This review examines the expanding role of the pulmonologist in the care of patients with lung cancer, including diagnosis, mediastinal staging, tissue stewardship, therapeutic bronchoscopy, and involvement in longitudinal pulmonary care. A multidisciplinary approach is essential in providing high-quality patient care. Emerging strategies include structured nodule programs, mobile health screening, and artificial intelligence to improve the timely diagnosis of lung cancer.

BACKGROUND:Robotic navigation bronchoscopy (RNB) is effective for accessing peripheral lung lesions with precision and safety. However, the incidence of atelectasis during RNB can impede lesion identification. Higher positive end-expiratory pressure (PEEP) levels may mitigate atelectasis, but bedside assessment is challenging. Transpulmonary pressure (Ptp) assessment, proven useful in optimizing PEEP in ARDS, remains unexplored in RNB. METHODS:This single-center, prospective study enrolled 21 consecutive patients undergoing RNB. All patients were paralyzed and ventilated equally, including PEEP 10 cmH2O and Vt 6 to 8 cc/kg of ideal body weight, and had an esophageal balloon placed using established techniques. Once an adequate esophageal pressure (Pes) waveform was identified, the Pes was recorded. We used Pes as a surrogate for intrathoracic pressure to calculate Ptp. RESULTS:A total of 21 patients were enrolled (male 11, 52%), BMI (27±4.1). The mean nodule size was 26.83±9.33 mm. The diagnostic yield was 87% for malignancy. The mean Vt was 7.15±1.16 cc/kg. Mean Pes and Ptp were 9.64±3.76 cmH2O and 0.36±1.2 cmH2O, respectively. Eight patients had negative Ptp, and compared with patients with positive Ptp, there were more eccentric or no signals (75% vs. 45%) by rEBUS. CONCLUSION:This study provides detailed instructions and feasibility of assessing Ptp in patients undergoing RNB and highlights a potential relationship between negative Ptp and the ability to obtain a concentric rEBUS signal. Our findings suggest that negative Ptp may be associated with a higher likelihood of encountering eccentric or absent rEBUS signals. Further research could enhance our understanding of pulmonary physiology during RNB.

Background  Airway surgery utilizing a heat source carries a risk of airway fire. Among the airway fire triad of oxidizer, fuel, and ignition source, oxygen concentration is a modifiable risk factor. Rigid bronchoscopy, commonly used during airway surgery, utilizes an open circuit. An open circuit, when combined with jet ventilation, makes measurement of airway oxygen concentration difficult. To decrease airway oxygen concentration, some centers use a pause in jet ventilation to allow airway concentration to decrease; however, the effect of this pause on central airway oxygen levels is not known. Our objective was to better understand changes in central airway oxygen concentration during apnea during rigid bronchoscopy, an important component of fire risk. Methods  We designed a prospective observational study of patients requiring rigid bronchoscopy. We utilized jet ventilation with 100% FiO2. To measure central airway oxygen concentration in the distal trachea, we connected a long rigid suction cannula to an oxygen analyzer and passed it through the bronchoscope. When central airway oxygen concentration was >90%, apnea was initiated, and we measured the time required for central airway oxygen concentration to decrease to less than 40%. This was repeated for the right and left main bronchi.  Results  The average time to reach airway oxygen concentration of less than 40% was 40.9±18.1s (mean±SD), 41.9±19.5s, and 41.6±21.7s for the trachea, right main bronchus, and left main bronchus, respectively.  Conclusions  We found that after a prolonged period of apnea, many patients had central airway oxygen concentration above levels conventionally considered optimal for airway surgery. This is the first description of this method for monitoring central airway oxygen concentration.

