Shape-Sensing Robotic-Assisted Bronchoscopy in the Multiple Pulmonary Nodules Diagnosis During a Single Anesthetic Event

INTRODUCTION

The widespread use of Computed tomography (CT) as a screening tool for early lung cancer has increased detection of pulmonary lesions. It is common to encounter patients with more than one peripheral pulmonary nodule (PPN) of uncertain etiology. Shape-sensing robotic-assisted bronchoscopy (ssRAB) emerges as a potential alternative to biopsy multiple PPN, in addition to mediastinal staging in single anesthetic procedure.

METHODS

Retrospective review of 22 patients who underwent ssRAB for evaluation of two or more PPN, between November 2021 and April 2023 at Mayo Clinic Florida, US.

RESULTS

A total of 46 PPN were biopsied in 22 patients. All lesions were ≤ 2 cm with a maximum and minimum median lesion size of 1.40cm and 1.05cm, respectively. Diagnostic yield was 84.8% (n=39) and target reach was 91.3% (n=42). Most lesions were in the upper lobes, a solid pattern was found in 78.3% (n=36), bronchus sign was present in 82.6% of cases (n=38), 54.4% (n=25) were malignant nodules, and 30.4% (n=14) were benign. Fourteen patients had one malignant lesion out of two or more nodules sampled and ten patients had a malignant diagnosis for all sampled lesions. The complication rate was 9% (n=2) and pneumothorax rate was 4.5% (n=1).

CONCLUSION

This study is, to our knowledge, the first to assess the use and safety of ssRAB for diagnosis of multiple PPN in a single anesthetic event. This procedure will mainly impact management decisions and subsequently shorten the time from diagnosis to treatment.

Mobile cone-beam computed tomography complementing shape-sensing robotic-assisted bronchoscopy in the small pulmonary nodule sampling: A multicentre experience

BACKGROUND AND OBJECTIVE

Shape-sensing robotic-assisted bronchoscopy (ssRAB) has expanded as an important diagnostic tool for peripheral pulmonary nodules (PPNs), with diagnostic yields ranging from 60% to 88%. However, sampling and diagnosing PPN less than 2 cm in size has historically been challenging. Mobile cone-beam computed tomography (mCBCT) has been recently integrated into ssRAB to improve diagnostic accuracy, but its added value remains uncertain. We aim to describe the role of mCBCT and determine if it provides any diagnostic advantage.

METHODS

A multicentre, retrospective study on the use of ssRAB and mCBCT in two tertiary care institutions: Mayo Clinic Florida and Massachusetts General Hospital. The primary outcome was diagnostic yield and sensitivity for malignancy of ssRAB complemented with mCBCT, compared to ssRAB with the standard 2D fluoroscopy.

RESULTS

A total of 192 nodules were biopsied from 173 patients. mCBCT was used in 117 (60.9%) nodules. The overall diagnostic yield was 85.4%. Diagnostic yield between subgroups with and without mCBCT was 83.8% and 88% (p = 0.417), respectively. The mCBCT group had fewer solid nodules (65.8% vs. 81.3%, p = 0.020) and a higher number of ground-glass nodules (10.3% vs. 1.3%, p = 0.016).

CONCLUSION

Overall, diagnostic yield between subgroups with and without mCBCT was similar. The complementary use of mCBCT to ssRAB allows proceduralists to target more complex and subsolid PPNs with a diagnostic yield comparable to simple solid PPNs while maintaining an excellent safety profile.

Shape-Sensing Robotic-Assisted Bronchoscopy versus Computed Tomography-Guided Transthoracic Biopsy for the Evaluation of Subsolid Pulmonary Nodules

INTRODUCTION

Lung cancer remains the leading cause of cancer death worldwide. Subsolid nodules (SSN), including ground-glass nodules (GGNs) and part-solid nodules (PSNs), are slow-growing but have a higher risk for malignancy. Therefore, timely diagnosis is imperative. Shape-sensing robotic-assisted bronchoscopy (ssRAB) has emerged as reliable diagnostic procedure, but data on SSN and how ssRAB compares to other diagnostic interventions such as CT-guided transthoracic biopsy (CTTB) are scarce. In this study, we compared diagnostic yield of ssRAB versus CTTB for evaluating SSN.

