Bronchoscopy Research Articles

Hospital volume and outcomes following bronchoscopy in patients with interstitial lung disease: A retrospective observational study using a national inpatient database in Japan

BackgroundInterstitial lung diseases (ILDs) are a group of diffuse parenchymal lung disorders that cause inflammation and fibrosis in the interstitium of the lungs. Histopathological examination is pivotal to accurately diagnose the type of ILD, and bronchoscopy (BS) is often performed to collect lung tissue. This study aimed to determine the relationship between hospital volume and outcomes following BS in patients with ILD. MethodsInpatient data on patients with ILD who underwent BS between July 1, 2010 and March 31, 2021 were extracted from the Japanese Diagnosis Procedure Combination database. The annual hospital volume of BS was categorized into four (very low- [≤15 cases/year], low- [16–29 cases/year], high- [30–54 cases/year], and very high- [≥55 cases/year] volume) groups. The primary outcome was all-cause 14-day mortality after BS. Multiple imputation methods followed by multivariable logistic regression analyses fitted with generalized estimating equations were used to estimate the association between hospital volume and 14-day mortality after BS. ResultsA total of 89,454 patients with ILD from 1002 hospitals underwent BS. The all-cause mortality within 14 days after BS was 0.77%. An inverse trend was observed between mortality and hospital volume. Compared with the very low-hospital volume group, the very high-hospital volume group was significantly associated with a lower mortality (adjusted odds ratio = 0.63, 95% confidence interval: 0.48–0.85, p = 0.002). ConclusionsHospital volume was inversely associated with all-cause mortality within 14 days after BS for hospitalized patients with ILD.

Detection of Mycobacterium avium-intracellulare Complex (MAC) by Bronchial Lavage and the Relationship with Titers of Anti-Glycopeptidolipid-Core IgA Antibodies to MAC in Patients with Pulmonary MAC Disease.

Higher rates of diagnosis of pulmonary Mycobacterium avium-intracellulare complex (MAC) disease by bronchoscopy (BS) in patients who could not diagnose by sputum cultures have been suggested, but the detailed utility of BS, especially in combination with anti-glycopeptidolipid-core IgA antibodies (anti-MAC Ab), is still unclear. A total of 111 patients at our hospital with suspected MAC who underwent BS because they were sputum-negative from April 2018 to March 2022 were analyzed prospectively. These patients were also divided into two groups, anti-MAC Ab-positive and anti-MAC Ab-negative, and compared. A total of 111 patients underwent BS, though 95 (38.0%) of 250 enrolled patients were sputum smear/culture-positive. The age of the 111 patients was 69.14 (31.0-89.0) years, and 90 (81.0%) were female; 69 (62.2%) of 111 patients were either smear-positive (n = 42, 37.8%) or culture-positive (n = 27, 24.3%) by BS. Of the total 111 patients, 69 (62.2%) were anti-MAC Ab-positive and 57 (82.6%) of 69 patients were also positive by BS. In contrast, only 12 (28.6%) of the 42 anti-MAC Ab-negative patients were positive by BS. The sensitivity and specificity of anti-MAC Ab for positive by BS were 82.6% and 71.4%, respectively, and the area under the curve (AUC) on receiver-operating characteristic (ROC) curve analysis was 0.807. BS and anti-MAC Ab showed similar usefulness to confirm the diagnosis in patients who could not be diagnosed by sputum examination, but pulmonary MAC disease was strongly suspected based on chest radiography/CT findings. These two examinations were correlated, and their combination appeared to provide more accurate diagnosis and earlier therapy.

Evaluation of patients' satisfaction with bronchoscopy procedure.

