Interventional Pulmonology: Extending the Breadth of Thoracic Care.

Interventional pulmonary medicine has developed as a subspecialty focused on the management of patients with complex thoracic disease. Leveraging minimally invasive techniques, interventional pulmonologists diagnose and treat pathologies that previously required more invasive options such as surgery. By mitigating procedural risk, interventional pulmonologists have extended the reach of care to a wider pool of vulnerable patients who require therapy. Endoscopic innovations, including endobronchial ultrasound and robotic and electromagnetic bronchoscopy, have enhanced the ability to perform diagnostic procedures on an ambulatory basis. Therapeutic procedures for patients with symptomatic airway disease, pleural disease, and severe emphysema have provided the ability to palliate symptoms. The combination of medical and procedural expertise has made interventional pulmonologists an integral part of comprehensive care teams for patients with oncologic, airway, and pleural needs. This review surveys key areas in which interventional pulmonologists have impacted the care of thoracic disease through bronchoscopic intervention.

Interventional pulmonology techniques in lung transplantation.

Lung transplantation is a key therapeutic option for several end-stage lung diseases. Interventional pulmonology techniques, mostly bronchoscopy, play a key role throughout the whole path of lung transplantation, from donor evaluation to diagnosis and management of post-transplant complications. We carried out a non-systematic, narrative literature review aimed at describing the main indications, contraindications, performance characteristics and safety profile of interventional pulmonology techniques in the context of lung transplantation. We highlighted the role of bronchoscopy during donor evaluation and described the debated role of surveillance bronchoscopy (with bronchoalveolar lavage and transbronchial biopsy) to detect early rejection, infections and airways complications. The conventional (transbronchial forceps biopsy) and the new techniques (i.e. cryobiopsy, biopsy molecular assessment, probe-based confocal laser endomicroscopy) can detect and grade rejection. Several endoscopic techniques (e.g. balloon dilations, stent placement, ablative techniques) are employed in the management of airways complications (ischemia and necrosis, dehiscence, stenosis and malacia). First line pleural interventions (i.e. thoracentesis, chest tube insertion, indwelling pleural catheters) may be useful in the context of early and late pleural complications occurring after lung transplantation. High quality studies are advocated to define endoscopic standard protocols and thus help improving long-term prognostic outcomes of lung transplant recipients.

Current Practices Supporting Rigid Bronchoscopy-An International Survey.

BACKGROUND: There are no guidelines for anesthesia or staff support needed during rigid bronchoscopy (RB). Identifying current practice patterns for RB pertinent to anesthesia, multidisciplinary teams, and algorithms of intra and post-procedural care may inform best practice recommendations. METHODS: Thirty-three-question survey created obtaining practice patterns for RB, disseminated via email to the members of the American Association of Bronchology and Interventional Pulmonology and the American College of Chest Physicians Interventional Chest Diagnostic Procedures Network. RESULTS: One hundred seventy-five clinicians participated. Presence of a dedicated interventional pulmonology (IP) suite correlated with having a dedicated multidisciplinary RB team ( P =0.0001) and predicted higher likelihood of implementing team-based algorithms for managing complications (39.4% vs. 23.5%, P =0.024). A dedicated anesthesiology team was associated with the increased use of high-frequency jet ventilation ( P =0.0033), higher likelihood of laryngeal mask airway use post-RB extubation ( P =0.0249), and perceived lower rates of postprocedural anesthesia adverse effects ( P =0.0170). Although total intravenous anesthesia was the most used technique during RB (94.29%), significant variability in the modes of ventilation and administration of muscle relaxants was reported. Higher comfort levels in performing RB are reported for both anesthesiologists ( P =0.0074) and interventional pulmonologists ( P =0.05) with the presence of dedicated anesthesia and RB supportive teams, respectively. CONCLUSION: Interventional bronchoscopists value dedicated services supporting RB. Multidisciplinary dedicated RB teams are more likely to implement protocols guiding management of intraprocedural complications. There are no preferred modes of ventilation during RB. These findings may guide future research on RB practices.

