European Respiratory Society
Interventional Pulmonology

The role of bronchoscopy in the evaluation and treatment of respiratory disease has evolved dramatically over the last decade. Originally a tool for examining and sampling the central endobronchial tree, it has broadened considerably to include techniques that now enable the treatment of an increasing number of conditions. In this ERS Monograph, the Guest Editors make this broad area easy to navigate by separating the book into three sections: technical aspects, diagnostic procedures, and therapeutic interventions. Within these sections, leading authors in the field provide chapters on: flexible and rigid bronchoscopy, bronchoscopy in intensive care, laryngoscopy, biopsy techniques, EBUS and EUS, cryobiopsy, early cancer therapies, airway stents and much more.

  • ERS Monograph
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    1. Page 1
      Abstract
      Johannes M.A. Daniels, Dept of Pulmonary Diseases, VU University Medical Center, ZH 4F-004, PO Box 7075, 1007 MB Amsterdam, The Netherlands. E-mail: j.daniels@vumc.nl

      Flexible bronchoscopy allows visual inspection of the airways and can be used for diagnostic and therapeutic purposes. Indications for diagnostic bronchoscopy are abundant and include evaluation of symptoms such as cough or haemoptysis, evaluation of clinical findings such as suspected malignancy or pneumonia of unknown aetiology and early detection of lung cancer. In addition, several therapeutic modalities are at the disposal of the bronchoscopist and many more are currently under development. Prerequisites for performing flexible bronchoscopy are good knowledge of the patient, equipment and sedation techniques as well as skill in handling the bronchoscope, performing sampling techniques and managing complications. Although bronchoscopy can be performed with only topical anaesthesia, it is an unpleasant examination and sedation should be offered to the patient. Specific precautions are necessary for adequate and safe sedation.

      Cite as: Daniels JMA. Flexible bronchoscopy. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 1–18. [https://doi.org/10.1183/2312508X.10002317].

    2. Page 19
      Abstract
      Maren Schuhmann, Dept of Respiratory and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Röntgenstrasse 1, 69126 Heidelberg, Germany. E-mail: maren.schuhmann@med.uni-heidelberg.de

      Rigid bronchoscopy was first introduced in the late 1890s, but its use declined in the 1960s with the development of flexible bronchoscopy. However, due to its many new applications and indications, it has seen a revival in recent years. Management of severe haemoptysis, stent placement and recanalisation are some of the many indications for rigid bronchoscopy, often used in combination with a flexible bronchoscope. Its main disadvantages are the need for general anaesthesia and limited opportunities for training due to a relatively low number of departments worldwide performing rigid bronchoscopy on a regular basis.

      Cite as: Schuhmann M. Rigid bronchoscopy. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 19–28 [https://doi.org/10.1183/2312508X.10002417].

    3. Page 29
      Abstract
      Suveer Singh, Respiratory and Intensive Care Medicine, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK. E-mail: suveer.singh@imperial.ac.uk

      Bronchoscopy in the intensive care unit developed in the early 1970s. Its flexibility and versatility provide a crucial diagnostic and therapeutic tool. Indications are commonly to facilitate placement of a definitive airway, airway sampling for infection and clearance of secretions. More complex situations such as airway haemorrhage, percutaneous tracheostomy insertion, foreign body removal, burns inhalation injury, tracheal tears and persistent air leaks in mechanically ventilated patients are amenable to therapeutic bronchoscopy. Single-use portable bronchoscopes are important in the emergency setting, where a fast response, rapid visualisation and prevention of decontamination delays are essential. Bronchoscopy of the acutely sick awake patient is a valuable skill, requiring expertise and experience. An understanding of working endobronchial anatomy, physiological effects, and the risks and complications of bronchoscopy in this setting is necessary. Protocols for preparation, documentation and World Health Organization-style “time outs” should be encouraged. Training programmes still require significant development to ensure maintenance of satisfactory contextual and experiential skills.

      Cite as: Singh S. Bronchoscopy in intensive care. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 29–48 [https://doi.org/10.1183/2312508X.10002517].

