Refractory secondary pneumothorax complicated with lung cancer treated by bronchial occlusion: a case report.

BACKGROUND: Pneumothorax is defined as the presence of air or gas in the pleural cavity. Secondary pneumothorax usually occurs in patients with overt underlying lung disease, most commonly chronic obstructive pulmonary disease (COPD). Patients with poor lung function often suffer from pneumothorax with a persistent air leak. Various strategies have been employed in the treatment of such refractory pneumothorax. Bronchial occlusion with an Endobronchial Watanabe Spigot (EWS) (Novatech, Grasse, France) has been shown to be useful in treating prolonged bronchopleural fistulas. Although the effects of bronchial occlusion with EWS are known, refractory pneumothorax often involves multiple affected bronchi, and in some cases the affected bronchi cannot be easily identified. In addition, secondary pneumothorax associated with advanced lung cancer often prolongs the treatment of pneumothorax, which can significantly reduce patients' quality of life and prognosis. CASE PRESENTATION: We report a case of refractory pneumothorax where collateral ventilation was successfully treated by bronchial occlusion of the affected bronchi using multiple methods. In August 2019, an 80-year-old Japanese man with asthma and COPD overlap was admitted for exacerbation triggered by respiratory tract infection. During hospitalization, he presented with chest pain due to pneumothorax. Subsequently, a chest drain tube was inserted and pleurodesis was performed; however, the lung could not be sufficiently expanded and an air leak remained. Further investigation revealed a tumor suspicious for lung cancer at the entrance of the left upper lobe bronchus. Due to poor lung function, surgical treatments were deemed high risk. Therefore, we performed bronchial occlusion using the Endobronchial Watanabe Spigot (EWS). Because we could not determine the affected bronchi by computed tomography (CT), we located the affected bronchi by balloon occlusion test and bronchography with iopamidol. After occlusion, the air leak decreased but still persisted. Thus, we performed pleurodesis twice, and the air leak ceased completely. CONCLUSIONS: Refractory secondary pneumothorax, which affected multiple bronchi and developed into collateral ventilation due to lung cancer, was treated successfully with bronchial occlusion and EWS. In cases where the affected bronchi cannot be determined by the balloon occlusion test, bronchography with iopamidol might be an effective treatment.

Immunological features of a lung cancer patient achieving an objective response with anti-programmed death-1 blockade therapy.

The role of immune checkpoint inhibitors in metastatic lung cancer has been established in recent years and the pretherapeutic profiles of the tumor microenvironment in responders have been increasingly reported. The role of salvage surgery and the immune profiles of the posttherapeutic specimens in patients achieving an objective response have rarely been studied. We report a case of metastatic lung cancer treated by anti-programmed death-1 Ab followed by surgical resection. The immune status of the tumor was assessed, showing germinal center formation, memory B cell infiltration, and a high frequency of interferon gamma -secreting T cells.

Assessment of Bronchial Obstruction Using Lateral Pressure Measurement during Bronchoscopy.

BACKGROUND: In patients with bronchial obstruction estimating the location of the maximal obstruction is crucial for guiding interventional bronchoscopy. However, flow-volume curves cannot discriminate between the right and left lungs. OBJECTIVES: The aim of this study was to physiologically evaluate bronchial obstruction during interventional bronchoscopy. METHODS: We prospectively measured lateral airway pressure (Plat) at either side of the obstruction using a double-lumen catheter (pressure-pressure [P-P] curve) simultaneously to assess the degree of bronchial obstruction in 22 patients. The shape of the P-P curve was assessed to confirm the site of maximal obstruction. RESULTS: In the experimental study, Plat was uniform between both bronchi in the normal model. For the unilateral and bilateral obstruction models, a phase shift was only seen for the more obstructed side. In healthy subjects, the angle of the P-P curve was close to 45° and linear in shape. In patients with bronchial obstruction, the angle was much smaller but approached 45° after the bronchoscopic procedure. The degree of bronchial obstruction was significantly correlated with the angle of the P-P curve (r = -0.51, p < 0.01). Dyspnea significantly increased when the airway lumen was obstructed by more than 60% (p < 0.0001), and when the P-P curve appeared loop-shaped (p < 0.01). CONCLUSIONS: The shape of the P-P curve could be used to detect the site of maximal obstruction for the optimal positioning of the stent and assess the need for additional procedures in real time in patients with bronchial obstruction.

