WABIP Newsletter

Passing the Pen: A Message of Gratitude to the WABIP Newsletter’s Editorial Board

After more than a decade of service, it is with very mixed emotions that I have decided to step down from my position as one of the Associate Editors of the World Association for Bronchology and Interventional Pulmonology (WABIP) Newsletter.

This was not an easy decision. However, with ever-increasing responsibilities at work, Interventional Pulmonology Institutes in Istanbul and Nairobi, editorial responsibilities with the Journal of Bronchology and Interventional Pulmonology, and my rapidly approaching presidency of the WABIP, I have reached a point where I need to step back from some of my other commitments. Just as importantly, I believe this is the right time to give this opportunity to a younger, energetic colleague who can bring new ideas, perspectives, and vision to the Newsletter.

One of the greatest privileges of this role has been the opportunity to work side by side with two of my closest friends and most respected colleagues: Dr. Kazu Yasufuku and Dr. Tim Murgu, who have served as Editor-in-Chief and Associate Editor, respectively. Working with them has been both an enlightening and deeply rewarding experience.

Kazu and Tim embody the highest standards of scientific integrity and possess an extraordinary depth of knowledge in interventional pulmonology and medicine. Their thoughtful leadership, maturity, and understanding of the needs of the global interventional pulmonology community have helped make the WABIP Newsletter an important and relevant source of up-to-date information for physicians around the globe. Their passion for education and for training physicians around the world is truly remarkable.

I will especially miss our editorial meetings—often informal and late at night, yet always productive—as we wrote, planned future issues, invited authors, and reviewed articles for the Newsletter. Those experiences, and the friendships behind them, will remain among my fondest memories of this role.

I am confident that the WABIP Newsletter will continue to grow and remain an accessible and valuable window into the world of interventional pulmonology for thousands of readers across the globe, particularly for those who may not have the same access to medical journals, textbooks, and educational resources that many of us in the developed world are fortunate to have.

I am also delighted to welcome Dr. Udit Chaddha as the new Associate Editor of the Newsletter. I truly could not have thought of a better person to take my place. Udit is a highly respected scholar, scientist, and leader in interventional pulmonology—and, as a fellow New Yorker, someone I am especially pleased to see joining the editorial team. I am confident that his energy, insight, and vision will help take the Newsletter to the next level.

I would also like to express my sincere gratitude to Judy McConnell for her extraordinary managerial support over the years. She has been an invaluable guide and steady presence for the editorial team, helping keep everything moving forward while the rest of us balanced these responsibilities with our demanding day jobs.

Although I am stepping down from my formal editorial role, I will always remain available to support the editorial board and the Newsletter in any way I can.

To Kazu, Tim, Judy, Udit, and the entire WABIP Newsletter team, thank you for the friendship, collaboration, learning, and countless wonderful memories over the years. It has been an honor and a privilege to serve alongside you.

I wish the WABIP Newsletter and its editorial team continued growth and every success in the years ahead.

Ali Musani, MD, FCCP, DAABIP

Managing Loss of the Airway During Rigid Bronchoscopy

Introduction

Loss of a patent airway during therapeutic rigid bronchoscopy is probably the most consequential emergency encountered in interventional pulmonology. Although rare, the consequences are potentially catastrophic as the situation can evolve within seconds from a controlled therapeutic procedure to profound hypoxemia, hemodynamic collapse, and hypoxic or anoxic brain injury. In the multicenter AQuIRE registry, complications occurred in 3.9% of 1,115 therapeutic bronchoscopies for malignant central airway obstruction, with substantial variation among centers. Urgent and emergent procedures and greater underlying illness were associated with higher complication rates, although there was no difference between flexible and rigid therapeutic bronchoscopic interventions (1). From those patients who had complications, 0.5% died (most within 24 hours post procedure). The paradox is that these procedures are often performed specifically to restore airway patency, yet manipulation of a critically narrowed central airway can transiently transform a severe but incomplete obstruction into a complete one. The margin for error is particularly small because many patients undergoing rigid bronchoscopy already have compromised pulmonary or cardiac reserve (2).

Several scenarios can precipitate sudden loss of ventilation. Massive hemorrhage may rapidly obstruct the central airways and obscure visualization. Large blood clots can form and completely obstruct the trachea and/ or mainstem bronchi. During mechanical or thermal tumor debulking, a large tumor fragment may become displaced and convert a partial obstruction into complete airway occlusion. The critical challenge is therefore anticipating how airway patency will be restored when visualization, ventilation, or both are suddenly lost. Successful management depends on preparation before induction, immediate availability of rescue equipment, familiarity with multiple methods of restoring airway patency, and proper communication between the bronchoscopy and the anesthesiology teams.

