No Fellow Left Behind,

Graduating Fellows’ Procedural Comfort Level With Pulmonary Critical Care Procedures Background: Graduating fellows from pulmonary and critical care programs are expected to independently perform bronchoscopy and common medical procedures in the intensive care unit. Given variable exposure and learning opportunities at different training programs, little is known about how comfortable graduating fellows are with these procedures. Methods: A survey concerning the ACGME required procedures for pulmonary and critical care fellowship was sent to graduating fellows and program directors at all ACGME accredited subspecialty fellowship programs in pulmonary, critical care, and combined pulmonary critical care medicine. Results: Critical care fellows performed the most intubations, paracenteses, arterial lines, central venous catheter insertions, and cardioversions, but did not perform as many bronchoscopy related procedures as the other subgroups. Pulmonary and combined pulmonary/critical care fellows performed and felt confident in most procedures. Program directors from all specialties agreed with the fellows overall about the procedural confidence gained during training. There also appeared to be a correlation between number of procedures performed and the confidence of the proceduralist. There appears to be a certain threshold number of successful completions to achieve confidence for independent practice for each surveyed procedure. Conclusion: There is a correlation between a fellow’s procedural comfort with independent practice and the number of successful attempts by a graduating fellow. There are no universal guidelines that outline the appropriate number of successful attempts needed for independent practice, and our data strongly suggests that there is a threshold for each procedure across these three subspecialties.

Tissue Acquisition During EBUS-TBNA: Comparison of Cell Blocks Obtained From a 19G Versus 21G Needle Background: Previous studies have shown that needle gauge size has no significant impact on diagnostic yield during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Our objective was to determine whether cell blocks obtained via the new Flex 19G EBUS-TBNA needle would contain more cellular material based on cell area compared with those obtained from a 21G needle. Methods: A prospective analysis of patients undergoing EBUS-TBNA at our institutions was performed. Sampling of the same lesion(s) with both the Flex 19G and 21G needles was performed in an alternating manner. In total, 47 patients with suspected lung cancer or mediastinal/hilar lymphadenopathy were included with a total of 83 lesions biopsied. Cell block area was calculated using the Aperio ImageScope software. Results: Mean cell area in the Flex 19G group was 7.34±12.46 mm2 compared with 5.23±10.73 mm2 in the 21G group (P=0.02). In the malignant subgroup, the average cell area was 16.16±16.30 mm2 in the Flex 19G group versus 11.09±15.55 mm2 in the 21G group (P=0.02). No significant difference was noted in the mean cell area within the nonmalignant subgroup, 1.80±3.01 mm2 in the 19G group versus 1.56±1.79 mm2 in the 21G group (P=0.60). Conclusion: The cell area obtained via the 19G needle was significantly larger than that obtained with the 21G needle. Further multicenter randomized studies are needed to identify the utility of the Flex 19G needle in diagnosing/subtyping lymphoproliferative disorders and adequacy for molecular testing in non–small cell lung cancer.

Radial Endobronchial Ultrasound-guided Transbronchial Cryobiopsy Background: Transbronchial lung cryobiopsy (TBLC) is a novel technique that has proved its diagnostic value in various diffuse parenchymal lung diseases (DPLD). However, there is substantial variability among interventional pulmonologists in procedural technique, diagnostic yield, and complication rate. Radial endobronchial ultrasound (R-EBUS) is useful for identification of ground-glass opacity lesions and can help identify target lung parenchyma. We aim to evaluate R-EBUS in TBLC histopathologic diagnosis for patients with DPLD. Methods: This was a prospective observational study of patients with clinical and radiologic features suggestive of DPLD who underwent TBLC. The R-EBUS probe was initially advanced to the desired lobe under fluoroscopic guidance until reaching 1 cm from the pleura. R-EBUS images were identified looking for either blizzard or mixed blizzard signs. TBLC samples were sent to pathology and microbiology laboratories for diagnostic analysis. Procedural complications were recorded. Results: In total, 40 patients (16 women/24 men) with a mean age of 63 years were included. The mean area of the samples was 36.2 mm2 (9 to 189 mm2) with mean number of samples per procedure of 3.45 (1 to 6). Definitive diagnosis was obtained in 37 patients (92.5%). The most frequent histopathologic patterns were: usual interstitial pneumonia (37.5%), nonspecific interstitial pneumonia (17.5%), and pulmonary infection (7.5%). There were 2 pneumothoraces (5%) and 5 cases of moderate bleeding (12.5%). Conclusion: The use of R-EBUS to locate and select target lung biopsy site before TBLC might increase diagnostic yield. Randomized studies comparing TBLC histopathologic diagnosis with and without R-EBUS are needed to ascertain its clinical value.

