All right, thank you everyone for being here. This is the fourth of the AABIP-sponsored interventional pulmonary talks at CHEST as we thank both the AABIP and CHEST for their support. This talk is about rigid bronchoscopy, whether it is alive and well or has gone the way of the dodo. So in the era of flexible bronchoscopy, robotic bronchoscopy, electromagnetic navigation, 3D imaging, we ask ourselves whether there's still a role for rigid bronchoscopy in therapeutics. As you know, rigid bronchoscopy started over 100 years ago and is still practiced in many institutions across the country. There are two teams for this debate. There is Team Rigid and Team Flexible. On Team Rigid, we have Dr. Folk from Mass General and Dr. Simoff from Henry Ford. For Team Flexible, we've got Dr. Mehta from Cleveland Clinic and Dr. Oberg from UCLA. There are a few ground rules we've just revised. Presenting remarks will be 10 minutes from each side. Then there will be three different cases where Dr. Folk and Dr. Oberg will be given opportunities to present how they would approach the case, either by rigid or flexible bronchoscopy. And then we will open up for questions at the end. So if you have any questions that come up in your mind throughout the course of these talks, save them for the end and we will open up to a more of a town hall debate style. We'll be keeping a clock so people have to stay on time on this side. Okay. Is Mike first? Oh, Mike. Mike is first. I'm first? Okay. While it's loading, my name is Mike Simoff. I'm the Director of Interventional at Henry Ford and Lung Cancer Screening. Disclosures. I am Associate Medical Officer at Intuitive, but it has nothing to do with rigid bronchoscopy nor does any other work that I've done. Let's see if things start. The biggest thing is let's look at a patient. If I move around at all, walking, talking, sleeping, running a mile and out of breath. I'm nervous, of course, but you got to do it. Can't climb like I am. There was something there. So rigid bronchoscopy is the original bronchoscopy. I mean, it's been around for 140 years. It has been used for that period of time. It's had upswings, downswings, et cetera. People look at it as barbaric. Oh, you know, look at this. He's a sword swallower. We're not actually doing a procedure. We're actually that. But what it is is an access to the airway. And the first and most important point is rigid bronchoscopy is minimally invasive. Yes, it looks kind of scary if you don't do it on a routine basis, but it's minimally invasive. We don't have to make incisions. We are able to access the airway and do a lot of things that can't be done. As an example of things that are difficult to be done, same patient, distal tracheal tumor, right main stem maybe 30%, 40% open, and left main stem almost completely closed. How do we approach that? We saw what the patient looked like. Is it important that we approach that? Is this additive? Am I just doing this and doing something that's going to make the patient feel better for a short period of time? What is the approaches, and why are we doing therapeutic bronchoscopy? We need to think of the expansive component. So let's talk rigid versus flexible. Airway control. With the rigid, I can control the airway. I can control the airway for bleeding. I can control the airway for ventilation. I can ventilate through it, jet ventilation, volume ventilation, whatever you choose. Rigid and multiple tools at the same time. I have the rigid in. I can have a flexible in, a laser in, a suction in, you could have electric cautery, and any number of other tools in combination, yet still control the airway, allowing you to control the airway with large volumes of suction, still do cautery, and resection. Other things are resection of tumor, applicoring. If there's a large tumor, it's an emergent situation. In a very quick motion, I can simply take the rigid, which is a tool. It's not just a tube. It's a tool. It allows me to cut. It allows me to control airways. It allows me to access things. I can control breathing. We can remove broncholiths that are in the airway and cause problems. Silastic stent use. If you deal with benign disease in your practice, you really need silastic stents. If you're going to use silastic stents, you can't do it with a flexible. It has to be done with a rigid. Also, it comes in very handy, silastic stents, to be used in some malignant disease where we treat the patient, we place the silastic stent, we allow the patient to get their full treatment, we remove the hardware later, and allow them to continue. Rigid dilatation of airways. If I have a stenosis, et cetera, I can go through, or a tumor, I can actually go through where the airway is, open it up, ventilate to an area that's difficult. Direct compression of bleeding. If I have an area bleeding, I can use the rigid bronchoscope up against the wall. Airway repair grafting. You can't put grafts and other tools into the airway through an ET tube and try and drag it down. We place it