1
|
Bhadra K, Baleeiro C, Patel S, Condra W, Bader BA, Setser RM, Youngblood S. High Tidal Volume, High Positive End Expiratory Pressure and Apneic Breath Hold Strategies (Lung Navigation Ventilation Protocol) With Cone Beam Computed Tomography Bronchoscopic Biopsy of Peripheral Lung Lesions: Results in 100 Patients. J Bronchology Interv Pulmonol 2024; 31:105-116. [PMID: 37459049 PMCID: PMC10984636 DOI: 10.1097/lbr.0000000000000938] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/31/2023] [Indexed: 04/04/2024]
Abstract
BACKGROUND A dedicated anesthesia protocol for bronchoscopic lung biopsy-lung navigation ventilation protocol (LNVP)-specifically designed to mitigate atelectasis and reduce unnecessary respiratory motion, has been recently described. LNVP demonstrated significantly reduced dependent ground glass, sublobar/lobar atelectasis, and atelectasis obscuring target lesions compared with conventional ventilation. METHODS In this retrospective, single-center study, we examine the impact of LNVP on 100 consecutive patients during peripheral lung lesion biopsy. We report the incidence of atelectasis using cone beam computed tomography imaging, observed ventilatory findings, anesthesia medications, and outcomes, including diagnostic yield, radiation exposure, and complications. RESULTS Atelectasis was observed in a minority of subjects: ground glass opacity atelectasis was seen in 30 patients by reader 1 (28%) and in 18 patients by reader 2 (17%), with good agreement between readers (κ = 0.78). Sublobar/lobar atelectasis was observed in 23 patients by reader 1 and 26 patients by reader 2, also demonstrating good agreement (κ = 0.67). Atelectasis obscured target lesions in very few cases: 0 patients (0%, reader 1) and 3 patients (3%, reader 2). Diagnostic yield was 85.9% based on the AQuIRE definition. Pathology demonstrated 57 of 106 lesions (54%) were malignant, 34 lesions (32%) were benign, and 15 lesions (14%) were nondiagnostic. CONCLUSION Cone beam computed tomography images confirmed low rates of atelectasis, high tool-in-lesion confirmation rate, and high diagnostic yield. LNVP has a similar safety profile to conventional bronchoscopy. Most patients will require intravenous fluid and vasopressor support. Further study of LNVP and other ventilation protocols are necessary to understand the impact of ventilation protocols on bronchoscopic peripheral lung biopsy.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Sloan Youngblood
- American Anesthesia of Tennessee, CHI Memorial Hospital, Chattanooga, TN
| |
Collapse
|
2
|
Bhadra K, Setser RM, Condra W, Bader BA, David S. A Cone Beam CT Bronchoscopy Study of the Ultrathin Cryoprobe for Biopsy of Peripheral Lung Lesions. J Bronchology Interv Pulmonol 2024; 31:117-125. [PMID: 37450607 PMCID: PMC10984630 DOI: 10.1097/lbr.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 05/28/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Compared with the standard cryoprobe, the novel ultrathin 1.1 mm cryoprobe (UTCP) has improved ergonomics, shape memory, and flexibility. The performance of UTCP has demonstrated promising results in several small trials. METHODS In this single-center, retrospective review, we examine 200 (N=200) consecutive patients referred for cone beam CT bronchoscopic biopsy of peripheral lung lesions. We utilized an extended multimodality approach, including transbronchial needle aspirate, brush, traditional forces biopsies, UTCP biopsies, and BAL. We analyzed tool in lesion, tool touch lesion, center strike rates, and diagnostic yield. We assessed for molecular adequacy and analyzed safety. RESULTS A total of 222 lesions were biopsied. We achieved a tool in lesion or tool touch lesion confirmation for all biopsy attempts (100%) and a center strike rate of 68%. AQuIRE diagnostic yield was 90%, with 60% malignant, 30% benign lung nodules, and 10% nondiagnostic. UTCP was diagnostic in 3.6 % of peripheral lung lesions biopsies when all other modalities were nondiagnostic; thus, raising our overall diagnostic yield from 86.4% to 90.1%. Our analysis demonstrates superior adequacy for molecular analysis for histologic samples (TBBX or UTCP) versus cytologic samples (FNA) ( P <0.001). Three patients (1.5%) had a pneumothorax, and 1 patient (0.5%) had moderate bleeding. CONCLUSION UTCP was diagnostic in 3.6% of peripheral lung lesions when all other modalities were nondiagnostic. In the setting of CBCT guidance, UTCP has a similar safety profile to standard biopsy tools. Future trials are warranted to assess UTCP and its impact on peripheral lung lesion biopsies.
