Stent Evaluation for Expiratory Central Airway Collapse: Does the Type of Stent Really Matter?

BACKGROUND: Careful selection of patients with expiratory central airway collapse (ECAC) that may benefit from tracheobronchoplasty (TBP) can be aided by a short-term airway stent evaluation. This can be performed with either silicone Y-stents (SYSs) or uncovered self-expanding metallic airway-stents (USEMAS). No direct comparison has been made between these 2 stent types. METHODS: This was a small retrospective review of consecutive patients that underwent a stent evaluation. A propensity score was used to match patients in the USEMAS and SYS groups. Outcomes included complications, changes in the health-related quality-of-life (HR-QoL), and changes in exercise capacity. Baseline measurements were compared with those obtained during stent evaluation and after TBP. RESULTS: Forty-two patients with severe ECAC underwent USEMAS placement, while 18 patients had an SYS placed. Propensity score matching resulted in 13 matched SYS and USEMAS pairs. The SYS group had an increased rate of mucus plugging (38.5% vs. 0%, P <0.047). Although not statically significant, a clinical improvement was observed in HR-QoL and exercise capacity in the USEMAS group during stent placement. In patients who underwent TBP, both USEMAS and SYS groups had a statistically significant change in the Modified Medical Research Council Dyspnea Scale during stent evaluation and after TBP. CONCLUSION: In patients with severe ECAC, short-term evaluation with airway stents appears to be safe and improves respiratory symptoms, HR-QoL, and exercise capacity. The use of USEMAS led to a lower complication rate, a greater improvement in HR-QoL and exercise capacity, and appeared to better predict how the patients would respond to TBP.

Comparison of Sample Adequacy and Diagnostic Yield of the 21-G and 25-G EBUS TBNA Needles.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA) of mediastinal lymphadenopathy has been shown to be equivalent and possibly even superior to mediastinoscopy. Since the original dedicated 22-G aspiration needle, 21-G, 25-G, and recently 19-G needles have been introduced. Smaller needles may be more flexible and adept at accessing more difficult nodes, and may have less blood contamination compared with larger needles. PATIENTS AND METHODS: This is a prospective observational study of 50 consecutive patients who underwent endobronchial ultrasound-guided transbronchial needle aspiration with a 21-G needle and a 25-G needle for a total of 100 biopsies. The study slides were examined by a dedicated lung cytopathologist, who was blinded to the needle size used for each slide. Demographic data, and lymph node size were recorded. Comparisons between the 2 needles with regards to sample adequacy and diagnostic yield was performed using the McNemar test for dichotomous variables and marginal homogeneity test for nondichotomous variables since samples were related. RESULTS: The majority of lymph nodes (96%) were at least >1 cm. Adequate specimens were obtained in 78% of cases with the 21-G needle and 86% of cases with 25-G needle (P-value=0.424). The overall diagnostic yield was 74% and 80% with the 21-G needle and 25-G needle, respectively (P-value=0.607). CONCLUSION: Our study demonstrates that the there is no difference in terms of specimen adequacy and diagnostic yield when the 25-G needle is compared with the 21-G needle.

Healthcare Personnel Safety During Percutaneous Tracheostomy in Patients With COVID-19: Proof-of-Concept Study.

BACKGROUND: Covid-19 pandemic has resulted in the development of severe and persistent respiratory failure requiring long term ventilatory support. This necessitates the need for a reliable and easy to implement tracheostomy protocol given the concern for viral transmission risk to the involved healthcare personnel due to the aerosol generating nature of the procedure. We describe a protocol with unique and novel modifications to the Ciaglia dilatational percutaneous tracheostomy, effectively implemented during the Covid-19 pandemic at our institution. METHODS: We describe the baseline characteristics of our initial 11 patients who underwent the procedure. Outlined are the healthcare personnel involved and the steps which are organized into 4 phases: planning, pre-procedure, intra-procedure and post-procedure. We have tracked procedural duration, provider safety as well as the development of new complications. RESULTS: We describe use of this protocol for 11 bedside percutaneous tracheostomies performed on patients with COVID-19. The average total procedural duration as well as incision to tracheostomy tube placement times was 32.6 minutes and 5.8 minutes respectively. All 3 providers performing the tracheostomies remained asymptomatic with negative COVID-19 RT-PCR testing at 3 weeks. CONCLUSIONS: We report an efficacious and adaptable protocol for elective bedside percutaneous tracheostomies for patients with persistent ventilatory requirements due to COVID-19 with an intent to provide standardized and safe care for the patient and the involved healthcare personnel.

