Niv versus HFOT versus conventional oxygen therapy in reducing bronchoscopy related complications in COPD patients: A triple arm randomized controlled trial (Nicobar) CTRI/2021/03/032190
Vinod Kumar Sharma, B. G. Manjunath, Pawan Singh, Dhruva Chaudhry
Department of PCCM, PT. B.D. Sharma PGIMS, Rohtak, Haryana, India. E-mail: sharmadr.vinod08@gmail.com
Background: Underlying COPD increases the complications of bronchoscopy. This study evaluated the efficacy of NIV and HFOT compared to conventional oxygen therapy (COT) in COPD patients undergoing bronchoscopy in preventing complications.
Methods: It was a three-arm, single center, randomized controlled trial. 90 confirmed COPD patients were randomly assigned into 3 intervention arms (COT, NIV and HFNC group). The lowest recorded SpO2, pre and post blood gases, vitals, ECG, patient and operator comfort during bronchoscopy were assessed.
Results: Mean age of the study population was 61.71±7.5 years (p=0.29). Mean post-bronchodilator FEV1/FVC was 58.91±8.3L (p=0.86) for all 90 cases out of which 51 cases were moderate, 34 and 5 cases were severe and very severe COPD, respectively. Rest of the baseline characteristics were not significantly different among study groups. SpO2 during FOB was lowest in COT group (COT: 87. 03±5.7 vs. HFOT: 95.57±5.0 vs. NIV: 97.40±1.6, p=0.000). Secondary objectives were not statistically different except respiratory rate which was highest among COT group (COT: 20. 23±3.1 vs. HFOT: 18.57±4.1 vs. NIV: 16.80±1.9, p=0.000) and Post FOB PaO2, highest among NIV group (NIV: 84.27±21.6 vs. HFOT: 69.03±13.6 vs. COT: 69.30±11.9, p=0.000). Mean post FOB PH was lower in NIV group (NIV: 7.36±0.03 vs. HFOT: 7.37±0.07 vs. COT: 7.37±0.06, P=0.91). Post FOB PaCO2 was numerically more in COT group (COT: 42.73±13.1 vs. HFOT: 40.47±11.7 vs. 40.33±8.6, p=0.43). NIV group faced more operator discomfort which was assessed with visual analogue scale (COT: 1.17±3.8 vs. HFOT: 3.00±5.5 vs. NIV: 16.67±6.0, p=0.000).
Conclusion: NIV and HFNC are superior over COT for oxygen supplementation during bronchoscopy procedure but NIV is associated with poor patient and operator comfort. This study is unique because no randomized trial has been done yet to see efficacy and safety of different oxygen delivery methods (Conventional Oxygen therapy, NIV, HFNC) in COPD patients undergoing bronchoscopy. This was a triple armed trial which never has been done in such type patients. Randomization and statistical analysis would be very difficult for a triple armed trial though we did this as accepting a challenge. We have registered this trial in clinical trial registry of India in the month of march 2021 after obtaining approval certificate from institutional review board of PGIMS, Rohtak. I had obtained Good Clinical Practice Certificate through E-learning course, for conducting clinical trials issued by NIDA clinical trial network, National Institute of health, USA. All the methods followed for this trial were legitimate and were according to the principles mentioned in GCP.
VATS management of catamenial pneumothorax
Harsh Vardhan Puri1, Mohan Venkatesh Pulle2, Sukhram Bishnoi2, Belal Bin Asaf2, Arvind Kumar2
1Medanta – The Medicity, Gurguram, Haryana, India, 2Institute of Chest Surgery, Medanta – The Medicity, Gurguram, Haryana, India. E-mail: drharshvardhanpuri@gmail.com
Introduction: Spontaneous recurrent pneumothorax during menstruation is called as catamenial pneumothorax. It is usually associated with diaphragmatic perforations and endometriosis. It usually is reported on right side but in lesser numbers on left and rarely bilateral. It is associated with pelvic endometriosis in 30- 50% cases. It is usually treated initially by chest tube insertion, but the definitive management is surgical. In yester era, open thoracotomy was the method of choice for doing such cases but from last two decades Video Assisted Thoracic Surgery (VATS) has become gold standard in such thoracic diseases.