Safety of Pleuroscopy Performed in Negative Pressure Bronchoscopy Rooms Background: The use of pleuroscopy has expanded over the last decade due to its higher diagnostic yield and low complications rate. Whether the infectious complications of pleuroscopy performed in negative pressure rooms is similar to that of pleuroscopy performed in positive pressure rooms remain unclear. To assess the safety of pleuroscopy performed in negative pressure rooms, we sought to determine the rate of infectious complications in patients who underwent pleuroscopy in negative pressure bronchoscopy rooms at our institution. Methods: This was a retrospective cohort study of all patients who underwent pleuroscopy in our institution’s negative pressure bronchoscopy rooms between January 2005 and January 2018. The primary outcome was the incidence of infectious complications at 14 and 30 days after the procedure. Results: We identified 318 patients. Of the 318 patients, 47 (15%) had hematological malignancies, 118 (37%) had lung cancer, 121 (38%) had solid non–lung cancers, and 32 (10%) had no cancer diagnosis before the procedure. At the end of pleuroscopy, 255 patients (80%) had an indwelling pleural catheter placed, 63 patients (20%) had only a chest tube placed, and 31 patients (9%) had both an indwelling pleural catheter and chest tube placed. No patients developed empyema within 14 days. Three patients (0.9%) developed empyema within 30 days after the procedure and was presumed to be due to pleural catheter infection in all cases. Conclusion: Our findings show that pleuroscopy performed in negative pressure rooms has a low incidence of infectious complications, provided that proper sterile precautions are maintained.

A Single Center Experience of Feasibility of a Novel Self-Expanding Metallic Airway Stent (Bonastent): A Case Series Background: Central airway obstruction (CAO) is defined as obstruction of the airway lumen in the trachea or mainstem bronchi, most commonly due to primary or metastatic malignancy; and is classified as extraluminal, endoluminal, or mixed. The majority of malignant CAO are advanced stage and require a multimodality palliative approach, including stent placement. We describe a retrospective review of a novel self-expandable metallic stent, the Bonastent; a fully covered, nitinol-braided airway stent which conforms to airway tortuosity without loss of diameter in the management of CAO. Methods: We performed a retrospective chart review of patients with CAO who underwent Bonastent placement at a single center between February 2017 and March 2018. Ease of stent placement, short-term complications (within 24 h of stent placement) and long-term complications (within 3 mo of stent placement) were recorded. Results: Eleven patients were identified, reviewed and included in the study. Thirteen stents in 11 patients were placed for predominantly malignant CAO. One patient had a short-term complication of stent migration. Four patients had long-term complications; of which 3 patients had in-stent mucus impaction requiring bronchoscopy. In our study, the stent-related complication rates were comparable to the reported literature. Conclusion: In our experience, Bonastent is an easy to use option which adds to the armamentarium of the self-expandable metallic stent to treat malignant CAO.

Fiberoptic Bronchoscopic Balloon Dilatation of Bronchial Stenosis in Children Background: Bronchial stenosis and treatment with balloon dilatation are rarely experienced in children. The aim of this study was to investigate the results of fiberoptic bronchoscopic balloon dilatation (BBD) in children. Methods: Between January 2016 and March 2018, 7 children diagnosed as having bronchial stenosis and who underwent BBD as the first treatment option were enrolled in the study. Results: A total of 10 BBDs were performed in 7 patients with a median age of 10 months. Underlying causes were as follows: prolonged intubation and prematurity in 4 patients, extubation failure in 2 patients, and recurrent pneumonia and malignancy in 1 patient. The only complication was laceration, seen in 2 patients. The patients were symptom free for 11 months. Conclusion: BBD is safe, effective, and might be the first-line treatment option for children with bronchial stenosis.

