Abdul Hamid Alraiyes

Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis

BACKGROUND: The indwelling pleural catheter (IPC), which was initially introduced for the management of recurrent malignant effusions, could be a valuable management option for recurrent benign pleural effusion (BPE), replacing chemical pleurodesis. The purpose of this study is to analyze the efficacy and safety of IPC use in the management of refractory nonmalignant effusions. METHODS: We conducted a systematic review and meta‐analysis on the published literature. Retrospective cohort studies, case series, and reports that used IPCs for the management of pleural effusion were included in the study. RESULTS: Thirteen studies were included in the analysis, with a total of 325 patients. Congestive heart failure (49.8%) was the most common cause of BPE requiring IPC placement. The estimated average rate of spontaneous pleurodesis was 51.3% (95% CI, 37.1%‐65.6%). The estimated average rate of all complications was 17.2% (95% CI, 9.8%‐24.5%) for the entire group. The estimated average rate of major complications included the following: empyema, 2.3% (95% CI, 0.0%‐4.7%); loculation, 2.0% (95% CI, 0.0%‐4.7%); dislodgement, 1.3% (95% CI, 0.0%‐3.7%); leakage, 1.3% (95% CI, 0.0%‐3.5%); and pneumothorax, 1.2% (95% CI, 0.0%‐4.1%). The estimated average rate of minor complications included the following: skin infection, 2.7% (95% CI, 0.6%‐4.9%); blockage and drainage failure, 1.1% (95% CI, 0.0%‐3.5%); subcutaneous emphysema, 1.1% (95% CI, 0.0%‐4.0%); and other, 2.5% (95% CI, 0.0%‐5.2%). One death was directly related to IPC use. CONCLUSIONS: IPCs are an effective and viable option in the management of patients with refractory BPE. The quality of evidence to support IPC use for BPE remains low, and high‐quality studies such as randomized controlled trials are needed.

The role of sedation in endobronchial ultrasound-guided transbronchial needle aspiration: Systematic review

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in diagnosis and staging of mediastinal lymph node (LN) lesions in lung cancer. Adequate sedation is an important part of the procedure since it provides patient′s comfort and potentially increases diagnostic yield. We aimed to compare deep sedation (DS) versus moderate sedation (MS) in patients undergoing EBUS-TBNA procedure. Methods: PubMed, EMBASE, MEDLINE, and Cochrane Library were searched for English studies of clinical trials comparing the two different methods of sedations in EBUS-TBNA until December 2015. The overall diagnostic yield, LN size sampling, procedural time, complication, and safety were evaluated. Results: Six studies with 3000 patients which compared two different modalities of sedation in patients performing EBUS-TBNA were included in the study. The overall diagnostic yield of DS method was 52.3%-100% and MS method was 46.1%-85.7%. The overall sensitivity of EBUS-TBNA of DS method was 98.15%-100% as compared with 80%-98.08% in MS method. The overall procedural times were 27.2-50.9 min and 20.6-44.1 min in DS and MS groups, respectively. The numbers of LN sampled were between 1.33-3.20 nodes and 1.36-2.80 nodes in DS and MS groups, respectively. The numbers of passes per LN were 3.21-3.70 passes in DS group as compared to 2.73-3.00 passes in MS group. The mean of LN size was indifferent between two groups. None of the studies included reported serious adverse events. Conclusions: Using MS in EBUS-TBNA has comparable diagnostic yield and safety profile to DS. The decision on the method of sedation for EBUS-TBNA should be individually selected based on operator experience, patient preference, as well as duration of the anticipated procedure.

Saber-sheath trachea in a patient with severe COPD

An 86-year-old man was evaluated for chronic cough and right lower lobe (RLL) mass. His medical history was significant for severe chronic obstructive lung disease (COPD). He had smoked one pack of cigarettes daily for 55u2005years. He had a barrel-shaped chest and diminished breath sounds in bilateral lungs were heard. CT of the chest noted RLL mass and abnormal configuration of the trachea (figure 1). Bronchoscopic examination showed an enlarged non-collapsible horseshoe-shaped trachea (figure 2). Endobronchial ultrasound with fine-needle aspiration of the left paratracheal lymph nodes revealed squamous cell carcinoma. A diagnosis of stage IIIb lung cancer was …

Intussusception technique of intrabronchial silicone stents: description of technique and a case report.

