Advanced endoscopic imaging in small airway disease : confocal laser endomicroscopy in emphysema and after lung transplantation

Chronic Obstructive Pulmonary Disease (COPD) occurs in 10% of the adult population and is currently the 4th leading cause of mortality. The associated morbidity, the economic burden as well as the societal impact of COPD is huge and one of the major health challenges of the future. COPD is characterized by progressive and irreversible airflow limitation and it is shown that these changes start at the level of the small airways even before symptoms occur. Long term survival after lung transplantation is mainly determined by the presence/absence of bronchiolitis obliterans syndrome (BOS). BOS is a result of chronic immunological processes inducing inflammation in and scarring of the smallest airways ('bronchioles'). Bronchoscopic biopsy samples are almost never contributive to the diagnosis. Both emphysema and BOS have common pathophysiological pathways. In both conditions one assumes that vanishing airways are at the beginning of the ultrastructural changes. In both diseases, changes at the bronchiolar level are driven by inflammation : immunological due to rejection/allo-immunity, as a result of toxic exposure (cigarette smoking, biomass combustion), as a result of auto-immunity or due to the inflammatory influence as a result of recurrent infection. The injury afflicted by inflammation results the development of an abnormal cytokine response profile inducing epithelial-mesenchymal transition and fibroproliferation. Probe-based confocal laser endomicroscopy (pCLE) is a novel endoscopic imaging technique that is capable of three dimensional and in vivo imaging during flexible endoscopy of the respiratory tract. The technique uses a thin, semi-flexible probe that can be advanced through the human airways by inserting it in the working channel of a bronchoscope. The scope of our research project is to standardize the implementation of pCLE during flexible bronchoscopy, to assess consistency and reliability of quantitative data and to assess changes at the level of the pulmonary acinus in small airway disease. For the latter purpose, the technique will be used in subjects with COPD and BOS. Consequently, we will try to correlate pCLE data with data from clinical examinations such as lung function and computerized tomography of the chest.status: publishe

To Boldly Go Where No Bronchoscope Has Gone Before

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Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: A single-centre experience

Background and objective: Malignant pleurisy is associated with advanced oncological disease and dyspnoea is the most common presenting symptom. Pleurodesis is the preferred palliative and supportive treatment option, targeting symptom relief. The identification of clinical and endoscopic features that determine the success of talc pleurodesis in malignant pleurisy could guide clinical decision-making. Methods: All symptomatic patients with malignant pleurisy subjected to talc pleurodesis through medical thoracoscopy between January 2012 and December 2015 were included. Univariate and multivariate analyses were performed to identify factors associated with successful pleurodesis. Results: Of the 155 patients, 122 (78%) were classified as having a successful pleurodesis based on clinical and radiological criteria. Factors associated with unsuccessful pleurodesis (univariate analysis) were the presence of pleural adhesions (odds ratio (OR): 0.43 (95% CI: 0.19–0.96); P = 0.04), extensive spread of pleural lesions (OR: 0.17 (95% CI: 0.05–0.59); P = 0.001), the use of systemic corticosteroids (OR: 0.28 (95% CI: 0.10–0.83); P = 0.02) and a prolonged time period between the clinical diagnosis of the pleural effusion and the moment of pleurodesis (OR: 0.14 (95% CI: 0.06–0.32); P < 0.0001). The latter being associated with failure of pleurodesis in a multivariate analysis (OR: 0.08 (95% CI: 0.01–0.25); P < 0.0001). Chest ultrasound prior to pleurodesis showed a sensitivity of 91% and a specificity of 88% in predicting the success of pleurodesis. Conclusion: The success rate of pleurodesis in malignant pleurisy could potentially be enhanced by correct patient selection and early referral for pleurodesis. Ultrasonic assessment of pleural adhesions and potential lung expansion prior to pleurodesis is useful in clinical decision-making.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Endoscopic advanced imaging of the respiratory tract: exploring probe-based confocal laser endomicroscopy in emphysema

