Position statement on endoscopic lung volume reduction in South Africa: 2022 update.

Chronic obstructive pulmonary disease (COPD) remains one of the most common causes of morbidity and mortality in South Africa. Endoscopic lung volume reduction (ELVR) was first proposed by the South African Thoracic Society (SATS) for the treatment of advanced emphysema in 2015. Since the original statement was published, there has been a growing body of evidence that a certain well-defined sub-group of patients with advanced emphysema may benefit from ELVR, to the point where the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines and the United Kingdom National Institute for Health and Care Excellence (NICE) advocate the use of endoscopic valves based on level A evidence. Patients aged 40 - 75 years with severe dyspnoea (COPD Assessment Test score ≥10) despite maximal medical therapy and pulmonary rehabilitation, with forced expiratory volume in one second (FEV1) 20 - 50%, hyperinflation with residual volume (RV) >175% or RV/total lung capacity (TLC) >55% and a six-minute walking distance (6MWD) of 100 - 450 m (post-rehabilitation) should be referred for evaluation for ELVR, provided no contraindications (e.g. severe pulmonary hypertension) are present. Further evaluation should focus on the extent of parenchymal tissue destruction on high-resolution computed tomography (HRCT) of the lungs and interlobar collateral ventilation (CV) to identify a potential target lobe. Commercially available radiology software packages and/or an endobronchial catheter system can aid in this assessment. The aim of this statement is to provide the South African medical practitioner and healthcare funders with an overview of the practical aspects and current evidence for the judicious use of the valves and other ELVR modalities which may become available in the country.

Diagnostic yield and safety of ultrasound-assisted biopsies in superior vena cava syndrome.

The yield and safety of ultrasound (US)-assisted transthoracic fine needle aspirations (TTFNA) and cutting needle biopsies (CNB) in the setting of superior vena cava (SVC) syndrome are unknown. The aims of the present prospective study were to asses the diagnostic yield and safety of US-assisted TTFNA and CNB in SVC syndrome with an associated mass lesion abutting the chest wall. Over a 3-yr period, the present authors screened 59 patients with SVC syndrome, and enrolled 25 patients who had an associated mass lesion that extended to the chest wall. US-assisted TTFNA with rapid on-site evaluation (ROSE) was performed in all cases. CNBs were performed where a provisional diagnosis of bronchogenic carcinoma could not be established, and in 57.1% of patients with bronchogenic carcinoma (limited due to safety constraints). ROSE of US-assisted TTFNA confirmed diagnostically useful material in 24 patients, and cytological diagnoses were ultimately made in all of these cases (diagnostic yield 96%). US-assisted CNB had a diagnostic yield of 87.5%. Minor haemorrhage occurred in one out of 25 TTFNA and three out of 16 CNB. Neither procedure resulted in major haemorrhage nor pneumothoraces. US-assisted TTFNA and CNB have a high diagnostic yield and are safe in the setting of SVC syndrome with an associated mass lesion abutting the chest wall.

Clinical and radiological grading of superior vena cava obstruction.

BACKGROUND: Superior vena cava obstruction (SVCO) is commonly caused by neoplastic venous compression and presents with typical symptoms and signs. Its clinical severity presumably depends on the degree of obstruction and the adequacy of venous collateral formation. OBJECTIVES: The development of novel clinical and radiological scoring systems based on the postulate that a reproducible relationship exists between the degree of SVCO, the presence of collateral circulation and the extent of clinical symptoms. METHODS: We prospectively evaluated consecutive cases of acute and subacute SVCO with a newly developed clinical scoring system, which is based on easily detectable clinical symptoms and signs of SVCO. In parallel, we recorded and scored the degree of SVCO and the extent of collaterals visible on contrast-enhanced computed tomography (CT). RESULTS: Thirty-four cases of SVCO were evaluated: 8 (23.5%) were clinically mild, 16 (47%) moderate and 10 (29.5%) severe. Lung cancer was the underlying histological diagnosis in 94% of cases. Radiologically, 53% had complete SVCO. A well-developed collateral system was found in 14 (41%). A scoring system subtracting a 'collateral score' from an 'obstruction score' showed a significant correlation with the clinical score (r = 0.75, p < 0.01). CONCLUSIONS: Clinical severity of SVCO depends upon the degree of SVCO and is ameliorated by collateral formation. The novel clinical scoring system can predict the underlying CT features in SVCO and may be valuable in the bedside assessment of SVCO severity.