Bronchoscopic Findings Research Articles

Evaluation of diagnostic outcomes of non-resolving pneumonia by fiberoptic bronchoscopy

Background: Non-resolving pneumonia (NRP) is a cause of concern among treating physicians due to its diagnostic dilemma. Bronchoalveolar lavage (BAL) is an important tool in diagnosing non resolving pneumonia. This study was undertaken to evaluate non resolving pneumonia by fiberoptic bronchoscopy and BAL to find the etiological diagnosis. Methodology: A prospective observational study was done at a tertiary care centre, Rajarajeshwari Medical College and Hospital Bangalore over the period of one and a half year. Total 64 cases of non-resolving pneumonia were included and patients were evaluated thoroughly by history, clinical examination, radiological tests like chest X-ray and CT-chest, laboratory investigations like white blood cell count, sputum culture and brochoscopic BAL culture were obtained in all patients. Results: 64 patients enrolled in the study out of which 46 (71.87%) male and 18(28.125%) female, mean age of the patients was 52.6 ±11.2. unilateral lung involvement was in 48(75%) of the patients and right lung was most commonly involved in 39(60.93%) patients. The bronchoscopic findings of mucosal inflammation and purulent secretion were most common findings in 36(56.25%). Bacterial culture was positive in 52(81.25%) in BAL analysis, among that Klebsiellae pneumoniae was most common organism in 23(35.93%). BAL AFB smear was positive in 7(10.93%) and 9(14.06%) positive for CBNAAT test. Conclusions: NRP is difficult to treat and diagnostic dilemma for physicians. Bronchoscopic interventions like BAL show significant results in etiological diagnosis of non-resolving pneumonia. Timely intervention of FOB BAL helps in treating patients of non-resolving pneumonia. Keywords: Fiberoptic bronchoscopy; Non resolving pneumonia.

Clinical, Bronchoscopic, and Imaging Findings of e-Cigarette, or Vaping, Product Use–Associated Lung Injury Among Patients Treated at an Academic Medical Center

e-Cigarette, or vaping, product use-associated lung injury (EVALI) has caused more than 2800 illnesses and 68 deaths in the United States. Better characterization of this novel illness is needed to inform diagnosis and management. To describe the clinical features, bronchoscopic findings, imaging patterns, and outcomes of EVALI. This case series of 31 adult patients diagnosed with EVALI between June 24 and December 10, 2019, took place at an academic medical center in Salt Lake City, Utah. e-Cigarette use, also known as vaping. Symptoms, laboratory findings, bronchoscopic results, imaging patterns, and clinical outcomes. Data from 31 patients (median [interquartile range] age, 24 [21-31] years) were included in the study. Patients were primarily men (24 [77%]) and White individuals (27 [87%]) who used e-cigarette products containing tetrahydrocannabinol (THC) (29 [94%]). Patients presented with respiratory (30 [97%]), constitutional (28 [90%]), and gastrointestinal (28 [90%]) symptoms. Serum inflammatory markers were elevated in all patients. Bronchoscopy was performed in 23 of 28 inpatients (82%) and bronchoalveolar lavage (BAL) revealed the presence of lipid-laden macrophages (LLMs) in 22 of 24 cases (91%). BAL samples tested positive for Pneumocystis jirovecii (3 patients [13%]), rhinovirus (2 patients [8%]), human metapneumovirus and Aspergillus (1 patient each [4%]); all except human metapneumovirus were determined to be false-positives or clinically inconsequential. The exclusive or dominant computed tomography (CT) pattern was organizing pneumonia in 23 of 26 cases (89%). Patients received antibiotics (26 [84%]) and corticosteroids (24 [77%]), and all survived; 20 patients (65%) seen in follow-up showed marked improvement, but residual symptoms (13 [65%]), radiographic opacities (8 [40%]), and abnormal pulmonary function tests (8 of 18 [44%]) were common. In this case series, patients with EVALI characteristically presented with a flu-like illness with elevated inflammatory markers, LLMs on BAL samples, and an organizing pneumonia pattern on CT imaging. Bronchoscopic testing for infection had a high incidence of false-positive results. Patients had substantial residual abnormal results at early follow-up. These data suggest a limited role for bronchoscopy in typical presentations of EVALI without risk factors for alternative diagnoses and the need for careful longitudinal follow-up.

