Interventional Pulmonary Procedures Research Articles

Chinese expert consensus on cone-beam CT-guided diagnosis, localization and treatment for pulmonary nodules.

Cone-beam computed tomography (CBCT) system can provide real-time 3D images and fluoroscopy images of the region of interest during the operation. Some systems can even offer augmented fluoroscopy and puncture guidance. The use of CBCT for interventional pulmonary procedures has grown significantly in recent years, and numerous clinical studies have confirmed the technology's efficacy and safety in the diagnosis, localization, and treatment of pulmonary nodules. In order to optimize and standardize the technical specifications of CBCT and guide its application in clinical practice, the consensus statement has been organized and written in a collaborative effort by the Professional Committee on Interventional Pulmonology of China Association for Promotion of Health Science and Technology.

Interventional pulmonary procedures and their outcomes in patients with STAT3 hyper IgE syndrome

BackgroundSTAT3 hyperimmunoglobulin E syndrome (STAT3-HIES) also referred to as autosomal dominant HIES (AD-HIES) is an inborn error of immunity characterized by the classic triad of eczema, frequent opportunistic infections, and elevated serum IgE levels. As a consequence of lung sequels due to repeated infections and impaired tissue healing, patients may require interventional pulmonary procedures.MethodFour patients with dominant-negative STAT3 mutations who had received interventional pulmonary procedures were enrolled. The demographic, clinical, and molecular characteristics were gathered through a medical record search. All reported STAT3-HIES patients in the literature requiring pulmonary procedures as part of their treatment were reviewed.ResultRecurrent episodes of pneumonia and lung abscess were the most prevalent symptoms. The most common non-immunological features were scoliosis, failure to thrive, and dental problems such as primary teeth retention and disseminated decays. Bronchiectasis, lung abscess, pneumatocele, and cavitary lesion were the most prevalent finding on high-resolution computed tomography at the earliest recording. All patients underwent pulmonary surgery and two of them experienced complications.ConclusionPatients with STAT3-HIES have marked pulmonary infection susceptibility which may necessitate thoracic surgeries. Since surgical procedures involve a high risk of complication, surgical options are recommended to be utilized only in cases of drug resistance or emergencies.

The impact of COVID-19 pandemic on the health services provided by the Cardiothoracic Minia University Hospital in Egypt: A single-center retrospective observational study.

The emergence of the new coronavirus (severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2) in late 2019 resulted in a worldwide pandemic, which had severe consequences on the global health systems. There were drastic strains on the public health services. This, in turn, markedly affected patients with non-coronavirus disease (COVID-19) problems. This study aimed to evaluate the impact of COVID-19 infection on the health services provided to patients at the cardiothoracic university hospital, Minia University. A retrospective analysis of data about services provided to patients at Minia Cardiothoracic University hospital was obtained from pre-pandemic era (2018-2019) and during the pandemic time (2020-2021). The two sets of data were compared together. Data were collected about the number of patients who underwent different procedures such as Pulmonary Function Tests (PFTs), sleep studies or interventional chest procedures (bronchoscopy and thoracoscopy). Also, data were collected about the number of patients admitted in the chest ward, respiratory intensive care unit (ICU) or Coronary care unit and the number of patients who visited cardiothoracic, cardiology or chest outpatient clinics. There is 81.4% reduction in the number of Pulmonary Function Testsperformed during the period 2020-2021 compared with the period 2018-2019, where the number of patients admitted to chest inward decreased by 66.4%. The number of sleep studies performed reduced by 61.5%, while the number of different outpatient clinical visits reduced to similar values (45.8% for cardiothoracic clinic, 45.4% for cardiology clinic and 40.5% for chest clinic). Regarding respiratory ICU admissions, the study reported a reduction of 35.7% and also Coronary care unit admissions decreased by 30.6%. Interventional pulmonary procedures had the lowest reduction rate (0.7%). Different health services were negatively affected by the emergence of COVID-19 era in both pulmonary and non-pulmonary fields.

