Endobronchial ultrasound sonographic characteristics of mediastinal lymph node in evaluation of lung cancer.

Endobronchial ultrasound (EBUS) and contrast enhanced computed tomography (CECT) are essential components of lung cancer evaluation. Features of mediastinal lymph nodes on EBUS and CECT can help in predicting metastatic disease. Clinical, radiological and EBUS data of patients with clinico-radiological suspicion of lung cancer and have undergone EBUS with no trans-bronchial needle aspiration (TBNA) or nonyielding EBUS-TBNA were retrospectively collected from medical records. EBUS features of lymph nodes for metastatic disease [Size >1cm, round shape, heterogeneous echo-texture, indistinct margin, coagulation necrosis(CN), absence of central hilar structures (CHS) and grade II-III vascularity] were noted. CECT findings were noted from CECT films and reports to analyse and compare with EBUS findings. Scoring criteria of EBUS sonographic characteristics from previous studies for discriminating benign and malignant lymph-nodes were also assessed for possible prediction. Thirty-one (31) patients [male=18 (58.1%), female=13 (41.9); age (mean±SD) =52.9±15.7 years] with CECT findings suggesting lung cancer were studied. EBUS showed mediastinal lymphadenopathy at 82 lymph node station in 29 patients. Size>1cm, round shape, heterogeneous echo-texture, distinct margin, CN, absence of CHS and grade II-III vascularity at 33 (40%), 28 (34%), 31 (38%), 55 (67%), 3 (4%), 77 (94%) and 6 (7.3%) lymph nodes, respectively. Malignant or benign status assigned to lymph nodes using different scoring criteria were highly discordant. Compared to EBUS, CECT revealed abnormal mediastinal lymph nodes (LN) in significantly less number of patients [21( 67.7%) vs 29 (93.5%), p=0.01] involving less number of lymph node stations (LNS) [(37 vs 82, p<0.001]. Lymphadenopathy frequency at different LNS on EBUS and CECT showed a weak positive but significant correlation (r=0.356; p=0.0426). EBUS characteristics and related scores have limited accuracy in differentiating benign and malignant nodes. CECT underestimates lymph-adenopathy in comparison to EBUS. Larger prospective study of EBUS features with cyto/histo-pathology correlation may elicit its clinical significance and help to create a better and composite scoring criteria.

Helmet NIV in Acute Hypoxemic Respiratory Failure due to COVID-19: Change in PaO2/FiO2 Ratio a Predictor of Success.

In acute respiratory failure due to severe coronavirus disease 2019 (COVID-19) pneumonia, mechanical ventilation remains challenging and may result in high mortality. The use of noninvasive ventilation (NIV) may delay required invasive ventilation, increase adverse outcomes, and have a potential aerosol risk to caregivers. Data of 30 patients were collected from patient files and analyzed. Twenty-one (70%) patients were weaned successfully after helmet-NIV support (NIV success group), and invasive mechanical ventilation was required in 9 (30%) patients (NIV failure group) of which 8 (26.7%) patients died. In NIV success vs failure patients, the mean baseline PaO2/FiO2 ratio (PFR) (147.2 ± 57.9 vs 156.8 ± 59.0 mm Hg; p = 0.683) and PFR before initiation of helmet (132.3 ± 46.9 vs 121.6 ± 32.7 mm Hg; p = 0.541) were comparable. The NIV success group demonstrated a progressive improvement in PFR in comparison with the failure group at 2 hours (158.8 ± 56.1 vs 118.7 ± 40.7 mm Hg; p = 0.063) and 24 hours (PFR-24) (204.4 ± 94.3 vs 121.3 ± 32.6; p = 0.016). As predictor variables, PFR-24 and change (delta) in PFR at 24 hours from baseline or helmet initiation (dPFR-24) were significantly associated with NIV success in univariate analysis but similar significance could not be reflected in multivariate analysis perhaps due to a small sample size of the study. The PFR-24 cutoff of 161 mm Hg and dPFR-24 cutoff of -1.44 mm Hg discriminate NIV success and failure groups with the area under curve (confidence interval) of 0.78 (0.62-0.95); p = 0.015 and 0.74 (0.55-0.93); p = 0.039, respectively. Helmet interface NIV may be a safe and effective tool for the management of patients with severe COVID-19 pneumonia with acute respiratory failure. More studies are needed to further evaluate the role of helmet NIV especially in patients with initial PFR <150 mm Hg to define PFR/dPFR cutoff at the earliest time point for prediction of helmet-NIV success. How to cite this article Jha OK, Kumar S, Mehra S, Sircar M, Gupta R. Helmet NIV in Acute Hypoxemic Respiratory Failure due to COVID-19: Change in PaO2/FiO2 Ratio a Predictor of Success. Indian J Crit Care Med 2021;25(10):1137-1146.

High-flow Tracheal Oxygenation: A New Tool for Difficult Weaning.

