The field of bronchoscopy is rapidly changing. Rapid advances in this field have paved the way for emergence of a new and exciting field of interventional pulmonology. Minimally invasive procedures by interventional pulmonologists have reduced the need for more traditional surgical approaches in many instances. For example, convex probe endobronchial ultrasound is rapidly replacing mediastinoscopy as the initial procedure of choice in mediastinal staging of lung cancer.1 Electromagnetic navigational bronchoscopy and radial probe ultrasound are allowing bronchoscopists to sample small peripheral lung nodules with greater accuracy.2 Several interventional bronchoscopy techniques such as lasers, electrocautery, argon plasma coagulation, cryotherapy, and airway stent placement provide excellent palliation of symptomatic central airway obstruction, allowing many patients with advanced disease to enjoy a better quality of life.3 Indications of interventional pulmonology procedures have also been extended to some of the most prevalent pulmonary disorders such as asthma4 and chronic obstructive pulmonary disease.5 The clinical applications of interventional pulmonology procedures continue to expand and we may not be far from clinical application of alveoloscopy6 and endobronchial stem cell therapy.7 The excitement and enthusiasm that interventional pulmonology sessions in national meetings generate are difficult to miss. Trained interventional pulmonologists have a high demand as an increasing number of academic pulmonary programs are seeking experts to provide such services for clinical care of their patients. In this regard, rapid growth in interventional pulmonology reminds us of the rapid emergence of the field of interventional cardiology and gastroenterology in 1980s that revolutionized the practise of cardiology and gastroenterology, respectively. A natural consequence of the development of interventional procedures in these specialties was advent of the fields of noninterventional cardiology and gastroenterology. Pulmonary medicine is going through similar evolutionary changes. The fundamental evolutionary pressure driving this change is new developments in the field of bronchoscopy.
It is important to recall that the flexible bronchoscope, originally introduced by Shigeto Ikeda in 1967, was primarily for diagnostic purpose.8 Rapid emergence of interventional procedures during bronchoscopy has not reduced the diagnostic value in any shape or form. If anything, rapid advances in this area have further reaffirmed our appreciation of the power of bronchoscopy as a diagnostic tool. Even though no interventions may be needed, bronchoscopy can still be very helpful in identifying the underlying cause of common challenges such as refractory cough,9 cryptogenic hemoptysis,10 difficult to control asthma, unexplained wheeze, recurrent pneumonia, and lung infiltrates in immunocompromised hosts.11 In fact, diagnostic bronchoscopy can provide very useful information in a host of idiopathic, autoimmune, and inflammatory disorders that tend to involve the central airways, such as sarcoidosis, amyloidosis, tracheobronchopathia osteochondroplastica, granulomatosis with polyangiitis, inflammatory bowel disease, endobronchial fungal and parasitic infections, and tracheobronchomalacia.12 It is also important to point out that availability of interventional procedures does not reduce the clinical value of established conventional bronchoscopic procedures such as bronchoalveolar lavage, endobronchial biopsies, transbronchial biopsies, and conventional transbronchial needle aspiration. For example, recent data from the AquIRE registry have shown peripheral transbronchial needle aspiration to be independently associated with higher diagnostic yield of bronchoscopy for peripheral lung lesions even when radial probe ultrasound and electromagnetic navigational bronchoscopy were performed.13 Unfortunately, the procedure was grossly underutilized, performed in only 16.4% of study subjects.
Every diagnostic procedure has a cognitive component and a technical aspect. Bronchoscopy is no exception. Although technical skills are clearly important, the students of bronchoscopy must first learn the cognitive components of the procedure. These include identification of correct indications, timing of the procedure, contraindications, limitations, choice of sampling procedure, and cost-effectiveness. Every bronchoscopist should also become proficient in identifying unique and diagnostic findings on endobronchial examination. The bronchoscopist should be able to recognize aspiration in the absence of a foreign body and perhaps diagnose inflammatory bowel disease before it involves the gastrointestinal tract.14–16 We believe that it is essential for every pulmonologist (interventional and noninterventional) to have a thorough understanding of the basic aspects of bronchoscopy and what it can offer to the patients. However, it is not important for every pulmonologist to perform interventional procedures. The equipment required for many of these interventional procedures is expensive, and there should be sufficient case volume not only to justify the cost of such a set-up but also to maintain technical skills. The provision of advanced bronchoscopy techniques is presently not an option but a necessity for a high-volume tertiary care medical center with a large referral base from regional medical centers and health care providers. With proper training, protocols and appropriate thoracic surgery and anesthesia support, many of these procedures can also be effectively offered in community hospitals. However, there is no compulsion for every hospital to have advanced interventional bronchoscopy set up. It is sufficient to have facility for a high-quality noninterventional bronchoscopy performed for appropriate indication with thorough attention to choice of sampling procedure, periprocedural care, and interpretation of bronchoscopy results. Such service has much to add to everyday patient care and this can be performed in a majority of health care settings. For selected indications, practising pulmonologists may seek assistance from regional tertiary care medical centers having advanced bronchoscopy services and skills. It will not only allow a more effective use of health care dollars but will also allow pulmonologists to focus on identifying the appropriate indication and timing of interventional bronchoscopy. In this regard, this model is very similar to cardiology and gastroenterology practises where the majority of providers practise noninvasive cardiology or gastroenterology and seek assistance from interventionalists whenever appropriate indication is identified. It is becoming increasing apparent to us that rapid growth of interventional pulmonology is leading the way to the emergence of a vibrant field of noninterventional or noninvasive pulmonology. An important message is that there is no reason for a pulmonologist to feel belittled if he or she is not performing an interventional procedure.
