Rahul Khosla

Bedside Lung Ultrasound in Emergency (BLUE) Protocol: A Suggestion to Modify

1the authors describe the use of lung ultrasound in evaluating patients with acute respiratory failure. The algorithmic approach Bedside Lung Ultrasound in Emergency, the BLUE protocol, is described with a diagnostic accuracy of 90.5%. Three hundred and one consecutive patients with acute respiratory failure were assessed; 260 were included (cardiogenic pulmonary edema, 64; pneumonia, 83; decompensated COPD, 49; acute asthma, 34; pulmonary embolism, 21; and pneumothorax, 9) and 41 were excluded from the study (rare causes, 9; no fi nal diagnosis, 16; and several fi nal diagnoses, 16). Among all the patients with a fi nal diagnosis, there was not a single patient with diaphragm paralysis. This could be because of the design of the BLUE protocol, as it does not have assessment of diaphragm function as a step in the algorithm. Diaphragm paralysis, although not a common cause of acute respiratory failure, is likely underdiagnosed, and it is not unusual for an intensivist to come across such a case. Diaphragm paralysis can be diagnosed with the use of bedside ultrasound. 2 , 3 Unilateral diaphragm dysfunction is easier to diagnose than bilateral and, in the presence of comorbid conditions, can be a cause of acute respiratory failure. Trauma (surgical or nonsurgical) and malignancy involving the phrenic nerve are common causes of diaphragm paralysis. 4 The assessment of diaphragm function in patients with these conditions and respiratory distress is important. I came across two cases with acute hypercapnic respiratory failure who had unilateral diaphragm paralysis (one left and one right), as seen on ultrasound and fl uoroscopy examination. In both cases, unilateral diaphragm paralysis was considered to be the main reason for respiratory failure, but comorbid conditions were believed to be contributory. I have been using the BLUE protocol in my clinical practice and have found it be helpful in bedside evaluation of patients with acute respiratory distress. I suggest that the addition of diaphragm function assessment, a simple technique, as a step in the BLUE protocol will enhance its diagnostic accuracy.

Ultrasound-guided Fine Needle Aspiration Biopsy of Pleural-based Intrathoracic Lesions.

BackgroundPleural-based intrathoracic lesions pose a diagnostic challenge. Image-guided percutaneous biopsy with fluoroscopy, computed tomography (CT) scan, and ultrasound (US) have been used to establish a diagnosis. We report the yield of US-guided fine needle aspiration biopsy (FNAB) of these lesions at our center. MethodsTwenty patients with pleural-based intrathoracic lesions underwent US-guided FNAB. All were considered to have an unresectable malignant process based on clinical evaluation. Nineteen patients had pleural-based parenchymal lesion and 1 had an anterior mediastinal mass touching the chest wall. ResultsTwenty patients underwent 21 US-guided FNAB procedures. A final diagnosis was established in all the patients: 19 malignancies and 1 benign lesion. US-guided FNAB established a diagnosis of malignancy in 17 of 19 patients (89.5%) in the first attempt. In 1 patient, a diagnosis of malignancy was made on a repeat US-guided FNAB, increasing the overall yield to 18 of 19 (95%). In 1 patient with a nondiagnostic US-guided FNAB, a diagnosis of malignancy was established with CT scan-guided FNAB. US-guided FNAB was able to diagnose 15 of 16 cases of non-small cell carcinoma and 3 of 3 (100%) small cell carcinoma. In 1 patient with benign lesion, US-guided FNAB showed pulmonary macrophages. This patient was diagnosed as having pneumonia after antibiotic therapy and repeat CT scan showed complete resolution. For a diagnosis of malignancy, US-guided FNAB had 94.7% sensitivity, 100% specificity, 95% diagnostic accuracy, 100% positive predictive value, and 50% negative predictive value. There were no major complications. ConclusionsUS-guided FNAB of pleural-based intrathoracic lesions is a rapid, simple, and safe procedure with a high yield for malignancy.

The minimum volume of pleural fluid required to diagnose malignant pleural effusion: A retrospective study.

Background: Pleural fluid cytology is a quick and accurate method to diagnose malignant pleural effusions. The optimal volume of fluid for cytological analysis has not yet been identified, and clinical recommendation based on some published clinical experiences has been to send large volumes of fluid for cytological analysis. A quality improvement initiative at our institution was conducted to determine the volume of fluid sufficient for a diagnosis of malignant pleural effusion. Materials and Methods: The study was approved by the Institutional Review Board. All pleural fluid specimens that were divided into three volumes (25 mL, 50 mL, and 150 mL) and sent for cytological examination were reviewed. Results: A total of 74 samples from 60 individual patients were evaluable. Thirty-six patients (60%) had a previous diagnosis of malignancy. Of the 74 specimens, 26 (35.1%) were positive for malignancy. The detection rate for malignant pleural effusion by cytology for 25 mL, 50 mL, and 150 mL were 88.5%, 96.2%, and 100.0%, respectively (P = 0.16). Two specimens that were negative in the 25 mL samples turned out to be positive in the 50 mL and 150 mL samples. One specimen was negative in the 25 mL and 50 mL samples but positive in the 150 mL sample. Conclusions: Our study did not show any statistically significant difference in the detection of malignant effusion in the 25 mL, 50 mL, and 150 mL group.

