0
Special Features: Pulmonary Procedures |

Latest Advances in Advanced Diagnostic and Therapeutic Pulmonary ProceduresUpdate on Pulmonary Procedures FREE TO VIEW

Gerard A. Silvestri, MD, FCCP; David Feller-Kopman, MD, FCCP; Alexander Chen, MD; Momen Wahidi, MD, FCCP; Kazuhiro Yasufuku, MD, PhD, FCCP; Armin Ernst, MD, MHCM, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Dr Silvestri), Medical University of South Carolina, Charleston, SC; Division of Pulmonary and Critical Care Medicine (Dr Feller-Kopman), Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine (Dr Chen), Washington University School of Medicine/Barnes-Jewish Hospital, St. Louis, MO; Division of Pulmonary and Critical Care Medicine (Dr Wahidi), Duke University, Durham, NC; Division of Thoracic Surgery (Dr Yasufuku), Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; and Division of Pulmonary and Critical Care Medicine (Dr Ernst), Steward St. Elizabeth’s Medical Center, Tufts Medical School, Boston, MA.

Correspondence to: Gerard A. Silvestri, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, 96 Jonathan Lucas St, Room 812 CSB, Charleston, SC 29425; e-mail: silvestri@musc.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(6):1636-1644. doi:10.1378/chest.12-2326
Text Size: A A A
Published online

Over the past 15 years, patients with a myriad of pulmonary conditions have been diagnosed and treated with new technologies developed for the pulmonary community. Advanced diagnostic and therapeutic procedures once performed in an operating theater under general anesthesia are now routinely performed in a bronchoscopy suite under moderate sedation with clinically meaningful improvements in outcome. With the miniaturization of scopes and instruments, improvements in optics, and creative engineers, a host of new devices has become available for clinical testing and use. A growing community of pulmonologists is doing comparative effectiveness trials that test new technologies against the current standard of care. While more research is needed, it seems reasonable to provide an overview of pulmonary procedures that are in various stages of development, testing, and practice at this time. Five areas are covered: navigational bronchoscopy, endobronchial ultrasound, endoscopic lung volume reduction, bronchial thermoplasty, and pleural procedure. Appropriate training for clinicians who wish to provide these services will become an area of intense scrutiny as new skills will need to be acquired to ensure patient safety and a good clinical result.

Figures in this Article

There has been an explosion in pulmonary procedure technology over the past 10 years. As recently as a decade ago, obtaining tissue with a high degree of accuracy from a mediastinal lymph node required surgical intervention and an overnight stay in the hospital. Now pulmonologists routinely perform endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) under moderate sedation in the outpatient setting. Malignant pleural effusion was a vexing problem that left patients dyspneic with a limited life expectancy and tethered to a chest tube in the hospital for a lengthy time. Now, a tunneled pleural catheter can be placed in an outpatient setting and managed effectively from home. New bronchoscopic approaches for the treatment of asthma and emphysema, diseases that cause significant morbidity, mortality, and limitations in quality of life, are in various stages of development, testing, and use in the United States and abroad. This article will endeavor to share the most recent data on advances in pulmonary procedures.

The interest in navigational bronchoscopy is closely tied to the increasing number of peripheral lesions detected on CT imaging incidentally and in screening efforts. Peripheral lesions frequently pose a dilemma for patients and physicians trying to establish the best strategy for workup. Approaches vary from watchful waiting, with possible delays in management when malignancy is ultimately discovered, to surgical resection, which removes uncertainty but carries significant morbidity and cost, and exposes a subset of patients to unnecessary surgery.1 An intermediate option is to perform a diagnostic procedure: transthoracic needle aspiration biopsy (TTNA) or bronchoscopy. Bronchoscopy has a lower rate of pneumothorax, but the diagnostic yield of traditional white-light bronchoscopy has been poor.1

Navigational bronchoscopy (NB) was developed to improve the diagnostic yield while preserving the safety of the procedure. In general, three types of technologies have been used: (1) radial probe EBUS (RP-EBUS), which is conventional radial EBUS using guide sheaths that allow the use of biopsy tools after successful navigation to the target; (2) virtual bronchoscopy, which is virtual navigational support by creating a CT scan-based “road map” overlaid on endoscopic real-time images; and (3) electromagnetic navigational bronchoscopy (ENB), combining a virtual navigation system with steerable devices.

ENB in its current form was first described in 2003 using an animal model, followed 3 years later by the first experience in humans.2,3 In brief, patients are placed in a small electromagnetic field in which devices equipped with small transponders can be tracked. Navigation occurs within a virtual reality environment, which is derived from a prior CT image. Once the lesion is reached, biopsies are obtained. It is noteworthy to emphasize that comparisons with global positioning system guidance are not quite correct. Global positioning systems work in real time such that the driver receives satellite-derived guidance while on the road; ENB develops a map prior to the procedure without real-time updates during the procedure. Several reports have been published that studied patients with a wide range of lesion diameters and moderate yields generally in the range of 60%-70%.4,5 The presence of a bronchus sign was found to correlate with an increased yield, as is the case with conventional bronchoscopy.6

Reports of RP-EBUS use date back to 2002, when it was used without a sheath. More recent publications report on use of RP-EBUS catheters in conjunction with a guide sheath.7 RP-EBUS is the only technology that allows for real-time confirmation that the target has been reached and has confirmed a better yield than conventional transbronchial biopsy with or without fluoroscopy.4,5 Using the miniature RP-EBUS, peripheral pulmonary lesions can be approached safely with good accuracy, as shown in a systematic review and meta-analysis.8 EBUS had point specificity of 1.00 (95% CI, 0.99-1.00) and point sensitivity of 0.73 (95% CI, 0.70-0.76) for the detection of lung cancer, although the sensitivity of EBUS may be influenced by the prevalence of malignancy, lesion size, and an air bronchus sign.8

Results of a randomized trial found that overall complication rates are higher for CT scan-guided needle biopsy compared with EBUS-guided biopsy (27% vs 3%, P = .03), while diagnostic accuracy of EBUS-guided biopsy was similar to that of CT scan-guided biopsy.9 Eberhardt et al10 performed a prospective, randomized trial comparing ENB alone, RP-EBUS alone, and a combination of ENB with RP-EBUS for pulmonary nodules. In 120 patients, the yield was 59% for ENB, 69% for RP-EBUS, and 88% for the combined procedures in lesions with a mean size of approximately 25 mm.10 Another randomized trial using the combination of virtual bronchoscopy with EBUS improved the diagnostic yield of peripheral pulmonary nodules compared with EBUS alone.11

A recent meta-analysis reported the accuracy and side effect profile of all available guided bronchoscopy procedures.12 In 39 studies, which together included > 3,000 patients, the pooled diagnostic yield was around 70% (with wide variation), which was significantly higher than conventional bronchoscopy, but significantly lower than TTNA. However, the pneumothorax rate for TTNA was 15%, of which 6% required chest tube placement and 1% had major hemorrhage.13 Guided bronchoscopy resulted in fewer pneumothoraces (< 2%) and a markedly lower need for chest tube insertion (< 1%).12 Navigation may be used for other purposes than biopsy of peripheral lesions, such as placement of fiducial markers for stereotactic radiation treatments.14

In summary, NB is an exciting new technology. There are still some limitations of this technology and better-quality trials are needed to assess its place in the evaluation of peripheral nodules. In addition, a randomized controlled trial comparing NB with TTNA is warranted to compare these technologies.

