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Objective To observe whether wrist-ankle acupuncture can reduce propofol dosage in painless bronchoscopy of elderly patients or not and its potential effect mechanism. Methods A total of 60 patients undergoing painless bronchoscopy were randomized into a wrist-ankle acupuncture group and a control group, 30 cases in each one. In the wrist-ankle acupuncture group, wrist-ankle acupuncture was received and the needles were retained for 30 min before entering to the operating room. In the control group, no any intervention was provided. The patients in two groups all received venous administration of midazolam, nalorphine and lidocaine and target controlled infusion of propofol. When the patient's consciousness was lost and the eyelash reflex disappeared, bronchoscopy was performed and the propofol dosage was increased accordingly during operation. Propofol dosage, vital signs and occurrence of adverse reactions, bronchoscopist satisfaction, operation time and recovering time were recorded in the patients of two groups. Results Propofol dosage in induction period and the total dosage of propofol in the wrist-ankle acupuncture group were lower than those in the control group, indicating the statistical differences (both P Conclusion In painless bronchoscopy, wrist-ankle acupuncture may effectively reduce propofol dosage, alleviate respiratory suppression, reduce adverse reaction and shorten the recovering time in elderly patients.

During the times of the ongoing COVID pandemic, aerosol-generating procedures such as bronchoscopy have the potential of transmission of severe acute respiratory syndrome coronavirus 2 to the healthcare workers. The decision to perform bronchoscopy during the COVID pandemic should be taken judiciously. Over the years, the indications for bronchoscopy in the clinical practice have expanded. Experts at the Indian Association for Bronchology perceived the need to develop a concise statement that would assist a bronchoscopist in performing bronchoscopy during the COVID pandemic safely. The current Indian Association for Bronchology Consensus Statement provides specific guidelines including triaging, indications, bronchoscopy area, use of personal protective equipment, patient preparation, sedation and anesthesia, patient monitoring, bronchoscopy technique, sample collection and handling, bronchoscope disinfection, and environmental disinfection concerning the coronavirus disease-2019 situation. The suggestions provided herewith should be adopted in addition to the national bronchoscopy guidelines that were published recently. This statement summarizes the essential aspects to be considered for the performance of bronchoscopy in COVID pandemic, to ensure safety for both for patients and healthcare personnel.

BACKGROUND Although radial endobronchial ultrasound (rEBUS) is an important verification tool in guided bronchoscopy, a navigational route was not provided. Manual airway mapping allows the bronchoscopist to translate the bronchial branching in computed tomography (CT) into a comparable bronchoscopic road map. We aimed to explore the feasibility of this technique in navigating conventional rEBUS bronchoscopy in the localisation of peripheral pulmonary lesion by determining navigation success and diagnostic yield. METHODS Retrospective review of consecutive rEBUS bronchoscopy performed with a 6.2 mm conventional bronchoscope navigated via manual bronchial branch reading technique over 18 months. RESULTS Ninety-eight target lesions were included. Median lesion size was 2.67 cm (IQR 2.22-3.38) with 96.9% demonstrating positive CT bronchus sign. Majority (86.7%) of lesions were situated in between the third and fifth airway generations. Procedure was performed with endotracheal intubation in 43.9% and fluoroscopy in 72.4%. 98.9% of lesions were successfully navigated and verified by rEBUS following the pre-planned airway road map. Bidirectional guiding device was employed in 29.6% of cases. Clinical diagnosis was secured in 88.8% of cases, majority of which were malignant disease. The discrepancy between navigation success and diagnostic yield was 10.1%. Target PPL located within five airway generations was associated with better diagnostic yield (95.1% vs. 58.8%, P

Introduction: Endobronchial Ultrasound Guided Trans bronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic modality for evaluating intra thoracic lymph nodes, becoming one of the important tool in the armamentarium of pulmonologists. The size of the fiberscope and sharing of the airway with the bronchoscopist poses unique challenges to the anesthesiologist. In light of these developments it is important to develop an office based anesthesia technique for this relatively new procedure. Hence we did this descriptive cohort study. Aim: To describe the accuracy and anaesthetic management of EBUS-TBNA as a day care procedure, done with general anesthesia (GA). Materials and Methods: Data was collected from January 2017 to December 2017 at our institute from patients who underwent EBUS-TBNA under GA using second generation laryngeal mask airway (LMA). Specifically, hemodynamic status, Oxygen saturation, duration of the procedure, diagnostic yield and complications of the procedure were recorded. Results: 23 patients underwent EBUS-TBNA under GA. All patients were found to be hemodynamically stable with fluctuations in blood pressure and heart rate being less than 20% from the baseline with no episodes of desaturation .The average number of biopsies taken is 3.3, with average duration of the procedure being 67.0±17.6 (mean±SD) minutes. The incidence of post procedural complications like cough and sore throat were minimal. Successful diagnostic yield was found in all cases with no incidence of recall of the procedure. Conclusion: The performance of EBUS-TBNA under general anesthesia with LMA provides great hemodynamic stability and adequate ventilation in a shared airway. It demonstrates excellent diagnostic accuracy. It provides comfort to the patient and the good examination conditions to the bronchoscopist. Clinical Significance: Use of P-LMA solves the dilemma of managing ventilation during EBUS TBNA without affecting the diagnostic yield of the pr

Objective To introduce a new method to do safe bronchoscopy, a highly aerosol generating procedure through disposable COVID box in this difficult COVID time. Methods We have introduced an unbelievably cheap and effective method “DISPOSABLE COVID BOX”. We took an acrylic board 70 × 20 cm and attached 3 bars 32 cm long and slide it under the side of the patient. A similar contraption is used on the other side. Then, it is covered by a polypropylene sheet 2’ × 2’. It makes a completely disposable airtight chamber with the polypropylene sheet. We make a 1 cm nick in the sheet and introduce the video-bronchoscope, which is further navigated into the patient without any discomfort either to the patient or Bronchoscopist. When the procedure is finished, scope is withdrawn from the patient and the polypropylene sheet is squeezed out. The polypropylene sheet is removed and disposed off with all precautions, and the acrylic boards and the bars are cleaned with 1% Sodium hypochlorite solution. This way, the cost is only of polypropylene sheet which is negligible. Results Videobronchoscopies in indicated patients were done using this novel disposable covid box. This new invention called Disposable COVID box has been practiced for the first time, it's an innovative technique about which we want the world to be known. Conclusion To conclude, there are no aerosols released in atmosphere after the procedure, making it absolutely safe for bronchoscopist and at same time patient also remains safe. We are ready again in no time with fresh polypropylene sheet to do the next bronchoscopy.

