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Senyei GD, Sagar AES, Tran B, Shah A, Miller R, Patel N, Van Nostrand K, Casal RF, Cheng GZ. Incremental Application of Positive End-Expiratory Pressure for the Evaluation of Atelectasis During RP-EBUS and Bronchoscopy (I-APPEAR). J Bronchology Interv Pulmonol 2024; 31:e0969. [PMID: 38953737 DOI: 10.1097/lbr.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/09/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND CT-to-body divergence-described as the difference between preprocedural CT scans and intraprocedural lung architecture-is a significant barrier to improving diagnostic yield during navigational bronchoscopy. A major proposed contributor to CT-to-body divergence is the development of atelectasis, which can confound visualization of peripheral lung lesions via radial probe endobronchial ultrasound (RP-EBUS). High positive end-expiratory pressure (PEEP) ventilatory strategies have been used to decrease atelectasis, allowing the lesion to re-APPEAR on intraprocedure imaging. However, standardized PEEP levels may not be appropriate for all patients due to hemodynamic and ventilatory impacts. METHODS We performed a multicenter, prospective observational study in which patients were imaged with RP-EBUS under general anesthesia to determine if subsegmental atelectasis would resolve as incremental increases in PEEP were applied. Resolution of atelectasis was based on the transition from a non-aerated pattern to an aerated appearance on RP-EBUS. RP-EBUS images were reviewed by 3 experienced operators to determine correlation. RESULTS Forty-three patients underwent RP-EBUS examination following navigational bronchoscopy. Thirty-seven patients underwent incremental PEEP application and subsequent RP-EBUS imaging. Atelectasis was determined to have resolved in 33 patients (88.2%) following increased PEEP. The intraclass correlation coefficient between reviewers was 0.76. A recruitment maneuver was performed in 7 (16.3%) patients after atelectasis persisted at maximal PEEP. Atelectasis was not identified in the examined subsegments in 6 (10.8%) patients despite zero PEEP. CONCLUSION RP-EBUS is an effective tool to monitor what pressure atelectasis within a lung segment has resolved with increasing levels of PEEP.
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Affiliation(s)
- Grant D Senyei
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Ala Eddin S Sagar
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Madinah, Saudi Arabia
| | - Brian Tran
- Department of Pulmonary Medicine, Naval Hospital Camp Pendleton, San Diego, CA
| | - Archan Shah
- Banner MD Anderson Cancer Center, Gilbert, AZ
| | - Russell Miller
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA
- Department of Pulmonary Medicine, Naval Medical Center San Diego, San Diego, CA
| | - Niral Patel
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA
| | - Keriann Van Nostrand
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA
| | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George Z Cheng
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA
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Park JY, Han JY, Choi SJ, Baek JW, Yun SY, Lee SK, Lee HY, Hong S. Impact of Respiratory Phase during Pleural Puncture on Complications in CT-Guided Percutaneous Lung Biopsy. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2024; 85:566-578. [PMID: 38873383 PMCID: PMC11166586 DOI: 10.3348/jksr.2023.0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/22/2023] [Accepted: 11/09/2023] [Indexed: 06/15/2024]
Abstract
Purpose This study investigated whether the respiratory phase during pleural puncture in CT-guided percutaneous transthoracic needle biopsy (PTNB) affects complications. Materials and Methods We conducted a retrospective review of 477 lung biopsy CT scans performed during free breathing. The respiratory phases during pleural puncture were determined based on the table position of the targeted nodule using CT scans obtained during free breathing. We compared the rates of complications among the inspiratory, mid-, and expiratory respiratory phases. Logistic regression analysis was performed to control confounding factors associated with pneumothorax. Results Among the 477 procedures, pleural puncture was performed during the expiratory phase in 227 (47.6%), during the mid-phase in 108 (22.6%), and during the inspiratory phase in 142 (29.8%). The incidence of pneumothorax was significantly lower in the expiratory puncture group (40/227, 17.6%; p = 0.035) and significantly higher in the mid-phase puncture group (31/108, 28.7%; p = 0.048). After controlling for confounding factors, expiratory-phase puncture was found to be an independent protective factor against pneumothorax (odds ratio = 0.571; 95% confidence interval = 0.360-0.906; p = 0.017). Conclusion Our findings suggest that pleural puncture during the expiratory phase may reduce the risk of pneumothorax during image guided PTNB.
