cancer (SCLC) constitutes 15%-25% of all lung cancers. Their treatment approach is different from nonsmall cell lung cancer. Central airway obstruction develops at the time of diagnosis or eventually at some time as the disease progress. Quick relief of symptoms with chemotherapy will cause to postpone interventional bronchoscopy which divest patient from benefits of this procedure. There is a few data about the use of interventional bronchoscopy in SCLC. SUBJECTS AND METHODS: Between January 2005 and December 2012, rigid bronchoscopy under general anaesthesia was done in a total of 944 cases. Among them, 52 consecutive SCLC cases were evaluated retrospectively. STATISTICAL ANALYSIS: Survival was calculated from the date of application of therapeutic bronchoscopy using statistical software. RESULTS: From the 52 cases (41 males) mean age of the patients were 56,87 ± 10,16 (range 34-78). Most common obstruction areas were distal trachea and carina invasion involving both main bronchus (n: 12; 23%). Most common method used was mechanical desobstruction after coagulation with diode diode laser or APC. A total of 16 stents was applied to 15 of the cases from 52 cases (28.8%). Most common used stent was silicon Y stent (n: 11). Most common complication during the procedure was bleeding that was mild in 11 cases and massive in 1. One patient died during the procedure (1.9%). CONCLUSIONS: Multimodal interventional bronchoscopic methods seem to be a last option but may be useful in the management of advanced airway obstruction in the setting of SCLC. The choice of modality may be chosen depending upon individual patient characteristics as appropriate.

Association Between Titration Method and Outcomes of First Night Satisfaction and CPAP Compliance.

INTRODUCTION: The gold standard therapy for obstructive sleep apnoea syndrome (OSAS) is continuous positive airway pressure (CPAP). Our study evaluated the relationship between first night satisfaction and CPAP compliance, and the effect of using the titration method in this relationship. METHODS: Between January 2012 and December 2012, 40 patients with the diagnosis of OSAS and without comorbidities, who had undergone CPAP titration, were included. Of these, 20 patients had undergone manual titration (MT) with polysomnography, whereas 20 patients had undergone auto-adjusted CPAP (APAP) titration. Questionnaires were administered during the morning of the titration night. The first-year adherence to treatment and patient compliance were evaluated. RESULTS: Forty patients were randomised in two groups; 35 patients who could procure the CPAP and were available at the end of the first year completed the study. From the 35 patients, 20 (6 males; 40%) were in the MT group while 15 (6 males; 30%) were in the APAP group. No significant difference was detected between the mean titration pressure levels obtained with the MT or APAP group. There was no difference in terms of responses to the questions on the questionnaire between the two groups. At the first-year evaluation, no significant difference was detected between the groups. CONCLUSIONS: The titration method used to detect CPAP pressure, MT, or APAP does not affect patient satisfaction on the day following the titration night, and does not affect first-year compliance.

Are flexible bronchoscopic cryoextraction practices an alternative to rigid bronchoscopy?

INTRODUCTION: We aimed to evaluate the efficacy of flexible bronchoscopic cryoextraction in the treatment of airw ay obstruction arise from mucus plugs and blood clots and present our experience. MATERIALS AND METHODS: The present study evaluated patients who previously underwent unsuccessful flexible bronchoscopy for the removal of secretions and blood clots in the central airway and who underwent flexible bronchoscopic cryoextraction between January 2013-November 2017. RESULT: The study included seven patients with a mean age of 58.29 ± 18.56 years (28-76). Three patients underwent bedside intervention in the intensive care unit, and four patients underwent an intervention in the bronchoscopy unit. Seven patients underwent a total of nine sessions of cryoextraction. Severe complications or mortality did not occur during the cryoextraction sessions. CONCLUSIONS: Flexible bronchoscopic cryoextraction offers a safe treatment strategy as an alternative to rigid bronchoscopy in patients in whom airway patency cannot be achieved using other flexible bronchoscopic interventions. and accuracy of PET was higher compared to CT with this cut-off value.

Bronchoscopic Treatment of Benign Endoluminal Lung Tumors.

