Therapeutic Rigid Bronchoscopy Intervention for Malignant Central Airway Obstruction Improves Performance Status to Allow Systemic Treatment.

BACKGROUND: Malignant central airway obstruction may result in an Eastern Cooperative Oncology Group Performance Status (ECOG PS) that precludes treatment with systemic therapies. We sought to evaluate outcomes of patients undergoing rigid bronchoscopy for malignant central airways obstruction (MCAO) and its effect on access to systemic therapies including immunotherapy. PATIENTS AND METHODS: We conducted a retrospective observational single-center study evaluating 77 consecutive patients who underwent rigid bronchoscopy from March 2015 to November 2019. Procedural details, preprocedural and postprocedural ECOG PS, complications, and proportions of patients receiving systemic therapy postprocedure were recorded. RESULTS: The majority of patients were ECOG PS 2 to 3 at diagnosis (62%). The most common indication was MCAO due to squamous cell carcinoma (35.1%). MCAO was managed with a debulking/dilatation procedure alone (51.9%) or in combination with stenting (48.1%). The laser was unavailable, electrocautery was used for hemostasis only not tumor ablation. Significant improvement in ECOG PS postprocedure in the group with baseline ECOG PS 3 to 4 (P<0.0001) and in those with baseline ECOG PS 0 to 4 (P<0.00001) was observed. The main complication was bleeding, controlled bronchoscopically with mechanical compression with a rigid bronchoscope and/or electrocautery (68.8% of patients). No deaths occurred. Overall, 70% of those presenting with ECOG 3 to 4 went onto receive systemic therapies that would have been contraindicated due to poor baseline ECOG PS. CONCLUSION: Therapeutic rigid bronchoscopy is safe and efficacious in the management of MCAO, improving ECOG PS allowing for the administration of systemic therapies. This is especially important in the era of immunotherapy and directed therapies, which have been shown to provide significant survival benefit over conventional therapies alone.

A new instrument to assess physician skill at chest tube insertion: the TUBE-iCOMPT.

Currently no tool exists to assess proceduralist skill at chest tube insertion. As inadequate doctor procedural competence has repeatedly been associated with adverse events, there is a need for a tool to assess procedural competence. This study aims to develop and examine the validity of a tool to assess competency at insertion of a chest tube, using either the Seldinger technique or blunt dissection. A 5-domain 100-point assessment tool was developed inline with British Thoracic Society guidelines and international consensus­the Chest Tube Insertion Competency Test (TUBE-iCOMPT). The instrument was used to assess chest tube insertion in mannequins and live patients. 29 participants (9 novices, 14 intermediate and 6 advanced) were tested by 2 blinded expert examiners on 2 occasions. The tool's validity was examined by demonstrating: (1) stratification of participants according to expected level of expertise (analysis of variance), and (2) test-retest and intertester reliability (intraclass correlation coefficient). The intraclass correlation coefficient of repeated scores for the Seldinger technique and blunt dissection, were 0.92 and 0.91, respectively, for test-retest results, and 0.98 and 0.95, respectively, for intertester results. Clear stratification of scores according to participant experience was seen (p<0.0001). There was no significant difference between scores obtained using mannequins or live patients. This study has validated the TUBE-iCOMPT, which could now be incorporated into chest tube insertion training programmes, providing a way to document acquisition of skill, guide individualised teaching, and assist with the assessment of the adequacy of clinician training.

Novel use of pleural ultrasound can identify malignant entrapped lung prior to effusion drainage.

BACKGROUND: The presence of entrapped lung changes the appropriate management of malignant pleural effusion from pleurodesis to insertion of an indwelling pleural catheter. No methods currently exist to identify entrapped lung prior to effusion drainage. Our objectives were to develop a method to identify entrapped lung using tissue movement and deformation (strain) analysis with ultrasonography and compare it to the existing technique of pleural elastance (PEL). METHODS: Prior to drainage, 81 patients with suspected malignant pleural effusion underwent thoracic ultrasound using an echocardiogram machine. Images of the atelectatic lower lobe were acquired during breath hold, allowing motion and strain related to the cardiac impulse to be analyzed using motion mode (M mode) and speckle-tracking imaging, respectively. PEL was measured during effusion drainage. The gold-standard diagnosis of entrapped lung was the consensus opinion of two interventional pulmonologists according to postdrainage imaging. Participants were randomly divided into development and validation sets. RESULTS: Both total movement and strain were significantly reduced in entrapped lung. Using data from the development set, the area under the receiver-operating curves for the diagnosis of entrapped lung was 0.86 (speckle tracking), 0.79 (M mode), and 0.69 (PEL). Using respective cutoffs of 6%, 1 mm, and 19 cm H2O on the validation set, the sensitivity/specificity was 71%/85% (speckle tracking), 50%/85% (M mode), and 40%/100% (PEL). CONCLUSIONS: This novel ultrasound technique can identify entrapped lung prior to effusion drainage, which could allow appropriate choice of definitive management (pleurodesis vs indwelling catheter), reducing the number of interventions required to treat malignant pleural effusion.

Can ICU stay be predicted accurately enough for fast-tracking cardiac surgical patients?

OBJECTIVES: To improve the precision of currently available models for predicting length of stay of individual patients in the intensive care unit, to assist in directing patients into fast-track management after coronary artery bypass graft (CABG) surgery. SETTING: ICU in an Australian teaching hospital. DESIGN AND PARTICIPANTS: Prospectively collected data from 333 patients who underwent elective CABG surgery were analysed by univariate and multivariate regression, to develop models of increasing power through the addition of factors covering the operative and early ICU phases (1, 4 and 8 hours postoperatively) to traditional preoperative risk of patient care. The model that gave the best combination of precision and availability for clinical decision-making was then validated on a series of 117 patients who underwent CABG surgery. Overall competence of this model was assessed. RESULTS: Addition of intraoperative factors to the first (preoperative only) model (R2 = 0.07) doubled the precision of the analysis (R2 = 0.18). Addition of factors derived from the first 4 hours of ICU management increased precision fivefold (R2 = 0.38). This model was satisfactorily validated: regression of actual versus predicted ICU stay from the validation set gave a slope of 0.85 and y intercept of 2.60 hours. The 95% confidence levels of individual predictions obtained from the development set, for an estimated ICU stay of 12 hours, spanned 43 hours. CONCLUSIONS: Although the optimal model greatly increases precision, it is still inadequate for scheduling fasttrack patients, where wrong predictions for individuals can cause major problems in resource allocation.