Usefulness of endoscopic ultrasound with bronchoscope-guided fine-needle aspiration for next-generation sequencing in patients with non-small cell lung cancer: A comparison with other bronchoscopic techniques.

BACKGROUND: Next-generation sequencing (NGS) is essential in treating advanced lung cancer. However, the effectiveness of endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) in NGS remains unclear. This study examined the usefulness of EUS-B-FNA in lung cancer NGS cases where EUS-B-FNA was performed for specimen submission in a nationwide genomic screening platform (LC-SCRUM-Asia) and compared specimens collected using other bronchoscopy methods (endobronchial ultrasound-guided transbronchial needle aspiration [EBUS-TBNA] and EBUS-guided transbronchial biopsy with a guide sheath [EBUS-GS-TBB]) during the same period. METHODS: We retrospectively compared the NGS success rates of NGS, DNA and RNA yields for EUS-B-FNA, EBUS-TBNA, and EBUS-GS-TBB from the records of the patients recruited for the Lung Cancer Genomic Screening Project for Individualized Medicine (LC-SCRUM)-Asia. RESULTS: Fifty-one patients were enrolled, and the NGS success rates were comparable for samples obtained by EUS-B-FNA, EBUS-TBNA, and EBUS-GS-TBB (100%, 90.9%, and 81.0%, respectively). Genetic alterations were detected in 73.7%, 90.9%, and 85.7% of patients, respectively, with druggable genetic alterations found in 31.6%, 72.7%, and 61.9% of patients, respectively. The DNA and RNA yields were significantly higher in EUS-B-FNA samples than in EBUS-GS-TBB samples (50.4 (interquartile range (IR): 15.45-72.35) ng/µl and 33.9 (IR: 9-76.8) ng/µl from EUS-B-FNA, and 3.3 (IR: 1.4-7.1) ng/µl and 15.1 (IR: 8.3-31.5) ng/µl from EBUS-GS-TBB, respectively, p < 0.05). CONCLUSION: EUS-B-FNA emerges as a promising bronchoscopic method for obtaining adequate samples for NGS in advanced lung cancer cases.

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.

The use of overlapping self-expandable covered stents in the management of long-segment tracheobronchomalacia: A case report.

Tracheomalacia is a condition where the tracheal wall is abnormally soft and prone to collapse during increased respiratory efforts. Airway malacia can manifest as segmental conditions like laryngomalacia, tracheomalacia and bronchomalacia, or as diffuse conditions such as tracheobronchomalacia (TBM). Unlike long-segment congenital tracheal stenosis, where surgery may be the preferred treatment, the management of long-segment TBM remains controversial.

Clinical and Bronchoscopy Assessment in Diagnosing the Histopathology Type of Primary Central Lung Tumors.

Background: The location and type of a tumor influence the prognosis of lung cancer. Primary Central Lung Tumors (PCLTs) are correlated with poor prognoses and certain histologic types. This study aimed to present a comprehensive exploration of clinical and bronchoscopic assessments for diagnosing the histopathology types of PCLTs and identified the factors associated with certain histologic types. Methods: This was an observational cross-sectional study of PCLTs, defined as tumors in direct contact with hilar structures or located within the inner two-thirds of the hemithorax. We gathered demographic and clinical data, as well as data on bronchoscopy assessment and histopathology type. Tumor stage, symptoms of superior vena cava syndrome, and enlargement of lymph nodes in the paratracheal and subcarinal regions were also documented. Results: Of the 895 patients, 37.87% had primary lung tumors, with 17.76% classified as PCLTs. Notably, PCLT cases exhibited a higher proportion of stage III (28.9% vs. 18.3%; p = 0.03) and Squamous Cell Carcinoma (SCC) histopathology (37.1% vs. 17.2%; p = 0.00) compared with non-PCLT cases. Bronchoscopic findings in PCLTs revealed a predilection for central airway masses (25.2%) and compressive distal airway stenosis (25.2%). Subgroup analysis of 159 PCLT cases identified 37.10% as SCC. Multivariate analysis underscored that intraluminal masses predict central SCC (odds ratio 2.075, 95% confidence interval 1.07-3.99; p = 0.028). Conclusion: The proportion of stage III, SCC histopathological type, and intraluminal lesions was higher in patients with PCLT than in non-PCLT cases. The presence of intraluminal lesions can predict the histopathological type of SCC in patients with PCLTs.

