British Thoracic Society guidelines on diagnostic flexible bronchoscopy

Sevoflurane-Based General Anesthesia Induction via Nasopharyngeal Endotracheal Tube Prior to Definitive Airway Control in Pediatric Oral Tumors

Airway-related tumors in pediatrics are always challenging for anesthesiologists. We present 2 cases of friable, bleeding large tumors in the oral cavity where conventional methods of securing the airway were not possible. Induction of general anesthesia could potentially lead to complete airway collapse and catastrophic obstruction in such cases. Awake fibrotic intubation is limited in pediatric patients. We describe the innovative use of an endotracheal tube inserted blindly as a nasopharyngeal airway guided by end-tidal carbon dioxide trace. This allowed us to bypass the anatomical obstruction and induce anesthesia using sevoflurane in high-flow oxygen. By the described technique, we were able to maintain and assist the spontaneous breathing of the child as well. We also highlight limitations of the use of a conventional nasopharyngeal airway in such situations.

Anesthesia for Advanced Bronchoscopic Procedures: State-of-the-Art Review

The bronchoscopic procedures have seen a remarkable increase in both numbers and complexity. Although many anesthesia providers have kept pace with the challenge, the practice is varied and frequently suboptimal. Shared airway during bronchoscopy poses unique challenges. The available reviews have tried to address this lacuna; however, these have frequently dealt with the technical aspects of bronchoscopy than anesthetic challenges. The present review provides evidence-based management insights into anesthesia for bronchoscopy-both flexible and rigid. A systematic approach toward pre-procedural evaluation and risk stratification is presented. The possible anatomical and physiological factors that can influence the outcomes are discussed. Pharmacological principles guiding sedation levels and appropriate selection of sedatives form the crux of safe anesthetic management. The newer and safer drugs that can have potential role in anesthesia for bronchoscopy in the near future are discussed. Ventilatory strategies during bronchoscopy for prevention of hypoxia and hypercarbia are emphasized.

Airway Inflammation in Chronic Rhinosinusitis with Nasal Polyps and Asthma: The United Airways Concept Further Supported

Background

It has been established that patients with chronic rhinosinusitis with nasal polyps (CRSwNP) often have co-existing asthma.

Objective

We aimed to test two hypotheses: (i) upper and lower airway inflammation in CRSwNP is uniform in agreement with the united airways concept; and (ii) bronchial inflammation exists in all CRSwNP patients irrespective of clinical asthma status.

Methods

We collected biopsies from nasal polyps, inferior turbinates and bronchi of 27 CRSwNP patients and 6 controls. All participants were evaluated for lower airway disease according to international guidelines. Inflammatory cytokines were investigated using a Th1/Th2 assay including 14 chemokines and cytokines; tissue concentrations were normalized according to tissue weight and total protein concentration. Individual cytokines and multivariate inflammatory profiles were compared between biopsy sites and between patients and controls.

Results

We found significantly higher concentrations of Th2 cytokines in nasal polyps compared to inferior turbinate and bronchial biopsies. In addition, we showed that the inflammatory profile of nasal polyps and bronchial biopsies correlated significantly (p<0.01). From the Th2 cytokines measured, IL-13 was significantly increased in bronchial biopsies from CRSwNP patients with, but not without asthma.

Conclusion

Our findings support the united airways concept; however, we did not find evidence for subclinical bronchial inflammation in CRSwNP patients without asthma. Finally, this study indicates for the first time that nasal polyps potentially play an important role in the airway inflammation rather than being a secondary phenomenon.

Trans-bronchoscopy with implantation of 125I radioactive seeds in patients with pulmonary atelectasis induced by lung cancer

To evaluate the role of low-dose-rate interstitial brachytherapy using trans-bronchoscope ¹²⁵I radioactive seeds implantation in patients with pulmonary atelectasis induced by lung cancer, in terms of feasibility, safety, quality of life (QOL), and survival time. Between April 2008 and June 2011, 15 patients from two medical institutions that had obstructive pulmonary atelectasis caused by inoperable lung cancer were assigned to receive ¹²⁵I implantation endoluminal brachytherapy by bronchoscopy. Subsequent to the implantation of ¹²⁵I seeds, the outcomes were measured in terms of procedure success rate, reopening of atelectasis, complications associated with the procedure, Karnofsky performance status (KPS) scores and survival time. The surgical procedure was successfully performed in all 15 patients. No procedure-associated mortality occurred and the complications were mild and considered acceptable. Irritable cough and temporary increase of hemoptysis occurred in 11 (73.3%) and 10 (66.7%) patients respectively, and were the most common complications. The pulmonary atelectasis reopening rate subsequent to the procedure was 86.7, 76.9, 80.0, 75.0 and 50.0% at 2, 6, 12, 18 and 24 months, respectively. The KPS score significantly improved following the implantation of ¹²⁵I seeds and the duration of improvement ranged between 3 and 27 months. The median and mean survival times were 15.6 and 16 months, respectively. Actuarial survival rates at 6, 12 and 24 months after the procedure were 86.7, 66.7 and 13.3%, respectively. In patients with advanced lung cancer and those presenting with obstructive pulmonary atelectasis, treatment with intraluminal implantation of ¹²⁵I seeds is a safe and effective therapy option with easy accessibility.

Prevention of lung-to-lung aspiration during emergency thoracic surgery: an experimental study

BACKGROUND

Lung separation is essential for an emergency thoracic surgery for massive hemoptysis. When using a double lumen tube (DLT), a commonly adopted lung separation device during thoracic surgery, a water-tight seal of endobronchial cuff is crucial to prevent lung-to-lung aspiration of blood. In this study, we investigated the fluid sealing characteristics of the endobronchial cuff of a DLT and examined the effect of gel lubrication on the fluid leakage beyond the endobronchial cuff of DLT.

METHODS

An artificial tracheobronchial tree was intubated with a DLT. In the first phase of the study, the intra-cuff pressure of endobronchial cuff of DLT was set to 25, 50, or 100 cmH2O (n = 7, each), and the non-dependent bronchus was filled with 5 ml of water. Fluid leakage to the dependent bronchus beyond the endobronchial cuff was collected for 6 h. The time until leakage was first detected and the time until 100% leakage occurred were measured. In the second phase, the endobronchial cuff was coated with either saline (group C, n = 10) or lubricant gel (group GEL, n = 10), and the same parameters were measured.

RESULTS

In the first phase of the study, the times to first leakage and 100% leakage at an intra-cuff pressure of 25 cmH2O were 21.0 (7.0 - 59.0) sec and 3.0 (2.0 - 4.0) min, respectively. Higher intra-cuff (50 and 100 cmH2O) resulted in longer time for the first leakage and 100% leakage, but the duration was not long enough for clinical purpose. In the second phase, all the DLTs in group C showed 100% fluid leakage during the 6-hour period. In contrast, in group GEL, fluid leakage beyond the endobronchial cuff was detected only in 50% of the DLTs and none of the DLT showed 100% fluid leakage during the study. Among the DLTs which exhibited fluid leakage, the time to first leakage was 252.0 (171.0-305.0) min and the leakage volume at the end of the study period was 0.3〔0.0-1.8〕ml.

CONCLUSIONS

Endobronchial cuff of DLT cannot prevent fluid leakage beyond the endobronchial cuff, but lubricant gel coating on the endobronchial cuff can effectively reduce the lung-to-lung aspiration.

Impact of multimedia information on bronchoscopy procedure: is it really helpful?

AIM:

In this study, we aimed to investigate the effect of written informed consent and comprehensive multimedia information on the anxiety level of patients, consumption of sedatives, difficulties during bronchoscopy, complications and duration of procedure.

METHODS:

150 patients undergoing bronchoscopy were included to this study. They were randomized into two groups Multimedia information group (MIG, n = 75) and written-informed consent group (WICG, n = 75)). Signed written informed consent was obtained from all patients. Patients in MIG group watched comprehensive multimedia presentation. State anxiety scores of all patients were evaluated with State and Trait anxiety inventory (STAI-S).

RESULTS:

STAI-S score of patients in MIG (40.31 ± 8.08) was lower than patients in WICG (44.29 ± 9.62) (P = 0.007). Satisfaction level was higher in MIG (P = 0.001). Statistically higher difficulties during passage through vocal cords and interventions during bronchoscopy were present in WICG group (P = 0.013 and P = 0.043, respectively). Total midazolam dose during bronchoscopy, and duration of bronchoscopy were statistically lower in MIG patients (P < 0.001 and P = 0.045, respectively). Difficulties during waiting period, passage through nasal/oral route, applications of local anesthesia and complication frequency were similar in both groups.

