Development of a Bronchoscopy-Radiologic Skills and Task Assessment Tool (BRadSTAT): A Tool for Evaluating the Radiological Skills of Bronchoscopists with Different Experience.

BACKGROUND: Competency using radiologic images for bronchoscopic navigation is presumed during subspecialty training, but no assessments objectively measure combined knowledge of radiologic interpretation and ability to maneuver a bronchoscope into peripheral airways. OBJECTIVES: The objectives of this study were (i) to determine whether the Bronchoscopy-Radiology Skills and Tasks Assessment Tool (BRadSTAT) discriminates between bronchoscopists of various levels of experience and (ii) to improve construct validity using study findings. METHODS: BRadSTAT contains 10 questions that assess chest X-ray and CT scan interpretation using multiple images per question and 2 technical skill assessments. After administration to 33 bronchoscopists (5 Beginners, 9 Intermediates, 10 Experienced, and 9 Experts), discriminative power was strengthened using differential weighting on CT-related questions, producing the BRadSTAT-CT score. Cut points for both scores were determined via cross-validation. RESULTS: Mean BRadSTAT scores for Beginner, Intermediate, Experienced, and Expert were 74 (±13 SD), 78 (±14), 86 (±9), and 88 (±8), respectively. Statistically significant differences were noted between Expert and Beginner, Expert and Intermediate, and Experienced and Beginner (all p ≤ 0.05). Mean BRadSTAT-CT scores for Beginner, Intermediate, Experienced, and Expert were 63 (±14), 74 (±15), 82 (±13), and 90 (±9), respectively, all statistically significant (p ≤ 0.03). Cut points for BRadSTAT-CT had lower sensitivity but greater specificity and accuracy than for BRadSTAT. CONCLUSION: BRadSTAT represents the first validated assessment tool measuring knowledge and skills for bronchoscopic access to peripheral airways, which discriminates between bronchoscopists of various experience levels. Refining BRadSTAT produced the BRadSTAT-CT, which had higher discriminative power. Future studies should focus on their usefulness in competency-based bronchoscopy programs.

Bronchoscopy in Patients With Known or Suspected COVID-19: Results From the Global Pandemic SARS-CoV-2 Bronchoscopy Database (GPS-BD).

BACKGROUND: Amid the Coronavirus Disease 2019 (COVID-19) pandemic, the benefits and risks of bronchoscopy remain uncertain. This study was designed to characterize bronchoscopy-related practice patterns, diagnostic yields, and adverse events involving patients with known or suspected COVID-19. METHODS: An online survey tool retrospectively queried bronchoscopists about their experiences with patients with known or suspected COVID-19 between March 20 and August 20, 2020. Collected data comprised the Global Pandemic SARS-CoV-2 Bronchoscopy Database (GPS-BD). All bronchoscopists and patients were anonymous with no direct investigator-to-respondent contact. RESULTS: Bronchoscopy procedures involving 289 patients from 26 countries were analyzed. One-half of patients had known COVID-19. Most (82%) had at least 1 pre-existing comorbidity, 80% had at least 1 organ failure, 51% were critically ill, and 37% were intubated at the time of the procedure. Bronchoscopy was performed with diagnostic intent in 166 (57%) patients, yielding a diagnosis in 86 (52%). and management changes in 80 (48%). Bronchoscopy was performed with therapeutic intent in 71 (25%) patients, mostly for secretion clearance (87%). Complications attributed to bronchoscopy or significant clinical decline within 12 hours of the procedure occurred in 24 (8%) cases, with 1 death. CONCLUSION: Results from this international database provide a widely generalizable characterization of the benefits and risks of bronchoscopy in patients with known or suspected COVID-19. Bronchoscopy in this setting has reasonable clinical benefit, with diagnosis and/or management change resulting from about half of the diagnostic cases. However, it is not without risk, especially in patients with limited physiological reserve.

A systematic review and metanalysis of diagnostic yield of BAL for detection of SARS-CoV-2.

