State of The Art IP
State of The Art IP
State of The Art IP
Interventional pulmonology (IP) has evolved over the past decade from an obscure subspe-
cialty in pulmonary medicine to a recognized discipline offering advanced consultative and
procedural services to patients with thoracic malignancy, anatomic airway disease, and pleural
disease. Innovative interventions are now also available for diseases not traditionally treated
procedurally, such as asthma and emphysema. The IP field has established certification ex-
aminations and training standards for IP training programs in an effort to enhance training
quality and ensure competency. Validating new technology and proving its cost-effectiveness
and effect on patient outcomes present the biggest challenge to IP as the health-care envi-
ronment marches toward value-based health care. High-quality research is now thriving in IP
and promises to elevate its practice into patient-centric evidence-based care.
CHEST 2020; 157(3):724-736
More than 10 years have passed since the rate to reach more than 40 available annual
initial publication on the state of the art in training positions; to ensure quality training,
interventional pulmonology (IP) in this the IP community standardized fellowship
journal.1 Much has changed in this past training and accreditation and created a
decade. IP is now a well-recognized board examination for certification.3-6
subspecialty of pulmonary medicine with a Innovations in IP have led to the
focus on advancing the care of patients with development of therapeutic options for
thoracic malignancy, airway disease, and benign and malignant disease. Novel
pleural disease via minimally invasive minimally invasive procedural interventions
techniques and innovative approaches.2 IP for asthma and COPD have been approved
training programs grew at an exponential by the Food and Drug Administration
ABBREVIATIONS: AABIP = American Association for Bronchology Care Medicine (Dr Herth), Thoraxklinik and Translational Lung
and Interventional Pulmonology; APC = argon plasma coagulation; Research Center, University of Heidelberg, Heidelberg, Germany; the
BLVR = bronchoscopic lung volume reduction; BTPNA = broncho- Division of Pulmonary and Critical Care Medicine (Dr Chen),
scopic transparenchymal nodule access; CAO = central airway Washington University School of Medicine, St. Louis, MO; and the
obstruction; CBCT = cone-beam CT; DNase = deoxyribonuclease; Division of Pulmonary and Critical Care Medicine (Dr Yarmus), Johns
DPLD = diffuse parenchymal lung disease; EBUS = endobronchial Hopkins University, Baltimore, MD.
ultrasound; EC = electrocautery; EM = electromagnetic; ENB = elec- FUNDING/SUPPORT: The authors have reported to CHEST that no
tromagnetic navigation bronchoscopy; ETTNA = electromagnetic funding was received for this study.
guidance transthoracic needle aspiration; FDA = Food and Drug CORRESPONDENCE TO: Momen M. Wahidi, MD, Division of Pul-
Administration; IP = interventional pulmonology; IPC = indwelling monary, Allergy and Critical Care Medicine, Duke University Medical
pleural catheter; PT = percutaneous tracheostomy; R-EBUS = radial Center, Box 102356, Durham, NC 27710; e-mail: momen.wahidi@
EBUS; RFA = radiofrequency ablation; SLB = surgical lung biopsy; duke.edu
TBNA = transbronchial needle aspiration; tPA = tissue plasminogen
activator Copyright Ó 2019 American College of Chest Physicians. Published by
Elsevier Inc. All rights reserved.
AFFILIATIONS: From the Division of Pulmonary, Allergy and Critical
DOI: https://doi.org/10.1016/j.chest.2019.10.013
Care Medicine (Drs Wahidi and Cheng), Duke University School of
Medicine, Durham, NC; the Department of Pneumology and Critical
The specific intervention in the airways is tailored to the Cryotherapy started as a modality to destroy tissue by
type of airway lesion, generally divided into exophytic rapidly freezing it to a very cold temperature (< 40oC).
