[Treatment specifics for spontaneous pneumothorax in flight personnel]

Spontaneous pneumothorax is one cause of aeronautical unfitness in flight personnel, because of the risk of recurrence in flight, making it an issue of flight safety. Specific treatment is required for fighter pilots, pilots flying single-pilot and pilots in professional training: surgical synthesis via video-thoracoscopy is obligatory from the first episode. Considering the exposure to an accumulation of aeronautical factors that are likely to encourage pneumothorax recurrence in flight, it is apical pleurectomy together with abrasion of the remaining pleura and resection of bullae/blebs that is required for fighter pilots to allow them to recover aeronautical fitness unrestrictedly. For all other categories of flight personnel, treatment is no different from that of the common patient. Knowledge of these treatment specifics is essential, to avoid unnecessary systematic surgical indication for all flight personnel, or jeopardise professional fitness in some of them due to inappropriate treatment.

Three-step needle withdrawal method: a modified technique for reducing the rate of pneumothorax after CT-guided lung biopsy

BACKGROUND

Computed tomography (CT)-guided transthoracic needle biopsy is reliable and has become popular for diagnosing pulmonary lesions. Pneumothorax is the most common complication of transthoracic needle biopsy. The aim of this study was to report our preliminary experience with a three-step needle withdrawal technique for CT-guided lung-biopsy, with emphasis on reduction of the pneumothorax rate.

METHODS

A total of 146 patients (85 men and 61 women; mean age, 66.1 years; age range 19-91 years) with a pulmonary lesion underwent single slice CT-guided lung biopsy. We used a 17-gauge coaxial needle for guidance and a 18- gauge cutting needle to perform the biopsy. We used a three-step method to withdraw the needle. Images were reviewed to assess the patients' posture and the size, location, and depth of the tumor. Any pneumothorax or chest tube usage was noted.

RESULTS

Pneumothorax occurred in 23 (15.8%) patients, two of whom underwent chest-tube insertion. All 23 patients with a lesion deeper than 4 cm deep hada pneumothorax. In all patients with pneumothorax, lesions were smaller than 2 cm.

CONCLUSIONS

Our modified CT-guided lung biopsy method with a three-step needle withdrawal technique appears effective with a relatively low pneumothorax rate. Predictors of pneumothorax in our study were a lesion deeper than 4 cm and a lesion smaller than 2 cm.

Anesthetic management of acute subcutaneous emphysema and pneumothorax following a Nuss procedure: a case report

The minimally invasive Nuss procedure has become the standard of care for surgical correction of pectus excavatum. Pectus excavatum is the most common congenital deformity of the chest wall. Historically, surgical correction was limited to the Ravitch procedure, an invasive procedure associated with significant drawbacks, where abnormal cartilage was removed and the sternum elevated and stabilized. Patients typically experienced a prolonged recovery period, from 6 to 9 months and significant postoperative pain. The Nuss procedure, invented in 1998, is much less invasive and has a success rate of 90% compared with the Ravitch procedure with a success rate of 70% to 80%. This more recent procedure normally has an exceedingly low complication rate, reported to be 8% to 11%. Postoperative analgesia ranges from patient controlled analgesia to a thoracic epidural depending on the surgeon's preference. This case report details an immediate postoperative complication that occurred with its subsequent anesthetic management.

Nasogastric tubes. 2: Risks and guidance on avoiding and dealing with complications

This is the second of a two-part unit on nasogastric tube management. Part 1 explored the indications, patient preparation, insertion technique and methods of verifying correct intragastric position. This focuses on complications related to nasogastric tubes.

[Uncomplicated covering technique for preventing the recurrence in the thoracoscopic surgery for pneumothorax]

Reinforcement of the visceral pleura along the stapled line and prevention of lung-chest wall adhesion is supposed to decrease the recurrence rate of video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax. Covering over the stapled line with an absorbable mesh; polyglycolic acid and regenerative oxidized cellulose mesh, and a fibrin glue is recognized useful for that, although, it tends to be troublesome in VATS procedure. In this article, we present the knack of the covering method: (1) installation of the absorbable mesh on the visceral pleura; a folded absorbable mesh is hold with the endoscopic autosuture or grasping foreceps and placed on the pleura without curling up; (2) installation of a fibrin glue over the pleura and the mesh using a rubbing device (U-rod); each of the fibrinogen solution and the thrombin solution are applied and rubbed on the pleura and the mesh. Surgeons can perform them without any complicated technique.

