Pulmonary Procedures in the COVID-19 Era.

Purpose of Review: The purpose of this review is to discuss the impact of the COVID-19 pandemic on pulmonary procedures, including new guidelines, restrictions, techniques, and overall effect on patient care. Recent Findings: SARS-CoV-2 predominately impacts the pulmonary system and can result in a severe lower respiratory tract infection. Early guidelines based largely on data from the SARS epidemic recommended significant restrictions on procedure volume out of concern for healthcare worker safety. Newer data suggests relative safety in performing airway and pleural procedures as long as appropriate precautions are followed and new techniques are utilized. The introduction of effective vaccines and more reliable testing has led to a re-expansion of elective procedures. Summary: Many guidelines and expert statements exist for the management and practice of pulmonary procedures during the COVID-19 pandemic. A flexible and individualized approach may be necessary as our understanding of COVID-19 continues to evolve.

The Epidemiology of Adult Tracheostomy in the United States 2002-2017: A Serial Cross-Sectional Study.

Describe the longitudinal national epidemiology of tracheostomies performed in acute care hospitals and describe the annual rate of tracheostomy performed for patients with respiratory failure with invasive mechanical ventilation. DESIGN: Serial cross-sectional study. SETTING: The 2002-2014 and 2016-2017 Healthcare Utilization Project's National Inpatient Sample datasets. PATIENTS: Discharges greater than or equal to 18 years old, excluding those with head and neck cancer or transferred from another hospital. We used diagnostic and procedure codes from the International Classification of Diseases, 9th and 10th revisions to define cases of respiratory failure, invasive mechanical ventilation, and tracheostomy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were an estimated 80,612 tracheostomies performed in 2002, a peak of 89,545 tracheostomies in 2008, and a nadir of 58,840 tracheostomies in 2017. The annual occurrence rate was 37.5 (95% CI, 34.7-40.4) tracheostomies per 100,000 U.S. adults in 2002, with a peak of 39.7 (95% CI, 36.5-42.9) in 2003, and with a nadir of 28.4 (95% CI, 27.2-29.6) in 2017. Specifically, among the subgroup of hospital discharges with respiratory failure with invasive mechanical ventilation, an annual average of 9.6% received tracheostomy in the hospital. This changed over the study period from 10.4% in 2002, with a peak of 10.9% in 2004, and with a nadir of 7.4% in 2017. Among respiratory failure with invasive mechanical ventilation discharges with tracheostomy, the annual proportion of patients 50-59 and 60-69 years old increased, whereas patients from 70 to 79 and greater than or equal to 80 years old decreased. The mean hospital length of stay decreased, and in-hospital mortality decreased, whereas discharge to intermediate care facilities increased. CONCLUSIONS: Over the study period, there were decreases in the annual total case volume and adult occurrence rate of tracheostomy as well as decreases in the rate of tracheostomy among the subgroup with respiratory failure with invasive mechanical ventilation. There is some evidence of changing patterns of patient selection for in-hospital tracheostomy among those with respiratory failure with invasive mechanical ventilation with decreasing proportions of patients with advanced age.

Variable Learning Curve of Basic Rigid Bronchoscopy in Trainees.

BACKGROUND: Despite increased use of rigid bronchoscopy (RB) for therapeutic indications and recommendations from professional societies to use performance-based competency, an assessment tool has not been utilized to measure the competency of trainees to perform RB in clinical settings. OBJECTIVES: The aim of the study was to evaluate a previously developed assessment tool - Rigid Bronchoscopy Tool for Assessment of Skills and Competence (RIGID-TASC) - for determining the RB learning curve of interventional pulmonary (IP) trainees in the clinical setting and explore the variability of learning curve of trainees. METHODS: IP fellows at 4 institutions were enrolled. After preclinical simulation training, all RBs performed in patients were scored by faculty using RIGID-TASC until competency threshold was achieved. Competency threshold was defined as unassisted RB intubation and navigation through the central airways on 3 consecutive patients at the first attempt with a minimum score of 89. A regression-based model was devised to construct and compare the learning curves. RESULTS: Twelve IP fellows performed 178 RBs. Trainees reached the competency threshold between 5 and 24 RBs, with a median of 15 RBs (95% CI, 6-21). There were differences among trainees in learning curve parameters including starting point, slope, and inflection point, as demonstrated by the curve-fitting model. Subtasks that required the highest number of procedures (median = 10) to gain competency included ability to intubate at the first attempt and intubation time of <60 s. CONCLUSIONS: Trainees acquire RB skills at a variable pace, and RIGID-TASC can be used to assess learning curve of IP trainees in clinical settings.

