Explore the vast range of titles available.

Each year, millions of pulmonary nodules are identified incidentally or through lung cancer screening, and many involve biopsy to distinguish cancer from benign processes. Both navigational bronchoscopy and computed tomography-guided transthoracic needle biopsy are commonly used in patients undergoing biopsies of peripheral pulmonary nodules, but the relative diagnostic accuracy of these two approaches is unclear. In this multicenter, randomized, parallel-group, noninferiority trial, we assigned patients with an intermediate-risk or high-risk peripheral pulmonary nodule measuring 10 to 30 mm in diameter to undergo navigational bronchoscopy or transthoracic needle biopsy at seven centers across the United States. The primary outcome was diagnostic accuracy, which was defined as the percentage of patients with biopsies that showed a specific diagnosis (cancer or a specific benign condition) that was confirmed to be accurate through 12 months of clinical follow-up (nonferiority margin, 10 percentage points). Secondary outcomes included procedural complications such as the occurrence of pneumothorax. Among the 234 patients included in the primary-outcome analysis (5 of whom were lost to follow-up), biopsy resulted in a specific diagnosis that was confirmed to be accurate through month 12 in 94 of 119 patients (79.0%) in the navigational bronchoscopy group and in 81 of 110 patients (73.6%) in the transthoracic needle biopsy group (absolute difference, 5.4 percentage points; 95% confidence interval, -6.5 to 17.2; P = 0.003 for noninferiority; P = 0.17 for superiority). Pneumothorax occurred in 4 of 121 patients (3.3%) in the navigational bronchoscopy group and in 32 of 113 patients (28.3%) in the transthoracic needle biopsy group and led to the placement of a chest tube, hospital admission, or both in 1 patient (0.8%) and 13 patients (11.5%), respectively. The diagnostic accuracy of navigational bronchoscopy was noninferior to that of transthoracic needle biopsy among patients with peripheral pulmonary nodules measuring 10 to 30 mm. (Funded by Medtronic and others; VERITAS ClinicalTrials.gov number, NCT04250194.).

Endobronchial valves (EBVs) have been successfully used in patients with severe heterogeneous emphysema to improve lung physiology. Limited available data suggest that EBVs are also effective in homogeneous emphysema. To evaluate the efficacy and safety of EBVs in patients with homogeneous emphysema with absence of collateral ventilation assessed with the Chartis system. Prospective, multicenter, 1:1 randomized controlled trial of EBV plus standard of care (SoC) or SoC alone. Primary outcome was the percentage change in FEV (liters) at 3 months relative to baseline in the EBV group versus the SoC group. Secondary outcomes included changes in FEV , St. George's Respiratory Questionnaire (SGRQ), 6-minute-walk distance (6MWD), and target lobe volume reduction. Ninety-three subjects (age, 63.7 ± 6.1 yr [mean ± SD]; FEV , % predicted, 29.3 ± 6.5; residual volume, % predicted, 275.4 ± 59.4) were allocated to either the EBV group (n = 43) or the SoC group (n = 50). In the intention-to-treat population, at 3 months postprocedure, improvement in FEV from baseline was 13.7 ± 28.2% in the EBV group and -3.2 ± 13.0% in the SoC group (mean between-group difference, 17.0%; P = 0.0002). Other variables demonstrated statistically and clinically significant changes from baseline to 3 months (EBV vs. SoC, respectively: SGRQ, -8.63 ± 11.25 vs. 1.01 ± 9.36; and 6MWD, 22.63 ± 66.63 m vs. -17.34 ± 52.8 m). Target lobe volume reduction at 3 months was -1,195 ± 683 ml (P < 0.0001). Of the EBV subjects, 97.2% achieved volume reduction in the target lobe (P < 0.0001). Procedure-related pneumothoraces occurred in 11 subjects (25.6%). Five subjects required removal/replacement of one or more valves. One subject experienced two valve migration events requiring removal/replacement of valves. EBV in patients with homogeneous emphysema without collateral ventilation results in clinically meaningful benefits of improved lung function, exercise tolerance, and quality of life.

