Archives of Pulmonology and Respiratory Care

Abid Butt1*, Rodrigo Cavallazzi2 and

Umair Gauhar2
1Department of Critical Care Medicine, King Faisal
Specialist Hospital & Research Center, Riyadh,
Kingdom of Saudi Arabia
2Division of Pulmonary, Critical Care, and Sleep
Disorders Medicine, Department of Medicine,
University of Louisville, KY, USA
Dates: Received: 25 May, 2016; Accepted: 02 July,
2016; Published: 04 July, 2016
*Corresponding author: Abid Butt, MD, FCCP,
Department of Critical Care Medicine, King Faisal
Specialist Hospital & Research Center Riyadh,
Kingdom of Saudi Arabia, Tel: +966 11 442 4731;
E-mail:
www.peertechz.com
Keywords: Interventional pulmonology; Survey; Practice patterns

Research Article

Interventional Pulmonology in 2015:

A Survey of Practice Patterns and
Future Directions of this Emerging
Field
Abstract
Background: Interventional Pulmonology (IP) training through formal fellowship programs have
become increasingly popular over the last several years. There is a dearth of data on the current
practice of IP in the United States. The objective of this study was to identify the practice patterns of
current IP practitioners.
Methods: We sent a survey to the members of the American Association of Bronchology and Interventional Pulmonology (AABIP) the largest association of American IP practitioners. We analyzed
the responses and stratified the responses to compare, when possible, how the practice patterns of
the IP fellowship trained physicians varied from those who did not undergo formal fellowship training.
Results: We received a reply from 97 individuals. There was a noticeable difference in the practice patterns of respondents who had undergone fellowship training in IP versus those who had not,
particularly with respect to volume and diversity of procedures performed. A small percentage of respondents appeared responsible for most of the advanced therapeutic procedures as well as ongoing
research in the field of IP.
Conclusions: Our study is, to our knowledge, the first to capture the state of affairs of practicing
Interventional Pulmonologists in the US. Our survey raises hopes as well as concerns about the benefits associated with an additional year of training in IP. We feel this survey will serve as an important
aid for IP practitioners, fellowship directors, and IP fellows (both current and future) to further define
clinical and research priorities and to foresee any future challenges in the field.

Introduction
Interventional pulmonology (IP) is a relatively new but rapidly
expanding branch of Pulmonology. While some of the tools used
by Interventional Pulmonologists are decades old (e.g. the flexible
bronchoscope was introduced in 1968) [1], the fields recent
popularity appears to stem from the rapid proliferation of technically
advanced diagnostic tools. Modern bronchoscopic equipment such as
endobronchial ultrasound (EBUS) and electromagnetic navigational
bronchoscopy (ENB) have revolutionized the management of
many pulmonary diseases and have been thoroughly validated [2],
in lung cancer staging and diagnosis of pulmonary parenchymal
abnormalities. There has also been a resurgence of interest in
advanced therapeutic bronchoscopy particularly rigid bronchoscopy.
This interest has driven a dramatic increase in the number of
training positions offering dedicated 12-month IP training in North
America. As an illustration, there were 5 such programs [3], listed
with the American Association of Bronchology and Interventional
Pulmonology (AABIP) in 2007. By the 2015-2016 training year,
this number had increased to 26, an increase of more than 500%.
Despite the significantly increased number of training positions, it
remains unclear whether this was in response to an unmet demand or
whether these supra-specialized graduates were vfinding themselves
in positions where they were unable to utilize all the skills they had
acquired in the additional year(s) of training. The goal of our survey

was to bridge this gap in our knowledge and gain an understanding of

the current practice paradigm of IP practitioners in the United States.

Materials and Methods

Our study is a cross-sectional analysis of Interventional
Pulmonology Practitioners using a web-based survey (www.
surveymonkey.com). We did not obtain Institutional Board Review
approval as there was no question pertained to private patient
information. The survey was sent to members of the American
Association of Bronchology and Interventional Pulmonology
(AABIP) after soliciting feedback on the survey design and question
content from the AABIP leadership. The AABIP was chosen as the
forum for the survey as it is the largest organization of American
practitioners of Interventional Pulmonology. Recipients of the survey
were asked to fill out a questionnaire on their IP training (whether via
a formal fellowship or self-directed), current practice, the scope and
volume of procedures they currently performed, the use of sedation
and anesthesia in their endoscopy suite, as well as satisfaction with
their career choice. Question formats included multiple choice,
matrix scale rating as well as single and multiple free text entries.

Statistical analysis
We performed descriptive analyses for all variables included in
the study. Median and interquartile range are reported for continuous

Citation: Butt A, Cavallazzi R, Gauhar U (2016) Interventional Pulmonology in 2015: A Survey of Practice Patterns and Future Directions of this Emerging
Field. Arch Pulmonol Respir Care 2(1): 020-023.

