Virtual Bronchoscopy Research Articles

A New Approach to Manual CT Scan Reading for Planning the Pathway to Peripheral Pulmonary Lesions.

Accurate navigation to peripheral pulmonary lesions through bronchoscopy is crucial for lung cancer diagnosis. Manual pathway planning using CT scans can be effective but is often hindered by a steep learning curve and cognitive complexity. Simplifying this process could make manual planning more accessible and reliable, especially when other systems like virtual bronchoscopy (VB) are unavailable or have limitations.In this study, we aimed to evaluate the effectiveness of a simplified manual planning method using multiplanar reconstruction (MPR) compared with VB system for pathway planning to peripheral pulmonary lesions. A retrospective study of 51 CT scans from patients undergoing r-EBUS-guided bronchoscopy was conducted. Pathway planning was performed using VB system (Archimedes) and a simplified manual method leveraging MPR performed by 3 different operators. Concordance between methods and planning times were compared. Pathway concordance was 78.5% (40/51 cases). The manual method identified additional bifurcations missed by VB in 7 cases and succeeded where VB failed in 3 cases. Mean planning times were 00:45±00:12 for VB and 01:30±00:44 for the manual method (P<0.0001). The simplified manual planning method demonstrated a high level of concordance with VB systems, while offering unique advantages in identifying additional bifurcations and resolving cases where VB systems were unsuccessful. Although the manual method required longer planning times, its cost-effectiveness and accessibility highlight its potential as a valuable alternative, particularly in resource-limited settings or as a tool to enhance bronchoscopists' spatial awareness and procedural confidence.

Assessment of navigation bronchoscopy with rapid on-site evaluation technique in detection of peripheral lung lesions

Background Diagnosing peripheral pulmonary lesions (PPLs) poses significant challenges due to their often-inaccessible location beyond conventional bronchoscopy reach. The integration of virtual navigation bronchoscopy (VBN) with rapid on-site evaluation (ROSE) provides a promising approach to enhance diagnostic accuracy through precise lesion localization. Patients and methods This prospective cohort study was conducted at Ain Shams University Hospitals from January 2022 to January 2024, involving patients with undiagnosed PPLs undergoing VBN with ROSE. Lesions were accessed with thin or adult bronchoscopes, utilizing forceps, cryoprobes, or both for biopsies, guided by C-arm fluoroscopy as needed. Immediate cytopathological feedback was provided by ROSE, with final diagnoses confirmed through histopathology, microbiology, or clinical follow-up. Results Of the 50 patients initially enrolled, 23 were included after excluding those with incidental endobronchial lesions. The cohort’s mean age was 56.8 years, with an average lesion size of 2.5 cm and 52.2% located in the upper lobe. Biopsies were performed using both forceps and cryoprobe in 56% of cases, and C-arm fluoroscopy was employed in 47.8% of cases. The overall diagnostic yield was 78.3%, with 60.9% of cases identified as malignant. ROSE exhibited a sensitivity of 94.4% and a specificity of 100%, demonstrating significant agreement (kappa=0.881) with final pathological results. The mean procedure duration was 43.9 min, with minimal complications, including mild bleeding in 8.7% of cases. Conclusion The findings underscore the effectiveness of VBN combined with ROSE in diagnosing PPLs, offering a reliable and safer alternative to conventional methods in challenging scenarios.

BronchoGAN: anatomically consistent and domain-agnostic image-to-image translation for video bronchoscopy.