through rigids under very controlled settings. Papillomatosis. Yes, people are going to say, oh, I can treat papillomatosis with a flexible, but it's not safe anymore. I mean, who wants to take the chance of rebreathing the virus? And that's what happens when any type of thermal energy is used. That's why we use micro-debreaters, and micro-debreaters can be used for a variety of different things. Foreign body removal. Again, we'll have the argument, yes, you can do foreign body removal. I'm sorry, micro-debreater. You can do foreign body removal. But here's a couple examples. That was an underwire bra, which was 7 centimeters folded in half, on the capsule for GI, large tacks, dentures. These things are very large and without the tools that we have to access them. So location. What can I work with with a rigid bronchoscope? Well, you can go from the vocal cords down to the main carina. You can work subglottic. You can work all the way through the trachea, main carina. Right, left main stem. The left main stem can be difficult in some cases, but we can go ahead and access that quite well. Right lower lobe, left lower lobe. Yes, you can remove tumors. You can get foreign bodies from down there, and you can access those. How about the right middle lobe and the left upper lobe? Yeah, we've actually placed silastic stents into the left upper lobe for lobar management of some complex diseases. So location, location, location. Flexible scopes have some limitations. Tracheal stenosis, yes, you can put in an LMA, but you're going to have a high-pressure ventilation with these patients. They're harder to manage in those regards. To lower the oxygen levels can be more capricious. And then the exactness, trying to keep a laser moving when the LMA can move, can be more difficult because a lot of anesthesiologists are uncomfortable going ahead and paralyzing those patients. Cannot place an ET tube. Tracheal stenosis, it's hard to place an ET tube, particularly if you have the second, third cartilaginous ring dealing with these. We talked about that. Training. One of the big things I want to bring up is training because I believe one of the reasons people are still uncomfortable is the lack of experience. Now, we were talking about this. I've trained 26 interventional fellows, but each of those interventional fellows has had more than 200, most over 250 rigids during their training year. And because of doing that for a while, I can tell you pretty confidently that you take a fellow, once they have 50 intubations, they're finally pretty confident. They can go in, access the airway, make it look very comfortable. After 100, they're now moving along and becoming very comfortable with procedures. They can access the airway. They can bring an electrocautery or snare or something else and move along. After 150, they become very confident in managing those airways. They can place a stent. They can make sure they're in more precise locations because they have the maneuverability. And after 200, they can really deal with the vast majority. Now, we talk about what can you do with, what's the strength and weaknesses of flexible versus rigid, and these types of charts have existed. Comfort for patients. I will argue with this. If you're placing an 8, 8.5, 9 endotracheal tube because you've got a bleeding patient, that's just as uncomfortable as me placing a rigid for a short period of time. There isn't that much difference. How about cryotherapy, photodynamic therapy? Sure, much easier with a flexible. But when you have rigid access to the airway, if you've done debulking, you want to use cryotherapy, you've done laser and you're going to use photodynamic therapy as a component, it can easily be done. What I can tell you is that with a rigid bronchoscope, there isn't any type of airway complication that I do not feel comfortable and confident with in terms of being able to manage that case. And that differs from using a flexible. And I've done 6,000 rigids and I don't even know how many thousands of flexibles, and still I feel more confident when I'm dealing with a complex airway to deal with it. So this whole rigid versus flexible bronchoscopy and the last big piece, therapeutic bronchoscopy is a combination. So I can use a rigid and use a flexible. You can't use a flexible and then say that you're going to use a rigid after. Last bit piece. Same patient. One day after a life-saving procedure for his lung cancer, Robert Yost is breathing without oxygen and walking without struggle. Amazing. That was 23 hours later. Do we make a difference with therapeutic bronchoscopy? This is the patient, you can see his tracheal disease on the CT scan. This was back in 2003. We managed him aggressively. We opened his airway, placed a stent. He could then go and get full-bore. He got his full-bore treatment, radiation, chemo. He tolerated that pretty well. And then he tolerated and tolerated. He started smoking again, got another cancer. I ran out of room, but in 2015 he finally died of cardiac