Ray W. Shepherd

Technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration CHEST guideline and expert panel report

BACKGROUND Endobronchial ultrasound (EBUS) was introduced in the last decade, enabling real-time guidance of transbronchial needle aspiration (TBNA) of mediastinal and hilar structures and parabronchial lung masses. The many publications produced about EBUS-TBNA have led to a better understanding of the performance characteristics of this procedure. The goal of this document was to examine the current literature on the technical aspects of EBUS-TBNA as they relate to patient, technology, and proceduralist factors to provide evidence-based and expert guidance to clinicians. METHODS Rigorous methodology has been applied to provide a trustworthy evidence-based guideline and expert panel report. A group of approved panelists developed key clinical questions by using the PICO (population, intervention, comparator, and outcome) format that addressed specific topics on the technical aspects of EBUS-TBNA. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and well-recognized document evaluation tools were used to assess the quality of included studies, to extract meaningful data, and to grade the level of evidence to support each recommendation or suggestion. RESULTS Our systematic review and critical analysis of the literature on 15 PICO questions related to the technical aspects of EBUS-TBNA resulted in 12 statements: 7 evidence-based graded recommendations and 5 ungraded consensus-based statements. Three questions did not have sufficient evidence to generate a statement. CONCLUSIONS Evidence on the technical aspects of EBUS-TBNA varies in strength but is satisfactory in certain areas to guide clinicians on the best conditions to perform EBUS-guided tissue sampling. Additional research is needed to enhance our knowledge regarding the optimal performance of this effective procedure.

Thoracentesis and Thoracic Ultrasound: State of the Art in 2013

Thoracentesis is one of the most common medical procedures performed today. With the advent of thoracic ultrasound, thoracentesis has been enhanced with additional preprocedural, intraprocedural, and postprocedural information. The authors review modern-day thoracentesis and the use of ultrasonography. Nearly 200,000 thoracenteses are performed among 1.5 million patients with pleural effusion each year. A solid foundation in didactic knowledge and procedural proficiency is important to avoid unwanted complications. Ultrasound has become an indispensable tool to guide performance of thoracentesis. Ultrasonography for this purpose has several advantages. The authors provide a contemporary review on thoracentesis and the use of ultrasonography.

Endobronchial ultrasound diagnosis of pulmonary embolism.

A 68-year-old woman presented for mediastinal lymph node sampling while undergoing work up for a solitary pulmonary nodule. During endobronchial ultrasound examination of the airways, an echogenic abnormality was noted within the right pulmonary artery. The patient underwent computed tomography angiography of the chest, and diagnosis of pulmonary embolism was confirmed. We describe endobronchial ultrasound evaluation of a pulmonary embolus.

Severe Tracheal Compression Causing Respiratory Failure After Transhiatal Esophagectomy

Complications after transhiatal esophagectomy include pneumonia, recurrent laryngeal nerve injury, and anastomotic leak. Although damage to the trachea is a potential complication, there are minimal reports of tracheal compression after esophagectomy with gastric pull-through. We report a case of severe tracheal compression and obstruction requiring mechanical ventilation presenting 2 days postoperatively. Placement of a silicone tracheal stent relieved the obstruction in the distal trachea and facilitated extubation.

Construct validity of the Simbionix bronch mentor simulator for essential bronchoscopic skills.

Background:Although simulation-based bronchoscopy has been shown to be an effective training modality, formal assessment should still be performed as new technology emerges. We sought to validate a simulator in essential bronchoscopic tasks, and survey perceptions of bronchoscopists on simulation. Methods:A cohort study at 2 medical centers used 3 groups to assess construct validity of the Simbionix Bronchoscopy Simulator: 7 first-year fellows with <10 bronchoscopies each (novice), 6 pulmonologists with 200 to 1000 bronchoscopies each (experienced), and 7 pulmonologists with >1000 bronchoscopies each (expert). Participants were tested in 4 tasks (1: scope manipulation, 2: guided anatomic navigation, 3: airway anatomy, and 4: lymph node anatomy). Participants were scored and surveyed on their impressions of simulation. The means and Kruskal-Wallis test among groups were compared by task item (P<0.05). Results:There were statistically significant differences in mean ranks among groups for tasks 1 and 3. For task 1, final score, time, mid-lumen time, and wall hits were discriminative (P=0.006, 0.006, 0.012, and 0.014, respectively). For task 3, time, bronchial segments identified, bronchial segments incorrectly identified, and bronchial segments skipped were discriminative (P=0.04, 0.012, 0.013, and 0.013, respectively). There was no statistically significant difference for task 2 and task 4. All participants agreed that simulation training is helpful and should be incorporated into bronchoscopic training. Conclusions:The simulator demonstrated validity in differentiating skill in scope manipulation and airway anatomy, but did not discriminate skill levels in anatomic orientation or identification of lymph nodes. Bronchoscopy simulation was viewed as helpful by all levels and should be considered before performance on patients.

