Blood loss during flexible bronchoscopy: a prospective observational study

Improved diagnostic yield of peripheral pulmonary malignant lesions with emphysema using a combination of radial endobronchial ultrasonography and rapid on-site evaluation

BACKGROUND

This is a retrospective cohort study from a single center of Chest Medical District of Nanjing Brain Hospital Affiliated to Nanjing Medical University, Jiangsu Province, China. It was aim to evaluate the diagnostic value of radial endobronchial ultrasound (R-EBUS) combination with rapid on-site evaluation (ROSE) guided transbronchial lung biopsy (TBLB) for peripheral pulmonary lesions in patients with emphysema.

METHODS

All 170 patients who underwent PPLs with emphysema received an R-EBUS examination with or without the ROSE procedure, and the diagnostic yield, safety, and possible factors influencing diagnosis were analyzed between the two groups by the SPSS 25.0 software.

RESULTS

The pooled and benign diagnostic yields were not different in the two groups (P = 0.224, 0.924), but the diagnostic yield of malignant PPLs was significantly higher in the group with ROSE than the group without ROSE (P = 0.042). The sensitivity of ROSE was 79.10%, the specificity, 91.67%, the positive predictive value, 98.15%, and the negative predictive value, 84.62%. The diagnostic accuracy, was 95.52%. In the group of R-EBUS + ROSE, the procedural time and the number of times of biopsy or brushing were both significantly reduced (all P<0.05). The incidence of pneumothorax (1.20%) and bleeding (10.84%) in the group of R-EBUS + ROSE were also less than those in the group of R-EBUS (P<0.05). The lesion's diameter ≥ 2 cm, the distance between the pleura and the lesion ≥ 2 cm, the positive air bronchograms sign, the location of the ultrasound probe within the lesion, and the even echo with clear margin feature of lesion ultrasonic image, these factors are possibly relevant to a higher diagnostic yield. The diagnostic yield of PPLs those were adjacent to emphysema were lower than those PPLs which were away from emphysema (P = 0.048) in the group without ROSE, however, in the group of R-EBUS + ROSE, there was no such difference whether the lesion is adjacent to emphysema or not (P = 0.236).

CONCLUSION

Our study found that the combination of R-EBUS and ROSE during bronchoscopy procedure was a safe and effective modality to improve diagnostic yield of PPLs with emphysema, especially for malignant PPLs. The distance between the pleura and the lesion ≥ 2 cm, the positive air bronchograms sign, the location of the ultrasound probe within the lesion, and the even echo with clear margin feature of lesion ultrasonic image, these factors possibly indicated a higher diagnostic yield. Those lesions' position is adjacent to emphysema may reduce diagnostic yield but ROSE may make up for this deficiency.

Comments on "Clinical, radiological and histopathological profile of patients with endobronchial lesions on fibreoptic bronchoscopy" by Sarma <em>et al</em>

Dear Editor, The article by Sharma et al. regarding endobronchial biopsy in 120 patients in northern India is an attempt to understand the clinical profile, etiology and pathology of the patients who presented with endobronchial findings. The article concluded that most of the population was middle-aged males with non-small cell carcinoma being the most common diagnosis. However, there are few important points to ponder and understand in the study.

Tranexamic Acid vs Adrenaline for Controlling Iatrogenic Bleeding During Flexible Bronchoscopy: A Double-Blind Randomized Controlled Trial

BACKGROUND

The most commonly used topical hemostatic agents during flexible bronchoscopy (FB) are cold saline and adrenaline. Data on use of other agents such as tranexamic acid (TXA) for this purpose are limited.

RESEARCH QUESTION

Is TXA effective and safe in controlling iatrogenic bleeding during FB compared with adrenaline?

STUDY DESIGN AND METHODS

We conducted a cluster-randomized, double-blind, single-center trial in a tertiary teaching hospital. Patients were randomized in weekly clusters to receive up to three applications of TXA (100 mg, 2 mL) or adrenaline (0.2 mg, 2 mL, 1:10000) after hemostasis failure after three applications of cold saline (4 ° C, 5 mL). Crossover was allowed (for up to three further applications) before proceeding with other interventions. Bleeding severity was graded by the bronchoscopist using a visual analog scale (VAS; 1 = very mild, 10 = severe).

RESULTS

A total of 2,033 FBs were performed and 130 patients were randomized successfully to adrenaline (n = 65) or TXA (n = 65), whereas 12 patients had to be excluded for protocol violations (two patients from the adrenaline arm and 10 patients from TXA arm). Bleeding was stopped in 83.1% of patients (54/65) in both groups (P = 1). The severity of bleeding and number of applications needed for bleeding control were similar in both groups (adrenaline: mean VAS score, 4.9 ± 1.3 [n = 1.8 ± 0.8]; TXA: mean VAS score, 5.3 ± 1.4 [n = 1.8 ± 0.8]). Both adrenaline and TXA were more successful in controlling moderate bleeding (86.7% and 88.7%, respectively) than severe bleeding (40% and 58.3%, respectively; P = .008 and P = .012, respectively) and required more applications for severe bleeding (3.0 ± 0 and 2.4 ± 0.5, respectively) than moderate bleeding (1.7 ± 0.8 and 1.7 ± 0.8, respectively) control (P = .006 and P = .002, respectively). We observed no drug-related adverse events in either group.

