Clinical Approach to Massive Hemoptysis: Perioperative Focus on Causes and Management

Massive hemoptysis is a time critical airway emergency in the perioperative setting, with an associated mortality exceeding 50%. Causes of hemoptysis in the perioperative setting include procedural complication, coagulopathy, malignancy, chronic lung disease, infection, left-sided cardiac disease, pulmonary vascular disease and autoimmune disease. A rapid and coordinated multidisciplinary response is required to secure the airway, isolate the lung, ensure adequate oxygenation and ventilation, identify the underlying cause and initiate specific systemic, bronchoscopic, endovascular, or surgical treatment. This review examines the etiology, pathophysiology, as well as approach to management and interventions in perioperative massive hemoptysis.

Single-use vs. reusable flexible bronchoscopes for airway management and in critical care: a narrative review

INTRODUCTION

Flexible bronchoscopes have become essential in the operating theatre environment and in critical care. This narrative review compared single-use and reusable flexible bronchoscopes with a focus on safety, efficacy, cost-effectiveness and environmental impact.

METHODS

We searched MEDLINE, Embase and PubMed databases for studies related to flexible bronchoscopes for airway management or use in critical care. Human or animal studies of any design assessing single-use and reusable flexible bronchoscopes were included and qualitatively synthesised. We also searched manufacturer websites for relevant data.

RESULTS

We included 52 studies and data from six manufacturer websites. There was mixed evidence for safety, and data on usability also showed significant heterogeneity, with different parameters, manufacturers and models examined. Neither single-use nor reusable flexible bronchoscopes appeared convincingly superior to the other for safety or usability. Cost analyses showed that the rate of use of flexible bronchoscopes per year, along with several other factors, affects cost-effectiveness for each institution, though the risk of cross-contamination is an advantage of single-use devices. However, sufficient evidence on the rate of bronchoscopy-induced infection in the operating theatre and critical care environment is lacking. Due to the risk of cross-contamination, single-use flexible bronchoscopes must be sterilised or incinerated after use, and completely recyclable single-use models are not currently available.

CONCLUSIONS

Further research is required on safety, usability and life cycle assessment in the operating theatre and critical care environment, as well as on the rate of bronchoscopy-induced infection. Future comparative studies, including new manufacturers and designs, may lend further insights.

Flexible versus Rigid Bronchoscopy for Tracheobronchial Foreign Body Removal in Children: A Comparative Systematic Review and Meta-Analysis

The removal of foreign bodies (FBs) from the airways of children is a critical procedure that can avert serious complications. While both flexible and rigid bronchoscopy techniques are employed for this purpose, their comparative efficacy and safety remain subjects of debate. Therefore, we conducted this investigation to compare between both procedures. Studies comparing flexible to rigid bronchoscopy (n = 14) were identified by searching PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar. We performed comparative meta-analyses of reported presentation characteristics and clinical outcomes, using fixed- and random-effects models. A diverse range of FB types and locations were identified. No difference was observed in the success rate of FB removal between flexible and rigid bronchoscopy (logOR = 0.27; 95%CI: -1.91:2.45). The rate of negative first bronchoscopy was higher in the flexible compared to the rigid group (logOR = 2.68; 95%CI: 1.68:3.67). Conversion rates to the alternative method were higher in the flexible bronchoscopy group. The overall complication rates were similar between both methods; however, the risk of desaturation was significantly lower with flexible bronchoscopy (logOR = -2.22; 95%CI: -3.36:-1.08). Flexible bronchoscopy was associated with a shorter length of hospital stay. The choice of bronchoscopy technique should be tailored to individual case characteristics.

Simple endoscopic estimation to predict anastomotic complications after bronchoplastic procedures

OBJECTIVES

Endoscopic evaluation of anastomosis is effective for the early detection of anastomotic complications after a bronchoplastic procedure. Herein, we aimed to clarify important findings for predicting anastomotic complications.

