Role of medical thoracoscopy in the treatment of complicated parapneumonic effusions.

OBJECTIVE: The role of medical thoracoscopy in the treatment of pleural infections is increasingly being recognized. This study was done to assess the role of medical thoracoscopy in the management of carefully selected subset of patients with complicated parapneumonic effusions (PPEs). MATERIALS AND METHODS: We analyzed retrospective data of 164 thoracoscopic procedures performed at our center on patients with complicated PPE in the past 10 years. Patients were subjected to medical thoracoscopy based on ultrasonographic stratification and a computed tomography (CT) thorax. Medical thoracoscopy was performed after an intercostal block under conscious sedation with midazolam (2 mg) and fentanyl (50 mcg) and local anesthesia with lignocaine 2% (10-15 ml), through a single port 10 mm diameter thoracoscope. RESULTS: A total of 164 patients (119 males and 45 females) underwent medical thoracoscopy during the study period. The mean age was 47.4 ± 15.9 (median, 50; range, 16-86). The final diagnosis by thoracoscopy was bacterial empyema in 93 patients and tuberculosis in 71 patients. Medical thoracoscopy was successful without subsequent intervention in 160 (97.5%) patients, two patients underwent a second procedure, in the form of decortication, and two patients died due to sepsis. There were no major procedure-related complications that required intervention. CONCLUSION: Early adhesiolysis and drainage of fluid using medical thoracoscopy should be considered in patients with multiloculated complicated PPE after careful radiological (ultrasonography and CT) stratification, as a more cost-effective and safe method of management.

Tracheobronchial stent sizing and deployment practices airway stenting practices around the world: a survey study.

BACKGROUND: Tracheobronchial stents types, uses, techniques for deployment and extraction have practice variations around the world. METHODS: We collected responses by sending an online survey of 8 questions to world interventional bronchology member societies and social media groups. RESULTS: There were 269 respondents from 47 countries. Europe had 97 respondents from 22 countries. There were 8 respondents from Australia, 7 from Africa (3 countries) and 7 from 4 countries in South America (SA). North America (NA) had 72 respondents from 3 countries. Asia had 78 respondents from 14 countries. For stent placements 15% [41] used fiberoptic bronchoscope (FB) only. Rigid bronchoscopy (RB) was solely utilized by 38% [102]. Forty-six percent [123] used a combination of RB and FB (P value <0.00001). For stent extraction 13% [19] used FB alone, 57% [85] used RB, and 36% [54] used a combination of RB and FB (P value <0.00001). Placement of stents were 50.5% [135] only by direct visualization. Twenty-three percent [61] always used fluoroscopic guidance. Twenty-six-point-five percent [71] used fluoroscopy in certain cases (P value <0.00001). Sixty percent [162] decided stent sizing by measurements of stenotic and non-stenotic areas on radiology. Twelve percent [32] respondents used sizing devices. Sixty-five percent [177] used a ruler and bronchoscope to measure stenotic areas. Thirty-eight percent [104] used visual estimation and experience. Seven percent [19] used serial balloon dilatation size. To prevent clogging of stents, 22% [59] prescribed mucolytics. Seventy-three percent [195] nebulized saline, 26% [70] had Mucomyst Nebulization, 24% [65] Nebulized bronchodilators and other methods 11% [30] were advised. Covered self-expandable metal stents (SEMS) 44% was the commonest type of stent used around the world. Silicone stents 37%, Y stents 15%, uncovered SEMS 12%, Montgomery T tube 5% followed. Polyflex stents 3% and custom-made stents 3% were least used. Biodegradable stents were used by 7.5%, and not used by 92.5%. CONCLUSIONS: Tracheobronchial stent practice norms have slowly evolved, but its practice variations lack uniformity, and have sparse evidence-based studies for its direction.

Yield of pleural biopsy in different types of tubercular effusions.

INTRODUCTION: The yield of mycobacteria is shown to be very low in pleural effusions as it is a pauci-bacillary disease. The present study looked at the yield of mycobacterium tuberculosis (MTB) in terms of GeneXpert for acid fast bacilli (AFB) and culture using a medical thoracoscopy guided biopsy and analysed whether the yield increases in more complicated effusions. MATERIALS AND METHODS: This is a retrospective analysis of patients who underwent medical thoracoscopy for tubercular pleural effusions at our institute over the last 5-years. Patients who had no or minimal thin septations were considered as simple effusions and were subjected to semi-rigid thoracoscopy (n = 61). While patients who had multiple loculations and thick septations were considered as complicated effusions and were subjected to rigid thoracoscopy (n = 64). We considered granuloma on a biopsy as the standard for diagnosis of Tuberculosis (TB). Xpert MTB/RIF and The BACTEC MGIT was used for culture. RESULTS: Out 125 patients with granulomatous inflammation on biopsy, 56 (44.8%) were positive for either GeneXpert or culture for MTB. Only GeneXpert was positive in 43 and only culture was positive in 13. Amongst 61 patients with simple effusion, 14 had either GeneXpert for AFB or AFB culture being positive and 9 out of these patients had GeneXpert for MTB detected on biopsy sample. Only culture was positive in 5 patients. In complicated pleural effusion group either GeneXpert or culture for mycobacterium was positive in 42 (65.6%) out of 64 patients. Only GeneXpert was positive in 34 and culture alone was positive in 8 patients. CONCLUSION: The yield of MTB increases as the pleural effusion becomes more complicated. GeneXpert in a biopsy sample is a useful marker for MTB yield especially in a complicated effusion.

