Bronchoscopic Lung Volume Reduction as the Treatment of Choice versus Robotic-Assisted Lung Volume Reduction Surgery in Similar Patients with Emphysema - An Initial Experience of the Benefits and Complications.

Objective: There is an assumption that because EBLVR requires less use of hospital resources, offsetting the higher cost of endobronchial valves, it should therefore be the treatment of choice wherever possible. We have tested this hypothesis in a retrospective analysis of the two in similar groups of patients. Methods: In a 4-year experience, we performed 177 consecutive LVR procedures: 83 patients underwent Robot Assisted Thoracoscopic (RATS) LVRS and 94 EBLVR. EBLVR was intentionally precluded by evidence of incomplete fissure integrity or intra-operative assessment of collateral ventilation. Unilateral RATS LVRS was performed in these cases together with those with unsuitable targets for EBLVR. Results: EBLVR was uncomplicated in 37 (39%) cases; complicated by post-procedure spontaneous pneumothorax (SP) in 28(30%) and required revision in 29 (31%). In the LVRS group, 7 (8%) patients were readmitted with treatment-related complications, but no revisional procedure was needed. When compared with uncomplicated EBLVR, LVRS had a significantly longer operating time: 85 (14-82) vs 40 (15-151) minutes (p<0.001) and hospital stay: 7.5 (2-80) vs 2 (1-14) days (p<0.01). However, LVRS had a similar total operating time to both EBLVR requiring revision: 78 (38-292) minutes and hospital stay to EBLVR complicated by pneumothorax of 11.5 (6.5-24.25) days. Use of critical care was significantly longer in RATS group, and it was also significantly longer in EBV with SP group than in uncomplicated EBV group. Conclusion: Endobronchial LVR does use less hospital resources than RATS LVRS in comparable groups if the recovery is uncomplicated. However, this advantage is lost if one includes the resources needed for the treatment of complications and revisional procedures. Any decision to favour EBLVR over LVRS should not be based on the assumption of a smoother, faster perioperative course.

Individualized rotation of left double lumen endobronchial tube to improve placement success rate: a randomized controlled trial.

BACKGROUND: In conventional practice, the left double lumen tube (DLT) is rotated 90° counterclockwise when the endobronchial cuff passes glottis. Success rate upon the first attempt is < 80%, likely owing to varying morphology of the bronchial bifurcation. METHODS: We conducted a randomized controlled trial to compare 90° counterclockwise rotation versus individualized degree of rotation in adult patients undergoing elective thoracic surgery using left DLT. The degree of rotation in the individualized group was based on the angle of the left main bronchi as measured on computed tomography (CT). The primary outcome was the first attempt left DLT placement success rate. RESULTS: A total of 556 patients were enrolled: 276 in the control group and 280 in the individualized group. The average angle of the left main bronchi was 100.6±9.5° (range 72° to 119°). The first attempt left DLT placement success rate was 82.6% (228/276) in the control group versus 91.4% (256/280) in the individualized group (P=0.02, χ2 test). The rate of carina mucosal injury, as measured at 30 min after the start of surgery under fibreoptic bronchoscopy, was significantly lower in individualized group than control group (14.0% versus 19.6%, P=0.041). The individualized group also had lower rate of postoperative sore throat (29.4% versus 44.0%, P<0.001) and hoarseness (16.8% versus 24.7%, P＜0.05). CONCLUSIONS: Individualized rotation of left DLT based on the angle of the left main bronchi on preoperative CT increased first attempt success rate in adult patients undergoing elective thoracic surgery. TRIAL REGISTRATION: The trial is registered at Chinese Clinical Trial Registry (ChiCTR2100053349; principal investigator Xiang Quan, date of registration November 19, 2021).

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.

Infection control in the bronchoscopy suite: effective reprocessing and disinfection of reusable bronchoscopes.

PURPOSE OF REVIEW: With advancements in technology, flexible bronchoscopes have become thinner in diameter and in need of more thorough reprocessing to prevent infection transmission than ever before. Many experienced bronchoscopists are not aware of the critical steps involved in effective bronchoscope reprocessing and we hope to bridge this gap by describing this process in detail. RECENT FINDINGS: Bronchoscope reprocessing includes several distinct steps (precleaning, leak testing, manual cleaning, visual inspection, terminal reprocessing, rinsing and drying). Each step is comprehensive and needs to be carried out systematically by trained personnel. Failure of any step can lead to serious downstream events such as outbreaks and pseudo-outbreaks. Some experts now recommend sterilization when feasible, although high-level disinfection remains the minimum standard. We also will review some literature on the utility of borescopes, automated endoscope reprocessors and disposable bronchoscopes. SUMMARY: Our article will focus on the most recent recommendations for effective reprocessing and disinfection of reusable bronchoscopes.

