Pulmonary hypertensive medical therapy in chronic thromboembolic pulmonary hypertension before pulmonary thromboendarterectomy.

BACKGROUND: The currently recommended treatment for chronic thromboembolic pulmonary hypertension is pulmonary thromboendarterectomy (PTE). No convincing evidence for the use of pulmonary hypertensive medical therapy (PHT) exists in operable candidates. We sought to determine the prevalence of the use of PHT on referral for PTE and the effects on pre-PTE hemodynamics and post-PTE outcomes/hemodynamics. METHODS AND RESULTS: We performed a retrospective analysis of chronic thromboembolic pulmonary hypertension patients referred for PTE during 2005-2007. The prevalence of PHT was determined for all patients referred to our institution. Hemodynamic and outcomes analysis involved only those undergoing PTE. Data included baseline demographics, PHT medication(s), dosage, duration of therapy, and time to referral. Hemodynamic data were acquired from the time of diagnosis, the time of referral visit, and after PTE. Outcomes included intensive care unit, hospital, and ventilator days; bleeding and infection rates; incidence of reperfusion lung injury; and in-hospital mortality. The control group (n=244) was compared with the PHT group (n=111); subgroups included monotherapy with bosentan, sildenafil, or epoprostenol and combination therapy. The prevalence of PHT significantly increased from 19.9% in 2005 to 37% in 2007. There was minimal benefit of treatment with PHT on pre-PTE mean pulmonary artery pressure, but its use was associated with a significant delay in time to referral for PTE. Both groups experienced significant improvements in hemodynamic parameters after PTE. The 2 groups did not differ significantly in any post-PTE outcome. Similar results were obtained for each subgroup. CONCLUSIONS: Our results suggest that PHT use has minimal effect on pre-PTE hemodynamics and no effect on post-PTE outcomes/hemodynamics.

Diagnosis of lung nodules with peripheral/radial endobronchial ultrasound-guided transbronchial biopsy.

BACKGROUND: : Pulmonary nodules are frequently encountered in clinical practice, but diagnostic sensitivity of traditional bronchoscopy remains less than desirable. Transbronchial biopsy (TBBX) under fluoroscopic guidance with flexible bronchoscopy has a sensitivity of 34% for lesions <20 mm and 63% for lesions >20 mm. Navigational technologies such as electromagnetic navigation bronchoscopy have increased the yields of TBBX to approximately 73%. We examine the sensitivity and factors that may impact the diagnostic yield of a similar technology, namely, radial endobronchial ultrasound (EBUS). METHODS: : We conducted a retrospective review of 40 consecutive patients at a single institution who underwent TBBX of lung nodules ≤3 cm using radial EBUS guidance. We evaluated patient demographics, lung function, procedural sedation, nodule size and location, presence of a radiographic airway leading into the nodule (ie, bronchus sign), distance from the pleura, and metabolic activity on positron emission tomography scan. Nonmalignant biopsy results were compared with subsequent surgical resection or establishment of nonmalignancy based on radiographic stability over time. RESULTS: : Overall, the diagnostic yield of radial EBUS-guided bronchoscopy was 65%. Sensitivity was 71% in malignant disease and 82% in nonmalignant disease. Presence of a bronchus sign, nodule size, nodule location, distance from the pleura, and method of sedation did not have any impact on the yield of radial EBUS-guided TBBX (P≥0.21). CONCLUSIONS: : Lesion size, distance, presence of a computerized tomography bronchus sign, or lobar location may not impact the diagnostic yield of bronchoscopic biopsy of peripheral lung nodules with radial EBUS navigation.

Multicenter experience with electromagnetic navigation bronchoscopy for the diagnosis of pulmonary nodules.

BACKGROUND: Physicians are increasingly encountering lung nodules in their practice, and tissue diagnosis is often required. Conventional bronchoscopic sampling yields a range from 14% to 69% depending on the nodule size and location within the lung. We aimed to evaluate the diagnostic yield of electromagnetic navigation bronchoscopy (ENB) in multiple centers and to determine what factors affect the yield of ENB. METHODS: A retrospective analysis of 92 consecutive ENB procedures at 5 centers was carried out. Data were collected on patient demographics, nodule characteristics, complications, type of samples obtained, diagnosis, and follow-up studies. Variables were analyzed to determine as to which factors had an impact on the diagnostic yield with multiple logistic regression analysis. RESULTS: Ninety-two patients underwent EMB at 5 centers between December 2008 and October 2009. The average nodule size was 2.61 cm (SD 1.42) at a distance of 1.81 cm (SD 1.32) from the pleural surface. The overall yield for ENB-guided sampling of pulmonary nodules was 65% (60/92). The ENB yield for nodules ≤2 versus >2 cm in size was significantly less after controlling for the distance from the pleura (50% vs. 76%, respectively; P=0.01). The distance from the pleura did not affect the ENB diagnostic yield after controlling for nodule size (P=0.92). The lobar location of the nodule also did not affect the diagnostic yield (P=0.59). CONCLUSIONS: The diagnostic yield of ENB-guided sampling of pulmonary nodules is impacted by the nodule size, but not by the distance from the pleura or the lobar location.

Tools of the Trade: A Novel Bronchoscope With a Built-in Miniature Video Screen, Camera, and Light Source.

OBJECTIVE: To evaluate the performance of a mobile bronchoscope with miniature video screen, light source, and a digital camera. DESIGN: Prospective study. SETTING: Inpatient and outpatient tertiary care center. INTERVENTIONS: None. PATIENTS: Twenty patients who were undergoing diagnostic or therapeutic bronchoscopy from May 2009 to July 2009. MEASUREMENTS AND MAIN RESULTS: Thirteen patients underwent bronchoscopy via the oral and nasal approach, 2 via a tracheostomy, and 5 via an endotracheal tube or laryngeal mask airway. The scope was also used in the placement of a percutaneous tracheostomy tube and in the operating room for 3 procedural endotracheal intubations. The overall performance of mobile bronchoscope was satisfactory. The majority of difficulties encountered by the bronchoscopists came from the performance of the monitor. The main issue was the need to turn the screen to view the image in an upright position. CONCLUSIONS: The Airway Mobile Scope is well suited for airway examination and interventions often needed in emergency rooms, intensive care units, operating rooms, and office settings. The ease of use of the bronchoscope could be enhanced with small changes to the display of the image on the LCD screen.