A case of naganishial pleuritis in a kidney transplant recipient.

The Naganishia species is a mycosis, previously classified as a non-neoformans Cryptococcus species. The increased number of naganishial infections occurs predominantly in immunocompromised conditions, especially in people living with HIV with low CD4 cell count, primary immunodeficiencies, and iatrogenic immunosuppression. The lungs can serve as the primary site of infection, leading to various pulmonary manifestations. However, naganishial pleural effusions are unrecognized and challenged in diagnosis because of their presentation, which can mimic tuberculous pleural effusion. Herein, we report the case of a 53-year-old man who had undergone kidney transplantation for more than 2 years and presented with chest tightness and dyspnea. Computed chest tomography demonstrated left pleural nodules and pleural effusion, later confirmed as exudative pleural effusion with a lymphocyte predominance. Pleuroscopy revealed multiple small pleural nodules, and biopsies of these nodules were performed. Naganishia spp. was identified by the 18S rRNA sequencing technique.

Rapidly progressive interstitial pneumonia associated with anti-NXP2 antibody secondary to malignancy.

The diagnosis of a diffuse lung disease is challenging for physicians and it requires a multidisciplinary team approach to solve this problem. Herein, we present a case of common bile duct obstruction from pancreatic ductal adenocarcinoma after biliary stent placement, which developed a rapidly progressive bilateral lung infiltration after oesophagogastroduodenoscopy. After a diagnostic evaluation based on clinical, radiographic, and pathological findings, a diagnosis of rapidly progressive interstitial pneumonia associated with anti-nuclear matrix protein (NXP) 2 antibody secondary to malignancy was made. In patients with interstitial lung disease with unclear aetiologies, autoantibodies, including antinuclear antibody and myositis-specific antibodies should be evaluated, even if there are no clinical signs of autoimmune disease. Although this is the first case report of an acute interstitial pneumonitis-associated anti-NXP2 antibody, physicians should recognise this condition as it can rapidly cause acute fulminant respiratory failure.

Myeloperoxidase-antineutrophil cytoplasmic antibody-associated diffuse alveolar hemorrhage caused by denosumab.

Denosumab is a bone anti-resorptive drug, commonly used for treating osteoporosis. Pulmonary involvement has rarely been reported as a possible serious adverse effect of this medication. Herein, we report the case of a 67-year-old woman who presented with non-massive hemoptysis, anemia, and extensive pulmonary opacities on a chest radiograph for 3 days after receiving denosumab. The patient was diagnosed with myeloperoxidase-antineutrophil cytoplasmic antibody-associated pulmonary hemorrhage secondary from denosumab. She was treated with high doses of intravenous methylprednisolone and cyclophosphamide combined with plasmapheresis. Subsequently, her clinical and radiological findings improved without residual abnormalities after treatment.

Malignant pleural mesothelioma in a kidney transplant recipient.

Post-transplantation malignancy is one of the most common complication-related mortality in transplant recipients. Here, we report the case of a kidney transplant patient for 2 years with malignant pleural effusion that was subsequently diagnosed as malignant pleural mesothelioma.

Comparison of different transbronchial biopsy sampling techniques for the diagnosis of peripheral pulmonary lesions with radial endobronchial ultrasound-guided bronchoscopy: A prospective study.

BACKGROUND: Data regarding the transbronchial biopsy (TBB) techniques in radial endobronchial ultrasound (R-EBUS)-guided bronchoscopy are limited. The purpose of this study was to compare three R-EBUS-guided TBB techniques for the diagnosis of peripheral pulmonary lesions (PPLs). METHODS: A prospective pilot study was conducted including 90 patients with positive bronchus sign PPLs, who underwent R-EBUS-guided TBB. TBB techniques were performed in all patients using small biopsy forceps with a guide sheath (GS). These samples were submitted for both cell block histology (CB) and conventional histology (SB). Standard biopsy forceps were used to collect further samples that were submitted for conventional histology (LB). The diagnostic yields of the three techniques were compared. RESULTS: The mean diameter of the PPLs was 25.5 ± 8.2 mm and the final diagnoses included 70 malignant and 20 benign lesions. The overall diagnostic yield of R-EBUS-guided bronchoscopy was 82.2%. Although the difference was not statistically significant, CB provided the highest yield of the three TBB techniques: 68.9%, 65.6%, and 62.2% for CB, SB, and LB, respectively (P = 0.20). When the GS was removed and standard biopsy forceps were introduced, misplacement (detected by fluoroscopy) was observed in 24 cases, and LB provided a diagnosis in 11 cases. PPLs ≤20 mm were associated with misplacement (P = 0.003). After the exclusion of misplaced cases, the diagnostic yields were 69.7%, 71.2%, and 68.2% for CB, SB, and LB, respectively (P = 0.65). CONCLUSIONS: Neither the size of biopsy forceps nor the histology process affected the diagnostic yield of R-EBUS-guided bronchoscopy.

