Recurrent pneumonias often occur in the setting of an airway obstruction and can be the presenting symptom of an undiagnosed malignancy. Little is known regarding the microbiology of these pneumonias making antibiotic therapy difficult to direct; however, the few studies available show these pneumonias to be polymicrobial. Examining the colonization patterns of at-risk populations such as patients with chronic obstructive pulmonary disease and using techniques such as ultrasound and computed tomography-guided biopsies may help in the treatment of these pneumonias. The following review is presented to highlight the current medical knowledge as well as suggest areas for future evaluation.

Bronchiectasis is a constellation of diseases characterized by abnormally dilated bronchi with thickened bronchial walls due to repeated infection and inflammation. Bronchiectasis causes impairment of mucociliary clearance, airflow limitation, bronchorrhea, and predisposes to recurrent respiratory infections. It has a number of potential underlying causes. Laennec first described bronchiectasis as a distinct clinical entity in 1819 (Barker 2002, O’Donnell 1998). The diagnosis, investigation and particularly management of bronchiectasis has been largely empirical and unfortunately, the subject of relatively few controlled clinical trials. Cystic fibrosis causes about a third of all bronchiectasis in United States (O’Donnell 1998), and is common worldwide. Cystic fibrosis (CF) is a recessive genetic disease characterized by dehydration of the airway surface liquid and impaired mucociliary clearance caused by altered functioning of a chloride channel called the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR). Impaired chloride conductance through the apical portion of airway cells leads to dehydration of airway secretions causing lung destruction through obstruction of the airways with thickened secretions. The resultant endobronchial infection and exaggerated inflammatory response leads to the development of bronchiectasis (destruction and widening of airways) and progressive obstructive airway disease. This chapter provides insight into the specific diagnostic and therapeutic roles of bronchoscopy in patients with bronchiectasis and Cystic Fibrosis.

Recurrent respiratory papillomatosis is caused by the Human Papilloma Virus and occurs primarily in children and adolescence. Most commonly, disease remains localized to the larynx and spontaneously regresses, but in rare cases there may be pulmonary involvement. We present a case of a 17 year old female with recurrent respiratory papillomatosis who develops pulmonary involvement in the form of squamous papilloma. We present the clinical findings; discuss the potential for malignant transformation and the need for screening and prevention.

BACKGROUND:Spontaneous pneumothorax (SPTX) is an uncommon phenomenon in the general population and is most commonly associated with prior bulbous emphysema, cystic parenchymal lung disease, and tuberculous lung disease. A rare cause of SPTX is malignant disease, either in the form of primary lung or pleural cancers, or in metastatic disease to the lungs. The purpose of this investigation was to compile patient characteristics, treatments received, and outcomes of patients with SPTX complicating sarcomatous cancer.METHODS:Case reports and series published in the medical literature were identified through a MEDLINE search and compiled to determine similarities among patient characteristics, treatments received, and outcomes.RESULTS:One hundred fifty-three cases representing 20 different sarcoma cell types were included; 126 (82.3%) had received some form of treatment prior to the development of pneumothorax, and 70 (45.7%) experienced recurrence of pneumothorax at an average of 61 (+/- 112) days. Patients had poor survival, with only seven of 81 subjects remaining alive 2 years after the initial diagnosis of SPTX.CONCLUSIONS:SPTX complicating sarcoma is associated with most cell types and is associated with increased mortality compared with patients without this complication.

