Bronchoscopy for small pulmonary nodules and mediastinal staging of lung cancer: just do it!
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Biopsy, Needle↗
Biomedical subjects
Prashant N Chhajed
Publications and source records attributed to Prashant N Chhajed.
Respiratory symptoms and smoking behaviour in Swiss conscripts.
AIM: Smoking is a major health hazard in young adults. Reducing smoking is the only well established effective primary prevention of chronic obstructive pulmonary disease. We undertook a prospective cross sectional study to determine the prevalence of respiratory symptoms, smoking behaviour and willingness to participate in a smoking cessation program in Swiss conscripts. METHODS: Conscripts completed a standardized questionnaire on respiratory symptoms, asthma and smoking behaviour and underwent spirometry measurement. RESULTS: 2604 conscripts were included. 1252 (48%) were current smokers, 144 (6%) were former smokers, 111 (4%) were recent beginners or low intensity smokers and 1097 (42%) were never smokers. Respiratory symptoms were significantly higher in smokers compared to never smokers (wheezing 16% vs. 7%, wheezing without cold 9% vs. 4%, exercise dyspnoea 15% vs. 10%, regular cough 35% vs. 10% and regular phlegm 15% vs. 2%). The mean score of the Fagerstrom Test for Nicotine Dependency (FTND) was 2.6 (+/-2.1). According to the transtheoretical model of stage of change 50% were in the precontemplation, 34% in the contemplation, 5% in the preparation, 5% in the action and 6% in the maintenance stage. Amongst the current smokers 33% were willing to participate in a smoking cessation program. Those willing to participate in a smoking cessation program included 17% precontemplators and 53% contemplators. CONCLUSION: There is a high prevalence of respiratory symptoms in young current smokers. The Fagerstrom Test for Nicotine Dependence score in conscripts is low thus favouring a potentially successful outcome of a smoking cessation intervention. Using motivational stages to tailor smoking cessation aids might preclude adequate interventions in individuals belonging to the precontemplation stage.
Adolescent↗
Pulmonary infections diagnosed by BAL: a 12-year experience in 1066 immunocompromised patients.
Bronchoalveolar lavage (BAL) is a useful tool in the diagnosis of pulmonary infections in immunocompromised patients. We aimed to compare the spectrum of infectious pulmonary complications diagnosed using BAL in a large consecutive cohort of immunocompromised patients. The diagnostic yield of 1066 BAL specimens was analyzed in 4 different groups of immunocompromised patients (HIV; solid organ transplants; high-dose chemotherapy and/or stem cell transplants; other immunosuppressive therapy) suffering from fever, respiratory symptoms and/or infiltrates on chest X-ray. Specimens were analyzed for bacteria, mycobacteria, fungi, Pneumocystis jiroveci, cytomegalovirus (CMV) and other viruses. Two time periods were compared (1992-1996; 1997-2003). The overall diagnostic yield of BAL was 34% for bacteria, 22% for CMV, 15% for P. jiroveci, 6% for other viruses, 6% for mycobacteria and 2% for aspergillus. There were significant changes in the pattern of opportunistic infections between the 2 time periods. Mycobacterial infections decreased considerably in the HIV group (17.9 vs. 8.5%, P=0.02), while the incidence of P. jiroveci decreased mainly in the transplant group (32.6 vs. 7.9%, P<0.00001). This study demonstrates a changed pattern of pulmonary infections in immunocompromised patients diagnosed by BAL. The overall diagnostic yield of BAL remains high in immunocompromised patients with respiratory symptoms.
Bacterial Infections↗
Sleep apnea and heart disease.
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Cardiovascular Diseases↗
Diagnostic yield of flexible bronchoscopy in current clinical practice.
