Acute pancreatitis is one of the leading gastrointestinal causes of hospitalization in the United States, with drug-induced acute pancreatitis being rare which is only about 0.1-2% of all acute pancreatitis cases (Balani and Grendell, 2008). Based on current publications, there are about 100 medications that can potentially cause drug-induced acute pancreatitis. In this article, we present a case of a 74-year-old man who had been treated with high doses of methylprednisolone for three days prior to the presentation of symptoms in accordance with those of acute pancreatitis. A detailed evaluation of the patient's medical history and exclusion of other probable etiologies confirmed the diagnosis of methylprednisolone-induced pancreatitis. The treatment is supportive care and withdrawal of the offending agent. The diagnosis of drug-induced pancreatitis remains a challenge for clinicians. This case may add further evidence for the role of methylprednisolone in drug-induced acute pancreatitis. It also serves as a reminder to look closely at the patient's history and medications when a cause for acute pancreatitis is not immediately found.

Appropriate management of lung nodules detected incidentally or on screening computed tomography is a clinical challenge. In many instances, tissue diagnosis is needed before any therapy can be recommended. Surgical biopsy is the gold standard, but it cannot be performed indiscriminately. Conventional bronchoscopy has limited role in obtaining tissue diagnosis. Transthoracic needle aspiration (TTNA) has high diagnostic yield but has high complication rate. Ability to obtain diagnosis has improved with advanced bronchoscopic techniques such as virtual bronchoscopy navigation (VBN), electromagnetic navigation bronchoscopy (ENB), and radial probe endobronchial ultrasound (RP-EBUS). Many other novel techniques such as bronchoscopic trans-parenchymal needle access and robotic bronchoscopy are in early stages of clinical development. Interventional pulmonologists are now routinely assisting thoracic surgeons during video-assisted thoracoscopic surgery and radiation oncologists for more targeted delivery of radiation therapy. There is also interest in bronchoscopic treatments for peripheral lung cancer. The need to work closely with thoracic surgery for a safer, more effective, and patient-centered approach has paved the way for hybrid theaters equipped with facilities for advanced bronchoscopic techniques and state-of-the-art imaging capabilities such as cone-beam computed tomography. A close collaboration between different specialties such as interventional pulmonology, interventional radiology, and thoracic surgery is the most effective way to provide high-quality patient care and perform research and development in this area.

Clinical role of bronchoscopy in everyday care of patients suffering from lung diseases is rapidly expanding. There is interest in providing minimally invasive bronchoscopic therapies as an alternative to more invasive procedures for a variety of lung diseases. Several studies have shown important contribution of bronchoscopy in diagnosis and management of conditions such as broncholithiasis, bronchogenic cysts, lung abscess, and bronchial carcinoids. The current status of bronchoscopy in diagnosis and treatment of these conditions is discussed. The goal of bronchoscopy in these conditions is not to replace traditional surgical approaches, but to provide a less invasive and more cost-effective adjunct or alternative to some highly selected patients deemed suitable for bronchoscopic therapies. The main paradigm shift in these entities is involvement of interventional pulmonologist, thoracic surgeons, and interventional radiologists from the outset. Many conditions discussed here are uncommon, and shared decision-making offers the best chance for favorable patient outcomes.

Bronchoscopy is essential to the practice of pulmonary medicine. It is an important diagnostic and therapeutic tool for many disease processes. Bronchoscopy can be performed in a variety of clinical settings, from the bedside to an operating room. Although bronchoscopy has been practiced for more than a century, consensus recommendations from stakeholders have yet to be developed for the planning, implementation, and construction of a bronchoscopy suite. A wide range of procedures can be performed via bronchoscopy; therefore, the required tools and the procedure area must be aligned with the needs of the facility. Designing a bronchoscopy suite is by no means a "one size fits all" process. We present an overview of critical features to be considered in the planning for an ideal bronchoscopy suite. We use the term "ideal" because it represents a subjective conception of what is perfect and does not convey a rigid, universal blueprint.

