Gaetane Michaud

Yale-New Haven Hospital, New Haven, Connecticut, United States

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Publications (49)232.87 Total impact

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    ABSTRACT: Aim: To compare measurements of expiratory collapse obtained using multidetector computed tomography (MDCT) of the central airways on routine axial and multiplanar reformatted (MPR) images. Materials and methods: Fifty volunteers with normal pulmonary function and no smoking history were imaged using a 64 MDCT system (40 mAs, 120 kVp, 0.625 mm collimation) with spirometric monitoring at end-inspiration and during forced expiration. Measurements of the trachea, right main (RMB) and left main bronchus (LMB) were obtained on axial and MPR images. Inspiratory and dynamic-expiratory cross-sectional area (CSA) measurements were used to calculate the mean percentage expiratory collapse (%Collapse). A paired t-test was used to assess within-subject differences and a Bland-Altman plot was used to assess agreement between the methods. Results: Among 24 men and 26 women (mean age±standard deviation 50±15 years), CSA values were significantly greater on axial than MPR images (all p<0.001); however, the mean difference in %Collapse values for axial versus MPR were small: trachea ≈1% (55 ±19 versus 56±18, p=0.338); LMB identical (60±20 versus 60±17 p=0.856); and, RMB 4% (62 ±19 versus 66±19 p<0.001). On average, creation of MPR required 12 minutes of additional time per case (range=10-15 min). Conclusion: Differences in mean %Collapse for axial versus MPR images were small and unlikely to influence clinical management. This finding suggests that MPR may not be indicated for routine assessment of central airway collapse.
    No preview · Article · Nov 2015 · Clinical Radiology

  • No preview · Article · Sep 2015 · Annals of the American Thoracic Society
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    ABSTRACT: Rationale: Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN to standard bronchoscopy. Objective: To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations. Methods: We used the AQuIRE registry to conduct a multicenter study of consecutive patients undergoing transbronchial biopsy (TBBx) for evaluation of peripheral lesions. Results: Fifteen centers with twenty-two physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no r-EBUS and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis peripheral transbronchial needle aspiration (TBNA), larger size, non-upper lobe location, and tobacco use were associated with increased diagnostic yield while EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic while TBBx was non-diagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33-73% (p=0.16). Conclusions: Peripheral TBNA improved diagnostic yield for peripheral lesions but was underutilized. The diagnostic yield of EMN and r-EBUS were lower than expected even after adjustment.
    No preview · Article · Sep 2015 · American Journal of Respiratory and Critical Care Medicine
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    ABSTRACT: The clinical practice of pulmonary and critical care medicine requires procedural competence in many technical domains, including vascular access, airway management, basic and advanced bronchoscopy, pleural procedures, and critical care ultrasonography. Simulation provides opportunities for standardized training and assessment in procedures without placing patients at undue risk. A growing body of literature supports the use and effectiveness of low-fidelity and high-fidelity simulators for procedural training and assessment. In this manuscript by the Skills-based Working Group of the American Thoracic Society Education Committee, we describe the background, available technology, and current evidence related to simulation-based skills training within pulmonary and critical care medicine. We outline working group recommendations for key procedural domains.
    No preview · Article · Feb 2015