BACKGROUND: Flexible bronchoscopy is a procedure commonly performed for diagnostic and therapeutic purposes. The aim of this study was to assess the diagnostic yield and the safety of routine bronchoscopy techniques including transbronchial needle aspiration and transbronchial biopsy at a university hospital in Switzerland. METHODS: 616 consecutive bronchoscopies performed at the Pulmonary Medicine Department (University Hospital Basel) over a period of 6 months were analysed retrospectively using bronchoscopy reports and hospital charts. Diagnostic procedures included bronchial washings, bronchoalveolar lavage, bronchial brushings, transbronchial needle aspiration and transbronchial biopsies. RESULTS: 430 bronchoscopies had a diagnostic, 186 a therapeutic indication. The overall diagnostic yield was 57% (245/430). Bronchoscopy performed for suspected tumours confirmed malignancy in 43% of cases. Bronchoscopy in suspected infection and tuberculosis identified pathogenic organisms in 46% and 27% of cases, respectively. The diagnostic yield for central and peripheral TBNA was 37.8 and 43.6%, respectively. Complications were very rare (n = 10, 1.6%) and were only minor. CONCLUSION: This study demonstrates that routine bronchoscopy techniques including transbronchial needle aspiration and transbronchial biopsy are safe and have a high diagnostic yield.
Adolescent↗
Reliability and validity of a German asthma quality of life questionnaire.
The Asthma Quality of Life Questionnaire (University of Sydney [AQLQ-Sydney]) is a self-administered questionnaire that has been developed in Australia and validated in different languages in Australia, the USA and Spain. We developed a German translation of this questionnaire by applying a sequential forward and backward translation approach. The objective of this study was to validate a German translation of the AQLQ-Sydney questionnaire in an outpatient population of asthmatic patients in Switzerland. Outpatients were assessed for a diagnosis of asthma and those who consented were selected for the validation study. All patients had spirometry, methacholine challenge testing, fractional exhaled nitric oxide recorded and answered the German AQLQ-Sydney. A subgroup of 17 patients answered the questionnaire for a second time after receiving asthma treatment with combined steroids and bronchodilators for two months. Test-retest-reliability was tested in 12 stable asthmatic patients without treatment modification. Of 90 patients assessed, 57 were diagnosed with asthma and participated in the validation study. The total score did not significantly correlate with any of the objective measures of severity of asthma. However, the "Breathlessness" subscale score correlated weakly with PD20 methacholine. Internal consistency was high with Cronbach's alpha of 0.97 for the total score and 0.91-0.97 for the subscale scores. Test-retest reliability was also high for the total score and the subscale scores. The questionnaire detected a significant improvement in total quality of life score and "Breathlessness" and "Mood" subscale scores after a period of combined treatment with inhaled steroids and long acting bronchodilators. The German translation of the AQLQ-Sydney had a good internal consistency and test-retest-reliability in stable asthmatic patients. It shows responsiveness to treatment. Some correlations with objective markers were detected.
Adolescent↗
Therapeutic bronchoscopy interventions before surgical resection of lung cancer.
BACKGROUND: Therapeutic bronchoscopy is used for endobronchial staging of lung cancer and symptomatic relief of central airway obstruction or postobstructive pneumonia. The aim of this study was to assess the utility of therapeutic bronchoscopy as a complementary tool in the combined bronchoscopic and surgical management of malignant airway lesions before curative lung surgery. METHODS: Seventy-four consecutive patients with nonsmall cell lung carcinoma undergoing a therapeutic bronchoscopy procedure followed by surgery with a curative intent were included. RESULTS: A single interventional bronchoscopic method was used in 27 patients (36%) and a combination of methods in 47 patients (64%). Median forced expiratory volume in 1 second (FEV1) before and after bronchoscopy were 1.7 L and 2.2 L, respectively, and forced vital capacity (FVC) was 2.5 L and 3.3 L, respectively. Sleeve upper lobectomy was performed in 22 patients (30%), sleeve upper bilobectomy in 16 patients (22%), lower bilobectomy in 2 patients (3%), pneumonectomy with sleeve resection in 2 patients (3%), and pneumonectomy in 28 patients (38%). The following surgeries were performed in 1 patient each: sleeve middle lobectomy, sleeve lower lobectomy, carina resection and complex reconstruction, and exploratory thoracotomy. Overall, parenchyma-sparing surgery (lobectomy or bilobectomy) could be performed in 57% patients after therapeutic bronchoscopy. There were no in-hospital deaths or deaths in the first 30 days after surgery. CONCLUSIONS: Therapeutic bronchoscopy can be used as a complementary tool in the combined bronchoscopic and surgical management of malignant airway obstruction before curative lung surgery. Therapeutic bronchoscopy might permit parenchyma-sparing surgery in patients with lung cancer.