BACKGROUND: The gold standard for diagnosing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is microbiological confirmation by reverse transcriptase-polymerase chain reaction (RT-PCR)1 most commonly done using oropharyngeal (OP) and nasopharyngeal swabs (NP). But in suspected cases, where these samples are false-negative, bronchoalveolar lavage (BAL) may prove diagnostic. OBJECTIVES: Hence, the diagnostic yield of BAL for detection of SARS-CoV-2 in cases of non-diagnostic upper respiratory tract samples is reviewed. METHODS: Databases such as MEDLINE, Scopus, and Google Scholar were searched using a systematic search strategy. The current study has been in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and has been registered with the International Prospective Registry of Systematic Reviews (CRD42020224088). RESULTS: 911 records were identified at initial database extraction, of which 317 duplicates were removed and, 596 records were screened for inclusion eligibility. We included total 19 studies in the systematic review, and 17 were included in metanalysis. The pooled estimate of SARS-CoV-2 positivity in BAL was 11% (95%CI: 0.01-0.24). A sensitivity analysis also showed that the results appear to be robust and minimal risk of bias amongst the studies. CONCLUSION: The current study demonstrates that BAL can be used to diagnose additional cases primary disease and superadded infections in patients with severe COVID-19 lower respiratory tract infection.

Assessing coronavirus disease 2019 (COVID-19) transmission to healthcare personnel: The global ACT-HCP case-control study.

OBJECTIVE: To characterize associations between exposures within and outside the medical workplace with healthcare personnel (HCP) SARS-CoV-2 infection, including the effect of various forms of respiratory protection. DESIGN: Case-control study. SETTING: We collected data from international participants via an online survey. PARTICIPANTS: In total, 1,130 HCP (244 cases with laboratory-confirmed COVID-19, and 886 controls healthy throughout the pandemic) from 67 countries not meeting prespecified exclusion (ie, healthy but not working, missing workplace exposure data, COVID symptoms without lab confirmation) were included in this study. METHODS: Respondents were queried regarding workplace exposures, respiratory protection, and extra-occupational activities. Odds ratios for HCP infection were calculated using multivariable logistic regression and sensitivity analyses controlling for confounders and known biases. RESULTS: HCP infection was associated with non-aerosol-generating contact with COVID-19 patients (adjusted OR, 1.4; 95% CI, 1.04-1.9; P = .03) and extra-occupational exposures including gatherings of ≥10 people, patronizing restaurants or bars, and public transportation (adjusted OR range, 3.1-16.2). Respirator use during aerosol-generating procedures (AGPs) was associated with lower odds of HCP infection (adjusted OR, 0.4; 95% CI, 0.2-0.8, P = .005), as was exposure to intensive care and dedicated COVID units, negative pressure rooms, and personal protective equipment (PPE) observers (adjusted OR range, 0.4-0.7). CONCLUSIONS: COVID-19 transmission to HCP was associated with medical exposures currently considered lower-risk and multiple extra-occupational exposures, and exposures associated with proper use of appropriate PPE were protective. Closer scrutiny of infection control measures surrounding healthcare activities and medical settings considered lower risk, and continued awareness of the risks of public congregation, may reduce the incidence of HCP infection.

Sending retirees to the frontlines?

Facing an unprecedented surge of patient volumes and acuity, institutions around the globe called for volunteer healthcare workers to aid in the effort against COVID-19. Specifically being sought out are retirees. But retired healthcare workers are taking on significant risk to themselves in answering these calls. Aside from the risks that come from being on the frontlines of the epidemic, they are also at risk due to their age and the comorbidities that often accompany age. If, for current or future COVID efforts, we as a society will be so bold as to exhort a vulnerable population to take on further risk, we must use much care and attention in how we involve them in this effort. Herein we describe the multifaceted nature of the risks that retired healthcare workers are taking by entering the COVID-19 workforce as well as suggest ways in which we might take advantage of their medical skills and altruism yet while optimizing caution and safety.

Artificial intelligence in pulmonary medicine: computer vision, predictive model and COVID-19.

Artificial intelligence (AI) is transforming healthcare delivery. The digital revolution in medicine and healthcare information is prompting a staggering growth of data intertwined with elements from many digital sources such as genomics, medical imaging and electronic health records. Such massive growth has sparked the development of an increasing number of AI-based applications that can be deployed in clinical practice. Pulmonary specialists who are familiar with the principles of AI and its applications will be empowered and prepared to seize future practice and research opportunities. The goal of this review is to provide pulmonary specialists and other readers with information pertinent to the use of AI in pulmonary medicine. First, we describe the concept of AI and some of the requisites of machine learning and deep learning. Next, we review some of the literature relevant to the use of computer vision in medical imaging, predictive modelling with machine learning, and the use of AI for battling the novel severe acute respiratory syndrome-coronavirus-2 pandemic. We close our review with a discussion of limitations and challenges pertaining to the further incorporation of AI into clinical pulmonary practice.

Training in interventional pulmonology: What we have learned and a way forward.

