Jason Akulian

Comparison of 21-Gauge and 22-Gauge Aspiration Needle in Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Results of the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation Registry

BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure originally performed using a 22-gauge (22G) needle. A recently introduced 21-gauge (21G) needle may improve the diagnostic yield and sample adequacy of EBUS-TBNA, but prior smaller studies have shown conflicting results. To our knowledge, this is the largest study undertaken to date to determine whether the 21G needle adds diagnostic benefit. METHODS We retrospectively evaluated the results of 1,299 patients from the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuIRE) Diagnostic Registry who underwent EBUS-TBNA between February 2009 and September 2010 at six centers throughout the United States. Data collection included patient demographics, sample adequacy, and diagnostic yield. Analysis consisted of univariate and multivariate hierarchical logistic regression comparing diagnostic yield and sample adequacy of EBUS-TBNA specimens by needle gauge. RESULTS A total of 1,235 patients met inclusion criteria. Sample adequacy was obtained in 94.9% of the 22G needle group and in 94.6% of the 21G needle group (P = .81). A diagnosis was made in 51.4% of the 22G and 51.3% of the 21G groups (P = .98). Multivariate hierarchical logistic regression showed no statistical difference in sample adequacy or diagnostic yield between the two groups. The presence of rapid onsite cytologic evaluation was associated with significantly fewer needle passes per procedure when using the 21G needle (P < .001). CONCLUSIONS There is no difference in specimen adequacy or diagnostic yield between the 21G and 22G needle groups. EBUS-TBNA in conjunction with rapid onsite cytologic evaluation and a 21G needle is associated with fewer needle passes compared with a 22G needle.

Cryoprobe Transbronchial Lung Biopsy in Patients After Lung Transplantation: A Pilot Safety Study

BACKGROUND Transbronchial biopsies using standard forceps (FTBBxs) are often limited by crush artifact and their small size. To date, there have been no studies aimed at assessing the safety and efficacy of cryoprobe biopsies (CPBxs) in the population of patients who have undergone lung transplants. We present the safety profile and biopsy results from the fi rst 21 procedures in a pilot study comparing CPBx to FTBBx in patients after lung transplantation. METHODS Patients who had undergone lung transplant and who were scheduled for bronchoscopy were sequentially enrolled between November 2011 and September 2012. Inclusion criteria included age . 18 years and bilateral, orthotopic lung transplant. Exclusion criteria were coagulopathy, FEV 1 < 0.8 L, diffuse bullous disease, hemodynamic instability, and severe hypoxemia (Pa(O2) < 55 mm Hg or Sp(O2) < 92% on room air). Twenty-one procedures were performed, 10 using rigid bronchoscopy followed by 11 via flexible bronchoscopy. Patients were monitored for complications including pneumothorax, hemodynamic instability, and/or respiratory distress. Bleeding was categorized on an adapted grading system. RESULTS Twenty-one procedures in 17 patients (median age: 52 years; 12 male patients) were performed. Specimen area and percent open alveoli were significantly greater using CPBx compared with FTBBx ( P < .05). No clinically significant procedural complications occurred and all patients were discharged the day of the procedure. CONCLUSIONS The use of the cryoprobe is a safe, alternative technique to FTBBx during post-lung transplant bronchoscopy. Further studies are needed to determine if larger samples obtained with CPBx translate to an increased diagnostic yield.

Optimizing Endobronchial Ultrasound for Molecular Analysis. How Many Passes Are Needed

BACKGROUND The current oncologic management of non-small cell lung cancer (NSCLC) requires pathologic differentiation between adenocarcinoma and squamous cell carcinoma. Furthermore, novel therapies for adenocarcinoma are clinically available for specific mutation profiles. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been shown to adequately obtain specimens for molecular profiling. However, it remains unclear what quantity of specimens is needed to provide suitable mutational genotyping for adenocarcinoma. The objective of this study was to determine the optimal number of aspirations per EBUS-TBNA procedure required in the presence of rapid on-site cytopathology evaluation (ROSE) for maximal diagnostic yield for molecular mutational analysis. METHODS From March 2010 to February 2012, cytopathologic data were collected from consecutive cases of adenocarcinoma or NSCLC not otherwise specified (NSCLC-NOS), diagnosed by EBUS-TBNA and ROSE. Samples of material obtained were air-dried and wet-fixed. Samples were tested for the KRAS, EGFR, and/or ALK mutations. MEASUREMENTS AND MAIN RESULTS Eighty-five patients who underwent EBUS-TBNA and were diagnosed with adenocarcinoma or NSCLC-NOS were identified. Of the 85 cases identified, 77 (90.6%) were classified as adenocarcinoma with the remaining 8 (9.4%) classified as NSCLC-NOS. Eighty-one of 85 (95.3%) were found to be adequate for molecular profiling. The median number of sites sampled was one. A median of four passes was needed to obtain adequate molecular profiling of 95.3%, using EBUS in conjunction with ROSE. CONCLUSIONS With the use of EBUS-TBNA and ROSE, a minimum of four needle passes may provide an adequate amount of specimen for advanced molecular marker analysis.

