Interventional Pulmonology Practice Research Articles

Interventional Pulmonology Productivity, Compensation, and Practice Benchmarks: The AABIP 2022 Report.

Interventional pulmonology (IP) is a growing field that has not yet been recognized by the American Board of Medical Specialties or incorporated into national benchmark organizations. As a result, there is a lack of data on IP practice patterns, physicians' compensation and productivity targets. We sent an anonymous survey to 647 current or past physician members of the AABIP. Domains included demographics, training background, academic rank, practice settings, work relative value unit (wRVU) targets, salary, and career satisfaction. The response rate to the survey was 28.3%; 17.8% were female. The median salary for IP faculty in academic institutions was $320,000 for assistant professors, $338,000 for associate professors, and $350,000 for full professors. Salaries were lower for women than for men in academic practice, even after adjusting for the number of years in practice (mean salary difference after adjustment $57,175, 95% CI: $19,585-$94,764, P=0.003). The median salary for private practice was higher at $428,000. Among respondents that used wRVU targets, the median targets for academic and private practice were 5500 and 6300, respectively. The majority of IP physicians are satisfied with their career choice. Productivity targets in IP are used less than half the time, and when they are used, they are set in line with the lower wRVU of IP procedures. IP compensation is higher than that of general pulmonary medicine, as reported by national benchmark associations. In academic practices, gender differences in salaries were found.

Forbearance with endobronchial stenting: cognisance before conviction.

Endobronchial stenting is an important aspect of the practice of interventional pulmonology. The most common indication for stenting is the management of clinically significant airway stenosis. The list of endobronchial stents available on the market continues to grow. More recently, patient-specific 3D-printed airway stents have been approved for use. Airway stenting should be considered only when all other options have been exhausted. Due to the environment of the airways and the stent-airway wall interactions, stent-related complications are common. Although stents can be placed in various clinical scenarios, they should only be placed in scenarios with proven clinical benefit. The unwarranted placement of a stent can expose the patient to complications with little or no clinical benefit. This article reviews and outlines the key principles of endobronchial stenting and important clinical scenarios in which stenting should be avoided.

Pre- and post-COVID practice of interventional pulmonology in adults in Portugal

Introduction and objectivesThere is a lack of information regarding bronchoscopy practice in adults in Portugal. Our objective was to obtain an overview of the characteristics, resources, techniques and behaviors in national interventional pulmonology (IP) units, before and after SARS-CoV-2 outbreak. Materials and MethodsAn online survey was developed by an expert panel with a total of 46 questions comprising the specifications of each unit, namely physical space, equipment, staff, procedure planning, monitoring, technical differentiation, and numbers pre- and post-COVID-19. Forty-one interventional pulmonology centers were invited to participate between April and May 2021. Results37 units (90.2%) responded to the survey. The majority (64.9%) have a fully dedicated space with a weekly presence of ≥3 chest physicians (82.1%) and support of an anesthesiologist on specific days (48.6%). There is marked heterogeneity in the IP unit's equipment, and 56.8% acquired disposable bronchoscopes after COVID-19 pandemics. Pre-bronchoscopy hemogram, platelet count and coagulation tests are regularly asked by more than 90% of the units, even when deep sedation or biopsies are not planned. In 97.3% of cases, topical anesthesia and midazolam are utilized. Propofol (21.6%) and fentanyl (29.7%) are occasionally employed in some institutions. Most units use ancillary sampling techniques to diagnose central or peripheral lesions, with radial EBUS being used for guidance of distal procedures in 37.8% of centers, linear EBUS and EUS-B-FNA for mediastinal diagnosis and/or staging in 45.9% and 27.0% of units, respectively. Cryobiopsies are used by 21.6% of respondents to diagnose diffuse lung diseases. Rigid bronchoscopy is performed in 37.8% of centers. There was a decrease in the number of flexible (p < 0.001) and rigid (p = 0.005) bronchoscopies and an upscale of personal protective equipment (PPE) during the COVID-19 outbreak. ConclusionsIP units have variable bronchoscopic practices, but during the COVID-19 pandemic, they complied with most international recommendations, as elective procedures were postponed and PPE levels increased.

