Um protocolo foi aprovado pelo Institutional Review Board locais (IRB). Os participantes fornecem assinaram o consentimento informado antes de completar o protocolo. 1. Pré-procedimento <ol><li> Certifique-se que os candidatos ao eletromagnética navegação aspiração com agulha transtorácica tem um nódulo pulmonar periférica. Determinar o uso nódulo pulmonar de imaginar estudos. NOTA: O mais comum e necessário para este protocolo é avaliando CT peito obtido anteriormente. </li><li> No dia do procedimento anexar as almofadas de ponto de referência electrónicos para o hemitórax contralateral da lesão alvo para minimizar a sobreposição do rato com o ponto de entrada TTNA biópsia. Obter uma linha de base inspiratória e tomografia de tórax sem contraste expiratório com intervalos de 0.5 mm e 0,67 - 0,75 milímetros de espessura. </li><li> Transfira a imagem digital e de comunicação de dados em medicina (DICOM) do scanner CT para o software de planejamento. Se DICOM não estiver disponível, uma cópia do disco compacto (CD) do CT podem ser carregados diretamente no sistema de planejamento. Selecione Digital da lesão alvo e reconstruir um mapa das vias aéreas tridimensional virtual. </li><li> Transportar o paciente de maca do scanner CT para a suíte broncoscopia com pontos de referência electrónicos em vigor. </li><li> Avaliar o paciente para a anestesia, estabelecer o acesso IV e anexar monitorização anestésica padrão. </li></ol> class = &quot;jove_title&quot; 2. Procedimento (Fase Bronchoscopic) <ol><li> Transferir o paciente para o conjunto de broncoscopia. Administrar anestesia sedação profunda usando uma infusão de propofol (100-200 mcg / kg / min). Uma via aérea é estabelecida com máscara laríngea (LMA) ou tubo endotraqueal traqueal (ETT). NOTA: Anestesia só pode ser administrada por um fornecedor de certificado. </li><li> Faça uma inspeção branco broncoscopia leve (WLB) na forma padrão examinando a árvore brônquica ao nível segmentar. </li><li> Executar uman EBUS-TBNA após a Associação Internacional para o Estudo do Câncer de Pulmão (IASLC) mapa do linfonodo para estadiamento do câncer de pulmão. Se estiver disponível, aspiração com agulha fina (PAAF) espécimes são citológico analisados ​​no local. Se não, a amostra é o lugar em formalina para posterior avaliação. </li><li> Use o broncoscópio WLB com a fase REM programa broncoscopia após o anteriormente reconhecido computador ou manualmente aplainada via endobrônquica à lesão alvo com um instrumento de escolha a critério procedimentalistas (escova de Citologia, as forças de biópsia de mandíbula, FNA Needle). </li><li> Avance o R-EBUS através do canal de trabalho e tentar confirmar o local da lesão. </li><li> Uma vez no destino, provar a lesão com o operador seleccionado rastreável instrumento usado para navegar. (Citologia escova, as forças de biópsia de mandíbula, FNA Needle). </li><li> Se o alvo é incapaz de ser verificada por EBUS radial ou a anatomia das vias aéreas proíbe navegação endobrônquica remover o broncoscópio e preparar tele paciente de uma abordagem transtorácica. Se a lesão não pode ser diagnosticada broncoscopicamente preparar o paciente para uma abordagem transtorácica. </li></ol> 3. Procedimento (Electromagnetic Transthoracic Agulha aspiração) <ol><li> Alocar todos os suprimentos necessários para o TTNA. (Ver Tabela Material) </li><li> Posicione o paciente em decúbito dorsal em uma forma similar usado para tomografia computadorizada de tórax de aquisição de imagem de varredura. </li><li> Usando uma agulha de navegação electromagnética teste seleccionar o ponto de entrada para a cavidade torácica e marcá-lo na superfície da pele. Ponto de entrada deve ser superior à superfície da nervura mais próxima e evitar estruturas ósseas e qualquer estrutura vascular. </li><li> Prepare a pele com a solução de clorexidina a 2%, armar o campo usando uma técnica estéril e anestesiar localmente (infiltração subcutânea de cerca de 1 a 2 cc de lidocaína a 1%). </li><li> Inserir a agulha estéril de navegação electromagnética na parte superior do ponto de entrada eselecionar o ângulo ao alvo com base na observação do transverso e coronal vistos nas telas do sistema eletromagnéticas. (Retículo marca em pelo menos dois planos diferentes). </li><li> Estabilizar a agulha e firmemente avançado através da parede torácica na lesão-alvo. </li><li> Retirar o estilete da agulha orientação da agulha e tomar cuidado para evitar o movimento da agulha. Neste ponto extremo cuidado deve ser usado para evitar o deslocamento da agulha inadvertida. Cobrir o centro da agulha com o dedo. Insira a 20 G FNA agulha através da agulha G 19. Experimente a lesão e fornecer a amostra para ROSE. </li><li> Programar a biópsia automática da agulha para a distância desejada ou jogar com base no tamanho da lesão, e inseri-la através da agulha G 19. Estabilizar tanto agulha e biópsia arma, disparar o mecanismo arma biópsia por agulha para realizar a biópsia e retire do interior do guia da agulha de navegação eletromagnética ter certeza que ele permanece na posição apropriadaition. </li><li> Suavemente avançar a sonda de orientação para trás para dentro do lúmen da agulha percutânea e mantê-lo estável. </li><li> Enquanto a agulha é continuamente estabilizado, o assistente usa a lâmina de bisturi para remover suavemente a amostra a partir da cânula interna da biópsia por agulha e coloque-o no 1/2 x 1/2 polegada previamente cortado almofada anti aderente. Mergulhe o pad em uma solução de formol. </li><li> Reconfirmar colocação apropriada da agulha no interior da lesão e, em seguida, repita a operação 4 a 5 vezes certificando-se de que a agulha do núcleo é girado no sentido horário ou anti-horário para provar diferentes áreas. </li><li> Uma vez satisfeito com os espécimes remover a agulha, aplique pressão e colocar um pequeno curativo sobre o sítio de punção. </li></ol> 4. Pós Procedimento <ol><li> Se disponíveis, realizar ultrassonografia cabeceira para avaliar a presença de pulmão deslizante (ausência de pneumotórax) ou utilizar qualquer outra modalidade de imagem (fluoroscopia, etc). </li><li> Transferir opaciente para a área de recuperação e observar no âmbito de protocolos de unidade cirúrgicos ambulatoriais normais antes de totalmente acordado. </li><li> Obter uma radiografia de tórax para descartar complicações. </li><li> Quitação paciente para casa após a educação é fornecida sobre as potenciais complicações do procedimento pós incluindo hemorragia e pneumotórax. </li></ol>

