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Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation.

The unique anatomy and physiology of the pleural space provides tight regulation of liquid within the space under normal physiologic conditions. When this balance is disrupted and pleural effusions develop, there can be significant impacts on the respiratory system. Drainage of effusions can lead to meaningful improvement in symptoms, primarily owing to improvement in the length-tension relationship of the respiratory muscles. Ultrasound examination to evaluate the movement and function of the diaphragm, as well as pleural manometry, have provided a greater understanding of the impact of pleural effusion and thoracentesis.

Background: Student-run free clinics (SRFCs) can provide quality mental health care to low-income and uninsured populations who are at a greater risk of depression. Evidence demonstrates the association between social support and severity of depression, but this relationship has not been analyzed in an SRFC. Thus, we assessed the association between social support and depressive symptoms.Methods: We used electronic health records data for patients from 2013-2020 (n=2,501 patients). The dependent variable was severity of depression symptoms as determined by scores on the patient health questionnaire-4 (PHQ-4). Higher PHQ-4 scores correspond to increased severity of depression. The main predictor was the patient's social support, which was defined by their employment status, marital status, and the number of individuals in their household. We conducted a multinomial regression model to control for other patient-level factors (i.e. race, sex, and age).Results: When controlling for other factors, patients with higher social support scores had lower odds of scoring a 4 on the PHQ-4 (Odds ratio [OR]=0.838, 95% Confidence interval (CI)=0.770-0.912). When examining specific social support sources, when compared to patients who reported being not-married, those who were married had lower odds of scoring a 4 on the PHQ-4 (OR=0.578, 95% CI=0.401-0.833). Compared to patients who reported being employed, those who were unemployed had greater odds of scoring a 4 on the PHQ-4 (OR=2.323, 95% CI=1.766-3.055). We observed no significant differences in PHQ-4 by the number of people in the household.Conclusion: Patients with greater social support were associated with fewer depressive symptoms. Specifically, employment status and marital status may be larger contributors to a patient’s social support. Our results allow SRFCs to offer interventions such as investing in social work programs and community partnerships that offer professional development and employment opportunities to patients.

Benchmarking state-of-the-art computations of D0(CH) with Active Thermochemical Tables reveals a systematic error in prior high-level computations.

Introduction Patients with COVID-19 ARDS require significant amounts of sedation and analgesic medications which can lead to longer hospital/ICU length of stay, delirium, and has been associated with increased mortality. Tracheostomy has been shown to decrease the amount of sedative, anxiolytic and analgesic medications given to patients. The goal of this study was to assess whether tracheostomy decreased sedation and analgesic medication usage, improved markers of activity level and cognitive function, and clinical outcomes in patients with COVID-19 ARDS. Study Design and Methods A retrospective registry of patients with COVID-19 ARDS who underwent tracheostomy creation at the University of Pennsylvania Health System or the Johns Hopkins Hospital from 3/2020 to 12/2020. Patients were grouped into the early (≤14 days, n = 31) or late (15 + days, n = 97) tracheostomy groups and outcome data collected. Results 128 patients had tracheostomies performed at a mean of 19.4 days, with 66% performed percutaneously at bedside. Mean hourly dose of fentanyl, midazolam, and propofol were all significantly reduced 48-h after tracheostomy: fentanyl (48-h pre-tracheostomy: 94.0 mcg/h, 48-h post-tracheostomy: 64.9 mcg/h, P = .000), midazolam (1.9 mg/h pre vs. 1.2 mg/h post, P = .0012), and propofol (23.3 mcg/kg/h pre vs. 8.4 mcg/kg/h post, P = .0121). There was a significant improvement in mobility score and Glasgow Coma Scale in the 48-h pre- and post-tracheostomy. Comparing the early and late groups, the mean fentanyl dose in the 48-h pre-tracheostomy was significantly higher in the late group than the early group (116.1 mcg/h vs. 35.6 mcg/h, P = .03). ICU length of stay was also shorter in the early group (37.0 vs. 46.2 days, P = .012). Interpretation This data supports a reduction in sedative and analgesic medications administered and improvement in cognitive and physical activity in the 48-h period post-tracheostomy in COVID-19 ARDS. Further, early tracheostomy may lead to significant reductions in intravenous opiate medication administration, and ICU LOS.

