Volume 12
Issue 01
JANUARY 2024
Inside This Issue
Editorial, 2-3
Technology Corner, 4-9
Tips from the Experts, 10-12
Humanitarian News, 13-18
Best Image Contest, 19
WABIP News, 20
Research, 21-22
Links, 23
Up and-coming Bronchoscopic Ablation Therapies for
Treatment of Lung Cancer
WABIP Newsletter
J A N U A R Y 2 0 2 4 V O L U M E 1 2 , I S S U E 1
EXECUTIVE BOARD
Stefano Gasparini, MD
Italy, Chair
Pyng Lee, MD, PhD
Singapore, Vice-Chair
Hideo Saka, MD
Japan , Immediate Past-
Chair
Silvia Quadrelli, MD
Membership Commiee
Chair
Jean-Michel Vergnon, MD
Educaon Commiee
Chair
Ali Musani, MD
Finance Commiee Chair
Naofumi Shinagawa, MD
Japan,
Secretary General
Menaldi Rasmin, MD, PhD
Indonesia , President
WCBIP 2024
Rajesh Thomas, MD, PhD
Melbourne , President
WCBIP 2026
STAFF
Michael Mendoza
General Manager
Judy McConnell
Administrator
Kazuhiro Yasufuku
Newsleer Editor-in-chief
P A G E 2
Stereotacc beam radiaon therapy (SBRT) has tra-
dionally been the standard of care for paents with
early-stage lung cancer and thoracic oligometastac
disease who are not surgical candidates. SBRT has
been dened as large doses of radiaon ( > 6 Gy/
fracon) administered over a few (<=5) fracons
1
.
This administraon of large doses of radiaon can
be associated with signicant toxicies both to the
treatment sites and the adjacent normal structures
that can become collateral damage. Complicaons
include pneumonia, pneumonis, chest wall pain, rib
fractures, brachial plexus injury, etc.
2
3
The risk of
complicaons seems to be higher for more central
and ‘ultra’ central tumors as they are situated closer
to the crical thoracic structures
4
. Similarly, paents
with pre-exisng intersal lung diseases are at a
higher risk of pneumonis as well, with some studies
reporng a risk of fatal radiaon pneumonis at 6%
5
.
Given the above limitaons, there has been a signi-
cant interest in developing minimally invasive abla-
ve technologies that can be administered via trans-
bronchial or image-guided transthoracic routes.
These modalies include radiofrequency ablaon
(RFA), microwave ablaon (MWA), cryoablaon, and
more recently pulsed electric eld (PEF) systems.
RFA involves placing a probe into the lesion, through
which alternang current is passed. This produces
heat and can generate a temperature of > 100◦C in
the vicinity of the target with resultant necrosis of the le-
sion
6
7
. However, as the lesion is charred, it impedes the
conductance of current and heat, which may limit the abla-
on zone. Similarly, blood owing through any adjacent
vessels acts as a ‘heat sink’, thereby making it harder to
reach the intended target temperature and therefore lim-
ing the ablaon ecacy and zone. MWA which uses alter-
nang electromagnec waves to oscillate water molecules
and generate friconal heat, is more resistant to these limi-
taons and therefore can potenally achieve higher tem-
perature and a larger ablaon zone
6
. Pneumothoraces and
bleeding are the most signicant complicaons for MWA
8
9
.
Tumor cryoablaon involves introducing a cryoprobe into
the lesion; mulple freeze-thaw cycles are then used to
induce cell death. Like most image-guided transthoracic
ablave modalies, the most frequent complicaon is
pneumothorax; however, more serious complicaons such
as hemopneumothorax and hemoptysis have also been
reported
10
.
The newest ablaon modality is the pulsed electric eld
(PEF) therapy. Unlike the aforemenoned therapies, it
doesn’t rely on heat or cold to degenerate tumors; rather, it
uses brief high voltage current to alter the cell membrane
potenals, thereby interfering with normal cell homeostasis
and eventually leading the cell death f
11
12
. As a result, the
extracellular matrix is preserved. Furthermore, angens are
released from the tumor, which may induce an an-tumor
immune response as well. The fact that extracellular matrix
and lymphac drainage are preserved, together with the
Muhammad Sajawal Ali MD
Assistant Professor of Medicine,
Weill Cornell Medicine,
New York, NY
Ali Musani MD
Professor of Medicine and Surgery,
University of Colorado School of
Medicine, Denver
W A B I P N E W S L E T T E R
P A G E 3
References:
1. Poers L et al. Int J Radiat Oncol Biol Phys. 2010;76(2):326–332.
2. Andolino DL et al. Int J Radiat Oncol Biol Phys. 2011;80(3):692–
697.
3. Forquer JA et al. Radiother Oncol. 2009;93(3):408–413.
4. Lindberg K et al. J Thorac Oncol. 2021;16(7):1200–1210.
5. Onishi H et al. Cancers (Basel). 2018;10(8):257.
6. Bartle EC et al. Lung Cancer 2023;176:14–23.
7. Zhong C-H et al. European Respiratory Journal [Internet] 2023
[cited 2024 Jan 3];62(suppl 67). Available from: hps://
erj.ersjournals.com/content/62/suppl_67/OA2598
8. Tran S et al. European Respiratory Journal [Internet] 2017
[cited 2024 Jan 3];50(suppl 61). Available from: hps://
erj.ersjournals.com/content/50/suppl_61/PA4282
9. Lau KKW et al. J Bronchology Interv Pulmonol. 2023 Sep 25. doi:
10.1097/LBR.0000000000000950.
10. Zhang Y-S et al. J Thorac Dis. 2016;8(Suppl 9):S705–S709.
11. Wagsta PG et al.. Onco Targets Ther. 2016;9:2437–2446.
12. Irreversible electroporaon of lung neoplasm: A case series -
PMC [Internet]. [cited 2024 Jan 3];Available from: hps://
www.ncbi.nlm.nih.gov/pmc/arcles/PMC3560719/
13. Galvanize Therapeucs, Inc. The Galvanize Therapeucs Early
Stage, Non-Small Cell Lung Cancer, Treat and Resect Study
[Internet]. clinicaltrials.gov; 2023 [cited 2023 Dec 31]. Available
from: hps://clinicaltrials.gov/study/NCT04732520
14. Inc GT. Galvanize Therapeucs Announces Promising Data on
the Aliya
TM
Pulsed Electric Field (PEF) System in Early-Stage Non-
Small Cell Lung Cancer [Internet]. [cited 2024 Jan 3];Available
from: hps://www.prnewswire.com/news-releases/galvanize-
therapeucs-announces-promising-data-on-the-aliya-pulsed-
electric-eld-pef-system-in-early-stage-non-small-cell-lung-cancer
-301977976.html
15. Inc GT. Galvanize Therapeucs Begins U.S. Clinical Study Using
Aliya
TM
Pulsed Electric Field (PEF) for Stage IV Non-Small Cell Lung
Cancer or Metastasis to the Lung [Internet]. [cited 2024 Jan
3];Available from: hps://www.prnewswire.com/news-releases/
galvanize-therapeucs-begins-us-clinical-study-using-aliya-pulsed
-electric-eld-pef-for-stage-iv-non-small-cell-lung-cancer-or-
metastasis-to-the-lung-301932837.html
fact that a capsule of scar ssue doesn’t form, can
potenally further enhance the immune response.
The an-tumor eect is achieved via both direct
ablaon and indirect immune response. The an-
tumor immune response can be observed at distal
tumor sites as well. INCITE-ES is an internaonal
treat and resect study for early-stage non-small cell
lung cancers to assess the safety and immune ac-
vaon
13
. Early results suggest PEF therapy induces
a strong immune response in the tumors
14
. AFFINI-
TY is another major mulcenter prospecve study
assessing the safety and eecveness of PEF thera-
py in paents with metastac pulmonary lesions
15
.
In summary, while the data is sll limited on the
safety, ecacy, and technical parameters for lung
cancer ablave therapies, mulple modalies ap-
pear promising. There is signicant excitement
around PEF therapy, since in addion to local abla-
on it may increase the ecacy of immunotherapy
both locally and at distant sites. These therapies
can be administered both via transthoracic and
bronchoscopic routes. Therefore, it would be feasi-
ble to potenally oer a tumor biopsy and therapy
in the same seng. Further studies are needed
before these ablave therapies can be rounely
adopted. However, they are well and truly on the
way to becoming alternaves and, in some cases,
even replacing SBRT and surgery.
