Respiration

<b><i>Background:</i></b> A diagnosis of interstitial lung diseases (ILDs) may include surgical lung biopsy (SLB), which is associated with significant morbidity and mortality and also appreciable costs. Transbronchial lung cryobiopsy (TBLC) is adopting an important role. <b><i>Objectives:</i></b> The aim of this study was to compare the diagnostic yield (DY) and safety of TBLC and SLB in a large cohort of patients and to perform a systematic review of the literature as well as a meta-analysis. <b><i>Methods:</i></b> We performed a retrospective analysis of 447 cases with ILD undergoing TBLC and/or SLB and a systematic review of the literature (MEDLINE and Embase for all original articles on the DY and safety of TBLC in ILDs up to July 2015). <b><i>Results:</i></b> A total of 150 patients underwent SLB and 297 underwent TBLC. The median time of hospitalization was 6.1 days (SLB) and 2.6 days (TBLC; p < 0.0001). Mortality due to adverse events was observed for 2.7% (SLB) and 0.3% (TBLC) of the patients. Pneumothorax was the most common complication after TBLC (20.2%). No severe bleeding was observed. TBLC was diagnostic for 246 patients (82.8%), SLB for 148 patients (98.7%, p = 0.013). A meta-analysis of 15 investigations including 781 patients revealed an overall DY of 0.81 (0.75-0.87); the overall pooled probability of developing a pneumothorax, as retrieved from 15 studies including 994 patients, was 0.06 (95% CI 0.02-0.11). <b><i>Conclusion:</i></b> Cryobiopsy is safe and has lower complication and mortality rates compared to SLB. TBLC might, therefore, be considered the first diagnostic approach for obtaining tissue in ILDs, reserving the surgical approach for cases in which TBLC is not diagnostic.

Transbronchial cryobiopsies (TBCB) have recently been introduced as a promising and safer alternative to surgical lung biopsy in the diagnostic approach to diffuse parenchymal lung diseases (DPLD). Despite a substantial and expanding body of literature, the technique has not yet been standardized and its place in the diagnostic algorithm of DPLD remains to be defined. In part, this reflects concerns over the diagnostic yield and safety of the procedure, together with the rapid spread of the technique without competency and safety standards; furthermore, there is a substantial procedural variability among centers and interventional pulmonologists. We report this expert statement proposed during the third international conference on “Transbronchial Cryobiopsy in Diffuse Parenchymal Lung Disease” (Ravenna, October 27–28, 2016), which formulates evidence- and expert-based suggestions on the indications, contraindications, patient selection, and procedural aspects of the procedure. The following 5 domains were reviewed: (1) what is the role of TBCB in the diagnostic evaluation of DPLD: patient selection; (2) pathological considerations; (3) contraindications and safety considerations; (4) how should TBCB be performed and in what procedural environment; and (5) who should perform TBCB. Finally, the existence of white paper recommendations may also reassure local hospital credentialing committees tasked with endorsing an adoption of the technique.

Hemoptysis is frequently encountered in clinical practice, and may be the presenting symptom of a number of diseases. Although massive hemoptysis accounts for only 5–15% of episodes, it should always be considered as a life-threatening condition that warrants effective assessment and management. In this article, we review the literature with regard to the definition, etiology, epidemiology, pathophysiology, diagnosis and treatment of massive hemoptysis, with special emphasis on the role of bronchoscopy as a diagnostic and therapeutic tool. We briefly present the circumstances under which the use of rigid bronchoscopy should be preferred for controlling massive bleeding. Moreover, we address the crucial importance of multidisciplinary collaboration by illustrating the roles of endovascular therapy and surgery in the optimal management of massive hemoptysis.

<i>Background:</i> Rapid on-site evaluation has been proposed as a method to improve the yield of transbronchial needle aspiration. <i>Objectives:</i> This study investigated whether on-site analysis facilitates routine diagnostic bronchoscopy in terms of sampling, yield and cost. <i>Methods:</i> Patients with lesions accessible for transbronchial needle aspiration on computed tomography were investigated. A cytopathologist screened the needle aspirates on site for the presence of diagnostic material. The bronchoscopic sampling process was adjusted according to the results. In 90 consecutive patients with neoplastic disease (n = 70; 78%), non-neoplastic disease (n = 16; 18%) or undiagnosed lesions (n = 4; 4%) we aspirated 162 lung lesions (paratracheal tumours or lymph nodes: 7%; tracheobronchial lymph nodes: 68%; other: 25%). <i>Results:</i> The diagnostic yield of needle aspiration was 77 and 25% in patients with neoplastic and non-neoplastic lesions, respectively. Sampling could be terminated in 64% of patients after needle aspiration had been performed as the only diagnostic modality, and on-site analysis identified diagnostic material from the first site aspirated in 50% of patients. Only in 2 patients (2%) diagnostic aspirates were not recognized on site. On-site analysis was cost effective due to savings for disposable diagnostic tools, which exceeded the extra expense for the on-site cytology service provided. <i>Conclusions:</i> Rapid on-site analysis of transbronchial aspirates is a highly useful, accurate and cost-effective addition to routine diagnostic bronchoscopy.

