Spray Cryotherapy for Benign Large Airway Stenosis: A Multicenter Retrospective Cohort Study of Safety and Practice Patterns.

BACKGROUND: Benign airway stenosis (BAS) represents a significant burden on patients, providers, and healthcare systems. Spray cryotherapy (SCT) has been proposed as an adjunctive treatment to reduce BAS recurrence. We sought to examine safety and practice variations of the latest SCT system when used for BAS. METHODS: We conducted a retrospective multicenter cohort study in seven academic institutions within the Interventional Pulmonary Outcomes Group. All patients who underwent at least one SCT session with a diagnosis of BAS at the time of procedure at these institutions were included. Demographics, procedure characteristics, and adverse events were captured through each center's procedural database and electronic health record. RESULTS: A total of 102 patients underwent 165 procedures involving SCT from 2013 to 2022. The most frequent etiology of BAS was iatrogenic (n = 36, 35%). In most cases, SCT was used prior to other standard BAS interventions (n = 125; 75%). The most frequent SCT actuation time per cycle was five seconds. Pneumothorax complicated four procedures, requiring tube thoracostomy in two. Significant post-SCT hypoxemia was noted in one case, with recovery by case conclusion and no long-term effects. There were no instances of air embolism, hemodynamic compromise, or procedural or in-hospital mortality. CONCLUSION: SCT as an adjunctive treatment for BAS was associated with a low rate of complications in this retrospective multicenter cohort study. SCT-related procedural aspects varied widely in examined cases, including actuation duration, number of actuations, and timing of actuations relative to other interventions.

Diagnostic outcomes of robotic-assisted bronchoscopy for pulmonary lesions in a real-world multicenter community setting.

BACKGROUND: Robot-assisted bronchoscopy (RAB) is among the newest bronchoscopic technologies, allowing improved visualization and access for small and hard-to-reach nodules. RAB studies have primarily been conducted at academic centers, limiting the generalizability of results to the broader real-world setting, while variability in diagnostic yield definitions has impaired the validity of cross-study comparisons. The objective of this study was to determine the diagnostic yield and sensitivity for malignancy of RAB in patients with pulmonary lesions in a community setting and explore the impact of different definitions on diagnostic yield estimates. METHODS: Data were collected retrospectively from medical records of patients ≥ 21 years who underwent bronchoscopy with the Monarch® Platform (Auris Health, Inc., Redwood City, CA) for biopsy of pulmonary lesions at three US community hospitals between January 2019 and March 2020. Diagnostic yield was calculated at the index RAB and using 12-month follow-up data. At index, all malignant and benign (specific and non-specific) diagnoses were considered diagnostic. After 12 months, benign non-specific cases were considered diagnostic only when follow-up data corroborated the benign result. An alternative definition at index classified benign non-specific results as non-diagnostic, while an alternative 12-month definition categorized index non-diagnostic cases as diagnostic if no malignancy was diagnosed during follow-up. RESULTS: The study included 264 patients. Median lesion size was 19.3 mm, 58.9% were peripherally located, and 30.1% had a bronchus sign. Samples were obtained via Monarch in 99.6% of patients. Pathology led to a malignant diagnosis in 115 patients (43.6%), a benign diagnosis in 110 (41.7%), and 39 (14.8%) non-diagnostic cases. Index diagnostic yield was 85.2% (95% CI: [80.9%, 89.5%]) and the 12-month diagnostic yield was 79.4% (95% CI: [74.4%, 84.3%]). Alternative definitions resulted in diagnostic yield estimates of 58.7% (95% CI: [52.8%, 64.7%]) at index and 89.0% (95% CI: [85.1%, 92.8%]) at 12 months. Sensitivity for malignancy was 79.3% (95% CI: [72.7%, 85.9%]) and cancer prevalence was 58.0% after 12 months. CONCLUSIONS: RAB demonstrated a high diagnostic yield in the largest study to date, despite representing a real-world community population with a relatively low prevalence of cancer. Alternative definitions had a considerable impact on diagnostic yield estimates.

Bronchoscopy in Patients With Known or Suspected COVID-19: Results From the Global Pandemic SARS-CoV-2 Bronchoscopy Database (GPS-BD).

