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Cryoprobe transbronchial lung biopsy (TBLB)/transbronchial lung cryobiopsy (TBLC) is increasingly being described as an alternative to surgical lung biopsy and provides larger lung biopsy samples as compared with conventional TBLB in patients with diffuse parenchymal lung diseases. The technique for cryoprobe TBLB procedure has not yet been standardized, and various authors describe different modalities. However, the use of an artificial airway (rigid bronchoscope or endotracheal tube) is preferred for airway protection. In addition, the use of an occlusion balloon provides safety to prevent excessive bleeding. The exclusive use of rigid bronchoscopy may limit the widespread adoption of this diagnostic modality. We describe a method to perform cryoprobe TBLB with exclusive use of a flexible bronchoscope and utilization of Arndt endobronchial blocker as an occlusion balloon. The procedure was performed in two patients under moderate conscious sedation. Adequate lung biopsies were obtained in both the cases without any complications. This modality may allow safe performance of cryoprobe TBLB with a flexible bronchoscope. Herein, we describe the technical and procedural considerations of this modality.

Background: The role of nebulized lignocaine administration for flexible bronchoscopy is unclear. Methods: In this randomized, double-blind, placebo-controlled trial, subjects undergoing diagnostic flexible bronchoscopy were randomized to receive either nebulized lignocaine (2.5 ml of 4% lignocaine) or nebulized (2.5 ml of 0.9%) saline (placebo). All received 10% lignocaine pharyngeal spray (4 sprays) and 5-ml nasal 2% lignocaine gel. 1% lignocaine solution was used for spray-as-you-go administration in all. Co-primary outcomes were Operator-rated overall procedure satisfaction and Operator-rated cough scores on Visual Analog Scale (VAS). Secondary objectives were cumulative lignocaine dose, proportion of subjects receiving >8.2-mg/kg lignocaine, and complications between the groups. Results: Two hundred and twenty subjects were randomized and 217 (109 – nebulized lignocaine and 108 – placebo) received the intervention. Baseline characteristics were comparable. Operator-rated overall procedure satisfaction scores on VAS (7.30 ± 1.54 nebulized lignocaine and 7.50 ± 1.31 placebo group, P = 0.85) and Operator-rated cough scores on VAS (3 [2–5] nebulized lignocaine and 3 [2–4] placebo group, P = 0.18) were similar. Cumulative lignocaine dose was significantly greater in nebulized lignocaine group (331.46 ± 9.41 mg vs. 232.22 ± 12.77 mg, P < 0.001), and a significantly greater number of subjects in this group received lignocaine dose >8.2 mg/kg. Minor complications occurred in 6 and 9 subjects in nebulized lignocaine and placebo groups, respectively, P = 0.41. Conclusion: Administration of nebulized lignocaine in addition to pharyngeal lignocaine spray, during no-sedation bronchoscopy, increases the cumulative lignocaine dose without improved procedural comfort. Additional nebulized lignocaine during bronchoscopy is not recommended.

Endobronchial ultrasound elastography is new ultrasound technology that is being reported recently for the evaluation of mediastinal lymphadenopathy during endobronchial ultrasound-guided (EBUS) transbronchial needle aspiration. This modality is based on the assessment of tissue stiffness that may be useful in differentiating benign from malignant lesions. Image generation leads to colored images with different colors signifying varying degrees of stiffness. The utility of this technique has been studied to differentiate between benign and malignant lymph nodes and various methods for representation of results which include visual color estimation, quantitative color estimation, and strain ratios have been described. Herein, we report two patients with mediastinal lymphadenopathy wherein EBUS elastography was employed. We also systemically review the studies describing this technique in differentiating benign from malignant lymph nodes.

Bronchial thermoplasty (BT) is an upcoming treatment for patients with asthma refractory to traditional pharmacotherapy. BT is an invasive procedure which carries a risk of coughing, wheezing, bronchospasm, and laryngospasm during and after the procedure. Some of these complications can be minimized using better anesthetic techniques during BT. We hereby report a case of a 63-year-old female with poorly controlled asthma posted for BT done under general anesthesia (GA) with supraglottic device. GA provides better working conditions for pulmonologists when compared with sedation. But still there is no consensus on what would be the ideal anesthetic technique for BT procedure. Till the time, considering anesthesiologist and pulmonologist's prospective, GA (total intravenous anesthesia) using supraglottic device would be a preferred choice for a safe and effective anesthetic strategy in BT.