A prospective randomized comparative study of high-flow nasal cannula oxygen and non-invasive ventilation in hypoxemic patients undergoing diagnostic flexible bronchoscopy.

BACKGROUND: Although oxygen supplementation during bronchoscopy in patients with pre-existing hypoxemia is provided, adequacy of oxygenation may not be achieved, resulting in the occurrence of respiratory failure that requires endotracheal tube intubation. The purpose of this study was to compare high-flow nasal cannula (HFNC) with non-invasive ventilation (NIV) in patients with pre-existing hypoxemia undergoing flexible bronchoscopy (FB) on the ability to maintain oxygen saturation during bronchoscopy. METHODS: A prospective randomized study was conducted in patients who had hypoxemia [defined as partial pressure of arterial oxygen (PaO2) less than 70 mmHg at room air] and required FB for the diagnosis of abnormal pulmonary lesions. Patients were randomized to receive either HFNC or NIV during FB. The primary outcome was the lowest oxygen saturation level during FB. RESULTS: Fifty-one patients underwent randomization to HFNC (n=26) or NIV (n=25). Baseline characteristics in terms of age, Simplified Acute Physiologic Score II values, and cardiorespiratory parameters were similar in both groups. After receiving HFNC or NIV, oxygen saturation as measured by pulse oximeter (SpO2) increased to greater than 90% in all cases. During FB, although the lowest SpO2 was similar in both groups, the lowest SpO2 <90% tended to occur more often in the HFNC group (34.6% vs. 12.0%; P=0.057). In patients with baseline PaO2 <60 mmHg on ambient air, a decrease in PaO2 from preprocedure to the end of FB was less in the NIV group (-13.7 vs. -57.0 mmHg; P=0.019). After FB, the occurrence of SpO2 <90% was 15.4% and 4.0% in the HFNC group and NIV group, respectively (P=0.17). CONCLUSIONS: In overall, NIV and HFNC provided the similar effectiveness in prevention of hypoxemia in hypoxemic patients undergoing FB. However, in subgroup analysis, NIV provided greater adequacy and stability of oxygenation than HFNC in patients with baseline PaO2 <60 mmHg on ambient air.

Prevalence and risk factors of drug-resistant extrapulmonary tuberculosis.

BACKGROUND: Physicians are usually aware of the occurrence of drug-resistant (DR) pulmonary tuberculosis (PTB), but lack concern about DR-extrapulmonary TB (EPTB). Data regarding the prevalence and risk factors of DR-EPTB remain limited. OBJECTIVES: To determine the prevalence and risk factors of DR-EPTB. METHODS: A retrospective study was performed in patients who had culture-proven Mycobacterium tuberculosis (MTB) from various specimens between January 2013 and December 2015. Patients were classified into three groups: PTB, EPTB and concomitant PTB and EPTB (PTB + EPTB). Clinical data, chest radiographic extent of disease and patterns of DR were collected. RESULTS: There were 1014 culture-proven MTB specimens (716 pulmonary specimens and 298 extrapulmonary specimens) from 986 patients (648 PTB, 218 EPTB and 120 PTB + EPTB). The prevalences of isoniazid-, rifampicin- and multidrug-resistant EPTB were 7.8%, .5% and .5%, respectively, which were lower than those of PTB. When PTB and EPTB coexisted, a higher rate of DR-TB was observed than for PTB alone. Of 338 EPTB patients, the extent of radiographic disease was associated with isoniazid-, rifampicin- and multidrug-resistant TB. Previous history of TB and use of steroids/immunosuppressive drugs were also associated with rifampicin- and multidrug-resistant TB in multivariate analysis. CONCLUSIONS: The prevalence of DR-EPTB was high in patients who had concomitant PTB. Although the prevalences of rifampicin- and multidrug-resistant TB were low in isolated EPTB, the prevalence of isoniazid-resistant TB remained high. Therefore, drug susceptibility testing should be performed in EPTB patients, especially those who carry the aforementioned risk factors.

