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Abstract Despite the latest developments in therapeutic agents targeting airway endotypes, a significant proportion of patients with asthma and chronic obstructive pulmonary disease (COPD) remain symptomatic. Endoscopic therapies have a complementary role in the management of these airway diseases. The sustained efficacy of bronchial thermoplasty (BT) among patients with asthma over 10 years has been encouraging, as it has been shown to improve symptom control and reduce hospital admissions and exacerbations. Studies suggest that BT helps ameliorate airway inflammation and reduce airway smooth muscle thickness. While studies suggest that it is as effective as biologic agents, its role in the management of severe asthma has yet to be clearly defined and GINA 2022 still suggests limiting its use to patients with characteristics of the various populations studied. Conversely, bronchoscopic lung volume reduction has shown promise among patients with advanced COPD. Rigorous patient selection is important. Patients with minimal collateral ventilation (CV) and higher heterogeneity index have shown to benefit the most from endobronchial valve (EBV) therapy. For those with ongoing CV, endobronchial coils would be more appropriate. Both therapeutic modalities have demonstrated improved quality of life, effort tolerance, and lung function indices among appropriately selected patients. The emerging evidence suggests that endoscopic procedures among airway disease still have a substantial role to play despite the development of new therapeutic options.

This clinical study presents a comprehensive investigation into the utility of breath analysis as a non-invasive method for the early detection of lung cancer. The study enrolled 14 lung cancer patients, 14 non-lung cancer controls with diverse medical conditions, and 3 tuberculosis (TB) patients for biomarker discovery. Matching criteria including age, gender, smoking history, and comorbidities were strictly followed to ensure reliable comparisons. A systematic breath sampling protocol utilizing a BIO-VOC sampler was employed, followed by VOC analysis using Thermal Desorption–Gas Chromatography–Mass Spectrometry (TD-GC/MS). The resulting VOC profiles were subjected to stringent statistical analysis, including Orthogonal Projections to Latent Structures—Discriminant Analysis (OPLS-DA), Kruskal–Wallis test, and Receiver Operating Characteristic (ROC) analysis. Notably, 13 VOCs exhibited statistically significant differences between lung cancer patients and controls. The combination of eight VOCs (hexanal, heptanal, octanal, benzaldehyde, undecane, phenylacetaldehyde, decanal, and benzoic acid) demonstrated substantial discriminatory power with an area under the curve (AUC) of 0.85, a sensitivity of 82%, and a specificity of 76% in the discovery set. Validation in an independent cohort yielded an AUC of 0.78, a sensitivity of 78%, and a specificity of 64%. Further analysis revealed that elevated aldehyde levels in lung cancer patients’ breath could be attributed to overactivated Alcohol Dehydrogenase (ADH) pathways in cancerous tissues. Addressing methodological challenges, this study employed a matching of physiological and pathological confounders, controlled room air samples, and standardized breath sampling techniques. Despite the limitations, this study’s findings emphasize the potential of breath analysis as a diagnostic tool for lung cancer and suggest its utility in differentiating tuberculosis from lung cancer. However, further research and validation are warranted for the translation of these findings into clinical practice.

More than half of all pleural effusions are due to malignancy of which lung cancer is the main cause. Pleural effusions can complicate the course of pneumonia, pulmonary tuberculosis, or underlying systemic disease. We explore the application of label-free surface-enhanced Raman spectroscopy (SERS) as a point of care (POC) diagnostic tool to identify if pleural effusions are due to lung cancer or to other causes (controls). Lung cancer samples showed specific SERS spectral signatures such as the position and intensity of the Raman band in different wave number region using a novel silver coated silicon nanopillar (SCSNP) as a SERS substrate. We report a classification accuracy of 85% along with a sensitivity and specificity of 87% and 83%, respectively, for the detection of lung cancer over control pleural fluid samples with a receiver operating characteristics (ROC) area under curve value of 0.93 using a PLS-DA binary classifier to distinguish between lung cancer over control subjects. We have also evaluated discriminative wavenumber bands responsible for the distinction between the two classes with the help of a variable importance in projection (VIP) score. We found that our label-free SERS platform was able to distinguish lung cancer from pleural effusions due to other causes (controls) with higher diagnostic accuracy.