Planning for Loss of the Airway

The management of catastrophic airway obstruction begins before the rigid bronchoscope enters the airway. The procedural team should identify the mechanism by which ventilation could potentially be lost and develop a rescue strategy appropriate to that mechanism. For instance, a patient with a nearly occlusive central airway tumor (Figure 1 top left) presents a different risk from a patient undergoing treatment of a highly vascular endobronchial lesion. Specifically, in the former scenario, the tumor must be bypassed or safely cored out to restore airway patency while in the latter, rigid bronchoscopic intubation of the opposite bronchus can be a temporizing measure if brisk bleeding occurs during tumor manipulation. For particularly high-risk cases, the pre-procedure discussion should address whether veno-venous extracorporeal membrane oxygenation (VV-ECMO) support may be necessary. When the likelihood of complete airway obstruction is substantial and conventional ventilation may become impossible, elective cannulation and even initiation of VV-ECMO before induction should be considered in collaboration with an experienced ECMO team. VV-ECMO is most useful in this setting when it is incorporated prospectively into the airway strategy rather than viewed as a last-minute rescue maneuver (3). Similarly, when major unilateral hemorrhage is a foreseeable complication, the equipment necessary to isolate the bleeding lung should already be immediately available. Endobronchial blockers can be particularly valuable because isolation of the affected lung may protect the contralateral lung from blood contamination while other measures are undertaken to achieve hemostasis. Of course, prevention of loss of airway is key in critical obstruction, and this may include proper laser coagulation of the tumor prior to debulking, and balloon dilation as a rapid recanalization tool prior to bypassing the obstruction.

Large Suction Tubing as an Airway-Rescue Tool

Effective suction is fundamental during rigid bronchoscopy, yet standard rigid suction instruments (Figure 1 top middle and right panels) are not always adequate when the airway suddenly fills with large quantities of blood, clot, secretions, or tumor debris. One practical approach is to use large-bore suction tubing designed to maintain high flow rates without collapsing under substantial negative pressure (Figure 1 bottom panels). In my operating room, I routinely use large suction tubing, (5 or 6 mm inner diameter), during rigid bronchoscopy. After removal of the terminal rubber connector (white or blue rubber component), the tubing itself can easily pass through a 12-mm rigid Efer Dumon bronchoscope and blindly suction large amount of blood or clots or tumor fragments (Figure 1 bottom panels). This simple modification provides a large-caliber, flexible suction conduit and can be substantially more effective than relying exclusively on conventional rigid bronchoscopy suction tubing when rapidly clearing the airway is necessary. As with any nonstandard equipment modification, however, the team should confirm compatibility with the specific bronchoscope before relying on it during an emergency. Another option, of course, is to use the actual rigid bronchoscopy suction catheter. In my experience, however, it is less effective for evacuating large volumes of blood or secretions during a true airway emergency. Grasping forceps and cryotherapy probes can be used for debulking and removing large tumor fragments but they may take a long time (in the case of forceps). While contemporary reviews of central airway obstruction include cryoextraction among bronchoscopic methods for clot removal (4), caution is needed with cryo (keep short freeze time), as longer times will lead to an ice ball-tumor block that can be larger than the rigid bronchoscope and the tumor can be dislodged from the probe during retrieval, fall back and obstruct the airway (Figure 2).

Bypassing the Obstruction: A Modified Seldinger Concept

When visualization is lost, repeatedly attempting to identify a small residual airway lumen with the tip of the rigid bronchoscope may be unsuccessful and potentially traumatic. An alternative is to apply the conceptual principles of the Seldinger technique: first establish a pathway through or beyond the obstruction using a smaller, more maneuverable device and then advance the larger instrument over that established pathway. The transparent suction catheter can serve this purpose (Figure 3). Because the catheter is substantially smaller and more maneuverable than the rigid bronchoscope, it may be possible to advance it through or beyond an obstructing tumor or clot even when direct visualization has become severely compromised. Once a path beyond the obstruction has been established, the catheter can function as a “guidewire” over which the rigid bronchoscope is carefully advanced, allowing the operator to bypass the obstruction and re-establish access to a patent distal airway (Figure 3). This technique can be particularly valuable when the normal visual landmarks have completely disappeared. Rather than depending entirely upon direct visualization, the operator uses an already established pathway to regain distal airway access and by advancing the rigid scope using tactile feedback. This is a “coring out” procedure but safer, in my opinion, as there is more reassurance that the rigid bronchoscope will remain co-axial with the airway. “Blind” advancement based on tactile feedback, however, is an acquired skill and even in experienced hands can lead to creation of a false passage especially if the airway structures are destroyed by tumor. In these satiations, if time allows, inserting a flexible scope that can bypass the obstruction and advancing the rigid tube over it to a patent distal airway may be a safer option.

