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The management of chylothorax remains challenging given the limited evidence and significant heterogeneity in practice. In addition, there are no practical guidelines on the optimal approach to manage this complex condition. We convened an international group of 27 experts from 20 institutions across five countries and 4 specialties (Pulmonary, Interventional Radiology, Thoracic Surgery & Nutrition) with experience and expertise in managing adult patients with chylothorax. We performed a literature and internet search for reports addressing 7 clinically relevant questions pertaining to the management of adult patients with chylothorax. This consensus statement, consisting of best practice statements based on expert consensus addressing these 7 PICO questions, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience. Panel members participated in the development of the final best practice statements using the modified Delphi technique. Our consensus statement aims to offer guidance in clinical decision making when managing patients with chylothorax while also identifying gaps in knowledge and inform future research., (Copyright ©The authors 2024. For reproduction rights and permissions contact permissions@ersnet.org.)

Background: Accurate assessment of the probability of lung cancer (pCA) is critical in patients with pulmonary nodules (PNs) to help guide decision-making. We sought to validate a clinical-genomic classifier developed using whole-transcriptome sequencing of nasal epithelial cells from patients with a PN ≤ 30 mm who smoke or have previously smoked., Research Question: Can the pCA in individuals with a PN and a history of smoking be predicted by a classifier that uses clinical factors and genomic data from nasal epithelial cells obtained by cytologic brushing?, Study Design and Methods: Machine learning was used to train a classifier using genomic and clinical features on 1,120 patients with PNs labeled as benign or malignant established by a final diagnosis or a minimum of 12 months of radiographic surveillance. The classifier was designed to yield low-, intermediate-, and high-risk categories. The classifier was validated in an independent set of 312 patients, including 63 patients with a prior history of cancer (other than lung cancer), comparing the classifier prediction with the known clinical outcome., Results: In the primary validation set, sensitivity and specificity for low-risk classification were 96% and 42%, whereas sensitivity and specificity for high-risk classification was 58% and 90%, respectively. Sensitivity was similar across stages of non-small cell lung cancer, independent of subtype. Performance compared favorably with clinical-only risk models. Analysis of 63 patients with prior cancer showed similar performance as did subanalyses of patients with light vs heavy smoking burden and those eligible for lung cancer screening vs those who were not., Interpretation: The nasal classifier provides an accurate assessment of pCA in individuals with a PN ≤ 30 mm who smoke or have previously smoked. Classifier-guided decision-making could lead to fewer diagnostic procedures in patients without cancer and more timely treatment in patients with lung cancer., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: J. H., J. D., M. J., W. A. B., and L. R. L. are employees of Veracyte, Inc, which developed the test; P. S. W. and G. C. K. are former employees. A. S. is an employee of Johnson & Johnson, Inc. M. M. W., C. R., D. J. F.-K., and C. R. L. have been the recipients of honoraria from Veracyte, Inc. None declared (K. M. R.-C., P. J. M.)., (Copyright © 2024. Published by Elsevier Inc.)

Malignant pleural effusions (MPE) have historically been associated with a poor prognosis, and patients often require a series of invasive procedures and hospitalizations that significantly reduce quality of life at the terminus of life. However, advances in the management of MPE have coincided with the era of immunotherapies, and to a lesser extent, antiangiogenic therapies for the treatment of lung cancer. Landmark studies have shown these drugs to improve overall survival and progression-free survival in patients with lung cancer, but a paucity of phase III trial data exists for the impact of immune checkpoint inhibitors (ICI) on lung cancers associated with MPE. This review will focus on the leading studies investigating the impact of ICI and antiangiogenic therapies in patients with lung cancer and MPE. The diagnostic and prognostic values of vascular endothelial growth factor and endostatin expression levels in malignancy will also be discussed. These advancements are changing the paradigm of MPE management from palliation to treatment for the first time since 1767 when MPE was first reported. The future holds the promise of durable response and extended survival in patients with MPE., Competing Interests: None declared., (Thieme. All rights reserved.)

