British Thoracic Society guidelines on diagnostic flexible bronchoscopy

Oxygenation during Endobronchial Ultrasound: Where do we stand?

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[Clinical practice guidelines for bronchoalveolar lavage in Chinese children (2024)]

Bronchoalveolar lavage (BAL) has become an important technique in the diagnosis and treatment of respiratory diseases in children. In order to standardize the clinical application of BAL in children, the Branch of Pediatric Critical Care Physicians of Chinese Medical Association, in collaboration with other institutions, has developed the "Clinical practice guidelines for bronchoalveolar lavage in Chinese children (2024)" based on the principles of the World Health Organization guidelines and the formulation/revision principles of the Chinese clinical practice guidelines (2022 edition). This guideline provides 30 recommendations to guide the operational procedures of BAL in children.

Comparative evaluation of lignocaine nebulization with and without dexmedetomidine for flexible videoendoscopic guided awake nasal intubation for general anaesthesia

Background and Aims

Awake fibreoptic intubation is considered a safe approach in airway management of a patient with difficult airway. Awake fibreoptic endoscopy needs appropriate anaesthesia of airway to suppress airway reflexes and prevent discomfort. We planned this study to evaluate effect of adding dexmedetomidine to lignocaine nebulization on conditions for awake videoendoscopic intubation.

Material and Methods

In this prospective randomized double blind controlled study, ninety six ASA grade I, II patients of either gender, aged 18-65 years, scheduled for elective surgeries under general anaesthesia, were randomly allocated into two groups, Group D and L to receive nebulization with 4% Lignocaine 5 ml + Dexmedetomidine 2 mcg/kg and 4% Lignocaine alone respectively, 20 min before procedure. Time taken to intubate the patient, ease of intubation assessed by cough severity score, patient comfort score, post-intubation patient satisfaction and hemodynamic changes were recorded and compared.

Results

Group D and L had comparable intubation time (196.8 ± 61.2 s) and (205.8 ± 52.2 s) (p = 0.437). Cough severity, patient comfort and quality of procedure with post intubation patient satisfaction score were significantly better in Group D. Haemodynamics parameters were better post nebulization in group D as compared to group L.

Conclusion

Addition of Dexmedetomidine 2 mcg/kg with 4% Lignocaine during nebulization improves intubating conditions during awake flexible videoendoscopy in terms of ease of intubation, cough severity, patients comfort and satisfaction along with providing stable Haemodynamics profile.

The clinical yield of bronchoscopy in the management of cystic fibrosis: A retrospective multicenter study

BACKGROUND

Pulmonary disease is the leading cause of morbidity and mortality in people with cystic fibrosis (pwCF). Several studies have shown no benefit for bronchoscopy and bronchoalveolar lavage (BAL) over sputum to obtain microbiological cultures, hence the role of bronchoscopy in pwCF is unclear.

AIM

To analyze how bronchoscopy results affected clinical decision-making in pwCF and assess safety.

METHODS

A retrospective analysis of all charts of pwCF from three CF centers in Israel, between the years 2008 and 2019. We collected BAL culture results as well as sputum cultures obtained within 1 month of the BAL sample. A meaningful yield was defined as a decision to start antibiotics, change the antibiotic regimen, hospitalize the patient for treatment, or the resolution of the problem that led to bronchoscopy (e.g., atelectasis or hemoptysis).

RESULTS

During the study years, of the 428 consecutive patient charts screened, 72 patients had 154 bronchoscopies (2.14 bronchoscopies/patient). Forty-five percent of the bronchoscopies had a meaningful clinical yield. The finding of copious sputum on bronchoscopy was strongly associated with a change in treatment (OR: 5.25, 95%CI: 2.1-13.07, p < 0.001). BAL culture results were strongly associated with a meaningful yield, specifically isolation of Aspergillus spp. (p = 0.003), Haemophilus influenza (p = 0.001). Eight minor adverse events following bronchoscopy were recorded.

CONCLUSIONS

In this multicenter retrospective analysis of bronchoscopy procedures from three CF centers, we have shown that a significant proportion of bronchoscopies led to a change in treatment, with no serious adverse events. Our findings suggest that bronchoscopy is a safe procedure that may assist in guiding treatment in some pwCF. Future studies should evaluate whether BAL-guided decision-making may also lead to a change in clinical outcomes in pwCF.

Estimation of the median effective dose and the 95% effective dose of alfentanil required to inhibit the bronchoscopy reaction during painless bronchoscopy with i-gel supraglottic airway device: an Up-and-Down Sequential Allocation Trial

Background

In practice, the optimal dose of alfentanil that should be used when painless bronchoscopy is performed is unknown. The purpose of this study was to investigate the effective dose of alfentanil in suppressing bronchoscopy responses to painless bronchoscopy with an i-gel supraglottic airway device.

Methods

Patients aged 18-70 years, with American Society of Anesthesiologists (ASA) physical status I-II, who planned to undergo painless bronchoscopy were recruited for this study. Alfentanil was administered intravenously 2 minutes before propofol administration. The response to bronchoscopy was measured, including oxygen saturation (SPO₂) and changes in respiratory rhythm. The median effective dose of alfentanil (ED₅₀) required to alleviate responses to the bronchoscopy was calculated using Dixon's up-and-down method in the female and male groups. Probit analysis was used to generate a dose-response curve in each group.

Results

A total of 48 patients were recruited for the study including 25 females and 23 males. The ED₅₀ of alfentanil for suppressing responses to painless bronchoscopy in females and males was 13.68±4.75 and 17.96±3.45 µg/kg, respectively. The difference was not statistically significant between the two groups (P=0.078). Probit analysis showed the ED₅₀ of alfentanil in female bronchoscopy was 12.4 µg/kg [95% confidence interval (CI): 4.5 to 17 µg/kg]. In men, the ED₅₀ of alfentanil was 16.4 µg/kg (95% CI: 12.1 to 20.1 µg/kg). According to the probit analysis, the 95% effective dose (ED₉₅) of alfentanil was 22.4 µg/kg (95% CI: 17.5 to 67.3 µg/kg) in female bronchoscopy. In men, the ED₉₅ of alfentanil was 23.3 µg/kg (95% CI: 19.8 to 46.2 µg/kg).

Conclusions

Our data suggest that there were no obvious differences between men and women in the effective dose of alfentanil in painless bronchoscopy.

Deep learning for anatomical interpretation of video bronchoscopy images

Anesthesiologists commonly use video bronchoscopy to facilitate intubation or confirm the location of the endotracheal tube; however, depth and orientation in the bronchial tree can often be confused because anesthesiologists cannot trace the airway from the oropharynx when it is performed using an endotracheal tube. Moreover, the decubitus position is often used in certain surgeries. Although it occurs rarely, the misinterpretation of tube location can cause accidental extubation or endobronchial intubation, which can lead to hyperinflation. Thus, video bronchoscopy with a decision supporting system using artificial intelligence would be useful in the anesthesiologic process. In this study, we aimed to develop an artificial intelligence model robust to rotation and covering using video bronchoscopy images. We collected video bronchoscopic images from an institutional database. Collected images were automatically labeled by an optical character recognition engine as the carina and left/right main bronchus. Except 180 images for the evaluation dataset, 80% were randomly allocated to the training dataset. The remaining images were assigned to the validation and test datasets in a 7:3 ratio. Random image rotation and circular cropping were applied. Ten kinds of pretrained models with < 25 million parameters were trained on the training and validation datasets. The model showing the best prediction accuracy for the test dataset was selected as the final model. Six human experts reviewed the evaluation dataset for the inference of anatomical locations to compare its performance with that of the final model. In the experiments, 8688 images were prepared and assigned to the evaluation (180), training (6806), validation (1191), and test (511) datasets. The EfficientNetB1 model showed the highest accuracy (0.86) and was selected as the final model. For the evaluation dataset, the final model showed better performance (accuracy, 0.84) than almost all human experts (0.38, 0.44, 0.51, 0.68, and 0.63), and only the most-experienced pulmonologist showed performance comparable (0.82) with that of the final model. The performance of human experts was generally proportional to their experiences. The performance difference between anesthesiologists and pulmonologists was marked in discrimination of the right main bronchus. Using bronchoscopic images, our model could distinguish anatomical locations among the carina and both main bronchi under random rotation and covering. The performance was comparable with that of the most-experienced human expert. This model can be a basis for designing a clinical decision support system with video bronchoscopy.

Severe mediastinitis and pericarditis after endobronchial ultrasound-guided transbronchial needle aspiration: A case report

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a safe and minimally invasive diagnostic tool for mediastinal and hilum evaluation. However, infectious complications may occur after EBUS-TBNA. Among these, mediastinitis and pericarditis are rare.