Background Two models, the Help with the Assessment of Adenopathy in Lung cancer (HAL) and Help with Oncologic Mediastinal Evaluation for Radiation (HOMER), were recently developed to estimate the probability of nodal disease in patients with non-small cell lung cancer (NSCLC) as determined by endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). The objective of this study was to prospectively externally validate both models at multiple centers. Research Question Are the HAL and HOMER models valid across multiple centers? Study Design and Methods This multicenter prospective observational cohort study enrolled consecutive patients with PET-CT clinical-radiographic stages T1-3, N0-3, M0 NSCLC undergoing EBUS-TBNA staging. HOMER was used to predict the probability of N0 vs N1 vs N2 or N3 (N2|3) disease, and HAL was used to predict the probability of N2|3 (vs N0 or N1) disease. Model discrimination was assessed using the area under the receiver operating characteristics curve (ROC-AUC), and calibration was assessed using the Brier score, calibration plots, and the Hosmer-Lemeshow test. Results Thirteen centers enrolled 1,799 patients. HAL and HOMER demonstrated good discrimination: HAL ROC-AUC = 0.873 (95%CI, 0.856-0.891) and HOMER ROC-AUC = 0.837 (95%CI, 0.814-0.859) for predicting N1 disease or higher (N1|2|3) and 0.876 (95%CI, 0.855-0.897) for predicting N2|3 disease. Brier scores were 0.117 and 0.349, respectively. Calibration plots demonstrated good calibration for both models. For HAL, the difference between forecast and observed probability of N2|3 disease was +0.012; for HOMER, the difference for N1|2|3 was −0.018 and for N2|3 was +0.002. The Hosmer-Lemeshow test was significant for both models (P = .034 and .002), indicating a small but statistically significant calibration error. Interpretation HAL and HOMER demonstrated good discrimination and calibration in multiple centers. Although calibration error was present, the magnitude of the error is small, such that the models are informative.

Background Bronchoscopy is commonly utilized for non-surgical sampling of indeterminant pulmonary lesions, but nondiagnostic procedures are common. Accurate assessment of the risk of malignancy is essential for decision making in these patients, yet we lack tools that perform well across this heterogeneous group of patients. We sought to evaluate the accuracy of three previously validated risk models and physician-assessed risk (PAR) in patients with a newly identified lung lesion undergoing bronchoscopy for suspected lung cancer where the result is nondiagnostic. Methods We performed an analysis of prospective data collected for the Percepta Bronchial Genomic Classifier Multicenter Registry. PAR and three previously validated risk models (Mayo Clinic, Veteran’s Affairs, and Brock) were used to determine the probability of lung cancer (low, intermediate, or high) in 375 patients with pulmonary lesions who underwent bronchoscopy for possible lung cancer with nondiagnostic pathology. Results were compared to the actual adjudicated prevalence of malignancy in each pre-test risk group, determined with a minimum of 12 months follow up after bronchoscopy. Results PAR and the risk models performed poorly overall in the assessment of risk in this patient population. PAR most closely matched the observed prevalence of malignancy in patients at 12 months after bronchoscopy, but all modalities had a low area under the curve, and in all clinical models more than half of all the lesions labeled as high risk were truly or likely benign. The studied risk model calculators overestimate the risk of malignancy compared to PAR, particularly in the subset in older patients, irregularly bordered nodules, and masses > 3 cm. Overall, the risk models perform only slightly better when confined to lung nodules Conclusion The currently available tools for the assessment of risk of malignancy perform suboptimally in patients with nondiagnostic findings following a bronchoscopic evaluation for lung cancer. More accurate and objective tools for risk assessment are needed. Trial registration: not applicable.

