WABIP Newsletter 2019, Issue 3

Volume 07

Issue 03

September 2019

Inside This Issue

Opinion/Editorial, 2

Technology Corner, 3-6

Tips from the Experts, 7-9

Humanitarian News, 10-12

Best Image Contest, 13

WABIP News, 14-16

Research, 17-18

Educaon, 19-21

Tribute, 22

Links, 23

Upcoming Events, 24

Guest Opinion/Editorial

WABIP Newsletter

S E P T E M B E R 2 0 1 9 V O L U M E 7 , I S S U E 3

EXECUTIVE BOARD

Silvia Quadrelli MD

Buenos Aires,

Argenna, Chair

Hideo Saka MD

Nagoya, Japan,

Vice-Chair

Zsolt Papai MD

Székesfehérvár,

Hungary, Immediate

Past-Chair

David Fielding MD

Brisbane Australia,

Treasurer

Naofumi Shinagawa,

Secretary General

Hokkaido, Japan

Guangfa Wang MD

Beijing, China,

President WCBIP 2020

Philip Astoul, MD

Marseille, France,

President WCBIP 2022

STAFF

Michael Mendoza

General Manager

Judy McConnell

Administrator

Kazuhiro Yasufuku

Newsleer Editor-in-

chief

P A G E 2

The Role of EUS-B-FNA in Lung Cancer Staging in 2019

Bin Hwangbo MD. PhD.

Director, Oce of Educaon & Human

Resources Development

Head, Department of Pulmonology

Naonal Cancer Center, Goyang,

Korea

Endoscopic ultrasound with broncho-

scope guided transbronchial needle

aspiraon (EUS-B-FNA) is a

transesophageal sampling method

using a convex probe ultrasound

bronchoscope. This technique was

rst introduced for the diagnosis and

staging of lung cancer in 2009[1]. As

convenonal endoscopic ultrasound-

guided ne needle aspiraon (EUS-

FNA) has been used for lung cancer

since the 90’s, EUS-B-FNA, which is

based on the same principle, was

relavely easily accepted by prac-

oners.

Currently, the primary procedure for

pre-operave invasive mediasnal

staging of lung cancer is endobron-

chial ultrasound-guided transbron-

chial needle aspiraon (EBUS-TBNA).

EBUS-TBNA can cover a larger area of

the mediasnum (staons 2R, 2L, 3P,

4R, 4L, 7 and some lymph nodes at

staons 1 and 8) than standard cervi-

cal mediasnoscopy. According to a

2013 meta-analysis by the American

College of Chest Physicians (ACCP),

the pooled sensivity of EBUS-TBNA

in mediasnal staging was 89%,

which was similar with that of video-

assisted mediasnoscopy [2].

The role of EUS techniques in lung

cancer staging cannot be discussed

separately from EBUS-TBNA. EUS-

FNA/EUS-B-FNA (EUS-(B)-FNA) have

dierent accessibility to the medias-

num than EBUS-TBNA. EUS-(B)-FNA

can reach mediasnal nodes adjacent

to the esophagus (staon 2L, 3P, 4L,

7, 8, 9 and some lymph nodes at sta-

on 1 and 5). Compared to EBUS-

TBNA, EUS has limitaons in tar-

geng lymph nodes anterior to the

trachea (staons 2R and 4R) com-

monly sampled in lung cancer, but

can access nodes inaccessible by

EBUS-TBNA (staons 8, 9 and some

nodes at staon 5). However, in gen-

eral, EUS-(B)-FNA has lower accessi-

bility to the mediasnum in lung can-

cer staging. One of our prior studies

found 79% of mediasnal nodal sta-

ons with at least one node > 5mm,

were reachable by EBUS-TBNA in

potenally operable lung cancer;

however 51% of nodal staons were

reachable by EUS-B-FNA. 34% of nod-

al staons were accessible only by

EBUS-TBNA (mostly staons 2R and

4R) and 6% were accessible only by

EUS-B-FNA (staons 5, 8 and 9) [3].

Considering the low accessibility to

the mediasnum of EUS, using EUS-

(B)-FNA as the single method for me-

diasnal staging may not be su-

cient. The 2013 ACCP guidelines rec-

ommend EUS as an inial test for

lung cancer staging based on high

diagnosc value [2]. However, the

guidelines also menon the possibil-

ity of selecon bias in EUS studies. In

another of our previous studies, the

sensivity of EUS-B-FNA was 60% for

the mediasnal staging of operable

lung cancer and it increased to 92%

aer adding EBUS-TBNA [4].

Therefore, the role of EUS-(B)-FNA in

lung cancer staging is complemen-

tary to EBUS-TBNA. In our studies,

adding EUS-B-FNA to EBUS-TBNA

increased sensivity by 3-7% (84% to

91% [3], 82% to 85% [4]). We ob-

served the benet in paents with

metastases at locaons accessible

only by EUS-B-FNA. Other studies

have reported greater addional

benets of EUS-(B)-FNA aer EBUS-

TBNA in sensivity (13% in a meta-

analysis [5]). Considering the addi-

onal benet of EUS-(B)-FNA, com-

bined EBUS/EUS staging is not rec-

ommendable in all cases. The deci-

sion to add EUS-B-FNA aer EBUS-

TBNA is not simple. The benet of

EUS-(B)-FNA can depend on the thor-

oughness of EBUS-TBNA. Personally I

perform EUS-B-FNA following EBUS-

TBNA in paents with inaccessible

nodes by EBUS only when the status

of the target node(s) can change the

treatment decision. EUS-B-FNA can

be considered when bronchoscopic

procedures are dicult or not toler-

ated.

EUS-B-FNA can be of benet in some

paents, but we must consider that

adding EUS-B-FNA increases poten-

al risk of complicaons. Serious

complicaons such as esophageal

perforaon, mediasnis, etc. have

been reported with EUS-FNA. [6].

Adding EUS-B-FNA just because of

technical ease is inappropriate. We

have to consider many clinical factors

to judge the ulity of EUS-B-FNA in

each paent. EUS-B-FNA is a dierent

procedure than EBUS-TBNA and re-

quires dedicated training.

References

1. Hwangbo B et al. Respirology.

2009;14:843-849

2. Silvestri GA et al. Chest.

2013;143:e211S-e250S

3. Hwangbo B et al. Chest. 2010;138;795

-802

4. Kang HJ et al. Thorax 2014;69:261–

268

5. Vilmann P et al. Endoscopy.

2015;47:545-559

6. von Bartheld MB et al. Respiraon.

