Medical thoracoscopy for pleural diseases.

PURPOSE OF REVIEW: The purpose of this review is to elaborate on the role of medical thoracoscopy for various diagnostic and therapeutic parietal pleural interventions. The renewed interest in medical thoracoscopy has been boosted by the growth of the field of interventional pulmonology and, possibly, well tolerated and evolving anesthesia. RECENT FINDINGS: Medical thoracoscopy to obtain pleural biopsies is established largely as a safe and effective diagnostic procedure. Recent data suggest how a pragmatic biopsy-first approach in specific cancer scenarios may be patient-centered. The current scope of medical thoracoscopy for therapeutic interventions other than pleurodesis and indwelling pleural catheter (IPC) placement is limited. In this review, we discuss the available evidence for therapeutic indications and why we must tread with caution in certain scenarios. SUMMARY: This article reviews contemporary published data to highlight the best utility of medical thoracoscopy as a diagnostic procedure for undiagnosed exudative effusions or effusions suspected to be secondary to cancers or tuberculosis. The potentially therapeutic role of medical thoracoscopy in patients with pneumothorax or empyema warrants further research focusing on patient-centered outcomes and comparisons with video-assisted thoracoscopic surgery.

Breath Analysis for Lung Cancer Early Detection-A Clinical Study.

This clinical study presents a comprehensive investigation into the utility of breath analysis as a non-invasive method for the early detection of lung cancer. The study enrolled 14 lung cancer patients, 14 non-lung cancer controls with diverse medical conditions, and 3 tuberculosis (TB) patients for biomarker discovery. Matching criteria including age, gender, smoking history, and comorbidities were strictly followed to ensure reliable comparisons. A systematic breath sampling protocol utilizing a BIO-VOC sampler was employed, followed by VOC analysis using Thermal Desorption-Gas Chromatography-Mass Spectrometry (TD-GC/MS). The resulting VOC profiles were subjected to stringent statistical analysis, including Orthogonal Projections to Latent Structures-Discriminant Analysis (OPLS-DA), Kruskal-Wallis test, and Receiver Operating Characteristic (ROC) analysis. Notably, 13 VOCs exhibited statistically significant differences between lung cancer patients and controls. The combination of eight VOCs (hexanal, heptanal, octanal, benzaldehyde, undecane, phenylacetaldehyde, decanal, and benzoic acid) demonstrated substantial discriminatory power with an area under the curve (AUC) of 0.85, a sensitivity of 82%, and a specificity of 76% in the discovery set. Validation in an independent cohort yielded an AUC of 0.78, a sensitivity of 78%, and a specificity of 64%. Further analysis revealed that elevated aldehyde levels in lung cancer patients' breath could be attributed to overactivated Alcohol Dehydrogenase (ADH) pathways in cancerous tissues. Addressing methodological challenges, this study employed a matching of physiological and pathological confounders, controlled room air samples, and standardized breath sampling techniques. Despite the limitations, this study's findings emphasize the potential of breath analysis as a diagnostic tool for lung cancer and suggest its utility in differentiating tuberculosis from lung cancer. However, further research and validation are warranted for the translation of these findings into clinical practice.

Sublobar resection versus lobectomy for stage IA non-small-cell lung cancer ≤ 2 cm: a systematic review and patient-level meta-analysis.

Despite lobectomy being the standard of care for early-stage non-small-cell lung cancer (NSCLC), sublobar resection (segmentectomy or wedge resection) has recently been suggested to achieve similar outcomes. An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) or propensity score-matched studies (PSMs) comparing lobectomy to sublobar resection in stage IA NSCLC ≤ 2 cm in size, with provision of Kaplan-Meier curves for overall survival (OS) and disease-free survival (DFS). A graphical reconstructive algorithm was used to obtain OS and DFS of individual patients, which was then pooled under random-effects individual patient data meta-analysis using Cox models to determine hazard ratios (HRs). Sensitivity analyses for OS and DFS were also performed, restricting to results from RCTs only. Seven studies (2528 patients) were retrieved. There were no significant differences in OS (shared-frailty HR = 0.92, 95% CI = 0.77-1.11, p = 0.378) or DFS (shared-frailty HR = 1.06, 95% CI = 0.90-1.24, p = 0.476) between lobectomy and sublobar resection. This comparison remained non-significant even when restricted to RCTs only. Pooled Kaplan-Meier curves of OS appeared to diverge over time, in favor of sublobar resection. This was confirmed on analysis of restricted mean survival time curves. This patient-level meta-analysis of high-quality studies demonstrates that sublobar resection is equivalent to lobectomy in patients with small stage IA NSCLC. Sublobar resection offers greater down-the-road benefits in patients who experience recurrence or a second primary tumor since the lung-sparing index surgery allows patients to receive further treatment safely. This heralds sublobar resection as the new standard of care in carefully selected early-stage patients.Trial registration: PROSPERO CRD42023385358.