The field of bronchoscopy is rapidly changing. Rapid advances in this field have paved the way for emergence of a new and exciting field of interventional pulmonology. Minimally invasive procedures by interventional pulmonologists have reduced the need for more traditional surgical approaches in many instances. For example, convex probe endobronchial ultrasound is rapidly replacing mediastinoscopy as the initial procedure of choice in mediastinal staging of lung cancer.1 Electromagnetic navigational bronchoscopy and radial probe ultrasound are allowing bronchoscopists to sample small peripheral lung nodules with greater accuracy.2 Several interventional bronchoscopy techniques such as lasers, electrocautery, argon plasma coagulation, cryotherapy, and airway stent placement provide excellent palliation of symptomatic central airway obstruction, allowing many patients with advanced disease to enjoy a better quality of life.3 Indications of interventional pulmonology procedures have also been extended to some of the most prevalent pulmonary disorders such as asthma4 and chronic obstructive pulmonary disease.5 The clinical applications of interventional pulmonology procedures continue to expand and we may not be far from clinical application of alveoloscopy6 and endobronchial stem cell therapy.7 The excitement and enthusiasm that interventional pulmonology sessions in national meetings generate are difficult to miss. Trained interventional pulmonologists have a high demand as an increasing number of academic pulmonary programs are seeking experts to provide such services for clinical care of their patients. In this regard, rapid growth in interventional pulmonology reminds us of the rapid emergence of the field of interventional cardiology and gastroenterology in 1980s that revolutionized the practise of cardiology and gastroenterology, respectively. A natural consequence of the development of interventional procedures in these specialties was advent of the fields of noninterventional cardiology and gastroenterology. Pulmonary medicine is going through similar evolutionary changes. The fundamental evolutionary pressure driving this change is new developments in the field of bronchoscopy. It is important to recall that the flexible bronchoscope, originally introduced by Shigeto Ikeda in 1967, was primarily for diagnostic purpose.8 Rapid emergence of interventional procedures during bronchoscopy has not reduced the diagnostic value in any shape or form. If anything, rapid advances in this area have further reaffirmed our appreciation of the power of bronchoscopy as a diagnostic tool. Even though no interventions may be needed, bronchoscopy can still be very helpful in identifying the underlying cause of common challenges such as refractory cough,9 cryptogenic hemoptysis,10 difficult to control asthma, unexplained wheeze, recurrent pneumonia, and lung infiltrates in immunocompromised hosts.11 In fact, diagnostic bronchoscopy can provide very useful information in a host of idiopathic, autoimmune, and inflammatory disorders that tend to involve the central airways, such as sarcoidosis, amyloidosis, tracheobronchopathia osteochondroplastica, granulomatosis with polyangiitis, inflammatory bowel disease, endobronchial fungal and parasitic infections, and tracheobronchomalacia.12 It is also important to point out that availability of interventional procedures does not reduce the clinical value of established conventional bronchoscopic procedures such as bronchoalveolar lavage, endobronchial biopsies, transbronchial biopsies, and conventional transbronchial needle aspiration. For example, recent data from the AquIRE registry have shown peripheral transbronchial needle aspiration to be independently associated with higher diagnostic yield of bronchoscopy for peripheral lung lesions even when radial probe ultrasound and electromagnetic navigational bronchoscopy were performed.13 Unfortunately, the procedure was grossly underutilized, performed in only 16.4% of study subjects. Every diagnostic procedure has a cognitive component and a technical aspect. Bronchoscopy is no exception. Although technical skills are clearly important, the students of bronchoscopy must first learn the cognitive components of the procedure. These include identification of correct indications, timing of the procedure, contraindications, limitations, choice of sampling procedure, and cost-effectiveness. Every bronchoscopist should also become proficient in identifying unique and diagnostic findings on endobronchial examination. The bronchoscopist should be able to recognize aspiration in the absence of a foreign body and perhaps diagnose inflammatory bowel disease before it involves the gastrointestinal tract.14–16 We believe that it is essential for every pulmonologist (interventional and noninterventional) to have a thorough understanding of the basic aspects of bronchoscopy and what it can offer to the patients. However, it is not important for every pulmonologist to perform interventional procedures. The equipment required for many of these interventional procedures is expensive, and there should be sufficient case volume not only to justify the cost of such a set-up but also to maintain technical skills. The provision of advanced bronchoscopy techniques is presently not an option but a necessity for a high-volume tertiary care medical center with a large referral base from regional medical centers and health care providers. With proper training, protocols and appropriate thoracic surgery and anesthesia support, many of these procedures can also be effectively offered in community hospitals. However, there is no compulsion for every hospital to have advanced interventional bronchoscopy set up. It is sufficient to have facility for a high-quality noninterventional bronchoscopy performed for appropriate indication with thorough attention to choice of sampling procedure, periprocedural care, and interpretation of bronchoscopy results. Such service has much to add to everyday patient care and this can be performed in a majority of health care settings. For selected indications, practising pulmonologists may seek assistance from regional tertiary care medical centers having advanced bronchoscopy services and skills. It will not only allow a more effective use of health care dollars but will also allow pulmonologists to focus on identifying the appropriate indication and timing of interventional bronchoscopy. In this regard, this model is very similar to cardiology and gastroenterology practises where the majority of providers practise noninvasive cardiology or gastroenterology and seek assistance from interventionalists whenever appropriate indication is identified. It is becoming increasing apparent to us that rapid growth of interventional pulmonology is leading the way to the emergence of a vibrant field of noninterventional or noninvasive pulmonology. An important message is that there is no reason for a pulmonologist to feel belittled if he or she is not performing an interventional procedure. The field of interventional bronchoscopy is still evolving. The future is bright. Even though the majority of these procedures are minimally invasive, there is an associated risk that needs to be carefully weighed against the benefit and cost of the procedure. An optimal interventional bronchoscopy procedure requires a team of trained personnel, appropriate patient selection, and a correct indication. Rapid advances in this field make it essential for every pulmonologist to learn the current indications and clinical role of interventional bronchoscopy in the routine care of their patients. Practising pulmonologists must also identify the provider in their community who could offer these services to their patients. This is the way to have the patient reap the most benefits from this rapidly advancing field. It is important to point out that in-depth knowledge of a wide range of pulmonary disorders is essential for any practising pulmonologist, interventional or otherwise. Cognitive and fundamental bronchoscopy skills (eg, airway examination and conventional sampling procedures) suffice the title of a “noninterventional pulmonologist,” whereas the additional procedural skills acquired through focused training are mandatory for an “interventional pulmonologist.”