Collapse
Affiliation(s)
- Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga, TN
| | | | - William Condra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga, TN
| | | | - Stephanie David
- Diagnostic Pathology Services, CHI Memorial Hospital, Chattanooga, TN
| |
Collapse
|
3
|
Soumagne T, Dutau H, Eapen G, Guibert N, Hergott C, Maldonado F, Saka H, Fortin M. An International Survey of Practices in the Investigation and Endoscopic Treatment of Peripheral Pulmonary Lesions amongst Interventional Bronchoscopists. Respiration 2024; 103:146-154. [PMID: 38402862 DOI: 10.1159/000536271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 12/18/2023] [Indexed: 02/27/2024] Open
Abstract
INTRODUCTION The investigation of peripheral pulmonary lesions (PPLs) can be challenging. Several bronchoscopic modalities have been developed to reach and biopsy PPL but the level of adoption of these techniques by interventional pulmonologists (IPs) is unknown. This international survey was conducted to describe current practices in PPL investigation among IP. METHODS This survey was sent to all members of the World Association for Bronchology and Interventional Pulmonology, Canadian Thoracic Society Procedures Assembly, AABIP, and the Groupe d'Endoscopie Thoracique et Interventionnel Francophone. The survey was composed of 48 questions and three clinical cases to establish a portrait of modalities used to investigate and treat PPL by IP around the world. RESULTS Three hundred and twelve IP responded to the survey. Most of them practice in Europe (n = 122), North America (n = 97), and Asia (n = 49). Half of responders perform more than 100 endoscopic procedures for PPL annually. General anesthesia and conscious sedation are used in similar proportions (53% and 47%, respectively). Rapid on site evaluation (ROSE) is used when sampling PPL by 42%. Radial EBUS (69%), fluoroscopy (55%), and electromagnetic navigation (27%) are the most widely used techniques. Most IP combine techniques (89%). Robotic bronchoscopy (15%) and cone-beam CT (8%) are almost exclusively used in the USA where, respectively, 60% and 37% of respondents reported using these modalities. Ten percent of IP currently had access to endoscopic treatment modalities for PPL. However, half of the remaining IP plan to acquire an endoscopic treatment modality in the next 2 years. CONCLUSION Available techniques and practices worldwide vary significantly regarding PPL investigation and treatment.
Collapse
Affiliation(s)
- Thibaud Soumagne
- Department of Pulmonology and Thoracic Surgery, Quebec Heart and Lung Institute, Laval University, Quebec, Québec, Canada
- Respiratory Medicine, Intensive Care and Bronchoscopy Department, European Hospital Georges Pompidou, APHP, Paris, France
| | - Hervé Dutau
- Thoracic Oncology, Pleural Diseases and Interventional Pulmonology Department, North University Hospital, Marseille, France
| | - Georgie Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicolas Guibert
- Interventional Pulmonology Unit, Pulmonology Department, Hospital Larrey, Toulouse, France
| | - Christopher Hergott
- Department of Medicine, Division of Respirology University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Fabien Maldonado
- Interventional Pulmonology, Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hideo Saka
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
- Department of Respiratory Medicine, Matsunami General Hospital, Gifu, Japan
| | - Marc Fortin
- Department of Pulmonology and Thoracic Surgery, Quebec Heart and Lung Institute, Laval University, Quebec, Québec, Canada
| |
Collapse
|
4
|
Khan A, Bashour S, Sabath B, Lin J, Sarkiss M, Song J, Sagar AES, Shah A, Casal RF. Severity of Atelectasis during Bronchoscopy: Descriptions of a New Grading System ( Atelectasi sSeverity Scoring System-"ASSESS") and At-Risk-Lung Zones. Diagnostics (Basel) 2024; 14:197. [PMID: 38248073 PMCID: PMC10814045 DOI: 10.3390/diagnostics14020197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
Atelectasis during bronchoscopy under general anesthesia is very common and can have a detrimental effect on navigational and diagnostic outcomes. While the intraprocedural incidence and anatomic location have been previously described, the severity of atelectasis has not. We reviewed chest CT images of patients who developed atelectasis in the VESPA trial (Ventilatory Strategy to Prevent Atelectasis). By drawing boundaries at the posterior chest wall (A), the anterior aspect of the vertebral body (C), and mid-way between these two lines (B), we delineated at-risk lung zones 1, 2, and 3 (from posterior to anterior). An Atelectasis Severity Score System ("ASSESS") was created, classifying atelectasis as "mild" (zone 1), "moderate" (zones 1-2), and "severe" (zones 1-2-3). A total of 43 patients who developed atelectasis were included in this study. A total of 32 patients were in the control arm, and 11 were in the VESPA arm; 20 patients (47%) had mild atelectasis, 20 (47%) had moderate atelectasis, and 3 (6%) had severe atelectasis. A higher BMI was associated with increased odds (1.5 per 1 unit change; 95% CI, 1.10-2.04) (p = 0.0098), and VESPA was associated with decreased odds (0.05; 95% CI, 0.01-0.47) (p = 0.0080) of developing moderate to severe atelectasis. ASSESS is a simple method used to categorize intra-bronchoscopy atelectasis, which allows for a qualitative description of this phenomenon to be developed. In the VESPA trial, a higher BMI was not only associated with increased incidence but also increased severity of atelectasis, while VESPA had the opposite effect. Preventive strategies should be strongly considered in patients with risk factors for atelectasis who have lesions located in zones 1 and 2, but not in zone 3.