Value of a Multidisciplinary Team Approach to Treatment of Emphysema.

Lung volume reduction surgery can significantly improve quality of life for properly selected patients who are symptomatic despite maximal medical management for emphysema. This requires a well-constructed multidisciplinary team (including transplant) to evaluate and treat these patients.

Joint Statement of the German Respiratory Society and German Society of Thoracic Surgery in Cooperation with the German Radiological Society: Structural Prerequisites of Centres for Interventional Treatment of Emphysema.

Interventional treatment of emphysema offers a wide range of surgical and endoscopic options for patients with advanced disease. Multidisciplinary collaboration of pulmonology, thoracic surgery, and imaging disciplines in patient selection, therapy, and follow-up ensures treatment quality. The present joint statement describes the required structural and quality prerequisites of treatment centres. This is a translation of the German article "Positionspapier der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin und der Deutschen Gesellschaft für Thoraxchirurgie in Kooperation mit der Deutschen Röntgengesellschaft: Strukturvoraussetzungen von Zentren für die interventionelle Emphysemtherapie" Pneumologie. 2020;74:17-23.

Nanotechnology in pulmonary medicine.

Nanotechnology in medicine-nanomedicine-is extensively employed to diagnose, treat, and prevent pulmonary diseases. Over the last few years, this brave new world has made remarkable progress, offering opportunities to address historical clinical challenges in pulmonary diseases including multidrug resistance, adverse side effects of conventional therapeutic agents, novel imaging, and earlier disease detection. Nanomedicine is also being applied to tackle the new emerging infectious diseases, including severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East Respiratory Syndrome Coronavirus (MERS-CoV), influenza A virus subtype H1N1 (A/H1N1), and more recently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this review we provide both a historical overview of the application of nanomedicine to respiratory diseases and more recent cutting-edge approaches such as nanoparticle-mediated combination therapies, novel double-targeted nondrug delivery system for targeting, stimuli-responsive nanoparticles, and theranostic imaging in the diagnosis and treatment of pulmonary diseases.

Recommendations for interventional pulmonology during COVID-19 outbreak: a consensus statement from the Portuguese Pulmonology Society.

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by a novel SARS-CoV-2 pathogen. Its capacity for human-to-human transmission through respiratory droplets, coupled with a high-level of population mobility, has resulted in a rapid dissemination worldwide. Healthcare workers have been particularly exposed to the risk of infection and represent a significant proportion of COVID-19 cases in the worst affected regions of Europe. Like other open airway procedures or aerosol-generating procedures, bronchoscopy poses a significant risk of spreading contaminated droplets, and medical workers must adapt the procedures to ensure safety of both patients and staff. Several recommendation documents were published at the beginning of the pandemic, but as the situation evolves, our thoughts should not only focus on the present, but should also reflect on how we are going to deal with the presence of the virus in the community until there is a vaccine or specific treatment available. It is in this sense that this document aims to guide interventional pulmonology throughout this period, providing a set of recommendations on how to perform bronchoscopy or pleural procedures safely and efficiently.

[Cryobiopsy]. / Durchführung der transbronchialen Kryobiopsie.

Cryosurgery has been successfully in bronchoscopy for several years. In addition to the local therapy of tumors and stenoses, cryo extraction enables the endobronchial and transbronchial extraction of large, high-quality biopsies. This is with regard to the diagnosis of diffuse lung diseases and the molecular analysis of malignant lung tumors of outstanding importance. This article explains the method and implementation of transbronchial cryobiopsy.

Development of Learning Curves for Bronchoscopy: Results of a Multicenter Study of Pulmonary Trainees.