In this trial, preterm infants who needed ventilatory assistance were randomly assigned to receive initial treatment with nasal continuous positive pressure (CPAP) ventilation, followed by intubation if their condition deteriorated, or immediate intubation and mechanical support. Although there were more pneumothoraxes and fewer days of mechanical ventilation in the CPAP group, there was no difference in mortality or bronchopulmonary dysplasia between the two groups. Preterm infants who needed ventilatory assistance were randomly assigned to receive nasal continuous positive airway pressure (CPAP) or intubation. Although there were more pneumothoraxes and fewer days of mechanical ventilation in the CPAP group, there was no difference in mortality or bronchopulmonary dysplasia between the two groups. For two decades, the standard treatment for very preterm infants was with assisted ventilation and surfactant. 1 , 2 However, since ventilation may damage the lungs, 3 , 4 it has been hypothesized that the avoidance of ventilation might lead to less bronchopulmonary dysplasia. Bronchopulmonary dysplasia 5 , 6 is a major cause of mortality and morbidity in very preterm infants. 7 Despite the increased use of antenatal corticosteroids, 8 surfactant, 9 and improved ventilation techniques, the incidence has not decreased. 10 , 11 Observational studies of variations in clinical practice have suggested that treating very preterm infants with nasal continuous positive airway pressure (CPAP) during resuscitation is possible and may . . .

PurposeEspecially in elderly and multimorbid patients, Coronavirus Disease 2019 (COVID-19) may result in severe pneumonia and secondary complications. Recent studies showed pneumothorax in rare cases, but tension pneumothorax has only been reported once.Case presentationA 47-year-old male was admitted to the emergency department with fever, dry cough and sore throat for the last 14 days as well as acute stenocardia and shortage of breath. Sputum testing (polymerase chain reaction, PCR) confirmed SARS-CoV-2 infection. Initial computed tomography (CT) showed bipulmonary groundglass opacities and consolidations with peripheral distribution. Hospitalization with supportive therapy (azithromycin) as well as non-invasive oxygenation led to a stabilization of the patient. After 5 days, sputum testing was negative and IgA/IgG antibody titres were positive for SARS-CoV-2. The patient was discharged after 7 days.On the 11th day, the patient realized pronounced dyspnoea after coughing and presented to the emergency department again. CT showed a right-sided tension pneumothorax, which was relieved by a chest drain (Buelau) via mini open thoracotomy. Negative pressure therapy resulted in regression of the pneumothorax and the patient was discharged after 9 days of treatment.ConclusionTreating physicians should be aware that COVID-19 patients might develop severe secondary pulmonary complications such as acute tension pneumothorax.Level of evidenceV

IntroductionTraumatic pneumothoraces are present in one of five victims of severe trauma. Current guidelines advise chest drain insertion for most traumatic pneumothoraces, although very small pneumothoraces can be managed with observation at the treating clinician’s discretion. There remains a large proportion of patients in whom there is clinical uncertainty as to whether an immediate chest drain is required, with no robust evidence to inform practice. Chest drains carry a high risk of complications such as bleeding and infection. The default to invasive treatment may be causing potentially avoidable pain, distress and complications. We are evaluating the clinical and cost-effectiveness of an initial conservative approach to the management of patients with traumatic pneumothoraces.Methods and analysisThe CoMiTED (Conservative Management in Traumatic Pneumothoraces in the Emergency Department) trial is a multicentre, pragmatic parallel group, individually randomised controlled non-inferiority trial to establish whether initial conservative management of significant traumatic pneumothoraces is non-inferior to invasive management in terms of subsequent emergency pleural interventions, complications, pain, breathlessness and quality of life. We aim to recruit 750 patients from at least 40 UK National Health Service hospitals. Patients allocated to the control (invasive management) group will have a chest drain inserted in the emergency department. For those in the intervention (initial conservative management) group, the treating clinician will be advised to manage the participant without chest drain insertion and undertake observation. The primary outcome is a binary measure of the need for one or more subsequent emergency pleural interventions within 30 days of randomisation. Secondary outcomes include complications, cost-effectiveness, patient-reported quality of life and patient and clinician views of the two treatment options; participants are followed up for 6 months.Ethics and disseminationThis trial received approval from the Wales Research Ethics Committee 4 (reference: 22/WA/0118) and the Health Research Authority. Results will be submitted for publication in a peer-reviewed journal.Trial registration numberISRCTN35574247.