Video-assisted thoracic surgery (VATS) is the treatment of choice for recurrence prevention in patients with spontaneous pneumothorax (SP). Although the optimal surgical technique is uncertain, bullous resection using staplers in combination with mechanical pleurodesis, chemical pleurodesis and/or staple line coverage is usually undertaken. Currently, patient satisfaction, postoperative pain and other perioperative parameters have significantly improved with advancements in thoracoscopic technology, which include uniportal, needlescopic and nonintubated VATS variants. Ipsilateral recurrences after VATS occur in less than 5% of patients, in which case a redo-VATS is a feasible therapeutical option. Randomized controlled trials are urgently needed to shed light on the best definitive management of SP.

Obstructive diseases of the airway are a diverse group, although they share in common airway narrowing as a sequel to inflammation, which leads to increased work of breathing. Optimal treatment strategies for this heterogeneous group of asthma, chronic bronchitis and emphysema should be multidimensional and embrace pharmacological and nonpharmacological means as well as surgery in a highly select group of patients with emphysema. We review the current status of the bronchoscopic interventions that have been in development for the past decade with the objectives of providing better symptom control in asthma and palliation in individuals with emphysema who are otherwise poor candidates for lung volume reduction surgery.

Pleural disease in lung cancer can be benign or malignant with the latter carrying a grave prognosis. In this review, we describe and discuss the advances in pleural imaging, procedures, and biomarkers for the diagnosis of pleural diseases in lung cancer. Ultrasound and computed tomography are increasingly applied in the planning of pleural procedures to enhance diagnostic accuracy and safety whilst pleuroscopy gives excellent yield in excess of 93% in the evaluation of cytology negative pleural effusions. Invasion beyond the elastic layer of the visceral pleura upstages lung cancer, and may indicate a need for adjuvant chemotherapy. Biomarkers isolated from pleural fluid or tissue may aid in diagnosis and guide treatment in the future. Magnetic resonance imaging, positron emission tomography, narrow band imaging of the pleura and autofluorescence thoracoscopy are technologies that require further evaluation to better define their respective roles in the diagnostic algorithms of pleural diseases in lung cancer.

Hydrated magnesium silicate (or "talc" particles) is a sclerosis agent commonly used in the management of malignant pleural effusions, a common symptom of metastatic diseases, including lung cancers. However, the direct effects of talc particles to lung carcinoma cells, which can be found in the malignant pleural effusion fluids from patients with lung cancer, are not fully understood. Here, we report a study of the signaling pathways that can modulate the cell death and IL-6 secretion induced by talc particles in human lung carcinoma cells. We found that talc-sensitive cells have higher mRNA and protein expression of PI3K catalytic subunits α and β. Further experiments confirmed that modulation (inhibition or activation) of the PI3K pathway reduces or enhances cellular sensitivity to talc particles, respectively, independent of the inflammasome. By knocking down specific PI3K isoforms, we also confirmed that both PI3Kα and -β mediate the observed talc effects. Our results suggest a novel role of the PI3K pathway in talc-induced cell death and IL-6 secretion in lung carcinoma cells. These cellular events are known to drive fibrosis, and thus further studies of the PI3K pathway may provide a better understanding of the mechanisms of talc sclerosis in the malignant pleural space. [ABSTRACT FROM AUTHOR]

Introduction: Malignant pleural effusion can complicate most cancers. It causes breathlessness and requires hospitalisation for invasive pleural drainages. Malignant effusions often herald advanced cancers and limited prognosis. Minimising time spent in hospital is of high priority to patients and their families. Various treatment strategies exist for the management of malignant effusions, though there is no consensus governing the best choice. Talc pleurodesis is the conventional management but requires hospitalisation (and substantial healthcare resources), can cause significant side effects, and has a suboptimal success rate. Indwelling pleural catheters (IPCs) allow ambulatory fluid drainage without hospitalisation, and are increasingly employed for management of malignant effusions. Previous studies have only investigated the length of hospital care immediately related to IPC insertion. Whether IPC management reduces time spent in hospital in the patients' remaining lifespan is unknown. A strategy of malignant effusion management that reduces hospital admission days will allow patients to spend more time outside hospital, reduce costs and save healthcare resources. Methods and analysis: The Australasian Malignant Pleural Effusion (AMPLE) trial is a multicentred, randomised trial designed to compare IPC with talc pleurodesis for the management of malignant pleural effusion. This study will randomise 146 adults with malignant pleural effusions (1:1) to IPC management or talc slurry pleurodesis. The primary end point is the total number of days spent in hospital (for any admissions) from treatment procedure to death or end of study follow-up. Secondary end points include hospital days specific to pleural effusion management, adverse events, self-reported symptom and quality-of-life scores. [ABSTRACT FROM AUTHOR]

The article discusses a study that examined the local and systemic reactions of pills that access the airways either by incidental aspiration or iatrogenic administration. The clinical presentation, mechanism of injury, diagnosis, and management of complications of the pills in the air passages are addressed. Physicians involved in the management of airway ailments are advised to be fully cognizant of the clinical presentations of pill aspirations.

