Diagnostic Flexible Bronchoscopy Research Articles

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.

Consensus on technical procedures for simulation-based training in thoracic surgery: an international needs assessment.

To identify and prioritize technical procedures for simulation-based training to be integrated into the thoracic surgical curriculum. A 3-round Delphi survey was conducted from February 2022 to June 2022 among 34 key opinion leaders in thoracic surgery from 14 countries worldwide. The 1st round was a brainstorming phase to identify technical procedures that a newly qualified thoracic surgeon should be able to perform. All the suggested procedures were categorized, qualitatively analysed and sent to the 2nd round. The second round investigated: the frequency of the identified procedure at each institution, the number of thoracic surgeons that should be able to perform these procedures, the degree of risk to the patient if the procedure is performed by a non-competent thoracic surgeon and the feasibility of simulation-based education. In the 3rd round, elimination and re-ranking of the procedures from the 2nd round were performed. Response rates in the 3 iterative rounds were 80% (28 out of 34), 89% (25 out of 28) and 100% (25 out of 25) in the 1st, 2nd and 3rd round, respectively. Seventeen technical procedures were included for simulation-based training in the final prioritized list. The top 5 procedures were Video-Assisted Thoracoscopic Surgery (VATS) lobectomy, VATS segmentectomy, VATS mediastinal lymph node dissection, diagnostic flexible bronchoscopy and robotic-assisted thoracic surgery port placement, robotic-assisted thoracic surgery docking and undocking. The prioritized list of procedures represents a consensus of key thoracic surgeons worldwide. These procedures are suitable for simulation-based training and should be integrated in the thoracic surgical curriculum.

Preparation and Findings in Diagnostic and Therapeutic Flexible Fiberoptic Bronchoscopy Procedures in Patients with COVID-19

The coronavirus disease 2019 (COVID-19), which has raised concerns about infection control for every clinical procedure, including flexible fiberoptic bronchoscopy (FFB), has drawn the attention of clinicians across the globe. A pulmonologist frequently conducts this procedure to diagnose and treat pulmonary diseases like COVID-19. This procedure involves direct airway observation and generates aerosol from the patient. However, it is considered a double-edged sword, as the risk of infection and instrument contamination always haunts its clinical benefit to the patients and the operators. Therefore, a guideline for preparing and indicating FFB in COVID-19 must be addressed appropriately by emphasizing the importance of infection prevention and control. Fortunately, several recommendations and findings have emerged over the past three years, which should support safe FFB procedures for its operators with controlled infection. This study summarizes the indication, objective, contraindication, risk, preparation, and findings in diagnostic and therapeutic FFB patients with COVID-19.

Safe sedation during diagnostic and therapeutic flexible bronchoscopy in Japan: A review of the literature.

We explored whether a combination of an opioid (fentanyl or pethidine) and midazolam could safely sedate Japanese patients undergoing bronchoscopic procedures. We searched the PubMed Medline and Igaku Chuo Zasshi (ICHUSHI) databases from 1980 to 2022 for papers on sedatives used during bronchoscopy, especially opioids (fentanyl and pethidine) and midazolam. The keywords were "bronchoscopy" and "sedation" ("kikanshikyo" and "chinsei", respectively, in Japanese). The results showed that midazolam was the preferred sedation agent during flexible bronchoscopy; with midazolam sedation is rapid, and the drug is associated with anterograde amnesia and decreased discomfort. A combination of an opioid (fentanyl or pethidine) and midazolam improved the patient tolerance and willingness to undergo a repeat procedure and also improved the working conditions for the physician. The British Thoracic Society guideline of 2013 suggested that a combination of an opioid (fentanyl or alfentanil) and midazolam should be considered to improve bronchoscopic tolerance. The American College of Chest Physicians Consensus Statement of 2011 suggested that fentanyl should be preferred; the onset of action and peak effect are rapid, and the effects are of relatively short duration. Emphasis has been placed on safety aspects, such as patient monitoring, the precautions that should be taken in patients with certain conditions, prevention and management of complications, adequate staffing, and optimal sedation and disinfection. In conclusion a combined opioid (fentanyl or pethidine) and midazolam sedation is optimal for diagnostic and therapeutic flexible bronchoscopy in Japanese patients.

