Interventional Pulmonology Procedures Research Articles

Radiation Principles, Protection and Reporting for Interventional Pulmonology.

The use and availability of diverse advanced X-ray based imaging and guidance systems in the field of interventional pulmonology is rapidly growing. This popularity links inextricably to an increase in ionizing radiation use. Knowing ionizing radiation is hazardous, knowledge and competent use of X-ray imaging and guidance systems are important. The globally implemented As Low As Reasonably Achievable (ALARA) principle demands careful attention to minimizing radiation exposure while achieving the precise goals of the intervention and imaging therein. To allow careful and targeted weighing of risk against reward while using X-ray based equipment, proper background knowledge of physics as well as imaging system aspects are needed. This white paper summarizes the principles of ionizing radiation which are crucial to enhance awareness and interpretation of dosimetric quantities. Consecutively, a consensus on standards for reporting radiation exposure in interventional pulmonology procedures is indicated to facilitate comparisons between different systems, approaches and results. Last but not least, it provides a list of practical measures, considerations and tips to optimize procedural imaging as well as reduce radiation dose to patients and staff.

Our Clinical Experience With Patients Requiring Intensive Care for Tracheal Stenosis: A Retrospective Case-Control Study.

Background and objective The clinical course in patients with tracheal stenosis (TS) ranges from being asymptomatic to respiratory failure requiring follow-up in the ICU. In this study, we aimed to assess the clinical characteristics, management,and outcome of TS patients who were admitted to the ICU. Materials and methods The data of patients hospitalized in the ICU due to TS between January 01, 2015, and January 01, 2016, were analyzed. The patients were classified into two groups: the post-intubation tracheal stenosis (PITS) group and the post-tracheostomy tracheal stenosis (PTTS) group. Demographic characteristics, body mass index (BMI), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the Sequential Organ Failure Assessment (SOFA)score of patients, factors that caused TS, management of TS, and ICU data of patients were compared. The outcome measures of our study were the ICU management of patients diagnosed with PITS or PTTS,their clinical characteristics, and differences in the treatment between patients diagnosed with PITS and those with PTTS in the ICU. Results Fifteen (75%) patients had PITS and five (25%)had PTTS. While BMI was significantly lower in patients in the PTTS group, the APACHE IIand SOFAscores were significantly higherin PTTS patients (p<0.05). In most of the patients in the PITS group, the location of the stenosis was subglottic and at the 1/3 upper part of the trachea, while in the PTTS group, it was located only at the upper 1/3 of the trachea (p>0.05).Mechanical dilatation was performed in all patients in both groups. Mechanical dilatation and cryotherapy were performed in 10 (66.7%) patients in the PITS group (p>0.05), and a stent was applied in addition to this treatment in three (20%) patients in the PITS group and four (80%) patients in the PTTS group (p<0.05). Mechanical ventilation was not needed in 10 (66.7%) PITS patients and three (60.0%) PTTS patients after the interventional procedure.All patients were eventually discharged from the ICU after treatment. Conclusion While higher BMI was common in PITS patients, the PTTS patients were generally in worse condition. In this patient group, interventional pulmonology procedures in the ICU can be life-saving.

Interventional Pulmonology Productivity, Compensation, and Practice Benchmarks: The AABIP 2022 Report.

Interventional pulmonology (IP) is a growing field that has not yet been recognized by the American Board of Medical Specialties or incorporated into national benchmark organizations. As a result, there is a lack of data on IP practice patterns, physicians' compensation and productivity targets. We sent an anonymous survey to 647 current or past physician members of the AABIP. Domains included demographics, training background, academic rank, practice settings, work relative value unit (wRVU) targets, salary, and career satisfaction. The response rate to the survey was 28.3%; 17.8% were female. The median salary for IP faculty in academic institutions was $320,000 for assistant professors, $338,000 for associate professors, and $350,000 for full professors. Salaries were lower for women than for men in academic practice, even after adjusting for the number of years in practice (mean salary difference after adjustment $57,175, 95% CI: $19,585-$94,764, P=0.003). The median salary for private practice was higher at $428,000. Among respondents that used wRVU targets, the median targets for academic and private practice were 5500 and 6300, respectively. The majority of IP physicians are satisfied with their career choice. Productivity targets in IP are used less than half the time, and when they are used, they are set in line with the lower wRVU of IP procedures. IP compensation is higher than that of general pulmonary medicine, as reported by national benchmark associations. In academic practices, gender differences in salaries were found.

