Transbronchial cryobiopsy followed by as-needed surgical lung biopsy versus immediate surgical lung biopsy for diagnosing interstitial lung disease (the COLD study): a randomised controlled trial

BACKGROUND

An adequate diagnosis for interstitial lung disease (ILD) is important for clinical decision making and prognosis. In most patients with ILD, an accurate diagnosis can be made by clinical and radiological data assessment, but in a considerable proportion of patients, a lung biopsy is required. Surgical lung biopsy (SLB) is the most common method to obtain tissue, but it is associated with high morbidity and even mortality. More recently, transbronchial cryobiopsy has been introduced, with fewer adverse events but a lower diagnostic yield than SLB. The aim of this study is to compare two diagnostic strategies: a step-up strategy (transbronchial cryobiopsy, followed by SLB if the cryobiopsy is insufficiently informative) versus immediate SLB.

METHODS

The COLD study was a multicentre, randomised controlled trial in six hospitals across the Netherlands. We included patients with ILD with an indication for lung biopsy as assessed by a multidisciplinary team discussion. Patients were randomly assigned in a 1:1 ratio to the step-up or immediate SLB strategy, with follow-up for 12 weeks from the initial procedure. Patients, clinicians, and pathologists were not masked to the study treatment. The primary endpoint was unexpected chest tube drainage, defined as requiring any chest tube after transbronchial cryobiopsy, or prolonged (>24 h) chest tube drainage after SLB. Secondary endpoints were diagnostic yield, in-hospital stay, pain, and serious adverse events. A modified intention-to-treat analysis was performed. This trial is registered with the Dutch Trial Register, NL7634, and is now closed.

FINDINGS

Between April 8, 2019, and Oct 24, 2021, 122 patients with ILD were assessed for study participation; and 55 patients were randomly assigned to the step-up strategy (n=28) or immediate SLB (n=27); three patients from the immediate SLB group were excluded. Unexpected chest tube drainage occurred in three of 28 patients (11%; 95% CI 4-27%) in the step-up group, and the number of patients for whom the chest tube could not be removed within 24 h was 11 of 24 patients (46%; 95% CI 2-65%) in the SLB group, with an absolute risk reduction of 35% (11-56%; p=0·0058). In the step-up strategy, the multidisciplinary team diagnostic yield after transbronchial cryobiopsy alone was 82% (64-92%), which increased to 89% (73-96%) when subsequent SLB was performed after inconclusive transbronchial cryobiopsy. In the immediate surgery strategy, the multidisciplinary team diagnostic yield was 88% (69-97%). Total in-hospital stay was 1 day (IQR 1-1) in the step-up group versus 5 days (IQR 4-6) in the SLB group. One (4%) serious adverse event occurred in step-up strategy versus 12 (50%) in the immediate SLB strategy.

INTERPRETATION

In ILD diagnosis, if lung tissue assessment is required, a diagnostic strategy starting with transbronchial cryobiopsy, followed by SLB when transbronchial cryobiopsy is inconclusive, appears to result in a significant reduction of patient burden and in-hospital stay with a similar diagnostic yield versus immediate SLB.

FUNDING

Netherlands Organisation for Health Research and Development (ZonMW) and Amsterdam University Medical Centers.

Bronchoscope-assisted Tritube® placement for resection of sequential tracheal stenosis

Symptomatic tracheal stenosis is a rare but significant complication of long-term tracheal intubation and mechanical ventilation. Airway management for tracheal resection in severe tracheal stenosis, especially sequential stenoses, requires multidisciplinary planning. A valuable method of airway management is the insertion of a small-bore, cuffed tracheal tube (Tritube®, Ventinova Medical B.V., Eindhoven, The Netherlands) in combination with flow-controlled ventilation. In this case, a patient with tracheal stenosis following prolonged ventilation required resection of the stenosed tissue. A Tritube was placed via a J-tipped guidewire inserted through the working channel of a bronchoscope. Bronchoscopic cuff visualisation along the tube in severe stenosis is impossible because of the outer diameter of the tracheal tube. In this case, we therefore estimated the position of the tube tip based on the distance from the vocal cords to the carina measured on pre-operative computed tomography imaging. During completion of the dorsal tracheal anastomosis, cross field ventilation using a conventional tracheal tube had to be started due to impeded ventilation caused by the Tritube protruding distal to the carina. In severe sequential tracheal stenosis, a small-bore tracheal tube can safely be placed by guidance with a J-tipped guidewire. However, it is important to plan a backup method of ventilation, such as cross field ventilation, prior to commencing a critical procedure.

Diagnostic Yield of Transbronchial Lung Cryobiopsy Compared to Transbronchial Forceps Biopsy in Patients with Sarcoidosis in a Prospective, Randomized, Multicentre Cross-Over Trial

Background: Transbronchial lung forceps biopsy (TBLF) is of limited value for the diagnosis of interstitial lung disease (ILD). However, in cases with predominantly peribronchial pathology, such as sarcoidosis, TBLF is considered to be diagnostic in most cases. The present study examines whether transbronchial lung cryobiopsy (TBLC) is superior to TBLF in terms of diagnostic yield in cases of sarcoidosis. Methods: In this post hoc analysis of a prospective, randomized, controlled, multicentre study, 359 patients with ILD requiring diagnostic bronchoscopic tissue sampling were included. TBLF and TBLC were both used for each patient in a randomized order. Histological assessment was undertaken on each biopsy and determined whether sarcoid was a consideration. Results: A histological diagnosis of sarcoidosis was established in 17 of 272 cases for which histopathology was available. In 6 out of 17 patients, compatible findings were seen with both TBLC and TBLF. In 10 patients, where the diagnosis of sarcoidosis was confirmed by TBLC, TBLF did not provide a diagnosis. In one patient, TBLF but not TBLC confirmed the diagnosis of sarcoidosis. Conclusions: In this post hoc analysis, the histological diagnosis of sarcoidosis was made significantly more often by TBLC than by TBLF. As in other idiopathic interstitial pneumonias (IIPs), the use of TBLC should be considered when sarcoidosis is suspected.

