Bronchoscopic lung volume reduction: status quo.

Emphysema is associated with irreversible loss of lung compliance leading to gas trapping and hyperinflation. Surgical lung volume reduction has proven to improve lung function, exercise capacity, cardiac health and survival in patients with advanced emphysema; however, this procedure is associated with significant morbidity and mortality. Bronchoscopic lung volume reduction (BLVR) has emerged as an alternative approach for these patients. In this article, we review the different techniques used for the purpose of this procedure, its advantages and disadvantages. In addition, we discuss in length valve therapy and the studies that led to its recent FDA approval. Finally, we provide thought-provoking challenges that may be topics for further future investigation to enhance the efficacy and benefit of this technique.

The Mechanisms of Benefit of High-Flow Nasal Therapy in Stable COPD.

High-flow nasal therapy (HFNT) is a unique system that delivers humidified, heated oxygen-enriched air via nasal cannula at high flow rates. It is a promising therapy for chronic obstructive pulmonary disease (COPD) patients. Several studies have examined the physiologic effects of this therapy in the patient population and have revealed that it improves mucociliary clearance, reduces nasopharyngeal dead space, and subsequently increases CO2 washout. It also improves alveolar recruitment and gas exchange. These mechanisms may explain the promising results observed in recently published studies that examined the role of HFNT in stable COPD patients.

Pneumothorax in COVID-19 disease- incidence and clinical characteristics.

BACKGROUND: Spontaneous pneumothorax is an uncommon complication of COVID-19 viral pneumonia. The exact incidence and risk factors are still unknown. Herein we review the incidence and outcomes of pneumothorax in over 3000 patients admitted to our institution for suspected COVID-19 pneumonia. METHODS: We performed a retrospective review of COVID-19 cases admitted to our hospital. Patients who were diagnosed with a spontaneous pneumothorax were identified to calculate the incidence of this event. Their clinical characteristics were thoroughly documented. Data regarding their clinical outcomes were gathered. Each case was presented as a brief synopsis. RESULTS: Three thousand three hundred sixty-eight patients were admitted to our institution between March 1st, 2020 and June 8th, 2020 for suspected COVID 19 pneumonia, 902 patients were nasopharyngeal swab positive. Six cases of COVID-19 patients who developed spontaneous pneumothorax were identified (0.66%). Their baseline imaging showed diffuse bilateral ground-glass opacities and consolidations, mostly in the posterior and peripheral lung regions. 4/6 cases were associated with mechanical ventilation. All patients required placement of a chest tube. In all cases, mortality (66.6%) was not directly related to the pneumothorax. CONCLUSION: Spontaneous pneumothorax is a rare complication of COVID-19 viral pneumonia and may occur in the absence of mechanical ventilation. Clinicians should be vigilant about the diagnosis and treatment of this complication.

Acute exacerbations of COPD versus IPF in patients with combined pulmonary fibrosis and emphysema.

RATIONALE: Patients with combined pulmonary fibrosis and emphysema (CPFE) may develop acute exacerbations of IPF (AE-IPF) or COPD (AE-COPD). The incidence and the characteristics of exacerbations in patients with CPFE (e.g., COPD vs IPF) have not been well described. OBJECTIVES: To compare the incidence and rate of exacerbations in patients with CPFE vs. IPF and evaluate their effect on clinical outcomes. METHODS: Comprehensive clinical data from CPFE and IPF patients were retrospectively reviewed. Baseline characteristics including lung function data, oxygen requirements, and pulmonary hemodynamics, were collected. Acute exacerbation events in both groups were defined clinically and radiographically. In the CPFE group, two patterns of exacerbations were identified. AE-COPD was defined clinically by symptoms of severe airflow obstruction causing respiratory failure and requiring hospitalization. Radiographic data were also defined based on previously published literature. AE-IPF was defined clinically as an acute hypoxic respiratory failure, requiring hospitalization and treatment with high dose corticosteroids. Radiographically, patients had to have a change in baseline imaging including presence of ground-glass opacities, interlobular septal thickening or new consolidations; that is not fully explained by other etiologies. RESULTS: Eighty-five CPFE patients were retrospectively compared to 112 IPF patients. Of 112 patients with IPF; 45 had AE-IPF preceding lung transplant (40.18%) compared to 12 patients in the CPFE group (14.1%) (p < 0.05). 10 patients in the CPFE group experienced AE-COPD (11.7%). Patients with AE-IPF had higher mortality and more likely required mechanical ventilation and extracorporeal membrane oxygenation (ECMO) compared to patients with AE-COPD, whether their underlying disease was IPF or CPFE. CONCLUSIONS: CPFE patients may experience either AE-IPF or AE-COPD. Patients with CPFE and AE-COPD had better outcomes, requiring less intensive therapy compared to patients with AE-IPF regardless if underlying CPFE or IPF was present. These data suggest that the type of acute exacerbation, AE-COPD vs AE-IPF, has important implications for the treatment and prognosis of patients with CPFE.

