Thoracic Endoscopy Book

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Chetan Patil, Neeraj Gupta, Varna Indushekar, Shahir Asfahan, Ramakant Dixit, Rakesh Gupta. Letter to Editor ..... Dhooria S, Agarwal R, Aggarwal AN, Bal A,.
ISSN number: 2455-6904 RNI number: 1254582


An official publication of Indian Association for Bronchology

January - June 2016 Volume 1, Issue 1


THORACIC ENDOSCOPY An official publication of Indian Association for Bronchology A peer reviewed journal

Editor-in-Chief Anand K. Patel Associate Professor – Respiratory Medicine, G. M. E. R. S. Medical College & General Hospital, Gotri, Vadodara, Gujarat - 390021, India. [email protected]

Associate Editors PratibhaSinghal, Mumbai, India R. Narasimhan, Chennai, India Rakesh Chawla, Delhi, India Ritesh Agarwal, Chandigarh, India S. K. Sarkar, Jaipur, India T. K. Jayalakshmi, Mumbai, India V. R. Pattabhiraman, Bangalore, India

Editorial Board A. C. Shah, Mumbai, India Abdul Khader, Calicut, India Atul C. Mehta, Ohio, USA F. D. Ghanchi, Jamnagar, India Haresh R. Shah, Vadodara, India K. B. Gupta, Rohtak, India M. L. Gupta, Jaipur, India Mahendra Kumar, Udaipur, India Pallav Shah, London, UK PrashantChhajjed, Mumbai, India R. B. Gupta, Jaipur, India RajanSantosham, Chennai, India Rajiv Goyal, Delhi, India S. K. Jindal, Chandigarh, India SandhyaNanjundiah, Banglore, India Shirish P. Shah, Mumbai, India Suresh Koolwal, Jaipur, India T. Mohankumar, Coimbatore, India V. K. Jain, Jaipur, India Varun Patel, Ahmedabad, India

M. Mesquita, Goa, India Amir Khoja, Pune, India Ayse E. Kupeli, Ankara, Turkey H. J. Singh, Jalandhar, India J. F. Turner Jr., Knoxville, TN Ko-Pen Wang, Japan M. Munavvar, Preston, UK Masood Ahmed, Aurangabad, India Pawan Gupta, Agra, India Pyng Lee, Singapore R. P. Meena, Jaipur, India Rajendra Prasad, New Delhi, India Ranjan Das, Kolkata, India S. S. Arora, Delhi, India SemraBilaceroglu, Ismir, Turkey Stefano Gasparini, Ancona, Italy Sushil Jain, Mumbai, India Tridib Chatterjee, Mumbai, India V. K. Vijayan, Chennai, India Yaser Abu El Sameed, UAE

Thoracic Endoscopy ● January – June 2016 ● Volume 1 ● Issue 1


The Journal Thoracic Endoscopy (print ISSN: 2455-6904), an official publication of Indian Association for Bronchology; is a peer reviewed, biannual print and online journal. The journal publishes articles on any aspect of bronchoscopy, thoracoscopy, interventional pulmonology and chest diseases. The journal is published biannually in January and July. Information for authors There are no charges of submission, processing and publication of articles. Instructions to authors has been given separately. Please check for further details. All manuscripts must be submitted to [email protected] Subscription information Copies of the journal are provided free of cost to the members of Indian Association for Bronchology. A subscription to Thoracic Endoscopy comprises two issues including postage charge. Annual subscription fees for non-members are Institutional: INR 1000/- for India USD 120/- for outside India Personal: INR 500/- for India USD 60/- for outside India For mode of payment and other details, please write [email protected] Claims for missing issues will be serviced at no charge if received within one month to the cover date for domestic subscribers, and two months for subscribers outside India. Duplicate copies cannot be sent to replace issues not delivered because of failure to notify publisher of change of address.The journal is published and distributed by Indian Association for Bronchology. It is illegal to acquire copies from any other source. If a copy is received for personal use as a member of association, one cannot resale or give-away the copy for commercial or library use. The copies of the journal to the members of the association are sent by ordinary post. The editorial board, association or publisher will not be responsible for nonreceipt of copies. If a copy returns due to incomplete, incorrect or changed address of a members will be deleted from the mailing list of the journal. Providing complete, correct and up to date address is the responsibility of the member/subscriber. Non-members are requested to send changed of address information to [email protected] Advertising policies The journal accepts display and classified advertising. Frequency discounts and special positions are available.