The article offers an American College of Chest Physician consensus statement that aims to provide suggestions for the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy. Topical anesthesia, analgesia, sedation are recommended in all patients undergoing bronchoscopy because of improved patient tolerance and satisfaction. Lidocaine is said to be the preferred topical anesthetic for bronchoscopy. Propofol is reportedly an effective agent for sedation in bronchoscopy.

The article describes the case of a 45-year-old asthmatic woman suffering from productive cough for six months referred to the Department of Respiratory and Critical Care Medicine at National University Hospital in Singapore. An endobronchial tumor was found to be obstructing the left main bronchus during bronchoscopy. She was diagnosed with typical bronchial carcinoid. It cites the need for a high index of suspicion for endobronchial pathology in difficult-to-treat obstructive airway disease.

Background: Transbronchial needle aspiration (TBNA) is a bronchoscopic technique that provides access to masses within the mediastinum. It is operator dependent, and factors such as needle type, lymph node site, and endobronchial ultrasosonography (EBUS) have been implicated as having an impact on its accuracy. This study aimed to develop a strategy for TBNA and specimen preparation techniques as the first step toward improving TBNA yield, and to determine whether EBUS can augment its application. Methods: Intervention included standardizing the use of the histology needle and the direct smear method. As competency improved, radial probe (RP) and linear EBUS were incorporated into TBNA. Results: The study assessed 35 conventional TBNA procedures before and 45 of these procedures after intervention as well as 45 RP-EBUS and 50 linear EBUS-guided TBNA procedures. Frequently sampled lymph node stations were 7, 4R, and 4L in the American Thoracic Society classification. The preintervention conventional TBNA yield was 43%, which improved to 82% after intervention. Although EBUS did not have an impact on TBNA yield ( p = 0.44) compared with the intervention ( p = 0.001), EBUS was useful for lymph nodes smaller than 2 cm ( p < 0.0001). Linear EBUS did not confer higher diagnostic accuracy than RP-EBUS ( p = 0.47). Conclusion: Proper TBNA and specimen preparation techniques are the first steps toward improving TBNA yield, and EBUS can be used to guide TBNA of small lymph nodes. [ABSTRACT FROM AUTHOR]

The article presents the case of a 46-year-old woman diagnosed with pulmonary nodules. The patient was presented to the respiratory clinic with exertional dyspnea and on examination, she was afebrile and not in respiratory distress. In connection, the patient was treated for postviral bronchoreactivity with superimposed chest infection.

Objective: This study aimed to assess prospectively the accuracy, safety and outcome of flex-rigid pleuroscopy in the diagnosis of patients with indeterminate pleural effusions. Methods: Included in the study were all patients with unilateral exudative pleural effusions of unknown aetiology who underwent diagnostic flex-rigid pleuroscopy from July 2003 to June 2005, and were followed until December 2005. The procedure was conducted in the endoscopy suite under local anaesthesia and, where indicated, talc poudrage was carried out at the same time. Clinical data, length of hospitalization, chest tube drainage, outcome, diagnostic accuracy of pleuroscopy and procedure-related adverse events were recorded prospectively. Results: Fifty-one patients were recruited (20 male and 31 female). Median age was 53 years (range 45–67). Flex-rigid pleuroscopy was 96% accurate and yielded a diagnosis in 49 out of 51 patients. It was safely carried out without need for surgical intervention, blood transfusion or endotracheal intubation. Culture-negative fever was observed in eight patients (16%), and five patients (10%) required additional analgesia for postoperative pain. Duration of chest tube drainage and length of stay for patients who underwent diagnostic pleuroscopy were 1 and 2 days, respectively, while they were both 3 days when talc poudrage was carried out. Success rates with pleuroscopic talc pleurodesis for malignant pleural effusions were 94%, 92% and 89.5% at 3, 6 and 12 months, respectively, and the 30-day mortality was 0%. Conclusion: Flex-rigid pleuroscopy is a safe procedure with a high diagnostic accuracy and should be considered for the evaluation of indeterminate pleural effusion. [ABSTRACT FROM AUTHOR]

Pleuroscopy provides the pulmonologist with a unique opportunity to visualize the contents of the pleural space, perform biopsy of the parietal pleura under direct visual guidance, allow optimal chest tube placement and perform pleurodesis to prevent recurrent pleural effusion or pneumothorax in selected patients. We discuss the techniques, indications, contraindications and complications of pleuroscopy using rigid and semirigid instruments. In addition, the potential value and expanding role of pleuroscopy with semirigid instrumentation is debated. [ABSTRACT FROM AUTHOR]