The bond dissociation energy of methylidyne

Isotropic hyperfine properties have been obtained for the second row elements Al–Cl using a systematic composite approach consisting of a sequence of core/valence correlation consistent basis sets, up through aug-cc-pCV7Z, along with configuration interaction and coupled cluster methods. The best nonrelativistic final values for the atomic ground states (in MHz) are −1.80 27Al (2Po1/2), −24.31 29Si (3P0), 63.70 31P (4So3/2), 20.77 33S (3P2), and 35.42 35Cl (2Po3/2). We find a large K shell contribution to the spin density at the nucleus that is almost canceled by the L and M shell contributions. The spin density in atomic units is approximately linear with respect to the atomic number.

Developing a feasible and accurate means of evaluating pleural pathology has been an ongoing effort for over 150 years. Pleural fluid cellular and biomarker analyses are simple ways of characterizing and uncovering pathologic entities of pleural disease. However, obtaining samples of pleural tissue has become increasingly important. In cases of suspected malignancy and certain infections histopathology, culture, and molecular testing are necessary to profile diseases more effectively. The pleura is sampled via several techniques including blind transthoracic biopsy, image-guided biopsy, and surgical thoracotomy. Given the heterogeneity of pleural disease, low diagnostic yields, or invasiveness no procedural gold standard has been established in pleural diagnostics.Herein, we provide a review of the literature on medical thoracoscopy (MT), its development, technical approach, indications, risks, current and future role in the evaluation of thoracic disease. Pubmed was searched for articles published on MT, awake thoracoscopy, and pleuroscopy with a focus on reviewing literature published in the past 5 years.As the proficiency and number of interventional pulmonologists continues to grow, MT is ideally positioned to become a front-line diagnostic tool in pleural disease and play an increasingly prominent role in the treatment algorithm of various pleural pathologies.

Malignant pleural effusion frequently complicates both solid and hematologic malignancies and is associated with high morbidity, mortality, and health care costs. Although no pleura-specific therapy is known to impact survival, both pleurodesis and indwelling pleural catheter (IPC) placement can significantly alleviate symptoms and improve quality of life. The optimal choice of therapy in terms of efficacy and particularly cost-effectiveness depends on patient preferences and individual characteristics, including lung expansion and life expectancy. Attempting chemical pleurodesis through an IPC in the outpatient setting appears to be a particularly promising approach in the absence of a nonexpandable lung.

Background Thoracentesis can be accomplished by active aspiration or drainage with gravity. This trial investigated whether gravity drainage could protect against negative pressure-related complications such as chest discomfort, re-expansion pulmonary edema, or pneumothorax compared with active aspiration. Methods This prospective, multicenter, single-blind, randomized controlled trial allocated patients with large free-flowing effusions estimated ≥ 500 mL 1:1 to undergo active aspiration or gravity drainage. Patients rated chest discomfort on 100-mm visual analog scales prior to, during, and following drainage. Thoracentesis was halted at complete evacuation or for persistent chest discomfort, intractable cough, or other complication. The primary outcome was overall procedural chest discomfort scored 5 min following the procedure. Secondary outcomes included measures of discomfort and breathlessness through 48 h postprocedure. Results A total of 142 patients were randomized to undergo treatment, with 140 in the final analysis. Groups did not differ for the primary outcome (mean visual analog scale score difference, 5.3 mm; 95% CI, –2.4 to 13.0; P = .17). Secondary outcomes of discomfort and dyspnea did not differ between groups. Comparable volumes were drained in both groups, but the procedure duration was significantly longer in the gravity arm (mean difference, 7.4 min; 95% CI, 10.2 to 4.6; P Conclusions Thoracentesis via active aspiration and gravity drainage are both safe and result in comparable levels of procedural comfort and dyspnea improvement. Active aspiration requires less total procedural time. Trial Registry ClinicalTrials.gov; No.: NCT03591952; URL: www.clinicaltrials.gov.

