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Little published data exist regarding the learning curve for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). We sought to assess the improvement in skill as trainees learned EBUS-TBNA in a clinical setting.This is a multicentre cohort study of EBUS-TBNA technical skill of interventional pulmonology (IP) fellows as assessed with EBUS-TBNA computer simulator testing every 25 clinical cases throughout IP fellowship training.Nine fellows from three academic centres in the United States and Canada were enrolled in the study. Ongoing improvements were seen for EBUS-TBNA efficiency score and percentage of lymph nodes correctly identified on ultrasound exam, even after 200 clinical cases. Expert-level technical skill was obtained for EBUS efficiency score and for percentage of lymph nodes correctly identified on ultrasound exam at a median of 212 and 164 procedures, respectively; however, 33% of fellows did not achieve expert-level technical skill for either metric during their fellowship training. Significant variation in learning curves of the fellows was observed.Significant variation is seen in the EBUS-TBNA learning curves of individual IP fellows and for individual procedure components, with ongoing improvement in EBUS-TBNA skill even after 200 clinical cases. These results highlight the need for validated, objective measures of individual competence, and can assist training programmes in ensuring adequate procedure volumes required for a majority of trainees to successfully complete these assessments.

The frequency at which housestaff need to assess volume status on medical inpatients is unknown. In this brief report, we invited 39 housestaff, over 13 randomly selected dates, to complete a 25-item survey. Participants (n = 31, 79%) logged a total of 455 hours, reporting 197 pages or telephone requests received regarding medical inpatients. Of these, 41 pages (21%) required a volume status assessment. Participants reported their volume status assessment competency to be moderate (median score = 3, interquartile range = 3 to 4, where 1 = not competent to perform independently and 6 = above average competence). In 9 of the 41 assessments (22%), at least 1 barrier was reported in determining volume status. The most commonly reported barriers were conflicting physical examination findings (n = 8, 20%) and suboptimal patient examination (n = 5, 12%). Over 20% of pages regarding admitted medical patients required volume status assessments by medical housestaff. Despite moderate self-reported competence in the ability to assess volume status, barriers such as conflicting physical examination findings and suboptimal patient examinations were present in up to 20% of assessments. Therefore, we urge educators to consider incorporating bedside ultrasound training for volume status into the internal medicine curriculum.

Solitary pulmonary nodules (SPNs) frequently require transbronchial needle aspiration (TBNA) or biopsy to determine malignant potential, but have variable diagnostic yields. Confirming needle placement within SPNs during TBNA could significantly increase diagnostic yield. Optical coherence tomography (OCT) provides nondestructive, high-resolution, microstructural imaging with potential to distinguish SPN from parenchyma. We have developed needle-based OCT probes compatible with TBNA. Before OCT can play any significant role in guiding clinical TBNA, OCT interpretation criteria for differentiating SPN from lung parenchyma must be developed and validated.OCT of SPN and parenchyma was performed on 111 ex vivo resection specimens. OCT criteria for parenchyma and SPN were developed and validated in a blinded assessment. Six blinded readers (two pulmonologists, two pathologists, and two OCT experts) were trained on imaging criteria in a 15-min training session prior to interpreting the validation data set.OCT of lung parenchyma displayed evenly spaced signal-void alveolar spaces, signal-intense backreflections at tissue-air interfaces, or both. SPNs lacked both of these imaging features. Independent validation of OCT criteria by the six blinded readers demonstrated sensitivity and specificity of 95.4% and 98.2%, respectively.We have developed and validated OCT criteria for lung parenchyma and SPN with sensitivity and specificitygt; 95% in this ex vivo study. We anticipate that OCT could be a useful complementary imaging modality to confirm needle placement during TBNA to potentially increase diagnostic yield.

Lung cancer is the leading cause of cancer related death. Macroscopic imaging techniques such as computed tomography are highly sensitivity at detecting small, ≤ 2cm, peripheral pulmonary lesions (PPLs) in the lung but lack the specificity necessary for diagnosis. Bronchoscopy is a procedure routinely performed to diagnose PPLs but is hindered with a low diagnostic yield due to challenging lesion localization. We have developed a flexible transbronchial optical frequency domain imaging (TB-OFDI) catheter that functions as a ‘smart needle’ to confirm the needle placement within the target lesion prior to biopsy. The TB-OFDI smart needle consists of a flexible and removable OFDI catheter that operates within a 21-gauge transbronchial needle aspiration (TBNA) needle. The OFDI catheter can be easily removed from the needle to facilitate subsequent aspiration or biopsy acquisition. The OFDI imaging core consists of an angled-polished ball lens with a spot size of 25 μm at a working distance of 160 μm from the catheter sheath. The ball-lens was designed to have an ellipsoid shape in order to compensate for the astigmatism caused by encasing the optics within a protective sheath. Transbronchial imaging of inflated excised swine lung parenchyma with the TB-OFDI smart needle yielded clear images of alveoli. In-vivo transbronchial imaging was also performed on three swine with artificial lesions injected transthoracially. Our results suggest that the TB-OFDI smart needle may be a useful tool for guiding biopsy acquisition to increase the diagnostic yield of PPLs.

