Long-Term Success of Metal Endobronchial Stents in Lung Transplant Recipients.

BACKGROUND: Bronchial stenosis is a common complication following lung transplantation. We evaluated long-term associations of the use of self-expandable metal stents (SEMSs) with lung function tests, patient safety, and survival. METHODS: A retrospective chart review of 582 lung transplantations performed at our institution between January 2002 and January 2018. Fifty-four patients with SEMSs (intervention group) were matched one-to-one to patients without SEMSs (control group) using propensity score matching for age, sex, the year, and type of transplantation (unilateral/bilateral), and underlying disease. Data regarding long-term lung function and survival were compared between the groups. RESULTS: During a median follow-up of 54.8 months, the difference in survival between the study groups was not statistically significant (p = 0.2). Following 5, 7.5 and 10 years, values of mean forced expiratory volume in 1 second (FEV1) were comparable between patients with and without SEMSs as follows: 59.5 versus 62.6% (p = 0.2), 55.9 versus 55.0% (p = 0.4), and 63.5 versus 61.9% (p = 0.3), respectively. In the intervention group, a significant increase in the mean FEV1 was observed in 60 days after stent insertion (from 41.9 ± 12.8 to 49.5 ± 16.7% days, p < 0.001). Long-term complications following stent insertion included severe bleeding (1.8%), stent fractures (7.4%), stent stenosis (7.4%), stent collapse (3.7%), endobronchial pressure ulcer (1.9%), and stent migration (1.9%). CONCLUSION: SEMS insertion is associated with a positive sustained effect on lung function, without increasing long-term mortality. Thus, airway stenosis after lung transplantation can be safely and successfully treated using endobronchial metal stenting, with tight bronchoscopic follow-up and maintenance.

Transbronchial Cryobiopsies for the Diagnosis of Diffuse Parenchymal Lung Diseases: Expert Statement from the Cryobiopsy Working Group on Safety and Utility and a Call for Standardization of the Procedure.

Transbronchial cryobiopsies (TBCB) have recently been introduced as a promising and safer alternative to surgical lung biopsy in the diagnostic approach to diffuse parenchymal lung diseases (DPLD). Despite a substantial and expanding body of literature, the technique has not yet been standardized and its place in the diagnostic algorithm of DPLD remains to be defined. In part, this reflects concerns over the diagnostic yield and safety of the procedure, together with the rapid spread of the technique without competency and safety standards; furthermore, there is a substantial procedural variability among centers and interventional pulmonologists. We report this expert statement proposed during the third international conference on "Transbronchial Cryobiopsy in Diffuse Parenchymal Lung Disease" (Ravenna, October 27-28, 2016), which formulates evidence- and expert-based suggestions on the indications, contraindications, patient selection, and procedural aspects of the procedure. The following 5 domains were reviewed: (1) what is the role of TBCB in the diagnostic evaluation of DPLD: patient selection; (2) pathological considerations; (3) contraindications and safety considerations; (4) how should TBCB be performed and in what procedural environment; and (5) who should perform TBCB. Finally, the existence of white paper recommendations may also reassure local hospital credentialing committees tasked with endorsing an adoption of the technique.

Bronchoscopic Drainage of Lung Abscesses Using a Pigtail Catheter.

BACKGROUND: Lung abscesses are commonly treated with antibiotics. However, some patients fail to respond and may require percutaneous catheter drainage or surgical intervention. Bronchoscopic drainage (BD) of lung abscesses emerged as a therapeutic alternative in selected patients. OBJECTIVE: To describe our experience with 15 patients who underwent BD at our center during 2006-2016. METHODS: Patients underwent flexible bronchoscopy. Under fluoroscopic guidance, a pigtail catheter was introduced into the abscess cavity, its correct position being confirmed by the injection of contrast medium. The catheter remained in place for a few days and was flushed repeatedly with antibiotics. RESULTS: Fifteen patients (9 males; median age 59 years) underwent 16 BD procedures. A pigtail catheter was successfully inserted and pus was drained from the abscess cavity in 13 procedures (81%) conducted in 12 patients, leading to rapid clinical improvement in 10 of them; resolution of fever occurred a median of 2 days (range <1-4) following pigtail insertion, and patients were discharged after 8 days (range 4-21). The pigtail catheter was extracted after a median of 4 days (range 2-6). CONCLUSION: BD of lung abscesses was achieved in 13 out of 16 procedures, leading to rapid improvement in the majority of patients. This work adds to the existing literature in establishing this procedure as an acceptable therapeutic alternative in selected patients who fail to respond to antibiotics, especially those with an airway obstruction or a fairly central lung abscess.

