Bronchology

Role of bronchoscopy in diagnosis of smear-negative pulmonary tuberculosis Rajendra Prasad, Abhijeet Singh Egyptian Journal of Bronchology 2019 13(1):1-5 Tuberculosis (TB) remains an important cause of morbidity and mortality in many developing countries including India. Prompt and accurate establishment of diagnosis is one of the essential basic principles of care for persons with TB. Sputum smear microscopy and culture remain the cornerstone of diagnosis but can be negative in a substantial proportion of pulmonary TB patients (multiple smear-negative status or scanty sputum). Bronchoscopy has been proven to be a safe and effective method for those patients with varying diagnostic yields ranging from 30 to 90%. Various specimens are obtained from a fiber-optic bronchoscope such as smear and culture for mycobacteria from the bronchial aspirate or wash, bronchoalveolar lavage fluid, bronchial brushing, postbronchoscopy sputum, transbronchial needle aspiration, and transbronchial biopsy. The diagnostic yield is significantly enhanced when nucleic acid amplification testing is applied to bronchoscopic specimens. The role of bronchoscopy in TB diagnosis is likely to be limited because of availability, cost, and logistical challenges. Future studies are needed to better define the role of the newer diagnostic modalities to improve early TB diagnosis.

Study of cardiopulmonary rehabilitation versus cardiac rehabilitation in patients suffering from coronary artery diseases and chronic obstructive pulmonary disease Yasser M Mohamed, Hala M Salem, Hazem M Khorshid, Karim H Abdel Fattah Egyptian Journal of Bronchology 2019 13(1):6-11 Introduction Chronic obstructive pulmonary disease (COPD) and coronary artery disease are common treatable and preventable chronic diseases. Rehabilitation is now considered an important part of the long-term management in both diseases and includes exercise, education, and smoking cessation. Patients and methods This study included 40 patients with COPD and coronary artery disease referred to the cardiac rehabilitation unit at Ain Shams University hospitals. Patients were assessed by clinical assessment, ECG, ECHO, modified Bruce protocol, spirometry, and St George’s Respiratory Questionnaire (SGRQ). Then, patients were divided into two groups: a cardiac rehabilitation group and a cardiopulmonary rehabilitation group. All patients received 8–12 weeks of rehabilitation and were reassessed by spirometry, the modified Bruce protocol, and SGRQ. Results Both groups improved in terms of spirometric parameters (forced expiratory volume in 1 s and forced expiratory volume in 1 s/forced vital capacity), SGRQ, and metabolic equivalents of tasks, but there was a statistically significant in resting heart rate in the cardiopulmonary rehabilitation group. Conclusion The inclusion of upper limb exercise and inspiratory muscles training in pulmonary rehabilitation improves exercise tolerance in patients suffering from both COPD and coronary artery disease compared with cardiac rehabilitation alone.

Cardiac evaluation of patients with chronic obstructive pulmonary disease using echocardiography Yasser Moustfa Mohammed, Ghada Samir ElShahid, Nehad Mohammed Osman, Nehal Qadry Abd ElHameed Egyptian Journal of Bronchology 2019 13(1):12-16 Background Chronic obstructive pulmonary disease (COPD) is a significant cause of death. Cardiovascular disease is a significant cause of morbidity and mortality in COPD. Aim We used echocardiography to evaluate cardiac function in patients with COPD and correlated echocardiographic findings with COPD severity. Patients and methods We performed a prospective cross-sectional study on 60 patients with stable COPD who presented to the Abbasia Chest Hospital during the period from November 2016 till August 2017. Spirometry was performed for all participants using American and European Thoracic Society (2005) recommendations. They were classified according to GOLD guidelines (2017) and evaluated by two-dimensional Doppler echocardiography according to American and European Association of Echocardiography ASE recommendations. Results Echocardiographic examination of left ventricular functions revealed no cases of left ventricular systolic dysfunction, but left ventricular diastolic dysfunction was found in ∼25%. Right ventricle dilatation was found in ∼18% of the patients. Tricuspid regurge was seen in ∼75%, with variable grades from mild to severe. Pulmonary hypertension (PH) was found in ∼40% of the patients. It was more prevalent in patients with severe and very severe disease. Correlation between echocardiographic findings and severity of COPD revealed significant positive correlation only with right ventricle size, tricuspid regurgitation, and PH. Conclusion Left ventricular diastolic dysfunction appears to be frequent in patients with COPD, but it is not related to the disease severity. Abnormal right heart changes could be expected. Presence of PH has a linear relationship with COPD severity.

