Journal of bronchology & interventional pulmonology, Oct 1, 2018
Background: The value of endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TB... more Background: The value of endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TBNA) in the mediastinal staging of lung cancer has been well established. However, data regarding its utility in the diagnosis of intrapulmonary lesions has been sparse. This study assesses the sampling utility of convex probe EBUS-visible intrapulmonary lesions not visualized by the white-light bronchoscopy. Methods: A retrospective analysis of EBUS-TBNA of EBUS-visible intrapulmonary lesions was performed between January 2010 and March 2015. Patients with visible endobronchial lesions by white-light bronchoscopy were excluded from analysis. Results: Among 108 procedures, the diagnostic yield of EBUS-TBNA for EBUS-visible intrapulmonary lesions was 87%. Following diagnoses were established: lung cancer (73/67.6%), lung metastases (10/9.2%), infection (5/4.6%), lymphoma (1/ < 1%), sarcoma/spindle cell sarcoma or neoplasm (3/2.8%), unspecified malignancy (1 < 1%), and hamartoma (1/ < 1%). EBUS-TBNA was nondiagnostic in 14 (13%); among these, 9 turned out to have benign disease based on additional bronchoscopy samples or other testing and/or follow-up imaging. Five were ultimately diagnosed with a malignant condition: lymphoma (1), epithelioid hemangioendothelioma (1), and non-small cell lung cancer (3). The sensitivity and the negative predicted value of EBUS-TBNA for differentiating malignancy from benign disease was 94.7% and 75%, respectively, while the accuracy for diagnosing the neoplastic disease was 95.3%. There was one major bleeding requiring bronchial artery embolization and 1 pneumothorax requiring chest tube drainage. Conclusion: EBUS-TBNA is safe and effective in the diagnosis of EBUS-visible intrapulmonary lesions. It should be considered as the diagnostic test of choice in patients with these lesions undergoing EBUS-TBNA for the staging of suspected lung cancer.
A central goal of an airway stent is to restore patency by preventing restenosis, holding the tra... more A central goal of an airway stent is to restore patency by preventing restenosis, holding the tracheobronchial wall, or occluding fistulas. Complications with stents, however, are frequent and can have grave repercussions. Stents are therefore viewed as a last resort in cases where other forms of treatment are ineffective. Furthermore, it is common for people with complex airways to have airway stents that do not fit them well, which can result in several complications. Three-dimensional printing technology was developed at the turn of the 20th century. It has been employed in a variety of applications and has transformed healthcare. This technology has mainly been employed in respiratory medicine to develop three-dimensional models of the airways and to make airway splints and prostheses to treat central airway diseases. In the past ten years, it has transformed and advanced personalized medicine, enabling the creation of patient-specific stents for people with complex airway diseases. Threedimensional printing might be used to create a patient-specific stent that would lessen risks, enhance the quality of life, and eliminate the need for additional procedures. This chapter discusses the most recent developments in three-dimensional printing technology, how they are being used to create airway prostheses to treat complex airway illnesses and the current body of research that supports their use.
Building an efficient facility for advanced bronchoscopic procedures involves many considerations... more Building an efficient facility for advanced bronchoscopic procedures involves many considerations. This review places particular emphasis on anesthesiology services, based on experience at a tertiary/quaternary care referral academic medical center. Topics include equipment requirements, applicable clinical standards and multidisciplinary collaboration. Patient flow arrangements for both outpatients and inpatients, from pre-operative care to discharge/disposition are highlighted. The importance of effective business planning, personnel training, leadership, communication, teambuilding, quality of care and patient safety are also discussed.
PURPOSE:Self Expanding Metallic Stents have been used to maintain airway patency in patients who ... more PURPOSE:Self Expanding Metallic Stents have been used to maintain airway patency in patients who are poor surgical candidates due to limited life expectancy or multiple comorbidities. SEMS have been associated with a variety of complications yet bronchovascular fistulas have rarely been reported. Retrospective study, tertiary care center. Review of charts of patients who developed broncho-vascular fistulas following SEMS placement between 1999 and 2007 using Wallstent or Ultraflex(Boston Scientific, Natick MA) stents. RESULTS:During the study period,6 patients were diagnosed with broncho-vascular fistula formation. Indications for stent placement were airway obstruction caused by neoplasia in two patients and airway complications of lung transplantation in the other four. Diagnosis of broncho-vascular fistula was suspected from the CT scan findings or when the patients presented with massive hemoptysis. Male to female ratio was equal, mean age of patients at time of stent placement was 51.3 years (range 24-73 years). Median duration of interval between the stent placement and the diagnosis of broncho-vascular fistula was 16 months (range 1-65 months). Five of these patients died withing hours with massive hemoptysis following the diagnosis while one is still alive at 65 months. CONCLUSION:SEMS should only be used in a select sub-group of patients, after exhaustive evaluation of other treatment options and require sequential follow-up to monitor for any complications. The cases presented here provide evidence that broncho-vascular fistulas can develop at any time after SEMS implantation for both benign and malignant conditions involving the major airways. Broncho-vascular fistula formation is invariably fatal thus suggesting the need for a more cautious approach especially in using SEMS for long term management. CLINICAL IMPLICATIONS:To highlight a potentially fatal complication of bronchovascular fistula formation from Self Expanding Metallic Stents.
