Sixto Arias

Comparison of Pleural Pressure Measuring Instruments

OBJECTIVE The objective of this study was to compare the accuracy of a handheld digital manometer (DM) and U-tube (UT) manometer with an electronic transducer (ET) manometer during thoracentesis. METHODS Thirty-three consecutive patients undergoing thoracentesis were enrolled in the study. Pleural pressure (Ppl) measurements were made using a handheld DM (Compass; Mirador Biomedical), a UT water manometer, and an ET (reference instrument). End-expiratory Ppl was recorded after catheter insertion, after each aspiration of 240 mL, and prior to catheter removal. Volume of fluid removed, symptoms during thoracentesis, pleural elastance, and pleural fluid chemistry were also evaluated. RESULTS A total of 594 Ppl measurements were made in 30 patients during their thoracenteses. There was a strong linear correlation coefficient between elastance for the DM and ET (r = 0.9582, P < .001). Correlation was poor between the UT and ET (r = 0.0448, P = .84). Among the 15 patients who developed cough, recorded ET pressures ranged from -9 to +9 cm H2O at the time of symptom development, with a mean (SD) of -2.93 (4.89) cm H2O. ET and DM measurements among those patients with cough had a low correlation between these measurements (R2 = 0.104, P = .24). Nine patients developed chest discomfort and had ET pressures that ranged from -26 to +6 cm H2O, with a mean (SD) of -7.89 (9.97) cm H2O. CONCLUSIONS The handheld DM provided a valid and easy-to-use method to measure Ppl during thoracentesis. Future studies are needed to investigate its usefulness in predicting clinically meaningful outcomes.

Diagnosis and management of pulmonary nodules

There are an increased number of pulmonary nodules discovered on CT scan images in part due to those performed for lung cancer screening. Risk stratification and patient involvement is critical in determining management ranging from interval imaging to invasive biopsy or surgery. A definitive diagnosis requires tissue biopsy. The choice of a particular biopsy technique depends on the risks/benefits of the procedure, the diagnostic yield and local expertise. This review will focus on the evaluation and management of pulmonary nodules based on the Fleischner Society and American College of Chest Physician guidelines. There have been recent changes to both societies’ recommendations for incidental detection of solid and subsolid nodules, risk stratification, imaging, minimally invasive diagnostic techniques and definitive surgical options.

Electromagnetic navigation transthoracic needle aspiration for the diagnosis of pulmonary nodules: a safety and feasibility pilot study

BACKGROUND Pulmonary nodules remain a diagnostic challenge for physicians. Minimally invasive biopsy methods include bronchoscopy and CT guided transthoracic needle aspiration (TTNA). A novel electromagnetic guidance transthoracic needle aspiration (ETTNA) procedure which can be combined with navigational bronchoscopy (NB) and endobronchial ultrasound (EBUS) in a single setting has become available. METHODS A prospective pilot study examining the safety, feasibility and diagnostic yield of ETTNA in a single procedural setting. All patients enrolled underwent EBUS for lung cancer staging followed by NB and ETTNA. Feasibility of performing ETTNA and a safety assessment by recording procedural related complications including pneumothorax or bleeding was performed. Diagnostic yield of ETTNA defined by a definitive pathologic tissue diagnosis was recorded. An additional diagnostic yield analysis was performed using a cohort analysis of combined interventions (EBUS + NB + ETTNA). All non-diagnostic biopsies were either followed with radiographic imaging or a surgical biopsy was performed. RESULTS Twenty-four subjects were enrolled. ETTNA was feasible in 96% of cases. No bleeding events occurred. There were five pneumothoraces (21%) of which only two (8%) subjects required drainage. The diagnostic yield for ETTNA alone was 83% and increased to 87% (P=0.0016) when ETTNA was combined with NB. When ETTNA and NB were performed with EBUS for complete staging, the diagnostic yield increased further to 92% (P=0.0001). CONCLUSIONS This is the first human pilot study demonstrating an acceptable safety and feasibility profile with a novel ETTNA system. Further studies are needed to investigate the increased diagnostic yield from this pilot study.

Utilization of the International Association for the Study of Lung Cancer and Wang's nodal map for the identification of mediastinum and hilar lymph nodes

Transbronchial needle aspiration (TBNA), serving as a remarkably invaluable and minimally invasive technique, has been widely used for the diagnosis and staging of mediastinal adenopathy and masses. To date, the International Association for the Study of Lung Cancer (IASLC) and Wangs nodal map are two well‐documented intrathoracic lymph node guidelines for the TBNA procedure.