growth (intrinsic), extrinsic compression from adjacent However, it gradually fell out of favor because it required
growths, or a combination of both diseases. Mechanical repeated freeze and thaw cycles on the target lesion and
debridement and ablative therapy are most appropriate had delayed effects, making it unsuitable for rapid relief
for exophytic lesions, whereas bronchoplasty and stent of CAO. Instead, a new application of cryotherapy
placement are best suited for extrinsic compression. emerged. Cryoadhesion is a technique in which the cold
Rigid bronchoscopy is preferred over flexible temperature of the probe is used to adhere to the tissue,
bronchoscopy for therapeutic procedures because the with the probe then being abruptly withdrawn, thereby
rigid bronchoscope has a larger diameter that allows for retrieving the attached tissue. This technique can be
effective suctioning and the removal of large pieces of used to remove luminal tumor tissue (cryocanalization),
tissue, there is also the ability to ventilate through the blood clots, mucous plugs, or foreign objects.13,14
scope, and the barrel of the scope is useful in coring out
The data on the efficacy of ablative therapy in the
tissue and dilating stenoses. Most bronchoscopists use a
airways is limited but, overall, show a high success rate
combination of rigid and flexible bronchoscopic
in achieving luminal patency (> 90%), relief of shortness
techniques in which the flexible scope is used through
of breath and a low rate of complications.15-17 Figure 1
the rigid scope for better visualization of distal lesions or
illustrates a typical case of therapeutic bronchoscopy in
easier articulation in curved or tortuous airways.
CAO.
Ablative Therapy: Laser, Electrocautery, Argon Other modalities, such as brachytherapy and
Plasma Coagulation, Cryotherapy photodynamic therapy, have a delayed therapeutic
Ablative therapy in the airway consists of both hot effect and often are not suitable for situations in which
(laser, electrocautery [EC], and argon plasma immediate relief of airway obstruction is desired. Both
coagulation [APC]) and cold (cryotherapy) modalities. modalities now are used less commonly because of cost,
The ideal lesion for ablative therapy is intraluminal and burdensome procedural steps, and unfavorable adverse
chestjournal.org 725
Figure 1 – Therapeutic bronchoscopy procedure images. A, A large, right mainstem bronchial mass. B, An electrocautery snare was first applied to the
mass and then detached the mass from its base. C and D, A cryotherapy probe then was used to adhere to and remove the mass. E and F, The residual
base of the mass was treated with touch cryotherapy.
event profiles (prolonged skin photosensitivity and fatal Mechanical Debridement and Bronchoplasty
hemoptysis in photodynamic therapy and massive Mechanical debridement of endobronchial lesions can
hemoptysis, radiation bronchitis, and airway stenosis in be achieved with flexible forceps, large rigid forceps, the
brachytherapy).18 beveled tip of the rigid scope, cryoavulsion or with the
chestjournal.org 727
Figure 2 – Images of airway stent placement in a patient with a lung transplant. A, A complex mixed lesion identified in the right mainstem bronchus.
B, Bronchoplasty with a balloon. C, Proximal view of hybrid stent placed in the right mainstem bronchus. D, Distal view of airway stent with patency of
distal airways.
Peripheral Bronchoscopy
Substantial effort has been made toward advancing the
diagnostic yield of bronchoscopy for peripheral
pulmonary lesions. A 2012 meta-analysis inclusive of
more than 3,000 patients suggested that the diagnostic
yield of guided bronchoscopy for peripheral lesions was
approximately 70% regardless of the method used.38
However, more recent data, including a prospective
study of more than 600 patients undergoing guided
bronchoscopy for peripheral lesions, revealed that
Figure 3 – Endobronchial ultrasound-guided transbronchial needle procedures were nondiagnostic in more than 40% of
aspiration image of the left interlobar lymph node (station 11L). A
needle is visible within the lymph node, which is surrounded by lung
patients.39 Therefore, efforts continue to determine the
tissue. true diagnostic yield of advanced guided procedures and
Figure 4 – Radial endobronchial ultrasonographic images of lung nodules. A, A concentric view indicates that the peripheral lesion surrounds the
bronchus. B, An eccentric view indicates that the lesion is positioned adjacent to the bronchus.
chestjournal.org 729
currently is being investigated in a prospective, large, 50% of patients.47,49 Early spontaneous pleurodesis with
multicenter study. an IPC decreases supply cost and risks of catheter failure
and infection and achieves the patient’s freedom from a
Bronchoscopic transparenchymal nodule access
catheter.50 Hence, there have been efforts to understand
(BTPNA) is a procedure in which navigational software
factors that promote the rate of spontaneous
is used to construct a direct pathway from a proximal
pleurodesis. In a multicenter, randomized, single-
bronchus through lung parenchyma to access peripheral
blinded trial, patients who underwent daily drainage had
lesions. Once the pathway has been constructed, the
a 24% increase in the spontaneous pleurodesis rate,
bronchoscopist uses a needle and dilation balloon to
occurring 36 days earlier when compared with
tunnel through pulmonary parenchyma to the
every-other day drainage.51 In a similar effort, the
peripheral lesion. A feasibility study in using BTPNA in
IPC-PLUS study evaluated the addition of talc slurry
12 patients undergoing planned resection for possible
through an IPC compared with use of an IPC alone; the
early stage lung cancer obtained a diagnosis in 10 (83%),
authors demonstrated a 20% improvement in the
and subsequent evaluation of the resected lung did not
pleurodesis rate with talc slurry through an IPC within
show any immediate complications.44 Additional studies
the first 5 weeks, without any additional adverse events
of BTPNA are ongoing and are warranted to validate the
in the outpatient setting.52
safety and efficacy of this approach.