Bronchoscopic examination of the tracheobronchial tree and associated diagnostic procedures are the trademark of most pulmonologists. The bronchoscope has been transitioning over the last 25 years from a purely diagnostic instrument to a therapeutic tool. The ability to advance from airway inspection to diagnostic procedures and subsequently to therapeutic interventions is reliant on the development of an appropriate skill set. Our pedagogic paradigm began with Sir William Halstead, when he introduced the German-style residency of apprenticeship with graded responsibility to Johns Hopkins University in the 1890s. The pedagogic approach involves a significant plasticity that provides several benefits, including the following: real-time feedback; flexibility for skills acquisition; and adaptability to regional or institutional missions. However, the appropriateness of the “see one, do one, teach one” approach is now being questioned in many procedural specialties. Procedural competency in bronchoscopy is currently judged by arbitrary thresholds of observed procedures and the subjective certification of the program director. Procedural competency is best determined by validated metrics evaluating both technical and cognitive components. In lieu of defined and validated metrics, recognized experts have provided important opinion-based guidelines1Bolliger CT Mathur PN Beamis JF et al.ERS/ATS statement on interventional pulmonology: European Respiratory Society/American Thoracic Society.Eur Respir J. 2002; 19: 356-373Crossref PubMed Scopus (491) Google Scholar, 2Ernst A Silvestri GA Johnstone D Interventional pulmonary procedures: guidelines from the American College of Chest Physicians.Chest. 2003; 123: 1693-1717Abstract Full Text Full Text PDF PubMed Scopus (531) Google Scholar delineating procedural training for basic and advanced bronchoscopy. This is inadequate. There is mounting evidence from the Interventional Chest Diagnostic Procedures Network Steering Committee-endorsed Multi-State Bronchoscopy Education Project that the current arbitrary numbers are an inadequate metric for technical competency (Gordon Downie, MD; personal communication, August 28, 2008).3Wahidi MM Silvestri G Conforti J et al.Assessment of pulmonary fellows acquisition of bronchoscopy skills.Chest. 2007; 132: 514S-515SAbstract Full Text Full Text PDF Google Scholar Furthermore, consistent with the current pedagogic approach, there is heterogeneity of core curriculums, if formal ones exist at all. Cognitive skills are therefore obtained by the self-study of textbooks or manuscripts, attending didactic sessions or “on-the-fly.” These are all valuable methods, but in the absence of objective assessments of core knowledge how do we ascertain competence? Early data4Downie G Bowling M Silvestri G et al.The Multi-State Bronchoscopy Education Project: acquisition of cognitive skills.Chest. 2007; 132: 664SAbstract Full Text Full Text PDF PubMed Google Scholar have suggested that the current paradigm provides inadequate cognitive training. Cognitive expertise is paramount to reaching technical expertise, and the teaching of cognitive skills has been shown to improve technical performance.5Kohls-Gatzoulis JA Regehr G Hutchison C Teaching cognitive skills improves learning in surgical skills courses: a blinded, prospective, randomized study.Can J Surg. 2004; 47: 277-283PubMed Google Scholar Cognitive competency in bronchoscopy is rarely evaluated by institutional testing and is inadequately evaluated on national board examinations. Procedural competency is based on several factors including technical psychomotor skills, organized formal knowledge on which reasoning is based, and sound clinical judgment. These facets of competency come together with effective team communication and awareness of complex processes to create domain-specific expertise. Threshold numbers delineating adequate experience will be replaced by expertise in determining competency.6Aggarwal R Darzi A Technical-skills training in the 21st century.N Engl J Med. 2006; 335: 2695-2696Crossref Scopus (174) Google Scholar Standards-based competencies are being defined and implemented in many procedural specialties. Testing each factor individually and as a system is critical to judging threshold expertise and hence competence. In this issue of CHEST (see page 315), Quadrelli and colleagues7Quadrelli S Davoudi M Galindez F et al.Reliability of a 25-item low-stakes multiple choice assessment of bronchoscopic knowledge.Chest. 2009; 135: 315-321Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar have added to our tools for determining bronchoscopic competency by presenting the validation of a low-stakes, multiple-choice question (MCQ) assessment. They have built on prior work8Davoudi M Osann K Colt HG Validation of two instruments to assess technical bronchoscopic skill using virtual reality simulation.Respiration. 2008; 76: 92-101Crossref PubMed Scopus (75) Google Scholar that helped to define the necessary knowledge for bronchoscopy. The current study is important, dealing with the timely and crucial issue of delineating competency-based metrics for bronchoscopy. Its significance is the well-derived validation and reliability of the questions. Whether the testing format is high stakes or low stakes, the questions must meet the standards of test design. By validating the degree of difficulty of the MCQ, the discriminative index and the internal consistency of the questions the authors have defined, within the pulmonary literature, a paradigm for the continued development of tools for testing cognitive metrics for bronchoscopy. The limitations of the study by Quadrelli et al7Quadrelli S Davoudi M Galindez F et al.Reliability of a 25-item low-stakes multiple choice assessment of bronchoscopic knowledge.Chest. 