Benchmark quality isotropic hyperfine properties have been obtained for first row elements (B-F) using a systematic composite approach consisting of a sequence of core/valence correlation consistent basis sets, up through aug-cc-pCV8Z, along with configuration interaction and coupled cluster theory methods. The best nonrelativistic final values (in MHz) are 10.64 (B), 20.22 (C), 10.59 (N), -31.74 (O), and 318.30 (F) and are in very good agreement with available experimental values for these difficult-to-describe properties. Agreement is especially close in the case of N, which has the most accurate experimental value. The spin densities derived from the best composite level of theory were found to closely follow a simple quadratic scaling with the atomic number, Z. Observed convergence rates in the 1-particle and n-particle expansions obtained here may be useful in judging likely accuracy that can be expected in studies of molecular systems.

The Percepta Genomic Sequencing Classifier (GSC) was developed to up-classify as well as down-classify the risk of malignancy for lung lesions when bronchoscopy is non-diagnostic. We evaluated the performance of Percepta GSC in risk re-classification of indeterminate lung lesions. This multicenter study included individuals who currently or formerly smoked undergoing bronchoscopy for suspected lung cancer from the AEGIS I/ II cohorts and the Percepta Registry. The classifier was measured in normal-appearing bronchial epithelium from bronchial brushings. The sensitivity, specificity, and predictive values were calculated using predefined thresholds. The ability of the classifier to decrease unnecessary invasive procedures was estimated. A set of 412 patients were included in the validation (prevalence of malignancy was 39.6%). Overall, 29% of intermediate-risk lung lesions were down-classified to low-risk with a 91.0% negative predictive value (NPV) and 12.2% of intermediate-risk lesions were up-classified to high-risk with a 65.4% positive predictive value (PPV). In addition, 54.5% of low-risk lesions were down-classified to very low risk with99% NPV and 27.3% of high-risk lesions were up-classified to very high risk with a 91.5% PPV. If the classifier results were used in nodule management, 50% of patients with benign lesions and 29% of patients with malignant lesions undergoing additional invasive procedures could have avoided these procedures. The Percepta GSC is highly accurate as both a rule-out and rule-in test. This high accuracy of risk re-classification may lead to improved management of lung lesions.

Empirical, highly accurate non-relativistic electronic total atomization energies (eTAEs) are established by combining experimental or computationally converged treatments of the nuclear motion and relativistic contributions with the total atomization energies of HF, CO, N

Intro: The pandemic has put a strain on healthcare services and resources. Overall procedure capacity was reduced and cancer diagnostic pathways were disrupted. The procedural urgency associated with symptomatic patients with often undiagnosed malignant pleural effusion means that nasopharyngeal PCR testing to exclude COVID-19 prior to procedures can often be impractical or logistically challenging Aim: To assess two hypotheses; that SARS-CoV-2 could not be detected in pleural fluid samples from patients with no clinical features of COVID-19 and that pleural procedures can be conducted safely using a pragmatic infection control strategy in the context of a respiratory pandemic Methods: 24 patients completed a screening questionnaire covering symptoms, travel and contacts. If there was no clinical evidence of COVID-19 infection, the day case intervention could proceed as planned, otherwise a negative nasopharyngeal PCR swab within 48 hours was required. Pleural fluid specimens were prospectively collected for the Oxford Radciffe Biobank study and promptly processed and stored using pre-specified protocols. Viral RNA extraction was performed using the QIAamp UltraSens kit (Qiagen, Germany) Result: All patients had no clinical evidence of COVID-19 infection and therefore none required nasopharyngeal PCR swabs. qPCR assays did not detect SARS-CoV-2 virus in pleural fluid of any of the patients. Conclusion: In the absence of clinical evidence of COVID-19, SARS-CoV-2 is unlikely to be detected in pleural fluid. In the face of an ongoing pandemic, urgent outpatient pleural procedures can be safely continued, so as not to negatively impact the care for non-COVID patients

Rationale: When stereotactic ablative radiotherapy is an option for patients with non–small cell lung cancer (NSCLC), distinguishing between N0, N1, and N2 or N3 (N2|3) disease is important.Objecti...

