Michele Mondoni

Rapid On-Site Evaluation Improves Needle Aspiration Sensitivity in the Diagnosis of Central Lung Cancers: A Randomized Trial

Background: Few prospective studies have evaluated the role of endobronchial needle aspiration in diagnosing central airways neoplasms. Rapid on-site evaluation has long been used in transbronchial needle aspiration of adenopathies and peripheral lesions, but its role in sampling central malignancies has not been substantiated yet. Objectives: In this study we evaluated if endobronchial needle aspiration may increase the sensitivity of bronchoscopy for diagnosing central airways neoplasms when added to conventional diagnostic methods (forceps biopsy, brushing and bronchial washing), and if rapid on-site evaluation may be beneficial in patients undergoing endobronchial needle aspiration. Methods: 125 patients (77% males, aged 70 ± 7 years; mean ± SD) with central lung cancers were randomized to undergo bronchoscopy including conventional diagnostic methods and needle aspiration, with or without rapid on-site evaluation, stratifying the patients on the basis of the neoplasm growth pattern (exophytic and submucosal/peribronchial disease). Results: Needle aspiration significantly increased the sensitivity of bronchoscopy when added to conventional methods (from 76 to 91%; p < 0.001), primarily resulting from differences in submucosal/peribronchial diseases (68 vs. 90%; p < 0.001) and independently from the presence of rapid on-site evaluation; needle aspiration guided by rapid on-site evaluation guaranteed a higher improvement in bronchoscopy sensitivity than conventional needle aspiration (98 vs. 84%, respectively; p = 0.004). Needle aspiration guided by rapid on-site evaluation showed a significantly higher sensitivity than the conventional method (97 vs. 76%, respectively; p = 0.001). Conclusions: Needle aspiration increases the sensitivity of bronchoscopy in diagnosing central airways malignancies when added to conventional diagnostic methods, with a further significant improvement when guided by rapid on-site evaluation.

Transbronchial needle aspiration in peripheral pulmonary lesions: a systematic review and meta-analysis.

Fluoroscopy-guided transbronchial needle aspiration (TBNA) has long been used in the diagnosis of peripheral pulmonary lesions (PPLs), although its diagnostic performance varies considerably. We conducted a systematic review and meta-analysis evaluating the accuracy of TBNA in the diagnosis of PPLs, comparing its diagnostic yield with transbronchial biopsy (TBB) and assessing the main predictors of a successful aspirate. In 18 studies, the overall TBNA yield was 0.53 (95% CI 0.44–0.61). TBNA showed a higher accuracy when directly compared to TBB (0.60 (95% CI 0.49–0.71) versus 0.45 (95% CI 0.37–0.54)). The subgroup analyses documented a higher TBNA yield when the computed tomography (CT) bronchus sign was present (0.70 (95% CI 0.63–0.77) versus 0.51 (95% CI 0.38–0.64)), when rapid on-site evaluation (ROSE) was performed (0.62 (95% CI 0.43–0.79) versus 0.51 (95% CI 0.42–0.60)), in the case of malignant lesions (0.55 (95% CI 0.44–0.66) versus 0.17 (95% CI 0.11–0.24)) and for lesions >3 cm (0.81 (95% CI 0.73–0.87) versus 0.55 (95% CI 0.47–0.63)). Conventional TBNA is a useful sampling technique for the diagnosis of PPL, with a higher diagnostic yield than TBB. The presence of CT bronchus sign, an underlying malignant process, lesion size >3 cm and ROSE employment are predictors of a higher yield. Fluoroscopy-guided transbronchial needle aspiration is a useful technique in diagnosing peripheral pulmonary lesions http://ow.ly/4mK0sB

Point-of-Care Lung Sonography: An Audit of 1150 Examinations

Point‐of‐care lung sonography has theoretical usefulness in numerous diseases; however clinical indications and the impact of this technique have not been fully investigated. We aimed to describe the current use of point‐of‐care lung sonography.

Observational, multicentre study on the epidemiology of haemoptysis

Haemoptysis, which is a challenging symptom accounting for 10–15% of all pulmonology consultations, may be associated with life-threatening medical conditions such as lung cancer [1–7]. Malignancy is the main haemoptysis aetiology in our Italian cohort http://ow.ly/goUb30gRT5b

Interventional pulmonology techniques in elderly patients with comorbidities

Respiratory diseases are common cause of disability in the elderly and are often concomitant with other non-respiratory medical conditions. Interventional pulmonology includes advanced diagnostic and therapeutic techniques, successfully employed for benign and malignant pulmonary diseases with a good safety profile. A few studies are available on the efficacy and the safety of these procedures (both bronchoscopic and pleural techniques) in the elderly. Paucity of data in these patients may support reluctant clinicians. We carried out a non-systematic review aimed at describing the scientific literature on interventional pulmonology techniques in elderly patients with comorbidities. We summarized indications, performance characteristics, and safety profile of bronchoscopic techniques in the elderly, comparing outcomes between older and younger patients. We explored the role of age on anesthesia and sedation protocols during endoscopic procedures and assessed the influence of comorbidities on bronchoscopic outcomes. This review underlines that older age is not a barrier for implementing interventional pulmonology for diagnostic and therapeutic purposes.

