The authors have no acknowledgments.

Following Danish law, an educational study without the participation of patients does not require ethical approval.
1. Handling of the scope
<ol>
	<li>Hold the bronchoscope in the left hand with the left thumb on the steering lever and the left forefinger on the suction button. Use the right hand to hold the distal part of the bronchoscope.</li>
	<li>Holding the scope with a straight arm and wrist, so the suction button is pointing directly forward and the steering lever is in the neutral position, is defined as the neutral position or 0&#176;. By twisting the wrist, turn the scope from the neutral position/0&#176;.</li>
	<li>Move the thumb up and down the lever to flex and extend the distal end of the endoscope. Move the wrist and hands, not the arm and body.</li>
</ol>
2. Structured progress: angle of the scope and the four landmarks
<ol>
	<li>Enter the airways either through the mouth or nostrils. Pass the vocal cords and enter the trachea.</li>
	<li>Find the four landmarks systematically from landmarks 1 to 4 and note the correct angle of the endoscope in each position (Table 1). 
	NOTE: The four landmarks approach is designed in a memorable way to decrease the cognitive load for novel bronchoscopists. It is based on a pairing between the angle of the bronchoscope and how to access the different lobes/landmarks. The approach, therefore, provides novice trainees with a basic training tool to navigate through the bronchial maze. As an example, by knowing if the bronchoscope is held at a 90&#176; angle to the right, the correct position to inspect the right upper lobe can be determined. When visualizing the lobe or landmark, one should defer from the designated angle to inspect the individual segments.</li>
	<li>Find the segments chronologically from 1-10, the right side first, then the left side according to the four landmarks.</li>
</ol>
3. Systematic bronchoscopy: the four landmarks approach
<ol>
	<li>Landmark 1: The carina with the right and the left main bronchus as seen from the trachea (Figure 2)
	<ol>
		<li>Locate the bronchoscope in the distal part of the trachea at a 0&#176; angle-the neutral position. If the orientation is lost, go back to landmark 1 to reorientate.</li>
	</ol>
	</li>
	<li>Landmark 2: Right segments 1, 2, and 3 (upper lobe) (Figure 3)
	<ol>
		<li>Turn the endoscope 90&#176; to the right while at the same time flexing the distal end of the bronchoscope upward by pushing the left thumb down to investigate the upper lobe. This landmark resembles the Mercedes star.</li>
		<li>When visualizing the Mercedes star, defer from the 90&#176; angle to inspect segments 1, 2, and 3.</li>
	</ol>
	</li>
	<li>Landmark 3: Right segments 4 and 5 (middle lobe) plus 6, 7, 8, 9, and 10 (lower lobe) (Figure 4)
	<ol>
		<li>Move on to the bronchus intermedius by placing the distal end of the endoscope at a 45&#176; angle to the right to see segments 4 and 5 (numbers from the lateral side at an oblique angle).</li>
		<li>Again, defer from the 45&#176; angle to inspect segments 4 and 5. Go back to the 45&#176; angle and extend the tip of the endoscope by pushing the stewing lewer upward with the left thumb to inspect segment 6 (just opposite the middle lobe).</li>
		<li>Turn the scope to a 0&#176; angle and progress to the lower lobe. Segment 7 is located medially, and segments 8, 9, and 10 (numbers from the lateral side at an oblique angle) at the bottom. Defer from the 0&#176; angle to inspect segments 7-10.</li>
	</ol>
	</li>
	<li>Landmark 4: Left segments 1+2, 3, 4, and 5 (upper lobe), plus segments 6, 8, 9, and 10 (lower lobe) (Figure 5)
	<ol>
		<li>Move the bronchoscope to the left main bronchus (90&#176; angle to the left), upward to see the upper lobe, and downward to see the lower lobe.</li>
		<li>Keep the scope at a 90&#176; angle to inspect the left upper lobe with the lingula. Defer from the 90&#176; angle to inspect segments 1+2 and 3 (left upper lobe) and segments 4 and 5 (lingula).</li>
		<li>Go back to the left main bronchus, turn the scope to a 45&#176; angle, and extend the end of the bronchoscope to inspect segment 6, which is opposite segments 4 and 5 (lingula).</li>
		<li>Turn the scope to a 0&#176; angle to visualize the lower lobe with segments 8, 9, and 10. Defer from the 0&#176; angle to inspect the segments. 
		NOTE: There is no segment 7 on the left side, as this area is filled out by the heart. Segments 4 and 5 plus 8, 9, and 10 follow the same numbering as for the right side, and are numbered from the lateral side at an oblique angle (Figure 6).</li>
	</ol>
	</li>
</ol>