The Feasibility of Interventional Pulmonology Methods for Detecting the T790M Mutation after the First or Second-Generation EGFR-TKI Resistance of Non-Small Cell Lung Cancer

The development of third-generation epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) targeting T790M-mutant non-small cell lung cancer (NSCLC) has raised the importance of re-biopsy after EGFR-TKI failure. This study aimed to investigate the feasibility of interventional pulmonology (IP) procedures as re-biopsy methods for identifying the T790M mutation in EGFR-TKI-resistant patients. One hundred and thirty-nine NSCLC patients who underwent IP procedures for re-biopsy as their initial investigation after EGFR-TKI treatment failure were enrolled in this study between January 2020 and August 2022. All patients underwent a first re-biopsy with IP methods, with a diagnostic yield of 81.2% and T790M mutation detection rate of 36%. Thirty patients underwent a second re-biopsy; IP methods were used for 17 (56.6%) patients and non-IP methods for 13 (43.4%) patients; the T790M mutation detection rate was 36.4%. Only six patients underwent a third re-biopsy; no T790M mutation was noted. The T790M mutation detection rate did not differ between IP and non-IP methods (33.6 % vs. 37.5%, p = 0.762). In 11 cases (7.5%), a re-biopsy revealed histologic transformation from lung adenocarcinoma. IP procedures, as first-line re-biopsy methods for NSCLC, are feasible and provide sufficient tissue for identification of the resistance mechanism and target gene T790M mutation.

Anesthesia management and challenges during interventional pulmonology procedures for central airway obstructions

Aim: Central airway obstructions (CAO) are one of the main reasons for morbidity and mortality, often originate in the lungs, and are generally unresectable. Interventional airway procedure is a preferred method in these cases. This study aimed to analyze anesthesia management in patients undergoing interventional procedures for CAO. We aimed to highlight the problem and solutions that may be encountered in such cases.&#x0D; Material and Method: The data of 49 patients who had interventional airway procedure were analyzed retrospectively. Patients’ demographic data, type of interventional procedures, localization of the lesion, and duration of the procedure were analyzed. Vital parameters and arterial blood gases (ABG) levels had been recorded before anesthesia induction (T1), after rigid bronchoscope insertion (T2), 20th-minute of the procedure (T3), after extubation (T4), and in the postoperative care unit (T5).&#x0D; Results: The mean age was 57.90±11.99 years. The mean duration of the procedure was 34.75±15.62 minutes. The majority of the patients had American Society of Anesthesiologists (ASA) III-IV physical status. CAOs were mostly found in the main bronchus. Tumors debulking, biopsy, mechanical dilatation, argon plasma coagulation, and mechanical tumor resection were the most performed procedures. Stent insertion was performed in 3 (6.1%) patients. Two patients (4.1%) had bleeding, 3 (6.1%) patients had desaturation, and 1 (2.1%) patient had atrial fibrillation.&#x0D; Conclusion: Interventional airway procedures are frequently used for high risk patients with CAO and comorbidities. Detailed preoperative evaluation, periprocedural teamwork, and close hemodynamic and ABG follow-up are keys to success.

A case series of interventional pulmonology in the era of coronavirus disease 2019

Abstract The coronavirus disease 2019 (COVID-19) pandemic is still ongoing, and respirology associations globally are updating and releasing guidelines to provide appropriate care for health care workers and patients. The virus can become airborne if aerosol-generating procedures (AGPs) are performed. Interventional pulmonology procedures were performed on 63 patients within the period of March–May 2020. During this pandemic, personnel involved per procedure is limited, personal protective equipment level 3 is utilized in AGPs, and level 2 personal protective equipment is used in non-AGPs. The majority of patients were male (54%) and were aged 30–49 years (35%). Bronchoscopy was the most frequent procedure performed (62%). The most common pulmonary conditions in these patients were pneumonia, pleural effusion, and lung mass/consolidation (all 24%). There were seven (11%) patients diagnosed as having probable COVID-19. Interventional pulmonology procedures can still be performed in the era of COVID-19 pandemic.

Interventional pulmonology during COVID times: A look back at the year gone by.