The bronchoscopy (BS) experience provokes anxiety amongst some patients. It can have a negative impact on the course of the procedure and on the willingness of patients to undergo the next BS in the future. We aimed to identify factors influencing patients' satisfaction with BS. The prospective study had been conducted between January and June 2019. It included patients hospitalized in our Department, who underwent elective BS. Patients assessed their anxiety and satisfaction level before and after BS using the Visual Analogue Scale (VAS). Data concerning the course of the bronchoscopy was collected. The median level of anxiety prior to the procedure was moderate, higher in women (p<0.0001). The majority of patients (116/125, 93%) were satisfied with appropriate information before the procedure. Almost one-third of the interviewees (39/125, 31%) declared complete satisfaction (VAS = 0) with their procedure, 17 patients (14%) were dissatisfied (VAS >5/10). Overall 113 (90%) patients declared unconditional consent for future bronchoscopy. Multivariate linear regression analysis revealed two factors affecting patients' satisfaction with bronchoscopy: anxiety prior to BS (standardized regression coefficient β = 0.264, p = 0.003) and discomfort (β = 0.205, p = 0.018). Neither age, degree of amnesia, duration of the procedure nor its type added any significant value as factors affecting patient satisfaction. The most common factors inducing patients' discomfort during BS were local anesthesia of the throat (56/125, 45%) and cough (47/125, 38%). Low anxiety level before bronchoscopy and reduced discomfort during the procedure are associated with better patient satisfaction. Thus, it is important to reduce patient anxiety and discomfort during the procedure.

A Case of Severe COVID-19 Pneumonia Diagnosed in Bronchoscopy With Negative Repeated Nasopharyngeal Swabs

Coronavirus disease 2019 (COVID-19) is a worldwide pandemic that had emerged in China since December 2019. The disease affects all age groups, with clinical manifestations in the spectrum from asymptomatic to rapidly lethal multi-organ failure, mainly involving the respiratory system. Diagnosis is confirmed mainly by a positive real-time polymerase chain reaction (PCR) nasopharyngeal swab. It is highly recommended to avoid performing invasive procedures in COVID-19 subjects to prevent the potential for dissemination of the pathogen. Treatment consists in particular of respiratory support and symptom relief. Dexamethasone is widely used with encouraging response. There were no cases in the literature that were diagnosed with positive reverse transcription-polymerase chain reaction (RT-PCR) testing only from fluid of involved organs, while repeated nasopharyngeal swabs returned negative for COVID-19. We here describe a case of COVID-19 that presented with moderate-severe pulmonary involvement, diagnosed by RT-PCR testing from broncho-alveolar lavage, while several nasopharyngeal swabs were consistently negative. The patient experienced no improvement under wide-spectrum antibiotics administered initially, and greatly improved after receiving systemic corticosteroids. One can realize from our case that COVID-19 could not be ruled out upon repeated negative RT-PCR nasopharyngeal swabs, and in subjects with highly suspected COVID-19, it is justified to perform invasive procedures, but still using maximal protective measures. J Med Cases. 2021;12(6):217-219 doi: https://doi.org/10.14740/jmc3679

3D CT airway evaluation-guided intraluminal placement of endobronchial blocker in pediatric patients: a randomized controlled study.

BackgroundThe aim of the present study was to propose a new approach for 3D computed tomography (CT) airway evaluation-guided endobronchial blocker placement in pediatric patients, and to determine its efficiency in clinical application.MethodsA total of 127 pediatric patients aged 0.5–3 years who were scheduled for elective thoracic surgery using one-lung ventilation (OLV) were randomized into the bronchoscopy (BRO) group and the CT group. The degree of lung collapse, postoperative airway mucosal injury, pulmonary infection within 72 h after surgery, and hoarseness after tracheal extubation; duration of postoperative mechanical ventilation, intensive care unit (ICU) stay and hospitalization; success rate of first blocker positioning; and required time and repositioning for successful blocker placement were compared between the 2 groups.ResultsThe degree of lung collapse, postoperative airway mucosal injury, pulmonary infection within 72 h after surgery, and hoarseness after tracheal extubation; duration of postoperative mechanical ventilation, ICU stay and hospitalization; success rate of first blocker positioning; and required time and repositioning for successful blocker placement were similar between the 2 groups (all P>0.05).ConclusionsFor pediatric patients undergoing surgery with OLV, preoperative 3D CT airway evaluation could be used to guide endobronchial blocker placement, with a blocking efficiency similar to that of BRO-guided blocker placement.