Purpose The limited availability of bronchoscopy images makes image synthesis particularly interesting for training deep learning models. Robust image translation across different domains-virtual bronchoscopy, phantom as well as in vivo and ex vivo image data-is pivotal for clinical applications. Methods This paper proposes BronchoGAN introducing anatomical constraints for image-to-image translation being integrated into a conditional GAN. In particular, we force bronchial orifices to match across input and output images. We further propose to use foundation model-generated depth images as intermediate representation ensuring robustness across a variety of input domains establishing models with substantially less reliance on individual training datasets. Moreover, our intermediate depth image representation allows to easily construct paired image data for training. Results Our experiments showed that input images from different domains (e.g., virtual bronchoscopy, phantoms) can be successfully translated to images mimicking realistic human airway appearance. We demonstrated that anatomical settings (i.e., bronchial orifices) can be robustly preserved with our approach which is shown qualitatively and quantitatively by means of improved FID, SSIM and dice coefficients scores. Our anatomical constraints enabled an improvement in the Dice coefficient of up to 0.43 for synthetic images. Conclusion Through foundation models for intermediate depth representations and bronchial orifice segmentation integrated as anatomical constraints into conditional GANs, we are able to robustly translate images from different bronchoscopy input domains. BronchoGAN allows to incorporate public CT scan data (virtual bronchoscopy) in order to generate large-scale bronchoscopy image datasets with realistic appearance. BronchoGAN enables to bridge the gap of missing public bronchoscopy images.

A review of the effectiveness of virtual bronchoscopy in biopsy of lung tumors. Evolution of lung tumor diagnosis

Lung cancer remains the leading cause of cancer-related mortality, emphasizing the need for advanced diagnostic methods. This study reviews modern bronchoscopy navigational techniques, focusing on Virtual Bronchoscopic Navigation (VBN) and Electromagnetic Navigation Bronchoscopy (ENB), assessing their efficacy and safety in biopsying pulmonary lesions. Based on literature from 2000 to 2023, VBN demonstrated superior diagnostic accuracy for smaller nodules, with success rates of 93% vs 89% for ENB, while both methods exhibited low complication rates. Despite higher upfront costs, these technologies may offer long-term savings due to improved outcomes. Further research is warranted to optimize lung cancer diagnostics and enhance patient care. Aim of the study This study aims to evaluate the effectiveness and safety of VBN and ENB in diagnosing lung nodules. By comparing diagnostic success rates, complication rates, procedure durations, and cost-effectiveness, we seek to identify the safer and more efficient technique for biopsying neoplastic lesions, ultimately improving patient outcomes. Materials and methods We searched the following databases: PubMed, Web of Science, clinical trial registry platforms, using key terms such as virtual bronchoscopy navigation, navigation system-guided biopsy, bronchoscopic lung biopsy. The results were limited to papers published between 2000 - 2023. Conclusion Navigational bronchoscopy techniques like VBN and ENB are safe and effective, with minimal adverse events and no hospitalization needed. They reduce procedure times and patient burden, offering long-term cost-effectiveness despite higher initial costs. Further research is necessary to enhance these technologies for better lung cancer diagnostics. Key words: lung biopsy, bronchoscopy navigation, lung cancer, bronchoscopic

Effectiveness of CT Navigation in the Diagnosis of Peripheral Pulmonary Lesions

The objective: to evaluate the diagnostic effectiveness of computed tomographic navigation (CTn), bronchoscopic navigation (BN) in transbronchial biopsy (TBB) of peripheral lesions in the lungs.Subjects and Methods. An analysis of CT navigation data during bronchoscopy (BS) of 201 patients (Ctn Group) with peripheral lung formations (area of interest) was carried out. The advancement of bronchoscope to the area of interest during bronchoscopy was performed under CT navigation with VBN playing the major role. Comparison was made to the group (CG) of 195 patients in whom no CT navigation was used.Results. The overall bronchoscopy effectiveness using CT navigation and bronchoscopic navigation was statistically significantly higher versus the cases when they were not used, 95/201 (47.2%) vs. 65/195 (33.3%), χ² =7.98; p&lt;0.01. Bronchoscopy effectiveness in the CTn and CG Groups differed significantly for lesion in the lung measuring &gt;1 to ≤2 cm (46.9% vs. 28.2%; pz=0.008) and lesions ≤1 cm (28.0% vs. 12.9%; pz=0.048). For large lesion &gt;2 to ≤3 cm, the differences did not reach statistical significance. There were significant differences in bronchoscopy effectiveness between the CTn and CG Groups when lesions were localized in the middle (61.2% vs. 35.8%; pz=0.008) and peripheral (32.0% vs. 22.2%; pz=0.048) zones of the lung. With lesions located in the central part and at its boundaries, the differences between the groups were not significant. When CT navigation and virtual bronchoscopy were used, the presence of connection to the bronchus significantly increased the likelihood of successful bronchoscopy (OR=6.35; 95% CI 3.43-11.78) than in the absence of one.