Background: Malignant pleural effusion (MPE) poses a considerable healthcare burden, but little is known about trends in directly attributable hospital utilization. Objective: We aimed to study national trends in healthcare utilization and outcomes among hospitalized MPE patients. Methods: We analyzed adult hospitalizations attributable to MPE using the Healthcare Cost and Utilization Project – National Inpatient Sample (HCUP-NIS) databases from 2004, 2009, and 2014. Cases were included if MPE was coded as the principal admission diagnosis or if unspecified pleural effusion was coded as the principal admission diagnosis in the setting of metastatic cancer. Annual hospitalizations were estimated for the entire US hospital population using discharge weights. Length of stay (LOS), hospital charges, and hospital mortality were also estimated. Results: We analyzed 92,034 hospital discharges spanning a decade (2004–2014). Yearly hospitalizations steadily decreased from 38,865 to 23,965 during this time frame, the mean LOS decreased from 7.7 to 6.3 days, and the adjusted hospital mortality decreased from 7.9 to 4.5% (p = 0.00 for all trend analyses). The number of pleurodesis procedures also decreased over time (p = 0.00). The mean inflation-adjusted charge per hospitalization rose from USD 41,252 to USD 56,951, but fewer hospitalizations drove the total annual charges down from USD 1.51 billion to USD 1.37 billion (p = 0.00 for both analyses). Conclusions: The burden of hospital-based resource utilization associated with MPE has decreased over time, with a reduction in attributable hospitalizations by one third in the span of 1 decade. Correspondingly, the number of inpatient pleurodesis procedures has decreased during this time frame.

Acute Upper Airway Obstruction Acute upper airway obstruction has varied causes with distinct pathophysiological features. High-flow oxygen remains the basis for management, but improvements in equ...

Objective The primary objective of our study was to determine the quality of life (QOL) using a talking tracheostomy tube. Methods Randomized clinical trial (NCT2018562). Adult intensive care unit patients who were mechanically ventilated, awake, alert, attempting to communicate, English-speaking, and could not tolerate one-way speaking valve were included. Intervention comprised a Blue Line Ultra Suctionaid (BLUSA) talking tracheostomy tube (Smiths Medical, Dublin, OH, US). Outcome measures included QOL scores measured using Quality of Life in Mechanically Ventilated Patients (QOL-MV) and Voice-Related Quality of Life (V-RQOL), Speech Intelligibility Test (SIT) scores, independence, and satisfaction. Results The change in V-RQOL scores from pre- to postintervention was higher among patients using a BLUSA (Smiths Medical) compared to those who did not (P = 0.001). The QOL-MV scores from pre- to postintervention were significantly higher among patients who used a BLUSA (Smiths Medical) compared to patients who did not use BLUSA (Smiths Medical) or a one-way speaking valve (P = 0.04). SIT scores decreased by 6.4 points for each 1-point increase in their Sequential Organ Failure Assessment scores (P = 0.04). The overall QOL-MV scores correlated moderately with the overall V-RQOL scores (correlation coefficient = 0.59). Cronbach alpha score for overall QOL-MV was 0.71. Seventy-three percent of the 22 intervention patients reported the ability to use the BLUSA (Smiths Medical) with some level of independence, whereas 41% reported some level of satisfaction with the use of BLUSA (Smiths Medical). The lengths of stay was longer in the intervention group. Conclusion Our study suggests that BLUSA (Smiths Medical) talking tracheostomy tube improves patient-reported QOL in mechanically ventilated patients with a tracheostomy who cannot tolerate cuff deflation. Level of evidence I Laryngoscope, 130:1249-1255, 2020.

The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.

High-level coupled cluster calculations obtained with the Feller–Peterson–Dixon (FPD) approach and new data from the most recent version of the Active Thermochemical Tables (ATcT) are used to reassess the enthalpy of formation of gas-phase C2H2O4 (oxalic acid). The theoretical value was further calibrated by comparing FPD and ATcT gas-phase enthalpies of formation for H2CO (formaldehyde) and the two low-lying conformations of C2H4O2 (syn and anti acetic acid). The FPD approach produces a theoretical enthalpy of formation of gas-phase oxalic acid of −732.2 ± 4.0 kJ/mol at 298.15 K (−721.8 ± 4.0 kJ/mol at 0 K). An independently obtained ATcT value, based on reassessing the existent experimental determinations and expanding the resulting thermochemical network with select mid-level composite theoretical results, disagrees with several earlier recommendations that were based solely on experimental determinations but is in excellent accord with the current FPD value. The inclusion of the latter in the most rec...