Detection of chronic obstructive pulmonary disease among shisha smokers in the Fayoum Governorate Assem F El Essawy, Radwa A Elhefny, Randa I Ahmed, Samar A Fouad Egyptian Journal of Bronchology 2019 13(1):17-28 Background Shisha smoking is a common practice among the population in Arabic countries. Shisha smoking has a negative effect on lung function; it is probably one of the causes for chronic obstructive pulmonary disease (COPD). Objective Detection of COPD among Shisha Smokers in the Fayoum Governorate. Design Prospective study. Setting Fayoum University Hospital in Egypt between 2016 and 2017. Patients and methods Of the 300 participants, 200 were shisha smokers for more than 20 years or their age above 40 years and 100 of them were nonsmoker volunteers. History of smoking was taken from the patients with recording of the COPD assessment score and then general and local examination was done followed by flow volume loop and finally by a chest radiography (posteroanterior view). Statistical analysis: case–control study Coding of the data was done and then entered with SPSS (statistical package for the social sciences) version number 24. After that data was summarized using mean, SD, median, minimum and maximum in the quantitative data with using frequency (count) and relative frequency (percentage) for categorization of data. Results Out of the 300 male patients included in this study 51% has obstructive airway disease and 19% had restrictive airway disease. The mean age was 56.20±10.98 years. Number of hagars smoked by the COPD patients were 10.82±9.88 hagars per day with a duration of smoking of 24.87±12.36 years. Conclusion Shisha smoking increases the risk of COPD and this risk increases with the increase in the duration of smoking and number of hagar smoked was the conclusion of the study.

Forced vital capacity as a primary clinical outcome measure of bronchodilator reversibility in chronic obstructive pulmonary disease Magdy Mohamed Khalil, Eman Badawy AbdelFattah, Yasmin Yousif Mostafa Egyptian Journal of Bronchology 2019 13(1):29-34 Background Spirometry is the most reproducible and objective measurement of airflow limitation. The effectiveness of inhaled bronchodilator in individual patients with chronic obstructive pulmonary disease (COPD) is assessed by comparing measurements from pulmonary function tests made before and after administration. Generally forced expiratory volume in one second (FEV1) is the marker used with the global initiative for COPD (Global Initiative for Chronic Obstructive Lung Disease) guidelines. An increase in FEV1 that is both greater than 0.2 l and 12% above the prebronchodilator FEV1 value is considered significant. The aim of this study is to assess forced vital capacity (FVC) as a clinical outcome measure of bronchodilator reversibility in patients with COPD. Patients and methods This was a prospective study conducted on 163 patients with COPD at Suez Chest Hospital during the period from first of October 2016 till the end of March 2017. Patients were diagnosed based on clinical and spirometric criteria, and then reversibility test was done using inhaled short-acting B2-agonist. All patients were subjected to COPD Assessment Test questionnaire. Results Overall, 14.11% of patients had significant increase in FEV1, whereas 54.6% of patients had significant increase in FVC after bronchodilator inhalation. There was a highly significant positive correlation in FEV1 and FVC value before and after bronchodilator inhalation, and there was a highly significant direct correlation between ΔFEV1 and ΔFVC. There was a statistically significant relation between age and COPD Assessment Test score and ΔFVC. Conclusion ΔFEV1 underestimates the true effect of bronchodilator as airway obstruction increases. The addition of ΔFVC to the evaluation will help physicians to better interpret airways reversibility tests, particularly in more severe patients, without adding spirometric maneuvers or measurements. Patients with COPD, even if nonresponders in terms of FEV1, may benefit from bronchodilators because they can breathe at a lower lung volume owing to reduced air-trapping, notwithstanding the fact that they are still flow limited. ΔFVC correlates better than ΔFEV1with the degree of airway obstruction and the clinical status of the patients.