<i>Background:</i> This report summarizes initial tests of an emphysematous lung synthetic polymer sealant (ELS) designed to reduce lung volume in patients with advanced emphysema. <i>Objectives:</i> The primary study objective was to define a therapeutic strategy to optimize treatment safety and effectiveness. <i>Methods:</i> ELS therapy was administered bronchoscopically to 25 patients with heterogeneous emphysema in an open-label, noncontrolled study at 6 centers in Germany. Treatment was performed initially at 2–4 subsegments. After 12 weeks, patients were eligible for repeat therapy to a total of 6 sites. Safety and efficacy were assessed after 6 months. Responses were evaluated in terms of changes from baseline in lung physiology, functional capacity, and health-related quality of life. Follow-up is available for 21 of 25 patients. <i>Results:</i> Treatment was well tolerated. There were no treatment-related deaths (i.e. within 90 days of treatment), and an acceptable short- and long-term safety profile. Physiological and clinical benefits were observed at 24 weeks. Efficacy responses were better among Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage III patients [n = 14; change in residual volume/total lung capacity (ΔRV/TLC) = –7.4 ± 10.3%; Δ forced expiratory volume in 1 s (ΔFEV₁) = +15.9 ± 22.6%; change in forced vital capacity (ΔFVC) = +24.1 ± 22.7%; change in carbon monoxide lung diffusion capacity (ΔDL<i>CO)</i> = +19.3 ± 34.8%; change in 6-min walk test (Δ6MWD) = +28.7 ± 59.6 m; change in Medical Research Council Dyspnea (ΔMRCD) score = –1.0 ± 1.04 units; change in St. George’s Respiratory Questionnaire (ΔSGRQ) score = –9.9 ± 15.3 units] than for GOLD stage IV patients (n = 7; ΔRV/TLC = –0.5 ± 6.4%; ΔFEV₁ = +2.3 ± 12.3%; ΔFVC = +2.6 ± 21.1%; ΔDL<i>CO</i> = –2.8 ± 17.2%; Δ6MWD = +28.3 ± 58.4 m; ΔMRCD = 0.3 ± 0.81 units; ΔSGRQ = –6.7 ± 7.0 units). <i>Conclusions:</i> ELS therapy shows promise for treating patients with advanced heterogeneous emphysema. Additional studies to assess responses in a larger cohort with a longer follow-up are warranted.

<i>Background: </i>Peripheral lung lesions are increasing in numbers. Endoscopic diagnosis is essential for the prevention of unnecessary operations. Conventional diagnostic procedures have limitations in availability and results. <i>Objectives:</i> Endobronchial ultrasonography (EBUS) was investigated as a means to guide transbronchial lung biopsy, to reduce the discomfort during the procedure and to improve diagnostic accuracy. <i>Methods:</i> In 50 cases, we performed transbronchial lung biopsy combined with EBUS and fluoroscopic guidance. The results were compared to 42 controls assessed by fluoroscopy only. <i>Results:</i> In 38 cases (76%), EBUS could describe the peripheral lesion (33 from inside, including 9 cases with difficulties in fluoroscopic observation, and 5 from an adjacent bronchus, indicating the correct location of the lesion). If successfully placed inside, a change in the patient’s position was not required, which helped to reduce patient discomfort. Lung cancer was diagnosed in 24 patients and benign disease in 25 patients; in 1 case diagnosis remained unknown. When the EBUS probe could be introduced inside the lesion, the sensitivity for cancer diagnosis and specificity for cancer exclusion were 100%, respectively (15/15, 18/18). Compared to the controls in whom the biopsy site was determined by fluoroscopy only, the sensitivity tended to be superior by EBUS, although it did not reach statistical significance (p = 0.06). However, specificity and accuracy were statistically significant (both p = 0.02). <i>Conclusions:</i> When the lesion can be correctly described by EBUS from inside the lesion, EBUS is useful to guide transbronchial lung biopsy, can contribute to a reduction in patient discomfort and improves the accuracy of diagnosis. Additional navigation tools to increase correct positioning of the EBUS probe are desirable.