Inflammatory bowel disease (IBD) is associated with a variety of pulmonary disorder. Although disorders of central airways are the most common form of respiratory diseases, recent epidemiological studies also suggest a higher than expected prevalence of asthma and chronic obstructive pulmonary disease (COPD) in patients with IBD. Clinical presentation of central airway obstruction in IBD varies from chronic cough and sputum production to acute respiratory failure needing intubation and mechanical ventilation. Many patients develop respiratory complications for the first time months to years after undergoing colectomy. A high index of suspicion is needed for early recognition of airway disease associated with IBD. Pulmonary function tests (PFTs) may be normal or may reveal airflow obstruction and abnormal flow volume loop. Chest computed tomography (CT) is the most useful imaging modality. Bronchoscopy provides most critical diagnostic information and should be performed without delay when involvement of central airways is clinically suspected. Systemic corticosteroids are the mainstay of treatment. Inhaled corticosteroids may be sufficient in patients with mild disease. A careful clinical follow-up supplemented by PFTs, radiological imaging, and bronchoscopy is essential for optimal outcome.

Tracheobronchopathia osteochondroplastica (TO) is a rare disorder of unknown etiology, characterized by the development of multiple cartilaginous and bony nodules in the submucosal layer of central airways. The clinical presentation is non-specific with chronic cough, sputum production, intermittent hemoptysis, and breathlessness. In many patients, diagnosis is made incidentally on computed tomography (CT) or bronchoscopy performed for unrelated indications. Occasionally, patients present with acute respiratory distress, hypoxemia, and unanticipated difficulty during intubation. Although chest CT is the most useful imaging modality, the diagnosis can be missed in the early stages of disease. Bronchoscopy is the gold standard for diagnosis. The presence of hard nodules projecting into the lumen from anterior and lateral walls with sparing of posterior wall provides an instant diagnosis during bronchoscopy. Whether biopsy is needed for definitive diagnosis is a debatable matter. The majority of patients follow a benign clinical course. No treatment is needed in asymptomatic or minimally symptomatic patients. Adequate long-term control of symptoms can be achieved with laser photoresection and mechanical debulking in symptomatic patients with advanced central airway obstruction. Surgery may be needed in some patients if the interventional bronchoscopic procedures are not feasible. TO should feature in the differential diagnosis of chronic and persistent cough, hemoptysis, and treatment-resistant asthma.

Central airways are involved in a variety of neoplastic and non-neoplastic disorders and cause non-specific symptoms such as cough, expectoration, dyspnea, wheezing, and hemoptysis. In the absence of distinctive clinical features, many of these patients are misdiagnosed as asthma or chronic obstructive pulmonary disease (COPD) for months to years before the underlying pathology is identified. Failure to diagnose the disease process in early stages can lead to progressive respiratory symptoms and respiratory failure in some patients. A high index of suspicion is essential for early diagnosis. A detailed clinical evaluation can provide useful clues, but advanced radiological imaging and bronchoscopy are often needed for diagnosis. Spirometry has a low sensitivity, but an abnormal flow volume loop is an important indicator of central airway pathology. Multidetector computed tomography (MDCT) of chest is the most useful radiological test. Multiplanar reconstruction of CT data provides additional useful information in selected cases. There should be low threshold to perform bronchoscopy in patients suspected to have central airway disorders. Apart from the direct endoscopic examination, biopsy and culture material obtained during bronchoscopy are very helpful in establishing the diagnosis. The treatment of central airway diseases depends on underlying diagnosis and may include close observation, medical treatments such as antimicrobial agents, systemic corticosteroids, immunosuppressive medications and biologic agents, interventional bronchoscopy procedures, and airway surgery. An early diagnosis is essential for optimal outcome. Due to the complex nature of the disease processes, need for multispecialty involvement, and high demand for equipment and expertise, an early referral to a center that specializes in advanced airway disorders is highly recommended.

Flexible bronchoscopy (FB) is a commonly performed procedure for diagnostic and therapeutic interventions of pulmonary disorders. Due to high prevalence of lung diseases especially lung cancer in the aging population, there is an increasing demand for FB in elderly patients. Flexible bronchoscopy is a well-tolerated procedure with low complication rate and mortality while providing valuable diagnostic and staging information. However, due to age-related decline in cardiopulmonary reserves and frequent presence of co-morbid conditions, procedural safety is the most critical issue in any elderly patient undergoing FB. A thorough understanding of these cardiopulmonary limitations and a careful assessment of medical issues, functional status and social support are essential in every elderly patient before performing bronchoscopy. Several studies have shown that age has no major effect on procedure-related complications or tolerance to bronchoscopy even with recent addition of increasingly complex and longer procedures. Advanced age by itself is not a contraindication to bronchoscopy.

