Volume 08
Issue 01
January 2020
Inside This Issue
Opinion/Editorial, 2,3
Technology Corner, 4,5,6
Tips from the Experts, 7,8,9,10
Humanitarian News, 11,12, 13
Best Image Contest, 14
WABIP News, 15
Research, 16
Tribute, 17
Links, 18
Upcoming Events, 19
Tissue diagnosis prior to resecon for lung cancer vs. surgical biopsy in the era of guided
bronchoscopy
Guest Opinion/Editorial
WABIP Newsletter
J A N U A R Y 2 0 2 0 V O L U M E 8 , I S S U E 1
EXECUTIVE BOARD
Silvia Quadrelli MD
Buenos Aires,
Argenna, Chair
Hideo Saka MD
Nagoya, Japan,
Vice-Chair
Zsolt Papai MD
Székesfehérvár,
Hungary, Immediate
Past-Chair
David Fielding MD
Brisbane Australia,
Treasurer
Naofumi Shinagawa,
MD
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
Newsleer Editor-in-
chief
P A G E 2
Guided bronchoscopy has signicantly improved the diagnosc yield of transbronchial biopsy. Electromagnec
navigaon bronchoscopy, for example, has a pooled diagnosc accuracy of 74%, compared to as low as 14% with
convenonal bronchoscopy.[1] Given its low rate of complicaons, transbronchial biopsy warrants special consid-
eraon in the comorbid paent.[1] The ecacy and safety of guided bronchoscopy favourably alters the risk-
benet calculaon for obtaining a preoperave biopsy.
However, these plaorms have not developed in isolaon. Risk-predicon calculators have been rened through
growing datasets. High-resoluon computed tomography (CT) can thoroughly characterize lung nodules. The mor-
bidity of surgical biopsy has declined with video-assisted thoracoscopic surgery. In such an environment, can we
proceed directly to surgical biopsy based on history and imaging alone, and if such a paradigm is valid where does
guided bronchoscopy t?
Only a small number of studies have compared proceeding to surgery with vs. without a ssue diagnosis. Rates of
benign disease on surgical biopsy ranged from 7.8-15%.[2,3] This dropped to 4.8% in one study focusing on nodu-
lar ground-glass opacies.[4] Such results suggest clinicians can feasibly disnguish between benign and malig-
nant lesions in most circumstances. Proceeding directly to surgery had several further advantages, including
shorter me to treatment and reduced costs.[2,4] One group went further, nding that upfront lobectomy, with-
out preoperave or intraoperave biopsy, had stascally equivalent rates of benign disease resecon (3.2% with
biopsy vs. 7% without), while reducing costs and intraoperave complicaons.[5]
Being retrospecve, many of these studies cannot inform how paents should be selected for upfront surgical
biopsy. Another challenge is the frequent conaon of primary lung cancer and lung metastases as ‘malignancy’.
However, consideraon of lung metastasectomy generally warrants short-term surveillance to conrm oligometa-
stac status and thorough discussion with the paent on prognosis. Conversely, some ‘inappropriate’ benign le-
sions may have had concerning features that could have mandated excisional biopsy.
There are many guidelines on the evaluaon and management of lung nodules. We refer readers to the 2015
Brish Thoracic Society guidelines in parcular, which among other features includes indicaons for discharge
from follow-up, a suggested imaging surveillance protocol, and a step-wise approach to risk-strafy nodules for
biopsy or resecon.[6] In the absence of changes on serial imaging, solid nodules ≥8mm or sub-solid nodules
≥5mm are rst evaluated using the Brock calculator. If the risk is ≥10%, subsolid nodules can be further evaluated
via imaging, biopsy, or resecon. For solid nodules, risk ≥10% should prompt evaluaon by PET, whereby PET avid-
ity is input into the more accurate Herder calculator. Paents with <10% recalculated malignancy risk should un-
Kazuhiro Yasufuku MD, PhD
Professor, Department of
Surgery,
University of Toronto
Alexander Gregor, MD
PhD Student, Division of
Thoracic Surgery
Surgical Resident, Division of
General Surgery,
University of Toronto
dergo CT surveillance, while those with >70% recalculated risk are recommended to proceed to biopsy or denive management.
Given that the pre-test probability of malignancy is so high in such paents, non-diagnosc or non-concordant biopsy results would
not necessarily countermand the need for excisional biopsy or resecon. Although other risk calculators have been described, a
comparave validaon trial found the Brock and Herder calculators had superior diagnosc performance.[7] This remained true
even when applied to populaons outside their inial inclusion/exclusion criteria (the Brock calculator was originally developed
from a cancer screening trial; the Herder cohort excluded extra-thoracic malignancy within 5 years).[7]
Even this algorithmic approach leaves a large group of intermediate-risk solid nodules and elevated-risk sub-solid nodules for
which biopsy results could guide management. Likewise, in the paent with a history of prior malignancy, preoperave biopsy may
allow earlier recognion of metastac disease. These paent groups are the most likely to benet from preoperave ssue diagno-
sis, including guided bronchoscopy. It is only through more informed and directed use of guided bronchoscopy that cost-eecve
integraon into current clinical pracce will be possible.
References:
1. Gex G et al. Respiraon 2014; 2:165-76
2. Heo E et al. Jpn J Clin Oncol 2011; 8:1017-22
3. Sihoe A et al. Eur J Cardio-thoracic Surg 2013; 2:231-7
4. Cho J et al. BMC Cancer 2014; 838:1-8
5. Kaaki S et al. J Surg Oncol 2018;5:977-84
6. Callister M et al. Thorax 2015;70:ii1-ii54
7. Al-Ameri et al. Lung Cancer 2015;1:27-30
W A B I P N E W S L E T T E R
P A G E 3
Technology Corner
Targeted lung denervaon for COPD
Background:
Increased cholinergic tone of parasympathec nerves is a hallmark of the pathophysiology in chronic obstrucve pulmonary dis-
ease (COPD). Release of acetylcholine via pulmonary nerves contributes to bronchial hyperresponsiveness, bronchoconstricon,
increased mucus producon, and inammaon. Pharmacologic blockade of acetylcholine binding to muscarinic receptors via the
inhaled route aims to aenuate these detrimental eects of cholinergic hyperacvity. A large subset of paents with COPD, how-
ever, remain symptomac and connue to experience exacerbaons despite inhaler treatment, due to lack of adherence, incorrect
inhaler technique, and/or failure of homogenous lung deposion.