Pleural infections (empyema or complex parapneumonic
Cone-beam CT (CBCT) scanning, a compact CT
effusion) are commonly encountered in clinical practice.
scanning system with a moving C-arm, can be used
The mainstay of therapy used to consist of antibiotics,
intraprocedurally during bronchoscopy to provide real-
drainage of the infected pleural space with tube
time confirmation of biopsy device location. A
thoracostomy, and possibly surgical decortication. The
prospective study of bronchoscopy with a thin
landmark Multi-Centre Intrapleural Sepsis Trial 2
bronchoscope, R-EBUS, and CBCT scanning in 20
demonstrated that twice-a-day intrapleural sequential
patients showed that post-CBCT scanning maneuvers
administration of tissue plasminogen activator (tPA) and
(redirecting sampling tools to the lesion based on CBCT
deoxyribonuclease (DNase) improved fluid drainage in
images) increased the diagnostic yield from 50% to 70%;
infected pleural effusions, reduced surgical referrals, and
the mean estimated effective dose of radiation to
decreased hospital stay.53 More recent studies aiming at
patients from CBCT scanning ranged from 8.6 to 23
reducing the complexity of the treatment regimen have
mSv.45 The body of evidence about CBCT scanning is
showed that concurrent instillation of tPA and DNase
slim but promising; its added value and safety need to be
could be as safe and as effective.54,55 A 2017
confirmed with larger prospective studies. However,
observational trial showed that starting with a reduced
adoption of CBCT scanning may be low given its cost
dose of intrapleural tPA (5 mg) and DNase (5 mg) in
and lack of availability in most endoscopy suites.
treating pleural infection is feasible,56 although
prospective comparative trials are needed to confirm
Pleural Interventions whether these modified schedules of administrations can
Pleural procedures ranging from pleural ultrasound be validated.
to medical thoracoscopy remained an active area for
Medical thoracoscopy or pleuroscopy has a diagnostic
research and clinical development in the past decade.
yield > 95% when used to evaluate lymphocytic
Indwelling pleural catheters (IPCs) have gained
exudative effusions without a clear cause (Fig 5).57 Since
tremendous popularity and have been declared by
its introduction, the procedure has evolved such that it
evidence-based guidelines to be as acceptable as
now is performed with the patient under moderate
chemical pleurodesis for the management of
sedation and as an outpatient treatment with excellent
symptomatic malignant pleural effusions.46 When
outcome.58,59 Narrow-band imaging and tissue
comparing IPCs and pleurodesis via talc slurry, two
autofluorescence have been used in pleuroscopy to
multicenter, open-label, randomized controlled trials
assess the pleura for targeted biopsy quickly.60,61
demonstrated that IPCs effectively relieved dyspnea and
Techniques to facilitate larger pleural biopsies by using a
decreased hospital stay and need for future
diathermy knife, hybrid knife, and cryobiopsy have been
procedures.47,48
described.62-64 None of the mentioned techniques have
Early data showed that the use of an IPC can lead to yet been validated with comparative trials to assess their
spontaneous pleurodesis, albeit often delayed, in up to added clinical value.
chestjournal.org 731
biopsy-proven early stage lung cancer in one procedural cancer must be proven in longitudinal studies (at least 5
setting. Limited experience with bronchoscopic years) demonstrating noninferiority in survival
radiofrequency ablation (RFA) exists, focusing mainly compared with that of the current gold standard of
on feasibility and safety.73,74 A longer-term study that stereotactic body radiation therapy.
treated 20 patients with nonsurgical early stage lung
cancer with bronchoscopic RFA illustrated a local Bronchoscopic Lung Volume Reduction
control rate of 82.6%, median progression-free survival
During the past decade, several bronchoscopic
of 35 months, and 5-year overall survival of 61.5%; three
therapeutic modalities have been tested in patients with
patients required hospitalization for acute ablation-
severe emphysema to mimic the physiologic effects of
related reaction (fever, chest pain), and all improved
surgical lung volume reduction in a less invasive fashion.