Transbronchial Lung biopsy (TBBx) also known as "Bronchoscopic Lung Biopsy" is one of the most important sampling procedures performed during flexible bronchoscopy. In majority of cases, TBBx is performed under conscious sedation in an outpatient setting. TBBx is performed for obtaining tissue specimen from peripheral lung masses and focal or diffuse lung infiltrates. The technique is useful in patients with suspected lung cancer, fungal and mycobacterial lung infections, unexplained infiltrates in immunocompromised hosts and in patients with suspected pulmonary sarcoidosis, lymphangitic carcinomatosis, and in selected cases of pulmonary Langerhan's cell histiocytosis, lymphangioleiomyomatosis, and cryptogenic organizing pneumonia. TBBx also plays important role in assessment of rejection and infectious complications following lung transplantation.TBBx is not useful for histological diagnosis of idiopathic pulmonary fibrosis or for distinguishing histological subtypes of idiopathic interstitial pneumonia. The diagnostic yield is also suboptimal in lung nodules smaller than 2 cm in diameter. Several recent techniques such as radial probe endobronchial ultrasound with guide sheath, electromagnetic navigation bronchoscopy, and virtual bronchoscopy navigation have been devised to improve the diagnostic yield of TBBx for solitary lung nodule. Hemoptysis and pneumothorax are the two leading complications of TBBx, occurring in less than 2 % of cases. Every bronchoscopists must be able to perform TBBx.

This chapter discusses the infection control issues surrounding bronchoscopy. It addresses the scope of the problem and the current guidelines on reprocessing of bronchoscopes, and discusses how to minimize the risk of transmitting infection during bronchoscopy. Bronchoscope can act as a vector in transmission of infection. A wide variety of bacteria, mycobacteria, and fungal agents have been implicated in bronchoscopy-related outbreaks. A new concern is a potential for transmission of infection with increasing use of a convex probe endobronchial ultrasound scope. The chapter also discusses potential health risks of radiation exposure to patients and healthcare workers during bronchoscopy and provides practical guidelines to minimize this risk. It also provides a basic understanding of radiation terminology and the possible health risks associated with diagnostic radiation.

BACKGROUNDOptimal performance of bronchoscopy requires patient's comfort, physician's ease of execution, and minimal risk. There is currently a wide variation in the use of topical anesthesia, analgesia, and sedation during bronchoscopy.METHODSA panel of experts was convened by the American College of Chest Physicians Interventional/Chest Diagnostic Network. A literature search was conducted on MEDLINE from 1969 to 2009, and consensus was reached by the panel members after a comprehensive review of the data. Randomized controlled trials and prospective studies were given highest priority in building the consensus.RESULTSIn the absence of contraindications, topical anesthesia, analgesia, and sedation are suggested in all patients undergoing bronchoscopy because of enhanced patient tolerance and satisfaction. Robust data suggest that anticholinergic agents, when administered prebronchoscopy, do not produce a clinically meaningful effect, and their use is discouraged. Lidocaine is the preferred topical anesthetic for bronchoscopy, given its short half life and wide margin of safety. The use of a combination of benzodiazepines and opiates is suggested because of their synergistic effects on patient tolerance during the procedure and the added antitussive properties of opioids. Propofol is an effective agent for sedation in bronchoscopy and can achieve similar sedation, amnesia, and patient tolerance when compared with the combined administration of benzodiazepines and opiates.CONCLUSIONSWe suggest that all physicians performing bronchoscopy consider using topical anesthesia, analgesic and sedative agents, when feasible. The existing body of literature supports the safety and effectiveness of this approach when the proper agents are used in an appropriately selected patient population.

