BACKGROUND:The primary pulmonary manifestation of chronic graft vs host disease (GvHD) is the development of bronchiolitis obliterans. Other pulmonary manifestations of chronic GvHD that have been reported include diffuse alveolar damage, lymphocytic interstitial pneumonia, bronchiolitis organising pneumonia and lymphocytic bronchiolitis/bronchitis.CASE PRESENTATION:We report an unusual case of a 34-year-old patient with acute myeloid leukaemia, status post-allogenic hematopoietic stem cell transplantation who subsequently developed GvHD with skin involvement. He presented to our hospital with new onset respiratory failure and on subsequent surgical lung biopsy was found to have non-specific interstitial pneumonia (NSIP).CONCLUSION:This is the third case of a patient with biopsy-proven GvHD who had NSIP pattern on surgical lung biopsy. We believe this may represent a rare manifestation of pulmonary GvHD.

Flexible bronchoscopy is a well-tolerated procedure with low mortality and complication rates. Despite the relative safety of the procedure, there have been concerns about the safety of the procedure when faced with an elderly patient. Even the most recent American Thoracic Society Guidelines on flexible bronchoscopy in adults list advanced age as a condition involving increased risk, considering the higher prevalence of ischemic heart disease and altered metabolism of sedatives and local anesthetics used during the procedure. Because of this, the myth that the elderly patient poses increased risk has been perpetuated. In this article we review the available literature to explore the validity of this myth.

Persistent air leaks are a well-documented complication occurring after invasive thoracic procedures but can occur in other cases of pneumothorax. Surgical repair has been the standard of care for patients having acceptable anesthesia and surgical risk. Previous attempts at less invasive endoscopic techniques for patients unable to tolerate surgery have shown variable success and can often only be applied in select situations. Currently, there are no consensus guidelines on the endoscopic management of persistent air leaks. Recent advances with regard to the use of 1-way endobronchial valves (EBV) in the treatment of heterogeneous emphysema have been extended to persistent air leaks. We found several case reports and case series documenting the use of EBVs in persistent air leaks, resulting in complete or partial resolution of the air leak, allowing healing of the bronchopleural fistula. Bronchoscopic placement of 1-way EBVs may provide a less invasive approach to the treatment of persistent air leaks and is a viable alternative to surgical interventions, especially in patients with unacceptable surgical risk.

BACKGROUND:Pleural fluid pH measured by a blood gas analyzer is the only recommended method of pH measurement to guide management for patients with parapneumonic pleural effusions. Not all hospitals use blood gas analyzers for pleural fluid pH determination and it is unknown if physicians are aware of this problem.OBJECTIVE:To determine if a discrepancy exists between the modality used for measuring pleural fluid pH and how physicians believe it is measured.METHODS:We surveyed pulmonologists randomly across the USA by e-mail inquiring how they thought pleural fluid pH was measured at their laboratory. We then independently contacted the laboratory and asked how pleural fluid pH was actually measured.RESULTS:Two hundred and sixty-seven pulmonologists completed the survey. Eighty-six percent of the pulmonologists use pleural fluid pH to manage complicated parapneumonic effusions. Forty-three percent did not recognize blood gas analyzer solely as the most accurate and validated method. Thirty-nine percent of the physicians who use pleural pH to manage effusions and believe that blood gas analyzers are the most accurate were wrong in their assumption that their laboratory was using this tool for pleural pH measurement.CONCLUSIONS:Whether it is due to inaccurate knowledge or a perception of how pleural fluid pH is tested, a significant number of pulmonologists, when treating complicated parapneumonic effusions, may be making management decisions based on erroneous information.

