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The aim of our study was to describe the incidence of infectious complications of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) and to analyze the potential risk factors in a prospective cohort of patients.We conducted a prospective multicenter study, with all consecutive patients referred for an EBUS-TBNA with patients at risk of developing an infectious complication (considering10 nodal samplings, known immunosuppression, bronchial colonization and cavitated or necrotic lesions) and a second group without any risk factor.Three hundred seventy patients were included: 245 with risk factors and 125 without risk factors (as the control group). Overall, 15 patients (4.05%) presented an acute infectious complication: fourteen in cases (5.7%) and 1 in controls (0.8%). Of these, 4 patients presented pneumonia, 1 mediastinitis, 4 obstructive pneumonitis and 6 mild complications (respiratory tract infection that resolved with antibiotic). Also 7 (1.9%) patients had self-limited fever. One-month follow-up showed 1 mediastinitis at sixteenth day post-EBUS, which required surgical treatment, and 3 pneumonias and 3 respiratory tract infections at nineteenth day (1.9%). All patients had a good evolution and there were no deaths related with infectious complication. We observed an increased risk of complication in patients with risk factors and in patients with necrosis (p=0.018).The incidence of infectious complications in a subgroup of patients with risk factors was higher than in patients without risk factors. Nevertheless, it remains low, and no fatal complication occurred, which reinforces the idea that EBUS-TBNA is a safe technique for the assessment of the mediastinum. Necrotic lesions are a risk factor of post-EBUS infection, and their puncture should be avoided.

Resumen Introduccion Analizar las caracteristicas clinico-patologicas de los pacientes operados por nodulo pulmonar solitario (NPS) y 18F-FDG PET-TC integrado tras su reseccion quirurgica. Material y metodos Estudio retrospectivo sobre una base de datos prospectiva de pacientes operados entre enero-2007 y octubre-2017 por NPS sin diagnostico preoperatorio. La variable dependiente fue el resultado anatomopatologico (benigno vs. maligno) del NPS. Las variables del estudio fueron: edad, sexo, captacion en PET-TC, SUVmax, tabaquismo, EPOC, antecedente de tumoracion maligna previa, localizacion del tumor y tamano en la TC. Resultados Un total de 305 pacientes fueron incluidos en el estudio, 225 (73,8%) varones, 80 (26,2%) mujeres, edad media = 63,9 (rango 29-86 anos), tamano medio NPS = 1,68 (d.t. 0,65 cm), benignos = 46 (15,1%), malignos = 258 (84,6%), tipo de reseccion: cuna = 151 (49,5%), lobectomia = 141 (46,2%), segmentectomia = 12 (3,9%), exploradora = 1 (0,3%). La mortalidad postoperatoria fue del 1,9%. EPOC = 50,8% casos, cancer previo = 172 casos (56,4%), tabaquismo = 250 casos (82%), PET positiva = 280 casos (91,8%), NPS en campos superiores = 204 casos (66,9%), SUVmax mediana = 3,4 (rango 0-20,7). El modelo de regresion logistica binaria por pasos hacia atras mostro que la edad, SUVmax, enfermedad maligna previa y sexo femenino fueron factores de riesgo independientes con significacion estadistica (p La sensibilidad, especificidad, el valor predictivo positivo, el valor predictivo negativo y la seguridad diagnostica fueron 94,6%, 23,4%, 87,1%, 44% y 83,6%, respectivamente. Hubo un total de 14 casos falsos negativos (4,6%) y 36 casos falsos positivos (11,8%). Conclusiones La edad, el SUVmax, antecedentes de enfermedad maligna previa y sexo femenino fueron factores de riesgo independientes en nuestro estudio. Cada caso debe ser evaluado de forma individual en un comite multidisciplinario y atender las inquietudes o preferencias de cada paciente. Hay que tener en cuenta que la opcion quirurgica no esta exenta de morbimortalidad, incluso en resecciones sublobares o en cuna.