disease, you know, that nasty one, not lung cancer. The idea is that we can make a difference, and I only bring that to your attention because I always get tired of the palliative thing. So the next man who's going to stand up I have nothing but tremendous respect for. He's taught me. He has been a leader in this area forever. But, Atul, in this argument, you're wrong. How do I get to him? Before I begin, I must thank ACCP and AABIP, and I want to thank Russ and Christian for inviting me for this. You know, Joseph, I gave this talk 43 years ago, and I'm going to repeat it again. I was right then, and now they invite me again to give this talk 43 years later. Okay? At my stage and at my age, I'm allowed to have biases, but none of my biases are financially driven, okay? I'm allowed it at my age. So the question is, you already saw this slide, the question is very simple. Can one swallow a sword? Yeah, I guess so. Can I swallow the sword? Maybe I can, but do I need to swallow the sword? That's the biggest question in this particular thing. So what you heard, you know, don't pay attention to it. Those who cannot remember the past are condemned to repeat it, and that's what you're listening here. As I always said, future of bronchoscopy lies in the GI tract of the patient. Joseph has converted into something different and dirty, but whatever gastroenterologists do it today, we do it 10 years later. And exactly at 10 years, after 1957, when Bashel Hershowitz performed the first upper endoscopy at University of Michigan, we performed flexible bronchoscopy, okay? Before that, what is this? Rigid esophagoscope. How many of you have seen rigid esophagoscope? Please raise your hand. Okay? It's a history, okay? I have seen it, yes, I have seen it, but I have not seen it for the last 42 years, okay? So we are following the footsteps of GI people. This is how my friend Eric Folk started doing medical pleuroscopy, and he was uncomfortable, so he started doing a flexi-rigid instrument to do pleuroscopy. He may have done 6,000 rigid ones, but then he needed a flexible one. Okay? We are in the era of flexibility. How many of you have seen this, what you call the sigmoidoscope, rigid one? How many? Ouch, it still hurts, you know? It has been replaced. It has been replaced with the flexible sigmoidoscope, and I'm sure the flexible cystoscope, all of you have heard about. So we are in the era of flexibility. What is this rigid stuff that I don't know? Now, one other thing which I have gone through, and maybe Mike remembers it, but this instrument, over the years, has been called this instrument of exclusivity. If you want to call yourself very exclusive, you use rigid bronchoscope, okay? It started like this. In 1847, Horace Green inserted a flexible elastic catheter to the larynx, and he was an otolaryngologist, and they didn't want him to use anything flexible, so they threw him out of society. Maybe Michael doesn't remember this, but when I started medical residency, at that time, the flexible bronchoscope was introduced, and all the thoracic surgeons and cardiac surgeons would say, oh, these medical guys are going to kill our patients by putting a flexible tube in the endocrine kill tree. I'm sure you remember that. Laser photoresection should never be performed to the flexible bronchoscope. That is what was when Dr. Dumas came out with the laser photoresection. No rigid bronchoscopy means no interventional pulmonology. So this was an exclusive tool reserved for exclusive people, and then we started self-expanding metallic stents, and I'm sure Tom Gilday remembers that. They made a black box warning against flexible stents so that you have to use a rigid scope to put silicon stents. So this is an instrument of exclusivity. Tom Gilday and I, many years ago, 1987, 88 consecutive laser photoresection, large lesions, small lesions, everything put together. Flexible scope, 93% good results, and we published. So how I didn't show you the inside picture, endobronchial pictures, but this is how we used to ventilator management. Distal trachea, no problem. Proximal trachea, we used to cut off the Murphy's eye, put some silicon glue at the cuff channel, and use that endotracheal tube, and if the lesion was vocal cord lesions, we'll use a jet injection cannula in this particular fashion. So laser has been taken care of. Electrocautery. We can use electrocautery very easily through the flexible bronchoscope, especially using the snare. As you see it, 47 patients out of 118 evaluation, outpatient conscious sedation, local anesthesia, flexible bronchoscope at the initial evaluation, and 90% success rate with the flexible bronchoscope. I also felt that that was safer through the, it was safer than through a metallic instrument because if the snare touches the rigid bronchoscope, you get a current. Okay? So that worked out for the electrocautery. I'm sorry, I'm not going to go through the cryotherapy and other therapies, arcane plasma, coagulation, and Rick, you have your fancy things, but