A Novel Simulator for Teaching Endobronchial Ultrasound-guided Needle Biopsy.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become standard for the diagnosis of lung cancer, and there is an increasing need for procedural competence in trainees. We evaluate a low-cost, gelatin-based EBUS-TBNA training simulator to assess pulmonary fellows' baseline skills and facilitate procedural development. METHODS: A low-cost ($30) gelatin-based, high-fidelity simulator was created to represent the airways, major vessels, and lymph node stations essential to identify for EBUS-TBNA. Trainees had a baseline skills assessment using the simulator and were then provided a 1-hour didactic session on EBUS-TBNA and additional practice time with the simulator. Trainees then underwent a postsimulation skills assessment using a modified endobronchial ultrasound (EBUS)-Skills and Tasks Assessment Tool (STAT) performance assessment tool. Simulator fidelity and trainee procedural confidence was assessed using a 10-point scale. RESULTS: Ten fellows received training on the EBUS-TBNA simulator. First-year trainees scored the lowest on the 18-point performance scale with a mean score of 9, while third-year trainees scored highest with a mean score of 17.5. Mean 18-point performance score improvement after simulator training and didactics was 4.31 points for all trainees with the largest change in first-year trainees amounting to 8.25 points. First-year trainees experienced the greatest improvement in EBUS procedural confidence by a mean of 2.5 points on a 10-point confidence survey. CONCLUSION: A low-cost EBUS simulator effectively differentiated early and advanced learners based on graded procedural performance scores. Simulation-based practice significantly improved learners' procedural performance, and the degree of improvement correlated with learner inexperience. The simulation significantly increased early learner confidence in EBUS-TBNA technique.

Oral Positive Expiratory Pressure Device for Excessive Dynamic Airway Collapse Caused by Emphysema.

Excessive dynamic airway collapse (EDAC) contributes to breathlessness and reduced quality of life in individuals with emphysema. We tested a novel, portable, oral positive expiratory pressure (o-PEP) device in a patient with emphysema and EDAC. MRI revealed expiratory tracheal narrowing to 80 mm2 that increased to 170 mm2 with the o-PEP device. After 2-weeks use of the o-PEP device for 33% to 66% of activities, breathlessness, quality of life, and exertional dyspnea improved compared with minimal clinically important differences (MCID): University of California-San Diego Shortness of Breath questionnaire score declined 69 to 42 (MCID, ≥5), St. George's Respiratory Questionnaire score decreased 71 to 27 (MCID, ≥4), and before and after the 6-minute walk test Borg score difference improved from Δ3 to Δ2 (MCID, ≥1). During the 6-minute walk test on room air without the use of the o-PEP device, oxyhemoglobin saturation declined 91% to 83%; whereas, with the o-PEP device, the nadir was 90%. Use of the o-PEP device reduced expiratory central airway collapse and improved dyspnea, quality of life, and exertional desaturation in a patient with EDAC and emphysema.

The Impact of Thoracentesis On Postprocedure Pulse Oximetry.

BACKGROUND: Although thoracentesis can offer considerable symptomatic relief to the patient, its physiologic impact on oxygen saturation has not been well established in the literature. This study aimed to evaluate the impact of thoracentesis on postprocedure pulse oximetry (SpO2) in an inpatient population. METHODS: A retrospective study of patients undergoing thoracentesis from January 2012 to November 2017 was performed. Inclusion criteria were age above 18 and thoracentesis performed in an inpatient setting. Records were reviewed for patient demographics, procedure reports, and laboratory values. SpO2 and FiO2 values were collected before and 6 and 24 hours postprocedure. Multivariable linear regression models were used to evaluate for changes in SpO2 and SpO2/FiO2. Analyses were adjusted for age, sex, serum hemoglobin, effusion etiology, volume removed, nonexpandable lung physiology and procedural complications and FiO2. RESULTS: A total of 502 patients were included. The mean (SD) age was 60 (14) years, and 53.4% of the patients were male. The most common cause of pleural effusion was malignant effusion (37%). The median (interquartile range) volume of fluid removed was 1400 (1000 to 2000) mL and nonexpandable lung physiology was noted in 35%. There was no significant within-subject difference in 24 hours postprocedure SpO2 compared with preprocedure SpO2. In multivariable analysis, there was a small increase in 24-hour postprocedure SpO2 [ß=0.31, 95% confidence interval (0.22, 0.41), P<0.01] and a similar small increase in 24-hour postprocedure SpO2/FiO2 [ß=0.84, 95% confidence interval: (0.68, 1.01), P<0.01). CONCLUSION: Among inpatients undergoing thoracentesis, there is no clinically significant change in SpO2 or SpO2/FiO2 at 24-hours post-procedure compared to pre-procedural SpO2 or SpO2/FiO2.

Bronchoscopic ablation techniques in the management of lung cancer.

Central airway involvement is a common manifestation of lung cancer during the disease course. Some patients will require bronchoscopic therapeutic interventions to palliate symptoms, or less commonly to provide more definitive therapy of airway involvement. We describe an overview specifically of bronchoscopic ablative techniques that are available for use in malignant airway obstruction. Techniques that are more commonly used include bronchoscopic application of laser, electrocautery, argon plasma coagulation (APC), cryotherapy and mechanical debulking techniques. Less commonly employed are brachytherapy and photodynamic therapy. These techniques may be applied via flexible or rigid bronchoscopy depending upon the clinical scenario. The choice of technique depends on available tools and expertise, the urgency of the clinical scenario, and whether the lesion is predominately endobronchial, extrinsic compression, or a combination of both. Malignant airway obstruction is a common finding in lung cancer and there are a number of effective bronchoscopic ablative techniques that may be employed safely to palliate patients with a significant symptom burden.

A systematic approach to the management of massive hemoptysis.

Massive hemoptysis is regarded as a potentially lethal condition that requires immediate attention, and prompt action. Although minor hemoptysis is frequently encountered by most clinicians, massive hemoptysis in far less frequent and most physicians are not prepared to manage this time-sensitive clinical presentation in a systematic and timely fashion. Critical initial steps in management need to be implemented in an expedited fashion, such that patients may have a chance at a more definitive treatment. In this article, we review the definition, vascular anatomy, etiology, diagnostic evaluation, epidemiology and prognostic markers of massive hemoptysis. A systematic approach to management, stabilization and treatment options is followed. An algorithm is proposed for the management of massive hemoptysis and the importance of a multidisciplinary approach is emphasized.