Background:Robotic navigation bronchoscopy (RNB) is effective for accessing peripheral lung lesions with precision and safety. However, the incidence of atelectasis during RNB can impede lesion identification. Higher positive end-expiratory pressure (PEEP) levels may mitigate atelectasis, but bedside assessment is challenging. Transpulmonary pressure (Ptp) assessment, proven useful in optimizing PEEP in ARDS, remains unexplored in RNB.Methods:This single-center, prospective study enrolled 21 consecutive patients undergoing RNB. All patients were paralyzed and ventilated equally, including PEEP 10 cmH2O and Vt 6 to 8 cc/kg of ideal body weight, and had an esophageal balloon placed using established techniques. Once an adequate esophageal pressure (Pes) waveform was identified, the Pes was recorded. We used Pes as a surrogate for intrathoracic pressure to calculate Ptp.Results:A total of 21 patients were enrolled (male 11, 52%), BMI (27 +/- 4.1). The mean nodule size was 26.83 +/- 9.33 mm. The diagnostic yield was 87% for malignancy. The mean Vt was 7.15 +/- 1.16 cc/kg. Mean Pes and Ptp were 9.64 +/- 3.76 cmH2O and 0.36 +/- 1.2 cmH2O, respectively. Eight patients had negative Ptp, and compared with patients with positive Ptp, there were more eccentric or no signals (75% vs. 45%) by rEBUS.Conclusion:This study provides detailed instructions and feasibility of assessing Ptp in patients undergoing RNB and highlights a potential relationship between negative Ptp and the ability to obtain a concentric rEBUS signal. Our findings suggest that negative Ptp may be associated with a higher likelihood of encountering eccentric or absent rEBUS signals. Further research could enhance our understanding of pulmonary physiology during RNB.

Navigational bronchoscopy is increasingly used to target peripheral pulmonary nodules using electromagnetic navigational platforms (ENB), fluoroscopic navigation, or robotic-assisted bronchoscopy. The selection of equipment largely depends on the availability of technology, expertise, and the characteristics of the nodule and patient. Radial EBUS (r-EBUS) is often combined with these techniques for real-time confirmation of the nodule location. A bronchus sign is considered to have a higher diagnostic yield when biopsy tools can directly reach the nodule. We describe a case series of creating a false airway into the nodule when an eccentric r-EBUS signal is seen to subsequently obtain a concentric signal.

Background and aim: Endobronchial biopsy (EBBX) has been reported to increase diagnostic yield for pulmonary sarcoidosis. The purpose of this study is to investigate the diagnostic yield for EBBX following endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). Methods: We identified a cohort of patients in the University of Minnesota Sarcoidosis Registry who had EBBx and EBUS-TBNA as part of workup for abnormal chest imaging. Data regarding demographics, biopsy approach and technique were recorded. Results: Our cohort included 37 patients (53.24 +/- 9.5, Male, 22 +/- 0.57; 3.8% were African American). In these patients who had EBBX, EBUS-TBNA was performed in 100% of patients and TBBX was performed in 2 patients (5%). EBBX was positive in 9 patients (24%) and EBUS-TBNA was positive in 34 patients (92%). TBBX was diagnostic in one of two patients. EBBX was the only diagnostic tissue in 3 of the 37 patients (8%). Conclusion: The diagnostic yield of EBBX is lower than previously reported, with only 8% of EBBXs demonstrating granulomatous inflammation. However, instrumentation used for obtaining EBBX as well as the presence of visible lesions does influence the diagnostic yield. Studies with adequate power are needed before implementing changes in clinical practice. When performed alongside EBUS-TBNA, EBBX did not significantly add to the diagnostic yield in sarcoidosis unless visible lesions were observed.

Background: Intrabronchial valves are approved for bronchoscopic lung volume reduction in chronic obstructive pulmonary disease patients and used for prolonged air leak. There is no data on bronchoscopic functional pneumonectomy (BFP) when treating patients with persistent air leak (PAL) or for lung volume reduction purposes. Methods: In this observational study, 10 consecutive patients who failed to improve with traditional therapies were assessed after they underwent BFP for PAL or lung volume reduction. Results: Ten patients underwent 17 valve placement procedures; 82 valves were placed (median: 8; range: 5 to 12). BFP was performed in 1 single lung transplant patient with hyperinflation of native lung compromising lung function. The rest of the patients had prolonged air leak because of various reasons; spontaneous (n=7) and postoperative (n=2). Pneumonia was the only procedure-related complication seen in 1 patient. Of patients with prolonged air leak with chest tubes (n=9), all had successful chest tube removal (median of 7 days; range: 3 to 21 d). The valves were removed within 6 weeks of chest tube removal in 6 patients. Prebronchoscopic and post-BFP actual forced expiratory volume in first second values in 2 transplant patients. Conclusion: PAL usually occurs in patients with severe underlying lung condition or after surgery. Management of PAL can be challenging despite pleurodesis (medical or surgical). BFP offers a minimally invasive management option.

