News From CHEST Physician®

Explore the talent of Canadian artists and the culture of Toronto during CHEST Annual Meeting 2017.

Over the last decade, Toronto’s art scene has moved to the former industrial district, creating a new home for galleries, especially those of contemporary art. While Toronto’s galleries may not be very busy outside of opening nights, they allow you to visit at any time and admire the artwork at your own pace. Along with art galleries, there are many options available to experience music and performance art, as well as family-friendly activities. Here are a few places you’ll want to visit:
 

Art Galleries

• The Power Plant (4-minute drive), one of Toronto’s most established contemporary art galleries, is located within Harbourfront in an actual power plant - one that was in operation for most of the 1900s. If you’re with young family members, a free, hands-on art workshop led by artists with activities designed around the current exhibitions is available called Power Plant: Power Kids.
• Art Metropole (15-minute drive) is a nonprofit organization with an eclectic collection of merchandise, including a huge selection of artist-created books, periodicals,

  

  By Raysonho @ Open Grid Scheduler / Grid Engine (Own work)

  posters, clothing, audio, video, and more. The name is taken from the building’s original tenant, Art Metropole, which operated as one of Toronto’s earliest galleries from 1911 to the 1940s. Art Metropole has always been the leader of Toronto’s artistic community. In 1997, over 13,000 items were transferred to the National Gallery of Canada as the “Art Metropole Collection.” The works of world-renowned artists, such as Yoko Ono, Sol Lewitt, Joseph Beuys, and Marcel Duchamp, are included in the collection.
• Daniel Faria Gallery (18-minute drive) is a bright contemporary art space found in a warehouse that used to be an auto body shop. A number of reputable, mostly Canadian, artists’ works are displayed by owner Daniel Faria, including works by Shannon Bool, Chris Curreri, Kristine Moran, and Coupland. Check out other neighboring galleries within walking distance, including Tomorrow Gallery and the artist-run Mercer Union.

Music and Theatre

• The Rex Jazz & Blues Bar (6-minute drive) has two to three (mostly free) shows every day, about 19 shows a week, jazz jams on Tuesdays, local and international talent, and a fantastic location. This place is truly hard to beat.
• Spend an evening at the Canadian Opera Company (6-minute drive). During the week of CHEST 2017, the COC will be showing The Elixir of Love, a Cinderella story presented with a twist, as a poor and uneducated young man dreams ofwinning the heart of a rich, clever, and beautiful woman.
• For a wide variety of events and visual art, visit the Harbourfront Centre (4-minute drive). During your time at CHEST 2017, you’ll find options for literary arts, like the International Festival of Authors, theatre, music, shopping, and more. You may even get a chance for family skating on the Natrel Rink, which opens in November!

Note: all estimated times assume you are starting at the Metro Toronto Convention Centre.The arts and culture of Toronto are sure to inspire you, as will CHEST 2017. When you visit Toronto, October 28 to November 1, you’ll have access to cutting-edge education on pulmonary, critical care, and sleep medicine topics.

Learn more, and register today at chestmeeting.chestnet.org.

Explore the talent of Canadian artists and the culture of Toronto during CHEST Annual Meeting 2017.

Over the last decade, Toronto’s art scene has moved to the former industrial district, creating a new home for galleries, especially those of contemporary art. While Toronto’s galleries may not be very busy outside of opening nights, they allow you to visit at any time and admire the artwork at your own pace. Along with art galleries, there are many options available to experience music and performance art, as well as family-friendly activities. Here are a few places you’ll want to visit:
 

Art Galleries

• The Power Plant (4-minute drive), one of Toronto’s most established contemporary art galleries, is located within Harbourfront in an actual power plant - one that was in operation for most of the 1900s. If you’re with young family members, a free, hands-on art workshop led by artists with activities designed around the current exhibitions is available called Power Plant: Power Kids.
• Art Metropole (15-minute drive) is a nonprofit organization with an eclectic collection of merchandise, including a huge selection of artist-created books, periodicals,

  

  By Raysonho @ Open Grid Scheduler / Grid Engine (Own work)

  posters, clothing, audio, video, and more. The name is taken from the building’s original tenant, Art Metropole, which operated as one of Toronto’s earliest galleries from 1911 to the 1940s. Art Metropole has always been the leader of Toronto’s artistic community. In 1997, over 13,000 items were transferred to the National Gallery of Canada as the “Art Metropole Collection.” The works of world-renowned artists, such as Yoko Ono, Sol Lewitt, Joseph Beuys, and Marcel Duchamp, are included in the collection.
• Daniel Faria Gallery (18-minute drive) is a bright contemporary art space found in a warehouse that used to be an auto body shop. A number of reputable, mostly Canadian, artists’ works are displayed by owner Daniel Faria, including works by Shannon Bool, Chris Curreri, Kristine Moran, and Coupland. Check out other neighboring galleries within walking distance, including Tomorrow Gallery and the artist-run Mercer Union.

Music and Theatre

• The Rex Jazz & Blues Bar (6-minute drive) has two to three (mostly free) shows every day, about 19 shows a week, jazz jams on Tuesdays, local and international talent, and a fantastic location. This place is truly hard to beat.
• Spend an evening at the Canadian Opera Company (6-minute drive). During the week of CHEST 2017, the COC will be showing The Elixir of Love, a Cinderella story presented with a twist, as a poor and uneducated young man dreams ofwinning the heart of a rich, clever, and beautiful woman.
• For a wide variety of events and visual art, visit the Harbourfront Centre (4-minute drive). During your time at CHEST 2017, you’ll find options for literary arts, like the International Festival of Authors, theatre, music, shopping, and more. You may even get a chance for family skating on the Natrel Rink, which opens in November!

Note: all estimated times assume you are starting at the Metro Toronto Convention Centre.The arts and culture of Toronto are sure to inspire you, as will CHEST 2017. When you visit Toronto, October 28 to November 1, you’ll have access to cutting-edge education on pulmonary, critical care, and sleep medicine topics.

Learn more, and register today at chestmeeting.chestnet.org.

Explore the talent of Canadian artists and the culture of Toronto during CHEST Annual Meeting 2017.

Over the last decade, Toronto’s art scene has moved to the former industrial district, creating a new home for galleries, especially those of contemporary art. While Toronto’s galleries may not be very busy outside of opening nights, they allow you to visit at any time and admire the artwork at your own pace. Along with art galleries, there are many options available to experience music and performance art, as well as family-friendly activities. Here are a few places you’ll want to visit:
 

Art Galleries

• The Power Plant (4-minute drive), one of Toronto’s most established contemporary art galleries, is located within Harbourfront in an actual power plant - one that was in operation for most of the 1900s. If you’re with young family members, a free, hands-on art workshop led by artists with activities designed around the current exhibitions is available called Power Plant: Power Kids.
• Art Metropole (15-minute drive) is a nonprofit organization with an eclectic collection of merchandise, including a huge selection of artist-created books, periodicals,

  

  By Raysonho @ Open Grid Scheduler / Grid Engine (Own work)

  posters, clothing, audio, video, and more. The name is taken from the building’s original tenant, Art Metropole, which operated as one of Toronto’s earliest galleries from 1911 to the 1940s. Art Metropole has always been the leader of Toronto’s artistic community. In 1997, over 13,000 items were transferred to the National Gallery of Canada as the “Art Metropole Collection.” The works of world-renowned artists, such as Yoko Ono, Sol Lewitt, Joseph Beuys, and Marcel Duchamp, are included in the collection.
• Daniel Faria Gallery (18-minute drive) is a bright contemporary art space found in a warehouse that used to be an auto body shop. A number of reputable, mostly Canadian, artists’ works are displayed by owner Daniel Faria, including works by Shannon Bool, Chris Curreri, Kristine Moran, and Coupland. Check out other neighboring galleries within walking distance, including Tomorrow Gallery and the artist-run Mercer Union.

Music and Theatre

• The Rex Jazz & Blues Bar (6-minute drive) has two to three (mostly free) shows every day, about 19 shows a week, jazz jams on Tuesdays, local and international talent, and a fantastic location. This place is truly hard to beat.
• Spend an evening at the Canadian Opera Company (6-minute drive). During the week of CHEST 2017, the COC will be showing The Elixir of Love, a Cinderella story presented with a twist, as a poor and uneducated young man dreams ofwinning the heart of a rich, clever, and beautiful woman.
• For a wide variety of events and visual art, visit the Harbourfront Centre (4-minute drive). During your time at CHEST 2017, you’ll find options for literary arts, like the International Festival of Authors, theatre, music, shopping, and more. You may even get a chance for family skating on the Natrel Rink, which opens in November!

Note: all estimated times assume you are starting at the Metro Toronto Convention Centre.The arts and culture of Toronto are sure to inspire you, as will CHEST 2017. When you visit Toronto, October 28 to November 1, you’ll have access to cutting-edge education on pulmonary, critical care, and sleep medicine topics.

Learn more, and register today at chestmeeting.chestnet.org.

Down syndrome (DS) is the most common chromosomal disorder with an estimated 250,700 children, teens, and adults living with DS in the United States in 2008 (CDC.gov). The life expectancy for individuals with DS has increased due to improved medical care, educational interventions, and identification and management of underlying psychiatric and behavioral problems. This has resulted in increased median age to 49 years, and the life expectancy of a 1-year-old child with DS to more than 60 to 65 years (Bittles et al. Dev Med Child Neurol. 2004;46[4]:282).

Sleep medicine specialists have been very involved in the care of the pediatric DS population but with the improved survival, more adult patients with DS are presenting to sleep clinics for their care. The complexity of caring for adult patients with DS poses a challenge to sleep specialists, especially with the paucity of literature and clinical guidelines.

Dr. Shaib is Associate Professor of Medicine, Medical Director, Baylor St Luke’s Center for Sleep Medicine, Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas.

