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Malignant Central Airway Obstruction (MCAO) encompasses significant and symptomatic narrowing of the central airways that can occur due to primary lung cancer or metastatic disease. Therapeutic bronchoscopy is associated with high technical success and symptomatic relief and includes a wide range of airway interventions including airway stents. Published literature suggests that stenting practices vary significantly across the world primarily due to lack of guidance. This document aims to address this knowledge gap by addressing relevant questions related to airway stenting in MCAO. An international group of 17 experts from 17 institutions across 11 countries with experience in using airway stenting for MCAO was convened as part of this guideline statement through the World Association for Bronchology and Interventional Pulmonology (WABIP). We performed a literature and internet search for reports addressing six clinically relevant questions. This guideline statement, consisting of recommendations addressing these six PICO questions, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with expert experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique., (© 2024 The Author(s). Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.)

Bronchoscopic sampling of PPL was significantly advanced by the development of the endobronchial ultrasound guide sheath method in the 1990s. Since then, a range of technical and procedural techniques have further advanced diagnostic yields. These include the use of thinner bronchoscopes with better working channel diameters, understanding the importance of peripheral transbronchial needle aspiration, and virtual bronchoscopic assistance. These have enabled better sampling of smaller and more technically challenging lesions including ground-glass nodules. Most recently, robotic bronchoscopy has been developed which, among other refinements, allows fine control of visual bronchoscopic navigation by replacing movements directed by the hand with electronic consoles and trackballs, and innovatively integrate virtual with real bronchoscopic pathways. The requirement for PPL diagnosis and treatment is expected to increase with more chest CT performed as part of CT screening programmes., (© 2020 Asian Pacific Society of Respirology.)

Background and Objective: A characteristic feature of asthma is hypertrophied airway smooth muscle, responsible for bronchoconstriction. This is the target of bronchial thermoplasty (BT). It is known that with increasing time and severity some patients develop remodelled airways with fixed airflow obstruction. The question arises whether these patients will still respond to BT., Methods: Forty-nine consecutive severe asthmatic patients were prospectively evaluated at baseline and then 6 months after BT. The characteristics recorded included medication usage, exacerbation history, spirometry and the Asthma Control Questionnaire 5-Item Version score (ACQ-5). Seven patients were excluded as they did not demonstrate airflow obstruction at baseline (forced expiratory ratio (forced expiratory volume in 1 s (FEV 1 )/forced vital capacity (FVC)) < 70%). The remaining 42 patients were divided into two cohorts based on their response to bronchodilator. Eighteen patients in whom the FEV 1 improved by at least 12% and 200 mL following bronchodilator were allocated to Group 1 (reversible). The remaining patients were allocated to Group 2 (fixed). The outcomes following BT in these two groups were then compared., Results: The patient age was 57.2 ± 12.4 years, the ACQ-5 was 3.2 ± 1.0 and the FEV 1 56.0 ± 16.4% predicted. At baseline, the patient cohorts were very similar, save for the response to bronchodilator, which was 28.1 ± 12.5% in Group 1 and 4.1 ± 5.3% in Group 2. Both groups responded to BT equally well, with significant improvements in ACQ-5, salbutamol usage, exacerbation frequency and the weaning of oral corticosteroids., Conclusion: In patients with severe asthma, the presence or absence of variable airflow obstruction as measured by spirometry does not appear to influence outcomes from BT., (© 2018 Asian Pacific Society of Respirology.)

The ability to perform bedside thoracic ultrasound is increasingly recognized as an essential skill for thoracic clinicians, extending the clinical examination and aiding diagnostic and therapeutic procedures. Thoracic ultrasound reduces complications and increases success rates when used prior to thoracentesis or intercostal chest tube insertion. It is increasingly difficult to defend performing these procedures without real or near-real time image guidance. To assist thoracic physicians and others achieve and demonstrate thoracic ultrasound competence, the Interventional Pulmonology Special Interest Group (IP-SIG) of the Thoracic Society of Australia and New Zealand (TSANZ) has developed a new pathway with four components: (i) completion of an approved thoracic ultrasound theory and hands-on teaching course. (ii) A log of at least 40 relevant scans. (iii) Two formative assessments (following 5-10 scans and again after 20 scans) using the Ultrasound-Guided Thoracentesis Skills and Tasks Assessment Tool (UG-STAT). (iv) A barrier assessment (UG-STAT, pass score of 90%) by an accredited assessor not directly involved in the candidate's training. Upon completion of these requirements a candidate may apply to the TSANZ for recognition of competence. This pathway is intended to provide a regional standard for thoracic ultrasound training., (© 2017 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.)

Background and Objective: Expert analysis of endobronchial ultrasound mini probe (EBUS-MP) images has established subjective criteria for discriminating benign and malignant disease. Minimal data are available for objective analysis of these images. The aim of this study was to determine if greyscale texture analysis could differentiate between benign and malignant lung lesions., Methods: Digital EBUS-MP images with a gain setting of 10/19 and contrast setting of 4/8 from 2007 until 2012 inclusive were included. These images had an expert-defined region of interest (ROI) mapped. ROI were analysed for the following greyscale texture features: mean pixel value, difference between maximum and minimum pixel value, standard deviation of the mean pixel value, entropy, correlation, energy and homogeneity. Significant greyscale texture features differentiating benign from malignant disease were used by two physicians to assess a validation set., Results: A total of 167 images were available. The first 85 lesions were used in the prediction set. Benign lesions had larger differences between maximum and minimum pixel values, larger standard deviations of the mean pixel values and higher entropy than malignant lesions (P < 0.0001 for all values). A total of 82 peripheral lesions were in the validation set. Physician 1 correctly classified 63/82 (76.8%) with a negative predictive value (NPV) for malignancy of 82% and positive predictive value (PPV) of 75%. Physician 2 correctly classified 62/82 (75.6%) with a NPV of 100% and PPV of 71.0%., Conclusions: Greyscale texture analysis of EBUS-MP images can help establish aetiology with a high NPV for malignancy., (© 2015 Asian Pacific Society of Respirology.)