A comparative study of conventional cytology and cell block method in the diagnosis of pleural effusion.

BACKGROUND: In a patient with pleural effusion, cytological study (CS) is one of the most useful investigations, especially when malignancy is suspected. Instead of applying only CS, the pleural fluid can be further processed using the cell block (CB) technique, which may augment the diagnostic utility. The aim of this study was to compare the diagnostic yields of CS, CB, and the combination of both, regardless of the etiology of pleural effusion. METHODS: A cross-sectional study was conducted on patients with pleural effusions who underwent thoracentesis from June 2015 to May 2016. All samples were submitted for routine biochemical analysis, CS, and CB histology. The results of cytopathological studies were compared to the final diagnoses. RESULTS: Out of a total of 353 samples, the final diagnoses included 278 (78.8%) malignancies, 41 (11.6%) infectious diseases, 16 (4.5%) other inflammatory diseases, and 18 (5.1%) transudative pleural effusions. CS and CB provided a similar diagnostic yield (48.7% vs. 49.9%, P=0.69), while the combination of both gave a higher yield (57.2%) (P<0.001, compared with CS). Among 278 malignant pleural effusions (MPE), the diagnostic yields of CS and CB were 61.2% and 61.9%, respectively. Combined CS and CB improved the diagnostic yield to 71.2% (P<0.001). However, both CS and CB had low diagnostic yields in infectious pleuritis, other inflammatory diseases, and transudative pleural effusions. CONCLUSIONS: In MPE, CB provides a similar diagnostic performance to CS, while application of both techniques can significantly increase the diagnostic yield. However, in other pleural diseases, CB and CS had limited values in diagnosis.

Diagnostic value of endobronchial ultrasound elastography for the differentiation of benign and malignant intrathoracic lymph nodes.

BACKGROUND AND OBJECTIVE: Endobronchial ultrasound (EBUS) findings can be used for benign/malignant differentiation of lymph nodes (LNs). Recently, EBUS elastography has been introduced as a complementary modality in the evaluation of intrathoracic lymphadenopathy. We evaluated the ability of EBUS elastography to differentiate between benign and malignant LNs. METHODS: A prospective study was conducted on patients sent for evaluation of intrathoracic lymphadenopathy. LNs were classified qualitatively according to elastographic colour pattern: type 1, predominantly non-blue; type 2, partly blue, partly non-blue and type 3, predominantly blue. Quantitative elastography of LNs was measured by the strain ratio (SR). Qualitative and quantitative elastographies were compared for the final diagnosis of LNs. RESULTS: There were 120 LNs from 72 patients who underwent EBUS elastography. The final diagnosis included 96 malignant and 24 benign LNs. All of the 16 type 1 LNs proved to be benign diseases, while 95 of the 101 type 3 LNs were finally diagnosed as malignancies. Three LNs classified as type 2 proved to be two benign and one malignant. Malignant LNs presented a higher median SR than benign LNs (73.50 vs 1.29, P = 0.001). An SR of >2.5 and non-type 1 elastographic pattern achieved similar diagnostic performance in benign/malignant differentiation (sensitivity, 100% vs 100%; specificity, 70.8% vs 66.7%; positive predictive value, 93.2% vs 92.3%; negative predictive value, 100% vs 100%). CONCLUSION: EBUS elastography is a promising diagnostic modality for the differentiation of benign and malignant LNs during EBUS-guided transbronchial needle aspiration (TBNA). Qualitative and quantitative EBUS elastographies provide similar diagnostic performance.

Endobronchial ultrasound-guided transbronchial needle aspiration rinse fluid polymerase chain reaction in the diagnosis of intrathoracic tuberculous lymphadenitis.

