Post-procedure Pneumothorax Research Articles

Surgeon-Led Point-Of-Care UltraSound-guided THORacic (POCUS-THOR) Biopsy: A New Paradigm in Efficient Diagnosis and Resource-Sparing Care

Tissue diagnosis through a variety of interventional approaches guides thoracic cancer management, but often introduces delay to definitive treatment and can be resource intensive. We introduced a thoracic surgeon-led, point-of-care ultrasound-guided biopsy program to provide rapid diagnosis for patients with thoracic cancers. We assessed the diagnostic yield and adverse events with this approach. A prospective cohort study was performed of consecutive patients undergoing ultrasound-guided biopsies performed by 5 thoracic surgeons from June 2021 to April 2024 at a tertiary Canadian thoracic surgery institution. Using a bedside ultrasound, 20-gauge tissue cores were obtained using multiple passes with a standard spinal needle. Descriptive univariable statistics were used. 160 patients underwent bedside biopsy for lung (n=101), liver (n=20), chest wall/pleural (n=20), mediastinal (n=18), or other (n=1) lesions. Tissue diagnosis was obtained in 86.3% of patients (n=138), and diagnostic yield was similar for high and low-volume providers and over time. All liver biopsies were diagnostic. Non-diagnostic biopsies were more likely to occur with benign pathology, chest wall/pleural lesions, or extensive necrosis; diagnosis was achieved with other modalities in most cases. There was 1 post-procedure pneumothorax (adverse event rate 0.6%). Thoracic surgeon-led ultrasound-guided biopsies are safe in an outpatient clinic setting, and have high diagnostic accuracy. This results in reduced time to diagnosis by an estimated 28-35 days, and frees up endoscopic and radiology resources for other patients. This low-cost procedure can be adopted as part of comprehensive thoracic malignancy assessment, and can accelerate patient access to cancer treatment.

Bronchoscopic Lung Volume Reduction as the Treatment of Choice versus Robotic-Assisted Lung Volume Reduction Surgery in Similar Patients with Emphysema - An Initial Experience of the Benefits and Complications.

There is an assumption that because EBLVR requires less use of hospital resources, offsetting the higher cost of endobronchial valves, it should therefore be the treatment of choice wherever possible. We have tested this hypothesis in a retrospective analysis of the two in similar groups of patients. In a 4-year experience, we performed 177 consecutive LVR procedures: 83 patients underwent Robot Assisted Thoracoscopic (RATS) LVRS and 94 EBLVR. EBLVR was intentionally precluded by evidence of incomplete fissure integrity or intra-operative assessment of collateral ventilation. Unilateral RATS LVRS was performed in these cases together with those with unsuitable targets for EBLVR. EBLVR was uncomplicated in 37 (39%) cases; complicated by post-procedure spontaneous pneumothorax (SP) in 28(30%) and required revision in 29 (31%). In the LVRS group, 7 (8%) patients were readmitted with treatment-related complications, but no revisional procedure was needed. When compared with uncomplicated EBLVR, LVRS had a significantly longer operating time: 85 (14-82) vs 40 (15-151) minutes (p<0.001) and hospital stay: 7.5 (2-80) vs 2 (1-14) days (p<0.01). However, LVRS had a similar total operating time to both EBLVR requiring revision: 78 (38-292) minutes and hospital stay to EBLVR complicated by pneumothorax of 11.5 (6.5-24.25) days. Use of critical care was significantly longer in RATS group, and it was also significantly longer in EBV with SP group than in uncomplicated EBV group. Endobronchial LVR does use less hospital resources than RATS LVRS in comparable groups if the recovery is uncomplicated. However, this advantage is lost if one includes the resources needed for the treatment of complications and revisional procedures. Any decision to favour EBLVR over LVRS should not be based on the assumption of a smoother, faster perioperative course.

