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Interventional pulmonology (IP) fellowship training has undergone increased popularity and growth. The Accreditation Council of Graduate Medical Education recently recognized IP medicine as a new subspecialty, which leads to new challenges and opportunities for a young subspecialty. Although the specialty-specific requirements are in progress, IP fellowship programs must plan ahead for the known common program requirements and anticipated accreditation process. The educational leadership in IP must identify and execute solutions to sustain continued excellence. This includes transitioning to a new regulatory environment with issues of funding new fellowships, keeping up to date with training/assessment of new procedures, and shaping the future through recruitment of talent to lead the young subspecialty., (Copyright © 2023 by the American Thoracic Society.)

Malignant pleural effusion is associated with a poor prognosis and, while risk stratification models exist, prior studies have not evaluated pleural fluid resolution and its association with survival. We performed a retrospective review of patients diagnosed with malignant pleural effusion between 2013 and 2017, evaluating patient demographics, pleural fluid and serum composition, and procedural and treatment data using Cox regression analysis to evaluate associations with survival. In total, 123 patients were included in the study, with median survival from diagnosis being 4.8 months. Resolution of malignant pleural fluid was associated with a significant survival benefit, even when accounting for factors such as placement of an indwelling pleural catheter, anti-cancer therapy, pleural fluid cytology, cancer pheno/genotypes, and pleural fluid characteristics. Elevated fluid protein, placement of an indwelling pleural catheter, and treatment with targeted or hormone therapies were associated with pleural fluid resolution. We conclude that the resolution of pleural fluid accumulation in patients with malignant pleural effusion is associated with a survival benefit possibility representing a surrogate marker for treatment of the underlying metastatic cancer. These findings support the need to better understand the mechanism of fluid resolution in patients with malignant pleural effusion as well as the tumor-immune interplay occurring with the malignant pleural space.

Background: Current medical society guidelines recommend a procedural number for obtaining electromagnetic navigational bronchoscopy (ENB) competency and for institutional volume for training., Objective: To assess learning curves and estimate the number of ENB procedures for interventional pulmonology (IP) fellows to reach competency., Methods: We conducted a prospective multicenter study of IP fellows in the United States learning ENB. A tool previously validated in a similar population was used to assess IP fellows by their local faculty and two blinded independent reviewers using virtual recording of the procedure. Competency was determined by performing three consecutive procedures with a competency score on the assessment tool. Procedural time, faculty global rating scale, and periprocedural complications were also recorded., Results: A total of 184 ENB procedures were available for review with assessment of 26 IP fellows at 16 medical centers. There was a high correlation between the two blinded independent observers (rho = 0.8776). There was substantial agreement for determination of procedural competency between the faculty assessment and blinded reviewers (kappa = 0.7074; confidence interval, 0.5667-0.8482). The number of procedures for reaching competency for ENB bronchoscopy was determined (median, 4; mean, 5; standard deviation, 3.83). There was a wide variation in the number of procedures to reach competency, ranging from 2 to 15 procedures. There were six periprocedural complications reported, four (one pneumomediastinum, three pneumothorax) of which occurred before reaching competence and two pneumothoraces after achieving competence., Conclusion: There is a wide variation in acquiring competency for ENB among IP fellows. Virtual competency assessment has a potential role but needs further studies., (Copyright © 2022 by the American Thoracic Society.)

Background: The impact of the coronavirus disease (COVID-19) pandemic extends beyond the realms of patient care and healthcare resource use to include medical education; however, the repercussions of COVID-19 on the quality of training and trainee perceptions have yet to be explored. Objective: The purpose of this study was to determine the degree of interventional pulmonology (IP) fellows' involvement in the care of COVID-19 and its impact on fellows' clinical education, procedure skills, and postgraduation employment search. Methods: An internet-based survey was validated and distributed among IP fellows in North American fellowship training programs. Results: Of 40 eligible fellows, 38 (95%) completed the survey. A majority of fellows (76%) reported involvement in the care of patients with COVID-19. Fellows training in the Northeast United States reported involvement in the care of a higher number of patients with COVID-19 than in other regions (median, 30 [interquartile range, 20-50] vs. 10 [5-13], respectively; P  < 0.01). Fifty-two percent of fellows reported redeployment outside IP during COVID-19, mostly into intensive care units. IP procedure volume decreased by 21% during COVID-19 compared with pre-COVID-19 volume. This decrease was mainly accounted for by a reduction in bronchoscopies. A majority of fellows (82%) reported retainment of outpatient clinics during COVID-19 with the transition from face-to-face to telehealth-predominant format. Continuation of academic and research activities during COVID-19 was reported by 86% and 82% of fellows, respectively. After graduation, all fellows reported having secured employment positions. Conclusion: Although IP fellows were extensively involved in the care of patients with COVID-19, most IP programs retained educational activities through the COVID-19 outbreak. The impact of the decrease in procedure volume on trainee competency would be best addressed individually within each training program. These data may assist in focusing efforts regarding the education of medical trainees during the current and future healthcare crises., (Copyright © 2021 by the American Thoracic Society.)

