Chronic obstructive pulmonary disease (COPD) affects 40–60

BACKGROUND:Atelectasis during peripheral bronchoscopy can cause CT-to-body divergence, can cause false-positive radial-probe endobronchial ultrasound images, and can obscure a target. As shown in prior studies, ventilatory strategies to prevent atelectasis, although useful, cannot completely avoid this phenomenon. RESEARCH QUESTION:Is a lateral decubitus superior to a ventilatory strategy in preventing atelectasis from obscuring targets in patients with lung nodules in dependent zones? STUDY DESIGN AND METHODS:This was a randomized controlled study (1:1) in which patients undergoing robotic bronchoscopy for nodules ≤ 3 cm in dependent lung zones were randomized to lateral decubitus strategy (LADS) vs a ventilatory strategy to prevent atelectasis (VESPA). Patients who developed atelectasis obscuring the target crossed over to the opposite arm. Primary outcome was the development of atelectasis obscuring the target detected with mobile cone-beam CT scan. Secondary end points included tool in lesion (TIL), diagnostic yield, and safety. RESULTS:A total of 62 patients were analyzed: 29 in LADS and 33 in VESPA. No patients developed atelectasis obscuring target in the LADS group, and 9 patients did in the VESPA group (27.3%; 95% CI, 13.3%-45.5%; P = .002). TIL was achieved in 29 patients (100%; 95% CI, 88.1%-100%) in the LADS group and in 24 patients (72.7%; 95% CI, 54.5%-86.7%) in the VESPA group (P = .005). Diagnostic yield on index biopsy was made in 25 patients (86.2%; 95% CI, 68.3%-96.1%) in the LADS group and 19 patients (57.6%; 95% CI, 39.2%-74.5%) in the VESPA group (P = .026). In all 9 patients who crossed over from the VESPA group to the LADS group, atelectasis was eliminated leading to TIL, and diagnosis was obtained in 7 (78%). There were no major complications and no differences in the rate of minor complications. INTERPRETATION:Our results suggest that LADS is superior to VESPA in preventing atelectasis from obscuring targets in patients with nodules located in dependent areas, can help eliminate atelectasis, is safe, and is also associated with better procedural outcomes such as TIL and diagnostic yield. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov; No.: NCT05714033; URL: www. CLINICALTRIALS:gov.

Background and Objective:For patients undergoing evaluation for mediastinal/hilar adenopathy or masses suspicious for lymphoma, endobronchial ultrasonography (EBUS)-transbronchial needle aspiration (TBNA) offers a lower-risk alternative to surgical or percutaneous biopsy. While the utility of EBUS-TBNA is well established in lung cancer diagnosis, including biomarker analysis, its role in lymphoma is more limited. This is because for accurate subtyping of lymphoma, larger intact tissue specimens are needed and EBUS-TBNA can only provide cytology specimens. To address this limit, various needle sizes and/or sampling techniques such as cryobiopsy have been investigated to improve diagnostic sensitivity for lymphoma. In this review, we discuss the current evidence for these various techniques in the diagnosis of lymphoma. Methods:We conducted a narrative review by searching PubMed/MEDLINE, Embase and Google Scholar for articles published during 1980-2025 using search terms including "EBUS", "EBUS-TBNA", "endobronchial ultrasound", "bronchoscopy", "lymphoma diagnosis", "mediastinal lymphadenopathy" and "interventional pulmonology". Only articles written in English that focused on evaluation of diagnostic sensitivity, specimen adequacy, and interventional techniques for suspected lymphoma were included in our review. Key Content and Findings:Several studies suggested that EBUS-TBNA combined with appropriate immunohistochemical, flow cytometry, cytogenetic, and molecular studies can achieve an accurate lymphoma diagnosis. However, its sensitivity for de novo lymphoma remains modest. Various techniques such as cryobiopsy, bigger needles, and forceps via EBUS may improve tissue acquisition but whether this translates into improved diagnostic yield is uncertain. Conclusions:For patients undergoing evaluation for mediastinal/hilar adenopathy or masses suspicious for lymphoma, EBUS with TBNA, or with other techniques such as cryobiopsy, may be a reasonable first diagnostic step, as it is less invasive with a better safety profile than surgical excision of these lymph nodes. Prospective studies are needed to establish best practices for the use of EBUS to diagnose lymphoma.