CASE SUMMARY

A 67-year-old woman was referred to our hospital due to paratracheal lymph node enlargement on chest computed tomography (CT). EBUS-TBNA was performed on the lymph node lesions, and prophylactic oral antibiotics were administered. Seven days after EBUS-TBNA, the patient visited the emergency room with a high fever and chest pain. Laboratory test results revealed leukocytosis with a left shift and elevated C-reactive protein level (25.7 mg/dL). Chest CT revealed the formation of a mediastinal abscess in the right paratracheal lymph node and pericardial and bilateral pleural effusions. The patient received intravenous antibiotic treatment, cardiac drainage through pericardiocentesis, and surgical management. The patient recovered favorably and was discharged 31 d after the operation.

CONCLUSION

Mediastinitis and pericarditis after EBUS-TBNA are rare but should be considered even after the use of prophylactic antibiotics.

Modified high-flow nasal cannula oxygen therapy versus conventional oxygen therapy in patients undergoing bronchoscopy: a randomized clinical trial

Background

Hypoxemia frequently occurs during bronchoscopy. High-flow nasal cannula (HFNC) oxygen therapy may be a feasible alternative to prevent the deterioration of gas exchange during bronchoscopy. With the convenience of clinical use in mind, we modified an HFNC using a single cannula. This clinical trial was designed to test the hypothesis that a modified HFNC would decrease the proportion of patients with a single moment of peripheral arterial oxygen saturation (SpO₂) < 90% during bronchoscopy.

Methods

In this single-center, prospective randomized controlled trial, hospitalized patients in the respiratory department in need of diagnostic bronchoscopy were randomly assigned to a modified HFNC oxygen therapy group or a conventional oxygen therapy (COT) group. The primary outcome was the proportion of patients with a single moment of SpO₂ < 90% during bronchoscopy.

Results

Eight hundred and twelve patients were randomized to the modified HFNC (n = 406) or COT (n = 406) group. Twenty-four patients were unable to cooperate or comply with bronchoscopy. Thus, 788 patients were included in the analysis. The proportion of patients with a single moment of SpO₂ < 90% during bronchoscopy in the modified HFNC group was significantly lower than that in the COT group (12.5% vs. 28.8%, p < 0.001). There were no significant differences in the fraction of inspired oxygen between the two groups. The lowest SpO₂ during bronchoscopy and 5 min after bronchoscopy in the modified HFNC group was significantly higher than that in the COT group. Multivariate analysis showed that a baseline forced vital capacity (FVC) < 2.7 L (OR, 0.276; 95% CI, 0.083–0.919, p = 0.036) and a volume of fluid instilled > 60 ml (OR, 1.034; 95% CI, 1.002–1.067, p = 0.036) were independent risk factors for hypoxemia during bronchoscopy in the modified HFNC group.

Conclusions

A modified HFNC could decrease the proportion of patients with a single moment of SpO₂ < 90% during bronchoscopy. A lower baseline FVC and large-volume bronchoalveolar lavage may predict desaturation during bronchoscopy when using a modified HFNC.

Trial registration ClinicalTrials. Gov: NCT02606188. Registered 17 November 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01744-8.

Transbronchial Needle Aspiration Cytology and Purulent Pericarditis

Endobronchial ultrasound with transbronchial needle aspiration (TBNA) is commonly performed for the evaluation of mediastinal lymphadenopathy. Purulent pericarditis is a rare, yet potentially fatal complication of TBNA. It commonly presents with nonspecific symptoms such as chest pain, shortness of breath, palpitations, or vague abdominal discomfort. Additionally, more severe symptoms such as cardiac tamponade and even death have been reported. In this article, we present the case of a 58-year-old male who developed purulent pericardial effusion with tamponade thought to be caused by TBNA cytology. This case raises an important question regarding the current guidelines for prophylactic antibiotic treatment for patients at high risk of developing purulent pericarditis as a complication of TBNA.

Comparison of Respiratory Effects between Dexmedetomidine and Propofol Sedation for Ultrasound-Guided Radiofrequency Ablation of Hepatic Neoplasm: A Randomized Controlled Trial

Patient’s cooperation and respiration is necessary in percutaneous radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). We compared the respiratory patterns of dexmedetomidine and propofol sedation during this procedure. Participants were randomly allocated into two groups: the continuous infusions of dexmedetomidine-remifentanil (DR group) or the propofol-remifentanil (PR group). We measured the tidal volume for each patient’s respiration during one-minute intervals at five points and compared the standard deviation of the tidal volumes (SDvt) between the groups. Sixty-two patients completed the study. SDvt at 10 min was not different between the groups (DR group, 108.58 vs. PR group, 149.06, p = 0.451). However, SDvt and end-tidal carbon dioxide (EtCO₂) level of PR group were significantly increased over time compared to DR group (p = 0.004, p = 0.021; ß = 0.14, ß = −0.91, respectively). Heart rate was significantly decreased during sedation in DR group (p < 0.001, ß = −2.32). Radiologist satisfaction was significantly higher, and the incidence of apnea was lower in DR group (p = 0.010, p = 0.009, respectively). Compared with propofol-remifentanil, sedation using dexmedetomidine-remifentanil provided a lower increase of the standard deviation of tidal volume and EtCO₂, and also showed less apnea during RFA of HCC.

A randomised study of comfort during bronchoscopy comparing conscious sedation and anaesthetist-controlled general anaesthesia, including the utility of bispectral index monitoring

Background

The difference in patient comfort with conscious sedation versus general anaesthesia for bronchoscopy has not been adequately assessed in a randomised trial. This study aimed to assess if patient comfort during bronchoscopy with conscious sedation is noninferior to general anaesthesia.

Methods

96 subjects were randomised to receive conscious sedation or general anaesthesia for bronchoscopy. The primary outcome was subject comfort. Secondary outcomes included willingness to undergo a repeat procedure if necessary and level of sedation assessed clinically and by bispectral index (BIS) monitoring.

Results

There was no significant difference between subject comfort scores (difference -0.01, 95% CI -0.63-0.61 on a 10-point scale; p=0.97) or willingness to undergo a repeat procedure (97.7% versus 91.8%, 95% CI -4.8-15.5%; p=0.37). Deeper levels of sedation in the general anaesthesia cohort was confirmed with both clinical and BIS monitoring. There was no significant difference in diagnostic accuracy (conscious sedation 93.9%, 95% CI 80.4-98.3% versus general anaesthesia 86.5%, 95% CI 72.0-94.1%; p=0.43). There were more complications (29.6%, 95% CI 18.2-44.2% versus 6.1%, 95% CI 2.1-16.5%; p<0.01) in the general anaesthesia group. There was no relationship between high BIS scores and subject discomfort. BIS levels <40 during a procedure were associated with increased complications.

Conclusion

Conscious sedation is not inferior to general anaesthesia in providing patient comfort during bronchoscopy, despite lighter sedation, and is associated with fewer complications and comparable diagnostic accuracy. BIS monitoring may have a role in preventing complications associated with deeper sedation.

A Before-and-After Study of Evidence-Based Recommendations for On-Call Bronchoscopy

BACKGROUND

Bronchoscopy is widely used and regarded as standard of care in most intensive care units (ICUs). Data concerning recommendations for on-call bronchoscopy are lacking.

OBJECTIVES

Evaluation of recommendations, complications, and outcome of on-call bronchoscopies.

METHOD

A retrospective single-centre analysis was conducted in a large university hospital. All on-call bronchoscopies performed outside normal working hours in the year before (period 1) and after (period 2) establishing a catalogue of recommendations for indications of on-call bronchoscopy on November 1, 2016, were included.

RESULTS

Overall, 924 bronchoscopies in 538 patients were analysed. A relative reduction of 83.6% from 794 bronchoscopies in 432 patients (1.84 per patient) during period 1 to 130 in 107 patients (1.21 per patient) during period 2 was observed. Most bronchoscopies (812/924, 87.9%) were performed in ICUs, and 416 patients (77.3%) were intubated. Bronchoscopies for excessive secretions decreased significantly during period 2. Fifty-three of 130 bronchoscopies (40.8%) fulfilled the specified recommendations during period 2, in comparison with 16.8% in period 1 (p < 0.001). Complications were recorded in 58 of 924 procedures (6.3%) and were more frequent in period 2, especially moderate bleeding. In-hospital mortality of patients undergoing on-call bronchoscopy did not differ between periods and was 28.7 and 30.2% in periods 1 and 2, respectively.

CONCLUSION

The introduction of recommendations for on-call bronchoscopy led to a significant decline of on-call bronchoscopies without negatively affecting outcome. More evidence is needed in on-call bronchoscopy, especially for ICU patients with intrinsic higher complication rates.

Epigenome-scale comparison of DNA methylation between blood leukocytes and bronchial epithelial cells

Aim: Agreement in DNA methylation (DNAm) at the genome scale between blood leukocytes (BL) and bronchial epithelial cells (BEC) is unknown. We examine as to what extent DNAm in BL is comparable with that in BEC and serves as a surrogate for BEC. Materials & methods: Overall agreement (paired t-tests with false discovery rate adjusted p > 0.05) and consistency (Pearson's correlation coefficients >0.5) between two tissues, at each of the 767,412 CpGs, were evaluated. Results: We identified 247,721 CpGs showing overall agreement and 47,371 CpGs showing consistency in DNAm. Identified CpGs are involved in certain immune pathways, indicating the potential of using blood as a biomarker for BEC at those CpGs in lower airway-related diseases. Conclusion: CpGs showing overall agreement and those without overall agreement are distributed differently on the genome.