Flexible Bronchoscopy for Novice Bronchoscopists

<ol><li>Bray, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Global+cancer+statistics+2018%3A+GLOBOCAN+estimates+of+incidence+and+mortality+worldwide+for+36+cancers+in+185+countries%5BTitle%5D)+AND+%22CA%3A+A+Cancer+Journal+for+Clinicians%22%5BJournal%5D)">Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.</a> CA: A Cancer Journal for Clinicians. 68 (6), 394-424 (2018).</li>
<li>Andolfi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+role+of+bronchoscopy+in+the+diagnosis+of+early+lung+cancer%3A+a+review%5BTitle%5D)+AND+%22Journal+of+Thoracic+Disease%22%5BJournal%5D)">The role of bronchoscopy in the diagnosis of early lung cancer: a review.</a> Journal of Thoracic Disease. 8 (11), 3329-3337 (2016).</li>
<li>Hsu, L. H., Liu, C. C., Ko, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Education+and+experience+improve+the+performance+of+transbronchial+needle+aspiration%3A+a+learning+curve+at+a+cancer+center%5BTitle%5D)+AND+%22Chest%22%5BJournal%5D)">Education and experience improve the performance of transbronchial needle aspiration: a learning curve at a cancer center.</a> Chest. 125 (2), 532-540 (2004).</li>
<li>Ouellette, D. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+safety+of+bronchoscopy+in+a+pulmonary+fellowship+program%5BTitle%5D)+AND+%22Chest%22%5BJournal%5D)">The safety of bronchoscopy in a pulmonary fellowship program.</a> Chest. 130 (4), 1185-1190 (2006).</li>
<li>Stather, D. R., MacEachern, P., Chee, A., Dumoulin, E., Tremblay, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Trainee+impact+on+procedural+complications%3A+An+analysis+of+967+consecutive+flexible+bronchoscopy+procedures+in+an+interventional+pulmonology+practice%5BTitle%5D)+AND+%22Respiration.+International+Review+of+Thoracic+Diseases%22%5BJournal%5D)">Trainee impact on procedural complications: An analysis of 967 consecutive flexible bronchoscopy procedures in an interventional pulmonology practice.</a> Respiration. International Review of Thoracic Diseases. 85 (5), 422-428 (2013).</li>
<li>McGaghie, W. C., Issenberg, S. B., Cohen, E. R., Barsuk, J. H., Wayne, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Medical+education+featuring+mastery+learning+with+deliberate+practice+can+lead+to+better+health+for+individuals+and+populations%5BTitle%5D)+AND+%22Academic+Medicine%22%5BJournal%5D)">Medical education featuring mastery learning with deliberate practice can lead to better health for individuals and populations.</a> Academic Medicine. 86 (11), e8-e9 (2011).</li>
<li>Konge, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Establishing+pass%2Ffail+criteria+for+bronchoscopy+performance%5BTitle%5D)+AND+%22Respiration%3B+International+Review+of+Thoracic+Diseases%22%5BJournal%5D)">Establishing pass/fail criteria for bronchoscopy performance.</a> Respiration; International Review of Thoracic Diseases. 83 (2), 140-146 (2012).</li>
<li>Konge, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Reliable+and+valid+assessment+of+clinical+bronchoscopy+performance%5BTitle%5D)+AND+%22Respiration%3B+International+Review+of+Thoracic+Diseases%22%5BJournal%5D)">Reliable and valid assessment of clinical bronchoscopy performance.</a> Respiration; International Review of Thoracic Diseases. 83 (1), 53-60 (2012).</li>
<li>Colt, H. G., Crawford, S. W., Galbraith 3rd, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Virtual+reality+bronchoscopy+simulation%3A+A+revolution+in+procedural+training%5BTitle%5D)+AND+%22Chest%22%5BJournal%5D)">Virtual reality bronchoscopy simulation: A revolution in procedural training.</a> Chest. 120 (4), 1333-1339 (2001).</li>
<li>Cold, K. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Using+structured+progress+to+measure+competence+in+flexible+bronchoscopy%5BTitle%5D)+AND+%22Journal+of+Thoracic+Disease%22%5BJournal%5D)">Using structured progress to measure competence in flexible bronchoscopy.</a> Journal of Thoracic Disease. 12 (11), 6797-6805 (2020).</li>
<li>Cold, K. M., Konge, L., Clementsen, P. F., Nayahangan, L. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Simulation-based+mastery+learning+of+flexible+bronchoscopy%3A+Deciding+factors+for+completion%5BTitle%5D)+AND+%22Respiration%3B+International+Review+of+Thoracic+Diseases%22%5BJournal%5D)">Simulation-based mastery learning of flexible bronchoscopy: Deciding factors for completion.</a> Respiration; International Review of Thoracic Diseases. 97 (2), 160-167 (2019).</li>
<li>Nayahangan, L. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Identifying+technical+procedures+in+pulmonary+medicine+that+should+be+integrated+in+a+simulation-based+curriculum%3A+A+national+general+needs+assessment%5BTitle%5D)+AND+%22Respiration%3B+International+Review+of+Thoracic+Diseases%22%5BJournal%5D)">Identifying technical procedures in pulmonary medicine that should be integrated in a simulation-based curriculum: A national general needs assessment.</a> Respiration; International Review of Thoracic Diseases. 91 (6), 517-522 (2016).</li>