Clinical Applicability of Three-Dimensional Holographic Virtual Bronchoscopy with Mixed Reality.

Clinical Applicability of Three-Dimensional Holographic Virtual Bronchoscopy with Mixed Reality.

Two-phase radial endobronchial ultrasound bronchoscopy registration.

Lung cancer remains the leading cause of cancer death. This has brought about a critical need for managing peripheral regions of interest (ROIs) in the lungs, be it for cancer diagnosis, staging, or treatment. The state-of-the-art approach for assessing peripheral ROIs involves bronchoscopy. To perform the procedure, the physician first navigates the bronchoscope to a preplanned airway, aided by an assisted bronchoscopy system. They then confirm an ROI's specific location and perform the requisite clinical task. Many ROIs, however, are extraluminal and invisible to the bronchoscope's field of view. For such ROIs, current practice dictates using a supplemental imaging method, such as fluoroscopy, cone-beam computed tomography (CT), or radial endobronchial ultrasound (R-EBUS), to gather additional ROI location information. Unfortunately, fluoroscopy and cone-beam CT require substantial radiation and lengthen procedure time. As an alternative, R-EBUS is a safer real-time option involving no radiation. Regrettably, existing assisted bronchoscopy systems offer no guidance for R-EBUS confirmation, forcing the physician to resort to an unguided guess-and-check approach for R-EBUS probe placement-an approach that can produce R-EBUS placement errors exceeding 30deg, an error that can result in missing many ROIs. Thus, because of physician skill variations, biopsy success rates using R-EBUS for ROI confirmation have varied greatly from 31% to 80%. This situation obliges the physician to turn to a radiation-based modality to gather sufficient information for ROI confirmation. We propose a two-phase registration method that provides guidance for R-EBUS probe placement. After the physician navigates the bronchoscope to the airway near a target ROI, the two-phase registration method begins by registering a virtual bronchoscope to the real bronchoscope. A virtual 3D R-EBUS probe model is then registered to the real R-EBUS probe shape depicted in the bronchoscopic video using an iterative region-based alignment method drawing on a level-set-based optimization. This synchronizes the guidance system to the target ROI site. The physician can now perform the R-EBUS scan to confirm the ROI. We validated the method's efficacy for localizing extraluminal ROIs with a series of three studies. First, for a controlled phantom study, we observed that the mean accumulated position and direction errors (accounting for both registration phases) were 1.94mm and 3.74deg (equivalent to 1.30mm position error for a 20mm biopsy needle), respectively. Next, for a live animal study, these errors were 2.81mm and 4.79deg (2.41mm biopsy needle error), respectively. For 100% of the ROIs considered in these two studies, the method enabled visualization of an ROI via R-EBUS in under 3min per ROI. Finally, initial operating-room tests on lung cancer patients indicated the method's efficacy, functionality, efficiency, and safety under standard clinical conditions. The method offers a quick, low-cost, radiation-free approach for examining peripheral extraluminal ROIs using R-EBUS. Although our studies focused on R-EBUS as the supplemental working channel instrument, the proposed method has general applicability to any clinical bronchoscopic task requiring a working channel instrument. Thus, the method has the potential to improve the efficiency and efficacy of bronchoscopic procedures for lung cancer patients.

