Instruments and Maintenance

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Training and practice in bronchoscopy a national survey in Italy

BACKGROUND AND AIM

Bronchoscopy is performed in a variety of different settings in Italy. The surveys conducted so far have highlighted the heterogeneity of the procedures and the frequent inability to adhere to the guidelines. The aim of this survey was to analyse procedures, training, and opinions of Italian respiratory physicians performing interventional bronchology in the clinical practice.

METHODS

The study was conducted retrospectively on 300 pulmonologists. From January to June 2008, these were invited to participate in an email survey to be sent out monthly to each participant for four consecutive months.

RESULTS

Two hundred and one respiratory physicians took part in the study, most of whom (83.5%) work in either Pulmonology or Interventional Pulmonology Units. The year before the survey, 21.2% of the participants had performed fewer than 100 examinations, 42.3% 100 to 300, and 36.6% more than 300 bronchoscopies; 53.9% were familiar with the international guidelines on the topic. Among the responders, 34.1% had received less than 6 months training, 55.3% considered further training in rigid bronchoscopy, laser procedures and thoracoscopy, invaluable for their professional activity. Adequate training for transbronchial needle aspirates, was reported by 49.6% of respondents.

CONCLUSIONS

Our data show that interventional bronchoscopy procedures are regularly performed according to current recommendations by over half of the Italian Pulmonologists participating in our survey. The need for more comprehensive basic education and training was put forward by the majority of physicians.

Large diameter fully covered self-expanding metal stent placement for palliation of proximal malignant esophageal strictures

In patients with malignant esophageal strictures within 6 cm from the upper esophageal sphincter, self-expanding metal stents placement represents a challenge because there is an increased risk of complications. The aim of this study was to assess the safety and effectiveness of large-diameter WallFlex(®) fully covered self-expanding metal stents for palliation of patients with proximal malignant esophageal strictures. From March 2010 to December 2012, 12 patients with proximal strictures (4-6 cm from the upper esophageal sphincter) and six with very proximal strictures (<4 cm from the upper esophageal sphincter) were palliated with this fully covered self-expanding metal stent and included in the study. Technical success was 100% and clinical success was 94%. The mean baseline dysphagia score was 3.2, and 1 week after stenting it improved significantly to 1.3 (P < 0.001). Early complications occurred in four patients, more frequently in patients with very proximal strictures as compared with patients with proximal strictures (P = 0.02). Late complications occurred in five patients, and there were no differences between patients with very proximal strictures or proximal strictures (P = 0.245). The mean survival after stent placement was 119 days, and no differences between patients with very proximal strictures versus proximal strictures were found (P = 0.851). There was no stent-related mortality or 30-day mortality. Our results suggested that a large-diameter fully covered self-expanding metal stent is an effective and secure device for palliation of patients with proximal malignant esophageal strictures.

Bronchoscopic curative therapy

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The importance of the proceedings in thoracic endoscopy of the AIPO Study Group of Interventional Pulmonology

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Transbronchial needle aspiration

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Incidence of complications in bronchoscopy. Multicentre prospective study of 20,986 bronchoscopies

AIM

To evaluate the frequency of complications in bronchoscopy from data compiled between 1/2/2002 to 1/2/2003.

MATERIALS AND METHODS

Nineteen Italian centres of thoracic endoscopy participated in the study, for a total of 20,986 bronchoscopies (FBS), including 10,658 explorative bronchoscopies (EB) (50.79%), 5,520 bronchial biopsies (BB) (26.30%), 1,660 transbronchial biopsies (TBB) (7.91%), 1,127 broncho-alveolar lavages (BAL) (5.37%), 930 transbronchial needle-aspirates (TBNA) (4.43%), 1.091 therapeutic bronchoscopies (TB), comprising ND-YAG Laser, argon-plasma, electrocautery knife, stent insertion (5.20%). 82.4% of the procedures involved the use of a flexible bronchoscope, 16.3% were carried out using a rigid bronchoscope and 1.3% using the mixed technique.

