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Lung cancer screening with low-dose computed tomography has demonstrated at least a 20% decrease in lung cancer-specific mortality, but it has the potential harm of unnecessary invasive procedures performed because of false-positive results. This study reports the outcomes of a structured multidisciplinary lung cancer screening program in an area of endemic histoplasmosis.A retrospective review of patients undergoing lung cancer screening from December 2012 to March 2019 was conducted. Findings suggestive of lung cancer were presented to a multidisciplinary thoracic tumor board. Patients were assigned to interval imaging follow-up, additional diagnostic imaging, or referral for an invasive procedure. Invasive procedures were then compared between benign and malignant diseases.A total of 4087 scans were performed on 2129 patients; 372 (9.1%) were suspicious and were presented to a multidisciplinary thoracic tumor board. Ultimately, 108 procedures were performed: 55 bronchoscopies, 7 percutaneous biopsies, and 46 operations. A total of 25 patients (1.2%) underwent bronchoscopy resulting in benign pathologic findings, significantly associated with an indication of an endobronchial lesion (P = .01). All percutaneous biopsy specimens revealed malignancy. Five patients (0.2%) who underwent resection had benign disease. Lung cancer was diagnosed in 67 patients (3.1% of the entire cohort), 46 of whom had stage I or II disease.Lung cancer screening in a structured, multidisciplinary program successfully identifies patients with early-stage lung cancer with limited unnecessary surgical interventions. Patients with isolated endobronchial lesions should undergo short interval imaging follow-up to avoid bronchoscopy for benign disease. Future studies to minimize unnecessary procedures could incorporate biomarkers and advanced imaging analysis into risk assessment models.

Plastic bronchitis is a rare condition characterized by the formation of airway casts occluding the lower respiratory tract. It is described more commonly in children, especially following correction of congenital heart disease. It involves lymphatic abnormalities leading to endobronchial lymph precipitating airway cast formation. When it presents acutely, it can lead to acute airway obstruction, which can be life-threatening. Plastic bronchitis has been rarely described in adults and is potentially underdiagnosed. The purpose of this case report is to emphasize, for the adult anesthesiologist and adult critical care physician, the importance of prompt diagnosis and respiratory support in a case of plastic bronchitis.A 40-yr-old female with severe aortic stenosis underwent a Ross procedure. The surgery was uneventful, but within two hours of arrival in the intensive care unit, the patient developed severe hypoxemia. Despite attempts to optimize her respiratory status, the patient remained severely hypoxemic, and veno-venous extracorporeal membrane oxygenation (ECMO) was initiated using a percutaneous femoro-femoral cannulation. A bronchoscopy showed bronchial secretions casting the proximal bronchus, suggestive of plastic bronchitis. After numerous bronchoscopies, we were able to clean the airways and wean the ECMO support on postoperative day 3.Plastic bronchitis can present in adult patients and be life-threatening when associated with acute respiratory failure. We report an unusual case of an adult patient treated with veno-venous ECMO for plastic bronchitis following cardiac surgery. Use of ECMO support while providing airway cleaning can be lifesaving in patients with respiratory failure secondary to plastic bronchitis.RéSUMé: OBJECTIF: La bronchite plastique est une affection rare caractérisée par la formation de bouchons muqueux qui moulent et obstruent les voies aériennes inférieures. Elle est plus fréquemment décrite chez les enfants, en particulier après la correction d’une cardiopathie congénitale. Elle découle d’anomalies lymphatiques conduisant à l’accumulation de lymphe endobronchique, précipitant la formation de bouchons muqueux dans les voies aériennes. Lorsqu’elle se présente de manière aiguë, la bronchite plastique peut entraîner une obstruction aiguë des voies aériennes, une complication potentiellement fatale. La bronchite plastique a rarement été décrite chez l’adulte et est potentiellement sous-diagnostiquée. L’objectif de cette présentation de cas est de souligner, pour l’anesthésiologiste et l’intensiviste s’occupant d’une population adulte, l’importance d’un diagnostic rapide et d’un support respiratoire en cas de bronchite plastique. CARACTéRISTIQUES CLINIQUES: Une femme de 40 ans souffrant d’une sténose aortique sévère a bénéficié d’une procédure de Ross. La chirurgie s’est déroulée sans incident, mais dans les deux heures suivant son arrivée à l’unité de soins intensifs, la patiente a présenté une hypoxémie sévère. Malgré les tentatives d’optimisation de son état respiratoire, la patiente est restée gravement hypoxémique et une oxygénation par membrane extracorporelle (ECMO) veino-veineuse a été amorcée à l’aide d’une canulation fémoro-fémorale percutanée. Une bronchoscopie a montré des sécrétions bronchiques moulant les bronches proximales, évoquant une bronchite plastique. Après de nombreuses bronchoscopies, nous avons pu nettoyer les voies aériennes et sevrer la patiente du soutien ECMO au 3ème jour postopératoire. CONCLUSION: La bronchite plastique peut se présenter chez les patients adultes et être potentiellement fatale lorsqu’elle est associée à une insuffisance respiratoire aiguë. Nous rapportons un cas inhabituel d’une patiente adulte traitée par ECMO veino-veineuse pour une bronchite plastique après une chirurgie cardiaque. L’utilisation du soutien par ECMO simultanément au nettoyage des voies aériennes peut être nécessaire chez les patients atteints d’insuffisance respiratoire secondaire à une bronchite plastique.

Background Normally functioning airway cilia is essential for efficient mucociliary clearance to protect the airway from various insults. Impaired clearance may lead to increased risk of infections and progressive lung damage. Significant morbidity in the immediate post lung transplantation period is associated with airway infection, which we hypothesize may be caused by impaired cilia function. Methods Airway cilia beating pattern (CBP) and frequency (CBF) were studied on brushing samples taken from above and below the transplant anastomosis of adult lung transplant recipients (n = 20) during routine bronchoscopies at 6, 12, and 26 weeks posttransplant. Bronchoaveolar Lavage (BAL) samples were also collected at each time points. Results At 6 weeks posttransplant (n = 16), CBP from the donated lung showed reduced beating amplitude with the overall CBF 2.28 Hz slower than the patients' native upper airway cilia (median ± SIQR: 5.36 ± 0.93 Hz vs. 7.64 ± 0.92 Hz, p value, Reduced airway cilia function is evident in the first 12 weeks post lung transplant, with both CBP and CBF returning to levels of function indistinguishable to the patients' upper airway cilia beyond this time. This difference may be a cause for increased risk of airway infection during this period.

BACKGROUND: Bronchoscopy is an aerosol-generating procedure and routine use for patients with coronavirus disease 2019 (COVID-19) has been discouraged. The purpose of this review was to discuss the indications, clinical utility, and risks associated with bronchoscopy in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. METHODS: A literature search was performed by using appropriate key terms to identify all relevant articles from medical literature databases up to August 1, 2021. RESULTS: Twelve cohorts (9 retrospective and 3 prospective) reported the performance of 2,245 bronchoscopies in 1,345 patients with COVID-19. The majority of the subjects were male. Nearly two thirds of the bronchoscopies (62%) were performed for therapeutic indications; the rest (38%) were for diagnostic purposes. Bronchoalveolar lavage had an overall yield of 33.1% for SARS-CoV-2 in subjects with negative results of real-time polymerase chain reaction on nasopharyngeal specimens. The incidence of a secondary infection ranged from 9.3% to as high as 65%. Antibiotics were changed in a significant number of the subjects (14%–83%) based on the bronchoscopic findings. Bronchoscopy was well tolerated in most subjects except those who required noninvasive ventilation, in whom the intubation rate after the procedure was 60%. The rate of transmission of SARS-CoV-2 among health-care workers was minimum. CONCLUSIONS: Bronchoscopy in patients with COVID-19 results in a significant change in patient management. Transmission of SARS-CoV-2 seems to be low with consistent use of appropriate personal protective equipment by health-care workers. Therefore, bronchoscopic evaluation should be considered for all diagnostic and therapeutic indications in this patient population.

BACKGROUND The July effect is the perceived notion that at the start of each academic year there is an increase in medical complications as the novice physician begins their new respective roles. Our study evaluated complication rates in the beginning versus end of the academic year with regards to bronchoscopy. METHODS This is a retrospective cohort study using the 2016 and 2017 Nationwide Inpatient Sample. Patients in the database that underwent bronchoscopy at teaching hospitals were determined using ICD-10 procedure codes. Our outcomes included length of hospital stay and several bronchoscope complications. We compared our outcomes in the first quarter of the academic year (July, August, and September) to the last quarter (April, May, and June). Multivariable logistic and linear regression analysis were used accordingly to adjust for confounders. RESULTS There was a total of 189,720 admission for bronchoscopy. Of these hospitalization 89,020 bronchoscopies were done in first academic Quarter (Q1) while 100,700 bronchoscopies were done in fourth academic Quarter (Q4) in 2016 to 2017 academic year. After adjusting for confounders, there was no difference in any postprocedural complications between Q1 and Q4 or length of stay. CONCLUSION Within the limitation of the national data set provided, there appears to be similar procedural complication rates for patients admitted Q1 compared with Q4 of the academic year in respect to bronchoscopy, signaling the possibility of lack of the July effect. Prospective studies with improved data granularity is needed to further verify the absence or presence of the July effect regarding bronchoscopy.