Targeted lung denervaon:
Targeted lung denervaon (TLD) is a novel bronchoscopic therapy with the intenon of permanently disrupng peribronchial para-
sympathec nerves via radio frequency (RF) ablaon at the level of the central airways. TLD has the potenal to mimic the eects
of long-acng anmuscarinic and at the same me to overcome the limitaons of inhaler therapy. TLD is delivered via a dual-
cooled RF catheter (Holaira, Minneapolis, Minnesota, USA) (Figure 1). As RF current passes from the electrode through the airway
and surrounding ssues, these ssues are heated. Coolant connuously circulated through the electrode and balloon removes heat
from the surface of the airway wall. The net eect is a narrow band of targeted ssue ablaon at depth around the main bronchi
with minimal heang and damage of the inner surface of the airway.
Following extensive preclinical tesng in animal and human cadaver models in which successful denervaon was demonstrated
without jeopardizing airway integrity, a rst-in-man study (IPS-1) was performed in a non-randomised, prospecve, sequenal, two
-dose study, conducted in South Africa and the Netherlands (1). Eligible paents were ≥40 years of age with symptomac COPD
and postbronchodilator FEV1 of 30%–60% predicted. Due to the construcon of this rst-generaon device, procedures were per-
formed via rigid bronchoscopy under general anaesthesia, with the RF delivery catheter placed in the airways next to the exible
bronchoscope for visualizaon. The primary endpoint was freedom from documented and sustained worsening of COPD directly
aributable to TLD to 1 year. Overall, 22 paents were included and randomized to receive either 15W or 20W TLD bilaterally us-
ing a sequenal treatment approach. The primary safety endpoint was achieved in 95% with asymptomac bronchial wall eects
observed in 3 paents at 20 W. The clinical safety proles were similar between the two energy doses, with numerically larger im-
provements in lung funcon, exercise capacity, and quality of life in the 20W group throughout 1 year.
A subsequent study was conducted to test feasibility and safety of TLD treatment in both lungs during a single procedure, as it was
presumed this would be the preferred mode of treatment. This study (IPS-2) was otherwise similar in design, paent selecon and
outcomes (2). A total of 15 paents were recruited at sites in Austria and France. Primary safety end point of freedom from wors-
ening of COPD was 100%. There were no procedural compli-caons reported. Results of lung funcon analysis and exercise capaci-
ty demonstrated similar benecial eects of TLD when compared with long-acng ancho-linergic therapy, with follow-up to 3
years post-TLD.
W A B I P N E W S L E T T E R
P A G E 4
Arschang Valipour, MD
Associate Professor
Head, Department of Respiratory and Crical Care Medicine
Director, Karl-Landsteiner-Instute for Lung Research and Pulmonary Oncology
Following these earlier studies, a second-generaon device was developed with a larger electrode (hence higher energy applicaon) to de-
crease procedure me and a delivery catheter that could be placed through 3.0mm working channel of a bronchoscope. The AIRFLOW-1
trial was the rst study to evaluate the safety of this second-generaon version of the device for safety, treatment dose, and device/
procedure performance (3). Thirty paents were randomized to receive TLD at two preselected doses (29 vs. 32 W) in a 1:1, double-blind,
mul-center study conducted at 10 European sites. Bronchoscopic and uoroscopic visualizaon was used to guide electrode placement
before and during energy delivery. All paents were prescribed 25–30 mg prednisone and 500 mg of azithromycin daily for 1 day before
and 2 days aer the procedure. The primary safety endpoint was the rate of TLD-associated adverse airway eects that required a thera-
peuc intervenon (dened as the administraon of anbiocs, conducon of another diagnosc test to assess the treatment area, or an
endoscopic procedure or surgery to treat ndings) through 3 months posreatment. Secondary endpoints included procedural success,
overall adverse events, and change from baseline to 1-year for pulmonary funcon tests, health-related quality of life, and exercise capacity
assessments.
Acute airway wall eects (primary outcome) were observed in 15% of treated paents, with full resoluon of all events at follow-up visits.
Overall, there was a trend towards more favorable clinical outcomes, i.e. improvements in lung funcon and quality of life data, in the high-
er energy dose group (32W), in the absence of dierences in the adverse events prole between the 2 energy groups in the blinded ran-
domized phase of the study. Aer treatment of the rst 13 subjects in the randomized dose evaluaon phase, however, reports of gastric
adverse events prompted suspension of treatments in AIFLOW-1 and a detailed invesgaon of all pernent events. The invesgaon sug-
gested that these events were related to inadvertent injury to esophageal branches of the vagus nerve during treatment. As a conse-
quence, protocol, procedural, and training enhancements were implemented to ensure opmal placement, visualizaon, and conrmaon
of the electrode posion relave to the esophagus prior to acvaon to migate against further gastric events. The new procedure version
thus included acve measurements of the distance between the electrode and the outer wall of the esophagus, by use of a commercially
available esophageal balloon lled to low pressure with a contrast agent, to assist in avoiding the thermally sensive vagus nerve (Figure 2).
To further migate gastrointesnal side eects, lower power (26 W) was used for treatment posions close to the main carina. In addion,
paents with a history of prior abdominal surgical procedures and/or a high gastrointesnal disorders symptom severity index were further
excluded from TLD treatment. Following these procedural enhancements, there was a subsequent reducon in treatment-related gastric
side eects conrmed in the randomized study populaon and in an addional open-label conrmaon group of 16 paents.