2014;87:343-351

Technology Corner

Robot-Assisted Bronchoscopy

Introducon

The use of robots in medicine has been around for 35 years, with the rst “robot surgeon” used on a human paent being PUMA

2000 in 1985, to perform CT guided neurosurgical biopsies. In 1990’s, sciensts developed a robot with remote manipulators con-

trolled by a surgeon for laparoscopic surgeries [1]. Since then, robocs has been used in the eld of general surgery, gynecologic

surgery, and urological surgery as well as cardiac and thoracic surgery. Roboc thoracic surgery oers mulple advantages over

tradional Video Assisted Thoracoscopic Surgery (VATS) such as increased 3-D visualizaon, increased degrees of freedom of mo-

on, beer ergonomics and increased precision and in 2011 comprised approximately 10% of all lobectomies in the United States

[2]. In the eld of thoracic oncology, the increasing need to eciently and safely sample lung lesions, has led to the development

of guided bronchoscopy systems such as virtual bronchoscopy (VB), radial endobronchial ultrasound (r-EBUS) and electromagnec

navigaon (EMN). The diagnosc yield of guided bronchoscopy using EMN ranges from 67-84%, with a one year follow up of the

NAVIGATE study showing a diagnosc yield of 73% [3], but is lower than CT-guided transthoracic needle aspiraon (92.1%) [4]

The lower diagnosc yield may be explained by the following factors which can be potenally overcome by using the newly availa-

ble robot-assisted bronchoscopic (RAB) systems. Some bronchoscopists may get disoriented beyond the 5

generaon airways and

miss a small peripheral airway leading to the lesion. The use of EMN has been combined with r-EBUS to increase diagnosc yield,

but can be limited by respiratory moon and CT-to-body divergence. The RAB technology allows the operator to navigate through

smaller airways under direct visualizaon while connuing to oer either EMN guidance (Monarch

plaorm by Auris Health Inc.)

or Fiberopc Sensing Navigaon (Ion

Endoluminal System by Intuive Surgical) to nd target airways and also provides stability

during sampling of the target lesion.

Background

There are currently two commercially available RAB plaorms on the US market. The Monarch

plaorm by Auris Health Inc. was

FDA approved in March 2018. In cadavers, the Monarch

plaorm was noted to have farther access to the periphery of the lung

when compared to a convenonal thin (4.2mm OD) bronchoscope (9 vs 6

airway generaons) [5]. Rojas-Solano et al performed the

rst feasibility study with the Monarch

plaorm in 15 paents that showed no pneumothoraces or signicant bleeding [6]. The

Ion

Endoluminal System by Intuive Surgical was approved by the FDA in February 2019. Fielding et al. demonstrated that the

Ion

system safely navigated to very small peripheral airways under direct visualizaon in 29 subjects, and were capable of bi-

opsing small solitary pulmonary nodules while maintaining a stac posion [7]. The dierences between the two available roboc

systems are highlighted in Table 1.

W A B I P N E W S L E T T E R

P A G E 3

Abhinav Agrawal, MD

The University of Chicago

Sepmiu Murgu, MD

The University of Chicago

Table 1. Comparison of the MonarchTM plaorm and IonTM Endoluminal System

W A B I P N E W S L E T T E R P A G E 4

Robot Assisted

Bronchoscopy

Plaorms

The Monarch

plaorm Auris Health Inc Ion

Endoluminal System Intuive Surgical

FDA Approval March, 2018 February, 2019

Bronchoscope

Specicaons

- Inner bronchoscope (4.2 mm) & Outer

sheath (6 mm), both with 4 way steering con-

trol

- The sheath can be locked in place and the

bronchoscope can be advanced to the airways

under EMN guidance and direct visualizaon

- 2.1 mm working channel

- Constant peripheral visualizaon during

workow at the target

- 3.5 mm outer diameter fully arculang catheter

- 2 mm working channel

- The catheter has a shape-sensing ber along its enre length

which provides posional and shape feedback

- Catheter arculates 180 degrees in any direcon

- Integrated vision probe that provides navigaon

- Vision probe has to be removed prior to ssue sampling

Navigaon

Technology

- Relies on Electromagnec Navigaon along

with peripheral vision and real me input

from the micro-camera at the p of the bron-

choscope

- Potenally limited by factors aecng elec-

tromagnec navigaon (interference with

AICD, pacemakers)

- The inial EMN soware is sensive to metal

objects (eg. Fluoroscopy C-arm)

- Relies on ber opc sensing technology “shape sensing” and

peripheral vision for navigaon

- The shape sensing technology is reportedly not sensive to

metal objects

Instruments - Auris needle (currently not available on the

market)

- Other needles such as Olympus Periview Flex

or Arc Point SuperDimension needles

- Can use R-EBUS, needle, biopsy forceps or

brush through the working channel

- The direcon and posioning of the R-EBUS,

needles, brushes or forceps instruments can

be re-oriented under direct guidance

- Flexible needle – Flexision

TM ;

The biopsy needle can be visual-

ized along its length, and its length can be set to avoid the pleu-

ra and reach the middle of the nodule.

- Can use R-EBUS, needle, biopsy forceps or brush

- Relies on the ber opc sensing technology as well as real

me posioning during ssue sampling

- No direct visualizaon available during biopsy as the vision

probe has to be removed

Controller - Two joyscks are used to drive and arculate

the bronchoscope while various buons are

used to control irrigaon, aspiraon and the

device state

- Trackball and scroll wheel which control catheter inseron

and retracon, and precise distal p arculaon. Also includes

a touch screen which is used to change system sengs during

the procedure.

Potenal

Advantages &

Limitaons

- Constant peripheral visualizaon that allows

for direconal targeng of instruments, espe-

cially in cases of eccentric lesions seen on r-

EBUS

- Visualizaon of possible complicaons while

working at the target-such as bleeding and

ability stay wedged in the target segment

- The sheath and bronchoscope can be locked

into posion to prevent accidental displace-

ment during ssue sampling.

- Larger size of bronchoscope (4.2mm) may

limit access of the actual scope to smaller air-

ways; however, instruments can sll be ad-

vanced in the target small airway under direct

visualizaon

- The ber opc sensing technology maintains acve roboc

control of the catheter posion and corrects unwanted deec-

on and secures it into a xed posion during ssue sampling

- No direct visualizaon while performing biopsies may limit the

ability for direconal targeng of instruments under direct vis-

ualizaon (relevant for cases of eccentric lesions seen on r-

EBUS); it is unclear at this me if this limitaon has any conse-

quences on diagnosc yield

-The 3.5 mm bronchoscope may provide further access to

smaller distal airways

Clinical Applicaon

For peripheral lung lesions sampling, roboc plaorms may overcome some limitaons of the currently available guided bronchoscopy sys-

tems. These systems may increase the diagnosc yield due to their stability, adjustable angulaon and peripheral visualizaon, when avail-

able. A retrospecve post-markeng study by Chaddha et al. showed that the Monarch

roboc plaorm was used in 82 cases to success-

fully navigate to 90.2% of the lung nodules (79.3% located in the outer third of the lung) [8]. Chen at al. in a mulcenter prospecve study

demonstrated lesion localizaon in 91.7% cases also using the Monarch

Auris roboc plaorm [9]. Both of these studies (presented in an

abstract form) did not report the diagnosc yield as the follow up period post intervenon was not sucient for dening true negave cas-

es. Fielding et al. recently published the rst study using the Ion

Endoluminal System showing an overall diagnosc yield of 79.3% and a

diagnosc yield for malignancy of 88% [7]. Both of these studies suggest that RAB is a feasible technology with low adverse events that has

the potenal of increasing the success of navigaon and diagnosc yield in paents with peripheral nodules.

In addion to their potenal for improving diagnosc rates, roboc bronchoscopies may guide ablave therapies for treang inoperable

peripheral lung tumors or oligometastac lesions. Animal and case studies in humans have demonstrated feasibility of guided broncho-

scopic ablave therapies such as laser intersal thermal therapy [10], photodynamic therapy [11] radiofrequency ablaon [12], micro-

wave ablaon [13] and bronchoscopic thermal vapor ablaon. Roboc assisted bronchoscopy may further increase the accuracy in guiding

exible catheters to peripheral lesions and provide a stable plaorm to deliver ablave therapies [14, 15]. It is, however, premature to say

that any of these therapeuc modalies are ready for clinical use. A few quesons that will have to be answered by future research include

but are not limited to: What are the exact energy sengs to be safely applied during peripheral MWA? How many bers should be used for

peripheral PDT? Is concentric locaon of the probe essenal for reliable ablaon? What is the opmal locaon and freezing me for periph-

eral cryoablaon?