The accuracy of electromagnetic navigation bronchoscopy compared to fluoroscopy in navigation of transbronchial lung cryobiopsy in patients with interstitial lung disease

BackgroundSafely implementing transbronchial lung cryobiopsy (TBLC) in patients with interstitial lung disease (ILD) requires accurate navigation. Traditional fluoroscopy falls short in reducing the risk of post-procedure pneumothorax. The potential of electromagnetic navigation bronchoscopy (ENB) as a more precise navigation method warrants further exploration.MethodsA prospective cohort study was conducted on ILD patients undergoing TBLC. Patients were assigned either fluoroscopy or ENB for cryoprobe positioning. Navigation accuracy was evaluated using cone beam computed tomography (CBCT) images as the standard. Safety and diagnostic yield were also observed.ResultsSeventeen patients underwent TBLC, with 10 guided by fluoroscopy and seven by ENB. Fluoroscopy-guided cryoprobe navigation required more adjustments [9/15 (60%) v.s. 1/9 (11%), p = 0.018] for subsequent TBLC compared to ENB, as confirmed by CBCT images. Clinical characteristics, post-procedure complications, and biopsy specimen size showed no significant differences between the groups. Fourteen patients obtained a pathological diagnosis, and 15 received a multidisciplinary discussion (MDD) diagnosis. In the fluoroscopy group, three patients failed to obtain a pathological diagnosis, and two failed to obtain an MDD diagnosis.ConclusionsENB demonstrates significantly superior accuracy in TBLC navigation compared to traditional fluoroscopy when CBCT images are used as a reference. Further studies are necessary to determine the value of ENB in TBLC navigation for ILD patients.

Computed Tomography Guided Transthoracic Lung Biopsy: Evaluating Risk Factors of Post-Procedure Pneumothorax- A Multivariate Analysis

Background: CT Guided lung biopsy is a common procedure in our department and pneumothorax is one of its commonest complications. To study the incidence of pneumothorax after CT guided lung biopsy and the various factors associated with the risk of developing pneumothorax after biopsy.&#x0D; Materials and Methods: Our study was a retrospective observational study. We analyzed 360 cases of lung biopsy performed using 18G Coaxial needle for assessing the incidence of post- procedure pneumothorax. The risk factors for pneumothorax were evaluated by univariate analysis, followed by multivariate logistic regression analysis to know the independent risk factors of pneumothorax.&#x0D; Results: The incidence of pneumothorax in our study was 41.9% (151/360 cases). On univariate analysis, we identified the following as risk factors of post-procedure pneumothorax: the presence of emphysema, smaller lesion size, Greater lesion depth, Lateral position, multiple passes and acute angulation of needle trajectory. On multivariate logistic regression analysis these were also revealed to be independent risk factors of post-procedure pneumothorax.&#x0D; Conclusion: Independent risk factors of post procedure pneumothorax are the presence of emphysema, smaller lesion size, greater lesion depth, Lateral position, multiple passes and acute angulation of needle trajectory. Of these lateral position is a novel predictor of pneumothorax that has been scarcely mentioned in literature. As such the radiologist should be prepared for managing pneumothorax in cases with one or more of these risk factors

Impact of day of admission on in-hospital outcomes of cardiogenic shock

BackgroundThe management of cardiogenic shock (CS) requires attentiveness to details and in some cases, invasive interventions. In the past, studies have shown relationships between the day of admission and cardiovascular outcomes. We aim to analyze the trends and in-hospital outcomes of patients admitted with CS over the weekends compared to weekdays. MethodWe identified all patients with CS from the National Inpatient Sample (NIS) database between 2016 and 2020. Using multivariate logistic regression analysis, baseline demographics and in-hospital outcomes were obtained and compared by weekend or weekday admission. ResultsOut of 854,684 CS admissions, 199,255 (23.6%) occurred on weekends. Patients admitted over the weekend had worse outcomes, including higher rates of mortality (aOR 1.09 CI 1.05 – 1.11, p<0.001), cardiac arrest (aOR 1.09 CI 1.04 -1.14, p<0.001), and respiratory failure. We also noted higher percutaneous coronary intervention (PCI) rates (aOR 1.2 CI 1.16 – 1.25, p<0.001) but lower rates of pulmonary artery catheterization (PAC) and post-procedure pneumothorax. Weekend admissions had shorter hospital lengths of stay, and they incurred lower charges ($223,222 vs. $247,908).Between 2016 and 2020, we observed a consistent downward trend in the mortality rates of the weekend and weekday CS admissions, with consistently higher weekend than weekday admissions. ConclusionWeekend admissions for CS are associated with worse outcomes, which have persisted for years. This now begs the question of whether physician dissatisfaction, understaffing, or burn-out are responsible for this finding.