it is given that it could be done through the flexible scope. Now we saw a beautiful picture of silicon stents. Okay? Let's say you cannot put the silicon stent through the flexible scope, and I give it to you. However, do you need it? Endobronchial stent, new generation, self-expanding metallic stents. All the articles you read, they are old articles, first generation and second generation metallic stents. Beautiful article, not only by Eva Sarala, but Freitag, who is the father of endobronchial stenting. He said, with improved understanding of stent-airway interaction, advancement in biomedical engineering, and larger emphasis on post-postural care, the use of metallic endobronchial stents has been resurrected. So we are using them more and more. I don't call them new generation, I call them next generation self-expanding. It is a good term for us, and there are so many of them which you can use and choose for your particular patients. Kristen, I don't know who, I know Majid Adnan, but I don't know who this guy is. Short-term use of uncovered stent for severe EDAP. He's on the other party? Ah, yeah, okay, other team, yes. First line, opening line of his article, opening line, guys. Higher number of complications with silicone stents. I rest my case. Eric Falk, okay? And then they were able to remove it in seven days. All right? This is good. 30 years experience of stent placement. As you see it right here, they were placing 600 stents a year. Today, even lower than 150, there is a drop by 75% in the number of stent placed in Marseille. That's where silicone stents get. Not only that, the number of self-expanding metallic stents is being used more and more and more. This was only up to 2017, and I have a follow-up up to 2022. These lines are almost matched. So 50% and 50%. So you can do it with a flexible-scope, self-expanding metallic stent. Let me show you, and Tom remembers this. On July 29, 2005, because people were placing stents with flexible-scope and causing granulation tissue, and then FDA put this moratorium that you cannot use metallic stents in benign conditions unless everything else has been tried. But I think today, that is October 10, 2023, the stent has risen from the grave, and there is less need for rigid bronchoscopy. Michael mentioned about massive hemoptysis. One minute. Yes, okay, sir. No, I'll take two. A.B. published a beautiful article with Samira, who is associate editor for Journal of Bronchology, and talking about disadvantages of rigid bronchoscopy in massive hemoptysis is very clearly mentioned. Since I don't have too much time, I'll not take into too much detail. But, Rick, you remember this. What is this? They insisted that endobronchial volume reduction must be performed with a rigid bronchoscope. With this valve. Many of you have not even heard about this valve. Tudor Tilma published the first article on this one. 74 some patients. That valve is designed to be changed for a flexible bronchoscope, my friends. So now you put this thing to a flexible scope, not to the rigid bronchoscope. You have heard about foreign bodies. Look at this foreign body article. In pediatric patients, I'll not take into the details, four complications in hurting rigid bronchoscopy. Flexible bronchoscope was successful in 100% of the patients. This is what we do these days. We don't have proximately located foreign bodies. These are very peripherally located foreign bodies that you need to use electromagnetic navigation to go after. Limitation, you heard. And, Catherine, this is your data. Correct me if I say it wrong. Only 4.4% of pulmonologists in this country are trained with a rigid bronchoscope. And, Dr. Fork, that's you right here. It says 31% of your IT physicians are being trained with a rigid bronchoscope. Maintenance of the skill, lung transplant complications, low bar stent, distal foreign bodies, alveoloscopy, trauma, all those things, you cannot do it with a rigid bronchoscope. And I just read this article a couple days ago, from rigid bronchoscope to robotic bronchoscopy. I read this article four times, and I didn't find a word, rigid bronchoscopy, even once. This is Eric, if you take the helmet off, this is Eric. This is part man, part machine, and all flexible bronchoscopy. Okay? All right, just a couple more slides. Yes, guys, both the procedures are necessary. If you really want to read about rigid bronchoscopy, this is one of the finest review articles that Michael Seymour published a few years ago. Only this article talks about complications of rigid bronchoscopy. I don't know any other article in this. Rigid bronchoscopy no longer a tool of exclusivity. One could be a part of the piping team without a rigid bronchoscope. Now, let me warn you this. The rigid bronchoscope is not an ET tube. Many places you go, you need to put rigid bronchoscope every time, and then you put flexible scope through the rigid scope. That's not rigid bronchoscopy. That's an endothelial tube, so don't count the 6,000 rigid bronchoscopies. Okay? I