Diagnostic Bronchoscopy Research Articles

Practices and perspectives on advanced diagnostic and interventional bronchoscopy among pediatric pulmonologists in the United States.

Advanced diagnostic bronchoscopy includes endobronchial ultrasound (EBUS) guided transbronchial lung and lymph node biopsies, CT navigation and robotic bronchoscopy. Interventional bronchoscopy refers to procedures performed for therapeutic purposes such as balloon dilation of the airway, tissue debulking, cryotherapy, removal of foreign bodies and insertion of endobronchial valves [1]. For adult patients, these procedures are standard of care [2, 3]. Despite a lack of formalized training, there are numerous case reports and case series describing the use of advanced diagnostic and interventional bronchoscopy techniques in children. The safety and feasibility of EBUS-TBNA, cryotherapy techniques, endobronchial valves among other techniques have been demonstrated in these publications [1, 4-9]. We sought to better understand the current practices and perspectives on interventional and advanced bronchoscopy among pediatric pulmonologists through surveys sent to pediatric teaching hospitals across the United States. We received 43 responses representing 28 programs from 25 states. The highest bronchoscopy procedure volume occurred in the 0-5 years age group. Among our respondents, 31% self-identified as a pediatric interventional/advanced bronchoscopist. 79% believe that advanced and interventional training is feasible in pediatric pulmonology and 77% believe it should be offered to pediatric pulmonary fellows. This is the first study to characterize current practices and perspectives regarding advanced diagnostic and interventional bronchoscopy procedures among pediatric pulmonologists in the United States. Pediatric interventional pulmonology (IP) is in its infancy and its beginnings echo those of the adult IP where only certain centers were performing these procedures.

Comparison of methods of non-mechanical pressure measurement in the cuff of an endotracheal tube

Bronchoscopy is a diagnostic and follow-up procedure. Despite the fact that this manipulation itself is minimally invasive, it can be a difficult test for both the patient and the doctor. Therefore, this manipulation definitely requires anesthesia and sedation. This study compared dexmedetomidine and propofol sedation methods during diagnostic bronchoscopy to assess their safety, effectiveness, and satisfaction. The results show a high level of safety of both methods, although some significant differences affecting the choice of sedation method were found. 32 patients participated in the study, divided into two groups depending on the used method of sedation: propofol or dexmedetomidine. Pulse oximetry, heart rate, capnography parameters were measured, the number and severity of iatrogenic lesions of the trachea, as well as the satisfaction of care and doctors were assessed. In some groups, there was a high level of safety of sedation. Dexmedetomidine sedation was associated with fewer cough episodes and greater satisfaction, but had a longer induction time with propofol. A low incidence of serious complications was observed in both groups. Dexmedetomidine can be considered a safe and effective sedation option for diagnostic bronchoscopy, offering additional benefits such as reduced cough episodes and increased patient satisfaction. The choice of the sedation method is based on the individual characteristics of the patient and the available resources of the hospital.

Outpatient care in pulmonology - a scientific analysis and a position paper of the German Society of Respiratory Medicine (DGP)

The ambulantization of patient care that were previously provided as inpatient service is one of the goals of the current reform in the German healthcare system. In pulmonology, this particularly applies to endoscopic procedures. However, the real costs of endoscopic services, which form the basis for the calculation of a future so called hybrid DRG or in the AOP catalog, are unclear. After selection of use cases including endoscopic procedures which can be performed on an outpatient basis by a committee of experts the appropriate DRGs were identified from the § 21-KHEntgG data for 2022 published by the Institute for the Hospital Remuneration System (InEK). The costs were calculated from the respective InEK cost matrix added by the calculated material costs. The use cases suitable for outpatient treatment were systematic endobronchial ultrasound (EBUS) with transbronchial needle aspiration (calculated costs € 2,175.60 without or € 3,315.60 including PET/CT), navigation-assisted bronchoscopy for peripheral lesions (depending on the methodology € 2,870.23 to €4,120.23) and diagnostic (flexible) bronchoscopy (€ 1,121.02). Outpatient treatment of endoscopic procedures that were previously performed inpatient is possible and necessary, and the costs calculated in this publication can form a reliable basis for appropriate reimbursement. Together with a structural quality that has been transformed to outpatient service and cross-sector cooperation, continued high-quality care for pneumological patients can be ensured.