Percutaneous Tracheostomy With Apnea During Coronavirus Disease 2019 Era: A Protocol and Brief Report of Cases.

OBJECTIVE: To assess feasibility of modified protocol during percutaneous tracheostomy in coronavirus disease 2019 pandemic era. DESIGN: A retrospective review of cohort who underwent percutaneous tracheostomy with modified protocol. SETTINGS: Medical, surgical, and neurologic ICUs. SUBJECTS: Patients admitted in medical, surgical, and neurologic units with prolonged need of mechanical ventilation or inability to liberate from the ventilator. INTERVENTIONS: A detailed protocol was written. Steps were defined to be performed before apnea and during apnea. A feasibility study of 28 patients was conducted. The key aerosol-generating portions of the procedure were performed with the ventilator switched to standby mode with the patient apneic. MEASUREMENTS AND MAIN RESULTS: Data including patient demographics, primary diagnosis, age, body mass index, and duration of apnea time during the tracheostomy were collected. Average ventilator standby time (apnea) during the procedure was 238 seconds (3.96 min) with range 149 seconds (2.48 min) to 340 seconds (5.66 min). Single-use (disposable) bronchoscopes (Ambu A/S [Ballerup, Denmark] or Glidescope [Verathon, Inc., Bothell, WA]) were used during all procedures except in nine. No desaturation events occurred during any procedure. CONCLUSIONS: Percutaneous tracheostomy performed with apnea protocol may help minimize aerosolization, reducing risk of exposure of coronavirus disease 2019 to staff. It can be safely performed with portable bronchoscopes to limit staff and minimize the surfaces requiring disinfection post procedure.

A 68-Year-Old Musician With Cough, Wheezing, and a Lung Mass.

A 68-year-old man was referred to the pulmonary clinic for evaluation of cough and a 5-cm right upper lobe mass. He was in his usual state of health until 1 year prior when he developed intermittent cough, wheezing, and sinus congestion. He denied any sputum production or hemoptysis. He also denied any fevers, chills, or weight loss. He had received various treatments within the prior 6 months, including short courses of oral prednisone, levofloxacin, and bronchodilators, without any relief of his symptoms.

Comparative cost analysis of endobronchial ultrasound-guided and blind TBNA in the evaluation of hilar and mediastinal lymphadenopathy.

BACKGROUND: The superior accuracy of endobronchial ultrasound (EBUS) averts many diagnostic surgical procedures. This likely leads to significant cost savings despite an increased per procedure cost. We sought to compare the true costs of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) compared with "blind" fiberoptic bronchoscopy-transbronchial needle aspiration (FB-TBNA) factoring in the impact of diagnostic surgical procedures in the diagnosis of mediastinal lymphadenopathy. METHODS: In this retrospective case study, we selected 294 patients with thoracic lymphadenopathy as diagnosed by computed tomography at a university hospital. Information was extracted from the electronic record. Costs were determined from the Centers for Medicare and Medicaid Services resource-based relative value scale. We defined a positive diagnosis as one where benign or malignant disease was found. A negative biopsy was one where lymph node sampling was confirmed, but no pathology (benign or malignant) was seen. A nondiagnostic biopsy was one where no pathology was seen and lymph node sampling could not be confirmed. The total cost of endoscopic and surgical diagnostic procedures was tallied for each patient to obtain mean costs per patient. RESULTS: Thirty-seven patients underwent FB-TBNA and 257 underwent EBUS-TBNA. A diagnosis was found in 90% of patients in the EBUS group and 62.2% of patients in the FB-TBNA group (P<0.001). More patients in the FB-TBNA group underwent a diagnostic surgical procedure (HR= -0.1573, 95% confidence interval, -0.30 to -0.15; P<0.001). After accounting for all diagnostic procedures, the mean savings with EBUS was $1071.09 (P=0.09) per patient. CONCLUSIONS: EBUS-TBNA is less expensive than blind FB-TBNA in the evaluation of thoracic lymphadenopathy when accounting for diagnostic surgical procedures.

