WABIP Newsletter

Honoring Leadership, Embracing the Future: A New Chapter for the WABIP Newsletter

The WABIP Newsletter has long served as an important platform for sharing knowledge, fostering collaboration, and connecting our global community. Much of its success is due to the exceptional leadership of Dr. Ali Musani, whose tenure as Associate Editor has made a lasting impact.

Dr. Musani’s contributions have been truly significant. With a clear vision and commitment to excellence, he strengthened the Newsletter’s role as a trusted voice in interventional pulmonology. He ensured that each issue reflected high-quality scientific content while also highlighting the collaborative and international spirit of WABIP. His thoughtful approach brought together diverse perspectives and encouraged contributions from clinicians and researchers at all stages of their careers.

Under his leadership, the Newsletter evolved into a dynamic platform for academic exchange, showcasing emerging techniques, research advances, and educational insights from around the world. Just as importantly, it became a space that fostered connection within our global community. Dr. Musani’s dedication, attention to detail, and passion for the field have left a strong foundation that will continue to guide the Newsletter moving forward. We extend our sincere gratitude for his outstanding service and lasting contributions.

As we recognize this legacy, we are delighted to welcome Dr. Udit Chaddha as the new Associate Editor of the WABIP Newsletter. Dr. Chaddha is widely respected for his expertise in interventional pulmonology and his commitment to both clinical care and academic advancement. As a clinician, educator, and researcher, he brings a forward-looking perspective and a strong focus on innovation and excellence.

Dr. Chaddha is also deeply committed to mentorship and global collaboration. He values the importance of creating platforms that engage and inspire a diverse international audience. We look forward to this next phase under Dr. Chaddha’s leadership and the continued growth of the WABIP Newsletter.

Please join us in thanking Dr. Musani and warmly welcoming Dr. Chaddha to his new role. Please join us in expressing heartfelt thanks to Dr. Musani and in warmly welcoming Dr. Chaddha to his new role.

The future of the WABIP Newsletter is bright, and we are excited for what lies ahead.

Dr. Kazuhiro Yasufuku

Editor-in-Chief WABIP Newsletter

Two Many Nodules: A Structured Approach to Biopsy Decisions in Patients with Multiple Pulmonary Lesions

Introduction:

Innovation in bronchoscopy—including extended catheter reach, advanced imaging for lesion localization, improved biopsy tools, and expanded molecular diagnostics—now allow access to nearly all regions of the lung¹. As a result, bronchoscopists can increasingly biopsy multiple pulmonary nodules (MPN) during a single anesthetic encounter, often combined with staging linear endobronchial ultrasound (EBUS). Early data suggest that this comprehensive approach can meaningfully alter cancer staging, prognosis, and treatment, particularly in high-risk populations where MPN prevalence approaches 50%^{2, 3}.

However, technical feasibility must not be conflated with clinical necessity. While prospective validation remains limited, biopsy decisions in MPN should be informed by evolving insights into tumor biology⁴, staging implications, and patient-centered risk–benefit considerations. A structured, reproducible framework is needed to guide appropriate patient selection and procedural planning across diverse practice environments.

Indications:

“Medicine is a science of uncertainty and an art of probability.” – Sir William Osler

Despite technological advances, careful clinical assessment remains foundational to decision-making. We utilize multiple tools to determine when, and perhaps more importantly, when to avoid MPN biopsy. We present a schematic in Figure 1 to help guide the decision-making process.

History and Physical Examination

Traditional predictors of malignancy—advanced age, cumulative tobacco exposure, and history of non-cutaneous malignancy—remain relevant. However, emerging evidence suggests synchronous primary lung cancers (SPLC) occur more frequently in women, particularly younger patients and those without smoking history⁵. In contrast, patients with known inflammatory lung disease or exposure to endemic fungal or mycobacterial infections may not require simultaneous biopsy of nodules without compelling radiographic progression. Understanding regional disease prevalence is essential.

Imaging Interpretation

Multifocal lung cancer poses recognized challenges in staging and management. The IASLC classifies MPN into four categories: intrapulmonary metastasis (IPM), separate primary lung cancer (SPLC), ground-glass/lepidic, and diffuse pneumonic type. CT features that inform pre-test probability include nodule size, morphology, density (with subsolid nodules carrying higher concern), margin characteristics, and FDG avidity⁶. Among these, interval change—particularly increasing size, volume doubling time, or solid component growth—remains the most informative predictor of malignancy. Multidisciplinary tumor board discussion is strongly encouraged when diagnostic uncertainty exists.