Background:The COVID-19 pandemic has created an unprecedented crisis, affecting every sphere of human life. A major challenge for health care workers (HCWs) is to care for patients with a highly contagious airborne disease, while making sure of their own safety. Interventional pulmonology (IP) procedures, like bronchoscopy, are particularly risky due to significant aerosol generation. Guidelines by several scientific bodies were framed on the precautions to be taken while performing IP procedures. We evaluated the IP procedures performed during the COVID-19 pandemic, and whether the precautions adopted proved adequate in preventing transmission amongst the HCWs involved in these procedures.Method:We performed a retrospective analysis of all patients who underwent IP procedures between March 2020 and November 2020, at a tertiary cancer hospital. We also evaluated the proportion of HCWs, who were involved in these procedures, and were affected by COVID-19, through their health care records.Results:We performed a total of 506 IP procedures. Two of the 18 HCWs, working in that unit, suffered from COVID-19 and recovered after a mild illness. Three HCWs were isolated with suspected infection but proved to be negative. The procedures in our IP unit were uninterrupted for the entire duration of the study period.Conclusion:IP procedures can be safely performed even in the presence of a highly contagious viral pandemic with adequate precautions.

Equipment and procedural setup for interventional pulmonology procedures in the intensive care unit

Procedural setup is an important aspect of any procedure. Interventional pulmonologists provide a procedural practice and have additional expertise in performing high-risk procedures needed in the critically ill patients in intensive care. Taking the time to plan the procedure setup in advance and having all necessary equipment readily available at the patient’s bedside is imperative for procedural services. This is especially essential to ensure patient safety, minimize risk of complications, and improve success for specialized procedures performed by interventional pulmonary in the intensive care unit. In this review we describe the equipment and procedural setup ideal for both pleural and airway procedures. These include flexible diagnostic and therapeutic bronchoscopy, ultrasound guided thoracentesis, chest tube insertion, difficult airway management, and bedside percutaneous dilatation tracheostomy. We provide a guide checklist for these procedures emphasizing the practical aspects of each procedure from selecting the appropriate size endotracheal tube to operator positioning to ensure efficiency and best access. The components of procedural setup are discussed in relation to patient factors that include patient positioning and anesthesia, personnel in the procedure team and the equipment itself. We further briefly describe the additional equipment needed for specialized techniques in therapeutic bronchoscopy used by interventional pulmonologists.

Ultrasound use in the ICU for interventional pulmonology procedures.

Critical care ultrasound has shifted the paradigm of thoracic imaging by enabling the treating physician to acquire and interpret images essential for clinical decision-making, at the bedside, in real-time. Once considered impossible, lung ultrasound based on interpretation of artifacts along with true images, has gained momentum during the last decade, as an integral part of rapid evaluation algorithms for acute respiratory failure, shock and cardiac arrest. Procedural ultrasound image guidance is a standard of care for both common bedside procedures, and advanced procedures within interventional pulmonologist’s (IP’s) scope of practice. From IP’s perspective, the lung, pleural, and chest wall ultrasound expertise is a prerequisite for mastery in pleural drainage techniques and transthoracic biopsies. Another ultrasound application of interest to the IP in the intensive care unit (ICU) setting is during percutaneous dilatational tracheostomy (PDT). As ICU demographics shift towards older and sicker patients, the indications for closed pleural drainage procedures, bedside transthoracic biopsies, and percutaneous dilatational tracheostomies have dramatically increased. Although ultrasound expertise is considered an essential IP operator skill there is no validated curriculum developed to address this component. Further, there is a need for developing an educational tool that matches up with the curriculum and could be integrated real-time with ultrasound-guided procedures.

Updates and controversies in anesthesia for advanced interventional pulmonology procedures.

Advanced bronchoscopic procedures continues to grow, and are now commonly used to diagnose and/or treat a variety of pulmonary conditions that required formal thoracic surgery in past decades. Pharmacologic developments have provided new therapeutic options, as have technical advances in both anesthesia and interventional pulmonology. This review discusses technical and clinical issues and advances in providing anesthesia for advanced bronchoscopic procedures. It also discusses some controversial issues that have yet to be fully resolved. We discuss anesthetic considerations for new procedures such as the new technology used in electromagnetic navigation bronchoscopy, and bronchoscopic cryotherapy. We also review new ventilation strategies as well as pharmacologic advances and recent trends in the utilization of anesthetic adjuvants, and the use of short-acting opioids like remifentanil, and alpha agonist sedatives such as dexmedetomidine. The anesthetic framework and the discussions presented here should help forge effective communication between the interventional pulmonologist and the anesthesiologist In the Bronchoscopy Suite nonoperating room anesthesia with the goal of enhancing patient safety.

