A New and Safe Mode of Ventilation for Interventional Pulmonary Medicine: The Ease of Nasal Superimposed High Frequency Jet Ventilation

Effectiveness and Safety of Superimposed High-Frequency Jet Ventilation in Rigid Bronchoscopy: A Single-Center, Retrospective Study

Introduction: Superimposed high-frequency jet ventilation (SHFJV) is a new type of jet ventilation, but its safety and effectiveness in rigid bronchoscopy have not been fully verified, especially in patients with airway stenosis and preoperative cardiovascular disease. This study is intended to retrospectively analyze the effectiveness and safety of SHFJV in the endobronchial treatment under rigid bronchoscopy. Methods: A total of 363 patients were included in this study. They were divided into 2 groups: Group A (n = 176)-presence of airway stenosis; Group B (n = 187)-absence of airway stenosis. Mean arterial pressure, heart rate, and pulse oxygen saturation were recorded before anesthesia and during the procedure. Arterial blood gases was recorded before anesthesia, at the end of the procedure and second-day postoperation respectively. The duration of procedure, extubation time, length of stay in the postanesthesia care unit (PACU), length of postoperative hospitalization, incidence of intraoperative and postoperative complications as well as 30 day mortality were also recorded. Results: All the patients had stable circulation during the procedure, including that with preoperative cardiovascular and pulmonary diseases. There were no substantial differences observed in terms of extubation time, PACU stay, and postoperative hospital days. Patients with severe preoperative airway stenosis exhibited longer procedure duration compared to those with mild to moderate stenosis, but there was no difference noted in terms of the extubation and PACU time. Conclusion: SHFJV is effective and safe in the endobronchial treatment for patients with airway stenosis and preoperative cardiovascular disease. It can serve as an ideal airway management strategy for rigid bronchoscopy.

Effects of unilateral superimposed high-frequency jet ventilation on porcine hemodynamics and gas exchange during one-lung flooding

BACKGROUND

Superimposed high-frequency jet ventilation (SHFJV) is suitable for respiratory motion reduction and essential for effective lung tumor ablation. Fluid filling of the target lung wing one-lung flooding (OLF) is necessary for therapeutic ultrasound applications. However, whether unilateral SHFJV allows adequate hemodynamics and gas exchange is unclear.

AIM

To compared SHFJV with pressure-controlled ventilation (PCV) during OLF by assessing hemodynamics and gas exchange in different animal positions.

METHODS

SHFJV or PCV was used alternatingly to ventilate the non-flooded lungs of the 12 anesthetized pigs during OLF. The animal positions were changed from left lateral position to supine position (SP) to right lateral position (RLP) every 30 min. In each position, ventilation was maintained for 15 min in both modalities. Hemodynamic variables and arterial blood gas levels were repeatedly measured.

RESULTS

Unilateral SHFJV led to lower carbon dioxide removal than PCV without abnormally elevated carbon dioxide levels. SHFJV slightly decreased oxygenation in SP and RLP compared with PCV; the lowest values of PaO2 and PaO2/FiO2 ratio were found in SP [13.0; interquartile range (IQR): 12.6-5.6 and 32.5 (IQR: 31.5-38.9) kPa]. Conversely, during SHFJV, the shunt fraction was higher in all animal positions (highest in the RLP: 0.30).

CONCLUSION

In porcine model, unilateral SHFJV may provide adequate ventilation in different animal positions during OLF. Lower oxygenation and CO2 removal rates compared to PCV did not lead to hypoxia or hypercapnia. SHFJV can be safely used for lung tumor ablation to minimize ventilation-induced lung motion.

Chronic Obstructive Pulmonary Disease and Non-Small Cell Lung Cancer an association

Objectives: Lung cancer is known to be associated with chronic obstructive pulmonary disease. Moreover; nutritional status is associated with chronic obstructive disease treatment and lung cancer. Our aim was to evaluate the interaction of the COPD status and treatment of non-small cell lung cancer. Methods: Eighty-two patients were enrolled in our multicenter study. Chronic obstructive disease stage, spirometry and treatment was recorded along with the treatment and Body Mass Index (BMI), Mediterranian Diet Score, Pack Years, Basic Metabolsim (RMR) (kcal/day), VO₂ (ml/min), Ve (lt/min) and Physical Activity. The statistical analysis was performed using the JMP 14.3 (SAS Inc 2018) software. Results: The drug pairs showed a steady and unchanged by time health condition for 48 patients. Overall, 31 patients were recorded with worse COPD health conditions. The one-way ANOVA clearly indicated that chemotherapy induced the best FEV1-difference conditions with a positive effect of 8.56 mean FEV volume, the combined treatment simply did not have an effect (-0.9), while immunotherapy and patients receiving radiation decreased their FEV1 volume down to -4.23 and -5.15 mean values. Conclusions: Patients receiving chemotherapy alone had their chronic obstructive disease improved with less drugs and exacerbations, while patients receiving immunotherapy had their chronic obstructive disease stable, while all other treatment combinations worsened the patients chronic obstructive disease. Nutritional status did not affect the chronic obstructive disease of these patients in any way.