Inquiries about advertising should be sent to [email protected] The journal reserves the right to reject any advertisement considered unsuitable according to the set policies of the journal.The appearance of advertising product information in the various sections of the journal does not constitute an endorsement or approval by the journal, editorial board and/or publisher of the quality or value of the said product or of claims made for it by its manufacturer. Copyright The entire content of the Thoracic Endoscopy are protected under Indian and international copyrights. All rights are reserved. No part of this publication should be reproduced and/or stored in a retrieved system or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without prior permission from the publishers. Disclaimer The statements and opinions contained in this journal are solely those of the authors/advertisers. The publishers and editor-in-chief, its editorial board, and employees disown all responsibilities for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements contained in this journal. Permission For information on how to request permissions to reproduce articles/information from this journal, please write to [email protected] Addresses Editorial Office Dr. Anand K. Patel, A/16 Krishnadeep Society, B/h Saurabh Park, Laxmipura Road, Subhanpura, Vadodara, Gujarat – 390023, India Email: [email protected] Mobile: +91 9879771079 Published by Indian Association for Bronchology 1201, Presidential Tower, “C” Wing, L. B. S. Marg, Mumbai, India. Printed at Gopinath Graphics & Traders 52, Sharad Purnima Society, Near Abhilasha Society, New Sama Road, Vadodara, Gujarat– 390008, India Email: [email protected]

Thoracic Endoscopy ● January – June 2016 ● Volume 1 ● Issue 1


Indian Association for Bronchology Governing Council President Dr. R. B. Gupta Past President Dr. V. K. Jain President Elect Dr. Tridib Chatterjee

Editor Dr. Anand K. Patel Members Dr. R. P. Meena Dr. M. L. Gupta Dr. S. S. Arora Dr. Pawan Gupta Dr. Masood Ahmed Dr. Rakesh Chawla

Sr Vice President Dr. K. B. Gupta Vice President Dr. Suresh Koolwal Secretary Dr. Pratibha Singhal Treasurer Dr. T. K. Jayalakshmi Website In-charge Dr. Sandhya Nanjundiah Joint Secretary Dr. Rajiv Goyal Dr. Abdul Khader Dr. Sushil Jain

Co-opted Member Dr. Mahendra Kumar Hall of Fame Dr. A. C. Shah Dr. Rajan Santosham Dr. S. K. Jindal Dr. S. K. Sarkar Dr. T. Mohankumar Dr. V. K. Vijayan Dr. Shirish Shah Dr. R. Narsimhan Dr. Amir Khoja Dr. A. M. Mesquita Dr. Rajendra Prasad Dr. Ranjan Das Dr. H. J. Singh

Thoracic Endoscopy ● January – June 2016 ● Volume 1 ● Issue 1


THORACIC ENDOSCOPY January – June 2016, Volume 1, Issue 1

Contents Editorial 11 Illusions of EBUS-TBNA in developing world Debabrata Bandhyopadhyay, Tanmay S. Panchabhai, Mohamed Munavvar, Amir Khoja, Atul C. Mehta

Rebuttal to Editorial 17 Illusions of EBUS-TBNA in developing world: are they delusions of the developed world? Preyas J. Vaidya, Prashant N. Chhajed

Original Articles 21 Medical thoracoscopic lung biopsy in the diagnosis of interstitial lung diseases: Ten years of experience from Pune Nitin Abhyankar, Vrushali Khadke, Jayshree Jain, Divya Patel, Ajit Tambolkar

