Ost David E, Ernst Armin, Lei Xiudong, Kovitz Kevin L, Benzaquen Sadia, Diaz-Mendoza Javier, Greenhill Sara, Toth Jennifer, Feller-Kopman David, Puchalski Jonathan, Baram Daniel, Karunakara Raj, Jimenez Carlos A, Filner Joshua J, Morice Rodolfo C, Eapen George A, Michaud Gaetane C, Estrada-Y-Martin Rosa M, Rafeq Samaan, Grosu Horiana B, Ray Cynthia, Gilbert Christopher R, Yarmus Lonny B, Simoff Michael
1 Department of Pulmonary Medicine and.
2 Department of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Boston, Massachusetts.
Am J Respir Crit Care Med. 2016 Jan 1;193(1):68-77. doi: 10.1164/rccm.201507-1332OC.
Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy.
To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations.
We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions.
Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16).
Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.
诸如电磁导航（EMN）等先进的支气管镜检查技术已在临床试验中得到研究，但尚无将EMN与标准支气管镜检查进行比较的随机研究。
测量并确定外周肺病变患者支气管镜检查诊断率的决定因素。次要结局包括不同采样技术的诊断率、并发症及实践模式差异。
我们利用AQuIRE（美国胸科医师学会质量改进注册、评估和教育）注册库，对连续接受经支气管活检（TBBx）以评估外周病变的患者进行多中心研究。
15个中心的22名医生纳入了581例患者。在这581例患者中，312例（53.7%）进行了诊断性支气管镜检查。在未对其他因素进行调整的情况下，未使用径向支气管内超声（r-EBUS）和EMN时诊断率为63.7%，单独使用r-EBUS时为57.0%，单独使用EMN时为38.5%，EMN联合r-EBUS时为47.1%。在多变量分析中，外周经支气管针吸活检（TBNA）、病变较大、非上叶位置及吸烟与诊断率增加相关，而EMN与较低的诊断率相关。16.4%的病例使用了外周TBNA。在同时进行TBNA和TBBx的病例中，9.5%的病例TBNA具有诊断性，而TBBx无诊断性。13例（2.2%）患者发生并发症，10例（1.7%）患者发生气胸。各中心和医生在病例选择、采样方法及麻醉方面存在显著差异。医疗中心的诊断率范围为33%至73%（P = 0.16）。
外周TBNA提高了外周病变的诊断率，但使用不足。即使经过调整，EMN和r-EBUS的诊断率仍低于预期。