Adenocarcinoma↗
Asthma control in Switzerland: a general practitioner based survey.
BACKGROUND: Achievement of optimal asthma control is the goal of the Global Initiative for Asthma (GINA) guidelines. METHODS: In a survey involving 281 physicians, asthma control was assessed using the Juniper asthma control questionnaire (ACQ); physicians were also asked to judge patients' asthma control subjectively. RESULTS: In total, 2127 patients were included. Follow-up was available in 1893 (89%) patients (885 females). The mean time between visits was 62 +/- 29.3 days; mean age was 45 years (+/- 19 years) and 30% were smokers. Well-controlled asthma was found in 298 patients (16%). Smokers were less likely to have well-controlled asthma (smokers 12% vs. non-smokers 18%). Physicians assessed asthma control to be good in 292 patients (15%), sufficient in 504 (27%), insufficient in 954 (50%) and poor in 137 (7%) patients. Of the 292 patients assessed by their physicians as 'good asthma control', only 142 (49%) were confirmed as 'well-controlled' by the ACQ. At the first visit, 1308 (69%) patients were pre-treated with any inhaled corticosteroids (ICS). Pretreatment with leukotriene receptor antagonists (LTRAs) was reported in 127 patients (7%). Add-on therapy with the LTRA montelukast was the most frequent treatment adjustment at the first visit. Out of 1893 patients who had a follow-up visit, 298 (16%) were well controlled at the first visit and 1170 (62%) at the follow-up visit. CONCLUSION: Asthma control is insufficient in the majority of patients. Improvement of asthma control can be achieved by using objective measures such as the ACQ in regular clinical practice and adapting therapy.
Administration, Inhalation↗
Outcome of treated advanced non-small cell lung cancer with and without central airway obstruction.
OBJECTIVE: In patients with advanced non-small cell lung cancer (NSCLC) treated with chemotherapy, we compared survival in patients with treated central airway obstruction to those who did not have central airway obstruction. METHODS: One hundred forty-four patients with advanced and inoperable NSCLC were included. These consisted of 52 consecutive patients treated with therapeutic bronchoscopy plus chemotherapy with or without radiotherapy (group A) and 92 consecutive patients who did not have central airway obstruction treated with chemotherapy alone (group B). Chemotherapy consisted of cisplatin or carboplatin, and one third-generation chemotherapy agent. RESULTS: There was no significant difference in the survival of patients with and without central airway obstruction (p = 0.395). There was no influence of the histologic subtype on survival in both groups combined and also in each group separately. Median survival in patients belonging to group A was 8.4 months and those in group B was 8.2 months; 3-, 6-, and 12-month survival rates in patients in group A were 90%, 71%, and 40%, respectively, and those in group B were 82%, 63%, and 34%. CONCLUSION: Patients having advanced NSCLC with locally treated malignant central airway obstruction in combination with chemotherapy do not have a worse survival compared to those with advanced NSCLC without central airway obstruction. Therapeutic bronchoscopy should be offered to patients with NSCLC and central airway obstruction.
Adenocarcinoma↗
Sedative drug requirements during bronchoscopy are higher in cystic fibrosis after lung transplantation.