Bronchoscopy for diagnosis of COVID-19 with respiratory failure: A case report

BACKGROUND

Although the imaging features of coronavirus disease 2019 (COVID-19) are starting to be well determined, what actually occurs within the bronchi is poorly known. Here, we report the processes and findings of bronchoscopy in a patient with COVID-19 accompanied by respiratory failure.

CASE SUMMARY

A 65-year-old male patient was admitted to the Hainan General Hospital on February 3, 2020 for fever and shortness of breath for 13 d that worsened for the last 2 d. The severe acute respiratory syndrome coronavirus 2 nucleic acid test was positive. Routine blood examination on February 28 showed a white blood cell count of 11.02 × 10⁹/L, 86.9% of neutrophils, 6.4% of lymphocytes, absolute lymphocyte count of 0.71 × 10⁹/L, procalcitonin of 2.260 ng/mL, and C-reactive protein of 142.61 mg/L. Oxygen saturation was 46% at baseline and turned to 94% after ventilation. The patient underwent video bronchoscopy. The tracheal cartilage ring was clear, and no deformity was found in the lumen. The trachea and bilateral bronchi were patent, while the mucosa was with slight hyperemia; no neoplasm or ulcer was found. Moderate amounts of white gelatinous secretions were found in the dorsal segment of the left inferior lobe, and the bronchial lumen was patent after sputum aspiration. The right inferior lobe was found with hyperemia and mucosal erosion, with white gelatinous secretion attachment. The patient’s condition did not improve after the application of therapeutic bronchoscopy.

CONCLUSION

For patients with COVID-19 and respiratory failure, bronchoscopy can be performed under mechanical ventilation to clarify the airway conditions. Protection should be worn during the process. Considering the risk of infection, it is not necessary to perform bronchoscopy in the mild to moderate COVID-19 patients.

Awake fiberoptic orotracheal intubation: a protocol feasibility study

Objective

To assess the feasibility of an awake fiberoptic intubation (AFOI) protocol.

Methods

We enrolled 40 patients with simulated difficult intubation. The protocol consisted of conscious sedation (midazolam, 0.03 mg/kg and sufentanil, 0.1 µg/kg), regional anesthesia, and intubation. The time, first-attempt intubation success rate, hemodynamic parameters, blood oxygen saturation (SpO₂), intubation amnesia rate, patient satisfaction, and relative complications were recorded.

Results

AFOI was completed in all patients. The average total AFOI time was 14.17 ± 1.47 minutes, and the time to placing the landmark-guided bilateral superior laryngeal nerve block was 1.24 ± 0.42 minutes. The first-attempt intubation success rate was 97.5%, and patient satisfaction was 90%. Blood pressure changed (<20%) briefly after administering conscious sedation. Heart rates did not change significantly, and SpO₂ remained stable and ≥95%. Three patients had a sore throat, which resolved on postoperative day 1 without other complications. On postoperative day 1, 82.5% (33/40) of the patients had no recall of AFOI, and 17.5% (7/40) had only an indistinct memory.

Conclusions

The protocol was feasible with a high first-attempt intubation success rate and low complications rate. Hemodynamic parameters and respiration remained stable, with high patient satisfaction and effective amnesia.

Performance of real-time PCR and immunofluorescence assay for diagnosis of Pneumocystis pneumonia in real-world clinical practice

Background

PCR is more sensitive than immunofluorescence assay (IFA) for detection of Pneumocystis jirovecii. However, PCR cannot always distinguish infection from colonization. This study aimed to compare the performance of real-time PCR and IFA for diagnosis of P. jirovecii pneumonia (PJP) in a real-world clinical setting.

Methods

A retrospective cohort study was conducted at a 1,300-bed hospital between April 2017 and December 2018. Patients whose respiratory sample (bronchoalveolar lavage or sputum) were tested by both Pneumocystis PCR and IFA were included. Diagnosis of PJP was classified based on multicomponent criteria. Sensitivity, specificity, 95% confidence intervals (CI), and Cohen's kappa coefficient were calculated.

Results

There were 222 eligible patients. The sensitivity and specificity of PCR was 91.9% (95% CI, 84.0%–96.7%) and 89.7% (95% CI, 83.3%–94.3%), respectively. The sensitivity and specificity of IFA was 7.0% (95% CI, 2.6%–14.6%) and 99.2% (95% CI, 95.6%–100.0%), respectively. The percent agreement between PCR and IFA was 56.7% (Cohen's kappa -0.02). Among discordant PCR-positive and IFA-negative samples, 78% were collected after PJP treatment. Clinical management would have changed in 14% of patients using diagnostic information, mainly based on PCR results.

Conclusions

PCR is highly sensitive compared with IFA for detection of PJP. Combining clinical, and radiological features with PCR is useful for diagnosis of PJP, particularly when respiratory specimens cannot be promptly collected before initiation of PJP treatment.

Be aware of misdiagnosis tied to COVID-19 focusing: a case report of abciximab-induced alveolar haemorrhage thought to be SARS-CoV-2 in a patient with ST-segment elevation myocardial infarction

Background

Early diagnosis of diffuse alveolar haemorrhage (DAH) can be extremely difficult, as the common clinical picture is often attributed to more common clinical conditions. High degree of suspicion is key to diagnosis which can be much more difficult during the coronavirus disease 2019 (COVID-19) pandemic.

Case summary

A 61-year-old man with inferolateral ST-segment elevation myocardial infarction treated by a stent to the left circumflex artery and intravenous abciximab treatment was started for the high thrombus burden. Two hours later, the patient developed dyspnoea and hypoxaemia. Chest examination revealed diffuse rales over both lung fields. Chest X-ray revealed bilateral diffuse alveolar infiltrates, while the echocardiography was normal. Chest computed tomography (CT) was performed and the ‘crazy paving appearance’, which is the typical radiological finding of COVID-19, was reported. The patient was considered to be suspected of COVID-19 and was transferred to a quarantine unit. Real-time reverse transcriptase–polymerase chain reaction (RT-PCR) test was obtained and azithromycin and hydroxychloroquine were initiated. 48 h later, 2.6 mmol/L reduction was observed in haemoglobin levels and haemoptysis was developed. After the second negative RT-PCR with an interval of 24 h, CT was repeated and the patient was diagnosed to have abciximab-induced DAH. The patient was later followed up conventionally and discharged after two weeks without additional complications.

Discussion

DAH and COVID-19 might share common clinical and radiological findings during examination. The physicians must be aware of the high motivation of the COVID-19 pandemic which can lead to misdiagnosis by overlooking other important clinical conditions.

Profiling of H3K27Ac Reveals the Influence of Asthma on the Epigenome of the Airway Epithelium

Background

Asthma is a chronic airway disease driven by complex genetic–environmental interactions. The role of epigenetic modifications in bronchial epithelial cells (BECs) in asthma is poorly understood.

Methods

We piloted genome-wide profiling of the enhancer-associated histone modification H3K27ac in BECs from people with asthma (n = 4) and healthy controls (n = 3).

Results

We identified n = 4,321 (FDR < 0.05) regions exhibiting differential H3K27ac enrichment between asthma and health, clustering at genes associated predominately with epithelial processes (EMT). We identified initial evidence of asthma-associated Super-Enhancers encompassing genes encoding transcription factors (TP63) and enzymes regulating lipid metabolism (PTGS1). We integrated published datasets to identify epithelium-specific transcription factors associated with H3K27ac in asthma (TP73) and identify initial relationships between asthma-associated changes in H3K27ac and transcriptional profiles. Finally, we investigated the potential of CRISPR-based approaches to functionally evaluate H3K27ac-asthma landscape in vitro by identifying guide-RNAs capable of targeting acetylation to asthma DERs and inducing gene expression (TLR3).

Conclusion

Our small pilot study validates genome-wide approaches for deciphering epigenetic mechanisms underlying asthma pathogenesis in the airways.

Airway Blocks Vs LA Nebulization- An interventional trial for Awake Fiberoptic Bronchoscope assisted Nasotracheal Intubation in Oral Malignancies

Background:

Patients with intra-oral malignancies warrants use of awake Fiberoptic assisted naso-thracheal intubation to secure an airway due to multiple risk factors leading to anticipated difficult airway. Different techniques such as airway blocks, local anesthesia (LA) gargles, spray, nebulization and mild sedation are in practice to improve the success rate of fiberoptic assisted intubation.

