Proposed quality indicators and recommended standard reporting items in performance of EBUS bronchoscopy: An official world association for bronchology and interventional pulmonology expert panel consensus statement

Background: Since their introduction, both linear and radial endobronchial ultrasound (EBUS) have become an integral component of the practice of Pulmonology and Thoracic Oncology. The quality of health care can be measured by comparing the performance of an individual or a health service with an ideal threshold or benchmark. The taskforce sought to evaluate quality indicators in EBUS bronchoscopy based on clinical relevance/importance and on the basis that observed significant variation in outcomes indicates potential for improvement in health care outcomes. Methods: A comprehensive literature review informed the composition of a comprehensive list of candidate quality indicators in EBUS. A multiple-round modified Delphi consensus process was subsequently performed with the aim of reaching consensus over a final list of quality indicators and performance targets for these indicators. Standard reporting items were developed, with a strong preference for items where evidence demonstrates a relationship with quality indicator outcomes. Results: Twelve quality Indicators are proposed, with performance targets supported by evidence from the literature. Standardized reporting items for both radial and linear EBUS are recommended, with evidence supporting their utility in assessing procedural outcomes presented. Conclusion: This statement is intended to provide a framework for individual proceduralists to assess the quality of EBUS they provide their patients through the identification of clinically relevant, feasible quality measures. Emphasis is placed on outcome measures, with a preference for consistent terminology to allow communication and benchmarking between centres

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic

BACKGROUND: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study\u27s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines. METHODS: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation. FINDINGS: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p\u3c0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p\u3c0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile. INTERPRETATION: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction

Diagnosis of peripheral pulmonary carcinoid tumor using endobronchial ultrasound

A 51-year-old woman with severe asthma underwent bronchoscopy and endobronchial ultrasound (EBUS) for investigation of a 15-mm peripheral lung nodule. Histology demonstrated a typical carcinoid tumor. Pulmonary location is the second commonest site for carcinoid tumors. Diagnosis of peripheral carcinoid tumor of the lung is difficult due to its small size, poor accuracy of cytologic diagnosis, and low sensitivity of positron emission tomography in detecting it. EBUS has a high diagnostic yield and a low complication rate in the evaluation of small solitary pulmonary nodules. The ultrasound appearance of carcinoid tumors is identical to that of lung carcinomas. Prompt diagnosis of carcinoid tumor is desirable as regional lymph node metastasis is seen in 10% of patients and is associated with a reduced 5-year survival. We feel that, where possible, all patients presenting with solitary pulmonary nodules should be investigated initially using EBUS due to its high diagnostic rate and the very low incidence of adverse events

Comparative effectiveness of radial probe endobronchial ultrasound versus CT-guided needle biopsy for evaluation of peripheral pulmonary lesions: A randomized pragmatic trial

SummaryIn many patients the optimal method of investigation of peripheral pulmonary lesions (PPL) is not clear. We performed a prospective randomized pragmatic trial to determine the comparative effectiveness of endobronchial ultrasound-guided transbronchial lung biopsy (EBUS-TBLB) and CT-guided percutaneous needle biopsy (CT-PNB) for the investigation of PPL. Overall complication rates were higher in those undergoing CT-PNB (27% v 3%, p = 0.03), while diagnostic accuracy of EBUS-TBLB was shown to be non-inferior to that of CT-PNB.Expected diagnostic accuracy and complication rates are likely to differ for individual patients on the basis of specific complex clinicoradiologic factors, which will influence the cost-benefit analysis between EBUS-TBLB and CT-PNB for individual patients. Further studies are required to examine the effect of these factors on clinical decision-making

Assessment of bronchoscopic dexterity and procedural competency in a low-fidelity simulation model

Background: Assessment of competency in bronchoscopy has traditionally been undertaken in clinical settings, however, recent recognition of increased procedural complications and learner anxiety have led to interest in simulation-based competency assessment. The aim of this study was to determine if low-fidelity simulation-based assessment allows discrimination of competency based on prior experience between bronchoscopists. Methods: Forty-four participants were allocated to 3 groups based on prior bronchoscopic experience [novices (n=31) with no prior experience, intermediates (n=7) with prior experience of 5 to 10 bronchoscopies, and expert bronchoscopists (n=6) with minimum 200 prior bronchoscopies performed]. Participants performed bronchoscopy in a 3D-printed anatomic airway model and were assessed according to time required to navigate to a target bronchus. Bronchoscopic dexterity was measured using a modified version of the validated Bronchoscopy Skills and Tasks Assessment Tool. Results: Competency based on successful navigation to a target bronchus differed significantly between each group [experts, 12/12 (100%); intermediates, 9/14 (64%); novices, 19/62 (31%); P<0.001]. Bronchoscopic dexterity as measured by modified Bronchoscopy Skills and Tasks Assessment Tool also differed significantly between groups with experts achieving consistently higher scores compared with other 2 groups [median (interquartile range) scores: novices, 3.5 (2.5 to 5); intermediate, 5 (4.5 to 7); experts, 8 (7.5 to 8); P<0.0.001). Conclusions: Multiple measures demonstrate that low-fidelity simulation-based assessment may reliably discriminate between different levels of skill in performing bronchoscopic navigation and airway inspection. Procedural dexterity of trainees may be assessed in a 0-risk simulation environment

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for the Evaluation of Suspected Lymphoma