The safety and efficacy of alfentanil combined with midazolam in fiberoptic bronchoscopy sedation: A randomized, double-blind, controlled trial.

Sedation is recommended by most guidelines to be offered to all patients undergoing diagnostic flexible bronchoscopy (DFB) without contraindications, and the most commonly reported regimen is midazolam in combination with a short-acting opioid (fentanyl or alfentanil) to provide both sedative and antitussive effects. However, the optimal dose or ideal regimen of the combination therapy with midazolam and opioids has not yet been found. So this randomized, double-blinded clinical trial was designed and registered (ChiCTR2100049052) to assess the safety and efficacy of midazolam combined with different doses of alfentanil in DFB sedation. Our study showed that relative high doses of alfentanil (10-25μg/kg) combined with a fixed low dose of midazolam can markedly reduce hemodynamic fluctuations, cough reactions, patients' discomforts, and improve their satisfaction in a dose-dependent manner during DFB, with no significant increase in the desaturation risks.

Intrabronchial haemorrhage – the bronchoscopist’s nightmare: A case of major haemoptysis due to pulmonary Dieulafoy’s disease

Massive haemoptysis is a term used to describe a large amount of expectorated blood or rapid rate of bleeding (>100 ml blood in 24 h) and is associated with a serious risk of death. However, there is no clear consensus on its definition [1]. In the present we report the case of a 39-year-old male, investigated for haemoptysis, quickly turning bad during diagnostic flexible bronchoscopy due to a rare condition. The congenital abnormality with displaced right upper lobe segmental bronchus and lack of the apical segment bronchus of the right lower lobetogether with the endoscopic narrow-band imaging were the diagnostic clues for the presence of pulmonary Dieulafoy‘s disease and angiographic glue embolization (n-butyl-2-cyanoacrylate) the treatment of choice.

Effect of Bronchoscopist-Directed Sedation and Other Factors on Patient Comfort during Diagnostic Flexible Bronchoscopy.

Background The factors affecting patient comfort during flexible bronchoscopy are not sufficiently addressed in resource-limited countries, and a need to devise strategies to improve patient experience is felt. The present study was undertaken to assess the effect of sedation and other factors on patient comfort during flexible bronchoscopy. Methods A total of 374 patients, aged ≥18 years undergoing flexible bronchoscopy, were enrolled in this prospective, single-center, cross-sectional study. The baseline clinical data of sedation and nonsedation groups were recorded. Anxiety level was assessed using Visual Analog Scale (VAS). Postprocedure VAS score (primary outcome measure) assessed the discomfort related to flexible bronchoscopy. Patient-reported willingness for a repeat procedure and occurrence of adverse events were used as secondary outcome measures. Based on the median of VAS score, the study population was divided into low discomfort and high discomfort groups, and the factors affecting comfort levels in these two groups were noted. Results Postprocedural VAS score (median (Q1, Q3)) for sedation and nonsedation groups was 20 (15, 30) and 25 (20, 40), respectively (<0.001). Willingness for a repeat procedure was significantly more in the sedation group (p=0.002). In the low and high discomfort groups, the preprocedural anxiety level (median (Q1, Q3)) was 20 (10, 25) and 30 (20, 40), respectively (p < 0.001). Conclusion Bronchoscopist-directed sedation significantly reduces patient discomfort and increases their willingness for a repeat procedure. Midazolam-fentanyl combination and lower prebronchoscopy anxiety are associated with lower discomfort levels during flexible bronchoscopy. This study is registered with the Clinical Trial Registry of India (CTRI/2018/11/016328).

Airway nerve block versus nebulization by lignocaine during diagnostic flexible bronchoscopy under moderate sedation: A randomized controlled trial