Pulmonary aspergilloma is a chronic fungal infection that has a high mortality when hemoptysis occurs. Surgery is the treatment of choice, but patients often have severe physiologic impairment putting them at risk for significant surgical morbidity and mortality. We present the case of a 63-year-old woman with a large aspergilloma, unfit for surgery due to medical reasons. The aspergilloma was enlarging, with progression of the patient's symptoms of anorexia, cough, chest discomfort, and hemoptysis. Bronchoscopy revealed an airway leading into a cavity with a large fungal ball. Biopsy confirmed Aspergillus fumigatus. Using flexible and rigid bronchoscopy, the aspergilloma was mechanically removed. Eighteen months later the patient reported no hemoptysis, reduced pain and cough, significant weight gain, and improved appetite, with no recurrence of the aspergilloma on repeat imaging. To our knowledge, this is the first reported case of bronchoscopic removal of a large cavitary aspergilloma. This important new treatment modality provides a viable alternative therapy for this potentially life-threatening problem.

Sequelae of foreign body aspiration can range from clinically silent and asymptomatic to immediate asphyxiation and death. Only two previous cases of bisphosphonate tablet aspiration have been reported. Ulcerative esophagitis, a known adverse effect of oral bisphosphonate formulations, occurs primarily with prolonged exposure of esophageal mucosa to the medication. Little is known about the effects of bisphosphonates on the airway mucosa. The authors present a case involving an 84-year-old woman who required multiple bronchoscopic debridements, intubation for airway protection and intensive care unit admission following airway injury believed to be due to delayed recognition of aspiration of an alendronate tablet.

BACKGROUND: Computer endobronchial ultrasound (EBUS) simulators have been demonstrated to improve trainee procedural skills before attempting to perform EBUS procedures on patients.OBJECTIVE: To compare EBUS performance following training with computer simulation proctored by EBUS-trained respiratory therapists versus the same simulation training proctored by an interventional respirologist.METHODS: The present analysis was a prospective study of respiratory medicine trainees learning EBUS. Two cohorts of trainees were evaluated using a previously validated method using simulated cases with performance metrics measured by the simulator. Group 1 underwent EBUS training by performing 15 procedures on an EBUS simulator (n=4) proctored by an interventional respirologist. Group 2 received identical training proctored by a respiratory therapist with special training in EBUS (n=10).RESULTS: No significant differences between group 1 and group 2 were apparent for the primary outcome measures of total procedure time (15.15±1.34 min versus 14.78±2.88 min; P=0.816), the percentage of lymph nodes successfully identified (88.8±5.4 versus 80.91±8.9; P=0.092) or the percentage of successful biopsies (100.0±0.0 versus 98.75±3.95; P=0.549). The learning curves were similar between groups, and did not show an obvious plateau after 19 simulated procedures in either group.DISCUSSION: Acquisition of basic EBUS technical skills can be achieved using computer EBUS simulation proctored by specially trained respiratory therapists or by an interventional respirologist. There appeared to be no significant advantage to having an interventional respirologist proctor the computer EBUS simulation.

Low-risk bronchoscopy techniques for retrieving biopsy samples for the diagnosis of lung cancer are hampered by low diagnostic yields, and trans-thoracic and surgical approaches carry higher intrinsic risk of complications. We are investigating the use of optical coherence tomography to increase the diagnostic yield of bronchial biopsy.

Endobronchial ultrasound (EBUS) is a relatively new technology in the field of pulmonary medicine. To determine EBUS knowledge, current clinical utilization, and perceived barriers to EBUS implementation, we surveyed physicians who had previously attended a 2-day hands-on EBUS course in our center. Our survey response rate was 51%. Overall, we found that more than one-third of course participants were currently performing linear EBUS and that over half had access to EBUS for their patients through another physician in their center. EBUS knowledge was excellent and many physicians used EBUS in their current clinical setting in the diagnosis of sarcoidosis, mediastinal lymphadenopathy, and lung cancer. Reported barriers to EBUS implementation included the high cost of equipment (73%), high per procedure cost (23%), inadequate support staff (32%), and limitations regarding use of sedation and anesthesia (18%). Only 14% cited lack of adequate training as a barrier to EBUS implementation, and none believed that low patient volumes for EBUS was a barrier to its implementation. It seems that participation in an EBUS course is useful in helping physicians incorporate EBUS in their practice, but barriers remain, some of which may not be modifiable through such activities.

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.

