Efficacy of Radial Endobronchial Ultrasound (R-EBUS) guided transbronchial cryobiopsy for peripheral pulmonary lesions (PPL...s): A systematic review and meta-analysis

BACKGROUND

Transbronchial lung cryobiopsy (TBLC) is frequently described for the diagnosis of diffuse parenchymal lung diseases (DPLD). A few studies have reported transbronchial cryobiopsy for the diagnosis of peripheral pulmonary lesions (PPL...s). We aimed to study the utility and safety of transbronchial cryobiopsy for the diagnosis of PPL...s.

METHODS

We performed a systematic search of the PubMed and Embase databases to extract the relevant studies. We then performed a meta-analysis to calculate the diagnostic yields of transbronchial cryobiopsy and bronchoscopic forceps biopsy.

RESULTS

Following a systematic search, we identified nine relevant studies (300 patients undergoing cryobiopsy). All used Radial Endobronchial Ultrasound (R-EBUS) for PPL localization. The pooled diagnostic yield of transbronchial cryobiopsy was 77% (95% CI, 71%...84%) (I^2=38.72%, p=0.11). The diagnostic yield of forceps biopsy was 72% (95% CI, 60%...83%) (I^2=78.56%, p<0.01). The diagnostic yield of cryobiopsy and forceps biopsy was similar (RR 1.05, 95% CI 0.96...1.15), with a 5% risk difference for diagnostic yield (95% CI, ...6% to 15%). There was significant heterogeneity (I^2=57.2%, p=0.017), and no significant publication bias. One severe bleeding and three pneumothoraxes requiring intercostal drain (ICD) placement (major complication rate 4/122, 1.8%) were reported with transbronchial cryobiopsy.

CONCLUSIONS

R-EBUS guided transbronchial cryobiopsy is a safe and efficacious modality. The diagnostic yields of TBLC and forceps biopsy are similar. More extensive multicentre randomized trials are required for the further evaluation and standardization of transbronchial cryobiopsy for PPL...s.

Clinical Profile of 327 patients with Sarcoidosis in India: An Ambispective Cohort Study in a Tuberculosis (TB) Endemic Population

Introduction:

Sarcoidosis is a multisystem granulomatous disease with a varied clinical presentation. We describe the clinical characteristics of patients with sarcoidosis from a tuberculosis (TB) endemic setting.

Methods:

We performed an analysis of the sarcoidosis database at a tertiary care facility in North India.

Results:

Of the 327 patients, 50.8% were male, with a mean age of 42.8 years (range: 16–70 years). Females were significantly older. 42.6% had comorbidities, of which diabetes (17.1%) was most common. More than half (57.1%) were obese. Serum angiotensin-converting enzyme levels were elevated in 186 (57.9%). Eleven (3.8%) had hypercalcemia, while hypercalciuria was present in 54 (31.7%). The majority (89.9%) were tuberculin skin test negative (<10 mm induration), while 71.9% were tuberculin anergic. 47.7% had normal spirometry, while a restrictive impairment was the most common abnormality (44.6%). Obstruction on spirometry was present in 8.3%. Nearly half (160, 49%) had involvement of an extrapulmonary site. Most patients were (96%) symptomatic. Cough, shortness of breath, fatigue, weight loss, and fever were the predominant symptoms. A majority had Stage 1 (47.7%) sarcoidosis. Two hundred and eighty-seven (87.8%) patients underwent bronchoscopy or endosonographic (endobronchial ultrasound-guided transbronchial needle aspiration [EBUS-TBNA] or transesophageal bronchoscopic ultrasound-guided fine-needle aspiration [EUS-B-FNA]) sampling. A histopathological diagnosis with the demonstration of granulomas was achieved in 90.8%. The diagnostic yield of EBUS-TBNA/EUS-B-FNA was 77.4%. In 13.5% of patients, necrotizing granulomas were present in tissue samples.

Conclusion:

The clinical profile of patients with sarcoidosis in TB endemic settings has certain differences from nonendemic populations. Bronchoscopy and endosonography allow a confident diagnosis in the majority of patients.

Mediastinal lymphadenopathy: a practical approach

Introduction: Mediastinal lymphadenopathy is secondary to various benign and malignant etiologies. There is a variation in the underlying cause in different demographic settings. The initial clue to the presence of enlarged mediastinal lymph nodes is through thoracic imaging modalities. Malignancy (Lung cancer, lymphoma, and extrathoracic cancer) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes. For a confident diagnosis, the clinician must choose from several available options and integrate the clinical, radiological, and pathology findings. An accurate diagnosis is necessary for optimal management.Areas covered: We performed a search of the PUBMED database to identify relevant articles on the causes, imaging modalities, and interventional modalities to diagnose these conditions. We discuss a practical approach toward the evaluation of a patient with mediastinal lymphadenopathy.Expert opinion: Mediastinal lymphadenopathy is a commonly encountered clinical problem. Treating physicians need to be aware of the clinico-radiological manifestations of the common diagnostic entities. Selecting an appropriate tissue diagnosis modality is crucial, with an intent to use the least invasive technique with good diagnostic yield. Endosonographic modalities (EBUS-TBNA, EUS-FNA, and EUS-B-FNA) have emerged as the cornerstone to most patients' diagnosis. An accurate diagnosis translates into favorable treatment outcomes.