Survival following lung transplantation for artificial stone silicosis relative to idiopathic pulmonary fibrosis.

BACKGROUND: Silicosis is a progressive lung disease resulting from the inhalation of respirable crystalline silica. Lung transplantation is the only treatment for end-stage silicosis. The aim of this study was to analyze the survival experience following lung transplantation among patients with silicosis. METHODS: We reviewed data for all patients who underwent lung transplantation for silicosis and a matched group undergoing lung transplantation for idiopathic pulmonary fibrosis (IPF) at a single medical center between March 2006 and the end of December 2013. Survival was followed through 2015. RESULTS: A total of 17 lung transplantations were performed for silicosis among 342 lung transplantations (4.9%) during the study period. We observed non-statistically significant survival advantage (hazard ratio 0.6; 95%CI 0.24-1.55) for those undergoing lung transplantation for silicosis relative to IPF patients undergoing lung transplantation during the same period. CONCLUSIONS: Within the limits of a small sample, survival in silicosis patients following lung transplantation was not reduced compared to IPF. Am. J. Ind. Med. 60:248-254, 2017. © 2017 Wiley Periodicals, Inc.

Successful Rituximab Therapy in Steroid-Resistant, Cryptogenic Organizing Pneumonia: A Case Series.

Cryptogenic organizing pneumonia (COP) is an interstitial lung disease that is usually responsive to corticosteroid treatment. The treatment of COP has not been studied in randomized controlled trials; thus, treatment decisions are based on practice guidelines. We herein present, for the first time, 4 cases of patients with biopsy-proven COP who did not respond to corticosteroids but benefited from rituximab therapy. This report consists of a retrospective case series of patients who experienced steroid-resistant, biopsy-proven COP. Patients included in this case series suffered from acute or chronic COP and did not respond to corticosteroid treatment for a few weeks to months but later responded to rituximab. In a series of 4 patients, 1 patient had a complete radiological and clinical response after rituximab therapy, and the steroids could be gradually tapered. Three patients had a chronic course but had been able to lower steroid dosage or even discontinue the drug after being treated with rituximab. Since 40% of the patients with COP do not respond to or stay dependent on steroids, we think that even the ability to lower the steroid dosage by using rituximab as a steroid-sparing agent with a good safety profile is worth the effort. However, further studies are warranted.

Safety of Cryo-Transbronchial Biopsy in Diffuse Lung Diseases: Analysis of Three Hundred Cases.

BACKGROUND: Transbronchial biopsy (TBB) which is performed with metal forceps (forceps TBB) has been accepted as a useful technique in establishing diagnoses of diffuse lung diseases (DLDs). The use of cryoprobes to obtain alveolar tissue (cryo-TBB) is a new method which is currently used by our institute as well as others with excellent results. OBJECTIVES: To assess the safety of cryo-TBB compared with conventional forceps TBB. METHODS: We performed a retrospective data evaluation of 300 consecutive patients who underwent cryo-TBB between January 2012 and April 2014 and compared them with historical cases treated with forceps TBB between 2010 and 2012. The results of both diagnostic modalities were compared based on pathological reports. The major complications (significant bleeding and pneumothorax) were compared, along with postprocedural hospitalization. RESULTS: Pneumothorax was observed in 15 cases (4.95%) treated with cryo-TBB versus 9 cases (3.15%) treated with forceps TBB, with no significant difference (p = 0.303). The insertion of a chest tube was necessary in 6 (2%) and 4 (1.3%) of the cases having undergone cryo-TBB or forceps TBB, respectively (p = 0.8). In the cryo-TBB group, bleeding was encountered in 16 cases (5.2%), and it occurred in 13 cases (4.5%) of the forceps TBB group, with no significant difference in rates (p = 0.706). Also, there was no significant difference in hospital admission rates between the groups [cryo-TBB: 10 (3.3%); forceps TBB: 4 (1.44%); p = 0.181]. The safety profile of cryo- and forceps TBB remained the same even when stratified according to indications for TBB, i.e. immunocompromised hosts, patients after lung transplantation and those with DLDs. CONCLUSION: In patients with DLDs, cryo-TBB is as safe as forceps TBB.