Evaluation of Supraglottic Jet Oxygenation and Ventilation in 105 Patients During Bronchoscopy Using the Twinstream® Microprocessor-Controlled Jet Ventilator and the Wei Nasal Jet® Tube

BACKGROUND The Twinstream® ventilator is a microprocessor-controlled electric jet ventilator that allows the simultaneous application of 2 different jet streams, one at low frequency and one at high frequency to result in pulsatile bi-level (p-BLV) mode of ventilation. This study aimed to evaluate supraglottic jet oxygenation and ventilation in 105 patients during bronchoscopy using the Twinstream® microprocessor-controlled jet ventilator and the Wei Nasal Jet® (WNJ) tube. MATERIAL AND METHODS Patients were randomly divided into 2 parallel groups (N=50 per group): group W using the WNJ tube and group M using an endoscopic face mask connected to Twinstream® microprocessor-controlled jet ventilator under monitored anesthesia care. Arterial blood gas was examined and recorded 15 minutes after the initiation of procedure. The demographic and clinical characteristics, procedure duration, doses of anesthetics, and adverse events in the 2 groups were also recorded. RESULTS The arterial partial pressure of carbon dioxide (PaCO₂) (P=0.006) and lactic acid (P=0.001) were significantly lower, while pH (P=0.024) was significantly higher than in the group M. Pearson analysis showed that PaCO₂ was significantly correlated with ventilation tools (P=0.006) and procedure duration (P=0.003). Multiple linear regression analysis showed that ventilation tools and procedure duration were both independent influencing factors (P=0.006, P=0.002). CONCLUSIONS Supraglottic jet oxygenation and ventilation using the WNJ tube can reduce PaCO2 and had advantages in enhancing oxygenation and ventilation function in patients during bronchoscopy intervention therapy under monitored anesthesia care.

Effective early diagnosis for NSCLC: an algorithm

INTRODUCTION

Lung cancer still remains undiagnosed for most patients until the disease is inoperable.

AREAS COVERED

We performed search on PubMed with the keywords: EBUS, radial-EBUS, bronchoscopy, lung cancer, electromagnetic navigation, ct-biopsy, transthoracic biopsy. We present diagnostic equipment and imaging techniques such as positron emission tomography, endoscopical navigation systems, endobronchial ultrasound, radial-endobronchial ultrasound, transthoracic ultrasound biopsy, and computed tomography guided biopsies.

EXPERT OPINION

However, lack of early disease symptoms remains the most important issue and therefore we should direct our efforts to screening and early disease diagnosis. An algorithm is proposed for biopsy upon initial disease diagnosis.

Anesthesia considerations to reduce motion and atelectasis during advanced guided bronchoscopy

Partnership between anesthesia providers and proceduralists is essential to ensure patient safety and optimize outcomes. A renewed importance of this axiom has emerged in advanced bronchoscopy and interventional pulmonology. While anesthesia-induced atelectasis is common, it is not typically clinically significant. Advanced guided bronchoscopic biopsy is an exception in which anesthesia protocols substantially impact outcomes. Procedure success depends on careful ventilation to avoid excessive motion, reduce distortion causing computed tomography (CT)-to-body-divergence, stabilize dependent areas, and optimize breath-hold maneuvers to prevent atelectasis. Herein are anesthesia recommendations during guided bronchoscopy. An FiO₂ of 0.6 to 0.8 is recommended for pre-oxygenation, maintained at the lowest tolerable level for the entire the procedure. Expeditious intubation (not rapid-sequence) with a larger endotracheal tube and non-depolarizing muscle relaxants are preferred. Positive end-expiratory pressure (PEEP) of up to 10-12 cm H₂O and increased tidal volumes help to maintain optimal lung inflation, if tolerated by the patient as determined during recruitment. A breath-hold is required to reduce motion artifact during intraprocedural imaging (e.g., cone-beam CT, digital tomosynthesis), timed at the end of a normal tidal breath (peak inspiration) and held until pressures equilibrate and the imaging cycle is complete. Use of the adjustable pressure-limiting valve is critical to maintain the desired PEEP and reduce movement during breath-hold maneuvers. These measures will reduce atelectasis and CT-to-body divergence, minimize motion artifact, and provide clearer, more accurate images during guided bronchoscopy. Following these recommendations will facilitate a successful lung biopsy, potentially accelerating the time to treatment by avoiding additional biopsies. Application of these methods should be at the discretion of the anesthesiologist and the proceduralist; best medical judgement should be used in all cases to ensure the safety of the patient.

