Interventional Pulmonology: Advances and Evolving Concepts

Scott S. Oh, DO

Erik Folch, MD, MSc

The field of interventional pulmonology (IP) has experienced significant growth in recent years, catalyzed by its expanding community. The refining of diagnostic techniques and development of therapeutic options coupled with technologic advances has augmented the ability of practitioners to provide a broader array of options to patients with diseases of the chest.

Minimally invasive endobronchial ultrasound (EBUS) has revolutionized the diagnostic and staging paradigm for lung cancer. Its position in lung cancer guidelines reflects its firmly established role. However, interventional pulmonologists continue to find new ways to apply this powerful technology to refine and expand its role with elastography, in the restaging of malignancies, in the diagnosis of nonmalignant disease including intranodal forceps sampling and transvascular biopsies of targets to name a few.

Bronchoscopic transbronchial lung cryobiopsies (TBLCB) is a new application of an old technology and has emerged as a potentially paradigm-shifting option in the diagnosis of interstitial lung diseases (ILD). The body of literature for TBLCB continues to rapidly expand offering a potentially safer and less invasive alternative to surgical lung biopsy for ILD. However, more work is needed to standardize techniques and better define its position in the diagnostic algorithm.

Pulmonary nodules in the periphery of the lung have been more challenging puzzle. Technologies, such as electromagnetic navigational bronchoscopy, virtual bronchoscopy, and radial EBUS have increased our ability but significant room for improvement yet remains. Bronchoscopy enhanced by the addition of augmented fluoroscopy, cone beam computed tomography (CT), and robotic bronchoscopy are exciting new technologies which hold great promise in not only our ability to diagnose pulmonary nodules but also to deliver therapeutics in a minimally invasive fashion.

Interventional pulmonologists continue to provide diagnostic and therapeutic options for diseases of the central airways with the re-emergence of rigid bronchoscopy playing a pivotal role. Awareness of excessive central airway collapse continues to increase, and less invasive therapeutic options are being explored. Bronchoscopic management often provides a minimally invasive definitive treatment option for those with benign central airway stenosis and palliation of life-threatening dyspnea in cases of malignant central airway obstruction.

Management of pleural disease has also been revolutionized by interventional pulmonologists who possess a skillset to provide a spectrum of options ranging from tunneled indwelling pleural catheters to medical pleuroscopy. This depth and breadth of knowledge permits interventional pulmonologists to quickly and comprehensively diagnose and treat a wide array of malignant and nonmalignant pleural diseases. Studies continue to refine how to best utilize these techniques to maximize outcomes in the least invasive way possible.

The maturation of the field is paralleled by the growth of formal training programs in IP. Education and the development of competency standards have become ever more important with this expansion to help in ensuring the quality of care provided to our patients. As medicine moves more toward competency based evaluation, simulation will likely continue to have a prominent and growing role in both education and evaluation.

The delivery of minimally invasive therapeutics is an area of tremendous potential for IP. Novel therapeutic options for common lung diseases, such as asthma and COPD (chronic obstructive pulmonary disease) are now available including bronchial thermoplasty and more recently bronchoscopic lung volume reduction in the United States. Many studies involving ablation technologies as well as the direct delivery of pharmacologic and biologic therapeutics are underway for malignancy.

In summary, it is an exciting time in IP, and we hope you find this issue informative, thought-provoking, and inspirational.