Journal of bronchology & interventional pulmonology, Apr 1, 2018
I pulmonology (IP) is the subspecialty that manages ailments of the central airways. It has progr... more I pulmonology (IP) is the subspecialty that manages ailments of the central airways. It has progressed from therapeutic interventions in lung cancer, to advanced diagnostic bronchoscopy, and, now, medical mediastinoscopy and pleuroscopy. Bronchoscopic thermoplasty, endobronchial volume reduction, and percutaneous dilatational tracheostomy are additional facets of this technologically advanced branch of pulmonary medicine. Successful lung transplantation could not be achieved without flexible bronchoscopy. The future of IP is quite promising with robotic bronchoscopy and the transbronchial application of microwave technology. A critical role for the IP physicians, however, lies in the prevention and early recognition of diseases of the central airways to maintain airway health. Undoubtedly, the mandate of protecting the health of the airways is the unique expertise of interventional pulmonologists. The attainment of this important objective requires thorough knowledge of conditions that could potentially involve the airways, meticulous selection of endoscopic procedures, and prevention of complications from established interventions. This goal is achieved through the skillful application of the art and the science of pulmonary interventions, and a multidisciplinary team approach in concert with anesthesiology, otolaryngology, radiology, pathology, oncology, and thoracic surgery specialists. The airways can be affected by factors intrinsic to patients and their diseases. The gastrointestinal tract deserves special attention. Swallowing disorders, among several others, put patients at risk for foreign body aspiration into the tracheobronchial tree, including pills.1 An aspirated iron pill, for example, can cause bronchial stenosis requiring endoscopic intervention.2–4 Oral administration of numerous pills should be avoided in patients with swallowing disorders, and all patients should swallow only 1 pill at a time.3–4 Gastroesophageal reflux disorder (GERD) has been associated with chronic cough and even tracheal stenosis.5 A causal relationship between GERD and these conditions remains unproven, yet it is worthwhile to rule out GERD and optimally treat the reflux when airway involvement is suspected.5,6 Inflammatory bowel disease (IBD) can affect any segment of the airways and could be the first indication of the disease. Bronchiectasis is the most common airway manifestation of IBD (66%), but tracheal involvement can occur in as many as 10% of patients.7 Other pulmonary as well as systemic diseases also have primary and secondary airway manifestations and may be the forme fruste of these conditions. Most patients with pulmonary sarcoidosis have airway abnormalities, and bronchoscopy frequently demonstrates erythema, plaques, nodules, or a cobblestone appearance.8 Proximal bronchial stenosis can occur and may
Granulomatosis with polyangiitis (GPA) is largely a systemic disease, with the lungs being the mo... more Granulomatosis with polyangiitis (GPA) is largely a systemic disease, with the lungs being the most commonly affected organs. Although it can affect the airways in up to 15-55% of cases, tracheobronchial disease remains under recognized, with paucity of published data. The aim of this study is to describe airway disease manifestations and various bronchoscopic therapies implemented in a large volume referral center. Retrospective review of charts of patients diagnosed with GPA who underwent bronchoscopies between January 2015 and January 2016. RESULTS: 23 patients with an established diagnosis of GPA underwent a total of 103 bronchoscopies. Female: Male ratio was 3:1, with a mean age of 41 years. 83% of patients were on immunosuppressive therapy at the time of bronchoscopy. The majority of patients were symptomatic (77%) with dyspnea (74%), cough (65%) and wheezing (37%) being the most common symptoms at presentation. On bronchoscopic examination, airway disease was identified in all patients, most commonly at the level of the subglottis (64%), trachea (51%) and distal airways (75%), while disease of the vocal cords was rarely seen (7%). The most common types of airway abnormalities included multifocal tracheobronchial stenosis (75%), subglottic stenosis (59%) and localized strictures (31%). Mucosal abnormalities such as edema, ulcerations and cobble stoning were seen in 36% of airway examinations. Other rare disease manifestations such as synechial membranes, pseudopolyps and submucosal tunnels were also observed. Additionally, thick crusty secretions were a common finding (39%). Endobronchial biopsies, when performed, showed no evidence of vasculitis. Notably, various bronchosopic interventions were effective at treating airway obstruction due to GPA. Balloon dilation was most commonly used (67%), along with steroid injections (63%) and application of mitomycin (39%). Other techniques included: rigid dilations (10%), electrosurgery (28%), cryotherapy (28%) and stent placement (14%). Improvement of airway disease was seen on 65% of repeat bronchoscopies. Moreover, symptoms improved in 89% of patients post intervention. No procedural complications or deaths were reported. CONCLUSIONS: Tracheobronchial disease is a common cause of morbidity in patients with GPA. It has various bronchoscopic manifestations, which can be at times subtle. Bronchoscopy plays an essential role in early diagnosis and therapy. CLINICAL IMPLICATIONS: Airway abnormalities can progress into scarring and stenosis despite appropriate immunosuppressive therapy. Various bronchoscopic techniques are effective in controlling the disease and providing immediate relief of symptoms.
