Assessing the accuracy of a multisection robotic bronchoscope prototype in localization and targeting of small pulmonary lesions.

Objectives: Robotic bronchoscopy (RB) has emerged as a novel technique to address issues with the biopsy of small peripheral lung lesions. The objective of this study was to quantitatively assess the accuracy of a novel multisection robotic bronchoscope compared with current standards of care. Methods: This is a prospective, single-blind, comparative study where the accuracy of a multisection RB was compared against the accuracy of standard electromagnetic navigational bronchoscopy (EM-NB) during lesion localization and targeting. Five blinded subjects of varying bronchoscopy experience were recruited to use both RB and EM-NB in a swine lung model. Accuracy of localization and targeting success was measured as the distance from the center of pulmonary targets at each anatomic location. Subjects used both RB and EM-NB to navigate to 4 pulmonary targets assigned using 1:1 block randomization. Differences in accuracy and time between navigation systems were assessed using Wilcoxon rank-sum test. Results: Of the 40 total attempts per modality, successful targeting was achieved on 90% and 85% of attempts utilizing RB and EM-NB, respectively. Furthermore, RB demonstrated significantly lower median distance to the real-time EM target (1.1 mm; interquartile range [IQR], 0.6-2.0 mm) compared with EM-NB (2.6 mm; IQR, 1.6-3.8) (P < .001). Median target displacement resulting from lung and bronchus deformation during bronchoscopy was found to be significantly lower using RB (0.8 mm; IQR, 0.5-1.2 mm) compared with EM-NB (2.6 mm; IQR, 1.4-6.4 mm) (P < .001). Conclusions: The results of this study demonstrate that the multi-section RB prototype allows for improved localization and targeting of small peripheral lung nodules compared with current nonrobot bronchoscopy modalities.

Subcutaneous fixation model for complex stenting of recurrent laryngotracheal stenosis.

BACKGROUND: A straight silicone stent can be used to treat proximal benign tracheal stenosis in non-surgical candidates. However, stent migration is a common complication when placed at a particular location and can lead to major complications. This case series of laryngotracheal stenosis reports a fixation method for straight silicone stents in the subglottic trachea (Stage 3 of the McCaffrey classification). METHODS: The medical charts of these patients scheduled for straight silicone stent placement with suture fixation between 2014 and 2020 at the CHU UCL Namur Hospital (Belgium) were retrospectively reviewed. The procedure was performed using a rigid bronchoscope. Details of the procedure were obtained from medical records. RESULTS: This case series included six patients (males: 4, females: 2). The median patient age was 59 years. Two suture fixations were placed following previous silicone stent migration episodes, whereas the others were placed proactively to avoid this risk. All fixations were performed by the device Freka® Pexact II ENFIt®, originally developed for gastropexy in endoscopic gastrostomy. The sutures were subcutaneously buried. CONCLUSIONS: During the 6-month follow-up period, complications such as fixation issues and stent migration were reported despite the off-label use of the treatment. The straight silicone stent fixation technique used in this case series was simple and effective for securing the stent in upper benign tracheal stenosis.

Characterizing the accuracy of robotic bronchoscopy in localization & targeting of small pulmonary lesions.

