Volume 08
Issue 03
September 2020
Inside This Issue
Editorial, 2
Technology Corner, 3-5
Tips from the Experts, 6-8
Humanitarian News, 9-13
Best Image Contest, 14
WABIP News, 15-16
Research, 17-18
Links, 19
Bronchoscopy during the COVID-19 Pandemic
WABIP Newsletter
S E P T E M B E R 2 0 2 0 V O L U M E 8 , I S S U E 3
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 almost a year since the detecon of
the severe acute respiratory syndrome corona-
virus 2 (SARSCoV‐2), the virus responsible for the
pandemic coronavirus disease 2019 (COVID19).
Beyond the personal and social stresses many of
us are dealing with during this dicult me, we
are also dealing with the strain and changes to
our own healthcare systems. For many of us, this
includes adapng to the changing guidelines re-
garding bronchoscopy and pulmonary interven-
ons. We must take into consideraon the health
of the clinician and healthcare workers in addion
to the paent. We consequently felt it would be
an appropriate me to focus on this in some areas
of this edion of the September newsleer.
The experts from the American Associaon for
Bronchology and Intervenonal Pulmonology
(AABIP) have created and released an ocial
statement on the recommendaons for bronchos-
copy during the COVID-19 Pandemic. As COVID-19
is feasibly transmied during bronchosopy as an
aerosol generang procedure, the statement has
been created to lower the risks to the operator,
support sta and paents in addion to allowing
the ability to carry out the necessary and im-
portant procedures for several diagnosc and
treatment purposes. In summary the suggesons
are as follows:
PPE: the use of an N-95 respirator (or a pow-
ered air purifying respirator), face shield,
gown and gloves is recommended especially
in both suspected and/or conrmed cases of
COVID-19 or in asymptomac paents in an
area of conrmed community spread
In areas where community spread is con-
rmed and tesng is available; a nasopharyn-
geal specimen should be obtained prior to
the procedure
Lower respiratory specimens should be obtained from
endotracheal aspirate or bronchoscopy with bron-
choalveolar lavage to conrm COVID-19 in paents
with severe or progressive disease that require intuba-
The procedure should be completed in a mely and
safe manner
Severity of infecon and the procedure indicaon and
duraon should be taken into account for cases of rou-
ne bronchoscopy in paents recovered from COVID-
For further recommendaons it is suggested to read the
arcle in its enrety: hps://www.sciencedirect.com/
Following these guidelines can help us to do our jobs in the
midst of this pandemic all while protecng ourselves and
others, achieving our goals and increasing the common
good. If the pandemic has taught us anything, its that we
need to think of ourselves as one big unit all trying to ght
this virus together.
Kazuhiro Yasufuku
Technology Corner
Single-use Flexible Bronchoscopes
Many endoscopy companies are either developing or have released single-use exible bronchoscopes (SUFBs) with several ad-
vantages over reusable exible bronchoscopes (RFBs) including complete sterility, ease-of-access and portability, providing a cheap
plaorm for o-site bronchoscopic training and research. To date, they have primarily been used in an anaesthec seng where
they have proven to perform to an acceptable and cost eecve level compared to standard RFBs. The few studies on their use in
the pulmonology suite suggest that they are equally ecacious as RFBs in the performance of bronchoalveolar lavage (BAL) whilst
their use will undoubtedly extend to more complex intervenonal procedures with ongoing improvements in handling, channel
size, angles of deecon and image quality.
The outbreak of nosocomial infecon secondary to contaminated RFBs is a well-documented phenomenon. The most prevalent
infecous agents in these scenarios are mycobacteria and Pseudomonas aeruginosa (1). Though previously, the majority of these
infecons were linked to breaches in the reprocessing guidelines, recent evidence showed residual proteins and potenally infec-
ous pathogens on RFBs that were ready for paent use despite complete adherence with reprocessing procedures (2). The dis-
ease-causing potenal of the organisms in this scenario has not been denitely established but obviously, the risk of transmission
is of concern. SUFBs are sterile and thus eliminate this risk enrely. The COVID-19 pandemic has refocused bronchoscopy units on
the nosocomial and health care provider infecon and the reduced handling required with SUFBs means that health care organisa-
ons are recommending their use in cases of suspected or conrmed COVID-19 (3, 4).
One would expect that SUFBs are a more expensive alternave to RUFBs, however when the cost of cleaning materials, mainte-
nance of automated endoscope reprocessors (AERs), personal protecve equipment (PPE) and wages for reprocessing sta is in-
corporated with the cost of treang potenal infecons arising from residual organic material on fully reprocessed RFBs they have
in fact, been shown to be more economical (5).
Clinical Applicaons
SUFBs have been studied in an anaesthec seng with regard to the placement of endotracheal tubes, use in unancipated di-
cult intubaons and for bronchial sampling and have been shown to be acceptable compared to RFBs in these sengs (3). One
study concluded that SUFBs were comparable to RFBs in cell yield and viability in BAL samples from healthy volunteers (6). Data is
lacking at present regarding their performance for more advanced procedures such as biopsy and transbronchial needle aspiraon
(Figure 1).
P A G E 3
Dr. Sarah Barron MB BCh BAO MRCPI,
Respiratory Registrar, Cork University
Dr. Marcus Kennedy MD FRCPI
Consultant Respiratory Physician,
Intervenonal Pulmonologist,
Cork University Hospital
However SUFBs have a number of characteriscs that prove advantageous for certain clinical and non-clinical applicaons and scenarios
(Table 1).
Ease of Mobility
The scope and portable monitor are light and portable and thus reduce sta and me requirement for moving equipment out of bronchos-
copy units to other healthcare sengs.
Having SUFBs readily available reduces the requirement for sta to clean and prepare bronchoscopes which is especially important in out-
of-hours, night and weekend bronchoscopy where RFBs may not be readily available. The impact of cleaning sta absence due to for in-
stance COVID-19 outbreak would therefore not impact bronchoscopy list. Full airway inspecons are oen required but not feasible with
current EBUS convex probe bronchoscopes and having access to SUFBs in this scenario precludes the requirement for RFBs to be ready in
case they are needed.
