Gaetane Michaud

Beth Israel Deaconess Medical Center, Boston, MA, United States

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Publications (25)105.71 Total impact

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    ABSTRACT: Abstract Morbid obesity may influence several aspects of airway function. However, the effect of morbid obesity on expiratory tracheal collapse in COPD patients is unknown. We thus prospectively studied 100 COPD patients who underwent full pulmonary function tests (PFTs), 6-minute walk test (6MWT), Saint George's Respiratory Questionnaire (SGRQ), and low-dose CT at total lung capacity and during dynamic exhalation with spirometric monitoring. We examined correlations between percentage dynamic expiratory tracheal collapse and body mass index (BMI). The association between tracheal collapse and BMI was compared to a control group of 53 volunteers without COPD. Patients included 48 women and 52 men with mean age 65 ± 7 years; BMI 30 ± 6; FEV1 64 ± 22% predicted and percentage expiratory collapse 59 ± 19%. Expiratory collapse was significantly associated with BMI (69 ± 12% tracheal collapse among 20 morbidly obese patients with BMI ≥35 compared to 57 ±19% in others, p = 0.002, t-test). In contrast, there was no significant difference in collapse between healthy volunteers with BMI ≥ 35 and < 35. COPD patients with BMI ≥ 35 also demonstrated shorter 6MWT distances (340 ± 139 m vs. 430 ± 139 m, p = 0.003) and higher (worse) total SGRQ scores (48 ± 19 vs. 36 ± 20, p = 0.013) compared to those with BMI < 35. In light of these results, clinicians should consider evaluating for excessive expiratory tracheal collapse when confronted with a morbidly obese COPD patient with greater quality of life impairment and worse exercise performance than expected based on functional measures.
    COPD Journal of Chronic Obstructive Pulmonary Disease 07/2013; · 2.31 Impact Factor
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    ABSTRACT: ABSTRACT BACKGROUND: Few studies of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have been large enough to identify risk factors for complications. The primary objective of this study was to quantify the incidence of and risk factors for complications in patients undergoing EBUS-TBNA. METHODS: Data from prospectively enrolled patients undergoing EBUS-TBNA in the American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education (AQuIRE) database were extracted and analyzed for the incidence, consequences and predictors of complications. RESULTS: We enrolled 1,317 patients at six hospitals. Complications occurred in 19 patients (1.44%; 95% CI, 0.87%-2.24%). TBBx was the only risk factor for complications, which occurred in 3.21% of patients who underwent the procedure and in 1.15% of those who did not (OR, 2.85; 95% CI, 1.07-7.59; P = 0.04). Pneumothorax occurred in seven patients (0.53%; 95% CI, 0.21%-1.09%). Escalations in level of care occurred in 14 patients (1.06%; 95% CI, 0.58%-1.78%); its risk factors included age > 70 years (OR, 4.06; 95% CI, 1.36-12.12; P = 0.012), inpatient status (OR, 4.93; 95% CI, 1.30-18.74; P = 0.019), and undergoing deep sedation or general anesthesia (OR, 4.68; 95% CI, 1.02-21.61; P = 0.048). TBBx was performed in only 12.6% of patients when rapid on-site cytologic evaluation (ROSE) was used and in 19.1% when it was not used (P = 0.006). Interhospital variation in TBBx utilization when ROSE was used was significant (P < 0.001). CONCLUSIONS: TBBx was the only risk factor for complications during EBUS-TBNA procedures. ROSE significantly reduced the use of TBBx.