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Background: Patients with trauma usually require highly specialized care in ICU and many times their recovery is complicated by infections. Aim of this study was to determine the profile of pathogens and their impact on outcome among these patients. Materials and Methods: The clinical records of 101 consecutive patients who were admitted for more than 48-hrs in ICU during Jun-Dec 2007 were analyzed. Results: Total of 953 samples from blood, urine, BAL or pus/collection were subjected to cultures. From 276 samples, 299 organisms were isolated. Among pathogens Candida Spp. [89 (29%)] were the most common, followed by Acinetobacter Spp. [69 (23%)], Pseudomonas Spp. [63 (21%)], Klebsiella Spp. [31 (10%)], coagulase negative Staphylococcus aureus [16 (5%)], E coli [12 (4%)], Enterobacter Spp. [7 (2%)], S aureus [6 (2%)], Enterococcus Spp. [5 (2%)], Citrobacter Spp. [2 (0.6%)], S maltophila [1 (0.3%)] and Providentia Spp. [1 (0.3%)]. For gram negative pathogens drug-resistance rates were as follows: Fluoroquinolones, 76%; 3 rd generation cephalosporins, 74%; aminoglycosides, 66%; β-lactams/β-lactamase inhibitors combinations, 64%; and carbapenems, 50%. Among these 27% of pathogens were resistant to all 5 classes of drugs. 58% of Staphylococcus aureus were methicillin-resistant whereas 85% of coagulase negative Staphylococcus were methicillin resistant. The mortality was higher among patients in whom pathogens were isolated [Odd's Ratio (OR) 0.185; 95% confidence interval (CI) 0.049-0.640; P = 0.002]. Conclusions: Isolation of multi-drug resistant pathogens is common among trauma patients admitted in ICU and is associated with increased mortality and could impact on the consumption of hospital resources. The importance of high rate of fungal isolation needs to be studied among these patients.

Hemoptysis is common in pulmonary aspergilloma. Current treatment modalities such as surgical resection or bronchial artery embolization (BAE) are limited by lack of technical expertise and risk of recurrence, respectively. We describe our experience of treating aspergilloma and hemoptysis with bronchoscopic instillation of voriconazole.We retrospectively reviewed records of patients with symptomatic aspergilloma undergoing bronchoscopic voriconazole instillation. Four sessions were carried out at weekly intervals using 400 mg voriconazole dissolved in 20 mL 0.9% normal saline.A total of 82 subjects were evaluated [66 males; mean (SD) age, 43.2 (14.1) y]. The commonest underlying etiology was posttubercular sequelae (95.1%). Of these, 18 patients (22%) had BAE within the last 1 year. The mean (SD) size of aspergilloma was 4.5 cm (1.5 cm). Following voriconazole instillation, 25 patients (30.5%) had significant resolution of hemoptysis after first session, and 52 patients (68.3%) after the second session. Transient postprocedure cough (n=38; 46.3%) was the commonest procedure-related adverse event. Follow-up CT (n=47) showed reduction in aspergilloma size in 54% and no change in 40.4%. The median (IQR) hemoptysis-free period was 12 months (IQR, 9 to 15.5 mo). Recurrence of significant hemoptysis occurred in 24 (29.3%) patients during a median follow-up of 14.5 months (IQR, 9-18 mo). A history of prior BAE and baseline aspergilloma size were significantly associated with recurrence of significant hemoptysis.Intrabronchial voriconazole instillation seems to be a safe and effective modality for hemoptysis control in pulmonary aspergilloma.

Background: Fractional Exhaled Nitric Oxide (FeNO) is a promising non invasive tool for detecting airway inflammation; however, it9s utility in predicting asthma control is not well defined. Aims and Objectives: The ability of serial measurements of FeNO in determining and predicting clinical control of asthma was investigated. Methods: Steroid naive asthmatics who were clinically eligible for receiving ICS were recruited and the following parameters were measured at inclusion and after 6 - 8 weeks of ICS treatment: FeNO (using Niox Mino point of care device), peak expiratory flow rate (PEFR) variability, asthma control test (ACT) score, forced expiratory volume in 1 sec (FEV1), and bronchodilator reversibility (BDR). Results: 96 patients were recruited (61% males; mean (SD) age, 33.4 (12.8) years). The median FeNO levels at baseline and after therapy were 41.5 (25 - 66) and 35.5 (19 - 47) ppb respectively (p=0.01). At baseline, FeNO levels correlated strongly with FEV1 (R= - 0.62, p Conclusions: FeNo levels correlate well with conventional parameters of clinical control in moderate bronchial asthma and may be a simple, non-invasive and useful method for assessing level of asthma control.