With increasing use of immune checkpoint inhibitors (ICIs) for advanced NSCLC, there is increasing recognition of immune-related adverse events associated with ICI use. We recently reported increased incidence of checkpoint inhibitor pneumonitis (CIP) in ICI-treated NSCLC patients. Since development of immune-related adverse events in other organ systems has been associated with either no change or even improvement in tumor response/cancer outcomes, we sought to better understand the impact of CIP development on overall survival in ICI-treated NSCLC patients. Using baseline and follow-up data collected on a cohort of 205 ICI-treated NSCLC patients, we used a multi-state modeling approach to understand the effect of developing CIP on the risk of death. We observed time-dependent changes in risk of developing and recovery from CIP, with an increased risk of both developing and recovering from CIP in the first year after initiating ICI. We found that developing CIP independently increased the risk of transitioning to death in both adjusted and unadjusted models. In the multivariate model, we found that the increase in mortality associated with CIP was only seen in patients with adenocarcinoma tumor histology. Collectively, these findings suggest that in NSCLC, development of CIP worsens survival in patients receiving immunotherapy.

Rationale: Observational studies describe high sedative and analgesic medication (SA) requirements in patients with COVID-19 ARDS. High levels of SA have been shown to increase ICU length-of-stay, incidence of delirium, and mortality;all of which increase health system utilization. The aim of this study is to evaluate SA parameters in patients with COVID-19 ARDS undergoing tracheostomy. Methods: We enrolled 55 COVID-19 positive adult patients undergoing tracheostomy between 4/16/20 and 8/26/20. Cumulative dosage and sedation parameters, Richmond Agitation-Sedation Scale (RASS) scores, Glasgow Coma Scale (GCS) were collected in the 48-hour periods pre-and post-tracheostomy via chart review. Data analysis was performed with Microsoft Excel Analysis ToolPak. Results: Baseline characteristics include a mean age of 60.2, mean BMI of 30.2 kg/m2, 28 (51%) were male, and 39 (70.9%) of the tracheostomies were placed percutaneously. Fentanyl was used in 38 (69.1%), dexmedetomidine in 28 (50.9%), midazolam in 13 (23.6%), hydromorphone in 13 (23.6%), and propofol in 12 (21.8%) patients. •Total fentanyl dose (6940.3 mcg to 5382.2 mcg p=0.02) and total propofol dose (67066 mcg/kg to 24098 mcg/kg, p=0.02) were significantly lower post-tracheostomy compared to pre-tracheostomy (Figure 1). •There was a trend toward lower dexmedetomidine (27.7 mcg/kg to 27.4 mcg/kg, p=0.91), midazolam (183.4 mg to 133.8 mg, p=0.27), and hydromorphone (216.0 mg to 206.2 mg, p=0.72) total doses in the post-tracheostomy period. •Mean ordered RASS goals were similar in both groups (-1.1 to-0.9, p=0.12). Mean RASS deviations from goal were also similar in both groups (-0.3 vs-0.2, p=0.64). •Mean GCS values (8.4 to 9.1, p=0.007) were significantly higher in the post-tracheostomy group. Conclusions: In this retrospective cohort of COVID-19 ARDS patients undergoing tracheostomy, SA requirements were decreased in the post-tracheostomy period. Both fentanyl (22.4% reduction) and propofol (64.1% reduction) total doses were significantly lower post-tracheostomy. All other recorded SA trended toward reduction in the post-tracheostomy period but without statistical significance (Figure 1). Assessment of sedation scores showed that reduction in SA use were not associated with changes in ordered RASS goals or worse adherence to RASS goals, as these were similar in both groups. These findings suggest that the same RASS goal, and an increased GCS, may be equally obtained with less sedation in the post-tracheostomy period. We recognize the limitations of a retrospective, single-enter, cohort study. Early tracheostomy should be considered in appropriate patients to reduce SA administration and reduce health care utilization, particularly with ICU beds at a premium.