    Chest 11/2012; · 5.85 Impact Factor
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    ABSTRACT: BACKGROUND:COPD has been described as a risk factor for excessive expiratory tracheal collapse, but its prevalence and clinical correlates have not been fully determined. The purpose of this study is to prospectively determine the prevalence of excessive expiratory tracheal collapse among COPD patients and to test the hypothesis that clinical and/or physiological parameters will correlate with the presence of excessive tracheal collapse. METHODS:We studied 100 adults meeting GOLD criteria for COPD, who underwent full pulmonary function tests (PFTs), 6-minute walk test (6MWT), Saint George's Respiratory Questionnaire (SGRQ), and low-dose CT at total lung capacity and during dynamic exhalation with spirometric monitoring. We examined correlations between percentage dynamic expiratory tracheal collapse and PFTs, 6MWT distance, and SGRQ scores. RESULTS:Patients included 48 women and 52 men with mean age 65 ± 7 years; FEV(1) 64 ± 22 % of predicted and percentage expiratory collapse 59 ± 19%. Twenty of 100 participants met study criteria for excessive expiratory collapse. There was no significant correlation between percentage expiratory tracheal collapse and any pulmonary function measure, total SGRQ score, or 6MWT distance. The SGRQ symptom subscale was weakly correlated with percentage collapse of the mid trachea (R=0.215, p=0.03). CONCLUSIONS:Excessive expiratory tracheal collapse is observed in a subset of COPD patients, but the magnitude of collapse is independent of disease severity and does not correlate significantly with physiological parameters. Thus, the incidental identification of excessive expiratory tracheal collapse in a general COPD population may not necessarily be clinically significant.
    Chest 06/2012; · 5.85 Impact Factor
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    ABSTRACT: Evidence-based treatment guidelines for non-small-cell lung cancer (NSCLC) exist to improve the quality of care for patients with this disease. However, how often evidence-based decisions are used for care of NSCLC is poorly understood. We examined patterns of care and rate of adherence to evidence-based guidelines for 185 new NSCLC patients seen between 2007 and 2009. Evidence-based care status was determined for 150 patients. Eighty-one percent of the patients were white, the mean age was 66 years, 49% were women, 11% were never smokers, 83% had Eastern Cooperative Oncology Group performance status 0 to 1, 49.7% of tumors were adenocarcinomas, 57.1% of never smokers had tumors genotyped (EGFR, ALK, KRAS), and 13.3% participated in clinical trials. The rate of evidence-based treatment adherence was 94.1% (16 of 17), 100% (21 of 21) and 100% (36 of 36) in patients with stages I, II, and III NSCLC, respectively. Stage IV disease, with adherence of 76.3% (58 of 76), was correlated with a higher rate of nonadherence when compared with stages I-III (odds ratio 16.33; 95% CI, 1.94 to 137.73). In patients with stage IV disease, the rate of evidence-based adherence was 95% (72 of 76) for first-line therapy, 95.2% (40 of 42) for second-line therapy, and only 33.3% (6 of 18) for third-line therapy (P < .001). There was no significant correlation between evidence-based adherence status and the patient's age, sex, performance status, smoking history, ethnicity, or the treating physician. These data point toward the need for improved evidence-based use of resources in the third-line setting of stage IV NSCLC.
    Journal of Oncology Practice 01/2012; 8(1):57-62.
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    ABSTRACT: Thoracentesis is one of the most commonly performed medical procedures with an excellent safety profile. We describe 2 patients, both of whom developed 2 very rare complications after image-guided thoracentesis. Both patients developed clinically relevant reexpansion pulmonary edema (RPE). Within 2 weeks of their first thoracentesis, both patients underwent a second thoracentesis, which was complicated by a large pneumothorax requiring drainage by tube thoracostomy. Pneumothorax and RPE are independent rare complications (<1%) that occur after thoracentesis. The development of these unusual complications in the same sequence in these 2 patients suggests that there may be a causal relationship between pneumothorax and RPE after sequential thoracenteses. Further investigations are necessary to better describe the underlying pathophysiology and mechanism that may explain this association.
    Journal of bronchology & interventional pulmonology. 10/2011; 18(4):343-7.