BACKGROUND High-flow nasal oxygen (HFNO) has recently gained popularity during administration of anesthesia in a variety of circumstances, including apneic oxygenation. Fully qualified anesthesiologists provide sedation for our outpatient bronchoscopy service. We adopted this therapy to assess its efficacy providing optimal conditions (using a variety of sedation regimens) for patient and bronchoscopist. METHODS We aimed to conduct a prospective feasibility evaluation. We collected data from all patients undergoing outpatient bronchoscopy or endobronchial ultrasound with anesthesiologist administered sedation over 21 months. Demographic data, high-flow settings, sedation techniques, and oxygen saturations (SpO2) were collected for each patient. Feedback from the bronchoscopists and anesthesiologists was recorded. Failure of the technique was defined as abandonment of the procedure or prolonged desaturation not amenable to basic airway maneuvers or increase in oxygen flow rate. RESULTS All 182 patients underwent satisfactory bronchoscopy or endobronchial ultrasound. Mean age was 63 (±14) years. High-flow rate varied from 10 to 70 L/min. All patients received a remifentanil infusion and 175 (96%) had a propofol infusion. SpO2 before the procedure were lower (96%) than the highest saturation during the procedure with high flow (100%, P

Endobronchial ultrasound (EBUS) combined with trans-esophageal endoscopic ultrasound bronchoscope guided fine need aspirate (EUS-B FNA) of mediastinal lymph nodes is an established procedure for diagnosis. The main barrier to a combined EBUS EUS-B FNA approach is availability of trained and accredited pulmonologist who can perform procedure safely and confidently. To address this gap, we undertook a training program for experienced EBUS bronchoscopists to train, learn, and incorporate combined EBUS EUS-B FNA into their procedural practice. Thirty-two patients were selected based on CT and or PET findings. Four experienced bronchoscopists participated by reading through learning material, observing 5 cases before performing EUS-B FNA under direct supervision. Forty-one lymph nodes and 6 non-nodal lesions were sampled. EUSAT assessment was performed by supervisor. Learning curves were derived from assessment scores. We observed that learning curve tends to plateau when participant can perform 3 or more consecutive cases with EUSAT score above 50. There were no complications. Our experience suggests that there is relative ease in transition to combined EBUS EUS-B TBNA procedures for mediastinal lymphadenopathy and lung cancer diagnosis and staging for experienced bronchoscopist using a program which incorporates direct supervision, EUSAT assessment, and extension of EUS B FNA training into daily real-world practice.

Background Pneumothorax is one complication of transbronchial biopsy (TBB) using endobronchial ultrasonography with a guide sheath (EBUS-GS-TBB). We sought to clarify the risk factors for pneumothorax after EBUS-GS-TBB under fluoroscopic guidance. Methods We retrospectively reviewed data from 916 patients who underwent EBUS-GS-TBB at Fujita Health University Hospital. We evaluated the following risk factors for pneumothorax after EBUS-GS-TBB: patient characteristics (sex, age, and pulmonary comorbidities); lesion data (location, size, existence of ground-glass opacities [GGOs], pleural involvement, computed tomography [CT] bronchus sign, visibility on fluoroscopy, and EBUS findings); final diagnosis; years of bronchoscopist experience; and guide sheath size. Univariate and multivariate logistic regression analyses were performed. Results Among the 916 patients, 30 (3.28%) presented with pneumothorax. With a univariate analysis, factors that independently predisposed to pneumothorax included lesions containing GGOs, lesions in sagittal lung segments on fluoroscopy, lesions that were not visible on fluoroscopy, and infectious lesions. A univariate analysis also showed that lesions in the right upper lobe or left upper division, as well as malignant lesions, were less likely to lead to pneumothorax. Age, underlying pulmonary disease, CT bronchus sign, EBUS findings, bronchoscopist experience, and guide sheath size did not influence the incidence of pneumothorax. A multivariate analysis revealed that only lesions containing GGOs (odds ratio [OR] 6.47; 95% confidence interval [CI] 2.13–19.6, P = 0.001) and lesions in lung segments with a sagittal orientation on fluoroscopy (OR 2.47; 95% CI 1.09–5.58, P = 0.029) were significant risk factors for EBUS-GS-TBB-related pneumothorax. Conclusions EBUS-GS-TBB of lesions containing GGOs or lesions located in sagittal lung segments on fluoroscopy correlate with a higher pneumothorax risk.

Introduction and rationale: Many patients with COVID-19 admitted to the intensive care units require prolonged mechanical ventilation. Tracheostomy has been avoided due to increased risk of aerosolization especially during tracheal dilation resulting in increased risk for personnel infection. We describe our novel protocol to prevent exposure during percutaneous tracheostomy.Methods: Patients with COVID-19, on mechanical ventilation requiring prolonged mechanical ventilation were evaluated for bed-side percutaneous tracheostomy. The procedure was performed under bronchoscopic guidance and using a disposable bronchoscope. The scope was secured in position 1 cm from the end of the endotracheal tube with tape at the insertion site to allow the bronchoscopist to withdraw the ETT/bronchoscope en-bloc to the appropriate location in the trachea for adequate visualization during the procedure. Once the puncture point was identified, an expiratory pause was performed during which the trachea was punctured, a guide wire was placed, the anterior wall was dilated, and a tracheostomy was advanced and placed in the trachea. The time of the expiratory pause, any desaturation, complication and personnel conversion were measured.Results: A total of 18 percutaneous tracheostomies were performed. The total time of the expiratory pause, tracheal puncture to tracheostomy placement was thirty seconds to sixty seconds. There was no evidence of desaturation during the procedure, and there were no cases of staff conversion to positive COVID-19 status up to 14 days post procedure.Conclusions: we conclude that expiratory pause during percutaneous tracheostomy is safe, and importantly, may play significant role in decreasing aerosolization and staff exposure in patients with COVID-19 respiratory failure.

Interventional pediatric flexible bronchoscopy has many advantages over radiologic investigations in diagnosing uncommon congenital H-type tracheoesophageal fistula (TEF), dual TEF, bronchoesophageal fistula (BEF) and fistula recurrence including higher rates of identification and anatomic localization with guide wire cannulation. We compare the diagnostic utility of flexible bronchoscopy to radiologic techniques for congenital aerodigestive fistula. A single center retrospective review was completed of all cases of pediatric TEF and BEF diagnosed with flexible bronchoscopy between January 2000 and November 2020. Fistulae were diagnosed 21 times in 18 patients at a median age of 1.22 years (interquartile range: 0.50 to 2.99). The median time from diagnosis to repair was 17.5 days (interquartile range: 5.5 to 43). Symptoms commonly related to fistula were found in all patients. Uncommon fistulae included single H-type TEF (n=10, 47.6%), dual H-type TEF (n=2, 9.5%), dual proximal and distal TEF with esophageal atresia (n=5, 23.8%), TEF recurrence (n=2, 14.3%), BEF (n=1, 4.8%), and a BEF recurrence (n=1, 4.8%). Flexible bronchoscopy confirmed the diagnosis in all fistulae using a guide wire cannulation or methylene blue dye injection. A combined procedure with simultaneous bronchoscopy and esophagoscopy was used for 6 fistulae. The positive examination rate was 75% for bronchoscopy compared with 2.6% for contrast swallow studies and 28.6% for tube esophagograms. Flexible bronchoscopy should be considered as a first line investigation in uncommon aerodigestive fistulae. In the absence of a skilled bronchoscopist, the best radiologic investigation is a pull-back tube esophagogram but may still require endoscopic confirmation at the time of fistula repair.