Comparison of Airway Measurements for Tracheobronchial Stenosis Between Stereoscopic Bronchoscope and MD-CT.

BACKGROUND: Stereoscopic bronchoscopy is a new diagnostic tool to measure the diameter and cross-sectional area of the airway. The stereoscopic bronchoscope, which operates the same as a standard bronchoscope, utilizes 2 lenses to measure the airway using the principles of triangulation. Furthermore, the stereoscopic bronchoscope has the capability to measure the size of the airway during intervention in real-time, including variable stenosis. MATERIALS AND METHODS: To prospectively compare preoperative stereoscopic and multidetector computed tomography (MD-CT) images to select the appropriate stent size for airway stenosis. Stereoscopic and MD-CT images were then measured to confirm the correct placement of the stent. RESULTS: Airway stenting was performed on 21 consecutive patients of whom, 15 were diagnosed with malignant and 6 with benign diseases. In total, 165 measurements were taken (134 healthy; 31 affected). For the diameter, Bland-Altman plots were used to measure data from 165 matched stereoscopic and MD-CT measurement sites (bias, 0.40±2.86 mm SD; percentage error, 33%), 134 healthy sites (bias, 0.554±2.83 mm SD; percentage error, 34%), and 31 affected sites (bias, 1.20±2.67 mm SD; percentage error, 52%). For the cross-sectional area, matched stereoscopic and MD-CT measurements were analyzed for 65 sites (bias, -10.53±92.85 mm SD; percentage error, 89%), 49 healthy sites (bias, -9.88±39.00 mm SD; percentage error, 32%), and 16 affected sites (bias, -13.12±48.81 mm SD; percentage error, 92%). CONCLUSION: Stereoscopic bronchoscopy was able to accurately measure the size of the airway during intervention, to assist in selecting the appropriate size of the stent.

Choke point physiology in airway stenting: A case presentation and discussion.

BACKGROUND: The point in the airway that allows the smallest maximal flow is known as the "choke point". The tube law describes the velocity of the expired air, which cannot exceed the wave-speed. Flow limitation during forced expiration is affected by the relationship between the transmural pressure (Ptm) and cross-sectional area (A) of the airway. Wave speed is dependent on the stiffness of the airway wall, as well as on the cross-section of the airway itself (dA/dPtm). METHODS: Airway stenting at the wave-speed, flow-limiting segment (choke point) is assessed by using a catheter, via the working channel of a stereoscopic bronchoscope, to measure the difference between lateral pressure and pleural pressure. RESULTS: Based on the wave-speed concept of maximal expiratory flow limitation, stenting at the choke point increased the cross-sectional area and supported the weakened airway wall, thus improving expiratory flow limitation and relieving dyspnea. CONCLUSION: To ensure correct stent positioning and thus optimal functional benefit, it is important to locate the exact position of tracheobronchial stenosis.

The correlation between lung sound distribution and pulmonary function in COPD patients.