Clinical Risk Calculators

Most validated malignancy risk calculators inadequately account for MPN or assume lower cancer risk in such patients (e.g., Brock model). We use a biopsy-specific risk assessment tool tailored to patients referred for diagnostic bronchoscopy, applied individually to each nodule to support shared decision-making⁷.

Liquid Biopsy

In patients with prior malignancy and known driver mutations, circulating tumor DNA (ctDNA) may identify residual or recurrent disease earlier than imaging. While informative, this approach remains costly, and limited in availability and broad insurance coverage.

Multidisciplinary Tumor Board Consultation

Advanced bronchoscopists are becoming increasingly facile with the onco-pulmonary literature and are commonly the ‘welcome mat’ for patients into the cancer world. As such, it is imperative that we as a profession develop easy communication pathways with our colleagues in medical and surgical oncology, as well as radiology and radiation oncology. Even in cases where we think MPN biopsy is feasible, determining whether a diagnostic outcome will alter management should take place prior to the day of bronchoscopy and risk exposure.

Planning

Careful planning begins with defining the diagnostic objective. When malignancy is suspected, the goals are tissue diagnosis and accurate staging. The significance of MPN is greatest when nodule size or location would upstage disease and preclude curative options such as surgical resection or stereotactic body radiotherapy.

Temporal behavior is also informative. Nodules with discordant growth patterns may represent separate disease processes and warrant individual pathologic confirmation.

Procedural Technology and Capability

Operators must realistically assess local expertise, available technologies, pathology support, and peri-procedural infrastructure. While robotic-assisted bronchoscopy, cone-beam CT, and rapid on-site evaluation (ROSE) enhance diagnostic confidence, they are not universally required. Success depends on aligning procedural ambition with institutional capability.

Informed Consent

Patients and providers alike should be advised that biopsy of MPN increases procedural complexity and risk. In our multicenter registry⁸, overall diagnostic yield exceeded 70%, with no difference between first and second nodules. However, pneumothorax occurred in 7.3% of cases (2.1% requiring chest tube), exceeding rates typical of single-nodule biopsy.

Sampling

Anesthesia Considerations

Our approach includes utilization of general anesthesia with supine positioning with moderate PEEP (8–12 cm H₂O), minimal FiO₂ to reduce resorptive atelectasis, and efficient intubation. Routine recruitment maneuvers are avoided but may be used selectively if atelectasis develops. Apneic oxygenation and lateral decubitus positioning can be considered if local expertise allows. We highly recommend discussion with your anesthesiology providers to determine protocols and expectations. Moderate sedation should be performed only by operators with significant experience, as these cases will frequently exceed an hour in duration.

Nodule Sequence

To minimize atelectasis-related targeting error, the most radiographically suspicious nodule should generally be biopsied first. If nodules are equally concerning, priority is given to anatomically vulnerable regions (e.g., dependent lower lobes or ground-glass lesions).

Role of Rapid On-Site Evaluation

Our registry demonstrated strong within-pair dependence of diagnostic outcomes: malignancy, benignity, and non-diagnostic results in the first nodule markedly increased the odds of concordant findings in the second. When available, ROSE can therefore inform whether continued sampling is likely to alter management, though this should be utilized with your pre-test probabilities as mentioned earlier.

Safety Between Biopsies

After the first biopsy, we routinely assess for a pneumothorax using fluoroscopy and or POCUS if local expertise allows. Continuous monitoring of airway pressures, oxygenation, and bleeding is essential before proceeding. Procedure duration, anesthesia exposure, staffing demands, and cumulative radiation dose should be weighed carefully, as longer and more complex procedures increase cost and patient risk.

Quality Control

As with any advanced procedural program, outcomes must be monitored to ensure clinical value. Diagnostic yield, complication rates, and downstream management changes should be tracked. Close collaboration with cytopathology is essential to optimize specimen adequacy and facilitate next-generation sequencing. Finally, engagement with the multidisciplinary thoracic oncology team helps ensure that biopsy practices align with evolving treatment pathways and patient-centered goals.