Medical thoracoscopy (MT) is a minimally invasive procedure with a well-established role in the diagnosis and management of malignant pleural disease; however, its therapeutic applications in benign pleural conditions remain variably adopted and inconsistently defined. In response to increasing clinical utilisation and emerging evidence, the World Association for Bronchology and Interventional Pulmonology (WABIP) and the American Association for Bronchology and Interventional Pulmonology (AABIP) convened a multidisciplinary, international expert panel to develop a consensus statement examining the therapeutic role of MT in benign pleural disease. Six clinically relevant PICO (patient, intervention, comparison and outcome) questions were formulated to guide a systematic literature review of PubMed, Scopus and Cochrane databases from 1980 through 2025. Evidence was appraised using standardised risk-of-bias tools and consensus was achieved using a modified Delphi methodology. This consensus statement summarises the available evidence regarding MT across a spectrum of benign pleural conditions, including recurrent benign pleural effusions, primary and secondary spontaneous pneumothorax, empyema, and tuberculous pleural disease. Emphasis is placed on procedural outcomes, complication profiles and comparative effectiveness relative to alternative medical and surgical approaches. The document also highlights key considerations related to patient selection, procedural complexity and the influence of operator expertise and local resources on clinical outcomes. Given the heterogeneity of underlying disease processes and the predominance of observational data, this work is presented as a consensus statement rather than a formal clinical practice guideline. Overall, it aims to consolidate current knowledge, identify gaps in evidence and provide a practical framework to inform multidisciplinary decision-making and future research on the therapeutic use of MT in benign pleural disease.

PURPOSE OF REVIEW:Malignant pleural effusion (MPE) is a common complication of advanced lung cancer and often represents the first sign of malignancy. Conventional diagnostic methods, including cytology and pleural biopsy, have limited sensitivity. This review provides a timely assessment of emerging pleural fluid biomarkers and their utility in differentiating malignant from benign effusions, as well as their role in guiding molecular characterization of lung cancer to improve diagnostic accuracy and therapeutic decision-making. RECENT FINDINGS:Recent studies highlight the diagnostic and molecular profiling potential of circulating tumor DNA (ctDNA), microRNAs, proteins, and metabolites detectable in pleural fluid. Advances in next-generation sequencing and liquid biopsy technologies have enabled noninvasive detection of actionable mutations (EGFR, ALK, KRAS, PD-L1), enhancing molecular profiling directly from pleural samples. Integration of multiple biomarkers shows promise for improving sensitivity and specificity compared to cytology alone. SUMMARY:Pleural fluid biomarker analysis offers a minimally invasive, clinically relevant approach for diagnosing MPE and identifying molecular targets in lung cancer. Further standardization and validation of testing protocols are needed, but these advances hold potential to refine early diagnosis, guide targeted therapies, and personalize management strategies for patients with lung cancer-related effusions.

Background: Malignant pleural effusions (MPEs) are common in cancer patients and significantly impair physical activity. Although symptom relief is the primary treatment goal, the extent of activity limitation and the effectiveness of interventions remain unclear. We used actigraphy to assess the impact of thoracentesis on activity level. The primary objective was to evaluate the association between physical activity (via ActiGraph), quality of life [Short Form 6-Dimension index (SF-6D) utility score], and dyspnea (Borg scale) at weeks 1 and 2 following thoracentesis. Methods: We conducted a prospective, observational, single-center study in adults with symptomatic, moderate-to-large MPEs. Results: Participants wore actigraphy devices for a mean of 17.7 hours daily. Higher average steps in week 2 significantly correlated with higher week 2 SF-6D utility scores. Higher calorie expenditure in week 1 significantly correlated with better week 1 SF-6D utility scores. However, no actigraphy metrics significantly affected SF-6D utility score changes from week 1 to week 2. For Borg, higher average triaxial movement in week 2 was modestly associated with lower dyspnea in week 2. Greater week 1 increases (slopes) in calories, moderate-to-vigorous physical activity (MVPA), and triaxial movement significantly predicted larger Borg scale reduction from week 1 to week 2. Conclusions: These findings suggest that improvement in SF-6D utility scores is tied to average activity levels (calories in week 1, steps in week 2), whereas dyspnea improvement by Borg scale over time is more strongly related to early gains in week 1 activity. Triaxial movement was also associated with less dyspnea in week 2.

