Efficiency of Electromagnetic Navigation Bronchoscopy and Virtual Bronchoscopic Navigation.

BACKGROUND: Image-guided bronchoscopy techniques have emerged as a means of improving pulmonary nodule biopsy yield. However comparisons of the diagnostic efficacy of electromagnetic navigation bronchoscopy (ENB) and virtual bronchoscopic navigation (VBN) have not reached a consensus. This meta-analysis evaluates the overall diagnostic yield and accuracy of ENB and VBN for pulmonary nodules. METHODS: A systematic search was conducted to identify relevant articles. Meta-analysis was used to summarize the sensitivities, specificities, and area under the curve for ENB and VBN. RESULTS: Thirty-two studies (1981 patients with pulmonary nodules) were included in this analysis. The pooled sensitivity, specificity, and area under the curve (95% confidence interval) of ENB were 0.80 (0.73-0.85), 0.81 (0.71-0.88), and 0.87 (0.84-0.90), respectively. Corresponding VBN values were 0.80 (0.76-0.83), 0.65 (0.56-0.73), and 0.81 (0.78-0.85), respectively. Comparison of the 2 techniques revealed that ENB had higher specificity and area under the curve but no difference in sensitivity. CONCLUSIONS: Both ENB and VBN are valuable tools in the diagnosis of lung nodules. ENB achieved a higher specificity than VBN in the diagnose of lung nodules, whereas ENB performed better than VBN for pulmonary nodules. These results are due to the real-time positioning function of ENB.

Thermal ablation for asthma: current status and technique.

Bronchial thermoplasty (BT) is a novel technique used in the treatment of severe asthma. A catheter is advanced through the bronchoscope and directed radiofrequency waves are applied to the segmental bronchi to reduce airway smooth muscle mass. Several randomized clinical trials demonstrate improvement in quality of life and reduction in exacerbation rates after treatment. BT is a safe and cost effective treatment option for severe asthma which is refractory to medical treatment. Further studies are needed in order to better describe the mechanism of action and the asthma subphenotype that was best benefit from this treatment.

The changing anatomic position of squamous cell carcinoma of the lung - a new conundrum.

BACKGROUND: Traditionally, squamous cell carcinoma (SCC) of the lung is a central rather than a peripheral form of lung cancer. Rates of SCC in the lung periphery are typically sited in the 15-30% range. Recently, we observed that a significant portion of newly diagnosed SCC was located on a periphery. A comprehensive review of the tumor data at our facility, a busy teaching hospital with a large cohort of cancer patients, was undertaken to assess whether there had been a substantive change in the traditional epidemiologic distributions of the lung cancer, specifically with respect to SCC. Given the differences in cell biology and carcinogenesis of central versus peripheral SCC, a potential epidemiologic shift might suggest a change in tumor biology. METHODS: From May 12, 2012 through May 13, 2013, all histopathologically confirmed diagnoses of SCC of the lung were retrospectively reviewed. Each patient's lesion was then classified as peripheral or central based on CT evidence. RESULTS: A total of 56 patients were diagnosed with SCC. Of these, 55% (n=31) had peripheral and 45% (n=25) had central SCC. Twenty-nine patients did not have any prior history of malignancy. Of this subset of patients, 62% (n=18) had peripheral SCC, and 38% (n=11) had central SCC. CONCLUSION: Our findings appear to correlate with our initial observation that, within our institution, there has been a substantive shift in the traditional distribution of SCC with the majority of these cancers now being diagnosed in the lung periphery as opposed to the more central locations.

Role of electromagnetic navigational bronchoscopy in pulmonary nodule management.

The incidence of pulmonary nodules and lung cancer is rising. Some of this increase in incidence is due to improved pick up by newer imaging modalities. However, the goal is to diagnose these lesion, many of which are located in the periphery, by safe and relatively non-invasive methods. This has led to the emergence of numerous techniques such as electromagnetic navigational bronchoscopy (ENB). Current evidence supports a role for these techniques in the diagnostic pathway. However, numerous factor influence the diagnostic accuracy. Thus despite significant advances, more research needs to be undertaken to further improve the currently available diagnostic technologies.

Percutaneous Bullectomy in Conjunction with Endobronchial Valve Placement as an Alternative to Surgical Management of Giant Bullae.