In conclusion, bronchoscopic technology has afforded patients and providers a pathway to MPN and lymph node staging in the same anesthesia event. Multidisciplinary coordination and careful patient selection are critical to program success.

References

1. Lentz RJ, Frederick-Dyer K, Planz VB, et al. Navigational Bronchoscopy or Transthoracic Needle Biopsy for Lung Nodules. N Engl J Med. 2025;392(21):2100-2112.

2. Murray C, Lee R, Bruce S, et al. Shape-Sensing Robotic Bronchoscopy With Simultaneous Biopsy of Multiple Ipsilateral and Bilateral Pulmonary Nodules. J Bronchology Interv Pulmonol. 2026;33(2).

3. de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced Lung-Cancer Mortality with Volume CT Screening in a Randomized Trial. N Engl J Med. 2020;382(6):503-513.

4. Hessey S, Bunkum A, Huebner A, et al. Evolutionary characterization of lung cancer metastasis. Nature. 2026.

5. Zitricky F, Sundquist K, Sundquist J, et al. Increase in second primary lung cancers in a nation-wide cohort study from Sweden. Thorax. 2026.

6. Detterbeck FC, Woodard GA, Bader AS, et al. The Proposed Ninth Edition TNM Classification of Lung Cancer. Chest. 2024;166(4):882-895.

7. Reid M, Choi HK, Han X, et al. Development of a Risk Prediction Model to Estimate the Probability of Malignancy in Pulmonary Nodules Being Considered for Biopsy. Chest. 2019;156(2):367-375.

8. Christopher M. Kapp1, Momen M. Wahidi1,2, Jamie H. Rowell 1,2, Sylvia S. Yong3, Benjamin J. Seides2, Sean B. Smith 1,2, Bharat Balan2, David Dibardino5, Kevin Haas4, Brian White2, Jeremy J. Kim6, Irene Riestra Guiance7, Rohan Bhargava1, Natalia H. Diaz10, Alejandra Y. Lee-Mateus8, David Abia Trujillo8, Gerard A. Silvestri9, Yupeng Liu1, Courtney Pfister1, Jeffrey Thiboutot10,. Robotic Assisted Bronchoscopy with Endobronchial Ultrasound for the Evaluation of Multiple Pulmonary Nodules: A Multi-Center Registry Ann Am Thorac Soc. 2026.

 Bhargava R,et al. Am. J. Respir. Crit. Care Med. 2026; 212(1). aamag162.3392, https://doi.org/10.1093/ajrccm/aamag162.3392

Achieving Expertise in Interventional Pulmonology

The world of procedural education is changing fast in the times of AI, social media, high tech simulators and an increasing number of hands-on workshops around the world. Interventional Pulmonology (IP) training has grown significantly over the last two decades with increasingly formalized and regulated training programs. We believe that addressing topics pertinent to IP training is not only timely and very interesting to us, the editors of this newsletter, but also relevant for trainees and educators globally. Starting with this issue of May 2026, the WABIP Newsletter editors are excited to introduce a new section with the main purpose being to empower interventional pulmonologists with the knowledge and skills to become more impactful educators and leaders. The main goals are to provide specific tips learned from the science of expertise, our experiences and evidence-based adult learning principles that we trust are universally applicable and possibly enduring, until new evidence may change our minds.

In this first issue, we are providing an overview of the principles that are believed to lead to expertise in any domain. This essay explores the meaning of expertise, the process by which it is developed, and the challenges physicians face while striving for expertise in IP. Future essays written by diverse IP experts will address each of these themes introduced below in more details.

Why do we seek expertise?

Expertise in IP, similarly to expertise in many non-medical domains, is not simply a product of titles, years of experience, or academic recognition. Instead, it is the result of a complex combination of deliberate practice, quality feedback, intuitive thinking, and adaptability developed over many years of disciplined work. Through insights drawn from psychology, medical education science, and the history of IP, we challenge clinicians to rethink how expertise in IP is defined and how it can be achieved.

