Ultrathin Bronchoscope Research Articles

Intracavitary Pulmonary Aspergilloma Removal Using Combined Virtual, Ultrathin, and Rigid Bronchoscopy - A Case Series

Intracavitary Pulmonary Aspergilloma Removal Using Combined Virtual, Ultrathin, and Rigid Bronchoscopy - A Case Series

Virtual Bronchoscopic Navigation Combined with Ultrathin Bronchoscopy. A Randomized Clinical Trial

In bronchoscopy, an ultrathin bronchoscope can be advanced to more peripheral bronchi. Because virtual bronchoscopic navigation (VBN) is a method to guide a bronchoscope under direct observation using VB images, VBN may be particularly useful when combined with ultrathin bronchoscopy. This prospective multicenter study evaluated the value of VBN-assisted ultrathin bronchoscopy for diagnosing peripheral pulmonary lesions. We randomly assigned 350 patients with peripheral pulmonary lesions (diameter, ≤30 mm) to VBN-assisted or non-VBN-assisted groups. An ultrathin bronchoscope (outer diameter, 2.8 mm) was introduced to the target bronchus using a VBN system in the VBN-assisted group, whereas only computed tomography axial images were referred to in the non-VBN-assisted group. Specimen sampling sites were verified using X-ray fluoroscopy. Subjects for analysis included 334 patients. There was no significant difference in the diagnostic yield between the VBN-assisted group (67.1%) and the non-VBN-assisted group (59.9%; P = 0.173). The subgroup analysis showed that the diagnostic yield was significantly higher in the VBN-assisted group than in the non-VBN-assisted group for right upper lobe lesions (81.3% vs. 53.2%; P = 0.004); lesions invisible on posterior-anterior radiographs (63.2% vs. 40.5%; P = 0.043); and lesions in the peripheral third of the lung field (64.7% vs. 52.1%; P = 0.047). VBN-assisted ultrathin bronchoscopy does not improve the diagnostic yield for peripheral pulmonary lesions. However, the method improves the diagnostic yield for lesions in the subcategories (right upper lobe, invisible, peripheral third), warranting further study. Clinical trial registered with www.umin.ac.jp/ctr/ (UMIN 000001536).

A Novel Minimally Invasive Technique to Create a Rabbit VX2 Lung Tumor Model for Nano-Sized Image Contrast and Interventional Studies

BackgroundThe rabbit VX2 lung cancer model is a large animal model useful for preclinical lung cancer imaging and interventional studies. However, previously reported models had issues in terms of invasiveness of tumor inoculation, control of tumor aggressiveness and incidence of complications.PurposeWe aimed to develop a minimally invasive rabbit VX2 lung cancer model suitable for imaging and transbronchial interventional studies.MethodsNew Zealand white rabbits and VX2 tumors were used in the study. An ultra-thin bronchoscope was inserted through a miniature laryngeal mask airway into the bronchus. Different numbers of VX2 tumor cells were selectively inoculated into the lung parenchyma or subcarinal mediastinum to create a uniform tumor with low incidence of complications. The model was characterized by CT, FDG-PET, and endobronchial ultrasound (EBUS). Liposomal dual-modality contrast agent was used to evaluate liposome drug delivery system in this model.ResultsBoth peripheral and mediastinal lung tumor models were created. The tumor making success rate was 75.8% (25/33) in the peripheral lung tumor model and 60% (3/5) in the mediastinal tumor model. The group of 1.0×106 of VX2 tumor cells inoculation showed a linear growth curve with less incidence of complications. Radial probe EBUS visualized the internal structure of the tumor and the size measurement correlated well with CT measurements (r2 = 0.98). Over 7 days of continuous enhancement of the lung tumor by liposomal contrast in the lung tumor was confirmed both CT and fluorescence imaging.ConclusionOur minimally invasive bronchoscopic rabbit VX2 lung cancer model is an ideal platform for lung cancer imaging and preclinical bronchoscopic interventional studies.