020

Butt et al. (2016)

variables. Proportions are reported for categorical variables. Statistical

inference was performed to compare participants with IP fellowship
training from those without it. We used the Wilcoxon Rank-Sum
(Mann-Whitney) test for comparing continuous variables, and the
Fishers exact test for comparing categorical variables. We carried
out all statistical analysis with Stata 10 (Stata Corp, College Station,
Texas). As some respondents did not answer every question in the
survey, the sample size for individual questions differed across the
survey. Answers from one respondent were removed from the final
analysis after it was noticed that the responses appeared contradictory
or not relevant to the question being asked. When an individual
answer was given in the form of a range, the median value was used
for statistical analysis purposes. In the few instances where an answer
was given as >x then x+1 was used for analysis purposes.

Results
The survey was answered by 97 individuals, of whom 26% (25 of
97) had dedicated fellowship training in IP (hereafter referred to as
Formal IP Trainees (FIPT)) while the remainder (Non-IP Trainees
or NIPT) acquired their skills during or after their Pulmonary and
Critical Care Fellowship (PCCF).

Matching into IP fellowships

The FIPT reported that 90% (18 of 20) matched into an IP
fellowship program within a year of applying, and that 85% (17 of 20)
started their IP training immediately following their PCCF.

Table 1: Utilization of total clinical time

All

IP fellowship
training

No IP fellowship
P value
training

% time in IP (n = 73)

30 (20
70)

90 (55 100)

30 (20 50)

< 0.001

% time in outpatient
(n = 66)

20 (10
30)

5 (0 20)

20 (10 30)

0.0047

% time in sleep
(n = 53)

0 (0 5)

0 (0 0)

0 (0 5)

0.0679

% time in ICU (n = 66)

20 (5
30)

2 (0 10)

20 (10 30)

0.0004

Practice setup of IP Practitioners

100%

90%

11

16

80%

38

70%
60%
50%
40%

79

30%

51

20%
10%
0%

Fellowship Trained
Academics

Private Practice

Non-Fellowship Trained
Academics/Private Practice/VA combination

Obtaining privileges to perform IP procedures

For the FIPT, 42% (7 of 19) obtained privileges to perform the
procedures they were trained in immediately, with 89% (17 of 19)
getting them within 3 months of starting. The remaining two had to
wait for 6 and 12 months to get full privileges. On the other hand, only
18% (8 of 45) of the NIPT obtained IP privileges immediately, with
66% (34 of 45) getting privileges within 3 months of starting. 24% (11
of 45) of the NIPT had to wait for more than 3 months, with the range
being four to thirty-five months to obtain full IP privileges. IP skills
training workshops proved popular among NIPT respondents, with
84% (56 of 67) reporting attending such training. Whether this was
related to privileging needs was unclear.

Clinical practice of IP
The breakdown of clinical time and practice setup is listed in
Table 1 and Figure 1 respectively. Note that there was no statistical
difference in the practice setup of the two groups.

Procedural colume
We asked the respondents to quantify the number of advanced
diagnostic, advanced therapeutic and pleural procedures they had
done over the last six months. These are listed in Table 2 and illustrated
in Figures 2,3. We were also curious to find out the variation in
practice regarding sedation for various procedures. Table 3 lists only
those procedures for which there was a statistical difference between
the cohorts.

Research and publications

56% (9 of 16) of the FIPT and 78% (38 of 49) of the NIPT reported
having less than 10% dedicated time for research, while 44% (7 of

021

Figure 1: Practice setup of IP Practitioners.

16) of the FIPT vs 18% (9 of 49) of the NIPT had 11-30% dedicated
time for research. 53% (8 of 15) of the FIPT reported receiving grant
monies or other sources of funding dedicated for research, while 27%
(14 of 51) of the NIPT had the same. While these differences were
not statistically significant, they did have an impact on the number of
publications reported by both groups (Table 4).

Satisfaction with career and training

We asked the respondents to quantify their satisfaction with IP
as their career choice, and specifically queried the FIPT regarding
their perceptions of the adequacy of their subspecialized training
using a satisfaction score ranging from 1-10 (with 10 representing
very satisfied) (Figure 4). We found that 70% (16 of 23) of the FIPT
respondents chose 9 or 10 on the scale with 30% (7 of 23) choosing
7 or 8. For the NIPT, 52% (22 of 42) chose 9 or 10 on the scale, 31%
(13 of 42) chose 7 or 8, while 12% (5 of 42) chose 5 or 6, and one
respondent each chose 3 and 1 on the scale.