2009; 135: 315-321Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar include the potential bias of elevated scores among those who had used the “Essential Bronchoscopist”© Web site and the small number of validated questions. The current pool of questions must be significantly increased and further evaluated among a large cohort to ensure an appropriate benchmark for defining cognitive competence. Despite these limitations, this current work has short-term and long-term implications for bronchoscopy training and competency evaluation. In the near term, the 11 ideal questions (presented in Quadrelli et al's Appendix7Quadrelli S Davoudi M Galindez F et al.Reliability of a 25-item low-stakes multiple choice assessment of bronchoscopic knowledge.Chest. 2009; 135: 315-321Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar) can be used as a valid in-training assessment tool. The low-stakes in-training examination will provide immediate assistance in evaluating the acquisition of knowledge. Subsequent nationwide implementation of a low-stakes examination is required and would provide suitable power to evaluate the validity of a comprehensive assessment tool and to define the benchmark for the delineation of pass and fail. The long-term implications are more important. The initial 25 questions from this study will likely form the core of the expanding population of MCQs. This proliferation of validated questions must continually refresh the required in-training evaluations to ensure an evidence-based threshold of cognitive competence and define the need for additional training. As our understanding of the critical formal knowledge and reasoning skills required for bronchoscopy grows, this database will require adjustments. Concurrent and repeated assessment for the level of difficulty, discrimination, internal consistency, and appropriate verbiage of this growing database of questions will follow the paradigm of validation described by Quadrelli and colleagues.7Quadrelli S Davoudi M Galindez F et al.Reliability of a 25-item low-stakes multiple choice assessment of bronchoscopic knowledge.Chest. 2009; 135: 315-321Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar The low-stakes evaluation is a required precursor to a more rigorous, validated process for testing competency. Subsequent creation of a high-stakes evaluation for bronchoscopic competency will be required. This study moves us purposefully toward a validated approach to measuring competence in bronchoscopic knowledge. The evolving demands of governmental bodies, nongovernmental organizations, third-party payers, and the public will drive a standards-based educational curriculum and procedure-based testing for bronchoscopists. “Our goal must be to design and implement a system of competency evaluation before one is mandated from external nonproceduralists in governmental and nongovernmental organizations.”9Lund ME Interventional pulmonology competency standards: the time is now.J Bronchol. 2006; 13: 1-5Crossref Scopus (9) Google Scholar Quadrelli and colleagues7Quadrelli S Davoudi M Galindez F et al.Reliability of a 25-item low-stakes multiple choice assessment of bronchoscopic knowledge.Chest. 2009; 135: 315-321Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar have provided the next step in the process. All of us involved in providing quality patient care, continued quality improvement, and procedural education must embrace the development of validated competency metrics. I would like to thank Gordon Downie, MD, for his personal communication and discussion regarding preliminary data from the Interventional Chest Diagnostic Procedures Network Steering Committee-endorsed Multi-State Bronchoscopy Education Project.

Although significant experience exists in placing airway stents, and knowledge of stent-related complications is widespread, information is lacking regarding methods of surveillance and maintaining patency of these stents. The purpose of this investigation was to determine the actual practice patterns used by interventional pulmonologists for airway stent maintenance. We prospectively surveyed members of the American Association of Bronchology and Interventional Pulmonology or attendees at their annual meeting during Chest 2008. Sixty-two respondents returned the completed surveys and were included in the analysis. Practice settings included university (50%), single specialty (27%), community academic (11%), and multispecialty (11%) settings. Annual placement of stents was ≤10 (31%); 11 to 30 (45%); and >30 (24%). Considerable variability existed in both medications used for maintenance and surveillance schedules, and less than 50% protocolized postplacement management. Although stent placement is common among experienced interventional pulmonologists, half have no protocol for surveillance or maintenance. Similarly, there is no discernable consistency or standard practice pattern to monitor for or prevent stent failure. Further study is required to determine the best practices for postdeployment surveillance and maintenance of airway stents.

Compounds derived from biologic sources, or biologicals, are increasingly utilized as therapeutic agents in malignancy. Development of anti-cancer targeted therapies from biologics is increasingly being utilized. Cetuximab, a chimeric monoclonal antibody, is one such anti-cancer targeted therapeutic that has shown efficacy in quelling the rate of patient decline in colorectal, head/neck, and non-small cell lung cancer. However, due to the relatively recent addition of biologic compounds to the therapeutic arsenal, information related to adverse reactions is less well known than those seen in traditional chemotherapeutics. Dermatologic reactions have been demonstrated as the most frequent side effect cited during cetuximab therapy for malignancy; however, other effects may lead to greater morbidity. In general, pulmonary complications of therapeutics can lead to significant morbidity and mortality. The purpose of this review is to compile the various pulmonary side effects seen in patients treated with cetuximab for various malignancies, and to compare the incidence of these adverse reactions to standard therapies.