Hybrid Cardiac Magnetic Resonance/Fluorodeoxyglucose Positron Emission Tomography to Differentiate Active From Chronic Cardiac Sarcoidosis

OBJECTIVES

The purpose of this study was to investigate the diagnostic value of simultaneous hybrid cardiac magnetic resonance (CMR) and ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) for detection and differentiation of active (aCS) from chronic (cCS) cardiac sarcoidosis.

BACKGROUND

Late gadolinium enhancement (LGE) CMR and FDG-PET are both established imaging techniques for the detection of CS. However, there are limited data regarding the value of a comprehensive simultaneous hybrid CMR/FDG-PET imaging approach that includes CMR mapping techniques.

METHODS

Forty-three patients with biopsy-proven extracardiac sarcoidosis (median age: 48 years, interquartile range: 37-57 years, 65% male) were prospectively enrolled for evaluation of suspected CS. After dietary preparation for suppression of myocardial glucose metabolism, patients were evaluated on a 3-T hybrid PET/MR scanner. The CMR protocol included T1 and T2 mapping, myocardial function, and LGE imaging. We assumed aCS if PET and CMR (ie, LGE or T1/T2 mapping) were both positive (PET+/CMR+), cCS if PET was negative but CMR was positive (PET-/CMR+), and no CS if patients were CMR negative regardless of PET findings.

RESULTS

Among the 43 patients, myocardial glucose uptake was suppressed successfully in 36 (84%). Hybrid CMR/FDG-PET revealed aCS in 13 patients (36%), cCS in 5 (14%), and no CS in 18 (50%). LGE was present in 14 patients (39%); T1 mapping was abnormal in 10 (27%) and T2 mapping abnormal in 2 (6%). CS was diagnosed based on abnormal T1 mapping in 4 out of 18 CS patients (22%) who were LGE negative. PET FDG uptake was present in 17 (47%) patients.

CONCLUSIONS

Comprehensive simultaneous hybrid CMR/FDG-PET imaging is useful for the detection of CS and provides additional value for identifying active disease. Our results may have implications for enhanced diagnosis as well as improved identification of patients with aCS in whom anti-inflammatory therapy may be most beneficial.

Overcoming barriers to data sharing with medical image generation: a comprehensive evaluation

Privacy concerns around sharing personally identifiable information are a major barrier to data sharing in medical research. In many cases, researchers have no interest in a particular individual's information but rather aim to derive insights at the level of cohorts. Here, we utilise generative adversarial networks (GANs) to create medical imaging datasets consisting entirely of synthetic patient data. The synthetic images ideally have, in aggregate, similar statistical properties to those of a source dataset but do not contain sensitive personal information. We assess the quality of synthetic data generated by two GAN models for chest radiographs with 14 radiology findings and brain computed tomography (CT) scans with six types of intracranial haemorrhages. We measure the synthetic image quality by the performance difference of predictive models trained on either the synthetic or the real dataset. We find that synthetic data performance disproportionately benefits from a reduced number of classes. Our benchmark also indicates that at low numbers of samples per class, label overfitting effects start to dominate GAN training. We conducted a reader study in which trained radiologists discriminate between synthetic and real images. In accordance with our benchmark results, the classification accuracy of radiologists improves with an increasing resolution. Our study offers valuable guidelines and outlines practical conditions under which insights derived from synthetic images are similar to those that would have been derived from real data. Our results indicate that synthetic data sharing may be an attractive alternative to sharing real patient-level data in the right setting.

Real-time prediction of COVID-19 related mortality using electronic health records

Coronavirus disease 2019 (COVID-19) is a respiratory disease with rapid human-to-human transmission caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Due to the exponential growth of infections, identifying patients with the highest mortality risk early is critical to enable effective intervention and prioritisation of care. Here, we present the COVID-19 early warning system (CovEWS), a risk scoring system for assessing COVID-19 related mortality risk that we developed using data amounting to a total of over 2863 years of observation time from a cohort of 66 430 patients seen at over 69 healthcare institutions. On an external cohort of 5005 patients, CovEWS predicts mortality from 78.8% (95% confidence interval [CI]: 76.0, 84.7%) to 69.4% (95% CI: 57.6, 75.2%) specificity at sensitivities greater than 95% between, respectively, 1 and 192 h prior to mortality events. CovEWS could enable earlier intervention, and may therefore help in preventing or mitigating COVID-19 related mortality.