Background: Current medical society guidelines recommend a procedural number for obtaining electromagnetic navigational bronchoscopy (ENB) competency and for institutional volume for training. Objective: To assess learning curves and estimate the number of ENB procedures for interventional pulmonology (IP) fellows to reach competency. Methods: We conducted a prospective multicenter study of IP fellows in the United States learning ENB. A tool previously validated in a similar population was used to assess IP fellows by their local faculty and two blinded independent reviewers using virtual recording of the procedure. Competency was determined by performing three consecutive procedures with a competency score on the assessment tool. Procedural time, faculty global rating scale, and periprocedural complications were also recorded. Results: A total of 184 ENB procedures were available for review with assessment of 26 IP fellows at 16 medical centers. There was a high correlation between the two blinded independent observers (rho = 0.8776). There was substantial agreement for determination of procedural competency between the faculty assessment and blinded reviewers (kappa = 0.7074; confidence interval, 0.5667-0.8482). The number of procedures for reaching competency for ENB bronchoscopy was determined (median, 4; mean, 5; standard deviation, 3.83). There was a wide variation in the number of procedures to reach competency, ranging from 2 to 15 procedures. There were six periprocedural complications reported, four (one pneumomediastinum, three pneumothorax) of which occurred before reaching competence and two pneumothoraces after achieving competence. Conclusion: There is a wide variation in acquiring competency for ENB among IP fellows. Virtual competency assessment has a potential role but needs further studies.

Background: Intrabronchial valves are approved for bronchoscopic lung volume reduction in chronic obstructive pulmonary disease patients and used for prolonged air leak. There is no data on bronchoscopic functional pneumonectomy (BFP) when treating patients with persistent air leak (PAL) or for lung volume reduction purposes. Methods: In this observational study, 10 consecutive patients who failed to improve with traditional therapies were assessed after they underwent BFP for PAL or lung volume reduction. Results: Ten patients underwent 17 valve placement procedures; 82 valves were placed (median: 8; range: 5 to 12). BFP was performed in 1 single lung transplant patient with hyperinflation of native lung compromising lung function. The rest of the patients had prolonged air leak because of various reasons; spontaneous (n=7) and postoperative (n=2). Pneumonia was the only procedure-related complication seen in 1 patient. Of patients with prolonged air leak with chest tubes (n=9), all had successful chest tube removal (median of 7 days; range: 3 to 21 d). The valves were removed within 6 weeks of chest tube removal in 6 patients. Prebronchoscopic and post-BFP actual forced expiratory volume in first second values in 2 transplant patients. Conclusion: PAL usually occurs in patients with severe underlying lung condition or after surgery. Management of PAL can be challenging despite pleurodesis (medical or surgical). BFP offers a minimally invasive management option.

BACKGROUND:There is a paucity of real-time imaging modalities available for the bronchoscopic biopsy of peripheral lung nodules. We aim to demonstrate the feasibility of the O-arm imaging system to guide real-time biopsies of peripheral lung nodules during electromagnetic navigation bronchoscopy.METHODS:A retrospective review was performed at 2 academic medical centers utilizing O-arm guidance.RESULTS:The average nodule size was 2.1×2.0 cm and were mostly solid (66%) with a positive bronchus sign (83%). O-arm imaging confirmed tool-in-lesion in all cases. The diagnostic yield was 33%. Four cases were nondiagnostic of the 6 cases performed. In these cases, necrotic tissue was the most common (75%) and showed resolution following subsequent imaging. The average 3-dimensional (3D) spin time was 23.5 seconds. The average number of 3D spins performed per case was 4.33. The average effective dose per 3D spin was 3.73 mSv.CONCLUSION:We have demonstrated the O-arm's feasibility with electromagnetic navigation bronchoscopy for peripheral lung nodules. The O-arm was able to confirm tool-in-lesion in all cases which added confidence to the biopsy. Four high-resolution 3D spins per case may limit the total computed tomography effective dose. We also noted that both metal and radiation scatter were minimal when appropriate radiation safety standards were met. Although additional experience and data will be required to verify the O-arm approach for routine use, our initial experience is promising.