Since its inception, the technique and application of EBUS has evolved to find a definitive place in the diagnosis, imaging, staging, and treatment of lung cancer and other thoracic malignancies. The convex probe EBUS (CP-EBUS) is used for real-time EBUS-TBNA of mediastinal and hilar lymph nodes and can be considered one of the most significant advances in diagnostic bronchoscopy.

The most common indication for EBUS-TBNA is for mediastinal lymph node staging of non-small cell lung cancer (NSCLC). Several systematic reviews have confirmed equivalent sensitivity for EBUS-TBNA to mediastinoscopy for staging NSCLC.1518 However, the high prevalence of mediastinal disease in EBUS-TBNA studies limits the comparison and extrapolation of the results. To further clarify this, a recent, prospective, controlled comparison of EBUS-TBNA and mediastinoscopy in 153 potentially resectable NSCLCs (prevalence of N2/N3 disease was 35%) showed that there were no significant differences between EBUS-TBNA and mediastinoscopy in determining the true pathologic N stage (McNemar test, P = .78) and, as performed in this study, EBUS-TBNA can replace mediastinoscopy in patients with potentially resectable NSCLC.19

EBUS-TBNA has both overlapping and complementary characteristics to endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). A randomized, controlled, multicenter trial in 241 patients with resectable NSCLC compared surgical staging alone to a combined EBUS-TBNA and EUS-FNA approach followed by surgical staging if no metastases were found by endosonography. The sensitivity was 79% (41 of 52; 95% CI, 66%-88%) by surgical staging vs 85% (56 of 66; 95% CI, 74%-92%) by endosonography (P = .47) and 94% (62 of 66; 95% CI, 5%-98%) by endosonography followed by surgical staging (P = .02). A combined EBUS/EUS approach plus surgical staging compared with surgical staging alone resulted in greater sensitivity and fewer unnecessary thoracotomies.20 Although the emerging technology of endoscopy can yield excellent results, as shown in this study, highly skilled endoscopists are required to achieve these exceptional outcomes. Interesting studies have also shown that the use of the EBUS-TBNA scope through both the bronchus and the esophagus, which mimics the EBUS/EUS combined approach, can achieve similar yields.21,22

In the era of personalized medicine, genetic variations and biomarker status of tumors are becoming increasingly important when deciding treatment regimens for patients with NSCLC. There is increasing demand for detailed analysis of EBUS-TBNA cytologic samples using molecular techniques. Initial studies from limited centers with expertise have shown that EBUS samples can be used for molecular analysis including epidermal growth factor receptor, v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog, p53, and echinoderm microtubule-associated protein-like 4-anaplastic lymphoma receptor tyrosine kinase fusion genes.23,24 More recently, a large, multicenter, pragmatic study demonstrated that EBUS-TBNA samples obtained in routine practice are suitable for subtyping of NSCLC as well as epidermal growth factor receptor mutation analysis.25 Although advances in technology may allow bronchoscopists to predict lymph node metastasis from imaging alone, tissue is still the issue for management of patients with NSCLC.26,27 There is a constant need for refinement of the technology in EBUS as well as tools available for tissue sampling.

Emphysema is a significant problem in the United States, affecting 2 million Americans and accounting for >100,000 deaths per year. The National Emphysema Treatment Trial was a randomized trial comparing lung volume reduction (LVR) surgery with medical therapy for severe emphysema.28 Since the addition of oxygen to the treatment of emphysema, LVR surgery has been the only therapy shown to convincingly decrease morbidity and mortality in a very select subgroup of patients. Unfortunately, the significant procedure-related complication rate led to minimal adoption of this treatment option.

Endoscopic LVR was conceived and developed to duplicate the benefits of the surgical procedure without the downside of the high rate of periprocedural and postprocedural surgical and anesthetic complications. Several different technologies have been developed (Fig 1). The most mature technique is one-way valves that facilitate airflow and drainage of secretions from emphysematous lung while prohibiting airflow into these areas.29,30 The Endobronchial Valve for Emphysema Palliation Trial was a prospective, multicenter trial of 321 patients randomized 2:1 to unilateral lobar treatment with the valve or standard medical care for patients with heterogeneous emphysema.31 FEV1 and 6-min walk test (6MWT) distance improved by 4.3% and 2.5%, respectively, in the treatment group and modest changes were seen in the St. George’s Respiratory Questionnaire (SGRQ) and scores on the modified Medical Research Council scale, although changes were not significant at 12 months. Further improvement in FEV1 in patients with intact lobar fissures was reported and subsequently demonstrated in a European study.32 This is forming the basis for new trials aimed at treatment of better-defined patient populations.

Use of different valve designs to avoid lobar collapse and subsequent reduction in lung volume have shown inconsistent results33 and are inferior to complete occlusion, as demonstrated in 22 patients by Eberhardt and colleagues34 with improvements in FEV1, 6MWT, and SGRQ demonstrated in the complete-occlusion group only. The biggest problem with lobar occlusion efforts is related to the presence of collateral ventilation, which, if present, prevents lobar collapse and reduces the efficacy of that approach.

Other technologies in development are designed to be independent of collateral ventilation and therefore ease proper patient selection pressures. Placing coils made from nitinol wire into emphysematous lung during bronchoscopy is one such approach. Once the wire is deployed, it returns to its preformed state, resembling a coil that retracts and compresses lung parenchyma.35 Slebos and colleagues36 performed a pilot study in which 16 patients with severe upper-lobe-predominant heterogeneous emphysema were treated using coils. Exacerbation of COPD was the most common adverse event and pneumothorax occurred in one patient. LVR coil treatment resulted in significant improvements in SGRQ, FEV1, and 6MWT.

Another area of interest is emphysematous lung sealant, a synthetic polymer that achieves LVR by occluding airways and collateral ventilation pathways, thereby sealing the collapsed region.37 Herth and colleagues38 reported on its use in 25 patients with heterogeneous emphysema. Exacerbation of COPD was the most common adverse event. Improvement in residual volume/total lung capacity ratio was statistically significant and correlated with changes in FEV1 and SGRQ.

Bronchoscopic thermal vapor ablation uses heated water vapor to create a thermal reaction in emphysematous lung, leading to local inflammation and, ultimately, permanent fibrosis and atelectasis of the targeted region.39 Snell and colleagues40 evaluated unilateral lobar treatment using bronchoscopic thermal vapor ablation in 44 patients with heterogeneous, upper-lobe-predominant emphysema. A 48% reduction in lobar volume was demonstrated by high-resolution CT scan with increases in ipsilateral lower lobe lung volume. Improvements in FEV1, SGRQ, and scores on the modified Medical Research Council scale were noted, and subsequent analysis of fissure integrity suggested effectiveness of the procedure independent of collateral ventilation.41 All of these technologies are designed for patients with heterogenous emphysema and are in varied stages of design and implementation of large-scale trials to assess efficacy and safety.

The only technology aimed at patients with homogenous disease was airway bypass, which is the creation of transbronchial passages connecting lung parenchyma to lobar and segmental bronchi, allowing trapped gas within emphysematous lung to escape, thereby reducing hyperinflation. Drug-coated stents were placed in these passages with the intent of maintaining patency.42,43 The Exhale Airway Stents for Emphysema trial randomized 315 patients 2:1 to intervention or sham control for homogenous emphysema.44 Transient improvement in FVC was seen immediately following airway bypass, although these results did not persist. The failure of the trial may have been related to insufficient patency of the created openings; to date, this approach has been abandoned.

