Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction

Mimicking Metastasis: Endobronchial Tuberculosis Presenting as a Mass in a Pediatric Patient With Yolk Sac Tumor

Before the advent of an effective antitubercular treatment for tuberculosis and bronchoscopy, endobronchial tuberculosis (EBTB) often greatly contributed to airway stenosis and lung atelectasis in children. Even after the advent of efficacious therapy, EBTB poses major challenges for pediatric patients, manifesting as airway stenosis or obstruction. We report a case of a two-year-old male with a previous history of yolk sac testicular tumor whose follow-up PET-CT scan showed right middle lobe collapse. Flexible bronchoscopy demonstrated endobronchial mass, and biopsy revealed EBTB, excluding metastasis. This case illustrates varied presentations of tuberculosis and highlights the significance of early diagnosis with bronchoscopy in treating this condition before it can lead to severe complications. Antitubercular therapy must be initiated at the earliest when managing EBTB. The follow-up procedures must be diligent, and timely interventions should be made for optimal patient outcomes despite the availability of improved diagnostic techniques and treatment methods.

Interventional bronchoscopy in lung cancer treatment

Interventional bronchoscopy has seen significant advancements in recent decades, particularly in the context of lung cancer. This method has expanded not only diagnostic capabilities but also therapeutic options. In this article, we will outline various therapeutic approaches employed through either a rigid or flexible bronchoscope in multimodal lung cancer treatment. A pivotal focus lies in addressing central airway obstruction resulting from cancer. We will delve into the treatment of initial malignant changes in central airways and explore the rapidly evolving domain of early peripheral malignant lesions, increasingly discovered incidentally or through lung cancer screening programmes. A successful interventional bronchoscopic procedure not only alleviates severe symptoms but also enhances the patient's functional status, paving the way for subsequent multimodal treatments and thereby extending the possibilities for survival. Interventional bronchoscopy proves effective in treating initial cancerous changes in patients unsuitable for surgical or other aggressive treatments due to accompanying diseases. The key advantage of interventional bronchoscopy lies in its minimal invasiveness, effectiveness and favourable safety profile.

Clinical Outcomes of Bronchoscopic Cryotherapy for Central Airway Obstruction in Adults: An 11-Years' Experience of a Single Center

BACKGROUND

Although bronchoscopic cryotherapy (BC) is a pragmatic modality for recanalization of central airway obstruction (CAO), the risk of complications, such as bleeding, remains a concern. This study aimed to present the clinical outcomes of BC and evaluate the factors associated with its complications.

METHODS

In this retrospective study, we reviewed the medical records of patients who underwent BC for CAO at the Asan Medical Center, South Korea. Most sessions were conducted via flexible bronchoscopy under moderate sedation. A multivariate logistic regression analysis was used to identify the factors associated with the success rate and complications.

RESULTS

BC was performed in 262 sessions in 208 patients between January 2009 and December 2020. The most common cause of cryotherapy was recanalization of the endobronchial tumor related CAO (233/262, 88.9%). More than partial re-establishment of airway patency was achieved in 211 of 233 (90.6%) sessions. The success rate did not differ significantly in the multivariate logistic regression analysis. The most common complication was intrabronchial bleeding (78/233, 35.5%); however, severe bleeding occurred only in one case (0.4%). Univariate and multivariate logistic regression analyses revealed that diabetes mellitus (odds ratio [OR] = 2.820, P = 0.011), respiratory failure before BC (OR = 3.546, P = 0.028), and presence of distal airway atelectasis (OR = 0.417, P = 0.021) were independently associated with moderate to severe intrabronchial bleeding, while the histologic type of tumor was not related to bleeding. BC for CAO caused by blood clot or foreign body was successful in most cases, and there were no complications.

CONCLUSION

BC is an efficient and relatively safe intervention for patients with CAO. Our findings suggest that diabetes, respiratory failure before BC, and the absence of distal airway atelectasis may be risk factors of moderate to severe intrabronchial bleeding.

Therapeutic and prophylactic effects of radiation therapy in the management of recurrent granulation tissue induced tracheal stenosis: a review on the role of Endobronchial brachytherapy and external beam radiation therapy

PURPOSE

Granulation tissue-induced tracheal stenosis (mainly secondary to intubation or lung transplantation) is one of the most common etiologies of benign airway obstructions. Recurrence rates after standard treatment options (surgical resection and/or endobronchial interventions) can inadvertently worsen the stricture through the stimulation of more granulation tissue generation (via increased fibroblast activity and roliferation). Low-dose radiotherapy could be a promising tool to prevent granulation tissue formation after surgery and/or endobronchial interventions regarding its established role in the treatment of keloids or hypertrophic scars, two benign diseases with similar a pathophysiology to tracheal stenosis. This study reviews case reports and small series that used endobronchial brachytherapy (EBBT) or external beam radiotherapy (EBRT) for the management of refractory granulation tissue-induced tracheal stenosis after surgery and/or endobronchial interventions.