Assessment of the impact and reorganization of interventional pulmonology services at a tertiary care centre during nationwide lockdown for COVID-19 pandemic

COVID 19 pandemic has brought about a sea change in health care practices across the globe. All specialities have changed their way of working during the pandemic. In this study, we evaluated the impact of COVID-19 on the practice of interventional pulmonology at our centre. All interventional pulmonology procedures done during the three months after implementation of lockdown were evaluated retrospectively for patient demographics, clinical diagnosis, indication for procedure and diagnostic accuracy. The changes in practices, additional human resources requirement, the additional cost per procedure and impact on resident training were also assessed. Procedures done during the month of January 2020 were used as controls for comparison. Twenty-two flexible bronchoscopies (75.8%), four semirigid thoracoscopies (13.7%) and three EBUS-TBNAs (10.3%) were carried out during three month lockdown period as compared to 174 during January 2020. Twenty-three of the procedures were for the diagnostic indication (79%), and six were therapeutic (20.6%). The diagnostic yield in suspected neoplasm was 100% while for suspected infections was 58.3%. The percentage of independent procedures being done by residents reduced from 45.4% to 0%. The workforce required per procedure increased from 0.75 to 4-8, and the additional cost per procedure came out to be 135 USD. To conclude, COVID 19 has impacted the interventional pulmonology services in various ways and brought about a need to reorganize the services, while also thinking of innovative ideas to reduce cost without compromising patient safety.

The diagnosis of lung cancer in the era of interventional pulmonology.

Advances in bronchoscopic and other interventional pulmonology technologies have expanded the sampling procedures pulmonologist can use to diagnose lung cancer and accurately stage the mediastinum. Among the modalities available to the interventional pulmonologist are endobronchial ultrasound-guided transbronchial needles aspiration (EBUS-TBNA) and transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA) for sampling peribronchial/perioesophageal central lesions and for mediastinal lymph node staging, as well as navigational bronchoscopy and radial probe endobronchial ultrasound (RP-EBUS) for the diagnosis of peripheral lung cancer. The role of the interventional pulmonologist in this setting is to apply these procedures based on the correct interpretation of clinical and radiological findings in order to maximise the chances of achieving the diagnosis and obtaining sufficient tissue for molecular biomarker testing to guide targeted therapies for advanced non-small cell lung cancer. The safest and the highest diagnosis-yielding modality should be chosen to avoid a repeat sampling procedure if the first one is non-diagnostic. The choice of site and biopsy modality are influenced by tumour location, patient comorbidities, availability of equipment and local expertise. This review provides a concise state-of-the art account of the interventional pulmonology procedures in the diagnosis and staging of lung cancer.

A survey of medical thoracoscopy practices in India.

Background:Medical thoracoscopy (MT) is a useful diagnostic and therapeutic procedure for a variety of pleural conditions. There is a lack of literature on prevalent practices of MT in India.Aims and Objectives:The objective of the study was to study the prevalent practices of MT in India.Materials and Methods:A structured online survey on various aspects of thoracoscopy was designed on the “Google Forms” web software.Results:One hundred and eight responses were received, of which 100 respondents performed MT. The majority were pulmonologists, and most had started performing thoracoscopy within the last 5 years. Rigid thoracoscope was the most commonly used instrument. The common indications of procedure included undiagnosed pleural effusion, talc pleurodesis, and adhesiolysis. Local anesthesia with conscious sedation was the preferred anesthetic modality. Midazolam, along with fentanyl, was the most widely used sedation combination. 2% lignocaine was the most commonly used concentration for local infiltrative anesthesia. Nearly two-thirds of the respondents reported having encountered any complication of thoracoscopy. Significant reported complications included empyema, incision/port-site infection, re-expansion pulmonary edema, and procedure-related mortality.Conclusion:MT is a rapidly evolving interventional pulmonology procedure in India. There is, however, a significant variation in practice and variable adherence to available international guidelines on thoracoscopy. Formal training programs within India and national guidelines for pleuroscopy considering the local resources are required to improve the safety and yield of this useful modality.