<li>Konge, L., Arendrup, H., von Buchwald, C., Ringsted, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Using+performance+in+multiple+simulated+scenarios+to+assess+bronchoscopy+skills%5BTitle%5D)+AND+%22Respiration%3B+International+Review+of+Thoracic+Diseases%22%5BJournal%5D)">Using performance in multiple simulated scenarios to assess bronchoscopy skills.</a> Respiration; International Review of Thoracic Diseases. 81 (6), 483-490 (2011).</li>
<li>Kennedy, C. C., Maldonado, F., Cook, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Simulation-based+bronchoscopy+training%3A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Chest%22%5BJournal%5D)">Simulation-based bronchoscopy training: systematic review and meta-analysis.</a> Chest. 144 (1), 183-192 (2013).</li>
<li>Sealy, W. C., Connally, S. R., Dalton, M. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Naming+the+bronchopulmonary+segments+and+the+development+of+pulmonary+surgery%5BTitle%5D)+AND+%22The+Annals+of+Thoracic+Surgery%22%5BJournal%5D)">Naming the bronchopulmonary segments and the development of pulmonary surgery.</a> The Annals of Thoracic Surgery. 55 (1), 184-188 (1993).</li>
<li>Naur, T. M. H., Nilsson, P. M., Pietersen, P. I., Clementsen, P. F., Konge, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Simulation-based+training+in+flexible+bronchoscopy+and+endobronchial+ultrasound-guided+transbronchial+needle+aspiration+%28EBUS-TBNA%29%3A+A+systematic+review%5BTitle%5D)+AND+%22Respiration%3B+International+Review+of+Thoracic+Diseases%22%5BJournal%5D)">Simulation-based training in flexible bronchoscopy and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): A systematic review.</a> Respiration; International Review of Thoracic Diseases. 93 (5), 355-362 (2017).</li>
<li>Sanz-Santos, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+compared+with+targeted+staging+with+endobronchial+ultrasound+in+patients+with+lung+cancer%5BTitle%5D)+AND+%22The+Annals+of+Thoracic+Surgery%22%5BJournal%5D)">Systematic compared with targeted staging with endobronchial ultrasound in patients with lung cancer.</a> The Annals of Thoracic Surgery. 106 (2), 398-403 (2018).</li>
<li>Colella, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Assessment+of+competence+in+simulated+flexible+bronchoscopy+using+motion+analysis%5BTitle%5D)+AND+%22Respiration%3B+International+Review+of+Thoracic+Diseases%22%5BJournal%5D)">Assessment of competence in simulated flexible bronchoscopy using motion analysis.</a> Respiration; International Review of Thoracic Diseases. 89 (2), 155-161 (2015).</li>
<li>Cold, K. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Automatic+and+objective+assessment+of+motor+skills+performance+in+flexible+bronchoscopy%5BTitle%5D)+AND+%22Respiration%3B+International+Review+of+Thoracic+Diseases%22%5BJournal%5D)">Automatic and objective assessment of motor skills performance in flexible bronchoscopy.</a> Respiration; International Review of Thoracic Diseases. 100 (4), 347-355 (2021).</li>
<li>Follmann, A., Pereira, C. B., Knauel, J., Rossaint, R., Czaplik, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evaluation+of+a+bronchoscopy+guidance+system+for+bronchoscopy+training%2C+a+randomized+controlled+trial%5BTitle%5D)+AND+%22BMC+Medical+Education%22%5BJournal%5D)">Evaluation of a bronchoscopy guidance system for bronchoscopy training, a randomized controlled trial.</a> BMC Medical Education. 19 (1), 430(2019).</li>
<li>Nilsson, P. M., Naur, T. M. H., Clementsen, P. F., Konge, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Simulation+in+bronchoscopy%3A+current+and+future+perspectives%5BTitle%5D)+AND+%22Advances+in+Medical+Education+and+Practice%22%5BJournal%5D)">Simulation in bronchoscopy: current and future perspectives.</a> Advances in Medical Education and Practice. 8, 755-760 (2017).</li>
<li>Strandbygaard, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+structured+four-step+curriculum+in+basic+laparoscopy%3A+development+and+validation%5BTitle%5D)+AND+%22Acta+Obstetricia+et+Gynecologica+Scandinavica%22%5BJournal%5D)">A structured four-step curriculum in basic laparoscopy: development and validation.</a> Acta Obstetricia et Gynecologica Scandinavica. 93 (4), 359-366 (2014).</li>
<li>Konge, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+simulation+centre+at+Rigshospitalet%2C+Copenhagen%2C+Denmark%5BTitle%5D)+AND+%22Journal+of+Surgical+Education%22%5BJournal%5D)">The simulation centre at Rigshospitalet, Copenhagen, Denmark.</a> Journal of Surgical Education. 72 (2), 362-365 (2015).</li>
</ol>