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    Gaetane Michaud, Armin Ernst
    Chest 09/2011; 140(3):578-9. · 5.85 Impact Factor
  • Gaetane Michaud, Armin Ernst
    Chest 09/2011; 140(3):576-7; discussion 577. · 5.85 Impact Factor
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    ABSTRACT: Tracheobronchomalacia (TBM) is characterized by excessive collapsibility of the central airways, typically during expiration. TBM may be present in as many as 50% of patients evaluated for COPD. The impact of central airway stabilization on symptom pattern and quality of life is poorly understood in this patient population. Patients with documented COPD were identified from a cohort of 238 patients assessed for TBM at our complex airway referral center. Pulmonary function testing, exercise tolerance, and health-related quality-of-life (HRQOL) measures were assessed at baseline and 2 to 4 weeks following tracheal stent placement/operative tracheobronchoplasty (TBP). Severity of COPD was classified according to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) staging system. One hundred three patients (48 women) with COPD and moderately severe to severe TBM were identified. Statistically and clinically significant improvements were seen in HRQOL measures, including the transitional dyspnea index (stent, P = .001; TBP, P = .008), the St. George Respiratory Questionnaire (stent, P = .002; TBP, P < .0001), and the Karnofsky performance score (stent, P = .163; TBP, P < .0001). The improvement appeared greatest following TBP and was seen in all GOLD stages. Clinical improvement was also seen in measured FEV(1) and exercise capacity as assessed by 6-min walk test. Central airway stabilization may provide symptomatic benefit for patients with severe COPD and concomitant severe airway malacia. Operative airway stabilization appears to impart the greatest advantage. Long-term follow-up study is needed to fully ascertain the ultimate efficacy of both stenting and surgical airway stabilization in this patient group.
    Chest 08/2011; 140(5):1162-8. · 5.85 Impact Factor
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    ABSTRACT: Mounier-Kuhn syndrome (MKS) is a condition characterized by tracheobronchomegaly resulting from the loss or atrophy of musculoelastic fibers within the airway wall. Concomitant tracheobronchomalacia is seen in most patients with MKS, often leading to significant respiratory compromise due to bronchiectasis, increased dead space, and impaired secretion clearance. We report a series of 12 patients with MKS and tracheobronchomalacia who were evaluated at our institution for significant respiratory problems. Stent trials were conducted in 10 patients, with seven proceeding to operative tracheobronchoplasty (TBP) and one continuing with long-term stent placement. One patient underwent TBP without prior stent placement. Of the remaining three patients, two had no improvement with trials of stent placement, and a stent could not be placed in the third because of a large tracheal diameter. Compared with baseline values, clinically significant improvements in health-related quality-of-life measures and pulmonary function testing were seen in patients who underwent central airway stabilization (n = 9). Complications of both stent placement and TBP were generally mild. However, one death was reported in the surgical group secondary to an exacerbation of preexisting interstitial pneumonia. An aggressive approach that targets central airway stabilization may improve outcomes for patients with MKS. ClinicalTrials.gov; No.: NCT00550602; URL: www.clinicaltrials.gov.
    Chest 04/2011; 140(4):867-73. · 5.85 Impact Factor
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    ABSTRACT: Tracheobronchomalacia is an underrecognized cause of dyspnea, recurrent respiratory infections, and cough. Surgical stabilization with posterior membranous tracheobronchoplasty has been shown to be effective in selected patients with severe disease. This study examines the technical details and complications of this operation. A prospectively maintained database of tracheobronchomalacia patients was queried retrospectively to review all consecutive tracheobronchoplasties performed from October 2002 to June 2009. Posterior splinting was performed with polypropylene mesh. Patient demographics, surgical outcomes, and operative data were reviewed. Sixty-three patients underwent surgical correction of tracheal and bilateral bronchial malacia. Twenty-three patients had chronic obstructive pulmonary disease, 18 had asthma, 5 had Mounier-Kuhn syndrome, and 4 had interstitial lung disease. Seven patients had a previous tracheotomy. Operative time was 373 ± 93 minutes. Median length of stay was 8 days (range, 4 to 92 days), of which 3 days (range, 0 to 91 days) were in intensive care. Seventy-five percent of patients were discharged home (28% with visiting nurse follow-up), and 25% went to a rehabilitation facility. Two patients (3.2%) died postoperatively-1 of worsening usual interstitial pneumonia, and the other of massive pulmonary embolism. Complications included a new respiratory infection in 14 patients, pulmonary embolism in 2, and atrial fibrillation in 6. Six patients required reintubation, and 9 received a postoperative tracheotomy; 47 patients required postoperative aspiration bronchoscopy. In experienced hands, tracheobronchoplasty can be performed with a very low mortality rate and an acceptable perioperative complications rate in patients with significant pulmonary comorbidity. Intervention for postoperative respiratory morbidity is often necessary.