METHODS

This single-centre retrospective study included patients who underwent bronchoplastic surgery between April 2013 and September 2023. Only cases in which bronchoscopy was performed both 1 and 2 weeks after surgery were included. Endoscopic findings (classification by Ludwig and Stoelben, mucosa colour, oedema, slough area and colour, and depression) were reviewed for all cases. The accuracy of these findings for predicting anastomotic complications was evaluated.

RESULTS

Of the 190 patients included in this study, 14 (7.4%) experienced anastomotic abnormalities, 11 had fistulas (5.8%), and 7 had stenosis (3.7%). The onsets of fistula and stenosis were 20-28 and 20-44 days after surgery, respectively. In 102 patients (53.7%), the slough worsened from the first to the second week post-surgery. Therefore, it was easier to evaluate slough 2 weeks post-surgery rather than 1-week post-surgery. The positive/negative predicted values of anastomotic complications in endoscopic findings 2 weeks post-surgery were circular slough, 34.2%/99.3%; slough with dark colour, 39.3%/98.1%; and depression, 54.2%/99.4%. The incidence of anastomotic abnormalities was 0% in cases without the three findings, 10% in cases with at least one finding, and 67% in cases with all three findings.

CONCLUSIONS

The endoscopic findings of slough on the anastomosis 2 weeks after bronchoplasty can be easily evaluated and accurately predict complications. Three important endoscopic findings were circular slough, dark colour, and depression.

H-marker via bronchoscopy under LungPro navigation combined with cone-beam computed tomography for locating multiple pulmonary ground-glass nodules: A case report and literature review

RATIONALE

Pulmonary ground-glass nodules (GGNs) pose challenges in intraoperative localization due to their primarily nonsolid composition. This report highlights a novel approach using H-marker deployment guided by LungPro navigation combined with cone-beam computed tomography (CBCT) for precise localization of multiple GGNs.

PATIENT CONCERNS

A 55-year-old female patient presented at Sir-Run-Run-Shaw Hospital, Zhejiang University School of Medicine, in June 2021, requiring thoracoscopic surgery for the management of multiple GGNs in her right lung. She had a recent history of thoracoscopic wedge resection for a lesion in her lower left lung 3 months prior.

DIAGNOSES

Computed tomography scans revealed the presence of 3 mixed GGNs in the right lung, with further confirmation identifying these as solitary pulmonary nodules, necessitating surgical intervention.

INTERVENTIONS

The patient underwent thoracoscopic surgery, during which the multiple nodules in her right lung were precisely localized utilizing an H-marker implanted bronchoscopically under the guidance of LungPro navigation technology, with CBCT providing additional confirmation of nodule positioning. This innovative combination of technologies facilitated accurate targeting of the lesions.

OUTCOMES

Postoperative histopathological analysis confirmed the nodules to be microinvasive adenocarcinomas. Radiographic examination with chest X-rays demonstrated satisfactory lung expansion, indicating effective lung function preservation following the procedure. Follow-up assessments have shown no evidence of tumor recurrence, suggesting successful treatment.

LESSONS

The employment of H-marker implantation guided by the LungPro navigation system with CBCT confirmation presents a feasible and efficacious strategy for localizing multiple pulmonary GGNs. To further validate its clinical utility and safety, large-scale, multicenter, prospective studies are warranted. This approach holds promise in enhancing the precision and outcomes of surgeries involving GGNs.

Progress in the Application of Bronchoscopic Cryotherapy in Pediatric Pulmonary Diseases

Cryotherapy in interventional bronchoscopy is a new treatment modality which has recently been made available for the pediatric airway. Lack of experience and safety concerns have led to hesitant adaptation. The aim of this work was to elaborate on the application progress of cryotherapy in pediatric pulmonary diseases and also to assess indications, success rates, and complications of airway cryotherapy in children. In summary, cryotherapy via flexible bronchoscopy is a safe and feasible method. The application scope in pediatrics is similar to that in adults, and it is mainly used in airway obstructive diseases. However, it is primarily caused by benign conditions, and the interventional treatment mainly seeks to provide long-lasting symptomatic alleviation. Thus, prevention, treatment, and prognosis of long-term complications are issues that should be carefully considered in pediatric applications.

