The "Hitch-Stitch" for Preventing High Tracheal Stent Migration: Expanding Indications and Extended Experience.

BACKGROUND: Airway stenting is a standard treatment option for tracheo-bronchial obstruction and other conditions like tracheo-esophageal fistula (TEF). METHODS: To prevent stent migration, a percutaneous fixation strategy called the "hitch-stitch" was described in 2016 as an efficient technique. We describe an extended experience of the "hitch-stitch" for silicone stents in high tracheal stenting situations and expanding indications to metal stents. RESULTS: Seventy-four percutaneous stitches were placed in 54 patients (36 males and 18 females). The mean age of the patients was 42 (±19) years. The indication for stenting was tracheal stenosis in 63/74 (85%) cases and TEF in 11/74 (15%) cases. Silicone stents were used in 56/74 (75.5%) cases while self-expanding metal stents (SEMS) were used in 18/74 (24.5%) cases. The majority of the stents (62/74, 85%) were high tracheal stents. The "hitch-stitch" as an anti-migration strategy had a high success rate, with distal stent migration in only 2 cases (2.7%) as the stitch had given way-these were repositioned and hitched with double stitches. Minor complications included delayed skin healing (2.8%) and suture site infection (1.4%), which was successfully managed with oral antibiotics. Stitch removal was easy with no complications. CONCLUSION: In this large series of percutaneous "hitch-stitch" as a stent migration prevention strategy, long-term data shows it is safe and effective in an expanded cohort of silicone stents. Its extended utility is the successful application to metal stents, especially in TEF, where the consequences can be deleterious. It is simple to do, with minimal extra requirements and not associated with any significant complications.

A customized multimodality approach for prolonged air leaks (PAL) in mechanically ventilated patients.

ARDS in general and severe COVID ARDS (CARDS) is particularly associated with high rates of barotrauma. Two cases with severe CARDS developed bilateral pneumothorax with persistent air leak (PAL). Conservative management with prolonged chest tube drainage did not help in PAL resolution and both patients continued to be on high-end ventilatory support. The course was further complicated by the presence of septic shock. The 1st patient was taken up for a challenging procedure after spending 23 days on the mechanical ventilator. Diagnostic pleuroscopy revealed left-sided bullae and a surgical staple bullectomy was done. The right side showed a large bronchopleural fistula (BPF) on pleuroscopy, which was occluded using a customized endobronchial silicone blocker (CESB, described in 2018). This led to the reduction and finally, resolution of the bilateral PAL with subsequent removal of chest drains and weaning off the ventilator and oxygen. The second patient was managed with 2 CESB devices for occlusion of RUL anterior and posterior segment fistulae, followed by chest drain removal. These cases highlight effective out-of-the-box multimodality treatment using a combination of interventional pulmonary techniques and surgical stapling for a life-threatening bilateral PAL secondary to CARDS.

Lower respiratory tract sampling in COVID-19 acute respiratory distress syndrome: A focus on microbiology, cellular morphology, cytology, and management impact.

Background: Lower respiratory tract (LRT) sampling through bronchoscopy has been done sparingly in COVID-19 acute respiratory distress syndrome (ARDS) due to the high aerosol risk for the health-care workers (HCWs). Valuable information can be gained by a detailed evaluation of bronchoscopic LRT samples. Methods: LRT samples were obtained by bedside bronchoscopy severe COVID-19 ARDS patients on mechanical ventilation. Microbiological, cellular, and cytological studies including LRT COVID-19 reverse transcription-polymerase chain reaction were analyzed. Results: A total of 100 samples were collected from 63 patients, 53 were males (84%). Forty-three patients (68%) had at least 1 comorbidity. 55% of cases had a secondary bacterial infection, commonly with multidrug-resistant organisms (94.5%). The most common organisms were Klebsiella pneumoniae and Acinetobacter baumannii in 56.3% and 14.5% of cases, respectively. Fungal superinfection was observed in 9 patients (14.3%). Bronchoscopy helped confirm COVID-19 diagnosis in 1 patient and helped rule out COVID-19 in 3 patients. The median bronchoalveolar lavage fluid (BALF) white blood cell (WBC) count was 953 (inter quartile range; 400-2717), with mean neutrophil count 85.2% (±13.9) and mean lymphocyte count 14.8% (±13.9). Repeat sampling done in some patients showed a progressive increase in the total WBC count in BALF, an increase in neutrophil percentage, and a higher chance of isolating an organism on the culture. Rate of superinfection increased with a longer duration of illness. Bronchoscopic LRT sampling contributed significantly to modifying antibiotic coverage and discontinuing steroids in 37% of cases. Conclusions: Our study provides a detailed analysis of bronchoscopic LRT sampling in critically ill COVID-19 patients, augmenting disease understanding and contributing to clinical management.

A shorter symptom onset to remdesivir treatment (SORT) interval is associated with a lower mortality in moderate-to-severe COVID-19: A real-world analysis.