Psychological assessment of patients with bronchial asthma: focus on some predictors of abnormalities Hend M Esmaeel, Hanan Y Aly Egyptian Journal of Bronchology 2019 13(1):35-42 Background Bronchial asthma is a common chronic respiratory illness. Psychiatric comorbidity is a neglected zone in the care and management of such important physical disorders as bronchial asthma. Objective The present study targeted a population sample of out-patient asthmatics, aiming at detailed psychocognitive evaluation. Predictors of depression, anxiety, and cognitive impairment were searched for by detailed assessment of patient sociodemographic and disease-related criteria. Patients and methods A total of 50 patients with confirmed asthma diagnosis were recruited and subjected to detailed respiratory and psychiatric evaluation using Mini-Mental State Examination, Beck Depression Inventory-II, and Taylor manifest anxiety scale tests. Results Mild, moderate, and severe depression were diagnosed in 26, 28, and 14% of patients, respectively, whereas mild, moderate, and severe anxiety were revealed in 32, 34, and 20%, respectively. Overall, 54% of the patients showed cognitive impairment. Asthmatic female patients were more common to have depression (P=0.022). The present analysis showed that predictors of cognitive impairment were older age, increasing frequency of hospital admission for asthma in the past year, improper adherence to treatment, and uncontrolled asthma. Meanwhile better education level proved to be protective from abnormal cognitive function. Conclusion There was high prevalence of depression, anxiety, and cognitive dysfunction among asthmatic patients in Sohag University. Improving patient education, patient adherence to treatment, and asthma level control may lessen the chance of cognitive abnormality.

Assessment of lung functions using impulse oscillometry before and after bronchoscopic lung volume reduction with histoacryl gel Adel M Khattab, Nevine Abd Elfattah, Ayman Farghaly, Alsayyed Hassan Egyptian Journal of Bronchology 2019 13(1):43-48 Background Many forms of bronchoscopic lung volume reduction were introduced as a treatment for patients with emphysema surpassing the surgical management and its fatality. Biological bronchoscopic lung volume reduction (BBLVR) proved to be a safe and competent solution inducing collapse of the emphysematous segment(s). Impulse oscillometry (IOS) constitutes an effortless but underused surrogate to spirometry in assessment of pulmonary function. Therefore, the aim of this study was to evaluate the use of IOS before and after BBLVR with histoacryl gel in comparison with spirometry among patients with emphysema. Patients and methods A prospective comparative follow-up study was performed at Kobry El-Kobba Military Hospital. A total of 30 patients with radiological evidence of heterogenous emphysema or emphysematous bullae were enrolled during the period from July 2014 to April 2015. BBLVR was accomplished by the instillation of the histoacryl gel into the affected segment(s) using standard technique. Clinical, radiological, and functional assessments were done before and 4 weeks after the procedure. Results After BBLVR, the following outcome was measured: 6-min walk test, partial pressure of O2 in arterial blood, forced expiratory volume in the first second, resistance at 5 Hz, resistance at 20 Hz, and reactance at 5 Hz. They improved with statistical significance among all the patients. There was a negative correlation between forced vital capacity and resistance at 5 Hz in the heterogenous emphysema group (ρ=0.47 and P<0.025); however, the forced expiratory volume at first second showed positive correlation with reactance at 5 Hz in emphysematous bullae group (ρ=0.82 and P<0.023). Conclusion BBLVR with histoacryl gel is associated with improvement in exercise capacity and lung functions. IOS provided comprehensive assessment of the pulmonary functions, which was in good correlation with spirometry.

Evaluation of lung cancer patterns and bronchoscopic presentations in patients admitted to Abbasia Chest Hospital Farrag A Muhammad, Diab S Haytham, Khalaf A Mostafa Egyptian Journal of Bronchology 2019 13(1):49-54 Background Lung cancer is the most common cause of cancer-related death worldwide, accounting for more cancer-related deaths compared with colon, breast, and prostate combined. Aim The aim of this work is to detect the predominant bronchoscopic presentations and anatomical sites for all histopathological types of lung cancer. Patients and methods This study was conducted prospectively in the bronchoscopy units in Abbasia Chest Hospital. It included 132 patients suspected clinically and radiologically to have lung cancer and admitted to the hospital during the period from July 2016 to March 2017. Of them, 81 patients were pathologically diagnosed as having primary lung cancer. Statistical analysis χ2 test was used to examine the relationship between the two qualitative variables. Student’s t test was used to assess the statistical significance of the difference between the two study group means. McNamara test was used assess the statistical significance of the difference between a qualitative variable measured twice for the same study group. Results A total of 81 patients (73 males and eight females) with primary lung cancer were included in the study; most of them were in the sixth decade of life. The main anatomical sites of bronchogenic carcinoma were main bronchi and lower lobe bronchi equally (24% each), followed by lower lobe bronchi (20%). Most common macroscopic bronchoscopic presentations of bronchogenic carcinoma were end bronchial lesion (46.91%) followed by external compression (12.35%) and then mucosal infiltration and external compression (9.88%). Conclusion Persistent pulmonary complaints like productive cough, dyspnea, chest pain, and hemoptysis should be investigated immediately. Proper screening and early diagnostic methods should be applied on a large scale to find out suspected patients who at risk to develop lung cancer.

