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SERIES EDITORIAL - EPILOGUE UPDATE IN INTERVENTIONAL PULMONOLOGY

Interventional pulmonology: The tipping point

Key words: bronchoscopy, education, pulmonology, pleural disease, practice.

interventional

Abbreviation: IP, interventional pulmonology.

In the series on ‘Update in Interventional Pulmonology’ (IP), we attempted to provide readers state-of-the-art detailed reviews on various fields pertaining to IP, encompassing such diverse topics as modern education paradigms in medicine, novel diagnostic techniques in bronchoscopy and evidence-based approaches to common clinical problems such as pleural diseases and lung cancer. While this review series was intended to highlight recently published data on a broad range of topics, it could by no means be expected to be comprehensive, and interesting emerging concepts such as the novel imaging techniques of optical coherence tomography or confocal microscopy, among others,1 or the more commonly discussed topics of endobronchial stenting and ablative interventions were deliberately not addressed, due to their limited clinical applicability for the former or lack of recent meaningful publications for the latter. We are very grateful for the excellent contributions provided by the invited authors, all recognized thought leaders in their respective fields, and sincerely hope that this series will both highlight recent and clinically relevant developments in IP, and motivate IP specialists to re-appraise their practice in light of the new standards proposed in the different articles. From an educational standpoint, it is difficult to continue to justify outdated models of knowledge delivery and acquisition through which patients carry the burden of procedural training.2 The antiquated apprenticeship model, illustrated by the Halstedian dictum of ‘see one, do one, teach one’, should be replaced by modern and evidence-based practices that include flipped-classroom models, problembased learning and other learner-centric interventions. While high-fidelity simulation costs remain prohibitive for most, so-called low-fidelity models have been shown to be as, if not more, effective in some instances, and should be offered at IP training centres around the world. Furthermore, trainees must be assessed using validated assessment tools, when available, and ongoing education research efforts should focus on providing additional data and developing increasingly efficient tools for trainers. © 2014 Asian Pacific Society of Respirology

From a clinical practice standpoint, a common thread that appears to emerge from various chapters on lung cancer staging, pleural diseases and cryobiopsies for diffuse parenchymal lung diseases is the ever-growing need for multidisciplinary approaches to diagnostic and treatment, requiring dynamic interactions between experts of various specialties including, but not limited to, pulmonary medicine, thoracic surgery, IP specialists, medical and radiation oncologists.3–7 Modern approaches to lung cancer management demand that systematic algorithms be followed to ensure that, in addition to establishing the diagnosis, accurate clinical staging is attained efficiently and sufficient samples are acquired for ancillary testing to guide individualized management.5 Ongoing communication between proceduralists and histo- and cyto-pathologists is paramount to adapt sampling techniques to local specimen processing methodologies and allow for appropriate molecular testing. Likewise, the last 5 years have witnessed a paradigm shift in the management of pleural diseases, with considerably less emphasis placed on surgical management in favour of minimally invasive diagnostic and therapeutic procedures which have been largely and quickly embraced by the IP community, such as the use of thoracic ultrasound, small bore chest tubes and intrapleural therapies. Multiple ongoing randomized controlled studies are rapidly moving the field from an empiric- to an evidence-based one.7 However, more importantly, it is the burgeoning IP research engine that will continue to drive the specialty forward. It is our belief that the field of IP has reached a tipping point, hesitating indecisively between the perspective of a promising and exciting future as a recognized subspecialty of pulmonary medicine and the risk of progressively falling into irrelevance, due to the relative paucity of evidence and quality research. Just as the landscape of lung cancer has profoundly changed over the last decade, the field of IP needs to evolve accordingly. For example, large airway obstruction from centrally located endobronchial squamous cell carcinoma is now far less commonly encountered than indolent peripheral adenocarcinomas, a disease for which locally delivered treatments should be considered over standard surgical lobectomy. Bronchoscopic approaches appear ideally positioned to answer this need, but efforts have been hampered by the dependence on conducting airways leading to these lesions, Respirology (2015) 20, 11–12 doi: 10.1111/resp.12431

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Editorial

the absence of adequate imaging techniques to confirm access to the tumor and the lack of efficacious peripheral ablative techniques, among others.6 Resources commensurate with the magnitude of the problem should be allocated to meet these challenges, particularly as lung screening is being implemented around the world. The same can be said of the diagnosis of diffuse lung diseases (via cryobiopsies for instance), treatment of chronic obstructive pulmonary diseases8 and management of pleural diseases. The new generation of IP specialists cannot continue to rely on the rich heritage passed down from the pioneers in the field, and should strive to develop a strong research infrastructure, seek funding to support these networks and, more importantly, continue to cultivate the spirit of enquiry necessary to discover and develop the future applications of IP, thereby ensuring a bright future for the specialty and the well-being of our patients. Fabien Maldonado, MD,1 Eric S. Edell, MD,1 Patrick J. Barron, PhD2,3 and Rex C. Yung, MD 1 Mayo Clinic, Rochester, Minnesota, USA 2Tokyo Medical University, Tokyo, Japan 3Seoul National University Bundang Hospital, Seoul, Korea

Respirology (2015) 20, 11–12

REFERENCES 1 Ohtani K, Lee AM, Lam S. Frontiers in bronchoscopic imaging. Respirology 2012; 17: 261–9. 2 Fielding DI, Maldonado F, Murgu S. Achieving competency in bronchoscopy: challenges and opportunities. Respirology 2014; 19: 472–82. 3 Breen DP, Daneshvar C. Role of interventional pulmonology in the management of complicated parapneumonic pleural effusions and empyema. Respirology 2014; 19: 970–8. 4 Poletti V, Casoni GL, Gurioli C, Ryu JH, Tomassetti S. Lung cryobiopsies: a paradigm shift in diagnostic bronchoscopy? Respirology 2014; 19: 645–54. 5 Saettele TM, Ost DE. Multimodality systematic approach to mediastinal lymph node staging in non-small cell lung cancer. Respirology 2014; 19: 800–8. 6 Gilbert C, Akulian J, Ortiz R, Lee H, Yarmus L. Novel bronchoscopic strategies for the diagnosis of peripheral lung lesions: present techniques and future directions. Respirology 2014; 19: 636–44. 7 Thomas R, Francis R, Davies HE, Lee YC. Interventional therapies for malignant pleural effusions: the present and the future. Respirology 2014; 19: 809–22. 8 Mineshita M, Slebos DJ. Bronchoscopic interventions for chronic obstructive pulmonary disease. Respirology 2014; 19: 1126–37.

© 2014 Asian Pacific Society of Respirology

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Interventional pulmonology: the tipping point.

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