Abstract

The ability to perform procedures is one of the defining characteristics that attracted so many of us to fellowships in pulmonary medicine, critical care medicine, and thoracic surgery. In fact, nearly 500,000 bronchoscopies are done each year in the United States. Additionally, approximately 15,000 airway stents are placed yearly worldwide. The number and complexity of procedures that can be performed in the bronchoscopy unit is increasing. For example, endobronchial electrocautery for tumor ablation and the treatment of hemoptysis can be performed under local anesthesia during a “routine” outpatient bronchoscopy.Unfortunately, our training and expertise is not uniform. An American College of Chest Physicians (ACCP) survey revealed that > 50% of respondents believed that their training in advanced diagnostic techniques such as transbronchial needle aspiration (TBNA) was inadequate. In another query of senior pulmonary fellows, Haponik et al found that while most fellows reported “adequate” training in bronchoscopy, only 72% had any instruction in TBNA and 27% in stent placement.Despite the proliferation in the number and type of chest procedures currently performed, there are presently no guidelines that ensure that the basic skills and competency needed to provide these services have been acquired by the pulmonologist, critical care physician, or thoracic surgeon (dedicated operators). To address this void, the development of guidelines for chest procedures was initiated through the Interventional Chest/Diagnostic Procedures Network of the ACCP (the “Network”). There were several compelling reasons to do so. First, these procedures carry inherent risks, and patient safety is of paramount concern. Second, defining the equipment and personnel required, indications, contraindications, risks, and training requirements of each of the procedures may facilitate uniform practice within fellowship training programs. In addition, these guidelines could be used as a guide to hospital nursing, respiratory therapy and administrative departments who wish to develop these services. Finally, dedicated operators who display competency in these individual procedures should have less difficulty overcoming the barriers that sometimes exist within local hospital credentialing committees.The guidelines themselves were developed by a group of physicians representing a wide range of interests within the college. The group was comprised of pulmonologists and thoracic surgeons, academics, and private practitioners who reside in the United States and abroad. Despite the diversity of practice views, consensus was reached on all of the parameters put forth in this document.For physicians wishing to learn how to perform one of these advanced procedures, there are several different educational approaches. There are intense short training programs (1 to 3 days). These are available throughout the United States and abroad. More formal mini-sabbaticals (1 to 6 months) are available as well. Several fellowship training programs have developed an additional year of fellowship training in advanced interventional techniques similar to other procedure-intensive internal medicine subspecialties such as cardiology and gastroenterology. Both of these groups have adopted minimum requirements for their trainees to achieve competence in advanced procedures. Still others have used novel approaches such as virtual reality-simulated bronchoscopy as a teaching tool for the novice dedicated operator. Innovative approaches to learning these techniques will no doubt become widely available in the future.These guidelines clearly have limitations. Although we do not have the necessary data on all of the procedures outlined in this document to make definitive statements on patient outcome and the necessary number of procedures to achieve competency, that does not mean we should shy away from competency guidelines altogether. Therefore, we have developed some competency parameters based on the expertise of our panel members. The ACCP Network hopes that fellowship program directors will use this document to assess the strengths and weaknesses of the procedural training they provide and adopt this working document to develop the highest level of procedural training. We hope that this document will focus interest on the diversity of techniques now available to our patients. These ACCP guidelines can also be built on as new procedures are brought out of the laboratory and into practice.When learning new techniques, the old adage “see one, do one, teach one” is no longer acceptable. The ACCP Network offers these guidelines as an alternative. We hope our membership will embrace it. The ability to perform procedures is one of the defining characteristics that attracted so many of us to fellowships in pulmonary medicine, critical care medicine, and thoracic surgery. In fact, nearly 500,000 bronchoscopies are done each year in the United States. Additionally, approximately 15,000 airway stents are placed yearly worldwide. The number and complexity of procedures that can be performed in the bronchoscopy unit is increasing. For example, endobronchial electrocautery for tumor ablation and the treatment of hemoptysis can be performed under local anesthesia during a “routine” outpatient bronchoscopy. Unfortunately, our training and expertise is not uniform. An American College of Chest Physicians (ACCP) survey revealed that > 50% of respondents believed that their training in advanced diagnostic techniques such as transbronchial needle aspiration (TBNA) was inadequate. In another query of senior pulmonary fellows, Haponik et al found that while most fellows reported “adequate” training in bronchoscopy, only 72% had any instruction in TBNA and 27% in stent placement. Despite the proliferation in the number and type of chest procedures