Volume 05
Issue 03
September 2017
Inside This Issue
Opinion/Editorial, 2
Technology Corner, 3,4
Tips from the Experts, 5,6
Humanitarian News, 7,8
Educaon and Training, 9
BOR News, 10
Research, 11
Bronchoscopy Around the World, 12
WABIP Academy Webcasts, 13
Links, 13
Upcoming Events, 14
While we have made major advanc-
es in the US, there remains more
work to be done. Our future chal-
lenges are like other medical educa-
tors which includes recognion/
support for educaonal eort,
aracng the best talent, and need
for faculty with formal training in
educaon. As our specialty conn-
ues to grow, we need to ensure that
the next generaon of IP physicians
are beer equipped than the prior.
This requires the support of our jun-
ior faculty through mentorship and
opportunies for grants/ awards as
these are the currency of an aca-
demic career. Like most problems,
the soluon probably lies with
starng small and escalang up,
grants and mentorship opportunies
need to start on a society and ins-
tuonal level which serves as a step-
ping stone to develop more sophis-
cated work.
The standardizaon of training
marks the end of the beginning as
we mandate minimum requirements
of our training programs and their
faculty. I’m opmisc of the future
as I meet our IP fellows and col-
leagues who have beneted from
our current training system.
References
1. Silvestri GA. J Bronchology Interv
Pulmonol. 2010;17:1–2.
2. Lee HJ et al. J Bronchology Interv
Pulmonol. 2011; 18: 5-6.
3. Lee HJ et al. Chest. 2013;143(6):1667
–70
4. Lamb C et al. Chest. 2010; 137: 195-9.
5. Mullon JJ et al. Chest 2017; 15(5):
1114-21.
Hans J Lee, MD FCCP
Associate Professor of
Medicine
Wang Intervenonal
Pulmonary Fellowship
Director
Pulmonary Disease and
Crical Care Medicine
Johns Hopkins University
Prior to the creaon of dedicated
intervenonal pulmonary (IP) fellow-
ship training (1996) in the United
States, Americans had to travel
abroad and/ or learn from their sur-
gical colleagues
1
. The landscape has
drascally changed since then with
over thirty-three IP fellowship train-
ing centers in the US with addional
programs on the horizon. IP fellow-
ships in the US requires 12 months of
dedicated training aer compleng
residency in internal medicine and
pulmonary/ crical care fellowship.
This training spans a minimum of 7
years aer medical school, equiva-
lent to that of our neurosurgery
training. With such sophiscated
learners, the need for an organized
and standardized training system
was inevitable.
Since the iniaon of the rst IP fel-
lowship program, standardized train-
ing has been an evolving process
stemming from the rapid increase in
the number of training programs. As
the number of training programs
expanded, an early growing pain was
the applicaon process to programs,
as applicants were applying to mul-
ple programs at the same me. In
the past, programs had competed to
make the earliest oers for the best
applicants, as applicants had no op-
ons but to accept their rst oer in
fear of not securing any posion.
The resoluon came through the
cooperaon of program directors to
standardize the applicaon process in
a fair and transparent manner
2
. The
organizaon of the process allowed
for other joint projects such as a na-
onal boot camp for IP fellows to
gather in their rst month of training
to have uniformed lectures/ hands-
on training. We now have a commu-
nity of educators/ program directors
working collaboravely to foster the
educaonal metrics and career devel-
opment
3 4
. Recently, there was a
mul-society guideline on the mini-
mum requirements of IP fellowship
programs
5
. Involving ve dierent
medical sociees (ACCP, ATS, AABIP,
AIPPD, APCCMPD) to agree on what
must be included was nothing short
of a small miracle. This allows us to
organize our educaonal eorts and
move best pracces from isolated
silos to naonal requirements. It also
denes instuonal and faculty re-
quirements, minimal number of pro-
cedures/ faculty, and curriculum.
The standardized training process is
crical for several reasons but most
importantly, it denes what is an in-
tervenonal pulmonologist. The cur-
riculum requirements during IP fel-
lowship is the reference for expecta-
on by fellowship applicants, non-IP
physicians, paents, and administra-
tors. Employers of IP physicians can
objecvely assess qualicaons with-
out ambiguity. With standardized
training comes formal recognion
which enhances professionalism by
creang pracce standards and de-
ned metrics. Only a recognized sub-
specialty can aract the best and the
most talented to commit their ca-
reers to further developing IP. This
has also been observed in other
young speciales where the develop-
ment of standardized training and
metrics leads to beer educators and
indirectly develop the best graduates.