<ol>
	<li>Govert, J. A., Dodd, L. G., Kussin, P. S., Samuelson, W. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective+comparison+of+fiberoptic+transbronchial+needle+aspiration+and+bronchial+biopsy+for+bronchoscopically+visible+lung+carcinoma.">A prospective comparison of fiberoptic transbronchial needle aspiration and bronchial biopsy for bronchoscopically visible lung carcinoma.</a> Cancer. 87, 129-134 (1999).</li><li>Gasparini, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bronchoscopic+biopsy+techniques+in+the+diagnosis+and+staging+of+lung+cancer.">Bronchoscopic biopsy techniques in the diagnosis and staging of lung cancer.</a> Monaldi Arch Chest Dis. 52, 392-398 (1997).</li><li>. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=United+States+cancer+statistics:+1999-2010+incidence+and+mortality+web-based+report.">United States cancer statistics: 1999-2010 incidence and mortality web-based report.</a> US Department of Health and Human Services Centers for Disease Control and Prevention and National Cancer Institute. , (2014).</li><li>Silvestri, G. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Methods+for+staging+non-small+cell+lung+cancer:+Diagnosis+and+management+of+lung+cancer,+3rd+ed:+American+College+of+Chest+Physicians+evidence-based+clinical+practice+guidelines.">Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.</a> Chest. 143, e211S-e250S (2013).</li><li>Steinfort, D. P., Khor, Y. H., Manser, R. L., Irving, L. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radial+probe+endobronchial+ultrasound+for+the+diagnosis+of+peripheral+lung+cancer:+systematic+review+and+meta-analysis.">Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis.</a> The European respiratory journal. 37, 902-910 (2011).</li><li>Gex, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+yield+and+safety+of+electromagnetic+navigation+bronchoscopy+for+lung+nodules:+a+systematic+review+and+meta-analysis.">Diagnostic yield and safety of electromagnetic navigation bronchoscopy for lung nodules: a systematic review and meta-analysis.</a> Respiration; international review of thoracic diseases. 87, 165-176 (2014).</li><li>Wang Memoli, J. S., Nietert, P. J., Silvestri, G. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis+of+guided+bronchoscopy+for+the+evaluation+of+the+pulmonary+nodule.">Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule.</a> Chest. 142, 385-393 (2012).</li><li>Lee, K. A., Raval, A. A., Amir, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cost-effectiveness+of+endobronchial+percutaneous+biopsy+compared+with+transthoracic+biopsy+for+diagnosis+of+peripheral+lung+lesions.">Cost-effectiveness of endobronchial percutaneous biopsy compared with transthoracic biopsy for diagnosis of peripheral lung lesions.</a> Lung Cancer Management. 3 (2), 135-148 (2014).</li><li>Rivera, M. P., Mehta, A. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+College+of+Chest,+P.+Initial+diagnosis+of+lung+cancer:+ACCP+evidence-based+clinical+practice+guidelines+(2nd+edition).">American College of Chest, P. Initial diagnosis of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition).</a> Chest. 132, 131S-148S (2007).</li><li>Wiener, R. S., Schwartz, L. M., Woloshin, S., Welch, H. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Population-based+risk+for+complications+after+transthoracic+needle+lung+biopsy+of+a+pulmonary+nodule:+an+analysis+of+discharge+records.">Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records.</a> Annals of internal medicine. 155, 137-144 (2011).</li></ol>

Os autores receberam financiamento da investigação que foi fornecida pelo Veran Medical Technologies Inc., que produz os instrumentos EM e TTNA utilizados nesta publicação.