currently performed, there are presently no guidelines that ensure that the basic skills and competency needed to provide these services have been acquired by the pulmonologist, critical care physician, or thoracic surgeon (dedicated operators). To address this void, the development of guidelines for chest procedures was initiated through the Interventional Chest/Diagnostic Procedures Network of the ACCP (the “Network”). There were several compelling reasons to do so. First, these procedures carry inherent risks, and patient safety is of paramount concern. Second, defining the equipment and personnel required, indications, contraindications, risks, and training requirements of each of the procedures may facilitate uniform practice within fellowship training programs. In addition, these guidelines could be used as a guide to hospital nursing, respiratory therapy and administrative departments who wish to develop these services. Finally, dedicated operators who display competency in these individual procedures should have less difficulty overcoming the barriers that sometimes exist within local hospital credentialing committees. The guidelines themselves were developed by a group of physicians representing a wide range of interests within the college. The group was comprised of pulmonologists and thoracic surgeons, academics, and private practitioners who reside in the United States and abroad. Despite the diversity of practice views, consensus was reached on all of the parameters put forth in this document. For physicians wishing to learn how to perform one of these advanced procedures, there are several different educational approaches. There are intense short training programs (1 to 3 days). These are available throughout the United States and abroad. More formal mini-sabbaticals (1 to 6 months) are available as well. Several fellowship training programs have developed an additional year of fellowship training in advanced interventional techniques similar to other procedure-intensive internal medicine subspecialties such as cardiology and gastroenterology. Both of these groups have adopted minimum requirements for their trainees to achieve competence in advanced procedures. Still others have used novel approaches such as virtual reality-simulated bronchoscopy as a teaching tool for the novice dedicated operator. Innovative approaches to learning these techniques will no doubt become widely available in the future. These guidelines clearly have limitations. Although we do not have the necessary data on all of the procedures outlined in this document to make definitive statements on patient outcome and the necessary number of procedures to achieve competency, that does not mean we should shy away from competency guidelines altogether. Therefore, we have developed some competency parameters based on the expertise of our panel members. The ACCP Network hopes that fellowship program directors will use this document to assess the strengths and weaknesses of the procedural training they provide and adopt this working document to develop the highest level of procedural training. We hope that this document will focus interest on the diversity of techniques now available to our patients. These ACCP guidelines can also be built on as new procedures are brought out of the laboratory and into practice. When learning new techniques, the old adage “see one, do one, teach one” is no longer acceptable. The ACCP Network offers these guidelines as an alternative. We hope our membership will embrace it. CryotherapyCHESTVol. 123Issue 5PreviewCryotherapy is a form of thermal tissue ablation. In contrast to the use of heat, it is the application of repetitive freeze/thaw cycles that cause tissue damage and destruction. Due to the particular action of cryotherapy, results are not immediate and may be delayed for several days. Full-Text PDF Photodynamic TherapyCHESTVol. 123Issue 5PreviewPhotodynamic therapy is a minimally invasive procedure that is done using a bronchoscope and targets tissue destruction using a selectively retained photosensitizer, which, when exposed to the proper amount and wavelength of light, produces an activated oxygen species that oxidizes critical parts of neoplastic cells. The photosensitizer is administered IV, and the light source, in the case of endobronchial treatment, is delivered endoscopically via a quartz fiber. Direct interstitial delivery of light energy is also possible. Full-Text PDF Medical Thoracoscopy/PleuroscopyCHESTVol. 123Issue 5PreviewMedical thoracoscopy/pleuroscopy is a minimally invasive procedure that allows access to the pleural space using a combination of viewing and working instruments. It also allows for basic diagnostic (undiagnosed pleural fluid or pleural thickening) and therapeutic procedures (pleurodesis) to be performed safely. This procedure is distinct from video-assisted thoracoscopic surgery, an invasive procedure that uses sophisticated access platform and multiple ports for separate viewing and working instruments to access pleural space. Full-Text PDF Rigid BronchoscopyCHESTVol. 123Issue 5PreviewRigid bronchoscopy is an invasive procedure that is utilized to visualize the oropharynx, larynx, vocal cords, and tracheal bronchial tree. It is performed for both the diagnosis and treatment of lung disorders. The procedure may be performed in an endoscopy suite with available anesthesia, but more appropriately in the operating room, and rarely in the ICU. It is frequently combined with flexible bronchoscopy to acquire and maintain better distal airway visualization and suctioning. Full-Text PDF Electrocautery and Argon Plasma CoagulationCHESTVol. 