Early radiologic and bronchoscopic changes after bronchial thermoplasty in patients with severe asthma.

Bronchial thermoplasty (BT) is a treatment to reduce the airway smooth muscle mass by delivering radiofrequency thermal energy to the airways. BT is used in patients with severe asthma. The present study reported on cases of pneumothorax directly after BT and retrospectively analyzed early radiologic and bronchoscopic modifications after BT. The clinical data and radiologic and bronchoscopic findings of 12 patients with severe asthma who were subjected to BT between July 2014 and October 2017 were analyzed. A total of 33 chest radiographs were collected within 18-24 h after BT. Radiological abnormalities were observed in 32 radiographs as atelectasis (53.1%), peribronchial consolidations (84.4%), pleural effusion (18.8%), effusion in oblique fissures (3.1%), pleural thickening (6.3%) and pneumothorax (3.1%). Of note, one patient suffered pneumothorax after the third BT session and underwent chest drain insertion, followed by mechanical ventilation at the intensive care unit and multiple bronchoscopic interventions, which revealed extensive phlegm plugs. A total of six patients with worsened symptoms and lobar atelectasis also required bronchoscopic intervention, which revealed that phlegm plugs occluded the bronchus in the treated lobe. No bronchoscopic intervention was required in the remaining five patients. During 16-30 days of follow-up, 95.7% of the findings on chest radiography were resolved. To the best of our knowledge, the present study reported the first case of pneumothorax following BT. Early radiologic modifications such as atelectasis and peribronchial consolidations appear common after BT. However, whether bronchoscopic intervention is required for atelectasis following BT warrants further investigation. Of note, BT should be audited and recorded in detail to ideally contribute to a framework of clinical trials to improve risk-benefit evaluations and the selection of patients likely to benefit from treatment.

Pulmonary infections mimicking malignancy on bronchoscopy: A retrospective single-center study in Japan.

BackgroundPulmonary infections can imitate pulmonary neoplasms. Pulmonary tuberculosis (TB) is a typical example of an infection that mimics cancer and results in unexpected exposure of healthcare workers to TB. A large number of patients with suspected lung malignancy are referred to cancer centers, although the epidemiology of the final diagnosis is unclear in Japan. This study aimed to determine the frequency and nature of pulmonary infections that imitate malignancy among patients with presumed lung cancer that is subsequently diagnosed as a pulmonary infection based on bronchoscopy findings. We also aimed to identify the prevalence of formerly undiagnosed pulmonary tuberculosis that could pose an occupational risk to healthcare workers.MethodsThis single‐center retrospective cross‐sectional study included patients with suspected pulmonary malignancy who underwent bronchoscopy at a tertiary care cancer center in Japan between April 2017 and March 2020. Electronic medical records of the bronchoscopy database were reviewed to identify the final diagnoses recorded by physicians.ResultsAmong the 460 patients enrolled in the present study, 362 (78.7%) and 8 (1.7%) had primary or metastatic pulmonary lesions and benign lesions, respectively. Sixty‐six patients (14.3%) had nonspecific findings or other pulmonary diseases. Infection was confirmed in 24 patients (5.2%). Mycobacterial infections (n = 16) were the most frequent infectious disease; four patients had TB and 12 had nontuberculous mycobacterial infections.ConclusionsDespite the rare occurrence of TB in patients with suspected lung malignancy, healthcare workers should remain vigilant regarding the possibility of TB to prevent occupational exposure during invasive procedures such as routine bronchoscopy.

Analysis of risk factors for the development of a post-bronchoscopy respiratory infection in lung cancer patients