Guest Opinion/Editorial
WABIP Newsletter
S E P T E M B E R 2 0 1 7 V O L U M E 5 , I S S U E 3
EXECUTIVE BOARD
Zsolt Papai MD
Székesfehérvár, Hun-
gary
Chair
Silvia Quadrelli MD
Buenos Aires, Argen-
na
Vice-chair
Hideo Saka MD
Nagoya, Japan
Secretary General
Hojoong Kim MD
Seoul, Korea
Treasurer
Eric Edell MD
Rochester MN, USA
President WCBIP 2018
Quangfa Wang MD
Beijing, China
President WCBIP 2020
Henri Colt MD
Laguna Beach, CA
Immediate Past-chair
STAFF
Michael Mendoza
General Manager
Judy McConnell
Administrator
Kazuhiro Yasufuku
Newsleer Editor-in-
chief
P A G E 2
Standardizaon of Intervenonal Pulmonology Training: a US perspecve
Technology Corner
Stereotacc Body Radiotherapy for Early-Stage Non-Small Cell Lung Cancer
Corey C. Foster, MD & James M. Melotek, MD, MS
Department of Radiaon and Cellular Oncology
The University of Chicago Medicine
Introducon: Lung cancer is the leading cause of cancer-related death worldwide. Risk factors include tobacco abuse with heavy
smokers having an approximately 20-fold higher risk compared to non-smokers. Unfortunately, the majority of cases are diag-
nosed aer the development of metastac disease with only ~15% of paents being diagnosed prior to spread to regional lymph
nodes or other organs. Fortunately, the proporon of paents with early-stage disease at presentaon may increase in the coming
years with the roune use of low-dose computed tomography (CT) for screening of high-risk populaons. For individuals with early
-stage non-small cell lung cancer (NSCLC), the standard of care is currently lobectomy with mediasnal lymph node sampling; how-
ever, many paents may not be suitable candidates for this procedure due to medical comorbidies. Alternave opons for deni-
ve management include sublobar resecon or stereotacc body radiotherapy (SBRT). SBRT uses sophiscated planning tech-
niques to deliver a high cumulave radiaon dose to the target lesion in 5 or fewer fracons with the goal of achieving tumor abla-
on while sparing normal ssues. The use of SBRT for operable candidates remains controversial, although emerging evidence
suggests that oncologic outcomes may be comparable to lobectomy (1).
Background: SBRT planning begins with a CT simulaon. During this process, immobilizaon devices are made to allow for repro-
ducible paent set-up at the me of treatment. Addionally, four-dimensional CT is commonly used to assess tumor moon and
the necessity for respiratory management during SBRT delivery. This is parcularly important for nodules located at the lung ba-
ses. For such lesions, respiratory gang may be ulized such that radiaon is delivered only during a xed phase of the respiratory
cycle. Alternavely, an “internal target volume” may be generated to treat the lesion of interest with an appropriate margin to
account for respiratory moon. Once the CT simulaon has been performed, diagnosc imaging may be fused to allow for accu-
rate target delineaon. An ideal plan (Figure 1) is then generated using an inverse planning process to select the opmal candidate
plan among all possible variaons that could treat the target lesion. This process considers priorized dose constraints in order to
deliver the highest possible dose to the tumor while sparing surrounding structures such as the normal lung, heart, proximal bron-
chial tree, esophagus, spinal cord, and chest wall. Although many dierent fraconaon schemes have been reported for SBRT for
early-stage NSCLC, all provide nearly equivalent local control so long as they achieve a biologically eecve dose (BED) ≥100 Gy (2).
BED calculaons ulize a radiobiological equaon to convert dierent fraconaon schemes to a comparable dose taking into con-
sideraon the inherent radiosensivity of a parcular ssue as well as the capacity for repair from radiaon-related damage.
Clinical applicaons: The pioneering phase II North American study invesgang the ecacy and toxicity of SBRT for medically
inoperable paents with T1-2N0M0 NSCLC was the Radiaon Therapy Oncology Group (RTOG) 0236 trial (3). In this study, 59 pa-
ents received a total dose of 54 Gy in 3 fracons over 1.5-2 weeks. The 5-year treated tumor control rate was 93%; however,
lobar, regional, and distant failure remained signicant with a 5-year locoregional failure rate of 38% and 5-year distant failure rate
of 31%. SBRT was generally well tolerated with 15 paents experiencing grade 3 or 4 toxicity and no reported grade 5 toxicity. Of
note, inoperable paents receiving SBRT for centrally-located, early-stage NSCLC (within 2 cm of the proximal bronchial tree) were
observed to experience unacceptable toxicity in a prospecve trial performed at Indiana University (4). Specically, paents with
central lesions had 2-year freedom from severe toxicity of 54% compared to 83% for paents with peripheral lesions. Addionally,
4 of 6 treatment-related deaths occurred in individuals with central tumors. Thus, a subsequent prospecve invesgaon by the
RTOG (0831) sought to determine the opmal treatment dose for inoperable, centrally-located, early-stage NSCLC. This phase I/II
trial used a dose-escalang 5-fracon SBRT schedule ranging from 10-12 Gy/fracon delivered over 1.5-2 weeks (5). In the phase II
poron, there was an esmated 7.2% chance of experiencing dose-liming toxicity when receiving 60 Gy in 5 fracons. Associated
2-year local control, progression-free survival, and overall survival with this dose and fraconaon were 87.7%, 54.5%, and 72.7%,
respecvely. Mulple retrospecve studies have also reported acceptable toxicity and local control with other fraconaon
schemes for centrally-located lesions. The possibility of oering denive SBRT for medically-operable, early-stage NSCLC remains
W A B I P N E W S L E T T E R
P A G E 3
controversial. Clinical trials designed to address this issue have been limited by poor accrual. However, in a pooled analysis of two such
trials, data from 58 paents showed 3-year overall survival and recurrence-free survival of 95% vs. 79% (P = 0.037) and 86% vs. 80% for
SBRT vs. lobectomy, respecvely (1).
Conclusions: SBRT uses sophiscated treatment planning to deliver ablave doses of radiaon to a target lesion in 5 or fewer fracons.