Although the exact incidence of nonbronchogenic endobronchial metastatic (EBM) disease is unknown, it appears a rare cause of central airway obstruction. It is likely that nonpulmonary endobronchial metastases are underdiagnosed, as many patients with known or suspected lung parenchymal metastases do not undergo bronchoscopy as part of their clinical evaluation. Colorectal carcinoma, the third most common cancer, remains a predominant cause of nonlung EBM. Other gastrointestinal tumors (gastric, pancreatic, hepatocellular, ampullary, and esophageal carcinoma) are also known to metastasize to the central airways. A high index of suspicion must be maintained for the possibility of EBM in patients with known metastatic disease elsewhere, as the symptoms may be subtle. Bronchoscopy offers the best method to evaluate the airway for EBM and evaluate therapeutic options. Currently, the standard of care for EBM is interventional bronchoscopy with endoluminal ablation and adjunctive techniques to provide rapid, effective, and safe restoration of the central airway lumen and maintain patency of the airway lumen. Most patients require multimodality approaches. Referral should be made to a center of excellence with the experience and availability of technology that allow multiple modalities to be used. (C) 2009 Elsevier Inc. All rights reserved.

Bronchopleural and alveolopleural fistulae from surgical and nonsurgical causes present unique management issues. A myriad of strategies have been employed to diminish airflow through the fistulous tracts. Frequently, treatment approaches need to be individually tailored on the basis of fistula size and location and to limit morbidity associated with treatment options. In unstable patients, a combination or staging of minimally invasive and surgical approaches may be necessary. Unfortunately, necessary resources may not be readily available for emergent intervention in all cases. We describe a novel approach of predeployment length modification of a self-expanding metallic airway stent. Deployment of this modified stent completely abrogated airflow through the intractable alveolopleural fistula that caused profound respiratory failure.

Central airway obstruction (CAO) is caused by a variety of malignant and nonmalignant diseases. It is unusual for most pulmonologists or thoracic surgeons to manage a significant volume of these patients. This inexperience and the apparent simplicity in treating central airway disorders may have led to complications and poor outcomes. In July 2005, the Food and Drug Administration (FDA) took notice and published a product advisory.1 The advisory was clearly focused on the inappropriate deployment of metallic stents in nonmalignant airway disease, and an inability to control the complications of this therapy. The American College of Chest Physicians' Interventional Chest and Diagnostic Procedures steering committee recently published an editorial, echoing the importance of the FDA recommendations.2 The frequency of complications mandates an ability to manage the stents after their placement.3,4–6 Known complications of stent placement, that can be seen in up to 35% of patients, include migration, mucus impaction, tumor in-growth or overgrowth, stent fracture, and exuberant granulation tissue.7–14 These complications were directly cited by the FDA. The advisory called for appropriate selection of patients and recommended “trained or experienced” physicians perform the procedures. The FDA further urged bronchoscopist's “to be aware of the guidelines from professional organizations regarding recommended provider skills and competency for these procedures.” (Table 1).TABLE 1: FDA Recommendations on Metallic Tracheal Stents1The recommendations of FDA are critically important, yet the guidance provided is only modestly helpful. The published guidelines for Interventional Pulmonary training, to which the advisory refers, are consensus statements from the ATS/ERS and the ACCP.15,16 While a good first step, they are not evidence-based and the thresholds for training are not derived from any validated metric. The training paradigm for basic bronchoscopy has never changed. The “see one, do one, teach one” philosophy has prevailed. All pulmonologists are initiated in roughly the same manner. The ACGME requires 50 supervised bronchoscopies for certification of fellows.17 Is this paradigm appropriate? Is 50 supervised procedures the appropriate threshold? In an on-going multicenter study of pulmonary fellows, the learning curve is still very steep for routine diagnostic bronchoscopies after 4 times that number.18 This clearly suggests an inadequacy of our current benchmark. Establishing competency based on an arbitrary number of bronchoscopies is fraught with complications. The ABIM has seen the difficulty in arbitrary quotas, but has not made any move to help establish the competence of their board-certified practitioners.19 There is a significant variation in the instruction of basic bronchoscopy.20 Furthermore, it has been shown that there is little correlation between bronchoscopy experience, extent of training, technical skill, and knowledge of bronchoscopic theory.21 We need a standardized and evidence-based curriculum. This curriculum should be based on validated, metrics for routine bronchoscopy. Dr Prakash22 has written that the focus in assessing specialty training is now “on quality of training rather than merely the quantity.” We agree! Unfortunately, definitive data are not yet present to define how we establish the appropriate quality of the training experience in standard diagnostic bronchoscopy. Interventional bronchoscopy is significantly more complex in the planning, execution and subsequent management than routine