Methods:

Sixty patients of ASA I and II with Mallampatti score 3 and above, posted for Commando operations were enrolled in this study and were divided into 2 groups. Group AB (Airway Block, n=30) were given Superior laryngeal nerve block bilaterally and recurrent laryngeal nerve block transtracheally with Inj 2% Lignocaine. Second Group AN (Airway Nebulization, n=30) patients airway was nebulized with 4% Lignocaine with ultrasonic nebulizer. After confirmation of satisfactory anesthesia clinically Fiber-optic assisted naso-tracheal intubation was attempted. Hemodynamic monitoring, total time taken for intubation, patients comfort and any complications occurred were noted. Statistical Analysis– All the observed values were tabulated and analyzed using software SPSS version 17.0.

Results:

Demography and Hemodynamic observations were comparable in the groups. The time taken for intubation, patient comfort score, intubation conditions were excellent in AB group than in group AN. Airway complications like laryngospasm and cough were noted in AN Group.

Conclusions:

Judicial use of combined Airway blocks such as Bilateral Superior and trans-tracheal recurrent laryngeal nerve blocks could facilitate a successful fiber-optic assisted awake naso-tracheal intubation in anticipated difficult intubation with negligible complications.

Oxygen desaturation during flexible bronchoscopy with propofol sedation is associated with sleep apnea: the PROSA-Study

BACKGROUND

Obstructive sleep apnea (OSA) is characterized by repetitive episodes of complete or partial obstruction of the upper airways during sleep. Conscious sedation for flexible bronchoscopy (FB) places patients in a sleep-like condition. We hypothesize that oxygen desaturation during flexible bronchoscopy may help to detect undiagnosed sleep apnea.

METHODS

Single-centre, investigator-initiated and driven study including consecutive patients undergoing FB for clinical indication. Patients completed the Epworth Sleepiness Scale (ESS), Lausanne NoSAS score, STOP-BANG questionnaire and the Berlin questionnaire and underwent polygraphy within 7 days of FB. FB was performed under conscious sedation with propofol. Oxygen desaturation during bronchoscopy was measured with continuous monitoring of peripheral oxygen saturation with ixTrend (ixellence GmbH, Germany).

RESULTS

145 patients were included in the study, 62% were male, and the average age was 65.8 ± 1.1 years. The vast majority of patients (n = 131, 90%) proved to fulfill OSA criteria based on polygraphy results: 52/131 patients (40%) had mild sleep apnea, 49/131 patients (37%) moderate sleep apnea and 30/131 patients (23%) severe sleep apnea. Patients with no oxygen desaturation had a significantly lower apnea-hypopnea index than patients with oxygen desaturation during bronchoscopy (AHI 11.94/h vs 21.02/h, p = 0.011). This association remained significant when adjusting for the duration of bronchoscopy and propofol dose (p = 0.023; 95% CI 1.382; 18.243) but did not hold when also adjusting for age and BMI.

CONCLUSION

The severity of sleep apnea was associated to oxygen desaturation during flexible bronchoscopy under conscious sedation. Patients with oxygen desaturation during bronchoscopy might be considered for sleep apnea screening.

TRIAL REGISTRATION

The Study was approved by the Ethics Committee northwest/central Switzerland, EKNZ (EK 16/13) and was carried out according to the Declaration of Helsinki and Good Clinical Practice guidelines. Due to its observational character, the study did not require registration at a clinical trial registry.

Effect of 4% nebulized lignocaine versus 2% nebulized lignocaine for awake fibroscopic nasotracheal intubation in maxillofacial surgeries

Introduction

Securing a difficult airway during maxillofacial surgeries is a great challenge for anesthetists, and the flexible fiber-optic bronchoscope is the gold standard while managing such cases. While passing the flexible bronchoscope by the nasal route, the success rate is higher as compared with oral approach as the nasopharynx is in line with the larynx and prevents acute angulation in the oropharynx.

Materials and Methods

A randomized control trial was planned in 73 patients out of whom sixty patients gave consent for the procedure. The patients we randomly divided into two groups (n = 30) with application of 4% nebulized lignocaine in one group and the use of 2% nebulized lignocaine in the other group, and the patient's comfort was noted using five-point Puchner scale.

Results

The mean value of patient comfort Puchner scale of Group A was 1.30 ± 0.08 and of Group B was 2.23 ± 0.12. The mean value of Puchner scale of Group B was significantly higher (41.8%) as compared to Group A (t = 6.208; df = 51; P < 0.0001). The secondary outcome measures were optimal intubating conditions and hemodynamic changes during awake fiber-optic nasotracheal intubation. The procedural time of two groups when compared showed that the mean procedural time of Group A was shorter (29.67 ± 5.40 min) than the time consumed in Group B (34.93 ± 5.52 min).

Conclusion

Four percent nebulized lidocaine provided adequate airway anesthesia and optimal intubating conditions along with stable hemodynamics for awake fiber-optic intubation as compared to 2% nebulized lidocaine.

Clinical Characteristics of and Risk Factors for Fever after Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Retrospective Study Involving 6336 Patients

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic for mediastinal and hilar lymphadenopathy/mass. This study investigated fever incidence and associated risk factors after EBUS-TBNA in 6336 patients who underwent EBUS-TBNA at Asan Medical Center from October 2008 to February 2018. Bronchoscopists evaluated participants’ medical records for fever the 24 h following EBUS-TBNA. Patients were placed in either a Fever group (n = 665) or a non-Fever group (n = 5671). Fever developed in 665 of 6336 patients (10.5%) with a mean peak body temperature of 38.3 °C (range, 37.8–40.6 °C). Multivariate analysis revealed that fever-associated risk factors after EBUS-TBNA are older age (adjusted OR 0.015, 95% CI (0.969–0.997), p = 0.015), bronchoscopic washing (adjusted OR 1.624, 95% CI (1.114–2.368), p = 0.012), more than four samples of EBUS-TBNA (adjusted OR 2.472, 95% CI (1.288–4.745), p = 0.007), hemoglobin levels before EBUS-TBNA (adjusted OR 0.876, 95% CI (0.822–0.933), p < 0.001), CRP levels before EBUS-TBNA (adjusted OR 1.115, 95% CI (1.075–1.157), p < 0.001), and a diagnosis of EBUS-TBNA tuberculosis (adjusted OR 3.409, 95% CI (1.870–6.217), p < 0.001). Clinicians should be aware of the possibility of fever after EBUS-TBNA because it is common. Additional, prospective, large-scale research should assess the need for prophylactic antibiotics for EBUS-TBNA.

Evaluation of a bronchoscopy guidance system for bronchoscopy training, a randomized controlled trial

BACKGROUND

Conventional training in bronchoscopy is performed either on patients (apprenticeship model) or phantoms. While the former is associated with increased rate of patient complications, procedure time, and amount of sedation, the latter does not offer any form of feedback to the trainee. This paper presents a study which investigates whether a bronchoscopy guidance system may be a helpful tool for training of novice bronchoscopists.

METHODS

A randomized controlled study with 48 medical students was carried out with two different groups (control and test group, each N = 24). Whereas the control group performed a conventional bronchoscopy on phantom the test group carried out an Electromagnetic Navigation Bronchoscopy (ENB) for tracking of the bronchoscopal tip in the bronchial system. All volunteers had a common task: to perform a complete and systematic diagnostic bronchoscopy within 10 min.

RESULTS

The test group examined significantly more lobes than the control group (p = 0.009). Due to the real-time feedback of the system, all students of test group felt more confident having analyzed the entire lung. Additionally, they were unanimous that the system would be helpful during the next bronchoscopy.

CONCLUSIONS

In sum, this technology may play a major role in unsupervised learning by improving accuracy, dexterity but above all by increasing the confidence of novices, students as well as physicians. Due to good acceptance, there may be a great potential of this tool in clinical routine.

Management of hemoptysis in patients with lung cancer

Hemoptysis related to malignancy is common and accounts for nearly a quarter of all cases of hemoptysis in the US, and approximately 20% of patients with lung cancer will experience some degree of hemoptysis during their disease course. Both minor and massive hemoptysis come with diagnostic and treatment challenges and are associated with increased mortality. We will discuss the definition and epidemiology of hemoptysis related to malignancy, outline our approach to the initial evaluation and diagnostic workup, and extensively review the management of minor and massive hemoptysis. Specific emphasis will be on relevant signs and symptoms, imaging, and the role of bronchoscopy, and the differences in approach for minor hemoptysis compared to massive hemoptysis. While the role of surgical management is very limited in this patient population, the role of endobronchial and endovascular management will be discussed in detail.