Introduction and Objectives Electronavigational bronchoscopy (ENB) facilitates the biopsy of small peripheral lesions in the lungs, otherwise inaccessible to conventional sampling techniques. It is most commonly performed under general anaesthetic in tertiary institutions. We sought to evaluate the ability to perform ENB under conscious sedation in a district general hospital. Methods Prospective data was gathered on the first 21 patients undergoing ENB between May 2019 and June 2020 using the Medtronic SuperDimension Navigation system. Neither cone beam CT nor fluoroscopy were used during the procedure. A lead operator performed all procedures assisted by another experienced consultant bronchoscopist. Patients were followed up for a minimum of three months, except for one who declined further review. A false negative was defined by either a subsequent biopsy proven cancer, or when treatment for cancer was given based on clinical and radiological suspicion despite a negative ENB biopsy. Results 21 patients with suspected lung cancer underwent 22 day-case ENB procedures under conscious sedation with no significant complications (Table). In our case series ENB had a diagnostic yield of 76.2% (52.8% – 91.8%); sensitivity of 68.8% (95% CI 41.3% – 89.0%); a specificity of 100.0% (47.8% – 100.0%); a positive predictive value of 100.0%; and a negative predictive value of 50.0% (32.6% – 67.4%). These results are similar to the largest published trial of ENB (81.4% done under GA; 94.9% with adjuvant cone beam CT or fluoroscopy) which had diagnostic yield, sensitivity, and negative predictive value and of 72.9%, 68.8%, and 56.3% respectively. Eight patients (38.1%) had undergone a prior non-diagnostic biopsy, and all had a subsequent diagnostic ENB. In cases where a positive diagnosis was obtained the size of the target lesion (27 mm) was comparable with that of the case series as a whole (24 mm). Conclusion ENB can be performed successfully in a district general hospital using conscious sedation and without reliance on cone beam CT or fluoroscopy, with diagnostic rates comparable with larger institutions under general anaesthesia.

Rigid bronchoscopy is a diagnostic and therapeutic tool used to treat complex airways disorders. It plays a central role in the management of central airway obstruction caused by benign or malignant diseases; and requires close cooperation between the bronchoscopist and the anesthesiologist as they share the same operative field. Rigid bronchoscopy requires deep sedation or general anesthesia, intubation with the rigid bronchoscope and adequate oxygenation and ventilation during the procedure. The choice of ventilation techniques include apneic oxygenation, spontaneous assisted ventilation, controlled ventilation and jet ventilation. Rigid bronchoscopy is used to relieve respiratory symptoms due to airway obstruction by dilation for a tracheal stenosis or the mechanical debulking of endoluminal tumours, and supporting the airway by the placement of an endoluminal stent. Two types of stents are currently in use: silicone stents and metal stents with different lengths, diameters and shape configurations. They can significantly improve patients symptoms and their quality of life. Therapeutic rigid bronchoscopy, performed in appropriately selected patients and by skilled operators is effective and has a low morbidity rate.

Flexible bronchoscopy is an efficient tool for diagnosing common respiratory complaints, including noisy breathing, chronic wheezing, and chronic cough. Accurate diagnosis involves not only recognition of anatomic abnormalities but also assessment of airway dynamics under conditions that can vary from sleep to forced exhalation. Thus, accurate diagnosis requires a recognition of the conditions under which the problem exists and an understanding of how the airways behave under normal and pathologic conditions. The bronchoscopist must understand the physiology of the airways under normal and abnormal conditions, taking into account how both transmural pressure and airways resistance can affect airway cross-sectional area. Aspects of the patient’s history, including timing, persistence, triggers, and predisposing factors for the problem, can all help identify which patient requires airway evaluation and under what conditions the evaluation will be most revealing. Similarly, the physical examination is directed toward the quality and characteristics of the abnormal sound, any associated changes to voice, clinical features that could predispose toward the problem, and the impact of the problem on the patient’s breathing effort and overall growth and development. Together, a careful history and physical examination, as well as an understanding of the conditions under which the respiratory abnormality occurs in a given patient, can enhance the diagnostic yield of the bronchoscopic procedure. Additionally, an understanding of dynamic airway mechanics under passive and dynamic conditions can help the endoscopist distinguish between normal and abnormal phenomena.

Flexible bronchoscopy results in many physiological consequences. This chapter reviews the studies about these effects including lung function, hemodynamics, gas exchange, body temperature, and intracranial pressure. It also discusses the additional physiological effects of bronchoalveolar lavage, the physiological effects of anesthesia commonly used for flexible bronchoscopy, and procedural anxiety. This chapter concludes with the clinical implications of these physiological effects and formulates twelve caveats for the prudent practice of flexible bronchoscopy in children.

Foreign body aspiration is a major medical problem affecting primarily children and the elderly. It can be a life-threatening emergency and, at times, a diagnostic dilemma. The role the pediatric pulmonologist plays is multi-faceted and collaborative. At the initial presentation, the pulmonologist can assist the frontline clinicians in the clinic, urgent care, or emergency department setting with the diagnostic evaluation using physical exam, radiographic examination, and possibly confirmatory flexible bronchoscopy. Then once the foreign body is found, rigid bronchoscopy is usually the safest method for extraction, however the pulmonologist can take on an interventional role instead of just one as a diagnostician and help with the removal of foreign bodies. This role is particularly salient when the foreign body is located in a distal airway or the size and shape of the foreign body make it more amenable to extraction utilizing some of the tools that the flexible bronchoscopist has at their disposal. Following removal, the pulmonologist is vital in helping with post-operative management including the identification and treatment of complications both acutely and chronically.

Pulmonary tuberculosis (TB) is the most frequent site of TB and the one leading its spread worldwide. Multiple specimens are commonly collected for TB diagnosis including those requiring invasive procedures. This study aimed to review the sampling strategy for the microbiological diagnosis of pulmonary TB.A retrospective analysis of collected samples from September 1st 2014 to May 1st 2016 in the Bacteriology laboratory of Pitié-Salpêtrière Hospital (Paris, France) was performed. All the samples collected in patients aged over 18 years for the bacteriological diagnosis of pulmonary TB were included.A total of 6267 samples were collected in 2187 patients. One hundred and twenty-six patients (6%) had a culture confirmed pulmonary TB. Among them, multiple sputum collections were sufficient for TB diagnosis in 63.5%, gastric lavages permitted to avoid bronchoscopy in only 7.1%, and bronchoscopy was necessary in 29.4%. The culture positivity of sputa (8.6%) was higher than that of bronchial aspirations (3.1%), bronchiolo-alveolar lavages (BAL) (2.3%) or gastric lavages (4.8%) (P0.001). From its 70.0% theoretical PPV value, the 46.1% selection in bronchial aspirations allocated to molecular test increased PPV up to 88.9%.Based on our data, we suggest to collect sputum consistently. If smear negative a bronchoscopy should be performed and molecular diagnosis be performed on a subset of bronchial aspirations based on expertise of the bronchoscopist.