Introduction Transbronchial lung cryobiopsy (TBLC) is increasingly used to diagnose interstitial lung disease (ILD). The 1.1-mm cryoprobe has recently been available in clinical practice. The diagnostic yield and safety of TBLC using a 1.1-mm cryoprobe need to be confirmed. Methods A prospective, randomized controlled trial was conducted in patients with suspected ILD and randomly assigned to 1.1-mm and 1.9-mm cryoprobe groups. The primary outcome was the diagnostic yield of multidisciplinary discussion. Secondary outcomes were sample quality and incidence of complications. The tension and stress effects during TBLC onto the target lobe caused by 1.1-mm and 1.9-mm cryoprobes were also evaluated using finite element analysis. Results A total of 224 patients were enrolled. No significant differences were observed in the diagnostic yield (80.4% vs. 79.5%, p  = 0.845) and sample quality scores (5.73 ± 0.64 vs. 5.66 ± 0.77; p  = 0.324) between the 1.9-mm cryoprobe group and 1.1-mm cryoprobe group. The average surface areas of samples in 1.1-mm cryoprobe group were smaller, while no difference in sample weights was observed. A decreased incidence of moderate bleeding was found in the 1.1-mm cryoprobe group (17.0% vs. 6.2%, p  = 0.027), while there was no difference in the incidence of the pneumothorax, there was a trend to higher rate of pneumothorax in 1.1-mm group. In finite element analysis, the 1.1-mm cryoprobe required the largest tension and produced the largest stress. Conclusion Compared with a 1.9-mm cryoprobe, there was no difference in specimen quality or diagnostic rate but smaller sample size with a 1.1-mm cryoprobe. There was a decreased risk of moderate bleeding, but a trend towards increased risk for pneumothorax with 1.1-mm cryoprobe. Trail Registration: Clinicaltrials.gov identifier NCT04047667; registered August 4, 2019.

PurposeThe Coronavirus Disease 2019 (COVID-19) may result not only in acute symptoms such as severe pneumonia, but also in persisting symptoms after months. Here we present a 1 year follow-up of a patient with a secondary tension pneumothorax due to COVID-19 pneumonia.Case presentationIn May 2020, a 47-year-old male was admitted to the emergency department with fever, dry cough, and sore throat as well as acute chest pain and shortness of breath. Sputum testing (polymerase chain reaction, PCR) and computed tomography (CT) confirmed infection with the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Eleven days after discharge, the patient returned to the emergency department with pronounced dyspnoea after coughing. CT showed a right-sided tension pneumothorax, which was relieved by a chest drain (Buelau) via mini open thoracotomy. For a period of 3 months following resolution of the pneumothorax the patient complained of fatigue with mild joint pain and dyspnoea. After 1 year, the patient did not suffer from any persisting symptoms. The pulmonary function and blood parameters were normal, with the exception of slightly increased levels of D-Dimer. The CT scan revealed only discrete ground glass opacities (GGO) and subpleural linear opacities.ConclusionTension pneumothorax is a rare, severe complication of a SARS-CoV-2 infection but may resolve after treatment without negative long-term sequelae.Level of evidenceV.

PurposeTo assess the efficacy of the tract embolization technique using gelatin sponge slurry after CT-guided lung biopsy to reduce pneumothorax and chest tube placement rates.Materials and MethodsWe retrospectively compared 231 CT-guided lung biopsies performed with the tract embolization technique using gelatin sponge slurry (treated group) with 213 biopsies performed without embolization (control group). All procedures were performed at our institution between January 2014 and September 2018 by one of three experienced interventional radiologists using a 19-gauge coaxial needle. Multivariate analysis was performed between groups for risk factors for pneumothorax and chest tube placement, including patient demographics and lesion characteristics.ResultsWhen comparing the two groups, there was no significant difference concerning age, gender, emphysema, lesion size, lesion location, lesion morphology, needle tract depth and biopsy-side down patient positioning. Compared to the control group, patients with gelatin sponge slurry tract embolization had statistically lower rates of pneumothorax (10% vs. 25.8%; p < 0.0001) and chest tube placement (3.5% vs. 12.2%; p = 0.0005). Using multiple logistic regression analysis, the only variable that had an influence on the pneumothorax rate was the group (OR 0.32, 95% CI 0.18–0.56, p < 0.0001), and the variables that had an influence on the chest tube insertion rates were the group (OR 0.21, 95% CI 0.08–0.51, p = 0.0006) and presence of emphysema (OR 3.50, 95% CI 1.53–8.03, p = 0.0031).ConclusionsTract embolization technique using gelatin sponge slurry after percutaneous CT-guided lung biopsy significantly reduces pneumothorax and chest tube placement rates.Level of EvidenceLevel 3a.