Fear in Patients Undergoing Bronchoscopy and Its Causes

Fear in Patients Undergoing Bronchoscopy and Its Causes

Clinical features of children with Mycoplasma pneumoniae pneumonia and peripheral lymphocytopenia

OBJECTIVE To study the clinical features of children with Mycoplasma pneumoniae pneumonia (MPP) and peripheral lymphocytopenia. METHODS A total of 310 MPP children who were hospitalized and underwent bronchoalveolar lavage from June 2018 to June 2019 were enrolled and divided into two groups: simple MPP group with 241 children (without peripheral lymphocytopenia) and MPP + peripheral lymphocytopenia group with 69 children. The two groups were compared in terms of clinical data and treatment outcome. RESULTS Compared with the simple MPP group, the MPP + peripheral lymphocytopenia group had significantly longer duration of fever and length of hospital stay and significant increases in C-reactive protein, lactate dehydrogenase, and Mycoplasma pneumoniae DNA copies in bronchoalveolar lavage fluid (P < 0.05). Compared with the simple MPP group, the MPP + peripheral lymphocytopenia group had significantly higher incidence rates of intrapulmonary consolidation, extrapulmonary complications, and serious lesions under bronchoscopy (erosion or sputum bolt) and a significantly higher proportion of patients with severe MPP (P < 0.05). CONCLUSIONS Children with MPP and peripheral lymphocytopenia tend to have more severe immunologic injury. Peripheral blood lymphocyte count may be used to evaluate the severity of MPP.

Evaluation of Transbronchial Needle Aspiration Samples from Sarcoidosis Patients for the Presence of Mycobacterium

Background: Tuberculosis (TB) and sarcoidosis are two chronic, systemic, and granulomatous diseases that have similar pulmonary and extrapulmonary manifestations. Given the similarities between the two diseases, it is suggested that the Mycobacterium genome may play a role in sarcoidosis. Identification of Mycobacterium species isolated from sarcoidosis patients optimizes the treatment process of patients. The present study investigates biopsy tissue samples from patients with sarcoidosis for the presence of Mycobacterium in the tissues. Methods: This descriptive cross-sectional study was performed on all sarcoidosis patients referred to Masih Daneshvari Hospital during 2017–2018 (401 patients). All patients who were outpatients or hospitalized in the bronchoscopy ward of Masih Daneshvari Hospital underwent transbronchial needle aspiration (TBNA). The cause of the TBNA procedure in patients was the presence of bilateral hilar lymphadenopathy in patients. Out of 401 patients with sarcoidosis, five patients showed positive smear or culture for Mycobacterium and were excluded from the study. Finally, 396 patients were included in the study. Results: The majority of participants in the present study were female (56.1%) with a mean age of 48.2 years and a mean ACE index of 73.4. Hypertension was found in16.2% of patients with sarcoidosis. 16.4% of patients had hyperlipidemia and 4.3% of patients had a history of ischemic heart disease. Redness of the eyes was seen in 13.1% of patients and 12.4% of the patients had diabetes. Also, 43.4% of the patients had skin lesions. Out of a total of 396 patients with sarcoidosis in the present study, 3.5% of the lymph and lung tissues of sarcoidosis patients (who were not infected with Mycobacterium tuberculosis by clinical signs and culture) contained amplifiable MTB DNA. Conclusion: In the present study and many previous related studies, the Mycobacterium genome has been observed in lymph node samples of mediastinal nodes and lung tissue of sarcoidosis patients. One of the strengths of the present study, which can make the results very reliable, is the high sample size in this study. It is suggested that similar studies with the use of control groups in large samples, investigate the presence of the Mycobacterium genome and its type in sarcoidosis patients.