Specic Scenarios where Reduced Risk of Cross Infecon is Crical
Many hospital protocols require decommissioning of bronchoscopes used in paents with suspected prion disease. Severely immunocom-
promised paents represent another group where SUFBs may have advantage.
Other Applicaons
The cost of shipping bronchoscopes and processors to temporary locaons is signicant. O site, cadaveric, bench and large animal re-
search are ideal scenarios for SUFBs where researchers and trainers require scopes on a temporary basis.
Whether or not a SUFB will be as ecient as an RFB in more complex procedures such as transbronchial needle aspiraon (TBNA) or cryobi-
opsy has yet to be determined. Many of the companies developing SUFBs are now on third and even fourth generaon devices with im-
provements in handling and angle p deecon with each generaon. Areas of concern regarding more complex procedures might arise
from the uniformity of the inner diameter in SUFBs and whether this might compromise more complex procedures. Addionally, previous
studies in an anaesthec seng have suggested that previous SUFBs image quality were not equivalent to RFBs (3) however scope develop-
ment will in no doubt lead to improvements. Larger trials invesgang the reliability of SUFBs in performance of standard biopsy proce-
dures are required.
SUFBs have been on the market now for approximately ten years with research and development improvements being considered with
each new generaon of device. They have proven to be acceptable for mulple anaesthesiologist-led procedures and in a research seng
for BAL. They have several advantages owing to their sterility, easy portability and the potenal for immediate access to the technology. As
well as this, there is mounng evidence that they are a more economical alternave to RFBs a pernent issue when cost analyses can
limit access to healthcare resources. However, as with any single-use technology, whether or not they will funcon to a sasfactory level in
more complex procedures where imaging quality and uniformity of materials may have a small but incremental impact on outcomes has
yet to be determined.
W A B I P N E W S L E T T E R P A G E 4
1. Kovaleva J et al.. Clin Microbiol Rev. 2013; 26(2): p. 231-54
2. Ofstead CL et al. Chest. 2018; 154(5): p. 1024-1034
3. Barron S et al. J Bronchology Interv Pulmonol . 2020 Apr 17;10.1097/LBR.0000000000000685
4. Wahidi MM et al. J Bronchology Interv Pulmonol. 2020 Mar 18. doi: 10.1097/LBR.0000000000000681
5. Mouritsen JM et al. Anaesthesia. 2020; 75(4): p. 529-540
6. Zaidi SR, et al. BMC Pulm Med. 2017 May 05; 17(83)
Table 1: Clinical and other scenarios where Single Use Flexible Bronchoscopes (SUFBs) have advantages over Reusable Flexible Broncho-
scopes (RFBs).
Ease of Mobility Praccality Specic Scenarios where
Reduced Risk of Cross Infecon is
Other Applicaons
ICU Bronchoscopy Out of hours bronchoscopy Immunocompromised paent Bronchoscopy Training
Emergency Department/ Ward
End of day list-sta are not
required to stay and clean
Prion Disease Veterinary Procedures
Emergency Bronchoscopy
outside Healthcare Facility
Weekend bronchoscopy where
sta are not available to clean
Large animal or
cadaveric research
Bronchoscope available for
airway inspecon with EBUS
W A B I P N E W S L E T T E R P A G E 5
Figure 1: Transbronchial needle aspiraon
(TBNA) using a single use exible broncho-
scope (SUFB) in a 66 year old male with
mediasnal adenopathy
1a. A single-use exible bronchoscope (The
Broncoex® Agile from Axess Vision
(Reproduced with permission))
1b. Endobronchial image of TBNA from
staon 7 subcarinal node using The Bron-
coex® Agile SUFB.
1c. TBNA sample displaying small cell lung
cancer (H and E 400x).
Tips from the Experts
P A G E 6 V O L U M E 8 , I S S U E 3
Bronchoscopy plays a crical diagnosc and therapeuc role in a variety of lung disorders but is considered an aerosolizing procedure and
potenally poses a high risk of viral exposure to healthcare workers and other paents in the periprocedural areas. As the COVID-19 pan-
demic connues to cause signicant morbidity and mortality throughout the globe, healthcare providers struggle to balance the philosophy
of mely care with that of safety. Eorts are focused on liming the risk of exposure of SARS-CoV-2 to paents and healthcare workers.
While data specic to bronchoscopy during the COVID-19 pandemic is scarce, various professional pulmonary sociees have provided guide-
lines on how to safely perform bronchoscopy amidst a pandemic.
Paent Selecon
Professional sociees have emphasized the importance of reviewing the need for all bronchoscopic procedures on a case-by-case basis and
have outlined recommendaons for ming the bronchoscopy based on its acuity (emergent, urgent or non-urgent). Some categorized bron-
choscopies in ve groups: emergent (same day), urgent (1-2 days), acute (within 2 weeks), subacute (aer 2 weeks) and elecve (reschedule
when possible). We believe that there is no substute for good clinical judgment and that the priorizaon of a procedure has to consider
the associated comorbidies, procedure factors (duraon, probability of hospitalizaon/ ICU stay) as well as the disease factors which in-
clude the availability and eecveness of non-bronchoscopic opons and the impact of a 2-week or 6-week delay on disease outcome. In
these regards, surgeons at the University of Chicago have validated a scoring system accounng for all these variables when priorizing
medically necessary, me sensive procedures.
