Czarnecka and Yasufuku published a comprehensive review on diagnostic bronchoscopic techniques for targeting peripheral pulmonary nodules or masses, mediastinal staging of thoracic malignancies and detection of early central airway cancers as well as pleuroscopy for the evaluation of pleural effusions. In the largest postal survey about bronchoscopic practice in Japan, questionnaires were mailed to 538 facilities accredited by Japan Society for Respiratory Endoscopy, and 95% responded. Bronchoscopy was performed by pulmonologists in 64%; surgeons in 5% and both pulmonologist and surgeons in 31% of the facilities surveyed. Majority of diagnostic bronchoscopy was conducted in an outpatient setting. Written informed consent was obtained in 96.8%; verbal consent in 2.8% and not obtained in 0.4%. Prebronchoscopy tests were checked in 80%, fluoroscopy utilized in 99.8% and post-transbronchial lung biopsy chest X-ray in 70%. While intravenous sedatives were used in 36%, atropine was administered in 67.5% of facilities. Most bronchoscopies were performed via the oral route and biopsy performed after antiplatelet drugs, and anticoagulants have been discontinued in 97%. Semiflexible pleuroscopy and convex endobronchial ultrasound-guided transbronchial needle aspiration under local anaesthesia were commonly performed except rigid bronchoscopy in 18.5% of facilities. The authors noted that there were improvements from 2006 survey with use of atropine decreased from 92% to 67.5%, cessation of antiplatelet drugs and anticoagulants before biopsy, and intravenous sedatives in 36%. Higher frequency of antibiotic administration, prebronchoscopy testing and via oral route signalled practice differences between Japan and other countries.
Stather DR et al. conducted a retrospective review of consecutive pulmonary procedures performed by an interventional pulmonologist from July 2007 to April 2011. More than 50% of 1100 procedures were advanced diagnostic procedures such as endobronchial ultrasound-guided transbronchial needle aspiration, electromagnetic navigation bronchoscopy (ENB) and/or peripheral endobronchial ultrasound. A trainee participated in 84% of these procedures with a trend towards increased complication rates in the trainee versus no trainee groups (4.7% vs 1.1%, P 0.076). Significant differences in procedural length in favour of the no-trainee group (58.32 min vs 37.69 min, P 0.001) as well as dose of propofol (178.3 mg vs 137.1 mg, P 0.002) were noted. The authors opined that in an academic interventional pulmonology centre that practiced the apprenticeship model, trainee participation led to increased procedure time, higher doses of sedation and a trend towards increased complications, incorporation of bronchoscopy simulators and low-fidelity models into the training curriculum could reduce the burden of procedural learning on patients.[81-83]
Radial endobronchial ultrasound (pEBUS) has improved the diagnostic yield of transbronchial biopsy of peripheral pulmonary lesions. Two measurable components are diagnostic and visualization yields which are intimately related as the diagnostic yield is demonstrably higher if the lesion is visualized on pEBUS. Tay JH et al. performed a retrospective analysis of 196 consecutive patients who underwent pEBUS. Size and distance of the lesion from the hilum and pleura were measured with CT scans. A definitive diagnosis was established in 56% of patients although the endobronchial ultrasound visualization yield was 79% indicative of diagnostic gap. pEBUS visualized lesions gave higher diagnostic yields (65%) than pEBUS-invisible lesions (20%; P 0.0001). Malignancy, lesions larger than 20 mm and within 50 mm from the hilum were factors associated with higher visualization yield. Clinicians should keep these in mind during the evaluation of patients with peripheral pulmonary lesions.
A previous study found that the path to the pulmonary nodule (≤30 mm) was the most significant factor in influencing the diagnostic accuracy, and navigation technology may aid in targeting the pulmonary nodule. Tamiya M et al. combined pEBUS with guide sheath (GS), thin bronchoscope and LungPoint (Broncus Medical, Inc. Mountain View, CA, USA), a virtual bronchoscopic navigation system for small pulmonary nodules. Sixty-eight consecutive patients were recruited and LungPoint was used to identify the bronchus leading to the pulmonary nodule. Overall, diagnostic yield was 77.9%; 83.7% for malignancy and 68.0% for benign disease. Univariate and multivariate analyses showed that pEBUS localization was the most significant contributor to diagnostic yield especially if the probe was within the lesion (92%) compared with adjacent to the lesion (60%). In another study, pEBUS-GS was performed first to localize peripheral pulmonary lesions, with as needed ENB if pEBUS-GS failed. Sixty patients were enrolled, average lesion size was 27 mm and mean pleural distance was 20 mm. pEBUS detected 75% of peripheral pulmonary lesions. Addition of ENB improved lesion visualization to 93%. However, diagnostic yields for pEBUS and combined pEBUS with ENB were not statistically different (43% vs 50%). Predictive factors for ENB were smaller peripheral pulmonary lesions and absent CT air bronchus sign. Although ENB improved localization, it was not adequate to achieve diagnosis, and improvements in sampling methods could bridge the gap between localization and diagnosis.