Background: Pulmonary aspergilloma causing hemoptysis is a therapeutic challenge. Surgical resection and bronchial artery embolization (BAE) have limited availability and efficacy respectively. Alternative measures are, thus needed. We describe our experience of fibreoptic bronchoscopy (FOB) guided voriconazole instillation for symptom control in aspergilloma. Methods: A retrospective review of patients with symptomatic aspergilloma undergoing FOB-guided voriconazole instillation was done. 400 mg of voriconazole dissolved in 20 ml of 0.9% normal saline was instilled into the affected segment / cavity. Upto four sessions at weekly intervals were performed. Results: Eighty two patients underwent the above procedure. Of these, 69 patients (84.1%) had severe hemoptysis (> 200 ml/day). The commonest underlying etiology was post-tubercular sequelae (95.1%). CT assessed mean (SD) size of aspergilloma was 4.56 (1.46) cms. Hemoptysis reduced significantly in 25 patients (30.5%) after the first session and another 52 (68.3%) after 2 sessions. Aspergilloma size reduced in 47 (54%) and remained unchanged in 40.4%. The hemoptysis - free period was 12 months (IQR, 9 -15.5 months). Over a median follow-up of 14.5 months (IQR, 9 -18 months), hemoptysis recurred in 24 (29.3%) patients. Prior BAE and larger baseline aspergilloma size were significantly associated with risk of hemoptysis recurrence. Conclusions: Intrabronchial voriconazole instillation appears to be a safe and promising modality for hemoptysis control in pulmonary aspergilloma.

Objective Reliable differentiation of benign from malignant mediastinal lymphadenopathy is important, especially in countries with a high tuberculosis burden. We hypothesized that specific sonographic features on endobronchial ultrasonography (EBUS) may differentiate benign from malignant nodes. In this study, the sonographic features of non-malignant and malignant nodes were compared. Methods This was a retrospective analysis of patients with intrathoracic lymphadenopathy who underwent EBUS-guided transbronchial needle aspiration (TBNA). Sonographic features such as nodal size, margin (distinct or indistinct), echogenicity (heterogeneous or homogeneous), and presence or absence of calcification, a central hilar structure, coagulation necrosis sign, and nodal conglomeration were recorded and compared in the 2 groups. Results During the study period, a diagnosis of tuberculosis (n = 71), sarcoidosis (n = 63), and malignancy (n = 36) was made in 170 patients by EBUS-TBNA. A total of 312 lymph node stations were examined. Presence of central hilar structure (15.6% versus 4%, P = .03) and the presence of nodal conglomeration (27.5% versus 8%, P

The relation between dietary intake and metabolic profile in non-small cell lung cancer (NSCLC) was evaluated. Patients with NSCLC were recruited and their caloric requirement and resting energy expenditure (REE) were calculated using the Harris-Benedict equation and Katch-McArdle formula respectively. Hypermetabolic state was defined as REE more than 10% above the basal metabolic rate (BMR). Body composition parameters were calculated by bioelectric impedance method. The 24-h dietary intake method and Malnutrition Universal Screening Tool assessed nutritional intake. One hundred and forty-eight subjects were included (87% males). Of these, 46.6% subjects were hypermetabolic and 31% cachexic, with lower calorie and protein intakes than recommended, although per cent of total energy derived from protein, fat and carbohydrates were similar. Hypermetabolic patients had lower BMI, though the per cent deficit in energy and protein consumption was similar. Cachexia was associated with lower BMR but not with deficit in energy or protein consumption. No correlation was seen between dietary intake and body composition parameters. The calorie and protein intake of NSCLC patients is lower than recommended. The discordance between elevated REE and dietary intake implies that the relationship between increased energy demands and food intake may be altered.