W A B I P N E W S L E T T E R
P A G E 4
Technology Corner
Tracheostomy Tubes: Types and their Pros and Cons
Introducon
Tracheostomy, a surgical procedure involving the creaon of an opening in the anterior wall of the trachea, is an intervenon per-
formed by many specialists (ENT, Intervenonal Pulmonology, Trauma, Crical Care, Thoracic Surgery) in a variety of urgent and non
-urgent scenarios. It establishes a secure airway in paents who can’t be intubated translaryngeally and facilitates transion of care
and potenally weaning o the venlator in crically ill paents who require prolonged respiratory support. Central to this proce-
dure is the tracheostomy tube, a device that maintains the patency of the tracheostomy stoma and airway patency. In this essay, we
explore the diverse types of tracheostomy tubes, discussing their features and clinical applicaons.
Background
Tracheostomy tubes have evolved over the years to meet the specic needs of paents across a spectrum of medical and surgical
condions. The basic design involves a tube inserted into the tracheostomy stoma to secure a patent airway. The materials, shape,
and addional features of these tubes vary, catering to the unique requirements of paents with dierent condions. Knowing the
indicaons and potenal problems of specic tracheostomy tubes is relevant for healthcare providers performing the procedure and
caring for paents with indwelling tracheostomy tubes.
Clinical Indicaons
Common indicaons include acute upper airway obstrucon, post-cricothyrotomy cases, facial/neck fractures, penetrang laryngeal
trauma, need for prolonged mechanical venlaon, compromised airway protecon (inability to clear secreons despite maximal
noninvasive measures), refractory sleep apnea/obesity hypovenlaon syndrome, special cases of subgloc stenosis (inoperable
and recurrent aer mulple endoscopic procedures and not amenable to stenng), severe vocal cord paralysis, burns or inhalaon
injuries, and anatomic abnormalies altering upper airway structure. In our pracce, primary use involves venlator weaning for
crically ill paents with acute respiratory failure or neurologic disorders requiring prolonged venlatory support.
Sepmiu Murgu, MD, FCCP, DAABIP
Department of Medicine,
Division of Pulmonary and Crical Care
The University of Chicago
Prince Namoah, MD
Department of Medicine,
Division of Pulmonary and Crical Care
The University of Chicago
W A B I P N E W S L E T T E R
P A G E 5
Types of Tracheostomy Tubes: Features and Clinical Ulizaon
Tracheostomy tubes come in various types from several manufacturers, each designed to address specic clinical needs (Table 1).
The dimensions of tracheostomy tubes are given by their inner diameter, outer diameter, length, and curvature (degree of angula-
on). Dierences in dimensions between tubes with the same inner diameter from dierent manufacturers may have important clini-
cal implicaons, depending on the other features.
Diameter: If the inner diameter is too small, it will increase the airow resistance through the tube and make the airway clearance
more dicult. Larger outer diameter tubes will be more dicult to pass through the stoma and could result in carlage fracture and
subsequent stenosis or malacia.
1–3
If the outer diameter is too large, the leak with the cu deated will be decreased, and this will
negavely impact the ability to use the upper airway with cu deaon for speech prior to the tracheostomy tube exchange (when
possible). Smaller outer diameter tubes, on the other hand, may require increases in the cu pressure needed to avoid signicant
cu leak and high pressures could eventually lead to stenosis at the level of the cu.
4
Length: If the tracheostomy tube is too short, the distal end can get obstructed against the posterior tracheal wall, or even against
the anterior wall if the inseron site is high (due to tube angulaon). This can be remedied by using a larger tube, a tube with a dier-
ent angle (see Table), a tube with a more exible sha, or a tube with extra length. Extra length tubes are constructed with extra
proximal length (vercal extra length) or with extra distal length (horizonal extra length) (Figure). Extra proximal length facilitates
tracheostomy tube placement in paents with a large neck circumference, which can be measured by bedside ultrasound or neck
computed tomography, when available. Extra distal length facilitates placement in paents with tracheal stenosis, tracheomalacia or
tracheal anomalies that need to be bypassed or, as in our pracce, in certain paents, to assure a more proper alignment of the tube
with the tracheal lumen axis. Care must be taken to avoid inappropriate use of these tubes because they may even cause carinal
trauma if too long or induce distal tracheal stenosis if the cu is inadvertently overinated.
Cu: Tracheostomy tubes can be cued or uncued. Uncued tubes allow airway clearance but provide no protecon from aspira-
on and cannot usually be used for venlaon if paents need venlatory support. Cued tracheostomy tubes allow secreon clear-
ance and oer some protecon from aspiraon, and posive pressure venlaon can be more eecvely applied when the cuis
inated. Specic types of cus used on tracheostomy tubes include high-volume low-pressure cus, ght-to-sha cus (low-volume
high-pressure), low volume-low pressure cus and foam cus (Table). High-volume low-pressure cus are most used and maintaining
opmal tracheal cu pressure is crucial for paent safety. The normal tracheal capillary perfusion pressure is 25–35 mm Hg. Cu
pressure should be kept at 20–30 cm H
2
O (15–22 mm Hg) and monitored every shi to minimize risks of tracheal injury (when too
high) and aspiraon (when too low). Regular monitoring, especially during tube changes or posion adjustments, is recommended
but in pracce this is extremely dicult to achieve and in fact, in a study, underinaon (pressure < 20 cm H
2
O) was noted in 54% of
paents, and overinaon (pressure > 30 cm H
2
O) occurred in 73% of paents.
5
Two cu types, the low volume, high pressure and
foam cu, serve dierent purposes. The former minimizes airow obstrucon outside of the tube when the cu is deated and is
intended for paents requiring intermient cu inaon. The foam cu consists of a large-diameter high residual volume cu com-
posed of polyurethane foam. It was designed to address the issues of high lateral tracheal wall pressures, that lead to complicaons
W A B I P N E W S L E T T E R
P A G E 6
such as tracheal necrosis and stenosis (Figure). Despite its advantages, the foam cu is not widely used, typically reserved for paents
with exisng tracheal injuries. Regular cu deaon is advised to check integrity and prevent adhesion to the tracheal mucosa.
The newer model of low pressure, low volume cus have a tapered shaped (Taper Guard) cu (Figure), and in experimental models
has less lateral wall pressure and larger inner diameter facilitang increased airow around the outer cannula (when cu deated).
There are reports of increased cu leak with these tubes as the tapered cu design may t dierently in paent’s airways over me
but this could also be due to decreased airway edema or a component of tracheomalacia at tracheostomy cu site
6
Adjustable tubes: Several tube designs have a spiral wire-reinforced exible design (See Bivona tube, Figure). These tubes are not
compable with lasers, electrosurgical devices, or magnec resonance imaging. Some have a moveable ange designed to allow ad-
justments to beer t the tube to the paent’s unique anatomy. Because the locking mechanism on the ange tends to deteriorate
over me, these tubes should be considered a temporary soluon. For long term use, the adjustable ange tube should be replaced
with a tube that has a xed ange. Custom-constructed tubes are available from several manufacturers to meet this need.
Inner cannula: Some tracheostomy tubes are used with an inner cannula known as dual-cannula tracheostomy tubes. In some cases,
the venlator adaptor is on the inner cannula, and the venlator cannot be aached unless the inner cannula is in place. The use of
the inner cannula allows it to be cleaned or replaced at regular intervals without removing the tracheostomy tube from its stoma.
The inner cannula can be removed to restore patent airway if the tube occludes, which may be an advantage for long term use out-
side an acute care facility. One potenal issue with the use of an inner cannula is that it reduces the inner diameter of the tracheosto-
my tube; thus, the imposed work of breathing for a spontaneously breathing is increased. Of note, if a fenestrated tracheostomy
tube is used, the inner cannula occludes the fenestraons unless there are also fenestraons on the inner cannula.
Fenestraon: The fenestrated tracheostomy tube is similar in construcon to standard tracheostomy tubes with the addion of an
opening in the posterior poron of the tube above the cu (Figure). With the inner cannula removed, the cu deated, and the nor-
mal airway passage inlet of the tube occluded (capped tube), the paent can inhale and exhale through the fenestraon and around
the tube, unless upper airway obstrucon precludes it. The cu must be completely deated before the tube is capped. In our experi-
ence, fenestrated tracheostomy tubes oen t poorly and thus do not always work as intended. The standard commercially available
tubes can signicantly increase ow resistance through the upper airway if the fenestraons are not properly posioned. Further-
more, the fenestraons may cause the formaon of granulaon ssue, resulng in airway compromise.