Effect of routine clopidogrel use on bleeding complications after ultrasound-guided thoracentesis.

BACKGROUND: Thoracentesis is one of the most commonly performed medical procedures with an excellent safety profile. Clopidogrel (a compound that inhibits adenosine diphosphate-induced platelet aggregation) is often prescribed for primary or secondary prevention of cardiovascular disease and has been associated with bleeding complications in patients undergoing surgical procedures. The purpose of this study was to assess the safety of ultrasound (US)-guided thoracentesis in patients receiving clopidogrel therapy. METHODS: Data were collected on 30 consecutive patients taking clopidogrel without other known underlying coagulation problems. These patients underwent 45 US-guided thoracenteses over 26 months. Clopidogrel was not discontinued before the thoracentesis in patients presenting with symptomatic pleural effusion. Thoracenteses were performed in these patients and the incidence of bleeding and other complications among patients was reported. RESULTS: Between June 2009 and August 2011, there were 30 consecutive patients on clopidogrel at the time of thoracenteses. These patients presented with respiratory distress because of pleural effusion and underwent a total of 45 thoracenteses. There was no significant bleeding or other complications in this patient population. No patient required transfusion after the procedure. CONCLUSION: Patients who are receiving clopidogrel and present with symptomatic pleural effusion can safely undergo US-guided thoracentesis without interrupting clopidogrel before the procedure. Larger studies are required to confirm these results.

Central intranodal vessels to predict cytology during endobronchial ultrasound transbronchial needle aspiration.

BACKGROUND: : There has been recent interest in identifying the endoscopic ultrasonographic characteristics of lymph nodes (LNs) that predict the presence or absence of malignant involvement. Normal LN anatomy includes the presence of a central intranodal blood vessel (CIV) that can be obliterated with invasion of malignant cells. We sought to determine whether examining LNs for the presence or absence of a CIV during endobronchial ultrasound (EBUS) could predict benign or malignant cytology of the samples obtained. METHODS: : We prospectively evaluated patients undergoing EBUS-transbronchial needle aspiration (TBNA) for mediastinal or hilar adenopathy in a tertiary care referral center. All LNs were prospectively characterized as having or not having a CIV and subsequently classified as benign or malignant by cytologic analysis. RESULTS: : A total of 56 patients undergoing EBUS-TBNA were evaluated. One hundred three LNs were available for analysis. Fifty-six of 103 LNs were positive for malignancy (54.3%). Ultrasonographic identification of a CIV was associated with benign LN cytology with a sensitivity of 83.0% and a specificity of 91.1% and an OR of 49.7 (95% confidence interval, 15.1-163.9). Finding a CIV had a positive predictive value for benign LN cytology of 88.6%. The absence of finding a CIV had a positive predictive value for malignant cytology of 86.4%. The presence or absence of a CIV had an overall diagnostic accuracy of 87.4% (correctly categorizing 90 of 103 LNs). CONCLUSIONS: : There are morphologic characteristics of LNs that can be visualized at the time of EBUS to help predict whether the nodes being evaluated have malignant involvement. The presence of a CIV suggests that the node is benign, whereas the absence of a central intranodal vessel increases the likelihood of malignancy. The presence or absence of a CIV has a good overall accuracy in predicting malignancy (87.4%).

Pleuroscopy for diagnosis and therapy for pleural effusions.

Pleuroscopy, also known as medical thoracoscopy, is a minimally invasive procedure to inspect and perform a biopsy of the pleural space as well as to perform therapeutic interventions. It differs from conventional video-assisted thoracic surgery in that it may be performed under moderate sedation in the endoscopy suite without the need for intubation or single-lung ventilation. The diagnostic accuracy of this procedure approaches 100% in malignant and tuberculous pleural effusions. Complication rates are low (2%-5%) and are typically minor (subcutaneous emphysema, bleeding, infection), with mortality rates <0.1%. Therapeutic interventions, such as chemical pleurodesis, may be performed during pleuroscopy for recurrent, symptomatic malignant pleural effusions, with success rates approaching 90%. In trained hands, pleuroscopy is a safe and well-tolerated procedure with high diagnostic accuracy and therapeutic efficacy.

