Transbronchial lung cryobiopsy in the diagnosis of interstitial lung disease.

Transbronchial cryoprobe lung biopsy (TBCLB) have recently been introduced as a safe diagnostic tool in the diagnosis of interstitial lung diseases. While we do not enough evidence its role and place as a diagnostic procedure, the technique has been adopted by many centers. In spite of expanding body of literature, there are variations in patient selection and procedural aspect of the procedure. It has been established as a safe procedure if safety measures are practiced. Diagnosis of interstitial lung diseases continuous to be challenging. Surgical lung biopsy considered as gold standard but its morbidity and mortality limit its utilization in every case. Multidisciplinary medical decision is a validated team work effort when approaching patients with interstitial lung disease.

Utility of Functional Pneumonectomy by Using Intrabronchial Valves: First Case Series and Single Center Experience.

BACKGROUND: Intrabronchial valves are approved for bronchoscopic lung volume reduction in chronic obstructive pulmonary disease patients and used for prolonged air leak. There is no data on bronchoscopic functional pneumonectomy (BFP) when treating patients with persistent air leak (PAL) or for lung volume reduction purposes. METHODS: In this observational study, 10 consecutive patients who failed to improve with traditional therapies were assessed after they underwent BFP for PAL or lung volume reduction. RESULTS: Ten patients underwent 17 valve placement procedures; 82 valves were placed (median: 8; range: 5 to 12). BFP was performed in 1 single lung transplant patient with hyperinflation of native lung compromising lung function. The rest of the patients had prolonged air leak because of various reasons; spontaneous (n=7) and postoperative (n=2). Pneumonia was the only procedure-related complication seen in 1 patient. Of patients with prolonged air leak with chest tubes (n=9), all had successful chest tube removal (median of 7 days; range: 3 to 21 d). The valves were removed within 6 weeks of chest tube removal in 6 patients. Prebronchoscopic and post-BFP actual forced expiratory volume in first second values in 2 transplant patients. CONCLUSION: PAL usually occurs in patients with severe underlying lung condition or after surgery. Management of PAL can be challenging despite pleurodesis (medical or surgical). BFP offers a minimally invasive management option.

A Multicenter Study Assessing Interventional Pulmonary Fellow Competency in Electromagnetic Navigation Bronchoscopy.

Background: Current medical society guidelines recommend a procedural number for obtaining electromagnetic navigational bronchoscopy (ENB) competency and for institutional volume for training. Objective: To assess learning curves and estimate the number of ENB procedures for interventional pulmonology (IP) fellows to reach competency. Methods: We conducted a prospective multicenter study of IP fellows in the United States learning ENB. A tool previously validated in a similar population was used to assess IP fellows by their local faculty and two blinded independent reviewers using virtual recording of the procedure. Competency was determined by performing three consecutive procedures with a competency score on the assessment tool. Procedural time, faculty global rating scale, and periprocedural complications were also recorded. Results: A total of 184 ENB procedures were available for review with assessment of 26 IP fellows at 16 medical centers. There was a high correlation between the two blinded independent observers (rho = 0.8776). There was substantial agreement for determination of procedural competency between the faculty assessment and blinded reviewers (kappa = 0.7074; confidence interval, 0.5667-0.8482). The number of procedures for reaching competency for ENB bronchoscopy was determined (median, 4; mean, 5; standard deviation, 3.83). There was a wide variation in the number of procedures to reach competency, ranging from 2 to 15 procedures. There were six periprocedural complications reported, four (one pneumomediastinum, three pneumothorax) of which occurred before reaching competence and two pneumothoraces after achieving competence. Conclusion: There is a wide variation in acquiring competency for ENB among IP fellows. Virtual competency assessment has a potential role but needs further studies.

Evaluation and Comparison of Performance Parameters and Impact of Telepathology and Operator Experience on Endobronchial and Endoscopic Ultrasound-Guided Fine-Needle Aspiration.