Using the learnings from AIRFLOW-1 the AIRFLOW-2 study was performed, a mulcentre, randomized, sham bronchoscopy–controlled,
double-blind trial of TLD at 32W in paents with symptomac COPD, with the primary endpoint being the rate of respiratory adverse
events between 3 and 6.5 months aer randomizaon (4). During this predened window, paents in the TLD group experienced signi-
cantly fewer respiratory adverse events than those in the sham group (32% vs. 71%, P = 0.008). Furthermore, the risk of COPD exacerbaon
requiring hospitalizaon in the 0- to 12.5-month window was signicantly lower in the TLD group than in the sham group. No hemoptysis,
pneumothorax, or airway changes were noted out to 1 year in this study. Furthermore, and consistent with the above there was a low
number and transient nature of gastrointesnal side eects. There was no stascally signicant dierence in paent reported symptoms,
or other physiologic measures at follow-up.
Future direcons:
Given the promising results of AIRFLOW-2 the ongoing AIRFLOW-3 study has been iniated with the intenon to invesgate the role of TLD
on COPD exacerbaon rates as a primary ecacy outcome. Paents with moderate to severe COPD despite opmised medical manage-
ment will be randomized to receive either TLD or a sham procedure, with follow-up planned up to 5 years. Compared to previous studies
the larger sample size in AIRFLOW-3 will also allow to conduct responder analysis, in order to address whether TLD may be more eecve
in paents with specic baseline characteriscs.
Furthermore, there is a need to be able to conrm successful peribronchial denervaon in the future. In this context the connecon be-
tween TLD and respiratory sinus arrythmia aenuaon (RSA) may serve as a tool for esmang the achieved eect of TLD in treated pa-
ents (5). Disrupon of pulmonary vagal nerve branches may aenuate the pulmonary stretch pathway, thereby altering RSA. Thus, RSA
using roune ECG recordings could be evaluated during a paent’s screening visit and then re-evaluated at a follow-up visit soon aer TLD.
Paents without RSA aenuaon could potenally be candidates for a second TLD procedure.
W A B I P N E W S L E T T E R P A G E 5
In conclusion, targeted lung denervaon may be a promising novel endoscopic treatment in paents with moderate-to-severe symptomac
COPD. Results from the ongoing AIRFLOW-3 study will need to conrm previous ndings before entering clinical implementaon in roune
pracce.
References:
1. Slebos DJ, et al. Thorax 2015; 70(5):411-9
2. Valipour A, et al. Int J Chron Obstruct Pulmon Dis 2018; 13:2163-2172
3. Valipour A, et al. Respiraon 2019; 98:329-339
4. Slebos DJ, et al. Am J Respir Crit Care Med 2019; 200:1477-1486
5. Valipour A, et al. Respiraon 2019; 98:434-439
Figure 1.
Figure 2.
W A B I P N E W S L E T T E R P A G E 6
Tips from the Experts
P A G E 7 V O L U M E 8 , I S S U E 1
Introducon
Bilateral whole lung lavage (WLL) is the most eecve proven treatment modality for symptomac pulmonary alveolar proteinosis (1). Vari-
ous other pathologic states such as radioacve dust inhalaon, alveolar microlithiasis, and lipoid pneumonis have been treated with WLL
with variable success (2) .
Pulmonary Alveolar Proteinosis
Primary pulmonary alveolar proteinosis (PAP) is a rare disorder caused by alveolar accumulaon of a lipoproteic material that has the aspect
of surfactant. Paents present with dyspnea and hypoxemia, aggravated by exercise. Granulocyte macrophage colony smulang factor
(GM-CSF) has a role in PAP pathogenesis, as it is required for normal surfactant homeostasis. PAP is associated with neutralizing autoan-
bodies against GM-CSF. GM-CSF treatment may benet a subset of paents with adult PAP (3). Other treatments have included monoclonal
anbodies, plasmapheresis and lung transplantaon. Among adults, the typical age of apparion of the illness is 30 to 50 years. The progno-
sis of PAP has greatly improved since the introducon of WLL by Ramirez in 1965 (4).
The diagnosis is primarily conrmed by high resoluon CT scanning (HRCT) revealing ground-glass opacicaon, predominantly in a homoge-
neous distribuon. Thickened intralobular structures and interlobular septa in typical polygonal shapes may also be observed, referred to as
"crazy-paving". Crazy-paving is characterisc but not specic to PAP. Pulmonary funcon tests show a restricve venlatory defect with re-
ducon in the total lung capacity, vital capacity and diusing capacity for carbon dioxide. Electron microscopic exam of broncho-alveolar
lavage (BAL) uid can conrm the diagnosis. When allowed to stand, the uid spontaneously separates into pale yellow, almost translucent
supernatant and thick sediment. An-GM-CSF anbodies are useful as a diagnosc tool in PAP. Surgical lung biopsy is rarely necessary to
make the diagnosis.
Physical removal of the lipoproteinaceous material through repeated diluons with saline soluon is believed to be the mechanism by which
WLL creates a benet. WLL oen only provides temporary symptomac benet, and has to be repeated several mes. WLL requires pro-
longed general anesthesia, and is associated with potenal morbidity including: hydro-pneumothorax and prolonged postoperave venla-
on.
Whole Lung Lavage Technique
In the Authors’ centers, the team is composed of an Anesthesiologist in charge of the anesthesia and of the lung lavage, two Physiothera-
pists, and two operang-room Nurses. WLL is performed in the operang room with basic anesthesia monitoring plus: core temperature,
urinary catheter, processed EEG and arterial cannulaon for beat-to-beat measurement of blood pressure and for blood gases analysis. Gen-
eral anesthesia is induced and maintained with an intravenous anesthec agent (propofol), and muscle relaxants. The procedure for unilat-
eral lavage lasts between 3 to 4 hours and 5 to 6 hours for a bilateral lavage. The use of a warming blanket over the legs helps to minimize
heat loss.
Lung separaon is obtained by using a le-sided double lumen tube (DLT). Posioning of the DLT is achieved with a pediatric beropc bron-
choscope (FOB). Air ghtness is conrmed by observing for absence of an underwater leak from the tubing aached to the non-venlated
lung during a prolonged stac inaon to 30 cmH2O of the venlated lung. Arterial blood gases are obtained pre-inducon and during inial
two-lung venlaon. They are repeated intermiently during and aer the procedure.