305: Acute Respiratory Failure in a Healthy Adolescent: It’s Not Always COVID-19

INTRODUCTION: During a time in which SARS-CoV-2 is endemic, it is possible to overlook other causes of acute hypoxemic respiratory failure We present the case of a teenager with a history of anxiety, depression, and PTSD who developed respiratory failure in the spring of 2020 He had recently returned from a wilderness camp in the Southwest United States, where he was exposed to caves, mice, bats, horses, and cows Upon return to the Midwest, he spent the 10 days prior to presentation living in urban parks, where he vaped tobacco and marijuana, and smoked used cigarettes METHODS: The patient was brought to the Emergency Department for 3-4 days of progressive cough and dyspnea On arrival, he was in respiratory failure requiring heated-high flow nasal cannula He was febrile to 39 7 Initial work-up was notable for a white cell count 29,000 with neutrophilia, elevated CRP, procalcitonin and D-dimer Chest xray showed diffuse reticulonodular interstitial pattern Chest CT showed bilateral nodular pleural thickening, peripheral airspace disease and ground glass opacities Antibiotics were initiated for pneumonia Initially, COVID-19 infection was considered the leading diagnosis;however, nasopharyngeal PCRs for SARS-CoV-2 were negative Given the patient's travel, a fungal pneumonia was considered, and fluconazole was started On hospital day 3, he developed worsening respiratory distress on non-invasive ventilation, so he was started on amphotericin and intubated A fungal pneumonia was still favored, but there was also concern for atypical infections, e-cigarette/vaping associated lung injury (EVALI), or other eosinophilic pneumonia He was given methylprednisone 1mg/kg Bronchoscopy demonstrated edematous-friable airways and copious brown-tinged secretions Cultures and immunologic studies were negative for infection BAL fluid notable for 31% eosinophils consistent with idiopathic eosinophilic pneumonia Steroids were continued with rapid improvement, and he was extubated 39 hours later RESULTS: This case highlights the overlapping differential of COVID-19 and other atypical pulmonary infections with EVALI and acute eosinophilic pneumonia in a patient with multiple risk factors A multidisciplinary stepwise approach to diagnosis led to diagnosis and targeted management

The Domestic Environment and the Lung Mycobiome

This study analyzes the relationship between the mycobiome of the Lower Respiratory Tract (LRT) and the fungi in the domestic environment. Samples studied consisted of Broncho-Alveolar Lavage (BAL) from 45 patients who underwent bronchoscopy for different diagnostic purposes, and dust and air from the houses (ENV) of 20 of them (44.4%). Additionally, five bronchoscopes (BS) were also analyzed and negative controls were included for every procedure. All samples were processed for DNA extraction and cultures, which were performed in Sabouraud Dextrose and Potato Dextrose Agar. The fungal Internal Transcribed Spacer (ITS2) was sequenced by the Solexa/Illumina system and sequences were analyzed by QIIME 1.8.0 and compared with the UNITE Database for identification. The similarity between the two fungal communities (BAL and ENV) for a specific patient was assessed via the percentage of coincidence in the detection of specific operational taxonomic units (OTUs), and about 75% of co-occurrence was detected between the mycobiome of the LRT and the houses. Cultures confirmed the presence of the core mycobiome species. However, the low rate of isolation from BAL suggests that most of its mycobiome corresponds to non-culturable cells. This likely depends on the patient’s immune system activity and inflammatory status.

