Learning curves and association of pathologist's performance with the diagnostic accuracy of linear endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA): a cohort study in a tertiary care reference centre.

OBJECTIVES: We aimed to assess the learning curves and the influence of the pathologist's performance on the endobronchial ultrasound transbronchial needle aspiration's (EBUS-TBNA's) diagnostic accuracy in a real-world study. DESIGN/SETTING: Cohort study conducted in a tertiary care university hospital (single centre) with patients referred for EBUS-TBNA. PARTICIPANTS/INTERVENTION: We initially evaluated 376 patients (673 lymph nodes), 368 (660 lymph nodes) of whom were recruited. The inclusion criterion was EBUS-TBNA indicated for the study of mediastinal or hilar lesions. The exclusion criteria were the absence of mediastinal and hilar lesions during EBUS confirmed by a normal mediastinum and hilum on chest CT (except in cases of mediastinal staging of cancer) and lost to follow-up. PRIMARY AND SECONDARY OUTCOME MEASURES: Diagnostic accuracy and related outcomes. METHODS: We included patients from a prospectively constructed database. We performed a logistic regression multivariate analysis to adjust for potential confounders of the association between pathologist performance and EBUS-TBNA accuracy. The Cumulative Summation (CUSUM) analysis was used to assess pathologists' performance and learning curves. RESULTS: Most indications for EBUS were suspicion of malignancy, including intrathoracic tumours (68.3%), extrathoracic tumours (9.8%) and cancer staging (7.0%). The patients' mean age was 63.7 years, and 71.5% were male. Overall EBUS-TBNA accuracy was 80.8%. In the multivariate logistic regression model, the factors independently associated with EBUS-TBNA accuracy included certain pathologists (ORs ranging from 0.16 to 0.41; p<0.017), a lymph node short-axis diameter <1 cm (OR: 0.36; 95% CI 0.21 to 0.62; p<0.001), and the aetiology of lymph node enlargement (ORs ranging from 7 to 37; p<0.001). CUSUM analysis revealed four different learning curve patterns, ranging from almost immediate learning to a prolonged learning phase, as well as a pattern consistent with performance attrition. CONCLUSIONS: Pathologists' proficiency conditioned EBUS-TBNA accuracy. This human factor is a potential source of error independent of factors conditioning tissue sample adequacy.

The role of bronchoscopy in patients with SARS-CoV-2 pneumonia.

BACKGROUND: The role of bronchoscopy in coronavirus disease 2019 (COVID-19) is a matter of debate. PATIENTS AND METHODS: This observational multicentre study aimed to analyse the prognostic impact of bronchoscopic findings in a consecutive cohort of patients with suspected or confirmed COVID-19. Patients were enrolled at 17 hospitals from February to June 2020. Predictors of in-hospital mortality were assessed by multivariate logistic regression. RESULTS: A total of 1027 bronchoscopies were performed in 515 patients (age 61.5±11.2 years; 73% men), stratified into a clinical suspicion cohort (n=30) and a COVID-19 confirmed cohort (n=485). In the clinical suspicion cohort, the diagnostic yield was 36.7%. In the COVID-19 confirmed cohort, bronchoscopies were predominantly performed in the intensive care unit (n=961; 96.4%) and major indications were: difficult mechanical ventilation (43.7%), mucus plugs (39%) and persistence of radiological infiltrates (23.4%). 147 bronchoscopies were performed to rule out superinfection, and diagnostic yield was 42.9%. There were abnormalities in 91.6% of bronchoscopies, the most frequent being mucus secretions (82.4%), haematic secretions (17.7%), mucus plugs (17.6%), and diffuse mucosal hyperaemia (11.4%). The independent predictors of in-hospital mortality were: older age (OR 1.06; p<0.001), mucus plugs as indication for bronchoscopy (OR 1.60; p=0.041), absence of mucosal hyperaemia (OR 0.49; p=0.041) and the presence of haematic secretions (OR 1.79; p=0.032). CONCLUSION: Bronchoscopy may be indicated in carefully selected patients with COVID-19 to rule out superinfection and solve complications related to mechanical ventilation. The presence of haematic secretions in the distal bronchial tract may be considered a poor prognostic feature in COVID-19.

Bronchoscopist's perception of the quality of the single-use bronchoscope (Ambu aScope4™) in selected bronchoscopies: a multicenter study in 21 Spanish pulmonology services.

BACKGROUND: The disposable bronchoscope is an excellent alternative to face the problem of SARS-CoV-2 and other cross infections, but the bronchoscopist's perception of its quality has not been evaluated. METHODS: To evaluate the quality of the Ambu-aScope4 disposable bronchoscope, we carried out a cross-sectional study in 21 Spanish pulmonology services. We use a standardized questionnaire completed by the bronchoscopists at the end of each bronchoscopy. The variables were described with absolute and relative frequencies, measures of central tendency and dispersion depending on their nature. The existence of learning curves was evaluated by CUSUM analysis. RESULTS: The most frequent indications in 300 included bronchoscopies was bronchial aspiration in 69.3% and the median duration of these was 9.1 min. The route of entry was nasal in 47.2% and oral in 34.1%. The average score for ease of use, image, and aspiration quality was 80/100. All the planned techniques were performed in 94.9% and the bronchoscopist was satisfied in 96.6% of the bronchoscopies. They highlighted the portability and immediacy of the aScope4TM to start the procedure in 99.3%, the possibility of taking and storing images in 99.3%. The CUSUM analysis showed average scores > 70/100 from the first procedure and from the 9th procedure more than 80% of the scores exceeded the 80/100 score. CONCLUSIONS: The aScope4™ scored well for ease of use, imaging, and aspiration. We found a learning curve with excellent scores from the 9th procedure. Bronchoscopists highlighted its portability, immediacy of use and the possibility of taking and storing images.

