[Bronchoscopic management of malignant central airway obstructions]

Up to 30% of lung cancer patients suffer from central airway obstruction, resulting in major deterioration in prognosis and quality of life. Interventional bronchoscopy combines a number of invasive techniques used during rigid bronchoscopy. It is designed to rapidly improve symptoms, primarily dyspnea. Applied according to very precise indications, this technique requires careful patient selection and needs to be incorporated into the multimodal oncological management in combination with systemic treatments, radiation therapy and surgery.

A novel pleural-bladder pump for the management of recurrent malignant pleural effusions: a feasibility animal study

Background

Recurrent malignant pleural effusions (MPE) are common and associated with significant morbidity in cancer patients. A new pump connecting the pleural cavity and the bladder may have application for the management of recurrent MPE. In a pre-clinical study, we investigated the utility of this pump in healthy pigs.

Methods

A novel pump system (Pleurapump® system) was inserted into four pigs under general anaesthesia. A tunnelled-pleural catheter was connected to a subcutaneously implanted pump while the urinary bladder was connected by percutaneous technique. Animals were ventilated mechanically and pump functioning was tested using a range of ventilation parameters and spontaneous breathing. Fluid was added to the pleural space to mimic pleural effusion and to assess the effectiveness of the pump at removing fluid to the bladder.

Results

The ‘pleurapump’ system successfully transported fluid from the pleural cavity to the bladder. Pressure variations caused by respiration and variations in the amount of fluid in the pleural cavity had no impact on the pumping. Pumping stopped when the pleural cavity was drained.

Conclusion

This pump can be implanted into pigs and successfully removed fluid from the pleural cavity to the bladder and may represent a new treatment for management of recurrent MPE. Evaluation in humans is planned.

Blood CD9+ B cell, a biomarker of bronchiolitis obliterans syndrome after lung transplantation

Bronchiolitis obliterans syndrome is the main limitation for long-term survival after lung transplantation. Some specific B cell populations are associated with long-term graft acceptance. We aimed to monitor the B cell profile during early development of bronchiolitis obliterans syndrome after lung transplantation. The B cell longitudinal profile was analyzed in peripheral blood mononuclear cells from patients with bronchiolitis obliterans syndrome and patients who remained stable over 3 years of follow-up. CD24^hi CD38^hi transitional B cells were increased in stable patients only, and reached a peak 24 months after transplantation, whereas they remained unchanged in patients who developed a bronchiolitis obliterans syndrome. These CD24^hi CD38^hi transitional B cells specifically secrete IL-10 and express CD9. Thus, patients with a total CD9⁺ B cell frequency below 6.6% displayed significantly higher incidence of bronchiolitis obliterans syndrome (AUC = 0.836, PPV = 0.75, NPV = 1). These data are the first to associate IL-10-secreting CD24^hi CD38^hi transitional B cells expressing CD9 with better allograft outcome in lung transplant recipients. CD9-expressing B cells appear as a contributor to a favorable environment essential for the maintenance of long-term stable graft function and as a new predictive biomarker of bronchiolitis obliterans syndrome-free survival.

[Trans-vocal cord prostheses - preliminary experience treating benign laryngotracheal stenosis in adults]

INTRODUCTION

Benign laryngotracheal stenosis is a rare pathology with multiple etiologies, the management of which is complex. This is because of the configuration and proximity of the larynx and the difficulty with surgical approaches, which are potentially mutilating, especially for the management of a benign disease. When surgery is challenging, iterative dilatations of the stricture or the fashioning of a definitive tracheotomy are therapeutic alternatives. Advances in rigid bronchoscopy and the evolution of prosthetic silicone material allow a new approach in the management of benign laryngotracheal stenosis, by placing flexible silicone prostheses which cover all the stenosis from the arytenoids to the trachea. This preliminary work aims to evaluate the feasibility, effectiveness, tolerance and complications of the implementation of this type of prosthesis.

PATIENTS AND METHODS

This is a retrospective single-centre study which analyzed the records of patients with symptomatic benign laryngotracheal stenosis who underwent placement of a transcordial prosthesis over a period of three years. The prosthesis used, inserted under general anesthesia during a rigid tube interventional bronchoscopy, was either a straight silicone prosthesis or a Montgomery T-tube for those with a pre-existing tracheotomy.