METHODS

A retrospective study of consecutive patients who underwent either ssRAB or CTTB for evaluating GGN and PSN with a solid component less than 6 mm from February 2020 to April 2023 at Mayo Clinic Florida and Rochester. Clinicodemographic information, nodule characteristics, diagnostic yield, and complications were compared between ssRAB and CTTB.

RESULTS

A total of 66 nodules from 65 patients were evaluated: 37 PSN and 29 GGN. Median size of PSN solid component was 5 mm (IQR: 4.5, 6). Patients were divided into two groups: 27 in the ssRAB group and 38 in the CTTB group. Diagnostic yield was 85.7% for ssRAB and 89.5% for CTTB (p = 0.646). Sensitivity for malignancy was similar between ssRAB and CTTB (86.4% vs. 88.5%; p = 0.828), with no statistical difference. Complications were more frequent in CTTB with no significant difference (8 vs. 2; p = 0.135).

CONCLUSION

Diagnostic yield for SSN was similarly high for ssRAB and CTTB, with ssRAB presenting less complications and allowing mediastinal staging within the same procedure.

Atypical distal tracheal fibrous bridge and bronchial stenosis in an adult patient with bronchopulmonary dysplasia

Tracheobronchial stenosis (TBS) in adults derives from congenital and acquired conditions, including prolonged mechanical intubation, expiratory central airway collapse, infectious or inflammatory disease, and malignancy. The most common clinical presentation is shortness of breath, recurrent infections, and chronic cough. TBS is usually diagnosed via computed tomography or bronchoscopy, with the latter doubling as a therapeutic tool. We present a case of an atypical fibrotic bridge connecting the walls of the distal trachea and fibrotic bronchial stenosis treated with electrocautery knife and balloon dilation, in an adult patient with bronchopulmonary dysplasia.

Diagnostic Yield of Shape-Sensing Robotic-Assisted Bronchoscopy for Ground-Glass Nodules and Subsolid Nodules with a Solid Component Less than 6 mm

BACKGROUND

Ground-glass pulmonary nodules (GGNs) are most commonly sampled by percutaneous transthoracic biopsy. Diagnostic yield for ground-glass nodules using robotic-assisted bronchoscopy has been scarcely described, with a reported yield of 70.6%.

OBJECTIVES

The aim of this study is to assess diagnostic yield for GGNs using shape-sensing robotic-assisted bronchoscopy (ssRAB).

METHOD

A retrospective study of patients who underwent ssRAB for evaluation of GGNs, from September 2021 to April 2023. Primary outcome was diagnostic yield of ssRAB for GGNs, secondary outcomes were sensitivity for malignancy, and complications that required admission or intervention.

RESULTS

A total of 23 nodules were biopsied from 22 patients. Median age was 71 years (IQR 66-81), 63.6% were female, and 40.9% had a previous history of cancer. Forty-three percent of nodules were in the right upper lobes, and the median lesion size was 1.8 × 1.21. Twelve were subsolid nodules (SSNs), and 11 were pure GGNs. Overall diagnostic yield was 87%, with a sensitivity for malignancy of 88.9%. Adenocarcinoma was the most common malignancy diagnosed (70%). No procedure-related complications were reported.

CONCLUSION

The use of ssRAB shows a high diagnostic yield for diagnosing GGN and SSN with less than 6 mm solid component with a low risk for complications.

One-stop-shop: Lung cancer and pheochromocytoma diagnosed by robotic-assisted bronchoscopy and EBUS scope on a single endoscopic event

Lung cancer is the deadliest cancer worldwide, therefore, early and prompt diagnosis is essential for better patient outcomes. It is known to have a high predilection for metastasis to the adrenal glands; however, two-thirds of adrenal masses in patients with lung cancer will turn out to be benign, so timely detection is crucial. We present a case of a lung squamous cell carcinoma diagnosed by shape-sensing robotic-assisted bronchoscopy (ssRAB), negative mediastinal and hilar staging with endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA), and a pheochromocytoma diagnosed through endoscopic ultrasound with bronchoscope (EUS-B) fine needle aspiration (FNA) all in the same endoscopic procedure.

