Interventional Pulmonology: Current State of the Art

Praveen N. Mathur; Venerino Poletti

Disclosures

Curr Opin Pulm Med. 2016;22(3):243-244. 

In May of 1993 at the American Thoracic Society International Conference, a postgraduate course entitled 'Therapeutic Thoracic Endoscopies: Lasers, Cryotherapy, Stents, Brachytherapy, and Thoracoscopy' was presented. This event led the subsequent publications in a monograph in 1995.[1] This was the first time the term definition interventional pulmonology was used and also defined as 'the art and science of medicine as related to the performance of diagnostic and invasive therapeutic procedures that require additional training and expertise beyond that required in a standard pulmonary medicine training program'. Although this definition is over 20 years old, it remains cogent despite the fact that the number of interventional pulmonology procedures has surged. In addition to therapeutic procedures for malignancies, there has been more emphasis on diagnosis and there has also been increasing interest in treating benign disorders such as asthma and emphysema. Again in 1995 at the American Thoracic Society International Conference, a postgraduate course was entitled 'interventional pulmonology'.

These initial efforts to define this entity led to efforts to publish guidelines and disseminate knowledge, and a small group of physicians wrote the European Respiratory Society/American Thoracic Society guidelines.[2] Thus interventional pulmonology was finally defined.

Interventional pulmonology has evolved over the last 3 decades into a multifaceted subspecialty of thoracic medicine and surgery that involves diagnostic and therapeutic bronchoscopy, pleuroscopy, and several other procedures. Advances in technology and the epidemic of lung cancer in the latter half of the last century were major stimuli in the development of interventional pulmonology.

The following articles will address the current practice of many interventional pulmonology bronchoscopic procedures in detail.

In the article, Management of endobronchial tumors', Gasparini and Bonifazi (pp. 245–251) describe the use of current practices for endobronchial therapies. Although laser and other endobronchial therapies revitalized rigid bronchoscopy, the use of this versatile instrument, except in Europe, remains limited. Standard pulmonary critical care medicine fellowships and cardiothoracic surgery residencies in the United States offer limited or no exposure to this procedure. The flexible bronchoscope has become the main therapeutic bronchoscopy tool in many institutions. There are many options for ablative endobronchial therapy: laser, electrocautery, brachytherapy, cryotherapy, and argon plasma coagulation.

Herth and Eberhardt (pp. 252–256) describes 'Airway stent: what is new and what should be discarded'. The Dumon type silicone stent has stood the test of time for the treatment of external airway compression or loss of cartilage support but still requires rigid bronchoscope insertion. The Ultraflex stent was the most widely used self-expanding metal stent for a number of years but recently is becoming supplanted by the AERO stent, a totally covered nitinol SEMS (Merit Medical Systems, Inc., South Jordan, Utah, USA). Both can be inserted with the flexible bronchoscope.

What is more important is new development and also what we should be discarding from our current practices.

Shepherd (pp. 257–264) describes the 'Bronchoscopic pursuit of the peripheral pulmonary lesion: navigational bronchoscopy, radial endobronchial ultrasound, and ultrathin bronchoscopy'. As the clinical presentation of lung cancer has shifted from central squamous cancers to predominantly peripheral adenocarcinomas there has been an increasing use of interventional pulmonology techniques to diagnose peripheral lesions. Electromagnetic navigation, radial endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) and ultrathin bronchoscopes are all being used to obtain tissue from peripheral lesions. The preferred technique varies among institutions and often these techniques are used together. They are in competition with trans-thoracic needle aspiration performed by interventional radiologists.

Although lung cancer has been an important disease where pulmonary physicians are involved, the two more common and large populations have either COPD or asthma. Kemp and Shah (pp. 265–270) describe 'An update on bronchoscopic treatments for chronic obstructive pulmonary disease'. This has been an evolving field with some limited success. The patient who will benefit by such techniques is still evolving. A variety of techniques have been unsuccessful, which has led to understanding of the subgroup of patients where benefits will happen. This in an exciting area of development and the future will bring some definitive treatment options.

Sardi and Islam (pp. 271–280) describe 'Early lung cancer detection, mucosal and alveolar imaging' Mucosal and alveolar imaging autofluorescence bronchoscopy (AFB) is another procedure that has been introduced to clinical practice but remains underutilized. AFB has been shown to be highly sensitive but not particularly specific in detecting preneoplastic airway lesions. Only one system, the D-Light system, has been approved for use in the United States (Karl Storz Endoscopy America, Inc., El Segundo, California, USA). Other systems are available for use in Europe and Japan. Newer technologies, such as narrow band imaging and optical coherence tomography have been developed to improve the specificity of AFB. The recent evidence that computed tomography screening for lung cancer improves mortality may spark the development of formal lung cancer screening programs that probably should incorporate AFB to screen for early airway lesions.

Annema and colleagues (pp. 281–288) describe 'Linear endobronchial and endoesophageal ultrasound: a practice change in thoracic medicine'. Linear EBUS has quickly become the standard of care for mediastinal staging of patients with lung cancer and for sampling mediastinal lymph nodes. Although this procedure can and should be performed by most bronchoscopists, the interventional pulmonologist seems to be taking the lead in incorporating EBUS into day-to-day practice. In addition to its role as a staging instrument, linear EBUS-TBNA is being used to obtain to obtain more tissue in advanced or recurrent lung cancer cases to guide targeted lung cancer therapy in the new era of personalized cancer therapy.

In patients with diffuse parenchymal diseases it has been difficult to obtain adequate tissue for diagnosis; Poletti and colleagues (pp. 289–296) describe 'Transbronchial cryobiopsy in diffuse parenchymal lung diseases'. There should be an abundant caution in the use of cryotherapy, as there has been a significant number of complications such as pneumothorax, bleeding, and prolonged ICU stay. This seems to more common when performed by poorly trained physicians.

Lee and Mathur (pp. 297–308) describe the 'Advances in pleural diseases: what is the future for medical thoracoscopy?'. Pleuroscopy by internists in the United States remains an uncommon, underutilized procedure despite excellent experience in a relatively few US centers and throughout Europe. With the development of the semirigid thoracoscope that has an appearance similar to that of a common video flexible bronchoscope and has been shown to be just as effective as rigid instruments in managing pleural diseases, it is hoped that more pulmonologists will incorporate this safe and highly sensitive and specific procedure into their practice.

Interventional pulmonology is just not the performance of procedures. It should be involving total care of patients with advanced malignancies, critical airway obstruction, and respiratory compromise from pleural effusions. Interventional pulmonology does requires more training and experience than is available in most pulmonary fellowships or thoracic surgery residencies. The future for interventional pulmonology seems very bright. For the foreseeable future, patients will continue to present with cancerous central airway lesions that require ablative therapy or stenting. EBUS is here to stay, both for staging and diagnosis, and is rapidly being brought from the academic centers to the community. Newer techniques to improve quality of life in patients with COPD and asthma are something to look forward to. We have been fortunate to be involved with the interventional pulmonology community from the beginning and have seen the specialty blossom and new generations of interventional pulmonologists join the ranks.

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