BackgroundThe development of pneumonia following bronchoscopy is a very important post-bronchoscopic complication, while lung abscesses after bronchoscopy are rare. However, bronchoscopic techniques have advanced, and recently, we have observed patients with lung abscess after bronchoscopy. Therefore, the risk factors might vary from those in past reports. This study was performed to identify the incidence of and risk factors for post-bronchoscopy respiratory infections. MethodsWe retrospectively studied adult patients diagnosed with lung cancer by bronchoscopy at Fukujuji Hospital from January 2017 to June 2019. The infection and noninfection groups were compared. The incidence of lung abscess was compared between recent periods and 2013, when endobronchial ultrasonography with a guide sheath (EBUS-GS) was not yet used in our hospital. ResultsWe reviewed 327 patients, including 20 patients (6.1%) with infections. The risk factors for infection were necrosis and/or a cavity in the tumor (p < 0.001), a large tumor diameter (≥30 mm) (p = 0.010), and a low serum albumin level (<4.0 g/dL) (p = 0.010). We developed a predictive score with these risk factors, and the area under the curve was 0.737 (95% Cl: 0.610–0.864). No significant differences in age, current smoking status, or abnormal bronchoscopic findings were observed, although these were previously reported as risk factors. In total, 12 patients had lung abscesses (3.7%), which is a higher incidence than that in 2013 (0.8%). ConclusionsThe risk factors for developing post-bronchoscopy respiratory infection in our study varied from those in past reports, possibly because of the advancements in bronchoscopic techniques, such as EBUS-GS.

A MATTER OF FLUX: A CASE REPORT ON ARC WELDER'S LUNG

SESSION TITLE: Medical Student/Resident Occupational and Environmental Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Occupational diseases are a major cause of individual health deterioration We present a case of occupational exposure to metal fumes resulting in Arc Welder’s Lungs (AWL). CASE PRESENTATION: A 63-year old male presented with shortness of breath and productive cough for 8 days. He was a welder for 27 years. He never smoked and was not taking any medications. He was afebrile, hypoxic at 78% O2 saturation, respiratory rate was 31, pulse of 97 and blood pressure of 172/90 mmHg. He had diffuse rhonchi most prominent in the bibasilar lung fields. Labs revealed a leukocytosis of 14.2 K/uL, normal liver and chemistry panels and a procalcitonin of 0.1 ng/mL. Chest X Ray showed perihilar and basilar multifocal consolidation.(Image A) A chest CT angiography was negative for pulmonary embolism but showed extensive bilateral focal consolidation and diffuse ground glass opacities with an enlarged main pulmonary artery.(Image B) He was started on antibiotics, steroids and required 6L of nasal cannula. Transthoracic echocardiography showed severe left ventricular hypertrophy, an ejection fraction of 70% and an estimated pulmonary artery pressure of 91 mmHg. His symptoms progressively worsened and oxygen requirements escalated. Viral panels, autoimmune serologies, amyloid workup and cultures were all negative. A right heart catheterization showed right atrial pressure of 6 mmHg, right ventricular pressure of 75/5 mmHg, pulmonary capillary wedge pressure of 10 mmHg, a cardiac index of 3.9 L/min/m2 and pulmonary vascular resistance of 5.3 WU suggesting a potential arteriopathy component in the setting of acute pulmonary inflammation. A bronchoscopy with lavage showed numerous hemosiderin laden macrophage with positive iron staining and positive oil red O stain. A transbronchial biopsy was not pursued due to potential bleeding risk in setting of pulmonary hypertension. Serum ferritin level was 2163 ng/mL. Based on occupational history and bronchoscopy findings, the patient was diagnosed with AWL. Given the acute inflammatory parenchymal process, pulse dose steroids were initiated with subsequent clinical improvement. DISCUSSION: AWL can present in different forms of lung disease.[1] Cases are usually “benign” without residual effects, however there are reports of symptomatic presentations with underlying fibrosis.[2] We describe the first welder’s lung case with an acute inhalational pneumonitis responsive to pulse dose steroids. Three months interval CT scan showed significant improvement of ground glass component with residual areas of underlying reticular and fibrotic changes in the bases, possibly suggestive of desquamative interstitial pneumonia.(Image C) CONCLUSIONS: Our case highlights the implications of occupational diseases which can be preventable and the possible variability in presentations. Physicians should be aware of AWL and include it in their differential diagnosis Reference #1: Riccelli MG, Goldoni M, Poli D, Mozzoni P, Cavallo D, Corradi M. Welding Fumes, a Risk Factor for Lung Diseases. Int J Environ Res Public Health. 2020;17(7):2552. Published 2020 Apr 8. doi:10.3390/ijerph17072552 Reference #2: M. P. Cosgrove, Pulmonary fibrosis and exposure to steel welding fume, Occupational Medicine, Volume 65, Issue 9, December 2015, Pages 706–712, https://doi.org/10.1093/occmed/kqv093 DISCLOSURES: No relevant relationships by Youssef Abouleish, source=Web Response No relevant relationships by Mit Patel, source=Web Response No relevant relationships by Anthony Quaranta, source=Web Response