Screening for lung cancer has changed substantially in the past decade since The National Lung Screening Trial. The resultant increased discovery of incidental pulmonary nodules has led to a growth in the number of lesions requiring tissue diagnosis. Bronchoscopy is one main modality used to sample lesions, but peripheral lesions remain challenging for bronchoscopic biopsy. Alternatives have included transthoracic biopsy or operative biopsy, which are more invasive and have a higher morbidity than bronchoscopy. In hopes of developing less invasive diagnostic techniques, technologies have come to assist the bronchoscopist in reaching the outer edges of the lung. Navigational bronchoscopy is able to virtually map the lung and direct the biopsy needle where the scope cannot reach. Robotic bronchoscopy platforms have been developed to provide stability and smaller optics to drive deeper into the bronchial tree. While these new systems have not yet proven better outcomes, they may reduce the need for invasive procedures and be valuable armamentarium in diagnosing and treating lung nodules, especially in the periphery.

Bronchoscopic interventions are preferred for sampling suspicious pulmonary lesions as they have lower complications and can achieve diagnosis and staging in one single procedure. Limitations in existing guided bronchoscopy platforms has led to developments in robotic assisted technologies. These devices may allow the bronchoscopist to more precisely maneuver the scope and instruments into the periphery of the lungs under direct visualization while also ensuring stability during sampling of the target lesions. These devices have the potential to improve the diagnostic yield in sampling peripheral lung lesions and may play a role in the treatment of non-operable or oligometastatic peripheral tumors using bronchoscopic ablative therapies. In this article, we review the existing robotic bronchoscopy technologies and summarize the available pre-clinical and clinical data supporting their use.

BACKGROUND Diagnostic and interventional flexible bronchoscopy (FB) is increasingly utilized in complex and high-risk patients. Patients are often sedated for comfort and procedure facilitation and hypoxia is commonly observed in this setting. We hypothesized that high-flow nasal oxygen (HFNO) would reduce the incidence of patients experiencing oxygen desaturation. METHODS In this randomized controlled trial, postlung transplant patients booked for FB with transbronchial lung biopsy were assigned to either HFNO or low-flow nasal oxygen (LFNO). The patient and bronchoscopist were blinded to group allocation. The primary endpoint was the proportion of patients experiencing mild desaturation [peripheral oxygen saturation (SpO2)

Background Interventional bronchoscopy for hypoxemic patients with central airway obstruction (CAO) is typically performed under general anesthesia. This approach poses remarkable challenge for both bronchoscopist and anesthesiologist. Noninvasive ventilation (NIV) during flexible bronchoscopy (FB) has been successfully used in hypoxemic patients, but rarely in the treatment of hypoxemic patients with CAO. Objective To evaluate the feasibility of therapeutic FB assisted with NIV for therapy of hypoxemic patients with CAO. Method Twenty-nine hypoxemic CAO patients treated with FB from December 2010 to May 2016 in our hospital were retrospectively reviewed, either aided with NIV under sedation (NIV group ) or through artificial airway under general anesthesia (control group). Interventional procedures included balloon dilation, electrocautery and argon plasma coagulation Result Fifteen patients were enrolled in the NIV group and 14 in the control group. The success rate (93.3% VS 92.9%, p = 1.0), procedure time (60.5 ± 4.2 min VS 67.8 ± 5.6 min, p = 0.31) and oxygenation improvement between the two groups have no significant difference. Less reduction of systolic blood pressure and heart rate during procedure was observed in the NIV group. The NIV group showed shorter admission time before procedure than the control group (35.1 ± 4.6 h VS 55.6 ± 5.6 h, p p Conclusion FB assisted with NIV is a safe, efficient and economic method for therapy of selected hypoxemic patients with CAO.

Background and objectives: Flexible bronchoscopy has been widely used for diagnosis and intervention, while various drugs are used for sedation during bronchoscopy. We examined two regular standardized sedation options (with or without dexmedetomidine) regularly used in our regional hospital. The aim was to assess the efficacy and safety of dexmedetomidine on conscious sedation under bronchoscopy. Materials and Methods: A retrospective chart review was conducted from April 2017 to March 2018. All patients undergoing flexible bronchoscopy with moderate sedation were enrolled. Patients having received dexmedetomidine-propofol-fentanyl were defined as group D, and those having received midazolam-propofol-fentanyl were defined as group M. The primary outcome was a safety profile during the procedure, including the incidence of procedural interference by patient cough or movement, transient hypoxemia, and hypotension. The secondary outcome was measured by the recovery profile (awake and ambulation time). Results: Thirty-five patients in group D and thirty-three in group M were collected in this retrospective study. All patients underwent the procedure successfully. Group D showed higher safety with fewer procedural interference incidences by cough or body movement than Group M (3.3% versus 36.3%, p &lt, 0.001) and minor respiratory adverse effects. Patients in group D showed faster recovery in a shorter ambulation time than group M (24.9 &plusmn, 9.7 versus 31.5 &plusmn, 11.9, p = 0.02). In group D, bronchoscopist satisfaction to sedation was higher than group M (p = 0.01). More transient bradycardia episodes were noted in patients receiving dexmedetomidine (p &lt, 0.05), but all recovered without atropine intervention. Overall post-procedural adverse events and satisfaction were comparable in the two groups. Conclusions: The co-administration of dexmedetomidine met the safety and recovery demands of flexible bronchoscopy. Compared to the conventional midazolam-propofol-fentanyl regimen, the application of dexmedetomidine improved sedative effectiveness with less procedural interruptions, shorter time to ambulation and higher bronchoscopist satisfaction.

Objective: To evaluate current practices in sedation for bronchoscopy in Latin America. Methods: This was an anonymous survey of select members of the Latin American Thoracic Association. The questionnaire, made available online from November of 2015 through February of 2016, was designed to collect data on demographic characteristics; type of facility (public or private); type/volume of bronchoscopies; type of sedation; and type of professional administering the sedation. Results: We received 338 completed questionnaires from 19 countries; 250 respondents (74.0%) were male. The mean respondent age was 36.0 ± 10.5 years. Of the 338 respondents, 304 (89.9%) were pulmonologists; 169 (50.0%) worked at public facilities; and 152 (45.0%) worked at teaching facilities. All of the respondents performed diagnostic fiberoptic bronchoscopy, 206 (60.9%) performed therapeutic fiberoptic bronchoscopy, 125 (37.0%) performed rigid bronchoscopy, 37 (10.9%) performed endobronchial ultrasound, and 3 (0.9%) performed laser therapy/thermoplasty/cryotherapy. Sedation for bronchoscopy was employed by 324 respondents (95.6%). Of the 338 respondents, 103 (30.5%) and 96 (28.4%) stated, respectively, that such sedation should “usually” and “never” be administered by a bronchoscopist; 324 (95.9%) supported training bronchoscopists in sedation. Sedation administered by a bronchoscopist was reported by 113 respondents, conscious sedation being employed by 109 (96.2%). The use of benzodiazepines, propofol, and opiates was reported, respectively, by 252 (74.6%), 179 (52.9%), and 132 (39.0%) of the 338 respondents. Deep sedation and general anesthesia were more common at private facilities. Conclusions: The consensus seems to be that a well-trained bronchoscopist can safely administer sedation for bronchoscopy. However, approximately 40% of bronchoscopists do not do so regularly.