Down syndrome (DS) is the most common chromosomal disorder with an estimated 250,700 children, teens, and adults living with DS in the United States in 2008 (CDC.gov). The life expectancy for individuals with DS has increased due to improved medical care, educational interventions, and identification and management of underlying psychiatric and behavioral problems. This has resulted in increased median age to 49 years, and the life expectancy of a 1-year-old child with DS to more than 60 to 65 years (Bittles et al. Dev Med Child Neurol. 2004;46[4]:282).

Sleep medicine specialists have been very involved in the care of the pediatric DS population but with the improved survival, more adult patients with DS are presenting to sleep clinics for their care. The complexity of caring for adult patients with DS poses a challenge to sleep specialists, especially with the paucity of literature and clinical guidelines.

Dr. Shaib is Associate Professor of Medicine, Medical Director, Baylor St Luke’s Center for Sleep Medicine, Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas.

Down syndrome (DS) is the most common chromosomal disorder with an estimated 250,700 children, teens, and adults living with DS in the United States in 2008 (CDC.gov). The life expectancy for individuals with DS has increased due to improved medical care, educational interventions, and identification and management of underlying psychiatric and behavioral problems. This has resulted in increased median age to 49 years, and the life expectancy of a 1-year-old child with DS to more than 60 to 65 years (Bittles et al. Dev Med Child Neurol. 2004;46[4]:282).

Sleep medicine specialists have been very involved in the care of the pediatric DS population but with the improved survival, more adult patients with DS are presenting to sleep clinics for their care. The complexity of caring for adult patients with DS poses a challenge to sleep specialists, especially with the paucity of literature and clinical guidelines.

Dr. Shaib is Associate Professor of Medicine, Medical Director, Baylor St Luke’s Center for Sleep Medicine, Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas.

Original Research

Allogeneic Human Mesenchymal Stem Cells in Patients With Idiopathic Pulmonary Fibrosis via Intravenous Delivery (AETHER): A Phase I Safety Clinical Trial. By Dr. M. K. Glassberg et al.



Adult Patients With Bronchiectasis: A First Look at the US Bronchiectasis Research Registry. By Dr. T. R. Aksamit et al.

Evidence-Based Medicine

Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. By Dr. J. J. Mullon et al.
 

Giants in Chest Medicine

Talmadge E. King Jr., MD, FCCP. By Dr. Harold R. Collard.

Original Research

Allogeneic Human Mesenchymal Stem Cells in Patients With Idiopathic Pulmonary Fibrosis via Intravenous Delivery (AETHER): A Phase I Safety Clinical Trial. By Dr. M. K. Glassberg et al.



Adult Patients With Bronchiectasis: A First Look at the US Bronchiectasis Research Registry. By Dr. T. R. Aksamit et al.

Evidence-Based Medicine

Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. By Dr. J. J. Mullon et al.
 

Giants in Chest Medicine

Talmadge E. King Jr., MD, FCCP. By Dr. Harold R. Collard.

Original Research

Allogeneic Human Mesenchymal Stem Cells in Patients With Idiopathic Pulmonary Fibrosis via Intravenous Delivery (AETHER): A Phase I Safety Clinical Trial. By Dr. M. K. Glassberg et al.



Adult Patients With Bronchiectasis: A First Look at the US Bronchiectasis Research Registry. By Dr. T. R. Aksamit et al.

Evidence-Based Medicine

Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. By Dr. J. J. Mullon et al.
 

Giants in Chest Medicine

Talmadge E. King Jr., MD, FCCP. By Dr. Harold R. Collard.

Interventional Chest/Diagnostic Procedures

Update: 8th ed IASLC lung cancer staging guidelines

The new 8th edition guidelines on the staging of non-small cell lung cancer sponsored by the International Association for the Study of Lung Cancer (IASLC), and developed jointly by the American Joint Committee on Cancer and the Union Internationale Contre le Cancer were enacted January 1, 2017, and provide a methodologically rigorous update to staging nomenclature (Detterbeck et al. Chest. 2017;151[1]:193). The new guidelines were developed using a database comprising 94,708 patients in 16 countries, integrating clinical, pathologic, and survival data with multivariate analysis to establish prognostically significant staging subgroups.

In the new guidelines, tumor size has been divided into 1-cm increments for T classifications with new subcategories of T1a <1 cm, T1b 1-2 cm, and T1c 2-3 cm (Rami-Porta et al. J Thorac Oncol. 2015;10[7]:990). Furthermore, T2 has been broadened to include main bronchus tumors causing lobar or whole lung atelectasis extending to the hilum. Tumors with diaphragmatic involvement have been reclassified as T4. Guidance on heterogeneous nodules has also been provided, with emphasis on measurement of the solid component (based on imaging) or depth of invasion (on pathology) to determine T classification.

The N classification remains unchanged from the 7th edition. Exploratory analysis suggested prognostic significance to the number of involved N1/N2 lymph nodes; however, this requires detailed pathologic assessment and was not adopted as a staging criterion (Asamura et al. J Thorac Oncol. 2015;10[12]:1675).

Classification of metastatic disease has been modified from M1a/M1b to M1a for thoracic metastasis, M1b for single/oligometastatic extrathoracic metastasis, and the new category M1c for multiple/disseminated metastases. M1c involvement now denotes stage IVb disease, with lower survival compared to IVa disease (0% vs 10% 5-year survival (Goldstraw et al. J Thorac Oncol. 2015;11[1]:39). Application in broader cohorts, including patients undergoing bronchoscopic staging, will be needed to further validate the new guidelines.

Vivek Murthy, MD

Fellow-in-Training MemberSteering Committee
 

Pulmonary Physiology, Function, and Rehabilitation

6-minute walk test

The 6-minute walk test (6MWT) is a widely used measure of functional status and exercise capacity. Though it does not diagnose specific etiologies of impairment, the 6MWT provides an assessment of the overall integrated physiologic responses to exercise (Am J Respir Crit Care Med. 2002;166[1]:111). The test is a self-paced, submaximal study. Patients are instructed to “walk as far as possible for 6 minutes” with this distance (6MWD) measured as the primary outcome. 6MWD is associated with clinical outcomes in many cardiopulmonary disorders and is reliable, valid, and responsive to treatment. Normative equations provide predicted and lower limit of normal values (Singh et al. Eur Respir J. 2014;44[6]:1447). In addition to patient comorbidities, several important factors impact 6MWD interpretation. Standardization of the testing course, patient instructions, encouragement, technician assistance, walking aids, and supplemental oxygen use are important in reducing testing variability (Holland et al. Eur Respir J. 2014;44[6]:1428). A significant learning effect exists during the first several walks. An improvement of about 26 m (range 24-29 m) has been reported in patients with COPD, with the majority improving during the second test despite a short time interval lapse. Assessing for longitudinal change in serial testing is based on the minimal clinically important difference (MCID). This represents the difference in 6MWD that is perceived as important to the patient or leads to change in management. Techniques to develop these estimates are based upon statistical analysis of study sample data (distribution-based) or changes in a different, but related, clinical variable that is used as a reference (anchor-based). While minor differences in MCID are reported based on specific disease processes, a European Respiratory Society/American Thoracic Society review based on data from patients with COPD, ILD, and PAH found a MCID value of about 30 m (range 25-33 m) for adults with chronic respiratory disease, independent of specific disease, which is only slightly larger than the short term variability (Puente-Maestu et al. Eur Respir J. 2016;47[2]:429). Knowledge of these factors can assist in proper interpretation of the 6MWT.

Lana Alghothani, MD

NetWork Member

Nitin Bhatt, MD

Steering Committee Member

Pulmonary Vascular Disease

Methamphetamine-associated pulmonary hypertension (MAPAH): “tip of the iceberg”

Pulmonary hypertension (PH) is a devastating condition with serious morbidity and mortality. The Evian Classification and more recent revisions (J Am Coll Cardiol. 2013;62(25 Suppl ):D34) reclassified PH into five subgroups based upon etio-pathogenesis. Group I PH (pulmonary arterial hypertension, PAH) represents a growing list of entities, with Drugs & Toxins (Group 1.3) as a separate subgroup. This subgroup was first recognized following the discovery of an association between PH and the ingestion of the anorexigen aminorex (Gurtner HP. Schweiz Med Wochenschr. 1985;115[24]:818).

Methamphetamine (ME) as a potential etiology for PAH was first reported in 1993 (Schaiberger et al. Chest. 1993;104[2]:614). More recently, Chin et al suggested an association between stimulant use and PAH in 28.9% of their patients diagnosed with idiopathic PAH (Chest. 2006;130[6]:1657). The growing body of evidence linking ME to PAH resulted in upgrading of ME from “Possible” to “Likely” in the latest revision of the PH classification.

Recent gene sequencing data showed carboxylesterase-1, an enzyme that protects against ME-mediated pulmonary vascular injury, may be downregulated in patients with methamphetamine-associated PAH (MAPAH) (Perez et al. Am J Respir Crit Care Med. 193;2016:A2912). Furthermore, amphetamines promote mitochondrial dysfunction and DNA damage in pulmonary hypertension (Chen PI. JCI Insight. 2017;2[2]:e90427). Importantly, Barnett et al demonstrated a poorer prognosis in MAPAH compared with individuals with idiopathic PAH, but they are less likely to be treated with infused prostanoid therapies (Circulation. 2012;126:A13817).

Amphetamine-type stimulants have become the second most widely used class of illicit drugs worldwide (United Nations Office on Drugs & Crime. World Drug Report 2012). An estimated 4.7 million Americans (2.1% of the US population) have tried MA at some time in their lives (J Psychoactive Drugs. 2000;32[2]:137). The true incidence and prevalence of MAPAH remains unknown. One can surmise that with the widespread use of ME, we are only witnessing the “tip of the iceberg.”