Respiratory tract infection with human papillomavirus has been associated with major airway complications, including tracheal stenosis. We report a case of recurrent respiratory papillomatosis infection complicated with iatrogenic airway fire injury causing airway stenosis. This was treated with reconstruction and a silicone Y stent placement. Three years after the stent placement, the patient presented with wheezing and shortness of breath. Bronchoscopy revealed tracheal narrowing proximal to the tracheal limb of the Y stent. The stenosis was treated with a stent intussusception technique with satisfactory results.

Detection of an Embolized Central Venous Catheter Fragment with Endobronchial Ultrasound.

An 84‐year‐old woman underwent Convex‐probe Endobronchial Ultrasound (CP‐EBUS) for 18F‐fluorodeoxyglucose avid subcarinal lymphadenopathy on Positron Emission Tomogram (PET) scan. Endobronchial ultrasound‐guided transbronchial needle aspiration of the subcarinal lymph node revealed squamous cell lung carcinoma. A small hyperechoic rounded density was noted inside the lumen of the azygous vein. Based on chest computed tomography findings and her clinical history, this was felt to be a broken fragment of a peripherally inserted central catheter, which was placed for intravenous antibiotics, a few months prior to this presentation. To the best of our knowledge, this is the first ever CP‐EBUS description of a broken fragment of central venous catheter.

Where Is the Convex-Probe Endobronchial Ultrasound Balloon? A Lessen to Learn

To the Editor: Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is a minimally invasive bronchoscopic procedure with overall complication rate <1.5%.1 The complications of EBUS-TBNA such as needle fracture and retention within the lymph nodes,2 pneumothorax, airway bleeding requiring intervention, mediastinitis, and hypoxic respiratory failure have been reported in the literature.1 We describe a case of dislodged convex-probe EBUS balloon in the bronchus. Its pathophysiologic mechanism, and preventive measures are also discussed. If such a complication is unrecognized, it could lead to life-threatening consequences. A 71-year-old woman underwent right upper lobectomy for stage IB squamous cell lung carcinoma followed by 4 cycles of chemotherapy. Surveillance computed tomography of the chest 6 months later demonstrated an enlarged right paratracheal lymph node (station 4R) measuring 18 13mm in size. EBUS-TBNA was performed to determine tumor recurrence in the mediastinum. She underwent general anesthesia with endotracheal tube placement because of difficulty placing the laryngeal mask airway. A flexible bronchoscopy was initially advanced through the endotracheal tube to determine the airway anatomy and no endobronchial lesion was found. The tip of the endotracheal tube was just 1 cm above the carina and was withdrawn a couple of centimeters to allow access to the right paratracheal node. The EBUS balloon had to be inflated to establish a firm contact with the airway mucosa overlying the right paratracheal lymph node for obtaining adequate ultrasonic visualization of the node. Multiple TBNA were obtained while the endotracheal tube remained slightly above the tip of the EBUS bronchoscope. Rapid on-site evaluation of the specimens demonstrated the presence of squamous cell carcinoma confirming the diagnosis of tumor recurrence. The EBUS scope was advanced to the left hilar area for lymph node evaluation; however, the balloon inflation was not successful because the small crescent of the balloon usually seen on the fiber-optic image was not identified. The EBUS scope was withdrawn to evaluate the balloon, which was not found at the tip of the scope. Airway inspection using the flexible bronchoscope showed a foreign body at the orifice of the right lower lobe bronchus (Fig. 1). It was identified to be the dislodged balloon of the EBUS scope and was successfully retrieved using suction. Our explanation of this occurrence is that the balloon attached to the probe was rubbing against the endotracheal tube during right paratracheal node aspirations forcing the balloon to slip from the probe to the right lower lobe bronchus. If the EBUS scope is removed without attempting to inflate the balloon to visualize the left hilar nodes, the balloon could be left in the airways, which could have led to complications such as atelectasis and postobstructive pneumonia. It is important to confirm the presence of the balloon at the end of the EBUS procedure and to recognize that balloon migration to the airways can lead to potential complications if it goes unnoticed. Laryngeal mask

Tracheobronchial Airway Necrosis: An Atypical Presentation of Recurrent Osteosarcoma.

