Frontiers in Respiratory Medicine

Since its advent in the late 1960s, flexible bronchoscopy has revolutionized pulmonary practice. It allows the pulmonologist to examine the airways to the subsegmental level while obtaining diagnostic samples using techniques such as bronchoalveolar lavage, endobronchial biopsy, cytology brushing, transbronchial lung biopsy, and transbronchial needle aspiration. Even recent advancements in bronchoscopic technology have not rendered essential bronchoscopic techniques irrelevant, and the well-trained pulmonologist must be well versed in all of these techniques to provide optimal patient care.

Complex airway diseases represent a therapeutic challenge and require multidisciplinary input including the interventional pulmonologist and thoracic surgeon. Surgery, if feasible, remains the definitive modality. However, minimally invasive endobronchial techniques have resulted in symptom control and, in selected patients, long-term improvements in quality of life. These techniques are, in general, safe and well tolerated when performed by experienced operators. Endobronchial laser therapy, cryotherapy, electrocautery or argon plasma coagulation and photodynamic therapy have been used successfully. Despite the introduction of new technologies, the rigid bronchoscope remains the method of choice for the treatment of both benign and malignant central airway obstruction. It allows rapid and safe dilation, mechanical debulking, foreign body removal and silicone stent placement. However, it has limited use if lesions are located in the upper lobes or lung periphery but significant technological advances allow for effective treatments using the flexible bronchoscope. Rigid and flexible bronchoscopes should be seen as complementary procedures and most cases will require the use of both modalities.

Bronchoscopy education and training form a foundation for novice bronchoscopists to acquire skills necessary to provide optimal patient care. This chapter reviews the process of instructional design, the application of teaching and learning principles to bronchoscopy education, the use of the Accreditation Council for Graduate Medical Education’s Core Competencies to guide curricula development in bronchoscopy education, the current literature regarding training practices and tools available to develop curricula.

Lung cancer is the leading cause of cancer-related deaths worldwide. While smoking cessation efforts are imperative, development of effective lung cancer screening approaches are essential given current lung cancer prevalence. Historical attempts to screen lung cancer through chest radiography and sputum cytology resulted in earlier diagnosis of lung cancers, without improvement in cancer-related mortality or stage shift. The National Lung Screening Trial (NLST) demonstrated that low-dose computed tomography (LDCT) screening for lung cancer decreases cancer-related and all-cause mortality. Current consensus guidelines recommend annual LDCT screening for individuals at high-risk for the development of lung cancer. Prospective trials are needed to refine selection of optimal screening populations, duration and intervals. Successful implementation of lung cancer screening programs will depend upon creation of a multi-disciplinary team allowing for nodule surveillance with expertise in lung cancer diagnosis and treatment.

Electromagnetic navigation bronchoscopy (EMN) is a platform that has been used to diagnose peripheral pulmonary nodules for over 10 years. The basic components of EMN consist of planning software, a location board that emit low frequency electromagnetic waves, computed tomography scan used to reconstruct a three dimensional map, a sensor and computer integration. There is a disparity between reports of diagnostic accuracy of the navigational platforms. This chapter discusses technical aspects of the procedure in addition to review the literature on diagnostic accuracy of ENB, inherent limitations to diagnostic accuracy and methods to increase yield. Also discussed are other applications of ENB in addition to future directions of ENB.

Radial probe endobronchial ultrasonography (EBUS) provides real-time imaging which allows guided exploration of the airways beyond the visual reach of traditional flexible bronchoscopy. Using this technology, bronchoscopists are able to improve successful navigation of biopsy instruments to peripheral lung lesions and substantially improve diagnostic yields. Radial EBUS can also be used to evaluate anatomic structures underlying the mucosal surface, such as for guidance of transbronchial needle aspiration (TBNA), as well as to aid other therapeutic modalities such as the placement of fiducial markers for radiation therapy. Because of this expanded capability to identify precise targets within the lung, guided bronchoscopic navigation technologies now play a significant role in the clinical evaluation of peripheral pulmonary lesions.

Lymph node staging is a critical part in management of lung cancer, which can directly affect the patient treatment and outcomes. It is imperative that the interventional pulmonologist to not only be aware of the up-to-date nodal classification proposed by the International Association for the Study of Lung Cancer (IASLC), but should also have a basic understanding of the station identification on Computed Tomography(CT) scans performed for staging. This review article will provide a simplistic approach to mediastinal nodal staging based on CT scan which an interventional pulmonologist can routinely use and incorporate it effectively in their daily practice.

Endobronchial Ultrasound Guided Transbronchial Needle Aspiration (EBUS TBNA) is the accepted first test in the pretreatment staging of lung cancer suitable for curative therapy. Virtually all patients having Surgery or Radical Radiotherapy should undergo the procedure, with the exception of clinical Stage 1A patients. Even cases with tumors larger than 3cm (Stage 2 and greater) who have a CT and PET clear mediastinum should have EBUS TBNA staging. Clinical (CT and PET) negative mediastinal nodes have an incidence of occult metastatic disease of over 20%. Technical aspects of EBUS TBNA are becoming standardized given its now over 10 years of use in the clinical setting. Rapid on site examination of EBUS TBNA samples can be extremely helpful in the performance of staging procedures particularly to allow curtailment of the procedure once malignant cells are detected. EBUS TBNA can be used to make the diagnosis of lung cancer especially where the mass is adjacent a proximal airway. EBUS TBNA material is ideally suited to be used for genetic analysis of malignant cases and this feature alone ensures EBUS TBNA will continue to have a central role in the management of lung cancer patients.