with conservative treatment.75
Bronchoscopic lung volume reduction (BLVR) via valve
Bronchoscopic microwave ablation also has been placement is a technique that was approved in the
proposed as a potential means to treat early stage lung United States by the FDA in 2018 (Fig 6). This approach
cancer. Bronchoscopic microwave ablation therapy has involves placement of one-way valves in the most
potential advantages over RFA, such as decreased destructed lung lobe, allowing air and mucus to exit and
treatment time and less susceptibility to the blocking air entry to achieve lobar collapse. The biggest
thermodilution generated by the heat sink effect of the challenge to this approach is the network of collateral
circulation in adjacent vasculature.76 Limited experience ventilation that may be connecting the target lobe to
has been reported using bronchoscopic microwave adjacent lobes, rendering anatomic airway blockage
therapy, and a pilot study was halted secondary to safety ineffective. Overcoming this obstacle requires assessing
concerns (NCT03603652), which highlights the critical collateral ventilation via chest CT scanning (on the basis
importance of rigorous protocol design and of the completeness of the fissures separating adjacent
implementation. Ultimately, the efficacy of lobes) or bronchoscopic measurement of the airflow of
bronchoscopic ablation of early stage nonoperable lung the occluded bronchus of the target lobe. Several clinical
Figure 6 – Images of bronchoscopic lung volume reduction with valves. A, Placement of Spiration valve (Olympus) in the apicoposterior segment of the
left upper lobe (LUL). B, Placement of Spiration valve in the anterior segment of the LUL. C, Placement of Zephyr valve (Pulmonx) in the apicoposterior
segment of the LUL. D, Placement of Zephyr valve in the anterior segment of the LUL.
chestjournal.org 733
Interventional Pulmonology (AABIP) has developed procedure competency, standardized curricula, and
and conducted annual certifying examinations in IP certification examinations, we must ensure that the
since 2013. Starting in 2017, completing 1 year of training for and practice of IP are grounded in evidence-
dedicated fellowship training in IP became a mandatory based medicine.
prerequisite for AABIP certification. That same year, the
Association of Interventional Pulmonary Program
Summary
Directors partnered with the AABIP, American Thoracic IP provides diagnostic and therapeutic options that span
Society, American College of Chest Physicians, and the spectrum of benign and malignant airway and
Association of Pulmonary and Critical Care Medicine pleural disorders. The constant innovations in
Program Directors to publish a consensus statement diagnostic and treatment modalities have continued to
defining minimum training standards for IP fellowship energize the field and further push the boundary of
programs.3 pulmonary medicine.
IP has gained recognition and interest from the medical
Challenges and Future Directions community and the public, and providers must strive to
IP, by the nature of its procedural focus, leads the way in practice evidence-based medicine supported by high-
innovation by challenging the status quo and seeking quality research and best-practice guidelines. The future
novel approaches to the diagnosis and treatment of is both exciting and challenging.
ailments afflicting a typically vulnerable and frail patient
population. With that privilege and enthusiasm comes a Acknowledgments
Financial/nonfinancial disclosures: The authors have reported to
great responsibility. First, IP has the scientific and moral CHEST the following: M. M. W. has served as a consultant to Boston
obligation to validate new technology. The 510(k) FDA Scientific; Nuvaira Inc; Olympus Corporation; and Veracyte, Inc and
has served as a reviewer on the Data Safety Monitoring Board for CSA
clearance pathway allows new medical devices with no Medical Inc. F. J. F. H. has served as a consultant to Broncus Medical,
substantial data to be used in patients as long as the Inc; BTG plc; Olympus Corporation; Pulmonx Inc; and Uptake
devices are shown to be substantially equivalent to a Medical and has received research funding from them. A. C. has served
as a consultant to Auris Health, Inc; Boston Scientific; and Olympus
currently FDA-approved device. This option is a Corporation and has received research funding from Auris Health, Inc;
blessing and a curse. The blessings come from the Boston Scientific; Olympus Corporation; and Veran Medical
Technologies. G. C. has served as a consultant to Boston Scientific;
acceleration of technology access for patients in need, Medtronic plc; Pinnacle Biologics, Inc; and Restor3D and has received
but the perils come from the relaxed requirement for research funding from Intuitive Surgical Inc and Pinnacle Biologics,
Inc. L. Y. has served as a consultant to AstraZeneca; Boston Scientific;
generation of data to prove safety and efficacy. Olympus Corporation; Veracyte, Inc; and Veran Medical Technologies.
chestjournal.org 735
53. Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue 73. Xie F, Zheng X, Xiao B, Han B, Herth FJF, Sun J. Navigation
plasminogen activator and DNase in pleural infection. N Engl J Med. bronchoscopy-guided radiofrequency ablation for nonsurgical
2011;365(6):518-526. peripheral pulmonary tumors. Respiration. 2017;94(3):293-298.
