Search

Background: Pleural effusions in post-operative thoracic surgery patients are common. Effusions can result in prolonged hospitalizations or readmissions, with prior studies suggesting mixed effects of pleural drainage on hypoxia. We aimed to define the impact of pleural drainage on pulse oximetry (SpO2) in post-thoracic surgery patients., Methods: A retrospective study of post-operative thoracic surgery patients undergoing pleural drainage was performed. SpO2 and supplemental oxygen (FiO2) values were recorded at pre- and post-procedure. The primary outcome was difference in pre-procedural and post-procedural SpO2., Results: We identified 95 patients with a mean age of 65 (SD - 13.8) years undergoing 122 pleural drainage procedures. Mean drainage volume was 619 (SD-423) mL and the majority of procedures (88.5 %) included a drainage of <1000 mL. SpO2 was associated with an increase from 94.0 % (SD-2.6) to 97.3 % (SD-2.0) at 24-h (p < 0.0001). FiO2 was associated with a decrease from 0.31 (SD-0.15) to 0.29 (SD-0.12) at 24-h (p = 0.0081). SpO2/FiO2 was associated with an increase from 344.5 (SD-99.0) to 371.9 (SD-94.7) at 24-h post-procedure (p < 0.0001)., Conclusions: Pleural drainage within post-operative thoracic surgery patients offers statistically significant improvements in oxygen saturation by peripheral pulse oximetry and oxygen supplementation; however the clinical significance of these changes remains unclear. Pleural drainage itself may be requested for numerous reasons, including diagnostic (fevers, leukocytosis, etc.) or therapeutic (worsening dyspnea) evaluation. However, pleural drainage may offer minimal clinical impact on pulse oximetry in post-operative thoracic surgery patients., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Bronchoscopy is currently the least invasive method for definitively diagnosing lung cancer, which kills more people in the United States than any other form of cancer. Successfully diagnosing suspicious lung nodules requires accurate localization of the bronchoscope relative to a planned biopsy site in the airways. This task is challenging because the lung deforms intraoperatively due to respiratory motion, the airways lack photometric features, and the anatomy's appearance is repetitive. In this paper, we introduce a real-time camera-based method for accurately localizing a bronchoscope with respect to a planned needle insertion pose. Our approach uses deep learning and accounts for deformations and overcomes limitations of global pose estimation by estimating pose relative to anatomical landmarks. Specifically, our learned model considers airway bifurcations along the airway wall as landmarks because they are distinct geometric features that do not vary significantly with respiratory motion. We evaluate our method in a simulated dataset of lungs undergoing respiratory motion. The results show that our method generalizes across patients and localizes the bronchoscope with accuracy sufficient to access the smallest clinically-relevant nodules across all levels of respiratory deformation, even in challenging distal airways. Our method could enable physicians to perform more accurate biopsies and serve as a key building block toward accurate autonomous robotic bronchoscopy.

Interventional pulmonology (IP) fellowship training has undergone increased popularity and growth. The Accreditation Council of Graduate Medical Education recently recognized IP medicine as a new subspecialty, which leads to new challenges and opportunities for a young subspecialty. Although the specialty-specific requirements are in progress, IP fellowship programs must plan ahead for the known common program requirements and anticipated accreditation process. The educational leadership in IP must identify and execute solutions to sustain continued excellence. This includes transitioning to a new regulatory environment with issues of funding new fellowships, keeping up to date with training/assessment of new procedures, and shaping the future through recruitment of talent to lead the young subspecialty., (Copyright © 2023 by the American Thoracic Society.)

Malignant pleural effusion is associated with a poor prognosis and, while risk stratification models exist, prior studies have not evaluated pleural fluid resolution and its association with survival. We performed a retrospective review of patients diagnosed with malignant pleural effusion between 2013 and 2017, evaluating patient demographics, pleural fluid and serum composition, and procedural and treatment data using Cox regression analysis to evaluate associations with survival. In total, 123 patients were included in the study, with median survival from diagnosis being 4.8 months. Resolution of malignant pleural fluid was associated with a significant survival benefit, even when accounting for factors such as placement of an indwelling pleural catheter, anti-cancer therapy, pleural fluid cytology, cancer pheno/genotypes, and pleural fluid characteristics. Elevated fluid protein, placement of an indwelling pleural catheter, and treatment with targeted or hormone therapies were associated with pleural fluid resolution. We conclude that the resolution of pleural fluid accumulation in patients with malignant pleural effusion is associated with a survival benefit possibility representing a surrogate marker for treatment of the underlying metastatic cancer. These findings support the need to better understand the mechanism of fluid resolution in patients with malignant pleural effusion as well as the tumor-immune interplay occurring with the malignant pleural space.

