Interventional pulmonology

Efficacy and Safety of Chinese Medicine Resuscitation Pack for Enhanced Recovery after Bronchoscopy: A Randomized, Single-Blind, Placebo-Controlled Clinical Trial

OBJECTIVE

To evaluate the efficacy and safety of a hospital-made resuscitation pack, a Chinese medicinal herbal compound formula designed to enhance recovery in post-bronchoscopy patients.

METHODS

In this randomized, single-blind, placebo-controlled clinical trial, eligible patients were randomly assigned 1:1 to either the treatment or control groups. The patients in the treatment group applied the resuscitation pack, which contained aromatic compounded Chinese herbs. The patients in the control group applied a hospital-made, single herb placebo pack. Packs were placed on the Tiantu (CV 22) acupuncture point for 4 h as soon as the bronchoscopy finished. Efficacy indicators, such as recovery time, patients' symptoms including nausea and dizziness, and adverse events (AEs) were observed and compared. The outcome indices were evaluated at baseline, 1 and 24 h after the bronchoscopy. Subgroup analysis was further performed by patients' age and depth of sedation.

RESULTS

When applying generalized estimating equations (GEE) to evaluate the intensity of post-bronchoscopy nausea and vomiting, the intensity was lower in the treatment group (163 cases) compared with the control group (162 cases; 95% CI: 0.004, 0.099, P=0.03]. Also, significantly lower intensity of nausea was observed in the 60-70 years of age subgroup (95% CI: 0.029, 0.169, P=0.006) and deep sedation subgroup (95% CI: 0.002, 0.124; P=0.04). There was no significant difference in dizziness between two groups by GEE (95% CI: -0.134, 0.297; P=0.459). In addition, no serious AEs were observed in either group.

CONCLUSIONS

Our study found that the resuscitation pack markedly improved patients' symptoms by reducing nausea and vomiting after bronchoscopy without AEs, compared with placebo in the perioperative period. (Trial registration No. ChiCTR2000038299).

Therapeutic and prophylactic effects of radiation therapy in the management of recurrent granulation tissue induced tracheal stenosis: a review on the role of Endobronchial brachytherapy and external beam radiation therapy

PURPOSE

Granulation tissue-induced tracheal stenosis (mainly secondary to intubation or lung transplantation) is one of the most common etiologies of benign airway obstructions. Recurrence rates after standard treatment options (surgical resection and/or endobronchial interventions) can inadvertently worsen the stricture through the stimulation of more granulation tissue generation (via increased fibroblast activity and roliferation). Low-dose radiotherapy could be a promising tool to prevent granulation tissue formation after surgery and/or endobronchial interventions regarding its established role in the treatment of keloids or hypertrophic scars, two benign diseases with similar a pathophysiology to tracheal stenosis. This study reviews case reports and small series that used endobronchial brachytherapy (EBBT) or external beam radiotherapy (EBRT) for the management of refractory granulation tissue-induced tracheal stenosis after surgery and/or endobronchial interventions.

METHODS AND MATERIALS

Case reports and series (published up to October 2022) that reported outcomes of patients with recurrent granulation tissue-induced tracheal stenosis (after surgery and/or endobronchial interventions) treated by EBBT or EBRT (in definitive or prophylactic settings) were eligible.

RESULTS

Sixteen studies (EBBT: nine studies including 69 patients, EBRT: seven studies including 32 patients) were reviewed. The pooled success rate across all studies was 74% and 97% for EBBT and EBRT, respectively.

CONCLUSIONS

Radiation therapy appears to be effective in the management of selected patients with recurrent/refractory tracheal stenosis. Response to this treatment is usually good, but further studies with a larger number of patients and long-term followup are necessary to determine the optimal technique, dose, and timing of radiation therapy, late complications, the durability of response, and criteria for patient selection.

Applications of cryobiopsy in airway, pleural, and parenchymal disease

INTRODUCTION

:Cryobiopsy is a novel diagnostic technique for thoracic diseases which has been extensively investigated over the past 20 years. It was originally proposed for the diagnosis of endobronchial lesions and diffuse parenchymal lung disease due to limitations of conventional sampling techniques including small size and presence of artifacts.

AREAS COVERED

:We will review recent evidence related to the expanding use of cryobiopsy in thoracic diseases. To identify references, the MEDLINE database was searched from database inception until May 2022 for case series, cohort studies, randomized controlled trials, systematic reviews and meta-analyses related to cryobiopsy.

EXPERT OPINION

Cryobiopsy has expanding applications in the field of thoracic diseases. Evidence to support transbronchial cryobiopsy as an alternative to surgical lung biopsy is increasing and was recently endorsed as a conditional recommendation by the latest American Thoracic Society guideline update for Idiopathic Pulmonary Fibrosis. Developments in technology and technique, in particular the availability of a 1.1 mm flexible cryoprobe, have extended applications to pulmonary diseases, including diagnosis of interstitial lung diseases, peripheral pulmonary lesions, and lung transplant rejection.

Current treatment landscape for oligometastatic non-small cell lung cancer

The management of patients with advanced non-small cell lung carcinoma (NSCLC) has undergone major changes in recent years. On the one hand, improved sensitivity of diagnostic tests, both radiological and endoscopic, has altered the way patients are staged. On the other hand, the arrival of new drugs with antitumoral activity, such as targeted therapies or immunotherapy, has changed the prognosis of patients, improving disease control and prolonging survival. Finally, the development of radiotherapy and surgical and interventional radiology techniques means that radical ablative treatments can be performed on metastases in any location in the body. All of these advances have impacted the treatment of patients with advanced lung cancer, especially in a subgroup of these patients in which all of these treatment modalities converge. This poses a challenge for physicians who must decide upon the best treatment strategy for each patient, without solid evidence for one optimal mode of treatment in this patient population. The aim of this article is to review, from a practical and multidisciplinary perspective, published evidence on the management of oligometastatic NSCLC patients. We evaluate the different alternatives for radical ablative treatments, the role of primary tumor resection or radiation, the impact of systemic treatments, and the therapeutic sequence. In short, the present document aims to provide clinicians with a practical guide for the treatment of oligometastatic patients in routine clinical practice.

