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This narrative review focuses on thoracic ultrasonography (lung and pleural) with the aim of outlining its utility for the critical care clinician. The article summarizes the applications of thoracic ultrasonography for the evaluation and management of pneumothorax, pleural effusion, acute dyspnea, pulmonary edema, pulmonary embolism, pneumonia, interstitial processes, and the patient on mechanical ventilatory support. Mastery of lung and pleural ultrasonography allows the intensivist to rapidly diagnose and guide the management of a wide variety of disease processes that are common features of critical illness. Its ease of use, rapidity, repeatability, and reliability make thoracic ultrasonography the “go to” modality for imaging the lung and pleura in an efficient, cost effective, and safe manner, such that it can largely replace chest imaging in critical care practice. It is best used in conjunction with other components of critical care ultrasonography to yield a comprehensive evaluation of the critically ill patient at point of care.

Background. Lung cancer is the leading cause of malignancy related mortality in the United States. Accurate staging of NSCLC influences therapeutic decisions. Transbronchial needle aspiration (TBNA) and endobronchial ultrasound-guided TBNA (EBUS-TBNA) has been accepted as a procedure for the diagnosis and staging of lung cancer. The aim of this study is to evaluate the efficacy and adequacy of TBNA and EBUS-TBNA for sampling of mediastinal adenopathy using the Wang’s eleven lymph node map stations. Methods. We retrospectively reviewed 99 consecutive cases diagnosed with malignancy by EBUS-TBNA and a series 74 patients evaluated for mediastinal adenopathy or a pulmonary lesion using conventional transbronchial needle aspiration. The IASLC lymph node map was correlated with Wang’s map. Results. A total of 182 lymph node stations were sampled using EBUS-TBNA. 96 were positive for nodal metastasis. A total of four cases of samples taken from station 2R showed malignant cells. From the 74 cases series using cTBNA 167 nodes were sampled in 222 passes. Lymphoid or malignant tissue was obtained in 67 (91.8%) cases; 55.1% of the nodes were 1 cm or less. Conclusions. The use of the eleven stations described in Wang’s map to guide TBNA of the mediastinal nodes allows sampling of radiologically considered nonpathological nodes. These data suggest that Wang’s map covers the most frequent IASLC nodal stations compromised with metastasis.

Context: Transbronchial biopsies using standard forceps (FTBBxs) can be limited by crush artifact and small fragment size. Cryoprobe biopsies (CPBxs) have recently become available for use in bronchoscopy. We have evaluated the safety and tissue quality of CPBx in 30 lung transplant patients undergoing surveillance biopsies and compared the results to matched FTBBxs. Design: The biopsies were performed on 30 lung transplant patients between November 2011 and December 2013. Inclusion criteria included age >18 years and bilateral orthotopic lung transplant. Exclusion criteria were coagulopathy, FEV1 < 0.8 L, diffuse bullous disease, hemodynamic instability, and severe hypoxemia (Pa[O.sub.2] < 55 mm Hg or Sp[O.sub.2] < 92% on room air). Patients were monitored for complications including pneumothorax, hemodynamic instability, and/ or respiratory distress. The biopsies were quantified on digitalized slides. The pathologic findings were evaluated and recorded for both specimen types and compared. Results: The cohort included 30 patients (11 women and 19 men; median age, 55 years). Specimen and alveolated area were greater when using CPBx than FTBBx. The diagnosis was the same except in 1 CPBx upgraded to A1BX from A0BX, while another CPBx showed a granuloma not present in the FTBBx. No clinically significant complications occurred and all patients were discharged the day of the procedure. None of the biopsies contained pleural tissue. Conclusions: Cryoprobe biopsy is a safe, alternative technique to FTBBx during post-lung transplant bronchoscopy that can provide larger alveolated lung parenchyma. Further studies are needed to determine if larger samples obtained with CPBx translate to an increased diagnostic yield.

Central airway obstruction is a problem facing all medical and surgical subspecialists caring for patients with chest diseases. The incidence of this disorder appears to be rising because of the epidemic of lung cancer; however, benign causes of central airway obstruction are being seen more frequently as well. The morbidity is significant and if left untreated, death from suffocation is a frequent outcome. Management of these patients is difficult, but therapeutic and diagnostic tools are now available that are beneficial to most patients and almost all airway obstruction can be relieved expeditiously. This review examines current approaches in the workup and treatment of patients suffering from airway impairment. Although large, randomized, comparative studies are not available, data show significant improvement in patient outcomes and quality of life with treatment of central airway obstruction. Clearly, more studies assessing the relative utility of specific airway interventions and their impact on morbidity and mortality are needed. Currently, the most comprehensive approach can be offered at centers with expertise in the management of complex airway disorders and availability of all endoscopic and surgical options.