Trachea is chondromembranous structure. Its posterior muscle fibers comprise of outer longitudina... more Trachea is chondromembranous structure. Its posterior muscle fibers comprise of outer longitudinal and inner transvers fibers which extends between the ends of the cartilages. Severe atrophy and separation of the tracheal smooth muscles (TSM) from the cartilages is rare and hasn't being studies well. Herein we present a case of severe atrophy and separation of TSM from the cartilages in a COPD patient.
Electromagnetic navigation bronchoscopy (ENB) aids in lung lesion biopsy. However, diagnostic yie... more Electromagnetic navigation bronchoscopy (ENB) aids in lung lesion biopsy. However, diagnostic yield is impacted by biopsy tool strategy and rapid on-site evaluation (ROSE) use. This analysis evaluates usage patterns, accuracy, and safety of tool strategy and ROSE in the multicenter NAVIGATE study. METHODS: NAVIGATE (NCT02410837) evaluates ENB using the superDimensionÔ navigation system. The US cohort prospectively enrolled 1215 consecutive subjects at 29 sites. Included herein are 416 who underwent ENB-aided biopsy of a single lung lesion positive for malignancy as of 1 year. "Limited" tool strategies (including only biopsy forceps, standard cytology brush, and/or lavage) were compared to "Extensive" tool strategies (including any of aspirating needle, triple-needle cytology brush, needle-tipped cytology brush, or GenCutÔ core biopsy system, with or without "Limited" tools). RESULTS: Of malignant cases, 86.8% (361/416) of true positive diagnoses were obtained using Extensive tool strategies versus only 13.2% (55/416) using Limited strategies. ROSE was used in 89.1% (49/55) and 69.5% (251/361) of subjects in the Limited and Extensive sets, respectively. A mean of 1.8AE0.8 (range 1-3) unique biopsy tools was used in the Limited group vs. 2.8AE 1.0 (range 1-5) in the Extensive arm (P<0.001). A malignant ROSE call was obtained in 50.9% (212/416), most (88.7%; 188/212) by the first biopsy tool used (49.5% with aspirating needle, 20.2% with cytology brush, 17.0% with forceps). Obtaining a malignancy with ROSE reduced the total number of tools used vs. cases without a malignant ROSE call (1.6AE0.8 vs. 2.1AE0.9 Limited, 2.7AE1.0 vs. 3.4AE1.0 Extensive). When used, ROSE was concordant with final pathology in 71.4% (35/49) and 70.5% (177/251) of the Limited and Extensive groups, respectively. Final pathology true positive rates were 86.6% (213/246) for aspirating needle, 83.8% (62/74) for GenCut, 81.6% (71/87) for needle-tipped brush, and 70.6% (72/102) for triple-needle brush. Among Limited tools, true positive rates were 86.9% (312/359) for forceps, 77.6% (156/201) for cytology brush, and 58.5% (69/118) for lavage. Procedurerelated pneumothorax occurred in 5.5% (3/55) and 2.8% (10/361) of the Limited and Extensive groups, respectively (3.6% [2/55)] vs. 1.1% [4/361] with intervention or hospitalization) and procedure-related hemorrhage occurred in 3.6% (2/55) vs. 1.1% (4/361). CONCLUSIONS: Advanced biopsy strategies were favored among NAVIGATE sites. Most true positive diagnoses were obtained by extensive strategies, without increased complications. Aspirating needle and biopsy forceps had the highest true positive rates. ROSE use, while concordant with final pathology in only 71%, impacted tool strategy. The pragmatic nature and large multicenter dataset of NAVIGATE allow a comprehensive analysis of practice variations in biopsy tool and ROSE use.
