Transthoracic placement of fiducials with ultrasound or electronic navigational bronchoscopy needle guidance by the interventional pulmonologist: A case series.

Stereotactic body radiotherapy (SBRT) has become one of the main options for treatment of thoracic malignancies, leading to the need for more fiducial marker placement. We report cases where these fiducials were placed transthoracically by interventional pulmonologists using ultrasound (US) and electronic navigational bronchoscopy (ENB) needle guidance. Six cases were identified in the Cooper University Hospital medical records where such procedures were performed, alone or in combination with other interventions. All six patients underwent successful placement of fiducials. Concomitant bronchoscopic procedures were performed in four cases. All patients proceeded to SBRT without the need for further interventions. The overall retention rate of fiducials was 80%. No complications were noted. Fiducials' placement by interventional pulmonologists using US or ENB needle guidance is safe and effective, and may be combined with other procedures in a single setting.

Patient-Reported Dyspnea Correlates Poorly with Aerobic Exercise Capacity Measured During Cardiopulmonary Exercise Testing.

BACKGROUND: Patient-reported dyspnea plays a central role in assessing cardiopulmonary disease. There is little evidence, however, that dyspnea correlates with objective exercise capacity measurements. If the correlation is poor, dyspnea as a proxy for objective assessment may be misleading. OBJECTIVE: To compare patient's perception of dyspnea with maximum oxygen uptake (MaxVO2) during cardiopulmonary exercise testing (CPET). METHODS: Fifty patients undergoing CPET for dyspnea evaluation were studied prospectively. Dyspnea assessment was measured by a metabolic equivalent of task (METs) table, Mahler Dyspnea Index, Borg Index, number of blocks walked, and flights of stairs climbed before stopping due to dyspnea. These descriptors were compared to MaxVO2. RESULTS: MaxVO2 showed low correlation with METs table (r = 0.388, p = 0.005) and no correlation with Mahler Index (r = 0.24, p = 0.093), Borg Index (r = -0.017, p = 0.905), number of blocks walked (r = 0.266, p = 0.077) or flights of stairs climbed (r = 0.188, p = 0.217). When adjusted for weight (maxVO2/kg), there was significant correlation between MaxVO2 and METs table (r = 0.711, p < 0.001), moderate correlation with blocks walked (r = 0.614, p < 0.001), and low correlation with Mahler Index (r = 0.488 p = 0.001), Borg Index (r = -0.333 p = 0.036), and flights of stairs (r = 0.457 p = 0.004). Subgroup analysis showed worse correlation when patients with normal CPET were excluded (12/50 excluded). Patients with BMI < 30 had no correlation between Max VO2 and the assessment methods, while patients with BMI > 30 had moderate correlation between MaxVO2 and METs table (r = 0.568, p = 0.002). CONCLUSION: Patient-reported dyspnea correlates poorly with MaxVO2 and fails to predict exercise capacity. Reliance on reported dyspnea may result in suboptimal categorization of cardiopulmonary disease severity.

Endobronchial valves for bronchopleural fistula: pitfalls and principles.

BACKGROUND: Placement of endobronchial valves for bronchopleural fistula (BPF) is not always straightforward. A simple guide to the steps for an uncomplicated procedure does not encompass pitfalls that need to be understood and overcome to maximize the efficacy of this modality. OBJECTIVES: The objective of this study was to discuss examples of difficult cases for which the placement of endobronchial valves was not straightforward and required alterations in the usual basic steps. Subsequently, we aimed to provide guiding principles for a successful procedure. METHODS: Six illustrative cases were selected to demonstrate issues that can arise during endobronchial valve placement. RESULTS: In each case, a real or apparent lack of decrease in airflow through a BPF was diagnosed and addressed. We have used the selected problem cases to illustrate principles, with the goal of helping to increase the success rate for endobronchial valve placement in the treatment of BPF. CONCLUSIONS: This series demonstrates issues that complicate effective placement of endobronchial valves for BPF. These issues form the basis for troubleshooting steps that complement the basic procedural steps.

Comparison of Chemical and Mechanical Prophylaxis of Venous Thromboembolism in Nonsurgical Mechanically Ventilated Patients.

Background. Thromboembolic events are major causes of morbidity, and prevention is important. We aimed to compare chemical prophylaxis (CP) and mechanical prophylaxis (MP) as methods of prevention in nonsurgical patients on mechanical ventilation. Methods. We performed a retrospective study of adult patients admitted to the Cooper University Hospital ICU between 2002 and 2010. Patients on one modality of prophylaxis throughout their stay were included. The CP group comprised 329 patients and the MP group 419 patients. The primary outcome was incidence of thromboembolic events. Results. Acuity measured by APACHE II score was comparable between the two groups (p = 0.215). Univariate analysis showed 1 DVT/no PEs in the CP group and 12 DVTs/1 PE in the MP group (p = 0.005). Overall mortality was 34.3% and 50.6%, respectively. ICU LOS was similar. Hospital LOS was shorter in the MP group. Multivariate analysis showed a significantly higher incidence of events in the MP prophylaxis group (odds ratio 9.9). After excluding patients admitted for bleeding in both groups, repeat analysis showed again increased events in the MP group (odds ratio 2.9) but this result did not reach statistical significance. Conclusion. Chemical methods for DVT/PE prophylaxis seem superior to mechanical prophylaxis in nonsurgical patients on mechanical ventilation and should be used when possible.

A case report on the diagnosis of a rare pleural tumor with endobronchial ultrasound: breaking new boundaries.

Convex endobronchial ultrasound (C-EBUS)-guided transbronchial needle aspiration (TBNA) is an effective tool for the diagnosis of hilar, mediastinal, and central parenchymal lung lesions. However, it has a limited utility for pleural-based masses. We report a unique case of a pleural synovial sarcoma recurrence that was diagnosed by C-EBUS. The patient had a history of inguinal synovial sarcoma. He presented with cough and chest pain. Imaging of chest revealed large right pleural mass. Bronchoscopy with EBUS-TBNA diagnosed pleural recurrence of synovial sarcoma. He underwent radical resection and pathological examination confirmed the diagnosis of pleural synovial sarcoma. He experienced complete recovery and resolution of symptoms. Synovial sarcoma should be included in the differential diagnosis of pleural masses. Convex EBUS-guided biopsies can provide adequate diagnosis of large pleural tumors adjacent to the central airways without need for more invasive diagnostic procedures.

Diffusion-weighted whole-body imaging with background body signal suppression in Castleman disease.

Castleman's disease (CD) is a rare lymphoproliferative disease characterized by angiofollicular lymph node hyperplasia. The case of a 74-year-old man with multicentric CD of the plasma cell type is described. The imaging findings on diffusion-weighted whole-body imaging with background body signal suppression at diagnosis and after treatment are reported.