PURPOSE: Considering the recent implementation of lung cancer screening guidelines, it is crucial that small pulmonary nodules are accurately diagnosed. There is a significant need for quick, precise, and minimally invasive biopsy methods, especially for patients with small lung lesions in the outer periphery. Robotic bronchoscopy (RB) has recently emerged as a novel solution. The purpose of this study was to evaluate the accuracy of RB compared to the existing standard, electromagnetic navigational bronchoscopy (EM-NB). METHODS: A prospective, single-blinded, and randomized-controlled study was performed to compare the accuracy of RB to EM-NB in localizing and targeting pulmonary lesions in a porcine lung model. Four operators were tasked with navigating to four pulmonary targets in the outer periphery of a porcine lung, to which they were blinded, using both the RB and EM-NB systems. The dependent variable was accuracy. Accuracy was measured as a rate of success in lesion localization and targeting, the distance from the center of the pulmonary target, and by anatomic location. The independent variable was the navigation system, RB was compared to EM-NB using 1:1 randomization. RESULTS: Of 75 attempts, 72 were successful in lesion localization and 60 were successful in lesion targeting. The success rate for lesion localization was 100% with RB and 91% with EM- NB. The success rate for lesion targeting was 93% with RB and 80% for EM-NB. RB demonstrated superior accuracy in reaching the distance from the center of the lesion, at 0.62 mm compared to EM-NB at 1.28 mm (p = 0.001). Accuracy was improved using RB compared to EM- NB for lesions in the LLL (p = 0.025), LUL (p < 0.001), and RUL (p < 0.001). CONCLUSION: Our findings support RB as a more accurate method of navigating and localizing small peripheral pulmonary targets when compared to standard EM-NB in a porcine lung model. This may be attributed to the ability of RB to reduce substantial tissue displacement seen with standard EM-NB navigation. As the development and application of RB advances, so will the ability to accurately diagnose small peripheral lung cancer nodules, providing patients with early-stage lung cancer the best possible outcomes.

Electromagnetic Navigational Bronchoscopy Learning Curve Regarding Pneumothorax Rate and Diagnostic Yield.

Electromagnetic navigational bronchoscopy (ENB) has emerged as an innovative technique for diagnosing peripheral and central nodules, offering an improved diagnostic yield compared to conventional bronchoscopy with fewer complications. That being said, pneumothorax remains a frequent complication. This retrospective study conducted at Castle Hill Hospital, UK, analysed ENB procedures over four years to assess the diagnostic yield and pneumothorax rates, exploring learning curves and procedural improvements specifically focusing on the diagnostic yield and pneumothorax rate as markers of change. A total of 246 patients underwent 358 peripheral lung biopsies, revealing an overall diagnostic yield of 61.3%. The diagnostic yield increased from 58.2% in 2020-2021 to 66.0% in 2022-2023 while the pneumothorax rate decreased significantly from 9.8% to 3.4% (p = 0.021*). The majority of pneumothorax cases occurred following upper lobe procedures. The study depicts the importance of procedural experience in improving outcomes, suggesting a learning curve effect. Additionally, it emphasizes the potential for technological advancements, such as robotic assistance, to mitigate operator-dependent variability and improve reproducibility in ENB procedures. These findings contribute to optimizing diagnostic pathways for lung lesions and improving patient safety in ENB interventions.

Diagnostic and Therapeutic Role of Electrocautery Snare Use in Endobronchial Polypoid Lesions.

INTRODUCTION: Electrocautery with a snare probe offers a tool for the treatment of endobronchial polyps. The aim of this study was to demonstrate the efficacy of the snare probe in patients undergoing rigid bronchoscopy due to central airway obstruction. METHODS: This retrospective descriptive study included patients who underwent rigid bronchoscopy with an electrocautery snare probe for the diagnosis and/or treatment of endobronchial polyps in an interventional pulmonology unit. RESULTS: The mean age of the 47 patients (38 men) with endobronchial polypoid lesions was 61.5 years. Six lesions (12.8%) were located in the trachea, 6 (12.8%) in the right main bronchus, 11 (23.4%) in the left main bronchus, and 24 (51.1%) in the lobar bronchi. Twenty-eight lesions (59.5%) were malignant. Prior to the procedure, 6 (12.8%) patients had grade 1 obstruction, 6 (12.8%) had grade 2 obstruction, 15 (31.9%) had grade 3 obstruction, and 20 (42.6%) had grade 4 obstruction. In terms of airway obstruction after the procedure, grade 1 was present in 46 (97.9%) patients and grade 2 was present in 1 (2.1%) patient. No major complication developed in 93.6% of the patients. During a mean follow-up period of 48 months, 85.1% of the patients did not experience recurrence. CONCLUSION: Our results demonstrate that the snare probe can be used to effectively and reliably establish airway patency in patients with central airway obstruction due to endobronchial polypoid lesions.

