Journal of Bronchology & Interventional Pulmonology最新文献

Background: Ultrasound-guided percutaneous needle biopsy (US-PNB) represents an efficacious, safe, and cost-effective alternative to CT-guided biopsy for accessible thoracic lesions. Emerging evidence suggests that respiratory physicians experienced in thoracic ultrasound may achieve comparable diagnostic yield and safety outcomes to interventional radiologists. This study aimed to determine the diagnostic yield and safety of US-PNB of accessible thoracic lesions as performed by respiratory physicians, in an Australasian context.

Methods: Demographic, clinical, and procedural information was prospectively collected at a single Australian tertiary centre for patients undergoing US-PNB of peripheral lung and pleural lesions, lymph nodes, and other accessible thoracic lesions in an outpatient setting between October 3, 2016 and December 20, 2019. The final diagnosis was determined following a discussion in a lung oncology multidisciplinary meeting. Twelve-month follow-up data was reviewed.

Results: One hundred and fifty-one patients underwent 162 US-PNB procedures. This included 3 patients who underwent US-PNB of separate sites, and 8 patients who underwent repeat US-PNB procedures of the same site. Overall, the diagnostic yield of US-PNB was 83% (95% CI: 76-88). Diagnostic yield varied by procedural site, with yields highest in lymph node biopsy (91%, 95% CI: 79-97) and lowest in pleural biopsy (66%, 95% CI: 50-79). Complications occurred during 23 procedures (14%) and were largely minor. Pneumothorax occurred in 4 patients (2.5%), with 1 patient requiring intercostal catheter insertion.

Conclusion: US-PNB of peripheral lung and pleural lesions, lymph nodes, and other accessible thoracic lesions performed by respiratory physicians is safe with high diagnostic yield.

Background: Medical thoracoscopy (MT) is a minimally invasive procedure performed to diagnose and treat pleural disorders. MT is usually accomplished with the use of monitored anesthesia care (MAC) and local anesthetic (LA) infiltration. There is little data regarding the analgesic benefits and use of peripheral nerve blocks (PNB) for MT.

Methods: A retrospective review was done looking at patients who underwent MT at a single center in New York City from January 2021 to September 2023, comparing the procedural times, intraoperative opioid consumption, and postoperative opioid consumption in the post-anesthesia care unit (PACU) of patients who received a PNB with MAC versus MAC alone.

Results: Ninety records were queried, 23 (25.6%) had a PNB, of which 14 (60.8%) received an erector spinae plane block (ESPB) and 9 (39.1%) received a serratus anterior plane block (SAPB). 67 (74.4%) received MAC alone. When comparing those who received a PNB with MAC versus MAC alone, there was a reduction in procedure time (34 vs. 40 min, P=0.007), in-room time (53 vs. 68 min, P=<0.001), median use of intraoperative opioids (milligram morphine equivalent, 3.0 vs. 6.0, P=<0.001), and overall need for dexmedetomidine (0 vs. 20.9%, P=0.04). There was no difference in the intraoperative opioid use or postoperative opioid consumption recorded in PACU.

Conclusion: The addition of a PNB, either SAPB or ESPB, to MAC for MT is safe and might reduce procedural time and overall intraoperative opioid use. However, larger randomized clinical trials are necessary to confirm these findings.

Background: Tunneled pleural catheters (TPCs) generate an inflammatory reaction, which, along with frequent drainage, aids in achieving pleurodesis enabling removal in 30% to 50% of patients. However, it is unknown whether the technique of TPC placement influences pleurodesis outcomes.

Methods: This is a retrospective, single-center study of patients who underwent TPC placement from 2010 through 2018. Pleurodesis success was defined as TPC removal within 90 days of placement in the setting of no further drainage and in the absence of catheter malfunction, infection, patient's choice for another treatment modality, or other catheter-related complications. Pleurodesis failure was defined as patients who did not have TPC removal within 90 days of insertion.

