Noelia Cubero

Tratamiento endoscópico de la fuga aérea persistente alveolo-pleural con una válvula endobronquial unidireccional

The persistent air leaks due to alveolopleural fistula are not an uncommon complication of pneumothorax, particularly secondary ones. Unidirectional flow endobronchial valves designed for lung volume reduction are the latest incorporation to the therapeutic armamentarium. We present the case of a patient with chronic obstructive pulmonary disease (COPD) with persistent pneumothorax in spite of treatment with three pleurodesis which was able to be resolved with the placement of two IBV™ valves.

Colchicine Treatment for Tracheobronchial Amyloidosis.

Tracheobronchial amyloidosis is an infrequent disease characterized by the deposition of proteinaceous material in the tracheobronchial tree. The disease generally has a high morbidity and variable mortality in the years following diagnosis. There is no consensus on the optimal treatment. We report a case of a 63-year-old woman who presented with a diffuse tracheobronchial amyloidosis associated with laryngeal involvement, which required a percutaneous tracheostomy due to high-grade subglottic stenosis, with no evidence of systemic amyloidosis. After treatment exclusively with colchicine, she had a complete resolution of the stenotic area, with a very good response from the tracheobronchial amyloidosis disease, with only minor yellow plaques persisting. The patient has remained asymptomatic in the next 4 years of follow-up, with no evidence of endoscopic progression. This is the first documented case of this kind of response of tracheobronchial amyloidosis to colchicine treatment alone. A review of the available literature is presented.

Positive Airway Pressure to Enhance Computed Tomography Imaging for Airway Segmentation for Virtual Bronchoscopic Navigation

Rationale: Virtual bronchoscopic navigation (VBN) guidance to peripheral pulmonary lesions is often limited by insufficient segmentation of the peripheral airways. Objectives: To test the effect of applying positive airway pressure (PAP) during CT acquisition to improve segmentation, particularly at end-expiration. Methods: CT acquisitions in inspiration and expiration with 4 PAP protocols were recorded prospectively and compared to baseline inspiratory acquisitions in 20 patients. The 4 protocols explored differences between devices (flow vs. turbine), exposures (within seconds vs. 15-min) and pressure levels (10 vs. 14 cmH2O). Segmentation quality was evaluated with the number of airways and number of endpoints reached. A generalized mixed-effects model explored the estimated effect of each protocol. Measurements and Main Results: Patient characteristics and lung function did not significantly differ between protocols. Compared to baseline inspiratory acquisitions, expiratory acquisitions after 15 min of 14 cmH2O PAP segmented 1.63-fold more airways (95% CI 1.07–2.48; p = 0.018) and reached 1.34-fold more endpoints (95% CI 1.08–1.66; p = 0.004). Inspiratory acquisitions performed immediately under 10 cmH2O PAP reached 1.20-fold (95% CI 1.09–1.33; p < 0.001) more endpoints; after 15 min the increase was 1.14-fold (95% CI 1.05–1.24; p < 0.001). Conclusions: CT acquisitions with PAP segment more airways and reach more endpoints than baseline inspiratory acquisitions. The improvement is particularly evident at end-expiration after 15 min of 14 cmH2O PAP. Further studies must confirm that the improvement increases diagnostic yield when using VBN to evaluate peripheral pulmonary lesions.

Combined Bronchial Artery Embolization and Endobronchial Resection for Bronchial Carcinoid: A Safety and Feasibility Pilot Study.

Background: There is growing evidence to support bronchoscopic resection of well-circumscribed typical carcinoids. However, massive bleeding and risk of recurrence can potentially complicate this approach. Objectives: The aim of this study was to assess the safety and feasibility of endobronchial resection of carcinoids preceded by bronchial artery embolization. Methods: Five patients with centrally located typical carcinoids were recruited, 4 with a curative intent and 1 for palliation of a carcinoid with mediastinal invasion. All patients underwent selective embolization of the feeding bronchial artery 24-48 h prior to endobronchial resection, which was performed with a rigid bronchoscope and neodymium:yttrium-aluminium-perovskite laser. Results: Minimal bleeding was noted during tumour resection. After a median (range) follow-up of 20 (14-48) months, only the case with segmental extension of the tumour had local recurrence, which was treated successfully using cryotherapy (with negative endobronchial biopsies since), and no cases of metastatic spread occurred. One patient, in whom the histopathological diagnosis was changed from typical to atypical carcinoid following resection, went on to have a surgical bilobectomy 3 months later. Extensive fibrosis was noted at the site of original tumour resection with no evidence of residual disease. Conclusions: Bronchial artery embolization prior to endobronchial resection of centrally located carcinoids is feasible and safe. The reduction in bleeding may facilitate and simplify the procedure. The possible application of this combined therapy to the management of atypical carcinoids warrants the design of a larger prospective clinical trial.

Colchicin in der Behandlung der tracheobronchialen Amyloidose

Die tracheobronchiale Amyloidose ist eine selten vorkommende Erkrankung, die durch Ablagerungen von Proteinstrukturen im Tracheobronchialbaum gekennzeichnet ist. Die Krankheit ist generell mit einer hohen Morbidität und einer variablen Mortalität in den Jahren nach der Diagnosestellung assoziiert. Über die optimale Behandlung besteht kein Konsens. Wir berichten über den Fall einer 63-jährigen Patientin, die sich mit einer diffusen tracheobronchialen Amyloidose mit begleitender Kehlkopferkrankung vorstellte und bei der aufgrund einer hochgradigen subglottischen Stenose eine perkutane Tracheotomie erforderlich wurde; Anzeichen einer systemischen Amyloidose lagen nicht vor. Nach der Behandlung allein mit Colchicin normalisierte sich der stenosierte Bereich vollständig, mit sehr gutem Ansprechen der tracheobronchialen Amyloidose, von der nur noch kleine gelbe Plaques übrig blieben. In den folgenden 4 Jahren der Nachbeobachtung blieb die Patientin symptomfrei, ohne Anzeichen einer endoskopischen Progression. Dies ist der erste dokumentierte Fall eines solchen Ansprechens auf alleinige Colchicinbehandlung bei tracheobronchialer Amyloidose. Die zum Thema vorliegende Literatur wird im Überblick dargestellt.

