1. Advanced Bronchoscopy at PRMC an evidence based practice Yashvir Sangwan

2. Current Status Advanced Diagnostic Bronchoscopy – Linear EBUS – Radial EBUS – Thin Bronchoscopy – Electromagnetic Navigational Bronchoscopy – Cryobiopsy Therapeutic Bronchoscopy Pleural Procedures Critical Care Procedures

3. Current Status Advanced Diagnostic Bronchoscopy Therapeutic Bronchoscopy – Electrocautery and APC – Cryo-recanalization – Balloon Bronchoplasty – Airway Stenting with SEMS – Airway Valves – Bronchial Thermoplasty Pleural Procedures Critical Care Procedures

4. Current Status Advanced Diagnostic Bronchoscopy Therapeutic Bronchoscopy Pleural Procedures – VATS – Chest tube – Pleurodesis including blood patch – Pleur-X indwelling pleural catheter Critical Care Procedures

5. Current Status Advanced Diagnostic Bronchoscopy Therapeutic Bronchoscopy Pleural Procedures Critical Care Procedures – Tracheostomy – Advanced Critical Airway management If we had Rigid Bronchoscopy we would be an Interventional Pulmonary Program.

7. Advanced Diagnostic Bronchology- Techniques for the peripheral lung nodule

8. Bronchoscopy First Reason #1 - Pneumothorax The pneumothorax rate for bronchoscopy techniques = 1.5% with 0.6 % requiring chest tube. J Wang Memoli et al. Meta-Analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. CHEST 2012; 142(2): 385-93. The pneumothorax rate for CT guided TTNA is 27% with 5% requiring chest tube. Huanqi L et al. Diagnostic accuracy and safety of CT –guided percutaneous aspiration biopsy of the lung. AJR Am J Roentgenol. 1996; 167: 105-9. Ohano Y et al. CT-guided transthoracic needle aspiration biopsy of small solitary pulmonary nodules. Am J Roentgenol. 2003; 180:1665-9.

9. Bronchoscopy First Reason #2- mediastinal staging

10. The only time you don’t do EBUS is when a patient has a lung nodule (<3 cm) in the peripheral 1/3rd of the lung with negative CT and negative PET. Eur J Cardiothorac Surg. 2014 May;45(5):787-98. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer.

11. Bronchoscopy First Reason #2- mediastinal staging If tumor size > 3 cm – full mediastinal staging is needed (even if CT + PET negative). If tumor (any size) is central – full mediastinal staging is needed (even if CT + PET negative). If even 1 N1 lymph node is suspected involved – full mediastinal staging is needed. (The new lymph node cut –off is > 0.5 cm.) Eur J Cardiothorac Surg. 2014 May;45(5):787-98. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non- small-cell lung cancer.

12. EBUS EBUS sensitivity for positive mediastinum is 90-100%. Mediastinoscopy 90%. PET 80%. CT 75%. Conventional TBNA 58-78%. Negative Predictive value – EBUS 91-97.4 %. Mediastinoscopy 91%. PET 85.2-91.5%. CT Scan 80-85%. Conventional TBNA 40-78%. – Herth F. Chest 2004; 125: 322-5. – Wallace MB. JAMA 2008; 299:540-6. – Holty JC et al. Thorax 2005;60:949-55. – Toloza EM et al. chest 2003; 123 : 157S-66S – Mol Clin Oncol. 2014 Jan;2(1):151-155. Epub 2013 Oct 23. A meta-analysis by Zhu T et al. – Lee BE et al. J Thorac Cardiovasc Surg 2012; 143: 585-90. – Yasufuku et al. J Thorac Cardiovasc Surg 2011; 142: 1393-400. E 1391. – Chest. 2014 Aug;146(2):389-97. Liberman M et. Al. – Herth FJ et al. EBUS in radiological and PET normal mediastinum. Chest 2008; 133:887-91.

13. EBUS Conventional TBNA is not recommended for lymph nodes < 1 cm in short axis. – Harrow E et al. Chest 1991; 100: 1592-6. – Oki M et al. Respiration 2004; 71: 523-7. Conventional TBNA best for LN> 2 cm in 7 or 4r position. EBUS staging followed by mediastinoscopy if EBUS negative is the most effective method. – JAMA. 2010 Nov 24;304(20):2245-52. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. Annema JT et al. – Health Technol Assess. 2012;16(18):1-75, Sharples LD et al. – J Thorac Oncol. 2010 Oct;5(10):1564-70. Steinfort DP et al. – Chest. 2014 Aug;146(2):389-97. Liberman M et. Al.

