Transbronchial lung biopsy and pneumothorax

Predictive risk factors for pneumothorax after transbronchial biopsy using endobronchial ultrasonography with a guide sheath

Background

Pneumothorax is one complication of transbronchial biopsy (TBB) using endobronchial ultrasonography with a guide sheath (EBUS-GS-TBB). We sought to clarify the risk factors for pneumothorax after EBUS-GS-TBB under fluoroscopic guidance.

Methods

We retrospectively reviewed data from 916 patients who underwent EBUS-GS-TBB at Fujita Health University Hospital. We evaluated the following risk factors for pneumothorax after EBUS-GS-TBB: patient characteristics (sex, age, and pulmonary comorbidities); lesion data (location, size, existence of ground-glass opacities [GGOs], pleural involvement, computed tomography [CT] bronchus sign, visibility on fluoroscopy, and EBUS findings); final diagnosis; years of bronchoscopist experience; and guide sheath size. Univariate and multivariate logistic regression analyses were performed.

Results

Among the 916 patients, 30 (3.28%) presented with pneumothorax. With a univariate analysis, factors that independently predisposed to pneumothorax included lesions containing GGOs, lesions in sagittal lung segments on fluoroscopy, lesions that were not visible on fluoroscopy, and infectious lesions. A univariate analysis also showed that lesions in the right upper lobe or left upper division, as well as malignant lesions, were less likely to lead to pneumothorax. Age, underlying pulmonary disease, CT bronchus sign, EBUS findings, bronchoscopist experience, and guide sheath size did not influence the incidence of pneumothorax. A multivariate analysis revealed that only lesions containing GGOs (odds ratio [OR] 6.47; 95% confidence interval [CI] 2.13–19.6, P = 0.001) and lesions in lung segments with a sagittal orientation on fluoroscopy (OR 2.47; 95% CI 1.09–5.58, P = 0.029) were significant risk factors for EBUS-GS-TBB-related pneumothorax.

Conclusions

EBUS-GS-TBB of lesions containing GGOs or lesions located in sagittal lung segments on fluoroscopy correlate with a higher pneumothorax risk.

Utility of Radial Probe Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy in Diffuse Lung Lesions

Background

Radial probe endobronchial ultrasound (R-EBUS) is widely used for diagnosing peripheral pulmonary lesions. However, the utility of R-EBUS-guided transbronchial lung biopsy (TBLB) for diffuse lung lesions (DLLs) remains unknown. We designed this study to evaluate the utility of R-EBUS-guided TBLB in DLLs.

Methods

This retrospective study enrolled patients admitted from January 2016 to November 2017 who underwent TBLB for DLLs. The R-EBUS-guided TBLB and blind TBLB groups were compared. DLL was defined as any lung disorder that involved more than one segment of the lung. In both the groups, fluoroscopy and guided sheath were not used during TBLB.

Results

A total of 127 patients underwent TBLB for DLLs (67 patients in the R-EBUS-guided TBLB group and 60 in the blind TBLB group). There were no differences in age, sex, and comorbid illnesses between the two groups. Furthermore, there was no difference in the TBLB diagnostic yield of the two groups (p=0.660) although more samples were collected from the R-EBUS-guided TBLB group (p=0.003). Procedure time was significantly longer in the R-EBUS-guided TBLB group than in the blind TBLB group (p<0.001). Thus, incidence of pneumothorax was significantly lower in the R-EBUS-guided TBLB group than in the blind TBLB group (p=0.032).

Conclusion

Diagnostic yield in DLLs did not differ between the R-EBUS-guided TBLB and blind TBLB groups. Findings show that R-EBUS-guided TBLB in DLLs may reduce risk of pneumothorax.

Transbronchial biopsy from the upper pulmonary lobes is associated with increased risk of pneumothorax - a retrospective study

BACKGROUND

Pneumothorax (PTX) is one of the most common complications of transbronchial biopsy (TBB). Previous research suggests that upper pulmonary lobe TBB may be associated with increased risk of PTX development. The aim of this study was to compare the risk of PTX after TBB performed from different pulmonary lobes.

METHODS

All bronchoscopic records from the period January 1st, 2015 - December 31st, 2017 (from the Department of Respiratory Diseases, University Hospital Brno, Czech Republic) were retrospectively analyzed. Of the 3542 bronchoscopic records, 796 patients underwent TBB and were further analyzed. Basic demographic data, TBB procedure-related factors, smoking history and radiological features were analyzed. Furthermore, in patients who developed PTX, PTX onset, PTX symptoms, distribution of the abnormal radiological findings and duration of hospitalization were also analyzed.

