How should this patient with repeated aspiration pneumonia be managed and treated?—a proposal of the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure

Cerebrovascular accident (CVA) is commonly seen among the elderly with a substantial proportion of patients suffering from long-term dysphagia and/or an inability to protect their airway. This potentially imposes on them an increased risk of malnutrition and aspiration pneumonia. In this article, we present a patient with malnutrition and dysphagia secondary to CVA. We propose a procedure for which we will name the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure for placement of percutaneous endoscopic gastrostomy (PEG) and tracheostomy tube (TT) at the same time. The medical literature was systematically reviewed for both PEG and tracheostomy, aiming to provide the state-of-the-art evidence for clinical use of the PENlIGhT procedure. In clinical practice, the PENlIGhT procedure is indicated for patients who are expected to have prolonged swallowing disturbance and mechanical ventilation. Some prediction tools and scores can be helpful to identify such groups of patients. Patients with poor neurological outcomes who require prolonged maintenance of life are also good candidates for the PENlIGhT procedure

A Dataset of Anatomical Environments for Medical Robots: Modeling Respiratory Deformation

Anatomical models of a medical robot's environment can significantly help guide design and development of a new robotic system. These models can be used for benchmarking motion planning algorithms, evaluating controllers, optimizing mechanical design choices, simulating procedures, and even as resources for data generation. Currently, the time-consuming task of generating these environments is repeatedly performed by individual research groups and rarely shared broadly. This not only leads to redundant efforts, but also makes it challenging to compare systems and algorithms accurately. In this work, we present a collection of clinically-relevant anatomical environments for medical robots operating in the lungs. Since anatomical deformation is a fundamental challenge for medical robots operating in the lungs, we describe a way to model respiratory deformation in these environments using patient-derived data. We share the environments and deformation data publicly by adding them to the Medical Robotics Anatomical Dataset (Med-RAD), our public dataset of anatomical environments for medical robots

The past, current and future of diagnosis and management of pleural disease

Pleural disease is frequently encountered by the chest physician. Pleural effusions arise as the sequelae of underlying disease processes including pressure/volume imbalances, infection and malignancy. In addition to pleural effusions, persistent air leaks after surgery and bronchopleural fistulae remain a challenge. Our understanding of pleural disease including its diagnosis and management, have made tremendous strides. The introduction of the molecular detection of organism specific infection, risk stratification and improvements in the non-surgical treatment of patients with pleural infection are all within reach and may be the standard of care in the very near future. Malignant pleural effusion management continues to evolve with the introduction of tunneled pleural catheters and procedures combining that and chemical pleurodesis. These advances in the diagnostic and therapeutic evaluation of pleural disease as well as what seems to be an increasing multidisciplinary interest in the space foretell a bright future

Endobronchial ultrasound transbronchial needle aspiration: a hybrid method

Conventional transbronchial needle aspiration (cTBNA) was first performed approximately 30 years ago; however TBNA was not widely adopted until the development of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA). Current EBUS-TBNA needle sizes are limited to 21- and 22-gauge. In order to determine whether a 19-gauge (19G) needle in EBUS-TBNA can further improve the diagnostic yield and simplify the methodology of EBUS-TBNA we developed a hybrid method. Here we report our initial experience in assessing the feasibility of performing EBUS-TBNA using a conventional 19G TBNA needle

Autonomous Medical Needle Steering In Vivo

The use of needles to access sites within organs is fundamental to many interventional medical procedures both for diagnosis and treatment. Safe and accurate navigation of a needle through living tissue to an intra-tissue target is currently often challenging or infeasible due to the presence of anatomical obstacles in the tissue, high levels of uncertainty, and natural tissue motion (e.g., due to breathing). Medical robots capable of automating needle-based procedures in vivo have the potential to overcome these challenges and enable an enhanced level of patient care and safety. In this paper, we show the first medical robot that autonomously navigates a needle inside living tissue around anatomical obstacles to an intra-tissue target. Our system leverages an aiming device and a laser-patterned highly flexible steerable needle, a type of needle capable of maneuvering along curvilinear trajectories to avoid obstacles. The autonomous robot accounts for anatomical obstacles and uncertainty in living tissue/needle interaction with replanning and control and accounts for respiratory motion by defining safe insertion time windows during the breathing cycle. We apply the system to lung biopsy, which is critical in the diagnosis of lung cancer, the leading cause of cancer-related death in the United States. We demonstrate successful performance of our system in multiple in vivo porcine studies and also demonstrate that our approach leveraging autonomous needle steering outperforms a standard manual clinical technique for lung nodule access.Comment: 22 pages, 6 figure

Pleural Fluid Resolution Is Associated with Improved Survival in Patients with Malignant Pleural Effusion

Malignant pleural effusion is associated with a poor prognosis and, while risk stratification models exist, prior studies have not evaluated pleural fluid resolution and its association with survival. We performed a retrospective review of patients diagnosed with malignant pleural effusion between 2013 and 2017, evaluating patient demographics, pleural fluid and serum composition, and procedural and treatment data using Cox regression analysis to evaluate associations with survival. In total, 123 patients were included in the study, with median survival from diagnosis being 4.8 months. Resolution of malignant pleural fluid was associated with a significant survival benefit, even when accounting for factors such as placement of an indwelling pleural catheter, anti-cancer therapy, pleural fluid cytology, cancer pheno/genotypes, and pleural fluid characteristics. Elevated fluid protein, placement of an indwelling pleural catheter, and treatment with targeted or hormone therapies were associated with pleural fluid resolution. We conclude that the resolution of pleural fluid accumulation in patients with malignant pleural effusion is associated with a survival benefit possibility representing a surrogate marker for treatment of the underlying metastatic cancer. These findings support the need to better understand the mechanism of fluid resolution in patients with malignant pleural effusion as well as the tumor–immune interplay occurring with the malignant pleural space

