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Point and Counterpoint |

COUNTERPOINT: Should Nurse Practitioners Perform Transbronchial Biopsies? NoNurses and Transbronchial Biopsies? No FREE TO VIEW

Nicholas J. Pastis, Jr, MD, FCCP; Charlton B. Strange, MD, FCCP
Author and Funding Information

From the Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina.

CORRESPONDENCE TO: Nicholas J. Pastis Jr, MD, FCCP, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, CSB-812, 96 Jonathan Lucas St, Charleston, SC 29425; e-mail: pastisn@musc.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts of interest: Dr Pastis received a consulting fee from Olympus Corporation of the Americas for teaching in an endobronchial ultrasound bronchoscopy course held in San Diego, California, in 2014. Dr Strange has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


Chest. 2015;147(3):596-597. doi:10.1378/chest.14-2840
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I (C. B. S.) was flying home from a conference in a Boeing 787 when I first began to write this editorial and wondered about the analogous questions from other industries. Did I really want a trained pilot in the cockpit? Could not anyone train on simulators enough to achieve competence in handling any airplane? What if someone put in sufficient hours of simulator and supervised flight time, might they then be given the controls of my 787? And the answer was that with enough training anyone can become sufficiently competent to perform any procedure in medicine.

But the question posed is not whether nurse practitioners (NPs) can perform transbronchial lung biopsies (TBLBs), but whether they should. In today’s busy medical workplace, it is mandatory that everyone work to the boundaries of their skillset. The skillset for TBLB includes cognitive understanding of the procedure’s indications and contraindications, appropriate training and experience, and situational awareness and skills to address complications during or following the procedure. We would argue that placing the best trained individual for the most complicated procedures in pulmonary medicine is the best option for our profession.

Because of a growing demand in certain health-care arenas, such as pulmonary/critical care, it has been proposed that NPs perform TBLB.1 Alternative bronchoscopic procedures such as therapeutic suctioning, use of a bronchoscope to guide percutaneous tracheostomy tube placement, and verification of endotracheal tube placement are safely and effectively performed by a variety of different health-care professionals. However, bronchoscopy with TBLBs is arguably the most risky bronchoscopic procedure, has very specific diagnostic indications, and, in many cases, has alternative bronchoscopic options that are safer and even more effective for attaining a diagnosis.

TBLB carries a higher risk of complications than other types of bronchoscopy. The incidence of major complications is as high as 7%,2 the mortality rate 0.1%, the pneumothorax rate 4%, and the hemorrhage rate 4% to 9%.3,4 Smaller studies have reported even higher rates of complications associated with TBLB. In one cohort of 78 patients, the mortality rate was 1.3% and the incidence of pulmonary hemorrhage and pneumothorax was 30.2%.5 Prior to performing this procedure, one must carefully weigh the risks and benefits, often without the benefit of published guidelines or controlled studies to guide decisions. Instead, the choice to perform TBLB stems from pulmonary training to balance the likelihood and benefit of diagnosis compared with the risk of performing the procedure.

There are scenarios where a patient’s respiratory status is compromised due to an undiagnosed pulmonary disease which poses an increased risk for TBLB, yet empirical long-term treatments for pulmonary diseases without obtaining a tissue diagnosis (the alternative to TBLB or surgical lung biopsy) may carry an even greater risk. For example, long-term empirical moderate to high-dose steroids may predispose patients to opportunistic infections or any of a myriad of steroid-induced complications, and certain antibiotics or antifungals may lead to drug resistance, nephrotoxicity, or hepatotoxicity. On the other hand, part of the skillset of a bronchoscopist is to understand when a less invasive approach may lead to the same positive outcome as a more invasive one. A classic example is the patient with HIV and ARDS who is on positive pressure ventilation. Pneumocystis jirovecii pneumonia (PJP) will need to be ruled out, and BAL can attain this diagnosis approximately 95% of the time, so TBLB need not be the initial diagnostic test. However, the conundrum occurs in the same situation when the patient is HIV negative yet has risk factors for PJP. In such cases, BAL has a lower yield for PJP (approximately 82%), and TBLB may be needed to attain the diagnosis. Such cases with varied or competing approaches to management typically require pulmonary expertise to establish the best course.

One may argue that these decisions can be made with pulmonary consultation and the procedure then performed by an NP, but ideally the pulmonologist benefits from performing this relatively short procedure which allows correlation between clinical and bronchoscopic findings. In addition, the pulmonologist is equipped to modify the originally intended procedure to best address findings during the airway inspection. Endobronchial disease may require forceps biopsies, brushings, and/or endobronchial needle aspiration to best achieve a diagnosis.6,7 Additional culture may be needed based on endobronchial findings that might otherwise have been overlooked if the bronchoscopy was ordered as only for TBLB.