BACKGROUND: There are currently no reference standards for the development of competence in bronchoscopy. RESEARCH QUESTION: The aims of this study were to (1) develop learning curves for bronchoscopy skill development and (2) estimate the number of bronchoscopies required to achieve competence. STUDY DESIGN AND METHODS: Trainees from seven North American academic centers were enrolled at the beginning of their pulmonology training. Performance during clinical bronchoscopies was assessed by supervising physicians using the Ontario Bronchoscopy Assessment Tool (OBAT). Group-level learning curves were modeled using a quantile regression growth model, where the dependent variable was the mean OBAT score and the independent variable was the number of bronchoscopies performed at the time the OBAT was completed. RESULTS: A total of 591 OBAT assessments were collected from 31 trainees. The estimated regression quantiles illustrate significantly different learning curves based on trainees' performance percentiles. When competence was defined as the mean OBAT score for all bronchoscopies rated as being completed without need for supervision, the mean OBAT score associated with competence was 4.54 (95% CI, 4.47-4.58). Using this metric, the number of bronchoscopies required to achieve this score varied from seven to 10 for the 90th percentile of trainees and from 109 to 126 for the lowest 10th percentile of trainees. When competence was defined as the mean OBAT score for the first independent bronchoscopy, the mean was 4.40 (95% CI, 4.20-4.60). On the basis of this metric, the number of bronchoscopies required varied from one to 11 for the 90th percentile of trainees and from 83 to 129 for the lowest 10th percentile of trainees. INTERPRETATION: We were able to generate learning curves for bronchoscopy across a range of trainees and centers. Furthermore, we established the average number of bronchoscopies required for the attainment of competence. This information can be used for purposes of curriculum planning and allows a trainee's progress to be compared with an established norm.

Proposals for managing patients with thoracic malignancies during COVID-19 pandemic.

The objective of this document is to formalize a degraded mode management for patients with thoracic cancers in the context of the COVID-19 pandemic. The proposals are based on those of the French High Council for Public Health, on published data outside the context of COVID-19, and on a concerted analysis of the risk-benefit ratio for our patients by a panel of experts specialized on thoracic oncology under the aegis of the French-Language Society of Pulmonology (SPLF)/French-language oncology group. These proposals are evolving (10 April 2020) according to the situations encountered, which will enrich it, and are to be adapted to our institutional organisations and to the evolution of resources during the COVID-19 epidemic. Patients with symptoms and/or COVID-19+ are not discussed in this document and are managed within the framework of specific channels.

Interventional Pulmonology: A Brave New World.

Interventional pulmonology is a dynamic and evolving field in respiratory medicine. Advances have improved the ability to diagnose and manage diseases of the airways. A shift toward early detection of malignant disease has generated a focus on innovative diagnostic techniques. With patient populations living longer with malignant and benign diseases, the role for interventional bronchoscopy has grown. In cancer groups, novel immunotherapies have improved the prospects of clinical outcomes and reignited a focus on optimizing patient performance status to enable access to anticancer therapy. This review discusses current and emerging diagnostic modalities and therapeutic approaches available to manage airway diseases.

The Lung Function Laboratory to Assist Clinical Decision-making in Pulmonology: Evolving Challenges to an Old Issue.

The lung function laboratory frequently provides relevant information to the practice of pulmonology. Clinical interpretation of pulmonary function and exercise tests, however, has been complicated more recently by temporal changes in demographic characteristics (higher life expectancy), anthropometric attributes (increased obesity prevalence), and the surge of polypharmacy in a sedentary population with multiple chronic degenerative diseases. In this narrative review, we concisely discuss some key challenges to test interpretation that have been affected by these epidemiologic shifts: (a) the confounding effects of advanced age and severe obesity, (b) the contemporary controversies in the diagnosis of obstruction (including asthma and/or COPD), (c) the importance of considering the diffusing capacity of the lung for carbon monoxide (Dlco)/"accessible" alveolar volume (carbon monoxide transfer coefficient) in association with Dlco to uncover the causes of impaired gas exchange, and (d) the modern role of the pulmonary function laboratory (including cardiopulmonary exercise testing) in the investigation of undetermined dyspnea. Following a Bayesian perspective, we suggest interpretative algorithms that consider the pretest probability of abnormalities as indicated by additional clinical information. We, therefore, adopt a pragmatic approach to help the practicing pulmonologist to apply the information provided by the lung function laboratory to the care of individual patients.