Emergent bronchoscopies are easy to dene as they warrant intervenons within hours. These include but are not limited to processes that
cause acute or impending respiratory failure: acute foreign body aspiraon, massive hemoptysis without a clear source for embolizaon,
airway stent migraon, tracheoesophageal stula with evidence of ongoing aspiraon, persistent air-leak in a paent who is unable to ven-
late, and crical central airway obstrucon. The challenge is to disnguish between the bronchoscopies that have to be performed within a
couple of weeks and those that can be deferred for 4-6 weeks. Diagnosis and staging of lung cancer via bronchoscopy fall within these cate-
gories, urgent or non-urgent depending on tumor size, locaon, nodal involvement and tumor biology. In these regards, published evidence
suggest that the risk of upstaging NSCLC signicantly increases aer delays of approximately 6 weeks. In addion, medical oncologists con-
sider the use of neoadjuvant or rst line chemotherapy in newly diagnosed lung cancer as a high priority. In the ESTRO/ASTRO statement,
there was a strong consensus (96%) among radiaon oncologists not to delay iniaon of treatment (by 4-6 weeks) for locally advanced
stage IIIA (bulky N2) NSCLC or to delay palliave radiotherapy for NSCLC.
In view of these recommendaons, we believe that as far as lung cancer is concerned, diagnosc and staging bronchoscopy should NOT be
deferred in the following scenarios:
Solid or predominantly solid lung nodule suspected of lung cancer >2 cm
Suspicion for N2/N3 node-posive lung cancer
Conrm stage II for neoadjuvant chemotherapy
Conrm stage III for neoadjuvant chemotherapy
Conrm stage III for denive chemoradiotherapy for inoperable paents
Conrm limited stage small cell lung cancer for chemoradiotherapy
Praccal ps for performing bronchoscopy for diagnosis and staging lung cancer
during the pandemic
Sepmiu Murgu MD, FCCP, DAABIP
University of Chicago
Elliot Ho, DO
University of Chicago
Tips from the Experts
P A G E 7 V O L U M E 8 , I S S U E 3
Obtain ssue for diagnosis, NGS/PD-L1 to iniate 1st line therapy for advanced disease
Conrm symptomac progression of disease for second line treatment
Paent evaluaon prior to bronchoscopy
Guidelines from various sociees recommend broad screening for COVID-19 in order to reduce the risk of infecon transmission. Paents
should be asked about symptoms, contacts, and travel history prior to scheduling and again prior to arrival for planned bronchoscopy. If the
paent has increased risk factors or signs and symptoms of acve viral infecon, the procedure should be delayed if possible.
SARS-CoV-2 RNA tesng within 72 hours prior to the procedure is now rounely performed in many instuons. Paents are also instructed
to self-isolate between the me of tesng and me of procedure. In paents with negave results, bronchoscopy can proceed with enhanced
personal protecve equipment including either N95 mask or PAPR, face shield/googles.
Virus prevenon measures before and aer the procedure include social distancing, video-visits, screening exposed providers, universal
masking in the hospital and limitaon of visitors.
In paents with posive COVID-19 results, it is recommended to postpone all non-emergent bronchoscopies. The me of rescheduling the
bronchoscopy depends on the outcomes of the disease as well as esmated duraon of viral shedding. In paents with conrmed COVID-19
infecon who recover and need a roune bronchoscopy, the AABIP/CHEST expert panel report suggest the ming of the procedure is cus-
tomized based on the indicaon for the procedure, the severity of the COVID-19 infecon and me from symptom resoluon. It would be
reasonable to wait at least 30 days from resoluon of symptoms with negave SARS-CoV-2 RNA tests from at least two consecuve nasopha-
ryngeal swab specimens collected ≥24 hours apart, but this may not be feasible in paents with suspected lung cancer at high risk for upstag-
ing, disease progression or who need immediate iniaon of radiaon or systemic therapy.
Personal protecve equipment
Frequent hand washing is the single most important intervenon and should be performed before and aer touching any equipment needed
for intubaon or bronchoscopy. Personal protecve equipment including gowns, masks, eye shields, and gloves should be worn during all
bronchoscopic procedures (Figure, boom panel). Healthcare workers are recommended to maximize their level of protecon by using either
N95 mask or PAPR when performing an aerosol-generang procedure. The CDC recommends aerosol-generang procedures such as bron-
choscopy be performed in negave pressure rooms when feasible. Liming the personnel in the room to essenal healthcare workers may
also reduce the risk of viral exposure and transmission.
Bronchoscopy in suspected or conrmed COVID-19 infecons
Bronchoscopy should be postponed in paents with highly suspected or conrmed COVID-19 infecon unless there is an emergent or urgent
indicaon. Although the sensivity of BAL is reportedly 93% as compared with the sensivity of nasopharyngeal swab of 63% in detecng
COVID-19 as per a recent study from China, bronchoscopy should not be used rounely to diagnose COVID-19. Upper respiratory specimens
such as nasopharyngeal swab should be the rst-line tesng modality for COVID-19 tesng. Lower respiratory tract specimens via ET aspirate
or bronchoscopy may be considered in paents with severe progressive respiratory failure aer two negave upper respiratory specimens
and addional specimen is needed to establish a diagnosis that will lead to a change in clinical management.
In paents with suspected or conrmed COVID-19 who require emergent or urgent bronchoscopy, it is recommended that healthcare work-
ers in the procedure and recovery room use full personal protecve equipment and N95 mask or PAPR. Extended use and reuse of N95 mask
is not recommended when performing a bronchoscopy in these paents.
Certain technical ps during the bronchoscopy could potenally reduce the risk of aerosolizaon. These include: performing bronchoscopy
via an endotracheal tube, having paents under general anesthesia with neuromuscular blockers to allow for intermient apnea during the
actual suconing, preoxygenaon with 100% FiO2 and ulizaon of disposable scopes for simple therapeuc aspiraons, BAL or for percuta-
neous tracheostomy. Disposable bronchoscopes are likely inadequate for complex bronchoscopic procedures and we believe are subopmal
for diagnosis of peripheral lung lesions and not an opon for mediasnal staging.
Procedural consideraons
In paents who require bronchoscopy, every eort should be made to minimize the me of aerosolizaon to reduce the risk of transmission.