Patients and Methods: Five women with mean age of 25.4 years presented with recurrent primary spontaneous pneumothorax. Four patients were on right side and one was bilateral on presentation. All underwent VATS and proceed with endoscopic stapling of involved diaphragmatic patch using endo-staplers with Talc pleurodesis in 3 cases, wedge resection of middle lobe with talc pleurodesis in 1 patient. Bilateral pneumothorax patient underwent simultaneous bilateral VATS with talc pleurodesis on both sides and biopsy of small endometrial deposits on right side.
Results: Postoperative course was uneventful. All were extubated on table. Average duration of chest tube was 3 days, average duration of hospital stay was 3.2 days. There was no recurrence, morbidity, or mortality on one year follow up.
Conclusion: Surgery is treatment of choice in catamenial pneumothorax. VATS is associated with good results; faster removal of chest tubes and shorter hospital stay as compared to open thoracotomy.
Use of indwelling pleural catheter for malignant pleural effusion: Experience at a tertiary care center in India
Amit Jain, Rajiv Goyal, Manish Aggarwal, Eshita Shah
Department of Interventional Pulmonology, RGCIRC, Delhi, India. E-mail: amit.jain1212@gmail.com
Background: Recurrent pleural effusion is a common cause of morbidity during the course of malignant diseases. Indwelling pleural catheters (IPC) are an established management option for malignant pleural effusion, for immediate symptom relief and pleurodesis apart from better patient mobility and reduced need of hospitalization.
Methods: In this single-center retrospective observational study patient characteristics, procedural variables and outcome in patients with IPC in malignancy were evaluated and potential complications were identified.
Results: From 2020 to 2021, 24 IPCs were inserted for malignant pleural effusion of whom 15 (62.5%) had lung and 37.5% extrapulmonary malignancies. The median length of IPC remaining in place was 38 days. An adequate symptom relief was achieved in 92% of all patients. Eight (33%) patients required intrapleural fibrinolytic. Four patients died with IPC in situ; 9 patients were lost to follow up and pleurodesis was observed in 7 out of 11 (63.6%) by talc/ autopleurodesis. Complications occurred in 29% cases, 16% concerning infections (local infections (n = 2) and empyema (n = 2)), local site pain (8%).
Conclusion: High efficacy in symptom relief and a favorable safety and patient comfort profile confirm IPC, as a suitable first line option in most malignant pleural effusions. The study likely presents the first dataset on IPC in Indian patients.
Pulmonary alveolar proteinosis in two children: Bilateral whole lung lavage using extracorporeal membrane oxygenation
Rashmi Ranjan Das, Krishna Mohan Gulla, Bikram Kishore Behera, Satyajit Mishra
Department of Pediatrics, Anaesthesiology and Critical Care, All India Institute of Medical Science, Bhubaneswar, Odisha, India. E-mail: rrdas05@gmail.com
Background: Pulmonary alveolar proteinosis (PAP) is characterized by accumulation of surfactants within alveoli causing progressive hypoxemia and respiratory failure. There is no definitive treatment, and whole lung lavage (WLL) provides temporary relief.
Case Study: A 22 months-old-child presented with cough and breathlessness after recovering from a viral illness. At admission, she had marked tachypnea and bilateral diffuse crackles with requirement of 10 L/min O2 to maintain SpO2 of 92%. CT chest revealed bilateral “crazy-paving” classical of PAP. WLL was technically difficult as double lumen endo-tracheal tube cannot be passed in such a small child. Finally, the child underwent WLL under veno-venous (VV) ECMO. After two settings of WLL one week apart, she got off oxygen. Another child, 40 months-old presented with recurrent cough and breathlessness since last one-year with progressive increase in O2 requirement. At admission, she had O2 requirement of 5 L/min to maintain SpO2 of 93-94%. She underwent WLL once and got off oxygen. Both are under follow-up. In both the children, genetic testing confirmed mutation in CSF2RA gene.