BACKGROUND: We noted that patients with cystic fibrosis tended to need higher doses of sedatives during bronchoscopy. We undertook this study to assess the sedative drug doses administered during bronchoscopy in lung transplant recipients and to assess if there is a change in the dosage requirements over time following lung transplantation. METHODS: In all, 773 transbronchial biopsy procedures performed via flexible bronchoscopy were analyzed in 140 consecutive lung transplant recipients. Conscious sedation was achieved with intermittent boluses of intravenous midazolam and fentanyl. Intravenous propofol boluses of 10 to 30 mg were administered when optimal sedation was not achieved with midazolam doses of 0.20 to 0.25 mg/kg and fentanyl 2 to 2.5 micrograms/kg. RESULTS: Mean doses of midazolam and fentanyl administered were 0.15+/-0.07 mg/kg (range 0.02 to 0.44 mg/kg) and 1.8+/-0.8 micrograms/kg (range 0.1 to 6.67 micrograms/kg) respectively. Midazolam and fentanyl doses administered to patients with cystic fibrosis were the highest compared to those with other disease types (P<0.0001). Examining the sedative doses administered over time following transplantation, there was a significant linear (P<0.001) and quadratic (P=0.0023) effect of time for midazolam and a significant linear (P=0.003) and a trend (P=0.08) for a quadratic effect for fentanyl. Propofol was effectively used in seven lung transplant recipients in whom adequate sedation could not be achieved with high doses of midazolam and fentanyl. CONCLUSIONS: There is an increase in sedative drug requirement with time for both midazolam and fentanyl after transplantation, which is significantly higher in patients with cystic fibrosis.
Adolescent↗
(Un) explained hyperventilation.
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Adult↗
Patterns of pulmonary complications associated with sirolimus.
Sirolimus inhibits human fibroblast cell proliferation in cell cultures from transbronchial biopsies of lung transplant recipients. However, a few cases of interstitial pneumonitis and bronchiolitis obliterans organizing pneumonia have been recently described in solid organ transplant recipients, including a fatality in a heart transplant recipient. We studied the patterns of pulmonary adverse effects associated with sirolimus in 4 renal transplant recipients who developed pulmonary opacities on chest radiograph, which were proved to be noninfectious in origin. Lung biopsy was performed to obtain histological diagnosis (3 interstitial pneumonitis, 1 necrotizing vasculitis). Symptoms were dyspnea (4), cough (2), hemoptysis (1), fever (1) and eyelid edema (1). Those with interstitial pneumonitis had bilateral basal opacities on chest X-ray, and histopathology showed mild lymphoplasmocytic interstitial inflammation, scattered intraalveolar epitheloid granulomas and a focal pattern of organizing pneumonia. Serum C-reactive protein (CRP) was elevated and bronchoalveolar lavage revealed lymphocytosis (77, 79.5 and 31%). The fourth patient had an opacity localized in the upper lobe, which progressed to both the lower lobes, and histopathology showed multifocal necroses of lung tissue with lymphoplasmocytic vasculitis and scattered granulomas. In this patient, the serum CRP level was not elevated and bronchoalveolar lavage was normal. Pulmonary symptoms and opacities on chest radiograph resolved and the serum CRP level became normal after sirolimus was stopped in all patients. Sirolimus may be a cause of interstitial pneumonitis or pulmonary vasculitis, and withdrawal of sirolimus is therapeutic.
Aged↗
Uncovered metallic stents for anastomotic dehiscence after lung transplantation.
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Anastomosis, Surgical↗
Detection of hypoventilation during thoracoscopy: combined cutaneous carbon dioxide tension and oximetry monitoring with a new digital sensor.