Vijay Balasubramanian, MD, FCCP

Steering Committee Member

Franck Rahaghi, MD, FCCP

NetWork Member
 

Thoracic Oncology

Immunotherapy for lung cancer

The management of non-small cell lung cancer has traditionally focused on surgical resection of early and limited stage tumors and radiation and cytotoxic chemotherapy for patients with advanced disease. Recent progress in the management of patients with metastatic lung cancer treatment has concentrated on the precise histologic diagnosis and the characterization of molecular drivers of malignant progression. Distinguishing small cell from non-small cell carcinomas, as well as differentiating adenocarcinoma from squamous cell carcinomas, enables clinicians to more effectively tailor appropriate chemotherapy. The identification of molecular mutations in EGFR (epidermal growth factor receptor) or fusions in ELM4-ALK translocations as drivers of the malignant process has facilitated tumor regression by targeting the molecular pathways with small molecular inhibitors (tyrosine-kinase inhibitors) or synthetic antibodies. Unfortunately, not all lung cancers carry activating mutations, and those that do may develop resistance to this molecular-targeted approach and show tumor progression.

Immunotherapy, an anticancer therapeutic approach that activates the host immune system to target the tumor, has historically been either a broad spectrum management utilizing immune cytokine modifiers to augment host immune activity or a directed adaptive recruitment and stimulation of host lymphocytes to attack targeted tumor cells. More recently, immunotherapy has taken a targeted molecular approach to modify immune checkpoint inhibitory pathways, the “brakes” of the immune system that tumor cells have manipulated to evade immune surveillance. Cancer cells may be attacked by activated T cells through the MHC complex and T cell receptor pathways. However, cancer cells that express a checkpoint ligand can deactivate T cells through its checkpoint pathway. Cancer cells may evade immune recognition by signaling inhibitory checkpoint receptor pathways, such as PD-1/PDL-1, or CTLA-4 receptors. Blocking the checkpoint inhibition may reactivate the immune response and enhance host immune recognition and killing of tumor cells. Infusions containing FDA-approved nivolumab (Opdivo) and pembrolizumab (Keytruda) block the PD-1 receptor checkpoint, whereas atezolizumab (Tecentriq) blocks PD-L1, the ligand that binds PD-1. These immune therapeutic approaches have been successfully utilized in a variety of solid tumors, including lung cancer and malignant melanomas. Impressive clinical results of prolonged tumor regression have been demonstrated in second-line immunotherapy with improvements over chemotherapy; newer immunotherapy trials have demonstrated efficacy in the first-line setting for metastatic disease. Tumors with high PDL-1 expression and high mutational load predict improved immunotherapy outcomes. As expected, blocking checkpoint immune inhibition may lead to autoimmune-like conditions of pneumonitis, hepatitis, colitis, and dermatitis. Tumor tissue markers predictive of a therapeutic immune response are in the research phase. Immunotherapy against lung cancer adds to the therapeutic armamentarium of cancer management and provides an exciting new research arena into the biology and immunology of lung cancer.

Arnold M. Schwartz, MD, PhD, FCCP

Steering Committee Member

References

Cousin-Frankel J. Breakthrough of the year 2013: cancer immunotherapy. Science . 2013;342[6165]:1432.

Sharma P, et al. The future of immune checkpoint therapy. Science . 2015;348[6230]:56.

Garon EB, et al. Pembrolizumab for the treatment of non-small cell lung cancer. N Engl J Med . 2015;372[21]:2018.

Brahmer J, et al. Nivolumab versus docetaxel in advanced squamous cell non-small cell lung cancer. N Engl J Med . 2015;373[2]:123.

Reck M, et al. Pembrolizumab versus chemotherapy for PDL-1 positive non-small cell cancer. N Engl J Med . 2016;375[19]:1823. Herbst RS, et al. Pembrolizumab versus docetaxel for previously treated PDL-1- positive advanced non-small cell lung cancer. Lancet . 2016;387[10027]:1540.

Interventional Chest/Diagnostic Procedures

Update: 8th ed IASLC lung cancer staging guidelines

The new 8th edition guidelines on the staging of non-small cell lung cancer sponsored by the International Association for the Study of Lung Cancer (IASLC), and developed jointly by the American Joint Committee on Cancer and the Union Internationale Contre le Cancer were enacted January 1, 2017, and provide a methodologically rigorous update to staging nomenclature (Detterbeck et al. Chest. 2017;151[1]:193). The new guidelines were developed using a database comprising 94,708 patients in 16 countries, integrating clinical, pathologic, and survival data with multivariate analysis to establish prognostically significant staging subgroups.

In the new guidelines, tumor size has been divided into 1-cm increments for T classifications with new subcategories of T1a <1 cm, T1b 1-2 cm, and T1c 2-3 cm (Rami-Porta et al. J Thorac Oncol. 2015;10[7]:990). Furthermore, T2 has been broadened to include main bronchus tumors causing lobar or whole lung atelectasis extending to the hilum. Tumors with diaphragmatic involvement have been reclassified as T4. Guidance on heterogeneous nodules has also been provided, with emphasis on measurement of the solid component (based on imaging) or depth of invasion (on pathology) to determine T classification.

The N classification remains unchanged from the 7th edition. Exploratory analysis suggested prognostic significance to the number of involved N1/N2 lymph nodes; however, this requires detailed pathologic assessment and was not adopted as a staging criterion (Asamura et al. J Thorac Oncol. 2015;10[12]:1675).

Classification of metastatic disease has been modified from M1a/M1b to M1a for thoracic metastasis, M1b for single/oligometastatic extrathoracic metastasis, and the new category M1c for multiple/disseminated metastases. M1c involvement now denotes stage IVb disease, with lower survival compared to IVa disease (0% vs 10% 5-year survival (Goldstraw et al. J Thorac Oncol. 2015;11[1]:39). Application in broader cohorts, including patients undergoing bronchoscopic staging, will be needed to further validate the new guidelines.

Vivek Murthy, MD

Fellow-in-Training MemberSteering Committee
 

Pulmonary Physiology, Function, and Rehabilitation

6-minute walk test

The 6-minute walk test (6MWT) is a widely used measure of functional status and exercise capacity. Though it does not diagnose specific etiologies of impairment, the 6MWT provides an assessment of the overall integrated physiologic responses to exercise (Am J Respir Crit Care Med. 2002;166[1]:111). The test is a self-paced, submaximal study. Patients are instructed to “walk as far as possible for 6 minutes” with this distance (6MWD) measured as the primary outcome. 6MWD is associated with clinical outcomes in many cardiopulmonary disorders and is reliable, valid, and responsive to treatment. Normative equations provide predicted and lower limit of normal values (Singh et al. Eur Respir J. 2014;44[6]:1447). In addition to patient comorbidities, several important factors impact 6MWD interpretation. Standardization of the testing course, patient instructions, encouragement, technician assistance, walking aids, and supplemental oxygen use are important in reducing testing variability (Holland et al. Eur Respir J. 2014;44[6]:1428). A significant learning effect exists during the first several walks. An improvement of about 26 m (range 24-29 m) has been reported in patients with COPD, with the majority improving during the second test despite a short time interval lapse. Assessing for longitudinal change in serial testing is based on the minimal clinically important difference (MCID). This represents the difference in 6MWD that is perceived as important to the patient or leads to change in management. Techniques to develop these estimates are based upon statistical analysis of study sample data (distribution-based) or changes in a different, but related, clinical variable that is used as a reference (anchor-based). While minor differences in MCID are reported based on specific disease processes, a European Respiratory Society/American Thoracic Society review based on data from patients with COPD, ILD, and PAH found a MCID value of about 30 m (range 25-33 m) for adults with chronic respiratory disease, independent of specific disease, which is only slightly larger than the short term variability (Puente-Maestu et al. Eur Respir J. 2016;47[2]:429). Knowledge of these factors can assist in proper interpretation of the 6MWT.

Lana Alghothani, MD

NetWork Member

Nitin Bhatt, MD

Steering Committee Member

Pulmonary Vascular Disease

Methamphetamine-associated pulmonary hypertension (MAPAH): “tip of the iceberg”

Pulmonary hypertension (PH) is a devastating condition with serious morbidity and mortality. The Evian Classification and more recent revisions (J Am Coll Cardiol. 2013;62(25 Suppl ):D34) reclassified PH into five subgroups based upon etio-pathogenesis. Group I PH (pulmonary arterial hypertension, PAH) represents a growing list of entities, with Drugs & Toxins (Group 1.3) as a separate subgroup. This subgroup was first recognized following the discovery of an association between PH and the ingestion of the anorexigen aminorex (Gurtner HP. Schweiz Med Wochenschr. 1985;115[24]:818).

Methamphetamine (ME) as a potential etiology for PAH was first reported in 1993 (Schaiberger et al. Chest. 1993;104[2]:614). More recently, Chin et al suggested an association between stimulant use and PAH in 28.9% of their patients diagnosed with idiopathic PAH (Chest. 2006;130[6]:1657). The growing body of evidence linking ME to PAH resulted in upgrading of ME from “Possible” to “Likely” in the latest revision of the PH classification.

Recent gene sequencing data showed carboxylesterase-1, an enzyme that protects against ME-mediated pulmonary vascular injury, may be downregulated in patients with methamphetamine-associated PAH (MAPAH) (Perez et al. Am J Respir Crit Care Med. 193;2016:A2912). Furthermore, amphetamines promote mitochondrial dysfunction and DNA damage in pulmonary hypertension (Chen PI. JCI Insight. 2017;2[2]:e90427). Importantly, Barnett et al demonstrated a poorer prognosis in MAPAH compared with individuals with idiopathic PAH, but they are less likely to be treated with infused prostanoid therapies (Circulation. 2012;126:A13817).

Amphetamine-type stimulants have become the second most widely used class of illicit drugs worldwide (United Nations Office on Drugs & Crime. World Drug Report 2012). An estimated 4.7 million Americans (2.1% of the US population) have tried MA at some time in their lives (J Psychoactive Drugs. 2000;32[2]:137). The true incidence and prevalence of MAPAH remains unknown. One can surmise that with the widespread use of ME, we are only witnessing the “tip of the iceberg.”