Collapse
Affiliation(s)
- Asad Khan
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (B.S.); (J.L.)
| | - Sami Bashour
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (B.S.); (J.L.)
| | - Bruce Sabath
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (B.S.); (J.L.)
| | - Julie Lin
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (B.S.); (J.L.)
| | - Mona Sarkiss
- Department of Anesthesia and Peri-Operative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ala-Eddin S. Sagar
- Department of Internal Medicine, King Faisal Specialist Hospital and Research Center, Madinah 42523, Saudi Arabia;
| | - Archan Shah
- Department of Onco-Medicine, Banner MD Anderson Cancer Center, Gilbert, AZ 85234, USA;
| | - Roberto F. Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (B.S.); (J.L.)
| |
Collapse
|
5
|
Shaller BD, Sethi S, Cicenia J. Imaging in peripheral bronchoscopy. Curr Opin Pulm Med 2024; 30:17-24. [PMID: 37933680 DOI: 10.1097/mcp.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
PURPOSE OF REVIEW Historically the sampling of peripheral lung lesions via bronchoscopy has suffered from inferior diagnostic outcomes relative to transthoracic needle aspiration, and neither a successful bronchoscopic navigation nor a promising radial ultrasonographic image of one's target lesion guarantees a successful biopsy. Fortunately, many of peripheral bronchoscopy's shortcomings - including an inability to detect and compensate for computed tomography (CT)-body divergence, and the absence of tool-in-lesion confirmation - are potentially remediable through the use of improved intraprocedural imaging techniques. RECENT FINDINGS Recent advances in intraprocedural imaging, including the integration of cone beam CT, digital tomosynthesis, and augmented fluoroscopy into bronchoscopic procedures have yielded promising results. These advanced imaging modalities may improve the outcomes of peripheral bronchoscopy through the detection and correction of navigational errors, CT-body divergence, and malpositioned biopsy instruments. SUMMARY The incorporation of advanced imaging is an essential step in the improvement of peripheral bronchoscopic procedures.
Collapse
Affiliation(s)
- Brian D Shaller
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, California
| | - Sonali Sethi
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph Cicenia
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
6
|
Sarkiss M, Lin J, Sabath BF, Casal RF. Selecting the Optimal Strategy to Prevent Atelectasis During Bronchoscopy. J Bronchology Interv Pulmonol 2024; 31:93-94. [PMID: 37811565 DOI: 10.1097/lbr.0000000000000952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Affiliation(s)
- Mona Sarkiss
- Department of Anesthesiology and Perioperative Medicine
| | - Julie Lin
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce F Sabath
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
7
|
Bhadra K, Rickman OB, Mahajan AK, Hogarth DK. "Tool-in-lesion" Accuracy of Galaxy System-A Robotic Electromagnetic Navigation BroncHoscopy With Integrated Tool-in-lesion-Tomosynthesis Technology: The MATCH Study. J Bronchology Interv Pulmonol 2024; 31:23-29. [PMID: 37072895 PMCID: PMC10763708 DOI: 10.1097/lbr.0000000000000923] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 03/21/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND The Galaxy System (Noah Medical) is a novel robotic endoluminal platform using electromagnetic navigation combined with integrated tomosynthesis technology and augmented fluoroscopy. It provides intraprocedural imaging to correct computerized tomography (CT) to body divergence and novel confirmation of tool-in-lesion (TIL). The primary aim of this study was to assess the TIL accuracy of the robotic bronchoscope with integrated digital tomosynthesis and augmented fluoroscopy. METHODS Four operators conducted the experiment using 4 pigs. Each physician performed between 4 and 6 nodule biopsies for 20 simulated lung nodules with purple dye and a radio pacifier. Using Galaxy's "Tool-in-Lesion Tomography (TOMO+)" with augmented fluoroscopy, the physician navigated to the lung nodules, and a tool (needle) was placed into the lesion. TIL was defined by the needle in the lesion determined by cone-beam CT. RESULTS The lung nodule's average size was 16.3 ± 0.97 mm and was predominantly in the lower lobes (65%). All 4 operators successfully navigated to all (100%) of the lesions in an average of 3 minutes and 39 seconds. The median number of tomosynthesis sweeps was 3 and augmented fluoroscopy was utilized in most cases (17/20 or 85%). TIL after the final TOMO sweep was 95% (19/20) and tool-touch-lesion was 5% (1/20). Biopsy yielding purple pigmentation was also 100% (20/20). CONCLUSION The Galaxy System demonstrated successful digital TOMO confirmed TIL success in 95% (19/20) of lesions and tool-touch-lesion in 5% (1/20) as confirmed by cone-beam CT. Successful diagnostic yield was achieved in 100% (20/20) of lesions as confirmed by intralesional pigment acquisition.