A PAN-POSITIVE, RAPIDLY PROGRESSIVE PULMONARY RENAL PUZZLER

SESSION TITLE: Fellows Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: A 78-year-old male with history of aortic sclerosis and anemia was admitted with two weeks of dyspnea, profound weakness, cough, and orthopnea On presentation he was afebrile and hemodynamically stable with normal oxygen saturations but was notably tachypneic which improved on simple nasal cannula On exam he had bilateral crackles to auscultation posteriorly with no peripheral edema Labs revealed hemoglobin 5 6g/dL with MCV 112 1, new acute kidney injury with creatinine 1 8mg/dL, and mildly elevated total and indirect bilirubin B-type natriuretic peptide was 518pg/mL Chest x-ray showed bilateral left greater than right hazy opacities CASE PRESENTATION: Initial concern was for Covid-19 with superimposed bacterial pneumonia Despite broad-spectrum antibiotics he declined over the following two days and was ultimately intubated He was noted to have a small blood clot in his posterior oropharynx at intubation Following two negative Covid-19 rt-PCR he underwent bronchoscopy with BAL that showed no blood in large airways but grossly bloody lavage return from right middle lobe and lingula Further workup was significant for elevated CRP (150 mg/dL), ANA 1:320 (homogenous) with weakly positive anti-histone antibodies, elevated anticardiolipin and anti-beta-2 microglobulin IgM, and positive p-ANCA with titer 1:640 and elevated anti-MPO and anti-PR3 Due to worsening creatinine he underwent renal biopsy which revealed crescentic necrotizing glomerulonephritis without thrombotic microangiopathy, and with IgG and C3 deposition After initiation of high dose steroids and rituximab the patient rapidly improved, was extubated and transferred to the floor Plasma exchange was deferred due to stabilization Further chart review revealed that he had been taking hydralazine for several years in increasing doses, most recently increased two months prior to his presentation DISCUSSION: Diffuse alveolar hemorrhage should be suspected in patients with systemic symptoms, anemia, and pulmonary infiltrates High dose steroids should be empirically started if there is high suspicion for inflammatory cause, particularly in the presence of concurrent renal dysfunction Immunomodulatory agents such as cyclophosphamide or rituximab should then be initiated based on serologies or pathology, as well as plasma exchange in patients with rapidly declining renal function or diffuse alveolar hemorrhage with respiratory compromise CONCLUSIONS: Unexpected overlap in rheumatologic markers should prompt consideration of drug-induced vasculitis Hydralazine induced vasculitis in particular is commonly associated with dual ANCA positivity with concurrent antiphospholipid and antihistone antibodies Renal biopsy shows pauci-immune crescentic glomerulonephritis and may also show IgM, IgG and C3 deposits without immune complexes Management consists of halting the offending agent and long-term immunosuppression Reference #1: Babar, F , Posner, J N , & Obah, E A (2016) Hydralazine-induced pauci-immune glomerulonephritis: intriguing case series with misleading diagnoses Journal of community hospital internal medicine perspectives, 6(2), 30632 Reference #2: Dobre, M , Wish, J , & Negrea, L (2009) Hydralazine-induced ANCA-positive pauci-immune glomerulonephritis: a case report and literature review Renal failure, 31(8), 745-748 DISCLOSURES: No relevant relationships by Natalie Achamallah, source=Web Response

Acute progressive dyspnea in a patient with chronic obstructive pulmonary disease.

The cause of acute dyspnea in chronic obstructive pulmonary disease is challenging. A 69-year old man complained of dyspnea, and cough. He had a diagnosis of chronic obstructive pulmonary disease for 6 years. Oxygen therapy started for respiratory failure. At the 6 th day of hospitalization, dyspnea progressively increased. Chest x-ray showed a right-sided radiolucency. The preliminary diagnosis was spontaneous pneumothorax but chest CT-scan demonstrated a space-occupying lesion in left main bronchus. The latter diagnosis was mucoid impaction but bronchoscopy revealed a malignant lesion. In conclusions, lung cancer can be a rare cause of acute dyspnea.

El papel de la broncoscopia flexible en la patología de vía aérea superior de pacientes inmunodeprimidos

El papel de la broncoscopia flexible en la patología de vía aérea superior de pacientes inmunodeprimidos

Protective Bronchoscopy Tent for the Pandemic Proceduralist

Protective Bronchoscopy Tent for the Pandemic Proceduralist

Clinical effect of propranolol in the treatment of respiratory hemangioma in infants and young children

To study the clinical effect of oral propranolol in the treatment of respiratory hemangioma in infants and young children. A retrospective analysis was performed from the chart review data of children with respiratory hemangioma treated by oral propranolol and diagnosed by bronchoscopy and laryngeal plain enhanced CT/MRI from November 2012 to December 2019. A total of 20 children were enrolled. All children had improvement in the symptoms of laryngeal stridor and dyspnea after oral administration of propranolol for 1-2 days. The median treatment time was 10 months (range 6-12 months). The median follow-up time was 10 months (range 3-15 months). Of the 20 children, 19 (95%) achieved regression of tumor, and 1 (5%) experienced an increase in tumor size during reexamination at 6 months after drug withdrawal and had no recurrence after the treatment with an increased dose of propranolol for 6 months. Only 1 child (5%) had adverse reactions, and 1 child (5%) was still under treatment. Oral propranolol can quickly relieve the symptoms such as dyspnea and achieve tumor regression, with few adverse events, and it is therefore an effective method for the treatment of respiratory hemangioma in infants and young children.

COVID-19 / Coronavirus Outbreak: How To Perform A Bronchoscopy

In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff while reducing the risk of infection. COVID patients often suffer from respiratory insufficiency and increased intrapulmonal secretion. A bronchoscopy is one of the standard procedures for resolving respiratory tract obstruction in intensive care medicine. On the downside, this procedure has a high potential for producing aerosol formations due to disconnections of the ventilator tubes, which creates an increased risk of infection to the medical staff. The indications for a bronchoscopy should be limited to the absolute minimum. This video gives a guidance for reducing personal infection risk without neglecting patient safety when performing a bronchoscopy.