Fluoroscopy-assisted thoracoscopic resection after computed tomography-guided bronchoscopic metallic coil marking for small peripheral pulmonary lesions

To re-evaluate the efficacy of fluoroscopy-assisted thoracoscopic resection after computed tomography (CT)-guided bronchoscopic metallic coil marking (FATS-CM), which was our original method for small peripheral pulmonary lesions. Fifty-eight patients with 63 lesions underwent FATS-CM. A metallic coil was installed in the bronchus nearest to the lesion under CT fluoroscopic guidance with ultrathin bronchoscopy. The virtual bronchoscopic navigation (VBN) system was used in 14 cases. Afterwards, we basically performed wide wedge resection (WWR) using a C-arm-shaped roentgenographic fluoroscope during thoracoscopic surgery initially, and then the final procedure was determined by intraoperative histological diagnosis. Moreover, we prospectively treated ground-glass opacity (GGO) lesions of <20 mm diameter according to our treatment protocol from September 2004. We could install coils in the objective bronchi in all cases. The average time required for the marking procedure was 38.9 (15-120) min. Pneumothorax was recognized in 1 (1.7%) case as a complication, but no fatal complications occurred. We could also install coils for each lesion in 4 cases (9 lesions) with multiple lesions. In 14 cases with the VBN system, the examination time and CT number were significantly reduced (P < 0.05 and <0.001, respectively), compared with those of 40 cases without the VBN system. The average interval between the CM and the operation was 5.6 (0-30) days. We never experienced a case of migration preoperatively. Sixty-two (98.4%) lesions were definitively identified, and WWRs were performed using three trocars in 58 (92.1%) cases during thoracoscopic surgery. Lobectomy was initially performed in only 1 case owing to coil migration. Thirty-seven of 40 cases (92.5%) were in line with the treatment protocol. There were no local-regional recurrences in all cases undergoing WWR. We could prospectively show that our method was suitable to perform WWR with a sufficient margin for small GGO lesions of <20 mm. Moreover, we reconfirmed that the advantages of our method were safety, permitting flexibility in scheduling operations and a high ability to deal with multiple lesions. Additionally, our method became a minimally invasive and mature technique by using a new VBN system.

Ultrathin Bronchoscopy in the Diagnosis of Peripheral Cavitary Lung Lesions

Ultrathin (UT) bronchoscopy has emerged as a useful tool to diagnose peripheral solid lung lesions of a malignant nature. This technology is superior to standard bronchoscopic techniques, which have low yield in identifying small lesions, especially as they extend further out along the bronchial tree. UT bronchoscopy can prevent the need to pursue more invasive open lung strategies to diagnose suspicious lesions. In this report, we present 3 distinct clinical scenarios where UT bronchoscopy was successful in diagnosing benign peripheral cavitary lesions after standard techniques failed. The use of UT bronchoscopy in each case was instrumental in allowing rapid initiation of appropriate therapy without need for more invasive surgical biopsies in the setting of a benign condition.

Obliterative lower airway lesions in childhood: Bronchoscopic diagnosis and clinical spectrum

Previous reports have described structural airway abnormalities in children with non-cystic fibrosis chronic supportive lung disease as well as obliterative membranes in the major bronchi of cystic fibrosis patients. The putative paradigm proposed in the evolution of these membranes invokes intense inflammation resulting in granulation tissue and neovascularization with the formation of pyogenic granuloma and eventually fibrosis. Our series of four cases widens the spectrum of conditions that may be conducive to large airway obliteration to include non-suppurative chronic infections and possibly immunosuppression. Obliteration of lumina in proximal and distal airways was visualized on bronchoscopy, the latter by the use of the ultrathin bronchoscopes. An attempt at invasive intervention by transbronchial breaching of the obstruction was unsuccessful in three cases, and in one case, the obliterative process resolved spontaneously and without any radiologic trace, presumably by resorption or rupture or through development of collateral ventilation. This series highlights the use of bronchoscopy for diagnosis and occasionally for therapeutic intervention in hitherto little recognized obliterative airway lesions. These acquired obliterative lesions should be considered in the evaluation of patients with isolated non-resolving pulmonary infiltrates or other conditions in which bronchial and bronchiolar patency may be impaired.