INITIAL EXPERIENCE WITH INTRAPROCEDURAL ELECTRICAL IMPEDANCE TOMOGRAPHY FOR EVALUATING REGIONAL VENTILATION CHANGES DURING BRONCHOSCOPIC LUNG VOLUME REDUCTION

INITIAL EXPERIENCE WITH INTRAPROCEDURAL ELECTRICAL IMPEDANCE TOMOGRAPHY FOR EVALUATING REGIONAL VENTILATION CHANGES DURING BRONCHOSCOPIC LUNG VOLUME REDUCTION

Nurse Initiative Driven Project Results in Increased Patient Satisfaction Scores

<h3>Introduction</h3> Since acquiring Interventional Pulmonary procedures within the last year, patient satisfaction scores showed consistent opportunities for improvement in discharge preparedness. <h3>Identification of the problem</h3> During Shared Governance discussions, it was determined that electronic medical record discharge instructions did not include procedure specific information. This lead to frustration amongst the staff due to being unable to answer the patient's questions. <h3>QI question/Purpose of the study</h3> The purpose of the study was to increase patient preparedness for discharge, including questions specific to what to do for bleeding, infection, pain, and patient perception of being prepared for recovery/discharge. <h3>Methods</h3> The Post Anesthesia Care Unit nurses collaborated with Endoscopy procedure nurse to develop specific procedure discharge instructions. The discharge instructions were then given to the head of the Interventional Pulmonology department for approval. Once approved, the discharge instructions were uploaded into the EPIC EMR system. A tip sheet was developed on how to attach the new discharge instructions to the patient After Visit Summary as a reference. Additionally, the Endoscopy procedure nurse developed and provided education to the PACU staff to increase understanding of the Interventional Pulmonary procedures. <h3>Outcomes/Results</h3> Patient satisfaction scores in the below categories increased within the three month implementation period: - Prepare for Recovery: 75 percent to 100 percent - Bleeding: 75 percent to 84.2 percent - Pain 58: percent to 100 percent - Infection: 58.3 percent to 88.9 percent Additionally, our post- procedure phone calls and surveys reported less concerns. <h3>Implications for perianesthesia nurses and future research</h3> Our Shared Governance reviews patient satisfaction scores and reports on a regular basis, thus leading to this idea for interdisciplinary collaboration. We are looking to further review other specialties that would benefit from enhanced discharge education for patients.

Rapid On-Site Cytologic Evaluation: A Feasibility Study Using Ancillary Interventional Pulmonary Personnel

Background: Ancillary health professionals helping in a procedural service is a common practice everywhere. Objectives: This was a proof-of-concept study to assess feasibility of using ancillary personnel for rapid on-site cytologic evaluation (ROSE) at interventional pulmonary procedures. Methods: After a training interval, a respiratory therapist (RT) performed ROSE on consecutive interventional pulmonary specimens. Sample sites included lymph nodes, lung, liver, and the left adrenal gland. RT findings were subsequently correlated with blinded cytopathology-performed ROSE and with final histopathology results, with primary foci of adequacy and the presence or absence of malignancy. Results: Seventy consecutive cases involved 163 separate sites for ROSE analysis. Adequacy: There was a high level of concordance between RT-performed ROSE (RT-ROSE) and cytopathology ROSE (CYTO-ROSE). They agreed upon the adequacy of 159 specimens. The Cohen’s κ coefficient ± asymptotic standard error (ASE) was 0.74 ± 0.175, with p < 0.0001. Malignancy: RT-ROSE concurred highly with CYTO-ROSE, with agreement on 150 (92%) of the 163 specimens. Cohen’s κ coefficient ± ASE was 0.83 ± 0.045, with p < 0.0001. When the comparison was for malignancy by case rather than individual site, Cohen’s κ coefficient ± ASE was 0.68 ± 0.08, with p < 0.0001. Conclusion: This study demonstrates that ancillary personnel supporting an interventional pulmonary service can be trained to perform initial ROSE. Cytopathology can be called after sampling and staining have produced adequate samples. This setup streamlines ROSE evaluation with regard to time and cost.

Unfit for a Single Prism: Procedural Education and Career Development Training.