BACKGROUND: Changes in Paco(2) have not been described during thoracoscopy under sedation-assisted local anesthesia. We hypothesized that hypoventilation might occur secondary to administration of sedatives and decreased ventilation in one lung. AIM: Prospectively measure cutaneous carbon dioxide tension (Pcco(2)) in addition to pulse oximetric saturation (Spo(2)) using a new combined digital sensor to examine the occurrence of hypoventilation during thoracoscopy under sedation-assisted local anesthesia. SETTING: University hospital. METHODS: Following validation studies, Pcco(2) was prospectively measured in 16 consecutive patients undergoing thoracoscopy under sedation-assisted local anesthesia using a combined digital earlobe sensor measuring Spo(2) (percentage) and Pcco(2) (millimeters of mercury). All patients received supplemental oxygen. Routine BP monitoring and Spo(2) was continued. Patients received IV hydrocodone, 5 mg, and intermittent boluses or IV midazolam and pethidine. RESULTS: Mean baseline Pcco(2) measurement was 39.1 +/- 7.2 mm Hg (+/- SD) [range, 27.5 to 50.5 mm Hg], and peak measurement during the procedure was 52.3 +/- 10.3 mm Hg (range, 37.2 to 77 mm Hg) [p < 0.001]. Median and mean changes in Pcco(2) measurement from baseline were 13.0 mm Hg and 13.2 +/- 5.3 mm Hg (range, 5.5 to 27.8 mm Hg), respectively. Mean fall in Spo(2) during the procedure was 4.6 +/- 3.2% (range, 1 to 14%). CONCLUSIONS: Thoracoscopy performed under sedation-assisted local anesthesia is associated with significant hypoventilation. Combined measurement of Spo(2) and Pcco(2) during thoracoscopy is a novel approach in the monitoring of ventilation, enhancing patient safety, and might allow to guide the administration of sedation in a better way.
Adult↗
Nebulized lidocaine for flexible bronchoscopy: a randomized, double-blind, placebo-controlled trial.
OBJECTIVE: Topical anesthesia for flexible bronchoscopy can be administered via transcricoid injection, nebulizer, or directly through the bronchoscope in a "spray as you go" fashion. We performed a prospective, randomized, double-blind, placebo-controlled trial to evaluate whether nebulized lidocaine provides additional benefit and reduces the total anesthetic dose required during bronchoscopy. SETTING: Tertiary care university hospital. METHODS: One hundred fifty patients (93 men; age, 20 to 89 years) undergoing diagnostic flexible bronchoscopy were randomized to receive either 4 mL of 4% lidocaine (160 mg) or 4 mL of saline solution as placebo via nebulization. Combined sedation was achieved using 5 mg of IV hydrocodone and midazolam boluses. Supplemental lidocaine doses and total midazolam required as judged by the bronchoscopist were recorded for each patient. After the procedure, both bronchoscopists and patients charted their perception of cough on a 10-cm visual analog scale (VAS). Similarly, patients recorded their discomfort related to the procedure on a 10-cm VAS. RESULTS: The most common procedures were BAL in 77 cases (51%), transbronchial biopsy in 40 cases (27%), and transbronchial needle aspiration in 34 cases (23%). Outcome parameters, including hemodynamic findings, duration of the procedure, cough scores for physicians and patients, discomfort score for patients, midazolam doses, and supplemental lidocaine doses, were similar in both groups. Mean total lidocaine dose required in the lidocaine group was 318 +/- 41 mg and was significantly higher than the total dose required in the placebo group (157 +/- 44 mg [+/- SD]) [p < 0.001]. CONCLUSION: Additional nebulized lidocaine cannot be recommended for flexible bronchoscopy performed under combined sedation.
Administration, Inhalation↗
Combining bronchoscopy and positron emission tomography for the diagnosis of the small pulmonary nodule < or = 3 cm.
