advances in interventional pulmonology

1. WHAT’S NEW IN
INTERVENTIONAL
PULMONOLOGY
DR MANJUNATH B G [MD,DM(PCCM)]
Associate Professor
Dept of PCCM
PGIMS Rohtak

2. •EBUS:
•CP EBUS: Transbronchial mediastinal cryobiopsy
•Radial EBUS: Real-time radial endobronchial ultrasound
biopsy
•Electromagnetic guidance transthoracic needle aspiration
(ETTNA)
•Augmented fluoroscopy
•Cone-beam CT guided sampling
•Confocal laser endomicroscopy
•Robotic bronchoscopy

3. TRANSBRONCHIAL
MEDIASTINAL CRYOBIOPSY
IN THE DIAGNOSIS OF
MEDIASTINAL LESIONS
Zhang J, Guo J-R, Huang Z-S, et al. Transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal
lesions: a randomised trial. Eur Respir J 2021; 58: 2100055 [DOI: 10.1183/ 13993003.00055-2021].
A small incision in the tracheobronchial wall adjacent to the
mediastinal lesion using a high-frequency electrosurgical knife
Knife replaced by the cryoprobe (1.1mm), & introduced into the lesion
Cooled( for 7 s), and then retracted with the bronchoscope and the
frozen biopsy tissue
post-procedural chest radiography and follow up for potential adverse
events for 4 weeks after biopsy

5. Zhang J, Guo J-R, Huang Z-S, et al. Transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal
lesions: a randomised trial. Eur Respir J 2021; 58: 2100055 [DOI: 10.1183/ 13993003.00055-2021].

6. Zhang J, Guo J-R, Huang Z-S, et al. Transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal
lesions: a randomised trial. Eur Respir J 2021; 58: 2100055 [DOI: 10.1183/ 13993003.00055-2021].

7. Zhang J, Guo J-R, Huang Z-S, et al. Transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal
lesions: a randomised trial. Eur Respir J 2021; 58: 2100055 [DOI: 10.1183/ 13993003.00055-2021].

8. REAL-TIME RADIAL ENDOBRONCHIAL
ULTRASOUND BIOPSY
The RT-EBUS-TBNA system-
Integrating r-EBUS and biopsy
needle into a single device:
• Specially constructed, flexible
sheath with both
– radial ultrasound catheter (disposable
40-MHz, 1.1-mm ultrasound probe)
– specially engineered needle (25-gauge)
• The device has an outer diameter
of 1.9 mm
• a stroke limiter on the handle to
limit its depth to a maximum of
2.5 cm
Yarmus LB, Mallow C, Pastis N, et al. Interventional Pulmonary Outcomes Group (IPOG). First-in-Human Use of a Hybrid Real-Time
Ultrasound-Guided Fine-Needle Acquisition System for Peripheral Pulmonary Lesions: A Multicenter Pilot Study. Respiration.

9. REAL-TIME RADIAL ENDOBRONCHIAL
ULTRASOUND BIOPSY
Bronchoscope positioned adjacent to the target
The guide sheath which included the RT-EBUSTBNA
device passed through the working channel of the
bronchoscope
The Radial US probe advanced into the parenchyma under fluoro
TBNA needle then deployed under direct ultrasound visualization
concentrically placed eccentrically placed
sampling
Needle retraction and the entire
sheathed device rotated and
repositioned

10. ELECTROMAGNETIC
GUIDANCE TRANSTHORACIC
NEEDLE ASPIRATION (ETTNA)
 Pilot study examining the safety, feasibility and diagnostic yield of ETTNA, NB
and EBUS in a single procedural setting
 Included undiagnosed SPN (≥10 mm and ≤30 mm surrounded by lung
parenchyma) that were accessible by an anterior or lateral chest percutaneous
approach with a clinical indication to undergo bronchoscopy for diagnosis of a SPN
 Excluded if they PET positive mediastinal lymphadenopathy and/or mediastinal
lymphadenopathy ≥10 mm on CT imaging
 Combined ETTNA along with a CP EBUS and EMN bronchoscopy for sampling
SPN
 Included 24 patients
Yarmus LB, Arias S, Feller-Kopman D, et al. Electromagnetic navigation transthoracic needle aspiration for the diagnosis of pulmonary
nodules: a safety and feasibility pilot study. J Thorac Dis. 2016 Jan;8(1):186-94.

11. Electromagnetic guidance TTNA planning of CT scan

12. percutaneous placement of an electromagnetic tip
tracked biopsy needle introducer (19 gauges × 105 mm)
under navigational guidance

13.  The diagnostic yield for ETTNA alone was 83%
 The combined diagnostic yield of ETTNA and NB was 87%
(P=0.0016; exact 95% CI: 65%, 97%)
 The diagnostic yield increased further when combining EBUS, NB
and ETTNA in a single procedure to 92% (P=0.0001).
 NB was diagnostic in only 33% of all cases, but had a diagnostic
yield of 73% when an air bronchus sign was present on CT scan
 ETTNA was the only biopsy method that was diagnostic in nine
subjects
 NB was the only diagnostic biopsy method in one subject
 There were five (5/24, 21%) pneumothoraces, 2 required chest tube
placement.
 4/5 had diagnosis only in ETTNA

14. CONE-BEAM CT GUIDED
SAMPLING

15.  Diagnostic Accuracy**
 All lesions - 93.5%
 <10mm (n=19)- 89.5%
 < 20mm (n=65)- 90.8%
 20mm (n=27)-100%
 Negative Predictive Value
79.3% - 89.7%
 Average CBCT scans per case: 1.5
 Average effective dose of 2.0 mSv per CBCT scan
Pritchett MA, Schampaert S, de Groot JAH,et al. Cone-Beam CT With Augmented Fluoroscopy Combined With Electromagnetic
Navigation Bronchoscopy for Biopsy of Pulmonary Nodules. J Bronchology Interv Pulmonol. 2018 Oct;25(4):274-282.