METHODS AND MATERIALS

Case reports and series (published up to October 2022) that reported outcomes of patients with recurrent granulation tissue-induced tracheal stenosis (after surgery and/or endobronchial interventions) treated by EBBT or EBRT (in definitive or prophylactic settings) were eligible.

RESULTS

Sixteen studies (EBBT: nine studies including 69 patients, EBRT: seven studies including 32 patients) were reviewed. The pooled success rate across all studies was 74% and 97% for EBBT and EBRT, respectively.

CONCLUSIONS

Radiation therapy appears to be effective in the management of selected patients with recurrent/refractory tracheal stenosis. Response to this treatment is usually good, but further studies with a larger number of patients and long-term followup are necessary to determine the optimal technique, dose, and timing of radiation therapy, late complications, the durability of response, and criteria for patient selection.

A Novel Approach to Repair of Tracheal Occlusion Secondary to Percutaneous Tracheostomy Creation

The number of endotracheal intubations increased in the United States during the COVID-19 pandemic with an associated rise in laryngotracheal injury. Our patient had a complete laryngeal occlusion just proximal to the first tracheal ring. The Neodymium-doped Yttrium Aluminum Garnet (Nd-YAG) laser is often used to resolve sub-laryngeal occlusions, and without access to the Nd-YAG laser, we had to find an alternative solution. Few centers have the access to an Nd-YAG laser, the optimal choice for sub-laryngeal occlusion and our novel approach allowed us to reestablish tracheal continuity and the patient's ability to speak.

Applications of cryobiopsy in airway, pleural, and parenchymal disease

INTRODUCTION

:Cryobiopsy is a novel diagnostic technique for thoracic diseases which has been extensively investigated over the past 20 years. It was originally proposed for the diagnosis of endobronchial lesions and diffuse parenchymal lung disease due to limitations of conventional sampling techniques including small size and presence of artifacts.

AREAS COVERED

:We will review recent evidence related to the expanding use of cryobiopsy in thoracic diseases. To identify references, the MEDLINE database was searched from database inception until May 2022 for case series, cohort studies, randomized controlled trials, systematic reviews and meta-analyses related to cryobiopsy.

EXPERT OPINION

Cryobiopsy has expanding applications in the field of thoracic diseases. Evidence to support transbronchial cryobiopsy as an alternative to surgical lung biopsy is increasing and was recently endorsed as a conditional recommendation by the latest American Thoracic Society guideline update for Idiopathic Pulmonary Fibrosis. Developments in technology and technique, in particular the availability of a 1.1 mm flexible cryoprobe, have extended applications to pulmonary diseases, including diagnosis of interstitial lung diseases, peripheral pulmonary lesions, and lung transplant rejection.

Efficacy and Safety of Cryobiopsy vs. Forceps Biopsy for Interstitial Lung Diseases, Lung Tumors, and Peripheral Pulmonary Lesions: An Updated Systematic Review and Meta-Analysis

Background

Cryobiopsy has emerged as a novel alternative to conventional forceps biopsy for the diagnosis of interstitial lung diseases (ILDs), lung tumors, and peripheral pulmonary lesions (PPLs). This study aims to compare cryobiopsy and forceps biopsy for the diagnosis of these lung pathologies with respect to efficacy and safety by performing a meta-analysis of updated evidence.

Methods

A number of databases, such as PubMed, Embase, Web of Science, the Cochrane Library, OVID, CNKI, and Wanfang database, were searched for eligible studies. Randomized and non-randomized comparative studies investigating the efficacy and safety of cryobiopsy vs. forceps biopsy for lung pathologies were included. Pooled results were calculated as an odds ratio (OR) or standardized mean difference (SMD) with 95% CI.

Results

A total of 39 studies, such as 9 RCTs with 3,586 biopsies (1,759 cryobiopsies and 1,827 flexible forceps biopsies) were analyzed. Cryobiopsy was associated with a significant increase in the diagnostic rates of ILDs (OR, 4.29; 95% CI, 1.85–9.93; p < 0.01), lung tumors (OR, 3.58; 95% CI, 2.60–4.93; p < 0.01), and PPLs (OR, 1.70; 95% CI, 1.23–2.34; p < 0.01). Cryobiopsy yielded significantly larger specimens compared with flexible forceps biopsy (SMD, 3.06; 95% CI, 2.37–3.74; p < 0.01). The cryobiopsy group had a significantly higher (moderate to severe) bleeding risk than the forceps group (OR, 2.17; 95% CI, 1.48–3.19; p < 0.01). No significant difference was observed in the incidence of pneumothorax between the groups (OR, 0.90; 95% CI, 0.44–1.85; p = 0.78).

Conclusion

Our results demonstrate that cryobiopsy is a safe and efficacious alternative to conventional forceps biopsy.

Current practices in the management of central airway obstruction

PURPOSE OF REVIEW

Airway obstruction continues to cause substantial pulmonary morbidity and mortality. We present a review of classic, current, and evolving management techniques, highlighting recently published studies on the topic. Recommendations have historically been primarily based on anecdotal experience, case reports, and retrospective studies, but more solid evidence has emerged in the last decade.