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Shaller BD, Sethi S, Cicenia J. Imaging in peripheral bronchoscopy. Curr Opin Pulm Med 2024; 30:17-24. [PMID: 37933680 DOI: 10.1097/mcp.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
PURPOSE OF REVIEW Historically the sampling of peripheral lung lesions via bronchoscopy has suffered from inferior diagnostic outcomes relative to transthoracic needle aspiration, and neither a successful bronchoscopic navigation nor a promising radial ultrasonographic image of one's target lesion guarantees a successful biopsy. Fortunately, many of peripheral bronchoscopy's shortcomings - including an inability to detect and compensate for computed tomography (CT)-body divergence, and the absence of tool-in-lesion confirmation - are potentially remediable through the use of improved intraprocedural imaging techniques. RECENT FINDINGS Recent advances in intraprocedural imaging, including the integration of cone beam CT, digital tomosynthesis, and augmented fluoroscopy into bronchoscopic procedures have yielded promising results. These advanced imaging modalities may improve the outcomes of peripheral bronchoscopy through the detection and correction of navigational errors, CT-body divergence, and malpositioned biopsy instruments. SUMMARY The incorporation of advanced imaging is an essential step in the improvement of peripheral bronchoscopic procedures.
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Affiliation(s)
- Brian D Shaller
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, California
| | - Sonali Sethi
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph Cicenia
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Fried I, Hoelscher J, Akulian JA, Pizer S, Alterovitz R. Landmark Based Bronchoscope Localization for Needle Insertion Under Respiratory Deformation. PROCEEDINGS OF THE ... IEEE/RSJ INTERNATIONAL CONFERENCE ON INTELLIGENT ROBOTS AND SYSTEMS. IEEE/RSJ INTERNATIONAL CONFERENCE ON INTELLIGENT ROBOTS AND SYSTEMS 2023; 2023:6593-6600. [PMID: 38947248 PMCID: PMC11214542 DOI: 10.1109/iros55552.2023.10342115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Bronchoscopy is currently the least invasive method for definitively diagnosing lung cancer, which kills more people in the United States than any other form of cancer. Successfully diagnosing suspicious lung nodules requires accurate localization of the bronchoscope relative to a planned biopsy site in the airways. This task is challenging because the lung deforms intraoperatively due to respiratory motion, the airways lack photometric features, and the anatomy's appearance is repetitive. In this paper, we introduce a real-time camera-based method for accurately localizing a bronchoscope with respect to a planned needle insertion pose. Our approach uses deep learning and accounts for deformations and overcomes limitations of global pose estimation by estimating pose relative to anatomical landmarks. Specifically, our learned model considers airway bifurcations along the airway wall as landmarks because they are distinct geometric features that do not vary significantly with respiratory motion. We evaluate our method in a simulated dataset of lungs undergoing respiratory motion. The results show that our method generalizes across patients and localizes the bronchoscope with accuracy sufficient to access the smallest clinically-relevant nodules across all levels of respiratory deformation, even in challenging distal airways. Our method could enable physicians to perform more accurate biopsies and serve as a key building block toward accurate autonomous robotic bronchoscopy.