BackgroundThe role of bronchoscopy in coronavirus disease 2019 (COVID-19) is a matter of debate.Patients and methodsThis observational multicentre study aimed to analyse the prognostic impact of bronchoscopic findings in a consecutive cohort of patients with suspected or confirmed COVID-19. Patients were enrolled at 17 hospitals from February to June 2020. Predictors of in-hospital mortality were assessed by multivariate logistic regression.ResultsA total of 1027 bronchoscopies were performed in 515 patients (age 61.5±11.2 years; 73% men), stratified into a clinical suspicion cohort (n=30) and a COVID-19 confirmed cohort (n=485). In the clinical suspicion cohort, the diagnostic yield was 36.7%. In the COVID-19 confirmed cohort, bronchoscopies were predominantly performed in the intensive care unit (n=961; 96.4%) and major indications were: difficult mechanical ventilation (43.7%), mucus plugs (39%) and persistence of radiological infiltrates (23.4%). 147 bronchoscopies were performed to rule out superinfection, and diagnostic yield was 42.9%. There were abnormalities in 91.6% of bronchoscopies, the most frequent being mucus secretions (82.4%), haematic secretions (17.7%), mucus plugs (17.6%), and diffuse mucosal hyperaemia (11.4%). The independent predictors of in-hospital mortality were: older age (OR 1.06; pConclusionBronchoscopy may be indicated in carefully selected patients with COVID-19 to rule out superinfection and solve complications related to mechanical ventilation. The presence of haematic secretions in the distal bronchial tract may be considered a poor prognostic feature in COVID-19.

Resumen Este documento de consenso esta elaborado por el area de Tecnicas y Trasplante y el area de Enfermeria de la Sociedad Espanola de Neumologia y Cirugia Toracica, asi como por la Asociacion Espanola de Endoscopia Respiratoria, con el objetivo de proporcionar conocimientos para el uso efectivo y seguro de la broncoscopia en pacientes con sospecha o con confirmacion de la infeccion por COVID-19. Es prioritario proporcionar la mayor seguridad a nuestros pacientes, a los sanitarios que los atienden y a la comunidad en general. En este momento de pandemia, la informacion de la que disponemos acerca del uso de la broncoscopia en este tipo de pacientes se basa en la experiencia de otros centros y paises, y las publicaciones cientificas son escasas. El objetivo de este documento es recoger esas experiencias y, en base a las recomendaciones de los organismos oficiales, ofrecer un documento de ayuda para la practica clinica diaria.

To analyse clinicopathological characteristics of patients operated for pulmonary solitary nodule (PSN) and 18F-FDG integrated PET-CT scan after surgical resection.Retrospective study on a prospective database of patients operated from January 2007 to October 2017 for PSN without preoperative diagnosis. Dependent variable was anatomopathological result (benign vs malignant) of PSN. Variables of the study were: age, sex, PET-CT uptake, SUVmax, smoking history, COPD, previous history of malignant disease, tumoral location, and tumour size on CT-scan.A total of 305 patients were included in this study, 225 (73.8%) men, 80 (26.2%) women, mean age = 63.9 (range 29-86 years), mean size PSN = 1.68 (s.d. .65 cm), benign = 46 (15.1%), malignant = 258 (84.6%), type of resection: pulmonary wedge = 151 (49.5%), lobectomy = 141 (46.2%), segmentectomy = 12 (3.9%), exploratory intervention = 1 (0.3%). Postoperative mortality was 1.9%. COPD = 50.8% cases, previous cancer disease = 172 cases (56.4%), smoking history = 250 cases (82.0%), positive PET = 280 cases (91.8%), PSN in upper pulmonary fields = 204 cases (66.9%), median SUVmax = 3.4 (range 0-20.7). Backward stepwise binary logistic regression model showed that age, SUVmax, previous malignant disease and female sex were independent risk factors with statistical significance (p.05). Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 94.6%, 23.4%, 87.1%, 44.0%, and 83.6% respectively. There were 14 false negative cases (4.6%) and 36 false positive cases (11.8%).Age, SUVmax, previous malignant disease, and female sex were independent risk factors in our study. Each case should be individually evaluated in a multidisciplinary committee, and the patient's preferences or concerns should be kept in mind in decision-making. Surgical resection of PSN is not exempt from morbidity and mortality, even in sublobar or pulmonary wedge resection.