OBJECTIVES: Endobronchial ultrasound- and endoscopic ultrasound-guided fine-needle aspiration (EBUS-/EUS-FNA) are minimally invasive techniques of diagnosing and staging malignancies. The procedures are difficult to master, requiring specific feedback for optimizing yield. METHODS: Over 2 years, EBUS-/EUS-FNA cases were gathered using the institutional pathology database. Patient and specimen characteristics were collected from the pathology database and electronic medical record. RESULTS: In 2 years, 789 unique FNA specimens were collected (356 EBUS and 433 EUS specimens). The cohort and each subgroup had excellent performance, which was enhanced by telepathology. The discrepancy rate was satisfactorily low. Hematolymphoid neoplasms are overrepresented in discrepant EBUS cases. The malignancy rates of cytology diagnostic categories were comparable to the literature. CONCLUSIONS: Using diagnostic yield and concordance results allow for comprehensive evaluation of the entire process of EBUS-/EUS-FNAs. This study's findings can influence patient management, training methods, and interpretation of results, while also acting as a model for others to investigate their own sources of inadequacy, discrepancy, and training gaps.

Transbronchial Lung Cryobiopsy in the Diagnosis of Interstitial Lung Disease: A Retrospective Single-center Experience.

BACKGROUND: Surgical lung biopsy (SLB) is the gold standard to aid diagnosis of interstitial lung disease (ILD). Complication rates are restrictive as routine approach for all patients with ILD. Transbronchial lung cryobiopsy (TBLC) is presumed to be a safe, less invasive alternative to assist multidisciplinary discussions regarding the diagnosis of ILD. Varying practice patterns and lack of consistent guidelines prohibit wide support of this technique. The purpose of this study was to evaluate safety and diagnostic yield of TBLC, with highlight of distinct technical features, in ILD. METHODS: Retrospective study of patients with ILD on the basis of high-resolution chest computed tomography who underwent TBLC. RESULTS: Of 121 TBLC, 40 patients (mean age, 57.2±13 y; 28 men) with ILD were referred for biopsy. Procedures were performed in endoscopy suite (60%) or operating room by using 1.9-mm cryoprobe. Biopsies were performed in 2 lobes with at least 3 to 5 specimens >5 mm in diameter. The average diameter and area of specimens were 5.7±2 mm and 40±2 mm, respectively. The most common diagnosis was nonspecific interstitial pneumonitis; usual interstitial pneumonia was diagnosed in 1 patient. Of 6 nondiagnostic specimens, 2 underwent SLB with subsequent diagnoses. Final histopathologic diagnostic rate was 85%. Bleeding was the most frequent complication. CONCLUSION: We provided a detailed description of our TLBC technique and highlighted areas of similarity and differences among comparative studies and attest that TBLC is a safe alternative to SLB in the diagnosis of ILD. Our data also indicated the tendency for moderate-to-severe bleeding occurred more in the endoscopy suite.

Acute exacerbation of interstitial lung disease after procedures.

Interstitial lung disease (ILD) is a category of diffuse parenchymal lung diseases characterized by inflammation and/or fibrosis. The best characterized ILD is idiopathic pulmonary fibrosis (IPF). Acute exacerbation of IPF is a dreaded occurrence with grim prognosis and suboptimal treatment options. There have been recent reports that acute exacerbation can occur in other ILDs (AE-ILD). Of note, some of these acute exacerbations follow lung procedures. This review summarizes the available information on AE-ILD and discusses the procedures reported to cause AE-ILD. We also discuss proposed mechanisms, risk factors, treatment and prognosis. This review should help to inform decision-making about risks versus benefits of procedures that are commonly recommended to diagnose ILD.

Endobronchial thermoplasty for asthma.

Asthma is an incurable chronic disease affecting approximately 24 million people in the United States. The hallmark features of asthma are reversible airflow obstruction, airway hyperresponsiveness, airway inflammation, bronchoconstriction, and excessive mucus secretion. Clinical symptoms include episodic or persistent breathlessness, wheezing, cough, or chest tightness/pressure. Forty-five percent of asthmatics continue to have yearly exacerbations and the disease is responsible for approximately 3,600 annual deaths. Pharmacologic advancements have continued to grow as the individual phenotypes of asthma are better delineated but there continues to be small population of asthmatics that are less responsive to pharmacologic therapy. Bronchial thermoplasty (BT) is an innovative procedure targeted primarily at decreasing airway smooth muscle (ASM) which is considered by some to be a vestigial organ. Decreasing the ASM bulk decreases hyperresponsiveness and bronchoconstriction leading to decreased exacerbations, decreased cost on the healthcare system, and improvement in patient quality of life.

An Expectorated "Stent": An Unexpected Complication of EBUS-TBNA.