Objectives Endobronchial ultrasound- and endoscopic ultrasound-guided fine-needle aspiration (EBUS-/EUS-FNA) are minimally invasive techniques of diagnosing and staging malignancies. The procedures are difficult to master, requiring specific feedback for optimizing yield. Methods Over 2 years, EBUS-/EUS-FNA cases were gathered using the institutional pathology database. Patient and specimen characteristics were collected from the pathology database and electronic medical record. Results In 2 years, 789 unique FNA specimens were collected (356 EBUS and 433 EUS specimens). The cohort and each subgroup had excellent performance, which was enhanced by telepathology. The discrepancy rate was satisfactorily low. Hematolymphoid neoplasms are overrepresented in discrepant EBUS cases. The malignancy rates of cytology diagnostic categories were comparable to the literature. Conclusions Using diagnostic yield and concordance results allow for comprehensive evaluation of the entire process of EBUS-/EUS-FNAs. This study’s findings can influence patient management, training methods, and interpretation of results, while also acting as a model for others to investigate their own sources of inadequacy, discrepancy, and training gaps.

TOPIC: Procedures TYPE: Original Investigations PURPOSE: Airway surgery utilizing a heat source carries a risk of airway fire. In the setting of mechanical ventilation, the fraction of inspired oxygen is decreased as much as possible per the ASA(American Society of Anesthesiologists) guidelines, with a usual goal of less than 30%. Most mechanical ventilators allow for close control of inhaled oxygen and accurate measure of exhaled oxygen concentration when a cuffed endotracheal tube is used. During rigid bronchoscopy supported by jet ventilation, monitoring airway oxygen concentration is more difficult. Therefore, a commonly used method for avoiding airway fire is to allow for 5-10 seconds of apnea prior to introducing an ignition source to the field. Although the incidence for airway fire during rigid bronchoscopy is rare, we sought to investigate the level of airway oxygen concentration (AOC) and time it takes to reach an end-tidal O2 concentration (ETO2) less than 40% during an apneic period. METHODS: During rigid bronchoscopy, apnea was initiated after reaching an ETO2 of 90% or greater. The concentration of oxygen in the airway was measured at three locations (distal trachea and proximal right and left mainstem bronchus). with a rigid suction catheter connected to a gas analyzer on the anesthesia machine. Once the desired spot was reached, the time required to reach AOC of 40% was recorded. If the patient did not tolerate apnea due to hypoxemia or other clinical reasons, ventilation was resumed. RESULTS: A total of eleven patients (Age 62.5±7.1, Male 5, 45%) met the criteria and successfully enrolled. Patients undergoing bronchoscopy included lung transplant for bronchial stenosis (8,73%) and lung cancer for tumor debulking (3, 27%). Average spirometry data include %predicted FVC (64±19.4), %predicted FEV1 (45±13.1), and %predicted DLCO (64±24.6). Theaverage time to reach AOC of 40% at the main carina was 45.1±26.2 sec, left mainstem bronchus was 39±17.2 sec, and right mainstem bronchus was 37.3±21.1 sec. No patients hadany complications to the study intervention. CONCLUSIONS: AOC during rigid bronchoscopy supported by jet ventilation were higher than expected and above those typically tolerated during at risk procedures using conventional mechanicalventilation. This is notable given the low reported risk of airway fires during this procedure. CLINICAL IMPLICATIONS: In the absence of direct measurement, AOC during rigid bronchoscopy should be assumed to be above the level commonly assumed to be safe. DISCLOSURES: Consultant relationship with Toray Industries Please note: 1/2021 to 9/2021 Added 04/21/2021 by Roy Cho, source=Web Response, value=Grant/Research Support No relevant relationships by Erhan Dincer, source=Web Response No relevant relationships by Joseph Keenan, source=Web Response No relevant relationships by Sudarshan Setty, source=Web Response No relevant relationships by Jennifer Wong, source=Web Response