Subgloc sucon: Tracheostomy tubes that provide a sucon port above the cu are available. The subgloc suconing cannula is
located on the exterior surface of the cannula as a separate lumen, which can be connected to intermient or connuous sucon,
and is intended for the evacuaon of secreons situated above the tracheostomy tube cu (Figure, Table).
Conclusion:
The diversity of tracheostomy tubes reects the mulfaceted nature of paent needs in various clinical scenarios. Selecng the ap-
propriate type involves a careful consideraon of the paent's medical condion, neck and airway anatomy, ancipated duraon of
tracheostomy dependence, and the need for specic features such as cu inaon or fenestraon. Advances in tracheostomy tube
W A B I P N E W S L E T T E R
P A G E 7
technology are needed to take into account the unique requirements of each paent, ensure opmal outcomes, avoid complicaons
and enhances the overall quality of life of paents with indwelling tracheostomy tubes.
Figure 1. Types of cued tracheostomy tubes
A. Portex; B. Shiley; C Shiley Proximal XLT; D Shiley
Distal XLT; E. Bivona adjustable; F. Low Pressure, low
volume cu (Taper Guard); G. Foam cu; H. Fenes-
trated tracheostomy tube; I. Subgloc sucon port
tracheostomy tube
Tracheostomy
tube Name
Manufacturer Sizes
ID/OD
(mm)
Inner
Cannula
Cuff Comments
Bivona Tight-To-
Shaft (TTS) Tubes
Smiths Medical 6.0/8.8
7.0/10
7.5/10.5
8.0/11
8.5/11.8
9.0/12.3
Yes Low volume high pressure
Cuff
(LVHP), Tapered cuff
These cuffs are filled with
sterile water, not air.
“Tight-to-shaft” means when deflated,
the cuff lays flat against the shaft of
the trach tube. Recommended for pa-
tients being weaned from ventilation.
Bivona Aire-Cuff
Tubes*
Smiths Medical 6.0/8.8
7.0/10
8.0/11
9.0/12.3
9.5/13.3
Yes “Aire” indicates cuff to be
filled with air. These are
“mid-range” high-volume,
low-pressure cuffs (HVLP).
They come in tapered or
cylindrical shapes;
**Portex-Bivona regular
length, fixed and adjustable
tracheostomy tubes typically
available with TTS cuffs or
Aire-Cuf. Air-filled cuffs
designed to provide a secure
and comfortable seal. The
Aire-Cuf technology al-
lows for cuff inflation and
deflation to achieve an opti-
mal seal while minimizing
the pressure on the tracheal
wall
Recommended for patients on long
term ventilatory support. Inflatable
cuff is soft, flexible, and designed for
secure seal with minimal pressure on
the tracheal wall. Additional options
include talk attachment, fixed or ad-
justable flanges
W A B I P N E W S L E T T E R
P A G E 8
Bivona Fome-Cuf
Tubes
Smiths Medical 9.5/13.3 No Tapered cuff design.
A foam-filled cuff refers to
the presence of a cuff that is
filled with a soft, pliable
foam material. This cuff
places lower pressure on the
tracheal wall. It passively
inflates
Recommended for patients
with risk of tracheomalacia.
Cuff expansion adjusts to tra-
cheal wall changes while main-
taining a seal. Suitable for
long term use.
Caution: If the cuff breaks in
the patient, the the foam part of
the cuff cannot be deflated
Bivona Blu-Select
Tubes
Smiths Medical 6.0/9.2
7.0/10.5
7.5/11.3
8.0/11.9
8.5/12.6
Yes Tapered cuff, HVLP Tubes and packaging are color
coded by size
Bivona Portex Blue
Line Ultra Tubes
Smiths Medical 6.0/9.2
7.0/10.5
7.5/11.3
8.0/11.9
Yes HVLP cuff
Cylindrical shape
The Blue Line Ultra cuff is
designed to offer a secure seal
with minimal pressure, suitable
for long-term use
Bivona Portex Blue
Line Ultra Fenes-
trated
Smiths Medical 6.0/9.2
7.0/10.5
7.5/11.3
8.0/11.9
Yes HVLP, Cylindrical Needs a fenestrated inner can-
nula to function for speaking
purposes. Caution: Fenestra-
tions can become clogged up
with secretions.
Bivona Blue Line
Ultra Suction-aid
Tubes
Smiths Medical 6.0/9.2
7.0/10.5
7.5/11.3
8.0/11.9
Yes HVLP Cylindrical Incorporates a subglottic suc-
tion line
Bivona Uni-Perc
Adjustable Flange
Smiths Medical 8.0/12.6
9.0/13.6
Yes HVLP, Cylindrical
Recommended for patients
with long or thick necks. Al-
low tube length variation on
vertical and horizontal planes.
Shiley “Legacy”
Tracheostomy tube
Medtronic 5.0/9.4
6.4/10.8
7.6/12.2
8.9/13.2
Yes HVLP, Barrell-shape It uses Jackson sizing*
Shiley Flexible
tracheostomy with
taper-guard
Medtronic 6.5/9.4
7.0/10.1
7.5/10.8
8.0/11.4
8.5/12.2
9.0/12.7
10.0/13.8
Yes Taper-guard Low volume
Low Pressure (LVLP)
Integrated 15 mm adapter is
part of the trach, and this al-
lows the tracheostomy tube to
be connected to the ventilator
with or without inner cannula
in place
Shiley Proximal
Extended long tra-
cheostomy tubes
(XLT)
Medtronic 5.0/9.6
6.0/11
7.0/12.3
8.0/13.3
Yes HVLP Choose extra length in the
proximal portion to accommo-
date increased skin-to-tracheal-
wall distances in patients with
large neck circumference.
Shiley Distal XLT Medtronic 5.0/9.6
6.0/11
7.0/12.3
8.0/13.3
Yes HVLP Tubes with extended distal
length compensate for condi-
tions such as tracheal stenosis
or malacia, which often require
extra length to bypass the ab-
normal tracheal pathology
Shiley Fenestrated
tubes
Medtronic 5.0/9.4
6.4/10.8
7.6/12.2
8.9/13.8
Yes HVLP
Taper
Allows airflow through fenes-
tration for speech
W A B I P N E W S L E T T E R
P A G E 9
Table 1. Types of commonly used cued tracheostomy tubes and their features.
HVLP: High volume, low pressure
LVHP: Low volume, high pressure
LVLP: Low volume, low pressure
*There are two dierent methods for sizing tracheostomy tubes, and it's important to note that sizes among brands are not equivalent.
Jackson sizing is specic to Shiley regular and their exible tracheostomy tubes only. The size of the tracheostomy tube does not corre-
spond to any actual measurement of the tube. Internaonal sizing organizaon (ISO) is used by all other tracheostomy tube manufacturers,
including for Shiley XLTs. The size of the tracheostomy tube refers to the inner diameter of the tube without the inner cannula.
Note: Custom-made tracheostomies can be made based on bedside or radiologic measurements
References
1. Anand VK et al. Laryngoscope. 1992;102(3):237-243. doi:10.1288/00005537-199203000-00002
2. Sarper A et al. Texas Hear Inst J. 2005;32(2):154-158.
3. Grillo HC et al. J Thorac Cardiovasc Surg. 1995;109(3):486-493. doi:10.1016/S0022-5223(95)70279-2
4. Kapidzic A et al. Med Arh. 2004;58(6):384-385. doi:10.1016/s0022-5223(95)70279-2
5. Nseir S et al.. Eur J Anaesthesiol. 2009;26(3):229-234. doi:10.1097/EJA.0b013e3283222b6e
6. Maguire S et al. An in vitro comparison of tracheostomy tube cus Introducon: The Shiley
TM
Flexible adult tracheostomy tube with
TaperGuard
TM
cu has. Published online 2015:185-192.
Tips from the Experts
P A G E 10 V O L U M E 1 2 , I S S U E 1
Post Intubaon Tracheal Stenosis (PITS) is a well-described complicaon of endotracheal intubaon that can pose signicant challenges to
manage eecvely. Symptomac PITS can aect 1-5% of paents who are intubated and treatment should be tailored for each paent
based on a muldisciplinary approach considering non-surgical (endoscopic) and surgical intervenons (1, 2).