RECENT FINDINGS

Novel endobronchial stents are being developed to mitigate the issues of stent migration, mucus plugging, fracture, and granulation tissue formation. Endobronchial drug delivery has become an active area of translational and clinical research, especially with regards to antineoplastic agents used for malignant airway stenosis. Even classic or updated techniques such as spray cryotherapy, injections of mitomycin-c, and balloon dilation have recently been examined in methodologically sound studies. Finally, recently published data have confirmed that patient breathlessness and quality of life improve significantly with therapeutic airway interventions. A multimodal and multidisciplinary approach to patient care is key to achieving the best outcomes.

SUMMARY

The treatment of central airway stenosis is often multimodal and should focus on patient-centric factors, taking into account risks and benefits of the procedure, operator, and center expertise, and always occur in the context of a multidisciplinary approach. Evidence-based clinical research is increasingly driving patient management.

Pediatric advanced diagnostic and interventional bronchoscopy

The indications and utility of flexible bronchoscopy have expanded over the past few decades with major innovations in design and development of new tools for endobronchial interventions and image-guided tissue sampling techniques. This review highlights the application of advanced diagnostic bronchoscopy (including endobronchial ultrasound and CT navigational techniques), cryotherapy and the use of one-way endobronchial valves for persistent air leak in the pediatric setting.

Bronchoscopic treatment of inoperable nonsmall cell lung cancer

Patients with unresectable lung cancer range from those with early-stage or pre-invasive disease with comorbidities that preclude surgery to those with advanced stage disease in whom surgery is contraindicated. In such cases, a multidisciplinary approach to treatment is warranted, and may involve medical specialties including medical oncology, radiation oncology and interventional pulmonology. In this article we review bronchoscopic approaches to surgically unresectable lung cancer, including photodynamic therapy, brachytherapy, endoscopic ablation techniques and airway stenting. Current and past literature is reviewed to provide an overview of the topic, including a highlight of potential emerging approaches.

Endobronchial lesions cases treated with interventional bronchoscopic techniques: Our single-center experiences

Background

In this study, we aimed to present our experience with interventional bronchoscopy in the treatment of endobronchial lesions in our clinic.

Methods

Between January 2010 and December 2018, a total of 18 patients (11 males, 7 females; mean age 55.1 years; range, 17 to 82 years) who were diagnosed with an endobronchial lesion using bronchoscopy in our clinic were retrospectively analyzed. Demographic characteristics, presenting symptoms, bronchoscopic procedure, location of the lesion, pathological diagnosis, treatment approaches, success of the bronchoscopic treatment, and follow-up outcomes of the patients were evaluated.

Results

Control bronchoscopy was performed in 14 patients and a second control bronchoscopy was performed in eight patients. The lesions were located in the right bronchial system in nine (50%), in the left bronchial system in six (33%), and in the trachea in three patients (17%). Except for one pregnant patient, all interventional procedures were performed with a rigid bronchoscope under general anesthesia. Distal areas which were unable to be reached with the rigid bronchoscope were evaluated by a flexible bronchoscope. There were no complications in any of the patients. At the end of the study, the final control biopsies of all patients were found to be normal. The success rate of interventional bronchoscopic methods was 100%.

Conclusion

Interventional bronchoscopic methods are the most effective procedures in the diagnosis and treatment of bronchial lesions with a high success rate. Based on our study findings, we suggest that bronchoscopic methods should be preferred as the first-line treatment of benign and selected some malignant endobronchial lesions.

Evaluation of Efficacy of a New Cryoprobe for Transbronchial Cryobiopsy: A Randomized, Controlled in vivo Animal Study

BACKGROUND

Forceps biopsy (FB) is still the most popular procedure for the bronchoscopic sampling of lung tissue. However, it has limitations like inadequate sample size and crush artifacts. Cryobiopsy (CB) has been introduced to obtain bronchoscopic biopsies with improved diagnostic yield compared to FB. Limitations of CB are the need to retract the cryoprobe en bloc with bronchoscope because samples are larger than the working channel and the variations of the freezing power of the reusable CB (rCB). Therefore, 3 new disposable cryoprobes (dCB) have been developed with different outer diameters: 1.1 mm (CB11-S) that can be retracted through the working channel of the bronchoscope, 1.7 mm (CB17) and 2.4 mm (CB24n), respectively.

OBJECTIVES

The aim was to evaluate the new cryoprobes with regard to feasibility, specimen area, specimen quality and complications.

METHODS

We compared biopsy samples of the new probes with those obtained by FB and by rCB in an in vivo (porcine) model. A flexible bronchoscope was used to perform biopsy at 4 different locations at the upper and lower lobes of the right and left lung, respectively. The biopsies were taken under fluoroscopic control. The biopsy tool and activation times were allocated randomly. Altogether 204 biopsy procedures were performed.

RESULTS

The sample quality of the dCB was superior to that of FB (all p < 0.05) and not significantly different to the rCB sample quality. Mean specimen sample area of all CB was significantly larger compared to FB (p < 0.05). The sample area of the small cryoprobe (CB11-S) was significantly smaller compared to the other CB probes (p < 0.05). No severe bleedings occurred. Pneumothoraces were detected in 3 of the 7 pigs.