It is recommended that the most experienced operator perform the procedure and personnel be limited to a minimum (Figure, boom pan-
el). Pernent to lung cancer diagnosis and staging, at the University of Chicago, we have connued to use the cytopathology team for rapid
on-site cytology evaluaon to potenally decrease the me of the procedure and to assure sucient material for molecular studies.
Tips from the Experts
P A G E 8 V O L U M E 8 , I S S U E 3
Intubang a paent prior to bronchoscopy oers the advantage over moderate sedaon in that it allows for a closed circuit and potenally
decreases coughing which has been associated with increased aerosolizaon. While intubang a paent prior to bronchoscopy, every eort
should be made to limit bagging during the pre-oxygenaon phase and aer the endotracheal tube is placed. Our team has used intubaon
boxes in the beginning of the pandemic, but now our anesthesia colleagues rounely use only video-laryngoscopy (Figure, top panel). Once
intubated, a HEPA lter should be placed between the endotracheal tube and the venlator circuit to lter out viral parcles. Pharmacologic
intervenons such as paralycs may be considered to decrease coughing.
It is suggested that the number of mes removing and reintroducing the bronchoscope into the endotracheal tube be kept to a minimum in
order to minimize interrupon of an otherwise closed circuit. Although there is no data to support this pracce, acve suconing can be used
during inseron and removal of the bronchoscope from the endotracheal tube in order to decrease aerosolizaon.
We have highlighted some lessons learned during the last 6 months and summarized recommendaons from various sociees on the topics
of paent selecon, paent screening, and procedural consideraons, with the focus on bronchoscopy for diagnosis and staging of lung can-
cer. In the midst of the pandemic, it has become more important than ever for the bronchoscopist to carefully weigh the need to deliver
mely care to paents while lowering the risk of infecon transmission to healthcare professionals and other paents. We trust that the data
from bronchoscopy studies during COVID-19 will allow physicians to again align the philosophy of safety with that of mely and eecve
1. Prachand VN et al. J Am Coll Surg. 2020 Aug;231(2):281-288.
2. Guckenberger M et al. Radiother Oncol. 2020 May;146:223-229.
3. Wahidi MM et al. Published online ahead of print, 2020 May 1]. Chest. 2020;S0012-3692(20)30850-3. doi:10.1016/j.chest.2020.04.036
4. Pritche MA et al. J Thorac Dis. 2020;12(5):1781-1798. doi:10.21037/jtd.2020.04.32
5. Lentz RJ et al. Respirology. 2020;25(6):574-577. doi:10.1111/resp.13824
6. Wang W et al. Published online ahead of print, 2020 Mar 11]. JAMA. 2020;323(18):1843-1844. doi:10.1001/jama.2020.3786
Figure 1: Room set up during a roboc bronchoscopy
during COVID-19.
Top panel: the intubaon box and the video-
laryngoscope used to minimize aerosolizaon during the
Boom panel: room set up and team wearing gowns,
masks, eye shields, gloves and either N95 mask or PAPR.
Humanitarian News
W A B I P N E W S L E T T E R P A G E 9
Throughout history, several lethal pandemics have challenged humankind. Two major causes of death are recognized: the
lethality of the disease itself but also the disrupon of basic health care, public health and public safety infrastructures. Dur-
ing the several epidemics lived in the last decades, many ethical issues have been analyzed: the right of governments to re-
strict some liberes in dierent forms of lockdown, the allocaon of limited resources, the equilibrium between individual
rights and the protecon of the whole community, the responsibility of the governments in providing adequate resources.
However, in many publicaons from the press or from scholars in ethics or medicine, it seems that the duty of careof
health care workers (HCW) is out of discussion. It has been argued tradionally that the special commitment of doctors to a
high standard of altruism and benecence (and consequently) to a duty to care even at risk to themselves, is one side of the
social contract between the profession and society at large. And that taking risks is just part of the job”.
However, far from being a subject with high levels of agreement, the denion, the extent, the origins and the very exist-
ence of a duty of care is a maer of great controversy amongst praccing doctors and scholars of ethics.
The disposion to work in the case of a potenally lethal infecous disease has been invesgated in several studies during
previous outbreaks. In a Taiwanese survey performed during the severe acute respiratory syndrome (SARS) epidemic in
2003, 26% of nurses declared they would look for another job or considering resigning because of risk. Other survey, also in
Taiwan, showed that 57% of nurses indicated that they were willing to care for paents infected with avian inuenza. One
study amongst US physicians, showed that only 40% announced that they were willing to put themselves at risk in order to
save otherslives and other in Maryland, demonstrated that nearly half of the local health department workers would not to
report to duty during an inuenza pandemic. A German study showed that 28% of the respondents HCWs of large terary
centres agreed that it would be professionally acceptable to abandon their workplace during a pandemic to protect them-
selves and their families and 19% of healthcare workers at the Nongham University Hospital NHS Trust in the United King-
dom said they would leave work in the case of a high-lethality infecous disease.
In fact, a working group gathered to idenfy the key ethical issues of the SARS epidemic in Toronto could not reach consen-
sus on the issue of duty to care, parcularly regarding the extent to which healthcare workers are obligated to risk their lives
in delivering clinical care.
Used in a vague, ill-dened, authoritave manner, the phrase duty of care might be ethically dangerous. As pointed by Sokol,
it could pressure HCWs into working in unacceptably risky condions while presenng the illusion of legimate moral jus-
caon. It has been proposed that the duty to treat denion should be narrow and unambiguous in order to allow to
establish with certainty when it does and does not apply. That assignment is not an easy task. Such a denion should take
into account the expectaons of the dierent physicians according to their choice about place and type of work, the abstrac-
ons of the ethical codes, the expectaons of the society (frequently based on many unrealisc assumpons) and, very im-
portantly, the consideraon of how to handle the duty when it conicts with one or more other dues with greater moral
Almost every physician assumes a primary ethical duty to place the welfare of their paents above their own interests. But
how far does the duty to paent welfare extend? Must physicians assume a serious risk to their own health to ensure that
paents receive needed care?
