One-session bilateral sequential whole lung lavage (OSBSWLL) for the management of pulmonary alveolar proteinosis

BACKGROUND: Whole Lung Lavage (WLL) has been an important part in the management of Pulmonary Alveolar Proteinosis (PAP) since it improves radiologic and clinical parameters. Bilateral WLL is usually performed in two sessions on different days. Few case reports have described one-session bilateral sequential lung lavage (OSBSWLL), and none have described ambulatory management (same-day discharge). METHODS: Demographic characteristics, physiologic parameters, procedure details and outcomes were retrospectively collected on consecutive patients who underwent OSBSWLL for PAP following an ambulatory protocol stablished in our institution. RESULTS: A total of 13 patients underwent 30 OSBSWLL (61.5% male; mean age 40). The mean SpO2 was 90% (IQR 9) and 94% (IQR 6), before and after OSBSWLL respectively. In 63.3% of cases, patients were discharged home the same day of procedure. Only in two cases (6.6%), patients required post-procedure prolonged mechanical ventilation (\u3e 4 h) due to persistent hypoxia. CONCLUSIONS: OSBSWLL can be performed with same-day discharge

Biopsy frequency and complications among lung cancer patients in the United States

Objective: This study aimed to describe the frequency and distribution of biopsy procedures for patients diagnosed and treated for primary lung cancer. Study design: Retrospective cohort study within an administrative database. Materials & methods: This observational study used data from the IBM MarketScan Results: The total number of lung biopsies performed among eligible subjects was 32,814; an average of 1.7 biopsies per patient. Bronchoscopy and percutaneous approaches accounted for 95% of all procedures. Complication rates by procedure are remarkably similar irrespective of biopsy frequency. Conclusion: Nearly half (46%) of patients in this population experienced multiple biopsies prior to diagnosis. Further, biopsy choice or sequence in patients receiving multiple procedures was unpredictable

Diphenhydramine as an adjunct to conscious sedation in bronchoscopy

Intravenous benzodiazepines are commonly used to achieve conscious sedation in outpatient bronchoscopy. Though effective, dose-dependent-adverse events may be encountered with the use of these sedatives. Diphenhydramine, a hypnotic, is sometimes used as an adjunctive agent in bronchoscopy to decrease sedative usage. However, data to support this practice is lacking. Our goal was to determine if adjunctive diphenhydramine significantly decreases doses of benzodiazepine in outpatient bronchoscopy. METHODS: We conducted a single-center retrospective analysis of all outpatient bronchoscopies from November 2013 to February 2016. Subjects included were those who each had two bronchoscopies: no diphenhydramine used (control) versus diphenhydramine used (intervention). The procedure time, total doses of midazolam and opiates (in morphine equivalence) for each procedure were collected. A multiple regression analysis was used to compare differences between bronchoscopy groups in midazolam and opiate use. RESULTS: Of 1164 patients with greater than 1 outpatient bronchoscopies, 61 unique subjects (female 56%) fulfilled the primary inclusion criteria thus resulting to 122 procedures. Mean body mass index was 32 kg/m2. Procedure time was 22.9 ± 16 mins in diphenhydramine group and 23.2 ± 17.8 mins in control group. Mean morphine equivalents administered was 5.6 ± 2.6 mg in diphenhydramine group and 6.2 ± 2.4 mg in control group. Mean midazolam use was 8.4 ± 3.2 mg in diphenhydramine group and 10.2 ± 3.8 mg in control group (difference: -1.795, p-value = 0.005). The mean dose of diphenhydramine used was 38.32 ± 15.12 mg. In a multivariate model, mean midazolam use remained less in the diphenhydramine group after adjusting for procedure time and morphine equivalents, (difference -1.28 mg, p-value = 0.005). CONCLUSIONS: Intravenous administration of diphenhydramine during outpatient bronchoscopy reduces midazolam usage, however, the absolute amount of dose reduction may not be clinically significant

(P44) Is Prophylactic Cranial Irradiation Necessary in Stage I-IIA Small Cell Lung Cancer Patients? A Single Institution Experience