RESULTS

The total number of complications recorded was 227 (1.08% of the cases examined), including 20 (0.09%) during local anesthesia and pre-medication, 195 (0.92%) during the endoscopic procedures and 12 (0.05%) in the two hours following FBS. The total number of deaths was 4 (0.02%), due to cardiac arrest, pulmonary edema, delayed respiratory failure and shock in pre-medication, respectively. 68.28% of the complications were treated medically, 25.99% by means of endoscopy and 5.72% with surgery. The healing percentage was 98.2%.

CONCLUSIONS

This study has shown that bronchoscopy is a safe method with low incidence of mortality and complications. The preparation, experience and continuous training of the operators of the medical and nursing team seem to play a fundamental role in reducing the incidence of complications at least in certain procedures such as BB and TBB.

Post-intubation tracheal stenoses: what is the curative yield of the interventional pulmonology procedures?

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The results of a randomized trial looking at 24 weeks vs 48 weeks of treatment with peginterferon alpha-2a (40 kDa) and ribavirin combination therapy in patients with chronic hepatitis C genotype 1

Peginterferon-alpha plus ribavirin is the most effective therapy for chronic hepatitis C. This study was designed to evaluate the effect of peginterferon alpha-2a (40 kDa) plus ribavirin on sustained virological response (SVR) when administered for 24 vs 48 weeks in genotype 1 naïve patients. One hundred and seventeen patients were enrolled in this controlled trial. Genotype 1 patients were randomized to 24 weeks treatment vs 48 weeks treatment. Genotype non-1 patients received 24 weeks treatment as an observational group. Outcomes were SVR (defined by hepatitis C virus-RNA-negative at week 24 of follow-up) and tolerability across the study period. The end-of-treatment response was 59% for genotype 1 (24 weeks treatment), 80% for genotype 1 (48 weeks treatment) and 92% for genotype non-1 (24 weeks treatment). The end-of-follow-up response was 19% (95% confidence interval (CI): 7.2-36.4) (genotype 1, 24 weeks) and 48% (95% CI: 30.2-66.9; P = 0.0175) (genotype 1, 48 weeks). Among genotype non-1, SVR was 76% (95% CI: 62.3-86.5). There were no unexpected adverse events. Almost half of the genotype 1 patients achieved an SVR after 48 weeks treatment with peginterferon alpha-2a (40 kDa) and low-dose ribavirin and confirmed that they should be treated for 48 weeks. Safety profile was acceptable.

Collapse of a new type of self-expanding metallic tracheal stent

Alveolus TB-STS is a new self-expanding, completely polyurethane-covered, metallic stent which has been designed to be successfully used even in the treatment of non-neoplastic airway strictures as it is supposed to be removable. We recently observed the collapse of an Alveolus tracheal stent, causing dyspnea and hemopthysis, in a 63-yr-old female patient with post-intubation tracheal stenosis. Such a complication, which to our knowledge has never been previously reported with metallic stent use, forced us to remove the stent.

On the matter of fluorescence bronchoscopy

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Acute lung injury associated with 5-fluorouracil and oxaliplatinum combined chemotherapy

Diarrhoea, T-CD4+ lymphopenia and bilateral patchy pulmonary infiltrates developed in a male 60 yrs of age, who was treated with oxaliplatinum and 5-fluorouracil for unresectable rectum carcinoma. The findings from transbronchial lung biopsy and bronchoalveolar lavage (BAL) were consistent with an organizing diffuse alveolar damage pattern. Once extensive microbiological studies proved negative, corticosteroids were given and a complete remission of clinical and radiological abnormalities was achieved. It is concluded that the aforementioned pathological manifestations were due to chemotherapy and included a pulmonary adverse reaction, a feature never previously associated with oxaliplatinum and 5-fluorouracil regimens.