Usefulness of a Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation in a neonate with Pierre Robin syndrome -A case report-

The case of a 33-day-old boy with Pierre Robin syndrome using a Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation is presented. After induction with sevoflurane, classical reusable laryngeal mask airway (LMA) #1 was inserted and ultrathin fiberoptic bronchoscope (FOB) was passed through. A Cook® airway exchange catheter (1.6 mm ID, 2.7 mm OD) was passed through the LMA under the guidance of the FOB but failed to enter the trachea despite many trials. Then, an endotracheal tube (3.0 mm ID) was mounted on the FOB and railroaded over the FOB. After successful intubation, the Cook® airway exchange catheter was placed in the midtrachea through the lumen of the endotracheal tube. Even though the tracheal tube was accidentally displaced out of the trachea during LMA removal, the endotracheal tube could be easily railroaded over the airway exchange catheter.

Meta-analysis of Guided Bronchoscopy for the Evaluation of the Pulmonary Nodule

The detection of pulmonary nodules (PNs) is likely to increase, especially with the release of the National Lung Screen Trials. When tissue diagnosis is desired, transthoracic needle aspiration (TTNA) is recommended. Several guided-bronchoscopy technologies have been developed to improve the yield of transbronchial biopsy for PN diagnosis: electromagnetic navigation bronchoscopy (ENB), virtual bronchoscopy (VB), radial endobronchial ultrasound (R-EBUS), ultrathin bronchoscope, and guide sheath. We undertook this meta-analysis to determine the overall diagnostic yield of guided bronchoscopy using one or a combination of the modalities described here. We performed a MEDLINE search using “bronchoscopy” and “solitary pulmonary nodule.” Studies evaluating the diagnostic yield of ENB, VB, R-EBUS, ultrathin bronchoscope, and/or guide sheath for peripheral nodules were included. The overall diagnostic yield and yield based on size were extracted. Adverse events, if reported, were recorded. Meta-analysis techniques incorporating inverse variance weighting and a random-effects meta-analysis approach were used. A total of 3,052 lesions from 39 studies were included. The pooled diagnostic yield was 70%, which is higher than the yield for traditional transbronchial biopsy. The yield increased as the lesion size increased. The pneumothorax rate was 1.5%, which is significantly smaller than that reported for TTNA. This meta-analysis shows that the diagnostic yield of guided bronchoscopic techniques is better than that of traditional transbronchial biopsy. Although the yield remains lower than that of TTNA, the procedural risk is lower. Guided bronchoscopy may be an alternative or be complementary to TTNA for tissue sampling of PN, but further study is needed to determine its role in the evaluation of peripheral pulmonary lesions.

The Peptide Nucleic Acid-Locked Nucleic Acid Polymerase Chain Reaction Clamp-Based Test for Epidermal Growth Factor Receptor Mutations in Bronchoscopic Cytological Specimens of Non-Small Cell Lung Cancer

Objectives: Cytological examination of samples obtained by bronchoscopy is a useful method for establishing the diagnosis of non-small cell lung cancer (NSCLC). However, the utility of a highly sensitive method for the detection of epidermal growth factor receptor (EGFR) mutation in the cytological specimens has not been fully evaluated. Methods: We retrospectively examined the efficacy of the peptide nucleic acid-locked nucleic acid polymerase chain reaction (PNA-LNA PCR) clamp method for detecting EGFR mutations in 122 bronchoscopic cytological specimens from NSCLC patients. Results: Overall, 41 specimens (33.6%) were positive for EGFR mutation. Twenty-nine (39.7%) of 73 specimens obtained by using endobronchial ultrasonography with a guide sheath, 7 (33.3%) of 21 specimens obtained under direct vision by using a conventional bronchoscope, 4 (36.4%) of 11 specimens obtained by using an ultrathin bronchoscope, and 1 (5.9%) of 17 specimens obtained by endobronchial ultrasound-guided transbronchial needle aspiration were positive for EGFR mutation. Furthermore, among 22 resected NSCLC cases, the EGFR mutation status obtained from bronchoscopic materials was consistent with the status obtained from surgical samples, with the exception of 1 case. Conclusion: The detection of EGFR mutation by subjecting bronchoscopic cytological specimens to a PNA-LNA PCR clamp assay proves useful.