WHOLE LUNG LAVAGE
Jean Bussieres, MD, FRCPC,
Dept. Anesthesiology,
Instute Universitaire de
Cardiologie et de Pneumologie,
Universite Laval, Quebec City,
Canada
Peter Slinger, MD, FRCPC,
Dept. Anesthesia,
Toronto General Hospital,
University of Toronto, Toronto,
Canada
Tips from the Experts
P A G E 8 V O L U M E 8 , I S S U E 1
The paent is kept in the supine posion on an imaging-compable operang-room table. To improve the eecveness of the lavage, venla-
on with FiO2 1.0 is iniated for a few minutes to denitrogenate both lungs. Prelavage evaluaon conrms which lung is the most impaired,
mainly through imaging evaluaons. The most impaired lung is the rst to be lavaged.
One-lung venlaon (OLV) (dal volume 4-5ml/kg IBW, RR 12-14 and PEEP 5cmH2O) is instuted in the non-lavaged lung, and conrmed by
the inspired and expired dal volumes of the Anesthec machine venlator. A disposable irrigaon and drainage system constructed with
cardiopulmonary bypass tubing is used to insll approximately 1 L of warm normal saline (37oC) by gravity. The irrigang soluon bag is sus-
pended 30 cm above the paent and the insllaon takes 2 to 3 min.
Chest physiotherapy is performed during the ling and drainage phases of each cycle to increase the ecacy of the WLL. The physiotherapy
technique consists of a combinaon of chest percussions, vibraons and pressure applied during the lling and the drainage phase. A annel
cloth is used to protect the paent’s skin from irritaon provoked by repeve manipulaons. Posional modicaons are very useful to
irrigate and to drain all the segments of the lung. The full lateral posion is used at least once during the procedure. Extreme care must be
taken to avoid the risk of leakage from the lavaged lung to the venlated lung.
Approximately two minutes aer the lung is completely lled with saline, it is rapidly drained over 5 to 10 minutes into a container posioned
below the paent’s mid-chest level. This process is repeated 10 mes or more, as necessary, to obtain a clear euent lavage uid. During the
insllaon phase the arterial oxygenaon (as measured by pulse oximetry) will increase as hydrostac pressure forces the pulmonary blood
to redistribute from the lavaged-lung to the venlated-lung (see Fig. 1). During the drainage phase oximetry will decrease as blood ow re-
turns to the lavaged lung.
Inslled and drained saline volumes are carefully recorded for each cycle to monitor for the possibility of a leak or a hydrothorax. A Surgeon
is always immediately available in the operang room suite to insert a chest drain if required. There is a small inial shorall of the drainage
volume. However, if the total drained volume falls to >1L behind the inslled volume, the procedure is halted and a portable chest X-ray is
obtained. When the euent lavage uid is clear from the rst lavaged lung, careful aspiraon is done, with a sucon catheter and also under
direct vision with the use of a FOB.
In order to safely proceed with WLL on the contralateral lung, a recuperaon period of at least 1h is required. Both lungs are venlated in a
protecve fashion with dal volumes (6-7 mL /kg) and PEEP at a level varying from 7 to 12 cmH2O. Furosemide is administered (10 mg IV) to
induce diuresis during this period and paent’s body is enrely covered with a warming blanket to keep its temperature close to normal.
Aer this recovery period during anesthesia, a trial of OLV with the recently lavaged lung is undertaken for 15 min. The goal is to obtain a
PaO2 greater than 70 mmHg with a FiO2 1.0, with trated PEEP prior to beginning WLL of the second lung. The second lung is then lavaged in
an idencal fashion to the rst lung. When sasfactory oxygenaon cannot be achieved to connue bilateral WLL the opons include: 1)
Stopping the procedure and binging the a paent back for single-lung lavage of the untreated side in 2-3 weeks (this was previously our de-
fault plan), 2) A trial of inhaled nitric oxide at 20 ppm to the venlated lung to decrease residual hypoxic pulmonary vasoconstricon, or 3)
The instuon of veno-venous extracorporeal membrane oxygenaon (VV-ECMO) to nish the lavage of the second lung (see Fig. 2). Recent-
ly, this has become our default plan using right internal jugular and femoral cannulaon and this is discussed with the paent and ECMO
team in advance. However, ECMO has been required in <25% of our cases.
Usually, between 10 to 15 L of saline are inslled into each lung (up to 50 L), and more than 90% of this volume is recovered, leaving a recu-
peraon decit of less than 10%. At the end of the procedure, the DLT is exchanged for a single-lumen endotracheal tube (ETT) and both
lungs are suconed with an adult FOB. Furosemide 10mg. IV is repeated aer the second lung lavage.
In some specic cases, when the distribuon of the alveolar inltraon is not homogeneous, selected segmental BAL is then performed aer
the WLL via the adult FOB.
Post Procedure management
The paent is transferred to the ICU or the post-anesthesia recovery room intubated, venlated and sedated with a propofol +/- dexme-
detomidine infusion. Lung protecve venlaon with trated PEEP is connued, usually for 2 to 4 hours, post-procedure unl the gas ex-
change improves to levels that are acceptable for weaning and extubaon at which point the muscle-relaxant is reversed and the sedaon
disconnued. A portable chest X-ray is obtained on admission to the ICU and repeated as required. Alveolar inltrates seen on the chest X-
ray immediately aer WLL normally clear within 24 to 36 hours. Observaon in the ICU or a Stepdown ward for 24 hours is the roune. Opi-
oid and non-steroidal analgesia is oen required for the rst 24-48h for chest wall pain from the physiotherapy. The paent is then mobilized
on the Thoracic Surgical ward for 2-3 days, as face-mask/nasal prong oxygen is weaned, unl t for discharge. Most paents are discharged
without supplemental oxygen.
Complicaons
Complicaons such as pneumothorax and hydrothorax are rare, but may need to be drained, resulng in a postponed procedure or delayed
recovery. Post procedure complicaons include pneumonia, sepsis, and rarely, acute respiratory distress syndrome.