Medical thoracoscopy in intensive care unit

During the last decade, there has been a tremendous effort towards making procedures less invasive, which could reduce complications, decrease hospital stay and minimize overall health care cost. Medical thoracoscopy (MT) or pleuroscopy is a minimally invasive procedure commonly performed by interventional pulmonologist in United States. It has a favorable safety profile allowing access to the pleural cavity with a thoracoscope via a small chest wall incision to perform diagnostic or therapeutic interventions under direct visualization. MT allows the physician to perform pleural biopsy with high accuracy, drain loculated pleural effusion, guide chest tube placement and perform pleurodesis. As compared to video-assisted thoracoscopic surgery (VATS), MT is less invasive, does not require single lung ventilation, has a comparable diagnostic yield, and better tolerated in high-risk patients. MT can also be performed at bedside in critically ill patients. Although MT is generally safe, a multi-disciplinary discussion between the interventional pulmonologist, intensive care team, anesthesiologist and thoracic team is necessary to ensure best clinical practice as well as minimize complications for such high-risk patients. The purpose of this article is to review technique, diagnostic and therapeutic indications, as well as contraindications of performing bedside MT in intensive care unit. It aims to review both advantages and limitations of performing MT in intensive care unit.

Review of the Physiology and Anesthetic Considerations for Pleuroscopy/Medical Thoracoscopy

Pleuroscopy or medical thoracoscopy is the second most common utilized procedure after bronchoscopy in the promising field of interventional pulmonology. Its main application is for the diagnosis and management of benign or malignant pleural effusions. Entry into the hemithorax is associated with pain and patient discomfort, whereas concurrently, notable pathophysiologic alterations occur. Therefore, frequently procedural sedation and analgesia is needed, not only to alleviate the patient's emotional stress and discomfort by mitigating the anxiety and minimizing the pain but also for yielding better procedural conditions for the operator. The scope of this review is to present the physiologic derangements occurring in pleuroscopy and compare the various anesthetic techniques and sedative agents that are currently being used in this context.

Risk-score model to predict prognosis of malignant airway obstruction after interventional bronchoscopy

Background

Interventional bronchoscopy exhibits substantial effects for patients with malignant airway obstruction (MAO), while little information is available regarding the potential prognostic factors for these patients.

Methods

Between October 31, 2016, and July 31, 2019, a total of 150 patients undergoing interventional bronchoscopy and histologically-confirmed MAO were collected, in which 112 eligible participants formed the cohort for survival study. External validation cohort from another independent institution comprised 33 MAO patients with therapeutic bronchoscopy. The least absolute shrinkage and selection operator regression (LASSO) was applied to the model development dataset for selecting features correlated with MAO survival for inclusion in the Cox regression from which we elaborated the risk score system. A nomogram algorithm was also utilized.

Results

In our study, we observed a significant decline of stenosis rate after interventional bronchoscopy from 71.7%±2.1% to 36.6%±2.7% (P<0.001) and interventional bronchoscopy dilated airway effectively. Patients in our study undergoing interventional bronchoscopy had a median survival time of 614.000 days (95% CI: 269.876–958.124). Patients receiving distinct therapeutic methods of interventional bronchoscopy had different prognosis (P=0.022), and patients receiving treatment of electrocoagulation in combination with stenting and electrosurgical snare had worse survival than those receiving other options. Multivariate Cox analysis revealed that nonsmoking status, adenoid cystic carcinoma, and low preoperative stenosis length, as independent predictive factors for better overall survival (OS) of MAO patients. Then, the nomogram based on Cox regression and risk score system based on results from LASSO regression were elaborated respectively. Importantly, this risk score system was proved to have better performance than the nomogram and other single biomarkers such as traditional staging system (area under the curve 0.855 vs. 0.392–0.739). Survival curves showed that patients with the higher risk-score had poorer prognosis than those with lower risk-score (third quantile of OS: 126.000 days, 95% CI: 73.588–178.412 vs. 532.000 days, 95% CI: 0.000–1,110.372; P<0.001).

Conclusions

Nonsmoking status, adenoid cystic carcinoma, and low preoperative stenosis length, were independent predictive factors for better OS of MAO patients. We proposed a nomogram and risk score system for survival prediction of MAO patients undergoing interventional bronchoscopy with good performance.

Monitored Anesthesia Care with Dexmedetomidine Supplemented by Midazolam/Fentanyl versus Midazolam/Fentanyl Alone in Patients Undergoing Pleuroscopy: Effect on Oxygenation and Respiratory Function

Although pleuroscopy is considered a safe and well tolerated procedure with a low complication rate, it requires the administration of procedural sedation and analgesia. The purpose of this study was to assess the effects of dexmedetomidine administration on oxygenation and respiratory function in patients undergoing diagnostic or therapeutic pleuroscopy. Through a prospective, single center, cohort study, we studied 55 patients receiving either a dexmedetomidine intravenous infusion supplemented by midazolam/fentanyl (Group DEX + MZ/F) or a conventional sedation protocol with midazolam/fentanyl (Group MZ/F). Our primary outcome was the changes in lung gas exchange (PaO₂/FiO₂ ratio) obtained at baseline and at predetermined end points, while changes in respiratory mechanics (FEV1, FVC and the ratio FEV1/FVC) and PaCO₂ levels, drug consumption, time to recover from sedation and adverse events were our secondary endpoints (NCT03597828). We found a lower postoperative decrease in FEV1 volumes in Group DEX + MZ/F compared to Group MZ/F (p = 0.039), while FVC, FEV1/FVC and gas exchange values did not differ between groups. We also found a significant reduction in midazolam (p < 0.001) and fentanyl consumption (p < 0.001), along with a more rapid recovery of alertness postprocedure in Group DEX + MZ/F compared to Group MZ/F (p = 0.003), while pain scores during the postoperative period, favored the Group DEX + MZ/F (p = 0.020). In conclusion, the use of intravenous dexmedetomidine during pleuroscopy is associated with a smaller decrease in FEV1, reduction of the consumption of supplementary sedatives and analgesics and quicker awakening of patients postoperatively, when compared to midazolam/fentanyl. Therefore, dexmedetomidine administration may provide clinically significant benefits in terms of lung mechanics and faster recovery of patients undergoing pleuroscopy.