Background: The pulmonary nodule (PN) poses a diagnostic and therapeutic challenge in the immunocompromised host. Common causes of PNs in lung transplant (LT) recipients include bacterial or fungal infections and posttransplant lymphoproliferative disorder (PTLD). However, experience in diagnosis and management of PNs is limited. Methods: Two hundred thirty-four LTs were performed between February 1990 and December 2000. Medical records of all patients with PNs were reviewed retrospectively. Data on presentation, radiographic features, diagnostic methods, therapy, and outcome were collected and analyzed. Results: Twenty-three patients had PNs after a follow-up of 20.1 ± 20.1 months (mean ± SD). The mean age was 45.5 ± 14.4 years, with a male:female ratio of 17:6. Thirteen patients received single LT, 9 patients received bilateral LT, and 1 patient received heart-LT. Cough and dyspnea were the most common symptoms at presentation, and PNs were better detected by CT than chest radiography. Solitary PNs were due to bronchogenic carcinoma and PTLD, while multiple PNs were due to invasive pulmonary aspergillosis (IPA), cytomegalovirus pneumonitis, bronchiolitis obliterans, and metastatic carcinoma. Bronchoscopy with BAL and transbronchial lung biopsy was the usual method of diagnosis (n = 17, 74%), and our morality rate was 70%. Conclusion: PNs are not uncommon in patients following LT. The majority were due to IPA and PTLD. Prophylaxis with itraconazole against Aspergillus, and acyclovir for Epstein-Barr virus negative LT recipients, serial CT and surveillance bronchoscopy for early detection of Aspergillus infections, and rituximab therapy for PTLD could improve the outcome of these patients. Key words: Aspergillus; carcinoma: cytomegalovirus; lung transplant; posttransplant lymphoproliferative disorder; pulmonary nodule. [ABSTRACT FROM AUTHOR]

Thoracoscopy is used increasingly as a diagnostic and therapeutic procedure in patients with pleural and pulmonary disease by thoracic surgeons and pulmonologists. The thoracic surgical community, through research and publications, has clearly delineated its scope in surgical practice. Data pertaining to pulmonologists' perceptions of thoracoscopy, however, are lacking. We surveyed a group of physicians attending a pleural disease course at the American Lung Association/American Thoracic Society 1999 International Conference to understand better the role of thoracoscopy in a pulmonologist's practice. A 14-item questionnaire was administered to all 142 attendees. Comparison of responses between groups was performed with the chi-square test, and p ≤ 0.05 was considered significant. One hundred forty-one fully completed questionnaires were analyzed. Ninety percent (n = 128) surveyed were pulmonologists, 9% (n = 12) were trainees, and 1% (n = 1) was not a pulmonologist. The majority worked in academic institutions and had been in practice for 5 years. Twenty-three percent reported having performed thoracoscopy, of which 10% practiced in the United States. Most preferred thoracoscopy to closed needle biopsy and chest tube pleurodesis, and were of the opinion that its role in pulmonary practice, although currently limited by the lack of training opportunities, was likely to increase in the future. Thoracoscopy was considered a valuable addition to a pulmonologist's armamentarium and could be performed by trained pulmonologists. [ABSTRACT FROM AUTHOR]

Discusses the case of a young woman with prominent right tracheobronchial mass detected on a preemployment chest radiograph. Examination of the cardiovascular and respiratory system; Deviation of the right paravertebral pleura; Result of absent infrahepatic inferior vena cava.

A letter to the editor is presented about a case of markedly increased pleural effusion in a patient who is responding to an oral epidermal growth factor receptor tyrosine kinase inhibitor.

Bronchial stenosis (BS) consequent to iron pill aspiration (IPA) has been observed in few reported cases. This condition is often irreversible and may necessitate lobectomy in severe cases. Unlike most foreign bodies (FBs); the iron pill disintegrates in the airway and cannot be detected on bronchoscopy. However, bronchial biopsy and lung tissue may reveal iron deposits along with airway inflammation months after the aspiration. Thus, IPA can be diagnosed by a triad of aspiration, airway inflammation, and iron deposits on histology even in the absence of an FB. We report a ease of IPA with BS in which the diagnosis was established by bronchial biopsy and was successfully managed with balloon bronchoplasty and therapy with topical mitomycin C. [ABSTRACT FROM AUTHOR]