BACKGROUND: Amid the Coronavirus Disease 2019 (COVID-19) pandemic, the benefits and risks of bronchoscopy remain uncertain. This study was designed to characterize bronchoscopy-related practice patterns, diagnostic yields, and adverse events involving patients with known or suspected COVID-19. METHODS: An online survey tool retrospectively queried bronchoscopists about their experiences with patients with known or suspected COVID-19 between March 20 and August 20, 2020. Collected data comprised the Global Pandemic SARS-CoV-2 Bronchoscopy Database (GPS-BD). All bronchoscopists and patients were anonymous with no direct investigator-to-respondent contact. RESULTS: Bronchoscopy procedures involving 289 patients from 26 countries were analyzed. One-half of patients had known COVID-19. Most (82%) had at least 1 pre-existing comorbidity, 80% had at least 1 organ failure, 51% were critically ill, and 37% were intubated at the time of the procedure. Bronchoscopy was performed with diagnostic intent in 166 (57%) patients, yielding a diagnosis in 86 (52%). and management changes in 80 (48%). Bronchoscopy was performed with therapeutic intent in 71 (25%) patients, mostly for secretion clearance (87%). Complications attributed to bronchoscopy or significant clinical decline within 12 hours of the procedure occurred in 24 (8%) cases, with 1 death. CONCLUSION: Results from this international database provide a widely generalizable characterization of the benefits and risks of bronchoscopy in patients with known or suspected COVID-19. Bronchoscopy in this setting has reasonable clinical benefit, with diagnosis and/or management change resulting from about half of the diagnostic cases. However, it is not without risk, especially in patients with limited physiological reserve.

Robot-assisted bronchoscopy for pulmonary lesion diagnosis: results from the initial multicenter experience.

BACKGROUND: The Robotic Endoscopic System (Auris Health, Inc., Redwood City, CA) has the potential to overcome several limitations of contemporary guided-bronchoscopic technologies for the diagnosis of lung lesions. Our objective is to report on the initial post-marketing feasibility, safety and diagnostic yield of this technology. METHODS: We retrospectively reviewed data on consecutive cases in which robot-assisted bronchoscopy was used to sample lung lesions at four centers in the US (academic and community) from June 15th, 2018 to December 15th, 2018. RESULTS: One hundred and sixty-seven lesions in 165 patients were included in the analysis, with an average follow-up of 185 ± 55 days. The average size of target lesions was 25.0 ± 15.0 mm. Seventy-one percent were located in the peripheral third of the lung. Pneumothorax and airway bleeding occurred in 3.6 and 2.4% cases, respectively. Navigation was successful in 88.6% of cases. Tissue samples were successfully obtained in 98.8%. The diagnostic yield estimates ranged from 69.1 to 77% assuming the cases of biopsy-proven inflammation without any follow-up information (N = 13) were non-diagnostic and diagnostic, respectively. The yield was 81.5, 71.7 and 26.9% for concentric, eccentric and absent r-EBUS views, respectively. Diagnostic yield was not affected by lesion size, density, lobar location or centrality. CONCLUSIONS: RAB implementation in community and academic centers is safe and feasible, with an initial diagnostic yield of 69.1-77% in patients with lung lesions that require diagnostic bronchoscopy. Comparative trials with the existing bronchoscopic technologies are needed to determine cost-effectiveness of this technology.

Mucosa-associated lymphoid tissue lymphoma of the trachea.

Primary malignant lymphoma of the trachea is rare. We report a case of a 60-year-old woman with a mucosa-associated lymphoid tissue lymphoma of the trachea and review the existing literature. This case highlights the importance of including intraluminal lesions in the differential diagnosis when a variable degree of obstruction is seen on pulmonary function testing.

Pseudallescheria Boydii pneumonia in an immunocompetent host.

BACKGROUND: Pseudallescheria boydii pneumonia is rarely reported among immunocompetent patients. CASE REPORT: We report a case of a 62 year old white female with pseudallescheria boydii pneumonia. The patient was non-immunocompromised, had a history of mycobacterium avium complex (MAC) infection prior to presentation. After successful response to initial antitubercular therapy, the patient developed recurrent symptoms and bibasilar nodular infiltrates. Second line therapy for MAC failed to improve symptomatology. Pseudallescheria boydii pneumonia was diagnosed from a bronchoscopic biopsy. Treatment with voriconazole resolved her symptomatology and radiological infiltrates. CONCLUSIONS: This case highlights the importance of a high index of suspicion for superimposed fungal infections in patients who are refractory to medical treatment of bacterial pneumonitis such as MAC. Further diagnostic interventions are encouraged when insufficient clinical improvement is observed. Prompt initiation of an antifungal regimen is warranted.

A near fatal case of invasive aspergillosis.

