Zachary S. DePew

Idiopathic subglottic stenosis: an evolving therapeutic algorithm.

Idiopathic subglottic stenosis (ISS) is a rare type of airway stenosis of unclear etiology. Open resection, while effective, remains a complex surgery and requires a hospital stay. Endoscopic management is often preferred but has historically been associated with a high recurrence rate. We aimed to analyze our experience, consisting of a standardized endoscopic approach combined with an empiric medical treatment.

Correlations Between Gait Speed, 6-Minute Walk Distance, Physical Activity, and Self-Efficacy in Patients With Severe Chronic Lung Disease

BACKGROUND: Four-meter gait speed (4MGS) has been associated with functional capacity and overall mortality in elderly patients, and may easily be translated to daily practice. We evaluated the association of 4MGS with meaningful outcomes. METHODS: In 70 subjects we conducted the 4MGS, 6-min walk test (6MWT), objectively measured physical activity, and assessed dyspnea, quality of life, and self-efficacy for walking and routine physical activity. 4MGS was measured in 3 separate time epochs during the 6MWT, to explore 4MGS variability. RESULTS: Diagnoses included COPD (51.4%), interstitial lung disease (38.6%), and other pulmonary conditions (10%). The mean ± SD values were: 4MGS 0.85 ± 0.21 m/s, 6-min walk distance (6MWD) 305 ± 115 m, and physical activity level 1.28 ± 0.17, which is consistent with severe physical inactivity. The gait speeds within the time epochs 1–2, 3–4, and 5–6 min during the 6MWT were not significantly different: 1.01 ± 0.29 m/s, 0.98 ± 0.31 m/s, and 1.00 ± 0.31 m/s, respectively. 4MGS had a significant correlation with 6MWD (r = 0.70, P < .001). 6MWD was the dominant variable for predicting 4MGS. Other significant predictors of 4MGS included dyspnea, self-efficacy, quality of life, and objectively measured physical activity. CONCLUSIONS: 4MGS is significantly and independently associated with 6MWD, and may serve as a reasonable simple surrogate for 6MWD in subjects with chronic lung disease. Gait speed was remarkably stable throughout the 6MWT, which supports the validity of an abbreviated walk test such as 4MGS.

Measuring Gait Speed in the Out-Patient Clinic: Methodology and Feasibility

BACKGROUND: Gait speed is a simple physical function measure associated with key outcomes in the elderly population. Gait speed measurements may improve clinical care in patients with COPD. However, there is a knowledge gap about the reliability and variability of gait speed testing protocols in COPD. We evaluated established techniques of measuring gait speed in patients with COPD and assessed feasibility of implementing gait speed as a routine vital sign in an out-patient clinic. METHODS: The usual 4-meter gait speed (4MGS) (“walk at a comfortable/natural pace”), maximal 4MGS (“walk as fast as you can safely”), usual 10-meter gait speed (10MGS), and maximal 10MGS of subjects with stable COPD were measured. Walks were measured using a stopwatch and automated timing system. For the feasibility/implementation phase, patients from the entire spectrum of respiratory diseases completed acceptability surveys, and clinical assistants administered gait speed measurements using an automated timing system. Time to train and to administer the test and acceptability by the staff were evaluated. RESULTS: Seventy subjects enrolled; 60% were men, and the mean age ± SD was 69 ± 10 years. All methods showed excellent test-retest reliability (intraclass correlation coefficient of 0.95–0.97). The difference between the two timing systems did not exceed the suggested minimal clinically important difference of 0.1 m/s for the usual pace instructions but did exceed 0.1 m/s for maximal pace walks. The difference between 4MGS and 10MGS was 0.13 ± 0.10 m/s. FEASIBILITY: Most subjects reported that gait speed measurement prior to clinic appointment was very acceptable (66%) or acceptable (33%). Time added to clinic visit measuring 4MGS was 95 ± 20 seconds, and clinical assistants reported gait speed measurements as very acceptable (60%), acceptable (30%), and somewhat acceptable (10%). CONCLUSIONS: Gait speed is a reliable measure in COPD, regardless of instructed pace, distance, or timing mechanism; however, adhering to one protocol is suggested. 4MGS was easily implemented into clinical practice with high acceptability by patients and clinic staff.

Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: A collaborative medical-surgical initiative

BACKGROUND Medical thoracoscopy (MT) is performed by relatively few pulmonologists in the United States. Recognizing that an outpatient minimally invasive procedure such as MT could provide a suitable alternative to hospitalization and surgery in patients with undiagnosed exudative pleural effusions, we initiated the Mayo Clinic outpatient MT program and herein report preliminary data on safety, feasibility, and outcomes. METHODS All consecutive patients referred for outpatient MT from October 2011 to August 2013 were included in this study. Demographic, radiographic, procedural, and histologic data were recorded prospectively and subsequently analyzed. RESULTS Outpatient MT was performed on 51 patients, with the most common indication being an undiagnosed lymphocytic exudative effusion in 86.3% of the cohort. Endoscopic findings included diffuse parietal pleural inflammation in 26 patients (51%), parietal pleural studding in 19 patients (37.3%), a normal examination in three patients (5.9%), diffuse parietal pleural thickening in two patients (3.9%), and a diaphragmatic defect in one patient (2%). Pleural malignancy was the most common histologic diagnosis in 24 patients (47.1%) and composed predominantly of mesothelioma in 14 (27.5%). Nonspecific pleuritis was the second most frequent diagnosis in 23 patients (45.1%). There were very few complications, with no significant cases of hemodynamic or respiratory compromise and no deaths. CONCLUSIONS Outpatient MT can be integrated successfully into a busy tertiary referral medical center through the combined efforts of interventional pulmonologists and thoracic surgeons. Outpatient MT may provide patients with a more convenient alternative to an inpatient surgical approach in the diagnosis of undiagnosed exudative pleural effusions while maintaining a high diagnostic yield and excellent safety.

Determinants of Gait Speed in COPD

BACKGROUND Measures of physical function, daily physical activity, and exercise capacity have been proposed for the care of patients with COPD but are not used routinely in daily office care. Gait speed is a powerful and simple measure of physical function in elderly patients and seems to be a promising measure for the daily care of patients with COPD. The objective of this study was to comprehensively evaluate the determinants and factors influencing gait speed in COPD, particularly the association of gait speed with objectively measured physical activity and the most used exercise capacity field test in cardiopulmonary disease: the 6-min walk test (6MWT). METHODS One hundred thirty patients with stable COPD performed two different 4-m gait speed protocols (usual and maximal pace). We modeled gait speed using demographics, lung function, dyspnea, quality of life, physical activity monitoring, exercise capacity, mood, cognitive function, and health-care use. RESULTS Gait speed was independently associated with 6MWT but not with daily physical activity. The correlation between gait speed and 6MWT was high regardless of protocol used (r = 0.77-0.80). Both 6MWT and gait speed shared similar constructs. Gait speed had an excellent ability to predict poor (≤ 350 m) or very poor (≤ 200 m) 6MWT distances (areas under the curve, 0.87 and 0.98, respectively). Gait speed was not independently associated with quality of life, mood, or cognitive function. CONCLUSIONS Gait speed is more indicative of exercise capacity (6MWT) than daily physical activity in COPD. Despite its simplicity, gait speed has outstanding screening properties for detecting poor and very poor 6MWT performance, making it a useful and informative tool for the clinical care of patients with COPD.

Endobronchial ultrasound and lymphoproliferative disorders: A retrospective study

BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been shown to have excellent diagnostic performance for mediastinal staging of lung cancer. The utility of EBUS-TBNA for the diagnosis of lymphoproliferative disorders involving the mediastinum or hila, or both, is unclear. METHODS A retrospective analysis was completed of all patients diagnosed with a lymphoproliferative disorder involving the mediastinum or hila, or both, who underwent an EBUS-TBNA within 3 months of the diagnosis. RESULTS Sixty-five patients with mediastinal or hilar lymph node, or both, involvement of their lymphoproliferative disorder underwent EBUS-TBNA within 3 months of their diagnosis. The initial EBUS-TBNA was nondiagnostic in 34 (52%), 11 were subsequently diagnosed by mediastinoscopy, and the remaining 23 were diagnosed by biopsy of a distant site, with involvement of the mediastinum or hilum assumed from preestablished radiographic criteria. A EBUS-TBNA specimen in 31 patients (48%) was interpreted as consistent with or suspicious for a lymphoproliferative disorder. The overall sensitivity of EBUS-TBNA for establishing a definitive diagnosis was 25 of 65 (38%). The sensitivity was lower for new patients, at 7 of 32 (22%), and better for patients with recurrence, at 18 of 33 (55%). CONCLUSIONS Contrary to previous studies, our findings suggest that EBUS-TBNA does not provide sufficient diagnostic material for accurate lymphoproliferative disorder subtyping in a significant number of patients and performs especially poorly when evaluating new patients. Mediastinoscopy should still be considered as the initial diagnostic procedure of choice when the clinical suspicion for a lymphoproliferative disorder is high, unless the patient is being evaluated for a recurrence of prior disorder.

How many steps are enough to avoid severe physical inactivity in patients with chronic obstructive pulmonary disease

While prognostically valuable, physical activity monitoring is not routinely performed for patients with COPD. We aimed to determine the number of daily steps associated with severe physical inactivity (physical activity level <1.40) in this population. We found that a daily step value <4580 is associated with severe physical inactivity. Our results are of significant value for clinicians counselling patients with COPD to help avoid the morbidity of severe physical inactivity.