Background/Objectives: Malignant pleural mesothelioma (MPM) is a rare, aggressive tumor with a poor prognosis and complex diagnostic pathways. Pulmonologists often play a central role in its initial recognition and investigation. This narrative review synthesizes the current evidence on the diagnostic approach to MPM, with emphasis on imaging, tissue sampling, histopathology, and emerging diagnostic innovations relevant to clinical pulmonology. Methods: English-language studies published between January 2005 and June 2025 were identified from PubMed and Scopus. International guidelines and consensus documents were also reviewed to provide an updated overview of diagnostic strategies. Results: Diagnosis of MPM relies on a stepwise integration of clinical, radiological, and pathological information. Thoracic ultrasound, computed tomography, positron emission computed tomography and magnetic resonance imaging complement each other across different stages of the diagnostic pathway. Image-guided pleural biopsy and medical thoracoscopy remain the gold standard for tissue confirmation, supported by immunohistochemistry and molecular testing. The 2021 World Health Organization classification of pleural tumors and the International Association Study of Lung Cancer 9th Edition Tumour-Node-Mestastatis system have refined histologic and staging criteria, thereby improving reproducibility and prognostic accuracy. Emerging tools, including liquid biopsy, novel serum and molecular biomarkers, artificial-intelligence-based radiomics, and breathomics, offer promise for earlier and less invasive diagnosis but require prospective validation. Conclusions: Current advances are redefining MPM diagnosis toward integrated, multidisciplinary, and precision-based models. Future priorities include standardizing diagnostic algorithms, validating minimally invasive biomarkers, and integrating AI and molecular profiling into clinical workflows to enhance patient stratification.

Pulmonary hypertension in patients with advanced solid organ tumors may be secondary to a rare diagnosis of pulmonary tumor thrombotic microangiopathy. Current literature is limited to case reports, and there is no consensus on diagnosis and management. This case highlights the importance of a high degree of clinical suspicion and the role of additional work-up for pulmonary tumor thrombotic microangiopathy including fludeoxyglucose-19-positron emission tomography and cytology of pulmonary artery blood sample at the time of right-sided heart catheterization. Future studies are needed to better understand the role of pulmonary vasodilators and targeted therapies, such as platelet-derived growth factor inhibitors, and their impact on the clinical outcomes for patients with poor prognosis secondary to their cancers.

Purpose. Transbronchial biopsy (TBB) is used in the diagnosis of lung cancer and has multiple approaches in clinical practice, including fluoroscopy with radial probe endobronchial ultrasound (EBUS) and CBCT-Guided robot assisted bronchoscopy (CBCT-Guided RAB). This work employs a statistical surgical process model (sSPM) as a quantitative means to compare the workflows and outcomes of these approaches to TBB. Method. A sSPM was developed for each guidance approach, with parameterization performed via retrospective review of clinical dose reports which include timestamped dose events. The work reported below specifically details analysis of dose reports from 15 bronchoscopy cases over 15 months to inform and validate statistical distributions of radiation dose and cycle time in a CBCT-Guided RAB sSPM. Dosimetric and temporal segmentation of the time-stamped dose report provided a means of phase estimation, including differentiation of fluoroscopy and CBCT imaging activities and the duration of procedural phases. Results. Dose reports provided insight on the exposure ranges and cycle times involved in each phase of TBB. Fluoroscopy events in CBCT-Guided RAB produced DAP levels up 6.0 Gy.cm(2) per event, with 76% of the events having dose levels < 1 Gy.cm2. CBCT dose ranged from 6.0-19.0 Gy.cm(2) per scan, with 68% of CBCT events having dose levels between 6.0 and 12.0 Gy.cm(2). The mean cycle time for three phases in CBCT-Guided RAB were 9.0 min (SD = 3.2 min), 11.2 min (SD = 6.7 min), and 21.3 min (SD = 9.0 min). Conclusions. Retrospective review of clinical dose reports was found to be a useful method for phase estimation, parameterization, and validation of dose and cycle times in an sSPM for CBCT-Guided RAB. Patterns in radiation dose were found to distinguish fluoroscopy and CBCT scans and the occurrence and duration of activities surrounding these radiation events were successfully mapped to the phase of the procedure.