Fruchter O et al. evaluated a novel sampling technique in a group of lung transplant recipients. Bronchoscopic lung biopsies remain the gold standard for assessment of allograft rejection or infection. Forty patients underwent cryo-transbronchial biopsies and were matched against 40 controls with forceps-transbronchial biopsies. There were no major complications. The mean diameter of cryo-biopsy was 10 mm against 2 mm with forceps-transbronchial biopsies (P < 0.05). This increase in size and quality of cryo-biopsies translated to increase in alveolated tissue (65% vs 34%, P < 0.05) that enabled histological diagnoses of acute rejection, pneumonitis, diffuse alveolar damage and confident exclusion of acute rejection, infection or pneumonitis. In addition, fluoroscopy time was shorter in patients undergoing cryo-biopsy compared with controls (25 s vs 90 s, P < 0.05).
Fifty-one patients with both malignant and benign central airway obstruction underwent microdebrider bronchoscopy. The lesions involved the trachea, main stem bronchi and bronchus intermedius with some patients having more than one. Satisfactory recanalization of central airway obstruction was achieved with microdebrider. There were no major complications: one patient developed pneumomediastinum while the other required stent removal, and two patients died within 30 days due to unrelated causes.
Retrospective chart review was conducted for 46 patients suspected of broncholithiasis. Cough occurred in 46%, haemoptysis in 41% and purulent sputum in 24%. Cough was more common in intraluminal broncholiths. The broncholiths were classified based on CT and bronchoscopic findings as intraluminal, mixed with both intraluminal and extraluminal components and extraluminal. All intraluminal broncholiths were removed successfully via flexible or rigid bronchoscopy. However for mixed types, complete removal of the broncholiths was not accomplished with bronchoscopy and 40% required surgery. For those with extraluminal broncholiths, they were surgically resected for symptom control. No surgical morbidity or 30-day mortality was observed. Management of broncholithiasis depends on chest CT and bronchoscopic findings: intraluminal broncholiths can be removed using bronchoscopic techniques, while surgery is considered for symptomatic mixed or extraluminal broncholiths.
This bronchoscopic subsection ends with a case report of chronic silicosis diagnosed on endobronchial ultrasound-guided transbronchial needle aspiration of enlarged hilar lymph node when radiological features were inconclusive of silicosis.
Clinical, radiographical and microbiological findings are considered important in determining NTM infection. The American Thoracic Society guidelines identify pulmonary nodules, cavities and bronchiectasis as acute infection. These criteria have been described for Mycobacterium avium complex, M. kansasii and M. abscessus. CT abnormalities and how they relate to symptomatology and microbiological findings are less well known in other less common species of NTM. Maselli and Fernandez described CT features and correlated them with symptoms and microbiological disease in pulmonary M. xenopi. Seventy consecutive immunocompetent patients with pulmonary M. xenopi isolation were classified according to American Thoracic Society diagnostic criteria as definite, possible and no disease. Mean age was 63 years, and 39% were women. Among patients with ‘definite disease’, CT showed nodules in 88%, cavities in 63% and bronchiectasis or tree-in-bud in 50%. All patients with ‘possible’ disease had nodules and 40% had bronchiectasis or tree-in-bud. For those with ‘no disease’, CT also showed nodules in 80%, bronchiectasis in 18% and tree-in-bud in 11%. Cavitation and nodules ≥ 5 mm satisfied microbiological criteria for disease, while bronchiectasis and nodules <5 mm were associated with symptoms of infection. The study by Marras TK et al. also sheds light on how CT abnormalities predict microbiological and clinical findings of M. xenopi infection in immunocompetent patients. NTM infection should be considered in the diagnostic workup of patients with cavitary lesions affecting the upper lobes.
Chest tube insertion can be life saving but is a high-stake procedure. In fact, one study showed that 10% of clinically identified sites for pleural intervention would have led to organ perforation. Ultrasound guidance is currently recommended for all pleural procedures. Although ultrasound guidance has reduced the risk of organ perforation, intrapleural haemorrhage from intercostal artery trauma from chest tube insertion remains a significant concern, and such bleeding can be uncontrollable given the negative intrapleural pressure and inaccessibility to external compression. The intercostal artery is exposed within 6 cm of the spinal column as confirmed by cadaveric dissection, CT studies and thoracoscopic observation,[98, 99] and guidelines recommend mid-axillary chest tube placement within the ‘safe triangle’ where the rib protects the intercostal artery. Anatomical variation can however occur. Salamonsen M et al. evaluated the sensitivity of thoracic ultrasound to detect the intercostal artery compared with CT. Fifty patients underwent ultrasound examination to visualize the vessel at three positions labelled with radio-opaque fiducial markers before contrast enhanced CT. The vessel was unshielded by a rib according to CT in 114 of the 133 positions. The sensitivity, specificity and negative predictive values of portable ultrasound to image the vessel when it was within the intercostal space on CT were 0.86, 0.30 and 0.27, respectively. Time required for a pulmonologist to locate the vessel was 42 s and 18 s using the portable and high-end ultrasound respectively, and there was no difference in performance between two ultrasound systems. The authors concluded that portable ultrasound can be used to screen for the intercostal artery vessel quickly in a busy clinical practice, and recommended its use before any planned pleural procedure to minimize trauma and complications. However, the findings need to be further validated prospectively in a robustly designed study.