Obliterative lower airway lesions in childhood: bronchoscopic diagnosis and clinical spectrum

Previous reports have described structural airway abnormalities in children with non-cystic fibrosis chronic supportive lung disease as well as obliterative membranes in the major bronchi of cystic fibrosis patients. The putative paradigm proposed in the evolution of these membranes invokes intense inflammation resulting in granulation tissue and neovascularization with the formation of pyogenic granuloma and eventually fibrosis. Our series of four cases widens the spectrum of conditions that may be conducive to large airway obliteration to include non-suppurative chronic infections and possibly immunosuppression. Obliteration of lumina in proximal and distal airways was visualized on bronchoscopy, the latter by the use of the ultrathin bronchoscopes. An attempt at invasive intervention by transbronchial breaching of the obstruction was unsuccessful in three cases, and in one case, the obliterative process resolved spontaneously and without any radiologic trace, presumably by resorption or rupture or through development of collateral ventilation. This series highlights the use of bronchoscopy for diagnosis and occasionally for therapeutic intervention in hitherto little recognized obliterative airway lesions. These acquired obliterative lesions should be considered in the evaluation of patients with isolated non-resolving pulmonary infiltrates or other conditions in which bronchial and bronchiolar patency may be impaired. Pediatr Pulmonol. 2014; 49:E27–E34. © 2013 Wiley Periodicals, Inc.

Computed tomography lymphography by transbronchial injection of iopamidol to identify sentinel nodes in preoperative patients with non–small cell lung cancer: A pilot study

The objective of the present study was to assess the safety and feasibility of computed tomography lymphography by transbronchial injection of a water-soluble extracellular computed tomography contrast agent. From April 2010 to May 2011, patients with clinical stage I non-small cell lung cancer who were candidates for lobectomy were enrolled in the present study. An ultrathin bronchoscope was inserted to the target bronchus under the guidance of virtual bronchoscopic navigation images. Computed tomography images of the chest were obtained 0.5 and 5 minutes after 2 or 3 mL of iopamidol was injected through a microcatheter. Sentinel nodes were identified when the maximum computed tomography attenuation value of the lymph nodes on the postcontrast computed tomography images increased by 30 Hounsfield units or more compared with the precontrast images. Patients underwent lobectomy with standard lymph node dissection. The ultrathin bronchoscope could access the targeted bronchus, and iopamidol was delivered into the peritumoral area in all 13 patients without any complications. Sentinel nodes were identified in 12 (92.3%) of the 13 patients. The average number of sentinel nodes was 1.5 (range, 1-2). Pathologic examination revealed metastatic lymph nodes in 2 patients. Metastatic nodes were included with the sentinel nodes. Computed tomography lymphography by transbronchial injection of iopamidol was a safe and feasible method to identify the sentinel nodes in patients with clinical stage I non-small cell lung cancer.

Anesthetic management of a neonate with congenital laryngeal cyst

Anesthetic management of a neonate with congenital laryngeal cyst

Update on Interventional Bronchoscopy for the Thoracic Radiologist

Interventional bronchoscopy, together with other domains of interventional pulmonology, has experienced tremendous technological advances. Diagnostic applications include endobronchial ultrasound, which enables endoscopists to see through airway walls. White light videobronchoscopy, autofluorescence imaging, and narrow band imaging have enhanced the ability to detect early lung cancer at a preinvasive stage. Electromagnetic navigational bronchoscopy, ultrathin bronchoscopy, and virtual bronchoscopy increase the diagnostic yield of biopsy of small peripheral lung lesions. The options that are currently available for the relief of central airway obstruction are also numerous, with both flexible and rigid bronchoscopic applications. Stents, although dichotomized to silicone and metal, come in various sizes and shapes to suit the requirements of the pathology being treated. Ablative techniques are categorized into those with an immediate effect and those with a delayed effect. Laser, electrocautery, and argon plasma coagulation can immediately relieve obstruction and control hemoptysis, whereas cryosurgery, brachytherapy, and photodynamic therapy have established roles in subacute airway obstruction and in the treatment of early lung cancer. Microdebriders have recently been added to the armamentarium of modalities for mechanical debulking of tumor. Distal airway obstruction has also been targeted with bronchial thermoplasty treatment of refractory asthma and with bronchoscopic lung volume reduction for the management of severe emphysema. This array of new technology has fostered collaborative work with a wide range of other medical specialties to deliver safer, more effective, minimally invasive treatment.

