Broncoscopia flexible en pacientes postoperatorios de cardiopatías congénitas en UCI pediátrica / Flexible bronchoscopy in postoperative period in pediatric patients with congenital heart disease in a ICU

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Future Treatment of Emphysema with Roles for Valves, Novel Strategies and Lung Volume Reduction Surgery.

Although there are multiple pharmacologic and nonpharmacological options to alleviate symptoms of emphysema, none of these treatment modalities halts disease progression. The expanding disease burden has led to development of innovative therapeutic strategies that also aim to induce lung volume reduction. Bronchoscopic lung volume reduction originated in 2001 and has continued to grow rapidly ever since. This article discusses more recent developments in bronchoscopic and novel interventions and speculates on how these novel strategies may impact the future of lung reduction interventions.

Single-Use (Disposable) Flexible Bronchoscopes: The Future of Bronchoscopy?

The coronavirus disease (COVID-19) pandemic has highlighted the importance of reducing occupational exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The reprocessing procedure for reusable flexible bronchoscopes (RFBs) involves multiple episodes of handling of equipment that has been used during an aerosol-generating procedure and thus is a potential source of transmission. Single-use flexible bronchoscopes (SUFBs) eliminate this source. Additionally, RFBs pose a risk of nosocomial infection transmission between patients with the identification of human proteins, deoxyribonucleic acid (DNA) and pathogenic organisms on fully reprocessed bronchoscopes despite full adherence to the guidelines. Bronchoscopy units have been hugely impacted by the pandemic with restructuring of pre- and post-operative areas, altered patient protocols and the reassessment of air exchange and cleaning procedures. SUFBs can be incorporated into these protocols as a means of improving occupational safety. Most studies on the efficacy of SUFBs have occurred in an anaesthetic setting so it remains to be seen whether they will perform to an acceptable standard in complex respiratory procedures such as transbronchial biopsies and cryotherapy. Here, we outline their potential uses in a respiratory setting, both during and after the current pandemic.

The significance of multidisciplinary classifications based on transbronchial pathology in possible idiopathic interstitial pneumonias.

Surgical lung biopsy is regarded as the golden standard for the diagnosis of idiopathic interstitial pneumonias (IIPs). Here, we attempted to show the diagnostic accuracy of multidisciplinary classifications based on transbronchial pathology including transbronchial lung cryobiopsy (TBLC) , bronchoalveolar lavage fluid (BALF) and endobronchial ultrasound-guided transbronchial needle aspiration biopsy (EBUS-TBNA).Patients with suspected interstitial lung diseases admitted from June 1, 2016 to December 31, 2018 were involved. Patients with known causes of interstitial lung diseases and typical idiopathic pulmonary fibrosis diagnosed through clinical, radiological information were excluded. Patients with atypical idiopathic pulmonary fibrosis and possible IIPs accepted transbronchial pathological evaluation. Initial multidisciplinary diagnosis (MDD) classifications were made depending on clinical, radiological and transbronchial pathological information by a multidisciplinary team (MDT). The final MDD classifications were confirmed by subsequent therapeutic effects. All patients were followed up for at least 6 months.A total of 70 patients were finally involved. The samples of lung parenchyma extracted through TBLC were enough for confirmation of pathological diagnoses in 68.6% (48/70) cases. Samples of 6 cases were extracted by EBUS-TBNA. Bacteriological diagnoses were positive in 1 case by BALF. Pathological diagnoses of 77.1% (54/70) cases were achieved through TBLC, EBUS-TBNA and BALF. During the follow up study, the pulmonary lesions of 60% patients were improved, 11.43% were relapsed when glucocorticoid was reduced to small dose or withdrawal, 14.29% were leveled off and 8.57% were progressed. The diagnoses of 4 patients with progressed clinical feature were revised. As a result, 94.3% initial MDD classifications based on transbronchial pathology were consistent with the final MDD, and the difference of diagnostic yield wasn't significant between initial and final MDD (Z = -1.414, P = .157).Classifications of IIPs based on transbronchial pathology were useful and quite agreed with final MDD.

Recent developments and advances in secondary prevention of lung cancer.

Lung cancer prevention may include primary prevention strategies, such as corrections of working conditions and life style - primarily smoking cessation - as well as secondary prevention strategies, aiming at early detection that allows better survival rates and limited resections. This review summarizes recent developments and advances in secondary prevention, focusing on recent technological tools for an effective early diagnosis.