For paents with medically-inoperable, early-stage NSCLC, long-term primary tumor control is excellent and esmated to be ≥90%. A three
-fracon regimen is generally well-tolerated for paents with peripheral lesions while centrally-located tumors should be treated in a larger
number of fracons to achieve a sucient biologically eecve dose with acceptable toxicity. Unfortunately, prospecve trials comparing
denive SBRT to lobectomy for operable paents have been limited by poor accrual but suggest that survival may be comparable between
both treatment strategies.
Figure 1: Radiaon isodose lines in the (A) axial and (B) coronal planes from an SBRT treatment plan for a paent with medically-inoperable, early-
stage NSCLC.
(A)
References
1. Chang JY et al. Lancet Oncol. 2015; 6:630-7.
2. Onishi H et al. J Thorac Oncol 2007; 7 Suppl 3:S94-100.
3. Timmerman RD et al. Int J Radiat Oncol Biol Phys 2014; 1 Suppl:S30.
4. Timmerman R et al. J Clin Oncol 2006; 30:4833-4839.
5. Bezjak A et al. Int J Radiat Oncol Biol Phys 2016; 2 Suppl:S8.
W A B I P N E W S L E T T E R P A G E 4
(B)
Tips from the Experts
P A G E 5 V O L U M E 5 , I S S U E 3
Background
The complex non-malignant pleural space is typically associated with pleural infecon. This review will summarise recent changes to the
approach and management of this common clinical problem.
Pleural infecon encompasses a spectrum of disorders ranging from exudave eusions to frank empyema and paents may progress
through stages of this condion. Pleural infecon has a high morbidity and mortality, and around 20% of paents with empyema will die
from their disease. This gure is unchanged over the last few decades, despite advances in modern treatment and diagnosc strategies.
Prognosc Indicators
A seminal meta-analysis demonstrated that, in the context of clinical suspicion of pleural infecon, an eusion with a pH of <7.20 or frank
pus requires immediate drainage to reduce morbidity and mortality (1). These eusions are termed either empyema (frank pus) or compli-
cated parapneumonic eusions (CPPE) (absence of pus and low pH).
Sonographically complex eusions (i.e. the presence of septaons and echogenic uid) are dierent from a biochemical diagnosis of CPPE
(2). While there is suggesve evidence that paents with complex septated pleural eusion (gure 1) on ultrasound have less successful
outcomes and a higher mortality than those without (3), prospecve and objecve data are lacking. One important point is that although
septaons on ultrasound appear to be solid, at thoracoscopy, they oen have evidence of mulple holes which may not appear on ultra-
sound, and may permit drainage through a single chest tube (gure 2).
The American College of Chest Physicians consensus statement also recommends chest tube drainage in paents with a parapneumonic
eusion occupying greater than 50% of the hemithorax, with loculaons or thickened parietal pleura, even without the recognised criteria
of pus, posive gram stain or pH <7.2 (4).
The RAPID score (5) uses a combinaon of age, urea, albumin, hospital acquired infecon and non-purulence to predict mortality. A mul-
centre, prospecve observaonal study in 550 paents has just been completed (the PILOT study) and primary results are expected in the
next few months. If proven to be eecve, this scoring system may prove clinically important in idenfying those with poor prognosis early,
and direcng aggressive therapy towards them.
Medical Management
The mainstay of management of pleural infecon is early diagnosis, appropriate anbiocs, and prompt drainage. There is no evidence that
large bore chest tubes are superior to small bore tubes (12F-16F) (6) but regular saline ushes are recommended (7). Appropriate anbiocs
should be given depending on the organism grown, local microbiological and resistance paerns. Anbiocs should be given for at least 3
weeks and oen considerably longer, based on clinical, ultrasound and inammatory marker response (7).
Nutrion is an important factor which is oen overlooked. Pleural infecon is a catabolic condion and supplemental feeding should be con-
sidered from the me of diagnosis (7). These paents are at high risk for venous thromboembolism and prophylaxis should be given unless
contraindicated (7).
Intrapleural Treatment
Paents who do not respond to medical management may be given intrapleural treatment, require surgical intervenon or be considered
for medical thoracoscopy / pleuroscopy.
The ecacy of brinolyc therapy has been assessed in two mulcentre trials. MIST 1 randomised paents to receive streptokinase or pla-
cebo, but no stascally signicant dierence in mortality or need for surgical intervenon was shown (8). MIST 2 (9), compared ssue plas-
minogen acvator (t-PA) and deoxyribonuclease (DNAse), in combinaon and alone, to placebo. The combinaon of t-PA and DNAse re-
duced the percentage of the hemithorax occupied by the eusion, reduced surgical referrals and the duraon of hospital stay. There was no
change in overall mortality or rate of complicaons between the arms.