Comparison of Tracheal Intubation Using the Air-Q ILA and LMA Blockbuster Among Adults Undergoing Elective Surgery: A Randomized Controlled Trial

Objective

Air-Q intubating laryngeal airway (ILA) is associated with a 58-77% success rate in blind intubation. The newer laryngeal mask airway (LMA) blockbuster is specially designed to facilitate easier endotracheal intubation and may have a higher success rate. The current study aimed to compare the success rate of endotracheal intubation using the Air-Q ILA and LMA blockbuster.

Methods

After ethics committee approval and informed written consent, 140 adult patients with normal airways who were scheduled for elective surgery under general anaesthesia requiring endotracheal intubation were recruited for this randomized controlled trial. Blind endotracheal intubation was performed using the Air-Q ILA in group A and the LMA blockbuster in group B with special maneuvers and/or tubes in the second attempt. Fibreoptic bronchoscope (FOB) guidance was used in the third attempt if required. The primary outcome was the success rate of intubation without FOB assistance. The number of attempts for supraglottic airway (SGA) insertion, the time taken for SGA insertion, and the overall intubation time was also noted.

Results

The success rate of intubation without FOB guidance was significantly higher in group B than in group A [91.4% vs 55.7%; relative risk (RR) 1.68; (95% confidence interval (CI) 1.34, 2.11); p<0.0001]. The number of attempts for SGA insertion was similar in groups A and group B [87% vs 90%; RR 1.03; (95% CI-0.92, 1.16); p=0.60]. The times for successful SGA insertion and endotracheal intubation were also similar between the groups.

Conclusion

The LMA blockbuster offers a significantly higher success rate for endotracheal intubation without FOB guidance than the Air-Q ILA in adult patients with normal airways. However, an increased success rate was achieved with the use of a specially designed flexible endotracheal tube and maneuvers.

The Ingestion Question: Public Knowledge of Safe Food Introduction in Children

OBJECTIVES

National guidelines advise delaying initiation of solid foods until after 4-6 months of age and avoiding "high-risk" foods under the age of 4 years. However, foreign body aspiration of food remains a common preventable pediatric emergency. Our primary aim was to investigate public knowledge regarding the safe age of introduction of different foods to children and determine if demographic factors affect this knowledge.

METHODS

An online survey was designed following a literature review and consultation with an expert panel. This was distributed via social media platforms. A review of our institutional data of bronchoscopy/foreign body retrievals was performed to identify trends.

RESULTS

There were 1000 survey responses: 79.4% of respondents cared for children and 21.5% were medical professionals; 37.7% of respondents (n = 385) would offer high-risk foods to children <2 years of age and 56.9% (n = 582) to children <3 years. At our institution nuts (65.7%) were the most common food-related foreign body retrieved from a total of 265 over 21 years. Notably, 80% of respondents (n = 800) would offer whole nuts to children <4 years. Respondents with medical training were more likely to hold off on introducing nuts to children until a later age.

CONCLUSION

Although the public has an overall appreciation of food safety, a significant proportion would feel comfortable offering high-risk foods to children under 2 and 3 years. There is a poor understanding of the danger of nuts and the appropriate age of introduction. Further research into effective public education strategies on safe food introduction in children are warranted.

LEVELS OF EVIDENCE

V Laryngoscope, 2024.

Pulmonary Artery Endograft Implantation Using a Parallel Stent Grafting Technique to Enable the Treatment of a Bronchial Anastomosis Complication After Lung Transplantation

BACKGROUND

Bronchial stenosis associated with bronchial anastomosis dehiscence after lung transplantation is a catastrophic complication following lung transplantation with a paucity of therapeutic solutions.

PURPOSE

To describe an adaptation of the parallel stent grafting technique in the pulmonary arterial territory to treat this challenging situation.

