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Alshabani K, Rivera E, Paton A, Lara JC, Fernandez-Bussy S, Majid A. Pleural Port-A-Cath for Symptomatic Refractory Hepatic Hydrothorax in Nontransplant Liver Patients. Ann Am Thorac Soc 2024; 21:823-826. [PMID: 38691004 DOI: 10.1513/annalsats.202306-580cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 12/08/2023] [Indexed: 05/03/2024] Open
Affiliation(s)
- Khaled Alshabani
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Estefania Rivera
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Alichia Paton
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Juan Camilo Lara
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | | | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
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Fernandez-Bussy S, Garza-Salas A, Barrios-Ruiz A, Balasubramanian P, Yu Lee-Mateus A, Koirala T, Hazelett BN, Chadha R, Patel NM, Reisenauer JS, Abia-Trujillo D. Shape-Sensing Robotic-Assisted Bronchoscopy in the Multiple Pulmonary Nodules Diagnosis During a Single Anesthetic Event. Respiration 2024:000538910. [PMID: 38648757 DOI: 10.1159/000538910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 04/10/2024] [Indexed: 04/25/2024] Open
Abstract
INTRODUCTION The widespread use of Computed tomography (CT) as a screening tool for early lung cancer has increased detection of pulmonary lesions. It is common to encounter patients with more than one peripheral pulmonary nodule (PPN) of uncertain etiology. Shape-sensing robotic-assisted bronchoscopy (ssRAB) emerges as a potential alternative to biopsy multiple PPN, in addition to mediastinal staging in single anesthetic procedure. METHODS Retrospective review of 22 patients who underwent ssRAB for evaluation of two or more PPN, between November 2021 and April 2023 at Mayo Clinic Florida, US. RESULTS A total of 46 PPN were biopsied in 22 patients. All lesions were ≤ 2 cm with a maximum and minimum median lesion size of 1.40cm and 1.05cm, respectively. Diagnostic yield was 84.8% (n=39) and target reach was 91.3% (n=42). Most lesions were in the upper lobes, a solid pattern was found in 78.3% (n=36), bronchus sign was present in 82.6% of cases (n=38), 54.4% (n=25) were malignant nodules, and 30.4% (n=14) were benign. Fourteen patients had one malignant lesion out of two or more nodules sampled and ten patients had a malignant diagnosis for all sampled lesions. The complication rate was 9% (n=2) and pneumothorax rate was 4.5% (n=1). CONCLUSION This study is, to our knowledge, the first to assess the use and safety of ssRAB for diagnosis of multiple PPN in a single anesthetic event. This procedure will mainly impact management decisions and subsequently shorten the time from diagnosis to treatment.
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Koratala A, Chandra NC, Balasubramanian P, Yu Lee-Mateus A, Barrios-Ruiz A, Garza-Salas A, Bowman A, Grage R, Fernandez-Bussy S, Abia-Trujillo D. Diagnostic Accuracy of a Computed Tomography-Guided Transthoracic Needle Biopsy for Ground-Glass Opacities and Subsolid Pulmonary Nodules. Cureus 2024; 16:e57414. [PMID: 38694634 PMCID: PMC11061815 DOI: 10.7759/cureus.57414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2024] [Indexed: 05/04/2024] Open
Abstract
Purpose The increasing use of computed tomography (CT) imaging has led to the detection of more ground-glass nodules (GGNs) and subsolid nodules (SSNs), which may be malignant and require a biopsy for proper diagnosis. Approximately 75% of persistent GGNs can be attributed to adenocarcinoma in situ or minimally invasive adenocarcinoma. A CT-guided biopsy has been proven to be a reliable procedure with high diagnostic performance. However, the diagnostic accuracy and safety of a CT-guided biopsy for GGNs and SSNs with solid components ≤6 mm are still uncertain. The aim of this study is to assess the diagnostic accuracy of a CT-guided core needle biopsy (CNB) for GGN and SSNs with solid components ≤6 mm. Methods This is a retrospective study of patients who underwent CT-guided CNB for the evaluation of GGNs and SSNs with solid components ≤6 mm between February 2020 and January 2023. Biopsy findings were compared to the final diagnosis determined by definite histopathologic examination and clinical course. Results A total of 22 patients were enrolled, with a median age of 74 years (IQR: 68-81). A total of 22 nodules were assessed, comprising 15 (68.2%) SSNs with a solid component measuring ≤6 mm and seven (31.8%) pure GGNs. The histopathological examination revealed that 12 (54.5%) were diagnosed as malignant, nine (40.9%) as benign, and one (4.5%) as non-diagnostic. The overall diagnostic accuracy and sensitivity for malignancy were 86.36% and 85.7%, respectively. Conclusion A CT-guided CNB for GGNs and SSNs with solid components measuring ≤6 mm appears to have a high diagnostic accuracy.
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Affiliation(s)
- Anoop Koratala
- Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, USA
| | - Nikitha C Chandra
- Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, USA
| | | | | | | | - Ana Garza-Salas
- Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, USA
| | | | - Rolf Grage
- Radiology, Mayo Clinic, Jacksonville, USA
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Abia-Trujillo D, Folch EE, Yu Lee-Mateus A, Balasubramanian P, Kheir F, Keyes CM, Villalobos R, Chadha RM, Hazelett BN, Fernandez-Bussy S. Mobile cone-beam computed tomography complementing shape-sensing robotic-assisted bronchoscopy in the small pulmonary nodule sampling: A multicentre experience. Respirology 2024; 29:324-332. [PMID: 38016646 DOI: 10.1111/resp.14626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/12/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND AND OBJECTIVE Shape-sensing robotic-assisted bronchoscopy (ssRAB) has expanded as an important diagnostic tool for peripheral pulmonary nodules (PPNs), with diagnostic yields ranging from 60% to 88%. However, sampling and diagnosing PPN less than 2 cm in size has historically been challenging. Mobile cone-beam computed tomography (mCBCT) has been recently integrated into ssRAB to improve diagnostic accuracy, but its added value remains uncertain. We aim to describe the role of mCBCT and determine if it provides any diagnostic advantage. METHODS A multicentre, retrospective study on the use of ssRAB and mCBCT in two tertiary care institutions: Mayo Clinic Florida and Massachusetts General Hospital. The primary outcome was diagnostic yield and sensitivity for malignancy of ssRAB complemented with mCBCT, compared to ssRAB with the standard 2D fluoroscopy. RESULTS A total of 192 nodules were biopsied from 173 patients. mCBCT was used in 117 (60.9%) nodules. The overall diagnostic yield was 85.4%. Diagnostic yield between subgroups with and without mCBCT was 83.8% and 88% (p = 0.417), respectively. The mCBCT group had fewer solid nodules (65.8% vs. 81.3%, p = 0.020) and a higher number of ground-glass nodules (10.3% vs. 1.3%, p = 0.016). CONCLUSION Overall, diagnostic yield between subgroups with and without mCBCT was similar. The complementary use of mCBCT to ssRAB allows proceduralists to target more complex and subsolid PPNs with a diagnostic yield comparable to simple solid PPNs while maintaining an excellent safety profile.
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Affiliation(s)
- David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Erik E Folch
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Fayez Kheir
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Colleen M Keyes
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Regina Villalobos
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ryan M Chadha
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Britney N Hazelett
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Balavenkataraman A, Garza Salas A, Barrios Ruiz A, Balasubramanian P, Fernandez-Bussy S, Abia Trujillo D. Early Pneumatocele Identification Post-Robotic Assisted Bronchoscopy Cryobiopsy: A Case Series Experience. Respiration 2024; 103:275-279. [PMID: 38471472 DOI: 10.1159/000538272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/29/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION The use of cryobiopsy in conjunction with robotic assisted bronchoscopy is on the rise due to the safety and increased diagnostic yield of cryobiopsy. The incorporation of 3D fluoroscopy in the procedure improves the workflow and helps confirm the accuracy of sampling of peripheral pulmonary nodules. METHODS We describe an observational series of 12 patients comprising 14 nodules where cryobiopsy was performed during shape-sensing robot-assisted bronchoscopy cryobiopsy under general anesthesia. 3D fluoroscopy was used to confirm accurate placement of the cryoprobe. All these patients underwent a second spin with the 3D fluoroscopy either to sample a second lesion intraoperatively or to investigate suspected pneumothorax. RESULTS The development of a pneumatocele was noted after cryobiopsy in each of the cases. The majority of these were in the upper lobe with the median size of a sampled nodule being 14 mm. The majority of patients were asymptomatic with 1 patient developing mild hemoptysis and 4 patients developing chest tightness or dyspnea. None of the patients required an intervention for the pneumatocele. CONCLUSION The development of pneumatoceles appears to be a fairly frequent and benign occurrence following cryobiopsy, likely due to increased tissue destruction. The increased use of intraoperative 3D fluoroscopy is likely to highlight changes to the pulmonary parenchyma that were previously not known. The occurrence of pneumatoceles does not appear to adversely impact the safety or tolerability profile of cryobiopsy.
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Affiliation(s)
| | - Ana Garza Salas
- Department of Research, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | | | | | | | - David Abia Trujillo
- Division of Pulmonary Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
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Fernandez-Bussy S, Yu Lee-Mateus A, Reisenauer J, Balasubramanian P, Barrios-Ruiz A, Garza-Salas A, Chandra NC, Koratala A, Nadrous A, Edell ES, Bowman AW, Grage RA, Reisenauer CJ, Kurup AN, Patel NM, Chadha R, Hazelett BN, Abia-Trujillo D. Shape-Sensing Robotic-Assisted Bronchoscopy versus Computed Tomography-Guided Transthoracic Biopsy for the Evaluation of Subsolid Pulmonary Nodules. Respiration 2024; 103:280-288. [PMID: 38471496 DOI: 10.1159/000538132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Lung cancer remains the leading cause of cancer death worldwide. Subsolid nodules (SSN), including ground-glass nodules (GGNs) and part-solid nodules (PSNs), are slow-growing but have a higher risk for malignancy. Therefore, timely diagnosis is imperative. Shape-sensing robotic-assisted bronchoscopy (ssRAB) has emerged as reliable diagnostic procedure, but data on SSN and how ssRAB compares to other diagnostic interventions such as CT-guided transthoracic biopsy (CTTB) are scarce. In this study, we compared diagnostic yield of ssRAB versus CTTB for evaluating SSN. METHODS A retrospective study of consecutive patients who underwent either ssRAB or CTTB for evaluating GGN and PSN with a solid component less than 6 mm from February 2020 to April 2023 at Mayo Clinic Florida and Rochester. Clinicodemographic information, nodule characteristics, diagnostic yield, and complications were compared between ssRAB and CTTB. RESULTS A total of 66 nodules from 65 patients were evaluated: 37 PSN and 29 GGN. Median size of PSN solid component was 5 mm (IQR: 4.5, 6). Patients were divided into two groups: 27 in the ssRAB group and 38 in the CTTB group. Diagnostic yield was 85.7% for ssRAB and 89.5% for CTTB (p = 0.646). Sensitivity for malignancy was similar between ssRAB and CTTB (86.4% vs. 88.5%; p = 0.828), with no statistical difference. Complications were more frequent in CTTB with no significant difference (8 vs. 2; p = 0.135). CONCLUSION Diagnostic yield for SSN was similarly high for ssRAB and CTTB, with ssRAB presenting less complications and allowing mediastinal staging within the same procedure.
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Affiliation(s)
| | | | - Janani Reisenauer
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Alanna Barrios-Ruiz
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Ana Garza-Salas
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Nikitha C Chandra
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Anoop Koratala
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Anthony Nadrous
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew W Bowman
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Rolf A Grage
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Anil N Kurup
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Neal M Patel
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan Chadha
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Britney N Hazelett
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Vu LH, Yu Lee-Mateus A, Edell ES, Hartley C, Vierkant RA, Fernandez-Bussy S, Reisenauer J. Accuracy of Preliminary Pathology for Robotic Bronchoscopic Biopsy. Ann Thorac Surg 2023; 116:1028-1034. [PMID: 36470566 DOI: 10.1016/j.athoracsur.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/24/2022] [Accepted: 11/11/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Diagnosis and treatment of peripheral pulmonary lesions (PPLs) currently require at least 2 procedures. An all-in-1 approach would require diagnosing malignancy with preliminary cytology results. This study investigated the concordance between preliminary cytology and final pathology results in biopsies of PPLs obtained by shape-sensing robotic-assisted bronchoscopy (ssRAB). METHODS This study was a retrospective, consecutive, single-arm, single-center study of 110 ssRABs for PPLs. Concordance was defined as agreement between preliminary cytology and final pathology results. Accuracy, sensitivity, specificity, positive and negative predictive values, and safety outcomes were examined. RESULTS The concordance was 89% for needle biopsies, 85% for forceps biopsies, and 92% overall, with substantial agreement. There was no significant association of concordance with patients' demographics or lesion characteristics. Preliminary cytology resulted in a malignant diagnosis in 70%, a nonmalignant diagnosis in 4%, and a nondiagnostic result in 26%, with accuracy of 86% and sensitivity of 84%. The total complication rate was 3.6%, with a pneumothorax rate of 1.8%. CONCLUSIONS This study compared the concordance of preliminary pathology results with final pathology results for ssRAB biopsies in PPLs. The results showed that preliminary samples have a high concordance with final pathology results and may enable management of PPLs with a single anesthetic procedure including biopsy, staging, and treatment.