REFERRAL PATTERN OF INTERVENTIONAL PULMONOLOGY PROCEDURES AT A QUATERNARY MEDICAL CENTER

SESSION TITLE: Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Interventional pulmonology (IP) focuses on management of malignant and benign airways and pleural diseases. Access to this specialized care is increasing nationwide, though is largely limited to academic medical centers. We hypothesized a patient’s referral (and subsequent advanced therapies) may be delayed due to access to care, socioeconomic factors, and lack of awareness or understanding of IP’s role in patient care. METHODS: We performed a retrospective analysis of patients who underwent advanced IP procedures in the Operating Room (OR) at our medical center from 7/1/2015 to 12/31/2018 after IRB approval. Procedures included rigid and flexible bronchoscopies for tumor debulking, stent placement, and tissue diagnosis. We obtained demographic data including age, sex, race, primary location of oncologic care, and date of death. We analyzed the distance from patient’s residence to our medical center, reason for referral, and advanced procedures performed. We calculated time intervals, including time to IP referral; to first IP evaluation; to procedure; to IP follow-up; and death. We used a cut-off distance of 51 miles from medical center to identify patients residing “near” versus “far”. Two-tailed Student’s t-test with alpha 0.05 was used for comparison. RESULTS: A total of 277 procedures were performed by IP practitioners on 227 patients during the study period. Forty five percent, (45.4%, 103/227) were female, with an average age of 60.8±11.2 years. The median distance of patient residences were 51 miles from our medical center. Eighty-two percent (188/227) had cancer; 30.3% (57/188) of these malignancies were diagnosed during the IP procedure. Patients residing near our medical center had significantly shorter interval from imaging to IP referral (11.3±18.8 days vs. 17.4±26.6 days, p=0.046). There were no statistically significant differences in days from referral to initial evaluation by IP (p=0.84) or from IP evaluation to time of procedure (p=0.66) between “near” and “far” patients. There was no significant difference in time interval from procedure to first clinic follow-up between the two groups (p=0.14). CONCLUSIONS: Patients residing more than 51 miles from our medical center were associated with an average delay of 6 days for IP referral for necessary intervention when compared to those living within 51 miles. There were no subsequent delays from the date of referral to IP evaluation, nor from date of IP evaluation to IP procedure performed. CLINICAL IMPLICATIONS: IP intervention is delayed for those living away from a quaternary medical center. Appropriate education of referring physicians, community access to IP physicians, and direct communication by telemedicine may be helpful to improve the delay. DISCLOSURES: no disclosure on file for Shaheen Islam; No relevant relationships by Divyesh Mehta, source=Web Response no disclosure on file for Shailesh Pinto; No relevant relationships by Alberto Revelo, source=Web Response No relevant relationships by Virgil Secasanu, source=Web Response No relevant relationships by Harsh Shah, source=Web Response

Standardizing education in interventional pulmonology in the midst of technological change.

Interventional pulmonology (IP) is a maturing subspecialty of pulmonary medicine. The robust innovation in technology demands standardization in IP training with both disease and technology driven training. Simulation based training should be considered a part of IP training as seen in other procedural and surgical subspecialties. Procedure volume is a component of training; however, this does not guarantee or translate into competency for learners. Basic competency skills can be assessed using standardized well validated assessment tools designed for various IP procedures including flexible bronchoscopy, endobronchial ultrasound guided transbronchial needle aspiration (EBUS TBNA), rigid bronchoscopy and chest tube placement; however, further work is needed to validate tools in all procedures as new technologies are introduced beyond fellowship training. Currently there are at least 39 IP fellowship programs in the United States (US) and Canada which has led to improved training by accreditation of programs who meet rigorous requirements of standardized curriculum and procedural volume. The challenge is to be innovative in how we teach globally with intention and how to best integrate new evolving technology training for those not only during fellowship training but also beyond fellowship training.

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.