    4. Page 49
      Abstract
      Sebastian Ley, Diagnostische und Interventionelle Radiologie, Chirurgisches Klinikum München Süd, Am Isarkanal 30, 81379 München, Germany. E-mail: ley@radiologie-ley.de

      Many tracheobronchial, parenchymal and mediastinal diseases can be assessed by interventional pulmonology procedures. Imaging of the thoracic structures is the most important prerequisite before intervention. The tasks are manifold and include detailed visualisation of the anatomy, risk assessment and definition of the target. In this context, CT plays a major role, as it allows fast, highly spatial and three-dimensional imaging of the pathologies to be addressed. CT enables virtual bronchoscopies in order to plan the actual intervention, or serves as database for navigated EBUS or biopsy. CT also allows assessment of the lung parenchyma and thus determination of the eligibility of a patient and the target lobes for endobronchial lung volume reduction treatment. However, CT is only a morphological imaging technique, and functional assessment of tissue (i.e. lymph nodes) must be done by PET or magnetic resonance imaging. Post-treatment follow-up can be done by radiography for regular post-treatment assessment or by CT imaging for suspected complications.

      Cite as: Ley S, Heussel CP. Imaging. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 49–63 [https://doi.org/10.1183/2312508X.10002617].

    5. Page 64
      Abstract
      Leizl Joy Nayahangan, Copenhagen Academy for Medical Education and Simulation, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail: leizl.joy.nayahangan@regionh.dk

      Interventional pulmonology has evolved dramatically to include more complex procedures. For example, the use of fibreoptic bronchoscopes has been transformed by advanced video bronchoscopes with new image-acquisition systems that allow access to difficult areas, such as structures outside the bronchial tree. With advancing technology and innovation, the challenge is how to train and develop proficient interventional pulmonologists. Training has traditionally been by apprenticeship under expert clinicians, in which residents learned procedural skills through direct observation and eventually performing the procedure under supervision. However, this training approach is discouraged in the modern healthcare system. The future of interventional pulmonology depends on proper training and certification, without practical testing on patients. Competency-based education is efficient for learning technical skills and ensuring competency before moving to the next level. Efficient instructional strategies should include rigorous approaches, such as mastery learning and deliberate practice, well-described objectives, predefined benchmarks and valid, reliable assessment tools.

      Cite as: Nayahangan LJ, Clementsen PF, Konge L. Training. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 64–77 [https://doi.org/10.1183/2312508X.10002717].

    1. Page 78
      Abstract
      Andrew Kinshuck, Dept of Ear, Nose and Throat Surgery, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK. E-mail: akinshuck@gmail.com

      Laryngoscopy has become a routine part of the examination of patients presenting to the ENT specialist. The development of flexible fibreoptic endoscopes has enabled laryngoscopy to be performed in the clinic in patients of all ages. It provides a visual assessment and allows dynamic evaluation of the larynx and upper airway. Laryngoscopy continues to gain popularity and is now regularly used by other specialists, including respiratory specialists, speech therapists and anaesthetists. There has been a continued growth in office-based procedures on the larynx using a variety of laryngoscopy and anaesthetic techniques. Suspension laryngoscopy allows the surgeon to perform endoscopy and surgical procedures on the entire airway, from the supraglottis to the bronchi, under general anaesthesia. Suspension laryngoscopy enables the surgeon to use both rigid and flexible endoscopes, surgical instruments, fibre lasers, cryoprobes, and insert stents. Adding the operative microscope allows binocular vision, magnification, improved illumination and use of the carbon dioxide laser through a “line-of-sight” technique.

      Cite as: Kinshuck AJ, Sandhu GS. Laryngoscopy. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 78–88 [https://doi.org/10.1183/2312508X.10002817].

    2. Page 89
      Abstract
      Renelle Myers, 675 West 10 Avenue, Vancouver, British Columbia, Canada, V5Z 1L3. E-mail: renelle.myers1@bccancer.bc.ca

      Lung cancer is the leading cause of cancer deaths worldwide as the majority of patients have advanced disease at diagnosis. Detection and early treatment of pre-invasive and minimally invasive lung cancer can significantly improve the current 5-year survival of <18%. Endoscopic optical imaging (such as autofluorescence imaging), NBI and OCT provide sensitive means to rapidly scan the central airways, in order to detect early lung cancer for biopsy confirmation and delineate the extent of the tumour spread to guide treatment. However, with the worldwide shift in lung cancer cell type to adenocarcinoma and the increasingly smaller lung lesions found by screening low dose CT, it is necessary to develop miniature imaging probes and better biopsy catheters to enable biopsy under real-time imaging.

      Cite as: Myers R, Lam S. Early cancer detection. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 89–102. [https://doi.org/10.1183/2312508X.10002917].

