Amit K. Mahajan

Electromagnetic navigational bronchoscopy: an effective and safe approach to diagnose peripheral lung lesions unreachable by conventional bronchoscopy in high-risk patients.

Purpose The purpose of this study was to investigate the diagnostic yield and safety of electromagnetic navigation bronchoscopy (ENB) on peripheral lung lesions deemed otherwise unreachable using conventional bronchoscopy in high-risk patients. Methods This was a retrospective chart review involving adults (age, 18 y and older) who underwent ENB for pulmonary lesions located at the fourth order of bronchi or beyond, including subpleural lesions, at the University of Chicago Medical Center. Forty-eight patients underwent ENB by 3 different trained operators from January 2006 to September 2008. There was a short period of inactivity when the device was withdrawn from the market. ENB was reserved for use only in lesions at the fourth order of bronchi or beyond, including subpleural lesions, in patients who are considered high risk for other invasive procedures. Pathologic, cytologic, and microbiologic studies were carried out on recovered samples. Postprocedural chest radiographs were obtained on all patients to detect the presence of procedure-associated complications. Results ENB led to the diagnosis of 37 of 48 (77%) lesions not amenable to conventional bronchoscopic biopsy in high-risk patients. Of the 37 successful procedures, malignancy was identified in 18 patients (49%). Nonsmall cell lung cancer (NSCLC) was diagnosed 16 times, whereas both small cell lung cancer and carcinoid tumor were diagnosed once. In addition, 4 lesions (11%) were found to be infectious, 1 lesion (3%) was found to be granulomatous (noncaseating), and 1 lesion (3%) was diagnosed as organizing pneumonia. Of the 37 successful diagnoses, 13 lesions (35%) were determined to be nonpathologic, benign lesions. Eleven procedures (22%) were unsuccessful in yielding the correct pathologic diagnosis. Nine of the 11 unsuccessful ENB cases (82%) were found to be malignant, 9 of which were identified as NSCLC. Other than NSCLC, 1 neuroendocrine tumor (9%) and 1 metastatic transitional cell carcinoma of the kidney (9%) were identified by alternative, invasive testing methods. The 2 other lesions unsuccessfully diagnosed by ENB were not malignant. One was determined to be infection (histoplasmosis) and the other was diagnosed as an organizing pneumonia. The most common complication noted by all modalities was pneumothorax. ENB carried a pneumothorax rate of 5 of 49 (10%), 2 of which required chest tube insertion for treatment. In the ENB success group, 4 cases (11%) were complicated by pneumothoraces. In the ENB failure group, 1 case (9%) was complicated by a pneumothorax. Conclusions ENB is an effective and low-risk modality for diagnosing pulmonary lesions that are difficult to reach in patients deemed to be at high risk for invasive procedures. Although no clear criteria for the use of ENB currently exist, our study shows that diagnostic sampling can be obtained in 77% of lesions at the fourth order of bronchi or beyond, including subpleural lesions. Clinical Implications ENB is an effective, minimally invasive method for the diagnosis of pulmonary nodules previously deemed unreachable by conventional bronchoscopy in high-risk patients and harbors a low complication rate.

Isolation of persistent air leaks and placement of intrabronchial valves

OBJECTIVES Alveolar-pleural fistulas causing persistent air leaks are conditions associated with prolonged hospital courses, high morbidity, and possibly increased mortality. Intrabronchial valves serve as a noninvasive therapeutic option for the closure of alveolar-pleural fistulas. METHODS The present review describes a brief history of, and indications for, the placement of intrabronchial valves in patients with persistent air leaks. The essential steps necessary for placement are air leak isolation, airway sizing, and valve deployment. Additionally, the indications and methods for intrabronchial valve removal, along with the potential complications from intrabronchial valve placement, are described. CONCLUSIONS The increased use of intrabronchial valves in the treatment of persistent air leaks requires bronchoscopists and clinicians to understand the procedural steps and techniques necessary for intrabronchial valve placement.

Safety and feasibility of bronchial thermoplasty in asthma patients with very severe fixed airflow obstruction: a case series.