Lung cancer is the most common cause of cancer deaths in the western world. The treatment of lung cancer depends on tumor histology and pathologic stage. In non-small cell lung cancer (NSCLC), complete surgical resection is the only chance of cure. Because the benefits of surgery are largely limited to patients with stage I and II NSCLCs, accurate staging is essential in every case. Imaging studies such as chest computed tomography and positron emission tomography scan frequently reveal mediastinal lymph node enlargement in patients with NSCLC. However, the decision to perform or deny surgery cannot be made on the basis of imaging studies, and pathologic mediastinal staging is essential in every case. Mediastinoscopy is widely accepted as the gold standard for evaluation of nodal disease.1 However, the procedure has several limitations. The reported sensitivity of mediastinoscopy is 80% to 90%.2 Several lymph node stations such as posterior subcarinal nodes (station 7), aortopulmonary window nodes (station 5), and inferior mediastinal nodes (stations 8 and 9) cannot be sampled with cervical mediastinoscopy. In one study, nearly 15% of lung cancer patients considered surgically curable on the basis of staging mediastinoscopy had unsuspected mediastinal lymph node involvement on thoracotomy.3 The procedure is invasive, costly, and needs general anesthesia. Over past 2 decades, several less invasive and less expensive alternatives for mediastinal staging have emerged. Among these, transbronchial needle aspiration (TBNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are of greatest interest to the practicing pulmonologists. Several studies have shown that standard TBNA is a useful and cost-effective alternative to mediastinoscopy in selected patients.4,5 The procedure has high yield for certain lymph node areas such as right paratracheal (2R, 4R), and subcarinal (station 7). Unfortunately, pulmonologists have been slow to embrace this technique, in part owing to the lack of training, and in part owing to discomfort with the “blind” nature of the technique.6 In recent years, several groups of investigators have reported a high success in mediastinal staging with EBUS-TBNA. The initial studies were performed using a miniature 20-MHz radial ultrasound probe to locate the enlarged lymph nodes, but it did not allow real-time imaging during the TBNA procedure.7 Real-time guidance during TBNA is now possible with the availability of a convex-probe endobronchial ultrasound attached to the tip of the flexible bronchoscope. Centers that have pioneered this technique have reported 90% to 95% sensitivity for mediastinal staging with real-time EBUS-TBNA.8,9 The technique seems to have great promise in mediastinal staging of patients with lung cancer. However, before incorporating any technology in clinical practice, it is important to show that it offers clear advantage(s) over the existing techniques, and that it is cost-effective. No study has directly compared the yield of standard TBNA with that of real-time EBUS-TBNA, but in uncontrolled studies, real-time EBUS-TBNA seems to have higher diagnostic yield than that reported with standard TBNA. Another apparent advantage is high success in sampling smaller lymph nodes and in sampling lymph nodes located in stations where standard TBNA is not applied. However, the upfront cost of real time EBUS-TBNA is higher than the cost of standard TBNA. Therefore, it is fair to ask whether or not it is cost effective to perform real-time EBUS-TBNA in place of standard TBNA for mediastinal staging. In the January issue of the Journal, Kunst and coworkers10 compare the cost of 5 different strategies for mediastinal staging in patients with lung cancer. The authors report that the most cost-effective approach to stage mediastinum is to first perform standard TBNA. If the results of standard TBNA are negative, real-time EBUS-TBNA is performed next. Mediastinoscopy is performed if both standard TBNA and EBUS-TBNA yield negative results. With this approach, very few patients require mediastinoscopy for pathologic staging. Their results remain robust for a cost range of ±10%. At a glance, the conclusions seem reasonable, but several issues need further consideration before a cost-analysis of this sort can be applied in policy decision or actual clinical practice. First, the authors assume that all patients with lung cancer who show enlarged mediastinal lymph nodes on initial computed tomography have mediastinal metastasis. In actual clinical practice, many patients with lung cancer have reactive lymph nodes without histologic evidence of metastatic spread. Studies have revealed 28% to 75% prevalence of mediastinal lymph node involvement with the tumor in lung cancer patients.2 With the staging scheme suggested by the authors, the cost of mediastinal staging would be very different for patients with different prevalence of tumor in mediastinal lymph nodes. For instance, when the cost data from this study is applied to a group of patients with a 40% prevalence of tumor involvement in the mediastinal lymph nodes, the cost of staging per patient will be 1414€ when standard TBNA is followed by mediastinoscopy; 1696€ when TBNA is followed by real time EBUS-TBNA, which if negative is followed by mediastinoscopy; and 1620€ if mediastinoscopy is performed as the initial test on all patients. Second, the choice of staging technique also depends on a number of other factors. For example, results of imaging studies such as positron emission tomography scan, availability of endoscopic ultrasound-guided fine needle aspiration, and rapid on-site evaluation of the sample have important role in mediastinal staging when applied in appropriate setting.11–13 The authors did not include any of these in their staging scheme and cost-effectiveness analysis. Finally, it is important to recall that high sensitivity with real time EBUS-TBNA used in this study largely comes from centers with extensive experience with this technique. It is unclear if the beginners will achieve the comparable results. The optimal approach to mediastinal staging remains a complicated and difficult issue. There is a rapid growth in minimally invasive techniques such as TBNA, real time EBUS-TBNA, and endoscopic ultrasound-guided fine needle aspiration for mediastinal staging of lung cancer patients. Although, negative results from these methods do not obviate need for further surgical staging, their application in carefully selected patients reduces the need for mediastinoscopy. However, from cost-effectiveness standpoint, no single approach is clearly superior to other when applied to an unselected patient population. In an individual case, the approach to pathologic mediastinal staging will depend on the size and stations of enlarged lymph nodes, and availability of local expertise. In this regard, the paper by Kunst and coworkers is a timely reminder that physicians must choose the most cost-effective approach for this purpose.

Several reports have linked topical application of benzocaine during endoscopic procedures to the development of methemoglobinemia. We report a case of benzocaine-induced methemoglobinemia and provide practical guidelines for early recognition and treatment of this important clinical entity.