Background: Electromagnetic navigational bronchoscopy (ENB) and robotic-assisted bronchoscopy (RB) require a high degree of decision-making and psychomotor skill. Cognitive load theory is the overall effort expended by individuals in response to a task and is closely related to the usability of devices for medical procedures. High cognitive workload leads to poor surgical outcomes and represents a bottleneck for learning that affects performance., Objective: To analyze the cognitive load associated with ENB and RB in experienced ENB practitioners learning RB., Methods: Six experienced ENB bronchoscopists performed ENB and RB on a human cadaver model of peripheral pulmonary nodules. To assess cognitive load, we used the Surgery Task Load Index (SURG-TLX) and biometric changes. The SURG-TLX questionnaire was given to the provider after every peripheral pulmonary nodule biopsy with ENB and RB. Pupillary dilation and screen changes were continuously measured throughout the procedure for each biopsy attempt to collect biometric measures of cognitive load. Procedural time and biopsy outcome were also recorded., Results: Forty procedures (ENB and RB) were analyzed. Task complexity (23%) and mental demand (21.4%) were the highest contributors to cognitive load in ENB and RB. The cumulative SURG-TLX was significantly lower for the RB (69.25 vs. 101.25; P  < 0.01). Total procedure time was greater for ENB (6.7 min; SD 1.5) compared with RB (4.4 min; SD 1.5; P  = 0.01). Pupillary diameter was similar across the modalities (RB vs. ENB), but the diameter was higher during the biopsy portion (4.25 mm) than the navigation portion (4.01 mm)., Conclusion: The intrinsic cognitive load of RB was highly manageable by existing ENB practitioners, and in this study, RB appeared to be less mentally demanding. Future development and training should focus on task complexity and mental demand for RB. The biopsy portion, regardless of bronchoscopic modality, should be a focus for education and training., (Copyright © 2021 by the American Thoracic Society.)

The maximum curvature of a steerable needle in soft tissue is highly sensitive to needle shaft stiffness, which has motivated use of small diameter needles in the past. However, desired needle payloads constrain minimum shaft diameters, and shearing along the needle shaft can occur at small diameters and high curvatures. We provide a new way to adjust needle shaft stiffness (thereby enhancing maximum curvature, i.e. "steerability") at diameters selected based on needle payload requirements. We propose helical dovetail laser patterning to increase needle steerability without reducing shaft diameter. Experiments in phantoms and ex vivo animal muscle, brain, liver, and inflated lung tissues demonstrate high steerability in soft tissues. These experiments use needle diameters suitable for various clinical scenarios, and which have been previously limited by steering challenges without helical dovetail patterning. We show that steerable needle targeting remains accurate with established controllers and demonstrate interventional payload delivery (brachytherapy seeds and radiofrequency ablation) through the needle. Helical dovetail patterning decouples steerability from diameter in needle design. It enables diameter to be selected based on clinical requirements rather than being carefully tuned to tissue properties. These results pave the way for new sensors and interventional tools to be integrated into high-curvature steerable needles.