Diagnostic testing is fundamental to medicine. However, studies of diagnostic testing in respiratory medicine vary significantly in terms of their methodology, definitions, and reporting of results. This has led to often conflicting or ambiguous results. To address this issue, a group of 20 respiratory journal editors worked to develop reporting standards for studies of diagnostic testing based on a rigorous methodology to guide authors, peer reviewers, and researchers when conducting studies of diagnostic testing in respiratory medicine. Four key areas are covered, including defining the reference standard of truth, measures of dichotomous test performance when used for dichotomous outcomes, measures of multichotomous test performance for dichotomous outcomes, and what constitutes a useful definition of diagnostic yield. The importance of using contingency tables for reporting results is addressed with examples from the literature. A practical checklist is provided as well for reporting studies of diagnostic testing., Competing Interests: Disclosure: D.E.O.: Research grant Intuitive Surgical, UpToDate author; prior ABIM test writing committee pulmonary medicine. D.F.K.: consulting fees from NOAH Medical, Boston Scientific and I am an Associate Editor for UpToDate. The remaining authors declare no conflict of interest or other disclosures., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

A new era in guideline creation began in 2011 with publication of the Institute of Medicine (now the National Academy of Medicine) Standards for Developing Trustworthy Clinical Practice Guidelines. The American Thoracic Society (ATS) was committed to developing guidelines in accordance with the new standards and decided that an experienced guideline methodologist would be required on ATS guideline projects to ensure correct implementation of the standards. The ATS Guideline Methodology Training Program was launched to increase the pool of trained methodologists. Each year, accepted trainees (methodology scholars) attend a workshop that introduces them to the terminology and process of guideline development and are given the option of participating in a guideline project. Scholars work with the mentorship of a lead methodologist to conduct and then present a systematic review to the guideline committee, discuss the evidence, and participate in the development of evidence-based graded recommendations. Scholars have participated in 22 ATS guidelines over the past 9 years, and most remain engaged in guideline development. For the past 2 years, the methodological aspects of all ATS guideline projects were led by graduates of the training program, and several scholars have accepted positions to lead guidelines for other professional societies. Guideline methodology is particularly suitable for clinician educators because the work is clinically oriented, and guidelines confer high academic capital. Those who elect not to continue in guideline development still acquire the skills to perform and publish systematic reviews, as well as to educate trainees in reading and reviewing literature., (Copyright © 2022 by the American Thoracic Society.)

Introduction: Malignant pleural effusions (MPEs) are common. MPE causes significant breathlessness and impairs quality of life. Indwelling pleural catheters (IPC) allow ambulatory drainage and reduce hospital days and re-intervention rates when compared to standard talc slurry pleurodesis. Daily drainage accelerates pleurodesis, and talc instillation via the IPC has been proven feasible and safe. Surgical pleurodesis via video-assisted thoracoscopic surgery (VATS) is considered a one-off intervention for MPE and is often recommended to patients who are fit for surgery. The AMPLE-3 trial is the first randomised trial to compare IPC (±talc pleurodesis) and VATS pleurodesis in those who are fit for surgery., Methods and Analysis: A multi-centre, open-labelled randomised trial of patients with symptomatic MPE, expected survival of ≥ 6 months and good performance status randomised 1:1 to either IPC or VATS pleurodesis. Participant randomisation will be minimised for (i) cancer type (mesothelioma vs non-mesothelioma); (ii) previous pleurodesis (vs not); and (iii) trapped lung, if known (vs not). Primary outcome is the need for further ipsilateral pleural interventions over 12 months or until death, if sooner. Secondary outcomes include days in hospital, quality of life (QoL) measures, physical activity levels, safety profile, health economics, adverse events, and survival. The trial will recruit 158 participants who will be followed up for 12 months., Ethics and Dissemination: Sir Charles Gairdner and Osborne Park Health Care Group (HREC) has approved the study (reference: RGS356). Results will be published in peer-reviewed journals and presented at scientific meetings., Discussion: Both IPC and VATS are commonly used procedures for MPE. The AMPLE-3 trial will provide data to help define the merits and shortcomings of these procedures and inform future clinical care algorithms., Trial Registration: Australia New Zealand Clinical Trial Registry ACTRN12618001013257 . Registered on 18 June 2018., Protocol Version: Version 3.00/4.02.19., (© 2022. The Author(s).)

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.

Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered for tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

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 drainage, daily drainage, or talc instillation through the IPC (IPC + talc). The relative cost-effectiveness of one strategy over the other is unknown. Objectives: We performed a decision tree model-based analysis to ascertain the cost-effectiveness of each IPC drainage strategy from a healthcare system perspective. Methods: We developed a decision tree model using theoretical event probability data derived from three randomized clinical trials and used 2019 Medicare reimbursement data for cost estimation. The primary outcome was incremental cost-effectiveness ratio (ICER) over an analytical horizon of 6 months with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY). Monte Carlo probabilistic sensitivity analysis and one-way sensitivity analyses were conducted to measure the uncertainty surrounding base case estimates. Results: IPC + talc was a cost-effective alternative to symptom-guided drainage, with an ICER of $59,729/QALY. Monte Carlo probabilistic sensitivity analysis revealed that this strategy was favored in 54% of simulations. However, symptom-guided drainage was cost effective for pleurodesis rates >20% and for life expectancy <4 months. Daily drainage was not cost effective in any scenario, including for patients with nonexpandable lung, in whom it had an ICER of $2,474,612/QALY over symptom-guided drainage. Conclusions: For patients with malignant pleural effusion and an expandable lung, IPC + talc may be cost effective relative to symptom-guided drainage, although considerable uncertainty exists around this estimation. Daily IPC drainage is not a cost-effective strategy under any circumstance.

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., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Video game playing requires many of the same skill sets as medical procedures such as bronchoscopy. These include visual-spatial awareness, rapid decision making, and psychomotor skills. The role of video game cross-training on learning bronchoscopy is unknown. Objective: We studied the association of baseline video gaming experience with, and the impact of short-term video game playing on, visual-spatial awareness and acquisition of basic bronchoscopic skills among medical trainees. Methods: Bronchoscopy-naive medical trainees underwent formal didactic and hands-on instruction on basic bronchoscopy, along with a baseline assessment measuring bronchoscopic and visual-spatial skills. Half of the subjects were subsequently randomized to playing a videogame (Rocket League) for 8 weeks. All participants returned at 4 weeks for a refresher course and at 8 weeks for a final assessment. Results: Thirty subjects completed the study, 16 of them in the intervention arm who all met the minimum video game playing time requirement. At baseline, video game players had significantly lower airway collision rates (6.82 collisions/min vs. 11.64 collisions/min; P  = 0.02) and higher scores on the Purdue Visual Spatial Test: Visualization of Rotations test (27.5 vs. 23.54; P  = 0.04). At completion, the intervention group had no significant differences in airway collisions, bronchoscopy time, or Bronchoscopy Skills and Tasks Assessment Tool scores. There was moderate correlation between airway collision rate and mean Purdue Visual Spatial Test: Visualization of Rotations score (Spearman's rho, -0.59; P  < 0.001). Conclusion: At baseline, learners with former video game-playing experience have higher visual-spatial awareness and fewer airway collisions. The impact of video game playing as an aid to simulation-based bronchoscopic education is uncertain., (Copyright © 2020 by the American Thoracic Society.)

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., (© 2020 S. Karger AG, Basel.)

Background: This Guideline, a collaborative effort from the American Thoracic Society, Society of Thoracic Surgeons, and Society of Thoracic Radiology, aims to provide evidence-based recommendations to guide contemporary management of patients with a malignant pleural effusion (MPE)., Methods: A multidisciplinary panel developed seven questions using the PICO (Population, Intervention, Comparator, and Outcomes) format. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the Evidence to Decision framework was applied to each question. Recommendations were formulated, discussed, and approved by the entire panel., Results: The panel made weak recommendations in favor of: 1) using ultrasound to guide pleural interventions; 2) not performing pleural interventions in asymptomatic patients with MPE; 3) using either an indwelling pleural catheter (IPC) or chemical pleurodesis in symptomatic patients with MPE and suspected expandable lung; 4) performing large-volume thoracentesis to assess symptomatic response and lung expansion; 5) using either talc poudrage or talc slurry for chemical pleurodesis; 6) using IPC instead of chemical pleurodesis in patients with nonexpandable lung or failed pleurodesis; and 7) treating IPC-associated infections with antibiotics and not removing the catheter., Conclusions: These recommendations, based on the best available evidence, can guide management of patients with MPE and improve patient outcomes.

Background: Widespread use of talc pleurodesis remains controversial for many providers concerned by adverse events such as respiratory failure, which are sometimes fatal. Particle talc size has been implicated in these adverse effects, mainly on the basis of animal studies utilizing large amounts of talc or in observational studies performed on different continents with different talc preparations and doses. Our aim was to determine the particle size and distribution of only the commercially available US-talc preparations and whether the fluid content can affect this distribution., Methods: Commercially available US talc was evaluated under scanning electron microscopy and dynamic light scattering (DLS). Distribution of talc particle size was obtained in saline and various protein-based solutions., Results: Talc particle size by DLS was performed with commercially available Sterile Talc Powder and Sclerosol Intrapleural Aerosol. Sterile Talc Powder demonstrated a median diameter of 26.57 μm with a range of particle sizes from 0.399 μm to 100.237 μm. Sclerosol demonstrated a median diameter of 24.49 μm with a range of particle sizes from 0.224 μm to 100.237 μm. The exposure of talc to a protein rich environment (bovine serum albumin and human pleural fluid) led to the development of measureable, new, larger aggregated particle (>100 μm)., Conclusions: Currently available US talc seems to have size characteristics similar to previous described "graded" talc preparations. The exposure of talc to a protein rich environment seems to modify the overall distribution of talc particle size when examined by DLS.