Bronchial thermoplasty (BT) is a novel bronchoscopic treatment for patients with severe persistent asthma who are maximally treated with inhaled corticosteroids and long-acting β agonists and continue to suffer from asthma symptoms.45 BT aims to reduce smooth-muscle mass in the airways by delivering heat energy to the bronchial wall. The treatment targets lobar and segmental bronchi and is divided into three sessions each 2 to 3 weeks apart. BT is performed using a radiofrequency electrical generator and a disposable catheter that passes through the working channel of a flexible bronchoscope and delivers heat at four contact points on its expandable distal basket.

The rationale behind the reduction of airway smooth muscles is their prominent role in bronchial constriction in response to various stimulants. However, it remains unclear whether this is the only mechanism responsible for the positive effect of BT on asthma symptoms or if there are other airway structures (eg, mucous glands, nerves, extracellular matrix) that are also modified by BT.

Histopathologic data on nonasthmatic animal and human airways showed that BT was able to ablate smooth muscles and caused an average 50% reduction in smooth-muscle mass in humans.46,47 Early clinical studies on BT in patients with asthma showed various levels of effectiveness and an acceptable safety profile.4850 The definitive study for BT was the Asthma Intervention Research-2 trial, a randomized, double-blind, sham-controlled study that enrolled 288 patients with severe asthma.51 Results showed a statistically significant improvement in the scores of the Asthma Quality of Life Questionnaire from baseline values in the BT group compared with the sham group; however, this difference in the primary outcome of the study fell below the clinically meaningful change in Asthma Quality of Life Questionnaire score ≥ 0.5. There was no difference between the two groups in morning peak flow, rescue medication use, or FEV1. The more remarkable findings of this study were its secondary outcomes: Subjects receiving BT experienced a significant reduction in severe exacerbations, ED visits, and days missed from work or school in the posttreatment period (6-52 weeks).

Short-term adverse events following BT include airway irritation and temporary worsening of asthma symptoms, which may require administration of additional steroids or antibiotics and, rarely, hospitalization. Other rare events include pneumonia, lobar or segmental collapse, or hemoptysis. Long-term safety data are accumulating and to date have shown radiographic and functional stability over 3- and 5-year periods after BT, respectively.52,53 Durability of effect of BT is unknown and has been documented, thus far, for ≤ 2 years in patients who underwent BT and maintained the benefits of low rate of asthma exacerbations, respiratory adverse events, and hospitalization.54

BT is performed in three separate sessions to attenuate the clinical consequences of irritating large surface areas in the asthmatic airways. The first two sessions target each lower lobe separately and the third session targets both upper lobes. The right middle lobe is not treated. The procedure can be performed in the bronchoscopy suite under topical anesthesia and moderate or deep sedation. A 5-day course of oral prednisone (50 mg/d) is started 2 to 3 days before the procedure and continued afterward to reduce airway inflammation. BT should be postponed if patients exhibit any signs of infection or asthma flare when they present for their procedures.55 Nebulized bronchodilators and spirometry, to establish current FEV1 baseline, are recommended immediately prior to bronchoscopy. Oxygen supplementation during the procedure should be decreased to < 40% to prevent airway fire. The bronchoscope is advanced to the segmental bronchi of the target lobe and the catheter is advanced via the working channel into airway branches. The distal basket must be visible when delivering energy, and, therefore, usually only airways of third to sixth generations are treated. The basket is expanded via a proximal handle to ensure contact of its wires with the airway wall. The energy is delivered by activating a foot switch and lasts approximately 10 s for each application. Once an application is complete, the basket is collapsed and retracted 5 mm to start the next application. Repeated applications are carried out from distal to proximal branches at 5-mm intervals to achieve contiguous, nonoverlapping treatment of the entire targeted airway.56 Postprocedure, patients are monitored in the recovery area and are discharged when stable and postprocedure FEV1 is ≥ 80% of preprocedure measurement.

BT received US Food and Drug Administration approval in April 2010, but has not been widely adopted due to lack of recognition and inconsistent reimbursement by governmental and private insurance. Additionally, patient selection has been challenging as the definitive clinical trial of BT limited its selection of patients with severe asthma to those who had an FEV1 > 60% and three or fewer exacerbations in the preceding year. The generalizability of BT to all patients with severe asthma (eg, patients with lower FEV1) remains questionable. Future research should focus on better understanding of the mechanism of BT, identification of patient, and disease factors that lead to optimal response, durability of effect, and long-term safety.

There have been several advances in the areas of pleural procedures over the last 5 years, with the majority of the literature focused on medical thoracoscopy (MT) and tunneled pleural catheters (TPCs) for the management of malignant pleural effusions (MPE). Three recent studies compared talc pleurodesis with TPCs. Davies et al57 randomized 106 patients with symptomatic pleural effusions in seven hospitals throughout the United Kingdom to receive TPCs placed as an outpatient vs pleurodesis with 4 g of talc slurry instilled through a 12F chest tube. There was no significant difference in dyspnea between the groups in the first 42 days. Analysis of the secondary end points showed that at 6 months, the patients who received TPCs had less dyspnea, improved quality of life, and an overall 16% lower rate of subsequent pleural interventions. There was no significant difference in survival between the groups, although there were more complications in those treated with the TPC. Hunt and colleagues58 reviewed 109 patients with symptomatic MPE treated with talc poudrage vs TPCs. In this study, patients who received TPCs had significantly lower rates of reintervention for symptomatic effusion, with no difference in complications. TPCs are performed on an outpatient basis; therefore, both studies found shorter lengths of hospital stay in the TPC group. In another randomized trial of talc poudrage vs talc slurry, immediate lung re-expansion (> 90%) did not seem to influence long-term clinical outcome.59 Reddy et al60 tried to “combine the best of both worlds” by performing MT with visualized TPC placement in addition to talc poudrage in 30 patients. Compared with historical pleurodesis success rates of 40% to 60% in the TPC group and hospital lengths of stay of 5 days in those treated with talc poudrage, patients in their “rapid pleurodesis” protocol were able to leave the hospital in a median 1.8 days and the TPC was removed in 91% of patients at a median 7.5 days. Finally, in one of the largest systematic reviews performed in patients with MPE (19 studies with 1,370 patients), Van Meter et al61 found symptomatic improvement in 96% of patients with TPCs, with a spontaneous pleurodesis rate of 46%, and in 88% of patients experiencing no complications.

For diagnosing MPE, thoracoscopy has been considered the technique of choice due to the ability to visualize the biopsy site. A recent study by Metintas et al,62 however, suggests that a CT scan-guided Abrams needle biopsy can offer very similar sensitivities (88% vs 94%). It should also be noted that 12% to 18% of patients with a nonspecific diagnosis of fibrinous pleuritis on thoracoscopic biopsy-specimen pathology may eventually develop malignancy, most commonly mesothelioma.63,64

There have been several recent reviews (some including video) outlining the role of MT for the diagnosis and management of pleural effusions,65,66 and all interested in pleural disease and procedures should be familiar with the recent guidelines from the British Thoracic Society.6769 Two studies investigated the volume of fluid required to maximize cytologic diagnosis. One study suggested minimal increase in yield after analysis of 50 mL,70 whereas the other suggested 150 mL should be analyzed if a cell block and direct smear are to be performed.71

Two publications have investigated the financial implications of treating patients with MPE.72,73 In their decision analysis, Puri and colleagues73 suggested that TPCs should be the preferred treatment of patients with limited survival, whereas talc slurry at the bedside is the most cost-effective treatment of patients with more prolonged expected survival.

