Diagnostic Yield and Complications of Bronchoscopy for Peripheral Lung Lesions. Results of the AQuIRE Registry.

RATIONALE: Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy. OBJECTIVES: To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations. METHODS: We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions. MEASUREMENTS AND MAIN RESULTS: Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16). CONCLUSIONS: Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.

FDG-PET imaging in patients with pulmonary carcinoid tumor.

PURPOSE: This study aimed to assess the imaging findings in patients with pathologically proven carcinoid tumors and determine if SUV can help to differentiate typical from atypical (more aggressive) pulmonary carcinoid tumors. PATIENTS AND METHODS: A retrospective review of patients with a biopsy-proven diagnosis of a pulmonary carcinoid tumor at our institution from 2002 to 2010 that had a preoperative PET scan was performed after institutional review board approval was obtained. PET results, including SUV uptake and location, were recorded as well as all data from pathology reports. Carcinoids were considered to be more aggressive if they showed pathological diagnosis consistent with atypical carcinoid, lymph node invasion, poor histological grade (poorly differentiated), or evidence of systemic metastases. Atypical carcinoid pathology consisted of focal necrosis or a higher mitotic index (2-10 per square millimeter) with features of nests, trabeculae, pleomorphic cells, or dense hyperchromasia. SUV uptake was then evaluated and compared between the typical and atypical carcinoid groups using nonparametric statistical methods. RESULTS: We identified 29 patients from 2002 to 2010 at our institution with a pathological diagnosis of pulmonary carcinoid. Twenty-three were histopathologically typical, and the other 6 showed atypia. Mean (SD) nodule size was 2.4 (1.3) cm in the typical group versus 5.0 (3.2) cm in the atypical group (P = 0.065). Mean (SD) SUV uptake in the typical carcinoid group was 2.7 (1.6) and in the atypical group the SUV was 8.1 (4.1) (P < 0.01). A cutoff SUV of 6 or greater is predictive of malignancy (odds ratio, 23.6; P < 0.01), as well as a nodule size of 3.5 cm or greater (odds ratio, 5.1; P = 0.024). CONCLUSIONS: Preoperative PET imaging result is frequently positive in carcinoid tumors, and the biological behavior correlates well with SUV; however, size is not as strong of a predictor of malignancy. Size of 3.5 cm or greater and SUV of 6 or greater have a predictive value of greater than 95% for malignant histology.

Computed tomographic assessment of the posterior junction line and its association with emphysema.

BACKGROUND: Visualization of a posterior junction line (PJL) on chest x-ray is evidence for emphysema. The correlation between the assessment of the PJL on computed tomography (CT) and emphysema is less clear. METHODS: One hundred thirty-seven patients were identified with CT and pulmonary function tests (PFTs) performed within 3 months of each other in a University hospital. The width of the PJL was measured at 2 levels by a blinded investigator: superiorly at the superior border of the aorta and inferiorly 2 cm below the aortic arch. This was correlated to clinical and PFT data and to CT evidence of emphysema. RESULTS: Narrowness of the junction line showed poor correlation with PFT findings of emphysema as assessed by forced expiratory volume in 1 second-forced vital capacity ratio and diffusing capacity of the lung for carbon monoxide percent predicted. The PJL also correlated weakly to CT emphysema severity scoring (r = 0.06; P < 0.002). The area under the receiver operator characteristic curve was 0.652, with maximum accuracy at a width of 1.3 cm. CONCLUSIONS: Our data suggest that despite statistical correlation between the narrowness of the PJL and emphysema, its clinical use is limited.

Interaction of clinical suspicion and PET in the diagnosis of suspected thoracic malignancy.

