Volume 08
Issue 01
January 2020
Inside This Issue
Opinion/Editorial, 2,3
Technology Corner, 4,5,6
Tips from the Experts, 7,8,9,10
Humanitarian News, 11,12, 13
Best Image Contest, 14
WABIP News, 15
Research, 16
Tribute, 17
Links, 18
Upcoming Events, 19
Tissue diagnosis prior to resecon for lung cancer vs. surgical biopsy in the era of guided
Guest Opinion/Editorial
WABIP Newsletter
J A N U A R Y 2 0 2 0 V O L U M E 8 , I S S U E 1
Silvia Quadrelli MD
Buenos Aires,
Argenna, Chair
Hideo Saka MD
Nagoya, Japan,
Zsolt Papai MD
Hungary, Immediate
David Fielding MD
Brisbane Australia,
Naofumi Shinagawa,
Secretary General
Hokkaido, Japan
Guangfa Wang MD
Beijing, China,
President WCBIP 2020
Philip Astoul, MD
Marseille, France,
President WCBIP 2022
Michael Mendoza
General Manager
Judy McConnell
Kazuhiro Yasufuku
Newsleer Editor-in-
P A G E 2
Guided bronchoscopy has signicantly improved the diagnosc yield of transbronchial biopsy. Electromagnec
navigaon bronchoscopy, for example, has a pooled diagnosc accuracy of 74%, compared to as low as 14% with
convenonal bronchoscopy.[1] Given its low rate of complicaons, transbronchial biopsy warrants special consid-
eraon in the comorbid paent.[1] The ecacy and safety of guided bronchoscopy favourably alters the risk-
benet calculaon for obtaining a preoperave biopsy.
However, these plaorms have not developed in isolaon. Risk-predicon calculators have been rened through
growing datasets. High-resoluon computed tomography (CT) can thoroughly characterize lung nodules. The mor-
bidity of surgical biopsy has declined with video-assisted thoracoscopic surgery. In such an environment, can we
proceed directly to surgical biopsy based on history and imaging alone, and if such a paradigm is valid where does
guided bronchoscopy t?
Only a small number of studies have compared proceeding to surgery with vs. without a ssue diagnosis. Rates of
benign disease on surgical biopsy ranged from 7.8-15%.[2,3] This dropped to 4.8% in one study focusing on nodu-
lar ground-glass opacies.[4] Such results suggest clinicians can feasibly disnguish between benign and malig-
nant lesions in most circumstances. Proceeding directly to surgery had several further advantages, including
shorter me to treatment and reduced costs.[2,4] One group went further, nding that upfront lobectomy, with-
out preoperave or intraoperave biopsy, had stascally equivalent rates of benign disease resecon (3.2% with
biopsy vs. 7% without), while reducing costs and intraoperave complicaons.[5]
Being retrospecve, many of these studies cannot inform how paents should be selected for upfront surgical
biopsy. Another challenge is the frequent conaon of primary lung cancer and lung metastases as malignancy.
However, consideraon of lung metastasectomy generally warrants short-term surveillance to conrm oligometa-
stac status and thorough discussion with the paent on prognosis. Conversely, some inappropriatebenign le-
sions may have had concerning features that could have mandated excisional biopsy.
There are many guidelines on the evaluaon and management of lung nodules. We refer readers to the 2015
Brish Thoracic Society guidelines in parcular, which among other features includes indicaons for discharge
from follow-up, a suggested imaging surveillance protocol, and a step-wise approach to risk-strafy nodules for
biopsy or resecon.[6] In the absence of changes on serial imaging, solid nodules ≥8mm or sub-solid nodules
≥5mm are rst evaluated using the Brock calculator. If the risk is ≥10%, subsolid nodules can be further evaluated
via imaging, biopsy, or resecon. For solid nodules, risk ≥10% should prompt evaluaon by PET, whereby PET avid-
ity is input into the more accurate Herder calculator. Paents with <10% recalculated malignancy risk should un-
Kazuhiro Yasufuku MD, PhD
Professor, Department of
University of Toronto
Alexander Gregor, MD
PhD Student, Division of
Thoracic Surgery
Surgical Resident, Division of
General Surgery,
University of Toronto
dergo CT surveillance, while those with >70% recalculated risk are recommended to proceed to biopsy or denive management.
Given that the pre-test probability of malignancy is so high in such paents, non-diagnosc or non-concordant biopsy results would
not necessarily countermand the need for excisional biopsy or resecon. Although other risk calculators have been described, a
comparave validaon trial found the Brock and Herder calculators had superior diagnosc performance.[7] This remained true
even when applied to populaons outside their inial inclusion/exclusion criteria (the Brock calculator was originally developed
from a cancer screening trial; the Herder cohort excluded extra-thoracic malignancy within 5 years).[7]
Even this algorithmic approach leaves a large group of intermediate-risk solid nodules and elevated-risk sub-solid nodules for
which biopsy results could guide management. Likewise, in the paent with a history of prior malignancy, preoperave biopsy may
allow earlier recognion of metastac disease. These paent groups are the most likely to benet from preoperave ssue diagno-
sis, including guided bronchoscopy. It is only through more informed and directed use of guided bronchoscopy that cost-eecve
integraon into current clinical pracce will be possible.
1. Gex G et al. Respiraon 2014; 2:165-76
2. Heo E et al. Jpn J Clin Oncol 2011; 8:1017-22
3. Sihoe A et al. Eur J Cardio-thoracic Surg 2013; 2:231-7
4. Cho J et al. BMC Cancer 2014; 838:1-8
5. Kaaki S et al. J Surg Oncol 2018;5:977-84
6. Callister M et al. Thorax 2015;70:ii1-ii54
7. Al-Ameri et al. Lung Cancer 2015;1:27-30
P A G E 3
Technology Corner
Targeted lung denervaon for COPD
Increased cholinergic tone of parasympathec nerves is a hallmark of the pathophysiology in chronic obstrucve pulmonary dis-
ease (COPD). Release of acetylcholine via pulmonary nerves contributes to bronchial hyperresponsiveness, bronchoconstricon,
increased mucus producon, and inammaon. Pharmacologic blockade of acetylcholine binding to muscarinic receptors via the
inhaled route aims to aenuate these detrimental eects of cholinergic hyperacvity. A large subset of paents with COPD, how-
ever, remain symptomac and connue to experience exacerbaons despite inhaler treatment, due to lack of adherence, incorrect
inhaler technique, and/or failure of homogenous lung deposion.