ABSTRACT Background Flexible bronchoscopy is an important procedure for the diagnosis and management of patients with respiratory diseases. This study aimed to assess safety and effectiveness of local anesthetic nebulization versus airway nerve block for upper airway anesthesia during diagnostic fiberoptic bronchoscopy under moderate sedation. Methods This randomized, controlled trial enrolled 120 patients scheduled for diagnostic fiberoptic procedures. The patients received 5 ml of 10% lignocaine by air-driven jet nebulizer for 20 minutes (Group A, n = 60) or bilateral superior laryngeal nerve block and trans-tracheal instillation of 4 ml of 2% lignocaine along with viscous lignocaine gargles twice (Group B, n = 60). In the postoperative period, the patient tolerance was assessed. Results Both groups were comparable in all baseline characteristics. The pain score was significantly lower in the nerve block group. Cough and requiring lignocaine were significantly more frequent in the nebulization group. No significant differences between the studied groups regarding intraoperative and postoperative PaO2, PaCO2, heart rate and mean blood pressure except heart rate; were significantly higher in the nebulized group. PaO2 reductions at intraoperative and postoperative (compared with induction) were non-significantly higher in the nebulized group. PaCO2, heart rate and mean blood pressure elevations in intraoperative and postoperative (compared with induction) were higher in the nebulized group, and the differences were non-significant in heart rate only. Conclusion Airway nerve block was associated with reduced consumption of lignocaine and less cough episodes during the procedure compared to nebulized lignocaine.

Flexible bronchoscopy for lung cancer diagnosis in patients aged ≥85 years.

Flexible bronchoscopy (FB) is a common modality for the diagnosis of lung cancer. Recently, the number of older patients with lung cancer is increasing, and FB is being utilized more for these patients. FB carried out in patients aged ≥85 years at St. Marianna University Hospital, Kawasaki, Japan, were reviewed. The indication of FB was decided on a case-by-case basis, taking into consideration the condition of the patient, which included mental status and accessibility of the lesion. Outcomes included complications, diagnostic yields, treatment options and survival after FB evaluation. From April 2015 to March 2019, 1604 diagnostic FBs were carried out. A total of 28 were carried out for the diagnosis of lung cancer (19 transbronchial lung biopsy, 9 transbronchial needle aspiration) in patients aged ≥85 years. Although there were three complications reported (pneumonia, fever, asthma exacerbation), they were successfully treated. A total of 19 cases were diagnosed with malignancy; five were treated with stereotactic body radiation therapy, five were prescribed targeted therapy, two underwent surgery and one was treated by cytotoxic monotherapy. Six patients were not included for active treatment. A total of 12 patients who received active treatment for lung cancer reported a 2-year survival rate of >60%. FB for lung cancer diagnosis in patients aged ≥85 years were carried out with acceptable safety and diagnostic yield. Considering the development of less invasive therapeutic measures for lung cancer, FB is safe and valuable in individuals aged ≥85 years suspected of lung cancer with therapeutic indications. Geriatr Gerontol Int 2022; 22: 32-35.

Association between Anxiety, Depressive Symptoms, and Quality of Life in Patients Undergoing Diagnostic Flexible Video Bronchoscopy.

Bronchoscopy is one of the basic invasive procedures in pulmonology accompanied by patients’ anxiety. This study aimed to find an association between predictors of state anxiety/depression and patient’s quality of life (QOL) with pulmonary symptoms undergoing diagnostic flexible video bronchoscopy (FVB). A total of 125 adult patients before FVB were included in a prospective observational study. The quality of life (QOL) was assessed by WHOQOL-BREF questionnaire, the depression possibility by the Beck’s Depression Inventory-II (BDI-II), and the anxiety level by Spielberger’s State-Trait Anxiety Inventory (STAI-S; STAI-T). Results show that the older patients and patients with more comorbidities showed a significantly higher anxiety level. The previous FVB under deep sedation significantly reduced state anxiety. A significantly positive association was found between the STAI score and total BDI-II score. More severe symptoms of anxiety were especially related to lower QOL (physical health, psychological and environmental domains) in patients. Statistically higher trait anxiety in lower social QOL domain scores was observed. Our findings show that high state and trait anxiety were associated with higher depression scores and lower quality of life in the elderly. It seems that the elderly and patients at risk of depression development require more attention in the clinical setting to minimize the anxiety accompanying the bronchoscopy.