The authors have nothing to disclose.

We propose a systematic and complete inspection of the bronchial segments, splitting the bronchoscopy into four landmarks to help guide novice bronchoscopists through the bronchial maze. As more specific guidelines that govern bronchoscopy training are needed14, we propose that our systematic and stepwise approach should be evaluated using three basic outcome measures: DC, SP, and PT. 
DC and PT are established outcome measures and the first used when evaluating broncho...

Lung cancer is the leading cause of cancer mortality1. Flexible bronchoscopy is essential to navigate through the bronchial tree and identify the correct segments for the diagnosis and staging of lung cancer and allocation to the correct treatment for the patient2. Lower yields of diagnostic biopsy material, higher complication rates, and increased patient discomfort are seen in the early part of a trainee&#39;s learning curve3,4,5. To ensure independent/unsupervised practice on patients, satisfactory educational levels must be met. A training modality to ensure basic competence is simulation-based mastery learning, where the trainee practices until proficiency criteria are met6. Several tools have been developed to assess bronchoscopy performance7,8, and the following performance measures have been established: (1) diagnostic completeness (DC)-proportion of visualized segments9; (2) structured progress (SP)-number of segments visited in the correct progression order10; and (3) procedure time (PT)-time from passing through the vocal cords to the end of the procedure9.
Novice bronchoscopists can be confused by the maze, looking like similar bronchi, and several fail to complete a course in simulation-based bronchoscopy11, even though it has been identified as the most important technical procedure to learn in pulmonary medicine12. Therefore, through this protocol, we propose a stepwise, structured progression through the bronchial tree (Figure 1), relying on four landmarks as a guide. We suggest that novice operators should be taught according to this approach to ensure visualization of all the bronchial segments in a structured way, in the shortest amount of time, with correct handling of the scope.