The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and t... more The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and the available literature as of the date posted. While we try to regularly update this content, any offered recommendations cannot be substituted for the clinical judgment of clinicians caring for individual patients.
Journal of bronchology & interventional pulmonology, Oct 1, 2014
Endobronchial involvement is a relatively uncommon but well-described presentation in Granulomato... more Endobronchial involvement is a relatively uncommon but well-described presentation in Granulomatosis with polyangiitis (GPA). Self-expandable metallic stents (SEMs) should be reserved for the malignant airway disorder to maintain airway patency, but have been used for benign disease in specific cases. We present a case of longstanding endobronchial GPA with recurrent bronchial stenosis. Three SEMs were deployed in the distal left main bronchus 10 years prior. Two were removed in the standard manner, but the remaining stent SEM was completely embedded in the bronchial mucosa making its removal extraordinarily difficult. We placed an oversized silicone stent inside the stent leading to necrosis of the mucosa allowing for a less formidable removal of the embedded stent. Another silicone stent was temporarily placed. SEMs removal can be extremely complicated and should only be performed by experienced bronchoscopists in an institution with sufficient resources.
The Journal of Thoracic and Cardiovascular Surgery, Nov 1, 2018
Video clip is available online. Airway stents are routinely used for the treatment of various dis... more Video clip is available online. Airway stents are routinely used for the treatment of various diseases of the central airways. To achieve the best possible alignment with the airway, stents are available in numerous dimensions, varying in diameter and length. In most cases, good results with significant relief of symptoms can be achieved with off-the-shelf stents. In some cases, however, the available stents cannot be used because of excessively enlarged airways, unusual branching angles, or airway distortion. Despite the substantial legal hurdles that have to be overcome before their clinical use, 3-dimensional (3D) modeling and printing applications in medicine are increasingly reported. The advantage of an airway stent designed and produced for an individual patient is that a perfect alignment with the mucosa can be achieved. This could decrease typical stent-related complications, such as biofilm formation and mucus retention between the airway and the stent, formation of granulation tissue, and stent migration. Experience, however, is limited to preclinical studies. We herein report the first 2 European clinical applications of customized silicone Y-stents, which were manufactured with 3D-printing technology.
American Journal of Respiratory and Critical Care Medicine, Nov 1, 2006
Rationale: Electromagnetic navigation bronchoscopy using super-Dimension/Bronchus System is a nov... more Rationale: Electromagnetic navigation bronchoscopy using super-Dimension/Bronchus System is a novel method to increase diagnostic yield of peripheral and mediastinal lung lesions. : A prospective, open label, single-center, pilot study was conducted to determine the ability of electromagnetic navigation bronchoscopy to sample peripheral lung lesions and mediastinal lymph nodes with standard bronchoscopic instruments and demonstrate safety. Methods: Electromagnetic navigation bronchoscopy was performed using the superDimension/Bronchus system consisting of electromagnetic board, position sensor encapsulated in the tip of a steerable probe, extended working channel, and real-time reconstruction of previously acquired multiplanar computed tomography images. The final distance of the steerable probe to lesion, expected error based on the actual and virtual markers, and procedure yield was gathered. Measurements: 60 subjects were enrolled between December 2004 and September 2005. Mean navigation times were 7 Ϯ 6 min and 2 Ϯ 2 min for peripheral lesions and lymph nodes, respectively. The steerable probe tip was navigated to the target lung area in all cases. The mean peripheral lesions and lymph nodes size was 22.8 Ϯ 12.6 mm and 28.1 Ϯ 12.8 mm. Yield was determined by results obtained during the bronchoscopy per patient. Results: The yield/procedure was 74% and 100% for peripheral lesions and lymph nodes, respectively. A diagnosis was obtained in 80.3% of bronchoscopic procedures. A definitive diagnosis of lung malignancy was made in 74.4% of subjects. Pneumothorax occurred in two subjects. Conclusion: Electromagnetic navigation bronchoscopy is a safe method for sampling peripheral and mediastinal lesions with high diagnostic yield independent of lesion size and location.
