Diagnostic Role of Bronchoalveolar Lavage in Patients with Suspected SARS-CoV-2 Pneumonia and Negative Upper Respiratory Tract Swab: A Systematic Review and Meta-Analysis

The added role of bronchoalveolar lavage (BAL) in SARS-CoV-2 detection in hospitalized patients with suspected COVID-19 pneumonia and at least one negative nasopharyngeal swab (NPS) has yet to be definitively established. We aimed to provide a systematic review and meta-analysis to summarize data from the literature on the diagnostic yield of BAL in this context. We searched Medline and Embase for all studies reporting outcomes of interest published up to October 2021. Two authors reviewed all titles/abstracts and retrieved the selected full texts according to predefined selection criteria. The summary estimate was derived using the random-effects model. Thirteen original studies, involving 868 patients, were included. The summary estimate of proportions of SARS-CoV-2 positivity in BAL fluid in patients with at least one previous negative NPS was 20% (95% confidence interval [CI]; 11–30%). Moreover, microbiological tests of BAL fluid led to the identification of other pathogens, mainly bacteria, in up to two-thirds of cases. BAL plays a crucial role in the diagnostic work-up of patients with clinical suspicion of COVID-19 and previous negative NPS, as it allowed to detect the infection in a significant proportion of subjects, who would have been otherwise misclassified, with relevant implications in the prevention of disease spread, especially in hospital settings

Conventional versus Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Hilar/Mediastinal Lymph Adenopathies: A Randomized Controlled Trial

BACKGROUND: Conventional transbronchial needle aspiration (c-TBNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are both valuable diagnostic techniques for the diagnosis of hilar/mediastinal lesions. Although a superiority of EBUS-TBNA over c-TBNA may be expected, evidence-based data on a direct comparison between these 2 procedures are still lacking. OBJECTIVES: We aimed to test the superiority of EBUS-TBNA over c-TBNA in a randomized trial and to evaluate the cost-effectiveness profile of a staged strategy, including c-TBNA as initial test followed by EBUS-TBNA, in case of inconclusive results at rapid on-site evaluation. METHODS: Eligible patients were randomized 1:1 to either the EBUS-TBNA or c-TBNA group. The primary endpoint was to test the superiority of EBUS-TBNA sensitivity over c-TBNA. The secondary endpoints included the sensitivity of the staged strategy, as well as costs and safety related to each procedure and to their sequential combination. RESULTS: A total of 253 patients were randomized to either EBUS-TBNA (n = 127) or c-TBNA (n = 126), and 31 patients of the c-TBNA group subsequently underwent EBUS-TBNA. The sensitivity of EBUS-TBNA was higher, but not significantly superior to that of c-TBNA (respectively. 92% [95% CI 87-97] and 82% [95% CI 75-90], p > 0.05). The sensitivity of the staged strategy was 94% (95% CI 89-98). No major adverse events occurred. CONCLUSIONS: EBUS-TBNA was the single best diagnostic tool, although not significantly superior to c-TBNA. Due to the favorable cost-effectiveness profile of their sequential combination, in selected scenarios with a high probability of success from the standard procedure, these should not be necessarily intended as competitive and the staged strategy could be considered in clinical practice

Silver nitrate through flexible bronchoscope in the treatment of bronchopleural fistulae

Objective: Bronchopleural fistula is a severe complication after pneumonectomy or lobectomy. Local application of silver nitrate to seal bronchopleural fistulae was reported once 25 years ago with considerable success but was never repeated. We aimed to develop and evaluate a concrete technique of applying silver nitrate through a flexible bronchoscope to treat bronchopleural fistulae in central airways. Methods: Consecutive patients with small (≤5 mm) bronchopleural fistulae in proximal airways were included in the study. After measurement of bronchopleural fistula size through a flexible videobronchoscopy, a standard bronchoscopic cytology brush covered with silver nitrate was passed through the working channel of the scope and was rubbed against the fistula's orifice producing blanching and edema on the mucosa. This procedure was repeated until closure of the fistula's orifice (treatment success) or absence of any tissue response after 2 bronchoscopic sessions (treatment failure). Results: Of 16 patients referred, 5 were excluded from treatment because of large (>5 mm) fistulae. Among the 11 treated patients (median fistula diameter 3 mm, range 2-5 mm), treatment failure was observed in 2 patients in whom treatment was attempted early (15 days postsurgery). In the remaining 9 patients, treatment success was achieved (81.8% success rate) after a median of 2.5 (range 1-10) applications of silver nitrate. After 11 (0.5-24) months of follow-up, no relapse was observed among successfully treated fistulae. Conclusion: The local application of silver nitrate through a flexible bronchoscopic brush produced a burn and healing process on the mucosa of small bronchopleural fistulae of the central airways, leading to effective and lasting treatment in most cases. © 2009 The American Association for Thoracic Surgery

Silver nitrate through flexible bronchoscope in the treatment of bronchopleural fistulae.

Bronchopleural fistula is a severe complication after pneumonectomy or lobectomy. Local application of silver nitrate to seal bronchopleural fistulae was reported once 25 years ago with considerable success but was never repeated. We aimed to develop and evaluate a concrete technique of applying silver nitrate through a flexible bronchoscope to treat bronchopleural fistulae in central airways.Consecutive patients with small (5 mm) fistulae. Among the 11 treated patients (median fistula diameter 3 mm, range 2-5 mm), treatment failure was observed in 2 patients in whom treatment was attempted early (15 days postsurgery). In the remaining 9 patients, treatment success was achieved (81.8\% success rate) after a median of 2.5 (range 1-10) applications of silver nitrate. After 11 (0.5-24) months of follow-up, no relapse was observed among successfully treated fistulae.The local application of silver nitrate through a flexible bronchoscopic brush produced a burn and healing process on the mucosa of small bronchopleural fistulae of the central airways, leading to effective and lasting treatment in most cases