BACKGROUND: Intrathoracic tuberculous (TB) lymphadenitis is a diagnostic challenge to the clinician. Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can obtain a sample from the affected lymph node, the diagnosis of TB lymphadenitis by cytopathology remains inaccurate. OBJECTIVE: To evaluate the efficacy of EBUS-TBNA rinse fluid TB polymerase chain reaction (PCR) assay for the diagnosis of intrathoracic TB lymphadenitis. METHODS: A retrospective study was conducted on 102 patients who underwent EBUS-TBNA for diagnostic evaluation of intrathoracic lymphadenopathy. EBUS-TBNA specimens were evaluated by cytopathological examination. Rinse fluid of the needle was routinely submitted for acid-fast bacillus (AFB) staining, mycobacterial culture, and TB-PCR using the AnyplexTM MTB/NTM real-time detection kit. RESULTS: Of 102 patients, 16 were diagnosed with intrathoracic TB lymphadenitis by either microbiology, cytopathology, or on clinical grounds. The sensitivity, specificity, positive predictive value, and negative predictive value of rinse fluid TB PCR assay were 56.2%, 100.0%, 100.0%, and 92.5%, respectively. Using the area under the ROC curve (AUC) as a measure of a diagnostic performance, TB-PCR had the highest AUC, compared with mycobacterial culture, AFB smear, and finding of necrotizing granulomatous inflammation (0.78, 0.75, 0.56, and 0.72, respectively). A combination of TB PCR, mycobacterial culture, and finding of necrotizing granulomatous inflammation provided the best diagnostic performance (sensitivity, specificity, positive predictive value, negative predictive value, and AUC of 75.0%, 100.0%, 100.0%, 95.6%, and 0.88, respectively). CONCLUSIONS: EBUS-TBNA rinse fluid TB-PCR is useful in the diagnosis of intrathoracic TB lymphadenitis. Combining TB-PCR with mycobacterial culture and cytopathological findings improved the diagnosis performance.

Fractured metallic tracheostomy tube: A rare complication of tracheostomy.

Although tracheostomy is a well-accepted procedure for airway management, some early and late complications may occur. Fracture of the tracheostomy tube (TT) is a rare complication, particularly in a patient with long-term use. Herein we report a case of fractured metallic TT migrating into the tracheobronchial tree. Rigid bronchoscopy was performed through the tracheostomy stoma and the fractured tube was successfully removed by a balloon catheter. Appropriate cleaning, routine careful examination, and scheduled replacement of the TT may help prevent this complication.

Chronic Klebsiella pneumonia: a rare manifestation of Klebsiella pneumonia.

K. pneumoniae can present as two forms of community-acquired pneumonia, acute and chronic. Although acute pneumonia may turn into necrotizing pneumonia, which results in a prolonged clinical course, it often has a rapidly progressive clinical course. In contrast, chronic Klebsiella pneumonia runs a protracted indolent course that mimics other chronic pulmonary infections and malignancies. Herein, we present two cases of chronic Klebsiella pneumonia. The diagnosis was made by microorganism identification, as well as absence of other potential causes. Clinical and radiographic findings improved after a prolonged course of antibiotic therapy.

A case of recurrent pneumothorax related to oral methylphenidate.

Primary spontaneous pneumothorax (PSP) commonly occurs in young, tall, and thin males, without any identifiable cause except for emphysema-like changes (ELCs). However, other risk factors may be overlooked. Herein, we report the case of a 19-year-old male who presented with recurrent spontaneous pneumothorax while taking oral methylphenidate.

Thoracic endometriosis with catamenial haemoptysis and pneumothorax: computed tomography findings and long-term follow-up after danazol treatment.

Thoracic endometriosis (TE) is an uncommon disorder affecting women of childbearing age. We herein report clinical and thin-section computed tomography (CT) findings of two cases, in which one woman presented with catamenial haemoptysis (CH) alone and another woman presented with bilateral catamenial pneumothoraces (CP) coinciding with CH, a rare manifestation of TE. The dynamic changes demonstrated on thin-section chest CT performed during and after menses led to accurate localisation and presumptive diagnosis of TE in both patients. Following danazol treatment, the patient with CH alone had a complete cure, while the patient with CP and CH had an incomplete cure and required long-term danazol treatment. We discuss the role of imaging studies in TE, with an emphasis on the appropriate timing and scanning technique of chest CT in women presenting with CH, potential mechanisms, treatment and patient outcomes.

Comparison of diagnostic performances among bronchoscopic sampling techniques in the diagnosis of peripheral pulmonary lesions.