It is possible that these intervenons will have to be performed under direct imaging guidance (maybe cone-beam CT) for precise applica-

on of the probes and for monitoring intra-procedural eect.

Conclusions

The currently available small studies suggest that RAB is feasible and safe, but further data are needed to determine whether these tech-

nologies improve the diagnosc yield when compared to current bronchoscopic-guided diagnosc modalies. In these authors’ opinion, the

vast majority of paents with suspected lung cancer require concurrent EBUS-TBNA either because of the primary lesion size, locaon,

presence of intrathoracic adenopathy on CT or PET or prior to stereotacc body radiaon therapy.

Auris Health, Inc. is currently conducng a mul-center prospecve trial to study navigaon success and diagnosc yield in paents with

peripheral pulmonary lesions using the Monarch

plaorm (hps://clinicaltrials.gov/ct2/show/NCT03727425). An ongoing mul-center

single arm study is evaluang early outcomes associated with the ION

Endoluminal System looking at navigaon success, biopsy success

as well as diagnosc yield trends in paents with lung nodules (hps://clinicaltrials.gov/ct2/show/NCT03893539).

If the studies using RAB reliably demonstrate the ability to reach peripheral lesions as conrmed by radial EBUS or cone beam CT, RAB

could eventually play a role in guiding ablave therapies for inoperable primary lung tumors or oligometastac lesions.

References

1. Ghezzi TL et al. World J Surg.2016 40: 2550

2. Novelis P et al. J Thorac Dis 2018 Feb; 10(2): 790–798.

3. Folch E et al. J Thorac Oncol. 2019 Mar;14(3):445-458

4. DiBardino D et al. J Thorac Dis. 2015; 7(Suppl 4): S304-S316

5. Chen AC et al. Ann Thorac Surg. 2018 Jul; 106(1):293-297

6. Rojas-Solan JR et al. J Bronchology Interv Pulmonol. 2018 Jul; 25(3):168-175.

7. Fielding et al. Respiraon. 2019;98(2):142-150

8. Chaddha U et al. ARJCCM 2019;199:A1266

9. Chen AC et al. ARJCCM 2019;199:A7304

10. Casal RF et al. J Bronchology Interv Pulmonol. 2018;25(4):322-329.

11. Musani A et al. Lasers Surg Med. 2018;50(5):483-490.

12. Koizumi T et al. Respiraon. 2015;90(1):47-55.

13. Howk K et al. AJRCCM 2016;193:A6019.

14. Chaddha U et al. Ann Am Thorac Soc. 2019 Jun 13. doi: 10.1513/AnnalsATS.201812-892CME.

15. Murgu SD. BMC Pulmonary Medicine. 2019;19(1):89

W A B I P N E W S L E T T E R P A G E 5

W A B I P N E W S L E T T E R P A G E 6

Figure 1: MonarchTM plaorm by Auris Inc.

A. Computed Tomography (CT) image of the right upper lobe nod-

ule.

B. Real me white light bronchoscopy view and target view on the

MonarchTM plaorm.

C. Fluoroscopic image of roboc bronchoscope.

D. Eccentric radial EBUS view of peripheral pulmonary nodule.

E. Di quick stain from needle aspirate (RUL nodule) showing non-

small cell lung cancer.

Figure 2: IonTM Endoluminal System by Intuive Surgical (Courtesy

of David Fielding, MD, Royal Brisbane and Women's Hospital, Bris-

bane, Queensland, Australia)

A. Real me view using the vision probe.

B & C. Global view with shape-sensing ber displaying the posion

of the catheter in the airway and distance from target lesion.

D. Fluoroscopic image demonstrang catheter posion.

Tips from the Experts

P A G E 7 V O L U M E 7 , I S S U E 3

Hyperinaon is one of the most devastang consequences of COPD, especially those with an emphysematous phenotype.

It correlates

with increased breathlessness, decreased exercise performance, worsened quality of life, respiratory failure, hospitalizaon and in those

most hyperinated, it is a major risk for mortality.

Lung volume reducon surgery (LVRS) in carefully selected individuals with hyperinaon

and advanced emphysema has shown to be benecial in improving lung funcon, exercise performance and quality of life, and in a subset

with upper lobe predominate disease and venlatory limited exercise, survival.

Despite the posive benets of LVRS on paent outcomes,

its perceived high morbidity and mortality and costs of care coupled with limited availability has relegated it to less than 200 Medicare ben-

eciaries with emphysema receiving that therapy on an annual basis.

For the last 2 decades, mulple bronchoscopically placed devices

using a variety of techniques have been developed to duplicate the eects of LVRS on deang the lungs of hyperinated paents with ad-

vanced emphysema. Although these techniques dier markedly from one another, they all share the main objecve to decrease thoracic

volume and thus improve lung, chest wall, respiratory muscle and cardiac performance.

3,5-7

Several of these techniques are shown in Figure 1; endobronchial valves have received FDA approval for clinical use in properly selected

paents with hyperinaon due to emphysema and the absence of collateral venlaon. The other therapies are not approved for clinical

care in the U.S. and some (lung coil, Aeriseal, vapor ablaon) are either undergoing clinical trial evaluaon, or have limited clinical access

(lung coil, vapor ablaon) outside the U.S. For those reasons, I will focus on the techniques and pracces of placing and removing endo-

bronchial valves.

1. Paent selecon. Paent selecon is key for which paents to treat, and which lobe to treat with endobronchial valve (EBV) therapy.

8,9

All paents should be maximally medically treated with maximal bronchodilator therapy, supplemental oxygen if criteria are met and use of

pulmonary rehabilitaon or evidence of an acve lifestyle. Dual long acng bronchodilators, supplemental oxygen and rehabilitaon all have

been shown to aenuate air trapping by either decreasing airways resistance or respiratory rate, respecvely, thus prolonging expiraon

and decreasing air trapping.

Paents morbidly obese (BMI > 34) or severely undernourished (BMI < 19) should have nutrional status op-

mized before considering an EBV procedure.

Paents selected for EBV should have advanced emphysema and suer from hyperinaon. Lung funcon tesng should demonstrate that

paents have severe airow obstrucon (FEV

15-45% predicted), hyperinaon (TLC >100%) and air trapping (RV >150% predicted). Addi-

onally, paents should not have severe gas exchange imbalance (PaO

< 45 mmHg, PaCO

> 50-55mm Hg, DLCO < 15% predicted, O

re-

quirements > 6L at rest or with ambulaon).

8,9

Paents should not have uncontrolled or severe comorbid condions that may be contribung to their symptom burden of breathlessness

or provoke signicant periprocedural or post procedural complicaons. Paents with coronary artery disease or severe pulmonary hyper-

tension should be avoided, uncontrolled or poorly controlled supraventricular tachycardias or symptomac CHF or low EF states should be

avoided. Hematologic abnormalies or the need ancoagulaon needs to be addressed to ensure that constant ancoagulaon is not need-

ed during or immediate post procedure when urgent chest tube placement may be needed.

All paents referred for EBV have muldisciplinary assessment for lung volume reducon surgery or lung transplantaon, the full array of

intervenons is individualized for what the paents’ needs are at that me and stage of their disease while always aempng to balance

the risks and the benets.

