Conservative Management of Airway Tear Related to Silicone Endobronchial Stenting in Bronchomalacia Secondary to Endobronchial Tuberculosis

( Nai-chien Huan ) 대한결핵 및 호흡기학회 2020 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.128 No.-

Tracheobronchial stenosis due to tuberculosis (TSTB) is a potentially debilitating complication of endobronchial tuberculosis (EBTB). Endobronchial interventions including silicone stent insertion is an acceptable approach to improve quality of life among patients with TSTB. However, little is known about the optimal management strategy for patients with bronchomalacia secondary to EBTB (B-EBTB) and whether stent-related complication rates are higher among this group of patients. Herein, we report 2 patients with B-EBTB who unfortunately developed bronchial tear related to silicone endobronchial stenting. Both patients were successfully managed conservatively without the need for emergency open surgery. We hypothesize that endobronchial intervention might be more beneficial for patients with pure TSTB and might be riskier in cases of bronchomalacia with reduced airway thickness and loss of airway cartilaginous support. In an event of airway tear, initial conservative approach might be appropriate with intense monitoring and proper surgical consult. More future studies are needed to bridge the current gap in knowledge regarding the optimal management and role of endobronchial interventions among patients with B-EBTB.

Optimizing the Utility of Pleural Fluid Adenosine Deaminase (ADA) for the Diagnosis of Tuberculous Pleural Effusion (TPE)

( Nai-chien Huan ),( Inn Shih Khor ),( Hema Yamini Ramarmuty ),( Ming Yao Lim ),( Kai Choon Ng ),( Alfieyanto Syaripuddin ),( Qin Zhi Lee ),( Wee Jing Teo ),( Kunji Kannan Sivaraman Kannan ) 대한결핵 및 호흡기학회 2020 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.128 No.-

Introduction Pleural fluid adenosine deaminase (pfADA) is a simple, rapid and inexpensive surrogate marker for tuberculous pleural effusion (TPE). A nationwide cut-off of 40U/L is currently used based on overseas data. There is a need to optimise the diagnostic utility of pfADA by establishing a local cut-off value. In this study, we aimed to: describe the demographics and clinical characteristics of patients with TPE and non-TPE; to determine the sensitivity and specificity of current pfADA of 40U/L; and to establish a new local pfADA cut-off for TPE. Methods We conducted a single centre, observational, prospective study of patients with exudative pleural effusion and pfADA measured from 1st October 2019 to 30th April 2020 at Queen Elizabeth Hospital, Malaysia. Results The diagnosis of analysed patients (n=93) included TPE (n=41), malignancy (n=28), parapneumonic effusion (n=12) and other causes (n=12) (figurer 1). The mean pfADA was 51.15 (SD=13.77)U/L among TPE group and 18.86 (SD=12.33)U/L among non- TPE. When analysis was restricted to TPE patients, the local pfADA cut-off is 29.6U/L, with sensitivity of 97.6% and specificity of 90.4% (figure 2). The current pfADA of 40U/L has a sensitivity of 87.8% and specificity of 92.3%. Conclusion We established a local pfADA cut-off of 29.6U/L for TPE. Optimising the utility of pfADA helps to enhance clinicians’ treatment confidence of TPE when initial work-up were inconclusive.

Outcomes of Therapeutic Bronchoscopy and Airway Stenting for Benign and Malignant Central Airway Diseases in Malaysia: A Tertiary Centre Experience

( Nai-chien Huan ),( Khai Lip Ng ),( Fatimah Azmah Mohammad ),( Nur Husna Mohd Aminudin ),( Kang Yang Ng ),( Lee Sy Yeong Mark ),( Swee Hung Ang ),( Noorul Afidza Muhammad ),( Ummi Nadira Daut ),( Mon 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.-