March 2024 Medical Image of the Month: Sputum Cytology in Patients with Suspected Lung Malignancy Presenting with Acute Hypoxic Respiratory Failure

No abstract available. Article truncated after 150 words. A 71-year-old woman presented with right-sided mass-like consolidation and pleural effusion on CT (Figure 1A), discovered incidentally after placement of a drug-eluting stent for coronary artery disease. The patient had a medical history significant for COPD, hypertension, hyperlipidemia, and coronary artery disease, status post a recent drug-eluting stent (less than 1 month ago). The patient received a presumptive diagnosis of pneumonia with parapneumonic effusion. Findings persisted despite multiple courses of empiric antibiotic therapy. She then underwent thoracentesis; pleural fluid was exudative; however, cytology was inconclusive. An FDG PET-CT (Figure 1B) revealed hypermetabolic activity in the right lower lobe with radiotracer activity up to 7.7 SUV concerning for malignancy. Diagnostic bronchoscopy was planned; however, her condition deteriorated suddenly the day before her planned procedure. EMS found the patient to be severely hypoxic, SpO2 in the 70s. Patient was taken by ambulance to the local emergency room. Upon arrival, the patient was …

Assessment of Advanced Diagnostic Bronchoscopy Outcomes for Peripheral Lung Lesions: A Delphi Consensus Definition of Diagnostic Yield and Recommendations for Patient-centered Study Designs. An Official American Thoracic Society/American College of Chest Physicians Research Statement.

Background: Advanced diagnostic bronchoscopy targeting the lung periphery has developed at an accelerated pace over the last two decades, whereas evidence to support introduction of innovative technologies has been variable and deficient. A major gap relates to variable reporting of diagnostic yield, in addition to limited comparative studies. Objectives: To develop a research framework to standardize the evaluation of advanced diagnostic bronchoscopy techniques for peripheral lung lesions. Specifically, we aimed for consensus on a robust definition of diagnostic yield, and we propose potential study designs at various stages of technology development. Methods: Panel members were selected for their diverse expertise. Workgroup meetings were conducted in virtual or hybrid format. The cochairs subsequently developed summary statements, with voting proceeding according to a modified Delphi process. The statement was cosponsored by the American Thoracic Society and the American College of Chest Physicians. Results: Consensus was reached on 15 statements on the definition of diagnostic outcomes and study designs. A strict definition of diagnostic yield should be used, and studies should be reported according to the STARD (Standards for Reporting Diagnostic Accuracy Studies) guidelines. Clinical or radiographic follow-up may be incorporated into the reference standard definition but should not be used to calculate diagnostic yield from the procedural encounter. Methodologically robust comparative studies, with incorporation of patient-reported outcomes, are needed to adequately assess and validate minimally invasive diagnostic technologies targeting the lung periphery. Conclusions: This American Thoracic Society/American College of Chest Physicians statement aims to provide a research framework that allows greater standardization of device validation efforts through clearly defined diagnostic outcomes and robust study designs. High-quality studies, both industry and publicly funded, can support subsequent health economic analyses and guide implementation decisions in various healthcare settings.