    The Annals of thoracic surgery 03/2011; 91(5):1574-80; discussion 1580-1. · 3.45 Impact Factor
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    ABSTRACT: Benign tracheo-neo-esophageal fistula is a rare complication after esophagectomy. We report a 60-year-old man who presented 12 years after a McKeown esophagectomy with a fistula between the tracheal carina and the gastric conduit. In view of his severe sepsis and profound malnutrition, he underwent placement of a silicon Y-stent with a successful three-stage surgical repair consisting of duodenal exclusion with drainage gastrostomy. Six weeks later, the patient had closure of the fistula through a right thoracotomy. He finally underwent Roux-en-Y gastro-jejunostomy through a left thoraco-abdominal approach to restore the gastrointestinal continuity. Eighteen months postoperatively, he reports no dysphagia and has regained his premorbid weight.
    The Annals of thoracic surgery 12/2010; 90(6):e83-5. · 3.45 Impact Factor
  • Gaetane Michaud, David M Berkowitz, Armin Ernst
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    ABSTRACT: Pleuroscopy, also known as medical thoracoscopy, is a minimally invasive procedure to inspect and perform a biopsy of the pleural space as well as to perform therapeutic interventions. It differs from conventional video-assisted thoracic surgery in that it may be performed under moderate sedation in the endoscopy suite without the need for intubation or single-lung ventilation. The diagnostic accuracy of this procedure approaches 100% in malignant and tuberculous pleural effusions. Complication rates are low (2%-5%) and are typically minor (subcutaneous emphysema, bleeding, infection), with mortality rates <0.1%. Therapeutic interventions, such as chemical pleurodesis, may be performed during pleuroscopy for recurrent, symptomatic malignant pleural effusions, with success rates approaching 90%. In trained hands, pleuroscopy is a safe and well-tolerated procedure with high diagnostic accuracy and therapeutic efficacy.
    Chest 11/2010; 138(5):1242-6. · 5.85 Impact Factor
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    ABSTRACT: The use of self-expandable metallic airway stents (SEMAS) for airway compromise may be associated with significant complications requiring their removal/replacement. The aim of this study is to describe the complications, health-care resources use (HRU), and costs associated with endoscopic removal of SEMAS. A retrospective analysis of patients who underwent endoscopic removal of SEMAS during a 10-year period (January 2000-August 2009) was performed. HRU was analyzed in terms of the number of endoscopic procedures, hospital and ICU stay, need for mechanical ventilation and airway restenting, and estimation of respective hospital costs. Fifty-five SEMAS were removed from 46 patients with a mean age of 58.6 +/- 15.8 years. Eighty percent of the stents were placed for benign airway disorders with an average stent in situ duration of 292 days. The median number of removal and total procedures during each encounter was one and two, respectively. Patients required hospitalization and ICU admission in 78% and 39% of the encounters with a median length of stay of 3.5 and 0 days, respectively. The estimated median total cost per encounter to remove the stents was $10,700, ranging from $3,700 to $69,800. The measured outcomes were statistically significantly better when in situ stent duration was <or= 30 days (P < .05). Endoscopic removal of SEMAS is feasible; however, it is associated with significant complications, HRU, and costs. The use of SEMAS should be restricted to a well-selected patient population and should be planned by a team experienced with this type of therapeutic strategy.