A critical overview of pleural infections was published in the British Thoracic Society pleural disease guideline 2010.74 Additionally, Rahman and colleagues75 showed that the addition of DNase to tissue plasminogen activator resulted in radiographic improvement in patients with empyema and reduced need for surgical referral and reduced hospital length of stay, whereas tissue plasminogen activator alone was no better than placebo. Rahman’s group also found that small-bore chest tubes were equally effective in draining parapneumonic effusions and empyema as larger bore tubes, but patients had significantly less pain during tube insertion and while the tubes were in place.76 For diagnosis of pleural infections, sending pleural fluid in blood culture bottles can increase the culture yield by 21%.77

In their study of pleural effusion following lung transplant, Wahidi and colleagues78 found that 27% of lung transplant recipients developed effusions that required thoracentesis, and 27% of these were infected. Importantly, fungal infections (primarily Candida albicans) accounted for > 60% of the infections, and pleural-space infection following lung transplant was associated with a reduced 1-year survival.

Over the last decade, there have been sweeping advances in type and complexity of pulmonary procedures available to clinicians to treat advanced lung disease. Procedures once solely in the domain of surgeons are now performed routinely by pulmonologists who have tools at their disposal that can fundamentally change how patients are managed. While it may appear that the five technologies described in this article are vastly different, there are some common themes that should drive the future of this field. Foremost is the research agenda. There are few prospective, randomized trials for any of these devices. Further, few technologies are compared head-to-head or against the previous gold standard. Strategies for patient selection must be well thought out so patients with the best chance of benefit receive the procedure and those who are likely to have adverse events without appreciable benefit do not. Training is a critical issue. Questions will and should arise as to whether the procedure should be regionalized to centers of excellence or made available to all pulmonologists with appropriate training. The appropriate training of clinicians who are already in practice is a challenge worth considering. Finally, with shrinking health-care resources, emphasis on evidence-based care, and the need to provide the best value to our patients, the body of knowledge needs to be established that will help determine how health systems can provide this very expensive technology to those who need it the most. Questions need to be answered about which technologies are “mission critical” vs those that only minimally alter how the disease is managed. While we ponder those questions, technology will advance inexorably forward and we suspect breakthrough treatments will result from it.

Figure Jump LinkFigure 1. Bronchoscopic lung volume reduction devices.Grahic Jump Location

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts: Dr Silvestri has received grant funding from Olympus America Inc, Bronchus, and Boston Scientific Corporation and has performed consulting services for Olympus America Inc and Bronchus in amounts <$10,000. Dr Feller-Kopman has been a consultant for Innovative Pulmonary Solutions, Inc and CareFusion Corporation and his affiliation, the Division of Pulmonary and Critical Care Medicine, has received educational grants from SuperDimension, Olympus America Inc, and Boston Scientific Corporation. Dr Chen has received honoraria from Olympus America Inc for serving on an advisory panel and from Boston Scientific Corporation for serving on the speaker’s bureau and received education grant support for CME coursework from Olympus America Inc and Veran Medical Technologies. Dr Wahidi has received educational grants from Boston Scientific Corporation and consulted with Olympus America Inc. Dr Yasufuku has received educational and research grants from Olympus Medical Systems Corporation and served as a consultant for Intuitive Surgical, Inc; Olympus America Inc; Covidien; and Novadaq Technologies Inc. Dr Ernst has served as a consultant for Boston Scientific Corporation, Olympus America Inc, Covidien, PneumRx, Pulmonx, UpTake, Innovative Pulmonary Solutions, Aeris Therapeutics, and Veran Medical Technologies.

6MWT

6-min walk test

BT

bronchial thermoplasty

CP-EBUS

convex probe endobronchial ultrasound

EBUS-TBNA

endobronchial ultrasound-transbronchial needle aspiration

ENB

electromagnetic navigational bronchoscopy

EUS-FNA

endoscopic ultrasound-guided fine-needle aspiration

LVR

lung volume reduction

MPE

malignant pleural effusion

NSCLC

non-small cell lung cancer

RP-EBUS

radial probe endobronchial

SGRQ

St. George’s Respiratory Questionnaire

TPC

tunneled pleural catheter

TTNA

transthoracic needle aspiration

Gould MK, Fletcher J, Iannettoni MD, et al. Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3):(suppl):108S-130S.
 
Schwarz Y, Mehta AC, Ernst A, et al. Electromagnetic navigation during flexible bronchoscopy. Respiration. 2003;70(5):516-522. [CrossRef] [PubMed]
 
Schwarz Y, Greif J, Becker HD, Ernst A, Mehta A. Real-time electromagnetic navigation bronchoscopy to peripheral lung lesions using overlaid CT images: the first human study. Chest. 2006;129(4):988-994. [CrossRef] [PubMed]
 
Gildea TR, Mazzone PJ, Karnak D, Meziane M, Mehta AC. Electromagnetic navigation diagnostic bronchoscopy: a prospective study. Am J Respir Crit Care Med. 2006;174(9):982-989. [CrossRef] [PubMed]
 
Makris D, Scherpereel A, Leroy S, et al. Electromagnetic navigation diagnostic bronchoscopy for small peripheral lung lesions. Eur Respir J. 2007;29(6):1187-1192. [CrossRef] [PubMed]
 
Seijo LM, de Torres JP, Lozano MD, et al. Diagnostic yield of electromagnetic navigation bronchoscopy is highly dependent on the presence of a Bronchus sign on CT imaging: results from a prospective study. Chest. 2010;138(6):1316-1321. [CrossRef] [PubMed]
 
Herth FJ, Ernst A, Becker HD. Endobronchial ultrasound-guided transbronchial lung biopsy in solitary pulmonary nodules and peripheral lesions. Eur Respir J. 2002;20(4):972-974. [CrossRef] [PubMed]
 
Steinfort DP, Khor YH, Manser RL, Irving LB. Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis. Eur Respir J. 2011;37(4):902-910. [CrossRef] [PubMed]
 
Steinfort DP, Vincent J, Heinze S, Antippa P, Irving LB. Comparative effectiveness of radial probe endobronchial ultrasound versus CT-guided needle biopsy for evaluation of peripheral pulmonary lesions: a randomized pragmatic trial. Respir Med. 2011;105(11):1704-1711. [CrossRef] [PubMed]
 
Eberhardt R, Anantham D, Ernst A, Feller-Kopman D, Herth F. Multimodality bronchoscopic diagnosis of peripheral lung lesions: a randomized controlled trial. Am J Respir Crit Care Med. 2007;176(1):36-41. [CrossRef] [PubMed]
 
Ishida T, Asano F, Yamazaki K, et al;. Virtual Navigation in Japan Trial Group Virtual Navigation in Japan Trial Group. Virtual bronchoscopic navigation combined with endobronchial ultrasound to diagnose small peripheral pulmonary lesions: a randomised trial. Thorax. 2011;66(12):1072-1077. [CrossRef] [PubMed]
 
Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest. 2012;142(2):385-393. [CrossRef] [PubMed]
 
Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155(3):137-144. [PubMed]
 
Anantham D, Feller-Kopman D, Shanmugham LN, et al. Electromagnetic navigation bronchoscopy-guided fiducial placement for robotic stereotactic radiosurgery of lung tumors: a feasibility study. Chest. 2007;132(3):930-935. [CrossRef] [PubMed]
 
Adams K, Shah PL, Edmonds L, Lim E. Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis. Thorax. 2009;64(9):757-762. [CrossRef] [PubMed]
 
Detterbeck FC, Jantz MA, Wallace M, et al. Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3)(suppl):202S-220S.
 
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;45(8):1389-1396. [CrossRef] [PubMed]
 
Varela-Lema L, Fernández-Villar A, Ruano-Ravina A. Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review. Eur Respir J. 2009;33(5):1156-1164. [CrossRef] [PubMed]
 
Yasufuku K, Pierre A, Darling G, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011;142(6):1393-1400.e1.
 
Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245-2252. [CrossRef] [PubMed]
 
Herth FJ, Krasnik M, Kahn N, Eberhardt R, Ernst A. Combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes through a single bronchoscope in 150 patients with suspected lung cancer. Chest. 2010;138(4):790-794. [CrossRef] [PubMed]
 
Hwangbo B, Lee GK, Lee HS, et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest. 2010;138(4):795-802. [CrossRef] [PubMed]
 
Nakajima T, Yasufuku K, Nakagawara A, Kimura H, Yoshino I. Multigene mutation analysis of metastatic lymph nodes in non-small cell lung cancer diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration. Chest. 2011;140(5):1319-1324. [CrossRef] [PubMed]
 
Sakairi Y, Nakajima T, Yasufuku K, et al. EML4-ALK fusion gene assessment using metastatic lymph node samples obtained by endobronchial ultrasound-guided transbronchial needle aspiration. Clin Cancer Res. 2010;16(20):4938-4945. [CrossRef] [PubMed]
 
Navani N, Brown JM, Nankivell M, et al. Suitability of endobronchial ultrasound-guided transbronchial needle aspiration specimens for subtyping and genotyping of non-small cell lung cancer: a multicenter study of 774 patients. Am J Respir Crit Care Med. 2012;185(12):1316-1322. [CrossRef] [PubMed]
 
Fujiwara T, Yasufuku K, Nakajima T, et al. The utility of sonographic features during endobronchial ultrasound-guided transbronchial needle aspiration for lymph node staging in patients with lung cancer: a standard endobronchial ultrasound image classification system. Chest. 2010;138(3):641-647. [CrossRef] [PubMed]
 
Memoli JS, El-Bayoumi E, Pastis NJ, et al. Using endobronchial ultrasound features to predict lymph node metastasis in patients with lung cancer. Chest. 2011;140(6):1550-1556. [CrossRef] [PubMed]
 
Fishman A, Martinez F, Naunheim K, et al;. National Emphysema Treatment Trial Research Group National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003;348(21):2059-2073. [CrossRef] [PubMed]
 
Wan IY, Toma TP, Geddes DM, et al. Bronchoscopic lung volume reduction for end-stage emphysema: report on the first 98 patients. Chest. 2006;129(3):518-526. [CrossRef] [PubMed]
 
Wood DE, McKenna RJ Jr, Yusen RD, et al. A multicenter trial of an intrabronchial valve for treatment of severe emphysema. J Thorac Cardiovasc Surg. 2007;133(1):65-73. [CrossRef] [PubMed]
 
Sciurba FC, Ernst A, Herth FJ, et al;. VENT Study Research Group VENT Study Research Group. A randomized study of endobronchial valves for advanced emphysema. N Engl J Med. 2010;363(13):1233-1244. [CrossRef] [PubMed]
 
Herth FJ, Noppen M, Valipour A, et al;. International VENT Study Group International VENT Study Group. Efficacy predictors of lung volume reduction with Zephyr valves in a European cohort. Eur Respir J. 2012;39(6):1334-1342. [CrossRef] [PubMed]
 
Sterman DH, Mehta AC, Wood DE, et al;. IBV Valve US Pilot Trial Research Team IBV Valve US Pilot Trial Research Team. A multicenter pilot study of a bronchial valve for the treatment of severe emphysema. Respiration. 2010;79(3):222-233. [CrossRef] [PubMed]
 
Eberhardt R, Gompelmann D, Schuhmann M, et al. Complete unilateral versus partial bilateral endoscopic lung volume reduction in patients with bilateral lung emphysema. Chest. 2012;142(4):900-908. [CrossRef]
 
Herth FJ, Eberhard R, Gompelmann D, Slebos DJ, Ernst A. Bronchoscopic lung volume reduction with a dedicated coil: a clinical pilot study. Ther Adv Respir Dis. 2010;4(4):225-231. [CrossRef] [PubMed]
 
Slebos DJ, Klooster K, Ernst A, Herth FJ, Kerstjens HA. Bronchoscopic lung volume reduction coil treatment of patients with severe heterogeneous emphysema. Chest. 2012;142(3):574-582. [CrossRef] [PubMed]
 
Reilly J, Washko G, Pinto-Plata V, et al. Biological lung volume reduction: a new bronchoscopic therapy for advanced emphysema. Chest. 2007;131(4):1108-1113. [CrossRef] [PubMed]
 
Herth FJ, Gompelmann D, Stanzel F, et al. Treatment of advanced emphysema with emphysematous lung sealant (AeriSeal®). Respiration. 2011;82(1):36-45. [CrossRef] [PubMed]
 
Snell GI, Hopkins P, Westall G, Holsworth L, Carle A, Williams TJ. A feasibility and safety study of bronchoscopic thermal vapor ablation: a novel emphysema therapy. Ann Thorac Surg. 2009;88(6):1993-1998. [CrossRef] [PubMed]
 
Snell G, Herth FJ, Hopkins P, et al. Bronchoscopic thermal vapour ablation therapy in the management of heterogeneous emphysema. Eur Respir J. 2012;39(6):1326-1333. [CrossRef] [PubMed]
 
Gompelmann D, Heussel CP, Eberhardt R, et al. Efficacy of bronchoscopic thermal vapor ablation and lobar fissure completeness in patients with heterogeneous emphysema. Respiration. 2012;83(5):400-406. [CrossRef] [PubMed]
 
Choong CK, Macklem PT, Pierce JA, et al. Airway bypass improves the mechanical properties of explanted emphysematous lungs. Am J Respir Crit Care Med. 2008;178(9):902-905. [CrossRef] [PubMed]
 
Lausberg HF, Chino K, Patterson GA, Meyers BF, Toeniskoetter PD, Cooper JD. Bronchial fenestration improves expiratory flow in emphysematous human lungs. Ann Thorac Surg. 2003;75(2):393-397. [CrossRef] [PubMed]
 
Shah PL, Slebos DJ, Cardoso PF, et al;. EASE trial study group EASE trial study group. Bronchoscopic lung-volume reduction with Exhale airway stents for emphysema (EASE trial): randomised, sham-controlled, multicentre trial. Lancet. 2011;378(9795):997-1005. [CrossRef] [PubMed]
 
Wahidi MM, Kraft M. Bronchial thermoplasty for severe asthma. Am J Respir Crit Care Med. 2012;185(7):709-714. [CrossRef] [PubMed]
 
Danek CJ, Lombard CM, Dungworth DL, et al. Reduction in airway hyperresponsiveness to methacholine by the application of RF energy in dogs. J Appl Physiol. 2004;97(5):1946-1953. [CrossRef] [PubMed]
 
Miller JD, Cox G, Vincic L, Lombard CM, Loomas BE, Danek CJ. A prospective feasibility study of bronchial thermoplasty in the human airway. Chest. 2005;127(6):1999-2006. [CrossRef] [PubMed]
 
Cox G, Miller JD, McWilliams A, Fitzgerald JM, Lam S. Bronchial thermoplasty for asthma. Am J Respir Crit Care Med. 2006;173(9):965-969. [CrossRef] [PubMed]
 
Cox G, Thomson NC, Rubin AS, et al;; AIR Trial Study Group AIR Trial Study Group. Asthma control during the year after bronchial thermoplasty. N Engl J Med. 2007;356(13):1327-1337. [CrossRef] [PubMed]
 
Pavord ID, Cox G, Thomson NC, et al;. RISA Trial Study Group RISA Trial Study Group. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med. 2007;176(12):1185-1191. [CrossRef] [PubMed]
 
Castro M, Rubin AS, Laviolette M, et al;. AIR2 Trial Study Group AIR2 Trial Study Group. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med. 2010;181(2):116-124. [CrossRef] [PubMed]
 
Cox G, Laviolette M, Rubin AS, et al. Long term safety of bronchial thermoplasty (BT): 3 year data from multiple studies. Am J Respir Crit Care Med. 2009;179:A2780.
 