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Affiliation(s)
- Linh H Vu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alejandra Yu Lee-Mateus
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Robert A Vierkant
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Sebastian Fernandez-Bussy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Janani Reisenauer
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Diaz-Churion F, Yu Lee-Mateus A, Mirzan H, Khoor A, Abia-Trujillo D, Fernandez-Bussy S. Patient With Metastatic Airway Calcification and Hypercalcemia Due to Secondary Hyperparathyroidism. J Bronchology Interv Pulmonol 2023; 30:387-390. [PMID: 37055879 DOI: 10.1097/lbr.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Affiliation(s)
| | | | - Haares Mirzan
- Division of Pulmonary, Allergy, and Sleep Medicine Mayo Clinic, Jacksonvile, FL
| | - Andras Khoor
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine Mayo Clinic, Jacksonvile, FL
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Low SW, Mullon JJ, Swanson KL, Kern RM, Nelson DR, Fernandez-Bussy S, Sakata KK. Feasibility and Efficacy of a Non-Opioid Based Pain Management After Medical Thoracoscopy. J Bronchology Interv Pulmonol 2023; 30:321-327. [PMID: 36541719 DOI: 10.1097/lbr.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Prescription opioids are a major cause of the opioid epidemic. Despite the minimally invasive nature of medical thoracoscopy (MT), data on the efficacy of non-opioid-based pain control after MT is lacking. The purpose of this study is to assess the feasibility and efficacy of a non-opioid-based pain management strategy in patients who underwent MT. METHODS We performed a retrospective analysis of all patients who underwent MT in the Mayo Clinic (Minnesota and Arizona) outpatient setting. We assessed their pain level and the need for analgesia post-MT from August 1, 2019, to May 24, 2021. RESULTS Forty patients were included. In the first 24 hours, 5/40 (12.5%) reported no pain. Twenty-eight patients out of 40 (70%) reported minor pain (pain scale 1-3), and 7/40 (17.5%) reported moderate pain (pain scale 4-6). No patients reported severe pain. Twenty-two out of 35 patients who experienced discomfort (63%) required acetaminophen, 6/35 patients (17%) required nonsteroidal anti-inflammatory drug, and 7/35 patients (20%) did not require analgesia. Of the 7 patients who had moderate pain, 5 (71%) reported that the moderate pain improved to mild at 72 hours post-MT. Zero patients required opioids, and none reported contacting any provider to manage the pain post-MT. Fourteen patients (78%) who had both parietal pleural biopsies and tunneled pleural catheter placed reported minor pain, 3 patients (17%) reported moderate pain, and 1 patient (6%) experienced no discomfort. CONCLUSION MT is well-tolerated by patients with non-opioid-based pain management strategy as needed if there is no absolute contraindication.
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Affiliation(s)
- See-Wei Low
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - John J Mullon
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Karen L Swanson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Ryan M Kern
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Darlene R Nelson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN
| | | | - Kenneth K Sakata
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ
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Abia-Trujillo D, Chandra NC, Koratala A, Yu Lee-Mateus A, Garza-Salas A, Barrios-Ruiz A, Patel NM, Chadha RM, Hazelett BN, Fernandez-Bussy S. Diagnostic Yield of Shape-Sensing Robotic-Assisted Bronchoscopy for Ground-Glass Nodules and Subsolid Nodules with a Solid Component Less than 6 mm. Respiration 2023; 102:899-904. [PMID: 37619549 DOI: 10.1159/000533314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/24/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Ground-glass pulmonary nodules (GGNs) are most commonly sampled by percutaneous transthoracic biopsy. Diagnostic yield for ground-glass nodules using robotic-assisted bronchoscopy has been scarcely described, with a reported yield of 70.6%. OBJECTIVES The aim of this study is to assess diagnostic yield for GGNs using shape-sensing robotic-assisted bronchoscopy (ssRAB). METHOD A retrospective study of patients who underwent ssRAB for evaluation of GGNs, from September 2021 to April 2023. Primary outcome was diagnostic yield of ssRAB for GGNs, secondary outcomes were sensitivity for malignancy, and complications that required admission or intervention. RESULTS A total of 23 nodules were biopsied from 22 patients. Median age was 71 years (IQR 66-81), 63.6% were female, and 40.9% had a previous history of cancer. Forty-three percent of nodules were in the right upper lobes, and the median lesion size was 1.8 × 1.21. Twelve were subsolid nodules (SSNs), and 11 were pure GGNs. Overall diagnostic yield was 87%, with a sensitivity for malignancy of 88.9%. Adenocarcinoma was the most common malignancy diagnosed (70%). No procedure-related complications were reported. CONCLUSION The use of ssRAB shows a high diagnostic yield for diagnosing GGN and SSN with less than 6 mm solid component with a low risk for complications.
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Affiliation(s)
- David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Nikitha C Chandra
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA,
| | - Anoop Koratala
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Ana Garza-Salas
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Alanna Barrios-Ruiz
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Neal M Patel
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan M Chadha
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Britney N Hazelett
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Yu Lee-Mateus A, Abia-Trujillo D, Edell ES, Chadha R, Hazelett BN, Fernandez-Bussy S. Shape-Sensing Robotic Bronchoscopy Live Images of Advanced Emphysema and Pulmonary Nodule. Respiration 2023; 102:632-634. [PMID: 37423210 DOI: 10.1159/000531298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/23/2023] [Indexed: 07/11/2023] Open
Affiliation(s)
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan Chadha
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Britney N Hazelett
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Abia-Trujillo D, Yu Lee-Mateus A, Hernandez-Rojas D, Pulipaka SP, Garcia-Saucedo JC, Saifi O, Majid A, Fernandez-Bussy S. Excessive Dynamic Airway Collapse Severity Scoring System: A Call Out for an Overall Severity Determination. J Bronchology Interv Pulmonol 2023; 30:200-206. [PMID: 36999946 DOI: 10.1097/lbr.0000000000000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 02/20/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Severe excessive dynamic airway collapse (EDAC) is defined as airway narrowing due to posterior wall protrusion into the airway lumen, >90%. We aimed to establish an overall severity score to assess severe EDAC and the need for subsequent intervention. METHODS A retrospective study of patients who underwent dynamic bronchoscopy for evaluation of expiratory central airway collapse between January 2019 and July 2021. A numerical value was given to each tracheobronchial segmental collapse: 0 points (<70%), 1 point (70% to 79%), 2 points (80% to 89%), and 3 points (>90%) to be added for an overall EDAC severity score per patient. We compared the score among patients who underwent stent trials (severe EDAC) and those who did not. Based on the receiver operating characteristics curve, a cutoff total score to predict severe EDAC was calculated. RESULTS One hundred fifty-eight patients were included. Patients were divided into severe (n = 60) and nonsevere (n = 98) EDAC. A cutoff of 9 as the total score had a sensitivity of 94% and a specificity of 74% to predict severe EDAC, based on an area under the curve 0.888 (95% CI: 0.84, 0.93; P < 0.001). CONCLUSION Our EDAC Severity Scoring System was able to discern between severe and nonsevere EDAC by an overall score cutoff of 9, with high sensitivity and specificity for predicting severe disease and the need for further intervention, in our institution.
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Affiliation(s)
| | | | | | | | - Juan C Garcia-Saucedo
- Department of Internal Medicine, Internal Medicine Resident, Morristown Medical Center, Morristown, NJ
| | - Omran Saifi
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Barrios-Ruiz A, Yu Lee-Mateus A, Hazelett BN, Walsh KL, Fernandez-Bussy S, Arunthari V, Colaco B, Taylor BJ, Abia-Trujillo D. Pneumatic stenting in the surgical candidacy assessment for cough variant expiratory central airway collapse. Respir Med Case Rep 2023; 45:101889. [PMID: 37457924 PMCID: PMC10344674 DOI: 10.1016/j.rmcr.2023.101889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/19/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
Expiratory Central Airway Collapse (ECAC) is a multifactorial, underdiagnosed entity that poses unique challenges. Airway stenting is used as a predictor for successful outcomes after central airway stabilization surgery via tracheobronchoplasty (TBP). This approach may pose suboptimal performance in certain ECAC variants. We hypothesize that Continuous Positive Airway Pressure (CPAP), used as a pneumatic stent, could be a non-invasive alternative to evaluate surgical candidacy in cough-predominant ECAC presentations. We report on a 67-year-old female with a history of chronic cough and confirmed ECAC. After optimization of medical therapy without significant relief and unsuccessful stent trial. We opted to perform CPAP trial during exercise, the patient exercised on a treadmill, and CPAP was applied at two levels (9 cmH2O, 11 cmH2O). The use of CPAP was associated with resolution of cough and a decrease in exercise-related perceived exertion. Applying CPAP during exercise may be a promising alternative to stent trials to determine patients' candidacy for surgical management of cough-predominant ECAC.
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Affiliation(s)
- Alanna Barrios-Ruiz
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Alejandra Yu Lee-Mateus
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Britney N. Hazelett
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Katherine L. Walsh
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Vichaya Arunthari
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Brendon Colaco
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Bryan J. Taylor
- Division of Circulatory Failure, Cardiovascular Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
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14
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Wadiwala IJ, Fernandez-Bussy S, Garg P, Ali M, Feinglass NG, Thomas M, Pham SM. Novel treatment of bronchopleural fistula in a lung transplant recipient with endobronchial sealant and endobronchial valve placement via robotic-assisted bronchoscopy. J Surg Case Rep 2023; 2023:rjad383. [PMID: 37434719 PMCID: PMC10331800 DOI: 10.1093/jscr/rjad383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/15/2023] [Indexed: 07/13/2023] Open
Abstract
Bronchopleural fistulas (BPFs) are a dreaded complication following pulmonary surgery. Endobronchial valves (EVs), with endobronchial sealant (ES), instilled with robotic bronchoscopy (RB), allow occlusion of BPF, avoiding surgery. The patient was a 71-year-old woman with a history of chronic obstructive pulmonary disease and bronchiectasis who underwent bilateral lung transplantation and wedge resection of the right middle lobe and left lingula. A BPF was discovered on postoperative day (POD) 21. Conservative measures with chest tubes failed, and robotic-assisted bronchoscopy aided in reaching the bronchial segment and instilling ES, and EV was deployed with the conventional bronchoscope. The pneumothorax was cleared 12 days later, and on POD 56, she was discharged. The RB procedure was successful, with no pneumothorax or BPF symptoms after a median follow-up of POD 284. Robotic endobronchial closure of BPF with EV and ES is an effective treatment option avoiding invasive surgeries.