Negative-Pressure Pulmonary Edema Induced by Flexible Bronchoscopy: A Case Report.

Negative-pressure pulmonary edema (NPPE) arises from excessive inspiratory effort due to upper airway obstruction, often associated with postoperative laryngospasm and upper airway infections like epiglottitis. We present a case of NPPE during bronchoscopy. A 45-year-old female patient, who was undergoing bronchoscopy for interstitial pneumonia evaluation, was examined using a tracheal tube with a 7.5 mm internal diameter and a bronchoscope with a 5.9 mm external diameter. The patient's respiratory condition gradually worsened after intubation. We continued with the examination, supplying approximately 5 L/min of oxygen through the intubation tube. We performed an alveolar lavage, and the recovered fluid gradually turned pale and bloody. After the examination, the patient continued to expectorate pink and frothy sputum and prolonged respiratory failure. Chest radiography revealed new extensive bilateral infiltrates. We ruled out cardiogenic causes through clinical examination, electrocardiogram (ECG), and transthoracic echocardiography. As a result, we suspected that temporary upper airway obstruction during bronchoscopy led to NPPE. Applying continuous positive airway pressure (CPAP) quickly improved the pulmonary edema. The risk of NPPE during bronchoscopy needs to be acknowledged, especially when using larger bronchoscopes and smaller tracheal tubes.

Patient in Mayfield Head Pins Requiring Prone Bronchoscopy for Mucus Plug Obstruction: A Case Report.

Mucus plug obstruction is a common complication in prone patients associated with loss of ventilation and hemodynamic instability. This case presents a 62-year-old female with chronic bronchitis who underwent posterior cervical fusion for a type III dens fracture with extension into the pars articularis and pedicles. Glycopyrrolate was administered to assist with fiberoptic intubation. After successful intubation, bronchoscopy revealed copious endotracheal secretions requiring preoperative therapeutic removal. Despite extensive removal of thick endotracheal secretions preoperatively, obstructive mucus plugging developed intraoperatively with complete loss of end-tidal carbon dioxide (ETCO2) while the patient was in Mayfield head pins. With limited airway access, suctioning and prone flexible bronchoscopy were performed, successfully restoring ETCO2. This experience underscores the need for heightened awareness and preparedness for mucus plug obstruction in chronic bronchitis patients undergoing prone cervical spine surgeries.

[Differential diagnosis of coccidioidomycosis manifested by peripheral pulmonary lesion]. / Differentsial'naya diagnostika koktsidioidomikoza, manifestirovannogo perifericheskim obrazovaniem legkogo.

We present this clinical case as a demonstration of difficulties in differential diagnosis of pulmonary coccidioidomycosis. Differential diagnostics of peripheral pulmonary lesion performed using bronchoscopy with BAL and TBCB and video-assisted thoracic surgery (VATS) biopsy. Diagnostic specimens were tested using microbiological (luminescent microscopy, culture for M. tuberculosis (BACTEC MGIT960 and Lowenstein-Jensen Medium), RT-PCR, cytological and morphological (hematoxylin-eosin, Ziehl-Neelsen, PAS, Grocott methenamine silver (GMS) stainings) examinations. A diagnosis was verified correctly In Russia the country is not endemic for coccidioidomycosis and patient was treated accordingly. Diagnostics of peripheral pulmonary lesions requires of multidisciplinary approaches. Morphological examination, based on detection of only granulomatous inflammation in lung biopsy cannot be used for finally DS and requires microbiological confirmation for TB or other infections, and dynamic monitoring of the patient with concordance their anamnesis vitae and morbi.

Percutaneous Tracheostomy Via Grigg's Technique in Children: Does Age and Size Matter?