Objective Little is known concerning the stability of the lower airway microbiome. We have compared the microbiota identified by repeated bronchoscopy in healthy subjects and patients with ostructive lung diseaseases (OLD). Methods 21 healthy controls and 41 patients with OLD completed two bronchoscopies. In addition to negative controls (NCS) and oral wash (OW) samples, we gathered protected bronchoalveolar lavage in two fractions (PBAL1 and PBAL2) and protected specimen brushes (PSB). After DNA extraction, we amplified the V3V4 region of the 16S rRNA gene, and performed paired-end sequencing (Illumina MiSeq). Initial bioinformatic processing was carried out in the QIIME-2 pipeline, identifying amplicon sequence variants (ASVs) with the DADA2 algorithm. Potentially contaminating ASVs were identified and removed using the decontam package in R and the sequenced NCS. Results A final table of 551 ASVs consisted of 19 × 106 sequences. Alpha diversity was lower in the second exam for OW samples, and borderline lower for PBAL1, with larger differences in subjects not having received intercurrent antibiotics. Permutational tests of beta diversity indicated that within-individual changes were significantly lower than between-individual changes. A non-parametric trend test showed that differences in composition between the two exams (beta diversity) were largest in the PSBs, and that these differences followed a pattern of PSB > PBAL2 > PBAL1 > OW. Time between procedures was not associated with increased diversity. Conclusion The airways microbiota varied between examinations. However, there is compositional microbiota stability within a person, beyond that of chance, supporting the notion of a transient airways microbiota with a possibly more stable individual core microbiome.

Background Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching. Research Question How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety? Study Design and Methods This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias. Results We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy. Interpretation Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.

Summary Background Tezepelumab is a human monoclonal antibody that blocks the activity of thymic stromal lymphopoietin (TSLP), an epithelial cell-derived cytokine. In phase 2b and 3 studies, tezepelumab significantly reduced exacerbations versus placebo in patients with severe uncontrolled asthma, irrespective of baseline levels of type 2 inflammatory biomarkers. We investigated the mechanism of action of tezepelumab by assessing its effects on airway inflammatory cells, airway remodelling, and airway hyperresponsiveness. Methods CASCADE was an exploratory, double-blind, randomised, placebo-controlled, parallel-group, phase 2 study done in 27 medical centres in Canada, Denmark, Germany, the UK, and the USA. Adults aged 18–75 years with uncontrolled, moderate-to-severe asthma were randomly assigned (1:1) to receive tezepelumab 210 mg or placebo administered subcutaneously every 4 weeks for a planned 28 weeks, extended to up to 52 weeks if COVID-19-related disruption delayed participants' end-of-treatment assessments. Randomisation was balanced and stratified by blood eosinophil count. The primary endpoint was the change from baseline to the end of treatment in the number of airway submucosal inflammatory cells in bronchoscopic biopsy samples. Eosinophils, neutrophils, CD3+ T cells, CD4+ T cells, tryptase+ mast cells, and chymase+ mast cells were evaluated separately. This endpoint was also assessed in subgroups according to baseline type 2 inflammatory biomarker levels, including blood eosinophil count. Airway remodelling was assessed via the secondary endpoints of change from baseline in reticular basement membrane thickness and epithelial integrity (proportions of denuded, damaged, and intact epithelium). Exploratory outcomes included airway hyperresponsiveness to mannitol. All participants who completed at least 20 weeks of study treatment, had an end-of-treatment visit up to 8 weeks after the last dose of study drug, and had evaluable baseline and end-of-treatment bronchoscopies were included in the primary efficacy analysis. All participants who received at least one dose of study drug were included in the safety analyses. This study is registered with ClinicalTrials.gov, NCT03688074. Findings Between Nov 2, 2018, and Nov 16, 2020, 250 patients were enrolled, 116 of whom were randomly assigned (59 to tezepelumab, 57 to placebo). 48 in the tezepelumab group and 51 in the placebo group completed the study and were assessed for the primary endpoint. Treatment with tezepelumab resulted in a nominally significantly greater reduction from baseline to the end of treatment in airway submucosal eosinophils versus placebo (ratio of geometric least-squares means 0·15 [95% CI 0·05–0·41]; nominal p 0·10). In assessment of secondary endpoints, there were no significant differences between treatment groups in reticular basement membrane thickness and epithelial integrity. In an exploratory analysis, the reduction in airway hyperresponsiveness to mannitol was significantly greater with tezepelumab versus placebo (least-squares mean change from baseline in interpolated or extrapolated provoking dose of mannitol required to induce ≥15% reduction in FEV1 from baseline: tezepelumab 197·4 mg [95% CI 107·9 to 286·9]; placebo 58·6 mg [−30·1 to 147·33]; difference 138·8 [14·2 to 263·3], nominal p=0·030). Adverse events were reported in 53 (90%) patients in the tezepelumab group and 51 (90%) patients in the placebo group, and there were no safety findings of concern. Interpretation The improvements in asthma clinical outcomes observed in previous studies with tezepelumab are probably driven, at least in part, by reductions in eosinophilic airway inflammation, as shown here by reduced airway eosinophil counts regardless of baseline blood eosinophil count. Tezepelumab also reduced airway hyperresponsiveness to mannitol, indicating that TSLP blockade might have additional benefits in asthma beyond reducing type 2 airway inflammation. Funding AstraZeneca and Amgen.

Introduction Alveolar macrophages (AMs) are lung-resident immune cells that phagocytose inhaled particles and pathogens, and help coordinate the lung’s immune response to infection. Little is known about the impact of chronic e-cigarette use (ie, vaping) on this important pulmonary cell type. Thus, we determined the effect of vaping on AM phenotype and gene expression. Aims and Methods We recruited never-smokers, smokers, and e-cigarette users (vapers) and performed research bronchoscopies to isolate AMs from bronchoalveolar lavage fluid samples and epithelial cells from bronchial brushings. We then performed morphological analyses and used the Nanostring platform to look for changes in gene expression. Results AMs obtained from smokers and vapers were phenotypically distinct from those obtained from nonsmokers, and from each other. Immunocytochemistry revealed that vapers AMs had significantly elevated inducible nitric oxide synthase (M1) expression and significantly reduced CD301a (M2) expression compared with nonsmokers or smokers. Vapers’ AMs and bronchial epithelia exhibited unique changes in gene expression compared with nonsmokers or smokers. Moreover, vapers’ AMs were the most affected of all groups and had 124 genes uniquely downregulated. Gene ontology analysis revealed that vapers and smokers had opposing changes in biological processes. Conclusions These data indicate that vaping causes unique changes to AMs and bronchial epithelia compared with nonsmokers and smokers which may impact pulmonary host defense. Implications These data indicate that normal “healthy” vapers have altered AMs and may be at risk of developing abnormal immune responses to inflammatory stimuli.

Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of mediastinal lymph nodes is currently considered to be the most effective minimally invasive diagnostic method in patients with suspected stage I and II sarcoidosis. However, diagnostic effectiveness depends on the experience and skills of the doctor which is dependent on the number of correctly performed procedures. The aim of the study is to compare the diagnostic effectiveness of the EBUS-TBNA test obtained by an expert in this field vs that of his student. Material and methods: in patients with a clinical and radiological suspicion of sarcoidosis, EBUS-TBNA procedures were performed by an expert (over 1000 previously performed tests) and by his student who completed basic training (15 procedures performed). In the expert’s opinion, the student was experienced enough to perform the EBUS-TBNA on his own. Previously, more than 100 conventional fibreoptic bronchoscopies had been performed by the student. During that time, he had been working in the department of pulmonary diseases and tuberculosis for two years. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR-), and accuracy of the EBUS-TBNA test in diagnosing sarcoidosis were calculated. Statistical evaluation was made using ROC curves for the expert and for the student. Results: The study included 215 patients between 22–68 years of age with suspected sarcoidosis who were diagnosed between 2013–2016. 124 EBUS-TBNA tests were performed by the expert, and 91 procedures were performed by the student. The presence of sarcoid granulomas was confirmed by a biopsy in 165 (76.7%) patients. In terms of the diagnosis of sarcoidosis, a higher sensitivity and accuracy of the EBUS test was found in the procedures done by the expert (76.7% and 95.3%, respectively) as compared to the results obtained by the student (66.1% and 93.1%, respectively). However, these differences were not statistically significant (p = 0.11). All tests were assessed in a hospital pathology unit, but not necessarily by one person, which may be a limitation of our research. In this study, only cytological smears were taken into consideration. Conclusions: In the diagnosis of sarcoidosis, the student, after appropriate training by an expert, achieved a comparable level of diagnostic effectiveness with EBUS-TBNA after performing 90 tests independently.

