Javier Diaz-Mendoza

Diagnostic Yield and Complications of Bronchoscopy for Peripheral Lung Lesions. Results of the AQuIRE Registry.

RATIONALE Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy. OBJECTIVES To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations. METHODS We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions. MEASUREMENTS AND MAIN RESULTS Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16). CONCLUSIONS Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.

Therapeutic Bronchoscopy for Malignant Central Airway Obstruction: Success Rates and Impact on Dyspnea and Quality of Life

BACKGROUND There is significant variation between physicians in terms of how they perform therapeutic bronchoscopy, but there are few data on whether these differences impact effectiveness. METHODS This was a multicenter registry study of patients undergoing therapeutic bronchoscopy for malignant central airway obstruction. The primary outcome was technical success, defined as reopening the airway lumen to > 50% of normal. Secondary outcomes were dyspnea as measured by the Borg score and health-related quality of life (HRQOL) as measured by the SF-6D. RESULTS Fifteen centers performed 1,115 procedures on 947 patients. Technical success was achieved in 93% of procedures. Center success rates ranged from 90% to 98% (P = .02). Endobronchial obstruction and stent placement were associated with success, whereas American Society of Anesthesiology (ASA) score > 3, renal failure, primary lung cancer, left mainstem disease, and tracheoesophageal fistula were associated with failure. Clinically significant improvements in dyspnea occurred in 90 of 187 patients measured (48%). Greater baseline dyspnea was associated with greater improvements in dyspnea, whereas smoking, having multiple cancers, and lobar obstruction were associated with smaller improvements. Clinically significant improvements in HRQOL occurred in 76 of 183 patients measured (42%). Greater baseline dyspnea was associated with greater improvements in HRQOL, and lobar obstruction was associated with smaller improvements. CONCLUSIONS Technical success rates were high overall, with the highest success rates associated with stent placement and endobronchial obstruction. Therapeutic bronchoscopy should not be withheld from patients based solely on an assessment of risk, since patients with the most dyspnea and lowest functional status benefitted the most.

Complications following therapeutic bronchoscopy for malignant central airway obstruction: Results of the AQuIRE registry

BACKGROUND There are significant variations in how therapeutic bronchoscopy for malignant airway obstruction is performed. Relatively few studies have compared how these approaches affect the incidence of complications. METHODS We used the American College of Chest Physicians (CHEST) Quality Improvement Registry, Evaluation, and Education (AQuIRE) program registry to conduct a multicenter study of patients undergoing therapeutic bronchoscopy for malignant central airway obstruction. The primary outcome was the incidence of complications. Secondary outcomes were incidence of bleeding, hypoxemia, respiratory failure, adverse events, escalation in level of care, and 30-day mortality. RESULTS Fifteen centers performed 1,115 procedures on 947 patients. There were significant differences among centers in the type of anesthesia (moderate vs deep or general anesthesia, P < .001), use of rigid bronchoscopy (P < .001), type of ventilation (jet vs volume cycled, P < .001), and frequency of stent use (P < .001). The overall complication rate was 3.9%, but significant variation was found among centers (range, 0.9%-11.7%; P = .002). Risk factors for complications were urgent and emergent procedures, American Society of Anesthesiologists (ASA) score > 3, redo therapeutic bronchoscopy, and moderate sedation. The 30-day mortality was 14.8%; mortality varied among centers (range, 7.7%-20.2%, P = .02). Risk factors for 30-day mortality included Zubrod score > 1, ASA score > 3, intrinsic or mixed obstruction, and stent placement. CONCLUSIONS Use of moderate sedation and stents varies significantly among centers. These factors are associated with increased complications and 30-day mortality, respectively.

A Prediction Model to Help with the Assessment of Adenopathy in Lung Cancer (HAL).

Rationale: Estimating the probability of finding N2 or N3 (prN2/3) malignant nodal disease on endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) in patients with non‐small cell lung cancer (NSCLC) can facilitate the selection of subsequent management strategies. Objectives: To develop a clinical prediction model for estimating the prN2/3. Methods: We used the AQuIRE (American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education) registry to identify patients with NSCLC with clinical radiographic stage T1‐3, N0‐3, M0 disease that had EBUS‐TBNA for staging. The dependent variable was the presence of N2 or N3 disease (vs. N0 or N1) as assessed by EBUS‐TBNA. Univariate followed by multivariable logistic regression analysis was used to develop a parsimonious clinical prediction model to estimate prN2/3. External validation was performed using data from three other hospitals. Measurements and Main Results: The model derivation cohort (n = 633) had a 25% prevalence of malignant N2 or N3 disease. Younger age, central location, adenocarcinoma histology, and higher positron emission tomography‐computed tomography N stage were associated with a higher prN2/3. Area under the receiver operating characteristic curve was 0.85 (95% confidence interval, 0.82‐0.89), model fit was acceptable (Hosmer‐Lemeshow, P = 0.62; Brier score, 0.125). We externally validated the model in 722 patients. Area under the receiver operating characteristic curve was 0.88 (95% confidence interval, 0.85‐0.90). Calibration using the general calibration model method resulted in acceptable goodness of fit (Hosmer‐Lemeshow test, P = 0.54; Brier score, 0.132). Conclusions: Our prediction rule can be used to estimate prN2/3 in patients with NSCLC. The model has the potential to facilitate clinical decision making in the staging of NSCLC.