Feasibility and acceptability of introducing advance care planning on a thoracic medicine inpatient ward: an exploratory mixed method study.

BACKGROUND AND AIMS: Advance care planning (ACP) is communication about wishes and preferences for end-of-life care. ACP is not routinely used in any Norwegian hospitals. We performed a pilot study (2014-2017) introducing ACP on a thoracic medicine ward in Norway. The aims of this study were to explore which topics patients discussed during ACP conversations and to assess how patients, relatives and clinicians experienced the acceptability and feasibility of performing ACP. METHODS: Conversations were led by a study nurse or physician using a semistructured guide, encouraging patients to talk freely. Each conversation was summarised in a report in the patient's medical record. At the end of the pilot period, clinicians discussed their experiences in focus group interviews. Reports and transcribed interviews were analysed using systematic text condensation. RESULTS: Fifty-one patients participated in ACP conversations (41-86 years; 9 COPD, 41 lung cancer, 1 lung fibrosis; 11 women); 18 were accompanied by a relative. Four themes emerged: (1) disturbing symptoms, (2) existential topics, (3) care planning and (4) important relationships. All participants appreciated the conversations. Clinicians (1 physician and 7 nurses) participated in two focus group interviews. Reports from ACP conversations revealed patient values previously unknown to clinicians; important information was passed on to primary care. Fearing they would deprive patients of hope, clinicians acted as gatekeepers for recruitment. Although they reported barriers during recruitment, many clinicians saw ACP as pertinent and called for time and skills to integrate it into their daily clinical practice. CONCLUSIONS: Patients, relatives and clinicians showed a positive attitude towards ACP. Focusing on present and future symptom control may be an acceptable way to introduce ACP. Important aspects for implementing ACP in this patient group are management support, education, training, feasible routines and allocated time to perform the conversations.

Competence in operative bronchoscopy.

We describe the current knowledge and skills for the main techniques of operative bronchoscopy and their applications in the treatment of malignant and benign central airway disorders. Rigid bronchoscopy has a history of over 100 years. The use of rigid bronchoscopy was abandoned upon the introduction of the fiberoptic bronchoscope but has made a reappearance with the development of interventional pulmonology in the late nineteenth and early twentieth century. The advantages of rigid bronchoscopy include allowing simultaneous procedures, such as ablation, debulking and suctioning, without limiting ventilation but at the moment there are no standard approaches to perform the procedure. Rigid bronchoscopy also plays a vital role in stent placement, repositioning, maintenance and removal. An interventional pulmonology practice should only be developed when there is a locoregional unmet medical need and when a dedicated interventional pulmonology unit can be guaranteed. These departments should be available 7 days a week and should provide a fast and appropriate response to referrals in emergency cases. There is a clear need to define a competency-based training program for rigid bronchoscopy, including stent placement. An optimal, multimodality training program for bronchoscopy should include didactic lectures, web-based learning, case-based reviews and hands-on training.

Thiol-Based Drugs in Pulmonary Medicine: Much More than Mucolytics.

Thiol-based drugs are considered as mucolytics because they decrease the viscosity and mostly decrease the elasticity of bronchial secretions by reducing disulfide bonds in proteins. However, they can also act as antioxidant drugs directly through free sulfhydryl groups that serve as a source of reducing equivalents, as well as indirectly through the replenishment of intracellular glutathione (GSH) levels. Modulation of neurokinin A levels may also be related to the effect of thiol drugs on oxidative stress. Moreover, thiol-based drugs interfere with inflammatory pathways and modulate human bronchial tone. They might also be considered as therapeutic agents against some types of infection because they reduce bacterial adhesion to the respiratory epithelial cell surface and inhibit biofilm formation, causing biofilm disruption and thereby improving the efficacy of antibiotic therapy.

[Behavioral and cognitive therapies in smoking cessation: What tools for the pulmonologist?] / Les thérapies comportementales et cognitives (TCC) dans le sevrage tabagique : quels outils pour le pneumologue ?