: Probe-based confocal laser endomicroscopy (pCLE) was performed in 15 patients with emphysema and 15 healthy subjects to visualise small airways in a direct and dynamic way. Morphometry shows that the median cross-sectional area of the alveolar openings at the level of the alveolar ducts is significantly larger in emphysema (7.2×10(4) µm(2)) as compared with healthy subjects (5.2×10(4) µm(2)) (p=0.0002). Normalised autofluorescence intensity histograms show a decrease in median autofluorescence intensity (mAFI) in emphysema (p=0.001). mAFI correlates well with Tiffeneau index (r=0.66, p=0.007, 95% CI 0.21 to 0.88). Autofluorescence intensity in emphysema correlates with corresponding data of CT-based quantification. pCLE-based morphometry and autofluorescence intensity analysis in emphysema is able to detect regional changes inside the 'quiet zone'.status: publishe

Endobronchial ultrasound in the management of nonsmall cell lung cancer

Flexible bronchoscopy plays a major role in the diagnosis and staging of lung cancer. One of the most important advances in this field is the development of endobronchial ultrasound (EBUS), which has extended the view of the bronchoscopist. These techniques are safe and allow assessment of the depth of tumour invasion in the central airways, detection of peripheral tumours before sampling, localisation of the central tumour in the lung parenchyma close to the central airways for real-time guided sampling, and staging of lymph nodes within the mediastinum. Progress in handling and analyses of the small samples obtained during EBUS procedures also allow modern pathological and molecular studies to be performed. This article reviews the data currently available in the field of convex and radial probe EBUS for the diagnosis and staging of nonsmall cell lung cancer and highlights the strengths but also the weaknesses of these new techniques

The impact of smoking history on IPF survival

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Perspectives using probe-based confocal laser endomicroscopy of the respiratory tract

Questions Under Study/Principles: Although probe-based confocal laser endomicroscopy (pCLE) is on the edge of entering daily practice in gastroenterological endoscopy, findings in the field of respiratory medicine are only rarely reported, keeping pCLE during flexible bronchoscopy as a mere preclinical research tool. Since the endomicroscopic aspects of normal bronchial and alveolar tissue have recently been described, we want to take part in the development of a pCLE glossary, describing the pCLE features of pulmonary pathologies. METHODS: We recruited among patients referred for diagnostic bronchoscopy for pCLE imaging. Images from the central airways were obtained in every patient and alveoloscopy was performed in at least five sub-segments per patient. RESULTS: Using pCLE imaging, we were able to discriminate normal from abnormal endomicroscopical patterns in four respiratory conditions. These findings were matched with classical histopathology. CONCLUSION: Reflecting on our own experience using pCLE imaging, we summarise the present state of knowledge, discuss five clinical cases and discuss current limitations and the future promise of this novel imaging tool.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Daily Home Spirometry: A New Milestone in the Field of Pulmonary Fibrosis

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The Role of Flexible Bronchoscopy in Swab-negative Patients During the SARS-CoV2 Pandemic.

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Towards the Essence of Progressiveness: Bringing Progressive Fibrosing Interstitial Lung Disease (PF-ILD) to the Next Stage

Although only recently introduced in the ILD community, the concept of progressive fibrosing interstitial lung disease (PF-ILD) has rapidly acquired an important place in the management of non-idiopathic pulmonary fibrosis fibrosing ILD (nonIPF fILD) patients. It confirms a clinical gut feeling that an important subgroup of nonIPF fILD portends a dismal prognosis despite therapeutically addressing the alleged triggering event. Due to several recently published landmark papers showing a treatment benefit with currently available antifibrotic drugs in PF-ILD patients, endorsing a PF-ILD phenotype has vital therapeutic consequences. Importantly, defining progressiveness is based on former progression, which has proven to be a rather moderate predictor of future progression. As fibrosis extent >20% and the presence of honeycombing have superior predictive properties regarding future progression, we advocate immediate initiation of antifibrotic treatment in the presence of these risk factors. In this perspective, we describe the historical context wherein PF-ILD has emerged, determine the currently employed PF-ILD criteria and their inherent limitations and propose new directions to mature its definition. Finally, while ascertaining progression in a nonIPF fILD patient clearly demonstrates the need for (additional) therapy, in the future, therapeutic decisions should be taken after assessing which pathway is ultimately driving the progression. Although not readily available, pathophysiological insight and diagnostic means are emergent to go full steam ahead in this novel direction.status: publishe