PILL ASPIRATION: BRONCHOSCOPIC CHARACTERISTICS OF IRON ASPIRATION COMPARED TO OTHER PILLS

SESSION TITLE: Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Pill aspiration is a rare but potentially serious event that can lead to airway damage. Case reports describe instances of iron pill aspiration, however series comparing iron and non-iron pill aspiration are lacking. Here we examined cases of pill aspiration managed with flexible bronchoscopy to describe the differences in clinical characteristics and degree of airway inflammation among patients aspirating iron and non-iron pills. METHODS: A single-center retrospective observational study was conducted at the Mayo Clinic in Rochester, MN. All cases of pill aspiration occurring between 2008 and 2020 were examined. Patient characteristics and bronchoscopy findings were gathered. The severity of inflammation was graded as mild, moderate, or severe based on the bronchoscopists’ operative notes. RESULTS: A total of 28 cases of pill aspiration were reviewed, nine of which were iron sulfate pill aspiration. Among the non-iron group, the various pills aspirated included magnesium sulfate, docusate, multivitamins, calcium carbonate, pantoprazole, nortriptyline, garcinia cambogia, and morphine. No definite identification of the pills could be made in nine cases, but was deemed to definitely not be iron based on the patients’ medication list. In the non-iron group, the mean age was 69 (SD = 16.8). 68% were female. The duration between the aspiration event and the bronchoscopy procedure was identified in 17 cases; the mean duration was 1.81 days (SD = 2.1). Pill material was visualized in 11 cases and in three of the cases, the entire pill was removed intact. 21% of the cases were noted to have severe inflammation and the remaining had mild or moderate inflammation as deemed by the operating bronchoscopists. In the iron group, the mean age was 72 (SD 9.6). 100% were female. The duration between aspiration and bronchoscopy was identified in seven cases; the mean duration was 2.28 days (SD = 2.3). Pill material was visualized in five cases. 78% of the cases were noted to have severe inflammation. Three of the cases had repeat bronchoscopy done one to four weeks after the initial procedure. All three cases were noted to have significant stenosis of the affected bronchi. CONCLUSIONS: Patients who suffer pill aspiration tend to be elderly and female. The iron group had a greater percentage of cases with severe inflammation even though the mean duration from aspiration to bronchoscopy was similar in the two groups, as was the percentage of cases where residual pill material was found. Currently published cases describing severe long term sequelae of pill aspiration typically had a longer delay between the aspiration event and intervention. CLINICAL IMPLICATIONS: Iron sulfate pill aspiration leads to a quicker and more intense inflammatory reaction compared to other pills. Early bronchoscopy is important as the pill material may be found and removed, thereby avoiding prolonged damage and long term complications. DISCLOSURES: No relevant relationships by Tyler Herzog, source=Web Response No relevant relationships by Harsha Mudrakola, source=Web Response No relevant relationships by Darlene Nelson, source=Web Response

Serious Inhalation Injuries From Military Operations in Afghanistan, Iraq, and Syria.

To characterize serious inhalation injuries seen during recent military operations, and assess whether bronchoscopic severity findings were associated with clinical presentation and outcomes. Service members who suffered inhalation injuries while deployed to Iraq, Afghanistan, or Syria from 2001-2018 were identified using ICD-9 and 10 codes from the Expeditionary Medical Encounter Database (EMED), which is abstracted from patient records in forward-deployed medical facilities. Further information including demographics, mechanism of injury, mortality, total burn surface area (TBSA), degree of facial burn, total Injury Severity Score (ISS), and first post-injury bronchoscopy notes were collected. Patients were excluded with ISS less than 16 or without sufficient details regarding bronchoscopy. Injuries were grouped based on bronchoscopic Abbreviated Injury Scores (AIS) into low-grade (AIS of 1), moderate-grade (AIS of 2), or high-grade (AIS of 3 or 4). 91 patients met inclusion criteria, with no significant differences in age, gender, paygrade, or service branch between degrees of injury. There were no statistical correlations between grade of injury and battle versus non-battle injury, blast versus non-blast mechanism, TBSA, or degree of facial burn. High-grade injuries had significantly higher ISS than low or moderate-grade injuries. After adjusting for ISS, the odds ratio of death was 10.4 (95% CI 1.47 to 74.53) for those with high-grade and 3.7 (95% CI 0.45 to 32.30) for those with moderate-grade compared to low-grade injuries. In this cohort of deployed military members with inhalation injuries, initial bronchoscopic severity findings are strongly associated with mortality even after adjusting for ISS. The AIS may be an important prognostic tool in all of those with serious inhalation injuries.