Lung volume reduction for emphysema using one-way endobronchial valves: An Australian cohort.

Emphysema can be associated with gas trapping and hyperinflation, which negatively impacts on quality of life, life expectancy, and functional capacity. Lung volume reduction (LVR) surgery can reduce gas trapping and improve mortality in select patients but carries a high risk of major complications. Bronchoscopic techniques for LVR using one-way endobronchial valves (EBV) have become an established efficacious alternative to surgery. A bi-center retrospective cohort study was conducted on patients with severe emphysema who underwent endoscopic lung volume reduction (ELVR) using Pulmonx Zephyr EBVs. Symptomatic patients with gas-trapping and hyperinflation on lung function testing were selected. Target-lobe selection was based on quantitative imaging analysis and ventilation-perfusion scintigraphy. Successful procedures were determined from clinical review, imaging and follow-up testing. Thirty-nine patients underwent ELVR. Mean pre-procedure forced expiratory volume in 1 second (FEV1) was 0.75 L, residual volume (RV) was 225% predicted and total lung capacity was 129% predicted. Most common treated-lobe was left upper lobe. Post-procedure pneumothorax occurred in 36.5% of patients with 73% requiring intercostal catheter insertion for drainage. Mean FEV1 improvement was +140 mL and 57% of patients achieved minimal clinical important difference FEV1 increase of ≥12%. Maximal mean RV change was -1010 mL with 69% of patients achieving minimal clinical important difference RV decrease of ≥350 mL. Clinician-determined success of ELVR was 78%. Procedure-related mortality was absent. LVR using EBVs is safe and can lead to significant improvements in lung function, particularly reduction of gas trapping and hyperinflation. Occurrence of pneumothorax post-procedure is a complication that must be monitored for and managed appropriately.

Sampling of Thoracic Lymph Nodes and Lung Lesions: Trends in Procedural Utilization

Background: Advances in bronchoscopy have impacted the practice patterns in the sampling of thoracic lymph nodes and lung lesions. Objectives: The aim of the study was to study the trends in utilization of mediastinoscopy, transthoracic needle aspiration (TTNA), and bronchoscopic transbronchial sampling. Methods: We conducted an analysis of patient claims for sampling of thoracic lymph nodes and lung lesions in the Medicare population and a sample of the commercial population between 2016 and 2020. We used Current Procedural Terminology codes to identify mediastinoscopy, TTNA, and bronchoscopic transbronchial sampling. Post-procedural pneumothorax rates were assessed by procedure type including subset analyses for patients with chronic obstructive pulmonary disease (COPD). Results: Between 2016 and 2020, utilization of mediastinoscopy has decreased in both the Medicare and commercial populations (−47.3% and −65.4%, respectively), while linear endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) has increased only in the Medicare population (+28.2%). Percutaneous lung biopsy claims dropped by −17.0% in the Medicare and −41.22% in the commercial population. The use of bronchoscopic TBNA and forceps biopsy declined in both populations, but the reliance on a combination of guided technology (radial EBUS-guided and navigation) grew in the Medicare and commercial populations (+76.3% and +25%). Rates of post-procedural pneumothorax were significantly higher following percutaneous biopsy compared to bronchoscopic transbronchial biopsy. Conclusions: Linear EBUS-guided sampling has surpassed mediastinoscopy as the technique for sampling thoracic lymph nodes. Transbronchial lung sampling is increasingly being performed with guidance technology. This trend is aligned with favorable rates of post-procedure pneumothorax for transbronchial biopsy.