Background: The use of mapping to guide peripheral lung navigation (PLN) represents an advance in the management of peripheral pulmonary lesions (PPL). Software has been developed to virtually reconstruct computed tomography images into 3-dimensional airway maps and generate navigation pathways to target PPL. Despite this there remain significant gaps in understanding the factors associated with navigation success and failure including the cartographic performance characteristics of these software algorithms. This study was designed to determine whether differences exist when comparing PLN mapping platforms., Methods: An observational direct comparison was performed to evaluate navigation planning software packages for the lung. The primary endpoint was distance from the terminal end of the virtual navigation pathway to the target PPL. Secondary endpoints included distal virtual and segmental airway generations built to the target and/or in each lung., Results: Twenty-five patient chest computed tomography scans with 41 PPL were evaluated. Virtual airway and navigation pathway maps were generated for each scan/nodule across all platforms. Virtual navigation pathway comparison revealed differences in the distance from the terminal end of the navigation pathway to the target PPL (robotic bronchoscopy 9.4 mm vs. tip-tracked electromagnetic navigation 14.2 mm vs. catheter based electromagnetic navigation 17.2 mm, P=0.0005) and in the generation of complete distal airway maps., Conclusion: Comparing PLN planning software revealed significant differences in the generation of virtual airway and navigation maps. These differences may play an unrecognized role in the accurate PLN and biopsy of PPL. Further prospective trials are needed to quantify the effect of the differences reported., Competing Interests: Disclosure: J.A.A., L.Y., and H.L.: Research, educational grants, and consulting fees from Intuitive, Veran Medical and Medtronic/SuperDimension. M.M.W.: Research, educational grants, and consulting fees from Intuitive. A.C.: Research, educational grants, and consulting fees from Auris. D.M: Research, educational grants, and consulting fees from Intuitive. F.M.: Research grants and/or consulting fees from Medtronic/SuperDimension and Intuitive. A.V.: Research grants from Broncus Medical. D.Y. has no conflict of interest or other disclosures., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Current medical society guidelines recommend a procedural number for obtaining electromagnetic navigational bronchoscopy (ENB) competency and for institutional volume for training., Objective: To assess learning curves and estimate the number of ENB procedures for interventional pulmonology (IP) fellows to reach competency., Methods: We conducted a prospective multicenter study of IP fellows in the United States learning ENB. A tool previously validated in a similar population was used to assess IP fellows by their local faculty and two blinded independent reviewers using virtual recording of the procedure. Competency was determined by performing three consecutive procedures with a competency score on the assessment tool. Procedural time, faculty global rating scale, and periprocedural complications were also recorded., Results: A total of 184 ENB procedures were available for review with assessment of 26 IP fellows at 16 medical centers. There was a high correlation between the two blinded independent observers (rho = 0.8776). There was substantial agreement for determination of procedural competency between the faculty assessment and blinded reviewers (kappa = 0.7074; confidence interval, 0.5667-0.8482). The number of procedures for reaching competency for ENB bronchoscopy was determined (median, 4; mean, 5; standard deviation, 3.83). There was a wide variation in the number of procedures to reach competency, ranging from 2 to 15 procedures. There were six periprocedural complications reported, four (one pneumomediastinum, three pneumothorax) of which occurred before reaching competence and two pneumothoraces after achieving competence., Conclusion: There is a wide variation in acquiring competency for ENB among IP fellows. Virtual competency assessment has a potential role but needs further studies., (Copyright © 2022 by the American Thoracic Society.)