We present the first reported case of the treatment and management of a giant bulla using percutaneous bullectomy and endobronchial valve placement. A 74-year-old woman with chronic obstructive pulmonary disease and a known large bulla in the left chest presented to the emergency department with acute-onset confusion after a traumatic fall. She was subsequently diagnosed with an intracranial hemorrhage in the distribution of the right basal ganglia. Chest imaging revealed a giant apical bulla occupying 80% of the left hemithorax. In addition, there was midline shift away from the affected side associated with volume loss in the right hemithorax and no radiographic evidence of aeration in the remainder of the left lung. Arterial blood gas analysis revealed significant hypercapnia. Surgical bullectomy was not an option, and thus, a novel approach was utilized to treat this patient.

The role of a nurse specialist in a modern lung-cancer service.

The delivery of a modern cancer service is dependent on the nurse specialist occupying a central role in the overall pathway. However, there are significant variations in the access to a lung cancer clinical nurse specialist (CNS) across the UK and the USA. In the UK, the lung cancer CNS plays a pivotal role in the delivery of high-quality care and treatment to patients with (presumed) thoracic malignancy. They are in an ideal position to provide holistic care to patients with lung cancer-ensuring that all needs are addressed from the time of initial referral to commencement of definitive treatment or palliative care. In addition the role provides support and advice to people on the increasingly complex treatment options and on survivorship, and plays an essential role in end-of-life care. In the USA, the nurse navigator is a core member of the lung cancer screening programme. In this review the authors provide a transatlantic perspective on the history, current practice and potential future roles for the lung cancer CNS in the UK and nurse navigator in the US.

Bronchoscopic interventions for severe COPD.

Chronic obstructive pulmonary disease (COPD) causes severe handicap among smokers. Most patients have to remain under continuous oxygen therapy at home. Moreover, respiratory infections are very common among these patients and vaccination is obligatory against influenza. Emphysema and bronchiectasis are observed with computed tomography (CT) and in several situations these parenchymal damages are responsible for pneumothorax in one case and pseudomonas aeroginosa infection. Novel mini-invasive techniques are used currently for emphysema treatments which are described extensively throughout our current work.

Thoracoscopic detection of occult indeterminate pulmonary nodules using bronchoscopic pleural dye marking.

BACKGROUND: The annual incidence of a small indeterminate pulmonary nodule (IPN) on computed tomography (CT) scan remains high. While traditional paradigms exist, the integration of new technologies into these diagnostic and treatment algorithms can result in alternative, potentially more efficient methods of managing these findings. METHODS: We report on an alternative diagnostic and therapeutic strategy for the management of an IPN. This approach combines electromagnetic navigational bronchoscopy (ENB) with an updated approach to placement of a pleural dye marker. This technique lends itself to a minimally invasive wedge resection via either video-assisted thoracoscopic surgery (VATS) or a robotic approach. RESULTS: Subsequent to alterations in the procedure, a cohort of 22 patients with an IPN was reviewed. Navigation was possible in 21 out of 22 patients with one patient excluded based on airway anatomy. The remaining 21 patients underwent ENB with pleural dye marking followed by minimally invasive wedge resection. The median size of the nodules was 13.4 mm (range: 7-29). There were no complications from the ENB procedure. Indigo carmine dye was used in ten patients. Methylene blue was used in the remaining 11 patients. In 81% of cases, the visceral pleural marker was visible at the time of surgery. In one patient, there was diffuse staining of the parietal pleura. In three additional patients, no dye was identified within the hemithorax. In all cases where dye marker was present on the visceral pleural surface, it was in proximity to the IPN and part of the excised specimen. CONCLUSIONS: ENB with pleural dye marking can provide a safe and effective method to localize an IPN and can allow for subsequent minimally invasive resection. Depending on the characteristics and location of the nodule, this method may allow more rapid identification intraoperatively.

Airway spray cryotherapy: initial outcomes from a multiinstitutional registry.