Variation in Incidence of Pneumothorax Complications After Percutaneous Lung Biopsies Among Veterans Health Administration Hospitals

Variation in Incidence of Pneumothorax Complications After Percutaneous Lung Biopsies Among Veterans Health Administration Hospitals

Implementation of ultrasound after central venous catheter insertion: A qualitative study in early adopters.

The adoption rate of point of care ultrasound (POCUS) for the confirmation of central venous catheter (CVC) positioning and exclusion of post procedure pneumothorax is low despite advantages in workflow compared to traditional chest X-ray (CXR). To explore why, we convened focus groups to address barriers and facilitators of implementation for POCUS guided CVC confirmation and de-implementation of post-procedure CXR. We conducted focus groups with emergency medicine and critical care providers to discuss current practices in POCUS for CVC confirmation. The semi-structured focus group interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach (NVivo software), aiming to identify priority categories that describe the barriers and facilitators of POCUS guided CVC confirmation. The coding dictionary of barriers and facilitators consisted of 21 codes from the focus group discussions. Our qualitative analysis revealed that 12 codes emerged spontaneously (inductively) within the focus group discussions and aligned directly to CFIR constructs. Common barriers included provider influences (e.g. knowledge and beliefs about POCUS for CVC confirmation), external network (e.g. societal guidelines, ancillary staff, and consultants), and inertia (habit or reflexive processes). Common facilitators included ultrasound protocol advantage and champions. Time and provider outcomes (cognitive offload, ownership, and independence) emerged as early barriers but late facilitators. Our qualitative analysis demonstrates real and perceived barriers against implementation of POCUS for CVC position confirmation and pneumothorax exclusion. Our findings discovered organizational and personal constructs that will inform development of multifaceted strategies toward implementation of POCUS after CVC insertion.

The Role of Ultrasonography in the Diagnosis and Decision Algorithm for the Management of Pneumothorax after Transbronchial Lung Cryobiopsy

Background: Pneumothorax is one of the main complications of transbronchial lung cryobiopsy (TBLC). Chest ultrasound (CUS) is a radiation-free alternative method for pneumothorax detection. Objective: We tested CUS diagnostic accuracy for pneumothorax and assessed its role in the decision algorithm for pneumothorax management. Secondary objectives were to evaluate the post-procedure pneumothorax occurrence and risk factors. Methods: Eligible patients underwent TBLC, followed by chest X-ray (CXR) evaluation 2 h after the procedure, as our standard protocol. Bedside CUS was performed within 30 min and 2 h after TBLC. Pneumothorax by CUS was defined by the absence of lung sliding and comet-tail artefacts and confirmed with the stratosphere sign on M-mode. Pneumothorax size was determined through lung point projection on CUS and interpleural distance on CXR and properly managed according to clinical status. Results: Sixty-seven patients were included. Nineteen pneumothoraces were detected at 2 h after the procedure, of which 8 (42.1%) were already present at the first CUS evaluation. All CXR-detected pneumothoraces had a positive CUS detection. There were 3 discordant cases (κ = 0.88, 95% CI: 0.76–1.00, p < 0.001), which were detected by CUS but not by inspiration CXR. We calculated a specificity of 97.5% (95% CI: 86.8–99.9) and a sensitivity of 100% (95% CI: 87.2–100) for CUS. Pneumothorax rate was higher when biopsies were taken in 2 lobes and if histology had pleural representation. Final diagnosis was achieved in 79.1% of patients, with the most frequent diagnosis being hypersensitivity pneumonitis. Regarding patients with large-volume pneumothorax needing drainage, the rate of detection was similar between CUS and CRX. Conclusion: CUS can replace CXR in detecting the presence of pneumothorax after TBLC, and the lung point site can reliably indicate its size. This useful method optimizes time spent at the bronchology unit and allows immediate response in symptomatic patients, helping to choose optimal treatment strategies, while preventing ionizing radiation exposure.

EUS-Guided versus Percutaneous Image-Guided Liver Biopsy: A Battle for Supremacy!