Every country may have parcular rules as those dictated by the common law and codes of ethics (somemes referred to as
an instrument of "so law," owing to its non-legislave nature). But those regulaons are not universal. On the other hand,
the moral grounds of a duty to care concern to HCWs all over the world.
One of the assumpons of members of the society and many physicians is that this duty of care has always existed”. But
this concept is wrong. No explicit menon is made about such an obligaon in Thucydides or Hippocrates and it is well
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W A B I P N E W S L E T T E R P A G E 10
known that Galen ed from Rome during the Antonine plague in the second century A.D., Sydenham from London in the
seventeenth, and recognized physicians in Philadelphia and New York during outbreaks of yellow fever in the eighteenth and
cholera in the nineteenth centuries.
Many physicians at those mes, although not expected to pracce in plague areas, chose to stay. But professional duty was
not the reason why they did so. During the plagues of the Middle Ages, the civic leaders of the cies used a variety of poli-
cies, oen in concert or in sequence, to insure minimum levels of palliave treatment for most of the populaon. Physicians
were somemes forbidden to leave some cies and their hinterlands. But fundamentally, they were oered high fees and
prizes to visit paents in the lazere (plague hospitals) and to serve in the hospital. The city leaders and physicians saw
these combinaons of incenves and disincenves to treat paents with plague simply as business proposions. As such,
they were regulated by contracts not very dierent from the commercial instruments used to regulate other commercial
acvies and that expressed the mutual self-interest of a physician and a city: high salaries, reimbursement for living expens-
es and the promise of cizenship in exchange to visit plague paents as frequently as necessary. In more modern history we
nd analogies to events in London during the outbreaks of plague in the seventeenth century and Americans reacted similar-
ly in similar situaons. It means than the history of dutyto care meant many physicians' incomes improved during epidem-
ics. Plague doctors performed the most dangerous tasks, but they were amply rewarded in cash and if they survived, in the
more important coin of social and professional status.
On the other hand, during medieval mes the duty was no doubt linked with religious obligaons, such as the duty of Chris-
an charity, whereas the 19th century physician adhering to the Thomas Percivals Code of Ethics might have been movat-
ed by more secular noons of the gentleman physician”.
It was not really unl the 1800s when the noon of professions as holding a social contract came. The AMA Code of Medical
Ethics version of 1847, specied this professional duty to treat in the face of personal danger which was strengthened in
1912 “to say there was an obligaon to connue taking care of people who posed a contagious threat, even if you were not
being paid to do so,Even when that Code (very inuenal but not valid in most of the other countries) contributed to build
the image of doctors as a sort of heroic gures in American culture, it is well known that this document evolved to dierent
formats that stressed dierently about that parcular topic along the years.
This means that the duty to treat cannot be rmly grounded on facts of medical history. So, accepng that tradionis not
the incontestable argument of a natural”, intrinsic duty which many authors rely on, but the result of negoaons, religious
movaons and fundamentally, dierent historical contexts, it is mandatory to menon the ethical grounds used as argu-
ments for those convinced of the existence of a duty to care.
The main reasons argued for the existence of a duty to care are (1) an explicit or implicit consent to accept such risks as part
of a professional career in medicine; (2) part of the oath or code of ethics that HCWs undertake when they enter the profes-
sion; (3) special training and experse that give physicians a higher responsibility and (4) a social contract with the public in
return for receiving benets such as subsidized training, high income, social presge and the privilege of professional self -
regulaon and autonomy.
Although each one of those points may be (and have been) quesoned by dierent ethicists, It is far beyond a short column
like this to explore in depth every line of reasoning. Lets menon however than not in all (and probably not in any) profes-
sional oath is explicitly told that a physician must face potenally lethal risks. The current generaon of physicians has expe-
rienced very lile exposure to serious occupaonal risk. Control of infecons have made doctors in developed countries be-
lieve (with some juscaon) that they are exempt from the riskier aspects of medicine that had claimed the lives of so
many of their predecessors. As the result of that pax anbioca, being a doctor did not mean at all that one was willing to
take personal risks for the benet of paents. Any doctor entered the profession with a keen appreciaon of the hazards.
Only during the last decade, reality abruptly changed, vanishing this percepon of relave safety. Most of contemporary
doctors have pledged to full this singular responsibility of defending the interests of their paents ahead of their own per-
sonal interests but not expecng to include facing life threatening risks.
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W A B I P N E W S L E T T E R P A G E 11
Some ethics scholars have gone very far in those arguments and so Masur et al wrote that “… physicians and nurses have an
obligaon to treat sick and potenally infecous paents because they are members of a profession whose primary goal is
an ethical calling: caring for the sick. This obligaon to serve the sick is constuve of medicine as a profession and is unique-
ly what disnguishes physicians, nurses, and other clinicians from other professionalsmeaning that avoiding risky paents
is a basic betrayal of professional identy. An argument very dicult to be sustained in front of the fact that many doctors
probably having chosen speciales because they do not carry special risks have very dierent expectaon than those who
have taken those that carry well known risks with them. The argument have also several weaknesses, as in any society many
dierent groups have special skills with special essenal goals and are not required to take that level of risk and if they are,
they easily reject to comply with those supposed expectaons on behalf of their freedom of choice and their right to pre-
serve their own lives (or even properes).
A classic argument is that a physician is like a reghter, they cannot excuse themselves from from entering a burning
building to search for those trapped inside”. You cant be a reghter if you cant serve the mission; and that mission carries
to be prepared to take substanal risks.
