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Correspondence |

Performing Pulmonary InterventionsWho Should Perform Pulmonary Interventions?: Pulmonologist or Pulmonary Interventionist FREE TO VIEW

Inderpaul Singh Sehgal, MD, DM; Ritesh Agarwal, MD, DM, FCCP
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From the Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research.

CORRESPONDENCE TO: Inderpaul Singh Sehgal, MD, DM, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India; e-mail: ipdoc_2000@hotmail.com


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST 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;148(2):e59-e60. doi:10.1378/chest.15-0589
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To the Editor:

We read with great interest in a recent issue of CHEST (March 2015) the Point and Counterpoint editorials by Blumenthal1 and Pastis and Strange.2 We agree that trained nurse practitioners (NPs) can perform several medical procedures, including intubation, CPR, and others.3 However, performing transbronchial lung biopsy (TBLB) requires not only training in flexible bronchoscopy but also several other aspects that a clinician acquires only after years of experience. Blumenthal1 suggests the training for flexible bronchoscopy received by the NPs and physicians is the same. However, this is debatable.

In India, training of a physician involves 4½ years of medical school followed by 1 year of internship. This is followed by 3 years of training in internal medicine and another 3 years of fellowship in pulmonary medicine before he or she can perform flexible bronchoscopy skillfully. In these 12 years, a physician is trained in various aspects of medicine (eg, etiology, pathogenesis, clinical features, diagnostic approach) apart from performing diagnostic procedures. The training program for NPs in India involves 3 to 4 years of training in various aspects of nursing care, with only an overview of anatomy, physiology, and other subjects. At least in India, the training schedule of a physician differs vastly from that of an NP. Whether the training program of a NP in the United States is different from other places is not clear.

Before performing any procedure, it is important to understand the indication for the procedure and assess the risk-benefit ratio. In carrying out TBLB, one needs to be trained not only in the art of flexible bronchoscopy (including management of complications associated with TBLB, such as bleeding and pneumothorax) but also in the interpretation of chest imaging (chest radiography and CT scans of thorax).4 Moreover, in several diseases, more than one procedure will be required. In sarcoidosis, for example, additional procedures, including endobronchial biopsy or transbronchial needle aspiration (either conventional or endobronchial ultrasound guided) may be needed.5 This requires an NP to be trained in the entire gamut of pulmonary procedures. We doubt that this would be practical.

Finally, TBLB is not a very complex procedure associated with high complication rate, as presented by Pastis and Strange.2 In fact, TBLB is a routine bronchoscopy procedure that is safe and is performed on an outpatient basis by a trained pulmonologists.4,6 Whether it can be performed by nonpulmonologists is the question.

References

Blumenthal NP. Point: should nurse practitioners perform transbronchial biopsies? Yes. Chest. 2015;147(3):594-595. [CrossRef] [PubMed]
 
Pastis NJ Jr, Strange CB. Counterpoint: should nurse practitioners perform transbronchial biopsies? No. Chest. 2015;147(3):596-597. [CrossRef] [PubMed]
 
Gershengorn HB, Wunsch H, Wahab R, et al. Impact of nonphysician staffing on outcomes in a medical ICU. Chest. 2011;139(6):1347-1353. [CrossRef] [PubMed]
 
Boskovic T, Stojanovic M, Stanic J, et al. Pneumothorax after transbronchial needle biopsy. J Thorac Dis. 2014;6(suppl 4):S427-S434. [PubMed]
 
Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 2014;146(3):547-556. [CrossRef] [PubMed]
 
Ahmad M, Livingston DR, Golish JA, Mehta AC, Wiedemann HP. The safety of outpatient transbronchial biopsy. Chest. 1986;90(3):403-405. [CrossRef] [PubMed]
 

Figures

Tables

References

Blumenthal NP. Point: should nurse practitioners perform transbronchial biopsies? Yes. Chest. 2015;147(3):594-595. [CrossRef] [PubMed]
 
Pastis NJ Jr, Strange CB. Counterpoint: should nurse practitioners perform transbronchial biopsies? No. Chest. 2015;147(3):596-597. [CrossRef] [PubMed]
 
Gershengorn HB, Wunsch H, Wahab R, et al. Impact of nonphysician staffing on outcomes in a medical ICU. Chest. 2011;139(6):1347-1353. [CrossRef] [PubMed]
 
Boskovic T, Stojanovic M, Stanic J, et al. Pneumothorax after transbronchial needle biopsy. J Thorac Dis. 2014;6(suppl 4):S427-S434. [PubMed]
 
Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 2014;146(3):547-556. [CrossRef] [PubMed]
 
Ahmad M, Livingston DR, Golish JA, Mehta AC, Wiedemann HP. The safety of outpatient transbronchial biopsy. Chest. 1986;90(3):403-405. [CrossRef] [PubMed]
 
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