Quality Control: The Rigid Bronchoscope Is the Airway

A thorough pre-procedure briefing must be done and include all seven elements of intent (purpose, objectives, steps of the procedure, rationale for the steps, critical steps, antigoals, constraints). Yet, careful equipment preparation, and explicit rescue strategy can reduce risk, but they cannot eliminate the possibility of catastrophic airway obstruction. The team must therefore also agree on what not to do when ventilation deteriorates. This is important as one suggestion that occasionally arises during a crisis is to remove the rigid bronchoscope so that the anesthesiologist can intubate the patient with an endotracheal tube. In most rigid bronchoscopy airway emergencies, I believe this approach should be resisted unless there is a compelling and specifically identified reason to abandon the rigid airway. The essential point is simple: there is already an airway in place—the rigid bronchoscope. Moreover, the rigid bronchoscope generally provides a working lumen larger than that of an endotracheal tube while simultaneously permitting passage of suction catheters, forceps, balloons, blockers, stents, and other rescue tools (i.e. application of hemostatic agents). Removing the rigid bronchoscope sacrifices both airway access and the therapeutic working channel precisely when those capabilities may be most valuable. Replacing the rigid bronchoscope with an endotracheal tube also requires withdrawing from an airway whose anatomy may already be distorted, obstructed, bleeding, or impossible to visualize. Furthermore, and more importantly, re-establishing access through the glottis does not necessarily solve the underlying problem below it. The critical issue is usually an obstructed distal trachea rather than failure to access the upper airway. The priority should therefore usually be to maintain the established rigid airway and restore patency with it and through it.

ECMO: Planning Strategy Rather Than Last-Minute Rescue

ECMO has broadened the management possibilities for selected patients with extraordinarily high-risk central airway obstruction. Published experience demonstrates that rigid bronchoscopic interventions can be successfully performed under ECMO support when conventional ventilation is considered unsafe or inadequate (3). However, when ventilation becomes critically impaired, calling the ECMO team may be too late. Although understandable, this can create a false sense that ECMO represents an immediately available rescue intervention. In a rapidly evolving complete airway obstruction, time is measured in minutes. Mobilizing an ECMO team, preparing equipment, obtaining vascular access, cannulating the patient, establishing an extracorporeal circuit, and achieving adequate oxygenation may take much longer than the brain can tolerate profound hypoxemia. ECMO guidelines and clinical trials emphasize that the duration from the moment the patient collapses to the moment the ECMO machine is fully running should ideally be under 60 minutes (5), clearly still too long of a time in case of an airway catastrophe during a rigid bronchoscopy. The precise feasibility and cannulation time will vary substantially among institutions and circumstances, but emergency ECMO should not be assumed to provide immediate oxygenation in a patient who has already lost the airway. Therefore, when ECMO is believed to be necessary to safely perform a procedure, the more reliable strategy is to incorporate it prospectively. In selected exceptionally high-risk cases, this may mean set up and cannulation (the most time-consuming steps) and if clinically justified, establishment of extracorporeal support before induction and before manipulating the airway.

Conclusion

Catastrophic loss of ventilation during rigid bronchoscopy is best managed by anticipating the mechanism of failure rather than improvising after it occurs. The procedural briefing should identify the likely threats of complete obstruction: hemorrhage, clot formation, displacement of tumor, inability to bypass a mass or fibrotic airway stricture, or contamination of the contralateral lung. Appropriate rescue equipment, including large-bore suction, endobronchial blockers, extraction devices, and rigid bronchoscopes that can be advanced and establish a path beyond an obstruction—should be immediately available. But if complete obstruction occurs, several principles become especially important: restore access to the patent more distal airway, effectively clear blood and tumor debris, isolate a bleeding lung when necessary, and be able to establish a pathway beyond an obstruction when conventional visualization is lost. The team should recognize that the rigid bronchoscope is itself the airway and an essential rescue tool. Removing this large working airway in favor of a smaller endotracheal tube during a central airway catastrophe will eliminate the very access required to resolve the problem. ECMO should primarily be regarded as a planned strategy for selected extraordinarily high-risk cases rather than as a dependable last-minute solution to an established airway emergency.