Objective To assess how often transbronchial biopsy (TBBx) added unique positive findings apart from other synchronous bronchoscopic sampling techniques including the bronchoalveolar lavage–immunocompromised host (BAL-ICH) panel that justified changes in management in an array of immunocompromised patients with new pulmonary radiographic abnormalities. Methods We retrospectively reviewed all bronchoscopies performed at Mayo Clinic Rochester between January 2012 and December 2017; on the basis of the physician’s selection of a BAL-ICH panel, we identified 192 immunocompromised patients who underwent bronchoscopy with both a BAL-ICH panel and TBBx. The results of the BAL-ICH panel and TBBx were compared and subsequent management decisions analyzed from clinical notes. We identified changes in immunosuppressive agents, antibiotics, chemotherapy, goals of care, and decisions on further evaluation and procedures. We assessed whether the TBBx findings added information not identified on the BAL-ICH panel and other bronchoscopic sampling methods performed during the same procedure that justified subsequent management changes. Results Of 192 bronchoscopic procedures performed on immunocompromised patients with acute and subacute pulmonary radiographic abnormalities, management changes justified by the unique positive results of the TBBx occurred 28% (51/192) of the time. Those immunocompromised by solid malignant neoplasms and receiving active immunosuppressive therapy had management changes justified 62.1% (18/29) of the time by the TBBx results. No additional fungal organisms were identified on TBBx that were accounted for on the BAL-ICH panel. Conclusion Transbronchial biopsy may add information to other bronchoscopic findings in immunocompromised patients, especially those with solid malignant neoplasms receiving active immunosuppressive treatment. These potential benefits must be weighed against the risks inherent to the procedure.

Sharyn A Roodenburg,1,2 Karin Klooster,1,2 Jorine E Hartman,1,2 T David Koster,1,2 Marlies van Dijk,1,2 Dirk-Jan Slebos1,2 1Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; 2Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The NetherlandsCorrespondence: Sharyn A RoodenburgDepartment of Pulmonary Diseases, AA11, University Medical Center Groningen, Hanzeplein 1, Groningen, 9713, GZ, The NetherlandsTel +31 50 361 9194Fax +31 050 3619320Email s.a.roodenburg@umcg.nlBackground: Endobronchial valve (EBV) treatment is an effective treatment for patients with severe emphysema. Revision bronchoscopies after endobronchial valve treatment can be essential to prolong the effect of treatment or address long-term complications.Purpose: To evaluate the indications, endoscopic findings and outcomes of revision bronchoscopies and investigate if any predictors for granulation tissue formation, after EBV treatment, can be identified.Patients and Methods: Patients who underwent EBV treatment between 2016 and 2019 in our hospital, as routine care, were included. If a patient underwent a revision bronchoscopy, data regarding revision bronchoscopies, including indication, finding, intervention and pulmonary function testing (PFT) after revision bronchoscopy were analysed.Results: One hundred seventy-nine patients were included of which 41% required at least one revision bronchoscopy. In 43% of the revision bronchoscopy patients, the indication was loss of initial treatment effect. In 53% of the revision bronchoscopy patients, granulation tissue was found to be the underlying cause. Valve replacement(s) were performed in 51% of the revision bronchoscopy cases. Permanent valve removal was required in 13% of all patients. Overall, revision bronchoscopies led to improvements in PFT outcomes for patients experiencing no or a loss of initial treatment effect. No clinically relevant predictors for granulation tissue formation were identified.Conclusion: Performing a revision bronchoscopy after EBV treatment is a useful procedure leading to an improved treatment effect in most patients. Granulation tissue formation, causing valve dysfunction, is the most common cause of longer term problems.Keywords: bronchoscopy, lung volume reduction, one-way valve, COPD

BACKGROUND AND OBJECTIVE Simulation enhances a physician's competency in procedural skills by accelerating ascent of the learning curve. Training programmes are moving away from the Halstedian model of 'see one, do one, teach one', also referred as medical apprenticeship. We aimed to determine if a 3-month structured bronchoscopy curriculum that incorporated simulator training could improve bronchoscopy competency among pulmonary medicine trainees. METHODS We prospectively recruited trainees from hospitals with accredited pulmonary medicine programmes. Trainees from hospitals (A, B and C) were assigned to control group (CG) where they received training by traditional apprenticeship while trainees from hospital D were assigned to intervention group (IG) where they underwent 3-month structured curriculum that incorporated training with the bronchoscopy simulator. Two patient bronchoscopy procedures per trainee were recorded on video and scored independently by two expert bronchoscopists using the modified Bronchoscopy Skills and Tasks Assessment Tool (BSTAT) forms. A 25 multiple choice questions (MCQ) test was administered to all participants at the end of 3 months. RESULTS Eighteen trainees participated; 10 in CG and eight in IG with equal female:male ratio. Competency assessed by modified BSTAT and MCQ tests was variable and not driven by volume as IG performed fewer patient bronchoscopies but demonstrated better BSTAT, airway anaesthesia and MCQ scores. Bronchoscopy simulator training was the only factor that correlated with better BSTAT (r = 0.80), MCQ (r = 0.85) and airway anaesthesia scores (r = 0.83), and accelerated the learning curve of IG trainees. CONCLUSION An intensive 3-month structured bronchoscopy curriculum that incorporated simulator training led to improved cognitive and technical skill performance as compared with apprenticeship training.

Background Navigational bronchoscopy is commonly used to sample lung nodules, with a better safety profile but lower diagnostic yield than computerized tomography-guided transthoracic needle biopsy. The addition of digital tomosynthesis to electromagnetic navigation, using intraprocedural images obtained from a C-arm fluoroscope to identify target lesion location and update navigational guidance, may improve diagnostic yield. Methods Consecutive bronchoscopies using tomosynthesis-assisted fluoroscopic electromagnetic navigational bronchoscopy (F-ENB) at a single institution over a 1-year period were included. The primary outcome was diagnostic yield. A bronchoscopy was defined as diagnostic if pathologic examination revealed malignancy or specific histological findings indicative of lesional sampling with confirmatory 6-month follow-up for benign lesions. Results A total of 324 patients with 363 nodules underwent F-ENB between April 25, 2018 and April 29, 2019. The average nodule size was 1.9±1.1 cm, 65% of the nodules were located in the peripheral third of the lung. A bronchus sign was present in 24% of cases. Of the 363 nodules, 299 (82.4%) had lesional findings. At 6-month follow-up, among these 299 nodules, 6 were found to be false negatives and 12 nodules were lost to follow-up. Considering all nodules lost to follow-up as false negatives, the 6-month diagnostic yield was 77.4%. Pneumothorax complicated 8 (2.5%) of cases. There was 1 episode of respiratory failure. Conclusion This retrospective study suggests the diagnostic yield of F-ENB may exceed that of traditional ENB. Future prospective and comparative studies are needed to confirm these promising data.

INTRODUCTION The safety of bronchoscopy in obese patients and those with obstructive sleep apnea (OSA) is unclear. Our objective was to evaluate the incidence of complications during bronchoscopy under moderate sedation in obese patients and to assess the impact of OSA, body mass index (BMI), and duration of the procedure. METHODS We performed a retrospective study in adult patients undergoing bronchoscopy from January 2010 to August 2019. All patients with BMI > 30 kg/m2 were included. Logistic regression analyses were used to identify the factors associated with all-complications and respiratory complications. RESULTS A total of 345 obese patients were identified. The average BMI in our cohort was 35.3 ± 5.1 kg/m2 . During the pre-procedure risk assessment, 165 (47.8%) patients were labelled as "suspected OSA." The most common doses of sedation given during the bronchoscopies were fentanyl 50 mcg (34.5%) and midazolam 3 mg (33.6%). The incidence of major complications was 0.6% and minor complications were 41.2%. Minor respiratory (22.9%) and cardiac (26.4%) complications were common. No deaths occurred due to bronchoscopy. Factors that were associated with increased respiratory complications were female gender, suspected OSA, and bronchoscopy duration 20-30 minutes and bronchoscopy duration greater than 1 hour. CONCLUSION Bronchoscopy under moderate sedation performed in obese patients is safe; however, increased risk may exist with females, increased procedure time, and suspected OSA.

