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The Future of Interventional Pulmonology and the Role of the Journal

Ost, David E. MD, MPH

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Journal of Bronchology & Interventional Pulmonology: July 2018 - Volume 25 - Issue 3 - p 161-164
doi: 10.1097/LBR.0000000000000531
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The field of interventional pulmonology (IP) has witnessed tremendous growth over the last 3 decades primarily because of significant innovation, education, and academic investigation. Although there are many different perspectives on what defines IP, the beginning of the discipline can be traced back to the invention of the flexible bronchoscope by Dr Ikeda. Bronchoscopy went on to be widely integrated into general pulmonary medicine, but many of the subsequent innovations that helped to define the IP field used bronchoscopy as a platform. Perhaps more importantly, the innovation of flexible bronchoscopy helped to raise the awareness of a generation of pulmonologists to the importance of procedural interventions and how technological advancements outside of the biological sciences could be leveraged to improve patient care.

As the field of bronchoscopy developed, there were 2 areas that were to prove critical to the development of IP: advanced diagnostic bronchoscopy and therapeutic bronchoscopy. Advanced diagnostic bronchoscopy began with the invention of transbronchial needle aspiration (TBNA) by Dr Wang for sampling of mediastinal masses and lymph nodes.1–3 Subsequent advances in ultrasound technology culminated in the development of endobronchial ultrasound (EBUS)-guided TBNA. The ability of the bronchoscope to effectively stage the mediastinum improved, such that eventually EBUS-TBNA replaced mediastinoscopy in the staging of lung cancer.4

In parallel with the advances in diagnostic flexible bronchoscopy, therapeutic rigid bronchoscopy interventions were being developed by Dr Dumon in the late 20th century.5–7 The initial work focused on therapeutic applications of lasers and stenting for airway problems. This served to expand and broaden the definition of IP as a discipline that develops minimally invasive procedural techniques for patients who have pulmonary problems. This broader view of IP included but was not limited to flexible bronchoscopy and, over time, other minimally invasive techniques came to be included under the IP umbrella, such as thoracoscopy, indwelling pleural catheters, and percutaneous tracheostomy.

However, as the pace of technological innovation in the field accelerated, so too did the need for improved methods of physician training. Training in therapeutic rigid bronchoscopy was more problematic because it was not available in pulmonary fellowship training in the United States. Therefore, training for rigid bronchoscopy often had to be conducted in Europe at one of a few select high-volume centers. The first IP course in the United States was established by Dr Beamis at the Lahey Clinic in 1983. This served as a catalyst for the development of an IP community, but the problem of how to obtain sufficient hands-on training remained.

In terms of TBNA training there were also problems. The technique was challenging and required a high degree of skill that could only be obtained at high-volume centers and was highly operator dependent. Because not all physicians were comfortable or well trained in TBNA, it was subsequently underutilized for such things as lung cancer staging and biopsy of peripheral pulmonary lesions and this in turn led to suboptimal outcomes and missed opportunities.8–10 This problem of underutilization because of inadequate training also led to suboptimal outcomes in the area of malignant pleural disease.11 The clear need for better training opportunities helped drive the establishment of IP fellowships and eventually a national fellowship matching program followed. Subsequently, the American Association of Bronchology and Interventional Pulmonology (AABIP) established a certification examination in 2013.

However, technology and training without systematic study of the determinants of outcomes is not sufficient to advance the frontiers of knowledge. Without systematic investigation, it becomes impossible to prove that new technology is more, less, or equally effective to previous standards of care. Fortunately, as technology and training methods in IP progressed, so did the academic rigor of clinical research. In terms of the methods of knowledge development and investigation, the field began with interesting observations, innovative ideas, case studies, and an occasional case series. Subsequently, prospective cohort studies evaluated the outcomes and complications of various IP procedures12–14 and these were soon followed by multicenter registries such as AQuIRE.15,16 Recent multicenter randomized-controlled trials on bronchial thermoplasty17–19 and bronchoscopic lung volume reduction20–22 serve to illustrate just how far the field has come in terms of methodology. This growth of the IP evidence base was critical in establishing the academic credibility of IP within the larger medical community. This is nontrivial because IP requires capital expenditures; thus, if the larger medical community of physician leaders is not convinced of the value proposition of IP, it makes obtaining capital equipment much more difficult.