was talking about another group. I was talking about another group. Hold on, Mike. Okay, no procedure should be performed just to maintain the skills. And in worst-case scenario, VV ECMO is an option which is being abused more often. This is my last slide for every lecture. Because it could be done, that does not mean it should be done. Good surgeon is the one who knows when not to perform a procedure. One has to be larger than his or her abilities. No procedure should be performed just to maintain the skills. Reducing healthcare costs is a civic responsibility. There is nothing more certain than the sun and the moon and the sky that we all are going to be patient one day. So the first thing is, remember what I say, first do no harm, as Auguste de Chaumet mentioned. Thank you very much, and I appreciate your attention. Okay, so what we're going to do now is before we get into the debate, we're going to have two minutes each for Eric and Kat to introduce themselves and give a couple opening slides. Thank you. Thank you for having me. Dr. Mehta, the stats on some of those were wrong. The percentages were wrong, but we can work it out later. So I'm going to introduce myself. I'm Eric Mehta. I'm a professor at the University of California, and the percentages were wrong, but we can work it out later. So these are my disclosures. They don't pertain to rigid bronchoscopy at all. However, I have to say in full disclosure, this is my new funding opportunity, E-Foil Waikiki, if you guys like sports and water sports. And my other disclosure is that I went and did it with Dr. Oberg, and we discussed flexible and rigid bronchoscopy at length yesterday. You guys should try it. So this is a mind map that shows you the procedures done by interventional pulmonologists, full-fledged programs containing all of this. And for fellows in the room and future fellows in the room, there is a big section there that says rigid bronchoscopy for debulking as well as stent placement, and within debulking, there's a variety of techniques, the latest one being microwave and the continuous development of cryo-debridement, laser, etc., etc., and those are possible but less able if you don't have a secure airway and you can go in and out. The second thing is I will show you my three arguments, and I base this on a three-legged stool that cannot... You know, if you have three arguments, it cannot fail. It's very steady. So one is time-proving, as Dr. Simov mentioned. Number two is the market growth value of rigid bronchoscopy. Dr. Mehta did that on purpose. And number three is the safety and effectiveness. So number one, I'm not going to dwell again on the history of it, more than 100 years and the proven value of it. Number two is the market growth in bronchoscopy. In 2022, it was $2.5 billion, and it's scheduled to be, or expected to be, 3.7 in 2027. And you would say, yeah, that's flexible. Not so much. Actually, it's divided equally between single disposable, the adult segment, the reusable segment, and the rigid bronchoscopy. So if I'm wrong, then the markets are wrong, and all the analysts are wrong. How's that, Dr. Mehta? And, of course, for those of you who don't analyse markets like I don't, the compound annual growth means the rate of return on their investment. They're not going to invest billions of dollars if they don't see it grow. Second is, of course, bronchoscopy today is done, as Dr. Mehta eloquently put, with half facts, but it is used frequently everywhere. However, the safety of rigid bronchoscopy in capable hands is incredibly high, with the mortality rate being less than 0.4%. So it is minimally invasive. And now Dr. Oberg will take over. So my two-minute intro, I think, is pretty quick, especially with what Dr. Mehta did. I basically think the argument is over, but I'll go ahead. So I think an important point to remember is something that takes us back to 1897. So what was going on in 1897? What was new and fresh? William McKinley was inaugurated as the 25th U.S. President. The very first Boston Marathon ever was run in 1897. There's gold in Alaska. This is hot off the presses in 1897. And then rigid bronchoscopy is introduced, wow, 126 years ago. And you may say that I'm not giving rigid bronchoscopy a fair shake, because surely it doesn't look like this 126 years later, right? Anything that was present in 1897 has been iterated. You know, it has been the next and best has happened, right? So I'm sure rigid, oh, no, rigid looks exactly the same way. So rigid bronchoscopy is old. Rigid bronchoscopy is not widely accessible. I think, as some of the points have been made already, is that you have to be a trained interventional pulmonologist. Thank you, Dr. Folk, Dr. Simoff. You have to have a large number for training. And I think, as Dr. Simoff eloquently put about, is it 50? Is it 100? Is it 150? You have to maintain your skills. So trained rigid bronchoscopists are not everywhere, but airway obstructions are. Subglottic stenosis is. Hemoptysis in the ICU is. So I think