Faculty Bibliography

BACKGROUND:COVID-19 is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy is not recommended by current guidelines as it is considered a super-spreading event due to aerosolization that unduly risks healthcare workers. METHODS:Patients with severe COVID-19 that were on mechanical ventilation ≥ 5 days were evaluated for percutaneous dilational tracheostomy. We developed a novel percutaneous tracheostomy technique that placed the bronchoscope alongside the endotracheal tube, not inside it. This improved visualization during the procedure and continued standard mechanical ventilation after positioning the inflated endotracheal tube cuff in the distal trachea. This technique offers a significant mitigation for the risk of virus aerosolization during the procedure. RESULTS:From March 10 to April 15, 2020, 270 patients with COVID-19 required invasive mechanical ventilation at New York University Langone Health Manhattan's campus of which 98 patients underwent percutaneous dilational tracheostomy. The mean time from intubation to the procedure was 10.6 days (SD ±5 days). Currently, thirty-two (33%) patients do not require mechanical ventilatory support, 19 (19%) have their tracheostomy tube downsized and 8 (8%) were decannulated. Forty (41%) patients remain on full ventilator support, while 19 (19%) are weaning from mechanical ventilation. Seven (7%) died as result of respiratory and multiorgan failure. Tracheostomy related bleeding was the most common complication (5 patients). None of health care providers have developed symptoms or tested positive for COVID-19. CONCLUSIONS:Our percutaneous tracheostomy technique appears to be safe and effective for COVID-19 patients and safe for healthcare workers.

BACKGROUND:Our objective is to report our outcomes and demonstrate our evolving technique for robotic sleeve resection of the airway, with or without lobectomy, using video vignettes. METHODS:We retrospectively reviewed a single surgeon prospective database from October 2010 to October 2019. RESULTS:Over 9 years, there were 5,573 operations of which 1951 were planned for a robotic approach. There were 755 robotic lobectomies, 306 robotic segmentectomies, and 23 consecutive patients were scheduled for elective completely portal, robotic sleeve resection. Sleeve lobectomy was performed in 18 patients: 10 right upper lobe, 6 left upper lobe, and 2 right lower lobe. Two patients had mainstem bronchus resections and two underwent right bronchus intermedius resections that preserved all of the lung. One patient had a robotic pneumonectomy. There was one conversion to open thoracotomy due to concern for anastomotic tension in a patient who received neoadjuvant therapy. All patients had an R0 resection. In the last 10 operations, we modified our airway anastomosis, using a running self-locking absorbable suture. The median length of stay was 3 days (range 1-11). There were no 30- or 90-day mortalities. Within a median follow-up of 18 months, there were no anastomotic strictures and no recurrent cancers. CONCLUSIONS:Our early and midterm results show that a completely portal robotic sleeve resection is safe and oncologically effective. The technical aspects of a robotic sleeve resection of the airway are demonstrated using video vignettes.

Aorticopulmonary paragangliomas are rare middle mediastinal masses that are often treated with surgery. In addition to the technical challenge of resection due to location near critical structures, these paragangliomas can have postoperative complications due to resection of cardiac sympathetic innervation. We present a patient with a non-functional aorticopulmonary paraganglioma that suffered from postoperative hypotension and heart block, with inability to tolerate his prior alpha and beta blockade on discharge.

Granulomatous fungal infections are common worldwide, and can result in mediastinal lymphadenopathy. However, infectious pulmonary artery masses are rare and have only been associated with tuberculosis or mucormycosis. Here, we present the first case of histoplasmosis resulting in a pulmonary artery mass, which was treated with debulking and reconstruction of pulmonary vasculature.