Objective The diagnosis of mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are on the rise. Most reports have demonstrated high yields with EBUS-TBNA and superiority of this procedure over conventional TBNA (cTBNA), but the relative roles of these procedures remain undefined. We present a comprehensive comparison of EBUS-TBNA to cTBNA. Methods We reviewed all of the bronchoscopies performed at our medical center from January 2009 through December 2010. We collected data on 82 EBUS-TBNAs and 209 cTBNAs performed. A cost analysis was subsequently performed. Results EBUS-TBNA was performed more often in patients with known prior cancer and suspicion of recurrence or staging compared with cTBNA (42% vs 18%, P < 0.001). cTBNA was more likely to be performed in patients suspected of having malignancy and needing diagnostic specimens (70% vs 46%, P = 0.009). The overall yield in which a diagnostic specimen or lymphoid tissue was obtained was not different in each group: EBUS 84% vs cTBNA 86% (P = 0.75). The cancer yield was 57% in cTBNAs compared with 44% in EBUS-TBNAs (P < 0.0001), with EBUS-TBNA more often targeting smaller nodes (mean 15 ± 7 mm vs 21 ± 11 mm; P < 0.0001) and paratracheal sites (67% vs 49%, P = 0.003). Per-procedure cost using a Medicare scale was higher for EBUS than it was for cTBNA ($1195 vs $808; P < 0.001). Conclusions EBUS-TBNA and cTBNA are complementary bronchoscopic procedures, and the appropriate diagnostic modality can be selected in a cost-effective manner based upon the primary indication for TBNA, lymph node size, and lymph node location.

Tunneled pleural catheters (TPC), such as the PleurX catheter system, have been shown to be effective in the management of recurrent malignant pleural effusions (MPEs) for symptomatic relief. Insertion of a TPC allows patient independence, avoidance of prolonged hospitalizations for classic thoracostomy tube drainage or talc poudrage, and the potential for spontaneous pleurodesis with resolution of the effusion. Currently, guidelines recommend against TPC use in recurrent nonmalignant effusions given that life expectancy is generally longer in patients with benign effusions and the risk of infection increases with time. Several case reports and series have documented the safe and efficacious use of these catheters in non-MPEs. We explore the myth that TPCs should not be used in the management of non-MPEs.

Asthma is a complex inflammatory disease of the airways involving multiple different cell types and inflammatory mediators affecting over 22 million people in the United States. Induction of bronchospasm or worsening asthma may dissuade pulmonologists from performing diagnostic bronchoscopy on patients with asthma. However, patients with bronchial hyperreactivity, like other populations with or without underlying lung disease, may warrant bronchoscopic evaluation at some point. We explore the myth that the presence of bronchial hyperreactivity should deter pulmonologists from performing diagnostic bronchoscopy in patients with asthma.

Benign pulmonary tumors are a rare entity but have been historically managed with surgical resection. When located endobronchially, they may be amenable to endoscopic therapy. We reviewed the literature for studies addressing endobronchial management of benign endobronchial tumors. We discovered an assortment of case series and retrospective cohorts describing innovative treatment modalities for patients with endobronchial disease that can be attempted before contemplating surgical options. When modalities are carefully selected and executed by an experienced operator, adverse events are minimal. Endobronchial devitalizing and debulking offers an effective method of removing benign endobronchial tumors that can spare the symptomatic patient invasive surgery.

Diagnosis of peripherally located lung masses is of low yield with flexible bronchoscopy and carries a high risk of pneumothorax with transthoracic fine needle aspiration. Electromagnetic navigation bronchoscopy has been used in these situations with reported high diagnostic yield and low risk of complications. We carried out a review of literature to assess the diagnostic yield and complication rate of electromagnetic navigation bronchoscopy compared with the traditionally used modalities for the diagnosis of peripheral lung lesions.

Reexpansion pulmonary edema is a well documented complication after interventions to treat pneumothorax and pleural fluid accumulation. Despite its documented occurrence with therapeutic chest tubes and thoracentesis, we found no documented occurrences of reexpansion pulmonary edema after the placement of tunneled pleural catheters as a therapeutic intervention for malignant pleural effusions. As the placement of these catheters is becoming widely practiced by pulmonologists, we explore the myth that there is a maximum fluid limit of drainage after this procedure.