RESEARCH DESIGN

This is a case report of a 52-year-old patient who presented bronchus stenosis and bronchial anastomosis dehiscence after lung transplantion. Bronchial stenting and lung retransplantation were contraindicated. Therefore, an endovascular approach using pulmonary artery endograft placement to prevent bleeding during repeated right bronchial balloon dilation was propposed. The technique consists of the deployment of an aortic extender endoprosthesis in the right main pulmonary artery and a balloon expandable stent in the upper lobe pulmonary artery (using a parallel graft configuration) through the common femoral and right internal jugular veins, respectively. Intraoperative transesophageal echocardiogram and one-lung ventilatory ventilation are needed.

RESULTS

The patient underwent a new bronchoscopy 16 days after the procedure, that showed epithelization at the previous eroded zone, enabling bronchocopic balloon dialtion to be safely performed. A post-operative contrast-enhanced CT scan revealed an adequate positioning of the stent grafts. Despite all eforts, the patient succumbed to ventilator associated pneumonia on postoperative day 108.

DATA ANALYSIS

The technique's advantages include its feasibility even in situations in which other techniques may be contraindicated and its potential use in emergencies. Its limitations include the need for experienced interventionists to perform it, and the potential risk of acute tricuspid regurgitation.

CONCLUSION

This study illustrates the early feasibility of the parallel stent grafting technique applied to the pulmonary artery territory. However, it's safety profile regarding infectious risk was not demontrated.

Plastic bronchitis linked to human bocavirus 1 identified through high-throughput next-generation sequencing: A case report

BACKGROUND

Plastic bronchitis (PB) is an uncommon and severe acute respiratory ailment characterized by the formation of casts in the trachea or bronchial tree. Some instances have been linked to human bocavirus (HBoV) infections.

CASE PRESENTATION

In this report, we present a case of PB secondary to HBoV1 infection in a previously healthy pediatric patient. A 17-month-old male was admitted due to respiratory distress following 2 days of cough and fever. A preadmission chest X-ray revealed atelectasis of the left lung. Emergency electronic bronchoscopy and foreign body forceps were employed to remove casts, leading to improved breathing. High-throughput next-generation sequencing detected only HBoV1. A subsequent electronic bronchoscopy 2 days later showed no casts.

CONCLUSIONS

PB associated with HBoV1 infection should be considered in children experiencing acute respiratory distress, and a second bronchoscopy intervention may not be necessary in cases related to HBoV1.

Franseen needle in endobronchial ultrasound-guided transbronchial needle aspiration: a phase II prospective study

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been used to diagnose and stage lung cancer. Acquire™ Pulmonary and Expect™ Pulmonary dedicated EBUS-TBNA needles were introduced as the Franseen and Lancet needles, respectively. It is still unclear whether the Franseen or Lancet needles yield a higher quality specimen especially focusing on next-generation sequencing-based molecular testing.

METHODS

A single-center, prospective study performed at the Chiba University Hospital randomly assigned patients to two groups: Group A, wherein the first and second EBUS-TBNA were performed using Lancet and Franseen needles, respectively, and Group B, wherein the first and second EBUS-TBNA were performed using Franseen and Lancet needles, respectively. Each specimen was compared and analyzed pathologically. The primary outcome was the histological tissue area except blood clot and the cellularity of each sample. We also examined the success rate of molecular testing.

RESULTS

Twelve patients who underwent EBUS-TBNA between November 2022 and February 2023 were enrolled in this study. The tissue area of the specimens obtained by the Franseen and Lancet needles was 13.3 ± 6.4 mm2 and 10.6 ± 6.3 mm2, respectively (P = .355). The tumor cellularity in the specimens obtained using the Franseen and Lancet needles was 54.0 ± 30.3 and 46.2 ± 36.3%, respectively (P = .608). The success rate of molecular testing using the single-pass sample by Franseen needle was 85.7 and 57.1% by Lancet needle. No serious complications were reported.

CONCLUSIONS

The Franseen needle tended to show a greater amount of specimen with higher tumor cellularity than the Lancet needle which may contribute higher success rate of molecular testing. Further studies must be conducted to validate the results of this study.

KEY FINDINGS

What is known and what is new?  What is the implication, and what should change now?