Tips on management of non-malignant complex pleural space
Dr Rachel Mercer (MRCP)
Oxford Respiratory Trials Unit
Churchill Hospital
Oxford, UK
Prof Najib M Rahman D Phil MSc FRCP
Associate Professor of Respiratory Medicine, Nueld Department of Medicine
Clinical Director, Oxford Respiratory Trials Unit, University of Oxford, UK
Consultant Respiratory Physician, Lead for Pleural Diseases, Oxford Centre for Respiratory Medicine
Dr M Munavvar MD DNB FRCP (Lon) FRCP (Edin)
Consultant Chest Physician/ Intervenonal Pulmonologist
Clinical Director, Respiratory Medicine
Lancashire Teaching Hospitals, Preston, UK
Tips from the Experts
P A G E 6 V O L U M E 5 , I S S U E 3
Intrapleural brinolycs can therefore be considered in paents who are failing medical management and would not be surgical candidates,
but we do not currently recommend their use in the roune management of pleural infecon (7), although several centres have started to
use them in all cases of “failing” medical therapy prior to surgery (10).
Surgical Intervenon
Paents who fail medical management may be referred for surgical intervenon, either in the form of a (Video-assisted thoracic surgery)
VATS or thoracotomy and decorcaon. The short term operave mortality is around 5% (11) although VATS may have slightly lower rates of
mortality along with reduced complicaons (12). There are no objecve criteria for when paents should be referred for surgical interven-
on, but it is usually considered in the presence of persisng sepsis AND persisng pleural collecon. Surgical treatment is especially valuable
where collecon has become organised, or a brin peel has developed.
The current randomised literature comparing immediate surgical intervenon to medical management shows an apparent benet of immedi-
ate surgery (13, 14). However, both studies were small, underpowered and lacked objecve decision-making criteria meaning the result is in
queson. Further adequately powered randomised controlled trials are needed, especially focussing on long term outcomes such as pain and
lung funcon, before we can truly understand whether aggressive medical or surgical management is the opmal rst line treatment in pleu-
ral infecon.
Future Direcons
There are a number of unanswered quesons in the management of pleural infecon. Saline lavage inslled intrapleurally has been shown in
a pilot randomised trial to improve pleural uid drainage and reduce surgical referral (15) – further larger studies are needed with this aord-
able and simple treatment.
Early medical thoracoscopy may help in the management of pleural infecon, with the potenal to aid drainage and tube placement but with
fewer complicaons than surgery. Medical thoracoscopy was used rst line in 127 paents with pleural infecon and a loculated eusion;
94% of these were cured by non-surgical intervenons (16). A feasibility study is being undertaken comparing direct medical thoracoscopy to
convenonal care in the UK (ISRCTN - 98460319).
The management of “chronic” pleural infecon in non-surgical candidates is a controversial area. Where previously local anaesthec rib re-
secon has been considered, indwelling pleural catheters have more recently been used with some posive case series (17).
There are a number of dierent management opons for the complex non-malignant pleural space, but currently this is oen decided on a
case by case basis. Further studies are needed to prognoscate and also use this informaon to decide on an evidenced based management
strategy.
References
1. Hener JE et al. Am J Respir Crit Care Med. 1995;151(6):1700-8.
2. Svigals PZ et al. Thorax. 2017;72(1):94-5.
3. Chen CH et al. Ultrasound Med Biol. 2009;35(9):1468-74.
4. Colice GL et al. Chest. 2000;118(4):1158-71.
5. Rahman NM et al. Chest. 2014;145(4):848-55.
6. Rahman NM et al. Chest. 2010;137(3):536-43.
7. Davies HE et al. Thorax. 2010;65 Suppl 2:ii41-53.
8. Maskell NA et al. NEJM. 2005;352(9):865-74.
9. Rahman NM et al. NEJM. 2011;365(6):518-26.
10. Piccolo F et al. Ann Am Thorac Soc. 2014;11(9):1419-25.
11. Marks DJ et al. PloS one. 2012;7(1):e30074.
12. Chambers A et al. Interact Cardiovasc Thorac Surg. 2010;11(2):171-7.
13. Bilgin M et al. ANZ J Surg. 2006;76(3):120-2.
14. Wait MA et al. Chest. 1997;111(6):1548-51.
15. Hooper CE et al. ERJ. 2015;46(2):456-63.
16. Brutsche MH et al. Chest. 2005;128(5):3303-9.
Figure 1: Ultrasound image of
a septated eusion
Figure 2: Photograph of
septaons taken during a
medical thoracoscopy
Humanitarian News
W A B I P N E W S L E T T E R P A G E 7
Humanitarian aid: what is it?
Harvey. Irma. Maria. Mexico earthquake, oods in India, Nepal and Bangladesh. Disaster can strike anywhere, at any me. A
natural disaster can be dened as some rapid, instantaneous or profound impact of the natural environment upon the socio-
economic system. It implies the presence of an extreme event and the lack of capacity of the human socioeconomic and
physiological system to buer the impact. Barely a year passes without a major natural disaster occurring. Natural disasters
have killed millions of people over the last twenty years, impacng the lives of at least one billion more people, and resulng
in enormous economic damages.
Natural disasters mean many deaths and thousands of people sll missing months later. It also means tens of thousands in
need of aid and rehabilitaon. The situaon is not only about the immediate destrucon created by disaster. The damage to
people, buildings and economical acvies usually will take years to remedy.