Background: The advent of screening chest computed tomography (CT) for high-risk patients has increased the patient population presenting with early-stage small cell lung cancer (SCLC). While surgical resection continues to be standard of care, stereotactic body radiation therapy (SBRT) is an option for non-surgical candidates. Although the effectiveness of PCI in patients with limited stage SCLC has been well established, decreasing the brain metastasis incidence from approximately 70% to 30%, the role of PCI in early-stage SCLC (T1-T2) has not been fully elucidated. This study reports our experience omitting PCI in early-stage SCLC. Objectives: This study reports our experience omitting PCI in early stage SCLC. Methods: Fourteen patients with early-stage SCLC, nine patients with clinical stage I (T1) and five patients with stage IA (T2) SCLC, ranging in age from 54-81 years old, treated with surgical resection or SBRT from July 2015 to May 2021 at our institution, were retrospectively reviewed. Positron emission tomography (PET) was used in the staging of 93% of patients. All patients had initial negative brain MRI and opted not to receive PCI. 71% of the patients had brain scan surveillance for follow-up. Risk factors including age, gender, and tumor size, were analyzed for overall survival (OS), loco-regional recurrence (LRR), and distant metastasis (DM) using the Log-rank test. Results: With a median follow-up of 13 months (range 2-63), none of our patients developed metastases to the brain. Adjuvant chemotherapy, with a mean of 4 cycles (2-6) was administered to 13 out of 14 patients (92%). The 2-year OS, LRR and DM estimates were 47% [95% CI (0.14, 0.75)], 57% [95% CI (0.19, 0.82)], and 51% [95% CI (0.17, 0.77)], respectively. The OS and the frequency of LRR were not found to be correlated with age, gender, or tumor size. DM was significantly higher in males vs females (P=0.016). Conclusions: Our experience in patients with Stage I-IIA SCLC treated with surgery or SBRT did not demonstrate any development of brain metastases. As PCI carries long term risks of neurotoxicity, close surveillance with regular brain imaging may be a reasonable alternative. Adjuvant systemic therapy remains an important component of treatment

Costs of Biopsy and Complications in Patients with Lung Cancer

PURPOSE: To describe the distribution of diagnostic procedures, rates of complications, and total cost of biopsies for patients with lung cancer. PATIENTS AND METHODS: Observational study using data from IBM Marketscan(®) Databases for continuously insured adult patients with a primary lung cancer diagnosis and treatment between July 2013 and June 2017. Costs of lung cancer diagnosis covered 6 months prior to index biopsy through treatment. Costs of chest CT scans, biopsy, and post-procedural complications were estimated from total payments. Costs of biopsies incidental to inpatient admissions were estimated by comparable outpatient biopsies. RESULTS: The database included 22,870 patients who had a total of 37,160 biopsies, of which 16,009 (43.1%) were percutaneous, 14,997 (40.4%) bronchoscopic, 4072 (11.0%) surgical and 2082 (5.6%) mediastinoscopic. Multiple biopsies were performed on 41.9% of patients. The most common complications among patients receiving only one type of biopsy were pneumothorax (1304 patients, 8.4%), bleeding (744 patients, 4.8%) and intubation (400 patients, 2.6%). However, most complications did not require interventions that would add to costs. Median total costs were highest for inpatient surgical biopsies ($29,988) and lowest for outpatient percutaneous biopsies ($1028). Repeat biopsies of the same type increased costs by 40-80%. Complications account for 13% of total costs. CONCLUSION: Costs of biopsies to confirm lung cancer diagnosis vary substantially by type of biopsy and setting. Multiple biopsies, inpatient procedures and complications result in higher costs

Robotic bronchoscopy for peripheral pulmonary lesions: A multicenter pilot and feasibility study (BENEFIT)