Perioperative Implications of Vaping

Over the past 10 - 15 years, there has been a significant increase in the use of electronic cigarettes. These devices are generally used to deliver nicotine through inhalation by aerosolization. While the long-term risk of lung cancer is yet to be known, the chemicals and impurities in the solutions may have other acute and chronic effects on the respiratory system including respiratory failure from adult respiratory distress syndrome. Recent concerns have been raised regarding the potential for significant acute and chronic health care risks of these devices including pneumonitis, airway reactivity and respiratory failure. Given that many of the acute effects are related to the respiratory system, anesthetic care may be required during diagnostic procedures including bronchoscopy to investigate the etiology of acute respiratory symptomatology. We present an adolescent who presented to the operating room for bronchoscopy and bronchoalveolar lavage to investigate the etiology of respiratory involvement following an episode of vaping. The healthcare and end-organ effects of nicotine, tobacco smoke and vaping are discussed, and potential anesthetic implications are presented. J Med Cases. 2020;11(5):129-134 doi: https://doi.org/10.14740/jmc3451

Expert consensus on preventing nosocomial transmission during respiratory care for critically ill patients infected by 2019 novel coronavirus pneumonia

Definite evidence has shown that the novel coronavirus (COVID-19) could be transmitted from person to person, so far more than 1 700 bedside clinicians have been infected. A lot of respiratory treatments for critically ill patients are deemed as high-risk factors for nosocomial transmission, such as intubation, manual ventilation by resuscitator, noninvasive ventilation, high-flow nasal cannula, bronchoscopy examination, suction and patient transportation, etc, due to its high possibility to cause or worsen the spread of the virus. As such, we developed this consensus recommendations on all those high-risk treatments, based on the current evidence as well as the resource limitation in some areas, with the aim to reduce the nosocomial transmission and optimize the treatment for the COVID-19 pneumonia patients. Those recommendations include: (1)Standard prevention and protection, and patient isolation; (2)Patient wearing mask during HFNC treatment; (3)Using dual limb ventilator with filters placed at the ventilator outlets, or using heat-moisture exchanger (HME) instead of heated humidification in single limb ventilator with HME placed between exhalation port and mask; avoid using mask with exhalation port on the mask; (4)Placing filter between resuscitator and mask or artificial airway; (5)For spontaneous breathing patients, placing mask for patients during bronchoscopy examination; for patients receiving noninvasive ventilation, using the special mask with bronchoscopy port to perform bronchoscopy; (6)Using sedation and paralytics during intubation, cuff pressure should be maintained between 25-30 cmH(2)O(1 cmH(2)O=0.098 kPa); (7)In-line suction catheter is recommended and it can be used for one week; (8)Dual-limb heated wire circuits are recommended and only changed with visible soiled; (9)For patients who need breathing support during transportation, placing an HME between ventilator and patient; (10)PSV is recommended for implementing spontaneous breathing trial (SBT), avoid using T-piece to do SBT. When tracheotomy patients are weaned from ventilator, HME should be used, avoid using T-piece or tracheostomy mask. (11)Avoid unnecessary bronchial hygiene therapy; (12) For patients who need aerosol therapy, dry powder inhaler metered dose inhaler with spacer is recommended for spontaneous breathing patients; while vibrating mesh nebulizer is recommended for ventilated patients and additional filter is recommended to be placed at the expiratory port of ventilation during nebulization.

Bronchoscopic, non-interventional management of hemoptysis in resource limited settings: insights from the literature.

The non-invasive management of clinically significant hemoptysis by bronchoscopy remains a therapeutic challenge. Various agents have been used endobronchially in order to control hemoptysis, such as cold saline, tranexamic acid, and epinephrine. This review summarizes all available data in that view, especially in resource limited settings, where more advanced means of controlling hemoptysis are not available.

Intersurgical Bronchoscopy Ports

Biomedical Safety & Standards 50(6):p 48, April 01, 2020. | DOI: 10.1097/01.BMSAS.0000658324.71822.f9