CONCLUSION

We conclude that CB with the new single-use instruments are feasible and represent a viable option to improve the diagnostic accuracy of histopathological evaluation compared to FB.

Blood clot removal by cryoextraction in critically ill patients with pulmonary hemorrhage

Background

Severe pulmonary hemorrhage is a life-threatening complication in critically ill patients. Due to tracheobronchial obstruction, ventilation is often impaired. Traditionally, rigid bronchoscopy is an option for recanalization. However, in comparison to flexible bronchoscopy, the application of rigid bronchoscopy is more complex. Against this background we evaluated the use of flexible cryo-probes for blood clot removal in critically ill patients.

Methods

Retrospectively, we identified 16 patients (median age: 60 years, 69% male patients), who suffered from severe airway obstruction due to blood clots. All patients required invasive ventilation and 11 patients depended on extracorporeal membrane oxygenation (ECMO). To remove blood clots, flexible bronchoscopic cryoextraction was performed in n=27 cases, whereas rigid bronchoscopy was only needed in two cases.

Results

Whereas in 9 cases single flexible cryoextraction was successful immediately, the procedure had to be repeated again in 7 patients. In all cases, tracheobronchial obstruction was treated with success and conditions of invasive ventilation were improved. In no case severe complications were observed.

Conclusions

In consideration of the underlying evaluation, we highly recommend flexible cryoextraction as both a safe and less complex technique for blood clot removal in critically ill patients.

An Open-label, Single-arm Study of CRYO2 for Debulking at the Site of Central Airway Obstruction or Stenosis

BACKGROUND

An open-label, single-arm study was conducted to assess the safety of a cryosurgery unit named CRYO2 for debulking at the site of obstruction or stenosis.

PATIENTS AND METHODS

In order to treat central airway tumor-related stenosis, debulking at the stenotic site of the airway was performed using CRYO2 under general or local anesthesia. The primary endpoint was the incidence of moderate to massive hemorrhage.

RESULTS

Incidence of moderate to massive hemorrhage during surgery was 3.8% (1/26) (95% confidence interval(CI)=0.1-19.6%). Technical success was 96.2% (25/26), with a 95% confidence interval of 80.4-99.9%.

CONCLUSION

CRYO2 for debulking at the site of obstruction or stenosis can be performed safely.

Bronchoscopic ablation techniques in the management of lung cancer

Central airway involvement is a common manifestation of lung cancer during the disease course. Some patients will require bronchoscopic therapeutic interventions to palliate symptoms, or less commonly to provide more definitive therapy of airway involvement. We describe an overview specifically of bronchoscopic ablative techniques that are available for use in malignant airway obstruction. Techniques that are more commonly used include bronchoscopic application of laser, electrocautery, argon plasma coagulation (APC), cryotherapy and mechanical debulking techniques. Less commonly employed are brachytherapy and photodynamic therapy. These techniques may be applied via flexible or rigid bronchoscopy depending upon the clinical scenario. The choice of technique depends on available tools and expertise, the urgency of the clinical scenario, and whether the lesion is predominately endobronchial, extrinsic compression, or a combination of both. Malignant airway obstruction is a common finding in lung cancer and there are a number of effective bronchoscopic ablative techniques that may be employed safely to palliate patients with a significant symptom burden.

Flexible Bronchoscopy Combined with Rigid Bronchoscopy for Treatment of Scarring in the Bronchus Caused by a Foreign Body

Foreign body (FB) aspiration into the tracheobronchial tree is an emergency in the pediatric department, particularly in children aged <3 years. FB granulation tissue is commonly found in children with FB aspiration. However, scarring in the bronchus caused by a FB is rare. We herein report a case involving aspiration of a plastic whistle toy with scarring in the bronchus. The scar tissue was successfully removed by interventional bronchoscopy combined with a flexible electrosurgery probe and carbon dioxide cryotherapy.

Safety and Usefulness of Cryobiopsy and Stamp Cytology for the Diagnosis of Peripheral Pulmonary Lesions

Reports on the use of cryobiopsy (CB) for lung cancer diagnosis are limited. The aims of the present study were to evaluate the safety and usefulness of CB using radial endobronchial ultrasonography, without a guide sheath, for the diagnosis of peripheral pulmonary lesions and determine the utility of stamp cytology, an on-site diagnostic technique for determining tumor inclusion in CB samples. We retrospectively analyzed data for 35 patients (36 lesions) with suspected peripheral lung cancer who underwent CB between August 2017 and February 2019 at our medical facility. The diagnostic yield, incidence of complications, and the utility of stamp cytology for diagnosis were investigated. The diagnostic yield of CB was 86.1% (31/36) with histological diagnosis, and 80.5% (29/36) with diagnosis using stamp cytology; the overall yield was 91.6% (33/36). Pneumothorax requiring thoracic drainage occurred in two patients, both of whom had lesions contacting the pleura. Grade 2 and grade 1 bleeding occurred in one and 25 patients, respectively. CB enables the collection of very large, nearly intact tissue samples, thus resulting in an improvement in the true diagnosis rate and facilitating the measurement of multiple biomarkers as well as rapid histological diagnosis.