The Centre for Research on the Epidemiology of Disasters shows an average of 65% greater frequency in natural disasters
over the last decade. Women and children are oen the most aected by emergencies, parcularly children under the age of
5 and single headed female households. The human responsibility in so-called natural disasters is well acknowledged. The
term natural disaster should not be understood as denying a major human responsibility for the consequences. Death tolls
are around 250,000 people every year and 95% of those deaths occurs in the Third World. Health and relave economic loss-
es of natural disasters disproporonately aect developing countries. Though richer naons do not experience fewer natural
disasters than poorer naons, they do suer less death from disaster. Economic development provides some insurance
against nature's shock eects. However, the impact on the developed countries is not neglectable and even when the num-
ber of deaths is small, the damages and the cost of migaons is increasingly important. According to the UN, the majority
of the world’s populaon now lives in areas aected by natural hazards. It is expected that this proporon will connue to
rise as a growing number of people are residing in seismic, coastal and other unsafe areas, oen in vast and unplanned ur-
ban communies. In addion, the OECD esmates that 1.5 billion people live in countries aected by repeated cycles of vio-
lence and insecurity.
In the same way, when armed conict breaks out or natural disasters strike, enre communies are aected, disrupng their
day-to-day lives and long-term development prospects. Humanitarian emergency", "man-made disaster", and "complex
emergency" are all terms used to refer to a crisis which could be due to armed conict, populaon displacement, or a combi-
naon of both. The complexity refers to the mulfaceted responses iniated by the internaonal community and further
complicated by the lack of protecon normally aorded by internaonal treaes, covenants, and the United Naons Charter
during convenonal wars. More than 200 million people live in countries in which complex emergencies aect not only refu-
gees and internally displaced people, but the enre populaon. The number of dependent refugees under the protecon
and care of the United Naons High Commissioner for Refugees (UNHCR) steadily increased from 5 million in 1980 to 42.5
million people ended 2011 either as refugees (15.2 million), internally displaced (26.4 million) or in the process of seeking
asylum (895,000). Those suering the consequences of the violence are primarily civilians (50-90%) and especially vulnera-
ble populaons of that include children, women, the elderly, and the disabled. In many of those situaons, humanitarian aid
is the only hope of survival for enre communies.
Humanitarian acon is intended to “save lives, alleviate suering and maintain human dignity during and aer man-made
crises and disasters caused by natural hazards, as well as to prevent and strengthen preparedness for when such situaons
occur”. It is designed to work during and in the immediate aermath of emergencies, whereas development aid responds to
ongoing structural issues, parcularly systemic poverty, that may hinder economic, instuonal and social development in
any given society, and assists in building capacity to ensure resilient communies and sustainable livelihoods. Both humani-
tarian and development aid are related, and dierent forms of aid oen have both humanitarian and development compo-
nents.
Humanity, imparality, neutrality, independence, voluntary service, unity and universality are the Fundamental Principles of
the humanitarian ethics expressed by the Internaonal Red Cross and Red Crescent Movement (RCRC), and rearmed in UN
General Assembly resoluons and numerous humanitarian standards and guidelines. Around the world, most of the humani-
tarian actors (government and non-government organisaons) provide relief and protecon programmes in favour of the
Humanitarian News
W A B I P N E W S L E T T E R P A G E 8
populaons aected by disasters or conicts guided by those principles. They guide dicult choices such as the dilemmas
related to dening priories when needs exceed limited resources, or the border denion between security of humanitari-
an workers and access to populaons.
The responsibilies of humanitarian aid work are vast and varied. Teams deployed in emergencies are required to iniate
rapid assessments and implement appropriate intervenons within days of a disaster. They must perform that rapid re-
sponse in condions of extreme physical and mental stress and they must work in unfamiliar demographics, cultures, poli-
cal environments and climates and many mes in very uncomfortable or currently, unsafe situaons.
The skills sucient in the beginnings of the of humanitarian NGOs and the inial intergovernmental agencies, are no longer
enough to succeed in the current humanitarian environment which has turned more technologically sophiscated, much
more morally complex and increasingly violent. The new humanitarians must nd the balance between keeping their spirit of
volunteers guided for the genuine desire of helping people in need, and the necessary professionality of technical skills and
accountability to the donors.
A great concern for people not involved in humanitarian aid is how much they can trust in a fair and transparent allocaon of
the collected funds. There is no universal obligaon for reporng expenditure on internaonal or domesc humanitarian
assistance. However, during the last decade dierent plaorms for internaonal humanitarian assistance like the Organisa-
on for Economic Co-operaon and Development (OECD)’s Development Assistance Commiee (DAC) and UN Oce for the
Coordinaon of Humanitarian Aairs (OCHA)’s Financial Tracking Service (FTS) provide the opportunity for all humanitarian
donors and implemenng agencies to voluntarily report contribuons of internaonally provided humanitarian assistance,
according to an agreed set of criteria for inclusion. Donors (companies, government, organisaons and individuals) may trust
that most of the major organisaons have a transparent report of the use of their funds.
In summary: humanitarian aid is strongly needed and it has become a highly professional work, from an instuonal and
from an individual point of view. And it must be reminded that, as stated by Mr Peter Maurer, President of the Internaonal
Commiee of the Red Cross, at the United Naons Security Council in Geneva 2014, there is not humanitarian aid without
humanitarian workers. No eecve acon is possible without allowing humanitarian personnel to go about their work and
acvely ensuring their safety.
