dimensional map essentially is used to create a pathway all the way from the proximal bronchus to the distal bronchus in <1 cm (10 mm) proximity to the lung mass and nodule to be sampled. EMN has now been widely studied and Gildea and colleagues described their yield of 74% and 100% with navigational bronchoscopy for sampling peripheral lesions and lymph nodes with a mean size of 22.8 ± 12.6 mm and 28.1 ± 12.8 mm, respectively [43]. Other factors and adjunct technologies that increase the yield of EMN are: concomitant RP-EBUS, guided sheath techniques, multidimensional fuoroscopy, and rapid onsite cytology evaluation (ROSE). With the results of the National Lung Screening Trial, navigational bronchoscopy coupled with a staging procedure using CP-EBUS is currently the main procedure adopted for the diagnosis and staging of peripheral lung nodules [44].

Bronchial Thermoplasty (2006–)

Using heat to induce structural changes in the airway wall and hence decrease airway reactivity is the basic principle of bronchial thermoplasty (BT). The Alair system from Boston Scienti c uses a radiofrequency controller with a treatment catheter to deliver 18 W of heat at each treatment site. Preliminary investigations in dogs showed that application of thermal energy to the airway decreased airway hyperresponsiveness, and replaced smooth muscle with connective tissue with no evidence of scarring at 3 years [45].

After early investigations testing the usefulness of BT in human subjects, Gerard Cox and colleagues established the safety of BT in 16 human subjects over a 2-year period with improvements in symptom-free days, and morning and evening peak fow rates, and without signi cant complications [46, 47].

The safety of BT and duration of its effects in patients with asthma in terms of decreased emergency room visits and acute exacerbations have been demonstrated in a large multicenter study [48].

Bronchoscopic Lung Volume

Reduction (2003)

The National Emphysema Treatment Trial (NETT) proved the bene cial effects of surgical lung volume reduction in carefully selected patients with emphysema [49]. As lung volume reduction surgery (LVRS) is a major surgery with post-surgical mortality and morbidity, signi cant interest was generated in the possibility of endobronchial lung volume reduction using minimally invasive techniques. Tudor Toma introduced the concept of endobronchial volume reduction using one-way valves in 2003 [50]. Since then two different types of endobronchial valves (EBVs), Zephyr (Pulmonx Inc.) and IBV (Spiration Inc.), have undergone multiple safety and ef cacy trials [51, 52].

The utility of endobronchial valves (EBVs) remains experimental in the United States. However, one major spin-off of the technology has been the application of EBVs to the management of bronchopleural stula. Researchers have clearly shown that EBVs help heal these stulas, thereby eliminating the need for surgical thoracic procedures [53]. It is also worth noting that the role of endobronchial coils in reestablishing elastic recoil of the lungs in patients with emphysema is being studied in a large international, multicenter trial [54].

Endobronchial Microwave Therapy (2004–)

Microwave coagulation refers to the electromagnetic wave with wavelengths ranging from 1 m to 1 mm, or with frequencies between 300 MHz and 300 GHz, which fall in between the high-­ frequency electric-argon plasma and laser coagulation techniques.

It is a fairly safe procedure because it induces no tissue vaporization and requires no oxygen during the operation. In addition, it has an appreciable treatment depth. It has been used to treat the trachea blockage condition caused by benign and malignant tumors within the airway, intima hyperplasia of tuberculosis, polyps, granulomas, and other complications.

Bronchoscopic microwave tissue coagulation (MTC) and microwave diathermy (MD) therapy were performed on 37 patients with severe tracheal stenosis at least two times. The effective rate immediately after treatment was 100% in all cases. After 1 month, the rate remained 100% in patients with benign diseases, but it dropped to 67% in patients with malignant tumors [55].

AFI can readily identify the vasculature pattern and suspicious areas along centimeters-long airway segments. Once identi ed, closer examination of OCT can verify if the site is appropriate for biopsy collection. Thus, DOCT-AFI may increase the ability to identify and locate pulmonary nodules and improve the safety of biopsy collection [60].

Endoscopic Doppler Optical

Coherence Tomography

and Autofuorescence Imaging

(DOCT-AFI) System (2014–) [56]

Autofuorescence imaging (AFI) can provide biochemical information of tissue by visualizing fuorescent tissue components such as collagen and elastin. AFI has been implemented in commercial bronchoscopes for wideeld imaging in the central airway. When illuminated by blue light, normal central airway tissue emits green autofuorescence (AF) while cancerous tissue is known to have a markedly reduced and red-­ shifted AF signal due to the breakdown of extracellular matrix components as well as increased absorption by blood [57].

Owing to this contrast mechanism, AFI is up to six times more sensitive compared to white-­ light bronchoscopy in detecting intraepithelial neoplastic lesions [58, 59]. This increased sensitivity comes at the cost of reduced speci city as infammation and chronic bronchitis can also lead to reduced AF.

Optical coherence tomography (OCT) can visualize signi cantly ner tissue structures compared to RP-EBUS with 1–2 mm imaging depth penetration into tissue.

This imaging technique can offer both structural and functional information for the localization and management of pulmonary nodules.

This technology is relatively safe and feasible for the evaluation of pulmonary nodules.

American Association for Bronchology and Interventional Pulmonology (AABIP) and Journal of Bronchology and Interventional Pulmonology (JOBIP) (1992–)

AABIP was founded in 1992 by a small group of dedicated bronchoscopists with the goal of advancing the eld of bronchoscopy and interventional pulmonology. The AABIP has successfully helped develop training and education programs in interventional pulmonology. The training programs in interventional pulmonology now work with the national residency matching program (NRMP). In addition, board certi cation has now been established for the specialty of interventional pulmonology that has further strengthened this subspecialty within the domains of pulmonary medicine.

JOBIP, the fagship publication of the society, was accepted in Index Medicus in 2011. This was a major boost to the research output and recognition of interventional pulmonology around the world [61, 62].

In this chapter and other articles, we have attempted to give the readers a brief glimpse of the development of modern day bronchoscopes and the innovation and creativity that went into building this present day science and technology (Fig. 42.12) [63]. These techniques have revolutionized the diagnosis and management of a variety of lung diseases and advances continue to be made therein [63].