Alcohol abuse enhances pulmonary edema in acute respiratory distress syndrome.

BACKGROUND: Pulmonary edema is a cardinal feature of the life-threatening condition known as acute respiratory distress syndrome (ARDS). Patients with chronic alcohol abuse are known to be at increased risk of developing and dying from ARDS. Based upon preclinical data, we hypothesized that a history of chronic alcohol abuse in ARDS patients is associated with greater quantities and slower resolution of pulmonary edema compared with ARDS patients without a history of alcohol abuse. METHODS: A PiCCO transpulmonary thermodilution catheter was inserted into 35 patients within 72 hours of meeting American European Consensus Criteria definition of ARDS. Pulmonary edema was quantified as extravascular lung water (EVLW) and measured for up to 7 days in 13 patients with a history of chronic alcohol abuse and 22 patients without a history of chronic alcohol abuse. RESULTS: Mean EVLW was higher in patients with a history of chronic alcohol abuse (16.6 vs. 10.5 ml/kg, p < 0.0001). Patients with alcohol abuse had significantly greater EVLW over the duration of the study (RM-ANOVA p = 0.003). There was a trend towards slower resolution of EVLW in patients with a history of alcohol abuse (a decrease of 0.5 ml/kg vs. 2.4 ml/kg, p = 0.17) over the study period. A history of alcohol abuse conferred a greater than 3-fold increased risk of elevated EVLW [OR 3.16, (1.26 to 7.93)] using multivariate logistic regression analysis. CONCLUSIONS: In patients who develop ARDS, alcohol abuse is associated with greater levels EVLW and a trend towards slower resolution of EVLW. Combined with mechanistic and preclinical evidence linking chronic alcohol consumption and ARDS, targeted therapies should be developed for these patients.

Accurate characterization of extravascular lung water in acute respiratory distress syndrome.

OBJECTIVES: Measurements of extravascular lung water (EVLW) correlate to the degree of pulmonary edema and have substantial prognostic information in critically ill patients. Prior studies using single indicator thermodilution have reported that 21% to 35% of patients with clinical acute respiratory distress syndrome (ARDS) have normal EVLW (<10 mL/kg). Given that lung size is independent of actual body weight, we sought to determine whether indexing EVLW to predicted or adjusted body weight affects the frequency of increased EVLW in patients with ARDS. DESIGN: Prospective, observational cohort study. SETTING: Medical and surgical intensive care units at two academic hospitals. PATIENTS: Thirty patients within 72 hrs of meeting American-European Consensus Conference definition of ARDS and 14 severe sepsis patients without ARDS. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: EVLW was measured for 7 days by PiCCO transpulmonary thermodilution; 225 measurements of EVLW indexed to actual body weight (ActBW) were compared with EVLW indexed to predicted body weight (PBW) and adjusted body weight (AdjBW). Mean EVLW indexed to ActBW was 12.7 mg/kg for ARDS patients and 7.8 mg/kg for non-ARDS sepsis patients (p < .0001). In all patients, EVLW increased an average of 1.1 +/- 2.1 mL/kg when indexed to AdjBW and 2.0 +/- 4.1 mL/kg when indexed to PBW. Indexing EVLW to PBW or AdjBW increased the proportion of ARDS patients with elevated EVLW (each p < .05) without increasing the frequency of elevated EVLW in non-ARDS patients. EVLW indexed to PBW had a stronger correlation to Lung Injury Score (r2 = .39 vs. r2 = .17) and PaO2/FiO2 ratio (r2 = .25 vs. r2 = .10) than did EVLW indexed to ActBW. CONCLUSIONS: Indexing EVLW to PBW or AdjBW reduces the number of ARDS patients with normal EVLW and correlates better to Lung Injury Score and oxygenation than using ActBW. Studies are needed to confirm the presumed superiority of this method for diagnosing ARDS and to determine the clinical treatment implications.