Orientação eletromagnética facilita a técnica de biópsia transtorácica percutânea. É fundamental durante o procedimento para verificar a calibração do equipamento adequado. Durante a manutenção de uma agulha de inserção ângulo constante e manter o alinhamento visuais usando pelo menos dois planos diferentes é essencial para alcançar efetivamente a lesão-alvo. Profundidade de inserção da agulha pode ser modificado entre biópsias para maximizar a área de cobertura. De um modo preferido, o procedimento pode ser assistida por um segundo operador, especialmente no momento da operação de arma biópsia, mas um procedimento único operador é viável. Familiarização com os instrumentos e técnica leva aproximadamente 2 a 3 agulha inserções. Se o treinamento disponível em modelos fantasmas ou modelos de cadáveres sob supervisão direta de um operador experiente é aconselhável. Eletromagnética navegação agulha aspiração transtorácica (E-TTNA) é uma nova tecnologia que complementam a curalugar arsenal para o diagnóstico de nódulos pulmonares periféricos. Potenciais limitações do procedimento são inerentes à tecnologia de navegação eletromagnética, como a CT divergência corpo e relacionado com a natureza dinâmica do sistema respiratório. Recomendamos antecipação para a gestão de complicações como pneumotórax e sangramento deve ser tomado durante todo o procedimento percutâneo. Neste artigo vamos descrever como o E-TTNA é realizada pelo pneumologista intervencionista ea incorporação da técnica para os atuais métodos broncoscópicos disponíveis para a avaliação de nódulos pulmonares. E-TTNA potencialmente pode reduzir a necessidade de outros procedimentos percutâneos imagem guiada transtorácicas proporcionando plena integração da broncoscopia e técnicas não broncoscópicas em um único procedimento potencialmente aumentando rendimento diagnóstico, melhorando a segurança e diminuindo o número total de procedimentos. Mais estudos são precisarEd para determinar a utilidade clínica desta técnica de biópsia moderna.