Background In advanced lung cancer, precision medicine requires repeated biopsies via bronchoscopy at therapy change. Since bronchoscopies are often stressful for patients, sedation using both fentanyl and midazolam is recommended in Europe and America. In Japan, bronchoscopies are generally orally performed under midazolam and oropharyngeal anesthesia. Nasal intubation creates a physiological route to the trachea, causing less irritation to the pharynx than intubation via the oral cavity; however, the necessity of oropharyngeal anesthesia remains unclear. We aimed to compare the safety, patient discomfort, and diagnostic rates for oropharyngeal anesthesia and sedation with pethidine and midazolam (Group A) and sedation with midazolam and fentanyl without oropharyngeal anesthesia (Group B) for ultrathin bronchoscopy of peripheral pulmonary lesions (PPLs) via nasal intubation. Methods We retrospectively reviewed 74 consecutive potential lung cancer patients who underwent ultrathin bronchoscopies at the Hakodate Goryoukaku Hospital between July 2019 and June 2020. We reviewed the following: diagnostic rates; cumulative doses of lidocaine, midazolam, and fentanyl; hemodynamic changes; procedural complications in both groups. Pharyngeal anesthesia in group A was administered by spraying 2% (w/v) lidocaine into the pharynx. The chi-squared test was used for statistical analyses. Results There were no significant changes in hemodynamic parameters and complications. The mean level of discomfort for bronchoscopic examinations was significantly lower in Group B (2.39 vs. 1.64; P = 0.014), with no significant inter-group difference in the diagnostic yields for PPLs (63.0% vs. 71.4%; P = 0.46). Conclusions Our findings indicate the advantages of sedation with fentanyl and midazolam without oropharyngeal anesthesia for ultrathin bronchoscopy through nasal intubation.

Introduction Thoracic imaging of people who have survived exposure to a volcanic pyroclastic flow has not been described. In December 2019, an active volcano in New Zealand erupted with loss of life and severe burns to groups of people who were within one kilometre of a new fissure. Our aim was to describe the range of pulmonary abnormality in patients admitted to the Burns unit at Middlemore Hospital. Methods We describe the initial radiographic and computed tomography (CT) appearance of lung injuries in 14 people close to this fissure who were transported to our national burns centre in Middlemore hospital. We compared these appearances with bronchoscopy findings and A-a gradients as a measure of oxygen utilisation. Results All patients had chest radiographs and eight had CT scans within two days after admission. Nine had bronchoscopies within the first week. Two were repatriated to Australia, one of whom did not survive. Two died within 3 days after admission, and the remaining ten patients survived the first week. Eight patients required ongoing ventilation, seven of whom had abnormal CXRs or CT scans on admission. Two of these patients developed an ARDS pattern of oedema reflecting lung injury from the toxic surge but they recovered. In the five patients who survived the first week with relatively minor evidence of lung injury, bibasal atelectasis was the most common finding. Conclusion Pyroclastic flow effect caused a variety of lung abnormalities most likely due to toxic gas emissions. Upper airway burns were seen at bronchoscopy in only 5 patients. An ARDS response in the lungs of two patients improved within three months.

Background This study aims to investigate the current use of pediatric flexible bronchoscopy (PFB) in western China. Methods A cross-sectional survey was conducted in western China between January 1, 2018 to December 30, 2018. Fifty-four centers were invited to answer a questionnaire for seeking information about performance of PFB. The data collected were analyzed to investigate the current status of western China, and hierarchical cluster analysis was conducted to identify developmental level of PFB of cities. Results Forty-seven centers were included in analysis. A total of 22,585 flexible bronchoscopies were carried out in the participating centers from January 1, 2018 to December 30, 2018. Eight centers (17.0%) performed more than 1,000 pediatric flexible bronchoscopies for children, but 20 centers (42.6%) performed less than 100. The median proportion of systematic and professional trained physicians in a single team was 50%, and the pooled rate was 59% (95% CI, 47-70%). Only 10, 8 and 11 centers performed balloon dilatation, thermal ablation and cryoablation, respectively. Obvious cough was the most frequent complication after the PFB procedure, the pooled rate is 24% (95% CI, 18-29%). No one died during and after the PFB procedure. Hierarchical cluster analysis showed that the development of PBF in western China varies, and Chongqing might be the most developed area in PFB use in western China. Conclusions Flexible bronchoscopy in children is now a mature and safe procedure, while the development of PFB varies in western China, especially for the advanced bronchoscopic intervention.

Introduction Lung transplantation is often the only treatment for end-stage lung disease. Following lung transplantation, infections and transplant rejections are major obstacles to short- and long-term success. Therefore, close monitoring for these complications is required after lung transplantation. The role of prescheduled surveillance bronchoscopies after lung transplantation is controversial. Thus, we aimed to retrospectively analyze the therapeutic implications of surveillance bronchoscopies in 110 consecutive lung transplant recipients. Materials and Methods Results of 400 prescheduled surveillance bronchoscopies of 110 consecutive lung transplant recipients were analyzed. Positive results (pathologic histology, microbiology, or virology) were further investigated for their effect on clinical decision making. Additionally, cellular composition of bronchoalveolar lavage (BAL) was analyzed. Results Two hundred five surveillance bronchoscopies showed pathologic findings. In 81 cases clinical treatment was changed based on the results. That is, 20% of all prescheduled bronchoscopies directly influenced clinical decision making. Furthermore, analyses of BAL indicate that increased alveolar eosinophils are associated with an increased risk of transplant rejection. Conclusions Prescheduled surveillance bronchoscopies identify clinically unsuspected but therapeutically relevant pathologic findings in approximately 20% of cases. BAL cell composition may confer additional information, especially in cases when biopsy is not possible.

Background: The significance of Candida in pulmonary secretions is unclear, and usually is regarded as colonization, not contributing to symptoms or disease. Yet, in our experience, Candida seemed associated with chronic sputum, mucus plugging, atelectasis, and poor outcome. Objective: The aim of this study is to describe the clinical findings of patients with Candida in pulmonary (sputum or bronchoscopy) secretions and the significance of Candida. Methods: Retrospective study of inpatients and outpatients referred for pulmonary consultation with Candida in pulmonary secretions. Clinical parameters and estimates of whether Candida was likely clinically significant, were determined. Results: 82 inpatients and 11 outpatients were identified, of which 61 (66%) had atelectasis and 68 (73%) bronchoscopies. Of patients having bronchoscopies, 56 (82%) had mucus, and 43 (63%) mucus plugging. Of the inpatients death (or probable death) occurred in 43 (63%), 42 (98%) of which were from definite or probable respiratory failure, with 13 (31%) likely related to mucus plugging, 16 (38%) possibly from mucus plugging, 6 (14%) unknown, and 7 (17%) not due to mucus plugging. Candida was felt likely clinically significant in 57 patients (61%), uncertain significance in 23 (25%), and not significant in 13 (14%). All outpatients had exacerbations, including 7 (64%) within a year. Conclusion: Patients requiring pulmonary consultation with Candida in pulmonary secretions often have chronic sputum production, exacerbations, mucus plugging, atelectasis, and death from respiratory failure. Candida was likely clinically significant in most patients. Recommendations to consider Candida in pulmonary secretions as colonization should be reconsidered.

Background: Variety of benign and malignant lesions of respiratory system presents as endobronchial lesions. Present study was carried out to study the spectrum of endobronchial lesions and role of flexible bronchoscopy in their diagnosis. Methodology: Retrospective study of case-records of patients with endobronchial lesions diagnosed by flexible bronchoscopy, bronchial washings and bronchial biopsy between January 2016 and October 2017. Results: Out of the 131 flexible bronchoscopies done during the study period, endobronchial lesions were evident in 32 patients (age range 10-85 years; 22 males). Twelve (37.5%) lesions were malignant; six (18.75%) lesions were benign, while 14 (43.75%) lesions were inconclusive. Conclusions: Though malignant lesions are common, benign lesions remain important causes of endobronchial lesions. Bronchoscopy with adequate sampling is an essential diagnostic modality for confirming the diagnosis of such lesions. Keywords: Bronchoscopy; Computed tomography; Endobronchial lesions.

Background There are currently no reference standards for the development of competence in bronchoscopy. Research Question The aims of this study were to (1) develop learning curves for bronchoscopy skill development and (2) estimate the number of bronchoscopies required to achieve competence. Study Design and Methods Trainees from seven North American academic centers were enrolled at the beginning of their pulmonology training. Performance during clinical bronchoscopies was assessed by supervising physicians using the Ontario Bronchoscopy Assessment Tool (OBAT). Group-level learning curves were modeled using a quantile regression growth model, where the dependent variable was the mean OBAT score and the independent variable was the number of bronchoscopies performed at the time the OBAT was completed. Results A total of 591 OBAT assessments were collected from 31 trainees. The estimated regression quantiles illustrate significantly different learning curves based on trainees’ performance percentiles. When competence was defined as the mean OBAT score for all bronchoscopies rated as being completed without need for supervision, the mean OBAT score associated with competence was 4.54 (95% CI, 4.47-4.58). Using this metric, the number of bronchoscopies required to achieve this score varied from seven to 10 for the 90th percentile of trainees and from 109 to 126 for the lowest 10th percentile of trainees. When competence was defined as the mean OBAT score for the first independent bronchoscopy, the mean was 4.40 (95% CI, 4.20-4.60). On the basis of this metric, the number of bronchoscopies required varied from one to 11 for the 90th percentile of trainees and from 83 to 129 for the lowest 10th percentile of trainees. Interpretation We were able to generate learning curves for bronchoscopy across a range of trainees and centers. Furthermore, we established the average number of bronchoscopies required for the attainment of competence. This information can be used for purposes of curriculum planning and allows a trainee’s progress to be compared with an established norm.

