NCCP-ICS joint consensus-based clinical practice guidelines on medical thoracoscopy.

ABSTRACT: Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.

Endobronchial ultrasound-guided intranodal forceps biopsy (EBUS-IFB) using 19G needle tract: First case series from India.

EBUS-TBNA is a well-established procedure for diagnosis of mediastinal lymphadenopathy replacing the need for mediastinoscopy. In certain diseases like lymphomas, the yield is reportedly 50%, sarcoidosis lymph nodes also give a yield of 80% with EBUS and at times, more material is needed for better characterization of malignancies. EBUS-intranodal forceps biopsy may be useful in these situations. In our series of seven cases, we describe a unique and safe technique of obtaining forceps biopsy from mediastinal lymph nodes under real-time endobronchial ultrasound guidance using a 19G EBUS-TBNA needle tract and thin biopsy forceps. Lymph node biopsy was able to give a conclusive diagnosis in 42% patients negative with TBNA, and was able to suggest a diagnosis in one case. No complications were seen. Thus, surgical biopsy can be avoided in nearly 50% of failed EBUS-FNAC cases.

A rare disease mimicking lung cancer.

We present an interesting case of a 34 year old gentleman with bilateral FDG avid lesions in the apex of the lung. He presented with a two month history of cough, fever and hemoptysis. A contrast enhanced CT scan showed a spiculated lesion in the right upper lobe. A CT guided biopsy was done which was suggestive of an inflammatory lesion. He was started empirically on anti tubercular therapy, but his symptoms did not subside. A PET CT scan was done, which showed the lesion to be FDG avid. A repeat biopsy was done and again it was reported as an inflammatory infiltrate. He was then referred to our center for a surgical biopsy. We repeated a PET scan and were surprised to find another lesion in the apex of the opposite lung. The case was discussed with our interventional pulmonogy team and an EBUS guided biopsy of the lesion was done. On microbiological analysis the specimen was found to be positive for Nocardia.

Multidrug resistance in tubercular mediastinal adenopathy diagnosed by endobronchial ultrasound-transbronchial needle aspiration.

BACKGROUND: Drug resistance in tuberculosis (TB) is a major public health problem. It is easy to assess for drug resistance in pulmonary samples, but the resistance pattern of TB in the mediastinal nodes has not been studied. The aim of this study is to assess the incidence of multidrug resistance in tubercular mediastinal adenopathy with the help of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration. MATERIALS AND METHODS: This was a prospective study at a tertiary care teaching hospital in New Delhi where 102 patients with positive mycobacterial cultures from mediastinal lymph node aspirates taken with the help of EBUS were enrolled over 24 months and their drug sensitivity to the first-line antitubercular drugs analyzed. RESULTS: There were 30 cases of drug resistance of 102 culture-positive cases. Of them, 8 patients had multidrug resistant TB (MDR-TB), 16 cases had only single drug resistance, and the remaining 6 cases had more than one drug resistance pattern but not MDR. In our study, the overall incidence of MDR-TB is 7.8% (8/102), although the incidence of MDR-TB in new and re-treatment cases is 2.2% (2/89) and 46.1% (6/13), respectively. CONCLUSION: Such a high percentage of drug-resistant patients is common in tertiary care hospitals; however, similar percentages may be found in other settings as well. Therefore, all efforts should be made to take samples for Mycobacterium tuberculosis culture from the involved nodes before commencing therapy to avoid treatment failures.

Bronchial thermoplasty for severe asthma: A position statement of the Indian chest society.