Um nódulo pulmonar solitário (SPN) é um cenário clínico frequente que está a aumentar devido ao número de exames de tórax radiográficos e da implementação de programas de rastreio do cancro do pulmão. Um nódulo do pulmão, por definição, é inferior a 3 cm de diâmetro e que normalmente está além dos brônquios segmentares broncoscopicamente visualizado. Uma lesão diâmetro superior a 3 cm é considerada uma massa de pulmão. As etiologias da maioria dos nódulos pulmonares são condições benignas (infecções, inflamatórios, vasculares) e em uma porcentagem menor são causadas por câncer de pulmão e outras doenças malignas. Avaliação de um SPN começa com a avaliação de fatores de risco, características radiográficas, tamanho, crescimento, localização, risco cirúrgico, etc. A estratificação de risco ajuda a selecionar a gestão individual mais adequado, que varia de vigilância radiológica para ressecção cirúrgica primária. Modalidades de diagnóstico incluem técnicas broncoscópicas: (lavado bronco-alveolar (LBA), escova de citologia, transbbiópsia ronchial (TBBx), aspiração com agulha transbrônquica (TBNA), sonda de ultra-som endobrônquica radial (R-EBUS), navegação eletromagnética (REM), ultrafinos broncoscopia, navegação broncoscopia virtual) e não-bronchoscopic: imagem guiada transtorácica biópsia por agulha e ressecção cirúrgica. O rendimento bronchoscopic usando técnicas simples convencionais para lesões menos &lt;3 centímetros varia de 14 -. 50% 1,2 cancro do pulmão continua a ser a principal causa de mortes por câncer. Ela representa 14% de todos os cânceres invasivos diagnosticados a cada ano e 28% de todas as mortes por câncer nos Estados Unidos. 3 Prognóstico e gestão de tratamento são determinados pelo palco. O estadiamento do cancro do pulmão de células não pequenas (NSCLC) é definido pelo sistema TNM. Determinação do N ou o status nodal exige uma avaliação rigorosa dos gânglios linfáticos do mediastino e hilares. Ultra-som endobrônquica (EBUS) é uma técnica minimamente invasiva que broncoscopia usars ultra-som para identificar estruturas contíguas para as vias aéreas, facilitando aspiração com agulha transbrônquica (TBNA). Para o câncer de pulmão de encenar uma meta-análise recente relatou uma sensibilidade média de 89% com valores que variam de 46% a 97% e um valor preditivo negativo PV médio de 91% para EBUS-TBNA. 4 Radial EBUS é outra ferramenta que pode ser bronchoscopic utilizados para localizar lesões do parênquima pulmonar. É um instrumento de 1,4 milímetros de diâmetro, com uma sonda de ultra-som de 20 MHz na ponta 360 que gera imagens com um grau de penetração de 5 cm. Recentemente relatou dados desta técnica mostrou uma sensibilidade de identificar neoplasia de 73% (IC 95%, ,70-0,76) para nódulos de qualquer tamanho e 71% (IC 95%, 0,66-0,75) para lesões menores do que 2,5 cm 5. Electromagnético de Navegação broncoscopia (ENB) é uma tecnologia que cria um campo magnético em torno do paciente permitindo a determinação da localização espacial de um dispositivo sensor dentro do campo magnético. Tsuas informações são sobrepostas nas imagens previamente obtidos tomografia computadorizada (TC), que permitem a visualização da localização dos sensores em relação à anatomia. Uma reconstrução broncoscopia virtual das vias aéreas do paciente facilita a navegação para a lesão alvo. Uma vez no destino, as amostras são colhidas diretamente usando uma das duas tecnologias disponíveis; instrumentos broncoscópicos rastreável ou através de um canal de trabalho estendida. A precisão do diagnóstico global foi 73,9% (CI de 95% 68,0% - 79,2%) e valor preditivo negativo 52,1% (IC 95% 43,5% - 60,6%) e quando se utiliza pelo menos uma das outras tecnologias (broncoscopia virtual, de ENB, Radial- EBUS, orientar bainha, ultrafino broncoscópio) o rendimento do diagnóstico foi de 70,0% com um IC 95% de 67,1% para 72,9% 6 7 Um dos sistemas disponíveis no mercado tem o recurso adicional para complementar a navegação bronchoscopic com a capacidade de converter de uma abordagem bronchoscopic para uma abordagem transtorácica agulha no casos onde a lesão não é capaz de ser acessado broncoscopicamente. Este sistema utiliza uma navegação guiada electromagnética 19 L de seguimento agulha que permite a recolha de amostras de biópsias do pulmão do núcleo utilizando um dispositivo automático de biópsia 20 L. Aspirativa por agulha transtorácica (TTNA) é um método diagnóstico não bronchoscopic para nódulos pulmonares e massas. TTNA de uma lesão pulmonar periférico pode ser realizada sob ultra-sonografia, fluoroscopia, a tomografia computadorizada ou a orientação eletromagnética. Em uma meta-análise atualizada por Rivera et al a sensibilidade combinada de TTNA para o diagnóstico de carcinoma broncogênico periférica foi de 0,90 (IC 95%, 0,88-0,91). 8 Em um estudo realizado por Wiener RS, que incluiu 15.865 pacientes com um risco relatado de pneumotórax após TTNA de 15% (IC 95%, 14% - 16%), com 7% (IC 95%, 6% - 7,2%). exige gestão com um dreno de tórax 9 ensaios clínicos que investigam a utilização de E-TTNA Atualmente andamento. CASE PRETação Um ex-fumante do sexo feminino de 83 anos com doença crônica dependente de oxigênio pulmonar obstrutiva foi encontrada por acaso com um PET fluorodeoxiglicose ávido 1,6 x 1,3 centímetros espiculado no lobo superior (LSD) nódulo direita (Figura 1). Embora sua probabilidade de malignidade foi alta, a paciente recusou intervenções cirúrgicas e optou por um procedimento de diagnóstico antes de considerar outras terapias. O cenário típico que podem levar à consideração para uma avaliação para biópsia seria um caso de probabilidade intermediária para malignidade ou com uma alta probabilidade de malignidade com uma contra-indicação para ressecção cirúrgica.

<table border="0" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td>20 G x 15 cm Programmable automatic biopsy needle</td>
			<td>SuperCore Argon Medical devices</td>
			<td align="right">701120150</td>
			<td></td>
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		<tr>
			<td>Non Adherent Pads</td>
			<td>Telfa&#160;</td>
			<td></td>
			<td></td>
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			<td>Sterile scissor</td>
			<td></td>
			<td></td>
			<td></td>
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			<td>2% chlorhexidine gluconate pad</td>
			<td></td>
			<td></td>
			<td></td>
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			<td>Surgical Blade #11</td>
			<td></td>
			<td></td>
			<td></td>
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			<td>Sterile surgical drape</td>
			<td></td>
			<td></td>
			<td></td>
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			<td>1% lidocaine</td>
			<td></td>
			<td></td>
			<td></td>
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		<tr>
			<td>Sterile gowns</td>
			<td></td>
			<td></td>
			<td></td>
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		<tr>
			<td>Sterile gloves</td>
			<td></td>
			<td></td>
			<td></td>
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		<tr>
			<td>Mask</td>
			<td></td>
			<td></td>
			<td></td>
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			<td>Scrub hair cap</td>
			<td></td>
			<td></td>
			<td></td>
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		<tr>
			<td>Electronic reference points&#160;</td>
			<td>vPAD2 (Veran Medical Technologies)</td>
			<td>INS-0049</td>
			<td></td>
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		<tr>
			<td>Planning software&#160;</td>
			<td>SPiNDrive&#160;2.0 (Veran Medical Technologies)&#160;</td>
			<td></td>
			<td></td>
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			<td>Eelectromagnetic navigation platform</td>
			<td>SPiNView (Veran Medical Technologies)</td>
			<td></td>
			<td></td>
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		<tr>
			<td>19 G x 105 mm Electromagnetic navigational needle</td>
			<td>SPiNPerc&#160; Veran Medical Technologies</td>
			<td>INS-0029</td>
			<td></td>
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		<tr>
			<td>Standard diagnostic Fiberoptic Bronchoscope</td>
			<td></td>
			<td></td>
			<td></td>
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		<tr>
			<td>EBUS Bronchoscope</td>
			<td></td>
			<td></td>
			<td></td>
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		<tr>
			<td>Radial EBUS probe UM-S20-17S</td>
			<td>Olympus</td>
			<td></td>
			<td></td>
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			<td>Formaldehyde-based fixative solution.</td>
			<td></td>
			<td></td>
			<td></td>
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		<tr>
			<td>Ethanol based fixative</td>
			<td></td>
			<td></td>
			<td></td>
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use of electromagnetic navigational transthoracic needle aspiration (e-ttna) for sampling of lung nodules