Principal diagnostic features of paediatric foreign body aspiration

ObjectivesThe aim of this study is to identify the most common and important features within the presenting history, clinical examination and chest radiograph that are associated with foreign body (FB) aspiration in the paediatric population, to support rationalised decision making in regards to proceeding with diagnostic bronchoscopy. MethodsA retrospective notes review was conducted of 70 patients over a 12-year period at our tertiary referral centre. Their presenting history, clinical and radiographic signs were documented and univariate logistic regression model used to calculate odds ratios. ResultsThe main features identified within our cohort with a positive FB finding at bronchoscopy were history of a cough (OR 5.1, p = 0.008) and radiographic evidence of hyperinflation or air trapping (OR 7.1, p = 0.016). Zero patients with a FB presented with only a positive history in the absence of other clinical or radiological signs. History of a witnessed choking episode neither increased or decreased the likelihood of as aspirated FB (OR 1, p = 0.967). ConclusionsWe have identified two principal features, as described above, which are associated with paediatric FB aspiration. Reliance on a positive clinical history alone, but specifically the history of a witnessed choking episode, did not support the presence of a FB and other associated signs need to be considered in deciding to proceed to bronchoscopy.

Bacterial load of the surroundings during rigid diagnostic bronchoscopy under high frequency jet-ventilation

High-frequency jet ventilation (HFJV) is used in pneumological endoscopy for rigid, diagnostic, and therapeutic bronchoscopies. It is unclear to what extent the unobstructed flow of respiratory gas from the patient's lungs causes microbial contamination of the surrounding air. After the start of the HFJV (15 min) in 16 rigid bronchoscopies, airborne pathogen measurements were taken directly at the distal endoscope outlet, at examiner height (40 cm above the endoscope outlet), at a 2 m distance from the endoscope in the room and at the supply air outlet of the examination room using an RCS air sampler. The number and type of pathogens isolated in the air samples were then determined, as well as germs in the bronchoalveolar lavage fluid (BALF) from the patient's lungs. An increased bacterial density (136 and 114 CFU/m3) was detected directly at the distal end of the endoscope and at examiner height at a distance of 40 cm, which decreased significantly with increasing distance from the bronchoscope (98 CFU/m3 at a distance of 2 m and 82 CFU/m3 at the supply air outlet). The most frequently detected bacteria were Staphylococcus spp., Micrococcus spp. and Bacillus spp. In the BALF, pathogens could only be cultivated in four of 16 samples, but the same pathogens were detected in the BALF and the ambient air. When performing a rigid bronchoscopy, in which patients are mechanically ventilated in a controlled manner using an open HFJV system, there is an increased pathogen load in the ambient air and therefore a potential risk for the examiner.

Spontaneous Emphysema, Pneumomediastinum and Pneumopericardium Revealing Unrecognized Inhalation of a Foreign Body

Inhalation of a foreign body is a frequent problem in pediatrics with a very difficult diagnosis in the absence of penetration syndrome. It is a very rare cause of emphysema moreover the combination of emphysema, pneumomediastinum or pneumopericardium is an exceptional form. We report an unrecognized case of inhalation of a foreign body, a 5-year-old girl was admitted for respiratory distress with diffuse subcutaneous emphysema in the eyelids , face, neck and chest more marked on the left . A chest CT revealed emphysema with pneumomediastinum, pneumopericardium and a focus of LIG condensation. The diagnostic bronchoscopy was performed under general anesthesia. A sunflower seed, landlocked completely obstructing the bronchial lumen was detected and recovered in the left main bronchus. The removal of the foreign body resulted in improvement of the emphysema and the gradual disappearance of symptoms.

Feasibility of a Prototype Image Reconstruction Algorithm for Motion Correction in Interventional Cone-Beam CT Scans

