Lobar Collapse Research Articles

Sediment dynamics of a major piedmont glacier: the Salzach Glacier in the North Alpine Foreland

Abstract. The foreland basins of the European Alps were repeatedly covered by major piedmont glaciers during Quaternary glacial maxima. The Salzach Glacier was the easternmost of a series of large Pleistocene piedmont glaciers entering the North Alpine Foreland through major Alpine valleys. It covered an area of more than 1000 km2 during at least four glacial maxima. The slightly elevated molasse bedrock provides a high potential for preservation of glacial landforms and offers an ideal setting to explore the erosional and depositional dynamics of a major glacier piedmont lobe. This field excursion guide leads to some selected key sites representing deposits of glacial advance, relative equilibrium, and ice lobe collapse.

Endobronchial Leiomyoma, an Unusual Tumor in an Unusual Site

Abstract Leiomyomas are benign smooth muscle tumors most commonly seen in the uterus occasionally in the gastrointestinal tract. Pulmonary localization is extremely rare with the incidence of <2%. We report the case of a 22-year-old nonsmoking female who presented with left-sided chest pain and streaky hemoptysis. Chest xray showed left lingular lobe and lower lobe collapse. Contrast-enhanced computed tomography showed endobronchial obstruction in the left main bronchus. Debulking was done with electrocautery snare. Histopathological examination showed spindle-shaped cells with eosinophilic cytoplasm. Immunohistochemistry showed smooth muscle actin positivity suggestive of leiomyoma. The patient is under follow-up without any complication and recurrence.

Lobar collapse: what radiologists need to know

Radiologists have to diagnose lobar collapse routinely, so they should be familiar with the direct and indirect signs of lobar atelectasis and with uncommon findings, for being able to make early diagnosis. Atelectasis can be caused by several mechanisms: by obstruction (due to neoplastic or non-neoplastic causes), by loss of negative pressure in the pleural space and/or by compression of lung parenchyma (e.g., pneumothorax, hydrothorax, and pleural effusion) or by an increase in alveolar surface tension (e.g., acute respiratory distress syndrome and neonatal respiratory distress syndrome). Collapses, moreover, can be observed in several ways. Lobar atelectasis occurs when entire pulmonary lobe is collapsed. Linear atelectasis (previously “plate like” or “band like”) is a local collapse with linear, plate-like or band-like shape which usually parallels the hemidiaphragms. Rounded atelectasis is a consequence of chronic or recurrent pleural effusion, which could be related to asbestos disease, chronic cardiac or renal failure, and thoracic malignancies. It occurs as a rounded mass abutting the pleura with adjacent pleural thickening. Collapsed lobes can assume quite limited forms and radiologists require familiarity with radiographic findings for helping clinical physician in the diagnostic process.

Brochoscopic cryoablation of a large endobronchial chondroid hematoma presented as right middle lobe collapse in a 63 years old male patient

Brochoscopic cryoablation of a large endobronchial chondroid hematoma presented as right middle lobe collapse in a 63 years old male patient

Misleading wheeze in a case of atypical large cell neuroendocrine carcinoma of lung - A deadly variety

Neuroendocrine tumors are neoplasms arising from cells of endocrine and nervous system containing special secretory granules with biogenic amines and polypeptide hormones. One of the varieties that occurs commonly in the lung is large cell neuro endocrine carcinoma. The replicative potential of these neuroendocrine malignancies is so rapid that the patients usually present with metastatic disease. We describe a case of 29-year-old-male presented with nocturnal wheeze which led on to a misdiagnosis of bronchial asthma and finally found to be LCNEC with endobronchial obstruction. They are usually peripherally located lesions, mostly in the upper lung zones of an elderly male smoker. But he had a hilar mass with right lower lobe collapse due to endobronchial obstruction. Hence careful examination of wheeze whether unilateral or bilateral, monophonic or polyphonic, random or fixed, inspiratory or expiratory or biphasic may help in early identification of the endobronchial lesions.