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently available to sample nodules for pathological diagnosis. Those technologies can be divided into bronchoscopic and non-bronchoscopic interventions. Electromagnetic navigational bronchoscopy is being extensively used for the endobronchial approach to peripheral lung nodules but has been hindered by anatomic challenges resulting in a 70% diagnostic yield. Electromagnetic navigational guided transthoracic needle lung biopsy is novel non-bronchoscopic method that uses a percutaneous electromagnetic tip tracked needle to obtain core biopsy specimens. Electromagnetic navigational transthoracic needle aspiration complements bronchoscopic techniques potentially allowing the provider to maximize the diagnostic yield during one single procedure. This article describes a novel integrated diagnostic approach to pulmonary lung nodules. We propose the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging; radial EBUS, navigational bronchoscopy and E-TTNA during one single procedure to maximize diagnostic yield and minimize the number of invasive procedures needed to obtain a diagnosis. This manuscript describes in detail how the navigation transthoracic procedure is performed. Additional clinical studies are needed to determine the clinical utility of this novel technology.

Todas as amostras de tecido obtidas por EBUS-TBNA e E-TTNA são processados ​​pelo laboratório central de patologia para análise posterior. Avaliação patológica das amostras inclui citológica e avaliação histológica. Avaliação rápida no local (ROSE) usa um corante de Romanowsky modificado que permite a avaliação de adequação e uma avaliação diagnóstica citomorfológico dos espécimes patológicos. Uma avaliação preliminar procedimento intra usando ROSE das biópsias EBUS-TBNA tiradas dos mediastino estações linfonodais 4L, 4R e 7 foi unrevealing de neoplasia óbvio. A fase bronchoscopic de navegação, apoiada com EBUS radial, não conseguiu localizar a lesão de lobo superior direito devido a limitações anatômicas. O procedimento foi rapidamente convertido em E-TTNA. E-TTNA foi realizada com sucesso e o tecido obtido foi suficiente para posterior análise patológica e genética. A patologia final das biópsias de amostras E-TTNA núcleo foi diagnóstica e consistente com adenocarcinoma. Sem complicações imediatas foram anotados. <img alt="Figura 1" src="/files/ftp_upload/52723/52723fig1.jpg" /> Figura 1. Tomografia computadorizada do tórax (Painel A) e Positron Emission Tomography (PET) (Painel B). Nódulo no lobo superior direito com um mediastino negativa PET. Escala em cm.

Watch this Scientific Journal Video about Use of Electromagnetic Navigational Transthoracic Needle Aspiration E-TTNA for Sampling of Lung Nodules at JoVE.com

Use of Electromagnetic Navigational Transthoracic Needle Aspiration E-TTNA for Sampling of Lung Nodules

We describe the novel use of electromagnetic navigational guided transthoracic needle aspiration for the pathologic assessment of human lung nodules.

Uso de Electromagnetic Navegação Transthoracic Agulha de Aspiração (E-TTNA) para amostragem de nódulos pulmonares

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently ...

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Nanyang Technological University

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JoVE Journal

Medicine

Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

22.2K visualizações.  Johns Hopkins University. We describe the novel use of electromagnetic navigational guided transthoracic needle aspiration for the pathologic assessment of human lung nodules. 

Vídeo: Use of Electromagnetic Navigational Transthoracic Needle Aspiration E-TTNA for Sampling of Lung Nodules

Transthoracic Echocardiography in Mice

In recent years, murine models have become the primary avenue for studying the molecular mechanisms of cardiac dysfunction resulting from changes in gene expression. Transgenic and gene targeting methods can be used to generate mice with altered cardiac size and function,1-3 and as a result, in vivo techniques are needed to evaluate their cardiac phenotype. Transthoracic echocardiography, pulse wave Doppler (PWD), and tissue Doppler imaging (TDI) can be used to provide dimensional measurements of the mouse heart and to quantify the degree of cardiac systolic and diastolic performance. Two-dimensional imaging is used to detect abnormal anatomy or movements of the left ventricle, whereas M-mode echo is used for quantification of cardiac dimensions and contractility.4,5 In addition, PWD is used to quantify localized velocity of turbulent flow,6 whereas TDI is used to measure the velocity of myocardial motion.7 Thus, transthoracic echocardiography offers a comprehensive method for the noninvasive evaluation of cardiac function in mice.