AbstractLiver biopsy has been the gold standard investigation for diagnosing and staging liver diseases. Image-guided percutaneous liver biopsy is a time-tested technique for obtaining the liver tissue in diffuse liver diseases. However, it is contraindicated in patients with ascites, altered mental status, skin infections, coagulopathy, and thrombocytopenia. It is associated with adverse events including postprocedure pain, bleeding, and pneumothorax. Transvenous liver biopsy can be performed in most cases with these contraindications, but it is an expensive technique and has its own inherent risks. Endoscopic ultrasound (EUS)-guided liver biopsy (EUS-LB) is a relatively new technique that has shown promising results and seems to have a potential of replacing percutaneous liver biopsy. In this news and views, we discuss the results of a randomized controlled trial (RCT) comparing EUS-guided and percutaneous techniques of liver biopsy. This RCT reported that percutaneous technique is superior in terms of diagnostic adequacy and total expenditure without any significant adverse effects compared with EUS-LB. EUS-LB is a promising technique that needs to be further explored in terms of appropriate situations in which it can be preferred over percutaneous or transvenous routes.

Ultrasound-Guided Percutaneous Core Needle Biopsy of Peripheral Pulmonary Nodules ≤ 2cm: Diagnostic Performance, Safety and Influence Factors.

PurposeTo evaluate diagnostic performance and safety of ultrasound-guided needle biopsy in the diagnosis of peripheral pulmonary nodules (PPLs) ≤ 2 cm, and the influence factors of sample adequacy and safety.Materials and Methods194 patients (99 men, 95 women; mean age, 56.2 ± 13.7 years) who received biopsy for PPLs ≤ 2 cm between January 2014 to January 2019 were included. Variables including patient demographics, lesion location, lesion size, presence of lesion necrosis, presence of emphysema on CT, patient position, biopsy needle size and number of needle passes were recorded. Univariate analysis and multivariate logistic regression analysis were performed to explore the influence factor of sample adequacy and safety.ResultsBiopsy specimens were adequate for diagnosis in 161/194 (83%) cases; the diagnostic accuracy was 81.4% (158/194). The overall complication rate was 8.8% (17/194), including pneumothorax, hemoptysis and pleural effusion, which occurred in 2.1% (4/194), 5.2% (10/194), and 1.5% (3/194) of patients, respectively. The incidence of pneumothorax in the 16-gauge-needle group were significantly higher than that of the 18-gauge-needle group (5.6% vs 0%, P=0.018). Adequate sampling of 16-gauge and 18-gauge needles were achieved in 90.3%(65/72) and 78.7%(96/122) cases, respectively. Multivariate logistic regression analysis revealed needle size (16-gauge vs 18-gauge) was an independent influence factors of sample adequacy (P=0.015, odds ratio=3.419). A receiver operating characteristic curve was plotted and the area under the curve was 0.774.ConclusionUS-guided percutaneous needle biopsy is a feasible and safe technique for small PPLs ≤ 2 cm. Needle size is an independent influence factor of sample adequacy and post-procedure pneumothorax. Sixteen-gauge needle has the advantage of achieving adequate sample for pathological analysis, though the risk of pneumothorax should be alerted.

Is Routine Chest Radiography Necessary After Endobronchial Ultrasound–guided Fine Needle Aspiration?

