Asthma is a chronic inflammatory disease of the airways in which many cell types play a role. These cells are involved in the regulation of the airways inflammation and initiate the process of remodelling by the release of cytokines and growth factors. In the article the authors describe changes in airways wall in asthmatic patients and their clinical consequences.

Airway remodeling in asthma

Tissue diagnosis of peripheral pulmonary lesions (PPLs) can be challenging. In the past, flexible bronchoscopy was commonly performed for this purpose but its diagnostic yield is suboptimal. This has led to the development of new bronchoscopic modalities such as radial endobronchial ultrasound (R-EBUS), electromagnetic navigation bronchoscopy (ENB) and virtual bronchoscopy (VB). We performed this meta-analysis using data from previously published R-EBUS studies, to determine its diagnostic yield and other performance characteristics. Ovid MEDLINE and PubMed databases were searched for R-EBUS studies in September 2016. Diagnostic yield was calculated by dividing the number of successful diagnoses by the total number of lesions. Meta-analysis was performed using MedCalc (Version 16.8). Inverse variance weighting was used to aggregate diagnostic yield proportions across studies. Publication bias was assessed using funnel plot and Duval and Tweedie's test. 57 studies with a total of 7872 lesions were included in the meta-analysis. These were published between October 2002 and August 2016. Overall weighted diagnostic yield for R-EBUS was 70.6% (95% CI: 68–73.1%). The diagnostic yield was significantly higher for lesions >2 cm in size, malignant in nature and those associated with a bronchus sign on computerized tomography (CT) scan. Diagnostic yield was also higher when R-EBUS probe was within the lesion as opposed to being adjacent to it. Overall complication rate was 2.8%. This is the largest meta-analysis performed to date, assessing the performance of R-EBUS for diagnosing PPLs. R-EBUS has a high diagnostic yield (70.6%) with a very low complication rate.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/resp.12980

Radial endobronchial ultrasound for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis

Background With the release of the National Lung Screening Trial results, the detection of peripheral pulmonary lesions (PPLs) is likely to increase. Computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) and radial probe endobronchial ultrasound (r-EBUS)-guided transbronchial lung biopsy (TBLB) are recommended for tissue diagnosis of PPLs. Methods A systematic review of published literature evaluating the accuracy of r-EBUS-TBLB and CT-PTNB for the diagnosis of PPLs was performed to determine point sensitivity and specificity, and to construct a summary receiver-operating characteristic curve. Results This review included 31 publications dealing with EBUS-TBLB and 14 publications dealing with CT-PTNB for the diagnosis of PPLs. EBUS-TBLB had point sensitivity of 0.69 (95% CI: 0.67-0.71) for the diagnosis of peripheral lung cancer (PLC), which was lower than the sensitivity of CT-PTNB (0.94, 95% CI: 0.94-0.95). However, the complication rates observed with EBUS-TBLB were lower than those reported for CT-PTNB. Conclusions This meta-analysis showed that EBUS-TBLB is a safe and relatively accurate tool in the investigation of PLC. Although the yield remains lower than that of CT-PTNB, the procedural risks are lower.

Comparison between endobronchial ultrasound-guided transbronchial biopsy and CT-guided transthoracic lung biopsy for the diagnosis of peripheral lung cancer: a systematic review and meta-analysis.

Bronchial asthma (referred to as “asthma” hereinafter in this consensus document) is a chronic inflammatory airway disease with well-accepted heterogeneity and complex pathophysiological processes (1). Severe asthma is recognized as a poorly controlled condition that seriously affects quality of life, accounts for massive use of medical resources, and imposes huge socioeconomic burdens, representing a primary cause of asthma-related disability and death in the patients (2-5). In this regard, improving the diagnosis and treatment of severe asthma should be of paramount importance towards better outcomes in overall control and prognosis, as well as lower medical costs (5).

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Chinese expert consensus on diagnosis and management of severe asthma.

Background: Tubercular lymphadenitis is the commonest extra pulmonary manifestation in cervical and mediastinal locations. Normal characteristics of lymph nodes (LN) have been described on ultrasonography as well as by Endoscopic Ultrasound. Many ultrasonic features have been described for evaluation of mediastinal lymph nodes. The inter and intraobserver agreement of the endosonographic features have not been uniformly established. Methods and Results: A total of 266 patients underwent endoscopic ultrasound guided fine needle aspiration and 134 cases were diagnosed as mediastinal tuberculosis. The endoscopic ultrasound location and features of these lymph nodes are described. Conclusion: Our series demonstrates the utility of endoscopic ultrasound guided fine needle aspiration as the investigation of choice for diagnosis of mediastinal tuberculosis and also describes various endoscopic ultrasound features of such nodes.