Behavioral therapies have been developed from Pavlov and Skinner's theories on learning. They have been enriched with knowledge about the processing of information, a process organizing the perception of events. For these two reasons they are called behavioral and cognitive therapies (CBT). CBTs take place in four stages: therapeutic alliance, functional analysis, behavioral and cognitive methods, and evaluation. Seven techniques allow the pulmonologist to increase motivation in patients, particularly at the contemplation stage: the motivational interviewing, the decision-making balance technique, recognition of vicious circles and their substitution by constructive circles, short and long-term evaluation of life, the "I owe it", being the Devil's advocate and the letter of rupture. The analysis of the literature highlights the effectiveness of CBT techniques, especially when they are combined with pharmacological treatments for smoking cessation (dual nicotine replacement therapy, bupropion or varenicline).

The impact of a patient decision aid on shared decision-making behaviour in oncology care and pulmonary medicine-A field study based on real-life observations.

OBJECTIVE: A patient decision aid (PtDA) is often developed and evaluated to support shared decision making (SDM) and a patient-centred approach. In this study, a PtDA template was developed to support two different preference sensitive decisions: adjuvant therapy for breast cancer and diagnostic workup for lung cancer. The aim of the study was to explore whether a PtDA improved SDM and supported a patient-centred approach from an observational point of view. METHODS: Real-life observations were conducted using the validated observational instrument OPTION 12. Three nurses conducted observations of consultations in two different clinical settings. The study consisted of a baseline cohort (phase 1) and an intervention cohort (phase 2). In phase 1, standard consultations were observed. Subsequently, the PtDA was introduced, and in phase 2, consultations with the clinician using the PtDA were observed. RESULTS: Twenty-nine observations were conducted in phase 1 and 24 in phase 2. Using a PtDA increased the overall OPTION score significantly (P < .0001), both in decisions on adjuvant treatment for breast cancer and on diagnostic workup of lung cancer. Items in the OPTION instrument regarding systematic conversation to obtain SDM had a higher increase of scores compared to items regarding a patient-centred approach. CONCLUSION: Real-life observations and the use of a validated observational tool provided comprehensive knowledge as to how a PtDA affects SDM in consultations. Applying a PtDA resulted in a significant overall increase of SDM behaviour in decisions on adjuvant treatment after breast cancer surgery and diagnostic workup in case of a small suspicion of lung cancer. In conclusion, the PtDA supports SDM in consultations independently of type of decision and department.

The Impact of an Interventional Pulmonary Program on Nontherapeutic Lung Resections.

BACKGROUND: Pulmonary resection can concurrently diagnose and treat known or suspected lung cancer, but is not without risk. Benign resection rates range widely (9% to 40%). We evaluated the impact of an Interventional Pulmonology (IP) program and dedicated Pulmonary Nodule Clinic on surgical benign resection rates at a single institution. METHODS: An IP program was initiated in August 2010 that offered advanced diagnostic techniques and a dedicated Pulmonary Nodule Clinic was opened in August 2013. We retrospectively reviewed all patients who underwent resection for known or suspected lung cancer between 2005 and 2015 at our tertiary referral hospital. Demographics, preoperative tissue diagnoses, surgical procedure, final pathology, and staging were collected. Quarterly benign resection rates were calculated and plotted on a statistical quality control chart (P-Chart) to determine the impact of the IP program and Pulmonary Nodule Clinic on benign resection rates over time. RESULTS: Of 1112 resections, 209 (19%) were benign. Variation in quarterly benign resection rates decreased after introduction of the IP program in 2010, and a significant (P<0.05) sustained decrease in the quarterly benign resection rate occurred after introduction of the pulmonary nodule clinic in 2013 to a new baseline of 12% compared with 24% before 2010. After introduction of the IP program, mean quarterly preoperative tissue diagnostic rates increased from 45% to 58% (P<0.01). CONCLUSION: Integration of an IP program employing advanced diagnostic bronchoscopic techniques has improved preoperative diagnostic rates of suspicious pulmonary nodules and in combination with a pulmonary nodule clinic has resulted in fewer benign resections.