Diagnosing peripheral lung lesions using endobronchial ultrasonography with guide sheath: A prospective registry study to assess the effect of virtual bronchoscopic navigation using a computed tomography workstation.

Bronchoscopy has a lower diagnostic yield for peripheral lung lesions (PLL). Endobronchial ultrasound guide sheath transbronchial lung biopsy (EBUS GS TBLB) has been used to overcome such limitation. Recent studies revealed that combined methods (e.g., EBUS GS TBLB plus electromagnetic navigation [EMN] or virtual bronchoscopic navigation [VBN]) further improve the diagnostic yield. However, those systems are associated with a high cost burden. Accordingly, we attempted to use VBN by computed tomography (CT) workstation (Aquarius iNtuition, TeraRecon) not dedicated only for VBN as an adjunctive tool for EBUS GS TBLB. We performed a prospective registry study to investigate whether VBN by CT workstation could improve the diagnostic yield of PLL.Between February 2017 and February 2018, 128 patients with PLL were divided into 2 groups (VBN and non-VBN [NVBN]). In NVBN group (n = 64), EBUS GS TBLB was performed using a hand-drawn bronchial map based on CT images. VBN group (n = 64) underwent EBUS GS TBLB using VBN images.VBN using CT workstation did not improve the diagnostic yield of EBUS GS TBLB for PLL (VBN vs NVBN, 72% vs 80%, P = .284). VBN slightly reduced procedure time (minute [mean ±â€ŠSD], 25.31 ±â€Š10.33 vs 25.81 ±â€Š9.22), navigation time (time to find the lesion) (9.10 ±â€Š7.88 vs 9.50 ±â€Š7.14), and fluoroscopy time (2.23 ±â€Š2.39 vs 2.86 ±â€Š4.61), while these differences were not statistically significant.The diagnostic yield of EBUS GS TBLB was not improved with VBN (compared with using a hand-drawn bronchial map). Although VBN slightly shortened the procedure-related times, which were not significantly different.

Interventional Bronchoscopy.

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.

Interventional Pulmonology and COVID-19: Experience from a Malaysian Tertiary Hospital.

The ongoing pandemic of COVID-19 has presented multiple challenges to global healthcare services, dictating changes in almost every aspect of daily medical practice. Performing aerosol generating procedures (AGPs) in the field of interventional pulmonology can lead to profound formation of aerosols, leading to a high risk of infection among healthcare workers (HCWs). We share our experiences on performing AGPs in the midst of a COVID-19 pandemic by focusing on changes in AGP practices. In a pandemic, HCWs ought to adapt to the ever-changing situation and use available resources to provide the best possible healthcare to patients, ensure safety of staff, and continue medical education of future pulmonologists.

Interventional Pulmonology and COVID-19: Experience from a Malaysian Tertiary Hospital

The ongoing pandemic of COVID-19 has presented multiple challenges to global healthcare services, dictating changes in almost every aspect of daily medical practice. Performing aerosol generating procedures (AGPs) in the field of interventional pulmonology can lead to profound formation of aerosols, leading to a high risk of infection among healthcare workers (HCWs). We share our experiences on performing AGPs in the midst of a COVID-19 pandemic by focusing on changes in AGP practices. In a pandemic, HCWs ought to adapt to the ever-changing situation and use available resources to provide the best possible healthcare to patients, ensure safety of staff, and continue medical education of future pulmonologists.

Pleural dye marking of lung nodules by electromagnetic navigation bronchoscopy.