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Affiliation(s)
- Ishaq J Wadiwala
- Cardiothoracic Surgery Research Unit, Mayo Clinic, Jacksonville, FL, USA
| | | | - Pankaj Garg
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Mostafa Ali
- Cardiothoracic Surgery Research Unit, Mayo Clinic, Jacksonville, FL, USA
| | - Neil G Feinglass
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Si M Pham
- Correspondence address. Mayo Clinic College of Medicine and Science Chair, Department of Cardiothoracic Surgery, Mayo Clinic Florida 4500 San Pablo Rd S, Jacksonville, Florida 32224, USA. Tel: 904-956-3212, 904-953-2000; Fax: 904-956-8060; E-mail:
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15
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Diaz Churion F, Walsh KL, Yu Lee-Mateus A, Sriram A, Abia-Trujillo D, Fernandez-Bussy S. Multiple Capillary Hemangiomas of the Lung with Multi-Organ Involvement. Respiration 2023:1-2. [PMID: 37231898 DOI: 10.1159/000530651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/31/2023] [Indexed: 05/27/2023] Open
Affiliation(s)
- Fabiana Diaz Churion
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA,
| | - Katherine L Walsh
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Alejandra Yu Lee-Mateus
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Aryaman Sriram
- Department of Statistics, University of Florida, Gainesville, Florida, USA
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
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Yu Lee-Mateus A, Chandra NC, Johnson MM, Abia-Trujillo D, Reisenauer J, Fernandez-Bussy S. Robotic-Assisted Bronchoscopy Integrated with Three-Dimensional Fluoroscopy for Sampling Bilateral Pulmonary Nodules in a Single Procedure. Respiration 2023:1-5. [PMID: 37105143 DOI: 10.1159/000530234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/15/2023] [Indexed: 04/29/2023] Open
Abstract
Bronchoscopic biopsy of peripheral pulmonary nodules has evolved in recent years with the emergence of new technologies such as shape-sensing robotic-assisted bronchoscopy. The use of three-dimensional (3D) fluoroscopy for intraoperative visualization of the biopsy tool in relation to the target nodule aims to overcome computed tomography-to-body divergence encountered during the procedure and allows for more accurate sampling to improve adequacy and diagnostic performance. Until recently, the robotic-assisted navigation plan and 3D imaging function as separate systems. We present a case where intraoperative 3D fluoroscopy images were integrated to the robotic bronchoscopy navigation system, resulting in a single, dynamic, real-time 3D virtual plan showing readjusted paths toward the lesion displayed in the robotic bronchoscopy navigation system, allowing in this case, biopsying two bilateral pulmonary nodules, resulting in different diagnosis within the same endoscopic procedure.
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Affiliation(s)
| | - Nikitha C Chandra
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Margaret M Johnson
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Janani Reisenauer
- Department of Pulmonary Medicine and Thoracic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Hernandez-Rojas D, Yu Lee-Mateus A, Abia-Trujillo D, Khoor A, Rojas C, Fernandez-Bussy S. Radiation-induced Airway Disease: A Growing Concern. J Bronchology Interv Pulmonol 2023; 30:184-187. [PMID: 35959893 DOI: 10.1097/lbr.0000000000000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | | | | | - Andras Khoor
- Department of Laboratory Medicine and Pathology, Mayo Clinic Florida Jacksonville, FL
| | - Carlos Rojas
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ
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18
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Tun AJ, Hoppe BS, Zhao Y, Makey I, Fernandez-Bussy S, Liang X. Radiation Therapy for Primary Adenoid Cystic Carcinoma of the Trachea: Photons, Protons, or Carbon? Int J Part Ther 2023; 9:302-305. [PMID: 37169012 PMCID: PMC10166014 DOI: 10.14338/ijpt-22-00036.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/08/2022] [Indexed: 01/13/2023] Open
Abstract
Abstract
Primary adenoid cystic carcinoma of the trachea (ACC-T) is an extremely rare cancer of the central bronchial system. It is usually associated with an excellent prognosis. Surgery is the standard treatment for resectable tumors, while radiation therapy is used for unresectable tumors or medically inoperable patients. Radiation therapy can be delivered with photons, protons, or carbon ion therapy. In this report, we review a case of unresectable ACC-T in a middle-aged female patient who was treated with radiation therapy and review the potential benefits of the different types of radiation therapy.
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Affiliation(s)
- Alexander J. Tun
- 1 Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL, USA
| | - Bradford S. Hoppe
- 2 Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Yujie Zhao
- 3 Division of Hematology Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Ian Makey
- 4 Department of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Xiaoying Liang
- 2 Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
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19
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Castillo-Larios R, Hernandez-Rojas D, Yu Lee-Mateus A, Abia-Trujillo D, Gomez V, Koop AH, Fernandez-Bussy S. Double Stenting for Management of a Bronchoesophageal Fistula: A Never-ending Dilemma. J Bronchology Interv Pulmonol 2023; 30:77-79. [PMID: 35839319 DOI: 10.1097/lbr.0000000000000843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
| | | | | | | | - Victoria Gomez
- Gastroenterology and Hepatology Mayo Clinic Florida, Jacksonville, FL
| | - Andree H Koop
- Gastroenterology and Hepatology Mayo Clinic Florida, Jacksonville, FL
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20
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Majid A, Ospina-Delgado D, Ayala A, Gangadharan SP, Alape D, Buitrago D, Parikh MS, Wilson JL, Chee AC, Fernandez-Bussy S, Herth FJF, Kheir F. Stent Evaluation for Expiratory Central Airway Collapse: Does the Type of Stent Really Matter? J Bronchology Interv Pulmonol 2023; 30:37-46. [PMID: 35318996 DOI: 10.1097/lbr.0000000000000842] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 11/05/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Careful selection of patients with expiratory central airway collapse (ECAC) that may benefit from tracheobronchoplasty (TBP) can be aided by a short-term airway stent evaluation. This can be performed with either silicone Y-stents (SYSs) or uncovered self-expanding metallic airway-stents (USEMAS). No direct comparison has been made between these 2 stent types. METHODS This was a small retrospective review of consecutive patients that underwent a stent evaluation. A propensity score was used to match patients in the USEMAS and SYS groups. Outcomes included complications, changes in the health-related quality-of-life (HR-QoL), and changes in exercise capacity. Baseline measurements were compared with those obtained during stent evaluation and after TBP. RESULTS Forty-two patients with severe ECAC underwent USEMAS placement, while 18 patients had an SYS placed. Propensity score matching resulted in 13 matched SYS and USEMAS pairs. The SYS group had an increased rate of mucus plugging (38.5% vs. 0%, P <0.047). Although not statically significant, a clinical improvement was observed in HR-QoL and exercise capacity in the USEMAS group during stent placement. In patients who underwent TBP, both USEMAS and SYS groups had a statistically significant change in the Modified Medical Research Council Dyspnea Scale during stent evaluation and after TBP. CONCLUSION In patients with severe ECAC, short-term evaluation with airway stents appears to be safe and improves respiratory symptoms, HR-QoL, and exercise capacity. The use of USEMAS led to a lower complication rate, a greater improvement in HR-QoL and exercise capacity, and appeared to better predict how the patients would respond to TBP.
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Affiliation(s)
- Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Daniel Ospina-Delgado
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Alvaro Ayala
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Daniel Alape
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
- Department of Internal Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Daniel Buitrago
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Mihir S Parikh
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Jennifer L Wilson
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Alex C Chee
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | | | - Felix J F Herth
- Department of Pulmonary and Critical Care Medicine, Thoraxklinik-University of Heidelberg, Heidelberg, Germany
| | - Fayez Kheir
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
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21
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Yu Lee-Mateus A, Reisenauer J, Garcia-Saucedo JC, Abia-Trujillo D, Buckarma EH, Edell ES, Grage RA, Bowman AW, Labarca G, Johnson MM, Patel NM, Fernandez-Bussy S. Robotic-assisted bronchoscopy versus CT-guided transthoracic biopsy for diagnosis of pulmonary nodules. Respirology 2023; 28:66-73. [PMID: 36104312 DOI: 10.1111/resp.14368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/18/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVE Currently, computed tomography-guided transthoracic biopsy (CTTB) is the most accurate diagnostic approach for pulmonary nodules suspected of malignancy. Traditional bronchoscopy has shown suboptimal diagnostic sensitivity, but the emergence of robotic-assisted bronchoscopy (RAB) has the potential to improve diagnostic accuracy, maximize diagnostic yield and complete mediastinal and hilar staging in a single procedure. We aim to assess the efficacy and diagnostic performance of RAB compared to CTTB for diagnosing pulmonary nodules suspected of lung cancer. METHODS A multicenter retrospective review of consecutive patients who underwent RAB and CTTB for evaluating pulmonary nodules from January 2019 to March 2021 at Mayo Clinic Florida and Mayo Clinic Rochester, United States. Clinical and demographic information, nodule characteristics, outcomes and complications were compared between RAB and CTTB. RESULTS A total of 225 patients were included: 113 in the RAB group and 112 in the CTTB group. Overall diagnostic yield was 87.6% for RAB and 88.4% for CTTB. For malignant disease, RAB had a sensitivity of 82.1% and a specificity of 100%, CTTB had a sensitivity of 88.5% and a specificity of 100%. Complication rate was significantly higher for CTTB compared to RAB (17% vs. 4.4%; p = 0.002). CONCLUSION RAB, when available, can be as accurate as CTTB for sampling pulmonary nodules with similar or reduced complications and should be considered as a means for nodule biopsy, particularly when mediastinal staging is also clinically warranted.
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Affiliation(s)
| | - Janani Reisenauer
- Department of Pulmonary Medicine and Thoracic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan C Garcia-Saucedo
- Internal Medicine Resident, Department of Internal Medicine, Morristown Medical Center, Morristown, New Jersey, USA
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rolf A Grage
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Andrew W Bowman
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Gonzalo Labarca
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret M Johnson
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Neal M Patel
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
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22
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Hazelett BN, Paton A, Majid A, Johnson MM, Patel NM, Abia-Trujillo D, Lee-Mateus AY, Kornafeld A, Fernandez-Bussy S. Coordination of Care for Expiratory Central Airway Collapse: A Structured Process for a Multifaceted Disease. Chest 2023; 163:185-191. [PMID: 36243063 DOI: 10.1016/j.chest.2022.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022] Open
Abstract
Common respiratory symptoms, including dyspnea, cough, sputum production, and recurrent infections, frequently remain without a clear cause and may be the result of expiratory central airway collapse (ECAC). Establishing the diagnosis and appropriate treatment plan for patients with ECAC is challenging and benefits from a multidisciplinary approach. A coordinator role is crucial in this process to ensure optimal patient-centered outcomes. We describe the coordination of care in the process of diagnosing and treating ECAC. The coordinator leads the organization of the multiple services involved in the care of patients with ECAC, including pulmonary medicine, interventional pulmonology, radiology, and thoracic surgery, as well as hospital inpatient staff. From initial screening to evaluation and management with airway stents and corrective treatment with tracheobronchoplasty, the ECAC coordinator oversees the entire process of care for patients with ECAC.
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Affiliation(s)
- Britney N Hazelett
- Division of Pulmonary, Allergy, Sleep Medicine and Respiratory Services.
| | - Alichia Paton
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Neal M Patel
- Division of Pulmonary, Allergy, Sleep Medicine and Respiratory Services
| | | | | | - Anna Kornafeld
- Division of Internal Medicine, Mayo Clinic Florida, Jacksonville, FL
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23
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Abia-Trujillo D, Fernandez-Bussy S. Nonmalignant Central Airway Obstruction: Options for Challenging Cases. Semin Respir Crit Care Med 2022; 43:530-535. [PMID: 35728604 DOI: 10.1055/s-0042-1747937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Benign central airway obstruction is commonly referred as nonmalignant central airway obstruction (NMCAO). This is in part related to its lack of benign nature and significant life-quality impairment in patients. It is a pathologic entity with various etiologies and therefore a wide range of therapeutic options are available. Evidence regarding the optimal management that could provide a sustained restoration of airway patency is lacking. The lack of a common pathophysiologic pathway translating into a nonspecific symptom presenting as NMCAO has complicated treatment standardization and subsequently limited solid research to favor of one approach over another one. Our intent is to describe the limited evidence of the most utilized nonsurgical treatment for NMCAO as well as some upcoming promising therapeutic options such as mitomycin C injection, microdebrider, biodegradable stents, radiotherapy, Hybrid Knife, and endoluminal spray cryotherapy. Our goal with this manuscript is to motivate other authors to venture into prospective, multicenter, open-label trials aimed to describe long-term outcomes in patients with NMCAO.