Interventional bronchoscopy for HPV 16 and 66 with the use of spraying interferon-α (2b) plus bevacizumab and anti-reflux agent

A fifty year old male was diagnosed with bronchial HPV. He was treated with local interventional treatment argon plasma coagulation and subcutaneous injections bevacizumab. Spraying of the regions followed with a specially designed catheter with interferon-α (2b). Systematic treatment of esomeprazole was also administered. After six months the patient is disease free and on close follow-up.

High frequency jet ventilation through mask contributes to oxygen therapy among patients undergoing bronchoscopic intervention under deep sedation

Background

High frequency jet ventilation (HFJV) is an open ventilating technique to maintain ventilation for emergency or difficult airway. However, whether jet ventilation or conventional oxygen therapy (COT) is more effective and safe in maintaining adequate oxygenation, is unclear among patients with airway stenosis during bronchoscopic intervention (BI) under deep sedation.

Methods

A prospective randomized cohort study was conducted to compare COT (high flow oxygen) with normal frequency jet ventilation (NFJV) and HFJV in oxygen supplementation during BI under deep sedation from March 2020 to August 2020. Patients receiving BI under deep sedation were randomly divided into 3 parallel groups of 50 patients each: the COT group (fractional inspired oxygen (FiO₂) of 1.0, 12 L/min), the NFJV group (FiO₂ of 1.0, driving pressure of 0.1 MPa, and respiratory rate (RR) 15 bpm) and the HFJV Group (FiO₂ of 1.0, driving pressure of 0.1 MPa, and RR of 1200 bpm). Pulse oxygen saturation (SpO₂), mean arterial blood pressure and heart rate were recorded during the whole procedure. Arterial blood gas was examined and recorded 15 min after the procedure was initiated. The procedure duration, dose of anesthetics, and adverse events during BI in the three groups were also recorded.

Results

A total of 161 patients were enrolled, with 11 patients excluded. The clinical characteristics were similar among the three groups. PaO₂ of the COT and NFJV groups was significantly lower than that of the HFJV group (P < 0.001). PaO₂ was significantly correlated with ventilation mode (P < 0.001), body mass index (BMI) (P = 0.019) and procedure duration (P = 0.001). Multiple linear regression showed that only BMI and procedure duration were independent influencing factors of arterial blood gas PaO₂ (P = 0.040 and P = 0.002, respectively). The location of airway lesions and the severity of airway stenosis were not statistically correlated with PaCO₂ and PaO₂.

Conclusions

HFJV could effectively and safely improve intra-operative PaO₂ among patients with airway stenosis during BI in deep sedation, and it did not increase the intra-operative PaCO₂ and the risk of hypercapnia. PaO₂ was correlated with ventilation mode, BMI and procedure duration. Only BMI and procedure duration were independent influencing factors of arterial blood gas PaO₂. PaCO₂ was not correlated with any preoperative factor.

Trial registration

Chinese Clinical Trial Registry. Registration number, ChiCTR2000031110, registered on March 22, 2020.

Application of a Simulator-Based Teaching Method in the Training of the Flexible Bronchoscope-Guided Intubation

BACKGROUND

The study aimed to explore the effect of a bronchoscopic simulator-based comprehensive teaching method in the training of flexible bronchoscope-guided intubation for suspected lung cancer patients for doctors without bronchofibroscopic operation background.

METHODS

We designed a prospective self-control study involved in 35 trainees from the Navy Military Medical University's affiliated hospital to evaluate flexible bronchoscope-guided intubation's training outcome. Before and after the practice training, we recorded the flexible bronchoscope passing time from nasal to visible glottis and carina, tracheal placement tube, and ventilation.

