Introduction Treatment of malignant tracheoor broncho-oesophageal fistulas (TOF) using therapeutic bronchoscopy (TB) is not standardised and its outcomes are poorly described. This study aimed to analyse the characteristics of patients treated with TB for a TOF and to identify prognostic factors. Methods We analysed data from 96 patients undergoing TB for TOF entered in the EpiGETIF registry between January 2019 and December 2022. Results The mean age was 61.4 years. Median survival after TB was 2.40 months (95% CI 1.81-3.32). Histology was mainly represented by oesophageal (72%) and lung (23%) cancers and did not influence prognosis (p=0.15), whereas smoking did (2.17 versus 3.32 months for nonsmokers, p=0.04). Patients with poor performance status (Eastern Cooperative Oncology Group >2) had shorter survival (1.99 versus 3.02 months, p=0.04). 69% of patients had already received oncologic treatment, with no difference in survival (3.02 versus 2.21 months for treatment-naive patients, p=0.14). Neither the localisation (trachea 61.5%, left main bronchus 34.4%, other 4.1%) nor the size of the fistulas (23% <5 mm, 20% 5-10 mm, 54% >10 mm) impacted survival (p=0.91 and p=0.83, respectively). An airway stent (AS) was placed in 92.7% of patients, mainly self-expanding metallic stents (45%). Patients treated with both an oesophageal stent and AS had a better prognosis than patients treated with an AS alone (2.88 versus 1.77 months, respectively, p=0.02). Conclusion Survival of patients treated with TB for a TOF is very poor, and is impacted by smoking, performance status and the presence of an oesophageal stent.

Lung cancer accounts for the second most frequent solid tumor and for about one in four deaths by cancer. Survival of lung cancer has improved since the 1990s because of early tumor detection, therapeutic advances through improvements in surgical techniques, and the development of immunotherapy and targeted therapy.1 However, new treatments resulted in new life-threatening side effects likely to require ICU admission.2,3

Background and study aims Endoscopic management of esophagorespiratory fistulas (ERF) is challenging and currently available options (stents, double pigtail, endoscopic vacuum therapy) are not very effective. We report the feasibility and efficacy of endoscopic placement of Amplatzer cardiovascular occluders for this indication. Patients and methods This was a single- center, prospective study (June 2019 to September 2020) of all patients with non-malignant ERF persistent after conventional management with esophageal and/or tracheal stents. The primary outcome was the technical feasibility of Amplatzer placement. Secondary outcomes were clinical success defined by effective ERF occlusion and resolution of respiratory symptoms allowing oral food intake. Results Endoscopic placement of Amplatzer occluders was feasible in 83% of patients (5/6), with a 50% (3/6) clinical success rate at 9 months. The mortality rate was 33% (2/6). Conclusions An Amplatzer cardiac or vascular occluder is a feasible and safe treatment option for refractory ERF, with a 50% short-term clinical success.

Background. Postoperative pneumonia (POP) is a severe complication of major lung resection. The objective of this study was to describe the current epidemiology and appropriateness of antibiotic prescriptions in severe POP, 4 years after implementation of an antimicrobial stewardship program that was based on weekly multidisciplinary review of all antibiotic therapies. Methods. This study was a retrospective analysis of a prospectively collected database. It included all cases of severe POP occurring within 30 days after major lung resection of in a 1,500-bed hospital between 2013 and 2015. Criteria for severe POP were acute respiratory failure, severe sepsis, or a rapidly extensive pulmonary infiltrate. The study collected data on incidence, clinical outcomes, and microbiological analyses. Appropriateness of antibiotic prescribing was assessed by quality indicators previously validated in the literature. Results. Over the study period, 1,555 patients underwent major lung surgery. Severe POP occurred in 91 patients (5.8%; confidence interval, 4.7%; 7.0%), with a mortality rate of 9.0% (8 of 91; confidence interval, 3.0%; 14.6%). In POP with positive microbiological results, the proportion of gram-negative bacteria other than Haemophilus was 76% (50 of 66 cases). All patients (91 of 91) had respiratory samples taken within 24 hours after the start of antibiotics; empiric therapy was concordant with the guideline in 80% (69 of 86), and it was switched to pathogen-directed therapy in 74% (46 of 62). In 71 of 91 patients (78%), the antibiotic duration was up to 7 days. Conclusions. This study reported a high proportion of gram-negative bacteria in severe POP. Four years after implementation of the program, quality indicators of antibiotic prescribing were all >70%. The rate of deescalation to pathogen-directed therapy could be improved, however. (C) 2019 by The Society of Thoracic Surgeons