High-flow tracheal oxygenation (HFTO), a modification of high-flow nasal cannula (HFNC), has been used in tracheostomized patients but only rarely for weaning. We present two cases on prolonged mechanical ventilation (PMV) where HFTO assisted weaning. HOW TO CITE THIS ARTICLE: Ramachandran L, Jha OK, Sircar M. High-flow Tracheal Oxygenation: A New Tool for Difficult Weaning. Indian J Crit Care Med 2021;25(2):224-227.

Noninvasive Ventilation-assisted Bronchoscopy in High-risk Hypoxemic Patients.

BACKGROUND AND AIMS: Hypoxemic patients undergoing fiber-optic bronchoscopy (FOB) are at risk of worsening of respiratory failure requiring mechanical ventilation due to FOB procedure itself and its complications. As patients with respiratory failure are frequently managed by non-invasive ventilation (NIV); feasibility of FOB through NIV mask has been evaluated in some studies to avoid intubation. We describe here our own case series. MATERIALS AND METHODS: Clinical data of 28 FOB done through NIV mask in 27 intensive care unit (ICU) patients over 6 years period at our center was collected retrospectively and analysed. RESULTS: Study comprises 27 (17 male; 52±21.6 years age) hypoxemic (PaO2 71.3±14.2, on NIV and oxygen supplementation) patients. All FOB were done at bedside, 15 of them were given sedation for the procedure. Twenty four patients had bronchoalveolar lavage (BAL); three underwent bronchial biopsies, four brush cytology and seven transbronchial biopsies. In 10 patients lung or lobar collapse was reversed. There was no significant change between pre and post bronchoscopy ABG parameters except for improved post FOB PaO2 (p = 0.0032) and SpO2 (p = 0.0046). One patient (3.57%) developed late pneumothorax and 3 patients (10.7%) had bleeding after biopsy. Prior to bronchoscopy 17 (16 BIPAP, 1 CPAP) patients were already on NIV. Two patients required mechanical ventilation 6 hours after FOB due to subsequent clinical deterioration but could be weaned off later. One patient died on third day after FOB from acute myocardial infarction. CONCLUSION: Hypoxemic patients in ICU can safely undergo bedside diagnostic and simple therapeutic bronchoscopy with NIV support while mostly avoiding intubation and with low complication rates. HOW TO CITE THIS ARTICLE: Sircar M, Jha OK, Chabbra GS, Bhattacharya S. Noninvasive Ventilation-assisted Bronchoscopy in High-risk Hypoxemic Patients. Indian J Crit Care Med 2019;23(8):363-367.

Perpetual dilemma: Pleural or parenchymal/congenital or acquired solitary cystic lesion with fluid level.

Congenital cystic adenomatoid malformations (CCAMs) are rare congenital, nonhereditary developmental anomalies of the lung with unknown etiology. CCAM is predominantly a disorder of infancy with the majority of the cases being diagnosed within the first 2 years of life. When CCAM presents in adults, it represents a diagnostic dilemma and requires careful evaluation. We here report a case of large solitary congenital pulmonary cystic adenomatoid malformation with infection and hemorrhage, which was diagnosed as encysted hydropneumothorax on computerized tomography scans but turned out to be infected pulmonary cystic adenomatoid malformation after surgical excision.

Hemorrhagic sarcoid pleural effusion: A rare entity.

Involvement of pleura by sarcoidosis remains a rare manifestation and varies from pleural effusion, pneumothorax, pleural thickening, hydropneumothorax, trapped lung, hemothorax, or chylothorax. Sarcoid pleural effusions presenting as hemorrhagic effusions are even more rare. We report a case of active pulmonary sarcoidosis presenting as hemorrhagic pleural effusion requiring tissue diagnosis to rule out malignancy. The rarity of the presentation prompted us to report this case.

Tombs of Aspergillus: A missed cause of recurrent respiratory infections in allergic bronchopulmonary aspergillosis.

Broncholithiasis is an often overlooked condition and has been associated with symptoms such as cough, hemoptysis, and recurrent respiratory infections. The most common mechanism of a broncholith formation is the enlargement and subsequent erosion of a lymph node into an adjacent airway. Here, we describe this entity in a patient with advanced allergic bronchopulmonary aspergillosis, with chronic hypercapnic respiratory failure, and with frequent infective exacerbations. These frequent exacerbations were initially attributed to the poor lung function of the patient and the inability to cough out the secretions. The diagnosis of broncholithiasis was eventually established on bronchoscopy, when the patient was intubated and mechanically ventilated. In this patient, the mixed broncholiths were not associated with mediastinal lymphadenopathy and with biopsy showing Aspergillus with no lymph node tissue indicating its bronchial origin. A high index of suspicion should be kept in patients with recurrent infective exacerbations of pulmonary diseases, especially when computed tomography images show calcifications in the vicinity of airways even in the absence of lymphadenopathy, as most of these can be treated with routine bronchoscopic interventions.