Does this highly professional work mean that the civil society may keep on doing their daily life as if nothing happened? Not
at all. Not only the money but mainly the commitment, the involvement, the recognion and the moral support from the
civil society are the pillars of the humanitarian aid. Every single worker risking his or her life in a ood, a hurricane, an out-
break or an armed conict needs the resources to do his or her work properly but mainly needs to know and to feel that
many people from their homes are supporng their work in some concrete way. Without that feeling of belonging to the
global community of mankind, they are never going to feel strong enough to face hard work, demoralisaon and risky situa-
ons.
They are helping people on our behalf. They need us. We should not let them down.
*The views expressed in this arcle are those of the author and do not
necessarily reect the ocial posions of the Execuve Board or Interna-
onal Board of Regents of the WABIP. Dr. Silvia Quadrelli is Vice-chair of
the WABIP.
WABIP “Introducon to Flexible Bronchoscopy” and “Dicult Airway” Courses
La Habana, Cuba 2017
In early June this year, an “Introducon to Flexible Bronchoscopy” and “Dicult Airway” Course were conducted by the WABIP in Habana, Cuba
under the ocial endorsement from La Habana University School of Medicine. An experienced bronchoscopist, Dr. Manuel Sarduy and his en-
thusiasc colleague, Dr. Crisna Borrazas organized the acvity, which was held at CIMEQ (Centro de Invesgaciones Médico Quirúrgicas).
This was the rst me an experience like this occurred in Cuba, allowing a group of parcipants to get in touch with Bronchoscopy Educaon
Project philosophy. Throughout this day and a half, didacc lectures, interacve sessions, group exercises, and key discussion points were facili-
tated by Henri Colt (Immediate past Chair WABIP and author of The Essenal Bronchoscopy Series of books). A one-day Introducon to Flexible
Bronchoscopy program was held for sixteen Cuban physicians in-pracce or in-training. The following day a Bronchoscopic Intubaon and Di-
cult Airway Course was conducted using newly developed materials (which will soon be available on the Bronchoscopy Internaonal website at
www.bronchoscopy.org.
As increasing interacon between students and faculty is key to acquire cognive, technical, aecve, and experienal knowledge, Master In-
structors from Argenna (Pedro Grynblat, Artemio García and Patricia Vujacich) provided individualized training using models and assessment
tools such as BSTAT. “Step-by-step” personalized instrucon was provided to enhance skills at bronchoscopic inspecon, biopsy, and intuba-
on. Assessment tools were used to idenfy weaknesses, maximizing the one-on-one teaching me provided by instructors. This was the very
rst me such a “learner-centered” approach using simulaon was used for bronchoscopic training in Cuba.
Parcipants also did group-based 4-box praccal approach exercises, familiarized themselves with checklists to enhance paent safety, and
took part in role-playing to pracce informed consent and communicaon skills. During debrieng sessions, the group declared that change in
the educaonal process in Cuba was desperately needed. Everyone received copies of the Bronchoscopy Educaon Project Training manual, as
well as The Essenal Flexible Bronchoscopist (in Spanish).
Our Master Instructors are connuing to mentor our Cuban colleagues, and under the leadership of Manual Sarduy, Cuba is joining the WABIP.
Inial plans to implement BEP training materials into the Cuban naonal training program were undertaken, and already, several Cuban univer-
sity programs have adopted BSTAT, Step-by-Step, Praccal Approach, and the Informed Consent Checklist into their training programs. We wel-
come Cuba to the WABIP community, and hope that further collaboraon and parcipaon will result in expanding bronchoscopic pracce (and
someday, we hope, introducing endobronchial ultrasound) in Cuba, a country with promising future.
Education and Training
P A G E 9
Figure 1: Crisna Borrazas (holding WABIP penant) and Manual Sarduy, with
course parcipants and Master instructors Patricia, Pedro, and Artemio (far
le).
Figure 2: Parcipants during a role-playing exercise for in-
formed consent.
Figure 3: Master Instructor Artmio Garcia (Argenna) providing individualized
instrucon using inanimate model and bronchoscopy step-by-step.
Figure 4: Group photo of course parcipants, Cuba 2017
Board of Regents News
NEW Board of Regents Members - The WABIP is honored and pleased to welcome four new members on the Board of Regents.
The new Regents are doctors: Isnin Anang Marhana (Indonesia), Sayedul Islam (Bangladesh), Wahju Aniwidyaningsih (Indonesa),
and Koichi Kaneko (Japan).
(Le to right: Dr. Marhana, Dr. Islam, Dr. Aniwidyaningsih, Dr. Kaneko)
WABIP Asia-Pacic Regional Regents Meeng –Board of Regent members are invited to aend this meeng on November 2,
2017, held at the 7
th
Asian-Pacic Congress on Bronchology in Bali Indonesia. We would like to thank the organizers of the APCB
(congress president Dr. Aniwidyaningsih, new WABIP Regent above, and colleagues) to help us make this meeng happen.
20
th
WCBIP/WCBE Congress – Acvies and preparaons are underway for the 2018 world congress to be held in Rochester, MN
USA on June 13-16, 2018. By going to the ocial website, you may REGISTER (special discount for WABIP members available), sub-
mit your ABSTRACT, submit your VIDEO FESTIVAL entry and much more. Visit the ocial congress site at hp://
www.WCBIPWCBE.com today!