<table><tbody><tr><td>Evis Exera II</td><td>Olympus</td><td>Not provided</td><td>Endoscopy Tower</td></tr><tr><td>BF-Q180 Bronchoscope</td><td>Olympus</td><td>Not provided</td><td>Flexible Bronchoscope</td></tr><tr><td>CLA Broncho Boy</td><td>CLA</td><td>Not provided</td><td>Bronchial Tree Phantom</td></tr></tbody></table>

systematic bronchoscopy: the four landmarks approach

Flexible bronchoscopy is a technically difficult procedure and has been identified as the most important procedure that should be integrated into a simulation-based training program for pulmonologists. However, more specific guidelines that govern bronchoscopy training are needed to meet this demand. To ensure patients a competent examination, we propose a systematic, stepwise approach, splitting the procedure into four &#34;landmarks&#34; to support novice endoscopists navigating the bronchial maze. The procedure can be evaluated based on three established outcome measures to ensure a thorough and effective inspection of the bronchial tree: diagnostic completeness, structured progress, and procedure time.
The stepwise approach relying on the four landmarks is used at all simulation centers in Denmark and is being implemented in the Netherlands. To provide instant feedback to novice bronchoscopists when training and to relieve time constraints from consultants, we suggest that future studies should implement artificial intelligence&#160;as a feedback and certification tool when training new bronchoscopists.

The four landmarks approach has been taught at CAMES since 2011, where the simulation-based bronchoscopy course is concluded by passing a finalizing test13. From 2015-2017, 77 participants entered the course, of which only 33 (43%) completed it11. The low completion rate was due to several factors: time constraints, the course not being mandatory, maternity leave, and no protected time to train. Of those who completed the course, 14 (42%) found the most important factor for...

Watch this Scientific Journal Video about Learning Systematic Bronchoscopy in a Simulation-Base Setting at JoVE.com

Author Spotlight: Learning Systematic Bronchoscopy in a Simulation-Base Setting 

Here, we present a protocol to navigate the bronchial maze in a structured manner, splitting the bronchoscopy into a stepwise approach-the four landmarks approach.

Systematic Bronchoscopy: the Four Landmarks Approach

Flexible bronchoscopy is a technically difficult procedure and has been identified as the most important procedure that should be integrated into a ...

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2.3K Views.  University of Copenhagen and the Capital Region of Denmark. Dit protocol biedt beginnende bronchoscopisten een gedenkwaardige manier om te leren navigeren door de bronchiale boom met behulp van de vier oriëntatiepuntenbenadering. Voor de onervaren operator is het vrij moeilijk om de weg te vinden in de bronchiën drie bij het uitvoeren van een bronchoscopie. We hebben een aanpak met vier oriëntatiepunten ontwikkeld, wat betekent dat je vier oriëntatiepunten moet vinden en dat je altijd terug kunt gaan naar de vier oriëntatiepunten als je de weg kw...

Video: Auteur in de schijnwerpers: systematische bronchoscopie leren in een simulatie-basisomgeving 