Combined Thoracoscopic Surgical Stapling and Endobronchial Valve Placement For Lung Volume Reduction With Incomplete Lobar Fissures: An Experimental Pilot Animal Study.

BACKGROUND: In patients with severe emphysema and complete fissures, bronchoscopic lung volume reduction with valves reduces target lobe volume providing improvement in respiratory symptoms, lung function, quality of life, and exercise capacity. It is estimated that up to 88% of patients with emphysema have at least 1 incomplete interlobar fissure. The aim of this study was to evaluate the feasibility of creating a complete fissure with stapling via minimally invasive video-assisted thoracoscopic surgery (VATS) followed by bronchoscopic valve placement to induce lobar collapse in a swine model. METHODS: Chest computed tomography (CT) scans were performed on 2 swine and at least 1 target incomplete fissure was identified. Both swine underwent VATS to complete the target fissure using a surgical stapler, followed by bronchoscopic placement of the Spiration endobronchial valves. A chest CT scan was performed immediately postprocedure. Follow-up bronchoscopy and CT scans were performed 2 weeks after the initial procedure prior to sacrifice. RESULTS: Successful fissure completion was accomplished using VATS and confirmed at postmortem explanted lung gross examination. Flexible bronchoscopy 2 weeks following valve placement showed proper positioning of the valves. Effectiveness of combined procedures was confirmed by a chest CT scan that showed complete atelectasis of the target lobe at 2-week follow-up. There was no perioperative or postoperative morbidity or mortality. CONCLUSION: Combined minimally invasive VATS fissure stapling with bronchoscopic valve placement to induce lobar atelectasis appears safe and feasible in the swine model. Future research in humans using a combined procedure is needed to confirm safety and clinical efficacy.

Bronchoscope-Guided Percutaneous Endoscopic Gastrostomy Tube Placement by Interventional Pulmonologists: A Feasibility and Safety Study.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tube placement is a procedure frequently done in the intensive care unit. The use of a traditional endoscope can be difficult in cases of esophageal stenosis and theoretically confers an increased risk of infection due to its complex architecture. We describe a technique using the bronchoscope, which allows navigation through stenotic esophageal lesions and also minimizes the risk of endoscopy-associated infections. METHODS: Prospective series of patients who had PEG tube placement guided by a bronchoscope. Procedural outcomes including successful placement, duration of the entire procedure, time needed for passage of the bronchoscope from the oropharynx to the major curvature, PEG tube removal rate, and mortality were collected. Procedural adverse events, including infections and long-term PEG-related complications, were recorded. RESULTS: A total of 84 patients underwent bronchoscope-guided PEG tube placement. Percutaneous endoscopic gastrostomy tube insertion was completed successfully in 82 (97.6%) patients. Percutaneous endoscopic gastrostomy tube placement was performed immediately following percutaneous tracheostomy in 82.1%. Thirty-day mortality and 1-year mortality were 11.9% and 31%, respectively. Overall, minor complications occurred in 2.4% of patients, while there were no major complications. No serious infectious complications were identified and no endoscope-associated hospital acquired infections were documented. CONCLUSIONS: The use of the bronchoscope can be safely and effectively used for PEG tube placement. The use of bronchoscope rather than a gastroscope has several advantages, which include the ease of navigating through complex aerodigestive disorders such as strictures and fistulas as well as decreased health-care utilization. In addition, it may have a theoretical advantage of minimizing infections related to complex endoscopes.

Regulatory T Cells in Respiratory Health and Diseases.

