Volume 08
Issue 02
May 2020
Inside This Issue
Opinion/Editorial, 2-3
Technology Corner, 4-6
Tips from the Experts, 7-9
Humanitarian News, 10-14
Best Image Contest, 15
WABIP News & Upcoming Events, 16
Research, 17-18
Links, 19
Bronchoscopy in Paents with Suspected or Conrmed COVID-19 Infecon
Guest Opinion/Editorial
WABIP Newsletter
M A Y 2 0 2 0 V O L U M E 8 , I S S U E 2
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
It has been more than 3 months since WHO was noed of the rst cases of pneumonia with unknown causein
China. Its incredible to reect on how dramacally the world has changed in such a short period. The total num-
ber of COVID-19 cases has passed three million, and the deaths related to COVID-19 is growing upwards of 217
thousand. No geographic region is spared from this pandemic. According to the latest WHO reports, the COVID-19
pandemic is spreading and taking grip in Africa aer Asia, Europe, and America. The devastang eects of COVID-
19 pandemic on human health, economy, and the social fabric of our global community will not be fully evident
for years to come. Unl then, extreme prevenons, necessary infecon control measures, and following expert
advice from the professionals will be the most prudent approach. No one country can combat this global pandem-
ic individually. Our approach to this highly fatal and devastang illness has to be global. Organizaons like WABIP
can genuinely play a global role in guiding its members around the world on how best to handle dicult issues of
performing necessary bronchoscopies and airway procedures vs. postponing them during this crisis. We can pro-
vide leadership to our members on how best to balance providing service to our fellow cizens and preserving
health care workers safety without feeling guilty or shame. We, the health care workers, are a nite resource for
the millions of very sick paents around the globe who need our help more than ever before. We need to be judi-
cious in ulizing this resource. Pulmonary and Crical Care Medicine is at the heart of the medical management
of COVID-19 paents. The vast majority of morbidity and mortality from COVID-19 stems from pulmonary prob-
Airway procedures, such as bronchoscopy, are being requested for reasons such as expedious diagnosis, man-
agement of complicaons, opmizing venlator management, and tracheostomy related to COVID -19 beside
roune indicaons. It is more important than ever to be extremely mindful and judicious in making decisions as to
the indicaons of these procedures. The risk and benets must be thoroughly weighed before embarking upon
any airway procedures in the backdrop of a highly contagious infecon that has no specic prophylacc or thera-
peuc opons. The implicaons of contaminaon of instruments and consequently infecng several people from
a straighorward procedure such a bronchoalveolar lavage could be devastang. These procedures could start a
cascade of eects jeopardizing the health of several health care workers and slow down the delivery of health
care to numerous other paents due to the consequent lack of health care workers and shortage of personal pro-
tecve equipment (PPE).
Below is the summary of guidelines provided by the American Associaon for Bronchology and Intervenonal
Pomology (AABIP) and the Society of Advance Bronchoscopists (SAB) in their recent consensus statements (1,2).
1. Its preferable to collect upper respiratory samples via nasopharyngeal and oropharyngeal swabs for the diag-
nosis of COVID-19 at any stage of the disease.
2. Induced Sputum Collecon is NOT recommended.
3. Bronchoscopy carries a very high risk of aerosolizaon of the virus. Hence it has a very limited role in the diag-
nosis of COVID-19 infecon.
4. If an alternave diagnosis is suspected aer COVID-19 infecon has been ruled out, the paent should be intu-
bated for bronchoscopy to minimize the aerosolizaon of the virus and to expose the physicians and the sta.
This should only be done when there is a substanal change in management expected from new/alternave dis-
Ali I. Musani MD, FCCP
Vice Chair, Global Health. Department of Medicine
Professor of Medicine and Surgery
Director, Complex Airway Pillar of the Center for Lung and Breathing
Director, Bronchoscopy Service, Intervenonal Pulmonology Program and Fellowship
Division of Pulmonary Sciences & Crical Care Medicine
University of Colorado School of Medicine, Denver
5. Bronchoscopy should be performed in an Airborne Infecon Isolaon Room (AIIR ) negave pressure room.
6. Extreme care should be taken when collecng and handling specimens from paents who could be COVID-19 posive. Even the
paents who were COVID-19 negave a few days prior to the procedure, could be posive for COVID-19 at the me of bronchosco-
py. The current tests for COVID-19 are not 100% sensive or specic.
7. Laboratory personnel should be alerted that the specimen is from suspected COVID-19 paents.
8. The bronchoscopy sta and specimen handling sta should be limited to the minimum required personnel.
9. All personnel should wear a powered, air-purifying respirator (PAPR) or N95 mask and eye protecon.
10. All personnel should wear standard Personal Protecve Equipment (PPE), which includes gown, gloves, respiratory protecon,
and eye protecon.
11. Follow US Centers for Disease Control (CDC) instrucons for proper donning and dong of all protecve equipment and dispos-
able devices.
12. Disposable bronchoscopes should be used the rst line when available.
13. Follow standard disinfecon protocol of durable re-usable video monitors.
14. Follow standard high-level disinfecon for re-usable bronchoscopes.
15. Emergent bronchoscopy (same day) should be considered for the following condions: Acute foreign body aspiraon, massive
hemoptysis without obvious sources for embolizaon, and severe symptomac airway obstrucon.
16. Urgent bronchoscopy (1-2 days) should be considered in condions such as neutropenic fevers with pulmonary inltrates with-
out any other explanaon and lung transplant paents with clinical deterioraon despite empiric therapy.
17. The numbers of COVID-19 paents around the world are declining slowly but surely. Procedure lists have obtained a short but
robust experience in performing the invasive procedure with utmost care. Most centers are now performing lung cancer diagnosis
and staging with bronchoscopy as soon as possible. The urgency of diagnosis and staging of lung cancer has superseded the ultra-
conservave approach of delaying lung cancer diagnosis and staging. Bronchoscopy, for the diagnosis of recurrent or unresponsive
lung cancer, is also considered as an urgent procedure requiring early aenon. These decisions are best made under the auspices
of mul-disciplinary lung cancer teams.