Background The disposable bronchoscope is an excellent alternative to face the problem of SARS-CoV-2 and other cross infections, but the bronchoscopist's perception of its quality has not been evaluated. Methods To evaluate the quality of the Ambu-aScope4 disposable bronchoscope, we carried out a cross-sectional study in 21 Spanish pulmonology services. We use a standardized questionnaire completed by the bronchoscopists at the end of each bronchoscopy. The variables were described with absolute and relative frequencies, measures of central tendency and dispersion depending on their nature. The existence of learning curves was evaluated by CUSUM analysis. Results The most frequent indications in 300 included bronchoscopies was bronchial aspiration in 69.3% and the median duration of these was 9.1 min. The route of entry was nasal in 47.2% and oral in 34.1%. The average score for ease of use, image, and aspiration quality was 80/100. All the planned techniques were performed in 94.9% and the bronchoscopist was satisfied in 96.6% of the bronchoscopies. They highlighted the portability and immediacy of the aScope4TM to start the procedure in 99.3%, the possibility of taking and storing images in 99.3%. The CUSUM analysis showed average scores > 70/100 from the first procedure and from the 9th procedure more than 80% of the scores exceeded the 80/100 score. Conclusions The aScope4™ scored well for ease of use, imaging, and aspiration. We found a learning curve with excellent scores from the 9th procedure. Bronchoscopists highlighted its portability, immediacy of use and the possibility of taking and storing images.

Do not push the tip of the bronchoscope into contact with the bronchial wall; it is imperative to control this step so that the tip of the bronchoscope advances in the center of the bronchial lumen. To move the tip of the flexible bronchoscope in the intended direction, the bronchoscopist monitors the up-/down-angle lever with one hand (left hand if right-handed) and rotates around the long axis of the bronchoscope as required while moving the bronchoscope back and forth with the remaining hand (right hand if right-handed). Furthermore, when pulling the bronchoscope, try to return to the center of the same bronchial lumen as you insert the bronchoscope.

Background: Flexible bronchoscopy (FB) can be performed under bronchoscopist administered moderate sedation (BAMS) with a midazolam/fentanyl combination or general anesthesia (GA). However, the outcome of BAMS has not been well established in children. Currently, most of the centers prefer FB under GA. Both techniques have their advantages and disadvantages with implications for safety, complications, and diagnostic yield. The primary objective of our study was to evaluate the safety, time efficiency, and cost-effectiveness of FB under BAMS as compared with FB under GA in a similar setting. Methods: We performed a retrospective chart review to compare BAMS versus GA for FB in children. We recruited BAMS children (n = 295) from University of Florida (UF) Health Shands Children's Hospital, and GA children (n = 100) from Penn State Children's Hospital (PSHCH). Both the groups had similar indications, complexities, and procedural environments. Comparisons of various time-intervals including preprocedure time, sedation-induction time, scope time, and post-procedure time among different BAMS versus GA age-groups were the primary outcomes. The secondary outcomes were the determination of the rates of complications, the dosages of sedative/anesthetic, cost-effectiveness, and sedation patterns under BAMS. Results: FB under BAMS required significantly higher preprocedure times and sedation-induction times (P

Background The propofol use for moderate sedation (MS) during endobronchial ultrasound (EBUS) bronchoscopy is primarily restricted for use by an anesthesiologist because of safety concerns. The goals of this study were to demonstrate the safety and the diagnostic yield of the use of propofol by bronchoscopists and trained endoscopy nurses during EBUS bronchoscopy without intubation. Methods We tested a bolus propofol administration protocol targeting MS for EBUS bronchoscopy. A fixed initial dose of 40 mg of propofol along with a fixed 50 mcg fentanyl dose were administered. Sedation assessment was performed every 2 minutes, and repeated bolus doses of propofol were given to maintain MS under the direction of the bronchoscopist. Results A total of 122 subjects underwent EBUS bronchoscopy with a goal of MS from August 2015 to April 2017. In total, 110 subjects who underwent convex EBUS bronchoscopy under MS with propofol were included in the analysis. Median procedure duration was 57 minutes (range, 15 to 97 min). Deep sedation and agitation-related delay were occurred in 14 and 21 subjects, respectively. Hemodynamic instability and hypoxemia occurred in 23 subjects. However, there was no need for vasopressors or artificial airway placement. Median of total propofol dose per case was 560 mg. Diagnostic yield for malignancy and granuloma was 68%, and a median of 4 lymph node stations were sampled per subject. All specimens with adenocarcinoma were sufficient for genetic marker analysis. There were no major sedation-related complications. Conclusion A bolus administration of propofol during EBUS bronchoscopy provided excellent adequacy of sedation and well tolerance safety profile.

Bronchoscopy has long been used as a diagnostic and therapeutic tool in medicine, with a wide range of appropriate sedative options. Flexible bronchoscopy is generally performed with sedation, and the choice of sedative is generally left to the practice pattern of the performing bronchoscopist. The concept of sedation is complex, with varying degrees of consciousness. A literature search was conducted on MEDLINE from 1969 to 2016, and appropriate data were reviewed. Randomized, controlled trials and prospective cohort studies were considered of highest impact. This article is a comprehensive review of existing data regarding sedation during bronchoscopy.

Background Bronchoscopy is a well-established maneuver in pulmonary medicine. It is an important method in the diagnosis, staging, and treatment of lung cancer and other pulmonary diseases. Various diagnostic techniques such as bronchial biopsy, bronchial washing and brushing, and transbronchial lung biopsy are used during fiberoptic bronchoscopy to increase the diagnostic yield of the procedure. Rigid and fibreoptic bronchoscopes remain complementary techniques, and are usually used concurrently during many procedures. Aim The aim of this study was to study the indications and outcome of bronchoscopic workup in the Bronchoscopy Unit, Chest Department, Ain Shams University Hospital in the period from May 2013 to October 2013. Patients and methods All patients undergoing either fiberoptic bronchoscopy or rigid bronchoscopy were subjected to full history and clinical examination, and monitored regarding their preprocedure investigations, procedure details and sampling techniques, postprocedure complications, and finally the patients were followed up regarding their histopathological and bacteriological results. Results One hundred cases were monitored, 65 male patients and 35 female patients. The mean age of the patients was 50.92±20.099 years. Fifty-six patients were smokers, whereas 44 patients were nonsmokers. The most frequent presenting symptom was dyspnea in 50% of cases, followed by hemoptysis in 27% of cases. Adenocarcinoma was diagnosed in seven patients, squamous cell carcinoma was diagnosed in six patients, small-cell lung cancer was diagnosed in four patients, and large-cell lung cancer was diagnosed in three patients. In 15 (40.54%) cases, the histopathological results were inflammatory, nonconclusive to malignancy. All patients with lung cancer showed radiological abnormalities. Two cases were diagnosed as TB in spite of their workup of TB such as tuberculin test and sputum Z&N being negative. There were no mortalities. There was no bronchoscopy-related complications in 85% of cases, whereas four (4%) cases suffered bleeding during biopsy and debulking of the tumor, which was controlled by local hemostatic measures In eight (8%) cases most of whom were smokers, suffered desaturation, due to prolonged time of the procedure. They were not hypoxic before the beginning of bronchoscopy. Only two (2%) cases were mechanically ventilated due to bleeding and hypoxia during and/or after the procedure, and one case had surgical emphysema, which was managed conservatively. Conclusion Bronchoscope is a very effective and safe procedure; safety and effectiveness obviously depend on the accuracy of selection of the patients for the procedure, the experience of the bronchoscopist, and on the facilities available. Proper use of diagnostic techniques provides a high degree of success, and the treatment modality to be used depending on the type of the lesion is mostly satisfactory.