Long-term effects of a 12-week exercise training program on clinical outcomes in idiopathic pulmonary fibrosis.

PURPOSE: Idiopathic pulmonary fibrosis (IPF) is a chronic, devastating, lung disease, with few therapeutic options. Data are limited with respect to the long-term effect of exercise training (ET) in IPF. This study sought to evaluate the long-term effects of a 12-week ET program on clinical outcomes in IPF patients. METHODS: Thirty-four IPF patients were randomly allocated to ET or control groups. ET group participated in a 12-week supervised exercise program, while the control group continued with regular medical treatment alone. Exercise capacity, 30 s-chair-stand test for leg strength, dyspnea, and Saint George's Respiratory Questionnaire (SGRQ) for quality of life (QOL) were assessed at baseline and re-evaluated at 11 months from baseline. In addition, at 30-month time point from baseline, the impact of the 12-week intervention was analyzed with respect to survival and cardio-respiratory-related hospitalizations. RESULTS: Thirty-two patients completed the 12-week intervention and 28 patients (14 in each group) were re-evaluated. At 11-month follow-up, no significant differences between the groups and time effect were demonstrated for most outcomes. ET group showed preserved values at the baseline level while the control group showed a trend of deterioration. Only the 30 s-chair-stand test (mean difference 3 stands, p = 0.01) and SGRQ (mean difference -6 units, p = 0.037) were significantly different between the groups. At 30 months, the survival analysis showed three deaths, eight hospitalizations occurred in the control group versus one death, one lung transplantation and seven hospitalizations in the ET group, with no significant differences between groups. CONCLUSIONS: At 11-month follow-up, the 12-week ET program showed clinical outcomes were preserved at baseline levels with some maintenance of improvements in leg strength and QOL in the ET group. The control group showed a trend of deterioration in the outcomes. At 30 months, the 12-week ET program did not show benefits in prognosis although the study was underpowered to detect such differences. We suggest including ET as a long-term continued treatment and as a core component of pulmonary rehabilitation programs for IPF patients.

Radiation exposure and attributed cancer risk following lung transplantation.

BACKGROUND: Lung transplant recipients are exposed to radiation from various imaging procedures during surveillance; however, the cumulative radiation exposure and subsequent cancer risk after lung transplantation is not known. METHODS: We included all patients who underwent lung transplantation at our institute since January 2000 and survived at least four-yr follow-up continued until March 21, 2012 or until death. We identified all procedures with radiation exposure and all malignancies that developed during the study period. Estimation of the effective dose exposure and subsequent cancer risk was derived from previous reports. RESULTS: The study included 107 patients. Mean follow-up was 6.49 ± 1.74 yr. Radiation exposure during mean follow-up was 137.8 mSv, and the total cumulative exposure over 11 yr reached 205.25 mSv. This represents an additional cancer risk of 0.55% and 0.82%, respectively. Twenty-four cases of cancer in 21 patients (19.6%) were identified. The difference between the radiation exposure in the patients who developed cancer and in the cancer-free patients was not statistically significant. CONCLUSION: Lung transplant recipients are exposed to 7.8 times greater radiation dose from medical imaging compared to the general population. Nevertheless, the lifetime increase in cancer risk due to radiation is small.