RESULTS

Six patients were included. Five are still alive, one patient died from a cause unrelated to the placement of the prosthesis. Four have no tracheostomy and two now have no transcordal prosthesis. The data collected on tolerance found, for three patients, two cases of minor aspiration and one case of transient cough. All patients had whispered voice dysphonia. We did not observe prosthesis migration or obstruction.

CONCLUSION

These preliminary results are encouraging. Transcordal prostheses in benign laryngotracheal stenosis have a complementary or alternative role compared to surgery with a palliative or even curative objective.

Malignant transformation of a tracheal chondroma: The second reported case and review of the literature

Tracheal tumors are rare, representing only 0.2% of the respiratory tract malignancies. Chondrosarcoma arising in the trachea was first described in 1959 by Jackson et al. and since then only 20 cases have been described. We report the second documented case of malignant transformation from an endotracheal chondroma, in a 75-year-old woman, and review the literature.

[Endobronchial ultrasound in the diagnosis of malignant pleural mesothelioma]

The diagnosis of malignant pleural mesothelioma relies mostly on the pathological examination of pleural samples, validated by a panel of experts and generally obtained during medical or surgical thoracoscopy performed for the management of an exudative pleural effusion. In the absence of pleural effusion (dry-type mesothelioma), the diagnostic approach depends on the features of the lesions (pleural thickness, nodules and/or masses) and their pleural location. Ultrasound and CT-guided needle aspiration represent recognized alternative diagnostic techniques in these situations. We present the case of a patient, presenting a dry-type mesothelioma, whose diagnosis was obtained by endobronchial ultrasound (EBUS)-guided needle aspiration of a pleural mediastinal mass and confirmed by a CT-guided needle aspiration of another pleural mass in close contact with the chest wall. The samples have been compared and show quantitative and qualitative similarities. EBUS represents a minimally invasive alternative diagnostic technique for dry-type mesothelioma, showing thickness of the mediastinal pleura in contact with a central airway or when thoracoscopy, which remains the "gold standard" diagnostic approach, is not feasible.

[Cost-effectiveness of lung volume reduction coil treatment in emphysema. STIC REVOLENS]

BACKGROUND

Medical therapeutic options for the treatment of emphysema remain limited. Lung volume reduction surgery is infrequently used because of its high morbi-mortality. Endobronchial lung volume reduction coil (LVRC(®), PneumRx, Mountain View, CA) treatment has been recently developed and has been shown to be feasible and associated with an acceptable safety profile, while resulting in improvements in dyspnea, exercise capacity and lung function. The objective of this study is to analyze the cost effectiveness of LVRC treatment in severe emphysema.

METHODS

This prospective, multicenter study, randomized with a 1:1 ratio (LVRC vs conventional treatment) will include 100 patients who will be followed up for 1year. The primary outcome measure is the 6-month improvement of the 6-minute walk test: the percentage of patients showing an improvement of at least 54m will be compared between groups. A cost-effectiveness study will estimate the cost of LVRC treatment, the global cost of this therapeutic option and will compare the cost between patients treated by LVRC and by medical treatment alone.

EXPECTED RESULTS

This study should allow validating the clinical efficacy of LVRC in severe emphysema. The cost-effectiveness study will assess the medical-economic impact of the LVRC therapeutic option.

Temporary endobronchial embolization with silicone spigots for moderate hemoptysis: a retrospective study

BACKGROUND

The management of airway bleeding is generally performed in an emergency to prevent hypoxemia and lung flooding. When the bleeding arises from peripheral lesions that are not visible endoscopically, bronchoscopic options have limited curative intents. Endobronchial embolization using silicone spigots (EESS) is a novel approach.

OBJECTIVES

We analyzed the efficacy and safety of EESS in a retrospective study.

METHODS

We retrospectively reviewed charts of patients referred to our center for moderate hemoptysis (MH) who underwent EESS. Successful management is defined as immediate bleeding cessation.