Pulmonary complications are the leading cause of death after bone marrow transplantation (BMT). A rapid identification of the etiology and prompt institution of appropriate therapy is the key to successful outcome. However, it is one of the most daunting challenges that a physician faces. The differential diagnosis is wide and several infectious and noninfectious processes manifest with similar clinical and radiological features. Several recent autopsy studies have shown that current diagnostic methods are highly inaccurate and that a majority of patients receive inappropriate treatment in the ante mortem period.1,2 Currently, bronchoscopy is accepted as the frontline diagnostic procedure for these patients.3 Unfortunately, most conclusions about its role are drawn from retrospective case series. Many fundamental questions regarding its efficacy remain debatable. In the current issue of the Journal, Hardak and coworkers report their retrospective data on the yield of bronchoalveolar lavage (BAL) in 94 subjects with hematologic malignancy and BMT. A specific diagnosis was obtained in 30% of patients. Bacterial infections, fungal infections, and diffuse alveolar hemorrhage were the leading specific diagnoses from bronchoscopy. Although no specific diagnosis was made, the investigators believed that a negative bronchoscopy led to a new therapeutic decision in an additional 22% of patients. No major procedure-related complication was reported. A diagnostic bronchoscopy did not translate into better patient survival. Several findings of this study merit further analysis. One issue is the diagnostic yield of bronchoscopy. Previous studies have shown 30% to 60% yield of bronchoscopy for specific diagnosis in BMT patients with lung infiltrates.4–8 Several factors could have contributed to lower diagnostic yield of bronchoscopy in the current study. The antimicrobial therapy that most study subjects were receiving before bronchoscopy could have lowered the yield from patients with lower respiratory tract infection. Importantly, the investigators did not perform semiquantitative culture; a currently accepted standard for processing BAL specimen for diagnosis of bacterial infection. Instead, the BAL culture was considered positive only when same organism was isolated both from BAL fluid and from blood. Thus, the diagnostic yield of BAL for bacterial infection in this study could not have exceeded that of blood culture. Low yield for respiratory virus and fungi could be related to aggressive antifungal prophylaxis and viral surveillance programs. The second important issue is the choice of sampling procedures. Similar to several previous studies,6,7 the investigators in this study limited the sampling procedure to BAL and did not perform transbronchial biopsies. Although BAL is uniformly safe, there is higher risk of complications when transbronchial biopsy (TBB) is performed. However, there is evidence to support an additive value of TBB in increasing diagnostic yield of bronchoscopy, especially when a larger proportion of study patients have a noninfectious etiology of lung infiltrates.9,10 Performing TBB ultimately remains a matter of clinical judgment, patient safety, and availability of local expertise. Our own experience indicates that in carefully selected immunocompromised patients with lung infiltrates, TBB is safe and increases overall diagnostic yield of bronchoscopy.11 The third important issue that needs further discussion is the value of a negative or nondiagnostic bronchoscopy in these patients. In the current study, management was changed in 22% of patients on the basis of negative BAL results. Antibiotics were discontinued in several patients. Unfortunately, there is no good information on the negative predictive value of BAL in this setting. On its face value, except for pneumocystis pneumonia treatment, it would seem highly inappropriate to discontinue antimicrobial therapy solely on the basis of negative BAL culture results.7 Ultimately, stopping or adding antibiotics in these patients remains a matter of clinical judgment. Certainly, the absence of proof is not a proof of absence in this situation. The most critical question is whether bronchoscopy has any role in improving the dismal outcome of these patients. Common sense dictates that patients in whom an early and correct diagnosis is made are more likely to receive directed and appropriate therapy. It is not unreasonable to expect a better survival in these patients. Contrary to expectation, most authors, including authors of current study have concluded that diagnostic bronchoscopies do not translate into better survival among BMT patients with pulmonary complications.7,8,12 An exception is a French study in which mortality was significantly lower among critically ill patients with diagnostic BAL compared with the patients with nondiagnostic BAL.13 Mortality in BMT patients with lung infiltrates is a complicated issue. Several factors influence the outcome. One factor strongly associated with poor outcome is delay in establishing correct diagnosis.14 BMT patients with lung infiltrates are profoundly immunocompromised and without appropriate treatment, there is high potential for rapid worsening and respiratory failure. Uniformly, those who develop respiratory failure and require mechanical ventilation have a poor outcome.15 Irrespective of the initial etiology, one of the most common autopsy findings in these patients is diffuse alveolar damage, which is an end-stage expression of a variety of infective and noninfective insults to the lungs.2,16 These observations underscore the critical need to establish diagnosis as soon as the lung infiltrate is identified. The chances of survival increase with early diagnosis. This would require urgent bronchoscopy, preferably before starting empirical antimicrobial therapy. It may be logistically difficult, but desperate times require desperate measures. Surgical lung biopsy (SLB) is considered gold standard for diagnosis of lung infiltrates in BMT patients. Subjecting a critically ill, debilitated patient with hypoxemia, coagulopathy, fluid overload, and renal insufficiency to an invasive procedure of this magnitude is not an easy decision. Generally, SLB is performed when bronchoscopy fails to provide diagnosis and the patient is not showing response to the empirical treatment. SLB often provides diagnosis when bronchoscopy is non-revealing. The results lead to management changes in two-third of patients.17,18 Its role in improving survival, however, remains unclear. Nevertheless, if SLB is considered, it is best performed earlier than later, before the onset of full blown acute respiratory distress syndrome. Given the magnitude of the problem, high-quality prospective studies using standardized diagnostic criteria and outcome measures are needed. Most pressing is the need for a prospective evaluation of urgent bronchoscopy in these patients before antimicrobial agents are administered. In the mean time, refinement in processing of BAL fluid and application of molecular techniques for rapid diagnosis holds some promise for the immediate future.19,20

