Transbronchial Cryobiopsy in Interstitial Lung Disease: Safety of a Standardized Procedure Background: Transbronchial lung cryobiopsy (TBCB) plays an increasing role in the evaluation of diffuse parenchymal lung disease with acceptable diagnostic yield and safety profile compared with that of video-assisted thoracoscopic surgical lung biopsy on most reports. However, published outcomes with regard to safety and complication rates vary. We aim to determine the safety profile of TBCB when performed using a standardized protocol consistent with recently published expert guidelines. Materials and Methods: We reviewed prospectively maintained databases from 5 Australian tertiary referral centers. The procedures were performed in accordance with a recent expert statement recommending standardization of TBCB procedures, in particular with fluoroscopy, a secured airway, and prophylactic bronchial blockers. Periprocedural complications were assessed along with clinical outcomes. Results: A total of 121 patients underwent TBCB between August 2013 and August 2017 following a standardized protocol using general anesthesia. Of them, 84 patients (66.7%) were discharged on the day of the procedure. Pneumothorax occurred in 18 patients (14.9%), 13 (10.7%) of whom required chest tube drainage. Moderate bleeding occurred in 15 patients (13.2%) and severe bleeding in 1 (0.83%). Histopathologic diagnosis was made in 80 patients (66.1%). Conclusion: Pooled outcomes from Australian tertiary centers indicate that TBCB is safe when performed in a protocolized fashion. Active measures to anticipate and manage bleeding and to direct biopsy position result in low rates of major complications. Disclosure: There is no conflict of interest or other disclosures. Reprints: Tajalli Saghaie, MD, FRACP, Department of Thoracic Medicine, Concord Hospital, Level 7w, 1 Hospital Road, Concord, Sydney, NSW 2137, Australia (e-mail: tajalli.saghaie@sydney.edu.au). Received April 11, 2019 Accepted September 20, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Career Development Training for Interventional Pulmonary Fellows: Are They Ready for the Workforce? Background: Interventional pulmonary (IP) fellows spend ≥6 years of postgraduate medical education before IP training. Given the high employment attrition rates of early medical professionals, we investigated the IP fellows’ self-assessed readiness for employment and the role of an intense preemployment educational intervention on improving the same. Materials and Methods: Over 2 consecutive academic years, IP fellows nationally were invited to a mid-year career development symposium focusing on employment search strategy and early career development. Attendees were anonymously surveyed presymposium/postsymposium and 6 months later at graduation. Both quantitative and qualitative data were collected. Attendees’ knowledge and skills were rated on a 5-point Likert scale. A control group of IP fellows that did not attend the symposium were also surveyed at graduation. Results: In total, 53 of 55 attendees (96% response rate) completed the presymposium survey and 50 of 55 (91%) completed the final survey at graduation. Overall, 16 of 18 (89%) nonattendees also completed the final survey at graduation. IP Fellows reported low baseline self-assessment scores on all question domains. Scores increased significantly postsymposium and were sustained at graduation (P<0.05). At graduation, the average response score of symposium attendees was significantly higher than that of nonattendees (P=0.04). Overall, 84% reported that the symposium helped them with their employment search. Conclusion: Advanced IP fellows were not well-equipped for a strategic employment search and early career development at the onset of their IP fellowship training. Participation in an intense educational intervention significantly improved fellows’ self-assessment scores, an effect that was sustained at 6 months. Supported by the Association of Interventional Pulmonology Program Directors. Disclosure: There is no conflict of interest or other disclosures. Reprints: Hans J. Lee, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 Building, 1800 Orleans Street, Zayed 7125L Baltimore, MD 21287 (e-mail: hlee171@jhmi.edu). Received July 25, 2019 Accepted September 20, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Aspergillus Tracheobronchitis Complicating Bronchial Thermoplasty No abstract available