Role of Serum (1,3)-Β-D-Glucan to Screen for Pneumocystis Pneumonia in Kidney Transplant Recipients

BackgroundPneumocystis pneumonia is a common opportunistic infection in kidney transplant recipients caused by the ascomycetous fungi Pneumocystis jirovecii. Its clinical presentation of a progressive nonproductive cough, shortness of breath, and fever is nonspecific and often delays diagnosis and appropriate treatment. Moreover, the plain radiograph may show a spectrum of findings from normal to bilateral diffuse infiltrates. Detection of serum (1,3)-β-D-glucan along with consistent clinical findings can be used as early screening tools to diagnose and initiate treatment for Pneumocystis pneumonia pending confirmation by bronchoscopy. MethodsThis case series describes 6 kidney transplant recipients who were diagnosed as having Pneumocystis pneumonia. The baseline demographic variables, presenting symptoms, radiographic findings, laboratory findings including lactate dehydrogenase and serum (1,3)-β-D-glucan levels, bronchoscopy findings, and its timing in relation to a positive serum (1,3)-β-D-glucan test, and response to treatment were collected. ResultsAll 6 patients who completed the first 3 months of prophylaxis against Pneumocystis pneumonia with sulfamethoxazole-trimethoprim were diagnosed as having Pneumocystis pneumonia between 2 to 24 years post transplant. They initiated treatment early based on a positive serum (1,3)-β-D-glucan and negative Histoplasma antigen and serum galactomannan test with a presumptive diagnosis of Pneumocystis pneumonia, which was later confirmed with a positive polymerase chain reaction on bronchoalveolar lavage fluid. ConclusionsPneumocystis pneumonia is a common opportunistic fungal infection in immunosuppressed kidney transplant recipients, and use of serum (1,3)-β-D-glucan can be used as an initial screening test for its early diagnosis and treatment.

Diffuse Alveolar Hemorrhage After Pediatric Hematopoietic Stem Cell Transplantation.

Pulmonary complications are common following hematopoietic cell transplantation (HCT) and contribute significantly to its morbidity and mortality. Diffuse alveolar hemorrhage is a devastating non-infectious complication that occurs in up to 5% of patients post-HCT. Historically, it carries a high mortality burden of 60–100%. The etiology remains ill-defined but is thought to be due to lung injury from conditioning regimens, total body irradiation, occult infections, and other comorbidities such as graft vs. host disease, thrombotic microangiopathy, and subsequent cytokine release and inflammation. Clinically, patients present with hypoxemia, dyspnea, and diffuse opacities consistent with an alveolar disease process on chest radiography. Diagnosis is most commonly confirmed with bronchoscopy findings of progressively bloodier bronchoalveolar lavage or the presence of hemosiderin-laden macrophages on microscopy. Treatment with glucocorticoids is common though dosing and duration of therapy remains variable. Other agents, such as aminocaproic acid, tranexamic acid, and activated recombinant factor VIIa have also been tried with mixed results. We present a review of diffuse alveolar hemorrhage with a focus on its pathogenesis and treatment options.

Multidisciplinary approach to paediatric aerodigestive disorders: A single-centre longitudinal observational study.

