Policy responses and statements

Name of organisation:

The British Thoracic Society

Name of policy document:

Draft Guidelines for advanced diagnostic and therapeutic flexible bronchoscopy in adults

Deadline for response:

9 June 2010

Background: This document was prepared by a sub-committee of the British Thoracic Society's Standards of Care Committee (SOCC). The British Thoracic Society formally invited feedback from the College on these draft recommendations.

COMMENTS ON
BRITISH THORACIC SOCIETY
GUIDELINE FOR ADVANCED DIAGNOSTIC AND THERAPEUTIC FLEXIBLE BRONCHOSCOPY IN ADULTS

The Royal College of Physicians of Edinburgh is pleased to respond to the British Thoracic Society on its Guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults.

The report has been well written with a thorough review of the existing literature.  We are slightly concerned that the potential benefits of some of the procedures has been over-emphasised because they are perceived to be clinical ‘state of the art’, rather than techniques with real potential clinical application.  Therefore, because of the limitations in some of the evidence, we feel that there should be statements advising that the bronchoscopy technique advocated may not be the preferred investigative choice (see examples below), although there is some evidence of efficacy.

Specific Comments

1. We do not believe that anyone would argue against the role of (and the guideline comments) about trans-bronchial needle aspiration (TBNA) and endobronchial ultrasound guided (EBUS) TBNA, for diagnosis and staging of lung cancer.  These may not be the best techniques for diagnosing sarcoidosis – the reason being that they are an “aspiration” technique (i.e. cytology), not a biopsy technique (and in the guideline, page 22, EBUS-TBNA is incorrectly referred to as “biopsying”).  While the guideline gives supported published evidence of diagnosis of sarcoid by TBNA, the actual studies quoted explored the technique’s value in a population of patients who were highly likely to have a diagnosis of sarcoid.  The technique has not really been tested in a population of really uncertain diagnosis.  To have a proper evaluation of the technique, one would need a comparison with other techniques also used to diagnose sarcoid eg. bronchial and transbronchial lung biopsy +/- bronchoalveolar lavage; nodal biopsy via EUS (endoscopic ultrasound).

2. There are a number of suggested techniques for endobronchial debulking of tumours.  The techniques work (published evidence) and the hazards are recognised.  The question really is how “generalisable” are these techniques?  That is, if a centre does not have any such technique available, how essential is it for that centre to obtain one?  What proportion of lung cancer patients who are treated in this fashion, as opposed to alternative strategies such as urgent radiotherapy, would really benefit?

3. The guidelines support the use of valves in the treatment of emphysema.  The truth is that there are studies that show such valves have efficacy in highly selected patients (ie there is an “evidence base” that they work).  However, the limitations of the studies are not made clear enough, and we believe that the guideline should be stating that there is some evidence of (limited) efficacy in selected patients, and the techniques hold out promise for the future, but their final place in patient management has yet to be established.

4. There are a small number of publications that show some benefits of bronchial thermoplasty in asthma.  However, the studies are selected and the outcome variables are only positive in some aspects (and for some of those the difference is small, although achieving statistical significance).  In one of the two bigger studies, the asthma treatment dosing with inhaled steroids was quite low and one therapy (long acting beta agonists) was withdrawn for part of the trial.  So bronchial thermoplasty is not compared with current best (or “maximal”) therapy.  Thus, we feel the true evidence base is not really further than “this is a treatment that might work in difficult asthma”.  The evidence base is not so compelling that all asthma units should establish bronchial thermoplasty.  Thus, the guideline should once again go no further than saying the technique holds out promise for the future, but the final place in patient management has yet to be established.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[7 June 2010]