Ravindra Mehta

A multicenter study on the utility and safety of EBUS-TBNA and EUS-B-FNA in children.

Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) and endoscopic ultrasound with an echobronchoscope‐guided fine needle aspiration (EUS‐B‐FNA) are useful modalities in the evaluation of mediastinal lymphadenopathy in adults; however, there is sparse data in children. The aim of this multicenter study is to describe the efficacy and safety of EBUS‐TBNA and EUS‐B‐FNA in children with mediastinal lymphadenopathy of undefined etiology.

Consensus and evidence-based Indian initiative on obstructive sleep apnea guidelines 2014 (first edition)

Obstructive sleep apnea (OSA) and obstructive sleep apnea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences among the general public as well as the majority of primary care physicians across India is poor. This necessitated the development of the Indian initiative on obstructive sleep apnea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health and Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep-related symptoms or co-morbidities or ≥15 such episodes without any sleep-related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents, and high-risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers, and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography is the gold standard for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances (OA) are indicated for use in patients with mild to moderate OSA who prefer OA to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioral measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

The safety and efficacy of different methods for obtaining transbronchial lung cryobiopsy in diffuse lung diseases

Most data on transbronchial lung cryobiopsy (TBLC) are from single centers, with little evidence on the outcome of different methods for performing TBLC.

The “Hitch Stitch”: An Effective Method of Preventing Migration in High Tracheal Stenosis

Background: The incidence of caudal stent migration in high tracheal stenting is 13-21% and is common with silicone stents. This can lead to major problems, including emergency repeat procedures. Several antimigration methods are described, but have limitations in terms of their success rate, availability, cost or ease of the procedure. Objectives: We describe an innovative method of stent migration prevention using a simple percutaneous anchoring “hitch stitch”, validated in a large series. Methods: After tracheal stent placement, an Ethilon suture was passed into the stent lumen through an 18-G needle. To take this suture back to the exterior to complete the stitch, a retrieval loop was passed through another 14-G percutaneous cannula inserted into the stent lumen. Bronchoscopically, using a forceps the first suture was pulled inside the loop, the loop was retracted, the suture was exteriorized, and the knot was completed and embedded subcutaneously. While removing the stent, an endoscopic scissor was used to cut the stitch to free the stent. Results: A total of 42 “hitch stitches” were done in 29 patients over 5 years, predominantly for silicone stents. Indications for stenting included postintubation tracheal stenosis (83.3%), malignancy (11.9%) and tracheoesophageal fistula (4.8%, metal stents). The procedure was successful in 41/42 (97.6%) patients. Stitch removal was uncomplicated. Conclusion: This is the largest series of an external stent anchoring procedure as a migration prevention strategy in high tracheal stenting, applicable to both silicone and metal stents. Stent migration prevention using this “hitch stitch” is simple, safe and successful, without any complications during stent removal.

Transesophageal bronchoscopic ultrasound‐guided fine‐needle aspiration (EUS‐B‐FNA)—Pushing the boundaries in the diagnosis

Isolated mediastinal adenopathy is a diagnostic challenge in the paediatric population, often requiring invasive surgical procedures for diagnosis. We describe a novel minimally invasive modality in a 20 month toddler—transesophageal bronchoscopic ultrasound‐guided fine‐needle aspiration (EUS‐B‐FNA). This is the youngest reported use of this modality, highlighting feasibility, technical issues, safety, and rapid diagnosis leading to expedited treatment.

An innovative solution for T-tube obstruction: The tracheostomy-customized stent combination: Replacement Strategy for MTT Obstruction

The Montgomery T‐tube (MTT) is a useful tool for post‐tracheostomy tracheal stenosis. However, MTTs can get blocked. We present a case series of life‐threatening MTT blockage, wherein a split‐function option was implemented, which was a customized silicone Dumon stent above the tracheostomy to maintain both airway and phonation. This tracheostomy–customized stent combination serves the same function as an MTT, with a greater margin of safety due to the easy suctioning capacity of the tracheostomy. With a fenestrated tracheostomy and stent above, speech is effectively preserved. We recommend this strategy in severe MTT blockage as a superior option to regular tracheostomy. Laryngoscope, 1795–1797, 2018

Transbronchial Lung Cryobiopsy for Diagnosis of Pediatric Interstitial Lung Disease

BackgroundTissue diagnosis of Childhood interstitial lung diseases is of paramount importance to outline management.Case characteristicsA 10-year-old boy with prolonged cough, and computed tomography of thorax with features suggestive of primary Langerhans’s cell histiocytosis.InterventionTransbronchial cryobiopsy of lung using flexible cryoprobe, revealed a final diagnosis of Surfactant protein C/ABCA3 deficiency.MessageTransbronchial cryobiopsy of the lung can provide adequate lung tissue for a categorical diagnosis of interstitial lung diseases in children.