Background During medical procedures with the potential to produce aerosols such as bronchoscopy, intubation or cardiopulmonary resuscitation, healthcare workers (HCWs) may be exposed to infectious bioaerosols. This is of particular concern when high consequence pathogens such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are circulating. Thus far thousands of HCWs have been infected, 14.8% of these have severe disease and several have died1. However, the determinants of aerosol generation during such procedures and their relative risk to HCWs remain poorly characterized. Research Question. We sought to characterize aerosols produced during airway intubation using an uninfected translational animal model and in human subjects undergoing elective aerosol-generating procedures. We also determined the particle size distribution of generated particles. Study Design and Methods. Aerosol generation was measured during highly controlled experimental (pig) intubations (N=16) and elective bronchoscopies in uninfected patients (N=49) using an optical particle counter (OPC). Recovery of normal respiratory flora was used as a surrogate for pathogen dispersion. Results There was a small but significant (p = 0.03) decrease in 0.3 μm particles during highly controlled pig intubations compared to baseline. The concentration of 1.0 μm and 5.0 μm aerosol particles did not significantly change though oral bacteria were collected from the air. For elective patient bronchoscopies, there was a significant decrease in the generation of larger particles (1.0 μm and 5.0 μm) compared to baseline (p < 0.01), however, 18 of 39 (46%) of patients showed increased aerosol production in 0.3 μm sized particles, 4 of whom demonstrated significant increases. Interpretation. While the total amount of aerosols produced during intubation and bronchoscopy did not increase significantly relative to pre-procedural levels, a small number of participants showed a significant increase in submicron particle emission, meriting further research to delineate determinants of fine particle production during aerosol-generating procedures.

OBJECTIVES The goal of this study was to assess which factors could affect outcomes in pediatric patients undergoing bronchoscopy for foreign body aspiration (FBA). METHODS This is a retrospective case series study evaluating patients who underwent bronchoscopies because of FBA at a tertiary pediatric hospital between January 1, 2010, and December 6. 2018. Data collected included demographic information, time of the aspiration event, history of developmental delay, time of the procedure, duration of the procedure, and outcome (discharged, admission to the hospital or pediatric intensive care unit [PICU], or deceased). Statistical analysis was performed using standard regression analysis and analysis of variance. RESULTS There were a total of 114 patients who underwent bronchoscopy for FBA (61% male and 39% female). The mean ± SD age was 2.8 ± 3.4 years, and 16% had developmental delay. The mean age for patients with developmental delay was 3.43 years, compared with 1.69 years for patients without developmental delay. The age difference between these 2 groups was statistically significant (P = 0.0047). The most commonly aspirated object was food (57%), and patients were usually with their parents at the time of aspiration (78%). Most aspiration events (57%) happened between 4 PM to 4 AM. The mean ± SD time of procedure was 38 ± 28 minutes. The probability of admission to the hospital, PICU, and death increased with the duration of the procedure (P < 0.001). Patients with procedures longer than 60 minutes had a 40% probability of admission to the PICU, and patients with cases longer than 120 minutes had 13% probability of mortality. CONCLUSIONS Most FBA s occurred in the evening while the children were with their parents. Education of families regarding the risk of aspiration is crucial, so they are always attentive to this issue. Although the focus on prevention tends to be with younger patients, it is essential to emphasize the risk of FBA in older patients with developmental delay. Because most episodes of aspiration occur later in the day, it is imperative that tertiary pediatric centers ensure that the evening staff is trained and have the available equipment for these complex cases.

As data about microbiological testing and the cellular composition of the broncho‐alveolar lavage (BAL) fluid in patients ventilated due to coronavirus disease 2019 (COVID‐19) are lacking, this was investigated in a retrospective analysis (n = 58). Co‐infection with pathogens was detected in 31 patients, whereas the analysis of BAL cellularity showed an increased total cell count and an alveolitis dominated by neutrophils. None of the physicians performing bronchoscopies in COVID‐19 patients had serological evidence of severe acute respiratory syndrome coronavirus 2 infection.

Background: The diagnostics in field of lung pathology with advent of bronchoscopic modalities comprises of BAL, BB, TBNA and TBLB. As the detection of malignancy at the earliest has taken so much importance in terms of treatment, prognosis and life expectancy use of cytological bronchoscopic modalities have come to an age and has promised early, accurate diagnosis and better patient outcome. In India as cases of lung diseases continues to increase, the use of cytology has a special role and in particular neoplastic lesions, infectious diseases and in ILD cases. TBNA technique should be encouraged due to its superior sensitivity. Materials and Methods: This study of BAL, BB, TBNA was done during routine diagnostic bronchoscopies at Government tertiary care centre and comparing their results with TBLB as gold standard. The study consisted of clinically diagnosed / suspected cases of lung lesions. The BAL/TBNA/BB cytology and TBLB specimens were taken by the pulmonologist. The clinical, radiological and bronchoscopic data was assessed. Only the cases where BAL, BB, TBNA and TBLB were received simultaneously were included. Investigations done were complete blood count, random blood sugar, blood urea, serum creatinine, electrolytes, HIV evaluation and Chest X-ray/ CT. Results: In our study of 200 cases, 62 were neoplastic and 109 non-neoplastic on and in 29 cases no abnormality was detected. Out of 62, 46 are of squamous cell carcinoma, 10 of adenocarcinoma and others were 06 in number. The non-neoplastic cases includes 06 cases of acute inflammatory lesions, 29 cases of Tuberculosis, 34 cases of Interstitial pneumonia, 6 cases of sarcoidosis, 1 case of fungal infection, and 17 cases of nonspecific inflammation. On combining TBNA with BAL and BB, overall sensitivity was 62.6% with total positive cases 114. For neoplastic lesions combined sensitivity for all BAL, BB and TBNA was 53.8% (n=62), and for non- neoplastic sensitivity was 73.9%. For assessing the level of agree

Background The diagnosis of lung nodules continues to be a challenge. Confirmed diagnosis allows appropriate treatment for cancers and allows avoidance of more invasive procedures for proven noncancers. Currently, available lung biopsy technologies each have their own limitations, which affect the ability to successfully navigate to a suspicious nodule and to collect a diagnostic sample. Additional advancements in endobronchial navigation, localization, and guided biopsy are needed to obtain higher rates of definitive diagnosis for lung nodules. Methods This is a prospective, multicenter study that assessed the localization success rate and diagnostic yield of bronchoscopies guided only by the LungVision platform. Physicians navigated to pulmonary nodules according to a proposed pathway and verified nodule location using radial endobronchial ultrasound before the biopsy. Results Fifty-five patients were enrolled in the study. Two patients had >1 nodule that was evaluated on the day of the procedure. During bronchoscopy, the nodule localization success rate was 93%. The overall diagnostic yield measured the day of the procedure, based on the immediate rapid on-site pathology report, was 75.4%. Conclusion LungVision provides reliable navigation and ability to biopsy pulmonary nodules with an acceptable success rate. The platform demonstrates a high localization rate of pulmonary nodules.

BACKGROUND Flexible bronchoscopy is an essential procedure for the evaluation and management of the pulmonary disease. However, this technology and related training is not available in many low-middle income countries (LMICs). We conducted a pilot training program for flexible bronchoscopy in Uganda. METHODS A multimodal curriculum was developed with pulmonologists from Uganda and the United States. The training included an online distance learning management system for video content, simulation, just-in-time training, and deliberate practice via clinical proctoring. Procedural standards and a de novo bronchoscopy suite were concurrently developed. Competency was assessed using the Bronchoscopic Skills and Tasks Assessment Tool written examination and the Ontario Bronchoscopy Assessment Tool. RESULTS We trained 3 pulmonary physicians with no prior experience in flexible bronchoscopy. Three bronchoscopies with bronchoalveolar lavage were performed during the training and an additional 11 cases were performed posttraining. All 3 Ugandan physicians had an increase in their written Bronchoscopic Skills and Tasks Assessment Tool and Ontario Bronchoscopy Assessment Tool in the competent range (P