Multiple microbiologic tests for tuberculosis improve diagnostic yield of bronchoscopy in medically complex patients

Background: Bronchoalveolar lavage (BAL) is indicated for medical evaluation of complex cases of lung disease.  There is limited data on the performance of tuberculosis (TB) microbiologic tests on BAL in such patients, particularly in human immunodeficiency virus (HIV) and TB endemic areas. Methods: We evaluated the performance of Mycobacterium tuberculosis (Mtb) culture and up to two simultaneous Xpert MTB/RIF tests on BAL fluid against a consensus clinical diagnosis in 98 medically complex patients undergoing bronchoscopy over a two-year period in Durban, South Africa. Results: TB was the most frequently diagnosed lung disease, found in 19 of 98 participants (19%) and was microbiologically proven in 14 of these (74%); 9 (47%) were culture positive and 5 were positive on at least one Xpert MTB/RIF assay. Immunosuppression prevalence was high (26% HIV-infected, 29% on immunosuppressive therapy and 4% on chemotherapy). Xpert MTB/RIF had low sensitivity (45%) and high specificity (99%) when assessed against the consensus clinical diagnosis. Compared to TB culture, a single Xpert MTB/RIF increased the diagnostic yield by 11% and a second Xpert MTB/RIF by a further 16%. Conclusion: Although Xpert MTB/RIF had a low sensitivity, sending two tests improved the microbiologically-proven diagnostic yield of bronchoscopy from 47% to 74% compared to culture alone.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Chinese multidisciplinary expert consensus: Guidelines on percutaneous transthoracic needle biopsy

Biopsy has been used to diagnose thoracic diseases for more than a century. Percutaneous needle biopsy plays a crucial role in the diagnosis, staging, and treatment planning for tumors in the lungs, thoracic wall, hilum, and mediastinum. With the continuous improvement in imaging techniques, the range of clinical applications for percutaneous needle biopsy is also expanding. It has become important to improve Chinese professionals’ and technicians’ understanding of percutaneous transthoracic needle biopsy (PTNB) in order to standardize operating procedures and to strengthen perioperative management. However, there is currently no Chinese expert consensus that provides systematic standardization and guidance for PTNB in clinical practice. The Committee of Chinese Society of Interventional Oncology (CSIO) of the Chinese Anti‐Cancer Association (CACA) initiated a Chinese multidisciplinary expert consensus on PTNB. The consensus includes image‐guided methods, indications, contraindications, multidisciplinary team recommendations, biopsy procedures, daytime/outpatient biopsy, complications, pathological examination, and management of negative results.

2018 recommendations for the management of community acquired pneumonia

Community-acquired pneumonia (CAP) is the leading cause of death worldwide. Despite the vast diversity of respiratory microbiota, Streptococcus pneumoniae remains the most prevalent pathogen among etiologic agents. Despite the significant decrease in the mortality rates for lower respiratory tract infections in recent decades, CAP ranks third as a cause of death in Brazil. Since the latest Guidelines on CAP from the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association) were published (2009), there have been major advances in the application of imaging tests, in etiologic investigation, in risk stratification at admission and prognostic score stratification, in the use of biomarkers, and in the recommendations for antibiotic therapy (and its duration) and prevention through vaccination. To review these topics, the SBPT Committee on Respiratory Infections summoned 13 members with recognized experience in CAP in Brazil who identified issues relevant to clinical practice that require updates given the publication of new epidemiological and scientific evidence. Twelve topics concerning diagnostic, prognostic, therapeutic, and preventive issues were developed. The topics were divided among the authors, who conducted a nonsystematic review of the literature, but giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. All authors had the opportunity to review and comment on all questions, producing a single final document that was approved by consensus.

Can positron emission tomography/computed tomography be predictive of diagnostic success in endobronchial biopsies performed through a fiber-optic bronchoscopy in lung cancer?

PURPOSE

The purpose of this study is to investigate the effect of homogeneous/heterogeneous (necrotic) involvement and maximum standardized uptake value (SUVmax) value of the lesion on positron emission tomography-computed tomography (PET-CT) of patients who underwent fiberoptic bronchoscopy (FOB) for prediagnosis of lung cancer and biopsy for endobronchial lesion on the diagnostic success of biopsy procedure.

METHODS

Between January 2014 and December 2016, patients with final diagnosis of pulmonary malignancy as determined by FOB biopsy and patients who failed to be diagnosed by FOB biopsy and diagnosed with pulmonary malignancy by a different diagnostic method were examined. These patients were divided into two groups as those with diagnosis by FOB biopsy (Group 1) and those who failed to be diagnosed by this method and diagnosed with pulmonary malignancy by a different diagnostic method (Group 2). The SUVmax values of the two groups were compared with lesion characteristics of homogeneous, heterogeneous involvement/presence of necrotic component as shown by PET-CT. Group data were assessed by Chi-square test and Mann-Whitney U-test. In all tests, P < 0.05 was considered significant.

FINDINGS

A total of 193 participants with a mean age of 61 ± 9.4 were included in the study. There were 128 (66.3%) cases in Group 1 and 65 (33.7%) cases in Group 2. The mean SUVmax value was 16.4 in Group 1 and 15.1 in Group 2. There was no statistically significant difference between the two groups (P = 0.329). Homogeneous involvement was present in 103 (80.3%) cases in Group 1 versus 42 (64.6%) cases in Group 2. In the presence of homogeneous PET-CT involvement, diagnosis rate by biopsy was significantly higher (P = 0.016).

CONCLUSION

We concluded that the high SUVmax value of the mass lesion on PET-CT did not increase the diagnostic value of the biopsy procedure in patients prediagnosed with lung cancer and that the diagnostic success of FOB biopsy was poor in cases where PET-CT showed heterogeneous involvement of the mass lesion.

The location, histologic type, and stage of lung cancer are associated with bleeding during endobronchial biopsy

Background

Several risk factors have been proposed for bleeding during bronchoscopy, including immunosuppression, thrombocytopenia, pulmonary arterial hypertension, and mechanical ventilation. However, research on bronchoscopic biopsy-induced bleeding in the population of lung cancer without these “proposed risk factors” remains lacking.

Patients and methods

A total of 531 lung cancer patients with endobronchial biopsy (EBB) were enrolled in this retrospective observational study. Patients were divided into biopsy-induced bleeding group (n=162) and non-bleeding group (n=369). Using multiple logistic regression, independent risk factors for EBB bleeding were identified.

Results

The location, histologic type, and stage of lung cancer were independently associated with EBB bleeding, as assessed by multiple logistic regression (p<0.05) in patients with lung cancer. Moreover, during EBB, the risk of bleeding of endobronchial lesions located in the central airways was significantly higher when compared to that in peripheral bronchi (odds ratio [OR], 2.211; 95% CI, 1.276–3.830; p=0.005). In addition, squamous cell carcinoma and small-cell lung carcinoma were more susceptible to bleeding during biopsy when compared with adenocarcinoma (OR, 3.107, 2.389; 95% CI, 1.832–5.271, 1.271–4.489; p=0.000, p=0.007, respectively). Patients with advanced lung cancer were more prone to EBB bleeding compared to patients in the early stages of disease (OR, 1.583; 95% CI, 1.065–2.354; p=0.023).

Conclusion

Lesions located in the central airways, histologic types of squamous cell carcinoma and small-cell lung carcinoma, and stages of advanced lung cancer were the independent risk factors for hemorrhage in EBB.

Role of Lignocaine Nebulization as an Adjunct to Airway Blocks for Awake Fiber-Optic Intubation: A Comparative Study

Context

Airway management is a crucial skill and area of concern for the anesthesiologist. Awake fiber-optic intubation (AFOI) remains the gold standard in managing difficult airway. Anaesthetizing the airway along with psychological assurance is the mainstay for Preparation of AFOI. Different topical and regional techniques have been developed to subdue reflexes and facilitate AFOI.

Aim

This randomized controlled study was performed to evaluate the effectiveness of using lignocaine nebulization in addition to specific airway blocks for AFOI.

Methodology

This was a comparative study conducted in 60 patients with difficult airway (LEMON score >2) and randomly allocated into two groups of 30 each. Group LB and Group NB received nebulization of 2% lignocaine 4 mL and 0.9% normal saline 4 mL, respectively. Both groups were then given airway blocks as bilateral superior laryngeal (2% lignocaine 1-2 mL each) and transtracheal (2% lignocaine 4 mL) block. Two puffs of 10% lignocaine to nose and postnasal space on each side were given in both groups. Fiber-optic bronchoscopy (FOB)-guided tracheal intubation was Performed. Vital parameters, side effects, bronchoscopy-guided intubation time and other parameters as intubation grading scale, patient comfort score, satisfaction score were recorded. Chi-square test and unpaired t-test were used for statistical analysis.

Results

Statistically, no significant differences were found in hemodynamic parameters, demographics, intubation time, and intubation grading scale in both groups. However, overall patient comfort and satisfaction score was better in Group LB.

Conclusion

Upper airway blocks provide adequate anesthesia for awake FOB, but when lignocaine nebulization is added to these blocks, it improves the quality of anesthesia and patient satisfaction.

Diagnostic Evaluation of Pulmonary Abnormalities in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation

Pulmonary complications (PC) of hematologic malignancies and their treatments are common causes of morbidity and mortality. Early diagnosis is challenging due to host risk factors, clinical instability, and provider preference. Delayed diagnosis impairs targeted treatment and may contribute to poor outcomes. An integrated understanding of clinical risk and radiographic patterns informs a timely approach to diagnosis and treatment. There is little prospective evidence guiding optimal modality and timing of minimally invasive lung sampling; however, a low threshold for diagnostic bronchoscopy during the first 24 to 72 hours after presentation should be a guiding principle in high-risk patients.