Introduction: Tracheobronchopathia Osteochondroplastica (TPO) is a rare, benign condition of the large airways that tends to affect mostly men.1 90% of cases are found incidentally on autopsy,2 and 55% of living and affected patients do not experience disease progression following their diagnosis.3 The diagnosis can be made by bronchoscopic appearance alone4 with osseocartilaginous nodules originating from airway cartilage with sparing of the posterior noncartilaginous membrane.1,5 Although the cause of TPO is unknown, metaplasia via chronic inflammation has been hypothesized.2 These nodules lead to airway obstruction and persistent respiratory symptoms, including recurrent upper airway infections, hemoptysis, and dyspnea.2 While most cases do not require intervention or are treated conservatively,3 symptomatic lesions may require bronchoscopic intervention.7 While most bronchoscopists use Nd:YAG for debulking procedures, urologic data have shown that the Holmium:YAG laser is a much more effective tool for calcium stone fragmentation8. We report the use of bronchoscopy with Holmium:YAG laser to ablate lesions and to restore the airway lumen in a patient with TPO refractory to conventional treatments. This laser ablates osseous lesions through a fiber-optic network9 without inducing injury to surrounding soft tissues.10,11 Case Summary: We present the case of a 62-year-old male with symptoms of dyspnea, wheezing, and recurrent pneumonias. Diagnostic bronchoscopy in 2015 demonstrated overgrowth of cartilaginous tissue, and the left mainstem was 90-100% obstructed secondary to cartilaginous overgrowth in various segments. Laser photocoagulation with the Nd:YAG laser was attempted with photo-desiccation along the most central overgrowths, which were not amenable to ballooning. Ultimately, debulking of calcium deposition in 2015 was unsuccessful, and the patient continued to experience dyspnea with exertion and at rest. Subsequent laser photocoagulation with Nd:YAG laser in 09/2019 was equally unsuccessful. After careful review, the team considered holmium laser therapy which was known to be more successful with regards to debulking calcium in other medical specialties. In 11/2019, the patient underwent rigid bronchoscopy with Ho:YAG. The contact laser fiber was used in small

Positron emission tomography (PET) has been a very useful tool for staging, managing, and monitoring the response of patients with lymphoma. However, 18F-fluorodeoxyglucose (FDG)-avid lymphadenopathy needs to be carefully evaluated in these patients, given that FDG/PET scans are highly sensitive, but not specific.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is now a standard of care to sample mediastinal lymph nodes and masses with high diagnostic accuracy and low complication rates. However, the procedure has potential complications that might be life-threatening. Here, we present the first case of Propionobacterium acnes (P. acnes) causing mediastinitis following EBUS-TBNA of a subcarinal lymph node.