BACKGROUND: There are many sampling techniques dedicated to radial endobronchial ultrasound (R-EBUS) guided flexible bronchoscopy (FB). However, data regarding the diagnostic performances among bronchoscopic sampling techniques is limited. This study was conducted to compare the diagnostic yields among bronchoscopic sampling techniques in the diagnosis of peripheral pulmonary lesions (PPLs). METHODS: A prospective study was conducted on 112 patients who were diagnosed with PPLs and underwent R-EBUS-guided FB between Oct 2012 and Sep 2014. Sampling techniques-including transbronchial biopsy (TBB), brushing cell block, brushing smear, rinsed fluid of brushing, and bronchoalveolar lavage (BAL)-were evaluated for the diagnosis. RESULTS: The mean diameter of the PPLs was 23.5±9.5 mm. The final diagnoses included 76 malignancies and 36 benign lesions. The overall diagnostic yield of R-EBUS-guided bronchoscopy was 80.4%; TBB gave the highest yield among the 112 specimens: 70.5%, 34.8%, 62.5%, 50.0% and 42.0% for TBB, brushing cell block, brushing smear, rinsed brushing fluid, and BAL fluid (BALF), respectively (P<0.001). TBB provided high diagnostic yield irrespective of the size and etiology of the PPLs. The combination of TBB and brushing smear achieved the maximum diagnostic yield. Of 31 infectious PPLs, BALF culture gave additional microbiological information in 20 cases. CONCLUSIONS: TBB provided the highest diagnostic yield; however, to achieve the highest diagnostic performance, TBB, brushing smear and BAL techniques should be performed together.

Peniciliosis endobronquial: presentación de un caso y revisión de la literatura / No disponible

La peniciliosis es una infección oportunista que se da en pacientes con infección por el VIH y otros pacientes inmunodeprimidos, sobre todo en el Sudeste Asiático, el sur de China, Hong Kong y Taiwán. Se producen manifestaciones respiratorias en alrededor de una tercera parte de los pacientes. Presentamos aquí el caso de un paciente de 26 años de edad inmunodeprimido, sin VIH, que comenzó con una peniciliosis endobronquial que obstruía las vías aéreas, junto con una revisión de la literatura de este trastorno muy poco frecuente

Penicilliosis is an opportunistic infection in HIV-infected and other immunocompromised patients mostly in Southeast Asia, Southern China, Hong Kong, and Taiwan, with respiratory manifestations in about onethird of patients. We report the case of a 26-year-old non-HIV immunocompromised patient presenting with an airway obstruction caused by penicilliosis, together with a review of the literature of this rare condition

Airway obstruction caused by penicilliosis: a case report and review of the literature.

Penicilliosis is an opportunistic infection in HIV-infected and other immunocompromised patients mostly in Southeast Asia, Southern China, Hong Kong, and Taiwan, with respiratory manifestations in about one-third of patients. We report the case of a 26-year-old non-HIV immunocompromised patient presenting with an airway obstruction caused by penicilliosis, together with a review of the literature of this rare condition.

Screening of obstructive sleep apnea during pregnancy: differences in predictive values of questionnaires across trimesters.

STUDY OBJECTIVES: Evaluation of Berlin and Stop-Bang questionnaires in detecting obstructive sleep apnea (OSA) across trimesters of pregnancy. METHODS: Pregnant women from a high-risk pregnancy clinic were recruited to complete sleep evaluations including Berlin and Stop-Bang Questionnaires. Overnight testing with Watch-PAT200 for diagnosis of OSA (cutoff point of apnea-hypopnea index ≥5 events/h) was performed. RESULTS: Seventy-two singleton pregnant women participated in the study. Enrollment consisted of 23, 24, and 25 women during first, second, and third trimesters, respectively. Of 72 pregnancies, 23 patients (31.9%) had OSA. Prevalence of OSA classified by trimesters from first to third was 30.4%, 33.33%, and 32.0%, respectively. Overall predictive values of Berlin and Stop-Bang questionnaires were fair (ROC area under curve, AUC 0.72 for Berlin, p = 0.003; 0.75 for Stop-Bang, p = 0.001). When categorized according to trimesters, predictive values substantially improved in second (AUC: 0.84 for Berlin; 0.78 for Stop-Bang) and third trimesters (AUC: 0.81 for Berlin; 0.75 for Stop-Bang), whereas performances of both questionnaires during first trimester were poorer (AUC: 0.49 for Berlin; 0.71 for Stop-Bang). Multivariate analyses show that pre-pregnancy body mass index (BMI) in first trimester, snore often in second trimester, and weight gain and pregnancy BMI in third trimester were significantly associated with OSA. CONCLUSIONS: In high-risk pregnancy, Berlin and Stop-Bang questionnaires were of limited usefulness in the first trimester. However their predictive values are acceptable as pregnancy progresses, particularly in second trimester. OSA in pregnancy seems to be a dynamic process with different predictors association during each trimester.