WABIP Awards Now Open
We are pleased to announce that nominaons for the next WABIP Awards are now
open. The awards will be presented during the opening ceremony of the WCBIP con-
gress held in Rochester, MN, USA in June 2018. Send us your nominaons for the fol-
lowing Awards of outstanding members of the Bronchology and Intervenonal Pulmo-
nology community: 1) The Gustav Killian Centenary Medal, 2) The WABIP-Dumon
Award, 3) The WABIP Lifeme Achievement Award, 4) The Heinrich Becker Young In-
vesgator Awards for Research and Clinical Innovaon. Read more at the following
link: hps://www.wabip.com/awards
Spotlight on a WABIP Member Society - Founded in 2008 by Prof. Takehiko Fujisawa, the Asia-Pacic
Associaon for Bronchology and Intervenonal Pulmonology (APAB) is dedicated to contribute further
progress of the art and science of bronchology and intervenonal pulmonology in the Asia–Pacic re-
gion -- from the Indian subconnent in the west, to Japan and the Pacic islands in the east, China in
the north and Australia and New Zealand in the south. The associaon’s congress, the APCB (details in
the following “Upcoming Events” event), will be held in Bali Indonesia in November 2017. For more
informaon about the associaon, please visit: hp://apab.jp/index.html
WABIP NEWS
P A G E 10
Expanding the Horizons of Airway Stenng
As the skills and technology march forward, we connue to concur the airway obstrucons beyond just the large airways. Unl recently, in a
myriad of situaons including, post-transplant strictures, post-surgical strictures, and other benign and malignant stenosis of lobar airways, our
limitaons were partly dictated by the lack of ability to stent lobar airways. With smaller and more versale scopes, sophiscated tools, im-
proved ablaon technologies, and perhaps most importantly with the advent of smaller, adaptable, removable, covered, and self-expandable
metallic stents we can help paents in a more comprehensive and personalized manner.
Mulple recent publicaons show their retrospecve experience in the use of small stents for smaller airways such as lobar airways. In one
study (1) Atrium iCAST stents (Atrium Medical, Hudson, NH) were used for mostly malignant disease/strictures. Originally, these stents were
designed as endovascular stents. Hence the small size. They are balloon-expandable, lm-cast encapsulated, fully covered metallic stents. These
stents were placed in paents with lobar strictures and obstrucon with exible catheters without any signicant complicaons and with good
outcomes. The most typical stent size deployed was 6x16 mm. Stent migraon and granulaon were noted in approximately 10 percent of pa-
ents each. Mucous plugging of stents was seen in about 5% of paents. These stents were easily removable.
In another study (2) The SMART ninol stent (Laser-cut, single Ninol tube; Cordis, Miami, FL) or PALMAZ (laser-cut stainless steel sloed tube;
Johnson & Johnson, New Brunswick, NJ, and Intervenonal Systems, Warren, NJ) were used. All stents were placed under conscious or deep
sedaon with exible bronchoscopes either under uoroscopic guidance or direct vision. Ablave procedures were performed rst in some cas-
es before the stent placement. Majority of these stents were placed for benign indicaons as opposed to the iCast stents menoned above,
such as post lung transplant stricture at the lobar levels.
The advent of smaller, easily deployable with exible bronchoscopes, and removable stents is a signicant milestone achieved in the eld of
airway stenng for both benign and malignant diseases. In situaons such as in single lung transplant paents with one or two lobar benign
strictures beyond the anastomoc site, maintenance of patency with these stents could make a huge dierence in the quality and quanty of
the paent.
The eld of intervenonal pulmonology con-
nues to gallop forward in all dierent di-
recons. Benign and malignant, diagnosc
and therapeuc, and airways and pleural.
References:
1. Majid A et al. J of Bronchol & Intervent
Pulmonol. 2017; 24(2): 174–7
2. Fruchter O et al. J Bronchol Intervent
Pulmonol 2017; 24(3):181-3
Editorial Staff
Associate editor: Dr. Ali Musani
Associate editor: Dr. Sepmiu Murgu
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Research
Primary Business Address:
Kazuhiro Yasufuku, Editor-in-Chief
WABIP Newsleer
c/o Judy McConnell
101 College St., TMDT 2-405
Toronto, Ontario M5G 1L7
Phone: 416-581-7486
E-mail: newsleer@wabip.com
P A G E 11
Figure: Atrium iCAST stent (7 16mm 120cm):Le lower lobe airway stenosis (A). Stent
with balloon advanced across the stenosis (B). Balloon dilataon of stent (C). Balloon
deaon (D). Stent aer retracon of the balloon (E). (1)
P A G E
12
BRONCHOSCOPY AROUND THE WORLD
Bronchoscopy Educaon Project acvity in Liverpool and Brisbane, Australia
In May 2017, Dr. Henri Colt, with Doctors Jonathan Williamson (Liverpool) and David Fielding (Brisbane), conducted Train the Trainer
programs with aached Introducon to Flexible Bronchoscopy Courses for physicians in Australia. Opinion leaders came together to
discuss competency-oriented pracces, and to enhance their skill using checklists, assessment tools a d case-based 4 box approach exer-
cises in a muldimensional instruconal program. Role playing exercises were used to pracce coaching, and several technical skill sta-
ons comprised of airway models were helpful for learning to teach bronchoscopy step-by-step. During the Introducon to Flexible
Bronchoscopy course (IFB), trainers applied newfound skills to share cognive, technical, experienal, and aecve knowledge with IFB
course parcipants. Trainers came from throughout Australia, while most of the parcipants in the IFB program were junior specialists
from local and regional medical centers. In addion to enhancing teaching skills, trainers discussed educaonal philosophies, and ways
to overcome exisng obstacles to implemenng the widespread use of assessment tools and checklists in Australia. Supported by
TSANZ, Australian leaders are moving forward with establishing competency oriented training guidelines to complement the apprence-
ship model and procedural log maintenance currently in place. The Bronchoscopy Internaonal team and WABIP also wish to congratu-
late Drs. Fielding and Williamson, who have met the criteria to be Master Trainers for the Bronchoscopy Educaon Project, as well Ma
Salamonson, who is now a cered trainer for the program. Two addional Train the Trainer programs are planned in Australia/New
Zealand for 2018 to carry this work forward and consolidate the educaonal paradigm shi down under so that paents may no longer
carry the burden of procedurerelated medical training and to establish a more uniform pracce around the country.
