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Introduction: Troublesome coughing that persists for more than 8 weeks without evident aetiology or effective therapy is termed unexplained chronic cough (UCC). Using impulse oscillometry (IOS) and spirometry, we assessed the functionalities of the large and small airways, respectively, in patients with UCC and in healthy control subjects.

Methods: On a single occasion, 50 patients with UCC (mean age, 61 years; 82% women) and 23 subjectively healthy controls (mean age, 58.9 years; 95.7% women) underwent IOS and spirometry. Patients with UCC were also subjected to fractional exhaled nitric oxide (FeNO) measurement, and they answered a local questionnaire, a visual analogue scale (VAS) for cough and cough-related symptoms, and a health-related quality of life questionnaire.

Results: Forty-nine (98%) patients with UCC reported cough symptoms from exposure to chemicals, 39 (78%) had problems with cold air, and 38 (76%) had cough symptoms following exercise. The mean VAS cough score was 62 mm in the patient group. FeNO was measured in 25 patients, showing a mean value of 16.6 ppb. Women with UCC had significantly greater airway resistance and reactance than men with UCC. The UCC group showed significantly increased peripheral airway resistance and reactance, and lower FEV1% predicted values (albeit within the normal range), as compared with the healthy control group.

Conclusion: Patients with UCC show increased peripheral airway resistance and significantly lower FEV1% predicted values compared with healthy control subjects. Routine measurements of lung function with both IOS and spirometry could have added value to the diagnosis of UCC.

Introduction: The incidence of pulmonary imaging abnormalities continues to increase. While standard convex probe endobronchial ultrasound bronchoscope (CP-EBUS) is safe and accurate, it has limited reach through smaller bronchi. Olympus BF-Y0069 thin convex probe EBUS (TCP-EBUS) has a smaller diameter and improved angulation. We assessed the safety and feasibility of the TCP-EBUS to evaluate lesions not accessible with CP-EBUS.

Methods: A single-center, prospective, pilot study evaluating TCP-EBUS enrolled patients undergoing bronchoscopy for lesions within the inner two-thirds of the lung. Patients underwent CP-EBUS to attempt visualization and biopsy. If unsuccessful, TCP-EBUS was used. Safety, lesion characteristics, and pathology results were collected.

Results: Fifty-one patients were enrolled with multiple lesion locations and no adverse safety events with TCP-EBUS. Seven cases (13.7%) were omitted as the target lesion was visualized by CP-EBUS and TCP-EBUS. CP-EBUS failed to provide biopsy for 44 cases. CP-EBUS visualized 7/44, however, was unable to biopsy. TCP-EBUS visualized 36/44 (81.8%) lesions and biopsied 27/44 (61%) lesions. 8/44 (15.7%) lesions could not be visualized with either device. Median lesion size biopsied with CP-EBUS was 41 mm (IQR: 22-48). Median size of lesions visualized with TCP-EBUS was 20 mm (IQR: 15.3-38), range 8-70. The median distance from the main carina was 62 mm (IQR: 60-89) for lesions biopsied with the CP-EBUS and 63.3 (IQR: 48.5-78.8) for TCP-EBUS. While average distances from main carina were similar in both groups, the furthest lesion TCP-EBUS visualized was 120 mm from the carina compared to 100 mm with CP-EBUS.

Conclusions: The use of TCP-EBUS was safe and effective without observed patient-associated complications, and it provided real-time ultrasonographic visualization and biopsy of lesions not accessible with CP-EBUS.

Introduction: Ultrasound-guided trans-thoracic needle biopsy (US-TTNB) is a method of choice for the diagnostic management of peripheral lung lesions and pleural masses for pulmonologists. If complication risk factors and diagnostic yield have been well reported for CT-guided biopsies, publications for US-TTNB in this field are very scarce.

Methods: The primary objective of this study was to describe the diagnostic yield of US-TTNB carried out by pulmonologists defined by a definitive histopathological diagnosis. Secondary objectives were to identify factors that may influence diagnostic yield and to describe complications of this procedure. Between September 2015 and December 2022, charts of consecutive patients presenting peripheral lesion with pleural contact and having undergone US-TTNB were retrospectively analyzed. ROC curves were performed to assess the probability of having a contributing biopsy (definitive histology) depending on scannographic measurements and the number of punctures. Univariate and then multivariate analyses were performed to look for variables associated with complications.

Results: One hundred and fifty-nine patients were enrolled in this study. Among them, diagnosis was obtained for 140 patients (88% success rate). The histology was in favor of a neoplastic process in 96% of cases (135/140). Analysis of the ROC curves showed that the depth of the lesion (AUC 75%; 95% CI: 65-85; cut-off 3.0 cm), the width of the lesion (AUC 73%; 95% CI: 63-86; cut-off 3.9 cm), the pleural contact (AUC 68%; 95% CI: 57-80; cut-off 3.8 cm), and the number of biopsies (AUC 70%; 95% CI: 59-81; cut-off 3 biopsies) were the variables associated with diagnostic yield. Complications occurred for 27 patients (17%), mainly pneumothorax (6%), hemoptysis (6%), and sepsis (6%). Univariate analysis showed a significant association between pneumothorax and lesion depth (OR 0.68; 95% CI: 0.65-0.92; p = 0.03) with a predicted probability >5% for a depth <4 cm according to general linear model analysis. Univariate and multivariate analysis revealed a significant association between the number of biopsies and the risk of sepsis (OR 1.90; 95% CI: 1.19-3.26; p = 0.01) with a predicted probability >5% for more than 4 biopsies.