The analogy proves to be weak. At entering the profession, reghters (or policemen or soldiers) know the sort of risk they
will face. But addionally, their duty implies to be ready to take certain level of risk, not any level of risk. Even for profes-
sions that carry an intrinsic high risk of death, the duty is not applied to risks much higher than the average, known and ac-
cepted by a member of the profession. A police ocer is not obliged to stop armed thieves in a car robbery that is not imply-
ing potenally lethal harm for human lives if he himself is unarmed and for a soldier joining a squad bomb is a volunteer
task, not compulsory to be accepted by every member of the Army.
Finally, one cannot deny that the social contractbetween society and doctors is quite eroded, especially in some countries.
It has been argued tradionally that the special commitment of doctors to a high standard of altruism and benecence, and
hence to a duty to care even at risk to themselves, is one side of the social contract between the profession and society at
large. Contracts oer benets in exchange for services rendered: the benets doctors seek in exchange for recognizing a
duty to care have been proposed to be self-regulaon, or the high status and generous remuneraon of the profession.
Some authors remark that the seless service of doctors during epidemics is perhaps not as seless as it appears: and under-
stand this seless serviceas something of a bargaining tool, in which doctors bargain for their status as independent prac-
oners, self-regulang, and beholden to no outside social body.
But, the concepon of a physician as a privileged cizenis no more than a caricature of the past. In most of the countries,
physicians (and not menoning nurses and other HCWs) receive much lower salaries or fees than in the recent past and then
those received by non-essenal professions. The supposed independence of doctors in the regulaon of their pracce does
not exist anymore. The generalizaon of third-party payers have transformed the majority of praccing doctors in informal
employees with no social benets who do not decide their fees, their hours of pracce their working condions and even
their choice of methods of diagnosis and treatments. But most of all, the presge of the medical profession itself has been
corroded (by many factors) and today, doctors are frequently vicms of manifestaons of disrespect, discriminaon and
verbal or even physical violence. Doctors feel today that they have endless obligaons and virtually no rights, just because of
being a physician.
However in spite of the many reasons HCWs have to dispute and even reject that supposed duty of care, most of physicians
have willingly accepted to take risk for them and their relaves and stay at the front line. There is lile doubt that the vast
majority of HCWs performed their jobs admirably. Why? Obviously, the factors playing into ethical decision making are not
exhausted by an implicit contractdened by past risk level accepted. A debate about duty to care in the context of an epi-
demic asks whether it is fair to expect of healthcare workers that they take on a risk of personal injury or death and the bur-
den of psychological stress associated with that risk in order to provide care.
If we cant say that caring for these paents is a basic duty shared by all professionals, it doesnt mean we can say nothing.
When we set the language of duty to one side, we can say something dierent: that the willingness to care for risky paents
is a very good and seless thing, which exemplies the highest ideals of the profession.
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W A B I P N E W S L E T T E R P A G E 12
Probably the duty to treat is grounded mainly in an empathic response to the paents medical need and vulnerability. Lack-
ing medical knowledge, the sick stand in a relaon of dependency toward those with the power to heal them. As the unique
possessors of medical skills, physicians hold an awesome and exclusive power, through their acons and omissions, to pro-
foundly aect the lives of others. This combinaon of extreme vulnerability and exclusive power in the context of the physi-
cian-paent encounter generates a strong duty, a moral responsibility. We may also think that the duty is also grounded on a
shared ideal of medicine as a profession dedicated to the good of others, a profession which has always had within it mem-
bers who have persistently seen themselves as more than merely self-interested tradesmen.
This noon implies a huge dierence, the dierence between being obliged to do something and making the choice of doing
something. A virtuous act is the elecon of a virtuous man. Not stealing a poor person is an obligaon, giving money to
someone in need is a personal choice. Physicians can be drawn to ideals even when theyre not driven by dues.
But accepng the free intervenon of the physicians as a moral agent also shows its own complexies. Some quesons like
who denes which virtues are required in a physician, which are the limits of that moral duty or how to solve the conicng
dues of a physicians (to himself, to his family and to the whole society) are not so easy to answer.
Virtues are not universal meless values, but shaped by a historical context. The shape of the professional obligaons has
been determined over me through negoaon with society. The negoaon is complex because it should be based on the
requirement of a common morality. The physicians duty to take risks has been forged in an ongoing dialogue with society at
large. Taking that into account, it should be accepted that the fact that virtuous physicians behaved one parcular way un-
der condions exisng long ago must not necessarily reect the concept of virtue today. Many things about medical pracce
have changed: the complexity of the management of diseases, the posion of physicians as only one more cog in the com-
plex machinery of medicine, the instuonal framework through which medical care is delivered. But mainly no longer is the
society in which the physician funcons what it was. There is no doubt that the current environment (and its values) are
more egocentric, more hedonisc, less community oriented and denitely more dedicated to the self. Polical leaders, ordi-
nary individual and mainly mass media exalt and promote rugged individualism and even demean social acon. In that con-
text, taking risks for social benet does not feel a natural virtueand make dicult to claim that the virtues remain un-
changed. Acknowledging that the virtues depend on context and are not immutable is what makes Arras suggest the emer-
gence of a historically determined model of the virtuous physician and why he asserts that virtues are "fragile". In a society
that does not call for high standards of virtues as empathy, solidarity and privileging the social good (and does not reward
those who pracce them) in many other essenal pracces, it may be dicult to ask only the HCWs to behave in such a vir-
tuous way.
Addionally, this duty even virtue-oriented must have limits. A disnct problem is to determine the threshold of acceptable
risk,the dividing line between duty and supererogaon. Some hazards clearly fall beyond the ambit of the doctors duty to
treat, but physicians should never be expected to subject themselves to blatantly suicidal risks or to go out of their way to
confront danger. Some extremely courageous acts may be deemed to be highly praiseworthy, but no one should induce doc-
tors to behave in that manner and much less blame a physician for not exposing him or herself to such high levels of risk.