Comparing bronchial thermoplasty with biologicals for severe asthma: Systematic review and network meta-analysis.

BACKGROUND: Bronchial thermoplasty (BT) has shown favorable safety and efficacy in several randomized controlled trials (RCTs), but has not been directly compared to biological therapies. METHODS: Electronic literature searches were performed on PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials, to retrieve RCTs of BT or FDA-approved biologicals against controls in patients with severe asthma. Six outcomes were analyzed: Asthma Control Questionnaire (ACQ), Asthma Quality of Life Questionnaire (AQLQ), the number of patients experiencing ≥1 asthma exacerbation, annualized exacerbation rate ratio (AERR), oral corticosteroid dose reduction (OCDR), and morning peak expiratory flow rate (amPEF). Random-effects, Frequentist network meta-analysis (NMA) were performed, and therapies were ranked using P-scores. RESULTS: Twenty-nine RCTs (15,547 patients) were included. Fewer patients treated with BT experienced ≥1 asthma exacerbation (risk ratio [RR] = 0.66, 95%CI = 0.45-0.98) compared to control. AERR of BT versus control was non-significant, but significant improvements in ACQ score (mean difference [MD] -0.41, 95%CI -0.63 to -0.20), AQLQ score (MD = 0.54, 95%CI = 0.30-0.77), amPEF and OCDR were found. No significant differences between BT and biologics were seen across indirect comparisons of all studies. CONCLUSIONS: Despite the lack of head-to-head comparative trials, this NMA suggests that BT is non-inferior to biologicals in terms of quality-of-life scores, and represents a promising alternative for patients with severe asthma.

Which Endoscopic Procedure to Use and in What Patient? Valves, Coils, Foam, and Heat in COPD and Asthma.

Despite the latest developments in therapeutic agents targeting airway endotypes, a significant proportion of patients with asthma and chronic obstructive pulmonary disease (COPD) remain symptomatic. Endoscopic therapies have a complementary role in the management of these airway diseases. The sustained efficacy of bronchial thermoplasty (BT) among patients with asthma over 10 years has been encouraging, as it has been shown to improve symptom control and reduce hospital admissions and exacerbations. Studies suggest that BT helps ameliorate airway inflammation and reduce airway smooth muscle thickness. While studies suggest that it is as effective as biologic agents, its role in the management of severe asthma has yet to be clearly defined and GINA 2022 still suggests limiting its use to patients with characteristics of the various populations studied. Conversely, bronchoscopic lung volume reduction has shown promise among patients with advanced COPD. Rigorous patient selection is important. Patients with minimal collateral ventilation (CV) and higher heterogeneity index have shown to benefit the most from endobronchial valve (EBV) therapy. For those with ongoing CV, endobronchial coils would be more appropriate. Both therapeutic modalities have demonstrated improved quality of life, effort tolerance, and lung function indices among appropriately selected patients. The emerging evidence suggests that endoscopic procedures among airway disease still have a substantial role to play despite the development of new therapeutic options.

Lung cancer screening.

Randomised controlled trials, including the National Lung Screening Trial (NLST) and the NELSON trial, have shown reduced mortality with lung cancer screening with low-dose CT compared with chest radiography or no screening. Although research has provided clarity on key issues of lung cancer screening, uncertainty remains about aspects that might be critical to optimise clinical effectiveness and cost-effectiveness. This Review brings together current evidence on lung cancer screening, including an overview of clinical trials, considerations regarding the identification of individuals who benefit from lung cancer screening, management of screen-detected findings, smoking cessation interventions, cost-effectiveness, the role of artificial intelligence and biomarkers, and current challenges, solutions, and opportunities surrounding the implementation of lung cancer screening programmes from an international perspective. Further research into risk models for patient selection, personalised screening intervals, novel biomarkers, integrated cardiovascular disease and chronic obstructive pulmonary disease assessments, smoking cessation interventions, and artificial intelligence for lung nodule detection and risk stratification are key opportunities to increase the efficiency of lung cancer screening and ensure equity of access.