A 35-year-old woman presented with anasarca and lower limb paraesthesias for 3 months. There was history of daily oral intake of 10–15 g of some indigenous preparation for low backache during the 2 months prior to current symptoms. On physical examination, respiratory rate was 18 breaths/min and oxygen saturation on room air was 95%. Serum creatinine was 1.4 mg/dL. Urine examination showed nephrotic proteinuria and chest radiograph demonstrated numerous small radiopaque densities (figure 1). High-resolution CT showed multiple metallic spherules …

Background: The diagnosis of ventilator associated pneumonia (VAP) remains a challenge because the clinical signs and symptoms lack both sensitivity and specificity and the selection of microbiologic diagnostic procedure is still a matter of debate. Aims and Objective: To study the role of various bronchoscopic and non-bronchoscopic diagnostic techniques for diagnosis of VAP. Settings and Design: This prospective comparative study was conducted in a medical ICU of a tertiary care center. Materials and Methods: Twenty-five patients, clinically diagnosed with VAP, were evaluated by bronchoscopic and non-bronchoscopic procedures for diagnosis. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of various bronchoscopic and non-bronchoscopic techniques were calculated, taking clinical pulmonary infection score (CPIS) of ≥6 as reference standard. Results: Our study has shown that for the diagnosis of VAP, bronchoscopic brush had a sensitivity, specificity, PPV and NPV of 94.9% [confidence interval (CI): 70.6-99.7], 57.1% (CI: 13.4-86.1), 85% (CI: 61.1-96) and 80% (CI: 21.9-98.7), respectively. Bronchoscopic bronchoalveolar lavage (BAL) had a sensitivity, specificity, PPV and NPV of 77.8% (CI: 51.9-92.6), 71.8% (CI: 24.1-94), 87.3% (CI: 60.4-97.8) and 55.5% (CI: 17.4-82.6), respectively. Sensitivity, specificity, PPV and NPV for non-bronchoscopic BAL (NBAL) were 83.3% (CI: 57.7-95.6), 71.43% (CI: 24.1-94), 88.2% (CI: 62.3-97.4) and 62.5% (CI: 20.2-88.2), respectively. Endotracheal aspirate (ETA) yield was only 52% and showed poor concordance with BAL (k-0.351; P-0.064) and NBAL (k-0.272; P-0.161). There was a good microbiologic concordance among different bronchoscopic and non-bronchoscopic distal airway sampling techniques. Conclusion: NBAL is an inexpensive, easy, and useful technique for microbiologic diagnosis of VAP. Our findings, if verified, might simplify the approach for the diagnosis of VAP.

e21094Background: The delays toward the diagnosis and management of lung cancer likely contribute to considerable morbidity and mortality among lesser income patients in the developing world. We so...

Transbronchial lung biopsy (TBLB) is commonly utilized for diagnosis of diffuse parenchymal lung diseases. TBLB has a high yield in granulomatous interstitial lung diseases like sarcoidosis, but small size of biopsies limits its utility in idiopathic interstitial pneumonia. Surgical lung biopsy provides large size tissue, but there is associated morbidity, longer hospital stay, the risk of air leak, and mortality. Cryoprobe-TBLB, a relatively newer diagnostic procedure, provides larger biopsies than TBLB that are usually crush artifact free and enable the pathologist to provide diagnosis with greater confidence. We describe our technique of performing cryoprobe-TBLB.

Patient–ventilator asynchrony is common with noninvasive ventilation (NIV) used for management of acute exacerbation of chronic obstructive pulmonary disease (COPD). Neurally adjusted ventilator assist (NAVA) is a mode of ventilatory support which can minimize the patient–ventilator asynchrony. Delivering NIV with NAVA (NIV–NAVA) during acute exacerbation of COPD seems a logical approach and may be useful in reducing patient–ventilator asynchrony. However, there are no published reports which describe the use of NIV–NAVA for management of acute exacerbation of COPD. We describe the successful management of a 56-year-old gentleman presenting to the emergency department of our hospital with acute exacerbation of COPD with hypercapnic respiratory failure with NIV–NAVA.