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Steerable needles that are able to follow curvilinear trajectories and steer around anatomical obstacles are a promising solution for many interventional procedures. In the lung, these needles can be deployed from the tip of a conventional bronchoscope to reach lung lesions for diagnosis. The reach of such a device depends on several design parameters including the bronchoscope diameter, the angle of the piercing device relative to the medial axis of the airway, and the needle's minimum radius of curvature while steering. Assessing the effect of these parameters on the overall system's clinical utility is important in informing future design choices and understanding the capabilities and limitations of the system. In this paper, we analyze the effect of various settings for these three robot parameters on the percentage of the lung that the robot can reach. We combine Monte Carlo random sampling of piercing configurations with a Rapidly-exploring Random Trees based steerable needle motion planner in simulated human lung environments to asymptotically accurately estimate the volume of sites in the lung reachable by the robot. We highlight the importance of each parameter on the overall system's reachable workspace in an effort to motivate future device innovation and highlight design trade-offs.

Background: The impact of the coronavirus disease (COVID-19) pandemic extends beyond the realms of patient care and healthcare resource use to include medical education; however, the repercussions of COVID-19 on the quality of training and trainee perceptions have yet to be explored. Objective: The purpose of this study was to determine the degree of interventional pulmonology (IP) fellows' involvement in the care of COVID-19 and its impact on fellows' clinical education, procedure skills, and postgraduation employment search. Methods: An internet-based survey was validated and distributed among IP fellows in North American fellowship training programs. Results: Of 40 eligible fellows, 38 (95%) completed the survey. A majority of fellows (76%) reported involvement in the care of patients with COVID-19. Fellows training in the Northeast United States reported involvement in the care of a higher number of patients with COVID-19 than in other regions (median, 30 [interquartile range, 20-50] vs. 10 [5-13], respectively; P  < 0.01). Fifty-two percent of fellows reported redeployment outside IP during COVID-19, mostly into intensive care units. IP procedure volume decreased by 21% during COVID-19 compared with pre-COVID-19 volume. This decrease was mainly accounted for by a reduction in bronchoscopies. A majority of fellows (82%) reported retainment of outpatient clinics during COVID-19 with the transition from face-to-face to telehealth-predominant format. Continuation of academic and research activities during COVID-19 was reported by 86% and 82% of fellows, respectively. After graduation, all fellows reported having secured employment positions. Conclusion: Although IP fellows were extensively involved in the care of patients with COVID-19, most IP programs retained educational activities through the COVID-19 outbreak. The impact of the decrease in procedure volume on trainee competency would be best addressed individually within each training program. These data may assist in focusing efforts regarding the education of medical trainees during the current and future healthcare crises., (Copyright © 2021 by the American Thoracic Society.)

Rationale: Patients with malignant or paramalignant pleural effusions (MPEs or PMPEs) may have tunneled pleural catheter (TPC) management withheld because of infection concerns from immunosuppression associated with antineoplastic therapy. Objectives: To determine the rate of infections related to TPC use and to determine the relationship to antineoplastic therapy, immune system competency, and overall survival (OS). Methods: We performed an international, multiinstitutional study of patients with MPEs or PMPEs undergoing TPC management from 2008 to 2016. Patients were stratified by whether or not they underwent antineoplastic therapy and/or whether or not they were immunocompromised. Cumulative incidence functions and multivariable competing risk regression analyses were performed to identify independent predictors of TPC-related infection. Kaplan-Meier method and multivariable Cox proportional hazards modeling were performed to examine for independent effects on OS. Results: A total of 1,408 TPCs were placed in 1,318 patients. Patients had a high frequency of overlap between antineoplastic therapy and an immunocompromised state (75-83%). No difference in the overall (6-7%), deep pleural (3-5%), or superficial (3-4%) TPC-related infection rates between subsets of patients stratified by antineoplastic therapy or immune status was observed. The median time to infection was 41 (interquartile range, 19-87) days after TPC insertion. Multivariable competing risk analyses demonstrated that longer TPC duration was associated with a higher risk of TPC-related infection (subdistribution hazard ratio, 1.03; 95% confidence interval [CI], 1.00-1.06; P  = 0.028). Cox proportional hazards analysis showed antineoplastic therapy was associated with better OS (hazard ratio, 0.84; 95% CI, 0.73-0.97; P  = 0.015). Conclusions: The risk of TPC-related infection does not appear to be increased by antineoplastic therapy use or an immunocompromised state. The overall rates of infection are low and comparable with those of immunocompetent patients with no relevant antineoplastic therapy. These results support TPC palliation for MPE or PMPEs regardless of plans for antineoplastic therapy.