    3. Page 103
      Abstract
      Samuel V. Kemp, Dept of Respiratory Medicine, Royal Brompton Hospital, Fulham Road, London, SW3 6NP, UK. E-mail: s.kemp@rbht.nhs.uk

      Fibreoptic bronchoscopy is the predominant method for obtaining diagnostic tissue in a wide range of respiratory diseases. There are many ways to obtain such tissue, and the choice of which technique to use is determined by the location of the lesion, experience of the bronchoscopist and availability of facilities. A basic set of abilities is essential for the independent bronchoscopist, comprising of histology and cytology collection methods, i.e. endobronchial biopsy and TBB (histology), bronchial brushing, bronchial washing and BAL (cytology), and TBNA (histology and cytology). With this simple set of skills, it is possible to successfully target central and peripheral lesions as well as masses and lymph nodes outside of the airways, and mastery of these techniques is encouraged.

      Cite as: Kemp SV. Biopsy techniques. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 103–120 [https://doi.org/10.1183/2312508X.10003017].

    4. Page 121
      Abstract
      Pravachan V.C. Hegde, Advanced Interventional Thoracic Endoscopy/Interventional Pulmonology, Division of Pulmonary Critical Care Medicine, University of California San Francisco-Fresno, 2335 East Kashian Lane, Suite 260, Fresno, CA 93701, USA. E-mail: pv.pulm@gmail.com

      Minimally invasive endosonographic techniques (combined EBUS/EUS/EUS-B) provide a much broader ability to biopsy lymph nodes compared with conventional mediastinoscopy in the staging of nonsmall cell lung cancer (NSCLC). When compared with traditional mediastinoscopy, the ability of combined EBUS/EUS/EUS-B to sample multiple stations and distant metastases, including structures below the diaphragm, with high sensitivities and negative predictive values makes endosonography a new gold standard in the initial staging of NSCLC when performed by an experienced operator. The two techniques (EBUS and EUS) should not be considered competitive; they are complementary. The physician should choose the best approach depending on the available resources, expertise and biopsy target location of interest. In addition, endosonographic fine-needle aspiration has become the first procedural test in cases where the clinical and imaging findings suggest an infectious and granulomatous lesion accessible by these techniques.

      Cite as: Hegde PVC, Liberman M. Minimally invasive endosonographic techniques: combined EBUS and EUS. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 121–140 [https://doi.org/10.1183/2312508X.10003117].

    5. Page 141
      Abstract
      Rajesh Thomas, School of Medicine, Harry Perkins Building, Queen Elizabeth II Medical Centre, Perth, WA 6009, Australia. E-mail: rajesh.thomas@health.wa.gov.au

      Bronchoscopic cryotherapy is one of several complementary modalities that can be used for the management of malignant and benign endobronchial diseases. Cryotherapy can safely restore airway patency and improve symptoms in patients with central airways obstruction from exophytic tumours. It is also used in the treatment of granulation tissue and benign strictures, and to remove inhaled foreign bodies or impacted biological matter. Bronchoscopic cryobiopsy in endobronchial tumours and ILD improves diagnostic yield, and provides large amounts of well-preserved, high-quality tissue. However, the risk of severe bleeding following cryobiopsy is a major concern, and knowledge gaps remain about the ideal technique and patient selection. Future research must characterise the risks versus benefits of cryobiopsy compared with surgical lung biopsy and its role in the evaluation of diffuse parenchymal lung diseases. Research into novel applications of cryotherapy is underway and has the potential to transform the practice of interventional pulmonology.

      Cite as: Thomas R, Phillips MJ. Bronchoscopic cryotherapy and cryobiopsy. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 141–161 [https://doi.org/10.1183/2312508X.10010517].

    6. Page 162
      Abstract
      Ralf Eberhardt, Pneumologie und Beatmungsmedizin, Thoraxklinik am Universitätsklinikum Heidelberg, Röntgenstrasse 1, 69126 Heidelberg, Germany. E-mail: ralf.eberhardt@med.uni-heidelberg.de

      Suspicious peripheral pulmonary nodules need to be clarified histologically. Depending on the probability of malignancy and the patient's comorbidities, the lesion can be resected surgically or a nonsurgical biopsy is necessary. The challenge in diagnosing a peripheral parenchymal nodule by bronchoscopy is to detect the nodule endoscopically, especially if it is not visible on fluoroscopy. Apart from TBB under fluoroscopic guidance, various navigation techniques such as radial EBUS, virtual bronchoscopy and electromagnetic navigation bronchoscopy are available to increase the diagnostic yield. Further developments are necessary in order to make bronchoscopic treatment of small malignant peripheral lesions possible, ideally in a one-step diagnostic and therapeutic procedure.