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Affiliation(s)
- David Abia-Trujillo
- Divisions of Pulmonary, Allergy, Sleep Medicine & Respiratory Services, Mayo Clinic, Jacksonville, Florida
| | - Sebastian Fernandez-Bussy
- Divisions of Pulmonary, Allergy, Sleep Medicine & Respiratory Services, Mayo Clinic, Jacksonville, Florida
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Reisenauer J, Duke JD, Kern R, Fernandez-Bussy S, Edell E. Combining Shape-Sensing Robotic Bronchoscopy With Mobile Three-Dimensional Imaging to Verify Tool-in-Lesion and Overcome Divergence: A Pilot Study. Mayo Clin Proc Innov Qual Outcomes 2022; 6:177-185. [PMID: 35509435 PMCID: PMC9059066 DOI: 10.1016/j.mayocpiqo.2022.02.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective To determine whether CT-to-body divergence can be overcome to improve the diagnostic yield of peripheral pulmonary nodules with the combination of shape-sensing robotic-assisted bronchoscopy (SSRAB) and portable 3-dimensional (3D) imaging. Patients and Methods A single-center, prospective, pilot study was conducted from February 9, 2021, to August 4, 2021, to evaluate the combined use of SSRAB and portable 3D imaging to visualize tool-in-lesion as a correlate to diagnostic yield. Results Thirty lesions were subjected to biopsy in 17 men (56.7%) and 13 women (43.3%). The median lesion size was 17.5 mm (range, 10-30 mm), with the median airway generation of 7 and the median distance from pleura of 14.9 mm. Most lesions were in the upper lobes (18, 60.0%). Tool-in-lesion was visualized at the time of the procedure in 29 lesions (96.7%). On the basis of histopathologic review, 22 (73.3%) nodules were malignant and 6 (20.0%) were benign. Two (6.7%) specimens were suggestive of inflammation, and the patients elected observation. The mean number of spins was 2.5 (±1.6) with a mean fluoroscopy time of 8.7 min and a mean dose area product of 50.3 Gy cm2 (±32.0 Gy cm2). There were no episodes of bleeding or pneumothorax. The diagnostic yield was 93.3%. Conclusion This pilot study shows that the combination of mobile 3D imaging and SSRAB of pulmonary nodules appears to be safe and feasible. In conjunction with appropriate anesthetic pathways, nodule motion and divergence can be overcome in most patients. Trial Registration https://clinicaltrials.gov Identifier NCT04740047
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Affiliation(s)
- Janani Reisenauer
- Division of Thoracic Surgery, Mayo Clinic Rochester MN
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester MN
- Correspondence: Address to Janani Reisenauer, MD, Division of General Thoracic Surgery, Mayo Clinic, 200 1st St, SW, Rochester, MN 55905.
| | - Jennifer D. Duke
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester MN
| | - Ryan Kern
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester MN
| | | | - Eric Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester MN
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25
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Castillo-Larios R, Hernandez-Rojas D, Spaulding AC, Yu Lee-Mateus A, Pulipaka P, Colibaseanu DT, Thomas M, Fernandez-Bussy S, Makey IA. Assessment of length of stay and cost of minimally invasive versus open thymectomies in patients with myasthenia gravis in Florida. Gland Surg 2022; 11:957-962. [PMID: 35800735 PMCID: PMC9253185 DOI: 10.21037/gs-22-83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/29/2022] [Indexed: 08/31/2023]
Abstract
BACKGROUND Thymectomy has become a standard component in treatment for myasthenia gravis. The best surgical approach is still subject to debate. Minimally invasive surgery may have a lower mortality and morbidity rate, improved cosmetic results, and equivalent efficacy at improving neurologic symptoms to open approaches. We compared the perioperative outcomes and cost between the two techniques. METHODS We queried Florida Inpatient Discharge Dataset for patients who underwent thymectomy and had a primary diagnosis of non-thymomatous myasthenia gravis using International Classification of Diseases (ICD)-9 and ICD-10 codes to carry out this retrospective cohort study. The dates ranged between January 1st, 2013, to December 31st, 2018. We compared outcomes of patients who underwent minimally invasive thymectomy versus those who had open thymectomy. RESULTS An open approach was used in 108 patients, whereas a minimally invasive approach was used in 40 patients. Minimally invasive surgery group had a shorter length of stay (3.0 vs. 6.0 days, P<0.001) and had a non-significant lower total cost ($18.4K vs. $22.1K, P=0.186). After adjusting for age and Elixhauser score, length of stay for minimally invasive group was 32% (P=0.01) lower compared to the open surgery group. CONCLUSIONS Patients who underwent minimally invasive thymectomy for Myasthenia gravis had a significantly shorter length of stay and a lower, although not significant, overall cost.
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Affiliation(s)
- Rocio Castillo-Larios
- Department of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Daniel Hernandez-Rojas
- Department of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Aaron C. Spaulding
- Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Alejandra Yu Lee-Mateus
- Department of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Priyanka Pulipaka
- Department of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Dorin T. Colibaseanu
- Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, FL, USA
- Division of Colon and Rectal Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Mathew Thomas
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Ian A. Makey
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
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Castillo-Larios R, Hernandez-Rojas D, Paciotti B, Lee-Mateus AY, Pulipaka P, Fernandez-Bussy S, Makey IA. Missing lung nodule? Intra-operative contingency plan with O-arm imaging: a case report. AME Case Rep 2022; 6:11. [PMID: 35475014 PMCID: PMC9010323 DOI: 10.21037/acr-21-71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/17/2021] [Indexed: 11/04/2023]
Abstract
Despite the availability of various modalities to locate small non-palpable pulmonary nodules during minimally invasive thoracoscopic surgery, precise lung nodule resection remains a challenge. Pre-operative localization techniques add additional time, expense, and complication rate. Intra-operative localization methods, such as ultrasound, may be a real-time solution, but challenges remain with visualizing deep parenchyma lesions and operator-dependent use. Many thoracoscopic wedge resections are performed using a combination of pre-operative imaging and intra-operative landmarks. Although usually cost and time-efficient, the problem occurs when a wedge resection is performed, and the nodule is not within the specimen. This case report describes the use of the O-arm Surgical Imaging System, a full-rotation imaging system that provides three-dimensional cone-beam imaging, in an 81-year-old male patient with a solid 8 mm left lower lobe lung nodule. After two unsuccessful wedge resections, we used the O-arm and finally resected the nodule with a negative surgical margin. The O-arm provided instant feedback regarding the nodule status, allowing a standard thoracoscopy room to function as a hybrid operating room without the need to reposition the patient. Rather than convert to a thoracotomy, proceed to a larger resection, or experience a missed nodule, the O-arm proved to be a helpful intra-operative tool to find a missing lung nodule.
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Affiliation(s)
- Rocio Castillo-Larios
- Department of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Daniel Hernandez-Rojas
- Department of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Breah Paciotti
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Alejandra Yu Lee-Mateus
- Department of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Priyanka Pulipaka
- Department of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Ian A. Makey
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
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Simoff MJ, Pritchett MA, Reisenauer JS, Ost DE, Majid A, Keyes C, Casal RF, Parikh MS, Diaz-Mendoza J, Fernandez-Bussy S, Folch EE. Shape-sensing robotic-assisted bronchoscopy for pulmonary nodules: initial multicenter experience using the Ion™ Endoluminal System. BMC Pulm Med 2021; 21:322. [PMID: 34656103 PMCID: PMC8520632 DOI: 10.1186/s12890-021-01693-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 09/28/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Traditional bronchoscopy provides limited approach to peripheral nodules. Shape-sensing robotic-assisted bronchoscopy (SSRAB, Ion™ Endoluminal System) is a new tool for minimally invasive peripheral nodule biopsy. We sought to answer the research question: Does SSRAB facilitate sampling of pulmonary nodules during bronchoscopists' initial experience? METHODS The lead-in stage of a multicenter, single-arm, prospective evaluation of the Ion Endoluminal System (PRECIsE) is described. Enrolled subjects ≥ 18 years old had recent computed tomography evidence of one or more solid or semi-solid pulmonary nodules ≥ 1.0 to ≤ 3.5 cm in greatest dimension and in any part of the lung. Subjects were followed at 10- and 30-days post-procedure. This stage provided investigators and staff their first human experience with the SSRAB system; safety and procedure outcomes were analyzed descriptively. Neither diagnostic yield nor sensitivity for malignancy were assessed in this stage. Categorical variables are summarized by percentage; continuous variables are summarized by median/interquartile range (IQR). RESULTS Sixty subjects were enrolled across 6 hospitals; 67 nodules were targeted for biopsy. Median axial, coronal and sagittal diameters were < 18 mm with a largest cardinal diameter of 20.0 mm. Most nodules were extraluminal and distance from the outer edge of the nodule to the pleura or nearest fissure was 4.0 mm (IQR: 0.0, 15.0). Median bronchial generation count to the target location was 7.0 (IQR: 6.0, 8.0). Procedure duration (catheter-in to catheter-out) was 66.5 min (IQR: 50.0, 85.5). Distance from the catheter tip to the closest edge of the virtual nodule was 7.0 mm (IQR: 2.0, 12.0). Biopsy completion was 97.0%. No pneumothorax or airway bleeding of any grade was reported. CONCLUSIONS Bronchoscopists leveraged the Ion SSRAB's functionality to drive the catheter safely in close proximity of the virtual target and to obtain biopsies. This initial, multicenter experience is encouraging, suggesting that SSRAB may play a role in the management of pulmonary nodules. Clinical Trial Registration identifier and date NCT03893539; 28/03/2019.
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Affiliation(s)
- Michael J Simoff
- Bronchoscopy and Interventional Pulmonology, Lung Cancer Screening Program, Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University School of Medicine, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Michael A Pritchett
- Pulmonary Department, Pinehurst Medical Clinic, Pinehurst, NC, USA.,Pulmonary Department, First Health Moore Regional Hospital, Pinehurst, NC, USA
| | - Janani S Reisenauer
- Department of Pulmonary Medicine and Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adnan Majid
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Colleen Keyes
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mihir S Parikh
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Javier Diaz-Mendoza
- Bronchoscopy and Interventional Pulmonology, Lung Cancer Screening Program, Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University School of Medicine, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | | | - Erik E Folch
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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28
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Abia-Trujillo D, Yu Lee-Mateus A, Garcia-Saucedo JC, Saifi O, Patel NM, Herth FJF, Woytanowski JR, Alshelli I, Alevas S, Uribe Becerra JP, Majid A, Edell ES, Dulohery-Scrodin MM, Reisenauer JS, Mehta HJ, Jantz MA, Abbas HK, Fernandez-Bussy S. Prevention of acute exacerbation of chronic obstructive pulmonary disease after bronchoscopic lung volume reduction with endobronchial valves. Clin Respir J 2021; 16:43-48. [PMID: 34605606 PMCID: PMC9060109 DOI: 10.1111/crj.13450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/15/2021] [Accepted: 09/22/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Bronchoscopic lung volume reduction (BLVR) with endobronchial valves (EBVs) has emerged as an important treatment method for patients with severe chronic obstructive pulmonary disease (COPD). Acute exacerbations of COPD (AECOPD) are a frequent complication following BLVR with EBV. However, there is no consensus on the prevention of AECOPD. OBJECTIVES Our study aims to compare the outcomes of different prophylactic measures on the occurrence of AECOPD after BLVR with EBV. METHODS We conducted a multicenter, retrospective study of patients who underwent BLVR with EBV at six different institutions. Emphasis was directed towards the specific practices aimed at preventing AECOPD: antibiotics, steroids, antibiotics plus steroids, or no prophylaxis. Subgroups were compared, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated. RESULTS A total of 170 patients were reviewed. The rate of AECOPD was 21.2% for the full cohort. Patients who received prophylaxis had a significantly lower rate of AECOPD compared with those who did not (16.7% vs. 46.2%; p = 0.001). The rate was lowest in patients who received antibiotics alone (9.2%). There was no significant difference in the rate of AECOPD between patients who received steroids alone or antibiotics plus steroids, compared with the other subgroups. The OR for AECOPD was 4.3 (95% CI: 1.8-10.4; p = 0.001) for patients not receiving prophylaxis and 3.9 (95% CI: 1.5-10.1; p = 0.004) for prophylaxis other than antibiotics alone. CONCLUSIONS Administration of antibiotics after BLVR with EBV was associated with a lower rate of AECOPD. This was not observed with the use of steroids or in combination with antibiotics.
