0
Point and Counterpoint |

Rebuttal From Drs Pastis and StrangeRebuttal From Drs Pastis and Strange 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):598-599. doi:10.1378/chest.14-2841
Text Size: A A A
Published online

As I reflect on my most recent episode of life-threatening hemoptysis after transbronchial lung biopsies (TBLBs), I compare it to an episode from earlier in my career. Even in the busiest bronchoscopy suites, these events are rare, and a year or more may pass between episodes. My first episode occurred after performing biopsies on a morbidly obese patient with multiple comorbidities, and I was terrified. Ultimately and with difficulty, an airway was established, and the nonbleeding lung was isolated with the endotracheal tube. After 2 days in the ICU, she was safe to discharge home. During my most recent episode 12 years later, our bronchoscopy staff and I were like a well-oiled machine. Within minutes, not only was an airway established, but an endobronchial blocker was placed deftly into the left lower lobe bronchus, and we were calmly updating the family.

We agree with the pro side by Ms Blumenthal1 in advocating for care delivered with fewer complications and at a lower cost; but we argue that it is critically important for the most experienced and skilled providers to perform invasive procedures such as TBLB which have the potential for life-threatening complications. Unlike other invasive procedures, there may not be time to ask for assistance. While nurse practitioners (NPs) can perform the technical aspects of TBLB, it is unclear whether they can provide the same quality as pulmonologists, improve access to a procedure not widely needed, and lower cost.

One must be careful in extrapolating NPs’ ability to perform TBLB from their ability to perform other procedures, especially ones commonly performed by first-year residents or in the case of intracranial pressure monitors, by second-year neurosurgical residents. Due to the potential for complications and the knowledge base required, the only physicians commonly performing TBLB are fellowship-trained chest physicians, and to the authors’ knowledge, there are no randomized, controlled studies comparing complication rates and patient satisfaction for NPs and physicians.

Since the American College of Chest Physicians (CHEST) guidelines for interventional pulmonary procedures were published in 2003,2 there has been a movement for a fourth year of fellowship to learn the majority of the procedures listed in that document. Thus, this document is less useful in 2014. Interventional pulmonology fellowships have standardized the procedural training with a foremost goal of improving the quality and safety for these procedures. An extra year also provides experience in dealing with procedural complications and with the cognitive aspects of these techniques.

We understand from the pro perspective1 that the desire to perform TBLB will not be over money, since there is limited financial reward for this procedure. This time-consuming procedure with expensive equipment is not a procedure that most NPs will likely try and perform. Unlike the downstream revenue following endobronchial ultrasound,3 the diseases diagnosed by TBLB are typically treated medically by pulmonologists. We wonder whether a business plan for TBLB would drive hospitals to offer this service if it was not already performed by the majority of pulmonary physicians.

As we bring millions of patients into our health-care system, NPs undoubtedly will assist with access to health care and lowering cost. For that reason, they are well suited to help in high-volume, lower risk areas that can free pulmonologists to use unique skills learned through years of training in pulmonary/critical care fellowships.

References

Blumenthal NP. Point: should nurse practitioners perform transbronchial biopsies? Yes. Chest. 2015;147(3):594-595.
 
Ernst A, Silvestri GA, Johnstone D; American College of Chest Physicians. Interventional pulmonary procedures: guidelines from the American College of Chest Physicians. Chest. 2003;123(5):1693-1717. [CrossRef] [PubMed]
 
Pastis NJ, Simkovich S, Silvestri GA. Understanding the economic impact of introducing a new procedure: calculating downstream revenue of endobronchial ultrasound with transbronchial needle aspiration as a model. Chest. 2012;141(2):506-512. [CrossRef] [PubMed]
 

Figures

Tables

References

Blumenthal NP. Point: should nurse practitioners perform transbronchial biopsies? Yes. Chest. 2015;147(3):594-595.
 
Ernst A, Silvestri GA, Johnstone D; American College of Chest Physicians. Interventional pulmonary procedures: guidelines from the American College of Chest Physicians. Chest. 2003;123(5):1693-1717. [CrossRef] [PubMed]
 
Pastis NJ, Simkovich S, Silvestri GA. Understanding the economic impact of introducing a new procedure: calculating downstream revenue of endobronchial ultrasound with transbronchial needle aspiration as a model. Chest. 2012;141(2):506-512. [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.

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