PURPOSE: Azole antifungals are commonly prescribed for fungal prophylaxis (ppx) following lung transplant, but have many side effects and drug interactions. Isavuconazole, a new broad-spectrum azole antifungal, may obviate these issues.
METHOD(S): We retrospectively reviewed all lung transplant recipients (LTR) from February 2018 through September 2019 who received either ISA or POS for fungal ppx for 3 months post-transplant. Prior to February 2019 all patients received POS for ppx. Starting February 2019, POS was replaced by ISA at standard dosing. All patients received basiliximab induction and standard triple immunosuppression post-transplant. Surveillance bronchoscopies were performed at 1, 3, 6, and 12 months post-transplant.
RESULT(S): In total, we reviewed 24 LTR who received ISA and 29 who received POS. Baseline characteristics were similar between groups. Median duration of follow-up was significantly shorter for the ISA group (137 vs. 340 days, p<0.01). Breakthrough fungal infections occurred in 3 (13%) and 2 (7%) patients in the ISA and POS groups, respectively (p=0.65). All ISA patients developed oropharyngeal candidiasis; in the POS group there was one each of candida empyema and mold colonization. Post-ppx fungal infections occurred in 1 (4%) and 5 (17%) patients in the ISA and POS groups, respectively (p=0.20). All of these were mold colonization except for one case of oropharyngeal candidiasis. There was no difference between fungal-infection free survival based on Kaplan-Meier analysis (p=0.69). POS was held in two cases and discontinued in 1 patient due to a drug interaction causing hepatotoxicity compared to zero patients receiving ISA (p=0.24).
CONCLUSION(S): Breakthrough fungal infections were similar between LTR receiving ISA or POS for fungal ppx. Longer follow-up of ISA patients is needed for definitive comparison of long-term infection risk. POS was discontinued in more patients due to drug interactions. ISA is a reasonable choice for primary fungal ppx in LTR.
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PURPOSE: We hypothesize that home monitoring and telehealth utilizing data from a mobile healthcare application in conjunction with laboratory values and chest imaging, can replace an outpatient appointment.
METHOD(S): Our study is comprised of patients who have received a single or bilateral lung transplant or a heart/lung transplant.Before our patients are discharged from their inpatient stay after Transplantation, the application for home monitoring is installed on their smart phone. This application was specifically designed for Lung Transplant Patients. A blood pressure cuff and spirometer are provided and linked to their mobile device using Bluetooth. A weighing scale is also provided which uses a cellular connection to a secure cloud relaying data to the patient's phone and to EPIC. Additional data including (e.g. temperature, pulse oximetry) are manually entered into the application. Physical fitness (steps) is also monitored. The team who created the application enabled the data to flow from the application to our electronic medical record. Alerts are set for each piece of data and any abnormal value is sent to our team's EPIC in-basket for further action.Patients who are compliant with their home monitoring are offered telehealth. Patients are sent for laboratory testing and imaging the week of the appointment close to their home.
RESULT(S): As of October 1, 2019, we have enrolled fifty patients in our home monitoring program. Fourteen patients are now one - year post transplant. Twelve of these patients are compliant with home monitoring. Eight of them have had telehealth visits throughout the year with five receiving the majority of their care utilizing home monitoring and telehealth. These visits occur bimonthly for the first three months after transplant and then monthly for the first year.
CONCLUSION(S): Home monitoring and telehealth visits can replace outpatient visits in the first year following lung transplantation. Patients find the devices easy to use and are satisfied with the care they receive during their telehealth visits. Additionally, telehealth improves patient quality of life by reducing visits to the medical center and avoiding additional costs such as parking and time off work. It also limits pathogen exposure. Long term use may enable early detection of rejection or infection.
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PURPOSE: Adequate pain control is essential following lung transplantation to reduce patient stress and minimize perioperative complications. Enhanced recovery after surgery (ERAS) protocols have demonstrated improvements in patient experience and reduced length of stay. However, the implementation of these protocols has not yet extended to the lung transplant population.
METHOD(S): We retrospectively reviewed all lung transplant recipients (LTR) at our institution from February 2018 to August 2019. An opioid-sparing, multimodal pain regimen was implemented that included preemptive analgesia with gabapentin and acetaminophen (APAP) pre-transplant; liposomal bupivacaine intercostal nerve block (INB) in the operating room; and a combination of APAP, gabapentin, and methocarbamol post-op with opioids given as indicated. Serratus anterior plane block was used for refractory pain.
RESULT(S): In total, we reviewed 48 LTR. The mean LAS was 43.74 and 21% were on mechanical ventilation or ECMO pre-transplant. Frequency of protocol adherence for each agent was as follows: liposomal bupivacaine INB (71%), APAP (100%), gabapentin (98%), methocarbamol (27%), and ketorolac (33%). Seven patients (15%) required a serratus plane block for refractory pain. Pain scores peaked at a median of 5 on postoperative day (POD) 1 and declined to a median of 3 by POD 3. By POD 4 only 54% of patients were still receiving opioids at a median of 15 mg oral morphine equivalents per day (IQR, 0-59). Only 3 patients were discharged on opioids and they were all on opioids pre-transplant. The median duration of mechanical ventilation was 1 day (IQR, 0.64-1.69) and 81% were extubated before 48 hours. The median hospital length of stay was 8 days (IQR, 6-15) and 30-day mortality was 0%.
CONCLUSION(S): Enhanced recovery and opioid-sparing pain protocols are feasible in LTR leading to minimal opioid use and acceptable pain scores. Outcomes with ERAS protocols should be compared to standard-of-care postoperative management.
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Over the past several decades, the operation of choice for end-stage lung disease secondary to severe pulmonary hypertension (PH) has shifted from heart-lung transplantation (HLT) to bilateral lung transplantation (BLT). This change has maintained excellent long-term outcomes and is appropriate for the majority of patients presenting with end-stage disease in need of transplantation. However, a distinct subset of patients with severe PH have an excessive early mortality within 90 days of transplantation. Based on the different causes of this early mortality compared to BLT recipients with other indications, right heart failure and refractory primary graft dysfunction (PGD) appear to play a significant role. It is therefore critical to identify this subset of patient during their evaluation for transplant. This distinction would allow specific patient referral for HLT, which may mitigate those causes of early mortality. Similarly, there is a subgroup of BLT recipients for severe PH that fail to recover right ventricular function, with suboptimal long-term functional status that is independent of early survival. Identification and referral for HLT of these patients may also be important. In this manuscript, we describe our institutional approach and consideration for the risks of early mortality from right heart failure and PGD, as well failure of right ventricular recovery long-term. The described evaluation is used to ascertain those patients with severe PH who may benefit from a HLT over BLT.

Increased detection of lung nodules has led to trying to improve technologies for localization and/or tissue acquisition. Previous bronchoscopic techniques have limitations that have led to further advancements in technology. Robotic bronchoscopy has emerged as new technology for the localization, diagnosis, and potential treatment of lung nodules. The robotic bronchoscopic platform was developed to improve peripheral reach of lung nodules, provide direct continuous visualization of the periphery, and offer more precise control of the instrumentation. We review the progression of bronchoscopy, evolution to the robotic platform and its early outcomes, with considerations for future advancements.