Objective: Postpneumonectomy acute respiratory failure leading to invasive mechanical ventilation carries a severe prognosis, especially when acute respiratory distress syndrome develops. The aim of this study was to describe the risk factors, management, and outcome of postpneumonectomy acute respiratory distress syndrome. Methods: We retrospectively reviewed the clinical files of patients undergoing pneumonectomy in a single center between 2005 and 2015. Risk factors for acute respiratory distress syndrome, management characteristics, and short- and long-term outcomes were assessed. Results: Among the 543 patients undergoing pneumonectomy, 89 (16.4%) needed reintubation within the 30th postoperative day, including 60 (11 degrees A) who developed acute respiratory distress syndrome. At multivariate analysis, right-side pneumonectomy (odds ratio [OR], 2.75; 95 degrees A confidence interval [CI], 1.51-5.02; P = .0009) and higher Charlson Comorbidity Index (OR, 1.26; 95% CI, 1.07-1.49; P = .007) were identified as independent risk factors for acute respiratory distress syndrome. Operative mortality was 8.1% for all pneumonectomies, 43.8% (n = 39/89) in intubated patients, and 56.7% (34/60) in patients with acute respiratory distress syndrome. Mortality was higher in severe (25/36, 69.4%) than in mild or moderate acute respiratory distress syndrome (9/24, 37.5%, P = .014). Logistic regression identified 3 independent predictors of operative mortality in patients with acute respiratory distress syndrome: age (OR, 1.08; 95% CI, 1.01-1.15; P = .02), right pneumonectomy (OR, 5.97; 95% CI, 1.33-26.71; P = .02), and severe acute respiratory distress syndrome (OR, 7.19; 95% CI, 1.74-29.73; P = .006). Five-year survival was 17.6% for patients with acute respiratory distress syndrome. Conclusions: Acute respiratory distress syndrome is a severe early complication of pneumonectomy with a poor outcome. The low survival underlines the need for novel management strategies.

Chronic obstructive pulmonary disease (COPD) is a risk factor of post-operative complications after lung cancer resection. The influence of the "frequent exacerbator (FE)" phenotype (at least three exacerbations per year) is unknown. Postoperative outcomes of frequent exacerbators (POFE) was a prospective observational study of patients with COPD undergoing lung resection for cancer. The inclusion criteria were: age >40 years, FEV1/FVC <70%, non-urgent surgery for lung cancer, filled out self-questionnaires. The primary outcome was assessment of postoperative pulmonary complications (purulent tracheobronchitis, atelectasis, pneumonia, acute respiratory failure, need of mechanical ventilation). Secondary outcomes encompassed the prevalence of the FE phenotype and its impact on postoperative complications. A total of 682 patients were screened from June 2014 to October 2015. 93 patients with COPD were included, 21 (23%) were FE. Postoperative tracheobronchitis, atelectasis pneumonia or respiratory failure (isolated or associated) occurred in 47%, 48%, 26%, and 38% of patients, respectively. Non-invasive and invasive mechanical ventilation were necessary in 4 (4%) and 22 (23%) patients. Purulent tracheobronchitis, pneumonia and hypercapnia (this last requiring noninvasive mechanical ventilation) were more frequent in FE (p = 0.043, 0.042, 0.015); however the number of patients wth at least one respiratory complication was not different (76% vs. 52%, p = 0.056). In all patients, multivariate logistic regression identified two independent factors of postoperative respiratory complications: male sex (OR 10.6 [95% CI 1.97-57.6], p = 0.006) and the FE phenotype (OR 6.33 [1.04-38.39], p = 0.045). Occurrence of postoperative complications in patients with COPD is high. FE phenotype is an independent risk factor.

La fistule bronchopleurale est une complication peu fréquente mais grave associée à une morbidité et mortalité élevée. L’étiologie la plus fréquente est la fistule bronchopleurale postrésection pulmonaire spécialement après une pneumonectomie. Le traitement est essentiellement chirurgical mais depuis quelques années, quelques petites séries rapportent des traitements par voie endoscopique. Suivant le délai postopératoire, la localisation et la taille de la fistule, plusieurs options thérapeutiques peuvent être envisagées. Cette mise au point développe les différentes techniques endoscopiques possibles et leurs résultats.