Background and Aim: Endobronchial benign tumors are a rarely seen clinical entity but may cause significant symptoms. Endobronchial treatment has the potential for relieving symptoms while saving the patient from invasive surgical procedures. No trials have been published that present and compare the various endobronchial treatment modalities for endobronchial benign tumors. The aim of the present study is to define safety and efficacy of endobronchial treatment in patients with benign endobronchial tumors from the point of complications and success rate. Methods: This study is a retrospective cohort study from a review of medical charts. Eligibility criteria included diagnosis of a benign endobronchial tumor. Our institution's bronchoscopy and pathology database was searched for specific benign tumors, and the results were further detailed based on the endobronchial location. Results: Forty-four patients with pathologically confirmed benign endobronchial tumors were included. Tumor regression was achieved in all patients with diode laser and argon plasma coagulation in combination with or without cryotherapy and without any major complication. There were no significant differences between the use of either diode laser or of argon plasma coagulation as a modality with immediate effect from the occurrence of residual tissue that needed cryotherapy (P > 0.05). There were no major complications. Eight patients had minor complications including minor bleeding (6 patients) and hypertension (2 patients) that were controlled medically. Thirty-one patients (70%) had very good response, and 13 patients (30%) had good response as defined in literature before. Conclusion: Diode laser and argon plasma coagulation in combination with or without cryotherapy are safe and effective methods for endobronchial treatment of benign endobronchial tumors.

Endoscopic and Surgical Treatment of Benign Tracheal Stenosis: A Multidisciplinary Team Approach.

PURPOSE: Surgical resection and reconstruction are considered the most appropriate approaches to treat post-intubation tracheal stenosis (PITS). Bronchoscopic methods can be utilized as palliative therapy in patients who are ineligible for surgical treatment or who develop post-surgical re-stenosis. We investigated treatment outcomes in patients with benign tracheal stenosis. METHODS: A retrospective review was performed in patients who were diagnosed with PITS. Tracheal resection was performed for operable cases, whereas endoscopic interventions were preferred for inoperable cases with a complex or simple stenosis. RESULTS: In total, 42 patients (23 treated by bronchoscopic methods, 19 treated by surgery) took part in this study. No significant differences were observed in segment length, the proportion of obstructed airways, or vocal cord distance between the two groups. In all, 15 patients in the bronchoscopic treatment group received a stent. Following the intervention, the cure rates in the bronchoscopic and surgical treatment groups were 43.47% and 94.7%, respectively. A multidisciplinary approach resulted in a cure or satisfactory outcome in 90.5% of the patients while failure was noted in 9.5% of the patients. CONCLUSION: Bronchoscopic methods are associated with a lower cure rate compared to surgery. A multidisciplinary approach was helpful for treatment planning in patients with PITS.

Safety and Efficacy of Oki Stenting Used to Treat Obstructions in the Right Mainstem Bronchus.

BACKGROUND: Silicone stenting has been used to palliatively manage respiratory symptoms in patients with airway stenoses. Oki and Saka recently developed stents that can be used to manage stenoses around the carina between the bronchus to the right upper lobe and the bronchus intermedius (termed the primary right carina). The aim of this study was to assess the efficacy and safety of Oki stenting used to treat airway stenosis around the primary right carina. METHODS: We included 5 patients with airway stenoses. All Oki stenting procedures were performed with the patients under general anesthesia using either rigid or flexible bronchoscopy. RESULTS: Oki stents were successfully placed in all 5 patients, and the dyspnea index improved in all. Modified Oki stenting was performed at the anastomotic site of 1 patient who had undergone sleeve resection. Four patients had airway obstructions caused by malignant disease. No serious procedural or early complication was noted. One patient died of liver insufficiency, and another with a malignancy died from cranial metastasis of the primary tumor. CONCLUSION: Oki stenting of the primary right carina is safe, efficient, and acceptable when used for palliative management of airway obstruction, even after sleeve resection; in the latter case, some procedural modifications are required.

Current Practice of Airway Stenting in the Adult Population in Europe: A Survey of the European Association of Bronchology and Interventional Pulmonology (EABIP).

BACKGROUND: Airway stenting (AS) commenced in Europe circa 1987 with the first placement of a dedicated silicone airway stent. Subsequently, over the last 3 decades, AS was spread throughout Europe, using different insertion techniques and different types of stents. OBJECTIVES: This study is an international survey conducted by the European Association of Bronchology and Interventional Pulmonology (EABIP) focusing on AS practice within 26 European countries. METHODS: A questionnaire was sent to all EABIP National Delegates in February 2015. National delegates were responsible for obtaining precise and objective data regarding the current AS practice in their country. The deadline for data collection was February 2016. RESULTS: France, Germany, and the UK are the 3 leading countries in terms of number of centres performing AS. These 3 nations represent the highest ranked nations within Europe in terms of gross national income. Overall, pulmonologists perform AS exclusively in 5 countries and predominately in 12. AS is performed almost exclusively in public hospitals. AS performed under general anaesthesia is the rule for the majority of institutions, and local anaesthesia is an alternative in 9 countries. Rigid bronchoscopy techniques are predominant in 20 countries. Amongst commercially available stents, both Dumon and Ultraflex are by far the most commonly deployed. Finally, 11 countries reported that AS is an economically viable activity, while 10 claimed that it is not. CONCLUSION: This EABIP survey demonstrates that there is significant heterogeneity in AS practice within Europe. Therapeutic bronchoscopy training and economic issues/reimbursement for procedures are likely to be the primary reasons explaining these findings.