Sleep Duration and Efficiency Associated With Better Functional Exercise Capacity in Black Smokers at Risk for COPD.

BACKGROUND: Black smokers have earlier development of lung disease as well as poorer sleep health than whites. RESEARCH QUESTION: In a sample of black smokers, to what extent does sleep health modify the association between smoking level and functional exercise capacity? DESIGN AND METHODS: Cross-sectional data from 209 black smokers (≥ 1 cigarette in last month), aged 40 to 65 years with no evidence of sleep-disordered breathing (apnea-hypopnea index < 15) or severe COPD (FEV1 > 50%), were used for the current study. Self-reported smoking rate, objectively measured sleep efficiency (SE), total sleep time (TST), and the 6-min walk test (6MWT) for functional exercise capacity were the key assessments. RESULTS: The mean age was 54.8 years (SD, 5.96), and mean cigarettes smoked per day (cpd) was 8.71 (SD, 6.78). Mean SE was 69.9% (SD, 12.3%), and mean TST was 307.99 min (SD 92.2). In adjusted linear regression models of the 6MWT (meters), TST (slope estimate, -0.14; P = .14) and SE (slope estimate, -1.0; P = .19) were negatively associated with 6MWT. The smoking rate × SE interaction was highly significant (slope estimate, 0.18; P = .007) such that in individuals who smoked ≥ 10 cpd, every additional percentage of SE garnered an additional distance of 0.83 to 6.62 m. Similarly, the smoking rate × TST interaction was significant (slope estimate, 0.019; P = .03) such that in smokers who smoked ≥ 10 cpd, every additional minute of TST garnered an additional distance of 0.04 to 0.60 m. INTERPRETATION: Higher SE and, to a lesser extent, longer TST, in black adults who smoke ≥ 10 cpd is associated with better 6MWT performance. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT03534076; URL: www.clinicaltrials.gov.

Endobronchial removal of uncovered stent using argon plasma coagulation via fibreoptic bronchoscopy.

Bronchial stenosis is a complication of lung transplantation that often requires repeated balloon dilation, endobronchial treatments, and possibly stent placement. Endobronchial stents, particularly uncovered ones, may have several complications including excessive granulation tissue that cause airways obstruction and impaired mucociliary clearance, which may lead to inflammation and infections. Removal of epithelized endobronchial stents is usually done in the operating room using rigid bronchoscopy. Argon plasma coagulation (APC) has been used for removal of biliary stents. One case report described an endotracheal uncovered stent removal using this technique. APC can be used via flexible bronchoscopy, which may carry less risk of complications and can be done in an outpatient setting. In this case, we report using APC, at a low energy level, for complete removal of a totally epithelialized endobronchial uncovered stent in a patient experiencing stent-related complications.

Tuberculous pleural effusion occurring concurrently with asbestos-related pleural disease.

An eighty-four-year-old man presented with progressive exertional dyspnea, productive cough and weight loss for two months. His physical exam was notable for diminished breath sounds at the right base, with dullness to percussion. Chest-x-ray showed moderate right-sided pleural effusion and bilateral calcified pleural plaques as well as diaphragmatic plaques consistent with asbestos-related pleural disease (ARPD). Pleural fluid was exudative with predominantly mononuclear cells, negative acid fast bacilli stain, negative cultures, and negative cytology for malignant cells. Due to recurrence of the effusion, 4 weeks after drainage, thoracoscopic pleural biopsy was planned but pleural fluid cultures came back positive for mycobacteria tuberculosis. Patient was started on anti-tubercular therapy but treatment had to be stopped due to liver toxicity. Patient subsequently developed pneumonia and deteriorated despite antibiotic therapy and expired.

Acute Respiratory Failure due to Neuromyelitis Optica Treated Successfully with Plasmapheresis.

Neuromyelitis Optica (NMO) is a demyelinating autoimmune disease involving the central nervous system. Acute respiratory failure from cervical myelitis due to NMO is known to occur but is uncommon in monophasic disease and is treated with high dose steroids. We report a case of a patient with NMO who developed acute respiratory failure related to cervical spinal cord involvement, refractory to pulse dose steroid therapy, which resolved with plasmapheresis.