Objective: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. Data Sources: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. Review Methods: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. Conclusions: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. Implications for Practice: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

Although our understanding of the pathogenesis of empyema has grown tremendously over the past few decades, questions still remain on how to optimally manage this condition. It has been almost a decade since the publication of the MIST2 trial, but there is still an extensive debate on the appropriate use of intrapleural fibrinolytic and deoxyribonuclease therapy in patients with empyema. Given the scarcity of overall guidance on this subject, we convened an international group of 22 experts from 20 institutions across five countries with experience and expertise in managing adult patients with empyema. We did a literature and internet search for reports addressing 11 clinically relevant questions pertaining to the use of intrapleural fibrinolytic and deoxyribonuclease therapy in adult patients with bacterial empyema. This Position Paper, consisting of seven graded and four ungraded recommendations, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique. Our Position Paper aims to address the existing gap in knowledge and to provide consensus-based recommendations to offer guidance in clinical decision making when considering the use of intrapleural therapy in adult patients with bacterial empyema.

Interventional pulmonology has undergone amazing ambitious changes and innovations over the past decades, which have to find their place in a wise multidisciplinary management of respiratory diseaseshttps://bit.ly/3dD237L

BACKGROUND: Prior studies in pulmonology have examined the validity of procedural training tools, however, translation of simulation skill acquisition into real world competency remains understudied. We examine an assessment process with a simulation training course for electromagnetic navigational (EMN) bronchoscopy and percutaneous transthoracic needle aspiration (PTTNA). METHODS: A cohort study was conducted by subjects using EMN bronchoscopy and PTTNA. A procedural assessment tool was developed to measure basic competency for EMN bronchoscopy and PTTNA at three different time points: first simulation case, final simulation case upon reaching a competent score, and at their first live case. The assessment tool was divided into four domains (total score 4–16, competency ≥ 12) with each domain requiring a passing score (1–4, competency ≥ 3.0). Complication, and procedural time were collected during their first live case. RESULTS: Twenty-two serial procedures (12 EMN bronchoscopies, 10 EMN PTTNA) were observed by fourteen subjects. The mean first simulation score for EMN bronchoscopy (4.66 ±0.89) improved after cadaver simulation (12.67 ±0.89, median 3 simulations attempts). The subjects’ mean score for their first live case was 13.0 ±0.85 (self-reported score 12.5 ±1.07). For EMN PTTNA, the mean first simulation score (4.3 ±2.40) improved after cadaver simulation (12.6 ±1.51, median 3 simulation attempts). The subjects’ mean score for their first live PTTNA case was 12.5 ±2.87 (self-reported score 12.1 ±1.05). There was only one minor complication. CONCLUSION: Learning EMN bronchoscopy/PTTNA is feasible using a structured simulation course with an assessment tool.

Rationale: The likelihood of achieving pleurodesis after indwelling pleural catheter (IPC) placement for malignant pleural effusion varies with the specific drainage strategy used: symptom-guided d...

In this work, the concept and mechanical design of a novel compact, lightweight, omnidirectional three-legged robot, featuring a hybrid serial–parallel topology including leg compliance is proposed. The proposal focusses deeply on the design aspects of the mechanical realisation of the robot based on its 3D-CAD assembly, while also discussing the results of multi-body simulations, exploring the characteristic properties of the mechanical system, regarding the locomotion feasibility of the robot model. Finally, a real-world prototype depicting a single robot leg is presented, which was built by highly leaning into a composite design, combining complex 3D-printed parts with stiff aluminium and polycarbonate parts, allowing for a mechanically dense and slim construction. Eventually, experiments on the prototype leg are demonstrated, showing the mechanical model operating in the real world.