One of the main questions is why we seek expertise in the first place. Motivation varies among physicians. Some are driven internally by intellectual curiosity, the desire for mastery, and the satisfaction of solving difficult problems. Others are influenced by external rewards such as professional recognition, career advancement, financial success, and respect from peers. For some clinicians, both intrinsic and extrinsic motivations become intertwined with personal identity. Being known as experts in IP becomes part of how they define themselves professionally and personally. Pursuing expertise, however, solely for recognition is insufficient and sustainable growth requires perseverance and commitment to lifelong learning.

How do we recognize an expert in IP?

Defining expertise itself is surprisingly difficult, especially in a field like IP, where there is paucity of benchmarks for quality and safety. Our community of IP peers and maybe patients alike often assume that experts are those with prestigious titles, an extensive list of publications or decades of experience. Yet, as in many other domains, experience alone is necessary but not sufficient for achieving expertise and by itself, experience does not necessarily predict future success. For instance, a physician might have performed many procedures for many years without consistently achieving optimal outcomes, maybe because of lack of oversight or feedback. Conversely, another clinician may demonstrate extraordinary technical skill and clinical judgment despite fewer years in practice. Expertise must ultimately be measured through performance rather than years of experience. There are other limitations in our routine methods used to identify experts. Academic publications reflect content expertise but may not accurately represent clinical proficiency. Certification standards are a step forward in the strive for expertise, but they differ among countries, making them imperfect markers of proficiency. Social media and conference presentations frequently showcase successful cases but are ignoring the “base rate”—the full range of outcomes, including complications and failures seen in the presenter’s practice. In addition, peer recognition can also be distorted by what psychologists call the “Halo effect,” a cognitive bias in which one commendable trait causes observers to overestimate expertise in unrelated areas. For instance, an engaging speaker with a charismatic personality may be assumed to possess superior procedural skills without objective evidence. Expertise, in fact, is often fragmented and domain, even procedure-specific rather than universally transferable between different areas of practice.

The Journey from Novice to Expert

To better understand the journey to expertise, we briefly discuss the Dreyfus model of skill acquisition. This model describes five developmental stages through which learners progress: novice, advanced beginner, competent, proficient, and expert. Novices depend heavily on rules, protocols, and checklists because they lack experiential understanding and they need structure and a step-by-step approach to performance of procedures. As experience accumulates, however, clinicians become more intuitive and adaptable. Experts no longer consciously analyze every step and instead, they recognize patterns rapidly and respond fluidly to dynamic situations. This transition from analytical reasoning to intuitive judgment is particularly important in IP, where procedures often unfold under conditions of uncertainty, time pressure, and high stakes.

Psychology studies argue that intuition is not mystical talent, but a sophisticated pattern recognition acquired through prolonged exposure and feedback. In complex clinical situations, experts frequently make rapid decisions because previous experiences allow them to recognize familiar patterns subconsciously. Research from psychologists including Daniel Kahneman and Gary Klein argue that true expertise emerges only under specific conditions: a sufficiently predictable environment, prolonged opportunities for practice, and availability of immediate, high-quality feedback. IP training and practice satisfy many of these conditions because clinicians repeatedly encounter similar anatomical and procedural challenges while receiving direct immediate feedback from patient outcomes and if fortunate, from their peers and mentors.

Grit and Deliberate Practice

Expertise also requires effort and perseverance. Drawing on the work of psychologist Angela Duckworth, we propose that expertise in IP depends on both developing skills and sustained effort. Procedural skills are developed through innate talent combined with long-lasting effort. Therefore, effort counts twice. The concept of “grit,” defined as passion and perseverance toward long-term goals, becomes essential in procedural medicine. Many individuals begin enthusiastically, but endurance is necessary to achieve expertise. We acknowledge the role of luck, mentorship, institutional support, and personal circumstances as successful careers are rarely shaped by individual determination alone.

Furthermore, to become experts, clinicians, like experts in other domains, require deliberate practice rather than mere repetition of tasks without a predefined goal. Deliberate practice involves focused, goal-oriented training designed specifically to improve performance in targeted areas. The work of the psychologist Anders Ericsson demonstrated that experts distinguish themselves by continuously practicing at the edge of their abilities while seeking corrective feedback. In IP, for example, this may involve repeated refinement of rigid intubation techniques, airway stent placement, or management of procedural complications. Simply accumulating procedure numbers without reflective improvement is likely insufficient to achieve expertise.