Conclusion: US-TTNB is a reliable diagnostic procedure that can be performed by pulmonologists. The depth, width, pleural contact of the lesion, and the number of biopsies are key variables associated with diagnostic yield. The depth of the lesion is associated with the risk of pneumothorax, and the number of biopsies with the risk of pulmonary sepsis.

Background: The nasopharyngolaryngoscopy (NPL) has emerged as a valuable tool for detecting early cases of head and neck cancers. However, misdiagnoses and missed diagnoses are still common phenomena. The expertise of examining physicians often serves as the primary limiting factor, leading to issues such as incomplete visualization, imprecise identification, and unclear vision. Over recent years, the application of artificial intelligence (AI) in medical imaging, particularly in the realm of gastrointestinal endoscopy, has instigated revolutionary changes in site quality control, lesion identification, and report generation. However, there remains a lack of standardized guidelines for the proper application of NPL across various countries.

Summary: In this paper, we set our sights on reviewing the current clinical applications and summarizing the primary shortcomings of NPL. In addition, we encapsulate the progress of AI application within gastrointestinal endoscopy and NPL. Drawing from real-world clinical practice, we propose future directions and prospects for AI research in NPL. We firmly believe that the pace of clinical application of AI in NPL will accelerate significantly in the near future.

Key messages: Incomplete examination coverage, failure to detect and diagnose lesions, and poor image quality happens in the current use of NPL. Currently, NPL examinations lack third-party supervision and quality control. AI application has achieved great advancements in gastrointestinal endoscopy concerning endoscopic quality control, lesion identification, and standardized reporting. While AI-related research in NPL is still in its nascent stages, it shows substantial potential for clinical application and endoscopic training. The interaction of AI into NPL examinations is potential and inevitable in the era of big data.

Purpose of the study We investigated the incidence of chronic pulmonary complications in allogeneic hematopoietic cell transplantation (allo-HCT) recipients and analyzed the role of transbronchial cryobiopsy (cryoTBB) as a tool to determine the nature of pulmonary changes and to guide clinical decisions.

Methods: Patients who survived at least 6 months post HCT were included in the study. Pulmonary functional tests (PFTs) were performed in all patients as a screening tool. In case of abnormal results computed tomography (CT) was done to verify inflammatory changes and the presence of air-trapping. Next, patients were qualified for microbiological analysis of bronchoalveolar lavage fluid. If the results of non-invasive tests were inconclusive, cryoTBB was performed.

Results: Among 186 patients, we identified 13 cases (7%) with abnormal PFTs. Mild, moderate, and severe chronic graft versus host disease (GvHD) was diagnosed in 1 (8%), 6 (46%), and 2 (15%) patients, respectively. Four (31%) patients did not present any manifestations of cGvHD at FEV1 decline. Eight 8 (62%) patients met the bronchiolitis obliterans syndrome criteria, 5 (48%) had restrictive disease, or mixed phenotype based on PFTs, only in 1 case air-trapping was present in CT. Pulmonary GvHD was confirmed by cryoTBB histopathology in 5 of 11 (45%) cases. Immunosuppression was either stopped or decreased in 6 patients with negative results for GvHD with further clinical improvement.

Conclusion: CryoTBB can be a helpful tool to verify the cause of chronic pulmonary complications in the HCT population. Based on negative biopsy results, some patients may benefit from IST discontinuation or reduction to mitigate recurrences of infectious complications and further lung destruction.

Introduction: Endoscopic lung volume reduction (ELVR) with valves is an effective intervention in patients with severe lung emphysema. Two types of valves are established in clinical practice: Zephyr endobronchial valves (EBVs) and Spiration Valve System (SVS). We aimed to compare outcomes and the safety associated with these two types of one-way valves.

Methods: Data were collected from three German lung emphysema centers as part of a prospective observational study focusing on lung volume reduction. Two groups were formed based on valve types. In both groups, lung function (FEV1, RV, diffusion capacity of the lung for carbon monoxide, pCO2), 6-min walking distance (6MWD), quality of life (SGRQ, mMRC, CAT), and complication rate were recorded at baseline and at follow-up 3 to 6 months later.

Results: A total of 54 patients were treated with SVS valves and 99 patients with EBV. There were no significant differences between both groups at baseline. Notably, both types of valves exhibited significant enhancements in lung function and quality of life. Interestingly, there were no significant differences in the median change of all measured parameters for both groups, suggesting comparable improvements in EBV and SVS. Pneumothorax was the most common complication for both valve types. The incidence of adverse events did not differ significantly between groups.