Bronchoscopic Lung Volume Reduction

The management of obstructive lung disease, particularly emphysematous lung disease, is aggressively being pursued. The patient populations that will experience the greatest benefit with lung volume reduction are those that are the worst candidates for surgical intervention. Identifying a bronchoscopic approach that has a true impact on this patient population will be a major accomplishment in the management of patients with chronic obstructive pulmonary disease. This article highlights the work currently ongoing in the area of bronchoscopic lung volume reduction. There are tools now clinically available in some locations throughout the world, but no standardized technique exists.

Endobronchial actinomycosis after airway stenting.

Actinomycosis is a chronic suppurative infection with filamentous, gram-positive, nonspore forming anaerobic bacteria of the genus Actinomyces. Actinomyces species are commensals of the human oropharynx, gastrointestinal tract, and female genitalia. Involvement of the thorax accounts for 15% to 20% of actinomycosis cases. Thoracic actinomycosis classically presents as an intrapulmonary infection of the alveoli, peribronchial tissue, and/or bronchioles. Endobronchial actinomycosis is a rare condition that has been reported in association with aspiration of a foreign body or broncholithiasis. A critical component in the pathogenesis is disruption of the mucosal barrier, thereby allowing invasion of the microorganisms from aspirated oropharyngeal secretions. Even with a high clinical suspicion, actinomycosis is a diagnostic challenge. The most common symptoms of endobronchial actinomycosis include cough, sputum production, and fever. The disease is often confused with lung cancer, tuberculosis, fungal infections, nocardiosis, and poorly responding pneumonia. The present case highlights the first reported case of endobronchial actinomycosis associated with a covered nitinol endobronchial stent.

Risk factors for pleural effusion recurrence in patients with malignancy: Pleural effusion recurrence

The main purpose of treatment in patients with malignant pleural effusion (MPE) is symptom palliation. Currently, patients undergo repeat thoracenteses prior to receiving a definitive procedure as clinicians are not aware of the risk factors associated with fluid recurrence. The primary objective of this study was to identify risk factors associated with recurrent symptomatic MPE.

Removal of Self-Expanding Metallic Stents.

Background:Despite their safety profile, self-expanding metallic stents (SEMS) have been difficult to remove. We aim to describe our experience in removal of SEMS at Henry Ford Hospital with a specific emphasis on safety. Methods:We reviewed the charts of all patients who underwent removal of a SEMS at Henry Ford Hospital between 2003 and 2013. We recorded demographic information, indication for initial stent placement, indication for stent removal, time to stent removal, procedure of removal, and any complications. Results:In all, 19 stents were removed in 16 separate procedures in 14 patients. The median age was 62 years, and 50% of the patients were female. Stents were removed at a median of 35 days (range, 2 to 595 d). No complications occurred in 10/16 (62.5%) procedures. In the remaining 5 patients, complications were not directly related to the stent removal, and serious complications were mostly related to severity of underlying lung disease. Of the 10 procedures done as outpatients, 70% were discharged immediately after the procedure. Conclusions:Removal of SEMS can be done safely. Routine postoperative ventilation and intensive care unit monitoring is not required. In the absence of severe underlying lung disease, patients can safely be discharged if there are no immediate postprocedure complications.

A Young Man with Acute Progressive Respiratory Distress and a Right Inguinal Mass

A 26-year-old immigrant Hispanic man with no known medical history presented to the emergency department with worsening dyspnea accompanied by a nonproductive cough, pleuritic chest pain, and weight loss over the previous 2 weeks. The patient drew attention to a mass in his groin that had increased gradually in size over the past 1.5 years. He received vancomycin and cefepime in the emergency department, and he was admitted in the intensive care unit because of respiratory distress. The man was afebrile and normotensive. The respiratory rate was 31, and arterial oxygen saturationmeasured by pulse oximetry was 92% while he breathed supplemental oxygen at 3 L/min via nasal cannula. Auscultation of the lungs revealed bilateral wheezes. No abdominal mass was palpated. There was a 53 5-cm fixed, nontender, solid, irregular mass on the right lateral side of the mons pubis. The testes were unremarkable. Laboratory studies disclosed white blood cell count of 6.7K/ml; the hemoglobin level was 16.1. Rapid HIV testing was negative. Results of routine blood and urine cultures were negative. A chest radiograph revealed extensive airspace opacities with a mediastinal fullness (Figure 1). Chest computed tomography imaging confirmed extensive lymphadenopathy (Figure 2). There were multiple bilateral pulmonary nodules. The radiologist also noted lobulated septal thickening and patchy interstitial opacities (Figure 3). Ultrasound of the groin revealed unremarkable testes but demonstrated a 7.53 5.53 5.9-cm complex vascular mass at the right edge of the mons pubis. Figure 1. Chest radiograph obtained at the time of admission.