Lung cancer is one of the deadliest types of cancer, and early diagnosis is crucial for successful treatment. Definitively diagnosing lung cancer typically requires biopsy, but current approaches either carry a high procedural risk for the patient or are incapable of reaching many sites of clinical interest in the lung. We present a new sampling-based planning method for a steerable needle lung robot that has the potential to accurately reach targets in most regions of the lung. The robot comprises three stages: a transorally deployed bronchoscope, a sharpened piercing tube (to pierce into the lung parenchyma from the airways), and a steerable needle able to navigate to the target. Planning for the sequential deployment of all three stages under health safety concerns is a challenging task, as each stage depends on the previous one. We introduce a new backward planning approach that starts at the target and advances backwards toward the airways with the goal of finding a piercing site reachable by the bronchoscope. This new strategy enables faster performance by iteratively building a single search tree during the entire computation period, whereas previous forward approaches have relied on repeating this expensive tree construction process many times. Additionally, our method further reduces runtime by employing biased sampling and sample rejection based on geometric constraints. We evaluate this approach using simulation-based studies in anatomical lung models. We demonstrate in comparison with existing techniques that the new approach (i) is more likely to find a path to a target, (ii) is more efficient by reaching targets more than 5 times faster on average, and (iii) arrives at lower-risk paths in shorter time.

Background: Electromagnetic navigational bronchoscopy (ENB) and robotic-assisted bronchoscopy (RB) require a high degree of decision-making and psychomotor skill. Cognitive load theory is the overall effort expended by individuals in response to a task and is closely related to the usability of devices for medical procedures. High cognitive workload leads to poor surgical outcomes and represents a bottleneck for learning that affects performance., Objective: To analyze the cognitive load associated with ENB and RB in experienced ENB practitioners learning RB., Methods: Six experienced ENB bronchoscopists performed ENB and RB on a human cadaver model of peripheral pulmonary nodules. To assess cognitive load, we used the Surgery Task Load Index (SURG-TLX) and biometric changes. The SURG-TLX questionnaire was given to the provider after every peripheral pulmonary nodule biopsy with ENB and RB. Pupillary dilation and screen changes were continuously measured throughout the procedure for each biopsy attempt to collect biometric measures of cognitive load. Procedural time and biopsy outcome were also recorded., Results: Forty procedures (ENB and RB) were analyzed. Task complexity (23%) and mental demand (21.4%) were the highest contributors to cognitive load in ENB and RB. The cumulative SURG-TLX was significantly lower for the RB (69.25 vs. 101.25; P  < 0.01). Total procedure time was greater for ENB (6.7 min; SD 1.5) compared with RB (4.4 min; SD 1.5; P  = 0.01). Pupillary diameter was similar across the modalities (RB vs. ENB), but the diameter was higher during the biopsy portion (4.25 mm) than the navigation portion (4.01 mm)., Conclusion: The intrinsic cognitive load of RB was highly manageable by existing ENB practitioners, and in this study, RB appeared to be less mentally demanding. Future development and training should focus on task complexity and mental demand for RB. The biopsy portion, regardless of bronchoscopic modality, should be a focus for education and training., (Copyright © 2021 by the American Thoracic Society.)

Background: The management of recurrent pleural effusions remains a challenging issue for clinicians. Advances in management have led to increased use of indwelling tunneled pleural catheters (IPC) because of their effectiveness and ease of outpatient placement. However, with the increase in IPC placement there have also been increasing reports of complications, including infections. Currently there is minimal guidance in IPC-related management issues after placement., Research Question: Our objective was to formulate clinical consensus statements related to perioperative and long-term IPC catheter management based on a modified Delphi process from experts in pleural disease management., Study Design and Methods: Expert panel members used a modified Delphi process to reach consensus on common perioperative and long-term management options related to IPC use. Members were identified from multiple countries, specialties, and practice settings. A series of meetings and anonymous online surveys were completed. Responses were used to formulate consensus statements among panel experts, using a modified Delphi process. Consensus was defined a priori as greater than 80% agreement among panel constituents., Results: A total of 25 physicians participated in this project. The following topics were addressed during the process: definition of an IPC infection, management of IPC-related infectious complications, interventions to prevent IPC infections, IPC-related obstruction/malfunction management, assessment of IPC removal, and instructions regarding IPC management by patients and caregivers. Strong consensus was obtained on 36 statements. No consensus was obtained on 29 statements., Interpretation: The management of recurrent pleural disease with IPC remains complex and challenging. This statement offers statements for care in numerous areas related to IPC management based on expert consensus and identifies areas that lack consensus. Further studies related to long-term management of IPC are warranted., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