Collapse
Affiliation(s)
- Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga
| | | | | | | |
Collapse
|
8
|
Graham J, Basist M, Frye L, Agrawal A, Nasim F. Advances in navigating to the nodule and targeting. Curr Opin Pulm Med 2024; 30:9-16. [PMID: 37930633 DOI: 10.1097/mcp.0000000000001021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
PURPOSE OF REVIEW The multitude of available platforms and imaging modalities for navigational bronchoscopy, in combination with the various sampling tools that can be used intra-procedurally, is complex. This review seeks to describe the recent developments in peripheral bronchoscopy in regards to navigation, imaging, and sampling target lesions in the pulmonary parenchyma. RECENT FINDINGS Robotic assisted bronchoscopy has improved navigation to the peripheral airways for sampling of peripheral parenchymal lesions. These navigational platforms use innovative technology utilizing electromagnetic navigation and shape-sensing technology for guidance. The greatest improvement has been the stabilization of the robotic scope in the periphery to allow for accurate sampling. Despite improvements in these platforms, limitations of CT to body divergence continue to impact navigation to the lesion and therefore diagnostic yield of the procedure. Advanced intraprocedural imaging with cone beam CT or augmented fluoroscopy has been a recent focus to improve this area. Further, the adoption of newer sampling tools, such as cryobiopsy, offers the possibility of increased diagnostic yield. SUMMARY The developments in advanced bronchoscopy will impact the role of biopsy in the diagnosis of peripheral pulmonary parenchymal lesions.
Collapse
Affiliation(s)
- Jeffrey Graham
- Interventional Pulmonology, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah Health, Salt Lake City, Utah
| | - Madeleine Basist
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Laura Frye
- Interventional Pulmonology, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah Health, Salt Lake City, Utah
| | - Abhinav Agrawal
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Faria Nasim
- Interventional Pulmonology, Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
9
|
Sikachi RR, Mishra KL, Anders M. Anesthetic considerations in interventional pulmonology. Curr Opin Pulm Med 2024; 30:99-106. [PMID: 37930637 DOI: 10.1097/mcp.0000000000001033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
PURPOSE OF REVIEW In this review, we highlight the important anesthetic consideration that relate to interventional bronchoscopic procedures for the management of central airway obstruction due to anterior mediastinal masses, endoluminal endobronchial obstruction, peripheral bronchoscopy for diagnosis and treatment of lung nodules, bronchoscopic lung volume reduction and medical pleuroscopy for diagnosis and management of pleural diseases. RECENT FINDINGS The advent of the field of Interventional Pulmonology has allowed for minimally invasive options for patients with a wide range of lung diseases which at times have replaced more invasive surgical procedures. Ongoing research has shed light on advancement in anesthetic techniques and management strategies that have increased the safety during peri-operative management during these complex procedures. Current evidence focusing on the anesthetic techniques is presented here. SUMMARY The field of Interventional Pulmonology requires a tailored anesthetic approach. Recent advancements and ongoing research have focused on expanding the partnership between the anesthesiologist and interventional pulmonologists which has led to improved outcomes for patients undergoing these procedures.