Vijay Balasubramanian, MD, FCCP

Steering Committee Member

Franck Rahaghi, MD, FCCP

NetWork Member
 

Thoracic Oncology

Immunotherapy for lung cancer

The management of non-small cell lung cancer has traditionally focused on surgical resection of early and limited stage tumors and radiation and cytotoxic chemotherapy for patients with advanced disease. Recent progress in the management of patients with metastatic lung cancer treatment has concentrated on the precise histologic diagnosis and the characterization of molecular drivers of malignant progression. Distinguishing small cell from non-small cell carcinomas, as well as differentiating adenocarcinoma from squamous cell carcinomas, enables clinicians to more effectively tailor appropriate chemotherapy. The identification of molecular mutations in EGFR (epidermal growth factor receptor) or fusions in ELM4-ALK translocations as drivers of the malignant process has facilitated tumor regression by targeting the molecular pathways with small molecular inhibitors (tyrosine-kinase inhibitors) or synthetic antibodies. Unfortunately, not all lung cancers carry activating mutations, and those that do may develop resistance to this molecular-targeted approach and show tumor progression.

Immunotherapy, an anticancer therapeutic approach that activates the host immune system to target the tumor, has historically been either a broad spectrum management utilizing immune cytokine modifiers to augment host immune activity or a directed adaptive recruitment and stimulation of host lymphocytes to attack targeted tumor cells. More recently, immunotherapy has taken a targeted molecular approach to modify immune checkpoint inhibitory pathways, the “brakes” of the immune system that tumor cells have manipulated to evade immune surveillance. Cancer cells may be attacked by activated T cells through the MHC complex and T cell receptor pathways. However, cancer cells that express a checkpoint ligand can deactivate T cells through its checkpoint pathway. Cancer cells may evade immune recognition by signaling inhibitory checkpoint receptor pathways, such as PD-1/PDL-1, or CTLA-4 receptors. Blocking the checkpoint inhibition may reactivate the immune response and enhance host immune recognition and killing of tumor cells. Infusions containing FDA-approved nivolumab (Opdivo) and pembrolizumab (Keytruda) block the PD-1 receptor checkpoint, whereas atezolizumab (Tecentriq) blocks PD-L1, the ligand that binds PD-1. These immune therapeutic approaches have been successfully utilized in a variety of solid tumors, including lung cancer and malignant melanomas. Impressive clinical results of prolonged tumor regression have been demonstrated in second-line immunotherapy with improvements over chemotherapy; newer immunotherapy trials have demonstrated efficacy in the first-line setting for metastatic disease. Tumors with high PDL-1 expression and high mutational load predict improved immunotherapy outcomes. As expected, blocking checkpoint immune inhibition may lead to autoimmune-like conditions of pneumonitis, hepatitis, colitis, and dermatitis. Tumor tissue markers predictive of a therapeutic immune response are in the research phase. Immunotherapy against lung cancer adds to the therapeutic armamentarium of cancer management and provides an exciting new research arena into the biology and immunology of lung cancer.

Arnold M. Schwartz, MD, PhD, FCCP

Steering Committee Member

References

Cousin-Frankel J. Breakthrough of the year 2013: cancer immunotherapy. Science . 2013;342[6165]:1432.

Sharma P, et al. The future of immune checkpoint therapy. Science . 2015;348[6230]:56.

Garon EB, et al. Pembrolizumab for the treatment of non-small cell lung cancer. N Engl J Med . 2015;372[21]:2018.

Brahmer J, et al. Nivolumab versus docetaxel in advanced squamous cell non-small cell lung cancer. N Engl J Med . 2015;373[2]:123.

Reck M, et al. Pembrolizumab versus chemotherapy for PDL-1 positive non-small cell cancer. N Engl J Med . 2016;375[19]:1823. Herbst RS, et al. Pembrolizumab versus docetaxel for previously treated PDL-1- positive advanced non-small cell lung cancer. Lancet . 2016;387[10027]:1540.

Interventional Chest/Diagnostic Procedures

Update: 8th ed IASLC lung cancer staging guidelines

The new 8th edition guidelines on the staging of non-small cell lung cancer sponsored by the International Association for the Study of Lung Cancer (IASLC), and developed jointly by the American Joint Committee on Cancer and the Union Internationale Contre le Cancer were enacted January 1, 2017, and provide a methodologically rigorous update to staging nomenclature (Detterbeck et al. Chest. 2017;151[1]:193). The new guidelines were developed using a database comprising 94,708 patients in 16 countries, integrating clinical, pathologic, and survival data with multivariate analysis to establish prognostically significant staging subgroups.

In the new guidelines, tumor size has been divided into 1-cm increments for T classifications with new subcategories of T1a <1 cm, T1b 1-2 cm, and T1c 2-3 cm (Rami-Porta et al. J Thorac Oncol. 2015;10[7]:990). Furthermore, T2 has been broadened to include main bronchus tumors causing lobar or whole lung atelectasis extending to the hilum. Tumors with diaphragmatic involvement have been reclassified as T4. Guidance on heterogeneous nodules has also been provided, with emphasis on measurement of the solid component (based on imaging) or depth of invasion (on pathology) to determine T classification.

The N classification remains unchanged from the 7th edition. Exploratory analysis suggested prognostic significance to the number of involved N1/N2 lymph nodes; however, this requires detailed pathologic assessment and was not adopted as a staging criterion (Asamura et al. J Thorac Oncol. 2015;10[12]:1675).

Classification of metastatic disease has been modified from M1a/M1b to M1a for thoracic metastasis, M1b for single/oligometastatic extrathoracic metastasis, and the new category M1c for multiple/disseminated metastases. M1c involvement now denotes stage IVb disease, with lower survival compared to IVa disease (0% vs 10% 5-year survival (Goldstraw et al. J Thorac Oncol. 2015;11[1]:39). Application in broader cohorts, including patients undergoing bronchoscopic staging, will be needed to further validate the new guidelines.

Vivek Murthy, MD

Fellow-in-Training MemberSteering Committee
 

Pulmonary Physiology, Function, and Rehabilitation

6-minute walk test

The 6-minute walk test (6MWT) is a widely used measure of functional status and exercise capacity. Though it does not diagnose specific etiologies of impairment, the 6MWT provides an assessment of the overall integrated physiologic responses to exercise (Am J Respir Crit Care Med. 2002;166[1]:111). The test is a self-paced, submaximal study. Patients are instructed to “walk as far as possible for 6 minutes” with this distance (6MWD) measured as the primary outcome. 6MWD is associated with clinical outcomes in many cardiopulmonary disorders and is reliable, valid, and responsive to treatment. Normative equations provide predicted and lower limit of normal values (Singh et al. Eur Respir J. 2014;44[6]:1447). In addition to patient comorbidities, several important factors impact 6MWD interpretation. Standardization of the testing course, patient instructions, encouragement, technician assistance, walking aids, and supplemental oxygen use are important in reducing testing variability (Holland et al. Eur Respir J. 2014;44[6]:1428). A significant learning effect exists during the first several walks. An improvement of about 26 m (range 24-29 m) has been reported in patients with COPD, with the majority improving during the second test despite a short time interval lapse. Assessing for longitudinal change in serial testing is based on the minimal clinically important difference (MCID). This represents the difference in 6MWD that is perceived as important to the patient or leads to change in management. Techniques to develop these estimates are based upon statistical analysis of study sample data (distribution-based) or changes in a different, but related, clinical variable that is used as a reference (anchor-based). While minor differences in MCID are reported based on specific disease processes, a European Respiratory Society/American Thoracic Society review based on data from patients with COPD, ILD, and PAH found a MCID value of about 30 m (range 25-33 m) for adults with chronic respiratory disease, independent of specific disease, which is only slightly larger than the short term variability (Puente-Maestu et al. Eur Respir J. 2016;47[2]:429). Knowledge of these factors can assist in proper interpretation of the 6MWT.

Lana Alghothani, MD

NetWork Member

Nitin Bhatt, MD

Steering Committee Member

Pulmonary Vascular Disease

Methamphetamine-associated pulmonary hypertension (MAPAH): “tip of the iceberg”

Pulmonary hypertension (PH) is a devastating condition with serious morbidity and mortality. The Evian Classification and more recent revisions (J Am Coll Cardiol. 2013;62(25 Suppl ):D34) reclassified PH into five subgroups based upon etio-pathogenesis. Group I PH (pulmonary arterial hypertension, PAH) represents a growing list of entities, with Drugs & Toxins (Group 1.3) as a separate subgroup. This subgroup was first recognized following the discovery of an association between PH and the ingestion of the anorexigen aminorex (Gurtner HP. Schweiz Med Wochenschr. 1985;115[24]:818).

Methamphetamine (ME) as a potential etiology for PAH was first reported in 1993 (Schaiberger et al. Chest. 1993;104[2]:614). More recently, Chin et al suggested an association between stimulant use and PAH in 28.9% of their patients diagnosed with idiopathic PAH (Chest. 2006;130[6]:1657). The growing body of evidence linking ME to PAH resulted in upgrading of ME from “Possible” to “Likely” in the latest revision of the PH classification.

Recent gene sequencing data showed carboxylesterase-1, an enzyme that protects against ME-mediated pulmonary vascular injury, may be downregulated in patients with methamphetamine-associated PAH (MAPAH) (Perez et al. Am J Respir Crit Care Med. 193;2016:A2912). Furthermore, amphetamines promote mitochondrial dysfunction and DNA damage in pulmonary hypertension (Chen PI. JCI Insight. 2017;2[2]:e90427). Importantly, Barnett et al demonstrated a poorer prognosis in MAPAH compared with individuals with idiopathic PAH, but they are less likely to be treated with infused prostanoid therapies (Circulation. 2012;126:A13817).

Amphetamine-type stimulants have become the second most widely used class of illicit drugs worldwide (United Nations Office on Drugs & Crime. World Drug Report 2012). An estimated 4.7 million Americans (2.1% of the US population) have tried MA at some time in their lives (J Psychoactive Drugs. 2000;32[2]:137). The true incidence and prevalence of MAPAH remains unknown. One can surmise that with the widespread use of ME, we are only witnessing the “tip of the iceberg.”

