Response

To the Editor:

I thank Drs Shulimzon and Segel for their thoughtful review and comments on our article in CHEST,¹ which provides data from the American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education (AQuIRE) program on technical success rates of therapeutic bronchoscopy in patients with malignant central airway obstruction. There is an accompanying article that provides data on complications for these same patients.²

Drs Shulimzon and Segel correctly point out that in the 1,115 procedures, 1,836 different treatment modalities were used. In this case, treatment modalities refer to any stent, dilation, or ablative procedure. Ablative refers to the use of modalities that destroy tissue, so, in this case, it is the use of electrocautery, argon plasma coagulation, laser, or cryotherapy. It is probably best to assess the cohort by considering ablation and stenting separately, since ablation techniques can be used somewhat interchangeably to deal with certain problems (eg, electrocautery or laser can either be used for an endobronchial lesion), but an ablation technique cannot be used as a substitute for stenting in certain cases (eg, extrinsic compression). A total of 982 ablative techniques were used in 879 procedures (79%), so, on average, 1.12 different ablative techniques were used per procedure. Stents were used in 406 procedures (36%). Not all institutions had access to every ablative technique, and not all centers performed rigid bronchoscopy. Therefore, the reason why a particular modality was chosen over another in a given case cannot be determined, and, in some cases, there was probably no choice. However, we did not find evidence that the type of ablative method used impacted outcome.

Whether patients who undergo ablation should have stenting afterward cannot be answered by this type of study. Patients with symptomatic malignant central airway obstruction > 50% purely due to extrinsic compression are good candidates for stenting. The more difficult question is whether patients with mixed disease or extensive mucosal involvement should have stenting after ablation. If ablation is completely unsuccessful, such that reopening of the airway cannot be achieved without a stent, then the benefits of stenting probably warrant the risks. However, in those patients who have significant reopening after ablation, the benefits and harms of stenting vs not stenting are less clear, and a more conservative strategy may be warranted. We agree that in such cases, physicians need to weigh the potential for symptomatic benefits¹ vs the potential harms.^2-5 Importantly, both short-term and long-term benefits and risks need to be considered, and this study only has data out to 30 days. Future studies will need to quantify the long-term impact of therapeutic bronchoscopy on health-related quality of life, as well as the long-term complications.