27 Pleuroscopy: Eight years experience in a tertiary care hospital in Kolkata, India Sivaresmi Unnithan, Ranjan K. Das, Don S Halliday

35 A clinical study to compare the diagnostic yield of pleural biopsy conducted under Computed Tomography (CT) guidance versus medical thoracoscopy in patients with exudative pleural effusion who require pleural tissue sampling Neha Jha, Vivek Nangia, R. S. Chatterji

45 Comparison of midazolam, fentanyl, combined sedation and propofol for transnasal bronchoscopy: A non inferiority trial Yagnesh Purohit, Gaurav Phale, Varun Patel, Mukesh Patel, Amrish Patel

Experimental Article 49 Utility of indigenous pleuroscopy conduits Hanmant G. Varudkar, Arti Julka, Piyush Gupta, Kallol Sinha, Abhisheka Kumar, Deepali Bhandari

Case Reports 59 A Rare case of pulmonary lymphangio-leiomyomatosis Minesh V. Patel, Nalin T. Shah, V. G. Vinod


Thoracic Endoscopy ● January – June 2016● Volume 1 ● Issue 1


Contents 63 A rare cause of pneumothorax with subcutaneous emphysema:Unusual syndrome named Boerhaave syndrome

presentation of rare

Ravish Kshatriya,Nimit Khara, Rajiv Paliwal, Satish Patel, Jignesh Rathod

67 MunierKunh syndrome - A rare case of tracheobronchomegaly Vaishal Sheth, Arun V Joy, Niraj Mehta, Kinjal Rami, Iva Chatterjee, F. D. Ghanchi

71 Lupus pleuritis as a cause of recurrent exudative pleural effusion: Rare case with thoracoscopic appearance Chetan Patil, Neeraj Gupta, Varna Indushekar, Shahir Asfahan, Ramakant Dixit, Rakesh Gupta

Letter to Editor 75 Hemoptysis - The Definition Should Be Revised Rakesh Chawla, Arun Madan, Aditya K. Chawla

Guidelines for Authors

Thoracic Endoscopy ● January – June 2016● Volume 1 ● Issue 1


Editorial Illusions of EBUS-TBNA in Developing World 1

Debabrata Bandyopadhyay, MBBS, MD, MRCP, FACP; Tanmay S. Panchabhai, MD, FACP, FACC; 3 Mohamed Munavvar, MD, DNB, FRCP; 4 Amir Khoja, MD; 5 Atul C. Mehta, MD, FACP, FCCP 2


Department of Thoracic Medicine, Geisinger Medical Center, Danville, PA, USA Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoeniz, AZ, USA 3 Lancashire Teaching Hospitals, Preston, UK 4 Department of Chest Medicine and Thoracic Endoscopy, Ruby Hall Clinic, Pune, Maharashtra, India 5 Respiratory Institute, Department of Pulmonary Medicine, Cleveland Clinic, OH, USA 2

The modern day diagnostic bronchoscopy now includes a novel technology of endobronchial ultrasound (EBUS). The technology has a dual form of applications, either using a radial probe (RP) or through a convex probe (CP). The former is useful in locating and evaluating peripheral lung lesions while a convex probe ultrasound provides detailed images of the mediastinal structures. The EBUS technology was first introduced to pulmonary literature in 1992 and the convex probe EBUS bronchoscope became commercially available in2003. Since then its diagnostic and therapeutic applications have evolved exponentially. The most common use of CP- EBUS is for sampling of the anterior and superior mediastinal and hilar lymph nodes (LN) for staging of lung cancer. Over the years, diagnostic utility of EBUS has expanded to many other conditions including airway wall assessment, evaluation of peribronchial lesions, mediastinal cysts as well as sampling of quasi central lesions and peripheral pulmonary nodules. Its trans-vascular application is also being studied.

