Rationale: Despite advancements in emphysema treatment, high morbidity and mortality rates highlight the need for innovative therapies. Hyperinflation is particularly significant for patients with emphysema as it is the main contributor to dyspnea, and much of the associated morbidity. To address this, a novel self-expanding nitinol airway scaffold was designed to alleviate lung hyperinflation by connecting emphysematous parenchyma with central bronchi, allowing trapped air to escape. Placed via a bronchoscope, the airway scaffold spans the native bronchial tree, with one end positioned in emphysematous lung tissue and the other in a more central bronchus. Methods: We conducted a pooled analysis of two studies (BREATHE-1 in Australia and BREATHE-2 in Europe) involving patients with heterogeneous or homogeneous emphysema treated bronchoscopically with up to three permanent airway scaffolds per lung performed over one or two procedures. The main objectives were to prospectively assess the feasibility, safety, and initial outcomes of the airway scaffolds in treating emphysema-related hyperinflation. The primary outcome was safety, measured by assessment of device- and/or procedure-related serious adverse events (SAEs) through six months. Secondary outcomes were technical feasibility, improvements in pulmonary function, quality of life, symptoms and exercise capacity at 3- and 6-months, and airway patency assessment by high-resolution computed tomography (CT). Results: 60 severe emphysema patients (33F/27M; mean age 65±8 years; mean RV percent predicted 255±47%) were included. 98 procedures were performed and 328 airway scaffolds were successfully placed. Thirteen patients (21.7%) experienced at least one related SAE within the 6-months following the initial procedure including pneumonia (10.0%) and COPD exacerbation (5.0%), with no pneumothoraxes. The technical success rate (successful deployment in the targeted airway as assessed by the investigator) was 92.4%. Residual volume (RV) improved by a mean decrease from baseline of 866±862 ml at 3-months and 753±874 ml at 6-months (p<0.0001). Significant improvements were also observed in spirometry, quality of life, symptoms and exercise capacity. Quantitative assessment of post-treatment CTs demonstrated preserved airway patency through 6-months in the majority of evaluable airways. Conclusions: Treatment with self-expanding nitinol airway scaffolds in emphysema patients is technically feasible and has an acceptable safety profile. Clinically meaningful and statistically significant reductions of hyperinflation were achieved at 3- and 6-months after treatment, with concurrent improvements in pulmonary function, exercise capacity and quality of life.

Rationale: Despite advancements in emphysema treatment, high morbidity and mortality rates highlight the need for innovative therapies. A novel self-expanding nitinol airway scaffold was designed to alleviate lung hyperinflation by connecting emphysematous parenchyma with central bronchi, releasing trapped air. Objectives: To assess the feasibility, safety, and initial outcomes of airway scaffolds in treating emphysema-related hyperinflation. Methods: We conducted a pooled analysis of two first-in-human studies (NCT05949645, NCT05854550) involving patients with heterogeneous or homogeneous emphysema treated bronchoscopically with up to three permanent airway scaffolds per lung. Measurements and Main Results: The primary outcome was safety, measured by procedure- and/or device-related serious adverse events over 6 months. Secondary outcomes were technical feasibility, pulmonary function, quality of life, symptoms, exercise capacity at 3 and 6 months, and airway patency assessment by high-resolution computed tomography. Sixty severe emphysema patients (33 female, 27 male; mean age, 66 ± 8 yr; mean residual volume percent predicted, 255 ± 47%) were included. Ninety-eight procedures were performed, and 328 airway scaffolds were successfully placed. A proportion of 21.7% of patients experienced at least one related serious adverse event within 6 months, including pneumonia (10.0%) and chronic obstructive pulmonary disease exacerbation (5.0%), but no pneumothoraxes occurred. Residual volume improved (decreased) from baseline by a mean [95% confidence interval] of 866 [626, 1,106] ml at 3 months and 753 [512, 994] ml at 6 months. Clinically meaningful improvements were further observed in spirometry, quality of life, symptoms, and exercise capacity. Conclusions: This study provides the first clinical evidence of the feasibility, safety, and initial outcomes after treatment with airway scaffolds in patients with emphysema-related hyperinflation.