Renal function preservation with the mTOR inhibitor, Everolimus, after lung transplant.

Chronic kidney disease (CKD) is a common complication of calcineurin inhibitors (CNIs) in solid organ transplantation. Previous data suggest that the use of everolimus as an immunosuppressant drug leads to improvement in renal function. The aim of our study was to establish the effect of everolimus in combination with lower doses of CNIs on renal function among lung transplant recipients. Data regarding renal function and pulmonary function were collected from 41 lung transplanted patients in whom treatment was converted to a combination of everolimus with lower doses of CNIs. Patients transferred to everolimus and low dose CNIs showed an improvement in renal function. Patients who continued treatment with everolimus showed improvement in renal function, as opposed to patients who discontinued the treatment. Subjects without proteinuria at baseline showed a better improvement compared with subjects with proteinuria. The incidence of graft rejection did not increase. We concluded that a protocol that includes everolimus and lower doses of CNIs is effective for preserving renal function in lung transplant recipients with CKD. We also believe that an early implementation of everolimus, before proteinuria occurs or creatinine clearance is reduced, could lead to better outcomes.

Histological diagnosis of interstitial lung diseases by cryo-transbronchial biopsy.

BACKGROUND AND OBJECTIVE: The gold standard for the histological diagnosis of interstitial lung diseases (ILD) is an open lung biopsy (OLB). Tissue samples obtained by forceps transbronchial lung biopsies (TBB) are usually too small. We aim to evaluate the efficacy and safety of cryo-TBB for the diagnosis of ILD and to explore its role as substitute for OLB. METHODS: Seventy-five patients (mean age 56.2 years) with clinical and radiological features suggestive of ILD underwent cryo-TBB under moderate sedation. The diagnostic contribution on the work-up of suspected ILD was assessed. RESULTS: No major complications occurred during cryo-TBB procedures. The mean cross-sectional area of the biopsy specimen obtained was 9 mm2 with an average of 70% alveolated tissue. The most common pathological diagnoses were idiopathic nonspecific interstitial pneumonitis (n = 22), cryptogenic organizing pneumonia (n = 11) and usual interstitial pneumonitis (n = 7). There were three patients of pulmonary Langerhans cell histiocytosis and one patient of pulmonary lymphangioleiomyomatosis. A definite and probable clinicopathological consensus diagnosis was possible in 70% and 28% of patients, respectively. In only 2% of patients' diagnosis could not be established. CONCLUSIONS: Cryo-TBB is a safe and effective minimally invasive modality for the diagnosis of ILD. No OLB is needed in the majority of patients.

Prospective randomized trial of bispectral index monitoring of sedation depth during flexible bronchoscopy.

BACKGROUND: The clinical benefits associated with the use of the bispectral index (BIS) to monitor the depth of sedation during flexible fiberoptic bronchoscopy (FFB) are questionable. OBJECTIVES: To evaluate the added value in terms of procedural safety and patients' awareness of monitoring sedation depth using the BIS compared to conventional clinical judgment alone in patients undergoing FFB under propofol sedation. METHODS: The cohort included 81 patients undergoing diagnostic or therapeutic bronchoscopy under propofol sedation that were prospectively randomized to guide the depth of sedation by BIS monitoring (BIS group; n = 40) or conventional monitoring (control group; n = 41). RESULTS: The mean durations of the procedure were 18 and 19 min in the BIS and control groups, respectively. No significant difference was noted in the dosage of propofol used between the BIS and control groups (168.7 vs. 167.3 mg, respectively). Average sedation-related oxygen saturation drop and transcutaneous CO2 rise were not significantly different between groups. There was also no significant difference in the percentage of patients that required either hemodynamic support (5 vs. 7.5%, respectively), oxygen supplementation by 100% O2 mask (67.5 vs. 82.5%, respectively) or Ambu face mask manual ventilation (2.5 vs. 5%, respectively) between the groups. No significant difference was noted in terms of patients' awareness during the procedure, which was assessed following recovery by a structured Brice interview. CONCLUSION: Using BIS to guide the depth of sedation during propofol sedation in patients undergoing FFB of relatively short duration offers no clinically significant advantages over conventional monitoring.