Bronchial Thermoplasty:  A Novel Therapeutic Approach to Severe Asthma

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled manner to reduce excessive airway smooth muscle. Reducing airway smooth muscle decreases the ability of the airways to constrict, thereby reducing the frequency of asthma attacks. Bronchial thermoplasty is delivered by the Alair System and is performed in three outpatient procedure visits, each scheduled approximately three weeks apart. The first procedure treats the airways of the right lower lobe, the second treats the airways of the left lower lobe and the third and final procedure treats the airways in both upper lobes. After all three procedures are performed the bronchial thermoplasty treatment is complete.
Bronchial thermoplasty is performed during bronchoscopy with the patient under moderate sedation. All accessible airways distal to the mainstem bronchi between 3 and 10 mm in diameter, with the exception of the right middle lobe, are treated under bronchoscopic visualization. Contiguous and non-overlapping activations of the device are used, moving from distal to proximal along the length of the airway, and systematically from airway to airway as described previously. Although conceptually straightforward, the actual execution of bronchial thermoplasty is quite intricate and procedural duration for the treatment of a single lobe is often substantially longer than encountered during routine bronchoscopy. As such, bronchial thermoplasty should be considered a complex interventional bronchoscopy and is intended for the experienced bronchoscopist. Optimal patient management is critical in any such complex and longer duration bronchoscopic procedure. This article discusses the importance of careful patient selection, patient preparation, patient management, procedure duration, postoperative care and follow-up to ensure that bronchial thermoplasty is performed safely.
Bronchial thermoplasty is expected to complement asthma maintenance medications by providing long-lasting asthma control and improving asthma-related quality of life of patients with severe asthma. In addition, bronchial thermoplasty has been demonstrated to reduce severe exacerbations (asthma attacks) emergency rooms visits for respiratory symptoms, and time lost from work, school and other daily activities due to asthma.

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled manner to reduce excessive airway smooth muscle. Reducing airway smooth muscle decreases the ability of the airways to constrict, thereby reducing the frequency of asthma attacks.

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled ...

Microsurgical Venous Pouch Arterial-Bifurcation Aneurysms in the Rabbit Model: Technical Aspects

For ruptured human cerebral aneurysms endovascular embolization has become an equivalent alternative to aneurysm clipping.1 However, large clinical trials have shown disappointing long-term results with unacceptable high rates of aneurysm recanalization and delayed aneurysm rupture.2 To overcome these problems, animal experimental studies are crucial for the development of better endovascular devices.3-5
Several animal models in rats, rabbits, canines and swine are available.6-8 Comparisons of the different animal models showed the superiority of the rabbit model with regard to hemodynamics and comparability of the coagulation system and cost-effectiveness.9-11 
The venous pouch arterial bifurcation model in rabbits is formed by a venous pouch sutured into an artificially created true bifurcation of both common carotid arteries (CCA). The main advantage of this model are true bifurcational hemodynamics.12 The major drawbacks are the sofar high microsurgical technical demands and high morbidity and mortality rates of up to 50%.13 These limitations have resulted in less frequent use of this aneurysm model in the recent years. These shortcomings could be overcome with improved surgical procedures and modified peri- and postoperative analgetic management and anticoagulation.14-16 Our techniques reported in this paper demonstrate this optimized technique for microsurgical creation of arterial bifurcation aneurysms.

An optimized technique for the microsurgical creation of arterial bifurcation aneurysms mimicking bifurcation human cerebral aneurysms is described. A venous pouch is sutured into an artificially created true bifurcation of both common carotid arteries. Facilitated microsurgical techniques and aggressive postoperative anticoagulation and analgesia lead to minimized morbidity rates and high aneurysm patency rates.

For ruptured human cerebral aneurysms endovascular embolization has become an equivalent alternative to aneurysm clipping.1 However, large clinical trials ...

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.

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

Simulation-Based Training of EBUS-TBNA

Systematic Endobronchial Ultrasound - The Six Landmarks Approach

Lung cancer is the leading cause of cancer mortality globally. To ensure the correct diagnosis and staging in relation to treatment options, it is crucial to obtain valid biopsies from suspected tumors and mediastinal lymph nodes and accurate identification of the mediastinal lymph nodes regarding the Tumor-Node-Metastasis (TNM)-classification. Flexible bronchoscopy combined with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is essential in the workup and diagnosis of patients suspected of lung cancer. EBUS-TBNA from mediastinal lymph nodes is a technically difficult procedure and has been identified as one of the most important procedures that should be integrated into a simulation-based training program for invasive pulmonologists. More specific guidelines that govern training in EBUS-TBNA are needed to meet this demand. We hereby propose a systematic, stepwise approach with specific attention to six landmarks that support the endoscopist when navigating through the bronchial maze. The stepwise approach relying on the six landmarks is used in the EBUS-certified training program offered by the European Respiratory Society (ERS).