diagnostic bronchoscopy. A full review of all the etiologies of CAO and potential therapeutics is well beyond the scope of this editorial. Generally, malignant CAO can be separated into endoluminal disease versus extrinsic compression and primary airway tumors versus metastatic disease. Patients with a primary neoplasm should always be considered for resection and their treatment should include a surgical consultation. Although airway stent placement can be used alone, the management of malignant CAO commonly involves the integration of multiple techniques, including rigid bronchoscopy for coring out tumor, laser photoablation, photodynamic therapy, and cryotherapy. Physicians who perform stent placement procedures must be competent in multiple techniques to avoid poor results and life-threatening complications. Nonmalignant CAO represent more of a diagnostic and therapeutic dilemma, because many of the etiologies remain a mystery. Nonmalignant CAO may involve a small segment of the airway or the entire tracheobronchial tree. Like malignant CAO, management usually involves the use of other therapeutic airway techniques in combination with stent placement. However, unlike patients with malignant CAO these patients may have relatively normal life expectancy and therefore their treatment should involve methods with low risks of long-term complications. Therefore, stent placement of intrinsic disease should be avoided at all cost in these patients.14 Therapeutic strategies for nonmalignant CAO generally require concurrent evaluation with an experienced airway surgeon. Other types of nonmalignant CAO, such as anastomotic strictures after lung transplantation or tracheal resection are best dealt with at institutions that are used to dealing with these types of patients.23 Just as there are multiple indications for airway stent placement, there are also multiple types of airway stents. Silicone stents require rigid bronchoscopy for placement but they are considered relatively easy to remove and may have a lower incidence of granulation tissue formation than other stents. Self-expanding metallic stents (SEMS) do not require rigid bronchoscopy for insertion and this has created a growing popularity for SEMS because of the apparent, “simplicity” of their deployment. Unfortunately, the ease of deploying SEMS has created a pervasive belief that stent placement is easy and thus, able to be offered by any bronchoscopist. For most of the nonmalignant CAO, thoracic surgery remains the gold standard of care. Proper use of endobronchial therapy is best decided during multidisciplinary evaluation. Although the advisory did not focus on interventional bronchoscopy, the FDA has recommended that only trained and experienced physicians place airway stents. They advised that when required, removal of an endothelialized stent should be performed only by an experienced interventional pulmonologist or airway surgeon. Most interventionalists find this to be a difficult procedure, which can be extremely hazardous to the patient.24,25 Serious complications are likely and include major bleeding, mucosal tears, tracheal perforations, pneumothorax, and permanent incorporation of stent fragments. What defines a “trained and experienced” bronchoscopist? Who and what determine expertise? The Cambridge handbook of Expertise and Expert Performance states: “We now have some evidence that surgical expertise is acquired and highly local. The ability to perform one task derives from one specific practice with that task and does not generalize to other, even apparently similar, surgical tasks.”26 This suggests that expertise in diagnostic bronchoscopy alone will not provide expertise in therapeutic bronchoscopy. In the evaluation of training for interventional procedures, it was determined that less than 30% of training programs offering interventional procedural therapies met published competency recommendations!27 Most “formally trained” interventional pulmonologists have dedicated an additional year of training under direct mentorship. The additional year provides sufficient volume to meet published recommendations.15,16 Just as importantly, this experience allows the trainee to see and manage difficult airways and complications of therapy, including complications of metallic stents. The development of expertise relies upon experience. “The interplay between formal knowledge of medicine and experiential knowledge has emerged as a central issue in understanding medical expertise.”26 If we want to provide the highest level of care to the patients at the highest risk of airway complications, we must understand what is required to develop both the cognitive and technical expertise and create pathways that fulfill the didactic, decision-making, and experiential needs required in training interventional pulmonologists. To say a pulmonologist is trained in bronchoscopy and therefore can perform any procedure through a bronchoscope is not supported by data available in the fields of cognitive task analysis and expertise evaluation. Transfer of skills between procedural tasks is difficult because of the high specificity of process learning.26 Single weekend or week long training courses are not likely to be the most effective method to train pulmonologists to perform therapeutic bronchoscopy. In a randomized controlled trial of surgical skills training, residents were assigned to a single training program or a distributed weekly program over 4 weeks.28 Surgical residents demonstrated better retention and transfer of skills when attending distributed sessions. The learning benefits of sequential and repetitive tasks have long been known. The benefits of the repetitive use of simulators over time was demonstrated with a prospective