Herein we present a few strategies and technical ps from intervenonal pulmonology (IP) and thoracic surgery (TS) employed at the Uni-
versity of Chicago Medicine.
Indicaons
Paents may present with central airway obstrucve symptoms such as progressive dyspnea, wheezing/stridor, and diculty clearing secre-
ons. As a rule of thumb, nearly 50% narrowing of the cross-seconal area of the trachea is needed before an acve person experiences
dyspnea. Audible stridor usually occurs when the airway diameter is about 4-6 mm. Other causes of dyspnea should also be considered,
parcularly for paents previously on mechanical venlaon who may have sustained neuromuscular and/or pulmonary parenchymal con-
tribuons to their symptoms.
It is reasonable to aempt endoscopic management rst, parcularly for simple strictures (<1 cm in length and without associated malacia
(chondris)) without cricoid involvement. The success rate of laser-assisted mechanical dilaon in such cases is >60% (3). Surgical referral
should be pursued in paents who have cricoid involvement, have required mulple endoscopic intervenons, and in those with complex
lesions (>1cm, with malacia or full thickness injury) as recurrence is very high (80%) (1). Repeat endoscopic intervenons may lead to exces-
sive mechanical or thermal trauma that can worsen the extent of the stenoc segment and potenally convert operable paents to inopera-
ble (4). In such cases, paent- and lesion-specic factors should be evaluated to assess whether tracheal resecon is anatomically and physi-
ologically appropriate. In appropriately selected paents surgery has a high success rate >95% (1).
Paents should not undergo surgical resecon if they are “unt” for surgery due to poor cardiopulmonary reserve, dependent on mechani-
cal venlaon, have underlying chronic disease or anatomy which would lead to anastomoc failure or re-stenosis (e.g. on high dose ster-
oids, inammatory disease such as GPA, long-segment stenosis (longer than 4-5 cm)) (1). Poor surgical candidates will need a silicone stent
either long term (typically 12 months or longer) or unl they become operable (1). Up to a half of paents who undergo stenng may have
them removed without the need for addional intervenon, perhaps as a result of airway remodeling (1). Paents who cannot tolerate
stenng and are also not surgical candidates may be considered for tracheostomy.
Planning
Bronchoscopy is essenal for appropriate paent selecon and subsequent procedural planning. Specically, we use it to obtain precise
measurements and dene airway anatomy (length of stenosis, locaon in relaon to cricoid and carina). Bronchoscopy can also idenfy oth-
er eologies for stenosis (e.g. GPA, RP), the presence or absence of malacia, acve inammaon, and rule out laryngeal lesions (such as in-
adequate glos from stenosis, ulceraon, granuloma, vocal cord paralysis) which would limit the success of tracheal intervenons.
Our typical pracce is to perform airway assessments with a exible bronchoscope. The seng and need for an arcial airway depend on
Management of Post Intubaon Tracheal Stenosis:
ps from a mul-disciplinary airway team
Sepmiu Murgu
Department of Medicine,
Division of Pulmonary and
Crical Care
The University of Chicago
Gaurav Ajmani
Department of Medicine,
Division of Pulmonary and
Crical Care
The University of Chicago
Maria Lucia Madariaga
Department of Surgery,
Division of Cardiothoracic Surgery
The University of Chicago
Tips from the Experts
P A G E 11 V O L U M E 1 2 , I S S U E 1
the operator’s preference and clinical scenario. We prefer to perform this under moderate sedaon so the paent can cooperate with vari-
ous respiratory maneuvers (deep inhalaon, forced exhalaon, coughing) which allow detecon of concurrent airway malacia or funconal
obstrucon. In an anesthezed paent we aempt to simulate this by applying sucon. Paents who are in respiratory distress are typically
taken directly to the OR as below (see Urgent Management). Addional workup includes serologic tesng for GPA, CT neck/chest to evaluate
for evidence of other airway pathology, and pulmonary funcon tesng with evaluaon of ow-volume loops and assessment of sing/
supine symptoms and forced vital capacity.
In all paents, management of concurrent or exacerbang condions should also ideally be opmized, including acid reux, cardiac disease
or volume overload, and obstrucve lung disease prior to invasive intervenons directed at PITS. Prior to surgical intervenon, chronic ster-
oids should be weaned, and diabetes mellitus should be controlled.
Procedure
Endoscopic treatment typically involves a combinaon of thermal therapy to cut the scar/stricture followed by gentle dilaon. Thermal thera-
pies include KTP laser or electrocautery knife or needle and in our pracce both are employed based on equipment availability and ability to
appropriately align the tool with the lesion in the airway. We will typically make anywhere from 1-3 radial incisions into an area of scar or
stricture depending on the extent of involvement. Dilaon following thermal therapy is likely to be more eecve than dilaon alone in
opening the airway and delaying recurrence. In addion, dilaon without prior radial incision will result in excessive mechanical trauma
which by itself can promote recurrence. Dilaon may be performed with commercially available dilang balloons and/or a rigid bronchoscope
if one is employed [Figure 1]. Occasionally, we use endotracheal tubes of increasing size or Jackson dilators, especially if working in conjunc-
on with ENT and the paent is under suspension laryngoscopy (for high stenoc lesions). In paents who had a signicant benet but expe-
rience a recurrence, we will proceed with a maximum of 3 repeat endoscopic intervenons while they undergo evaluaon for surgical candi-
dacy. We will also consider intra-lesional steroid injecon under direct visualizaon (40mg of triamcinolone) in paents who recur with evi-
dence of inammaon at me of repeat bronchoscopy.
Silicone stents improve respiratory symptoms, however migraon and mucus occlusion are important adverse consideraons. Further, plac-
ing an appropriately sized silicone tracheal stent requires an adequately sized rigid bronchoscope, which in our experience is not always easy
to insert and maneuver. A smaller rigid tube may only permit placement of a smaller diameter stent that is more prone to migraon. Mucus
plugging can also be an issue if paents are not adherent with saline nebulizers. We therefore typically reserve the use of silicone stents long-
term for paents whose disease is not amenable to thermal therapy/dilaon and who are not surgical candidates. Bare metal stents carry a
black box warning by the U.S. Food and Drug Administraon for benign airway stenosis and should not be used.
Surgical management involves either laryngotracheal resecon (if the cricoid is involved) or tracheal resecon, followed by reconstrucon. In
our instuon, we use cross-eld venlaon and total intravenous anesthesia. Aer adequate exposure of the trachea through a collar inci-
sion, the stenoc segment is resected. Stay sutures are placed so that intermiently the surgeon can check the level of anastomoc tension
by approximang the 2 cut ends of trachea. Once sased with resecon, the anastomosis is performed using absorbable suture. Muscle
buress aps are placed to protect the anastomosis and a chin stch (“Grillo stch”) is applied to remind the paent not to extend the neck
excessively. Surveillance bronchoscopy is performed on postoperave day 7 to assess the integrity of the anastomosis [Fgure 2].
Urgent management
Symptomac paents with a crical airway may require urgent intervenon without the extensive prior evaluaon detailed above. We favor
transferring these paents to the ICU and temporizing with upright posioning and consideraon of posive airway pressure and/or heliox
(eecve at 80:20 or 70:30 mix and should not be used if the paent requires more than 30% oxygen ). Intubaon or bronchoscopy at the
bedside should be avoided when paents are crical, especially if there is a lack of advanced equipment and personnel availability. Securing
the crical airway should be done in the operang room with readiness to use a rigid bronchoscope if needed. Surgical teams may be needed
on standby to access the airway if this is not possible from above depending on operator experience and instuonal process. In appropriate
paents who are markedly and rapidly decompensated, extracorporeal support (ECMO) may also be considered, though in our experience
this has not been necessary with a muldisciplinary airway team. There is no role for emergent tracheal resecon and reconstrucon.
Quality Control
We conduct thorough pre-procedural assessments as above aimed at conrming that a paent’s symptoms are most likely from PITS, that
contribung and comorbid factors are well managed. Muldisciplinary meengs are the norm in our instuon and oen paents undergo
Tips from the Experts
P A G E 12 V O L U M E 1 2 , I S S U E 1
joint procedures by two or more airway specialists (IP, ENT and TS). These discussions as well as pre-intervenon bronchoscopy aid greatly in
personalizing treatment and assuring avoidance of unnecessary repeated endoscopic procedures for complex lesions or premature surgical
resecon of simple strictures that would have otherwise responded to laser-assisted mechanical dilaons. With all intervenons, we will typi-
cally perform surveillance exible bronchoscopy – around 1-3 months following endoscopic intervenon, and for surgical paents at 1 week
and 3 months post-op.