Impact of bronchoalveolar lavage multiplex polymerase chain reaction on microbiological yield and therapeutic decisions in severe pneumonia in intensive care unit.

PURPOSE: The purpose of the study is to evaluate the impact of adding bronchoalveolar lavage multiplex polymerase chain reaction (M-PCR) to conventional cultures (CC) on microbiological yield and therapeutic decisions in adult intensive care unit patients with pneumonia and severe sepsis or septic shock. MATERIAL AND METHODS: In this retrospective case-control study, bronchoalveolar lavage cultures were taken for control (58 patients, 58 admissions) and study arms (57 patients, 58 admissions). Bronchoalveolar lavage M-PCR was sent simultaneously for the latter. RESULTS: A total of 267 microorganisms were identified (M-PCR alone, 211; CC alone, 15; both, 41) in the study arm vs 64 in controls. Concordance between M-PCR and culture was complete in 32 (55.17%), partial in 4 (6.9%), and discordant in 22 (37.93%) including 17 with positive M-PCR but negative CC. Time to antibiotic therapy modification was significantly less (P < .001) in M-PCR group compared to controls (32.40 ± 14.41 vs 41.74 ± 45.61 hours). There was no significant difference in index episode resolution (48.3% vs 50%; P = 1), intensive care unit mortality (57.4% vs 51.2%; P = .67), and hospital mortality (59.6% vs 61.5%; P = 1) in study and control arms, respectively, despite more septic shock patients in the study arm (89.7% vs 75.9%; P = .05). CONCLUSION: Bronchoalveolar lavage M-PCR with culture leads to higher microbiological yield and earlier modification of antibiotics compared to conventional culture.

Novel computed tomography indexes of left atrial appendage stasis.

Contrast enhanced multi-detector computed tomography (MDCT) may detect left atrial appendage (LAA) thrombus; however, its ability to qualify LAA stasis has not been studied. We sought to identify MDCT derived LAA radiographic parameters which could qualify LAA stasis as defined by established transesophageal echocardiography (TEE) parameters. Pre-procedural MDCT followed by TEE (median procedural time difference of 11 days) from 45 patients who underwent ablation for atrial fibrillation were analyzed retrospectively. Contrast enhanced, non-gated, helical MDCT (64 detector row) was performed according to the institutional protocol. Using a combination of parametric and nonparametric tests, the mean attenuation and heterogeneity parameters of LAA attenuation were correlated with the presence of spontaneous echocardiographic contrast and Doppler derived LAA emptying velocity on TEE. If significant correlation is observed, a receiver operating curve analysis will be performed. The baseline characteristics of the studied population were; age, 62 ± 11; CHADS2 score, 2.0 ± 1.2; heart rate, 79 ± 10 bpm; left ventricular ejection fraction, 49 ± 14%. SEC was seen on TEE in 19 patients; ten with mild, eight with moderate, and one had severe SEC. No patients had LAA thrombus. Compared with the group without SEC, those with SEC had significantly increased coefficient of variation (0.19 vs. 0.14, p = 0.014) and range to mean ratio (1.04 vs. 0.73, p = 0.011). There was no significant correlation between mean LAA attenuation and LAA emptying velocity. However, the range, range to mean ratio, standard deviation and coefficient of variation of LAA attenuation had a significantly negative correlation with LAA emptying velocity (r = -0.486, r = -0.497, r = -0.434, r = -0.466, respectively, all p < 0.05). On receiver operating curve analysis, each of the heterogeneity parameters significantly discriminated LAA emptying velocities ≤30 cm/s, with areas under the curve of 0.88, 0.83, 0.81 and 0.76 respectively. In patients with atrial fibrillation, increased contrast heterogeneity within the LAA on MDCT correlated with decreased LAA emptying velocity on TEE. Contrast enhanced MDCT provides an adjunctive, noninvasive technique for Qualification of LAA stasis.

Reversible hypogonadism in Bardet-Biedl syndrome.

OBJECTIVE: To report a patient with Bardet-Biedl syndrome (BBS) with known hypogonadotrophic hypogonadism who developed spontaneous reversal of hypogonadism in adulthood. DESIGN: Case report and discussion. SETTING: Endocrine unit of a tertiary hospital. PATIENT(S): A 30-year-old male patient with BBS. INTERVENTION(S): Clinical evaluation, fine-needle aspiration of the testes, hormonal, cytogenetic, and pathologic evaluation. MAIN OUTCOME MEASURE(S): Serum gonadotropins and testosterone levels and presence of spermatogenesis in testicular aspirate. RESULT(S): Serum testosterone and gonadotropin levels were within the normal adult male range. Testicular aspirates showed spermatogenic cells of all series, including numerous spermatozoa and a few intact seminiferous tubules. The overall picture appeared to be consistent with normal spermatogenesis. CONCLUSION(S): This is the first case of reversal of hypogonadotrophic hypogonadism in a male patient with BBS. Clinicians should look for such reversal in other patients with hypogonadotrophic hypogonadism and give appropriate prognosis.