Tips from the Experts
P A G E 9 V O L U M E 8 , I S S U E 1
Post Procedure Evoluon
Paents are followed aer discharge by their Respirologist or Family Physician. Most paents will have an improvement in symptoms, imag-
ing and pulmonary funcon tests (see Fig. 3 A&B). Repeat WLL is performed as required according to the clinical assessment. Most paents
will require one or more repeat lavages. The symptom-free period may vary between 6 months and several years.
Pediatric Whole Lung Lavage
Pediatric paents are not managed at either of the Authors’ hospitals. Small size DLTs (26-32F) can be used in paents > 8yr. age and the pro-
cedure is similar to adult WLL(5). For smaller children the opons are less straighorward and may include repeated segmental BAL during
general anesthesia with a single-lumen ETT or ECMO.
References:
1. Bussieres J et al. Whole Lung Lavage. Chapt. 45 in Principles and Pracce of Anesthesia for Thoracic Surgery, 2nd ed., Slinger P Ed. Springer, Switzer-
land, 2019: 747-760
2. Wilt J et al. J Occup Environ Med. 1996;38(6):619-24
3. Kumar A et al. Lancet Resp Med. 2018; 6(7): 554-565
4. Ramirez-Riviera J, et al. Ann Intern Med. 1965;63(5):819-28
5. Paquet C et al. Anesthesiology. 2009;110(1):190-2
Figure 1:
A) During the lling phase (circle) saline ows
by gravity through one lumen of the double
lumen tube (in this diagram to the le lung)
while the other lung is venlated. During
lling, there is reducon of blood ow to
the lavaged lung, by compression of the
pulmonary blood vessels (arrow).
B) During the drainage phase (circle), there is
reperfusion of the non-venlated lung
(arrow), creang an increased shunt, and
leading to a decrease in arterial oxygen
saturaon.
Figure 2:
The Physiotherapist performs chest compressions during
lavage of the second lung (in this case the right lung) with
oxygenaon supported by V-V ECMO. ECMO cannulaon
is via the right femoral and internal jugular veins. The An-
esthesiologist is steadying the double-lumen tube (DLT) to
prevent displacement during physiotherapy. The paent is
being venlated via the bronchial lumen (blue connector)
of the DLT. The proximal tracheal (clear) lumen of the DLT
is clamped and the distal lumen is draining to the le side
of the operang table.
Tips from the Experts
P A G E 10 V O L U M E 8 , I S S U E 1
Figure 3A : Pre-procedure Chest X-ray of a 48 y.o. male with primary alveolar proteinosis showing bilateral inl-
trates.
Figure 3B: Chest X-ray of the same paent 3 months post-procedure showing marked improvement.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 11
LET’S TALK ABOUT MONEY
One of the main concerns of the general public about the humanitarian aid is how the relief agencies collect and spend the
money. The general distrust of the populaon about almost all the government and non-government organizaons that han-
dle money with any purpose is unfortunately extended to the humanitarian world. Not few comments about seeing a big
business with hidden prots in humanitarian aid have been spread with or without second intenons. A beer understand-
ing of the organizaon and funding resources of the humanitarian assistance may help to be able to have an independent
unbiased opinion about those relevant maers.
One of the main source of funding for foreign aid are the states. The reasons behind states working as donors are diverse.
Humanitarian aid is the most high-prole and emove part of a donor government’s aid budget, and can play an important
ambassadorial and public relaons role. General public humanitarian concerns are the main reason for supporng overseas
aid. Also countries oen provide foreign aid to enhance their own security. Thus, economic assistance may be used to pre-
vent friendly governments from falling under the inuence of unfriendly ones or as a retribuon for the right to establish or
use military bases on foreign soil. At the same me foreign aid helps in spreading donor’s language, culture, or religion.
States addionally provide aid to relieve suering caused by natural disasters or armed conicts to promote economic devel-
opment when it is consider helpful to protect global interests like control of diseases or destrucon of the environment.
Beyond any generous purpose, the granng and receipt of foreign assistance serves the commercial interests of donor coun-
tries as in a certain way it works as an incenve to adjust the polics of the recipient in front of the risk of terminaon of aid.
Also, the states are obliged by internaonal agreements. In the aermath of the Second World War with a devastated
Europe, several world leaders saw the need of rebuilding those ruined countries as a requisite for keeping peace,
allowing the rebirth of internaonal commerce and protect against the abuses of war. It resulted in the creaon of
the United Naons. As one of the of the purposes of the UN, as stated in its Charter, is "to achieve internaonal co
-operaon in solving internaonal problem of an economic, social, cultural, or humanitarian character", all mem-
ber countries are engaged in sustaining those nancial aid eorts.
Most funding into internaonal humanitarian assistance comes from a small number of Western governments. In absolute
dollar value the USA and the European Community’s Humanitarian Aid Oce (ECHO) lead the table of donors most years,
Dening why and how donor governments act in internaonal crises through their funding mechanisms explain why some
crises are well funded and others not, and also why funds are given through NGOs more than to local governments.
The USA remains the single largest donor, contribung nearly 33 percent of global government funding in 2005, followed by
the European Union with 15 percent, Japan with 7 percent and France and the UK each with 6 percent. Global humanitarian
assistance more than doubled during the 1990s, from $2.1 billion in 1990 to $5.9bn in 2000, mainly because of the increase
of complex conict-related emergencies. In 2001, donors contributed $2.1bn in response to 20 complex emergencies, and
$311 million for 49 natural disasters. Although the number of people and countries aected by natural disasters is greater
than for complex emergencies, conict-related crises usually cause greater loss of life and entail more expensive response
operaons.
People may be sased (or amazed or concerned) that humanitarian assistance has grown, but it is good to know that donor
countries are contribung a smaller and smaller share of their wealth to overseas development aid (ODA). In the 1970s and
1980s, they contributed around half of the UN’s target of 0.7% of gross naonal product (GNP); by the 1990s, overseas aid
had declined as low of 0.22%. In the US, less than 0.1% of the naonal budget is spent on ODA in the last decade. Even tradi-
onally generous countries like Denmark are cung their spending in this area. As a percentage of total ODA, humanitarian
aid reached 10.5% in 2000, compared with an average of 5.8% between 1989 and 1993, mainly because the whole of ODA
amount decreased.