Targeted lung denervaon:
Targeted lung denervaon (TLD) is a novel bronchoscopic therapy with the intenon of permanently disrupng peribronchial para-
sympathec nerves via radio frequency (RF) ablaon at the level of the central airways. TLD has the potenal to mimic the eects
of long-acng anmuscarinic and at the same me to overcome the limitaons of inhaler therapy. TLD is delivered via a dual-
cooled RF catheter (Holaira, Minneapolis, Minnesota, USA) (Figure 1). As RF current passes from the electrode through the airway
and surrounding ssues, these ssues are heated. Coolant connuously circulated through the electrode and balloon removes heat
from the surface of the airway wall. The net eect is a narrow band of targeted ssue ablaon at depth around the main bronchi
with minimal heang and damage of the inner surface of the airway.
Following extensive preclinical tesng in animal and human cadaver models in which successful denervaon was demonstrated
without jeopardizing airway integrity, a rst-in-man study (IPS-1) was performed in a non-randomised, prospecve, sequenal, two
-dose study, conducted in South Africa and the Netherlands (1). Eligible paents were ≥40 years of age with symptomac COPD
and postbronchodilator FEV1 of 30%60% predicted. Due to the construcon of this rst-generaon device, procedures were per-
formed via rigid bronchoscopy under general anaesthesia, with the RF delivery catheter placed in the airways next to the exible
bronchoscope for visualizaon. The primary endpoint was freedom from documented and sustained worsening of COPD directly
aributable to TLD to 1 year. Overall, 22 paents were included and randomized to receive either 15W or 20W TLD bilaterally us-
ing a sequenal treatment approach. The primary safety endpoint was achieved in 95% with asymptomac bronchial wall eects
observed in 3 paents at 20 W. The clinical safety proles were similar between the two energy doses, with numerically larger im-
provements in lung funcon, exercise capacity, and quality of life in the 20W group throughout 1 year.
A subsequent study was conducted to test feasibility and safety of TLD treatment in both lungs during a single procedure, as it was
presumed this would be the preferred mode of treatment. This study (IPS-2) was otherwise similar in design, paent selecon and
outcomes (2). A total of 15 paents were recruited at sites in Austria and France. Primary safety end point of freedom from wors-
ening of COPD was 100%. There were no procedural compli-caons reported. Results of lung funcon analysis and exercise capaci-
ty demonstrated similar benecial eects of TLD when compared with long-acng ancho-linergic therapy, with follow-up to 3
years post-TLD.
P A G E 4
Arschang Valipour, MD
Associate Professor
Head, Department of Respiratory and Crical Care Medicine
Director, Karl-Landsteiner-Instute for Lung Research and Pulmonary Oncology
Following these earlier studies, a second-generaon device was developed with a larger electrode (hence higher energy applicaon) to de-
crease procedure me and a delivery catheter that could be placed through 3.0mm working channel of a bronchoscope. The AIRFLOW-1
trial was the rst study to evaluate the safety of this second-generaon version of the device for safety, treatment dose, and device/
procedure performance (3). Thirty paents were randomized to receive TLD at two preselected doses (29 vs. 32 W) in a 1:1, double-blind,
mul-center study conducted at 10 European sites. Bronchoscopic and uoroscopic visualizaon was used to guide electrode placement
before and during energy delivery. All paents were prescribed 2530 mg prednisone and 500 mg of azithromycin daily for 1 day before
and 2 days aer the procedure. The primary safety endpoint was the rate of TLD-associated adverse airway eects that required a thera-
peuc intervenon (dened as the administraon of anbiocs, conducon of another diagnosc test to assess the treatment area, or an
endoscopic procedure or surgery to treat ndings) through 3 months posreatment. Secondary endpoints included procedural success,
overall adverse events, and change from baseline to 1-year for pulmonary funcon tests, health-related quality of life, and exercise capacity
Acute airway wall eects (primary outcome) were observed in 15% of treated paents, with full resoluon of all events at follow-up visits.
Overall, there was a trend towards more favorable clinical outcomes, i.e. improvements in lung funcon and quality of life data, in the high-
er energy dose group (32W), in the absence of dierences in the adverse events prole between the 2 energy groups in the blinded ran-
domized phase of the study. Aer treatment of the rst 13 subjects in the randomized dose evaluaon phase, however, reports of gastric
adverse events prompted suspension of treatments in AIFLOW-1 and a detailed invesgaon of all pernent events. The invesgaon sug-
gested that these events were related to inadvertent injury to esophageal branches of the vagus nerve during treatment. As a conse-
quence, protocol, procedural, and training enhancements were implemented to ensure opmal placement, visualizaon, and conrmaon
of the electrode posion relave to the esophagus prior to acvaon to migate against further gastric events. The new procedure version
thus included acve measurements of the distance between the electrode and the outer wall of the esophagus, by use of a commercially
available esophageal balloon lled to low pressure with a contrast agent, to assist in avoiding the thermally sensive vagus nerve (Figure 2).
To further migate gastrointesnal side eects, lower power (26 W) was used for treatment posions close to the main carina. In addion,
paents with a history of prior abdominal surgical procedures and/or a high gastrointesnal disorders symptom severity index were further
excluded from TLD treatment. Following these procedural enhancements, there was a subsequent reducon in treatment-related gastric
side eects conrmed in the randomized study populaon and in an addional open-label conrmaon group of 16 paents.