[Clinical analysis and prevention of complications associated with ultrasound-guided percutaneous thick needle biopsy]

OBJECTIVE

To investigate the occurrence of complications in US-guided percutaneous biopsy using core (>19G) gauge cutting needle.

METHODS

A retrospective analysis of 5366 US-guided thick needle biopsies was conducted to analyze the incidence of complications after biopsy at different positions.

RESULTS

The total incidence of complications was 1.08%, including most frequent hemorrhage, pneumothorax, hemotysis and infection.

CONCLUSION

Ultrasound-guided automatic biopsy is easy to operate and safe, and strict execution of the procedures can lower the incidence of the complications.

[Anesthetic management of a patient with pulmonary tuberous sclerosis complicated with renal angiomyolipoma]

A 55-year-old woman underwent total hysterectomy. She suffered from tuberous sclerosis and was complicated with lymphangioleiomyomatosis and renal angiomyolipoma. There have been only a few reports of anesthetic management on patients with these three diseases. Anesthesia was maintained with combined spinal-epidural anesthesia. Patients with tuberous sclerosis should be examined precisely. This case was managed carefully to avoid pneumothorax and acute bleeding from renal angiomyolipoma. There was no postoperative anesthesia-related complications.

Animal derived surfactant extract for treatment of respiratory distress syndrome

BACKGROUND

Respiratory distress syndrome (RDS) is caused by a deficiency or dysfunction of pulmonary surfactant. A wide variety of surfactant products have been formulated and studied in clinical trials. These include synthetic surfactants and animal derived surfactant extracts. Trials of surfactant replacement have either tried to prevent the development of respiratory distress in high-risk premature infants or treat established respiratory distress in premature infants.

OBJECTIVES

To assess the effect of administration of animal derived surfactant extract on mortality, chronic lung disease and other morbidities associated with prematurity in preterm infants with established respiratory distress syndrome. Subgroup analysis were planned according to the specific surfactant product, the degree of prematurity, and the severity of disease.

SEARCH STRATEGY

Searches were made of the Oxford Database of Perinatal Trials, MEDLINE, EMBASE, and CINAHL from 1975 through December 2008. In addition, searches were made of previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants and journal hand searching in the English language.

SELECTION CRITERIA

Randomized or quazi-randomized controlled trials that compared the effect of animal derived surfactant extract treatment administered to infants with established respiratory distress syndrome in order to prevent complications of prematurity and mortality.

DATA COLLECTION AND ANALYSIS

Data regarding clinical outcomes were excerpted from the reports of the clinical trials by the review authors. Data analysis was done in accordance with the standards of the Cochrane Neonatal Review Group.

MAIN RESULTS

Thirteen randomized controlled trials were included in the analysis. The studies demonstrated an initial improvement in respiratory status (improved oxygenation and decreased need for ventilator support). The meta-analysis supports a significant decrease in the risk of any air leak (typical relative risk 0.47, 95% CI 0.39, 0.58; typical risk difference -0.16, 95% CI -0.21, -0.12), pneumothorax (typical relative risk 0.42, 95% CI 0.34, 0.52; typical risk difference -0.17, 95% CI -0.21, -0.13), and a significant decrease in the risk of pulmonary interstitial emphysema (typical relative risk 0.45, 95% CI 0.37, 0.55; typical risk difference -0.20, 95% CI -0.25, -0.15). There is a significant decrease in the risk of neonatal mortality (typical relative risk 0.68, 95% CI 0.57, 0.82; typical risk difference -0.09, 95% CI -0.13, -0.05), a significant decrease in the risk of mortality prior to hospital discharge (typical relative risk 0.63, 95% CI 0.44, 0.90; typical risk difference -0.10, 95% CI -0.18, -0.03) and a significant decrease in the risk of bronchopulmonary dysplasia (BPD) or death at 28 days of age (typical relative risk 0.83, 95% CI 0.77, 0.90; typical risk difference -0.11, 95 CI -0.16, -0.06). No differences are reported in the risk of patent ductus arteriosus, necrotizing enterocolitis, intraventricular hemorrhage, BPD or retinopathy of prematurity.

AUTHORS' CONCLUSIONS

Infants with established respiratory distress syndrome who receive animal derived surfactant extract treatment have a decreased risk of pneumothorax, a decreased risk of pulmonary interstitial emphysema, a decreased risk of mortality, and a decreased risk of bronchopulmonary dysplasia or death.

