Mark Andrews, Leanne Griffin, Timothy Asibey-Berko, Rob Bevan, Rhys Howell, Gautham Appanna and Keir Lewis
Hywel Dda UHB, ABMU Health Board, Cardiff University, Bevan Commission and Swansea University
LungPoint® Navigational bronchoscopy provides an option to aid sampling of lung lesions not easily or safely reached via current bronchoscopic techniques. However, there is currently a paucity of evidence for its use (Eberhardt et al, 2010). Our study was designed to build upon this and assess its potential to address prudent healthcare principles.
Prudent Principle 1
Achieve health and wellbeing with the public, patients and professionals and as equal partners through co-production.
Patient selection for consideration of navigational bronchoscopy as a method of sampling their lung lesion involves firstly a multidisciplinary decision making process, weighing up this option against alternative strategies. Secondly an open and honest discussion with the patients about the procedure and any possible alternatives to reach a collaborative decision about whether and how to proceed.
Prudent Principle 2
Care for those with the greatest health need first, making most effective use of all skills and resources.
The current standard modality for sampling peripheral lung lesions not directly visible within the airway lumen involves CT-guided percutaneous biopsy. This requires substantial use of valuable radiology resources and time, leading to longer waiting times, limited availability of the procedure and obstruction of the CT services for other tests and procedures. Performing a bronchoscopic procedure instead addresses these issues, freeing up radiology resources to allow faster and better access for those who really need them, and providing a more immediately available option for those who don’t. However, this needs to be balanced against additional time and resources required for navigational bronchoscopy, which we are looking at within our study.
Prudent Principle 3
Do only what is needed, no more, no less and do no harm.
CT-guided biopsy carries a significantly greater complication risk compared with bronchoscopy. A recent study of CT-guided biopsy reported an 80% diagnostic rate but a 27% rate of pneumothorax as a complication (Priola et al, 2010). In comparison the LungPoint® study also reported an 80% diagnostic rate, but only 1 patient (4%) experienced a small pneumothorax which resolved spontaneously without needing intercostal drainage (Eberhardt et al, 2010). We therefore hypothesise that the use of LungPoint® for peripheral lesions will reduce complications while retaining accuracy compared to CT-guided biopsies.
Prudent Principle 4
Reduce inappropriate variation using evidence based practices consistently and transparently.
Phase 1 of our study was designed to allow the operators to get familiar with the navigation tool, and to confirm that it correctly navigates to and identifies the intended area. A 100% pass rate was achieved, but the learning curve provided some valuable lessons, and certain issues were identified with the procedure. By reporting and publishing this information, it should allow what we learned to serve others as well as ourselves in using the tool optimally.
Phase 2 will assess the diagnostic sensitivity, complication rate and practical use of LungPoint® to guide transbronchial sampling from peripheral lesions not seen endobronchially. We also intend to determine the implications in terms of costs, time requirements and technical difficulties. Early results are promising, with a good diagnostic rate and low complication rate being achieved.
Part of Cohort Bevan Fellows 2015-16