The maximum curvature of a steerable needle in soft tissue is highly sensitive to needle shaft stiffness, which has motivated use of small diameter needles in the past. However, desired needle payloads constrain minimum shaft diameters, and shearing along the needle shaft can occur at small diameters and high curvatures. We provide a new way to adjust needle shaft stiffness (thereby enhancing maximum curvature, i.e. "steerability") at diameters selected based on needle payload requirements. We propose helical dovetail laser patterning to increase needle steerability without reducing shaft diameter. Experiments in phantoms and ex vivo animal muscle, brain, liver, and inflated lung tissues demonstrate high steerability in soft tissues. These experiments use needle diameters suitable for various clinical scenarios, and which have been previously limited by steering challenges without helical dovetail patterning. We show that steerable needle targeting remains accurate with established controllers and demonstrate interventional payload delivery (brachytherapy seeds and radiofrequency ablation) through the needle. Helical dovetail patterning decouples steerability from diameter in needle design. It enables diameter to be selected based on clinical requirements rather than being carefully tuned to tissue properties. These results pave the way for new sensors and interventional tools to be integrated into high-curvature steerable needles.

Background: Approximately twenty percent of lymph node (LN) negative non-small cell lung cancer (NSCLC) patients who undergo curative intent surgery have pan-cytokeratin immunohistochemistry (IHC)-detectable occult micro-metastases (MMs) in resected LNs. The presence of the MMs in NSCLC is associated worsened outcomes. As a substantial proportion of NSCLC LN staging is conducted using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), we sought to determine the frequency of detection of occult MMs in EBUS-TBNA specimens and to evaluate the impact of MMs on progression-free and overall survival., Methods: We performed retrospective IHC staining for pan-cytokeratin of EBUS-TBNA specimens previously deemed negative by a cytopathologist based on conventional hematoxylin and eosin staining. The results were correlated with clinical variables, including survival outcomes., Results: Of 887 patients screened, 44 patients were identified meeting inclusion criteria with sufficient additional tissue for testing. With respect to the time of the EBUS-TBNA procedure, 52% of patients were clinical stage I, 34% clinical stage II, and clinical 14% stage IIIa NSCLC. Three patients (6.8%) were found to have cytokeratin positive MMs. All 3 MMs detected were at N2 LN stations. The presence of MMs was associated with significantly decreased progression-free (median 210 vs. 1,293 days, P=0.0093) and overall survival (median 239 vs. 1,120 days, P=0.0357)., Conclusions: Occult LN MMs can be detected in EBUS-TBNA specimens obtained during staging examinations and are associated with poor clinical outcomes. If prospectively confirmed, these results have significant implications for EBUS-TBNA specimen analyses and possibly for the NSCLC staging paradigm., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Electromagnetic navigation (EMN) has improved bronchoscopic access to peripheral pulmonary nodules. A novel EMN system utilizing novel tip-tracked instruments for endobronchial [electromagnetic navigation bronchoscopy (ENB)] as well as transthoracic lung biopsy [electromagnetic-guided transthoracic needle aspiration (EMTTNA)] has become available. The system provides real-time feedback as well as the ability to biopsy lesions outside of the airway. These advances have the potential to improve diagnostic yield over previous EMN systems., Methods: We performed a retrospective review of consecutive peripheral bronchoscopy cases utilizing a novel EMN platform for biopsy and/or fiducial marker (FM) placement at a tertiary care university hospital. We analyzed factors that may influence diagnostic yield including lesion size., Results: Our study included 108 patients who underwent EMN-guided bronchoscopy between June 2015 and April 2017 for the diagnosis of peripheral lung lesions and/or the placement of FMs for stereotactic body radiotherapy. Ninety-three patients underwent biopsy utilizing ENB +/- EMTTNA. The combined diagnostic yield was 78%. EMTTNA provided a diagnosis for 5 patients in whom the ENB biopsy results were negative. Diagnostic yield by nodules <20, 20 to 30, and >30 mm in size was 30/45 (67%), 27/30 (90%), and 16/18 (89%), respectively. Sixty-five patients underwent FM placement with a total of 133 FM placed., Conclusion: This novel tip-tracked EMN system incorporating both ENB and EMTTNA can guide biopsy and FM placement with a high degree of success and with a low complication rate. Multicentered prospective trials are required to develop algorithmic approaches to combine ENB and EMTTNA into a single procedure.