BACKGROUND: This study assesses the accuracy and interaction of clinical suspicion and positron emission tomography (PET) scans in diagnosis of suspected thoracic malignancy. MATERIAL/METHODS: 313 patients evaluated in a University Hospital lung cancer evaluation center who underwent PET scanning and subsequently had tissue confirmation or a course of stability by CT scans over a period of two years. At the time of the initial visit, clinical suspicion based on history, physical exam and computerized tomography (CT) characteristics was assigned as low, intermediate or high probability of malignancy. Subsequently PET results were classified as negative, intermediate or positive, based on standardized uptake value [SUV] of 0, between 0 and 2.5, greater than 2.5 respectively. RESULTS: ROC analysis showed similar results for clinical suspicion (0.762) and PET (0.779). High clinical suspicion and positive PET had a PPV of 96.6%; low clinical suspicion and negative PET had a NPV of 100%. When PET and clinical suspicion were fully discordant, clinical suspicion was accurate in 80%, PET in 20%. When PET scan or clinical suspicion was intermediate, 35% were malignant. CONCLUSIONS: Clinical suspicion and PET are both accurate in diagnosing thoracic malignancy. When suspicion and PET are concordant, diagnostic accuracy is very high; when discordant, clinical suspicion was more accurate. When clinical suspicion or PET were intermediate, there is a significant likelihood for cancer.

Aerosolized antibiotics and ventilator-associated tracheobronchitis in the intensive care unit.

CONTEXT: In critically ill intubated patients, signs of respiratory infection often persist despite treatment with potent systemic antibiotics. OBJECTIVE: The purpose of this study was to determine whether aerosolized antibiotics, which achieve high drug concentrations in the target organ, would more effectively treat respiratory infection and decrease the need for systemic antibiotics. DESIGN: Double-blind, randomized, placebo-controlled study performed from 2003 through 2004. SETTING: The medical and surgical intensive care units of a university hospital. PATIENTS: Critically ill intubated patients were randomized if: 1) > or = 18 yrs of age, intubated for a minimum of 3 days, and expected to survive at least 14 days; and 2) had ventilator-associated tracheobronchitis defined as the production of purulent secretions (> or = 2 mL during 4 hrs) with organism(s) on Gram stain. Of 104 patients monitored, 43 consented for treatment and completed the study. No patients were withdrawn from the study for adverse events. INTERVENTION: Aerosol antibiotic (AA) or aerosol saline placebo was given for 14 days or until extubation. The responsible clinician determined the administration of systemic antibiotics (SA). Patients were followed for 28 days. MAIN OUTCOME MEASURES: Primary: Centers for Disease Control National Nosocomial Infection Survey diagnostic criteria for ventilator-associated pneumonia (VAP) and clinical pulmonary infection score. Secondary: white blood cell count, SA use, acquired antibiotic resistance, and weaning from mechanical ventilation. RESULTS: Most patients had VAP at randomization. With treatment, the AA group had reduced signs of respiratory infection: reduced Centers for Disease Control National Nosocomial Infection Survey VAP (14/19; 73.6%) to (5/14; 35.7%) vs. placebo (18/24; 75%) to (11/14; 78.6%), reduction in clinical pulmonary infection score, lower white blood cell count at day 14, reduced bacterial resistance, reduced use of SA, and increased weaning (all p < or = .05). CONCLUSIONS: In critically ill patients with ventilator-associated tracheobronchitis, AA decrease VAP and other signs and symptoms of respiratory infection, facilitate weaning, and reduce bacterial resistance and use of systemic antibiotics.

Sublobar resection in nonsmall cell lung carcinoma.

PURPOSE OF REVIEW: Though lobectomy remains the standard of care for resection of nonsmall cell lung cancer, a number of studies have been published in the last 24 months exploring the role of sublobar resection in the treatment of stage I nonsmall cell lung cancer. RECENT FINDINGS: Large retrospective studies comparing lobar and sublobar resection show similar overall and disease-free survival. Survival and local control for sublobar resections are best for tumors smaller than 2 cm and with margins greater than 2 cm. Importantly, sublobar resections commonly have less thorough nodal dissection and incomplete pathologic staging; this may have important therapeutic consequences. No formal comparison of segmentectomy to wedge resection has been performed although bias towards segmentectomy resulting in better outcomes than nonanatomic wedge resection continues. Sublobar resection is especially interesting for patients with prior resection, bronchoalveolar carcinoma, and the elderly. Radiologic criteria for selecting candidates appropriate for sublobar resection are evolving. SUMMARY: Sublobar resection is an alternative therapy for stage I nonsmall cell lung cancer for patients with physiologic impairment unable to undergo lobectomy. The literature also suggests a role for patients with prior lung resection, bronchoalveolar carcinoma, peripheral tumors less than 2 cm, and for the elderly.