Assessment of the impact and reorganization of interventional pulmonology services at a tertiary care centre during nationwide lockdown for COVID-19 pandemic

COVID 19 pandemic has brought about a sea change in health care practices across the globe. All specialities have changed their way of working during the pandemic. In this study, we evaluated the impact of COVID-19 on the practice of interventional pulmonology at our centre. All interventional pulmonology procedures done during the three months after implementation of lockdown were evaluated retrospectively for patient demographics, clinical diagnosis, indication for procedure and diagnostic accuracy. The changes in practices, additional human resources requirement, the additional cost per procedure and impact on resident training were also assessed. Procedures done during the month of January 2020 were used as controls for comparison. Twenty-two flexible bronchoscopies (75.8%), four semirigid thoracoscopies (13.7%) and three EBUS-TBNAs (10.3%) were carried out during three month lockdown period as compared to 174 during January 2020. Twenty-three of the procedures were for the diagnostic indication (79%), and six were therapeutic (20.6%). The diagnostic yield in suspected neoplasm was 100% while for suspected infections was 58.3%. The percentage of independent procedures being done by residents reduced from 45.4% to 0%. The workforce required per procedure increased from 0.75 to 4-8, and the additional cost per procedure came out to be 135 USD. To conclude, COVID 19 has impacted the interventional pulmonology services in various ways and brought about a need to reorganize the services, while also thinking of innovative ideas to reduce cost without compromising patient safety.

POST-PNEUMONECTOMY CENTRAL AIRWAY OBSTRUCTION: MANAGEMENT CHALLENGES

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Management of central airway obstruction (CAO) is challenging post-pneumonectomy due to limited respiratory reserve and the potential for life-threatening intraprocedural complications. We present a case of malignant CAO in a patient with a single lung that has been treated bronchoscopically with success for 3 years. CASE PRESENTATION: A 73-year-old man with pT2bN1M0 squamous cell carcinoma of the right lung 6 years ago s/p chemotherapy, radiation, and right pneumonectomy presented to the hospital for one week of exertional dyspnea and blood-tinged sputum. He was in no acute distress but had stridor. Computed tomography showed thickening of the tracheal mucosa and narrowing of the tracheal lumen. Fiberoptic bronchoscopy revealed friable, polypoid lesions extending the length of the trachea narrowing the lumen to 4 mm in the most affected region. Rigid bronchoscopy was performed with jet ventilation. The endotracheal tumor was devitalized using neodymium-doped yttrium aluminum garnet (Nd:YAG) laser. Pathology revealed squamous cell carcinoma consistent with metastatic disease from the former right lung. The patient completed radiation and chemotherapy but had recurrent dyspnea from CAO. 12 rigid bronchoscopies with laser tumor destruction have been performed to-date over 3 years. The patient continues to walk 30 minutes per day and maintains an active lifestyle. DISCUSSION: Bronchoscopic management of CAO with laser resection can improve quality of life, functional status, and prolong survival (1). The Nd:YAG laser is particularly advantageous because of its deep penetration, superior coagulation characteristics, resecting ability, and versatility to be utilized through a flexible or rigid bronchscope (1). We chose rigid bronchoscopy for airway security, the ability to tamponade a hemorrhage, and superior oxygenation with jet ventilation. Laser therapy is useful for lesions in the trachea or mainstem bronchi that are polypoid, less than 4 cm, and have a visible distal airway lumen with functional lung (1). Complications include perforation of the mediastinum, vascular structures, or esophagus which is why lesions that obliterate anatomical boundaries are not usually amenable to laser therapy. Essential elements of tumor debulking in complex cases like this one include the following: deep sedation and muscle relaxation, proper estimation of bronchoscope size, atraumatic rigid intubation, use of the Nd:YAG laser conforming to established technical standards (2) with intermittent exposures (0.5 to 1 second) not higher than 45 Watts (3), use of hemostatic agents such as Surgicel and cottonoids, and an anesthesia team experienced in jet ventilation. CONCLUSIONS: Endotracheal tumor resection can be safely performed in single lung patients. The Nd:YAG laser is especially advantageous for tumor debulking and hemostasis with the ability to improve quality of life and extend survival. Reference #1: Angel LF, Levine DJ. Basic Therapeutic Techniques. In: Introduction to Bronchoscopy. Ernst A, Herth FJF, editors. Cambridge: Cambridge University Press; 2017. pp. 184. Reference #2: Hoag JB. Use of Medical Lasers for Airway Disease. In: Principles and Practice of Interventional Pulmonology. Ernst A, Herth FJF, editors. Berlin: Springer; 2013. pp.364. Reference #3: Dumon JF, Shapshay S, Bourcereau J, et al. Principles for safety in application of neodymium-YAG laser in bronchology. Chest. 1984;86(2):163-168. DISCLOSURES: No relevant relationships by Brian Cody Adkinson, source=Web Response No relevant relationships by Sisir Akkineni, source=Web Response No relevant relationships by Sixto Arias, source=Web Response