The field of interventional bronchoscopy is still evolving. The future is bright. Even though the majority of these procedures are minimally invasive, there is an associated risk that needs to be carefully weighed against the benefit and cost of the procedure. An optimal interventional bronchoscopy procedure requires a team of trained personnel, appropriate patient selection, and a correct indication. Rapid advances in this field make it essential for every pulmonologist to learn the current indications and clinical role of interventional bronchoscopy in the routine care of their patients. Practising pulmonologists must also identify the provider in their community who could offer these services to their patients. This is the way to have the patient reap the most benefits from this rapidly advancing field.
It is important to point out that in-depth knowledge of a wide range of pulmonary disorders is essential for any practising pulmonologist, interventional or otherwise. Cognitive and fundamental bronchoscopy skills (eg, airway examination and conventional sampling procedures) suffice the title of a “noninterventional pulmonologist,” whereas the additional procedural skills acquired through focused training are mandatory for an “interventional pulmonologist.”
1. Nakajima T, Yasufuku K, Yoshino I. Current status and perspective of EBUS-TBNA. Gen Thorac Cardiovasc Surg. 2013;61:390–396.
2. Mudambi L, Ost DE. Advanced bronchoscopic techniques for the diagnosis of peripheral pulmonary lesions. Curr Opin Pulm Med. 2016;22:309–318.
3. Walters DM, Wood DE. Operative endoscopy of the airway. J Thorac Dis. 2016;8(suppl 2):S130–S139.
4. Laxmanan B, Hogarth DK. Bronchial thermoplasty in asthma: current perspectives. J Asthma Allergy. 2015;8:39–49.
5. Herth FJF, Slebos D-J, Rabe KF, et al.. Endoscopic lung volume reduction: an expert panel recommendation. Respiration. 2016;91:241–250.
6. Thiberville L, Salaün M. Bronchoscopic advances: on the way to the cells. Respiration. 2010;79:441–449.
7. Petrella F, Spaggiari L, Acocella F, et al.. Airway fistula closure after stem cell infusion. N Engl J Med. 2015;372:96–97.
8. Panchabhai TS, Mehta AC. Historical perspective of bronchoscopy. Connecting the dots. Ann Am Thorac Soc. 2015;12:631–641.
9. Decalmer S, Woodcock A, Greaves M, et al.. Airway abnormalities at flexible bronchoscopy in patients with chronic cough. Eur Respir J. 2007;30:1138–1142.
10. Sakr L, Datau H. Massive hemoptysis: an update on role of bronchoscopy in diagnosis and management. Respiration. 2010;80:38–58.
11. Jain P, Sandur S, Meli Y, et al.. Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates. Chest. 2004;125:712–722.
12. Jain P, Mehta ACMehta AC, Jain P, Gildea TR. Diseases of central airways: an overview. Diseases of the Central Airways, 1st ed. Switzerland: Springer International Publishing; 2016:1–70.
13. Ost DE, Ernst A, Lei X, et al.. Diagnostic yield and complications of bronchoscopy for peripheral lung lesions. Results of the AquIRE registry. Am J Respir Crit Care Med. 2016;193:68–77.
14. Kupeli E, Khemasuan D, Lee P, et al.. Special feature: “pills” and the air passages. Chest. 2013;144:651–660.
15. Kupeli E, Khemasuan D, Tunsupon P, et al.. Special feature: “pills” and the air passages: a continuum. Chest. 2015;147:242–250.
16. Jain P, Mehta ACMehta AC, Jain P, Gildea TR. Preface. Diseases of the Central Airways, 1st ed. Switzerland: Springer International Publishing; 2016:I–II.