This study aimed to investigate the diagnostic utility of peripheral endobronchial ultrasound (pEBUS) followed by as-needed electromagnetic navigation bronchoscopy (ENB) for sampling peripheral lung nodules.The study was a single-arm, prospective cohort study of patients with peripheral lung nodules. Peripheral lung lesion localization was initially performed using a pEBUS probe with guide sheath. If localization failed with pEBUS alone, ENB was used to help identify the lesion. Transbronchial biopsy, bronchial brush, transbronchial needle aspiration and bronchial washings were performed.Sixty patients were enrolled with average lesion size of 27 mm and mean pleural distance of 20 mm. Lesions were found with pEBUS alone in 75% of cases. The addition of ENB improved lesion localization to 93%. However, diagnostic yield for pEBUS alone and pEBUS with ENB were 43% and 50%, respectively. Factors predicting need for ENB use included smaller lesion size and absence of an air bronchus sign on computed tomography.ENB improves localization of lung lesions after unsuccessful pEBUS but is often not sufficient to ensure confirmation of a specific diagnosis. Technical improvements in sampling methods could improve the diagnostic yield.

Background: Tunneled pleural catheters (TPC) are used in the management of malignant pleural effusions (MPE), but the impact of this palliative procedure on patient quality of life (QoL) has not been well described. Objectives: To ascertain the impact of TPCs on symptoms and QoL of patients with recurrent MPE. Methods: Patients with recurrent MPE completed the EORTC QLQ-C30 and LC13 QoL questionnaires at baseline, 2 and 14 weeks; FACIT-TS-G© treatment satisfaction surveys were completed at 14 weeks. Results: A total of 82 patients were recruited. Thirty-seven patients (37/82, 45%) died prior to their 14-week follow-up appointment. Significant improvements in dyspnea at 2 weeks were demonstrated with both dyspnea scores (LC13 baseline score 64.1, 2-week score 43.7, mean change –20.4, n = 56, p < 0.001; C30 baseline score 78.9, 2-week score 46.6, mean change –32.4, n = 68, p < 0.001), as well as with the MRC score (baseline median score 4, 2-week score 3, n = 70, p < 0.001). Global health status/QoL was also significantly improved at 2 weeks (baseline score 34.1, 2-week score 46.3, mean change 12.3, n = 68, p < 0.001). Improvements in cough, fatigue and all functional scales were noted at 2 weeks. The improvements in dyspnea and global health status/QoL were maintained to 14 weeks in surviving subjects and there was further improvement in the MRC score at 14 weeks. Patients who completed the FACIT-TS-G survey demonstrated overall satisfaction with TPC treatment. Conclusions: TPCs are associated with a significant improvement in global health status, QoL and dyspnea at the 2-week time point in patients with recurrent MPE.

Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) is a pulmonary procedure that can be challenging to learn. This study aims to compare trainee EBUS-TBNA performance during clinical procedures, following training with a computer EBUS-TBNA simulator versus conventional clinical EBUS-TBNA training.A prospective study of pulmonary trainees performing EBUS-TBNA procedures on patients with suspected lung cancer and mediastinal adenopathy. Two cohorts of trainees were each evaluated while performing EBUS-TBNA on two patients. Group 1 received training by performing 15 cases on an EBUS-TBNA simulator (n = 4) and had never performed a clinical EBUS-TBNA procedure. Group 2 received training by doing 15-25 EBUS-TBNA procedures on patients (n = 4).There was no significant difference in the primary outcome measure of total EBUS-TBNA procedure time/number of successful aspirates between Groups 1 and 2 (3.95 (±0.93) vs 3.64 (±0.89), P = 0.51). Total learner EBUS-TBNA procedure time in minutes (23.67 (±5.58) vs 21.81 (±5.36), P = 0.17) and percentage of successful aspirates (93.3% (±5.8%) vs 86.3% (±6.7%), P = 0.12) were not significantly different between Group 1 and Group 2. The only significant difference found between Group 1 and Group 2 was time to intubation in minutes (0.99 (±0.46) vs 0.50 (±0.42), P = 0.04).EBUS-TBNA simulator use leads to rapid acquisition of clinical EBUS-TBNA skills comparable with that obtained with conventional training methods using practice on patients, suggesting that skills learned using an EBUS-TBNA simulator are transferable to clinical EBUS-TBNA performance. EBUS-TBNA simulators show promise for training, potentially minimizing the burden of procedural learning on patients.

Transbronchial needle aspiration (TBNA) is a procedure routinely performed to diagnose peripheral pulmonary lesions. However, TBNA is associated with a low diagnostic yield due to inappropriate needle placement. We have developed a flexible transbronchial optical frequency domain imaging (TB-OFDI) catheter that functions as a "smart needle" to confirm the needle placement within the target lesion prior to biopsy. The TB-OFDI smart needle consists of a flexible and removable OFDI catheter (430 µm dia.) that operates within a standard 21-gauge TBNA needle. The OFDI imaging core is based on an angle polished ball lens design with a working distance of 160 µm from the catheter sheath and a spot size of 25 µm. To demonstrate the potential of the TB-OFDI smart needle for transbronchial imaging, an inflated excised swine lung was imaged through a standard bronchoscope. Cross-sectional and longitudinal OFDI results reveal the detailed network of alveoli in the lung parenchyma suggesting that the TB-OFDI smart needle may be a useful tool for guiding biopsy acquisition to increase the diagnostic yield.