Wissam Abouzgheib

An algorithmic approach to chronic dyspnea

QUESTION The objective of the study was to prospectively evaluate an algorithmic approach to the cause(s) of chronic dyspnea. MATERIALS/PATIENTS/METHODS: Prospective observational study. The study group consisted of 123 patients with a chief complaint of dyspnea of unknown cause present for >8 weeks. Dyspnea severity scores were documented at entry and after therapy. Patients underwent an algorithmic approach to dyspnea. Therapy could be instituted at any time that data supported a treatable diagnosis. Whenever possible, accuracy of diagnosis was confirmed with an improvement in dyspnea after therapy. Tests required, spectrum and frequency of diagnoses, and the values of individual tests were determined. RESULTS Cause(s) was(were) diagnosed in 122/123 patients (99%); 97 patients had one diagnosis and 25 two diagnoses. Fifty-three percent of diagnoses were respiratory and 47% were non-respiratory. Following therapy, dyspnea improved in 63% of patients. CONCLUSIONS The prospective algorithmic approach led to diagnoses in 99% of cases. A third of patients were diagnosed with each tier of the algorithm, thus minimizing the need for invasive testing. Specific diagnoses led to improvement in dyspnea in the majority of cases. Based on the results of this study, the algorithm can be revised to further minimize unnecessary tests without loss of diagnostic accuracy.

Excessive dynamic airway collapse for the internist: new nomenclature or different entity?

Excessive dynamic airway collapse (EDAC) refers to abnormal and exaggerated bulging of the posterior wall within the airway lumen during exhalation. This condition is pathological if the reduced airway lumen is <50% of the normal. It is a relatively new disease entity that is recognised more easily now with the increased use of multi-detector row CT. EDAC is often asymptomatic and diagnosed incidentally. Although the term excessive dynamic airway collapse is often used interchangeably with tracheobronchomalacia, both entities represent morphologically and physiologically distinct processes. Considering the confusion between the two entities, the prevalence of stand-alone EDAC remains unclear. The prevalence of tracheobronchomalacia and EDAC depends upon the patient population, associated comorbidities and underlying aetiologies, diagnostic tools used and criteria used to define the airway collapse. This review defines EDAC and describes its pathophysiology, precipitating factors, associated symptoms and potential treatments.

Cough and asthma.

Purpose of review The intention of this article is to discuss and place into perspective recent articles on cough and asthma. Recent findings Asthma continues to be a major diagnosis in most studies of cough. The first prospective study of sub-acute cough demonstrated an asthma incidence lower than that for chronic cough, a logical finding; upper airway cough syndrome often causes cough in the postinfectious state. The first prospective study of cough in infants suggested asthma to be a minor cause of cough in infants, but methodological flaws make the conclusions uncertain. Efforts to separate cough-variant asthma from classic asthma continue. One group has demonstrated that the maximal bronchoconstrictor response in cough-variant asthma is blunted when compared with classic asthma, a possible explanation for the absence of wheeze and dyspnea in cough-variant asthma. Another look at airway resistance showed a less rapid rate of rise in resistance in cough-variant asthma with increasing methacholine dosing than in classic asthma. On the biochemical front, a group has demonstrated differences in vascular endothelial growth factor, which may be the underpinnings of differences between cough-variant asthma and classic asthma. Summary Recent data suggest that cough-variant asthma is part of a continuum in the expression of asthma symptoms and in the asthmatic inflammatory response.

Is chest tube insertion with ultrasound guidance safe in patients using clopidogrel

Background and objective:  Drainage of the pleural space is a common procedure. The safety of chest tube insertion in patients using clopidogrel has not been investigated.

Pleuroscopic Pleurodesis Combined With Tunneled Pleural Catheter for Management of Malignant Pleural Effusion: A Prospective Observational Study.