To the Editor: We report a case of a 41-year-old man who developed a delayed, recurrent bilious pleural effusion (cholethorax) following open hepatectomy and cholecystectomy. CASE REPORT A 41-year-old man presented to the emergency department with right-sided back pain. A computed tomography (CT) scan of the abdomen was unremarkable. He was discharged home; however, returned a few days later with intractable back pain and dyspnea with diminished breath sounds over the right lung field. A chest CT with intravenous (IV) contrast showed a new right-sided pleural effusion. He was admitted and a bedside thoracentesis showed dark green fluid. Five-hundred seventy milliliters of fluid was removed and analysis determined it to be an exudate (pleural fluid showed: lactate dehydrogenase was 2214 U/L, total protein 3.2 g/dL, glucose 114 mg/dL, white blood cell count 18060 with 97% neutrophils) with negative cultures. Bilirubin was not sent. His chest pain improved and he was discharged home with outpatient oncology follow-up to await cytology results, which later returned negative. He developed dyspnea and received an outpatient thoracentesis 3 weeks later with 1200 mL of yellow fluid removed. His dyspnea again improved. Pleural studies were similar to initial findings and cytology was negative. Lacking a unifying diagnosis, he was referred to interventional pulmonary (IP) for evaluation. In IP clinic, he appeared healthy, and complained of dyspnea on exertion. His medical history was significant for rectal cancer metastatic to the liver that was diagnosed 20 months prior. He had received neoadjuvant chemotherapy with leucovorin, fluorouracil, and oxaliplatin (FOLFOX) followed by concurrent chemoradiation with capecitabine. Six months after initiating chemotherapy, he achieved partial response in primary and metastatic lesions, and underwent abdominoperineal resection with end descending colostomy and 4 separate liver wedge resections followed by ultrasound-guided microwave ablation of remaining lesions. This was followed by adjuvant chemotherapy with FOLFOX to complete 8 cycles; however, he had recurrence in the liver (Fig. 1) and was started on treatment with leucovorin, fluorouracil, and irinotecan (FOLFIRI) along with bevacizumab. Nine months after the initial surgery, he underwent right hepatectomy, segmental liver resection, and cholecystectomy. A 10.3×6.8×12.1 cm simple fluid collection was noted on imaging following this procedure. This fluid collection was again noted on presentation to the emergency department. It was stable in size and attributed to postoperative seroma.FIGURE 1: A–C, Magnetic resonance imaging of the abdomen showing multiple T2 hyperintense liver lesions, improvement in size of liver lesions after treatment with FOLFOX 2 months later, recurrence of liver lesions 1 year after initial magnetic resonance imaging.Given this history, the suspicion for cholethorax or malignant effusion was high and repeat thoracentesis with positron emission tomography-computed tomography was recommended. A total of 2000 mL was extracted with guidance of pleural manometry (Fig. 2). The pleural elastance was 5 cm H2O/L, consistent with free-flowing fluid. The total bilirubin content of the fluid was 3.4 mg/dL (serum bilirubin 0.5 mg/dL), which was consistent with a cholethorax. positron emission tomography-computed tomography did not show fluorodeoxyglucose avidity in the parietal pleura. Given the elevated bilirubin, an magnetic resonance imaging (MRI) of the abdomen with IV gadoxetate disodium (Eovist) was performed which showed a 4.0×7.4 cm fluid collection between the resection margin and the right hemidiaphragm with rapid accumulation of Eovist, consistent with biloma. Eovist is a hepatobiliary specific agent that is taken up by organic anion transporter proteins on hepatocytes (same transporter protein for bilirubin) and undergoes ∼50% excretion through the biliary route, providing delayed hepatic and biliary tree imaging.1 The MRI also showed potential extravasation into the pleural space (Fig. 3).FIGURE 2: Right pleural effusion and thoracentesis. Demonstration of large right-sided pleural effusion (A) and appearance of the pleural fluid postthoracentesis (B).FIGURE 3: Cholethorax from communication with biloma. Magnetic resonance imaging abdomen with Eovist contrast (A) demonstrating potential communication to right pleural space (arrow). Intraoperative ERCP (B) with direct biliary contrast injection noting takeup into the percutaneous biloma drain (arrow) confirming bile leak (C). ERCP indicates endoscopic retrograde cholagiopancreatography.After consultation with interventional gastroenterology and radiology, a percutaneous drainage catheter (Argon Skater Medical, Frisco, TX) was placed into the biloma. An endoscopic retrograde cholangiopancreatography with cholangiogram was performed and showed a bile leak from the right posterior intrahepatic duct. A10 Fr×9 cm Sof-Flex plastic stent (Cook Medical, Bloomington, IN) was placed in the common bile duct. Concurrently, a 14 Fr chest tube (Teleflex Medical, Research Triangle Park, NC) was inserted to remove the rest of the