Ultrasound-guided central line placement as compared with standard landmark technique: some unpleasant arithmetic for the economics of medical innovation

OBJECTIVE

We perform a simple cost estimation of ultrasound guidance for the placement of central venous access, considering the US federal reimbursement for ultrasound guidance of central line placement to the federal reimbursement for treating the complication of pneumothorax.

METHODS

We utilize national statistics on the number of central lines placed annually to determine the cost savings incurred if all central lines placed in the United States were placed with ultrasound guidance.

RESULTS

The initial "cost" of placing central lines was found to be 390,780,000 to 651,300,000 dollars per year by the landmark technique, as compared with 494,820,000 to 824,700,000 dollars per year by ultrasound guidance.

CONCLUSIONS

The cost of ultrasound guidance was not mitigated by its reduction in the cost of treating pneumothoraces.

Ultrasound-guided trigger point injections in the cervicothoracic musculature: a new and unreported technique

BACKGROUND

Myofascial pain is defined as pain that originates from myofascial trigger points in skeletal muscle. It is prevalent in regional musculoskeletal pain syndromes, either alone or in combination with other pain generators. The myofascial pain syndrome is one of the largest groups of under diagnosed and under treated medical problems encountered in clinical practice. Trigger points are commonly seen in patients with myofascial pain which is responsible for localized pain in the affected muscles as well as referred pain patterns. Correct needle placement in a myofascial trigger point is vital to prevent complications and improve efficacy of the trigger point injection to help reduce or relieve myofascial pain. In obese patients, these injections may not reach the target tissue. In the cervicothoracic spine, a misguided or misplaced injection can result in a pneumothorax. Here, we describe an ultrasound-guided trigger point injection technique to avoid this potential pitfall. Office based ultrasound-guided injection techniques for musculoskeletal disorders have been described in the literature with regard to tendon, bursa, cystic, and joint pathologies. For the interventionalist, utilizing ultrasound yields multiple advantages technically and practically, including observation of needle placement in real-time, ability to perform dynamic studies, the possibility of diagnosing musculoskeletal pathologies, avoidance of radiation exposure, reduced overall cost, and portability of equipment within the office setting. To our knowledge, the use of ultrasound guidance in performing trigger point injection in the cervicothoracic area, particularly in obese patients, has not been previously reported.

METHODS

A palpable trigger point in the cervicothoracic musculature was localized and marked by indenting the skin with the tip of a plastic needle cover. The skin was then sterile prepped. Then, using an ultrasound machine with sterile coupling gel and a sterile latex free transducer cover, the musculature in the cervicothoracic spine where the palpable trigger point was detected was visualized. Then utilizing direct live ultrasound guidance, a 25-gauge 1.5 inch needle connected to a 3 mL syringe was placed into the muscle at the exact location of the presumed trigger point. This guidance helps confirm needle placement in muscle tissue and not in an adipose tissue or any other non-musculature structure.

RESULTS

The technique is simple to be performed by a pain management specialist who has ultrasound system training.

CONCLUSION

Ultrasound-guided trigger point injections may help confirm proper needle placement within the cervicothoracic musculature. The use of ultrasound-guided trigger point injections in the cervicothoracic musculature may also reduce the potential for a pneumothorax by an improperly placed injection.

Patterns, Effects, and Thoracic Volume Changes of Thoracoscopic Pleurodesis in Rabbits

BACKGROUND

The ideal thoracoscopic pleurodesis method for preventing recurrence of spontaneous pneumothorax remains controversial. This study was conducted to compare the patterns, effects, and thoracic volume changes achieved using a variety of thoracoscopic procedures in rabbits.

MATERIALS AND METHODS

Thirty-six New Zealand White rabbits were randomly assigned to undergo the following thoracoscopic procedures in the left hemithorax: (a) parietal pleural abrasion; (b) minocycline instillation; (c) combination of abrasion and minocycline; or (d) examination alone. The rabbits were euthanatized 30 days after the operation to determine pleurodesis score, area of greatest adhesion, thoracic volume change, and histopathological findings.

RESULTS

Grossly, pleural abrasion produced moderate localized apical pleural symphysis with no obvious thoracic volume change. Minocycline instillation induced moderate generalized pleurodesis with a significant decrease in thoracic volume. The combination of abrasion and minocycline instillation produced the greatest generalized pleurodesis as well as a significant decrease in thoracic volume. On microscopic examination, the combination procedure produced the greatest inflammation and fibrosis of the visceral and parietal pleura. Increased intensity of pleurodesis score as well as pleural inflammation and fibrosis is associated with decreased thoracic volume.