AIM: To assess the role of bronchoscopy and positron emission tomography (PET) scanning in an integrated approach for the diagnosis of noncalcified, small, chest radiologic lesions (< or = 3 cm). METHODS: Seventy-four consecutive patients (29 men; mean age, 64 years) with a pulmonary nodule < or = 3 cm undergoing both combined PET and bronchoscopy were included. When bronchoscopy and PET findings were negative, a multidisciplinary decision was taken to perform further invasive diagnostics or follow-up. RESULTS: Malignancy was diagnosed in 51 patients (69%), and a positive benign diagnosis was made in 9 patients (12%). Six patients (8%) had endobronchial lesions. Bronchoscopy was diagnostic in 53% patients (cancer, n = 35; benign, n = 4). PET findings were positive in 19 of 35 patients with a nondiagnostic bronchoscopy. In these 19 patients, malignant diagnosis was made in 14 patients (CT-fine needle aspiration [FNA], n = 3; thoracoscopic biopsy, n = 3; resection, n = 7; FNA of PET-positive supraclaviclar lymph node, n = 1), and a benign diagnosis was made in 5 patients (CT-FNA, n = 1; thoracoscopic biopsy, n = 1; resection, n = 1; follow-up, n = 2). In 16 patients with nondiagnostic bronchoscopy and negative PET findings, 5 patients had a tissue diagnosis (cancer, n = 2 [< 1 cm]; benign, n = 3) and 11 patients were followed up. Sixty-seven patients had a lesion 11 mm to 3 cm; among these, all 12 patients who were bronchoscopy negative and PET negative had benign lesions. In 24 patients without mediastinal adenopathy (solitary pulmonary nodule), bronchoscopy was diagnostic in 12 patients (cancer, n = 11; bronchiolitis obliterans organizing pneumonia, n = 1). In the remaining 12 patients, PET findings were positive in 6 patients (cancer, n = 3; resection, n = 2; CT-FNA, n = 1) and negative in 6 patients (benign, n = 2, both on resection; follow-up, n = 4). CONCLUSION: Combining bronchoscopy and PET scanning has an useful role in the diagnosis of noncalcified chest radiologic lesions < or = 3 cm in size. Bronchoscopy has a diagnostic yield of > 50% and also allows the diagnosis of endobronchial lesions. If bronchoscopy is nondiagnostic, a PET scan should be performed.
Aged↗
Combined pulse oximetry/cutaneous carbon dioxide tension monitoring during colonoscopies: pilot study with a smart ear clip.
BACKGROUND: We compared the accuracy and practicability of a new combined ear sensor device measuring pulse oximetry and transcutaneous carbon dioxide tension. METHODS: Validation studies were done by comparing the results of the combined sensor with arterial blood gas measurements. In an observational part, monitoring data were obtained from 25 patients undergoing colonoscopy, sedated with midazolam and alfentanil and from 8 patients without sedation. RESULTS: There was an excellent correlation between the oxygen saturation and carbon dioxide tension measurements comparing the combined sensor with arterial blood gas analysis (R 0.96 and 0.93, respectively). A mean rise in transcutaneous carbon dioxide tension of 7.6 mm Hg was detectable during sedation with midazolam/alfentanil and of 2.3 mm Hg without sedation. CONCLUSION: Combined POX/PcCO2 monitoring at the ear lobe is a novel approach to improve patient safety during sedation and may be helpful in preventing an unintentional slide into a state of deep sedation with impairment of ventilation.
Aged↗
Association of minimal rejection in lung transplant recipients with obliterative bronchiolitis.
The clinical significance of minimal acute rejection (grade A1) in lung transplant recipients is unknown. We prospectively analyzed 1,159 transbronchial lung biopsies in 184 patients. Two hundred seventy-nine biopsies in 128 participants confirmed A1 histology at a mean postoperative day of 229 +/- 340. Sixty four of 255 surveillance A1 lesions progressed to high-grade acute rejection by 3 months of follow-up, whereas 40 developed new lymphocytic bronchiolitis. Twenty-four A1 biopsies were symptomatic, with only two cases progressing to high-grade rejection after steroid therapy. Seventy-eight of 184 patients experienced multiple (> or = 2) A1 biopsies in the first 12 months after transplant. Bronchiolitis obliterans syndrome developed in 68% of patients with multiple A1 lesions at a mean of 599 +/- 435 days, compared with 43% of patients with one or less A1 lesions at a mean of 819 +/- 526 (p = 0.022). Eighteen patients experienced multiple A1 biopsies after transplant in the absence of high-grade rejection episodes yet also developed earlier obliterative bronchiolitis (456 +/- 245 days, p = 0.020). We conclude that for A1 transbronchial lung biopsies, the conventional treatment of observation only is now challenged even in patients who are asymptomatic. Patients who experience multiple A1 lesions develop an earlier onset of obliterative bronchiolitis and may warrant alternative immunosuppressive strategies.
Adolescent↗