Use of the All Patient Refined-Diagnosis Related Group (APR-DRG) Risk of Mortality Score as a Severity Adjustor in the Medical ICU.

OBJECTIVE: To evaluate the performance of APR-DRG (All Patient Refined-Diagnosis Related Group) Risk of Mortality (ROM) score as a mortality risk adjustor in the intensive care unit (ICU). DESIGN: Retrospective analysis of hospital mortality. SETTING: Medical ICU in a university hospital located in metropolitan New York. PATIENTS: 1213 patients admitted between February 2004 and March 2006. MAIN RESULTS: Mortality rate correlated significantly with increasing APR-DRG ROM scores (p < 0.0001). Multiple logistic regression analysis demonstrated that, after adjusting for patient age and disease group, APR-DRG ROM was significantly associated with mortality risk in patients, with a one unit increase in APR-DRG ROM associated with a 3-fold increase in mortality. CONCLUSIONS: APR-DRG ROM correlates closely with ICU mortality. Already available for many hospitalized patients around the world, it may provide a readily available means for severity-adjustment when physiologic scoring is not available.

Eosinophilic pneumonia due to duloxetine.

A 32-year-old man presented with a 2-month history of worsening fever, chills, and cough despite therapy with oral antibiotics. Chest radiographs demonstrated migrating, peripheral upper lobe infiltrates. A CBC count demonstrated significant eosinophilia. At bronchoscopy, eosinophil-rich mucus was seen impacted throughout his bronchi. A transbronchial biopsy confirmed the diagnosis of eosinophilic pneumonia. Symptoms, eosinophilia, and radiographic abnormalities were reversed with cessation of duloxetine. This case report briefly reviews the diagnosis of drug-induced pulmonary infiltrates with eosinophilia (PIEs) and eosinophilic pneumonia. To our knowledge, this is the first reported case of PIEs due to duloxetine.

Growing PET positive nodule in a patient with histoplasmosis: case report.

BACKGROUND: Pulmonary histoplasmosis is a mycotic infection that often resembles pulmonary malignancy and continues to complicate the evaluation of pulmonary nodules. CASE PRESENTATION: We report a case of an immunocompetent patient who, despite adequate treatment for known histoplasmosis lung infection, presented with radiological and F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) findings mimicking primary lung malignancy which eventually required surgical resection. CONCLUSION: Histoplasmosis infection may radiologically resemble pulmonary malignancy, often causing a diagnostic dilemma. PET imaging is currently used for and considered accurate in the evaluation of pulmonary nodules. However, overlap in PET standardized uptake value (SUV) between granulomatous and malignant lesions decreases the accuracy of PET as a diagnostic modality. Future advances in PET imaging are needed to improve its accuracy in the evaluation of pulmonary nodules in areas where histoplasmosis is endemic.

Pulmonary infiltration from chronic lymphocytic leukemia.

We present 2 patients with chronic lymphocytic leukemia infiltration of the lung resulting in centrilobular nodularity on computed tomography. We present the x-ray and computed tomography patterns with pathological findings in these cases.

Sedation during mechanical ventilation: a trial of benzodiazepine and opiate in combination.

