For the above reasons, it is apparent that more research is needed before the TBCB can be more widely adopted in a broad range of clinical settings. We found marked variations in the procedural protocols between studies. Flexible versus rigid bronchoscopy, laryngeal mask airway versus endotracheal tube, use of prophylactic bronchial blockers, the size of the cryoprobes, number of samples taken, contact time of cryoprobe, use of fluoroscopy, etc., are some of the areas where there was significant variation between the studies. Supplementary Table 3 (Supplemental Digital Content 5, http://links.lww.com/LBR/A167), highlights the different procedure protocols followed by different investigators. Perhaps standardizing the procedure will help further increase the diagnostic yield and reduce the complication rates for TBCB. For example, Ravaglia and colleagues prophylactically used Fogarty balloons after each TBCB and no significant bleeding episodes were seen in their study. In contrast, most of the other investigators did not use prophylactic bronchial blockers, which may have led to higher bleeding rates. Other experts have also called on the community of interventional pulmonologists and interstitial lung disease experts, to shoulder the responsibility of formulating a consensus statement, guiding the implementation of TBCB.70
Randomized controlled trials can allow for head to head comparison between SLB, TBFB, and TBCB. Such trials will allow for standardization of the procedure and will also allow to better study the factors that might be associated with higher complications rates. An understanding of these factors can lead to a more informed patient selection which in turn will improve TBCB’s safety profile. Experts have also called for mandatory procedure-specific training for interventional pulmonologists before implementation of TBCB programs and creation of an international registry.70
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