Macarena R. Vial

Diagnostic performance of endobronchial ultrasound-guided mediastinal lymph node sampling in early stage non-small cell lung cancer: A prospective study

Standard nodal staging of lung cancer consists of positron emission tomography/computed tomography (PET/CT), followed by endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) if PET/CT shows mediastinal lymphadenopathy. Sensitivity of EBUS‐TBNA in patients with N0/N1 disease by PET/CT is unclear and largely based on retrospective studies. We assessed the sensitivity of EBUS‐TBNA in this setting.

Evaluation of Appropriate Mediastinal Staging among Endobronchial Ultrasound Bronchoscopists

Rationale: Endobronchial ultrasound (EBUS) has transformed mediastinal staging in lung cancer. A systematic approach, beginning with lymph nodes contralateral to the primary tumor (N3), is considered superior to selective sampling of radiographically abnormal nodes. However, the extent to which this recommendation is followed in practice remains unknown. Objectives: To assess the frequency with which pulmonologists, pulmonary fellows, and interventional pulmonologists endoscopically stage lung cancer appropriately. Methods: Bronchoscopists currently performing EBUS were surveyed about their practice patterns, procedural volume, and self‐confidence in EBUS skills; they then performed a proctored simulated staging EBUS. The primary outcome was the proportion of participants who appropriately initiated ultrasonographic evaluation with the N3 nodal stations in a simulated patient undergoing EBUS for mediastinal staging. Results: Sixty physicians (22 interventional pulmonologists, 18 general pulmonologists, and 20 pulmonary fellows) participated in the study. The rates of appropriate staging by study group were 95.5% (21 of 22) for interventional pulmonologists, 44.4% (8 of 18) for general pulmonologists, and 30.0% (6 of 20) for pulmonary fellows (P < 0.001). Increased procedural volume correlated with appropriate staging practices (P < 0.001). Within each group, we assessed the concordance between self‐confidence in EBUS and simulation performance. Among interventional pulmonologists, the concordance was 95.4%, followed by 61.1% for general pulmonologists and 40.0% for pulmonary fellows. Conclusions: General pulmonologists and pulmonary fellows were less likely than interventional pulmonologists to perform appropriate EBUS staging. In addition, the lack of concordance between self‐confidence and appropriate staging performance among noninterventionists signals a need for improved dissemination of guidelines for EBUS‐guided mediastinal staging.

Evidence-based guidelines for the use of tracheostomy in critically ill patients.

Objectives: To provide evidence‐based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. Methods: A taskforce composed of representatives of 10 member countries of the Pan‐American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. Results: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions. Conclusions: Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long‐term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Guías basadas en la evidencia para el uso de traqueostomía en el paciente crítico

OBJECTIVES Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Intrapleural Fibrinolytic Therapy in Patients With Nondraining Indwelling Pleural Catheters.

Background:Tissue plasminogen activator (tPA) has been successfully used to relieve obstruction of dysfunctional devices, including vascular catheters. Intrapleural tPA is used by some centers to restore flow of nondraining indwelling pleural catheters (IPCs) in symptomatic patients with malignant pleural effusions (MPEs). Because few studies have evaluated its safety and effectiveness, we conducted a retrospective cohort study of outcomes after tPA treatment during a 10-year period at our institution. Methods:We studied 97 patients with MPE and a nondraining IPC in the setting of persistent pleural fluid who were treated with intrapleural tPA. The primary outcome was restoration of flow after treatment. Secondary outcomes included complication rates and the need for further pleural interventions. Symptomatic relief was assessed using the Borg perceived scale. Results:We identified 97 patients with MPE and a nondraining IPC who were treated with tPA. Flow was restored after 1 tPA dose in 83 of 97 patients (86%; 95% confidence interval, 77%-92%). Reocclusion after 1 dose was seen in 27 of 83 patients (32%), and 22 (81%) of these patients were treated with a second tPA dose. Among these 22, flow was restored in 16 (72%; 95% confidence interval, 44%-84%). Borg score improvement was only seen in patients who had restored flow (P=0.024). This finding was independent of the size of the effusion upon chest x-ray. There were 5 complications: 2 hemothoraxes and 3 infectious complications. Conclusion:On the basis of our finding of successful flow restoration with few complications, we recommend intrapleural tPA treatment for symptomatic patients with nondraining IPCs in the setting of persistent pleural fluid.

Needle Fracture during Endobronchial Ultrasound–guided Transbronchial Needle Aspiration

Needle Fracture during Endobronchial Ultrasound–guided Transbronchial Needle Aspiration Macarena R. Vial, John O. O’Connell, Horiana B. Grosu, David E. Ost, George A. Eapen, and Carlos A. Jimenez Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; and Department of Pulmonary Medicine, Clinica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile

Endobronchial Oxygen Insufflation: A Novel Technique for Localization of Occult Bronchopleural Fistulas

Endobronchial Oxygen Insufflation: A Novel Technique for Localization of Occult Bronchopleural Fistulas Macarena Rodriguez Vial, Charlie Lan, Lorraine Cornwell, Shuab Omer, and Roberto F. Casal Division of Pulmonary Medicine, Clinica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile; and Division of Pulmonary and Critical Care Medicine and Department of Thoracic Surgery, The Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas

Non-specific pleuritis in patients with active malignancy

Pleuroscopy is the test of choice for patients with suspected malignant pleural effusion and negative cytology. Biopsies negative for malignancy are frequently attributed to non‐specific pleuritis, which poses a dilemma in patients with a known active malignancy, raising concern for a false‐negative result. Our primary objective was to determine the outcomes of patients with active malignancy who had a non‐malignant diagnosis on pleuroscopy.