Percutaneous Tracheostomy has become the preferred method of tracheostomy placement in critically ill patients. The most common indications are prolonged mechanical ventilation and inability to protect the airway. The procedure is safe, simple and is easily performed by non-surgical providers. It has advantages over surgical tracheostomy in terms of fewer stoma infections and decreased costs. The most widely used method of performing percutaneous dilatational tracheostomy is the single dilator method (Ciaglia Blue Rhino). Although there are several other techniques, the single dilator method has the most experience and best safety profile. The use of bronchoscopy and ultrasound as adjuncts facilitates placement of the tracheostomy tube, minimizes complications and enhances patient safety.

Expiratory central airway collapse has been better understood within the recent years due to development in computed tomography, bronchoscopic imaging and physiologic measurements of flow dynamics in the central airways. This article is a comprehensive narrative review of tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC). We address in detail their pathophysiology and treatment options. The current literature supports the fact that EDAC is essentially distinct from TBM, caused by different factors and may not represent a true central airway disorder that needs invasive treatment such as surgery or stent insertion. Intermittent positive pressure ventilation could function as pneumatic stenting, which helps the selected patients recover from chronic cough and inability to raise secretions. Symptomatic patients with true TBM (crescent type) may need silicone stent insertion, followed by membranous tracheoplasty if symptoms improve. Future research will clarify the flow limitation in EDAC and TBM and assist in determining the appropriate therapy for individual patients.

Central airway obstruction can arise from a variety of disease processes, both benign and malignant in etiology, and result in significant morbidity and mortality to the patient. Both surgical and endoscopic techniques can be used to successfully manage central airway obstruction. The decision regarding how to approach each patient should be based on their own unique anatomic and physiologic considerations. In this chapter, we will discuss the etiologies of tracheal and bronchial stenosis, the physiologic effects of central airway stenosis, and the various bronchoscopic techniques that can be applied to manage central airway obstruction.

Airway stenting is an important technique for the treatment of central airway obstruction and is a major component of an integrated Interventional Pulmonology service. Indications for this intervention can be broadly divided into malignant and benign conditions. Malignant airway obstruction is the commonest indication and can happen due to endobronchial tumors or external compression. Benign conditions include stenosis, fistula and airway malacia. An important consideration in benign conditions is patient longevity. Two groups of stents are available- silicon and metallic. Each is associated with advantages and disadvantages and the choice of stents depends on a number of factors including airway and disease related factors, physician choice and expertise and the available equipment within the endoscopy unit. Silicone stents require rigid bronchoscopy for placement while metallic stents can be deployed using flexible bronchoscopy. Irrespective of prosthesis type, stent related complications occur and include migration, stent obstruction from mucus, tumor ingrowth or granulation tissue and stent fracture. Finally, novel drug eluting and biodegradable stents are being studied with promising early results.

Point of Care Ultrasound use is becoming an extension of physical examination in a variety of situations and particularly in the Emergency Departments and Intensive care units. Ultrasound is an important tool in the arsenal of Interventional Pulmonologist. Thoracic ultrasound is easily available bedside tool that is more sensitive than conventional x-ray in rapid diagnosis of pleural effusion and pneumothorax. Ultrasound use has become the standard of care for pleural procedures as it minimizes complications. Understanding and recognition of basic pleuropulmonary ultrasound patterns are keys to proper usage and incorporation of this technology in the daily practice of Interventional Pulmonary. Ultrasound is also being increasingly used for percutaneous tracheostomy for optimizing patient selection and minimizing inadvertent vascular injury.

Malignant pleural effusion (MPE) is common and the management options available for MPE are often limited. The key goal in the management of MPE is to relieve patient’s symptoms with the least invasive means and in the most cost-effective manner. The approach to the management of MPE should be tailored according to patient’s overall prognosis, symptoms, functional status, social support, treatment availability, and financial situation. Pleurodesis has been the standard of care for the management of MPE for years and talc continues to be the most effective sclerosant available for pleurodesis in MPE. However, it is also associated with more invasive procedure and longer hospitalization. Most clinical studies on MPE treatments in the past were focused on the creation of successful pleurodesis in an attempt to stop reaccumulation of pleural fluid rather than patient-related outcome measures (PROM). The current trend of incorporating indwelling pleural catheter (IPC) in the management of MPE has been shown to be as equally effective as talc pleurodesis with significantly fewer hospitalization days and may be less costly compared to pleurodesis .