Machine Learning Assisted Real-Time Label-Free SERS Diagnoses of Malignant Pleural Effusion due to Lung Cancer.

More than half of all pleural effusions are due to malignancy of which lung cancer is the main cause. Pleural effusions can complicate the course of pneumonia, pulmonary tuberculosis, or underlying systemic disease. We explore the application of label-free surface-enhanced Raman spectroscopy (SERS) as a point of care (POC) diagnostic tool to identify if pleural effusions are due to lung cancer or to other causes (controls). Lung cancer samples showed specific SERS spectral signatures such as the position and intensity of the Raman band in different wave number region using a novel silver coated silicon nanopillar (SCSNP) as a SERS substrate. We report a classification accuracy of 85% along with a sensitivity and specificity of 87% and 83%, respectively, for the detection of lung cancer over control pleural fluid samples with a receiver operating characteristics (ROC) area under curve value of 0.93 using a PLS-DA binary classifier to distinguish between lung cancer over control subjects. We have also evaluated discriminative wavenumber bands responsible for the distinction between the two classes with the help of a variable importance in projection (VIP) score. We found that our label-free SERS platform was able to distinguish lung cancer from pleural effusions due to other causes (controls) with higher diagnostic accuracy.

Airway interventions for tracheobronchial involvement in esophageal carcinoma: a retrospective cohort outcome study and algorithmic approach.

Background: In advanced esophageal carcinoma (EC), there is limited data on risk factors predicting tracheobronchoesophageal fistula (TEF) formation and survival among patients who required airway interventions. Methods: A retrospective analysis of consecutive patients with EC, who had airway involvement requiring intervention, was conducted from 1998 to 2018. Demographics, clinical progress, disease stage, treatment and survival outcomes were recorded. Patients were followed up till death or until completion of the study. Survival was estimated with the Kaplan-Meier method and curves compared by log-rank test. Multivariate analyses of risk factors were performed using Cox proportional hazard regression. Results: A total of 122 patients were included. The median (IQR) survival from time of airway intervention was 3.30 (1.57-6.88) months, while the median (IQR) survival from time of histological diagnosis was 8.90 (4.91-14.45) months. Tumour location within 20 mm of the carina, prior radiotherapy and/or esophageal stenting were significantly associated with formation of TEF. Mid EC [adjusted hazard ratio (HR) 1.9; 95% confidence interval (CI): 1.1-3.2] or presence of TEF (adjusted HR 1.8; 95% CI: 1.0-3.2) were associated with lower survival. Patients receiving chemotherapy (adjusted HR 0.46; 95% CI: 0.25-0.84), or esophageal stenting whether before or after airway intervention (adjusted HR 0.32; 95% CI: 0.15-0.68 and adjusted HR 0.51; 95% CI: 0.29-0.90) were associated with increased survival. Conclusions: Factors associated with TEF formation include airway location, radiotherapy and prior esophageal stenting, and the development of TEF was associated with poorer survival. An algorithmic approach towards tracheobronchial involvement in EC is proposed based on these findings and a review of the literature.

Strategy for Safe Bronchoscopy During the COVID-19 Pandemic.

Aerosol-generating procedures are avoided for patients with coronavirus disease 2019 (COVID-19) to lower the risk of transmission to health care providers. However, when bronchoscopy is indicated, it remains unclear whether the procedure performed while the patient is under general anesthesia leads to contamination of the surroundings and whether standard endoscopy reprocessing methods are effective in eradicating severe acute respiratory syndrome coronavirus 2. This report describes a case of bronchoscopic retrieval of a foreign body in the airway of a patient under general anesthesia who tested positive for COVID-19. The report focuses on anesthesia techniques to minimize aerosolization.

Thoracoscopy for Spontaneous Pneumothorax.