BACKGROUND: Regional lung sound intensity in chronic obstructive pulmonary disease (COPD) patients is influenced by the severity and distribution of emphysema, obstructed peripheral airways, and altered ribcage and diaphragm configurations and movements due to hyperinflation. Changes in the lung sound distribution accompanied by pulmonary function improvements in COPD patients were observed after bronchodilator inhalation. We investigated the association of lung sound distribution with pulmonary functions, and the effects of emphysematous lesions on this association. These studies were designed to acquire the basic knowledge necessary for the application of lung sound analysis in the physiological evaluation of COPD patients. METHODS: Pulmonary function tests and the percentage of upper- and lower-lung sound intensity (quantitative lung data [QLD]) were evaluated in 47 stable male COPD patients (54 - 82 years of age). In 39 patients, computed tomography taken within 6 months of the study was available and analyzed. RESULTS: The ratio of lower QLD to upper QLD showed significant positive correlations with FEV1 %predicted (%FEV1; ρ=0.45, p<0.005) and MEF50 %predicted (%MEF50; ρ=0.46, p<0.005). These correlations were not observed in COPD patients with dominant emphysema (% low attenuation area >40%, n=20) and were stronger in less emphysematous patients (n=19, %FEV1; ρ=0.64, p<0.005, %MEF50; ρ=0.71, p<0.001). CONCLUSIONS: In COPD patients, the ratio of lower- to upper-lung sound intensities decreased according to the severity of obstructive changes, although emphysematous lesions considerably affected lung sound distribution.

Vibration response imaging in healthy Japanese subjects.

BACKGROUND: Vibration response imaging (VRI) records the intensity and distribution of lung sounds during the respiration cycle. Our objective was to analyze VRI findings in healthy Japanese adults. METHODS: VRI images of 106 healthy subjects (33.7±9.6 years, 52 male and 54 female), including 67 nonsmokers and 39 asymptomatic smokers, were recorded. The regional intensity of vibrations was assessed using quantitative lung data (QLD), and VRI dynamic images by rater assessment, left and right lung asynchrony (gap index), and regional lung asynchrony (asynchrony score). RESULTS: A dominance of total left lung QLD was observed in all subjects, and this phenomenon was more prominent in female subjects. However, there was no significant difference between the total left and total right lung QLD in smokers. Rater assessments showed that 81.1% of all subjects had a normal final assessment. Male subjects had a significantly higher percentage of good or normal assessments for all image scores, except dynamic image scoring. The asynchrony score was significantly higher in female subjects. There were no significant differences in these qualitative assessments between non-smokers and smokers. CONCLUSIONS: Although our QLD results were similar to those of a previous report, there were discrepancies between sexes for the qualitative assessments. A significantly higher number of female subjects had abnormal images as assessed by the raters. Furthermore, significantly higher asynchrony scores were observed in female subjects. The VRI variability in sex may be considered normal among the Japanese population. This study is registered with UMIN-CTR under registration number UMIN000002355.

Complete tracheal duplication with unilateral atelectasis in an adult.

Duplication of the trachea is an extremely rare condition that has been infrequently reported in the medical literature. We report an adult case with complete tracheal duplication associated with unilateral atelectasis, which was incidentally detected by computed tomography. Tracheal duplication should be considered as a possible cause of severe atelectasis in adults.

New technique for endobronchial ultrasound-guided transbronchial needle aspiration to improve diagnostic yield.

BACKGROUND: Although the pooled sensitivity of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) using a convex scanning ultrasound bronchoscope is equivalent to the gold standard of mediastinoscopy, diagnosis cannot be obtained in a small number of patients with poor cellularity. The method described was investigated with the aim of avoiding puncturing the cartilage and enabling reliable tissue harvesting, as this can be expected to improve diagnostic yield. METHODS: Outer sheath method (OSM): While pressing the outer sheath (OS) of the puncture needle gently against the bronchial wall, the hyperechoic line appeared on surface of the bronchial wall on EBUS image. Then pulling and pushing the entire bronchoscope, the tip of OS moved to the epithelium above the bronchial cartilage while detecting the best position for puncturing on the EBUS images simultaneously. The bronchoscopist could visualize the cartilage moving longitudinally on EBUS image. The movement of the cartilage was stopped when the tip of the OS was caught in a concavity between 2 rings of cartilage. Group A consisted of 169 patients who underwent EBUS-TBNA before the introduction of OSM, and group B consisted of 169 patients who underwent EBUS-TBNA after the introduction of OSM. These 2 groups were compared with to investigate the usefulness of OSM. RESULTS: Adding this operation enabled a suitable puncture site to be identified, significantly improving diagnostic yield from 92.7% (group A) to 98.2% (group B). CONCLUSIONS: This method was regarded as useful for improving diagnostic yield by enabling the selection of a puncture site between rings of cartilage during EBUS-TBNA.