INTERPRETATION

We found no significant difference between adrenaline and TXA for controlling noncatastrophic iatrogenic endobronchial bleeding after cold saline failure, adding to the body of evidence that TXA can be used safely and effectively during FB.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT04771923; URL: www.

CLINICALTRIALS

gov.

Complications and safety analysis of diagnostic bronchoscopy in COPD: a systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) often coexists with many diseases that require bronchoscopy. We conducted this systematic review and meta-analysis to assess the safety and complication rate of diagnostic bronchoscopy in patients with COPD.

METHODS

We retrieved clinical trials that reporting the complications of conducting diagnostic bronchoscopy on patients with COPD through electronic databases. Analyses of the overall major complication rate of bronchoscopy and potential risk factors in patients with COPD were conducted.

RESULTS

18 trials/arms were evaluated. The overall major complication rate of bronchoscopy was 4.3% (95% CI, 2.2%-8.2%; 18 trials/arms, n = 2000). The major complication rate of the patients with an exacerbation of COPD was higher than that of the stable patients (7.8% vs. 4.5%, Q-value = 11.29, df (Q) = 1, p < 0.01); using of sedative medicine was also related with higher major complication rate (Q-value = 6.303, df (Q) = 2, p = 0.043). Patients with severe COPD who were GOLD stages III and IV (Q = 13.40, df = 1, p < 0.01; R² = 0.66) or had a high BMI (Q = 30.83, df = 1, p < 0.01; R² = 0.91) more easily encountered complications during bronchoscopy.

CONCLUSIONS

The major complication rate of diagnostic bronchoscopy in patients with COPD was acceptable and low Exacerbations of COPD and using sedative medicine were related with higher major complication rate.

EXPERT OPINION

COPD is a major risk factor for lung cancer and infection, so the patients with COPD often required bronchoscopy. Although our results showed diagnostic bronchoscopy might not be more fatal for patients with COPD, further studies are needed to explore the potential risk factors for major complications of bronchoscopy in patients with COPD.

Comparison of the Detection Rates of Different Diagnostic Methods for Primary Peripheral Lung Cancer

Objective

The present study aims to compare the detection rates of different diagnostic methods for primary peripheral lung cancer (PPLC).

Methods

The detection rate and patient information were collected from a total of 359 cases of PPLC or a suspected diagnosis of lung cancer; among these, 186 cases were simultaneously treated with fibreoptic bronchoscopy, brush inspection and flush inspection, and 173 cases underwent a computed tomography (CT)-guided percutaneous lung biopsy (PNB). The positive detection rates of the different methods were compared.

Results

In the detection of peripheral lesions (diameter of <5 cm), the CT-PNB had the significantly highest detection rate, followed by the combined basic method (fibreoptic bronchoscopy + brushing + flushing). The independent use of the three basic sampling methods showed a significantly lower detection rate compared with the combined use.

Conclusion

In the diagnosis of peripheral lung cancer, the CT-PNB had the best detection rate; hence, it could be used in clinical practice for the diagnosis of such lesions.

Association between blood pressure and the risk of biopsy-induced endobronchial hemorrhage during bronchoscopy

BACKGROUND

Hemorrhage is one of the most common complications of bronchoscopy. Although several hemorrhage risk factors have been proposed, it remains unclear whether blood pressure affects the onset of biopsy-induced endobronchial hemorrhage.

METHODS

We conducted a retrospective cohort study of 643 consecutive adults with lung cancer over an approximately 4-year period (from January 2014 to February 2018) at a large tertiary care hospital. Patients were divided into the hemorrhage group and the non-hemorrhage group based on endobronchial biopsy (EBB) findings. The association between systolic pressure (SP), diastolic pressure (DP), mean arterial pressure (MAP), pulse pressure (PP), PP to DP ratio (PP/DP) and the risk of EBB-induced hemorrhage was evaluated using multivariate regression analysis and smooth curve fitting adjusted for potential confounding factors.

RESULTS

The EBB-induced bleeding incidence was 37.8% (243/643) in our cohort. An independent association was found between PP/PD and the EBB-induced hemorrhage risk (per 1 SD, adjusted odds ratio, 0.788; 95% confidence interval, 0.653-0.951). The multivariate regression analysis performed using quartiles of PP/DP revealed that lower level of PP/DP ratio was related to a higher risk of EBB-induced hemorrhage (P for trend <0.05) after adjustment for potential confounders. However, no association was observed between SP, DP, MAP, PP and EBB-induced hemorrhage.

CONCLUSIONS

Low PP/DP was the independent risk factor for biopsy-induced endobronchial hemorrhage during bronchoscopy in patients with lung cancer.

Infectious complications of EBUS-TBNA: A nested case-control study using 10-year registry data

OBJECTIVES

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a standard procedure, but little is known about its infectious complications. The aim of this study is to evaluate the incidence and risk factors of infectious complications of EBUS-TBNA and its clinical course, including effects on anti-cancer treatment.

METHODS

This is a nested case-control study of patients who received EBUS-TBNA and were followed for at least 2 months at Samsung Medical Center from August 2009 to April 2019. Patients with clinical symptoms of infection and correlating chest images were defined as the infection group (n = 33). The controls were randomly selected from patients without infectious complication. Multivariate logistic regression with backward selection was used to identify the risk factors of infectious complications.