<b><i>Background:</i></b> There is still no clinical evidence available to support or to oppose corticosteroid treatment for coronavirus disease 2019 (COVID-19) pneumonia. <b><i>Objective:</i></b> To investigate the efficacy and safety of corticosteroid given to the hospitalized patients with COVID-19 pneumonia. <b><i>Methods:</i></b> This was a prospective, multicenter, single-blind, randomized control trial. Adult patients with COVID-19 pneumonia who were admitted to the general ward were randomly assigned to either receive methylprednisolone or not for 7 days. The primary end point was the incidence of clinical deterioration 14 days after randomization. <b><i>Results:</i></b> We terminated this trial early because the number of patients with COVID-19 pneumonia in all the centers decreased in late March. Finally, a total of 86 COVID-19 patients underwent randomization. There was no difference of the incidence of clinical deterioration between the methylprednisolone group and control group (4.8 vs. 4.8%, <i>p</i> = 1.000). The duration of throat viral RNA detectability in the methylprednisolone group was 11 days (interquartile range, 6–16 days), which was significantly longer than that in the control group (8 days [2–12 days], <i>p</i> = 0.030). There were no significant differences between the 2 groups in other secondary outcomes. Mass cytometry discovered CD3⁺ T cells, CD8⁺ T cells, and NK cells in the methylprednisolone group which were significantly lower than those in the control group after randomization (<i>p</i> &#x3c; 0.05). <b><i>Conclusions:</i></b> From this prematurely closed trial, we found that the short-term early use of corticosteroid could suppress the immune cells, which may prolong severe acute respiratory syndrome coronavirus 2 shedding in patients with COVID-19 pneumonia. <b><i>Trial Registration:</i></b> ClinicalTrials.gov, NCT04273321.

<b><i>Background:</i></b> In China, both the levels and patterns of outdoor air pollution have altered dramatically with the rapid economic development and urbanization over the past two decades. However, few studies have investigated the association of outdoor air pollution with respiratory mortality, especially in the high pollution range. <b><i>Objective:</i></b> We conducted a retrospective cohort study of 9,941 residents aged ≥35 years old in Shenyang, China, to examine the association between outdoor air pollutants [particulate matter <10 µm in aerodynamic diameter (PM₁₀), sulfur dioxide (SO₂) and nitrogen dioxide (NO₂)] and mortality using 12 years of data. <b><i>Methods:</i></b> We applied extended Cox proportional hazards modeling with time-dependent covariates to respiratory mortality. Analyses were also stratified by age, sex, educational level, smoking status, personal income, occupational exposure and body mass index (BMI) to examine the association of air pollution with mortality. <b><i>Results:</i></b> We found significant associations between PM₁₀ and NO₂ levels and respiratory disease mortality. Our analysis found a relative risk of 1.67 [95% confidence interval (CI) 1.60–1.74] and 2.97 (95% CI 2.69–3.27) for respiratory mortality per 10 µg/m³ increase in PM₁₀ and NO₂, respectively. The effects of air pollution were more apparent in women than in men. Age, sex, educational level, smoking status, personal income, occupational exposure, BMI and exercise frequency influenced the relationship between outdoor PM₁₀ and NO₂ and mortality. For SO₂, only smoking, little regular exercise and BMI above 18.5 influenced the relationship with mortality. <b><i>Conclusion:</i></b> These data contribute to the scientific literature on the long-term effects of air pollution for the high-exposure settings typical in developing countries.

<i>Background:</i> The question of which combination of procedures gives the best diagnostic yield following fiberoptic bronchoscopy is controversial. <i>Objectives:</i> To evaluate the value of various diagnostic techniques following fiberoptic bronchoscopy in the diagnosis of endoscopically visible lung cancer. <i>Methods:</i> The study included 98 patients found to have endobronchially visible tumor during routine daily bronchoscopy. Endobronchial lesions were classified as mass, submucosal lesion and infiltration. Washings, brushings and forceps biopsies were obtained in all subjects. Transbronchial needle aspirations were performed in 67 of 76 cases with mass or submucosal lesions. <i>Results:</i> Bronchoscopy was diagnostic for cancer in 88 (89.8%) of the 98 patients. Forceps biopsy specimens gave positive result in 82.7% of cases, transbronchial needle aspirates in 68.6%, brushings in 68.4%, and washings in 31.6%. Combination of forceps biopsy and brushing cytology yielded a positive result for lung cancer in 87 patients. The addition of brushings increased the diagnostic yield of bronchoscopy from 82.7% to 88.8% (p < 0.05). Collection of washing specimens in addition to forceps biopsy did not increase the yield of forceps biopsy. Transbronchial needle aspiration gave an additional yield of 1%. <i>Conclusions:</i> Routine cytological examination of bronchial washings does not increase the yield of forceps biopsy specimens. Transbronchial needle aspiration may give an additional positive yield to forceps biopsy. We conclude that a combination of forceps biopsy and brushing is the best strategy in the diagnosis of bronchoscopically visible lung cancer.