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A man in his early 70s with a long-standing history of chronic bronchitis presented to our department 3 years ago with debilitating chronic cough and excessive sputum production. He had no previous diagnosis of chronic obstructive pulmonary disease and without evidence of severe respiratory tract infections. Due to his symptom burden and impairments in daily activities, the patient was considered to be an appropriate candidate for bronchial rheoplasty, a novel endoscopic treatment for patients with chronic bronchitis. The patient responded well to bilateral treatment but then experienced symptom recurrence roughly 14 months after completing the initial treatment. In the absence of an alternative explanation for the return of these symptoms, he then underwent uneventful retreatment. The patient, again, reported significant symptom improvement and no adverse effects since retreatment. While further studies are necessary to assess the safety and efficacy of retreatment, the findings from this case are encouraging., Competing Interests: Competing interests: WK: chief medical officer–Galvanize Therapeutics; AV: personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Menarini, Merck, Novartis and Roche for lectures and/or advisory boards outside of the submitted study., (© BMJ Publishing Group Limited 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Patients living with chronic bronchitis (CB) suffer from physical limitations and poor quality of life. In general, treatment options that directly address the mucus hypersecretion component of CB are quite limited. Chronic airway inflammation and the associated hypersecretion and cough that are pathognomonic for CB generally result from long-term exposure to airway irritants such as tobacco use and other environmental insults. This, in turn, results in an increase in the quantity and change in composition of the airway mucosa as a consequence of altered goblet cells, club cells, and submucosal glands. Pulsed electric fields (PEFs) provide a method for eradicating the cellular constituents of tissue with limited impact on the stromal proteins. Preclinical evidence in porcine airways demonstrated that particular PEF waveforms allowed for salutary remodeling of the epithelial and submucosal airway tissue layers and appeared to foster rapid regeneration and recovery of the tissue. Therefore, a therapeutic opportunity might exist whereby the application of a specific form of PEF may result in a reduction of the cellular secretory constituents of the airway while also reducing airway mucosal inflammation. This review discusses the use of such PEF to address the underlying disease processes in CB including challenges around device design, dosing, and appropriate delivery methods. Further, we outline considerations for the transition to human airways along with a brief examination of the initial work treating CB patients, suggesting that the therapy is well tolerated with limited adverse events., (© 2023 S. Karger AG, Basel.)

Background: Currently there are several techniques for endoscopic diagnosis of parenchymal lung abnormalities. Electromagnetic navigation with or without endobronchial ultrasound for diagnosis of the above has been well described. Bronchoscopic Trans Bronchial Access Tool is a novel endoscopic technique that creates a virtual pathway to the lesion and is less limited by location of the airway. The CrossCountryTM Transbronchial Access Tool (CovidienTM, Plymouth, MN, USA) is a Food and Drug Administration (FDA) approved off airway device that utilizes a catheter equipped guide sheath for a trans-parenchymal approach to a distal lesion. Cone beam computer tomography (CBCT) is a real-time onsite extrathoracic navigational modality used in the bronchoscopy suite that allows for an open working channel. All three of the above modalities can have reasonable diagnostic yields when used independently. While utilizing the above tools we frequently found ourselves in situations where one technique was not enough, prompting the use of a combination of modalities to obtain the most efficient and accurate diagnosis. We are reporting the feasibility and safety of utilizing these three modalities in conjunction with one another., Methods: Patients with peripheral pulmonary nodules on chest computed tomography underwent a navigation bronchoscopy under general anesthesia. CBCT and radial ultrasound was used in every case to confirm navigation to the target lesion. Lesions without definitive airways leading to them were accessed with the transbronchial access tool (TBAT)., Results: Electromagnetic bronchoscopy using CBCT and radial US was performed on 22 patients from April 2016 to September 2016. The TBAT tool was used in 7 patients. The overall diagnostic yield was 77.2% (17 of 22). Diagnostic yield of with use TBAT was 100% (7 of 7). There were no complications. Average case length was 79.95 (range, 50-124) minutes and average fluoroscopy time was 10.39 (1-21.7) minutes., Conclusions: TBAT is a useful and safe tool when accessing peripheral pulmonary nodules and is used in conjunctions with electromagnetic navigation and CBCT., Competing Interests: Conflict of Interest: William Krimsky: (I) Part-time employee, Medtronic; (II) Gala Therapeutics, consultant with options; (III) Innovital Systems, consultant with options; (IV) Peytant Solutions, consultant with options; (V) CSA medical. The other authors have no conflicts of interest to declare.