54. Majid A, Kheir F, Folch A, et al. Concurrent intrapleural instillation 74. Tanabe T, Koizumi T, Tsushima K, et al. Comparative study of three
of tissue plasminogen activator and DNase for pleural infection: a different catheters for CT imaging-bronchoscopy-guided
single-center experience. Ann Am Thorac Soc. 2016;13(9):1512-1518. radiofrequency ablation as a potential and novel interventional
55. Bishwakarma R, Shah S, Frank L, Zhang W, Sharma G, Nishi SP. therapy for lung cancer. Chest. 2010;137(4):890-897.
Mixing it up: coadministration of tPA/DNase in complicated 75. Koizumi T, Tsushima K, Tanabe T, et al. Bronchoscopy-guided
parapneumonic pleural effusions and empyema. J Bronchology Interv cooled radiofrequency ablation as a novel intervention therapy for
Pulmonol. 2017;24(1):40-47. peripheral lung cancer. Respiration. 2015;90(1):47-55.
56. Popowicz N, Bintcliffe O, De Fonseka D, et al. Dose de-escalation of 76. Healey TT, March BT, Baird G, Dupuy DE. Microwave ablation for
intrapleural tissue plasminogen activator therapy for pleural lung neoplasms: a retrospective analysis of long-term results. J Vasc
infection: the Alteplase Dose Assessment for Pleural Infection Interv Radiol. 2017;28(2):206-211.
Therapy project. Ann Am Thorac Soc. 2017;14(6):929-936.
77. Criner GJ, Sue R, Wright S, et al. A multicenter randomized
57. Blanc FX, Atassi K, Bignon J, Housset B. Diagnostic value of medical
controlled trial of Zephyr endobronchial valve treatment in
thoracoscopy in pleural disease: a 6-year retrospective study. Chest.
heterogeneous emphysema (LIBERATE). Am J Respir Crit Care Med.
2002;121(5):1677-1683.
2018;198(9):1151-1164.
58. Kyskan R, Li P, Mulpuru S, Souza C, Amjadi K. Safety and
performance characteristics of outpatient medical thoracoscopy and 78. Criner GJ, Delage A, Voelker KG; for the EMPROVE Trial
indwelling pleural catheter insertion for evaluation and diagnosis of Investigator Group. The EMPROVE trial: a randomized, controlled
pleural disease at a tertiary center in Canada. Can Respir J. multicenter clinical study to evaluate the safety and effectiveness of
2017;2017:9345324. the SpirationÒ valve system for single lobe treatment of severe
emphysema [abstract]. Am J Respir Crit Care Med. 2018;197:
59. DePew ZS, Wigle D, Mullon JJ, Nichols FC, Deschamps C, A7753.
Maldonado F. Feasibility and safety of outpatient medical
thoracoscopy at a large tertiary medical center: a collaborative 79. Ravaglia C, Wells AU, Tomassetti S, et al. Diagnostic yield and risk/
medical-surgical initiative. Chest. 2014;146(2):398-405. benefit analysis of trans-bronchial lung cryobiopsy in diffuse
parenchymal lung diseases: a large cohort of 699 patients. BMC Pulm
60. Ishida A, Ishikawa F, Nakamura M, et al. Narrow band imaging Med. 2019;19(1):16.
applied to pleuroscopy for the assessment of vascular patterns of the
pleura. Respiration. 2009;78(4):432-439. 80. Romagnoli M, Colby TV, Berthet JP, et al. Poor concordance
between sequential transbronchial lung cryobiopsy and surgical lung
61. Chrysanthidis MG, Janssen JP. Autofluorescence videothoracoscopy biopsy in the diagnosis of diffuse interstitial lung diseases. Am J
in exudative pleural effusions: preliminary results. Eur Respir J. Respir Crit Care Med. 2019;199(10):1249-1256.
2005;26(6):989-992.
81. DiBardino DM, Haas AR, Lanfranco AR, Litzky LA, Sterman D,
62. Pathak V, Shepherd RW, Hussein E, Malhotra R. Safety and
Bessich JL. High complication rate after introduction of
feasibility of pleural cryobiopsy compared to forceps biopsy during
transbronchial cryobiopsy into clinical practice at an academic
semi-rigid pleuroscopy. Lung. 2017;195(3):371-375.
medical center. Ann Am Thorac Soc. 2017;14(6):851-857.