Cambios en la tendencia histológica del cáncer pulmonar / Changes in lung cancer's histological trend

El cáncer pulmonar se establece como la segunda causa de muerte en países desarrollados y en algunos en vías de desarrollo. Su diagnóstico es tardío, sus opciones de resección y su curación aun con terapias adyuvantes son limitadas, lo que incide en la pobre sobrevida a 5 años, es por ello que se necesitan mayores esfuerzos para combatir el hábito del tabaco, principal agente etiológico. Material y Métodos: Se trata de un estudio descriptivo transversal en pacientes adultos atendidos de 01 de enero del 2011 al 31 de diciembre del 2021, ingresados al servicio de cirugía del Hospital San Vicente de Guatemala, con diagnósticos de cáncer pulmonar, masa pulmonar, derrame pleural o nódulo pulmonar solitario. Resultados: Se atendieron 202 pacientes con diagnósticos presuntivos de cáncer pulmonar, no encontrando diferencias significativas en relación al sexo. La edad mayormente afectada se estableció entre los 50 y 70 años. Prevalecieron los estadíos IIIA, IIIB y IV basados en los hallazgos clínicos, tomográficos y transoperatorios y solo al 10% se le sometió a una cirugía de resección pulmonar mayor. Los cánceres de células no pequeñas NSCLC fueron reportados en el 68.7% y el adenocarcinoma fue la variedad más frecuente con el 54.95% sobre el 7.29% del epidermoide. La mortalidad a los treinta días se estableció en 2.97%. Conclusión: El adenocarcinoma pulmonar ocupa el primer lugar en la incidencia de los cánceres pulmonares, desplazando así al carcinoma epidermoide popularizado desde la mitad del siglo pasado. Esta tendencia en el cambio histológico está firmemente asociado a las modificaciones en los hábitos del fumar (AU)

Lung cancer is established as the second cause of death in developed countries and in some developing ones. Its diagnosis is late, its resection options and its cure even with adjuvant therapies are limited, which affects the poor survival at 5 years, which is why greater efforts are needed to combat the tobacco habit, the main etiological agent. Material and Methods: This is a cross-sectional descriptive study in adult patients treated from January 1, 2011 to December 31, 2021, admitted to the surgery service of the Hospital San Vicente de Guatemala, with diagnoses of lung cancer, lung mass, effusion pleural or solitary pulmonary nodule. Results: 202 patients with presumptive diagnoses of lung cancer were treated, finding no significant differences in relation to sex and the most affected age was established between 50 and 70 years. Stages IIIA, IIIB, and IV prevailed based on clinical, tomographic, and intraoperative findings, and only 10% underwent major lung resection surgery. NSCLC non-small cell cancers were reported in 68.7% and adenocarcinoma was the most frequent variety with 54.95% over 7.29% of epidermoid. Thirty-day mortality was established at 2.97%. Conclusion: Pulmonary adenocarcinoma occupies the first place in the incidence of lung cancers, thus displacing squamous cell carcinoma popularized since the middle of the last century. This trend in histological change is strongly associated with changes in smoking habits.

Appropriate tube temperature for fiberoptic bronchoscope-guided intubation of thermally softened double-lumen endotracheal tubes: A CONSORT-compliant article.

BACKGROUND: To compare the effects of thermal softening of double-lumen endotracheal tubes (DLT) at different temperatures during fiberoptic bronchoscopy (FOB)-guided intubation. METHODS: We randomly divided 144 patients undergoing thoracic surgery into 4 groups as follows: T1 (T = 24 ± 1°C, n = 36), T2 (T = 36 ± 1°C, n = 36), T3 (T = 40 ± 1°C, n = 36), and T4 (T = 48 ± 1°C, n = 36). All groups underwent FOB-guided double-lumen endotracheal intubation and positioning. We recorded the duration of positioning and intubation using DLT, intubation resistance (IR), the success rate of the first attempt at endotracheal intubation, and the incidence of postoperative vocal cord injury and hoarseness. RESULTS: The time to intubation was longer in the T1 group than that in the T2, T3, and T4 groups (P < .05). The time for positioning was longer in the T4 group than that in the T1, T2, and T3 groups (P < .05). IR was lower in the T3 and T4 groups than those in T1 and T2 groups (P < .05). The success rate of the first attempt at endotracheal intubation was higher in the T2, T3, and T4 groups than that in the T1 group (P < .05). Postoperative glottic injury and hoarseness were higher in the T1 and T2 groups than those in the T3 and T4 groups (P < .05). CONCLUSION: A thermally softened DLT shortened the time to intubation, reduced the IR, improved the success rate of the first attempt at endotracheal intubation, and lowered the incidence of postoperative glottic injury and hoarseness. The optimal tube temperature for FOB-guided intubation of thermally softened DLT was 40 ± 1°C.