14. – Verhagen AFT et al. Lung Cancer 2004; 44 : 175-81. – Detterbeck FC et al. Chest 2007; 132 : 202S-20S – Leyn PD et al. Eur J Cardiothoracic surgery 2007; 32: 1-8. – Hwangbo B et al. Chest 2009; 135:1280-7. – Yasufuku.Chest 2006; 130:710-8. – Clin Lung Cancer. 2012 Mar;13(2):81-9. Wang J et al. – Clin Lung Cancer. 2014 Aug 15. Robson JM et al. – Ann Thorac Surg. 2014 Aug 19. Shingyoji M ET al. – Kerr KM. Thorax 1992; 47: 337-41; – Gomez-Caro A et al. Eur J Cardiothoracic Surg 2010; 37 : 1168-74. – Ernst A et al. J Thoracic Oncol 2008;3: 577-82. – Adams K – meta-analysis and systematc review- Thorax 2009; 64- 757-62. – Gu P et al. Eur J cancer 2009; 45: 1389-96. – Varela-Lema L. Eur Respir J. 2009; 33:1156-64. – JAMA. 2010 Nov 24;304(20):2245-52. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. Annema JT et al. – Health Technol Assess. 2012;16(18):1-75, Sharples LD et al. – J Thorac Oncol. 2010 Oct;5(10):1564-70. Steinfort DP et al.

15. Reason #3 – Bronchoscopy is effective Traditional Broncho- scopy CT guided TTNA Thin Scope with radial EBUS + GS EMN Super D Combined EMN + Radial EBUS Lesion <2 cm 34%74%73%74%76% Lesion >=2 cm 63%90%80%84%88%

16. Rivera et al. CHEST 2007; 132:131S-48 Kurimoto et al. CHEST 2004; 126:959-65. Asano t al. Lung Cancer 2008; 60: 366-73. Gildea et al. AJRCCM 2006;174: 982-9. Eberhardt et al. AJRCCM 2007; 176: 36-41. Ishida et al. Thorax 2011; 66:1072-7.

17. Lesion >3 cm with bronchus sign - Tbbx Diagnostic yield is highest (78%) when used with correct size alligator forceps, fluoroscopy with C arm rotation technique, combined with peripheral TBNA, Brush and BAL and 6-10 specimens are taken. – Cox ID et al. Relationship of radiologic position to the diagnostic yield of fiberoptic bronchoscopy in bronchial carcinoma. Chest 1984; 85: 519-22. – Smith LS et al. Comparison of forceps used for transbronchial lung biopsy. Chest 1985;87:574-6. – Descombes E et al. Transbronchial lung biopsy : an analysis of 530 cases. Monaldi Arch Chest Dis. 1997; 52:324-9. – Rivera MP, Mehta AC. Initial Diagnosis of lung cancer. ACCP evidence based clinical practice guidelines Chest 2007; 132:131S-48.

18. Lesion < 3 cm : Radial EBUS – Kurimoto N et al. Endobronchial US using a guide sheath Chest 2004; 126:959-65. – Paone G et al. Endobronchial US driven biopsy in diagnosis of peripheral lung lesion. Chest 2005; 128 :3551-7.

19. Lesion < 3cm : EMN

20. EMN Electromagnetic Navigation uses a board below the patient to generate a magnetic field around the patient’s thorax. Sensors on the patient’s chest and in the bronchoscope are used to match patient’s airway to a CT scan. Once the match happens the computer guides us to the lesion. – Gildea TR et al. EMN bronchoscopy A prospective study. Am J respir Crit Care Med 2006; 174:982-9. – Eberhardt R et al. Multimodality bronchoscopic diagnosis of peripheral lung lesions. Am J Respir Crit Care Med 2007; 176:36-31.

21. EMN

22. Cryobiopsy

23. Summary A majority of patients with suspected lung cancer need EBUS/ mediastinal staging. The bronchoscopic yield of peripheral lesions has significantly improved. Exceptions to bronchoscopy first – (a) advanced stage disease (b) non-surgical candidate and (c ) the < 3 cm peripheral nodule with negative PET and CT.