Pleural fluid procalcitonin to distinguish infectious from noninfectious etiologies of pleural effusions

In this study we investigate the diagnostic value of pleural fluid procalcitonin (PCT) in distinguishing infectious and noninfectious etiologies of pleural effusion. We reviewed the medical records of 75 hospitalized patients who underwent thoracentesis between 2011 and 2012. Data on pleural fluid lactate dehydrogenase (LDH), protein, albumin, cell count and differential, pH, Gram stain and culture, cytology, triglyceride, cholesterol, amylase, and PCT were collected. Data on serum LDH, protein, albumin, prothrombin time, normalized, and blood culture were also collected. Pleural effusions were classified into 2 groups, infectious and noninfectious. There were 18 infectious pleural effusions (IPE) and 57 noninfectious pleural effusions (NIPE). Median pleural fluid PCT was 1.088 ng/mL (0.312-2.940 ng/mL) in IPE and 0.123 ng/mL (0.05-0.263 ng/mL) in NIPE, with a P value < 0.0001. Pleural fluid PCT > 0.25 ng/mL had a sensitivity of 77.78% and specificity of 74.14% for diagnosing an IPE. A subgroup analysis of PCT in exudative infectious effusions versus exudative noninfectious malignant/paramalignant effusions showed higher levels in the former. PCT is a novel biomarker for diagnosing infectious pleural effusion, and it would be worthwhile to investigate the role of pleural PCT in assessing severity of illness, risk stratification, and antibiotic stewardship in hospitalized patients with pleural effusions. Journal of Hospital Medicine 2016;11:363-365. 2016 Society of Hospital Medicine.

A case of massive airway clotting after use of activated factor VII for massive hemoptysis: management with flexible bronchoscopy and cryoadhesion.

This case describes the use of flexible bronchoscopy and cryoadhesion in an 83-year-old man who developed large airway clots following treatment with activated factor VII for a complication of pulmonary hemorrhage during coronary artery bypass graft.

Metastatic endobronchial melanoma.

patients [1] . The most frequent nonpulmonary primary tumors with endobronchial metastases are breast, kidney and colon. Malignant melanoma is known to metastasize to the lung with isolated lung metastases found in 19% of patients with melanoma [2] . The radiographic characteristics of pulmonary melanoma are varied and include endobronchial masses, solitary or multiple pulmonary nodules and a miliary pattern. A 68-year-old male with a history of left thumb melanoma treated by amputation 12 years ago presented with a 6-month history of nonproductive cough. The patient denied hemoptysis, chest pain and weight loss. Physical examination, including skin exam, was normal. Chest Xray showed a right upper lung zone mass. Chest CT revealed the 6.3 ! 4.0 cm right upper lobe mass ( fig. 1 ) as well as multiple nodules in all lung lobes. Bronchoscopy revealed multiple pigmented lesions throughout the trachea ( fig. 2 ) and distal airways bilaterally, typical of endobronchial melanoma. Biopsies of the largest distal tracheal lesion as well as the right upper lobe lesion were performed. Biopsy specimens from both sites were human melanoma black 45 positive by immunohistochemistry. Endobronchial metastases from nonpulmonary primary malignancies are rare, occurring in less than 2% of Published online: January 5, 2007

Ultrasound-guided versus computed tomography-scan guided biopsy of pleural-based lung lesions

Background: Computed tomography (CT) guided biopsies have long been the standard technique to obtain tissue from the thoracic cavity and is traditionally performed by interventional radiologists. Ultrasound (US) guided biopsy of pleural-based lesions, performed by pulmonologists is gaining popularity and has the advantage of multi-planar imaging, real-time technique, and the absence of radiation exposure to patients. In this study, we aim to determine the diagnostic accuracy, the time to diagnosis after the initial consult placement, and the complications rates between the two different modalities. Methods: A retrospective study of electronic medical records was done of patients who underwent CT-guided biopsies and US-guided biopsies for pleural-based lesions between 2005 and 2014 and the data collected were analyzed for comparing the two groups. Results: A total of 158 patients underwent 162 procedures during the study period. 86 patients underwent 89 procedures in the US group, and 72 patients underwent 73 procedures in the CT group. The overall yield in the US group was 82/89 (92.1%) versus 67/73 (91.8%) in the CT group (P = 1.0). Average days to the procedure was 7.2 versus 17.5 (P = 0.00001) in the US and CT group, respectively. Complication rate was higher in CT group 17/73 (23.3%) versus 1/89 (1.1%) in the US group (P < 0.0001). Conclusions: For pleural-based lesions the diagnostic accuracy of US guided biopsy is similar to that of CT-guided biopsy, with a lower complication rate and a significantly reduced time to the procedure.

Endobronchial Ultrasonography vs Conventional Transbronchial Needle Aspiration in the Diagnosis of Sarcoidosis

1 . Jantz MA . The old and the new of sedation for bronchoscopy . Chest . 2009 ; 135 ( 1 ): 4 6 . 2 . US Food and Drug Administration. Lusedra (Fospropofol disodium) prescribing information. http :// www . accessdata . fda . gov / drugsatfda_docs / label / 2008 / 022244lbl . pdf . Accessed July 31, 2009 . 3 . Silvestri GA , Vincent BD , Wahidi MM , Robinette E , Hansbrough JR , Downie GH . A phase 3, randomized, doubleblind study to assess the effi cacy and safety of fospropofol disodium injection for moderate sedation in patients undergoing fl exible bronchoscopy . Chest . 2009 ; 135 ( 1 ): 41 47 . 4 . Cohen LB . Clinical trial: a dose-response study of fospropofol disodium for moderate sedation during colonoscopy . Aliment Pharmacol Ther . 2008 ; 27 ( 7 ): 597 608 . American College of Chest Physicians ( www . chestjournal . org / site / misc / reprints . xhtml ). DOI: 10.1378/chest.09-1825