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.

Using a Dedicated Interventional Pulmonology Practice Decreases Wait Time Before Treatment Initiation for New Lung Cancer Diagnoses

While there is significant mortality and morbidity with lung cancer, early stage diagnoses carry a better prognosis. As lung cancer screening programs increase with more pulmonary nodules detected, expediting definitive treatment initiation for newly diagnosed patients is imperative. The objective of our analysis was to determine if the use of a dedicated interventional pulmonology practice decreases time delay from new diagnosis of lung cancer or metastatic disease to the chest to treatment initiation. Retrospective chart analysis was done of 87 consecutive patients with a new diagnosis of primary lung cancer or metastatic cancer to the chest from our interventional pulmonology procedures. Demographic information and time intervals from abnormal imaging to procedure and to treatment initiation were recorded. Patients were older (mean age 69) and former or current smokers (72%). A median of 27 days (1-127days) passed from our diagnostic biopsy to treatment initiation. A median of 53 total days (2-449days) passed from abnormal imaging to definitive treatment. Endobronchial ultrasound-guided transbronchial needle aspiration was the most commonly used diagnostic procedure (59%), with non-small cell lung cancer the majority diagnosis (64%). For surgical patients, all biopsy-negative lymph nodes from our procedures were cancer-free at surgical excision. Compared to prior reports from international and United States cohorts, obtaining a tissue biopsy diagnosis through a gatekeeper interventional pulmonology practice decreases median delay from abnormal imaging to treatment initiation. This finding has the potential to positively impact patient outcomes and requires further evaluation.

SUBGLOTTIC STENOSIS: A CASE SERIES

SESSION TITLE: Allergy and Airway SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Subglottic stenosis remains a rare and challenging disease with many potential etiologies. No clear risk factors have been identified, although reflux disease or female sex have been proposed. No definitive management algorithm exists, with treatment dependent on provider experience and patient preference. Endoscopic procedures are now widely used, as they can be performed outpatient, preserve vocal function, and offer relatively immediate symptom relief. Despite these interventions, however, recurrence is high. This case series describes the characteristics of subglottic stenosis patients and reviews their outcomes after undergoing interventional pulmonology (IP) procedures. METHODS: In this single center, retrospective case series, all consecutive patients presenting to our IP practice from February 2016 to December 2017 for subglottic stenosis were evaluated. Patients were included if subglottic stenosis was confirmed bronchoscopically and excluded for a malignancy history, prior or current tracheostomy, or tracheobronchial stenting. Patients were further divided into idiopathic subglottic stenosis (ISS), defined as those without a clear cause, post-intubation subglottic stenosis (PIT), defined as those with a known history of prolonged or traumatic intubation, and tracheal resection with reanastomosis (TRA), defined as those whom eventually required surgical intervention. Chart review was performed for demographic characteristics, interventional treatments, and outcomes of patients with subglottic stenosis. RESULTS: 15 patients with subglottic stenosis met inclusion criteria, with the majority being female (87%), never smokers (73%), and white (53%) or Hispanic (40%) with a median age of 49 (range 24-71). Asthma, reflux, and hypothyroidism were common comorbidities (40%, 33%, 27%, respectively). PIT was the most common etiology (80%). 11 patients underwent only IP procedures, while 4 patients eventually underwent surgical intervention. All patients had a history of at least one intubation. For patients undergoing surgery, symptom duration prior to evaluation for IP procedure was significantly shorter than those who did not (0.625 vs 31 months, p<0.003). Various IP procedures were utilized for airway recannulization, with 60% of patients requiring multiple IP procedures with a median time to second procedure of 58 weeks (range 2.7 to 155 weeks). CONCLUSIONS: In our case series, subglottic stenosis patients were predominantly female with PIT as the etiology. Patients undergoing surgery presented with symptoms significantly sooner. Regardless of intervention, recurrence rates were high. CLINICAL IMPLICATIONS: It will be important to determine if additional prognostic information may be obtained to better risk-stratify which subgroup of patients may ultimately benefit from repeat IP procedures versus early surgical intervention. DISCLOSURES: No relevant relationships by Bryan Benn, source=Web Response No relevant relationships by Drew Sheldon, source=Web Response