Assess the feasibility of a prototype image reconstruction algorithm in correcting motion artifacts in cone-beam computed tomography (CBCT) scans of interventional instruments in the lung. First, phantom experiments were performed to assess the algorithm, using the Xsight lung phantom with custom inserts containing straight or curved catheters. During scanning, the inserts moved in a continuous sinusoidal or breath-hold mimicking pattern, with varying amplitudes and frequencies. Subsequently, the algorithm was applied to CBCT data from navigation bronchoscopy procedures. The algorithm's performance was assessed quantitatively via edge-sharpness measurements and qualitatively by three specialists. In the phantom study, the algorithm improved sharpness in 13 out of 14 continuous sinusoidal motion and five out of sevenbreath-hold mimicking scans, with more significant effects at larger motion amplitudes. Analysis of 27 clinical scans showed that the motion corrected reconstructions had significantly sharper edges than standard reconstructions (2.81 (2.24-6.46) vs. 2.80 (2.16-4.75), p=0.003). These results were consistent with the qualitative assessment, which showed higher scores in the sharpness of bronchoscope-tissue interface and catheter-tissue interface in the motion-corrected reconstructions. However, the tumor demarcation ratings were inconsistent between raters, and the overall image quality of the new reconstructions was rated lower. Our findings suggest that applying the new prototype algorithm for motion correction in CBCT images is feasible. The algorithm improved the sharpness of medical instruments in CBCT scans obtained during diagnostic navigation bronchoscopy procedures, which was demonstrated both quantitatively and qualitatively.

Blastomycosis: An Underrecognized Climate Sensitive Fungal Pathogen Causing Pneumonia in 52-year-old Immunocompetent Women from Southwestern Ohio—A Case Report and Literature Review

Blastomycosis, formerly known as Gilchrist disease, Chicago disease, North American blastomycosis, or Namekagos fever, is an uncommon but underappreciated fungal infection seen mostly in immunocompetent people, caused by the fungi Blastomyces. Blastomyces dermatitidis and Blastomyces gilchristii are the most common species responsible for most infections in the United States of America. Blastomycosis can cause a wide variety of diseases, the most common being pneumonia as the lungs are usually the main primary entrance source of infection after inhalation of Blastomyces spores. However, dissemination from the lungs to other organs such as skin, bones, genitourinary, and central nervous system can occur. We describe a 52-year-old female who was admitted to the hospital for unresolved pneumonia after failure to respond to multiple outpatient antibiotic treatments for a presumed diagnosis of community-acquired pneumonia, presenting with right-sided chest pain, fever, cough and weight loss for three weeks duration. Her initial Chest-X ray and CT chest revealed right middle lobe infiltrate, while her laboratory studies were significant for elevated white blood cells (WBC). The patient underwent diagnostic bronchoscopy which showed erythema of the right middle lobe bronchus with purulent secretion. Furthermore, cytology examination of specimens from bronchoalveolar lavage and bronchial brush from right middle lobe with (PAP) satin on thin prep and H&E stain on the cell block revealed an abundance of broad-base budding yeast consistent with Blastomyces organism, which was confirmed by molecular testing with DNA probe assay. Her serum and urine Blastomyces antigens were positive, above the limit of quantification. The patient was started on antifungal therapy with Amphotericin-B intravenously. In the process, her fever resolved and her respiratory symptoms slowly improved. She was discharged home with oral itraconazole which was to be continued for 6-12 months as an outpatient.

The Lung Cancer Prediction Model “Stress Test”: Assessment of Models’ Performance in a High-Risk Prospective Pulmonary Nodule Cohort

Pulmonary nodules represent a growing health care burden because of delayed diagnosis of malignant lesions and overtesting for benign processes. Clinical prediction models were developed to inform physician assessment of pretest probability of nodule malignancy but have not been validated in a high-risk cohort of nodules for which biopsy was ultimately performed. Do guideline-recommended prediction models sufficiently discriminate between benign and malignant nodules when applied to cases referred for biopsy by navigational bronchoscopy? We assembled a prospective cohort of 322 indeterminate pulmonary nodules in 282 patients referred to a tertiary medical center for diagnostic navigational bronchoscopy between 2017 and 2019. We calculated the probability of malignancy for each nodule using the Brock model, Mayo Clinic model, and Veterans Affairs (VA) model. On a subset of 168 patients who also had PET-CT scans before biopsy, we also calculated the probability of malignancy using the Herder model. The performance of the models was evaluated by calculating the area under the receiver operating characteristic curves (AUCs) for each model. The study cohort contained 185 malignant and 137 benign nodules (57% prevalence of malignancy). The malignant and benign cohorts were similar in terms of size, with a median longest diameter for benign and malignant nodules of 15 and 16 mm, respectively. The Brock model, Mayo Clinic model, and VA model showed similar performance in the entire cohort (Brock AUC, 0.70; 95% CI, 0.64-0.76; Mayo Clinic AUC, 0.70; 95% CI, 0.64-0.76; VA AUC, 0.67; 95% CI, 0.62-0.74). For 168 nodules with available PET-CT scans, the Herder model had an AUC of 0.77 (95% CI, 0.68-0.85). Currently available clinical models provide insufficient discrimination between benign and malignant nodules in the common clinical scenario in which a patient is being referred for biopsy, especially when PET-CT scan information is not available.