18. Bronchoscopic procedures such as Bronchoscopic Lung Volume Reducon (BLVR), Bronchial Thermoplasty (BT), specimen col-
lecon for chronic infecons such as atypical mycobacterial and fungal infecons, and roune surveillance bronchoscopies for lung
transplant paents should be postponed unl the polices for such procedures have been developed, and the risk of COVID-19 is
signicantly lower.
19. Avoid rigid bronchoscopy, if possible, and if necessary, use without jet venlaon .
20. If a bronchoscopist or a bronchoscopy team member is exposed during the procedure, he/she should let the other bronchosco-
pist/team member nish the case (if safely possible). He/she should be tested if the source paent is conrmed as posive for
COVID-19. Return to work should follow the hospital and local polices around tesng, resoluon of symptoms, and permission
from a physician.
In conclusion, bronchoscopy should be avoided in the vast majority of paents with suspected or proven COVID-19 unless there
are emergent or urgent indicaons. If it must be performed, extreme precauons and safety measures should be taken by using
proper PPE and curtailing of aerosolizaon of the virus. The recommendaons for bronchoscopy and all other procedures are rap-
idly evolving with our understanding of transmission, virulence, possible therapies, and improving technologies for dealing with
COVID-19. The recommendaons may also vary depending upon the local burden of disease, resources, and experse. Please con-
nue to follow local and internaonal guidelines and expert reports.
1. American Associaon for Bronchology and Intervenonal Pulmonology ( AABIP ) Statement on the Use of Bronchoscopy and Respiratory
Specimen Collecon in Paents with Suspected or Conrmed COVID-19 Infecon. Accepted for publicaon in journal of Bronchology. aabron-
2. J Thorac Dis 2020 | hp://dx.doi.org/10.21037/jtd.2020.04.32
P A G E 3
Technology Corner
Trans-parenchymal nodule access
During the past decade, there has been a remarkable advancement in diagnosc technological innovaons with respect to bron-
choscopic approaches of an indeterminate pulmonary nodule. These include: ultrathin bronchoscopy, radial endobronchial ultra-
sound (rEBUS), virtual bronchoscopy, electromagnec navigaon bronchoscopy, roboc bronchoscopy as well as combinaons of
these techniques. The diagnosc yield of such technologies is usually dependent on several factors such as size of the pulmonary
nodule, anatomical locaon, airway bronchus sign, eccentric or concentric view on rEBUS and CT-to-body divergence during bron-
choscopy. Furthermore, airway anatomy is complex making navigaon and maneuvering through several subsegments very chal-
lenging leading to probably lower yield beyond fourth-generaon bronchial segments.
One of the limitaons of the above technologies is the challenge of accessing a lung nodule without a bronchus sign on CT chest.
Two novel bronchoscopic techniques, bronchoscopic trans-parenchymal nodule access (BTPNA) and transbronchial access tool
(TBAT), have been developed that allows bronchoscopists to overcome such limitaon by accessing nodules through an airway wall
independent of an airway leading to the lesion.
The Archimedes Virtual Bronchoscopy Navigaon System (Broncus Medical, Mountain View, California, USA) (Figure 1) recon-
structs pre-procedural CT scan into a 3D model which provides guidance of a sheath from the point of entry on the airway wall
through the lung parenchyma directly to the lung nodule using a balloon catheter equipped guided sheath. The point of exit to the
airway wall can be computer selected or adjusted per physician preference. The vasculature is highlighted with a virtual Doppler
funcon to help avoid vessels at the exit point. During the procedure, airway wall is punctured with a 18G needle followed by di-
lang the hole with a balloon then advancing the guide sheath with blunt stylet (steerable catheter) through parenchymal ssue
into the nodule under real-me uoroscopy. There is a fusion of the virtual plan from CT data with the real-me uoroscopy image
where the passage of the sheath can be corrected real me.
The CrossCountry
TBAT (Transbronchial Access Tool) (Medtronic, Minneapolis, Minnesota, USA) (Figure 2) has been also de-
signed to allow access through an airway wall and into the lung parenchyma for lesions without an airway. Once the opmal air-
way exit point is planned, constructed from pre-procedural CT data and reached during the electromagnec navigaon bronchos-
copy, a small sharp pped wire is deployed through the airway wall and into the parenchyma. Then, a cone-shaped dilator is
P A G E 4
Adnan Majid, MD
Division of Thoracic Surgery and
Intervenonal Pulmonology, Beth
Israel Deaconess Medical Center,
Harvard Medical School, Boston, MA
Fayez Kheir, MD MSc
Division of Thoracic Surgery and
Intervenonal Pulmonology, Beth
Israel Deaconess Medical Center,
Harvard Medical School, Boston, MA
advanced over the wire, through the airway wall and into the parenchyma to the lung nodule. Using Seldinger technique, the extended
working channel/Edge
catheter is advanced over the dilator while pulling the wire back. The catheter is directed over the central dilator
unl the proximal end of the lung nodule is reached. The wire and dilator are then removed leaving access for biopsy tools though the ex-
tended working channel/Edge
catheter under uoroscopy.
Clinical data regarding BTPNA is sll emerging. The rst-in-human report was published by Herth et al. in 2015. 10 out of 12 paents with
suspicious lung nodules were successfully accessed using Archimedes Virtual Bronchoscopy Navigaon System in combinaon with com-
puter-enhanced fused uoroscopy transparenchymal access followed immediately by surgical resecon. Adequate biopsies were obtained
from the 10 paents (83%), which correlated with the histological ndings from the surgical resecon.
There were no peri or post-
operave complicaons aside from a transient elevaon of troponin in one paent. Inspecon of the resected lobes showed no hemor-
rhage or parenchymal laceraons. Another small study performed in a bronchoscopy suite showed that successful BTPNA and adequate
biopsy was obtained in 5 out of 6. Pneumothorax was reported in 2 of the 5 paents (one required chest tube) and no other adverse events
were reported.
