Successful Treatment of Massive Pulmonary Embolism in Pregnancy with Catheter-Directed Embolectomy.

Introduction Pulmonary embolism (PE) is associated with approximately 10.5% of maternal deaths in the United States. Despite heightened awareness of its mortality potential, there islittle data available to guide its management in pregnancy. We present the case of a massive PE during gestation successfully treated with catheter-directed embolectomy. Case Presentation A 37-year-old G2P1001 presented with a syncopal episode preceded by dyspnea and chest pain. Upon presentation, she was hypotensive, tachycardiac, and hypoxic. Imaging showed an occlusive bilateral PE, right heart strain, and a possible intrauterine pregnancy. Beta-human chorionic gonadotropin was positive. She was taken emergently for catheter-directed embolectomy. Her condition immediately improved afterward. Postprocedure pelvic ultrasound confirmed a viable intrauterine pregnancy at 10 weeks gestation. She was discharged with therapeutic enoxaparin and gave birth to a healthy infant at 38 weeks gestation. Conclusion Despite being the gold standard for PE treatment in nonpregnant adults, systemic thrombolysis is relatively contraindicated in pregnancy due to concern for maternal or fetal hemorrhage. Surgical or catheter-based thrombectomies are rarely recommended. Limited alternative options force their consideration, particularly in a hemodynamically unstable patient. Catheter-directed embolectomy can possibly bypass such complications. Our case exemplifies the consideration of catheter-directed embolectomy as the initial treatment modality of a hemodynamically unstable gestational PE.

A Multicenter Study Assessing Interventional Pulmonary Fellow Competency in Electromagnetic Navigation Bronchoscopy.

Background: Current medical society guidelines recommend a procedural number for obtaining electromagnetic navigational bronchoscopy (ENB) competency and for institutional volume for training. Objective: To assess learning curves and estimate the number of ENB procedures for interventional pulmonology (IP) fellows to reach competency. Methods: We conducted a prospective multicenter study of IP fellows in the United States learning ENB. A tool previously validated in a similar population was used to assess IP fellows by their local faculty and two blinded independent reviewers using virtual recording of the procedure. Competency was determined by performing three consecutive procedures with a competency score on the assessment tool. Procedural time, faculty global rating scale, and periprocedural complications were also recorded. Results: A total of 184 ENB procedures were available for review with assessment of 26 IP fellows at 16 medical centers. There was a high correlation between the two blinded independent observers (rho = 0.8776). There was substantial agreement for determination of procedural competency between the faculty assessment and blinded reviewers (kappa = 0.7074; confidence interval, 0.5667-0.8482). The number of procedures for reaching competency for ENB bronchoscopy was determined (median, 4; mean, 5; standard deviation, 3.83). There was a wide variation in the number of procedures to reach competency, ranging from 2 to 15 procedures. There were six periprocedural complications reported, four (one pneumomediastinum, three pneumothorax) of which occurred before reaching competence and two pneumothoraces after achieving competence. Conclusion: There is a wide variation in acquiring competency for ENB among IP fellows. Virtual competency assessment has a potential role but needs further studies.

COVID-19 Impact on Interventional Pulmonology Training.

Background: The impact of the coronavirus disease (COVID-19) pandemic extends beyond the realms of patient care and healthcare resource use to include medical education; however, the repercussions of COVID-19 on the quality of training and trainee perceptions have yet to be explored. Objective: The purpose of this study was to determine the degree of interventional pulmonology (IP) fellows' involvement in the care of COVID-19 and its impact on fellows' clinical education, procedure skills, and postgraduation employment search. Methods: An internet-based survey was validated and distributed among IP fellows in North American fellowship training programs. Results: Of 40 eligible fellows, 38 (95%) completed the survey. A majority of fellows (76%) reported involvement in the care of patients with COVID-19. Fellows training in the Northeast United States reported involvement in the care of a higher number of patients with COVID-19 than in other regions (median, 30 [interquartile range, 20-50] vs. 10 [5-13], respectively; P < 0.01). Fifty-two percent of fellows reported redeployment outside IP during COVID-19, mostly into intensive care units. IP procedure volume decreased by 21% during COVID-19 compared with pre-COVID-19 volume. This decrease was mainly accounted for by a reduction in bronchoscopies. A majority of fellows (82%) reported retainment of outpatient clinics during COVID-19 with the transition from face-to-face to telehealth-predominant format. Continuation of academic and research activities during COVID-19 was reported by 86% and 82% of fellows, respectively. After graduation, all fellows reported having secured employment positions. Conclusion: Although IP fellows were extensively involved in the care of patients with COVID-19, most IP programs retained educational activities through the COVID-19 outbreak. The impact of the decrease in procedure volume on trainee competency would be best addressed individually within each training program. These data may assist in focusing efforts regarding the education of medical trainees during the current and future healthcare crises.