Diagnostic Yield vs Diagnostic Accuracy for Peripheral Lung Biopsy Evaluation: Evidence Supporting a Future Pragmatic End Point

Diagnostic yield and accuracy endpoints have been used inconsistently in the evaluation of advanced diagnostic bronchoscopy devices and techniques, limiting between-study comparisons. In addition, diagnostic accuracy can only be adjudicated after prolonged clinical follow-up which delays reporting on the performance of novel devices. Will a conservative diagnostic yield definition would result in few false negative initial results to closely approximate diagnostic accuracy and represent a useful outcome for future studies of diagnostic utility? Commonly utilized definitions of diagnostic yield were applied to a prospective dataset of consecutive peripheral pulmonary lesions sampled by navigational bronchoscopy from 2017 to 2019. All consider malignancy to be diagnostic but differ in their classification of non-malignant biopsy findings, which were subcategorized as specific benign, nonspecific benign, or normal lung. Diagnostic yield calculations were also compared to diagnostic accuracy, defined as the proportion of biopsies deemed diagnostic by each definition that were confirmed accurate through two years of follow-up. A total of 450 biopsied lesions were analyzed. The prevalence of malignancy was 60.9% (274 of 450). On initial bronchoscopy pathology, there were 227 malignant diagnoses (50.4%), with a single false-positive (0.4%). Among 104 biopsies with specific benign findings, only two were false negative for malignancy (1.9%). There were 119 nonspecific benign biopsies with 46 false negatives for malignancy (38.7%). The discrepancy between diagnostic yield and accuracy was 0.7% for the conservative definition which only considered malignant or specific benign findings as diagnostic. A conservative diagnostic yield definition excluding nonspecific benign diagnoses closely approximated diagnostic accuracy through two years follow-up, with a less than 1% discrepancy. Using this conservative yield definition may allow for dissemination of reliable diagnostic utility data without protracted delays needed for follow-up data in this era of rapid technological change in advanced diagnostic bronchoscopy.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): revolutionizing the landscape of lung disease diagnostics.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a revolutionary diagnostic tool for lung diseases, including lung cancer, sarcoidosis, and lymphoproliferative diseases. This minimally invasive procedure offers a superior diagnostic yield while ensuring maximum patient safety when compared to traditional invasive techniques such as mediastinoscopy and thoracoscopy. By enabling real-time imaging and sampling of mediastinal and hilar lymph nodes and masses directly from the bronchoscope, EBUS-TBNA has redefined the precision of diagnostic bronchoscopy. This comprehensive review explores the origins, development, and current status of EBUS-TBNA, highlighting its successes and identifying potential areas for improvement. Technological advancements have continuously enhanced the reliability and efficacy of EBUS-TBNA over time. The mechanisms underlying the superior diagnostic yield of EBUS-TBNA are thoroughly discussed, further solidifying its position as the gold standard for lung cancer staging and diagnosis. Furthermore, this review delves into the crucial role of EBUS-TBNA in lung cancer diagnosis, supported by studies comparing its accuracy, safety, and cost-effectiveness to other diagnostic tools. Looking ahead, ongoing research aims to expand the applications of EBUS-TBNA and improve its diagnostic performance. Notable advancements in needle design and sampling techniques hold promise for further enhancing its efficacy. Maximizing its potential through comprehensive training and continuous technological developments will enable broader clinical applications, ultimately leading to improved patient outcomes. As EBUS-TBNA continues to evolve, its diagnostic impact is expected to increase, solidifying its position as an indispensable tool in the diagnosis and management of lung diseases.