Diagnóstico de lesiones pulmonares periféricas con broncoscopia bajo guía de ecografía endobronquial radial / Diagnosis of Peripheral Pulmonary Lesions With Radial Probe Endobronchial Ultrasound-Guided Bronchoscopy

Introducción: El diagnóstico de las lesiones pulmonares periféricas (LPP) constituye un verdadero reto para los neumólogos. La ecografía endobronquial radial (R-EBUS) es una técnica que se ha desarrollado para mejorar el rendimiento diagnóstico. El objetivo de este estudio fue evaluar la efectividad de la R-EBUS en el diagnóstico de las LPP. Métodos: Se llevó a cabo un estudio retrospectivo en 174 pacientes a los que se habían diagnosticado LPP y a los que se practicó una broncoscopia bajo guía de EBUS. Para el diagnóstico se evaluó el examen histológico de las muestras obtenidas mediante biopsia pulmonar transbronquial (BPTB) y los exámenes citológicos del frotis de cepillado, líquido de irrigación del cepillado y líquido de lavado broncoalveolar (LLBA). Resultados: El diámetro medio de las LPP fue de 25,1 ± 10,7 mm. Los diagnósticos finales fueron 129 enfermedades malignas y 45 lesiones benignas. El rendimiento diagnóstico global de la broncoscopia bajo guía de EBUS fue del 79,9%. Ni el tamaño ni la etiología de las LPP mostraron influencia alguna en el rendimiento diagnóstico de la broncoscopia bajo guía de EBUS (82,9% frente al 74,6% para las LPP de tamaño > 20 mm y las LPP de tamaño ≤ 20 mm; p = 0,19, y 82,9% frente al 71,1% para las enfermedades malignas y benignas; p = 0,09). La BPTB fue la que obtuvo el máximo rendimiento de entre estas diversas muestras (69,0, 50,6, 42,0 y 44,3% para las muestras de BPTB, frotis de cepillado, líquido de irrigación de cepillado y LLBA, respectivamente; p < 0,001). La combinación de BPTB, frotis de cepillado y LLBA aportó el máximo rendimiento diagnóstico, mientras que el líquido de irrigación de cepillado no añadió una mejora adicional de los resultados. Conclusión: La broncoscopia bajo guía de R-EBUS es una técnica útil en el diagnóstico de las LPP. Para alcanzar el máximo rendimiento diagnóstico deben utilizarse conjuntamente la BPTB, el frotis de cepillado y el lavado broncoalveolar

Introduction: The diagnosis of peripheral pulmonary lesions (PPLs) is a challenging task for pulmonologists. Radial probe endobronchial ultrasound (R-EBUS) has been developed to enhance diagnostic yield. The objective of this study was to evaluate the effectiveness of R-EBUS in the diagnosis of PPLs. Methods: A retrospective study was conducted on 174 patients diagnosed with PPLs who underwent EBUS-guided bronchoscopy. Histological examination of specimens obtained by transbronchial lung biopsy (TBLB) and cytological examinations of brushing smear, brush rinse fluid and bronchoalveolar lavage fluid (BALF) were evaluated for the diagnosis. Results: The mean diameter of the PPLs was 25.1 ± 10.7 mm. The final diagnoses included 129 malignancies and 45 benign lesions. The overall diagnostic yield of EBUS-guided bronchoscopy was 79.9%. Neither size nor etiology of the PPLs influenced the diagnostic performance of EBUS-guided bronchoscopy (82.9% vs 74.6% for PPLs >20 mm and PPLs ≤ 20 mm; P=0.19, and 82.9% vs 71.1% for malignancy and benign diseases; P = 0.09). TBLB rendered the highest yield among these specimens (69.0%, 50.6%, 42.0%, and 44.3% for TBLB, brushing smear, brush rinse fluid, and BALF, respectively; P < 0.001). The combination of TBLB, brush smear, and BALF provided the greatest diagnostic yield, while brush rinse fluid did not add benefits to the outcomes. Conclusion: R-EBUS-guided bronchoscopy is a useful technique in the diagnosis of PPLs. To achieve the highest diagnostic performance, TBLB, brushing smear and bronchoalveolar lavage should be performed together