Collapse
Affiliation(s)
- Rutuja R Sikachi
- Department of Anesthesiology, Perioperative and Pain Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Kelly Louise Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Megan Anders
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
10
|
DiBardino DM, Kim RY, Cao Y, Andronov M, Lanfranco AR, Haas AR, Vachani A, Ma KC, Hutchinson CT. Diagnostic Yield of Cone-beam-Derived Augmented Fluoroscopy and Ultrathin Bronchoscopy Versus Conventional Navigational Bronchoscopy Techniques. J Bronchology Interv Pulmonol 2023; 30:335-345. [PMID: 35920067 PMCID: PMC10538603 DOI: 10.1097/lbr.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pulmonary nodules suspicious for lung cancer are frequently diagnosed. Evaluating and optimizing the diagnostic yield of lung nodule biopsy is critical as innovation in bronchoscopy continues to progress. METHODS This is a retrospective cohort study. Consecutive patients undergoing guided bronchoscopy for suspicious pulmonary nodule(s) between February 2020 and July 2021 were included. The cone-beam computed tomography (CBCT)+ radial endobronchial ultrasound (r-EBUS) group had their procedure using CBCT-derived augmented fluoroscopy along with r-EBUS. The CBCT+ ultrathin bronchoscope (UTB)+r-EBUS group had the same procedure but with the use of an ultrathin bronchoscope. The r-EBUS group underwent r-EBUS guidance without CBCT or augmented fluoroscopy. We used multivariable logistic regression to compare diagnostic yield, adjusting for confounding variables. RESULTS A total of 116 patients were included. The median pulmonary lesion diameter was 19.5 mm (interquartile range, 15.0 to 27.5 mm), and 91 (78.4%) were in the peripheral half of the lung. Thirty patients (25.9%) underwent CBCT+UTB, 27 (23.3%) CBCT, and 59 (50.9%) r-EBUS alone with unadjusted diagnostic yields of 86.7%, 70.4%, and 42.4%, respectively ( P <0.001). The adjusted diagnostic yields were 85.0% (95% CI, 68.6% to 100%), 68.3% (95% CI, 50.1% to 86.6%), and 44.5% (95% CI, 31.0% to 58.0%), respectively. There was significantly more virtual navigational bronchoscopy use in the r-EBUS group (45.8%) compared with the CBCT+UTB (13.3%) and CBCT (18.5%) groups, respectively. CBCT procedures required dose area product radiation doses of 7602.5 µGym 2 . CONCLUSION Compared with the r-EBUS group, CBCT + UTB + r-EBUS was associated with higher navigational success, fewer nondiagnostic biopsy results, and a higher diagnostic yield. CBCT procedures are associated with a considerable radiation dose.
Collapse
Affiliation(s)
- David M. DiBardino
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Roger Y. Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Yulei Cao
- Drexel University College of Medicine, Philadelphia, PA
| | - Michelle Andronov
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Anthony R. Lanfranco
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Andrew R. Haas
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Anil Vachani
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Kevin C. Ma
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| | - Christoph T. Hutchinson
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Section of Interventional Pulmonology and Thoracic Oncology, Philadelphia, PA
| |
Collapse
|
11
|
Advanced Imaging for Robotic Bronchoscopy: A Review. Diagnostics (Basel) 2023; 13:diagnostics13050990. [PMID: 36900134 PMCID: PMC10001114 DOI: 10.3390/diagnostics13050990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Recent advances in navigational platforms have led bronchoscopists to make major strides in diagnostic interventions for pulmonary parenchymal lesions. Over the last decade, multiple platforms including electromagnetic navigation and robotic bronchoscopy have allowed bronchoscopists to safely navigate farther into the lung parenchyma with increased stability and accuracy. Limitations persist, even with these newer technologies, in achieving a similar or higher diagnostic yield when compared to the transthoracic computed tomography (CT) guided needle approach. One of the major limitations to this effect is due to CT-to-body divergence. Real-time feedback that better defines the tool-lesion relationship is vital and can be obtained with additional imaging using radial endobronchial ultrasound, C-arm based tomosynthesis, cone-beam CT (fixed or mobile), and O-arm CT. Herein, we describe the role of this adjunct imaging with robotic bronchoscopy for diagnostic purposes, describe potential strategies to counteract the CT-to-body divergence phenomenon, and address the potential role of advanced imaging for lung tumor ablation.