evaluation of GI fellows using simulation laboratory training over 7 months compared with solely clinical training for interventional endoscopy.29 Expertise has been found to be most related to repeated practice under a carefully controlled training program.26 The cognitive training required for a solid foundation, upon which technical training builds, is as important as procedural skill. Teaching cognitive skills has been demonstrated to improve technical ability.30 We must better understand what defines expertise in bronchoscopy and determine what decision making is critical to procedural success. The ACCP, the ACGME, and the AAB should demand and support further study to delineate procedural metrics, define competency, and subsequently mandate evidence based cognitive and technical training. The FDA's advisory is singularly more about bronchoscopists than about the stents. As a profession, we must understand what defines the expert and create a program to improve the cognitive and technical skill of the physician, providing both diagnostic and therapeutic bronchoscopy. Just as the science of stent placement in the tracheobronchial tree must continue to advance, so too must our understanding of procedural competence. It is only with this evidence that we, as a profession, can elucidate the most appropriate curriculum and determine the suitable metrics to define competency. Until these metrics are established, the published guidelines of the ACCP15 and the ATS/ERS16 regarding recommended provider training requirements, clinical experience, and competency must be followed. It is important that all bronchoscopists' heed the FDA's advisory and practice restraint in airway stent placement. Broad recommendations to clinicians interested in stent placement should include: Patient selection is critical and benign disease should only be managed with a stent as a last resort and probably be referred to a center with expertise in this area. Physicians placing airway stents should follow best practice, understand the indications and be able to manage the complications should they arise. Further, it is recommended that they should have access to expertise in rigid bronchoscopy or airway surgery. Physicians with experience in stent placement can manage malignant CAO. If problems arise referral to a center with expertise in airway management is warranted. It is also the responsibility of every pulmonologist or surgeon performing interventional bronchoscopy to report all adverse outcomes from stent placement to the FDA, and to review these complications in regularly scheduled morbidity and mortality conferences.

Airway stenting has become a common technique for treating central airway obstruction (CAO) caused by a variety of malignant and benign diseases. The original stents used by Duvall and Bauer,1Duvall AJ Bauer W An endoscopically introducible T-tube for tracheal stenosis.Laryngoscope. 1977; 87: 2031-2037Crossref PubMed Scopus (26) Google Scholar Cooper et al,2Cooper JD Pearson FG Patterson GA et al.Use of silicone stents in the management of airway problems.Ann Thorac Surg. 1989; 47: 371-378Abstract Full Text PDF PubMed Scopus (178) Google Scholar and Dumon3Dumon JF A dedicated tracheobronchial stent.Chest. 1990; 97: 328-332Abstract Full Text Full Text PDF PubMed Scopus (580) Google Scholar were silastic and required general anesthesia and rigid bronchoscopy for placement. The advent of the Wallstent (Boston Scientific Corporation; Natick, MA) introduced a new generation of stents that were metallic, self-expanding, and easily deployable, the so-called self-expanding metal stent (SEMS). However, the ease of deployment came with a cost. Over time, the metallic stents integrate into the airway, leading to complications such as stent fracture, erosion into adjacent structures, mucous retention, and granulation tissue formation. This is especially true in patients with benign airway disease, whose life expectancy is not inherently limited by their primary disease and in whom the stents can exist for years. This point was highlighted by Stephens and Wood,4Stephens KE Wood DE Bronchoscopic management of central airway obstruction.J Thorac Cardiovasc Surg. 2000; 119: 289-296Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar who found that the vast majority of all early and late deaths following airway procedures for patients with benign and malignant CAO occurred in the malignant group. Over the past 5 years, there has been an increase in the number of adverse events reported after the deployment of SEMS for benign airway disease. This apparent increase in metallic airway stent failures led the Food and Drug Administration (FDA) to publish an advisory on the use of metallic stents in patients with benign airway disease in 2005 (Fig 1).5Food and Drug Administration. FDA public health notification: complications from metallic tracheal stents in patients with benign airway disorders, 2005. Available at: www.fda.gov/cdrh/safety/072905-tracheal.html. Accessed January 15, 2007Google Scholar Despite the publishing of this advisory, there still are no consensus recommendations for the use of SEMS in patients with benign CAO. Many physicians who regularly treat patients with CAO have seen and managed complications of metallic stents placed for nonmalignant disease. Despite this fact, several studies6Saad CP Murthy S Krizmanich G et al.Self-expandable metallic airway stents and flexible bronchoscopy: long-term outcome analysis.Chest. 2003; 124: 1993-1999Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar7Madden BP Loke TK Sheth AC Do expandable metallic airway stents have a role in the management of patients with benign tracheobronchial disease?.Ann Thorac Surg. 2006; 82: 274-278Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar8Thornton RH Gordon RL Kerlan RK et al.Outcomes of tracheobronchial stent placement for benign disease.Radiology. 