As the presentation of pulmonary nodules increases, the importance of a safe and accurate method of sampling peripheral pulmonary nodules is highlighted. First-generation robotic bronchoscopy has successfully assisted navigation and improved peripheral reach during bronchoscopy. Integrating tool-in-lesion tomosynthesis (TiLT) may further improve yield. We performed a first-in-human clinical trial of a new robotic electromagnetic navigation bronchoscopy system with integrated digital tomosynthesis technology (Galaxy System, Noah Medical). Patients with moderate-risk peripheral pulmonary nodules were enrolled in the study. Robotic bronchoscopy was performed using electromagnetic navigation with TiLT-assisted lesion guidance. Non-specific results were followed up until either a clear diagnosis was achieved or repeat radiology at 6 months demonstrated stability. Eighteen patients (19 nodules) were enrolled. The average lesion size was 20 mm, and the average distance from the pleura was 11.6 mm. The target was successfully reached in 100% of nodules, and the biopsy tool was visualized inside the target lesion in all cases. A confirmed specific diagnosis was achieved in 17 nodules, 13 of which were malignant. In one patient, radiological monitoring confirmed a true non-malignant result. This translates to a yield of 89.5% (strict) to 94.7% (intermediate). Complications included one pneumothorax requiring observation only and another requiring an overnight chest drain. There was one case of severe pneumonia following the procedure. In this first-in-human study, second-generation robotic bronchoscopy using electromagnetic navigation combined with integrated digital tomosynthesis was feasible with an acceptable safety profile and demonstrated a high diagnostic yield for small peripheral lung nodules.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease that may lead to alveolar destruction, impaired gas exchange, hyperinflation and reduced exercise capacity. It is a major cause of morbidity and mortality in Australia, with over 6300 deaths from the disease in 2020 and over 50 000 hospitalisations.1, 2 There are comprehensive guides for the management of COPD in Australia and New Zealand (COPD-X)3 where the cornerstones of management include smoking cessation, inhaled pharmacotherapy, pulmonary rehabilitation and long-term oxygen therapy. However, endoscopic lung volume reduction (ELVR) is recommended in selected patients with severe emphysema. International guidelines for COPD management, such as the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2023)4 also recommend this with endobronchial valve therapy (EBV) being assessed as 'Evidence A'. The evidence for this is predominantly through multicentre randomised controlled international trials.5-8 These studies suggest that the patients with COPD who benefit most from ELVR with EBV are those with severe or very severe heterogeneous emphysema and have significant gas trapping and complete or near-complete fissures of the targeted lobe (no collateral ventilation).9 While ELVR with EBV has been performed in Australia since 2007, local evidence has been, until recently, focussed on mechanisms of action and assessment criteria.10-12 However, there have now been two recent studies published with local data utilising accepted international guidelines for selection, which allows us to examine the local experience. The first by Sidhu et al.13 was a retrospective consecutive review of 39 patients undergoing ELVR with EBV at two Victorian centres. The clinical improvement in lung function and exercise capacity were similar to published randomised controlled trials (RCTs), although postprocedure pneumothorax (36.5%) and repeat bronchoscopies (56.1%) for loss of effect or complications were higher than expected. The second study, published in this issue of the Internal Medicine Journal, is the paper by Brown et al.14 This too is a retrospective study, but of 57 patients treated with EBVs at a single Australian centre (Royal Adelaide Hospital). Clinical results were also similar to those reported in international multicentre RCTs,6, 7, 15 with targeted lung volume reduction in 77.2% and significant improvements in FEV1 (+170 mL), residual volume (−610 mL) and 6-min walk distance (+57.34 m) at 3 months. These improvements were mostly maintained at 6 months, with the FEV1 and residual volume improvements reducing at 12 months. The heterogeneous emphysema group had significantly better response than the homogenous group, as expected. Postprocedure pneumothorax was seen in 17.5% of patients and follow-up bronchoscopy for complications or loss of effect (e.g. valve migration and granulation tissue) was performed in 28.0% of patients. These results are within the range of responses and complications published in the international RCTs and highlight the fact that clinically significant improvement in lung function and functional parameters can be achieved in a real-world setting and outside the controlled environment of a clinical trial. In addition, the complication rates and other outcomes of safety are also comparable.16 Some of the more unique data coming from the Royal Adelaide group relates to its data on fissure integrity. They nicely demonstrate that the greater the fissure integrity the greater the response.14 Chartis assessment revealing no collateral ventilation helped in selecting the correct patients for ELVR but was still erroneous in predicting response in 50% of patients with fissure integrity between 80% and 90% and incorrect in 30% of patients with incomplete fissures greater than 90%. Expert guidelines17 recommend Chartis assessment if fissure integrity is between 80% and 95% complete, but Brown et al.'s study suggests that Chartis may be unreliable in this cohort. The subset for this analysis is small and needs to be confirmed in larger studies. The implications for this are that there are existing studies looking at more definitive therapy in this incomplete fissure group with significantly better responses. This involves the use of biopolymer to seal any fissural defects before EBV insertion.18 Results suggest that biopolymer with EBV in patients with 80–95% complete fissures obtain similar improvements to patients having EBV alone when fissures are complete. There is a large multicentre study that has just finished recruitment with the aim of confirming these results.19 The biggest limitation of the study by Brown et al. is the lack of control data. However, this is a retrospective descriptive study with much-needed local data on real-world outcomes. It is therefore reassuring to see that the clinical efficacy, adverse reactions and response rates are comparable to the larger published RCTs. Overall, these results are promising with the potential to encourage an expansion in ELVR as a procedure that more patients within Australia both in the public and private hospital setting can have equitable access to. However, it is important to emphasise existing expert guideline recommendations, adhered to in Brown et al.'s study, which are a very specific set of inclusion and exclusion criteria, that the procedure should only be performed in expert centres, and that the patients selected to undergo ELVR with EBV should be discussed at an interventional pulmonology multidisciplinary meeting with experienced interventional pulmonologists, radiologists and cardiothoracic surgeons. ELVR is recommended as a treatment option for patients with severe COPD and should be offered to those who fit endobronchial valve candidacy.