INTRODUCTION: Electromagnetic navigation bronchoscopy (ENB)-guided pleural dye marking is useful to localize small peripheral pulmonary nodules for sublobar resection. OBJECTIVE: To report findings on the use of ENB-guided dye marking among participants in the NAVIGATE study. METHODS: NAVIGATE is a prospective, multicentre, global and observational cohort study of ENB use in patients with lung lesions. The current subgroup report is a prespecified 1-month interim analysis of ENB-guided pleural dye marking in the NAVIGATE United States cohort. RESULTS: The full United States cohort includes 1215 subjects from 29 sites (April 2015 to August 2016). Among those, 23 subjects (24 lesions) from seven sites underwent dye marking in preparation for surgical resection. ENB was conducted for dye marking alone in nine subjects while 14 underwent dye marking concurrent with lung lesion biopsy, lymph node biopsy and/or fiducial marker placement. The median nodule size was 10 mm (range 4-22) and 83.3% were <20 mm in diameter. Most lesions (95.5%) were located in the peripheral third of the lung, at a median of 3.0 mm from the pleura. The median ENB-specific procedure time was 11.5 minutes (range 4-38). The median time from dye marking to resection was 0.5 hours (range 0.3-24). Dye marking was adequate for surgical resection in 91.3%. Surgical biopsies were malignant in 75% (18/24). CONCLUSION: In this study, ENB-guided dye marking to localize lung lesions for surgery was safe, accurate and versatile. More information is needed about surgical practice patterns and the utility of localization procedures.

Recent advances in bronchoscopy.

Bronchoscopy is a very common tool for diagnosis and therapeutic purposes in dealing with diseases of the lungs and the airways. Thankfully, a multitude of new technologies have made it more accessible for the use of physicians. This article is a review of the indication of bronchoscopy as it is being used today for a variety of chest pathologies.

A method for addressing right upper lobe obstruction with right-sided double-lumen endobronchial tubes during surgery: a randomized controlled trial.

BACKGROUND: A right-sided double-lumen tube (R-DLT) tends to obstruct the right upper lobe intraoperatively due to anatomical distortion during surgery. If the R-DLT is poorly matched with the patient's airway anatomy, it will not be possible to correctly replace the tube with a fiberoptic bronchoscope (FOB). In our study, we aimed to explore an efficient method for difficult repositioning caused by right upper lobe occlusion during surgery: repositioning the R-DLT from the right main bronchus into the left main bronchus. The current study was designed to assess the efficacy and safety of this method. METHODS: Sixty adult patients scheduled to undergo left-sided thoracic surgery were randomly assigned to two groups. With the patient in the right lateral position during surgery, the R-DLT was pulled back to the trachea while being rotated 90° clockwise; it was then either rotated 90° clockwise for placement into the left main bronchus (Group L) or rotated 90° anticlockwise and returned to the right main bronchus (Group R) using FOB guidance. The primary outcomes included clinical performance, which was measured by intubation time, and the quality of lung collapse. A secondary outcome was safety, which was determined according to bronchial injury and vocal cord injury. RESULTS: The median intubation time (IQR [range]) required for placement of a R-DLT into the left main bronchus was shorter than the time required for placement into the right main bronchus (15.0 s [IQR, 12.0 to 20.0 s]) vs 23.5 s [IQR, 14.5 to 65.8 s], P = 0.005). The groups showed comparable overall results for the quality of lung collapse during the total period of one-lung ventilation (P = 1.000). The numbers of patients with bronchial injuries or vocal cord injuries were also comparable between groups (Group R, 11/30 vs. Group L 8/30, P = 0.580 for bronchus injuries; Group R, 15/30 vs. Group L 13/30, P = 0.796 for vocal cord injuries). CONCLUSIONS: Repositioning a R-DLT from the right main bronchus into the left main bronchus had good clinical performance without causing additional injury. This may be an efficient method for the difficult repositioning of a R-DLT due to right upper lobe occlusion during surgery. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR-IPR-15006933 , registered on 15 August 2015.

Criobiopsia pulmonar y el principio KISS / Lung cryobiopsy and the KISS principle

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Prevalence and incidence of sarcoidosis in Korea: a nationwide population-based study.

BACKGROUND: The prevalence and incidence of sarcoidosis varies worldwide. We estimated the prevalence and incidence of sarcoidosis in Korea using nationwide claims data from the Korean Health Insurance Review and Assessment Service. METHODS: Cases of sarcoidosis were identified for any visit between 2007 to 2016 that listed the Korean Classification of Disease, 7th edition code of sarcoidosis and rare incurable disease exempted calculation code. A narrow case definition was used as follows: 1) ≥ two sarcoidosis-coded visits within 1 year of the first claim, 2) no claims for other diseases that could form granuloma. RESULTS: A total of 4791 patients (narrow, n = 2388) visited medical institutions for sarcoidosis during the study period; 2999 patients (narrow, n = 1696) were newly identified between 2009 and 2015. The sarcoidosis prevalence was 9.37 per 105 people (narrow, 4.69) and was highest between ages 60-69 years. The incidence rate was 0.85 per 105 population at risk (narrow, 0.48), with the highest incidence rate between ages 50-59 years. For incident cases (mean age: 48.5 year), the age distribution in whole population and females showed monophasic patterns peaking at aged 50-59 years, while males had biphasic incidence peak at aged 30-39 years and 60-69 years. The annual incidence rates showed increasing trends from 0.85 per 105 population at risk in 2009 to 0.97 per 105 population at risk in 2015. CONCLUSIONS: In comparison with previous reports, the prevalence and incidence of sarcoidosis in Korea have increased and middle-aged women showed the highest risk.