Figure 1 A: Physician trainers and course parcipants conducng a 4box case-
based praccal approach exercise in Liverpool, Australia. Figure 1 B: Dr. Jona-
than Williamson (far right) with Introducon to Flexible Bronchoscopy course
parcipants and trainers.
Figure 2A: Dr. Jonathan Williamson and Dr. David Fielding at the Clinical Skills
Development Center of Royal Brisbane and Women’s Hospital center in Bris-
bane Figure 2B: Train the Trainer faculty parcipants in Brisbane Australia.
Figure 3A: Trainers teaching bronchoscopy step-by-step using simulaon
models. Figure 3B: Introducon to Flexible Bronchoscopy course parci-
pants and bronchoscopy educators from the Train the Trainer program in
Brisbane, Australia 2017
W A B I P N E W S L E T T E R
P A G E 12
P A G E
13
WABIP ACADEMY- WEBCASTS
The WABIP has started a new educaon project recently: THE WABIP ACADEMY. The WABIP Academy will pro-
vide free online webcasts with new and hot topics that will interest pulmonologists and intervenonalists.
Current webcast topic: Tissue acquision for biomarker directed therapy of NSCLC
You can reach these webcasts by using this link: hp://www.wabipacademy.com/webcast/
www.bronchology.com Home of the Journal of Bronchology
www.bronchoscopy.org Internaonal educaonal website for
bronchoscopy training with u-tube and
facebook interfaces, numerous teachiing
videos, and step by step tesng and assess
ment tools
www.aabronchology.org American Associaon for Bronchology and I
ntervenonal Pulmonology (AABIP)
www.eabip.org European Associaon for Bronchology and
Intervenonal Pulmonology
W A B I P N E W S L E T T E R
Links
www.chestnet.org Intervenonal Chest/Diagnosc Procedures (IC/DP)
NetWork
www.thoracic.org American Thoracic Society
www.ctsnet.org The leading online resource of educaonal and
scienc research informaon for cardiothoracic
surgeons.
www.jrs.or.jp The Japanese Respirology Society
sites.google.com/site/asendoscopiarespiratoria/
Asociación Sudamericana de Endoscopía Respiratoria
P A G E 13
P A G E
14
UPCOMING EVENTS
Postgraduate Intervenonal Pulmonology Course (22nd year, Slovenia)
When: September 29-30, 2017
Where: Golnik, Slovenia
Program Director: Ales Rozman, MD
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees), Educaonal seminar (for trainees only), Hands-
on workshop, Conference (didacc lectures)
Introducon to Flexible Bronchoscopy & Faculty Development Program (Serbia)
When: September 29-30, 2017
Where: University Hospital of Pulmonology, Clinical Center of Serbia, Belgrade Serbia
Program Director: Spasoje Popevic, MD, PhD
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees), Educaonal seminar (for trainees only), Hands-
on workshop
Website: hps://www.wabip.com/upcoming-events-category/312-i-fdp-2017
4th Annual Percutaneous Tracheostomy and Advanced Airway Cadaver Course (MD, USA)
When: October 9, 2017
Where: Johns Hopkins University School of Medicine
Program Director: Hans Lee, MDROSMADI ISMAIL, MD
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees), Hands-on workshop, Conference (didacc
lectures)
Website: hps://hopkinscme.cloud-cme.com/aph.aspx?P=5&EID=9772
ERS School on Intervenonal Bronchoscopy (Greece)
When: October 12-14, 2017
Where: Soria Hospital, Athens, Greece
Program Director: Grigoris Stratakos, MD
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees), Hands-on workshop
Website: hps://www.ersnet.org/professional-development/courses/intervenonal-bronchoscopy-october-2017
3rd Annual MABIP Assembly (Malaysia)
When: 3-5 OCTOBER 2017
Where: LE MERIDIEN PUTRAJAYA, MALAYSIA
Program Director: ROSMADI ISMAIL, MD
Program Type: Hands-on workshop, Conference (didacc lectures)
Website: hp://www.mabip.com/
Asian-Pacic Congress on Bronchology and Intervenonal Pulmonology 2017 (Indonesia)
When: November 2-4, 2017
Where: Ayodya Nusa Dua Bali, Indonesia
Program Director: Wahyu Aniwidyaningsih, MD, PhD, MD
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees)
Hands-on workshop, Conference (didacc lectures)
Website: hp://apcb2017.com
W A B I P N E W S L E T T E R
P A G E 14