Results: A total of 326 patients underwent TPC insertion by thoracic surgery, interventional pulmonology, or interventional radiology. Fourteen patients were excluded due to insufficient follow-up. Of the 312 patients included in the final analysis, 32.7% achieved pleurodesis. Patients who had their TPC inserted thoracoscopically achieved higher pleurodesis success compared with a percutaneous technique (61.2% vs 24.9%, P < 0.001). Thoracoscopically placed catheters had two times greater chance of removal than those inserted percutaneously (hazard ratio: 2.04, 95% CI: 1.14-3.64, P = 0.02) after controlling for pleural biopsies and sclerosing agents used during thoracoscopy.

Conclusion: Thoracoscopic TPC placements may be associated with higher pleurodesis rates compared with a percutaneous technique. Our results are only hypothesis-generating, and these findings warrant confirmation in prospective studies.

Background: Single-use flexible bronchoscopes (SFBs) are increasingly used to minimize cross-infection risk, particularly in immunocompromised and intensive care unit patients. However, broader adoption requires cost analysis. We conducted a 1-year cost-minimization analysis comparing SFBs and reusable flexible bronchoscopes (RFBs) at a tertiary care university hospital.

Methods: We evaluated the costs per procedure, considering capital equipment, maintenance, repair, reprocessing, and overhead costs. We also analyzed the impact of annual procedure volume on costs and performed a sensitivity analysis to assess the effect of uncertainty on costs.

Results: A total of 1394 bronchoscopies were performed. RFBs were less expensive for an annual volume of >50 bronchoscopies/year, with a 22% lower cost per procedure than that for SFBs (€203 vs. €259). This cost advantage became increasingly favorable with an increasing number of procedures, reaching a plateau after exceeding 250 bronchoscopies/year. The capital equipment, the annual number of bronchoscopies, and reprocessing were the major cost drivers for RFBs. During nonworking hours, the cost per procedure of RFBs ranged from €349.45 to €392.29. Using RFBs during interventions involving a high risk of bronchoscope damage (frequency of damage >10%) would increase the cost per bronchoscopy to >€263 (exceeding the cost of SFBs).

Conclusion: RFBs were 22% less expensive than SFBs for services with a moderate to high volume of bronchoscopies. However, this difference could not justify using RFBs in patients with a high cross-infection risk. SFBs might be less costly for procedures outside working hours and interventions involving a high risk of bronchoscope damage.

Background: The Olympus bronchoscope is equipped with an insertion tube rotation function; however, data on its usefulness are currently limited. Here, we evaluated the amount of body and wrist movement required by bronchoscopists, the operability of the bronchoscope, and its ease of use with and without the insertion tube rotation function.

Methods: This study was performed on 10 bronchoscopists using 2 cadaveric bodies. The primary endpoint was the amount of movement exerted by the bronchoscopist, which was evaluated using motion capture. We also assessed the deepest bronchial generations that could be reached by the bronchoscope and the time required for insertion. Immediately after the procedures, the bronchoscopists completed a questionnaire to evaluate their perceived difficulty level.

Results: The bronchoscopists achieved a 33.5% reduction in wrist rotation (67.8 vs. 110.2 degrees, P<0.05) and a 23.9% reduction in body rotation (17.2 vs. 24.4 degrees, P<0.05) using the insertion tube rotation function for all segmental bronchi. During forceps insertion to simulated lesions, the bronchoscopists' body movement was reduced by 65.1% (11.6 vs. 33.9 degrees, P<0.05), and wrist rotation by 47.6% (63.5 vs. 122.7 degrees, P<0.05). Furthermore, bronchoscopists experienced significantly reduced difficulty inserting biopsy forceps toward simulated target lesions (3.9 vs. 3.2 points, P<0.05) and required less assistance (4.0 vs. 2.0 points, P<0.05) when using the insertion tube rotation function.

Conclusion: The insertion tube rotation function of the bronchoscope facilitated its insertion and improved operability.

Background: In the United States, Pulmonary and Critical Care Medicine (PCCM) fellowship training traditionally requires performing a minimum number of bronchoscopy and pleural procedures to be deemed competent. However, expert panel recommendations favor assessments based on skill and knowledge. PCCM trainees have a variable exposure to the advanced procedures in the presence of interventional pulmonary (IP) fellowships, so we surveyed the PCCM program directors (PD) across the United States to assess the procedural volume and competency of their fellows.