A large mulcenter trial including 6 U.S., 1 Germany and 3 China ses, Evaluaon of the ArchimedesSystem for Transpar-
enchymal Nodule Access 2 (EAST2) (NCT02867371), was recently completed with data presented in the recent ERS Congress.
A total of 106
paents were enrolled in the study and the results will hopefully provide further data on the techniques safety and diagnosc yield.
There is sll paucity of literature regarding TBAT. Two small case series have been published on the safety and feasibility of such device.
Anciano et al. described three cases using TBAT.
Although the nodule was successfully reached in all three cases, only 2 had denive diag-
nosis. There were no adverse events reported. Another small case series by Bowling et al. used a combinaon of cone beam computed to-
mography scan, electromagnec navigaon and TBAT.
9 out of 12 lung nodules/masses (75%) were successfully accessed with TBAT with a
diagnosc yield of 66% (8 of 12). One paent had a pneumothorax and required a chest tube.
Furthermore, about a third of paents with potenally curable disease do not undergo surgical resecon due to dierent reasons such as
advanced lung disease, medical comorbidies or age. Trans-parenchymal nodule access may facilitate local treatment of early lung cancers
in such paent populaon.
Numerous advanced bronchoscopic techniques have occurred in the pursuit of improved diagnosc yield for peripheral pulmonary nod-
ules. The ability to safely access lung nodules located away from the bronchial airway for diagnosc and eventually therapeuc modality is
appealing. However, high-quality mulcenter trials to validate diagnosc yield and safety results as well as comparing such technique
against transthoracic or even among dierent modalies of transbronchial lung biopsies are needed.
1. Herth FJ et al. Thorax 2015; 70:326-32
2. Harzheim D et al. Respiraon 2016; 91:302-6
3. European Respiratory Journal 2019; 54: Suppl. 63, OA1614
4. Anciano C et al. J Bronchology Interv Pulmonol 2017; 24:253-6
5. Bowling MR et al. Ann Thorac Surg 2017; 104:443-9
W A B I P N E W S L E T T E R P A G E 5
Figure 1: A. Procedure room, B. Selecng path image, C. Idenfying vessels, D. Selecng point of exit (Images courtesy of Broncus Medical)
Figure 2. Crosscountry transbronchial access tool (Images courtesy of Medtronic)
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
Lung cancer screening and the increased use of chest computed tomography (CT) has led to a signicantly high rate of lung nodules detec-
on. In the United States, 1.6 million nodules are predicted to be detected every year. The limitaons of currently available convenonal
and guided bronchoscopy plaorms for diagnosing peripheral lung nodules have led to the introducon of robot assisted bronchoscopy.
This technology allows the bronchoscopists to navigate through small airways under direct visualizaon and EMN guidance. Two roboc
systems have been commercially available for almost 2 years and have shown promising results in cadaveric models in regards to further
reach to the periphery compared to convenonal bronchoscopy. A recent retrospecve post post-markeng mulcenter study using the
Auris roboc plaorm in 165 paents showed successful navigaon (dened as acquision of a r-EBUS image or diagnosc s-
sue) to 88.6% of the lung nodules. In this study, the maximum diagnosc yield was esmated at 77% and the majority (70.7%) of the nod-
ules were located in the outer third of the lung. From this experience, we learned several planning and technical ps that we believe could
lead to improved access and diagnosc yield.
Prior to each case, we carefully review the CT scan and idenfy the airways in the proximity of the lesion. If there is no airway directly lead-
ing to the lesion (lack of the bronchus sign”), we follow the blood vessel adjacent or leading to it, based on the understanding of pulmonary
segmental anatomy. This assumes that lesions without a bronchus signwith a vessel leading to them have an adjoining airway, even if not
seen on the CT scan (as its oen the case in paents with emphysema). We also always create our own manual path using the systems
soware and do not only rely on the automac planning. In addion, we write a mental pathway(scope orientaon at each branching
A standard room set up is used with a dedicated team who received prior training. We ensure removal of any large metallic objects from the
operang table and surrounding the EM eld generator during the set up and EM navigaon phase of the procedure. We use general anes-
thesia with an 8.5 endotracheal tube. An airway inspecon is performed prior to the procedure to assess for endobronchial lesions and ther-
apeuc aspiraon of secreons. Once that is completed, the roboc bronchoscope is loaded and advanced to the trachea. Registraon is
completed by touching the carina and advancing the bronchoscope into the contralateral mainstem bronchus. This is a smooth, unrushed
process while avoiding airway wall trauma. Unless precluded by the underlying disease, dal volumes of 6-8 ml/kg and PEEP levels of 8-15
are used to splint open the distal airways. These sengs are applied prior to wedging the roboc bronchoscope sheath in a segmental air-
way. The bronchoscope and the sheath are advanced as a unit into the target segmental or even sub-segmental airway. This helps wedge
the scope and protect ipsilateral lobes or contralateral lung in case of bleeding. The inner bronchoscope is then advanced to the target seg-
ments based on virtual guidance from the EMN system or based on the operators own mental plan”. While the RAB systems allow for an
enhanced reach in the lung periphery, on occasion the small airway may not be visualized due to their collapsibility (as is the case in paents
with severe emphysema). This can be overcome by allowing pressure equilibraon between the target airway and the atmosphere by transi-
ently disconnecng the proximal valve of the working channel. If this is not successful, the scope can be relaxed (it takes a co-axial posion)
and air can be insuated through the working channel using a 60 ml syringe allowing for transient splinng of the small airways. While the
airways are opening up with gentle air insuaon, the scope is advanced to the next generaon airway. Occasionally, we use a closed for-
ceps tool as a guidewire to enter increasingly smaller peripheral airways.
