Ultrasound-guided forceps for pleural biopsy

AbstractPurposeUltrasound guided forceps for pleural biopsy is a technique that can cover the diagnostic yield gap between the needle biopsy of the pleura and thoracoscopy or thoracotomy. This technique enables operator to take biopsy from multiple pleural sites. Study objectives were: (1) to describe the ultrasound guided forceps for pleural biopsy as a technique not in common use in our practice to obtain pleural biopsy. (2) To evaluate the diagnostic yield of this technique in undiagnosed exudative pleural effusion.MethodsThis study included 96 patients admitted to Chest Department – Assiut University Hospital during the period from March 2010 to January 2012. All patients had exudative pleural effusion with the first pleural tapping being undiagnostic. Patients with bleeding tendency or blood coagulation defects were excluded from the study. Each one was submitted for the procedure once. The equipment used were ultrasound apparatus (ALOKA – Prosound – SSD – 3500SV), biopsy forceps (KARL – STORZ – Germany 10329L – BS), trocar and cannula of Cope’s needle and rubber inlet seal. The procedure was performed under local anesthesia (Xylocaine 2%) and aseptic condition. The patients were premedicated by analgesic (Ketorolac thromethamine 20mg). Three to five biopsy fragments were obtained from each case and sent in 10% formaldehyde to the pathology laboratory. All patients were submitted for thoracoscopy under local anesthesia and thoracoscopic forceps biopsies of pleura were taken.ResultsCompared to thoracoscopy the sensitivity of ultrasound guided forceps pleural biopsy in the diagnosis of malignant and tuberculous lesions was 85% and 88% respectively. The technique was absolutely specific in the diagnosis of malignant and tuberculous lesions.ConclusionsUltrasound-guided forceps for pleural biopsy is a simple, efficient, and safe procedure. It can be carried out easily and safely even in sick and obese patients. On the other hand, the procedure appears similar to the thoracoscopy in obtaining adequate pleural tissue specimens. Yet, it is simpler and less traumatic.Clinical implicationsUltrasound-guided forceps for pleural biopsy can overcome many of the limitations of the conventional needle biopsy procedures, provides multiple biopsy specimens of the parietal pleura that are inaccessible to the biopsy needle, and can be carried out easily and safely even in sick and obese patients. The diagnostic yield is nearly similar to thoracoscopy

Ultrasound guided pleural brushing: A new method for obtaining pleural specimen in malignant effusion

Purpose: Encouraging positive diagnostic yields in malignant pleural effusion could be obtained by pleural brushing performed through two techniques, the first was closed and the second was thoracoscopic. Until now the ultrasound guided pleural brushing is not included within these techniques and its diagnostic yield therefore is not evaluated. So the aim of this study was to evaluate the diagnostic yield of this procedure and its contributions as a technique not used previously in the interventional pulmonology practice to obtain pleural specimen for cytological examination in malignant pleural effusion. Methods: This prospective interventional study was conducted in the Chest Department – Assiut University Hospital during the period from July 2014 to September 2015. Patients who had highly suspicious malignant pleural effusion (clinical, radiological, and laboratory) were hospitalized and enrolled in this study. Patients with bleeding tendency or coagulation profile abnormalities were excluded from the study. Patients were also excluded from this study if the etiology of effusion was proved to be benign. Informed written consent was obtained from all patients. The equipment used in our study were ultrasound apparatus (ALOKA – Prosound – SSD – 3500SV), biopsy forceps (KARL – STORZ – Germany 10329L – BS), the bronchoscopic cleaning brush (PENTAX CS6002SN) trocar and cannula of Cope’s needle and the semi rigid thoracoscope (LTF; Olympus; Tokyo, Japan). Thoracentesis, pleural brushing and biopsy forceps of the pleura were performed for all enrolled patients in the ultrasound unit of the Chest Department while thoracoscopy was done in the endoscopy unit only for patients in whom the diagnosis could not be achieved by these procedures. Results: Among 22 patients who were finally documented to have malignancy, the ultrasound guided pleural brushing provided diagnosis in 9 (41%)/22 cases, it was exclusively diagnostic in 3 patients. Interestingly, the yield of this procedure had its contributions regarding the final pathological diagnosis of our cases, it could augment the positive yield to be 55% instead of 41% (for pleural fluid cytology alone), 82% instead of 68% (for biopsy forceps alone) and 86% instead of 72% (for both fluid cytology and forceps biopsy). The recorded complications in our study were minimal and not associated with any mortality. Conclusions: Ultrasound-guided pleural brushing is a new method for obtaining pleural specimens. It is a simple and relatively safe procedure. This technique provides additional diagnostic yield in malignant pleural effusion. We recommend it beside others in our diagnostic practice for suspicious malignant effusion especially when thoracoscopy is not available