The value of using radial endobronchial ultrasound to guide transbronchial lung cryobiopsy

Conventional transbronchial biopsies have a low diagnostic yield for interstitial lung disease (ILD) and peripheral lung nodules due to crush artifact and smaller tissue samples. Transbronchial lung cryobiopsies (TBLC) circumvent these drawbacks but are associated with higher incidence of complications including life threatening airway bleeding and pneumothoraces. Radial probe endobronchial ultrasound (RP-EBUS) can be used during the TBLC for assessing the biopsy site prior to the cryobiopsy to avoid vasculature and to decrease the risk of complications. There is no standardized protocol for this technique and the available literature mostly consists of single center case reports/series. The aim of this review is to investigate the existing literature for RP-EBUS assisted TBLC for diagnosing both ILD and peripheral lung nodules. We will describe the techniques used and compare the diagnostic yield and complication rates with other modalities.

Competence in transbronchial cryobiopsy

Over the last decade transbronchial lung cryobiopsy (TBLC) has proven to be an "innovative application" of an "old procedure" for the histologic diagnosis of diffuse interstitial lung diseases (DILDs). Thus, the technique of TBL cryobiopsy is now adopted for diagnostic purposes, transbronchially in peripheral airways to sample lung parenchyma, whereas this same technique was traditionally employed in the past for therapeutic purposes, essentially for the management of malignant obstruction of central airways. When patients with interstitial lung diseases (ILDs) need histopathological data in their diagnostic pathway, this bioptic approach could be a valid alternative to surgical lung biopsy, that is still the gold standard at the moment. TBL cryobiopsy has a good safety profile, its sensitivity and specificity appear good overall in idiopathic pulmonary fibrosis. In the last ten years, many papers have been published about this procedure defining modalities by which cryobiopsy should be performed. These studies have shown that TBL cryobiopsy is feasible, it allows to obtain larger lung parenchymal specimens (3 times larger than "classic" transbronchial biopsies), characterized by unaltered and artefact-free morphology, and it represents a safe and poorly invasive diagnostic tool for the histologic diagnosis of ILDs. The technical aspects are really important, and they still need a complete standardization. TBL cryobiopsy should be part of an equipment of the modern interventional pulmonologist, who should know indications and contraindications of this methodic and the technical aspects of the procedure. This is a complex procedure requiring to be performed by endoscopists working in specialized centers with specific knowledge of DILDs, and a multidisciplinary approach, which represent pre-requisites for admission to training in this procedure.

Post-intubation tracheobronchomalacia in a young adult: A rare case report

Tracheobronchomalacia (TBM) is characterized by weakness of cartilaginous supporting structures of tracheal and bronchial walls, resulting in central airway obstruction. It is a rare condition that can occur after prolonged intubation. Here, we report a 26-year-old, alcoholic male who had TBM, mild subglottic, and severe tracheal stenosis following 2 weeks of intubation.

Subglottic and tracheal stenosis can occur after extubation but TBM is uncommon. The exact mechanism is still unknown but post-intubation TBM is a life-threatening condition with high morbidity and mortality if left untreated. Early detection and timely management can improve the outcome of patients.

Unimodality and Multimodality Cryodebridement for Airway Obstruction. A Single-Center Experience with Safety and Efficacy

RATIONALE

Cryodebridement (CD) refers to the removal of obstructive material from the lumen of the tracheobronchial tree by freezing with a cryoprobe, which is usually inserted through a flexible bronchoscope. This method of achieving instant recanalization of airways has been established for over 20 years, but published experience comprises limited case series.

OBJECTIVES

This study describes a single large-volume referral center experience, including clinical outcomes and safety profile.

METHODS

Electronic medical records of 156 patients who underwent bronchoscopic CD between December 2007 and March 2012 as the primary method to relieve airway obstruction were reviewed retrospectively.

MEASUREMENTS AND MAIN RESULTS

The most frequent cause of airway obstruction was malignancy (n = 88), with non-small-cell lung cancer and metastatic renal cell carcinoma being the most common etiologies. The site of obstruction was localized to the central airways in 63 patients (40%) and the distal airways in 44 patients (28%), and it was diffuse in 49 patients (32%). Bronchoscopic airway patency was achieved in 95% of patients, with the highest success rates found in those with obstruction localized in the central airways. Improvement in symptoms occurred in 118 (82%) of 144 symptomatic patients. Serious complications were reported in 17 patients (11%) and included respiratory distress, severe bleeding, airway injury, and hemodynamic instability. All patients responded to treatment, and no intra- or postoperative deaths were reported.

CONCLUSIONS

CD, when used alone or in combination with other endoscopic treatment modalities, appears to be safe and effective in treating endoluminal airway obstruction.