Conclusion: Our study suggests that both types of valves are safe and effective in the treatment of severe lung emphysema. We recommend choosing the valve type based on individual bronchial anatomy. However, further randomized studies are needed to confirm our results.

Introduction: During endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA), a saline-filled balloon placed over the tip of the bronchoscope is used to improve coupling of the ultrasound transducer to the airway wall. However, it is unknown whether it objectively improves image quality or affects procedural outcomes. Our aim was to establish whether the use of a balloon during EBUS impacts image quality, diagnostic yield, procedure duration or complications.

Methods: A pilot randomized control trial of patients undergoing EBUS-TBNA of mediastinal lymph nodes was performed at a single academic center. Patients were randomized to use a saline-filled balloon (versus no balloon use) during EBUS-TBNA of the right lower paratracheal lymph node (station 4R). The EBUS videos were recorded and scored on a 4-point Likert scale by three blinded external reviewers. The primary outcome of this study was ultrasound image quality. Secondary outcomes included diagnostic yield, procedure duration, and complications.

Results: Forty-six patients were randomized. In the balloon group, 61% of patients had an image quality score of "excellent" or "good," compared to 47% in the no balloon group (p = 0.009). There was no significant difference in diagnostic yield, procedure duration, or complications between the groups.

Conclusion: Inflation of the balloon during EBUS-TBNA at the right lower paratracheal lymph node improves ultrasound image quality but does not impact diagnostic yield, procedure duration, or safety. This study provides a framework for additional studies with complete nodal assessment to determine if balloon use has a clinically meaningful benefit to procedural outcomes.

Introduction: Idiopathic pulmonary fibrosis (IPF) can occur at any age; however, studies on younger IPF patients are scarce because it primarily affects the elderly. This study aimed to investigate the clinical features and outcomes of younger IPF patients.

Methods: We analyzed the National Korean Health Insurance Review and Assessment Service (HIRA) database from 2015 to 2021. Patients with IPF were identified using the International Classification of Diseases 10th Revision (ICD-10) codes and the Rare Intractable Diseases codes and were categorized into three age groups: <50, ≥50 and <65, and ≥65 years. The risk of acute exacerbation (AE) and mortality was analyzed.

Results: Among 4,243 patients with IPF, 91 were under 50. These younger patients, who were predominantly female, exhibited less comorbidities and received more systemic steroids, whereas older group received more pirfenidone. Although AE risk increased with age, it was not statistically significant. Mortality and lung transplantation risks increased notably with age from the <50 group to the ≥50 and <65 group (hazard ratio [HR]: 1.52, 95% confidence interval [CI]: 0.93-2.49) and the ≥65 group (HR: 2.44, 95% CI: 1.51-3.93). These risks were influenced by factors such as age, comorbidities, previous AEs, and steroid use. Conversely, pirfenidone treatment reduced the risk.

Conclusion: While younger IPF patients had a lower risk of mortality and lung transplantation, with no significant differences in the risk of AEs, they were less likely to receive antifibrotic therapy and more often treated with steroids, which may affect outcomes. Early, targeted treatment strategies, including antifibrotic use, are crucial for improving their prognosis.

Introduction: Individuals who survive acute coronavirus disease 2019 (COVID-19) might experience diaphragm muscle weakness. Diaphragm ultrasound may be an easy-to-obtain bedside tool for determining diaphragm function. However, twitch transdiaphragmatic pressure (twPdi) following magnetic stimulation (MS) of the phrenic nerves is the gold standard for non-volitional assessment of diaphragm strength. This study investigated whether diaphragm thickening ratio (DTR) measured on diaphragm ultrasound reflects diaphragm strength as measured by twPdi following MS of the phrenic nerves or other (volitional) invasively obtained pressure values and could therefore be used to accurately diagnose diaphragm weakness.

Methods: One year after discharge, 50 individuals (14 female, age 58 ± 12 years) who had been hospitalised and treated for moderate-severe COVID-19 underwent standard spirometry and diaphragm ultrasound. TwPdi following cervical MS of the phrenic nerve and volitional inspiratory manoeuvres (Sniff and Mueller manoeuvre) were measured using oesophageal and gastric balloon catheters after transnasal placement.

Results: At follow-up, no clinically meaningful restrictive lung function impairment was evident on spirometry. On diaphragm ultrasound, diaphragm dysfunction, i.e., an impaired DTR was detected in 24% (12/50) of participants. An objective diagnosis of diaphragm dysfunction, defined as twPdi <16 cm H2O, was made in 60% (30/50) of participants. The measurement results of the two methods did not agree, given that there were many false-negative but also false-positive results, so diaphragm ultrasound diagnosed in parts other patients with diaphragm dysfunction than twPdi. Diaphragm ultrasound had a sensitivity of 26.67% and a specificity of 80.0% in the detection of diaphragm dysfunction (positive predictive value 66.67%, negative predictive value 42.10%).

Conclusion: Diagnosis of diaphragm weakness in individuals who have recovered from COVID-19 cannot be made accurately on diaphragm ultrasound (via DTR) but requires twPdi as the gold standard for assessment of diaphragm strength.