IP encompasses a complex list of procedures requiring knowledge, technical skills and competence. Modern, learner-centric educational philosophies and an explosion of multidimensional educational tools including manikins, simulators, online resources, social media and formal programs can foster learning in IP, promoting professionalism and a culture of lifelong learning. This paper provides background and guidance to a structured, multidimensional and learner-centric strategy for medical procedural education. Focusing on our experience in IP, we describe how competency-based measures, simulation technology and various teaching modalities contribute to a more uniform learning environment in which patients do not suffer the burdens of procedure-related training.

Learning Gain and Skill Retention Following Unstructured Bronchoscopy Simulation in a Low-fidelity Airway Model.

BACKGROUND: Simulation is invaluable for bronchoscopy training. Studies report improved procedure time, dexterity/technique, and trainee satisfaction supported by low-fidelity and high-fidelity simulators in structured-training programs. We sought to determine (1) Learning-gain in bronchoscopic dexterity after a single 45-minute unstructured exposure using a low-fidelity simulator. (2) Whether acquired skills are maintained 8 weeks later, during which trainees receive no interim exposure to simulation or clinical bronchoscopy. METHODS: Using a low-fidelity model, medical students were assessed for bronchoscopicdexterity before and after an unstructured, self-directed 45-minute simulation. Bronchoscopic dexterity was assessed according to: (1) Ability to enter a target-bronchus within a specified time. (2) The modified Bronchoscopy Skills and Tasks Assessment Tool (mBSTAT). Scores were compared at baseline, postsimulation, and 8 weeks postsimulation. Individual domains of the mBSTAT were compared with identify specific skills demonstrating more significant deterioration. RESULTS: Twenty-eight medical students completed the initial-simulation session. Fifteen returned at 8 weeks. Statistically significant improvement in bronchoscopic-skills was observed immediately following the simulation session (mBSTAT scores 3.7±1.2 pretest vs. 7.0±0.9 posttest, P<0.001). mBSTAT scores had deteriorated significantly at 8 weeks (5.7±1.8, P=0.03) but remained superior to baseline scores (P=0.002). Of the 4 domains assessed, only Precision did not demonstrate any change between post-test and review assessments (P=0.14). All other domains demonstrated trends towards significant deterioration between posttest and review. CONCLUSION: A single 45-minute unstructured bronchoscopy simulation session resulted in significant improvement in bronchoscopic dexterity. Significant decay in bronchoscopic dexterity is observed, suggesting repeat simulation may be valuable following periods without bronchoscopy exposure.

Assessment of Bronchoscopic Dexterity and Procedural Competency in a Low-fidelity Simulation Model.

BACKGROUND: Assessment of competency in bronchoscopy has traditionally been undertaken in clinical settings, however, recent recognition of increased procedural complications and learner anxiety have led to interest in simulation-based competency assessment. The aim of this study was to determine if low-fidelity simulation-based assessment allows discrimination of competency based on prior experience between bronchoscopists. METHODS: Forty-four participants were allocated to 3 groups based on prior bronchoscopic experience [novices (n=31) with no prior experience, intermediates (n=7) with prior experience of 5 to 10 bronchoscopies, and expert bronchoscopists (n=6) with minimum 200 prior bronchoscopies performed]. Participants performed bronchoscopy in a 3D-printed anatomic airway model and were assessed according to time required to navigate to a target bronchus. Bronchoscopic dexterity was measured using a modified version of the validated Bronchoscopy Skills and Tasks Assessment Tool. RESULTS: Competency based on successful navigation to a target bronchus differed significantly between each group [experts, 12/12 (100%); intermediates, 9/14 (64%); novices, 19/62 (31%); P<0.001]. Bronchoscopic dexterity as measured by modified Bronchoscopy Skills and Tasks Assessment Tool also differed significantly between groups with experts achieving consistently higher scores compared with other 2 groups [median (interquartile range) scores: novices, 3.5 (2.5 to 5); intermediate, 5 (4.5 to 7); experts, 8 (7.5 to 8); P<0.0.001). CONCLUSIONS: Multiple measures demonstrate that low-fidelity simulation-based assessment may reliably discriminate between different levels of skill in performing bronchoscopic navigation and airway inspection. Procedural dexterity of trainees may be assessed in a 0-risk simulation environment.