Using the learnings from AIRFLOW-1 the AIRFLOW-2 study was performed, a mulcentre, randomized, sham bronchoscopy–controlled,
double-blind trial of TLD at 32W in paents with symptomac COPD, with the primary endpoint being the rate of respiratory adverse
events between 3 and 6.5 months aer randomizaon (4). During this predened window, paents in the TLD group experienced signi-
cantly fewer respiratory adverse events than those in the sham group (32% vs. 71%, P = 0.008). Furthermore, the risk of COPD exacerbaon
requiring hospitalizaon in the 0- to 12.5-month window was signicantly lower in the TLD group than in the sham group. No hemoptysis,
pneumothorax, or airway changes were noted out to 1 year in this study. Furthermore, and consistent with the above there was a low
number and transient nature of gastrointesnal side eects. There was no stascally signicant dierence in paent reported symptoms,
or other physiologic measures at follow-up.
Future direcons:
Given the promising results of AIRFLOW-2 the ongoing AIRFLOW-3 study has been iniated with the intenon to invesgate the role of TLD
on COPD exacerbaon rates as a primary ecacy outcome. Paents with moderate to severe COPD despite opmised medical manage-
ment will be randomized to receive either TLD or a sham procedure, with follow-up planned up to 5 years. Compared to previous studies
the larger sample size in AIRFLOW-3 will also allow to conduct responder analysis, in order to address whether TLD may be more eecve
in paents with specic baseline characteriscs.
Furthermore, there is a need to be able to conrm successful peribronchial denervaon in the future. In this context the connecon be-
tween TLD and respiratory sinus arrythmia aenuaon (RSA) may serve as a tool for esmang the achieved eect of TLD in treated pa-
ents (5). Disrupon of pulmonary vagal nerve branches may aenuate the pulmonary stretch pathway, thereby altering RSA. Thus, RSA
using roune ECG recordings could be evaluated during a paents screening visit and then re-evaluated at a follow-up visit soon aer TLD.
Paents without RSA aenuaon could potenally be candidates for a second TLD procedure.
W A B I P N E W S L E T T E R P A G E 5
In conclusion, targeted lung denervaon may be a promising novel endoscopic treatment in paents with moderate-to-severe symptomac
COPD. Results from the ongoing AIRFLOW-3 study will need to conrm previous ndings before entering clinical implementaon in roune
1. Slebos DJ, et al. Thorax 2015; 70(5):411-9
2. Valipour A, et al. Int J Chron Obstruct Pulmon Dis 2018; 13:2163-2172
3. Valipour A, et al. Respiraon 2019; 98:329-339
4. Slebos DJ, et al. Am J Respir Crit Care Med 2019; 200:1477-1486
5. Valipour A, et al. Respiraon 2019; 98:434-439
Figure 1.
Figure 2.
W A B I P N E W S L E T T E R P A G E 6
Tips from the Experts
P A G E 7 V O L U M E 8 , I S S U E 1
Bilateral whole lung lavage (WLL) is the most eecve proven treatment modality for symptomac pulmonary alveolar proteinosis (1). Vari-
ous other pathologic states such as radioacve dust inhalaon, alveolar microlithiasis, and lipoid pneumonis have been treated with WLL
with variable success (2) .
Pulmonary Alveolar Proteinosis
Primary pulmonary alveolar proteinosis (PAP) is a rare disorder caused by alveolar accumulaon of a lipoproteic material that has the aspect
of surfactant. Paents present with dyspnea and hypoxemia, aggravated by exercise. Granulocyte macrophage colony smulang factor
(GM-CSF) has a role in PAP pathogenesis, as it is required for normal surfactant homeostasis. PAP is associated with neutralizing autoan-
bodies against GM-CSF. GM-CSF treatment may benet a subset of paents with adult PAP (3). Other treatments have included monoclonal
anbodies, plasmapheresis and lung transplantaon. Among adults, the typical age of apparion of the illness is 30 to 50 years. The progno-
sis of PAP has greatly improved since the introducon of WLL by Ramirez in 1965 (4).
The diagnosis is primarily conrmed by high resoluon CT scanning (HRCT) revealing ground-glass opacicaon, predominantly in a homoge-
neous distribuon. Thickened intralobular structures and interlobular septa in typical polygonal shapes may also be observed, referred to as
"crazy-paving". Crazy-paving is characterisc but not specic to PAP. Pulmonary funcon tests show a restricve venlatory defect with re-
ducon in the total lung capacity, vital capacity and diusing capacity for carbon dioxide. Electron microscopic exam of broncho-alveolar
lavage (BAL) uid can conrm the diagnosis. When allowed to stand, the uid spontaneously separates into pale yellow, almost translucent
supernatant and thick sediment. An-GM-CSF anbodies are useful as a diagnosc tool in PAP. Surgical lung biopsy is rarely necessary to
make the diagnosis.
Physical removal of the lipoproteinaceous material through repeated diluons with saline soluon is believed to be the mechanism by which
WLL creates a benet. WLL oen only provides temporary symptomac benet, and has to be repeated several mes. WLL requires pro-
longed general anesthesia, and is associated with potenal morbidity including: hydro-pneumothorax and prolonged postoperave venla-
Whole Lung Lavage Technique
In the Authorscenters, the team is composed of an Anesthesiologist in charge of the anesthesia and of the lung lavage, two Physiothera-
pists, and two operang-room Nurses. WLL is performed in the operang room with basic anesthesia monitoring plus: core temperature,
urinary catheter, processed EEG and arterial cannulaon for beat-to-beat measurement of blood pressure and for blood gases analysis. Gen-
eral anesthesia is induced and maintained with an intravenous anesthec agent (propofol), and muscle relaxants. The procedure for unilat-
eral lavage lasts between 3 to 4 hours and 5 to 6 hours for a bilateral lavage. The use of a warming blanket over the legs helps to minimize
heat loss.