The Role for Tunneled Indwelling Pleural Catheters in Patients With Persistent Benign Chylothorax

Background:Utilization of tunneled indwelling pleural catheters (TIPCs) for persistent pleural effusions is increasingly more common; however, the presence of chylothorax is generally considered a contraindication for utilization of a TIPC due to concerns regarding potential nutritional, immunologic and hemodynamic complications. Therefore, in this study, a cohort of patients with persistent benign chylothorax managed with TIPCs is described. Methods:A retrospective analysis of patients with persistent benign chylothorax managed with a TIPC at the study center between January 1, 2008, and March 1, 2012, was completed. Extracted data included patient characteristics, chylothorax etiologies, prior interventions, outcomes and complications. Results:Eleven patients (14 hemithoraces) had persistent benign chylothorax treated with placement of a TIPC during the inclusion time frame. Etiology of the chylothorax was nontraumatic in 8 of the 11 patients, with the remaining 3 secondary to thoracic surgery. Pleurodesis was achieved in 9 of the 14 hemithoraces, with a median time to pleurodesis of 176 days. All procedures were well tolerated, and no immediate periprocedural complications were reported. One serious complication was encountered in the form of a postoperative pulmonary embolism after replacement of an occluded TIPC, resulting in the patient’s death. Two patients had transient occlusions of their TIPCs successfully treated with intracatheter thrombolytic therapy. No significant adverse nutritional, hemodynamic or immunologic outcomes were reported during follow-up for any included patient. Conclusions:Utilization of a TIPC for the management of persistent benign chylothorax should be considered early because pleurodesis may be frequently and safely achieved in this patient population.

Screening for severe physical inactivity in chronic obstructive pulmonary disease: the value of simple measures and the validation of two physical activity questionnaires.

Objectively measured severe physical inactivity (SPI) has been reported as the strongest independent predictor of mortality in patients with chronic obstructive pulmonary disease (COPD). Activity monitoring is not feasible in routine clinical practice; therefore, we set out to determine the utility of simple clinical measures for predicting SPI in patients with COPD. A total of 165 patients with COPD wore an activity monitor for 5 days to define the presence or absence of SPI. Logistic models were generated including the modified Medical Research Council (MMRC) dyspnea grade, spirometry and the age–dyspnea–airflow obstruction (ADO) index. Physical Activity Scale for the Elderly (PASE) and Stanford Brief Activity Scale (SBAS) were also tested for validity and reliability in a subgroup of 67 patients. The MMRC dyspnea grade, PASE score, ADO index and SBAS score were associated with SPI, but general self-efficacy and spirometry were not. An MMRC dyspnea grade ≥3 was the best independent predictor of SPI (AUC: 0.74; PPV: 0.83; NPV: 0.68) followed closely by a PASE score of <111. The combination of MMRC dyspnea grade and PASE score provided the most robust model (AUC: 0.83; Positive Predictive Value (PPV): 0.95; Negative Predictive Value (NPV): 0.63). The results were confirmed using 5000 bootstrapped models from the cohort of 165 patients. MMRC dyspnea grade ≥3 may be the best triage tool for SPI in patients with COPD. The combination of the MMRC and PASE score provided the most robust prediction. Our results may have significant practical applicability for clinicians caring for patients with COPD.

Impact of pleural manometry on the development of chest discomfort during thoracentesis: a symptom-based study.

Background:Routine manometry is recommended to prevent complications during therapeutic thoracentesis, but has not definitively been shown to prevent pneumothorax or reexpansion pulmonary edema. As chest discomfort correlates with negative pleural pressures, we aimed to determine whether the use of manometry could anticipate the development of chest discomfort during therapeutic thoracentesis. Methods:A retrospective chart review of 214 consecutive adults who underwent outpatient therapeutic thoracentesis at our institution between January 1, 2011 and June 30, 2013 was performed. We compared preprocedural to postprocedural discomfort (using a linear analog scale from 0 to 10) in patients undergoing thoracentesis with or without manometry. We used a multivariate model to adjust for possible confounders. Changes of dyspnea scores were also analyzed. Results:Manometry was performed in 82/214 patients (38%). On univariate and multivariate analyses, neither the change in chest discomfort nor dyspnea scores was significantly different in the manometry versus the control group (P=0.12 and 0.24, respectively). Similar results were also found in the subgroup of large-volume thoracentesis (P=0.32 for discomfort, P=1.0 for dyspnea). Conclusions:In our retrospective study, the use of manometry did not appear to anticipate the development of chest discomfort during therapeutic thoracentesis. Prospective studies are needed to confirm these findings.