Acute lung injury associated with 5-fluorouracil and oxaliplatinum combined chemotherapy

Diarrhoea, T-CD4+ lymphopenia and bilateral patchy pulmonary infiltrates developed in a male 60 yrs of age, who was treated with oxaliplatinum and 5-fluorouracil for unresectable rectum carcinoma. The findings from transbronchial lung biopsy and bronchoalveolar lavage (BAL) were consistent with an organizing diffuse alveolar damage pattern. Once extensive microbiological studies proved negative, corticosteroids were given and a complete remission of clinical and radiological abnormalities was achieved. It is concluded that the aforementioned pathological manifestations were due to chemotherapy and included a pulmonary adverse reaction, a feature never previously associated with oxaliplatinum and 5-fluorouracil regimens.

Delayed non-infectious lung disease in allogeneic bone marrow transplant recipients

BACKGROUND AND AIM OF THE WORK

The studies on late-onset non-infectious respiratory complications after allogeneic bone marrow transplantation (allo-BMT) have been mainly focused on bronchiolitis obliterans to date. The aim of this work was to analyze the incidence, clinico-pathologic characteristics and outcome of the entire spectrum of entities falling into the group of delayed non-infectious lung disease (DLD).

METHODS

Retrospective chart review was carried out of 112 patients who underwent allo-BMT for hematologic malignancies between April 1995 and November 1998 at a single Institution. The categorization of the pulmonary disease was made by analyzing clinical data, bronchoalveolar lavage (BAL), high-resolution computed tomography (HRCT) and histology when possible.

RESULTS

DLD occurred in 10 (10%) out of 97 recipients who survived at least 100 days following allo-BMT and was defined as bronchiolitis obliterans (BO; 4 cases), acute lung injury (ALI; 1 case) and subacute cellular interstitial pneumonia (SCIP; 5 cases). The BAL-profile was characterized by a marked increase of the neutrophil percentage in BO cases and of the lymphocyte (predominantly CD8+) percentage in parenchymal DLDs (SCIP, ALI). HRCT proved to be helpful to correctly identify BO cases, whereas histology was always needed to better define DLD presenting with an interstitial and/or alveolar pattern. The predominant airway involvement as well as the acute-onset of a respiratory illness with histological evidence of diffuse alveolar damage were associated with a worse prognosis because of a poor response to the immunosuppressive treatment.

CONCLUSIONS

DLDs represent a group of entities heterogeneous in regard to variables such as onset and clinical behaviour (acute, subacute or chronic), predominant pattern of lung involvement (airway or parenchymal), response to treatment. Although immunopathologic mechanisms related to c-GVHD probably have a relevant pathogenic importance in this setting, the possible role of associated events (eg, drug toxicity and infections) at least in priming the lung damage need to be better clarified for its therapeutical implications.

Photodynamic laser therapy for the treatment of early-stage bronchogenic carcinoma

Photodynamic therapy (PDT) is an effective modality that can be used in the treatment of bronchogenic squamous cancer. PDT can be curative in cases of early-stage central type lung cancer and, for this reason, is an alternative to surgery in patients with in situ carcinoma or minimally invasive squamous cell carcinoma. PDT was performed in 26 early bronchogenic cancers in 23 patients, and 16 complete remissions and 10 partial remissions were obtained. It is concluded that photodynamic therapy is effective in the treatment of superficial lung cancer in which complete remission can be expected. The combination of different endoscopic therapeutic modalities and trials comparing endoscopic therapy with surgical resection are anticipated.

[Efficacy of bronchoscopic Nd:YAG laser therapy for laryngotracheal stenoses after long-term intubation]

From 1987 to 1993, 38 patients with laryngotracheal stenosis due to prolonged intubation were treated with the Nd:YAG-laser. A total of 45 stenoses were identified and classified according to endoscopic assessment. Patients who had an asymptomatic airway for at least 8 months and did not require further intervention were considered treatment successes. The best results were found in the diaphragmas and granulomas (86% and 65%), in stenoses less than 1 cm in length (61%) and in cases with less than 70% obstruction of the tracheal lumen (61%).