OBJECTIVES: Percutaneous tracheostomy is rarely performed in children, especially in infants. In the present study, we aimed to evaluate the complications and outcomes of PT via the Griggs technique according to the age and size of pediatric patients. METHODS: This study included 110 PICU patients who underwent PT using the Griggs technique between 2012 and 2020. The patients were divided into six groups according to their age, demographic data, primary disease, mean duration of intubation before PT, mean duration of PICU and hospitalization after PT, complications, and decannulation outcomes were compared between these groups. RESULTS: The mean age and mean weight of the patients were 43.6 ± 58.9 months (1 month-207 months) and 14.6 ± 14.9 kg (2.6-65 kg), respectively. Mean intubation times before the procedures were 64.6 ± 40 days and 38.6 ± 37.9. Thirty-seven (33.6%) infants were under 6 months of age(Group 1). There were no intraoperative complications. Tracheostomy site stenosis was significantly greater in Group 1 than in the other age groups (p = 0.032). Granuloma formation and dermatitis incidence were similar in all age groups. CONCLUSION: PT is a safe and feasible procedure even in small infants. The accidental decannulation risk is lower than standard tracheostomy. Interacting with rigid bronchoscopy guidance is essential to perform a safer procedure. The first tracheostomy change after PT in small infants under 6 months of age, the possibility of tracheostomy site (stoma) stenosis should be considered. LEVEL OF EVIDENCE: Level III Laryngoscope, 2024.

Improving diagnostic strategies in bronchoscopy for peripheral pulmonary lesions.

INTRODUCTION: In the past two decades, bronchoscopy of peripheral pulmonary lesions (PPLs) has improved its diagnostic yield due to the combination of various instruments and devices. Meanwhile, the application is complex and intertwined. AREAS COVERED: This review article outlines strategies in diagnostic bronchoscopy for PPLs. We summarize the utility and evidence of key instruments and devices based on the results of clinical trials. Future perspectives of bronchoscopy for PPLs are also discussed. EXPERT OPINION: The accuracy of reaching PPLs by bronchoscopy has improved significantly with the introduction of combined instruments such as navigation, radial endobronchial ultrasound, digital tomosynthesis, and cone-beam computed tomography. It has been accelerated with the advent of approach tools such as newer ultrathin bronchoscopes and robotic-assisted bronchoscopy. In addition, needle aspiration and cryobiopsy provide further diagnostic opportunities beyond forceps biopsy. Rapid on-site evaluation may also play an important role in decision making during the procedures. As a result, the diagnostic yield of bronchoscopy for PPLs has improved to a level comparable to that of transthoracic needle biopsy. The techniques and technologies developed in the diagnosis will be carried over to the next step in the transbronchial treatment of PPLs in the future.

Remimazolam and Its Place in the Current Landscape of Procedural Sedation and General Anesthesia.

Remimazolam was derived from its parent compound by adding an ester linkage into its structure so that the drug becomes a substrate for ester metabolism. As a result, it undergoes organ-independent ester hydrolysis, although the clinical benefits in terms of shorter recovery are not uniformly observed in clinical practice. Remimazolam is mainly tested in procedural sedation. In comparison to propofol, the current gold standard for procedural sedation, its proposed attractiveness is shorter wake-up times and a clear-headed recovery. Its clear advantages over propofol are better hemodynamic stability, lack of pain on injection and availability of a reversal agent in the form of flumazenil. Data on patient and proceduralist satisfaction are lacking. Remimazolam is also used for induction and maintenance of general anesthesia in Japan (where it is approved for this purpose). In this scenario, it is not clear if it can achieve the same degree of lack of recall as propofol. The use of remimazolam in obstetrics, pediatrics and high-risk populations is an emerging area.

Obstructive Tracheobronchitis in Influenza-Associated Pulmonary Aspergillosis.

We report a bronchoscopic image of a 36-year-old with significant airway obstruction from obstructive tracheobronchitis secondary to invasive pulmonary aspergillosis. It is rare to see such a severe form of obstructive tracheobronchitis, likely caused by the patient'sp immunocompromised status and rapid progression nature of influenza-associated pulmonary aspergillosis.