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Affiliation(s)
- Inbar Fried
- I. Fried, J. Hoelscher, S. Pizer, and R. Alterovitz are with the Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- I. Fried is also with the Medical Scientist Training Program, University of North Carolina School of Medicine, Chapel Hill, NC, 27599, USA
| | - Janine Hoelscher
- I. Fried, J. Hoelscher, S. Pizer, and R. Alterovitz are with the Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Jason A Akulian
- J. A. Akulian is with the Division of Pulmonary Diseases and Critical Care Medicine at the University of North Carolina at Chapel Hill, NC 27599, USA
| | - Stephen Pizer
- I. Fried, J. Hoelscher, S. Pizer, and R. Alterovitz are with the Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Ron Alterovitz
- I. Fried, J. Hoelscher, S. Pizer, and R. Alterovitz are with the Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Verhoeven RLJ, Kops SEP, Wijma IN, Ter Woerds DKM, van der Heijden EHFM. Cone-beam CT in lung biopsy: a clinical practice review on lessons learned and future perspectives. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:361. [PMID: 37675336 PMCID: PMC10477635 DOI: 10.21037/atm-22-2845] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/03/2022] [Indexed: 09/08/2023]
Abstract
Pulmonary nodules with intermediate to high risk of malignancy should preferably be diagnosed with image guide minimally invasive diagnostics before treatment. Several technological innovations have been developed to endobronchially navigate to these lesions and obtain tissue for diagnosis. This review addresses these technological advancements in navigation bronchoscopy in three basic steps: navigation, position confirmation and acquisition, with a specific focus on cone-beam computed tomography (CBCT). For navigation purposes ultrathin bronchoscopy combined with virtual bronchoscopy navigation, electromagnetic navigation and robotic assisted bronchoscopy all achieve good results as a navigation guidance tool, but cannot confirm location or guide biopsy positioning. Diagnostic yield has seen improvement by combining these techniques with a secondary imaging tool like radial endobronchial ultrasound (rEBUS) and fluoroscopy. For confirmation of lesion access, rEBUS provides local detailed ultrasound-imaging and can be used to confirm lesion access in combination with fluoroscopy, measure nodule-contact area length and determine catheter position for sampling. CBCT is the only technology that can provide precise 3D positioning confirmation. When focusing on tissue acquisition, there is often more than 10% difference between reaching the target and getting a diagnosis. This discrepancy is multifactorial and caused by breathing movements, small samples sizes, instrument tip displacements by tool rigidity and tumour inhomogeneity. Yield can be improved by targeting fluorodeoxyglucose (FDG)-avid regions, immediate feedback of rapid onsite evaluation, choosing sampling tools with different passive stiffnesses, by increasing the number biopsies taken and (future) catheter modifications like (robotic assisted-) active steering. CBCT with augmented fluoroscopy (CBCT-AF) based navigation bronchoscopy combines navigation guidance with 3D-image confirmation of instrument-in-lesion positioning in one device. CBCT-AF allows for overlaying the lesion and navigation pathway and the possibility to outline trans-parenchymal pathways. It can help guide and verify sampling in 3D in near real-time. Disadvantages are the learning curve, the inherent use of radiation and limited availability/access to hybrid theatres. A mobile C-arm can provide 3D imaging, but lower image quality due to lower power and lower contrast-to-noise ratio is a limiting factor. In conclusion, a multi-modality approach in experienced hands seems the best option for achieving a diagnostic accuracy >85%. Either adequate case selection or detailed 3D imaging are essential to obtain high accuracy. For current and future transbronchial treatments, high-resolution (CBCT) 3D-imaging is essential.