some of this has been reflected in the innovation in the world of flexible bronchoscopy to be able to deal with these issues. This is a picture of Dr. Folk at the Ether Dome in MGH, and he's either talking about ancient Greek or ancient Hebrew or rigid bronchoscopy or some sort of lecture that they do in Boston. He is wearing clothes. And then point number three is that rigid bronchoscopy is not usually just pure rigid. And I think they've pointed this part out, too. This is a case from a week or two ago, and so you can see the rigid bronchoscope is in, but it really is just a conduit here. You're using the flexible. You're putting the therapies through the flexible. And so as we go through the cases, I'm going to show you actual cases that we did with therapeutic approaches going through a flexible endotracheal tube. Why should you believe me? I am a board-certified interventional pulmonologist. I am the IP Fellowship Program Director. I have given talks and talks on rigid bronchoscopy. Our fellows do well over 100 rigids every year. So I hope from this you'll take that when I tell you these things can be done safely and effectively by flexible, you'll believe me that it's not for lack of rigid skill. All right. Great opening statement. So our first case is a 60-year-old male with moderate COPD who was brought in by ambulance with one month of progressive dyspnea, which was slowly progressive and worsened to the point where he called 911 that morning. A CT was done in the ER with the findings here. with a large tumor obstructing the left brain stem and partially obstructing the trachea. During his ER stay, he became progressively more hypoxic with increased worrisome breathing, necessitating urgent intubation and IC admission. Due to persistent hypoxia and difficulty ventilating, IP was consulted for urgent intervention. You have two sets of ridges that are both being sterilized and we're just informed that there was a chemical leak in HLD. You will not be able to access his equipment until tomorrow. Catherine, can you please start off with your opinion on how you might be able to manage this today? Sure. So what I took from this case, 60, somebody who already has lung disease, moderate obstructive lung disease, so not completely healthy. He has a total occlusion of the left main stem bronchus. It's encroaching on the trachea. He's critically ill. He's in respiratory failure. He's intubated. He's in the ICU. And even there, he's not ventilating well. He's hypoxic. And so my three points for this case would be that waiting until some nebulous time that the rigid scopes are available doesn't make a lot of sense medically. And that even if you had a rigid scope, he may not tolerate it because it's typically through jet ventilation. And that this case can be done safely and effectively by a flexible bronchoscope. So to my point of waiting doesn't make sense. So these are all cases that I've had over the years. And I think for people who especially are in the ICU and on the floor and on the pulmonary team, everybody knows that they're just one mucus plug away from a disaster, right? Especially the patients that have tracheal disease. So waiting until things are all ready and perfect, you want to make sure that you're prepared. But waiting until three weeks until the rigid set is available may not make sense. This is not the case that you want to do emergently. So when you see this, this is not when you say like, well, maybe tomorrow or maybe the next day or I'm not sure if it's all ready. You want to go ahead and do this now so you're not getting called at 2 a.m. when they're coding. And again, what if the rigid set isn't ready until tomorrow? This patient may not tolerate rigid. So, you know, rigid is typically done with jet ventilation. These are, I'm seeing head shaking. There are some people that do closed ventilation, but a lot of us do open ventilation. And this is a study looking at that about how well people do with jet ventilation or not and what some of the risk factors are for not tolerating jet ventilation. And you can see here that if you're starting off hypoxic, if you're an ASA 4 or above, you may not tolerate jet ventilation well at all. So you may not even be able to do this on this patient. And the most important thing is that it can be safely done by flexible bronchoscopy. You can still take this patient to the OR and have anesthesia ready and all the team members. If the ET tube they put in the ER is small, you can change that out easily. You can put a Fogarty balloon beside the ET tube. So it's not that everything has to go through the ET tube channel. So even if you don't have a rigid conduit, you can do this trick very easily. I didn't have a beautiful picture of it, but this is the concept that they're both going through the vocal cords, not through the scope. Cryo, snare, APC, cautery, flexible balloons, all of these things done by flexible. And you can do all of that in this situation. And even if you needed to put in a stent, you can