Spray Cryotherapy for Benign Large Airway Stenosis: A Multicenter Retrospective Cohort Study of Safety and Practice Patterns.

BACKGROUND: Benign airway stenosis (BAS) represents a significant burden on patients, providers, and healthcare systems. Spray cryotherapy (SCT) has been proposed as an adjunctive treatment to reduce BAS recurrence. We sought to examine safety and practice variations of the latest SCT system when used for BAS. METHODS: We conducted a retrospective multicenter cohort study in seven academic institutions within the Interventional Pulmonary Outcomes Group. All patients who underwent at least one SCT session with a diagnosis of BAS at the time of procedure at these institutions were included. Demographics, procedure characteristics, and adverse events were captured through each center's procedural database and electronic health record. RESULTS: A total of 102 patients underwent 165 procedures involving SCT from 2013 to 2022. The most frequent etiology of BAS was iatrogenic (n = 36, 35%). In most cases, SCT was used prior to other standard BAS interventions (n = 125; 75%). The most frequent SCT actuation time per cycle was five seconds. Pneumothorax complicated four procedures, requiring tube thoracostomy in two. Significant post-SCT hypoxemia was noted in one case, with recovery by case conclusion and no long-term effects. There were no instances of air embolism, hemodynamic compromise, or procedural or in-hospital mortality. CONCLUSION: SCT as an adjunctive treatment for BAS was associated with a low rate of complications in this retrospective multicenter cohort study. SCT-related procedural aspects varied widely in examined cases, including actuation duration, number of actuations, and timing of actuations relative to other interventions.

Bronchoscopic blood patch for treatment of persistent alveolar-pleural fistula.

Airway pleural fistulas remain a significant treatment challenge despite improved antimicrobial therapy and surgical techniques. We present a case of a 56-year-old female who was admitted with severe bilateral cavitary pneumonia requiring mechanical ventilation. The patient suffered bilateral pneumothoraces related to necrotic pneumonia resulting in bilateral chest tube placement. Despite conservative measures, the air leak persisted preventing chest tube removal. Bronchoscopy with Fogarty balloon (Edwards) occlusion was performed in attempts to isolate an airway responsible for the air leak. No one single airway could be bronchoscopically occluded to isolate the right-sided fistula. Efforts were focused on the left airway where the fistula could be isolated to the anteromedial basal segment. Several alternating layers of an absorbable hemostat (knitted fabric prepared by controlled oxidation of cellulose-Surgicel; Ethicon) were placed within the left anteromedial basal segment using bronchoscopy forceps. Through a cut Fogarty balloon, 3 mL of the patient's blood was delivered onto the absorbable hemostat to create an occluding blood patch. No air leak was present at the completion of the procedure. While on mechanical ventilation, the left chest tube was removed 2 days later without radiographic recurrence of her pneumothorax.

Interfractional positional variability of fiducial markers and primary tumors in locally advanced non-small-cell lung cancer during audiovisual biofeedback radiotherapy.

PURPOSE: To evaluate implanted markers as a surrogate for tumor-based setup during image-guided lung cancer radiotherapy with audiovisual biofeedback. METHODS AND MATERIALS: Seven patients with locally advanced non-small-cell lung cancer were implanted bronchoscopically with gold coils. Markers, tumor, and a reference bony structure (vertebra) were contoured for all 10 phases of the four-dimensional respiration-correlated fan-beam computed tomography and weekly four-dimensional cone-beam computed tomography. RESULTS: The systematic/random interfractional marker-to-tumor centroid displacements were 2/3, 2/2, and 3/3 mm in the x (lateral), y (anterior-posterior), and z (superior-inferior) directions, respectively. The systematic/random interfractional marker-to-bone displacements were 2/3, 2/3, and 2/3 mm in the x, y, and z directions, respectively. The systematic/random tumor-to-bone displacements were 2/3, 2/4, and 4/4 mm in the x, y, and z directions, respectively. All displacements changed significantly over time (p < 0.0001). CONCLUSIONS: Although marker-based image guidance may decrease the risk for geometric miss compared with bony anatomy-based positioning, the observed displacements between markers and tumor centroids indicate the need for repeated soft tissue imaging, particularly in situations with large tumor volume change and large initial marker-to-tumor centroid distance.

Tracheal ring herniation.

Inspection bronchoscopy during percutaneous dilational tracheostomy has become the standard of care to reduce complications of the procedure. During bronchoscopy, anatomic defects can be visualized before performing the procedure. We describe a case of discovering herniated tracheal rings in preprocedure bronchoscopy and subsequent treatment of this rare finding.

New concepts in sepsis.

An estimated 750,000 cases of severe sepsis occur annually in the United States, and the mortality rate is about 30%. As a condition that disproportionately affects the elderly and is related to invasive and immunosuppressive healthcare, increases in the frequency of sepsis are anticipated. The complex pathophysiology of sepsis encompasses the interplay of pro- and anti-inflammatory mediators, activated circulating and resident inflammatory cells, disrupted coagulation, endothelial activation and injury, vasodilatation and vascular hyporesponsiveness to vasoactive mediators, cardiac dysfunction, and cellular dysoxia. Current management of severe sepsis includes eradication of infection through source control and antimicrobial therapy, aggressive and targeted shock resuscitation that includes fluid administration, correction of anemia, vasopressor support, modest inotropic therapy, infusion of human recombinant activated protein C to selected patients, and compulsive supportive care to manage organ dysfunction and to avoid complications.