  • No preview · Article · Sep 2014
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    ABSTRACT: Decision-Making in Lung CancerSESSION TYPE: Original Investigation SlidePRESENTED ON: Wednesday, October 30, 2013 at 07:30 AM - 09:00 AMPURPOSE: Screening with LDCT reduces lung cancer mortality in the population defined by the National Lung Screening Trial (NLST). Screening of non-NLST populations is recommended by several guidelines, though benefits are unproven. Our group sought to compare physician estimates of the probability of lung cancer with published prediction models, and to determine whether presentation of the risk model results influenced physician decisions in considering lung cancer screening.METHODS: We surveyed physicians visiting the Yale Lung SCAN CHEST 2012 Center of Excellence exhibit using case vignettes (two that met NLST criteria and three that did not); participants were asked whether they would perform screening and to estimate lung cancer risk over 5 and 10 years. Physicians then viewed a tablet application generating risk predictions from five published lung cancer predictive models, and their decisions on whether to screen for lung cancer were again solicited.RESULTS: 102 physicians participated. For the two cases meeting the NLST criteria, 69% and 74% of physicians recommended screening. Physician estimates of 10-year lung cancer risk were 23% and 15%, compared to 6% and 11% predicted by the Bach model, respectively. After viewing the results from the model, 75% and 91% of physicians recommended screening, respectively. For the three non-NLST cases screening was recommended by 56%, 43%, and 84% of physicians; estimates of 5-year lung cancer risk were 15%, 11%, and 14%, compared to 0.1%, 8.5%, and 6.5% predicted by the Liverpool model, respectively. After viewing the model predictions, 31%, 57%, and 72% of physicians recommended screening, respectively.CONCLUSIONS: Compared to validated prediction models, physicians overestimated the risk of developing lung cancer. Physician decisions relating to screening appeared to be influenced by results of the prediction models.CLINICAL IMPLICATIONS: Clinical prediction models have the potential to inform physicians regarding individual risk of lung cancer and may influence decision-making regarding lung cancer screening. As the models become more user friendly, they may play an important role in comprehensive lung cancer screening programs.DISCLOSURE: Frank Detterbeck: Consultant fee, speaker bureau, advisory committee, etc.: Lilly - memeber of international staging committe and lectures about staging. , Consultant fee, speaker bureau, advisory committee, etc.: Oncimmune - avisory panel to review data, Consultant fee, speaker bureau, advisory committee, etc.: Pfizer - external grant administration board 2012, Grant monies (from industry related sources): Medela - particpated in a multicenter study of hte value of Medela thoracic drainage collection devices. Particpated as an advisory board of experts in 2009. , Consultant fee, speaker bureau, advisory committee, etc.: Covidien- Advisory board member 2009 , Grant monies (from industry related sources): Deepbreeze - PI of multicenter study to assess how well VRI can predict regional lung function and posoperative lung fucntion in patiens who are undergoing resection for lung cancer. The following authors have nothing to disclose: Amanda Reid, Gaetane Michaud, Paul Guillod, Lynn TanoueNo Product/Research Disclosure Information.
    No preview · Article · Oct 2013 · Chest
  • Christopher T Erb · Armin Ernst · Gaëtane C Michaud
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    ABSTRACT: Interventional pulmonologists are regularly asked to perform more complicated and advanced procedures, but reimbursement for the time, effort and skill involved in these procedures has not kept up with other procedural specialties. Further changes in funding and reimbursement are likely under the Affordable Care Act. Understanding and effectively using the current system of funding for interventional pulmonology practices are imperative as we adapt to changing medical needs, legislative mandates, and reimbursement policy. This article reviews the current landscape of insurance and reimbursement in health care and anticipates some changes that might be expected from implementation of the Affordable Care Act.
    No preview · Article · Sep 2013 · Clinics in chest medicine
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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.
    No preview · Article · Jul 2013 · COPD Journal of Chronic Obstructive Pulmonary Disease
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    ABSTRACT: Many patients with lung cancer will develop symptoms related to their disease process or the treatment they are receiving. These symptoms can be as debilitating as the disease progression itself. To many physicians these problems can be the most difficult to manage. A detailed review of the literature using strict methodologic review of article quality was used in the development of this article. MEDLINE literature reviews, in addition to Cochrane reviews and other databases, were used for this review. The resulting article lists were then reviewed by experts in each area for quality and finally interpreted for content. We have developed recommendations for the management of many of the symptom complexes that patients with lung cancer may experience: pain, dyspnea, airway obstruction, cough, bone metastasis, brain metastasis, spinal cord metastasis, superior vena cava syndrome, hemoptysis, tracheoesophageal fistula, pleural effusions, venous thromboembolic disease, depression, fatigue, anorexia, and insomnia. Some areas, such as dyspnea, are covered in considerable detail in previously created high-quality evidence-based guidelines and are identified as excellent sources of reference. The goal of this guideline is to provide the reader recommendations based on evidence supported by scientific study. Improved understanding and recognition of cancer-related symptoms can improve management strategies, patient compliance, and quality of life for all patients with lung cancer.