Flexible and Rigid Bronchoscopy for Critically Ill Children on Extracorporeal Membrane Oxygenation

BACKGROUND

We aim to describe our experience with bronchoscopy to diagnose and relieve tracheobronchial obstruction in anticipation of decannulation in children on extracorporeal membrane oxygenation (ECMO) support.

METHODS

A retrospective cohort study of children on ECMO between 1/2018 and 12/2022.

RESULTS

A total of 107 children required ECMO support during the study period for cardiac (n = 48, 45%), pulmonary (n = 38, 36%), or cardiopulmonary dysfunction (n = 21, 20%). Thirty-seven (35%) patients underwent 99 bronchoscopies while on ECMO. Most (76%, n = 75) experienced no improvement or worsening of chest radiography 24 hours following bronchoscopy. Clinical improvement in tidal volumes 48 hours after the first bronchoscopy was noted in 13/25 patients with available data (p = 0.05). Adverse events were seen in 18 (49%) patients who underwent bronchoscopy, including pneumothorax (n = 8, 22%), pneumonia (n = 7, 19%), pulmonary hemorrhage (n = 6, 16%), and sepsis (n = 5, 14%). ECMO courses were longer (25.4 ± 37.2 vs 6.1 ± 8.8 days, p < 0.0001) and more likely to be complicated by pneumonia (p = 0.0004) and sepsis (p = 0.047) in patients who underwent bronchoscopy compared with those who did not. Adverse events following bronchoscopy were associated with the number of bronchoscopies (p = 0.0003) and the presence of obstructive materials but not with the type of bronchoscopy or indication for ECMO. Mortality rates were similar between patients who underwent bronchoscopy and those who did not.

CONCLUSION

Children requiring bronchoscopy represent a subset of the sickest children on ECMO. Bronchoscopy may provide benefit in children with persistent cardiopulmonary failure who could not otherwise be decannulated. Adverse events are associated with the number of bronchoscopies and the presence of obstructive material.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4134-4140, 2024.

Complete removal of a ruptured pulmonary hydatid cyst during conscious sedation bronchoscopy: A case report and literature review

The complete removal of a pulmonary hydatid cyst by bronchoscopy occurs rarely in clinical practice. We describe a 22-year-old male originally from Lebanon, with suspected hydatid cyst rupture on computed tomography chest after experiencing sudden onset fevers and cough whilst taking empiric anthelmintic therapy. Bronchoscopy revealed white gelatinous material in the posterior segment of the left lower lobe. The complete membranes of a hydatid cyst were removed with grasping forceps. Histologic examination confirmed the diagnosis of echinococcosis.

Determinants of radiation exposure during mobile cone-beam CT-guided robotic-assisted bronchoscopy

BACKGROUND AND OBJECTIVE

Robotic-assisted bronchoscopy (RAB) is an emerging modality to sample pulmonary lesions. Cone-beam computed tomography (CBCT) can be incorporated into RAB. We investigated the magnitude and predictors of patient and staff radiation exposure during mobile CBCT-guided shape-sensing RAB.

METHODS

Patient radiation dose was estimated by cumulative dose area product (cDAP) and cumulative reference air kerma (cRAK). Staff equivalent dose was calculated based on isokerma maps and a phantom simulation. Patient, lesion and procedure-related factors associated with higher radiation doses were identified by logistic regression models.

RESULTS

A total of 198 RAB cases were included in the analysis. The median patient cDAP and cRAK were 10.86 Gy cm2 (IQR: 4.62-20.84) and 76.20 mGy (IQR: 38.96-148.38), respectively. Among staff members, the bronchoscopist was exposed to the highest median equivalent dose of 1.48 μSv (IQR: 0.85-2.69). Both patient and staff radiation doses increased with the number of CBCT spins and targeted lesions (p < 0.001 for all comparisons). Patient obesity, negative bronchus sign, lesion size <2.0 cm and inadequate sampling by on-site evaluation were associated with a higher patient dose, while patient obesity and inadequate sampling by on-site evaluation were associated with a higher bronchoscopist equivalent dose.