BACKGROUND: Mechanical insufflation-exsufflation (MI-E) applied via tracheostomy tubes in patients with amyotrophic lateral sclerosis (ALS) who are on home mechanical ventilation via tracheostomy is an effective procedure for respiratory secretion management. Nonetheless, tenacious secretions may remain and increase the risk of respiratory infections. The aim of this study was to determine whether adding oscillations to MI-E could reduce the rate of respiratory infections and the need for bronchoscopy to remove secretions in patients with ALS on home mechanical ventilation via tracheostomy. METHODS: This was a 2-y, prospective, crossover study. Subjects were treated with conventional MI-E and MI-E with oscillations for 2 alternate 6-month periods. Data were collected on episodes of respiratory infections, hospital admission, and number of bronchoscopy procedures. RESULTS: In the 19 ALS subjects enrolled, the median (interquartile range [IQR]) number of acute respiratory infections per subject was 1.0 (0.5–2.0) in the MI-E period and 0.0 (0.0–2.0) in the MI-E plus oscillations period (P = .92). The median (IQR) number of hospital stays was 0.0 (0.0–1.0) in the MI-E period and 0.0 (0.0–1.0) in the MI-E plus oscillations period (P = .80). The median (IQR) number of bronchoscopies per subject was 0.0 (0.0–1.0) in MI-E period and 0.0 (0.0–0.5) in the MI-E plus oscillations period (P = .26). MI-E plus oscillations treatment had no impact on the risk of respiratory infections (odds ratio 3.71, 95% CI 0.81–16.84, P = .09) or the need for bronchoscopy (odds ratio 2.70, 95% CI 0.44–16.68, P = .29). CONCLUSIONS: Adding oscillations to MI-E therapy in subjects with ALS on home mechanical ventilation via tracheostomy did not decrease the risk of respiratory infections, hospital admission, or need for bronchoscopy.

BACKGROUND: Fiberoptic bronchoscopy (FOB) with broncho-alveolar lavage (BAL) is frequently performed in patients with hematological malignancies and pulmonary opacities. While the safety of the procedure in this patient population has been shown, data about the diagnostic yield widely differ between studies. Furthermore, data comparing diagnostic yield and safety of flexible bronchoscopy to narrow sources of pulmonary infections in patients with and without underlying hematological malignancy are lacking. METHODS: We carried out a retrospective analysis of bronchoscopies done for the diagnostic work-up of pulmonary infections. Diagnostic yield and the occurrence of complications in patients with and without hematological disease were compared. RESULTS: In total n=268 bronchoscopies were done in patients suffering from a hematological malignancy (HM) compared to n=408 bronchoscopies in patients without hematological malignancy (NHM). The overall diagnostic yield was similar and did not differ between the groups (HM: 67.2% vs. NHM: 64.7%; P=0.5622). However, when cultures positive for Candida were not considered as clinically relevant diagnostic yield was higher in the HM group (HM: 62.7% vs. NHM: 53.9%; P=0.0261) due to a higher detection rate of fungi and viruses (both P0.05). There was no difference in the complication rate between the groups and most complications were considered as minor. CONCLUSIONS: In summary, our data demonstrate similar diagnostic yield and safety of flexible bronchoscopy for diagnosing pulmonary infection in patients with and without underlying hematological malignancy.

Thyroidectomy is considered an overall low-risk procedure. However, severe life-threatening complications, including tracheal necrosis may occur postoperatively. A 45-year-old male patient was referred to our clinic for papillary thyroid carcinoma surgery. The patient had mediastinitis signs and symptoms seven days after total thyroidectomy. Subsequent imaging demonstrated air leak and with mediastinitis as the primary diagnosis, and the patient underwent reoperation. During the operation, four necrotic tracheal rings were found to be the source of air leak. Due to tissue inflammation and infection, neither primary repair with tracheal resection and anastomosis, nor strap muscle plugging procedure were feasible. Therefore, a pedicle flap derived from the right pectoralis major muscle was transferred to the necrotic trachea. The patient’s clinical condition improved after the operation and subsequent bronchoscopies confirmed healing of trachea. During six-month follow-up, no complications were observed. In conclusion, the technique discussed in the current report shows promising outcomes for reconstructing large tracheal defects in inflammatory conditions where primary repair techniques are not suitable.

Aim This study aimed to determine operator impressions of an airway obstruction procedure using a custom silicone model of low cost and high accuracy. Background Current procedural education for therapeutic bronchoscopy relies on animal models, supervised in-patient training, and inanimate artificial models. Model manufacturing via lost-wax casting allows for the flexibility of the material selection and reproduction of complex airway shapes. Methods A patient computed tomography scan was anonymized and segmented into a stereolithographic (STL) file. The water dissolvable interior airway mold was 3-dimensional (D) printed using polyvinyl alcohol and the exterior mold was printed with polylactic acid. Flexible silicone was injected into the mold. During advanced bronchoscopy courses (2017-2018) at Beth Israel Deaconess Medical Center, participants were asked to evaluate both standard bronchoscopy manikin and the manikin with 3D customization. Results We evaluated 17 participants with different levels in training in the pulmonary field. All of them reported that they previously have performed >100 bronchoscopies, 88% having treated patients with airway stenosis. In total, 77% of participants thought the 3D model was better or much better for airway inspection when compared with Broncho-Boy. Overall, 94% of participants reported the 3D model was accurate or very accurate for realism. In total, 69% of trainees reported the overall experience as excellent. All of them reported 3D model would improve their skills on stent placement. Conclusion 3D printing with silicone lost wax casting can be used to reproduce airway abnormalities for tactile simulation bronchoscopy. Reproducible custom airway models can be created for a relatively low cost.

Case Presentation A 71-year-old ex-bus driver (ex-smoker, 20 pack-years) was admitted for the first time to the respiratory department because of chronic dry cough and progressive exertional dyspnea with insidious onset 8 years ago. The patient also reported weight loss of about 20 kg in 3 years and proximal muscle weakness. A decade ago, he was diagnosed with gastric adenocarcinoma and subjected to partial gastrectomy and splenectomy, followed by an unspecified chemotherapy regimen. Additionally, the patient has coronary disease and underwent coronary bypass graft surgery 7 years ago. In the course of his disease, many diagnostic procedures have been performed including Mantoux tests, five CT scans, a CT-guided biopsy, two bronchoscopies, and an 18F-fluorodeoxyglucose PET scan with inconclusive results. The patient was referred to the hospital to have his long-lasting condition diagnosed and treated.

Objectives This study investigated benefits of routine panendoscopy in staging of oral squamous cell cancer patients. Materials and methods From 2013 to 2017, 194 oral squamous cell cancer patients were staged. Reports of routine flexible panendoscopy including oropharyngolaryngoscopy, bronchoscopy, and esophagogastroduodenoscopy were retrospectively analyzed for diagnoses of inflammation and second primary malignancies (carcinoma in situ or cancer) and compared to results of computed tomography. The effects of alcohol and tobacco history of 142 patients were assessed. Results Overall, a second primary malignancy was detected in seven patients. In four patients this discovery was only found by panendoscopy. One invasive carcinoma (esophagus) was detected as well as three carcinoma in situ. The second primary malignancies were located in the lung (3), esophagus (3), and stomach (1). In one patient index tumor therapy was modified after panendoscopy. Upper gastrointestinal inflammation was present in 73.2% of patients and 61.9% required treatment. About 91.8% of bronchoscopies and 34.5% of panendoscopies were without therapeutic consequences. Patients with higher risk from smoking were more likely to benefit from panendoscopy and to have a Helicobacter pylori infection. Conclusion We do not recommend routine panendoscopy for all oral squamous cell cancer patients. Esophagogastroduodenoscopy benefitted smoking patients primarily concerning the secondary diagnosis of inflammation of the upper digestive tract. Selective bronchoscopy, esophagogastroduodenoscopy, and oropharyngolaryngoscopy should be performed if clinical examination or medical history indicates risks for additional malignancies of the upper aerodigestive tract. Clinical relevance Routine panendoscopy is not recommended in all, especially not in low-risk oral cancer patients like non-smokers and non-drinkers.

Background Bronchoscopy is commonly used to evaluate suspicious lung lesions. The yield is likely dependent on patient, radiographic, and bronchoscopic factors. Few studies have assessed these factors simultaneously while also including the preprocedure physician-assessed probability of cancer (pCA) when assessing yield. Methods This study is a secondary data analysis from a prospective multicenter trial. Diagnostic yield of standard bronchoscopy with biopsy ± fluoroscopy, endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), electromagnetic navigation, and combination bronchoscopies was assessed. Definitions for diagnostic and nondiagnostic bronchoscopies were rigorously predefined. The association of diagnostic yield with individual variables was examined by using univariate and multivariate logistic regression analyses where appropriate. Results A total of 687 patients were included from 28 sites. Overall diagnostic yield was 69%; 80% for EBUS, 55% for bronchoscopy with biopsy ± fluoroscopy, 57% for electromagnetic navigation, and 74% for combination procedures (P 60% yielded a positive result in 77% (P Conclusions This study is the first to assess the yield of bronchoscopy according to physician-assessed pCA in a large, prospective multicenter trial. The yield of bronchoscopy varied greatly according to physician suspicion that cancer is present, the patients’ clinical/radiographic features, and the type of procedure performed. Of the procedures performed, EBUS-TBNA was the most likely to provide a diagnosis.

Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy is the gold standard for the diagnosis of infection or acute cellular rejection in lung transplantation (LTx) recipients, but there is some controversy to perform it in asymptomatic patients. We conducted a retrospective analysis of medical reports of LTx recipients who survived in the first year after transplant during the period of August 2003 to February 2018 to evaluate the applicability of this procedure in the management of asymptomatic acute cellular rejection in our center. We assessed 1252 bronchoscopies of 247 patients during this period, and, facing the histopathological results, we defined our management that included conservative or intervention therapy. In our service the information obtained by surveillance bronchoscopy was sufficient to modify the management mainly in the first 2 surveillance bronchoscopies (second and sixth week post LTx). This effect seems to dilute after the second month, making its applicability more questionable.

Rigid bronchoscopy is the gold standard treatment for pediatric tracheobronchial foreign bodies. This procedure gives jitters to young ENT surgeons. The only aim of this study is to aware young ENT surgeons of different challenges they may face during bronchoscopy and their subsequent management. Clinical and demographic presentations of airway foreign bodies are also presented. This prospective observational study was conducted from Jan 2013 to Jan 2020 on patients with tracheobronchial foreign bodies. Patients were divided in four Groups (A, B, C and D) on the basis of mode of presentation. Rigid bronchoscopies using basic instruments without the use of telescope/telescopic forceps in patients fulfilling the inclusion/exclusion criteria were done by first author under the supervision of senior authors. The challenges and difficulties encountered and their subsequent management were noted. Out of seventy cases, maximum patients (50) were in the age group of 2–6 years. Majority of patients (76.2%) in Group A and B in total reported to hospital within 0–2 days. Majority of patients in Group A and B as a whole were educated as per our criteria while majority in group C were uneducated. Cough was the most common symptom seen in all groups at the time of examination. Decreased air entry abnormal breath sounds on examination were seen in 75%, 73%, and 100% of (patients in) Group A, B and C, respectively while it was normal for Group D. Most common X-ray finding was Hyperinflation followed by normal X-ray in group A and B. Most common Grade of modified Cormack–Lehane on direct laryngoscopy was Grade 1. Most common foreign body was nuts/legumes/pulses. Difficulty in inserting appropriate size rigid bronchoscope through vocal cords, Intraoperative drop in oxygen saturation, breakage of foreign bodies into pieces, stucking of forceps into tracheal mucosa, stucking of foreign body in sub glottis while removing and bleed/edema in old foreign bodies were main problems encountered. Rigid bronchoscopy is a life saving procedure. The sophisticated telescopes/forceps and other gadgets may not be always available. The young ENT surgeon should be well acquainted with basic instruments and their usage. The common difficulties/challenges faced should not cause panic as these challenges can be easily overcomed with simple maneuvers.

Background Gastroesophageal reflux (GER) in recipients of lung transplant (LTX) is associated with chronic allograft rejection, presumably via microaspiration that damages airway epithelium. Most LTX programs perform a single post-LTX esophageal study to evaluate for GER; the efficacy of this test is unclear. Methods Patients with 1 year of post-LTX follow-up, including routine bronchoscopies with bronchoalveolar lavage fluid (BALF) samples as well as high-resolution esophageal manometry and pH probe monitoring (HREMpH), were evaluated. BALF samples were analyzed with competitive enzyme-linked immunosorbent assay to detect bile salts, which are indicative of aspiration. These results were compared to results of HREMpH studies post LTX. Results Ninety BALF samples were analyzed for bile salts and acted as disease positive for this evaluation. Of the 13 HREMpH cases, 8 were positive for GER, but only 3 were positive for bile salts via assay. Of the 5 HREMpH-negative cases, 2 experienced aspiration. A solitary HREMpH study had 60.0% sensitivity and 37.5% specificity with positive and negative likelihood ratios: 0.96 and 1.07, respectively. Conclusion Microaspiration appears to be an intermittent phenomenon, and HREMpH screening poorly correlates with BALF evidence of aspiration; which may not be adequate. As aspiration detection is crucial in this population, further analysis is warranted.

Objectives To evaluate the impact of early inpatient bedside injection laryngoplasty (IL) in hospitalized patients with iatrogenic unilateral vocal fold immobility (UVFI). Study design Retrospective cohort study. Methods A retrospective review of hospitalized patients with iatrogenic UVFI undergoing IL between September 2013 and June 2017 was performed. Patients had a swallow evaluation by a speech-language pathologist and bedside IL. Evaluated outcomes included swallow scores, return to diet, secondary events/procedures, and hospital length of stay. Outcomes related to etiology of UVFI were also examined. Results The cohort consisted of 90 patients (61% male, 52% after cardiac/cardiothoracic surgery). Seventy-seven percent of all patients who could improve had increased swallow scores after IL. The lowest number (40%) from the subgroup of patients with high vagal injuries as the cause of UVFI obtained improvement in swallow scores, whereas 87% of those in the cardiac surgery group improved. There were more bronchoscopies and reintubations in patients before IL than after IL. Conclusion Hospitalized patients with UVFI are at increased risk of morbidity and mortality due to dysphagia. We advocate for early swallow evaluation and intervention with IL if there is dysphagia and risk of aspiration. Coordination of care between interdisciplinary teams is paramount to a successful inpatient IL program. Level of evidence 2b Laryngoscope, 131:115-120, 2021.

BACKGROUND Invasive pulmonary aspergillosis (IPA) is a significant cause of morbidity and mortality in lung transplant recipients (LTRs). It is unclear how a targeted prophylaxis/ preemptive antifungal therapy strategy impacts the incidence of IPA beyond the first-year posttransplant. METHODS This is a retrospective cohort of LTRs from January 2010 to December 2014. We included all LTRs who survived beyond the first year and followed them until death or 4 years postoperatively. Incidence of probable/proven IPA and Aspergillus colonization were assessed as per International Society for Heart and Lung Transplantation (ISHLT) criteria. Patients with risk factors, positive Aspergillus cultures, or galactomannan (GM) received targeted prophylaxis/preemptive therapy within the first-year posttransplant. RESULTS During the study period, 350 consecutive LTRs underwent 1078 bronchoscopies. Positive bronchoalveolar lavage for GM or Aspergillus cultures was reported for 15% (52/350) of LTRs between 2 and 4 years after transplantation. Among them, the median time to positive Aspergillus culture or GM positivity was 703 days (interquartile range, 529-754 d). The incidence rate of IPA and Aspergillus colonization was 30 of 1000 patient-y, and 63 of 1000 patient-y, respectively. The mortality rate was significantly higher in patients with IPA than without IPA (107/1000 patient-years versus 18/1000 patient-years; P

Background: Nicotine-containing electronic cigarette (e-cig) use has become widespread. However, understanding the biological impact of e-cigs compared with smoking on the lung is needed. There are major gaps in knowledge for chronic effects and for an etiology to recent acute lung toxicity leading to death among vapers. Methods: We conducted bronchoscopies in a cross-sectional study of 73 subjects (42 never-smokers, 15 e-cig users, and 16 smokers). Using bronchoalveolar lavage and brushings, we examined lung inflammation by cell counts, cytokines, genome-wide gene expression, and DNA methylation. Results: There were statistically significant differences among never-smokers, e-cig users, and smokers for inflammatory cell counts and cytokines (FDR q < 0.1). The e-cig users had values intermediate between smokers and never-smokers, with levels for most of the biomarkers more similar to never-smokers. For differential gene expression and DNA methylation, e-cig users also more like never-smokers; many of these genes corresponded to smoking-related pathways, including those for xenobiotic metabolism, aryl hydrocarbon receptor signaling, and oxidative stress. Differentially methylated genes were correlated with changes in gene expression, providing evidence for biological effects of the methylation associations. Conclusions: These data indicate that e-cigs are associated with less toxicity than cigarettes for smoking-related pathways. What is unknown may be unique effects for e-cigs not measured herein, and a comparison of smokers completely switching to e-cigs compared with former smokers. Clinical trials for smokers switching to e-cigs who undergo serial bronchoscopy and larger cross-sectional studies of former smokers with and without e-cig use, and for e-cigs who relapse back to smoking, are needed. Impact: These data can be used for product regulation and for informing tobacco users considering or using e-cigs. What is unknown may be unique effects for e-cigs not measured herein, and clinical trials with serial bronchoscopy underway can demonstrate a direct relationship for changes in lung biomarkers.