63. Sasada S, Kawahara K, Kusunoki Y, et al. A new electrocautery
pleural biopsy technique using an insulated-tip diathermic knife 82. Maldonado F, Danoff SK, Wells AU, et al. Transbronchial cryobiopsy
during semirigid pleuroscopy. Surg Endosc. 2009;23(8):1901-1907. for the diagnosis of interstitial lung diseases: CHEST Guideline and
Expert Panel Report [published online ahead of print November 26,
64. Yin Y, Eberhardt R, Wang XB, et al. Semi-rigid thoracoscopic punch 2019]. Chest. https://doi.org/10.1016/j.chest.2019.10.048.
biopsy using a hybrid knife with a high-pressure water jet for the
diagnosis of pleural effusions. Respiration. 2016;92(3):192-196. 83. Yarmus LB, Semaan RW, Arias SA, et al. A randomized controlled
trial of a novel sheath cryoprobe for bronchoscopic lung biopsy in a
65. Higgins KM, Punthakee X. Meta-analysis comparison of open versus porcine model. Chest. 2016;150(2):329-336.
percutaneous tracheostomy. Laryngoscope. 2007;117(3):447-454.
84. Hetzel J, Maldonado F, Ravaglia C, et al. Transbronchial
66. Yarmus L, Pandian V, Gilbert C, et al. Safety and efficiency of
cryobiopsies for the diagnosis of diffuse parenchymal lung diseases:
interventional pulmonologists performing percutaneous
expert statement from the cryobiopsy working group on safety and
tracheostomy. Respiration. 2012;84(2):123-127.
utility and a call for standardization of the procedure. Respiration.
67. Mirski MA, Pandian V, Bhatti N, et al. Safety, efficiency, and cost- 2018;95(3):188-200.
effectiveness of a multidisciplinary percutaneous tracheostomy
program. Crit Care Med. 2012;40(6):1827-1834. 85. Wahidi MM, Kraft M. Bronchial thermoplasty for severe asthma.
Am J Respir Crit Care Med. 2012;185(7):709-714.
68. Fielding D, Bashirzadeh F, Son JH, et al. First human use of a new
robotic-assisted navigation system for small peripheral pulmonary 86. Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of
nodules demonstrates good safety profile and high diagnostic yield bronchial thermoplasty in the treatment of severe asthma: a
[abstract]. Chest. 2017;152(4):A858. multicenter, randomized, double-blind, sham-controlled clinical
trial. Am J Respir Crit Care Med. 2010;181(2):116-124.
69. Rojas-Solano JR, Ugalde-Gamboa L, Machuzak M. Robotic
bronchoscopy for diagnosis of suspected lung cancer: a feasibility 87. Chupp G, Laviolette M, Cohn L, et al; Other members of the PAS2
study. J Bronchology Interv Pulmonol. 2018;25(3):168-175. Study Group. Long-term outcomes of bronchial thermoplasty in
subjects with severe asthma: a comparison of 3-year follow-up
70. Chen AC, Gillespie CT. Robotic Endoscopic Airway Challenge:
results from two prospective multicentre studies. Eur Respir J.
REACH assessment. Ann Thorac Surg. 2018;106(1):293-297.
2017;50(2):pii:1700017.
71. National Institutes of Health Clinical Center. Robotic bronchoscopy
for peripheral pulmonary lesions: A multicenter pilot and feasibility 88. Mahmood K, Wahidi MM, Osann KE, et al. Development of a tool
study. NCT03727425.ClinicalTrials.gov. Bethesda, MD: National to assess basic competency in the performance of rigid
Institutes of Health; 2018. https://clinicaltrials.gov/ct2/show/ bronchoscopy. Ann Am Thorac Soc. 2016;13(4):502-511.
NCT03727425?cond=robotic+bronchoscopy&draw=2&rank=1. 89. Davoudi M, Colt HG, Osann KE, Lamb CR, Mullon JJ.
Updated September 25, 2019. Endobronchial ultrasound skills and tasks assessment tool: assessing
72. Yarmus L, Mallow C, Akulian J, et al. Prospective multicentered the validity evidence for a test of endobronchial ultrasound-guided
safety and feasibility pilot for endobronchial intratumoral transbronchial needle aspiration operator skill. Am J Respir Crit Care
chemotherapy. Chest. 2019;156(3):562-570. Med. 2012;186(8):773-779.