LAUSR

In 1994, the landscape of interventional work for a thoracic physician was very different than it is now. Procedures were still often performed with direct-view fibreoptic scopes or sometimes with a handheld attachment for an observer. Most procedures were performed with either little or no conscious sedation, sometimes in side rooms of thoracic wards. Bronchoscopies were mostly carried out for large central airway lesions. Most peripheral nodules were sampled by computed tomography (CT) needle biopsy, and where bronchoscopy was performed, it was with large-diameter scopes using fluoroscopy, an extremely difficult assignment. Despite the demonstrated safety of transbronchial needle aspiration with a Wang needle, this was very uncommonly performed, and mediastinoscopy or other surgical procedures were essentially the only thoracic staging modality. A select few performed laser bronchoscopies for recanalization of bronchi and stenting for relief of dyspnoea, including with the (then) relatively new silastic stent system championed by Dumon. Pleural procedures tended to be performed with large-bore tubes inserted with the aid of chest wall percussion or blind pleural biopsies. Medical thoracoscopy had been on the scene for decades but was only infrequently performed. CT imaging was well established, but the idea that a fluffy ground-glass shadow could have any significance was poorly understood. Positron emission tomography (PET) scans were still relatively new; however, there was a tendency for PET to be interpreted ‘histologically’ without the need for tissue confirmation. Some parallel advances in other fields have significantly assisted proceduralists. First, the quality of imaging has advanced significantly, allowing for better procedure planning with fine-cut CT and avoidance of procedures in conditions such as classic usual interstitial pneumonia (UIP). PET CT imaging has transformed our ability to adequately stage lung cancer. Second, the nihilism of the latter part of the 20th century has been transformed by oncology treatments such as targeted molecular therapies and check-point inhibitors. At the very least, this has likely ensured that more patients are considered for biopsy. It also means great care has gone into studying how best to obtain quality samples to allow therapeutic decisions. In earlier times, it was often enough to say that a sample showed non-small cell or small cell cancer—now not so much. Third, pathology has advanced, making great use of small samples, often cytological, sparing patients large resections, and access to and improvements in anaesthetics have significantly assisted bronchoscopists in performing more complex procedures. So, here are top 10 putative advances in interventional pulmonology from the last 25 years in approximate chronological order. Video bronchoscopy—Following his development of fibreoptic bronchoscopy in the 1960s, Ikeda was also a driving force behind video bronchoscopy that became widely commercially available in the early 1990s. The video scope had a charge-coupled device (CCD) located at the distal tip of the scope to sense and transmit images. A transformation of image quality occurred; this also allowed magnification, improving procedural proficiency, and monitor viewing greatly widened the ‘accessibility’ of bronchoscopy. In addition, still and video images could be easily recorded. Virtually all the advances in bronchoscopy that followed used video scopes as their platform (Fig. 1). Autofluorescence bronchoscopy and narrow-band imaging—Stephen Lam showed that tissue autofluorescence to a blue light could be detected by highly sensitive cameras, and very subtle in situ changes in mucosa not visible in standard white light could also be detected, allowing biopsy. Narrow-band imaging also used autofluorescence; however, the narrow band was that of the tissue fluorescence of haemoglobin. As such, small endobronchial vessel patterns could be shown in far greater detail and allow ‘histological’-like assessments of subtle endobronchial dysplasias. The methods remain in use in high-risk groups, particularly narrow band imaging (NBI), which is standard for many bronchoscopes, and is often used to quickly interrogate a non-specific endobronchial change. EBUS guide sheath—Whilst aerated lung is echo poor, a solid peripheral nodule or mass can be readily identified by ultrasound. The technique places a thin ultrasound probe within a plastic (guide) sheath, which is left in place to allow sampling of the nodule. It was far more sensitive than the previous use of X-ray fluoroscopy alone and was safe as the sheath itself tamponaded the airway after biopsies. The technique also allowed ultrasound image analysis. It has been accompanied by advances in scope miniaturization and virtual navigation using CT-derived plans. For interventional pulmonologists, it has given a far greater overall awareness of airway anatomy. EBUS-TBNA—Yasufuku et al.’s study of 2004 ushered in a new era of access to the hilum and mediastinum, demonstrating not only safety but also highly accurate node sampling. Subsequent large metaanalyses have confirmed excellent diagnostic accuracy; in 1300 patients, endobronchial ultrasound-guided