Transbronchial biopsy in the management of pulmonary complications of hematopoietic stem cell transplantation

The utility of transbronchial biopsy in the management of pulmonary complications following hematopoietic stem cell transplantation has shown variable results. Herein, we examine the largest case series of patients undergoing transbronchial biopsy following hematopoietic stem cell transplantation. We performed a retrospective analysis of 130 transbronchial biopsy cases performed in patients with pulmonary complications post-hematopoietic stem cell transplantation. Logistic regression models were applied to examine diagnostic yield, odds of therapy change and complications. The most common histologic finding on transbronchial biopsy was a non-specific interstitial pneumonitis (n= 24 cases, 18%). Pathogens identified by transbronchial biopsy were rare, occurring in < 5% of cases. A positive transbronchial biopsy significantly increased the odds of a subsequent change in corticosteroid therapy (OR=3.12, 95% CI 1.18–8.23; p=0.02) but was not associated with a change in antibiotic therapy (OR=1.01, 95% CI 0.40–2.54; p=0.98) or changes in overall therapy (OR=1.92, 95% CI 0.79–4.70; p=0.15). Patients who underwent a transbronchial biopsy had increased odds of complications related to the bronchoscopy (OR=3.33, 95% CI 1.63–6.79; p=0.001). In conclusion, transbronchial biopsy may contribute to the diagnostic management of non-infectious lung injury post-hematopoietic stem cell transplantation, while its utility in the management of infectious pulmonary complications of HSCT remains low.

A systematic approach to the management of massive hemoptysis

Massive hemoptysis is regarded as a potentially lethal condition that requires immediate attention, and prompt action. Although minor hemoptysis is frequently encountered by most clinicians, massive hemoptysis in far less frequent and most physicians are not prepared to manage this time-sensitive clinical presentation in a systematic and timely fashion. Critical initial steps in management need to be implemented in an expedited fashion, such that patients may have a chance at a more definitive treatment. In this article, we review the definition, vascular anatomy, etiology, diagnostic evaluation, epidemiology and prognostic markers of massive hemoptysis. A systematic approach to management, stabilization and treatment options is followed. An algorithm is proposed for the management of massive hemoptysis and the importance of a multidisciplinary approach is emphasized.

Adverse outcomes after percutaneous dilatational tracheostomy versus surgical tracheostomy in intensive care patients: case series and literature review

Tracheostomy is a routinely done procedure in the setting of intensive care unit (ICU) in patients requiring prolonged mechanical ventilation. There are two ways of making a tracheostomy: an open surgical tracheostomy and percutaneous dilatational tracheostomy. Percutaneous dilatational tracheostomy is associated with fewer complications than open tracheostomy. In this study, we would like to compare both techniques of performing a tracheostomy in ICU patients and to present possible complications, methods of diagnosing and treating and minimizing their risk.

Toll-like Receptor 7 Is Reduced in Severe Asthma and Linked to an Altered MicroRNA Profile

RATIONALE

Asthma is one of the most common chronic diseases worldwide, and individuals with severe asthma experience recurrent exacerbations. Exacerbations are predominantly viral associated and have been linked to defective airway IFN responses. Ascertaining the molecular mechanisms underlying this deficiency is a major research goal to identify new therapeutic targets.

OBJECTIVES

We investigated the hypothesis that reduced Toll-like receptor 7 (TLR7)-derived signaling drove the impaired IFN responses to rhinovirus by asthmatic alveolar macrophages (AMs); the molecular mechanisms underlying this deficiency were explored.

METHODS

AMs were recovered from bronchoalveolar lavage from healthy subjects and patients with severe asthma. Expression of pattern-recognition receptors and microRNAs was evaluated by quantitative polymerase chain reaction and Western blotting. A TLR7-luciferase reporter construct was created to evaluate binding of microRNAs to the 3' untranslated region of TLR7. IFN production was measured by quantitative polymerase chain reaction and ELISA.

MEASUREMENTS AND MAIN RESULTS

The expression of TLR7 was significantly reduced in severe asthma AMs and was associated with reduced rhinovirus and imiquimod-induced IFN responses by these cells compared with healthy AMs. Severe asthma AMs also expressed increased levels of three microRNAs, which we showed were able to directly reduce TLR7 expression. Ex vivo knockdown of these microRNAs restored TLR7 expression with concomitant augmentation of virus-induced IFN production.

CONCLUSIONS

In severe asthma, TLR7 deficiency drives impaired innate immune responses to virus by AMs. Blocking a group of microRNAs that are up-regulated in these cells can restore antiviral innate responses, providing a novel approach for therapy in asthma.

Endobronchial aspergilloma: A case report and literature review

The present study aimed to investigate the clinical and radiological characteristics in addition to the bronchoscopic appearance in patients with endobronchial aspergilloma (EBA). Clinical and radiological characteristics were analyzed alongside the bronchoscopic appearance in 17 patients with EBA diagnosed by bronchoscopy with histological examination. The present study assessed the relevant literature and 13 males and 4 females were included in the comparison, with a median age of 59. Associated diseases included 8 previous diagnoses of pulmonary tuberculosis (47.6%), 4 previous diagnoses lung cancer (23.5%), 1 pulmonary resection (5.9%) and 1 bronchial foreign body (5.9%). The primary symptom was hemoptysis (9/17, 53%). Chest computed tomography (CT) indicated a markedly higher incidence of aspergillosis lesion in the left lung (13/17; 76.5%) compared with the right lung (4/17; 23.5%). CT manifestation included space occupying disease in 10 patients (58.8%), aspergilloma in 3 patients (17.6%), pneumonic consolidation in 2 patients (11.8%) and ground glass opacity in 1 patient (5.9%). Bronchoscopy examination identified masses in all 17 patients' bronchial lumen and 15 patients had endobronchial obstruction by necrotic material. The case presented in the current study demonstrated the merits of combining bronchosopic intervention with voriconazole. The dominant symptom of EBA was hemoptysis. Chest CT demonstrated that aspergillosis lesions were more frequently identified in the left lung compared with the right. EBA often occurs in individuals with underlying lung diseases, which cause lumen structural change or bronchial obstruction. EBA may be clearly diagnosed by bronchoscopy biopsy, although the potential for a co-exististing tumor requires consideration. Bronchoscopic intervention and anti-fungal therapy may have an advantage in the effective treatment of patients with EBA.

Effect of Prior Atorvastatin Treatment on the Frequency of Hospital Acquired Pneumonia and Evolution of Biomarkers in Patients with Acute Ischemic Stroke: A Multicenter Prospective Study

Objective. To investigate whether prior treatment of atorvastatin reduces the frequency of hospital acquired pneumonia (HAP). Methods. Totally, 492 patients with acute ischemic stroke and Glasgow Coma Scale ≤ 8 were enrolled in this study. Subjects were assigned to prior atorvastatin treatment group (n = 268, PG) and no prior treatment group (n = 224, NG). All the patients were given 20 mg atorvastatin every night during their hospital stay. HAP frequency and 28-day mortality were measured. Levels of inflammatory biomarkers [white blood cell (WBC), procalcitonin (PCT), tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6)] were tested. Results. There was no significant difference in the incidence of HAP between PG and NG (25.74% versus. 24.55%, p > 0.05) and 28-day mortality (50.72% versus 58.18%, p > 0.05). However, prior statin treatment did modify the mortality of ventilator associated pneumonia (VAP) (36.54% versus 58.14%, p = 0.041) and proved to be a protective factor (HR, 0.564; 95% CI, 0.310~0.825, p = 0.038). Concentrations of TNF-α and IL-6 in PG VAP cases were lower than those in NG VAP cases (p < 0.01). Conclusions. Prior atorvastatin treatment in patients with ischemic stroke was associated with a lower concentration of IL-6 and TNF-α and improved the outcome of VAP. This clinical study has been registered with ChiCTR-ROC-17010633 in Chinese Clinical Trial Registry.

The respiratory microbiome in bronchial mucosa and secretions from severe IgE-mediated asthma patients

BACKGROUND

The bronchial microbiome in chronic lung diseases presents an abnormal pattern, but its microbial composition and regional differences in severe asthma have not been sufficiently addressed. The aim of the study was to describe the bacterial community in bronchial mucosa and secretions of patients with severe chronic asthma chronically treated with corticosteroids in addition to usual care according to Global Initiative for Asthma. Bacterial community composition was obtained by 16S rRNA gene amplification and sequencing, and functional capabilities through PICRUSt.