Bronchial thermoplasty was recently approved for treating severe refractory asthma that is not we... more Bronchial thermoplasty was recently approved for treating severe refractory asthma that is not well controlled by high-dose inhaled corticosteroids and long-acting bronchodilator therapy. This article reviews its indications, evidence of efficacy, and protocols.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this p... more The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Journal of bronchology & interventional pulmonology, Oct 1, 2018
Background: The value of endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TB... more Background: The value of endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TBNA) in the mediastinal staging of lung cancer has been well established. However, data regarding its utility in the diagnosis of intrapulmonary lesions has been sparse. This study assesses the sampling utility of convex probe EBUS-visible intrapulmonary lesions not visualized by the white-light bronchoscopy. Methods: A retrospective analysis of EBUS-TBNA of EBUS-visible intrapulmonary lesions was performed between January 2010 and March 2015. Patients with visible endobronchial lesions by white-light bronchoscopy were excluded from analysis. Results: Among 108 procedures, the diagnostic yield of EBUS-TBNA for EBUS-visible intrapulmonary lesions was 87%. Following diagnoses were established: lung cancer (73/67.6%), lung metastases (10/9.2%), infection (5/4.6%), lymphoma (1/ < 1%), sarcoma/spindle cell sarcoma or neoplasm (3/2.8%), unspecified malignancy (1 < 1%), and hamartoma (1/ < 1%). EBUS-TBNA was nondiagnostic in 14 (13%); among these, 9 turned out to have benign disease based on additional bronchoscopy samples or other testing and/or follow-up imaging. Five were ultimately diagnosed with a malignant condition: lymphoma (1), epithelioid hemangioendothelioma (1), and non-small cell lung cancer (3). The sensitivity and the negative predicted value of EBUS-TBNA for differentiating malignancy from benign disease was 94.7% and 75%, respectively, while the accuracy for diagnosing the neoplastic disease was 95.3%. There was one major bleeding requiring bronchial artery embolization and 1 pneumothorax requiring chest tube drainage. Conclusion: EBUS-TBNA is safe and effective in the diagnosis of EBUS-visible intrapulmonary lesions. It should be considered as the diagnostic test of choice in patients with these lesions undergoing EBUS-TBNA for the staging of suspected lung cancer.
A central goal of an airway stent is to restore patency by preventing restenosis, holding the tra... more A central goal of an airway stent is to restore patency by preventing restenosis, holding the tracheobronchial wall, or occluding fistulas. Complications with stents, however, are frequent and can have grave repercussions. Stents are therefore viewed as a last resort in cases where other forms of treatment are ineffective. Furthermore, it is common for people with complex airways to have airway stents that do not fit them well, which can result in several complications. Three-dimensional printing technology was developed at the turn of the 20th century. It has been employed in a variety of applications and has transformed healthcare. This technology has mainly been employed in respiratory medicine to develop three-dimensional models of the airways and to make airway splints and prostheses to treat central airway diseases. In the past ten years, it has transformed and advanced personalized medicine, enabling the creation of patient-specific stents for people with complex airway diseases. Threedimensional printing might be used to create a patient-specific stent that would lessen risks, enhance the quality of life, and eliminate the need for additional procedures. This chapter discusses the most recent developments in three-dimensional printing technology, how they are being used to create airway prostheses to treat complex airway illnesses and the current body of research that supports their use.
Building an efficient facility for advanced bronchoscopic procedures involves many considerations... more Building an efficient facility for advanced bronchoscopic procedures involves many considerations. This review places particular emphasis on anesthesiology services, based on experience at a tertiary/quaternary care referral academic medical center. Topics include equipment requirements, applicable clinical standards and multidisciplinary collaboration. Patient flow arrangements for both outpatients and inpatients, from pre-operative care to discharge/disposition are highlighted. The importance of effective business planning, personnel training, leadership, communication, teambuilding, quality of care and patient safety are also discussed.
PURPOSE:Self Expanding Metallic Stents have been used to maintain airway patency in patients who ... more PURPOSE:Self Expanding Metallic Stents have been used to maintain airway patency in patients who are poor surgical candidates due to limited life expectancy or multiple comorbidities. SEMS have been associated with a variety of complications yet bronchovascular fistulas have rarely been reported. Retrospective study, tertiary care center. Review of charts of patients who developed broncho-vascular fistulas following SEMS placement between 1999 and 2007 using Wallstent or Ultraflex(Boston Scientific, Natick MA) stents. RESULTS:During the study period,6 patients were diagnosed with broncho-vascular fistula formation. Indications for stent placement were airway obstruction caused by neoplasia in two patients and airway complications of lung transplantation in the other four. Diagnosis of broncho-vascular fistula was suspected from the CT scan findings or when the patients presented with massive hemoptysis. Male to female ratio was equal, mean age of patients at time of stent placement was 51.3 years (range 24-73 years). Median duration of interval between the stent placement and the diagnosis of broncho-vascular fistula was 16 months (range 1-65 months). Five of these patients died withing hours with massive hemoptysis following the diagnosis while one is still alive at 65 months. CONCLUSION:SEMS should only be used in a select sub-group of patients, after exhaustive evaluation of other treatment options and require sequential follow-up to monitor for any complications. The cases presented here provide evidence that broncho-vascular fistulas can develop at any time after SEMS implantation for both benign and malignant conditions involving the major airways. Broncho-vascular fistula formation is invariably fatal thus suggesting the need for a more cautious approach especially in using SEMS for long term management. CLINICAL IMPLICATIONS:To highlight a potentially fatal complication of bronchovascular fistula formation from Self Expanding Metallic Stents.