Topical nasal xylometazoline for flexible bronchoscopy (VAIN): A randomized, double-blind, placebo-controlled trial

BACKGROUND

The role of topical nasal vasoconstrictor administration during flexible bronchoscopy is unclear.

METHODS

Consecutive subjects undergoing flexible bronchoscopy were randomized to receive either topical xylometazoline (0.1%) or placebo (saline nasal spray, 0.74% w/v isotonic solution) before bronchoscopy. Background topical anesthesia included 2% nasal lignocaine gel, pharyngeal spray of 10% lignocaine, and 1% lignocaine solution for spray-as-you-go administration. The primary outcome was the operator rated ease of nasal negotiation of the bronchoscope on the visual analog scale (Negotiation VAS). Secondary objectives included assistant rated facial pain scale score, patient-rated nasal pain score (Pain VAS), time to reach the vocal cords after bronchoscope insertion, operator rated nasal mucosal trauma score (Trauma VAS), hemodynamic changes, and complications between the groups.

RESULTS

In all, 148 subjects were recruited and randomized to the placebo (73) and xylometazoline groups (75). Operator rated ease of nasal bronchoscope negotiation (Negotiation VAS) was similar in both the groups [Median (IQR), 1 (1-2) in both groups, p = 0.79]. There were no differences in the other outcomes including assistant rated score of facial pain [(Median (IQR), 2 (2-4) placebo and 2 (2-4) xylometazoline, p = 0.36], Pain VAS [Median (IQR), placebo 2 (1-2) and xylometazoline 2 (1-3), p = 0.28], Trauma VAS, [Median (IQR), placebo 1 (0-2) and xylometazoline 1 (0-1), p = 0.28], hemodynamic changes, or complications between the two groups.

CONCLUSION

The findings of this study do not support the administration of topical nasal xylometazoline in flexible bronchoscopy.

TRIAL REGISTRY

Trial registered on Clinicaltrials.gov, www.clinicaltrials.govNCT03424889, on January 02, 2018.

Effect of proning in patients with COVID-19 acute hypoxemic respiratory failure receiving noninvasive oxygen therapy

Background:

Novel coronavirus (SARS-CoV-2) infection is associated with hypoxemic respiratory failure. Mechanical ventilation (MV) is reported to have high mortality in SARS-CoV-2 acute respiratory distress syndrome. We aimed to investigate whether awake prone positioning (PP) can improve oxygenation and prevent intubation when employed early.

Methods:

This prospective interventional study included proven coronavirus disease 2019 (COVID-19) patients with room air saturation 93% or less. The primary outcome was the rate of intubation between the two groups. The secondary outcomes included ROX index (SpO₂/FiO₂%/respiratory rate, breaths/min) at 30 min following the intervention, ROX index at 12 h, time to recovery of hypoxemia, and mortality.

Results:

A total of 45 subjects were included (30 cases and 15 controls) with a mean (standard deviation [SD]) age of 53.1 (11.0) years. The age, comorbidities, and baseline ROX index were similar between the two groups. The median duration of PP achieved was 7.5 h on the 1^st day. The need for MV was higher in the control group (5/15; 33.3%) versus prone group (2/30; 6.7%). At 30 min, there was a statistically significant improvement in the mean (SD) ROX index of cases compared with that of the controls (10.7 [3.8] vs. 6.7 [2.6], P < 0.001). No significant adverse effects related to intervention were noted.

Conclusion:

Awake PP is associated with significant improvement in oxygenation and may reduce the need for MV in subjects with COVID-19.

MicroRNAs in pulmonary sarcoidosis: A systematic review

Sarcoidosis is a multisystemic granulomatous disorder of unknown etiology. Diagnosis of sarcoidosis is made by correlating clinical and radiological features along with the histopathological demonstration of non-necrotizing granulomas in tissue samples. Diagnosis is often challenging as the clinical profile may mimic other granulomatous disorders, including infections, inflammatory diseases, and lymphoid malignancies. Differentiation from tuberculosis is especially crucial in endemic regions where exclusion of mediastinal tuberculosis is necessary before any immunosuppressant treatment can be initiated for symptomatic sarcoidosis. Identification of biomarkers, which can aid in diagnosis as well as prognosis, can be helpful in clinical decision making. MicroRNAs are small non-coding regulatory RNAs that serve as post-transcriptional regulators of gene expression and have been studied as emerging biomarkers in many other respiratory diseases, including lung cancer, asthma, idiopathic pulmonary fibrosis, and chronic obstructive pulmonary disease. In the context of sarcoidosis, miRNA expression has been studied in the lungs, lymph nodes, bronchoalveolar lavage fluid, and peripheral blood mononuclear cells. A comprehensive search of the PubMed database was performed by two authors independently, and relevant studies were retrieved for review. This systematic review summarizes the current information on miRNAs in sarcoidosis, the biological mechanisms involved in CD4⁺ T-helper 1 and macrophage polarization, and the use of exhaled breath condensate as an alternative, noninvasive and potential source of miRNAs.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Tricky typhus ticks two: A report of two sisters from North India presenting with acute respiratory distress syndrome due to scrub typhus

Scrub typhus is emerging as an important cause of acute febrile illness in Northern India. This is a report of two sisters presenting concurrently with acute respiratory distress syndrome. A diagnosis of scrub typhus was made in both the patients, and they were successfully treated with doxycycline.