BACKGROUND AND OBJECTIVE:As the presentation of pulmonary nodules increases, the importance of a safe and accurate method of sampling peripheral pulmonary nodules is highlighted. First-generation robotic bronchoscopy has successfully assisted navigation and improved peripheral reach during bronchoscopy. Integrating tool-in-lesion tomosynthesis (TiLT) may further improve yield. METHODS:We performed a first-in-human clinical trial of a new robotic electromagnetic navigation bronchoscopy system with integrated digital tomosynthesis technology (Galaxy System, Noah Medical). Patients with moderate-risk peripheral pulmonary nodules were enrolled in the study. Robotic bronchoscopy was performed using electromagnetic navigation with TiLT-assisted lesion guidance. Non-specific results were followed up until either a clear diagnosis was achieved or repeat radiology at 6 months demonstrated stability. RESULTS:Eighteen patients (19 nodules) were enrolled. The average lesion size was 20 mm, and the average distance from the pleura was 11.6 mm. The target was successfully reached in 100% of nodules, and the biopsy tool was visualized inside the target lesion in all cases. A confirmed specific diagnosis was achieved in 17 nodules, 13 of which were malignant. In one patient, radiological monitoring confirmed a true non-malignant result. This translates to a yield of 89.5% (strict) to 94.7% (intermediate). Complications included one pneumothorax requiring observation only and another requiring an overnight chest drain. There was one case of severe pneumonia following the procedure. CONCLUSION:In this first-in-human study, second-generation robotic bronchoscopy using electromagnetic navigation combined with integrated digital tomosynthesis was feasible with an acceptable safety profile and demonstrated a high diagnostic yield for small peripheral lung nodules.

Cyclophosphamide induced pneumonitis is a rare adverse event in patients receiving adjuvant chemotherapy for breast cancer. It has been infrequently reported in the literature and based on the described cases it appears to be associated with dose dense regimens. We report three cases of cyclophosphamide induced pneumonitis who were treated at our centre. Our cases illustrate that careful attention must be paid to timing of symptoms to ensure the correct causative chemotherapy agent is identified so that potentially curative agents in the chemotherapy regime are not omitted.