    No preview · Article · May 2013 · Chest
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    ABSTRACT: Stage III non-small cell lung cancer (NSCLC) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky nodal disease. This review updates the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients. Systematic searches were conducted through MEDLINE, Embase, and the Cochrane Database for Systematic Review up to December 2011, focusing primarily on randomized trials, selected meta-analyses, practice guidelines, and reviews. For individuals with stage IIIA or IIIB disease, good performance scores, and minimal weight loss, treatment with combined chemoradiotherapy results in better survival than radiotherapy alone. Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported. Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation. Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy; however, weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate. The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery. Postoperative radiotherapy improves local control without improving survival. Multimodality therapy is preferable in most subsets of patients with stage III lung cancer. Variability in the patients included in randomized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios. Future trials are needed to investigate the roles of individualized chemotherapy, surgery in particular cohorts or settings, prophylactic cranial radiation, and adaptive radiation.
    No preview · Article · May 2013 · Chest
  • Renelle Myers · Gaetane Michaud
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    ABSTRACT: Tunneled pleural catheters (TPCs) are a safe, effective, and well-tolerated option for palliation in patients with malignant pleural effusion (MPEs) on an outpatient basis. TPCs are incorporated into international guidelines for the management of MPEs and appear to be the most cost-effective option according to current data.
    No preview · Article · Mar 2013 · Clinics in chest medicine
  • Gaëtane Michaud
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    ABSTRACT: Approximately 1.5 million pleural effusions are diagnosed each year in the USA. Light’s Criteria are used to categorize the effusions into exudates and transudates on biochemical grounds. This distinction is important as the stratification helps elucidate the most probable etiologies leading to the accumulation of pleural fluid. Despite an appropriate evaluation including pleural fluid analysis, approximately one quarter of patients with exudative effusions will fail to have a cause identified. If medical thoracoscopy is performed and the histologic diagnosis is nonspecific pleuritis, conservative management has been shown to be appropriate.
    No preview · Article · Jan 2013
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    ABSTRACT: PURPOSE Chronic bronchitis has recently been reported in association with metabolic syndrome (MetS) among patients with COPD. Our purpose is to determine if another manifestation of the airway phenotype, dynamic expiratory tracheal collapse, is associated with MetS in patients with COPD. METHOD AND MATERIALS 100 COPD patients prospectively underwent pulmonary function testing (PFT), 6-minute walk test (6MWT), Saint George’s respiratory quality of life questionnaire (SGRQ), and spirometrically-monitored MDCT at total lung capacity (TLC) and during dynamic exhalation (64-MDCT, 40 mAs, 120 kVp, and 0.625 mm detector collimation). Cross-sectional area (CSA) of the trachea was measured 1 cm above the aortic arch at TLC and dynamic expiration, and percentage expiratory reduction in the tracheal lumen was calculated. We compared mean values of percentage expiratory tracheal collapse, 6MWT distance, and SGRQ scores between subgroups of COPD patients with and without coexisting MetS. RESULTS The presence or absence of MetS was definitively established in 94 participants. The two subgroups with (n=16) and without (n=78) MetS were similar in age and gender distribution (mean age, 65 ± 6 yrs versus 65 ± 7 yrs, respectively; 56% women versus 45% women respectively). Although percent predicted FEV1 did not differ significantly between the 2 subgroups (69 ± 17 versus 64 ± 23, p = 0.263), participants with MetS demonstrated significantly greater expiratory tracheal collapse (mean 69 ± 13% versus 57 ± 19%, p = 0.004), higher (worse) SGRQ scores (mean 48 ± 16 versus 35 ± 20, p = 0.012) and shorter 6MWT distance (mean 333 ± 145m versus 431 ± 114m, p = 0.019) compared to those without MetS. Similar differences were observed when the subgroup without MetS was limited to 16 age- and gender-matched controls: tracheal collapse = 69 ± 13% in MetS versus 54 ± 21% in controls (p=0.026); SGRQ = 48 ± 16 versus 37 ± 22 (p=0.121); and, 6MWT = 333 ± 145 versus 420 ± 106 (p=0.07). CONCLUSION COPD patients with coexisting MetS exhibit significantly greater expiratory tracheal collapse, worse respiratory quality of life, and decreased exercise capacity than those without MetS. This may reveal an association of MetS with an inflammatory airway phenotype that includes expiratory tracheal collapse. CLINICAL RELEVANCE/APPLICATION Radiologists and pulmonologists should have higher suspicion for excessive expiratory tracheal collapse in COPD patients with coexisting MetS.