Ultrasound-guided forceps for pleural biopsy

Purpose: Ultrasound guided forceps for pleural biopsy is a technique that can cover the diagnostic yield gap between the needle biopsy of the pleura and thoracoscopy or thoracotomy. This technique enables operator to take biopsy from multiple pleural sites. Study objectives were: (1) to describe the ultrasound guided forceps for pleural biopsy as a technique not in common use in our practice to obtain pleural biopsy. (2) To evaluate the diagnostic yield of this technique in undiagnosed exudative pleural effusion. Methods: This study included 96 patients admitted to Chest Department – Assiut University Hospital during the period from March 2010 to January 2012. All patients had exudative pleural effusion with the first pleural tapping being undiagnostic. Patients with bleeding tendency or blood coagulation defects were excluded from the study. Each one was submitted for the procedure once. The equipment used were ultrasound apparatus (ALOKA – Prosound – SSD – 3500SV), biopsy forceps (KARL – STORZ – Germany 10329L – BS), trocar and cannula of Cope’s needle and rubber inlet seal. The procedure was performed under local anesthesia (Xylocaine 2%) and aseptic condition. The patients were premedicated by analgesic (Ketorolac thromethamine 20 mg). Three to five biopsy fragments were obtained from each case and sent in 10% formaldehyde to the pathology laboratory. All patients were submitted for thoracoscopy under local anesthesia and thoracoscopic forceps biopsies of pleura were taken. Results: Compared to thoracoscopy the sensitivity of ultrasound guided forceps pleural biopsy in the diagnosis of malignant and tuberculous lesions was 85% and 88% respectively. The technique was absolutely specific in the diagnosis of malignant and tuberculous lesions. Conclusions: Ultrasound-guided forceps for pleural biopsy is a simple, efficient, and safe procedure. It can be carried out easily and safely even in sick and obese patients. On the other hand, the procedure appears similar to the thoracoscopy in obtaining adequate pleural tissue specimens. Yet, it is simpler and less traumatic. Clinical implications: Ultrasound-guided forceps for pleural biopsy can overcome many of the limitations of the conventional needle biopsy procedures, provides multiple biopsy specimens of the parietal pleura that are inaccessible to the biopsy needle, and can be carried out easily and safely even in sick and obese patients. The diagnostic yield is nearly similar to thoracoscopy

Ultrasound confirmation of endotracheal tube placement

Introduction Endotracheal intubation is an important technique in airway management. Although, little experience is present in the use of ultrasound in endotracheal intubation, studies suggest that it is reliable and fast as other usual methods and is a simple, feasible, portable, and noninvasive tool. Aim To assess the usefulness of ultrasonography compared with capnography and chest radiography in confirmation of correct endotracheal tube position in ICU patients. Patients and methods Fifty patients in need for intubation were included in this study. All patients were subjected immediately after intubation to the following to confirm correct endotracheal intubation: clinical evaluation, neck ultrasound, chest ultrasound, and chest radiographs. All methods were compared with capnography, the gold standard method for confirmation. Results Successful endotracheal intubation was confirmed by the presence of three successive waves in the capnography. This was achieved in 48 (96%) of cases (endotracheal tube), and in two (4%) cases, the tube was falsely placed in the esophagus. Direct localization of intubation by neck ultrasound had 97.7% sensitivity and 100% specificity to confirm correct intubation. On the contrary, indirect localization of the tube by chest ultrasound had 93.7% sensitivity and 100% specificity. Although localization of the tube by chest radiography has 97.8% sensitivity, it took longer time to be done in such critical casas (29236.44 ± 768.27 s). Clinical evidence of intubation had 95.8% sensitivity and 100% specificity. Conclusion Ultrasonography is a feasible, fast, and cost-effective method for the confirmation of the correct endotracheal tube placement