Aerodigestive clinics (ADCs) are multidisciplinary programmes for the care of children with complex congenital or acquired conditions affecting breathing, swallowing and growth. Our objective was to describe the demographic, clinical, etiological and investigational profile of children attending the inaugural ADC at a tertiary paediatric centre in Queensland. Children referred to the ADC at Queensland Children's Hospital from August 2018 to December 2019 were included. Data on clinical, growth and lung function parameters, bronchoscopy and upper gastrointestinal endoscopy findings, thoracic imaging and comorbidities were retrospectively analysed. Fifty-six children (median (range) age 4 years (3 months-15 years); 18 female) attended the ADC during this 17-month period. Forty-six (82%) children had previous oesophageal atresia with tracheo-oesophageal fistula; 43 of these were type C. Previous isolated oesophageal atresia, congenital diaphragmatic hernia and congenital pulmonary malformation were the underlying disorder in three (5%) children each, with one child having a repaired laryngeal cleft. Vertebral Anal Tracheo Esophageal Renal Limb anomalies (VACTERL)/Vertebral Anal Tracheo Esophageal renal anomalies (VATER) association was seen in 21 (38%) children. Growth was adequate (median weight and body mass index z-score -0.63 and -0.48, respectively). Thirty-four (61%) children reported ongoing wet cough, with 12 (21%) requiring previous hospital admission for lower respiratory tract infection. Fourteen (25%) had bronchiectasis on computed tomography chest and 33 (59%) had clinical tracheomalacia, apparent on bronchoscopic examination in 21 patients. Dysphagia was reported in 15 (27%) children, 11 (20%) were gastrostomy feed-dependent and 5 (9%) had biopsy-proven eosinophilic oesophagitis. High proportion of children attending the ADC have ongoing respiratory symptoms resulting in chronic pulmonary suppuration and bronchiectasis. Potential benefits of this model of care need to be studied prospectively to better understand the outcomes.

The direct laryngoscopy and rigid bronchoscopy findings and the subsequent management of infants with failed extubations

IntroductionThere is limited data regarding the role of direct laryngoscopy and rigid bronchoscopy (DLRB) in infants with failed extubations. Pediatric otolaryngologists are frequently consulted to perform DLRB in infants with failed extubations. ObjectiveTo determine the DLRB findings in infants with failed extubations and the interventions performed based on these findings. MethodsA retrospective chart review was performed on infants less than 12 months old undergoing DLRB for failed extubations from January 2013–June 2017 at a tertiary care children's hospital. Data was collected on age, birth weight, perinatal complications, comorbid conditions, number of failed extubations, length of most recent intubation, operative findings, and subsequent interventions, including tracheostomy. Descriptive and comparative analyses were performed. ResultsOf the 62 subjects who met study criteria, median age at DLRB was 3.0 months, corrected age was 1.0 months, gestational age was 27.1 weeks, birth weight was 0.97 kg, and number of failed extubations was 2.0. About 80% had respiratory distress at birth requiring intubation, and 76% carried a diagnosis of bronchopulmonary dysplasia (BPD). The median number of days intubated prior to DLRB was 27. Twenty-seven percent of subjects had no significant abnormal findings on DLRB, and 26% had subglottic stenosis. The majority (74%) underwent tracheostomy. Eighteen percent of subjects had an initial intervention for abnormal DLRB finding(s) other than tracheostomy and were able to avoid tracheostomy as a future intervention. Tracheostomy placement was associated with a diagnosis of BPD (RR 1.78, 95% CI 1.02, 3.10), having a birth weight less than 0.71 kg (RR 1.45, CI 1.01, 2.10), and being intubated for 48 or more days prior to DLRB (RR 1.57, 95% CI 1.05, 2.36); it was not associated with the number of failed extubations prior to DLRB. ConclusionsInfants with failed extubations commonly had abnormal findings on airway evaluation by DLRB. Most children in this population still required tracheostomy placement, but about 20% were able to have an alternate intervention and avoid tracheostomy.

Hypersensitivity pneumonitis: clinical, radiological and pathological profile of 103 patients from North India.

Hypersensitivity pneumonitis (HP) is an interstitial lung disease, commonly occurring due to exposure to various inciting agent related to occupation. Few studies have shown that it can also occur without any occupation exposure. In this study we are presenting clinical, radiological and bronchoscopic finding of 103 HP patients. We retrospective analysis of 5½ years HP patient's data from a chest institute of India. The diagnosis of HP was considered with following criteria: i) known exposure to an inciting antigen; ii) presence of respiratory symptoms; iii) radiologic evidence of diffuse lung disease; iv) no other identifiable cause; v) lung biopsy specimen that demonstrated features of HP; and vi) bronchoalveolar lavage lymphocytosis (≥30%). The mean ±SD age was 47±12.8 years; 67% were female. The common symptoms were cough (97%) and dyspnea (91%). History of exposure to inciting agent was present in 61% with pigeon exposure being the most common (56%). Majority of patients (86%) were having chronic symptoms for >6 months. On 6MWT oxygen desaturation >4% was seen in 57% patients. Centrilobular nodules (61%) and ground glass opacity (47.5%) were common finding on HRCT chest. Bronchoalveolar lavage (BAL) lymphocytosis >30% was present in 48.5% and histopathological diagnosis HP on transbronchial lung biopsy (TBLB) and/or endobronchial lung biopsy (EBLB) was in 50% patients. HP is exposure related environmental disease, as it can occur without any occupational history. Bronchoscopy with BAL and lung biopsy should do in all suspected cases to confirm diagnosis in our country as it is less invasive, day care procedure with less complication.