Interstitial lung disease: the diagnostic role of bronchoscopy

Interstitial lung diseases (ILDs) form one of the most fascinating fields in pulmonary medicine. They also pose one of the greatest challenges for accurate diagnosis and proper treatment. Even within the recommended and warranted multidisciplinary approach, differentiating between one disease and another may lead to frustration, especially when proper lung tissue is not available for adequate pathological review. A surgical lung biopsy (SLB) might render enough tissue for histopathology, but this could come at the expense of high morbidity and even mortality, as in the case of usual interstitial pneumonia (UIP). Could bronchoscopy and its various techniques offer a safer and higher yield alternative? Since the very late 19th century, efforts have been made to better examine the airways, obtain tissue and treat various conditions. This resulted in the successive emergence of bronchoalveolar lavage (BAL), endobronchial and transbronchial forceps biopsies, until recently when transbronchial cryobiopsy surfaced as a nascent technique with much promise. The use of endobronchial ultrasound revolutionized the diagnosis and staging of lung cancer, while adding to the yield of other conditions such as sarcoidosis. Ongoing research, efforts and studies have continuously scrutinized the roles of various techniques in the approach to ILDs. For example, BAL seems to serve mostly to eliminate infection as an etiology or a complicating factor in the acute worsening of a fibrotic lung disease, while a predominant cellular component might be diagnostic, such as eosinophilia in eosinophilic lung disease, or lymphocytosis in hypersensitivity pneumonitis (HP). On the other hand, endobronchial biopsy's (EBB) role appears limited to sarcoidosis. As for transbronchial biopsy by forceps, the small sample size and related artifact appear to be limiting factors in making an accurate diagnosis. Recently, however, the use of cryotherapy via employing a cryoprobe in obtaining transbronchial lung biopsies is unfolding into a refined interventional method which might transform indefinitely our approach to the pathological diagnosis of the various ILDs.

Hemodynamic Instability Following Airway Spray Cryotherapy

BACKGROUND

Spray cryotherapy (SCT) of airway lesions is used to effectively palliate respiratory symptoms related to airway obstruction, but significant intraoperative hemodynamic complications have been noted. We reviewed the experience at a single institution using SCT for the treatment of obstructive airway tumors.

METHODS

A retrospective review of a single institution experience with intraoperative and postoperative hemodynamic complications associated with SCT was performed. Descriptive statistics were performed.

RESULTS

Between June 2009 and April 2010, 34 treatment sessions were performed on 28 patients. Median age was 60 years (range, 15-88 years). Tumor characteristics were as follows: 13 primary lung cancers (43%), 11 pulmonary metastases (50%), 1 direct extension of an esophageal cancer (3%), and 2 benign pulmonary lesions (7%). Twenty-one tumors (75%) were distal to the carina; 14 (50%) were >95% occlusive. Median procedure length was 78 minutes (range, 15-176 minutes). Eleven sessions (31%) led to severe hypotension and/or bradycardia, with 2 patients requiring cardiopulmonary resuscitation. One patient died intraoperatively after cardiac arrest; a second patient was stable intraoperatively but died within 24 hours of SCT. Four patients required reintubation and short-term mechanical ventilation.

CONCLUSIONS

Unpredictable life-threatening hemodynamic instability can follow endobronchial SCT. We propose that the most likely cause is pulmonary venous gaseous emboli entering the right heart, the coronary arteries, and the systemic circulation. Although SCT may offer advantages over airway laser therapy (such as no risk of fire and rapid hemostasis), further study is needed to delineate the relative likelihood of therapeutic benefit versus catastrophic complications.

Transbronchial cryobiopsy in diffuse parenchymal lung diseases

PURPOSE OF REVIEW

The diagnostic yield of conventional transbronchial lung biopsy varies among various parenchymal lung diseases: in pulmonary sarcoidosis and lymphangitis carcinomatosa, a diagnosis can be obtained in up to 80% of patients; this method is considered inadequate, however, in identifying more complex histological patterns such as usual interstitial pneumonitis or nonspecific interstitial pneumonitis, mainly because the specimens are tiny and the interpretation is confounded by crush artifacts. Recently, the use of cryoprobes has achieved a significant impact on this issue. This review is about this promising application of cryobiopsy in the diagnostic process of diffuse parenchymal lung diseases.

RECENT FINDINGS

Recent studies document that with transbronchial cryobiopsies, the diagnosis of usual interstitial pneumonitis can be made confidently by pathologists with a good interobserver agreement. Pneumothorax is the main complication (reported in up to one-quarter of cases in some series); bronchial bleeding is usually controlled using Fogarty balloon.

SUMMARY

Transbronchial cryobiopsy is a promising new technique that may become a valid alternative to surgical lung biopsy in the near feature.

Intra-patient comparison of parietal pleural biopsies by rigid forceps, flexible forceps and cryoprobe obtained during medical thoracoscopy: a prospective series of 80 cases with pleural effusion

BACKGROUND

There is only few data available on the use of cryotechnique during medical thoracoscopy.

METHODS

Medical thoracoscopy was performed in consecutive patients with pleural effusion. Prospectively, biopsies were taken by rigid forceps, flexible forceps and cryoprobe. Specimen size, depth and diagnostic yield were compared.