      Cite as: Eberhardt R, van der Horst J. Navigational bronchoscopy in solitary pulmonary nodules. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 162–175 [https://doi.org/10.1183/2312508X.10003317].

    7. Page 176
      Abstract
      Pyng Lee, Yong Loo Lin Medical School, National University of Singapore, Division of Respiratory and Critical Care Medicine, Dept of Medicine, National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 10, Singapore 119228. E-mail: mdclp@nus.edu.sg

      With thoracoscopy the physician is provided with a window into the pleural space. It allows biopsy of the parietal pleura under direct visualisation with good accuracy, and achieves fluid drainage, guided chest tube placement and pleurodesis. Over a century ago, Hans-Christian Jacobaeus described thoracoscopy as a technique used to collapse the underlying tuberculous lung; this fell out of use owing to effective anti-tuberculous drugs. Thoracoscopy later reappeared as minimally invasive surgery, also known as medical thoracoscopy (MT) and VATS. VATS is performed under general anesthesia using single-lung ventilation. MT is performed by the pulmonologist in an endoscopy suite using non-disposable-rigid or flexi-rigid instruments, local anaesthesia and conscious sedation. MT is less invasive than VATS, and a comparable diagnostic yield is achieved with flexi-rigid instrument as with VATS. Flexi-rigid pleuroscopy can be used as an out-patient procedure and is well tolerated under local anaesthesia. Use of accessories that are compatible with the flexi-rigid pleuroscope (e.g. insulated-tip knife and cryoprobe) can enhance biopsy quality. This chapter will discuss indications, complications and advances in thoracoscopy.

      Cite as: Lee P. Thoracoscopy. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 176–190 [https://doi.org/10.1183/2312508X.10003417].

    1. Page 191
      Abstract
      George Z. Cheng, Duke University Medical Center, DUMC Box 102356, Durham, NC 27710, USA. E-mail: george.cheng@duke.edu

      Haemoptysis is a common clinical entity encountered in pulmonology. Its presentation ranges from blood-streaked sputum to massive haemoptysis. Appropriate assessment and management of this potentially life-threatening entity can lead to improved clinical outcomes. Here, we focus on the definition, anatomy, aetiology, diagnosis and management of massive haemoptysis. We evaluate the utility of bronchoscopy and CT scans in the diagnostic evaluation pathway. We also discuss bronchoscopic, radiological and surgical approaches in haemoptysis management. Most importantly, we stress the multidisciplinary approach in management to achieve the desired clinical outcomes.

      Cite as: Cheng GZ, Wahidi MM. Haemoptysis. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 191–209 [https://doi.org/10.1183/2312508X.10003517].

    2. Page 210
      Abstract
      Antoni Rosell, Bronchoscopy Unit, Dept of Respiratory Medicine, Hospital Universitari de Bellvitge, Universitat de Barcelona, IDIBELL, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907 Barcelona, Spain. E-mail: arosell@bellvitgehospital.cat

      Bronchoscopic therapies for early lung cancer have shown very promising results but strong evidence comparing available treatments is still lacking. Endobronchial therapies have been attempted in proximal lesions, including Nd-YAG laser therapy, electrocautery, cryotherapy, brachytherapy, APC and PDT. Approaching the lung periphery is still challenging and peripheral lesions in patients who cannot undergo surgery often have to be managed using a CT-guided percutaneous approach. Percutaneous techniques include laser ablation, RFA, microwave ablation, cryotherapy and PDT. Newer bronchoscopically guided and navigational technologies may be able to deliver these therapies effectively to peripheral lesions in the near future with fewer complications than the percutaneous approach.

      Cite as: Díez-Ferrer M, Gutierrez C, Rosell A. Early cancer therapies. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 210–223 [https://doi.org/10.1183/2312508X.10010817].