J Thorac Cardiovasc Surg 2004;127:1427–1431. Hetzel M, Hetzel J, Schumann C, Marx N, Babiak A. Study Summary: In this study, the authors examine the effectiveness of a newly developed cryoprobe in patients with airway stenosis as a result of exophytic tumors. The new probe has greater freezing power than the currently available probe. It is 78-cm long and has a 2.3-mm diameter and is designed for use with any therapeutic bronchoscope. The authors used this probe to treat airway stenosis in 60 patients. Of these, 23 had complete bronchial obstruction, 37 had high-grade stenosis, and 17 had segmental or lobar atelectasis. Underlying cause of stenosis was malignancy in all but 3 cases of granulation tissue over the tracheal stents. The procedure was performed under conscious sedation. The bronchoscope was introduced through an 8.5-mm endotracheal tube. The probe tip was placed 1 to 2 cm inside the tumor and was cooled for 5 to 20 seconds. The frozen tumor was extracted by pulling strongly on the probe. The bronchoscope and the cryoprobe with tumor attached to its tip were retrieved together. Immediate complete recanalization was achieved in 37 (61%) patients. Partial response was observed in 13 (22%) patients. In 10 (17%) patients, the procedure was unsuccessful. The procedure lasted for 41 ± 16 minutes. On average, 13 applications of cryoprobe were needed in each session. Minor bleeding was encountered in most cases. Six patients had moderate bleeding (100–300 mL) that was controlled with argon plasma coagulation. Fourteen patients developed restenosis during follow up. The authors call their technique cryocanalization and found it to be safe and effective for immediate relief of critical airway stenosis. Comments: Cryotherapy is an important treatment option for patients with endobronchial tumors. It is a safe technique without any risk of airway perforation, electrical accidents, or endobronchial fires (Chest 2001;120:3–5). There are no radiation issues. The instrument is relatively inexpensive and the technique is easy to learn. The main limitations are delayed results and need for ″clean up″ bronchoscopy 1- to 2-week after the procedure to remove the necrotic tissue and debris (Chest 1996;110:718). In many patients, multiple sessions of cryotherapy are needed before desired results are achieved (Journal of Bronchology 1995;2:145–153). As a result of delayed results, acute life-threatening airway stenosis that requires immediate measures to restore airway patency is considered a contraindication for cryotherapy (Chest 2003;123:1693–1717). In these situations, laser photoresection and bronchoscopic electrosurgery with or without airway stents are preferred (Clin Chest Med 2002;23:241–256). The use of a new probe in this study allowed a rapid relief of airway stenosis in majority of patients. The impressive results were mostly the result of a more effective cryoprobe. The other important factor was the different cryotherapy technique that authors used. Usually, the tumor is initially frozen to induce necrotic changes and coagulation and the cryoprobe tip is retrieved after the tumor thaws. The necrotic and devitalized tissue is then removed using biopsy forceps (Chest 1996;110:718). In comparison, the authors firmly pulled the cryoprobe while it was still attached to the frozen tumor. This allowed a larger amount of tumor to be avulsed from the airways. Because most of the tumor was removed during the cryocanalization procedure; there was no need for follow-up bronchoscopy. Some limitations of the study should be noted. Although patients had high-grade stenosis, no patient was critically hypoxic, on ventilatory support, or at immediate risk of asphyxiation. The results, therefore, cannot be applied to patients in extreme distress. This is especially important because the procedure was unsuccessful in 17% of patients. Also, although no major adverse outcome was noted, significant bleeding was noted in 10% of patients. This is higher than that previously reported with cryotherapy (Chest 1986;90:159–164). Lastly, like with any new technique, more studies are needed to independently confirm these findings. The preliminary findings are clearly encouraging and, if confirmed, this technique represents a significant advance in bronchoscopic cryotherapy.

Thorax 2003;58:149–52. Lai Y-F, Chao Y-H, Wang Y-H, Lin A-S. Comments: The authors performed a randomized, controlled trial to study whether placement of a pigtail catheter is beneficial in the management of patients with tubercular pleural effusion. All patients had closed-needle pleural biopsy and diagnostic thoracentesis. The biopsies showed caseating granuloma with or without acid-fast bacilli in every patient. Chest roentgenograms were performed on a monthly basis. A visual analog score (VAS) was used to grade dyspnea, cough, night sweats, appetite, and sense of well-being, and so on. The outcome measures in this study were duration of fever and dyspnea after starting treatment, improvement in VAS, forced vital capacity, and residual pleural thickening (RPT) 6 months after treatment. Initially, 65 patients were enrolled into the study, but 5 patients were excluded from final analysis because they were either noncompliant with the medications or were lost to follow up. Of the remaining 61 patients, 30 received pigtail catheter and antitubercular treatment, and 31 patients received only antitubercular treatment. The authors do not provide information on how long the pigtail catheter was kept in the pleural space. The baseline characteristics were similar in both groups. The only difference in outcome was a more rapid resolution of dyspnea in those who had received the pigtail catheter and antitubercular treatment (median duration, 4 days) compared with antitubercular treatment only (median duration, 8 days; P <0.001). Both groups showed similar improvement in VAS score after initiating the treatment. The forced vital capacity (FVC) was similar in both groups (85.5% of predicted in the drainage group and 88% in the nondrainage group) after the completion of therapy. The incidence of RPT was also similar at 6 months (53% in the drainage group and 51% in the nondrainage group). The authors concluded that the addition of a pigtail catheter to effective antitubercular treatment is not warranted and does not reduce the incidence of RPT. Residual pleural thickening develops in 40% to 50% of patients after treatment of tubercular pleural effusion (Chest 1991;100:1264–7, Chest 1997;112:1293–7). The role of pleural drainage to reduce the chances of residual pleural thickening has been a controversial subject. This well-conducted study by Lai and coworkers shows that there are no benefits from pleural drainage in patients with tubercular pleural effusion. Although nearly one half of all patients developed some degree of RPT in this study, its functional consequences were minimal. The majority of patients did not develop a significant restrictive pulmonary defect. Based on this study, it can be concluded that drainage of the pleural cavity on a routine basis is not helpful in patients with tubercular pleural effusion.

