Robert J. Lentz

Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill

RATIONALE Hypoxemia is common during endotracheal intubation of critically ill patients and may predispose to cardiac arrest and death. Administration of supplemental oxygen during laryngoscopy (apneic oxygenation) may prevent hypoxemia. OBJECTIVES To determine if apneic oxygenation increases the lowest arterial oxygen saturation experienced by patients undergoing endotracheal intubation in the intensive care unit. METHODS This was a randomized, open-label, pragmatic trial in which 150 adults undergoing endotracheal intubation in a medical intensive care unit were randomized to receive 15 L/min of 100% oxygen via high-flow nasal cannula during laryngoscopy (apneic oxygenation) or no supplemental oxygen during laryngoscopy (usual care). The primary outcome was lowest arterial oxygen saturation between induction and 2 minutes after completion of endotracheal intubation. MEASUREMENTS AND MAIN RESULTS Median lowest arterial oxygen saturation was 92% with apneic oxygenation versus 90% with usual care (95% confidence interval for the difference, -1.6 to 7.4%; P = 0.16). There was no difference between apneic oxygenation and usual care in incidence of oxygen saturation less than 90% (44.7 vs. 47.2%; P = 0.87), oxygen saturation less than 80% (15.8 vs. 25.0%; P = 0.22), or decrease in oxygen saturation greater than 3% (53.9 vs. 55.6%; P = 0.87). Duration of mechanical ventilation, intensive care unit length of stay, and in-hospital mortality were similar between study groups. CONCLUSIONS Apneic oxygenation does not seem to increase lowest arterial oxygen saturation during endotracheal intubation of critically ill patients compared with usual care. These findings do not support routine use of apneic oxygenation during endotracheal intubation of critically ill adults. Clinical trial registered with www.clinicaltrials.gov (NCT 02051816).

Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults.

Objective:To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults. Design:A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows. Setting:Medical ICU in a tertiary, academic medical center. Patients:Critically ill patients 18 years old or older. Interventions:Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation. Measurements and Main Results:Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator’s previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82–5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy. Conclusions:In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.

Transbronchial cryobiopsy for diffuse parenchymal lung disease: a state-of-the-art review of procedural techniques, current evidence, and future challenges

Transbronchial lung biopsy with a cryoprobe, or cryobiopsy, is a promising new bronchoscopic biopsy technique capable of obtaining larger and better-preserved samples than previously possible using traditional biopsy forceps. Over two dozen case series and several small randomized trials are now available describing experiences with this technique, largely for the diagnosis of diffuse parenchymal lung disease (DPLD), in which the reported diagnostic yield is typically 70% to 80%. Cryobiopsy technique varies widely between centers and this predominantly single center-based retrospective literature heterogeneously defines diagnostic yield and complications, limiting the degree to which this technique can be compared between centers or to surgical lung biopsy (SLB). This review explores the broad range of cryobiopsy techniques currently in use, their rationale, the current state of the literature, and suggestions for the direction of future study into this promising but unproven procedure.

Transbronchial Cryobiopsy Can Diagnose Constrictive Bronchiolitis in Veterans of Recent Conflicts in the Middle East.

Transbronchial lung biopsy with a cryoprobe, or cryobiopsy, provides larger tissue samples than traditional forceps biopsy (1, 2). Investigations of this technique in diffuse parenchymal lung diseases have reported favorable results, with diagnostic yield similar to surgical lung biopsy, while maintaining the safety profile of traditional bronchoscopic biopsy (1–8). We hypothesized that cryobiopsy would be able to diagnose other conditions poorly evaluated by traditional transbronchial biopsy, including the bronchiolitides (9). Since describing the phenomenon in 2011 (10), our institution has maintained an interest in postdeployment constrictive bronchiolitis affecting veterans returning from recent conflicts in the Middle East. This series represents our initial investigation into the use of cryobiopsy as a possible alternative to surgical lung biopsy for establishing this diagnosis. An abbreviated version of this work was presented as a poster discussion at the ATS Conference in 2015 (11).

A Multicenter Randomized Trial of a Checklist for Endotracheal Intubation of Critically Ill Adults