    No preview · Conference Paper · Nov 2012
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    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 on 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%). Transbronchial lung biopsy (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 5 .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 were age . 70 years (OR, 4.06; 95% CI, 1.36-12.12; P 5 .012),inpatient status (OR, 4.93; 95% CI, 1.30-18.74; P 5 .019), and undergoing deep sedation or general anesthesia (OR, 4.68; 95% CI, 1.02-21.61; P 5 .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 5 .006).Interhospital variation in TBBx use when ROSE was used was significant ( P , .001). Conclusions: TBBx was the only risk factor for complications during EBUS-TBNA procedures.ROSE significantly reduced the use of TBBx.
    No preview · Article · Nov 2012 · Chest
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    ABSTRACT: Background: Many older patients with early stage non-small cell lung cancer (NSCLC) do not receive curative therapy. New surgical techniques and radiation therapy modalities, such as video-assisted thoracoscopic surgery (VATS), potentially allow more patients to receive treatment. The adoption of these techniques and their impact on access to cancer care among Medicare beneficiaries with stage I NSCLC are unknown. Methods: We used the Surveillance, Epidemiology and End Results-Medicare database to identify patients with stage I NSCLC diagnosed between 1998 and 2007. We assessed temporal trends and created hierarchical generalized linear models of the relationship between patient, clinical, and regional factors and type of treatment. Results: The sample comprised 13,458 patients with a mean age of 75.7 years. The proportion of patients not receiving any local treatment increased from 14.6% in 1998 to 18.3% in 2007. The overall use of surgical resection declined from 75.2% to 67.3% ( P , .001), although the proportion of patients undergoing VATS increased from 11.3% to 32.0%. Similarly, although the use of new radiation modalities increased from 0% to 5.2%, the overall use of radiation remained stable. The oldest patients were less likely to receive surgical vs no treatment (OR, 0.12; 95% CI, 0.09-0.16) and more likely to receive radiation vs surgery (OR, 13.61; 95% CI, 9.75-19.0). Conclusion: From 1998 to 2007, the overall proportion of older patients with stage I NSCLC receiving curative local therapy decreased, despite the dissemination of newer, less-invasive forms of surgery and radiation.
    No preview · Article · Sep 2012 · Chest
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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 patients with COPD and to test the hypothesis that clinical and/or physiologic parameters will correlate with the presence of excessive tracheal collapse. Methods: We studied 100 adults meeting GOLD (Global Initiative for Obstructive Lung Disease) criteria for COPD, who underwent full pulmonary function tests (PFTs), 6-min walk test (6MWT), St. George's Respiratory Questionnaire (SGRQ), and low-dose CT scan 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, FEV₁ 64% ± 22% 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 = .03). Conclusions: Excessive expiratory tracheal collapse is observed in a subset of patients with COPD, but the magnitude of collapse is independent of disease severity and does not correlate significantly with physiologic parameters. Thus, the incidental identification of excessive expiratory tracheal collapse in a general COPD population may not necessarily be clinically significant.
    No preview · Article · Jun 2012 · Chest
  • Source
    Andrés F. Sosa · Gaëtane C. Michaud
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    ABSTRACT: Metallic stents have proven to be valuable tools for the management of both malignant and benign airway obstruction. Their use has become popular worldwide as has our knowledge of their long-term effects on the airway. It is essential to understand the implications of placing a metallic stent since they are not devoid of potentially significant complications. It is also important to acknowledge that metallic stents are not always easily removed and a lack of familiarity with the complexities of their removal can have serious consequences. In general, their use should be reserved for malignant airway obstruction or in rare cases of benign disease where all other options have been ruled out.
    Full-text · Article · Mar 2012
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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.
    Preview · Article · Jan 2012 · Journal of Oncology Practice
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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.
    No preview · Article · Oct 2011 · Journal of Bronchology and Interventional Pulmonology
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    Gaetane Michaud · Armin Ernst

    Preview · Article · Sep 2011 · Chest

Publication Stats

560 Citations
232.87 Total Impact Points


  • 2012-2015
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
  • 2011-2015
    • Yale University
      New Haven, Connecticut, United States
    • St. Elizabeth's Medical Center
      Boston, Massachusetts, United States
  • 2014
    • Oregon Health and Science University
      • Department of Medicine
      Portland, Oregon, United States
  • 2008-2012
    • Beth Israel Deaconess Medical Center
      • Department of Radiology
      Boston, Massachusetts, United States
  • 2008-2011
    • Harvard University
      Cambridge, Massachusetts, United States