Background: In evaluating patients with suspected lung cancer, it is important to not only obtain a tissue diagnosis, but also to obtain enough tissue for both histologic and molecular analysis in order to appropriately stage the patient with a safe and efficient strategy. The diagnostic approach may often be dependent on local resources and practice patterns rather than current guidelines. We Describe lung cancer staging at two large academic medical centers to identify the impact different procedural approaches have on patient outcomes., Methods: We conducted a retrospective cohort study of all patients undergoing a lung cancer diagnostic evaluation at two multidisciplinary centers during a 1-year period. Identifying complication rates and the need for multiple biopsies as our primary outcomes, we developed a multivariate regression model to determine features associated with complications and need for multiple biopsies., Results: Of 830 patients, 285 patients were diagnosed with lung cancers during the study period. Those staged at the institution without an endobronchial ultrasound (EBUS) program were more likely to require multiple biopsies (OR 3.62, 95% CI: 1.71-7.67, P=0.001) and suffer complications associated with the diagnostic procedure (OR 10.2, 95% CI: 3.08-33.58, P<0.001). Initial staging with transthoracic needle aspiration (TTNA) and conventional bronchoscopy were associated with greater need for subsequent biopsies (OR 8.05 and 14.00, 95% CI: 3.43-18.87 and 5.17-37.86, respectively) and higher complication rates (OR 37.75 and 7.20, 95% CI: 10.33-137.96 and 1.36-37.98, respectively)., Conclusions: Lung cancer evaluation at centers with a dedicated EBUS program results in fewer biopsies and complications than at multidisciplinary counterparts without an EBUS program., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Purpose: Few guidelines exist regarding the selection of a particular type or size of tracheostomy tube. Although nonstandard tubes can be placed over the percutaneous kit dilator, clinicians often place standard tracheostomy tubes and change to nonstandard tubes only after problems arise. This practice risks early tracheostomy tube change, possible bleeding, or loss of the airway. We sought to identify predictors of nonstandard tracheostomy tubes., Materials and Methods: In this matched case-control study at an urban, academic, tertiary care medical center, we reviewed 1220 records of patients who received a tracheostomy. Seventy-seven patients received nonstandard tracheostomy tubes (cases), and 154 received standard tracheostomy tubes (controls)., Results: Sex, endotracheal tube size, severity of illness, and computed tomography scan measurement of the distance from the trachea to the skin at the level of the superior aspect of the anterior clavicle were significant predictors of nonstandard tracheostomy tubes. Specifically, trachea-to-skin distance >4.4 cm and endotracheal tube sizes ≥8.0 were associated with nonstandard tracheostomy., Conclusions: The findings suggest that clinicians should consider using nonstandard tracheostomy tubes as the first choice if the patient is male with an endotracheal tube size ≥8.0 and has a trachea-to-skin distance >4.4 cm on the computed tomography scan., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Rationale: The Hirsch index (h-index) has been validated as a measure of academic productivity and may be an appropriate tool to assess the scholarly activity of interventional pulmonology (IP)., Objectives: This study aimed to elucidate the factors associated with increasing h-index scores among IP training programs., Methods: A cross-sectional study was conducted of IP training programs across the United States and Canada. Data, including their respective h-index, number of publications, academic rank, geographic location, and possession of an advanced degree, were collected on IP faculty and fellows from 23 teaching institutions., Measurements and Main Results: Ninety-three IP physicians (48 faculty, 45 fellows) in all were included in the study from 23 institutions with a total of 101 data points. The faculty h-index mean was 3.88. The proportion of faculty with an h-index greater than the mean value was increased significantly with higher academic rank (P < 0.0001). In addition, physicians holding an advanced degree beyond an M.D./D.O. had a significantly higher h-index than did those without (P = 0.0062)., Conclusions: For academic interventional pulmonologists, the h-index rises with increasing academic rank and possession of an advanced degree. The h-index for IP is roughly comparable to that for other surgical and procedural-based specialties.