In Reply: We are pleased to learn that Nayahangan and colleagues find our research study titled, “Career Development Training for Interventional Fellows: Are they ready for the workforce?” interesting and we would like to thank them for their comments. Although we are not intimately familiar with the details of interventional pulmonology (IP) training in Denmark, we would be glad to explore with our Danish educator colleagues any future opportunities to meet, exchange ideas, and collaborate for the mutual benefit of our respective trainees in IP. In the United States, formal IP training comprises 12 months dedicated to interventional pulmonary procedures and consultation in a supervised setting.1 This IP fellowship follows at least 3 years of separate fellowship training in general pulmonary and critical care medicine, which is accredited by the Accreditation Council for Graduate Medical Education (ACGME). All IP fellowship training programs are expected to meet consensus-based minimum standards in terms of procedural volumes as well as other metrics.2 Most if not all of this journal’s esteemed readership would likely agree with the points made by Nayahangan and colleagues, and so do we. However, we would like to point out that the subject of our study was altogether different from that of their commentary. Our educational intervention did not comprise clinical or procedural training, nor did we measure clinical or procedural skills to evaluate the impact of our intervention. Rather, our study was focused on career development training of advanced IP fellows. Career development training included topics such as understanding the hiring process, developing a job search strategy, making a business plan, personal branding, research funding, purchasing capital equipment, engaging in mentorship, and pathways to promotion or partnership.3 Nayahangan and colleagues also make valid comments about the pitfalls of using self-assessment instead of other assessment tools and that, “Luckily, a vast selection of such dedicated assessment tools with proven evidence of validity are available in the field of IP.” We would again like to point out that those validated assessment tools of clinical or procedural skills are not relevant to this study. To conclude, the subject of our study was not clinical or procedural competence in IP but rather career development of advanced IP fellows. These are 2 different sets of competencies that must not be viewed from the same prism. Majid Shafiq, MD, MPH* Jason Akulian, MD, MPH† Neeraj Desai, MD‡ Kim French, MHSA‡ Ashutosh Sachdeva, MBBS§ Carla Lamb, MD∥ Samira Shojaee, MD, MPH¶ Angela C. Argento, MD# Hans J. Lee, MD***Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital Harvard Medical School, Boston∥Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA†Division of Pulmonary and Critical Care Medicine, University of North Carolina Chapel Hill, NC‡Chicago Chest Center#Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL§Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine**Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Baltimore, MD¶Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA

Supraglottic airway versus endotracheal tube during interventional pulmonary procedures \u2013 a retrospective study

BackgroundAs the field of interventional pulmonology (IP) expands, anesthesia services are increasingly being utilized when complex procedures of longer duration are performed on sicker patients with high risk co-morbidities and lung pathology. Yet, evidence on the optimal anesthetic management for these patients remains lacking. Our aim was to characterize the airway management and, secondarily anesthetic maintenance patterns used for IP procedures at our institution.MethodsFrom 2894 identified encounters, charts of 783 patients undergoing an IP procedure with general anesthesia over a 5-year period, employing an endotracheal tube (ETT) or a supraglottic airway (SGA) for airway maintenance, were identified and reviewed after exclusions. Patients posted for a concurrent thoracic surgical procedure and those already intubated at presentation were excluded. Baseline patient demographics, procedure, proceduralist type, anesthesia maintenance modality, neuromuscular blocking drug (NMBD) use, and airway management characteristics were extracted and analyzed.ResultsInhaled general anesthesia with an ETT for airway maintenance was most commonly employed; however, SGAs were used in one-third of patients with a very low conversion rate (0.4%), and their use was associated with a significant reduction in NMBD use.ConclusionsIn this large series of patients receiving general anesthesia for IP procedures, inhaled anesthetic agents and ETTs were favored. However, in appropriately selected patients, SGA use was effective for airway maintenance and allowed for a reduction in NMBD use, which may have implications in this patient population who may have an increased risk for pulmonary complications and warrants further investigation.