Tips for improving the navigaon, visualizaon and specimen quality during
Roboc Assisted Bronchoscopy
Sepmiu Murgu MD, FCCP, DAABIP
University of Chicago
Abhinav Agrawal MD
University of Chicago
P A G E 8
V O L U M E 8 , I S S U E
Once we reach the target based in EMN guidance, radial-EBUS (rEBUS) is always performed to conrm the target and to assess its relaon to
the bronchial wall (Figure). Once an acceptable rEBUS view is obtained (concentric or eccentric), the bronchoscope is locked in place, and we
start sampling using a transbronchial aspiraon needle to perform 4-5 passes under uoroscopic guidance. During sampling, in case an eccen-
tric rEBUS view is noted, the scope can be oriented towards the target airway as rEBUS can be used to idenfy the locaon of lesion as long
as peripheral visualizaon is maintained. Subsequently, the needle is advanced in the same direcon to puncture through the airway wall and
samples are obtained.
Rapid onsite cytology evaluaon is performed in all cases in our instuon, although the value of this pracce remains to be determined. The
Di Quik smeared needle specimens are reviewed by a pathologist. If an adequate representave specimen is conrmed, we ensure that
more adequate material is obtained for any ancillary tesng including molecular markers; this involves performing extra needle passes (our
molecular laboratory uses cytology smears for comprehensive molecular tesng) and then we proceed with transbronchial forceps biopsies.
If the needle aspiraon is non-diagnosc aer 4- 5 passes, then we use the Auris transbronchial biopsy forceps to perform 4-5 biopsies under
uoroscopic guidance. Touch preps are performed for rapid onsite cytopathology evaluaon. These samples are sent for further histopatho-
logic exam in 10% formalin soluon. Of note, we do not ush the needles with saline unless there is diculty reloading the stylet. If needles
are ushed with saline, then they should be subsequently ushed with air several mes unl the working channel is dried out. This is because
the presence of saline uid in the working channel could compromise the quality of the subsequent Di-Quik smear.
Quality control
Appropriate history and physical examinaon should be performed and the expected diagnosc yield, limitaons, as well as the risk and ben-
ets should be thoroughly discussed with the paent prior to proceeding with RAB. In paents with pacemakers or debrillators, the use of
the electromagnec eld generator may interfere with their funconing, and thus the use of an alternave technology of guided bronchosco-
py or other modalies for biopsy should be considered unl more data proves safety of RAB in this paent populaon.
A careful review of the chest CT scan prior to planning a roboc bronchoscopy is essenal to set up for a successful procedure. Apart from
idenfying the lesion and the adjacent airways, it is also essenal to assess for presence of possible endobronchial lesion, especially in the
distal airways leading to the target lesion. If an endobronchial lesion is noted, a thin exible bronchoscope can be used instead of a using the
expensive RAB scope and tools to achieve the diagnosis. Similarly, the CT and PET/CT should be assessed for mediasnal adenopathy. If nodal
enlargement or involvement is noted or expected, a linear EBUS may suce to provide diagnosis and staging with a lower risk of complica-
ons and precluding the roboc assisted bronchoscopy altogether. On the other hand, if suspicion of nodal involvement is low, the RAB
should be performed rst, before the EBUS-TBNA. This is because we are learning that aer approximately 20 mins of general anesthesia,
certain areas of the lung may become atelectac, making navigaon more dicult and potenally giving false posive rEBUS or cone beam
CT images.
The small roboc scope and a steady sheath provide the ability to navigate to distal airways, but in some paents with radiaon associated
brosis, COPD or tortuous airways, it might be dicult to navigate the roboc bronchoscope into the apical or posterior segments of the right
upper lobe. In these cases, the operator should acknowledge the limitaon, and if repeated aempts are unsuccessful, look for alternave
modalies to achieve the diagnosis rather that risk injury to the airway by persistent maneuvering. The use of saline, in addion to potenally
compromising the quality of the specimens, can also give false posive rEBUS image or cone beam CT images by causing alveolar lling. In
cases with poor airway visualizaon, air insuaon can be used to enhance the view as menoned above. Finally, a post-procedure radiog-
raphy should be performed at the end of the procedure to assess for any complicaons.
RAB oers improved access to the periphery of the lung and stability while working at the target. Aer 18 months of experience with this
technology, we learned several ps for improving planning, navigaon, peripheral airway visualizaon and specimen handling. We trust that
some of these technical aspects can be applied in future studies of RAB with the aim to further improve the inially reported diagnosc yield.
1. Gould, ML et al. AJRCCM. 2015;192:1208-14.
2. Murgu, S. BMC Pulmonary Medicine. 2019;19(1);89.
3. Chaddha U et al. BMC Pulmonary Medicine. 2019;19(1);243
4. Chen AC et al. Respiraon. 2020;99:56-61
5. Agrawal A et al. Journal of Thoracic Disease. 2020.
Tips from the Experts
P A G E 9
V O L U M E 8 , I S S U E
Figure 1. Roboc bronchoscopy for a 2.1 cm peripheral right upper lobe nodule. Top Le: CT Chest demonstrang a 2.1 cm right upper
lobe nodule. Top Right: Robot bronchoscopy using the Monarch Auris Roboc Assisted Bronchoscope with an endobronchial view and
electromagnec navigaon guidance showing the locaon of the nodule. Boom Le: Eccentric rEBUS view conrming the locaon of the
nodule. Boom Right: Di Quick stain demonstrang adenocarcinoma.
Tips from the Experts
Humanitarian News
W A B I P N E W S L E T T E R P A G E 10
Medicine and public health are two complementary and interacng approaches for promong and protecng health. Yet
medicine and public health can, and also must be dierenated, because in several important ways they are not the same.
The fundamental dierence involves the populaon emphasis of public health, which contrasts with the essenally individu-
al focus of medical care. Public health idenes and measures threats to the health of populaons, develops governmental
policies in response to these concerns, and seeks to assure certain health and related services. In contrast, medical care fo-
cuses upon individuals-diagnosis, treatment, relief of suering and rehabilitaon.