RESULTS

Patients who developed PTX had significantly lower body mass index (BMI) and more than 4 samples taken during procedure (all p < 0.05). TBB performed from the left upper pulmonary lobe was associated with a significant risk of PTX development (OR 2.27; 95% CI 1.18-4.35; p = 0.02). On the contrary, TBB performed from the right lower lobe was associated with a significant reduction of risk of developing PTX (OR 0.47; 95% CI 0.22-0.98; p = 0.04). Logistic regression analysis showed BMI (OR 1.08; 95% CI 1.02-1.16; p = 0.01), left upper lobe as sampling site (OR 2.15; 95% CI 1.13-4.11; p = 0.02) and more than 4 samples taken (OR 1.91; 95% CI 1.04-3.49; p = 0.04) to be significantly associated with PTX development.

CONCLUSIONS

We conclude that TBB from the left upper pulmonary lobe is associated with significantly increased risk of post-procedural PTX. The right lower pulmonary lobe seems to be the safest sampling site to perform TBB. In patients with diffuse-type pulmonary disease, TBB should be performed preferably from the right lower lobe in order to decrease the risk of post-procedural PTX.

Delayed Pneumothorax: A Potential Complication Of Transbronchial Lung Biopsy

The purpose of this article is to report a case of secondary tension pneumothorax presenting seven weeks post Transbronchial Lung biopsy. A 62 year old male with a known history of germ cell tumor was found to have a left-sided pneumothorax which later complicated to a tension pneumothorax.To the best of our knowledge this is the second case being reported for a delayed pneumothorax post a Transbronchial Lung Biopsy .The purpose of this case report is to create awareness among physicians to consider this diagnosis even at a later stage and the importance of patient education regarding the signs and symptoms of pneumothorax. Our case adds to the medical literature, a new presentation of a rare complication of delayed pneumothorax post TBB.

Endobronchial ultrasound convex probe for lymphoma, sarcoidosis, lung cancer and other thoracic entities. A case series

Endobronchial ultrasound endoscopy is a state of the art diagnostic endoscopic procedure for the thorax. Firstly it was designed mainly for the staging of lung cancer and of course for the diagnosis of suspicious findings in large central airways. The main limitation of the equipment is the diameter of the instrument and therefore it can only be guided through large airways. However; the diameter of the working channel also provides a large tissue sample nowadays with the 19G biopsy needle. We will provide our experience with the 22G needle of the endobronchial convex-probe in several medical situations of the thorax.

Minimally invasive procedures

Minimally invasive procedures, which include laparoscopic surgery, use state-of-the-art technology to reduce the damage to human tissue when performing surgery. Minimally invasive procedures require small "ports" from which the surgeon inserts thin tubes called trocars. Carbon dioxide gas may be used to inflate the area, creating a space between the internal organs and the skin. Then a miniature camera (usually a laparoscope or endoscope) is placed through one of the trocars so the surgical team can view the procedure as a magnified image on video monitors in the operating room. Specialized equipment is inserted through the trocars based on the type of surgery. There are some advanced minimally invasive surgical procedures that can be performed almost exclusively through a single point of entry-meaning only one small incision, like the "uniport" video-assisted thoracoscopic surgery (VATS). Not only do these procedures usually provide equivalent outcomes to traditional "open" surgery (which sometimes require a large incision), but minimally invasive procedures (using small incisions) may offer significant benefits as well: (I) faster recovery; (II) the patient remains for less days hospitalized; (III) less scarring and (IV) less pain. In our current mini review we will present the minimally invasive procedures for thoracic surgery.

Pneumothorax: an up to date "introduction"

The pneumothorax is an abnormal collection of air or gas in the pleural space that separates the lung from the chest wall. Like pleural effusion where a large abnormal concentration of fluid (>100 mL) is liquid buildup in that space, pneumothorax may interfere with normal breathing. A medical term that it is used is the collapsed lung, although that term may also refer to atelectasis. There are two major types of pneumothorax; there is one that occurs without an apparent cause and in the absence of significant lung disease, while the so called; "secondary" pneumothorax occurs in the presence of existing lung pathology. In a minority of cases, the amount of air in the chest increases markedly when a one-way valve is formed by an area of damaged tissue, leading to a third type of pneumothorax, called "tensioned".

Heimlich valve and pneumothorax

The Heimlich valve is a small one-way valve used for chest drainage that empties into a flexible collection device and prevents return of gases or fluids into the pleural space. The Heimlich valve is less than 13 cm (5 inches) long and facilitates patient ambulation. Currently there are several systems in the market. It can be used in many patients instead of a traditional water seal drainage system. The Heimlich chest drainage valve was developed so that the process of draining the pleural cavity could be accomplished in a safe, relatively simple, and efficient manner. This valve system has replaced the cumbersome underwater drainage bottle system. Moreover; the Heimlich valve system connects to chest tubing and allows fluid and air to pass in one direction only. This system functions in any position, and it does not ever need to be clamped, a regulated suction can be attached to it if necessary. The valve drains into a plastic bag that can be held at any level, allowing the patient undergoing chest drainage to be ambulatory simply by carrying the bag. In the current mini review we will present the Heimlich valve system and method of insertion.