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Affiliation(s)
- David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Alejandra Yu Lee-Mateus
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Juan C Garcia-Saucedo
- Department of Internal Medicine, Morristown Medical Center, Morristown, New Jersey, USA
| | - Omran Saifi
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Neal M Patel
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Felix J F Herth
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | | | - Ihab Alshelli
- Respiratory Institute, Cleveland Clinic Florida, Weston, Florida, USA
| | - Sajive Alevas
- Respiratory Institute, Cleveland Clinic Florida, Weston, Florida, USA
| | - Juan P Uribe Becerra
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Hiren J Mehta
- Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Michael A Jantz
- Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Hawazin K Abbas
- Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
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Helgeson SA, Imam JS, Burnside RC, Fernandez-Bussy S, Brigham TJ, Patel NM. Transbronchial Forceps Biopsy in the Intensive Care Unit: A Systematic Review and Meta-analysis. J Bronchology Interv Pulmonol 2021; 28:281-289. [PMID: 33758151 DOI: 10.1097/lbr.0000000000000767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 02/10/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND A transbronchial forceps lung biopsy performed in mechanically ventilated patients with respiratory failure of unknown etiology has significant uncertainty of diagnostic yield and safety along with sparse literature. This study investigated the complication rate of transbronchial biopsies in mechanically ventilated patients in the intensive care unit and its ability to obtain a diagnosis and change current therapy. METHODS PubMed, Ovid MEDLINE, and Ovid Cochrane Central Register of Controlled Trials databases were systematically searched for all publications of transbronchial lung biopsies in mechanically ventilated patients. We pooled the results of individual studies using random-effects meta-analysis models to achieve the summary proportions. RESULTS Of the identified 9 observational studies with a total of 232 patients undergoing a transbronchial biopsy, complications occurred in 67 patients [25.2%; 95% confidence interval (CI), 11.5%-42.0%; I2=70.0%]. Pneumothorax occurred in 24 patients (9.5%; 95% CI, 4.5%-16.2%; I2=15.9%) and bleeding in 18 patients (8.9%; 95% CI, 4.1%-15.3%; I2=0%). A diagnosis was given in 146 patients (62.9%; 95% CI, 56.0%-69.1%; I2=74.6%), with 103 of 210 patients (49.0%; 95% CI, 44.6%-55.1%; I2=74.9%) having a change in treatment. CONCLUSION The results of this meta-analysis suggest that a transbronchial forceps biopsy when performed in mechanically ventilated patients with respiratory failure of unclear etiology had a moderate complication rate. These biopsies resulted in varied diagnoses with a high rate of management change. Randomized controlled trials are necessary to identify the ideal patients to perform a transbronchial forceps biopsy on in the intensive care unit.
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Affiliation(s)
| | - Jaafer S Imam
- Department of Pulmonary and Critical Care Medicine, University of Texas Medical Branch, Galveston, TX
| | | | | | | | - Neal M Patel
- Departments of Pulmonary and Critical Care Medicine
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30
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Yu Lee-Mateus A, Garcia-Saucedo JC, Abia-Trujillo D, Labarca G, Patel NM, Pascual JM, Fernandez-Bussy S. Comparing diagnostic sensitivity of different needle sizes for lymph nodes suspected of lung cancer in endobronchial ultrasound transbronchial needle aspiration: Systematic review and meta-analysis. Clin Respir J 2021; 15:1328-1336. [PMID: 34402194 DOI: 10.1111/crj.13436] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/12/2021] [Accepted: 08/10/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a safe and minimally invasive procedure for evaluating hilar and mediastinal lymph nodes. The reported sensitivity and specificity of EBUS-TBNA are 95% and 97%, respectively. A comparison of diagnostic sensitivity for lymph nodes suspected of lung cancer according to needle size in EBUS-TBNA is needed. OBJECTIVES To compare the diagnostic sensitivity of the 19-G, 21-G, 22-G and 25-G needles for lymph nodes suspected of non-small cell lung cancer (NSCLC) using EBUS-TBNA. METHODS A literature search from PubMed, EMBASE, LILACS, DOAJ and CENTRAL through October 2020 was performed by two reviewers. The extracted data were evaluated using STATA® and Open Meta Analyst software for meta-analysis with a binary method model to compare sensitivity, specificity and summary receiver operating characteristic curve for each needle size. RESULTS Fourteen studies including 1296 participants were considered for the analysis. The overall sensitivity of EBUS-TBNA was 88.2% (95% CI 84%, 91%) and 93% (95% CI 88%, 95%) for the 19-G needle, 87.6% (95% CI 79.6%, 92.8%) for the 21-G needle and 85% (95% CI 80%, 88%) for the 22-G needle. The overall sensitivity of EBUS-TBNA for diagnosing NSCLC was 88.3% (95% CI, 81%, 93%) and 92.9% (95% CI, 85%, 97%) for the 19-G needle, 89.4% (95% CI 79.4%, 94.8%) for the 21-G needle and 82.1% (95% CI 66%, 91%) for the 22-G needle. CONCLUSION The 19-G, 21-G and 22-G needles present a similarly high diagnostic sensitivity in EBUS-TBNA. The 19-G needle provided better sample adequacy for molecular and immunohistochemical testing, improving diagnostic yield in this subgroup.
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Affiliation(s)
- Alejandra Yu Lee-Mateus
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Juan C Garcia-Saucedo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - David Abia-Trujillo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Gonzalo Labarca
- Department of Internal Medicine, Faculty of Medicine, University of Concepcion, Concepcion, Chile
| | - Neal M Patel
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Jorge M Pascual
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
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31
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Reisenauer J, Simoff MJ, Pritchett MA, Ost DE, Majid A, Keyes C, Casal RF, Parikh MS, Diaz-Mendoza J, Fernandez-Bussy S, Folch EE. Ion: technology and techniques for shape-sensing robotic-assisted bronchoscopy. Ann Thorac Surg 2021; 113:308-315. [PMID: 34370981 DOI: 10.1016/j.athoracsur.2021.06.086] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 06/06/2021] [Accepted: 06/26/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE The authors describe the Ion Endoluminal System and practices for safe and effective use in patients with small peripheral pulmonary nodules (PPNs). DESCRIPTION The shape-sensing robotic-assisted bronchoscopy system allows airway visualization and navigation to reach and biopsy small PPNs through a stable platform. The system provides three-dimensional mapping and visualization of the airways, a flexible, fully articulating 3.5-mm (outer diameter) catheter, peripheral vision probe, and system-specific biopsy needles. EVALUATION The system was evaluated in an ongoing prospective, multicenter trial including 241 patients with 270 PPNs (largest mean cardinal measurement: 18.84±6.5 mm). Mean time to register and navigate decreased from 10 minutes in the first 10 cases to 7 minutes in the subsequent cases. Asymptomatic pneumothorax occurred in 8 subjects (3.3%), one (0.4%) with pigtail catheter placement. Two subjects (0.8%) experienced airway bleeding; both resolved within 5 minutes of tamponade. CONCLUSIONS The Ion Endoluminal System's unique shape-sensing technology can be leveraged to facilitate localization and sampling of PPNs and potentially improve diagnostic accuracy.
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Affiliation(s)
- Janani Reisenauer
- Department of Pulmonary Medicine and Thoracic Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Michael J Simoff
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Michael A Pritchett
- Pulmonary Department, Pinehurst Medical Clinic, Pinehurst, North Carolina; Pulmonary Department, FirstHealth Moore Regional Hospital, Pinehurst, North Carolina
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adnan Majid
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center-Harvard Medical School, Boston, Massachusetts
| | - Colleen Keyes
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
| | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mihir S Parikh
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center-Harvard Medical School, Boston, Massachusetts
| | - Javier Diaz-Mendoza
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | | | - Erik E Folch
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
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Fernandez-Bussy S, Kornafeld A, Labarca G, Abia-Trujillo D, Patel NM, Johnson MM, Reisenauer JS, Herth FJ. Risk of complications rise with coronary artery disease and diabetes mellitus after endobronchial valve placement in severe heterogeneous emphysema. Clin Respir J 2021; 15:1194-1200. [PMID: 34302313 DOI: 10.1111/crj.13426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/03/2021] [Accepted: 07/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) commonly have comorbidities which may impact both symptoms and prognosis. Endoscopic lung volume reduction (ELVR) with endobronchial valves (EBV) is an innovative, effective and safe treatment for patients with severe emphysema who remain symptomatic despite optimal medical therapy. OBJECTIVES To evaluate medical comorbidities associated with increased risk of complications after EBV procedure. METHOD This was a retrospective cohort review of patients with severe, heterogeneous emphysema who underwent Zephyr® EBV installation for ELVR. Demographics, baseline comorbidities, dyspnea scores, data regarding procedure, pulmonary function test, minimal clinically important difference and post-EBV complications were recorded. RESULTS Of a total 82 participants, 24 were identified as having a post procedure complication. There was a significant difference in the incidence of type 2 diabetes mellitus (T2DM) at baseline (25%) in complication group compared with non-complication group (5.1%) (p value = 0.01). There was also a significant difference between baseline coronary artery disease (CAD) in those with (58.3%) or without (29.3%) complication (p = 0.01). Multivariate analysis of other covariables, identified associations of both CAD and T2DM with a heightened risk of complication (adjusted OR 4.19 CI: 1.23-14.2, p value = 0.02 and adjusted OR of 6.1 CI: 1.3-26.1, p value = 0.02 respectively). CONCLUSIONS Our study found that patients with severe, heterogeneous emphysema who undergo ELVR utilizing Zephyr® EBV and suffer complications during post-procedure period are more likely to have CAD or T2DM as baseline comorbidity. These data suggest that baseline CAD and T2DM might be predictive of increased risk of complications following ELVR with EBV.
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Affiliation(s)
| | - Anna Kornafeld
- Division of Pulmonary Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Gonzalo Labarca
- Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, University of Concepcion, Concepcion, Chile
| | | | - Neal M Patel
- Division of Pulmonary Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Felix J Herth
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRCH), Heidelberg, Germany
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33
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Labarca G, Henríquez-Beltrán M, Lastra J, Enos D, Llerena F, Cigarroa I, Lamperti L, Ormazabal V, Ramirez C, Espejo E, Canales N, Fuentes F, Horta G, Fernandez-Bussy S, Nova-Lamperti E. Analysis of clinical symptoms, radiological changes and pulmonary function data 4 months after COVID-19. Clin Respir J 2021; 15:992-1002. [PMID: 34086416 PMCID: PMC8239617 DOI: 10.1111/crj.13403] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/27/2021] [Accepted: 06/01/2021] [Indexed: 12/15/2022]
Abstract
Background Coronavirus disease 2019 (COVID‐19) ranges from asymptomatic disease to respiratory failure and requires invasive mechanical ventilation (IMV). Data about the sequelae after infection are scarce. The study aims to describe the prevalence of symptoms, pulmonary function tests (PFTs), and radiological changes after four months of follow‐up. Methods A prospective, cross‐sectional, multicentre study was performed. Patients with different illness severities were consecutively included (mild; moderate: hospitalized without IMV; severe: hospitalized with IMV). Clinical variables, health‐related quality of life (HRQoL), PFT (spirometry, diffusing capacity of the lungs for carbon monoxide (DLCO)), and (CT) scans of the chest were obtained. The association between the risk of sequelae (DLCO <80%) and altered CT was analysed using logistic regression adjusted for confounding variables. Results 60 patients (18 mild, 17 moderate, and 25 severe) were included. Fatigue was found in 11% of the mild, 47% of the moderate and 36% of the severe group. Altered DLCO (mild: 5.5%, moderate: 41%, severe: 28%, p < .05) and change in HRQoL (mild: 50%, moderate: 94%, severe: 60%), while the severe group showed a higher prevalence of altered CT (88% vs. 64%). Awake prone position (APP) and high‐flow nasal cannula (HFNC) was independently associated with altered DLCO, Odds ratio (OR) 7.28 (CI, 1.10‐47.81; p < .05), and altered CT, OR 9.50 (CI, 1.26‐71.5; p < .05). Besides, prolonged time in IMV was associated with altered CT, OR 1.24 (CI, 1.05‐1.46; p < .05). Discussion It is common to find sequelae in symptoms, radiology, and PFT. In our series, the use of APP+HFNC and days on IMV were associated with an increased risk of sequelae.