Given this historical context, what is the future of IP and what is the role of the Journal of Bronchology and Interventional Pulmonology (JOBIP)? IP is still a very young field and there are many challenges awaiting innovative solutions. The diversity of expertise and technologies within IP is a strength because it often leads to innovative solutions to otherwise intractable problems. However, this needs to be tempered and combined with rigorous methods of analysis so that there is a valid method of selection when it comes to deciding between new ideas, techniques, and technologies. Without rigorous methods of analysis, the discipline can easily devolve into a field dominated by opinion and superstition.

The development and testing of new ideas, techniques, and technologies is one of the fundamental activities of science. However, it is important to recognize that science is a function carried out by many individuals. The individuals who make up the scientific community form a complex adaptive system (CAS).23,24 A CAS is a system in which diverse autonomous agents are interrelated and interdependent through many interconnections and behave as a unified whole in learning from experience and adapting to the environment. Interconnectivity and communication are two of the key features of all CAS. This is where the Journal Fits–it facilitates high-quality communication of complex competing ideas.

The Journal helps advance the field of IP by providing a forum for the exchange of evidence and ideas. Within this marketplace, the scientific method helps to select which ideas prevail. However, the ultimate decision-maker in this case is not the editor or the editorial Board–it is the reader/practitioner who ultimately decides. Indeed, one of the characteristics of CAS is that control mechanisms are distributed rather than centralized. The role of the Journal’s editorial board is to assess, triage, and curate the manuscripts that are submitted. In this manner, the most important data are presented to the reader/practitioner/decision-maker. In a sense, the Journal functions as a free market of ideas, with data and rigorous analysis helping to determine the value of an idea.

Now society meetings, conferences, internet applications, and training courses all provide alternative methods of interconnectivity and communication. Each of these has merit and indeed CAS are characterized by a high degree of interconnectivity across multiple dimensions. However, what distinguishes the Journal from these other methods of communication is the academic peer-review process. Ideally, peer review helps to ensure that appropriate methodology is utilized and that conclusions are supported by sound data. Thus, peer-review journals provide a higher degree of information quality than other information marketplaces and are a key component of any academic discipline.

Indeed, progress in the discipline of IP has been mirrored by progress in the JOBIP. The first issue of the Journal was published in January 1994, with Dr Udaya Prakash as editor. Subsequently, Dr Atul Mehta became editor in 2004. The Journal was granted indexing status by Index Medicus in 2012. The number of original investigations published per year has increased 47%, whereas the number of narrative reviews and other features has decreased. Since 2014, the number of manuscripts submitted to the Journal has also increased by 36%. These are all signs of a maturing and more rigorous discipline that is producing more high-quality information.

So what is the future of IP? In one sense, this might be a question about which technologies will rise to dominate the field. However, specific technologies rise and fall on the basis of the data and competing technologies; thus, predicting technology winners and losers is not easy. More importantly, it is not the role of the Journal. Indeed, the future of IP is not really about any one technology. The future of IP is really about the development and application of various technologies to a particular set of clinical problems. The Journal’s role within this context is to provide a forum for the exchange of high-quality information and to facilitate the free and fair competition of ideas, with the individual practitioner picking winners and losers on the basis of the quality of the data and the analysis.

With this in mind, the goal of the Journal over the next several years will be to focus on improving the academic rigor of the manuscripts published. This will include original research on IP techniques, evidence-based reviews, epidemiologic methods as applied to IP, and educational methods for the IP field. In this way, the Journal will focus on facilitating the exchange of reliable high-quality information to sustain the three pillars of IP: innovation, education, and academic investigation. It is these 3 pillars that will help to improve patient care. Although technological innovation rightfully receives most of the attention because it is the primary means used to achieve the end result, it is only when innovation, education, and academic investigation are combined that we see real and lasting progress.


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