Pneumothorax as a complication of central venous catheter insertion

The central venous catheter (CVC) is a catheter placed into a large vein in the neck [internal jugular vein (IJV)], chest (subclavian vein or axillary vein) or groin (femoral vein). There are several situations that require the insertion of a CVC mainly to administer medications or fluids, obtain blood tests (specifically the "central venous oxygen saturation"), and measure central venous pressure. CVC usually remain in place for a longer period of time than other venous access devices. There are situations according to the drug administration or length of stay of the catheter that specific systems are indicated such as; a Hickman line, a peripherally inserted central catheter (PICC) line or a Port-a-Cath may be considered because of their smaller infection risk. Sterile technique is highly important here, as a line may serve as a port of entry for pathogenic organisms, and the line itself may become infected with organisms such as Staphylococcus aureus and coagulase-negative Staphylococci. In the current review we will present the complication of pneumothorax after CVC insertion.

Pacemaker insertion

A pacemaker (PM) (or artificial PM, so as not to be confused with the heart's natural PM) is a medical device that uses electrical impulses, delivered by electrodes contracting the heart muscles, to regulate the beating of the heart. The primary purpose of this device is to maintain an adequate heart rate, either because the heart's natural PM is not fast enough, or there is a block in the heart's electrical conduction system. Modern PMs are externally programmable and allow the cardiologist to select the optimum pacing modes for individual patients. Some combine a PM and defibrillator in a single implantable device. PMs can be temporary or permanent. Temporary PMs are used to treat short-term heart problems, such as a slow heartbeat that's caused by a heart attack, heart surgery, or an overdose of medicine. Permanent PMs are used to control long-term heart rhythm problems. A PM can relieve some arrhythmia symptoms, such as fatigue and fainting. A PM also can help a person who has abnormal HRs resume a more active lifestyle. In the current mini review we will focus on the insertion of a PM and the possible pneumothorax that can be caused.

Pneumothorax from diagnosis to treatment, hands on course: Part II

Pneumothorax is a situation where air is inserted in the pleural space that separates the lung from the chest wall. Pneumothorax can be primary or secondary. There is also a third type called; tensioned. Based on the concentration of air and type of pneumothorax the proper treatment has to be selected. There are cases where the concentration is minimal and observation is enough and more severe cases where surgery is required. Currently there are many techniques used for the biopsy of lung lesions. The bronchoscope (forceps, fine needle aspiration), fine needle aspiration under computed tomography scan and endobronchial ultrasound (EBUS) are commonly used. However, all these techniques have in common a possible side effect; pneumothorax. In our current issue we will focus on the different minimally invasive techniques of pneumothorax management. Moreover, a presentation will be made for several systems that are being used for air or fluid aspiration.

Chest drainage systems in use

A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air in the case of pneumothorax or fluid such as in the case of pleural effusion, blood, chyle, or pus when empyema occurs from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter. Insertion of chest tubes is widely performed by radiologists, pulmonary physicians and thoracic surgeons. Large catheters or small catheters are used based on each situation that the medical doctor encounters. In the current review we will focus on the chest drain systems that are in use.

Video-assisted thoracic surgery and pneumothorax

Video-assisted thoracoscopic surgery (VATS) is a type of thoracic surgery performed using a small video camera that is introduced into the patient's chest via a scope. It is considered a minimally invasive technique where the surgeon is able to view the instruments that are being used along with the anatomy on which the surgeon is operating. The camera and instruments are inserted through separate holes in the chest wall also known as "ports", depending on the patient and problem there are surgeries with one port "uniport", two or three ports. These small ports have the advantage that fewer infections are observed. This allows for a faster recovery. Traditionally, thoracic surgery performed for diagnosis or treatment of chest conditions has required access to the chest through thoracotomy or sternotomy incisions. Vats minimally invasive technique has replaced in many cases thoracotomy or sternotomy. In our current review we will present this technique in detail.

Semi-Fowler vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis

BACKGROUND AND OBJECTIVE

The aim of this study is to compare usefulness of Semi-Fowler position vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis.