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Affiliation(s)
- Gonzalo Labarca
- Facultad de Medicina, Universidad de Concepción, Concepción, Chile.,Complejo Asistencial Dr. Victor Rios Ruiz, Los Angeles, Chile.,Laboratorio de Inmnunologia Translacional, Departmento de Bioquimica Clinica e Inmunologia, Facultad de Farmacia, Universidad de Concepcion, Concepcion, Chile
| | | | - Jaime Lastra
- Facultad de Medicina, Universidad de Concepción, Concepción, Chile.,Medicina Interna, Hospital Regional Dr. Guillermo Grant Benavente, Concepción, Chile
| | - Daniel Enos
- Facultad de Medicina, Universidad de Concepción, Concepción, Chile.,Complejo Asistencial Dr. Victor Rios Ruiz, Los Angeles, Chile
| | - Faryd Llerena
- Laboratorio de Inmnunologia Translacional, Departmento de Bioquimica Clinica e Inmunologia, Facultad de Farmacia, Universidad de Concepcion, Concepcion, Chile
| | - Igor Cigarroa
- Escuela de Kinesiología, Facultad de Salud, Universidad Santo Tomás, Los Angeles, Chile
| | - Liliana Lamperti
- Laboratorio de Inmnunologia Translacional, Departmento de Bioquimica Clinica e Inmunologia, Facultad de Farmacia, Universidad de Concepcion, Concepcion, Chile
| | - Valeska Ormazabal
- Laboratorio de Inmnunologia Translacional, Departmento de Bioquimica Clinica e Inmunologia, Facultad de Farmacia, Universidad de Concepcion, Concepcion, Chile
| | - Carlos Ramirez
- Complejo Asistencial Dr. Victor Rios Ruiz, Los Angeles, Chile
| | - Eric Espejo
- Complejo Asistencial Dr. Victor Rios Ruiz, Los Angeles, Chile
| | - Nicole Canales
- Complejo Asistencial Dr. Victor Rios Ruiz, Los Angeles, Chile
| | - Fabiola Fuentes
- Complejo Asistencial Dr. Victor Rios Ruiz, Los Angeles, Chile
| | - Gloria Horta
- Medicina Interna, Hospital Regional Dr. Guillermo Grant Benavente, Concepción, Chile
| | | | - Estefania Nova-Lamperti
- Laboratorio de Inmnunologia Translacional, Departmento de Bioquimica Clinica e Inmunologia, Facultad de Farmacia, Universidad de Concepcion, Concepcion, Chile
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Fernandez-Bussy S, Abia-Trujillo D, Majid A, Folch EE, Patel NM, Herth FJF, Reisenauer JS. Management of Significant Airway Bleeding during Robotic Assisted Bronchoscopy: A Tailored Approach. Respiration 2021; 100:547-550. [PMID: 33774623 DOI: 10.1159/000514830] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/26/2021] [Indexed: 11/19/2022] Open
Abstract
Robotic assisted bronchoscopy represents a major turning point in bronchoscopic history. The management strategies to address significant airway bleeding in this "robotic era" are not well documented, and further guidance is required. We present a case report that exemplifies our approach and management strategy using a combined and simultaneous flexible/robotic bronchoscopy if this complication is encountered.
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Affiliation(s)
- Sebastian Fernandez-Bussy
- Divisions of Pulmonary, Allergy, Sleep Medicine & Respiratory Services/Mayo Clinic, Jacksonville, Florida, USA
| | - David Abia-Trujillo
- Divisions of Pulmonary, Allergy, Sleep Medicine & Respiratory Services/Mayo Clinic, Jacksonville, Florida, USA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology/Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Erik E Folch
- Department of Pulmonary and Critical Care Medicine/Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Neal M Patel
- Divisions of Pulmonary, Allergy, Sleep Medicine & Respiratory Services/Mayo Clinic, Jacksonville, Florida, USA
| | - Felix J F Herth
- Department of Pulmonology and Critical Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany
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Kukhon FR, Lan X, Helgeson SA, Arunthari V, Fernandez-Bussy S, Patel NM. Occult lymph node metastasis in radiologic stage I non-small cell lung cancer: The role of endobronchial ultrasound. Clin Respir J 2021; 15:676-682. [PMID: 33630405 DOI: 10.1111/crj.13344] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/19/2021] [Indexed: 12/25/2022]
Abstract
RATIONALE The use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is currently recommended for staging non-small cell lung cancer (NSCLC) in centrally located tumors, tumors >3 cm, or with radiologic evidence of lymph node (LN) metastasis. Current guidelines do not recommend staging EBUS-TBNA in patients with stage I NSCLC who do not have any of the aforementioned conditions. OBJECTIVE We hypothesize that using EBUS-TBNA is useful for detecting occult metastasis in radiologic stage I NSCLC. METHODS In this single-center, retrospective study, charts of patients ≥18 years old who underwent staging EBUS-TBNA from January 2005 to May 2019 were reviewed. Only patients with combined positron-emission tomography and computed tomography (PET/CT) scans consistent with radiologic stage I NSCLC were included. Identified variables included: age, gender, personal history of any cancer, smoking history, tumor location, tumor centrality, tumor size, tumor PET activity, histopathologic type of NSCLC, and LN biopsy results. Patients whose LN samples showed a diagnosis other than NSCLC were excluded. The association between LN positivity, and each of the variables was assessed using Pearson's correlation for categorical variables, and logistic regression analysis for continuous variables. RESULTS From the 2,892 initially screened patients, 188 were included. Of those, 13 (6.9%; 95% CI, 4%-11%) had a malignancy-positive LN biopsy. The number needed to test (NNT) in order to detect one case of any occult metastasis was 15. Among the included variables, a significant association was found between LN positivity and tumor centrality, with central tumors found in 61.5% of patients with positive LN (n = 8) (p < 0.01). This association stayed significant after adjusting for age, gender, smoking history, tumor size, tumor location, and PET activity (p = 0.015). Among patients with malignancy-positive LN biopsies, five (38.5%; 95% CI, 17.6%-64.6%) were upstaged to N1, and eight (61.5%; 95% CI, 35.4%-82.4%) were upstaged to N2, with NNT of 23 to detect one case of occult N2 metastasis. Subgroup analysis comparing LN-positive patients based on their N stage did not show statistically significant association with any of the variables. CONCLUSION Based on our results and along with the existing evidence, EBUS-TBNA should be recommended as part of the routine staging in all patients with radiologic stage I NSCLC.
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Affiliation(s)
- Faeq R Kukhon
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Xinyue Lan
- Department of Biology, Zanvyl Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Scott A Helgeson
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Vichaya Arunthari
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Neal M Patel
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA
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Folch EE, Oberg CL, Mehta AC, Majid A, Keyes C, Fernandez-Bussy S. Argon Plasma Coagulation: Elucidation of the Mechanism of Gas Embolism. Respiration 2021:1-5. [PMID: 33540412 PMCID: PMC8089431 DOI: 10.1159/000512687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 10/09/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Argon plasma coagulation (APC) is a tool used in the management of tracheobronchial obstruction or bleeding. Complications include gas embolism which can cause devastating effects including hemodynamic instability, cardiac arrest, and stroke. Multiple theories as to how gas embolism occurs with APC have been postulated; however, none have identified the exact mechanism. OBJECTIVES To identify the mechanism by which APC causes gas embolism in the tracheobronchial tree. METHODS Using an explanted porcine tracheobronchial tree with lung parenchyma, the APC catheter was applied through noncontact and direct contact to the endobronchial airway mucosa via flexible bronchoscopy. This was done at multiple gas flow settings and pulse durations. Visual changes in the mucosa were photographed, videoed, and described. RESULTS Gross evidence of submucosal gas transfer occurred when the APC catheter was in direct contact with the mucosa at all gas flow settings in all applications, despite using shorter pulse durations. Whenever the catheter was not in contact with the mucosa, there was no transfer of gas at any gas flow setting or pulse duration. CONCLUSIONS Direct mucosal contact with the APC probe leads to submucosal gas deposition and is a likely mechanism for gas entry into the intravascular space. In reported cases of APC-associated gas embolism, presence of a vascularized endobronchial tumor may have increased the risk of gas tracking into the intravascular space. Care should be taken when applying APC during brisk bleeding or limited vision, as inadvertent mucosal contact may occur and could increase the risk of gas embolism.
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Affiliation(s)
- Erik E Folch
- Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonary, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,
| | - Catherine L Oberg
- Division of Pulmonary, Critical Care, Allergy and Immunology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Atul C Mehta
- Division of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Colleen Keyes
- Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonary, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abia-Trujillo D, Johnson MM, Patel NM, Hazelett B, Edell ES, Kern RM, Midthun D, Reisenauer J, Nelson D, Mullon JJ, Sakata KK, Swanson K, Fernandez-Bussy S. Bronchoscopic Lung Volume Reduction: A New Hope for Patients With Severe Emphysema and Air Trapping. Mayo Clin Proc 2021; 96:464-472. [PMID: 32829903 DOI: 10.1016/j.mayocp.2020.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 10/23/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is common and has significant morbidity and mortality as the fourth leading cause of death in the United States. In many patients, particularly those with emphysema, COPD is characterized by markedly increased residual volume contributing to exertional dyspnea. Current therapies have limited efficacy. Surgical resection of diseased areas of the lung to reduce residual volume was effective in identified subgroups but also had significant mortality in and suboptimal cost effectiveness. Lung-volume reduction, using bronchoscopic techniques, has shown substantial benefits in a broader patient population with less morbidity and mortality. This review is meant to spread the awareness about bronchoscopic lung-volume reduction and to promote its consideration and early referral for patients with advanced COPD and emphysema frequently encountered by both primary care physicians and specialists. A search was conducted on PubMed (MEDLINE), EMbase, and Cochrane library for original studies, using the following keywords: "lung-volume reduction." "endobronchial valves," "intrabronchial valves," "bronchoscopic lung-volume reduction," and "endoscopic lung-volume reduction." We included reports from systematic reviews, narrative reviews, clinical trials, and observational studies. Two reviewers evaluated potential references. A total of 27 references were included in our review. Included studies report experience in the diagnosis and bronchoscopic treatment for emphysema; case reports and non-English or non-Spanish studies were excluded.
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Affiliation(s)
- David Abia-Trujillo
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Margaret M Johnson
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Neal M Patel
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Britney Hazelett
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Eric S Edell
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - Ryan M Kern
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - David Midthun
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | | | - Darlene Nelson
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - John J Mullon
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | | | - Karen Swanson
- Division of Pulmonary Medicine, Mayo Clinic, Phoenix, AZ
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Kheir F, Thakore SR, Uribe Becerra JP, Tahboub M, Kamat R, Abdelghani R, Fernandez-Bussy S, Kaphle UR, Majid A. Cone-Beam Computed Tomography-Guided Electromagnetic Navigation for Peripheral Lung Nodules. Respiration 2021; 100:44-51. [PMID: 33401270 DOI: 10.1159/000510763] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/09/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Electromagnetic navigation bronchoscopy (ENB) is a minimally invasive technology for the diagnosis of peripheral pulmonary nodules. However, ENB is limited by the lack of real-time confirmation of various biopsy devices. Cone-beam computed tomography (CBCT) could increase diagnostic yield by allowing real-time confirmation to overcome the inherent divergence of nodule location. OBJECTIVES The aim of this study was to assess the diagnostic yield of ENB plus CBCT as compared with ENB alone for biopsy of peripheral lung nodules. METHOD We conducted a retrospective study of patients undergoing ENB before and after the implementation of CBCT. Data from 62 consecutive patients with lung nodules located in the outer two-thirds of the lung who underwent ENB and combined ENB-CBCT were collected. Radial endobronchial ultrasound was used during all procedures as well. Diagnostic yield was defined as the presence of malignancy or benign histological findings that lead to a specific diagnosis. RESULTS Thirty-one patients had ENB-CBCT, and 31 patients had only ENB for peripheral lung lesions. The median size of the lesion for the ENB-CBCT group was 16 (interquartile range (IQR) 12.6-25.5) mm as compared to 21.5 (IQR 16-27) mm in the ENB group (p = 0.2). In the univariate analysis, the diagnostic yield of ENB-CBCT was 74.2% and ENB 51.6% (p = 0.05). Following multivariate regression analysis adjusting for the size of the lesion, distance from the pleura, and presence of bronchus sign, the odds ratio for the diagnostic yield was 3.4 (95% CI 1.03-11.26, p = 0.04) in the ENB-CBCT group as compared with ENB alone. The median time for the procedure was shorter in patients in the ENB-CBCT group (74 min) than in those in the ENB group (90 min) (p = 0.02). The rate of adverse events was similar in both groups (6.5%, p = 0.7). CONCLUSIONS The use of CBCT might increase the diagnostic yield in ENB-guided peripheral lung nodule biopsies. Future randomized clinical trials are needed to confirm such findings.