Plastic Bronchitis in a Case of Recurrent Wheezer

Abstract Plastic bronchitis (PB) is a rare disease characterized by partial or complete obstruction of the trachea or bronchi caused by endogenous tree-like mucus cast. It can lead to atelectasis or consolidation of the lung segment with symptoms of cough and dyspnea. A 23-month-old child was referred to us because of recurrent fever, cough, and breathing difficulty with suspicion of soft tissue mass on virtual bronchoscopy. He had past three episodes of hospitalization before presenting to us. Flexible video bronchoscopy aspirated a thick bronchial cast and the bronchoalveolar lavage sample was positive for Klebsiella pneumoniae. The patient was discharged without any recurrence of respiratory symptoms in follow-up.

Aspiration of an unusual Foreign Body: A case report.

Foreign body aspiration is an important cause of death in children, having a spectrum of presentations. Date seed aspiration is an unusual event and here we present a case of a 4-year-old child who was referred to our hospital after aspirating a date seed. 12 days prior to referral, the child aspirated the seed and had breathing difficulty and cough. The parents took the child to a hospital for examination and CT Virtual Bronchoscopy was done revealing FB in the right main bronchus at which point the child was referred to our hospital where bronchoscopy was done and the child recovered without any complication.

Advantages and rational application of indocyanine green fluorescence in pulmonary nodule surgery: a narrative review.

The early detection and early treatment of high-risk pulmonary nodules directly affect the long-term survival rate of patients. However, conventional nodule localization methods, such as hook-wire, technetium-99m, and methylene blue are associated with issues such as a high-frequency of complications, low patient tolerance, serious side effects, and inability to identify pigmented lungs. For patients who require segmentectomy, there is often a lack of effective path planning, resulting in insufficient resection margins or excessive loss of lung function. Therefore, effective and rational nodule localization and surgical approaches are crucial. This narrative review aimed to evaluate the advantages of indocyanine green (ICG) fluorescence in pulmonary nodule surgery and clarify its application in various types of patients. We searched the PubMed and Web of Science databases from January 2010 to January 2024 using the terms "localization of pulmonary nodules", "localization of pulmonary nodules AND indocyanine green", "localization of pulmonary nodules AND complication", "localization of pulmonary nodules AND surgical planning", and "localization of pulmonary nodules AND underlying lung disease". Information used to write this narrative review was from clinical phenomena, statistical data, and authors' conclusions. The commonly used localization methods of pulmonary nodule such as computed tomography (CT)-guided percutaneous placement of hook-wire are accompanied with serious complications: including hemopneumothorax and ache. Meanwhile, routine dye commonly fails to localize the nodules in patients with anthracosis. ICG with the enhanced permeability and retention (EPR) effect can be used effectively for preoperative and intraoperative localization of pulmonary nodules and its nature of allowing the observance of the condition of pulmonary blood vessels has gradually become a hotspot of research in this field. For nodules with a depth of less than 1 cm, no penetration depth problem is encountered when ICG fluorescence is used. Percutaneous puncture can effectively identify the location of nodules at low cost. Compared with other localization methods, it can effectively avoid problems such as pain, radiation exposure, marker displacement, and the existence of anthrax lesions in the lungs. For patients on whom it is difficult to locate nodules due to tissue results, virtual bronchoscopy or electromagnetic navigation bronchoscopy can effectively identify nodules and reduce complications such as pneumothorax. For patients whose operation is postponed due to fever, sudden cardiovascular and cerebrovascular diseases, there is no risk of nodule localization material detachment by using ICG. ICG can also be used in patients with pulmonary physiological or pathological diseases. Meanwhile, in patients with deep pulmonary nodules, ICG fluorescence can help plan the surgical path, ensure the margin of resection, reduce lung function damage, and prevent bronchial fistula. Therefore, the rational use of ICG fluorescence technology can effectively locate nodules, assist surgeons in planning surgical methods, potentially reducing complications and ultimately improving patient prognosis.