Assessment of Extensive Airway Obstruction Using Point-by-Point Lateral Pressure Measurements during Bronchoscopy

BACKGROUND

The positioning of the stent at the flow-limiting segment is crucial for patients with extensive airway obstruction to relieve dyspnea. However, CT and flow-volume curves cannot detect the area of maximal obstruction.

OBJECTIVES

The aim of this study is to physiologically evaluate extensive airway obstruction during interventional bronchoscopy.

METHODS

We prospectively measured point-by-point lateral airway pressure (Plat) at multiple points from the lower lobe bronchus to the upper trachea using a double-lumen catheter in 5 patients. The site of maximal obstruction was evaluated continuously to measure point-by-point Plat at multiple points when the airway catheter was withdrawn from the lower lobe bronchus to the upper trachea.

RESULTS

Remarkable pressure differences occurred at the site of maximal obstruction assessed by point-by-point Plat measurements. After initial stenting in 1 case, migration of the maximal obstruction to a nonstented segment of the weakened airway was seen with extensive stenosis from the trachea to the bronchi. In the second case, in addition to radiological analysis, point-by-point Plat measurements could identify the location of the maximal obstruction which contributed to dyspnea.

CONCLUSIONS

Point-by-point Plat measurement could be used to detect the site of maximal obstruction physiologically. Furthermore, Plat measurement could assess the need for additional procedures in real time in patients with extensive airway obstruction.

Brachytherapy for lung cancer

Brachytherapy (BT) is a minimally invasive anticancer radiotherapeutic modality where the tumor is directly irradiated via a radioactive source that is precisely implanted in or adjacent to the tumor. BT for lung cancer may be conducted in the form of endobronchial BT and radioactive seed implantation (RSI-BT), mainly for nonsmall cell lung cancer (NSCLC). For patients with early-stage lung cancer who are not suitable for surgery or external beam radiotherapy (EBRT), BT may be used as an alternative treatment, and curative results could be achieved in certain patients with cancer confined to the trachea lumen. For patients with locally advanced/metastatic lung cancer, BT could be selectively applied alone or as a boost to EBRT, which could improve the local tumor control and patient's survival. In addition, BT is also useful as a salvage treatment in select patients with locally recurrent/residual lung cancer that failed other treatments (e.g., surgery, chemotherapy, and EBRT). However, clinical outcomes are mainly obtained from retrospective studies. Prospective studies are limited and needed. In recent years, the introduction of modern image guidance, novel radioactive seeds, BT treatment planning systems (BT-TPS), after-loading technique, and three-dimensional printing template (3D-PT) assistance, among others, have potentially improved the clinical outcomes of BT. However, a comprehensive review of BT with newly published literature was lacking. This review is to discuss BT for NSCLC based on recent literature published in PubMed.

Recommendations for interventional pulmonology during COVID-19 outbreak: a consensus statement from the Portuguese Pulmonology Society

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by a novel SARS-CoV-2 pathogen. Its capacity for human-to-human transmission through respiratory droplets, coupled with a high-level of population mobility, has resulted in a rapid dissemination worldwide. Healthcare workers have been particularly exposed to the risk of infection and represent a significant proportion of COVID-19 cases in the worst affected regions of Europe. Like other open airway procedures or aerosol-generating procedures, bronchoscopy poses a significant risk of spreading contaminated droplets, and medical workers must adapt the procedures to ensure safety of both patients and staff. Several recommendation documents were published at the beginning of the pandemic, but as the situation evolves, our thoughts should not only focus on the present, but should also reflect on how we are going to deal with the presence of the virus in the community until there is a vaccine or specific treatment available. It is in this sense that this document aims to guide interventional pulmonology throughout this period, providing a set of recommendations on how to perform bronchoscopy or pleural procedures safely and efficiently.

Recent Advances in Interventional Pulmonology

The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.

Prognostic factors for survival after bronchoscopic intervention in patients with airway obstruction due to primary pulmonary malignancy

BACKGROUND

Malignant central airway obstruction (MCAO) occurs in 20-30% of patients with primary pulmonary malignancy. Although bronchoscopic intervention is widely performed to treat MCAO, little data exist on the prognosis of interventional bronchoscopy. Therefore, we evaluated the clinical outcomes and prognostic factors of bronchoscopic interventions in patients with MCAO due to primary pulmonary malignancy.

METHODS

This retrospective study was conducted at a university hospital and included 224 patients who received interventional bronchoscopy from 2004 to 2017, excluding patients with salivary gland-type tumor. A multivariable Cox proportional hazard regression analysis was used to identify independent prognostic factors associated with survival after the first bronchoscopic intervention.

RESULTS

Among 224 patients, 191 (85.3%) were males, and the median age was 63 years. The most common histological type of malignancy was squamous cell carcinoma (71.0%). Technical success was achieved in 93.7% of patients. Acute complications and procedure-related death occurred in 15.6 and 1.3% of patients, respectively. The median survival time was 7.0 months, and survival rates at one year and two years were 39.7 and 28.3%, respectively. Poor survival was associated with underlying chronic pulmonary disease, poor performance status, extended lesion, extrinsic or mixed lesion, and MCAO due to disease progression and not receiving adjuvant treatment after bronchoscopic intervention.

CONCLUSIONS

Interventional bronchoscopy could be a safe and effective procedure for patients who have MCAO due to primary pulmonary malignancy. In addition, we found several prognostic factors for poor survival after intervention, which will help clinicians determine the best candidates for bronchoscopic intervention.