CONCLUSION:

Besides reducing the state anxiety, multimedia information can reduce the dose of sedation, shorten the processing duration and reduce the difficulties during bronchoscopy.

Utility of endobronchial ultrasound-guided transbronchial needle aspiration in diagnosis of intrathoracic lymphadenopathy in patients with human immunodeficiency virus infection

Objective. Intrathoracic lymphadenopathy (LAD) in patients with Human Immunodeficiency Virus (HIV) infection is common, with wide-ranging diagnoses, from benign to malignant causes. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a relatively new technology with established applications in lung cancer, sarcoidosis, and tuberculosis. We sought to find out whether the addition of EBUS-TBNA to the diagnostic algorithm for LAD in HIV patients will reduce the need for mediastinoscopy. Methods. Retrospective chart review of all EBUS-TBNA procedures performed in our centre from August 2008 to December 2012. Results. 513 patients had EBUS-TBNA performed during this period. We identified nine HIV-infected patients who had LAD of unknown cause and underwent EBUS-TBNA. The procedure reduced the need for mediastinoscopy in eight patients (89%). Conclusions. Potential mediastinoscopies can be avoided by utilising EBUS-TBNA in HIV patients with LAD.

Mediastinitis and pericarditis after endobronchial ultrasound-guided transbronchial needle aspiration

A 73-year-old man was admitted to our hospital for further investigation of multiple lung nodules and lymphadenopathy that were observed on chest radiography. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed to sample the lower paratracheal lymph node (4R), leading to a definitive diagnosis of squamous cell carcinoma of the lung. About 2 weeks after EBUS-TBNA, the patient had a high temperature, anterior chest pain, tachycardia, and hypotension. The diagnosis of infectious mediastinitis and pericarditis as complications of EBUS-TBNA, which were successfully treated with systemic antibiotics, was made after examinations. EBUS-TBNA is minimally invasive and useful for the diagnosis of hilar and mediastinum lesions particularly in determining the extent of lung cancer. With the increased employment of this method, critical complications may also increase. Clinicians should be aware of the rare but critical complications associated with EBUS-TBNA.

Topical airway anesthesia for awake fiberoptic intubation: Comparison between airway nerve blocks and nebulized lignocaine by ultrasonic nebulizer

Overview:

Awake fiberoptic bronchoscope (FOB) guided intubation is the gold standard of airway management in patients with cervical spine injury. It is essential to sufficiently anesthetize the upper airway before the performance of awake FOB guided intubation in order to ensure patient comfort and cooperation. This randomized controlled study was performed to compare two methods of airway anesthesia, namely ultrasonic nebulization of local anesthetic and performance of airway blocks.

Materials and Methods:

A total of 50 adult patients with cervical spine injury were randomly allocated into two groups. Group L received airway anesthesia through ultrasonic nebulization of 10 ml of 4% lignocaine and Group NB received airway blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal) each with 2 ml of 2% lignocaine and viscous lignocaine gargles. FOB guided orotracheal intubation was then performed. Hemodynamic variables at baseline and during the procedure, patient recall, vocal cord visibility, ease of intubation, coughing/gagging episodes, and signs of lignocaine toxicity were noted.

Results:

The observations did not reveal any significant differences in demographics or hemodynamic parameters at any time during the study. However, the time taken for intubation was significantly lower in Group NB as compared with the Group L. Group L had an increased number of coughing/gagging episodes as compared with Group NB. Vocal cord visibility and ease of intubation were better in patients who received airway blocks and hence the amount of supplemental lignocaine used was less in this group. Overall patient comfort was better in Group NB with fewer incidences of unpleasant recalls as compared with Group L.

Conclusion:

Upper airway blocks provide better quality of anesthesia than lignocaine nebulization as assessed by patient recall of procedure, coughing/gagging episodes, ease of intubation, vocal cord visibility, and time taken to intubate.

A novel visual sputum suctioning system is useful for endotracheal suctioning in a dog model

OBJECTIVE

This study is to test the effectiveness of fiber-optic-guided endotracheal suction catheter (visual sputum suctioning system or VSSS) in dog models.

METHODS

Dog sputum models were established by administering dimethoate emulsifiable. Twenty-seven intubated dogs were equally randomized into three groups of conventional suctioning (CS) group, VSSS with no supplemental oxygen (VSSS) group and VSSS with 100% oxygen (VSSS/O2) group. The suctioning efficiency, vital signs and tracheal wall injury were assessed.

RESULTS

The VSSS/O2 (8.6 ± 0.7g) and VSSS groups (8.5 ± 0.9 g) collected significantly more sputum than the CS group (5.9 ± 0.8 g) (P < 0.05 for VSSS/O2 group versus CS group; P < 0.05 for VSSS group versus CS group). Immediately after suctioning, the arterial partial pressure of oxygen (PaO2 ) of VSSS/O2 group was significantly higher than that of the VSSS group or the CS group (both P < 0.05), and 5 min after suction the PaO2 , the mean arterial pressure (MAP) and heart rate (HR) in all groups returned to the baseline (p = 0.54, P = 0.67, P = 0.11, respectively). Moreover, in the VSSS/O2 and VSSS groups all the three variables were higher than the CS group at 5 min after suctioning (P < 0.01, P = 0.03; P = 0.02, P < 0.01; P = 0.02, P = 0.01 respectively).

CONCLUSIONS

Visual sputum suctioning system collected more sputum and caused less tracheal mucosa damage than conventional suctioning.

A microRNA network dysregulated in asthma controls IL-6 production in bronchial epithelial cells

MicroRNAs are short non-coding single stranded RNAs that regulate gene expression. While much is known about the effects of individual microRNAs, there is now growing evidence that they can work in co-operative networks. MicroRNAs are known to be dysregulated in many diseases and affect pathways involved in the pathology. We investigated dysregulation of microRNA networks using asthma as the disease model. Asthma is a chronic inflammatory disease of the airways characterized by bronchial hyperresponsiveness and airway remodelling. The airway epithelium is a major contributor to asthma pathology and has been shown to produce an excess of inflammatory and pro-remodelling cytokines such as TGF-β, IL-6 and IL-8 as well as deficient amounts of anti-viral interferons. After performing microRNA arrays, we found that microRNAs -18a, -27a, -128 and -155 are down-regulated in asthmatic bronchial epithelial cells, compared to cells from healthy donors. Interestingly, these microRNAs are predicted in silico to target several components of the TGF-β, IL-6, IL-8 and interferons pathways. Manipulation of the levels of individual microRNAs in bronchial epithelial cells did not have an effect on any of these pathways. Importantly, knock-down of the network of microRNAs miR-18a, -27a, -128 and -155 led to a significant increase of IL-8 and IL-6 expression. Interestingly, despite strong in silico predictions, down-regulation of the pool of microRNAs did not have an effect on the TGF-β and Interferon pathways. In conclusion, using both bioinformatics and experimental tools we found a highly relevant potential role for microRNA dysregulation in the control of IL-6 and IL-8 expression in asthma. Our results suggest that microRNAs may have different roles depending on the presence of other microRNAs. Thus, interpretation of in silico analysis of microRNA function should be confirmed experimentally in the relevant cellular context taking into account interactions with other microRNAs when studying disease.

Pneumothorax after transbronchial needle biopsy

Currently there several diagnostic techniques that re used by radiologists and pulmonary physicians for lung cancer diagnostics. In several cases pneumothorax (PNTX) is induced and immediate action is needed. Both radiologists and pulmonary physicians can insert a chest tube for symptom relief. However; only pulmonary physicians and thoracic surgeons can provide a permanent solution for the patient. The final solution would be for a patient to undergo surgery for a final solution. In our current work we will provide all those diagnostic cases where PNTX is induced and treatment from the point of view of expert radiologists and pulmonary physicians.

Optimizing tissue sampling for the diagnosis, subtyping, and molecular analysis of lung cancer

Lung cancer has entered the era of personalized therapy with histologic subclassification and the presence of molecular biomarkers becoming increasingly important in therapeutic algorithms. At the same time, biopsy specimens are becoming increasingly smaller as diagnostic algorithms seek to establish diagnosis and stage with the least invasive techniques. Here, we review techniques used in the diagnosis of lung cancer including bronchoscopy, ultrasound-guided bronchoscopy, transthoracic needle biopsy, and thoracoscopy. In addition to discussing indications and complications, we focus our discussion on diagnostic yields and the feasibility of testing for molecular biomarkers such as epidermal growth factor receptor and anaplastic lymphoma kinase, emphasizing the importance of a sufficient tumor biopsy.