References

1. Ost DE et al. Chest. 2015 Aug;148(2):450-471.

2. Chaddha U et al. Respirology. 2021 Jan;26(1):14-18

3. Wu H et al. Front Oncol. 2023 Mar 27;13:1098594.

4. Chaddha U et al. Ann Am Thorac Soc. 2019 Oct;16(10):1220-1229

5. Richardson ASC et al. ASAIO J. 2021 Mar 1;67(3):221-228

Figure 1. Top left: near complete lower tracheal obstruction from tumor ( already post initial coagulation with thermal energy); Top middle: complete airway obstruction during attempted debulking of airway tumor; Top right: small pieces of tumor being suctioned with the rigid bronchoscopy suction catheter ; Bottom left: large suction tubing available in many operating rooms; Bottom middle: cutting the rubber piece to allow insertion in the rigid tube; Bottom right: large suction tubing inserted through the 12 mm Efer Dumon rigid bronchoscope after removal of the telescope to effectively remove large clots and tumor fragments.

Figure 2. Top left: cryoprobe inside tumor prior to extraction; Top middle: bleeding and tumor fragments occluding the distal trachea immediately post attempted cryodebulking; Top right: clear airway after using the large suction tubing to remove blood and tumor debris that had completely occluded the airway.

Figure 3. Top left: tracheal tumor in the beginning of “coring out”; Top right: as the rigid tube is advanced, the view is progressively lost due to near complete airway closure- a small airway opening is noticed at 7 o’clock position (arrow); Bottom left: The rigid bronchoscopy suction catheter (arrow) is advanced through the residual airway opening in the distal airway; Bottom right: the rigid bronchoscope successfully bypassed the tumor and main carina is visualized.

Checklists and Assessment Tools in Bronchoscopy

Introduction

Bronchoscopy education is increasingly moving away from the traditional assumption that competence can be inferred from the number of procedures performed. Back in 2015, the CHEST Adult Bronchoscopy Training expert panel has advocated a transition from volume-based certification toward a model based on demonstrated skill acquisition, knowledge, and competency (1). This shift raised an important educational question: How should bronchoscopy skills and competency actually be measured?

Two approaches are particularly relevant to bronchoscopists: procedural checklists and skills assessment tools. Although these terms are sometimes used interchangeably, they serve different purposes. A checklist primarily breaks a procedure into observable steps and can function as a dynamic teaching and feedback instrument. A skills assessment tool goes further by providing a structured method for judging performance, often incorporating technical execution, procedural strategy, knowledge, and sometimes global performance ratings. Understanding this distinction is especially important as bronchoscopy training moves toward competency-based education and as validated assessment instruments become incorporated into training programs and certification (2)

Procedural Checklists: Definition and Purpose

A procedural checklist is a structured list of the essential actions or steps required to complete a procedure correctly. In bronchoscopy, a checklist might describe the sequence required to perform flexible bronchoscopy, intubate a patient with a rigid bronchoscope, conduct a systematic EBUS examination, obtain an EBUS-TBNA specimen, or perform BLVR. Checklists should not be viewed simply as reminders designed to prevent omission of a step. In procedural education, they can function as dynamic learning tools. By decomposing a complex procedure into specific observable behaviors, they permit faculty to provide immediate, objective, and specific feedback rather than relying on vague comments such as “you need more practice.” For example, rather than telling a trainee that rigid bronchoscopy intubation was “not smooth,” an instructor using a checklist can identify the particular step that needs improvement: positioning of the head, protection of the teeth and lips, identification and elevation of the epiglottis, visualization of the vocal cords, rotation of the bronchoscope, or advancement into the trachea (3). The feedback therefore becomes actionable. This characteristic makes checklists particularly useful for formative assessment—assessment intended to improve performance rather than simply determine whether someone passes or fails.