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Affiliation(s)
- Roel L J Verhoeven
- Department of Pulmonary Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stephan E P Kops
- Department of Pulmonary Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge N Wijma
- Department of Pulmonary Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Desi K M Ter Woerds
- Department of Pulmonary Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Podder S, Chaudry S, Singh H, Jondall EM, Kurman JS, Benn BS. Efficacy and Safety of Cone-Beam CT Augmented Electromagnetic Navigation Guided Bronchoscopic Biopsies of Indeterminate Pulmonary Nodules. Tomography 2022; 8:2049-2058. [PMID: 36006070 PMCID: PMC9412509 DOI: 10.3390/tomography8040172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/10/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Bronchoscopic biopsy results for indeterminate pulmonary nodules remain suboptimal. Electromagnetic navigation bronchoscopy (ENB) coupled with cone beam computed tomography (CBCT) for confirmation has the potential to improve diagnostic yield. We present our experience using this multimodal approach to biopsy 17 indeterminate nodules in 14 consecutive patients from April to August 2021. Demographic information, nodule characteristics, and biopsy results were recorded. Procedures were performed in a hybrid operating room equipped with a Siemens Artis Q bi-plane CBCT (Siemens, Munich, Germany). After ENB using the superDimension version 7.1 (Medtronic, Plymouth, MN, USA) to target the lesion, radial endobronchial ultrasound was used as secondary confirmation. Next, transbronchial needle aspiration was performed prior to CBCT to evaluate placement of the biopsy tool in the lesion. The average nodule size was 21.7+/−15 mm with 59% (10/17) < 2 cm in all dimensions and 35% (6/17) showing a radiographic bronchus sign. The diagnostic yield of CBCT-guided ENB was 76% (13/17). No immediate periprocedural or postprocedural complications were identified. Our experience with CBCT-guided ENB further supports the comparable efficacy and safety of this procedure compared to other mature biopsy modalities. Studies designed to optimize the lung nodule biopsy process and to determine the contributions from different procedural aspects are warranted.
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4D Electromagnetic Navigation Bronchoscopy for the Sampling of Pulmonary Lesions: First European Real-Life Experience. Lung 2021; 199:493-500. [PMID: 34562105 PMCID: PMC8510943 DOI: 10.1007/s00408-021-00477-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/12/2021] [Indexed: 12/19/2022]
Abstract
Purpose The use of Electromagnetic navigation bronchoscopy (ENB) for the diagnosis of pulmonary peripheral lesions is still debated due to its variable diagnostic yield; a new 4D ENB system, acquiring inspiratory and expiratory computed tomography (CT) scans, overcomes respiratory motion and uses tracked sampling instruments, reaching higher diagnostic yields. We aimed at evaluating diagnostic yield and accuracy of a 4D ENB system in sampling pulmonary lesions and at describing their influencing factors. Methods We conducted a three-year retrospective observational study including all patients with pulmonary lesions who underwent 4D ENB with diagnostic purposes; all the factors potentially influencing diagnosis were recorded. Results 103 ENB procedures were included; diagnostic yield and accuracy were, respectively, 55.3% and 66.3%. We reported a navigation success rate of 80.6% and a diagnosis with ENB was achieved in 68.3% of cases; sensitivity for malignancy was 61.8%. The majority of lesions had a bronchus sign on CT, but only the size of lesions influenced ENB diagnosis (p < 0.05). Transbronchial needle aspiration biopsy was the most used tool (93.2% of times) with the higher diagnostic rate (70.2%). We reported only one case of pneumothorax. Conclusion The diagnostic performance of a 4D ENB system is lower than other previous navigation systems used in research settings. Several factors still influence the reachability of the lesion and therefore diagnostic yield. Patient selection, as well as the multimodality approach of the lesion, is strongly recommended to obtain higher diagnostic yield and accuracy, with a low rate of complications.