Chest radiography is routinely performed after endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) to detect clinically occult pneumothorax. Because the established rate of postprocedure pneumothorax is low, this study sought to determine whether routine chest radiography can be safely eliminated and to ascertain the potential cost reduction with its omission. Patients who underwent EBUS-FNA between January 1, 2017 and December 31, 2018 at Memorial Sloan Kettering Cancer Center (New York, NY) were retrospectively identified. Patient-related factors were summarized using descriptive statistics. Outcomes werecompared using the χ2, Fisher exact, and analysis of variance tests. Univariate regression analysis was used to identify factors predictive of postprocedure pneumothorax. A total of 757 patients were included in the study: 72.4% (548 of 757) underwent routine chest radiography in the postanesthesia care unit. Clinically relevant or radiographically evident pneumothorax developed in 1.5% of patients (11 of 757). Of the patients who underwent chest radiography, 0.5% (3 of 548) required unplanned admission for postprocedure pneumothorax, and 0.2% (1 of 548) required tube thoracostomy. Of the 209 patients who did not undergo chest radiography, none experienced a clinically evident pneumothorax. In total, only 1 patient (0.1%) had symptomatic pneumothorax. The pneumothorax event rate was so low that no association with demographic or clinical factors and no predictive factors could be identified. The number of patients needed to be screened by chest radiography to identify 1 patient requiring deviation from routine management is 183. The potential total cost reduction if routine chest radiography had been eliminated was $33,950. The extremely low rate of postprocedure pneumothorax precluded informative statistical analysis. Routine chest radiography after EBUS-FNA may not be necessary, and its omission may confer a cost savings.

P636 A unique case of purulent pericarditis resulting in cardiac tamponade

Abstract Introduction and case report description A 54-year-old male with no past cardiac disease was experiencing a productive cough, fevers, chills, and shortness of breath for 3 days in the community. His dyspnea worsened significantly, and he then presented to the emergency room. He admitted to using intravenous recreational drugs. His initial vital signs included a temperature of 38.2 degrees Celsius, a heart rate of 116 beats per minute, and a blood pressure of 88/42 mmHg. He had a positive pulses paradoxus with a decrease in systolic blood pressure of 14 mmHg on inspiration. Description of the problem and procedures This presentation was consistent with cardiac tamponade. He had an emergent echocardiogram showing a large pericardial effusion in the apical-four-chamber view (Image 1, A), including collapse of the right ventricle during diastole (Image 1, B, Green Arrow). There were also fibrin strands seen in a modified parasternal long axis view (Image 1, C, Blue Arrow). He had an emergency pericardiocentesis using real-time ultrasound guidance, which drained 400 mL of thick brown purulent fluid. A pigtail catheter was inserted to allow for continued drainage. Immediately afterwards, the patient’s blood pressure normalized, and his shortness of breath improved significantly. Using the ultrasound, the physician also saw bilateral pleural effusions. The larger left pleural effusion was drained, and a pigtail catheter was inserted into the left pleural space. After confirming that there was no post-procedure left pneumothorax, the right pleural effusion was also drained. An echocardiogram after the pericardiocentesis showed a significant decrease in the size of the pericardial effusion (Image 1, D). The patient was started on broad-spectrum antibiotics, which was then narrowed after cultures from both the pericardial fluid and pleural fluid grew methicillin-susceptible Staphylococcus aureus. Discussion Cardiac tamponade results in increased compression of the cardiac chambers due to raised pericardial pressures. As it progresses, it can result in significant impairment in venous return, cardiac output, and blood pressure. This is a life-threatening condition if it is not promptly treated. In this case, the patient had a methicillin-susceptible Staphylococcus aureus empyema which spread contiguously into the pericardium and resulted in cardiac tamponade. Conclusions and implications for clinical practice This case highlights the clinical benefits of being proficient in performing a point-of-care ultrasound because a bedside echocardiogram by the physician immediately confirmed the diagnosis and allowed for safer drainage of the pericardial effusion using ultrasound guidance to decrease the chance of causing a perforation of the ventricle. Using ultrasound, the clinician was also able to promptly diagnose the pleural effusions and urgently drain them, which was necessary for achieving source control in order to fully treat the infection. Abstract P636 Figure. Image 1. Cardiac Tamponade