Two different methods of lidocaine inhalation before diagnostic flexible bronchoscopy: effects on post-bronchoscopy respiratory symptoms

Use of topical anesthesia before flexible bronchoscopy for the evaluation of the upper airways prevents cough and stridor during and after the procedure while reducing the need for sedation. In practice, lidocaine is the medication of choice before bronchoscopy. There various types of nebulizers used for inhalation treatments. In this study, we compared the respiratory tract symptoms after flexible bronchoscopy between children who received pre-procedure topical lidocaine with mesh or jet nebulizers. We enrolled 4–18 years old subjects that underwent flexible bronchoscopy due to treatment-resistant asthma in this retrospective case-control study. Twenty subjects received topical lidocaine with jet nebulizers while 20 received it with mesh nebulizers. Age, sex, duration of bronchoscopy, duration of anesthesia, time to awaken, and time to recovery were recorded as well as cough and laryngospasm scores after flexible bronchoscopy. Severe cough after flexible bronchoscopy was not encountered in the mesh nebulizers group but was seen in 10% of the jet nebulizers group (p = 0.027). On the other hand, age, sex, duration of bronchoscopy, duration of anesthesia, time to awaken, and time to recovery were not significantly different between the mesh and jet nebulizer groups (p = 0.44, 0.34, 0.51, 0.88, 0.88, and 0.22, respectively). Moreover, croup and laryngospasm scores between the two groups were similar (p = 0.62, 0.50 respectively). Cough score was significantly worse jet nebulizers group (p = 0.03). Topical lidocaine application with mesh nebulizers decreases the most common complication, cough, after flexible bronchoscopy in children more effectively compare to jet nebulizers. Thus, mesh nebulizers may be a faster way of nebulization before flexible bronchoscopy as an alternative to jet nebulizers.

Operative Airway Exposure in an Otolaryngology-Head and Neck Surgery Training Program. A Survey of Current Trainees.

To survey Otolaryngology residents to evaluate their operative airway exposure during their training and to assess if the exposure was adequate to decide whether to pursue fellowship in pediatric. A modified and validated survey was distributed among otolaryngology trainees in the Western region of Kingdom of Saudi Arabia. It assesses operative airway exposure during training, adequacy of experience to decide on whether to pursue fellowship in pediatric otolaryngology, and plan to perform the following six procedures (diagnostic rigid bronchoscopy, diagnostic flexible bronchoscopy, endoscopic airway foreign body removal, rigid esophagoscopy with or without foreign body removal, suspension microlaryngoscopy procedures, open tracheostomy) in practice. Only 24/60 (60%) of respondents perceived that they had adequate training as to whether or not to make them decide to pursue fellowship in pediatric. In regard to over all assessment of the level of exposure: the vast majority of trainees regarded the training as adequate 30/60 (50%), 3/60 (5%) thought it was excellent, 6/60 (10%) thought it was good, and 21/60 (35%)assessed the training adequacy as poor. 24/33 (72.7%) perceived that the presence of a pediatric fellow with them enhanced their training. In regards to performing surgeries after training, 78% were planning to perform rigid bronchoscopy, flexible bronchoscopy (58%), endoscopic airway FB removal (92%), esophagoscopy (54%), suspension microlaryngoscopy (82%), and open tracheostomy (100%). The presence of a pediatric fellow in service was thought of by most residents as being beneficial, however, the exposure to airway surgeries were not adequate as to inform trainees if they want to pursue fellowship in pediatric, when they were not exposed to a fellow.

Role of flexible bronchoscopy in the diagnosis of invasive fungal infections.

There are sparse data on the role of flexible bronchoscopy (FB) in diagnosing invasive mould infections (IMIs). To investigate the safety and usefulness of FB in IMI. We evaluate the factors associated with a successful diagnosis of IMI using FB. Further, we compare subjects of invasive pulmonary aspergillosis (IPA) with pulmonary mucormycosis (PM). We retrospectively reviewed the clinical features, imaging data, bronchoscopy, microbiology and pathology details of subjects who underwent FB for suspected IMI. We categorised FB as diagnostic if it contributed to the diagnosis of IMI. We performed a multivariate analysis to identify the factors associated with a diagnostic bronchoscopy. Of the 3521 FB performed over 18months, 132 (3.7%) were done for suspected IMIs. We included 107 subjects for the final analysis. The risk factors for IMI included renal transplantation (29.0%), diabetes (27.1%), haematological malignancy (10.3%) and others. We found bronchoscopic abnormalities in 33 (30.8%) subjects, and these were more frequent in those with confirmed PM (67%) than IPA (27%). IMI was confirmed in 79 (14 proven, 48 probable and 17 possible) subjects. FB was diagnostic in 71%. We experienced major complications in three cases (2.7%), including one death. On multivariate analysis, the visualisation of endobronchial abnormalities during FB (OR [95%, CI], 8.5 [1.4-50.4]) was the only factor associated with a diagnostic FB after adjusting for age and various risk factors. Flexible bronchoscopy is a useful and safe procedure in diagnosing IMIs. The presence of endobronchial abnormalities predicts a successful diagnostic yield on FB.