We were both a bit circumspect when asked to write this pro-con debate because of the great respect that we both have for the physicians’ assistants and nurse practitioners who are an integral part of the health-care team. Our goals have always been to empower each member of the team to his or her full potential. However, the time required for TBLB is relatively short and the cognitive needs of the practitioner great with this procedure. TBLB is rarely emergent, and there is certainly enough work to fill the day of every individual on the frontlines of medicine without having our physician extenders perform this procedure.

Ideally, pulmonary physicians should be skilled in airway management when performing bronchoscopy. However, with the increase in anesthesia support by hospitals where bronchoscopy is performed, an NP may manage patients with acute respiratory failure infrequently. But relying on anesthesia providers to manage other complications of TBLB may be problematic. Treatment of major bleeding requires understanding and usage of a systematic approach including but not limited to positioning the patient with the bleeding lung down, use of iced saline or epinephrine, bronchial blocker placement, or selective lung intubation. Some cases require emergent consultation with interventional radiology for bronchial artery embolization or with thoracic surgery for resection. The management of bronchoscopic bleeding which is relatively low frequency but life-threatening is ideally taught in formal fellowship at high-volume bronchoscopic centers to maximize opportunities for exposure to these events.

In addition, there are occasions when there may not be adequate time to call for assistance when an emergent chest tube is needed for a tension pneumothorax. In patients on positive pressure ventilation, pneumothorax may occur up to 15% of the time with TBLB. Competence in mechanical ventilation and tube thoracostomy is a requirement to graduate from pulmonary/critical care fellowships and places the pulmonologist in ideal position to manage this complication.

Bronchoscopy is the defining procedure of the pulmonologist for good reason. It provides a window into a patient’s disease process, and is best used in combination with the pulmonologist’s clinical evaluation. While technically feasible for NPs to perform the procedure, there are cognitive and technical aspects related to the indications, contraindications, endoluminal evaluation, alternative or additional procedures, and complications which make TBLB ideally performed by the pulmonologist. To isolate the TBLB as a procedure that can be taught independent of a comprehensive evaluation is not best medicine for our profession.

References

Barber PV, Martin J, O’Donnell PN. The development of the first nurse-led bronchoscopy post in the United Kingdom. Respir Med. 2004;98(6):504-508. [CrossRef] [PubMed]
 
Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest. 1995;107(2):430-432. [CrossRef] [PubMed]
 
Villaneuve M, Kvale P. Transbronchial lung biopsy.. In:Feinsilver SH, Fein A., eds. Textbook of Bronchoscopy. Baltimore, MD: Lippincott Williams & Wilkins; 1995:64.
 
Zavala DC. Complications following fiberoptic bronchoscopy. The “good news” and the “bad news.” Chest. 1978;73(6):783-785. [CrossRef] [PubMed]
 
Burgher LW. Complications and results of transbronchoscopic lung biopsy. Nebr Med J. 1979;64(8):247-248. [PubMed]
 
Govert JA, Dodd LG, Kussin PS, Samuelson WM. A prospective comparison of fiberoptic transbronchial needle aspiration and bronchial biopsy for bronchoscopically visible lung carcinoma. Cancer. 1999;87(3):129-134. [CrossRef] [PubMed]
 
Govert JA, Kopita JM, Matchar D, Kussin PS, Samuelson WM. Cost-effectiveness of collecting routine cytologic specimens during fiberoptic bronchoscopy for endoscopically visible lung tumor. Chest. 1996;109(2):451-456. [CrossRef] [PubMed]
 

Figures

Tables

References

Barber PV, Martin J, O’Donnell PN. The development of the first nurse-led bronchoscopy post in the United Kingdom. Respir Med. 2004;98(6):504-508. [CrossRef] [PubMed]
 
Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest. 1995;107(2):430-432. [CrossRef] [PubMed]
 
Villaneuve M, Kvale P. Transbronchial lung biopsy.. In:Feinsilver SH, Fein A., eds. Textbook of Bronchoscopy. Baltimore, MD: Lippincott Williams & Wilkins; 1995:64.
 
Zavala DC. Complications following fiberoptic bronchoscopy. The “good news” and the “bad news.” Chest. 1978;73(6):783-785. [CrossRef] [PubMed]
 
Burgher LW. Complications and results of transbronchoscopic lung biopsy. Nebr Med J. 1979;64(8):247-248. [PubMed]
 
Govert JA, Dodd LG, Kussin PS, Samuelson WM. A prospective comparison of fiberoptic transbronchial needle aspiration and bronchial biopsy for bronchoscopically visible lung carcinoma. Cancer. 1999;87(3):129-134. [CrossRef] [PubMed]
 
Govert JA, Kopita JM, Matchar D, Kussin PS, Samuelson WM. Cost-effectiveness of collecting routine cytologic specimens during fiberoptic bronchoscopy for endoscopically visible lung tumor. Chest. 1996;109(2):451-456. [CrossRef] [PubMed]
 
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