Objective: Post-pneumonectomy acute respiratory failure leading to invasive mechanical ventilation carries a severe prognosis especially when acute respiratory distress syndrome occurs. The aim of this study was to describe risk factors and outcome of acute respiratory failure. Methods: We retrospectively reviewed clinical files of all patients who underwent pneumonectomy in a single center between 2005 and 2015. Risk factors and outcome of acute respiratory failure were assessed in univariate and multivariate analysis. Results: Among the 543 patients who underwent pneumonectomy in the period of study, 89 (16.4%) needed reintubation within the 30th postoperative day and 60 of these (11 degrees A of all pneumonectomies) developed acute respiratory distress syndrome. In multivariate analysis, right-side of pneumonectomy (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.24-4.22), chronic cardiac disease (OR, 2.15; 95% CI, 1.08-4.25), Charlson Comorbidity Index (OR, 1.35; 95% CI, 1.14-1.61), carinal resection (OR, 3.23; 95% CI, 1.26-8.29), and extrapleural pneumonectomy (OR, 8.36; 95% CI, 3.31-21.11) were identified as independent risk factors of reintubation. Thirty-day mortality was 7.7% for all pneumonecto mies, 41.6% (37/89) in the invasive ventilation group, and 53.3% (32/60) in patients with acute respiratory distress syndrome. In non-reintubated patients, 30-day mortality was 1.1% (5/454). In reintubated patients, 5-year survival was 27.1% (95% CI, 17.8-41.4). Conclusions: Early acute respiratory failure requiring reintubation remains a severe complication of pneumonectomy with a poor outcome.

An unusual case of pleural empyema related to Nocardia farcinica and Ureaplasma urealyticum, occurring after autologous haematopoietic stem cell transplantation in a 30-year-old patient with lymphoma, is reported. This case illustrates the role of repeated and comprehensive microbiological investigations and the contribution of molecular techniques in reaching the aetiological diagnosis.

Pneumonia is a dreaded complication of varicella-zoster virus (VZV) infection in adults; however, the data are limited. Our objective was to investigate the clinical features, management, and outcomes of critically ill patients with VZV-related community-acquired pneumonia (VZV-CAP).

A 36-year old patient with relapsing T-cell prolymphocytic leukemia was admitted in intensive care unit for acute respiratory failure and pulmonary infiltrates. A flexible bronchoscopy with bronchoalveolar lavage was performed while the patient was under noninvasive ventilation. Cytological examination and immunophenotyping of BAL lymphoid cells confirmed the diagnosis of lung infiltration with prolymphocytic T-cell leukemia. An associated organized pneumonia was suspected. The rapid clinical and radiological response to corticosteroids followed by immunotherapy with alemtuzumab strengthened our hypothesis. To our knowledge, this is the first reported case of prolymphocytic T-cell leukemia with a specific pulmonary lung involvement associated with an organized pneumonia.

Le taux de CPOR (pneumopathies postopératoire [PPO], atélectasies, insuffisances respiratoires aiguës [IRA]) après RP varie entre 12 et 40 %, et augmente en cas de BPCO. Les objectifs de l’étude POFE sont de préciser le taux de CPOR après RP chez les patients atteints de BPCO et l’influence de différents facteurs de risque possibles, notamment le phénotype « exacerbateur fréquent » (EF, au moins 2 exacerbations par an). Il s’agit d’une étude monocentrique observationnelle prospective chez les pts consécutifs de plus de 40 ans atteints de BPCO hospitalisés en vue d’une RP pendant 1 an. À ce jour, 90 pts ont été inclus (67,8 % d’hommes, 67 ± 8 ans), dont 36,7 % de stades GOLD I, 47,8 % de stade II, 10 % de stade III et 14,4 % de phénotype EF (2 pts GOLD I, 5 pts GOLD II, 3 pts GOLD III). La population EF ne se distinguait pas de la population non EF en termes de score de Charlson, d’ASA, de thoracoscore, de grade de dyspnée MRC, de CAT, de score d’activité IPAQ2 (Tableau 1). En conclusion, les patients BCPO sont à fort risque de développer des CORP (Tableau 1). Le phénotype EF ne semble pas exposer à un sur-risque.