TIME IS MONEY: OPERATING ROOM VS ENDOSCOPY FOR INTERVENTIONAL PULMONARY PROCEDURES

SESSION TITLE: Interventions to Advance Patient Care SESSION TYPE: Original Investigations PRESENTED ON: 10/08/2018 04:30 pm - 05:30 pm PURPOSE: Interventional pulmonary (IP) procedures are fast becoming more accessible and a cornerstone in the management of multiple pulmonary diseases. They can be performed in the operating room (OR) vs Endoscopy suite (ES) depending on the center and availability. To our knowledge, there is no data comparing the delay in initiating the procedure between the 2 locations. We present a single center retrospective analysis comparing the time delay from scheduled procedure time in the OR vs the ES using the same staff. METHODS: A single center retrospective study at a major metropolitan hospital with expertise in IP was performed for a time duration of 11 weeks in each location. The same nursing staff were used to process and transport the patient in the OR and the ES. A two-sided Mann-Whitney test with a 0.05 significance level was used to compare the mean delay times at the 2 locations. Time delayed was calculated as the difference between the scheduled procedure time to the start time. Start time was defined as the time of insertion of a bronchoscope or a needle for pleural procedures. RESULTS: Between 9/8/2017 and 11/21/2017 a total of 74 IP procedures were performed in ES and between 11/28/2017 and 2/13/2018 a total of 72 IP procedures were performed in the OR. Linear EBUS with a transbronchial needle aspiration was the most common procedure in the ES (45%) and the OR (50%). The median delay time in the O.R. was significantly larger compared to the median delay time in the ES (median=60min vs. 40min, respectively; p=0.02, using a two-sided Mann-Whitney test). The most common reason for delay in ES was patient processing (49.2%) while it was room turnover (54.6%) in the OR. CONCLUSIONS: The time delayed was significantly less in the ES in comparison to the OR at our hospital by a mean of 20mins. Increased utilization of the OR time due to this delay invariably leads to more utilization of resources and increases cost in comparison to the ES. We hope that our experience can help those institutions setting up an IP program and are debating where to perform their procedures. Being a retrospective study there is an inherent selection bias which acts as one of the limitations of the study. More studies are needed to confirm our results. Another limitation is that the results are based on the interior design and architecture of our ES and OR. Other institutions may have different results based on their interior design. CLINICAL IMPLICATIONS: Our study can help future programs in determining a location for performing their procedures. Performing these procedures in the ES can potentially be faster and save valuable resources and money. DISCLOSURES: No relevant relationships by Erica Altschul, source=Web Response No relevant relationships by Habtamu Belete, source=Web Response No relevant relationships by Khalid Gafoor, source=Web Response No relevant relationships by Bryan Husta, source=Web Response No relevant relationships by Maly Oron, source=Web Response No relevant relationships by Shalin Patel, source=Web Response No relevant relationships by Varun Shah, source=Web Response

Anesthesia for interventional pulmonology procedures: a review of advanced diagnostic and therapeutic bronchoscopy.

Interventional pulmonology is a growing subspecialty of pulmonary medicine with flexible and rigid bronchoscopies increasingly used by interventional pulmonologists for advanced diagnostic and therapeutic purposes. This review discusses different technical aspects of anesthesia for interventional pulmonary procedures with an emphasis placed on pharmacologic combinations, airway management, ventilation techniques, and common complications. Relevant medical literature was identified by searching the PubMed and Google Scholar databases for publications on different anesthesia topics applicable to interventional pulmonary procedures. Cited literature included case reports, original research articles, review articles, meta-analyses, guidelines, and official society statements. Interventional pulmonology is a rapidly growing area of medicine. Anesthesiologists need to be familiar with different considerations required for every procedure, particularly as airway access is a shared responsibility with pulmonologists. Depending on the individual case characteristics, a different selection of airway method, ventilation mode, and pharmacologic combination may be required. Most commonly, airways are managed with supraglottic devices or endotracheal tubes. Nevertheless, patients with central airway obstruction or tracheal stenosis may require rigid bronchoscopy and jet ventilation. Although anesthetic approaches may vary depending on factors such as the length, complexity, and acuity of the procedure, the majority of patients are anesthetized using a total intravenous anesthetic technique. It is fundamental for the anesthesia provider to be updated on interventional pulmonology procedures in this rapidly growing area of medicine.