Endobronchial ultrasound-guided transbronchial needle aspiration has a low complication rate and is a cost-effective procedure for mediastinal staging and diagnosis when compared with the more invasive mediastinoscopy. There are increasing case reports of unexpected complications including equipment failures with and without significant medical consequences. Knowledge of complications, including those that are rare, is essential for the physician performing this minimally invasive procedure. We report a case of a retained foreign body from the unexpected separation of a distal spring/coil mechanism from the Olympus ViziShot Aspiration needle following early needle deployment within the working channel of the bronchoscope.

Acute Exacerbation of Interstitial Lung Disease After Cryobiopsy.

Cryotherapy has been used in treatment of lung cancer for decades. The utility of cryotechnology in diagnosis of lung diseases is emerging and gaining popularity. Cryobiopsy (CB) of the lung, when compared with conventional transbronchial forceps lung biopsy, has proposed to have a higher diagnostic yield in interstitial lung disease by providing larger biopsy specimen and less crush artifact. Acute exacerbation of interstitial lung disease (AEILD) has been well described with surgical lung biopsies and, rarely, with conventional transbronchial forceps biopsy. The incidence of AEILD after CB is not known. Here we are presenting a case of AEILD after CB.

A new needle on the block: EchoTip ProCore endobronchial ultrasound needle.

Endobronchial ultrasound has become the first choice standard of care procedure to diagnose benign or malignant lesions involving mediastinum and lung parenchyma adjacent to the airways owing to its characteristics of being real-time and minimally invasive. Although the incidence of lung cancer has been decreasing, it is and will be the leading cause of cancer-related mortality in the next few decades. When compared to other cancers, lung cancer kills more females than breast and colon cancers combined and more males than colon and prostate cancers combined. The type of lung cancer has changed in recent decades and adenocarcinoma has become the most frequent cell type. Prognosis of lung cancer depends upon the cell type and the staging at the time of diagnosis. The cell type and molecular characteristics of adenocarcinoma may allow individualized targeted treatment. Other malignant conditions in the mediastinum and lung (eg, metastatic lung cancers and lymphoma) can be biopsied using endobronchial ultrasound needles. Endobronchial ultrasound needle biopsies provides mostly cytology specimens due to its small sizes of needles (22 gauge or larger) which may not give enough tissue to make a definitive diagnosis in malignant (eg, lymphoma) or benign conditions (eg, sarcoidosis). EchoTip ProCore endobronchial needle released in early 2014 provides histologic biopsy material. Larger tissue biopsies may potentially provide a higher diagnostic yield and it eliminates mediastinoscopy or other surgical interventions. Here we aim to review bronchoscopic approach in the diagnosis of mediastinal lesions with emphasis of EchoTip ProCore needles.

Usefulness of lymphoid granulomatous inflammation culture obtained by endobronchial ultrasound-guided transbronchial needle aspiration in a fungal endemic area.

BACKGROUND AND OBJECTIVES: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the procedure of choice for the evaluation of mediastinal/hilar lymph node enlargements. Granulomatous inflammation of the mediastinal/hilar lymph nodes is often identified on routine histology. In addition, mediastinal lymphadenopathy may be present with undiagnosed infection. We sought to determine the usefulness of routine cultures and histology for infectious etiologies in a fungal endemic area when granulomatous inflammation is identified. MATERIALS AND METHODS: We identified 56 of 210 patients with granulomatous inflammation on EBUS-TBNA biopsies from October 2012 through October 2014. An onsite cytologist evaluated all biopsies and an additional TBNA pass for microbiologic stains and cultures were obtained in those with granulomatous inflammation. RESULTS: Of the 56 patients with granulomatous inflammation, 20 patients had caseating (necrotizing) granulomas while noncaseating (nonnecrotizing) granulomas were detected in 36 of the remainder patients. In patients with caseating granulomas, fungal elements were identified in 6 of 20 (30%) patients (histoplasma; N = 5, blastomyces; N = 1) on Grocott methenamine silver (GMS) stain. Lymph node cultures identified 3 of 20 (20%) patients as being positive for Mycobacterium tuberculosis (N = 1), Histoplasma capsulatum (N = 1), and Blastomyces dermatitidis (N = 1). Among patients with noncaseating granulomas, only 2 out of 36 (5%) were positive for fungal elements on GMS stain, identified as Histoplasma, although the lymph node cultures remained negative. CONCLUSION: The incidence of granulomatous inflammation of mediastinal lymph nodes was 26.6% in our series. Of these patients, noncaseating granulomas were more common (64% vs. 36%). Infectious organisms, fungal or acid-fast bacilli (AFB), on either staining or lymph node culture were rarely identified in noncaseating granulomas, 5% and none, respectively. Caseating granulomas were more commonly associated with positive lymph node fungal stain and culture, 35% and 15%, respectively. In a fungal endemic area, lymph node staining and culture can be considered in cases with caseating granulomatous inflammation, if known at the time of biopsy.

