Clinical and echocardiographic predictors of mortality in acute pulmonary embolism

Purpose: The aim of this study was to evaluate the utility of adding quantitative assessments of cardiac function from echocardiography to clinical factors in predicting the outcome of patients with acute pulmonary embolism (PE). Methods: Patients with a diagnosis of acute PE, based on a positive ventilation perfusion scan or computed tomography (CT) chest angiogram, were identified using the Duke University Hospital Database. Of these, 69 had echocardiograms within 24–48 h of the diagnosis that were suitable for offline analysis. Clinical features that were analyzed included age, gender, body mass index, vital signs and comorbidities. Echocardiographic parameters that were analyzed included left ventricular (LV) ejection fraction (EF), regional, free wall and global RV speckle-tracking strain, RV fraction area change (RVFAC), Tricuspid Annular Plane Systolic Excursion (TAPSE), pulmonary artery acceleration time (PAAT) and RV myocardial performance (Tei) index. Univariable and multivariable regression statistical analysis models were used. Results: Out of 69 patients with acute PE, the median age was 55 and 48 % were female. The median body mass 2 index (BMI) was 27 kg/m . Twenty-nine percent of the cohort had a history of cancer, with a significant increase in cancer prevalence in non-survivors (57 % vs 29 %, p = 0.02). Clinical parameters including heart rate, respiratory rate, troponin T level, active malignancy, hypertension and COPD were higher among non-survivors when compared to survivors (p ≤ 0.05). Using univariable analysis, NYHA class III symptoms, hypoxemia on presentation, tachycardia, tachypnea, elevation in Troponin T, absence of hypertension, active malignancy and chronic obstructive pulmonary disease (COPD) were increased in non-survivors compared to survivors (p ≤ 0.05). In multivariable models, RV Tei Index, global and free (lateral) wall RVLS were found to be negatively associated with survival probability after adjusting for age, gender and systolic blood pressure (p ≤ 0.05). Conclusion: The addition of echocardiographic assessment of RV function to clinical parameters improved the prediction of outcomes for patients with acute PE. Larger studies are needed to validate these findings

Multimodality bronchoscopic approach in management of stump dehiscence after pneumonectomy.

The occurrence of bronchopleural fistula (BPF) after pneumonectomy is associated with infection and high mortality. Thus, the closure of BPF and chest tube drainage is recommended. Case presentation: A 56 year old male with history of steroid-dependent rheumatoid arthritis and non-small cell lung cancer of the left lung. Patient underwent pneumonectomy. Two months after the surgery, patient developed gradual onset hypoxemic respiratory distress. CT scan of the chest showed bronchopleural fistula (BPF) of left bronchial stump and large air-fluid content in the left hemithorax. Large bore chest tube was placed and broad spectrum antibiotics were started. Patient was found to have persistent air leak from the chest tube. Bronchoscopic evaluation showed a long left main stem stump (54 mm from main carina) with a presence of 4 mm BPF at lateral wall of the stump. Rigid bronchoscopy was performed with the plan for BPF closure. There are three steps in this procedure. Firstly, an allograft bone chip was grinned in a cone shape (4mm) and it was plugged inside the BPF. Secondly, 5 mL of fibrin sealant was instilled into the distal end of the stump. Lastly, a 16 mm Dumon stent with 50 mm length was clipped each side and one end was closed with a nylon suture. An alloderm graft was cut and wrapped around the stent so it covered the end of the stent. After the wrapping, a suture was used to sew the alloderm to the stent. The modified stent was deployed by using the Storz Y-system. Upon completion of the procedure, the air leak had resolved. Then, patient underwent Video assisted thoracoscopic surgery with debridement of chest cavity and insertion of indwelling pleural catheter for management of infection. Patient was discharged home with six-week course of intravenous antibiotics. Discussion: The use of fibrin sealant for a closure of BPF of the central airways is usually not effective as the sealant spills into the pleural space. Fibrin sealant and Alloderm patch have been used for a closure of BPF. However, the alloderm patch is difficult to deploy and to stabilize in the desired location. We used a bone chip to clog the fistula which delayed the spillage of fibrin sealant into pleural cavity. We also report the use of Dumon stent as the splint to hold the alloderm patch in place. This method will allow the granulation tissue to heal and completely close the fistula. (Figure presented)

Lung cancer screening: detected nodules, what next?

Since the success of the NLST study, the incorporation of lung cancer screening programs into current academic programs has been growing. Center for Medicare and Medicaid Services have acknowledged the importance and potential impact of lung cancer screening by making it a reimbursable study. Based on Fleischner Society Guidelines, many nodules will require follow-up imaging. The remainder of those nodules will need tissue to appropriately make the diagnosis. The use of bronchoscopy with transbronchial biopsy has been a standard technique for many years, but as smaller nodules need to be assessed, more advanced tools, such as endobronchial ultrasound and electromagnetic navigation are now improving the yield on the diagnosis of these smaller peripheral nodules. As electromagnetic navigation and peripheral ultrasound are significant changes from practice only 10 years ago, further advancements in the technology, such as bronchoscopic robots and advanced optical imaging tools, that are becoming available, need to be assessed as to their possible incorporation into the evaluation of peripheral nodules. The ceiling to the diagnosis of these small lesions remains at 70-75%; techniques and tools need to be used to improve upon this to maximize the impact of lung cancer screening and minimize the risk to patients

Complex metallic stent removal: decade after deployment

Endobronchial involvement is a relatively uncommon but well-described presentation in Granulomatosis with polyangiitis (GPA). Self-expandable metallic stents (SEMs) should be reserved for the malignant airway disorder to maintain airway patency, but have been used for benign disease in specific cases. We present a case of longstanding endobronchial GPA with recurrent bronchial stenosis. Three SEMs were deployed in the distal left main bronchus 10 years prior. Two were removed in the standard manner, but the remaining stent SEM was completely embedded in the bronchial mucosa making its removal extraordinarily difficult. We placed an oversized silicone stent inside the stent leading to necrosis of the mucosa allowing for a less formidable removal of the embedded stent. Another silicone stent was temporarily placed. SEMs removal can be extremely complicated and should only be performed by experienced bronchoscopists in an institution with sufficient resources