A Pilot Study of a Novel through-the-Scope Self-Expandable Metallic Airway Stents Delivery System in Malignant Central Airway Obstruction

Objective

Self-expandable metallic (SEM) airway stents are an important approach to malignant central airway obstruction (CAO). SEM airway stent insertions are usually performed under fluoroscopic guidance over a guide wire placed through a flexible bronchoscope often resulting in a longer procedure time and exposure to radiation. In this pilot study, we designed a novel delivery system of the through-the-scope (TTS) SEM airway stent insertion and observed its feasibility.

Methods

From Jan 2015 to Sept 2016, 25 consecutive patients with inoperable malignant CAO were enrolled requiring airway stent implantation. All patients were followed up to death or at least 6 months.

Results

36 TTS stents were inserted into 25 patients using a flexible bronchoscope under general anesthesia or local anesthesia. All stents were successfully deployed directly through the working channel (2.8 mm diameter) of the flexible bronchoscope in 91.7% (33/36) of the subjects. The mMRC score and stenosis grade improved significantly after stent implantation. The common stent-related complications were secretion retention (25%, 9/36), development of granulation tissue (13.9%, 5/36), tumor in-growth (13.9%, 5/36), and hemoptysis (8.3%, 3/36). The 6-month overall survival (OS) was 44% (11/25).

Conclusion

The novel TTS stent release system was an effective and safe approach in malignant central airway obstruction.

Interventional Pulmonology: A Focused Review for Primary Care Physicians

Interventional pulmonology (IP) has evolved in recent decades, and recent advances have greatly expanded the services offered by IP physicians. IP is best defined as the use of advanced techniques for the evaluation and treatment of benign and malignant pulmonary disorders. The field has further advanced with the recent establishment of a board certification via the American Association of Bronchology and Interventional Pulmonology and the release in 2017 of accreditation standards for specialized fellowship training. This article provides a broad overview of the field to serve as a resource for primary care physicians.

Treatment of Tracheobronchial Injuries: A Contemporary Review

Tracheobronchial injury is a rare but a potentially high-impact event with significant morbidity and mortality. Common etiologies include blunt or penetrating trauma and iatrogenic injury that might occur during surgery, endotracheal intubation, or bronchoscopy. Early recognition of clinical signs and symptoms can help risk-stratify patients and guide management. In recent years, there has been a paradigm shift in the management of tracheal injury towards minimally invasive modalities, such as endobronchial stent placement. Although there are still some definitive indications for surgery, selected patients who meet traditional surgical criteria as well as those patients who were deemed to be poor surgical candidates can now be managed successfully using minimally invasive techniques. This paradigm shift from surgical to nonsurgical management is promising and should be considered prior to making final management decisions.

Bronchoscopic Treatment of Benign Endoluminal Lung Tumors

Background and Aim

Endobronchial benign tumors are a rarely seen clinical entity but may cause significant symptoms. Endobronchial treatment has the potential for relieving symptoms while saving the patient from invasive surgical procedures. No trials have been published that present and compare the various endobronchial treatment modalities for endobronchial benign tumors. The aim of the present study is to define safety and efficacy of endobronchial treatment in patients with benign endobronchial tumors from the point of complications and success rate.

Methods

This study is a retrospective cohort study from a review of medical charts. Eligibility criteria included diagnosis of a benign endobronchial tumor. Our institution's bronchoscopy and pathology database was searched for specific benign tumors, and the results were further detailed based on the endobronchial location.

Results

Forty-four patients with pathologically confirmed benign endobronchial tumors were included. Tumor regression was achieved in all patients with diode laser and argon plasma coagulation in combination with or without cryotherapy and without any major complication. There were no significant differences between the use of either diode laser or of argon plasma coagulation as a modality with immediate effect from the occurrence of residual tissue that needed cryotherapy (P > 0.05). There were no major complications. Eight patients had minor complications including minor bleeding (6 patients) and hypertension (2 patients) that were controlled medically. Thirty-one patients (70%) had very good response, and 13 patients (30%) had good response as defined in literature before.

Conclusion

Diode laser and argon plasma coagulation in combination with or without cryotherapy are safe and effective methods for endobronchial treatment of benign endobronchial tumors.

A Design-Based Stereologic Method to Quantify the Tissue Changes Associated with a Novel Drug-Eluting Tracheobronchial Stent

BACKGROUND

Granulation tissue is a common complication of airway stenting, but no published methods can quantify the volume and type of tissue that develops.

OBJECTIVE

To use design-based stereology to quantify changes in tissue volume and type associated with airway stenting.

METHODS

We compared drug-eluting stents (DES) filled with gendine to standard silicone stents in pigs in an assessor-blinded randomized trial. Tracheal stents were placed via rigid bronchoscopy. After 1 month, animals were euthanized and necropsies were performed. Antimicrobial effects of the DES were assessed in trachea tissue samples, on the DES surface, and with residual gel from the DES reservoir. Tracheal thickness was measured using orthogonal intercepts. Design-based stereology was used to quantify the volume density of tissues using a point-counting method. The volume of each tissue was normalized to cartilage volume, which is unaffected by stenting.

RESULTS

Pigs were randomized to DES (n = 36) or control stents (n = 9). The drug was successfully eluted from the DES, and the stent surface showed antibacterial activity. DES and controls did not differ in tissue microbiology, tracheal thickness, or granulation tissue volume. Compared to nonstented controls, stented airways demonstrated a 110% increase in soft-tissue volume (p = 0.005). Submucosal connective tissue (118%; p < 0.0001), epithelium (70%; p < 0.0001), submucosal glands (47%; p = 0.001), and smooth muscle (41%; p < 0.0001) increased in volume.

CONCLUSION

Stenting doubles the volume of soft tissue in the trachea. Design-based stereology can quantify the tissue changes associated with airway stenting.

