Interventional pulmonology continues to expand its reach into the realm of minimally invasive diagnostic and therapeutic procedures focused on diseases of the chest. The ongoing endeavors of its ever-growing community have further refined established procedures and have catalyzed the development of innovative new technologies.

One of the most exciting advancements has been fueled by the introduction of robotic bronchoscopy. This advancement provides unprecedented maneuverability, stability, and accuracy with the ability to reach all regions of the lung. This technology combined with real-time three-dimensional imaging is anticipated not only to provide the accuracy needed to significantly increase the diagnostic utility of bronchoscopy but also to provide a foundation for the delivery of therapeutics for lung cancer while minimizing complications. Efforts to establish bronchoscopically delivered therapeutics will be a focus for the next phase of projects for the interventional pulmonology community. Interventional pulmonologists have been able to extrapolate a significant knowledge base from the field of interventional radiology in radiofrequency, cryo, and microwave ablation for peripheral tumors. Early safety and feasibility studies are showing promising results in patients with early lung cancer with prohibitive surgical risk, as well as ablation of limited metastatic disease.

Thoracic endoscopy through the esophagus continues to have an increasing role by providing an additional route to access regions otherwise inaccessible to interventional pulmonologists to perform minimally invasive procedures. Combined endobronchial ultrasound (EBUS) and endoscopic ultrasound is recognized as being superior to either alone. The COVID (coronavirus disease) pandemic has highlighted the benefit of combined percutaneous tracheostomy and percutaneous endoscopic gastrostomy by the same team by limiting exposures and expediting care facilitating timely patient disposition.

The role of EBUS has become engrained as the standard of care in the diagnosis and mediastinal staging of lung cancer. Its importance has been further highlighted by the expansion of the role of neoadjuvant therapies as well as nonsurgical options for early-stage disease. Appropriate mediastinal staging will be critical to optimize outcomes as studies investigate the feasibility and efficacy of bronchoscopically delivered nonsurgical local ablative options for early-stage lung cancer.

In the area of therapeutic interventions, malignant and benign central obstruction often present significant challenges in management. These challenges may be associated with severely limited physiologic reserve, with challenging anatomy or a combination. The growing availability of extracorporeal membrane oxygenation offers a level of security when performing high-risk cases but indications and management strategies when combined with bronchoscopy for critical central airway obstruction are yet to be well defined. Three-dimensional printed stents are also now commercially available and offer a level of unprecedented customization, particularly for anatomically challenging cases.

Pleural effusions of both malignant and benign etiologies can present both diagnostic and therapeutic challenges. Fortunately, investigators continue to improve and develop novel methods to improve diagnostic certainty as well as minimally invasive therapeutic options to palliate symptoms.

The role of transbronchial lung cryobiopsy has been better defined by a growing body of literature and is now included in societal guidelines for the diagnosis of interstitial lung diseases. Details on the technical aspects of procedural techniques continues to be better defined with increased standardization. Although significant questions remain, its role is better established than ever and continues to garner growing interest.

The body of literature further defining the benefits of bronchoscopic therapies for obstructive lung disease also continues to grow. For emphysema, bronchoscopic lung volume reduction offers a minimally invasive option with significant improvements in symptoms and quality of life. Recent literature even supports a possible mortality benefit. Therapeutic options for moderate chronic obstructive lung disease, chronic bronchitis, and asthma are also areas of active investigation with promising possibilities.

Interventional pulmonology continues to enjoy ongoing growth and innovation with a growing community of dedicated practitioners. We hope you find this update informative, thought-provoking, and inspirational.

Article published online:
14 September 2022

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