A SINGLE-CENTER RETROSPECTIVE EVALUATION OF ENDOBRONCHIAL VALVES FOR LUNG VOLUME REDUCTION IN EMPHYSEMA PATIENTS

SESSION TITLE: Wednesday Electronic Posters 4 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: Lung volume reduction (LVR) surgery was shown to improve exercise tolerance in patients with emphysema. Criner et al. (LIBERATE) reinforced the utility of endobronchial valve (EBV) placement in patients with emphysema and hyperinflation to improve lung function. In this study we report our experience with bronchoscopic LVR following the commercial availability of EBVs. METHODS: Retrospective review of patients who were treated by bronchoscopic LVR over a 6-month period at a single site. Inclusion criteria were age ≥40 with emphysema and hyperinflation with Total Lung Capacity (TLC) >100% predicted and Residual Volume (RV) >150% predicted. Data gathered include baseline characteristics, 45-day spirometric data, and complications (pneumothorax, pleural effusion, COPD exacerbation, arrhythmia). The primary endpoint was post bronchodilator response FEV1 ≥ 15% increase from baseline. Secondary endpoints were TLC change, absolute change in FEV1, and complication rates of EBV. RESULTS: A total of 18 patients were treated during this period. The average age of the patients evaluated was 69 years-old. 61% of patients were female (11) and 88.9% were Caucasian (16). Baseline 6 minute walk distance (6MWD) was 251 meters. The average baseline RV was 4.54L (217% of predicted) and baseline post-bronchodilator FEV1 was 750mL (30.3% predicted). At the 45-day mark, our patients had a FEV1 increase of 79.2mL (increase of 3% predicted), 30.7% showed an improvement in FEV1 ≥15% from baseline. RV decrease was on average 190mL. Total lung volume reduction on average was 610mL with 75% exhibiting a decrease ≥350mL. Regarding complications, 38.9% of our patients did have post-procedure pneumothorax with 22.2% of the patients requiring partial or total EBV removal. 27.8% of patients did have post procedure COPD exacerbation requiring medical attention with 80% of those patients having COPD exacerbations in the first 45 days. One patient had a previous treatment with vapor to the contralateral lung and another had alpha 1 antitrypsin deficiency. Both had positive outcomes. CONCLUSIONS: At the 45-day point, our center’s experience provided similar positive results as the LIBERATE study. Additionally, our patients exhibited a comparable incidence of pneumothorax post EBV placement. To our knowledge, this is the first and largest published single center experience on EBV for lung volume reduction since the Food and Drug Administration (FDA) approved the device in June 2018. We anticipate similar positive results at the one-year mark. CLINICAL IMPLICATIONS: Heterogeneous and homogeneous emphysema can be effectively treated with endobronchial valves to improve patients’ lung function. DISCLOSURES: No relevant relationships by Raed Alalawi, source=Web Response No relevant relationships by Richard Sue, source=Web Response No relevant relationships by Steve Tseng, source=Web Response No relevant relationships by Leigha Vick, source=Web Response

Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine.

Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine.

Routine use of ultrasound to avert mechanical complications during placement of tunneled dialysis catheters for hemodialysis

ObjectiveWhile placement of tunneled dialysis catheters for hemodialysis access is considered a routine procedure, it is associated with a small chance of mechanical complications. Because the literature examining these issues is not recent and our impression of the incidence of these postprocedural complications is at variance with the existing literature, we decided to review our experience. MethodsSince 1998, our vascular service has placed 1766 tunneled hemodialysis catheters in 1065 patients for hemodialysis access. All catheters were placed with ultrasound guidance for the puncture, with selective use of a micropuncture set for patients with low-volume status. All patients underwent chest radiography at the end of each procedure. ResultsThe average age of the patients was 61 ± 21 (standard deviation) years. Among the 1065 patients, 44% were female; 93% of catheters were placed in the right internal jugular vein and 7% in the left internal jugular vein. The prevalence of diabetes and hypertension in our population of patients was 52% and 72%, respectively. In this consecutive series, no case of postprocedure hemothorax or pneumothorax was encountered. Two cutdowns had to be performed because of injury to branches of the external carotid artery. Three patients had to have a subsequent revision because of malpositioning of the catheter. ConclusionsUsing modern-day techniques, the incidence of mechanical complications during placement of tunneled catheters can be diminished. Hence, routine use of ultrasound guidance for insertion of tunneled dialysis catheters should become the standard of care.

Evaluation of various patient-, lesion-, and procedure-related factors on the occurrence of pneumothorax as a complication of CT-guided percutaneous transthoracic needle biopsy.