OBJECTIVE: To compare the efficacy of continuous intravenous sedation with midazolam alone vs. midazolam plus fentanyl ("co-sedation") during mechanical ventilation. DESIGN: A randomized, prospective, controlled trial. SETTING: A ten-bed medical intensive care unit at a university hospital. PATIENTS: Thirty patients with respiratory failure who were expected to require >48 hrs of mechanical ventilation and who were receiving a sedative regimen that did not include opiate pain control. INTERVENTIONS: An intravenous infusion of either midazolam alone or co-sedation was administered by a nurse-implemented protocol to achieve a target Ramsay Sedation Score set by the patient's physician. Study duration was 3 days, with a brief daily "wake-up." MEASUREMENTS AND MAIN RESULTS: We recorded the number of hours/day that patients were "off-target" with their Ramsay Sedation Scores, the number of dose titrations per day, the incidence of patient-ventilator asynchrony, and the time required to achieve adequate sedation as measures of sedative efficacy. We also recorded sedative cost in U.S. dollars and adverse events including hypotension, hypoventilation, ileus, and coma. Compared with the midazolam-only group, the co-sedation group had fewer hours per day with an "off-target" Ramsay Score (4.2 +/- 2.4 and 9.1 +/- 4.9, respectively, p < .002). Fewer episodes per day of patient-ventilator asynchrony were noted in the co-sedation group compared with midazolam-only (0.4 +/- 0.1 and 1.0 +/- 0.2, respectively, p < .05). Co-sedation also showed nonsignificant trends toward a shorter time to achieve sedation, a need for fewer dose titrations per day, and a lower total sedative drug cost. There was a trend toward more episodes of ileus with co-sedation compared with midazolam-only (2 vs. 0). CONCLUSIONS: In mechanically ventilated patients, co-sedation with midazolam and fentanyl by constant infusion provides more reliable sedation and is easier to titrate than midazolam alone, without significant difference in the rate of adverse events.

Impact of rapid on-site cytologic evaluation during transbronchial needle aspiration.

STUDY OBJECTIVE: To determine the extent to which rapid on-site cytologic evaluation (ROSE) of transbronchial needle aspiration (TBNA) samples can safely and cost-effectively reduce the need for additional biopsy during bronchoscopy. SETTING: University Hospital in Long Island, NY. PATIENT AND METHODS: Forty-four bronchoscopies with TBNA, most of which utilized ROSE, were evaluated prospectively. The number and types of biopsies performed during each procedure were compared to a preprocedural algorithm to determine the impact of knowing ROSE results during the procedure. Bronchoscopies performed with and without ROSE were compared, as were bronchoscopies with diagnostic and nondiagnostic ROSE results. A cost analysis was performed comparing the Medicare reimbursement for ROSE to the savings of deferring multiple biopsies. RESULTS: Thirty-two bronchoscopies were performed with ROSE; 12 were performed without ROSE. Fewer biopsies were performed during bronchoscopies utilizing ROSE. Diagnostic yield, TBNA sensitivity and accuracy, and procedural time were similar between these two groups. CONCLUSIONS: ROSE during TBNA allows for deferring additional biopsy without loss in diagnostic yield, likely lowers procedural risk, and is cost-effective.

Stable patients receiving prolonged mechanical ventilation have a high alveolar burden of bacteria.

INTRODUCTION: In patients receiving prolonged mechanical ventilation (PMV), quantitative bronchoscopic culture has not been validated for the diagnosis of ventilator-associated pneumonia (VAP). OBJECTIVE: To measure the alveolar burden of bacteria in patients receiving PMV. SETTING: Respiratory care units of a university hospital and a long-term care facility. PATIENTS: Fourteen patients requiring PMV without clinical evidence of pneumonia. MEASUREMENTS: Quantitative culture of BAL from the right middle lobe and lingula. RESULTS: In 29 of 32 lobes, there was growth of at least one organism at > 10(4) cfu/mL. Most lobes had polymicrobial growth. CONCLUSIONS: Stable patients receiving PMV without clinical pneumonia have a high alveolar burden of bacteria. The bacterial burden in most patients exceeds the commonly accepted threshold for diagnosing VAP. The utility of quantitative bronchoscopic culture in the diagnosis of VAP in this patient population requires further study.

Palliation of endobronchial disease: flexible and rigid bronchoscopic options.

Many patients with lung cancer develop airway obstruction and hemoptysis. Endoscopic palliation can relieve symptoms and improve the quality of life for many patients. Patient factors, lesion characteristics and location, and regional expertise are important to consider when planning therapy. Cost, convenience, time to relief of symptoms, duration of palliation, and the need for serial procedures should also be considered. Further advances in technology will likely allow better palliation in the future. A wide armamentarium of modalities and careful communication with the patient's other providers are essential for optimal patient outcome.