Bronchoscopic lung cryobiopsy: An Indian association for bronchology position statement.

BACKGROUND: Bronchoscopic lung cryobiopsy (BLC) is a novel technique for obtaining lung tissue for the diagnosis of diffuse parenchymal lung diseases. The procedure is performed using several different variations of technique, resulting in an inconsistent diagnostic yield and a variable risk of complications. There is an unmet need for standardization of the technical aspects of BLC. METHODOLOGY: This is a position statement framed by a group comprising experts from the fields of pulmonary medicine, thoracic surgery, pathology, and radiology under the aegis of the Indian Association for Bronchology. Sixteen questions on various technical aspects of BLC were framed. A literature search was conducted using PubMed and EMBASE databases. The expert group discussed the available evidence relevant to each question through e-mail and a face-to-face meeting, and arrived at a consensus. RESULTS: The experts agreed that patients should be carefully selected for BLC after weighing the risks and benefits of the procedure. Where appropriate, consideration should be given to perform alternate procedures such as conventional transbronchial biopsy or subject the patient directly to a surgical lung biopsy. The procedure is best performed after placement of an artificial airway under sedation/general anesthesia. Fluoroscopic guidance and occlusion balloon should be utilized for positioning the cryoprobe to reduce the risk of pneumothorax and bleeding, respectively. At least four tissue specimens (with at least two of adequate size, i.e., ≥5 mm) should be obtained during the procedure from different lobes or different segments of a lobe. The histopathological findings of BLC should be interpreted by an experienced pulmonary pathologist. The final diagnosis should be made after a multidisciplinary discussion. Finally, there is a need for structured training for performing BLC. CONCLUSION: This position statement is an attempt to provide practical recommendations for the performance of BLC in DPLDs.

Cryobiopsy of the Pleura: An Improved Diagnostic Tool.

BACKGROUND: Medical thoracoscopy (rigid and semirigid pleuroscopy) has revolutionized the approach to the diagnosis of pleural disease by offering a very high diagnostic yield. Rigid pleuroscopy offers the advantages of therapeutic intervention and larger biopsy specimens, whereas semirigid pleuroscopy using a standard biopsy forceps yields smaller and more superficial pleural samples. Cryobiopsy through semirigid pleuroscope in anecdotal studies has been used to overcome these disadvantages. We compared the safety and efficacy of cryobiopsy with conventional forceps biopsy in terms of the specimen size and diagnostic yield. METHODS: We analyzed data of 139 (87 cryobiopsies and 52 forceps biopsies) patients with undiagnosed pleural effusion who underwent pleuroscopy using a semirigid pleuroscope. A cryoprobe (ERBE, 2.4 mm) was passed through the working channel of the semirigid pleuroscope, the target area of parietal pleura was frozen for an average freezing time of 8 seconds, then the semirigid pleuroscope along with the probe was forcibly withdrawn en bloc avulsing the frozen parietal pleura. Two to 3 samples were taken from each patient. RESULTS: The diagnostic yield was 99% with cryobiopsy and 96% with forceps biopsy. The average specimen size through cryoprobe (13.2±6.7; range, 7 to 35 mm) was significantly larger than with the conventional forceps (6.8±3.3; range, 2 to 15 mm) (P<0.001), and no major complications were noted. CONCLUSION: Cryobiopsy of the parietal pleura through the semirigid pleuroscope is a safe procedure with a very high diagnostic yield.

Radial endobronchial ultrasound for the diagnosis of bronchoscopically invisible lesions: First case series from India.

BACKGROUND: A peripheral, bronchoscopically invisible pulmonary lesion is a diagnostic challenge. Transthoracic needle aspiration has long been the investigation of choice but runs the risk of pneumothorax (up to 44%). Newer technologies like radial endobronchial ultrasound (R-EBUS) offer a safer approach. We present our results of R-EBUS in the diagnosis of bronchoscopically invisible lesions. This is the first large case series from India. AIMS: (1) To determine the yield of R-EBUS for the diagnosis of bronchoscopically invisible lesions. (2) To compare the yields of forceps versus cryobiopsies in the diagnosis of these lesions. SETTING: Tertiary care cancer center. DESIGN: Prospective study. METHODS: Consecutive patients presenting between January and October 2015 with bronchoscopically invisible peripheral pulmonary lesions were included. R-EBUS was used to localize and sample the lesion and the yields were analyzed. Yields of cryo and forceps biopsy were compared where both methods had been used. Data were analyzed using SPSS version 22. RESULTS: A definite diagnosis obtained in 67.3% (37/55) patients with no major complications. No significant difference was found in yield between: (1) small (<3 cm) and large (>3 cm) lesions: (46.2% versus 78.6%, P = 0.38). (2) central and adjacent lesions: 61.5% versus 70%. (3) forceps and cryobiopsy (n = 28, 75% versus 67.9% P = 0.562). CONCLUSIONS: R-EBUS is a safe procedure in our setting and its yield is comparable to that reported in literature. The yield of central and adjacent lesions and forceps or cryobiopsy appears similar. Further refinements in the technique could improve yield.

Foreign body in the lung following dental procedure.

This is an interesting case report of a foreign body (FB) aspiration in an adult patient. The FB in question was a dental drill, which accidentally went into the airways during a dental procedure. The extraction was technically difficult due to the peripheral location and thin and sharp tip of the FB. The extraction of this FB required a unique innovation through the rigid bronchoscope.