RESULTS

All 35 trainees could complete flexible bronchoscope-guided intubation independently after training.

CONCLUSIONS

The bronchial diagnosis for suspected lung cancer patients and treatment-based model can be widely applied in tracheal intubation training.

Lung cancer biopsies: Comparison between simple 22G, 22G upgraded and 21G needle for EBUS-TBNA

Introduction: Novel technologies are currently used for lung cancer diagnosis. EBUS-TBNA 22G is considered one of the most important tools. However; there are still issues with the sample size.Patients and Methods: 223 patients underwent EBUS-TBNA with a 21G Olympus needle, 22GUS Mediglobe and 22GUB Mediglobe. In order to evaluate the efficiency of 22GUB novel needle design. In order to evaluate the sample size of each needle, we constructed cell blocks and measured the different number of slices from each biopsy site. Results: The 22GUB novel needle had similar and larger number of slices from each biopsy site compared to 21G needle. Discussion: Firstly as a novel methodology we used the number of slices from the constructed cell blocks in order to evaluate the sample size. Secondly, we should seek novel needle designs and not only concentrate on the volume of the sample size.

The development of bronchoscopy in China: a national cross-sectional study

Objective: To investigate the development of bronchoscopy in China and compare it with its application in the early 21st century. Methods: The data collection was based on questionnaires. Three hundred and nineteen hospitals, which distributed across 30 provinces and 130 cities, were included in the study. Data about the application of bronchoscopy in Shanghai and Hunan province in the early 21st century are also involved for comparison. Results: The median period of performing diagnostic and therapeutic bronchoscopy was 19.7±11.0 and 7.4±7.0 years, respectively. On average, about 155.2 cases and 28.4 cases received diagnostic and therapeutic bronchoscopy in each hospital per month. The average area and number of the examination room was 122.7m² and 2.2m², respectively. More examination items were performed in specialty hospitals than those in general hospitals (P<0.05) and specialty hospitals owned more rooms exclusively for bronchoscopy (P<0.05), while no difference of the number of allocated doctors was found (P>0.05). On the other side, the whole amount of diagnosis and therapeutic items in teaching hospitals was slightly higher than that in non-teaching hospitals (P<0.01). Comparison of diagnosis and therapeutic endoscopy in Shanghai and Hunan province shows that the number of flexible bronchoscopy increased by 5.8 times in Shanghai from 2002 to 2017, while that increased by 3.4 times in Hunan province from 2005 to 2017. Furthermore, the average number of allocated doctors increased by 0.85 times in Shanghai, which was more rapidly compared with that of Hunan province (0.66 times) (P<0.05). Besides, the development rate of the diagnosis and therapeutic projects in Shanghai was significantly higher than that in Hunan province (P<0.05). Conclusion: All different classes of hospitals in China are capable of carrying out conventional bronchoscopy diagnosis and therapeutic projects, and newly developed bronchoscopy technology has gradually spread in high-level hospitals since 21st century. The higher class the hospital was, the earlier bronchoscopy was performed. Respiratory endoscopy in China has developed rapidly since the early 21st century and the construction of respiratory endoscopy center and the personnel training are on the right track, but it is also faced with inadequate equipment, unbalanced regional development and insufficient personnel allocation.

Virtual or reality: divergence between preprocedural computed tomography scans and lung anatomy during guided bronchoscopy

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.

Inhaled chemotherapy adverse effects: mechanisms and protection methods

Lung cancer is still diagnosed at a late stage due to a lack of symptoms. Although there are novel therapies, many patients are still treated with chemotherapy. In an effort to reduce adverse effects associated with chemotherapy, inhaled administration of platinum analogs has been investigated. Inhaled administration is used as a local route in order to reduce the systemic adverse effects; however, this treatment modality has its own adverse effects. In this mini review, we present drugs that were administered as nebulized droplets or dry powder aerosols for non-small-cell lung cancer. We present the adverse effects and methods to overcome them.

Scar tissue to lung cancer; pathways and treatment

Lung cancer still remains diagnosed at a late stage although we have novel diagnostic techniques at our disposal. However; for metastatic disease we have novel therapies based on pharmacogenomics. Tumor heterogenity provides us different treatments. There are several reasons for carcinogenesis; fibrosis and scar tissue provides an environment that induces malignancy. In the current review we will try and elucidate the pathways involved from scar tissue to carcinogenesis.