[An Unexpected Complication: Contralateral Tension Pneumothorax following Transbronchial Forceps Biopsy]. / Eine unerwartete Komplikation: Kontralateraler Spannungspneumothorax nach transbronchialer Zangenbiopsie.

Ipsilateral pneumothoraces are a common complication after transbronchial forceps biopsy. In this case report, a contralateral tension pneumothorax and a pneumoperitoneum occurred following transbronchial forceps biopsy in addition to an ipsilateral pneumothorax.

Rotura bronquial secundaria a la colocación de un drenaje pleural / Bronchial Rupture Secondary to Placing a Drainage

No disponible

Ion: Technology and Techniques for Shape-sensing Robotic-assisted Bronchoscopy.

PURPOSE: This report describes the Ion Endoluminal System (Intuitive Surgical, Inc, Sunnyvale, CA) and practices for safe and effective use in patients with small peripheral pulmonary nodules (PPNs). DESCRIPTION: This shape-sensing robotic-assisted bronchoscopy system allows airway visualization and navigation to reach and biopsy small PPNs through a stable platform. The system provides 3-dimensional mapping and visualization of the airways, a flexible and fully articulating 3.5-mm (outer diameter) catheter, a peripheral vision probe, and system-specific biopsy needles. EVALUATION: The Ion Endoluminal System was evaluated in an ongoing prospective, multicenter trial including 241 patients with 270 PPNs (largest mean cardinal measurement, 18.8 ± 6.5 mm). Mean time to register and navigate decreased from 10 minutes in the first 10 cases to 7 minutes in the subsequent cases. Asymptomatic pneumothorax occurred in 8 patients (3.3%), 1 (0.4%) with pigtail catheter placement. Two patients (0.8%) experienced airway bleeding; both cases of bleeding resolved within 5 minutes of tamponade. CONCLUSIONS: The Ion Endoluminal System's unique shape-sensing technology can be leveraged to facilitate localization and sampling of PPNs and potentially improve diagnostic accuracy.

Endobronchial closure of the bronchopleural fistula with the ventricular septal defect occluder: a case series.

OBJECTIVES: The ventricular septal defect (VSD) occluder has been reported to be a novel method for the closure of bronchopleural fistula (BPF). Our study was to confirm the use of VSD occluder in treating BPF after pneumonectomy or lobectomy. METHODS: We performed a single-center, retrospective study of 10 consecutive patients (8 men and 2 women aged 29-70 years) with postoperative BPF receiving the VSD occluder treatment. We used the HeartR™ Membranous VSD occluder (Lifetech Scientific Co., Shenzhen, China) for the closure of BPF through flexible bronchoscopy under general anesthesia. Demographic characteristics, BPF characteristics, and clinical outcomes were collected from patients' files using the standardized data abstraction forms. RESULTS: The underlying diseases were lung cancer in 6 patients, pulmonary tuberculosis in 3, and bronchiectasis in 1. Right-sided BPFs occurred in 6 patients, and left-sided BPFs occurred in 4. Five patients were underweight with a body mass index < 18.5 kg/m2. The VSD was placed in all 10 patients with a 100% technical success rate and a 70% complete closure rate during follow-up with no complications, on a median follow-up period of 115 days (range 46-975 days). In 1 patient, the VSD occluder was reinstalled with complete closure; in 1 and 2 patients with underweight and chronic empyema, the VSD occluders partially and completely failed with good physical tolerance, respectively. CONCLUSIONS: Our study demonstrated the bronchoscopic closure of BPF after lung resection using the VSD occluder is an off-label but safe and effective method. We prefer to stabilize the BPF by eradicating the underlying diseases and providing nutritional support to those receiving VSD occluder closure treatment.

Oxygenation strategies during flexible bronchoscopy: a review of the literature.