Bronchial thermoplasty (BT) is an interventional bronchoscopic treatment for severe asthma. There is a need to define patient selection criteria to guide clinicians in offering the appropriate treatment options to patients with severe asthma. METHODOLOGY: An expert group formed this statement under the aegis of the Indian Chest Society. We performed a systematic search of the MEDLINE and EMBASE databases to extract evidence on patient selection and the technical performance of BT. RESULTS: The experts agreed that the appropriate selection of patients is crucial and proposed identification of the asthma phenotype, a screening algorithm, and inclusion/exclusion criteria for BT. In the presence of atypical clinical or chest radiograph features, there should be a low threshold for obtaining a thoracic computed tomography scan before BT. The patient should not have had an asthma exacerbation in the preceding two weeks from the day of the procedure. A 5-day course of glucocorticoid should be administered, beginning three days before the procedure day, and continued until the day following the procedure. General Anesthesia (total intravenous anesthesia with a neuromuscular blocker) provides ideal conditions for performing BT. A thin bronchoscope with a 2.0 mm working channel is preferable. An attempt should be made to deliver the maximum radiofrequency activations. Middle lobe treatment is not recommended. Following the procedure, overnight observation in the hospital, and a follow-up visit, a week following each treatment session, is desirable. CONCLUSION: This position statement provides practical guidance regarding patient selection and the technical performance of BT for severe asthma.

Bronchoscopic lung cryobiopsy: An Indian association for bronchology position statement.

BACKGROUND: Bronchoscopic lung cryobiopsy (BLC) is a novel technique for obtaining lung tissue for the diagnosis of diffuse parenchymal lung diseases. The procedure is performed using several different variations of technique, resulting in an inconsistent diagnostic yield and a variable risk of complications. There is an unmet need for standardization of the technical aspects of BLC. METHODOLOGY: This is a position statement framed by a group comprising experts from the fields of pulmonary medicine, thoracic surgery, pathology, and radiology under the aegis of the Indian Association for Bronchology. Sixteen questions on various technical aspects of BLC were framed. A literature search was conducted using PubMed and EMBASE databases. The expert group discussed the available evidence relevant to each question through e-mail and a face-to-face meeting, and arrived at a consensus. RESULTS: The experts agreed that patients should be carefully selected for BLC after weighing the risks and benefits of the procedure. Where appropriate, consideration should be given to perform alternate procedures such as conventional transbronchial biopsy or subject the patient directly to a surgical lung biopsy. The procedure is best performed after placement of an artificial airway under sedation/general anesthesia. Fluoroscopic guidance and occlusion balloon should be utilized for positioning the cryoprobe to reduce the risk of pneumothorax and bleeding, respectively. At least four tissue specimens (with at least two of adequate size, i.e., ≥5 mm) should be obtained during the procedure from different lobes or different segments of a lobe. The histopathological findings of BLC should be interpreted by an experienced pulmonary pathologist. The final diagnosis should be made after a multidisciplinary discussion. Finally, there is a need for structured training for performing BLC. CONCLUSION: This position statement is an attempt to provide practical recommendations for the performance of BLC in DPLDs.

Dealing with technical challenges in embolization of a rare aberrant left inferior bronchial artery arising from the left gastric artery in a patient with massive hemoptysis.

Bronchial artery embolization is an established intervention for management of recurrent massive hemoptysis in a majority of patients. The source of bleeding in a majority of cases is systemic arteries - orthotopic bronchial arteries, anomalous bronchial arteries, or nonbronchial systemic collaterals. We report a case of an aberrant left inferior bronchial artery arising from the left gastric artery (LGA) in a patient with massive hemoptysis. Such origin from infradiaphragmatic vessels and specially left gastric arteries is very rare and needs to be considered by interventional radiologists and pulmonologists in case with hemoptysis disproportionate to supply by orthotopic arteries. Technical challenges were present in the present case in the form of an aneurysm in the aberrant artery and nontarget hepatic and gastric branches arising from LGA. Appropriate selection of hardware and embolic agents was done to deal with the clinical situation.

Mediastinal Adenopathy in India: Through the Eyes of Endobranchial Ultrasound.