    3. Page 224
      Abstract
      Christophe Dooms, Dept of Respiratory Diseases, University Hospitals KU Leuven, UZ Leuven Campus Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium. E-mail: christophe.dooms@uzleuven.be

      Neoplastic central airway obstruction (CAO) with imminent respiratory failure, stridor and/or severe dyspnoea requires immediate and appropriate care and action. Initial evaluation of CAO involves CT and bronchoscopy in order to decide upon timely referral for interventional pulmonology, consisting of mechanical debulking with or without thermocoagulation to restore airway patency and with or without airway stenting to preserve central airway patency. The assessment and treatment of benign central airway strictures should be reserved for selected centres that provide a multidisciplinary, dedicated interventional approach and are evaluated based on qualitative long-term outcome.

      Cite as: Dooms C, Rosell A. Central airway obstruction. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 224–235 [https://doi.org/10.1183/2312508X.10003717].

    4. Page 236
      Abstract
      Hervé Dutau, Dept of Thoracic Oncology, Pleural Disease and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France. E-mail: hdutau@ap-hm.fr

      In this chapter, we review the most frequent indications for airway stenting, the types of airway stents available and the data about potential new airway stenting technologies (biodegradable, drug-eluting and three-dimensional printed airway stents). We also discuss the complications associated with airway stenting and the necessary surveillance after airway stenting.

      Cite as: Fortin M, Dutau H. Airway stents. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 236–251 [https://doi.org/10.1183/2312508X.10010117].

    5. Page 252
      Abstract
      Sebastian Fernandez-Bussy, Interventional Pulmonology Unit, Clinica Alemana-Universidad del Desarrollo, Manquehue Norte 1410, 7650567 Santiago, Chile. E-mail: sfernandezbussy@alemana.cl

      Foreign body aspiration is a potentially life-threatening condition. It has a bimodal distribution, with two higher-incidence age groups clearly described: children and persons aged >75 years. The clinical presentation may be acute (dyspnoea, asphyxia, cardiac arrest, etc.) or chronic (recurrent pneumonia, atelectasis, chronic cough, etc.). Thus, a high index of suspicion is necessary. When foreign body aspiration is suspected, a multidisciplinary team should evaluate the patient and remove the foreign body as rapidly as possible. The traditional procedures for the diagnosis and treatment of foreign body aspiration are interventional methods such as rigid bronchoscopy. However, flexible bronchoscopy is a satisfactory option, particularly in centres without access to rigid bronchoscopy. Bronchoscopists may use different extraction tools such as cryoprobes, baskets, snares and forceps.

      Cite as: Fernandez-Bussy S, Labarca G. Foreign bodies. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 252–263 [https://doi.org/10.1183/2312508X.10003917].

    6. Page 264
      Abstract
      Christophe Dooms, Dept of Respiratory Diseases, University Hospitals KU Leuven, 3000 Leuven, Belgium. E-mail: christophe.dooms@uzleuven.be

      Airway fistulas are categorised by their localisation (tracheo-oesophageal, bronchopleural or alveolopleural) and by aetiology (spontaneous or as the result of an intervention). The mainstay in the treatment of nonmalignant fistulas is surgical repair, although endoscopic treatment plays a potential role when surgery is considered to be morbid or technically unfeasible. In general, the grade of evidence for endoscopic interventions is low, with expert opinion guiding clinical practice, with the exception of the use of unidirectional valves to treat alveolopleural fistulas. The latter have been subject of several cohort studies. Spontaneous airway fistulas most often originate from neoplastic disorders, infection, or macro- or microscopic deformities of the subpleural region. In neoplastic disorders, the role of surgical repair is limited, since the occurrence of the airway fistula is often a consequence of locoregional advanced disease in which endoscopic treatment plays an important role in palliation.

      Cite as: Dooms C, Yserbyt J. Airway fistulas. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 264–275 [https://doi.org/10.1183/2312508X.10004017].

    7. Page 276
      Abstract
      Dirk-Jan Slebos, Dept of Pulmonary Diseases/Interventional Bronchoscopy AA11, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands. E-mail: d.j.slebos@umcg.nl

      Bronchoscopic lung volume reduction (BLVR) is becoming the last-resort treatment option for patients with severe emphysema where current pharmaceutical treatments are not sufficient and surgical treatments are contraindicated. Over the past decade a number of devices and techniques have been developed to accommodate the very different emphysema phenotypes. The treatment options can be divided into “blocking” and “nonblocking” techniques. Blocking techniques use unidirectional valves to induce the collapse of a single lobe. This treatment is currently the most effective and fully reversible option, although it is only possible in emphysema patients with absence of interlobar collateral ventilation. In patients who do not qualify for a blocking technique, nonblocking techniques using nitinol coils or “sclerosing” techniques, such as vapour ablation or sealants, can be used as an alternative. Due to the complexity of the disease, patient selection, treatment logistics and dealing with complications in these very diseased patients, BLVR should only be performed in centres of excellence where multiple options are available and using a multidisciplinary team approach.