OBJECTIVES: Remdesivir is the current recommended anti-viral treatment in moderate-to-severe COVID-19. However, data on impact of timing of therapy, efficacy, and safety are limited. We evaluated the impact of timing of remdesivir initiation (symptom onset to remdesivir treatment [SORT] interval) on in-hospital all-cause mortality in patients with moderate-to-severe COVID-19. METHODS: This retrospective study was conducted between June 25 and October 3, 2020, at a tertiary care dedicated COVID center in India. Patients with moderate-to-severe COVID-19 (moderate: SpO2 <94%; severe: SpO2 <90%) were included. The main outcome was impact of SORT interval on in-hospital all-cause mortality. Subgroups were formed and analyzed based on SORT interval. RESULTS: Of 350 patients treated with remdesivir, 346 were included in the final analysis. Overall, 76 (22.0%) patients died (moderate: 3 [2.8%], severe: 73 [30.8%]). All-cause mortality was significantly lower in patients with SORT interval ≤9 days (n = 260) vs SORT interval >9 days (n = 86; 18.1% vs 33.7%; p = 0.004). The odds of death were significantly lower in patients with SORT interval ≤9 days vs >9 days (odds ratio = 0.43; 95% CI, 0.25-0.75; p = 0.003). CONCLUSION: Remdesivir initiation ≤9 days from symptom onset was associated with mortality benefit, defining a treatment window and reinforcing the need for appropriately-timed remdesivir in moderate-to-severe COVID-19.

Use of an Extended Working Channel in High-Risk Transbronchial Biopsy: An Innovative Use of an Existing Modality to Minimize Bleeding and Hypoxia.

OBJECTIVE: Bleeding is one of the main complications of transbronchial lung biopsy (TBBx) more so with conditions such as azotaemia and coagulopathy. Baseline hypoxia worsens the consequences of TBBx bleeding and can lead to escalation of care. In our experience, TBBx performed through a guide sheath (GS) using it as an extended working channel (EWC) helps minimize bleeding risk. We hypothesized that the EWC produces a tamponade effect in the close vicinity of the biopsy site, both reducing bleeding risk and restricting bleeding to a smaller segment. In this study, we assessed the impact of an additional EWC in high-risk (HR) patients undergoing TBBx, to reduce bleeding and enhance safety. METHODS: Retrospective study between January 2014 and December 2018 looking at the risk of bleeding following TBBx performed through a GS (EWC) in patients at high risk for bleeding-related complications. Bleeding incidence and consequent hypoxic events requiring escalation of care were noted. The specimen diagnostic yield was also analyzed. SPSS statistics were used-data are reported as mean and standard deviation for continuous variables, and number and percentage for discrete variables. RESULTS: Eight hundred four TBBxs were performed during the study period, and 105 (13.1%) procedures were done in the HR individuals using a GS as an EWC. No significant bleeding requiring escalation of care was seen with the use of EWC-GS. Histopathology revealed adequate sampling in all cases. CONCLUSIONS: A GS as an EWC was used to reduce the bleeding risk, consequent hypoxia, and prevent escalation of care in TBBx in HR patients. Adequate tissue was obtained without any complications. Though prospective, randomized, multicenter trials using an EWC in HR-TBBx are important, they are challenging to do due to the HR population under study.

A Randomized Controlled Trial of Noninvasive Ventilation with Pressure Support Ventilation and Adaptive Support Ventilation in Acute Exacerbation of COPD: A Feasibility Study.

Whether the use of adaptive support ventilation (ASV) during noninvasive ventilation (NIV) is as effective as pressure support ventilation (PSV) remains unknown. In this exploratory study, we compared the delivery of NIV with PSV vs. ASV. We randomized consecutive subjects with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) to receive NIV either with the PSV or the ASV mode. The primary outcome was NIV failure (endotracheal intubation, re-institution of NIV within 48 h of discontinuation or mortality). The secondary outcomes were the duration of mechanical ventilation (invasive and noninvasive), the number of NIV manipulations, the visual analogue score (VAS) for physician's ease of use and patient's comfort, and the complications of NIV use. We enrolled 74 subjects (n = 38, PSV; n = 36, ASV; 78.4% males) with a mean (SD) age of 60.5 (9.5) years. The baseline characteristics were similar between the two groups. The overall NIV failure rate was 28.4% and was similar between the two groups (PSV vs. ASV: 34.2% vs. 22.2%, p = 0.31). There was a 9% reduction in the intubation rate with ASV. There were six deaths (PSV vs. ASV: 2 vs 4, p =0.311). There was no difference in the secondary outcomes. The application of NIV using ASV was associated with a similar success rate as PSV in subjects with AECOPD. Due to the small sample size, the results of our study should be confirmed in a larger trial. Trial registry: ww.clinicaltrials.gov (NCT02877524).

Joint Indian Chest Society-National College of Chest Physicians (India) guidelines for spirometry.

Although a simple and useful pulmonary function test, spirometry remains underutilized in India. The Indian Chest Society and National College of Chest Physicians (India) jointly supported an expert group to provide recommendations for spirometry in India. Based on a scientific grading of available published evidence, as well as other international recommendations, we propose a consensus statement for planning, performing and interpreting spirometry in a systematic manner across all levels of healthcare in India. We stress the use of standard equipment, and the need for quality control, to optimize testing. Important technical requirements for patient selection, and proper conduct of the vital capacity maneuver, are outlined. A brief algorithm to interpret and report spirometric data using minimal and most important variables is presented. The use of statistically valid lower limits of normality during interpretation is emphasized, and a listing of Indian reference equations is provided for this purpose. Other important issues such as peak expiratory flow, bronchodilator reversibility testing, and technician training are also discussed. We hope that this document will improve use of spirometry in a standardized fashion across diverse settings in India.