Introduction Therapeutic bronchoscopy and airway stenting are acceptable measures for managing patients with severe symptomatic benign and/or malignant central airway diseases(CAD). Nevertheless, gaps in knowledge still exist in real-life clinical setting regarding predictors of both successful procedure and stent-related complications. The objective of this study was to determine if demographics, clinical presentation, radiological features, bronchoscopy findings and stent characteristics can identify patients who will benefit and/or develop complications from airway stenting. Methods Post-hoc analysis of patients with severe symptomatic benign/malignant CAD who underwent therapeutic bronchoscopy and airway stenting from January 2018 - January 2021. Results We included 24 patients(58.3%male) with median age of 51.0years. 14(58.3%) had malignant conditions and 10(41.7%) had benign disease. Presenting symptoms included cough(87.5%), dyspnoea(83.3%), orthopnoea(29.2%), and stridor(16.7%). Of radiological features: 54.2% had tracheal involvement, 50.0% main bronchus involvement, and 91.2% had patent airways distal to CAD. Equal number of cases(12 each) were conducted as emergency(performed within 1-day from presentation) and as semi-emergency(performed within 1-week from presentation). Bronchoscopy revealed that 54.2% had pure intrinsic lesions, 20.8% pure extrinsic lesions and 25.0% mixed lesions. 20.8% had concurrent bronchomalacia. Of stent characteristics, 62.5% received metallic stents, 33.3% silicone and 4.2% hybrid stents. Majority(75%) expressed immediate symptom relief after stenting. There was no intra-procedure mortality and complications were observed in 11(45.8%) patients, where obstruction by granulation tissue/tumour overgrowth being the most common complication(42.9%), followed by stent migration(28.6%), obstruction by secretion(14.3%) and airway tear/injuries(14.3%). There was significant association between the absence of bronchomalacia and successful procedure(Cramer’sV=0.515,p<0.05). Semi-emergency procedures(as opposed to emergency procedures) were associated with a successful outcome(Cramer’sV=0.507,p<0.05). Discussion and Conclusion Airway stenting is an effective procedure that offers rapid relief in symptoms but at the expense of potential complications. Further large-scale studies are required to identify predictors of both successful procedure and airway stenting related complications among patients with both benign and malignant CAD.

Thrombocytopenia as First Manifestation of Acute Massive Pulmonary Embolism

( Nai-chien Huan ),( Kang Yang Ng ),( Khai Lip Ng ),( Jamalul Azizi Abdul Rahaman ) 대한결핵 및 호흡기학회 2020 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.128 No.-

Introduction Massive acute pulmonary embolism (PE) is a life-threatening medical emergency. Occasionally, patients with massive PE can develop concurrent thrombocytopenia due to various aetiologies including heparin-induced thrombocytopenia and acute thrombosis associated thrombocytopenia. Here, we present a case of massive PE with thrombocytopenia as first manifestation of the disease. Case Report A 64-year-old lady was admitted for left femur osteomyelitis with subperiosteal abscess, causing pain and immobility for a month prior to admission. There were no signs and symptoms to suggest underlying thrombophilia, malignancy or connective tissue disease. On day 5 of admission, while waiting for operation, she developed acute onset respiratory distress, necessitating urgent intubation, mechanical ventilation and vasopressor support. Computed tomography pulmonary angiogram demonstrated massive PE involving left main trunk and left ascending branch of pulmonary artery (figure 2). She had unexplained worsening thrombocytopenia for 4 days (from 401x109/L on admission to 22x109/L on day 5 of stay) prior to clinical manifestation of massive PE despite without heparin use. Other blood parameters including haemoglobin levels, total white cell count, coagulation profile, renal and liver function tests remained stable or unremarkable. There was clear indication for thrombolysis but unfortunately was contraindicated. After a multidisciplinary meeting it was then decided to optimise the platelet counts prior to consideration for surgical embolectomy. Unfortunately, she succumbed after 2 days despite maximal supportive therapy. Discussion and Conclusion Our Case Report highlighted a patient with massive PE associated with severe thrombocytopenia necessitating systemic thrombolysis and anticoagulation which unfortunately was contraindicated. Clinicians ought to be vigilant when dealing with patients with unexplained thrombocytopenia and to consider acute thrombosis associated thrombocytopenia, especially among high risk patients. Early detection and prompt intervention are vital to ensure a better clinical outcome.