RESULTS

Of the 6826 patients, 33 (0.48%) infectious complications were identified, comprising pneumonia (n = 20) and mediastinal infections (n = 13). Target lesions with necrotic features on chest computed tomography (CT) scan (adjusted odds ratio [aOR], 3.08; 95% confidence interval [CI], 1.49-6.40; P = 0.002) and procedures that were performed via the esophagus (aOR, 3.19; 95% CI, 1.47-6.88; P = 0.003) were independently associated with infectious complications. Among patients ultimately diagnosed with cancer, the infection group tended to refuse anti-cancer treatment compared to controls (32/459, 7.0% vs. 5/30, 16.7%; P = 0.066). However, among the patients who received anti-cancer treatment, there was no delay in onset of treatment.

CONCLUSIONS

Infectious complications of EBUS-TBNA are rare; however, attention should be paid if the target lesion appears necrotic on chest CT or if the procedure is performed via the esophagus. Although it was not conclusive due to its rarity, patients with infectious complications tended not to receive anti-cancer treatment.

Complications and discomfort after research bronchoscopy in the MicroCOPD study

Background

Data on discomfort and complications from research bronchoscopy in chronic obstructive pulmonary disease (COPD) and asthma is limited. We present complications and discomfort occurring within a week after bronchoscopy, and investigate personal and procedural risk factors.

Methods

239 subjects with COPD, asthma or without lung disease underwent research bronchoscopies as part of a microbiome study of the lower airways (the MicroCOPD study). Bronchoscopy was done in the supine position with oral scope insertion with the option of light conscious alfentanil sedation. Sampling consisted of protected specimen brushes, bronchoalveolar lavage, small volume lavage and for some, endobronchial biopsies. Bleeding, desaturation, cough, haemodynamic changes, dyspnoea and other events that required an unplanned intervention or early termination of bronchoscopy were prospectively recorded. Follow-up consisted of a telephone interview where subjects rated discomfort and answered questions about fever sensation and respiratory symptoms in the week following bronchoscopy.

Results

An unplanned intervention or early termination of bronchoscopy was required in 25.9% of bronchoscopies. Three subjects (1.3%) experienced potentially severe complications, of which all recovered without sequelae. COPD subjects experienced more dyspnoea than controls. Sedation and lower age was associated with less unplanned intervention or premature termination. About half of the subjects (47.7%) reported fever. Discomfort was associated with postprocedural fever, dread of bronchoscopy, higher score on the COPD Assessment Test and never-smoking. In subjects undergoing more than one bronchoscopy, the first bronchoscopy was often predictive for complications and postprocedural fever in the repeated bronchoscopy.

Conclusion

Research bronchoscopies were not associated with more complications or discomfort in COPD subjects. 47.7% experienced postbronchoscopy fever sensation, which was associated with discomfort.

Budget Impact of Microbial Cell-Free DNA Testing Using the Karius® Test as an Alternative to Invasive Procedures in Immunocompromised Patients with Suspected Invasive Fungal Infections

BACKGROUND

Invasive fungal infection is a major source of morbidity and mortality. The usage of microbial cell-free DNA for the detection and identification of invasive fungal infection has been considered as a potential alternative to invasive procedures allowing for rapid results.

OBJECTIVE

This analysis aimed to assess the budget implications of using the Karius^® Test in patients suspected of invasive fungal infection in an average state in the USA from a healthcare payer perspective.

METHODS

The analysis used a decision tree to capture key stages of the patient pathway, from suspected invasive fungal infection to either receiving treatment for invasive fungal infection or being confirmed as having no invasive fungal infection. The analysis used published costs and resource use from a targeted review of the literature. Because of the paucity of published evidence on the reduction of diagnostic tests displaced by the Karius Test, the analysis used a 50% reduction in the use of bronchoscopy and/or bronchoalveolar lavage. The impact of this reduction was tested in a scenario analysis.

RESULTS

The results of the analysis show that the introduction of the Karius Test is associated with a cost saving of US$2277 per patient; when multiplied by the estimated number of cases per year, the cost saving is US$17,039,666. The scenario analysis showed that the Karius Test only had an incremental cost of US$87 per patient when there was no reduction in bronchoscopy and bronchoalveolar lavage.

CONCLUSIONS

The Karius Test may offer a valuable and timely option for the diagnosis of invasive fungal infection through its non-invasive approach and subsequent cost savings.

Performance and safety of diagnostic procedures in superior vena cava syndrome

Superior vena cava syndrome (SVCS) is an uncommon condition resulting from extrinsic compression or intraluminal blockade of the superior vena cava. The increased upper body venous pressure results in distended subcutaneous vessels and oedema of the head, neck and arms. SVCS can be a medical emergency if associated with laryngeal or cerebral oedema. The most common SVCS aetiologies are intrathoracic malignancies, accounting for 60 to 86% of cases [1–3].

Standard bronchoscopy and EBUS-TBNA have good diagnostic yield and are relatively safe procedures in the setting of SVCS. However, complications may arise from the underlying malignancy and its proximity to central vital structures.https://bit.ly/37HXFUY

Prophylactic use of tranexamic acid for prevention of bleeding during transbronchial lung biopsies - A randomized, double-blind, placebo-controlled trial

BACKGROUND

Although massive bleeding following transbronchial lung biopsies (TBLB) is rare, even minor hemorrhage may prolong the procedure and result in inadequate sampling. Tranexamic acid (TXA) is an antifibrinolytic agent, which reduces bleeding in numerous scenarios, however, its prophylactic use in mitigating post-TBLB bleeding has not been investigated. We conducted a prospective, randomized, double-blind, placebo-controlled trial to determine whether topical infusion of TXA prior to TBLB would reduce bleeding, shorten procedure duration and increase the number of biopsies obtained.