Genomic characterisation of small cell lung cancer patient-derived xenografts generated from endobronchial ultrasound-guided transbronchial needle aspiration specimens

Patient-derived xenograft (PDX) models generated from surgical specimens are gaining popularity as preclinical models of cancer. However, establishment of PDX lines from small cell lung cancer (SCLC) patients is difficult due to very limited amount of available biopsy material. We asked whether SCLC cells obtained from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) could generate PDX lines that maintained the phenotypic and genetic characteristics of the primary tumor. Following successful EBUS-TBNA sampling for diagnostic purposes, we obtained an extra sample for cytologic analysis and implantation into the flanks of immunodeficient mice. Animals were monitored for engraftment for up to 6 months. Histopathologic and immunohistochemical analysis, and targeted next-generation re-sequencing, were then performed in both the primary sample and the derivative PDX line. A total of 12 patients were enrolled in the study. EBUS-TBNA aspirates yielded large numbers of viable tumor cells sufficient to inject between 18,750 and 1,487,000 cells per flank, and to yield microgram quantities of high-quality DNA. Of these, samples from 10 patients generated xenografts (engraftment rate 83%) with a mean latency of 104 days (range 63–188). All but one maintained a typical SCLC phenotype that closely matched the original sample. Identical mutations that are characteristic of SCLC were identified in both the primary sample and xenograft line. EBUS-TBNA has the potential to be a powerful tool in the development of new targeting strategies for SCLC patients by providing large numbers of viable tumor cells suitable for both xenografting and complex genomic analysis.

Safety and immunogenicity of a candidate tuberculosis vaccine MVA85A delivered by aerosol in BCG-vaccinated healthy adults: a phase 1, double-blind, randomised controlled trial

Background

Intradermal MVA85A, a candidate vaccine against tuberculosis, induces high amounts of Ag85A-specific CD4 T cells in adults who have already received the BCG vaccine, but aerosol delivery of this vaccine might offer immunological and logistical advantages. We did a phase 1 double-blind trial to compare the safety and immunogenicity of aerosol-administered and intradermally administered MVA85A

Methods

In this phase 1, double-blind, proof-of-concept trial, 24 eligible BCG-vaccinated healthy UK adults were randomly allocated (1:1) by sequentially numbered, sealed, opaque envelopes into two groups: aerosol MVA85A and intradermal saline placebo or intradermal MVA85A and aerosol saline placebo. Participants, the bronchoscopist, and immunologists were masked to treatment assignment. The primary outcome was safety, assessed by the frequency and severity of vaccine-related local and systemic adverse events. The secondary outcome was immunogenicity assessed with laboratory markers of cell-mediated immunity in blood and bronchoalveolar lavage samples. Safety and immunogenicity were assessed for 24 weeks after vaccination. Immunogenicity to both insert Ag85A and vector modified vaccinia virus Ankara (MVA) was assessed by ex-vivo interferon-γ ELISpot and serum ELISAs. Since all participants were randomised and vaccinated according to protocol, our analyses were per protocol. This trial is registered with ClinicalTrials.gov, number NCT01497769.

Findings

Both administration routes were well tolerated and immunogenic. Respiratory adverse events were rare and mild. Intradermal MVA85A was associated with expected mild local injection-site reactions. Systemic adverse events did not differ significantly between the two groups. Three participants in each group had no vaccine-related systemic adverse events; fatigue (11/24 [46%]) and headache (10/24 [42%]) were the most frequently reported symptoms. Ag85A-specific systemic responses were similar across groups. Ag85A-specific CD4 T cells were detected in bronchoalveolar lavage cells from both groups and responses were higher in the aerosol group than in the intradermal group. MVA-specific cellular responses were detected in both groups, whereas serum antibodies to MVA were only detectable after intradermal administration of the vaccine.

Interpretation

Further clinical trials assessing the aerosol route of vaccine delivery are merited for tuberculosis and other respiratory pathogens.

Funding

The Wellcome Trust and Oxford Radcliffe Hospitals Biomedical Research Centre.

Diagnostic yield of bronchial washing fluid analysis for hemoptysis in patients with bronchiectasis

PURPOSE

Bronchiectasis is the main cause of hemoptysis. When patients with bronchiectasis develop hemoptysis, clinicians often perform bronchoscopy and bronchial washing to obtain samples for microbiological and cytological examinations. Bronchial washing fluids were analyzed from patients with bronchiectasis who developed hemoptysis, and the clinical impacts of these analyses were examined.

MATERIALS AND METHODS

A retrospective observational study of patients who underwent fiberoptic bronchoscopy for hemoptysis in Seoul National University Bundang Hospital, a university affiliated tertiary referral hospital, between January 2006 and December 2010 were reviewed. Among them, patients who had bronchiectasis confirmed by computed tomography and had no definite cause of hemoptysis other than bronchiectasis were reviewed. The demographic characteristics, bronchoscopy findings, microbiological data, pathology results and clinical courses of these patients were retrospectively reviewed.

RESULTS

A total of 130 patients were reviewed. Bacteria, non-tuberculous mycobacteria (NTM), and Mycobacterium tuberculosis were isolated from bronchial washing fluids of 29.5%, 21.3%, and 0.8% patients, respectively. Suspected causal bacteria were isolated only from bronchial washing fluid in 19 patients, but this analysis led to antibiotics change in only one patient. Of the 27 patients in whom NTM were isolated from bronchial washing fluid, none of these patients took anti-NTM medication during the median follow-up period of 505 days. Malignant cells were not identified in none of the patients.

CONCLUSION

Bronchial washing is a useful method to identify microorganisms when patients with bronchiectasis develop hemoptysis. However, these results only minimally affect clinical decisions.

Liquid-based cytological test of samples obtained by catheter aspiration is applicable for the bronchoscopic confirmation of pulmonary malignant tumors

The aim of the present study is to confirm the value of electronic bronchoscopy-aided catheter aspiration technique with liquid-based cytological test in the diagnosis of bronchogenic carcinoma. A total of 815 patients of lung cancer were evaluated by bronchoscopy between February 2011 and June 2012. Catheter aspiration technique and forceps biopsy during bronchoscopy were employed to obtain adequate tissue specimens. Liquid-based cytological test and conventional smears for catheter aspiration were used for cytological detection of the tumors. For all cytological specimens, slide preparations with LCT and CS were reviewed by two senior pathologists, who were blinded to patient medical history. Complications related to electronic bronchoscopy, such as bleeding, were clinically judged as light, moderate or severe by the needs for clinical interventions. The diagnostic yield of catheter aspiration in endobronchial visible lesions (tumor, infiltrative and necrotic lesions) was 94.6% (success rates concerning malignancy), which was slightly higher than that of the forceps biopsy (91.4%, P<0.05). The diagnostic yield of catheter aspiration in endobronchial invisible lesions (normal, compressive and nonspecific lesions) was 82.8%, which was significantly higher than that of the forceps biopsy (51.4%, P<0.01). The combination of the forceps biopsy with the cytological analysis of the catheter aspiration increased the diagnostic sensitivity in both lesion types (P<0.05). For catheter aspiration, the positive rate of lung cancer by liquid-based cytological test was superior to that by conventional smears (P<0.05). The catheter aspiration is a sampling technique that produces higher diagnostic rate for lung cancers compared with forceps biopsy. Liquid-based cytological test is routinely applicable for the diagnosis of lung cancer using samples collected through electronic bronchoscopy.

Bronchoalveolar lavage (BAL) for research; obtaining adequate sample yield

We describe a research technique for fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) using manual hand held suction in order to remove nonadherent cells and lung lining fluid from the mucosal surface. In research environments, BAL allows sampling of innate (lung macrophage), cellular (B- and T- cells), and humoral (immunoglobulin) responses within the lung. BAL is internationally accepted for research purposes and since 1999 the technique has been performed in > 1,000 subjects in the UK and Malawi by our group. Our technique uses gentle hand-held suction of instilled fluid; this is designed to maximize BAL volume returned and apply minimum shear force on ciliated epithelia in order to preserve the structure and function of cells within the BAL fluid and to preserve viability to facilitate the growth of cells in ex vivo culture. The research technique therefore uses a larger volume instillate (typically in the order of 200 ml) and employs manual suction to reduce cell damage. Patients are given local anesthetic, offered conscious sedation (midazolam), and tolerate the procedure well with minimal side effects. Verbal and written subject information improves tolerance and written informed consent is mandatory. Safety of the subject is paramount. Subjects are carefully selected using clear inclusion and exclusion criteria. This protocol includes a description of the potential risks, and the steps taken to mitigate them, a list of contraindications, pre- and post-procedure checks, as well as precise bronchoscopy and laboratory techniques.