Methods: Survey invitations were emailed between April 2022 and May 2022, and responses were collected from PCCM fellowship programs. The PD assessed the competency and volume of procedures performed by PCCM fellows at the end of training. The primary objective was to determine the effect of IP fellowship or IP faculty on fellows' procedural competency. The secondary objective was to assess the same impact on procedural volume.

Results: The survey response rate was 41.9% (n=109/260) with an average of 4.23 fellows/program (95% CI: 3.9-4.6). 74.5% (73/98) programs reported having access to IP faculty, while 26.5% (26/98) had an AABIP-accredited IP fellowship. No significant difference was noted for procedural competency or volume in programs with or without an IP fellowship or IP faculty during training. Most programs reported that PCCM fellows do not perform advanced bronchoscopy procedures.

Conclusion: An IP fellowship or IP faculty at a PCCM training institution did not appear to influence the PD-assessed volume or competency of common bronchoscopy and pleural procedures performed by fellows.

Background: This study aimed to quantify radiation doses during navigational bronchoscopy procedures, comparing them with reported cohorts and evaluating the LungVision (Body Vision Medical Inc.) system's efficacy in dose reduction.

Methods: This retrospective observational study included 52 consecutive navigational bronchoscopy cases, categorized into 4 imaging groups based on the C-arm: Cios Spin (Siemens Healthineers), or OEC 9900 (GE HealthCare); and the 3D tomographic imaging algorithm: Cios Spin's onboard imaging, or LungVision's AI-driven imaging. Patient and lesion data, outcomes, and radiation indices were collected. Existing literature on 3D image guidance for bronchoscopic lung nodules was reviewed to compare reported radiation doses.

Results: Combining LungVision with Cios Spin significantly reduced radiation dose in all cases compared with using Cios Spin alone: Cumulative air kerma (Ka,r) reduced from 238.7 to 119.1 mGy (P=0.03), and air kerma-area product (KAP) decreased from 28.19 to 15.09 Gy·cm2 (P=0.03). For biopsy cases, LungVision led to notable dose reductions: Ka,r of 279 to 129.1 mGy, and KAP of 30.70 to 16.27 Gy·cm2. LungVision notably reduced radiation indices in 7 paired spins, isolating the 3D imaging algorithm as the sole variable with the same Cios Spin C-arm. A literature review provides additional context on radiation for bronchoscopic biopsies.

Conclusion: Following the "as low as reasonably achievable" (ALARA) principle minimizes ionizing radiation exposure, benefiting patients and operators. Physicians should compare baseline radiation levels with the literature and adopt dose-reduction techniques. LungVision's lower dose indices render it effective for real-time 3D imaging during navigational bronchoscopy while reducing radiation dose.

Background: Diagnosis of sarcoidosis often involves endobronchial biopsy (EBB), but studies have shown varying yields for EBB in suspected sarcoidosis, partly due to differences in identifying abnormal mucosa under white light (WL). Narrow band imaging (NBI) may assist in the visualization of abnormal mucosa, but its role in sarcoidosis remains to be characterized.

Methods: Individuals referred for suspected sarcoidosis were considered for enrollment. Bronchoscopy with both WL and NBI was conducted, followed by EBB. The main objectives were to characterize NBI abnormalities in this patient population and determine the incremental yield of NBI-directed EBB.

Results: In our cohort of 100 suspected sarcoidosis patients (66% male, median age 42), 88 were diagnosed with sarcoidosis, through cytopathology (n=78) or clinical evaluation (n=10). NBI high-grade lesions were more common than WL high-grade lesions (58% vs. 27%, difference 31%, 95% CI 18.3-42.5% P<0.001). High-grade WL EBB were more likely to be positive than low-grade WL biopsies [20/31 (65%) vs. 20/91 (22%), odds ratio (OR) 6.5, 95% CI 2.7-15.6, P<0.01]). Conversely, high-grade NBI lesions were no more likely to be positive than low-grade NBI lesions [23/63 (37%) vs. 17/59, (29%), OR 1.42, 95% CI 0.66-3.0, P=0.366]. EBB positivity and false-negative EBUS-TBNA were more common in patients with Scadding stage 2 or greater, suggesting that the chest radiography stage may help select patients more likely to benefit from adjunctive EBB.