CONCLUSIONS

Thoracoscopic pleurodesis achieved using pleural abrasion and minocycline instillation induced different patterns of pleurodesis, and a combination of each method generated a synergy and produced a better pleurodesis. However, as the generalization and intensity of the pleurodesis were inversely associated with thoracic volume, the optimal method should be determined on an individual basis according to the clinical situation.

[Elective videothoracoscopy--a tool for prevention of primary spontaneous pneumothorax?]

AIM

Based on the retrospective analysis of the selected group of patients with primary spontaneous pneumothorax (PSP), the authors aim to demonstrate contribution of CT scan examinations and elective videothoracoscopic procedures in diagnostics and treatment of pulmonary conditions, predisposing the patient to the disorder.

MATERIAL AND METHODOLOGY

During 2005-2007, 45 patients with PSPs underwent post-treatment CT lung examinations. Pathological findings potentially resulting in collapsed lung, were detected in nearly 25% of the subjects. All of the subjects (males, the mean age of 22.4 years) were then indicated for elective videothoracoscopy, in order to prevent potential PSP events. The procedure included peripheral endostapler lung lesion resection and mechanical pleurodesis (pleuroabrasion), resp. partial apical pleurectomy.

RESULTS

Pathological changes of the lung tissue were detected with the same rate in the both, right and left lung apices. In miniinvasive procedures, they were always easily located, as anticipated. In all of the subjects, the changed tissue was removed using peripheral lung resections, with concomittant pleuroabrasion in a half of the subjects, while in the other half of the subject, the procedure was combined with partial apical pleurectomy. Intraoperative morbidity and mortality were nil. The mean period of postoperative drainage was 5.5 days, the mean duration of hospitalization was a week. During the study period, no further PSP events were recorded.

CONCLUSION

CT examination-based detection of pneumothorax-predisposing pathological lung tissue changes and their subsequent removal using elective videothoracoscopy, is a valid and a patient-beneficial procedure.

Ultrasound-guided vascular access in adults and children: beyond the internal jugular vein puncture

Based on our clinical experience and a review of the current literature, this paper describes a large variety of ultrasound-guided vascular puncture techniques used in adults and children far beyond the well described puncture of the internal jugular vein. This includes low or posterior approaches of the internal jugular vein, puncture of the subclavian vein and its variant in children, infraclavicular access to the axillary vein and also more peripheral punctures of the basilic, brachial and cephalic veins. Arterial line placement in the radial, humeral, axillary or femoral are also described as well as the aid of ultrasonography for peripheral insertion of central catheters (PICC Lines). Additional information on ultrasonographic assessment of potentially related complications, like pneumothorax or hemopericardium, will complete this review.

[Fewer lung complications following inspiratory muscle training in patients undergoing coronary bypass surgery: a randomized trial]

OBJECTIVE

The aim of this study was to evaluate the prophylactic efficacy of preoperative physiotherapy, including inspiratory muscle training (IMT), on the incidence of postoperative pulmonary complications (PPCs) in high-risk patients scheduled for elective coronary artery bypass grafting (CABG).

DESIGN

Randomized controlled clinical trial (www.controlled-trials. com/isrctn17691887).

METHOD

Of 655 patients referred to a university medical centre in The Netherlands for elective CABG, 299 met the criteria for being at high risk of developing PPCs. A total of 279 were enrolled and monitored up to discharge from hospital. Patients were randomly assigned to receive either preoperative IMT (n=140) or usual care (n=139). Both groups received the same postoperative treatment.

RESULTS

Both groups were comparable at baseline. Before CABG, 2 control group patients and 1 IMT group patient died. After CABG surgery, PPCs were present in 25 (18%) of 139 patients in the IMT group and 48 (35%) of 137 patients in the control group (OR: 0.52; 95% CI: 0.30-0.92). Pneumonia occurred in 9 (6.5%) of 139 patients in the IMT group and in 22 (16.1%) of 137 patients in the usual care group (OR: 0.40; 95% CI: 0.19-0.84). Mean duration of postoperative hospitalization was 7 (range 5-41) days in the IMT group versus 8 (range 6-70) days in the usual care group (Mann-Whitney test; Z: -2.42; p = 0.015).