Lung Ultrasound B Lines: Etiologies and Evolution with Age

nologist-performed lung ultrasounds in an Italian university hospital [2] . We included all lung ultrasound examinations showing a B-line pattern (multiple close B lines visible in 1 single scan) in at least 1 lung field. Ultrasound findings were standardized according to guidelines [4] , and final diagnoses were adjudicated by the attending physician at patient discharge [2] . Overall, a B-line pattern was reported in 397 cases (34.5%) of the 1,150 examinations performed. Of these, 54 were obtained in children (18 females, [mean ± standard deviation] 4 ± 3 years old), 69 in adults between 19 and 64 years of age (29 females, 46 ± 13 years old), 178 in patients aged >64 years (68 females, 75 ± 5 years old), and 96 in patients >80 years (50 females, 86 ± 5 years old). Figure 1 shows that community-acquired pneumonia represents the main cause of B-line patterns in children (89%) and middle-aged adults (51%), whereas acute heart failure prevails in the elderly (37% between 64 and 80 years old, 50% if older than 80 years). However, etiologies are heterogeneous since interstitial lung diseases, lung cancer, empyema, atelectasis, pulmonary infarction, and even the normal lung may show lung areas with a B-line pattern in about half of the adult population. In conclusion, when a large population and multiple conditions are considered, we should expect that one-third of the lung ultrasound studies show a B-line pattern in at least 1 thoracic area, with etiology varying throughout different age groups. Since this pattern could be attributed to a wide range of conditions, its interpretation cannot withstand analysis of the distribution, extension, and severity of the B-line pattern together with an accurate clinical correlation. Lung ultrasound is a field of growing importance in respiratory medicine [1, 2] . B lines, previously termed ‘‘comet tails,” are vertical hyperechoic reverberations moving synchronously with the lung and represent key artifacts in interpreting pulmonary ultrasound findings [3, 4] . The physiologic basis of B lines relates to decreased lung aeration [5] , a finding that is nonspecific. Here, we aimed to explore the specific clinical diagnoses associated with the B-line pattern and their evolution with age. We therefore undertook a secondary analysis of a 2-year audit of consecutive pulmoPublished online: July 22, 2017

Bronchoscopic techniques in the management of patients with tuberculosis.

Tuberculosis (TB) is one of the leading causes of morbidity and mortality worldwide. Early diagnosis and treatment are key to prevent Mycobacterium tuberculosis transmission. Bronchoscopy can play a primary role in pulmonary TB diagnosis, particularly for suspected patients with scarce sputum or sputum smear negativity, and with endobronchial disease. Bronchoscopic needle aspiration techniques are accurate and safe means adopted to investigate hilar and mediastinal lymph nodes in cases of suspected TB lymphadenopathy. Tracheobronchial stenosis represents the worst complication of endobronchial tuberculosis. Bronchoscopic procedures are less invasive therapeutic strategies than conventional surgery to be adopted in the management of TB-related stenosis. We conducted a non-systematic review aimed at describing the scientific literature on the role of bronchoscopic techniques in the diagnosis and therapy of patients with TB. We focused on three main areas of interventions: bronchoscopic diagnosis of smear negative/sputum scarce TB patients, endobronchial TB diagnosis and treatment and needle aspiration techniques for intrathoracic TB lymphadenopathy. We described experiences on bronchoalveolar lavage, bronchial washing, and biopsy techniques for the diagnosis of patients with tracheobronchial and pulmonary TB; furthermore, we described the role played by conventional and ultrasound-guided transbronchial needle aspiration in the diagnosis of suspected hilar and mediastinal TB adenopathy. Finally, we assessed the role of the bronchoscopic therapy in the treatment of endobronchial TB and its complications, focusing on dilation techniques (such as balloon dilation and airway stenting) and ablative procedures (both heat and cold therapies).

Huge Tracheal Diverticulum in a Patient with Mounier-Kuhn Syndrome

Tracheal diverticulum is a rare benign entity. Tracheobronchomegaly (TBM), also known as Mounier-Kuhn syndrome, is a rare disorder characterized by marked dilation of the trachea and main bronchi, associated with thinning or atrophy of the elastic tissue. Because of the weakened trachea and increased intraluminal pressure related to chronic cough, some patients may develop mucosal herniation leading to tracheal diverticulosis. We report the case of a patient with TBM with a huge tracheal diverticulum, diagnosed by bronchoscopy and computed tomography with three-dimensional reconstruction. to our knowledge this is the largest tracheal diameter described in a patient affected by this syndrome. LEARNING POINTS Tracheal diverticulum is a rare condition that should be considered in the presence of bronchopulmonary disorders characterized by chronic cough and repeated bronchial infection, such as Mounier-Kuhn syndrome. The differential diagnosis of tracheal diverticulum includes laryngocele, pharyngocele, Zenker’s diverticulum, apical lung hernia and lung bullae. Bronchoscopy and CT scans with three-dimensional reconstruction are useful tools for diagnosing this rare condition.