Diagnostic Value and Safety of Addition of Transbronchial Needle Aspiration to Transbronchial Biopsy Through Endobronchial Ultrasonography Using a Guide Sheath Under Virtual Bronchoscopic Navigation for the Diagnosis of Peripheral Pulmonary Lesions.

The diagnostic yield of peripheral pulmonary lesions (PPLs) through endobronchial ultrasonography with a guide sheath transbronchial biopsy (EBUS-GS TBB) under virtual bronchoscopic navigation is unsatisfactory because radial EBUS probe is not always located within the lesion. Transbronchial needle aspiration with a guide sheath (GS-TBNA) has the potential to overcome the lower diagnostic yield by improving the relationship between the probe and the lesion and enabling repeated sampling while maintaining the location of a GS near the lesion. However, there are few data regarding the diagnostic yield and safety for diagnosing PPLs in this procedure. We retrospectively analyzed consecutive 363 lesions (83 lesions underwent GS-TBNA/EBUS-GS TBB and 280 lesions underwent EBUS-GS TBB) at our institution between April 1, 2019 and March 31, 2022. We investigated the diagnostic efficacy and complications of GS-TBNA/EBUS-GS TBB and compared them with those of EBUS-GS TBB. The lesion size, distance from the hilum, presence of bronchus leading to the lesion, and EBUS images during the examination differed significantly between the two procedures. Logistic regression analysis adjusted for these 4 covariates revealed that GS-TBNA/EBUS-GS TBB was a significant factor affecting the diagnostic success of PPLs compared with EBUS-GS TBB (odds ratio=2.43, 95% CI=1.16-5.07, P=0.018). Neither procedure differed significantly in terms of complications (6.0% vs. 5.7%, P>0.999). GS-TBNA performed in addition to EBUS-GS TBB might be a promising sampling method for improving the diagnostic yield for PPLs without increasing the incidence of complications.

Bronchoscopy-Guided High-Power Microwave Ablation in an in vivo Porcine Lung Model

Introduction: Percutaneous microwave ablation (MWA) is clinically accepted for the treatment of lung tumors and oligometastatic disease. Bronchoscopic MWA is under development and evaluation in the clinical setting. We previously reported on the development of a bronchoscopy-guided MWA system integrated with clinical virtual bronchoscopy and navigation and demonstrated the feasibility of transbronchial MWA, using a maximum power of 60 W at the catheter input. Here, we assessed the performance of bronchoscopy-guided MWA with an improved catheter (maximum power handling of up to 120 W) in normal porcine lung in vivo (as in the previous study). Methods: A total of 8 bronchoscopy-guided MWA were performed (n = 2 pigs; 4 ablations per pig) with power levels of 90 W and 120 W applied for 5 and 10 min, respectively. Virtual bronchoscopy planning and navigation guided transbronchial or endobronchial positioning of the MWA applicator for ablation of lung parenchyma. Following completion of ablations and post-procedure CT imaging, the lungs were harvested and sectioned for gross and histopathologic ablation analysis. Results: Bronchoscopy-guided MWA with applied energy levels of 90 W/5 min and 120 W/10 min yielded ablation zones with short-axis diameters in the range of 20–28 mm (56–116% increase) as compared to ∼13 mm from our previous study (60 W/10 min). Histology of higher-power and previous lower-power ablations was consistent, including a central necrotic zone, a thermal fixation zone with intact tissue architecture, and a hemorrhagic periphery. Catheter positioning and its confirmation via intra-procedural 3D imaging (e.g., cone-beam CT) proved to be critical for ablation consistency. Conclusion: Bronchoscopy-guided MWA with an improved catheter designed for maximum power 120 W yields large ablations in normal porcine lung in vivo.

Diagnostic yield and safety of diagnostic techniques for pulmonary lesions: systematic review, meta-analysis and network meta-analysis.