Background: Approximately twenty percent of lymph node (LN) negative non-small cell lung cancer (NSCLC) patients who undergo curative intent surgery have pan-cytokeratin immunohistochemistry (IHC)-detectable occult micro-metastases (MMs) in resected LNs. The presence of the MMs in NSCLC is associated worsened outcomes. As a substantial proportion of NSCLC LN staging is conducted using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), we sought to determine the frequency of detection of occult MMs in EBUS-TBNA specimens and to evaluate the impact of MMs on progression-free and overall survival., Methods: We performed retrospective IHC staining for pan-cytokeratin of EBUS-TBNA specimens previously deemed negative by a cytopathologist based on conventional hematoxylin and eosin staining. The results were correlated with clinical variables, including survival outcomes., Results: Of 887 patients screened, 44 patients were identified meeting inclusion criteria with sufficient additional tissue for testing. With respect to the time of the EBUS-TBNA procedure, 52% of patients were clinical stage I, 34% clinical stage II, and clinical 14% stage IIIa NSCLC. Three patients (6.8%) were found to have cytokeratin positive MMs. All 3 MMs detected were at N2 LN stations. The presence of MMs was associated with significantly decreased progression-free (median 210 vs. 1,293 days, P=0.0093) and overall survival (median 239 vs. 1,120 days, P=0.0357)., Conclusions: Occult LN MMs can be detected in EBUS-TBNA specimens obtained during staging examinations and are associated with poor clinical outcomes. If prospectively confirmed, these results have significant implications for EBUS-TBNA specimen analyses and possibly for the NSCLC staging paradigm., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Pleural effusions are considered rare in cystic fibrosis (CF) patients. There is a paucity of available information in the literature concerning the nature and significance of pleural effusions in non-transplanted CF patients., Methods: We conducted a multicenter retrospective evaluation of non-transplanted adult CF patients. Given the small sample size, only descriptive statistics were performed., Results: A total of 17 CF patients with pleural effusion were identified, of whom 9 patients underwent thoracentesis. The crude incidence of pleural effusion was 43 per 10,000 person-years in hospitalized CF patients at large CF centers. All sampled effusions were inflammatory in nature. All samples submitted for culture grew at least one organism., Conclusion: Pleural effusions are rare in adult non-transplanted CF patients. These fluid collections appear to be quite inflammatory with a higher rate of empyema than in the general population., (Copyright © 2016 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Lung cancer remains a common and deadly disease. Many modalities are available to the bronchoscopist to evaluate and stage lung cancer. We review the role of bronchoscopy in the staging of the mediastinum with convex endobronchial ultrasound (EBUS) and discuss emerging role of esophageal ultrasonography as a complementary modality. In addition, we discuss advances in scope technology and elastography. We review the bronchoscopic methods available for the diagnosis of peripheral lung nodules including radial EBUS and navigational bronchoscopy (NB) with a consideration of the basic methodologies and diagnostic accuracies. We conclude with a discussion of the comparison of the various methodologies.

The maintenance of CMV-specific T cell memory in lung transplant recipients (LTRs) is critical for host defense and allograft durability, particularly in donor(+) /recipient(-) (D(+) R(-) ) individuals who demonstrate increased mortality. We studied CD4(+) and CD8(+) CMV-specific memory responses to phosphoprotein 65 (pp65) in a prospective cohort of 18 D(+) R(-) LTRs, from bronchoalveolar lavage (BAL)-obtained lung mononuclear cells (LMNC) and PBMC. Unexpectedly, pp65-specific CD4(+) and CD8(+) IFN-γ memory responses from LMNC were similar, in contrast to persistent CD8(+) predominance in PBMC. Unlike the pulmonary CD8(+) predominance during acute primary infection, compartmental equalization occurred in the CMV-specific CD8(+) memory pool during chronic infection, whereas CMV-specific CD4(+) memory was enriched in the bronchoalveolar space. Moreover, CMV-specific CD4(+) memory T cells with multifunctional production of IFN-γ, TNF-α, IL-2 and MIP-1β were significantly increased in LMNCs, in contrast to similar intercompartmental CD8(+) memory function. Moreover, the absolute number of CMV-specific CD4(+) IFN-γ(+) memory cells in BAL was significantly increased in LTRs exhibiting viral control compared to those with CMV early antigen positivity. Collectively, these data demonstrate both preferential distribution and functional quality of CMV-specific CD4(+) memory in the lung allograft during chronic infection, and show an important association with CMV mucosal immunity and viral control., (© Copyright 2012 The American Society of Transplantation and the American Society of Transplant Surgeons.)