Figure Legend
Figure 1. Complex, circumferenal tracheal stenosis seen during rigid bronchoscopic intubaon (top le) and close view (top center). This was managed by
laser assisted mechanical dilaon. The stricture was cut using KTP laser for two radial incisions (top right and boom le images). In this case, we decided to
inially use a balloon for the dilaon ( boom center) as the stricture felt very hard, and we try to avoid both mechanical and thermal trauma when manag-
ing these paents. The airway patency was restored (boom le).
Figure 2. Resected tracheal stenosis segment showing “full thickness” airway involvement, unlikely to resolve with mulple dilaons (le). Bronchoscopy at
day 7 (center) and 3 months post op (right) showing healed anastomosis and no recurrence.
References
1. Agrawal A et al. Respir Med. 2021;187:106582.
2. Murgu SD et al. Endobronchial Prostheses. In: Díaz-Jimenez JP, Rodriguez AN, editors. Intervenons in Pulmonary Medicine. Cham: Springer Interna-
onal Publishing; 2018. p. 213-41.
3. Mehta AC et al. Chest. 1993;104(3):673-7.
4. Gaissert HA et al J Thorac Cardiovasc Surg. 2003;126(3):744-7.
5. Grillo H.C. (2003). Posntubaon Stenosis. In H.C. Grillo (Eds.), Surgery of the Trachea and Bronchi. (1
st
ed., pp. 301-339). B.C. Decker.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 13
Internaonal Humanitarian Law and the Israel-Palesne Conict
Most of people are likely to nd it challenging to maintain raonality amidst the overwhelming sense of sorrow that accom-
panies the recent events in Israel and Gaza.
Even if the Hamas incursion and Israel's siege and shelling of the densely populated Gaza Strip connue to cause crimes and
deaths, internaonal law can guide an examinaon of the current situaon. New informaon is released daily. Verifying spe-
cics takes me, disinformaon is widespread, and debates about unsubstanated claims may get boring. War rules deter-
mine what maers and what should happen next.
In fact, the exceedingly complex situaon in the Gaza Strip has led to discussions over whether both groups' acvies vio-
late internaonal humanitarian law. Like many other subjects, the public, communicators, and media voice strong opinions
without knowing internaonal humanitarian law or how it applies to this conict's protagonists. Emoons, prejudices, geo-
polical interests, and polical posionings drive polical leaders, human rights advocates, and ordinary individuals to view
informaon dierently. Dierent judicial bodies may rule dierently on the same text, as with any legal theory. This form of
inescapable ambiguity is not exhausve, as many civil, criminal, and internaonal legal situaons are clearly right or wrong.
Internaonal humanitarian law comprises a set of regulaons aimed at migang the impact of armed conicts for humani-
tarian reasons. It safeguards individuals who are not acvely parcipang in hoslies and imposes limitaons on the meth-
ods and means of warfare. Addionally known as the law of war or the law of armed conict, internaonal humanitarian law
is an integral component of internaonal law, which governs the interacons between sovereign states. This body of law is
delineated in agreements such as treaes or convenons, customary rules derived from state pracces seen as legally bind-
ing, and general principles.
The scope of internaonal humanitarian law is restricted to armed conicts and does not dictate whether a state is per-
mied to employ force; this aspect is governed by a disnct secon of internaonal law outlined in the United Naons Char-
ter. While the roots of humanitarian law trace back thousands of years, the modern version, encapsulated in the Geneva
Convenons of 1949 and other treaes, has evolved over me. The universal codicaon of these laws commenced in the
nineteenth century, with states progressively agreeing upon praccal rules shaped by the harsh lessons of contemporary
warfare. These rules aim to strike a delicate balance between humanitarian consideraons and the military needs of states.
Today, internaonal humanitarian law represents a universally recognized body of legal principles.
Nearly every government has signed the Fourth Geneva Convenons of 1949 and the 1977 Addional Protocols that protect
vicms in armed conicts and enhance these Convenons.
Various agreements restrict certain weapons and military methods while protecng parcular organisaons and assets as
the 1954 Convenon for the Protecon of Cultural Property in the Event of Armed Conict, the 1972 Biological Weapons
Convenon, the 1980 Convenonal Weapons Convenon with its ve protocols, the 1993 Chemical Weapons Convenon,
the 1997 Oawa Convenon on an-personnel mines, and the 2000 Oponal Protocol to the Convenon on the Rights of
the Child on child involvement in armed
Many parts of internaonal humanitarian law are customary law, binding on all governments. This legislaon only applies to
military conicts, not internal tensions or isolated violence. Aer a disagreement begins, the law applies imparally to all
sides. Internaonal humanitarian law disnguishes between internaonal (IAC) and non-internaonal armed conicts
(NIAC), with the former involving at least two naons and operang under the Fourth Geneva Convenons and Addional
Protocol I. On the other hand, non-internaonal armed conicts refer to hoslies that are limited to the territory of a single
State and include either convenonal armed forces combang armed dissident organisaons or armed groups engaging in
combat with each other.
There is oen a misconcepon regarding the interchangeability of humanitarian law with human rights law. It is essenal to
dierenate between them. While there may be some parallels in their legislaon, these two legal systems have developed
separately and are covered by separate treaes. Human rights legislaon is specically valid during periods of peace, in con-
trast to internaonal humanitarian law. However, some provisions under human rights law may be temporarily suspended
during mes of armed conict.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 14
The rules of law are non-reciprocal, meaning they are applicable regardless of the acons of the opposing party. Violaons,
such as intenonally targeng civilians or imposing collecve punishment, cannot be jused by arguing that another party
has commied violaons or that there are power imbalances or other injusces.
The primary principle of internaonal humanitarian law during armed conicts is that all pares are obligated to consistently
dierenate between combatants and civilians. It is imperave to refrain from targeng civilians and civilian enes. Pares
involved are only allowed to target combatants and military objecves. It goes as far as considering that merely asserng
that civilians are not the intended vicms of the aack is insucient. According to internaonal humanitarian law, the par-
es involved in the conict are obligated to take all praccal measures to reduce injury to people and civilian infrastructure.
Aacks that do not disnguish between combatants and civilians or that are likely to cause excessive harm to civilians rela-
ve to the military advantage are strictly forbidden.
Prisoners of war and maimed, stranded, or unwell combatants who have ceased parcipaon are also safeguarded under
internaonal humanitarian law. Respect for the physical and mental health of individuals belonging to these parcular
groups is warranted, on account of their mere existence. Ensuring the protecon and compassionate treatment of individu-
als without any form of discriminatory treatment is of the utmost importance.
It is strictly prohibited to intenonally inict death or injury upon an adversary who surrenders or becomes incapacitated
during combat. The party in a posion of authority is responsible for gathering and providing medical assistance to individu-
als who are injured or unwell. Under no circumstances are aacks on medical personnel, medical supplies, hospitals, or
healthcare instuons permied.
The IHL species that it is imperave to ensure the safeguarding of all ambulances. Addionally, there exist comprehensive
regulaons that dictate the specic requirements for the connement of prisoners of war and the treatment of civilians. This
include the supply of sustenance, lodging, and healthcare, as well as the entlement to communicate with their relaves.
The legislaon establishes a variety of unambiguous symbols that can be employed to disnguish individuals, locaons, and
items that are under protecon. The primary symbols include the red cross, the red crescent, and the emblems that desig-
nate cultural property and civil defence instuons.
Furthermore, internaonal humanitarian law strictly forbids any taccs or strategies used in bale that do not disnguish
between combatants and non-combatants, such as civilians. It is also crucial to prevent any excessive harm or avoidable
suering. Humanitarian law has therefore banned the use of many weapons, including exploding bullets, chemical and bio-
logical weapons, blinding laser weapons and an-personnel mines.
The laws of war require pares engaged in combat with the intent to damage civilians to furnish "eecve advance warn-
ing," unless the situaon renders such acon unfeasible. However, issuing a warning does not absolve any party of the re-
sponsibility to protect civilians. Civilians who do not evacuate remain protected despite having been issued a warning. Main-
taining their anonymity is of the utmost importance, and assailants must implement every feasible measure to protect them.