Video-assisted thoracic surgery (VATS) is the treatment of choice for recurrence prevention in patients with spontaneous pneumothorax (SP). Although the optimal surgical technique is uncertain, bullous resection using staplers in combination with mechanical pleurodesis, chemical pleurodesis and/or staple line coverage is usually undertaken. Currently, patient satisfaction, postoperative pain and other perioperative parameters have significantly improved with advancements in thoracoscopic technology, which include uniportal, needlescopic and nonintubated VATS variants. Ipsilateral recurrences after VATS occur in less than 5% of patients, in which case a redo-VATS is a feasible therapeutical option. Randomized controlled trials are urgently needed to shed light on the best definitive management of SP.

Impact of structured curriculum with simulation on bronchoscopy.

BACKGROUND AND OBJECTIVE: Simulation enhances a physician's competency in procedural skills by accelerating ascent of the learning curve. Training programmes are moving away from the Halstedian model of 'see one, do one, teach one', also referred as medical apprenticeship. We aimed to determine if a 3-month structured bronchoscopy curriculum that incorporated simulator training could improve bronchoscopy competency among pulmonary medicine trainees. METHODS: We prospectively recruited trainees from hospitals with accredited pulmonary medicine programmes. Trainees from hospitals (A, B and C) were assigned to control group (CG) where they received training by traditional apprenticeship while trainees from hospital D were assigned to intervention group (IG) where they underwent 3-month structured curriculum that incorporated training with the bronchoscopy simulator. Two patient bronchoscopy procedures per trainee were recorded on video and scored independently by two expert bronchoscopists using the modified Bronchoscopy Skills and Tasks Assessment Tool (BSTAT) forms. A 25 multiple choice questions (MCQ) test was administered to all participants at the end of 3 months. RESULTS: Eighteen trainees participated; 10 in CG and eight in IG with equal female:male ratio. Competency assessed by modified BSTAT and MCQ tests was variable and not driven by volume as IG performed fewer patient bronchoscopies but demonstrated better BSTAT, airway anaesthesia and MCQ scores. Bronchoscopy simulator training was the only factor that correlated with better BSTAT (r = 0.80), MCQ (r = 0.85) and airway anaesthesia scores (r = 0.83), and accelerated the learning curve of IG trainees. CONCLUSION: An intensive 3-month structured bronchoscopy curriculum that incorporated simulator training led to improved cognitive and technical skill performance as compared with apprenticeship training.

Characteristics and Outcomes of Airway Involvement in Esophageal Cancer.

BACKGROUND: Airway involvement, such as airway invasion, compression, and tracheobronchoesophageal fistula (TEF), in esophageal cancer is associated with significant morbidity. However, the risk factors and outcomes of airway complications remain unclear, with limited evidence to guide management. METHODS: This retrospective analysis included 804 patients with a diagnosis of esophageal cancer from 1998 to 2018 at a tertiary care medical center (Singapore General Hospital, Singapore). Patients' demographics, treatment details, and airway involvement, as determined by bronchoscopic evaluation or computed tomographic imaging, were recorded and analyzed to determine risk factors and outcomes of airway involvement. RESULTS: The incidence of airway involvement and TEF was 36.6% and 13.1%, respectively. Airway involvement was associated with reduced survival from the time of diagnosis (hazard ratio, 1.52; 95% confidence interval [CI], 1.30 to 1.79) and increased hospitalizations per year (4.53 ± 4.80 vs 2.75 ± 3.68; P < .001). On multivariate analysis, midesophageal tumors (odds ratio [OR], 11.0; 95% CI, 6.3 to 19.0) and upper esophageal tumors (OR, 8.5; 95% CI, 4.7 to 15.6), previous treatment with esophageal stenting (OR, 17.8; 95% CI, 4.1 to 77.6), and chemotherapy or radiotherapy were associated with development of airway involvement. In patients with TEF, treatment with chemotherapy (OR, 0.34; 95% CI, 0.20 to 0.60) and combined airway and esophageal stenting (OR, 0.48; 95% CI, 0.25 to 0.91) were independently associated with improved survival. CONCLUSIONS: Airway involvement and TEF are common and are associated with increased morbidity and poorer survival. Clinicians should remain vigilant for airway complications after treatment with esophageal stenting, chemotherapy, or radiotherapy, especially in patients with midesophageal and upper esophageal cancers. In patients with TEFs, survival is improved when they are treated with airway stenting, esophageal stenting, or chemotherapy.