Long-term quality-adjusted survival following therapeutic bronchoscopy for malignant central airway obstruction

Background

While therapeutic bronchoscopy has been used to treat malignant central (CAO) airway obstruction for >25 years, there are no studies quantifying the impact of therapeutic bronchoscopy on long-term quality-adjusted survival.

Methods

We conducted a prospective observational study of consecutive patients undergoing therapeutic bronchoscopy for CAO. Patients had follow-up at 1 week and monthly thereafter until death. Outcomes included technical success (ie, relief of anatomic obstruction), dyspnoea, health-related quality of life (HRQOL) and quality-adjusted survival.

Results

Therapeutic bronchoscopy was performed on 102 patients with malignant CAO. Partial or complete technical success was achieved in 90% of patients. At 7 days postbronchoscopy, dyspnoea improved (mean ∆Borg-day-7=−1.8, 95% CI −2.2 to −1.3, p<0.0001) and HRQOL improved (median prebronchoscopy 0.618 utiles, 25%–75% IQR 0.569 to 0.699, mean ∆utility-day-7+0.047 utiles, 95% CI +0.023 to 0.071, p=0.0002). Improvements in dyspnoea and HRQOL were maintained long-term. Compared with the prebronchoscopy baseline, HRQOL per day of life postbronchoscopy improved (mean ∆utility-long-term+0.036 utiles, 95% CI +0.014 to 0.057, p=0.002). Median quality-adjusted survival was 109 quality-adjusted life-days (QALDs) (95% CI 74 to 201 QALDs). Factors associated with longer quality-adjusted survival included better functional status, treatment-naïve tumour, endobronchial disease, less dyspnoea, shorter time from diagnosis to bronchoscopy, absence of cardiac disease, bronchoscopic dilation and receiving chemotherapy.

Conclusions

Therapeutic bronchoscopy improves HRQOL as compared with baseline, resulting in approximately a 5.8% improvement in HRQOL per day of life. The risk-benefit profile in these carefully selected patients was very favourable.

Trial registration number

Results; NCT03326570.

Primary tracheal hyalinizing clear cell carcinoma

Hyalinizing clear cell carcinomas (HCCC), now referred to as clear cell carcinomas (CCC) by the World Health Organization (WHO), are rare tumors usually arising from the salivary glands of the head and neck. We present the first case of a CCC originating from the trachea. A 66 year-old woman with history of hypertension, former smoker, presented to the emergency department reporting worsening shortness of breath. Computed chest tomography revealed a polypoid mass arising from the left posterior-lateral wall of the trachea. The patient developed worsening respiratory failure requiring mechanical ventilation. Bronchoscopy was completed which relieved a malignant airway obstruction and pathology revealed nests of cells with monomorphic nuclei and clear cytoplasm set in a hyalinized stroma. Using break apart probe fluorescence in situ hybridization testing the tissue revealed the presence of a recurring translocation of the Ewing sarcoma (EWSR1) gene, confirming the diagnosis. CCC is a rare primary airway tumor. CCC was first reported to originate in the lung in 2015. We present the first case of CCC arising from the trachea.

Pulmonary Perfusion Using Intrabronchial Capnography in Pulmonary Artery Stenosis

Stenting at the flow-limiting segment can improve the ventilation-perfusion ratio in patients with central airway stenosis. However, there is no quantitative examination for assessing the perfusion status during interventional bronchoscopy. Intrabronchial capnography can estimate regional gas exchange by measuring carbon dioxide concentration. We herein report a case of bilateral bronchial stenosis where stenting was able to improve ventilation-perfusion ratio using intrabronchial capnography. A 44-year-old man was admitted to our institution with orthopnea. Chest computed tomography showed an extrinsic compression at the bilateral main bronchus and right pulmonary artery due to a mediastinal mass. After introduction of general anesthesia, arterial oxygen tension suddenly decreased in the supine position. After initial stenting, an increase was seen in ventilation at the right lung; however, a ventilation-perfusion mismatch occurred due to an increase in dead-space ventilation at the right pulmonary artery stenosis. Intrabronchial capnography was an effective modality to confirm the regional perfusion status during interventional bronchoscopy in real time.

Outcome of advanced lung cancer with central airway obstruction versus without central airway obstruction

Patients with central airway obstruction (CAO) from advanced lung cancer present with significant morbidity and are assumed to have lower survival. Hence, they are offered only palliative support. We asked if patients who have advanced lung cancer with CAO (recanalised and treated) will behave similarly to those with advanced lung cancer without CAO. This study was a retrospective review of the medical records of the patients managed for advanced lung cancer during 2010 and 2015 at our institution. 85 patients were studied. Median survival and 1-, 2- and 5-year survival were 5.8 months, 30.3%, 11.7% and 2.3% versus 9.3 months, 35.7%, 9.6% and 4.7%, respectively, in the CAO and no CAO groups (p=0.30). More patients presented with respiratory failure (15 (35%) versus none; p=0.0001) and required assisted mechanical ventilation (10 (23.3%) versus none; p=0.001) in the CAO group compared with the no CAO group. Fewer patients received chemotherapy in the CAO group (11 (25.5%)) compared with the no CAO group (23 (54.7%); p=0.008). There was no difference in survival among patients with advanced lung cancer whether they presented with CAO or without CAO. Survival was similar to those without CAO in patients with recanalised CAO despite greater morbidity and lesser use of chemotherapy, strongly advocating bronchoscopic recanalisation of CAO. These findings dispel the nihilism associated with such cases.

Interventional bronchoscopy in malignant central airway obstruction by extra-pulmonary malignancy

Background

Interventional bronchoscopy is considered an effective treatment option for malignant central airway obstruction (MCAO). However, there are few reports of interventional bronchoscopy in patients with MCAOs due to extra-pulmonary malignancy. Therefore, the objective of this study was to investigate treatment outcomes and prognostic factors for bronchoscopic intervention in patients with MCAO due to extra-pulmonary malignancy.

Methods

We retrospectively analyzed consecutive 98 patients with MCAO due to extra-pulmonary malignancy who underwent interventional bronchoscopy between 2004 and 2014 at Samsung Medical Center (Seoul, Korea).