PurposeTo assess the influence of various patient-, lesion-, and procedure-related variables on the occurrence of pneumothorax as a complication of CT-guided percutaneous transthoracic needle biopsy.Material and methodsIn a total of 208 patients, 215 lung/mediastinal lesions (seven patients were biopsied twice) were sampled under CT guidance using coaxial biopsy set via percutaneous transthoracic approach. Incidence of post procedure pneumothorax was seen and the influence of various patient-, lesion-, and procedure-related variables on the frequency of pneumothorax with special emphasis on procedural factors like dwell time and needle-pleural angle was analysed.ResultsPneumothorax occurred in 25.12% (54/215) of patients. Increased incidence of pneumothorax had a statistically significant correlation with age of the patient (p = 0.0020), size (p = 0.0044) and depth (p = 0.0001) of the lesion, and needle-pleural angle (p = 0.0200). Gender of the patient (p = 0.7761), emphysema (p = 0.2724), site of the lesion (p = 0.9320), needle gauge (p = 0.7250), patient position (p = 0.9839), and dwell time (p = 0.9330) had no significant impact on the pneumothorax rate.ConclusionsThis study demonstrated a significant effect of the age of the patient, size and depth of the lesion, and needle-pleural angle on the incidence of post-procedural pneumothorax. Emphysema as such had no effect on pneumothorax rate, but once pneumothorax occurred, emphysematous patients were more likely to be symptomatic, necessitating chest tube placement. Gender of the patient, site of the lesion, patient position during the procedure, and dwell time had no statistically significant relation with the frequency of post-procedural pneumothorax. Surprisingly, needle gauge had no significant effect on pneumothorax frequency, but due to the small sample size, non-randomisation, and bias in needle size selection as per lesion size, further studies are required to fully elucidate the causal relationship between needle size and post-procedural pneumothorax rate. The needle should be as perpendicular as possible to the pleura (needle-pleural angle close to 90°), to minimise the possibility of pneumothorax after percutaneous transthoracic needle biopsy.

Microwave Ablation of Metastatic Lung Lesions Under Guidance of Augmented Reality CT Navigation System (Sirio): A Case Report

Microwave ablation (MWA) of lung lesions under guidance of computed tomography (CT) and SIRIO system (Sistema robotizzato assistito per il puntamento intraoperatorio) is providing accurate and real time visualization system. We present a case of 65 y male patient with multiple metastatic lung lesions from gluteal mesenchymal tumor confirmed histopathologically, MWA of two lesions under general anesthesia using double lumen endotracheal tube to exclude LT lung. Complete ablation of lesions was achieved, post-procedure pneumothorax was treated by (Heimlich valve) insertion, 24 hours follow up revealed complete resolution of pneumothorax. In this case report we found that the total procedure time and the total effective radiation dose of the whole procedure were reduced in compared with a previous case of MW ablation of similar sizes lesions under CT guidance only.

Unexpandable lung from pleural disease.

Unexpandable lung is a common complication of malignant pleural effusions and inflammatory pleural diseases, such as pleural infection (e.g. empyema and complicated parapneumonic effusion) and noninfectious fibrinous pleuritis. Unexpandable lung due to pleural disease may be because of an active pleural process, and is referred to as malignant or inflammatory lung entrapment. An unexpandable lung may also be encountered in the setting of remote pleural inflammation resulting in a mature fibrous membrane overlying the visceral pleura preventing full expansion of the lung. This condition is termed trapped lung and may be understood as a form of defective healing of the pleural space. Trapped lung typically presents as a chronic, stable pleural effusion without evidence of active pleural disease. An unexpandable lung most often manifests itself as an inability of fully expanding the lung with pleural space drainage. Patients will either develop chest pain preventing complete drainage of the pleural space or develop a post-procedure pneumothorax. Pleural manometry and radiological imaging are useful in the assessment of an unexpandable lung. Pleural manometry can demonstrate abnormal lung expansion during drainage and imaging will demonstrate abnormal visceral pleural thickening found in trapped lung or malignant and inflammatory lung entrapment.