Clinicoradiological Profile of Endobronchial Tuberculosis: A Cross-sectional Study

Introduction: Tuberculosis (TB) is a disease that causes severe mortality and morbidity worldwide, including India. Endobronchial Tuberculosis (EBTB) is an uncommon form of TB, which is often underdiagnosed due to the difficulty in diagnosis. This form of TB often has a poor prognosis and long-lasting sequelae. Aim: To study the proportion of EBTB in clinically diagnosed pulmonary TB and to study the clinicoradiological and bronchoscopic profile of EBTB. Materials and Methods: This study was a hospital-based recordbased cross-sectional study that included patients with sputum smear negative for Acid-Fast Bacilli (AFB) and Mycobacterium tuberculosis (M. tuberculosis) not detected on Nucleic Acid Amplification Test (NAAT), who were clinically diagnosed with TB. Bronchoscopy was performed on such patients, and samples were sent for investigations, including histopathology and NAAT. Demographic characteristics, bronchoscopy and radiology findings , and microbiology results were documented. Quantitative variables were summarised as means, and categorical variables were presented as percentages. Results: A total of 198 underwent bronchoscopy, of which 20 (10%) were diagnosed with EBTB. The mean age was 22 years, and 65% were females. The most common clinical feature in these patients was fever, the most common radiological presentation was lobar collapse, and the most common bronchoscopy feature was a tumorous lesion. NAAT detected M. tuberculosis in the bronchial wash in 50% of patients diagnosed with EBTB. A total of 45% of patients had TB which was diagnosed on histopathology. Conclusion: EBTB was diagnosed in 10% of smear-negative, NAAT-negative cases. The use of NAAT on bronchoscopy wash samples resulted in a high yield in diagnosis.

Flexible bronchoscopy for removal of airway foreign bodies: A single center experience

Background: Airway foreign bodies are rare in occurrence and challenging to manage. The presentation varies depending upon the size, site, and nature of the aspirated material. Although rigid bronchoscopy is the preferred choice in children; distally lodged foreign bodies in adults have high success rate of extraction with flexible bronchoscope. Objective: The aim of this study is to evaluate the utility of flexible bronchoscopy for removal of airway foreign bodies in adolescents and adults. Methods: In a retrospective study conducted between January 2018 to March 2024 at National Academy of Medical Sciences, Bir hospital; medical records of patients undergoing bronchoscopy for airway foreign bodies were extracted. Methods and Material: Demographic parameters, type and location of foreign body, extraction procedure, accessory equipment used, and the success rates were analyzed. Complications during and after the procedure were also recorded. Results: During the study period, a total of 3143 bronchoscopies were performed, of which 18 (0.57%) were done for foreign body extraction. Patients were aged between 12 to 89 years; cough was the commonest symptom and lobar collapse was the commonest radiological sign. Organic foreign bodies accounted for 61% cases and inorganic 39%. Right lower lobe was the commonest site. Successful flexible bronchoscopy assisted extraction was achieved in 89%. Of the 18 patients, 12 (67%) were successfully removed with rat toothed forceps and five (28%) with basket device. No major complications were noted. Conclusions: Flexible bronchoscopy has a high success rate in management of airway foreign bodies and should always be considered as first line in adults.

Sclerosing epithelioid fibrosarcoma associated with WRN gene variant presenting as chronic dyspnea and pathologic cervical fracture: a case report and review of the literature