RESULTS

80 Patients were included. 408 biopsies were taken (205 rigid biopsies, 104 flexible biopsies, 99 cryobiopsies). Mean surface area of rigid biopsies was 22.6 ± 20.4 mm(2) (flexible biopsies: 7.1 ± 9.3 mm(2), cryobiopsies: 14.4 ± 12.8 mm(2)). Rigid biopsies were significantly larger than cryobiopsies (p < 0.001) and flexible biopsies (p < 0.001), crybiopsies were significantly larger than flexible biopsies (p < 0.01). A deep biopsy containing fatty tissue was harvested in 63 % of rigid biopsies (cryobiopsy: 49.5 % flexible biopsy: 39.5 %). In 79/80 cases (98.7 % 95 % CI cannot be calculated) a diagnosis was obtained by rigid biopsy (cryobiopsy: 73/80 cases (91.3 % 95 % CI 86.0 - 96.5 %), flexible biopsy: 74/80 cases (92.5 % 95 % CI 88.6 - 97.4 %)). Diagnostic yield achieved with cryobiopsies was inferior to the yield of rigid biopsies (Difference: 12.7 %), but non-inferior to flexible biopsies (Difference: 6.5 %).

CONCLUSION

Cryobiopsies in medical thoracoscopy are safe with high diagnostic yield, non-inferior to flexible biopsies with increased tissue quantity and quality. Cryotechnique can develop an important role in medical thoracoscopy in the near future when rigid thoracoscopy is not available.

Cryosurgery for Tumors — A Clinical Overview

Cryosurgery, a method of treating disease by the production of freezing temperatures in the tissue, is a useful technique for the treatment of tumors. When the modern era of cryosurgery began in the mid 1960's, the technique was used only for tumors easily accessible by direct observation or via endoscopy, such as those of the skin, oral cavity, and prostate gland. In general, the technique had limited usefulness in the next two decades. However, with the advent of intraoperative ultrasound as a method of monitoring the process of freezing and with the development of more effective cryosurgical apparatus, the cryosurgical treatment of tumors of the viscera and other deep tissues became practical in the 1990's. This review assesses the present day status of cryosurgery in the management of diverse tumors.

Rigid bronchoscopy and silicone stents in the management of central airway obstruction

The field of interventional pulmonology has grown significantly over the past several decades now including the diagnosis and therapeutic treatment of complex airway disease. Rigid bronchoscopy is an invaluable tool in the diagnosis and management of several malignant and non-malignant causes of central airway obstruction (CAO) and has become integral after the inception of airway stenting. The management of CAO can be a complicated endeavor with significant risks making the understanding of basic rigid bronchoscopy techniques, ablative technologies, anesthetic care and stenting of utmost importance in the care of these complex patients. This review article will focus on the history of rigid bronchoscopy, the technical aspects of performing a rigid bronchoscopy as well as the use of silicone stents their indications, complications and placement techniques.

From electrocautery, balloon dilatation, neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) laser to argon plasma coagulation and cryotherapy

Over the past decade, there has been significant advancement in the development/application of therapeutics in thoracic diseases. Ablation methods using heat or cold energy in the airway is safe and effective for treating complex airway disorders including malignant and non-malignant central airway obstruction (CAO) without limiting the impact of future definitive therapy. Timely and efficient use of endobronchial ablative therapies combined with mechanical debridement or stent placement results in immediate relief of dyspnea for CAO. Therapeutic modalities reviewed in this article including electrocautery, balloon dilation (BD), neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) laser, argon plasma coagulation (APC), and cryotherapy are often combined to achieve the desired results. This review aims to provide a clinically oriented review of these technologies in the modern era of interventional pulmonology (IP).

Recurred Post-intubation Tracheal Stenosis Treated with Bronchoscopic Cryotherapy

Post-intubation tracheal stenosis accounts for the greatest proportion of whole-cause tracheal stenosis. Treatment of post-intubation tracheal stenosis requires a multidisciplinary approach. Surgery or an endoscopic procedure can be used, depending on the type of stenosis. However, the efficacy of cryotherapy in post-intubation tracheal stenosis has not been validated. Here, we report a case of recurring post-intubation tracheal stenosis successfully treated with bronchoscopic cryotherapy that had previously been treated with surgery. In this case, cryotherapy was effective in treating web-like fibrous stenosis, without requiring more surgery. Cryotherapy can be considered as an alternative or primary treatment for post-intubation tracheal stenosis.

CT-guided percutaneous cryoablation of central lung tumors

PURPOSE

Cryoablation has been successfully used to treat lung tumors. However, the safety and effectiveness of treating tumors adjacent to critical structures has not been fully established. We describe our experience with computed tomography (CT)-guided percutaneous cryoablation of central lung tumors and the role of ice ball monitoring.

MATERIALS AND METHODS

Eight patients with 11 malignant central lung tumors (nine metastatic, two primary; mean, 2.6 cm; range, 1.0-4.5 cm) located adjacent to mediastinal or hilar structures were treated using CT-guided cryoablation in 10 procedures. Technical success and effectiveness rates were calculated, complications were tabulated and intraprocedural imaging features of ice balls were described.