Lung separaon is obtained by using a le-sided double lumen tube (DLT). Posioning of the DLT is achieved with a pediatric beropc bron-
choscope (FOB). Air ghtness is conrmed by observing for absence of an underwater leak from the tubing aached to the non-venlated
lung during a prolonged stac inaon to 30 cmH2O of the venlated lung. Arterial blood gases are obtained pre-inducon and during inial
two-lung venlaon. They are repeated intermiently during and aer the procedure.
Jean Bussieres, MD, FRCPC,
Dept. Anesthesiology,
Instute Universitaire de
Cardiologie et de Pneumologie,
Universite Laval, Quebec City,
Peter Slinger, MD, FRCPC,
Dept. Anesthesia,
Toronto General Hospital,
University of Toronto, Toronto,
Tips from the Experts
P A G E 8 V O L U M E 8 , I S S U E 1
The paent is kept in the supine posion on an imaging-compable operang-room table. To improve the eecveness of the lavage, venla-
on with FiO2 1.0 is iniated for a few minutes to denitrogenate both lungs. Prelavage evaluaon conrms which lung is the most impaired,
mainly through imaging evaluaons. The most impaired lung is the rst to be lavaged.
One-lung venlaon (OLV) (dal volume 4-5ml/kg IBW, RR 12-14 and PEEP 5cmH2O) is instuted in the non-lavaged lung, and conrmed by
the inspired and expired dal volumes of the Anesthec machine venlator. A disposable irrigaon and drainage system constructed with
cardiopulmonary bypass tubing is used to insll approximately 1 L of warm normal saline (37oC) by gravity. The irrigang soluon bag is sus-
pended 30 cm above the paent and the insllaon takes 2 to 3 min.
Chest physiotherapy is performed during the ling and drainage phases of each cycle to increase the ecacy of the WLL. The physiotherapy
technique consists of a combinaon of chest percussions, vibraons and pressure applied during the lling and the drainage phase. A annel
cloth is used to protect the paents skin from irritaon provoked by repeve manipulaons. Posional modicaons are very useful to
irrigate and to drain all the segments of the lung. The full lateral posion is used at least once during the procedure. Extreme care must be
taken to avoid the risk of leakage from the lavaged lung to the venlated lung.
Approximately two minutes aer the lung is completely lled with saline, it is rapidly drained over 5 to 10 minutes into a container posioned
below the paents mid-chest level. This process is repeated 10 mes or more, as necessary, to obtain a clear euent lavage uid. During the
insllaon phase the arterial oxygenaon (as measured by pulse oximetry) will increase as hydrostac pressure forces the pulmonary blood
to redistribute from the lavaged-lung to the venlated-lung (see Fig. 1). During the drainage phase oximetry will decrease as blood ow re-
turns to the lavaged lung.
Inslled and drained saline volumes are carefully recorded for each cycle to monitor for the possibility of a leak or a hydrothorax. A Surgeon
is always immediately available in the operang room suite to insert a chest drain if required. There is a small inial shorall of the drainage
volume. However, if the total drained volume falls to >1L behind the inslled volume, the procedure is halted and a portable chest X-ray is
obtained. When the euent lavage uid is clear from the rst lavaged lung, careful aspiraon is done, with a sucon catheter and also under
direct vision with the use of a FOB.
In order to safely proceed with WLL on the contralateral lung, a recuperaon period of at least 1h is required. Both lungs are venlated in a
protecve fashion with dal volumes (6-7 mL /kg) and PEEP at a level varying from 7 to 12 cmH2O. Furosemide is administered (10 mg IV) to
induce diuresis during this period and paents body is enrely covered with a warming blanket to keep its temperature close to normal.
Aer this recovery period during anesthesia, a trial of OLV with the recently lavaged lung is undertaken for 15 min. The goal is to obtain a
PaO2 greater than 70 mmHg with a FiO2 1.0, with trated PEEP prior to beginning WLL of the second lung. The second lung is then lavaged in
an idencal fashion to the rst lung. When sasfactory oxygenaon cannot be achieved to connue bilateral WLL the opons include: 1)
Stopping the procedure and binging the a paent back for single-lung lavage of the untreated side in 2-3 weeks (this was previously our de-
fault plan), 2) A trial of inhaled nitric oxide at 20 ppm to the venlated lung to decrease residual hypoxic pulmonary vasoconstricon, or 3)
The instuon of veno-venous extracorporeal membrane oxygenaon (VV-ECMO) to nish the lavage of the second lung (see Fig. 2). Recent-
ly, this has become our default plan using right internal jugular and femoral cannulaon and this is discussed with the paent and ECMO
team in advance. However, ECMO has been required in <25% of our cases.
Usually, between 10 to 15 L of saline are inslled into each lung (up to 50 L), and more than 90% of this volume is recovered, leaving a recu-
peraon decit of less than 10%. At the end of the procedure, the DLT is exchanged for a single-lumen endotracheal tube (ETT) and both
lungs are suconed with an adult FOB. Furosemide 10mg. IV is repeated aer the second lung lavage.
In some specic cases, when the distribuon of the alveolar inltraon is not homogeneous, selected segmental BAL is then performed aer
the WLL via the adult FOB.
Post Procedure management
The paent is transferred to the ICU or the post-anesthesia recovery room intubated, venlated and sedated with a propofol +/- dexme-
detomidine infusion. Lung protecve venlaon with trated PEEP is connued, usually for 2 to 4 hours, post-procedure unl the gas ex-
change improves to levels that are acceptable for weaning and extubaon at which point the muscle-relaxant is reversed and the sedaon
disconnued. A portable chest X-ray is obtained on admission to the ICU and repeated as required. Alveolar inltrates seen on the chest X-
ray immediately aer WLL normally clear within 24 to 36 hours. Observaon in the ICU or a Stepdown ward for 24 hours is the roune. Opi-
oid and non-steroidal analgesia is oen required for the rst 24-48h for chest wall pain from the physiotherapy. The paent is then mobilized
on the Thoracic Surgical ward for 2-3 days, as face-mask/nasal prong oxygen is weaned, unl t for discharge. Most paents are discharged
without supplemental oxygen.