Purpose Acute cellular rejection (ACR) is a histopathologic diagnosis made by assessment of transbronchial biopsies (TBBX). Consensus guidelines recommend a minimum of 5 alveolated samples for histologic adequacy; it is not uncommon for samples to be inadequate for diagnosis. This study was designed to determine what factors impact the recovery of adequate specimens for ACR grading, as well as explore discrepancies in “sample calling” between the pathologist & bronchoscopist. Methods Observational, single center study including retrospective chart review of 142 bronchoscopies with TBBX performed on 128 lung transplant recipients (LTRs) who underwent surveillance bronchoscopy between May 2017 & May 2018. For the purpose of our study we defined inadequate samples as Results Of 142 TBBX procedures, 22 (15.5%), resulted in inadequate sampling. Of note, pathologists called less sample fragments than bronchoscopists 70% of the time. Characteristics associated with inadequate sampling included both LTR & procedural characteristics (Table 1 & 2). Conclusion Bronchoscopists may overestimate the number of total fragments obtained compared with pathologists. Both demographic & procedure characteristics may aid in identifying LTRs at higher risk for inadequate sampling during TBBx.

Bronchoscopy is a safe and commonly performed procedure for diagnostic as well as therapeutic indications. Bronchoscopy is also an aerosol-generating procedure, and due to the risk of severe acute respiratory syndrome coronavirus 2 transmission during the procedure, routine bronchoscopy has been discouraged by multiple professional societies, despite any solid evidence. There are only a few reports of bronchoscopy in patients with coronavirus disease 2019 in the literature. Bronchoscopy in this patient population plays a crucial role not only in the diagnosis of coronavirus disease 2019 but also in the identification of secondary bacterial or fungal infections and in directing appropriate antimicrobial therapy. Bronchoscopy with therapeutic interventions may be lifesaving. Based on the literature, the risk of coronavirus disease 2019 transmission appears to be low among bronchoscopists and other healthcare workers when appropriate personal protective equipment is used. Bronchoscopy in patients with coronavirus disease 2019 should be strongly considered when clinically indicated.

The reimbursement for procedures using moderate (conscious) sedation has changed significantly as of January 1, 2017. Due to the increasing use of anesthesia services to provide moderate sedation during endoscopy, the Centers for Medicare & Medicaid Services made the decision to remove work relative value units from many of the services requiring moderate sedation, including the bronchoscopy codes. If a bronchoscopist provides moderate sedation to a patient without using anesthesia services or another qualified provider, that work (and revenue) can be reclaimed by using the relevant codes. An understanding of the recent changes in coding and billing is essential for appropriate reimbursement.

A thorough understanding of intrathoracic anatomy enables the interventional bronchoscopist to perform procedures efficaciously. The review of the anatomy of the thoracic cavity focuses first on the trachea and the relationship of the airway with surrounding structures, knowledge important for the safe conduct of bronchoscopic procedures. We then describe the anatomy of the pleural cavity relevant to the practitioner performing pleuroscopy.

Background Aspiration of button battery in children is increasing in recent years due to more accessibility of electronic toys to the children. The electrochemical composition of button battery may cause extensive damage. It should be promptly and immediately removed otherwise it leads to complications and death. Objective To study the clinical presentations and outcome of the button battery aspiration among the children. Study design A retrospective study. Methods Six children those aspirated button battery and underwent rigid bronchoscopy with spontaneous ventilation and followed by removal from the tracheobronchial tree during December 2012 to January 2017. Results Button battery aspiration is common among male child in our study. All children were symptomatic after aspiration. One child came with stridor. The time interval between battery aspiration and attending hospital was 25.33 h. Out of 6 patients two showed button battery in left bronchus, three in right bronchus and one is near the carina. Average hospital stay was 3.16 days. Conclusion Early detection of such foreign bodies is essential to safe removal. Management approach has to be systematic. Preoperative history taking, radiological assessment followed by rapid intervention by skilled bronchoscopist usually results in favorable outcome.

Background Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be performed under either conscious sedation or general anesthesia. Herein, we describe the diagnostic yield and complications of EBUS-TBNA performed under bronchoscopist-directed conscious sedation. Methods This is a retrospective analysis of data collected in the bronchoscopy suite of this center on EBUS-TBNA or endoscopic ultrasound with a bronchoscope-guided fine needle aspiration (EUS-B-FNA) procedures performed between July 2011 and January 2016. All procedures were performed under bronchoscopist-directed conscious sedation with midazolam and pentazocine. The diagnostic yield, sample adequacy rate, complications, and doses of sedative agents are presented. Results Of the total 1005 EBUS-TBNA/EUS-B-FNA procedures performed during the study period, 1004 were performed under conscious sedation in spontaneously breathing subjects [mean (SD) age, 45.9 (15.8) years; 378 (37.6%) women]. The mean (SD) doses of midazolam and pentazocine used were 2.53 (1.8) mg and 30.9 (6.9) mg, respectively. The diagnostic yield of the procedure (972 subjects) was 61.2%. Complications related to EBUS were observed in 60 (5.9%) subjects. Majority of them were minor and self-limiting; major complications occurred in 11 (1.1%) subjects and included respiratory failure requiring assisted ventilation (n=6), arrhythmia (n=3), and hypotension (n=2). Escalation of the level of care was needed in only 8 (0.8%) subjects. Conclusion EBUS-TBNA/EUS-B-FNA performed under bronchoscopist-guided conscious sedation was found to be safe and is associated with a reasonable diagnostic yield.

Hemoptysis is a frequent manifestation of a wide variety of diseases, with mild to life-threatening presentations. The diagnostic workup and the management of severe hemoptysis are often challenging. Advances in endoscopic techniques have led to different new therapeutic approaches. Cold saline, vasoconstrictive and antifibrinolytic agents, oxidized regenerated cellulose, biocompatible glue, laser photocoagulation, argon plasma coagulation, and endobronchial stents and valves are amongst the tools available to the bronchoscopist. In this article, we review the evidence regarding the definition, etiology, diagnostic modalities, and treatment of severe hemoptysis in the modern era with emphasis on bronchoscopic techniques.

