Endobronchial-valve treatment for advanced heterogeneous emphysema induced modest improvements in lung function, exercise tolerance, and symptoms at the cost of more frequent exacerbations of COPD, pneumonia, and hemoptysis after implantation. (Funded by Pulmonx; ClinicalTrials.gov number, NCT00129584.)

Rationale: Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy.Objectives: To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations.Methods: We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions.Measurements and Main Results: Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16).Conclusions: Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.

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A ssessing mediastinal lymph node (LN) involvement is critical to staging and treating non-small cell lung cancer. 1-3 CT and PET scans are useful for staging the mediastinum but are limited by false-positive and false-negative results. Therefore, in patients with mediastinal LN enlargement and no evidence of distant metastasis, tissue confi rmation of nodal involvement is recommended. 2,4,5 Transbronchial needle aspiration (TBNA) biopsy has been used to obtain tissue for mediastinal staging for decades, although it has been underused because of variations in training, operator skill, perceived risk, and diagnostic yield. 6 However, its use is increasing because of recent advances in bronchoscopic technology. In particular, endobronchial ultrasound-guided TBNA (EBUS-TBNA) biopsy has been found in randomized trials to have Results:We enrolled 891 patients at six hospitals. Most procedures (95%) were performed with ultrasound guidance. A specifi c diagnosis was made in 447 cases. Unadjusted diagnostic yields were 37% to 54% for different hospitals, with signifi cant between-hospital heterogeneity ( P 5 .0001). Diagnostic yield was associated with annual hospital TBNA volume (OR, 1.003; 95% CI, 1.000-1.006; P 5 .037), smoking (OR, 1.55; 95% CI, 1.02-2.34; P 5 .042), biopsy of more than two sites (OR, 0.57; 95% CI, 0.38-0.85; P 5 .015), lymph node size (reference . 1-2 cm, Յ 1 cm: OR, 0.51; 95% CI, 0.34-0.77; P 5 .003; . 2-3 cm: OR, 2.49; 95% CI, 1.61-3.85; P , .001; and . 3 cm: OR, 3.61; 95% CI, 2.17-6.00; P , .001), and positive PET scan (OR, 3.12; 95% CI, 1.39-7.01; P 5 .018). Biopsy was performed on more and smaller nodes at high-volume hospitals ( P , .0001). Conclusions: To our knowledge, this is the fi rst bronchoscopy study of risk-adjusted diagnostic yields on a hospital-level basis. High-volume hospitals were associated with high diagnostic yields. This study also demonstrates the value of procedural registries as a quality improvement tool. A larger number and variety of participating hospitals is needed to verify these results and to further investigate other determinants of diagnostic yield.CHEST 2011; 140(6):1557-1566Abbreviations: ACCP 5 American College of Chest Physicians; AQuIRE 5 American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education; EBUS-TBNA 5 endobronchial ultrasound-guided transbronchial needle aspiration; LN 5 lymph node; QI 5 quality improvement; TBNA 5 transbronchial needle aspiration

on behalf of the AQuIRE Bronchoscopy Registry BACKGROUND: Th ere is signifi cant variation between physicians in terms of how they perform therapeutic bronchoscopy, but there are few data on whether these differences impact eff ectiveness.