Journal of Bronchology & Interventional Pulmonology最新文献

Background: Prescription opioids are a major cause of the opioid epidemic. Despite the minimally invasive nature of medical thoracoscopy (MT), data on the efficacy of non-opioid-based pain control after MT is lacking. The purpose of this study is to assess the feasibility and efficacy of a non-opioid-based pain management strategy in patients who underwent MT.

Methods: We performed a retrospective analysis of all patients who underwent MT in the Mayo Clinic (Minnesota and Arizona) outpatient setting. We assessed their pain level and the need for analgesia post-MT from August 1, 2019, to May 24, 2021.

Results: Forty patients were included. In the first 24 hours, 5/40 (12.5%) reported no pain. Twenty-eight patients out of 40 (70%) reported minor pain (pain scale 1-3), and 7/40 (17.5%) reported moderate pain (pain scale 4-6). No patients reported severe pain. Twenty-two out of 35 patients who experienced discomfort (63%) required acetaminophen, 6/35 patients (17%) required nonsteroidal anti-inflammatory drug, and 7/35 patients (20%) did not require analgesia. Of the 7 patients who had moderate pain, 5 (71%) reported that the moderate pain improved to mild at 72 hours post-MT. Zero patients required opioids, and none reported contacting any provider to manage the pain post-MT. Fourteen patients (78%) who had both parietal pleural biopsies and tunneled pleural catheter placed reported minor pain, 3 patients (17%) reported moderate pain, and 1 patient (6%) experienced no discomfort.

Conclusion: MT is well-tolerated by patients with non-opioid-based pain management strategy as needed if there is no absolute contraindication.

Background: Thoracoscopic pleural biopsy is the gold standard for diagnosing tubercular pleural effusion (TPE). Various thoracoscopic appearances like sago grain nodules, caseous necrosis, and adhesions have been described in TPE. However, none of these have high specificity for diagnosing TPE. In this study we evaluate a novel finding on thoracoscopy, the " Pleural Pustule."

Methods: This is a retrospective analysis of patients who underwent thoracoscopy for undiagnosed pleural effusion. Visual inspection of the pleura was performed to identify abnormalities. Biopsies were obtained from those areas and sent for histopathology, acid fast bacillus (AFB) smear, culture, and Xpert MTB/Rif assay. Pleural pustule was defined as a pus filled nodule on the pleural surface.

Results: Of the 259 patients included, 92 were diagnosed with TPE. Pleural pustule(s) were identified in 16 patients with TPE. Presence of pleural pustule had a sensitivity, specificity, positive predictive value, and negative predictive value of 17.4%, 100%, 100% and 68.7%, respectively, for diagnosing TPE. Histopathology of pleural pustule demonstrated necrotizing granulomas in all. In patients with pleural pustule, a microbiological diagnosis of tuberculosis was achieved in 93.7% patients (AFB smear, Xpert MTB/Rif assay, and MTB culture positive in 31.3%, 93.7%, and 43.7% cases, respectively). There is a strong association between pleural pustule and positive Xpert MTB/Rif assay ( P =0.002) and microbiologic confirmation of diagnosis ( P =0.017).

Conclusion: The presence of pleural pustule on thoracoscopy has a high positive predictive value for TPE. In tuberculosis-endemic countries, this can be considered suggestive for TPE. When identified, a biopsy from the pleural pustule should be performed as it will likely yield a positive microbiologic diagnosis.

Background: Local anesthetic thoracoscopy (LAT) is important in the diagnosis of unilateral pleural effusions. Indwelling pleural catheters (IPC) can be inserted during LAT if a nonexpandable lung is suspected. Subcutaneous emphysema (SCE) is a known complication and is associated with increased morbidity and length of stay. It is unclear however if the incidence of SCE is affected if IPC is inserted through a separate incision to the LAT port. We aim to establish the incidence and grading of SCE when IPC is inserted during LAT and to determine if the site of IPC placement influences this.

Methods: Retrospective analysis of LAT electronic records and radiology images over 8 years in a University Hospital. The incidence of SCE was assessed during admission and follow-up with the severity of SCE graded 0 to 4 (0 none; 1 at IPC site; 2 ipsilateral chest wall; 3 ipsilateral neck; 4 contralateral chest wall).

Results: 55 combined LAT and IPC procedures were performed. In 28 patients the IPC was inserted through the LAT port and in 27 the IPC was inserted in a separate intercostal space (ICS) to the LAT port. On day zero, the incidence of any SCE was lower if the IPC was inserted using a separate ICS to the LAT port compared with the same site as the LAT port( P =0.01). This was similarly reduced on discharge chest radiographs and subsequent follow-up.

Conclusion: IPC insertion at LAT using a separate ICS to the LAT port is associated with a reduction in the incidence of SCE during admission and follow-up.

Background: Nonsurgical patients with complex postintubation tracheal stenosis (PITS) and tracheostomy-associated tracheal stenosis (PTTS) often require airway stenting. However, the optimal approach is unknown. Identifying patients at higher risk for restenosis after stent removal may allow the treating physician to individualize the vigilance and duration of airway stenting, and help optimize outcomes.

Methods: This was a single-center retrospective analysis of prospectively collected data on all patients with complex PITS and/or PTTS treated with protocolized bronchoscopic airway stenting over a consecutive 16-year period. The primary outcome analyzed was restenosis rate at 1 year after stent removal. Predictors for restenosis and factors influencing risk for death during stent therapy were also assessed.

Results: Of the 181 subjects treated with silicone airway stenting, 128 were available for analysis of the primary outcome. Restenosis by 1 year after stent removal occurred in 58%. Independent predictors for restenosis were coexisting diabetes [odd ratio (OR)=3.10, 95% confidence interval (CI)=1.04-9.24; P =0.04], morbid obesity (OR=3.13, 95% CI=1.20-8.17; P =0.02), and occurrence of stent-associated complications requiring bronchoscopic management (OR=2.13, 95% CI=1.12-4.03; P =0.02). The overall mortality during the initial stenting period was 14%, and a silicone Y-stent was associated with a higher risk of death (OR=3.58, 95% CI=1.40-9.14; P =0.008).

Conclusion: Tracheal restenosis after silicone stent therapy for complex PITS and PTTS is common and more likely to occur in patients with diabetes, morbid obesity, and frequent stent-associated complications. Mortality risk during stent therapy is not negligible, and a Y-stent should be utilized only after careful consideration. These findings may be incorporated into the approach to bronchoscopic airway stenting in these patients.