Objective. Bronchial thermoplasty (BT) can provide relief for patients with severe, uncontrolled asthma despite maximal medical therapy. However, it is unclear whether BT is safe in patients with very severe airflow obstruction. Methods. We performed BT in eight patients with severe asthma as defined by Expert Panel Report 3 (EPR-3) guidelines who were poorly controlled despite step 5 therapy. Data were available on each subject for 1 year prior to and 15–72 weeks following BT. Results. The mean (±SEM) pre-bronchodilator forced expiratory volume in one second (FEV1) prior to BT was 51.8 ± 8.6% of predicted, and the mean (±SEM) number of hospitalizations for asthma in the year prior to BT was 2.9 ± 1.2. No subject had an unexpected severe adverse event due to BT. Among the eight patients with follow-up of at least 15 weeks, there was no significant decline in FEV1 (p = .4). Conclusion. We suggest that BT may be safe for asthma patients with severe airflow obstruction and higher hospitalization rates than previously reported.

Intrabronchial valves: a case series describing a minimally invasive approach to bronchopleural fistulas in medical intensive care unit patients.

Background:Bronchopleural fistulas (BPF) are conditions associated with prolonged hospital course, high morbidity, and possibly increased mortality. The presence of BPFs in critically ill patients may cause difficulty in ventilation and increased oxygen requirements. Intrabronchial valves (Spiration IBV) serve as a noninvasive therapeutic option for the closure of BPFs. Methods:This report is a retrospective description of 3 patients transferred to our medical intensive care unit (ICU) with BPFs and persistent air leaks (PAL). One patient required high levels of oxygen supplementation through a nonrebreather face mask, whereas 2 required mechanical ventilation because of respiratory failure. IBVs were placed in each patient with the intention of closing their BPF and weaning them from respiratory support. Results:The use of IBVs in ICU patients with BPFs and PALs resulted in 1 patient being weaned from the persistent need for a nonrebreather face mask to room air and also aided in the liberation from mechanical ventilation of 2 patients who had been failing spontaneous breathing trials. Conclusions:The use of IBVs is safe and well tolerated in ICU patients with BPFs and PALs. The placement of IBVs results in significant clinical improvement, allowing for either weaning from high levels of oxygen support or liberation from mechanical ventilation.

High frequency chest wall oscillation for asthma and chronic obstructive pulmonary disease exacerbations: a randomized sham-controlled clinical trial

BackgroundHigh frequency chest wall oscillation (HFCWO) is used for airway mucus clearance. The objective of this study was to evaluate the use of HFCWO early in the treatment of adults hospitalized for acute asthma or chronic obstructive pulmonary disease (COPD).MethodsRandomized, multi-center, double-masked phase II clinical trial of active or sham treatment initiated within 24 hours of hospital admission for acute asthma or COPD at four academic medical centers. Patients received active or sham treatment for 15 minutes three times a day for four treatments. Medical management was standardized across groups. The primary outcomes were patient adherence to therapy after four treatments (minutes used/60 minutes prescribed) and satisfaction. Secondary outcomes included change in Borg dyspnea score (≥ 1 unit indicates a clinically significant change), spontaneously expectorated sputum volume, and forced expired volume in 1 second.ResultsFifty-two participants were randomized to active (n = 25) or sham (n = 27) treatment. Patient adherence was similarly high in both groups (91% vs. 93%; p = 0.70). Patient satisfaction was also similarly high in both groups. After four treatments, a higher proportion of patients in the active treatment group had a clinically significant improvement in dyspnea (70.8% vs. 42.3%, p = 0.04). There were no significant differences in other secondary outcomes.ConclusionsHFCWO is well tolerated in adults hospitalized for acute asthma or COPD and significantly improves dyspnea. The high levels of patient satisfaction in both treatment groups justify the need for sham controls when evaluating the use of HFCWO on patient-reported outcomes. Additional studies are needed to more fully evaluate the role of HFCWO in improving in-hospital and post-discharge outcomes in this population.Trial RegistrationClinicalTrials.gov: NCT00181285

Correction of Coagulopathy in the Setting of Acute Liver Failure

The depletion of vital coagulation factors and proteins in the setting of acute liver failure (ALF) is common and multifactorial. The management of critically ill patients with ALF is difficult and requires a multidisciplinary approach to effective treatment. Critical care nurses are essential in identifying potential sources of bleeding, monitoring for transfusion reactions, and staying vigilant for medication-related adverse reactions. Prevention and treatment of bleeding disorders is a priority because ineffective therapy can lead to hazardous consequences. Correction of coagulopathy for treatment of bleeding and reversal for invasive procedures should include a multifactorial therapeutic plan emphasizing the correction of all coagulation factors. The limitations of current knowledge in effective correction should serve as a stimulus for future research.