Background Atherosclerotic cardiovascular disease (CVD) is the major cause for mortality in rheumatoid arthritis (RA). Dyslipidemia is an important risk factor for CVD and is influenced by the disease activity of RA. There is paucity of data on this subject in Indian patients with RA. Objectives To study the lipid levels in patients with RA and their relation with disease activity. Method The prospective study was carried out at a tertiary care centre in northern India. Results The study population included 96 patients with RA. Using the “high” cut-off values of National Cholesterol Education Programme–Adult Treatment Panel (NCEP-ATP III) as many as 38.5% (37/96) of patients exhibited dyslipidemia. Low high-density lipoprotein cholesterol (HDL-C) was the commonest abnormality seen in 34.3% of (33/96) patients. Disease activity scores (DAS-28) were at baseline and on a follow-up visit after 3 months they were 4.9 (1.02) and 4.4 (0.9), respectively (P = 0.003). With a decline in disease activity, a rising trend was observed for all lipids, statistically significant only for HDL. DAS-28 showed significant negative correlation with TC, r = 0.302 (0.003) and LDL-C, r = 0.274 (0.007). For HDL and TG, the correlation was not significant. Conclusion Lipid abnormalities are common in Indian patients with RA. Low HDL is the commonest abnormality. Disease activity is negatively related with lipids.

A 25-year-old female patient presented with dry coughs of 20 days duration and fever for four days. Examination of respiratory system revealed no significant abnormality. Chest radiograph was normal. CT scan of the thorax revealed endobronchial opacity in the right main bronchus suggestive of a foreign body. Patient retrospectively recollected history of betel nut aspiration just prior to onset of symptoms. Flexible bronchoscopy revealed a large sized blackishbrownish large foreign body (betel nut) in the right main bronchus which was successfully removed using the flexible bronchoscope itself. Due to the hygroscopic character of betel nut, it had absorbed moisture and had considerably increased in size. Although rigid bronchoscope is the preferable modality for removal of large sized airway foreign bodies, flexible bronchoscope is especially useful and often preferable as it obviates the need for general anesthesia. On examination, blood pressure (100/78mmHg), pulse rate (94/ min) and respiratory rate (22/min) were normal. Examination of chest revealed no significant abnormality. Other systemic examination was also unremarkable. Posteroanterior radiograph of chest was normal (Figure 1). In view of persistent symptoms, CT scan examination of the thorax was (Figure 2) done. It revealed endobronchial opacity in the right main bronchus suggestive of a foreign body which was almost completely occluding the lumen of the right main bronchus. Hyperlucency of the right lung fields was also observed suggestive of post obstructive hyperinflation. The opacity looked well defined and did not appear to arise from the wall of the bronchus. Patient’s history was reviewed again and she recollected that on the night prior to onset of symptom, she was chewing a betel nut and while laughing on a joke during conversation she had likely aspirated it. With a diagnosis of FB aspiration in the right main bronchus, Background

Purpose: The aim of this study was to assess inter- and intra-observer variability of arm muscle thickness measured by critical care physicians using bedside ultrasonography (USG). Methodology: This prospective study included twenty patients admitted with sepsis. Three measurements of thickness of right arm muscles of each patient using B-mode USG were taken by two critical care fellows, independently. Intra- and inter-observer reliability was tested using intraclass correlation coefficient (ICC). Results: The mean 1st, 2nd, and 3rd measurements of muscle thickness recorded by observer 1 and 2 were 23.620 (±4.171) versus 23.840 (±3.849) mm, 23.235 (±3.620) versus 23.625 (±4.062) mm, and 24.125 (±4.098) versus 23.965 (±3.651) mm, respectively. The average muscle thickness measured by first and second observer was 23.660 (±3.834) mm and 23.810 (±3.674) mm, respectively. ICC for intra-observer variability for observer 1 and 2 was 0.964 (95% confidence interval [CI] 0.924–0.985) and 0.949 (95% CI 0.892–0.978), respectively. ICC for inter-observer variability was 0.995 (95% CI 0.988–0.998). Conclusions: USG is a reliable tool for assessment of arm muscle thickness by critical care physicians.

Dieulafoy's disease is an uncommon condition, the usual site of occurrence being the gastrointestinal tract. The condition refers to the presence of a dysplastic submucosal artery with mucosal vascular branches that has propensity to cause recurrent bleeding. Dieulafoy's disease of the bronchus is rare. Herein, we describe the case of a 26-year-old male who presented with recurrent bouts of hemoptysis and bronchial Dieulafoy's disease was diagnosed. Flexible bronchoscopy was performed, and argon plasma coagulation (APC) of the bleeding lesion was done. The procedure was successful and was followed by complete eradication of the vascular malformation and cessation of hemoptysis. APC is a useful tool in the armamentarium of an interventional pulmonologist that can allow rapid and safe control of bleeding from superficially located and bleeding endobronchial lesions, and can be easily and effectively applied using a flexible bronchoscope.