Les pneumonies postopératoires (PPO) après résections pulmonaires sont fréquentes et sévères et le plus souvent d'origine bactérienne [1]. Les pneumonies à HSV sont possibles chez les patients de réanimation suspects de PAVM [2]. Objectifs de notre étude : étudier la fréquence de la détection d'HSV dans les LBA des patients suspects de PPO, décrire les caractéristiques de ces patients et identifier les facteurs associés à la présence d'HSV dans les LBA. Étude de cohorte monocentrique prospective incluant des patients suspects de PPO qui avaient bénéficié d'une chirurgie thoracique dans les 60 jours précédents, hospitalisés en soins intensifs respiratoires ou en réanimation thoracique. En cas de suspicion de PPO, et en l'absence de contre indication ou de documentation microbiologique non invasive chez les patients non ventilés, une fibroscopie bronchique pour aspiration bronchique à visée bactériologique et LBA avec examen virologique était réalisée (PCR HSV, culture virale et examen anatomopathologique). Dans le même temps étaient réalisées des prélèvements sanguins : PCR sanguine à la recherche d' HSV et de CMV (prélevé le jour de la fibroscopie et 1 fois par semaine au cours du séjour hospitalier). Les critères de pneumonie à HSV confirmé étaient : la présence d'une PCR HSV positive dans le LBA associé à un effet cytopathogène en culture ou en anatomopathologie. La présence d'une PCR HSV positive dans le LBA sans effet cytopathogène représente le groupe de pneumonie à HSV probable. Une suspicion de PPO a été portée chez 97 patients (35 % des admis). Cinquante patients ont eu des prélèvements endoscopiques à la recherche d'une PPO bactérienne et d'une pneumonie herpétique (50/97), 2 patients ont été exclus de l'analyse car ils n'ont pas eu de PCR HSV dans le LBA. Sur ces 48 patients, nous mettons en évidence de l'HSV par PCR dans le LBA chez 33,5 % des patients. Chez 7 d'entre eux, il s'associait à une PCR sanguine positive (44 %) et chez 5 (31 %) un effet cytopathogène sur le LBA, permettant le diagnostic de broncho-pneumonie herpétique chez 10,4 % des patients suspects de PPO. Les 5 patients avec pneumonie HSV confirmée ont des PCR quantitatives dans le LBA supérieur à 5,19 log. La présence d'une PCR HSV positive dans le LBA s'associe à une évolution respiratoire plus sévère avec une mortalité plus élevée à 90 jours (50 % vs 22 % ; p = 0,048). La PCR quantitative sur le LBA pourrait permettre un diagnostic de pneumonie herpétique rapide et spécifique en s'affranchissant des limites de la culture virale et de l'examen anatomopathologique. La détermination d'un seuil de positivité reste à établir pour notre population spécifique de malade de post opératoire de chirurgie thoracique.

Objectives To investigate whether prophylactic postoperative NIV prevents respiratory complications following lung resection surgery in COPD patients. Methods In seven thoracic surgery departments, 360 COPD patients undergoing lung resection surgery were randomly assigned to two groups: conventional postoperative treatment without ( n = 179) or with ( n = 181) prophylactic NIV, applied intermittently during 6 h per day for 48 h following surgery. The primary endpoint was the rate of acute respiratory events (ARE) at 30 days postoperatively (ITT analysis). Secondary endpoints were acute respiratory failure (ARF), intubation rate, mortality rate, infectious and non-infectious complications, and duration of ICU and hospital stay. Measurements and main results ARE rates did not differ between the prophylactic NIV and control groups (57/181, 31.5 vs. 55/179, 30.7 %, p = 0.93). ARF rate was 18.8 % in the prophylactic NIV group and 24.5 % in controls ( p = 0.20). Re-intubation rates were similar in the prophylactic NIV and control group [10/181 (5.5 %) and 13/179 (7.2 %), respectively, p = 0.53]. Mortality rates were 5 and 2.2 % in the control and prophylactic NIV groups, respectively ( p = 0.16). Infectious and non-infectious complication rates, and duration of ICU and hospital stays were similar between groups. Conclusions Prophylactic postoperative NIV did not reduce the rate of ARE in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of ICU and hospital stay.