Diagnostic performance of trans-thoracic sonography in patients of pneumonia and pulmonary embolism

Background: Trans-thoracic ultrasonography (TUS) has attracted great interest in the last few years in the diagnosis of some chest diseases that have a high mortality rate. Objective: This study was conducted to determine the diagnostic accuracy of TUS in patients with pneumonia and pulmonary embolism. In addition, the sonomorphological changes in both diseases were studied. Patients and methods: The study population comprised of 17 cases of pneumonia (10 males and 7 females) with a mean age of 52.02 years and 14 cases of pulmonary embolism (9 males and 5 females) with a mean age of 43.4 years. Diagnosis was based on the standard guidelines. Chest X-rays, arterial blood gases, CT chest and TUS were performed. Lung profile and other sonographic abnormalities were assessed by TUS. Results: The sensitivities, specificities and diagnostic accuracies of TUS based on lung profile vs. CT findings were 88.2%, 87.5% and 93.5% for pneumonia, 71.4%, 80.9% and 87.1% for pulmonary embolism, respectively. Chest X-ray was diagnostic for pneumonia in 11/17 cases (sensitivity 64.7%) whereas TUS was positive in 14/17 (sensitivity 82.4%) with a significant higher area under the curve for TUS vs. chest X-ray (0.84 vs. 0.70, P = 0.02). 82% and 64.3% of patients with pneumonia and pulmonary embolism, respectively had abnormal parenchymal lesions with most of these lesions showing no significant difference in the two disease entities. Conclusions: Lung profiles that can be detected using TUS can perform well to some extent as a rapid diagnostic technique among patients with pneumonia and pulmonary embolism. TUS seems to be superior to chest X-ray in the diagnosis of pneumonia. However, TUS failed to discriminate between pneumonia and pulmonary embolism on studying their parenchymal lesions

BACTERIAL PROFILE, ANTIBIOTIC SENSITIVITY AND RESISTANCE OF LOWER RESPIRATORY TRACT INFECTIONS IN UPPER EGYPT

BACKGROUND: Lower respiratory tract infections (LRTI) account for a considerable proportion of morbidity and antibiotic use. We aimed to identify the causative bacteria, antibiotic sensitivity and resistance of hospitalized adult patients due to LRTI in Upper Egypt. METHODS: A multicentre prospective study was performed at 3 University Hospitals for 3 years. Samples included sputum or bronchoalveolar lavage (BAL) for staining and culture, and serum for serology. Samples were cultured on 3 bacteriological media (Nutrient, Chocolate ,MacConkey's agars).Colonies were identified via MicroScan WalkAway-96. Pneumoslide IgM kit was used for detection of atypical pathogens via indirect immunofluorescent assay. RESULTS: The predominant isolates in 360 patients with CAP were S.pneumoniae (36%), C. pneumoniae (18%), and M. pneumoniae (12%). A higher sensitivity was recorded for moxifloxacin, levofloxacin, macrolides, and cefepime. A higher of resistance was recorded for doxycycline, cephalosporins, and β-lactam-β-lactamase inhibitors. The predominant isolates in 318 patients with HAP were, methicillin-resistant Staphylococcus aureus; MRSA (23%), K. pneumoniae (14%), and polymicrobial in 12%. A higher sensitivity was recorded for vancomycin, ciprofloxacin, and moxifloxacin. Very high resistance was recorded for β-lactam-β-lactamase inhibitors and cephalosporins. The predominant organisms in 376 patients with acute exacerbation of chronic obstructive pulmonary diseases (AECOPD) were H. influnzae (30%), S. pneumoniae (25%), and M. catarrhalis(18%). A higher sensitivity was recorded for moxifloxacin, macrolides and cefepime. A higher rate of resistance was recorded for aminoglycosides and cephalosporins CONCLUSIONS: The most predominant bacteria for CAP in Upper Egypt are S. pneumoniae and atypical organisms, while that for HAP are MRSA and Gram negative bacteria. For acute exacerbation of COPD,H.influnzae was the commonest organism. Respiratory quinolones, macrolides, and cefepime are the most efficient antibiotics in treatment of LRTI in our locality