Tracheal penetration of esophageal self-expanding metallic stents (SEMS) with/without tracheoesophageal fistula (TEF) formation is a rare occurrence. We report the case of a 66-year-old female patient with advanced esophageal squamous cell carcinoma who had undergone palliative esophageal stenting on three occasions for recurrent esophageal stent obstruction. On evaluation of symptoms of breathing difficulty and aspiration following third esophageal stent placement, tracheal erosion and TEF formation due to the tracheal penetration by esophageal stent were diagnosed. The patient was successfully managed by covered tracheal SEMS placement under flexible bronchoscopy.

Background: Endobronchial involvement is frequently absent in many patients with bronchogenic carcinoma. Malignant involvement may be confined to lymph nodes/peribronchial locations only or may be present along with endobronchial lesions. Transbronchial needle aspiration (TBNA) is a flexible bronchoscopic technique which can be employed to obtain tissue samples from mediastinal lymph nodes or peribronchial locations. Although a safe and cost effective bronchoscopic modality, it is frequently underutilized owing to concerns regarding its diagnostic utility and safety. Herein, we describe our experience over 1 year on the diagnostic utility of TBNA without rapid on-site evaluation (ROSE) in patients with suspected diagnosis of lung cancer. Materials and Methods: We retrospectively reviewed the cases in which conventional TBNA-without ROSE was performed for suspected lung cancer, between January 2012 and December 2012. Each lymph node station from which aspiration was performed was sampled thrice and smears were prepared on slides which were later examined by a cytopathologist. Results: Twenty-six cases were retrieved in which conventional TBNA without ROSE for suspected lung cancer with mediastinal involvement was performed during the study period. Adequate lymph node sampling could be achieved in 57.7% cases. Conventional TBNA was diagnostic in 11 out of the 26 (42.3%) patients. The diagnostic yield improved to 73.3% in patients in whom an adequate lymph nodal sample could be obtained. TBNA was the sole diagnostic sample in six (54.5%) patients. Alternative diagnoses (sarcoidosis and tuberculosis) were obtained in two patients. Conclusion: Conventional TBNA without ROSE is a safe and efficacious flexible bronchoscopic procedure which should be performed routinely from bronchoscopically accessible locations in patients with a suspected diagnosis of lung cancer.

Background Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a widely accepted minimally invasive procedure for the evaluation of mediastinal lymphadenopathy. Most of the published literature on EBUS-TBNA is focused on the diagnostic and staging aspects of lung cancer. Literature on the utility of this modality from developing countries and settings with a high prevalence of tuberculosis (TB) is limited. We herein describe our preliminary experience over 1 year on the utility of EBUS-TBNA from a tertiary care teaching center in North India. Methods The primary objective was to evaluate the utility of convex probe EBUS-TBNA as a modality for diagnosis in patients with mediastinal lymphadenopathy presenting to our center. EBUS-TBNA was performed under local anesthesia and conscious sedation in the bronchoscopy laboratory. Rapid on-site evaluation was available for most of the procedures. Patients were discharged the same day from the hospital. Results A total of 102 patients with mean age of 42.1±14.2 years underwent EBUS-TBNA for a clinical indication of enlarged mediastinal lymph nodes, between September 2012 and September 2013.There were 63 males (61.8%) and 39 females (38.2%). EBUS-TBNA was performed for staging lung cancer in 5 patients.A total of 216 lymph node stations were sampled in 102 patients. Rapid on-site evaluation was performed in 95 patients (93.1%). Adequate/representative samples could be obtained in 98 of 102 patients (96.1%). Overall, EBUS-TBNA was diagnostic in 76 patients (74.5%). EBUS-TBNA was diagnostic in 80.9%, 84.8%, and 75% of patients with sarcoidosis, TB, and lung cancer, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value of EBUS-TBNA were 81.7%, 100%, 100%, and 22.73%, respectively. Conclusions EBUS-TBNA is a safe and efficacious procedure for obtaining tissue diagnosis in patients with mediastinal lymph node enlargement. The yield of EBUS-TBNA in diagnosis of mediastinal lymph node enlargement due to TB is especially high.

