Background and objective The diagnostic yield of electromagnetic navigation bronchoscopy (ENB) is inferior to that of computed tomography (CT)‐guided needle biopsy for pulmonary nodules. One explanation for this is divergence between the nodule location on the pre‐procedure CT scan and its actual location during the procedure. Fluoroscopic ENB (F‐ENB) consists of digital tomosynthesis using a conventional C‐arm to re‐register the target lesion based on near real‐time imaging. We performed a retrospective review of ENB cases at our institution before and after introduction of F‐ENB to assess diagnostic yield. Methods All consecutive ENB procedures performed at our institution from 25 December 2017 to 25 August 2018 were reviewed. F‐ENB was introduced on 25 April 2018. Two cohorts were analysed: standard ENB (S‐ENB) from 25 December 2017 to 24 April 2018 and F‐ENB from 25 April 2018 to 25 August 2018. All procedural, demographic and diagnostic data were collected. Descriptive statistics, chi‐square, Wilcoxon test and Student's t‐test were used where appropriate. A multivariable regression analysis was performed to assess factors associated with diagnostic yield. Results A total of 101 and 67 nodules were biopsied in the S‐ENB and F‐ENB groups, respectively. Diagnostic yield was 54% in S‐ENB cohort and 79% in the F‐ENB group (P = 0.0019). Factors independently associated with a positive diagnosis were F‐ENB and a positive radial ultrasound view (odds ratio (OR): 3.57, 95% CI: 1.56–8.18 and OR: 3.74, 95% CI: 1.37–11.05, respectively). Complications were minimal (pneumothorax: 1.5%). Conclusion The use of F‐ENB may increase the diagnostic yield of ENB and has a low complication rate.

Background: In patients with non-expandable lung, pleural fluid removal can result in excessively negative pleural pressure, associated with chest discomfort, pneumothorax, and reexpansion pulmonary edema. Monitoring pleural pressure during thoracentesis may reduce discomfort and protect against complications. Methods: In this prospective randomized single-blind trial, subjects with large pleural effusions at two academic medical centers were randomly assigned (1:1 ratio) to symptom-guided ("control") versus symptom-plus-manometry-guided ("manometry") thoracentesis. All had free-flowing effusions meeting pre-specified criteria suggesting volume of at least 500 milliliters. Subjects, who were blinded to assignment, rated chest discomfort on visual analog scales before, during, and after drainage. Pleural pressure was measured at regular intervals in the manometry group. Drainage was discontinued before complete evacuation for persistent chest discomfort, incessant cough, complication, rapidly falling pleural pressure, or end-expiratory pleural pressure lower than-20 cm H2O (latter two only in the manometry group). We performed a modified intention-to-treat analysis. The primary outcome was overall procedural chest discomfort through 5 minutes post-procedure. This trial was registered at clinicaltrials.gov, NCT02677883. Findings: Between March 4, 2016 and September 8, 2017, 191 patients were screened. One hundred twenty-eight eligible subjects were randomized with four excluded from the final analysis of 62 subjects per group due to manometer malfunction (n=2), inability to access effusion due to pleural tumor burden (n=1), and inability to remain seated (n=1). There was no difference in the primary outcome of overall procedural chest discomfort between groups (mean difference 2.4, 95% CI-5.7-10.5; p = 0.78). Six asymptomatic pneumothoraces ex-vacuo occurred in the control group; no serious complications occurred in either group. Interpretation: Measurement of pleural pressure during large-volume thoracentesis does not alter procedure-related chest discomfort. This is the first study to directly assess the impact of pleural manometry on important patient-centered clinical outcomes during thoracentesis, and does not support its routine use. Funding: Centurion Medical Products PANEL: RESEARCH IN CONTEXT Evidence before this study Chest discomfort, reexpansion pulmonary edema, and pneumothorax ex-vacuo complicating thoracentesis have been associated with development of excessively negative pleural pressure in the setting of nonexpandable lung. Routine pleural manometry during aspiration has been advocated as potentially protective against these complications, but prospective comparative studies are lacking. Added value of this study This is the first prospective, randomized trial of routine pleural manometry during therapeutic thoracentesis for important clinical and patient-centered outcomes. Manometry did not reduce chest discomfort and there were no serious complications in either group. Implications of all the ava...

Background: Navigational bronchoscopy is commonly used to sample lung nodules, with a better safety profile but lower diagnostic yield than computerized tomography-guided transthoracic needle biopsy. The addition of digital tomosynthesis to electromagnetic navigation, using intraprocedural images obtained from a C-arm fluoroscope to identify target lesion location and update navigational guidance, may improve diagnostic yield.Methods: Consecutive bronchoscopies using tomosynthesis-assisted fluoroscopic electromagnetic navigational bronchoscopy (F-ENB) at a single institution over a 1-year period were included. The primary outcome was diagnostic yield. A bronchoscopy was defined as diagnostic if pathologic examination revealed malignancy or specific histological findings indicative of lesional sampling with confirmatory 6-month follow-up for benign lesions.

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Surgical lung biopsy (SLB) in diffuse parenchymal lung disease (DPLD) has been associated with significant in-hospital mortality (16% for non-elective patients, 1.7% for elective patients, overall 6.4%) [1,2]. Overall 30-day mortality from SLB is reported at 1.5-4.5% from case series and 2.4% from a large European database [3]. Transbronchial cryobiopsy (TBC) has been proposed as a safer alternative to SLB for diagnosis of DPLD [4]. Existing studies on TBC report immediate procedural complications, but data on mortality at 30 and 90 days is sparse [2]. This is a report of 30-and 90-day mortality after TBC at a large volume interventional pulmonary practice in the USA examined in relation to indices of baseline disease severity. Individual case elements that led to practice changes are described. These descriptions elucidate clinical features potentially portending an increased risk of poor outcome.