Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians.

T he ability to perform procedures is one of the defining characteristics that attracted so many of us to fellowships in pulmonary medicine, critical care medicine, and thoracic surgery. In fact, nearly 500,000 bronchoscopies are done each year in the United States. Additionally, approximately 15,000 airway stents are placed yearly worldwide. The number and complexity of procedures that can be performed in the bronchoscopy unit is increasing. For example, endobronchial electrocautery for tumor ablation and the treatment of hemoptysis can be performed under local anesthesia during a “routine” outpatient bronchoscopy. Unfortunately, our training and expertise is not uniform. An American College of Chest Physicians (ACCP) survey revealed that 50% of respondents believed that their training in advanced diagnostic techniques such as transbronchial needle aspiration (TBNA) was inadequate. In another query of senior pulmonary fellows, Haponik et al found that while most fellows reported “adequate” training in bronchoscopy, only 72% had any instruction in TBNA and 27% in stent placement. Despite the proliferation in the number and type of chest procedures currently performed, there are presently no guidelines that ensure that the basic skills and competency needed to provide these services have been acquired by the pulmonologist, critical care physician, or thoracic surgeon (dedicated operators). To address this void, the development of guidelines for chest procedures was initiated through the Interventional Chest/Diagnostic Procedures Network of the ACCP (the “Network”). There were several compelling reasons to do so. First, these procedures carry inherent risks, and patient safety is of paramount concern. Second, defining the equipment and personnel required, indications, contraindications, risks, and training requirements of each of the procedures may facilitate uniform practice within fellowship training programs. In addition, these guidelines could be used as a guide to hospital nursing, respiratory therapy and administrative departments who wish to develop these services. Finally, dedicated operators who display competency in these individual procedures should have less difficulty overcoming the barriers that sometimes exist within local hospital credentialing committees. The guidelines themselves were developed by a group of physicians representing a wide range of interests within the college. The group was comprised of pulmonologists and thoracic surgeons, academics, and private practitioners who reside in the United States and abroad. Despite the diversity of practice views, consensus was reached on all of the parameters put forth in this document. For physicians wishing to learn how to perform one of these advanced procedures, there are several different educational approaches. There are intense short training programs (1 to 3 days). These are available throughout the United States and abroad. More formal mini-sabbaticals (1 to 6 months) are available as well. Several fellowship training programs have developed an additional year of fellowship training in advanced interventional techniques similar to other procedure-intensive internal medi*From the Department of Pulmonary Medicine (Dr. Ernst), Beth Israel Deaconess Medical Center, Boston, MA; Division of Pulmonary Medicine (Dr. Silvestri), Medical University of South Carolina, Charleston, SC; and Division of Cardiothoracic Surgery (Dr. Johnstone), University of Rochester, Rochester, NY. †A list of participants is given in Appendix 1. Manuscript received November 22, 2002; revision accepted November 25, 2002. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: permissions@chestnet.org). Correspondence to: Armin Ernst, MD, FCCP, Director, Interventional Pulmonology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215; e-mail: aernst@caregroup. harvard.edu