State of the art: peripheral diagnostic bronchoscopy.

Lung cancer is the leading cause of cancer related death worldwide and in the United States according to the World Health Organization and National Cancer Institute. Improvements in the diagnosis and treatment of lung cancer are of the utmost importance. A prompt diagnosis is a crucial factor to improve outcomes in the treatment of lung cancer. Although the implementation of lung cancer screening guidelines and the overall steady growth in the use of computed tomography have improved the likelihood of detecting lung cancer at an earlier stage, the diagnosis of peripheral pulmonary lesions (PPLs) has remained a challenge. The bronchoscopic techniques for PPL sampling have historically offered modest diagnostic yields at best in comparison to computed tomography guided transthoracic needle aspiration (TTNA). Fortunately, recent advances in technology have ushered in a new era of diagnostic peripheral bronchoscopy. In this review, we discuss the introduction of advanced intraprocedural imaging included digital tomosynthesis (DT), augmented fluoroscopy (AF), and cone beam computed tomography. We discuss robotic assisted bronchoscopy with a review of the currently available platforms, and we discuss the implementation of novel biopsy tools. These technologic advances in the bronchoscopic approach to PPLs offer greater diagnostic certainty and pave the way toward peripheral therapeutics in bronchoscopy.

Added Value of a Robotic-assisted Bronchoscopy Platform in Cone Beam Computed Tomography-guided Bronchoscopy for the Diagnosis of Pulmonary Parenchymal Lesions.

BACKGROUND: Cone beam computed tomography (CBCT)-guided bronchoscopic sampling of peripheral pulmonary lesions (PPLs) is associated with superior diagnostic outcomes. However, the added value of a robotic-assisted bronchoscopy platform in CBCT-guided diagnostic procedures is unknown. METHODS: We performed a retrospective review of 100 consecutive PPLs sampled using conventional flexible bronchoscopy under CBCT guidance (FB-CBCT) and 100 consecutive PPLs sampled using an electromagnetic navigation-guided robotic-assisted bronchoscopy platform under CBCT guidance (RB-CBCT). Patient demographics, PPL features, procedural characteristics, and procedural outcomes were compared between the 2 cohorts. RESULTS: Patient and PPL characteristics were similar between the FB-CBCT and RB-CBCT cohorts, and there were no significant differences in diagnostic yield (88% vs. 90% for RB-CBCT, P=0.822) or incidence of complications between the 2 groups. As compared with FB-CBCT cases, RB-CBCT cases were significantly shorter (median 58 min vs. 92 min, P<0.0001) and used significantly less diagnostic radiation (median dose area product 5114 µGy•m2 vs. 8755 µGy•m2, P<0.0001). CONCLUSION: CBCT-guided bronchoscopy with or without a robotic-assisted bronchoscopy platform is a safe and effective method for sampling PPLs, although the integration of a robotic-assisted platform was associated with significantly shorter procedure times and significantly less radiation exposure.

Imaging in peripheral bronchoscopy.

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.

Malignant Central Airway Obstruction: What's New?

Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.

Systemic arterial gas embolism (SAGE) as a complication of bronchoscopic lung biopsy: a case report and systematic literature review.

BACKGROUND: Systemic arterial gas embolism (SAGE) is a rare yet serious and underrecognized complication of bronchoscopic procedures. A recent case of presumed SAGE after transbronchial needle aspiration prompted a systematic literature review of SAGE after biopsy procedures during flexible bronchoscopy. METHODS: We performed a systematic database search for case reports and case series pertaining to SAGE after bronchoscopic lung biopsy; reports or series involving only bronchoscopic laser therapy or argon plasma coagulation (APC) were excluded. Patient data were extracted directly from published reports. RESULTS: A total of 29 unique patient reports were assessed for patient demographics, specifics of the procedure, clinical manifestations, diagnostic findings, and clinical outcomes. Cases of SAGE occurred after multiple types of bronchoscopic biopsy and under both positive and negative pressure ventilation. The most common clinical findings were neurologic, followed by cardiac manifestations; temporal patterns included acute onset of cardiac or neurologic emergencies immediately after biopsy, or delayed awakening post-procedure. There was a high mortality rate among cases (28%), with residual neurologic deficits also common (24%). DISCUSSION: SAGE is an underrecognized but severe adverse effect of bronchoscopic lung biopsy, which often presents with acute coronary or cerebral ischemia or delayed awakening from sedation. It is important for all physicians who perform bronchoscopic biopsies to be aware of the clinical manifestations and therapeutic management of SAGE in order to mitigate morbidity and mortality among patients undergoing these procedures.

What is the value of electromagnetic navigation in lung cancer and to what extent does it require improvement?

INTRODUCTION: Lung nodules are being identified with increasing frequency. With this growing burden of nodules comes a growing need for diagnostic technologies extending beyond the current reach of conventional bronchoscopy. One such method for diagnosing peripheral lung lesions is electromagnetic navigational bronchoscopy (ENB), which comprises a set of tools designed to aid the bronchoscopist in identifying, accessing, and sampling peripheral lung lesions under virtual guidance. AREAS COVERED: Herein we present an in-depth review of ENB, including commercially available electromagnetic navigation platforms, factors influencing diagnostic yield, adjunctive imaging and biopsy tools, potential risks, cost, technical shortcomings, and competing technologies. A review of the scientific literature was conducted primarily through PubMed, ScienceDirect, and Google Scholar, and pertinent publications and abstracts from the inception of electromagnetic navigation through early 2020 were considered. We also share our perspective on the future of ENB from both a diagnostic and a therapeutic standpoint. EXPERT OPINION: ENB is currently a leading tool in the diagnostic evaluation of peripheral lung lesions. The future of ENB rests not only on its potential to expand into the therapeutic realm but also on its ability to keep pace with competing diagnostic and therapeutic technologies.