BACKGROUND AND OBJECTIVE: The main purpose of treatment in patients with malignant pleural effusion (MPE) is symptom palliation. Currently, patients undergo repeat thoracenteses prior to receiving a definitive procedure as clinicians are not aware of the risk factors associated with fluid recurrence. The primary objective of this study was to identify risk factors associated with recurrent symptomatic MPE. METHODS: Retrospective multicentre cohort study of patients who underwent first thoracentesis was performed. The primary outcome was time to fluid recurrence requiring intervention in patients with evidence of metastatic disease. We used a cause-specific hazard model to identify risk factors associated with fluid recurrence. We also developed a predictive model, utilizing Fine–Gray subdistribution hazard model, and externally validated the model. RESULTS: A total of 988 patients with diagnosed metastatic disease were included. Cumulative incidence of recurrence was high with 30% of patients recurring by day 15. On multivariate analysis, size of the effusion on chest X-ray (up to the top of the cardiac silhouette (hazard ratio (HR): 1.84, 95% CI: 1.21–2.80, P = 0.004) and above the cardiac silhouette (HR: 2.22, 95% CI: 1.43–3.46, P = 0.0004)), larger amount of pleural fluid drained (HR: 1.06, 95% CI: 1.04–1.07, P < 0.0001) and higher pleural fluid LDH (HR: 1.008, 95% CI: 1.004–1.011, P < 0.0001) were associated with increased hazard of recurrence. Negative cytology (HR: 0.52, 95% CI: 0.43–0.64, P < 0.0001) was associated with decreased hazard of recurrence. The model had low prediction accuracy. CONCLUSION: Pleural effusion size, amount of pleural fluid drained, LDH and pleural fluid cytology were found to be risk factors for recurrence.

Background and objective Malignant airway obstruction (MAO), a common complication of patients with advanced lung cancer, causes debilitating dyspnoea and poor quality of life. Two common interventions used in the treatment of MAO include bronchoscopy with airway stenting and external beam radiotherapy (EBRT). Data are limited regarding their clinical effectiveness and overall effect on survival. Methods A retrospective chart review of patients treated with airway stenting and/or EBRT at the Johns Hopkins Hospital for MAO between July 2010 and January 2017 was reviewed. Demographics, performance status, cancer histology, therapeutic intervention and date of death were recorded. Survival was calculated using cox regression analysis. Results Of the 606 patients who were treated for MAO, 237 were identified as having MAO and included in the study. Sixty-eight patients underwent rigid bronchoscopy and stenting, 102 EBRT and 67 a combined approach. Patients who underwent stenting hand an increased hazard ratio (HR) of death in comparison to those who received combination therapy (HR: 2.12, 95% CI: 1.02, 4.39), while there was a trend towards significance in the EBRT alone group in comparison to the combination therapy group (HR: 1.62, 95% CI: 0.93, 2.83). Conclusion In this retrospective analysis, combination therapy with stenting and EBRT led to better survival in comparison to stenting or EBRT alone. Prospective cohort trials are needed to confirm these results.

Flexible bronchoscopy is a cornerstone diagnostic and therapeutic procedure in pulmonary medicine. Since its first introduction in the late 1960s,1 bronchoscopy has evolved and improved over time. It has gone from a tool used for simple visualisation of the airway to a modality that can be used for simple tasks from surveying the airway to complex therapeutic interventions often done by an interventional pulmonologist. With its long list of indications, flexible bronchoscopy is commonly performed in patients with an array of comorbidities, and, as with all procedures, is associated with complications. For this reason, it is up to the proceduralist to adequately asses their patients and decide how to best proceed to minimise the risk of complications. Hypoxaemia associated with bronchoscopy can occur before, during, and/or after the procedure. Many patients are hypoxaemic even before the procedure starts. Likewise, hypoxaemia can be worsened due to the administration of a sedating agent, resulting in central respiratory depression and apneic or obstructive processes. The insertion of the bronchoscope past the glottis into the trachea can itself induce hypoxaemia.2 Taking into consideration a normal diagnostic bronchoscope with an outer diameter of 4.2 mm and the diameter of the trachea being between 15–20 mm, insertion of the bronchoscope can cause an element of airway obstruction that can exacerbate hypoxaemia, especially in someone who already has underlying lung disease.3 Suctioning during a bronchoscopy can cause atelectasis and …