[Recommendations for Performing Bronchoscopy in Times of the COVID-19 Pandemic - Update 12/2020]

Die Pandemie ausgelöst durch SARS-CoV-19 geht weltweit unverändert mit einer bedeutsamen Morbidität und Mortalität einher, sodass Schutzmaßnahmen zur Verhinderung der Transmission des Virus weiterhin notwendig sind. Mitarbeiter im Gesundheitswesen sind einem höheren Risiko ausgesetzt, und dies gilt insbesondere im Rahmen sog. Aerosol-generierender Verfahren wie der Bronchoskopie. Seit der Veröffentlichung konsentierter Empfehlungen zur Durchführung einer Bronchoskopie unter diesen Bedingungen vor mehr als einem halben Jahr hat sich die Gefahrenlage nicht wesentlich verändert, aber aufgrund des erheblichen Erkenntnisgewinns in der Zwischenzeit war ein Update der Empfehlungen notwendig. Die erneuerten Empfehlungen umfassen u. a. die Verminderung der Aerosolentstehung, den persönlichen Schutz der beteiligten Personen sowie Maßnahmen zur besseren Organisation der Abläufe in der Endoskopie, um eine sichere Durchführung auch in Zeiten von COVID-19 zu gewährleisten.

Transbronchial cryobiopsy increases diagnostic confidence in interstitial lung disease: a prospective multicentre trial

INTRODUCTION

The accurate diagnosis of individual interstitial lung diseases (ILD) is often challenging, but is a critical determinant of appropriate management. If a diagnosis cannot be made after multidisciplinary team discussion (MDTD), surgical lung biopsy is the current recommended tissue sampling technique according to the most recent guidelines. Transbronchial lung cryobiopsy (TBLC) has been proposed as an alternative to surgical lung biopsy.

METHODS

This prospective, multicentre, international study analysed the impact of TBLC on the diagnostic assessment of 128 patients with suspected idiopathic interstitial pneumonia by a central MDTD board (two clinicians, two radiologists, two pathologists). The level of confidence for the first-choice diagnoses were evaluated in four steps, as follows: 1) clinicoradiological data alone; 2) addition of bronchoalveolar lavage (BAL) findings; 3) addition of TBLC interpretation; and 4) surgical lung biopsy findings (if available). We evaluated the contribution of TBLC to the formulation of a confident first-choice MDTD diagnosis.

RESULTS

TBLC led to a significant increase in the percentage of cases with confident diagnoses or provisional diagnoses with high confidence (likelihood ≥70%) from 60.2% to 81.2%. In 32 out of 52 patients nondiagnostic after BAL, TBLC provided a diagnosis with a likelihood ≥70%. The percentage of confident diagnoses (likelihood ≥90%) increased from 22.7% after BAL to 53.9% after TBLC. Pneumothoraces occurred in 16.4% of patients, and moderate or severe bleeding in 15.7% of patients. No deaths were observed within 30 days.

INTERPRETATION

TBLC increases diagnostic confidence in the majority of ILD patients with an uncertain noninvasive diagnosis, with manageable side-effects. These data support the integration of TBLC into the diagnostic algorithm for ILD.

Tracheobronchial Polyposis after Inhalation Trauma

Supplemental Digital Content is available in the text.

Life-threatening pneumonitis after first-line treatment with osimertinib for primary T790M mutated non-small cell lung cancer

Epithelial growth factor receptor (EGFR) directed tyrosine kinase inhibitor (TKI) treatment is the standard approach in patients with advanced, EGFR‐mutated non‐small cell lung cancer (NSCLC). Although benefit/risk ratio is favorable for these TKI and side effects are manageable in the vast majority of patients, severe and even life‐threatening side effects have been reported. TKI‐induced interstitial lung disease (ILD) has been reported for single cases in modest severity, predominantly in EGFR‐TKI pretreated patients. Here, we report a case of successful stabilization of a life‐threatening ILD in a de novo T790M mutated NSCLC during first‐line treatment with osimertinib. As osimertinib will be used more often in many EGFR‐positive NSCLC patients in the future, this potentially life‐threatening side effect should receive special attention, especially in first‐line treatment.

[Recommendations for Performing Bronchoscopy in Times of the COVID-19 Pandemic]

COVID-19, caused by coronavirus SARS-CoV-2 is a new and ongoing infectious disease affecting healthcare systems worldwide. Healthcare worker are at high risk for COIVD-19 and many have been infected or even died in countries severely affected by COVID-19 like China or Italy. Bronchoscopy causes cough and aerosol production and has to be considered a significant risk for the staff to get infected. Particular recommendations should guide to prevent spreading COVID-19 and to protect healthcare worker when performing a bronchoscopy.

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Evaluation of Efficacy of a New Cryoprobe for Transbronchial Cryobiopsy: A Randomized, Controlled in vivo Animal Study

BACKGROUND

Forceps biopsy (FB) is still the most popular procedure for the bronchoscopic sampling of lung tissue. However, it has limitations like inadequate sample size and crush artifacts. Cryobiopsy (CB) has been introduced to obtain bronchoscopic biopsies with improved diagnostic yield compared to FB. Limitations of CB are the need to retract the cryoprobe en bloc with bronchoscope because samples are larger than the working channel and the variations of the freezing power of the reusable CB (rCB). Therefore, 3 new disposable cryoprobes (dCB) have been developed with different outer diameters: 1.1 mm (CB11-S) that can be retracted through the working channel of the bronchoscope, 1.7 mm (CB17) and 2.4 mm (CB24n), respectively.

OBJECTIVES

The aim was to evaluate the new cryoprobes with regard to feasibility, specimen area, specimen quality and complications.

METHODS

We compared biopsy samples of the new probes with those obtained by FB and by rCB in an in vivo (porcine) model. A flexible bronchoscope was used to perform biopsy at 4 different locations at the upper and lower lobes of the right and left lung, respectively. The biopsies were taken under fluoroscopic control. The biopsy tool and activation times were allocated randomly. Altogether 204 biopsy procedures were performed.