Exercise training-based pulmonary rehabilitation program is clinically beneficial for idiopathic pulmonary fibrosis.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a chronic, devastating, interstitial lung disease, with few therapeutic options. IPF is characterized by pulmonary restriction, dyspnea, hypoxemia, exercise intolerance and poor quality of life (QOL). OBJECTIVES: We aimed to examine the effect of exercise training (ET) on clinical outcomes in IPF patients. METHODS: A randomized controlled study included thirty-two IPF patients (aged 68 ± 8 years) who were allocated either to the ET group (n = 15), participating in a 12-week, twice-weekly 60-min supervised ET-based pulmonary rehabilitation program, or to a control group (n = 17) continuing with regular medical treatment alone. Cardiopulmonary exercise test, 6-min walking distance (6MWD) test, 30-second chair-stand test, pulmonary function tests, dyspnea and QOL were assessed at baseline and at the end of the 12-week intervention. RESULTS: Significant differences were observed between the ET and the control groups in raw mean deltas (Δ = post- - pre-intervention): Δ6MWD, 81 m, p < 0.001; ΔVO2 peak, 2.6 ml/kg/min, p = 0.002; Δwork rate, 22 W, p < 0.001; Δanaerobic threshold, 3.1 ml/kg/min, p < 0.001, and ΔFVC % predicted, 6%, p = 0.038. Dyspnea, QOL and 30-second chair-stand were also improved significantly following the program. CONCLUSIONS: ET improves exercise tolerance, functional capacity, pulmonary function, dyspnea and QOL in patients with IPF, suggesting a short-term treatment efficacy for clinical improvement, and should be considered the standard care for IPF.

Efficacy of bronchoscopic closure of a bronchopleural fistula with amplatzer devices: long-term follow-up.

BACKGROUND: The development of a bronchopleural fistula (BPF) is associated with high rates of morbidity and mortality. We have developed a minimally invasive method of bronchoscopic BPF closure using Amplatzer devices (AD) and Amplatzer vascular plugs (AVP), with excellent short-term results. OBJECTIVES: The aim of the present report was to explore the long-term outcome of patients treated by Amplatzer occluders and the durability of this novel modality of BPF treatment. METHODS: A total of 31 central BPF in 31 patients (mean age 66.8 years, range 19-91) were sealed under moderate sedation bronchoscopically by either AD (n = 19) or AVP (n = 12). The average follow-up period was 17.6 months (range 1-68 months). RESULTS: The main etiology for BPF was surgery (n = 24), pneumonectomy (n = 14) or lobectomy/segmentectomy (n = 10). The underlying disease was either primary (n = 19) or metastatic (n = 2) lung cancer. The immediate success rate was 96% as symptoms related to BPF disappeared in 30 of the 31 patients. Short-term (<30 days) mortality was 13% (4 patients). At follow-up, 14 patients (45%) are still alive. Out of 12 patients with late mortality, in 5 patients (41%) the death was directly related to cancer relapse, and no patient died due to BPF recurrence. CONCLUSION: Endobronchial closure of BPF using both types of Amplatzer occluders (AD and AVP) is a minimally invasive effective modality of treatment with high safety profile and satisfactory long-term outcome considering the poor prognosis in this particular group of patients.

[Bronchial thermoplasty--a novel method for the treatment of severe asthma].

Bronchial thermoplasty was approved for treating severe refractory asthma that is not well controlled by high-dose inhaled corticosteroids and long-acting bronchodilator therapy. This article reviews its indications, its safety profile, evidence of short-term and long-term efficacy, and clinical protocols.

Transbronchial cryo-biopsy in lung transplantation patients: first report.