Background:Malignant pleural effusion (MPE) is associated with poor prognosis and it often impinges upon quality of life; effective and efficient management is desirable. Combining pleuroscopic pleurodesis (PP) with a tunneled pleural catheter (TPC) could minimize hospitalization, effect rapid pleurodesis in most cases, and allow ongoing control of MPE for those not successfully pleurodesed. Methods:Consecutive patients with pleural effusion associated with malignancy and with documented lung reexpansion after pleural fluid drainage were prospectively enrolled to undergo PP with TPC placement. TPC was drained daily and was removed when output was <50 mL/d. Patients were followed for up to 6 months. The data collected were compared with historical controls as provided by a previously published study by our group on conventional pleuroscopic pleurodesis (CPP). Results:Thirty patients were enrolled between January 2012 and August 2013. Twenty-nine completed the protocol. Pleurodesis was successful in 92% of patients at 1 month. Of the patients alive at 6 months, 96% continued to have effective pleurodesis. The median duration of TPC placement was 6 days. The median LOS was 3 days (2 to 7.25). All patients experienced significant improvement in dyspnea scores. The median LOS was significantly lower than those who received CPP (median LOS, 9 d; range, 4 to 13 d; P=0.002). There was no significant difference in mortality rates and pleurodesis success rates. Conclusions:The combination of PP with TPC can effect pleurodesis at a rate similar to CPP, shortens LOS, shortens time to pleurodesis, and helps to control symptoms when pleurodesis fails.

Transpulmonary artery needle aspiration of hilar masses with endobronchial ultrasound: a necessary evil.

The safety with regard to bleeding complications of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) of hilar and mediastinal lymphadenopathy has been well established. The real-time visualization of targeted and surrounding structures allows the operator to avoid puncturing even small vessels. However, on occasions, the only way to reach the target is by traversing vessels. We report 2 cases of right hilar masses that were successfully diagnosed with EBUS-TBNA performed by traversing the pulmonary artery without any complications. We suggest that transpulmonary artery needle aspiration can be safely conducted but should be performed only by experienced operators and should be reserved as a last resort for making a diagnosis.

Hodgkin disease of the trachea.

Endobronchial Hodgkin disease (HD) is very rare. We report the case of a women who presented with life-threatening airway obstruction. She was diagnosed with HD 4 years earlier and was in remission after treatment with a combination of chemotherapy and radiation. Bronchoscopy showed a polypoid mass obstructing the tracheal lumen almost completely. The mass was resected using an electrocautery snare loop, providing immediate relief of symptoms. Pathology and staging investigations revealed HD isolated to the trachea. This presentation and treatment is extremely unique for HD.

EBUS-TBNA and EUS-FNA: Risk Assessment for Patients Receiving Clopidogrel.

Background:Clopidogrel is widely used for the prevention of thrombotic vascular complications. Its primary potential toxicity is bleeding. Management of clopidogrel therapy for patients undergoing invasive procedures is an area of ongoing study. We sought to evaluate the bleeding risk for patients undergoing needle aspiration biopsy by endobronchial ultrasound (EBUS) or esophageal ultrasound (EUS) while taking clopidogrel. Methods:Retrospective review of sequential cases of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound fine needle aspiration (EUS-FNA). Results:Three hundred ninety-five consecutive procedures were reviewed. Thirty-seven patients were taking clopidogrel at time of biopsy. The patients taking clopidogrel were significantly older than those in the control group. Two patients (1%) in the control group were admitted for observation, but neither was found to have a significant bleed. There were no clinically significant bleeding complications in either of the study groups. Conclusions:It is reasonable to proceed with EBUS-TBNA or EUS-FNA when both, (1) clopidogrel cannot be stopped and, (2) an important diagnostic question is at stake.

Percutaneous dilational tracheostomy in patients receiving antiplatelet therapy: is it safe?

Antiplatelet agents have become a mainstay therapy for vascular diseases; yet, it increases the risk of bleeding. The latter has a potential to impact the safety of invasive procedures. A retrospective chart review of patients undergoing percutaneous dilational tracheostomy (PDT) at each of the 2 institutions was performed to determine the bleeding risk for patients on antiplatelet therapy who underwent PDT. Out of the 246 patients who underwent PDT over the study period, 20 qualified for the study group. All were being treated with clopidogrel. A control group of 137 patients was created. No major bleeding occurred in either of the group. Minor bleeding occurred in 1 study patient (5%) and in 5 (3.6%) of the control patients (P=0.85). The data support the performance of PDT without stopping clopidogrel if there was a clear and ongoing indication for the antiplatelet agent.

Oesophageal applications of the convex curvilinear ultrasound bronchoscope; an illustrative case series

A series of cases is used to demonstrate use of convex curvilinear ultrasound bronchoscope via the oesophagus in the diagnosis of non‐nodal thoracic disease. This scope has a breadth of application that has not to date been fully explored. Criteria for preferential use of the oesophagus are delineated.