Results

The most common primary site of malignancy was esophageal cancer (37.9%), followed by thyroid cancer (16.3%) and head & neck cancer (10.2%). Bronchoscopic interventions were usually performed using a combination of mechanical debulking (84.7%), stent insertion (70.4%), and laser cauterization (37.8%). Of 98 patients, 76 (77.6%) patients had MCAO due to progression of malignancy, and 42 (42.9%) patients had exhausted all other anti-cancer treatment at the time of bronchoscopic intervention. Technical success was achieved in 89.9% of patients, and acute complications and procedure-related deaths occurred in 20.4% and 3.1% of patients, respectively. Reduced survival was associated with MCAO due to cancer other than thyroid cancer or lymphoma, mixed lesions, and not receiving adjuvant treatment after bronchoscopic intervention.

Conclusions

Bronchoscopic intervention could be a safe and effective procedure for MCAO due to end-stage extra-pulmonary malignancies. In addition, we identified possible prognostic factors for poor survival after intervention, which could guide clinicians select candidates that will benefit from bronchoscopic intervention.

Immunological Aspects of Cryoablation of Non-Small Cell Lung Cancer: A Comprehensive Review

In cryoimmunotherapy, target tumors are treated with cryoablation to generate antitumor immune responses. Because immune checkpoint inhibitors have demonstrated that lung cancer can be an immunotherapy-responsive disease, there has been renewed interest in the immunological aspects of cryoablation of lung cancer. Herein, we review preclinical and clinical trials of cryoablation of primary lung tumors. We examine the magnitude of cryoablation-induced antitumor immune responses and the synergy between cryoablation and either other immunotherapies or molecular targeted therapies to improve treatment responses in advanced lung cancer. We further discuss a rationale for the addition of cryoablation to immune checkpoint inhibitors for the treatment of advanced lung cancer, which is currently under clinical investigation.

Assessment of Bronchial Obstruction Using Lateral Pressure Measurement during Bronchoscopy

BACKGROUND

In patients with bronchial obstruction estimating the location of the maximal obstruction is crucial for guiding interventional bronchoscopy. However, flow-volume curves cannot discriminate between the right and left lungs.

OBJECTIVES

The aim of this study was to physiologically evaluate bronchial obstruction during interventional bronchoscopy.

METHODS

We prospectively measured lateral airway pressure (Plat) at either side of the obstruction using a double-lumen catheter (pressure-pressure [P-P] curve) simultaneously to assess the degree of bronchial obstruction in 22 patients. The shape of the P-P curve was assessed to confirm the site of maximal obstruction.

RESULTS

In the experimental study, Plat was uniform between both bronchi in the normal model. For the unilateral and bilateral obstruction models, a phase shift was only seen for the more obstructed side. In healthy subjects, the angle of the P-P curve was close to 45° and linear in shape. In patients with bronchial obstruction, the angle was much smaller but approached 45° after the bronchoscopic procedure. The degree of bronchial obstruction was significantly correlated with the angle of the P-P curve (r = -0.51, p < 0.01). Dyspnea significantly increased when the airway lumen was obstructed by more than 60% (p < 0.0001), and when the P-P curve appeared loop-shaped (p < 0.01).

CONCLUSIONS

The shape of the P-P curve could be used to detect the site of maximal obstruction for the optimal positioning of the stent and assess the need for additional procedures in real time in patients with bronchial obstruction.

[Argon-laser ablation is a new method of airways recanalization for tumoral stenosis]

AIM

To develop the new method of laser recanalization of airways for tumoral stenosis.

MATERIAL AND METHODS

It is proposed to conduct laser effect in the gas environment that does not support combustion (argon). Also the device for these AIM: is suggested. The method is called argon-laser ablation (ALA). A comparison of ALA and conventional high-energy laser exposure (LPD) was performed.

RESULTS

ALA and LPD were used in 46 patients and 17 patients with non-small cell lung cancer. The duration of endobronchial operations and incidence of complications were significantly higher in group 2. The incidence of complete remission was significantly higher in group 1.

CONCLUSION

Endobronchial argon-laser ablation of tracheal and bronchial tumors removes exophytic tumoral component in more favorable conditions compared with conventional high-energy laser exposure. Also it significantly increases an efficiency and reduces the frequency of complications.

Obstruction of the right stem bronchus due to ovarian local metastasis: a 5-year follow-up

Currently interventional bronchoscopy is used for debulking, desobstruction and airway patency stabilization. The interventional techniques are being used for both benign and malignant cases. There are two types of stents that are currently being used, silicon and self-expandable metallic. The method of application and stent remains for the treating physician to choose. In the current case we will present a case of metastatic disease from ovarian cancer in the airway lumen and a long term follow-up.

Laser tracheobronchoplasty: a novel technique for the treatment of symptomatic tracheobronchomalacia

The management of tracheobronchomalacia is a very challenging problem with few treatment options. This study aims to evaluate the outcomes of a novel surgical treatment for membranous tracheobronchomalacia. A consecutive series of patients with tracheobronchomalacia were treated with two to three holmium laser scarring surgeries of the hyperdynamic tracheal and bronchial walls for the purpose of stiffening them through fibrosis. Patients filled out a Dyspnea Index questionnaire before and after treatment. Ten patients were treated for their tracheobronchomalacia with a mean age of 54 years. Symptoms included severe dyspnea, dry cough, recurrent pulmonary infections, and respiratory failure. Fifty percent of patients presented with wheezing refractory to traditional treatment. Tracheobronchomalacia was associated with gastroesophageal reflux disease (n = 8), obstructive sleep apnea (n = 5), and tracheal stenosis (n = 3). Only 50 % of patients presented with morbid obesity. All cases showed significant improvement of their respiratory symptoms with a mean postoperative difference of 22.3 out of a maximum impairment score of 40 (P < 0.01) on the Dyspnea Index. The mean number of procedures was 2.3 per patient with the average laser energy delivered per procedure of 1600 J. Laser tracheobronchoplasty is a safe, easy to adopt, and effective technique for the treatment of membranous tracheobronchomalacia. It presents a simple alternative to the commonly used procedures like endoluminal stenting and open tracheobronchoplasty.