BACKGROUND AND OBJECTIVE: Transbronchial lung biopsies remain the gold standard to establish the presence of allograft rejection or infection after lung transplantation. The aim of this study was to evaluate the efficacy and safety of cryo-transbronchial biopsies (cryo-TBB) in lung transplantation patients. METHODS: Forty lung transplantation patients (mean age 58.3 years) underwent cryo-TBB, either routine post lung transplantation surveillance bronchoscopy (n = 27), or clinically indicated bronchoscopy (n = 13). During the procedure, two to three biopsy samples were taken. Procedure characteristics, complications and the diagnostic yield were compared with 40 matched controls who underwent conventional forceps-TBB. RESULTS: No major complications occurred in the cryo-TBB group. The mean diameter of the specimen taken by cryo-TBB was 10 mm(2) compared with only 2 mm(2) using forceps-TBB (P < 0.05). The increased size and quality of biopsy samples in the study group translated to a significant increase in the percentage of alveolated tissue (65% vs 34% respectively, P < 0.05) that enabled a clear histological detection of acute rejection (n = 4), pneumonitis (n = 3), diffuse alveolar damage (n = 1) and confident exclusion of acute rejection, infection or pneumonitis (n = 32). Fluoroscopy time was significantly shorter in the cryo-biopsy patients compared with controls (25 s vs 90 s, respectively, P < 0.05). CONCLUSIONS: Cryo-TBB for both surveillance and clinically indicated bronchoscopy in lung transplantation patients provides larger and more diagnostic lung parenchyma specimens with low complication rate and shorter intervention time than traditional forceps biopsies.

Transbronchial cryobiopsy in immunocompromised patients with pulmonary infiltrates: a pilot study.

BACKGROUND: In immunocompromised patients with pulmonary infiltrates, transbronchial lung biopsies (TBB) obtained by forceps has been shown to increase the diagnostic yield over simple bronchoalveolar lavage. Cryo-TBB is a novel modality for obtaining lung biopsies. We aimed to evaluate for the first time the efficacy and safety of cryo-TBB in immunocompromised patients. METHODS: Fifteen immunocompromised patients with pulmonary infiltrates underwent cryo-TBB. During the procedure two to three biopsy samples were taken. Procedure characteristics, complications, and the diagnostic yield were retrospectively evaluated. RESULTS: Most patients (n = 11) were immunocompromised due to hematological malignancies. The remaining four patients were receiving chronic immunosuppressive treatment due to previous solid-organ transplantation (n = 2) or collagen-vascular disease (n = 2). No major complications occurred in the cryo-TBB group. The mean surface area of the specimen taken by cryo-TBB was 9 mm(2). The increase in surface area and quality of biopsy samples translated to a high percentage of alveolated tissue (70 %) that enabled a clear histological detection of the following diagnoses: noncaseating granulomatous inflammation (n = 2), acute interstitial pneumonitis consistent with drug reaction (n = 5), nonspecific interstitial pneumonia fibrotic variant (n = 1), diffuse alveolar damage (n = 3), organizing pneumonia (n = 3), and pulmonary cryptococcal pneumonia (n = 1). Diagnostic information obtained by cryo-TBB led to change in the management of 12 patients (80 %). CONCLUSION: Cryo-TBB in immunocompromised patients with pulmonary infiltrates provides clinically important diagnostic data with a low complication rate. These advantages should be further compared with traditional forceps TBB in a prospective randomized trial.

Effect of fissure integrity on lung volume reduction using a polymer sealant in advanced emphysema.