Evaluation of the efficacy of transcricoid lignocaine as adjunctive local anaesthesia for fiberoptic bronchoscopy

INTRODUCTION

Optimisation of patient comfort during flexible bronchoscopy is achieved with the use of intravenous sedation and vocal anaesthesia.

METHODS

The effect of transcricoid lignocaine injection was investigated with regards to ease of procedure and frequency of cough. A single-blinded study was carried out and two visual analogue scales were used as markers of efficacy. Treatment groups were matched for age, gender and total dose of lignocaine administered.

RESULTS

The results highlighted a significant improvement in the perceived ease of procedure (p < 0.0001) and frequency of coughing during the procedure (p < 0.0001).

CONCLUSION

The findings of the study demonstrate that the use of transcricoid injection of lignocaine provided a safe adjunct for anaesthesia in flexible bronchoscopy.

Bronchoscopic intratumoral injection of tranexamic acid to prevent excessive bleeding during multiple forceps biopsies of lesions with a high risk of bleeding: a prospective case series

BACKGROUND

Significant bleeding may occur following endobronchial forceps biopsy or brushing of necrotic or hypervascular tumors in the airways. In some cases, methods such as endobronchial instillation of iced saline lavage and epinephrine may fail to control bleeding. The present study evaluated the efficacy and safety of a new bronchoscopic technique using intratumoral injection of tranexamic acid (IIT) for control of bleeding during forceps biopsy in patients with endobronchial tumors with a high risk of bleeding.

METHODS

The study was a prospective case series carried out in a single center. Bronchoscopic IIT was performed in those patients who had endoscopically visible tumoral lesions with persistent active bleeding following the first attempt at bronchoscopic sampling. Tranexamic acid (TEA) was injected through a 22-gauge Wang cytology needle into the lesion in nominal doses of 250-500 mg. After 2-3 minutes, multiple forceps biopsy specimens were obtained from the lesion.

RESULTS

Of the 57 consecutive patients included in the study, 20 patients (35.1%) underwent bronchoscopic IIT. The first attempt in 18 patients was endobronchial forceps biopsy (EBB), and because of a high risk of bleeding, the first attempt for the remaining two patients, who were on continuous dual antiplatelet therapy (aspirin and clopidogrel), employed endobronchial needle aspiration (EBNA) as a precautionary measure. Following IIT, subsequent specimens were obtained using EBB in all patients. Multiple forceps biopsy specimens (3-10) were obtained from the lesions (8 necrotic and 12 hypervascular) without incurring active bleeding. The following histopathologic diagnoses were made: squamous cell carcinoma (n = 14), adenocarcinoma (n = 2), small-cell lung cancer (n = 3), and malignant mesenchymal tumor (n = 1). No side effects of TEA were observed.

CONCLUSIONS

Bronchoscopic IIT is a useful and safe technique for controlling significant bleeding from a forceps biopsy procedure and can be considered as a pre-biopsy injection for lesions with a high risk of bleeding.

TRIAL REGISTRATION

ISRCTN23323895.

Exhaled IL-8 in systemic lupus erythematosus with and without pulmonary fibrosis

The purpose of this study is to evaluate the relationship between the concentration of interleukin-8 (IL-8) in exhaled breath condensate (EBC) and bronchoalveolar lavage fluid (BALF) with the disease activity score and pulmonary function of systemic lupus erythematosus (SLE) patients with and without pulmonary fibrosis. Thirty-four SLE patients and 31 healthy controls were enrolled and evaluated using high-resolution computed tomography (HRCT), pulmonary function tests, systemic lupus activity measure (SLAM), assessing BALF and EBC. IL-8 levels in BALF and EBC samples were measured with an enzyme-immunosorbent assay kit. The mean (±SEM) IL-8 concentrations in BALF and EBC were higher in SLE patients compared to healthy controls (34.84 ± 95.0 vs. 7.65 ± 21.22 pg/ml, p < 0.001; 3.82 ± 0.52 pg/m vs. 1.7 ± 1.7 pg/ml, p < 0.001, respectively). SLE patients had increased percentage of neutrophils in BALF when compared with control group (1.00 ± 5.99 vs. 0.00 ± 0.56 %, p = 0.0003). Pulmonary fibrosis in HRCT was found in 50 % of SLE patients. The disease activity scored by SLAM was significantly higher and total lung capacity was significantly lower in SLE patients with pulmonary fibrosis (8.00 ± 3.17 vs. 6.00 ± 2.31, p = 0.01; 88.00 ± 28.29 vs. 112.00 ± 21.08 % predicted, p = 0.01, respectively). In SLE patients with pulmonary fibrosis, correlations were found between SLAM and IL-8 concentration in BALF, forced expiratory volume in 1 s and forced vital capacity (r = 0.65, p = 0.006; r = −0.53, p = 0.035; r = −0.67, p = 0.006, respectively). Our results indicate that IL-8 plays an important role in the pathogenesis of SLE. An increased concentration of IL-8 according to BALF could be considered as a useful biomarker of SLE activity and pulmonary fibrosis in SLE.

Comparison of moderate versus deep sedation for endobronchial ultrasound transbronchial needle aspiration

RATIONALE

Most bronchoscopic procedures are performed using moderate sedation achieved by combining a short-acting benzodiazepine with an opioid agent. Propofol (2.6-diisopropylphenol), a short-acting hypnotic agent, has been increasingly used to provide deep sedation in the endoscopy community with an acceptable safety profile.

OBJECTIVES

To compare the impact of moderate versus deep sedation on the adequacy and diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

METHODS

A retrospective review of prospectively collected data was performed at two academic institutions with interventional pulmonary fellowships using two methods of sedation during EBUS (deep vs. moderate sedation). Rapid on-site cytologic evaluation was used on all procedures in both groups. EBUS-TBNA nodal sampling was considered adequate if the aspirate yielded a specific diagnosis or lymphocytes. EBUS-TBNA was considered diagnostic if a lymph node aspirate yielded a specific diagnosis or if subsequent surgical sampling or prolonged radiographic surveillance revealed no nodal pathology.

MEASUREMENTS AND MAIN RESULTS

No difference was observed in the indication for EBUS-TBNA between the two groups. More lymph nodes were sampled per patient in the deep sedation group (314 nodes from 163 patients; 2.2 nodes per patient) than in the moderate sedation group (181 lymph nodes from 146 patients; 1.4 nodes per patient; P < 0.01). The EBUS-TBNA diagnostic yield was higher for the deep sedation group (80% of patients) than for the moderate sedation group (66% of patients; P < 0.01).

CONCLUSIONS

Diagnostic yield and number of lymph nodes sampled using deep sedation is superior to moderate sedation in patients undergoing EBUS-TBNA. Prospective studies accounting for other factors including patient selection and cost are needed.

[How practical guidelines can be applied in poor countries? Example of the introduction of a bronchoscopy unit in Cambodia]

According to UN, Cambodia is one of the poorest countries in the World. Respiratory diseases are current public health priorities. In this context, a new bronchoscopy unit (BSU) was created in the respiratory medicine department of Preah Kossamak hospital (PKH) thanks to a tight cooperation between a French and a Cambodian team. Aim of this study was to describe conditions of introduction of this equipment. Two guidelines for practice are available. They are respectively edited by the French and British societies of pulmonology. These guidelines were reviewed and compared to the conditions in which BS was introduced in PKH. Each item from guidelines was combined to a categorical value: "applied", "adapted" or "not applied". In 2009, 54 bronchoscopies were performed in PKH, mainly for suspicion of infectious or tumour disease. In total, 52% and 46% of the French and British guideline items respectively were followed in this Cambodian unit. Patient safety items are those highly followed. By contrast "staff safety" items were those weakly applied. Implementation of EBS in developing countries seems feasible in good conditions of quality and safety for patients. However, some recommendations cannot be applied due to local conditions.

Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy

Flexible endoscopy is a widely used diagnostic and therapeutic procedure. Contaminated endoscopes are the medical devices frequently associated with outbreaks of health care-associated infections. Accurate reprocessing of flexible endoscopes involves cleaning and high-level disinfection followed by rinsing and drying before storage. Most contemporary flexible endoscopes cannot be heat sterilized and are designed with multiple channels, which are difficult to clean and disinfect. The ability of bacteria to form biofilms on the inner channel surfaces can contribute to failure of the decontamination process. Implementation of microbiological surveillance of endoscope reprocessing is appropriate to detect early colonization and biofilm formation in the endoscope and to prevent contamination and infection in patients after endoscopic procedures. This review presents an overview of the infections and cross-contaminations related to flexible gastrointestinal endoscopy and bronchoscopy and illustrates the impact of biofilm on endoscope reprocessing and postendoscopic infection.

Quality improvement in Respiratory Medicine: Designing and implementing a bronchoscopy checklist at Southend University Hospital

There is currently no standardised procedure checklist for bronchoscopies in the United Kingdom. Furthermore, very few hospitals appear to routinely use any form of checklist for these procedures. Conversely, the World Health Organisation surgical checklist has become standard practice in most hospitals, our own included, for all surgical procedures. Based on our own needs, we decided to create a bronchoscopy checklist which could be used at our hospital with the primary emphasis on ensuring patient safety and improving clinical outcomes. We surveyed local surgical checklists as well as endoscopic checklists used in hospitals around the world. We then created an initial draft which was sent out to consultation to all Respiratory Physicians in our hospital. Comments were also taken from the endoscopy nursing staff. After a series of consultations, a checklist was trialled over the course of two weeks. Feedback from use in the endoscopy suite resulted in further modifications and a final version of the checklist came into use in May 2013. It is now used for all bronchoscopic procedures carried out by Respiratory Physicians in the hospital. An audit is planned for later this year to monitor uptake of the checklist and to determine if it has changed outcomes.

Functional KCa3.1 channels regulate steroid insensitivity in bronchial smooth muscle cells

Identifying the factors responsible for relative glucocorticosteroid (GC) resistance present in patients with severe asthma and finding tools to reverse it are of paramount importance. In asthma we see in vivo evidence of GC-resistant pathways in airway smooth muscle (ASM) bundles that can be modeled in vitro by exposing cultured ASM cells to TNF-α/IFN-γ. This action drives GC insensitivity via protein phosphatase 5-dependent impairment of GC receptor phosphorylation. In this study, we investigated whether KCa3.1 ion channels modulate the activity of GC-resistant pathways using our ASM model of GC insensitivity. Immunohistochemical staining of endobronchial biopsies revealed that KCa3.1 channels are localized to the plasma membrane and nucleus of ASM in both healthy controls and asthmatic patients, irrespective of disease severity. Western blot assays and immunofluorescence staining confirmed the nuclear localization of KCa3.1 channels in ASM cells. The functional importance of KCa3.1 channels in the regulation of GC-resistant chemokines induced by TNF-α/IFN-γ was assessed using complementary inhibitory strategies, including KCa3.1 blockers (TRAM-34 and ICA-17043) or KCa3.1-specific small hairpin RNA delivered by adenoviruses. KCa3.1 channel blockade led to a significant reduction of fluticasone-resistant CX3CL1, CCL5, and CCL11 gene and protein expression. KCa3.1 channel blockade also restored fluticasone-induced GC receptor-α phosphorylation at Ser(211) and transactivation properties via the suppression of cytokine-induced protein phosphatase 5 expression. The effect of KCa3.1 blockade was evident in ASM cells from both healthy controls and asthmatic subjects. In summary, KCa3.1 channels contribute to the regulation of GC-resistant inflammatory pathways in ASM cells: blocking KCa3.1 channels may enhance corticosteroid activity in severe asthma.

Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy

Background

With the recent widespread use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), there have been occasional reports on complications associated with its use. Previous reviews on EBUS-TBNA have been limited to studies by skilled operators, thus the results may not always be applicable to recent clinical practice. To assess the safety of EBUS-TBNA for the staging and diagnosis of lung cancer in Japan, a nationwide survey on its current usage status and complications associated with its use was conducted by the Japan Society for Respiratory Endoscopy (JSRE).

Methods

A questionnaire about EBUS-TBNA performed between January 2011 and June 2012 was mailed to 520 JSRE-accredited facilities.

Results

Responses were obtained from 455 facilities (87.5%). During the study period, EBUS-TBNA was performed in 7,345 cases in 210 facilities (46.2%) using a convex probe ultrasound bronchoscope, for 6,836 mediastinal and hilar lesions and 275 lung parenchymal lesions. Ninety complications occurred in 32 facilities. The complication rate was 1.23% (95% confidence interval, 0.97%-1.48%), with hemorrhage being the most frequent complication (50 cases, 0.68%). Infectious complications developed in 14 cases (0.19%) (Mediastinitis, 7; pneumonia, 4; pericarditis, 1; cyst infection, 1; and sepsis, 1). Pneumothorax developed in 2 cases (0.03%), one of which required tube drainage. Regarding the outcome of the cases with complications, prolonged hospitalization was observed in 14 cases, life-threatening conditions in 4, and death in 1 (severe cerebral infarction) (mortality rate, 0.01%). Breakage of the ultrasound bronchoscope occurred in 98 cases (1.33%) in 67 facilities (31.9%), and that of the puncture needle in 15 cases (0.20%) in 8 facilities (3.8%).

Conclusions

Although the complication rate associated with EBUS-TBNA was found to be low, severe complications, including infectious complications, were observed, and the incidence of device breakage was high. Since the use of EBUS-TBNA is rapidly expanding in Japan, an educational program for its safe performance should be immediately established.

Significance of anaerobes and oral bacteria in community-acquired pneumonia

BACKGROUND

Molecular biological modalities with better detection rates have been applied to identify the bacteria causing infectious diseases. Approximately 10-48% of bacterial pathogens causing community-acquired pneumonia are not identified using conventional cultivation methods. This study evaluated the bacteriological causes of community-acquired pneumonia using a cultivation-independent clone library analysis of the 16S ribosomal RNA gene of bronchoalveolar lavage specimens, and compared the results with those of conventional cultivation methods.

METHODS

Patients with community-acquired pneumonia were enrolled based on their clinical and radiological findings. Bronchoalveolar lavage specimens were collected from pulmonary pathological lesions using bronchoscopy and evaluated by both a culture-independent molecular method and conventional cultivation methods. For the culture-independent molecular method, approximately 600 base pairs of 16S ribosomal RNA genes were amplified using polymerase chain reaction with universal primers, followed by the construction of clone libraries. The nucleotide sequences of 96 clones randomly chosen for each specimen were determined, and bacterial homology was searched. Conventional cultivation methods, including anaerobic cultures, were also performed using the same specimens.

RESULTS

In addition to known common pathogens of community-acquired pneumonia [Streptococcus pneumoniae (18.8%), Haemophilus influenzae (18.8%), Mycoplasma pneumoniae (17.2%)], molecular analysis of specimens from 64 patients with community-acquired pneumonia showed relatively higher rates of anaerobes (15.6%) and oral bacteria (15.6%) than previous reports.

CONCLUSION

Our findings suggest that anaerobes and oral bacteria are more frequently detected in patients with community-acquired pneumonia than previously believed. It is possible that these bacteria may play more important roles in community-acquired pneumonia.

The potential regimen of target-controlled infusion of propofol in flexible bronchoscopy sedation: a randomized controlled trial

OBJECTIVES

Target-controlled infusion (TCI) provides precise pharmacokinetic control of propofol concentration in the effect-site (Ce), eg. brain. This pilot study aims to evaluate the feasibility and optimal TCI regimen for flexible bronchoscopy (FB) sedation.

METHODS

After alfentanil bolus, initial induction Ce of propofol was targeted at 2 μg/ml. Patients were randomized into three titration groups (i.e., by 0.5, 0.2 and 0.1 μg/ml, respectively) to maintain stable sedation levels and vital signs. Adverse events, frequency of adjustments, drug doses, and induction and recovery times were recorded.