True Negative Predictive Value of Preoperative Staging Endosonography by Combined Endobronchial Ultrasound and Endoscopic Ultrasound in Non-Small Cell Lung Cancer

SESSION TITLE: Interventional Pulmonary Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: Complete endosonographic mediastinal staging modalities have become a new standard in the pre-operative staging of non-small cell lung cancer in some centers. This study was performed to understand the value of mediastinal lymph node (LN) sampling and dissection at time of pulmonary resection in the setting of a negative pre-operative staging endosonography by combined EBUS & EUS. METHODS: This study consisted of a retrospective, single-institution, tertiary care referral center review of a prospectively maintained database between January 2009 and December 2014. Two hundred and thirty-two consecutive patients with non-small cell lung cancer with negative results on lymph node staging by combined endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) fine needle aspiration (FNA) that subsequently underwent pulmonary resection or attempt at pulmonary resection were included. The endosonographic results were compared with the final pathological staging utilizing final pathology results of lymph nodes sampled during surgery. Chi-Square test was used for statistical analysis. A p-value of <0.05 was considered statistically significant. RESULTS: Twenty-five out of 232 patients with negative results on LN staging by combined EBUS / EUS - FNA had metastases in LNs sampled during pulmonary resection. 10 patients had N1 disease and 15 patients had N2 disease. The negative predictive value (NPV) of EBUS/EUS was 89.2% (p<0.01). Twenty-one out of these 25 patients who had surgical LN sampling at resection did not have the same station sampled pre-operatively by EBUS/ EUS. Therefore a direct comparison at surgical resection could not be made on these 21 patients. Eleven out of these 21 patients had Station 5 and Station 6 involvement and these stations are routinely difficult to sample using endoscopic modalities. If these 21 patients are omitted for comparison, only 4 out of 232 patients had false negative results by EBUS / EUS - FNA giving a true negative predictive value of 98.3% (p<0.01). 3 out of these 4 patients had N2 disease (Station 4L, 5 and 7) and 1 patient had N1 (Station 11R) disease detected at Pulmonary resection. CONCLUSIONS: Staging endosonography by combined EBUS & EUS in potentially resectable patients is associated with a high NPV. If pre-operative results of biopsy of a particular LN station by EBUS/EUS-FNA are negative, then sampling of the same station at surgery can potentially be omitted. LN stations not sampled by endosonography should be sampled at surgery. CLINICAL IMPLICATIONS: Can potentially change the practice and the way lymph node station sampling and dissection is done during pulmonary resection. This may reduce the operative time and avoid unnecessary dissection of the lymph nodes already biopsied at pre operative staging procedure. DISCLOSURE: The following authors have nothing to disclose: Pravachan Hegde, Vicky Thiffault, Vipul Jain, Akshatha Gowda, Pasquale Ferraro, Moishe Liberman No Product/Research Disclosure Information

Safety and Utility of Bronchoscopy in the Very Elderly

SESSION TITLE: Interventional Pulmonary Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: To evaluate if flexible bronchoscopy (FB) in the very elderly provides clinically useful information that affects treatment decisions with an acceptable risk profile. There are several studies evaluating the safety and utility of bronchoscopy in the elderly, but this study describes the oldest population studied to date. METHODS: All bronchoscopies performed in the San Antonio Military Health System over a five year period were reviewed and all patients aged over 85 years old with bronchoscopies performed outside of the ICU were included. A control group of patients aged 65-79 with bronchoscopies performed during the same time period was collected. Procedural data was collected from the electronic medical record including, age at time of procedure, type of bronchoscopy, sampling techniques, medication doses, complications, diagnostic yield, and subsequent treatment. Variables were analyzed with a student’s t-test or a fisher’s exact test. RESULTS: 73 bronchoscopies were performed in the study group, with a mean age of 87.1 (85-96 y). The patient complication rate in the study group was similar to the control group, 9.6% vs 8.2%, p > 0.99. Hypoxia occurred in 5 patients, 3 post procedure ICU transfers, 2 deaths within 30 days, and 1 each of pneumothorax, intubation, bipap use. There were no instances of oversedation requiring reversal agents and no deaths within 72 hours of procedure. Evaluation for malignancy was the most common indication for bronchoscopy(68% vs 59%, p = 0.3) and the most common finding (48% vs 38%, p = 0.24). The study group had statistically significant differences from the control group in the following categories: higher mean age(p < 0.001), higher ASA class(p = 0.03), lower mean midazolam dose (2mg vs 2.6 mg, p = 0.004), and fewer cancer patients who underwent lobectomy (0% vs 5%, p = 0.03). There were no statistically significant differences in the indications for bronchoscopy (p = 0.15), patients undergoing transbronchial biopsy (29% vs 25%, p = 0.7), the diagnostic yield (44% vs 33%, p = 0.17), or the number of patients diagnosed with cancer who received any form of cancer therapy (66% vs 70%, p = 0.79). CONCLUSIONS: This is the oldest cohort of patients undergoing FB studied for procedural complications and diagnostic yield. Despite the fact that the study group was older with a higher average ASA class, the results suggest that bronchoscopy is has essentially the same safety profile for the very elderly. Additionally, it suggests the information obtained from bronchoscopy is utilized in guiding therapy and age does not prevent patients from receiving therapy for malignancy. The lower rate of lobectomies in the study group may reflect poorer functional status and inability to tolerate surgical intervention, or it may be a result of higher TNM stage at time of diagnosis. CLINICAL IMPLICATIONS: These results demonstrate FB in the very elderly has a similar complication rate and diagnostic yield when compared to a younger population, and that malignancy is treated at the same frequency in the very elderly as a younger population. This suggests FB is a safe and efficacious procedure in the very elderly. DISCLOSURE: The following authors have nothing to disclose: Cameron Mclaughlin, Ellis Easterling, Andrew Skabelund No Product/Research Disclosure Information