During flexible fiberoptic bronchoscopy (FOB) the arterial partial pressure of oxygen can drop, increasing the risk for respiratory failure. To avoid desaturation episodes during the procedure several oxygenation strategies have been proposed, including conventional oxygen therapy (COT), high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV). By a review of the current literature, we merely describe the clinical practice of oxygen therapies during FOB. We also conducted a pooled data analysis with respect to oxygenation outcomes, comparing HFNC with COT and NIV, separately. COT showed its benefits in patients undergoing FOB for broncho-alveolar lavage (BAL) or brushing for cytology, in those with peripheral arterial oxyhemoglobin saturation < 93% prior to the procedure or affected by obstructive disorder. HFNC is preferable over COT in patients with mild to moderate acute respiratory failure (ARF) undergoing FOB, by improving oxygen saturation and decreasing the episodes of desaturation. On the opposite, CPAP and NIV guarantee improved oxygenation outcomes as compared to HFNC, and they should be preferred in patients with more severe hypoxemic ARF during FOB.

[Expert Consensus on Technical Specifications of Domestic Electromagnetic Navigation Bronchoscopy System in Diagnosis, Localization and Treatment (2021 Edition)].

Electromagnetic navigation bronchoscopy (ENB) is a novel type of bronchoscopy based on electromagnetic positioning technique combined with virtual bronchoscopy, three-dimensional computed tomography (CT) imaging and respiratory gating technique, which has been widely applied in clinic practice. In recent years, the domestic electromagnetic navigation system has also been developed rapidly, and its effectiveness and safety in the diagnosis, localization, and treatment of peripheral pulmonary lesions have been initially verified. In order to optimize and standardize the technical specifications of domestic ENB and guide its application in clinical practice, the consensus statement has been organized and written in a collaborative effort by the Professional Committee on Respiratory Equipment Technology of Chinese Medical Equipment Association and the Expert Group on Technical of Domestic Electromagnetic Navigation Bronchoscopy.
.

Airway devices for awake tracheal intubation in adults: a systematic review and network meta-analysis.

BACKGROUND: Awake tracheal intubation is commonly performed with flexible bronchoscopes, but the emerging role of alternative airway devices, such as videolaryngoscopes, direct laryngoscopes, and optical stylets, has been recognised. METHODS: CENTRAL, CINAHL, EMBASE, MEDLINE, and Web of Science were searched for RCTs that compared flexible bronchoscopes, direct laryngoscopes, optical stylets and channelled or unchannelled videolaryngoscopes in adult patients having awake tracheal intubation were included. The co-primary outcomes were first-pass success rate and time to tracheal intubation. Continuous outcomes were extracted as mean and standard deviation, and dichotomous outcomes were converted to overall numbers of incidence. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced. RESULTS: Twelve RCTs were included, none of which evaluated direct laryngoscopes. The first-pass success rate was not different between flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes, with the quality of evidence rated as moderate in view of imprecision. Optical stylets, followed by unchannelled videolaryngoscopes and then felxible bronchoscopes resulted in the shortest time to tracheal intubation, with the quality of evidence rated as high. No differences were shown between the airway devices with respect to the incidence of oesophageal intubation, change of airway technique, oxygen desaturation, airway bleeding, or the rate of hoarseness and sore throat. CONCLUSIONS: Flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes were clinically comparable airway devices in the setting of awake trachela intubation and the time to tracheal intubation was shortest with optical stylets and longest with flexible bronchoscopes.

The LungVision navigational platform for peripheral lung nodule biopsy and the added value of cryobiopsy.

BACKGROUND: The LungVision system is a novel augmented-fluoroscopy-based real-time navigation and guidance technology for bronchoscopy that can be integrated with any standard biopsy tool, including the cryoprobe, to enable real-time visualization and localization of pulmonary nodules. OBJECTIVES: To evaluate the diagnostic yield and safety among patients undergoing peripheral pulmonary nodule biopsy with the LungVision system. METHODS: This prospective, single-center study was conducted at Rabin Medical Center in Israel. All patients that underwent peripheral pulmonary nodule biopsy with the LungVision system from January 2016 to August 2020 were included. All procedures were performed under moderate sedation. The primary outcome was tissue diagnosis by either identification of malignant cells or benign diagnosis. Secondary outcomes were safety and the added value of cryobiopsy. RESULTS: Sixty-three procedures were performed during the study period. Median lesion size (interquartile range) was 25.0 mm (18-28 mm). The diagnostic yield overall was 27/33 (81.8%) and for lesions smaller than 20 mm was 13/18 (72.2%). In nine cases the transbronchial cryobiopsy showed tissue with malignant cells that were not found in any other biopsy material taken with other sampling tools. One patient was treated with a chest tube for a pneumothorax. No other major complications were reported. CONCLUSIONS: The LungVision system showed good feasibility and safety for peripheral pulmonary nodule biopsy. The system is compatible with all biopsy tools, including the cryoprobe. Randomized controlled trials are needed to accurately ascertain its diagnostic yield.