Amedeo Modigliani: Bohemio ebrio o enfermo contagioso / Amedeo Modigliani: Bohemian drunk or contagious sick

Our life histories are undeniably affected by changes imposed on us by age and disease, and thus, by the trajectory of medicine which itself is enmeshed in the social order of our times. Each has an effect on our identities, which lingers regardless of our will. In this essay, I illustrate how Amedeo Modigliani's art and illness not only coexisted, but were tragically interwoven in the web of his life. My goal is to describe several aspects of his work and lesser known elements related to the disease that killed him when he was only 35. For Modi - gliani, as for others, understanding this interplay between art, life, and illness provides insight to the creative spirit where beauty and truth are found

El rol del neumonólogo en el estudio de los marcadores moleculares en el cáncer de pulmón no pequeñas células / The Pulmonologist's Role Studying Molecular Markers in Non Small-Cell Lung Cancer

La mayor parte de los paciente con cáncer de pulmón son diagnosticados, estadificados o re-estadificados utilizando muestras pequeñas obtenidas a través de broncoscopía o punción aspiración. En la era actual de tratamiento personalizado del cáncer de pulmón, el tejido no se require solamente para el análisis histológicomorfológico sino también para el análisis molecular que ayuda a predecir los resultados de determinadas terapias sistémicas. Existen variedad de maneras de procesar las muestras de pequeño volumen para el diagnóstico y la tipificación molecular, las estrategias óptimas varían de una institución a la otra, dependiendo de la infraestructura, experiencia, recursos de laboratorio y tecnología disponible. Este nuevo paradigma en el cual la tipificación molecular de rutina se ha transformado en standar de tratamiento requerirá un manejo más standartizado de la adquisición y el procesamiento de los pequeños especímenes

Assessment of central airway obstruction using impulse oscillometry before and after interventional bronchoscopy.

BACKGROUND: Spirometry is used to physiologically assess patients with central airway obstruction (CAO) before and after interventional bronchoscopy, but is not always feasible in these patients, does not localize the anatomic site of obstruction, and may not correlate with the patient's functional impairment. Impulse oscillometry may overcome these limitations. We assessed the correlations between impulse oscillometry measurements, symptoms, and type of airway narrowing, before and after interventional bronchoscopy, and whether impulse oscillometry parameters can discriminate between fixed and dynamic CAO. METHODS: Twenty consecutive patients with CAO underwent spirometry, impulse oscillometry, computed tomography, dyspnea assessment, and bronchoscopy, before and after interventional bronchoscopy. The collapsibility index (the percent difference in airway lumen diameter during expiration versus during inspiration) was calculated using morphometric bronchoscopic images during quiet breathing. Variable CAO was defined as a collapsibility index of > 50%. Fixed CAO was defined as a collapsibility index of < 50%. The degree of obstruction was analyzed with computed tomography measurements. RESULTS: After interventional bronchoscopy, all impulse oscillometry measurements significantly improved, especially resistance at 5 Hz, which decreased from 0.67 ± 0.29kPa/L/s to 0.38 ± 0.17kPa/L/s (P < .001), and reactance at 20 Hz, which increased from -0.09 ± 0.11 to 0.03 ± 0.08 (P < .001). Changes in dyspnea score correlated with resistance at 5 Hz, the difference between the resistance at 5 Hz and the resistance at 20 Hz, and the reactance at 5 Hz, but not with spirometry measurements. The type of obstruction also correlated with dyspnea score, and showed distinct impulse oscillometry measurements. CONCLUSIONS: Impulse oscillometry measurements correlate with symptom improvements after interventional bronchoscopy. Impulse oscillometry might be useful to discriminate variable from fixed central airway obstruction. (University Hospital Medical Information Network, http://www.umin.ac.jp/english, ID000005322).

Role of the pulmonologist in ordering post-procedure molecular markers in non-small-cell lung cancer: implications for personalized medicine.

In the growing era of personalized medicine for the treatment of non-small-cell lung cancer (NSCLC), it is becoming increasingly important that sufficient quality and quantity of tumor tissue are available for morphologic diagnosis and molecular analysis. As new treatment options emerge that might require more frequent and possibly higher volume biopsies, the role of the pulmonologist will expand, and it will be important for pulmonologists to work within a multidisciplinary team to provide optimal therapeutic management for patients with NSCLC. In this review, we discuss the rationale for individualized treatment decisions for patients with NSCLC, molecular pathways and specific molecular predictors relevant to personalized NSCLC therapy, assay technologies for molecular marker analysis, and specifics regarding tumor specimen selection, acquisition, and handling. Moreover, we briefly address issues regarding racial and socioeconomic disparities as they relate to molecular testing and treatment decisions, and cost considerations for molecular testing and targeted therapies in NSCLC. We also propose a model for an institution-based multidisciplinary team, including oncologists, pathologists, pulmonologists, interventional radiologists, and thoracic surgeons, to ensure adequate material is available for cytological and histological studies and to standardize methods of tumor specimen handling and processing in an effort to provide beneficial, individualized therapy for patients with NSCLC.