Complicaons such as pneumothorax and hydrothorax are rare, but may need to be drained, resulng in a postponed procedure or delayed
recovery. Post procedure complicaons include pneumonia, sepsis, and rarely, acute respiratory distress syndrome.
Tips from the Experts
P A G E 9 V O L U M E 8 , I S S U E 1
Post Procedure Evoluon
Paents are followed aer discharge by their Respirologist or Family Physician. Most paents will have an improvement in symptoms, imag-
ing and pulmonary funcon tests (see Fig. 3 A&B). Repeat WLL is performed as required according to the clinical assessment. Most paents
will require one or more repeat lavages. The symptom-free period may vary between 6 months and several years.
Pediatric Whole Lung Lavage
Pediatric paents are not managed at either of the Authorshospitals. Small size DLTs (26-32F) can be used in paents > 8yr. age and the pro-
cedure is similar to adult WLL(5). For smaller children the opons are less straighorward and may include repeated segmental BAL during
general anesthesia with a single-lumen ETT or ECMO.
1. Bussieres J et al. Whole Lung Lavage. Chapt. 45 in Principles and Pracce of Anesthesia for Thoracic Surgery, 2nd ed., Slinger P Ed. Springer, Switzer-
land, 2019: 747-760
2. Wilt J et al. J Occup Environ Med. 1996;38(6):619-24
3. Kumar A et al. Lancet Resp Med. 2018; 6(7): 554-565
4. Ramirez-Riviera J, et al. Ann Intern Med. 1965;63(5):819-28
5. Paquet C et al. Anesthesiology. 2009;110(1):190-2
Figure 1:
A) During the lling phase (circle) saline ows
by gravity through one lumen of the double
lumen tube (in this diagram to the le lung)
while the other lung is venlated. During
lling, there is reducon of blood ow to
the lavaged lung, by compression of the
pulmonary blood vessels (arrow).
B) During the drainage phase (circle), there is
reperfusion of the non-venlated lung
(arrow), creang an increased shunt, and
leading to a decrease in arterial oxygen
Figure 2:
The Physiotherapist performs chest compressions during
lavage of the second lung (in this case the right lung) with
oxygenaon supported by V-V ECMO. ECMO cannulaon
is via the right femoral and internal jugular veins. The An-
esthesiologist is steadying the double-lumen tube (DLT) to
prevent displacement during physiotherapy. The paent is
being venlated via the bronchial lumen (blue connector)
of the DLT. The proximal tracheal (clear) lumen of the DLT
is clamped and the distal lumen is draining to the le side
of the operang table.
Tips from the Experts
P A G E 10 V O L U M E 8 , I S S U E 1
Figure 3A : Pre-procedure Chest X-ray of a 48 y.o. male with primary alveolar proteinosis showing bilateral inl-
Figure 3B: Chest X-ray of the same paent 3 months post-procedure showing marked improvement.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 11
One of the main concerns of the general public about the humanitarian aid is how the relief agencies collect and spend the
money. The general distrust of the populaon about almost all the government and non-government organizaons that han-
dle money with any purpose is unfortunately extended to the humanitarian world. Not few comments about seeing a big
business with hidden prots in humanitarian aid have been spread with or without second intenons. A beer understand-
ing of the organizaon and funding resources of the humanitarian assistance may help to be able to have an independent
unbiased opinion about those relevant maers.
One of the main source of funding for foreign aid are the states. The reasons behind states working as donors are diverse.
Humanitarian aid is the most high-prole and emove part of a donor governments aid budget, and can play an important
ambassadorial and public relaons role. General public humanitarian concerns are the main reason for supporng overseas
aid. Also countries oen provide foreign aid to enhance their own security. Thus, economic assistance may be used to pre-
vent friendly governments from falling under the inuence of unfriendly ones or as a retribuon for the right to establish or
use military bases on foreign soil. At the same me foreign aid helps in spreading donors language, culture, or religion.
States addionally provide aid to relieve suering caused by natural disasters or armed conicts to promote economic devel-
opment when it is consider helpful to protect global interests like control of diseases or destrucon of the environment.
Beyond any generous purpose, the granng and receipt of foreign assistance serves the commercial interests of donor coun-
tries as in a certain way it works as an incenve to adjust the polics of the recipient in front of the risk of terminaon of aid.
Also, the states are obliged by internaonal agreements. In the aermath of the Second World War with a devastated
Europe, several world leaders saw the need of rebuilding those ruined countries as a requisite for keeping peace,
allowing the rebirth of internaonal commerce and protect against the abuses of war. It resulted in the creaon of
the United Naons. As one of the of the purposes of the UN, as stated in its Charter, is "to achieve internaonal co
-operaon in solving internaonal problem of an economic, social, cultural, or humanitarian character", all mem-
ber countries are engaged in sustaining those nancial aid eorts.
Most funding into internaonal humanitarian assistance comes from a small number of Western governments. In absolute
dollar value the USA and the European Communitys Humanitarian Aid Oce (ECHO) lead the table of donors most years,
Dening why and how donor governments act in internaonal crises through their funding mechanisms explain why some
crises are well funded and others not, and also why funds are given through NGOs more than to local governments.
The USA remains the single largest donor, contribung nearly 33 percent of global government funding in 2005, followed by
the European Union with 15 percent, Japan with 7 percent and France and the UK each with 6 percent. Global humanitarian
assistance more than doubled during the 1990s, from $2.1 billion in 1990 to $5.9bn in 2000, mainly because of the increase
of complex conict-related emergencies. In 2001, donors contributed $2.1bn in response to 20 complex emergencies, and
$311 million for 49 natural disasters. Although the number of people and countries aected by natural disasters is greater
than for complex emergencies, conict-related crises usually cause greater loss of life and entail more expensive response
People may be sased (or amazed or concerned) that humanitarian assistance has grown, but it is good to know that donor
countries are contribung a smaller and smaller share of their wealth to overseas development aid (ODA). In the 1970s and
1980s, they contributed around half of the UNs target of 0.7% of gross naonal product (GNP); by the 1990s, overseas aid
had declined as low of 0.22%. In the US, less than 0.1% of the naonal budget is spent on ODA in the last decade. Even tradi-
onally generous countries like Denmark are cung their spending in this area. As a percentage of total ODA, humanitarian
aid reached 10.5% in 2000, compared with an average of 5.8% between 1989 and 1993, mainly because the whole of ODA
amount decreased.