2. Selecng the lobe for EBV treatment. EBV is only eecve when total lobar occlusion leads to a signicant decrease in targeted lobe vol-

ume reducon, at least 350 ml reducon. Most studies should that this can be achieved in about 70-80% of paents if the following selec-

on criteria are used: a) more than 40-50% destrucon of the EBV target lobe, b) ssure integrity or lack of physiologically determined en-

dobronchial airow between the targeted lobe and ipsilateral non treated lobe, c) greater inspiratory lobar volume, and d) decreased lobar

perfusion. Addional consideraons should include the degree of heterogeneity between the target and ipsilateral non targeted lobe- a

greater dierence may indicate a beer treatment response, picking a lung to treat that lacks evidence of pleural adhesions, lung nodules,

Bronchoscopic Lung Volume Reducon

Techniques and Pialls of Placing and Adjusng Endobronchial Valves

Gerard J. Criner, M.D.

Professor and Founding Chair

Department of Thoracic Medicine and Surgery

Lewis Katz School of Medicine at Temple University

gerard.criner@tuhs.temple.edu

Tips from the Experts

P A G E 8 V O L U M E 7 , I S S U E 3

signicant bronchiectasis or intersal inltrates.

The paern of emphysema needs to be considered- those with predominately pre pleural

emphysema may benet from surgical resecon of peripheral emphysema areas rather than sacricing funconal parenchyma with EBV total

lobar occlusion.

In homogenous cases, a perfusion assessment is recommended to select a lobe that is less than 20% perfused compared to

other lung lobes.

Depending upon an individual paent’s anatomy, mulple targets may be possible, preplanning the procedure to priorize

the lobar targets that achieve the removal of the greatest volume of dead space is recommended.

3. EBV placement. During the procedure, an airway examinaon is performed to exclude any endobronchial lesions, sucon any secreons

and if purulence is found submit for microbiological culture. Assessment of collateral venlaon can be performed using a balloon pped

catheter inserted via the bronchoscope and inated into the target or non-targeted lobe to asses ow across a major ssure.

8,14

Alternavely,

analysis of a pre procedural HRCT analyzed for ssure integrity has been reported to be eecve in selecng the lobe for EBV treatment.

The

segmental orices in the lobe targeted for EBV treatment are then sized for EBV length and width using either a calibrated balloon or using

an unloaded deployment catheter with ap-tabs that measures airway width.(Figures 2 and 3) Airway length is sized with calibrated markings

on the catheter sha.(Figure 2) Sizing is recommended to be sequenal aer EBV placement- some conguraonal changes may be made in

the airway dimensions once an EBV is placed in the adjacent orice. Care should be taken that the EBV is inserted parallel to the airway wall

to prevent rotaonal changes or development of granulaon ssue and that the valve is seated with its struts below the segmental orice

and the valve structure occludes the orice without gaps, overdistenon or protrusion of the valve structure outside of the airway orice. In

some dicult to access segments, a j-wire device may be used to deploy the EBV or using venlator inaon hold, change in head or body

posion may also enable beer access during deployment.(Figure 4) Post procedure insllaon of saline should be done to assess for any

bubbles that may emanate around the valve border with the airway wall indicang lack of lobar occlusion. We perform a pre and post proce-

dural ultrasound of the intended lung and lobe of treatment to demonstrate absence of sliding aer EBV therapy in the target lobe and con-

nued sliding in the ipsilateral non targeted lobe to indicate lobar occlusion of the target lobe and no evidence of pneumothorax post proce-

dure.

4. Post procedural assessment. At our instuon we perform a CXR post procedure on the table, at one and 3 and 8 hours post and then

daily ll discharge. We keep paents hospitalized for 4 nights and see them in clinic at one-week post discharge with a CXR and 6-minute

walk test for oxygen assessment. At day 45 we perform a HRCT to assess for target lobe volume reducon and if less than 50% targeted lobe

reducon we consider repeat bronchoscopy with valve adjustment based on any changes in valve posion idened by HRCT or lack of clini-

cal response.

Valves are easily removed by using forceps remembering to remove the EBV from the orice by rotang it out of the airway

before withdrawing it into the central airway. Sizing is then performed as previously menoned. On repeat examinaon if signicant granula-

on ssue is present, we remove it with directed cryotherapy or APC treatment. We then perform HRCT annually to assess for treatment

eect and lung cancer surveillance based on prior smoking history and age according to published recommendaons.

5. Long term goals of EBV treatment. Treatment of hyperinaon is the goal of eecve EBV, paents with total lobar collapse may have a

survival benet based on some cohort single center studies. Emphysema is a progressive disease, EBV is only one part of an individual pa-

ent’s treatment regime to reduce hyperinaon, other medical and non-pharmacologic treatments such as supplemental oxygen and physi-

cal acvity need to connue. Some paents may move on to transplant or in case where EBV is not successful lung volume reducon surgery.

A successful EBV program should follow and assess the paent’s outcome longitudinally to opmize outcome post EBV and more importantly

improve the paent’s long-term trajectory of this devastang disease.

References

1. Langer D et al. Expert Rev Respir Med. 2014;8(6):731-749.

2. Casanova CP et al. Am J Respir Crit Care Med. 2005;171(6):591-597.

3. Criner GJ, et al. Am J Respir Crit Care Med. 2011;184(8):881-893.

4. Marche N et al. Semin Respir Crit Care Med. 2015;36(4):592-608.

5. Criner G et al.. Am J Respir Crit Care Med. 1998;157(5 Pt 1):1578-1585.

6. Criner GJ. Chest. 2010;138(1):6-8.

7. Criner RN, et al. Chronic Obstr Pulm Dis. 2018;6(1):40-50.

8. Criner GJ et al. Am J Respir Crit Care Med. 2018;198(9):1151-1164.

9. Criner GJ et al. Am J Respir Crit Care Med. 2019.

10. Di Marco et al. Respir Res. 2018;19(1):18.

11. Sciurba FC et al. N Engl J Med. 2010;363(13):1233-1244.

12. Valipour A et al. Respiraon. 2015;90(5):402-411.

13. Valipour A et al. Am J Respir Crit Care Med. 2016;194(9):1073-1082.

14. Gompelmann D et al. Respirology. 2014;19(4):524-530.

Tips from the Experts

P A G E 9 V O L U M E 7 , I S S U E 3

Figure 1

Figure 2

Figure 3

Figure 4

Humanitarian News

W A B I P N E W S L E T T E R P A G E 10

ON BEING NEUTRAL: CURRENT CHALLENGES OF NEUTRALITY IN

HUMANITARIAN AID

Humanitarian principles dene what humanitarian aid is: delivering life-saving assistance to those in need, without any ad-

verse disncon. Adherence to the humanitarian principles facilitates access and acceptance, and helps humanitarian work-

ers to do their work. One the cornerstone principles of humanitarian aid is neutrality which means that humanitarian aid

must not favour any side in an armed conict or other dispute.

Neutrality does not only dene the nature of humanitarian acon, but is also essenal to securing access to people in need

of protecon and assistance in environments living polical turmoil or during war conicts. Neutrality allows to gain the trust

of armed groups for them to permit access to zones under their control. Any humanitarian acon demands to be judged

neither a hosle act, nor a contribuon to the war eorts of the belligerent pares.

