David W. Hsia

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.

Percutaneous Dilational Tracheostomy

Tracheostomy is a commonly performed intervention with several benefits in the treatment of patients with chronic respiratory failure. Percutaneous dilational tracheostomy techniques have allowed bedside tracheostomy placement in the modern intensive care unit. Percutaneous dilational tracheostomy can be safely performed by interventional pulmonologists, medical intensive care physicians, and surgical specialists. When performed with the assistance of adjuncts, such as flexible bronchoscopy, the percutaneous dilational method has a favorable complication rate, efficiency, and cost profile compared with surgical tracheostomy.

Management of malignant pleural effusions

Malignant pleural effusions (MPE) are a common occurrence in many advanced malignancies. They are a significant cause of morbidity and mortality; symptoms can be debilitating to patients and impair quality of life, especially as many of these patients are already functionally impaired by their underlying cancer and medical treatment. MPE generally represent advanced stage malignancy and the primary goal of therapy is palliation of symptoms. The purpose of this article is to review the therapeutic options available in the treatment of MPE and discuss clinical factors affecting management decision-making.

Diffuse Alveolar Hemorrhage Induced by Sevoflurane

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Management options for the complicated pleural space

Clinicians frequently encounter patients with malignant and benign diseases involving the pleural space. Complications from these disease processes pose clinical challenges that often require a multi-disciplinary management approach. Here we discuss therapeutic options available for complicated diseases of the pleural space, including loculated malignant effusions, complicated pleural infections, hemothorax, nonexpanding lung, pleural thickening, and persistent bronchopleural fistulas. Our objective is to review current literature on management of these complex issues.

Novel use of a percutaneous endoscopic gastrostomy tube fastener for securing silicone tracheal stents in patients with benign proximal airway obstruction.

Background:Benign tracheal obstruction occurs for a variety of reasons. Bronchoscopic intervention includes silicone stent placement, which effectively maintains airway patency. Stent migration is a common complication, particularly when placed in the proximal trachea. We used a novel technique of securing tracheal stents with a percutaneous endoscopic gastrostomy tube fastener (PEG-TF) to prevent stent migration. The purpose of this study was to determine the feasibility of securing silicone stents in the proximal trachea with PEG-TF. Methods:Silicone stents were placed under general anesthesia by rigid bronchoscopy in 7 consecutive patients with inoperable benign proximal tracheal obstruction. PEG-TFs were placed under sterile conditions with direct bronchoscopic visualization. A needle was inserted through the anterior neck and silicone stent wall allowing stylet introduction of a T-fastener into the interior of the stent. The T-fastener was secured externally by a metal clamp and cotton pledget at the surface of the neck. Patients had routine outpatient follow-up and covered the external portion of the PEG-TF with a waterproof dressing when showering. Results:All 7 PEG-TFs were placed without complications. The PEG-TFs were left in for 1 to 25 weeks. Complications of the PEG-TF included localized cellulitis and suture breakage. No stent migration occurred while the fastener was in place. Two stents were removed within 2 weeks due to patient’s difficulty tolerating the stent. Conclusions:Securing silicone stents in the proximal trachea is feasible and may prevent stent migration, but further study and possible modification of the PEG-TF device are needed.

Primary Laryngotracheal Amyloidosis With Bilateral Vocal Cord Involvement and Associated Bronchiectasis

Localized tracheobronchial amyloidosis is a rare disease that results from submucosal deposition of insoluble amyloid proteins in the large airways. Amyloidosis affecting the larynx and subglottic space typically results in unilateral, nodular vocal cord infiltration. It rarely can present with bilateral vocal cord involvement and can progress to lifethreatening respiratory failure due to upper airway obstruction. In these patients, typical treatment modalities such as CO2 laser ablation are often ineffectual. Bronchiectasis is a predisposing risk factor associated with the secondary (AA) form of disease. We present a patient with the primary (AL) form of localized laryngotracheal amyloidosis with pre-existing bronchiectasis, and also review the existing literature on this disease.

The latest generation in flexible bronchoscopes: a description and evaluation.

Background:Since the introduction of the flexible bronchoscope over 50 years ago, bronchoscopists have seen vast improvement in the technology available for diagnostics and therapeutics in the bronchoscopy laboratory. We set forth to evaluate the latest evolution in flexible bronchoscopes with features designed to improve imaging and airway navigation. Methods:The BF-Q190, BF-H190, and/or BF-1TH190 bronchoscopes were evaluated prospectively in 105 patients undergoing bronchoscopy from November 2010 to August 2011 at 2 tertiary care centers in the United States. Data collected from each procedure included method of insertion, airway images, and therapeutic interventions. At the completion of the study, 10 bronchoscopists were surveyed using a 7-point Likert scale to identify the perceived benefits of the design. Results:Insertion methods included nasal, oral, laryngeal mask airway or endotracheal tube, and tracheostomy. Procedures performed included bronchoalveolar lavage, endobronchial biopsy or brushing, transbronchial biopsy, transbronchial needle aspiration or injection, peripheral navigation, and large airway therapeutic interventions. Survey of bronchoscopists revealed that when compared with current bronchoscopes, the features rated as having the most significant impact on functionality are the 210-degree tip angulation (average 2.4/3) and rotational capability of the insertion tube (average 2.4/3). Conclusions:The new-generation flexible bronchoscope offers improvement in image quality, magnification options, unique insertion tube rotation, and an increased 210-degree distal tip angulation over currently available flexible bronchoscopes. The bronchoscopes are an overall improvement to the current generation of bronchoscopes. The increased tip angulation and novel rotating insertion tube add the most to improvement in functionality.

Pulmonary inflammatory pseudotumor causing lung collapse responding to corticosteroid therapy

Pulmonary inflammatory pseudotumor (PIP) is a rare benign tumor that represents less than one percent of all tumors found in the lungs. Despite the benign etiology, PIP can cause significant clinical problems due to its growth rate and potential to compromise adjacent pulmonary and thoracic structures. Complete surgical resection is the preferred therapy for PIP to prevent recurrence, however, this is not possible in some patients due to the size or location of the tumor. We present the case of an 18 year-old male presenting with PIP in the proximal left mainstem bronchus causing complete left lung collapse. Surgical resection was not possible due to tumor location, and therefore the patient was treated with corticosteroids with marked response. Corticosteroid use has for PIP has been described in few other situations, and this case demonstrates the potential for this therapeutic option in patients with PIP who have a contraindication to surgical resection.

Bronchoscopic Therapies for Peripheral Lung Malignancies

Current advances in guided bronchoscopy methods permit minimally invasive access to essentially any area of the lungs. This provides a potential means to treat patients with localized lung malignancies who might not otherwise tolerate conventional treatment, which commonly relies on surgical resection. Ablation methods have long been used for bronchoscopic treatment of central airway malignancies and percutaneous treatment of peripheral lung cancer. This article reviews ablation technologies being adapted for use with guided bronchoscopy and the current state of investigation for the treatment of peripheral lung malignancies.