Long-term outcomes of tracheobronchial stenosis due to tuberculosis (TSTB) in symptomatic patients: airway intervention vs. conservative management.

BackgroundPatients with tracheobronchial stenosis due to tuberculosis (TSTB) have a variable clinical course and response to treatment including airway intervention. There are no clear guidelines on the best approach to manage such patients. This study examines long-term outcomes of patients with TSTB and factors associated with recurrent symptoms or need for repeat airway intervention following initial bronchoscopic intervention.MethodsThis is a retrospective analysis of patients with TSTB over an 18-year period. Symptoms, radiological, bronchoscopic findings, airway interventions and complications were obtained. Multivariate logistic regression analysis was performed to identify factors predictive of recurrence of symptoms or need for repeat airway intervention.ResultsA total of 131 patients with mean age 50±18 years and median follow-up 5 (interquartile range, 2–10) years were included. Nineteen (29.7%) patients underwent balloon dilatation alone, 22 (34.4%) had additional resection or stenting, and 19 (29.7%) underwent all 3 procedures. Among patients conservatively managed, a larger proportion (55.6%) of patients with no recurrence of symptoms had active TB. Patients who developed recurrent symptoms had longer symptom duration (12 vs. 3 months, P=0.025), and more had recurrent lower respiratory tract infections (50% vs. 5.6%, P=0.003), lung collapse (90.0% vs. 41.7%, P=0.011) or linear fibrosis (70.0% vs. 30.6%, P=0.033) compared to those without recurrent symptoms. Bronchomalacia (OR =17.18; 95% CI, 3.43–86.18) and prior bronchoscopic airway resection (OR =4.97; 95% CI, 1.20–20.60) were strongly associated with the recurrence of symptoms or need for repeat airway intervention on multivariate logistic regression analysis.ConclusionsBronchomalacia and prior bronchoscopic airway resection are associated with the recurrence of symptoms despite airway intervention. Patients who are diagnosed with TSTB early in the course of active TB may be conservatively managed.

Smoke inhalation injury: bronchoscopy findings.

Smoke inhalation injury: bronchoscopy findings.

Unique Bronchoscopy Findings in a Child with Severe Bronchiolitis Obliterans Following Overlapping Triggers

Unique Bronchoscopy Findings in a Child with Severe Bronchiolitis Obliterans Following Overlapping Triggers

Tracheobronchial foreign body aspiration in children: A retrospective single-center cross-sectional study.

Foreign body (FB) aspiration is a common and serious problem in childhood as it requires early recognition and treatment to avoid potentially lethal consequences. This study aimed to characterize the clinical and epidemiological features of airway FBs in a pediatric Chinese population.A retrospective review of medical records of children aged 0 to 14 years who attended with a diagnosis of FB aspiration the Shanghai Children's Hospital between January 2013 and December 2017 was carried out. Descriptive analysis was used to assess patient's demographics, clinical, radiographic, bronchoscopic findings, time to presentation, and characteristics of the FBs.Among the 200 patients included in the study, 92% were under 3 years of age, with a peak incidence of FB aspiration occurring between 1 and 2 years old. The male to female ratio was about 2.6:1. Twenty-three percent of the patients were admitted within 24 hours of the event, 40% within 1 week, 30% within 1 month, and 7% more than 1 month after aspiration. The most common presenting symptoms of laryngotracheal FBs were cough, dyspnea, and wheezing; those of bronchial FBs were cough, decreased air entry, and wheezing. Chest X-ray was normal in four-fifths of the children with laryngotracheal FBs, whereas most common abnormal X-ray findings in children with bronchial FBs were mediastinal shift, obstructive emphysema, and pneumonia. There was a trend that in children younger than 2 years FBs were more frequently found in the left bronchus, whereas in older children FBs were more frequently found in the right bronchus. Ninety-three percent of the removed FBs were organic materials such as food items and the most frequently aspirated FBs were peanuts. Flexible bronchoscopy was performed in 82.5% of the patients, while rigid bronchoscopy or direct laryngoscopy in 17.5% of the patients. Four patients were subjected to thoracic surgery and 1 died during rigid bronchoscopy due to acute respiratory failure.FBs is a frequent pathology among Chinese children. Tracheobronchial FBs should be strongly suspected in young children who have sudden onset of cough and wheezing episode, even when physical and radiographic evidence is absent.

