Is chest tube insertion with ultrasound guidance safe in patients using clopidogrel?

Background and objective: Drainage of the pleural space is a common procedure.The safety of chest tube insertion in patients using clopidogrel has not been investigated. Methods: Ultrasound-guided chest tube insertions performed on 24 patients who were being actively treated with clopidogrel were retrospectively reviewed. Results: No excessive bleeding occurred in any of these patients. Conclusions: Given the known effects of clopidogrel on platelet function, these results were interpreted as indicating that clopidogrel therapy is a relative but not an absolute contraindication to chest tube insertion, if an experienced operator places a small-bore tube under ultrasound guidance

Oxygen insufflation through the bronchoscope channel for sedation-induced hypoxia: safe and effective

Objectives: To evaluate both efficacy and safety parameters for insufflation through the bronchoscope as a method of recovery from sedation-induced hypoxia. To explore parameters applicable to use in human beings using an animal model. Materials and methods: Two adult pigs were sedated enough to depress respiratory drive. The effects of insufflation at 15 l/min (the upper limits of flow that might be used clinically) were then evaluated. Pressure and volume responses to bronchoscopy during intubation and without an endotracheal tube in place were recorded. Several assays were performed for each scenario, with each animal acting as its own control. Recovery from hypoxemia using insufflation was compared with recovery using mechanical ventilation. Results: Insufflation was effective, with rapid increases in fraction of inspired oxygen (FIO 2 ), saturation, and partial pressure of arterial oxygen (PaO 2 ). The rate of recovery using insufflation was faster than that from institution of mechanical ventilation. Insufflation in an intubated animal with cuff inflated led to a rapid and dangerous rise in pressure. With balloon deflated, there were no adverse pressure consequences from insufflation via the endotracheal tube at a rate of 15 l/min. Conclusion: Insufflation through the bronchoscope for episodes of sedation-induced hypoxia should be safe and effective as long as not delivered within a closed system

Impact of Moderate Sedation versus Monitored Anesthesia Care on Outcomes and Cost of Endobronchial Ultrasound Transbronchial Needle Aspiration

Background and Objectives. The ideal type of sedation for endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is not known. Two previous studies comparing the diagnostic yield between moderate sedation (MS) and deep sedation/general anesthesia (DS/GA) had provided conflicting results with one study clearly favoring the latter. No study had addressed cost. This is concerning for pulmonologists without routine access to anesthesia services. Our objective was to assess the impact of MS and Monitored Anesthesia Care (sedation administered and monitored by an anesthesiologist) on the outcomes and cost of EBUS-TBNA. Materials and Methods. We performed a retrospective review of prospectively collected data on consecutive EBUS-TBNA performed under two different types of sedation in a single academic center. A diagnostic TBNA was defined as an aspirate yielding any specific diagnosis or if subsequent surgery or follow-up of nondiagnostic/normal aspirates showed no pathology. Current Medicare time-based allowances were used for professional charges calculation. Results. There was no difference observed between MS and MAC in regards of the diagnostic yield (92.9% versus 91.9%), procedure duration, number, location, and size of lymph node (LN) sampled, but there were more passes per LN with MAC. The average charges were 74.30 USD for MS and 319.91 for MAC. There were more hypotensive and desaturations episodes with MAC but none required escalation of care. Conclusions. When performed under MS, EBUS-TBNA has similar diagnostic yield as under MAC but may be associated with less side effects. The difference in sedation cost is modest; however, an additional 245$ for each EBUS done under MAC would have significant cost implications on the health system. These findings are of critical importance for bronchoscopists without routine access to anesthesia services and for optimization of healthcare cost and resource utilization

Safety and Feasibility of a Novel Protocol for Percutaneous Dilatational Tracheostomy in Patients with Respiratory Failure due to COVID-19 Infection: A Single Center Experience

Introduction. The rapidly spreading Novel Coronavirus 2019 (COVID-19) appeared to be a highly transmissible pathogen in healthcare environments and had resulted in a significant number of patients with respiratory failure requiring tracheostomy, an aerosol-generating procedure that places healthcare workers at high risk of contracting the infection. Instead of deferring or delaying the procedure, we developed and implemented a novel percutaneous dilatational tracheostomy (PDT) protocol aimed at minimizing the risk of transmission while maintaining favorable procedural outcome. Patients and Methods. All patients who underwent PDT per novel protocol were included in the study. The key element of the protocol was the use of apnea during the critical part of the insertion and upon any opening of the ventilator circuit. This was coupled with the use of enhanced personnel protection equipment (PPE) with a powered air-purifying respirator (PAPR). The operators underwent antibody serology testing and were evaluated for COVID-19 symptoms two weeks from the last procedure included in the study. Results. Between March 12th and June 30th, 2020, a total of 32 patients underwent PDT per novel protocol. The majority (80%) were positive for COVID-19 at the time of the procedure. The success rate was 94%. Only one patient developed minor self-limited bleeding. None of the proceduralists developed positive serology or any symptoms compatible with COVID-19 infection. Conclusion. A novel protocol that uses periods of apnea during opening of the ventilator circuit along with PAPR-enhanced PPE for PDT on COVID-19 patients appears to be effective and safe for patients and healthcare providers

Endobronchial valves for bronchopleural fistula: pitfalls and principles

Background: Placement of endobronchial valves for bronchopleural fistula (BPF) is not always straightforward. A simple guide to the steps for an uncomplicated procedure does not encompass pitfalls that need to be understood and overcome to maximize the efficacy of this modality. Objectives: The objective of this study was to discuss examples of difficult cases for which the placement of endobronchial valves was not straightforward and required alterations in the usual basic steps. Subsequently, we aimed to provide guiding principles for a successful procedure. Methods: Six illustrative cases were selected to demonstrate issues that can arise during endobronchial valve placement. Results: In each case, a real or apparent lack of decrease in airflow through a BPF was diagnosed and addressed. We have used the selected problem cases to illustrate principles, with the goal of helping to increase the success rate for endobronchial valve placement in the treatment of BPF. Conclusions: This series demonstrates issues that complicate effective placement of endobronchial valves for BPF. These issues form the basis for troubleshooting steps that complement the basic procedural steps