Bernice Frimpong

Use of One-Way Intrabronchial Valves in Air Leak Management after Tube Thoracostomy Drainage

BACKGROUND A persistent air leak represents significant clinical management problems, potentially affecting morbidity, mortality, and health care costs. In 2008, a unidirectional, intrabronchial valve received humanitarian device exemption for use in managing prolonged air leak after pulmonary resection. Since its introduction, numerous reports exist but no large series describe current utilization or outcomes. Our aim was to report current use of intrabronchial valves for air leaks and review outcome data associated with its utilization. METHODS A multicenter, retrospective review of intrabronchial valve utilization from January 2013 to August 2014 was performed at eight centers. Data regarding demographics, valve utilization, and outcomes were analyzed. RESULTS We identified 112 patients undergoing evaluation for intrabronchial valve placement, with 67% (75 of 112) undergoing valve implantation. Nearly three quarters of patients underwent valve placement for off-label usage (53 of 75). A total of 195 valves were placed in 75 patients (mean 2.6 per patient; range, 1 to 8) with median time to air leak resolution of 16 days (range, 2 to 156). CONCLUSIONS We present the largest, multicenter study of patients undergoing evaluation for intrabronchial valve use for air leak management. Our data suggest the majority of intrabronchial valve placements are occurring for off-label indications. Although the use of intrabronchial valves are a minimally invasive intervention for air leak management, the lack of rigorously designed studies demonstrating efficacy remains concerning. Prospective randomized controlled studies remain warranted.

Electromagnetic navigation transthoracic needle aspiration for the diagnosis of pulmonary nodules: a safety and feasibility pilot study

BACKGROUND Pulmonary nodules remain a diagnostic challenge for physicians. Minimally invasive biopsy methods include bronchoscopy and CT guided transthoracic needle aspiration (TTNA). A novel electromagnetic guidance transthoracic needle aspiration (ETTNA) procedure which can be combined with navigational bronchoscopy (NB) and endobronchial ultrasound (EBUS) in a single setting has become available. METHODS A prospective pilot study examining the safety, feasibility and diagnostic yield of ETTNA in a single procedural setting. All patients enrolled underwent EBUS for lung cancer staging followed by NB and ETTNA. Feasibility of performing ETTNA and a safety assessment by recording procedural related complications including pneumothorax or bleeding was performed. Diagnostic yield of ETTNA defined by a definitive pathologic tissue diagnosis was recorded. An additional diagnostic yield analysis was performed using a cohort analysis of combined interventions (EBUS + NB + ETTNA). All non-diagnostic biopsies were either followed with radiographic imaging or a surgical biopsy was performed. RESULTS Twenty-four subjects were enrolled. ETTNA was feasible in 96% of cases. No bleeding events occurred. There were five pneumothoraces (21%) of which only two (8%) subjects required drainage. The diagnostic yield for ETTNA alone was 83% and increased to 87% (P=0.0016) when ETTNA was combined with NB. When ETTNA and NB were performed with EBUS for complete staging, the diagnostic yield increased further to 92% (P=0.0001). CONCLUSIONS This is the first human pilot study demonstrating an acceptable safety and feasibility profile with a novel ETTNA system. Further studies are needed to investigate the increased diagnostic yield from this pilot study.

Role of the Endobronchial Landmarks Guiding TBNA and EBUS-TBNA in Lung Cancer Staging

Background. Lung cancer is the leading cause of malignancy related mortality in the United States. Accurate staging of NSCLC influences therapeutic decisions. Transbronchial needle aspiration (TBNA) and endobronchial ultrasound-guided TBNA (EBUS-TBNA) has been accepted as a procedure for the diagnosis and staging of lung cancer. The aim of this study is to evaluate the efficacy and adequacy of TBNA and EBUS-TBNA for sampling of mediastinal adenopathy using the Wangs eleven lymph node map stations. Methods. We retrospectively reviewed 99 consecutive cases diagnosed with malignancy by EBUS-TBNA and a series 74 patients evaluated for mediastinal adenopathy or a pulmonary lesion using conventional transbronchial needle aspiration. The IASLC lymph node map was correlated with Wangs map. Results. A total of 182 lymph node stations were sampled using EBUS-TBNA. 96 were positive for nodal metastasis. A total of four cases of samples taken from station 2R showed malignant cells. From the 74 cases series using cTBNA 167 nodes were sampled in 222 passes. Lymphoid or malignant tissue was obtained in 67 (91.8%) cases; 55.1% of the nodes were 1 cm or less. Conclusions. The use of the eleven stations described in Wangs map to guide TBNA of the mediastinal nodes allows sampling of radiologically considered nonpathological nodes. These data suggest that Wangs map covers the most frequent IASLC nodal stations compromised with metastasis.

Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently available to sample nodules for pathological diagnosis. Those technologies can be divided into bronchoscopic and non-bronchoscopic interventions. Electromagnetic navigational bronchoscopy is being extensively used for the endobronchial approach to peripheral lung nodules but has been hindered by anatomic challenges resulting in a 70% diagnostic yield. Electromagnetic navigational guided transthoracic needle lung biopsy is novel non-bronchoscopic method that uses a percutaneous electromagnetic tip tracked needle to obtain core biopsy specimens. Electromagnetic navigational transthoracic needle aspiration complements bronchoscopic techniques potentially allowing the provider to maximize the diagnostic yield during one single procedure. This article describes a novel integrated diagnostic approach to pulmonary lung nodules. We propose the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging; radial EBUS, navigational bronchoscopy and E-TTNA during one single procedure to maximize diagnostic yield and minimize the number of invasive procedures needed to obtain a diagnosis. This manuscript describes in detail how the navigation transthoracic procedure is performed. Additional clinical studies are needed to determine the clinical utility of this novel technology.

An Examination of Blood Cell Membrane Potential as a Diagnostic Test of Attention Deficit Disorder in Children

Objective: To reexamine previous findings that reported that blood cells’ membrane potential ratios (MPRs™) differ between youth with ADHD and controls and to determine whether psychostimulants affect MPRs™. Method: Forty-four youth (ages 6-17) with ADHD (not currently taking psychostimulants; n = 24) and controls (n = 20) completed the Mini-International Neuropsychiatric Interview 7 (MINI 7) and a blood draw to determine MPR™. Youth with ADHD provided another blood draw 30 days after receiving psychostimulants. Results: MPR™ values of participants with ADHD who were not taking stimulants were not significantly different from those of the controls. MPR’s™ sensitivity was 79.2% and specificity 25.0%. Among youth with ADHD, there was a trending association between lower MPRs™ and taking stimulants (compared with baseline). Conclusion: Results neither replicate prior findings nor support MPRs’™ utility in diagnosing ADHD in youth. We identified possible MPR™ changes after participants with ADHD began stimulants. Further studies are needed to establish the clinical significance of this finding.

Procedural Learning Perspectives of Pulmonary Fellows and Practitioners

Background: Procedural learning requires both didactic knowledge and motor skills. Optimal teaching styles and techniques remain to be defined for pulmonary procedural learning. We investigated the preferences of learners at 2 different points in a pulmonary career; as pulmonary fellows and as clinical practitioners. Methods: A perception survey was conducted among pulmonary fellows and practitioners from multiple institutions throughout the United States. Fellows and practitioners were immediately surveyed on procedural learning factors after completing a procedural learning course using low/high-fidelity and/or cadaver simulators. Survey questions consisting of biographical information and multiple choice, Likert style, and qualitative questions regarding learning preferences were collected. Results: Seventy-five physicians (44 pulmonary fellows, 31 practitioners) from 35 centers completed the survey. Pulmonary practitioners preferred an academic expert, whereas fellows preferred familiar faculty as lecturers for procedural learning (P=0.03). There were no statistical differences between fellows/practitioners value of the use of simulators, didactics, or handouts. Both groups preferred animal/cadaver and high-fidelity simulators to low-fidelity simulators. Both groups also preferred a traditional course structure to problem-based learning/flipped classroom. The most common answer to barriers for learning a new procedure was “time” for training followed by “opportunities” to learn. Conclusions: Pulmonary fellows and practitioners we surveyed preferred a traditional course structure with cadaver/animal models and high-fidelity simulation training as compared with a flipped classroom model and low-fidelity simulators, but whether this holds true for the wider population is unknown. Larger studies are needed to validate learning perception with outcomes.

Stylet Use Does Not Improve Diagnostic Outcomes in Endobronchial Ultrasonographic Transbronchial Needle Aspiration: A Randomized Clinical Trial

BACKGROUND: Endobronchial ultrasonographically guided transbronchial needle aspiration (EBUS‐TBNA) of thoracic structures is a commonly performed tissue sampling technique. The use of an inner‐stylet in the EBUS needle has never been rigorously evaluated and may be unnecessary. METHODS: In a prospective randomized single‐blind controlled clinical trial, patients with a clinical indication for EBUS‐TBNA underwent lymph node sampling using both with‐stylet and without‐stylet techniques. Sample adequacy, diagnostic yield, and various cytologic quality measures were compared. RESULTS: One hundred twenty‐one patients were enrolled, with 194 lymph nodes sampled, each using both with‐stylet and without‐stylet techniques. There was no significant difference in sample adequacy or diagnostic yield between techniques. The without‐stylet technique resulted in adequate samples in 87% of the 194 study lymph nodes, which was no different from the with‐stylet adequacy rate (82%; P = .371). The with‐stylet technique resulted in a diagnosis in 50 of 194 samples (25.7%), which was similar to the without‐stylet group (49 of 194 [25.2%]; P = .740). There was a high degree of concordance in the determination of adequacy (84.0%; 95% CI, 78.1–88.9) and diagnostic sample generation (95.4%; 95% CI, 91.2–97.9) between the two techniques. A similar qualitative number of lymphocytes, malignant cells, and bronchial respiratory epithelia were recovered using each technique. CONCLUSIONS: Omitting stylet use during EBUS‐TBNA does not affect diagnostic outcomes and reduces procedural complexity. TRIAL REGISTRY: ClinicalTrials.Gov: No. NCT 02201654; URL:www.clinicaltrials.gov.