Background: Endobronchial ultrasound (EBUS) was introduced in the last decade, enabling real-time guidance of transbronchial needle aspiration (TBNA) of mediastinal and hilar structures and parabronchial lung masses. The many publications produced about EBUS-TBNA have led to a better understanding of the performance characteristics of this procedure. The goal of this document was to examine the current literature on the technical aspects of EBUS-TBNA as they relate to patient, technology, and proceduralist factors to provide evidence-based and expert guidance to clinicians., Methods: Rigorous methodology has been applied to provide a trustworthy evidence-based guideline and expert panel report. A group of approved panelists developed key clinical questions by using the PICO (population, intervention, comparator, and outcome) format that addressed specific topics on the technical aspects of EBUS-TBNA. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and well-recognized document evaluation tools were used to assess the quality of included studies, to extract meaningful data, and to grade the level of evidence to support each recommendation or suggestion., Results: Our systematic review and critical analysis of the literature on 15 PICO questions related to the technical aspects of EBUS-TBNA resulted in 12 statements: 7 evidence-based graded recommendations and 5 ungraded consensus-based statements. Three questions did not have sufficient evidence to generate a statement., Conclusions: Evidence on the technical aspects of EBUS-TBNA varies in strength but is satisfactory in certain areas to guide clinicians on the best conditions to perform EBUS-guided tissue sampling. Additional research is needed to enhance our knowledge regarding the optimal performance of this effective procedure., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Malignant pleural effusion (MPE) is associated with a significant impact on health-related quality of life. Palliative interventions abound, with varying costs and degrees of invasiveness. We examined the relative cost-utility of 5 therapeutic alternatives for MPE among adults., Methods: Original studies investigating the management of MPE were extensively researched, and the most robust and current data particularly those from the TIME2 trial were chosen to estimate event probabilities. Medicare data were used for cost estimation. Utility estimates were adapted from 2 original studies and kept consistent with prior estimations. The decision tree model was based on clinical guidelines and authors' consensus opinion. Primary outcome of interest was the incremental cost-effectiveness ratio for each intervention over a less effective alternative over an analytical horizon of 6 months. Given the paucity of data on rapid pleurodesis protocol, a sensitivity analysis was conducted to address the uncertainty surrounding its efficacy in terms of achieving long-term pleurodesis., Results: Except for repeated thoracentesis (RT; least effective), all interventions had similar effectiveness. Tunneled pleural catheter was the most cost-effective option with an incremental cost-effectiveness ratio of $45,747 per QALY gained over RT, assuming a willingness-to-pay threshold of $100,000/QALY. Multivariate sensitivity analysis showed that rapid pleurodesis protocol remained cost-ineffective even with an estimated probability of lasting pleurodesis up to 85%., Conclusions: Tunneled pleural catheter is the most cost-effective therapeutic alternative to RT. This, together with its relative convenience (requiring neither hospitalization nor thoracoscopic procedural skills), makes it an intervention of choice for MPE.

Background: Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging., Methods: We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge., Results: Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained., Conclusions: DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

Rationale: The indwelling tunneled pleural catheter has altered the management of patients with dyspnea related to malignant pleural effusions. However, indwelling tunneled pleural catheter placement does not remain free from risk. The most commonly reported risk is infection., Objectives: The aim of this paper is to describe our continuous quality improvement program for infection rate recognition, the process changes implemented for improvement, and subsequent outcomes., Methods: All patients undergoing indwelling tunneled pleural catheter placement at The Johns Hopkins Medical Institutions between May 2009 and April 2014 were identified. The primary outcome was the incidence of infection within the preintervention and intervention cohorts. Intervention was identified as use of preoperative antibiotics, full sterile draping, and limiting placement to a single defined location., Measurements and Main Results: A total of 225 indwelling tunneled pleural catheter placements were performed in 201 patients during the study period, and the overall infection rate was 5.8%. During the preintervention period, 134 placements were performed, and 91 placements occurred during the intervention period. A preintervention infection rate was identified as 8.2%, with a significant decrease to 2.2% (P = 0.049) within the intervention cohort., Conclusions: The use of a continuous quality improvement program to review indwelling tunneled pleural catheter practices can result in the identification of infectious complications and lead to implementation of measures to improve patient outcomes.