A Comparison of Specimen Size and Diagnostic Performance of 19G vs 22G EBUS-TBNA Needles: A Preclinical Study

SESSION TITLE: Interventional Pulmonary Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: The 21G and 22G EBUS-TBNA needles are limited in the amount of tissue that they can provide for extended molecular and histopathological analysis. Recently, a new 19G ViziShot FLEX needle (Olympus Respiratory America, Redmond, WA) became available, but to date comparative data has been limited. We compared the specimen size and diagnostic performance of the new 19G needle to that of the ViziShot 22G (Olympus, Tokyo, Japan) needle in a swine model of granulomatous lymphadenopathy. METHODS: The mediastinal lymph nodes of 10 domestic swine were measured prior to the injection of a talc slurry that, over time, induced granulomatous inflammation. After maturation, affected LNs were re-measured and sampled with the 19G and 22G needles by three clinicians experienced in EBUS-TBNA using a standardized sampling technique. Each sample was weighed and photographed prior to histopathological processing. The study animals were subsequently euthanized and the LNs were preserved. Tissue core area was determined by quantifying sample area using image analysis software (ImageJ, NIH, Bethesda, MD). Volume was estimated using sample area and known needle measurements. A pathologist, blinded to the type of needle used, provided a numerical Biopsy Core Morphology Grade (BCMG) assessing sample quality and a Biopsy Diagnostic Correlation Grade (BDCG) comparing the needle samples to the corresponding LN specimens. RESULTS: A total of 132 paired samples were collected from 38 LNs (2R, 4R, 4L and 7). There was a significant increase in the average LN size from a baseline of 11.6±3.2 to 15.2±3.8mm; p<0.001. The average mass of the TBNA samples collected by the 19G was higher than that of samples collected by the 22G needle, 33.78±47.48 vs. 25.18±32.08 mg, (p <0.002). The calculated core tissue volume collected by the 19G was higher than that of the samples collected by the 22G needle, 11.40±13.91 vs. 6.91±6.42 mm3, (p <0.0004). The pooled needle biopsy samples for the 19G and the 22G needles had similar BCMG (19G 1.38±0.86 vs 22G 1.43±0.87, p>0.2) and BDCG grades (19G 1.54±0.93 vs 22G 1.57±0.93, p>0.2). The samples collected by the 19G needle demonstrated a trend towards more frequent identification of granuloma (46% vs. 32% of specimens, p=0.06) but also contained more cartilage (4.81±16.49% vs. 0.49±1.46%, p<0.003). There was a tendency for the 22G needle to collect more blood (p=0.057). No procedure-related complicatons were detected. CONCLUSIONS: In the hands of experienced clinicians, the 19G and the 22G EBUS-TBNA needles had similar diagnostic yields in the swine model of granulomatous lymphadenopathy. However, the samples collected by the 19G were larger with potentially less blood contamination and a trend towards a higher detection rate of granulomatous inflammation than the samples collected by the 22G needle. CLINICAL IMPLICATIONS: Larger diameter needles may be advantageous for EBUS-TBNA, provided they do not increase procedural risk and/or blood contamination of the sample. DISCLOSURE: Kasia Czarnecka-Kujwa: Consultant fee, speaker bureau, advisory committee, etc.: I have received a consulting honorarium from the Olympus America Anna Sczaniecka: Employee: Employee of Spiration d/b/a Olympus Respiratory America Sujeeth Parthiban: Employee: Employee of Spiration d/b/a Olympus Respiratory America David Dillard: Employee: Employee of Spiration d/b/a Olympus Respiratory America Xavier Gonzalez: Employee: Spiration d/b/a Olympus Respiratory America Alain Tremblay: Consultant fee, speaker bureau, advisory committee, etc.: Received a consulting honorarium from Spiration d/b/a Olympus Respiratory America Kazuhiro Yasufuku: Consultant fee, speaker bureau, advisory committee, etc.: Received a consulting honorarium from Spiration d/b/a Olympus Respiratory America No Product/Research Disclosure Information