Checklists and the “Curse of Knowledge”

Checklists also address an important problem in procedural education: the curse of knowledge (4). Once an expert has performed a procedure hundreds or thousands of times, it can become difficult to remember how complicated the procedure appeared to a novice. With experience, individual procedural steps become consolidated into larger cognitive and motor units. Psychologists describe this process as “chunking.” An experienced bronchoscopist does not consciously think through every individual movement involved in rigid bronchoscopy or EBUS. Instead, multiple actions are bundled into a larger learned pattern and performed almost automatically. This expertise creates an educational paradox. The better clinicians become at performing a procedure, the harder it may become for them to explicitly describe everything that they do. Experts may forget how much detailed information they had to acquire when they were novices and may underestimate how long another person needs to learn a technical skill. Thus, a well-designed checklist forces the expert to deconstruct expertise. The apparently seamless performance of the expert is converted back into individual observable steps that can be taught, practiced, assessed, and corrected.

Checklists and Skill Acquisition

The educational role of checklists can also be understood through the Dreyfus model of skill acquisition (5). Stuart and Hubert Dreyfus described five stages through which individuals progress as they acquire expertise. A central concept of this model is that novices initially depend heavily on explicit rules. As experience accumulates, performance becomes increasingly contextual, adaptive, and intuitive. This progression is highly relevant to bronchoscopy. A novice learning EBUS may initially need an explicit sequence: intubate the trachea with the EBUS scope → locate the appropriate lymph-node station → optimize the ultrasound image → position the needle → confirm safe needle trajectory → obtain the specimen (6).

The expert bronchoscopist does not necessarily consciously rehearse this sequence. Anatomy, ultrasound findings, bronchoscope position, needle trajectory, patient movement, and procedural objectives are integrated almost simultaneously. Thus, checklists are particularly valuable during the early stages of skill acquisition, when learners require explicit rules and clearly defined procedural steps. As expertise develops, strict dependence on the checklist should diminish. Experienced operators increasingly recognize patterns, adapt to unexpected circumstances, and modify their approach according to context. The objective of training is therefore not to create clinicians who can merely follow checklists. Rather, the checklist provides scaffolding that helps novices develop the knowledge and procedural habits from which more sophisticated expertise can eventually emerge.

Skills Assessment Tools: A Different Purpose

A skills assessment tool is different from a procedural checklist. Its principal purpose is not simply to determine whether individual procedural steps were completed, but to measure the quality or level of performance of a defined skill. Assessment can occur in several environments, including simulation using inanimate models, cadavers, virtual-reality systems, simulated patients, or actual patients. Assessment may also involve direct bedside observation, peer assessment, or portfolios documenting self-directed learning.

Bronchoscopy-specific examples include but are not limited to: EBUS-STAT (Endobronchial Ultrasound Skills and Tasks Assessment Tool) — designed to evaluate skills related to EBUS performance (6) and RIGID-TASC — an assessment instrument focused on skills associated with rigid bronchoscopy (3). These instruments illustrate an important distinction. A checklist may ask, “Did the learner perform the required steps?” A skills assessment tool asks a broader question: “How well did the learner perform the skill?”

Assessment Tools Must Be Valid for Their Intended Purpose

When assessment results are used to make important educational or certification decisions, simply creating a scoring form is insufficient. High-stakes assessments require evidence supporting the validity of the assessment process and the interpretation of its scores. The Standards for Educational and Psychological Testing define validity in terms of the degree to which evidence and theory support interpretation of test scores for their proposed uses. This distinction is critical: validity does not simply reside within an instrument itself. It relates to how the scores are interpreted and what decisions are made from them. An assessment instrument might therefore be appropriate for providing feedback to a first-year pulmonary fellow but insufficiently validated for determining whether an interventional pulmonologist should receive certification. The higher the consequences of the decision, the stronger the required validity evidence should be. High-stakes assessments use validated tools (2).

Assessment in Training: No-Stakes, Low-Stakes, and High-Stakes Uses

Procedural- based assessments require either real patients or simulation-based assessments and they can be considered according to the consequences—or stakes—associated with the result. At the no-stakes level, assessment is used purely for learning. A trainee might perform bronchoscopy on a simulator, receive structured feedback, repeat the procedure, and progressively improve without any consequence attached to the score. This is what is done at many bronchoscopy workshops. At the low-stakes level, competency-focused assessments can support coaching, deliberate practice, team training, and systems evaluation. The results identify deficiencies and guide subsequent training rather than functioning primarily as pass/fail examinations. At the high-stakes level, however, assessment may contribute to formal in-training evaluation or certification (2). Because such decisions have meaningful consequences for the learner, a much higher level of supporting evidence is required. This progression illustrates a fundamental principle: The higher the stakes of the decision, the stronger the evidence required to support the assessment and interpretation of its results.