Ultrasound guided pleural brushing: A new method for obtaining pleural specimen in malignant effusion

PurposeEncouraging positive diagnostic yields in malignant pleural effusion could be obtained by pleural brushing performed through two techniques, the first was closed and the second was thoracoscopic. Until now the ultrasound guided pleural brushing is not included within these techniques and its diagnostic yield therefore is not evaluated. So the aim of this study was to evaluate the diagnostic yield of this procedure and its contributions as a technique not used previously in the interventional pulmonology practice to obtain pleural specimen for cytological examination in malignant pleural effusion. MethodsThis prospective interventional study was conducted in the Chest Department – Assiut University Hospital during the period from July 2014 to September 2015. Patients who had highly suspicious malignant pleural effusion (clinical, radiological, and laboratory) were hospitalized and enrolled in this study. Patients with bleeding tendency or coagulation profile abnormalities were excluded from the study. Patients were also excluded from this study if the etiology of effusion was proved to be benign. Informed written consent was obtained from all patients. The equipment used in our study were ultrasound apparatus (ALOKA – Prosound – SSD – 3500SV), biopsy forceps (KARL – STORZ – Germany 10329L – BS), the bronchoscopic cleaning brush (PENTAX CS6002SN) trocar and cannula of Cope’s needle and the semi rigid thoracoscope (LTF; Olympus; Tokyo, Japan). Thoracentesis, pleural brushing and biopsy forceps of the pleura were performed for all enrolled patients in the ultrasound unit of the Chest Department while thoracoscopy was done in the endoscopy unit only for patients in whom the diagnosis could not be achieved by these procedures. ResultsAmong 22 patients who were finally documented to have malignancy, the ultrasound guided pleural brushing provided diagnosis in 9 (41%)/22 cases, it was exclusively diagnostic in 3 patients. Interestingly, the yield of this procedure had its contributions regarding the final pathological diagnosis of our cases, it could augment the positive yield to be 55% instead of 41% (for pleural fluid cytology alone), 82% instead of 68% (for biopsy forceps alone) and 86% instead of 72% (for both fluid cytology and forceps biopsy). The recorded complications in our study were minimal and not associated with any mortality. ConclusionsUltrasound-guided pleural brushing is a new method for obtaining pleural specimens. It is a simple and relatively safe procedure. This technique provides additional diagnostic yield in malignant pleural effusion. We recommend it beside others in our diagnostic practice for suspicious malignant effusion especially when thoracoscopy is not available.

Analysis of employment data for interventional pulmonary fellowship graduates.

Interventional pulmonology (IP) is a maturing field in the subspecialty of pulmonary medicine. Over the last few years, there has been an increased number of listed IP fellowship training programs in the United States and Canada, causing debate about the employment market for IP fellowship graduates. To analyze employment data of IP fellowship graduates. Interventional pulmonary fellows, during their IP in-service examination, were surveyed on employment position after graduation. The survey occurred in May or June in the years 2012, 2013, and 2014. An IP position was defined as a position encompassing more than 60% of effort directly toward IP. Geographic location and practice structure (i.e., academic, private/hybrid, and existing or initiating IP practice) were collected and analyzed. There was an 88.5% response rate, with 53 IP fellows participating in the survey. The majority of IP fellowship graduates (75%; 39/52) had positions in academic IP practices. All seven IP private practice positions were to create an IP program. One IP graduate was in a non-IP academic position, four were in non-IP private practice, one was in a research position, and one had no known employment. Most IP fellowship graduates were men (77.4%). Most IP positions were filled in states east of the Mississippi River; only 8 of 53 (15.1%) positions were filled in states west of the Mississippi river. Despite speculation about the scarcity of academic jobs after fellowship, recently trained IP fellows are more likely to practice in academic settings and join established practices.