Comparison of Moderate versus Deep Sedation for Endobronchial Ultrasound Transbronchial Needle Aspiration

RATIONALE Most bronchoscopic procedures are performed using moderate sedation achieved by combining a short-acting benzodiazepine with an opioid agent. Propofol (2.6-diisopropylphenol), a short-acting hypnotic agent, has been increasingly used to provide deep sedation in the endoscopy community with an acceptable safety profile. OBJECTIVES To compare the impact of moderate versus deep sedation on the adequacy and diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). METHODS A retrospective review of prospectively collected data was performed at two academic institutions with interventional pulmonary fellowships using two methods of sedation during EBUS (deep vs. moderate sedation). Rapid on-site cytologic evaluation was used on all procedures in both groups. EBUS-TBNA nodal sampling was considered adequate if the aspirate yielded a specific diagnosis or lymphocytes. EBUS-TBNA was considered diagnostic if a lymph node aspirate yielded a specific diagnosis or if subsequent surgical sampling or prolonged radiographic surveillance revealed no nodal pathology. MEASUREMENTS AND MAIN RESULTS No difference was observed in the indication for EBUS-TBNA between the two groups. More lymph nodes were sampled per patient in the deep sedation group (314 nodes from 163 patients; 2.2 nodes per patient) than in the moderate sedation group (181 lymph nodes from 146 patients; 1.4 nodes per patient; P < 0.01). The EBUS-TBNA diagnostic yield was higher for the deep sedation group (80% of patients) than for the moderate sedation group (66% of patients; P < 0.01). CONCLUSIONS Diagnostic yield and number of lymph nodes sampled using deep sedation is superior to moderate sedation in patients undergoing EBUS-TBNA. Prospective studies accounting for other factors including patient selection and cost are needed.

Source of Biomass Cooking Fuel Determines Pulmonary Response to Household Air Pollution

Approximately 3 billion people-half the worldwide population-are exposed to extremely high concentrations of household air pollution due to the burning of biomass fuels on inefficient cookstoves, accounting for 4 million annual deaths globally. Yet, our understanding of the pulmonary responses to household air pollution exposure and the underlying molecular and cellular events is limited. The two most prevalent biomass fuels in India are wood and cow dung, and typical 24-hour mean particulate matter (PM) concentrations in homes that use these fuels are 300 to 5,000 μg/m(3). We dissected the mechanisms of pulmonary responses in mice after acute or subchronic exposure to wood or cow dung PM collected from rural Indian homes during biomass cooking. Acute exposures resulted in robust proinflammatory cytokine production, neutrophilic inflammation, airway resistance, and hyperresponsiveness, all of which were significantly higher in mice exposed to PM from cow dung. On the contrary, subchronic exposures induced eosinophilic inflammation, PM-specific antibody responses, and alveolar destruction that was highest in wood PM-exposed mice. To understand the molecular pathways that trigger biomass PM-induced inflammation, we exposed Toll-like receptor (TLR)2-, TLR3-, TLR4-, TLR5-, and IL-1R-deficient mice to PM and found that IL-1R, TLR4, and TLR2 are the predominant receptors that elicit inflammatory responses via MyD88 in mice exposed to wood or cow dung PM. In conclusion, this study demonstrates that subchronic exposure to PM collected from households burning biomass fuel elicits a persistent pulmonary inflammation largely through activation of TLR and IL-1R pathways, which could increase the risk for chronic respiratory diseases.

Original ResearchInterventional PulmonologyCryoprobe Transbronchial Lung Biopsy in Patients After Lung Transplantation: A Pilot Safety Study

BACKGROUND Transbronchial biopsies using standard forceps (FTBBxs) are often limited by crush artifact and their small size. To date, there have been no studies aimed at assessing the safety and efficacy of cryoprobe biopsies (CPBxs) in the population of patients who have undergone lung transplants. We present the safety profile and biopsy results from the fi rst 21 procedures in a pilot study comparing CPBx to FTBBx in patients after lung transplantation. METHODS Patients who had undergone lung transplant and who were scheduled for bronchoscopy were sequentially enrolled between November 2011 and September 2012. Inclusion criteria included age . 18 years and bilateral, orthotopic lung transplant. Exclusion criteria were coagulopathy, FEV 1 < 0.8 L, diffuse bullous disease, hemodynamic instability, and severe hypoxemia (Pa(O2) < 55 mm Hg or Sp(O2) < 92% on room air). Twenty-one procedures were performed, 10 using rigid bronchoscopy followed by 11 via flexible bronchoscopy. Patients were monitored for complications including pneumothorax, hemodynamic instability, and/or respiratory distress. Bleeding was categorized on an adapted grading system. RESULTS Twenty-one procedures in 17 patients (median age: 52 years; 12 male patients) were performed. Specimen area and percent open alveoli were significantly greater using CPBx compared with FTBBx ( P < .05). No clinically significant procedural complications occurred and all patients were discharged the day of the procedure. CONCLUSIONS The use of the cryoprobe is a safe, alternative technique to FTBBx during post-lung transplant bronchoscopy. Further studies are needed to determine if larger samples obtained with CPBx translate to an increased diagnostic yield.