Assessment of a Skill Is Not the Same as Assessment of Competency

Perhaps the most important distinction is between assessment of an individual procedural skill and assessment of overall clinical competency. Skills assessment tools are commonly outcomes-based assessments. They measure completion or performance of particular tasks or domains of knowledge and are often summative. In many cases, they represent a snapshot of performance during a particular encounter—essentially a measurement of one event. Competency is broader. Competency asks whether the learner can integrate knowledge, technical ability, clinical judgment, communication, and decision-making in real-world practice. It therefore focuses not merely on performance of a task but on the clinician's ability to manage a clinical problem. For example, relevant to bronchoscopy, placing an endobronchial blocker correctly during a simulation or in a real patient is a technical skill. Managing a patient with massive hemoptysis is a clinical competency. The latter may require recognizing life-threatening bleeding, protecting the nonbleeding lung, selecting appropriate airway equipment, positioning the patient, choosing between flexible and rigid bronchoscopy, deploying a blocker correctly, coordinating with anesthesia, communicating with interventional radiology or surgery, and adapting the plan when circumstances change. Similarly, demonstrating the ability to identify lymph-node stations during EBUS is a skill. Competently performing a thorough and guideline- based mediastinal staging for lung cancer requires substantially more: selecting the appropriate patient, interpreting imaging, determining which stations require sampling, performing systematic staging, acquiring adequate specimens, managing complications, and interpreting the procedure within the broader oncologic context. Thus, a checklist assesses steps while a skills assessment tool measures performance of a defined skill. Competency assessment asks whether the clinician can integrate multiple skills and knowledge to manage a clinical problem effectively.

From Procedure Numbers to Demonstrated Competence

Historically, procedural education has often relied on minimum numbers. A trainee performs a specified number of bronchoscopies or EBUS procedures and is subsequently considered adequately trained. The competency-based approach challenges this assumption. Procedure numbers document exposure, not necessarily competence. Two trainees who each perform the same number of procedures may acquire skills at very different rates. Checklists and structured assessment tools make it possible to observe this learning process directly. A trainee can practice a defined procedure, receive immediate feedback using a checklist, repeat the procedure through deliberate practice, and subsequently demonstrate performance using an appropriate assessment tool. Rather than asking simply, “How many procedures has this trainee performed?”, competency-based education increasingly asks, “What can this trainee actually do, and what evidence supports that conclusion?”

Conclusion

Checklists and assessment tools are complementary but fundamentally different components of bronchoscopy education. Procedural checklists deconstruct complex procedures into observable steps. They are particularly useful for novice learners, provide specific and immediate feedback, counteract the expert's curse of knowledge, and create a structure for deliberate practice. Skills assessment tools measure the quality of performance of defined technical skills. Bronchoscopy-specific examples include BSTAT, EBUS-STAT, and RIGID-TASC but there are others and more are being validated. Their use can range from formative coaching to high-stakes assessment, but the strength of validity evidence required should increase as the consequences of the assessment increase. Neither approach alone fully establishes clinical competency as competency requires the integration of procedural skill with knowledge, judgment, adaptability, and performance in real-world clinical situations. A trainee may demonstrate the ability to perform an isolated technical task without yet demonstrating the broader ability to manage the patient or clinical problem in which that skill is embedded. The evolution of bronchoscopy education should therefore not simply replace procedural numbers with another isolated metric. Instead, training programs around the world should combine checklists for learning, validated assessment tools for measuring skills, and broader competency assessments for determining whether clinicians can integrate those skills effectively in patient care. Such an approach provides a more defensible pathway from novice performance to independent practice—and from counting procedures to demonstrating competence.

References

1. Ernst A et al. Chest. 2015 Aug;148(2):321-332.

2. Certificate of Added Qualifications in Advanced Bronchoscopy. Available at: https://www.aabronchology.org/information-apply-caq-kat-and-pat; accessed on 9/28/2026

3. Mahmood K et al. Ann Am Thorac Soc. 2016 Apr;13(4):502-11.

4. Fisher M et al. Cogn Sci. 2016 Jul;40(5):1251-69. 

5. Mind Over Machine: The Power of Human Intuition and Expertise in the Era of the Computer (1986, Free Press, New York).

6. Davoudi M et al. Am J Respir Crit Care Med. 2012 Oct 15;186(8):773-9

Welcoming New Members

WABIP is pleased to welcome two new member societies: the Pan African Thoracic Society, which joined in July, and the Somali IP Society which joined in September. We also welcome Dr. Mohamed Mahdi Sh. Mousa to the WABIP Board of Regents.