With recent advancements in bronchoscopic procedures, data on the best modality to sample peripheral pulmonary lesions (PPLs) is lacking, especially comparing bronchoscopy with computed tomography-guided transthoracic biopsy or needle aspiration (CT-TBNA). We performed a meta-analysis, pairwise meta-analysis and network meta-analysis on studies reporting diagnostic yield and complications with the use of CT-TBNA, radial endobronchial ultrasound (rEBUS), virtual bronchoscopy (VB), electromagnetic navigation (EMN) or robot-assisted bronchoscopy (RAB) to sample PPLs. The primary outcome was diagnostic yield and the secondary outcome was complications. We estimated the relative risk ratios using a random-effects model and used the frequentist approach for the network meta-analysis. We performed extensive analysis to assess the heterogeneity including reporting bias, publication bias, subgroup and meta-regressional analysis. We assessed the quality of the studies using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) and QUADAS-Comparative (QUADAS-C). We included 363 studies. The overall pooled diagnostic yield was 78.1%, the highest with CT-TBNA (88.9%), followed by RAB (84.8%) and the least with rEBUS (72%). In the pairwise meta-analysis, only rEBUS showed inferiority to CT-TBNA. The network meta-analysis ranked CT-TBNA as likely the most effective approach followed by VB, EMN and RAB, while rEBUS was the least effective, with a low-GRADE certainty. CT-TBNA had the highest rate of complications. Although CT-TBNA is the most effective approach to sample PPLs, RAB has a comparable diagnostic yield with a lesser complication rate. Further prospective studies are needed comparing CT-TBNA and RAB.

Navigational bronchoscopy with tranbronchial cryobiopsy in differential diagnosis of peripheral pulmonary lesions

To evaluate the efficacy and safety of tranbronchial cryobiopsy (TBCB) with 1.9-mm and 1.1-mm cryoprobes in patients with peripheral pulmonary lesions (PPLs). We analyzed 34 patients (mean age 60 years) with PPLs who underwent bronchoscopy with TBCB. Mean lesion size was 31.5 mm, upper lobe localization was predominant (47% of cases). CT signs of appropriate bronchus were identified in 79% (27/34) of cases. Manual branch tracking and virtual bronchoscopy (VB) were performed pre-procedurally, and radial endobronchial ultrasonography (rEBUS) was performed during bronchoscopy for accurate positioning of PPLs. TBCB was performed using 1.9-mm (n=19) or 1.1-mm (n=15) cryoprobes without fluoroscopic guidance. Incidence and severity of bleeding and pneumothorax were evaluated in all patients. Total efficacy of TBCB was 76.5% (26/34): 78.9% (15/19) for 1.9-mm cryoprobe and 73.3% (11/15) for 1.1-mm cryoprobe (p=0.702). Efficacy depended on the presence of CT signs of bronchus (presence - 94%, absence 14.3%, p<0.001) and PPL size (94% for PPL >30 mm and 58.8% for PPL <30 mm, p=0.016). Central probe position during rEBUS was associated with 94.7% diagnostic efficacy (18/19), adjacent probe position - 72.7% (8/11) (p=0.088). Bleeding grade 3 (Nasville) occurred in 5.8% (2/34) of cases, and no pneumothorax was observed. TBCB is an effective and safe diagnostic method for PPLs.

Integrating local and distant radiation-induced lung injury: Development and validation of a predictive model for ventilation loss.