About recipient countries, in 2004, six countries received an esmated half of all humanitarian assistance: Iraq (16 percent),
Sudan (11 percent), Palesne (8 percent), Ethiopia (6 percent), Afghanistan (6 percent), and the DRC (4 per- cent). The re-
maining 49 percent was shared among 148 countries. Globally food aid, its purchase and distribuon, represents the biggest
Humanitarian News
W A B I P N E W S L E T T E R P A G E 12
sector for humanitarian expenditure. In 2005, it accounted for 40 percent of global humanitarian expenditure.
It is important when reading these gures to be able to dene what is considered foreign aid”, a permanent concern of ex-
penditure for taxpayers, mainly in the United States. Globally in 2017, the United States spent over $46 billion in foreign aid.
Over 38.5% of that budget went to just ten countries: Afghanistan ($4.89 billion), Iraq ($3.36 billion), Israel ($3.18 billion)
and then Jordan, Ethiopia. South Sudan, Kenya, Pakistan, Nigeria and Uganda. But is also worth knowing how that foreign
aidis distributed: of the $17.7 billion foreign aid dollars given to the top 10 countries, about 59% of it was designated as
military funds compared to the 28% of military funding of its foreign aid budget in 2017. The United States administers
humanitarian support through two oces. First, within USAID, humanitarian aid ows through the Bureau for Democracy,
Conict, and Humanitarian Assistance, and through it to the Oce of Foreign Disaster Assistance (OFDA), the Food for Peace
Program (FFP), and the Oce for Transional Iniaves (OTI). OFDA deals with most funding responses to emergencies. FFP
administers US food aid.
The other main donor actor is Europe In an average year, the European Union provides around 30 percent of global humani-
tarian aid mainly through its humanitarian oce (ECHO). ECHO has been established in 1992 as part of the consolidaon of
the polical and administrave funcons of the European Union. Nearly 60 percent of ECHOs funding is given through inter-
naonal NGOs (primarily those based in the European Union). The rest goes to UN agencies, the Red Cross Movement, and
some funds may go directly to the aected states.
Numerous agencies of the United Naons have a role in humanitarian aairs. These include the Security Council and oces
within the Secretariat, as well as some of the specialized agencies. A broad division of labor exists within the United Naons
system. The Oce for the Coordinaon of Humanitarian Assistance (OCHA) is in charge of the policy and planning frame-
work; World Food Program (WFP) is responsible for emergency food delivery; the United Naons High Commission for Refu-
gees (UNHCR) is in charge of emergency shelter; United Naons Children Fund (UNICEF) is responsible for nutrion and wa-
ter and sanitaon; and the Food and Agricultural Organizaon (FAO) is responsible for emergency agriculture.
OCHA is the UN body delegated to coordinate the response and acvies of relief agencies to humanitarian emergencies
worldwide to ensure that no populaons or sectors are neglected and mainly to prevent overlap in work between organiza-
ons. OCHAs coordinaon acvies extend beyond the UN system and include NGOs, private organizaons—such as the
ICRC, and some others.
Parcularly important during the armed conicts, the Oce of the United Naons High Commissioner for Refugees (UNHCR)
was created by the UN General Assembly in 1950 to lead and coordinate assistance to and protecon of refugees interna-
onally. UNHCR is funded almost enrely by voluntary contribuons, largely from states or other internaonal organizaons.
Since the 1990s, its budget has held steady at around $1 billion annually, with oces located in nearly 100 countries.
Over the past 30 years, an increasing percentage of Ocial Development Assistance (ODA) has been spent on humanitarian
assistance;. In an average year in the mid-2000s around of $1012 billion was made available for global humanitarian assis-
tance. As most of that money comes from the states, it nally comes from the tax payers. According to the Global Humani-
tarian Assistance the ocial total humanitarian assistance contribuon per cizen of countries belonging to the Organizaon
for Economic Cooperaon and Development in 2006 was an average $10. Contribuons per country varied widely with the
United States contribung $10 per cizen, Japan $2, the UK $18, Switzerland $26 and Norway $81. To compare these ex-
penditures with some others, Joseph Sglitz (Nobel Economics Prize laureate) calculates that the United States is spending
$16bn a month on the wars in Iraq and Afghanistan, a monthly sum almost double than the annual humanitarian spend and
equivalent to the whole annual budget of the UN.
A very relevant internaonal humanitarian actor is the Internaonal Commiee of Red Cross. The ICRC is funded both by
contribuons from the States Party to the Geneva Convenons and by donor governments and the general public. Thus,
some of its budget each year, though voluntary, comes from states as part of their obligaons under the Geneva Conven-
ons. On average, ICRCs total budget is around $900 million: an important amount of money but signicantly less than the
major internaonal NGO grouping, World Vision Internaonal.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 13
Finally, a large scale humanitarian key actor is a vast and varied group of humanitarian NGOs. Many of them are transnaon-
al with budgets even over the one of major corporaons or small states. They represent a very wide range of interests, phi-
losophies and working methods and they implement the vast majority of the operang work of the internaonal humanitari-
an system.
When giving funds for humanitarian assistance, governments have to decide how to channel those funds. NGOs have be-
come the channel of choice for donor governments and the funding public from the US and Europe handling around $4 bil-
lion a year. They have very dierent proporons of private donors to government funding, according to their policies, philos-
ophies and ability to reach the general public. Agencies like Médecins Sans Fronères (MSF) privilege the voluntary funds in
order to keep the independence they achieve by being almost enrely independent of government funding. On the other
hand CARE Internaonal network receives almost half of its funding from governments. In 2006, Oxfam UK reported of their
total income of £290, £70 million was derived from governments.