Original ResearchPulmonary ProceduresComparison of 21-Gauge and 22-Gauge Aspiration Needle in Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Results of the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation Registry

BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure originally performed using a 22-gauge (22G) needle. A recently introduced 21-gauge (21G) needle may improve the diagnostic yield and sample adequacy of EBUS-TBNA, but prior smaller studies have shown conflicting results. To our knowledge, this is the largest study undertaken to date to determine whether the 21G needle adds diagnostic benefit. METHODS We retrospectively evaluated the results of 1,299 patients from the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuIRE) Diagnostic Registry who underwent EBUS-TBNA between February 2009 and September 2010 at six centers throughout the United States. Data collection included patient demographics, sample adequacy, and diagnostic yield. Analysis consisted of univariate and multivariate hierarchical logistic regression comparing diagnostic yield and sample adequacy of EBUS-TBNA specimens by needle gauge. RESULTS A total of 1,235 patients met inclusion criteria. Sample adequacy was obtained in 94.9% of the 22G needle group and in 94.6% of the 21G needle group (P = .81). A diagnosis was made in 51.4% of the 22G and 51.3% of the 21G groups (P = .98). Multivariate hierarchical logistic regression showed no statistical difference in sample adequacy or diagnostic yield between the two groups. The presence of rapid onsite cytologic evaluation was associated with significantly fewer needle passes per procedure when using the 21G needle (P < .001). CONCLUSIONS There is no difference in specimen adequacy or diagnostic yield between the 21G and 22G needle groups. EBUS-TBNA in conjunction with rapid onsite cytologic evaluation and a 21G needle is associated with fewer needle passes compared with a 22G needle.

Novel bronchoscopic strategies for the diagnosis of peripheral lung lesions: Present techniques and future directions

The diagnosis of the peripheral lung lesion has been a long‐standing clinical challenge—balancing accuracy with patient safety. With recent data revealing mortality benefits with lung cancer screening via low‐dose computed tomography, now more than ever, clinicians will be challenged with the task of providing the means to provide a safe and minimally invasive method of obtaining accurate tissue diagnostics for the pulmonary nodule. In this review, we present available technologies to aid clinicians in attempts at minimally invasive techniques and the data supporting their use. In addition, we review novel tools under investigation that may further increase yield and provide additional benefit in obtaining an early diagnosis of lung cancer.

The use of convex probe endobronchial ultrasound-guided transbronchial needle aspiration in a pediatric population: A multicenter study

The presence of intrathoracic lymphadenopathy and mediastinal masses in the pediatric population often presents a diagnostic challenge. With limited minimally invasive methodologies to obtain a diagnosis, invasive sampling via mediastinoscopy or thoracotomy is often pursued. Endobronchial ultrasound transbronchial needle aspiration (EBUS‐TBNA) is a minimally invasive, outpatient procedure that has demonstrated significant success in the adult population in the evaluation of such abnormalities. Within the pediatric literature there is limited data regarding the use of EBUS‐TBNA. We report the first multicenter review of a pediatric population undergoing EBUS‐TBNA procedures identifying the feasibility, safety, utility, and outcomes of this procedure.

EBUS-TBNA by a new Fuji EBUS scope

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been widely used for sampling of the mediastinum and hilar lesions for diagnosis or for staging of lung cancer. The viewing fields of EBUS Scope are 35 or 45 degrees forward oblique. This makes the manipulation of the scope very difficult. Plus its bigger external diameter, it is unusable for routine airway examination and biopsy. It is uncomfortable for the patient and often need general anesthesia and usually is preceded by a standard bronchoscopic examination. We tested a Fuji EBUS scope (EB-530 US) extensively on a bronchial cast and EBUS teaching phantom, then applied to the patient. This case report describes the unique quality of this EBUS scope and its potential. It has a 10 degrees forward oblique view and smaller external diameter. It might be able to eliminate the need of a second scope and makes the TBNA with or without EBUS simpler to do and easier to learn.