Electromagnetic Transthoracic Nodule Localization for Minimally Invasive Pulmonary Resection

Background: Increased use of chest computed tomography and the institution of lung cancer screening have increased the detection of ground-glass and small pulmonary nodules. Intraoperative localization of these lesions via a minimally invasive thoracoscopic approach can be challenging. We present the feasibility of perioperative transthoracic percutaneous nodule localization using a novel electromagnetic navigation platform. Methods: This is a multicenter retrospective analysis of a prospectively collected database of patients who underwent perioperative electromagnetic transthoracic nodule localization before attempted minimally invasive resection between July 2016 and March 2018. Localization was performed using methylene blue or a mixture of methylene blue and the patient's blood (1:1 ratio). Patient, nodule, and procedure characteristics were collected and reported. Results: Thirty-one nodules were resected from 30 patients. Twenty-nine of 31 nodules (94%) were successfully localized. Minimally invasive resection was successful in 93% of patients (28/30); 7% (2/30) required conversion to thoracotomy. The median nodule size was 13 mm (interquartile range 25%-75%, 9.5-15.5), and the median depth from the surface of the visceral pleura to the nodule was 10 mm (interquartile range 25%-75%, 5.0-15.9). Seventy-one percent (22/31) of nodules were malignant. No complications associated with nodule localization were reported. Conclusions: The use of intraoperative electromagnetic transthoracic nodule localization before thoracoscopic resection of small and/or difficult to palpate lung nodules is safe and effective, potentially eliminating the need for direct nodule palpation. Use of this technique aids in minimally invasive localization and resection of small, deep, and/or ground-glass lung nodules

Safety and diagnostic performance of pulmonologists performing electromagnetic guided percutaneous lung biopsy (SPiNperc)

Background and objectivePercutaneous lung biopsy for diagnostic sampling of peripheral lung nodules has been widely performed by interventional radiologists under computed tomography (CT) guidance. New technology allows pulmonologists to perform percutaneous lung biopsies using electromagnetic (EM) guided technology. With the adoption of this new technique, the safety, feasibility and diagnostic yield need to be explored. The goal of this study was to determine the safety, feasibility and diagnostic yield of EMâ guided percutaneous lung biopsy performed by pulmonologists.MethodsWe conducted a retrospective, multicentre study of 129 EMâ guided percutaneous lung biopsies that occurred between November 2013 and March 2017. The study consisted of seven academic and three community medical centres.ResultsThe average age of participants was 65.6â years, BMI was 26.3 and 50.4% were females. The majority of lesions were in the right upper lobe (37.2%) and left upper lobe (31.8%). The mean size of the lesions was 27.31â mm and the average distance from the pleura was 13.2â mm. Practitioners averaged two fineâ needle aspirates and five core biopsies per procedure. There were 23 (17.8%) pneumothoraces, of which 16 (12.4%) received smallâ bore chest tube placement. The diagnostic yield of percutaneous lung biopsy was 73.7%. When EMâ guided bronchoscopic sampling was also performed during the same procedural encounter, the overall diagnostic yield increased to 81.1%.ConclusionIn this large multicentred series, the use of EM guidance for percutaneous lung biopsies was safe and feasible, with acceptable diagnostic yield in the hands of pulmonologists. A prospective multicentre trial to validate these findings is currently underway (NCT03338049).Lung cancer screening has led to the discovery of over 1â million pulmonary nodules each year. New technology allows pulmonologists to perform percutaneous lung biopsies using electromagnetic (EM) guided technology. In this retrospective analysis, we demonstrate that EM percutaneous needle biopsy is safe, feasible and provides an acceptable diagnostic yield.See related EditorialPeer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149341/1/resp13471.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149341/2/resp13471_am.pd

Feasibility of a prototype carbon nanotube enabled stationary digital chest tomosynthesis system for identification of pulmonary nodules by pulmonologists

Background: Screen detected and incidental pulmonary nodules are increasingly common. Current guidelines recommend tissue sampling of solid nodules >8 mm. Bronchoscopic biopsy poses the lowest risk but is paired with the lowest diagnostic yield when compared to CT-guided biopsy or surgery. A need exists for a safe, mobile, low radiation dose, intra-procedural method to localize biopsy instruments within target nodules. This retrospective cross sectional reader feasibility study evaluates the ability of clinicians to identify pulmonary nodules using a prototype carbon nanotube radiation enabled stationary digital chest tomosynthesis system. Methods: Patients with pulmonary nodules on prior CT imaging were recruited and consented for imaging with stationary digital chest tomosynthesis. Five pulmonologists of varying training levels participated as readers. Following review of patient CT and a thoracic radiologist’s interpretation of nodule size and location the readers were tasked with interpreting the corresponding tomosynthesis scan to identify the same nodule found on CT. Results: Fifty-five patients were scanned with stationary digital chest tomosynthesis. The median nodule size was 6 mm (IQR =4–13 mm). Twenty nodules (37%) were greater than 8 mm. The radiation entrance dose for s-DCT was 0.6 mGy. A significant difference in identification of nodules using s-DCT was seen for nodules <8 vs. ≥8 mm in size (57.7% vs. 90.9%, CI: −0.375, −0.024; P<0.001). Inter-reader agreement was fair, and better for nodules ≥8 mm [0.278 (SE =0.043)]. Conclusions: With system and carbon nanotube array optimization, we hypothesize the detection rate for nodules will improve. Additional study is needed to evaluate its use in target and tool co-localization and target biopsy