RESULTS

The sample quality of the dCB was superior to that of FB (all p < 0.05) and not significantly different to the rCB sample quality. Mean specimen sample area of all CB was significantly larger compared to FB (p < 0.05). The sample area of the small cryoprobe (CB11-S) was significantly smaller compared to the other CB probes (p < 0.05). No severe bleedings occurred. Pneumothoraces were detected in 3 of the 7 pigs.

CONCLUSION

We conclude that CB with the new single-use instruments are feasible and represent a viable option to improve the diagnostic accuracy of histopathological evaluation compared to FB.

The effect of intraparenchymal blood patching on the rate of pneumothorax in patients undergoing percutaneous CT-guided core biopsy of the lung

PURPOSE

To assess the effect of intraparenchymal blood patching (IBP) as well as tumor- and operator-related risk factors on the rate of pneumothoraxes after percutaneous CT-guided core needle biopsy of the lung.

MATERIALS AND METHODS

We performed a retrospective analysis of 868 CT-guided lung biopsies that were conducted at our institution between 2003 and 2018, of which 419 (48%) received an IBP. Outcome variable included the rates of pneumothorax and chest tube placement, as well as lesion size (<3 cm versus ≥3 cm long axis diameter), lesion depth (≤2 cm, >2-4 cm, >4-5 cm and >5 cm distance to the pleura), location within the lungs (upper lobe, lower lobe, middle lobe), needle caliber (13 G, 15 G, 17 G, 19 G), number of samples taken (1-3 versus ≥4 samples), and experience of the performing physician.

RESULTS

The rate of pneumothorax was significantly (p < 0.05) lower in the group with IBP (10.7%) compared to the group without IBP (15.4%). The number of post-interventional chest tube placements was also lower in the IBP group (3.1% vs. 5.8%) but not statistically significant. The lesion size correlated negatively with the rate of pneumothoraxes, whereas in both groups (±IBP) lesions ≥ 3 cm showed a significantly lower rate of pneumothorax (p < 0.05). With increasing lesion depth, the pneumothorax rate increased with (p < 0.01) and without (p < 0.001) IBP. The rate of pneumothorax was significantly lower (p < 0.05) for 17 G needles with IBP, but not for other calibers. For biopsies in the lower lobe, the pneumothorax rate reduced significantly (p < 0.001) with IBP. In case of ≥4 tissue samples, the pneumothorax rate was significantly lower with IBP (p < 0.01). For experienced operators, the overall pneumothorax rate was significantly lower compared to less experienced operators (p < 0001).

CONCLUSIONS

IBP significantly reduces the rate of pneumothorax following CT-guided lung biopsies in particular for lesions located deeper in the lungs, when ≥4 samples are taken, when samples are taken by less-experienced operators, and when sampling from the lower lobes.

Prediction of response to endobronchial coiling based on morphologic emphysema characterization of the lung lobe to be treated and the ipsilateral non-treated lobe as well as on functional computed tomography-data: correlation with clinical and pulmonary function

Background

To test if the emphysema type of the targeted lobe, ipsilateral non-targeted lobe, and lobes of the contralateral lung impact outcome of endobronchial lung volume reduction (ELVR) treatment, and to document lobar volume changes in treated and non-treated lung lobes.

Methods

Thirty patients (16 men, 14 women; median age, 66±6 years; range, 48-78 years) underwent chest-computed tomography (CT) before and after endobronchial coiling for lung volume reduction (LVR) at our institution between December 2011 and March 2016. Forty-five pulmonary lobes were coiled. We classified the treated lobes into homogenous or heterogeneous emphysema phenotype based on the distribution of voxels showing tissue attenuation of less than -950 HU. Clinical response was defined as an increase or consistency in the walking distance (6MWT) 6 months after LVR-therapy. Lung volume changes were compared for treated, ipsilateral, and contralateral lobes. Additionally, pulmonary function tests (PFT), chronic obstructive pulmonary disease (COPD) assessment test (CAT), and blood gas analysis were performed.

Results

Responder (19/30, 63.3%) showed a significant improvement of 6 MWT from 281.05 to 335.26 (P=0.001). Non-responder (11/30, 36.7%) showed a decrease in 6MWT from 308.18 to 255.45 (P=0.001). Responders showed a significant reduction in CAT test from 23.23 to 20.73 points (P=0.038) and pCO₂ from 42.94 to 40.31 (P=0.001), whereas non-responders showed an increase in pCO₂ (P=0.003; from 44.27 to 47.45). There were no significant changes in PFT-parameters. In responders, there was a significant volume reduction in treated lobes from 1,627.68 to 1,519.21 mL (P=0.009). In responders, treated lobes/non-treated ipsilateral lobes were homogenous (n=11/5) and heterogeneous (n=10/28). In non-responders, treated lobes/non-treated ipsilateral were homogenous (n=5/4) and heterogeneous (n=7/16). In responders and non-responders, the emphysema phenotype in treated, ipsilateral non-treated and even contralateral lobes (P=0.250) did not differ and or change significantly before and after therapy. Only the volume of treated lobes in responders changed significantly after coiling.

Conclusions

The emphysema-phenotype in the targeted and non-targeted ipsilateral lobe has no impact on the outcome of endobronchial coiling for LVR and also does not change significantly after treatment, whereas the volume of the treated lobe significantly decreases in responders.