Discussion
The field of modern IP is relatively new and appears to be
increasingly popular among trainees as evidenced by the burgeoning
number of training positions. A fellowship in Interventional
Pulmonology entails an additional 1-2 years of advanced training.
During this time trainees are exposed to advanced procedures, both
diagnostic and therapeutic, to which their exposure in traditional
Pulmonary and Critical Care fellowship has traditionally been limited

Citation: Butt A, Cavallazzi R, Gauhar U (2016) Interventional Pulmonology in 2015: A Survey of Practice Patterns and Future Directions of this Emerging
Field. Arch Pulmonol Respir Care 2(1): 020-023.

Butt et al. (2016)

Table 2: Procedural Volume

Rigid bronchoscopies (n = 63)

All

IP fellowship training

No IP fellowship training

P value

5 (0-5)

30 (20 50)

3 (0 -10)

< 0.001

Radial EBUS (n = 63)

20 (2-40)

22.5 (0-40)

20 (2 35)

0.97

Curvilinear EBUS (n = 64)

62.5 (30 100)

77.5 (50 137)

60 (30 100)

0.0786

Electromagnetic Navigational Bronchoscopies (n =64)

19 (0.5 30)

16.5 (5 20)

20 (0 -40)

0.69

Autofluorescence (n = 63)

0 (0-0)

0 (0 0)

0 (0 0)

0.172

Narrow Band Imaging (n = 64)

0.5 (0 19)

1 (0 10)

0 (0 -25)

0.80

Cryobiopsy (n = 64)

0 (0 5)

0 (0 4)

0 (0 5)

0.88

APC (n = 62)

6 (1 - 20)

12.5 (0 30)

5.5 (1 -20)

0.47

Laser (n = 59)

0 (0 1)

2 (0 7)

0 (0 0)

0.0014

Stent Placement/Removal (n = 63)

5 (1 12)

13.5 (5 15)

3 (0 6)

0.0041

Electocautery (n = 62)

5 (0 15)

6.5 (2 15)

4.5 (0 15)

0.33

Bronchial Thermoplasty (n = 61)

0 (0 4)

1 (0 2)

0 (0 5)

0.8503

Cryotherapy (n = 61)

3 (0 10)

4 (3 10)

2 (0 10)

0.3297

Brachytherapy (n = 58)

0 (0 0)

0 (0 0)

0 (0 0)

0.7951

Thoracostomy (n = 62)

10 (4 20)

7.5 (4 25)

10 (4.5 20)

0.9663

Indwelling pleural Catheter Placement (n = 63)

6 (2 15)

15 (5 20)

5 (0 12)

0.0085

Medical Thoracoscopy (n = 62)

0 (0 5)

0 (0 10)

0 (0 4.5)

0.6083

Percutaneous Tracheostomy (n = 63)

5 (0 10)

5.5 (0 10)

2 (0 10)

0.7760

Transtracheal Oxygen Catheter Placement (n = 61)

0 (0 0)

0 (0 0)

0 (0 - 0)

0.7524

100

Table 3: Procedural Sedation

All

75
50
25
0

Fellowship

Rigid bronchoscopies
Laser
Indwelling

Curvilinear
Stent

Deep sedation

8
(13.33)

3 (21.43)

5 (10.87)

General anesthesia

21 (35)

4 (28.57)

17 (36.96)

Local anesthesia

1 (1.67) 0 (0)

1 (2.17)

Moderate sedation

23
(38.33)

2 (14.29)

21 (45.65)

7
(11.67)

5 (35.71)

2 (4.35)

Total
intravenousanesthesia

80
60

0.047

Deep sedation

5 (9.43) 2 (18.18)

3 (7.14)

General anesthesia

19
(35.85)

16 (38.10)

Local anesthesia

1 (1.89) 0 (0)

1 (2.38)

Moderate sedation

21
(39.62)

2 (18.18)

19 (45.24)

7
(13.21)

4 (36.36)

3 (7.14)

Total intravenous
anesthesia

3 (27.27)

20

40

Navigational
Bronchoscopy
(n = 54)

No fellowship
5 or less
15 or more

Figure 3: Number of Medical Thoracoscopies.

6 to 14

0.045

Deep sedation

7
(12.96)

2 (15.38)

5 (12.20)

General anesthesia

25
(46.30)

4 (30.77)

21 (51.22)

Local anesthesia

1 (1.85) 0 (0)

1 (2.44)

Moderate sedation

11
(20.37)

1 (7.69)

10 (24.39)

10
(18.52)

6 (46.15)

4 (9.76)

Fellowship

Total intravenous
anesthesia

P
value
0.008

Radial EBUS
(n = 53)

Figure 2: Procedural Volume.

percent

No IP fellowship
training

Curvilinear EBUS
(n = 60)

No fellowship

022

IP fellowship
training

Citation: Butt A, Cavallazzi R, Gauhar U (2016) Interventional Pulmonology in 2015: A Survey of Practice Patterns and Future Directions of this Emerging
Field. Arch Pulmonol Respir Care 2(1): 020-023.