Statements that are not genuine warnings and instead seek to induce dread in the public through the use of threats of vio-
lence in order to coerce them into evacuang are strictly prohibited.
The signicance of Internaonal Humanitarian Law transcends naonal boundaries and precludes any exempon for mili-
tary, security, or naonal consideraons. This is because military imperaves are already duly considered in all instruments
of internaonal humanitarian law, which reconcile military necessity with human demands. The Internaonal Commiee of
Red Cross (ICRC) Commentary on the 4th Geneva Convenon states that: "… no Contracng Party can oer any valid pretext,
legal or otherwise, for not respecng the Convenon in its enrety. ('In all circumstances') also means that the applicaon of
the Convenon does not depend on the nature of the conict. "In addion, Arcle 27 of the Vienna Convenon points out
that "a party may not invoke the provisions of its internal law as juscaon for its failure to perform a treaty."
Despite the existence of notable cases in which internaonal humanitarian law has successfully protected civilians, prison-
ers, the injured, and the inrm, as well as restricted the use of cruel weapons, it is evident to an unbiased observer that
breaches of internaonal humanitarian law are numerous and on the rise. Civilians are increasingly becoming the principal
casuales of warfare and are enduring incalculable suering.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 15
Evidently, substanal obstacles will inevitably be encountered in the enforcement of this legislaon, given that it is designed
to be implemented during periods of profound unrest. However, it is equally apparent that the internaonal community
employs dierenal standards in its eorts to ensure eecve compliance with regulaons based on geopolical or alliance
consideraons.
The issue of the Israeli-Palesnian conict is notably sensive. Palesne's complex history of conicng claims, numerous
geopolical interests in the Middle East, ambiguous legal status of Palesnian territories, divergent posions within the in-
ternaonal community, the unconvenonal armed force status of Hamas (considered a terrorist organisaon by many
states), and misinterpretaons of opinions regarding Israel's foreign policy as those regarding the Jewish people all contrib-
ute to this complexity. Therefore, in addion to the inherent technical challenges associated with interpreng the implemen-
taon of Internaonal Humanitarian Law (IHL) in this intricate situaon, the conduct of each party operang within that legal
structure is subject to varying interpretaons among scholars, policymakers, polical gures, and ordinary cizens world-
wide.
The unique Israeli-Palesnian conict, agreements, and memoranda have created a lex specialis regime that governs all as-
pects of their relaonship, including the status of each party in relaon to the territory. The UN Resoluon adopted by the
General Assembly on 9 December 2015 (on the report of the Special Polical and Decolonizaon Commiee) declared that
UN: 1) Rearms that the Geneva Convenon relave to the Protecon of Civilian Persons in Time of War, of 12 August
1949, is applicable to the Occupied Palesnian Territory, including East Jerusalem, and other Arab territories occupied by
Israel since 1967 and 2) Demands that Israel accept the de jure applicability of the Convenon in the Occupied Palesnian
Territory, including East Jerusalem, and other Arab territories occupied by Israel since 1967, and that it comply scrupulously
with the provisions of the Convenon;
In spite of that, in the opinion of Peter Maurer, President of the Internaonal Commiee of the Red Cross in 2012 (so be-
fore the Hamas aack and declaraon of war by Israel), the recurrent claim that the Fourth Geneva Convenon applies to
the territories ignores the unique posion of Palesne and this essenal body of accords and as Israeli-Palesnian agree-
ments require a nal status negoaon to determine territory fate, so he called the ICRC and the internaonal community to
remain neutral and not prejudge the conclusion.
Assisng Professor Jérôme de Hempnne of Utrecht University conducts an exhausve analysis of whether the NIAC or IAC
branch of Internaonal Humanitarian Law pertains to the hoslies between the Israeli and Hamas military wing in Gaza.
Under IHL, the classicaon of these conicts is conngent on whether Palesne is a state and Gaza is an occupied territory.
According to him, this categorizaon is vital for establishing the legal framework that safeguards the rights and obligaons of
individuals and combatants. The applicability of the IAC and NIAC's hoslies laws at this juncture of the conict is now com-
parable as a result of customary IHL. Regarding the accountability of violators of internaonal humanitarian law (IHL) under
internaonal criminal law, they diverge. His analysis concludes that the enre Gaza conict ought to be governed by the one
-of-a-kind IAC system. This method also strengthens legal protecon for hoslies-threatened persons and property. The
Internaonal Criminal Court (ICC) would then be competent to prosecute and try several important war crimes that fall un-
der its jurisdicon only if they are commied in IAC, such as disproporonate aacks, using human shields, or using starva-
on as a weapon. The enre regime of protecon in 4
th
Geneva Convenon would benet civilian populaons on both sides,
and the ICRC would have regular access to all detainees to verify their condions and restore family links without belligerent
consent (Rule 124 of ICRC Customary Law Study).
Since October 7, Hamas and its supporters have launched hundreds of missiles from Gaza onto Israel, and have breached the
Gaza-Israel border barrier on October 7, capturing Israeli military checkpoints and invading Israeli communies and Kibbutz-
es. They massacred hundreds and abducted 220 troops and civilians to Gaza. Aer Israeli bombings on Gaza began, Hamas
vowed to kill a capve if Israel targeted houses without noce. These violent acts likely constuted IHL breaches under Art. 7
of the Rome Statute of the Internaonal Criminal Court (intenonal killings, unlawful imprisonments, and civilian hostage-
takings may be war crimes under Rome Statute). Aer Palesne joined the Rome Statute in April 2015, the Internaonal
Criminal Court has jurisdicon over war crimes perpetrated on Palesnian territory and by Palesnians, including Hamas and
PIJ members. Addionally, Art. 34 of the Fourth Geneva Convenon and Art. 3 of the Four Geneva Convenons ban the kid-
napping of hostages in internaonal and non-internaonal conicts.
On the other hand, the day aer Hamas-led strikes, Israeli Prime Minister Benjamin Netanyahu declared war and retaliated.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 16
He stated Israel wanted to annihilate Hamas's Gaza military. Israeli Defence Minister Yoav Gallant then said that he will block
o Gaza since airpower would not be adequate to bale Hamas. Instead, Gaza Strip supplies must be cut o. No food, ener-
gy, gasoline, medicaon, or drinking water has been transported to Gaza over Israel's border since October 9, 2023. Prime
Minister Netanyahu has stated that Israel will not provide help unl Hamas releases the hostages. On October 12, 2023, the
Gaza Strip's lone electrical plant stopped down due to fuel shortages. This caused the public electrical supply to collapse,
aecng health and drinking water.
Prime Minister Netanyahu urged Gazan civilians to ee bale zones before the air aacks. On October 13, the Israeli military
ordered civilians and foreign organisaons to evacuate the northern Gaza Strip within 24 hours in preparaon for an intensi-
ed air campaign or land invasion. In contrast, the Hamas-led administraon urged residents to stay in northern Gaza, ac-
cording to the Israeli military. The UN and human rights organisaons asked for the Israeli statement to be withdrawn since
a mass evacuaon of 1.1 million people was unachievable in 24 hours.
Aer those events, Gaza's civilian populaon has few safety opons. The UN has no civilian shelters or bunkers, although a
few hundred thousand have found refuge in hospitals. Only lile supplies and protecon are guaranteed there. Rafah, the
Palesnian border crossing to Egypt, is restricted to Gazans who wish to ee and has been bombarded by Israel mulple
mes. Hamas has released few hostages into Egypt.
Regardless maer who started the war, internaonal humanitarian law applies to all sides. What internaonal law allows in
an armed confrontaon does not rely on whether the side is an aggressor or defence. The only purpose is to safeguard civil-
ians, medical sta, journalists, and cultural property. Indiscriminate assaults (those that target civilians and ghters) must be
prevented to guarantee this protecon. This restricon applies to all armed conicts and is codied in Art. 48 of the First and
Second Addional Protocols to the Geneva Convenons. Hospitals and medical staare protected from military strikes if
designated properly. Violaon of this ban is a war crime under Rome Statute Art. 8.
Due to connuous ghng with Israel and Egypt closing border crossings, Gaza Strip civilians cannot exit the blockade. Egypt
permied some Palesnians to ee Gaza in the early days of the military assault but has subsequently closed the border.