While dening acceptable risk in the line of duty may be ambiguous amongst healthcare workers, moral dilemmas also arise
for those who feel their obligaons as healthcare professionals conicted with their obligaons to others as family members
and caregivers. Exalng altruism and heroism have the risk of forgeng that the rst duty of a physician during a pandemic
is to stay alive and that their delay of treatment to paents in order to take the me to suit up and protect themselves, is not
only jusable but necessary. Idencaon of duty to care with altruism makes invisible moral conicts between the vari-
ous pares to whom a person may owe care, and interferes with the need of healthcare professionals to understand and
accept that they must take all possible measures consistent with the social need for a funconing healthcare system to pro-
tect themselves in an epidemic. Duty to care should not be understood as the obligaon to noble self-sacrice. Physicians
have dues not only to current and future paents but to themselves as well as their families, colleagues, community and
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W A B I P N E W S L E T T E R P A G E 13
The processes of planning for pandemic inuenza, must include ethical discussion and must be carried out in advance. Oth-
erwise, there is a risk of making unjust and indefensible decisions aecng thousands of people. Physicians have to be pro-
tected, as well. They have the same rights as every human being and the duty of the government, policy makers and public
in general is to protect them as they are asking them for such exceponal behavior.
Finally, as a professional community we should understand that virtues and superogatory acts are ideals and aspiraons.
And it means that struggle and failure are compable with full possession of virtues and aspiraons. The possession of a vir-
tue or an aspiraon does not require its achievement or enactment on every occasion. Virtues are disposions revealed in
paerns of behaviour over me. We do not have the right to judge whether a person is courageous enough from a single
performance. Physicians who avoid caring for a risky paent but who in their other behaviour reveal their altruisc nature
should not be judged to lack this virtue.
This discussion should cover a multude of subjects. We cannot be blind at the fact that many doctors are already saying,
that they do not share the tradional vision of the good and that the current culture push physicians to the idea of medicine
as a career and not as a potenally self-sacricial vocaon. If some kind of opposion to the tradional duty grows up in the
medical profession, it could eventually undermine the claim that a professional duty sll exists.
Teaching dierently, specifying the limits of the duty of care, wring unambiguous codes, asking for a full understanding of
the sort of commitment required at the moment of entering the profession or creang clear contracts by which dierent
doctors may take dierent levels of commitment and receive dierent benets according to that , have all been proposed as
potenal soluons.
There is no doubt that this issue requires urgent aenon from researchers, regulatory bodies, and the public. And that if
civil society expects a high level of engagement and a special status of morality from the medical community, it will only be
possible if the medical profession regain its presge and independence and if during periods of crisis a more basic and uni-
versal social contract emerges. That broader social contract underlying the duty to care claims for the general public to per-
form his side of the contract in their role of supporng the healthcare system, to take responsibility of turning their work-
places as safe enough under the circumstances; in adhering the recommendaons for protecng themselves and their
neighbours and in expressing their sincere support of the health care workers in concrete and human ways. Public must un-
derstand that in not doing that, they violate what ought to be a shared commitment to enacng a social value. This pandem-
ic (that for sure will not be the last one) highlights the need for calling for a broader social pact. If the society expects an al-
truisc behavior from HCWs and a health care system with the ability and the resources to give adequate answers during an
emergency, their members should crically reect about which moral values want to promote in the society and they must
promote and support egalitarian access to a strong health care system where the duty of care of the whole system sets the
general welfare above nancial prot or scal restraints.
1. Singer P et al. BMJ. 2003; 327:13424.
2. Zuger A et al. JAMA. 1987; 258(14):1924-1928
3. Fox DM. The Polics of Physicians' Responsibility in Epi-
demics: A Note on History. Hasngs Center Report 1988, 18:
4. Daniels N. Duty to treat or Right to refuse. Hasngs Cen-
ter Report. 1991; 21(2): 3646.
5. Malm H et al. Am J Bioeth 2008; 8:4-19
6. Pellegrino ED et al. New York: Oxford University Press,
7. Tomlinson T. Journal of Medical Ethics. 2008;34:458-462
8. Bailey T et al. Am J Bioeth 2008; 8: 29-31
9. Reid L. Bioethics 2005; 19(4):348-61
*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 (3 of 3)
Descripon: A polypoid lesion on the right lower tracheal wall ocluding almost completely the airway. The
lesion was resected with polipectomy snare and pathology revealed a WHO Type A thymoma. The paent, an
87-year-old woman, had been submited to surgical resecon of thymoma eleven years early.
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
In Memory of Jean-François DUMON, M.D. (1939 - 2020)
It is with an extreme sadness, we have been informed that one of the fathers of intervenonal bronchoscopy, Dr. Jean-
François DUMON, passed away on July 14. 2020.
In such circumstances, it is common to draw the panegyric of the person, and even more when dealing with a promi-
nent medical leader and senior gure. It seems to be inappropriate for Jean-François DUMON because of the universal-
ly known link between his name and silicone stents. He was a strong advocate of intervenonal bronchoscopy through
rigid bronchoscopy and endobronchial laser.
He was in parcular a visionary for the use of silicone stents to manage endobronchial stenosis or obstrucon, based
on a strong daily clinical experience, demonstrang several decades ago, against the medical community at the begin-
ning, that this medical device was totally safe and useful for the paents. Jean-François DUMON has brought a revolu-
on in the management of central airway diseases and, in addion, was a dynamic leader both for the naonal and
internaonal organizaons dedicated to intervenonal bronchoscopy as well as for research in this eld. For his work
he has received numerous internaonal awards, among them the Killian Award of the WABIP being the most presg-
The internaonal pulmonology community has lost an instrumental leader and for several people, in parcular in our
area, a mentor and, humbly, a friend. His footsteps are heavily printed, and may his legacy be to a blessing for the next
generaons of intervenonal pulmonologists and for all the paents waing for new developments.
Our thoughts, these days, go to his family who stood by his side throughout his whole career, and to all the numerous
pulmonologists who have been trained or have aended courses in his laser centerat Sainte Marguerite Hospital,
Marseille, to modestly catch a bit of his knowledge in rigid bronchoscopy, laser, and airway stenng.