Butt et al. (2016)

Table 4: Support for research

IP fellowship
training

All

No IP fellowship
P value
training

Research time (n = 65)

<10%

0.140
47 (72.31) 9 (56.25)

38 (77.55)

11-20%

11 (16.92) 4 (25)

7 (14.29)

21-30%

5 (7.69)

3 (18.75)

2 (4.08)

0 (0)

2 (4.08)

31-40%

2 (3.08)

Grant (n = 66)

22 (33.33) 8 (53.33)

14 (27.45)

0.062

Manuscripts (n = 67)

2 (0 5)

1 (0 4)

0.0108

5 (2 9.5)

Satisfaction with IP Fellowship Training

120
100
80

26

25

74

75

35

60
40

65

20
0

Didactics

Case Diversity
Room for Improvement

Procedural Volume
Satised

Figure 4: Satisfaction with Fellowship training in IP.

at best. There are however, several unanswered questions regarding

the significance of this extensive undertaking, some of which we have
tried to address. We believe our data provides the first comprehensive
look at practice patterns among members of the Interventional
Pulmonology community in North America.
We presumed that by looking at practice patterns of both
fellowship trained and non-fellowship trained IP practitioners, we
would get some insight into the demands of the US healthcare system,
and that by categorizing the respondents into those who had formal
IP fellowship training (FIPT) and those who did not (NIPT), we
would be able to discern differences in the practice patterns of these
two cohorts.
We found that FIPT were significantly more likely to spend their
clinical time in Interventional Pulmonary and less likely to be doing
either general Pulmonary or Critical Care. The FIPT cohort was also
more likely though not significantly so, to practice in an academic
setting. We also noted that the FIPT performed more advanced airway
procedures, particularly rigid bronchoscopy, laser use in the airway,
airway stenting as well as placement of indwelling pleural catheters.
Notwithstanding a recent paper [4], showing no change in the yield or
time taken to do Electromagnetic Navigation Bronchoscopy between
moderate sedation and general anesthesia, greater than 65% of our
survey respondents reported using deep sedation or anesthesia while
performing ENBs.
Our data suggested ongoing demand for FIPT physicians, as
the time duration between finishing fellowship and starting at an IP
position was less than six months for all respondents. Despite no real

difference in time allocated for research, they were publishing more

manuscripts than their non-IP trained peers. This difference may be
a function of the varying nature of employment model with resultant
pressures and markers of performance between the two cohorts
because the FIPT were more likely (though not significantly so) to be
in academics than the NIPT.
As there are only a limited number of academic positions
available in the country, it remains unclear whether there is enough
of a market outside the tertiary care, academic medical centers for
these highly skilled physicians. If there isnt, this may result in future
graduates being shunted into the private practice employment model,
where the time spent to reimbursement ratio can be a determinant in
how patient care is driven [5]. We suspect that in this model, FIPT
physicians would have limited time and opportunity for practicing
their therapeutic skills outside of some limited airway debulking. This
contention should give pause to the current ever-increasing number
of training positions offered in IP. Already, most FIPT graduates felt
they had gaps in their training, and if these gaps were compounded
by low volumes experiences once they were out in practice, this
would lead to questions of ongoing competency. Our data does not
support this contention, except indirectly in that NIPT physicians in
private practice appeared to be performing less advanced therapeutic
procedures. This would form an interesting idea for a future study.
There are of course several limitations to our study. As with any
survey, our analysis is limited to those who responded to the survey,
and we were unable to ascertain the total number of people the
survey was sent to. In addition, there are IP practitioners not on the
AABIP mailing list. As such, we cannot claim that our data is fully
representative of every single practitioner. Some of the answers could
not reach statistical significance because of the small sample size.
We feel this report identifies important trends in the IP community,
both promising and worrisome. Overall, career satisfaction amongst
IP practitioners remains high but whether this will be sustained given
the challenges mentioned above, in conjunction with the uncertainty
of and ongoing evolution in the American healthcare delivery system
is difficult to predict.

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Copyright: 2016 Butt A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

023

Citation: Butt A, Cavallazzi R, Gauhar U (2016) Interventional Pulmonology in 2015: A Survey of Practice Patterns and Future Directions of this Emerging
Field. Arch Pulmonol Respir Care 2(1): 020-023.