Thomson NC, Rubin AS, Niven RM, et al;; AIR Trial Study Group AIR Trial Study Group. Long-term (5 year) safety of bronchial thermoplasty: Asthma Intervention Research (AIR) trial. BMC Pulm Med. 2011;11:8. [CrossRef] [PubMed]
 
Castro M, Rubin A, Laviolette M, Hanania NA, Armstrong B, Cox G. AIR2 Trial Study Group AIR2 Trial Study Group. Persistence of effectiveness of bronchial thermoplasty in patients with severe asthma. Ann Allergy Asthma Immunol. 2011;107(1):65-70. [CrossRef] [PubMed]
 
Castro M, Musani AI, Mayse ML, Shargill NS. Bronchial thermoplasty: a novel technique in the treatment of severe asthma. Ther Adv Respir Dis. 2010;4(2):101-116. [CrossRef] [PubMed]
 
Mayse ML, Rubin A, Lampron N, et al. Clinical pearls for bronchial thermoplasty. J Bronchol. 2007;14(2):115-123.
 
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389. [PubMed]
 
Hunt BM, Farivar AS, Vallières E, et al. Thoracoscopic talc versus tunneled pleural catheters for palliation of malignant pleural effusions. Ann Thorac Surg. 2012;94(4):1053-1059. [CrossRef] [PubMed]
 
Terra RM, Junqueira JJ, Teixeira LR, Vargas FS, Pêgo-Fernandes PM, Jatene FB. Is full postpleurodesis lung expansion a determinant of a successful outcome after talc pleurodesis?. Chest. 2009;136(2):361-368. [CrossRef] [PubMed]
 
Reddy C, Ernst A, Lamb C, Feller-Kopman D. Rapid pleurodesis for malignant pleural effusions: a pilot study. Chest. 2011;139(6):1419-1423. [CrossRef] [PubMed]
 
Van Meter ME, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med. 2011;26(1):70-76. [CrossRef] [PubMed]
 
Metintas M, Ak G, Dundar E, et al. Medical thoracoscopy vs CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: a randomized, controlled trial. Chest. 2010;137(6):1362-1368. [CrossRef] [PubMed]
 
Davies HE, Nicholson JE, Rahman NM, Wilkinson EM, Davies RJ, Lee YC. Outcome of patients with nonspecific pleuritis/fibrosis on thoracoscopic pleural biopsies. Eur J Cardiothorac Surg. 2010;38(4):472-477. [CrossRef] [PubMed]
 
Metintas M, Ak G, Cadirci O, Yildirim H, Dundar E, Metintas S. Outcome of patients diagnosed with fibrinous pleuritis after medical thoracoscopy. Respir Med. 2012;106(8):1177-1183. [CrossRef] [PubMed]
 
Michaud G, Berkowitz DM, Ernst A. Pleuroscopy for diagnosis and therapy for pleural effusions. Chest. 2010;138(5):1242-1246. [CrossRef] [PubMed]
 
Tassi GF, Davies RJ, Noppen M. Advanced techniques in medical thoracoscopy. Eur Respir J. 2006;28(5):1051-1059. [CrossRef] [PubMed]
 
Havelock T, Teoh R, Laws D, Gleeson F. BTS Pleural Disease Guideline Group BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii61-ii76. [CrossRef] [PubMed]
 
Rahman NM, Ali NJ, Brown G, et al;. British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guideline Group. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii54-ii60. [CrossRef] [PubMed]
 
Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ. BTS Pleural Disease Guideline Group BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii32-ii40. [CrossRef] [PubMed]
 
Abouzgheib W, Bartter T, Dagher H, Pratter M, Klump W. A prospective study of the volume of pleural fluid required for accurate diagnosis of malignant pleural effusion. Chest. 2009;135(4):999-1001. [CrossRef] [PubMed]
 
Swiderek J, Morcos S, Donthireddy V, et al. Prospective study to determine the volume of pleural fluid required to diagnose malignancy. Chest. 2010;137(1):68-73. [CrossRef] [PubMed]
 
Haas AR, Sterman DH, Musani AI. Malignant pleural effusions: management options with consideration of coding, billing, and a decision approach. Chest. 2007;132(3):1036-1041. [CrossRef] [PubMed]
 
Puri V, Pyrdeck TL, Crabtree TD, et al. Treatment of malignant pleural effusion: a cost-effectiveness analysis. Ann Thorac Surg. 2012;94(2):374-379.-.. [CrossRef] [PubMed]
 
Davies HE, Davies RJ, Davies CW. BTS Pleural Disease Guideline Group BTS Pleural Disease Guideline Group. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii41-ii53. [CrossRef] [PubMed]
 
Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365(6):518-526. [CrossRef] [PubMed]
 
Rahman NM, Maskell NA, Davies CW, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010;137(3):536-543. [CrossRef] [PubMed]
 
Menzies SM, Rahman NM, Wrightson JM, et al. Blood culture bottle culture of pleural fluid in pleural infection. Thorax. 2011;66(8):658-662. [CrossRef] [PubMed]
 
Wahidi MM, Willner DA, Snyder LD, Hardison JL, Chia JY, Palmer SM. Diagnosis and outcome of early pleural space infection following lung transplantation. Chest. 2009;135(2):484-491. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Bronchoscopic lung volume reduction devices.Grahic Jump Location

Tables

References

Gould MK, Fletcher J, Iannettoni MD, et al. Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3):(suppl):108S-130S.
 
Schwarz Y, Mehta AC, Ernst A, et al. Electromagnetic navigation during flexible bronchoscopy. Respiration. 2003;70(5):516-522. [CrossRef] [PubMed]
 
Schwarz Y, Greif J, Becker HD, Ernst A, Mehta A. Real-time electromagnetic navigation bronchoscopy to peripheral lung lesions using overlaid CT images: the first human study. Chest. 2006;129(4):988-994. [CrossRef] [PubMed]
 
Gildea TR, Mazzone PJ, Karnak D, Meziane M, Mehta AC. Electromagnetic navigation diagnostic bronchoscopy: a prospective study. Am J Respir Crit Care Med. 2006;174(9):982-989. [CrossRef] [PubMed]
 
Makris D, Scherpereel A, Leroy S, et al. Electromagnetic navigation diagnostic bronchoscopy for small peripheral lung lesions. Eur Respir J. 2007;29(6):1187-1192. [CrossRef] [PubMed]
 
Seijo LM, de Torres JP, Lozano MD, et al. Diagnostic yield of electromagnetic navigation bronchoscopy is highly dependent on the presence of a Bronchus sign on CT imaging: results from a prospective study. Chest. 2010;138(6):1316-1321. [CrossRef] [PubMed]
 
Herth FJ, Ernst A, Becker HD. Endobronchial ultrasound-guided transbronchial lung biopsy in solitary pulmonary nodules and peripheral lesions. Eur Respir J. 2002;20(4):972-974. [CrossRef] [PubMed]
 
Steinfort DP, Khor YH, Manser RL, Irving LB. Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis. Eur Respir J. 2011;37(4):902-910. [CrossRef] [PubMed]
 