    Chest 08/2010; 138(2):350-6. · 5.85 Impact Factor
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    ABSTRACT: We present a patient with a typical bronchopulmonary carcinoid tumor who presented with proximal muscle weakness. Laboratory analysis and a muscle biopsy specimen led to the diagnosis of polymyositis. Chest imaging revealed a bronchopulmonary carcinoid tumor. Symptoms and laboratory derangements remitted after removal of the tumor. This case represents a rare report of a typical carcinoid tumor presenting with the paraneoplastic syndrome of polymyositis.
    The Annals of thoracic surgery 04/2010; 89(4):1276-8. · 3.45 Impact Factor
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    ABSTRACT: Multiple new diagnostic bronchoscopic technologies are available, but little is known about their comparative performance and specific yield when adjusted for location of lesions, target size, and diagnosis. We present a multi-institutional prospective-outcomes database to assess diagnostic yields of advanced bronchoscopic procedures, as well as related morbidity and mortality. Data were extracted and reviewed from an ongoing, paper-based, prospective, multi-institutional outcomes database for advanced diagnostic bronchoscopic procedures. All consecutive eligible patients are entered into this database, and information on demographics, procedure, and lesion characteristics as well as complications were documented. Descriptive statistical analyses were performed. A total of 310 diagnostic procedures were performed over a 1-year period in four institutions by 15 different clinicians. The majority of the patients were white (66%), male (56%), former smokers (55%), with a mean age of 61 +/- 14 years. The average procedure time was 36 min, and the most common procedure was transbronchial needle aspiration (TBNA) (n = 198). Nodal tissue was obtained in 82.3% from TBNA sampling with a mean of three passes using endobronchial ultrasound guidance with a 22-gauge needle and mostly without on-site cytology. The overall diagnostic yield for all procedures was 75%. There were few complications, and none required a change in disposition. Prospective and ongoing data analysis for bronchoscopic procedures is feasible and valuable. Lesion-adjusted diagnostic yields can be documented and potentially used for comparative assessment of different technologies and operators, as well as benchmarking and quality improvement initiatives. Extending the number of participating centers and web-based submission to minimize missing data components are the next, already-initiated steps.
    Chest 04/2010; 138(1):165-70. · 5.85 Impact Factor
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    ABSTRACT: The advent of endoscopic lung volume reduction (ELVR), especially relying on valve technology to achieve atelectasis, has aroused new interest in the assessment of collateral ventilation, which has been implicated in ELVR failures. We are reporting on the use of a catheter-based device that measures airway pressures and flows, and calculates airway resistance in vivo. To assess the safety of this catheter-based system and the feasibility of obtaining measurements predictive of atelectasis after ELVR. Patients undergoing ELVR were prospectively included in this double-blind cohort study. Each lobe targeted for ELVR was blocked with a catheter system (Chartis® System; Pulmonx, Inc., Redwood, Calif., USA); pressures and flows were assessed continuously. The primary endpoints were to evaluate the safety and feasibility; the secondary endpoint was to assess whether there was a relationship between the measurements and the incidence of atelectasis following ELVR. From June 2008 to November 2008, 25 patients were included in the study. All procedures could be performed without any complications. Due to pneumothorax in 1 case and inability to assess the catheter-based measurements in 4 cases, the final analysis included 20 patients. Atelectasis occurred in 8 out of 20 cases following implantation. In 18 patients (90%), the resistance measurements correlated with the postimplantation atelectasis visualized on a chest X-ray; in 2 patients (10%), a mismatch was detected. Resistance measurements were safely and successfully achieved. In 90% of the analyzable cases, the resistance measurements correlated with the occurrence of atelectasis after ELVR. The clinical impact of these findings will need to be evaluated in subsequent trials.