Conclusion: NBI abnormalities are common in patients with sarcoidosis, but unlike WL abnormalities, do not predict the finding of granulomatous inflammation on EBB. The chest radiography stage may be useful to identify patients more likely to benefit from EBB in addition to EBUS-TBNA.

Background: Peripheral pulmonary lesions (PPLs) are frequently identified and require diagnostic sampling. Diagnostic yield of radial endobronchial ultrasound (rEBUS) guided bronchoscopic biopsies is suboptimal, despite ultrasound confirmation of navigation success. Pairing ultrathin bronchoscopy and peripheral transbronchial needle aspiration (pTBNA) may improve yield.

Methods: We prospectively recruited consecutive patients undergoing Olympus MP190F ultrathin bronchoscopy with rEBUS-guided sampling of PPLs. Cases were randomized to pTBNA (Olympus Periview FLEX) either before or after the usual transbronchial forceps biopsy (TBLBx) and brush. Diagnostic yield from cytology or histopathology, clinical outcomes to a minimum 24 months follow-up and complications were recorded.

Results: One hundred one sampled lesions were included (pTBNA first 61, pTBNA last 40). Overall diagnostic yield was 66.3%, with no significant difference between groups (64% vs. 70% P=0.528) or prespecified subgroups according to sampling order. Seventy lesions had an end diagnosis of malignancy, of which 50 were correctly diagnosed (71.4%). TBLBx (49/96, 49%) and pTBNA (48/101, 47.5%) had the highest individual positive yield. For 12 (11.9%) participants, pTBNA was the only positive sample. Lesions <20 mm and those with eccentric rEBUS image seemed to benefit most from this approach. Rapid on-site cytologic examination (ROSE) was associated with both positive procedural diagnosis (P=0.019) and pTBNA-positive samples (P=0.004). Pneumothorax occurred in 4% and moderate bleeding in 5%. Thirteen percent had an unplanned admission within 1 month of bronchoscopy.

Conclusion: Adding pTBNA to conventional sampling through an ultrathin bronchoscope guided by rEBUS, improved diagnostic yield (11.9% additional diagnoses). The sampling sequence did not affect the yield of pTBNA.

Background: In 2020, a mandatory, nationwide 1-day bronchoscopy simulation-based training (SBT) course was implemented for novice pulmonology residents in the Netherlands. This pretest-posttest study was the first to evaluate the effectiveness of such a nationwide course in improving residents' simulated basic bronchoscopy skills.

Methods: After passing a theoretical test, residents followed a 1-day SBT course, available in 7 centers, where they practiced their bronchoscopy skills step-by-step on a virtual reality simulator under pulmonologist supervision. Residents practiced scope handling efficiency (task 1) and navigational skills combined with lung anatomy knowledge (task 2). Task 1 outcome measures were navigational skill simulator metrics: percentage of time at mid-lumen, percentage of time with scope-wall contact, procedure time (PT), number of wall contacts and number of wall contacts per minute of PT. Task 2 outcome measures were PT, observational assessment scores of a validated tool with a 5-point scale (1 representing the worst and 5 the best competence) and blinded dexterity assessments.

Results: The study included 100 residents. All outcome measures of task 1 improved significantly (P<0.001), except for the number of wall contacts per minute of PT (4.3 [IQR 3.0 to 6.2] pre vs. 3.5 [IQR 2.6 to 5.3] post, P=0.07). For task 2, PT was reduced by 54% (10.3±2.7 minutes pre vs. 4.7±0.9 minutes post, P<0.001) with an improvement in overall-competence scores (2.0 [IQR 1.0 to 2.0] pre vs. 4.0 [IQR 4.0 to 5.0] post, P<0.001) and all dexterity parameters (P<0.001).

Conclusion: Nationwide implementation of a SBT course led to rapid improvement of residents' basic bronchoscopy skills while halving PT.