Emerging technologies to improve transbronchial sampling of lung lesions include mobile C-arm cone-beam CT (CBCT) and robotic assistance. Surgical Process Modeling (SPM) was used to quantify performance in such procedures performed using a conventional bronchoscope with guidance via 2D fluoroscopy and radial probe endobronchial ultrasound (RP-EBUS) (“Conventional Bronchoscopy”) compared to robot-assisted bronchoscopy with CBCT guidance (“CBCT-Guided RAB”). Statistical SPMs were implemented for Conventional Bronchoscopy and CBCT-Guided RAB for simulation and analysis of procedural outcomes, including cycle time, radiation dose, and geometric accuracy. The SPMs were parameterized and validated with respect to clinical observation, published literature, and expert input. 9000 simulation runs were computed for each method, analyzing differences in performance and evaluating the influence of body mass index (BMI), lesion location (upper, middle, or lower lobe), and lesion size. The SPMs exhibited reasonable agreement with retrospective clinical evaluation of cycle time and dose, and variations in geometric accuracy were consistent with clinical literature. CBCT-Guided RAB resulted in a 14

Pre-CAR-T pulmonary function tests (PFTs) may predict toxicities in lymphoma patients undergoing CAR-T therapy. In a retrospective study of 66 patients, higher lung function scores correlated with increased CRS risk, while better FEV1 and FVC were protective against ICANS. PFT abnormalities were not linked to mortality. Background: Chimeric antigen receptor T-cell therapy (CAR-T) has transformed the treatment of certain hematologic malignancies, but toxicities limit efficacy. The role of pre-CAR-T pulmonary function testing (PFT) to predict toxicities is unclear. Objective: Our aim was to examine the association between PFTs obtained prior to CAR-T and subsequent complications in patients with lymphoma. Study Design: We conducted a retrospective study of patients who underwent standard-of-care CAR-T at our institution with pretherapy PFTs. Race-neutral normative equations from the Global Lung Initiative were used to generate percent-predicted values (PPV) for spirometry and diffusing capacity of the lungs for carbon monoxide (DLCO). Lung function score (LFS) was calculated by combining the forced expiratory volume in the first second (FEV1) and the diffusion capacity of the lung for carbon monoxide corrected for hemoglobin level (cDLCO) in an equally distributed manner, with higher score denoting worse lung function. Binary logistic regression models were used to compare the association of PFTs with complications after CAR-T. Cox regression models were additionally fit to identify predictors of mortality. Results: Of 218 individuals who underwent CAR-T therapy, 66 had PFTs performed within 12 months prior to lymphodepletion. Higher LFS was associated with higher risk of CRS (OR 4.3, 95% CI, 1.4-29, P = .048), after adjusting for lines of treatment. When adjusting for lines of treatment, both FEV1 (OR = 0.96, 95% CI, 0.93-0.99, P = .05) and FVC (OR = 0.96, 95% CI 0.92-0.99, P = .03) are protective for ICANS. PFT abnormalities were not associated with early or late mortality. Conclusion: The combination of pre-CAR-T spirometry and cDLCO may help clinicians understand the risk for toxicities after CAR-T cell therapy.

Pulmonary hypertension in patients with advanced solid organ tumors may be secondary to a rare diagnosis of pulmonary tumor thrombotic microangiopathy. Current literature is limited to case reports, and there is no consensus on diagnosis and management. This case highlights the importance of a high degree of clinical suspicion and the role of additional work-up for pulmonary tumor thrombotic microangiopathy including fludeoxyglucose-19-positron emission tomography and cytology of pulmonary artery blood sample at the time of right-sided heart catheterization. Future studies are needed to better understand the role of pulmonary vasodilators and targeted therapies, such as platelet-derived growth factor inhibitors, and their impact on the clinical outcomes for patients with poor prognosis secondary to their cancers.