Various Indications for Endobronchial Valve Placement in Patients with Chronic Obstructive Pulmonary Disease: A Case Series

( Nai-chien Huan ),( Jamalul Azizi Abdul Rahaman ) 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.-

Background EBV placement is increasingly being adopted as a treatment option for carefully selected patients with COPD. Originally for patients with severe emphysema, the use of EBV have recently been expanded to include endoscopic reduction of emphysematous bullae and persistent air leak. Hereby, we report 3 patients with COPD who underwent EBV placement for various indications. Result Case-1 A 53-year-old gentleman with COPD (GOLD group-D) underwent EBV placement at left upper lobe for endoscopic lung volume reduction back in 2015. Pre-procedural lung function test showed severe hyperinflation (residual volume 515% predicted, total lung capacity 200% predicted) while computed tomography demonstrated heterogenous emphysema with intact lung fissures. He attained intentional atelectasis of targeted lobes with sustained symptomatic relief (Borg scale dyspnoea score from 5 pre-EBV to 2 post-EBV) 6 years post prodecure. Case-2 A 60-year-old gentleman with COPD (GOLD group-D) was referred for endoscopic volume reduction of a huge left upper lobe emphysematous bulla. Surgical bullectomy was deemed prohibitively dangerous due to poor lung reserve. 4 EBVs were inserted at left upper lobe under general anaesthesia and rigid bronchoscopy. Whilst he developed intra-procedural bronchospasm, his procedure was both technically (reduced bulla size) and clinically successful (improvements in functional status). Case-3 A 47-year-old lady with COPD presented with left secondary spontaneous pneumothorax 2-months after completion of chemotherapy for pulmonary tuberculosis. A chest drain was inserted but was complicated with persistent air leak. As other options including surgery and pleurodesis were risky, she underwent a Chartis system guided EBV insertion at left upper lobe. The procedure led to successful resolution of air leak and she was discharged 4-days later without a chest tube. Conclusion EBV placement is a useful adjunct for COPD patients, especially among those with poor lung reserves. Careful patient selection remains the key to maximise efficacy and to minimise complications.

Pulmonary Mucormycosis Masquerading as Endobronchial Tumour in an Immunocompetent Pregnant Young Lady

( Khai Lip Ng ),( Nai-chien Huan ),( Ummi Nadira Daut ),( Sanusi Zulkifli ),( Noorul Afidza Muhammad ),( Mona Zaria Nasaruddin ),( Jamalul Azizi Abdul Rahaman ) 대한결핵 및 호흡기학회 2020 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.128 No.-

Introduction Pulmonary murcomycosis is an uncommon fungal infection that typically affects immunocompromised patients. Rarely, it can affect immunocompetent patients, presenting as endobronchial lesions mimicking lung malignancy. Herein we report a patient with pulmonary murcomycosis with favourable treatment outcome via a multimodality approach utilizing antifungal agents and endobronchial intervention. Case Report A 31-year-old lady with no prior medical condition presented with a 3-month history of cough associated with weight loss of more than 5 kilograms and occasional haemoptysis (blood streaks in sputum). Chest radiograph and computed tomography demonstrated mediastinal lymphadenopathy and left hilar mass with infiltration into left main bronchus. Flexible bronchoscopy revealed presence of an endobronchial mass occluding the left main bronchus. Her tuberculosis workup, diabetes screening and retroviral tests were all negative but she was found to be pregnant at 6weeks. She was subsequently scheduled for rigid bronchoscopy and debulking of endobronchial mass. To our surprise, histopathological examination revealed inflamed tissue with presence of fungal organism which was subsequently confirmed to be Rhizopus microspores via fungal polymerase-chain-reaction. With the diagnosis in mind, she was promptly treated with intravenous amphotericin-B for a total of 2 weeks in duration, which was accompanied by clinical improvements and total radiological resolution. Amphotericin-B was chosen instead of other anti-fungal agents after taking into account of her pregnancy status. Conclusion Murcomycosis should be considered among young patients who presented with endobronchial lesion. Rapidly progressing nature of the disease warrants early diagnosis and treatment to ensure a better clinical outcome.