CONCLUSION

The magnitude of patient and staff radiation exposure during CBCT-RAB is aligned with safety thresholds recommended by regulatory authorities. Factors associated with a higher radiation exposure during CBCT-RAB can be identified pre-operatively and solicit procedural optimization by reinforcing radiation protective measures. Future studies are needed to confirm these findings across multiple institutions and practices.

Pull-up surprise: Chronic foreign body aspiration

Foreign body aspiration is rare in adults but can be life-threatening. This case highlights the subtlety of chronic foreign body aspiration presentation and the importance of judicious use of radiological tool and comprehensive history-taking especially in patients with chronic cough.

Additional benefit of endoscopic ultrasound with bronchoscope-guided fine needle aspiration to endobronchial ultrasound-guided transbronchial needle aspiration in the evaluation of lung cancer: a systematic review and meta-analysis

Background

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA) are minimally invasive procedures for the diagnosis and staging of lung cancer. This study aimed to investigate the additional diagnostic value of EUS-B-FNA following EBUS-TBNA.

Methods

We performed a systematic literature review of PubMed, Embase, and the Cochrane Central Register databases and extracted the studies reporting the implementation of the combined EBUS-TBNA/EUS-B-FNA. A proportional meta-analysis was conducted to determine the pooled diagnostic yield of this procedure.

Results

We identified nine studies involving 2,375 patients. The overall pooled diagnostic yield of EBUS-TBNA alone and combined EBUS-TBNA/EUS-B-FNA was 0.87 [95% confidence interval (CI): 0.79-0.95, I2=96.55%] and 0.92 (95% CI: 0.85-0.99, I2=97.89%), respectively. Adding EUS-B-FNA to EBUS-TBNA increased the diagnostic yield by approximately 0.05. There was statistical heterogeneity among the studies (I2=54.49%). Among the 832 patients in seven studies, additional diagnostic benefits of EUS-B-FNA were observed in 37 lesions. The most common diagnosed lesion was in station 4L (n=10), followed by station 5 (n=8) and station 7 (n=8).

Conclusions

In pooled estimates, the addition of EUS-B-FNA to EBUS-TBNA increased the diagnostic yield for the diagnosis and staging of lung cancer. Nodal station 4L, station 5, and station 8 were lesions frequently diagnosed by the addition of EUS-B-FNA. Because of statistical between-study heterogeneity, our findings should be interpreted with caution.

Safety and efficacy of a novel transbronchial radiofrequency ablation system for lung tumours: One year follow-up from the first multi-centre large-scale clinical trial (BRONC-RFII)

BACKGROUND AND OBJECTIVE

Radiofrequency ablation (RFA) is an emerging treatment of lung cancer, yet it is accompanied by certain safety concerns and operational limitations. This first multi-centre, large-scale clinical trial aimed to investigate the technical performance, efficacy and safety of an innovative transbronchial RFA system for lung tumours.

METHODS

The study enrolled patients with malignant lung tumours who underwent transbronchial RFA using an automatic saline microperfusion system between January 2021 and December 2021 across 16 medical centres. The primary endpoint was the complete ablation rate. The performance and safety of the technique, along with the 1-year survival rates, were evaluated.

RESULTS

This study included 126 patients (age range: 23-85 years) with 130 lung tumours (mean size: 18.77 × 14.15 mm) who had undergone 153 transbronchial RFA sessions, with a technique success rate of 99.35% and an average ablation zone size of 32.47 mm. At the 12-month follow-up, the complete ablation rate and intrapulmonary progression-free survival rates were 90.48% and 88.89%, respectively. The results of patients with ground-glass nodules (GGNs) were superior to those of the patients with solid nodules (12-month complete ablation rates: solid vs. pure GGN vs. mixed GGN: 82.14% vs. 100% vs. 96.08%, p = 0.007). No device defects were reported. Complications such as pneumothorax, haemoptysis, pleural effusion, pulmonary infection and pleural pain were observed in 3.97%, 6.35%, 8.73%, 11.11% and 10.32% of patients, respectively. Two subjects died during the follow-up period.