Vijay Balasubramanian, MD, FCCP

Steering Committee Member

Franck Rahaghi, MD, FCCP

NetWork Member
 

Thoracic Oncology

Immunotherapy for lung cancer

The management of non-small cell lung cancer has traditionally focused on surgical resection of early and limited stage tumors and radiation and cytotoxic chemotherapy for patients with advanced disease. Recent progress in the management of patients with metastatic lung cancer treatment has concentrated on the precise histologic diagnosis and the characterization of molecular drivers of malignant progression. Distinguishing small cell from non-small cell carcinomas, as well as differentiating adenocarcinoma from squamous cell carcinomas, enables clinicians to more effectively tailor appropriate chemotherapy. The identification of molecular mutations in EGFR (epidermal growth factor receptor) or fusions in ELM4-ALK translocations as drivers of the malignant process has facilitated tumor regression by targeting the molecular pathways with small molecular inhibitors (tyrosine-kinase inhibitors) or synthetic antibodies. Unfortunately, not all lung cancers carry activating mutations, and those that do may develop resistance to this molecular-targeted approach and show tumor progression.

Immunotherapy, an anticancer therapeutic approach that activates the host immune system to target the tumor, has historically been either a broad spectrum management utilizing immune cytokine modifiers to augment host immune activity or a directed adaptive recruitment and stimulation of host lymphocytes to attack targeted tumor cells. More recently, immunotherapy has taken a targeted molecular approach to modify immune checkpoint inhibitory pathways, the “brakes” of the immune system that tumor cells have manipulated to evade immune surveillance. Cancer cells may be attacked by activated T cells through the MHC complex and T cell receptor pathways. However, cancer cells that express a checkpoint ligand can deactivate T cells through its checkpoint pathway. Cancer cells may evade immune recognition by signaling inhibitory checkpoint receptor pathways, such as PD-1/PDL-1, or CTLA-4 receptors. Blocking the checkpoint inhibition may reactivate the immune response and enhance host immune recognition and killing of tumor cells. Infusions containing FDA-approved nivolumab (Opdivo) and pembrolizumab (Keytruda) block the PD-1 receptor checkpoint, whereas atezolizumab (Tecentriq) blocks PD-L1, the ligand that binds PD-1. These immune therapeutic approaches have been successfully utilized in a variety of solid tumors, including lung cancer and malignant melanomas. Impressive clinical results of prolonged tumor regression have been demonstrated in second-line immunotherapy with improvements over chemotherapy; newer immunotherapy trials have demonstrated efficacy in the first-line setting for metastatic disease. Tumors with high PDL-1 expression and high mutational load predict improved immunotherapy outcomes. As expected, blocking checkpoint immune inhibition may lead to autoimmune-like conditions of pneumonitis, hepatitis, colitis, and dermatitis. Tumor tissue markers predictive of a therapeutic immune response are in the research phase. Immunotherapy against lung cancer adds to the therapeutic armamentarium of cancer management and provides an exciting new research arena into the biology and immunology of lung cancer.

Arnold M. Schwartz, MD, PhD, FCCP

Steering Committee Member

References

Cousin-Frankel J. Breakthrough of the year 2013: cancer immunotherapy. Science . 2013;342[6165]:1432.

Sharma P, et al. The future of immune checkpoint therapy. Science . 2015;348[6230]:56.

Garon EB, et al. Pembrolizumab for the treatment of non-small cell lung cancer. N Engl J Med . 2015;372[21]:2018.

Brahmer J, et al. Nivolumab versus docetaxel in advanced squamous cell non-small cell lung cancer. N Engl J Med . 2015;373[2]:123.

Reck M, et al. Pembrolizumab versus chemotherapy for PDL-1 positive non-small cell cancer. N Engl J Med . 2016;375[19]:1823. Herbst RS, et al. Pembrolizumab versus docetaxel for previously treated PDL-1- positive advanced non-small cell lung cancer. Lancet . 2016;387[10027]:1540.

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with our first woman President, Dr. Deborah Shure.

Deborah Shure, MD, Master FCCP

President 1995-1996

When I began my year as President of the American College of Chest Physicians in 1995 in New York City, I became the first woman to serve in that role in the then 60-year history of the College. One major theme for my presidential year was inclusiveness. With the support of the Regents and the members of the College, we sought to increase the roles of our International Fellows and Affiliate Members, as well as the participation of all of our FCCPs. We also expanded the role of the College in global tobacco control.

With a focus on these goals, the presidential year was truly an exciting and fulfilling one. I was honored to meet so many members worldwide and, through the College, enable the support of regional meetings internationally. Our efforts in the Asia-Pacific area lent essential support to one of the early conferences on tobacco control in the Philippines (Asia Pacific Conference on Control of Tobacco, Subic, Philippines, 1998). My presentation in 1996 in Bangkok was the College’s first International Partnering for World Health Award to H.M. King Bhumibol of Thailand for his work in the prevention and treatment of chest diseases in Thailand, was an unforgettable experience.

My presidential year ended in San Francisco. Since that time, my professional life has been varied and interesting. I was fortunate to continue my academic career encompassing both clinical and basic research. In 2005, I tried a new path and worked for the FDA Center for Devices and Radiological Health, using my background in device development (the angioscope) and clinical trials. Since 2012, I have been using my clinical, academic, and regulatory experience as an independent consultant in clinical trial design.

On a personal note, my partner of many years, Aymarah Robles, MD, FCCP, and I were finally able to marry in January 2015. So, we are now a happy and official two pulmonary, Cuban-American household enjoying the culture of Little Havana and the many outdoor activities of Miami!

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with our first woman President, Dr. Deborah Shure.

Deborah Shure, MD, Master FCCP

President 1995-1996

When I began my year as President of the American College of Chest Physicians in 1995 in New York City, I became the first woman to serve in that role in the then 60-year history of the College. One major theme for my presidential year was inclusiveness. With the support of the Regents and the members of the College, we sought to increase the roles of our International Fellows and Affiliate Members, as well as the participation of all of our FCCPs. We also expanded the role of the College in global tobacco control.

With a focus on these goals, the presidential year was truly an exciting and fulfilling one. I was honored to meet so many members worldwide and, through the College, enable the support of regional meetings internationally. Our efforts in the Asia-Pacific area lent essential support to one of the early conferences on tobacco control in the Philippines (Asia Pacific Conference on Control of Tobacco, Subic, Philippines, 1998). My presentation in 1996 in Bangkok was the College’s first International Partnering for World Health Award to H.M. King Bhumibol of Thailand for his work in the prevention and treatment of chest diseases in Thailand, was an unforgettable experience.

My presidential year ended in San Francisco. Since that time, my professional life has been varied and interesting. I was fortunate to continue my academic career encompassing both clinical and basic research. In 2005, I tried a new path and worked for the FDA Center for Devices and Radiological Health, using my background in device development (the angioscope) and clinical trials. Since 2012, I have been using my clinical, academic, and regulatory experience as an independent consultant in clinical trial design.

On a personal note, my partner of many years, Aymarah Robles, MD, FCCP, and I were finally able to marry in January 2015. So, we are now a happy and official two pulmonary, Cuban-American household enjoying the culture of Little Havana and the many outdoor activities of Miami!

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with our first woman President, Dr. Deborah Shure.

Deborah Shure, MD, Master FCCP

President 1995-1996

When I began my year as President of the American College of Chest Physicians in 1995 in New York City, I became the first woman to serve in that role in the then 60-year history of the College. One major theme for my presidential year was inclusiveness. With the support of the Regents and the members of the College, we sought to increase the roles of our International Fellows and Affiliate Members, as well as the participation of all of our FCCPs. We also expanded the role of the College in global tobacco control.

With a focus on these goals, the presidential year was truly an exciting and fulfilling one. I was honored to meet so many members worldwide and, through the College, enable the support of regional meetings internationally. Our efforts in the Asia-Pacific area lent essential support to one of the early conferences on tobacco control in the Philippines (Asia Pacific Conference on Control of Tobacco, Subic, Philippines, 1998). My presentation in 1996 in Bangkok was the College’s first International Partnering for World Health Award to H.M. King Bhumibol of Thailand for his work in the prevention and treatment of chest diseases in Thailand, was an unforgettable experience.

My presidential year ended in San Francisco. Since that time, my professional life has been varied and interesting. I was fortunate to continue my academic career encompassing both clinical and basic research. In 2005, I tried a new path and worked for the FDA Center for Devices and Radiological Health, using my background in device development (the angioscope) and clinical trials. Since 2012, I have been using my clinical, academic, and regulatory experience as an independent consultant in clinical trial design.

On a personal note, my partner of many years, Aymarah Robles, MD, FCCP, and I were finally able to marry in January 2015. So, we are now a happy and official two pulmonary, Cuban-American household enjoying the culture of Little Havana and the many outdoor activities of Miami!

The Board of Regents of the American College of Chest Physicians (CHEST) has finalized the appointment of Stephen J. Welch as executive vice president and chief executive officer.

The Board of Regents of the American College of Chest Physicians (CHEST) has finalized the appointment of Stephen J. Welch as executive vice president and chief executive officer.

The Board of Regents of the American College of Chest Physicians (CHEST) has finalized the appointment of Stephen J. Welch as executive vice president and chief executive officer.

Get ready to visit the metropolitan hub of Canada. Explore new grounds with the chest medicine community for current pulmonary, critical care, and sleep medicine topics presented by world-renowned faculty in a variety of innovative instruction formats.

You will have access to our cutting-edge education, Oct 28 - Nov 1, but don’t forget to take advantage of all that Toronto has to offer.

Food

Nature parks

One of the city’s largest and oldest parks, High Park is Toronto’s version of New York City’s Central Park. There’s plenty to enjoy, such as Grenadier Pond, numerous ravine-based hiking trails, playgrounds, athletic areas, restaurants, a museum, and even a zoo!

If you want a different type of nature excursion, there is always beautiful Niagara Falls, Ontario, which is just a short drive from Toronto. Don’t miss seeing the Tesla monument in Queen Victoria Park, or go 10 minutes north of the Falls to the Botanical Gardens, home to the Butterfly Conservatory with over 2,000 butterflies.