Discussion: Our first case is the youngest child to undergo WLL under ECMO among the published reports till date from India. Congenital PAP is due to GM-CSF mutations (CSF2RA or CSF2RB genes). Our patients had CSF2RA mutations. In small children, passage of double-lumen endotracheal is difficult. This poses challenge in maintaining oxygenation during WLL. Hence, we planned VV-ECMO in our cases for successful WLL.
Conclusions: WLL with ECMO is better tolerated in small children who cannot tolerate single-lung ventilation.
Bronchoscopic management of bronchopleural fistula due to COVID-19 a nonsurgical option
Manish Aggarwal, Rajiv Goyal, Sruthi Mohan
Jaipur Golden Hospital, Rohini, Delhi, India. E-mail: aggarmanish@gmail.com
Background: COVID-19 has become a dreadful pandemic. One of the important complication is the development of pneumothorax/ pneumomediastinum which gets further complicated by bronchopleural fistula.
Case Study: A 44year male patient with severe COVID pneumonia developed Left sided pneumothorax and treated conservatively with ICD and negative suctioning for 2 months and referred to us with persistent pneumothorax with BPF. As patient was unfit for surgery, bronchoscopic management was planned. With flexible bronchoscope, 6F Fogarty balloon was passed and inflated, leak site was identified in left upper lobe upper division. A Watanabe spigot size 5 was deposited at the opening of upper division and manipulated to apical segment. Other small openings were sealed with cyanoacrylate glue and autologous blood patch. After procedure negative suction was reapplied. Repeat Xray showed resolution of pneumothorax. Pleurodesis was done with talc slurry, post pleurodesis showed no pneumothorax and ICD was removed. Patient was discharged, follow up X ray after 4weeks showed no evidence of pneumothorax.
Discussion: In most cases of BPF, leak seals after tube thoracostomy, only 3-5% will continue to have persistent leak. For medically inoperable cases, bronchoscopic balloon occlusion of site and subsequent injection with fibrin glue, liquid bioadhesive or blood patch can be done. For large leak; Amplatzer device, stents, spigots, coils are used.
Conclusion: Bronchoscopic treatment can work well for a medically inoperable, complicated pneumothorax in COVID-19 disease.
An Interesting case series of Endobronchial obstruction with varied clinical presentations: Every roadblock tells a different story
M. Sai Durga, Prasanna Poorna
Department of Pulmonology, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India. E-mail: aalaya004@gmail.com
Background: Endobronchial mass may be an incidental finding of chest imaging or an incidental finding during bronchoscopy or it may present with common symptoms like cough, dyspnea or hemoptysis but sometimes it may present unusually as wheeze, pleural effusion, SVC syndrome, fever, All Endobronchial obstruction are not neoplasms because in some the diagnosis is TB and in some Both. We will discuss the differential diagnosis of endobronchial obstruction in this case series.
Case Study: This case study was a prospective study conducted in 6 patients, the patients were in the age group of 15-65 years who were diagnosed with an Endobronchial obstruction using Bronchoscopy in our hospital were analysed. Demographic characteristics, presenting symptoms, bronchoscopic procedure, location of obstruction, pathological diagnosis (biopsy for HPE and BAL for CBNAAT), treatment approaches were evaluated. The diagnosis of these 6 patients came out to be carcinoid tumour, bronchogenic carcinoma, squamous cell carcinoma, endobronchial tb, bronchoalveolar carcinoma. some have both malignancy and tuberculosis.
Discussion: Bronchoscopy is an invasive procedure utilized for the diagnosis and treatment of Endobronchial mass. Benign neoplasms are rare (10%), they usually settle towards lumen and may cause obstruction which may result in life-threatening complications such as respiratory insufficiency, bleeding, infection while delay in the diagnosis of malignancies may cause death, Delay in TB treatment may cause complications.