RESULTS

From December 2008 to January 2012, 9 patients were treated with EESS in our endoscopy unit. The MH originated from the left upper lobe in 4 cases, the right upper lobe in 3 cases and the right middle lobe and left lower lobe in 1 case each. Thirteen spigots were inserted. The success rate was 78%. Of the 9 patients, 7 were referred to interventional radiology for bronchial artery embolization, with a success rate of 86%, and 2 were referred for thoracic surgery. One patient had EESS as definitive treatment; the silicone spigots were bronchoscopically removed after a median of 4 days in 6 of the remaining 8 patients. Only 2 patients had hemoptysis recurrence after a median follow-up of 107 days (ranging from 13 to 1,017 days). None of the patients died from hemoptysis.

CONCLUSION

EESS is an original, temporary technique that requires only a flexible bronchoscope and biopsy forceps for placement and removal. EESS ensures airway protection while waiting for definitive management.

Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management

Hemoptysis is frequently encountered in clinical practice, and may be the presenting symptom of a number of diseases. Although massive hemoptysis accounts for only 5-15% of episodes, it should always be considered as a life-threatening condition that warrants effective assessment and management. In this article, we review the literature with regard to the definition, etiology, epidemiology, pathophysiology, diagnosis and treatment of massive hemoptysis, with special emphasis on the role of bronchoscopy as a diagnostic and therapeutic tool. We briefly present the circumstances under which the use of rigid bronchoscopy should be preferred for controlling massive bleeding. Moreover, we address the crucial importance of multidisciplinary collaboration by illustrating the roles of endovascular therapy and surgery in the optimal management of massive hemoptysis.

[A rare cause of stridor in a 59 year old woman in intensive care]

INTRODUCTION

Stridor in the post extubation period occurs frequently and is most commonly caused by laryngeal oedema. During this period, the trachea can also be obstructed by pseudomembranes.

CASE REPORT

We report the case of a 59 year old woman who required re-intubation, 15 days after extubation because of the acute onset of severe respiratory distress secondary to pseudomembranes in her trachea.

CONCLUSION

It is essential that physicians who care for patients during the post extubation period are aware of this severe and life threatening cause of stridor. Definitive treatment with the rigid bronchoscope allows for rapid recanalisation of the airway.

[Specific emergencies in thoracic oncology: pleurisy, superior vena cava syndrome, and tracheobronchial obstruction]

In patients with lung cancer, the appearance of pleurisy, superior vena cava syndrome, or tracheobronchial obstruction are complications that require specialized care, often in an emergency context. Our objective is to present the different therapeutic options available in each of these three complications and to suggest recommendations on the care to provide in everyday clinical practice.

A multicenter retrospective study investigating the role of interventional bronchoscopic techniques in the management of endobronchial lipomas

BACKGROUND

Pulmonary lipomas are rare benign tumors that are usually found endobronchially. Undiagnosed, they can lead to the serious late sequelae associated with endobronchial obstruction. In the majority of cases, they are located in the first three subdivisions of the tracheobronchial tree, and therefore, they are amenable to endoscopic techniques for diagnostic and therapeutic purposes.

OBJECTIVES

It was our aim to retrospectively study the bronchoscopic management and follow-up of a large series of endobronchial lipomas, as well as defining the demographic and endoscopic characteristics of patients.

METHODS

A retrospective multicenter study was performed to identify all cases of lipomas that were treated endoscopically in 4 institutions in the period from 1981 to 2002. Demographic, radiological, endoscopic and histological data were collected.

RESULTS

Thirty-eight patients were included in the study; 81.6% of cases were males and the average age was 63.5 +/- 15.2 years. The majority of the patients were symptomatic (63.2%). Lipomas were located proximally in 18 cases (47.4%) and distally in 20 subjects (52.6%). Specimens obtained by rigid bronchoscopy were diagnostic in all cases. Thirty-six out of 38 patients underwent therapeutic rigid bronchoscopy. Laser and mechanical debulking was performed in 29 cases (76.3%), cryotherapy and mechanical debulking in 7 subjects (18.4%), and mechanical debulking alone in 2 cases (5.3%). No cases of recurrence occurred during the follow-up period.

CONCLUSIONS

This study demonstrates that endoscopic techniques are effective for the diagnosis and treatment of endobronchial lipomas when there is no evidence of severe distal bronchiectasis. This should be the treatment of choice after a full clinicoradiological evaluation.