Intrabronchial Valve Treatment for Prolonged Air Leak: Can We Justify the Cost?

Background. Prolonged air leak is defined as an ongoing air leak for more than 5 days. Intrabronchial valve (IBV) treatment is approved for the treatment of air leaks. Objective. To analyze our experience with IBV and valuate its cost-effectiveness. Methods. Retrospective analysis of IBV from June 2013 to October 2014. We analyzed direct costs based on hospital and operating room charges. We used average costs in US dollars for the analysis not individual patient data. Results. We treated 13 patients (9 M/4 F), median age of 60 years (38 to 90). Median time from diagnosis to IBV placement was 9.8 days, time from IBV placement to chest tube removal was 3 days, and time from IBV placement to hospital discharge was 4 days. Average room and board costs were $14,605 including all levels of care. IBV cost is $2750 per valve. The average number of valves used was 4. Total cost of procedure, valves, and hospital stay until discharge was $13,900. Conclusion. In our limited experience, the use of IBV to treat prolonged air leaks is safe and appears cost-effective. In pure financial terms, the cost seems justified for any air leak predicted to last greater than 8 days.

Simultaneous Chronic Invasive Fungal Infection and Tracheal Fungus Ball Mimicking Cancer in an Immunocompetent Patient.

Fungal infections of the lung are uncommon and mainly affect people with immune deficiency. There are crucial problems in the diagnosis and treatment of this condition. Invasive pulmonary aspergillosis and candidiasis are the most common opportunistic fungal infections. Aspergillus species (spp.) are saprophytes molds that exist in nature as spores and rarely cause disease in immunocompetent individuals. In patients with immune deficiency or chronic lung disease, such as cavitary lung disease or bronchiectasis, Aspergillus may cause a variety of aspergillosis infections. Here we present a case of a 57-year-old patient without immunodeficiency or chronic lung disease who was diagnosed with endotracheal fungus ball and chronic fungal infection, possibly due to Aspergillus. Bronchoscopic examination showed a paralyzed right vocal cord and vegetating mass that was yellow in color, at the posterior wall of tracheal lumen. After 3 months, both the parenchymal and tracheal lesions were completely resolved.

Efficacy and safety of electromagnetic navigation bronchoscopy with or without radial endobronchial ultrasound for peripheral lung lesions.

BACKGROUND AND OBJECTIVES: Electromagnetic navigation bronchoscopy (ENB) is a promising new technology to increase the diagnostic yield of peripheral lung and mediastinal lesions. Conventional flexible bronchoscopy has a limited yield in peripheral pulmonary lesions, even in experienced hands. Radial endobronchial ultrasound (r-EBUS) with its real-time imaging capability can help to diagnose peripheral pulmonary lesions. In the present study, we aimed to investigate the diagnostic yield and safety of ENB with or without r-EBUS for peripheral lung lesions. MATERIALS AND METHODS: This study was conducted in a tertiary medical center, and 56 consecutive patients who were thought to be the best candidates for bronchoscopic biopsies at a multidisciplinary meeting were enrolled. ENB was performed under conscious sedation by using an electromagnetic tracking system with multiplanar reconstruction of previously acquired computed tomography (CT) data. Sampling was performed by biopsy forceps, endobronchial brush, and bronchoalveolar lavage. RESULTS: Fifty-six patients (50 men and 6 women; mean age, 60 ± 9 years) were studied. While an electromagnetic navigation system was used in all patients, r-EBUS was used in 26 of 56 patients. The median diameter of the lesions was 30 mm (interquartile range: 23-44 mm). Mean distance of the lesions from the pleura was 14.9 ± 14.6 mm. Mean procedure time was 20 ± 11.5 min. Mean registration error was 5.8 ± 1.5 mm. Mean navigation error was 1.2 ± 0.5 mm. The diagnostic yield of the procedure was 71.4% for peripheral lesions (non-small cell lung cancer = 23, small cell lung cancer = 3, benign diseases = 14). Pneumothorax occurred in only 1 patient (1.7%). CONCLUSION: ENB with or without r-EBUS is a safe, efficient, and easily applied method for sampling of peripheral lung lesions, with high diagnostic yield independent of lesion size and location.