Collapse
|
12
|
Endoscopic Technologies for Peripheral Pulmonary Lesions: From Diagnosis to Therapy. Life (Basel) 2023; 13:life13020254. [PMID: 36836612 PMCID: PMC9959751 DOI: 10.3390/life13020254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/18/2023] Open
Abstract
Peripheral pulmonary lesions (PPLs) are frequent incidental findings in subjects when performing chest radiographs or chest computed tomography (CT) scans. When a PPL is identified, it is necessary to proceed with a risk stratification based on the patient profile and the characteristics found on chest CT. In order to proceed with a diagnostic procedure, the first-line examination is often a bronchoscopy with tissue sampling. Many guidance technologies have recently been developed to facilitate PPLs sampling. Through bronchoscopy, it is currently possible to ascertain the PPL's benign or malignant nature, delaying the therapy's second phase with radical, supportive, or palliative intent. In this review, we describe all the new tools available: from the innovation of bronchoscopic instrumentation (e.g., ultrathin bronchoscopy and robotic bronchoscopy) to the advances in navigation technology (e.g., radial-probe endobronchial ultrasound, virtual navigation, electromagnetic navigation, shape-sensing navigation, cone-beam computed tomography). In addition, we summarize all the PPLs ablation techniques currently under experimentation. Interventional pulmonology may be a discipline aiming at adopting increasingly innovative and disruptive technologies.
Collapse
|
13
|
Salahuddin M, Sarkiss M, Sagar AES, Vlahos I, Chang CH, Shah A, Sabath BF, Lin J, Song J, Moon T, Norman PH, Eapen GA, Grosu HB, Ost DE, Jimenez CA, Chintalapani G, Casal RF. Ventilatory Strategy to Prevent Atelectasis During Bronchoscopy Under General Anesthesia: A Multicenter Randomized Controlled Trial (Ventilatory Strategy to Prevent Atelectasis -VESPA- Trial). Chest 2022; 162:1393-1401. [PMID: 35803302 DOI: 10.1016/j.chest.2022.06.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Atelectasis negatively influences peripheral bronchoscopy, increasing CT scan-body divergence, obscuring targets, and creating false-positive radial-probe endobronchial ultrasound (RP-EBUS) images. RESEARCH QUESTION Can a ventilatory strategy reduce the incidence of atelectasis during bronchoscopy under general anesthesia? STUDY DESIGN AND METHODS Randomized controlled study (1:1) in which patients undergoing bronchoscopy were randomized to receive standard ventilation (laryngeal mask airway, 100% Fio2, zero positive end-expiratory pressure [PEEP]) vs a ventilatory strategy to prevent atelectasis (VESPA) with endotracheal intubation followed by a recruitment maneuver, Fio2 titration (< 100%), and PEEP of 8 to 10 cm H2O. All patients underwent chest CT imaging and a survey for atelectasis with RP-EBUS bilaterally on bronchial segments 6, 9, and 10 after artificial airway insertion (time 1) and 20 to 30 min later (time 2). Chest CT scans were reviewed by a blinded chest radiologist. RP-EBUS images were assessed by three independent, blinded readers. The primary end point was the proportion of patients with any atelectasis (either unilateral or bilateral) at time 2 according to chest CT scan findings. RESULTS Seventy-six patients were analyzed, 38 in each group. The proportion of patients with any atelectasis according to chest CT scan at time 2 was 84.2% (95% CI, 72.6%-95.8%) in the control group and 28.9% (95% CI, 15.4%-45.9%) in the VESPA group (P < .0001). The proportion of patients with bilateral atelectasis at time 2 was 71.1% (95% CI, 56.6%-85.5%) in the control group and 7.9% (95% CI, 1.7%-21.4%) in the VESPA group (P < .0001). At time 2, 3.84 ± 1.67 (mean ± SD) bronchial segments in the control group vs 1.21 ± 1.63 in the VESPA group were deemed atelectatic (P < .0001). No differences were found in the rate of complications. INTERPRETATION VESPA significantly reduced the incidence of atelectasis, was well tolerated, and showed a sustained effect over time despite bronchoscopic nodal staging maneuvers. VESPA should be considered for bronchoscopy when atelectasis is to be avoided. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04311723; URL: www. CLINICALTRIALS gov.
Collapse
Affiliation(s)
- Moiz Salahuddin
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mona Sarkiss
- Department of Anesthesia and Peri-Operative MedicineThe University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ala-Eddin S Sagar
- Department of Onco-Medicine, Banner MD Anderson Cancer Center, Gilbert, AZ
| | - Ioannis Vlahos
- Thoracic Imaging Department, Division of Diagnostic Imaging, Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher H Chang
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Archan Shah
- Department of Onco-Medicine, Banner MD Anderson Cancer Center, Gilbert, AZ
| | - Bruce F Sabath
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Julie Lin
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Teresa Moon
- Department of Anesthesia and Peri-Operative MedicineThe University of Texas MD Anderson Cancer Center, Houston, TX
| | - Peter H Norman
- Department of Anesthesia and Peri-Operative MedicineThe University of Texas MD Anderson Cancer Center, Houston, TX
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
| |
Collapse
|
14
|
Lentz RJ, Shojaee S. The Intersection of Ventilatory Strategy to Prevent Atelectasis and Teslas in Navigational Bronchoscopy. Chest 2022; 162:1236-1237. [PMID: 36494124 DOI: 10.1016/j.chest.2022.08.2202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/06/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- Robert J Lentz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Nashville, TN; Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Veterans Affairs Medical Center, Nashville, TN
| | - Samira Shojaee
- Division of Allergy, Pulmonary, and Critical Care Medicine, Nashville, TN; Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN.