Pneumatic stenting in the surgical candidacy assessment for cough variant expiratory central airway collapse

Expiratory Central Airway Collapse (ECAC) is a multifactorial, underdiagnosed entity that poses unique challenges. Airway stenting is used as a predictor for successful outcomes after central airway stabilization surgery via tracheobronchoplasty (TBP). This approach may pose suboptimal performance in certain ECAC variants. We hypothesize that Continuous Positive Airway Pressure (CPAP), used as a pneumatic stent, could be a non-invasive alternative to evaluate surgical candidacy in cough-predominant ECAC presentations. We report on a 67-year-old female with a history of chronic cough and confirmed ECAC. After optimization of medical therapy without significant relief and unsuccessful stent trial. We opted to perform CPAP trial during exercise, the patient exercised on a treadmill, and CPAP was applied at two levels (9 cmH₂O, 11 cmH₂O). The use of CPAP was associated with resolution of cough and a decrease in exercise-related perceived exertion. Applying CPAP during exercise may be a promising alternative to stent trials to determine patients' candidacy for surgical management of cough-predominant ECAC.

Coordination of Care for Expiratory Central Airway Collapse: A Structured Process for a Multifaceted Disease

Common respiratory symptoms, including dyspnea, cough, sputum production, and recurrent infections, frequently remain without a clear cause and may be the result of expiratory central airway collapse (ECAC). Establishing the diagnosis and appropriate treatment plan for patients with ECAC is challenging and benefits from a multidisciplinary approach. A coordinator role is crucial in this process to ensure optimal patient-centered outcomes. We describe the coordination of care in the process of diagnosing and treating ECAC. The coordinator leads the organization of the multiple services involved in the care of patients with ECAC, including pulmonary medicine, interventional pulmonology, radiology, and thoracic surgery, as well as hospital inpatient staff. From initial screening to evaluation and management with airway stents and corrective treatment with tracheobronchoplasty, the ECAC coordinator oversees the entire process of care for patients with ECAC.

Nurse Coordinator Roles and Responsibilities for Bronchoscopic Lung Volume Reduction With Endobronchial Valves

COPD may cause profound dyspnea, functional impairment, and reduced quality of life. Available pharmacologic therapy provides suboptimal symptom improvement in many patients. Bronchoscopic lung volume reduction (BLVR), achieved with endobronchial valve placement, can effectively improve dyspnea and functional status in appropriately selected patients. Operationalizing a safe and effective BLVR program requires appropriate oversight, which can be achieved by a BLVR nurse coordinator (NC). By identifying and developing screening practices, coordinating multidisciplinary diagnostic evaluation, and establishing safe efficient patient flow throughout the entire care process, a BLVR NC can optimize patient care, safety, experience, efficiency, and overall outcomes. This article details the role of our NC to facilitate extrapolation to other institutions.

Central Airway Collapse, an Underappreciated Cause of Respiratory Morbidity

Dyspnea, cough, sputum production, and recurrent respiratory infections are frequently encountered clinical concerns leading patients to seek medical care. It is not unusual for a well-defined etiology to remain elusive or for the therapeutics of a presumed etiology to be incompletely effective. Either scenario should prompt consideration of central airway pathology as a contributor to clinical manifestations. Over the past decade, recognition of dynamic central airway collapse during respiration associated with multiple respiratory symptoms has become more commonly appreciated. Expiratory central airway collapse may represent the answer to this diagnostic void. Expiratory central airway collapse is an underdiagnosed disorder that can coexist with and mimic asthma, chronic obstructive pulmonary disease, and bronchiectasis. Awareness of expiratory central airway collapse and its spectrum of symptoms is paramount to its recognition. This review includes clear definitions, diagnostics, and therapeutics for this challenging condition. We performed a narrative review through the PubMed (MEDLINE) database using the following MeSH terms: airway collapse, tracheobronchomalacia, tracheomalacia, and bronchomalacia. We include reports from systematic reviews, narrative reviews, clinical trials, and observational studies from 2005 to 2020. Two reviewers evaluated potential references. No systematic reviews were found. A total of 28 references were included into our review. Included studies report experience in the diagnosis and/or treatment of dynamic central airway collapse; case reports and non-English or non-Spanish studies were excluded. We describe the current diagnostic dilemma, highlighting the role of dynamic bronchoscopy and tracheobronchial stent trial; outline the complex therapeutic options (eg, tracheobronchoplasty); and present future directions and challenges.