Diagnostic utility of bronchoscopy in newly diagnosed acute leukemia patients.

e19510 Background: Over 40% of newly diagnosed acute leukemia patients receiving induction therapy develop acute respiratory failure. Bronchoscopy is a valuable tool for evaluating airway disease, but its diagnostic yield in this setting has not been fully explored. Methods: We performed a retrospective chart review of 75 newly diagnosed acute leukemia patients who had bronchoscopies. Data recorded prior to bronchoscopy included age, diagnosis, induction treatment regimen, chest imaging, assisted ventilation, duration of neutropenia and antibiotic therapy and microbiological studies. Bronchoalveolar lavage (BAL) cultures were sorted by organism, as well as by other pathologic findings. The primary outcome was antibiotic change supported by culture data. Results: The study population is summarized in the table. Induction regimen backbones included 7+3 (51), 7+4+ATRA (2), decitabine (12), hyperCVAD (2), AYA (3), other (1) and none (4); 18 patients were treated on clinical trial. Average days of neutropenia was 10.92 and average days of antibiotic therapy was 10.57. Thirty-eight patients had chest infiltrates, 11 received NIPPV, and 17 were mechanically ventilated. We identified 24 patients with +BAL studies. Of these, 37.5% (9) had + blood, urine or sputum studies before bronchoscopy, but only 3 had cultures positive for the same organism as the BAL. Of 51 patients with –BAL studies, 33.3% (17) had prior negative cultures. Infections were most commonly bacterial (15, 62.5%), followed by viral (5, 20.8%) and fungal (4, 16.7%). The most common organisms were rhinovirus, vancomycin sensitive Enterococcus (4, 16.7% each) followed by VRE, Candida albicans and MRSA (2, 8.3% each). Five patients (6.7%) had alveolar hemorrhage. Of the 24 patients with +BAL cultures, bronchoscopy findings supported changing antibiotics in 18. In contrast, antibiotics were changed in 16 patients without +BAL cultures. Conclusions: We investigated the utility of bronchoscopy on AL patients during their initial admission. BAL cultures were positive in 32% of newly diagnosed AL patients undergoing bronchoscopy. However, +BAL cultures identified a new organism in 87.5% and guided antibiotic therapy in 75% of these patients. Further studies will be needed to establish predictors of bronchoscopy findings in this patient population. [Table: see text]

Incidental synchronous bronchial tumour: an unusual bronchoscopic finding.

Key messageWe describe a patient with incidental endobronchial synchronous hamartoma and typical carcinoid with different management strategy.

Utility of Flexible Bronchoscopy for Airway Foreign Bodies Removal in Adults.

Foreign body aspiration is relatively infrequent in adults. Airway foreign bodies (AFBs) can be removed by flexible bronchoscopy (FB) or rigid bronchoscopy (RB). We performed a retrospective analysis of FBs performed in our centre over a 25 year period, focusing on the procedures that revealed an AFB during the examination stage. We recorded demographic data, clinical characteristics and radiological and bronchoscopic findings. During the study period, 12,588 FBs were performed in adults. Airway foreign bodies were identified in 32 of these cases, giving a prevalence of 0.25%. The most frequent clinical presentation was cough, sputum and fever. The most frequent radiological findings were alveolar infiltrates and atelectasis. In 94% of cases, AFBs were removed successfully by FB; RB was necessary in only 6% of cases. There were no FB-related complications. The most common AFB location was the right bronchial tree (69%). We classified AFBs as organic (85%: animal 57%; vegetable 28%), inorganic (6%) and iatrogenic (9%). Bronchial infection occurred in 51% of cases, and Actinomyces spp. was the most common causal microorganism. In conclusion, AFBs are a rare entity with nonspecific clinical presentation, most AFBs were organic, and FB is a safe and effective method for AFB removal.