Aims: The aims of our study were to quantify the incidence of infectious complications in EBUS-TBNA, in a selected group of patients and try to identify the major risk factors. Material/Methods: Prospective + multicentre study, with patients submitted to an EBUS-TBNA. We collected clinical characteristics: presence of necrosis signs in radiology or EBUS image and mediastinal adenopathies evaluation. A post-procedure blood test, bronchoaspirate (BAS), blood cultures and chest X-ray were performed. All these tests repeated 48h late. Results: First 24h: 3 patients presented bacteremia and fever (1 pneumonia, 1 respiratory infection and 1 asymptomatic) and 4 presented fever without bacteremia (1 pneumonia and 3 asymptomatic). 48h: 1 presented fever and bacteremia developing a mediastinitis and 1 presented self-limited fever. After 30 days of follow-up: The rate of infectious complications was 6.4%. We identified a significant increase in white blood cell count (WBC) and C-reactive protein (CRP) in those patients. We analyzed the possible relationship between immunosuppression, the characteristics of the lesions, the number of punctures performed and the appearance of fever in the follow 48h, without significant association. A slight non-significant trend was observed at a higher risk of fever in >10 lymph nodes puncture (OR 3.9 (95% CI 0.80-19.24 p=0.092)), but not in other groups. Conclusions: The average of infectious complications was higher than those described in literature. A subgroup of susceptible patients could be identified. There was an WBC/CRP increase and a non-significant tendency of higher risk of fever in >10 lymph nodes puncture. Supported by SEPAR

Resumen La hemoptisis es la expectoracion de sangre proveniente del arbol traqueobronquial. Las enfermedades que mas frecuentemente la originan son las bronquiectasias, la bronquitis cronica y el carcinoma broncogenico. Las arterias bronquiales son el origen de la mayoria de las hemoptisis. Ante un paciente con sospecha de hemoptisis se debe confirmar su existencia, establecer su gravedad, localizar el origen y determinar su causa. La radiografia de torax posteroanterior y lateral es la primera prueba de imagen que debe realizarse, aunque la existencia de una radiografia de torax normal no excluye la posibilidad de malignidad u otra patologia de base. Debe realizarse TC multidetector (TCMD) de torax en todos los pacientes con hemoptisis franca, en los que presentan esputo hemoptoico y sospecha de bronquiectasias o factores de riesgo de carcinoma broncogenico, y en los que tienen radiografia de torax patologica. La angio-TCMD ha sustituido a la arteriografia como metodo diagnostico de las arterias que son fuente de sangrado en las hemoptisis. La angio-TCMD es una tecnica de imagen no invasiva que identifica correctamente la presencia, el origen, el numero y el trayecto de las arterias sistemicas toracicas, bronquiales y no bronquiales, y de las arterias pulmonares que pueden ser fuente del sangrado. El tratamiento mas seguro y eficaz para detener el sangrado en la mayoria de los casos de hemoptisis masiva o recurrente es la embolizacion endovascular. La embolizacion esta indicada en todos los pacientes con hemoptisis amenazante o recurrente en los que se detectan arterias patologicas en la angio-TCMD. La broncoscopia flexible juega un papel primordial en el diagnostico de la hemoptisis, tanto de la expectoracion hemoptoica como de la hemoptisis franca. Puede ser realizada rapidamente en la cama del paciente (UCI) y, ademas de su utilidad en el control inmediato de la hemorragia, tiene una alta rentabilidad en la localizacion del sangrado. La broncoscopia flexible es el procedimiento inicial de eleccion en pacientes con hemoptisis amenazante e inestabilidad hemodinamica, donde el control de la hemorragia es vital. La cirugia en estos casos tiene una tasa de mortalidad muy alta, por lo que la indicacion actual de cirugia en la hemoptisis amenazante esta reservada para aquellas situaciones en las que la causa de la misma sea tributaria de tratamiento quirurgico y haya una localizacion concreta y fiable del origen de la hemorragia.

