Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Dec 2014
ReviewInterventional pulmonology in the intensive care unit: percutaneous tracheostomy and gastrostomy.
Bedside percutaneous tracheostomy and gastrostomy tube placement are cost-effective and safe techniques employed in the management of critically ill patients requiring prolonged mechanical ventilation. Both procedures have been well characterized and studied in the surgical and gastroenterology literature. ⋯ We will discuss the techniques available and the relevant background data regarding choice of method and its integration into clinical practice. In addition, we discuss the creation of a multidisciplinary tracheostomy care team, its effect on patient care, hospital finances, and the interventional pulmonologists role.
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Interventional pulmonology (IP) is a maturing subspecialty of pulmonary medicine focused on advanced diagnostic and therapeutic pulmonary and thoracic medical procedures for a variety of illnesses. This rapidly growing field requires highly specific knowledge and skill sets beyond its parent specialty. While the future of IP will continue to show growth, we postulate on a few upcoming technologies which may influence the field and discuss some of the challenges associated with growth in IP.
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Semin Respir Crit Care Med · Dec 2014
ReviewCurrent controversies in the management of malignant pleural effusions.
Malignant pleural effusion (MPE) can complicate most malignancies and is a common clinical problem presenting to respiratory and cancer care physicians. Despite its frequent occurrence, current knowledge of MPE remains limited and controversy surrounds almost every aspect in its diagnosis and management. A lack of robust data has led to significant practice variations worldwide, inefficiencies in healthcare provision, and threats to patient safety. ⋯ Strategies combining pleurodesis and IPC are being studied. MPE consists of a heterogenous group of diseases and careful phenotyping of malignant effusion patients can provide important clinical information that will advance the field and allow better stratification of patients and planning of therapy accordingly. This review addresses the controversies in MPE diagnosis and management and exposes the deficits in knowledge of MPE that should be the focus of future research.
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Semin Respir Crit Care Med · Dec 2014
ReviewRadial probe endobronchial ultrasound and novel navigation biopsy techniques.
Peripheral pulmonary lesions are an increasingly common finding in clinical practice. While many nodules are followed with radiographic surveillance, some may require biopsy. Conventional bronchoscopy with transbronchial lung biopsy has traditionally performed poorly for small, peripheral lesions, and transthoracic needle aspiration with computed tomographic (CT) guidance has been favored as the diagnostic test of choice. ⋯ Virtual bronchoscopy and electromagnetic navigation are CT-based image guidance systems that create virtual bronchoscopic representations of the tracheobronchial tree to assist the bronchoscopist in locating peripheral lesions. Radial probe endobronchial ultrasound utilizes real-time ultrasound to confirm the location of peripheral lesions before biopsy. This article summarizes the technical platforms, procedures, and clinical evidence for these emerging technologies.
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Central airway obstruction (CAO) is seen in malignant and nonmalignant airway disorders and can lead to significant morbidity and mortality. Endobronchial ablative therapies are used in conjunction with mechanical debridement to achieve hemostasis and restore airway patency. These therapies can be classified into modalities with immediate or delayed effect. ⋯ Therapies with delayed effect include cryotherapy, brachytherapy, and photodynamic therapy. These modalities should not be used for acutely symptomatic CAO, and typically require follow-up bronchoscopy for removal of debris from the airway. Multimodality approach typically leads to better outcomes.