Navigational Bronchoscopy

Christine Argento, MD, FCCP

Interventional Pulmonology

Northwestern University

Disclosures

• Consultant to:

Biodesix

Olympus

Outline

• Peripheral Pulmonary Nodules

• Navigational Platforms

– EMN

– VBN

– Radial EBUS

– Cone Beam CT

– Robotic

• Clinical Realities

Peripheral Pulmonary Nodules

• Pulmonary nodules are an increasingly common

finding

• 4.5-14 million CT chest yearly

• NLST by NCI

– > 25% of the low dose CT group had positive finding

– 96.4% false positive

– 20% RRR in mortality from lung cancer

• MANY more CT scans will be ordered

N Engl J Med 2011; 365:395-409

Kardiochirurgia i Torakochirurgia Polska 2014; 11 (4): 397-403

Approach

• Does the patient need a biopsy?

– Malignant or benign

– Operative?

• Safety vs Efficacy

• Efficiency

– get all the information you need in one setting

ACCP Guidelines 2013

• In patients with peripheral lung lesions difficult to reach with conventional bronchoscopy, electromagnetic navigation guidance is recommended if the equipment and the expertise are available (Grade 1C).

• Remark: The procedure can be performed with or without fluoroscopic guidance and it has been found complementary to radial probe ultrasound

• Remark: If electromagnetic navigation is not available, TTNA is recommended.

CHEST May 2013Volume 143, Issue 5,

Supplement, Pages 7S–37S

GPS for the lung?

Electromagnetic Navigation

• Acquires spatial navigation in virtual time

– based on reconstruction of previously acquired

images

Planning• 3D reconstruction from

dedicated CT of the

chest w/ thin slices

• Slice thickness < 1.25

mm

• Slice spacing < 0.625

mm

– The thinner the

better

• Select Target(s)

Planning • 3D-Airway Tree View

• Automatic calculation

of airway paths to

target(s)

• Review Virtual

Bronchoscopy

– Three paths generated• Path 1: Ends closest to the

target

• Path 2: Potentially provides

(better) angle to target

• Path 3: Utilizes different

branch of airway

YieldHigher• Size > 2cm

• Bronchus sign

• Closer to the hilum

• Further from the diaphragm

• Obstructive lung disease

• Multiple modality procedure

Electromagnetic Navigation

SuperDimension iLogic System

• Uses previously performed thin cut non-contrast CT.

• Tip-tracked locatable guide (LG) through a catheter system.

• LG removed and biopsies are done through thecatheter working channel.

• Longest tenure/track record of navigation systems.

Lamptrcht et al Respir Med 2012

Karnak et al Ann Thor Med 2013

Gildea et al Am J Respir Crit Care Med 2006

Ebhardt et al Am J Respir Crit Care Med 2

Screen Shot

Evidence for SuperDimension

Veran

• Same day scan with expiratory

planning

– Can use a historical CT scan if needed

• No room mapping limitations

• ‘Always on instrumentation’

• tip tracked steerable working

channels, needles, brushes, forceps

and guidewires

Always-On Tip Tracked Instruments

Screen Shot

SPIN perc

Virtual Bronchoscopy• Direct Path, Cybernet system

Broncus- Lung Point

• Pattern Recognition Software

VBN – Does it Work?

Respiration 2014; 88:430-440

3.0 mm OD/1.7 mm WC 4.0 mm OD/2.0 mm WC

AJRCCM 2015. 192(4): 468-476

Thorax 2011.66(12):1072

VBN Pro/Con

• Pro– Easy to use software

– Requires no proprietary hardware

– System DOES NOT require specialized, disposable instruments

– Complements other technologies well

– Case cost is likely less than other navigation platforms

• Con– Variable CT quality

– “Prisoner” of airway

– Confirmation of biopsy instruments at target not synchronized

– Dependence on additional infrastructure

Transparenchymal Nodule Access

(TPNA)

Radial EBUS

• Ultrasound used in the periphery of the lung

– Introduced through the working channel of the

bronchoscope

• Frequency 20 MHz

Remember to breathe!

CHEST 2015; 147(5):1275-1281

Multi-Modality

Multi-Modality

Eberhardt et al, AJRCCM 2007; 176: 36

Cone Beam CT

Robotic

Collaborative Efforts

• Pleural dye marking

• Localization for VATS/RATS

• EMN guided wedge resections

• Fiducial placement

J Thorac Dis. 2017 Mar;9(3):802-808.

Ann Thorac Surg 2008;85:S797–801

Ann Thorac Surg 2014;98:471–6

Sem Thorac and Cardio Surg Vol 22 (3):262-265

Journal of Community Hospital Internal Medicine Perspectives 2014, 4:

Summary

• Navigational bronchoscopy platforms are useful

to diagnose peripheral pulmonary lesions

• Often performed as multi-modality

– That increases yield

• New technology for navigational bronchoscopy

is being developed

• Collaboration efforts with Thoracic Surgery are

an important use of navigational bronchoscopic

platforms

Thank YouQuestions?

angela.argento@nm.org