BACKGROUND: Spray cryotherapy (SCT) uses a noncontact system to deliver liquid nitrogen (2 to 4 psi) through an endoscopic catheter. Rapid freezing and thawing of tissue causes cellular death and is also hemostatic. We report the preliminary results from 6 institutions in which SCT was used for the treatment of malignant airway tumors. METHODS: SCT was performed on patients with symptomatic airway tumors and reviewed retrospectively. Airway narrowing was graded as 25% or smaller, 26% to 50%, 51% to 75%, and exceeding 75%. All events were documented and assessed. RESULTS: Eighty patients (45 male [56%]) underwent 114 treatments. Median age was 66 years (range, 15 to 90 years). All patients were treated with minimal blood loss. Fifty-eight percent of the cases were outpatient procedures. Airway obstruction exceeded 75% in most of the lesions treated. There were 21 intraoperative events (19%), including hypotension, bradycardia and tachycardia, ST segment changes, desaturation, and an airway tear. Three pneumothoraces occurred, one requiring emergency chest tube placement. Two intraoperative deaths were associated with bradycardia. Three postoperative deaths occurred in patients who were transitioned to comfort care. All but 1 patient had airway patency after treatment. CONCLUSIONS: SCT can be used in patients with highly vascular tumors, with reduced bleeding complications and a low overall complication rate. Caution is needed before SCT is used on a widespread basis, given the intraoperative complications. Although the potential benefit of SCT is considerable, this needs to be confirmed in larger studies.

Optimization of mediastinal staging in potential candidates for stereotactic radiosurgery of the chest.

OBJECTIVE: Patients with medically inoperable nonsmall-cell lung cancer generally have limited staging of the mediastinum using computed tomography and combined positron emission tomography and computed tomography, before stereotactic radiosurgery. Historical data have demonstrated the superiority of tissue sampling techniques such as endobronchial ultrasonography and mediastinoscopy compared with imaging studies in accurately determining the nodal stage. We believe, that at a minimum, mediastinal interrogation with endobronchial ultrasonography should be performed before patients undergo stereotactic radiosurgery. METHODS: A retrospective review of 59 consecutive patients undergoing bronchoscopic fiducial marker placement as potential candidates for stereotactic radiosurgery was done. All these patients had undergone endobronchial ultrasonography to assess the mediastinum. Transbronchial needle aspirates were taken using standard criteria defined by a lymph node size greater than 5 mm in diameter and/or in the appropriate lymph node drainage pathway. The biopsies were reviewed by the institution's pathologists. RESULTS: Mediastinal lymph node specimens were not taken in 9 patients because they did not meet our criteria. Of the 50 patients who underwent mediastinal lymph node sampling, 10 had evidence of nodal involvement. On review, 2 of these 10 patients had evidence of mediastinal adenopathy on computed tomography. After excluding those 2 patients, the mediastinal lymph nodes were positive for metastatic disease in 8 (16%) of 50 patients without previous radiographic evidence of disease. These patients were previously thought to be suitable candidates for stereotactic radiosurgery. Also 5 of 10 patients with endobronchial ultrasound-positive lymph nodes had had positron emission tomography-negative findings in the mediastinum. Finally, 10% of the patients suspected to have stage II or III were downstaged with endobronchial ultrasonography and considered for stereotactic radiosurgery. CONCLUSIONS: Endobronchial ultrasonography-transbronchial needle aspirates is more accurate than computed tomography and positron emission tomography in staging the mediastinum, can be performed with minimal morbidity, and should be considered for all patients considered candidates for stereotactic radiosurgery.

Feasibility of spray cryotherapy and balloon dilation for non-malignant strictures of the airway.

OBJECTIVE: Benign airway strictures can be complex and challenging to manage. Although resection is preferred, this is not always feasible, and hence, endoscopic therapies are often performed. However, endoscopic therapies can be problematic, with granulation tissue and fibrosis leading to early failure. Spray cryotherapy (SC) is a new approach that may modulate the healing response leading to less fibrosis and decrease the need or the duration of time to intervention. We report the initial results of SC for benign airway strictures. METHODS: Over a 22-month period, 35 patients underwent SC. Median age was 51(18-81) years. Prior therapy had been undertaken in 14 (41.2%) of patients. Stricture etiology included post intubation (n=5), prior tracheostomy (n=6), radiation induced (n=2), prior surgery (n=3), other causes (n=12), or unknown etiology (n=7). Airway narrowing was graded as follows: 1=0-25%, 2=26-50%, 3=51-75%, and 4=76-100%. For the purpose of analysis, this was treated as a continuous variable. The usual treatment algorithm consisted of ×3-4 SC cycles, followed by balloon dilation, and then by additional SC cycles. RESULTS: Stricture locations were subglottic (n=18), tracheal (n=9), and bronchial (n=8). Seventeen (49%) patients required additional SC therapy, resulting in a total of 63 SC treatment sessions. Only two (3.2%) complications occurred and these included pneumothorax (n=1) and intra-operative tracheostomy (n=1). Mean follow-up was available in 33/35 patients at a mean of 8.2 (1-19) months. Twelve (of 33) patients (36.4%) were asymptomatic, 16/33 (48.5%) were improved, 4/33(12.1%) had no improvement or were worse, and 1/33(3%) patient died from an unrelated cancer. On follow-up bronchoscopy, performed in 28 patients, airway narrowing improved significantly from 3.5 to 2.03 (p<0.001). CONCLUSIONS: Initial experience with SC for benign airway strictures suggests that this can be used safely. This is effective in improving symptoms and reducing the severity of airway narrowing. Re-intervention is still required. Further study should be undertaken to determine factors that may be associated with success or failure as well as the relative efficacy of SC compared with other endoscopic therapies.