Airway measurements in tracheobronchial stenosis using endobronchial ultrasonography during stenting.

PURPOSE: To assess airway measurements, endobronchial ultrasonography (EBUS) and multidetector, row computed tomography (MDCT) images were compared in patients with tracheal stenosis. METHODS: Airway stenting was performed on 31 patients, 25 malignant and 6 benign. EBUS and MDCT images were compared before intervention to assess the degree of airway narrowing at 212 sites. Of these, 130 sites were considered normal and 82 abnormal. For malignant stenosis, airway measurements were taken at 160 sites including 112 normal and 48 abnormal. For benign stenosis, airway measurements were taken at 52 sites including 18 normal and 34 abnormal. This technique enables the EBUS probe to measure the distal end to the proximal end of the stenosis whereby the inflated balloon size changes according to the degree of stenosis. RESULTS: The diameter and length of the stenotic sites measured by EBUS and MDCT were nearly equal in all patients. Significant correlation was seen at all 212 sites (r=0.805, P<0.0001), 130 normal (r=0.758, P<0.0001) and 82 abnormal (r=0.654, P<0.0001). For malignant cases, there was significant correlation in a total of 160 sites (r=0.810, P<0.0001), 112 normal (r=0.782, P<0.0001) and 48 abnormal (r=0.564, P<0.0001). Benign cases showed significant correlations in total 52 sites (r=0.780, P<0.0001), 18 normal (r=0.778, P<0.0001) and 34 abnormal (r=0.731, P<0.0001). CONCLUSION: This EBUS technique was successful in establishing accurate airway measurements for suitable airway stent sizes in interventional procedures, especially in cases with tracheobronchial malacia.

Novel use of a disposable curved stent insertion plastic device for silicone stent placement in patients with limited neck extension.

As granulation tissue formation frequently complicates the insertion of metallic tracheobronchial stents in patients with longer life expectancy, the inert silicone tracheobronchial stent remains the treatment of choice for inoperable benign tracheal stenosis. Similarly, the Y silicone stent insertion also plays an important role for refractory malignant stenoses involving the carina and tracheobronchial junction. The classic insertion method of a straight or Y silicone stent requires rigid bronchoscopy under general anesthesia with a hyperextended neck. This is not an option for patients with limited neck extension. We report a novel method of silicone stent insertion using a disposable curved stent insertion plastic device to solve the problem in 2 patients. The new device may have a role in managing patients with central airway obstruction but limited neck extension. As a valuable alternative to conventional rigid bronchoscope, it also adds to the ease of the silicone stent placement.

[Outpatient chemotherapy and clinical pathway for non-small cell lung cancer].

We investigated the usefulness of outpatient chemotherapy in 54 cases of non-small cell lung cancer in which outpatient chemotherapy was performed between August 1999 and October 2001. This chemotherapy accounted for 67% of all chemotherapy. Assessment of therapeutic effect revealed a PR in 14 of the 54 cases, and the efficacy rate was 26%. Therapeutic effect according to chemotherapy regimen revealed the highest efficacy rate, 50%, for paclitaxel + CBDCA. The median survival time was 14.7 months, and the 1-year survival rate was 61.1%. On the basis of the above results, a 16-day inpatient clinical pathway using weekly paclitaxel + CBDCA was devised for non-small cell lung cancer. The aim was to shorten the number of inpatient days, standardize treatment, and introduce outpatient chemotherapy. The clinical pathway was introduced in 8 patients with recurrent non-small cell lung cancer between August and October 2002. Variance was found only in one patient whose hospital discharge had to be postponed by two days because of a Grade 3 side effect. Introduction of a clinical pathway with weekly paclitaxel + CBDCA successfully reduced the inpatient days to an average of 16.3 days.