Conclusion: Bronchoscopy is the most effective procedure in the diagnosis of Endobronchial mass. Based on our study findings we suggest that it should be performed in case of susupicion with unusual presentations and normal chest imaging.
An interesting case of left lung collapse treated with interventional bronchoscopy
Devendra Pratap Yadav, Govind Narayan Srivastav, Aiyush Jain, Shivam Dixit
Department of TB and Respiratory Diseases, Institute of Medical Sciences BHU, Varanasi, Uttar Pradesh, India. E-mail: devendraims027@gmail.com
Background: Interventional bronchoscopy is a rapidly expanding field in pulmonary medicine offering minimally invasive therapeutic and palliative procedure.
Case History: A 24 year old nonsmoker male presented to us with acute onset breathlessness for 2 days without any cough or fever. On detailed history patient told that he was admitted in gastrology Department for 1 week hematemesis caused due to abdominal trauma. No h/o limb swelling, nausea vomiting. On clinical examination, pallor was present and patient was tachypnoeic. On respiratory examination, trachea was deviated to left with decreased chest movement on left side. Tactile vocal fremitus was increased on left with dull note in percussion and decreased breath sound on left side. Rest general and systemic examination was normal. In lab investigations, hemoglobin was 8.7. Other parameters were normal. Chest x ray suggested left side hemipacity with ipsilateral tracheal deviation. ECG showing sinus tachycardia. CT findings were s/o sequele of chronic infective etiology with ipsilateral trachea mediastinal shift. On bronchoscopy, blood clot with food content lodged in left main bronchus was visible causing left lung collapse. It was degraded using physical traction under bronchoscopy guidance in two settings. Patient was completely symptom free and repeat Chest Xray showed complete expansion of affected lung.
Discussion: Fibreoptic bronchoscopy may used as therapeutic modality for removal of an aspirated foreign body, clearance of tenacious secretions, instillation of drugs and insertion of an endotracheal tube.
Conclusion: Proper history is must in reaching the conclusive diagnosis. Interventionl bronchoscopy became boon for this patient.
Accuracy of endobronchial ultrasound in the staging of lung cancer – First report from India of comparison of EBUS with pathological nodal staging
Eshita Shah, Rajiv Goyal, Manish Agarwal, Amit Jain
Department of Interventional Pulmonology, Rajiv Gandhi Cancer Institute, New Delhi, India. E-mail: eshita_90@yahoo.com
Background: Staging of lung cancer patients requires evaluation of the mediastinum for lymph nodal involvement and screening of the whole body for distant metastasis. Patients undergo a noninvasive Positron Emission Tomography and Computerized Tomography (PET-CT) screening to look for mediastinal or distant spread. However, these modalities though sensitive, suffer from poor specificity. Invasive sampling must be done especially from the mediastinal lymph nodes to look for regional spread of cancer to select patients who will benefit from surgery. For this purpose, Endobronchial ultrasound guided transbronchial fine needle aspiration (EBUS-TBNA) has replaced Mediastinoscopy as the first line investigation for evaluation of the mediastinum.
Objective: To study the diagnostic accuracy of Endobronchial Ultrasound in staging of lung cancer.
Methodology: We present a retrospective analysis of patients who have been operated for lung cancer and in whom EBUS was performed preoperatively for staging. A comparison has been made between histological findings by EBUS and the final pathology after surgical lymph node dissection.
Results: Sixty-two patients underwent curative surgery for lung cancer. The concordance of EBUS, with post-surgical histopathological results in 115 lymph nodes, was analyzed. The sensitivity, specificity, positive predictive value, negative predictive value, Diagnostic accuracy of EBUS-TBNA in predicting mediastinal metastasis were 35.71%, 100%, 100% and 91.82%, 92.71% respectively.
Conclusion: EBUS-TBNA has a highly reliable diagnostic accuracy, for lung cancer staging.