Transthoracic echocardiography offers a noninvasive method for the evaluation of cardiac function in mice. A combination of ultrasound and Doppler imaging modalities can be used to obtain dimensional measurements of the heart and intracardiac blood flow, which together provide an assessment of cardiac systolic and diastolic performance.

Ecocardiografia transtorácica em Ratos

In recent years, murine models have become the primary avenue for studying the molecular mechanisms of cardiac dysfunction resulting from changes in gene ...

Medicina

The Bovine Lung in Biomedical Research: Visually Guided Bronchoscopy, Intrabronchial Inoculation and In Vivo Sampling Techniques

There is an ongoing search for alternative animal models in research of respiratory medicine. Depending on the goal of the research, large animals as models of pulmonary disease often resemble the situation of the human lung much better than mice do. Working with large animals also offers the opportunity to sample the same animal repeatedly over a certain course of time, which allows long-term studies without sacrificing the animals.
The aim was to establish in vivo sampling methods for the use in a bovine model of a respiratory Chlamydia psittaci infection. Sampling should be performed at various time points in each animal during the study, and the samples should be suitable to study the host response, as well as the pathogen under experimental conditions.
Bronchoscopy is a valuable diagnostic tool in human and veterinary medicine. It is a safe and minimally invasive procedure. This article describes the intrabronchial inoculation of calves as well as sampling methods for the lower respiratory tract. Videoendoscopic, intrabronchial inoculation leads to very consistent clinical and pathological findings in all inoculated animals and is, therefore, well-suited for use in models of infectious lung disease. The sampling methods described are bronchoalveolar lavage, bronchial brushing and transbronchial lung biopsy. All of these are valuable diagnostic tools in human medicine and could be adapted for experimental purposes to calves aged 6-8 weeks. The samples obtained were suitable for both pathogen detection and characterization of the severity of lung inflammation in the host.

The Bovine Lung in Biomedical Research: Visually Guided Bronchoscopy, Intrabronchial Inoculation and In Vivo Sampling Techniques

This article describes bronchoscopic techniques in the bovine lung under experimental conditions, i.e. bronchoscopically guided inoculation, bronchoalveolar lavage, bronchial brushing, and transbronchial lung biopsy.

O pulmão bovino em Investigação Biomédica: visualmente guiada Broncoscopia, intrabrônquico Inoculação e<em&gt; In Vivo</em&gt; Técnicas de Amostragem

There is an ongoing search for alternative animal models in research of respiratory medicine. Depending on the goal of the research, large animals as ...

Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the lack of a standardized definition for STG. Biopsy is often required to differentiate benign from malignant lesions. Unlike cervical thyroid, the overlying sternum precludes ultrasound-guided percutaneous fine needle aspiration of STG. Consequently, surgical mediastinoscopy is performed in the majority of cases, causing significant procedure related morbidity and cost to healthcare. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a frequently used procedure for diagnosis and staging of non-small cell lung cancer (NSCLC). Minimally invasive needle biopsy for lesions adjacent to the airways can be performed under real-time ultrasound guidance using EBUS. Its safety and efficacy is well established with over 90% sensitivity and specificity. The ability to perform EBUS as an outpatient procedure with same-day discharges offers distinct morbidity and financial advantages over surgery. As physicians performing EBUS gained procedural expertise, they have attempted to diversify its role in the diagnosis of non-lymph node thoracic pathologies. We propose here a role for EBUS-TBNA in the diagnosis of substernal thyroid lesions, along with a step-by-step protocol for the procedure.

Substernal thyroid lesions are common, and need to be differentiated from malignancy. Obtaining percutaneous fine needle biopsy is not possible due to its retrosternal location. This article proposes a protocol for biopsy of substernal thyroid lesions using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA).

Substernal Tireóide Biópsia Usando endobrônquica guiada por ultrassom transbrônquica Punção Aspirativa por Agulha

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the ...

Open Tracheostomy Gastric Acid Aspiration Murine Model of Acute Lung Injury Results in Maximal Acute Nonlethal Lung Injury