Acute lung inflammation: neutrophil elastase versus neutrophils in the bronchoalveolar lavage--neutrophil elastase reflects better inflammatory intensity

OBJECTIVE

To test the hypothesis whether PMN-Elastase in bronchoalveolar lavage fluid (BALF) could reflect neutrophil activity in the lower respiratory tract.

DESIGN

Prospectively, morphologic findings of acute and chronic inflammation in the transbronchial lung biopsy specimens were compared with the numbers of neutrophils in the BALF and the concentration of PMN-Elastase in the same.

SETTING

Ambulatory outpatient service of bronchology and respiratory physiopathology and intensive care unit of a communal hospital.

PATIENTS

50 ambulatory outpatients and 10 critically ill patients of the ICU, presenting infiltrative lung diseases.

INTERVENTIONS

Transbronchial lung biopsies and bronchoalveolar lavage were performed through a fiberoptic bronchoscope. Venous blood samples were obtained after bronchoscopy.

MEASUREMENTS AND RESULTS

Biopsy specimens and cell count in the BALF were examined by light microscopy. PMN-Elastase and albumin were measured in the BALF-supernatant and in the plasma. C-reactive protein (CRP) and a1 proteinase inhibitor (a1-PI) were measured in the plasma. Intrapulmonary originating PMN-Elastase was calculated with reference to albumin. The results concerning acute inflammation obtained by transbronchial lung biopsy (TBLB) (n = 16) correlated better with the levels of PMN-Elastase in the BALF (n = 21) than with the neutrophil count (n = 28) (p < 0.5 versus p < 0.025 for chi 2). The sensitivities and specificities of the above methods were respectively 76.9%, 100%, 100% and 100%, 95.2%, 63.1%. The intrapulmonary originating PMN-Elastase was about 99.7% of the measured BALF-Elastase.

CONCLUSION

The PMN-Elastase concentration in the BALF is a more accurate indicator of the inflammatory intensity in the alveolar structures than in the number of neutrophils. It may therefore be useful to the clinician in his attempt to detect acute inflammation in the lower respiratory tract.

Diffuse panbronchiolitis observed in an Italian male

We describe a case of a 43 year old man who presented with productive cough, dyspnea, severe obstructive ventilatory failure and diffuse micronodular shadows on chest roentgenogram. Bronchoalveolar lavage fluid analysis showed an increased total cellularity sustained by a huge neutrophilia. Sweat test was negative. Transbronchial lung biopsy and autopsy showed unit lesion of diffuse panbronchiolitis. This report represents, to the best of our knowledge, the first case of diffuse panbronchiolitis observed in Europe.

Pneumoconiosis (silicosis) in the confectionery industry

Pneumoconiosis is not reported in food industry workers, and more specifically in the confectionery industry. We diagnosed diffuse pulmonary interstitial nodular fibrosis due to inhalation of powder containing quartz in a 54 year-old asymptomatic woman. Silicosis was due to a 5-year period of talc dust exposure 35 years earlier in the confectionery industry. The diagnosis was supported by a history of exposure, transbronchial lung biopsy specimen, 67Gallium scan, and CT scan. Our patient had an unusual history of exposure, which was not readily disclosed until the patient's memories, and after consultation with an expert in confectionery techniques, indicated she had been exposed to talc powder during her employment in the confectionery industry.

Primary acute pulmonary cavitation in asymptomatic sarcoidosis

Sarcoidosis has a large variety of chest x-ray manifestations, but primary acute cavitation is very rare. We report a case of cavitary sarcoidosis occurring in an asymptomatic 25 year-old white patient. The diagnosis was established from chest x-ray, transbronchial biopsy specimen, bronchoalveolar lavage and gallium 67 scan. The peculiarities of this case are: 1) the presence of hilar adenopathy; 2) the cavitation occurred during the decreased activity of the disease; 3) the resolution of cavity without therapy. We suggest asymptomatic sarcoidosis should be considered in the differential diagnosis of pulmonary cavitation.