Confocal Laser Endomicroscopy as a Guidance Tool for Transbronchial Lung Cryobiopsies in Interstitial Lung Disorder

BACKGROUND

Transbronchial cryobiopsy (TBCB) of the lung parenchyma is a minimally invasive alternative for surgical lung biopsy in interstitial lung disease (ILD) patients. Drawbacks are the nondiagnostic rate and complication risk of pneumothorax and bleeding. Fluoroscopy is the current guidance tool for TBCB, which is limited by 2D imaging and a radiation dose for the patient. Confocal laser endomicroscopy (CLE) is a high-resolution imaging technique that provides immediate feedback during bronchoscopy about the elastin fiber network of peripheral lung areas. Both the visceral pleura and fibrotic lung areas consist of elastin fibers and are therefore potentially detectable with CLE.

OBJECTIVES

To investigate whether CLE is capable of (1) distinguishing fibrotic from normal alveolar areas and (2) identifying the pleura.

METHODS

In and ex vivo CLE imaging obtained during bronchoscopy was compared with histology of lung biopsies in 14 ILD patients.

RESULTS

CLE imaging of the alveolar compartment was feasible in all patients without adverse events. Based on CLE imaging, key characteristics that influence both diagnostic yield (dense fibrotic areas) and complication rate (pleura and subpleural space) were visualized.

CONCLUSIONS

CLE seems a promising alternative to fluoroscopy as a guidance tool for TBCB procedures.

Transbronchial Lung Cryobiopsy in Interstitial Lung Diseases: Best Practice

The lung biopsy in interstitial lung disease (ILD) represents an important diagnostic step when the clinical and radiological data are insufficient for a firm diagnosis. A growing body of evidence suggests the utility of transbronchial lung cryobiopsy (TBLC) in the diagnostic algorithm of ILD as it allows, compared to transbronchial lung biopsy with conventional forceps, a better identification of complex histological patterns - such as usual interstitial pneumonia - and can provide information which has a clinical impact on the multidisciplinary discussion similar to that provided by surgical lung biopsy. Performed correctly, it appears to have a better safety profile than surgery. The decision to perform a lung biopsy should be a multidisciplinary decision process where it is felt that there is sufficient diagnostic doubt after a careful clinical evaluation including review of the computed tomograms of the thorax. The presence of severe pulmonary hypertension (> 50 mm Hg), poor lung function (FVC < 50%), or dismissed gas transfer (DLCO of < 35%) are considered relative contraindications for TBLC. Anticoagulants and antiplatelet drugs should be discontinued for the minimum period required for the specific drugs. The greatest consideration should be given to ensure the biopsy is performed safely and we recommend the use of either an endotracheal tube or rigid bronchoscopy. Deep sedation or general anesthesia allow better control of the procedure and a better patient experience. Prophylactic balloon blockers should be used to tamponade any bleeding and also to prevent overspill of blood from the segment that is being sampled. The procedure should be performed under fluoroscopy to ensure that samples are ideally obtained about 10 mm from the pleural edge. The cryoprobe is activated for about 5 s for the first biopsy and then adjusted according to the sample size obtained. With a careful standardized approach it is possible to obtain good-quality lung specimens for diagnosis in a safe manner.

Results of quantitative chest-CT in chronic pulmonary graft-vs.-host disease (cGvHD) 3 years after allogeneic stem cell transplantation

BACKGROUND

To quantify lung parenchymal changes in symptomatic patients with chronic pulmonary graft-versus-host disease 3 years after allogeneic stem cell transplantation (allo-SCT) by means of CT-densitometry (CTD) and to compare results with those of established pulmonary function tests (PFT).

METHODS

The study group consisted of 26 patients with pulmonary cGvHD (19 males, 7 females; mean age, 49.29±15.89; range, 19-72 years). The diagnosis was based on clinical symptoms, PFT and chest-CT findings. CTD and PFT were performed both in the pre- and post-transplantation setting and results compared with each other. CT scans were obtained during suspended deep inspiration including the whole lungs. The mean lung attenuation (MLD), low attenuation values (LAV) and distribution of focal parenchymal abnormalities compatible with emphysema (HU <-950) were quantitatively calculated with histograms and graphics. On PFT, total lung capacity (TLC), residual volume (RV), vital capacity (VC), forced expiratory volume in 1 s (FEV1s) and diffusion capacity for carbon monoxide (DLCOSB) were registered.

RESULTS

Changes in end-inspiratory lung volume and density (MLD and LAV) in symptomatic cGvHD patients in mean three years after allo-SCT proved all not significant, but there was a clear trend towards an increase in lung volume and a decrease in lung attenuation. These results were similar throughout all classes of bronchiolitis obliterans (BO) by cGvHD. PFT showed a significant decrease in VC, FEV1s but only a minimal decrease in DLCOSB. Changes in FVC after stem cell transplantation correlated with changes in LAV (r=0.649, P=0.031). Predicted VC correlated with changes in LAV (r=0.771, P=0.005). There was a correlation between the absolute difference of FEV1 and DLCOSB (r=0.64, P=0.14) before and after stem cell transplantation.

CONCLUSIONS

End-inspiratory phase CT lung parenchyma quantification in symptomatic patients with pulmonary cGvHD 3 years after allo-SCT shows discrete changes over the pre-transplantation setting representing airway obstruction, mirroring airflow limitation on PFT. Its use enables exclusion of relevant parenchymal destruction (emphysema-equivalent lung density) at this time.