Author Spotlight: Demonstrating Systematic Endobronchial Ultrasound to New Endoscopists 

Endobronchial ultrasound-guided sampling using transbronchial needle aspiration plays a key role in staging and diagnosing lung cancer. We propose a systematic stepwise approach dividing the procedure into six landmarks that should be taught to new operators.

Lung cancer is the leading cause of cancer mortality globally. To ensure the correct diagnosis and staging in relation to treatment options, it is crucial ...

Cancer Research

A Novel Approach to Monitoring Graft Neovascularization in the Human Gingiva

Laser speckle contrast imaging (LSCI) is a novel method for measuring superficial blood perfusion over large areas. Since it is non-invasive and avoids direct contact with the measured area, it is suitable for monitoring blood flow changes during wound healing in human patients. Vestibuloplasty is periodontal surgery to the oral vestibule, aiming to restore vestibular depth with simultaneous enlargement of the keratinized gingiva. In this special clinical case, a split thickness flap was elevated at the first upper premolar and a xenogenic collagen matrix was adapted to the resulting recipient bed. LSCI was used to monitor the re- and neovascularization of the graft and the surrounding mucosa for one year. A protocol is introduced for the correct adjustment of microcirculation measurement in the oral mucosa, highlighting difficulties and possible failures.
The clinical case study presented demonstrated that &#8212; following the appropriate protocol &#8212; LSCI is a suitable and reliable method for following up microcirculation in a healing wound in the human oral mucosa and gives useful information on graft integration.

This study introduces a protocol for measuring microcirculation in human oral mucosa by laser speckle contrast imaging. The monitoring of wound healing after vestibuloplasty combined with a xenogenic collagen graft is presented on a clinical case.

Laser speckle contrast imaging (LSCI) is a novel method for measuring superficial blood perfusion over large areas. Since it is non-invasive and avoids ...

Posterior Approach for Debridement of the Psoas Abscess

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior approach to the spine was performed to ensure that the anterior longitudinal ligament and the psoas muscle could be visualized. All the abdominal organs were removed. Subsequently, a posterior approach was performed to remove the paraspinal muscles from L1&#8211;L5. The transverse processes, pars interarticularis and lamina of L1&#8211;L5 were identified. The exiting nerve root was identified between the transverse processes and followed into the substance of the psoas muscle. Using the anterior and posterior approach, the lumbar plexus was isolated from the substance of the psoas muscle. Before and after various steps of dissection, digital photographs were obtained. These images were uploaded into ImageJ and multiple measurements, including the distance between the lateral superior and inferior tip of each TP to the most lateral region of the plexus, the distance between the lateral superior and inferior tip of the TP to the lateral edge of the psoas, and the width of the lumbar plexus were recorded. The safe zone for entering the substance of the psoas muscle was defined between the lateral edge of the psoas muscle and the lateral edge of the lumbar plexus. The relationship of this interval to the tip of the transverse process at each level was measured and reported.

This is a cadaveric study investigating the landmarks for the posterior approach for irrigation and debridement of the psoas abscess. The interval between the transverse processes (TP) was used to access the substance of the psoas muscle.

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the external auditory canal, the middle ear, and epitympanon. Such an approach avoids a retroauricular or endaural skin incision; however, working through a narrow space needs angled microsurgical instruments and specific training in otologic surgery. The transcanal approach restricts the working space; however, it offers a binocular microscopic vision into the middle ear without extended skin incisions and thus, reducing post-operative pain and bleeding. In addition, this minimally invasive approach avoids scar tissue complications, hypoesthesia of the auricle, and potential protrusion of the pinna. Despite its numerous advantages, this method is still not routinely performed by otologic surgeons. Since this minimally invasive technique is more challenging, there is a need for extensive training in order for it to be widely adopted by otologic surgeons. This article provides step-by-step surgical instructions for stapes surgery and reports possible indications, pitfalls, and limitations using this microscopic transcanal technique.

This article describes the microscopic transcanal technique for stapes surgery, providing step-by-step surgical instructions for familiarizing surgeons with this approach.

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the ...