A Prospective Randomized Study Comparing Manual and Wall Suction in the Performance of Bronchoalveolar Lavage.

BACKGROUND: Bronchoalveolar lavage (BAL) may be performed using a hand-held syringe or wall suction. OBJECTIVES: The aim was to study BAL volume and diagnostic yields based on BAL technique. METHODS: A total of 220 consecutive patients undergoing BAL at our center were included. Manual aspiration was performed in 115 patients (group 1), and wall suction (<50 mm Hg of negative pressure) was used in 105 patients (group 2). All bronchoscopies were performed under conscious sedation applying topical anesthesia with lidocaine. Three 50-ml sterile saline aliquots were instilled in all patients. RESULTS: The mean total amount of fluid recovered was 67 ± 20 ml in group 1 and 55 ± 22 ml in group 2 (p < 0.001). More patients in the manual aspiration group met American Thoracic Society criteria (recovery of ≥30% of instilled fluid) for an optimal BAL (81 vs. 59%; p < 0.001). The quantity of recovered fluid was also related to BAL location (p < 0.001) and radiologic findings (p = 0.002). Forty-eight (22%) BALs were diagnostic (23 in group 1 and 25 in group 2), including 37 positive bacterial cultures, 6 positive stains for Pneumocystis, and 5 cases of malignancy. No statistically significant difference in diagnostic yield was observed between the two groups. A BAL diagnosis was more likely in patients with certain radiologic (p = 0.033) and endoscopic findings (p = 0.001). When taking into account all bronchoscopic techniques performed during the procedure (e.g. biopsies, brushing, etc.), bronchoscopy was diagnostic in 37% of patients. CONCLUSIONS: Manual aspiration is superior to wall suction during BAL yielding a larger quantity of aspirate. Diagnostic yields are similar for both techniques.

Antracofibrosis o antracoestenosis / Anthracofibrosis or Anthracostenosis

La antracofibrosis es una estenosis bronquial debida a una fibrosis mucosa local que presenta además una mucosa con pigmento antracótico. La causa no está bien aclarada, y se da una frecuente asociación con la tuberculosis y la exposición a humos de combustión de biocombustibles (o biomasa). Se trata de una entidad no descrita en España, aunque la afluencia de personas originarias de zonas rurales de países en desarrollo o de zonas rurales de nuestro medio debe hacernos tener presente esta entidad en el diagnóstico diferencial de nuestros pacientes. Se presentan 3 casos detectados en España (2 de ellos autóctonos) diagnosticados mediante broncoscopia y biopsia bronquial, técnicas necesarias para su confirmación. No hay tratamiento específico, salvo el tuberculostático en el caso de coexistencia de ambas entidades(AU)

Anthracofibrosis is a bronchial stenosis due to local mucosal fibrosis that also presents anthracotic pigment in the mucosa. The cause has not been well clarified, although there is a frequent association with tuberculosis and the exposure to smoke from biofuel or biomass combustion. It is an entity that has not been reported in Spain, although the influx of people from rural areas of developing countries or rural areas of our own country should make us contemplate this entity in the differential diagnosis of our patients. We present 3 cases detected in Spain (2 of them natives) diagnosed by bronchoscopy and bronchial biopsy, which are techniques necessary to confirm the diagnosis. There is no specific treatment, except for tuberculostatic treatment in cases with coexisting tuberculosis(AU)

Anthracofibrosis or anthracostenosis.

Anthracofibrosis is a bronchial stenosis due to local mucosal fibrosis that also presents anthracotic pigment in the mucosa. The cause has not been well clarified, although there is a frequent association with tuberculosis and the exposure to smoke from biofuel or biomass combustion. It is an entity that has not been reported in Spain, although the influx of people from rural areas of developing countries or rural areas of our own country should make us contemplate this entity in the differential diagnosis of our patients. We present 3 cases detected in Spain (2 of them natives) diagnosed by bronchoscopy and bronchial biopsy, which are techniques necessary to confirm the diagnosis. There is no specific treatment, except for tuberculostatic treatment in cases with coexisting tuberculosis.

Tracheal compression in a patient with Marfan's syndrome-associated tracheomegaly treated by an XXL stent: the largest diameter airway stent ever placed in a previously undescribed airway condition.

A 43-year-old man was referred to our institution with severe extrinsic compression of the trachea at the level of the main carina secondary to an aortic aneurysm, causing respiratory distress and requiring mechanical ventilation. The patient had a past history of Marfan's syndrome and tracheomegaly (the estimated tracheal diameter bronchoscopically was 28 mm). Palliation of the compression was successfully achieved by a custom-made, self-expandable, fully covered metallic stent with a diameter of 28 mm and a length of 60 mm. The patient was weaned off ventilation. The stent stayed in place for 2 years without major complications. This case represents the first stent ever inserted in a very rare condition combining tracheomegaly and extrinsic compression in Marfan's syndrome. It is also the first report of successful placement of the largest tracheal stent which was manufactured exclusively for the airway.