Journal of bronchology & interventional pulmonology, Apr 1, 2018
I pulmonology (IP) is the subspecialty that manages ailments of the central airways. It has progr... more I pulmonology (IP) is the subspecialty that manages ailments of the central airways. It has progressed from therapeutic interventions in lung cancer, to advanced diagnostic bronchoscopy, and, now, medical mediastinoscopy and pleuroscopy. Bronchoscopic thermoplasty, endobronchial volume reduction, and percutaneous dilatational tracheostomy are additional facets of this technologically advanced branch of pulmonary medicine. Successful lung transplantation could not be achieved without flexible bronchoscopy. The future of IP is quite promising with robotic bronchoscopy and the transbronchial application of microwave technology. A critical role for the IP physicians, however, lies in the prevention and early recognition of diseases of the central airways to maintain airway health. Undoubtedly, the mandate of protecting the health of the airways is the unique expertise of interventional pulmonologists. The attainment of this important objective requires thorough knowledge of conditions that could potentially involve the airways, meticulous selection of endoscopic procedures, and prevention of complications from established interventions. This goal is achieved through the skillful application of the art and the science of pulmonary interventions, and a multidisciplinary team approach in concert with anesthesiology, otolaryngology, radiology, pathology, oncology, and thoracic surgery specialists. The airways can be affected by factors intrinsic to patients and their diseases. The gastrointestinal tract deserves special attention. Swallowing disorders, among several others, put patients at risk for foreign body aspiration into the tracheobronchial tree, including pills.1 An aspirated iron pill, for example, can cause bronchial stenosis requiring endoscopic intervention.2–4 Oral administration of numerous pills should be avoided in patients with swallowing disorders, and all patients should swallow only 1 pill at a time.3–4 Gastroesophageal reflux disorder (GERD) has been associated with chronic cough and even tracheal stenosis.5 A causal relationship between GERD and these conditions remains unproven, yet it is worthwhile to rule out GERD and optimally treat the reflux when airway involvement is suspected.5,6 Inflammatory bowel disease (IBD) can affect any segment of the airways and could be the first indication of the disease. Bronchiectasis is the most common airway manifestation of IBD (66%), but tracheal involvement can occur in as many as 10% of patients.7 Other pulmonary as well as systemic diseases also have primary and secondary airway manifestations and may be the forme fruste of these conditions. Most patients with pulmonary sarcoidosis have airway abnormalities, and bronchoscopy frequently demonstrates erythema, plaques, nodules, or a cobblestone appearance.8 Proximal bronchial stenosis can occur and may
Granulomatosis with polyangiitis (GPA) is largely a systemic disease, with the lungs being the mo... more Granulomatosis with polyangiitis (GPA) is largely a systemic disease, with the lungs being the most commonly affected organs. Although it can affect the airways in up to 15-55% of cases, tracheobronchial disease remains under recognized, with paucity of published data. The aim of this study is to describe airway disease manifestations and various bronchoscopic therapies implemented in a large volume referral center. Retrospective review of charts of patients diagnosed with GPA who underwent bronchoscopies between January 2015 and January 2016. RESULTS: 23 patients with an established diagnosis of GPA underwent a total of 103 bronchoscopies. Female: Male ratio was 3:1, with a mean age of 41 years. 83% of patients were on immunosuppressive therapy at the time of bronchoscopy. The majority of patients were symptomatic (77%) with dyspnea (74%), cough (65%) and wheezing (37%) being the most common symptoms at presentation. On bronchoscopic examination, airway disease was identified in all patients, most commonly at the level of the subglottis (64%), trachea (51%) and distal airways (75%), while disease of the vocal cords was rarely seen (7%). The most common types of airway abnormalities included multifocal tracheobronchial stenosis (75%), subglottic stenosis (59%) and localized strictures (31%). Mucosal abnormalities such as edema, ulcerations and cobble stoning were seen in 36% of airway examinations. Other rare disease manifestations such as synechial membranes, pseudopolyps and submucosal tunnels were also observed. Additionally, thick crusty secretions were a common finding (39%). Endobronchial biopsies, when performed, showed no evidence of vasculitis. Notably, various bronchosopic interventions were effective at treating airway obstruction due to GPA. Balloon dilation was most commonly used (67%), along with steroid injections (63%) and application of mitomycin (39%). Other techniques included: rigid dilations (10%), electrosurgery (28%), cryotherapy (28%) and stent placement (14%). Improvement of airway disease was seen on 65% of repeat bronchoscopies. Moreover, symptoms improved in 89% of patients post intervention. No procedural complications or deaths were reported. CONCLUSIONS: Tracheobronchial disease is a common cause of morbidity in patients with GPA. It has various bronchoscopic manifestations, which can be at times subtle. Bronchoscopy plays an essential role in early diagnosis and therapy. CLINICAL IMPLICATIONS: Airway abnormalities can progress into scarring and stenosis despite appropriate immunosuppressive therapy. Various bronchoscopic techniques are effective in controlling the disease and providing immediate relief of symptoms.