Radial Endobronchial Ultrasound and Electromagnetic Navigation Bronchoscopy with Fluoroscopy for the Diagnosis of Peripheral Lung Lesions

Diagnosing lung cancer using a flexible bronchoscope is a safe procedure with a very low risk of complications. Bronchoscopy has high diagnostic accuracy for endobronchial lesions, but it falls short when sampling peripheral lesions. Therefore, several modalities have been invented to guide the bronchoscope to the lesion and confirm the location of the tumor before tissue sampling. 
Fluoroscopy is used during bronchoscopy to provide a 2D X-ray image of the thorax during the procedure. The bronchoscope and tools will be visible, as well as lesions if larger than 2.0-2.5 cm. Radial endobronchial ultrasound (rEBUS) consists of an ultrasound probe, small enough to be inserted into the working channel of the bronchoscope. The ultrasound probe is used to differentiate between consolidated tissue, such as tumor tissue, and normal air-filled lung parenchyma. Electromagnetic navigation bronchoscopy (ENB) creates a 3D model of the bronchial tree from computed tomography (CT) scans of the patient. Prior to the bronchoscopy, a route from the trachea to the lesion is planned, to create real-time guidance of the bronchoscope to the lesion during the procedure, similar to the Global Positioning System. The aim of this article is to describe a stepwise approach to performing bronchoscopy with rEBUS and fluoroscopy, bronchoscopy with ENB, rEBUS, and fluoroscopy. In the discussion section, the pros and cons of each modality will be discussed.

Diagnosing small lung tumors is quite difficult using a bronchoscope alone. Electromagnetic navigation bronchoscopy is used to locate the lesion, similar to the Global Positioning System. Radial endobronchial ultrasound and fluoroscopy confirm the correct location and monitor the sampling.

Diagnosing lung cancer using a flexible bronchoscope is a safe procedure with a very low risk of complications. Bronchoscopy has high diagnostic accuracy ...

Advancements in Pulmonary Lesion Biopsy Through Robotic Bronchoscopy

Robotic-assisted Bronchoscopy Combined with Multimodal Imaging for Targeted Lung Cryobiopsies

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways under direct vision after establishing a pathway to a target lesion based on mapping performed on a 3-dimensional (3D) lung and airway reconstruction obtained from a pre-procedure thin-slice computed tomography chest. RAB has maneuverability to distal airways throughout the lung, precise catheter tip articulation, and stability with the robotic arm. Adjunct imaging tools such as fluoroscopy, radial endobronchial ultrasound (r-EBUS), and cone beam computed tomography (CBCT) can be used with RAB. Studies using shape-sensing robotic-assisted bronchoscopy (ssRAB) have shown favorable diagnostic outcomes and safety profiles in both malignant and non-malignant processes for the biopsy of peripheral pulmonary lesions (PPLs). A 1.1 mm cryoprobe combined with ssRAB has been shown to be safe and effective for the diagnosis of PPLs compared to a traditional bronchoscopy with forceps biopsy. This technique can also be used for targeted lung sampling in benign processes. The aim of this article is to describe a stepwise approach to performing RAB combined with fluoroscopy, r-EBUS, and CBCT to obtain targeted transbronchial lung cryobiopsies (TBLC).

Author Spotlight: Expanding Interventional Pulmonology Research with Robotic-Assisted Bronchoscopy

This article aims to describe a stepwise approach to performing robotic-assisted bronchoscopy combined with fluoroscopy, radial endobronchial ultrasound, and cone beam computed tomography to obtain targeted transbronchial lung cryobiopsies.&#160;

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways ...

COVID-19 / Coronavirus Outbreak: How To Perform A Bronchoscopy

In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff while reducing the risk of infection. COVID patients often suffer from respiratory insufficiency and increased intrapulmonal secretion. A bronchoscopy is one of the standard procedures for resolving respiratory tract obstruction in intensive care medicine. On the downside, this procedure&#160;has a high potential for producing aerosol formations due to disconnections of the ventilator tubes, which creates&#160;an increased risk of infection to the medical staff. The indications for a bronchoscopy should be limited to the absolute minimum. This video gives a guidance for reducing&#160;personal infection risk without neglecting patient safety when performing a bronchoscopy.&#160;

Systematic Bronchoscopy: the Four Landmarks Approach

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