Long-term clinical outcomes of cardiac sympathetic denervation in patients with refractory ventricular arrhythmias.

BACKGROUND: Cardiac sympathetic denervation (CSD) is a useful therapeutic option in patients with structural heart disease (SHD) and ventricular tachycardia (VT) who are otherwise refractory to standard antiarrhythmic drug (AAD) therapy or catheter ablation (CA). In this study, we sought to retrospectively analyze the long-term outcomes of CSD in patients with refractory VT and/or VT storm with a majority of the patients being taken up for CSD ahead of CA. METHODS: We included consecutive patients with SHD who underwent CBD from 2010 to 2019 owing to refractory VT. A complete response to CSD was defined as a greater than 75% reduction in the frequency of ICD shocks for VT. RESULTS: A total of 65 patients (50 male, 15 female) were included. The underlying VT substrate was ischemic heart disease (IHD) in 30 (46.2%) patients while the remaining 35 (53.8%) patients had other nonischemic causes. The mean duration of follow-up was 27 ± 24 months. A complete response to CSD was achieved in 47 (72.3%) patients. There was a significant decline in the number of implantable cardioverter-defibrillator (ICD) or external defibrillator shocks post-CSD (24 ± 37 vs. 2 ± 4, p < .01). Freedom from a combined endpoint of ICD shock or death at 2 years was 51.5%. An advanced New York Heart Association class (III and IV) was the only parameter found to be associated with this combined endpoint. CONCLUSION: The current retrospective analysis re-emphasizes the role of surgical CSD and explores its role ahead of CA in the treatment of patients with refractory VT or VT storm.

Advanced Diagnostic and Therapeutic Bronchoscopy: Technology and Reimbursement.

Advanced interventional pulmonary procedures of the airways, pleural space, and mediastinum continue to evolve and be refined. Health care, finance, and clinical professionals are challenged by both the indications and related coding complexities. As the scope of interventional pulmonary procedures expands with advanced technique and medical innovation, program planning and ongoing collaboration among clinicians, finance executives, and reimbursement experts are key elements for success. We describe advanced bronchoscopic procedures, appropriate Current Procedural Terminology coding, valuations, and necessary modifiers to fill the knowledge gap between basic and advanced procedural coding. Our approach is to balance the description of procedures with the associated coding in a way that is of use to the proceduralist, the coding specialist, and other nonclinical professionals.

Basic and Advanced Pleural Procedures: Coding and Professional Fees Update for Pulmonologists.

There is an evolution of pleural procedures that involve broadened clinical indication and expanded scope that include advanced diagnostic, therapeutic, and palliative procedures. Finance and clinical professionals have been challenged to understand the indication and coding complexities that accompany these procedures. This article describes the utility of pleural procedures, the appropriate current procedural terminology coding, and necessary modifiers. Coding pearls that help close the knowledge gap between basic and advanced procedures aim to address coding confusion that is prevalent with pleural procedures and the risk of payment denials, potential underpayment, and documentation audits.

Use of Tracheostomy During the COVID-19 Pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors Expert Panel Report.

BACKGROUND: The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing, and technique while minimizing the risk of infection to health care workers (HCWs). METHODS: A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidence-based consensus statement and expert panel report. RESULTS: Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health-care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19-related respiratory failure. CONCLUSION: This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic.

Career Development Training for Interventional Pulmonary Fellows: Are They Ready for the Workforce?

BACKGROUND: Interventional pulmonary (IP) fellows spend ≥6 years of postgraduate medical education before IP training. Given the high employment attrition rates of early medical professionals, we investigated the IP fellows' self-assessed readiness for employment and the role of an intense preemployment educational intervention on improving the same. MATERIALS AND METHODS: Over 2 consecutive academic years, IP fellows nationally were invited to a mid-year career development symposium focusing on employment search strategy and early career development. Attendees were anonymously surveyed presymposium/postsymposium and 6 months later at graduation. Both quantitative and qualitative data were collected. Attendees' knowledge and skills were rated on a 5-point Likert scale. A control group of IP fellows that did not attend the symposium were also surveyed at graduation. RESULTS: In total, 53 of 55 attendees (96% response rate) completed the presymposium survey and 50 of 55 (91%) completed the final survey at graduation. Overall, 16 of 18 (89%) nonattendees also completed the final survey at graduation. IP Fellows reported low baseline self-assessment scores on all question domains. Scores increased significantly postsymposium and were sustained at graduation (P<0.05). At graduation, the average response score of symposium attendees was significantly higher than that of nonattendees (P=0.04). Overall, 84% reported that the symposium helped them with their employment search. CONCLUSION: Advanced IP fellows were not well-equipped for a strategic employment search and early career development at the onset of their IP fellowship training. Participation in an intense educational intervention significantly improved fellows' self-assessment scores, an effect that was sustained at 6 months.