OBJECTIVE: Aetiology of mediastinal adenopathy is likely to vary with geographic location and socioeconomic status of a population. Whilst most of adenopathy in the West could be attributed to malignant disorders, causes of the same in a developing country like India has not been extensively studied earlier due to lack of less invasive tools to sample these nodes for cytological and microbiological analysis. Endobronchial ultrasound (EBUS) helps us reach these nodes as a minimally invasive procedure to take aspirations under real-time ultrasound guidance. The aim of the present study is to study the aetiology of mediastinal adenopathy in our population with the help of EBUS. METHODS: This was a retrospective analysis of all EBUS procedures done by the authors and the diagnosis thus obtained at Sir Ganga Ram Hospital, New Delhi, India between April 2010 and December 2011. RESULTS: A total of 300 patients underwent EBUS in the above period. Most common aetiology encountered in our population was a granulomatous disorder (53% cases) like tuberculosis and sarcoidosis whilst malignancy was third in order of diagnosis (17% cases). Lymph node enlargement due to anthracosis was another uncommon aetiology encountered in the study (5% cases). CONCLUSIONS: Benign granulomatous disorders like tuberculosis and sarcoidosis are the most common causes of mediastinal adenopathy in our population. EBUS is proving its worth for diagnosing mediastinal adenopathy.

Can cytomorphology of granulomas distinguish sarcoidosis from tuberculosis? Retrospective study of endobronchial ultrasound guided transbronchial needle aspirate of 49 granulomatous lymph nodes.

BACKGROUND: The differential diagnosis of tuberculosis (TB) and sarcoidosis on fine needle aspiration material is very challenging in tubercular endemic regions. We carried out a pilot study to explore cytomorphologic features of granulomas which could help in differentiation between sarcoidosis and TB. Final diagnoses in these patients were based on clinical, microbiologic and follow-up studies. MATERIALS AND METHODS: Endobronchial ultrasound guided transbronchial needle aspiration smears of 49 consecutive patients with a final cytologic diagnosis of granulomatous lymphadenitis were reviewed. Based on cytologic features two cytologic categories were enunciated and the results were correlated with microbiologic studies and/follow-up of minimum of 6 months. RESULTS: The cytologic categories did not correlate with the final clinical outcome of patients. CONCLUSIONS: Different patterns of granulomas observed in cytology smears do not help distinguish TB from sarcoidosis. The novel non-invasive techniques of mediastinal sampling though help in confirming granulomatous pathology, distinction between these entities and treatment decisions still depend upon correlating cytologic, microbiologic, clinical and radiological data in a large number of cases in tubercular endemic regions.

Hilar lymph node eroding into the pulmonary artery diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration.

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is a novel minimally invasive procedure useful for the evaluation and diagnosis of mediastinal lymph nodes and the lung parenchymal lesions. A 75-year-old woman diagnosed as a case of infiltrating duct adenocarcinoma of left breast 15 years back for which she underwent a modified radical mastectomy followed by radiotherapy and chemotherapy. The patient presented to us with haemoptysis. During EBUS, the enlarged left hilar lymph node was seen to be eroding into the left pulmonary artery leading to a filling defect in the left pulmonary artery. This filling defect was first sampled by EBUS-guided TBNA followed by sampling of left hilar lymph node. The results of cytomorphology revealed malignancy which was compatible with a metastasis from a carcinoma breast. EBUS-TBNA is a novel, safe and minimally invasive procedure with a few complications.

Ruptured pulmonary hydatid disease mimicking a lung mass: diagnosed by flexible video bronchoscopy.

Echinococcosis is frequently seen in an endemic country like India. The vast majority of infestations in humans are caused by Echinococcosis granulosus. The cyst is most commonly seen in the liver in about 74% of the cases, followed by pulmonary involvement in about 24% of cases. In our case report, a 25-year-old man presented with a mass-like lesion in the upper and middle lobe of the right lung. The patient had deteriorated clinically as the mass like opacity grew in size. Here, we have highlighted an uncommon presentation of hydatid disease of the lung diagnosed by video bronchoscopy and bronchoalveolar lavage (BAL) as clinico-radiological examination along with FNAC (fine-needle aspiration cytology) of the lesion proved insufficient tools to make a diagnosis.