BackgroundEvidence regarding the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the assessment of isolated mediastinal lymphadenopathy (IMLN) is evolving. Its diagnostic accuracy in the evaluation of suspected lymphoma remains uncertain.MethodsWe reviewed a prospectively recorded database of consecutive patients with suspected lymphoma who underwent EBUS-TBNA to evaluate IMLN. Patients in whom EBUS-TBNA was nondiagnostic subsequently underwent surgical biopsy or a minimum of 6 months radiologic surveillance.ResultsNinety-eight patients underwent EBUS-TBNA for evaluation of IMLN. Clinicoradiologic features suggested sarcoidosis as the likely diagnosis in 43 patients. In the remaining 55 patients, EBUS-TBNA achieved definitive diagnosis in 42 patients (76%; 95% confidence interval [CI] 55–90). Lymphoma was ultimately diagnosed in 21 of 55 patients (38%). EBUS-TBNA demonstrated lymphoma in 16 (76%) patients; however, four patients required further surgical biopsy to completely characterize lymphoma subtypes. Surgical biopsy was required to diagnose specific lymphoma subtypes not readily amenable to diagnosis with low volume specimens. Sensitivity and specificity for definitive diagnosis of lymphoma were 57% (95% CI 37–76) and 100% (95% CI 91–100), respectively.ConclusionsAlthough the diagnostic accuracy of EBUS-TBNA for lymphoma is lower than that for the lung cancer staging, the procedure is an appropriate investigative technique for the patients with IMLN because of the low incidence of lymphoma in this population, and the significant proportion of such patients (76%) in whom surgical biopsy is obviated

Automatic delineation of functional lung volumes with 68Ga-ventilation/perfusion PET/CT

Abstract Background Functional volumes computed from 68Ga-ventilation/perfusion (V/Q) PET/CT, which we have shown to correlate with pulmonary function test parameters (PFTs), have potential diagnostic utility in a variety of clinical applications, including radiotherapy planning. An automatic segmentation method would facilitate delineation of such volumes. The aim of this study was to develop an automated threshold-based approach to delineate functional volumes that best correlates with manual delineation. Thirty lung cancer patients undergoing both V/Q PET/CT and PFTs were analyzed. Images were acquired following inhalation of Galligas and, subsequently, intravenous administration of 68Ga-macroaggreted-albumin (MAA). Using visually defined manual contours as the reference standard, various cutoff values, expressed as a percentage of the maximal pixel value, were applied. The average volume difference and Dice similarity coefficient (DSC) were calculated, measuring the similarity of the automatic segmentation and the reference standard. Pearson’s correlation was also calculated to compare automated volumes with manual volumes, and automated volumes optimized to PFT indices. Results For ventilation volumes, mean volume difference was lowest (− 0.4%) using a 15%max threshold with Pearson’s coefficient of 0.71. Applying this cutoff, median DSC was 0.93 (0.87–0.95). Nevertheless, limits of agreement in volume differences were large (− 31.0 and 30.2%) with differences ranging from − 40.4 to + 33.0%. For perfusion volumes, mean volume difference was lowest and Pearson’s coefficient was highest using a 15%max threshold (3.3% and 0.81, respectively). Applying this cutoff, median DSC was 0.93 (0.88–0.93). Nevertheless, limits of agreement were again large (− 21.1 and 27.8%) with volume differences ranging from − 18.6 to + 35.5%. Using the 15%max threshold, moderate correlation was demonstrated with FEV1/FVC (r = 0.48 and r = 0.46 for ventilation and perfusion images, respectively). No correlation was found between other PFT indices. Conclusions To automatically delineate functional volumes with 68Ga-V/Q PET/CT, the most appropriate cutoff was 15%max for both ventilation and perfusion images. However, using this unique threshold systematically provided unacceptable variability compared to the reference volume and relatively poor correlation with PFT parameters. Accordingly, a visually adapted semi-automatic method is favored, enabling rapid and quantitative delineation of lung functional volumes with 68Ga-V/Q PET/CT

Systematic endobronchial ultrasound-guided transbronchial needle aspiration improves radiotherapy planning in non-small cell lung cancer

Objectives: Patients suitable for radical chemoradiotherapy for lung cancer routinely have radiotherapy (planning) volumes based on positron emission tomography (PET)-computed tomography (CT) imaging alone. Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) can identify PET-occult malignancy and benign PET-avid regions. We investigated the impact of EBUS-TBNA on curative-intent radiotherapy in non-small cell lung cancer (NSCLC). Methods: A prospective multicentre trial was undertaken, investigating the impact of systematic EBUS-TBNA in addition to PET-CT for patients considered for radical chemoradiotherapy with NSCLC. A subset analysis of patients with discordant findings between PET-CT and EBUS-TBNA was performed. Radiotherapy plans investigated tumour coverage and dose to critical organs at risk (OARs) using PET-CT alone in comparison to PET-CT and EBUS-TBNA. Results: Of 30 patients enrolled, 10 had discordant findings between PET-CT and EBUS-TBNA. EBUS-TBNA-derived plans allowed for reduction in dose to OARs in patients downstaged by EBUS-TBNA, and reduced the risk of geographic miss in treating PET-occult disease in four patients where EBUS-TBNA identified malignant involvement of PET-negative lymphadenopathy. With the addition of EBUS-TBNA to radiotherapy planning, reductions were noted of 5.7%, 3.7% and 12.5% for the risks of symptomatic pneumonitis, mean heart dose and mean oesophageal dose, respectively. Conclusions: This study demonstrates for the first time that systematic EBUS-TBNA prior to radical-intent radiotherapy significantly improves coverage of subclinical disease through detection of PET-occult metastases. Identification of false-positive lymph node involvement in highly selected cases may reduce radiation dose to critical structures, and risk of organ toxicity