Endoscopic ultrasound in mediastinal tuberculosis.

Objective
To assess the effectiveness and safety of bronchial thermoplasty (BT)in the treatment of severe asthma.


Methods
The safety and effectiveness of BT were studied prospectively in 6 patients with poorly controlled severe asthma on long-term inhaled high-dose glucocorticoids and long-acting beta2-agonists in the First Affiliated Hospital of Guangzhou Medical University. Outcomes assessed after BT included asthma symptoms, frequency of acute exacerbations, pulmonary function, medication adjustment, and postoperative complications at 6 and 12 months after treatment.


Results
The mini-AQLQ scores(6.4±0.5), the frequency of acute exacerbations[0.4(0.1-1.3)times/month], and the symptom-free days[(21.2±7.2)days/month] were significantly improved at 6 months after operation compared to those before operation[5.2±0.9, 2.0(0.9-4.0)times/month, (14.5±3.7)days/month, respectively, P 0.05). The PEF values and lung function measurements remained stable throughout the study period. The most common complications were cough (24.1%), wheezing(13.8%), followed by lower respiratory infection and atelectasis during the treatment. Pneumothorax and respiratory failure occurred in 1 patient 12 h after the third procedure.


Conclusion
Our preliminary study demonstrated promising effect of BT in the treatment of severe asthma, although there are some complications which need further observation.


Key words: 
Asthma; Therapeutics; Bronchial thermoplasty

Bronchial thermoplasty in the treatment of severe asthma

Objective
To evaluate the diagnostic utility of endobronchial ultrasound combined with virtual bronchoscopic navigation guided transbronchial lung biopsy for solitary pulmonary nodules.


Methods
A total of 105 patients with suspected peripheral pulmonary lesions who underwent transbronchial lung biopsy in the First Affiliated Hospital of Guangzhou Medical University between January and December 2013 were prospectively evaluated. The patients were divided into a conventional group, an endobronchial ultrasound group(EBUS group)and a virtual bronchoscopic navigation combined with endobronchial ultrasound(VB+ EBUS) group. The diagnostic yield and operation time were compared.


Results
The lesion size of the conventional group, the EBUS group and the EBUS+ VB group were (23±8), (20±8)and(18±7)mm, respectively, and there was no significant difference in diagnostic yields by the lesion size (F=0.52, P=0.60). The EBUS+ VB group had the highest diagnostic yield(22 of 29, 76%), which was higher than that of the conventional group(17 of 36, 47%, χ2=7.47, P=0.024), but not that of the EBUS group(29 of 40, 72%, χ2=0.10, P=0.75). The EBUS group and the EBUS+ VB group did not differ in lesion location by pulmonary segments or histologic findings. The procedure time was significantly longer in the EBUS group than the EBUS+ VB group [(365±221)s verses (256±205)s, t=2.08, P=0.042].


Conclusions
EBUS guided TBLB improves the diagnostic yield in solitary pulmonary lesions, but it should be combined with virtual bronchoscopic navigation for the optimal yield.


Key words: 
Biopsy; Ultrasonography; Bronchoscopy; Pulmonary

The diagnostic utility of virtual bronchoscopic navigation combined with endobronchial ultrasound guided transbronchial lung biopsy for peripheral pulmonary lesions

Objective
To explore the sonographic features of malignant hilar and mediastinal lymph nodes and the predictive value.


Methods
We performed retrospective analysis of 390 lymph nodes under the endobronchial ultrasound-guided transbronchial needle aspiration for diagnosis in the bronchoscope center of the First Affiliated Hospital of Guangzhou Medical University from November 1st, 2012 to November 31st, 2013.They were divided into malignant and benign groups, and sonographic features of lymph nodes were analyzed, including the length of short axis, shape, margin, echogenicity, homogenicity, coagulation necrosis, calcification, coalesence and posterior acoustic enhancement.