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Affiliation(s)
- Fayez Kheir
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA.,Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sanket R Thakore
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA.,Division of Interventional Pulmonary, Department of Pulmonary, Critical Care and Sleep Medicine, Yale University, New Haven, Connecticut, USA
| | - Juan Pablo Uribe Becerra
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohammad Tahboub
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Rahul Kamat
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Ramsy Abdelghani
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA.,Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Upendra R Kaphle
- Division of Pulmonary and Critical Care, Kaiser Permanente Roseville and Sacramento Medical Center, Roseville, California, USA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA,
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Duke JD, Fernandez-Bussy S, Reisenauer J. Combined portable cone beam computed tomography and robotic-assisted bronchoscopy impacting diagnosis of a solitary pulmonary nodule: a case report. AME Case Rep 2021; 6:23. [PMID: 35928581 PMCID: PMC9343982 DOI: 10.21037/acr-22-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/25/2022] [Indexed: 11/20/2022]
Abstract
Background Lung cancer is the leading cause of cancer-related mortality in men and women throughout the world. Historically, bronchoscopy played a limited role in pulmonary nodule management due to a limited diagnostic accuracy. With the emergence of robotic bronchoscopy, proceduralists can now navigate to more peripheral lesions completely extrinsic to the airways with increased diagnostic yield. Despite the increased diagnostic yield from robotic-assisted bronchoscopy, challenges in exact localization of the lesion during a procedure can occur. This case highlights a novel use of robotic bronchoscopy combined with mobile three-dimensional (3D) imaging to optimize lesion location for biopsy previously not reported in the literature. Case Description We describe a case where the combination of robotic bronchoscopy with new mobile 3D imaging was essential for the accurate biopsy of an incidentally found pulmonary nodule in a 72-year-old woman. Initial navigation to the nodule using robotic bronchoscopy resulted in the catheter being inferior to the area of interest. After renavigation using the information provided by mobile 3D imaging, we were able to confirmed tool-in-lesion prior to biopsy. The patient was diagnosed with adenocarcinoma with papillary features and underwent a lobectomy with a favorable prognosis. Conclusions A diagnosis of adenocarcinoma was made for this patient utilizing the novel combined technique of robotic peripheral pulmonary nodule biopsy with portable 3D imaging, which may improve overall diagnostic accuracy of bronchoscopic biopsy.
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Affiliation(s)
| | | | - Janani Reisenauer
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
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40
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Hazelett BN, Paton A, Majid A, Schreefer K, Folch E, Johnson MM, Patel NM, Abia-Trujillo D, Fernandez-Bussy S. Nurse Coordinator Roles and Responsibilities for Bronchoscopic Lung Volume Reduction With Endobronchial Valves. Chest 2020; 159:2090-2098. [PMID: 33338444 DOI: 10.1016/j.chest.2020.11.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/06/2020] [Accepted: 11/30/2020] [Indexed: 11/25/2022] Open
Abstract
COPD may cause profound dyspnea, functional impairment, and reduced quality of life. Available pharmacologic therapy provides suboptimal symptom improvement in many patients. Bronchoscopic lung volume reduction (BLVR), achieved with endobronchial valve placement, can effectively improve dyspnea and functional status in appropriately selected patients. Operationalizing a safe and effective BLVR program requires appropriate oversight, which can be achieved by a BLVR nurse coordinator (NC). By identifying and developing screening practices, coordinating multidisciplinary diagnostic evaluation, and establishing safe efficient patient flow throughout the entire care process, a BLVR NC can optimize patient care, safety, experience, efficiency, and overall outcomes. This article details the role of our NC to facilitate extrapolation to other institutions.
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Affiliation(s)
- Britney N Hazelett
- Division of Pulmonary, Allergy, Sleep Medicine, and Respiratory Services, Mayo Clinic in Florida, Jacksonville, FL.
| | - Alichia Paton
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kimberly Schreefer
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Erik Folch
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Margaret M Johnson
- Division of Pulmonary, Allergy, Sleep Medicine, and Respiratory Services, Mayo Clinic in Florida, Jacksonville, FL
| | - Neal M Patel
- Division of Pulmonary, Allergy, Sleep Medicine, and Respiratory Services, Mayo Clinic in Florida, Jacksonville, FL
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, Sleep Medicine, and Respiratory Services, Mayo Clinic in Florida, Jacksonville, FL
| | - Sebastian Fernandez-Bussy
- Division of Pulmonary, Allergy, Sleep Medicine, and Respiratory Services, Mayo Clinic in Florida, Jacksonville, FL
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Abia-Trujillo D, Majid A, Johnson MM, Mira-Avendano I, Patel NM, Makey IA, Thomas M, Kornafeld A, Hazelett BN, Fernandez-Bussy S. Central Airway Collapse, an Underappreciated Cause of Respiratory Morbidity. Mayo Clin Proc 2020; 95:2747-2754. [PMID: 32829904 DOI: 10.1016/j.mayocp.2020.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 10/23/2022]
Abstract
Dyspnea, cough, sputum production, and recurrent respiratory infections are frequently encountered clinical concerns leading patients to seek medical care. It is not unusual for a well-defined etiology to remain elusive or for the therapeutics of a presumed etiology to be incompletely effective. Either scenario should prompt consideration of central airway pathology as a contributor to clinical manifestations. Over the past decade, recognition of dynamic central airway collapse during respiration associated with multiple respiratory symptoms has become more commonly appreciated. Expiratory central airway collapse may represent the answer to this diagnostic void. Expiratory central airway collapse is an underdiagnosed disorder that can coexist with and mimic asthma, chronic obstructive pulmonary disease, and bronchiectasis. Awareness of expiratory central airway collapse and its spectrum of symptoms is paramount to its recognition. This review includes clear definitions, diagnostics, and therapeutics for this challenging condition. We performed a narrative review through the PubMed (MEDLINE) database using the following MeSH terms: airway collapse, tracheobronchomalacia, tracheomalacia, and bronchomalacia. We include reports from systematic reviews, narrative reviews, clinical trials, and observational studies from 2005 to 2020. Two reviewers evaluated potential references. No systematic reviews were found. A total of 28 references were included into our review. Included studies report experience in the diagnosis and/or treatment of dynamic central airway collapse; case reports and non-English or non-Spanish studies were excluded. We describe the current diagnostic dilemma, highlighting the role of dynamic bronchoscopy and tracheobronchial stent trial; outline the complex therapeutic options (eg, tracheobronchoplasty); and present future directions and challenges.
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Affiliation(s)
- David Abia-Trujillo
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Margaret M Johnson
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Isabel Mira-Avendano
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Neal M Patel
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Ian A Makey
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Mathew Thomas
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Anna Kornafeld
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Britney N Hazelett
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
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Criner GJ, Eberhardt R, Fernandez-Bussy S, Gompelmann D, Maldonado F, Patel N, Shah PL, Slebos DJ, Valipour A, Wahidi MM, Weir M, Herth FJ. Interventional Bronchoscopy. Am J Respir Crit Care Med 2020; 202:29-50. [PMID: 32023078 DOI: 10.1164/rccm.201907-1292so] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.
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Affiliation(s)
- Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Ralf Eberhardt
- Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | | | - Daniela Gompelmann
- Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Fabien Maldonado
- Department of Medicine and Department of Thoracic Surgery, Vanderbilt University, Nashville, Tennessee
| | - Neal Patel
- Division of Pulmonary Medicine, Mayo Clinic, Jacksonville, Florida
| | - Pallav L Shah
- Respiratory Medicine at the Royal Brompton Hospital and National Heart & Lung Institute, Imperial College, London, United Kingdom
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Krankenhaus Nord, Vienna, Austria; and
| | - Momen M Wahidi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mark Weir
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Felix J Herth
- Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
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Valipour A, Fernandez-Bussy S, Ing AJ, Steinfort DP, Snell GI, Williamson JP, Saghaie T, Irving LB, Dabscheck EJ, Krimsky WS, Waldstreicher J. Bronchial Rheoplasty for Treatment of Chronic Bronchitis. Twelve-Month Results from a Multicenter Clinical Trial. Am J Respir Crit Care Med 2020; 202:681-689. [PMID: 32407638 PMCID: PMC7462406 DOI: 10.1164/rccm.201908-1546oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 05/13/2020] [Indexed: 12/17/2022] Open
Abstract
Rationale: Chronic bronchitis (CB) is characterized by productive cough with excessive mucus production, resulting in quality-of-life impairment and increased exacerbation risk. Bronchial rheoplasty uses an endobronchial catheter to apply nonthermal pulsed electrical fields to the airways. Preclinical studies have demonstrated epithelial ablation followed by regeneration of normalized epithelium.Objectives: To evaluate the feasibility, safety, and initial outcomes of bronchial rheoplasty in patients with CB.Methods: Pooled analysis of two separate studies enrolling 30 patients undergoing bilateral bronchial rheoplasty was conducted. Follow-up through 6 months (primary outcome) and 12 months included assessment of adverse events, airway histology, and changes in symptoms using the Chronic Obstructive Pulmonary Disease (COPD) Assessment Test and St. George's Respiratory Questionnaire (SGRQ).Measurements and Main Results: Bronchial rheoplasty was performed in all 30 patients (63% male; mean [SD] age, 67 [7.4]; mean [SD] postbronchodilator FEV1, 65% [21%]; mean [SD] COPD Assessment Test score 25.6 [7.1]; mean [SD] SGRQ score, 59.6 [15.3]). There were no device-related and four procedure-related serious adverse events through 6 months, and there were none thereafter through 12 months. The most frequent nonserious, device- and/or procedure-related event through 6 months was mild hemoptysis in 47% (14 of 30) patients. Histologically, the mean goblet cell hyperplasia score was reduced by a statistically significant amount (P < 0.001). Significant changes from baseline to 6 months in COPD Assessment Test (mean, -7.9; median, -8.0; P = 0.0002) and SGRQ (mean, -14.6; median, -7.2; P = 0.0002) scores were observed, with similar observations through 12 months.Conclusions: This study provides the first clinical evidence of the feasibility, safety, and initial outcomes of bronchial rheoplasty in symptomatic patients with CB.Clinical trial registered with www.anzctr.org.au (ACTRN 12617000330347) and clinicaltrials.gov (NCT03107494).
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Affiliation(s)
- Arschang Valipour
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Vienna, Austria
| | - Sebastian Fernandez-Bussy
- Division of Pulmonary Medicine, German Clinic of Santiago, Chile
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, Florida
| | - Alvin J. Ing
- MQ Health, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Daniel P. Steinfort
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Respiratory Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Gregory I. Snell
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Australia
| | | | - Tajalli Saghaie
- MQ Health, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Louis B. Irving
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Respiratory Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Eli J. Dabscheck
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Australia
| | - William S. Krimsky
- Medstar Franklin Square Medical Center, Baltimore, Maryland; and
- Gala Therapeutics, Menlo Park, California
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Fernandez-Bussy S, Kornafeld A, Labarca G, Abia-Trujillo D, Patel NM, Herth FJF. Endoscopic Lung Volume Reduction in Relation to Body Mass Index in Patients with Severe Heterogeneous Emphysema. Respiration 2020; 99:477-483. [PMID: 32492686 DOI: 10.1159/000507591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 03/30/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In chronic obstructive pulmonary disease (COPD), body mass index (BMI) is significantly lower in the emphysema-dominant type. Endoscopic lung volume reduction (ELVR) is an innovative way of treating severe emphysema. However, the specific associations of low BMI values and outcomes of ELVR is not well-studied. OBJECTIVES We evaluated associations between initial BMI and changes in major outcomes after endobronchial valve (EBV) placement in patients with heterogeneous severe emphysema. METHODS In a retrospective cohort study, patients were divided into 2 groups based on their baseline BMI (higher BMI ≥21 kg/m2 [n = 18] and lower BMI <21 kg/m2 [n = 63]). Demographics, procedure data, pulmonary function test and 6-min-walk test (6MWT), dyspnea score (according to the modified Medical Research Council [mMRC] scale), BODE (BMI, airflow obstruction, dyspnea, exercise capacity) index, and complications were recorded. After 6 months, changes in variables (dWeight and dBMI) were recorded. RESULTS Comparing the 2 groups, we found the following: a dWeight of -2.34 kg and +3.39 kg (p value <0.01) and a dBMI of -0.74 and +1.99 kg/m2, in the higher BMI and lower BMI group, respectively (p value <0.01). Changes in forced expiratory volume <1 s (FEV1), 6MWT, mMRC score, and BODE index were not statistically significant. The most common complication was pneumothorax. The lower BMI group experienced more complications than the higher BMI group (40 vs. 24%). CONCLUSION Baseline BMI is relevant when selecting candidates for ELVR. Our results show that the COPD patients with a lower BMI gained a significant amount of weight, thus increasing their BMI after the procedure. The rate of complications was higher in the lower BMI group. These findings should alert physicians and encourage nutritional assessment in this population.