Predictors of Indwelling Pleural Catheter Removal and Infection: A Single-center Experience With 336 Procedures Background: Indwelling pleural catheters (IPCs) offer ambulatory management of symptomatic persistent pleural effusions, but their widespread use is somewhat hampered by the risk of pleural infection and the inconvenience of carrying a catheter for a prolonged period of time. Factors associated with these 2 limitations were analyzed in this study. Materials and Methods: Retrospective review of consecutive patients who had undergone IPC placement over a 5 ½-year period. Time to IPC removal was analyzed with the Fine and Gray competing risks survival model, with competing risk being death. A binary logistic regression method was used to evaluate factors influencing IPC-related pleural infections. Results: A total of 336 IPCs were placed in 308 patients, mostly because of malignant effusions (83%). IPC removal secondary to pleurodesis was achieved in 170 (51%) procedures at a median time of 52 days. Higher rates of IPC removal were associated with an Eastern Cooperative Oncology Group (ECOG) grade of 0 to 2 [subhazard ratio (SHR)=2.22], an expandable lung (SHR=1.93), and development of a multiseptated pleural space (SHR=1.37). IPC-related pleural infections occurred in 8% of the cases, and were more often seen in hepatic hydrothoraces [odds ratio (OR)=4.75] and pleural fluids with a C-reactive protein <15 mg/L before the IPC insertion (OR=4.42). Conclusion: IPC removal is more likely to occur in patients with good performance status whose lungs fully expand after drainage. Hepatic hydrothorax is the most significant predictor of IPC-related infections. Disclosure: There is no conflict of interest or other disclosures. Reprints: José M. Porcel, MD, FCCP, FACP, FERS, Department of Internal Medicine, Pleural Medicine Unit, Arnau de Vilanova University Hospital, Avda Alcalde Rovira Roure 80, Lleida 25198, Spain (e-mail: jporcelp@yahoo.es). Received May 13, 2019 Accepted September 30, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Bronchoscopy for Chronic Unexplained Cough: Use of Biopsies and Cultures Increase Diagnostic Yield Background: Prior studies assessing the diagnostic utility of bronchoscopy for chronic unexplained cough have focused primarily on identifying endobronchial anomalies to determine chronic cough etiology. On the basis of our institutional experience, expanding bronchoscopy to include cultures and biopsies can considerably increase its diagnostic yield for identifying the etiology of chronic unexplained cough. Materials and Methods: This retrospective review analyzed bronchoscopies conducted in our institution between 2013 and 2017. Eligibility criteria were bronchoscopies conducted for chronic unexplained cough for which no etiology had been identified before the bronchoscopy. Microbiology, pathology, and cytology results from bronchoscopy were reviewed to identify the etiology of the cough. Results: Over the study period, 169 bronchoscopies met the eligibility criteria. The average patient age at bronchoscopy was 59.7±14.8 years; 61% were female individuals. Direct visualization identified anatomic etiologies in 48 (28%) patients, most commonly tracheobronchomalacia, and less common conditions, such as tracheobronchopathia osteochondroplastica. Microbiology cultures were positive in 33 (20%) patients, principally Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, and nontuberculosis mycobacterium. Pathology results from endobronchial biopsies identified respiratory conditions associated with cough, primarily eosinophilic bronchitis (n=15), as well as neurofibromatosis (n=1) and amyloidosis (n=1). Cytology results did not reveal alternate diagnoses not previously identified. Conclusion: Inclusion of bronchial washings and endobronchial biopsies during bronchoscopy for chronic unexplained cough increased diagnostic yield from 28%, attributable to directly visualized anatomic etiologies, to 41%. The addition of microbiology cultures and pathology analysis significantly increased the diagnostic yield of bronchoscopy in identifying the potential etiology of chronic heretofore unexplained cough. Disclosure: There is no conflict of interest or other disclosures. Reprints: Moshe Heching, MD, Rabin Medical Center, 39 Ze’ev Jabotinsky Road, Petah Tikva, 4941492 Israel (e-mail: moshehe@clalit.org.il). Received January 9, 2019 Accepted September 20, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Ultrasound Evaluation of Hemidiaphragm Function Following Thoracentesis: A Study on Mechanisms of Dyspnea Related to Pleural Effusion Introduction: Dyspnea is the major symptom caused by pleural effusion. The pathophysiological pathways leading to dyspnea are poorly understood. Dysfunction of respiratory mechanics may be a factor. We aimed to study the change in diaphragmatic function following thoracentesis. Methods: Patients undergoing thoracentesis at a highly specialized pleural center, underwent ultrasound evaluation of hemidiaphragm movement, before and after thoracentesis was performed. The change was compared to the reduction of dyspnea measured at the modified Borg scale. Results: Thirty-two patients were included. Dyspnea was reduced from 5.01 [95% confidence interval (CI): 4.12-6.04] to 2.6 (95% CI: 1.87-3.4, P<0.0001). Low hemidiaphragmatic movement before thoracentesis on the side of pleural effusion was improved by 17.4 cm2 (95% CI: 13.04-21.08), equalizing movement to the side without pleural effusion. On average, 1283 mL (SD: 469) fluid was drained. Multiple linear regression analysis showed that prethoracentesis ultrasound evaluation of hemidiaphragmatic function was correlated with successful thoracentesis. Conclusion: Hemidiaphragm function is reduced on the side of pleural effusion, and thoracentesis restores function. Improvement in diaphragm movement is related to a reduction in dyspnea. Some of the data were presented as a poster at the European Respiratory Society Congress in 2019. S.H.S.: concepted hypothesis, generated study design, and was involved in the collection, analysis, and interpretation of data and writing of manuscript. G.M. and P.C.: contributed to the study design, interpretation of data, and writing of manuscript. S.L., A.V., and F.Q.: contributed to the acquisition of data, interpretation of data, and writing of manuscript. Disclosure: There is no conflict of interest or other disclosures. Reprints: Søren H. Skaarup, MD, Department of Respiratory Medicine and Allergy, Aarhus University Hospital, Palle Juul Jensens Boulevard, Aarhus N 8200, Denmark (e-mail: soeska@rm.dk). Received June 1, 2019 Accepted September 6, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Jet Ventilation Decreases Target Motion and Increases Yield of ENB Especially in Lesions With Negative Bronchus Sign Background: Electromagnetic navigational bronchoscopy (ENB) is used to obtain peripheral lung tissue samples for evaluation and staging of central and peripheral lung lesions. Jet ventilation delivers and maintains a sustained airway pressure at high frequency, chest wall and diaphragmatic movement is drastically reduced compared with traditional ventilation. The current study looks to examine the effectiveness of tissue sampling (diagnostic yield) while using jet ventilation on target-lesion movement when compared with traditional ventilation. Methods: A total of 36 patients received total intravenous anesthesia with both jet and traditional ventilation during ENB procedure where sensor to lesion displacement was recorded. When planning the ENB procedure, the presence or absence of a viable airway to the lesion was recorded. Sensor to lesion movement was recorded and compared for significance using χ2 and t tests, utilizing stringent P-values. Results: Overall patients with an airway to the lesion (n=23) had a higher proportion of successful diagnostic biopsies, 83% compared with those patients that lacked an airway to the lesion (n=13) 70% proportion of successful diagnostic biopsies. When using jet ventilation, the chance of nonzero displacement was 8.3% (0.14 mm), regardless of the presence of an airway. Compared with traditional ventilation, the chance of a nonzero displacement between the sensor and target-lesion was 83% (6.4 mm), independent of airway presence to the lesions. Conclusion: In patients without an airway, jet ventilation significantly decreased target displacement when compared with traditional ventilation (2 vs. 17 mm). In patients with direct airway to the lesion, jet ventilation did not significantly decrease target