MATERIALS AND METHODS

From January 2009 to January 2010, 263 consecutive patients with palmar and axillar hyperhidrosis underwent thoracoscopic sympathectomy Th2-Th4. Patients were divided into two groups: group A (n=133) underwent thoracoscopic sympathectomy through lateral decubitus using double lumen endotracheal intubation, and group B (n=130) underwent thoracoscopic sympathectomy through Semi-Fowler supine position (semi sitting with arm abducted) using single lumen endotracheal intubation without insufflation of CO2, but with short apnea period. All operations were performed through two 5 mm operating ports, videothoracoscopic camera 0° and endoscopic ultrasound activated harmonic scalpel.

RESULTS

There were 107 males and 156 females with median age 30.31±8.35 years. Two groups were comparable in gender, age, severity of sweating. All operations were successfully performed with no complications or perioperative morbidity. For group A average operation time for both sides was 31.2±3.87 min and for group B average time was 14.19±4.98 min. In group B apnea period per one lung lasts 2.86±1.15 min and during that period observed saturation was 92.65%±5.66% without significant cardiorespiratory disturbances. Pleural drains were taken off on operation table after forced manually lung reexpansion. Patients were discharged from hospital for few hours, after the operation and radiologic confirmation of complete lung reexpansion.

CONCLUSIONS

Based on this data (shorter operating time, lack of incomplete lung collapse, insignificant apnea and better reexpansion of lungs) we concluded that thoracoscopic sympathectomy through Semi-Fowler supine position is highly effective and easy to perform for primary hyperhidrosis.

Open thoracotomy for pneumothorax

A thoracotomy is an incision into the pleural space of the chest. It is performed by surgeons (or emergency physicians under certain circumstances) to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine. This surgical procedure is a major surgical maneuver it is the first step in many thoracic surgeries including lobectomy or pneumonectomy for lung cancer and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation, rigid bronchoscope can be also used if necessary. Thoracotomies are thought to be one of the most difficult surgical incisions to deal with post-operatively, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading to atelectasis or pneumonia. In the current review we will present the steps of this procedure.

Barotrauma and pneumothorax

Barotrauma is physical damage to body tissues caused by a difference in pressure between a gas space inside, or in contact with the body, and the surrounding fluid. This situation typically occurs when the organism is exposed to a significant change in ambient pressure, such as when a scuba diver, a free-diver or an airplane passenger ascends or descends, or during uncontrolled decompression of a pressure vessel, but it can also happen by a shock wave. Whales and dolphins are also vulnerable to barotrauma if exposed to rapid and excessive changes in diving pressures. In the current review we will focus on barotraumas from definition to treatment.

Pleura space anatomy

The pleural cavity is the potential space between the two pleurae (visceral and parietal) of the lungs. The pleurae are serous membranes which fold back onto themselves to form a two-layered membranous structure. The thin space between the two pleural layers is known as the pleural cavity and normally contains a small amount of pleural fluid. There are two layers; the outer pleura (parietal pleura) is attached to the chest wall and the inner pleura (visceral pleura) covers the lungs and adjoining structures, via blood vessels, bronchi and nerves. The parietal pleurae are highly sensitive to pain, while the visceral pleura are not, due to its lack of sensory innervation. In the current review we will present the anatomy of the pleural space.

Physiology of the pleural space

The pleural cavity is created between the 4(th) and 7(th) week of embryologic development. These embryonic components of visceral and parietal pleurae develop different anatomic characteristics with regard to vascular, lymphatic, and nervous supply. There are two layers: a superficial mesothelial cell layer facing the pleural space and an underlying connective tissue layer. The pleura might present inflammatory response and maintenance of the pleural fluid is observed. The latter function is especially important in the mechanical coupling of the lung and chest wall. Fluid is filtered into the pleural space according to the net hydrostatic oncotic pressure gradient. It flows downward along a vertical pressure gradient, presumably determined by hydrostatic pressure and resistance to viscous flow. There also may be a net movement of fluid from the costal pleura to the mediastinal and interlobar regions. In these areas, pleural fluid is resorbed primarily through lymphatic stomata on the parietal pleural surface. In the current review we will present the physiology of the pleural space in a step by step manner.

Postoperative pain management

Postoperative pain is a very important issue for several patients. Indifferent of the surgery type or method, pain management is very necessary. The relief from suffering leads to early mobilization, less hospital stay, reduced hospital costs, and increased patient satisfaction. An individual approach should be applied for pain control, rather than a fix dose or drugs. Additionally, medical, psychological, and physical condition, age, level of fear or anxiety, surgical procedure, personal preference, and response to agents given should be taken into account. The major goal in the management of postoperative pain is minimizing the dose of medications to lessen side effects while still providing adequate analgesia. Again a multidisciplinary team approach should be pursued planning and formulating a plan for pain relief, particularly in complicated patients, such as those who have medical comorbidities. These patients might appear increase for analgesia-related complications or side effects.