Cyclophosphamide induced pneumonitis is a rare adverse event in patients receiving adjuvant chemotherapy for breast cancer. It has been infrequently reported in the literature and based on the described cases it appears to be associated with dose dense regimens. We report three cases of cyclophosphamide induced pneumonitis who were treated at our centre. Our cases illustrate that careful attention must be paid to timing of symptoms to ensure the correct causative chemotherapy agent is identified so that potentially curative agents in the chemotherapy regime are not omitted.

The traditional indications for lobectomy for resectable Non‐small Cell Lung Cancer (NSCLC) may be set to change. Recently, anatomical segmentectomy (AS) versus lobectomy as an approach for early‐stage NSCLC has been described in phase 3 randomised controlled trials. The demand for methods to facilitate AS may increase as a consequence. We describe three cases of AS using the combination of endobronchial infiltration of indocyanine green (ICG) to identify the intersegmental plane (critical for the performance of AS), and Computed Tomography (CT) guided methylene blue injection for lesion localisation. The operations were completed successfully demonstrating satisfactory post‐operative outcomes including lesion resection with clear surgical margins and acceptable length of stay. We believe that endobronchial instillation of ICG and CT‐guided methylene blue injection for lesion localisation show promise as a technique to complement parenchymal sparing thoracic oncological surgery.

The first dedicated tracheobronchial silicone stent was designed by the French pulmonologist Jean-Paul Dumon. The most common indications for stenting are to minimise extrinsic airway compression from mass effect, maintain airway patency due to intrinsic obstruction or treat significant nonmalignant airway narrowing or fistulae. Silicone stents require rigid bronchoscopy for insertion; however, they are more readily repositioned and removed compared with metallic stents. Metallic stents demonstrate luminal narrowing when loads are applied to their ends, therefore stents should either be reinforced at the ends or exceed the area of stenosis by a minimum of 5 mm. Nitinol, a nickel-titanium metal alloy, is currently the preferred material used for airway stents. Airway stenting provides effective palliation for patients with severe symptomatic obstruction. Drug-eluting and three-dimensional printing of airway stents present promising solutions to the challenges of the physical and anatomical constraints of the tracheobronchial tree. Biodegradable stents could also be a solution for the treatment of nonmalignant airway obstruction.

Background and Objective: Outside clinical trials, there is limited long-term data following bronchial thermoplasty (BT). In a cohort of real-world severe asthmatics in an era of biological therapy, we sought to evaluate the safety and efficacy of BT 5 years post-treatment. Methods: Every patient treated with BT at two Australian tertiary centres were recalled at 5 years, and evaluated by interview and record review, Asthma Control Questionnaire (ACQ), spirometry and high-resolution CT Chest. CT scans were interpreted using the modified Reiff and BRICS CT scoring systems for bronchiectasis. Results: Fifty-one patients were evaluated. At baseline, this cohort had a mean age of 59.0 +/- 11.8 years, mean ACQ of 3.0 +/- 1.0, mean FEV1 of 55.5 +/- 18.8% predicted, and 53% were receiving maintenance oral steroids in addition to triple inhaler therapy. At 5 years, there was a sustained improvement in ACQ scores to 1.8 +/- 1.0 (p < 0.001). Steroid requiring exacerbation frequency was reduced from 3.8 +/- 3.6 to 1.0 +/- 1.6 exacerbations per annum (p < 0.001). 44% of patients had been weaned off oral steroids. No change in spirometry was observed. CT scanning identified minor degrees of localized radiological bronchiectasis in 23/47 patients with the modified Reiff score increasing from 0.6 +/- 2.6 at baseline to 1.3 +/- 2.5 (p < 0.001). However, no patients exhibited clinical features of bronchiectasis, such as recurrent bacterial infection. Conclusion: Sustained clinical benefit from BT at 5 years was demonstrated in this cohort of very severe asthmatics. Mild, localized radiological bronchiectasis was identified in a portion of patients without clinical features of bronchiectasis.