CT-guided Ultrathin Bronchoscopy: Bioptic Approach and Factors in Predicting Diagnosis

The diagnostic sensitivity of current bronchoscopy for peripheral lung cancer is inadequate because the bronchoscope insertion range is limited and confirmation of the position of the biopsy apparatus at the lesion under X-ray fluoroscopy is inaccurate. The combination of ultrathin bronchoscopy and computed tomography (CT) is effective for solving these problems. This study was a retrospective study analyzing prospectively collected data to identify factors contributing to the diagnosis and the appropriate biopsy method in CT-guided ultrathin bronchoscopy for peripheral lung cancer. The subjects comprised 86 patients (88 lesions) who underwent CT-guided ultrathin bronchoscopy and were finally diagnosed with peripheral lung cancer. We evaluated the diagnostic yield according to specific factors and also according to the sample collection method. Sixty-nine lesions were diagnosed as lung cancer, and the diagnostic yield was 78.4% (80.3% in lesions ≤2 cm in diameter). Multivariate analysis showed that the factors contributing to the diagnosis were the observation range by ultrathin bronchoscopy and the presence/absence of the involved bronchus or pulmonary artery. Pathological evaluation facilitated histological diagnoses in 53 (65.4%) of 81 lesions. In 16 lesions, only the cytological diagnosis was positive. CT-guided ultrathin bronchoscopy may be particularly useful for lesions for which the involved bronchus or pulmonary artery can be confirmed, and observation of bronchi of the 6th generation or more is possible. Since the specimen preparation rate is low, the combination of histopathological diagnosis with cytological diagnosis particularly that of the discharge attached to the forceps, is optimal.

Self-Expanding Metallic Stent Placement with Laryngeal Mask in Lung Transplant Recipients

Background Bronchial stent insertion is a suitable method to treat airway complications. We present our experience with laryngeal mask airway (LMA) for stent insertion in lung transplant (LT) recipients. Methods From April 2007 to March 2009, 27 LT recipients underwent insertion of self-expanding nitinol stents to manage airway complications after LT, using LMA for general anesthesia. All procedures were performed with flexible fiberoptic bronchoscopy without fluoroscopy; stent release was visualized with ultrathin bronchoscopes. We followed technical success, safety, improvement of lung function, and clinical symptoms. Results Forty-one stents were inserted in 27 patients in 32 sessions. The indications for stent insertion were necrotic Iesions (7%) and obstructive lesions (90%). Technical success and safety were 94%. Twice, the stent dislocated, requiring replacements. In 91% of patients, postinterventional improvement in graft function (1 minute forced expiratory volume) was >10% after the intervention. Improvement of clinical symptoms was achieved in 94%. The median procedure time was 38 minutes (range, 30–85 minutes). Conclusions LMA offerred an excellent condition for stent insertion in LT recipients with airway complications. It provided adequate ventilation and safe airway control during the procedure. This technique may serve as alternative to established techniques using fluoroscopy and rigid bronchoscopy.

Ultrathin Bronchoscopy and Contrast Bronchography in the Diagnosis of a Peripheral Cavitary Lesion in a Patient With Wegener Granulomatosis

Ultrathin Bronchoscopy and Contrast Bronchography in the Diagnosis of a Peripheral Cavitary Lesion in a Patient With Wegener Granulomatosis

A New Technique for the Examination of Tracheal Tumors

Flexible bronchoscopy is useful for confirming an endotracheal tumor. However, observation of the distal end of the tumor is difficult because of the presence of the lesion itself. Here we describe a technique that we termed "bronchoscopic turned around procedure," which can be used to observe the distal extent of the lesion using an ultrathin bronchoscope. The scope is passed distal to the endotracheal tumor and is flexed upward by 180 degrees in the trachea for full visualization of the distal extent of the lesion and the airway anatomy. We found this procedure to be an effective technique to assess surgical candidates by confirming the surface structure of the tracheal lumen, which cannot be obtained by computed tomography or virtual bronchoscopy.