2026 WABIP Award Recipients

The WABIP Awards Committee has selected the 2026 award recipients:

• Dr. Alvin Ing: Gustav Killian Centenary Medal

• Dr. Pyng Lee: WABIP-Dumon Award

• Dr. Levent Dalar: Distinguished WABIP Regent Award

• Dr. Heinrich Becker: WABIP Lifetime Achievement Award

The awards will be presented at the Opening Ceremony of WCBIP 2026 in Melbourne on the evening of December 3, 2026. Congratulations to all recipients.

WABIP Video Festival

The Video Festival received 70 submissions from around the world. Under the leadership of Awards Committee Chair Dr. Atul Mehta, four judges scored each video on educational value, novelty and rarity, image and video quality, and presentation. The finalists have been chosen for four categories: Best Imaging, Best Innovation, Best Scientific Content and Best Overall Video. We thank all participants and judges.

WCBIP 2026 Melbourne

WCBIP 2026 has passed 600 registered attendees and is expected to reach 700 to 800 participants. Hands-on workshops on December 3 will cover radial EBUS and cryobiopsy, endobronchial valves and robotic bronchoscopy. WABIP members receive discounted registration.

Interventional Pulmonology Institute (IPI)

IPI Nairobi welcomed its first fellows in October 2026 under the direction of Dr. Naveed Merali. Fellows rotate through Kenyatta National Hospital and leading private hospitals. The inaugural fellows are Dr. Mohammed Mahdi (Somalia) and Dr. Abdulaziz Mahmoud (Mombasa, Kenya).

The IPI Fellowship Application Review Committee has completed the 2027 selection. It chose the cohort from an exceptionally large pool of applicants, using objective criteria and regional balance. The 2027 fellows will train in Nairobi and Türkiye, with additional rotations in Athens and Madrid.

The Q3 IP fellow examination was completed successfully by Dr. Saadia Asraf and Dr. Theeb Sulaiman, supervised by Prof. Daniela Gompelman.

Congratulations to Dr. Tay Zar Tun Myint (Myanmar) and Dr. Ashish Shrestha (Nepal), who received the 2027 Prof. Levent Dalar IPI Scholarship.

Applications for the 2028 fellowship will open from April to June 2027. IPI relies on donations for fellow housing, bronchoscopic equipment, simulation tools and educational resources, and we welcome support through the WABIP donation page.

Reduced-dose tPA: Time to ADAPT? – Interview with Gary Lee

Gary Lee, MBChB PhD FCCP FRCP FRACP FAHMS

Professor of Respiratory Medicine,

University of Western Australia,

Consultant & Head of Pleural Services,

Sir Charles Gairdner Hospital

Udit: What sparked you to start the reduced-dose tPA ADAPT trials?

Gary: We know that the doses of tPA and DNase were chosen empirically based on a small number of case reports. It never went through the usual dose-escalation phase I studies.

After the MIST2 study was published, we reproduced the 90+% success rate from MIST2 in a separate cohort of 107 patients. tPA is expensive and, at least initially, there were a lot of concerns about bleeding. We thought that if we could reduce the tPA dose, it might help reduce costs and perhaps reduce the risk of bleeding.

So that sparked us to embark on a dose de-escalation program. After reproducing the approximately 90% success rate with 10 mg, we went down to 5 mg¹, then 2.5 mg². In our latest series³, we used 1 mg and still maintained a 94% success rate. We defined success as being cured of the pleural infection, survived to hospital discharge and without requiring surgery for 90 days after discharge.

One of my favorite examples is the horse study, where in a series of 25 horses the median tPA dose required to drain the empyema was only 3.75 mg⁴. These are horses weighing 400–500 kg.

There’s also a recent short paper measuring tPA activity after intrapleural tPA. They found that the pleural fluid still contained a huge amount of residual tPA activity⁵. The concentration was, from memory, about eight times the blood concentration achieved during systemic thrombolysis with 100 milligrams of tPA for heart attack or stroke. So, I think there’s plenty of evidence to support the idea that 10 milligrams is really an overkill.

Udit: We have tPA in 2 mg and 50 mg vials, so I think the cost benefit is clear even here in the United States. I know these are prospective studies and not very large, but have you really seen the lower bleeding risk borne out in the ADAPT series?