    Respiration 01/2010; 80(5):419-25. · 2.62 Impact Factor
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    Armin Ernst, Gaëtane Michaud
    Chest 12/2009; 136(6):1447-8. · 5.85 Impact Factor
  • Gaëtane Michaud, Chakravarthy Reddy, Armin Ernst
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    ABSTRACT: Pulmonary alveolar proteinosis (PAP) is a disease characterized by the deposition of amorphous lipoproteinaceous material in the alveoli secondary to abnormal processing of surfactant by macrophages. Whole-lung lavage often is performed as the first line of treatment for this disease because it is a means to wash out the proteinaceous material from the alveoli and reestablish effective oxygenation and ventilation. Whole-lung lavage is a large-volume BAL that is performed mainly in the treatment of PAP. In brief, it involves the induction of general anesthesia followed by isolation of the two lungs with a double-lumen endotracheal tube and performance of single-lung ventilation while large-volume lavages are performed on the nonventilated lung. Warmed normal saline solution in 1-L aliquots (total volumes up to 20 L) is instilled into the lung, chest physiotherapy is performed, then the proteinaceous effluent is drained with the aid of postural positioning. The sequence of events is repeated until such time as the effluent, which is initially milky and opaque, becomes clear. This procedure results in significant clinical and radiographic improvement secondary to the washing out of the proteinaceous material from the alveoli. The whole-lung lavage video details all aspects of the procedure, including case selection, patient preparation and equipment, a step-by-step review of the procedure, and postoperative considerations.
    Chest 12/2009; 136(6):1678-81. · 5.85 Impact Factor
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    ABSTRACT: Bronchoscopic procedures to ablate endobronchial lesions (EBL) from renal cell carcinoma (RCC) are frequently complicated by hemorrhage because of the vascular nature of the metastases. After ablation, recurrence of symptoms from the EBLs is common. Photodynamic therapy (PDT), because of its mode of action, may be a safer and a more effective alternative in the nonemergent management of EBL from RCC. Medical records of patients undergoing PDT at the authors' institutions between December 2005 and December 2008 were reviewed and patients undergoing treatment for EBLs from RCC were identified. Procedure-related complications, 30-day mortality, and efficacy of PDT measured by recurrence in symptoms and the need for additional interventions on the treated EBLs were reviewed. Eleven patients underwent a total of 13 treatments with PDT. Hemoptysis, with or without symptomatic airway obstruction, was the most common presenting symptom. The most common location for the EBLs was the lobar or segmental bronchi. Six patients had undergone other interventions (rigid bronchoscopy, mechanical debridement, or argon plasma coagulation) before treatment with PDT, with recurrence in symptoms. No immediate complications were seen with PDT and none of the patients had recurrence of symptoms or required airway interventions during the 30-day follow-up. Four patients died at a median of 4 months (range: 3 to 6 mo) after PDT and all deaths were due to progression of cancer and none of the deaths were due to airway complications. PDT is a safe and effective option for the management of hemoptysis or airway obstruction caused by EBLs from RCC.
    Journal of bronchology & interventional pulmonology. 10/2009; 16(4):245-9.
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    ABSTRACT: Airway stents are commonly used to palliate malignant central airway obstruction and tracheo-/bronchoesophageal fistulas. Despite their efficacy in immediately relieving airway obstruction, they can be associated with a variety of complications. We report the case of a 44-year-old woman with a malignant bronchoesophageal fistula treated initially with a self-expanding silicone mesh stent in the left main bronchus followed 2 weeks later by an esophageal stent. Shortly afterward, she presented with chest pain, worsening cough, and breathlessness. A CT scan of the chest revealed the airway stent in the contralateral mediastinum perforating the right main bronchus. We discuss her subsequent management and complications associated with self-expanding airway stents in this setting.
    Chest 06/2009; 135(5):1353-5. · 5.85 Impact Factor