About recipient countries, in 2004, six countries received an esmated half of all humanitarian assistance: Iraq (16 percent),
Sudan (11 percent), Palesne (8 percent), Ethiopia (6 percent), Afghanistan (6 percent), and the DRC (4 per- cent). The re-
maining 49 percent was shared among 148 countries. Globally food aid, its purchase and distribuon, represents the biggest
Humanitarian News
W A B I P N E W S L E T T E R P A G E 12
sector for humanitarian expenditure. In 2005, it accounted for 40 percent of global humanitarian expenditure.
It is important when reading these gures to be able to dene what is considered “foreign aid”, a permanent concern of ex-
penditure for taxpayers, mainly in the United States. Globally in 2017, the United States spent over $46 billion in foreign aid.
Over 38.5% of that budget went to just ten countries: Afghanistan ($4.89 billion), Iraq ($3.36 billion), Israel ($3.18 billion)
and then Jordan, Ethiopia. South Sudan, Kenya, Pakistan, Nigeria and Uganda. But is also worth knowing how that “foreign
aid” is distributed: of the $17.7 billion foreign aid dollars given to the top 10 countries, about 59% of it was designated as
military funds compared to the 28% of military funding of its foreign aid budget in 2017. The United States administers
humanitarian support through two oces. First, within USAID, humanitarian aid ows through the Bureau for Democracy,
Conict, and Humanitarian Assistance, and through it to the Oce of Foreign Disaster Assistance (OFDA), the Food for Peace
Program (FFP), and the Oce for Transional Iniaves (OTI). OFDA deals with most funding responses to emergencies. FFP
administers US food aid.
The other main donor actor is Europe In an average year, the European Union provides around 30 percent of global humani-
tarian aid mainly through its humanitarian oce (ECHO). ECHO has been established in 1992 as part of the consolidaon of
the polical and administrave funcons of the European Union. Nearly 60 percent of ECHO’s funding is given through inter-
naonal NGOs (primarily those based in the European Union). The rest goes to UN agencies, the Red Cross Movement, and
some funds may go directly to the aected states.
Numerous agencies of the United Naons have a role in humanitarian aairs. These include the Security Council and oces
within the Secretariat, as well as some of the specialized agencies. A broad division of labor exists within the United Naons
system. The Oce for the Coordinaon of Humanitarian Assistance (OCHA) is in charge of the policy and planning frame-
work; World Food Program (WFP) is responsible for emergency food delivery; the United Naons High Commission for Refu-
gees (UNHCR) is in charge of emergency shelter; United Naons Children Fund (UNICEF) is responsible for nutrion and wa-
ter and sanitaon; and the Food and Agricultural Organizaon (FAO) is responsible for emergency agriculture.
OCHA is the UN body delegated to coordinate the response and acvies of relief agencies to humanitarian emergencies
worldwide to ensure that no populaons or sectors are neglected and mainly to prevent overlap in work between organiza-
ons. OCHA’s coordinaon acvies extend beyond the UN system and include NGOs, private organizaons—such as the
ICRC, and some others.
Parcularly important during the armed conicts, the Oce of the United Naons High Commissioner for Refugees (UNHCR)
was created by the UN General Assembly in 1950 to lead and coordinate assistance to and protecon of refugees interna-
onally. UNHCR is funded almost enrely by voluntary contribuons, largely from states or other internaonal organizaons.
Since the 1990s, its budget has held steady at around $1 billion annually, with oces located in nearly 100 countries.
Over the past 30 years, an increasing percentage of Ocial Development Assistance (ODA) has been spent on humanitarian
assistance;. In an average year in the mid-2000s around of $10–12 billion was made available for global humanitarian assis-
tance. As most of that money comes from the states, it nally comes from the tax payers. According to the Global Humani-
tarian Assistance the ocial total humanitarian assistance contribuon per cizen of countries belonging to the Organizaon
for Economic Cooperaon and Development in 2006 was an average $10. Contribuons per country varied widely with the
United States contribung $10 per cizen, Japan $2, the UK $18, Switzerland $26 and Norway $81. To compare these ex-
penditures with some others, Joseph Sglitz (Nobel Economics Prize laureate) calculates that the United States is spending
$16bn a month on the wars in Iraq and Afghanistan, a monthly sum almost double than the annual humanitarian spend and
equivalent to the whole annual budget of the UN.
A very relevant internaonal humanitarian actor is the Internaonal Commiee of Red Cross. The ICRC is funded both by
contribuons from the States Party to the Geneva Convenons and by donor governments and the general public. Thus,
some of its budget each year, though voluntary, comes from states as part of their obligaons under the Geneva Conven-
ons. On average, ICRC’s total budget is around $900 million: an important amount of money but signicantly less than the
major internaonal NGO grouping, World Vision Internaonal.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 13
Finally, a large scale humanitarian key actor is a vast and varied group of humanitarian NGOs. Many of them are transnaon-
al with budgets even over the one of major corporaons or small states. They represent a very wide range of interests, phi-
losophies and working methods and they implement the vast majority of the operang work of the internaonal humanitari-
an system.
When giving funds for humanitarian assistance, governments have to decide how to channel those funds. NGOs have be-
come the channel of choice for donor governments and the funding public from the US and Europe handling around $4 bil-
lion a year. They have very dierent proporons of private donors to government funding, according to their policies, philos-
ophies and ability to reach the general public. Agencies like Médecins Sans Fronères (MSF) privilege the voluntary funds in
order to keep the independence they achieve by being almost enrely independent of government funding. On the other
hand CARE Internaonal network receives almost half of its funding from governments. In 2006, Oxfam UK reported of their
total income of £290, £70 million was derived from governments.