Relation of high resolution pulmonary CT findings and clinical condition of COVID-19 patients

Introduction: At present, chest computed tomography (CT) is accepted as a tool for assessment COVID-19 patients. However, there are few data about the relationship between initial imaging results at presentation and the presence of systemic inflamma-tory mediators and outcome in patients with COVID-19. The aim of study is to evaluate the relation of initial high resolution com-puted tomography (HRCT) chest findings to inflammatory indices and clinical course of COVID-19 patients during hospitalization. Material and methods: This is a retrospective cohort study carried out on 108 confirmed COVID-19 patients. Demographic, lab-oratory and radiological data were recorded from patients medical records. Based on predominant HRCT density, patients were classified into either normal, ground glass opacity (GGO) and consolidation groups. By HRCT score, patients were classified into either no infilteration, ≤ 50% infilteration and > 50% infilteration groups. Comparison between clinical and laboratory parameters were observed among the groups.Results: More hypoxemia, higher inflammatory indices (CRP, d-dimer, ferritin), more requirement of ventilatory support and more mortality rate were observed in consolidation group compared to GGO (p < 0.05) and in patients with HRCT score > 50% compared to ≤ 50% infilteration group (p < 0.05). Conclusions: Consolidation pattern and high CT chest quantitative score are associated with elevated inflammatory indices and poor outcome in COVID-19 patients. HRCT chest can be used for risk stratification of COVID-19 patients

Relation of High Resolution Pulmonary CT Findings and Clinical Condition of COVID-19 Patients

Introduction: At present, chest computed tomography (CT) is accepted as a tool for assessment COVID-19 patients. However, there are few data about the relationship between initial imaging results at presentation and the presence of systemic inflammatory mediators and outcome in patients with COVID-19. The aim of study is to evaluate the relation of initial high resolution com-puted tomography (HRCT) chest findings to inflammatory indices and clinical course of COVID-19 patients during hospitalization. Material and Methods: This is a retrospective cohort study carried out on 108 confirmed COVID-19 patients. Demographic, laboratory and radiological data were recorded from patients medical records. Based on predominant HRCT density, patients were classified into either normal, ground glass opacity (GGO) and consolidation groups. By HRCT score, patients were classified into either no infilteration, ≤50% infilteration and >50% infilteration groups. Comparison between clinical and laboratory parameters were observed among the groups. Results: More hypoxemia, higher inflammatory indices (CRP, d-dimer, ferritin), more requirement of ventilatory support and more mortality rate were observed in consolidation group compared to GGO (p < 0.05) and in patients with HRCT score > 50% compared to ≤50% infilteration group (p < 0.05). Conclusions: Consolidation pattern and high CT chest quantitative score are associated with elevated inflammatory indices and poor outcome in COVID-19 patients. HRCT chest can be used for risk stratification of COVID-19 patients

Uniportal VATS Right Lower Lobectomy and Lymphadenectomy: Step-by-Step

Uniportal VATS resection, done through a single port, adds advantages over multiport VATS approaches regarding pain and cosmesis, yet some surgeons do not adopt it as they fear difficulty manipulating multiple instruments in the same port with the camera. The authors present a case of right lower lobe lobectomy for adenocarcinoma with a step-by-step approach, in which they demonstrate how to use advanced instrumentation in uniportal VATS in order to decrease the number of instruments used and to get the best exposure inside the chest.<div>This video demonstrates the case of a 59-year-old female patient who complained of cough and expectoration of whitish sputum for 4 months. She sought medical advice many times with no improvement of her condition. Imaging studies showed a malignant-appearing right lower lobe mass with no apparent mediastinal lymph nodes. She underwent a uniportal VATS right lower lobectomy and lymphadenectomy through a 3 cm port incision in the right 5th intercostal space in the midaxillary line. The tumor pathology showed a pT1N0M0 R0 adenocarcinoma.<br></div