Exophytic Tracheal Mass. A Rare Presentation of Rosai–Dorfman Disease

A 77-year-old female with a history of previously treated breast cancer presented with intractable cough for 6 weeks and no other associated symptoms. Physical examination disclosed coarse breath sounds throughout both lung fields, but no wheezing or stridor. Routine laboratory studies were notable only for an elevated white blood count of 12,400/ml with 86.3% neutrophils. Computed tomographic chest imaging (Figure 1) showed a roughly spherical exophytic mass arising from the anterior wall of the trachea with near occlusion of the airway. Associated mediastinal and left hilar adenopathy was also observed. Given the history of breast cancer, metastatic disease was considered a strong possibility. A primary tracheal malignancy was also considered as part of the differential diagnosis. As the patient was stable, flexible fiberoptic bronchoscopy was performed in the bronchoscopy suite under moderate sedation. The lesion was visualized in the mid-trachea (Figure 2). An electrocautery snare (Olympus, Center Valley, PA) was then used to ablate and debulk the mass (Figure 3). The patient tolerated the procedure uneventfully. The next day, she was taken to the operating room. With the assistance of an anesthesiologist, she underwent direct intubation with a rigid tracheoscope (BryanDumon 12/11 mm; Bryan Corporation, Woburn, MA) under general anesthesia. Jet ventilation was used throughout the procedure. The remaining tumor was cored out with the rigid scope. A Xomed microdebrider (Medtronic, Minneapolis, MN) was used to further shave down the tumor along the anterior and lateral walls of the trachea. Argon plasma coagulation was used on the residual tumor surface to achieve coagulation (Figure 4). There was no bleeding and the patient was extubated uneventfully. Histological examination of biopsy samples showed that the mass consisted predominantly of large histiocytes with ample finely vacuolated eosinophilic cytoplasm. A mixed inflammatory infiltrate consisting of lymphocytes, plasma cells, and neutrophils was interspersed in between the large cells. Emperipolesis was noted (Figure 5). Immunohistochemical stains were positive for CD68 and S-100 (Figure 5) and negative for pan-cytokeratin AE1/AE3 and pan-melanoma cocktail. The morphology and immune profile of the mass confirmed a diagnosis of Rosai–Dorfman disease. Adjunct treatment with prednisone (60 mg daily for 2 wk) was initiated and she was discharged home. Repeat imaging 5 months later showed that the tumor had regrown. Low-dose radiation therapy (20 Gy

The Use of Octreotide to Manage Symptoms of Bronchorrhea: A Case Report

Octreotide, a synthetic analogue of the hormone somatostatin, is primarily used in palliative medicine because of its antisecretory effect and has been shown to be effective in the management of bowel obstruction, nausea, and diarrhea. Octreotide also has been successfully used for the management of bronchorrhea in both inpatient and outpatient settings. We report the case of a 47-year-old female with a history of bronchioloalveolar cell carcinoma whose copious bronchial secretions were controlled with octreotide. Octreotide should be further evaluated as a first-line treatment for bronchorrhea.

Palliative Interventional Pulmonology Procedures in the Incarcerated Population with Cancer: A Case Series

RationaleCancer is the second most common cause of death in incarcerated population and lung cancer is the most common cause of cancer death in this group. Inmates are excluded from most published surveys and research, thus the effectiveness of lung cancer palliation in this population is not known.ObjectiveTo report the feasibility and safety of palliative interventional pulmonary procedures in inmates with cancer.Study DesignRetrospective review of registry data from a single center.Materials and MethodsInmate data on prospectively enrolled data registry (2009–2012) from the interventional pulmonology procedural registry at Virginia Commonwealth University was extracted and analyzed for safety and efficacy. Inmates with lung cancer and advanced malignancies with pleural or airway metastasis requiring airway debulking (mechanical/thermal), airway stenting, and tunneled pleural catheter (TPC) placement were included in the analysis.ResultsA total of 16 procedures were performed in 12 incarcerated patients. These included six TPC placements in six patients. Ten procedures were performed in seven patients with airway obstruction. These procedures included rigid and flexible bronchoscopy with mechanical (rigid and balloon dilation) and thermal (laser, argon plasma coagulation, and cautery) tumor debulking and dilation, airway stenting, and tracheostomy in one case. All six TPC patients had immediate symptomatic relief and improved lung aeration on chest radiograph. Three of six patients had successful auto-pleurodesis. In the seven patients with airway obstruction, three patients reported symptomatic relief and one had resolution of post-obstructive pneumonia. No immediate- or long-term procedure-related complications were reported.ConclusionIncarcerated patients with advanced malignancy may benefit from interventional pulmonology procedures with low complications. Palliative interventional pulmonology procedures in inmates should not be withheld solely on their incarceration status.