Chest 2003;124:1073–80. Snell GI, Holsworth L, Borrill ZL, et al. Comments: In this study, the authors examine the feasibility and safety of the bronchoscopic lung volume reduction (BLVR) procedure using an endobronchial prosthesis. The purpose of placing the prosthesis was to promote the absorption atelectasis of the distal lung to achieve physiological changes similar to those seen after lung volume reduction surgery (LVRS). The investigators used the Emphasys Medical endobronchial prosthesis, which are silicone-based, one-way valves mounted in a Nitinol bronchial stent. The design of this prosthesis is purported to be such that it allows venting of air and passage of secretions from the distal parts of the lung to the proximal airways, but blocks the movement of air from proximal airways to the distal parts of the lung. Free movement of air from distal to proximal airways across the prosthesis is thought to reduce the chances pressure build-up distal to the prosthesis that could cause valve expulsion. The procedure was performed under general anesthesia. To select a prosthesis of matching size, the investigators estimated the caliber of the target airway using an Olympus M2/1C measuring device and a Swan-Ganz catheter balloon. The valve was placed using an introducer delivery system advanced over the guidewire. The goal was to place multiple prostheses in both upper lobes to produce complete bilateral upper lobe obstruction. The primary end point was 30-day major complications. Secondary end points were radiologic changes, lung functions, 6-minute walk distance, and distribution of nuclear ventilation and perfusion. Ten patients with severe, predominantly upper-lobe emphysema were included in the study. The mean baseline FEV1 was 0.73 L (30%), TLC was 6.81 L (128%), RV was 4.2 L (209%), DLCO was 7.47 (31%), PaO2 on room air was 73.9 mm Hg, and 6-minute walk distance was 340.4 m. The average total anesthesia time was 2 hours 24 minutes. A mean of 6.7 ± 2.2 valves were placed in different segments of both upper lobes. There was no immediate or 30-day life-threatening complication. The mean length of hospital stay was 3.4 ± 2.1 days. One patient had postprocedure pneumothorax needing simple aspiration. During follow up, 3 patients developed acute exacerbation of chronic obstructive pulmonary disease, and 1 patient developed pneumonia. Perivalvular leak was suspected in 2 patients on follow-up bronchoscopy. Prosthesis migration, hyperinflation, or excessive coughing was not seen. No statistically significant difference in FEV1, forced vital capacity (FVC), RV, TLC, arterial blood gas, Medical Research Council dyspnea scale, and 6-minute walk distance were observed at 30 days as compared with baseline values. Diffusion capacity showed minor improvement from 7.47 ± 2.0 to 8.26 ± 2.6 (P = 0.04). Similarly, perfusion of upper lobes on 99mTc perfusion scan showed minor decline (P = 0.02). The atelectasis on chest computed tomography examination was minimal. Overall, the results appear to indicate that although it was safe to place the endobronchial prosthesis, there was no improvement in most clinically relevant end points. The main problems with LVRS are high early surgical mortality and high perioperative complication rates. For instance, in the National Emphysema Treatment Trial, the overall 90-day mortality after surgery was 7.9% as compared with 1.3% among medically treated patients (N Engl J Med 2003;348:2059–73). Patients with more advanced disease have higher surgical mortality, and the LVRS is not suitable for them (N Engl J Med 2001;345:1075–83). Nonfatal complications, especially prolonged air leak, are seen in nearly one half of all patients after LVRS (J Thorac Cardiovasc Surg 2003;125:513–25). The primary reason to develop the BLVR procedure is to avoid surgical complications and early surgical mortality associated with LVRS. In this context, the patients enrolled by Snell and coworkers experienced no serious complications as a result of the procedure. Unfortunately, there were no clinical benefits either. The main setback was a failure to achieve atelectasis in the areas of the lung supplied by the segmental bronchi in which the prostheses were placed. The authors offer several explanations for this failure. The leading hypothesis was that collateral ventilation from the surrounding lobes into the target area prevented the development of atelectasis. However, it is more likely that desired results were not achieved as a result of the inability of the prosthesis to fully block the passage of air into the lung during inspiration. A recent study seems to support this argument (Lancet 2003;361:931–3). In this study, unilateral BLVR was attempted in 8 patients with severe emphysema using a modified version of the same endobronchial valve. The outcome data were more encouraging. After valve insertion, median FEV1, as well as diffusion capacity, improved significantly. However, the computed tomography scan showed the intended lobar collapse only in 4 of 8 patients. The results, nonetheless, were better than those of Snell and coworkers. In conclusion, while the BLVR procedure appears safe; the initial clinical results are mixed and somewhat disappointing. Much work is needed before this technique can be put into clinical use.