Management of anticoagulant and antiplatelet therapy in patients undergoing interventional pulmonary procedures

There has been great progress in antithrombotic therapy over the past several years. Its use has increased with the advent of novel anticoagulants, as these medications do not require frequent blood tests for monitoring. Antithrombotic therapy is aimed at reducing the risk of thromboembolic events in patients with atrial fibrillation, coronary artery disease, deep vein thrombosis, valvular heart disease and pulmonary embolism. These patients are often critically ill and frequently undergo urgent interventions requiring discontinuation of anticoagulant or antiplatelet therapy which can increase the risk of thrombosis; however, continuing these agents can lead to increased risk of haemorrhage.The purpose of this article is to summarise the literature surrounding the safety of using antiplatelet and anticoagulant therapies in patients undergoing interventional pulmonary procedures.

General Management Principles of the Pregnant Woman

Pregnancy is a dynamic process that consists of profound physiological changes mediated by hormonal, mechanical, and circulatory pathways. Understanding of changes in physiology is essential for distinguishing abnormal and normal signs and symptoms in a pregnant patient. These physiological changes also have important pharmacotherapeutic considerations for a pregnant patient. Although there are limited data to guide decisions regarding medications and diagnostic procedures in pregnancy, a careful review of risks should be balanced with review of risk of withholding a medication or procedure. Interventional pulmonary procedures can be safely performed in pregnant women while keeping in mind the maternal anatomic and physiologic changes. Furthermore, management of a maternal cardiopulmonary arrest requires important modifications in patient positioning and intravenous access to ensure adequate efficacy of chest compressions, circulation, and airway management. This review will provide an overview of maternal physiologic changes with a focus on cardiopulmonary physiology, pharmacotherapeutic considerations, diagnostic and interventional pulmonary procedures during pregnancy, and cardiopulmonary resuscitation in pregnancy.

Stenting of critical tracheal stenosis with adjuvant cardio-pulmonary bypass.

Severe and critical central airway obstruction causing impaired ventilation and/or oxygenation can impose tremendous challenges on the interventional pulmonologist. Near total airway obstruction can rapidly evolve into potentially fatal complete airway occlusion during bronchoscopic airway manipulation under moderate sedation; as well as during the induction of the general anesthesia. Although there are currently interventional pulmonary procedures available to tackle the critical airway obstruction in extreme situations, cardio-pulmonary bypass should be considered prior to the intervention to maintain the adequate gas exchange during the procedure. Orotracheal intubation with mechanical ventilation in this situation can be fatal itself if the obstructing airway lesion functions as a “one way valve” allowing air to follow distally during inspiration but impeding expiratory flow leading to gas trapping, high intrathoracic pressure, tension pneumothorax, and ultimately a cardiac arrest.

Palliative interventional pulmonology procedures in the incarcerated population with cancer: a case series.