      Cite as: Slebos D-J, Klooster K, Ten Hacken NHT. Bronchoscopic lung volume reduction. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 276–293 [https://doi.org/10.1183/2312508X.10004117].

    8. Page 294
      Abstract
      Michel Aubier, INSERM UMR1152, Paris Diderot University, Faculty of Medicine, Bichat campus, 16 rue Henri Huchard, 75018 Paris, France. E-mail: michel.aubier@inserm.fr

      Bronchial thermoplasty is an endoscopic procedure for use in patients with severe asthma who remain uncontrolled despite optimal medical treatment. Through the delivery of local radiofrequency energy to the airways, bronchial thermoplasty generates improvements in different clinical outcomes, such as asthma control and exacerbations. In 2010, bronchial thermoplasty was approved by the US Food and Drug Administration for the treatment of severe persistent asthma in patients ≥18 years of age whose asthma cannot be not well controlled with inhaled corticosteroids and long-acting β2-agonists; in 2011, it was CE marked and has been available in Europe since that time.

      Bronchial thermoplasty aims to reduce the airway smooth muscle mass, a key feature of airway remodelling. The mechanism of action, however, is likely to be much more complex and is still incompletely understood. In the clinical setting, bronchial thermoplasty represents an attractive alternative management strategy in patients with severe asthma that is difficult to control with the available pharmacological treatments, including the new biologics. However, larger studies are still needed to investigate the mechanism of action of bronchial thermoplasty, and to search for clinical and biomarkers that differentiate responder from the non-responder patients.

      Cite as: Aubier M, Dombret M-C, Debray M-P, Pretolani M. Bronchial thermoplasty. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 294–306. [https://doi.org/10.1183/2312508X.10014117].

    9. Page 307
      Abstract
      Rahul Bhatnagar, Academic Respiratory Unit, University of Bristol, Learning and Research Building, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK. E-mail: Rahul.Bhatnagar@Bristol.ac.uk

      Interventional pulmonologists are increasingly using local anaesthetic thoracoscopy to diagnose and treat pleural diseases. Within this technique, there are a range of applications that may be considered more advanced and are thus usually performed by those practitioners with additional experience or a research interest. This chapter discusses the evidence and practicalities behind advanced thoracoscopic procedures, including cryoprobe biopsy, the use of diathermy, talc pleurodesis, and the management of pneumothorax and pleural infection.

      Cite as: Bhatnagar R, Jones R, Maskell N. Advanced techniques in local anaesthetic thoracoscopy. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 307–324 [https://doi.org/10.1183/2312508X.10004317].

    10. Page 325
      Abstract
      Daniela Gompelmann, Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Röntgenstrasse 1, 69126 Heidelberg, Germany. E-mail: daniela.gompelmann@med.uni-heidelberg.de

      Interventional bronchoscopy is a rapidly expanding field in pneumology offering minimally invasive therapeutic approaches in various pulmonary diseases. In the last decade, various bronchoscopic techniques have evolved for patients with COPD. Targeted lung denervation, the latest development in the field of endoscopic therapies in COPD, provides radiofrequency ablative therapy targeting the parasympathomimetic innervation of the airways leading to sustainable bronchodilation. Furthermore, endoscopic cryospray therapy that may destroy the mucus-producing glands in patients with chronic bronchitis presents an area of current investigation. Further fields of research include biodegradable stents in central airway obstruction that maintain the airway patency over time. One essential focus in bronchoscopy is the diagnostic and therapeutic approach for solitary pulmonary nodules. Bronchoscopic transparenchymal nodule access is the first guidance technique that allows access to the pulmonary nodules via the healthy lung parenchyma. Bronchoscopic therapies for early-stage peripheral lung cancer are also currently under investigation, including transbronchial brachytherapy, bronchoscopy-guided RFA, bronchoscopic thermal vapour ablation and bronchoscopy-guided microwave ablation.

      Cite as: Gompelmann D. Upcoming techniques. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 325–336 [https://doi.org/10.1183/2312508X.10004417].

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