Clinical Implementation of β-Tubulin Gene-Based Aspergillus Polymerase Chain Reaction for Enhanced Aspergillus Diagnosis in Patients with Hematologic Diseases: A Prospective Observational Study.

The β-tubulin (benA) gene is a promising target for the identification of Aspergillus species. Assessment of the clinical implementation and performance of benA gene-based Aspergillus polymerase chain reaction (PCR) remains warranted. In this study, we assessed the analytical performance of the BenA probe PCR in comparison with the Aspergenius kit. We prospectively collected bronchoalveolar lavage (BAL) fluid via diagnostic bronchoscopy from adult patients with hematologic diseases. BenA gene-based multiplex real-time PCR and sequential melting temperature analysis were performed to detect the azole resistance of Aspergillus fumigatus. In total, 76 BAL fluids in 75 patients suspicious of invasive pulmonary aspergillosis (IPA) were collected. Before the application of PCR, the prevalence of proven and probable IPA was 32.9%. However, after implementing the benA gene-based PCR, 15.8% (12 out of 76) of potential IPA cases were reclassified as probable IPA. The analytical performance of the BenA probe PCR in BAL samples was comparable to that of the Aspergenius kit. The diagnostic performance was as follows: sensitivity, 52.0%; specificity, 64.7%; positive predictive value, 41.9%; negative predictive value, 73.3%; positive likelihood ratio, 1.473; and negative likelihood ratio, 0.741. Moreover, benA gene-based Aspergillus PCR discriminated all major sections of Aspergillus, including cryptic species such as Aspergillus tubingensis. Sequential melting temperature analysis successfully detected 2 isolates (15.4%) of A. fumigatus carrying resistant mutations. BenA gene-based Aspergillus PCR with melting temperature analysis enhances diagnostic accuracy and detects not only cryptic species but also resistant mutations of A. fumigatus. It shows promise for clinical applications in the diagnosis of IPA.

Diagnostic value of bronchoscopy in sputum‑negative presumptive pulmonary tuberculosis patients and its clinicoradiological profile

Abstract: CONTEXT: Tuberculosis (TB) remains endemic in India. Little local data have been reported on bronchoscopic evaluation of sputum‑negative pulmonary TB patients, which poses a significant diagnostic and therapeutic challenge. AIMS: To determine the diagnostic value of bronchoscopy and bronchoalveolar lavage (BAL) and its clinical and radiological profile in sputum‑negative, pulmonary TB patients. METHODS: We performed an analysis of patients with probable pulmonary TB with overall negative (smear and/or polymerase chain reaction [PCR]) or scanty sputum that had undergone bronchoscopy with BAL over a period of 11 months. Patients’ symptoms, radiological features, lung lobe lavaged, BAL acid‑fast bacilli (AFB) stain, Mycobacterium TB (MTB)‑PCR, and mycobacterial cultures were analyzed. Mycobacterial culture was used as a reference standard. RESULTS: 54 patients underwent a diagnostic bronchoscopy. Dry cough and fever were the most common symptoms. Uncontrolled diabetes mellitus was the most frequent comorbidity identified in 15 (28%) patients. Fifty‑nine percent of the patients had diffuse lung infiltrates, with consolidation being the most common abnormality (41%), followed by cavitation (39%). Right upper lobe was the most frequent lung lobe lavaged (31%). BAL mycobacterial culture and MTB Polymerase Chain Reaction (PCR) were positive in 43 (80%) and 41 (76%) patients and BAL AFB was positive in 5 patients respectively. Using BAL culture as reference, male gender, predominant upper lobe disease, upper lobe lavage, and presence of cavities on chest imaging had the highest diagnosticyield (82%, 100%, 63%, and 89%, respectively) (P = 0.02,0.006, 0.03, and 0.02, respectively).There was 100% concordance among the three diagnostic modalities. CONCLUSIONS: An overall diagnostic yield of 80% was achieved with combined use of BAL MTB PCR, culture, and AFB staining. Keywords: Broncho alveolar lavage, bronchoscopy, Mycobacterium tuberculosis polymerase chain reaction, sputum negative, tuberculosis