RATIONALE: Interlobar fissure integrity has previously correlated with responsiveness to endobronchial lung volume reduction therapy in patients with advanced emphysema. OBJECTIVE: This report summarises the effect of interlobar fissure integrity on responses to treatment with a novel endoscopic tissue sealant (AeriSeal emphysematous lung sealant (ELS)) that collapses hyperinflated lung. METHODS: Fissure status, lung volumes, tissue density and disease heterogeneity were assessed radiographically in 28 patients (age 63.4±6.1 years, 20 men) with advanced upper lobe predominant emphysema (density=888.0±18.2 HU; upper lobe tissue density < -950 = 2.62±1.74). Post-treatment changes in lobar volume, pulmonary function, exercise capacity, symptoms and quality of life were compared in patients with complete fissures (CFs) and incomplete fissures (ICFs). RESULTS: ELS therapy reduced lung volumes independent of interlobar fissure integrity. In patients with upper lobe emphysema and CFs, lobar volume reduction was 214±127 ml/treatment compared with 256±175 ml/treatment in those with ICFs (p=0.453). Reductions in gas trapping and improvements in spirometry, functional capacity and quality of life were similar in patients with CFs and ICFs. Stepwise multiple regression modelling confirmed that fissure integrity did not contribute to post-treatment changes in forced expiratory volume in 1 s, residual volume/total lung capacity ratio or lobar volume measured by CT analysis. CONCLUSIONS: Interlobar fissure integrity, an important determinant of responsiveness to endobronchial lung volume reduction therapy in prior studies, had minimal impact on physiological and functional responses to ELS therapy in patients with severe upper lobe predominant emphysema. CLINICAL TRIAL REGISTRATION NUMBER: Registration numbers for trials contributing to datasets in this report: NCT00884962, NCT01051258 and NCT01181466.

[Bronchoscopic treatment of emphysema].

Bronchoscopic techniques for the management of emphysema have evolved from the success of surgical treatment. Lung volume reduction surgery (LVRS) involves the removal of 20% to 30% of each lung and targets the most emphysematous segments. Patients with heterogeneous upper lobe emphysema and a low baseline exercise capacity have been identified as a subgroup within COPD in whom mortality benefits can even be achieved, along with improvements in exercise capacity and quality of life. Increased short-term mortality of approximately 5% and postoperative morbidity are the main limitations of LVRS. The extremely restrictive selection criteria for LVRS coupled with the relatively high mortality/morbidity have been the impetus for developing less invasive endoscopic modalities. Bronchoscopic lung volume reduction (BLVR) researchers have pursued various approaches using a range of modalities, such as blockers, stents, valves, sealants, and implants. BLVR appears to be safer than LVRS in terms of mortality and morbidity. This safety profile presents an attractive alternative for patients with COPD who are fragile physiologically because of the severity of their lung disease and the presence of co-morbid illnesses. The current report aims to describe the various minimally invasive modalities available for the treatment of emphysema.

Propofol safety in bronchoscopy: prospective randomized trial using transcutaneous carbon dioxide tension monitoring.

BACKGROUND: Midazolam is commonly used for sedation during flexible bronchoscopy because of its relatively wide therapeutic window. Recently, sedation with propofol for bronchoscopy has gained popularity, although concern has been raised regarding its potential ability to induce severe respiratory depression. OBJECTIVES: The aim of this study was to evaluate the safety of sedation under midazolam + alfentanil compared to propofol. METHODS: We conducted a prospective randomized trial using continuous transcutaneous carbon dioxide tension monitoring. The study group included 115 patients undergoing bronchoscopy, prospectively randomized to receive sedation with either midazolam + alfentanil (n = 59) or propofol (n = 56). RESULTS: Intra-procedural carbon dioxide tension values were higher in the midazolam + alfentanil group than in the propofol group (maximum 53.72 vs. 49.49 mm Hg, mean 46.78 vs. 43.78 mm Hg), but the differences did not reach statistical significance (p = 0.149 and 0.193, respectively). Carbon dioxide tension values were significantly higher in the midazolam + alfentanil group than in the propofol group at 5 and 10 min following procedure (51.7 vs. 49.3 mm Hg, p = 0.026, and 50.8 vs. 42.7 mm Hg, p < 0.01, respectively), and significantly more patients in the midazolam + alfentanil group needed oxygen supplementation or airway support (24 vs. 8 patients, respectively). CONCLUSION: Midazolam + alfentanil and propofol are equally safe for sedation during bronchoscopy. Sedation with propofol, using small boluses at short intervals, does not cause excessive respiratory drive depression and represents an excellent alternative to traditional sedation agents.