RATIONALE: Pleural effusion evaluation using thoracic ultrasound (US) is standard of care, serving to characterize the effusion, mark procedure site, and assess volume. While various pleural effusion volume prediction models have been proposed, none have been implemented into widespread clinical use. We hypothesize that assessing pre-thoracentesis pleural effusion by counting rib spaces using ultrasound is a practical and easily adoptable method for estimating pleural fluid volume. METHODS: Patients with free-flowing non-septated effusions who underwent thoracentesis and had complete evacuation of the pleural space [confirmed by pre-and post-procedure CXR and US evaluation by 4 blinded experts (2-pulmonologists and 2-radiologists)] were recruited prospectively. Volume drained was compared to upright thoracic ultrasound assessment of pre-thoracentesis pleural effusion by counting rib spaces using ultrasound and volume estimates by the leading prediction model (Goecke 2 formula) in the anterior, mid-axillary and posterior views. Multivariable linear regression models were used to assess the associations between actual effusion drainage volume and independent variables (rib space count or estimated Goecke 2 volume), adjusted for age and gender. To correct for optimism, internal validation and calibration were performed with 2000 resamples via bootstrap method. RESULTS: We included a total of 45 patients. All effusions were free-flowing, largely anechoic (77.8%), large volume (median 1200mL, 3 rib spaces in anterior and axillary views, 4 rib spaces posteriorly), right-sided (66.7%) and of mixed etiology (55.6% malignant, 18.5% hepatic hydrothorax). Age and gender were identified covariates in all views. Rib space count correlated with effusion volume, with significant differences noted when stratified by gender in all US views (Table 1). Furthermore, the rib space count model performed similarly to Goecke formula estimations in all views, most optimally in the anterior view (Rib space model: original sample: R2=0.692, MSE=0.0786; optimism-adjusted bootstrap sample: R2=0.6315, MSE=0.0978 vs. Goecke model: original sample: R2=0.6466, MSE=0.0904; optimism-adjusted bootstrap sample: R2=0.5450, MSE=0.121). When comparing overall volume estimates per rib space across different views, a rib space in the anterior view is associated with a greater total volume compared to the equivalent mid-axillary and posterior views, varied by gender (Table 1). CONCLUSION: Thoracic rib space count by ultrasound is an accurate and easily adoptable bedside estimate of pleural effusion volume. Effusion volume estimates are highly influenced by thoracic US view and gender and likely reflect thoracic anatomical differences. The development of a simple and efficient bedside ultrasound volume estimate tool can guide interval medical and procedural management of pleural effusions.

Background/Objectives: Patients with non-small cell lung cancer (NSCLC) being evaluated for stereotactic body radiation therapy (SBRT) are frequently staged non-invasively with positron emission tomography/computed tomography (PET/CT). Performing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in addition to PET/CT scanning may increase clinical certainty in lymph node staging, but the magnitude of added benefit of EBUS-TBNA over non-invasive staging methods is unclear. Methods: A single-center prospective cohort study involving patients with suspected or confirmed Stage I or IIa NSCLC referred for EBUS-TBNA prior to SBRT was performed. The primary outcome was concordance between PET/CT and EBUS-TBNA for nodal metastases. Secondary endpoints included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET/CT, and clinical outcomes based on staging results. Results: Among 115 patients, the concordance between PET/CT and EBUS-TBNA was 84.3% (95% CI: 0.76 0.90). EBUS-TBNA led to a stage shift in 15.7% of cases: 4 of 98 PET/CT N0 patients (4.1%) had nodal metastases, while 14 of 17 PET/CT N1 patients (82.4%) were downstaged to N0. PET/CT sensitivity was 42.9% (95% CI: 0.09–0.81), specificity 87% (95% CI: 0.79–0.93), PPV 17.6% (95% CI: 0.04–0.43), and NPV 95.9% (95% CI: 0.90–0.99). PET/CT-positive, EBUS-TBNA-negative patients had worse survival (HR 4.25, 95% CI: 1.24–14.53, p = 0.021) compared with double-negative patients. Conclusions: EBUS-TBNA improves staging accuracy over PET/CT in early-stage NSCLC, impacting SBRT candidacy. However, PET/CT-positive, EBUS-TBNA-negative patients had worse outcomes in comparison to double-negative patients, suggesting a need for additional therapy or surveillance in that population.