Over the last decade, the urban health care in India has been transformed as well. The new technologies from the advanced nations have been acquired and practiced at state-of-art medical facilities. One such technique is indeed EBUS-guided transbronchial needle aspiration (EBUSTBNA).The practice of EBUS-TBNA, as a diagnostic modality, has increased manifold in India in recent times as evidenced by number of high quality papers published in the literature.1,2 While this is a very welcoming development for the country, time has come to take a pause and reflect on the spirit of its practice in India today. Certainly, some of the authors of this commentary do not practice in India. Our comments are strictly based on the personal interactions with the local bronchoscopists at the national as well as international meetings, review of the articles submitted for publications on the subject and the interest of the physicians receiving ad-hoc brief EBUSTraining abroad. The sensitivity of EBUS-TBNA as an initial diagnostic and staging tool for lung

Corresponding Author: Atul C Mehta MD, FACP, FACC Professor of Medicine, Lerner College of Medicine The Buoncore Family Endowed Chair in Lung Transplantation Staff Physician, Respiratory Institute, Cleveland Clinic Senior Editor, Journal of Bronchology and Interventional Pulmonology Email: [email protected]

12 Illusions of EBUS-TBNA in Developing World

cancer is reported over 93%worldwide.3 Sadly but truly, staging bronchoscopy is seldom required in Indian population. It is a reliable rumor that only 3-5 % of the lung cancer patients in India present at a stage that requires mediastinal staging. So acquisition of the technology for its most ideal indication is practical only at the centers of excellences or in formally trained hands. Moreover, the diagnostic performance of EBUS-TBNA in the context of extrathoracic malignancy is also variable depending on the origin of the cancer with a concluding diagnosis in no more than 50% of the cases.4 The probability of diagnosing tuberculosis (TB) by EBUS-TBNA is highly variable. The sensitivity of EBUS-TBNA in the diagnosis of TB is reported to be around 85% by some studies, however, at some centers its efficacy for TB-lymphadenitis has been as low as 50%.2,3,5 This is of a significant relevance in a country like India as the accuracy of EBUS-TBNA in diagnosing TBlymphadenitis in an endemic population is not yet fully ascertained. Although the initial results from studies show a positive trend, the study methodology has several limitations.2,7 In our opinion an optimal way to establish the diagnosis of TB is using means other than flexible bronchoscopy, with or without EBUS-TBNA to avoid exposure of the health care personnel.8 Similarly, the sensitivity of flexible bronchoscopy with EBUS-TBNA to detect sarcoidosis has also been reported around 8892%, yet, the diagnostic accuracy of the latter could be as low as 60%, as initial diagnostic tool.3,9Thus the added value of EBUS-TBNA in the diagnosis of sarcoidosis is questionable. In a recent report from India itself, diagnostic yield of conventional diagnostic bronchoscopy was as good as that with the addition of EBUS-TBNA.10The study clearly proved that clinical acumen is the most

reliable tool while making the diagnosis of Sarcoidosis. It is an attractive argument that in the areas endemic for tuberculosis, EBUSTBNA is required for tissue confirmation. Interestingly, only 8% of patients clinically suspected to have Sarcoidosis were found to have TB in this well conducted study from the area with high endemicity for the disease. Besides, in India sarcoidosis and tuberculous lymphadenopathy are known co-exist in several patients and one may also wonder how many of these 8% of patients had coexisting conditions.6 There is no argument that the role of EBUS-TBNA still needs to be established in the diagnosis of certain variants of lymphoma.11 In the developing world, while dealing with an isolated hilar or mediastinal lymphadenopathy it should be kept in mind that it may be caused by malignant as well as benign lesions. In fact, a significant proportion of patients with isolated mediastinal lymphadenopathy, following thorough clinical evaluation are likely tobe due to a reactive process.16 In that scenario a close surveillance rather than an invasive approach would be safe, prudent and cost effective alternative. All these factors, underscore the necessity to select carefully the indications of EBUS-TBNA in an appropriate patient population. The next major issue is related to the required training for EBUS-TBNA. It has been clearly shown by several studies that it takes over 100 EBUS-TBNA procedures to acquire the skills at this complex procedure. It has been quoted over and over in the literature that the days of “see one, do one, teach one” are behind us. There is a steep learning curve for EBUS-TBNA.12 The study looking at the EBUS-TBNA learning curve as well as the “initial experience”, in patients with mediastinal lymphadenopathy from diverse