Virtual Bronchoscopic Navigation in the Diagnosis of Peripheral Pulmonary Lesions with, an Ultrathin Bronchoscope

Virtual Bronchoscopic Navigation in the Diagnosis of Peripheral Pulmonary Lesions with, an Ultrathin Bronchoscope

A Feasibility and Efficacy Study on Bronchoscopy With a Virtual Navigation System

The purpose of this study was to evaluate the diagnostic accuracy of bronchoscopy with virtual bronchoscopy (VB) navigation. Forty-two consecutive patients with ≤30-mm diameter peripheral pulmonary shadows or lesions that were difficult or impossible to identify on plain x-rays regardless of size were selected. Before bronchoscopy, multidetector computed tomography was performed, and VB images were created. Then, ultrathin bronchoscopy was carried out with VB navigation followed by conventional 4-mm diameter bronchoscopy. Thirty-seven patients were finally enrolled. There were 12 re-examination cases in which earlier conventional bronchoscopy was nondiagnostic. Diagnosis was established in 28 patients (25 malignant and 3 benign lesions), with the diagnostic yield of 75.7% (sensitivity 86.2%, specificity 62.5%, positive predictive value 89.3%, negative predictive value 55.6%, and accuracy 81.1%). The diagnostic yield for lesions of diameter ≤20 mm, 21 to 30 mm, and ≥31 mm were 76.9%, 76.5%, and 71.4%, respectively, for all patients, and 90%, 84.6%, and 83.3%, respectively, for malignant cases. The diagnostic yield in patients who underwent re-examinations was 83.3% for all cases and 88.9% for malignant cases. Three patients had completely invisible shadows on x-ray fluoroscopy and all of these cases were diagnosed on bronchoscopy. No statistically significant difference was observed between the diagnostic yield for the different sizes, pathology, and number of bronchoscopies required. Bronchoscopy with VB navigation yielded high accuracy even for small peripheral pulmonary nodules and shadows that were difficult or impossible to identify on plain x-rays, even for patients in whom earlier conventional bronchoscopy was nondiagnostic.

Virtual bronchoscopy-guided transbronchial biopsy for aiding the diagnosis of peripheral lung cancer

Objective The aim of this study was to evaluate the clinical value of virtual bronchoscopy (VB) in aiding diagnosis of peripheral lung cancer by transbronchial biopsy (TBB). In addition, we sought to systematically analyze the factors that affect the diagnostic sensitivity of VB-guided TBB for the evaluation of peripheral lung cancers. Materials and methods A hundred and twenty-two peripheral lung cancers from 122 patients (82 men and 40 women, 38–84 years; median 68.5 years) who were performed VB-guided TBB were evaluated retrospectively. VB was reconstructed from 1- or 0.5-mm slice thickness images of multi-detector CT (MDCT). Experienced pulmonologists inserted the conventional and ultrathin bronchoscopes into the target bronchus under direct vision following the VB image. Results A definitive diagnosis was established by VB-guided TBB in 96 lesions (79%). The diagnostic sensitivity of small pulmonary lesions ≤30 mm in maximal diameter (71%) was significantly lower than that of lesions >30 mm (91%, p = 0.008). For small pulmonary lesions ≤30 mm ( n = 76), internal opacity of the lesion was the independent predictor of diagnostic sensitivity by VB-guided TBB, and the non-solid type lung cancers were significantly lower than the solid type and part-solid type lung cancers for diagnostic sensitivity (odds ratio = 0.161; 95% confidence interval = 0.033–0.780; p = 0.023). Conclusion Use of an ultrathin bronchoscope and simulation with VB reconstructed by high quality MDCT images is thought to improve pathological diagnosis of peripheral lung cancers, especially for solid and partly solid types. For small pulmonary lesions ≤30 mm, the lesion internal opacity is a significant factor for predicting the diagnostic sensitivity, and the sensitivity was low for small non-solid type of lung cancers.