Phase Locking the Spin Precession in a Storage Ring

This Letter reports the successful use of feedback from a spin polarization measurement to the revolution frequency of a 0.97  GeV/c bunched and polarized deuteron beam in the Cooler Synchrotron (COSY) storage ring in order to control both the precession rate (≈121  kHz) and the phase of the horizontal polarization component. Real time synchronization with a radio frequency (rf) solenoid made possible the rotation of the polarization out of the horizontal plane, yielding a demonstration of the feedback method to manipulate the polarization. In particular, the rotation rate shows a sinusoidal function of the horizontal polarization phase (relative to the rf solenoid), which was controlled to within a 1 standard deviation range of σ=0.21  rad. The minimum possible adjustment was 3.7 mHz out of a revolution frequency of 753 kHz, which changes the precession rate by 26  mrad/s. Such a capability meets a requirement for the use of storage rings to look for an intrinsic electric dipole moment of charged particles.

Segmental bronchi collapsibility: computed tomography-based quantification in patients with chronic obstructive pulmonary disease and correlation with emphysema phenotype, corresponding lung volume changes and clinical parameters

BACKGROUND

Global pulmonary function tests lack region specific differentiation that might influence therapy in severe chronic obstructive pulmonary disease (COPD) patients. Therefore, the aim of this work was to assess the degree of expiratory 3^rd generation bronchial lumen collapsibility in patients with severe COPD using chest-computed tomography (CT), to evaluate emphysema-phenotype, lobar volumes and correlate results with pulmonary function tests.

METHODS

Thin-slice chest-CTs acquired at end-inspiration & end-expiration in 42 COPD GOLD IV patients (19 females, median-age: 65.9 y) from November 2011 to July 2014 were re-evaluated. The cross-sectional area of all segmental bronchi was measured 5 mm below the bronchial origin in both examinations. Lung lobes were semi-automatically segmented, volumes calculated at end-inspiratory and end-expiratory phase and visually defined emphysema-phenotypes defined. Results of CT densitometry were compared with lung functional tests including forced expiratory volume at 1 s (FEV₁), total lung capacity (TLC), vital capacity (VC), residual volume (RV), diffusion capacity parameters and the maximal expiratory flow rates (MEFs).

RESULTS

Mean expiratory bronchial collapse was 31%, stronger in lobes with homogenous (38.5%) vs. heterogeneous emphysema-phenotype (27.8%, P=0.014). The mean lobar expiratory volume reduction was comparable in both emphysema-phenotypes (volume reduction 18.6%±8.3% in homogenous vs. 17.6%±16.5% in heterogeneous phenotype). The degree of bronchial lumen collapsibility, did not correlate with expiratory volume reduction. MEF₂₅ correlated weakly with 3^rd generation airway collapsibility (r=0.339, P=0.03). All patients showed a concentric expiratory reduction of bronchial cross-sectional area.

CONCLUSIONS

Changes in collapsibility of 3^rd generation bronchi in COPD grade IV patients is significantly lower than that in the trachea and the main bronchi. Collapsibility did not correlate with the reduction in lung volume but was significantly higher in lobes with homogeneous vs. heterogeneous emphysema phenotype. Changes in the 3^rd generation bronchial calibres between inspiration and expiration are not predictive for the degree of small airway collapsibility and related airflow limitation.

Bronchial Artery Embolization in Hemoptysis: 10-Year Survival and Recurrence-Free Survival in Benign and Malignant Etiologies - A Retrospective Study

Purpose: The aim of the study was to evaluate safety, effectiveness, recurrence rate and 10-year survival after bronchial artery embolization (BAE) in benign and malignant etiologies. Methods: The retrospective study includes 100 BAE procedures in 88 patients. Underlying disease was classified as benign (n = 67) and malignant (n = 21) etiologies. Immediate bleeding control and procedure safety were evaluated in all patients. In 51 (58 %) patients, follow-up data with a median follow-up time of 1015 days (range, 494 to 3727 days) were acquired to assess overall survival, time-to-recurrence of bleeding and recurrence-free survival, using Kaplan-Maier estimates to compare differences between both subgroups. Results: Immediate bleeding control was achieved after 96/100 procedures (96 %), with a minor complication rate of 5.0 %. No major complications occurred. The overall survival was 74 % after 1 year and 59 % after 5 years and 10 years. There was a significant difference in survival between the malignant and benign groups (p < 0.0001). Survival was 90 %, 80 % and 76 % at 1 year, 3 years and 10 years, respectively, in the benign group and 18 % and 0 % at 1 year and 3 years, respectively in the malignant group. The median time to recurrence of bleeding and recurrence-free survival were 239 days and 94 % after 1 year and 87 % after 10 years in the benign group, compared to 66 days and 34 % after 1 year and 0 % after 3 years in the malignant group (p = 0.0107). Conclusion: BAE is a safe and highly effective treatment option in hemoptysis. However, the recurrence rate and survival are highly dependent on the underlying disease. Key Points: • BAE is a safe and highly effective treatment option in hemoptysis.• Recurrence rate and survival are strongly dependent on the underlying disease with significantly impaired results in patients with malignant diseases. • Coil embolization is an effective BAE treatment method. Nevertheless, it should be mentioned, that reinterventions can be impeded, if embolization is performed in the proximal part of bronchial arteries. Citation Format: • Syha R, Benz T, Hetzel J et al. Bronchial Artery Embolization in Hemoptysis: 10-Year Survival and Recurrence-Free Survival in Benign and Malignant Etiologies - A Retrospective Study. Fortschr Röntgenstr 2016; 188: 1061 - 1066.