Background: Bronchoscopy for the diagnosis of peripheral pulmonary lesions continues to present clinical challenges, despite increasing experience using newer guided techniques. Robotic bronchoscopic platforms have been developed to potentially improve diagnostic yields. Previous studies in cadaver models have demonstrated increased reach into the lung periphery using robotic systems compared to similarly sized conventional bronchoscopes, although the clinical impact of additional reach is unclear. Objectives: This study was performed to evaluate the performance of a robotic bronchoscopic system’s ability to reach and access artificial tumor targets simulating peripheral nodules in human cadaveric lungs. Methods: Artificial tumor targets sized 10–30 mm in axial diameter were implanted into 8 human cadavers. CT scans were performed prior to procedures and all cadavers were intubated and mechanically ventilated. Electromagnetic navigation, radial probe endobronchial ultrasound, and fluoroscopy were used for all procedures. Robotic-assisted bronchoscopy was performed on each cadaver by an individual bronchoscopist to localize and biopsy peripheral lesions. Results: Sixty-seven nodules were evaluated in 8 cadavers. The mean nodule size was 20.4 mm. The overall diagnostic yield was 65/67 (97%) and there was no statistical difference in diagnostic yield for lesions Conclusions: The robotic bronchoscopic system was successful at biopsying 97% of peripheral pulmonary lesions 10–30 mm in size in human cadavers. These findings support further exploration of this technology in prospective clinical trials in live human subjects.

Background: Self-expandable metallic Y-shaped airway stents (SEMYS) are commonly used in the management of airway stenosis and fistulae caused by thoracic neoplasms. Methods: A new technique using a slightly modified regular endotracheal tube has been developed for the deployment of SEMYS with flexible bronchoscopy alone. The technique and devices are described. Results: To date, successful deployment of SEMYS with this method has been carried out successfully in 17 out of 20 patients without major complications while the other 3 required conversion to rigid bronchoscopy because of limited pharyngeal cavity space, massive hemorrhage and severe cicatrization of the airway, respectively. Conclusions: This simplified deployment technique with the modified endotracheal tube enables safe, simple and fast insertion of SEMYS in a regular bronchoscopy suite, which may benefit the vast less privileged institutions where SEMYS are necessary but rigid bronchoscopy and fluoroscopy are not available. The skill of the bronchoscopist, cautious selection of patients and effective coordination of the operating team are crucial for the procedure.

Interventional pulmonology procedures have been performed traditionally with rigid bronchoscopy (RB), however flexible bronchoscopy (FB) is now on the rise. Sample of therapeutic bronchoscopies (TB) performed between 2017-2018 (n=57) predominantly in males (84%), with a mean age of 61.3 years. Most frequent indications were: central airway desobstructive treatment (DT) (n=16), endobronchial (E) brachytherapy (n=16), location and endoscopic closure of bronchopleural fistula (n=10), distal airway DT (n=5) and endobronchial foreign bodies extraction (n=3). 77% of the procedures were performed exclusively with FB -group A-, while the remaining 23% -group B- used combined procedures of RB + FB. No statistically significant differences were found neither between the procedure success nor the complications when comparing the E treatment and the type of BT performed (p FB is an excellent tool for E T treatment with an adequate safety profile in the hands of an expert bronchoscopist who which can avoid invasive mechanical ventilation and general anesthesia in 40% of cases, reducing costs and further complications associated with it.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is recommended for the diagnosis of mediastinal lymph nodes by the American College of Chest Physicians guidelines; however, the guidelines state that this procedure should only be performed by a trained bronchoscopist. Complications related to needle malfunction during the EBUS-TBNA procedure have recently been reported. We herein describe a rare case involving the successful management of a needle breakage that occurred as an unusual complication of EBUS-TBNA. An 81-year-old male patient with a medical history of myocardial infarction was introduced to our institution to undergo an evaluation for mediastinal and right hilar lymphadenopathy on chest computed tomography (CT). We performed EBUS-TBNA in a 14×10 mm subcarinal lymph node station using a 22 G aspiration needle (NA-201SX-4022, Vizishot®, Olympus, Japan) for diagnosing and staging of the patient's lung cancer. After the second aspiration, we noticed that the needle tip was broken and that it was stuck in the right main bronchus. We immediately removed the broken needle tip from the right main bronchus by flexible bronchoscopy using an ID 8.5 mm tracheal tube without cuff inflation. The length of the needle tip was 13 mm and it was considerably bent. The EBUS scope did not suffer any apparent damage. The patient did not have any other procedure-related complications. Needle breakage during EBUS-TBNA is rare; however, inhaling or swallowing of a broken needle tip has the potential to cause serious complications. Bronchoscopists should therefore be aware of the possibility of needle breakage, which is an important complication during EBUS-TBNA.

The report must describe the condition of observation, complications, lesions noted and their accurate location. Exploration is always complete and bilateral. The description will be used as baseline for comparison. Conclusion must provide the diagnostic opinion of the bronchoscopist.

Background: Recent advances in lung cancer treatment have changed the requirement for the amount and quality of biopsy specimens needed to characterize the tumor and select the best treatment. One adjunct to guide the bronchoscopist on the quality and quantity of specimens during bronchoscopic biopsies for the diagnosis of lung cancer is rapid on-site evaluation (ROSE) of cytological specimens. This technique has been shown to add to the diagnostic yield of bronchoscopy when obtaining adequate specimens for molecular profiling in lung cancer. ROSE is not available at all medical centers. We describe our initial experience using intra-procedural Frozen Section Evaluation (FROSE) of bronchoscopic biopsy specimens as an alternative to ROSE. Methods: A retrospective analysis of all interventional pulmonology cases using FROSE between February and July 2015 was performed. Results analyzed to evaluate the success in obtaining adequate specimens for molecular profiling. Results: A total of 88 interventional pulmonology cases employing a frozen section in at least one site were identified. In 94.3% of cases, a definitive diagnosis of benign or malignant was made. The concordance of frozen section diagnoses of benign or malignant was 100% with final diagnoses. Thirteen of the eighty-eight cases were ultimately sent for molecular analysis. Of these, twelve of thirteen (92.3%) cases were adequate to perform all ordered molecular testing. In all cases there was sufficient tissue to perform EGFR and ALK testing. Conclusions: In medical centers where ROSE may not be available, the use of FROSE by the local pathologist can be an effective technique to obtain adequate tissue and cytological samples for the diagnosis and molecular profiling of lung cancers. Further prospective study in bronchoscopic tissue sampling techniques to obtain the optimum quantity and quality of samples for molecular profiling of lung cancers for targeted treatments is needed.

Blood supply of the tracheobronchial tree is derived from a dual system involving pulmonary and bronchial circulation. Various primary and secondary abnormalities of central airway vasculature can present with patterns that are distinct during bronchoscopy. These patterns maybe visualized during bronchoscopic evaluation of a patient with hemoptysis or as an incidental finding during an airway examination for other indications. Thorough knowledge of airway vasculature abnormalities and recognition of possible underlying pathophysiology is vital for the bronchoscopist. This review is a comprehensive description of vascular anatomy of the airway and the different vascular abnormalities that can be encountered during bronchoscopy.