Intradiscal Pulsed Radiofrequency Application Duration Effect on Lumbar Discogenic Low Back Pain.

BACKGROUND: Discogenic pain is recognized as the most important and most common cause of low back pain (LBP). Intradiscal pulsed radiofrequency (ID-PRF) is used for the treatment of chronic discogenic pain. OBJECTIVES: We investigated the effects of the duration of percutaneous monopolar ID-PRF application on chronic discogenic LBP. STUDY DESIGN: Retrospective study. SETTING: Department of Anesthesiology and Pain Medicine, Neurosurgery at Wooridul Spine Hospital. METHODS: Forty-five patients were included in this retrospective study. The patients were assigned into 2 groups according to the duration of the PRF procedure they underwent (7-minute group = 17 patients vs. 15-minute group = 28 patients). The main outcome measures tested were pain score, as determined by the Numeric Rating Scale (NRS-11) and the Oswestry Disability Index (ODI), at baseline, at 2-week, and 6-month follow-up visits. Success was defined as a reduction in NRS-11 of 50% or more or an ODI reduction of 40% or more. RESULTS: The mean posttreatment pain scores at 2 weeks and 6 months were significantly lower (P < 0.05) in both groups, but the differences between the groups were not significant. ODI scores were also significantly lower compared with the baseline, but the differences between the groups were not significant. At the 6-month follow-up, 12 patients (70.6%) in the 7-minute group and 20 patients (71.4%) in the 15-minute group reported more than 50% reduction in the pain score (P = 0.16), and there was no significant difference between the 2 groups in the number of patients with more than 40% reduction in ODI score (P = 0.23). LIMITATIONS: This study was performed with a small sample size and there was no control group. Additional well-designed and well-controlled studies that include parameters such as the stimulation duration, mode, and intensity of PRF are needed to fully assess the efficiency of ID-PRF. CONCLUSIONS: ID-PRF was shown to be effective for the treatment of discogenic LBP regardless of duration of ID-PRF application (7 vs. 15 minutes).

Powered Air Purifying Respirator (PAPR) restores the N95 face mask induced cerebral hemodynamic alterations among Healthcare Workers during COVID-19 Outbreak.

BACKGROUND AND AIM: COVID-19 pandemic has resulted in an unprecedented increased usage of Personal protective equipment (PPE) by healthcare-workers. PPE usage causes headache in majority of users. We evaluated changes in cerebral hemodynamics among healthcare-workers using PPE. METHODS: Frontline healthcare-workers donning PPE at our tertiary center were included. Demographics, co-morbidities and blood-pressure were recorded. Transcranial Doppler (TCD) monitoring of middle cerebral artery was performed with 2-MHz probe. Mean flow velocity (MFV) and pulsatility index (PI) were recorded at baseline, after donning N95 respirator-mask, and after donning powered air-purifying respirator (PAPR), when indicated. End-tidal carbon-dioxide (ET-CO2) pressure was recorded for participants donning PAPR in addition to the N95 respirator-mask. RESULTS: A total of 154 healthcare-workers (mean age 29 ± 12 years, 67% women) were included. Migraine was the commonest co-morbidity in 38 (25%) individuals while 123 (80%) developed de-novo headache due to N95 mask. Donning of N95 respirator-mask resulted in significant increase in MFV (4.4 ± 10.4 cm/s, p < 0.001) and decrease in PI (0.13 ± 0.12; p < 0.001) while ET-CO2 increased by 3.1 ± 1.2 mmHg (p < 0.001). TCD monitoring in 24 (16%) participants donning PAPR and N95 respirator mask together showed normalization of PI, accompanied by normalization of ET-CO2 values within 5-min. Combined use of N95 respirator-mask and PAPR was more comfortable as compared to N95 respirator-mask alone. CONCLUSION: Use of N95 respirator-mask results in significant alterations in cerebral hemodynamics. However, these effects are mitigated by the use of additional PAPR. We recommend the use of PAPR together with the N95 mask for healthcare-workers doing longer duties in the hospital wards.

Bronchial thermoplasty: Redefining its role.

In this review, we trace (i) the origins of bronchial thermoplasty, (ii) the development of a solid evidence base for efficacy and safety, (iii) the emerging understanding of the pathophysiological mechanisms of action and (iv) the place in therapy today. Future challenges are then discussed.