Immunotherapy agents in metastatic non-small cell lung cancer (NSCLC) can result in improved quality of life and survival when compared with platinum-based chemotherapy. Novel response patterns such as pseudoprogression and hyperprogression, however, have been described and pose a challenge to treating physicians. Predictors of hyperprogressive disease (HPD) have not yet been identified. Evaluation and management by a multidisciplinary team involving medical and radiation oncologists, thoracic radiologists, and proceduralists is necessary to identify this subset of patients in a timely manner. Repeat biopsy distinguishes HPD from pseudoprogression and may eventually elucidate predictive biomarkers. We describe the epidemiology of these two phenomena, their diagnostic criteria, and their relevance for interventional pulmonologists.

Malignant Central Airway Obstruction (MCAO) encompasses significant and symptomatic narrowing of the central airways that can occur due to primary lung cancer or metastatic disease. Therapeutic bronchoscopy is associated with high technical success and symptomatic relief and includes a wide range of airway interventions including airway stents. Published literature suggests that stenting practices vary significantly across the world primarily due to lack of guidance. This document aims to address this knowledge gap by addressing relevant questions related to airway stenting in MCAO. An international group of 17 experts from 17 institutions across 11 countries with experience in using airway stenting for MCAO was convened as part of this guideline statement through the World Association for Bronchology and Interventional Pulmonology (WABIP). We performed a literature and internet search for reports addressing six clinically relevant questions. This guideline statement, consisting of recommendations addressing these six PICO questions, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with expert experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique. image

Bordetella bronchiseptica is a pleomorphic gram-negative coccobacillus that commonly causes respiratory tract infections in canines, felines, and swine. Human infections are rare. We report a case of Bordetella bronchiseptica pneumonia in a 67-year-old immunocompromised host. His past medical history included multiple myeloma treated with autologous bone marrow transplant followed by a chimeric antigen receptor cell therapy for relapse. He was admitted with unrelenting diarrhea due to HHV-6 pancolitis. During the hospital course he developed high-grade fever (102.3°F), cough and respiratory failure requiring mechanical ventilation. Chest imaging demonstrated bilateral opacities most pronounced at lung bases and worsening mediastinal lymphadenopathy. Bronchoalveolar lavage cultures grew Bordetella bronchiseptica. He was treated with piperacillin/tazobactam, but developed progressive multiorgan failure, transitioned to comfort care, and expired in the hospital. Bordetella bronchiseptica is an organism that do not cause serious infection in immunocompetent persons but can sometimes cause serious illness in immunocompromised populations. It causes “kennel cough” in dogs and spready by respiratory droplets. Dogs and cats are not uniformly vaccinated against this pathogen. Therefore, transmission through animal contact is becoming increasingly common. Realize that unlike other Bordetella spp, this pathogen is not typically responsive to erythromycin and is often resistant to ampicillin and cephalosporins so the typical neutropenic fever coverage with an antipseudomonal cephalosporin and azithromycin might not be effective. Given the increasing recognition of this zoonosis as a threat to the immunocompromised, it is essential to educate immunocompromised patients to minimize zoonotic exposure, as immunization of pets might not confer protection to humans.

Objective. We evaluated the use of a one-week ambulatory pessary trial in predicting patients' postoperative outcomes for occult stress incontinence.Methods. Patients with anterior vaginal wall prolapse were offered a pessary trial to predict response to reconstruction. We performed a retrospective review of 4 years of cases. All patients underwent a detailed evaluation including videourodynamics with and without pessary reduction.Results. Twenty-six patients completed the 1-week pessary trial. Ten (38%) women showing no evidence of stress urinary incontinence (SUI) underwent surgical repair of prolapse without anti-incontinence procedure. None of these patients had SUI postoperatively. Sixteen women (61%) had occult stress urinary incontinence on evaluation and underwent concurrent sling procedure. Three (19%) of these patients were identified by the pessary trial alone. Twenty-five of the 26 patients were without clinical stress incontinence at a mean follow up of 12 months (range 4–37 months). The pessary trial correctly predicted persistent urgency in six patients and persistent frequency in five. No patients with SUI or persistent voiding difficult were missed in a pessary trial.Conclusion. An ambulatory pessary trial is an effective, easy, and inexpensive method to approximate anatomic results achieved by surgery under real-life conditions. In our series, 20% of patients with occult SUI were identified by pessary trial alone.

Persistent air leak (PAL) is a challenging clinical entity, particularly in the setting of critical illness. It is a significant cause of morbidity, health care expenditure, and resource utilization. Data on its prevalence in the critically ill patient population are limited. Unique patient factors often necessitate an individualized approach. Guidelines on this subject are antiquated and do not specially address patients on mechanical ventilation. Critically ill patients may not be able to tolerate surgical intervention. Treatment in this population relies upon lung protective ventilation, various anecdotal modalities, chemical pleurodesis, autologous blood patching, and bronchoscopic insertion of endobronchial valves. Ventilation strategies center on rapid weaning and reduction of airway pressures. Anecdotal methods include implantable devices and chemical agents. Data on these modalities are limited to case reports. None have United States Food and Drug Administration (FDA) approval. The Spiration Valve System is FDA approved as a Humanitarian Device Exemption. Data on endobronchial valves are based on large case series, and only one small case series has focused exclusively on critically ill patients. The majority of valves in critically ill mechanically ventilated patients are used for non-FDA approved indications. Updated guidelines are desperately needed to ensure a standardized approach to this common clinical situation.