Bronchoscopy during the COVID-19 pandemic: effect on current practices and strategies to reduce procedure-associated transmission.

Introduction: Bronchoscopy and related procedures have unambiguously been affected during the Corona Virus Disease 2019 (COVID-19) pandemic caused by Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS COV-2). Ordinary bronchoscopy practices and lung cancer services might have changed over this pandemic and for the years to come.Areas covered: This manuscript summarizes the utility of bronchoscopy in COVID-19 patients, and the impact of the pandemic in lung cancer diagnostic services, in view of possible viral spread during these We conducted a literature review of articles published in PubMed/Medline from inception to November 5th, 2020 using relevant terms.Expert opinion: Without doubt this pandemic has changed the way bronchoscopy and related procedures are being performed. Mandatory universal personal protective equipment, pre-bronchoscopy PCR tests, dedicated protective barriers and disposable bronchoscopes might be the safest and simpler way to perform even the most complicated procedures.

Closed Bronchoscopy System: An Innovative Approach to Minimize Aerosolization During Bronchoscopy.

Health care workers performing aerosolizing procedures on patients with transmissible infections such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are at high-risk for disease acquisition. Current guidelines designed to protect health care workers during aerosolizing procedures prioritize personal protective equipment and enhanced infection control techniques, in particular during procedures such as intubation. To date, little emphasis has been placed on risk mitigation in the setting of bronchoscopy, a procedure that has significant aerosolization potential. Herein, we present an innovative closed bronchoscopy system designed to reduce aerosolization during bronchoscopy.

The use of pediatric flexible bronchoscopy in the COVID-19 pandemic era.

On March 11, 2020, the World Health Organization (WHO) declared the pandemic because of a novel coronavirus, called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In January 2020, the first transmission to healthcare workers (HCWs) was described. SARS-CoV-2 is transmitted between people because of contact, droplets, and airborne. Airborne transmission is caused by aerosols that remain infectious when suspended in air over long distances and time. In the clinical setting, airborne transmission may occur during aerosol generating procedures like flexible bronchoscopy. To date, although the role of children in the transmission of SARS-CoV-2 is not clear the execution of bronchoscopy is associated with a considerably increased risk of SARS-CoV-2 transmission to HCWs. The aim of this overview is to summarize available recommendations and to apply them to pediatric bronchoscopy. We performed systematic literature searches using the MEDLINE (accessed via PubMed) and Scopus databases. We reviewed major recommendations and position statements published at the moment by the American Association for Bronchology and Interventional Pulmonology, WHO, European Center for Disease Prevention and Control and expert groups on the management of patients with COVID-19 to limit transmission among HCWs. To date there is a lack of recommendations for safe bronchoscopy during the pandemic period. The main indications concern adults and little has been said about children. We have summarized available recommendations and we have applied them to pediatric bronchoscopy.

Endobronchial Balloon Blockers: A Retrospective Analysis of Their Implementation for Use in Transbronchial Cryobiopsy Under Conscious Sedation.

INTRODUCTION: Transbronchial lung cryobiopsy (TBLC) is a promising technique that is evolving as a standard diagnostic procedure in the diagnosis of interstitial lung disease. However, there are a variety of non-standardised techniques adopted for this procedure. We aim to describe our approach to TBLC with balloon blockade under conscious sedation (CS). METHODS: We performed a retrospective analysis of patients undergoing TBLC using flexible bronchoscopy under CS in our institution over the calendar years 2017-2018; before and after a transition to the use of endobronchial balloon blockers (EBB) in 2017. RESULTS: 25 patients underwent transbronchial cryobiopsy during the study period. Of these; 12 procedures used EBB. EBB subjects had significantly less moderate or severe airway bleeding (8.3% vs 38.5%) despite higher biopsy rates in the EBB group, 2.9 (2-4) vs 2.4 (1-4) in the non-EBB group. No severe airway bleeding occurred in the EBB group. A multidisciplinary meeting (MDM) confirmed diagnosis was achieved in 88% of patients. 10/12 subjects (83%) in the EBB group and 12/13 subjects (92%) in the non-EBB group (p = 0.5). CONCLUSION: Our institution is novel in using EBB as standard during TBLC specifically under CS with flexible bronchoscopy in the bronchoscopy suite. This retrospective analysis demonstrates that EBB enhances the safety profile of performing TBLC under CS and did not appear to impact diagnostic yield or patient safety.