The clinical practice of pulmonary and critical care medicine requires procedural competence in many technical domains, including vascular access, airway management, basic and advanced bronchoscopy, pleural procedures, and critical care ultrasonography. Simulation provides opportunities for standardized training and assessment in procedures without placing patients at undue risk. A growing body of literature supports the use and effectiveness of low-fidelity and high-fidelity simulators for procedural training and assessment. In this manuscript by the Skills-based Working Group of the American Thoracic Society Education Committee, we describe the background, available technology, and current evidence related to simulation-based skills training within pulmonary and critical care medicine. We outline working group recommendations for key procedural domains.

Objective: To develop and validate a new instrument for measuring health-related quality of life in mechanically ventilated patients in the ICU., Design: Expert panel consensus and a prospective longitudinal survey., Setting: Urban, academic, tertiary care medical center., Patients: One hundred fifteen awake, mechanically ventilated, ICU patients who either received a tracheostomy or remained endotracheally intubated., Interventions: A new quality-of-life instrument was developed and validated by using pilot study data; informal interviews of patients, families, and nurses; expert panel consensus; and item analyses. The new instrument was used to measure quality of life at three time points (5 d, 10 d, and 15 d after intubation)., Measurements and Main Results: A new 12-item quality-of-life questionnaire for mechanically ventilated patients was developed. Patients' responses to the quality-of-life questionnaire revealed moderate-to-high correlations with EuroQol scores (r = -0.4 to -0.9) and the EuroQol Visual Analog Scale (r = 0.6-0.9) across the three times and a moderate correlation with the Sequential Organ Failure Assessment tool (r = 0.5) at 10 days after intubation. Cronbach α ranged from 0.80 to 0.94 across the three times. The quality-of-life questionnaire for mechanically ventilated patients was responsive to changes in treatment modalities (tracheostomy vs no tracheostomy and early vs late tracheostomy demarcated by 10 d of intubation). Exploratory factor analysis revealed that this instrument was unidimensional in nature., Conclusions: The new quality-of-life questionnaire for mechanically ventilated patients is valid and can reliably measure quality of life in mechanically ventilated ICU patients. It may provide clinicians with an accurate assessment of patients' quality of life and facilitate optimal decision making regarding patients' ICU plan of care.

Objectives/hypothesis: To develop and assess the feasibility of a new standardized protocol to guide tracheostomy decannulation., Study Design: Descriptive review of quality improvement project., Methods: A quality improvement project was conducted in the inpatient setting of a tertiary urban academic hospital. Adult patients who had received a tracheostomy and for whom the indication for tracheostomy had resolved were included. A multidisciplinary task force reviewed input from clinicians caring for tracheostomy patients and developed a protocol for screening, capping, and decannulation. The primary outcome measured was successful decannulation., Results: Fifty-seven patients were screened for a capping trial over a 12-month period; 54 were capped. Six patients were lost to follow-up. Fifty patients passed the capping trial, and all 50 were decannulated successfully. When decannulation was pursued in one patient who had twice failed the screening criteria and subsequent capping trials, the patient failed decannulation and ultimately required reintubation for the management of secretions. The screening tool had high sensitivity (90%) and positive predictive value (100%) for successful decannulation. Additionally, the number of reported patient safety concerns decreased from seven in the 6 months preceding implementation of the program to one report in the 6 months after implementation., Conclusion: The new tracheostomy capping and decannulation protocol assisted in predicting both successful and failed decannulation. Although several patients failed certain capping criteria initially, the protocol stipulated modifications of care that enabled successful decannulation. The screening tool had high sensitivity and promoted communication, standardization of practice, and patient safety., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: To describe the types of talking tracheostomy tubes available, present four case studies of critically ill patients who used a specialized tracheostomy tube to improve speech, discuss their advantages and disadvantages, propose patient selection criteria, and provide practical recommendations for medical care providers., Methods: Retrospective chart review of patients who underwent tracheostomy in 2010., Results: Of the 220 patients who received a tracheostomy in 2010, 164 (74.55%) received a percutaneous tracheostomy and 56 (25.45%) received an open tracheostomy. Among the percutaneous tracheostomy patients, speech-language pathologists were consulted on 113 patients, 74 of whom were on a ventilator. Four of these 74 patients received a talking tracheostomy tube, and all four were able to speak successfully while on the mechanical ventilator even though they were unable to tolerate cuff deflation., Conclusions: Talking tracheostomy tubes allow patients who are unable to tolerate-cuff deflation to achieve phonation. Our experience with talking tracheostomy tubes suggests that clinicians should consider their use for patients who cannot tolerate cuff deflation.