Siege warfare—starvaon of enemy civilians—is also illegal in all armed conicts. This implies that only a valid military goal
may be locked down or sieged. Civilians may not be targeted by the siege, and basic items may be supplied. Even if combat-
ants could get food, it shouldn't be blocked. A complete shutdown, which makes it impossible to supply Gaza’s civilian popu-
laon with food, drinking water and medicines, is, unlike prevenng the import of fuel or the supply of electricity, under no
circumstances proporonate and permissible under internaonal law. Not least, the blockade of supplies vital for life is a
collecve punishment
in accordance with Art. 33 of the Fourth Geneva Convenon and hence violates internaonal humani-
tarian law.
The commitment to Israel's security, condemnaon of Hamas's atrocies, and support for Israel's goal of eliminang Hamas
do not exempt it from internaonal law. Thus, the internaonal community should use its close relaons to Israel to nego-
ate hostage release. It should also establish protecon zones, refrain from using prohibited warfare methods, ensure hu-
manitarian access (and halt violence for humanitarian purposes), and facilitate the delivery of drinking water, food, medi-
cines, and hospital generator fuel to all of Gaza. For medical emergencies and internaonal civilian evacuaon, humanitarian
corridors are needed. Simultaneously, states with es to Hamas, such as Egypt and Qatar, must pressure the group to pro-
tect hostages, advocate for their release, stop rocket re at Israel, and allow civilians to evacuate combat zones.
We should all be outraged by Hamas' October 7th strikes on Israel. Jusce, responsibility, and retribuon for these horrible
killings, the safe repatriaon of capves, and a halt to strikes into Israel must be demanded. However, channelling anger and
anguish towards innocent people, like the 99 United Naons Relief and Works Agency for Palesne Refuges (UNRWA) sta
members who died, cannot preserve peace and security. Some events taking place in the Gaza strip are obscene, and heart-
breaking.
The Israeli government has garnered support from the majority of Western naons since the commencement of the conict.
But over me, several events that many interpret that violate Internaonal Humanitarian Law (IHL) and are deemed taboo
have caused signicant concern, cricism, and calls for acon to stop the bloodshed. Israel's military oensive in Gaza, char-
acterised by the use of powerful explosive weapons that have destroyed tens of thousands of structures, is having signicant
humanitarian and human rights repercussions, as acknowledged by various polical leaders, scholars, and UN agency sta,
despite ongoing polical backing.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 17
A considerable number of experienced humanitarian workers who are currently on the eld nd it dicult to fully grasp the
abhorrent condions to which they and the local populace are being exposed. The casuales incurred by humanitarian work-
ers during this conict, in the rst four weeks, surpassed the cumulave toll of humanitarian workers throughout the Syrian
civil war that has aicted the region for the past four years. Intenonally singled out hospitals include Al Shifa Hospital and
the Indonesia Hospital; the severity of these assaults on medical facilies is truly disconcerng. The road infrastructure in the
vicinity has been signicantly impaired due to the strikes, thereby impeding access to the facility. Addional evacuaon di-
recves have been promulgated for certain establishments, in conjuncon with the overarching instrucons for all inhabit-
ants of northern Gaza to evacuate. Nevertheless, these evacuaons, which contravene World Health Organisaon recom-
mendaons, are tantamount to a "fatal sentence" in southern Gaza, where hospitals are unable to accept addional paents
due to the total collapse of the healthcare infrastructure.
Under internaonal humanitarian law, medical units must always be protected and respected, with access to humanitarian
assistance in its many forms—food, water, and medical supplies—guaranteed in parcular. Any Palesnian armed group that
defends itself with civilians or property is in violaon of war laws. The conduct exhibited by Palesnian armed groups does
not absolve Israel (or any other country in similar circumstances) of its responsibility to safeguard civilians and maintain dis-
ncon, proporonality, and safeguards in the face of assault. Neglecng to do so constutes a breach of military regula-
ons. A considerable number of targeted individuals are in no way associated with violaons commied by armed groups
aliated with the state or non-state. Reducing or eliminang civilian rights in response to the acons of armed groups over
which they have no authority would be illogical.
Self-defense, as invoked by Israel in its response, stands as one of the juscaons for war, with Arcle 51 of the UN Charter
safeguarding this right "if an armed aack occurs". The exercise of this right of self-defense, nevertheless, connues to be
governed by internaonal humanitarian law. State enes are obligated by jus in bello (jusce in war) to alleviate suering
during armed conicts; the lawful exercise of self-defense does not authorise unrestricted use of force. The humanitarian
agencies' asseron that both sides should adhere to the principles of Internaonal Humanitarian Law (IHL) does not imply a
crical assessment of the Israeli government's decision to conduct a military operaon, a lessening of the internaonal com-
munity's outrage over the inial Hamas aack, or an endorsement of one side or the other in the conict. Jus in bello
(internaonal humanitarian law), is merely the body of legislaon that governs the course of hoslies. Its solely humanitari-
an objecve is to alleviate the suering that armed conicts inict. It operates autonomously from the movaons or raon-
ales that drive war, as dictated by jus ad bellum. Furthermore, it is not the intenon of humanitarian actors to comment on
polical and legal issues aecng the status of Territories and who is entled to what. However, defending the lives and dig-
nity of aid workers and noncombatants is a crical component of our mission, and we would be failing miserably to our du-
ty if we did not remind both sides of their respecve use-of-force restricons and demand both sides to honour their com-
mitments.
Those who have extensively engaged with press or social media recently may have observed individuals intertwining the
righteousness of the conict itself with the righteousness of its conduct. Some seem to jusfy the killing of Israeli civilians by
condemning Israel's occupaon of Palesnian territories, while others seem to downplay the killing of Palesnian civilians in
airstrikes, asserng Israel's right to self-defense.
Approaching causes and conduct as disnct maers, as the law does, serves as a method to maintain a clear focus on the
intricacies of war and the underlying polical quesons, without losing sight of the shared humanity on all sides. In the
words of Josep Borrell, the head of foreign policy for the European Union, "Israel has the right to defend itself, but it must do
so in compliance with internaonal and humanitarian law."
Furthermore, this duty of protecon safeguards humanity against its darkest demons, as well as against the disgrace and
degradaon of the human race, in addion to ensuring the lives and welfare of the aected populace. Beyond the scope of
any legislaon, violence, bodily injury, fear, hunger, and harm perpetrated on defenceless persons incapable of reprisal are
not acceptable under the universal moral code. While this does not imply that it has never occurred before, it does indicate
a setback in the development of a moral community. Regardless of the severity of an individual's crimes, even in mes of
peace and across vastly diverse cultures, the criminal jusce system emphasises the value of every human life,. Disrespect
for human life inicts severe suering upon the vicms, but inicts an even greater harm upon the human condion and
community membership of those who commit such acons, which are illegal but primarily immoral in nature.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 18
The Gazan people are currently completely dependant on internaonal aid; but, with no gasoline, electricity, food, or water,
and a besieged region, humanitarian assistance is impossible to deliver. Almost all humanitarian assistance currently de-
pends on UNRWA, whose capacity is nearing the brink of collapse. Characterising the daily situaon in Gaza as inhumane
would be an inaccurate and insucient portrayal. A universal senment among humanitarian workers who have recent-
ly worked in Gaza—and all of them with extensive experience and, unfortunately, a sombre history of witnessing atrocies—
is "I never imagined something of this magnitude was even possible."
As a result, an increasing number of non-governmental organisaons, United Naons ocers, humanitarian aairs experts,
and scholars of internaonal humanitarian law are speaking out in support of an immediate ceasere and suspension of the
siege so that adequate aid can be delivered. We do not inquire about the resoluon of the conict or oer suggesons on
how it ought to be carried out. We refrain from discussing or expressing public views regarding the legal ramicaons of the
manner in which the war was conducted. We simply implore the cessaon of violence, the guarantee of protecon for hu-
manitarian personnel, and the provision of secure access for all recipients of humanitarian aid. We peon for the provision
of shelter, food, water, medical care, and medical aenon, the release of the capves, and the prevenon of any human
rights violaons that may be brought before the courts.
In addion to the exceedingly perilous repercussions that may befall thousands upon thousands of individuals not only in the
region but also in neighbouring or remote naons, we are currently observing one of the most abhorrent humanitarian ca-
tastrophes during a modern war. Indeed, we are not merely losing human lives; we are also profoundly losing the scant rem-
nants of humanity that remain on this planet.