The internaonal NGOs network is increasingly concentrated, mainly because of the increasing demands of professionality,
accountability and experse to do their job in the context of more complex scenarios and with many new security challeng-
es. The 30 largest humanitarian agencies (which represent 4% of the total number of emergency aid agencies) receive on
average 85 percent of the total available funding and 1% of those agencies control 70 percent of the resources. Those large
internaonal NGOs are far from being a bunch of good-hearted amateurs. They perform an extremely complex work and
have high standards of accountability and professional performance.
Humanitarian assistance has been the target of varied cricism in the last years. It should be noted that humanitarian aid
(mainly with the NGOs that include advocacy and denounces of human right violaons becoming main actors in the eld) is a
deeply polical acvity and the judgement of their performance if far from being polically unbiased. Financial transparency
should not be a main concern about humanitarian aid.
No maer their limitaons, challenges and debates, humanitarian eorts do sll follow the human imperave of solidarity,
compassion and empathy with human suering. Addionally, it not only helps the recipient aected populaons, but also
help in a great deal the wealthy countries far from the aected areas. If the living condions of a populaon are unbearable,
too painful or too dangerous we leave them only one opon: to eed their vicious hell looking for some opportunity some-
where else, whichever the risks it means.
*The views expressed in this arcle are those of the author (Silvia Quadrelli) and do not necessarily reect the ocial
posions of the Execuve Board or Internaonal Board of Regents of the WABIP.
Best Image Contest 2020 Recipient (1 of 3)
Descripon: Complex tracheal stenosis secondary to blastomicosis.
Submiers: Liu Estradioto, MD and Rodrigo Beega de Araújo, MD.
This image is 1 of 3 selected among 100+ submissions to our Best Image Contest held in 2019. Please stay tuned to the next Image
Contest, opening later this year!
Find the above image and more at the WABIP Academy Image Library!
Best Image Contest
P A G E 14
WCBIP Shanghai 2020 Postponed & Rescheduled
We regret to inform you that due to the impact of the virus epidemic in Wu-
han China and its surrounding areas, the WCBIP organizers must postpone
this congress from April to September. The new dates for the Shanghai
WCBIP is September 24-27, 2020. Please visit www.WCBIP.org for all the
latest congress updates.
Board of Regents Meeng 2020
As the new business year has started, WABIP Regents (member society representaves) shall meet and vote
on WABIP acvity and nancial reports for our annual lings as a non-prot organizaon in Japan. The
meeng will be held via teleconferencing on FEBRUARY 29, 2020. Regents may also submit their votes to ap-
prove the said reports via proxy. The WABIP Execuve Board shall also eld quesons and discussions per-
taining to the Shanghai WCBIP and other WABIP business items.
WABIP Vising Scholar Travel Grant Recipients 2020
Aer a thorough review of over a dozen qualied applicants, we have nally nar-
rowed down the candidates to one nal recipient - Dr. Sangit Kasaju (Nepal). Dr.
Deepak shall be travelling to the United Kingdom for his observership program under
supervisor Dr. Anindo K Banerjee.
We would like to thank those who have submied their applicaons. We look for-
ward to receiving your documents again for our 2021 grants.
New Member Sociees
We are excited to announce ve new member sociees in the WABIP: Lebanese Pulmonary Society, Nepal
College of Chest Physicians, Asociación Colombiana de Broncoscopia y Neumología Intervencionista
(Colombia), Mexico City Bronchology Associaon and the Scotland Intervenonal Pulmonology group.
The sociees are represented by Dr. Ralph Nehme (Lebanon), Dr. Sangit Kasaju (Nepal), Dr. Echeverri Franco
(Colombia), Dr. Olivia Sanchez Cabral (Mexico) and Dr. Sanago Giavedoni (Scotland). We are proud to wel-
come these new friends and colleagues in our ever-growing associaon with now over 9,200 members repre-
senng over 60 naonal and regional sociees around the world.
P A G E 15
Liquid Biopsy – Whats going to happen to Bronchoscopy?
Finding a few millimeters pulmonary nodules with current technological advancements in radiology such as thin slice and high-resoluon CTs is
not the problem. However, even despite the most studied and evidence-based strategies to strafy these nodules into benign versus malignant
has been a frustrang task. In the Naonal Lung Cancer Screening Trial (NSLT), where even in the high-risk populaon of paents (extensive
smoking history in older age, etc.), the vast majority of nodules biopsied/resected turned out to be benign. Risk calculators for these nodules to
predict the likelihood of malignancy are quite variable and unreliable in their approaches and outcomes as well.
A biomarker that can be easily isolated from many body uids (blood, saliva, urine, ascites, pleural eusion, etc.), as well as a ssue biopsy, is
oen referred to as a Liquid Biopsy. The liquid biopsy includes circulang tumor cells (CTCs), circulang tumor DNA (ctDNA), and exosomes CTCs
generated by the detachment of tumor cells from the tumor. Both CTC, ctDNA as well as exosomes, can be isolated from plasma and be used as
a liquid biopsy of the disease. The liquid biopsies may be used for early diagnosis, prognosis and risk stracaon as well as to gauge the re-
sponse to therapies, and to idenfy therapeuc targets and resistance mechanisms.
In a recently published trial (1), the authors aempted to answer a fundamental queson: Can a biomarker help risk-strafy intermediate-risk
pulmonary nodules? In a well-designed clinical study (Pulmonary Nodule Plasma Proteomic Classier (PANOPTIC) trial) the authors examine the
impact of an integrated classier using expression of two plasma proteins associated with lung cancer and cancer immune response, LG3BP,
and C163A, in addion to clinical and radiographic risk factors usually used (age, smoking status, nodule diameter, shape, and locaon), to
dierenate between benign and malignant pulmonary nodules. The invesgators only focused on nodules classied as low to intermediate risk
(0-50%) for malignancy based on clinical criteria.