Combination of sedatives such as fentanyl and midazolam during bronchoscopy is recommended by American College of Chest Physician due to its favourable drug profile. It improves patient comfort and tolerance, and is commonly given unless contraindicated. We describe a rare case of fentanyl-induced chest wall rigidity syndrome during a routine bronchoscopy with endobronchial ultrasound guided-transbronchial needle aspiration (EBUS-TBNA) in a 55 year old male presenting with a lung mass and mediastinal lymphadenopathy. This was effectively managed with neuromuscular blockade, intubation and reversal agents including naloxone. This rare complication should be effectively managed by all bronchoscopist as it carries significant mortality and morbidity if not recognised early. We review the literature on the occurrence of fentanyl-induced chest wall rigidity and its predisposing risks factors.

During bronchoscopy, discomfort is mainly caused by an unavoidable cough; however, there are no reports of any predictive factors for strong cough during bronchoscopy identified before the procedure. To clarify the factors underlying the discomfort status and predictive factors for strong cough during bronchoscopy, we prospectively evaluated patients who underwent bronchoscopy at Kyorin University Hospital between March 2018 and July 2019. Before and after bronchoscopy, the enrolled patients answered a questionnaire regarding the procedure. At the same time, bronchoscopists evaluated cough severity using a four-grade cough scale. We evaluated patient characteristics and predictive factors associated with bronchoscopy from the perspective of discomfort and strong cough. A total of 172 patients were ultimately enrolled in this study. On multivariate logistic regression analysis, comparison of the subjective data between the discomfort and comfort groups revealed that factors that were more common in the former group were younger age (OR = 0.96, p = 0.002), less experienced bronchoscopist (OR = 2.08, p = 0.047), and elevation of cough score per 1 point (OR = 1.69, p < 0.001). Furthermore, the predictive factors for strong cough prior to performing bronchoscopy were female sex (OR = 2.57, p = 0.009), EBUS-TBNA (OR = 2.95, p = 0.004), and prolonged examination time of more than 36 min (OR = 2.32, p = 0.022). Regarding patients’ discomfort, younger age, less experienced bronchoscopist, and the elevation of cough score per 1 point were important factors for discomfort in bronchoscopy. On the other hand, female sex, EBUS-TBNA, and prolonged examination time were crucial factors for strong cough.

Sedation improves patient and bronchoscopist’s satisfaction, allowing complex procedures to be performed satisfactorily with good tolerance. However, it requires specific training. Our center recently incorporated deep sedation (SP) with propofol (P) using TCI. We consider mandatory compare its safety profile with our gold standard -GS- until then (administration of P in continuous perfusion after induction with boluses) Observational study: Sample 1 (prospective cohort of 20 deep sedation bronchoscopies with TCI system) and sample 2 (retrospective cohort of 20 patients our GS in deep sedation). We analyzed: age, weight, total P dose, P mg/kg dose, vital sings derived from continuous cardio-respiratory monitoring and complications rate. A greater dose of total P and dose of P (mg/kg) in group 1 was observed, with a lower incidence of complications. (hypotension -fall ≥20% with respect to the initial systolic blood pressure (SBP)- and desaturations -drop ≥6% measured by pulse oximetry-). Table 1 • After an specific training, TCI system administered by a pulmonologist is a safe procedure • The total dose of P used and the dose (measured in mg / kg) was higher in sample 1, however it showed a better safety profile • Continuous monitoring is essential to avoid complications, due to the doctor who administers the SP must be in charge of reversing it.

Introduction: One of the challenges to bronchoscopic biopsy of Solitary Pulmonary Nodule (SPN) where there is no airway leading to the nodule or no CT bronchus sign has been the ability to access the SPN, which is reflected in the low diagnostic yield (31%; Seijo, L.M. et al. CHEST 2010; 138(6):1316-1321). The Archimedes system (Broncus Medical) has been demonstrated to enable safe and accurate guided tunneling from the central airway wall through parenchyma to the SPN. Aims: Evaluate the diagnostic yield and safety of Bronchoscopic TransParenchymal Nodule Access (BTPNA) in patients with no leading airway path to the SPN, using Archimedes system. Methods: A series of 16 SPNs lack an airway path for biopsy was sampled by BTPNA using Archimedes system from October 2016 until January 2018 at 5 clinical sites. Trained bronchoscopist marked suspected SPN and selected suitable guided-bronchoscopy path to point of entry (POE) on airway wall. Hole creation and dilation at POE were performed prior to guide sheath insertion via the hole toward SPN under fused CT/Fluoroscopy guidance to get biopsy samples. Results: Overall diagnostic yield was 75% on SPNs with a mean major axis of 18.9±10.0 mm without major complications or pneumothorax. Conclusion: The results of this evaluation shows significant improvements over existing guided transbronchial biopsy in diagnosing SPN without CT bronchus sign. With additional experience in BTPNA procedures, we anticipate further improvement in diagnostic yield and will be reported in the future.

Objective: We compared efficacy and safety of dexmedetomidine (DEX) to midazolam (MID) in patients undergoing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Methods: We randomly assigned 200 subjects to receive DEX (1 µg/kg before, and 0.6 µg/kg/hour during, procedure) or MID (2 mg before procedure) sedation, and later excluded three subjects (EBUS-TBNA not done). Primary outcome was number of rescue MID boluses needed to achieve targeted Ramsay Sedation Scale (RSS) score of two or more. We also studied mean sedation depth during procedure, adverse hemodynamic and hypoxemic events, bronchoscopist and patient satisfaction with procedure, and time-to-discharge from recovery room. Results: Rescue MID requirement was significantly lesser in 99 DEX group (0.9±1.2 boluses), than in 98 MID group (2.0±2.4 boluses), subjects (p Conclusion: DEX provided more effective sedation during EBUS-TBNA, and faster post-procedure recovery, as compared to MID. However, it caused hypotension and bradycardia more frequently.

Nowadays, lung cancer is one of common cancers around the world. To increase the survival rate of the patient, early diagnosis is necessary. To achieve this, bronchoscopists usually use endobronchial ultrasound for navigating surgery in endobronchoscopy. However, because the bronchoscopist has to continuously re-navigate/re-target the bronchoscope to collect specimens from the same tumor, the whole navigating/ targeting process has to be repeated many times in one surgery. Due to this, navigating/targeting the bronchoscope to correct/same tumor is still a time-consuming process. Therefore, a more accurately tumor-targeting approach is needed to significantly save time in navigating surgery. To address this issue, recently researchers combined electromagnetic (magnetic-sensor-based) targeting technology with conventional endobronchial ultrasound as a hybrid targeting approach to achieve a more accurate realtime tumor-targeting in endobronchoscopy [1]. However, when comparing conventional bronchoscopes, the bronchoscope with magnetic sensor is more expensive and less compatible. Thus, a cheaper and compatible electromagnetic targeting technology is required. Recently, some researchers demonstrated electromagnetic-induction/magnetic-interaction approaches to target distal screw-hole in intramedullary interlocking-nail surgery [2]- [5]. We think that these targeting approaches can be modified to develop as a new, cheaper, and compatible electromagnetic targeting technology for general endobronchoscopy. Hence, in this paper, we demonstrate the electromagnetic targeting system for endobronchoscopy.