Background: Traditionally, squamous cell carcinoma (SCC) of the lung is a central rather than a peripheral form of lung cancer. Rates of SCC in the lung periphery are typically sited in the 15-30% range. Recently, we observed that a significant portion of newly diagnosed SCC was located on a periphery. A comprehensive review of the tumor data at our facility, a busy teaching hospital with a large cohort of cancer patients, was undertaken to assess whether there had been a substantive change in the traditional epidemiologic distributions of the lung cancer, specifically with respect to SCC. Given the differences in cell biology and carcinogenesis of central versus peripheral SCC, a potential epidemiologic shift might suggest a change in tumor biology., Methods: From May 12, 2012 through May 13, 2013, all histopathologically confirmed diagnoses of SCC of the lung were retrospectively reviewed. Each patient's lesion was then classified as peripheral or central based on CT evidence., Results: A total of 56 patients were diagnosed with SCC. Of these, 55% ( n= 31) had peripheral and 45% ( n= 25) had central SCC. Twenty-nine patients did not have any prior history of malignancy. Of this subset of patients, 62% ( n= 18) had peripheral SCC, and 38% ( n= 11) had central SCC., Conclusion: Our findings appear to correlate with our initial observation that, within our institution, there has been a substantive shift in the traditional distribution of SCC with the majority of these cancers now being diagnosed in the lung periphery as opposed to the more central locations., Competing Interests: and funding The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

Background: Recent advances in lung cancer treatment have changed the requirement for the amount and quality of biopsy specimens needed to characterize the tumor and select the best treatment. One adjunct to guide the bronchoscopist on the quality and quantity of specimens during bronchoscopic biopsies for the diagnosis of lung cancer is rapid on-site evaluation (ROSE) of cytological specimens. This technique has been shown to add to the diagnostic yield of bronchoscopy when obtaining adequate specimens for molecular profiling in lung cancer. ROSE is not available at all medical centers. We describe our initial experience using intra-procedural Frozen Section Evaluation (FROSE) of bronchoscopic biopsy specimens as an alternative to ROSE., Methods: A retrospective analysis of all interventional pulmonology cases using FROSE between February and July 2015 was performed. Results analyzed to evaluate the success in obtaining adequate specimens for molecular profiling., Results: A total of 88 interventional pulmonology cases employing a frozen section in at least one site were identified. In 94.3% of cases, a definitive diagnosis of benign or malignant was made. The concordance of frozen section diagnoses of benign or malignant was 100% with final diagnoses. Thirteen of the eighty-eight cases were ultimately sent for molecular analysis. Of these, twelve of thirteen (92.3%) cases were adequate to perform all ordered molecular testing. In all cases there was sufficient tissue to perform EGFR and ALK testing., Conclusions: In medical centers where ROSE may not be available, the use of FROSE by the local pathologist can be an effective technique to obtain adequate tissue and cytological samples for the diagnosis and molecular profiling of lung cancers. Further prospective study in bronchoscopic tissue sampling techniques to obtain the optimum quantity and quality of samples for molecular profiling of lung cancers for targeted treatments is needed.

We present the first reported case of the treatment and management of a giant bulla using percutaneous bullectomy and endobronchial valve placement. A 74-year-old woman with chronic obstructive pulmonary disease and a known large bulla in the left chest presented to the emergency department with acute-onset confusion after a traumatic fall. She was subsequently diagnosed with an intracranial hemorrhage in the distribution of the right basal ganglia. Chest imaging revealed a giant apical bulla occupying 80% of the left hemithorax. In addition, there was midline shift away from the affected side associated with volume loss in the right hemithorax and no radiographic evidence of aeration in the remainder of the left lung. Arterial blood gas analysis revealed significant hypercapnia. Surgical bullectomy was not an option, and thus, a novel approach was utilized to treat this patient., (© 2016 S. Karger AG, Basel.)

Chronic obstructive pulmonary disease (COPD) causes severe handicap among smokers. Most patients have to remain under continuous oxygen therapy at home. Moreover, respiratory infections are very common among these patients and vaccination is obligatory against influenza. Emphysema and bronchiectasis are observed with computed tomography (CT) and in several situations these parenchymal damages are responsible for pneumothorax in one case and pseudomonas aeroginosa infection. Novel mini-invasive techniques are used currently for emphysema treatments which are described extensively throughout our current work.

Teflon-coated pledgeted sutures can be used to reinforce the bronchial anastomosis site following a pulmonary resection in order to prevent bronchopleural fistula formation. The authors describe the case of a 42-year-old woman with recurrent haemoptysis secondary to the erosion of a pledgeted suture through the distal trachea. The pledgeted suture was used to reinforce a defect in the wall of the distal trachea after a right upper lobectomy for stage 2a squamous cell carcinoma. Surgically, a completion pneumonectomy with carinal reconstruction was thought necessary to treat the haemoptysis. Given her age and potential surgical morbidities, the decision was made to perform serial bronchoscopies with careful pruning and eventual removal of the pledget by using the cryoprobe and a flexible scissors. This resulted in the eventual removal of the suture. Follow-up bronchoscopy 4 weeks postremoval demonstrated no residual defect on the airway wall.