right-sided pleural effusion (∼2200 mL) and immediately removed after ultrasound confirmation of complete fluid evacuation. The effusion was negative for malignancy. Following this procedure, the biloma drain output and color improved, along with his pulmonary symptoms. A few weeks later, he presented with fever and chills secondary to a right-sided empyema that developed from misposition of the biloma drain. The biloma drain was revised and chest drainage eventually grew Actinomyces odontolyticus. This was treated initially with piperacillin and tazobactam, then transitioned to levofloxacin and metronidazole to complete a 3 week course (final culture results were still pending at time of discharge from hospital). Two weeks later, he underwent video-assisted thoracoscopic surgery and decortication of the right lung. He is currently doing well as an outpatient and has had no recurrence of the cholethorax or right-sided chest pain. DISCUSSION Bilious pleural effusion, or cholethorax, is a rare presentation that has only been reported in case reports. Traumatic causes that have been associated with a cholethorax include endoscopic retrograde cholagiopancreatography for biliary tract obstruction with stent placement,2 placement of percutaneous transhepatic biliary drain,3,4 open and laparoscopic cholecystectomy,5,6 and liver biopsy.7 There has also been a case not associated with trauma or surgery, as referenced in a case report of a spontaneous left-sided cholethorax in the setting of pancreatitis.8 A proposed mechanism of a spontaneous bilious pleural effusion, in the absence of a detectable fistula, are small fenestrations in the diaphragm allowing for passage of bilious fluid from the peritoneal cavity to the pleural space, similar to a hepatic hydrothorax.2 A pleural to serum total bilirubin ratio of >1 and the presence of pleural glycoholic acid support the diagnosis of a cholethorax.9 Once a cholethorax has been identified, it is important to diagnose the source of the biliary leak to guide further management. Noninvasive imaging modalities to consider include: (1) abdominal ultrasound as a quick screen for intra-abdominal ascites, perihepatic discrete fluid collections, and fluid collections in the gallbladder surgical bed; (2) CT scan to assess for presence and age of biloma based on peripheral rim thickness and for peritoneal thickness and enhancement which may be suggestive of biliary peritonitis; (3) hepatobiliary cholescintigraphy to assess for leakage of radiotracer outside biliary tree; and (4) MRI with hepatobiliary contrast agents to show source of leak, presence of fistula, and extent of biliary damage.1,10–12 Interestingly, PET-CT may not be sensitive to evaluate for biliary communications, as illustrated in this report. Our case is unique given the delayed presentation of cholethorax after an invasive abdominal procedure. In this patient, while the biloma formed soon after the right hepatectomy and cholecystectomy, he did not develop a cholethorax until 7 months after the surgery. All of the case reports cited above reported presence of a cholethorax within several days of the inciting procedure,2–5,7 with the exception of the case report of a cholethorax occurring 16 months after open cholecystectomy.6 The incidence of bile duct injury following an open cholecystectomy has been cited from 0.1% to 0.25%.13 Although rare, it is important to identify a cholethorax promptly as most cases will require interventions such as percutaneous biliary drain placement, endoscopic retrograde cholagiopancreatography with biliary stent placement, and in some cases, surgical intervention to repair the leak. Management of the cholethorax involves complete drainage of the pleural fluid for both pain relief and to remove a potential medium for bacterial infection. Bile is also a potent chemoirritant and autopleurodesis may occur with evacuation of the pleural space.3 Thus, it is important to add cholethorax to the differential in cases of unexplained pleural effusion following abdominal procedures for early diagnosis to avoid further complications. Jennifer Wong, MD* Erhan H. Dincer, MD† Joseph C. Keenan, MD† Roy J. Cho, MD†*Department of Pulmonary, Critical Care and Sleep Medicine†Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, Interventional Pulmonology Division, University of Minnesota, Minneapolis, MN

Transbronchial cryoprobe lung biopsy (TBCLB) have recently been introduced as a safe diagnostic tool in the diagnosis of interstitial lung diseases. While we do not enough evidence its role and place as a diagnostic procedure, the technique has been adopted by many centers. In spite of expanding body of literature, there are variations in patient selection and procedural aspect of the procedure. It has been established as a safe procedure if safety measures are practiced. Diagnosis of interstitial lung diseases continuous to be challenging. Surgical lung biopsy considered as gold standard but its morbidity and mortality limit its utilization in every case. Multidisciplinary medical decision is a validated team work effort when approaching patients with interstitial lung disease.