BackgroundSclerosing epithelioid fibrosarcoma is an aggressive sarcoma subtype with poor prognosis and limited response to conventional chemotherapy regimens. Diagnosis can be difficult owing to its variable presentation, and cases of sclerosing epithelioid fibrosarcoma are rare. Sclerosing epithelioid fibrosarcoma typically affects middle-aged individuals, with studies inconsistently citing gender predominance. Sclerosing epithelioid fibrosarcoma typically arises from the bones and soft tissues and often has local recurrence after resection and late metastases. Immunohistochemical staining typically is positive for mucin-4. Werner syndrome is due to an autosomal recessive mutation in the WRN gene and predisposes patients to malignancy.Case presentationA 37-year-old Caucasian female presented to the emergency department with 4 months of dyspnea and back pain. She had been treated for pneumonia but had persistent symptoms. A chest, abdomen, and pelvis computed tomography showed near-complete right upper lobe collapse and consolidation, mediastinal lymphadenopathy, lytic spinal lesions, and a single 15-mm hypodense liver nodule. The patient underwent a transthoracic right upper lobe biopsy, bronchoscopy, endobronchial ultrasound with transbronchial lymph node sampling, and bronchoalveolar lavage of the right upper lobe. The bronchoalveolar lavage cytology was positive for malignant cells compatible with poorly differentiated non-small cell carcinoma; however, the cell block materials were insufficient to run immunostains for further investigation of the bronchoalveolar lavage results. Consequently, the patient also underwent a liver biopsy of the liver nodule, which later confirmed a diagnosis of sclerosing epithelioid fibrosarcoma. Next-generation sequencing revealed a variant of unknown significance in the WRN gene. She was subsequently started on doxorubicin.ConclusionSclerosing epithelioid fibrosarcoma is a very rare entity, only cited approximately 100 times in literature to date. Physicians should be aware of this disease entity and consider it in their differential diagnosis. Though pulmonary involvement has been described in the context of sclerosing epithelioid fibrosarcoma, this malignancy may affect many organ systems, warranting extensive investigation. Through our diagnostic workup, we suggest a possible link between sclerosing epithelioid fibrosarcoma and the WRN gene. Further study is needed to advance our understanding of sclerosing epithelioid fibrosarcoma and its clinical associations as it is an exceedingly rare diagnosis.

Environmental evolution of western Tierra del Fuego (∼54°S) since ice-free conditions and its zonal/hemispheric implications

By virtue of its position adjacent to the Drake Passage, Tierra del Fuego in South America allows examining the vegetation and environmental history of the southernmost continental landmass outside Antarctica, and the evolution of the Southern Westerly Winds-Southern Ocean (SWW–SO) coupled system since the Last Glacial Maximum (LGM). For that purpose, we studied sediment cores from Lago Charquito, a small closed-basin lake in central-west Tierra del Fuego with a continuous lacustrine record since ∼17.3 ka. Ice-free conditions at the site imply a ∼70 km retreat of the Bahía Inútil glacier lobe from its LGM position during a ∼800-year interval, a trend that continued until its disappearance ∼100 km upstream from L. Charquito, ∼800 years later. Our palynological data show an open landscape dominated by cold-tolerant shrubs and herbs between ∼17.3–12.9 ka, with increases in precipitation of SWW origin at ∼16.3 ka, ∼14.7 ka, between ∼8.7–7.6 ka, and after ∼6.8 ka. Warming at ∼12.9 ka initiated an abrupt afforestation trend that stalled during the early Holocene (∼12–8.7 ka) owing to a precipitation decline and wildfires, and later resumed in response to invigorated SWW. We hypothesize that sparse Nothofagus tree populations inhabited the periphery of the Patagonian Ice Sheet (PIS) during the LGM and migrated toward the Andes contemporaneous with glacier recession as temperature rose during the Last Glacial Termination (T1). We posit that besides establishing topographic and climatic barriers for land biota, the PIS enabled the connectivity of cold-tolerant hygrophilous plant populations along a humid fringe adjacent to its land-based perimeter, despite the presumably dry conditions downwind from the eastern PIS margin. Our results suggest that southward shifts or expansion of the SWW toward or beyond Tierra del Fuego enhanced upwelling and ventilation of deep waters in the SO, northward shifts or weakening had the opposite effect. We observe that the time evolution of atmospheric CO2 concentrations, high-latitude air and sea-surface temperatures, and sea level during T1 fall short in explaining the timing and abruptness of the Bahía Inútil glacier lobe collapse, and quite possibly multiple other glacier lobes from the PIS.