Objective The diagnosis of foreign body aspiration (FBA) is challenging. In a previous study, we developed a computerized scoring system (CSS) to support decision-making. In the present study, we aimed to validate it on a further cohort. Study design In this observational study, 100 children referred to the emergency department of a tertiary pediatric hospital for suspected FBA and treated according to standard protocol, were assigned a probability score using the CSS, between 0 and 1 (0, very low probability; 1, very high). The diagnosis of FBA was based on bronchoscopy, and if discharged without bronchoscopy, determined via telephone questionnaire, 4 to 6 months after discharge, supplemented by clinical re-evaluation and bronchoscopy, if respiratory symptoms persisted. Results Thirty-five out of 100 children (35%) underwent bronchoscopy with 12 of 35 (34%) positive for FBA. Sixty-five patients were discharged without bronchoscopy and completed a telephone questionnaire. Seven patients required clinical re-evaluation for persistent respiratory symptoms, in two out of them, additional bronchoscopies were performed and were negative. The CSS median probability score was 0.94 in patients with FBA, as compared to 0.73 in patients without FBA (P = .007). The CSS area under the receiver operating curve was 0.74. At a probability score threshold of 0.6, the sensitivity and specificity were 100% and 41%, respectively. Conclusion The present validation study suggests a high sensitivity of the CSS for the identification of FBA in children. We suggest that it might aid decision-making with regard to the need for bronchoscopy in children presenting to the emergency room.

Background Fiberoptic bronchoscopy (FB) is an endoscopic technique for visualizing the inside of the airway for diagnostic and therapeutic purposes. FB is a simple, useful examination suitable for investigation without general anesthesia. Aim We aimed to report our 5-year experience with the diagnostic yield of FB at the Al-Azhar University Hospital. Patients and methods A retrospective review of bronchoscopy reports was performed at the Chest Department, El-Hussein University Hospital, Al-Azhar University, during the 5 years from January 2012 to December 2016. Data collected were encoded into MS Excel 2017 for windows XP professional. Age was presented as mean. Due to the descriptive nature of this study; all other data were presented as percentage. The calculation was done using Excel. Results Bronchoscopy was successful for giving a final diagnosis in 275 (78.6%) patients out of 350 patients. Of these, 190 patients were men and 160 patients were women. Malignancies were diagnosed in 66.3% of cases; tuberculosis was diagnosed in 2.8%; and interstitial lung diseases were diagnosed in 3.7% of cases. Conclusion FB can be performed easily in hospitals with appropriate preparation, observation, and attachment to protocol. This study confirms that FB is a valuable diagnostic tool, with low cost and low rates of complication, particularly in patients with lung cancer. Bronchoscopists face many challenges to reach the correct diagnosis of peripheral lung diseases. Some diagnostic bronchoscopies fail to reach the diagnosis, so bronchoscopy can be repeated or search for other diagnostic modalities. Bronchoscopy, performed under local anesthesia in the endoscopy suite, gives a solution in most cases with minimal complications. Recommendation Every pulmonologist should be aware and well trained in bronchoscopy.

Objective In children, pulmonary and cardiac diseases are closely associated, and their integrated evaluation is important. Flexible fiber-optic bronchoscopy (FFB) can be used for both diagnostic and therapeutic purposes in pediatric cardiac intensive care units (PCICU). The objective of this study was to evaluate the utility of FFB in children with congenital heart disease (CHD). Materials and methods A retrospective, descriptive study was conducted at a tertiary care center in pediatric patients who underwent FFB in PCICU over a period of 6 years (2012-2017). Results Total 71 bronchoscopies were done in 58 patients with CHD with median age and weight of 2.5 months and 3.4 kg, respectively. Total of 20 different cardiac lesions were present among patients who underwent FFB. While 38 (53.5%) and 30 (42.3%) procedures were performed in pre-op and postoperative patients, respectively, 3 intraoperative bronchoscopies were also performed. The main indications for FFB were persistent atelectasis (42/71), prolonged oxygen requirement (13/71), stridor (8/71), and suspected airway anomaly (6/71). Tracheobronchitis was the commonest bronchoscopy finding (51/71, 71.8%) followed by tracheobronchomalacia (27/71, 38.3%). Cause of stridor detected in 7/8 cases. Associated preoperative and postoperative respiratory complications were detected and necessary interventions were done. These included slide tracheoplasty (5/58), tracheostomy (5/58), antibiotic change based on bronchoalveolar lavage (BAL) cultures (11/71), and continued positive pressure ventilation (4/71). Nonconsequential complications were transient hypoxemia (10/71), bleeding (2/71), and transient bradycardia (1/71). Conclusion Bedside FFB is a safe and a valuable diagnostic tool that also helps in guiding interventions in children with cardiac diseases. How to cite this article Sachdev A, Chhawchharia R, Gupta D, Gupta N, Joshi R, Agarwal N. Flexible Fiber-optic Bronchoscopy-directed Interventions in Children with Congenital Heart Diseases. Indian J Crit Care Med 2020;24(5):340-343.

Background Recent standards of care mention chest radiography (CR) but not chest computed tomography (CT) in routine annual follow-up of children with cystic fibrosis (CF). To minimise radiation risk, CT or CR should only be performed if they impact clinical decision making. We investigated whether in addition to a wide range of commonly used clinical parameters, chest CT and/or CR in routine follow-up of CF patients influence clinical decisions. Methods 36 web based clinical vignettes (i.e. case simulations) were designed using clinical data from patients aged 8–18 years, randomly selected from two CF centres in The Netherlands. In a randomized cross-over design, clinicians assessed eight vignettes and suggested therapeutic/diagnostic management on two occasions, with a ten-week interval. Radiological information (CT or CR) was included at only one of the two assessments, in random order. Any differences in management could be attributed to information from CT or CR, and were compared by McNemar analysis. Results 44 European and Australian clinicians completed a total of 143 CT vignette pairs and 167 CR vignette pairs. CT was associated with a significant increase in antifungal treatment (Risk Ratio (RR) 2.8 (1.3–6.0, p = .02)), bronchoscopies (RR 1.6 (1.1–2.5, p = .04)), mycobacterial cultures (RR 1.3 (1.0–1.5, p = .02)), and ‘need for hospitalization’ (i.e. intravenous antibiotics and/or bronchoscopy) (RR 1.4 (1.0–1.9, p = .03)). CR led to a significant increase in inhaled antibiotics only (RR 1.3 (1.0–1.6, p = .04)). Conclusions CT but not CR, at routine biennial follow-up was associated with several changes in treatment and/or diagnostic testing, including the need for hospitalization.

Bronchoscopy can be considered among the most significant advances in diagnostics and treatment of respiratory disease. There are several types of bronchoscopies, including rigid and flexible, each with their own particular characteristics and indications. In the field of thoracic surgery, flexible bronchoscopy has a crucial importance. Flexible bronchoscopes are still a key element in the management of anesthesia for thoracic surgery, particularly in confirming the correct position of the isolation device used to achieve one lung ventilation. Parallel to the traditional use of the flexible bronchoscope in thoracic surgery, its uses in the field of interventional pneumonology continues to expand and develop. More and more procedures are being performed with both the rigid and flexible bronchoscope, which require adequate levels of sedation for tolerability and patient comfort. This presents a challenge for the anesthesiologist both because of the comorbidity of the subsidiary patients and because of the difficulties involved in ventilation and maintenance of the permeable airway. This is when the anesthesiologist has to share the airway with the surgeon and must have a close communication with the surgical team. This review describes the use of the bronchoscope in thoracic surgery and the anesthetic management of the main branches of interventional pneumology: diagnostic and therapeutic bronchoscopy.

Cunninghamella is a member of the class Zygomycetes. Cunninghamella species include ubiquitous filamentous fungi; infections caused by Cunninghamella species are less frequent but have higher mortality rates than infections caused by Mucorales group members such as Rhizopus and Mucor. Herein, we reported a rare fatal case of endobronchial metastasis from breast cancer accompanied with Cunninghamella bertholletiae tracheobronchial mycetoma. A 73-year-old female with a history of right-sided breast cancer who had undergone mastectomy 11 years previously and had no recurrence presented to our emergency department with a 1-week history of left-sided back pain. Chest X-ray revealed left lung atelectasis; bronchoscopy revealed an endobronchial mass lesion in the left main bronchus. Pathological examination revealed fungal mycetoma but malignant lesions were not detected. Endobronchial and lung mycetoma caused by Cunninghamella bertholletiae were initially diagnosed; liposomal amphotericin B was administered, but her condition deteriorated. Rigid endoscopy showed growth of hemorrhagic tissue occupying the left main bronchus just under the carina. Pathological examination of the shaved lesion revealed metastasis from breast cancer covered with abundant necrotic tissue. No mold was observed in the necrotic tissue; this was probably due to liposomal amphotericin B treatment. To our knowledge, this is the first case of endobronchial metastasis from breast cancer accompanied with Cunninghamella bertholletiae mycetoma. Distinguishing endobronchial metastases from breast cancer and atypical presentations of Cunninghamella endobronchial mycetomas can be very difficult. Repeated bronchoscopies maybe helpful in establishing an accurate diagnosis when clinical prognosis does not match the initial diagnosis.