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Shi J, He J, He J, Li S. Electromagnetic navigation-guided preoperative localization: the learning curve analysis. J Thorac Dis 2021; 13:4339-4348. [PMID: 34422360 PMCID: PMC8339733 DOI: 10.21037/jtd-21-490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/19/2021] [Indexed: 12/11/2022]
Abstract
Background The electromagnetic navigation bronchoscopy (ENB) was increasingly used to mark small pulmonary nodules (PNs) for video-assisted thoracic surgery (VATS) resection due to high effectiveness and low risk. However, no study reports the learning curve of ENB-guided preoperative localization. In the study, we aimed to describe the learning curve of ENB-guided preoperative PNs localization initially. Methods Consecutive PNs cases that underwent ENB localizations between October 2018 and October 2019 by the same surgeon in our center were included in the study. The cumulative sum (CUSUM) method was used to analyze the learning curve of ENB localization. Results A total of 89 ENB localization from 64 patients were included in this study. The learning curve was divided into 3 phases: Phase I (the initial 11 cases), Phase II (the 12th to the 47th cases), and Phase III (the 47th to the 89th cases). The success rate of ENB localization has increased with the accumulation of operational experience in 3 phases (72.73%, 91.67%, and 97.62%, P=0.049). The distance from the ENB guide wire tip to the center of the lesion in Phase I was significantly longer than those in Phase II and Phase III (2.46±1.76 vs. 1.36±0.94 and 1.47±0.97 cm, P=0.014 and 0.027, respectively). Sex, bronchus sign, and learning curve phase were independent risk factors influencing operative time (OT) (OR =8.187, 18.847, and 13.920, respectively). Conclusions The technical competency, which is indicated by higher success rate, localization accuracy, and shorter OT, for ENB-guided preoperative PNs localization was achieved at the 47th operation.
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Affiliation(s)
- Jiang Shi
- Department of Thoracic Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory and National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jiaxi He
- Department of Thoracic Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory and National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory and National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Shuben Li
- Department of Thoracic Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,State Key Laboratory and National Clinical Research Center for Respiratory Disease, Guangzhou, China
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Wang N, Ma H, Huang H, Feng Y. Electromagnetic Navigation Bronchoscopy Combined Endobronchial Ultrasound in the Diagnosis of Lung Nodules. Medicine (Baltimore) 2021; 100:e23979. [PMID: 33545984 PMCID: PMC7837957 DOI: 10.1097/md.0000000000023979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/30/2020] [Accepted: 11/30/2020] [Indexed: 12/26/2022] Open
Abstract
ABSTRACT Electromagnetic navigational bronchoscopy (ENB) combined with a radial endobronchial ultrasound probe realizes a combination of magnetic navigation and ultrasound imaging, allowing for the accurate navigation of peripheral lung lesions in real time during surgery. ENB has been evaluated in many studies. However, a comparative report on the feasibility of ENB combined radial endobronchial ultrasound diagnosis in different density lung nodules was small, and few of these studies have reported long-term follow-up results to exclude false negative results. The aim of this study is to explore the applicability of ENB combined radial endobronchial ultrasound in the diagnosis of lung nodules with different densities.Patients underwent biopsy in our medical center from 2016-09 to 2019-03 were divided into 2 groups: the solid nodule group and the subsolid pulmonary nodule group. We collected and analyzed the diagnostic accuracy, the diagnostic yield, the false negative rate and the incidence of complications between these 2 groups.A total of 37 lesions in 25 patients were biopsied, 14 lesions were subsolid pulmonary nodules and 23 were solid nodules. The diagnostic accuracy (success rate to obtain meaningful pathology tissues) was 34/37 (91.8%). Lost to follow-up in 1 case and three cases were undiagnosed. After at least 12 months of follow-up, the total diagnostic yield (true positive rate+ true negative rate) was 27/36 (75%) (P = .006). The false negative rate was 9/19 (47.3%) (P = .26). Complications occurred in 1/36 (2.7%) lesions. For the subsolid pulmonary nodule group, the diagnostic accuracy was 13/14 (92.8%) and the diagnostic yield was 7/14 (50%). For the solid nodule group, the diagnostic accuracy was 21/23 (91.3%), and the diagnostic yield was 20/22 (90.9%).Electromagnetic navigational bronchoscopy combined with radial endobronchial ultrasound in peripheral lung nodule biopsies is safe and effective, especially for solid nodules, but the diagnostic yield in subsolid nodule biopsies remains to be improved.
