The Pulse | Friday, July 31, 2020
Exploring Interventional Pulmonology Part 1: Education Needs, Treatments and Tools
Interventional pulmonology is a rapidly evolving field that continues to grow in size and scope, and is often housed within gastroenterology- and endoscopy-focused sections of the hospital. Interventional pulmonologists, however, often depend on staff that may be unfamiliar with lung disease and the requisite tools and processes involved with therapeutic bronchoscopy. Patients frequently have severe chronic obstructive pulmonary disease and/or lung cancer and are post-lung transplant and/or chronically ill with limited respiratory reserve.
As the discipline expands, bronchoscopic procedures will continue to become more complex in efforts to increase the diagnostic yield for cancer, to more efficiently and safely relieve airway obstruction and treat airway disease. Anticipated nursing responsibilities for equipment management and airway complications are important for patient safety and aid in the procedure outcome. A comprehensive education reform is needed for nursing and staff to ensure positive outcomes.
To give a primer on the subject, part one of this series will explore the need for greater education, procedure locations and types of tools and treatments. Part two of this series will explore various procedures in detail.
The Need for Education Reform
Interventional pulmonary is an expanding area of pulmonary medicine. With recent innovations in minimally invasive approaches, procedures are becoming more advanced and intricate. The interventional pulmonologist’s patient care settings are varied, ranging from outpatient bronchoscopy suites to operating rooms. The support for patient care is also varied — it can be with or without a dedicated anesthesia team, and often with endoscopy staff who are unfamiliar with lung disease and the requisite tools and processes involved with therapeutic bronchoscopy. A direct education plan for interventional pulmonology nursing and support staff is sparse, thus stressing the essential and paramount need for a comprehensive education plan for pulmonary endoscopy nursing for optimal patient safety.
Choice of Bronchoscope
Both rigid and flexible bronchoscopes are used to diagnose and treat individuals with pulmonary disease, ranging from lung cancer to lung transplant airway complications. The flexible bronchoscopes allow visualization of the airways through a fiberoptic camera and the use of small tools through a working channel that runs through the scope. They are more widely utilized, require less specialized training and can be inserted nasally or orally. Rigid bronchoscopes consist of a long, hollow barrel with a beveled tip and were first introduced in the 19th century (Batra, H. & Yarmus, L. 2018). Rigid bronchoscopy requires more specialized training and is generally reserved for more advanced tumor debulking and stent placement within the airways.
Bronchoscopy procedures may be commonly performed in the operating room, including inpatient and outpatient facilities. Depending on the organizational structure, there may be a dedicated endoscopy suite or shared operating area with shared thoracic/cardiac staff. Teams for procedure rooms typically include a procedure technician (assisting with scope and tool management), procedure nurse (assisting the procedure technician, assisting with procedure, overseeing patient safety and administrating sedation in lieu of anesthesia support) and an anesthesia provider (administering anesthesia and managing the airway in conjunction with the proceduralist). Across institutions, there is a great amount of variability in case volume, consistency, comfort and expertise levels.
Treatment Types and Tools
The field of bronchoscopy has evolved rapidly and grown extensively over the past half century and has revolutionized diagnostic and therapeutic measures. Diagnostic approaches have expanded to include many different methods of tissue sampling, primarily for cancer diagnosis, but also for infections, transplant rejection and other lung disease processes. Therapeutic bronchoscopy — a vital tool for managing airway complications of lung cancer — demands a great deal of procedural intricacy and provides a highly-specialized intervention, involving a wide variety of equipment and tools.
The field of therapeutic bronchoscopy includes airway dilations and stent placement, tumor debulking, control of large-volume hemoptysis and foreign body extractions. Additionally, ablative therapies like electrocautery, argon plasma coagulation, laser and cryotherapy are often used as adjunctive strategies for a variety of indications. Mechanical relief of airway obstructions (by tumor, foreign bodies or stenosis) can be obtained by flexible forceps, rigid forceps and/or the bevel of the rigid bronchoscope.
Now that you’re up to speed with treatment types and tools, procedural locations, choosing a bronchoscope and why education reform is so important in this rapidly evolving field, keep an eye out for part 2 — focusing on advanced procedures and techniques — coming soon.
Batra, H., & Yarmus, L. (2018). Indications and complications of rigid bronchoscopy. Expert Review of Respiratory Medicine, 12(6), 509-520. doi:10.1080/17476348.2018.1473037