| |
Collapse
|
15
|
Lateral Decubitus Positioning for Mobile CT-guided Robotic Bronchoscopy: A Novel Technique to Prevent Atelectasis. J Bronchology Interv Pulmonol 2022; 29:220-223. [PMID: 35730780 DOI: 10.1097/lbr.0000000000000844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/09/2021] [Indexed: 11/27/2022]
|
16
|
Should We Start With Navigation or Endobronchial Ultrasound Bronchoscopy?: Insights From Monte Carlo Simulations. Chest 2022; 162:265-268. [PMID: 35248550 DOI: 10.1016/j.chest.2022.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/16/2022] [Accepted: 02/23/2022] [Indexed: 12/16/2022] Open
|
17
|
Reisenauer J, Duke JD, Kern R, Fernandez-Bussy S, Edell E. Combining Shape-Sensing Robotic Bronchoscopy With Mobile Three-Dimensional Imaging to Verify Tool-in-Lesion and Overcome Divergence: A Pilot Study. MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES 2022; 6:177-185. [PMID: 35509435 PMCID: PMC9059066 DOI: 10.1016/j.mayocpiqo.2022.02.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective To determine whether CT-to-body divergence can be overcome to improve the diagnostic yield of peripheral pulmonary nodules with the combination of shape-sensing robotic-assisted bronchoscopy (SSRAB) and portable 3-dimensional (3D) imaging. Patients and Methods A single-center, prospective, pilot study was conducted from February 9, 2021, to August 4, 2021, to evaluate the combined use of SSRAB and portable 3D imaging to visualize tool-in-lesion as a correlate to diagnostic yield. Results Thirty lesions were subjected to biopsy in 17 men (56.7%) and 13 women (43.3%). The median lesion size was 17.5 mm (range, 10-30 mm), with the median airway generation of 7 and the median distance from pleura of 14.9 mm. Most lesions were in the upper lobes (18, 60.0%). Tool-in-lesion was visualized at the time of the procedure in 29 lesions (96.7%). On the basis of histopathologic review, 22 (73.3%) nodules were malignant and 6 (20.0%) were benign. Two (6.7%) specimens were suggestive of inflammation, and the patients elected observation. The mean number of spins was 2.5 (±1.6) with a mean fluoroscopy time of 8.7 min and a mean dose area product of 50.3 Gy cm2 (±32.0 Gy cm2). There were no episodes of bleeding or pneumothorax. The diagnostic yield was 93.3%. Conclusion This pilot study shows that the combination of mobile 3D imaging and SSRAB of pulmonary nodules appears to be safe and feasible. In conjunction with appropriate anesthetic pathways, nodule motion and divergence can be overcome in most patients. Trial Registration https://clinicaltrials.gov Identifier NCT04740047
Collapse
Affiliation(s)
- Janani Reisenauer
- Division of Thoracic Surgery, Mayo Clinic Rochester MN
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester MN
- Correspondence: Address to Janani Reisenauer, MD, Division of General Thoracic Surgery, Mayo Clinic, 200 1st St, SW, Rochester, MN 55905.