Value-Based Proposition for a Dedicated Interventional Pulmonology Suite: An Adaptable Business Model.

Value-based care is evolving with a focus on improving efficiency, reducing cost, and enhancing the patient experience. Interventional pulmonology has the opportunity to lead an effective value-based care model. This model is supported by the relatively low cost of pulmonary procedures and has the potential to improve efficiencies in thoracic care. We discuss key strategies to evaluate and improve efficiency in interventional pulmonology practice and describe our experience in developing an interventional pulmonology suite. Such a model can be adapted to other specialty areas and may encourage a more coordinated approach to specialty care.

Fiducial marker placement for stereotactic body radiation therapy via convex probe endobronchial ultrasound: a case series and review of literature.

Convex probe endobronchial ultrasound (CP-EBUS) and stereotactic body radiotherapy (SBRT) are valuable tools in the diagnosis, staging, and treatment of thoracic malignancies. With widespread clinical adoption, novel uses of CP-EBUS beyond mediastinal diagnosis and staging continue to be discovered. SBRT is an attractive treatment strategy in early-stage lung cancer and oligo-metastatic disease of the chest when a surgical approach is either not feasible or desirable. Accurate application of SBRT is aided by the placement of radio-opaque fiducial markers (FM) to compensate for respiratory cycle movements. We describe eight patients with central thoracic lesions, either known or suspected to be malignant, who underwent EBUS bronchoscopy with lesion sampling and successful intralesional placement of modified FM via our technique, review the existing literature on this topic, and discuss the nuances of coding and billing aspects of FM placement.

Interventional Pulmonology: The Role of Simulation Training and Competency-Based Evaluation.

Medical education and training are becoming more complex endeavors as technological and research advancements lead to new tools and methods to care for patients. In recent years, there has been a paradigm shift in medical education to competency-based assessments. Another important recent development in medical education has been the increasing use of simulation-based learning for procedural training. Interventional pulmonology (IP) is a relatively young and rapidly evolving procedural-based subspecialty. There are several well-validated competency-based assessment tools available to measure training adequacy in many of the most commonly performed procedures in IP. These tools have been shown to improve learning curves and training outcomes. The extent of how widely these tools are being used in clinical and educational spheres, however, remains unclear. Moreover, several commonly performed procedures in IP have no or limited validation tools currently available. Standardized training using simulation has also been shown to lead to positive training outcomes as compared with more traditional training models. However, widespread adoption of simulators has been limited due to the cost and availability.

Diagnosis and management of malignant pleural effusions: state of the art in 2017.

Malignant pleural effusion (MPE) is a known complication of both thoracic and extra thoracic malignancies. The presence of MPE regardless of the primary site translates into advanced stage disease. Diagnosis and management of MPE with the goals of palliation and improving quality of life poses a challenge for chest physicians. Recently, multiple studies have made attempts to answer questions regarding optimal management in various clinical scenarios. We will review the current evidence and available options for the management of MPE.

Patient evaluation for rapid pleurodesis of malignant pleural effusions.

BACKGROUND: Malignant pleural effusions (MPEs) represent advanced stage disease with potentially significant patient discomfort due to dyspnea. Palliative management options include repetitive thoracenteses, placement of a tunneled pleural catheter (TPC), chemical pleurodesis, or some combination of these procedures. The rapid pleurodesis procedure combines thoracoscopic talc pleurodesis and insertion of a TPC at the same time with the goals of reducing both the length of hospitalization and the duration of catheter use. The rapid pleurodesis procedure has previously been described to achieve both of these goals in a pilot study of 30 patients with fully expandable lungs. Both symptoms of dyspnea and quality of life improved with few complications. Additional data on procedural effectiveness is needed to optimize patient selection for this procedure. METHODS: We performed a retrospective analysis of patients who had undergone rapid pleurodesis protocol at two academic institutions over a 40-month period. Data was collected and analyzed on time to removal of the TPC, chemotherapy, malignancy type, complications, age, and catheter occlusion. RESULTS: A total of 29 patients underwent the rapid pleurodesis protocol with a median hospital length of stay of 2 days. Total length of hospitalization was not significantly different between patients with and without primary lung cancer. Median duration of the indwelling TPC was 10 days. Patients with primary lung cancer and those actively or recently undergoing chemotherapy maintained the catheter longer than their counterparts. CONCLUSIONS: The rapid pleurodesis protocol should be considered a viable treatment option for select patients with symptomatic recurrent MPEs undergoing chemical pleurodesis.