Respiratory diseases compromise the health of millions of people all over the world and are strongly linked to the immune dysfunction. CD4+FOXP3+ T regulatory cells, also known as Tregs, have a central role maintaining tissue homeostasis during immune responses. Their activity and clinical impact have been widely studied in different clinical conditions including autoimmune diseases, inflammatory conditions, and cancer, amongst others. Tregs express transcription factor forkhead box P3 (FOXP3), which allows regulation of the immune response through anti-inflammatory cytokines such as IL-10 or transforming growth factor beta (TGF-ß) and direct cell-to-cell interaction. Maintenance of immune tolerance is achieved via modulation of effector CD4+ T helper 1, 2 or 17 (Th1, Th2, Th17) cells by Tregs. This review highlights the recent progress in the understanding of Tregs in different disorders of the respiratory system.

The Prevalence of Gastroesophageal Reflux in Patients With Excessive Central Airway Collapse.

BACKGROUND: Gastroesophageal reflux (GER) is increasingly recognized as an exacerbating or causal factor in several respiratory diseases. There is a high prevalence of GER in infants with airway malacia. However, such data are lacking in adults. METHODS: This retrospective study was conducted to determine the relationship between GER and excessive central airway collapse (ECAC). The study included consecutive patients with ECAC referred to the Complex Airway Center at Beth Israel Deaconess Medical Center who underwent esophageal pH testing for GER between July 2014 and June 2018. RESULTS: Sixty-three of 139 patients with ECAC (45.3%) had documented GER as shown by an abnormal esophageal pH test result. The mean DeMeester score was 32.2, with a symptom association probability of 39.7% of GER-positive patients. Twenty-nine of 63 patients (46%) with GER reported improvement in respiratory symptoms following maximal medical therapy or antireflux surgery without requiring further treatment for ECAC. CONCLUSIONS: GER is prevalent among patients with ECAC, and aggressive reflux treatment should be considered in these patients prior to considering invasive airway procedures or surgery.

Longitudinal Follow-up of Patients With Tracheobronchomalacia After Undergoing Tracheobronchoplasty: Computed Tomography Findings and Clinical Correlation.

PURPOSE: The purpose of this study was to evaluate intermediate and long-term changes in expiratory tracheal collapsibility by computed tomography (CT) in patients with tracheobronchomalacia following surgical treatment with tracheobronchoplasty and to correlate CT findings with clinical findings. MATERIALS AND METHODS: Between 2003 and 2016, 18 patients with tracheobronchomalacia underwent tracheobronchoplasty and were imaged preoperatively and postoperatively at both intermediate and long-term intervals. Imaging included end-inspiratory and dynamic expiratory phase scans. The cross-sectional area of the airway lumen was measured at 2 standard levels (1 cm above the aortic arch and carina). These measurements were used to calculate % collapsibility. Clinical findings recorded included a questionnaire on symptomatology and a 6-minute walk test. RESULTS: Before surgery, expiratory collapsibility of the upper trachea was 72%±25% (mean±SD) and that of the lower trachea was 68%±22%. On intermediate follow-up (mean, 1.5 y), collapsibility significantly decreased to 37%±21% at the upper trachea and 35%±19% at the lower trachea (P<0.001). On long-term follow-up (mean, 6 y), collapsibility increased to 51%±20% at the upper trachea and 47%±17% at the lower trachea and was significantly worse than on intermediate follow-up (P=0.002). However, collapsibility on long-term follow-up remained significantly lower than preoperative collapsibility (P=0.015). Clinical findings showed a similar trend as quantitative CT measurements. CONCLUSION: Expiratory tracheal collapsibility substantially decreases after tracheobronchoplasty on intermediate follow-up. At long-term follow-up, tracheal collapsibility shows a modest increase, but remains significantly lower than the preoperative baseline. Quantitative measurements from dynamic CT have the potential to play an important role as imaging biomarkers for assessing response to tracheobronchoplasty.

Frailty Characteristics Predict Respiratory Failure in Patients Undergoing Tracheobronchoplasty.