Practices and perspectives on advanced diagnostic and interventional bronchoscopy among pediatric pulmonologists in the United States.

INTRODUCTION: Advanced diagnostic bronchoscopy includes endobronchial ultrasound (EBUS) guided transbronchial lung and lymph node biopsies, CT navigation and robotic bronchoscopy. Interventional bronchoscopy refers to procedures performed for therapeutic purposes such as balloon dilation of the airway, tissue debulking, cryotherapy, removal of foreign bodies and insertion of endobronchial valves [1]. For adult patients, these procedures are standard of care [2, 3]. Despite a lack of formalized training, there are numerous case reports and case series describing the use of advanced diagnostic and interventional bronchoscopy techniques in children. The safety and feasibility of EBUS-TBNA, cryotherapy techniques, endobronchial valves among other techniques have been demonstrated in these publications [1, 4-9]. METHODS: We sought to better understand the current practices and perspectives on interventional and advanced bronchoscopy among pediatric pulmonologists through surveys sent to pediatric teaching hospitals across the United States. RESULTS: We received 43 responses representing 28 programs from 25 states. The highest bronchoscopy procedure volume occurred in the 0-5 years age group. Among our respondents, 31% self-identified as a pediatric interventional/advanced bronchoscopist. 79% believe that advanced and interventional training is feasible in pediatric pulmonology and 77% believe it should be offered to pediatric pulmonary fellows. DISCUSSION: This is the first study to characterize current practices and perspectives regarding advanced diagnostic and interventional bronchoscopy procedures among pediatric pulmonologists in the United States. Pediatric interventional pulmonology (IP) is in its infancy and its beginnings echo those of the adult IP where only certain centers were performing these procedures.

Airway stenting for liberation from positive pressure ventilation in patients with central airway obstruction presenting with acute respiratory failure.

BACKGROUND: Central airway obstruction (CAO) can lead to acute respiratory failure (RF) necessitating positive pressure ventilation (PPV). The efficacy of airway stenting to aid liberation from PPV in patients with severe acute RF has been scarcely published. We present a systematic review and our recent experience. METHODS: A systematic review of PubMed was performed, and a retrospective review of cases performed at our two institutions from 2018 to 2022 in adult patients who needed stent insertion for extrinsic or mixed CAO complicated by RF necessitating PPV. RESULTS: Fifteen studies were identified with a total of 156 patients. The weighted mean of successful liberation from PPV post-stenting was 84.5% and the median survival was 127.9 days. Our retrospective series included a total of 24 patients. The most common etiology was malignant CAO (83%). The types of PPV used included high-flow nasal cannula (HFNC) (21%), non-invasive ventilation (NIV) (17%) and Invasive Mechanical Ventilation (62%). The overall rate of successful liberation from PPV was 79%, with 55% of HFNC and NIV cases being liberated immediately post-procedure. The median survival of the patients with MCAO that were successfully liberated from PPV was 74 days (n = 16, range 3-893 days), and for those with that failed to be liberated from PPV, it was 22 days (n = 4, range 9-26 days). CONCLUSION: In patients presenting with acute RF from extrinsic or mixed morphology CAO requiring PPV, airway stenting can successfully liberate most from the PPV. This may allow patients to receive pathology-directed treatment and better end-of-life care.

Transbronchial Cryobiopsy Using the Ultrathin 1.1-mm Cryoprobe with Ultrathin Bronchoscopy under Radial Endobronchial Ultrasound Guidance for Diagnosis of Peripheral Pulmonary Lesions.