RESULTS

Thirteen patients with severe asthma were included and provided 11 bronchial biopsies (BB) and 12 bronchial aspirates (BA) suitable for sequence analyses. Bacteroidetes, Firmicutes, Proteobacteria and Actinobacteria showed relative abundances (RAs) over 5% in BB, a cutoff that was reached by Streptococcus and Prevotella at genus level. Legionella genus attained a median RA of 2.7 (interquartile range 1.1-4.7) in BB samples. In BA a higher RA of Fusobacteria was found, when compared with BB [8.7 (5.9-11.4) vs 4.2 (0.8-7.5), p = 0.037], while the RA of Proteobacteria was lower in BA [4.3 (3.7-6.5) vs 17.1 (11.2-33.4), p = 0.005]. RA of the Legionella genus was also significantly lower in BA [0.004 (0.001-0.02) vs. 2.7 (1.1-4.7), p = 0.005]. Beta-diversity analysis confirmed the differences between the microbial communities in BA and BB (R² = 0.20, p = 0.001, Adonis test), and functional analysis revealed also statistically significant differences between both types of sample on Metabolism, Cellular processes, Human diseases, Organismal systems and Genetic information processing pathways.

CONCLUSIONS

The microbiota in the bronchial mucosa of severe asthma has a specific pattern that is not accurately represented in bronchial secretions, which must be considered a different niche of bacteria growth.

Implementing flexible bronchoscopy in least developed countries according to international guidelines is feasible and sustainable: example from Phnom-Penh, Cambodia

BACKGROUND

Flexible bronchoscopy is pivotal for the diagnosis of most respiratory diseases. A flexible bronchoscopy unit (FBU) was created in 2008 in the Preah Kossamak university hospital (Phnom Penh, Cambodia) through a cooperation program between a French and a Cambodian team. In 2009 we conducted an assessment of the compliance of the FBU to international standards and found that most of French and British guidelines were fully applied or adapted to local practice. The aim of the current work was to assess FBU again 6 years later, in order to determine if compliance to international guidelines was sustainable.

METHODS

The 2015 evaluation was conducted identically to 2009. All recommendation items from the French and the British Thoracic Societies guidelines were assessed individually. Each recommendation was assigned a status expressing the level at which it was respected in Cambodia: applied, adapted, not applied and not evaluable. An endoscope microbial sampling was performed as recommended by the French Ministry of Health.

RESULTS

Between 2009 and 2015, the pattern of international recommendations in the Cambodian FBU did not change. Notably the rates of applied French evaluable recommendations remained stable: respectively 58% vs 57%. Main changes in French guidelines occurred in adapted items that became applied (n = 5/15) while 4 previously adapted/applied items became not applied. Furthermore, all microbial analyses showed sterile results.

CONCLUSIONS

Our results show that implementation of a high quality FBU in a least-developed country is feasible. In addition, the performance is maintained in the long-term.

Lung cancer screening: detected nodules, what next?

Since the success of the NLST study, the incorporation of lung cancer screening programs into current academic programs has been growing. Center for Medicare and Medicaid Services have acknowledged the importance and potential impact of lung cancer screening by making it a reimbursable study. Based on Fleischner Society Guidelines, many nodules will require follow-up imaging. The remainder of those nodules will need tissue to appropriately make the diagnosis. The use of bronchoscopy with transbronchial biopsy has been a standard technique for many years, but as smaller nodules need to be assessed, more advanced tools, such as endobronchial ultrasound and electromagnetic navigation are now improving the yield on the diagnosis of these smaller peripheral nodules. As electromagnetic navigation and peripheral ultrasound are significant changes from practice only 10 years ago, further advancements in the technology, such as bronchoscopic robots and advanced optical imaging tools, that are becoming available, need to be assessed as to their possible incorporation into the evaluation of peripheral nodules. The ceiling to the diagnosis of these small lesions remains at 70-75%; techniques and tools need to be used to improve upon this to maximize the impact of lung cancer screening and minimize the risk to patients.

Propofol and Remifentanil Sedation for Bronchial Thermoplasty: A Prospective Cohort Trial

BACKGROUND

Bronchial thermoplasty (BT) is a rapidly emerging bronchoscopic treatment for patients with moderate-to-severe asthma. Different sedation strategies are currently used, ranging from mild midazolam sedation to general anesthesia requiring tracheal intubation.

OBJECTIVES

The aim of this study was to assess the feasibility, safety, and both patients' and bronchoscopists' satisfaction with propofol and remifentanil sedation administered by specialized sedation anesthesiology nurses during BT in severe asthma patients.

METHODS

A prospective observational cohort study in BT-treated severe asthma patients of the TASMA trial was designed. Patients were asked to rate their overall BT procedure satisfaction and tolerance with propofol/remifentanil sedation using a visual analogue scale (VAS) ranging from 0 to 10. Similarly, bronchoscopists were asked to rate patient cooperation and tolerance. Sedation-associated adverse events and the number of BT activations were recorded.

RESULTS

Thirty-two BT procedures in 13 severe asthma patients were performed under moderate target-controlled infusion (TCI) propofol/remifentanil sedation. Patients' median VAS scores were as follows: overall satisfaction 9.6 (interquartile range [IQR] 8.5-10.0), dyspnea 0.0 (IQR 0.0-0.6), pain 0.1 (IQR 0.0-1.0), cough 0.5 (IQR 0.0-2.1), and anxiety 0.1 (IQR 0.0-0.7). Bronchoscopists' median VAS scores were as follows: overall patient cooperation 9.1 (IQR 8.5-9.6), dyspnea 0.3 (IQR 0.0-0.9), pain 0.2 (IQR 0.0-1.3), cough 1.2 (IQR 0.7-2.0), and discomfort 0.6 (IQR 0.3-1.5). All patients were willing to undergo the procedure again and would recommend this form of sedation to their best friend. One case of conversion to general anesthesia occurred and no serious adverse events were reported.

CONCLUSIONS

Moderate sedation with propofol and remifentanil TCI provided by specialized sedation anesthesiology nurses is feasible and safe and results in high satisfaction rates of both patients and bronchoscopists.

Shifted focus of bronchoalveolar lavage in patients with suspected thoracic malignancy: an analysis of 224 patients

BACKGROUND

Bronchoscopies are extensively adopted for diagnosing and staging thoracic malignancies, but studies are missing as how to keep the process streamlined and more efficient. To evaluate current role of bronchoalveolar lavage (BAL) for cancer and possible infection diagnosis when practicing comprehensive bronchoscopy for patients suspected with thoracic malignancy, and provide foundation for possible practice modification.

METHODS

We retrospectively analyzed a prospectively kept database of immunocompetent patients undergoing bronchoscopy for suspected non-hematologic malignancies. Clinical, radiographic data, bronchoscopic sampling techniques and diagnostic results were recorded. Initially undiagnostic patients were followed up for 2 years for a definitive diagnosis.

RESULTS

Of 224 patients included, 179 (79.9%) were confirmed with active thoracic malignancies. BAL diagnostic yield of cancer based on different radiographic characters of target lesion are as follow: isolated lymphadenopathies 0%, central lesions 45.5%, peripheral masses (diameter ≥3 cm) 21.4%, peripheral large nodules (2≤ diameter <3 cm) 15.8%, and peripheral small nodules (diameter <2 cm) 7.1%, while composite bronchoscopy achieved diagnostic yield of 93.3%, 95.5%, 91.7%, 76.9%, and 66.7% in corresponding lesion types. No cancer was diagnosed solely by BAL-cytology. Proportions of patients with positive BAL culture did not differ significantly between patients with and without pre-test suspicion for infections (P=0.199). In multivariable analysis, infections were associated with age ≥75 (OR 3.0; 95% CI: 1.29-7.06), chronic obstructive pulmonary disease (COPD) (OR 2.7; 95% CI: 1.14-6.26) and diabetes mellitus (DM) (OR 4.5; 95% CI: 1.90-10.44).

CONCLUSIONS

Omitting BAL cytology in settings of comprehensive bronchoscopy may not compromise cancer diagnosis. For patients primarily suspected with thoracic malignancy, performing BAL culture only based on clinical suspicion could miss important infectious etiology.

Diffuse Parenchymal Lung Diseases with Clinicoradiological Discordance: Role of Transbronchial Lung Biopsy as a Diagnostic Tool - An Observational Study

INTRODUCTION

The diagnosis of Diffuse Parenchymal Lung Disease (DPLD) requires a multidisciplinary approach with reconciliation of clinicoradiological and histopathological data. But when the preliminary clinicoradiological profile fails to suggest a diagnosis, an adequate lung biopsy specimen with meticulous histological examination and a multidisciplinary approach usually yields results. There is also a high chance of sampling error due to patchy and heterogeneous involvement of the disease process and due to the small volume of tissue taken. As seen in our study, Trans-Bronchial Lung Biopsy (TBLB) if performed by an experienced bronchoscopist can be done as an outpatient procedure yielding adequate specimens for diagnosis and guide effective treatment in these patients.

AIM

To study the utility and diagnostic yield of TBLB in DPLD patients when there is clinicoradiological discordance.