METHODS

We blindly randomized patients undergoing TBLB to receive topical TXA or placebo in the lobar bronchus prior to biopsies. Vital signs, procedure length, fluid balance (as a measure of the amount of bleeding), operator's assessment of bleeding, and number of biopsies obtained were measured. Data was analyzed using the two-tailed Student's T-Test, Chi-square or Mann-Whitney tests as appropriate.

RESULTS

Fifty patients were randomized, 26 to the TXA arm. The bleeding in the TXA group was significantly lower (P = 0.0037), with more specimens being obtained (placebo 7 (6, 9) (median and interquartile range) vs. TXA 9 (8, 10), P = 0.023) and no difference in procedure length (placebo 30 min (29.3, 34.3) vs. TXA 30 (24.8, 36), P = 0.90). There were no clinically significant adverse events in any of the groups up to one month of follow up.

CONCLUSION

Endobronchial installation of TXA prior to obtaining TBLB results in less bleeding and allows more biopsies to be obtained with no additional adverse events. The prophylactic use of TXA during TBLB may be considered as standard.

Rapid On-Site Evaluation During Radial Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy for the Diagnosis of Peripheral Pulmonary Lesions

Objective:

To evaluate the diagnostic value of radial endobronchial ultrasound (R-EBUS) combination with rapid on-site evaluation (ROSE) guided transbronchial lung biopsy (TBLB) for peripheral pulmonary lesions.

Methods:

Peripheral pulmonary lesions identified by computed tomography underwent R-EBUS with or without ROSE randomly from February 2016 to August 2017. The diagnostic yield and the operation time were compared.

Results:

In total, 158 patients were involved in and completed this research, including 84 cases in the group of R-EBUS with ROSE, and 74 in the group without ROSE. The diagnostic yield of ROSE group was 85.7%. Among these positive cases, 69.4% cases were malignant tumors, and 30.6% cases were benign lesions. The operation time was (24.6 ± 6.3) min. In the group without ROSE, the diagnostic yield was 70.3%, including 35 malignant tumors (67.3%), and 17 benign lesions (32.7%). The operation time was (31.5 ± 6.8) min. There were significant differences between both groups in the diagnostic yield (χ2 = 5.556, P = 0.018) and in the operation time (t = 3.187, P < 0.01). No serious procedure related complications were observed, such as pneumothorax and hemorrhage.

Conclusion:

ROSE can improve the diagnostic yield, and shorten the operation time. R-EBUS combined with ROSE is a safe and effective technique for peripheral pulmonary lesions.

Early complications in flexible bronchoscopy at a university hospital

Objective:

To analyze the complications related to flexible bronchoscopy (FB) and its collection procedures in outpatients and inpatients with various lung and airway diseases treated at a university hospital.

Methods:

This was a retrospective analysis of complications occurring during or within 2 h after FB performed between January of 2012 and December of 2013, as recorded in the database of the respiratory endoscopy department of a hospital complex in the city of São Paulo, Brazil.

Results:

We analyzed 3,473 FBs. Complications occurred in 185 procedures (5.3%): moderate to severe bleeding, in 2.2%; pneumothorax, in 0.7%; severe bronchospasm, in 0.8%; general complications (hypoxemia, psychomotor agitation, arrhythmias, vomiting, or hypotension), in 1.6%; and cardiopulmonary arrest, in 0.03%. There were no deaths related to the procedures. Specifically, among the 1,728 patients undergoing biopsy, bronchial brushing, or fine-needle aspiration biopsy, bleeding occurred in 75 (4.3%). Among the 1,191 patients undergoing transbronchial biopsy, severe pneumothorax (requiring chest tube drainage) occurred in 24 (2.0%).

Conclusions:

In our patient sample, FB proved to be a safe method with a low rate of complications. Appropriate continuing training of specialist doctors and nursing staff, as well as the development of standardized care protocols, are important for maintaining those standards.

The diagnosis value of endobronchial ultrasound transbronchial lung biopsy combined with rapid on-site evaluation in peripheral lung cancer

INTRODUCTION

Rapid on-site evaluation (ROSE) has the potential to increase endobronchial ultrasound transbronchial lung biopsy with guide sheath (EBUS-GS-TBLB) accuracy in the diagnosis of peripheral lung cancer. However, studies have reported controversial results.

OBJECTIVES

The aim of the study was to evaluate the diagnosis value of EBUS-GS-TBLB combination with ROSE in peripheral lung cancer.

METHODS

A total of 138 patients undergoing EBUS-GS-TBLB and ultimately diagnosed with lung cancer were allocated into the ROSE group and non-ROSE group. The result of the diagnostic yields, number of biopsy sites, the complication, cytopathological diagnostic cost and procedure times of EBUS-GS-TBLB with ROSE and without ROSE were compared.

RESULTS

The diagnostic yields of TBLB were 87.8% and 78.1% in ROSE group and non-ROSE group, respectively (P < .05). The number of biopsy, procedure times and the percentage of the complication in ROSE group was significantly lower than in non-ROSE group (P < .05, respectively). The cytopathological diagnostic cost of ROSE group was lower compared with non-ROSE group (P < .05).

CONCLUSIONS

EBUS-GS-TBLB combined with ROSE could be helpful to diagnose peripheral lung cancer, and could reduce the number of biopsy, procedure times, cytopathological diagnostic cost and complication.