BACKGROUND: Hypoxemia and hypotension are common complications during endotracheal intubation of critically ill adults. Verbal performance of a written, preintubation checklist may prevent these complications. We compared a written, verbally performed, preintubation checklist with usual care regarding lowest arterial oxygen saturation or lowest systolic BP experienced by critically ill adults undergoing endotracheal intubation. METHODS: A multicenter trial in which 262 adults undergoing endotracheal intubation were randomized to a written, verbally performed, preintubation checklist (checklist) or no preintubation checklist (usual care). The coprimary outcomes were lowest arterial oxygen saturation and lowest systolic BP between the time of procedural medication administration and 2 min after endotracheal intubation. RESULTS: The median lowest arterial oxygen saturation was 92% (interquartile range [IQR], 79‐98) in the checklist group vs 93% (IQR, 84‐100) with usual care (P = .34). The median lowest systolic BP was 112 mm Hg (IQR, 94‐133) in the checklist group vs 108 mm Hg (IQR, 90‐132) in the usual care group (P = .61). There was no difference between the checklist and usual care in procedure duration (120 vs 118 s; P = .49), number of laryngoscopy attempts (one vs one attempt; P = .42), or severe life‐threatening procedural complications (40.8% vs 32.6%; P = .20). CONCLUSIONS: The verbal performance of a written, preprocedure checklist does not increase the lowest arterial oxygen saturation or lowest systolic BP during endotracheal intubation of critically ill adults compared with usual care. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02497729; URL: www.clinicaltrials.gov.

Acute exacerbations of interstitial lung disease: Don't just do something, stand there!: Editorial

See article, page 352

Foreign body aspiration in adult airways: therapeutic approach

Tracheobronchial foreign body (FB) aspiration is an uncommon but potentially life-threatening event in adults. Symptoms typically consist of a choking event followed by cough and dyspnea, however, these findings are inconsistent and symptoms may mimic more chronic lung diseases such as asthma or chronic obstructive pulmonary disease. Chest radiography and computed tomography can provide information regarding the location and characteristics of foreign bodies and aid in diagnosis. Bronchoscopy remains the gold standard for diagnosis and management of FB aspiration. The authors describe the typical clinical presentation, diagnostic evaluation, and bronchoscopic management of foreign bodies in adult airways with a focus on bronchoscopic techniques and potential complications of FB extraction.

Cannulation of the Internal Thoracic Artery with a Central Venous Catheter

Figure 2. Digital subtraction angiography as contrast dye is injected into the central venous catheter confirms cannulation of the internal thoracic artery (at the solid arrow) several centimeters distal to its origin from the subclavian artery (dashed arrow). A 68-year-old man with Crohn’s disease and receiving adalimumab transferred to our institution for respiratory failure and shock complicating an influenza-like illness. He was intubated, and a right internal jugular central venous catheter (CVC) was placed under ultrasound guidance by house staff after three vessel cannulation attempts. Predilation, the position of the wire was misinterpreted as being within the internal jugular on the basis of ultrasound. The post-procedure chest radiograph appeared deceptively normal (Figure 1). Routine transduction for central venous pressure, however, revealed an arterial waveform. Contrast injection demonstrated the CVC to be within the internal thoracic artery (Figure 2). Computed tomography further delineated the path of the catheter (Figures 3 and 4), but the exact track from neck to internal thoracic artery remained unclear (Video 1). The patient died of progressive respiratory failure before planned surgical catheter removal. Antemortem cultures eventually grew Histoplasma capsulatum.

Interstitial Pneumonia with Autoimmune Features: An emerging challenge at the intersection of rheumatology and pulmonology

Interstitial lung disease (ILD) remains a cause of significant morbidity and mortality in patients with connective tissue disease (CTD)–associated ILD. While some patients meet clear classification criteria for a systemic rheumatic disease, a subset of patients do not meet classification criteria but still benefit from immunosuppressive therapy. In 2015, the American Thoracic Society and European Respiratory Society described classification criteria for interstitial pneumonia with autoimmune features (IPAF) to identify patients with lung‐predominant CTD who lack sufficient features of a systemic rheumatic disease to meet classification criteria. Although these criteria are imperfect, they are an important attempt to classify the patient with undifferentiated disease for future study. Rheumatologists play a key role in the evaluation of potential IPAF in patients, especially as many patients with a myositis‐spectrum disease (e.g., non–Jo‐1 antisynthetase syndrome, anti–melanoma differentiation–associated protein 5 antibody inflammatory myositis, or anti–PM/Scl antibody–associated inflammatory myositis) would be classified under IPAF using the currently available criteria for inflammatory myositis, and would therefore benefit from rheumatologic comanagement. The aim of this review was to describe the historical context that led to the development of these criteria and to discuss the limitations of the current criteria, diagnostic challenges, treatment options, and strategies for disease monitoring.

Diagnostic approach to pleural diseases: new tricks for an old trade

The burden of pleural diseases has substantially increased in the past decade because of a rise in the incidence of pleural space infections and pleural malignancies in a patient population that is older and more immunocompromised and has more comorbidities. This complexity increasingly requires minimally invasive diagnostic options and tailored management. Implications for patients are such that the limitations of current diagnostic methods need to be addressed by multidisciplinary teams of investigators from the fields of imaging, biology, and engineering. Ignored for a long time as an epiphenomenon at the crossroad of many unrelated medical problems, pleural diseases are finally getting the attention they deserve and have spurred a vibrant and exciting field of research.