Trachea is chondromembranous structure. Its posterior muscle fibers comprise of outer longitudina... more Trachea is chondromembranous structure. Its posterior muscle fibers comprise of outer longitudinal and inner transvers fibers which extends between the ends of the cartilages. Severe atrophy and separation of the tracheal smooth muscles (TSM) from the cartilages is rare and hasn't being studies well. Herein we present a case of severe atrophy and separation of TSM from the cartilages in a COPD patient.
Electromagnetic navigation bronchoscopy (ENB) aids in lung lesion biopsy. However, diagnostic yie... more Electromagnetic navigation bronchoscopy (ENB) aids in lung lesion biopsy. However, diagnostic yield is impacted by biopsy tool strategy and rapid on-site evaluation (ROSE) use. This analysis evaluates usage patterns, accuracy, and safety of tool strategy and ROSE in the multicenter NAVIGATE study. METHODS: NAVIGATE (NCT02410837) evaluates ENB using the superDimensionÔ navigation system. The US cohort prospectively enrolled 1215 consecutive subjects at 29 sites. Included herein are 416 who underwent ENB-aided biopsy of a single lung lesion positive for malignancy as of 1 year. "Limited" tool strategies (including only biopsy forceps, standard cytology brush, and/or lavage) were compared to "Extensive" tool strategies (including any of aspirating needle, triple-needle cytology brush, needle-tipped cytology brush, or GenCutÔ core biopsy system, with or without "Limited" tools). RESULTS: Of malignant cases, 86.8% (361/416) of true positive diagnoses were obtained using Extensive tool strategies versus only 13.2% (55/416) using Limited strategies. ROSE was used in 89.1% (49/55) and 69.5% (251/361) of subjects in the Limited and Extensive sets, respectively. A mean of 1.8AE0.8 (range 1-3) unique biopsy tools was used in the Limited group vs. 2.8AE 1.0 (range 1-5) in the Extensive arm (P<0.001). A malignant ROSE call was obtained in 50.9% (212/416), most (88.7%; 188/212) by the first biopsy tool used (49.5% with aspirating needle, 20.2% with cytology brush, 17.0% with forceps). Obtaining a malignancy with ROSE reduced the total number of tools used vs. cases without a malignant ROSE call (1.6AE0.8 vs. 2.1AE0.9 Limited, 2.7AE1.0 vs. 3.4AE1.0 Extensive). When used, ROSE was concordant with final pathology in 71.4% (35/49) and 70.5% (177/251) of the Limited and Extensive groups, respectively. Final pathology true positive rates were 86.6% (213/246) for aspirating needle, 83.8% (62/74) for GenCut, 81.6% (71/87) for needle-tipped brush, and 70.6% (72/102) for triple-needle brush. Among Limited tools, true positive rates were 86.9% (312/359) for forceps, 77.6% (156/201) for cytology brush, and 58.5% (69/118) for lavage. Procedurerelated pneumothorax occurred in 5.5% (3/55) and 2.8% (10/361) of the Limited and Extensive groups, respectively (3.6% [2/55)] vs. 1.1% [4/361] with intervention or hospitalization) and procedure-related hemorrhage occurred in 3.6% (2/55) vs. 1.1% (4/361). CONCLUSIONS: Advanced biopsy strategies were favored among NAVIGATE sites. Most true positive diagnoses were obtained by extensive strategies, without increased complications. Aspirating needle and biopsy forceps had the highest true positive rates. ROSE use, while concordant with final pathology in only 71%, impacted tool strategy. The pragmatic nature and large multicenter dataset of NAVIGATE allow a comprehensive analysis of practice variations in biopsy tool and ROSE use.