Background: Pulmonary nodules are a common but difficult issue for physicians as most identified on imaging are benign but those identified early that are cancerous are potentially curable. Multiple diagnostic options are available, ranging from radiographic surveillance, minimally invasive biopsy (bronchoscopy or transthoracic biopsy) to more invasive surgical biopsy/resection. Each technique has differences in diagnostic yield and complication rates with no established gold standard. Currently, the safest approach is bronchoscopic but it is limited by variable diagnostic yields. Percutaneous approaches are limited by nodule location and complications. With the recent advent of electromagnetic navigation (EMN), a combined bronchoscopic and transthoracic approach is now feasible in a single, staged procedure. Here, we present the study design and rationale for a single-arm trial evaluating a staged approach for the diagnosis of pulmonary nodules., Methods: Participants with 1-3 cm, intermediate to high-risk pulmonary nodules will undergo a staged approach with endobronchial ultrasound (EBUS) followed by EMN-bronchoscopy (ENB), then EMN-transthoracic biopsy (EMN-TTNA) with the procedure terminated at any stage after a diagnosis is made via rapid onsite cytopathology. We aim to recruit 150 EMN participants from eight academic and community settings to show significant improvements over other historic bronchoscopic guided techniques. The primary outcome is overall diagnostic yield of the staged approach., Conclusion: This is the first study designed to evaluate the diagnostic yield of a staged procedure using EBUS, ENB and EMN-TTNA for the diagnosis of pulmonary nodules. If effective, the staged procedure will increase minimally invasive procedural diagnostic yield for pulmonary nodules., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Pleural effusions are considered rare in cystic fibrosis (CF) patients. There is a paucity of available information in the literature concerning the nature and significance of pleural effusions in non-transplanted CF patients., Methods: We conducted a multicenter retrospective evaluation of non-transplanted adult CF patients. Given the small sample size, only descriptive statistics were performed., Results: A total of 17 CF patients with pleural effusion were identified, of whom 9 patients underwent thoracentesis. The crude incidence of pleural effusion was 43 per 10,000 person-years in hospitalized CF patients at large CF centers. All sampled effusions were inflammatory in nature. All samples submitted for culture grew at least one organism., Conclusion: Pleural effusions are rare in adult non-transplanted CF patients. These fluid collections appear to be quite inflammatory with a higher rate of empyema than in the general population., (Copyright © 2016 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Lung cancer remains a common and deadly disease. Many modalities are available to the bronchoscopist to evaluate and stage lung cancer. We review the role of bronchoscopy in the staging of the mediastinum with convex endobronchial ultrasound (EBUS) and discuss emerging role of esophageal ultrasonography as a complementary modality. In addition, we discuss advances in scope technology and elastography. We review the bronchoscopic methods available for the diagnosis of peripheral lung nodules including radial EBUS and navigational bronchoscopy (NB) with a consideration of the basic methodologies and diagnostic accuracies. We conclude with a discussion of the comparison of the various methodologies.

Background: Stereotactic radiotherapy is a useful therapeutic modality in patients with lung cancer and patients with pulmonary metastases who cannot tolerate, are not candidates for, or do not want surgery. Successful use of radial endobronchial ultrasound (EBUS) and navigation bronchoscopy to guide the placement of the fiducials required for stereotactic radiotherapy in peripheral lung lesions has been previously reported. We present the first series of patients in which convex-probe EBUS was used to deliver fiducials to hilar and mediastinal lymph nodes as well as central thoracic lesions., Methods: Retrospective case series of 5 patients in which convex-probe EBUS was used to place fiducials in central lesions., Results: Fiducial markers were successfully placed in all 5 patients and were durable. There were no procedure-related complications., Conclusion: Convex-probe EBUS is a useful tool in the placement of fiducial markers in patients with malignant lymphadenopathy and central parenchymal lung lesions.