How to Reach a Thousand-Second in-Plane Polarization Lifetime with 0.97-GeV/c Deuterons in a Storage Ring

We observe a deuteron beam polarization lifetime near 1000 s in the horizontal plane of a magnetic storage ring (COSY). This long spin coherence time is maintained through a combination of beam bunching, electron cooling, sextupole field corrections, and the suppression of collective effects through beam current limits. This record lifetime is required for a storage ring search for an intrinsic electric dipole moment on the deuteron at a statistical sensitivity level approaching 10^{-29}  e cm.

A New Tool for Transbronchial Cryobiopsies in the Lung: An Experimental Feasibility ex vivo Study

BACKGROUND

Transbronchial cryobiopsy (TBCB) is a minimally invasive procedure to establish a diagnosis of interstitial lung disease though with the disadvantage that samples have to be extracted together with the bronchoscope.

OBJECTIVES

The aim of the present study was to evaluate the feasibility of a new cryoprobe with which biopsy samples can be obtained through the working channel of the flexible bronchoscope.

METHODS

The feasibility of obtaining transbronchial specimens with TBCB was tested and the technique was compared to transbronchial forceps biopsy (TBFB) in a prospectively randomized ex vivo animal study using a standard flexible bronchoscopy technique. The rate of successful biopsies and the duration of the sampling procedure were recorded for both methods. Size and quality of the biopsies were histologically evaluated and measured.

RESULTS

Biopsy samples could be obtained in 93.3% of TBCB and in 79.0% of TBFB procedures (p = 0.182). Sampling procedure time did not differ in any clinically relevant manner between the two methods. The mean specimen area of TBCB samples was significantly higher compared to that of TBFB samples (8.08 ± 5.80 vs. 2.61 ± 2.14 mm2; p < 0.0001). TBCB specimens showed less artifacts and a significantly higher percentage of alveolar tissue (53.57 vs. 25.42%; p = 0.0285) than TBFB specimens.

CONCLUSIONS

It is feasible to retrieve TBCB samples of good quality and size with the new mini cryoprobe through the working channel of the bronchoscope, while the bronchoscope remains within the central airways throughout the whole procedure. Further studies are necessary to evaluate the safety and efficacy in an in vivo setting.

Cross-Sectional Survey on Bronchoscopy in Germany--The Current Status of Clinical Practice

OBJECTIVES

Bronchoscopy is an integral part of pulmonary medicine. In recent years, a series of new technologies have evolved. It is to assume that significant changes have also occurred in clinical practice. We conducted a nationwide survey to evaluate the current status of care and to compare it with earlier reports.

METHODS

A standard questionnaire was sent to 1875 institutions to assess the clinical practice of bronchoscopy in Germany with respect to general issues, education, sedation/anaesthesia and technical aspects.

RESULTS

The returned questionnaires cover 301,965 bronchoscopies, performed by 2158 physicians over 12 months, making it the largest survey to date. The proportion of rigid bronchoscopies has decreased and amounts to 7.3% at present. Atropine as a premedication is hardly used any more. Sedation is routinely applied in 88% of flexible bronchoscopies, for which a combination of propofol and midazolam is preferred by most institutions (41.3%), followed by propofol monotherapy (28.3%). 74.4% of institutions accept aspirin for transbronchial biopsy, 8.1% dual platelet inhibition. 62.4% of all institutions perform airway recanalisation, favouring cryotherapy and argon plasma coagulation. 9.1% of bronchoscopies are supported by endobronchial ultrasound.

CONCLUSION

Compared to preceding surveys, the experience of bronchoscopists, especially regarding interventional procedures, has increased. Endobronchial ultrasound has become a standard of care, as has patient sedation with propofol.

New Method for a Continuous Determination of the Spin Tune in Storage Rings and Implications for Precision Experiments

A new method to determine the spin tune is described and tested. In an ideal planar magnetic ring, the spin tune-defined as the number of spin precessions per turn-is given by ν(s)=γG (γ is the Lorentz factor, G the gyromagnetic anomaly). At 970  MeV/c, the deuteron spins coherently precess at a frequency of ≈120  kHz in the Cooler Synchrotron COSY. The spin tune is deduced from the up-down asymmetry of deuteron-carbon scattering. In a time interval of 2.6 s, the spin tune was determined with a precision of the order 10^{-8}, and to 1×10^{-10} for a continuous 100 s accelerator cycle. This renders the presented method a new precision tool for accelerator physics; controlling the spin motion of particles to high precision is mandatory, in particular, for the measurement of electric dipole moments of charged particles in a storage ring.

Nasal high-flow oxygen therapy in patients with hypoxic respiratory failure: effect on functional and subjective respiratory parameters compared to conventional oxygen therapy and non-invasive ventilation (NIV)

Background

Aim of the study was to compare the short-term effects of oxygen therapy via a high-flow nasal cannula (HFNC) on functional and subjective respiratory parameters in patients with acute hypoxic respiratory failure in comparison to non-invasive ventilation (NIV) and standard treatment via a Venturi mask.