Results
A total of 390 lymph nodes were evaluated, including 207 malignant and 183 benign lymph nodes, respectively.The accuracy based on the length of short axis, shape, margin, echogenicity, homogenicity, coagulation necrosis, calcification, coalesence and posterior acoustic enhancement to predict the malignancy were 61.0% (238/390), 75.4% (294/390), 75.6% (295/390), 73.8% (288/390), 65.9% (257/390), 68.2% (266/390), 51.8% (202/390), 55.1% (215/390), 67.4% (263/390), respectively.Binary multivariable logistic regression analysis revealed that 5 parameters, including round, distinct margin and heterogeneous, hypoechoic, and posterior acoustic enhancement possessed a significant predictive value(P<0.05). We found that only 35.3% (73/207) malignant lymph nodes possessed these 5 ultrasonographic characteristics, and the diagnosis rate was 93.6% (73/78).72.46% (150/207) malignant lymph nodes possessed any 4 or more positive sonographic features, and the diagnosis rate was 85.2% (150/176).85.0% (176/207) malignant lymph nodes had any 3 or more positive sonographic features, and the diagnosis rate was 84.6% (176/208).


Conclusion
The combination of gray scale sonographic features has a predictive value in the diagnosis of malignant hilar and mediastinal lymph nodes.


Key words: 
Ultrasonography, interventional; Lymph nodes; Lung

The predictive value of gray scale sonographic features in malignant hilar and mediastinal lymph node

Bronchial thermoplasty (BT) is a treatment to reduce the airway smooth muscle mass by delivering radiofrequency thermal energy to the airways. BT is used in patients with severe asthma. The present study reported on cases of pneumothorax directly after BT and retrospectively analyzed early radiologic and bronchoscopic modifications after BT. The clinical data and radiologic and bronchoscopic findings of 12 patients with severe asthma who were subjected to BT between July 2014 and October 2017 were analyzed. A total of 33 chest radiographs were collected within 18-24 h after BT. Radiological abnormalities were observed in 32 radiographs as atelectasis (53.1%), peribronchial consolidations (84.4%), pleural effusion (18.8%), effusion in oblique fissures (3.1%), pleural thickening (6.3%) and pneumothorax (3.1%). Of note, one patient suffered pneumothorax after the third BT session and underwent chest drain insertion, followed by mechanical ventilation at the intensive care unit and multiple bronchoscopic interventions, which revealed extensive phlegm plugs. A total of six patients with worsened symptoms and lobar atelectasis also required bronchoscopic intervention, which revealed that phlegm plugs occluded the bronchus in the treated lobe. No bronchoscopic intervention was required in the remaining five patients. During 16-30 days of follow-up, 95.7% of the findings on chest radiography were resolved. To the best of our knowledge, the present study reported the first case of pneumothorax following BT. Early radiologic modifications such as atelectasis and peribronchial consolidations appear common after BT. However, whether bronchoscopic intervention is required for atelectasis following BT warrants further investigation. Of note, BT should be audited and recorded in detail to ideally contribute to a framework of clinical trials to improve risk-benefit evaluations and the selection of patients likely to benefit from treatment.

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Early radiologic and bronchoscopic changes after bronchial thermoplasty in patients with severe asthma

Objective: To evaluate the safety of the procedures of whole lung lavage(WLL) for pulmonary alveolar proteinosis(PAP) in perioperative period. Methods: In this retrospective study, we collected clinical data from 78 WLL procedures of PAP patients from January 2006 to June 2016 in Guangzhou Institute of Respiratory Disease. The causes of perioperative complications were analyzed. Results: Eighteen (23.07%) of the 78 procedures developed complications, including pleural effusion(n=4), pneumonia(n=4), cardiac failure(n=2), cardiac arrhythmia (n=2), pneumothorax(n=2), atelectasis(n=1), lung edema(n=1), laryngeal edema(n=1), pleural effusion and pneumonia(n=1). All complications were mild and easy to treat. Seventy-four procedures had successful extubation, but 4 procedures developed a prolonged time of extubation. Age, DSS, PaCO(2,)FEV(1,)lavage volume, lavage times and underlying diseases were not predictors for any complications(each P>0.05). High fluid recovering rate had a protective effect against the occurring of complications (Wald=7.672, OR<0.01, P<0.05). Conclusions: Whole lung lavage was a safe procedure in the treatment of PAP. Complications could recovery after proper therapy. The perioperative complications showed a correlation with low fluid recover rate. Operation under guideline was the key to avoid complications.

Yu Chen

Papers

Bronchial thermoplasty in the treatment of severe asthma

The diagnostic utility of virtual bronchoscopic navigation combined with endobronchial ultrasound guided transbronchial lung biopsy for peripheral pulmonary lesions

The predictive value of gray scale sonographic features in malignant hilar and mediastinal lymph node

Early radiologic and bronchoscopic changes after bronchial thermoplasty in patients with severe asthma

A retrospective study of the perioperative complications following whole lung lavage in the treatment of pulmonary alveolar proteinosis