RESULTS

The study was closed early due to significantly severe hypoxemia events (oxyhemoglobin saturation <70%) in the group titrated at 0.5 μg/ml. Forty-nine, 49 and 46 patients were enrolled into the 3 respective groups before study closure. The proportion of patients with hypoxemia events differed significantly between groups (67.3 vs. 46.9 vs. 41.3%, p = 0.027). Hypotension events, induction and recovery time and propofol doses were not different. The Ce of induction differed significantly between groups (2.4±0.5 vs. 2.1±0.4 vs. 2.1±0.3 μg/ml, p = 0.005) and the Ce of procedures was higher at 0.5 μg/ml titration (2.4±0.5 vs. 2.1±0.4 vs. 2.2±0.3 μg/ml, p = 0.006). The adjustment frequency tended to be higher for titration at 0.1 μg/ml but was not statistically significant (2 (0∼6) vs. 3 (0∼6) vs. 3 (0∼11)). Subgroup analysis revealed 14% of all patients required no further adjustment during the whole sedation. Comparing patients requiring at least one adjustment with those who did not, they were observed to have a shorter induction time (87.6±34.9 vs. 226.9±147.9 sec, p<0.001), a smaller induction dose and Ce (32.5±4.1 vs. 56.8±22.7 mg, p<0.001; 1.76±0.17 vs. 2.28 ±0.41, p<0.001, respectively), and less hypoxemia and hypotension (15.8 vs.56.9%, p = 0.001; 0 vs. 24.1%, p = 0.008, respectively).

CONCLUSION

Titration at 0.5 μg/ml is risky for FB sedation. A subgroup of patients required no more TCI adjustment with fewer complications. Further studies are warranted to determine the optimal regimen of TCI for FB sedation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01101477.

Biomarkers for gastroesophageal reflux in respiratory diseases

Gastroesophageal reflux (GER) is commonly associated with respiratory symptoms, either through a vagal bronchoconstrictive reflex or through microaspiration of gastric contents. No diagnostic test is available, however, to diagnose when respiratory illnesses are caused by GER and when not, but research in this field has been moving forward. Various biomarkers in different types of biosamples have been studied in this context. The aim of this review is to summarize the present knowledge in this field. GER patients with respiratory diseases seem to have a different biochemical profile from similar patients without GER. Inflammatory biomarkers differ in asthmatics based on GER status, tachykinins are elevated in patients with GER-related cough, and bile acids are elevated in lung transplant patients with GER. However, studies on these biomarkers are often limited by their small size, methods of analysis, and case selections. The two pathogenesis mechanisms are associated with different respiratory illnesses and biochemical profiles. A reliable test to identify GER-induced respiratory disorders needs to be developed. Bronchoalveolar lavage is too invasive to be of use in most patients. Exhaled breath condensate samples need further evaluation and standardization. The newly developed particles in exhaled air measurements remain to be studied further.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of intrathoracic lymph node metastases from extrathoracic malignancies

Intrathoracic lymph node enlargement is a common finding in patients with extrathoracic malignancies. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a technique that is commonly used for lung cancer diagnosis and staging but that has not been widely investigated for the diagnosis of enlarged mediastinal and lobar lymph nodes in patients with extrathoracic malignancies. We conducted a retrospective study of 117 patients with extrathoracic malignancies who underwent EBUS-TBNA for diagnosis of intrathoracic lymph node enlargement from October 2005 to December 2009 and compared the EBUS-TBNA findings with the final diagnoses. EBUS-TBNA diagnosed mediastinal metastases in 51 of the 117 (43.6 %) cases and gave an alternate diagnosis or ruled out the presence of malignancy in 35 (56.4 %). Fourteen of these 35 patients underwent further surgical investigation, while the remaining 21 had clinical and radiological follow-up for 18 months. No false negatives were found in the surgery group. In the follow-up group, 13 patients had stable or regressive lymphadenopathy, and eight developed clinicoradiological progression and were assumed to have been false negatives by EBUS-TBNA. The sensitivity and negative predictive value of EBUS-TBNA were 86.4 and 75 %, respectively. Immunohistochemical staining (IHC) was performed in 80.4 % of the samples obtained by EBUS-TBNA. In samples obtained from ten patients with metastatic breast cancer, estrogen receptor expression was successfully assessed in eight patients and progesterone receptor and human epidermal growth factor receptor 2 in four. EBUS-TBNA is an accurate procedure for the diagnosis of thoracic lymph node metastases in patients with extrathoracic malignancies and should be an initial diagnostic tool in these patients. Furthermore, EBUS-TBNA can obtain high-quality specimens from metastatic lymph nodes for use in molecular analyses.

Diagnostic management of patients with suspected ocular sarcoidosis

BACKGROUND

Ophthalmologists often refer patients with suspected ocular sarcoidosis to pulmonologists for diagnostic examination of sarcoidosis. However, no recommendation has been proposed for managing such patients. This study aims to prospectively evaluate the diagnostic values of examinations and propose the management of patients with suspected ocular sarcoidosis.

METHODS

Consecutive patients with suspected ocular sarcoidosis were prospectively investigated according to type of ocular lesions, measurement of serum ACE, and findings of chest radiography, chest CT, bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB). Diagnostic values were calculated on the basis of pathological results.

RESULTS

Forty-two patients were included (female, 71.4%; mean age, 56.2±14.8 years), of whom 64.3% was diagnosed with sarcoidosis. Patient characteristics and ocular lesions did not differ significantly, regardless of the presence of sarcoidosis. Chest CT had low specificity and very high sensitivity for detecting sarcoidosis; in contrast, chest radiography and direct findings of bronchofiberscopy had high specificity and low sensitivity. Serum ACE and BAL did not have high diagnostic value. A flow chart was proposed to diagnose sarcoidosis, and this chart reduced the requirement of TBLB to 50% in our population. During the median follow-up of 51 months, 7 patients in the sarcoidosis group (25.9%) developed new lesions.

CONCLUSIONS

Application of our flow chart appears to detect avoidable TBLB. Development of a more comprehensive flow chart including survey of ocular findings is warranted.

Multidetector CT and postprocessing in planning and assisting in minimally invasive bronchoscopic airway interventions

A widening spectrum of increasingly advanced bronchoscopic techniques is available for the diagnosis and treatment of various bronchopulmonary diseases. The evolution of computed tomography (CT)-multidetector CT in particular-has paralleled these advances. The resulting development of two-dimensional and three-dimensional (3D) postprocessing techniques has complemented axial CT interpretation in providing more anatomically familiar information to the pulmonologist. Two-dimensional techniques such as multiplanar recontructions and 3D techniques such as virtual bronchoscopy can provide accurate guidance for increasing yield in transbronchial needle aspiration and transbronchial biopsy of mediastinal and hilar lymph nodes. Sampling of lesions located deeper within the lung periphery via bronchoscopic pathways determined at virtual bronchoscopy are also increasingly feasible. CT fluoroscopy for real-time image-guided sampling is now widely available; electromagnetic navigation guidance is being used in select centers but is currently more costly. Minimally invasive bronchoscopic techniques for restoring airway patency in obstruction caused by both benign and malignant conditions include mechanical strategies such as airway stent insertion and ablative techniques such as electrocauterization and cryotherapy. Multidetector CT postprocessing techniques provide valuable information for planning and surveillance of these treatment methods. In particular, they optimize the evaluation of dynamic obstructive conditions such as tracheobronchomalacia, especially with the greater craniocaudal coverage now provided by wide-area detectors. Multidetector CT also provides planning information for bronchoscopic treatment of bronchopleural fistulas and bronchoscopic lung volume reduction for carefully selected patients with refractory emphysema.

Resistin-like molecule-β is induced following bronchoconstriction of asthmatic airways

BACKGROUND AND OBJECTIVE

Resistin-like molecule-β (RELM-β) is a necessary and sufficient stimulus for airway remodelling in animal models of asthma, but until recently, its role in human disease had not been investigated. The hypothesis that RELM-β expression would increase with increasing asthma severity and further increase following acute bronchoconstrictor challenges has been examined.

METHODS

Bronchial biopsies from healthy subjects and patients with mild and severe asthma were immunostained for RELM-β, as were airway biopsies obtained in mild asthmatics before and 4 days after repeated inhalation challenges with either allergen, methacholine or methacholine preceded by salbutamol as a control. Bronchial brushings were also evaluated for RELM-β mRNA.

RESULTS

RELM-β immunoreactivity, which co-localized to airway epithelial cells, increased with disease severity; healthy volunteers, median per cent epithelial area 1.98%, mild asthma 3.49% and severe asthma 5.89% (P < 0.001 between groups). RELM-β immunoreactivity significantly and inversely correlated in asthma with forced expiratory volume in 1 s % predicted (P = 0.005). Acute changes in immunoexpression were evident after repeated inhalation challenge with allergen (2.15 % to 4.35 % (P = 0.01)) and methacholine (4.21 % to 6.16 % (P = 0.01)) but did not change in the salbutamol/methacholine challenge group. These changes correlated with change in basement membrane thickness (r = 0.38, P = 0.02). Epithelial RELM-β gene expression was not altered in asthma.