The role of medical thoracoscopy in the management of empyema Ahmad G El Gazzar, Mohammad A.E El-Mahdy, Gehan F Al Mehy, Asmaa El Desoukey Mohammad Egyptian Journal of Bronchology 2019 13(1):55-62 Background Empyema thoracis is defined as accumulation of pus in the pleural space. Despite advanced medical diagnostic and therapeutic methods, thoracic empyema remains a common clinical entity and a serious problem all over the world with significant associated morbidity and mortality. Aim The aim of this work was to study the efficacy and safety of medical thoracoscopy (MT) in the management of empyema. Patients and methods This study included 30 inpatients with empyema. Included patients had frank pus on aspiration (turbid purulent fetid fluid) with or without positive Gram stain smear and microbiological culture findings or pH less than 7.20, with signs of sepsis. Patients were managed by MT. MT using rigid thoracoscopy was performed with evacuation of the purulent fluid, visualization of the pleural space, assessment of adhesions and purulent material, forceps adhesiolysis, and irrigation by normal saline with partial debridement of accessible parietal pleural surface. Results The present study included 30 patients with empyema (17 men, 13 women with a mean age of 47.4±14.5 years; range, 18–70 years); 19 (63.3%) patients had free-flowing empyema (by computed tomography/ultrasonography) and 11 (36.7%) patients had multiloculated empyema. The etiology of empyema included pneumonia (parapneumonic effusion) (33.3%), malignancy (23.3%), tuberculosis (6.7%), lung abscess (6.7%), and no cause was identified in nine patients (spontaneous pleural infection) (30%). MT was considered successful without subsequent interventional procedures in 26 of 30 (86.7%) patients, including all patients with free-flowing empyema (19 patients), 63.6% of patients with multiloculated empyema (seven patients), and four (13.3%) patients required surgical intervention (surgical decortication). No procedure-related mortality or chronic morbidity occurred in this study. Conclusion MT is a simple, safe, minimally invasive, and effective modality in the management of empyema.

Evaluation of safety and diagnostic yield of pleural cryobiopsies during thoracoscopy Mona M Ahmed, Samar H AlSharkawy, Amr M Shoukri, Yousra T AbouBakr Egyptian Journal of Bronchology 2019 13(1):63-66 Background Biopsies using cryoprobe are now widely used in interventional pulmonology. There are only few data available on the use of cryotechnique through rigid thoracoscopy. Aim The aim of this work was to evaluate the diagnostic yield and safety of pleural cryobiopsies using rigid thoracoscopy. Patients and methods A total of 30 patients with undiagnosed exudative pleural effusion who underwent rigid thoracoscopy were included in our study. Biopsies were obtained from suspicious areas by rigid forceps and cryoprobe. Results A total of 30 patients with undiagnosed exudative pleural effusion have been analyzed. Histopathological results of thoracoscopic pleural biopsies revealed that the most common diagnosis was malignancy (50%), followed by tuberculosis (26.7%). Cryobiopsy specimens were larger than forceps biopsy specimens, with no difference in diagnostic yield (76.7%). Cryotechnique proved to be beneficial in cases of thin highly vascular pleura, allowing easier biopsies with lesser risk of bleeding. In cases of thickened fibrous pleura, there was no difference between both the techniques. Conclusion Pleural cryobiopsies through rigid thoracoscopy is a simple and safe procedure. It has a high diagnostic yield similar to rigid forceps biopsy, and it showed better performance in thin highly vascular pleura where biopsies can be performed with minimal risk of bleeding.