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Peter Wallbridge,1,2 Mark Hew,1,3,4 Selina M Parry,5 Louis Irving,1,2 Daniel Steinfort1,2 1Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia; 2Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia; 3Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia; 4Allergy, Asthma & Clinical Immunology, Alfred Health, Prahran, VIC, Australia; 5Department of Physiotherapy, The University of Melbourne, Parkville, VIC, AustraliaCorrespondence: Peter WallbridgeDepartment of Respiratory Medicine, Level 5 East, Royal Melbourne Hospital, Grattan St, Parkville, VIC 3050, AustraliaTel +61 3 9342 7000Fax +61 3 9342 3141Email peter.wallbridge@mh.org.auBackground and Objectives: Parasternal intercostal ultrasound morphology reflects spirometric COPD severity. Whether this relates to the systemic nature of COPD or occurs in response to hyperinflation is unknown. We aimed to assess changes in ultrasound parasternal intercostal muscle quantity and quality (echogenicity) in response to relief of hyperinflation. We hypothesised that reduction in hyperinflation following endobronchial valve (EBV) insertion would increase ultrasound parasternal thickness and decrease echogenicity.Methods: In this prospective cohort study, eight patients with severe COPD underwent evaluation of health-related quality of life, lung function, and sonographic thickness of 2nd parasternal intercostal muscles and diaphragm thickness, both before and after EBV insertion. Relationships between physiological and radiographic lung volumes, quality of life and ultrasound parameters were determined.Results: Baseline FEV1 was 1.02L (SD 0.37) and residual volume (RV) was 202% predicted (SD 41%). Median SGRQ was 63.26 (range 20– 70.6). Change in RV (− 0.51 ± 0.9L) following EBV-insertion showed a strong negative correlation with change in parasternal thickness (r = − 0.883) ipsilateral to EBV insertion, as did change in target lobe volume (− 0.89 ± 0.6L) (r = − 0.771). Parasternal muscle echogenicity, diaphragm thickness and diaphragm excursion did not significantly change.Conclusions: Dynamic changes in intercostal muscle thickness on ultrasound measurement occur in response to relief of hyperinflation. We demonstrate linear relationships between intercostal thickness and change in hyperinflation following endobronchial valve insertion. This demonstrates the deleterious effect of hyperinflation on intrinsic inspiratory muscles and provides an additional mechanism for symptomatic response to EBVs.Keywords: endobronchial valve, COPD, ultrasound, respiratory muscle, measurement

Traditional conscious sedation for endobronchial ultrasound procedures places patients at risk of desaturation, and high-flow nasal oxygen may reduce the risk. We designed a parallel-group randomised controlled trial of high-flow nasal oxygen at a flow rate of 30-70 l.min-1 via nasal cannulae, compared with standard oxygen therapy at 10 l.min-1 via a bite block in adults planned for conscious sedation for endobronchial ultrasound. The primary outcome was the proportion of patients experiencing desaturation (defined as SpO2 < 90%). Secondary outcomes included oxygen saturation after pre-oxygenation, lowest oxygen saturation during procedure, number of hypoxic episodes, duration of hypoxia, end-procedure end-tidal CO2 , satisfaction scores and complications. Thirty participants were allocated to each group. Baseline patient characteristics, procedure time and anaesthetic agents used were similar between the groups. Desaturation occurred in 4 out of 30 patients allocated to the high-flow nasal oxygen group, compared with 10 out of 30 allocated to the standard oxygenation group, a non-significant difference (p = 0.07) with intention to treat analysis. The difference was significant (p = 0.047) when using a per-protocol analysis. Oxygen saturation after pre-oxygenation and the lowest oxygen saturation during procedure were significantly higher in the high-flow nasal oxygen group compared with the standard oxygenation group; median (IQR [range] 100 (99-100 [93-100]) vs. 98 (97-99 [94-100]), p = 0.0001 and 97.5 (94-99 [77-100]) vs. 92 (88-95 [79-98]), p < 0.001, respectively. There were no differences in other secondary outcomes. Although high-flow nasal oxygen may prevent desaturation due to some causes, it does not protect against hypoxaemia in all circumstances. [ABSTRACT FROM AUTHOR]

Correlation with functional measures of ventilation or perfusion varies widely and no prior study has evaluated correlation between densitometry and lobar ventilation/perfusion in patients with severe emphysema. The aim of this study was to evaluate the utility and findings of Gallium-68 ventilation/perfusion positron emission tomography-CT ( SP 68 sp Ga-VQ/PET-CT) in severe emphysema assessment. [Extracted from the article]

A 51-year-old woman with severe asthma underwent bronchoscopy and endobronchial ultrasound (EBUS) for investigation of a 15-mm peripheral lung nodule. Histology demonstrated a typical carcinoid tumor. Pulmonary location is the second commonest site for carcinoid tumors. Diagnosis of peripheral carcinoid tumor of the lung is difficult due to its small size, poor accuracy of cytologic diagnosis, and low sensitivity of positron emission tomography in detecting it. EBUS has a high diagnostic yield and a low complication rate in the evaluation of small solitary pulmonary nodules. The ultrasound appearance of carcinoid tumors is identical to that of lung carcinomas. Prompt diagnosis of carcinoid tumor is desirable as regional lymph node metastasis is seen in 10% of patients and is associated with a reduced 5-year survival. We feel that, where possible, all patients presenting with solitary pulmonary nodules should be investigated initially using EBUS due to its high diagnostic rate and the very low incidence of adverse events.

The use of beta-blockers in patients with chronic obstructive pulmonary disease and co-morbid cardiovascular disease is controversial, despite increasing evidence to support their use as safe and efficacious. This study retrospectively assessed the rates of beta-blocker prescription in patients admitted to two Australian tertiary hospitals for acute exacerbation of chronic obstructive pulmonary disease. This revealed that less than half of patients (45%) with known cardiac indications were receiving beta-blocker therapy, evident across all degrees of airways disease severity. Further work is needed to ensure that medical management of this patient group is optimised. [ABSTRACT FROM AUTHOR]