Hemoptysis is the expectoration of blood from the tracheobronchial tree. It is commonly caused by bronchiectasis, chronic bronchitis, and lung cancer. The expectorated blood usually originates from the bronchial arteries. When hemoptysis is suspected, it must be confirmed and classified according to severity, and the origin and cause of the bleeding determined. Lateral and AP chest X-ray is the first study, although a normal chest X-ray does not rule out the possibility of malignancy or other underlying pathology. Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis or risk factors for lung cancer, and in those with signs of pathology on chest X-ray. MDCT angiography has replaced arteriography in identifying the arteries that are the source of bleeding. MDCT angiography is a non-invasive imaging technique that can pinpoint the presence, origin, number and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding. Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis. Embolization is indicated in all patients with life-threatening or recurrent hemoptysis in whom MDCT angiography shows artery disease. Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis in patients with hemoptoic sputum or frank hemoptysis. The procedure can be performed rapidly at the bedside (intensive care unit); it can be used for immediate control of bleeding, and is also effective in locating the source of the hemorrhage. Flexible bronchoscopy is the first-line procedure of choice in hemodynamically unstable patients with life-threatening hemoptysis, in whom control of bleeding is of vital importance. In these cases, surgery is associated with an extremely high mortality rate, and is currently only indicated when bleeding is secondary to surgery and its source can be accurately and reliably located.

Objective Mortality due to lung cancer in Spain is increasing continuously. The aim of the present study was to collect information on the hospital incidence of lung cancer, as well as information on clinical management, in different regions of Spain. Material and methods A prospective observational study of patients diagnosed with lung cancer in 2003 was carried out in 13 centers in 9 autonomous communities. Epidemiological, clinical, diagnostic, and therapeutic variables were assessed. Results Of a total population of 2 726 601 inhabitants (1 346 483 men and 1 380 118 women), 1064 male and 125 female lung cancer patients were included. The incidence standardized to the world population varied between 42.4/100 000 and 61.8/100 000 in men and between 1.5/100 000 and 8.6/100 000 in women. Overall, 51% were aged over 70 years, and 97.5% of the men and 32% of the women were smokers or ex-smokers. Cytologic or histologic confirmation was obtained for 93.1% of the cases (20.8% of which were small cell lung cancers and 79.2% were non-small cell lung cancers). The main initial symptoms were cough, chest pain, and weight loss. In 13.7%, lung cancer was suspected because of abnormal chest x-ray. The percentage with clinical TNM stages I and II ranged from 6.3% to 26.9%. The most common stage was stage IV in all centers. The percentage of patients undergoing surgery ranged from 2.5% to 20.6%, with a mean of 14.8% (19.9% of whom were patients with non-small cell lung cancer); 27% received palliative treatment only. Conclusions The proportion of women suffering from lung cancer increased with respect to previous studies, with notable differences among regions. Despite diagnostic improvements, the percentage of patients undergoing surgery is low, though interregional variation is considerable.