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13 Illusions of EBUS-TBNA in Developing World

etiologies have reported yields between 65% and 75% only.13 In our opinion, in the 21st century EBUS-TBNA should be performed only following a formal training. The “Gungho” approach has no place in current medical practice. Lack of accredited training centers in India is definitely a barrier to appropriate implementation of EBUS-TBNA. Incidentally, even after acquiring proper skills, it takes at least 50 procedures/year, to remain proficient with this technique. An institution and an individual must have adequate work load to justify the involvement with the procedure. It should be loud and clear that no procedure should be performed just to maintain the skills, especially at the cost of the patient. Compounding to the fact, some of the aggressive pulmonologists have also started performing esophageal ultrasound (EUS) guided procedures without any experience with upper endoscopy. Such practices certainly violate patient’s rights and safety. Unfortunately, with an increasing focus on EBUS technique in India, the training of pulmonary physicians in performing conventional TBNA with flexible bronchoscopy is taking a back seat. It is becoming a lost art, accruing unnecessary financial burden on the payer. It should also be noted that EBUSTBNA is an expensive diagnostic modality; this is especially important in the context of resource-limited countries. Reported barriers to EBUS implementation include high cost of equipment, high per procedure cost, inadequate support staff, and limitations regarding use of sedation and anesthesia. Before acquiring the tools the bronchoscopist must be aware that the procedural cost is minimum of US $ 250, including the cost for the disposable needle and the balloon and average repair cost; while excluding the cost of general anesthesia and the disposable laryngeal mask airway. High price of this

diagnostic tool on occasion leads to undesirable scenarios. Often the bronchoscopists are compelled to use EBUSTBNA over the more economical alternative to capture return on their investment! Moreover, some bronchoscopists try to get multiple uses out of the “single use” disposable needle. The latter practice has a potential to cause grave consequences for the patient besides over staging of lung cancer. Above all, the true benefits of EBUSTBNA is best realized when a Rapid on-site cytological examination (ROSE) is available. It is unclear, how often this aspect of the procedure is applied in the developing world, in order to compromise with cost escalation. It is crucial to remember that the “costeffectiveness” of EBUS-TBNA has been compared to surgical mediastinoscopy only and not with other minimally invasive procedures. A study from India noted that the conventional TBNA, even without a rapid on site cytological analysis (ROSE), is a safe, efficacious and cost-effective procedure and can be performed in patients with a suspected diagnosis of lung cancer.14 Like any other technological advances, EBUS has its fair share of complications. In general a safe procedure but severe complications can be encountered. The serious complications associated with EBUSTBNA include mediastinitis, pneumonia, pericarditis, cyst infection besides other infectious complications.15 As the old saying goes “a good surgeon knows well where to stop, when to stop and how to stop.” Accordingly, a good bronchoscopist is the one who knows when not to perform a bronchoscopy. In the developing world the appropriate modality of investigation must be chosen based on the performer’s expertise and patients’ clinical profile and their best interest in mind. A procedure should never be performed for self-

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14 Illusions of EBUS-TBNA in Developing World

gratification. A good bronchoscopist with proper skills at conventional TBNA should never feel belittled for not acquiring EBUSTBNA. There is a vast difference in the value of a diagnostic modality between the developed and developing world. This is based on the prevalence of disease entities, opportunity for appropriate training and local medical economics. A physician should always stand as the champion of the patient’s welfare than being a champion of the procedure.




References 1.