BACKGROUND: Respiratory complications are the leading cause of morbidity in patients undergoing tracheobronchoplasty, yet risk stratification systems on this population are insufficient. We investigated the association between frailty and risk of major respiratory complications after tracheobronchoplasty. METHODS: A retrospective review was made of 161 consecutive tracheobronchoplasties (October 2002 to September 2016). A frailty index was developed by the deficit-accumulation approach comprising 26 multidomain preoperative variables. The main outcome was a composite endpoint of major respiratory complications within 30 days of surgery. Odds ratio (OR) and 95% confidence interval (CI) were estimated using logistic regression. RESULTS: The cohort consisted of 103 women (64%), median age of 58 years (interquartile range, 51 to 66) and median FI of 0.25 (interquartile range, 0.1 to 0.3). Forty-eight patients (30%) had respiratory complications, the most common being respiratory failure (n = 27, 16.8%) and pneumonia (n = 25, 15.5%). Severe frailty (frailty index ≥0.33) was strongly associated with major respiratory complications (73.8% versus 2.5%; OR 58.8, 95% CI: 9.6 to 358.3). The association with severe frailty appeared stronger for respiratory failure (47.6% versus 2.5%; OR 30, 95% CI: 4.7 to 189.9) than for pneumonia (40.5% versus 0%; OR 35.2. 95% CI: 2.0 to 599.8). Further adjustment for intraoperative crystalloid volume or forced expiratory volume in 1 second moderately attenuated the association between frailty with major respiratory complications (OR 17.4. 95% CI: 2.0 to 150.8), respiratory failure (OR 13.1, 95% CI: 1.7 to 95.8), and pneumonia (OR 20.1, 95% CI: 1.1 to 341.8). CONCLUSIONS: Frailty, as indicated by frailty index, was associated with major respiratory complications, particularly respiratory failure after tracheobronchoplasty. Preoperative identification of frailty may help guide decision making for patients considering this effective, although arduous procedure.

Convex Probe EBUS-guided Fiducial Placement for Malignant Central Lung Lesions.

BACKGROUND: Stereotactic body radiotherapy (SBRT) had become a therapeutic modality in patients with primary tumors, locally recurrent as well as oligometastasis involving the lung. Some modalities of SBRT require fiducial marker (FM) for dynamic tumor tracking. Previous studies have focused on evaluating bronchoscopic-guided FM placement for peripheral lung nodules. We describe the safety and feasibility of placing FM using real-time convex probe endobronchial ultrasound (CP-EBUS) for SBRT in patients with centrally located hilar/mediastinal masses or lymph nodes. METHODS: This is a retrospective review of patients who were referred to Beth Israel Deaconess Medical Center's multidisciplinary thoracic oncology program for FM placement to pursue SBRT. RESULTS: Thirty-seven patients who underwent real-time CP-EBUS were included. Patients had a median age of 71 years [interquartile range (IQR), 59.5 to 80.5]. The median size of the lesion was 2.2 cm (IQR, 1.4 to 3.3 cm). The median distance from the central airway was 2.4 cm (IQR, 0 to 3.4 cm). A total of 51 FMs (median of 1 per patient) were deployed in 37 patients. At the time of SBRT planning, 46 (90.2%) were confirmed radiologically in 32 patients. Patients with unsuccessful fiducial deployment (n=5) underwent a second procedure using the same technique. Of those, 3 patients had a successful fiducial placement via bronchoscopy, 1 patient required FM placement by percutaneous computed tomography-guided approach and 1 patient required FM placement through EUS by gastroenterology. CONCLUSION: CP-EBUS-guided FM placement for patients with malignant lymph nodes and central parenchymal lung lesions appears to be safe and feasible.

Single-Center Experience of Tracheobronchoplasty for Tracheobronchomalacia: Perioperative Outcomes.