Steinfort DP, Vincent J, Heinze S, Antippa P, Irving LB. Comparative effectiveness of radial probe endobronchial ultrasound versus CT-guided needle biopsy for evaluation of peripheral pulmonary lesions: a randomized pragmatic trial. Respir Med. 2011;105(11):1704-1711. [CrossRef] [PubMed]
 
Eberhardt R, Anantham D, Ernst A, Feller-Kopman D, Herth F. Multimodality bronchoscopic diagnosis of peripheral lung lesions: a randomized controlled trial. Am J Respir Crit Care Med. 2007;176(1):36-41. [CrossRef] [PubMed]
 
Ishida T, Asano F, Yamazaki K, et al;. Virtual Navigation in Japan Trial Group Virtual Navigation in Japan Trial Group. Virtual bronchoscopic navigation combined with endobronchial ultrasound to diagnose small peripheral pulmonary lesions: a randomised trial. Thorax. 2011;66(12):1072-1077. [CrossRef] [PubMed]
 
Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest. 2012;142(2):385-393. [CrossRef] [PubMed]
 
Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155(3):137-144. [PubMed]
 
Anantham D, Feller-Kopman D, Shanmugham LN, et al. Electromagnetic navigation bronchoscopy-guided fiducial placement for robotic stereotactic radiosurgery of lung tumors: a feasibility study. Chest. 2007;132(3):930-935. [CrossRef] [PubMed]
 
Adams K, Shah PL, Edmonds L, Lim E. Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis. Thorax. 2009;64(9):757-762. [CrossRef] [PubMed]
 
Detterbeck FC, Jantz MA, Wallace M, et al. Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3)(suppl):202S-220S.
 
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;45(8):1389-1396. [CrossRef] [PubMed]
 
Varela-Lema L, Fernández-Villar A, Ruano-Ravina A. Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review. Eur Respir J. 2009;33(5):1156-1164. [CrossRef] [PubMed]
 
Yasufuku K, Pierre A, Darling G, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011;142(6):1393-1400.e1.
 
Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245-2252. [CrossRef] [PubMed]
 
Herth FJ, Krasnik M, Kahn N, Eberhardt R, Ernst A. Combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes through a single bronchoscope in 150 patients with suspected lung cancer. Chest. 2010;138(4):790-794. [CrossRef] [PubMed]
 
Hwangbo B, Lee GK, Lee HS, et al. Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest. 2010;138(4):795-802. [CrossRef] [PubMed]
 
Nakajima T, Yasufuku K, Nakagawara A, Kimura H, Yoshino I. Multigene mutation analysis of metastatic lymph nodes in non-small cell lung cancer diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration. Chest. 2011;140(5):1319-1324. [CrossRef] [PubMed]
 
Sakairi Y, Nakajima T, Yasufuku K, et al. EML4-ALK fusion gene assessment using metastatic lymph node samples obtained by endobronchial ultrasound-guided transbronchial needle aspiration. Clin Cancer Res. 2010;16(20):4938-4945. [CrossRef] [PubMed]
 
Navani N, Brown JM, Nankivell M, et al. Suitability of endobronchial ultrasound-guided transbronchial needle aspiration specimens for subtyping and genotyping of non-small cell lung cancer: a multicenter study of 774 patients. Am J Respir Crit Care Med. 2012;185(12):1316-1322. [CrossRef] [PubMed]
 
Fujiwara T, Yasufuku K, Nakajima T, et al. The utility of sonographic features during endobronchial ultrasound-guided transbronchial needle aspiration for lymph node staging in patients with lung cancer: a standard endobronchial ultrasound image classification system. Chest. 2010;138(3):641-647. [CrossRef] [PubMed]
 
Memoli JS, El-Bayoumi E, Pastis NJ, et al. Using endobronchial ultrasound features to predict lymph node metastasis in patients with lung cancer. Chest. 2011;140(6):1550-1556. [CrossRef] [PubMed]
 
Fishman A, Martinez F, Naunheim K, et al;. National Emphysema Treatment Trial Research Group National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003;348(21):2059-2073. [CrossRef] [PubMed]
 
Wan IY, Toma TP, Geddes DM, et al. Bronchoscopic lung volume reduction for end-stage emphysema: report on the first 98 patients. Chest. 2006;129(3):518-526. [CrossRef] [PubMed]
 
Wood DE, McKenna RJ Jr, Yusen RD, et al. A multicenter trial of an intrabronchial valve for treatment of severe emphysema. J Thorac Cardiovasc Surg. 2007;133(1):65-73. [CrossRef] [PubMed]
 
Sciurba FC, Ernst A, Herth FJ, et al;. VENT Study Research Group VENT Study Research Group. A randomized study of endobronchial valves for advanced emphysema. N Engl J Med. 2010;363(13):1233-1244. [CrossRef] [PubMed]
 
Herth FJ, Noppen M, Valipour A, et al;. International VENT Study Group International VENT Study Group. Efficacy predictors of lung volume reduction with Zephyr valves in a European cohort. Eur Respir J. 2012;39(6):1334-1342. [CrossRef] [PubMed]
 
Sterman DH, Mehta AC, Wood DE, et al;. IBV Valve US Pilot Trial Research Team IBV Valve US Pilot Trial Research Team. A multicenter pilot study of a bronchial valve for the treatment of severe emphysema. Respiration. 2010;79(3):222-233. [CrossRef] [PubMed]
 
Eberhardt R, Gompelmann D, Schuhmann M, et al. Complete unilateral versus partial bilateral endoscopic lung volume reduction in patients with bilateral lung emphysema. Chest. 2012;142(4):900-908. [CrossRef]
 
Herth FJ, Eberhard R, Gompelmann D, Slebos DJ, Ernst A. Bronchoscopic lung volume reduction with a dedicated coil: a clinical pilot study. Ther Adv Respir Dis. 2010;4(4):225-231. [CrossRef] [PubMed]
 
Slebos DJ, Klooster K, Ernst A, Herth FJ, Kerstjens HA. Bronchoscopic lung volume reduction coil treatment of patients with severe heterogeneous emphysema. Chest. 2012;142(3):574-582. [CrossRef] [PubMed]
 
Reilly J, Washko G, Pinto-Plata V, et al. Biological lung volume reduction: a new bronchoscopic therapy for advanced emphysema. Chest. 2007;131(4):1108-1113. [CrossRef] [PubMed]
 
Herth FJ, Gompelmann D, Stanzel F, et al. Treatment of advanced emphysema with emphysematous lung sealant (AeriSeal®). Respiration. 2011;82(1):36-45. [CrossRef] [PubMed]
 
Snell GI, Hopkins P, Westall G, Holsworth L, Carle A, Williams TJ. A feasibility and safety study of bronchoscopic thermal vapor ablation: a novel emphysema therapy. Ann Thorac Surg. 2009;88(6):1993-1998. [CrossRef] [PubMed]
 
Snell G, Herth FJ, Hopkins P, et al. Bronchoscopic thermal vapour ablation therapy in the management of heterogeneous emphysema. Eur Respir J. 2012;39(6):1326-1333. [CrossRef] [PubMed]
 
Gompelmann D, Heussel CP, Eberhardt R, et al. Efficacy of bronchoscopic thermal vapor ablation and lobar fissure completeness in patients with heterogeneous emphysema. Respiration. 2012;83(5):400-406. [CrossRef] [PubMed]
 
Choong CK, Macklem PT, Pierce JA, et al. Airway bypass improves the mechanical properties of explanted emphysematous lungs. Am J Respir Crit Care Med. 2008;178(9):902-905. [CrossRef] [PubMed]
 