Objetivo La mortalidad por cancer de pulmon en Espana aumenta ininterrumpidamente. El objetivo del presente estudio ha sido conocer su incidencia hospitalaria, asi como otros datos de manejo clinico, en varias regiones espanolas. Material y metodos Se ha realizado un estudio prospective observacional de los pacientes diagnosticados de cancer de pulmon en 2003 en 13 centros de 9 comunidades autonomas. Se evaluaron variables epidemiologicas, clinicas, diagnosticas y terapeuticas. Resultados Se han registrado 1.064 varones y 125 mujeres correspondientes a una poblacion total de 2.726.601 habitantes (1.346.483 varones y 1.380.118 mujeres). Las tasas estandarizadas segun poblacion mundial variaron entre 42,4 y 61,8/100.000 en varones y entre 1,5 y 8,6/100.000 en mujeres. El 51% tenia mas de 70 anos. El 97,5% de los varones y el 32% de las mujeres eran fumadores o ex fumadores. Se obtuvo confirmacion citohistologica en el 93,1% de los casos (un 20,8% microciticos y un 79,2% no microciticos). Los sintomas iniciales predominantes fueron tos, dolor toracico y perdida de peso. En el 13,7% el diagnostico se sospecho solo por anormalidad radiologica. La proporcion de estadios TNM clinicos I y II vario entre el 6,3 y el 26,9%. El estadio IV fue el mas comun en todos los centros. La tasa de intervenciones vario entre el 2,5 y el 20,6%; el promedio fue del 14,8% (un 19,9% del total de no microciticos). El 27,0% solo recibio medidas paliativas. Conclusiones Entre los casos de cancer de pulmon aumenta la proporcion de mujeres con respecto a estudios previos, con notables diferencias interregionales. Pese a las mejoras diagnosticas, la tasa de intervenciones, muy variable entre diferentes centros, es muy baja.

Resumen Se entiende por sindrome posneumonectomia la obstruccion bronquial postoperatoria, causada por un desplazamiento exagerado del mediastino. Este sindrome esta bien documentado en la literatura medica como complicacion tardia de una neumonectomia derecha, pero su produccion tras una reseccion del pulmon izquierdo es excepcional, pues apenas se ha publicado una decena de casos. La fisiopatologia, las manifestaciones clinicas, el pronostico y el tratamiento son similares para ambos lados. Presentamos el caso de un paciente adulto a quien se practico una neumonectomia izquierda y que desarrollo un sindrome posneumonectomia a los 15 meses del postoperatorio. La estenosis del bronquio intermediario se produjo entre el cuerpo vertebral y la arteria pulmonar derecha. Se efectuo eficazmente tratamiento endoscopico con una protesis metalica autoexpandible, con lo cual se observo la remision completa de los sintomas durante los 6 meses de seguimiento.

The current edition of the tumor, node and metastasis (TNM) classification of lung cancer (LC) divides the presence of metastasis (M1) into two categories: M1a and M1b, depending on its anatomical location. To assess this new classification, the survival and the M descriptors of LC patients with metastatic disease registered by the Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pneumology and Thoracic Surgery II (GCCB-S-II), were analyzed.Non-small cell lung cancer (NSCLC) patients, with M1a or M1b disease, included in the GCCB-S-II, from April 2009 to December 2010, staged in accordance with the prospective staging project protocol of the International Association for the Study of Lung Cancer (IASLC), and with complete TNM staging and follow-up data, were studied. The overall survival associated with each M1 category and each M descriptor, besides other prognostic factors (sex, age, performance status [PS] and others) were analyzed by univariate and multivariate models.640 NSCLC patients (195 M1a and 445 M1b) were included. M1b tumors had significantly worse survival than M1a tumors (p0.001). The prognostic value of M1 category was independent from other prognostic variables such as PS, weight loss, and others. The number of metastatic sites (isolated versus multiple) and the number of lesions (single versus multiple) in patients with isolated metastasis showed prognostic value, especially in those with brain metastasis.The current division of the M1 category into two subsets (M1a and M1b) is warranted by their prognostic significance. The number of metastatic sites and the number of lesions in patients with isolated metastasis should be taken into account, because they also have prognostic relevance.

Postpneumonectomy syndrome is characterized by postoperative bronchial obstruction caused by mediastinal shift. The syndrome is well documented in the medical literature as a late complication of right pneumonectomy; however, it rarely occurs following resection of the left lung, and only 10 cases have been published. The pathophysiology, clinical manifestations, prognosis, and treatment are similar for both sides of the lung. We present the case of an adult patient who underwent left pneumonectomy and developed postpneumonectomy syndrome 15 months later. Stenosis of the intermediate bronchus occurred between the vertebral body and the right pulmonary artery. Endoscopic treatment with a self-expanding metal wallstent was successful, and complete remission was observed over the 6 months of follow-up.