A Single-Center Case Series Describing Tracheobronchial Bonastent Implantation Background: The Bonastent is one of the newest self-expanding metallic tracheobronchial prostheses being used in the central airways. Experience with this stent is limited; there is a gap in literature. We report herein a case series of Bonastent implantation across a variety of tracheobronchial pathologies. Methods: All adult patients who had a Bonastent implanted within the tracheobronchial tree between November 2017 through May 2018 were included in this case series. Data were derived from a combination of sources: electronic medical records and a Research Electronic Data Capture–based bronchoscopy registry. Demographic, procedural, and short-term outcome data were collected for each patient. Results: Thirteen Bonastents were implanted in 11 patients during the observational period. Seven patients were male (64%); the mean age was 62.2 years. The most common indication was nonmalignant airway obstruction in a transplanted lung (n=6, 56%). Over half of all stents (n=8) were implanted in the bronchus intermedius. Three patients (27%) had clinically significant obstruction from their Bonastent. Conclusion: The Bonastent is the newest self-expanding metallic endotracheobronchial stent on the market. Like any other stent, it has its advantages and drawbacks. Interestingly, we noted 3 instances of tissue ingrowth through the covered portion of the stent. Larger studies with a longer follow-up periods are needed to assess long-term efficacy and safety of this relatively novel stent.

Predictors of Severe Bleeding During Endobronchial Biopsy: Experience of 537 Cases Background: Endobronchial biopsy (EBB) remains the standard procedure for evaluating endobronchial lesions visualized during flexible bronchoscopy. However, the predictors of bleeding and its impact on the diagnostic yield of EBB remains unknown. Methods: This was a retrospective study of subjects who underwent EBB for suspected neoplastic endobronchial lesion. We noted the demographic details, radiology, bronchoscopy findings (vascularity and location of the lesion), and the procedural details. Immediately after EBB, the bronchoscopist recorded the severity of bleed as none, mild, moderate, or severe (requiring instillation of cold saline/topical adrenaline or tamponade to control bleed). We assessed the diagnostic yield of EBB, the incidence and predictors of severe bleeding. Results: A total of 537 subjects with a mean age of 59.7 years (84.2% males) were included. On histopathology, malignancy was confirmed in 429 (85.8%) subjects. Severe bleeding occurred in 45 (8%) subjects. On a multivariate logistic regression analysis, bronchoscopic appearance of increased vascularity [odds ratio (95% confidence interval), 2.68 (1.38-5.19)] and the central location of the tumor [odds ratio (95% confidence interval), 3.01 (1.52-5.96)] were independent predictors of severe bleeding during EBB. Severe bleeding led to significantly lesser median number of biopsies (4 vs. 6, P=0.001) obtained, and a higher proportion of nondiagnostic biopsies (20% vs. 7.1%, P=0.004). Conclusion: Severe bleeding during EBB was associated with a decrease in the number of biopsies obtained and a lower diagnostic yield. A centrally located and vascular-appearing lesion on bronchoscopy predicted severe bleeding.

Incidence of Bleeding Complications With Flexible Bronchoscopy in Cancer Patients With Thrombocytopenia Background: Bronchoscopy is a safe procedure, but current guidelines recommend transfusion for platelets <20 K/μL. Studies of bronchoscopy in thrombocytopenia are limited. Objectives: Our objective was to evaluate the incidence of bleeding with flexible bronchoscopy in those with thrombocytopenia especially those <20 K/μL. Method: We performed a retrospective review of all flexible bronchoscopies between June 1, 2008 and December 31, 2010. Biopsies and therapeutic procedures were excluded. The χ2, Fisher exact, and Rank-sum test were conducted to evaluate associations of clinically significant bleeding. Results: There were 1711 patients who underwent 2053 flexible bronchoscopies. Cancer diagnosis included hematologic (61.3%) and solid organ malignancy (34.9%). Half of the bronchoscopies had moderate to severe thrombocytopenia (<100 K/μL) with the following ranges: 14.7% with 50 to <100 K/μL, 20.6% with 20 to <50 K/μL, 10.6% with 10 to <20 K/μL, 4.1% with <10 K/μL. Platelet transfusion was given in 90.6% of those with platelets <10 K/μL and 55.5% of those with platelets 10 to <20 K/μL. The nasal route for bronchoscopy was used in 92.4%. Bleeding complication rate however was 1.1% (0.2% major) and not affected by platelets. Conclusion: Bronchoscopy with lavage can be safely performed without platelet transfusion in those with platelets of ≥10 K/μL. In the absence of nasal bleeding, trauma, or deformity, the nasal route can be used for bronchoscopy.