Background The aim of this study is to evaluate cardiovascular and respiratory effects of intrathoracic pressure overshoot (higher than insufflation pressure) in patients who underwent thoracoscopic esophagectomy procedures with carbon dioxide (CO 2 ) pneumothorax. Methods This prospective research included 200 patients who were scheduled for esophagectomy from August 2016 to July 2020. The patients were randomly divided into the Stryker insufflator (STR) group and the Storz insufflator (STO) group. We recorded the changes of intrathoracic pressure, peak airway pressure, blood pressure, heart rate and central venous pressure (CVP) during artificial pneumothorax. The differences in blood gas analysis, the administration of vasopressors and the recovery time were compared between the two groups. Results We found that during the artificial pneumothorax, intrathoracic pressure overshoot occurred in both the STR group (8.9 mmHg, 38 times per hour) and the STO group (9.8 mmHg, 32 times per hour). The recorded maximum intrathoracic pressures were up to 58 mmHg in the STR group and 51 mmHg in the STO group. The average duration of intrathoracic pressure overshoot was significantly longer in the STR group (5.3 ± 0.86 s) vs. the STO group (1.2 ± 0.31 s, P < 0.01). During intrathoracic pressure overshoot, a greater reduction in systolic blood pressure (SBP) (5.6 mmHg vs. 1.1 mmHg, P < 0.01), a higher elevation in airway peak pressure (4.8 ± 1.17 cmH 2 O vs. 0.9 ± 0.41 cmH 2 O, P < 0.01), and a larger increase in CVP (8.2 ± 2.86 cmH 2 O vs. 4.9 ± 2.35 cmH 2 O, P < 0.01) were observed in the STR group than in the STO group. Vasopressors were also applied more frequently in the STR group than in the STO group (68% vs. 43%, P < 0.01). The reduction of SBP caused by thoracic pressure overshoot was significantly correlated with the duration of overshoot ( R = 0.76). No obvious correlation was found between the SBP reduction and the maximum pressure overshoot. Conclusions Intrathoracic pressure overshoot can occur during thoracoscopic surgery with artificial CO 2 pneumothorax and may lead to cardiovascular adverse effects which highly depends on the duration of the pressure overshoot. Trial registration Clinicaltrials.gov ( NCT02330536 ; December 24, 2014).

Endobronchial ultrasound (EBUS) and electromagnetic navigation bronchoscopy (ENB) have increased the diagnostic yield of bronchoscopic diagnosis of peripheral lung lesions. However, the role of combining these modalities to overcome each individual technique's limitations and, consequently, to further increase the diagnostic yield remains untested. A prospective randomized controlled trial involving three diagnostic arms: EBUS only, ENB only, and a combined procedure. All procedures were performed via flexible bronchoscopy and transbronchial forceps biopsies were obtained without fluoroscopic guidance. In the combined group, after electromagnetic navigation, the ultrasound probe was passed through an extended working channel to visualize the lesion. Biopsies were taken if ultrasound visualization showed that the extended working channel was within the target. Primary outcome was diagnostic yield. The reference \"gold standard\" was a surgical biopsy if bronchoscopic biopsy did not reveal a definite histological diagnosis compatible with the clinical presentation. Secondary outcomes were yields by size, lobar distribution, and lesion pathology. Complication rates were also documented. Of the 120 patients recruited, 118 had a definitive histological diagnosis and were included in the final analysis. The diagnostic yield of the combined procedure (88%) was greater than EBUS (69%) or ENB alone (59%; p = 0.02). The combined procedure's yield was independent of lesion size or lobar distribution. The pneumothorax rates ranged from 5 to 8%, with no significant differences between the groups. Combined EBUS and ENB improves the diagnostic yield of flexible bronchoscopy in peripheral lung lesions without compromising safety.