Standardized Definitions of Bleeding After Transbronchial Lung Biopsy: A Delphi Consensus Statement From the Nashville Working Group

BACKGROUND

Transbronchial lung biopsies are commonly performed for a variety of indications. Although generally well tolerated, complications such as bleeding do occur. Description of bleeding severity is crucial both clinically and in research trials; to date, there is no validated scale that is widely accepted for this purpose. Can a simple, reproducible tool for categorizing the severity of bleeding after transbronchial biopsy be created?

METHODS

Using the modified Delphi method, an international group of bronchoscopists sought to create a new scale tailored to assess bleeding severity among patients undergoing flexible bronchoscopy with transbronchial lung biopsies. Cessation criteria were specified a priori and included reaching > 80% consensus among the experts or three rounds, whichever occurred first.

RESULTS

Thirty-six expert bronchoscopists from eight countries, both in academic and community practice settings, participated in the creation of the scale. After the live meeting, two iterations were made. The second and final scale was vetted by all 36 participants, with a weighted average of 4.47/5; 53% were satisfied, and 47% were very satisfied. The panel reached a consensus and proposes the Nashville Bleeding Scale.

CONCLUSIONS

The use of a simplified airway bleeding scale that can be applied at bedside is an important, necessary tool for categorizing the severity of bleeding. Uniformity in reporting clinically significant airway bleeding during bronchoscopic procedures will improve the quality of the information derived and could lead to standardization of management. In addition to transbronchial biopsies, this scale could also be applied to other bronchoscopic procedures, such as endobronchial biopsy or endobronchial ultrasound-guided needle aspiration.

Low-density lipoprotein cholesterol levels are positively associated with the risk of endobronchial biopsy-induced refractory hemorrhage in patients with lung cancer

Background

Lipoprotein concentrations have been associated with the major risk of bleeding events. However, whether plasma levels of LDL-C are associated with the risk of biopsy-related endobronchial hemorrhage remain elusive. Therefore, the present study was initiated to investigate the explicit association of low-density lipoprotein cholesterol (LDL-C) with endobronchial biopsy (EBB)-induced refractory hemorrhage in patients with lung cancer.

Methods

This retrospective study included a total of 659 consecutive patients with lung cancer who had undergone EBB at a tertiary hospital between January 2014 and April 2018. Using multiple regression analysis, the association between LDL-C and the risk of EBB-induced refractory hemorrhage was assessed after adjusting for potential confounding factors.

Results

A significant proportion (13.8%, 91/659) of the patients experienced refractory hemorrhage following EBB. In multivariate regression analysis, higher plasma LDL-C concentrations were associated with increased risk of EBB-induced refractory hemorrhage in patients with lung cancer after adjusting for potential confounders (P < 0.05). Using the lowest quartile of plasma LDL-C as the reference group, the odds ratio (95% confidence interval) of Q2, Q3, and Q4 were 2.32 (1.07, 5.03), 2.37 (0.94, 5.95), and 3.65 (1.16, 11.51), respectively (P for trend < 0.05). Moreover, this association was noticeably more pronounced in male patients with lung cancer in the subgroup analysis (P < 0.05).

Conclusions

Plasma LDL-C was positively correlated with the increased risk of EBB-induced refractory hemorrhage in patients with lung cancer; predominantly, the associated risk was more pronounced in male patients with lung cancer.

Risk of bleeding in patients undergoing pulmonary procedures on antiplatelet or anticoagulants: A systematic review

As many as 25% of all patients undergoing invasive pulmonary procedures are receiving at least one antiplatelet or anticoagulant agent. For those undergoing elective procedures, the decision-making process is uncomplicated and the procedure may be postponed until the antiplatelet or anticoagulant agent may be safely held. However, many invasive pulmonary procedures are semi-elective or emergent in nature in which case a risk-benefit calculation and discussion occur between the provider and patient or surrogate decision-maker. Therefore, it is critical for providers to have an awareness of the risk of bleeding complications with different pulmonary procedures on various antiplatelet and anticoagulant agents. This systematic review summarizes the bleeding complications associated with different pulmonary procedures in patients on various antiplatelet or anticoagulant agents in the literature and reveals a paucity of high-quality evidence across a wide spectrum of pulmonary procedures and antiplatelet or anticoagulant agents. The results of this review can help inform providers of the bleeding risk in these patients to aid in the shared decision-making process and risk vs benefit discussion.

Non-linear association of plasma level of high-density lipoprotein cholesterol with endobronchial biopsy bleeding in patients with lung cancer

Background

Despite a large body of studies have demonstrated the multifaceted behavior of high-density lipoproteins (HDLs) in several physiological and pathological processes, the levels of plasma HDL-cholesterol (HDL-C) that may be associated with endobronchial biopsy (EBB)-related bleeding have never been examined.

Methods

We conducted a single-center retrospective cohort study of 628 consecutive patients with primary lung cancer who had undergone EBB at a large tertiary hospital between January 2014 and February 2018. Patients were divided into the bleeding group and the non-bleeding group according to the bronchoscopy report. The association between HDL-C levels and EBB-induced bleeding was evaluated using the LASSO regression analysis, multiple regression analysis and smooth curve fitting adjusted for potential confounders.