Cancer is the second most common cause of death in incarcerated population and lung cancer is the most common cause of cancer death in this group. Inmates are excluded from most published surveys and research,thus the effectiveness of lung cancer palliation in this population is not known. To report the feasibility and safety of palliative interventional pulmonary procedures in inmates with cancer. Retrospective review of registry data from a single center. Inmate data on prospectively enrolled data registry (2009–2012) from the interventional pulmonology procedural registry at Virginia Commonwealth University was extracted and analyzed for safety and efficacy. Inmates with lung cancer and advanced malignancies with pleural or airway metastasis requiring airway debulking (mechanical/thermal), airway stenting, and tunneled pleural catheter (TPC) placement were included in the analysis. A total of 16 procedures were performed in 12 incarcerated patients. These included six TPC placements in six patients. Ten procedures were performed in seven patients with airway obstruction. These procedures included rigid and flexible bronchoscopy with mechanical (rigid and balloon dilation) and thermal (laser, argon plasma coagulation, and cautery) tumor debulking and dilation,airway stenting, and tracheostomy in one case. All six TPCpatients had immediate symptomatic relief and improved lung aeration on chest radiograph. Three of six patients had successful auto-pleurodesis. In the seven patients with airway obstruction, three patients reported symptomatic relief and one had resolution of post-obstructive pneumonia. No immediate- or long-term procedure-related complications were reported. Incarcerated patients with advanced malignancy may benefit from interventional pulmonology procedures with low complications. Palliative interventional pulmonology procedures in inmates should not be withheld solely on their incarceration status.

Procedural Volume and Structure of Interventional Pulmonary Fellowships: A Survey of Fellows and Fellowship Program Directors

Current interventional pulmonary (IP) procedural guidelines for competency are based on expert opinion. There are few objective data to support competency metrics for IP procedures. This survey reports procedural volume during IP fellowships to help define new standards in training and curriculum development. A web-based survey was developed to evaluate IP training procedural volume. The survey was administered to all US and Canadian IP fellowship directors and graduates in training from 2006 to 2011. The survey inquired about all diagnostic and therapeutic procedures performed during the specialized year of IP training. Questions regarding the training program structure were collected and analyzed. There was a 92.5% fellow response rate (37 of 40) and 77% fellowship director response rate (10 of 13) from programs in existence at the time of the survey. Procedural volume was consistent between fellowship directors and graduates (P = .64). Although there was a wide range of procedural volume and types of procedures between different programs, the procedural mean volumes were all significantly higher than the American College of Chest Physicians (ACCP) and American Thoracic Society/European Respiratory Society (ATS/ERS) guideline recommendations (P &lt; .005). US and Canadian IP fellowships produce fellows with variable procedural volumes; however, these are significantly higher than ACCP and ATS/ERS guidelines for most programs and procedures. With a uniform training curriculum being adopted by the majority of IP fellowship programs in the United States and Canada, as well as data showing improved core knowledge in IP fellows undergoing a dedicated year of additional training, further metrics examining the impact of advanced IP training on patient outcomes are needed.

Anesthetic considerations for interventional pulmonary procedures

To discuss the anesthetic considerations of various procedures now performed by the interventional pulmonologist. With recent technological advances, many of these procedures represent acceptable alternatives to the invasive surgical procedures. For example, the placement of endobronchial valves can substitute for lung reduction surgery and can greatly reduce the postoperative recovery period. However, many of these complex procedures require anesthesia services. The nature and indication for the procedure as well as the patient's overall health will have an impact on the anesthetic choice. New studies have documented common complications from interventional pulmonology procedures and recent ways to avoid these complications have been suggested. Strategies to avoid obstruction, bleeding, pneumothorax and air embolism are discussed in this article. Potential benefits of high frequency jet ventilation in reducing airway pressures and, perhaps, barotraumas are cited. Novel interventional pulmonary procedures are described. As the array of diagnostic and therapeutic pulmonary interventions is expanding, the types of anesthetic techniques and ventilatory modes are varying to fit the procedural requirements. Some pulmonary procedures are best accomplished in the lightly sedated patient, who is breathing spontaneously, whereas procedures that use the working channel of a rigid bronchoscope are better performed in the patient under general anesthesia and mechanical ventilation that often use jet ventilation to minimize respiratory movements.

Bronchoscopy induced pulmonary interventional procedures in pediatrics:training experience in Taipei Veterans General Hospital Taiwan, China

Interventional pulmonary procedures performed by flexible bronchoscopy has been widely used in the adult clinics.However,pediatric interventional pulmonary procedures are different from adult in anesthesia methods,equipment,technology and so on.At present.it is more limited.This review showed the experiences of pediatric bronchoscopy in Taipei Veterans General Hospital of Taiwan,China. Key words: Bronchoscopy ; Interventional General pulmonology procedures; Children