Clinical usefulness of intermediate-dose dexmedetomidine (0.75 μg/kg) in flexible bronchoscopy - A prospective, randomized, double-blinded study.

BACKGROUND:Dexmedetomidine, although an effective drug for conscious sedation during flexible bronchoscopy, has occasional side effects on the cardiovascular system which need to be addressed.MATERIALS AND METHODS:Patients between 18 and 65 years, requiring diagnostic flexible bronchoscopy, found eligible, after screening, were randomized to either receive 0.75 μg/kg intravenous dexmedetomidine over 10 min or intravenous midazolam 0.035 mg/kg over 1 min. Composite score was used as the primary outcome measure. Additional parameters recorded were: Hemodynamic variables, oxygen saturation, Ramsay sedation score, for pain intensity and distress Numerical Rating Scale, number of rescue medication doses, ease of doing bronchoscopy, Visual Analog Scale score for cough and response of the patient 24 h after bronchoscopy.RESULTS:In each group, 24 patients were enrolled. The composite score was in the ideal category in 24 patients in dexmedetomidine group and 21 in midazolam group, at nasopharynx (P = 0.234). The corresponding values at the level of trachea were 23 and 16 (P = 0.023). In dexmedetomidine group, patient response after 24 h of bronchoscopy showed quality of sedation to be excellent in 0 subjects, good in 13, fair in 9 and poor in 2 and discomfort to be nil in 7, mild 10, moderate in 7 and severe in 0. The corresponding values in midazolam group for quality of sedation were 0, 4, 14, 6, and for discomfort 0, 10, 14, 0. The Visual Analog Scale (VAS) for cough revealed a mean score of 0.800 and 1.812 (P = 0.011) during and 2.092 and 3.542 (P = 0.016) 24 h after bronchoscopy in the respective study groups.CONCLUSION:Low-dose dexmedetomidine (0.75 μg/kg single dose) appears to provide better patient comfort and equivalent safety profile when compared with midazolam.

Scoping the Problem

Scoping the Problem

The Role of Flexible Bronchoscopy in Swab-negative Patients During the SARS-CoV2 Pandemic.

The Role of Flexible Bronchoscopy in Swab-negative Patients During the SARS-CoV2 Pandemic.

COUGH-INDUCED DIFFUSE BRONCHIAL HEMORRHAGE

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bleeding from the tracheobronchial tree is usually caused by neoplasms, bronchitis, bronchiectasis, mucosal infections, and/or iatrogenic mucosal erosions. We present a rare case of petechial tracheobronchial hemorrhage developing after a severe bout of cough. CASE PRESENTATION: An 81-year-old male with past medical history of Acquired immunodeficiency syndrome (AIDS), combined pulmonary fibrosis and emphysema, pulmonary hypertension, and chronic hypoxemia on supplemental oxygen (3 L/min), presented with gradually worsening dyspnea and non-productive cough over 6 months. Computed tomography (CT) scan of the chest showed a right upper lobe cavitary lesion for which further evaluation with diagnostic flexible fiberoptic bronchoscopy was planned. His home medications included low dose aspirin (81 mg) daily for the primary prevention of cardiovascular disease. He did not have any prior history of hemoptysis or coagulopathy. The patient received aerosolized topical anesthesia with nebulized lidocaine orally prior to bronchoscopy after which he developed a strong coughing fit. Patient was intubated with a laryngeal mask and flexible bronchoscopy was performed under monitored anesthesia care using Propofol. Inspection of the airways incidentally showed numerous mucosal petechiae with oozing of blood in the entire tracheobronchial tree distal to the vocal cords [Figure 1]. Patient was admitted due to worsening hypoxia and hemoptysis post procedure. He had mild hemoptysis for the next two days after which it resolved without any intervention. Broncho alveolar lavage cultures showed Mycobacterium avium intracellulare complex for which he was treated. DISCUSSION: We describe an unusual case of diffuse bronchial hemorrhage that, given the clinical course, developed due to severe coughing fit immediately prior to bronchoscopy. Only a few cases of cough induced diffuse bronchial hemorrhage, also called as the "hemorrhagic bronchial mucosa syndrome", have been previously reported [1-3]. The presence of mucosal petechiae with evidence of bleeding is a characteristic finding and usually improves with conservative management. It has been postulated that high intrathoracic pressures during coughing can increase intravascular pressure resulting in local vessel damage and bleeding [3]. Immunocompromised status due to AIDS, old age, use of aspirin, and pulmonary hypertension may have been additional risk factors predisposing to hemorrhage in this case. CONCLUSIONS: Diffuse bronchial hemorrhage or "hemorrhagic bronchial mucosa syndrome” is a rare complication that can occur during bronchoscopy due to severe coughing and measures to prevent coughing should be considered. Reference #1: Panjwani A. Hemorrhagic bronchial mucosa syndrome. The Egyptian Journal of Internal Medicine. 2015;27(4):151-153. Reference #2: Hira HS. Cough-induced Tracheobronchial Mucosal Bleeding. J Bronchology Interv Pulmonol. 2011;18(1):51-52. Reference #3: Milman N. Diffuse bleeding from the bronchial mucosa on flexible bronchoscopy in lung transplanted patients: 'the hemorrhagic bronchial mucosa syndrome'. Respiration. 2009;77(4):416-419. DISCLOSURES: No relevant relationships by Steven Shaw, source=Web Response No relevant relationships by Abhishek Singla, source=Web Response