MATERIALS AND METHODS

The current retrospective observational study was undertaken in the Institute of Chest Diseases, Government Medical College, Kozhikode, Kerala, India, from January 2012 to December 2014. Out of 169 DPLD patients who attended the tertiary care centre, 66 patients without a definite diagnosis by clinicoradiological assessment were included in the study. They underwent TBLB using a fibre-optic video bronchoscope. An open lung biopsy was advised if the TBLB did not yield a definite diagnosis.

RESULTS

Among the 66 patients, histopathological confirmation was obtained in 51 patients, 39 of which were by TBLB (59%). Few diagnoses like invasive adenocarcinoma, Pneumocystis jirovecii pneumonia and Aspergillus infection were least expected.

CONCLUSION

TBLB if performed correctly can be an effective intervening modality in establishing the diagnosis of DPLD before going for an invasive surgical biopsy.

Comparison of Transbronchial and Cryobiopsies in Evaluation of Diffuse Parenchymal Lung Disease

BACKGROUND

Diffuse parenchymal lung diseases (DPLDs) are common. An accurate diagnosis is essential due to differences in etiology, clinicopathologic features, therapeutic options, and prognosis. Transbronchial lung biopsies (TBLBs) are often limited by small specimen size, crush artifact, and other factors. Transbronchial lung cryobiopsies (TBLCs) are under investigation to overcome these limitations.

METHODS

We conducted a retrospective study of 56 patients in a single, tertiary-care academic center to compare the yield of both techniques when performed in the same patient. Patients underwent flexible bronchoscopy using moderate sedation with TBLB followed by TBLC in the most radiographically abnormal areas. Clinical data and postprocedural outcomes were reviewed, with a final diagnosis made utilizing a multidisciplinary approach.

RESULTS

The mean age of patients was 60 years and 54% were male. Comorbidities included COPD (14%) and prior malignancy (48%). The number of TBLB specimens ranged from 1 to 10 per patient (mean 4) and size varied from 0.1 to 0.8 cm. The number of TBLC specimens ranged from 1 to 4 per patient (mean 2) and size ranged from 0.4 to 2.6 cm. Both techniques provided the same diagnosis in 26 patients (46%). An additional 11 (20%) patients had a diagnosis established by adding TBLC to TBLB. Compared with TBLB, TBLC had a higher diagnostic yield in patients with hypersensitivity pneumonitis and interstitial lung disease. Only 2 patients required video-assisted thoracoscopic surgery to establish a diagnosis. Complications included pneumothorax (20%) and massive hemoptysis (2%).

CONCLUSION

TBLC used with TBLB can improve the diagnostic yield of flexible bronchoscopy in patients with DPLD.

Exposure to Mycobacterium tuberculosis during Flexible Bronchoscopy in Patients with Unexpected Pulmonary Tuberculosis

OBJECTIVE

Recent guidelines recommend the use by healthcare personnel of a fit-tested N95 particulate respirator or higher-grade respiratory precaution in a patient undergoing bronchoscopy when pulmonary tuberculosis (PTB) is suspected. However, PTB may be unexpectedly diagnosed in this setting and therefore not evaluated, resulting in the unexpected exposure to Mycobacterium tuberculosis (MTB) of healthcare workers in the bronchoscopy suite. Here, we examined the incidence of unexpected exposure to MTB during flexible bronchoscopy and determined the exposure-related factors.

METHODS

Between 2011 and 2013, a retrospective study was conducted to evaluate unexpected diagnoses of PTB in the bronchoscopy suite. During the study period, 1650 consecutive patients for whom previous CT scans were available and who underwent bronchoscopy for respiratory disease other than PTB were included. The results of bronchial washing, bronchoalveolar lavage, and post-bronchoscopic sputum were reviewed.

RESULTS

PTB was unexpectedly diagnosed in 76 patients (4.6%). The presence of anthracofibrosis [odds ratio (OR), 3.878; 95% confidence interval (CI), 1.291-11.650; P = 0.016), bronchiectasis (OR, 1.974; 95% CI, 1.095-3.557; P = 0.024), or atelectasis (OR, 1.740; 95% CI, 1.010-2.903; P = 0.046) as seen on chest CT scan was independently associated with unexpected PTB. Patients with both anthracofibrosis and atelectasis were at much higher risk of unexpected PTB (OR, 4.606; 95% CI, 1.383-15.342; P = 0.013).

CONCLUSIONS

The risk of MTB exposure by healthcare personnel in the bronchoscopy suite due to patients with undiagnosed PTB has been underestimated. Therefore, in geographic regions with an intermediate PTB prevalence, such as South Korea (97/100,000 persons per year), higher-grade respiratory precaution, such as a fit-tested N95 particulate respirator, should be considered to prevent occupational exposure to MTB during routine bronchoscopy, especially in patients with CT-confirmed anthracofibrosis, bronchiectasis, or atelectasis.

Mechanical Strain Causes Adaptive Change in Bronchial Fibroblasts Enhancing Profibrotic and Inflammatory Responses

Asthma is characterized by periodic episodes of bronchoconstriction and reversible airway obstruction; these symptoms are attributable to a number of factors including increased mass and reactivity of bronchial smooth muscle and extracellular matrix (ECM) in asthmatic airways. Literature has suggested changes in cell responses and signaling can be elicited via modulation of mechanical stress acting upon them, potentially affecting the microenvironment of the cell. In this study, we hypothesized that mechanical strain directly affects the (myo)fibroblast phenotype in asthma. Therefore, we characterized responses of bronchial fibroblasts, from 6 normal and 11 asthmatic non-smoking volunteers, exposed to cyclical mechanical strain using flexible silastic membranes. Samples were analyzed for proteoglycans, α-smooth muscle actin (αSMA), collagens I and III, matrix metalloproteinase (MMP) 2 & 9 and interleukin-8 (IL-8) by qRT-PCR, Western blot, zymography and ELISA. Mechanical strain caused a decrease in αSMA mRNA but no change in either αSMA protein or proteoglycan expression. In contrast the inflammatory mediator IL-8, MMPs and interstitial collagens were increased at both the transcriptional and protein level. The results demonstrate an adaptive response of bronchial fibroblasts to mechanical strain, irrespective of donor. The adaptation involves cytoskeletal rearrangement, matrix remodelling and inflammatory cytokine release. These results suggest that mechanical strain could contribute to disease progression in asthma by promoting inflammation and remodelling responses.

Adult Bronchoscopy Training: Current State and Suggestions for the Future: CHEST Expert Panel Report

BACKGROUND

The determination of competency of trainees in programs performing bronchoscopy is quite variable. Some programs provide didactic lectures with hands-on supervision, other programs incorporate advanced simulation centers, whereas others have a checklist approach. Although no single method has been proven best, the variability alone suggests that outcomes are variable. Program directors and certifying bodies need guidance to create standards for training programs. Little well-developed literature on the topic exists.

METHODS

To provide credible and trustworthy guidance, rigorous methodology has been applied to create this bronchoscopy consensus training statement. All panelists were vetted and approved by the CHEST Guidelines Oversight Committee. Each topic group drafted questions in a PICO (population, intervention, comparator, outcome) format. MEDLINE data through PubMed and the Cochrane Library were systematically searched. Manual searches also supplemented the searches. All gathered references were screened for consideration based on inclusion criteria, and all statements were designated as an Ungraded Consensus-Based Statement.

RESULTS

We suggest that professional societies move from a volume-based certification system to skill acquisition and knowledge-based competency assessment for trainees. Bronchoscopy training programs should incorporate multiple tools, including simulation. We suggest that ongoing quality and process improvement systems be introduced and that certifying agencies move from a volume-based certification system to skill acquisition and knowledge-based competency assessment for trainees. We also suggest that assessment of skill maintenance and improvement in practice be evaluated regularly with ongoing quality and process improvement systems after initial skill acquisition.

CONCLUSIONS

The current methods used for bronchoscopy competency in training programs are variable. We suggest that professional societies and certifying agencies move from a volume- based certification system to a standardized skill acquisition and knowledge-based competency assessment for pulmonary and thoracic surgery trainees.

Sevoflurane-Based General Anesthesia Induction via Nasopharyngeal Endotracheal Tube Prior to Definitive Airway Control in Pediatric Oral Tumors

Airway-related tumors in pediatrics are always challenging for anesthesiologists. We present 2 cases of friable, bleeding large tumors in the oral cavity where conventional methods of securing the airway were not possible. Induction of general anesthesia could potentially lead to complete airway collapse and catastrophic obstruction in such cases. Awake fibrotic intubation is limited in pediatric patients. We describe the innovative use of an endotracheal tube inserted blindly as a nasopharyngeal airway guided by end-tidal carbon dioxide trace. This allowed us to bypass the anatomical obstruction and induce anesthesia using sevoflurane in high-flow oxygen. By the described technique, we were able to maintain and assist the spontaneous breathing of the child as well. We also highlight limitations of the use of a conventional nasopharyngeal airway in such situations.