The internaonal NGOs network is increasingly concentrated, mainly because of the increasing demands of professionality,
accountability and experse to do their job in the context of more complex scenarios and with many new security challeng-
es. The 30 largest humanitarian agencies (which represent 4% of the total number of emergency aid agencies) receive on
average 85 percent of the total available funding and 1% of those agencies control 70 percent of the resources. Those large
internaonal NGOs are far from being a bunch of good-hearted amateurs. They perform an extremely complex work and
have high standards of accountability and professional performance.
Humanitarian assistance has been the target of varied cricism in the last years. It should be noted that humanitarian aid
(mainly with the NGOs that include advocacy and denounces of human right violaons becoming main actors in the eld) is a
deeply polical acvity and the judgement of their performance if far from being polically unbiased. Financial transparency
should not be a main concern about humanitarian aid.
No maer their limitaons, challenges and debates, humanitarian eorts do sll follow the human imperave of solidarity,
compassion and empathy with human suering. Addionally, it not only helps the recipient aected populaons, but also
help in a great deal the wealthy countries far from the aected areas. If the living condions of a populaon are unbearable,
too painful or too dangerous we leave them only one opon: to eed their vicious hell looking for some opportunity some-
where else, whichever the risks it means.
*The views expressed in this arcle are those of the author (Silvia Quadrelli) and do not necessarily reect the ocial
posions of the Execuve Board or Internaonal Board of Regents of the WABIP.
Best Image Contest 2020 Recipient (1 of 3)
Descripon: Complex tracheal stenosis secondary to blastomicosis.
Submiers: Liu Estradioto, MD and Rodrigo Beega de Araújo, MD.
*****
This image is 1 of 3 selected among 100+ submissions to our Best Image Contest held in 2019. Please stay tuned to the next Image
Contest, opening later this year!
Find the above image and more at the WABIP Academy Image Library!
Best Image Contest
P A G E 14
WCBIP Shanghai 2020 Postponed & Rescheduled
We regret to inform you that due to the impact of the virus epidemic in Wu-
han China and its surrounding areas, the WCBIP organizers must postpone
this congress from April to September. The new dates for the Shanghai
WCBIP is September 24-27, 2020. Please visit www.WCBIP.org for all the
latest congress updates.
Board of Regents Meeng 2020
As the new business year has started, WABIP Regents (member society representaves) shall meet and vote
on WABIP acvity and nancial reports for our annual lings as a non-prot organizaon in Japan. The
meeng will be held via teleconferencing on FEBRUARY 29, 2020. Regents may also submit their votes to ap-
prove the said reports via proxy. The WABIP Execuve Board shall also eld quesons and discussions per-
taining to the Shanghai WCBIP and other WABIP business items.
WABIP Vising Scholar Travel Grant Recipients 2020
Aer a thorough review of over a dozen qualied applicants, we have nally nar-
rowed down the candidates to one nal recipient - Dr. Sangit Kasaju (Nepal). Dr.
Deepak shall be travelling to the United Kingdom for his observership program under
supervisor Dr. Anindo K Banerjee.
We would like to thank those who have submied their applicaons. We look for-
ward to receiving your documents again for our 2021 grants.
New Member Sociees
We are excited to announce ve new member sociees in the WABIP: Lebanese Pulmonary Society, Nepal
College of Chest Physicians, Asociación Colombiana de Broncoscopia y Neumología Intervencionista
(Colombia), Mexico City Bronchology Associaon and the Scotland Intervenonal Pulmonology group.
The sociees are represented by Dr. Ralph Nehme (Lebanon), Dr. Sangit Kasaju (Nepal), Dr. Echeverri Franco
(Colombia), Dr. Olivia Sanchez Cabral (Mexico) and Dr. Sanago Giavedoni (Scotland). We are proud to wel-
come these new friends and colleagues in our ever-growing associaon with now over 9,200 members repre-
senng over 60 naonal and regional sociees around the world.
WABIP NEWS
P A G E 15
Liquid Biopsy – What’s going to happen to Bronchoscopy?
Finding a few millimeters pulmonary nodules with current technological advancements in radiology such as thin slice and high-resoluon CTs is
not the problem. However, even despite the most studied and evidence-based strategies to strafy these nodules into benign versus malignant
has been a frustrang task. In the Naonal Lung Cancer Screening Trial (NSLT), where even in the high-risk populaon of paents (extensive
smoking history in older age, etc.), the vast majority of nodules biopsied/resected turned out to be benign. Risk calculators for these nodules to
predict the likelihood of malignancy are quite variable and unreliable in their approaches and outcomes as well.
A biomarker that can be easily isolated from many body uids (blood, saliva, urine, ascites, pleural eusion, etc.), as well as a ssue biopsy, is
oen referred to as a Liquid Biopsy. The liquid biopsy includes circulang tumor cells (CTCs), circulang tumor DNA (ctDNA), and exosomes CTCs
generated by the detachment of tumor cells from the tumor. Both CTC, ctDNA as well as exosomes, can be isolated from plasma and be used as
a liquid biopsy of the disease. The liquid biopsies may be used for early diagnosis, prognosis and risk stracaon as well as to gauge the re-
sponse to therapies, and to idenfy therapeuc targets and resistance mechanisms.
In a recently published trial (1), the authors aempted to answer a fundamental queson: Can a biomarker help risk-strafy intermediate-risk
pulmonary nodules? In a well-designed clinical study (Pulmonary Nodule Plasma Proteomic Classier (PANOPTIC) trial) the authors examine the
impact of an integrated classier using expression of two plasma proteins associated with lung cancer and cancer immune response, LG3BP,
and C163A, in addion to clinical and radiographic risk factors usually used (age, smoking status, nodule diameter, shape, and locaon), to
dierenate between benign and malignant pulmonary nodules. The invesgators only focused on nodules classied as low to intermediate risk
(0-50%) for malignancy based on clinical criteria.
The primary endpoint of the study shows that the integrated classier is associated with high sensivity (97%) and high negave predicve val-
ue (98%) for disnguishing between malignant and benign pulmonary nodules. These values are beer than a PET scan and some of the most
popular lung cancer risk predicon models.