| | - Jennifer D. Duke
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester MN
| | - Ryan Kern
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester MN
| | | | - Eric Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester MN
| |
Collapse
|
18
|
Wagner MG, Periyasamy S, Schafer S, Laeseke PF, Speidel MA. Three-dimensional catheter navigation of airways using continuous-sweep limited angle fluoroscopy on a C-arm. J Med Imaging (Bellingham) 2021; 8:055001. [PMID: 34671695 DOI: 10.1117/1.jmi.8.5.055001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 10/01/2021] [Indexed: 11/14/2022] Open
Abstract
Purpose: To develop an imaging-based 3D catheter navigation system for transbronchial procedures including biopsy and tumor ablation using a single-plane C-arm x-ray system. The proposed system provides time-resolved catheter shape and position as well as motion compensated 3D airway roadmaps. Approach: A continuous-sweep limited angle (CLA) imaging mode where the C-arm continuously rotates back and forth within a limited angular range while acquiring x-ray images was used for device tracking. The catheter reconstruction was performed using a sliding window of the most recent x-ray images, which captures information on device shape and position versus time. The catheter was reconstructed using a model-based approach and was displayed together with the 3D airway roadmap extracted from a pre-navigational cone-beam CT (CBCT). The roadmap was updated in regular intervals using deformable registration to tomosynthesis reconstructions based on the CLA images. The approach was evaluated in a porcine study (three animals) and compared to a gold standard CBCT reconstruction of the device. Results: The average 3D root mean squared distance between CLA and CBCT reconstruction of the catheter centerline was 1 ± 0.5 mm for a stationary catheter and 2.9 ± 1.1 mm for a catheter moving at ∼ 1 cm / s . The average tip localization error was 1.3 ± 0.7 mm and 2.7 ± 1.8 mm , respectively. Conclusions: The results indicate catheter navigation based on the proposed single plane C-arm imaging technique is feasible with reconstruction errors similar to the diameter of a typical ablation catheter.
Collapse
Affiliation(s)
- Martin G Wagner
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Medical Physics, Madison, United States
| | - Sarvesh Periyasamy
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Radiology, Madison, United States
| | | | - Paul F Laeseke
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Radiology, Madison, United States
| | - Michael A Speidel
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Medical Physics, Madison, United States.,University of Wisconsin-Madison, School of Medicine and Public Health, Department of Medicine, Madison, United States
| |
Collapse
|
19
|
Pritchett MA, Lau K, Skibo S, Phillips KA, Bhadra K. Anesthesia considerations to reduce motion and atelectasis during advanced guided bronchoscopy. BMC Pulm Med 2021; 21:240. [PMID: 34273966 PMCID: PMC8286573 DOI: 10.1186/s12890-021-01584-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
Partnership between anesthesia providers and proceduralists is essential to ensure patient safety and optimize outcomes. A renewed importance of this axiom has emerged in advanced bronchoscopy and interventional pulmonology. While anesthesia-induced atelectasis is common, it is not typically clinically significant. Advanced guided bronchoscopic biopsy is an exception in which anesthesia protocols substantially impact outcomes. Procedure success depends on careful ventilation to avoid excessive motion, reduce distortion causing computed tomography (CT)-to-body-divergence, stabilize dependent areas, and optimize breath-hold maneuvers to prevent atelectasis. Herein are anesthesia recommendations during guided bronchoscopy. An FiO2 of 0.6 to 0.8 is recommended for pre-oxygenation, maintained at the lowest tolerable level for the entire the procedure. Expeditious intubation (not rapid-sequence) with a larger endotracheal tube and non-depolarizing muscle relaxants are preferred. Positive end-expiratory pressure (PEEP) of up to 10-12 cm H2O and increased tidal volumes help to maintain optimal lung inflation, if tolerated by the patient as determined during recruitment. A breath-hold is required to reduce motion artifact during intraprocedural imaging (e.g., cone-beam CT, digital tomosynthesis), timed at the end of a normal tidal breath (peak inspiration) and held until pressures equilibrate and the imaging cycle is complete. Use of the adjustable pressure-limiting valve is critical to maintain the desired PEEP and reduce movement during breath-hold maneuvers. These measures will reduce atelectasis and CT-to-body divergence, minimize motion artifact, and provide clearer, more accurate images during guided bronchoscopy. Following these recommendations will facilitate a successful lung biopsy, potentially accelerating the time to treatment by avoiding additional biopsies. Application of these methods should be at the discretion of the anesthesiologist and the proceduralist; best medical judgement should be used in all cases to ensure the safety of the patient.
Collapse
Affiliation(s)
- Michael A Pritchett
- Chest Center of the Carolinas at First Health, President of the Society for Advanced Bronchoscopy, FirstHealth of the Carolinas and Pinehurst Medical Clinic, 205 Page Road, Pinehurst, NC, 28374, USA.
| | - Kelvin Lau
- Thoracic Surgery, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Scott Skibo
- Interventional Thoracic Oncology, Pulmonary Critical Care, Haywood Regional Medical Center (A Duke LifePoint Hospital), 262 Leroy George Drive, Clyde, NC, 28721, USA
| | - Karen A Phillips
- Anesthesiologist and Intensivist, Medtronic, 2101 Faraday Avenue, Carlsbad, CA, 92008, USA
| | - Krish Bhadra
- Interventional Pulmonology, CHI Memorial Rees Skillern Cancer Institute, 725 Glenwood Dr E-500, Chattanooga, TN, 37401, USA
| |
Collapse
|