The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and t... more The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and the available literature as of the date posted. While we try to regularly update this content, any offered recommendations cannot be substituted for the clinical judgment of clinicians caring for individual patients.
Journal of bronchology & interventional pulmonology, Oct 1, 2014
Endobronchial involvement is a relatively uncommon but well-described presentation in Granulomato... more Endobronchial involvement is a relatively uncommon but well-described presentation in Granulomatosis with polyangiitis (GPA). Self-expandable metallic stents (SEMs) should be reserved for the malignant airway disorder to maintain airway patency, but have been used for benign disease in specific cases. We present a case of longstanding endobronchial GPA with recurrent bronchial stenosis. Three SEMs were deployed in the distal left main bronchus 10 years prior. Two were removed in the standard manner, but the remaining stent SEM was completely embedded in the bronchial mucosa making its removal extraordinarily difficult. We placed an oversized silicone stent inside the stent leading to necrosis of the mucosa allowing for a less formidable removal of the embedded stent. Another silicone stent was temporarily placed. SEMs removal can be extremely complicated and should only be performed by experienced bronchoscopists in an institution with sufficient resources.
The Journal of Thoracic and Cardiovascular Surgery, Nov 1, 2018
Video clip is available online. Airway stents are routinely used for the treatment of various dis... more Video clip is available online. Airway stents are routinely used for the treatment of various diseases of the central airways. To achieve the best possible alignment with the airway, stents are available in numerous dimensions, varying in diameter and length. In most cases, good results with significant relief of symptoms can be achieved with off-the-shelf stents. In some cases, however, the available stents cannot be used because of excessively enlarged airways, unusual branching angles, or airway distortion. Despite the substantial legal hurdles that have to be overcome before their clinical use, 3-dimensional (3D) modeling and printing applications in medicine are increasingly reported. The advantage of an airway stent designed and produced for an individual patient is that a perfect alignment with the mucosa can be achieved. This could decrease typical stent-related complications, such as biofilm formation and mucus retention between the airway and the stent, formation of granulation tissue, and stent migration. Experience, however, is limited to preclinical studies. We herein report the first 2 European clinical applications of customized silicone Y-stents, which were manufactured with 3D-printing technology.
American Journal of Respiratory and Critical Care Medicine, Nov 1, 2006
Rationale: Electromagnetic navigation bronchoscopy using super-Dimension/Bronchus System is a nov... more Rationale: Electromagnetic navigation bronchoscopy using super-Dimension/Bronchus System is a novel method to increase diagnostic yield of peripheral and mediastinal lung lesions. : A prospective, open label, single-center, pilot study was conducted to determine the ability of electromagnetic navigation bronchoscopy to sample peripheral lung lesions and mediastinal lymph nodes with standard bronchoscopic instruments and demonstrate safety. Methods: Electromagnetic navigation bronchoscopy was performed using the superDimension/Bronchus system consisting of electromagnetic board, position sensor encapsulated in the tip of a steerable probe, extended working channel, and real-time reconstruction of previously acquired multiplanar computed tomography images. The final distance of the steerable probe to lesion, expected error based on the actual and virtual markers, and procedure yield was gathered. Measurements: 60 subjects were enrolled between December 2004 and September 2005. Mean navigation times were 7 Ϯ 6 min and 2 Ϯ 2 min for peripheral lesions and lymph nodes, respectively. The steerable probe tip was navigated to the target lung area in all cases. The mean peripheral lesions and lymph nodes size was 22.8 Ϯ 12.6 mm and 28.1 Ϯ 12.8 mm. Yield was determined by results obtained during the bronchoscopy per patient. Results: The yield/procedure was 74% and 100% for peripheral lesions and lymph nodes, respectively. A diagnosis was obtained in 80.3% of bronchoscopic procedures. A definitive diagnosis of lung malignancy was made in 74.4% of subjects. Pneumothorax occurred in two subjects. Conclusion: Electromagnetic navigation bronchoscopy is a safe method for sampling peripheral and mediastinal lesions with high diagnostic yield independent of lesion size and location.
Bronchial thermoplasty was recently approved for treating severe refractory asthma that is not we... more Bronchial thermoplasty was recently approved for treating severe refractory asthma that is not well controlled by high-dose inhaled corticosteroids and long-acting bronchodilator therapy. This article reviews its indications, evidence of efficacy, and protocols.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this p... more The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Papers by Thomas Gildea