This cohort study shows that early administration of concurrent tPA/DNase in patients with pleural infection is relatively safe and effective. Given the high cost of therapy, it is feasible to guide therapy on the basis of clinical and radiographic response.

Background: Patients with severe symptomatic expiratory central airway collapse (ECAC) undergo a stent trial to determine whether they are candidate for tracheobronchoplasty. Most stent trials were done using silicone stents. However, there was a higher number of silicone stent-related complications. Objectives: The aim of this study was to evaluate the safety and efficacy of short-term uncovered self-expanding metallic airway stents (USEMAS) in patients with ECAC. Methods: This was a retrospective review. Baseline measurements were compared to those obtained after 7-14 days. Measurements included: Modified Medical Research Council (mMRC), Cough Quality of Life Questionnaire (CQLQ), spirometry testing, and 6-Minute Walk Test (6MWT). Stent- and procedure-related complications were reported. Results: 33 patients (median age, 52 years) underwent the USEMAS trial. Presenting symptoms were dyspnea in 100%, intractable cough in 90.3%, recurrent infection in 42.2%, and inability to clear secretions in 21.4%. Dyspnea, cough, and secretion clearance improved in 88, 70, and 57%, respectively. Overall, there was a significant improvement in mMRC (p < 0.001), CQLQ (p = 0.015), and 6MWT (p = 0.015). There was 1 airway infection, 1 stent migration, and 1 pneumothorax. The median duration of USEMAS was 7 days. All stents were removed without any complications. At the time of stent removal, no granulation tissue was observed in 30.9%, and mild granulation tissue was observed in 69.1%. Conclusion: The short-term USEMAS trial improves respiratory symptoms, quality of life, and exercise capacity with few complications in patients with severe symptomatic ECAC when performed by a multidisciplinary airway team in highly specialized centers with experience in the evaluation and treatment of this patient population.

Despite an arduous hospital course with significant risk of severe complication, patients undergoing tracheobronchoplasty for severe tracheobronchomalacia have low risk of mortality and most are discharged directly to home.

Respiratory diseases compromise the health of millions of people all over the world and are strongly linked to the immune dysfunction. CD4+FOXP3+ T regulatory cells, also known as Tregs, have a central role maintaining tissue homeostasis during immune responses. Their activity and clinical impact have been widely studied in different clinical conditions including autoimmune diseases, inflammatory conditions, and cancer, amongst others. Tregs express transcription factor forkhead box P3 (FOXP3), which allows regulation of the immune response through anti-inflammatory cytokines such as IL-10 or transforming growth factor beta (TGF-β) and direct cell-to-cell interaction. Maintenance of immune tolerance is achieved via modulation of effector CD4+ T helper 1, 2 or 17 (Th1, Th2, Th17) cells by Tregs. This review highlights the recent progress in the understanding of Tregs in different disorders of the respiratory system.

Background: Percutaneous endoscopic gastrostomy (PEG) tube placement is a procedure frequently done in the intensive care unit. The use of a traditional endoscope can be difficult in cases of esophageal stenosis and theoretically confers an increased risk of infection due to its complex architecture. We describe a technique using the bronchoscope, which allows navigation through stenotic esophageal lesions and also minimizes the risk of endoscopy-associated infections. Methods: Prospective series of patients who had PEG tube placement guided by a bronchoscope. Procedural outcomes including successful placement, duration of the entire procedure, time needed for passage of the bronchoscope from the oropharynx to the major curvature, PEG tube removal rate, and mortality were collected. Procedural adverse events, including infections and long-term PEG-related complications, were recorded. Results: A total of 84 patients underwent bronchoscope-guided PEG tube placement. Percutaneous endoscopic gastrostomy tube insertion was completed successfully in 82 (97.6%) patients. Percutaneous endoscopic gastrostomy tube placement was performed immediately following percutaneous tracheostomy in 82.1%. Thirty-day mortality and 1-year mortality were 11.9% and 31%, respectively. Overall, minor complications occurred in 2.4% of patients, while there were no major complications. No serious infectious complications were identified and no endoscope-associated hospital acquired infections were documented. Conclusions: The use of the bronchoscope can be safely and effectively used for PEG tube placement. The use of bronchoscope rather than a gastroscope has several advantages, which include the ease of navigating through complex aerodigestive disorders such as strictures and fistulas as well as decreased health-care utilization. In addition, it may have a theoretical advantage of minimizing infections related to complex endoscopes.

BACKGROUND: Gastroesophageal reflux (GER) is increasingly recognized as an exacerbating or causal factor in several respiratory diseases. There is a high prevalence of GER in infants with airway malacia. However, such data are lacking in adults.METHODS: This retrospective study was conducted to determine the relationship between GER and excessive central airway collapse (ECAC). The study included consecutive patients with ECAC referred to the Complex Airway Center at Beth Israel Deaconess Medical Center who underwent esophageal pH testing for GER between July 2014 and June 2018.RESULTS: Sixty-three of 139 patients with ECAC (45.3%) had documented GER as shown by an abnormal esophageal pH test result. The mean DeMeester score was 32.2, with a symptom association probability of 39.7% of GER-positive patients. Twenty-nine of 63 patients (46%) with GER reported improvement in respiratory symptoms following maximal medical therapy or antireflux surgery without requiring further treatment for ECAC.CONCLUSIONS: GER is prevalent among patients with ECAC, and aggressive reflux treatment should be considered in these patients prior to considering invasive airway procedures or surgery.

CD, when used alone or in combination with other endoscopic treatment modalities, appears to be safe and effective in treating endoluminal airway obstruction.

Background: Covid-19 pandemic has resulted in the development of severe and persistent respiratory failure requiring long term ventilatory support. This necessitates the need for a reliable and easy to implement tracheostomy protocol given the concern for viral transmission risk to the involved healthcare personnel due to the aerosol generating nature of the procedure. We describe a protocol with unique and novel modifications to the Ciaglia dilatational percutaneous tracheostomy, effectively implemented during the Covid-19 pandemic at our institution. Methods: We describe the baseline characteristics of our initial 11 patients who underwent the procedure. Outlined are the healthcare personnel involved and the steps which are organized into 4 phases: planning, pre-procedure, intra-procedure and post-procedure. We have tracked procedural duration, provider safety as well as the development of new complications. Results: We describe use of this protocol for 11 bedside percutaneous tracheostomies performed on patients with COVID-19. The average total procedural duration as well as incision to tracheostomy tube placement times was 32.6 minutes and 5.8 minutes respectively. All 3 providers performing the tracheostomies remained asymptomatic with negative COVID-19 RT-PCR testing at 3 weeks. Conclusions: We report an efficacious and adaptable protocol for elective bedside percutaneous tracheostomies for patients with persistent ventilatory requirements due to COVID-19 with an intent to provide standardized and safe care for the patient and the involved healthcare personnel.