Aspirin use is safe in patients undergoing transbronchial lung cryobiopsy

BackgroundAspirin has been shown to be safe for patients undergoing certain diagnostic bronchoscopy procedures, such as transbronchial biopsies and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration. However, there are no studies documenting the safety of aspirin in patients undergoing trans-bronchial lung cryobiopsy (TBLC). ObjectiveTo determine whether aspirin increases the risk of bleeding during or following TBLC. Methods172 consecutive patients undergoing TBLC were included in this retrospective cohort study. Data on demographic characteristics, comorbidities etc. were collected. Bleeding severity was defined by the intervention needed to stop the bleeding: mild-cold saline injection, moderate-adrenalin/hexakarpon injection, or severe - Intensive Care Unit admission after bronchoscopy. ResultsFifty-one patients (29.6 %) were under aspirin treatment at the time of TBLC. Overall, there was no significant difference between the aspirin and the control groups regarding the incidence of moderate-severe bleeding (41.2 % vs. 33.1 %, respectively, p.0.31). the Clopidogrel was found as a risk factor for increased bleeding when taken together with aspirin (Odds ratio = 9.8 (1.1–86), p = 0.013). When taken alone, clopidogrel was also found as a risk factor to increased bleeding, yet these results didn't reach significance due to low number of patients (fig. 1, N = 5, Odds ratio = 2.8 (0.46–17.35), p = 0.245). No difference was observed between the groups regarding additional post-procedural complications, including pneumothorax, hospitalizations, and mortality. ConclusionTo the best of our knowledge, this is the first study examining bleeding risk of cryobiopsy under aspirin treatment. Based on our results, it seems safe to perform TBLC under aspirin treatment, except for patients who are concurrently treated with clopidogrel. Further research should be conducted to substantiate this conclusion.

Advances in interventional diagnostic bronchoscopy for peripheral pulmonary lesions

Advances in interventional diagnostic bronchoscopy for peripheral pulmonary lesions

Microbiological diagnosis of pulmonary invasive aspergillosis in critically ill patients with severe SARS-CoV-2 pneumonia: a bronchoalveolar study