However, during the last decade, praccal issues have challenged the concept of neutrality and for many humanitarian ac-

tors today, neutrality is an impraccal and unrealisc standard if not an empty declaraon that may cost many lives. The

underlying basis for neutrality has come under sustained aack mainly by the polical and military instrumentalizaon of the

"with us or against us" discourse aer September 11. Neutral provision of aid becomes impossible if for some governments

the enemy is so barbaric that they do not deserve human treatment. As expressed by Oxfam's policy adviser on Iraq, Jo

Nickolls, Bush's “with-us-or-against-us” doctrine denies the possibility of neutrality by simply vanishing it away. That doc-

trine denes two sides of the conict as ‘terrorism’ versus ‘freedom’ and ‘civilizaon’”. That concept of terrorists as ‘evil’ but

mainly populaons sympathec to their cause considered not worthy of assistance and protecon, dees the very principle

of humanity and poses extreme challenges to the humanitarian movement. In the current scenario, conicts exacerbate rad-

icalizaon, suspicion and hatred, and the mere idea of assisng all those aected without discriminaon, in line with the

principles of humanity and imparality, is insncvely regarded as unacceptable by many actors in or out the humanitarian

environment.

It is true that there has never been absolute neutrality, in an indirect way any humanitarian acon may have benets for one

of the belligerent sides. But currently, in certain conicts, the maintenance of neutrality may pose major problems and,

mainly the percepon of the local populaon about neutrality can no longer be given for granted. A combatant's percepon

of the humanitarian operaon may be very dierent from the past one and it jeopardizes the safety of humanitarian aid

workers.

Not only are military forces increasingly and explicitly co-opng humanitarian eorts, but also several aid agencies appear as

either willingly collaborang with coalion forces or doing lile to disassociate themselves from them arguing that it does

not maer how polical their acons are as long they provide help to those who need it.

This growing confusion in disnguishing between military and humanitarian actors in conict regions can have (and is hav-

ing) fatal consequences for aid workers.

On the other hand, neutrality has been cricized for pung vicms and their tormentors on an equal status. Humanitarian

principles are seen by some scholars and policy-makers as helping fuel conicts by jusfying the provision of aid to all sides

without disncon, regardless of their moral rights or wrongs, without joining the eorts of polical actors to address the

causes of conict and intent to produce changes that may conduct to the end of the conicts and the suering of civilians.

The humanitarian system itself is far from being homogeneous and has varied ethical posions at the me of interpreng

the principle of neutrality. In fact, the humanitarian world is composed of a wide variety of agencies and organizaons, that

include very dierent sectors of the civil society and, although all are driven by the principle of humanity, they may dier

substanally in the philosophy and ethics underlying their work. Hugo Slim (a leading scholar in humanitarian studies with

parcular experse in humanitarian ethics) has pointed that some organizaons are driven by deontological ethics (so, they

Humanitarian News

W A B I P N E W S L E T T E R P A G E 11

consider the moral good of a parcular acon by itself and not necessarily by its consequences) whilst others are driven by

consequenalist ethics, and so consider that the morality of an acon must be measured by its consequences.

This crisis of the neutral humanitarianism has led some scholars like David Chandler to sustain that neutral humanitarianism

is impossible in this new internaonal context. One of the main reasons is for him the increasing manipulaon of humanitari-

an aid with polical purposes. Former Secretary of States of the US Collin Powell said that internaonal NGOs may be “force

mulpliers” of the aims of the United States. During the Kosovo and Afghanistan conicts, American soldiers frequently worn

civilian clothes and perform “humanitarian acvies”, distribung food at the me that they carried guns. Those declara-

ons and behaviors created an increasing confusion between military and humanitarian operaons making the percepon of

neutrality almost impossible for the target populaons.

This is an open debate in the humanitarian eld and there is not a unique answer to the dilemma. It is a topic worthy to be

analyzed because it remarks that humanitarian acon is not a naive, romanc acon that can be carried by willing amateurs

but a deeply polically complex acvity with profound impact and consequences in the life of the populaons that are the

target of their operaons. But also, because in ceasing to be seen as absolutely neutral in the percepon of combatants and

the civilian populaons (whose limits are currently blurred too), the humanitarian workers have become a target of the vio-

lence of the war. A quite praccal approach to this dilemma has been exposed by Kate Mackintosh (a very experienced hu-

manitarian worker and currently Deputy Registrar of the Internaonal Criminal Tribunal for the former Yugoslavia in The

Hague) during the World Humanitarian Summit in 2015. She started by assuming that, of course, every humanitarian worker

has his or her own views on the conict he is working at which means that in his mind he is probably not neutral. She sees

neutrality more as a tool to accomplish the adherence to the humanity principle than as an absolute principle. In that way,

she describes two dierent categories of neutrality, the “ideological” and “praccal” neutrality. As David Forsythe stated

“not taking one side does not mean being indierent, ICRC (Internaonal Commiee of Red Cross, the most adherent organ-

izaon to the principle of neutrality) tries to avoid or minimize the impact of their acons on the various facons that strug-

gle for power”. He recognizes that, of course, it is not an easy task as even the most basic acvies may give some advantage

to one of the sides compared to the other. On the other hand, Pierre Krähenbühl (Director of Operaons of ICRC) remarks

that not taking side does not mean that the ICRC is neutral in the face of violaons of the internaonal humanitarian law.

And in this way, he also considers neutrality as a means to an end and not an end in itself. In the terms of Kate Mackintosh it

means that a humanitarian actor may be exible about “ideological” neutrality and (according the prole of each organiza-

on) and may speak out more or less about their disagreement with the acons of a host country, even knowing that it may

be at the cost of having to stop their acvies in that country. It is imperave to understand that humanitarians cannot be

neutral about atrocies against the civilian populaons and that at that extent neutrality overlaps with complicity. On the

other hand “praccal” neutrality refers to the concept that no acvity performed by a humanitarian acon should alter the

balanced between the two sides of the hoslies. In fact, following the Geneva Convenon, if any humanitarian operaon

results in an advantage (military or economical) to one of the belligerent sides, it is not neutral and so, the party in control of

that area is not obliged to permit access. So, praccal neutrality cannot ever be violated as it means losing the privileged

posion of being a neutral actor and not only being denied access (with the consequent impossibility of delivering aid) but

also in a certain way entering the conict and creang a great menace for every involved humanitarian worker.

The general principle that any acvity that is humanitarian and is imparal is neutral is a good start. But we cannot deny the

extreme dicules humanitarian movement is facing in order to keep their fundamental principles. With all the dierences

in interpretaons, most of the humanitarian actors strongly believe that the principles themselves should not be compro-

mised; even when somemes it means that a humanitarian operaon should be stopped. Humanitarian acon cannot solve

problems that are polical in nature. Most importantly, in order to be able to deliver aid framed in the principles of the hu-

manitarian principles, it is essenal to understand that the use of force should be absolutely independent of the humanitari-

an operaon. The only chance of success of a humanitarian operaon is to be clearly separated from the internaonal com-

munity's eorts at polical containment.

Humanitarian News

W A B I P N E W S L E T T E R P A G E 12

*The views expressed in this arcle are those of the author (Silvia Quadrelli) 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.

We are pleased to present to you below the nal best image from the 2018 Image Contest campaign. Due to the popu-

larity of contest, we are excited to have underway another Best Image Contest campaign for publishing in next year’s

Newsleer issues. We look forward to receiving your submissions.

Descripon: Comparing benign airway tumors - chondroma of the le mainstem bronchus (le image) and

endobronchial hamartoma of the right upper lobe (right image)

Contributor: Dhaval Thakkar MD, Carla Lamb MD, and Sara Shadchehr MD

WABIP Member Society: : American Associaon for Bronchology and Intervenonal Pulmonology

Best Image Contest

P A G E 13

World Lung Cancer Day - August 1

marked World Lung Cancer Day, a day to commemorate

and support those aected by lung cancer and, also, to recognize the ongoing eorts world-

wide to advance prevenon and treatment of this disease.