Investigations on radiation-induced lung injury (RILI) have predominantly focused on local effects, primarily those associated with radiation damage to lung parenchyma. However, recent studies from our group and others have revealed that radiation-induced damage to branching serial structures such as airways and vessels may also have a substantial impact on post-radiotherapy (RT) lung function. Furthermore, recent results from multiple functional lung avoidance RT trials, although promising, have demonstrated only modest toxicity reduction, likely because they were primarily focused on dose avoidance to lung parenchyma. These observations emphasize the critical need for predictive dose-response models that effectively incorporate both local and distant RILI effects. We develop and validate a predictive model for ventilation loss after lung RT. This model, referred to as P+A, integrates local (parenchyma [P]) and distant (central and peripheral airways [A]) radiation-induced damage, modeling partial (narrowing) and complete (collapse) obstruction of airways. In an IRB-approved prospective study, pre-RT breath-hold CTs (BHCTs) and pre- and one-year post-RT 4DCTs were acquired from lung cancer patients treated with definitive RT. Up to 13 generations of airways were automatically segmented on the BHCTs using a research virtual bronchoscopy software. Ventilation maps derived from the 4DCT scans were utilized to quantify pre- and post-RT ventilation, serving, respectively, as input data and reference standard (RS) in model validation. To predict ventilation loss solely due to parenchymal damage (referred to as P model), we used a normal tissue complication probability (NTCP) model. Our model used this NTCP-based estimate and predicted additional loss due radiation-induced partial or complete occlusion of individual airways, applying fluid dynamics principles and a refined version of our previously developed airway radiosensitivity model. Predictions of post-RT ventilation were estimated in the sublobar volumes (SLVs) connected to the terminal airways. To validate the model, we conducted a k-fold cross-validation. Model parameters were optimized as the values that provided the lowest root mean square error (RMSE) between predicted post-RT ventilation and the RS for all SLVs in the training data. The performance of the P+A and the P models was evaluated by comparing their respective post-RT ventilation values with the RS predictions. Additional evaluation using various receiver operating characteristic (ROC) metrics was also performed. We extracted a dataset of 560 SLVs from four enrolled patients. Our results demonstrated that the P+A model consistently outperformed the P model, exhibiting RMSEs that were nearly half as low across all patients (13±3 percentile for the P+A model vs. 24±3 percentile for the P model on average). Notably, the P+A model aligned closely with the RS in ventilation loss distributions per lobe, particularly in regions exposed to doses ≥13.5Gy. The ROC analysis further supported the superior performance of the P+A model compared to the P model in sensitivity (0.98vs. 0.07), accuracy (0.87vs. 0.25), and balanced predictions. These early findings indicate that airway damage is a crucial factor in RILI that should be included in dose-response modeling to enhance predictions of post-RT lung function.

Use of the Archimedes navigation system to diagnose peripheral pulmonary lesions: preliminary Italian results.

Diagnosis of peripheral pulmonary lesions (PPL) is one of the most challenging fields in early lung cancer diagnosis. Despite novel techniques and new approaches to the periphery of the lung, almost 25% of PPL remains undiagnosed. Virtual bronchoscopy navigation (VBN) potentially allows to sample PPL previously not reachable with conventional bronchoscopy. In this preliminary report, we described nine cases of PPL (in which conventional bronchoscopy did not reach the lesion) sampled with VBN, from which we obtained a diagnosis in seven out of nine cases (77.8%), consistent with other reported results in literature. More large-scale data are needed to whether VBN can increase diagnostic yield (DY) of PPL.

Experts consensus on transbronchial diagnosis, localization and treatment of peripheral pulmonary nodules guided by the augmented reality optical lung navigation

Lung cancer is the second most common malignancy with the highest mortality rate worldwide. In recent years, the rapid development of various bronchoscopic navigation techniques has provided conditions for the minimally invasive diagnosis and treatment of peripheral pulmonary nodules through the airway.Augmented reality optical lung navigation is a new technology that combined virtual bronchoscopy navigation (VBN) with augmented reality (AR) and optical navigation technology, which could assist bronchoscopist and has been widely applied in clinics. The clinical evidence certified that the navigation, has the advantages of safety and efficacy in guiding transbronchial diagnosis, localization, and treatment of pulmonary nodules. In order to standardize the clinical operation of augmented reality optical lung navigation technology and guide its application in clinical practice, Interventional Group, Society of Respiratory Diseases, Chinese Medical Association/Interventional Pulmonology Group of the Zhejiang Medical Association organized multidisciplinary experts to take the lead in formulating the Consensus of experts on transbronchial diagnosis, localization and treatment of peripheral pulmonary nodules guided by the augmented reality optical lung navigation after multiple rounds of discussion, and provided recommendation opinions and clinical guidance for the indications and contraindications, equipment and devices, perioperative treatment, operating process and complication management of peripheral pulmonary nodules applicable to augmented reality optical lung diagnosis navigation technology.