CONCLUSION

Preoperative physiotherapy, including IMT, statistically significantly reduced the incidence ofPPCs and the duration ofpostoperative hospitalization in patients at high risk of developing a pulmonary complication on undergoing CABG.

Electromyographically guided trigger point injections in the cervicothoracic musculature of obese patients: a new and unreported technique

BACKGROUND

Myofascial pain is defined as pain that originates from myofascial trigger points in skeletal muscle. It is prevalent in regional musculoskeletal pain syndromes, either alone or in combination with other pain generators. The myofascial pain syndrome is one of the largest groups of under-diagnosed and under-treated medical problems encountered in clinical practice. Trigger points are commonly seen in patients with myofascial pain that can be responsible for localized pain in the affected muscles as well as referred pain patterns. Correct needle placement in a myofascial trigger point is vital to prevent complications and improve efficacy of the trigger point injection to help reduce or relieve myofascial pain. In the obese patients, these injections may not reach the target tissue. In the cervicothoracic spine, a misguided or misplaced injection can result in a pneumothorax. Here, we review an electromyographically guided trigger point injection technique to avoid this potential pitfall.

METHODS

Using a disposable Teflon coated hypodermic injection needle attached to an electromyography (EMG) machine, a trigger point injection can be performed utilizing electromyographic guidance. This guidance by observing motor unit action potentials (MUAPs) on the EMG screen helps confirm the needle placement to be within the muscle tissue and not in an adipose tissue or any other non-musculature structure.

RESULTS

The technique is simple when performed by a pain management specialist who has electromyographic training.

CONCLUSION

This technique helps confirm proper needle placement within the cervicothoracic musculature in an obese patient in whom the musculature is not readily palpated. This, thus, reduces the potential for a pneumothorax by an improperly placed injection.

Rigid fixation of the sternum using a new coupled titanium transverse plate fixation system

Restoration of sternal integrity after median sternotomy for cardiac interventions better ensures optimal postoperative pulmonary function and minimizes overall morbidity. Sternal dehiscence or nonunion mitigates against such a successful outcome. Under such circumstances, if enough viable and uninfected sternum remains, an anatomic reduction should be attempted. Rewiring usually proves unsuccessful, and rigid plate fixation is more rewarding. A new titanium sternal fixation system that permits transverse orientation of plates has been used in 4 patients who had sterile complete or imminent sternal dehiscence to allow eventual sternal union. The specific advantage of this new system is the presence of a releasing pin in the center of coupled plates to allow rapid chest reentry if required without the specific need for cumbersome plate removal. One patient had delayed removal of an infected plate after sternal union was achieved.

En bloc stapled diaphragmatic resection for local invasion during hepatectomy: a simple technique without opening the pleural cavity

Diaphragmatic invasion is not uncommon in patients undergoing hepatectomy for liver tumors. Where there are limited attachments of the diaphragm to the tumor, the authors describe a stapled technique for en bloc resection of the diaphragm without opening the chest cavity, thus performing an oncologic resection, while avoiding the need for pleural drainage.

Use of small-bore feeding tubes: successes and failures

PURPOSE OF REVIEW

Early enteral nutrition is the preferred option for feeding patients who cannot meet their nutrient requirements orally. This article reviews complications associated with small-bore feeding tube insertion and potential methods to promote safe gastric or postpyloric placement. We review the available bedside methods to check the position of the feeding tube and identify inadvertent misplacements.

RECENT FINDINGS

Airway misplacement rates of small feeding tubes are considerable. Bedside methods (auscultation, pH, aspirate appearance, air bubbling, external length of the tube, etc.) to confirm the position of a newly inserted small-bore feeding tube have limited scientific basis. Radiographic confirmation therefore continues to be the most accurate method to ascertain tube position. Fluoroscopic and endoscopic methods are reliable but costly and are not available in many hospitals. Rigid protocols to place feeding tubes along with new emerging technology such as CO2 colorimetric paper and tubes coupled with signaling devices are promising candidates to substitute for the blind placement method.

SUMMARY

The risk of misplacement with blind bedside methods for small-bore feeding tube insertion requires a change in hospital protocols.

Experimental Use of N-Butyl Cyanoacrylate Tissue Adhesive on Lung Parenchyma after Pulmonary Resection

BACKGROUND

The aim of this study was to investigate the effectiveness of N-butyl cyanoacrylate tissue adhesive for the prevention of air leak together with the morphological changes to lung parenchyma.