As part of our own campaign to spread awareness, the WABIP is proud to have released an

Ebook collecon of top arcles published in the past year about IP in lung cancer, with com-

ments from the WABIP Journal Club and a variety of leading experts regarding lung cancer

treatment. Download Ebook

Call for Nominaons and Applicaons – Vice-chair, Awards, Travel Grants, WCBIP

2026 Bids

As we approach the end of the year and head into nal preparaons for Shanghai

WCBIP 2020, the WABIP is now accepng a variety of nominaons and applicaons

(listed below). Leave your mark in the future of the WABIP by subming your nomina-

ons and applicaons via the below links:

Vice-Chair 2020 • WABIP Awards 2020 • Travel Grants 2020 • WCBIP 2026 Bids

Ecuadorian Society of Thisiology and Thorax Diseases Joins the WABIP

We are pleased to announce that Ecuadorian Society of Thisiology and Thorax Diseases

(SETET) have joined the WABIP. We welcome society representave Dr. Rocio De Janon Q

and friends in our internaonal community with now over 9,000 members represenng 60

naonal and regional sociees.

WABIP Academy Podcast – 8 bronchoscopy experts at the 2019 ECBIP congress shared their insights with the WABIP in

this series of brief interviews recorded during the congress. Dr. Manuel Ibarrola goes one-on-one with these experts

and asks a series of quesons regarding the main aspects of some of their most relevant

and important arcles related to IP.

LISTEN online at: hps://www.wabipacademy.com/podcast

WABIP Vising Scholar Report – Dr. Desk Deepak (India) - We are pleased to report that Dr. Deepak has successfully

completed his 6-week training at the University of Maryland Medical Center (USA), with the support of the WABIP Vis-

ing Scholar Grant awarded to the young doctor.

WABIP NEWS

P A G E 14

Dr. Deepak spent his inial 2 weeks rounding with thoracic surgeons to beer

understand mediasnal and thoracic anatomy and surgical aspects of pulmo-

nary diseases. Observaons included: mediasnoscopies and thoracic surgeries

including wedge resecon, lobectomy, tracheal resecon and anastomosis,

lung volume reducon surgery and thoracoscopic management of complicated

pleural space.

An addional 4 weeks was dedicated to Intervenonal Pulmonology, and Dr.

Deepak was fortunate to have parcipated in following:

• Sampling of lung nodules using radial EBUS, electromagnec navigaon, and uoroscopy to assist with cy-

tology brushings, needles, and biopsy forceps. Dr. Deepak observed protocols for sample processing and

management of procedure related bleeding.

• Curvilinear endobronchial ultrasound bronchoscopy for sampling of mediasnal lesions and systemac

evaluaon of mediasnum for staging of lung cancer.

• Cryotherapy for debulking, cryo-extracon, devitalizaon and obtaining ssue samples.

• Mulmodality management of central airway obstrucon using rigid bronchoscopy, cryotherapy and bal-

loon dilataon. Technique for mucosal drug injecon.

• Management of trachea-esophageal stulas with placement of silicone and hybrid stents and their long-

term care.

• Management of malignant pleural eusions with indwelling tunneled pleural catheter.

• Placement of small bore catheter with Seldinger technique for pleural irrigaon.

In total, Dr. Deepak parcipated in 48 pulmonary intervenon procedures

in 29 paents.

The WABIP Vising Scholar Grant enabled Dr. Deepak to beer understand

the requirements for developing specic programs. Dr. Deepak is enthused

to advance the science of Intervenonal Pulmonology in India and share

experiences with fellow pulmonologists in his country.

WABIP NEWS

P A G E 15

With Dr Joseph Friedberg, Chair, Division

of Thoracic Surgery, at University of Mary-

land Medical Center, Balmore, Maryland,

USA

LUNG CANCER diagnosis and staging: an interacve, hands-on seminar

Philip Emmanouil MD, Athens, Greece

In the midst of summer, a 2-day seminar on diagnosis and staging of lung cancer took place

in the experimental center ELPEN in Athens, Greece, under the auspices of WABIP. Scienc

director of the program was Assoc. Prof. Grigoris Stratakos. This seminar included selected

lectures and hands-on staons aimed to indulge the parcipants in the current algorithms

of lung cancer diagnosis and staging and not just train on IP instrumentaon. Lectures in-

cluded the latest data on lung cancer screening, the role of PET CT in staging and re-staging,

necessity of sample adequacy for molecular analysis as well as re-biopsy, recent EBUS/EUS

staging guidelines, pulmonary nodule algorithms

and management, and nally therapeuc bronchos-

copy. Both trainers and trainees had the opportuni-

ty to hear up-to-date informaon from pul-

monologists as well as other specialists. The hands-on workshops focused on

sample acquision with electrocautery and cryoprobe, bleeding control with

APC, convenonal TBNA and rapid on site evaluaon, EBUS simulaon scenari-

os and needle handling. The session photos depict the passion invested by

trainers and trainees likewise.

WABIP Academy Lecture Library —We are pleased to present a brand new on-demand videos series on the latest In-

tervenonal Pulmonology topics presented by lecturers from around the world. This collecon is and will always be

FREE for anyone to watch and use. Without further ado, follow any below link to begin:

• Thirty Years of Airway Stenng: The Lessons Learned

Hervé Dutau, MD

• Bronchial Thermoplasty: A Nonpharmacological Therapy for Severe Asthma

Ali Musani, MD

• Ultrasound for pneumologist? Needs, Training, Expectaons

Tudor Toma, PhD, FRCP.

WABIP NEWS

P A G E 16

Bronchoscopic Lung Volume Reducon

A Dream Come True for Millions of Paents Around the World

Lung Volume Reducon Surgery (LVRS) blazed the trail for the current success of Bronchoscopic Lung Volume Reducon (BLVR) almost 20 years

ago. The Naonal Emphysema Treatment Trial (1) (NETT) outlined the physiologic principals, paent selecon criteria, and pialls of managing

severe emphysema paents with surgical procedures. Bronchoscopic management of emphysema followed NETT criteria to establish the safety

and ecacy of Bronchoscopic Lung Volume Reducon (BLVR) more than a decade ago. Since then newer iteraon of devices and procedures

have led to many successful clinical trials and approval of several BLVR products around the world. Various types of valves and coils have been

approved in Europe and Asia for clinical use. Some other products, such as bronchoscopic applicaon of steam, are undergoing clinical trials.

Like any other technology development, there have been failures along the way. One such product/technique, which made an excellent concep-

tual sense, was rejected by the Food and Drug Administraon (FDA) aer human trials because of poor performance or safety concerns. This

technique/technology was based on the creaon of transbronchial passages into the lung to release trapped air, supported with paclitaxel-

coated stents to ease the mechanics of breathing ("EASE Trial)"(2). Recently valves were approved by the FDA for clinical use in the US. This

approval has created great enthusiasm among paents and pulmonologists alike.

As we know, two-thirds of paents with emphysema have a homogenous type which did not show signicant benet in the NETT trial, but re-

cent studies have shown that BLVR can help paents with homogenous emphysema as well. Conceivably, this benet is at least in part due to

risk reducon of procedural complicaons due to the sheer extent and nature of the surgical procedure. The valves are also removable in case

the paent does not see expected benets or develops complicaons associated with the device such as worsening of respiratory symptoms,

post obstrucve pneumonia, and persistent air leak/pneumothorax.