Relaxation

After eventful days of absorbing all the new science CHEST 2017 has to offer, you may want to relax your mind and body. Elmwood spa, located in downtown Toronto, is where “four spacious floors of treatment and renewal options mean that Elmwood Spa can provide the convenience and flexibility to cater to demanding schedules,” according to Elmwood.

Learn more about Toronto opportunities at blogTO.com, and find out more about CHEST 2017 at chestmeeting.chestnet.org.

Get ready to visit the metropolitan hub of Canada. Explore new grounds with the chest medicine community for current pulmonary, critical care, and sleep medicine topics presented by world-renowned faculty in a variety of innovative instruction formats.

You will have access to our cutting-edge education, Oct 28 - Nov 1, but don’t forget to take advantage of all that Toronto has to offer.

Food

Nature parks

One of the city’s largest and oldest parks, High Park is Toronto’s version of New York City’s Central Park. There’s plenty to enjoy, such as Grenadier Pond, numerous ravine-based hiking trails, playgrounds, athletic areas, restaurants, a museum, and even a zoo!

If you want a different type of nature excursion, there is always beautiful Niagara Falls, Ontario, which is just a short drive from Toronto. Don’t miss seeing the Tesla monument in Queen Victoria Park, or go 10 minutes north of the Falls to the Botanical Gardens, home to the Butterfly Conservatory with over 2,000 butterflies.

Relaxation

After eventful days of absorbing all the new science CHEST 2017 has to offer, you may want to relax your mind and body. Elmwood spa, located in downtown Toronto, is where “four spacious floors of treatment and renewal options mean that Elmwood Spa can provide the convenience and flexibility to cater to demanding schedules,” according to Elmwood.

Learn more about Toronto opportunities at blogTO.com, and find out more about CHEST 2017 at chestmeeting.chestnet.org.

Get ready to visit the metropolitan hub of Canada. Explore new grounds with the chest medicine community for current pulmonary, critical care, and sleep medicine topics presented by world-renowned faculty in a variety of innovative instruction formats.

You will have access to our cutting-edge education, Oct 28 - Nov 1, but don’t forget to take advantage of all that Toronto has to offer.

Food

Nature parks

One of the city’s largest and oldest parks, High Park is Toronto’s version of New York City’s Central Park. There’s plenty to enjoy, such as Grenadier Pond, numerous ravine-based hiking trails, playgrounds, athletic areas, restaurants, a museum, and even a zoo!

If you want a different type of nature excursion, there is always beautiful Niagara Falls, Ontario, which is just a short drive from Toronto. Don’t miss seeing the Tesla monument in Queen Victoria Park, or go 10 minutes north of the Falls to the Botanical Gardens, home to the Butterfly Conservatory with over 2,000 butterflies.

Relaxation

After eventful days of absorbing all the new science CHEST 2017 has to offer, you may want to relax your mind and body. Elmwood spa, located in downtown Toronto, is where “four spacious floors of treatment and renewal options mean that Elmwood Spa can provide the convenience and flexibility to cater to demanding schedules,” according to Elmwood.

Learn more about Toronto opportunities at blogTO.com, and find out more about CHEST 2017 at chestmeeting.chestnet.org.

Dr. Mahajan and colleagues present a compelling case for requiring minimum standards to perform an EBUS-guided bronchoscopy. Their opinion piece epitomizes the classic tension between physicians with advanced training and those who can only have practice-based training. A middle ground may exist, as perhaps competence could be achieved by simulation, clinical cases performed, and observation by a regional expert? Physicians in practice must have a pathway to adopt new technology whether it is thoracic ultrasound or endobronchial ultrasound, but it must be done in a safe manner. As a referring physician, I would only send my patients who required mediastinal staging to a pulmonologist who I knew performed EBUS regularly.

Nitin Puri, MD, FCCP

Endobronchial ultrasound (EBUS) bronchoscopy is a tool that has transformed the diagnosis and staging of lung cancer. Through real-time ultrasound imaging, EBUS provides clear images of lymph nodes and proximal lung masses that can be adequately sampled through transbronchial needle aspiration. EBUS is a minimally invasive, outpatient procedure that can also be used for diagnosing benign disease within the chest. Large studies investigating the use of EBUS for mediastinal staging have shown the procedure to be highly sensitive and specific while harboring an excellent safety profile.¹ As a result, EBUS has essentially replaced mediastinoscopy for the staging of lung cancer.

EBUS bronchoscopy was primarily offered at major academic centers when first released and was performed by physicians who were formally trained in the procedure during interventional pulmonology or thoracic surgery fellowships. Over time, the tool has been adopted by established general pulmonologists without formal training in EBUS. Some of these pulmonologists only develop their skills by attending 1- to 2-day courses, which is insufficient supervision to become competent in this important procedure.

An ongoing debate continues as to how many supervised EBUS bronchoscopies should be performed prior to being considered proficient.² As procedural competence has been associated with the number of EBUS procedures performed, the learning curve required to master EBUS is an important component of proficiency. While most consider learning curves to be variable, evidence produced by Fernandez-Villar and colleagues revealed that EBUS performance continues to improve up to 120 procedures.³ This analysis was performed in unselected consecutive patients based on diagnostic yield, procedure length, number of lymph nodes passes performed in order to obtain adequate samples, and the number of lymph nodes studied per patient. The learning curve was evaluated based on consecutive groups of 20 patients, the number of adequate samples obtained, and the diagnostic accuracy. Their results indicated that the diagnostic effectiveness of EBUS-TBNA improves with increasing number of procedures performed, allowing for access to a greater number of lymph nodes without necessarily increasing the length of the procedure, and by reducing the number of punctures at each nodal station. Based on their results, the first 20 procedures performed yielded a 70% accuracy, 21 to 40 procedures performed resulted in 81.8% accuracy, 41 to 60 procedures performed resulted in 83.3% accuracy, 61 to 80 procedures performed resulted in 89.8% accuracy, 81 to 100 procedures performed resulted in 90.5% accuracy, and 101 to 120 procedures performed resulted in 94.5% accuracy.

While the American Thoracic Society (ATS) and the American College of Chest Physicians (CHEST) both recommend a minimum number of 40 to 50 supervised EBUS bronchoscopies prior to performing the procedure independently, along with 20 procedures per year for maintenance of competency, most institutions do not track the number of EBUS procedures performed and they do not follow the ATS or CHEST recommendations.^4,5 As a result, a number of physicians are independently performing EBUS without adequate experience, resulting in possibly poor quality care. Unfortunately, some short courses, intended to generate interest and encourage attendees to pursue further training, are mistakenly assumed to be sufficient by the novice user.

As the number of interventional pulmonary fellowships continues to expand, the growing number of subspecialized pulmonologists with extensive training in EBUS grows. During a dedicated interventional pulmonary fellowship, fellows perform well above the number of EBUS bronchoscopies suggested by the ATS and CHEST in a single year. Recently published accreditation guidelines require a minimum of 100 cases per interventional pulmonary fellow.⁶ These fellowship-trained interventional pulmonologists are then tested to become board-certified in a wide array of minimally invasive procedures, including EBUS. As a result, a model has developed where both board-certified interventional pulmonologists with extensive training in EBUS and general pulmonologists not meeting ATS or CHEST minimum requirements practice at the same institution. Proponents of a more liberal access to credentialing in EBUS have suggested that adhering to competency requirements constitutes a “barrier to entry” in which incumbent practitioners benefit from limiting competition. However, like any other regulatory metric, the rationale is to prevent asymmetric information. In this example, the physician knows more than the patient. The patient cannot make an informed decision on which provider to choose and what are the minimum requirements that are likely to produce the most useful information (ie, complete staging). For these reasons, it is imperative that regulations protect the patient.

Without question, EBUS bronchoscopy should not be performed only by board-certified interventional pulmonologists. Instead, hospital credentialing committees should adhere to both the ATS and CHEST recommendations for the number of supervised cases necessary prior to performing EBUS independently. As EBUS use continues to grow, fellows in 3- or 4-year pulmonary and critical care fellowships will be likely capable of meeting the minimal number of observed cases, but, if these numbers are not achieved, additional training should be required. Understandably, this could be challenging for physicians who are unable to take time away from their practice to gain this training. However, if these numbers cannot be met, credentialing requirements should be enforced.

Even more challenging than establishing quality measures for EBUS, is to ensure the highest level of care delivery for patients when there exist multiple levels of experience in the same institution. Undoubtedly, patients undergoing EBUS bronchoscopy, or any procedure for that matter, would want the most skilled physician who has attained certification in the procedure. Unfortunately, no formal certification of EBUS exists outside of gaining board certification in interventional pulmonology. To ensure excellence in care, physicians performing EBUS should be involved in quality improvement initiatives and review pathologic yields along with complications on a regular basis in a group setting. Unlike emergency interventions, EBUS bronchoscopy is an entirely elective procedure.

The advent of EBUS bronchoscopy has revolutionized the diagnosis and staging of lung cancer. As use of EBUS continues to become more widespread, the incidence of high volume and low volume proceduralists will become a more commonly encountered scenario. Guidelines have been set by the professional pulmonary societies based on the data and observations available. At the local level, stringent guidelines need to be established by hospitals to ensure a high level of quality with appropriate oversight. Patients undergoing EBUS deserve a physician who is skilled in the procedure and has performed at least the minimum number of procedures to provide the adequate care.



Dr. Mahajan is Medical Director, Interventional Pulmonology, Inova Heart and Vascular Institute - Inova Fairfax Hospital, and Associate Professor, Virginia Commonwealth Medical School; Dr. Khandhar is Medical Director, Thoracic Surgery, Inova Heart and Vascular Institute - Inova Fairfax Hospital, and Assistant Clinical Professor, Virginia Commonwealth Medical School; Falls Church, VA. Dr. Folch is Co-Director, Interventional Pulmonology Chief, Complex Chest Diseases Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA.