Why feedback matters?

Feedback is particularly important because clinicians often overestimate their competence, especially after a limited period of experience. Very early in training, true novices know they are inexperienced and their perception of their skills (or lack of) is accurate. However, after an initial success, confidence may rise faster than actual ability, creating a dangerous overconfidence. This phenomenon is known metaphorically as reaching the summit of “Mount Stupid.” Without honest feedback and remediation plan, physicians may remain unaware of their deficiencies. Checklists and structured evaluations help address this problem for novices and advanced beginners by breaking complex procedures into observable steps that can be objectively assessed. As far as educators are concerned, these tools also combat the “curse of expertise,” in which highly skilled individuals struggle to teach novices because many aspects of their performance have become automatic and unconscious as part of complex mental modeling.

Enriching clinical experience through simulation

Simulation training offers a powerful method for developing expertise. High-quality simulation enables trainees to encounter rare complications and difficult scenarios in a safe environment without risking patient harm. By recreating technical and cognitive challenges, simulation accelerates learning and enhances pattern recognition. In modern procedural medicine, simulation may provide more educational value than simply waiting for appropriate cases to arise naturally in clinical practice. Not every simulation training needs expensive tools or technologies. In fact, mental simulation, and routine application of “premortem” analyses, could be very useful in addressing the relatively low frequency, high impact scenarios in IP.

Nothing lasts forever

Finally, expertise is dynamic rather than permanent. Technologies evolve, procedures change, and once-dominant techniques may become obsolete. For example, airway laser therapy, once central to IP practice, has declined in popularity (at least in the USA) with the emergence of newer cryotherapy and electrosurgical technologies. Experts must therefore remain adaptable and committed to continuous learning as failure to evolve results in professional stagnation and inability to stay relevant in the current educational environment.

We conclude this introductory IPED essay by stating that expertise in IP is not defined only by status, experience, or public recognition. True expertise emerges through many years of deliberate practice, structured training, resilience, feedback, and the gradual development of intuitive judgment grounded in experience. It requires adaptability and lifelong learning and is not destination but an ongoing process of refinement and growth. The pursuit of expertise for us, IP physicians, is a lifelong challenge and a professional responsibility.

Septimiu Murgu, MD, FCCP, DAABIP

Professor of Medicine

Director, Interventional Pulmonology Training Program

The University of Chicago

smurgu@uchicagomedicine.org  

References:

1. Hubert Deyfus, Stuart Deyfus. Mind Over Machine: The Power of Human Intuition and Expertise in the Era of the Computer (Free Press).

2. Angela Duckworth. Grit: The Power of Passion and Perseverance (Simon & Shuster)

3. Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009 Sep;64(6):515-26.

4. Anders Ericsson, Robert Pool. Peak: Secrets from the New Science of Expertise (Eamon Dolan/HMH) 

5. Fisher M, Keil FC. The Curse of Expertise: When More Knowledge Leads to Miscalibrated Explanatory Insight. Cogn Sci. 2016 Jul;40(5):1251-69. 

Future IPED Corner topics in the WABIP Newsletter

• Optimizing skill acquisition in IP

• Checklists and Assessment tools

• Intuitive Judgment in IP

• Simulation Training in IP

• Premortem analysis for high-risk procedures

• Adaptive Expertise for IP educators

• Heuristics versus Statistics in IP Decision Making

• Deliberate Practice in IP: why, what, how and when?

• Naturalistic Decision Making in High-Risk Procedures

• Feedback during IP procedures: is it different from regular training?

• Tough Stories in IP: lessons learned from non-routine events!

• Cognitive biases in IP education: the “Halo” and “Dunning Kruger “effects

Announcing June 2 as World Interventional Pulmonology Day
Joint Statement by WABIP, EABIP, AABIP, APAB, TTS and TSANZ

The World Association for Bronchology and Interventional Pulmonology (WABIP), the European Association for Bronchology and Interventional Pulmonology (EABIP), the American Association for Bronchology and Interventional Pulmonology (AABIP), the Asian-Pacific Association for Bronchology and Interventional Pulmonology (APAB), the Turkish Thoracic Society (TTS) and Thoracic Society of Australia and New Zealand (TSANZ) are proud to stand aligned in announcing the official establishment of World Interventional Pulmonology Day, to be celebrated globally every year on June 2.