Gary: I think it would be hard to show because the bleeding risk is already quite low. It would require a very large number of patients to demonstrate a statistically significant reduction in bleeding. If we really wanted to study that, we’d probably should measure the hematocrit of the pleural fluid and the total amount of fluid drained. Anecdotally, I would tell you that the fluid is far less red when we use 1 mg than when we use 10 mg. But whether that translates into a clinically significant reduction in bleeding requiring blood transfusion—which is our definition of bleeding—is difficult to tell.

Udit: Since you’ve maintained efficacy with these lower doses in your studies, if a patient with empyema walked through your door today, would you start with 1 mg?

Gary: Yes. We’ve been using 1 mg as our starting dose for the last four or five years. We initially treated 100 patients in our series, and after that we’ve simply continued using it routinely.

Udit: What would prompt you to escalate that dose, and after how many so-called failed doses would you do that?

Gary: Pleural infection is very difficult to protocolize. If patients remain septic, it’s usually because they either need better drainage or they need escalation of antibiotics. Sometimes the challenge is deciding which of those problems is the more important one to address first.

We haven’t seen many situations where 1 mg fails because of inadequate local fibrinolysis. More often, the issue is whether there’s another loculation elsewhere that the drug simply isn’t reaching. In those situations, you have to decide whether to increase the tPA dose in the hope that it reaches the other loculation, or whether it’s more appropriate to insert a second drain. In our ADAPT-3 series, about 25% of patients ended up having more than one chest tube.

Udit: If you decide to escalate, do you usually do it after one failed dose, or after a couple of failed doses? And when you escalate, do you typically go to 5 mg or 10 milligrams?

Gary: Usually, we would escalate to 2.5 or 5 milligrams. We assess the patient every day, and there are three things we’re looking for. First, does the patient better? Has the fever improved? Is their overall well-being improving? Second, are the systemic inflammatory markers improving—especially the white cell count and CRP? Third, what does the imaging show? We don’t need to drain every last drop of pleural fluid, but we do need to see that things are moving in the right direction and not getting worse. That’s really what guides us.

Udit: We know two things about empyema management: tPA works, and delaying surgery hurts patients. So, is it correct to say that if you decide to escalate the dose, that decision is made fairly early?

Gary: Yes. During the first one or two days, we wouldn’t continue through all six doses if the patient clearly wasn’t improving. From the very beginning, we didn’t want to delay patients by giving a lower dose for more than about one day. So, if the patient isn’t getting better by the following day, we have a low threshold for doing something else. That “something else” may be escalating the tPA dose, changing the antibiotics, or inserting a second drain, depending on the circumstances.

The difficult part is that patients with pleural infection usually don’t just have pleural infection. They may also have underlying pneumonia, lung abscess, or subdiaphragmatic infection etc. Those conditions need to be treated optimally at the same time if the patient isn’t improving. So, it’s not always the pleural drainage that’s dictating the clinical course. On an individual patient basis, it’s not always obvious which component should be addressed first.

Udit: If I were to play devil’s advocate and write a guideline today, I think most authors would still recommend starting with the 10 mg dose because it’s supported by a randomized trial, albeit one that is over a decade old and included only about 50 patients in the tPA/DNase group.

If you wanted to definitively change practice, how would you design the ideal tPA dosing trial today?

Gary: That study is actually already underway⁵. Designing this type of trial is extremely difficult because treatment success and treatment failure aren’t easily defined. The way we’ve designed it is that patients are randomized to receive either 2.5 mg or 10 mg of tPA. The treating team and the patients, are blinded to which dose they’re receiving. After the initial 2 doses of treatment, if the patient isn’t improving, the clinician can break the blind and escalate treatment, in an open label manner, as they feel appropriate. That way, the patient is exposed to a potentially lower dose for only about 24 hours before other interventions can be made.

Ultimately, what we all want to know is whether a lower starting dose provides equivalent outcomes while reducing drug use, lowering costs, and perhaps reducing bleeding. If that’s the case, then I think practice will naturally evolve.

Udit: Gary, thank you so much for your time. This has been incredibly insightful.

Gary: Thank you. 

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2. Popowicz N et al. Respirology. 2022;27(7):510-516.

3. Lau EPM et al. Respiration. Published online July 13, 2026:1-16.

4. Tomlinson JE et al. J Vet Intern Med. 2015;29(5):1403-1409.

5. Maginot ER et al. Am J Respir Crit Care Med. 2026;212(5):1037-1040.

6. Chan KKP et al. Respirol Case Rep. 2026;14(4):e70580.