Transarterial EBUS-TBNA in the Diagnosis of Hilar Lesions.

ton PA, et al. Pulmonary intravascular tumor emboli: dilated and beaded peripheral pulmonary arteries at CT. Radiology. 1993;187:797–801. 7. Masson RG, Ruggieri J. Pulmonary microvascular cytology. A new diagnostic application of the pulmonary artery catheter. Chest. 1985;88:908–914. 8. Desai NR, Greenhill SR, Vance M, et al. Pulmonary tumor embolism diagnosed by endo bronchial ultrasound. Endobronchial Ultrasound. 2011;A44: A1567–A1567. 9. Blanc AL, Jardin C, Faivre JB, et al. Pulmonary artery tumourembolism diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration. Eur Respir J. 2011;38:477–479. 10. Chamorro N, Blanco I, Sánchez M, et al. The expanding horizons of endobronchial ultrasound: diagnosis of a tumor embolism. Chest. 2012;142:1334–1336. 11. Aumiller J, Herth FJ, Krasnik M, et al. Endobronchial ultrasound for detecting central pulmonary emboli: a pilot study. Respiration. 2009;77:298–302.

Two-year experience with the use of fully covered self-expandable metal stents

Introduction: there are only few reports on fully covered self-expandable metal stents (SEMS), and none on the new Aerstent (Leufen Bess AG, Germany, Europe). Aims and objective: to report and analyze our experience with Aerstent in the management of malignant tracheobronchial disorders. Methods: retrospective review of medical records of patients who underwent stenting with fully covered SEMS, between October 2012 and October 2014. Results: 22 stents were placed in 19 patients, mean age of 62 years (SD 4), 84% males, with lung cancer (n=8), endobronchial metastasis (n=6) and esophageal cancer (n=5). The median follow-up was 44 days (range 21-318), with a median survival of 72 days (range 3-374). SEMS were inserted through a rigid bronchoscope, under fluoroscopic and endoscopic guidance, in the main bronchi (n=13), trachea (n=8), tracheobronchial (n=1) and tracheobronchial with a telescoped bronchial (n=1). In 2 cases (9%) reimplantation was needed, and the same stents were reloaded during the procedure. No migrations, metal fractures or foldings were recorded. Mucostasis was observed in 86% of cases, without mucous plugging, mild granulation tissue formation in 31.7%, silicone coating detachment in 9% and poliurethane coat perforation in 4%. In 3 cases, stents were easily removed through the rigid bronchoscope without complications. Conclusions: fully covered Aerstent are safe, easy to implant, replace and remove. They present an outstanding performance as far as the metal mesh is concerned, but some concerns arise from its coating, after observing high mucostasis (86%) and detachment (9%).

Diastolic Dysfunction With Nondilated Left Atrium

We appreciate the comments by Dr O’Connell and colleagues on our article published in CHEST 1 describing the cumulative incidence and pretransplant risk factors for post-lung transplant renal dysfunction in adult patients with cystic fi brosis (CF). We agree that serum creatinine concentration alone should not be relied upon solely to assess renal function in CF because of its poor sensitivity. Although the use of glomerular fi ltration rate (GFR) estimating equations, such as the Cockcroft-Gault formula and the abbreviated Modifi ed Diet in Renal Disease (aMDRD) equation, represent improvements compared with serum creatinine alone, as they factor in patient age, weight, and sex, these equations still tend to overestimate renal function in CF compared with gold standard measurement techniques. 2 Patients with CF tend to be malnourished compared with the general population, with less muscle mass per body weight. Low muscle mass leads to reduced creatinine pro duction, which results in overestimation of GFR. 3 The estimated 2-year cumulative incidence of post-lung transplant renal dysfunc tion of 35% derived in our study is conservative, since we used the Cockcroft-Gault formula and have likely overestimated renal func tion. Future studies are required to identify more sensitive markers of renal function with less reliance on serum creatinine. We also agree that patients with CF have several unique risk factors for the development of renal dysfunction posttransplant, which may increase their risk relative to patients with idiopathic pulmonary fi brosis or COPD. However, we are not aware of any studies that have specifi cally compared the risk of renal dysfunction in these recipient populations. Our study did not focus on post-lung transplant risk factors, but we appreciate Dr O’Connell and colleagues pointing out that oxalate nephropathy and pigmented tubulopathy are well-recognized histopathologic fi ndings following renal biopsy in the early posttransplant period and are likely related to perioperative stressors such as dehydration, hypoxia, and antibiotics. 4 Our analy sis excluded patients diagnosed with renal dysfunction in the fi rst month post-lung transplant to reduce the chance of includ ing acute cases. Our study found that CF-related diabetes requir ing insulin is an important pretransplant risk factor and likely plays an important role in renal function loss in the late posttransplant period. This is in keeping with a published renal biopsy series, which dem onstrated that histopathologic fi ndings responsible for late epi sodes of renal function loss were primarily vascular (ie, diabetic glomerulosclerosis). 4