In recent years, an increasing trend has been recognized in the number of centers performing medical thoracoscopy across the world, mainly as a gold standard investigation for undiagnosed exudative effusion. It is a particularly useful diagnostic and therapeutic tool with a very low rate of complications that should be incorporated in the respiratory physicians’ armamentarium. Pleural biopsies under direct vision, therapeutic evacuation of effusions, and pleurodesis can be performed in one sitting. This chapter summarizes the important literature relating to the equipment, clinical indications, safety, complications and technical aspects of the procedure. We also aim to inform the reader regarding the latest research advances and potential areas of that MT will have a role in the future.

Palliative care has been defined as “the active total care of patients whose disease is not responsive to curative treatment.” The focus of palliative care/ hospice medicine according to the World Health Organization (WHO), is to prevent and relieve suffering by early identification, assessment, and treatment of pain and other debilitating symptoms. Unfortunately, lung cancer and chronic obstructive pulmonary disease are among the leading causes of death in the United States. Therefore, pulmonologists are often called upon to participate in the care of terminally ill patients. By incorporating components of palliative care, pulmonologists can help relieve their suffering. When conservative therapies fail, interventional pulmonologists can palliate the symptoms associated with disorders such as malignant pleural effusion, airway obstruction and hemoptysis. Commonly offered interventions in this regard include, indwelling pleural catheters (IPC), pleurodesis, endobronchial laser, electrocautery, argon plasma coagulation (APC), endobronchial brachytherapy, rigid bronchoscopy and airway stenting.

Pulmonary Alveolar Proteinosis (PAP) is a rare disease characterized by the accumulation of proteinaceous material in the alveoli, resulting in progressive hypoxemia and functional limitation. Whole lung lavage under general anesthesia with normal saline has become established as a safe and effective treatment for PAP. The technique varies slightly from institution to institution, but essentially involves the instillation and removal of 500-1000ml aliquots of normal saline from one lung at a time, which removes the offending material from the alveoli. There is often significant functional improvement within weeks that can persist for months or years. Repeat lavage can be done when symptoms return.

Treatment of severe asthma refractory to standard therapies such as inhaled corticosteroids or bronchodilators is limited. Newer pharmacologic agents focus on the allergic subset of asthmatics limiting their use to a smaller subgroup. Bronchial thermoplasty is a novel procedure developed over the past decade where airway smooth muscles are ablated using radiofrequency thermal energy during bronchoscopy to prevent bronchoconstriction. Current data suggest that the procedure is relatively safe with a potential for transient and mild worsening of respiratory symptoms. Bronchial thermoplasty has shown a significant decrease in the number of exacerbations and emergency department visits during the year following therapy. While FDA approved since 2010 for refractory asthma not responding to conventional therapies, some individual health plans are yet to approve it for reimbursement limiting its wide use. Current guidelines endorse cautionary use until further data is available regarding the efficacy of the procedure.

Emphysema is a form of the chronic obstructive pulmonary disease characterized by destruction of alveolar tissue, abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles. The physiologic consequences of the anatomical changes include loss of elastic recoil, early airway closure during exhalation, and air trapping in the distal air spaces. Alveolar wall destruction with the formation of emphysematous blebs and bullae leads to increased physiologic dead space and loss of gas exchanging surface. Further, air trapping and hyperinflation press the diaphragm into a flat configuration and place all the muscles of respiration at a mechanical overstretch disadvantage. In combination, these mechanisms lead to refractory dyspnea in affected individuals. Lung volume reduction surgery (LVRS) is a surgical treatment for patients with advanced emphysema whose dyspnea is poorly controlled with the usual therapies. LVRS entails reducing the lung volume by wedge excisions of emphysematous tissue. However, surgical morbidity is high, and non-pulmonary comorbidities may preclude surgery. Minimally invasive techniques have been created, and provide similar benefits to surgical outcomes with significantly less morbidity and mortality. Bronchoscopic Lung Volume Reduction (BLVR) refers to techniques developed to treat hyperinflation due to emphysema, using devices deployed via a flexible bronchoscope. The devices and techniques for BLVR will be reviewed in this manuscript.

The presence of foreign bodies in the airways may be a life-threatening emergency that requires quick and decisive action. Sometimes the foreign body aspiration may go unnoticed by the patient and the doctors, as may manifest in many ways, such as asthma-like symptoms, recurrent infections or even pulmonary abnormalities (e.g. bronchiectasis or areas of air-trapping). Therefore, the diagnosis of these situations can be complex and requires a high degree of clinical suspicion. Among the complementary tests, chest x-ray may provide us with important information on those radiopaque foreign bodies. However, in other instances a computerized tomography (CT) is necessary to confirm the diagnosis and to determine the physical characteristics and exact location of the foreign body. Since Gustav Killian extracted the first foreign body in 1897 using an esophagoscope, various techniques have been used for this purpose. Due to its larger working channel, rigid bronchoscopy allows an easier handling, removal and treatment of possible complications. Following the invention of the flexible bronchoscope by Shigeto Ikeda, and its subsequent development, this technique has emerged as a less invasive alternative to traditional procedures with encouraging results in selected cases and requiring fewer resources.