Successful EGFR Mutation Detection in Cytological Specimens of Lung Cancer with Challenging Biopsies by Integrating Virtual Bronchoscopy Navigation and Endobronchial Ultrasound Guidance with Highly Sensitive Next-Generation Sequencing: A Case Report.

Introduction: This case report presents the successful detection of an EGFR exon 19 deletion using virtual bronchoscopic navigation (VBN) and endobronchial ultrasound with guide sheath (EBUS-GS) brushing, integrated with highly sensitive next-generation sequencing (NGS), even in challenging biopsy scenarios. The growing prevalence of driver gene alterations in non-small cell lung cancer necessitates effective bronchoscopic technology and reliable multiplex gene NGS panels. However, data regarding the optimal bronchoscopic techniques when using highly sensitive NGS panels are limited. Herein, we report a case utilizing VBN-guided EBUS-GS brushing as an exploratory approach to address this challenge. Case Presentation: A 71-year-old man was evaluated for a band-like lesion near the left pleura during spinal cord infarction. Transbronchial specimens were obtained from lesions invisible on conventional chest radiography and X-ray fluoroscopy using VBN and EBUS-GS brushing. Cytological brushing specimens revealed lung adenocarcinoma, and highly sensitive NGS identified an EGFR exon 19 deletion. He was diagnosed with stage IB disease and underwent radical radiotherapy owing to his fragile condition. If recurrence occurs, the patient will be treated with an EGFR inhibitor. Conclusion: VBN-guided EBUS-GS brushing, a minimally invasive approach, combined with highly sensitive NGS has the potential to provide accurate molecular diagnoses to more patients with lung cancer, thereby offering opportunities for personalized treatment. Our findings warrant further investigation to determine optimal bronchoscopic technologies for obtaining tumor specimens.

Bronchoscopy-Guided High-Power Microwave Ablation in an in vivo Porcine Lung Model.

Introduction: Percutaneous microwave ablation (MWA) is clinically accepted for the treatment of lung tumors and oligometastatic disease. Bronchoscopic MWA is under development and evaluation in the clinical setting. We previously reported on the development of a bronchoscopy-guided MWA system integrated with clinical virtual bronchoscopy and navigation and demonstrated the feasibility of transbronchial MWA, using a maximum power of 60 W at the catheter input. Here, we assessed the performance of bronchoscopy-guided MWA with an improved catheter (maximum power handling of up to 120 W) in normal porcine lung in vivo (as in the previous study). Methods: A total of 8 bronchoscopy-guided MWA were performed (n = 2 pigs; 4 ablations per pig) with power levels of 90 W and 120 W applied for 5 and 10 min, respectively. Virtual bronchoscopy planning and navigation guided transbronchial or endobronchial positioning of the MWA applicator for ablation of lung parenchyma. Following completion of ablations and post-procedure CT imaging, the lungs were harvested and sectioned for gross and histopathologic ablation analysis. Results: Bronchoscopy-guided MWA with applied energy levels of 90 W/5 min and 120 W/10 min yielded ablation zones with short-axis diameters in the range of 20-28 mm (56-116% increase) as compared to ∼13 mm from our previous study (60 W/10 min). Histology of higher-power and previous lower-power ablations was consistent, including a central necrotic zone, a thermal fixation zone with intact tissue architecture, and a hemorrhagic periphery. Catheter positioning and its confirmation via intra-procedural 3D imaging (e.g., cone-beam CT) proved to be critical for ablation consistency. Conclusion: Bronchoscopy-guided MWA with an improved catheter designed for maximum power 120 W yields large ablations in normal porcine lung in vivo.

Diagnostic yield and safety of repeat bronchoscopy in pulmonary disease: A five-year retrospective analysis.