Novel approaches of genomic and proteomic proling of paents with pulmonary nodules have developed rapidly over the last decade or so.
More markers are under study. These markers can be obtained without any invasive procedures and add substanal condence in the straca-
on of low to the intermediate-risk paent populaon, which seems to be at the highest risk of unnecessary procedures. Further use of these
markers in prognoscaon, relapse/metastasis diagnosis, and drug response could be of enormous potenal.
Reference:
1. Silvestri, et al. Chest. 2018 Sep;154(3):491-500
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Research
Primary Business Address:
Kazuhiro Yasufuku, Editor-in-Chief
WABIP Newsleer
c/o Judy McConnell
200 Elizabeth St, 9N-957
Toronto, ON M5G 2C4 Canada
E-mail: newsleer@wabip.com
P A G E 16
Associate editor:
Dr. Ali Musani
Associate editor:
Dr. Sepmiu Murgu
In Memoriam: Professor Patrick Barron
In Memory of Prof. Patrick Barron
By Hiroaki Osada, M.D.
Past-Chair of the WABIP
It is with great regret to inform you that Professor Emeritus Patrick Barron has unexpectedly passed away on
August 17th, 2019 at the age of 71. Many of our colleagues who knew Patrick deeply share the same regret
and sorrow.
As a nave of Scotland, Patrick le his country for the United States to pursue and complete his university
educaon. He then came to Japan at the end of 1960s where he lived in Tokyo, Japan since.
More than a quarter century ago, I met Patrick for the rst me in St. Marianna University School of Medi-
cine, Kawasaki Japan, where we both were working. I quickly found Patrick to be a man of righteousness and
humility. Aer his tenure at St. Marianna, Patrick was invited to Tokyo Medical College by virtue of his quali-
caons and enthusiasm for Medical English educaon and complete uency in the Japanese language.
Over the years, thousands of Japanese Medical students and doctors have beneted and appreciated Pat-
rick’s teachings in professional medical English, including myself. Addionally, Patrick was central to the rise
and development of the WAB (precursor organizaon to WABIP) and many other scienc organizaons
around the world. Patrick also contributed to COPE (Commiee on Publicaon Ethics, registered in the Unit-
ed Kingdom). Last but not least, Patrick served as a leading editorial member of Journal of Bronchology. In
spite of Patrick’s many great contribuons, he refused to receive any reward in return.
I cannot forget how much Patrick helped us, when our small work-
ing group tasked to revitalize the WAB was struggling to nd a way
to accomplish its goals in and around 2009-2011. With the inclu-
sion of Patrick’s eorts into our working group, the WABIP was re-
sultantly born to where we are now with over 9,200 respiratory
physician members, represenng over 60 naonal and regional so-
ciees around the world.
Patrick, we shall never forget you! The WABIP shall connue to
grow and prosper as a truly worldwide associaon that strives to
connect with every bronchologist around the world, as you have
been dreaming for many years. We pray for your eternal rest and
peace.
P A G E 17
P A G E
18
WABIP ACADEMY- WEBCASTS
The WABIP has started a new educaon project recently: THE WABIP ACADEMY. The WABIP Academy will pro-
vide free online webcasts with new and hot topics that will interest pulmonologists and intervenonalists.
Current webcast topic: Tissue acquision for biomarker directed therapy of NSCLC
You can reach these webcasts by using this link: hp://www.wabipacademy.com/webcast/
www.bronchology.com Home of the Journal of Bronchology
www.bronchoscopy.org Internaonal educaonal website for
bronchoscopy training with u-tube and
facebook interfaces, numerous teachiing
videos, and step by step tesng and assess
ment tools
www.aabronchology.org American Associaon for Bronchology and I
ntervenonal Pulmonology (AABIP)
www.eabip.org European Associaon for Bronchology and
Intervenonal Pulmonology
W A B I P N E W S L E T T E R
Links
www.chestnet.org Intervenonal Chest/Diagnosc Procedures (IC/DP)
NetWork
www.thoracic.org American Thoracic Society
www.ctsnet.org The leading online resource of educaonal and
scienc research informaon 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 18
UPCOMING EVENTS
BRONCOCON 2020
When: February 1-2, 2020
Where: HICC, Hyderabad, INDIA
Program Director: Dr. Hari Kishan Gonuguntla
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees)
Hands-on workshop
10th Annual Evaluaon and Management of Pleural Disease
When: February 3, 2020 - February 4, 2020
Where: Chevy Chase Bank Conference Center, 1800 Orlenas St., Balmore, MD 21287, USA
Program Director: Dr. David Feller-Kopman
Program Type: Hands-on workshop, Conference (didacc lectures)
Website: hps://hopkinscme.cloud-cme.com/default.aspx?P=0&EID=18619
WABIP Rigid Bronchoscopy Japonica
When: February 15, 2020 (Saturday)
Where: Shinjuku, Tokyo, Japan
Program Director: Dr. Hideo Saka
Program Type: Hands-on workshop, Conference (didacc lectures)
Website: hps://www.wabip.com/events/483-rigidbroncoscopy-japan2020
WABIP Navigaon Bronchoscopy with Cone-Beam CT Course
When: March 11-13, 2020
Where: Radboud University Medical Center, Nijmegen, The Netherlands
Program Director: Erik van der Heijden, MD, PhD
Program Type: Workshop, Educaonal seminar (postgraduate may include physicians in pracce and trainees)
Website: hps://www.wabip.com/navigaon
21st WCBIP Congress
When: September 24-27, 2020
Where: Shanghai, China
Program Director: Prof. Guangfa Wang
Program Type: Hands-on workshop, Conference (didacc lectures), Educaonal seminar (postgraduate may include physicians in
pracce and trainees), Educaonal seminar (for trainees only)
Conference (didacc lectures)
Website: hps://www.WCBIP.org
W A B I P N E W S L E T T E R
P A G E 19
W A B I P N E W S L E T T E R
W A B I P N E W S L E T T E R
P A G E 2
W A B I P N E W S L E T T E R
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