Reexpansion pulmonary edema is a well documented complication after interventions to treat pneumothorax and pleural fluid accumulation. Despite its documented occurrence with therapeutic chest tubes and thoracentesis, we found no documented occurrences of reexpansion pulmonary edema after the placement of tunneled pleural catheters as a therapeutic intervention for malignant pleural effusions. As the placement of these catheters is becoming widely practiced by pulmonologists, we explore the myth that there is a maximum fluid limit of drainage after this procedure.

PURPOSE: Human metapneumovirus (hMPV) is a paramyxovirus most closely related to respiratory syncytial virus (RSV). First recognized in 2003, hMPV has been associated with self-limited episodes of bronchiolitis in children and pneumonia in infants. The spectrum of disease is not well described in adults in the United States. The virus causes a flulike illness, but there have also been reports of severe COPD exacerbations requiring hospitalization as well as an outbreak of severe lower respiratory tract infections in a long-term care facility.

Since its introduction over 9 years ago, capsule video endoscopy has become increasingly popular within the gastroenterology community, leading to its use in a growing number of patients including the elderly. With the widespread adoption of this diagnostic modality within the elderly population comes the added risk of capsule aspiration. We present such a case where a 90-year-old patient was admitted after accidental aspiration of a capsule. Removal of the capsule posed a therapeutic challenge. In the article, we discuss the novel use of a Roth Net expandable foreign body extractor to remove the capsule using a flexible bronchoscope with minimal need for sedation. As video capsule endoscopy is used more routinely in elderly patients and clinical pulmonologists will be more frequently called up to assist in foreign body removal, our experience highlights that it is possible to remove these large capsules with a flexible bronchoscope and avoid the need for rigid bronchoscopy in this high-risk patient group.

Objectives: Maintenance of mean arterial pressure >65 mm Hg has been associated with improved clinical outcomes in many studies of critically ill patients. Current guidelines for the management of septic shock and guidelines for managing other critical illnesses suggest intra-arterial blood pressure measurement is preferred over automated oscillometric noninvasive blood pressure measurement. Despite these recommendations, anecdotal experience suggested that the use of noninvasive blood pressure measurement in our institution and others in preference to intra-arterial blood pressure measurement remained prevalent.Design: We designed an online survey and sent it by e-mail.Setting: Intensive care units.Patients and Subjects: A randomly selected group from the membership of the Society for Critical Care Medicine.Interventions: None.Measurements and Main Results: Use of non-invasive and invasive blood pressure devices. Eight hundred eighty individuals received an invitation to complete the survey and 149 responded. We found that 71% (105 of 149) of intensivists estimated the correct cuff size rather than measuring arm circumference directly. In hypotensive patients, 73% of respondents (108 of 149) reported using noninvasive blood pressure measurement measurements for patient management. In patients on a vasopressor medication, 47% (70 of 149) of respondents reported using noninvasive blood pressure measurement for management.Conclusions: The use of noninvasive blood pressure measurement measurements in critically ill patients is common despite the paucity of evidence validating its accuracy in critically ill patients. Given this widespread use, accuracy and precision validation studies comparing noninvasive blood pressure measurement with intra-arterial blood pressure measurement in critically ill patients should be performed. (Crit Care Med 2010; 38:2335-2338)

In Brief Uremia is associated with an increased risk of bleeding by virtue of alteration in platelet adhesion. Pulmonologists are frequently called upon to perform flexible bronchoscopy in patients with chronic renal insufficiency. The high blood urea nitrogen levels may predispose these patients to a high risk of bleeding complications with bronchoscopic procedures. We carried out a literature review to evaluate the myth that bronchoscopy is unsafe in uremic patients. This article discusses a literature review to evaluate the myth that bronchoscopy is unsafe in uremic patients.