In a mulcenter, randomized, controlled trial to evaluate the eecveness and safety of Zephyr Endobronchial Valve (EBV) in paents with lile

to no collateral venlaon (LIBERATE Trial) (3) 24 sites from around the world parcipated. One hundred and ninety paents were enrolled to

see the improvement in FEV1 (primary outcome) with valves compared to controls. The secondary outcomes were the six-minute walk test

(6MWT) and St. Georges Respiratory Quesonnaire (SGRQ), among others. The study found that more than 47% of paents improved their FE-

V1 by 15% or more compared to only under 17% in the control arm at 12 months. There was also a stascally signicant improvement in the

6MWT and SGRQ in the group that received the valves compared to the control group. The most common complicaon noted was the pneumo-

thorax, as expected. Approximately 26% of paents in the valve group developed pneumothorax in the rst 45 days. The vast majority of them

took place in the early 3-4 days. It should be emphasized that regardless of the type of valve used, pneumothorax remains a common complica-

on of this procedure. Pneumothorax should be expected, and the team placing the valves should be prepared to manage it in a mely fashion.

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., PMCRT 2-405

Toronto, Ontario M5G 1L7

Phone: 416-581-7486

E-mail: newsleer@wabip.com

P A G E 17

This is also the primary reason why paents are hospitalized for 3-5 days post-valve placement since the majority of pneumothoraces happen

during this period.

In another mulcenter, prospecve, randomized controlled trial to assess the safety and eecveness of the Spiraon® Valve System (SVS)

compared to standard medical care in paents with severe emphysema (REACH Trial), ninety-nine paents were randomized in 2:1 rao into

the treatment group with Spiraon valve vs. control group. FEV1 was the primary endpoint again while SGRQ and 6MWT were secondary

endpoints besides others. Stascally signicant improvement in FEV1 and reducon in the volume of the targeted lobes were seen. Second-

ary endpoints of improvements in 6MWT and SGRQ were noted as well.

There are not many clinical trials looking at BLVR in homogenous emphysema paents. However, a recent randomized controlled, mulcen-

ter trial compared the eect of Zephyr valve vs. standard of care in paents with homogenous emphysema (4). Ninety-three paents were

randomized into two groups, intervenon group that was treated with mulple Zephyr valves for homogenous emphysema with intact s-

sures and the standard of care group. Primary (FEV1) and secondary endpoints (including 6MWT, and SGRQ) showed stascal and stascal

plus clinical improvement, respecvely. Pneumothorax was noted in 25% of paents. This Trial importantly indicates the success of BLVR in

homogenous emphysema paents who comprise almost 65% of all emphysema paents.

Hence both types of valves have shown promising results in subjecve and objecve improvment in breathing in a well-selected group of

paents suering from homogeneous and heterogeneous emphysema. Finally, BLVR does not preclude one from having lung transplanta-

ons in the future.

References:

1. Naonal Emphysema Treatment Trial Research Group. N Engl J Med. 2003; 348:2059-2073

2. Shah PL et al. Lancet. 2011; 378: 997–1005

3. Criner GJ et al. Am J Respir Crit Care Med. 2018; 198(9):1151-1164

4. Valipour A et al; Am J Respir Crit Care Med.2016;194(9):1073-1082

Research

P A G E 18

Device Heterogene-

ous

Interlo-

bar Fis-

sure

Collateral

Flow

Coils

Not ap-

proved in

Yes Not Re-

quired

Unaect-

Sealants

Not ap-

proved in

No Not Re-

quired

Unaect-

Steam

Not ap-

proved in

No Not Re-

quired

Unaect-

Spira-

on

Valves

Approved

in the US

Yes Required Aected

Zephyr

Valves

Approved

in the US

Yes Required Aected

Bronchoscopy Educaon Program - Madrid, Spain, 2019

Figure 1: Congratulaons to Dr. Javier Flandes, Dr. Henri Colt, and everyone who parcipated in the Bronchoscopy Educaon Program held in

Madrid, Spain, 2019.

Success in Madrid, 2019

Madrid is the city of Miguel de Cervantes (1547-1616), author of Don Quixote and perhaps the greatest of Spanish novelists. It is

also home to Lope de Vega, renown poet and playwright of the Spanish Golden Age (early 16th century to late 17th century). The

city boasts two of the world’s most marvelous museums: The Museo Centro de Arte Reina Soa, once an important public hospital

and now the exhibion place of the powerful El Guernica by Pablo Picasso, and the Museo Nacional del Prado with its incredible

collecon of European art dang back to the 12th century, and it’s reputaon of hosng world-class exhibions of contemporary

art (when I was there I saw the retrospecve of David Wojnarowicz (1954-1992), an important American painter, photographer,

and lmmaker who made his name as an AIDS acvist and sadly died from the disease in 1992.

Figure 2A: Hospital Universitario Fondacion Jimenez Diaz. Figure 2B: Central hall of the Muséo Nacional de Arté Reina Soa (previously 18th cen-

tury Hospital de San Carlos)

In May, 2019, under the leadership of Dr. Javier Flandes MD, PhD, an innovave Bronchoscopy Educaon Program was held at the

Hospital Universitario Fundacion Jimenez Diaz just ten minutes from the city center. This hospital, which opened in 1955, has be-

come an important referral center and primary care health care instuon with state-of-the-art facilies. Professor Flandes is a

disnguished leader, Secon Head of the Pulmonary Division, President of the Spanish Associaon for Bronchoscopy and

P A G E 19

Intervenonal Pulmonology, Regent to the WABIP, and Director of the Bronchoscopy and Intervenonal Pulmonary unit. He and

his team of expert nurses, physicians, and administrave sta perform more than 2000 procedures each year, including endobron-

chial valves, radial and convex-probe EBUS, stents and ablave airway procedures, navigaonal bronchoscopy, cryobiopsy and tho-

racoscopy. In addion to medical residents, pulmonary trainees and students, the service hosts many foreign bronchoscopists who

wish to observe procedures and learn about building a successful referral center.

During the course, about thirty pulmonary specialists, trainees, anesthesiologists and intensivists gathered to learn more about

exible bronchoscopy. The course itself was built around the use of airway models and hands-on training using no more than two

students per workstaon*. Teaching objecves for each staon were explicit, using Bronchoscopy Step-byStep and the validated

Bronchoscopy Skills and Tasks Assessment Tool. Addional me was devoted to interacve hands-on sessions about how to organ-

ize a bronchoscopy procedure room, and equipping an emergency cart to help handle procedure-related complicaons. Focused

lectures were highly interacve, leaving plenty of room for quesons and debate. These were designed to be student-centric and

modied as needed to t the desires and educaonal requirements of intensivists and anesthesiologists, while sll providing useful

informaon for trainees and praccing bronchoscopists.

An unexpected addion to the program was the emergency hospitalizaon of a paent with hemoptysis. Bronchoscopy was sched-

uled immediately and performed by Javier’s assistant Adjunct Physician, Dr. Iker Fernandez Navamuel Basozabal. The course par-

cipants gathered in a separate conference room to watch the procedure on a large High-Denion screen while Dr. Flandes com-

mented and answered quesons. At no me was there communicaon with the bronchoscopist or the bronchoscopy team who

were able to focus all of their aenon on the problem at hand and care for their paent. A lesion was discovered in the le upper

lobe, and the paent was sent to intervenonal radiology for urgent embolizaon. This was an excellent example of how to con-

duct teaching without interrupng the ow of a case in “real-me” and without creang any teaching-related risks to the paent.