[Endobronchial administration of netilmicin in patients with bronchopulmonary infections seen in the neurosurgical intensive care unit]

The Authors report the results obtained in the treatment of bronchopulmonary infections in patients hospitalized in the Neurosurgical Intensive Care Unit. Netilmicin was administered by systemic and endobronchial routes. The cleaning of the bronchial tree was always performed. Twenty-six patients (16 males and 10 females) were enrolled and assigned to one of the following groups. Group A: 16 patients with confirmed pneumonia; Group B: 10 patients without bronchopulmonary infections, as controls for serum pharmacokinetic study. In the majority of the cases pneumonia was caused by Staphylococcus aureus and Pseudomonas aeruginosa. The results obtained were positive: pneumonia resolution was observed in 10 patients (67%), improvement in 4 (27%) and failure in one case (6%). A pharmacokinetic study has confirmed bacteriologically active serum levels of netilmicin and also the availability of netilmicin within the bronchial secretions. Endobronchial plus systemic netilmicin administration was active and well tolerated in these critical patients.

Transbronchial lung biopsy in infiltrative lung disease. The importance of the pathologic approach

Infiltrative diffuse lung diseases represent a heterogenous group of lesions with overlapping clinical and roentgenological features. Their diagnosis frequently needs a pathologic approach. We report our experience (671 patients with lung infiltrates) with transbronchial lung biopsy (TBB) procedure. The results of morphologic investigation were subdivided into three groups: 1) A specific morphologic diagnosis was made in 192 cases (29%) 2) Histopathologic changes well consistent with the clinical pattern were present in 258 patients (38%) 3) Non-specific lesions were found in 221 cases (33%). The diagnosis yield of the method was of 67%. UIP, DIP, Pulmonary Angiitis and Granulomatosis, Bronchiolitis Obliterans-Organizing Pneumonia and other rarer lung diseases may not be diagnosed on the basis of lesions present in TBB specimens.

Transbronchial lung biopsy and bronchoalveolar lavage in diagnosis of diffuse infiltrative lung diseases

We investigated 801 patients with lung infiltrates who underwent transbronchial lung biopsy (TBB) and performed cytologic studies of lavage fluid of 491 patients who also underwent bronchoalveolar lavage (BAL). A specific histopathological diagnosis was made in 232 cases (29%). Histopathological changes consistent with the clinical pattern were present in 296 cases (37%). The diagnostic yield of TBB was 66%. Routine evaluation of BAL fluid allowed us to make a specific diagnosis in 49 cases. The role of the pulmonary pathologist in the interpretation of TBB and BAL specimens is discussed.

Transbronchial lung biopsy in pulmonary sarcoidosis. Is it an evaluable method in detection of disease activity?

To assess the value of transbronchial lung biopsy in the evaluation of disease activity in pulmonary sarcoidosis, lung biopsy specimens obtained from 37 patients with this disease and their cellular patterns of bronchoalveolar lavage were studied. Morphologic analysis has showed peculiar lesions: predominant interstitial alveolitis consisting of mononuclear cells and scattered neutrophils, and eosinophils, diffuse in 13 cases and focal in 11 cases, interstitial nodular clusterings of mononuclear cells (five cases), diffuse intraalveolar infiltration of macrophages (one case), granulomas (27 cases), hyaline membranes (one case), intraalveolar (two cases) and interstitial (six cases) fibrosis, and finally cuboidal metaplasia of alveolar lining cells (eight cases). Hyaline membranes were always combined to a diffuse alveolitis consisting of some neutrophils. Only diffuse alveolitis was significantly associated with a high lymphocytosis in BAL (p less than 0.05).