CONCLUSIONS

RELM-β may play an important role not only in animal models of airway remodelling, but also in human airway pathology.

Acute and chronic inflammatory responses induced by smoking in individuals susceptible and non-susceptible to development of COPD: from specific disease phenotyping towards novel therapy. Protocol of a cross-sectional study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease with pulmonary and extra-pulmonary manifestations. Although COPD is a complex disease, diagnosis and staging are still based on simple spirometry measurements. Different COPD phenotypes exist based on clinical, physiological, immunological and radiological observations. Cigarette smoking is the most important risk factor for COPD, but only 15-20% of smokers develop the disease, suggesting a genetic predisposition. Unfortunately, little is known about the pathogenesis of COPD, and even less on the very first steps that are associated with an aberrant response to smoke exposure. This study aims to investigate the underlying local and systemic inflammation of different clinical COPD phenotypes, and acute effects of cigarette smoke exposure in individuals susceptible and non-susceptible for the development of COPD. Furthermore, we will investigate mechanisms associated with corticosteroid insensitivity. Our study will provide valuable information regarding the pathogenetic mechanisms underlying the natural course of COPD.

METHODS AND ANALYSIS

This cross-sectional study will include young and old individuals susceptible or non-susceptible to develop COPD. At a young age (18-40 years) 60 'party smokers' will be included who are called susceptible or non-susceptible based on COPD prevalence in smoking family members. In addition, 30 healthy smokers (age 40-75 years) and 110 COPD patients will be included. Measurements will include questionnaires, pulmonary function, low-dose CT scanning of the lung, body composition, 6 min walking distance and biomarkers in peripheral blood, sputum, urine, exhaled breath condensate, epithelial lining fluid, bronchial brushes and biopsies. Non-biased approaches such as proteomics will be performed in blood and epithelial lining fluid.

ETHICS AND DISSEMINATION

This multicentre study was approved by the medical ethical committees of UMC Groningen and Utrecht, the Netherlands. The study findings will be presented at conferences and will be reported in peer-reviewed journals.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00807469 (study 1) and NCT00850863 (study 2).

Safety of performing fiberoptic bronchoscopy in critically ill hypoxemic patients with acute respiratory failure

BACKGROUND

The safety of fiberoptic bronchoscopy (FOB) in nonintubated critically ill patients with acute respiratory failure has not been extensively evaluated. We aimed to measure the incidence of intubation and the need to increase ventilatory support following FOB and to identify predictive factors for this event.

METHODS

A prospective multicenter observational study was carried out in eight French adult intensive care units. The study included 169 FOB performed in patients with a PaO(2)/FiO(2) ratio ≤ 300. The main end-point was intubation rate. The secondary end-point was rate of increased ventilatory support defined as an increase in oxygen requirement >50 %, the need to start noninvasive positive pressure ventilation (NI-PPV) or increase NI-PPV support.

RESULTS

Within 24 h, an increase in ventilatory support was required following 59 bronchoscopies (35 %), of which 25 (15 %) led to endotracheal intubation. The existence of chronic obstructive pulmonary disease (COPD; OR 5.2, 95 % CI 1.6-17.8; p = 0.007) or immunosuppression (OR 5.4, 95 % CI 1.7-17.2; p = 0.004] were significantly associated with the need for intubation in the multivariable analysis. None of the baseline physiological parameters including the PaO(2)/FiO(2) ratio was associated with intubation.

CONCLUSIONS

Bronchoscopy is often followed by an increase in ventilatory support in hypoxemic critically ill patients, but less frequently by the need for intubation. COPD and immunosuppression are associated with the need for invasive ventilation in the 24 h following bronchoscopy.

Foreign body aspiration in pregnancy

A 24-year-old morbidly obese African American gravida 1, with a history of severe asthma complicated by multiple inpatient admissions, presents at 30 weeks gestation with a foreign body in her left main stem bronchus. After a failed bronchoscopy postpartum, the patient slipped into respiratory failure and was subsequently intubated, spending two weeks in the intensive care unit. After two more attempts of trying to retrieve the foreign object from her lung via bronchoscopy, she eventually contracted a postobstructive pneumonia and underwent a left lower lung lobectomy for curative treatment.

Microbiome diversity in the bronchial tracts of patients with chronic obstructive pulmonary disease

Culture of bacteria from bronchial secretions in respiratory patients has low sensitivity and does not allow for complete assessment of microbial diversity across different bronchial compartments. In addition, a significant number of clinical studies are based on sputum samples, and it is not known to what extent they describe the real diversity of the mucosa. In order to identify previously unrecognized lower airway bacteria and to investigate the complexity and distribution of microbiota in patients with chronic obstructive pulmonary disease (COPD), we performed PCR amplification and pyrosequencing of the 16S rRNA gene in patients not showing signs or symptoms of infection. Four types of respiratory samples (sputum, bronchial aspirate, bronchoalveolar lavage, and bronchial mucosa) were taken from each individual, obtaining on average >1,000 16S rRNA sequences per sample. The total number of genera per patient was >100, showing a high diversity, with Streptococcus, Prevotella, Moraxella, Haemophilus, Acinetobacter, Fusobacterium, and Neisseria being the most commonly identified. Sputum samples showed significantly lower diversity than the other three sample types. Lower-bronchial-tree samples, i.e., bronchoalveolar lavage and bronchial mucosa, showed a very similar bacterial compositions in contrast to sputum and bronchial aspirate samples. Thus, sputum and bronchial aspirate samples are upper bronchial tree samples that are not representative of the lower bronchial mucosa flora, and bronchoalveolar lavage samples showed the results closest to those for the bronchial mucosa. Our data confirm that the bronchial tree is not sterile in COPD patients and support the existence a different microbiota in the upper and lower compartments.

Bronchoscopic management of bronchopleural fistula with intrabronchial instillation of glue (N-butyl cyanoacrylate)

Context:

Bronchopleural fistula (BPF) is a communication between the pleural space and bronchial tree.

Materials and Methods:

A series of 9 cases are reported where BPF was identified and managed with intrabronchial instillation of glue (N-butyl-cyanoacrylate) through a video bronchoscope.

Results:

Out of 9 patients the BPF was successfully sealed in 8 cases (88.88%). In 1 patient of postpneumonectomy, the fistula was big, that is >8 mm who had a recurrence after the procedure. In one case of pyopneumothorax the leak reduced slowly and it took us 14 days to remove the intercostal drainage tube. Rest of the patients had a favorable outcome. No complications were observed in a follow-up of 6 months.

Conclusions:

In our opinion, it is a cost-effective, viable, and safe alternative compared with costly, time-consuming, and high-risk surgical procedures.

Fibreoptic bronchoscopy without sedation: Is transcricoid injection better than the "spray as you go" technique?

Aim:

The aim of the study was to compare transcricoid injection with spray as you go technique for diagnostic fibreoptic bronchoscopy, to perform the procedure without sedation and to record any complication or side effects.

Methods:

Sixty patients belonging to the age group 20–70 years, undergoing diagnostic bronchoscopy over a period of 6 months, were randomly selected and divided into two groups alternatively to receive 3 ml of 4% lignocaine by a single transcricoid puncture (group I) or 2 ml of 4% lignocaine instilled through the bronchoscope on to the vocal cords and further 1 ml of 2% lignocaine into each main bronchus (group II). Additional dose of lignocaine as required was given in both the groups. All patients were given intramuscular atropine 0.6 mg, 20 min before the procedure. Nebulisation with 3 ml of 4% lignocaine was given to all patients. The time from nasal insertion of the bronchoscope to reach the carina was recorded, and the total dose of lignocaine required in both the groups was calculated and compared. The cough episodes during the procedure, systolic blood pressure, and pulse rate were compared before the procedure and 5 min after the procedure in both the groups. A0–10 visual analogue scale (VAS) was used to assess discomfort 30 min after the procedure.

Results:

The time to reach carina was more in group II (P<0.02), and cough episodes were also more in group II (P<0.05) than in group I. The vitals before the procedure were comparable in both the groups, but 5 min after the procedure the vitals were more stable in group I than in group II, and the total dose of lignocaine required in group II was more than in group I (P<0.001). However, the VAS score was comparable in both the groups.

