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Correspondence |

Therapeutic BronchoscopyCommentary on Therapeutic Bronchoscopy: “Can” Does Not Necessarily Mean “Should” FREE TO VIEW

Tiberiu R. Shulimzon, MD; Michael J. Segel, MD
Author and Funding Information

From the Department of Interventional Pulmonology, Sheba Medical Center.

CORRESPONDENCE TO: Tiberiu R. Shulimzon, MD, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel 5265601; e-mail: tiberiu.shulimzon@sheba.health.gov.il


Editor’s Note: Authors are invited to respond to Correspondence that cites their previously published work. Those responses appear after the related letter. In cases where there is no response, the author of the original article declined to respond or did not reply to our invitation.

CONFLICT OF INTEREST: M. J. S. has received honoraria for lectures and/or serving on advisory boards for Pfizer Inc, Roche Holding AG, Rafa Laboratories Ltd, Actelion Pharmaceuticals Ltd, Teva Pharmaceutical Industries Ltd, and Bayer AG and has been reimbursed for travel expenses to scientific meetings by Rafa Laboratories Ltd and Bayer AG. None declared (T. R. S.).

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


Chest. 2015;148(5):e161. doi:10.1378/chest.15-1555
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To the Editor:

We read with interest the report by Ost et al1 on behalf of the American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education (AQuIRE) Bronchoscopy Registry in CHEST (May 2015). The authors meticulously summarize data from 15 leading medical centers in North America and the United Kingdom on bronchoscopic interventions to treat malignant obstruction of central airways.1 Registries allow clinicians to learn from the pooled experience of others. The practitioner must then adapt this experience to his or her local environment (eg, operator skills, available equipment, and reimbursement).

The primary outcome in this report was defined as technical success (> 50% patency), which was achieved in 93% of interventions. Notably, even in lobar bronchial obstructions (which many would not consider to be “central airways”), the success rate was 92%.

Two strategies were used: ablative techniques and stent placement. In a total of 1,115 procedures, 1,836 individual treatment modalities were used—an average of 1.6 modalities per procedure. It is unclear which combinations of modalities were used and why. While stent placement is the only bronchoscopic intervention available for extraluminal obstruction, for intraluminal and mixed obstruction, the best strategy is less clear.2 Is technical success with ablative therapy enough, or should ablation be followed by stent deployment to maintain patency? Unfortunately, the current report does not answer this question.

The secondary outcomes were dyspnea (Borg score) and health-related quality of life (assessed by the Short Form-6D). In these procedures, which probably have little effect on survival, palliation is the central goal. The authors report an improvement of dyspnea and health-related quality of life in 42% and 48% of cases, respectively. A high baseline dyspnea score predicted a better response to therapy. Unfortunately, data regarding these critical outcomes were available for only about 20% of subjects. The 30-day mortality rate was a sobering 14.8%.

The sensation of impending suffocation suffered by these patients is terrifying, and every effort must be made to alleviate it. Technologic developments in interventional pulmonology enable us to perform an array of interventions in patients with malignant central airway obstruction.3 This report shows that the technical success rate is high, but palliation is achieved in less than one-half of interventions. Thus “can do” does not necessarily mean “should do.”

Our own approach is this: Palliate dyspnea caused by malignant airway obstruction, using the single procedure for which you have the skills and the facilities, as soon as possible. Primum non nocere should be weighed against the poor prognosis of these patients and modest success in achieving palliation.

References

Ost DE, Ernst A, Grosu HB, et al; on behalf of the AQuIRE Bronchoscopy Registry. Therapeutic bronchoscopy for malignant central airway obstruction: success rates and impact on dyspnea and quality of life. Chest. 2015;147(5):1282-1298. [CrossRef] [PubMed]
 
Bolliger CT, Mathur PN, Beamis JF, et al; European Respiratory Society/American Thoracic Society. ERS/ATS statement on interventional pulmonology. Eur Respir J. 2002;19(2):356-373. [CrossRef] [PubMed]
 
Shulimzon TR. Interventional pulmonology: a new medical specialty. Isr Med Assoc J. 2014;16(6):379-384. [PubMed]
 

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References

Ost DE, Ernst A, Grosu HB, et al; on behalf of the AQuIRE Bronchoscopy Registry. Therapeutic bronchoscopy for malignant central airway obstruction: success rates and impact on dyspnea and quality of life. Chest. 2015;147(5):1282-1298. [CrossRef] [PubMed]
 
Bolliger CT, Mathur PN, Beamis JF, et al; European Respiratory Society/American Thoracic Society. ERS/ATS statement on interventional pulmonology. Eur Respir J. 2002;19(2):356-373. [CrossRef] [PubMed]
 
Shulimzon TR. Interventional pulmonology: a new medical specialty. Isr Med Assoc J. 2014;16(6):379-384. [PubMed]
 
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