Irtaza Khan

Training in and Experience with Endobronchial Ultrasound

Background: Diagnosing mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) are on the rise, but uncertainty surrounds the optimal number of cases needed to achieve acceptable yields. Objectives: To determine the threshold at which EBUS-TBNA reaches adequate yields among trainees and skilled bronchoscopists. Methods: We reviewed all EBUS-TBNAs performed at our medical center since implementing the use of EBUS (n = 222). Results: EBUS-TBNAs were performed in 222 patients (344 nodes). The percentage of adequate specimens sampled (diagnostic specimens or nodal tissue) rose from 66% in 2008 to 90% in 2012 (p < 0.01) and cancer yield improved from 34% in 2008 to 48% in 2012 (p < 0.01). Attending physicians who performed an average of more than 10 procedures per year had higher yields compared to those who performed fewer than 10 procedures per year (86 vs. 68%, p < 0.01). The yield of trainees also improved with every 10 procedures (79, 90 and 95%, p < 0.001) and that of attending physicians with experience (1-25 procedures: 78% yield, 26-50 procedures: 87% yield and 50+ procedures: 90% yield; p < 0.01). Among trainees, failure rates declined steadily. Conclusion: EBUS-TBNA yield (malignant and benign) increases with increasing experience amongst experienced bronchoscopists and trainees as early as the first 20-25 procedures. Pulmonary trainees had a rapid decline in failure rates. These findings suggest that in an academic environment a minimum of 20-25 procedures is needed to achieve acceptable yields.

Bronchoscopy Safety in Patients With Chronic Obstructive Lung Disease.

Background: Flexible bronchoscopy is a safe and minimally invasive diagnostic tool used by pulmonologists, but few studies have prospectively compared outcomes in patients with objectively defined obstructive lung disease to those without obstruction. Methods: We determined whether complications in patients undergoing moderate sedation bronchoscopy differ in those without obstruction compared with chronic obstructive pulmonary disease (COPD). We prospectively followed all patients undergoing moderate sedation bronchoscopy in an inpatient or outpatient setting. Results: Over 12 months, data were collected prospectively in 258 patients. A total o 151 patients had pulmonary function testing with classification of COPD according to GOLD Criteria. Sixty-seven of those patients (44%) had COPD: 6 mild (9%), 29 moderate (42%), 27 severe (41%), and 5 very severe (8%). COPD patients were more likely to receive outpatient inhaled corticosteroids and long-acting bronchodilators and anticholinergics (P<0.001) as would be clinically appropriate. Among all patients with COPD, there were 13% minor complications and 5% major complications, with no deaths. Respiratory complications occurred more often in patients with severe to very severe COPD (22%) compared with patients without COPD (6%) (P=0.018). When adjusted for age, body mass index, and use of home oxygen, this difference was still significant (P=0.045). Conclusion: Bronchoscopy is generally safe with few complications in most patients with COPD. Patients with objectively confirmed severe to very severe COPD had more frequent respiratory complications than patients without COPD. The risks were not prohibitively high, but should be taken into consideration for COPD patients undergoing moderate sedation flexible bronchoscopy.

Sedation for Bronchoscopy and Complications in Obese Patients

Background: Bronchoscopy is a safe and minimally invasive diagnostic tool, but no studies have reported prospectively on sedation and outcomes in patients with objectively defined obesity. Objectives: The purpose of the study is to determine if obese patients require more sedation or had more procedural complications during bronchoscopy under moderate sedation than non-obese patients. Methods: We evaluated complications and sedation requirements in non-obese versus obese patients, defined by multiple criteria including body mass index (BMI), neck circumference, abdominal height, and Mallampati scores. Results: Data were collected prospectively in 258 patients undergoing bronchoscopy under moderate sedation. By varying criteria, there were the following proportions of obese patients: 30% by BMI >30, 39% by neck circumference >40 cm, and 35% by abdominal height >22 cm in males and >20 cm in females. Sedative and analgesic dosing was not clinically significantly higher in obese patients than in non-obese patients. There was no difference in complications or procedural success based on obesity criteria. Hemoglobin oxygen desaturations occurred more often during bronchoscopy in patients with increasing Mallampati scores (p = 0.04), but this had no effect on bronchoscopy time or successful completion of the procedure. A subset of patients with previous polysomnogram-proven obstructive sleep apnea were more likely to have earlier termination of their procedure (15.8%) than patients with no diagnosed sleep apnea (2.3%; p = 0.002). Conclusion: In this prospective assessment of patients with obesity, we found neither clinically significant differences in sedation needs nor increases in complications in obese versus non-obese patients using a variety of indices of obesity.

A new pattern of pulmonary graft vs host disease in a hematopoietic stem cell transplant patient.

The primary pulmonary manifestation of chronic graft vs host disease (GvHD) is the development of bronchiolitis obliterans. Other pulmonary manifestations of chronic GvHD that have been reported include diffuse alveolar damage, lymphocytic interstitial pneumonia, bronchiolitis organising pneumonia and lymphocytic bronchiolitis/bronchitis.

Use of microdebrider bronchoscopy for the treatment of endobronchial leiomyoma

Aims:  Pulmonary leiomyomas are rare benign tumors that may cause symptoms when they spread endobronchially. Traditionally they were managed surgically or through interventional bronchoscopy with the aid of thermal modalities to assist in debulking of tumor. We report the novel use of microdebrider bronchoscopy to debulk an endobronchial leiomyoma in a symptomatic patient.

Contents Vol. 88, 2014

I.M. Adcock, London K.E. Bloch, Zürich A. Boehler, Zürich D.E. Bouros, Alexandroupolis A. Chetta, Parma V. Cottin, Lyon C. Dooms, Leuven E. Eber, Graz S. Gasparini, Ancona J. Hammer, Basel J. Johnston, Vancouver, B.C. C.F. Koegelenberg, Cape Town M. Lommatzsch, Rostock M. Miravitlles, Barcelona J. Müller-Quernheim, Freiburg L.P. Nicod, Lausanne D. Olivieri, Parma W. Randerath, Solingen P.L. Shah, London S. Siddiqui, Leicester T. Terashima, Ichikawa O.S. Usmani, London S. van Eeden, Vancouver, B.C. K. Yasufuku, Toronto, Ont.