Conclusion:

Transcricoid puncture for diagnostic bronchoscopies without sedation was associated with no complication and discomfort and required lesser dose of local anaesthetic with more stable vitals and good conditions for bronchoscopists.

Flexible bronchoscopy may decrease respiratory muscle strength: premedicational midazolam in focus

BACKGROUND

Flexible bronchoscopy (FB) is a procedure accepted to be safe in general, with low complication rates reported. On the other hand, it is known that patients with pre-existing respiratory failure have developed hypoventilation following FB. In this study the effects of FB on respiratory muscle strength were investigated by measuring maximum respiratory pressures.

METHODS

One hundred and forty patients, aged between 25 and 90 years, who had undergone diagnostic bronchoscopy between February 2012 and May 2012, were recruited to the study. Pre- and post-procedure maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured. A correlation between the MIP and MEP changes and patient characteristics and FB variables were investigated.

RESULTS

Significant decreases in both MIP and MEP values were observed following FB (p < 0.001 for both). Decreases were attributed to the midazolam used for sedation. Significant decreases in respiratory muscle strengths were observed especially in the high-dose midazolam group, compared to both low-dose and non-midazolam groups.

CONCLUSIONS

It was determined that respiratory muscle weakness may arise post-procedure in patients who have undergone FB, and this is constitutively related to midazolam premedication. Respiratory muscle weakness might play a role in potential hypoventilation in critical patients who undergo FB.

Bronchoalveolar lavage results are independent of season, age, gender and collection site

Background

Clinical interpretation of bronchoalveolar lavage fluid results is dependent on the availability of reference values for healthy individuals. Only a few studies have published such reference values and the applicability of results is restricted by small sample sizes and the limited representativeness of the study population. We aim to investigate the influence of age, gender, collection site and season on bronchoalveolar lavage fluid results and to establish reference values for use in clinical practice.

Methodology/Principal Findings

Bronchoalveolar lavage fluid data from 295 healthy never-smoking volunteers, investigated during 1990–2009, were analyzed retrospectively. 47 volunteers had 2–5 repeat lavages during the course of several years. Fluid recovery, total number of cells, cell concentration, and differential cell counts on cytospin prepared slides were recorded. Reference values, as represented by the 5^th to the 95^th percentile, were 72–96% for macrophages, 2–26% for lymphocytes, 0–4% for neutrophils and 0–1% for eosinophils. Basophils and mast cells were rare. When repeat lavages were performed, there was a relatively large intra-individual variability, mainly for macrophages and lymphocytes. An age dependent decrease of lavage fluid return was present, but there was no age dependent correlation with any of the other BALF parameters. The BALF cell parameters were independent of gender, season and site (lingula vs. middle lobe).

Conclusions/Significance

Our data show that bronchoalveolar lavage fluid cell differential count is independent of age, gender, season and collection site (RML or lingua). It therefore seems acceptable to use the same reference values for all never-smoking individuals.

Population-based estimates of transbronchial lung biopsy utilization and complications

BACKGROUND

Little is known about trends in the utilization or complication rates of transbronchial lung biopsy, particularly in community hospitals.

METHODS

We used the Healthcare Cost and Utilization Project Florida State Inpatient and State Ambulatory Surgical Databases to assess trends in transbronchial lung biopsy utilization in adults from 2000 to 2009. We subsequently calculated population based estimates of complications associated with transbronchial lung biopsy (iatrogenic pneumothorax and procedure-related hemorrhage) and identified characteristics associated with complications.

RESULTS

From 2000 to 2009, the age-adjusted rate of transbronchial biopsies per 100,000 adults in Florida decreased by 25% from 74 to 55 (p < 0.0001), despite stability in the overall utilization of bronchoscopy. Analysis of 82,059 procedures revealed that complications associated with transbronchial biopsy were uncommon and stable over the study period, with 0.97% (95% CI 0.94-1.01%) of procedures complicated by pneumothorax, 0.55% (95% CI 0.52-0.58%) by pneumothorax requiring chest tube placement, and 0.58% (95% CI 0.55-0.61%) by procedure-related hemorrhage. Patients with COPD (OR 1.51, 95% CI 1.31-1.75) and women (OR 1.32, 95% CI 1.15-1.52) were at increased risk for pneumothorax, while renal failure (OR 2.85, 95% CI 2.10-3.87), cirrhosis (OR 2.31, 95% CI 1.18-4.52), older age (OR 1.17, 95% CI 1.09-1.25) and female sex (OR 1.40, 95% CI 1.17-1.68) were associated with higher risk of procedure-related hemorrhage.

CONCLUSIONS

Utilization of transbronchial lung biopsy is decreasing relative to the overall use of bronchoscopy. Nevertheless, it remains a safe procedure with low risk of complications.

The importance of a satisfactory biopsy for the diagnosis of lung cancer in the era of personalized treatment

Advances in molecular biology are improving the understanding of lung cancer and changing the approach to treatment. A satisfactory biopsy that allows for histologic characterization and mutation analysis is becoming increasingly important. Most patients with lung cancer are diagnosed at an advanced stage, and diagnosis is often based on a small biopsy or cytology specimen. Here, we review the techniques available for making a diagnosis of lung cancer, including bronchoscopy, ultrasound-guided bronchoscopy, mediastinoscopy, transthoracic needle aspiration, thoracentesis, and medical thoracoscopy. We also discuss the indications, complications, and tissue yields of those techniques, especially as they pertain to testing for molecular markers.

An update on the drainage of pyogenic lung abscesses

Most lung abscesses (80-90%) are now successfully treated with antibiotics; however, this conservative approach may occasionally fail. When medical treatment fails, pulmonary resection is usually advised. Alternatively, percutaneous transthoracic tube drainage or endoscopic drainage can be considered, though both remain controversial. In this communication, the medical literature focusing on percutaneous tube drainage efficacy, indications, techniques, complications, and mortality, as well as available data regarding endoscopic drainage are reviewed.

Fiberoptic bronchoscopy, as a valuable diagnostic option in sputum negative pulmonary tuberculosis: A prospective study

CONTEXT

World Health Organization recommends bacteriological confirmation of pulmonary tuberculosis (PTB) by the detection of acid-fast bacilli (AFB) in respiratory specimens. However about 40-60% of patients with PTB suspected clinically or radiologically may fail to produce sputum, or when it is available, AFB may be negative on repeated smear examination. These sputum smear negative patients and those who fail to produce any sputum can be diagnosed by flexible fiberoptic bronchoscopy.

AIMS

Our study was an attempt to analyze the role of fiberoptic bronchoscopy in sputum smear negative PTB patients with respect to their association with clinical and radiological profile.

MATERIALS AND METHODS

In this prospective, open label, observational study, 40 cases of sputum smear negative PTB were subjected to bronchoscopic examination after taking informed consent and samples like bronchial aspirate, bronchoalveolar lavage and post bronchoscopy sputum were collected. The data was analysed and the results were given in percentage.

RESULTS

Out of the total 40 patients, overall diagnosis was confirmed in 24 (60%) patients. Of these 24 patients, 17 patients were confirmed for PTB whereas 7 had other diagnoses.

CONCLUSION

The study concludes that fiberoptic bronchoscopy is a useful tool in diagnosing sputum smear negative PTB patients with respect to their association with clinical and radiological profile, and also identifies individuals at a higher risk for progression of disease, at an early stage despite not meeting routine bacteriological criteria for confirmation of PTB.

EBUS-TBNA in patients presented with superior vena cava syndrome

INTRODUCTION

Expedient pathological diagnosis is crucial in selection of appropriate treatment in patients presented with superior vena cava syndrome (SVCS). The performance and safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in this setting is unknown.

METHODS

Over a 4-year period, patients presented with SVCS in the presence of mediastinal mass and referred for EBUS-TBNA were enrolled for the study. The procedure was performed under local anaesthesia with conscious sedation. TBNA was performed under real-time with the curvilinear probe of EBUS. Rapid on site cytological examination (ROSE) was not available.

RESULTS

Eighteen procedures of EBUS-TBNA were performed in 17 patients. Malignancy was confirmed in 16 patients (diagnostic yield 94.1%). There was no major complication including significant bleeding or pneumothorax related to the procedures.

CONCLUSIONS

EBUS-TBNA has high diagnostic yield and is safe in patients presented with SVCS and mediastinal mass.