METHODS

Twelve New Zealand rabbits were used. The rabbits were ventilated with pressure-controlled ventilation during the experiment, beginning with a pressure level of 10 cm H (2)O. After a 2 x 2-cm pulmonary wedge resection, the resection surface was sealed with N-butyl cyanoacrylate and the pressure level was increased every five minutes in 5-cm H (2)O increments. The pressure level which caused an air leak from the resection surface was recorded. The morphological damage to the lung parenchyma was evaluated under light microscopy.

RESULTS

The mean value of the pressure levels that caused air leak was 43.3 +/- 8.8 cm H (2)O. No tissue damage to lung parenchyma was recorded after histopathological examination.

CONCLUSION

N-butyl cyanoacrylate was effective in preventing air leak from the pulmonary resection surface even with high airway pressure levels. It could be used as an aid for pulmonary resection lines or to control the air leak from pulmonary parenchyma.

Advanced Practice Organ Procurement Techniques: Insertion of Thoracic Catheters

Advanced practice coordinators who perform procedures that may be associated with complications must be proficient at treating those untoward events. This discussion reviews the diagnosis of a pneumothorax as a complication of insertion of a central venous catheter and mechanical ventilation. The method for inserting the Wayne Pneumothorax Set thoracic catheter is presented. This and similar commercially available catheters may also be used to evacuate a pleural effusion or nonclotted blood from the thorax for diagnostic purposes or when treating hypoxemia. It is essential for organ procurement organizations to provide appropriate training and quality assurance programs to ensure safe practice.

Potential foramen to allow communication between the pleural cavity and retroperitoneal space during laparoscopic surgery: a cadaver study of Bochdalek’s triangle

The indications for laparoscopic retroperitoneal surgery have recently been greatly extended and the technique has become popular, but concomitant pleural injury or pneumothorax has been reported from numerous hospitals in Japan. Which anatomical information is useful to avoid surgical injury of the suggested weak portion of the diaphragm? We identified a diaphragm-free triangular area or Bochdalek's triangle in 90.1% of elderly Japanese cadavers (100/111 cadavers), comprising about 622.8 mm(2) in area (height 47.9 mm, base 25.0 mm). In most cases (80.1%; 129/161), the entire triangle was restricted to the superior side of the 12th rib in addition to the medial side of the distal end of the rib. A "potential foramen" (PF) was defined as the diaphragm-free triangle >100 mm(2) in area on the parietal pleura. Most triangles (77.6%, 125/161) met this criterion. The PF was often covered by the kidney (93.3%), and had a mean area of 318.9 mm(2). The PF was located 42.3 mm from the distal end of the 12th rib, while the inferior pleural margin was 27.8 mm superior to the rib end. When the triangle was large, the PF was also large, with the PF often occupying >50% of the triangle area (62/125; 49.6%). To avoid the distal end of the 12th rib, in laparoscopic retroperitoneal surgery, we recommend making a transverse skin incision at the midpoint between the end of the 12th rib and the iliac crest.

Lung tumor tracking during stereotactic radiotherapy treatment with the CyberKnife: Marker placement and early results

Lung tumor tracking during stereotactic radiotherapy with the CyberKnife requires the insertion of markers in or close to the tumor. To reduce the risk of pneumothorax, three methods of marker placement were used: 1) intravascular coil placement, 2) percutaneous intrathoracal, and 3) percutaneous extrathoracal placement. We investigated the toxicity of marker placement and the tumor response of the lung tumor tracking treatment. Markers were placed in 20 patients with 22 tumors: 13 patients received a curative treatment, seven a palliative. The median Charlson Comorbidity Score was 4 (range: 1-8). Platinum fiducials and intravascular embolisation coils were used as markers. In total, 78 markers were placed: 34 intrathoracal, 23 intravascular and 21 extrathoracal. The PTV equaled the GTV + 5 mm. A median dose of 45 Gy (range: 30-60 Gy, in 3 fractions) was prescribed to the 70-85% isodose. The response was evaluated with a CTscan performed 6-8 weeks after the last treatment and routinely thereafter. The median follow-up was 4 months (range: 2-11). No severe toxicity due to the marker placement was seen. Pneumothorax was not seen. The local control was 100%. Four tumors in four patients showed a complete response, 15 tumors in 14 patients a partial response, and three tumors in two patients with metastatic disease had stable disease. No severe toxicity of marker placement was seen due to the appropriate choice of one of the three methods. CyberKnife tumor tracking with markers is feasible and resulted in excellent tumor response. Longer follow-up is needed to validate the local control.