AIM: In this study, we aim to analyze the frequency and indications of repeat bronchoscopic procedures performed at our hospital over a five-year period. METHODS: This retrospective study was conducted at the Department of Pulmonary Diseases, Akdeniz University, and included patients who underwent bronchoscopy between January 1, 2018, and May 31, 2024. Patients who required a repeat bronchoscopy were identified. Inclusion criteria for the repeat bronchoscopy group were non-diagnostic initial bronchoscopy or the need for additional samples for molecular testing in lung cancer patients. Exclusion criteria included patients with incomplete medical records or those who did not provide informed consent for the repeat procedure. FINDINGS: A total of 3877 patients underwent bronchoscopy in this time periods. Among these, 69 patients (1.8 %) required a repeat bronchoscopy. The mean age of these patients was 61.3 ± 11.7 years, with 54 (78 %) being male. The most common reason for the repeat procedure was the non-diagnostic outcome of the initial bronchoscopy (n = 53, 77 %), followed by cases where the initial bronchoscopy was diagnostic for lung cancer but insufficient for molecular testing (n = 16, 23 %). Among the 16 patients who underwent molecular testing, sufficient samples for molecular tests were obtained in 12 patients (75 %) following the second bronchoscopy. Molecular tests were negative for driver mutations in 6 patients, while 6 patients tested positive (PD-L1, n = 5; EGFR, n = 1). In 4 patients (25 %), the sample was reported as insufficient for molecular testing. Patients who underwent repeat bronchoscopy had the second procedure an average of 38.5 ± 59.7 days after the initial procedure. No complications developed in patients undergoing repeat bronchoscopy, except for bleeding not requiring intervention related to the bronchoscopy procedure. CONCLUSION: In conclusion, regardless of the reason, repeated bronchoscopy in suitable patients is safe and has a high diagnostic yield.

An alternative bronchoscopic transparenchymal nodule access by "invisible tunnel" technique under electromagnetic navigation without the transbronchial access tool.

BACKGROUND: The diagnosis of peripheral pulmonary lesions (PPL) is still challenging. We describe a novel method for sampling PPL without bronchial signs by creating invisible tunnel under electromagnetic navigation without the transbronchial access tool (TABT). METHODS: During electromagnetic navigation, we adjust the angle of the edge extended working channel catheter based on the real-time position of the lesion in relation to the locating guide rather than preset route. A biopsy brush or biopsy forceps is used to punch a hole in the bronchial wall. A locating guide is then re-inserted to real-time navigate through the lung parenchyma to the lesion. Safety and feasibility of this method was analyzed. RESULTS: A total of 32 patients who underwent electromagnetic navigation bronchoscopy were retrieved. The mean size of the lesion is 23.1 mm. The mean operative time of all patients was 12.4 min. Ten of the patients did not have a direct airway to the lesion, thus creating an invisible tunnel. For them, the length of the tunnel from the bronchial wall POE to the lesion was 11-30 mm, with a mean length of 16.9 mm and a mean operation time of 14.1 min. Adequate samples were obtained from 32 patients (100%), and the diagnostic yield was 87.5% (28/32). Diagnostic yield of with create the invisible tunnel TBAT was 90% (9/10), and one patient undergone pneumothorax after operation. CONCLUSIONS: This method is feasible and safe as a novel approach sampling pulmonary lesions without bronchial signs, and it further improves current tunnel technique.

Bronchoscopic retrieval of an aspirated tooth following high-speed motor vehicle accident.

A 28-year-old man aspirated a tooth into his right lower lobe bronchus following a high-speed motor vehicle accident. Initial retrieval attempts failed with a flexible bronchoscope, but a cryoprobe successfully dislodged and retrieved the tooth. Cryoprobe should be considered for bronchoscopic foreign body removal when conventional methods are unsuccessful.

How green is my reusable bronchoscope?