Philippe ASTOUL, MD, PhD
Department of Thoracic Oncology, Pleural Diseases and Intervenonal Pulmonology - Hôpital NORD – Marseille -
P A G E 15
WABIP Awards Recipients 2020 -- We are very pleased to announce the recipients of the 2020 WABIP Awards. Our as-
sociaon humbly recognizes the below persons for their achievements and clinical pracces that have long made signicant
impact on the art and science of bronchology and intervenonal pulmonology:
Descripons of the Awards may be found at hps://www.wabip.com/awards
The WABIP Awards are presented bi-annually at our WCBIP. As our coming congress will be held virtually this year, presenta-
ons will also be in the same format. We will announce further details via social media and email. Stay tuned!
WCBIP Congress 2020 goes virtual only -- Due to local re-
stricons in Shanghai, our November 19-22 congress will be a virtu-
al-only event in which we will oer both live streaming and pre-
recorded lectures.
We are very excited to move forward with many lecturers around
the world contribung to our scienc program. Lectures will in-
clude topics ranging from EBUS TBNA, Cryobiopsy, Navigaonal bronchoscopy, bronchoscopic treatment of obstrucve lung
disease (emphysema, bronchis, asthma, Pediatric IP and much more!
Registraon fees have been reduced to $49 for WABIP members, and $69 for non-WABIP members. Further details of the
program, format, faculty and more at hp://www.WCBIP.org
We look forward to your parcipaon in our WCBIP Shanghai Virtual this November.
P A G E 16
The Gustav Killian Centenary Medal
Recipient: Eric Edell, MD
The WABIP-Dumon Award
Recipient: Hervé Dutau, MD
The WABIP Lifeme Achievement Award
Recipient: Hugo Boo, MD
The Disnguished WABIP Regent Award
Recipient: Erik van der Heijden, MD
Tracheostomy in COVID-19 paents
Damned if I do, damned if I dont
Like many procedures in medicine and surgery, tracheostomy has been reevaluated in the backdrop o COVID-19 Pandemic. Air-
way procedures such as tracheostomy and bronchoscopy expose proceduralists and the ancillary sta present in the room to a
much higher risk of airborne infecons than non-airway procedures. However, tracheostomys ambiguity of indicaons and urgent
nature should make us pause and think about this procedure's necessity and safety in these unprecedented mes.
It is imperave to understand the balance between the need and the risk of performing a tracheostomy in paents with COVID 19
and venlator-dependent respiratory failure. A concerted eort by CHEST led to the publicaon of a consensus statement (1) to
provide a guide on the issues of preparaon, ming, and technique of tracheostomy in COVID 19 paents while minimizing the risk
of infecon to health care workers (HCW).
I have extracted the following points from the expert panel report with a clear understanding that this is a uid document that was
put together with limited experience and informaon on COVID 19. Our knowledge of how the COVID 19 spreads and impacts ex-
tremely variable hosts due to comorbidies and inherent biological variability are rapidly evolving. I am condent that this docu-
ment will connue to morph as we gain more knowledge and experience in COVID 19.
The expert panel suggested that:
1. Tracheostomy be considered in coronavirus disease 2019 (COVID-19) paents when prolonged mechanical venlaon is anc-
ipated (Strong Consensus).
2. There is insucient evidence for recommending a specic ming for tracheostomy in COVID-19 related respiratory fail-
ure (Consensus).
3. In paents with COVID-19 related respiratory failure, either open surgical tracheostomy (OST) or percutaneous dilataonal
tracheostomy (PDT) can be performed in paents expected to require prolonged mechanical venlaon (Strong Consensus).
Remarks: Ulizaon of techniques which minimize aerosolizaon is recommended when performing tracheostomy (Strong Consen-
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
P A G E 18
4. Enhanced personal protecve equipment (PPE) be used to migate the risk of health care worker related infecon during tra-
cheostomy (Strong Consensus).
Remarks: Tracheostomy is an aerosol generang procedure (AGP) and poses an infecon risk to HCW involved in the procedure
(Strong Consensus).
5. In paents with COVID-19 related respiratory failure, tracheostomy is performed in a negave-pressure room, preferably in
the ICU. As an alternave, a negave-pressure room in the OR could be used, with special aenon to minimizing transportaon
-related risk of exposure (Strong Consensus).
Remarks: If negave pressure rooms are unavailable, the procedure could be performed in a normal pressure room equipped with
HEPA lters in the presence of a strict door policy (Strong Consensus).
6. Roune RT-PCR tesng (nasopharyngeal swab or lower respiratory sample) prior to performing tracheostomy in paents with
conrmed COVID-19 related respiratory failure is NOT needed (Strong Consensus).
Remarks: There is insucient evidence to recommend RT-PCR tesng in paents with non-COVID-19 respiratory failure prior to
tracheostomy. If such tesng is performed, we suggest that a lower respiratory sample (endotracheal aspirate) rather than a naso-
pharyngeal swab be obtained (Consensus).
7. In paents with COVID-19 related respiratory failure, tracheostomy is performed by a team consisng of the least number of
providers with the highest level of experience (Strong Consensus).
Remarks: Authors suggest that prior to the iniaon of tracheostomy, a muldisciplinary group of providers including the primary
crical care team, palliave care, infecous disease, the procedural and airway team ulize respecve experse to determine the
goals of care, paent selecon, procedural consideraons, as well as workow to opmize safety of both paent and HCW (Strong
8. Paents be maintained with a closed circuit while on mechanical venlaon with a tracheostomy tube and with in-line suc-
on (Strong Consensus).
An extensive detail regarding the raonale and the references behind each recommendaon menoned above can be found in the
original statement. I strongly recommend anyone doing tracheostomy to review this statement. Be safe!
1. Carla Lamb et al: Chest. 2020 Jun 6. doi: 10.1016/j.chest.2020.05.571
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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