CONCLUSION

Transbronchial RFA utilizing an automatic saline microperfusion system is a viable, safe and efficacious approach for the treatment for lung tumours, particularly for patients with GGNs.

Factors associated with antibiotic resistance and survival analysis of severe pneumonia patients infected with Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa: A retrospective cohort study in Jakarta, Indonesia

Background

Antimicrobial resistance is one of the most significant challenges to global public health and the risk factors in severe pneumonia are constantly growing. Therefore, this study aimed to identify factors associated with antimicrobial resistance and conduct survival analysis of severe pneumonia patients with single and multiple pathogens in the National Referral Hospital, Jakarta, Indonesia.

Methods

A retrospective method was used, and secondary data were collected from severe pneumonia patients admitted to the intensive care unit at Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia, from January 2016 to December 2022. Respiratory specimens were collected through bronchial washing. Furthermore, univariate and multivariate analyses were performed to analyze factors associated with antimicrobial resistance. Kaplan‒Meier survival curves were generated with the log-rank test to compare 30-day mortality between patients infected with single, dual, and multiple pathogens.

Results

The results showed that a total of 333 patients from 415 enrolled were analyzed. Klebsiella pneumoniae (35.4%), Acinetobacter baumannii (29.3%), and Pseudomonas aeruginosa (15.4%) were the most frequently isolated Gram-negative pathogens. Factors associated with resistance to aminoglycoside, carbapenem, and quinolone were sepsis, cerebrovascular disease, and ventilator-associated pneumonia, as indicated by p < 0.05. In addition, the Kaplan-Meier curves showed that multiple pathogens influenced the survival rate of severe pneumonia patients (p < 0.05).

Conclusions

Sepsis, cerebrovascular disease, and ventilator-associated pneumonia were associated with antimicrobial resistance in severe pneumonia patients. The survival rate of patients infected with multiple pathogens was low. This suggests the importance of further awareness regarding empirical antibiotic stewardship and mortality assessment in severe pneumonia patients.

SARS-CoV-2 coinfection in children with severe airway obstruction due to pulmonary tuberculosis

INTRODUCTION

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic had a significant impact on tuberculosis (TB) control globally, with the number of new TB diagnoses decreasing. Coinfection with some viruses, especially measles, could aggravate TB in children. This is presumably a result of depressed cellular immunity. Reports on children with TB and SARS-CoV-2 coinfection are limited.

METHODS

A retrospective analysis of children up to 13 years old admitted to Tygerberg Hospital, Cape Town, South Africa, from March 2020 to December 2022 with suspected TB-induced airway compression requiring bronchoscopy. Children were included if they presented with severe intrathoracic airway obstruction and/or radiographic evidence of complicated TB. The patients were divided into two groups based on SARS-CoV-2 respiratory polymerase chain reaction results. Demographics, TB exposure, microbiology, SARS-CoV-2 laboratory data, imaging, inflammatory cytokine levels, and bronchoscopy data were collected. Statistical analyses compared SARS-CoV-2 positive and negative groups.

RESULTS

Of the 50 children undergoing bronchoscopy for TB airway obstruction, 7 (14%) were SARS-CoV-2 positive. Cough was more prevalent in the SARS-CoV-2 positive group (p = 0.04). There was no difference in TB culture yield between groups. However, SARS-CoV-2 positive children showed slower radiological improvement at 1 month (p = 0.01), pleural effusions (p < 0.001), and a higher need for endoscopic enucleation (p < 0.001). FDG PET/CT scans indicated an ongoing inflammation in the SARS-CoV-2 positive group.

CONCLUSIONS

Coinfection with SARS-CoV-2 in children with TB airway obstruction appears to complicate the disease course, necessitating more medical interventions and demonstrating a longer duration of the TB inflammatory process. Further research is needed to understand the impact of viral infections on TB progression and outcomes in pediatric patients.

