Jose Vempilly

Severe Tracheomalacia in the ICU: Identification of Diagnostic Criteria and Risk Factor Analysis From a Case Control Study

BACKGROUND: Severe tracheomalacia (STM) is being increasingly recognized as a cause for respiratory failure in the ICU. The diagnosis is often overlooked, as chest radiography appears normal, and the role of invasive diagnostic testing for this diagnosis is not well described in the ICU setting. The prevalence and risk factors for STM are not known, and computed tomography (CT) based diagnostic criteria for ventilated patients are not well studied. METHODS: Patients admitted between January 2008 and December 2010, with respiratory failure and who failed ventilator discontinuation or required reintubation, were screened for the presence of any tracheal collapse, utilizing prior CT of the chest. Bronchoscopically confirmed cases were compared with age and sex matched controls to identify risk factors. RESULTS: Twenty-five subjects were identified as having STM, which represented 0.7% of ICU admissions and 1.6% of subjects with respiratory failure. The mean ICU stay was significantly longer in STM (30 d, 95% CI 19.7–40 d), compared to controls (4.4 d, 95% CI 3.6–5.2 d). Obesity (odds ratio 1.26, 95% CI 1.04–1.54) and gastro-esophageal reflux (odds ratio 31, 1.7- 586) were associated with increased risk for STM. The pre-intubation PaCO2 (68 mm Hg, 95% CI 57–79 mm Hg) was significantly higher in STM, compared to controls (38 mm Hg, 95% CI 35–41). The distal tracheal antero-posterior diameter (2.80 mm, 95% CI 2.15–3.46) was significantly lower in STM. A receiver operating characteristic analysis showed a distal tracheal antero-posterior diameter < 7 mm to be the optimal cutoff measurement to diagnose STM. CONCLUSION: STM was associated with prolonged ICU stay. A distal tracheal antero-posterior diameter < 7 mm on a non-intubated CT chest was suggestive of STM that required a confirmatory bronchoscopy. Gastroesophageal reflux disease and obesity were potential risk factors.

Office spirometry correlates with laboratory spirometry in patients with symptomatic asthma and COPD

Spirometry remains underutilized in the evaluation of obstructive lung disease. While office spirometry (OS) has been compared to formal laboratory‐based spirometry (LS) in healthy subjects, the correlation has never been formally assessed in patients with symptomatic obstructive lung disease. The aim of this study was to investigate the correlation in this population.

Transesophageal approach to lung, adrenal biopsy and fiducial placement using endoscopic ultrasonography (EUS): An interventional pulmonology experience. Initial experience of the UCSF-FRETOC (fresno tracheobronchial & oesophageal center) study group

BACKGROUND Routine lung cancer surveillance has resulted in early detection of pulmonary nodules and masses. Combined endobronchial ultrasound (EBUS) and trans-esophageal endoscopic ultrasound (EUS) are approved methods for sampling lymph nodes or masses. Furthermore, EUS allows for adrenal sampling as part of staging, and can assist with fiducial placement for stereotactic body radiation therapy (SBRT). OBJECTIVES Promote use of EUS by interventional pulmonologists in the United States when diagnosing and staging lung cancer or when placing fiducials. METHODS All patients undergoing EUS and/or EBUS were serially entered into a prospectively maintained database. Only patients undergoing EUS guided lung and/or adrenal biopsy and/or fiducial placement were selected for analysis. All patients underwent a post-procedure chest radiograph and were followed outpatient. RESULTS 20 of 39 patients underwent sampling of a suspicious lung mass. An adequate sample was obtained in 19 of 20 patients. In all 19 patients a definitive diagnosis was achieved (95%). In all 13 patients who underwent adrenal sampling, presence or absence of metastasis was conclusively established. 6 patients successfully underwent fiducial placement. In all 39 patients, no major procedure related complications were noted for a period of 30 days. One patient had a small pneumothorax that resolved spontaneously. CONCLUSIONS EUS can be safely performed by a trained interventional pulmonologist for the diagnosis of lung, adrenal masses and placement of fiducials. We think that interventional pulmonologists in the United States involved in lung cancer staging should receive training in EUS techniques.

Pulmonary Rehabilitation Maintenance Program May Prevent Accelerated FEV1 Decline in Patients With COPD

Introduction: Limited data exist on outcomes from prolonged exercise maintenance therapy (EMT) after initial completion of a pulmonary rehabilitation (PR) program. The objective of this study was to investigate the impact of prolonged EMT (>2 y) on patient-centered and functional outcomes. Methods: A total of 36 subjects (EMT, n=12 and control, n=24) were screened; 6 cases and 17 controls completed the study. All subjects underwent a 6-week PR program. Subjects in the EMT group (but not the control group) underwent additional EMT for at least 2 years. Spirometry and 6-minute walk test were assessed at baseline (post-PR) and post-EMT. All subjects also completed questionnaires (Short Form 36 and health care utilization), underwent exhaled nitric oxide (fraction of exhaled nitric oxide) test, and musculoskeletal assessments including ultrasound measurements of the rectus femoris and diaphragmatic thickness, post-EMT. Results: There were 6 EMT patients (mean age, 76±11.9 y, with mean 50±16 sessions/y) versus 17 control patients (mean age, 71±10.7 y, with mean 10±0 sessions/y). We noted a statistically significant decline in forced expiratory volume in 1 second in the control group (P<0.009) but not in the EMT group, with the significance in the EMT group possibly limited by the small numbers of patients. Although not statistically significant, there appeared to be a lower number of exacerbations in the EMT group. There were no differences in all other outcomes compared. Conclusions: EMT appears to prevent accelerated FEV1 decline and may reduce exacerbations in patients with chronic obstructive pulmonary disease. This does not appear to be mediated by improvement of muscle strength or inflammatory markers.