Bronchoscopic Lung Volume Reduction: Highlighting the Patient Selection Process

Patients with advanced emphysema frequently experience severe dyspnea that is inadequately treated with medical therapy alone. Over the past 4 years, we have seen increased usage of bronchoscopic lung volume reduction (BLVR) with endobronchial valves. Success of the procedure is dependent on patient selection because it is not necessarily appropriate for all patients with severe emphysema. (Table 1) The purpose of this review is to highlight the selection process at a single institution. We also discuss the influence of this process on outcomes. Between March 1, 2019, and October 12, 2021, 2402 patients were referred to a dedicated chronic obstructive pulmonary disease clinic at Mayo Clinic – Rochester, whereas 161 patients were subsequently referred for multidisciplinary BLVR review. Of those patients, 53 (32.9%) were selected to receive valves and 35 (21.7%) ultimately underwent the procedure. The main reasons for exclusion included an incompatible quantitative computed tomography analysis (n=37, 34.3%), presence of pulmonary nodule or active malignancy (n=14, 13.0%), or need for completion of pulmonary rehabilitation (n=9, 8.3%). Full or partial (>70%) target lobe collapse was observed in 58.6% of patients who received valves. Those with collapse experienced statistically significant improvements in spirometric measures. Twelve patients experienced a pneumothorax (34.3%), with 10 patients requiring thoracostomy tube placement and prolonged hospitalization (median, 11 days; range, 4-39 days). Nineteen patients required a secondary procedure within the first year. The study highlights how a multidisciplinary approach to the BLVR selection process enables individualization of a complex procedure and enhances the exclusion of inappropriate candidates.

Rigid Bronchoscopy for Post-Tuberculosis Tracheobronchial Stenosis.

The healing process of tracheobronchial tuberculosis (TB) result in tracheobronchial fibrosis causing airway stenosis in 11-42% of patients. In Korea, where pulmonary TB is still prevalent, post-TB tracheobronchial stenosis (PTTS) is one of the main causes of benign airway stenosis causing progressive dyspnea, hypoxemia and often representing life-threatening respiratory insufficiency. The development of rigid bronchoscopy replaced surgical management since last 30 years, and nowadays PTTS is mainly managed by bronchoscopic intervention in Korea. When diagnosed, tracheobronchial TB is treated by combination of anti-TB medications as other pulmonary TB. The indication of rigid bronchoscopy is more than ATS grade 3 dyspnea in PTTS patients. At first narrowed airway is dilated by multiple techniques, including ballooning, laser resection, bougienation under general anesthesia. Then, most of patients need silicone stenting to maintain the patency of dilated airway. 1.5~2 years after indwelling, the stent could be removed with 70% of success rate. Acute complications develops in less than 10% of patients without mortality. Subgroup analysis showed successful removal of stent was significantly associated with male sex, young age, good baseline lung function and absence of complete one lobe collapse. In conclusion, rigid bronchoscopy could be applied to PTTS patients with acceptable efficacy and tolerable safety.

Recurrent endobronchial occlusion and aorto-bronchial fistula formation in Behcet’s disease