INTRODUCTION: Today, the increasing number of incidentally detected peripheral pulmonary lesions (PPLs) within and outside lung cancer screening trials is a diagnostic challenge. This fact encourages further improvement of diagnostic procedures to increase the diagnostic yield of transbronchial biopsy, which has been shown to have a low complication rate. The purpose of this study was to evaluate the safety and feasibility of a new ultrathin 1.1 cryoprobe that can be placed through an ultrathin bronchoscope (UTB) using fluoroscopy and radial endobronchial ultrasonography (rEBUS) navigation for assessing PPLs. METHODS: Thirty-five patients with PPL less than 4 cm in diameter were prospectively enrolled to receive transbronchial cryobiopsies (TBCBs) using the ultrathin 1.1-mm cryoprobe. Navigation to the PPL was accomplished with the UTB. Under rEBUS and fluoroscopy guidance up to 4 cryobiopsies were obtained. The sample sizes of the biopsies were compared to a historic collective derived from a 1.9-mm cryoprobe and standard forceps. The feasibility and safety of the procedure, the cumulative and overall diagnostic yield, and the cryobiopsy sizes were evaluated. RESULTS: After detection with the rEBUS, TBCB was collected from 35 PPLs, establishing a diagnosis in 25 cases, corresponding to an overall diagnostic yield of 71.4%. There was no difference in diagnostic yield for PPL <20 mm or ≥20 mm. All cryobiopsies were representative with a mean tissue area of 11.9 ± 4.3 mm2, which was significantly larger compared to the historic collective (p = 0.003). Six mild and four moderate bleeding events and 1 case of pneumothorax were observed. CONCLUSIONS: Using the ultrathin 1.1-mm cryoprobe combined with an UTB for rEBUS-guided TBCB of PPL is feasible and safe. This diagnostic approach improves bronchoscopic techniques for diagnosing peripheral lung lesions and may contribute to improve diagnosis of lung cancer even in small PPL.

Impact of Interventional Bronchoscopy on Long-Term Survival in Patients with Primary Tracheal Adenoid Cystic Carcinoma: A Single-Center Experience.

Introduction: Primary tracheal adenoid cystic carcinoma (TACC) is a rare low-grade lung cancer of bronchial gland origin. Surgery is the first choice of treatment; however, in cases of recurrence or inoperability, a combination of radiation and chemotherapy is administered as a multimodality treatment. Interventional bronchoscopy is also used as a multidisciplinary treatment; however, its impact on long-term prognosis has not been thoroughly investigated. Case Presentation: Eight patients diagnosed with TACC and treated at Shinshu University Hospital between December 2000 and August 2023 were analyzed retrospectively. We investigated the duration of intervention and overall survival (OS) in 3 patients with recurrence who underwent interventional bronchoscopy in combination with chemotherapy and evaluated whether interventional bronchoscopy prolonged the survival. The initial treatment for the 3 patients was surgery in 1 patient and chemoradiotherapy in 2. In all patients, raised lesions were observed in the trachea at the time of recurrence. The duration of interventional bronchoscopy, the time from recurrence of the first-line treatment to death, and OS, which was defined time from induction of the first-line treatment to death, were 69.3/70.7/112.5 months, 179.2/196.1/220.4 months, and 15.4/66.3/104.4 months, respectively. Conclusion: Long-term survival benefits may be obtained with concomitant interventional bronchoscopy in combination with chemotherapy in patients with locally recurrent TACC.

Low bleeding rates following transbronchial lung cryobiopsy in unclassifiable interstitial lung disease.