displacement when compared with the traditional approach. Disclosure: There is no conflict of interest or other disclosures. Reprints: Tracey N. Webb, BS, Department of Psychology, Emory University, 2691 Mercedes Drive N.E., Atlanta, GA 30345 (e-mail: webb.tnicole@gmail.com). Received December 18, 2018 Accepted May 3, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A Prospective Outcome Assessment After Bronchoscopic Interventions for Malignant Central Airway Obstruction Background: A systematic assessment of comprehensive clinical outcomes after various therapeutic procedures for malignant central airway obstruction (CAO) is lacking. Methods: Patients with symptomatic malignant CAO undergoing various therapeutic bronchoscopy procedures were assessed for symptomatic and functional improvement using the Speiser Score, spirometry, 6-minute walk distance (6MWD), and St. George Respiratory Questionnaire (SGRQ) up to 3 months after the procedures. Results: A total of 83 intervention procedures were performed in 65 patients, comprising 43 (66.2%) male individuals [overall mean age, 52.4; SD, 15.4 y]. The majority of these (92.3%) was done using rigid bronchoscope under general anesthesia. Airway stenting was the most common intervention performed (56.6%), followed by mechanical debulking (26.5%), cryodebulking (6%), electrosurgical removal (4.8%), balloon dilatation (3.6%), and laser ablation (2.4%). A total of 15 complications (18.1%) were noted. Of these, 8 (53.3%) were early complications and 7 (46.7%) were late complications. Early complications included airway bleeding, hypoxia, vocal cord injury, laryngeal injury, and pneumothorax. Late complications included significant granulation tissue formation in metallic stents and lung collapse because of mucus plug. The survival rates at 4, 8, and 12 weeks were 83%, 70.7%, and 66.1%, respectively. Significant improvement was observed in dyspnea, cough, Speiser Score, 6MWD, forced expiratory volume in 1 s, forced vital capacity, and SGRQ scores at 48 hours, 4 weeks, and at 12 weeks after the procedures and no procedure-related mortality occurred. Conclusion: Various therapeutic bronchoscopic interventions, including combined modalities, provide rapid and sustained improvements in symptoms, respiratory status, exercise capacity, and quality of life in malignant CAO and have a good safety profile. Disclosure: There is no conflict of interest or other disclosures. Reprints: Anant Mohan, MD, PhD, FRCP, Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi 110029, India (e-mail: anantmohan@yahoo.com). Received September 30, 2017 Accepted August 8, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Assessment of Ergonomic Strain and Positioning During Bronchoscopic Procedures: A Feasibility Study Background: Poor ergonomics place health care workers at risk for work-related overuse injuries. Repetitive and prolonged hand maneuvers, such as those performed during endoscopic procedures, may lead to musculoskeletal complaints and work-related injuries. However, the prevalence of health care–related work injuries among physicians is thought to be underreported and there is a paucity of literature investigating the impact of ergonomic strain on bronchoscopy. We designed a feasibility study to explore the differences in ergonomic strain and muscle activity of bronchoscopists. Materials and Methods: A prospective study of bronchoscopic procedures was performed in a simulated environment. Preselected target areas were identified and airway sampling was performed with real-time ergonomic assessment utilizing electromyogram (EMG), grip strength, and musculoskeletal use and motion analysis. Results: Procedural data was obtained for all procedures (78 bronchoscopies by 13 subjects) for both ergonomic and EMG scores. Experienced bronchoscopists demonstrated less EMG burden (P=0.007) and improved ergonomic positioning (P=0.007) during bronchoscopy when compared with less experienced bronchoscopists. Procedures performed with rotational-head bronchoscopes trended toward improved ergonomics (P=0.15) and lower EMG scores (P=0.88). A significant improvement in ergonomic scores was seen with the rotational-head bronchoscope when targeting the left upper lobe (P=0.036). Conclusion: Poor ergonomic positioning and excessive muscle strain appear present within