2006; 240: 273-282Crossref PubMed Scopus (75) Google Scholar have shown that SEMS can be used successfully in patients with benign CAO but with complication rates that approach 45%. Disastrous complications include erosion of stents into adjacent structures.9Shiraishi T Shirakusa T Ninomiya H et al.Penetration to the aortic wall by a metal airway stent. A successfully treated case with left pneumonectomy and aortic repair.J Cardiovasc Surg. 2005; 46: 473-475PubMed Google Scholar More commonly, stents can become colonized with bacteria, leading to increased mucous production and formation of granulation tissue. Noppen and colleagues10Noppen M Pierard D Meysman M et al.Bacterial colonization of central airways after stenting.Am J Respir Crit Care Med. 1999; 160: 672-677Crossref PubMed Scopus (95) Google Scholar reported an 80% incidence of bacterial colonization after airway stent placement in patients without evidence of colonization prior to stenting. Pathogens included pseudomonas, Staphylococcus aureus, Streptococcus pneumonia, and klebsiella.10Noppen M Pierard D Meysman M et al.Bacterial colonization of central airways after stenting.Am J Respir Crit Care Med. 1999; 160: 672-677Crossref PubMed Scopus (95) Google Scholar This is compared to a study11Noppen M Perrard D Meysman M et al.Absence of bacterial colonization of the airways after therapeutic rigid bronchoscopy without stenting.Eur Respir J. 2000; 16: 1147-1151Crossref PubMed Scopus (9) Google Scholar that showed a 20% decrease in the incidence of bacterial airway colonization in patients with airway obstruction following therapeutic rigid bronchoscopy without subsequent stent placement. Although bacterial colonization can occur also with silastic stents, the ability to remove these stents makes this issue less critical. While removal of granulation tissue in a stent can be achieved relatively easily with Nd-YAG laser, cryotherapy, or argon beam coagulation, complete removal of an endothelialized or infected incorporated stent may be necessary. This procedure is difficult and can be extremely hazardous to the patient.12Murthy S Gildea TR Mehta AC Removal of self-expanding metallic stents: is it possible?.Semin Respir Crit Care Med. 2004; 25: 381-385Crossref PubMed Scopus (35) Google Scholar Lunn et al13Lunn W Feller-Kopman D Wahidi M et al.Endoscopic removal of metallic airway stents.Chest. 2005; 127: 2106-2112Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar reported on stent extractions in 30 patients, 20 of whom had benign airway disease, and found that 97% of the complications associated with the stent extraction occurred in the benign CAO group and included mucosal tears, retained stent fragments, and airway obstruction. All of the difficulties encountered in patients with long-term airway SEMS highlight the point that SEMS should be avoided whenever possible in patients with benign CAO, with exceptions for patients with inoperable disease or significant comorbidities that render them inoperable. Even in these patients, other therapies such as airway debridement or dilatation and the placement of removable stents should be considered prior to the placement of a SEMS. Therapeutic strategies in these patients are best dealt with in a multidisciplinary setting, where pulmonologists and surgeons, knowledgeable in airway diseases, can decide on the best therapy for the patient. Postsurgical CAO involving anastomotic strictures following lung transplantation or tracheal resection is best dealt with at institutions that are used to dealing with these patients,14Mughal MM Gildea TR Murthy S et al.Short-term deployment of self-expanding metallic stents facilitates healing of bronchial dehiscence.Am J Respir Crit Care Med. 2005; 172: 768-771Crossref PubMed Scopus (123) Google Scholar who may require frequent bronchoscopies, stent changes, or other surgical procedures to treat the involved airway. The FDA advisory highlighted an ongoing concern held by many pulmonologists and surgeons: stents are being employed in patients with benign airway obstruction without consideration for other therapeutic modalities and without consideration of the possible long-term complications inherent with the use of SEMS. The members of the American College of Chest Physicians (ACCP) Interventional and Chest Diagnostics Network Steering Committee fully support the FDA warning. Although there are no universally agreed-on guidelines defining proficiency for stent placement, all physicians who utilize endotracheal/bronchial therapies should be familiar with the ACCP and the American Thoracic Society/European Respiratory Society guidelines regarding recommended provider training requirements, clinical experience, and competency.15Ernst A Silvestri GA Johnstone D Interventional pulmonary procedures: guidelines from the American College of Chest Physicians.Chest. 2003; 123: 1693-1717Abstract Full Text Full Text PDF PubMed Scopus (545) Google Scholar16Bolliger CT Mathur PN Beamis JF et al.ERS/ATS statement on interventional pulmonology: European Respiratory Society/American Thoracic Society.Eur Respir J. 2002; 19: 356-373Crossref PubMed Scopus (506) Google Scholar Furthermore, all physicians who perform airway stenting should report all adverse device events to the FDA as well as discuss them in their conferences on morbidity and mortality. Current stent technology is far from ideal, and it will be a long time before a stent is developed that is not associated with significant airway problems. Therefore, recognizing the potential complications prior to stent placement is the best way to avoid them.