Results

There was an inverse association of plasma HDL-C concentration with the incidence of EBB-induced bleeding as assessed by univariate analysis (P < 0.05). However, in piecewise linear regression analysis, a non-linear relationship with threshold saturation effects was observed between plasma HDL-C concentrations and EBB-induced bleeding. The incidence of EBB-induced bleeding decreased with HDL-C concentrations from 1.5 mmol/L up to 2.0 mmol/L (adjusted OR, 0.39; 95% CI, 0.20–0.74), but increased with HDL-C levels above the inflection point (HDL-C = 2.0 mmol/L).

Conclusions

There was a non-linear association between plasma HDL-C concentrations and the risk of EBB-induced bleeding in patients with lung cancer. The plasma level of HDL-C above 2.0 mmol/L or below 1.5 mmol/L may increase the risk of EBB-induced bleeding.

[Value of C-ROSE During EBUS-TBNA to Obtain the Tissue Sample in the Diagnosis of Lung Cancer]

背景与目的

在肺及纵隔占位性病变的患者中大部分临床考虑诊断为原发性肺癌，超声支气管镜引导下的经支气管针吸活检术(endobronchial ultrasound-guided transbronchial needle aspiration, EBUS-TBNA)是一种常用的获取病理组织明确诊断的手术。在EBUS-TBNA过程中，快速现场细胞学评价(cytological rapid on-site evaluation, C-ROSE)是一项有用的辅助技术。本研究探讨C-ROSE在EBUS-TBNA取样诊断肺癌中的价值。

方法

对141例经胸部计算机断层扫描(computed tomography, CT)发现存在纵隔和(或)肺门病灶(包括肿大的淋巴结/肿块)且临床高度疑诊原发性肺癌而行EBUS-TBNA患者进行回顾性分析，其中术中行C-ROSE者81例，未行C-ROSE者60例，分析两组患者的穿刺情况及并发症发生率，同时分析C-ROSE联合EBUS-TBNA取样对肺癌诊断的敏感度、特异度、阳性预测值、阴性预测值。

结果

C-ROSE组与非C-ROSE组穿刺针数及穿刺部位数无统计学差异，穿刺合格率分别为98.77%和90.00%(P < 0.05)，诊断率分别为88.89%和75.00%(P < 0.05)，并发症发生率分别为1.23%和11.67%(P < 0.05)。C-ROSE联合EBUS-TBNA对肺癌诊断的敏感度为92.21%，特异度为100.00%，阳性预测值为100.00%，阴性预测值为40.00%。

结论

C-ROSE在疑诊肺癌行EBUS-TBNA中应用可以提高穿刺成功率及诊断率、减少并发症，值得推广。

A Case Report of Cangrelor Bridge Therapy for a Diagnostic Bronchoscopy With Biopsy

Although premature discontinuation of dual antiplatelet therapy (DAPT) is associated with an increased risk of ischemic complications, patients may present with an urgent need for surgery that would require interruption of DAPT. Antiplatelet bridge therapy using cangrelor, an intravenous P2Y₁₂ inhibitor, has been studied as a potential option to ensure continuation of DAPT perioperatively. However, limited evidence exists supporting the off-label use of cangrelor bridge therapy to noncardiac procedures. We describe the case of a 67-year-old class 3 obese female on DAPT (aspirin and ticagrelor) for recent drug-eluting stent placement who required a bronchoscopy with biopsy for suspected lung cancer. Cangrelor bridge therapy was utilized both preoperatively and postoperatively without ischemic or bleeding complications, and the patient was subsequently able to begin radiation therapy after a confirmed diagnosis of lung cancer.

Plasma apolipoprotein E level is associated with the risk of endobronchial biopsy-induced bleeding in patients with lung cancer

Background

Factors affecting the risk of bleeding by bronchoscopic biopsy in patients with lung cancer remain unclear. The levels of plasma apolipoprotein E (ApoE) that may be associated with endobronchial biopsy (EBB)-induced bleeding have never been examined.

Methods

This was a retrospective study using data collected from 615 consecutive patients who had undergone EBB and been diagnosed with primary lung cancer from January 2014 through February 2018. Patients were either classified as the bleeding group (n = 214) or the non-bleeding group (n = 391) based on the bronchoscopy report. Multiple regression analysis was done to estimate the independent relationship between ApoE levels and EBB-induced bleeding, with an adjustment for potential confounders.

Results

The mean plasma ApoE concentration was higher in the non-bleeding group compared to that in the bleeding group (P < 0.05). However, a non-linear relationship with threshold effects was observed between plasma ApoE levels and EBB-induced bleeding in a piecewise linear regression analysis. The risk of EBB-induced bleeding decreased with ApoE concentrations from 3.5 mg/dL up to 5.9 mg/dL (adjusted odds ratio, 0.64; 95% confidence interval, 0.43–0.94); however, the incidence of EBB-induced bleeding increased with ApoE levels above the turning point (ApoE = 5.9 mg/dL).

Conclusions

There was a non-linear association between plasma ApoE levels and the risk of EBB-induced bleeding. Higher plasma ApoE concentrations (> 5.9 mg/dL) are the independent risk factor for hemorrhage during EBB in patients with lung cancer.

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.

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.