BACKGROUND: We present trends in practice as our experience has grown and report the postoperative morbidity and its associated factors after tracheobronchoplasty. METHODS: A retrospective cohort study was conducted of 161 patients who underwent tracheobronchoplasty from October 2002 to September 2016. The main outcome was development of a postoperative complication within 30 days of the operation. Postoperative complication events were graded using the Clavien-Dindo system. The study patients were divided into two consecutive cohorts to examine trends in systems of care. Postoperative morbidity was examined using a log-binomial regression model. RESULTS: The cohort consisted of 103 women (64%), with a median age of 58 years (interquartile range, 52 to 66 years). Postoperative morbidity occurred in 75 patients (47%). Severe complications (Clavien-Dindo grade ≥IIIa) occurred in 38 patients (24%), most of which were respiratory in nature, including 27 (17%) with respiratory failure. Median intensive care unit length of stay was 4 days (interquartile range, 3 to 5 days), with a total length of stay of 8 days (interquartile range, 6 to 11 days). In-hospital mortality occurred in 2 patients (1%). Discharge was directly to home in 68% of patients (37% without assistance and 31% with visiting nurse follow-up) and to a rehabilitation facility in 31%. After adjusting for age, sex, race, operative time, and intraoperative blood loss, forced expiratory volume in 1 second was an independent predictor (odds ratio, 0.97; 95% confidence interval, 0.95 to 0.99; p = 0.01) for postoperative morbidity. CONCLUSIONS: Despite an arduous hospital course with significant risk of severe complication, patients undergoing tracheobronchoplasty for severe tracheobronchomalacia have low risk of mortality and most are discharged directly to home.

Covered Balloon-Expanding Stents in Airway Stenosis.

BACKGROUND: The balloon-expanding stents are widely available but rarely described for use within the tracheobronchial tree. This report describes our experience with these stents in airway stenosis particularly as a lobar salvage therapy. METHODS: This was a retrospective review of all records in which the balloon-expanding stents were used at a tertiary medical center. Ages, sex, location of stenosis, etiology of stenosis, stent size, duration of stent placement and associated interventions for airway stenosis were recorded. Patient's self-reported respiratory symptoms, dyspnea scale, and radiographic imaging at baseline and after stent placement were also reported. RESULTS: Twenty-one Atrium iCAST stents were inserted in 18 patients with malignant and benign airway disease. The median age was 69.5 years (interquartile range, 53.5 to 74). Most stents (n=20, 95%) were deployed in the lobar airways. There was a significant improvement in the modified Medical Research Council dyspnea scale from median of 3 to 2 (P<0.05). Self-reported respiratory symptoms improved in 14 patients (78%, P<0.05). Radiographic improvement post Atrium iCAST stent placement was achieved in 15 patients (83%). No deaths were related to airway stenting complications. Adverse events related to stents included migration (n=2, 9.5%), granulation tissue formation (n=2, 9.5%) and mucus plugging (n=1, 4.8%). CONCLUSIONS: Lobar stenting with balloon-expanding metallic stents appears feasible, safe and improves symptoms as well as radiographic atelectasis in patients with lobar airway stenosis in this small case series. Larger studies are needed to confirm this observation and to address long-term safety.

Short-Term Use of Uncovered Self-Expanding Metallic Airway Stents for Severe Expiratory Central Airway Collapse.

BACKGROUND: Patients with severe symptomatic expiratory central airway collapse (ECAC) undergo a stent trial to determine whether they are candidate for tracheobronchoplasty. Most stent trials were done using silicone stents. However, there was a higher number of silicone stent-related complications. OBJECTIVES: The aim of this study was to evaluate the safety and efficacy of short-term uncovered self-expanding metallic airway stents (USEMAS) in patients with ECAC. METHODS: This was a retrospective review. Baseline measurements were compared to those obtained after 7-14 days. Measurements included: Modified Medical Research Council (mMRC), Cough Quality of Life Questionnaire (CQLQ), spirometry testing, and 6-Minute Walk Test (6MWT). Stent- and procedure-related complications were reported. RESULTS: 33 patients (median age, 52 years) underwent the USEMAS trial. Presenting symptoms were dyspnea in 100%, intractable cough in 90.3%, recurrent infection in 42.2%, and inability to clear secretions in 21.4%. Dyspnea, cough, and secretion clearance improved in 88, 70, and 57%, respectively. Overall, there was a significant improvement in mMRC (p < 0.001), CQLQ (p = 0.015), and 6MWT (p = 0.015). There was 1 airway infection, 1 stent migration, and 1 pneumothorax. The median duration of USEMAS was 7 days. All stents were removed without any complications. At the time of stent removal, no granulation tissue was observed in 30.9%, and mild granulation tissue was observed in 69.1%. CONCLUSION: The short-term USEMAS trial improves respiratory symptoms, quality of life, and exercise capacity with few complications in patients with severe symptomatic ECAC when performed by a multidisciplinary airway team in highly specialized centers with experience in the evaluation and treatment of this patient population.