Methods

Fourteen patients with acute hypoxic respiratory failure were treated with HFNC (FiO₂ 0.6, gas flow 55 l/min), NIV (FiO₂ 0.6, PEEP 5 cm H₂O Hg, tidal volume 6–8 ml/kg ideal body weight,) and Venturi mask (FiO₂ 0.6, oxygen flow 15 l/min,) in a randomized order for 30 min each. Data collection included objective respiratory and circulatory parameters as well as a subjective rating of dyspnea and discomfort by the patients on a 10-point scale. In a final interview, all three methods were comparatively evaluated by each patient using a scale from 1 (=very good) to 6 (=failed) and the patients were asked to choose one method for further treatment.

Results

PaO₂ was highest under NIV (129 ± 38 mmHg) compared to HFNC (101 ± 34 mmHg, p <0.01 vs. NIV) and VM (85 ± 21 mmHg, p <0.001 vs. NIV, p <0.01 vs. HFNC, ANOVA). All other functional parameters showed no relevant differences. In contrast, dyspnea was significantly better using a HFNC (2.9 ± 2.1, 10-point Borg scale) compared to NIV (5.0 ± 3.3, p <0.05), whereas dyspnea rating under HFNC and VM (3.3 ± 2.3) was not significantly different. A similar pattern was found when patients rated their overall discomfort on the 10 point scale: HFNC 2.7 ± 1.8, VM 3.1 ± 2.8 (ns vs. HFNC), NIV 5.4 ± 3.1 (p <0.05 vs. HFNC). In the final evaluation patients gave the best ratings to HFNC 2.3 ± 1.4, followed by VM 3.2 ± 1.7 (ns vs. HFNC) and NIV 4.5 ± 1.7 (p <0.01 vs. HFNC and p <0.05 vs. VM). For further treatment 10 patients chose HFNC, three VM and one NIV.

Conclusions

In hypoxic respiratory failure HFNC offers a good balance between oxygenation and comfort compared to NIV and Venturi mask and seems to be well tolerated by patients.

Trial registration

German clinical trials register: DRKS00005132.

Diagnostic yield of transbronchial cryobiopsy in interstitial lung disease: a randomized trial

BACKGROUND AND OBJECTIVE

Transbronchial lung biopsy (TBLB) is required for evaluation in selected patients with interstitial lung disease (ILD). The diagnostic yield of histopathologic assessment is variable and is influenced by factors such as the size of samples and the presence of crush artefacts left by conventional biopsy forceps. We compared the diagnostic yield and safety of TBLB with cryoprobe sampling versus conventional forceps sampling.

METHODS

This randomized clinical trial analysed data for 77 patients undergoing TBLB for evaluation of ILD; patients were assigned to either a conventional-forceps group or a cryoprobe group. Two pathologists assessed the tissue samples and agreed on histopathologic diagnoses. We also compared the duration of procedures, complications and sample-quality variables.

RESULTS

The most frequent diagnosis observed in the cryoprobe group was non-specific interstitial pneumonia. Histopathologic diagnoses were identified in more cases in the cryoprobe group (74.4%) than in the conventional-forceps group (34.1%) (P < 0.001), and the diagnostic yield was higher in the cryoprobe group (51.3% vs 29.1% in the conventional forceps group; P = 0.038). A larger mean area of tissue was harvested by cryoprobe (14.7 ± 11 mm(2) ) than by conventional forceps (3.3 ± 4.1 mm(2)) (P < 0.001). More grade 2 bleeding (not statistically significant) occurred in the cryoprobe group (56.4%) than in the conventional-forceps group (34.2%). No differences in other complications were observed.

CONCLUSIONS

TBLB by cryoprobe is safe and potentially useful in the diagnosis of ILD. Larger multisite randomized trials are required to confirm the potential benefits of this procedure. Clinical trial registration at ClinicalTrials.gov: NCT01064609.

Does volume perfusion computed tomography enable differentiation of metastatic and non-metastatic mediastinal lymph nodes in lung cancer patients? A feasibility study

OBJECTIVES

To compare the perfusion characteristics of mediastinal lymph node metastases with those of non-metastatic nodes in patients with newly diagnosed lung cancer using volume perfusion computed tomography (VPCT).

MATERIALS AND METHODS

Between January 2010 and October 2011, 101 patients with histologically confirmed, untreated lung cancer received a 40-s VPCT of the tumor bulk; 32/101 patients had evident hilar/mediastinal metastatic disease and 17/101 patients had proven non-metastasized lymph nodes within the VPCT scan range. Validation or exclusion of metastatic node involvement was proven by mediastinoscopy, biopsy, positron emission tomography imaging and/or unequivocal volume dynamics on follow-up computed tomography. A total of 45 metastases and 23 non-metastatic lymph nodes were found within the scan range and subsequently evaluated. Blood flow (BF), blood volume (BV) and K(trans) were determined. Tumor volume was recorded as whole tumor volume.

RESULTS

In a comparison between metastatic and non-metastatic lymph nodes, we controlled for age, lymph node volume, lung tumor volume, lung tumor location, and histologic type effects and found no significant differences with respect to BF, BV, K(trans) or heterogeneity in nodal perfusion (P > 0.05, respectively), even after adjusting lymph node perfusion values to the perfusion parameters of the primary tumor (P > 0.05, respectively). Metastatic lymph node volume had a significant increasing effect on perfusion heterogeneity (P < 0.05, respectively) and BV in the primary was a highly significant factor for BV in metastatic disease (P < 0.001).

CONCLUSION

Perfusion characteristics of mediastinal metastatic and non-metastatic lymph nodes in untreated lung cancer show considerable overlap, so that a reliable differentiation via VPCT is not possible.