BackgroundBehcet’s disease is a multi-system inflammatory disorder. A small subset of patients with Behcet’s develop relapsing polychondritis which is classified as a separate disease known as Mouth and Genital ulcers with inflamed cartilage (MAGIC syndrome). It has previously been observed that this condition can also affect the cartilaginous tissue in the tracheobronchial tree.Case presentationWe present the case of a 44-year-old lady with Behcet’s Disease, Mouth and Genital ulcers with inflamed cartilage (MAGIC) syndrome and an aortic Frozen Elephant Trunk (FET) who presented to hospital with recurrent episodes of left lobar collapse of the lung. During bronchoscopy, we found the presence of multiple inflammatory endobronchial webs occluding segments of the left bronchial tree. Repeated examinations showed evidence that these inflammatory webs were progressing in size, density and location. Furthermore, we noticed herniation of her descending aortic FET into her left bronchial tree forming an aorto-bronchial fistula which was complicated by a graft infection. Her descending aortic FET section was surgically replaced with an open procedure and bronchoscopic interventions attempted to remove the occlusions in her bronchial tree. Despite optimisation of medical management and surgical correction, this patient continued to develop progressive occlusion of her left bronchial tree, resulting in a chronically collapsed left lung.ConclusionsA multi-disciplinary team approach is of paramount importance in order to optimally manage patients with Behcet’s disease, balancing immunosuppressive regimens that need close monitoring and titration in the context of potential surgical intervention and the risk for intercurrent infection.

A RIDDLE WRAPPED IN A MYSTERY: MUCOEPIDERMOID CARCINOMA (MEC) FOUND DURING EVALUATION OF PERSISTENT LUNG COLLAPSE

A RIDDLE WRAPPED IN A MYSTERY: MUCOEPIDERMOID CARCINOMA (MEC) FOUND DURING EVALUATION OF PERSISTENT LUNG COLLAPSE

SQUAMOUS CELL CARCINOMA OF THE LUNG LEADING TO MALIGNANT CARDIAC TAMPONADE DUE TO LARGE CARDIAC METASTASES

SQUAMOUS CELL CARCINOMA OF THE LUNG LEADING TO MALIGNANT CARDIAC TAMPONADE DUE TO LARGE CARDIAC METASTASES

UTILIZATION OF CONTINUOUS REMOTE MONITORING FOR A HIGH-RISK PATIENT REQUIRING INTERVAL TUMOR DEBULKING PALLIATIVE THERAPY

UTILIZATION OF CONTINUOUS REMOTE MONITORING FOR A HIGH-RISK PATIENT REQUIRING INTERVAL TUMOR DEBULKING PALLIATIVE THERAPY

Historical Treatment of Cavitary Tuberculosis

Two patients in their 80s were undergoing evaluation for valvular heart disease. They endorsed remote history of cavitary tuberculosis that was treated in their 20s. Both patients remained free of reactivation tuberculosis since. The first patient’s chest radiograph showed left upper lobe collapse created by multiple polyethylene balls (each <1 inch in diameter) tightly packed in the extrapleural space of the left upper hemithorax (Figure A). The second patient’s radiograph showed a large, densely calcified opacity in the right upper hemithorax with complete collapse of the right upper lobe caused by extrapleural injection of paraffin oil (Figure B).

813 Giant Inginoscrotal Hernias: Considerations for Optimisation of Patient Outcomes

Abstract Giant inguinoscrotal hernias (GISH) are unique and complex surgical challenges due to their rare presentation in the western world and the high risk of post-repair complications such as abdominal compartment syndrome and multi-organ failure. They are defined as inguinoscrotal hernias that extend below mid inner thigh. Due to the potential complications, optimising these patients throughout their hospital admission is crucial. Here, we present a 30-year-old Caucasian male who was admitted to our surgical unit in a public health system with a painful giant inguinoscrotal hernia, the complications he encountered and the lessons we learned. His CT scan demonstrated a strangulated hernia, for which he underwent an emergency open mesh repair. Post-operatively, he experienced severe respiratory compromise due to lower lobe collapse, which was attributed to the concomitant pneumonia present on admission, sub-optimal utilisation of analgesia and loss of domain. The complications were compounded by anxiety about medical intervention which delayed investigations and treatments. We highlight the importance of early identification of GISH, ensuring cardio-respiratory function is optimised pre- and post-operatively, and a multi-disciplinary approach to improve compliance with treatment including extensive counselling to increase engagement with healthcare services.