BACKGROUND: Invasive aspergillosis (IA) rarely presents with endobronchial nodules or pseudomembranes on bronchoscopy. We describe a case of invasive aspergillosis in a patient with systemic lupus erythematosus (SLE), in which a fungal etiology was suspected after visualization of scattered, white endobronchial nodules. CASE REPORT: A 36-year-old-female with history of SLE developed cardiorespiratory shock. Bronchoscopy indicated the presence of endobronchial lesions, and serologic studies were consistent with IA. Given high index of suspicion for fungal disease in an immunocompromised host, empiric antifungals were discontinued and voriconazole initiation resulted in a successful therapy. CONCLUSIONS: This case highlights the importance of a high index of suspicion for fungal diseases, especially among critically ill hosts with endobronchial lesions, who develop rapid cardio-respiratory impairment. Failure to recognize endobronchial patterns of fungal infection may lead to treatment delay and adverse clinical outcomes.

Bioavailability of fondaparinux to critically ill patients.

INTRODUCTION: Venous thromboembolism is a common problem in the intensive care unit (ICU). To decrease its incidence, prophylactic pharmacologic interventions are part of the ICU routine. However, common ICU conditions may impair the bioavailability of subcutaneously administered agents. The present study evaluates the bioavailability of prophylactic subcutaneous fondaparinux to critically ill patients. PURPOSE: The purpose of the study was to evaluate vasopressor effect on the bioavailability of subcutaneously administered fondaparinux. MATERIALS AND METHODS: A 2-center, prospective, observational study was performed. Forty patients were enrolled and divided into 2 groups depending on their vasopressor requirements. All subjects were critically ill patients admitted to a medical ICU for an anticipated stay of more than 72 hours. INTERVENTIONS: All patients received subcutaneous fondaparinux 2.5 mg/d, and serum anti-Xa factor was serially assessed during the first 100 hours of medical ICU stay. RESULTS: Therapeutic anti-factor Xa levels among patients receiving vasopressors were observed. In hemodynamically normal patients, subtherapeutic concentrations were detected during the first 48 hours of fondaparinux administration. CONCLUSIONS: Vasopressor therapy does not appear to affect fondaparinux bioavailability or to reduce anti-factor Xa levels. Subtherapeutic concentrations were detected during the first 48 hours of fondaparinux administration in hemodynamically stable patients. The clinical significance of reduced levels during the first 2 days of fondaparinux administration remains unknown.

Mucoid plugs in eosinophilic pneumonia.

A 47-year-old woman developed dyspnea, sputum production, and intermittent cough, which persisted for several months. She had received treatment for asthma without resolution of symptoms. Radiologic evidence of bilateral pulmonary infiltrates prompted a bronchoscopic examination, which showed extensive bronchial plugging. The material had a mucoid appearance. Bronchioalveolar lavage showed abundant eosinophils. Microscopy showed signs of eosinophilic pneumonia and detached allergic mucin. The patient received oral corticosteroids and aggressive bronchopulmonary toilette with resolution of symptoms.

Anticonvulsant hypersensitivity syndrome: is there a role for immunomodulation?

The anticonvulsant hypersensitivity syndrome (AHS) is an idiosyncratic immunologic reaction to certain anticonvulsant medications, in which internal organ involvement may lead to fatal multisystemic failure. This syndrome has been associated with the use of aromatic ring-containing agents such as phenytoin, carbamazepine, or phenobarbitone. Clinically, this condition presents with the classic triad of fever, rash, and lymphadenopathy. We review the existing literature on AHS pathogenesis and illustrate a case complicated by liver dysfunction where the use of N-acetylcysteine (N-AC) and intravenous immunoglobulin (IVIG) may have altered the course of the disease. The rationale of suggesting N-AC and IVIG for the treatment of this syndrome relies on the theoretical synergistic effects of the two agents. Although treatment for this syndrome remains controversial and relies heavily on anecdotal evidence, the progression of hepatic injury may be prevented by the addition of N-AC. The scavenging properties of N-AC may palliate and possibly prevent free radical-mediated liver damage. In addition, IVIG may effectively modulate the overreactive immune system in AHS. We discuss the possible role of using immunomodulating agents for the treatment of this syndrome and suggest that alternative regimens should be given special consideration especially in those critical clinical situations where supportive measures appear to be unsuccessful.

HIV-associated nemaline rod myopathy: role of intravenous immunoglobulin therapy in two persons with HIV/AIDS.

Nemaline rod myopathy is a rare disease associated with muscle weakness and the presence of rod-shaped structures in the muscle fibers. Various acquired conditions have been associated with slow progressing presentations during adulthood. Several cases have been diagnosed in adults with HIV infection. The use of intravenous immunoglobulin (IVIG) has not been previously described for the treatment of these patients. We report the cases of 2 patients with HIV-related nemaline rod myopathy who successfully responded to IVIG therapy.