Lung transplantation in Turkey: lessons from surgeons and pulmonologists.

BACKGROUND/AIM: In order to actualize an efficient lung transplantation program, it is necessary to determine priorities and set up strategies. This study aimed to estimate the present situation in Turkey by determining the level of interest and knowledge of pulmonologists and thoracic surgeons regarding lung transplantation. MATERIALS AND METHODS: A questionnaire was prepared to establish the level of interest and knowledge of physicians on lung transplantation. It was sent to 2131 pulmonologists and thoracic surgeons, and 130 physicians completed the questionnaire. RESULTS: Of the 130 physicians who responded, 42 were thoracic surgeons and 88 were pulmonologists. There was no significant difference between the two groups regarding the availability of lung transplantation at their hospitals. The rates of correct answers to the questions and responses supporting the transplant initiative were higher in the thoracic surgeon group than in the pulmonologist group. CONCLUSION: The establishment of a successful system for lung transplantation in Turkey requires an increase in interest, knowledge, and dedication of physicians, coupled with adequate and continuous training. There also needs to be sufficient equipment and financing in addition to disciplined multidisciplinary teams and cooperation. This survey shows there is still much work to be done to achieve success in lung transplantation in Turkey.

Is silicone stent insertion a clinically useful option for tracheobronchomalacia?

BACKGROUND/AIM: Tracheobronchomalacia (TBM) leads to the obstruction of expiratory airflow and interference with secretion clearance. Stabilization of the airway wall using a silicon stent or laser coagulation of the posterior wall may be treatment options. This study aimed to retrospectively analyze which interventional bronchoscopic method could be used to provide airway stabilization and gain control of symptoms and for whom this method could be used. MATERIALS AND METHODS: Fifteen patients who had received treatment in our interventional pulmonology unit were analyzed. We analyzed the techniques used, stent duration, complications, and long-term treatment success retrospectively. RESULTS: Stents were used in 10 patients: 4 patients had silicon Y-stents and 4 patients had silicon tracheal stents. Stents were removed due to early migration in 3 patients. In 5 of the 7 cases, the stent was removed due to frequent obstructions of the stent due to recurrent severe mucostasis. A suitable stent was not found for one patient who had an extremely enlarged trachea. Good clinical results were achieved in just two cases. The frequency of admissions to the emergency room and hospitalizations were diminished during the follow-up time in these two patients. CONCLUSION: Silicon stents may be a good treatment option in selected patients with TBM and dynamic collapse. However, our patients were high-risk; thus, the criteria for candidates for bronchoscopic treatment should be carefully defined.

Endobronchial Watanabe Spigot in the treatment of bronchobiliary fistula.

Bronchobiliary fistula (BBF) is a rare condition in which an abnormal communication exists between the bile ducts and the bronchial tree. Malignancy is the most common etiology of BBF, although many others are possible. A 74-year-old male patient with an inoperable Klatskin tumor presented with a complaint of yellow-green sputum and cough; the patient underwent fiber-optic bronchoscopy based on a preliminary diagnosis of bronchobiliary fistula. Using fiber-optic rigid bronchoscopy, the laterobasal segment of the lower right lung lobe was occluded using three pieces of 5-mm Endobronchial Watanabe Spigot. Bile drainage subsequently ceased. A bronchoscopic approach provides an alternative option for BBF treatment, particularly in patients who choose not to undergo surgery, or for whom surgery is not an option due to their underlying general condition.

Therapeutic bronchoscopic interventions for malignant airway obstruction: A retrospective study from experience on 547 patients.

There is no definitive consensus about the factors affecting the choice of interventional bronchoscopy in the management of malignant airway obstruction. The present study defines the choice of the interventional bronchoscopic modality and analyzes the factors influencing survival in patients with malignant central airway obstruction. Totally, over 7 years, 802 interventional rigid bronchoscopic procedures were applied in 547 patients having malignant airway obstruction. There was a significant association between the type of stent and the site of the lesion in the present study. Patients with tracheal involvement and/or involvement of the main bronchi had the worst prognosis. The sites of the lesion and endobronchial treatment modality were independent predictors of survival in the present study. The selection of different types of airway stents can be considered on the base of site of the lesion. Survival can be estimated based on the site of the lesion and endobronchial brochoscopic modality used.