Fetal cervical sarcoma: Comparison between virtual and real fetal bronchoscopy

Fetal cervical tumors are a life-threatening condition if proper diagnosis and perinatal care are inadequate. The most common causes of fetal cervical masses are teratomas and lymphangiomas. Less common tumors may obstruct the fetal airway due to cervical compression. In this case report, a fetus with a cervical sarcoma was evaluated by ultrasound and MRI. The prenatal imaging characteristics of the tumor were described, virtual navigation of the fetal airway was performed and compared with fetal bronchoscopy to evaluate the consistency of the tumor. Neonatal outcome was also described.

Bronchoalveolar Lavage Fluid Cellular Analysis and Radiologic Patterns in Patients With Fibrotic Interstitial Lung Disease

BACKGROUND

Bronchoalveolar lavage (BAL) cellular analysis is often recommended during the initial diagnostic evaluation of fibrotic interstitial lung disease (ILD). Despite recommendation for its use, between-center heterogeneity exists and supportive data concerning the clinical utility and correlation of BAL findings with radiologic features or patterns remain sparse.

RESEARCH QUESTION

In patients with fibrotic ILD, are BAL findings associated with radiologic features, patterns, and clinical diagnoses?

STUDY DESIGN AND METHODS

Patients with fibrotic ILD who underwent BAL for diagnostic evaluation and who were enrolled in the prospective Canadian Registry for Pulmonary Fibrosis were re-reviewed in a standardized multidisciplinary discussion (MDD). BAL was categorized according to guideline-recommended thresholds, and using thresholds of lymphocytosis > 20% and neutrophils > 4.5%. High-resolution CT (HRCT) scans were scored (blinded to clinical data) for specific features and percentage lung involvement. Radiologists classified HRCT scans according to guideline-defined patterns for idiopathic pulmonary fibrosis and fibrotic hypersensitivity pneumonitis (fHP); then, MDD diagnoses were assigned, considering all available data.

RESULTS

Bronchoscopy with cellular analysis was performed in 209 of 1,593 patients (13%). Lymphocyte % was weakly negatively correlated with total fibrosis % (r = -0.16, P = .023) but not statistically significantly correlated with ground glass opacity % (r = 0.01, P = .94). A mixed BAL pattern was the most frequent in all radiologic patterns (range, 45%-69%), with a minority classifiable according to BAL guidelines. BAL lymphocytosis appeared with similar frequency across HRCT patterns of fHP (21%) and usual interstitial pneumonia (18%). Only 5% of patients with MDD-based fHP had a guideline-defined isolated lymphocytosis > 15%.

INTERPRETATION

BAL cellular analyses did not significantly correlate with radiologic features, guideline patterns, or MDD-based diagnoses. Ground glass opacities are often interpreted to represent pulmonary inflammation, but were not associated with BAL lymphocytosis in this cohort.

Effectiveness of AERO Stent Placement for Malignant Airway Disorder in Patients with a Poor Performance Status

Objective Airway stenting is an established procedure for treating various airway disorders. The AERO stent (Merit Medical Systems, South Jordan, USA) is a fully covered self-expandable metallic stent approved for use in Japan in 2014. However, its effectiveness in treating malignant airway disorders in patients with a poor performance status remains unclear. Therefore, we investigated the safety and efficacy of the AERO stent in patients with malignant airway disorders and a poor performance status. Methods We retrospectively reviewed the medical records of all patients who underwent AERO stent placement at our institute between April 2016 and March 2022, and 21 patients underwent 25 procedures for malignant airway disorders. All AERO stenting procedures were performed using an over-the-wire delivery system with flexible and/or rigid bronchoscopy. Results Eighteen of the 21 patients (85.7%) had a poor general condition (Eastern Cooperative Oncology Group performance status 3 or 4). AERO stents were successfully placed in 23 of the 25 procedures and migrated in the remaining 2 cases. Complications occurred in 10 cases, with infection being the most common (3 cases). Fourteen patients (66.6%) showed an improvement in their performance status. In addition, 5 of the 6 intubated patients were extubated following AERO stenting, and 11 patients subsequently received anticancer treatment. Conclusion The placement of the AERO stent is useful in patients with a poor performance status, including those who are intubated and afflicted with malignant airway disorders.