Ashutosh Sachdeva

Thoracentesis and Thoracic Ultrasound: State of the Art in 2013

Thoracentesis is one of the most common medical procedures performed today. With the advent of thoracic ultrasound, thoracentesis has been enhanced with additional preprocedural, intraprocedural, and postprocedural information. The authors review modern-day thoracentesis and the use of ultrasonography. Nearly 200,000 thoracenteses are performed among 1.5 million patients with pleural effusion each year. A solid foundation in didactic knowledge and procedural proficiency is important to avoid unwanted complications. Ultrasound has become an indispensable tool to guide performance of thoracentesis. Ultrasonography for this purpose has several advantages. The authors provide a contemporary review on thoracentesis and the use of ultrasonography.

Endobronchial ultrasound diagnosis of pulmonary embolism.

A 68-year-old woman presented for mediastinal lymph node sampling while undergoing work up for a solitary pulmonary nodule. During endobronchial ultrasound examination of the airways, an echogenic abnormality was noted within the right pulmonary artery. The patient underwent computed tomography angiography of the chest, and diagnosis of pulmonary embolism was confirmed. We describe endobronchial ultrasound evaluation of a pulmonary embolus.

Hematological Issues in Liver Disease

Acute and chronic liver failure are associated with numerous alterations in different features of the coagulation system. Consequently, there is widespread confusion regarding the potential for both bleeding and thrombosis in patients with liver disease. The risk of bleeding is related to the hemodynamic changes in portal pressures and venous congestion whereas the thrombotic risk stems from changes in the coagulation system. Antithrombotic prophylaxis and treatment of patients with hemorrhage and thrombosis requires careful assessment, interpretation of laboratory workup, and attention to coexistent morbidities. A framework for the management of these conditions is presented for clinicians.

Organizing pneumonia/non-specific interstitial pneumonia overlap is associated with unfavorable lung disease progression.

BACKGROUND Overlapping forms of interstitial pneumonia have been recognized, but are likely underappreciated, and their clinical, radiologic, and histologic characteristics are not well-defined. METHODS We identified 38 patients with surgical lung biopsy demonstrating histologic organizing pneumonia (OP) or histologic organizing pneumonia/non-specific interstitial pneumonia overlap (OP/NSIP) who met established multi-disciplinary clinical-radiologic-histologic criteria for OP. For each patient, radiologic and co-histologic findings were assessed, and clinical outcome was characterized as disease resolution (complete or near-complete resolution of radiologic opacities and absence of chronic respiratory symptoms) or unfavorable disease progression (death due to respiratory failure or forced vital capacity < 70% predicted > six months from diagnosis). RESULTS Seven of 38 patients had clinical-radiologic-histologic focal OP. Focal OP was associated with histologic OP (p = 0.019), and all seven patients demonstrated disease resolution. In the remaining 31 patients with cryptogenic or autoimmune-associated OP, 21 patients had histologic OP/NSIP, and 10 had histologic OP. Histologic OP/NSIP was associated with ground glass opacity (GGO, p = 0.012), reticulation (p = 0.029), traction bronchiectasis (p = 0.029), reactive pneumocytes (p = 0.013), and unfavorable disease progression (p < 0.0001). Histologic OP was associated with consolidation (p = 0.028) and disease resolution (p < 0.0001). Multivariate analysis demonstrated histologic OP/NSIP (p < 0.001) and radiologic GGO (p = 0.041) to be independently associated with unfavorable disease progression. CONCLUSIONS OP/NSIP overlap, either idiopathic or autoimmune-associated and identified by histologic and radiologic findings, was associated with unfavorable disease progression, and should therefore be recognized as a characteristic clinical-radiologic-histologic entity.

From electrocautery, balloon dilatation, neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) laser to argon plasma coagulation and cryotherapy

Over the past decade, there has been significant advancement in the development/application of therapeutics in thoracic diseases. Ablation methods using heat or cold energy in the airway is safe and effective for treating complex airway disorders including malignant and non-malignant central airway obstruction (CAO) without limiting the impact of future definitive therapy. Timely and efficient use of endobronchial ablative therapies combined with mechanical debridement or stent placement results in immediate relief of dyspnea for CAO. Therapeutic modalities reviewed in this article including electrocautery, balloon dilation (BD), neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) laser, argon plasma coagulation (APC), and cryotherapy are often combined to achieve the desired results. This review aims to provide a clinically oriented review of these technologies in the modern era of interventional pulmonology (IP).

Microscopic organizing pneumonia and cellular non-specific interstitial pneumonia are widespread in macroscopically normal-appearing lung tissue in idiopathic pulmonary fibrosis

coagulation and possibly improve patients’ outcomes. As we have shown that hemolysis does not falsely elevate aPTT values, both tests should be used to characterize anti-coagulation intensity in patients with suspected pump thrombosis. In conclusion, aPTT and anti-Xa levels may be discordant in many CF-LVADs patients. In our experience, hemolysis does not falsely raise aPTT values. More studies are needed to prove the superiority of one assay over the other. For now, the decision to titrate UFH based on aPTT or anti-Xa should be carefully weighed in appropriate clinical contexts.

Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position

Prone positioning (PP) was shown to reduce mortality in mechanically ventilated (MV) patients with severe ARDS [1]. Despite its common use, safety concerns inhibit use of flexible bronchoscopy (FB) in patients with ARDS, and there are few reports of FB performed in PP [2]. We reviewed all adults receiving FB in PP in one institution between April 2016 and September 2017. The study was approved by the institutional review board. Four men and three women were identified (Table 1). In five patients, FB was indicated for clearance of thick secretions, and in two patients for microbial analysis. The mode of mechanical ventilation was not changed for FB, but FIO2 was universally set to 100%. All subjects had invasive hemodynamic and pulse oximetry monitoring. End-tidal carbon dioxide (EtCO2) was monitored in 3/7 subjects. With the subject’s head tilted to the side, the bronchoscope was advanced into the airways, repeatedly, and in short cycles, allowing time for oxygenation, ventilation, and lung recruitment between insertions. Therapeutic aspiration was performed in 6/7 subjects. Bronchoalveolar lavage was performed in two subjects. No significant hemodynamic compromise was observed during any of the procedures. Significant oxygen desaturation and rising EtCO2 were observed in one case (patient 4). Both derangements resolved with withdrawal of the bronchoscope and recruitment. No additional complications were documented. Figure 1 illustrates evolution of the PaO2:FIO2 ratio over time for each subject. Six subjects had antibiotics modified based on FB-obtained cultures. Consistent with previous data [3], 4/7 subjects survived 30 days following discharge from the ICU. Although PP is lung-protective, it may result in mobilization of secretions into the airways, impairing oxygenation and providing nidus for infection [4]. Despite documented risks [5], FB may be beneficial in this situation. Several limitations need to be addressed when interpreting our data. This is a retrospective analysis. Although physiologic monitoring was automatically captured, ventilator data were not and ventilator output during FB could not be accurately analyzed. Additionally, EtCO2 was not measured in all cases during FB. Finally, PP was shown to reduce mortality in patients with moderate to severe ARDS, however, our study subjects’ oxygenation had started to improve by the time FB was performed (Fig. 1, T1). This likely reflects reluctance to perform FB in subjects with severe hypoxemia due to excessive risks. Our report demonstrates the feasibility of FB performed in brief increments in carefully monitored patients with ARDS ventilated in PP. Further studies are needed to better delineate optimal ventilator management during FB in PP.

Transcriptomic evidence of immune activation in macroscopically normal-appearing and scarred lung tissues in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a fatal lung disease manifested by overtly scarred peripheral and basilar regions and more normal-appearing central lung areas. Lung tissues from macroscopically normal-appearing (IPFn) and scarred (IPFs) areas of explanted IPF lungs were analyzed by RNASeq and compared with healthy control (HC) lung tissues. There were profound transcriptomic changes in IPFn compared with HC tissues, which included elevated expression of numerous immune-, inflammation-, and extracellular matrix-related mRNAs, and these changes were similar to those observed with IPFs compared to HC. Comparing IPFn directly to IPFs, elevated expression of epithelial mucociliary mRNAs was observed in the IPFs tissues. Thus, despite the known geographic tissue heterogeneity in IPF, the entire lung is actively involved in the disease process, and demonstrates pronounced elevated expression of numerous immune-related genes. Differences between normal-appearing and scarred tissues may thus be driven by deranged epithelial homeostasis or possibly non-transcriptomic factors.

Lenalidomide-induced eosinophilic pneumonia: Lenalidomide and eosinophilic pneumonia

Multiple myeloma is a plasma cell dyscrasia accounting for 10% of haematologic malignancies. Lenalidomide is an immunomodulatory drug analogous to thalidomide that is approved for use in patients with myelodysplastic syndrome, and in combination with dexamethasone for refractory or relapsed multiple myeloma. Lenalidomide is preferred to thalidomide because of reduced toxicity, and pulmonary side effects are considered rare. We present, to our knowledge, an unusual and first reported case of a patient with relapsed multiple myeloma who received lenalidomide after autologous stem cell transplant, then developed eosinophilic pneumonia presenting as dyspnoea, peripheral eosinophilia, and bilateral pulmonary opacities. Bronchoscopy with bronchoalveolar lavage was negative for infection, and transbronchial lung biopsies showed eosinophilic pneumonia. After discontinuation of lenalidomide and initiation of prednisone therapy, his dyspnoea improved and eosinophilia resolved; however, symptoms recurred when the drug was restarted at a lower dose, confirming its causative role. In the absence of infection, clinicians should always bear in mind drug toxicity in the differential diagnosis of patients receiving lenalidomide and related agents.

Training program of interventional pulmonology fellowships: USA

Interventional pulmonary (IP) is an emerging subspecialty of pulmonary medicine which focuses on procedures of the airway, lung, and pleura. As the number of advance procedures increases with the growth of this field, additional formal training is required to offer the full complement of techniques. IP fellowship is a dedicated 12 months fellowship in the United States which occurs after pulmonary/critical care fellowship. There have been several recent milestones in this field which include validated exams based on didactic knowledge and structural organization of fellowship organizations.