We cannot aord to remain indierent. We do not advocate for an idealised or romancised future; rather, we cauon that
failure to establish a minimally more peaceful and compliant global order will render all regions unsafe, because no locaon
is immune to violence in an inhumane world where we forget that even war has rules.
References
1. Convenon (IV) relave to the Protecon of Civilian Persons in Time of War. Geneva, 12 August 1949.hps://ihl-databases.icrc.org/
en/ihl-treaes/gciv-1949 (accessed December 12, 2023)
2. Protocol Addional to the Geneva Convenons of 12 August 1949, and relang to the Protecon of Vicms of Internaonal Armed
Conicts (Protocol I), 8 June 1977. hps://ihl-databases.icrc.org/en/ihl-treaes/api-1977 (accessed December 12, 2023)
3. Arnold R et al.. Internaonal Humanitarian Law and Human Rights Law: Towards a New Merger in Internaonal Law. 2008
4. Carey J et al. Pritchard R (ed). Internaonal Humanitarian Law: Prospects. Transnaonal Publishers Inc. New York, 2006
5. Ba Aker – Internaonal humanitarian law, ICRC and Israel’s status in the Territories Internaonal Review of the Red Cross.
doi:10.1017/S181638311300060X
6. Hempnne Jérôme Classifying the Gaza Conict Under Internaonal Humanitarian Law, a Complicated Maer. European Journal of
Internaonal Law (Oxford). November 2023, hps://www.ejiltalk.org/classifying-the-gaza-conict-under-internaonal-humanitarian-
law-a-complicated-maer/ (accessed December 13, 2023)
7. Asseburg, Muriel; Wiese, Lisa: Hamas’ Atrocies, Israel’s Response, and the Primacy of Internaonal Law to Protect Civilians,
VerfBlog, 2023/10/31, hps://verfassungsblog.de/protect-civilians/, DOI: 10.59704/597372b78adb07fc.
*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.
Best Image Contest 2024 (1 of 3)
Category: Pleural Diseases
Descripon: RENAL CELL CARCINOMA- METASTASIS TO THE PLEURAL CAVITY
Submier(s): Pree Vidyasagar, Harikishan Gonuguntla, Suhas Dhulipala, Geetha Sekar
Best Image Contest
P A G E 19
This image is 1 of 3 selected among 100+ submissions to our Best Image Contest held in late 2023. Our next
Image Contest will open later this year. We look forward to receiving your image submissions.
P A G E 20
WABIP News
Highlights of WCBIP/
WCBE Congress 2022
Marseille, France during
the X Paraguayan Con-
gress of Pneumology 2023
On October 25, 2023 the presentaon of the
highlights of the WCBIP MARSELLE 2022 was
held in Paraguay during the X Paraguayan
Congress of Pneumology 2023.
We had the pleasure of having an interna-
onal speaker Dr. Mohammed Munavvar who presented Pre-Congress
Course "Hands-on Intervenonal Bronchoscopy Workshop Course", which
was coordinated by the Naonal Regents Dr. Adid Aluan (current) and Dr.
Domingo Perez (former) of the WABIP (World Associaon for Bronchology
and Intervenonal Pulmonology).
We appreciate the support of these internaonal organizaons for the
collaborave scienc acvity, extending our thanks to the regents of
Argenna on behalf of Dr. Agusn Buero and Dr. Silvia Quadrelli with the
aim of solidifying the pulmonary intervenonalism and thereby increase
the quality of paent care in Lan America.
Call for Abstracts - WCBIP Bali Indonesia 2024
We are excited to receive your abstracts for our com-
ing World Congress. Researchers and professionals in
bronchoscopy and intervenonal pulmonology com-
munity are welcome to contribute original abstracts
in the following areas:
Intervenonal Pulmonology, Laryngology, Pleural,
Tracheobronchology, Throracic Surgery, Esophagolo-
gy,
Intrathoracic Cancer, Pediatric Intervenonal Pulmo-
nology
hps://wcbip2024.com/abstract
Submit your abstracts by May 1, 2024
Cooking Lung Cancer!
Transbronchial Microwave Ablaon of Peripheral Lung Tumors
The exploraon and development of Transbronchial Microwave Ablaon (TBMA) for lung cancer treatment have been driven by several factors.
The increasing availability of CT scans and evidence supporng low-dose CT screening in high-risk populaons have led to the incidental discovery
of small lung nodules, many of which may be premalignant or early-stage tumors. This has emphasized the need for local treatment of these early-
stage lung cancers and oligometastases, parcularly in paents unt for surgery. Tradional thermal ablaon methods, such as radiofrequency
ablaon, carried risks like pneumothorax, bronchopleural stula, and tumor seeding. Microwave energy, less aected by lung ssue impedance,
creates a larger, more predictable ablaon zone, making TBMA a promising alternave.
TBMA combines the benets of microwave energy with a transbronchial approach to avoid pleural puncture and reach lung regions dicult for
percutaneous routes. It uses electromagnec navigaon bronchoscopy for navigaon and cone-beam CT for accurate determinaon of the ablaon
zone. The technique has shown a high technical success rate, short hospital stays, and low complicaon rates. However, TBMA is not without limi-
taons, such as risks associated with nodule size and locaon, requiring careful case selecon.
Future direcons of TBMA include using mobile C-arm machines for 3D reconstrucons, making TBMA feasible outside of hybrid operang rooms.
Advancements in roboc bronchoscopy are also paving the way for easier, more intuive TBMA approaches. Invesgaons into other energy
forms, such as thermal vapor and pulsed electric eld, are ongoing. TBMA, along with these adjuncts, represents an excing development in the
treatment of lung cancer.
The NAVABLATE study was designed to invesgate transbronchial MWA as a minimally invasive treatment opon for lung cancer paents ineligible
for tradional surgery or stereotacc body radiaon therapy(1).
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Research
Primary Business Address:
Kazuhiro Yasufuku, Editor-in-Chief WABIP
Newsleer
c/o Judy McConnell
200 Elizabeth St, 9N-957
Toronto, ON M5G 2C4 Canada
E-mail: newsleer@wabip.com
P A G E 21
Associate editor:
Dr. Ali Musani
Associate editor:
Dr. Sepmiu Murgu
Uzair Ghori MD
Assistant Professor of Medicine,
Medical College of WI,
Medical College of Wisconsin/ VA
Milwaukee
Ali I. Musani MD, FCCP
Professor of Medicine and Surgery,
University of Colorado School of
Medicine, Denver
Conducted in two centers in the UK and China, the study enrolled 30 subjects with lung malignancies, 66.7% of which were primary lung can-
cers and 33.3% oligometastac. The mean age of parcipants was 68.4 years, with 40% female representaon. A striking aspect of the study
was its inclusivity, as 47% of parcipants were not candidates for surgery or SBRT, with others declining these opons.
The technical success of the procedure was outstanding, with a 100% success rate in reaching and ablang targeted nodules. Furthermore,
the one-month post-procedure imaging showed 100% technique ecacy, with no new metastac disease or lymphadenopathy observed.
These results are parcularly encouraging, considering the mean nodule size was 13.7 mm.
In terms of safety, the NAVABLATE study demonstrated a low adverse event rate. Only 3.3% of parcipants experienced mild hemoptysis,
and there were no incidences of pneumothorax or deaths. Addionally, 13.3% experienced grade 3 complicaons, but no higher-grade com-
plicaons were observed.
Paents reported minimal pain and discomfort post-procedure, with a signicant decrease in reported pain over a one-month period. This
was paralleled by a slight improvement in the overall health assessment of parcipants, as measured by the EQ-5D-3L scale.
The NAVABLATE study signies a major leap in lung cancer treatment, establishing transbronchial MWA as a viable, less invasive alternave.
Its high success rate and minimal complicaons mark it as a potenal game-changer for paents with limited treatment opons. The results
pave the way for future studies and the potenal widespread adopon of this technique(2).
References:
1. Lau KKW et al. [published online ahead of print, 2023 Sep 25]. J Bronchology Interv Pulmonol. 2023;10.1097/LBR.0000000000000950. doi:10.1097/
LBR.0000000000000950
2. Chan JWY et al. Cancers (Basel). 2023;15(4):1068. Published 2023 Feb 8. doi:10.3390/cancers15041068
Research
P A G E 22
P A G E
23
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