Role of the Interventional Pulmonologist in the Intensive Care Unit

Interventional pulmonology is a new field within the pulmonary and critical care medicine specialty with a focus on invasive diagnostic and therapeutic modalities in airway and pleural disorders. The interventional pulmonologist is highly qualified to take a prominent role in the intensive care unit in a consultative fashion to provide assistance with pleural procedures, establishment and care of artificial airways, and management of patients with respiratory failure attributable to structural central airway disorders. The presence of a dedicated operator with advanced skills facilitates access to specialized procedures in an expeditious and safe manner. Clear communication between the interventional pulmonologist and intensivist is vital to ensure a collaborative effort that delivers optimal patient care.

Placement of self-expandable bifurcated metallic stents without use of fluoroscopic and guidewire guidance to palliate central airway lesions

Background

Self-expandable metallic stents (SEMS) can be used to treat malignant obstructions and fistulas of the central airways. SEMS can be placed using different methods. Recently, a rigid bronchoscope has been used for stent placement without the need for fluoroscopy. We retrospectively evaluated patients for whom SEMS were placed using a rigid bronchoscope, without employing guidewires or fluoroscopy. We describe the intra- and post-procedural complications of the method.

Methods

Data collected between January 2014 and July 2015 were retrospectively evaluated by reference to hospital records.

Results

The mean patient age was 58.14 ± 8.48 years (44–72 years) and 13 out of the 14 patients were male. Twelve had lung cancer, one a thyroid papillary carcinoma with a bronchomediastinal fistula, and one an esophageal carcinoma with a tracheoesophageal fistula. Covered metallic Y-shaped stents were placed in all patients. Before placement, argon plasma coagulation was performed on two patients, diode laser treatment on four, and de-obstruction on nine. No procedure-related mortality was noted. Only two patients required follow-up in the intensive care unit; they were moved to a regular ward after two days. No patient required stent replacement or repositioning. The most common early complication was mucus plugs.

Conclusion

Endobronchial placement of covered self-expandable metallic stents was safe and readily performed in patients with airway obstructions. Neither fluoroscopic nor guidewire guidance was required. Neither patients nor staff were exposed to radiation, and costly guidewire guidance was not necessary. The procedure is cost-effective.

Safety and Complications of Medical Thoracoscopy

Objectives. To highlight the possible complications of medical thoracoscopy (MT) and how to avoid them. Methods. A retrospective and prospective analysis of 127 patients undergoing MT in Nagoya Medical Center (NMC) and Toyota Kosei Hospital. The data about complications was obtained from the patients, notes on the computer system, and radiographs. Results. The median age was 71.0 (range, 33.0-92.0) years and 101 (79.5%) were males. The median time with chest drain after procedure was 7.0 (range, 0.0-47.0) days and cases with talc poudrage were 30 (23.6%). Malignant histology was reported in 69 (54.3%), including primary lung cancer in 35 (27.5), mesothelioma in 18 (14.2), and metastasis in 16 (12.6). 58 (45.7%) revealed benign pleural diseases and TB was diagnosed in 15 (11.8%). 21 (16.5%) patients suffered from complications including lung laceration in 3 (2.4%), fever in 5 (3.9%) (due to hospital acquired infection (HAI) in 2, talc poudrage in 2, and malignancy in 1), HAI in 2 (1.6%), prolonged air-leak in 14 (11.0%), and subcutaneous emphysema in 1 (0.8%). Conclusions. MT is generally a safe procedure. Lung laceration is the most serious complication and should be managed well. HAI is of low risk and can be controlled by medical treatment.

Interventional pulmonology approaches in the diagnosis and treatment of early stage non small cell lung cancer

Lung cancer management is complex and requires a multi-disciplinary approach to provide comprehensive care. Interventional pulmonology (IP) is an evolving field that utilizes minimally invasive modalities for the initial diagnosis and staging of suspected lung cancers. Endobronchial ultrasound guided sampling of mediastinal lymph nodes for staging and detection of driver mutations is instrumental for prognosis and treatment of early and later stage lung cancers. Advances in navigational bronchoscopy allow for histological sampling of suspicious peripheral lesions with minimal complication rates, as well as assisting with fiducial marker placements for stereotactic radiation therapy. Furthermore, IP can also offer palliation for inoperable cancers and those with late stage diseases. As the trend towards early lung cancer detection with low dose computed tomography is developing, it is paramount for the pulmonary physician with expertise in lung nodule management, minimally invasive sampling and staging to integrate into the paradigm of multi-specialty care.

Left and right lung asynchrony as a physiological indicator for unilateral bronchial obstruction in interventional bronchoscopy

BACKGROUND

In patients with bronchial obstruction, pulmonary function tests may not change significantly after intervention. The airflow asynchrony in both lungs due to unilateral bronchial obstruction may be applicable as a physiological indicator. The airflow asynchrony is reflected by the difference in the left and right lung sound development at tidal breathing.

OBJECTIVES

To investigate the usefulness of left and right lung asynchrony due to unilateral bronchial obstruction as a physiological indicator for interventional bronchoscopy.

METHODS

Fifty cases with central airway obstruction were classified into three groups: tracheal, bronchial and extensive obstruction. The gap index was defined as the absolute value of the average of gaps between the left and right lung sound intensity peaks for a 12-second duration.

RESULTS

Before interventional bronchoscopy, the gap index was significantly higher in the bronchial (p<0.05) and extensive obstruction groups (p<0.05) than in the tracheal group. The gap index in cases with unilateral bronchial obstruction of at least 80% (0.18±0.04 seconds) was significantly higher than in cases with less than 80% obstruction (0.02±0.01 seconds, p<0.05). After intervention for bronchial obstruction, the dyspnea scale (p<0.001) and gap index significantly improved (p<0.05), although no significant improvements were found in spirometric assessments. The responder rates for dyspnea were 79.3% for gap indexes over 0.06 seconds and 55.6% for gap indexes of 0.06 seconds or under.