BACKGROUND AND OBJECTIVE: Bronchoscopic transbronchial lung cryobiopsy (TBLC) is a guideline-endorsed alternative to surgical lung biopsy for tissue diagnosis in unclassifiable interstitial lung disease (ILD). The reported incidence of post-procedural bleeding has varied widely. We aimed to characterize the incidence, severity and risk factors for clinically significant bleeding following TBLC using an expert-consensus airway bleeding scale, in addition to other complications and diagnostic yield. METHODS: A retrospective cohort study of consecutive adult outpatients with unclassifiable ILD who underwent TBLC following multidisciplinary discussion at a single centre in the UK between July 2016 and December 2021. TBLC was performed under general anaesthesia with fluoroscopic guidance and a prophylactic endobronchial balloon. RESULTS: One hundred twenty-six patients underwent TBLC (68.3% male; mean age 62.7 years; FVC 86.2%; DLCO 54.5%). Significant bleeding requiring balloon blocker reinflation for >20 min, admission to ICU, packed red blood cell transfusion, bronchial artery embolization, resuscitation or procedural abandonment, occurred in 10 cases (7.9%). Significant bleeding was associated with traction bronchiectasis on HRCT (OR 7.1, CI 1.1-59.1, p = 0.042), a TBLC histological pattern of UIP (OR 4.0, CI 1.1-14, p = 0.046) and the presence of medium-large vessels on histology (OR 37.3, CI 6.5-212, p < 0.001). BMI ≥30 (p = 0.017) and traction bronchiectasis on HRCT (p = 0.025) were significant multivariate predictors of longer total bleeding time (p = 0.017). Pneumothorax occurred in nine cases (7.1%) and the 30-day mortality was 0%. Diagnostic yield was 80.6%. CONCLUSION: TBLC has an acceptable safety profile in experienced hands. Radiological traction bronchiectasis and obesity increase the risk of significant bleeding following TBLC.

Deformable 3D/3D CT-to-digital-tomosynthesis image registration in image-guided bronchoscopy interventions.

Traditional navigational bronchoscopy procedures rely on preprocedural computed tomography (CT) and intraoperative chest radiography and cone-beam CT (CBCT) to biopsy peripheral lung lesions. This navigational approach is challenging due to the projective nature of radiography, and the high radiation dose, long imaging time, and large footprints of CBCT. Digital tomosynthesis (DTS) is considered an attractive alternative combining the advantages of radiography and CBCT. Only the depth resolution cannot match a full CBCT image due to the limited angle acquisition. To address this issue, preoperative CT is a good auxiliary in guiding bronchoscopy interventions. Nevertheless, CT-to-body divergence caused by anatomic changes and respiratory motion, hinders the effective use of CT imaging. To mitigate CT-to-body divergence, we propose a novel deformable 3D/3D CT-to-DTS registration algorithm employing a multistage, multiresolution approach and using affine and elastic B-spline transformation models with bone and lung mask images. A multiresolution strategy with a Gaussian image pyramid and a multigrid strategy within the B-spline model are applied. The normalized correlation coefficient is included in the cost function for the affine model and a multimetric weighted cost function is used for the B-spline model, with weights determined heuristically. Tested on simulated and real patient bronchoscopy data, the algorithm yields promising results. Assessed qualitatively by visual inspection and quantitatively by computing the Dice coefficient (DC) and the average symmetric surface distance (ASSD), the algorithm achieves mean DC of 0.82±0.05 and 0.74±0.05, and mean ASSD of 0.65±0.29mm and 0.93±0.43mm for simulated and real data, respectively. This algorithm lays the groundwork for CT-aided intraoperative DTS imaging in image-guided bronchoscopy interventions with future studies focusing on automated metric weight setting.

The role of interventional bronchoscopy in the management of malignant central airway obstruction.

Nearly a third of patients with primary lung cancer present with malignant central airway obstruction (MCAO), and some of them appear to have advanced disease. In these patients, accurate staging is crucial. Although the literature extensively outlines the role of interventional bronchoscopy in palliation, its contribution to refining the staging of patients with MCAO is noteworthy. Here, we present a case of a patient initially diagnosed with stage IV cancer due to a left mainstem tumor causing complete lung collapse. He was referred to our institution for palliative treatment of his cough. Following interventional bronchoscopy, the patient's staging was revised to T1a, and subsequently, he underwent lobectomy without complications.