Received for publication March 6, 2016; accepted July 26, 2016. From the *Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University at Buffalo; and wRoswell Park Cancer Institute, Buffalo, NY. P.T., K.H., J.B., and A.H.A. prepared the manuscript or revised it critically for important intellectual content. Disclosure: There is no conflict of interest or other disclosures. Reprints: Pichapong Tunsupon, MD, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University at Buffalo, Western New York Veterans Administration Healthcare System, 3495 Bailey Avenue, Buffalo, NY 14215 (e-mail: ptunsupon@gmail.com). Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/LBR.0000000000000327 IMAGES IN INTERVENTIONAL PULMONOLOGY

Reporting of central airway obstruction on radiology reports and impact on bronchoscopic airway interventions and patient outcomes

Background: Central airway obstruction (CAO) is a serious condition that affects patients with both benign and malignant diseases. Timely recognition of CAO is crucial for prompt intervention aimed at improving the symptoms and quality of life of these patients. The aim of this study is to evaluate the formal radiology reporting of CAO and its impact on patients’ outcomes. Methods: The medical records of patients who underwent advanced therapeutic bronchoscopy for CAO from August 2013 to September 2014 were retrospectively reviewed. Three researchers each reviewed 14 of the 42 formal radiology reports that were performed at 16 different medical and radiology centers. Patient characteristics were reported as means, medians, and standard deviations for continuous variables, and as frequencies and relative frequencies for categorical variables. Results: Out of 42 patients who underwent advanced bronchoscopy for planned therapeutic intervention, only 30 had radiology and pulmonology concordance about the airway findings of CAO. This is an agreement rate of 71.4% [95% confidence interval (CI): 56.7–83.3%] or a disagreement rate of 28.6% (95% CI: 16.7–43.3%). The radiology reports did not mention 31% of CAO on CT scans. The median time from CT imaging to bronchoscopy was significantly longer in patients with CAO not reported by the radiologists (21 versus 10 days; p = 0.011). Most patients improved postoperatively with no significant difference between the two groups. Conclusions: Findings of CAOs were not described in a significant proportion of radiology reports. This results in significant delay in bronchoscopic airway management.

Aspirin use and the risk of bleeding complications after therapeutic bronchoscopy

Background: Aspirin use has been shown to be safe for patients undergoing certain diagnostic bronchoscopy procedures such as transbronchial biopsies and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration. However, there are no studies documenting the safety of aspirin in patients undergoing therapeutic bronchoscopy. The aim of this study is to evaluate whether aspirin increases the risk of bleeding following therapeutic bronchoscopy. Methods: This was a retrospective study to determine if there was a higher risk of bleeding in patients on aspirin undergoing therapeutic bronchoscopy compared with those not on aspirin. Patient characteristics were reported by cohort using the mean, median, and standard deviation for continuous variables, and using frequencies and relative frequencies for categorical variables. Results: Of the 108 patients who had multimodality therapeutic bronchoscopy, 17 (15.7%) were taking aspirin and 91 (84.3%) were not on aspirin. Patients in the aspirin group were older than those in the no aspirin group (median age: 66 versus 60 years, p = 0.007). The treatment modalities were similar in both groups except that more patients in the no aspirin group were treated with argon plasma coagulation (APC) compared to the aspirin group (60.4% versus 29.4%, p = 0.031). The estimated blood loss (EBL) between the aspirin and no aspirin groups was not significantly different (mean: 6.0 versus 6.7 ml; median: 5.0 versus 5.0, p = 0.36). Overall, there was no difference in complications between both groups. Conclusion: Aspirin use was not associated with increased risk of bleeding or procedure-related complications after therapeutic bronchoscopy.

Medical Thoracoscopy Technique and Application

Medical thoracoscopy (MT) is a procedure that involves access to the pleural space with an endoscope allowing direct visualization of the pleural space and intrathoracic structures while aiding in obtaining tissue or performing interventions under direct visual guidance. This article reviews the technique, applications, and complications of MT.