BACKGROUND: The diagnosis of peripheral pulmonary lesions (PPL) continues to present clinical challenges. Despite extensive experience with guided bronchoscopy, the diagnostic yield has not improved significantly. Robotic-assisted bronchoscopic platforms have been developed potentially to improve the diagnostic yield for PPL. Presently, limited data exist that evaluate the performance of robotic systems in live human subjects. RESEARCH QUESTION: What is the safety and feasibility of robotic-assisted bronchoscopy in patients with PPLs? STUDY DESIGN AND METHODS: This was a prospective, multicenter pilot and feasibility study that used a robotic bronchoscopic system with a mother-daughter configuration in patients with PPL 1 to 5 cm in size. The primary end points were successful lesion localization with the use of radial probe endobronchial ultrasound (R-EBUS) imaging and incidence of procedure related adverse events. Robotic bronchoscopy was performed in patients with the use of direct visualization, electromagnetic navigation, and fluoroscopy. After the use of R-EBUS imaging, transbronchial needle aspiration was performed. Rapid on-site evaluation (ROSE) was used on all cases. Transbronchial needle aspiration alone was sufficient when ROSE was diagnostic; when ROSE was not diagnostic, transbronchial biopsy was performed with the use of the robotic platform, followed by conventional guided bronchoscopic approaches at the discretion of the investigator. RESULTS: Fifty-five patients were enrolled at five centers. One patient withdrew consent, which left 54 patients for data analysis. Median lesion size was 23 mm (interquartile range, 15 to 29 mm). R-EBUS images were available in 53 of 54 cases. Lesion localization was successful in 51 of 53 patients (96.2%). Pneumothorax was reported in two of 54 of the cases (3.7%); tube thoracostomy was required in one of the cases (1.9 %). No additional adverse events occurred. INTERPRETATION: This is the first, prospective, multicenter study of robotic bronchoscopy in patients with PPLs. Successful lesion localization was achieved in 96.2% of cases, with an adverse event rate comparable with conventional bronchoscopic procedures. Additional large prospective studies are warranted to evaluate procedure characteristics, such as diagnostic yield. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT03727425; URL: www.clinicaltrials.gov

Necrotizing Sarcoid Granulomatosis with Hemoptysis: A Case Report and Literature Review

We present a case of 39-year-old male with the symptoms of fever, cough, chest pain and bloody phlegm, whose chest CT showed multiple subpleural nodules and inflammatory infiltration. Video-Assisted Thoracic Surgery ( VATS ) for right subplural nodule was performed and confirmed the diagnosis of necrotizing sarcoid granulomatosis. Prednisolone was administered and the symptoms were under control untill the occurrence of intermittent hemoptysis after 10 months. Chest CT and bronchoscope revealed the right lower lobe nodule with intraluminal necrotic tissue in the right lower lobe posterior basal segment respectively. Fatal hemoptysis happened during endobronchial biopsy by flexible bronchoscope forcep. Based on this case, we reviewed the relevant literature and discussed the clinical features, pathological changes and prognosis of the disease

Understanding the patient journey to diagnosis of lung cancer

OBJECTIVE: This research describes the clinical pathway and characteristics of two cohorts of patients. The first cohort consists of patients with a confirmed diagnosis of lung cancer while the second consists of patients with a solitary pulmonary nodule (SPN) and no evidence of lung cancer. Linked data from an electronic medical record and the Louisiana Tumor Registry were used in this investigation. MATERIALS AND METHODS: REACHnet is one of 9 clinical research networks (CRNs) in PCORnet®, the National Patient-Centered Clinical Research Network and includes electronic health records for over 8 million patients from multiple partner health systems. Data from Ochsner Health System and Tulane Medical Center were linked to Louisiana Tumor Registry (LTR), a statewide population-based cancer registry, for analysis of patient\u27s clinical pathways between July 2013 and 2017. Patient characteristics and health services utilization rates by cancer stage were reported as frequency distributions. The Kaplan-Meier product limit method was used to estimate the time from index date to diagnosis by stage in lung cancer cohort. RESULTS: A total of 30,559 potentially eligible patients were identified and 2929 (9.58%) had primary lung cancer. Of these, 1496 (51.1%) were documented in LTR and their clinical pathway to diagnosis was further studied. Time to diagnosis varied significantly by cancer stage. A total of 24,140 patients with an SPN were identified in REACHnet and 15,978 (66.6%) had documented follow up care for 1 year. 1612 (10%) had no evidence of any work up for their SPN. The remaining 14,366 had some evidence of follow up, primarily office visits and additional chest imaging. CONCLUSION: In both cohorts multiple biopsies were evident in the clinical pathway. Despite clinical workup, 70% of patients in the lung cancer cohort had stage III or IV disease. In the SPN cohort, only 66% were identified as receiving a diagnostic work-up