Srinivasan A, Agarwal R, Gupta N, Aggarwal AN, Gupta D. Initial experience with real time endobronchial ultrasound guided transbronchial needle aspiration from a tertiary care hospital in north India. Indian J Med Res 2013; 137(4): 803-7. Madan K, Mohan A, Ayub II, Jain D, Hadda V, Khilnani GC, Guleria R. Initial experience with endobronchial ultrasound-guided transbronchial needle aspiration (EBUSTBNA) from a tuberculosis endemic population. J Bronchology Interv Pulmonol. 2014; 21(3): 208-14. Choi YR, An JY, Kim MK, Han HS, Lee KH, Kim SW, Lee KM, Choe KH. The diagnostic efficacy and safety of endobronchial ultrasound-guided transbronchial needle aspiration as an initial diagnostic tool. Korean J Intern Med. 2013; 28(6): 660-7. Tercé G, Dhalluin X, Delattre C, Bouchindhomme B, Copin MC, Ramon PP, Fournier C. Diagnostic performance of EBUS-TBNA in patients with mediastinal lymphadenopathy and extrathoracic malignancy. Rev Mal Respir 2013; 30(9): 758-63. Sun J, Teng J, Yang H, Li Z, Zhang J, Zhao H, Garfield DH, Han B. Endobronchial ultrasound-guided transbronchial needle aspiration in diagnosing intrathoracic tuberculosis. Ann Thorac Surg 2013; 96(6): 2021-7.







Gupta D, Agarwal R, Aggarwal AN, Jindal SK. Sarcoidosis and tuberculosis: the same disease with different manifestations or similar manifestations of different disorders. Curr Opin Pulm Med. 2012; 18(5): 506-16. Dhooria S, Agarwal R, Aggarwal AN, Bal A, Gupta N, Gupta D. Differentiating tuberculosis from sarcoidosis by sonographic characteristics of lymph nodes on endobronchial ultrasonography: a study of 165 patients. J Thorac Cardiovasc Surg 2014; 148(2): 662-7. Culver DA, Gordon SM, Mehta AC. Infection control in the bronchoscopy suite: a review of outbreaks and guidelines for prevention. Am J Respir Crit Care Med 2003; 167(8): 1050-6. Plit ML, Havryk AP, Hodgson A, James D, Field A, Carbone S, Glanville AR, Bashirzadeh F, Chay AM, Hundloe J, Pearson R, Fielding D. Rapid cytological analysis of endobronchial ultrasound-guided aspirates in sarcoidosis. Eur Respir J 2013; 42: 1302– 1308. Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest 2014; 146(3): 547-56. Bandyopadhyay D, Panchabhai TS, Mehta AC. EBUS-TBNA for the Diagnosis of Lymphoma. Still an Achilles Heel. Ann Am Thorac Soc 2015; 12(9): 1263-4. Wang H, D'Cruz C, Yam DC, Dilla LM, Tsang P. Learning curve for endobronchial ultrasound-guided transbronchial needle aspiration: experience of a community-based teaching hospital. Mol Med Rep 2014; 10(5): 2441-6. Tian Q, Chen LA, Wang HS, Zhu BH, Tian L, Yang Z, An Y. Endobronchial ultrasoundguided transbronchial needle aspiration of undiagnosed mediastinal lymphadenopathy. Chin Med J (Engl) 2010; 123(16): 2211-4. Walia R, Madan K, Mohan A, Jain D, Hadda V, Khilnani GC, Guleria R. Diagnostic utility of conventional transbronchial needle aspiration without rapid on-site evaluation in

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15 Illusions of EBUS-TBNA in Developing World patients with lung cancer. Lung India 2014; 31(3): 208-11. 15. Jalil BA, Yasufuku K, Khan AM. Uses, limitations, and complications of endobronchial ultrasound. Proc (Bayl Univ Med Cent) 2015; 28(3): 325-30.

16. Evison M, Crosbie PA, Morris J, Martin J, Barber PV, Booton R. A study of patients with isolated mediastinal and hilar lymphadenopathy undergoing EBUS-TBNA. BMJ Open Respir Res 2014; 1(1): e000040.

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