In early bioethics, the good of the individual, and parcularly his or her autonomy, was the dominant theme, not populaon
health. The last two decades following infecous outbreaks and global health threats have produced a resurgence of visibil-
ity for public health. Addionally, it is becoming impossible to avoid the recognion that the health of populaons is a func-
on more of good public health measures and socioeconomic condions than of biomedical advances, a well-known concept
within the public health community, but that has been neglected by most outside the eld.
Populaons are constuted by diverse communies of heterogeneous beliefs and pracces. These may at mes come into
conict. Individual versus community rights and conicts within and between communies are the origin of ethical discus-
sions in public health pracce. Hence, public health ethics must recognize and be able to reason through issues relang to
social, polical and cultural contexts; the existence of compeng values and perspecves and perhaps, diverse and some-
mes conicng world views.
Along the years, public health, has struggled to dene and arculate its core values and the language and structure of its
ethics. Given its populaon focus, and its interest in the underlying condions upon which health is predicated it seems evi-
dent that its ethical framework must express fundamental values in societal terms.
In social development, ethical discussions show the ongoing debate on values and choices in which each individual compares
and reects on his own experience and thought in juxtaposion to experience and thought of others. It is important to re-
mind that the credibility and viability of a democrac sociees depend crically on the conduct of ethical debate both
amongst members of the public and between members of the public and decision-makers.
Obviously, ethics in public health cannot be divorced to the background values of the general society, and the parcular
communies, in which it will be carried out. It is not realisc to expect that health care could survive as some sort of sepa-
rate enclave enrely dierent of society values. Those values both good and bad will inevitably permeate health care.
However, this does not mean health care has to be merely a passive observer of what is happening in society.
A main concern about the possibility of dening a set of core ethical values in public health is that public health measures
can quickly become policized. Even when many mes polical controversy may be seen (and really becomes) and obstacle
to raonality, the governmental role of public health turns polics unavoidable and necessary. Polics is a necessary compo-
nent of public health, precisely in order to achieve public health policies and pracces.
But beyond any polical controversies and even in pluralisc and diverse sociees, some ethical foundaons should be a
common ground shared by the whole society and the polical leaders and those are the grounds of the respect of human
Jonathan Mann famously theorized that public health, ethics, and human rights are complementary elds movated by the
paramount value of human well-being. He felt that people could not be healthy if governments did not respect their rights
and dignity as well as engage in health policies guided by sound ethical values. Nor could people have their rights and dignity
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W A B I P N E W S L E T T E R P A G E 11
if they were not healthy, Mann and his colleagues argued that public health and human rights are integrally connected: Hu-
man rights violaons adversely aect the communitys health, coercive public health policies violate human rights, and ad-
vancement of human rights and public health reinforce one another.
Thus, in the modern world, public health ocials have, for the rst me, two fundamental responsibilies to the public: to
protect and promote public health, and to protect and promote human rights. Promong and protecng human rights is
inextricably linked with promong and protecng health, because human rights oers a societal-level framework for iden-
fying and responding to the underlying-societal—determinants of health. Human rights are respected not only for their in-
strumental value in contribung to public health goals but for themselves, as societal goods of pre-eminent importance. And
some of the most relevant founding basis of human rights are the respect for human dignity, solidarity and jusce and equi-
Mann, in both his naonal and internaonal work, conceived of human rights and ethics as centrally important to the work
of public health. Consequently, he passionately argued that the primary funcon of public health is to promote dignity, re-
duce inequity, and raise living standards for communies everywhere.
The Universal Declaraon of Human Rights starts by placing dignity rst, "all people are born equal in dignity and rights".
Some scholars have argued that dignity does not have a vocabulary, or taxonomy to dene dignity violaons. Some have
gone as far as declaring that dignity is a useless concept”. However, we all know when our dignity is violated or impugned.
Dignity can be dened in several dierent, but complementary ways, which fall broadly into two categories: these are
inherent dignityand non-inherent dignity’. Inherent dignity refers to a quality of value or worth belonging equally to every
human being; it is permanent, uncondional, indivisible and inviolable. Inherent dignity is related to, and oen used inter-
changeably with, the similar concept of intrinsic valuei.e. inviolable worth arising from within each person. Non-inherent
dignity (NID) is an acquired and variable condion; it is conngent upon a persons circumstances and behaviour.
As Alasdair MacIntyre has pointed out, moral concepts are not meless or unchanging and so, the concept of dignity has
been used over me, in a variety of contexts with dierent meanings. But the concept of inherent dignity can be traced from
remote mes. A concepon of uncondional inherent dignity has been developed in both Chrisanity and Judaism. A theo-
logical understanding of dignity connues to be for some people based on the belief that humans are made in the image of
God and considered sucient to ground for the inviolability of human life.
This concept of dignity being connected to human nature is found in the Summa Theologiae by Aquinas and persisted during
the Renaissance period, when it began to be associated with freedom and autonomy.
However, there is no doubt that the most important development about dignity were the wrings of Immanuel Kant. Kant
argued that dignity is grounded in morality and autonomy. The Kanan concepon of dignity forms the foundaon of the
current understanding of inherent dignity used in much of human rights legislaon. Kants concepon of inherent dignity did
not depend on God in the tradional way, Kant laid the way for a secular understanding of inherent dignity. In his own words
A raonal being belongs to the realm of ends as a member when he gives universal laws in it while also himself subject to
those laws. He belongs to it as sovereign when he, as legislang, is subject to the will of no other.
Following publicaon of Darwins Origin of Species in 1859 some people quesoned assumpons about our species, and
under the inuence of Social Darwinism the unique inherent value of humans was rejected and even enabled the advance-
ment of the eld of eugenics. Aer the atrocies of WW2, an emphasis on dignity re-emerged in much of the internaonal
legislaon and the world returned to the concept of inherent dignity in declaring that all humans were inherently equal and
had intrinsic value, and thus that all human lives deserved protecon. Thus the United Naons in the UDHR (1948), states in
the preamble, recognion of the inherent dignity and of the equal and inalienable rights of all members of the human family
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W A B I P N E W S L E T T E R P A G E 12
is the foundaon of freedom, jusce and peace in the world. Human dignity is now the most widely accepted fundamental
moral and legal value, appearing in the constuons of 157 countries, it is 81 per cent of the total number of sovereign
states of the UN.