The Direct Oblique Method: A New Gold Standard for Bronchoscopic Navigation That is Superior to Automatic Methods.

BACKGROUND: The purpose of this study was to identify bronchi on computed tomographic (CT) images, manual analysis is more accurate than automatic methods. Nonetheless, manual bronchoscopic navigation is not preferred as it involves mentally reconstructing a route to a bronchial target by interpreting 2-dimensional CT images. Here, we established the direct oblique method (DOM), a form of manual bronchoscopic navigation that does not necessitate mental reconstruction, and compared it with automatic virtual bronchoscopic navigation (VBN). METHODS: Routes were calculated to 47 identical targets using 2 automatic VBNs (LungPoint and VINCENT-BFsim) and the DOM, using 3 general application CT viewers (Aquarius, Synapse Vincent, and OsiriX). Results of all analyses were compared. RESULTS: The DOM drew routes to more targets than the VBNs [94% (the DOM on any viewer) vs. 49% (LungPoint) vs. 62% (VINCENT-BFsim), P<0.0001]. For the 44 targets with the CT-bronchus or CT-artery signs, 100% of the DOM routes led to targets. In the bronchoscopic simulation phase, the DOM covered 100% of the bifurcations identified on CT, whereas some bifurcations were skipped and some bronchial walls appeared partially transparent in the VBNs. Manual analysis identified more bronchi near the targets than the VBNs [32.1±3.4 (manual analysis) vs.18.9±2.1 (LungPoint) vs. 22.9±2.7 (VINCENT-BFsim), mean±SEM, P<0.0001]. The DOM took around 5 minutes on average. CONCLUSION: On the basis of precise manual CT analysis using general application CT viewers, the DOM drew routes leading to more targets and provided better bronchoscopic simulation than the automatic route calculation of the VBNs.

Sequential broncho-alveolar lavages reflect distinct pulmonary compartments: clinical and research implications in lung transplantation.

BACKGROUND: Bronchoalveolar lavage (BAL) has proven to be very useful to monitor the lung allograft after transplantation. In addition to allowing detection of infections, multiple BAL analytes have been proposed as potential biomarkers of lung allograft rejection or dysfunction. However, BAL collection is not well standardized and differences in BAL collection represent an important source of variation. We hypothesized that there are systematic differences between sequential BALs that are relevant to BAL analysis. METHODS: As part of 126 consecutive bronchoscopies in lung transplant recipients, two sequential BALs (BAL1 and BAL2) were performed in one location during each bronchoscopy by instilling and suctioning 50 ml of normal saline twice into separate containers. Cell concentration, viability and differentials, Surfactant Protein-D (SP-D), Club Cell Secretory Protein (CCSP), and levels of CXCL10, IL-10, CCL2, CCL5, VEGF-C, RAGE, CXCL9, CXCL1, IL-17A, IL-21, PDGF, and GCSF were compared between BAL1 and BAL2. RESULTS: Total cell concentration did not differ between BAL1 and BAL2; however, compared to BAL2, BAL1 had more dead cells, epithelial cells, neutrophils, and higher concentrations of airway epithelium-derived CCSP and inflammatory markers. BAL2 had a higher concentration of SP-D compared to BAL1. CONCLUSION: In this study performed in lung transplant recipients, we show that sequential BALs represent different lung compartments and have distinct compositions. BAL1 represents the airway compartment with more epithelial cells, neutrophils, and epithelium-derived CCSP. Conversely, BAL2 samples preferentially the distal bronchoalveolar space with greater cell viability and higher SP-D. Our findings illustrate how the method of BAL collection can influence analyte concentrations and further emphasize the need for a standardized approach in translational research involving BAL samples.