Innovations to Improve Lung Isolation Training for Thoracic Anesthesia: A Narrative Review.

A double-lumen tube or bronchial blocker positioning using flexible bronchoscopy for lung isolation and one-lung ventilation requires specific technical competencies. Training to acquire and retain such skills remains a challenge in thoracic anesthesia. Recent technological and innovative developments in the field of simulation have opened up exciting new horizons and possibilities. In this narrative review, we examine the latest development of existing training modalities while investigating, in particular, the use of emergent techniques such as virtual reality bronchoscopy simulation, virtual airway endoscopy, or the preoperative 3D printing of airways. The goal of this article is, therefore, to summarize the role of existing and future applications of training models/simulators and virtual reality simulators for training flexible bronchoscopy and lung isolation for thoracic anesthesia.

Pediatric Critical Care Fellow Perception of Learning through Virtual Reality Bronchoscopy.

Virtual reality (VR) simulators have revolutionized training in bronchoscopy, offering unrestricted availability in a low-stakes learning environment and frequent assessments represented by automatic scoring. The VR assessments can be used to monitor and support learners' progression. How trainees perceive these assessments needs to be clarified. The objective of this study was to examine what assessments learners select to document and receive feedback on and what influences their decisions. We used a sequential explanatory mixed methods strategy. All participants were pediatric critical care medicine trainees requiring competency in bronchoscopy skills. During independent simulation practice, we collected the number of learning-focused practice attempts (scores not recorded), assessment-focused practice (scores recorded and reviewed by the instructor for feedback), and the amount of time each attempt lasted. After simulation training, we conducted interviews to explore learners' perceptions of assessment. There was no significant difference in the number of attempts for each practice type. The average time per learning-focused attempt was almost three times longer than the assessment-focused attempt (mean [standard deviation] 16 ± 1 min vs. 6 ± 3 min, respectively; P < 0.05). Learners perceived documentation of their scores as high stakes and only recorded their better scores. Learners felt safer experimenting if their assessments were not recorded. During independent practice, learners took advantage of automatic assessments generated by the VR simulator to monitor their progression. However, the recording of scores from the simulation program to document learners' trajectory to a set goal was perceived as high stakes, discouraging learners from seeking supervisor feedback.

Role of Virtual Bronchoscopy in Evaluation of Suspected Foreign Body in Children's Tracheobronchial Tree.

Introduction The presence of foreign bodies in the airways remain a diagnostic challenge to healthcare professionals. They can become life threatening emergencies that require immediate intervention or go unnoticed for weeks and even months. Prevention is best but early recognition remains a critical factor in treatment of foreign body inhalation in children. Objective To study the diagnostic advantages of virtual over rigid bronchoscopy in the evaluation of children with suspected foreign body in the tracheobronchial tree and plan for early management. Methods A crossectional study conducted at a tertiary care hospital & medical college in India. A total 24 patients (0-12-years-old) who presented with complaints of sudden onset of coughing, choking, and breathing difficulty were included during the 2-year duration, from January 2018 to December 2019. All patients underwent virtual and rigid bronchoscopy. Results In 8 patients, foreign bodies detected by virtual bronchoscopy were confirmed by rigid bronchoscopy. There was one case in which virtual bronchoscopy showed no foreign body, but rigid bronchoscopy detected it. In 15 cases virtual and rigid bronchoscopy did not show foreign bodies. The sensitivity, specificity, positive and negative predictive value of virtual bronchoscopy were 88.88, 100, 100, and 93.75%, respectively. Conclusions Virtual bronchoscopy is less invasive and does not require general anesthesia but cost and availability are limitations. It can be used as method of investigation in children with suspected foreign body aspiration.