bronchoscopy procedures but may be improved in those with more bronchoscopy experience. Technological advances in bronchoscope design may also have the potential to improve procedural ergonomics. Additional prospective studies are warranted to define the long-term impact on bronchoscopic ergonomics. C.R.G. and J.T.: contributed equally.C.R.G., J.T., C.M., A.C., N.J.P., A.C.A., J.M., R.A.L., A.D.L., D.H.Y., B.S., D.L., H.J.L., L.B.Y. all contributed to study design, data acquisition, and analysis, drafting of the manuscript, final approval of the manuscript. All authors agree to be accountable for all aspects of the final submitted manuscript. Supported by research funding/equipment/support from Olympus Corporation of the Americas. The study sponsors did not participate in study design, data collection, data analysis, data interpretation, manuscript preparation, final manuscript approval, and/or the decision to submit the manuscript. This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number T32HL007534 and F32HL144121-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Disclosure: C.R.G., A.C., N.J.P., A.C.A., L.B.Y., have worked in the past and/or are currently consultants for Olympus Corporation of the Americas. The remaining authors declare no conflicts of interest or other disclosures. Reprints: Christopher R. Gilbert, DO, MS, Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, 1101 Madison Street, Suite 900, Seattle, WA 98104 (e-mail: christopher.gilbert@swedish.org). Received March 27, 2019 Accepted July 8, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Programmed Death Ligand 1 Testing of Endobronchial Ultrasound–guided Transbronchial Needle Aspiration Samples Acquired For the Diagnosis and Staging of Non–Small Cell Lung Cancer Rationale: Immunotherapy has become an integral part of management in patients with advanced non–small cell lung cancer (NSCLC). Programmed death ligand 1 (PD-L1) expression in at least 50% of tumor cells on histologic samples has been correlated with improved efficacy of the immune checkpoint inhibitor pembrolizumab. A limited number of studies have examined the suitability of endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) specimens for assessment of PD-L1 status. Objective: We sought to examine the feasibility and results of PD-L1 testing performed on EBUS-TBNA samples acquired for the diagnosis and staging of NSCLC. Materials and Methods: Patients were identified from a prospectively maintained pathology database. Baseline characteristics were tabulated. Hematoxylin and eosin slides were reviewed to categorize cellularity between <100, 100 to 500, and >500 viable tumor cells. Samples were tested using Dako’s PD-L1 IHC 22C3 pharmDx kit, with a minimum of 100 viable tumor cells. For patients in whom additional tissue samples were available, the results of PD-L1 testing were compared. Results: PD-L1 testing was attempted on 120 EBUS-TBNA samples. The most common NSCLC subtype was adenocarcinoma (78%). Seventy-six specimens (63%) had a cellularity >500 tumor cells. Among 110 of 120 (92%) patients with an adequate endobronchial ultrasound (EBUS) sample, 53 of 110 (48.2%) had high PD-L1 expression, defined as a Tumor Proportion Score ≥50%. EBUS PD-L1 results were concordant with an available histologic sample in 14 of 18 patients (78%), with no false-negative results. Conclusion: PD-L1 testing was feasible in the majority of EBUS-TBNA samples acquired for the diagnosis and staging of NSCLC. Comparison of EBUS results with histologic samples revealed moderate concordance, with no false-negative results. Supported by Rossy Cancer Network Research Fund. Disclosure: A.V.G. was the recipient of an FRQS chercheur-boursier-clinicien award and holds a grant from the Rossy Cancer Network. H.W. reports personal fees from Pfizer, Merck, and AstraZeneca, outside the submitted work. P.-O.F. reports personal fees from AstraZeneca, Merck, and Pfizer, outside the submitted work. The remaning authors have no conflict of interest or other disclosures. Reprints: Anne V. Gonzalez, MD, MSc, Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre Research Institute, 5252 Boul. de Maisonneuve West, 3D.63, Montreal, QC, Canada H4A 3S5 (e-mail: anne.gonzalez@mcgill.ca). Received March 10, 2019 Accepted August 5, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.