Using a Dedicated Interventional Pulmonology Practice Decreases Wait Time Before Treatment Initiation for New Lung Cancer Diagnoses

While there is significant mortality and morbidity with lung cancer, early stage diagnoses carry a better prognosis. As lung cancer screening programs increase with more pulmonary nodules detected, expediting definitive treatment initiation for newly diagnosed patients is imperative. The objective of our analysis was to determine if the use of a dedicated interventional pulmonology practice decreases time delay from new diagnosis of lung cancer or metastatic disease to the chest to treatment initiation. Retrospective chart analysis was done of 87 consecutive patients with a new diagnosis of primary lung cancer or metastatic cancer to the chest from our interventional pulmonology procedures. Demographic information and time intervals from abnormal imaging to procedure and to treatment initiation were recorded. Patients were older (mean age 69) and former or current smokers (72%). A median of 27 days (1-127days) passed from our diagnostic biopsy to treatment initiation. A median of 53 total days (2-449days) passed from abnormal imaging to definitive treatment. Endobronchial ultrasound-guided transbronchial needle aspiration was the most commonly used diagnostic procedure (59%), with non-small cell lung cancer the majority diagnosis (64%). For surgical patients, all biopsy-negative lymph nodes from our procedures were cancer-free at surgical excision. Compared to prior reports from international and United States cohorts, obtaining a tissue biopsy diagnosis through a gatekeeper interventional pulmonology practice decreases median delay from abnormal imaging to treatment initiation. This finding has the potential to positively impact patient outcomes and requires further evaluation.

SUBGLOTTIC STENOSIS: A CASE SERIES

SESSION TITLE: Allergy and Airway SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Subglottic stenosis remains a rare and challenging disease with many potential etiologies. No clear risk factors have been identified, although reflux disease or female sex have been proposed. No definitive management algorithm exists, with treatment dependent on provider experience and patient preference. Endoscopic procedures are now widely used, as they can be performed outpatient, preserve vocal function, and offer relatively immediate symptom relief. Despite these interventions, however, recurrence is high. This case series describes the characteristics of subglottic stenosis patients and reviews their outcomes after undergoing interventional pulmonology (IP) procedures. METHODS: In this single center, retrospective case series, all consecutive patients presenting to our IP practice from February 2016 to December 2017 for subglottic stenosis were evaluated. Patients were included if subglottic stenosis was confirmed bronchoscopically and excluded for a malignancy history, prior or current tracheostomy, or tracheobronchial stenting. Patients were further divided into idiopathic subglottic stenosis (ISS), defined as those without a clear cause, post-intubation subglottic stenosis (PIT), defined as those with a known history of prolonged or traumatic intubation, and tracheal resection with reanastomosis (TRA), defined as those whom eventually required surgical intervention. Chart review was performed for demographic characteristics, interventional treatments, and outcomes of patients with subglottic stenosis. RESULTS: 15 patients with subglottic stenosis met inclusion criteria, with the majority being female (87%), never smokers (73%), and white (53%) or Hispanic (40%) with a median age of 49 (range 24-71). Asthma, reflux, and hypothyroidism were common comorbidities (40%, 33%, 27%, respectively). PIT was the most common etiology (80%). 11 patients underwent only IP procedures, while 4 patients eventually underwent surgical intervention. All patients had a history of at least one intubation. For patients undergoing surgery, symptom duration prior to evaluation for IP procedure was significantly shorter than those who did not (0.625 vs 31 months, p<0.003). Various IP procedures were utilized for airway recannulization, with 60% of patients requiring multiple IP procedures with a median time to second procedure of 58 weeks (range 2.7 to 155 weeks). CONCLUSIONS: In our case series, subglottic stenosis patients were predominantly female with PIT as the etiology. Patients undergoing surgery presented with symptoms significantly sooner. Regardless of intervention, recurrence rates were high. CLINICAL IMPLICATIONS: It will be important to determine if additional prognostic information may be obtained to better risk-stratify which subgroup of patients may ultimately benefit from repeat IP procedures versus early surgical intervention. DISCLOSURES: No relevant relationships by Bryan Benn, source=Web Response No relevant relationships by Drew Sheldon, 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.

Recent advances in interventional pulmonology procedures

The diagnostic ability and specificity of interventional bronchoscopy procedures has been renovated in the past decade. The evaluation of abnormal thoracic findings including lung nodules and masses, mediastinal lymphadenopathy, and pleural diseases has been revolutionized using these techniques, minimizing the need for more invasive procedure especially in patients with compromised lung functions.