A Quality Improvement Intervention to Reduce Indwelling Tunneled Pleural Catheter Infection Rates

RATIONALE The indwelling tunneled pleural catheter has altered the management of patients with dyspnea related to malignant pleural effusions. However, indwelling tunneled pleural catheter placement does not remain free from risk. The most commonly reported risk is infection. OBJECTIVES The aim of this paper is to describe our continuous quality improvement program for infection rate recognition, the process changes implemented for improvement, and subsequent outcomes. METHODS All patients undergoing indwelling tunneled pleural catheter placement at The Johns Hopkins Medical Institutions between May 2009 and April 2014 were identified. The primary outcome was the incidence of infection within the preintervention and intervention cohorts. Intervention was identified as use of preoperative antibiotics, full sterile draping, and limiting placement to a single defined location. MEASUREMENTS AND MAIN RESULTS A total of 225 indwelling tunneled pleural catheter placements were performed in 201 patients during the study period, and the overall infection rate was 5.8%. During the preintervention period, 134 placements were performed, and 91 placements occurred during the intervention period. A preintervention infection rate was identified as 8.2%, with a significant decrease to 2.2% (P = 0.049) within the intervention cohort. CONCLUSIONS The use of a continuous quality improvement program to review indwelling tunneled pleural catheter practices can result in the identification of infectious complications and lead to implementation of measures to improve patient outcomes.

Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently available to sample nodules for pathological diagnosis. Those technologies can be divided into bronchoscopic and non-bronchoscopic interventions. Electromagnetic navigational bronchoscopy is being extensively used for the endobronchial approach to peripheral lung nodules but has been hindered by anatomic challenges resulting in a 70% diagnostic yield. Electromagnetic navigational guided transthoracic needle lung biopsy is novel non-bronchoscopic method that uses a percutaneous electromagnetic tip tracked needle to obtain core biopsy specimens. Electromagnetic navigational transthoracic needle aspiration complements bronchoscopic techniques potentially allowing the provider to maximize the diagnostic yield during one single procedure. This article describes a novel integrated diagnostic approach to pulmonary lung nodules. We propose the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging; radial EBUS, navigational bronchoscopy and E-TTNA during one single procedure to maximize diagnostic yield and minimize the number of invasive procedures needed to obtain a diagnosis. This manuscript describes in detail how the navigation transthoracic procedure is performed. Additional clinical studies are needed to determine the clinical utility of this novel technology.

Tridimensional Medical Thoracoscopy

A 26-year-old man with a history of HIV presented with a recurrent right side lymphocytic exudative pleural effusion. A medical thoracoscopy was performed using a novel tridimensional (3D) articulating (Endoeye 3D, Flex LTF 19010-3D; Olympus Medical System, Tokyo, Japan). High-resolution 3D images and articulating scope properties allowed a realistic appreciation of the anatomy, depth perception, and spatial relationship, and a complete chest cavity inspection.

The future of interventional pulmonology.

Interventional pulmonology (IP) is a maturing subspecialty of pulmonary medicine focused on advanced diagnostic and therapeutic pulmonary and thoracic medical procedures for a variety of illnesses. This rapidly growing field requires highly specific knowledge and skill sets beyond its parent specialty. While the future of IP will continue to show growth, we postulate on a few upcoming technologies which may influence the field and discuss some of the challenges associated with growth in IP.

Airway stent complications: the role of follow-up bronchoscopy as a surveillance method

Background Airway stenting has become an integral part of the therapeutic endoscopic management of obstructive benign and malignant central airway diseases. Despite increased use of airway stents and frequent stent-associated complications, no clear guidelines for surveillance and maintenance exist. This study aim is to elucidate predictive factors associated with development of stent complications, as well as an optimal surveillance period for follow-up bronchoscopy for early detection and possible prevention of stent-associated complications. Methods Retrospective cohort study of all patients who underwent airway stent placements at our institution from April 2010 to December 2013 for benign and malignant airway diseases. Metallic, silicone (straight, Y stent, T-tube) and hybrid stents were included in the study. Stent complications were analyzed at the time of follow-up bronchoscopy performed four to six weeks after initial stent placement or earlier if patients became symptomatic. Results The study included 134 patients of which 147 stents were placed. Follow-up bronchoscopy was performed in 94 patients. Symptomatic status at the time of follow-up bronchoscopy was not associated with stent complications [odds ratio (OR) =1.88; 95% CI: 0.79-4.45; P=0.15]. Patient age, sex, indication for stent placement, and stent location, were not associated with development of complications (all P>0.05). Compared to all other stents, hybrid stents were more likely to migrate (OR =6.60; 95% CI: 2.16-20.2; P=0.001) or obstruct by secretions (OR =2.53; 95% CI: 1.10-5.84; P=0.03). There were no complications associated with surveillance bronchoscopy. Conclusions Surveillance bronchoscopy within 4 to 6 weeks of stent placement may be useful for early detection of complications and their subsequent management, regardless of symptomatic status and indication for stent placement. Prospective multicenter studies are needed to compare optimal surveillance methods and the impact on patient mortality, morbidity and healthcare costs.

Pleuropulmonary Kaposi Sarcoma in the Setting of Immune Reactivation

We present a case of a 26 year with history of HIV/AIDS who presented with a pleural effusion. Serial radiography, pleural fluid analysis as well as clinical symptoms revealed development of Kaposi Sarcoma related immune reconstitution inflammatory syndrome (KS-IRIS) in the setting of initiation of effective anti- retroviral therapy.