CONCLUSIONS

Assessment of left and right lung asynchrony in central airway obstruction with bronchial involvement may provide useful physiological information for interventional bronchoscopy.

Role of interventional pulmonology in the management of complicated parapneumonic pleural effusions and empyema

Pleural infection is a major problem that affects 80,000 cases per year in the UK and USA. It is increasing in incidence, and in an ageing population, it presents a complex challenge that requires a combination of medical therapies and may lead to the need for surgery. This article focuses on the role of the interventional pulmonologist in the diagnosis and management of pleural infection. In particular, we examine the role of pleural ultrasound in diagnostics, thoracocentesis and real-time guided procedures, and the current management strategies, including the controversial role of medical thoracoscopy.

Use of lung-preserving surgery in left inflammatory bronchial occlusion and distal atelectasis: preliminary results

OBJECTIVES

Lung-preserving surgery was proved to be effective and safe to treat patients with benign bronchial strictures. However, this surgical treatment has been rarely reported in patients with complete occlusion in the left main bronchus. The aim of this study was to assess the value of this procedure and report our experience in the treatment of these patients with left atelectasis caused by inflammatory bronchial occlusion.

METHODS

We reviewed and analysed the medical records of 8 patients who had undergone left main bronchus sleeve resection for symptomatic left atelectasis caused by inflammatory bronchial occlusion from May 2007 to April 2011.

RESULTS

Eight patients (3 men and 5 women) with a medical history of active pulmonary tuberculosis were involved in this study. The median age was 23 years. Parenchyma-sparing left main bronchus resection was performed in 4 patients, 1 of whom received partial wedge resection in the lingual lobe. Left main bronchus sleeve resection plus superior lobectomy was performed in 2 patients and left main bronchus sleeve resection plus left inferior lobectomy in 2 patients, 1 of whom received additional partial wedge resection of the lingual lobe. The procedure was completed successfully in all 8 patients without postoperative deaths. The mean follow-up time was 49.3 months, ranging from 23 to 69 months. No major complications, including stenosis and atelectasis, were observed during the follow-up period. The symptoms of pulmonary atelectasis disappeared and pulmonary ventilation function improved significantly.

CONCLUSIONS

In symptomatic patients with left atelectasis caused by inflammatory bronchial occlusion, lung-preserving surgery is an effective and safe surgical treatment.

Tracheal stenosis after tracheostomy treated successfully with papillotome electrocautery

A 39-year-old woman presented with symptoms of dyspnea. Ten years previously, she had received a tracheostomy because of the decision to not continue taking an anticonvulsant drug. Presently, chest computed tomography showed diffuse stenosis and focal web at the cervical trachea. We performed bronchoscopy and found a two-thirds reduction of the upper trachea due to the web-like fibrotic stenosis. Papillotome electrocautery removed the stenotic lesion. Endobronchial electrocautery is a valuable tool with potential for therapy of an endobronchial obstructing airway lesion. We report this case to introduce the successful treatment with papillotome electrocautery.

Critical airway obstruction by mediastinal masses in the intensive care unit

Critical airway obstruction is a dreaded complication of a mediastinal mass. The acute management is difficult and catastrophic outcomes have been reported. A total of 19 patients, aged between 13 and 69 years, who had critical major airway obstruction due to mediastinal mass requiring mechanical ventilation were reviewed. Three patients had benign pathologies (retrosternal goitre, bronchogenic cyst, giant left atrium) and three had lymphoma. The remaining patients had advanced malignancies: metastatic mediastinal lymphadenopathy (n=6), thyroid carcinoma (n=1) and oesophageal carcinoma (n=6). Three patients underwent surgery, three received chemotherapy and 15 had airway stenting under deep intravenous sedation. Apart from one patient who had brain haemorrhage and nosocomial infection after cardiac surgery, all other patients were successfully weaned off ventilation within five days after the interventions to alleviate the major airway obstruction without major complications. All patients were discharged from hospital without supplemental oxygen. Patients who had benign pathologies and lymphoma (n=6, 32%) were still alive after a mean follow-up period of six years (range 3 to 10) and those with metastatic disease died after a mean survival period of 3.3 months (range 1 to 9). In summary, critical major airway obstruction is caused by a heterogeneous group of mediastinal pathologies, and the definitive treatment and long-term prognosis of these patients are highly dependent on the underlying aetiology. Combining various therapeutic modalities can lead to successful separation of these patients from mechanical ventilation within a short period of time.

Anesthetic considerations for interventional pulmonary procedures

PURPOSE OF REVIEW

To discuss the anesthetic considerations of various procedures now performed by the interventional pulmonologist. With recent technological advances, many of these procedures represent acceptable alternatives to the invasive surgical procedures. For example, the placement of endobronchial valves can substitute for lung reduction surgery and can greatly reduce the postoperative recovery period. However, many of these complex procedures require anesthesia services. The nature and indication for the procedure as well as the patient's overall health will have an impact on the anesthetic choice.

RECENT FINDINGS

New studies have documented common complications from interventional pulmonology procedures and recent ways to avoid these complications have been suggested. Strategies to avoid obstruction, bleeding, pneumothorax and air embolism are discussed in this article. Potential benefits of high frequency jet ventilation in reducing airway pressures and, perhaps, barotraumas are cited. Novel interventional pulmonary procedures are described.

SUMMARY

As the array of diagnostic and therapeutic pulmonary interventions is expanding, the types of anesthetic techniques and ventilatory modes are varying to fit the procedural requirements. Some pulmonary procedures are best accomplished in the lightly sedated patient, who is breathing spontaneously, whereas procedures that use the working channel of a rigid bronchoscope are better performed in the patient under general anesthesia and mechanical ventilation that often use jet ventilation to minimize respiratory movements.