Most bronchoscopic procedures are performed using moderate sedation achieved by combining a short-acting benzodiazepine with an opioid agent. Propofol (2.6-diisopropylphenol), a short-acting hypnotic agent, has been increasingly used to provide deep sedation in the endoscopy community with an acceptable safety profile. To compare the impact of moderate versus deep sedation on the adequacy and diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). A retrospective review of prospectively collected data was performed at two academic institutions with interventional pulmonary fellowships using two methods of sedation during EBUS (deep vs. moderate sedation). Rapid on-site cytologic evaluation was used on all procedures in both groups. EBUS-TBNA nodal sampling was considered adequate if the aspirate yielded a specific diagnosis or lymphocytes. EBUS-TBNA was considered diagnostic if a lymph node aspirate yielded a specific diagnosis or if subsequent surgical sampling or prolonged radiographic surveillance revealed no nodal pathology. No difference was observed in the indication for EBUS-TBNA between the two groups. More lymph nodes were sampled per patient in the deep sedation group (314 nodes from 163 patients; 2.2 nodes per patient) than in the moderate sedation group (181 lymph nodes from 146 patients; 1.4 nodes per patient; P < 0.01). The EBUS-TBNA diagnostic yield was higher for the deep sedation group (80% of patients) than for the moderate sedation group (66% of patients; P < 0.01). Diagnostic yield and number of lymph nodes sampled using deep sedation is superior to moderate sedation in patients undergoing EBUS-TBNA. Prospective studies accounting for other factors including patient selection and cost are needed.

Complications of metallic airway stents include granulation tissue formation, fracture of struts, migration, and mucous plugging. When these complications result in airway injury or obstruction, it may become necessary to remove the stent. There have been few reports detailing techniques and complications associated with endoscopic removal of metallic airway stents. We report our experience with endoscopic removal of 30 such stents over a 3-year period. We conducted a retrospective review of 25 patients who underwent endoscopic stent removal from March 2001 to April 2004. The patients ranged in age from 17 to 80 years (mean, 56.3 years). There were 10 male and 15 female patients. The stents had been placed for nonmalignant disease in 20 patients (80%) and malignant disease in 5 patients (20%). All procedures were done under general anesthesia with a rigid bronchoscope. Special attention was focused on the technique of stent removal and postoperative complications. Thirty metallic airway stents were successfully removed from 25 consecutive patients over a 3-year period. The basic method of removal involved the steady application of traction to the stent with alligator forceps. In all cases, an instrument such as the barrel of the rigid bronchoscope or a Jackson dilator was employed to help separate the stent from the airway wall before removal was attempted. In some instances, the airway wall was pretreated with thermal energy prior to stent removal. Complications were as follows: retained stent pieces (n = 7), mucosal tear with bleeding (n = 4), reobstruction requiring temporary silicone stent placement (n = 14), need for postoperative mechanical ventilation (n = 6), and tension pneumothorax (n = 1). Although metallic stents may be safely removed endoscopically, complications are common and must be anticipated. Other investigators have described airway obstruction and death as a result of attempted stent removal. Placement and removal of metallic airway stents should only be performed at centers that are prepared to deal with the potentially life-threatening complications.

[...]the US examinations were performed by two experienced radiologists.

A 61-year-old woman with amyloid lightchain (AL) amyloidosis was referred for management of a recurrent pleural effusion of undetermined cause. This woman presented for diagnosis and treatment of a recurrent, symptomatic pleural effusion in the setting of systemic AL amyloidosis. Consideration of endotracheal intubation for video-assisted thoracic surgery was complicated by a difficult airway associated with macroglossia. Using this approach, the researchers confirmed the presence of deposits within the parietal pleura and achieved complete talc pleurodesis to prevent recurrence of the effusion. Medical thoracoscopy may be therapeutic as well as diagnostic. In this instance, they used direct visualization to confirm uniform insufflation of sterile talc and to place an indwelling pleural catheter. The use of both of these modalities together to attempt pleurodesis has recently been described with success for malignant pleural effusions. Medical thoracoscopy can be considered in the management of patients with recurrent exudative effusions, particularly if comorbidities increase the risk associated with use of an artificial airway or general anesthesia.

INTRODUCTION:  Training residents in medical procedures is an area of growing interest. Studies demonstrate that internal medicine residents are inadequately trained to perform common medical procedures, and program directors report residents do not master these essential skills. The American Board of Internal Medicine requires substantiation of competence in procedure skills for all internal medicine residents; however, for most procedures, standards of competence do not exist. OBJECTIVE:  1) Create a new and standardized approach to teaching, performing, and evaluating inpatient medical procedures; 2) Determine the number of procedures required until trainees develop competence, by assessing both clinical knowledge and psychomotor skills; 3) Improve patient safety. DESIGN:  A Medical Procedure Service (MPS), consisting of select faculty who are experts at common inpatient procedures, was established to supervise residents performing medical procedures. Faculty monitor residents’ psychomotor performance, while clinical knowledge is taught through a complementary, comprehensive curriculum. After the completion of each procedure, the trainee and supervising faculty member independently complete online questionnaires. RESULTS:  During this pilot program, 246 procedures were supervised, with a pooled major complication rate of 3.7%. 123 thoracenteses were supervised, with a pneumothorax rate of 3.3%; this compares favorably with a pooled analysis of the literature. 87% of surveyed house staff felt the procedure service helped in their education of medical procedures. CONCLUSIONS:  The “see one, do one, teach one” model of procedure education is dangerously inadequate. Through the development of a Medical Procedure Service, and an associated procedure curriculum and a mechanism of evaluation, we hope to reduce the rate of complications and errors related to medical procedures and to determine at what point competency is achieved for these procedures.

Interventions in those with CAS was categorized as none (observation alone), balloon bronchoplasty or stent placement (silicone or covered self-expandable metallic stent). Conclusion: Our results show that for those who underwent endoscopic intervention for post-lung transplant related CAS, stent placement lead to improvement in PFT's at 8-12 months where balloon bronchoplasty did not.