Iatrogenic bleeding during flexible bronchoscopy: risk factors, prophylactic measures and management

Significant iatrogenic bleeding during flexible bronchoscopy is fortunately rare and usually self-limiting. Life-threatening bleeding, however, can occur, especially after conventional or cryoprobe-assisted transbronchial biopsy. The aim of this review is to provide the practising pulmonologist with a concise overview of the incidence, severity and risk factors for bleeding, to provide sensible advice on prophylactic measures and to suggest a plan of action in the case of significant bleeding. Bronchoscopy units should have a standardised approach and plan of action in the case of life-threatening haemorrhage. Wedging the bronchoscope in the bleeding segment, turning the patient in an anti-Trendelenburg position and onto the side in order for the bleeding lung to be in the dependent position, installing vasoconstrictors and using a tamponade balloon early are the recommended first-line strategies. Involving a resuscitation team should be considered early in the case of massive bleeding, desaturation and haemodynamic instability.

Complications and discomfort of bronchoscopy: a systematic review

Objective

To identify bronchoscopy-related complications and discomfort, meaningful complication rates, and predictors.

Method

We conducted a systematic literature search in PubMed on 8 February 2016, using a search strategy including the PICO model, on complications and discomfort related to bronchoscopy and related sampling techniques.

Results

The search yielded 1,707 hits, of which 45 publications were eligible for full review. Rates of mortality and severe complications were low. Other complications, for instance, hypoxaemia, bleeding, pneumothorax, and fever, were usually not related to patient characteristics or aspects of the procedure, and complication rates showed considerable ranges. Measures of patient discomfort differed considerably, and results were difficult to compare between different study populations.

Conclusion

More research on safety aspects of bronchoscopy is needed to conclude on complication rates and patient- and procedure-related predictors of complications and discomfort.

eNose technology can detect and classify human pathogenic molds in vitro: a proof-of-concept study of Aspergillus fumigatus and Rhizopus oryzae

Invasive pulmonary mold disease (IPMD) is often fatal in neutropenic patients. This is because IPMD is difficult to diagnose timely, especially when non-Aspergillus molds are the causative agent, as they are usually not associated with a positive galactomannan assay. In 2013 we showed that exhaled breath analysis might be used to diagnose invasive aspergillosis through profiling of patterns in exhaled volatile organic compounds (VOCs) by electronic nose (eNose) technology. The current study aimed to determine (1) whether molds can be discriminated from other microorganisms (using two mold species: Aspergillus fumigatus and a pathogenic mold not associated with a positive galactomannan assay, i.c. Rhizopus oryzae) and (2) whether both molds can be discriminated from each other. First, we cultured strains of Streptococcus pneumoniae, Escherichia coli, Pseudomonas aeruginosa, Candida albicans, A. fumigatus and R. oryzae in separate airtight bottles. We examined whether an eNose (Cyranose 320) could discriminate the headspaces of bottles with molds from those with bacteria/yeasts. Second, we examined whether an eNose could discriminate A. fumigatus and R. oryzae. Diagnostic algorithms were created using canonical discriminant analysis after principle component analysis. Primary outcome parameter was the validated accuracy. The eNose discriminated A. fumigatus from bacteria/yeasts with a cross-validated accuracy of 92.9% (sensitivity 95.2%, specificity 91.9%). The eNose had an accuracy (validated using split-half analysis) of 100% in discriminating A. fumigatus from R. oryzae. Our study suggests that an eNose can identify and classify molds in vitro. This warrants prospective in vivo studies aimed at detecting and classifying IPMD using exhaled breath.

Flexible bronchoscopy-induced massive bleeding: A 12-year multicentre retrospective cohort study

BACKGROUND AND OBJECTIVE

Although massive bleeding is the most life-threatening complication caused by flexible bronchoscopy, data on flexible bronchoscopy-induced massive bleeding are scarce, and the associated clinical characteristics and prognostic factors are unknown.

METHODS

This was a multicentre retrospective cohort study of all patients who underwent flexible bronchoscopy in 33 tertiary hospitals from January 2001 to June 2013. The clinical characteristics and outcomes were collected and analysed.

RESULTS

A total of 194 patients with massive bleeding were identified among 520 343 patients who underwent flexible bronchoscopy. The average blood loss reached up to 378 mL. The overall incidence and mortality were 0.037% and 0.004%, respectively, and the overall fatality was 10.8%. The risk of massive bleeding induced by therapeutic bronchoscopies was significantly higher than that induced by diagnostic bronchoscopies (incidence: 0.059% vs 0.031%, P < 0.001; mortality: 0.012% vs 0.003%, P < 0.001; fatality: 20% vs 8.4%, P = 0.068). Multivariate analysis showed that age ≥65 years, tracheal bleeding, blood loss ≥500 mL and occurrence of shock were independent factors predicting poor outcome, while emergency surgery was an independent protective factor. Re-bleeding occurred in six patients, resulting in three deaths within a month.

CONCLUSION

Flexible bronchoscopy-induced massive bleeding is rare but life-threatening. Age, bleeding location, bleeding volume, circulation condition and emergency surgery were independent prognostic factors.