Tracheobronchomalacia and excessive dynamic airway collapse.

Tracheobronchomalacia and excessive dynamic airway collapse are morphologic types of expiratory central airway collapse with specific pathophysiology, cause, and structural changes in airway wall. Physicians caring for symptomatic patients with expiratory central airway collapse must localize the flow-limiting airway segments amenable to bronchoscopic or surgical interventions. Functional bronchoscopy and dynamic radiologic studies are performed for the initial evaluation and to design follow-up strategies. Research is needed to determine noninvasive and reliable physiologic methods for localizing the flow-limiting segments that might guide patient selection for treatment and predict response to interventions.

Combined optical coherence tomography and endobronchial ultrasonography for laser-assisted treatment of postintubation laryngotracheal stenosis.

OBJECTIVES: We describe the use of combined optical coherence tomography (OCT) and endobronchial ultrasonography (EBUS) to identify the residual hypertrophic tissues and persistent inflammation that are known contributors to stricture recurrence after laser-assisted mechanical dilation (LAMD) oflaryngotracheal stenosis (LTS). METHODS: Commercially available high-frequency EBUS (approximately 100-microm resolution) and time-domain OCT (approximately 10- to 20-microm resolution) systems were used to visualize airway wall microstructures in the area of hypertrophic tissue formation before and after LAMD in 2 patients with complex circumferential postintubation LTS. RESULTS: Before LAMD, EBUS revealed a homogeneous layer consistent with hypertrophic tissue overlying a hyperechogenic layer corresponding to tracheal cartilage. OCT revealed a homogeneous light backscattering layer and an absence of layered microstructures within hypertrophic tissue. Immediately after LAMD, OCT of the laser-charred tissue showed high backscattering and shadowing artifacts; OCT of noncharred tissue showed bright light backscattering regions that suggested acute inflammation. EBUS revealed thinner but persistent hypertrophic tissue overlying the cartilage. Stenosis recurred in both patients. CONCLUSIONS: Intraoperative use of EBUS and OCT could potentially identify residual hypertrophic tissues and persistent inflammation during or after LAMD. It might help physicians predict stricture recurrence, prompting alternative therapeutic strategies and avoidance of repeated endoscopic treatments for LTS.

Follow-up and surveillance of the patient with lung cancer after curative-intent therapy: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.

BACKGROUND: These guidelines are an update of the evidence-based recommendations for follow-up and surveillance of patients after curative-intent therapy for lung cancer. Particular updates pertain to whether imaging studies, health-related quality-of-life (HRQOL) measures, tumor markers, and bronchoscopy improve outcomes after curative-intent therapy. METHODS: Meta-analysis of Observational Studies in Epidemiology guidelines were followed for this systematic review, including published studies on posttreatment outcomes in patients who received curative-intent therapy since the previous American College of Chest Physicians subject review. Four population, intervention, comparison, and outcome questions were formulated to guide the review. The MEDLINE and CINAHL databases were searched from June 1, 2005, to July 8, 2011, to ensure overlap with the search strategies used previously. RESULTS: A total of 3,412 citations from MEDLINE and 431 from CINAHL were identified. Only 303 were relevant. Seventy-six of the 303 articles were deemed eligible on the basis of predefined inclusion criteria after full-text review, but only 34 provided data pertaining directly to the subject of the questions formulated to guide this review. In patients undergoing curative-intent surgical resection of non-small cell lung cancer, chest CT imaging performed at designated time intervals after resection is suggested for detecting recurrence. It is recommended that treating physicians who are able to incorporate the patient's clinical findings into decision-making processes be included in follow-up and surveillance strategies. The use of validated HRQOL instruments at baseline and during follow-up is recommended. Biomarker testing during surveillance outside clinical trials is not suggested. Surveillance bronchoscopy is suggested for patients with early central airway squamous cell carcinoma treated by curative-intent photodynamic therapy and for patients with intraluminal bronchial carcinoid tumor who have undergone curative-intent bronchoscopic treatment with Nd:YAG laser or electrocautery. CONCLUSIONS: There is a paucity of well-designed prospective studies specifically targeting follow-up and surveillance modalities aimed at improving survival or QOL after curative-intent therapy. Additional research is warranted to clarify which curative-intent treatment modalities affect HRQOL the most and to identify patients who are at the most risk for recurrence or impaired QOL after treatment. Further evidence is needed to determine how the frequency and duration of surveillance programs that include imaging studies, QOL measurements, tumor markers, or bronchoscopy affect patient morbidity, survival, HRQOL, and health-care costs.