BackgroundDiagnosing COVID-19-associated pulmonary aspergillosis (CAPA) can be challenging since radiological and clinical criteria in the critically ill patient are nonspecific. Microbiological diagnostic support is therefore crucial. The aim of this study was to document the incidence of aspergillosis using bronchoalveolar lavage (BAL) as the diagnostic method and to determine the performance of the current mycological diagnostic tests most widely used for the diagnosis of CAPA, together with evaluation of the Asp lateral flow device (LFD).MethodsProspective cohort study conducted between March 2020 and June 2022. Inclusion criteria were critically ill patients admitted to the ICU with SARS-CoV-2 pneumonia requiring invasive mechanical ventilation. Diagnostic bronchoscopy and BAL were performed at the beginning of invasive mechanical ventilation. The sensitivity, specificity, positive and negative predictive value (PPV and NPV), positive and negative likelihood ratio (LR + and LR-) of BAL culture, direct examination with calcofluor white stain, ELISA (Platelia) and LFD (AspLFD) for detection of galactomannan (GM) were evaluated. Aspergillus-qPCR was applied when discrepancies between diagnostic tests arose.ResultsOf the 244 critically ill patients with SARS-CoV-2 pneumonia admitted to the ICU, the majority (n = 200, 82%) required invasive mechanical ventilation. Diagnostic bronchoscopic procedures were performed in 160 patients (80%), who were enrolled in this study. The incidence of CAPA was 18.7% (n = 30). LFD-GM demonstrated a sensitivity of 84%, specificity of 99%, PPV 94%, NPV 97%, LR(+) of 84, and LR(-) of 0.16. At GM-ELISA indices of ≥ 0.5 and ≥ 1.0, sensitivity was 92% and 79%, specificity was 95% and 99%, PPV 76% and 91%, NPV 99% and 96%, LR(+) 18 and 79, and LR(-) 0.08 and 0.21, respectively. The optimal cut-off index from the ROC curve was 0.48, with sensitivity of 95% and specificity of 95%.ConclusionsUsing a diagnostic strategy based on bronchoscopy and BAL, we documented a high incidence of pulmonary aspergillosis in patients with severe SARS-CoV-2 pneumonia. Asp-LFD showed moderate sensitivity and excellent specificity, with a high PPV, and could be used for rapid diagnosis of patients with suspected CAPA.

Anesthetic management of inguinal hernia in an ex-premature infant with subglottic stenosis: a case report

BackgroundWe report the anesthetic management of inguinal hernia repair for an infant with subglottic stenosis. A previously scheduled operation had been cancelled due to unexpected airway trouble during the induction.Case presentationA boy was born at 24 weeks of gestation and his trachea was intubated for 45 days. At 16 months old, surgery for inguinal hernia was planned, but cancelled due to unexpected narrow airway, and subglottic stenosis was first suspected. At 17 months old, he was transferred to us for inguinal hernia surgery. After careful discussion between the surgical team and the anesthesiologists, a strategy to manage this patient was developed. He underwent open hernia surgery under spinal anesthesia and diagnostic rigid bronchoscopy under tubeless general anesthesia separately, which revealed low-grade stenosis and some subglottic cysts. The postoperative course was uneventful.ConclusionInterdepartmental discussion weighing risks and benefits may deduce the safest and most appropriate anesthesia method.

Thirty-Day Complications, Unplanned Hospital Encounters, and Mortality after Endosonography and/or Guided Bronchoscopy: A Prospective Study.

Limited data exist regarding the adverse events of advanced diagnostic bronchoscopy, with most of the available information derived from retrospective datasets that primarily focus on early complications. We conducted a 15-month prospective cohort study among consecutive patients undergoing endosonography and/or guided bronchoscopy under general anesthesia. We evaluated the 30-day incidence of severe complications, any complication, unplanned hospital encounters, and deaths. Additionally, we analyzed the time of onset (immediate, within 1 h of the procedure; early, 1 h-24 h; late, 24 h-30 days) and identified risk factors associated with these events. Thirty-day data were available for 697 out of 701 (99.4%) enrolled patients, with 85.6% having suspected malignancy and multiple comorbidities (median Charlson Comorbidity Index (IQR): 4 (2-5)). Severe complications occurred in only 17 (2.4%) patients, but among them, 10 (58.8%) had unplanned hospital encounters and 2 (11.7%) died within 30 days. A significant proportion of procedure-related severe complications (8/17, 47.1%); unplanned hospital encounters (8/11, 72.7%); and the two deaths occurred days or weeks after the procedure. Low-dose attenuation in the biopsy site on computed tomography was independently associated with any complication (OR: 1.87; 95% CI 1.13-3.09); unplanned hospital encounters (OR: 2.17; 95% CI 1.10-4.30); and mortality (OR: 4.19; 95% CI 1.74-10.11). Severe complications arising from endosonography and guided bronchoscopy, although uncommon, have significant clinical consequences. A substantial proportion of adverse events occur days after the procedure, potentially going unnoticed and exerting a negative clinical impact if a proactive surveillance program is not implemented.