INTRODUCTION: Single-use bronchoscopes have replaced reusable ones in many institutions. This study aimed to evaluate the environmental and financial impacts of both strategies: reusable and single-use bronchoscopes. MATERIAL AND METHODS: We conducted a pragmatic study in a 21-bed polyvalent ICU, in Saint-Brieuc, Bretagne, France. The eco-audit consisted of estimating greenhouse gas (GHG) emissions, considering the life cycle of each strategy. Greenhouse gas (GHG) emissions related to construction, packaging, transport and waste elimination were compared between 2 devices: the reusable bronchoscope, a Pentax® FI-16RBS that was disinfected twice daily; and the single-use bronchoscope, the bronchoflex agile® from TSC. RESULTS: For the reusable bronchoscope, GHG emissions were marginally impacted by the number of bronchoscopies performed (from 185 kg eq.CO2 per year to 192 kg eq.CO2 for 10 or 110 bronchoscopies per year). For the reusable device, GHG emissions directly depended on the number of bronchoscopies performed with 3.82 kg eq.CO2 emitted per bronchoscopy. The breakeven point for the reusable bronchoscope was estimated at 50 bronchoscopies in terms of GHG emissions and 96 bronchoscopies for financial considerations. CONCLUSION: Considering current practice in our ICU, reusable bronchoscopes have lower GHG emissions when used more than 50 times a year and a lower cost when used more than 96 times a year as compared with single-use bronchoscopes.

Evaluation of radiofrequency identification tag accuracy using bronchoscopy with fluoroscopy and virtual navigation guidance before segmentectomy.

BACKGROUND: The use of sublobar resection has increased with advances in imaging technologies. However, it is difficult for thoracic surgeons to identify small lung tumours intraoperatively. Radiofrequency identification (RFID) lung-marking systems are useful for overcoming this difficulty; however, accurate placement is essential for maximum effectiveness. METHODS: We retrospectively reviewed patients who underwent RFID tag placement via fluoroscopic bronchoscopy under virtual bronchoscopic navigation (VBN) guidance before our institution's sublobar resection of lung lesions. Thirty-one patients with 31 lung lesions underwent RFID lung-marking with fluoroscopic bronchoscopy under VBN guidance. RESULTS: Of the 31 procedures, 26 tags were placed within 10 mm of the target site, 2 were placed more than 10 mm away from the target site, and 3 were placed in a different area from the target bronchus. No clinical complications were associated with RFID tag placement, such as pneumothorax or bleeding. The contribution of the RFID lung-marking system to surgery was high, particularly when the RFID tag was placed at the target site and tumour was located in the intermediate hilar zone. CONCLUSIONS: An RFID tag can be placed near the target site using fluoroscopic bronchoscopy in combination with VBN guidance. RFID tag placement under fluoroscopic bronchoscopy with VBN guidance is useful for certain segmentectomies.

Diagnostic accuracy of imaging-guided biopsy of peripheral pulmonary lesions: a systematic review.

The histologic definition of peripheral pulmonary lesion (PPL) is critical for a correct diagnosis and appropriate therapy. Non-invasive techniques for PPL biopsy are imaging-guided, using endobronchial ultrasound (EBUS), computed tomography (CT), and electromagnetic navigation bronchoscopy (ENB). To assess the diagnostic accuracy of PPL biopsy and provide a framework for reporting data for accuracy studies of PPL biopsy. A systematic review was conducted on PubMed, Scopus, and Web of Science to identify all the articles assessing the accuracy of EBUS, CT, and ENB between January 2000 and June 2023 basing search queries on keywords emerging from PICO question. Only studies investigating biopsy of PPL and reporting accuracy or necessary data to calculate it independently were included. Risk of bias was based on QUADAS-2 tool. In total, 81 studies were included. Median accuracy was 0.78 (range=0.51-0.94) in the EBUS group, 0.91 (range=0.73-0.97) in the CT group, 0.72 (range=0.59-0.97) in the ENB group, and 0.77 (range=0.61-0.92) in the combined group. Sensitivity and NPV ranges were 0.35-0.94 and 0.26-0.88 in the EBUS group, 0.71-0.97 and 0.46-1.00 in the CT group, 0.55-0.96 and 0.32-0.90 in the ENB group, and 0.70-0.90 and 0.28-0.79 in the combined group. Specificity and PPV were 1.00 in almost all studies. Overall complication rate was 3%, 30%, 8%, and 5% in the EBUS, CT, ENB, and combined groups. CT-guided biopsy was the most accurate technique, although with the highest complication rate. When calculating accuracy, indeterminate results must be considered false negatives according to the "intention-to-diagnose" principle.