[Bronchoscopy in the diagnosis of lung cancer: an evaluation of current practice]

INTRODUCTION

Bronchoscopy is frequently practised by respiratory physicians, particularly when there is a suspicion of lung cancer. However, few guidelines are available and practice varies widely.

BACKGROUND

Studies of current practice are few and unstandardised. Few data are available regarding equipment or procedure (information, prior investigations, environment, standardised reporting etc.). The evaluation of new techniques such as endobronchial ultrasound, autofluorescence bronchoscopy, transbronchial needle aspiration (TBNA) has been covered in recent publications. These evaluations are often undertaken without rigourous methodology (retrospective studies) but underline the feasibility of these techniques. Some, especially TBNA are nevertheless underused in practice. In the published studies evaluating practice the results of these investigations are often similar to those obtained in clinical trials even if a learning period is necessary. Complications are rare. Few studies of cost effectiveness are available but they support the use of these new techniques.

VIEWPOINT

A national study under the aegis of the SLPF (French Respiratory Society) is necessary to obtain comprehensive and reliable data on the practice of bronchoscopy in the investigation of lung cancer.

CONCLUSIONS

Studies evaluating current practices are few and unstandardised, and probably give only a partial survey of the success achieved and the difficulties encountered by respiratory physicians in their clinical routine.

Prevalence of asthma and rhinitis in relation to long-term exposure to gaseous air pollutants

The relationship between long-term exposure to air pollutants, especially with regard to photochemical air pollutants, and asthma prevalence in developed countries is controversial. The objective of this cross-sectional survey was to compare mean levels of the main gaseous air pollutants and prevalence rates of rhinitis, asthma, and asthmatic symptoms. It included 2,445 children from the 8th and 9th school grades who had been living for at least 3 years in an area where some communities undergo the heaviest photochemical exposure in France. Data on rhinitis, asthmatic symptoms, and asthma prevalence were gathered with the ISAAC paper and video questionnaires. The relation between level of air pollutants and asthma was assessed first by comparison of crude prevalence rates (chi-square test), and then by simple regression analysis and multiple logistic regression analysis. No consistent association between mean SO2 and NO2 levels, and prevalence of rhinitis, asthma, or asthmatic symptoms could be demonstrated. In contrast, there were statistically significant associations between prevalence of asthmatic symptoms and mean ozone O3) concentration. The interpretation of such findings is not straightforward, as these symptoms can be interpreted either as respiratory irritation due to exposure to nonspecific airway stimuli or as a true asthmatic state. Additional studies are required to clarify this important issue. In conclusion, this large cross-sectional epidemiologic survey performed in an area of high photochemical air pollution did demonstrate statistically significant associations between the prevalence of asthmatic symptoms and mean O3 concentration.

[Evaluation of a questionnaire on the home environment of asthmatic patients]

Indoor environment outpatient asthmatics plays a major role in modulating asthma severity. Therefore many surveys devoted to studying risk factors for asthma include a questionnaire about housing characteristics. However no such questionnaire has been to date validated. In this study, we tried to validate such a questionnaire by comparing answers of a group of asthmatics outpatient to a questionnaire to de visu finding performed by a field worker during a home visit. Thirty asthmatic patients were included in the study. Housing characteristics were generally correctly acknowledged. Questions on the heating system should be clearly and simply formulated. Energetic supply of stoves and ventilation system is not always known. In the field of house equipment, especially bedding, photographs or drawings can be useful.

[Epidemiology of respiratory allergies: current data]

Respiratory allergic diseases include seasonal allergic rhinitis or hay fever, perennial allergic rhinitis and allergic asthma. Prevalence of asthma is difficult to assess through epidemiological questionnaires. In France hay fever roughly affects 6% of children and 18% of teenagers and nasal allergies, more than one fourth of young adults. Prevalence of asthma is equal to 10 to 15% in teenagers and 7 to 9% in young adults. Risk factors include genetic as well as environmental factors. The role of the former have been exemplified in family studies, especially twin studies, and surveys of inbred populations. Environmental factors can be allergic or non-allergic. The influence of allergenic exposure on sensitization, occurrence and severity of respiratory allergic disease is well documented. The triggering influence of non-allergenic factors on established allergic diseases is also clear. In contrast, their implication in allergic sensitization and occurrence of allergic diseases need to be clarified.