Angiotensin-converting Enzyme as a Predictor of Extrathoracic Involvement of Sarcoidosis.

BACKGROUND: Sarcoidosis is a multisystem disease, with extrathoracic involvement occurring in 25-50% of patients. Multi-organ involvement is often associated with a more chronic and severe course. The value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in diagnosing extrathoracic involvement in sarcoidosis has been demonstrated; however, because of the radiation dose and high cost, indications for its use must be well defined. Angiotensin-converting enzyme (ACE) is produced by active granuloma cells; thus, serum ACE (sACE) levels may reflect the total granuloma load. OBJECTIVES: In this retrospective study, we evaluated the diagnostic value of sACE in the detection of extrathoracic involvement in sarcoidosis. METHODS: 43 patients with biopsy-proven sarcoidosis underwent FDG-PET/CT during the initial workup. Positive findings were classified as thoracic and/or extrathoracic. The diagnostic value of sACE was estimated using sensitivity, specificity, and area under the receiver operating characteristic curves (AUCs). RESULTS: Of the 43 patients studied, 17 (39.7%) had extrathoracic involvement. In this group, sACE values were higher than in patients without extrathoracic involvement (331 vs. 150, p=0.002) and correlated positively with extrathoracic involvement (R:0.532 p=0.02). Receiver operator characteristic curve analysis revealed an AUC of 0.816 [95% confidence interval: 0.669-0.963, p=0.002], 70.6% sensitivity and 80% specificity at the sACE cut-off value. CONCLUSIONS: In sarcoidosis, extrathoracic involvement may be life threatening or indicative of poor outcome. sACE levels are easily determined and may predict extrathoracic involvement. In patients with sarcoidosis, sACE levels can be used to better define those who would benefit from FDG-PET/CT examination to detect extrathoracic involvement.

Use of One-Way Intrabronchial Valves in Air Leak Management After Tube Thoracostomy Drainage.

BACKGROUND: A persistent air leak represents significant clinical management problems, potentially affecting morbidity, mortality, and health care costs. In 2008, a unidirectional, intrabronchial valve received humanitarian device exemption for use in managing prolonged air leak after pulmonary resection. Since its introduction, numerous reports exist but no large series describe current utilization or outcomes. Our aim was to report current use of intrabronchial valves for air leaks and review outcome data associated with its utilization. METHODS: A multicenter, retrospective review of intrabronchial valve utilization from January 2013 to August 2014 was performed at eight centers. Data regarding demographics, valve utilization, and outcomes were analyzed. RESULTS: We identified 112 patients undergoing evaluation for intrabronchial valve placement, with 67% (75 of 112) undergoing valve implantation. Nearly three quarters of patients underwent valve placement for off-label usage (53 of 75). A total of 195 valves were placed in 75 patients (mean 2.6 per patient; range, 1 to 8) with median time to air leak resolution of 16 days (range, 2 to 156). CONCLUSIONS: We present the largest, multicenter study of patients undergoing evaluation for intrabronchial valve use for air leak management. Our data suggest the majority of intrabronchial valve placements are occurring for off-label indications. Although the use of intrabronchial valves are a minimally invasive intervention for air leak management, the lack of rigorously designed studies demonstrating efficacy remains concerning. Prospective randomized controlled studies remain warranted.

A case of tubulointerstitial nephritis and uveitis in an adult male.

We report a case of tubulointerstitial nephritis and uveitis (TINU) syndrome in an adult male. A 40-year-old man was found to have bilateral anterior uveitis and mild renal insufficiency with high urinary beta-2 microglobulin. Work up for connective tissue and infectious diseases were negative. His kidney function normalized spontaneously and remained normal at 1 year without intervention. Uveitis responded completely to local corticosteroid treatment and has not recurred.