The proliferation of endobronchial ultrasound as the standard of care in lymph node sampling has significantly impacted the way fellows are trained in transbronchial needle aspiration (TBNA). To assess the impact of starting an endobronchial ultrasound (EBUS) program on fellows training of conventional TBNA (cTBNA), we reviewed all TBNAs performed at the Johns Hopkins Hospital from September 2006 until December of 2009. The number of nodes sampled, specimen adequacy, diagnostic yield, and fellow involvement were recorded. We found that the initiation of an EBUS program was associated with a significantly increased number of cases performed, as well as a significantly higher diagnostic yield, when compared with cTBNA. There was an associated significant decline in the number of cTBNA procedures performed by the pulmonary fellows, as well as the diagnostic yield and accuracy, when compared with EBUS. As interventional pulmonology fellowships and the overall use of EBUS become more prevalent, institutions will need to consider how to train their fellows in lymph node sampling.

Background: Physicians are increasingly encountering lung nodules in their practice, and tissue diagnosis is often required. Conventional bronchoscopic sampling yields a range from 14% to 69% depending on the nodule size and location within the lung. We aimed to evaluate the diagnostic yield of electromagnetic navigation bronchoscopy (ENB) in multiple centers and to determine what factors affect the yield of ENB., Methods: A retrospective analysis of 92 consecutive ENB procedures at 5 centers was carried out. Data were collected on patient demographics, nodule characteristics, complications, type of samples obtained, diagnosis, and follow-up studies. Variables were analyzed to determine as to which factors had an impact on the diagnostic yield with multiple logistic regression analysis., Results: Ninety-two patients underwent EMB at 5 centers between December 2008 and October 2009. The average nodule size was 2.61 cm (SD 1.42) at a distance of 1.81 cm (SD 1.32) from the pleural surface. The overall yield for ENB-guided sampling of pulmonary nodules was 65% (60/92). The ENB yield for nodules ≤2 versus >2 cm in size was significantly less after controlling for the distance from the pleura (50% vs. 76%, respectively; P=0.01). The distance from the pleura did not affect the ENB diagnostic yield after controlling for nodule size (P=0.92). The lobar location of the nodule also did not affect the diagnostic yield (P=0.59)., Conclusions: The diagnostic yield of ENB-guided sampling of pulmonary nodules is impacted by the nodule size, but not by the distance from the pleura or the lobar location.

Background: One of the greatest challenges facing both practitioners and risk managers is the identification of previously unknown clinical hazards and defects. With the rapid proliferation of new health care services, unknown hazards may propagate as new therapies are integrated into the existing health care system. The main goal of risk analysis is to make these hazards visible by proactively searching and probing the system. Yet, a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated. Patient care teams can use the proposed framework when introducing new therapies., A Practical Framework: The framework includes a background investigation and literature search; an in situ simulation (in the actual clinical setting used for patients); a Failure Mode and Effects Analysis to determine the severity, probability, and risk of the potential hazards; and a multidisciplinary protocol and safety checklist to standardize practice and ensure provider accountability., Case Examples: Application of this framework to three operative scenarios--intraoperative radiation therapy (IORT), hyperthermic intraperitoneal chemotherapy (HIPEC), and an interventional pulmonology program--demonstrates its flexibility. Its use prospectively identified and mitigated 20 IORT, 5 HIPEC, and 18 interventional pulmonology hazards/defects. Subsequent patient cases were largely uneventful. All cases and patient safety reporting systems are monitored to identify any new defects in an effort to continuously improve patient care., Conclusion: The use of a comprehensive framework to identify and mitigate hazards in an on-site simulated environment promotes safer care for target patient populations; results in familiarity with procedures, amelioration of staff concerns, and standardization of practice; and facilitates teamwork and communication.