References

1. Gomez M, Silvestri GA. Endobronchial ultrasound for the diagnosis and staging of lung cancer. Proc Am Thorac Soc. 2009;6(2):180-186.

2. Folch E, Majid A. Point: Are >50 Supervised Procedures Required to Develop Competency in Performing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Mediastinal Staging? Yes. Chest. 2013;143(4):888-891.

3. Fernandez-Villar A, Leiro-Fernandez V, Botana-Rial M, Represas-Represas C, Nunez-Delgado M. The endobronchial ultrasound-guided transbronchial needle biopsy learning curve for mediastinal and hilar lymph node diagnosis. Chest. 2012; 141(1):278-279.

4. Ernst A, Silvestri GA, Johnstone D. Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians. Chest. 2003;123(5):1693-1717.

5. Bolliger CT, Mathur PN, Beamis JF, et al. ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society. Eur Respir J. 2002;19(2):356-373.

6. Mullon JJ, Burkhart KM, Silvestri G. Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multi-society Interventional Pulmonology Fellowship Accreditation Committee. Chest. 2017. doi:10.1016/j.chest.2017.01.024.

Dr. Mahajan and colleagues present a compelling case for requiring minimum standards to perform an EBUS-guided bronchoscopy. Their opinion piece epitomizes the classic tension between physicians with advanced training and those who can only have practice-based training. A middle ground may exist, as perhaps competence could be achieved by simulation, clinical cases performed, and observation by a regional expert? Physicians in practice must have a pathway to adopt new technology whether it is thoracic ultrasound or endobronchial ultrasound, but it must be done in a safe manner. As a referring physician, I would only send my patients who required mediastinal staging to a pulmonologist who I knew performed EBUS regularly.

Nitin Puri, MD, FCCP

Endobronchial ultrasound (EBUS) bronchoscopy is a tool that has transformed the diagnosis and staging of lung cancer. Through real-time ultrasound imaging, EBUS provides clear images of lymph nodes and proximal lung masses that can be adequately sampled through transbronchial needle aspiration. EBUS is a minimally invasive, outpatient procedure that can also be used for diagnosing benign disease within the chest. Large studies investigating the use of EBUS for mediastinal staging have shown the procedure to be highly sensitive and specific while harboring an excellent safety profile.¹ As a result, EBUS has essentially replaced mediastinoscopy for the staging of lung cancer.

EBUS bronchoscopy was primarily offered at major academic centers when first released and was performed by physicians who were formally trained in the procedure during interventional pulmonology or thoracic surgery fellowships. Over time, the tool has been adopted by established general pulmonologists without formal training in EBUS. Some of these pulmonologists only develop their skills by attending 1- to 2-day courses, which is insufficient supervision to become competent in this important procedure.

An ongoing debate continues as to how many supervised EBUS bronchoscopies should be performed prior to being considered proficient.² As procedural competence has been associated with the number of EBUS procedures performed, the learning curve required to master EBUS is an important component of proficiency. While most consider learning curves to be variable, evidence produced by Fernandez-Villar and colleagues revealed that EBUS performance continues to improve up to 120 procedures.³ This analysis was performed in unselected consecutive patients based on diagnostic yield, procedure length, number of lymph nodes passes performed in order to obtain adequate samples, and the number of lymph nodes studied per patient. The learning curve was evaluated based on consecutive groups of 20 patients, the number of adequate samples obtained, and the diagnostic accuracy. Their results indicated that the diagnostic effectiveness of EBUS-TBNA improves with increasing number of procedures performed, allowing for access to a greater number of lymph nodes without necessarily increasing the length of the procedure, and by reducing the number of punctures at each nodal station. Based on their results, the first 20 procedures performed yielded a 70% accuracy, 21 to 40 procedures performed resulted in 81.8% accuracy, 41 to 60 procedures performed resulted in 83.3% accuracy, 61 to 80 procedures performed resulted in 89.8% accuracy, 81 to 100 procedures performed resulted in 90.5% accuracy, and 101 to 120 procedures performed resulted in 94.5% accuracy.

While the American Thoracic Society (ATS) and the American College of Chest Physicians (CHEST) both recommend a minimum number of 40 to 50 supervised EBUS bronchoscopies prior to performing the procedure independently, along with 20 procedures per year for maintenance of competency, most institutions do not track the number of EBUS procedures performed and they do not follow the ATS or CHEST recommendations.^4,5 As a result, a number of physicians are independently performing EBUS without adequate experience, resulting in possibly poor quality care. Unfortunately, some short courses, intended to generate interest and encourage attendees to pursue further training, are mistakenly assumed to be sufficient by the novice user.

As the number of interventional pulmonary fellowships continues to expand, the growing number of subspecialized pulmonologists with extensive training in EBUS grows. During a dedicated interventional pulmonary fellowship, fellows perform well above the number of EBUS bronchoscopies suggested by the ATS and CHEST in a single year. Recently published accreditation guidelines require a minimum of 100 cases per interventional pulmonary fellow.⁶ These fellowship-trained interventional pulmonologists are then tested to become board-certified in a wide array of minimally invasive procedures, including EBUS. As a result, a model has developed where both board-certified interventional pulmonologists with extensive training in EBUS and general pulmonologists not meeting ATS or CHEST minimum requirements practice at the same institution. Proponents of a more liberal access to credentialing in EBUS have suggested that adhering to competency requirements constitutes a “barrier to entry” in which incumbent practitioners benefit from limiting competition. However, like any other regulatory metric, the rationale is to prevent asymmetric information. In this example, the physician knows more than the patient. The patient cannot make an informed decision on which provider to choose and what are the minimum requirements that are likely to produce the most useful information (ie, complete staging). For these reasons, it is imperative that regulations protect the patient.

Without question, EBUS bronchoscopy should not be performed only by board-certified interventional pulmonologists. Instead, hospital credentialing committees should adhere to both the ATS and CHEST recommendations for the number of supervised cases necessary prior to performing EBUS independently. As EBUS use continues to grow, fellows in 3- or 4-year pulmonary and critical care fellowships will be likely capable of meeting the minimal number of observed cases, but, if these numbers are not achieved, additional training should be required. Understandably, this could be challenging for physicians who are unable to take time away from their practice to gain this training. However, if these numbers cannot be met, credentialing requirements should be enforced.

Even more challenging than establishing quality measures for EBUS, is to ensure the highest level of care delivery for patients when there exist multiple levels of experience in the same institution. Undoubtedly, patients undergoing EBUS bronchoscopy, or any procedure for that matter, would want the most skilled physician who has attained certification in the procedure. Unfortunately, no formal certification of EBUS exists outside of gaining board certification in interventional pulmonology. To ensure excellence in care, physicians performing EBUS should be involved in quality improvement initiatives and review pathologic yields along with complications on a regular basis in a group setting. Unlike emergency interventions, EBUS bronchoscopy is an entirely elective procedure.

The advent of EBUS bronchoscopy has revolutionized the diagnosis and staging of lung cancer. As use of EBUS continues to become more widespread, the incidence of high volume and low volume proceduralists will become a more commonly encountered scenario. Guidelines have been set by the professional pulmonary societies based on the data and observations available. At the local level, stringent guidelines need to be established by hospitals to ensure a high level of quality with appropriate oversight. Patients undergoing EBUS deserve a physician who is skilled in the procedure and has performed at least the minimum number of procedures to provide the adequate care.



Dr. Mahajan is Medical Director, Interventional Pulmonology, Inova Heart and Vascular Institute - Inova Fairfax Hospital, and Associate Professor, Virginia Commonwealth Medical School; Dr. Khandhar is Medical Director, Thoracic Surgery, Inova Heart and Vascular Institute - Inova Fairfax Hospital, and Assistant Clinical Professor, Virginia Commonwealth Medical School; Falls Church, VA. Dr. Folch is Co-Director, Interventional Pulmonology Chief, Complex Chest Diseases Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA.

References

1. Gomez M, Silvestri GA. Endobronchial ultrasound for the diagnosis and staging of lung cancer. Proc Am Thorac Soc. 2009;6(2):180-186.

2. Folch E, Majid A. Point: Are >50 Supervised Procedures Required to Develop Competency in Performing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Mediastinal Staging? Yes. Chest. 2013;143(4):888-891.

3. Fernandez-Villar A, Leiro-Fernandez V, Botana-Rial M, Represas-Represas C, Nunez-Delgado M. The endobronchial ultrasound-guided transbronchial needle biopsy learning curve for mediastinal and hilar lymph node diagnosis. Chest. 2012; 141(1):278-279.

4. Ernst A, Silvestri GA, Johnstone D. Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians. Chest. 2003;123(5):1693-1717.

5. Bolliger CT, Mathur PN, Beamis JF, et al. ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society. Eur Respir J. 2002;19(2):356-373.

6. Mullon JJ, Burkhart KM, Silvestri G. Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multi-society Interventional Pulmonology Fellowship Accreditation Committee. Chest. 2017. doi:10.1016/j.chest.2017.01.024.

Dr. Mahajan and colleagues present a compelling case for requiring minimum standards to perform an EBUS-guided bronchoscopy. Their opinion piece epitomizes the classic tension between physicians with advanced training and those who can only have practice-based training. A middle ground may exist, as perhaps competence could be achieved by simulation, clinical cases performed, and observation by a regional expert? Physicians in practice must have a pathway to adopt new technology whether it is thoracic ultrasound or endobronchial ultrasound, but it must be done in a safe manner. As a referring physician, I would only send my patients who required mediastinal staging to a pulmonologist who I knew performed EBUS regularly.

Nitin Puri, MD, FCCP

Endobronchial ultrasound (EBUS) bronchoscopy is a tool that has transformed the diagnosis and staging of lung cancer. Through real-time ultrasound imaging, EBUS provides clear images of lymph nodes and proximal lung masses that can be adequately sampled through transbronchial needle aspiration. EBUS is a minimally invasive, outpatient procedure that can also be used for diagnosing benign disease within the chest. Large studies investigating the use of EBUS for mediastinal staging have shown the procedure to be highly sensitive and specific while harboring an excellent safety profile.¹ As a result, EBUS has essentially replaced mediastinoscopy for the staging of lung cancer.