Benign strictures of the airway can be complex and challenging to manage. Although resection has the best long-term results, this is not always feasible, and there will be groups of patients who require additional therapy for failure after open operations or who are not surgical candidates and require endoluminal management. A number of stents are available; however, not all perform well for the longer duration that will be required for patients with benign compared with malignant strictures. For this reason, stenting should be considered a temporary solution or a last resort for patients with benign airway strictures. Combinational modalities hold promise; for example, radial laser incisions with dilatation and mitomycin C for tracheal stenosis. Many techniques, however, have been associated with failure, particularly for long strictures. Spray cryotherapy is a new technique that may have advantages over other treatments by modulating the healing response and resulting in improved healing and less refibrosis. A number of current and new therapies are reviewed in this article., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Malignancies of the parietal pleura, whether primary or metastatic, are a therapeutic challenge, and current therapies target their symptoms and not their tumor burden. Therefore, alternatives to standard approaches seem warranted. A patient with a parietal pleura-based adenocarcinoma was treated with low-pressure spray cryotherapy after failing more traditional approaches. The patient underwent therapeutic pleuroscopy with moderate sedation and local analgesia of the right chest. She was treated with the CSA Medical spray cryotherapy system, which was introduced into the chest via the working channel of a semi-rigid pleuroscope. Pleuroscopic examination 3 days after spray cryotherapy revealed >50% reduction in tumor size. No adverse events or complications occurred as a result of treatment. At the 3-month follow-up, a slightly raised mound of tissue was noted at the treatment site. This area was biopsied and found to be negative for tumor, containing only chronic inflammatory tissue. No evidence of residual cancer was observed. Initial observations include lack of a bystander effect on lung and pleura; no significant side effects or symptoms; a 50% tumoricidal response 3 days after treatment, and a complete tumoricidal response 90 days after treatment without evidence of tumor on the parietal pleura.

Objective: In the pathogenesis of septic shock, caused by either bacterial toxins or trauma, increased production of multiple proinflammatory mediators, such as phospholipase A(2) (PLA(2)), cytokines, and chemokines, is known to be of major importance. The present study was undertaken to investigate the influence of a newly designed extracellular PLA(2) inhibitor (ExPLI) on synthesis of proinflammatory mediators and mortality rate in a rat sepsis model., Design: Prospective, randomized animal study., Setting: Experimental laboratory., Subjects: Male Wistar-rats weighing 200-300 g., Interventions: Mortality was induced by intraperitoneal bolus administration of lipopolysaccharide 15 mg/kg in 22 rats that were pretreated with NaCl or ExPLI (150 mg/kg). Furthermore, nine rats received a sublethal bolus of lipopolysaccharide (7.5 mg/kg) and nine rats received lipotechoic acid (8 mg/kg) simultaneously with or after ExPLI administration. Blood samples were collected from these rats, and cytokine concentrations were assessed by enzyme-linked immunosorbent assay. Lung and kidney were removed for RNA isolation and immunohistological analysis., Measurements and Main Results: ExPLI treatment significantly reduced lipopolysaccharide-induced mortality of rats (90.9 and 36.4%, p <.05). Up-regulation of tumor necrosis factor-alpha and interleukin-6 production in serum after endotoxin treatment was significantly inhibited when ExPLIs were administered at the time of or before sepsis induction by using lipopolysaccharide or lipotechoic acid (p <.01). Similarly, messenger RNA expression of secreted PLA(2)-IIA, interleukin-1, or inducible nitric oxide synthase and the expression of intercellular adhesion molecule-1 were significantly down-regulated in lung and kidney of ExPLI-treated rats, as demonstrated by RNase protection assay, reverse transcription-polymerase chain reaction, or immunohistochemistry., Conclusions: ExPLIs may be considered as potentially effective compounds to prevent the production of inflammatory mediators and to improve mortality rate in septic patients.

We report a case of pituitary hemorrhage and review the literature on that condition. Our patient presented with a sudden bifrontal headache associated with vague transient visual blurring but without nausea or other associated symptoms. After a negative workup at another hospital, including an unremarkable brain computed tomography without contrast, and resolution of headache following treatment with injectable sumatriptan, he was diagnosed with "atypical migraine." The patient's symptoms soon returned, and brain magnetic resonance imaging revealed an enlarged, cystic pituitary gland with a small intraparenchymal hemorrhage.

A case of infective endocarditis involving the vestigial eustachian valve is presented and the available English medical literature is reviewed. Only 5 prior cases have been reported: 4 of those required transesophageal echocardiography for diagnosis, and the other was found at autopsy. This clinical entity is routinely missed on transthoracic echocardiography. Injection drug use is a common predisposing factor, and Staphylococcus aureus is the most commonly identified organism. This report broadens the differential diagnosis of endovascular infections in injection drug users and highlights the importance of transesophageal echocardiography for diagnosis in selected patients.