BACKGROUNDAirway stenting is a procedure that is performed increasingly often, and the availability of metallic stents placed by flexible bronchoscopy may have contributed to the increased usage. These procedures have an impact on the required physician skill set and practice management. We review the indications for airway stenting, and how the requirement of combined therapies and technical aspects of central airway stenting pertain to practice management.PROCEDUREWe compared several reimbursement scenarios for managing stent placement using the Centers for Medicare and Medicaid Services relative value units (RVUs) and average reimbursement amounts. We also compared the reimbursement to other commonly performed activities performed by pulmonary and critical care physicians. An analysis of Medicare facility outpatient and inpatient payment for procedures using silicone and metallic stents was also conducted.RESULTSProfessional reimbursement is identical regardless of stent type, method of insertion, and anesthesia administered. The net facility reimbursement largely depends on stent costs. The RVUs alone are a poor comparator for the reimbursement of therapeutic bronchoscopy because of Correct Coding Initiatives edits. Considering the time necessary for performing advanced therapeutic bronchoscopy, the professional fees are not attractive. The net facility reimbursement largely depends on stent costs.CONCLUSIONThe placement of airway stents is not reimbursed at competitive rates and may even lead to a net loss for the facility. The practice management benefits of central airway therapy are probably best obtained by a multidisciplinary airway team with an established cost center structure.

The last 20 years has seen the progressive growth of both available technology and interest in interventional pulmonology. Minimally invasive endoscopic and percutaneous procedures have grown continually in scope and public acceptance. In response to this growth, numerous specialty groups, including the American College of Cardiology (ACC), American Society of Gastrointestinal Endoscopy (ASGE), American Gastrointestinal Association, Society of Cardiovascular and Interventional Radiology, American Board of Radiology, and Society of Vascular Surgery have created opinion-based specific training tracks and requirements to assure physicians, the public, and third-party payors that these procedures are being performed by qualified individuals. 1-7 Over the same 20-year interval, there has been a significant drive by governmental, nongovernmental organizations, and insurers (see Table 1) to control quality and cost by focusing on board certification, appropriate training, physician profiling, outcomes measures, complications, and quantification of continued experience.There is a semantic misunderstanding of privileging, certification, and competency. According to the Accreditation Council for Graduate Medical Education (ACGME), certification is "a process to provide assurance to the public that a certified medical specialist has successfully completed an approved educational program and an evaluation, including an examination process designed to assess knowledge, experience and skills requisite to the provision of high quality care in that specialty.'' 8 Competencies are "specific knowledge, skills, behaviors and attitudes and appropriate educational experiences required of [trainees] to complete GME programs.''Granting of privileges is a local medical staff function.Education of interventional pulmonologists has been discussed in this journal and at national meetings. 9,10 The publication of procedural guidelines has also stimulated discussion. 11-13 These guidelines were and are needed. It is likely that every formally trained interventional pulmonologist has seen or managed metallic stents placed for benign disease; many of them in retrospect need not have been deployed. The U. S. Food and Drug Administration (FDA) has taken notice and recently published a product advisory. 14 This advisory is clearly related to either the inappropriate use of metallic stents in benign airway disease or an inability to control the complications of therapy. The cognitive process of knowing when to perform a procedure, when not to intervene, and what alternatives are more appropriate comes with experience and not just procedural skill. Teaching cognitive skills has been demonstrated to improve technical ability.