Considering the success of this program, and the unanimously posive feedback from parcipants, Dr. Flandes, who is also a Mas-

ter Instructor for Bronchoscopy Internaonal (using Bronchoscopy Educaon Project teaching tools such as videos from the Bron-

chOrg YouTube channel, Praccal Approach exercises, Checklists, and Assessment tools in his own unit), plans to implement a simi-

lar teaching program on a yearly basis. This will provide an important educaonal opportunity for Spanish bronchoscopists in and

around Madrid.

Figure 3A: Course parcipants gathering to discuss the organizaon of a bronchoscopy procedure room. Figure 3B. Students learning Step-by-

Step under the guidance of Professor Javier Flandes. Figure 3C. Course parcipants thoroughly enlightened aer watching a case of bronchoscopy

for hemoptysis transmied in real-me to their conference room.

*Many thanks for contribung sponsors including Olympus Corporaon, Trucorp Airway models (Airsim), and Ambu Disposable bronchoscopes.

P A G E 20

When Less Means More in Bronchoscopy Educaon

Training is teaching or developing in oneself or others any skills and knowledge that relate to specic competencies. Training has

specic goals of improving one’s capability, capacity, producvity and performance. Procedural training has long been an im-

portant component in the specialty of pulmonology and bronchoscopy-based procedures have been a dening skill for the pul-

monologist.

The training for bronchoscopy in Romania is sll made under the supervision of an experienced trainer. There are 3 months of

bronchoscopy training in the Pulmonology curriculum. The residents learn bronchology directly on the paents under the supervi-

sion of a bronchologist.

This educaon has been more theorecal than praccal because the trainees did not have the possibility to use the specic equip-

ment, scarcely available in the hospital. The Secon of Bronchoscopy of SRP has organized bronchology workshops for beginners as

well as for the advanced, with a complex program involving a theorecal part and handson. The Bronchoscopy Educaonal Project

is a new project for us and a new model of bronchoscopy educaon with very well-structured training program, useful and validat-

ed assessment tools. In spite of all these yearly workshops, the training in bronchoscopy for pulmonologists was not enough.

The WABIP cost-sharing program was a very good opportunity to improve the training in bronchology for our trainees and helped

us a lot.

Due to this program in Romania, in Cluj-Napoca nowadays there is the possibility to use the Broncho-Sim in our daily pracce for

training and the young doctors are very sased with this kind of educaon and this model will improve their bronchoscopy skills.

"Being able to train on Broncho-Sim, under the guidance of Dr Simon, has been very useful to gain basic experience and skills in the

pracce of bronchoscopy before performing the procedure safely on paents. It improves our learning, but also our awareness and

selfcondence." - one of my trainees said.

Many thanks to Prof. Colt for the idea and WABIP for this program, which gave us the opportunity to improve our training in bron-

chology and to learn bronchoscopy step by step.

P A G E 21

In Mourning: Professor Victor Sokolov

In 1826, The Russian poet Alexander Pushkin wrote “But with the truth he aracted hearts. But with science he quelled mo-

res.” (From, Stanzas). Such words could be used to describe the life and work of my friend Professor Viktor Sokolov, who died last

month at the young age of 73.

Viktor was an accomplished surgeon, anesthesiologist and bronchoscopist. He created the Russian Bronchology Group and was the

rst Russian regent to the WABIP. He fought to defeat convenonal wisdoms and dedicated his life to modernize bronchoscopy

pracce in his country. In addion to numerous leadership posions, Professor Sokolov was also a former Chair for the Endoscopy

Commission of the Russian Ministry of Health, and a long me member of the Academic Council.

As department head at the Moscow Research instute he led eorts to perform novel intervenons

in paents with early cancer of the larynx, trachea and bronchi, esophagus, stomach and duodenum,

bile duct, choledochus, rectum and colon. He helped promote the use of electrosurgery, argon plas-

ma coagulaon, laser thermal destrucon, photodynamic therapy and stent inseron. He published

more than 300 original scienc papers, dozens of monographs, clinical care guidelines, and 10

teaching manuals. He held 26 patents for scienc methodologies and instruments.

For more than ten years, I corresponded frequently with Viktor and his son Dmitry (also an expert

bronchoscopist). It was a great honor to help them build a training program in Moscow. A few years

ago, with my colleagues Nikos Koufos, Rosa Cordovilla, and Enrique Cases, we helped faculty imple-

ment the use of training models, checklists and assessment tools in bronchoscopy educaon. This

has been parcularly helpful for building skills in endobronchial ultrasound.

Viktor was a scienst at heart, and it is as a scienst that he approached his medical pracce. His dream was to cure lung and di-

gesve cancers in their earliest stages, and for this he was always on the alert for technologies that might assist with early diagno-

sis and treatment. Because his rst love was actually pediatric surgery back in the 1970s, Professor Sokolov was parcularly excit-

ed to see the recent growth of pediatric bronchoscopy (we have more than 400 doctors communicang through our WhatsApp

Peds Groups).

Viktor, we shall miss your humor, your intelligence, and most of all the inspiraon of your relentless pursuit of truth.

Farewell, my friend.

P A G E 22

Viktor Viktorovich Sokolov (1946-2019)

P A G E

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 23

UPCOMING EVENTS 
 
8th Annual Internaonal Pulmo-Delta Conference of the Egypan Society of Chest Diseases and Tuberculosis 
October 10-12, 2019  •  Hilton Heliopolis Hotel, Cairo Egypt  
Website: hps://www.wabip.com/events/447-8th-pulmodelta 
 
5th MABIP Annual Scienc Meeng (Malaysia) 
October 18-20 , 2019  •  Kuching, Sarawak, Malaysia  
Website: hp://www.mabip.com/ 
 
Congreso Sudamericano de Broncologia XII (Chile) 
November 8-9, 2019  •  Hotel Enjoy Coquimbo  
Website: hp://www.serchile.cl/ 
 
18th Regional Annual Assembly of ESSB (Egypt) 
December 4-6, 2019  •  Semiramis Interconnental Hotel, Cairo, Egypt  
Website: hp://www.essb-eg.org/ 
 
Faculty Development Program (Algeria) 
December 4-6, 2019  •  Medical University of Mostaganem, Algeria  
Website: hps://www.wabip.com/events/417-fdp-algeria2019 
 
10th Annual Evaluaon and Management of Pleural Disease (MD, USA) 
February 3, 2020 - February 4, 2020  •  Chevy Chase Bank Conference Center, 1800 Orlenas… 
Website: hps://hopkinscme.cloud-cme.com/default.aspx?P=0&EID=18619 
 
Bronchoscopy Course NEUQUEN 2019 (Argenna) 
Annual Course (May 2019-April 2020)  •  Neuquén. Argenna  
Website: hps://www.wabip.com/events/458-neuquen2019-2020 
 
21st WCBIP Congress・April 16-19, 2020, Shanghai China 
April 16-19, 2020  •  Shanghai, China  
Website: hps://www.wcbip.org/ 
 
6th European Congress for Bronchology and Intervenonal Pulmonology (Greece) 
April 22-24, 2021  •  Megaron Athens Internaonal Conference Centre - Athens, Greece  
Website: hps://pcoconvin.eventsair.com/QuickEventWebsitePortal/ecbip21/web 
W A B I P   N E W S L E T T E R  
P A G E   24 

W A B I P N E W S L E T T E R