The primary endpoint of the study shows that the integrated classier is associated with high sensivity (97%) and high negave predicve val-
ue (98%) for disnguishing between malignant and benign pulmonary nodules. These values are beer than a PET scan and some of the most
popular lung cancer risk predicon models.
Novel approaches of genomic and proteomic proling of paents with pulmonary nodules have developed rapidly over the last decade or so.
More markers are under study. These markers can be obtained without any invasive procedures and add substanal condence in the straca-
on of low to the intermediate-risk paent populaon, which seems to be at the highest risk of unnecessary procedures. Further use of these
markers in prognoscaon, relapse/metastasis diagnosis, and drug response could be of enormous potenal.
1. Silvestri, et al. Chest. 2018 Sep;154(3):491-500
Editor-in-Chief: Dr. Kazuhiro Yasufuku
Primary Business Address:
Kazuhiro Yasufuku, Editor-in-Chief
WABIP Newsleer
c/o Judy McConnell
200 Elizabeth St, 9N-957
Toronto, ON M5G 2C4 Canada
E-mail: newsleer@wabip.com
P A G E 16
Associate editor:
Dr. Ali Musani
Associate editor:
Dr. Sepmiu Murgu
In Memoriam: Professor Patrick Barron
In Memory of Prof. Patrick Barron
By Hiroaki Osada, M.D.
Past-Chair of the WABIP
It is with great regret to inform you that Professor Emeritus Patrick Barron has unexpectedly passed away on
August 17th, 2019 at the age of 71. Many of our colleagues who knew Patrick deeply share the same regret
and sorrow.
As a nave of Scotland, Patrick le his country for the United States to pursue and complete his university
educaon. He then came to Japan at the end of 1960s where he lived in Tokyo, Japan since.
More than a quarter century ago, I met Patrick for the rst me in St. Marianna University School of Medi-
cine, Kawasaki Japan, where we both were working. I quickly found Patrick to be a man of righteousness and
humility. Aer his tenure at St. Marianna, Patrick was invited to Tokyo Medical College by virtue of his quali-
caons and enthusiasm for Medical English educaon and complete uency in the Japanese language.
Over the years, thousands of Japanese Medical students and doctors have beneted and appreciated Pat-
ricks teachings in professional medical English, including myself. Addionally, Patrick was central to the rise
and development of the WAB (precursor organizaon to WABIP) and many other scienc organizaons
around the world. Patrick also contributed to COPE (Commiee on Publicaon Ethics, registered in the Unit-
ed Kingdom). Last but not least, Patrick served as a leading editorial member of Journal of Bronchology. In
spite of Patricks many great contribuons, he refused to receive any reward in return.
I cannot forget how much Patrick helped us, when our small work-
ing group tasked to revitalize the WAB was struggling to nd a way
to accomplish its goals in and around 2009-2011. With the inclu-
sion of Patricks eorts into our working group, the WABIP was re-
sultantly born to where we are now with over 9,200 respiratory
physician members, represenng over 60 naonal and regional so-
ciees around the world.
Patrick, we shall never forget you! The WABIP shall connue to
grow and prosper as a truly worldwide associaon that strives to
connect with every bronchologist around the world, as you have
been dreaming for many years. We pray for your eternal rest and
P A G E 17
The WABIP has started a new educaon project recently: THE WABIP ACADEMY. The WABIP Academy will pro-
vide free online webcasts with new and hot topics that will interest pulmonologists and intervenonalists.
Current webcast topic: Tissue acquision for biomarker directed therapy of NSCLC
You can reach these webcasts by using this link: hp://www.wabipacademy.com/webcast/
www.bronchology.com Home of the Journal of Bronchology
www.bronchoscopy.org Internaonal educaonal website for
bronchoscopy training with u-tube and
facebook interfaces, numerous teachiing
videos, and step by step tesng and assess
ment tools
www.aabronchology.org American Associaon for Bronchology and I
ntervenonal Pulmonology (AABIP)
www.eabip.org European Associaon for Bronchology and
Intervenonal Pulmonology
www.chestnet.org Intervenonal Chest/Diagnosc Procedures (IC/DP)
www.thoracic.org American Thoracic Society
www.ctsnet.org The leading online resource of educaonal and
scienc research informaon for cardiothoracic
www.jrs.or.jp The Japanese Respirology Society
Asociación Sudamericana de Endoscopía Respiratoria
P A G E 18
When: February 1-2, 2020
Where: HICC, Hyderabad, INDIA
Program Director: Dr. Hari Kishan Gonuguntla
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees)
Hands-on workshop
10th Annual Evaluaon and Management of Pleural Disease
When: February 3, 2020 - February 4, 2020
Where: Chevy Chase Bank Conference Center, 1800 Orlenas St., Balmore, MD 21287, USA
Program Director: Dr. David Feller-Kopman
Program Type: Hands-on workshop, Conference (didacc lectures)
Website: hps://hopkinscme.cloud-cme.com/default.aspx?P=0&EID=18619
WABIP Rigid Bronchoscopy Japonica
When: February 15, 2020 (Saturday)
Where: Shinjuku, Tokyo, Japan
Program Director: Dr. Hideo Saka
Program Type: Hands-on workshop, Conference (didacc lectures)
Website: hps://www.wabip.com/events/483-rigidbroncoscopy-japan2020
WABIP Navigaon Bronchoscopy with Cone-Beam CT Course
When: March 11-13, 2020
Where: Radboud University Medical Center, Nijmegen, The Netherlands
Program Director: Erik van der Heijden, MD, PhD
Program Type: Workshop, Educaonal seminar (postgraduate may include physicians in pracce and trainees)
Website: hps://www.wabip.com/navigaon
21st WCBIP Congress
When: September 24-27, 2020
Where: Shanghai, China
Program Director: Prof. Guangfa Wang
Program Type: Hands-on workshop, Conference (didacc lectures), Educaonal seminar (postgraduate may include physicians in
pracce and trainees), Educaonal seminar (for trainees only)
Conference (didacc lectures)
Website: hps://www.WCBIP.org
P A G E 19
P A G E 2