*Department of Internal Medicine, Monterrey Institute of Technology and Higher Education, Monterrey, Mexico †Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX Disclosure: There is no conflict of interest or other disclosures.

The management of chylothorax remains challenging given the limited evidence and significant heterogeneity in practice. In addition, there are no practical guidelines on the optimal approach to manage this complex condition. We convened an international group of 27 experts from 20 institutions across five countries and four specialties (pulmonary, interventional radiology, thoracic surgery and nutrition) with experience and expertise in managing adult patients with chylothorax. We performed a literature and internet search for reports addressing seven clinically relevant PICO (Patient, Intervention, Comparison and Outcome) questions pertaining to the management of adult patients with chylothorax. This consensus statement, consisting of best practice statements based on expert consensus addressing these seven PICO questions, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience. Panel members participated in the development of the final best practice statements using the modified Delphi technique. Our consensus statement aims to offer guidance in clinical decision making when managing patients with chylothorax while also identifying gaps in knowledge and informing future research.

BACKGROUND:Prior studies have found no differences in procedural chest discomfort for patients undergoing manual syringe aspiration or drainage with gravity after thoracentesis. However, whether gravity drainage could protect against chest pain due to the larger negative-pressure gradient generated by wall suction has not been investigated. RESEARCH QUESTION:Does wall suction drainage result in more chest discomfort compared with gravity drainage in patients undergoing large-volume thoracentesis? STUDY DESIGN AND METHODS:In this multicenter, single-blinded, randomized controlled trial, patients with large free-flowing effusions of ≥ 500 mL were assigned at a 1:1 ratio to wall suction or gravity drainage. Wall suction was performed with a suction system attached to the suction tubing and with vacuum pressure adjusted to full vacuum. Gravity drainage was performed with a drainage bag placed 100 cm below the catheter insertion site and connected via straight tubing. Patients rated chest discomfort on a 100-mm visual analog scale before, during, and after drainage. The primary outcome was postprocedural chest discomfort at 5 minutes. Secondary outcomes included measures of postprocedure chest discomfort, breathlessness, procedure time, volume of fluid drained, and complication rates. RESULTS:Of the 228 patients initially randomized, 221 were included in the final analysis. The primary outcome of procedural chest discomfort did not differ significantly between the groups (P = .08), nor did the secondary outcomes of postprocedural discomfort and dyspnea. Similar volumes were drained in both groups, but the procedure duration was longer in the gravity arm by approximately 3 minutes. No differences in rate of pneumothorax or reexpansion pulmonary edema were noted between the two groups. INTERPRETATION:Thoracentesis via wall suction and gravity drainage results in similar levels of procedural discomfort and dyspnea improvement. CLINICAL TRIAL REGISTRY:ClinicalTrials.gov; No.: NCT05131945; URL: www. CLINICALTRIALS:gov.

We present a case report of a patient with a history of aggressive thyroid cancer managed by surgery, chemotherapy, and radiation to the neck. A year later, he presented with hemoptysis. Endobronchial ultrasound showed a pulsatile vessel; however, a CT scan and conventional angiogram were negative. Three days later, a repeat angiogram revealed a pseudoaneurysm arising from the right common carotid artery. Carotid sacrifice was performed after passing balloon test occlusion. Three years later the patient presented with coil herniation into the trachea. The carotid stump was closed with a vascular plug to prevent rebleeding from coil removal. Four months later the patient experienced an intractable cough and underwent laryngoscopy-assisted removal of the residual coil mass. This case report discusses the rare scenario of a carotid blowout into the trachea and the subsequent course of events.

Torre De León, Alejandro J. MS; Valles Bastidas, Herik MS; Grosu, Horiana B. MD, MPH Author Information