Defining expanded areas in EBUS sampling: EBUS guided trans- and intra-pulmonary artery needle aspiration, with review of transvascular EBUS

Endobronchial Ultrasound‐guided Transbronchial Needle Aspiration (EBUS‐TBNA) has revolutionized the diagnostic approach to mediastinal diseases. Lesions located lateral to the pulmonary artery (trans‐PA, Station 5), or in the lumen of the PA (intra‐PA) are in the ‘blind‐spot’ of EBUS.

Placement of tracheobronchial silicone Y-stents: Multicenter experience and systematic review of the literature

Background: Airway obstruction or tracheoesophageal fistula (TEF) near the tracheal carina requires placement of Y-shaped stents. Herein, we describe our multicenter experience with the placement of Dumon silicone Y-stents. We also conduct a systematic review for studies describing the deployment of airway silicone Y-stents. Methods: This was a retrospective analysis of consecutive subjects who underwent placement of silicone Y-stents. The clinical details including the underlying diagnosis, indication for the placement of silicone Y-stents, success of stent placement, and follow-up are presented. The PubMed and EMBASE databases were also reviewed for studies describing the placement of silicone Y-stents. Results: During the study, 27 silicone Y-stents were placed. The mean (standard deviation) age of the study population (85.2% males) was 57.7 (13.5) years. The stents were placed for airway obstruction in 77.8% and TEF in 29.6% of the patients. The most common underlying disease was carcinoma of the esophagus. The degree of airway obstruction was grade 3–4 in 18 subjects, and respiratory failure was encountered in 18 subjects. The stent was deployed successfully in all the subjects. No deaths were encountered during stent placement. Most subjects had rapid relief of symptoms following the procedure. Excessive secretions and mucostasis were the most common stent-related complications followed by the development of granulation tissue. The systematic review yielded nine studies (338 subjects with airway obstruction and/or TEF). The most common indication for silicone Y-stent placement was tracheobronchial obstruction and TEF due to malignancy. Benign disorders that necessitated stent placement included postintubation tracheal stenosis, airway malacia, and others. The stent was successfully placed in 98% with only one periprocedural death. Granulation tissue formation and mucostasis were the most common stent-related complications. Conclusion: Placement of silicone Y-stent is a safe and effective procedure that provides quick relief of symptoms in subjects presenting with airway obstruction and TEF at or near the tracheal carina.

Conventional Transbronchial Needle Aspiration: The Original Guard Who Still Has a Role in Mediastinal Lymph Node Sampling

Introduction: Conventional transbronchial needle aspiration (C-TBNA) is the originally described method for sampling mediastinal lymph nodes (MLN). After the advent of endobronchial ultrasound, the practice and reports of C-TBNA have dwindled. We report a large series of C-TBNA from the Indian subcontinent, highlighting aspects such as pathological spectrum, yield and complications, and reiterating its relevance in MLN sampling. Methods: The study population included 400 consecutive patients over 6.8 years who had C-TBNA done for MLN ≥1 cm in size. C-TBNA was done using a 19-G needle, with conscious sedation. A maximum of 7 passes per node were done. Rapid-on-site evaluation was done in >95% cases. Lymph nodes sampled were labeled “adequate” if lymphocytes were present, and “diagnostic” if a definitive diagnosis was made. Results: The study included 228 males and 172 females, mean age 49.4±14.7 years. The “adequacy” rate was 383/400 (95.75%), and “diagnostic” yield was 347/400 (86.75%). C-TBNA was the sole diagnostic modality in 215/400 (53.75%) patients. The diagnoses included tuberculosis (43%), sarcoidosis (25.5%) and malignancy (18.25%). Complications were rare. Conclusions: This is one of the largest studies of C-TBNA in literature, and one of the few studies to define accurate pathologic diagnosis of enlarged MLN in India. This is also the one of the largest series to define the yield of TBNA with rapid-on-site evaluation in MLN sampling. Currently, in many parts of the world, C-TBNA is still the most common MLN sampling procedure, from an availability, expertise, economic, and safety perspective.