Typical carcinoid of the trachea presenting as an endoluminal polypoidal mass is a rare occurrence. Herein, we report a case of a 34-year-old female patient who presented with features of central airway obstruction. Flexible bronchoscopy demonstrated a large pedunculated growth arising from the lower end of the trachea near carina which was flopping in and out of the main tracheal lumen and the proximal right bronchus leading to dynamic airway obstruction. Successful electrosurgical excision (using a snare loop) of the polypoidal growth was performed using the flexible bronchoscope itself. The patient had immediate relief of airway obstruction and histopathological examination of the polyp demonstrated features of typical carcinoid (WHO Grade I neuroendocrine tumor).

Background and Objective: There are sparse data regarding the impact of ventilator-associated pneumonia (VAP) on outcome among patients with chronic obstructive pulmonary disease (COPD) exacerbation. Materials and Methods: This retrospective study included patients with COPD exacerbation requiring endotracheal intubation for more than 48 h admitted in a single respiratory unit from January 2008 to December 2009. Records of these patients were checked for the occurrence of VAP. Results: One hundred and fifty-three patients required endotracheal intubation for COPD exacerbation during this period. The mean age of this cohort was 61.46 ± 11.3 years. The median duration of COPD was 6 years (range: 1-40). A total of 35 (22.8%) patients developed VAP (early: 9 and late: 26). The risk of mortality was comparable between two groups, that is, patients with and without VAP [odd′s ratio (OR)−1.125; 95% confidence interval (CI), 0.622-2.035]. The duration of mechanical ventilation and hospital stay (median ± standard error, 95% CI) was 32 ± 10 (95% CI, 13-51) versus 10 ± 2 (95% CI, 6-14) days; P ≤ 0.001 and 53 ± 26 (95% CI, 3-103) versus 18 ± 7 (95% CI, 5-31) days; P = 0.031, respectively was higher among patients with VAP. Conclusions: Our study has shown that VAP leads to increased duration of mechanical ventilation and hospital stay; however, the mortality is not affected.

A 60-year-old man, a non-smoker, was referred to us for evaluation of an abnormal chest radiograph that had been taken 2 months earlier when the patient had fever and cough. The fever and cough had subsided after treatment with antibiotics. The patient was asymptomatic at the time of presentation to us. Examination was unremarkable. The chest radiograph showed an air pocket in the right paratracheal region. The diagnosis and differential diagnoses are discussed in this case report.

A 30-year-old woman presented with a history of progressive shortness of breath, cough, and hoarseness. Stridor was audible on examination. Chest X-ray showed normal lung fields and contrast-enhanced computed tomography thorax showed lower tracheal occlusion with endoluminal growth. Diagnostic flexible bronchoscopy demonstrated multiple whitish glistening nodules over both vocal cords and lower tracheal occlusion by whitish nodular growth. In view of critical central airway obstruction, rigid bronchoscopy and excision of the lower tracheal growth were performed. Histopathological examination of the excised specimen demonstrated features of squamous papillomas. A diagnosis of respiratory papillomatosis was established. On follow-up surveillance bronchoscopy, there was a gradual spontaneous regression of the residual lesions, and the patient remains currently asymptomatic 1 year since the procedure.

A 17 year old girl presented with a history of intermittent low grade fever for the past one and a half months. She also reported loss of appetite and body weight—about 4 kg. She had no history of cough, expectoration, dyspnoea, chest pain, or haemoptysis. No abdominal symptoms, headache, neck pain or stiffness, or alteration in sensorium were seen. She had no history suggestive of connective tissue disease and her occupational history did not suggest exposure to asbestos. She had been diagnosed with lymph node tuberculosis five years ago at another hospital and had received antituberculous drugs for nine months. An abnormality was seen on a chest radiograph (fig 1⇓) so computed tomography of the chest was performed (fig 2⇓). She was referred to us with a working diagnosis of pleural malignancy. Fig 1 Posterioanterior radiograph of the chest Fig 2 Computed tomogram of the chest Physical examination showed mild fever (38oC). Her pulse (90 beats/min) and blood pressure (110/70 mm Hg) were normal. She had no pallor, icterus, or peripheral lymph node enlargement. Examination of the chest showed a dull percussion note and decreased breath sounds in the left infra-axillary area. Examination of the cardiovascular system was normal. Examination of the abdomen found no organomegaly or ascites. The neurological examination was also unremarkable. Her white blood cell count was normal (8.3×109/L; reference range 4.0-11.0) and erythrocyte sedimentation rate was 77 mm during the first hour (0-20). Results of extensive laboratory testing (infection, immunology, and biochemistry) were otherwise unrevealing. Enzyme linked immunoassay for HIV was negative.