Book Review: Principles and Practice of Interventional Pulmonology

Book Review: Principles and Practice of Interventional Pulmonology

Trainee Impact on Procedural Complications: An Analysis of 967 Consecutive Flexible Bronchoscopy Procedures in an Interventional Pulmonology Practice

Background: Increased complications have been demonstrated in patients undergoing some medical procedures performed by trainees. Flexible bronchoscopy is generally considered a safe procedure; however, complications can include pneumothorax, bleeding and even death. Objectives: This study aimed to determine the impact of trainees during interventional pulmonology procedures on procedure time, sedation use and complications. Methods: A retrospective review of a quality improvement database from all consecutive medical procedures performed by an interventional pulmonologist (D.R.S.) at the University of Calgary, from July 1, 2007, to April 1, 2011. Results: Of 1,100 consecutive procedures during the study period, 967 were flexible bronchoscopies. A trainee participated in 82.2% of the procedures. Complications occurred in 38 patients (3.9%). No death occurred. Significant differences were seen when a trainee participated in the procedure versus when no trainee participated for procedure length [50.81 vs. 32.49 min, difference 18.32 min (95% CI 16.04-20.60), p = 0.001], dose of midazolam used [6.34 vs. 5.73 mg, difference 0.61 mg (95% CI 0.15-1.08), p = 0.01], dose of propofol used [153.08 vs. 111.60 mg, difference 41.48 mg (95% CI 21.81-61.15), p = 0.001], as well as the number of complications [4.5 vs. 1.2%, difference 3.3%, p = 0.048]. Conclusions: In an academic interventional pulmonology practice utilizing the apprenticeship model for procedural education, trainee participation in procedures can increase procedure time and the amount of sedation required, and result in increased complications. Medical procedural training methods that do not involve practicing on patients warrant further investigation in order to reduce the burden of procedural learning for patients.

Trainee impact on advanced diagnostic bronchoscopy: An analysis of 607 consecutive procedures in an interventional pulmonary practice

Complications during advanced diagnostic bronchoscopy are rare and include: pneumothorax, bleeding, mediastinitis and lymphadenitis. Increased complications have been demonstrated in patients undergoing routine bronchoscopy procedures performed by trainees. This study aimed to determine the impact of trainees during advanced diagnostic bronchoscopy on procedure time, sedation use and complications. A retrospective review of a quality improvement database including consecutive pulmonary procedures performed by an interventional pulmonologist (D.R.S.) at the University of Calgary, from 1 July 2007 to 1 April 2011. Six hundred seven (55.2%) of the 1100 procedures involved an advanced diagnostic procedure defined as: endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), electromagnetic navigation bronchoscopy (ENB) and/or peripheral EBUS. A trainee participated in 512 (84.3%) procedures. A complication occurred in 25 patients (4.1%), with a trend towards increased complication rates in the trainee group (4.7% vs 1.1%, difference 3.6%, P = 0.076). Significant differences were seen when a trainee participated versus when no trainee participated for procedure length (58.32 min vs 37.69 min, difference 20.63 min (95% confidence interval: 19.07-22.19), P = 0.001) and for the dose of propofol (178.3 mg vs 137.1 mg, difference 41.2 mg (95% confidence interval: 19.81-63.38), P = 0.002). In an academic interventional pulmonology practice utilizing the apprenticeship model, trainee participation in advanced diagnostic bronchoscopy increased procedure time, increased the amount of sedation used and resulted in a trend to increased complications. Attempts to modify trainee procedural training to reduce the burden of procedural learning for patients are warranted.

Guidelines for Training and Practice of Interventional Pulmonology

Guidelines for Training and Practice of Interventional Pulmonology

Practice of Interventional Pulmonology in Canad

PURPOSE: Interventional pulmonology has evolved to become mainstream practice of pulmonary medicine. In Canada, how many pulmonary physicians perform invasive pulmonary procedures or what procedures are performed, is not known. We conducted a mail survey to study the practice profile of Canadian pulmonologists with respect to performance of interventional procedures (IP).