The prevalence of reported asthma is independent of exposure in house dust mite-sensitized children

In areas with low house dust mite (HDM) allergen exposure, both mite sensitization and asthma prevalence are low. In most other areas, HDM allergen exposure is higher than the threshold for sensitization. In this setting, is HDM allergen exposure a factor which is causally related to the development of asthma in HDM-sensitive individuals? To answer this question, the cumulative prevalence of asthma was evaluated in a group of 157 schoolchildren, aged 10 and 11 yrs, who were allergic to HDM allergen, and compared it with HDM allergen exposure and atopic status, using univariate and multivariate analysis. HDM allergen levels were measured in mattress dust using an enzyme-linked immunosorbent assay (ELISA) method. Of mattress dust samples, 94% had an HDM allergen level >2 microg x g dust(-1). Atopy was evaluated by means of skin prick tests using five common allergens. Among the predictive variables studied by means of univariate analysis, only the number of positive skin tests and male sex correlated with asthma prevalence, but not HDM allergen exposure. Logistic regression analysis also demonstrated that the number of positive skin tests correlated with asthma prevalence (odds ratio (OR)=1.38, p=0.05), whereas the OR for HDM allergen exposure was 1.0. This survey suggests that, in a geographical area with high HDM allergen exposure, asthma prevalence is not linked with HDM allergen levels.

Role of allergens in the natural history of childhood asthma

This review article deals with the role of allergens in the natural history of asthma. Several studies clearly demonstrate a strong relationship between allergen exposure, especially mite-allergen exposure, and risk of sensitization. Those studies have led to the proposed threshold equal to 2 micrograms/g dust. However, more recent evidence shows that there is no threshold for sensitization, especially in children born to atopic parents. As far as occurrence of asthma is concerned, geographical comparisons of asthma prevalence across Europe, Australia or in other populations with contrasted exposure to mite allergens do show such a relationship. The latter is not exemplified in studies performed within the same geographical area, probably because the exposure categories are not contrasted enough. Finally, asthma severity in mite sensitive asthmatics is partly modulated by allergen exposure but repeated exposure to low amounts of allergen can trigger disease activity. In conclusion, allergen exposure is involved at each step of the natural history of asthma. Even low doses can play a significant role. Thus avoidance methods, in order to be efficient in primary and secondary prevention, should lead to a drastic decrease in allergenic exposure.

[Risk factors in severe asthma]

Risk factors for severe acute asthma involve the patient, the environment and the society in general. In addition, there are strong interrelationships between these factors. Personal characteristics linked to acute severe asthma include age (teenagers), denial leading to poor compliance, depression with atypical symptoms in children, and some medical features of asthma associated with increased severity. Environmental factors include airborne allergens, infections, irritants such as air pollutants and passive smoking. Life events have not been extensively studied but are likely to play a predominant role. The social setting, particularly the health care system, acts as an interface between the patient and the environment. Most all asthma deaths are avoidable and related to dysfunctions in the health care system.

[Pollution and allergy: the epidemiological data]

This area is controversial, mostly because of disagreement between experimental and epidemiological data. Even though modulation of asthma by the level of atmospheric pollution has been well shown by panel and ecological studies, the relationship between pollution and genesis of allergic diseases has not been confirmed by epidemiological studies. Comparison of the frequency of asthma in urban and rural surroundings in general shows, in the urban environment, an advantage of irritation symptoms but not for asthma. In contrast, the prevalence of atopy seems higher in the urban environment, which is perhaps a reflection of a different way of life, like that shown in east-west studies. Several recent investigations showed that at the centre of a development additional respiratory symptoms related to the intensity of automobile traffic, but no relationship was shown with atopy. In the same way, no epidemiological investigation has shown a relationship between automobile pollution and prevalence of atopy. Thus, at present no solid elements exist to support an increase of the frequency of asthma and especially atopy, in a relationship with modern atmospheric pollution, essentially of automobile origin.