This specific date has been chosen to commemorate the birthday of Gustav Kilian, historically recognized as the pioneer of bronchoscopy. Dr. Kilian’s groundbreaking work laid the foundation for our specialty. By marking his birthday as a day of global recognition, we embrace our shared mission: Honoring the past. Advancing the future.

World Interventional Pulmonology Day recognizes the profound impact of interventional pulmonology in improving the lives of patients with respiratory diseases worldwide. Today, our field utilizes cutting-edge, minimally invasive techniques to diagnose and treat complex thoracic conditions, offering hope and improved quality of life to millions.

This day serves as a unified, global declaration of our core objective: Better Airways, Better Care, Better Outcomes.

The unprecedented alignment of WABIP, EABIP, AABIP, APAB, TTS and TSANZ underscores a shared, borderless commitment to advancing the science, education, and clinical practice of interventional pulmonology. Together, we strive to ensure that patients across all continents have access to the highest standard of care.

We invite medical professionals, healthcare institutions, industry partners, and patient advocacy groups around the world to join us every June 2. Together, let us celebrate the achievements of our field, raise awareness about the importance of respiratory health, and continue the legacy of innovation sparked by Gustav Kilian.

Signed,

Pyng Lee, MD PhD
Chair, WABIP

Erik H.F.M. van der Heijden, MD, PhD
President, EABIP

Carla Lamb, MD, FACP, FCCP
President, AABIP

Kiyoshi Shibuya, MD, PhD
Chair, APAB

Çağlar Çuhadaroğlu, MD, PhD
President, TTS

Natasha Smallwood, MD, BMedSci, MBBS, MSc, MHLM, AFRACMA, FRCP, FRACP, PhD, FThorSoc, FAPSR, GAICD
President, TSANZ

Best Image Contest 2026 (2 of 3)

Pleural Diseases

Rare Visualization of a Diaphragmatic "Chocolate Cyst" in Bilateral Catamenial Pneumothorax: This thoracoscopic image captures a defining macroscopic view of the left hemidiaphragm in a 38-year-old female who presented with acute, spontaneous bilateral pneumothorax. The central lesion is a classical "chocolate cyst" (diaphragmatic endometrioma), containing thick, dark-brown altered blood. The surrounding tissue exhibits neovascularization and hemosiderin deposition, reflecting the repeated cyclical hemorrhage characteristic of Thoracic Endometriosis Syndrome (TES). While TES is frequently suspected, this vivid visualization of the endometrial implant provides definitive confirmation of the transdiaphragmatic pathophysiology underlying the patient’s rare dual lung collapse. Such direct thoracoscopic visualization of hepatic herniation in thoracic endometriosis is exceptionally rare.

Credits / Image courtesy of

Dr Neelesh Guttikonda, Dr Vijay Kumar Chennamchetty

Re-Visiting Accessing a Dry Pleural Space During Medical Thoracoscopy

Medical thoracoscopy (MT), by enabling direct visualization of the pleural cavity and targeted biopsies of the parietal pleura, plays a central role in the diagnosis of both, malignant and benign pleural conditions. MT is usually performed in patients with an existing pleural effusion, with the proceduralist using the fluid as a ‘window’ to safely access the pleural space. However, a subset of patients with pleural diseases may not have a sufficient pleural effusion – either at baseline or following a recent pleural fluid aspiration. In these cases, the lung remains closely apposed to the parietal pleura, creating what is referred to as a ‘dry pleural space’. Accessing this space in a spontaneously breathing patient, as is standard during MT, is inherently different than in a surgical setting where controlled lung deflation is achieved under general anesthesia. The primary concern during MT in a dry space is the risk of lung injury due to the absence of a fluid ‘window’ during pleural entry. Historically, a few techniques have been employed to mitigate this risk, including induction of a pneumothorax using a Boutin or Veress needle, the use of blunt-tipped instruments, or blunt dissection through the chest wall. Recently the use of an optical trocar has also been described, with the potential advantage of adding real-time visual confirmation of tissue planes during entry in addition to the tactile feedback.