16. AUGMENTED FLUOROSCOPY
 The LungVision platform (Body Vision Medical LTD, Ramat Ha Sharon, Israel)
 3-D structural map of the lungs generated from preoperative CT images paired
with real-time fluoroscopic

 Assists in identifying the nodule location and a potential pathway to the nodule
 The pathway is provided as an augmented overlay on the standard fluoroscopic
screen, guiding the endobronchial tools to the nodule in real time
Cicenia, Joseph MD*; Bhadra, et al. Augmented Fluoroscopy, Journal of Bronchology & Interventional
Pulmonology: April 2021 - Volume 28 - Issue 2 - p 116-123

17. The platform integrates with available endobronchial
modalities including bronchoscope, fluoroscope, and
radial endobronchial ultrasound (REBUS) to present an
augmented real-time pathway
Cicenia, Joseph MD*; Bhadra, et al. Augmented Fluoroscopy, Journal of Bronchology & Interventional
Pulmonology: April 2021 - Volume 28 - Issue 2 - p 116-123

18.  LungVision catheter: A modified working channel scored with radioopaque
markers used for location analytics; its distal tip is curved and used for steering
Cicenia, Joseph MD*; Bhadra, et al. Augmented Fluoroscopy, Journal of Bronchology & Interventional
Pulmonology: April 2021 - Volume 28 - Issue 2 - p 116-123

19.  Using LungVision guidance CT-to-body registration is first performed
 Once registration occurs, navigation to the targeted nodule is undertaken
according to LungVision guidance.
 This guidance consists of a fluoroscopic overlay of the airway pathway and the
target itself.
 Navigation along this pathway performed under live fluoroscopic imaging.

20. Cicenia, Joseph MD*; Bhadra, et al. Augmented Fluoroscopy, Journal of Bronchology & Interventional
Pulmonology: April 2021 - Volume 28 - Issue 2 - p 116-123

21. CONFOCAL LASER
ENDOMICROSCOPY
 A novel tool in the armamentarium.
 It allows invivo on-site histological information.
 Based on low-power blue laser light based tissue
exposure and fluorescence.
 The laser light is focused on an area of interest and back
scattered light is then refocused onto the detection
system by the lens.
 High resolution laser-based imaging technique
performed with intravenous administration of the
contrast agent fluorescein
Kramer T, Wijmans L, de Bruin M, et al. Bronchoscopic needle-based confocal laser
endomicroscopy (nCLE) as a real-time detection tool for peripheral lung cancer. Thorax.
2022 Apr;77(4):370-377.

22.  Prior to bronchoscopy, an 18G needle preloaded with
the CLE miniprobe using a locking device
 Bronchoscopic inspection of the airways to exclude
endobronchial abnormalities
 REBUS & fluoro check
 rEBUS probe removed and the needle (containing the
preloaded CLE probe) advanced
 Lesion puncture using fluoroscopic guidance
 fluorescein (2.5mL of 10% fluorescein dinatrium
solution) administered intravenously
 CLE miniprobe was advanced in a forward direction
 Based on real-time nCLE imaging, the optimal
TBNA/biopsy location identified
Kramer T, Wijmans L, de Bruin M, et al. Bronchoscopic needle-based confocal laser
endomicroscopy (nCLE) as a real-time detection tool for peripheral lung cancer. Thorax.
2022 Apr;77(4):370-377.

23. Kramer T, Wijmans L, de Bruin M, et al. Bronchoscopic needle-based confocal laser
endomicroscopy (nCLE) as a real-time detection tool for peripheral lung cancer. Thorax.

24. ROBOTIC BRONCHOSCOPY
 The system combines a robotically controlled catheter, with
direct airway visualisation
 Navigated through the airways along a virtual pathway to a
target nodule
 The robotic components allow controlled advancement of the
catheter
 Subtle directional movements in all planes at the catheter tip
 The catheter has the unique property of maintaining a single
position and angulation while not being advanced
 Sufficiently large working channel (2 mm)
 A safety and feasibility study in patients with small peripheral
lesions measuring between 1 and 3 cm showed an overall
diagnostic yield of 83%, and diagnostic yield for malignancy
was 89%
Fielding D, Bashirzadeh F, Son JH, et al. First human use of a new robotic-assisted navigation system for small peripheral
pulmonary nodules demonstrates good safety profile and high diagnostic yield. Chest 2017; 152: A858.

25.  The field of IP continues to evolve rapidly
 The basics of interventional pulmonology will always remain the same
 Novel uses of real-time fluoroscopy and cone beam computed
tomography continue to transform the approach to lung nodules
 Real-time radial endobronchial ultrasound biopsy could be the game
changer in future
 Robotic bronchoscopy and realtime imaging are emerging as potentially
useful adjuncts or alternatives in difficult-to-access, peripheral lung
lesions
 Techniques of invivo pathologic assessment may increase the accuracy
CONCLUSION