Nose Stud Screw Aspiration- A Tiny Foreign Body with Potentially Huge Disaster: 2 Cases with Different Ways of Retrieval

( Khai Lip Ng ),( Nai Chien Huan ),( Mona Zaria Nasaruddin ),( Noorul Afidza Muhammad ),( Ummi Nadira Daut ),( Jamalul Azizi Abdul Rahaman ) 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.-

Nose piercing is traditionally a common practice among women of Indian ancestry. The practice of nose piercing has gained significant popularity in various communities worldwide for the past decade. The practice can potentially lead to aspiration of nose jewelleries such as screws of nose studs. Aspiration of small foreign bodies can be silent although potentially serious and life-threatening sequelae can happen in long term. Herein, we present 2 patients of Indian ancestry who aspirated screw of nose studs with different Methods of retrieval. Both of the patients are assymptomatic and foriegn body was found incidentally on chest radiograph. They could not recall the timing of aspiration of foreign body, which is nose stud screw in this case. Small foriegn body such the nose stud screw could potentially dislodge into subsegmental bronchi, rendering retrieval extermely difficult. The 2 cases are presented to show that the same type of foreign body can be retrieved easily if it remains in the main bronchus simply with flexible bronchoscope and grasping forceps, or require various method such as retrieval basket, magnet etc under rigid bronchoscopy. Small foriegn body could lead to serious complications such as severe infection, or massive hemoptysis if left in the airway. While aspiration of scarf pins among Muslim girls and ladies who wears a hijab, called the “hijab syndrome” have been extensively reported, there is a paucity of publications regarding “nosestud syndrome” among Indian communities. To the best of our knowledge, this is the first case report delineating aspiration of screw of nose studs and their retrieval Methods. The incidence and burden of nose stud aspiration remains unknown, and is likely underreported and underrecognized, as patients can remain asymptomatic. We hope that our case report can help to increase awareness and understanding of potential dangers of nose piercing.

Successful Treatment of Excessive Dynamic Airway Collapse with Noninvasive Positive Pressure Ventilation - A Case Report

( Khai Lip Ng ),( Nai Chien Huan ),( Mona Zaria Nasaruddin ),( Noorul Afidza Muhammad ),( Ummi Nadira Daut ),( Jamalul Azizi Abdul Rahaman ) 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.-

Introduction Excessive central airway collapse (ECAC) can present as unexplained dyspnea, wheezing or stridor. ECAC can easily be misdiagnosed as bronchial asthma, COPD and heart failure. ECAC can occur as a result of tracheobronchomalacia or excessive dynamic airway collapse (EDAC).There are various Methods of diagnosis and treatment of ECAC but it has to be tailored according patient’s circumstances. Case Report We present a 75-year-old lady with multiple comorbidities including vascular dementia who was brought in by her daughter after she noticed that her mother had wheezing, shortness of breath and reduced effort tolerance for the past 2 months. Her symptoms were worse on exertion and during sleep. She was given bronchodilator without any improvements. She was overweight and her STOPBANG score of 6. CT thorax showed posterior indentation of mid distal trachea with significant luminal narrowing. Unfortunately, she couldn’t comply to dynamic chest CT test due to vascular dementia. Flexible bronchoscopy done under conscious sedation confirmed almost total occlusion of both left and right main bronchus together with narrowing of tracheal diameter of more than 80% that were present only during expiration. Partial sleep study done showed evidence of OSA with an AHI of 58/hour, and a lowest oxygen saturation at 51%. Both her EDAC and OSA was treated successfully with a CPAP machine. On subsequent follow up, her daughter reported that her symptoms has resolved together with improvements in her effort tolerance. Discussion and Conclusion There are various Methods to diagnose and manage a patient with EDAC, some of which are invasive and thus are risky for elderly patients with multiple co-morbidities. Choices of investigations and treatment for this condition need to be tailored according to patient’s need and circumstances. CPAP in this case was given without real time titration under flexible bronchoscopy with success in her case.