Cricothyrotomy, percutaneous dilation tracheostomy, and surgical tracheostomy are cost-effective and safe techniques employed in the management of critically ill patients requiring insertion of an artificial airway. These procedures have been well characterized and studied in the surgical, emergency medicine, and critical care literature. This article focuses on the role of each of these modalities in airway management, specifically comparing the data for each procedure in regard to procedural outcomes. The authors discuss the techniques available and the relevant background data regarding choice of each method and its integration into clinical practice., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Rationale: The indwelling tunneled pleural catheter has altered the management of patients with dyspnea related to malignant pleural effusions. However, indwelling tunneled pleural catheter placement does not remain free from risk. The most commonly reported risk is infection., Objectives: The aim of this paper is to describe our continuous quality improvement program for infection rate recognition, the process changes implemented for improvement, and subsequent outcomes., Methods: All patients undergoing indwelling tunneled pleural catheter placement at The Johns Hopkins Medical Institutions between May 2009 and April 2014 were identified. The primary outcome was the incidence of infection within the preintervention and intervention cohorts. Intervention was identified as use of preoperative antibiotics, full sterile draping, and limiting placement to a single defined location., Measurements and Main Results: A total of 225 indwelling tunneled pleural catheter placements were performed in 201 patients during the study period, and the overall infection rate was 5.8%. During the preintervention period, 134 placements were performed, and 91 placements occurred during the intervention period. A preintervention infection rate was identified as 8.2%, with a significant decrease to 2.2% (P = 0.049) within the intervention cohort., Conclusions: The use of a continuous quality improvement program to review indwelling tunneled pleural catheter practices can result in the identification of infectious complications and lead to implementation of measures to improve patient outcomes.

Introduction: The presence of intrathoracic lymphadenopathy and mediastinal masses in the pediatric population often presents a diagnostic challenge. With limited minimally invasive methodologies to obtain a diagnosis, invasive sampling via mediastinoscopy or thoracotomy is often pursued. Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, outpatient procedure that has demonstrated significant success in the adult population in the evaluation of such abnormalities. Within the pediatric literature there is limited data regarding the use of EBUS-TBNA. We report the first multicenter review of a pediatric population undergoing EBUS-TBNA procedures identifying the feasibility, safety, utility, and outcomes of this procedure., Methods: All patients of 18 years of age or younger undergoing EBUS-TBNA at six major academic medical centers from the years 2007 through 2013 were reviewed. Data regarding procedural performance, outcomes, and complications were recorded., Results: A total of 21 patients meeting the inclusion criteria were identified in six centers. The mean age of the cohort was 13.7 (±4.1) years. EBUS-TBNA provided adequate sampling in 20/21 (95%) of the cases with diagnostic material obtained in 10 (48%) cases. Eight patients (38%) underwent additional surgical procedures to confirm or obtain diagnostic tissue. Within our cohort, 13 patients (62%) were able to avoid invasive surgical biopsy procedures. No procedural or anesthesia related complications were identified., Conclusion: We report the first multicenter study to date confirming the feasibility and utility of EBUS-TBNA in the pediatric population. Due to the low overall procedural risk of EBUS-TBNA, it should be considered as a potential first line diagnostic option for children presenting with mediastinal or hilar abnormalities but further prospective studies are needed., (© 2013 Wiley Periodicals, Inc.)

Purpose: Studies have found different rates of antimicrobial resistance among patients in medical and surgical intensive care units (ICUs). We studied whether these differences were a function of geography or differences in the patient populations, by comparing resistance rates among bacteria isolated from a combined medical/surgical ICU., Materials and Methods: We retrospectively evaluated the results of bacterial cultures of each patient admitted to the ICU between February 2005 and September 2006. Data collection included patient demographics and culture and sensitivity results. Intensive care unit populations were compared using the Fisher exact test and the Student t test., Results: One hundred seventy-one medical and 94 surgical patients with positive cultures were studied. Organisms were grouped into 4 classes: Staphylococcus aureus, nonlactose fermenting gram-negative bacilli, Enterococcus species, and gram-negative enteric bacteria. In the 4 classes, no significant difference in antibiotic resistance was found between medical and surgical patients., Conclusion: Reported differences in resistance patterns among bacteria cultured from medical and surgical patients may be due to geographic separation of the ICUs as opposed to differences in the patient characteristics. This study suggests that ICU-specific antibiograms remain a useful tool to guide the choice of antimicrobial therapy, even in medical/surgical ICUs., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Ergonomics is defined by the United States Department of Labor as "the science of fitting workplace conditions and job demands to the capabilities of the working population." Currently, there remains a deficiency in available data regarding the impact that musculoskeletal pain and ergonomics have within the field of pulmonary endoscopic procedures. We sought to define the impact of musculoskeletal pain and ergonomics in physicians with an interest in interventional pulmonology., Methods: A 25-question Internet-based survey was distributed to current members of the American Association of Bronchology and Interventional Pulmonology., Results: A total of 199 surveys were distributed to members, with an overall response rate of 81% (161/199). The majority of respondents were male (85.6%) and classified themselves as interventional pulmonologists (49%). Musculoskeletal pain was present in 50.6% of the respondents, with a minority (12.3%) of respondents reporting significant adverse events related to this pain. Risks factors for work-related musculoskeletal pain included small glove size (P=0.01), younger age (P=0.02), and years in practice (P=0.01)., Conclusion: The presence of musculoskeletal pain seems to be common within a cohort of pulmonologists performing procedures. Although only a minority of bronchoscopists experienced adverse events related to pain directly impacting patient care, long-term outcomes impacting both patient care and the long-term careers of physicians remain uncertain. Further research regarding the role of musculoskeletal pain and ergonomics remains paramount in the continued development of technology and equipment within the field.