Concurrent Intrapleural Instillation of Tissue Plasminogen Activator and DNase for Pleural Infection. A Single-Center Experience.

RATIONALE: Treatment of pleural infection with instillation of intrapleural tissue plasminogen activator (tPA) and human recombinant DNase (DNase) has been proven to decrease the length of hospital stay, decrease surgical referral, and improve drainage. The optimal dosage, administration, timing, and frequency of the regimen remain unclear. It is unknown if the two drugs can be administered immediately one after the other (referred to as concurrent) instead of instilling them separately with a 1- to -2-hour interval in between. OBJECTIVES: To assess the safety and efficacy of concurrent instillation of intrapleural tPA/DNase guided by radiographic and clinical response in patients with pleural infection. METHODS: We conducted a retrospective cohort study. Consecutive patients with pleural infection who received concurrent tPA/DNase were included. The initiation and number of doses of tPA/DNase therapy were based on pleural fluid drainage, clinical response, and radiographic findings. MEASUREMENTS AND MAIN RESULTS: Seventy-three patients received concurrent tPA/DNase therapy. Treatment was successful in 90.4% of them; 80.8% were effectively treated with fewer than six doses of therapy (median, 2; interquartile range [IQR], 1-3.5); and 71.2% received their first dose of tPA/DNase within 24 hours after chest tube insertion. The median hospital stay from the first dose of tPA/DNase to discharge was 7 days (IQR, 5-11 d). The volume of pleural fluid drained increased from a median of 295 ml (IQR, 97.5-520 ml) 24 hours before treatment to a median of 1,102 ml (IQR, 627-2,200 ml) 72 hours following therapy (P < 0.001). Nonfatal pleural bleeding occurred in 5.4%, 15.1% had chest pain, and 2.7% died as a result of pleural infection. CONCLUSIONS: This cohort study shows that early administration of concurrent tPA/DNase in patients with pleural infection is relatively safe and effective. Given the high cost of therapy, it is feasible to guide therapy on the basis of clinical and radiographic response.

Unimodality and Multimodality Cryodebridement for Airway Obstruction. A Single-Center Experience with Safety and Efficacy.

RATIONALE: Cryodebridement (CD) refers to the removal of obstructive material from the lumen of the tracheobronchial tree by freezing with a cryoprobe, which is usually inserted through a flexible bronchoscope. This method of achieving instant recanalization of airways has been established for over 20 years, but published experience comprises limited case series. OBJECTIVES: This study describes a single large-volume referral center experience, including clinical outcomes and safety profile. METHODS: Electronic medical records of 156 patients who underwent bronchoscopic CD between December 2007 and March 2012 as the primary method to relieve airway obstruction were reviewed retrospectively. MEASUREMENTS AND MAIN RESULTS: The most frequent cause of airway obstruction was malignancy (n = 88), with non-small-cell lung cancer and metastatic renal cell carcinoma being the most common etiologies. The site of obstruction was localized to the central airways in 63 patients (40%) and the distal airways in 44 patients (28%), and it was diffuse in 49 patients (32%). Bronchoscopic airway patency was achieved in 95% of patients, with the highest success rates found in those with obstruction localized in the central airways. Improvement in symptoms occurred in 118 (82%) of 144 symptomatic patients. Serious complications were reported in 17 patients (11%) and included respiratory distress, severe bleeding, airway injury, and hemodynamic instability. All patients responded to treatment, and no intra- or postoperative deaths were reported. CONCLUSIONS: CD, when used alone or in combination with other endoscopic treatment modalities, appears to be safe and effective in treating endoluminal airway obstruction.