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Affiliation(s)
| | - Anna Kornafeld
- Division of Pulmonary and Critical Care, Mayo Clinic, Jacksonville, Florida, USA
| | - Gonzalo Labarca
- Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, University of Concepcion, Concepcion, Chile
| | - David Abia-Trujillo
- Division of Pulmonary and Critical Care, Mayo Clinic, Jacksonville, Florida, USA
| | - Neal M Patel
- Division of Pulmonary and Critical Care, Mayo Clinic, Jacksonville, Florida, USA
| | - Felix J F Herth
- Thoraxklinik, Department of Pulmonology and Respiratory Care Medicine, University of Heidelberg, Heidelberg, Germany
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Folch EE, Labarca G, Ospina-Delgado D, Kheir F, Majid A, Khandhar SJ, Mehta HJ, Jantz MA, Fernandez-Bussy S. Sensitivity and Safety of Electromagnetic Navigation Bronchoscopy for Lung Cancer Diagnosis: Systematic Review and Meta-analysis. Chest 2020; 158:1753-1769. [PMID: 32450240 DOI: 10.1016/j.chest.2020.05.534] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 05/01/2020] [Accepted: 05/08/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Bronchoscopy is a useful tool for the diagnosis of lesions near central airways; however, the diagnostic accuracy of these procedures for peripheral pulmonary lesions (PPLs) is a matter of ongoing debate. In this setting, electromagnetic navigation bronchoscopy (ENB) is a technique used to navigate and obtain samples from these lesions. This systematic review and meta-analysis aims to explore the sensitivity of ENB in patients with PPLs suspected of lung cancer. RESEARCH QUESTION In patients with peripheral pulmonary lesion suspected of lung cancer, what is the sensitivity and safety of electromagnetic navigation bronchoscopy compared to surgery or longitudinal follow up? STUDY DESIGN AND METHODS A comprehensive search of several databases was performed. Extracted data included sensitivity of ENB for malignancy, adequacy of the tissue sample, and complications. The study quality was assessed using the QUADAS-2 tool, and the combined data were meta-analyzed using a bivariate method model. A summary receiver operatic characteristic curve (sROC) was created. Finally, the quality of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS Forty studies with a total of 3,342 participants were included in our analysis. ENB reported a pooled sensitivity of 77% (95% CI, 72%-82%; I2 = 80.6%) and a specificity of 100% (95% CI, 99%-100%; I2 = 0%) for malignancy. The sROC showed an area under the curve of 0.955 (P = .03). ENB achieved a sufficient sample for ancillary tests in 90.9% (95% CI, 84.8%-96.9%; I2 = 80.7%). Risk of pneumothorax was 2.0% (95% CI, 1.0-3.0; I2 = 45.2%). We found subgroup differences according to the risk of bias and the number of sampling techniques. Meta-regression showed an association between sensitivity and the mean distance of the sensor tip to the center of the nodule, the number of tissue sampling techniques, and the cancer prevalence in the study. INTERPRETATION ENB is very safe with good sensitivity for diagnosing malignancy in patients with PPLs. The applicability of our findings is limited because most studies were done with the superDimension navigation system and heterogeneity was high. TRIAL REGISTRY PROSPERO; No.: CRD42019109449; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Erik E Folch
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Gonzalo Labarca
- Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, University of Concepcion, Concepcion, Chile
| | - Daniel Ospina-Delgado
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Fayez Kheir
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Hiren J Mehta
- Division of Pulmonary and Critical Care, University of Florida, Gainesville, FL
| | - Michael A Jantz
- Division of Pulmonary and Critical Care, University of Florida, Gainesville, FL
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Biswas A, Jantz MA, Fernandez-Bussy S, Flanagan M, Mehta HJ. Repositioning of migrated self-expanding metallic tracheobronchial stent: predictors of a successful maneuver and its impact on survival. J Thorac Dis 2020; 12:1866-1876. [PMID: 32642090 PMCID: PMC7330314 DOI: 10.21037/jtd-20-608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Endobronchial stents that are used to treat airway obstruction may migrate over time. These stents can be repositioned. However, not much has been reported about this technique. We retrospectively reviewed our experience with self-expanding metallic stents (SEMS) and attempted to determine—(I) factors related to successful stent repositioning; (II) determine its impact on survival. Methods Demographic, medical history, and stent-related procedure factors were extracted from the electronic health record. Primary outcomes were bronchial stent repositioning success and survival (days until death). As validation of successful repositioning, the durations of successful and failed repositioning procedures were compared using an independent t-test. Results Seventy-six patients underwent stent repositioning, of which, 55.3% (n=42) were successfully repositioned. The probability of success in repositioning procedures was accounted for by patient sex, stent location, and stent diameter. Females were more likely to have a successful repositioning compared to males. Stent repositioning in the LMS was more likely to be successful and stents larger in diameter tended to increase the likelihood of successful repositioning. Long-term survival was higher for those who had a successful procedure. Stent location and disease subgroups predicted average length of survival. Conclusions Repositioning of migrated stents can be successfully performed regardless of the reasons for initial placement, duration of stenting and degree of original obstruction. Larger stents are easier to reposition and so were stents in the left main stem (LMS) airway. A successful stent repositioning maneuver improved long-term survival although did not have any impact survival in the immediate post-procedural period.
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Affiliation(s)
| | | | | | - Mindy Flanagan
- Parkview Regional Medical Center, Fort Wayne, Indiana, USA
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Luo F, Darwiche K, Singh S, Torrego A, Steinfort DP, Gasparini S, Liu D, Zhang W, Fernandez-Bussy S, Herth FJF, Shah PL. Performing Bronchoscopy in Times of the COVID-19 Pandemic: Practice Statement from an International Expert Panel. Respiration 2020; 99:417-422. [PMID: 32344422 PMCID: PMC7251585 DOI: 10.1159/000507898] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 02/05/2023] Open
Abstract
These recommendations for physicians who perform bronchoscopy will help to protect those patients (un)-affected by the current COVID-19 pandemic, minimize the risk of transmission, and maintain clinical care for all patients.
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Affiliation(s)
- Fengming Luo
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Kaid Darwiche
- Department of Interventional Pneumology, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Suveer Singh
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Chelsea and Westminster Hospital, London, United Kingdom
| | - Alfonso Torrego
- Respiratory Department, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Daniel P Steinfort
- Department Respiratory Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Stefano Gasparini
- Department of Biomedical Sciences and Public Health, Polytechnic University of Marche Region Azienda Ospedali Riuniti, Ancona, Italy
| | - Dan Liu
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | | | - Felix J F Herth
- Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Heidelberg, Germany,
- Translational Lung Research Center Heidelberg, Heidelberg, Germany,
| | - Pallav L Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Chelsea and Westminster Hospital, London, United Kingdom
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48
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Holden VK, Ospina-Delgado D, Chee A, Parikh MS, Carreiro MM, Alape Moya D, Fernandez-Bussy S, Herth FJF, Majid A. Safety and Efficacy of the Tracheobronchial Bonastent: A Single-Center Case Series. Respiration 2020; 99:353-359. [PMID: 32259817 DOI: 10.1159/000506815] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/24/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tracheobronchial stents are widely used devices in interventional pulmonology; however, the current literature on the effectiveness and complication rates of the different types of stents is limited. OBJECTIVE We report the largest case series of airway Bonastent placement and describe the efficacy and early (<30 days) and late (≥30 days) complication rates. METHODS We performed a retrospective review of our prospectively collected database of patients who underwent therapeutic bronchoscopy with stent placement. All adult patients who had a tracheal/bronchial Bona-stent placed between July 1, 2017, and July 30, 2019, for any indication at our institution were included. The efficacy as well as intraoperative and short- and long-term complications of Bonastent placement were evaluated. RESULTS Sixty Bonastents were placed in 50 patients. The etiology was malignant in 90% of the cases, while 2 patients had a tracheoesophageal fistula. All procedures were performed via rigid bronchoscopy. The most common location for stent placement was the bronchus intermedius, followed by the trachea, in 32 and 30% of the cases, respectively. Seventy percent of the patients (35/50) had improvement of respiratory symptoms within 30 days. Twenty-eight stents (48%) were removed at a mean of 74 days. Seventeen patients (34%) died within 30 days of stent placement. The overall complication rate was 54% (27/50 patients) at a mean follow-up of 111 days. The stent-related complication rate was 23.3% (14/60 cases) within <30 days and 53% (18/34 cases) at ≥30 days. CONCLUSIONS The tracheobronchial Bonastent is effective for the treatment of patients with central airway obstruction and tracheoesophageal fistulae with an acceptable safety profile.
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Affiliation(s)
- Van Kim Holden
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA, .,Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA,
| | - Daniel Ospina-Delgado
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alex Chee
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mihir S Parikh
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Megan M Carreiro
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Alape Moya
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | | | - Felix J F Herth
- Department of Pulmonary and Critical Care Medicine, Thoraxklinik-University of Heidelberg, Heidelberg, Germany
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Gando S, Labarca G, Majid A, Folch E, Mehta HJ, Jantz M, Fernandez-Bussy S. [Airway tridimensional printing]. Rev Med Chil 2020; 147:1315-1322. [PMID: 32186640 DOI: 10.4067/s0034-98872019001001315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/30/2019] [Indexed: 11/17/2022]
Abstract
Tridimensional printing is becoming relevant in medicine, specially in surgical and interventional specialties. We review the technical aspects and clinical application of airway tridimensional printing. Using this technique, simulation models for bronchoscopy and models for diagnostic and therapeutic procedures such as stent design, tracheal reconstruction and airway models can be created.
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Affiliation(s)
| | - Gonzalo Labarca
- Facultad de Medicina, Universidad San Sebastián, Concepción, Chile
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, United States
| | - Erik Folch
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, United States
| | - Hiren J Mehta
- Division of Pulmonary and Critical Care, University of Florida, Gainesville, United States
| | - Michael Jantz
- Division of Pulmonary and Critical Care, University of Florida, Gainesville, United States
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50
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Folch EE, Mahajan AK, Oberg CL, Maldonado F, Toloza E, Krimsky WS, Oh S, Bowling MR, Benzaquen S, Kinsey CM, Mehta AC, Fernandez-Bussy S, Flandes J, Lau K, Krishna G, Nead MA, Herth F, Aragaki-Nakahodo AA, Barisione E, Bansal S, Zanchi D, Zgoda M, Lutz PO, Lentz RJ, Parks C, Salio M, Perret K, Keyes C, LeMense GP, Hinze JD, Majid A, Christensen M, Kazakov J, Labarca G, Waller E, Studnicka M, Teba CV, Khandhar SJ. Standardized Definitions of Bleeding After Transbronchial Lung Biopsy: A Delphi Consensus Statement From the Nashville Working Group. Chest 2020; 158:393-400. [PMID: 32067944 DOI: 10.1016/j.chest.2020.01.036] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 12/03/2019] [Accepted: 01/25/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Transbronchial lung biopsies are commonly performed for a variety of indications. Although generally well tolerated, complications such as bleeding do occur. Description of bleeding severity is crucial both clinically and in research trials; to date, there is no validated scale that is widely accepted for this purpose. Can a simple, reproducible tool for categorizing the severity of bleeding after transbronchial biopsy be created? METHODS Using the modified Delphi method, an international group of bronchoscopists sought to create a new scale tailored to assess bleeding severity among patients undergoing flexible bronchoscopy with transbronchial lung biopsies. Cessation criteria were specified a priori and included reaching > 80% consensus among the experts or three rounds, whichever occurred first. RESULTS Thirty-six expert bronchoscopists from eight countries, both in academic and community practice settings, participated in the creation of the scale. After the live meeting, two iterations were made. The second and final scale was vetted by all 36 participants, with a weighted average of 4.47/5; 53% were satisfied, and 47% were very satisfied. The panel reached a consensus and proposes the Nashville Bleeding Scale. CONCLUSIONS The use of a simplified airway bleeding scale that can be applied at bedside is an important, necessary tool for categorizing the severity of bleeding. Uniformity in reporting clinically significant airway bleeding during bronchoscopic procedures will improve the quality of the information derived and could lead to standardization of management. In addition to transbronchial biopsies, this scale could also be applied to other bronchoscopic procedures, such as endobronchial biopsy or endobronchial ultrasound-guided needle aspiration.
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Affiliation(s)
- Erik E Folch
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA.
| | | | - Catherine L Oberg
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | | | | | - Scott Oh
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Mark R Bowling
- Division of Pulmonary, Critical Care, and Sleep Medicine, East Carolina University, Greenville, NC
| | | | | | | | | | - Javier Flandes
- Interventional Pulmonology Service, Hospital Universitario Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, Madrid, Spain
| | | | | | | | - Felix Herth
- Department of Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Heidelberg, Germany
| | | | - Emanuela Barisione
- Interventional Pulmonology Unit, IRCCS San Martino Hospital-IST National Cancer Research Institute, Genoa, Italy
| | | | - Dragos Zanchi
- Pulmonary and Sleep of Tampa Bay Inc, Wesley Chapel, FL
| | | | | | | | | | - Mario Salio
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Colleen Keyes
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | - Gonzalo Labarca
- Department of Internal Medicine, Pontifical Catholic University, Santiago, Chile
| | | | - Michael Studnicka
- Department of Pulmonary Medicine, the Paracelsus Medical University, Salzburg, Austria
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