Interventional Pulmonology: Diagnostic and Therapeutic Advances in Bronchoscopy

A case of congenital bronchial atresia with tracheobronchial stenosis caused by emphysema: Successful management with thoracoscopic surgery

Introduction

Congenital bronchial atresia (CBA), as a rare developmental abnormality of the lung, is usually asymptomatic and is accidently discovered in most cases. Currently, no standardized guidelines for the treatment or management of CBA have been established.

Case presentation

A 22-year-old male soldier was referred to Shanghai Changhai Hospital, The First Affiliated Hospital of Naval Medical University due to chest tightness and shortness of breath after repeated strenuous activities. Contrast-enhanced computed tomography (CT) revealed an 18mm × 11mm solitary, well-circumscribed, and solid nodule with no enhancement in the right upper lobe (RUL), and emphysematous changes distributed throughout the RUL. A flexible bronchoscopic examination showed extrinsic compression stenosis in the bronchial opening of the right middle lobe (RML). After three-dimensional (3D) reconstruction CT and a multidisciplinary consultation, a diagnosis of CBA in the anterior segment (B3) of RUL was established. Subsequently, thoracoscopic right upper lobectomy was performed and resulted in an improved respiratory capacity 6 months after surgery. To date, the patient has good quality of life without any complication.

Conclusion

This study underscores the role of bronchoscopy, 3D reconstruction CT, and a multidisciplinary consultation in the diagnosis of CBA, and highlights that a thoracoscopic intervention should be considered in such case.

Exercise-Induced Pulmonary Hemorrhage in a Non-Athletic Child: Implications for Military Recruits

Hemoptysis is a rare presenting symptom in pediatric and young adult patients with a highly variable outcome ranging from an isolated mild occurrence to severe illness and death. Exercise-induced pulmonary hemorrhage (EIPH) has several reports in adult literature but has not previously been reported in pediatric patients. A 12-year-old female with a history of trisomy X (47, XXX), obesity, depression, anxiety, and obstructive sleep apnea presented to the pediatric pulmonology clinic after several episodes of hemoptysis. Spirometry, imaging, and laboratory evaluation for autoimmune vasculitides and other causes associated with pediatric hemoptysis did not reveal an etiology for the hemoptysis. A combined bronchoscopy with pediatric and adult providers revealed no airway lesions or sources of bleeding. EIPH is a diagnosis of exclusion. This patient was diagnosed with EIPH and had spontaneous resolution with improved fitness. Many military training and service activities are similar to those reported with EIPH. Trainees with various levels of aerobic fitness are at risk of developing EIPH. The hemoptysis evaluation is important for military providers given the range of severity in presentations, even though it is a rare occurrence. In addition to a novel presentation of EIPH, this case demonstrates the value of collaboration between pediatric and adult specialists in the Military Health System (MHS). Military care providers should be aware of this rare phenomenon in service members and trainees who are at risk during maximal aerobic effort.

The Association of Subspecialty and Sex with Industry Payments to Internal Medicine Physicians Who Recently Completed Training

BACKGROUND

Financial relationships with drug and medical device companies may impact quality of care and academic research. However, little is known when and how these financial relationships develop among newly independent physicians who recently completed from residency or fellowship programs in internal medicine (IM).

OBJECTIVE

To compare patterns of industry payments among IM graduates.

DESIGN

Retrospective, observational cohort study.

SUBJECTS

IM graduates from residency or fellowship programs between January 2015 and December 2019.

MAIN MEASURES

We analyzed Open Payments reports made between July 2015 and June 2021 to recent graduates of U.S. Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs in IM. The primary outcome was general payments accepted by these physicians, stratified by procedural (i.e., critical care medicine/pulmonary medicine, cardiac/cardiovascular disease, and gastroenterology) and non-procedural (i.e., infectious disease, general internal medicine, and other specialties) subspecialties. The secondary outcomes included general payments stratified by sex and age at residency or fellowship training completion.

KEY RESULTS

There were 41,669 IM physicians with a median age of 33.0 years. In the first 3 years after completion, the proportion of physicians accepting any general payments was 72.6%, 91.9%, and 86.8% in Critical Care Medicine/Pulmonary Medicine, Cardiac/Cardiovascular Disease, and Gastroenterology, compared to 56.1%, 52.6%, and 52.3% in Infectious Disease, General Internal Medicine, and Other Specialties (p<0.0001). After adjusting for confounding variables, the procedural group showed an increased hazard ratio (HR) for accepting any general payments and at least $5000 of general payments compared to the non-procedural group. The HRs of accepting any general payments in the procedural subspecialty were 2.26 (95% CI, 2.11-2.42) and 2.83 (95% CI, 2.70-2.97) in female and male physicians, respectively (p-value < 0.0001).

CONCLUSION

Industry financial relationships among newly independent physicians in IM exist immediately after completion of training and are influenced by subspecialty, sex, and age.

A prediction model for risk of low oxygen saturation in patients with post-tuberculosis tracheobronchial stenosis during bronchoscopy

BACKGROUND

Low oxygen saturation (LOS) is a frequent occurrence for patients with post-tuberculosis tracheobronchial stenosis (PTTS) during bronchoscopic procedures. However, there are currently no systematic assessment tools to predict LOS risk in PTTS patients during bronchoscopy.

OBJECTIVES

This study aimed to develop an effective preoperative predictive model to guide clinical practice.

DESIGN

Retrospective cohort study.

METHODS

Data was retrospectively collected from PTTS patients who underwent bronchoscopic interventions between January 2017 and December 2022. Among all patients included in this study, patients between January 2017 and December 2021 were used as training cohort for the logistic regression model, and patients between January 2022 and December 2022 were utilized as validation cohort for internal validation. We used consistency index (C-index), goodness-of-fit test and calibration plot to evaluate the model performance.

RESULTS

A total of 465 patients who met the inclusion criteria were enrolled in the study. The overall incidence of LOS was 26.0% (121/465). Comorbidity, degree of stenosis, bronchoscopist level, thermal ablation therapy, balloon dilation, and airway stenting, as independent risk factors for the presence of LOS, were used to construct the nomogram prediction model. The C-index of training cohort was 0.827 (95% CI, 0.786-0.869), whereas that of validation cohort was 0.836 (95% CI, 0.757-0.916), combining with the results of the calibration plot and goodness-of-fit test, demonstrating that this model had good predictive ability.

CONCLUSION

The predictive model and derived nomogram with good predictive ability has been developed to preoperatively predict the risk of LOS in PTTS patients during bronchoscopy, allowing for individualized interventions for high-risk patients.