The Diagnosis and Management of Airway Complications Following Lung Transplantation

&NA; Airway complications following lung transplantation result in considerable morbidity and are associated with a mortality of 2% to 4%. The incidence of lethal and nonlethal airway complications has decreased since the early experiences with double‐ and single‐lung transplantation. The most common risk factor associated with post‐lung transplantation airway complications is anastomotic ischemia. Airway complications include the development of exophytic granulation tissue, bronchial stenosis, bronchomalacia, airway fistula, endobronchial infection, and anastomotic dehiscence. The broadening array of bronchoscopic therapies has enhanced treatment options for lung transplant recipients with airway complications. This article reviews the risk factors, clinical manifestations, and treatments of airway complications following lung transplantation and provides our expert opinion when evidence is lacking.

Pleural manometry: ready for prime time.

P leural manometry is not a novel technique. In fact, the use of water manometers to measure pleural pressure changes as fluid is drained out during thoracentesis has been described for decades. The elastance curves derived from the measurements of pleural manometry enable physicians to distinguish “trapped lung physiology” from normal lung reexpansion.1 Unfortunately, the application of this valuable diagnostic technique has failed to be integrated into everyday practice. The cause of this delay is multifactorial but is primarily related to the lack of training in pleural disease in most fellowship programs, the difficulty in accurately recording pleural pressure, and the lack of a simple technique of measurement during pressure swings resulting from inspiration and exhalation. Fortunately, this gap in knowledge appears to be closing. Objectively, the number of papers in Medline under the search term “pleural pressure” and “pleural manometry” has significantly increased over the past decade. Also at an all-time high is the number of abstracts presented at international conferences. These findings represent translation of physiologic research to bedside practice. So, what are the reasons for measuring pleural pressure and why should we be interested? Pleural pressure measurement can identify patients who are likely to benefit from pleurodesis. Recognition of this patient population is essential, as pleurodesis requires apposition of the visceral and parietal pleura for symphysis to occur. A low elastance (<14.5 cm H2O) measured by pleural manometry allows us to identify patients who are likely to gain full lung reexpansion following thoracentesis. Similarly, other studies have proven that patients with high elastance and trapped-lung physiology derive a clinical benefit when treated with tunneled pleural catheter drainage.3 Numerous studies have also described the use of pleural manometry to minimize pressure-related complications of pleural fluid removal, such as reexpansion pulmonary edema.4 Finally, safe removal of large amounts of pleural fluid (>1.5L) may improve symptoms, decrease the interval for repeated procedures, and allow visualization of the underlying lung parenchyma, which in itself is an excellent reason to perform pleural manometry.1,5 Riding on this wave of increased interest in measuring pleural pressure, the paper of Boshuizen et al6 has been published with opportune timing. They describe serial measurement of pleural pressure in 30 patients after sequential removal of 200mL of pleural fluid while measuring pleural pressure with an electronic pressure transducer and customized software to record pressure signals with a temporal resolution of <100ms. They measured pleural pressure 40 times per second for 13 seconds. The result is a

Topics in Practice ManagementTaking Control of Your Digital Library: How Modern Citation Managers Do More Than Just Referencing

Physicians are constantly navigating the overwhelming body of medical literature available on the Internet. Although early citation managers were capable of limited searching of index databases and tedious bibliography production, modern versions of citation managers such as EndNote, Zotero, and Mendeley are powerful web-based tools for searching, organizing, and sharing medical literature. Effortless point-and-click functions provide physicians with the ability to develop robust digital libraries filled with literature relevant to their fields of interest. In addition to easily creating manuscript bibliographies, various citation managers allow physicians to readily access medical literature, share references for teaching purposes, collaborate with colleagues, and even participate in social networking. If physicians are willing to invest the time to familiarize themselves with modern citation managers, they will reap great benefits in the future.

Taking control of your digital library: how modern citation managers do more than just referencing.

Physicians are constantly navigating the overwhelming body of medical literature available on the Internet. Although early citation managers were capable of limited searching of index databases and tedious bibliography production, modern versions of citation managers such as EndNote, Zotero, and Mendeley are powerful web-based tools for searching, organizing, and sharing medical literature. Effortless point-and-click functions provide physicians with the ability to develop robust digital libraries filled with literature relevant to their fields of interest. In addition to easily creating manuscript bibliographies, various citation managers allow physicians to readily access medical literature, share references for teaching purposes, collaborate with colleagues, and even participate in social networking. If physicians are willing to invest the time to familiarize themselves with modern citation managers, they will reap great benefits in the future.