Bronchoscopy findings in children with congenital lung and lower airway abnormalities.

Congenital lung and lower airway abnormalities are rare, but they are an important differential diagnosis in children with respiratory diseases, especially if the disease is recurrent or does not resolve. The factors determining the time of presentation of congenital airway pathologies include the severity of narrowing, association with other lesions and the presence or absence of congenital heart disease (CHD). Bronchoscopy is required in these cases to assess the airway early after birth or when intubation and ventilation are difficult or not possible. Many of these conditions have associated abnormalities that must be diagnosed early, as this determines surgical interventions. It may be necessary to combine imaging and bronchoscopy findings in these children to determine the correct diagnosis as well as in operative management. Endoscopic interventional procedures may be needed in many of these conditions, ranging from intubation to balloon dilatations and aortopexy. This review will describe the bronchoscopic findings in children with congenital lung and lower airway abnormalities, illustrate how bronchoscopy can be used for diagnosis and highlight the role of interventional bronchoscopy in the management of these conditions.

Tracheobronchial stents: an expanding prospect.

The first dedicated tracheobronchial silicone stent was designed by the French pulmonologist Jean-Paul Dumon. The most common indications for stenting are to minimise extrinsic airway compression from mass effect, maintain airway patency due to intrinsic obstruction or treat significant nonmalignant airway narrowing or fistulae. Silicone stents require rigid bronchoscopy for insertion; however, they are more readily repositioned and removed compared with metallic stents. Metallic stents demonstrate luminal narrowing when loads are applied to their ends, therefore stents should either be reinforced at the ends or exceed the area of stenosis by a minimum of 5 mm. Nitinol, a nickel-titanium metal alloy, is currently the preferred material used for airway stents. Airway stenting provides effective palliation for patients with severe symptomatic obstruction. Drug-eluting and three-dimensional printing of airway stents present promising solutions to the challenges of the physical and anatomical constraints of the tracheobronchial tree. Biodegradable stents could also be a solution for the treatment of nonmalignant airway obstruction.

Interventional bronchoscopy in pediatric pulmonary tuberculosis.

INTRODUCTION: Lymphobronchial tuberculosis (TB) is common in children with primary TB and enlarged lymph nodes can cause airway compression of the large airways. If not treated correctly, airway compression can result in persistent and permanent parenchymal pathology, as well as irreversible lung destruction. Bronchoscopy was originally used to collect diagnostic samples; however, its role has evolved, and it is now used as an interventional tool in the diagnosis and management of complicated airway disease. Endoscopic treatment guidelines for children with TB are scarce. AREAS COVERED: The role of interventional bronchoscopy in the diagnosis and management of complicated pulmonary TB will be discussed. This review will provide practical insights into how and when to perform interventional procedures in children with complicated TB for both diagnostic and therapeutic purposes. This discussion incorporates current scientific evidence and refers to adult literature, as some of the interventions have only been done in adults but may have a role in children. Limitations and future perspectives will be examined. EXPERT OPINION: Pediatric pulmonary TB lends itself to endoscopic interventions as it is a disease with a good outcome if treated correctly. However, interventions must be limited to safeguard the parenchyma and prevent permanent damage.

Our Clinical Experience With Patients Requiring Intensive Care for Tracheal Stenosis: A Retrospective Case-Control Study.