EBUS bronchoscopy was primarily offered at major academic centers when first released and was performed by physicians who were formally trained in the procedure during interventional pulmonology or thoracic surgery fellowships. Over time, the tool has been adopted by established general pulmonologists without formal training in EBUS. Some of these pulmonologists only develop their skills by attending 1- to 2-day courses, which is insufficient supervision to become competent in this important procedure.

An ongoing debate continues as to how many supervised EBUS bronchoscopies should be performed prior to being considered proficient.² As procedural competence has been associated with the number of EBUS procedures performed, the learning curve required to master EBUS is an important component of proficiency. While most consider learning curves to be variable, evidence produced by Fernandez-Villar and colleagues revealed that EBUS performance continues to improve up to 120 procedures.³ This analysis was performed in unselected consecutive patients based on diagnostic yield, procedure length, number of lymph nodes passes performed in order to obtain adequate samples, and the number of lymph nodes studied per patient. The learning curve was evaluated based on consecutive groups of 20 patients, the number of adequate samples obtained, and the diagnostic accuracy. Their results indicated that the diagnostic effectiveness of EBUS-TBNA improves with increasing number of procedures performed, allowing for access to a greater number of lymph nodes without necessarily increasing the length of the procedure, and by reducing the number of punctures at each nodal station. Based on their results, the first 20 procedures performed yielded a 70% accuracy, 21 to 40 procedures performed resulted in 81.8% accuracy, 41 to 60 procedures performed resulted in 83.3% accuracy, 61 to 80 procedures performed resulted in 89.8% accuracy, 81 to 100 procedures performed resulted in 90.5% accuracy, and 101 to 120 procedures performed resulted in 94.5% accuracy.

While the American Thoracic Society (ATS) and the American College of Chest Physicians (CHEST) both recommend a minimum number of 40 to 50 supervised EBUS bronchoscopies prior to performing the procedure independently, along with 20 procedures per year for maintenance of competency, most institutions do not track the number of EBUS procedures performed and they do not follow the ATS or CHEST recommendations.^4,5 As a result, a number of physicians are independently performing EBUS without adequate experience, resulting in possibly poor quality care. Unfortunately, some short courses, intended to generate interest and encourage attendees to pursue further training, are mistakenly assumed to be sufficient by the novice user.

As the number of interventional pulmonary fellowships continues to expand, the growing number of subspecialized pulmonologists with extensive training in EBUS grows. During a dedicated interventional pulmonary fellowship, fellows perform well above the number of EBUS bronchoscopies suggested by the ATS and CHEST in a single year. Recently published accreditation guidelines require a minimum of 100 cases per interventional pulmonary fellow.⁶ These fellowship-trained interventional pulmonologists are then tested to become board-certified in a wide array of minimally invasive procedures, including EBUS. As a result, a model has developed where both board-certified interventional pulmonologists with extensive training in EBUS and general pulmonologists not meeting ATS or CHEST minimum requirements practice at the same institution. Proponents of a more liberal access to credentialing in EBUS have suggested that adhering to competency requirements constitutes a “barrier to entry” in which incumbent practitioners benefit from limiting competition. However, like any other regulatory metric, the rationale is to prevent asymmetric information. In this example, the physician knows more than the patient. The patient cannot make an informed decision on which provider to choose and what are the minimum requirements that are likely to produce the most useful information (ie, complete staging). For these reasons, it is imperative that regulations protect the patient.

Without question, EBUS bronchoscopy should not be performed only by board-certified interventional pulmonologists. Instead, hospital credentialing committees should adhere to both the ATS and CHEST recommendations for the number of supervised cases necessary prior to performing EBUS independently. As EBUS use continues to grow, fellows in 3- or 4-year pulmonary and critical care fellowships will be likely capable of meeting the minimal number of observed cases, but, if these numbers are not achieved, additional training should be required. Understandably, this could be challenging for physicians who are unable to take time away from their practice to gain this training. However, if these numbers cannot be met, credentialing requirements should be enforced.

Even more challenging than establishing quality measures for EBUS, is to ensure the highest level of care delivery for patients when there exist multiple levels of experience in the same institution. Undoubtedly, patients undergoing EBUS bronchoscopy, or any procedure for that matter, would want the most skilled physician who has attained certification in the procedure. Unfortunately, no formal certification of EBUS exists outside of gaining board certification in interventional pulmonology. To ensure excellence in care, physicians performing EBUS should be involved in quality improvement initiatives and review pathologic yields along with complications on a regular basis in a group setting. Unlike emergency interventions, EBUS bronchoscopy is an entirely elective procedure.

The advent of EBUS bronchoscopy has revolutionized the diagnosis and staging of lung cancer. As use of EBUS continues to become more widespread, the incidence of high volume and low volume proceduralists will become a more commonly encountered scenario. Guidelines have been set by the professional pulmonary societies based on the data and observations available. At the local level, stringent guidelines need to be established by hospitals to ensure a high level of quality with appropriate oversight. Patients undergoing EBUS deserve a physician who is skilled in the procedure and has performed at least the minimum number of procedures to provide the adequate care.



Dr. Mahajan is Medical Director, Interventional Pulmonology, Inova Heart and Vascular Institute - Inova Fairfax Hospital, and Associate Professor, Virginia Commonwealth Medical School; Dr. Khandhar is Medical Director, Thoracic Surgery, Inova Heart and Vascular Institute - Inova Fairfax Hospital, and Assistant Clinical Professor, Virginia Commonwealth Medical School; Falls Church, VA. Dr. Folch is Co-Director, Interventional Pulmonology Chief, Complex Chest Diseases Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA.

References

1. Gomez M, Silvestri GA. Endobronchial ultrasound for the diagnosis and staging of lung cancer. Proc Am Thorac Soc. 2009;6(2):180-186.

2. Folch E, Majid A. Point: Are >50 Supervised Procedures Required to Develop Competency in Performing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Mediastinal Staging? Yes. Chest. 2013;143(4):888-891.

3. Fernandez-Villar A, Leiro-Fernandez V, Botana-Rial M, Represas-Represas C, Nunez-Delgado M. The endobronchial ultrasound-guided transbronchial needle biopsy learning curve for mediastinal and hilar lymph node diagnosis. Chest. 2012; 141(1):278-279.

4. Ernst A, Silvestri GA, Johnstone D. Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians. Chest. 2003;123(5):1693-1717.

5. Bolliger CT, Mathur PN, Beamis JF, et al. ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society. Eur Respir J. 2002;19(2):356-373.

6. Mullon JJ, Burkhart KM, Silvestri G. Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multi-society Interventional Pulmonology Fellowship Accreditation Committee. Chest. 2017. doi:10.1016/j.chest.2017.01.024.

Original Research

Clinical Predictors of Hospital Mortality Differ Between Direct and Indirect ARDS. By Dr. L. Luo, et al.

Giants in Chest Medicine

Professor James C. Hogg. By Dr. Manuel G. Cosio.

Commentary

Pulmonary Hypertension Care Center Network: Improving Care and Outcomes in Pulmonary Hypertension. By Dr. S. Sahay, et al.

Evidence-Based Medicine

Use of Management Pathways or Algorithms in Children With Chronic Cough: CHEST Guideline and Expert Panel Report. By Dr. A. B. Chang, et al; on behalf of the CHEST Expert Cough Panel.

Symptomatic Treatment of Cough Among Adult Patients With Lung Cancer: CHEST Guideline and Expert Panel Report. By Dr. A. Molassiotis, et al; on behalf of the CHEST Expert Cough Panel.

Management of Children With Chronic Wet Cough and Protracted Bacterial Bronchitis: CHEST Guideline and Expert Panel Report. By Dr. A. B. Chang, et al; on behalf of the CHEST Expert Cough Panel.

Original Research

Clinical Predictors of Hospital Mortality Differ Between Direct and Indirect ARDS. By Dr. L. Luo, et al.

Giants in Chest Medicine

Professor James C. Hogg. By Dr. Manuel G. Cosio.

Commentary

Pulmonary Hypertension Care Center Network: Improving Care and Outcomes in Pulmonary Hypertension. By Dr. S. Sahay, et al.

Evidence-Based Medicine

Use of Management Pathways or Algorithms in Children With Chronic Cough: CHEST Guideline and Expert Panel Report. By Dr. A. B. Chang, et al; on behalf of the CHEST Expert Cough Panel.

Symptomatic Treatment of Cough Among Adult Patients With Lung Cancer: CHEST Guideline and Expert Panel Report. By Dr. A. Molassiotis, et al; on behalf of the CHEST Expert Cough Panel.

Management of Children With Chronic Wet Cough and Protracted Bacterial Bronchitis: CHEST Guideline and Expert Panel Report. By Dr. A. B. Chang, et al; on behalf of the CHEST Expert Cough Panel.

Original Research

Clinical Predictors of Hospital Mortality Differ Between Direct and Indirect ARDS. By Dr. L. Luo, et al.

Giants in Chest Medicine

Professor James C. Hogg. By Dr. Manuel G. Cosio.

Commentary

Pulmonary Hypertension Care Center Network: Improving Care and Outcomes in Pulmonary Hypertension. By Dr. S. Sahay, et al.

Evidence-Based Medicine

Use of Management Pathways or Algorithms in Children With Chronic Cough: CHEST Guideline and Expert Panel Report. By Dr. A. B. Chang, et al; on behalf of the CHEST Expert Cough Panel.

Symptomatic Treatment of Cough Among Adult Patients With Lung Cancer: CHEST Guideline and Expert Panel Report. By Dr. A. Molassiotis, et al; on behalf of the CHEST Expert Cough Panel.

Management of Children With Chronic Wet Cough and Protracted Bacterial Bronchitis: CHEST Guideline and Expert Panel Report. By Dr. A. B. Chang, et al; on behalf of the CHEST Expert Cough Panel.