Background: Acquired tracheobronchomalacia (TBM) can cause central airway collapse in patients with COPD and may worsen airflow obstruction and symptoms. It is usually not known whether central airway malacia contributes to airflow obstruction. This study was undertaken to quantify central airway collapsibility and relate it to expiratory flow limitation in patients with TBM., Methods: Eighty patients evaluated for acquired TBM and 4 healthy control subjects were studied with measurements of central airway narrowing derived from bronchoscopic videotapes and simultaneous pressure measurements in the trachea and esophagus. Tracheal narrowing was assessed by a shape index and plotted against the transtracheal pressure to measure collapsibility. Subsequently, airflow and transpulmonary pressure (PL) were measured to identify expiratory flow limitation during quiet breathing and to determine the critical PL required for maximum expiratory flow., Results: Tracheal collapsibility varied widely among patients. Some had profound tracheal narrowing during quiet breathing, and others showed substantial collapse only during forced exhalation. Of the patients, 15% were not flow limited during quiet breathing, 53% were flow limited throughout exhalation, and 30% were flow limited only during the latter part of the exhalation. Patients with flow limitation at rest showed greater tracheal narrowing than those without (p = 0.009), but the severity of expiratory flow limitation was not closely related to tracheal collapsibility. Twenty-three patients were flow limited during quiet exhalation at PLs that did not cause central airway collapse., Conclusions: In TBM, central airway collapse is not closely related to airflow obstruction, and expiratory flow limitation at rest often occurs in peripheral airways without central airway collapse.

Purpose: To retrospectively determine the prevalence of expiratory computed tomographic (CT) abnormalities, including malacia and air trapping, in patients with relapsing polychondritis and to retrospectively determine the frequency with which expiratory abnormalities are accompanied by inspiratory abnormalities on CT scans., Materials and Methods: Institutional review board approval was obtained, and informed consent was not required for this retrospective HIPAA-compliant study. A computerized hospital information system was used to identify all patients with clinically diagnosed or biopsy-proved relapsing polychondritis who were referred for CT airway imaging during a 17-month period. The study cohort comprised 18 patients (15 women, three men; mean age, 47 years; age range, 20-71 years). Multidetector helical CT was performed in all patients by using a standard protocol, which included end-inspiratory and dynamic expiratory volumetric imaging. Two observers who were blinded to the original scan interpretations simultaneously reviewed CT scans. Findings were recorded in consensus. Dynamic expiratory CT scans were assessed for malacia that involved the trachea and main bronchi (reduction in cross-sectional area of more than 50%) and for air trapping (failure of lung parenchyma to increase in attenuation during expiration). Air trapping was visually classified according to pattern and extent (lobular, segmental, lobar, or whole lung). Inspiratory CT scans were evaluated for tracheal and bronchial stenosis (>25% luminal diameter narrowing compared with a corresponding uninvolved segment), wall thickening (>2 mm), and calcification., Results: Expiratory CT abnormalities were present in 17 (94%) of 18 patients and included malacia in 13 patients (72%) and air trapping in 17 patients (94%). Inspiratory CT abnormalities were found in eight (47%) of 17 patients who had expiratory CT abnormalities. Calcification of the airway walls was present in seven (39%) of 18 patients. All patients who had inspiratory CT abnormalities demonstrated expiratory CT abnormalities., Conclusion: Expiratory CT abnormalities were present in the majority of patients with relapsing polychondritis who were referred for airway imaging, yet only half of these patients demonstrated abnormalities on routine inspiratory CT scans. Thus, dynamic expiratory CT should be a standard component of imaging assessment in patients with relapsing polychondritis., (RSNA, 2006)

Purpose: Resident physicians learn to perform inpatient bedside procedures in a manner that is neither standardized nor rigorous. As a result, residents may be unskilled and uncomfortable performing procedures. This study characterizes residents' comfort performing medical procedures and identifies factors associated with lack of comfort., Subjects: Study subjects were internal medicine resident physicians who performed one of four medical procedures (central line, lumbar puncture, paracentesis, or thoracentesis) on adult medical inpatients between July 1, 2003, and June 30, 2004., Methods: This prospective cohort study was conducted at a 556-bed Boston teaching hospital. Resident physicians evaluated their comfort with 9 aspects of 4 medical procedures, recording this information in an electronic log. We also abstracted operator characteristics and patient demographic data. We analyzed residents' comfort with each aspect of the procedure and defined "overall comfort" as comfort with each of the 9 aspects., Results: A majority of resident physicians reported lack of comfort with at least one aspect of the procedure. Residents reported lack of comfort with 37% of unsupervised procedures. They also reported lack of comfort with the prospect of managing complications in 35% of procedures. In the multivariable analysis, overall comfort was associated with the use of a dedicated medical procedure service (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.4) and inversely associated with postgraduate year 1 status (OR 0.3, CI 0.1-0.5), first time performing the procedure (OR 0.4, CI 0.2-0.8), thoracenteses (OR 0.4, CI 0.2-0.8), and emergent procedures (OR 0.6, CI 0.3-1.0)., Conclusions: Many resident physicians are uncomfortable performing common bedside procedures. Experience and supervision mitigate some, but not all, discomfort.