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Affiliation(s)
- Nan Wang
- Department of Thoracic Surgery, Suzhou Dushuhu Public Hospital (Dushuhu Public Hospital Affiliated to Soochow University), No.9 Chongwen Road, Suzhou Industrial Park
| | - Haitao Ma
- Department of Thoracic Surgery, the First Affiliated Hospital of Soochow University, No. 188 Shizi Road, Canglang District, Suzhou City, Jiangsu, P. R. China
| | - Haitao Huang
- Department of Thoracic Surgery, the First Affiliated Hospital of Soochow University, No. 188 Shizi Road, Canglang District, Suzhou City, Jiangsu, P. R. China
| | - Yu Feng
- Department of Thoracic Surgery, the First Affiliated Hospital of Soochow University, No. 188 Shizi Road, Canglang District, Suzhou City, Jiangsu, P. R. China
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Sagar AES, Sabath BF, Eapen GA, Song J, Marcoux M, Sarkiss M, Arain MH, Grosu HB, Ost DE, Jimenez CA, Casal RF. Incidence and Location of Atelectasis Developed During Bronchoscopy Under General Anesthesia: The I-LOCATE Trial. Chest 2020; 158:2658-2666. [PMID: 32561439 DOI: 10.1016/j.chest.2020.05.565] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/25/2020] [Accepted: 05/31/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Despite the many advances in peripheral bronchoscopy, its diagnostic yield remains suboptimal. With the use of cone-beam CT imaging we have found atelectasis mimicking lung tumors or obscuring them when using radial-probe endobronchial ultrasound (RP-EBUS), but its incidence remains unknown. RESEARCH QUESTION What are the incidence, anatomic location, and risk factors for developing atelectasis during bronchoscopy under general anesthesia? STUDY DESIGN AND METHODS We performed a prospective observational study in which patients undergoing peripheral bronchoscopy under general anesthesia were subject to an atelectasis survey carried out by RP-EBUS under fluoroscopic guidance. The following dependent segments were evaluated: right bronchus 2 (RB2), RB6, RB9, and RB10; and left bronchus 2 (LB2), LB6, LB9, and LB10. Images were categorized either as aerated lung ("snowstorm" pattern) or as having a nonaerated/atelectatic pattern. Categorization was performed by three independent readers. RESULTS Fifty-seven patients were enrolled. The overall intraclass correlation agreement among readers was 0.82 (95% CI, 0.71-0.89). Median time from anesthesia induction to atelectasis survey was 33 min (range, 3-94 min). Fifty-one patients (89%; 95% CI, 78%-96%) had atelectasis in at least one of the eight evaluated segments, 45 patients (79%) had atelectasis in at least three, 41 patients (72%) had atelectasis in at least four, 33 patients (58%) had atelectasis in at least five, and 18 patients (32%) had atelectasis in at least six segments. Right and left B6, B9, and B10 segments showed atelectasis in > 50% of patients. BMI and time to atelectasis survey were associated with increased odds of having more atelectatic segments (BMI: OR, 1.13 per unit change; 95% CI, 1.034-1.235; P = .007; time to survey: OR, 1.064 per minute; 95% CI, 1.025-1.105; P = .001). INTERPRETATION The incidence of atelectasis developing during bronchoscopy under general anesthesia in dependent lung zones is high, and the number of atelectatic segments is greater with higher BMI and with longer time under anesthesia. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03523689; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Ala-Eddin S Sagar
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce F Sabath
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - George A Eapen
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Juhee Song
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mathieu Marcoux
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mona Sarkiss
- Department of Anesthesia and Peri-Operative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Muhammad H Arain
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Horiana B Grosu
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Roberto F Casal
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX.