Full inherent dignityis a quality of value or worth belonging equally to every being with full moral status and thus it is indi-
visible: there are not degrees of dignity, either a being has it or they do not; it cannot be had in part. Full inherent dignity is
both a permanent and uncondional quality.
The fundamental premise to the concept of full inherent human dignity is that it is innate to all human beings; in this regard
it can be thought to amount to (at least part of) what it is to be human. It implies that human dignity comes from belonging
to a natural kind, whose members have full moral status, such as humankind and determines the requirement that one be
treated with deference and respect, irrespecve of circumstances, no maer his age, race, sex, cognive autonomy, contri-
buon to society or the well-being of others. Each life is unique and irreplaceable, human beings should be treated as an end
in themselves and not as a means to something else. Just because they are human they value in itself and their inherent val-
ue does not depend on anything else, that is the foundaon of the Kanan imperave Act in such a way that you treat hu-
manity, whether in your own person or in the person of another, always at the same me as an end and never simply as a
means. Therefore, inherent human dignity has normave implicaons grounding fundamental human rights, such as the
rights to freedom and equality, and the right to live free from cruel and degrading treatment.
The Italian philosopher Corrado Viafora has advocated for the incorporaon of human dignity in ethically driven clinical case
management and some scholars have applied his concepts to public health. According to Viafora In dealing with issues of
commutave and distribuve jusce, clinical ethics extends beyond its specic competence and steps, respecvely, into the
eld of polics and in the eld of law.The recognion of intrinsic valuebased on the recognion of human dignity, is thus
the ulmate criterion for disnguishing amongst moral and immoral pracces.
A reference to human dignity has been incorporated into the 1997 Oviedo Convenon of the Council of Europe and also into
the Charter of Fundamental Rights of the EU in 2000, establishing a common ethico-legal foundaon for all 28 sociees of
the EU Member States. According to Lucy Michael “(human) dignity maers, because it forms the foundaon of civilized soci-
As such, human dignity understood in a public health ethical context should have the potenal to funcon as a common ba-
sis for jusfying legislave endeavors through ethical judgments in a pluralisc society, as being the value that fosters cultur-
al understanding to grant cizens a dignied life and above all to guarantee the uncondional worth of every human being.
But we human beings not only have dignity in common. In Dependent Raonal Animals, Alasdair MacIntyre remarks that the
philosophical tradion has neglected the importance of need or dependence as an aspect of human life. Especially since the
Enlightenment, the nature of human beings has been focused only on their freedom, raonality, or autonomy. But some
areas of philosophy (mainly but not exclusively amongst Chrisan thinkers) have always understood the human situaon as
one of dignity and dependence: a dignity that is common to all human beings but equally a neediness that is common to all.
While some individuals may think themselves independent and even self-made or self-sufcient, we are all dependent not
only physically but also culturally and intellectually, on a wider community and a longer tradion. All human beings are more
or less dependent on one another and accounts of human dignity should not seek to obscure this fact.
In the last two decades, several outbreaks of viral diseases that created a new global public health threat. It has been argued
there is an urgent necessity of intense and transnaonally coordinated preparaon of public health systems to combat those
pandemic threats. Consequently, transnaonal collaboraons are considered crucial to eecve exchange of genomic, clini-
cal, and epidemiologic data leading to the development of vaccines and treatment protocols and the idencaon of popu-
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W A B I P N E W S L E T T E R P A G E 13
laon-based strategies. It is well known by experts in the epidemiological eld that a mely prevenve preparaon of
healthcare systems can be eecve in saving dozens of thousands of lives. Avoiding this hidden death threatis rst and
foremost a task of establishing a sustainable health prevenon policy that cares for its cizens on a populaon basis and on
grounds of human dignity, having as its rst and indeclinable objecve to protect the life of each individual cizen.
Somemes human beings can be morally responsible for the outcomes of not man-made disasters, blaming disgrace does
not erase such responsibility ascripons that will most oen be grounded in culpable negligence, including the culpable fail-
ure to prevent the side-eects of our acons or omissions. Denialism (as dened by Hoofnagle & Hoofnagle) is not a minor
component of these wrong policies. HIV does not cause AIDS, the world was created in 4004 BCE, smoking does not cause
cancer, there were no gas chambers in Auschwitz and climate change has nothing to do with man-made CO2 emissions.
The consequences of policies based on views such as these can be fatal. Thabo Mbekis denial that that HIV caused AIDS pre-
vented thousands of HIV posive mothers in South Africa from receiving an-retrovirals so that they, unnecessarily, trans-
mied the disease to their children. Denialism, dened as the employment of rhetorical arguments to give the appearance
of legimate debate where there is none, is driven by a range of movaons, from greed, lured by some big corporaons to
ideology or faith, causing them to reject anything incompable with their fundamental beliefs. Whichever the reasons, the
potenally fatal consequences of those atudes make people responsible of contribung to them or using them whichever
their purposes. The higher in the hierarchy of decisions about health care policies and decisions, the higher the responsibil-
The applicaon of general ethical principles to public health decisions can be dicult. The mandate of public health has been
prevenon, and the arena of public health pracce has been the community. In situaons when the enre community is
assumed to be vulnerable and in need of protecon, collecve intervenons are proposed which are mandatory, universal,
and passive, to minimize the risks. Public health disasters accelerate and accentuate the vulnerability dimensions of human
Since the mission of public health is to achieve the greatest health benets for the greatest number of people, it draws from
the tradions of ulitarianism or consequenalism. The public health model,has been told, assumes that the appropriate
mode of evaluang opons is some form of cost-benet (or cost-eecveness) calculaon across individuals. Public health,
according to this view, appears to permit, or even to require, that the most fundamental interests of individuals be sacriced
in order to produce the best overall outcome. But that oversimplicaon misperceives, that the eld of public health is inter-
ested in securing the greatest benets for the most.