RESULTS

All procedures were technically successful; imaging after 24 hours demonstrated no residual tumor. Five tumors recurred, three of which were re-ablated successfully. A hypodense ice ball with well-defined margin was visible during the first (n=6, 55%) or second (n=11, 100%) freeze, encompassing the entire tumor in all patients, and abutting (n=7) or minimally involving (n=4) adjacent mediastinal and hilar structures. Pneumothorax developed following six procedures (60%); percutaneous treatment was applied in three of them. All patients developed pleural effusions, with one patient requiring percutaneous drainage. Transient hemoptysis occurred after six procedures (60%), but all cases improved within a week. No injury occurred to mediastinal or hilar structures.

CONCLUSION

CT-guided percutaneous cryoablation can be used to treat central lung tumors successfully. Although complications were common, they were self-limited, treatable, and not related to tumor location. Ice ball monitoring helped maximize the amount of tumor treated, while avoiding critical mediastinal and hilar structures.

Airway complications after lung transplantation

Airway complications after lung transplantation present a formidable challenge to the lung transplant team, ranging from mere unusual images to fatal events. The exact incidence of complications is wide-ranging depending on the type of event, and there is still evolution of a universal characterization of the airway findings. Management is also wide-ranging. Simple observation or simple balloon bronchoplasty is sufficient in many cases, but vigilance following more severe necrosis is required for late development of both anastomotic and nonanastomotic airway strictures. Furthermore, the impact of coexisting infection, rejection, and medical disease associated with high-level immunosuppression further complicates care.

Endobronchial tuberculosis

Endobronchial tuberculosis refers to tuberculous infection of the tracheobronchial tree. Diagnosis requires a high index of suspicion since symptoms are attributed to co-existing pulmonary tuberculosis and airway lesions are not detectable on chest radiograph. While computed tomography and bronchoscopy are useful for the evaluation of tracheobronchial stenosis or obstruction, goals of treatment remain in the eradication of tubercle bacilli and prevention of airway stenosis. Corticosteroids may halt progression of active disease to fibro-stenotic stage, however if tracheobronchial stenosis causing post-obstructive pneumonia, atelectasis and dyspnea has occurred, airway patency must be restored mechanically by surgery or bronchoscopic techniques.

Pleuroscopic cryoprobe biopsies of the pleura: a feasibility and safety study

BACKGROUND AND OBJECTIVE

Flexi-rigid pleuroscopy is a useful tool in the work-up of pleural effusions, but pleural biopsy using flexible forceps can be difficult in some patients. This study evaluated the feasibility, safety and diagnostic value of using a flexible cryoprobe to obtain parietal pleural biopsies during pleuroscopy.

METHODS

This was a single-centre retrospective study. In patients undergoing diagnostic pleuroscopy, pleural biopsy using flexible forceps, followed by a flexible cryoprobe introduced through the pleuroscope, were performed. A pathologist independently reviewed all biopsies. Any complications, particularly bleeding, were recorded. All patients were followed up for ≥ 6 months (median 12 months (range 7-26)).

RESULTS

Twenty-two patients (21 males; median age 72 years; 14 right-sided effusions) were included. All underwent flexible forceps biopsies (FFB) and cryoprobe biopsies (CB) of pleura. FFB and CB established a definitive diagnosis in 20/22 (90%). CB successfully obtained pleural tissue suitable for histopathological analysis in all patients. CB was larger than FFB (median, 25-75 IQR of 10, 7-15.8mm vs 4, 3-8mm), and had better preserved cellular architecture and tissue integrity. Crush artefacts were less common with CB (2/22) compared with FFB (21/22). No significant bleeding was reported.

CONCLUSIONS

CB during flexi-rigid pleuroscopy is feasible, safe and effective. Its routine use during flexi-rigid pleuroscopy requires further evaluation.

Challenges in endobronchial tuberculosis: from diagnosis to management

Despite the rapid advancement in diagnostic and therapeutic modalities, endobronchial tuberculosis (EBTB), defined as tuberculous infection of the tracheobronchial tree, continues to remain challenging for clinicians. Nonspecific respiratory symptoms along with normal chest radiograph in 10–20% of cases may be alleged for the diagnostic delay. Variable diagnostic yield with sputum microscopy might further compound the problem. In such cases, high resolution computed tomography (HRCT) works as a more sensitive tool and demonstrates involvement of tracheobronchial tree described classically as “tree-in-bud” appearance. Bronchoscopic biopsy is considered the most reliable method for confirmation of the diagnosis with 30% to 84% positivity in different series. Evolution of the disease is also unpredictable with frequent progression to bronchostenosis, therefore requiring regular follow-up and early intervention to halt the natural course. This review article elaborates various aspects of the disease with specific focus on diagnostic dilemma and recent advances in interventional bronchoscopy. In addition, this discussion evokes optimism for further research and introduction of innovative therapeutic modalities.