Background and objective The clinical course in patients with tracheal stenosis (TS) ranges from being asymptomatic to respiratory failure requiring follow-up in the ICU. In this study, we aimed to assess the clinical characteristics, management, and outcome of TS patients who were admitted to the ICU. Materials and methods The data of patients hospitalized in the ICU due to TS between January 01, 2015, and January 01, 2016, were analyzed. The patients were classified into two groups: the post-intubation tracheal stenosis (PITS) group and the post-tracheostomy tracheal stenosis (PTTS) group. Demographic characteristics, body mass index (BMI), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the Sequential Organ Failure Assessment (SOFA) score of patients, factors that caused TS, management of TS, and ICU data of patients were compared. The outcome measures of our study were the ICU management of patients diagnosed with PITS or PTTS, their clinical characteristics, and differences in the treatment between patients diagnosed with PITS and those with PTTS in the ICU. Results Fifteen (75%) patients had PITS and five (25%) had PTTS. While BMI was significantly lower in patients in the PTTS group, the APACHE II and SOFA scores were significantly higher in PTTS patients (p<0.05). In most of the patients in the PITS group, the location of the stenosis was subglottic and at the 1/3 upper part of the trachea, while in the PTTS group, it was located only at the upper 1/3 of the trachea (p>0.05). Mechanical dilatation was performed in all patients in both groups. Mechanical dilatation and cryotherapy were performed in 10 (66.7%) patients in the PITS group (p>0.05), and a stent was applied in addition to this treatment in three (20%) patients in the PITS group and four (80%) patients in the PTTS group (p<0.05). Mechanical ventilation was not needed in 10 (66.7%) PITS patients and three (60.0%) PTTS patients after the interventional procedure. All patients were eventually discharged from the ICU after treatment. Conclusion While higher BMI was common in PITS patients, the PTTS patients were generally in worse condition. In this patient group, interventional pulmonology procedures in the ICU can be life-saving.

[Interventionnal bronchoscopy for the treatment of tracheobronchomalacia]. / Place de la bronchoscopie interventionnelle dans la prise en charge des trachéobronchomalacies.

Tracheobronchomalacia is usually characterized by more than 50% expiratory narrowing in diameter of the trachea and the bronchi. The expiratory collapse includes two entities: (1) the TBM related to the weakness of the cartilaginous rings, and (2) the Excessive Dynamic Airway Collapse (EDAC) due to the excessive bulging of the posterior membrane. Patients have nonspecific respiratory symptoms like dyspnea and cough. Diagnosis is confirmed by dynamic tests: flexible bronchoscopy and/or computed tomographic scan of the chest. There are different forms of tracheobronchomalacia in adults: primary (genetic, idiopathic) or secondary to trauma, tracheotomy, intubation, surgery, transplantation, emphysema, infection, inflammation, chronic bronchitis, extrinsic compression; or undiagnosed in childhood vascular rings. Some management algorithms have been proposed, but no specific recommendation was established. Only symptomatic patients should be treated. Medical treatments and noninvasive positive pressure ventilation should be the first line therapy, after evaluation of various quality measures (functional status, performance status, dyspnea and quality of life scores). If symptoms persist, therapeutic bronchoscopy permits: (1) patient's selection by stent trial to determine whether patient benefit for surgical airway stabilization; (2) malacic airways stenting in patients who are not surgical candidates, improving QOL despite a high complication rate; (3) the management of stent-related complication (obstruction, plugging, migration granuloma); (4) alternative therapeutics like thermo-ablative solution. Lasty, the development of new types of stents would reduce the complication rates. These different options remained discussed.

A Millimeter-Scale Soft Robot for Tissue Biopsy Procedures.

While interest in soft robotics as surgical tools has grown due to their inherently safe interactions with the body, their feasibility is limited in the amount of force that can be transmitted during procedures. This is especially apparent in minimally invasive procedures where millimeter-scale devices are necessary for reaching the desired surgical site, such as in interventional bronchoscopy. To leverage the benefits of soft robotics in minimally invasive surgery, a soft robot with integrated tip steering, stabilization, and needle deployment capabilities is proposed for lung tissue biopsy procedures. Design, fabrication, and modeling of the force transmission of this soft robotic platform allows for integration into a system with a diameter of 3.5 mm. Characterizations of the soft robot are performed to analyze bending angle, force transmission, and expansion during needle deployment. In-vitro experiments of both the needle deployment mechanism and fully integrated soft robot validate the proposed workflow and capabilities in a simulated surgical setting.