The evoluon of PHE frameworks signies turning to the collecve values and more specied norms such as ulity, evidence
based eecveness, distribuve jusce and fairness, solidarity and social responsibility, community empowerment and par-
cipaon, transparency, accountability and trust that some of them can be considered as mid-level principles. In addion to
distribuve jusce, what should be considered in developing a PHE framework is considering the achievement of well-being
dimensions adequately signies developing healthy social structures, promong individual capabilies, developing ability to
reasoning and strengthening autonomy based on the theory of social jusce.
Public health and ethics are undeniably bound together. Many people in public health even see the muldisciplinary public
health as a moral endeavour: to protect the health of whole populaons and to draw special aenon to the weaker mem-
bers of sociees.
The naonal policy agenda of any naon in front of a pandemic is set and resolved by the compeve interplay of special-
interest groups, but what claims are privileged, which priories are dened and which members of the society are going to
be given the strongest protecon, is an ethical decision made by the policy makers and adhered to (or not) by the general
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W A B I P N E W S L E T T E R P A G E 14
Ethics in public health cannot turned into concrete measures without taking into consideraon the values of the general so-
ciety as well as that of the parcular communies where the public ethical course of acon is needed. As Kotalik argues
"every discourse about health care has not only a scienc but also a moral dimension, [pandemic inuenza] plans also pre-
suppose certain ethical values, principles, norms, interests and preferences".
Beyond dierent moral theories and a not completely ethical framework developed for public health, the guiding principle
should be the common agreement about the supreme value of a human life. The quest for dignity is universally accepted
and should be a starng point as a guarantee of the respect of human rights. Human rights are shared values. Human rights
are our common possession. When abuses are commied against anyone in any society, the dignity of humanity as a whole
is compromised. When we abandon eorts to sustain human dignity, we forfeit the essenal meaning of being human, and
when we hesitate in our commitment to the idea of human rights, we abandon our moral principles.
On those basis, whichever the policies adopted in order to control a pandemic, the responsible policy-makers should be able
to raonally demonstrate that preserving human life, any and every human life and prevenng premature deaths are their
governing principles. Otherwise, the acceptance that in some circumstance human life is worthy sacricing, would radically
change many of the universal ethical assumpons we uphold today from euthanasia to end of life dilemmas, from resource
allocaon policies to the provision of expensive treatments. Polical leaders must give robust ethically grounded reasons for
any measure that cannot be indisputably grounded in the values enshrined in the Universal Declaraon of Human Rights and
above all, the universal precepts that everyone's right to life shall be protected by law and that human dignity is inviolable
and must be respected and protected in any circumstance. Just because humanity, which is present in even the lowliest of
men, gives each individual a dignity that must be respected by all other individuals, society, and the state. A dignity that can-
not be taken away from us ever, not by anyone.
1. Callahan D et al. Am. J. Public Health. 2002;92(2):169176
2. Jennings B. Acta Bioethica. 2003; 9:165176.
3. Kass NE. Am J Public Health. 2001; 91:17761782.
4. Kotalik J. Bioethics. 2005; 19:422431.
5. MacIntyre A. Dependent Raonal Animals: Why Human Beings Need the Virtues. Open Court Publishing, 1999.
6. Mann JM et al. Health Hum Rights. 1994;1(1):623
7. Michael L. New Bioethics 20(1):12-34
8. Singer PA et al. Br. Med. J. 2003;327(7427):13421344
*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 (2 of 3)
Descripon: Proximal airway of a 59 year-old female presenng with 3 months of progressive dyspnea fol-
lowing a non-tramauc intubaon in the seng of surgical resecon of the colon. In this picture, we are visu-
alizing proximal subgloc stenosis that is actually tacking open the true vocal cords (also visualized).
Submier: Dr. Daniel G. Dunlap
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 15
Biennial Board of Regents Meeng —We are pleased to announce that the Board of Regents meeng will be held this
September in which BOR members will be able to connect via Zoom teleconferencing. The Vice-chair elecons shall
also take place during this teleconference using anonymous online ballots.
WCBIP 2026 bids & presentaons—The WABIP has postponed 2026 presentaons & vong to WCBIP 2022. In the
coming months, we will re-open and accept addional applicaons for 2026 bids. The Board of Regents shall vote on
the 2026 host site and congress president in April 2022 in Marseille, France.
New member society - We are pleased to announce that the Vietnam Respiratory Society
(VNRS) has joined the WABIP. Please join us in welcoming one of the fastest growing res-
piratory sociees in Southeast Asia. VNRS was established in 2014 as a non-prot organiza-
on dedicated to respiratory work, community and research in Vietnam. We will be part-
nering with VNRS execuve members Prof.Dr. Ngo Quy Chau & Prof. Giap Vu Van in organ-
izing a bronchoscopy workshop co-sponsored by the WABIP at the VNRS annual congress
this November 2020. Society website: hp://hoihohapvietnam.org/en
11th Bronchoscopy Workshop - SCOPE 2020: Intervenonal Pulmonology in Lung Cancer (Philippines)
When: August, 2020
Where: Novotel, Manila, Philippines
Program Director: Ronald A. Fajardo, MD
Program Type: Educaonal seminar (postgraduate may include physicians in pracce and trainees), Hands-on work-
shop, Conference (didacc lectures)
21st World Congress for Bronchology and Intervenonal Pulmonology (WCBIP)
When: September 24-27, 2020
Where: Shanghai, China
President: Guangfa Wang, MD, PhD
Website: hps://www.WCBIP.org
6th European Congress for Bronchology and Intervenonal Pulmonology
When: April 22-24, 2021
Where: Megaron Athens Internaonal Conference Centre - Athens, Greece
President: Prof. Grigoris Stratakos
Website: hp://www.ecbip2021.org/
P A G E 16
Cryobiopsy: Is it worth the risk?