Acid pneumonitis is a major cause of sterile acute lung injury (ALI) in humans. Acid pneumonitis spans the clinical spectrum from asymptomatic to acute respiratory distress syndrome (ARDS), characterized by neutrophilic alveolitis, and injury to both alveolar epithelium and vascular endothelium. Clinically, ARDS is defined by acute onset of hypoxemia, bilateral patchy pulmonary infiltrates and non-cardiogenic pulmonary edema. Human studies have provided us with valuable information about the physiological and inflammatory changes in the lung caused by ARDS, which has led to various hypotheses about the underling mechanisms. Unfortunately, difficulties determining the etiology of ARDS, as well as a wide range of pathophysiology have resulted in a lack of critical information that could be useful in developing therapeutic strategies.
Translational animal models are valuable when their pathogenesis and pathophysiology accurately reproduce a concept proven in both in vitro and clinical settings. Although large animal models (e.g., sheep) share characteristics of the anatomy of human trachea-bronchial tree, murine models provide a host of other advantages including: low cost; short reproductive cycle lending itself to greater data acquisition; a well understood immunologic system; and a well characterized genome leading to the availability of a variety of gene deletion and transgenic strains. A robust model of low pH induced ARDS requires a murine ALI that targets mainly the alveolar epithelium, secondarily the vascular endothelium, as well as the small airways leading to the alveoli. Furthermore, a reproducible injury with wide differences between different injurious and non-injurious insults is important.
The murine gastric acid aspiration model presented here using hydrochloric acid employs an open tracheostomy and recreates a pathogenic scenario that reproduces the low pH pneumonitis injury in humans. Additionally, this model can be used to examine interaction of a low pH insult with other pulmonary injurious entities (e.g., food particles, pathogenic bacteria).

This protocol induces acute lung injury in a mouse that has close fidelity to the pathogenesis of acid pneumonitis observed in humans. We generate a maximal acute nonlethal low pH lung injury and account for differences in rodent-human anatomic respiratory structure using an open tracheostomy coupled with circumferential pressure release.

Abrir traqueostomia ácido gástrico aspiração Modelo murino de lesão pulmonar aguda Resultados em Maximal aguda não-letal Lung Injury

Acid pneumonitis is a major cause of sterile acute lung injury (ALI) in humans. Acid pneumonitis spans the clinical spectrum from asymptomatic to acute ...

Transthoracic Speckle Tracking Echocardiography for the Quantitative Assessment of Left Ventricular Myocardial Deformation

The value of conventional echocardiography is limited by differences in inter-individual image interpretation and therefore largely dependent on the examiners&#39; expertise. Speckle tracking Echocardiography (STE) is a promising but technically challenging method that can be used to quantitatively assess regional and global systolic and diastolic myocardial performance. Myocardial strain and strain rate can be measured in all three dimensions&#160;&#8212; radial, circumferential, longitudinal &#8212; of myocardial deformation. Standard cross-sectional two-dimensional B-mode images are recorded and subsequently postprocessed by automated continuous frame-by-frame tracking and motion analysis of speckles within the myocardium. Images are recorded as digital loops and synchronized to a 3-lead EKG for timing purposes. Longitudinal deformation is assessed in the apical 4-, 3-, and 2-chamber views. Circumferential and radial deformation are measured in the parasternal short axis plane.
Optimal image quality and accurate tissue tracking are paramount for the correct determination of myocardial performance parameters. Utilizing transthoracic STE in a healthy volunteer, the present article is a detailed outline of the essential steps and potential pitfalls of quantitative echocardiographic myocardial deformation analysis.

Speckle tracking echocardiography is an emerging diagnostic imaging technique for the quantitative assessment of global and regional myocardial performance. Standard view echocardiographic motion images are recorded and deformation parameters are subsequently measured by automated continuous frame-by-frame tracking and motion analysis of speckles within the B-mode images of the myocardium.

Transtorácica salpico de rastreamento A ecocardiografia para a avaliação quantitativa do Ventrículo Esquerdo do miocárdio Deformação

The value of conventional echocardiography is limited by differences in inter-individual image interpretation and therefore largely dependent on the ...

Absorption of Nasal and Bronchial Fluids: Precision Sampling of the Human Respiratory Mucosa and Laboratory Processing of Samples

The methods of nasal absorption (NA) and bronchial absorption (BA) use synthetic absorptive matrices (SAM) to absorb the mucosal lining fluid (MLF) of the human respiratory tract. NA is a non-invasive technique which absorbs fluid from the inferior turbinate, and causes minimal discomfort. NA has yielded reproducible results with the ability to frequently repeat sampling of the upper airway. 
By comparison, alternative methods of sampling the respiratory mucosa, such as nasopharyngeal aspiration (NPA) and conventional swabbing, are more invasive and may result in greater data variability. Other methods have limitations, for instance, biopsies and bronchial procedures are invasive, sputum contains many dead and dying cells and requires liquefaction, exhaled breath condensate (EBC) contains water and saliva, and lavage samples are dilute and variable.
BA can be performed through the working channel of a bronchoscope in clinic. Sampling is well tolerated and can be conducted at multiple sites in the airway. BA results in MLF samples being less dilute than bronchoalveolar lavage (BAL) samples.
This article demonstrates the techniques of NA and BA, as well as the laboratory processing of the resulting samples, which can be tailored to the desired downstream biomarker being measured. These absorption techniques are useful alternatives to the conventional sampling techniques used in clinical respiratory research.

This manuscript describes the use of nasal and bronchial absorption techniques, specifically using synthetic absorptive matrices (SAM) to sample the mucosal lining fluid (MLF) of the upper and lower airway. These methods provide better standardization and tolerability than existing respiratory sampling techniques.