High-flow Nasal Oxygen Versus Standard Oxygen During Flexible Bronchoscopy in Lung Transplant Patients: A Randomized Controlled Trial.

Diagnostic and interventional flexible bronchoscopy (FB) is increasingly utilized in complex and high-risk patients. Patients are often sedated for comfort and procedure facilitation and hypoxia is commonly observed in this setting. We hypothesized that high-flow nasal oxygen (HFNO) would reduce the incidence of patients experiencing oxygen desaturation. In this randomized controlled trial, postlung transplant patients booked for FB with transbronchial lung biopsy were assigned to either HFNO or low-flow nasal oxygen (LFNO). The patient and bronchoscopist were blinded to group allocation. The primary endpoint was the proportion of patients experiencing mild desaturation [peripheral oxygen saturation (SpO2)<94%]. Secondary endpoints included desaturation (SpO2<90%), the number of airway interventions required and procedure interruptions, the duration of oxygen desaturation and patient, bronchoscopist and anesthesiologist satisfaction scores. The trial analyzed data from 76 patients (LFNO, n=39; HFNO, n=37). HFNO reduced the proportion of patients experiencing SpO2<94% (43.2% vs. 89.7%, P<0.001) and SpO2<90% (16.2% vs. 69.2%, P<0.001). The FB was interrupted 11 times in 9 patients in the LFNO group, whereas there were no interruptions in the HFNO group. There were no differences in patient and bronchoscopist satisfaction scores between groups, anesthesiologists had higher satisfaction scores when using HFNO (P<0.001). Hypoxia occurred less commonly in postlung transplant patients receiving HFNO during FB. Further studies are warranted in other high-risk populations undergoing longer duration FB.

Comparison of midazolam and low-dose dexmedetomidine in flexible bronchoscopy: A prospective, randomized, double-blinded study.

BACKGROUND:Dexmedetomidine is a clinically useful drug for providing sedation, but concern regarding its cardiovascular side effect profile can limit its widespread use during routine diagnostic flexible bronchoscopy (FB).MATERIALS AND METHODS:Patients between 18 and 65 years of age, who required diagnostic FB, were screened. Eligible patients were randomized to either receive 0.5 μg/kg intravenous dexmedetomidine over 10 min or intravenous midazolam 0.035 mg/kg over 1 min. If required, rescue medication (intravenous midazolam 0.5 mg bolus) was administered. The primary outcome measure was the composite score. Other parameters observed were numerical rating scale, hemodynamic variables, oxygen saturation, number of doses of rescue medication, visual analog scale score for cough, ease of bronchoscopy, Ramsay Sedation Score, and postprocedure patient response after 24 h of bronchoscopy.RESULTS:A total of 54 patients were enrolled, 27 in each group. Total composite score (mean ± standard deviation) in dexmedetomidine and midazolam group at nasopharynx was 7.04 ± 2.19 and 6.59 ± 1.55 (P = 0.387), respectively. The corresponding values at the level of trachea were 9.22 ± 3.69 and 8.63 ± 2.13 (P = 0.475). In the dexmedetomidine group, patient response after 24 h of bronchoscopy showed the quality of sedation to be excellent in three patients, good in 10, fair in 11, and poor in 3 and discomfort to be nil in 14, mild 7, moderate in 3, and severe in 3. The corresponding values in the midazolam group for the quality of sedation were 0, 9, 18, 0 and for discomfort 10, 16, 1, 0. Other parameters did not reveal any statistically significant difference.CONCLUSION:Dexmedetomidine at a dose of 0.5 μg/kg may provide clinically useful conscious sedation, comparable to midazolam.