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Shaller BD, Gildea TR. What is the value of electromagnetic navigation in lung cancer and to what extent does it require improvement? Expert Rev Respir Med 2020; 14:655-669. [DOI: 10.1080/17476348.2020.1748012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Brian D. Shaller
- Interventional Pulmonology, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas R. Gildea
- Interventional Pulmonology, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Pritchett MA, Bhadra K, Calcutt M, Folch E. Virtual or reality: divergence between preprocedural computed tomography scans and lung anatomy during guided bronchoscopy. J Thorac Dis 2020; 12:1595-1611. [PMID: 32395297 PMCID: PMC7212155 DOI: 10.21037/jtd.2020.01.35] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Guided bronchoscopy offers a minimally invasive and safe method for accessing indeterminate pulmonary nodules. However, all current guided bronchoscopy systems rely on a preprocedural computed tomography (CT) scan to create a virtual map of the patient's airways. Changes in lung anatomy between the preprocedural CT scan and the bronchoscopy procedure can lead to a divergence between the expected and actual location of the target lesion. Termed "CT-to-body divergence", this effect reduces diagnostic yield, adds time to the procedure, and can be challenging for the operator. The objective of this paper is to describe the concept of CT-to-body divergence, its contributing factors, and methods and technologies that might minimize its deleterious effects on diagnostic yield.
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Affiliation(s)
- Michael A Pritchett
- FirstHealth of the Carolinas and Pinehurst Medical Clinic, Pinehurst, NC, USA
| | - Krish Bhadra
- CHI Memorial Rees Skillern Cancer Institute, Chattanooga, TN, USA
| | - Mike Calcutt
- Clinical Education, Medtronic, Minneapolis, MN, USA
| | - Erik Folch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Comparison of End-Expiration Versus End-Inspiration Breath-Holds With Respect to Respiratory Motion Artifacts on T1-Weighted Abdominal MRI. AJR Am J Roentgenol 2019; 212:1024-1029. [PMID: 30835515 DOI: 10.2214/ajr.18.20239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE. The purpose of this study was to compare respiratory motion artifact and diagnostic image quality between end-inspiration and end-expiration breath-holding techniques on unenhanced and contrast-enhanced axial T1-weighted MRI of the liver. MATERIALS AND METHODS. This retrospective observational study included 50 consecutive subjects undergoing axial T1-weighted liver MRI, with unenhanced images acquired with both end-inspiration and end-expiration breath-holding techniques, and with contrast-enhanced images acquired for 47 of the subjects with either the end-inspiration or the end-expiration breath-holding technique. Three radiologists performed blinded independent evaluations of each unenhanced sequence, contrast-enhanced sequence, and subtraction (contrast-enhanced minus unenhanced) image, using a scale ranging from 1 point (denoting nondiagnostic imaging) to 5 points (denoting no artifacts). Blinded side-by-side assessment of each pair of unenhanced sequences was also performed. Two-tailed Wilcoxon signed rank and Wilcoxon rank sum tests were used to assess statistical significance. RESULTS. A significant improvement in motion scores was noted for sequences acquired in end-expiration, compared with those acquired in end-inspiration, for unenhanced sequences (mean, 3.35 vs 2.80; p < 0.00001), contrast-enhanced sequences (mean, 4.02 vs 3.46; p = 0.0003), and subtraction images (mean, 3.67 vs 2.41; p < 0.00001). Severe degradation of image quality or nondiagnostic image quality was noted for 15% of unenhanced images (23/150), 0% of contrast-enhanced images, and 8% (5/63) of subtraction images acquired on end-expiration, whereas it was noted for 36% (54/150) of unenhanced images, 13% (10/78) of contrast-enhanced images, and 59% (46/78) of subtraction images acquired on end-inspiration. When side-by-side assessment of paired unenhanced sequences was performed, images acquired in end-expiration were significantly favored in 59% of paired sequences (88/150) (p < 0.00001), and no difference between images acquired with both breath-hold techniques was noted for 21% (32/150) of paired sequences. CONCLUSION. The end-expiration breath-holding technique leads to significant decreases in respiratory motion artifacts, compared with the end-inspiration technique, on unenhanced and contrast-enhanced T1-weighted liver MRI.
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Mehta AC, Hood KL, Schwarz Y, Solomon SB. The Evolutional History of Electromagnetic Navigation Bronchoscopy. Chest 2018; 154:935-947. [DOI: 10.1016/j.chest.2018.04.029] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 04/09/2018] [Accepted: 04/18/2018] [Indexed: 01/05/2023] Open
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