Diagnostic Accuracy of Lactate Dehydrogenase/Adenosine Deaminase Ratio in Differentiating Tuberculous and Parapneumonic Effusions: A Systematic Review

( Larry Ellee Nyanti ),( Muhammad Aklil Abd Rahim ),( Nai-chien Huan ) 대한결핵 및 호흡기학회 2024 Tuberculosis and Respiratory Diseases Vol.87 No.1

Background: Tuberculous pleural effusion (TPE) and parapneumonic effusion (PPE) are often difficult to differentiate owing to the overlapping clinical features. Observational studies demonstrate that the ratio of lactate dehydrogenase to adenosine deaminase (LDH/ADA) is lower in TPE compared to PPE, but integrated analysis is warranted. Methods: We conducted a systematic review to evaluate the diagnostic accuracy of the LDH/ADA ratio in differentiating TPE and PPE. We explored the PubMed and Scopus databases for studies evaluating the LDH/ADA ratio in differentiating TPE and PPE. Results: From a yield of 110 studies, five were included for systematic review. The cutoff value for the LDH/ADA ratio in TPE ranged from <14.2 to <25. The studies demonstrated high heterogeneity, precluding meta-analysis. Quality Assessment of Diagnostic Accuracy Studies Tool 2 assessment revealed a high risk of bias in terms of patient selection and index test. Conclusion: LDH/ADA ratio is a potentially useful parameter to differentiate between TPE and PPE. Based on the limited data, we recommend an LDH/ADA ratio cutoff value of <15 in differentiating TPE and PPE. However, more rigorous studies are needed to further validate this recommendation.

Diagnostic Accuracy of Lactate Dehydrogenase/Adenosine Deaminase Ratio in Differentiating Tuberculous and Parapneumonic Effusions: A Systematic Review

Larry Ellee Nyanti, M.R.C.P.I.,Muhammad Aklil Abd Rahim, Dr.P.H.,Nai-Chien Huan, M.R.C.P. 대한결핵및호흡기학회 2024 Tuberculosis and Respiratory Diseases Vol.87 No.1

Background: Tuberculous pleural effusion (TPE) and parapneumonic effusion (PPE) areoften difficult to differentiate owing to the overlapping clinical features. Observationalstudies demonstrate that the ratio of lactate dehydrogenase to adenosine deaminase(LDH/ADA) is lower in TPE compared to PPE, but integrated analysis is warranted. Methods: We conducted a systematic review to evaluate the diagnostic accuracy of theLDH/ADA ratio in differentiating TPE and PPE. We explored the PubMed and Scopusdatabases for studies evaluating the LDH/ADA ratio in differentiating TPE and PPE. Results: From a yield of 110 studies, five were included for systematic review. The cutoffvalue for the LDH/ADA ratio in TPE ranged from <14.2 to <25. The studies demonstratedhigh heterogeneity, precluding meta-analysis. Quality Assessment of DiagnosticAccuracy Studies Tool 2 assessment revealed a high risk of bias in terms of patientselection and index test. Conclusion: LDH/ADA ratio is a potentially useful parameter to differentiate betweenTPE and PPE. Based on the limited data, we recommend an LDH/ADA ratio cutoff valueof <15 in differentiating TPE and PPE. However, more rigorous studies are needed tofurther validate this recommendation.