Thus far, most published evidence in dry space MT is derived from retrospective, single-enter experience from high-volume centers, questioning their generalizability to all practice settings. Moreover, heterogenous techniques and outcome definitions limit accurate interpretation of the data. Only 4 studies included more than 50 patients (Corcoran 2015, Watanabe 2014, Yang 2024, Ganjaei 2025). However, now with a cohort of more than 400 patents in published literature (Huan 2025, Ganjaei 2025), we can draw a few meaningful conclusions on dry pleural space access during MT:

1. Dry space access remains a procedure requiring a greater degree of technical skill

• While sonographic lung sliding is used as a surrogate to confirm the absence of extensive adhesions, it remains imperfect. In some series, 10-60% of patients had adhesions (Marchetti 2015, Corcoran 2016, Imabayashi 2021, Yang 2024, Ganjaei 2025) which likely required systematic adhesiolysis to achieve adequate exposure for pleural space inspection and biopsies. Given these challenges, some series have reported an inability to obtain biopsies in 8-13% of patients (Watanabe 2014, Yang 2024, Corcoran 2015).

• Reported complication rates are non-negligible. While most series report no complications, a couple of series report a small number of cases of lung injury (Watson 2018, Yang 2024).

2. Procedural nuances

• Given the occasional need for concurrent adhesiolysis, these procedures should be performed when rigid thoracoscopy equipment are available. Another important consideration is the administration of local anesthesia. Conventionally, pleural fluid allows for precise placement of an anesthetic just superficial to the parietal pleura. In dry spaces, this step is challenging and relies either on ultrasound-guided, in-plane injection or a pre-procedure regional nerve block to provide more reliable analgesia.

3. Patient selection remains the key

• Dry space access with MT should be avoided in patients who have undergone prior lung surgeries, due to the higher likelihood of encountering complex adhesions in these cases. While the presence of lung sliding on ultrasound at the site of entry to confirm the absence of adhesions, remains imperfect, the absence of lung sliding at the site of entry should contraindicate dry space access during MT. In such scenarios patients should be referred for VATS, or percutaneous image-guided sampling, when a prominent pleural target is present.

4. The added value of utilizing an optical trocar for dry space access needs to be determined in a multicenter prospective setting.

Given the above points of caution, we must highlight, that when expertise is available and dry space access is deemed feasible, it may serve tremendous value. As discussed above, many patients with pleural disease, particularly those with early malignancy, tuberculous pleuritis or indolent inflammatory conditions, may not have significant effusions at presentation. Delaying a fluid aspiration or biopsy until ‘sufficient’ fluid accumulates can lead to diagnostic delays, potential impacting staging, treatment decisions and overall outcomes. Lung cancer, for example, often presents with minimal effusion with or without pleural deposits (Kim Radiology 2011, Ryu J Clinc Onc 2013); early diagnosis here is critical for appropriate staging and molecular characterization (which is fairly easily achieved with large thoracoscopic pleural biospies). Patients with “dry” pleural disease have demonstrated improved survival compared to those with large effusions; however, this likely reflects a lead-time bias than an intrinsic biological difference.

In summary, accessing a dry space during MT to obtain pleural biopsies is feasible and safe, and data have demonstrated >90% success rates (Huan 2025). Nevertheless, success remains highly dependent on operator expertise, careful patient selection, and meticulous technique. Moreover, none of the studies report long-term outcomes which does limit interpretation of the true diagnostic accuracy. Prospective, multicenter research should be prioritized with standardized definitions and follow-up, to better define patient selection, technique, predictors of success and complications. Comparative effectiveness trials against VATS, while ideal to clarify success and safety, will be more challenging to conduct. As experience with dry space MT grows and more data emerges, this approach will help expand the diagnostic reach of MT, enabling earlier and more accurate evaluation of pleural diseases. As more proceduralists in high-volume MT centers familiarize themselves with the ‘not-so-new’ technique of accessing a dry pleural space, I hope that this gets embedded into training pathways and dedicated hands-on thoracoscopy workshops.

Figure 1: 30-year-old female with history of a kidney transplant 3 years prior was noted to have pleural nodules and no effusion on a CT chest scan performed for cough. Dry space MT was performed and biopsies of these parietal pleural nodules demonstrated post-transplant lymphoproliferative disorder.