Fiducial marker placement using endobronchial ultrasound and navigational bronchoscopy for stereotactic radiosurgery: an alternative strategy.

BACKGROUND: Stereotactic radiosurgery is being increasingly used to treat patients with early-stage non-small cell lung cancers (NSCLC) who are not candidates for surgical resection. Stereotactic radiosurgery usually needs fiducial markers (FMs) for the tracking process. FMs have generally been placed using percutaneous computed axial tomography scan guidance. We report the results of FM placement using endobronchial ultrasound (EBUS) in 43 patients. METHODS: A multidisciplinary tumor board evaluates NSCLC patients before they are offered stereotactic radiosurgery. In patients selected for stereotactic radiosurgery, FMs were inserted into peripheral, central, and mediastinal tumors using EBUS and, in selected patients, navigational bronchoscopy. Patients underwent repeat computed axial tomography chest scans 2 weeks later to ensure stability of the FMs before beginning stereotactic radiosurgery. RESULTS: Included were 43 consecutive patients (21 men, 22 women; mean age, 74.4 years). Forty-two (98%) had NSC carcinomas (5 recurrences); 1 had a carcinoid tumor. Twenty-two tumors were located in the left lung, 19 in the right lung, 1 at the carina, and 1 pretracheal. Two to 5 FMs were placed in and around all tumor masses using EBUS and, for peripheral lesions, EBUS combined with navigational bronchoscopy. Thirty patients had no displacement of FMs. In the 13 who had displaced 1 or more FMs, the ability to use the remaining FMs for stereotactic radiosurgery was unimpaired. CONCLUSIONS: EBUS and navigational bronchoscopy are safe and effective methods to position FMs for preparing patients with both central and peripheral lung cancers for stereotactic radiosurgery.

Spray cryotherapy for the treatment of glottic and subglottic stenosis.

OBJECTIVES/HYPOTHESIS: Functional partial occlusion of the glottic and subglottic areas by stenosis and strictures is challenging to manage despite a variety of surgical and endoluminal approaches that are prone to complications and inconsistent outcomes. We report here the first three human cases of glottic and subglottic narrowing treated with spray cryotherapy alone or in combination with balloon dilation. STUDY DESIGN: Institutional review board-approved clinical human trial. METHODS: A 42-year-old female with idiopathic subglottic strictures, a 74-year-old female with glottic strictures and vocal cord stenosis following neck radiation, and a 33-year-old female with strictures from a previous tracheal stent were treated by four cycles of a 5-second cryotherapy spray alone or with balloon dilation. The effects of treatment were observed up to 6 months, 12 weeks, and 9 months, respectively. RESULTS: In all cases, patency of the stenosed areas was achieved with minimal bleeding and at least some degree of normalization of the glottic and subglottic mucosa. Airway patency and laryngeal functions were restored without complications. CONCLUSIONS: The use of spray cryotherapy alone or in conjunction with balloon dilation is a promising and effective therapeutic approach to treating glottic and subglottic narrowing.

Evaluation of the dyspneic patient in the office.

Dyspnea is a nonspecific symptom of any disease involving the respiratory system. Although diseases of the lungs, chest wall, pleura, diaphragm, upper airway, and heart are most common, diseases of many other organ systems (eg, neuromuscular, skeletal, renal, endocrine, rheumatologic, hematologic, and psychiatric) may involve the respiratory system and present with dyspnea. Dyspnea should be evaluated systematically, and a thorough history and physical examination and baseline tests of heart and lung function are necessary to establish a complete database. More sophisticated testing may be needed when the cause is not readily apparent from the initial work-up. Treatment is best and most effective when geared toward a specific etiology, but if this is not possible, nonspecific treatment of the symptom pf dyspnea may afford the patient some benefit.