Lausberg HF, Chino K, Patterson GA, Meyers BF, Toeniskoetter PD, Cooper JD. Bronchial fenestration improves expiratory flow in emphysematous human lungs. Ann Thorac Surg. 2003;75(2):393-397. [CrossRef] [PubMed]
 
Shah PL, Slebos DJ, Cardoso PF, et al;. EASE trial study group EASE trial study group. Bronchoscopic lung-volume reduction with Exhale airway stents for emphysema (EASE trial): randomised, sham-controlled, multicentre trial. Lancet. 2011;378(9795):997-1005. [CrossRef] [PubMed]
 
Wahidi MM, Kraft M. Bronchial thermoplasty for severe asthma. Am J Respir Crit Care Med. 2012;185(7):709-714. [CrossRef] [PubMed]
 
Danek CJ, Lombard CM, Dungworth DL, et al. Reduction in airway hyperresponsiveness to methacholine by the application of RF energy in dogs. J Appl Physiol. 2004;97(5):1946-1953. [CrossRef] [PubMed]
 
Miller JD, Cox G, Vincic L, Lombard CM, Loomas BE, Danek CJ. A prospective feasibility study of bronchial thermoplasty in the human airway. Chest. 2005;127(6):1999-2006. [CrossRef] [PubMed]
 
Cox G, Miller JD, McWilliams A, Fitzgerald JM, Lam S. Bronchial thermoplasty for asthma. Am J Respir Crit Care Med. 2006;173(9):965-969. [CrossRef] [PubMed]
 
Cox G, Thomson NC, Rubin AS, et al;; AIR Trial Study Group AIR Trial Study Group. Asthma control during the year after bronchial thermoplasty. N Engl J Med. 2007;356(13):1327-1337. [CrossRef] [PubMed]
 
Pavord ID, Cox G, Thomson NC, et al;. RISA Trial Study Group RISA Trial Study Group. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med. 2007;176(12):1185-1191. [CrossRef] [PubMed]
 
Castro M, Rubin AS, Laviolette M, et al;. AIR2 Trial Study Group AIR2 Trial Study Group. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med. 2010;181(2):116-124. [CrossRef] [PubMed]
 
Cox G, Laviolette M, Rubin AS, et al. Long term safety of bronchial thermoplasty (BT): 3 year data from multiple studies. Am J Respir Crit Care Med. 2009;179:A2780.
 
Thomson NC, Rubin AS, Niven RM, et al;; AIR Trial Study Group AIR Trial Study Group. Long-term (5 year) safety of bronchial thermoplasty: Asthma Intervention Research (AIR) trial. BMC Pulm Med. 2011;11:8. [CrossRef] [PubMed]
 
Castro M, Rubin A, Laviolette M, Hanania NA, Armstrong B, Cox G. AIR2 Trial Study Group AIR2 Trial Study Group. Persistence of effectiveness of bronchial thermoplasty in patients with severe asthma. Ann Allergy Asthma Immunol. 2011;107(1):65-70. [CrossRef] [PubMed]
 
Castro M, Musani AI, Mayse ML, Shargill NS. Bronchial thermoplasty: a novel technique in the treatment of severe asthma. Ther Adv Respir Dis. 2010;4(2):101-116. [CrossRef] [PubMed]
 
Mayse ML, Rubin A, Lampron N, et al. Clinical pearls for bronchial thermoplasty. J Bronchol. 2007;14(2):115-123.
 
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA. 2012;307(22):2383-2389. [PubMed]
 
Hunt BM, Farivar AS, Vallières E, et al. Thoracoscopic talc versus tunneled pleural catheters for palliation of malignant pleural effusions. Ann Thorac Surg. 2012;94(4):1053-1059. [CrossRef] [PubMed]
 
Terra RM, Junqueira JJ, Teixeira LR, Vargas FS, Pêgo-Fernandes PM, Jatene FB. Is full postpleurodesis lung expansion a determinant of a successful outcome after talc pleurodesis?. Chest. 2009;136(2):361-368. [CrossRef] [PubMed]
 
Reddy C, Ernst A, Lamb C, Feller-Kopman D. Rapid pleurodesis for malignant pleural effusions: a pilot study. Chest. 2011;139(6):1419-1423. [CrossRef] [PubMed]
 
Van Meter ME, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med. 2011;26(1):70-76. [CrossRef] [PubMed]
 
Metintas M, Ak G, Dundar E, et al. Medical thoracoscopy vs CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: a randomized, controlled trial. Chest. 2010;137(6):1362-1368. [CrossRef] [PubMed]
 
Davies HE, Nicholson JE, Rahman NM, Wilkinson EM, Davies RJ, Lee YC. Outcome of patients with nonspecific pleuritis/fibrosis on thoracoscopic pleural biopsies. Eur J Cardiothorac Surg. 2010;38(4):472-477. [CrossRef] [PubMed]
 
Metintas M, Ak G, Cadirci O, Yildirim H, Dundar E, Metintas S. Outcome of patients diagnosed with fibrinous pleuritis after medical thoracoscopy. Respir Med. 2012;106(8):1177-1183. [CrossRef] [PubMed]
 
Michaud G, Berkowitz DM, Ernst A. Pleuroscopy for diagnosis and therapy for pleural effusions. Chest. 2010;138(5):1242-1246. [CrossRef] [PubMed]
 
Tassi GF, Davies RJ, Noppen M. Advanced techniques in medical thoracoscopy. Eur Respir J. 2006;28(5):1051-1059. [CrossRef] [PubMed]
 
Havelock T, Teoh R, Laws D, Gleeson F. BTS Pleural Disease Guideline Group BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii61-ii76. [CrossRef] [PubMed]
 
Rahman NM, Ali NJ, Brown G, et al;. British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guideline Group. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii54-ii60. [CrossRef] [PubMed]
 
Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ. BTS Pleural Disease Guideline Group BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii32-ii40. [CrossRef] [PubMed]
 
Abouzgheib W, Bartter T, Dagher H, Pratter M, Klump W. A prospective study of the volume of pleural fluid required for accurate diagnosis of malignant pleural effusion. Chest. 2009;135(4):999-1001. [CrossRef] [PubMed]
 
Swiderek J, Morcos S, Donthireddy V, et al. Prospective study to determine the volume of pleural fluid required to diagnose malignancy. Chest. 2010;137(1):68-73. [CrossRef] [PubMed]
 
Haas AR, Sterman DH, Musani AI. Malignant pleural effusions: management options with consideration of coding, billing, and a decision approach. Chest. 2007;132(3):1036-1041. [CrossRef] [PubMed]
 
Puri V, Pyrdeck TL, Crabtree TD, et al. Treatment of malignant pleural effusion: a cost-effectiveness analysis. Ann Thorac Surg. 2012;94(2):374-379.-.. [CrossRef] [PubMed]
 
Davies HE, Davies RJ, Davies CW. BTS Pleural Disease Guideline Group BTS Pleural Disease Guideline Group. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii41-ii53. [CrossRef] [PubMed]
 
Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365(6):518-526. [CrossRef] [PubMed]
 
Rahman NM, Maskell NA, Davies CW, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010;137(3):536-543. [CrossRef] [PubMed]
 
Menzies SM, Rahman NM, Wrightson JM, et al. Blood culture bottle culture of pleural fluid in pleural infection. Thorax. 2011;66(8):658-662. [CrossRef] [PubMed]
 
Wahidi MM, Willner DA, Snyder LD, Hardison JL, Chia JY, Palmer SM. Diagnosis and outcome of early pleural space infection following lung transplantation. Chest. 2009;135(2):484-491. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

CHEST Journal Articles
CHEST Collections
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543