Expresión de PD-L1 en muestras de cáncer pulmonar no microcítico obtenidas por EBUS-TBNA

Her initial chest X-ray showed a multifocal abscessing pneumonia (Fig. 1A). CT was immediately performed which confirmed multifocal abscessus in lungs (Fig. 1B). Admission labs revealed hemoglobin 12.5 gm/dL, white count 8.8 × 109/L, neutrophil 5.59 × 109, platelets count 197 × 109/L. Her serum sodium levels were 138 mEq/dL, and the blood urea nitrogen (BUN) and creatinine values were 20 mg/dL and 0.9 mg/dL respectively. C reactive protein (CRP) was 252 ng/ml, while procalcitonin was 78.7 g/L. Arterial blood gas showed a pH of 7.30 and PaO2 of 60 mmHg, PCO2 46 mmHg, SaO2 90%. Initially, the patient was started empirically with broadspectrum antibiotics: Vancomycin 1 g/12 h, Amikacin 1 g/12 g and Orvagyl 500 mg/8 h. Blood culture, throat culture, blood fungal culture, acid-fast bacillus blood culture, and urine culture were all negative. Despite antibiotics therapy, patient was febrile up to 38 C, and in the absence of adequate laboratory as well as radiologically answer, therapy was changed into Meropenem 1 g/12 h and Orvagyl 500 mg/8 h. On third day, patient was afebrile and feeling better. Her CRP was 9.7 ng/ml, white count 11.2 × 109/L, platelets 210 × 109/L. During the following days, the patient’s condition, and laboratory parameters improved in parallel with the neutrophil count. She received above mentioned therapy for fourteen days after she was discharged in good condition and radiological finding. She was released from the hospital with recommended Propylthiouracil 50 mg twice daily. She was regularly checked up by endocrinologist and pulmonologist with no relapse of disease. Antithyroid drugs, especially thioamides—including propylthiouracil, methimazole and carbimazole—have adverse hematological effects, ranging from mild leukopenia to agranulocytosis and aplastic anemia. Agranulocytosis, defined as a marked decrease in the number of granulocytes, frequently <500/ L, is a rare complication. Fever and sore throat are common symptoms of antithyroid drug induced agranulocytosis.3 Patients with an absolute neutrophil count <100/ L tend to have a greater risk of infectious and fatal complications than do patients with a neutrophil count >100/ L. The mortality rate is greater in patients aged ≥65 years than in those aged <65 years.4 The lungs are the most common organ to be infected in febrile neutropenic patients. The chest radiograph is the standard initial investigation to look for pulmonary changes, but its sensitivity has been shown to be very low. High resolution computed tomography (HRCT) chest can detect the abnormality with a high degree of accuracy, as well as differentiate between different types of infections.5 It is extremely useful in early detection or exclusion of a focus of infection and characterization of the focus. Exact etiological diagnosis is not possible in most of the cases, but identification of broad category of infective causes itself is very important for the appropriate therapy. Previous studies have proven that the most common cause of febrile condition is Pseudomonas aeruginosa.5 Our case was different from previous described in literature, in its beginning, but similar in good prognosis after granulocyte colonystimulating factor and empirical antibiotic therapy. However, the recovery time in our cases was slightly longer than in previous cases (14 vs. 6.8 days).6 Nowadays, more people are undergoing surgical treatment as a permanent solution.7 In conclusion, ATD-induced agranulocytosis is rare, but the severity of this possibly life-threatening condition means its management is essential to a good prognosis. Our case suggests that patients with antithyroid drug-induced agranulocytosis who present with severe infections should be treated empirically with broad-spectrum antibiotics with antipseudomonal activity. Alternative way in patients with hyperthyroidisms is surgery or radioactive iodine which seem to be effective options to restore an euthyroid state. In fact, radioactive iodine was demonstrated as a successful option, with 88.8% of patients experiencing euthyroidism after treatment.

What Exactly Is a Centrally Located Lung Tumor? Results of an Online Survey

Rationale: Accurate mediastinal staging is a cornerstone in the management of patients with lung cancer. For patients with radiographically normal mediastinum, current lung cancer guidelines recommend invasive mediastinal staging when tumors are centrally located. However, definitions of central tumors are nonspecific, and there are discrepancies among guidelines (e.g., some use the inner one‐third of the hemithorax, whereas others use the inner two‐thirds). Objectives: To describe the definitions of central tumors used by pulmonologists and thoracic surgeons in their practices. Methods: An online questionnaire was e‐mailed to members of the American Association for Bronchology and Interventional Pulmonology and members of the Cardiothoracic Surgery Network. Measurements and Main Results: A total of 218 participants completed our survey (12% response rate). Most common definitions for central tumors were: inner one‐third of the hemithorax (55%), in contact with hilar structures (29%), and inner two‐thirds of the hemithorax (15%). Of note, 29% of participants chose a definition fabricated specifically for this survey and not supported by guidelines. Regarding the method to delineate the thirds of the hemithorax, 182 (84%) participants chose a system of concentric lines arising in the hilum, whereas 31 (14%) chose straight lines in the sagittal plane of the chest. We found strikingly similar responses in members of both societies. Conclusions: A uniform definition of tumor centrality is currently lacking, and should be formulated. Studies using objective measurements that evaluate the ability of these different definitions of central lung tumors to predict N2 disease are needed to construct a clear and evidence‐based definition.