An unique case of isolated right upper lobe lung agenesis with abnormal middle lobe segmentation

BackgroundIsolated right upper lobe pulmonary agenesis is a highly uncommon congenital anomaly, usually detected at adulthood when the patient is evaluated for an incidental abnormal chest radiograph. Chest radiography findings are non-specific. Chest computed tomography with pulmonary angiography is the modality of choice for diagnosing pulmonary agenesis.Case presentationWe describe a case of isolated right upper lobe agenesis in a young man who presented with mild shortness of breath and an abnormal chest radiograph. High-resolution computed tomography chest showed right upper lobe pulmonary agenesis which was initially erroneously diagnosed as right lower lobe collapse on chest X-ray. Abnormal segmentation of the middle lobe was also seen which has not been described earlier according to our literature search.ConclusionsThere should be a high index of suspicion for congenital anomalies on chest X-ray to recommend further imaging studies. This case highlights the importance of computed tomography with pulmonary angiography to adequately assess and characterize the congenital lung anomalies.

Bronchoscopy in the emergency department

BackgroundFlexible bronchoscopy has been safely used for decades in ambulatory and critical care settings to aid in the diagnosis and treatment of tracheobronchial tree disorders. Although emergency physicians have the requisite skills to operate and interpret flexible bronchoscopy, no reports exist on the use of bronchoscopy by emergency physicians apart from endotracheal tube placement and confirmation. ObjectiveThe primary goal of this study was to describe the indications, outcomes and complications of flexible bronchoscopy performed by emergency physicians in an urban academic emergency department. MethodsThis was a single-center retrospective cohort study involving chart and video review of 146 patients over a 10.5-year study period. Patients of any age were included if they had been tracheally intubated or mechanically ventilated and underwent flexible bronchoscopy in the emergency department. After patients were identified, manual chart and video review was used to collect data on patient demographics, indications for intubation, indications for bronchoscopy, details of the bronchoscopy procedure, procedural findings, outcomes of the procedure, complications, provider training levels, and additional bronchoscopies performed after admission. The data was analyzed using descriptive statistics. Results146 patients were included in the study and all bronchoscopies were performed or supervised by attending emergency physicians. After bronchoscopy, 24% of patients displayed improvement in oxygenation or lobar collapse while most patients had no change in clinical status. One patient had temporary hypoxemia after bronchoscopy. When another physician performed a subsequent bronchoscopy during admission, the findings were in agreement with the ED bronchoscopy 86% of the time. ConclusionAt our institution, emergency physicians can safely and effectively use flexible bronchoscopy to diagnose and treat critically ill patients.

Radiological evidence in clinical prevalence of hematological changes in multidrug resistant pulmonary tuberculosis

Background: Globally, tuberculosis is the leading cause of death. India accounts for the highest proportion of drug resistant tuberculosis among all other countries. Objectives: This study investigated the changes in hematological parameters with respect to radiological evidences in multidrug resistant tuberculosis patients. Materials and Methods: The study enrolled a total of 273 patients with the confirmative diagnosis of multidrug resistant tuberculosis. The radiological evidences were classified into mild, moderate and severe lung involvement. Results: The chest radiographs illustrated tracheal deviation (74), loss of lung volume (35), pleural effusion (25), lobar collapse and fibrotic manifestations. The defensive leucocytes, phagocytic neutrophils, anucleated platelet cells and platelet volume observed an increase with severe lung grading (p&lt;0.0001). Reduced lymphocyte count, mean platelet size observed with the intense lung involvement. Prevalence of normocytic, normochromic anemia, anisocytosis was prominent in these patients. The erythrocyte sedimentation rate observed no significant changes in the categorized radiological grades of lung. Radiological grading reported a weak positive correlation with the hematological parameters. Conclusion: The study noticed the changes in the complete blood count parameters with radiological signs and recommend monitoring of these investigations in determining the progression of the lung involvement in the multidrug resistant pulmonary tuberculosis patients.