Absorção de fluidos nasais e brônquicas: amostragem de precisão da Mucosa respiratória humana e laboratório de processamento de amostras

The methods of nasal absorption (NA) and bronchial absorption (BA) use synthetic absorptive matrices (SAM) to absorb the mucosal lining fluid (MLF) of the ...

Echocardiographic Measurement of Right Ventricular Diastolic Parameters in Mouse

Diastolic dysfunction is a prominent feature of right ventricular (RV) remodeling associated with conditions of pressure overload. However, the RV diastolic function is rarely quantified in experimental studies. This might be due to technical difficulties in the visualization of the RV in the apical four-chamber view in rodents. Here we describe two positions facilitating the visualization of the apical four-chamber view in mice to assess the RV diastolic function.
The apical four-chamber view is enabled by tilting the mouse fixation platform to the left and caudally (LeCa) or to the right and cranially (RiCr). Both positions provide images of comparable quality. The results of the RV diastolic function obtained from two positions are not significantly different. Both positions are comparably easy to perform. This protocol can be incorporated into published protocols and enables detailed investigations of the RV function.

Here we describe and compare two positions for obtaining the apical four-chamber view in mice. These positions enable the quantification of the right ventricular function, provide comparable results, and can be used interchangeably.

Mensuração ecocardiográfica dos parâmetros diastólicos do ventrículo direito no mouse

Diastolic dysfunction is a prominent feature of right ventricular (RV) remodeling associated with conditions of pressure overload. However, the RV ...

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

Localização do nódulo transtorácico de navegação eletromagnética para cirurgia torácica minimamente invasiva

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

Generation of Human 3D Lung Tissue Cultures (3D-LTCs) for Disease Modeling

Translation of novel discoveries to human disease is limited by the availability of human tissue-based models of disease. Precision-cut lung slices (PCLS) used as 3D lung tissue cultures (3D-LTCs) represent an elegant and biologically highly relevant 3D cell culture model, which highly resemble in situ tissue due to their complexity, biomechanics and molecular composition. Tissue slicing is widely applied in various animal models. 3D-LTCs derived from human PCLS can be used to analyze responses to novel drugs, which might further help to better understand the mechanisms and functional effects of drugs in human tissue. The preparation of PCLS from surgically resected lung tissue samples of patients, who experienced lung lobectomy, increases the accessibility of diseased and peritumoral tissue. Here, we describe a detailed protocol for the generation of human PCLS from surgically resected soft-elastic patient lung tissue. Agarose was introduced into the bronchoalveolar space of the resectates, thus preserving lung structure and increasing the tissue&#39;s stiffness, which is crucial for subsequent slicing. 500 &#181;m thick slices were prepared from the tissue block with a vibratome. Biopsy punches taken from PCLS ensure comparable tissue sample sizes and further increase the amount of tissue samples. The generated lung tissue cultures can be applied in a variety of studies in human lung biology, including the pathophysiology and mechanisms of different diseases, such as fibrotic processes at its best at (sub-)cellular levels. The highest benefit of the 3D-LTC ex vivo model is its close representation of the in situ human lung in respect of 3D tissue architecture, cell type diversity and lung anatomy as well as the potential for assessment of tissue from individual patients, which is relevant to further develop novel strategies for precision medicine.

Generation of Human 3D Lung Tissue Cultures 3D-LTCs for Disease Modeling

Here, we present a protocol for the preparation of agarose-filled human precision-cut lung slices from resected patient tissue that are suitable for generating 3D lung tissue cultures to model human lung diseases in biological and biomedical studies.

Geração de culturas de tecido de pulmão humano de 3D (3D-CTIs) para modelagem de doença

Translation of novel discoveries to human disease is limited by the availability of human tissue-based models of disease. Precision-cut lung slices (PCLS) ...

Transthoracic Echocardiographic Examination in the Rabbit Model

Large animal models such as the rabbit are valuable for translational preclinical research. Rabbits have a similar cardiac electrophysiology compared to that of humans and that of other large animal models such as dogs and pigs. However, the rabbit model has the additional advantage of lower maintenance costs compared to other large animal models. The longitudinal evaluation of cardiac function using echocardiography, when appropriately implemented, is a useful methodology for preclinical assessment of novel therapies for heart failure with reduced ejection fraction (e.g. cardiac regeneration). The correct use of this non-invasive tool requires the implementation of a standardized examination protocol following international guidelines. Here we describe, step by step, a detailed protocol supervised by veterinary cardiologists for performing echocardiography in the rabbit model, and demonstrate how to correctly obtain the different echocardiographic views and imaging planes, as well as the different imaging modes available in a clinical echocardiography system routinely used in human and veterinary patients.

Here we describe, step by step, a detailed protocol for performing echocardiography in the rabbit model. We show how to correctly obtain the different echocardiographic views and imaging planes, as well as the different imaging modes available in a clinical echocardiography system routinely used in human and veterinary patients.

Exame ecocardiográfico transtorácico no modelo coelho

Large animal models such as the rabbit are valuable for translational preclinical research. Rabbits have a similar cardiac electrophysiology compared to ...