Background and Objective: There is widespread adoption of FDG-PET/CT in staging of lung cancer, but no universally accepted criteria for classifying thoracic nodes as malignant. Previous studies show high negative predictive values, but reporting criteria and positive predictive values varies. Using Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) results as gold standard, we evaluated objective FDG-PET/CT criteria for interpreting mediastinal and hilar nodes and compared this to expert visual interpretation (EVI)., Methods: A retrospective review of all patients with lung cancer who had both FDG-PET/CT and EBUS-TBNA from 2008 to 2010 was performed. Scan interpretation was blinded to histology. Patients from 2008/2009 were used for the prediction set. The validation set analysed patients from 2010. Objective FDG-PET/CT criteria were SUVmax lymph node (SUVmaxLN), ratio SUVmaxLN/SUVmax primary lung malignancy, ratio SUVmaxLN/SUVaverage liver, ratio SUVmaxLN/SUVmax liver and ratio SUVmaxLN/SUVmax blood pool. A nuclear medicine physician reviewed all scans and classified nodal stations as benign or malignant., Results: Eighty-seven malignant lymph nodes and 41 benign nodes were in the prediction set. All objective FDG-PET/CT criteria analysed were significantly higher in the malignant group (P < 0.0001). EVI correctly classified 122/128 nodes (95.3%). Thirty-four malignant nodes and 19 benign nodes were in the validation set. The new proposed cut-off values of the objective criteria from the prediction set correctly classified 44/53 (83.0%) nodes: 28/34 (82.4%) malignant nodes and 16/19 (84.2%) benign nodes. EVI had 91% accuracy: 33/34 (97.1%) malignant nodes and 15/19 (79.0%) benign nodes., Conclusions: Objective analysis of 18-F FDG PET/CT can differentiate between malignant and benign nodes but is not superior to EVI., (© 2014 Asian Pacific Society of Respirology.)

Background and Objective: Laceration of the intercostal artery during pleural procedures is a rare but serious complication. This study evaluates the utility of thoracic ultrasound (US) to screen for a vulnerable vessel compared with the gold standard computed tomography (CT)., Methods: Before undergoing contrast-enhanced CT chest, thoracic US was performed on 50 patients with a high-end and portable machine, and an attempt made to visualize the vessel at three positions across the back to the axilla. These positions were labelled with radio-opaque fiducial markers. On both US and CT images, the location of the vessel at each position, relative to the overlying rib, was calculated and compared., Results: The vessel was unshielded by a rib according to CT in 114 of the 133 positions. The sensitivity, specificity and negative predictive value of portable US to image the vessel, when it was within the intercostal space on CT, was 0.86, 0.30 and 0.27 respectively. The performance of a high-end machine was not significantly different. The median time required for a pulmonologist to locate the vessel was 42 s and 18 s for the portable and high-end US respectively., Conclusions: US can be used to screen for a vulnerable vessel prior to pleural procedures, in a time amenable to use in clinical practice. Further, it is achievable by a pulmonologist using a portable US machine. If thoracentesis or chest tube insertion is being performed on a patient at increased risk of bleeding, screening for a vulnerable vessel with US prior to beginning the procedure is recommended., (© 2013 The Authors. Respirology © 2013 Asian Pacific Society of Respirology.)

Training in interventional pulmonology procedures is increasing in popularity. However, the nature of training is difficult to define, particularly with respect to an adequate number of cases. These guidelines approach training not just from a modest number of supervised cases, but also from a range of educational and outcome targets which give a rounded approach to the issue. These include prerequisite skills from basic procedures, the place of simulated training, formal simulation testing, modest procedural outcome and side effect targets, audit presentations, ongoing reading, and hands-on training expectations. All of this would still be under the supervision of an experienced trainer., (© 2012 The Authors. Respirology © 2012 Asian Pacific Society of Respirology.)

Objectives: Medical thoracoscopy and thoracoscopic talc poudrage (TTP) are accepted procedures in the management of pleural effusions. The relative merits of TTP compared with pleurodesis via intercostal catheter (ICC) continue to be debated. However, of the two procedures, only medical thoracoscopy allows both tissue diagnosis and pleurodesis to be achieved reliably in one procedure. The aim of this study was to assess the feasibility and accuracy of using frozen section analysis of samples taken during medical thoracoscopy to assist the thoracoscopist's decision to complete the procedure with a TTP., Methodology: Twenty patients with undiagnosed pleural effusions after at least one diagnostic pleurocentesis underwent medical thoracoscopy and biopsy., Results: Frozen sections were easily performed within the timeframe of medical thoracoscopy. The final diagnosis based on paraffin sections was malignant in 10 cases and benign in 10 cases. Frozen section at the time of thoracoscopy (before TTP) correctly identified nine of 10 cases as being benign and six of 10 cases as malignant. In the malignant group, reasons for incorrect identification as benign were sampling from superficial benign adipose tissue overlying the malignant deposits, difficult access to the most involved parts of the pleura and intense cellular infiltrate initially thought to be benign., Conclusion: Frozen sections taken during medical thoracoscopy have the potential to facilitate decision-making prior to pleurodesis, particularly for accurate identification of benign histology on thoracoscopic pleural biopsies, in order that pleurodesis is not performed unnecessarily.