123Issue 5PreviewEndobronchial electrocautery and argon plasma coagulation (APC) are modes of thermal tissue destruction that may be used via the flexible or rigid bronchoscope. Similar to laser tissue destruction, the effect of both endobronchial electrocautery and APC is determined by heat and tissue interaction, and is fairly rapid. Heat is created through the application of high-frequency electric currents to coagulate or vaporize tissue. The difference between the two procedures centers on the fact that APC is a noncontact mode of tissue coagulation. Full-Text PDF Flexible BronchoscopyCHESTVol. 123Issue 5PreviewFlexible bronchoscopy is an invasive procedure that is utilized to visualize the nasal passages, pharynx, larynx, vocal cords, and tracheal bronchial tree. It is utilized for both the diagnosis and treatment of lung disorders. The procedure may be performed in an endoscopy suite, the operating room, the emergency department, a radiology suite, or at the bedside in the ICU. Full-Text PDF Laser TherapyCHESTVol. 123Issue 5PreviewThe word laser is an acronym for light amplification of stimulated emission of radiation. The wavelength of the laser determines the characteristics of each type. Tissues absorb the intense light of the laser, and energy is dissipated, mainly in the form of heat. This tissue/light interaction is used for tissue destruction and coagulation. Full-Text PDF EBUSCHESTVol. 123Issue 5PreviewEBUS is an invasive procedure in which physicians use ultrasound devices inside the airways and the lung for exploration of the structures of airway walls, the surrounding mediastinum, and the lungs. Full-Text PDF Thoracic Percutaneous Needle Aspiration/Core BiopsyCHESTVol. 123Issue 5PreviewThoracic percutaneous needle aspiration (TPNA) and core biopsy are both minimally invasive procedures in which samples are obtained through the skin with a fine-bore hollow needle or coring needle. Lesions of the lung parenchyma, pleura, chest wall, or mediastinum are sampled in this manner, usually using image guidance such as CT or ultrasound. Full-Text PDF Airway StentsCHESTVol. 123Issue 5PreviewAirway stents, similar to vascular stents, are devices designed to keep tubular structures open and stable. Airway stents are intended for placement in the central tracheobronchial tree. Depending on the design, they may be placed with either flexible or rigid bronchoscopes. Full-Text PDF Pediatric SectionCHESTVol. 123Issue 5PreviewBronchoscopy has been performed in infants, children, and adolescents by pediatric surgeons and specialists for > 50 years. Until the 1980s, the approach was almost exclusively via the rigid bronchoscope and the operators, at least in the United States, were almost exclusively surgeons. Today, however, pediatric pulmonologists perform flexible bronchoscopy more often on children than rigid bronchoscopy. Due to this preference, this section focuses on flexible bronchoscopy. The equipment, techniques, and indications are quite different than those applied in adult populations. Full-Text PDF Tube ThoracostomyCHESTVol. 123Issue 5PreviewTube thoracostomy is a minimally invasive procedure in which a drainage catheter is placed percutaneously into the pleural space. Full-Text PDF Autofluorescence BronchoscopyCHESTVol. 123Issue 5PreviewAutofluorescence bronchoscopy is a bronchoscopic procedure in which a blue light rather than a white light is employed for illumination, and premalignant and malignant tissue is distinguished by a change in color from normal tissue without the need for fluorescence-enhancing drugs. Fluorescence techniques used with bronchoscopy have demonstrated detection of dysplasia, carcinoma in situ, and early invasive cancers not visible by standard white light bronchoscopy (WLB) through a specialized bronchoscope. Full-Text PDF TBNACHESTVol. 123Issue 5PreviewTBNA is a minimally invasive procedure that provides a nonsurgical means to diagnose and stage bronchogenic carcinoma by sampling the mediastinal lymph nodes. Applications of bronchoscopic needle aspiration have expanded to include not only sampling of paratracheal or mediastinal lymph nodes, but peripheral, submucosal, and endobronchial lesions. The procedure allows for sampling tissue through the trachea or bronchial wall, and sampling of tissue beyond the vision of the dedicated operator. Full-Text PDF DisclaimerCHESTVol. 123Issue 5PreviewAll access to and use of the ACCP Guidelines are conditioned on compliance with the following four paragraphs. Full-Text PDF Transtracheal Oxygen TherapyCHESTVol. 123Issue 5PreviewTranstracheal oxygen therapy (TTOT) is a minimally invasive procedure that is achieved through percutaneously placed devices that allow for long-term oxygen use. This procedure only deals with methods not employing surgically created stomas, and is usually a multistep procedure. Full-Text PDF Percutaneous Dilatational TracheostomyCHESTVol. 123Issue 5PreviewPercutaneous dilatational tracheostomy (PDT) is an invasive procedure in which the placement of a tracheostomy tube is achieved after establishing a tracheal stoma through dilation, rather than surgical creation of a stoma. Full-Text PDF BrachytherapyCHESTVol. 123Issue 5PreviewBrachytherapy is a minimally invasive procedure that allows localized delivery of radiation therapy within the body. Methods of brachytherapy delivery include direct implantation of radioactive seeds into the tumor area; image-guided implantation of radioactive sources; transbronchial source implantation with a bronchoscope; and, most commonly, delivery of a radioactive source through a transnasal catheter placed via the lumen of a bronchoscope. This section applies only to the last, most commonly utilized method of delivery. Full-Text PDF Percutaneous Pleural BiopsyCHESTVol. 123Issue 5PreviewPercutaneous pleural biopsy is a minimally invasive procedure performed to obtain pleural tissue using a pleural biopsy needle. This may be performed untargeted for pleural effusions, or using image guidance for pleural masses. Full-Text PDF