Detection of Airway Colonization by Aspergillus fumigatus by Use of Electronic Nose Technology in Patients with Cystic Fibrosis

Currently, there is no noninvasive test that can reliably diagnose early invasive pulmonary aspergillosis (IA). An electronic nose (eNose) can discriminate various lung diseases through an analysis of exhaled volatile organic compounds. We recently published a proof-of-principle study showing that patients with prolonged chemotherapy-induced neutropenia and IA have a distinct exhaled breath profile (or breathprint) that can be discriminated with an eNose. An eNose is cheap and noninvasive, and it yields results within minutes. We determined whether Aspergillus fumigatus colonization may also be detected with an eNose in cystic fibrosis (CF) patients. Exhaled breath samples of 27 CF patients were analyzed with a Cyranose 320. Culture of sputum samples defined the A. fumigatus colonization status. eNose data were classified using canonical discriminant analysis after principal component reduction. Our primary outcome was cross-validated accuracy, defined as the percentage of correctly classified subjects using the leave-one-out method. The P value was calculated by the generation of 100,000 random alternative classifications. Nine of the 27 subjects were colonized by A. fumigatus. In total, 3 subjects were misclassified, resulting in a cross-validated accuracy of the Cyranose detecting IA of 89% (P = 0.004; sensitivity, 78%; specificity, 94%). Receiver operating characteristic (ROC) curve analysis showed an area under the curve (AUC) of 0.89. The results indicate that A. fumigatus colonization leads to a distinctive breathprint in CF patients. The present proof-of-concept data merit external validation and monitoring studies.

Uses, limitations, and complications of endobronchial ultrasound

Endobronchial ultrasound (EBUS) plays a pivotal role in the minimally invasive staging of non-small cell lung cancer. The role of EBUS is progressively expanding to include the evaluation of peribronchial lesions, pulmonary nodules, and other mediastinal abnormalities. Recently, EBUS has assisted in the diagnosis of many other disease entities, including malignancies and various infections such as tuberculosis and sarcoidosis. This article reviews the indications and contraindications of EBUS, with emphasis on the technique and complications encountered during the procedure.

Anesthesia for Advanced Bronchoscopic Procedures: State-of-the-Art Review

The bronchoscopic procedures have seen a remarkable increase in both numbers and complexity. Although many anesthesia providers have kept pace with the challenge, the practice is varied and frequently suboptimal. Shared airway during bronchoscopy poses unique challenges. The available reviews have tried to address this lacuna; however, these have frequently dealt with the technical aspects of bronchoscopy than anesthetic challenges. The present review provides evidence-based management insights into anesthesia for bronchoscopy-both flexible and rigid. A systematic approach toward pre-procedural evaluation and risk stratification is presented. The possible anatomical and physiological factors that can influence the outcomes are discussed. Pharmacological principles guiding sedation levels and appropriate selection of sedatives form the crux of safe anesthetic management. The newer and safer drugs that can have potential role in anesthesia for bronchoscopy in the near future are discussed. Ventilatory strategies during bronchoscopy for prevention of hypoxia and hypercarbia are emphasized.

[The value of transbronchial needle aspiration combined with rapid on-site evaluation of cytology in the diagnosis of lung cancer]

背景与目的

国内外目前已有多篇现场细胞学应用于经支气管镜针吸活检（transbronchial needle aspiration, TBNA）的报道，但专门针对肺癌患者的研究很少。本研究的目的是探讨TBNA联合现场细胞学在肺癌诊断中的作用。

方法

回顾性分析2012年12月-2013年12月在滨州市人民医院行TBNA并最终确诊为肺癌的69例患者，其中行现场细胞学者37例，未行现场细胞学者32例。比较现场细胞学结果与最终HE染色结果的一致性，同时比较两组患者的诊断率、每个淋巴结穿刺针数、并发症发生率及细胞学诊断费用。

结果

现场细胞学与HE染色一致性为94.1%（32/34）。现场细胞学组诊断率与非现场细胞学组相比无统计学差异（91.9% vs 78.1%, P=0.20）；但平均穿刺针数及并发症发生率，现场细胞学组少于非现场细胞学组（t=29.5, P < 0.05; χ²=4.4, P < 0.05），现场细胞学组患者细胞学诊断费用低于非现场细胞学组（t=10.9, P < 0.05）。

结论

TBNA联合现场细胞学诊断肺癌，与HE染色一致性好，且能减少穿刺针数及并发症，节省细胞学诊断费用，值得推广。

Invasive diagnostic strategies in immunosuppressed patients with acute respiratory distress syndrome

Immunosuppression predisposes the host to development of pulmonary infections, which can lead to respiratory failure and the development of acute respiratory distress syndrome (ARDS). There are multiple mechanisms by which a host can be immunosuppressed and each is associated with specific infectious pathogens. Early invasive diagnostic modalities such as fiber-optic bronchoscopy with bronchoalveolar lavage, transbronchial biopsy, and open lung biopsy are complementary to serologic and noninvasive studies and assist in rapidly establishing an accurate diagnosis, which allows initiation of appropriate therapy and may improve outcomes with relative safety.

Diagnostic bronchoscopy in solid-organ and hematopoietic stem cell transplantation

Fiberoptic bronchoscopy is a valuable diagnostic tool in solid-organ and hematopoietic stem cell transplant recipients presenting with a range of pulmonary complications. This article provides a comprehensive overview of the utility and potential adverse effects of diagnostic bronchoscopy for transplant recipients. Recommendations are offered on the selection of patients, the timing of bronchoscopy, and the samples to be obtained across the spectrum of suspected pulmonary complications of transplantation. Based on review of the literature, the authors recommend early diagnostic bronchoscopy over empiric treatment in transplant recipients with evidence of certain acute, subacute, or chronic pulmonary processes. This approach may be most critical when an underlying infectious etiology is suspected. In the absence of prompt diagnostic information on which to base effective treatment, the risks associated with empiric antimicrobial therapy, including medication side effects and the development of antibiotic resistance, compound the potential harm of delaying targeted management.