Rationale: Most bronchoscopic procedures are performed using moderate sedation achieved by combining a short-acting benzodiazepine with an opioid agent. Propofol (2.6-diisopropylphenol), a short-acting hypnotic agent, has been increasingly used to provide deep sedation in the endoscopy community with an acceptable safety profile., Objectives: To compare the impact of moderate versus deep sedation on the adequacy and diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)., Methods: A retrospective review of prospectively collected data was performed at two academic institutions with interventional pulmonary fellowships using two methods of sedation during EBUS (deep vs. moderate sedation). Rapid on-site cytologic evaluation was used on all procedures in both groups. EBUS-TBNA nodal sampling was considered adequate if the aspirate yielded a specific diagnosis or lymphocytes. EBUS-TBNA was considered diagnostic if a lymph node aspirate yielded a specific diagnosis or if subsequent surgical sampling or prolonged radiographic surveillance revealed no nodal pathology., Measurements and Main Results: No difference was observed in the indication for EBUS-TBNA between the two groups. More lymph nodes were sampled per patient in the deep sedation group (314 nodes from 163 patients; 2.2 nodes per patient) than in the moderate sedation group (181 lymph nodes from 146 patients; 1.4 nodes per patient; P < 0.01). The EBUS-TBNA diagnostic yield was higher for the deep sedation group (80% of patients) than for the moderate sedation group (66% of patients; P < 0.01)., Conclusions: Diagnostic yield and number of lymph nodes sampled using deep sedation is superior to moderate sedation in patients undergoing EBUS-TBNA. Prospective studies accounting for other factors including patient selection and cost are needed.

The maintenance of CMV-specific T cell memory in lung transplant recipients (LTRs) is critical for host defense and allograft durability, particularly in donor(+) /recipient(-) (D(+) R(-) ) individuals who demonstrate increased mortality. We studied CD4(+) and CD8(+) CMV-specific memory responses to phosphoprotein 65 (pp65) in a prospective cohort of 18 D(+) R(-) LTRs, from bronchoalveolar lavage (BAL)-obtained lung mononuclear cells (LMNC) and PBMC. Unexpectedly, pp65-specific CD4(+) and CD8(+) IFN-γ memory responses from LMNC were similar, in contrast to persistent CD8(+) predominance in PBMC. Unlike the pulmonary CD8(+) predominance during acute primary infection, compartmental equalization occurred in the CMV-specific CD8(+) memory pool during chronic infection, whereas CMV-specific CD4(+) memory was enriched in the bronchoalveolar space. Moreover, CMV-specific CD4(+) memory T cells with multifunctional production of IFN-γ, TNF-α, IL-2 and MIP-1β were significantly increased in LMNCs, in contrast to similar intercompartmental CD8(+) memory function. Moreover, the absolute number of CMV-specific CD4(+) IFN-γ(+) memory cells in BAL was significantly increased in LTRs exhibiting viral control compared to those with CMV early antigen positivity. Collectively, these data demonstrate both preferential distribution and functional quality of CMV-specific CD4(+) memory in the lung allograft during chronic infection, and show an important association with CMV mucosal immunity and viral control., (© Copyright 2012 The American Society of Transplantation and the American Society of Transplant Surgeons.)