AN UNSUSPECTING CASE OF CENTRILOBULAR PULMONARY NODULES

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: The incidence of IV drug use continues to rise with a concomitant rise in IV drug related complications. It is not uncommon for this population to inject medicine intended for oral use, which can lead to deposition of foreign material causing granulomas. Adequate tissue sampling with a high index of suspicion are key in forming this diagnosis. CASE PRESENTATION: 41 yo female with Crohn’s disease presents with progressively worsening dyspnea. She has received total parenteral nutrition via a Hickman catheter over the past 9 years since undergoing bowel resection and ileostomy. Prior to her acute presentation she underwent outpatient CT/PET chest imaging demonstrating tiny hypermetabolic bibasilar ground-glass centrilobular nodules. On presentation, blood cultures performed were consistent with poylmicrobial bacteremia with a repeat chest CT now demonstrating diffuse bilateral subsolid micronodules in a centrilobular distribution which had increased in number and size. Diagnostic flexible bronchoscopy was inconclusive and ultimately transbronchial lung cryobiopsy (TBLCB) was performed. Pathology revealed non-necrotizing granulomas with inclusions of talc and other foreign material. After initially denying, the patient did admit to intravenous injection of her oral dilaudid. DISCUSSION: Talc functions as a structural binder in many oral tablets including opioids. Pulmonary talcosis is seen in IV drug abusers who inject drugs intended for oral administration2. The lungs are the first capillaries exposed to intravascularly administered foreign material and thus house the majority of this deposition4. When deposited in tissue, talc induces an inflammatory non-necrotizing granulomatous reaction within the lung interstitium leading to interstitial pulmonary fibrosis and intravascular talcosis within the pulmonary vasculature. Tissue biopsy is required to establish the diagnosis and can be challenging as the tissue sample can miss the area of deposition. TBLCB is a relatively novel technique offering an alternative less invasive diagnostic modality to surgical options. Cryobiopsy specimens increase the sensitivity of conventional transbronchial forceps biopsy techniques through larger and more preserved tissue sampling5. The reporting pathologist in this case made mention that the diagnosis may not have been apparent without this sampling technique. CONCLUSIONS: The management of TALC induced granulomas is not well understood. Accurate diagnosis will allow for further research into treatment options. TBLCB is a relatively new tool in our armamentarium for diagnostic bronchoscopy that can potentially avoid more invasive open surgical diagnostic approaches. Reference #1: Lentz, R. Transbronchial cryobiopsy for diffuse parenchymal lung disease: a state-of-the-art review of procedural techniques, current evidence, and future challenges. Journal of Thoracic disease. 2017 Jul; 9(7): 2186–2203. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542930/ Reference #2: Kazerooni, E. High-resolution CT of the lungs. American Journal of Roentgenology. 2001;177 (3): 501-19. https://www.ajronline.org/doi/full/10.2214/ajr.177.3.1770501 Reference #3: Matrosovich, E. Dyspnea following IV drug use. Respiratory Medicine Case Reports. Volume 20, 2017, pages 192-194. https://www.sciencedirect.com/science/article/pii/S2213007116301770?via%3Dihub DISCLOSURES: No relevant relationships by Mohammad Beizaeipour, source=Web Response No relevant relationships by Ismael Matus, source=Web Response No relevant relationships by Jonathan Norton, source=Web Response No relevant relationships by Haroon Raja, source=Web Response