Specimens from transbronchial lung biopsies are usually very small and lack architectural integrity due to crush arfact to diagnose diuse lung
diseases with condence. Transbronchial Lung Cryobiopsy (TBLC) is a novel, minimally invasive technique for obtaining lung ssue for histo-
pathological assessment in Intersal Lung Disease (ILD). The major advantage of this procedure is that larger ssue samples with a higher per-
centage of alveolar ssue can be obtained with fewer crush arfacts and less atelectasis.
The cryosurgical equipment operates by the Joule–Thompson eect, which dictates that a compressed gas released at high ow rapidly expands
and creates a very low temperature. The cooling agent (carbon dioxide or nitrous oxide) is applied under high pressure through the central ca-
nal of the probe. The gas at the p suddenly expands due to the dierence in pressure (relave to atmospheric pressure), causing a drop in
temperature at the p of the probe (in the ssue of approximately −50°C to −60°C). The probe is cooled for approximately 3 to 6 seconds (larger
probe cooled for 78 seconds). The frozen ssue aached to the probes p is removed by pulling the cryoprobe together with the broncho-
scope. The frozen specimen is then thawed in physiological saline and xed in formalin.
Recently several studies have been published on the feasibility and safety of this technique. The fundamental queson regarding this technique
remains the balance between the risk of complicaons and the benet of geng a beer sample with a higher yield for diagnosis.
A prospecve, mulcenter, diagnosc accuracy study (COLDICE) (1) invesgated diagnosc concordance between TBLC and Surgical Lung Biopsy
(SLB)- the gold standard, across nine Australian hospitals. A muldisciplinary team of physicians decided if the paent needed a lung biopsy to
establish a denive diagnosis. The paents were then referred for a sequenal TBLC and SLB under one procedural setup. Pathologists were
blinded as to the nature of the procedure performed to obtain the samples. A muldisciplinary team of physicians and radiologists then evalu-
ated the pathological report in a blinded fashion with the clinical and radiographic informaon to render the nal diagnosis. Co-primary end-
points were the agreement of histopathological features in TBLC and SLB for paerns of denite or probable usual intersal pneumonia (UIP),
indeterminate for UIP, and alternave diagnosis; and for the agreement of consensus clinical diagnosis using TBLC and SLB at Mul-Disciplinary
Discussion (MDD).
Sixty-ve paents (31 [48%] men, 34 [52%] women; TBLC (7·1 mm, SD 1·9) and SLB (46·5 mm, 14·9) underwent lung biopsies. Samples were
taken from two separate ipsilateral lobes. Histopathological agreement between TBLC and SLB was 70·8%, and the diagnosc agreement at
MDD was 76·9%. For TBLC with high or denite diagnosc condence at MDD (39 [60%] of 65 cases), 37 (95%) were concordant with SLB diag-
noses. In the 26 (40%) of 65 cases with low-condence or unclassiable TBLC diagnoses, SLB reclassied six (23%) to alternave high-condence
or denite MDD diagnoses. Mild-moderate airway bleeding occurred in 14 (22%) paents due to TBLC. The 90-day mortality was 2% (one of 65
paents), following acute exacerbaon of idiopathic pulmonary brosis.
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 17
Associate editor:
Dr. Ali Musani
Associate editor:
Dr. Sepmiu Murgu
A large metanalysis published in 2017 (2) compared the TLBC with Video-Assisted Thoracoscopic Surgery (VATS) which revealed
that TBLC pooled diagnosc yield was 83.7% (76.9-88.8%), pooled sensivity was 87% (85-89%), and a pooled specicity was 57%
(40-73%). In contrast, VATS pooled diagnosc yield was 92.7% (87.6-95.8%), pooled sensivity was 91.0% (89-92%), and pooled
specicity was 58% (31-81%). The incidence of moderate to severe endobronchial bleeding aer TBLC and of post-procedural
pneumothorax was 4.9% (2.2-10.7%) and 9.5% (5.9-14.9%), respecvely. This metanalysis shows that the diagnosc yield of TBLC is
signicantly lower than the VATS. However, the risk of potenal procedural complicaons, such as pneumothorax and moderate to
severe bleeding, need to be weighed in when considering this procedure.
Another study (3) looking at the complicaons of TBLC demonstrated that out of 257 TBLCs analyzed, complicaons were observed
in 15.2% of paents, and only 5.4% of all paents required hospital admission on the day of the procedure. Hemorrhage was the
most frequent complicaon. In the 30 and 90 days following the TBLC, rates of readmission were 1.3% and 3.5%. No outpaents
died in the rst 30 days. The 30- and 90-day mortality rates were 0.37% and 0.78%, respecvely, but none of the deaths were
linked to the TBLC procedure.
In view of evolving experience and data, TBLC should be considered a specialized procedure that should be oered in centers with
experse and resources to perform the procedure safely. I refer readers to the following recommendaons from the American
College of Chest Physicians Guidelines, 2020 (4).
at least two dierent sites (either dierent segments in the same lobe or dierent lobes should be biopsied to ensure ample
ssue acquision
the biopsy should be performed with the p of the cryoprobe located 1 cm from the pleura
uoroscopy should be used
a bronchial blocker either through an endotracheal tube or rigid bronchoscope should be ulized
a small cryoprobe (1.9 mm) rather than a larger cryoprobe (2.4 mm) should be used
1. Troy LK et al. Lancet Respir Med. 2020;8(2):171-181.
2. Iikhar IH et al. Ann Am Thorac Soc. 2017;14(7):1197-1211.
3. Aburto M et al. Respir Med. 2020 Apr - May;165:105934. doi: 10.1016/j.rmed.2020.105934. Epub 2020 Mar 19.
4. Maldonaldo F et al. CHEST 2020; 157(4):1030-1042
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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
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