do side-by-side vision where you put a scope outside of the ET tube through the vocal cords. You can use fluoroscopy. And you don't have to use just flexible stents. And usually we do, or just silicone stents. And oftentimes we don't use silicone stents in these. So I think seeing is believing. So this is a case I had not long ago. Didn't tolerate jet ventilation well. We switched to the flexible. You can see right main stem obstruction into the trachea. So pretty scary looking tumor. This is us, again, with an ET tube. Cryo debulking, APC. This video is a little long. So I'm gonna see if I can speed it up. Because at the end, you're gonna see us pull this giant chunk of tumor out through the endotracheal tube. You can see the tip of the Fogarty balloon there that we snuck alongside the ET tube. And when it's coming out, you can see that the Fogarty is outside of the tube. And then voila, looks a lot better. And there, a nice view of our endotracheal tube, our non-rigid tube. And this is all the tumor we got out. And he's doing great. So, Dr. Folt. So, again, patient with acute and chronic respiratory failure requiring mechanical ventilation cannot use my RIDGID. I'm not sure. I think from this table, as you can see, the strengths of the suction capability as well as the diameter of the RIDGID are in front of your eyes. It's hard to argue against a better tool that has, you know, withheld with time. But nevertheless, this is a similar case we did with RIDGID bronchoscopy. And as you can see from the CAT scan, most of the airway is occluded. And I took this quote that I think is very good. That is, there's no value in performing a bronchoscopic examination if the clinical condition of the patient precludes acting on it. So, there is a chance that with a flexible bronchoscope, the patient would have had a difficult outcome or a bad outcome. I can't say for sure. But I have to say that when you look at the literature on deaths, these are examples, 12 cases in this survey by Surat showing 12 cases of death. And the 12 cases were related to massive hemoptysis. Not all of them, some were MIs and some were other conditions. But some of, all of them were done with flexible bronchoscopy. So, I would call this missed opportunities. And maybe the case they're presenting to us would be a missed opportunity to use the right tool. Also, important quotations from this book by the late David Sugarbaker, where you can see flexible bronchoscopy generally is used for the evaluation of biopsy. Rigid bronchoscopes are uniquely capable of establishing and maintaining the airway control in life-threatening situations. So, I have to say, the references are on my side. Not all of them. But Dr. Mehta, do you recognize this book? Yes. Okay, do you recognize the table in which they did a breakdown of the success rate of flexible versus rigid removal of foreign objects? And I'm gonna say that the tumor in this case would act like a foreign object. But because you can't see, there are so many series done with flexible, so many series done with rigid. But when you tally it out, 98% success rate with a rigid versus 84 with a flexible. That is statistically significant. That book, too, says not every pulmonologist who performs flexible bronchoscopy is comfortable managing the potential consequences of a failed procedure. When in doubt, it's best to stabilize the patient and refer them to an institution who's capable in both flexible and rigid bronchoscopy. Dr. Mehta, you recognize that text? Yeah. I wrote it before you were born or something like that. So, so, the joke is on you because you asked me to write it and I wrote it and that's me. Well. So, it's after I was born. I calculated the mortality rate. Now, you heard Dr. Simov saying 0.4% mortality. Flexible bronchoscopy, 12 out of 48,000. That is 0.0025% mortality. That's the mortality. How about this recent study on the failed cases? 57 patients enrolled, flexible bronchoscopy, and they were successful in 73% and had to be rescued with a rigid. This is my personal case. I, you know, I, the fellow insisted we, Dr. Mehta said we can do it through the flexible. Fine, here you go. I'm going to give Dr. Mehta a minute to give a rebuttal followed by Dr. Simov. One minute. Well, I'll try. Well, okay, the minute's over. No, the thing is that you don't have rigid instrument. It is not available for 24 hours. It's all fair reason to go ahead and do it with the flexible scope. I have no problem with that. I fully agree with what has been said. And again, I know in IP people, many of you are now started using ECMOs also. Correct me if I'm wrong. How many of you have been using ECMO for your procedures? I heard that one. There you go. At least Dr. Ortiz is using. And so it could be, under the worst circumstances, it could still be done. That is what I'm trying to say. I would not wait for 24 hours for that particular patient. It could be done. We have done it. We have published it. Thank you. Well, they make it uniquely difficult to say that, oh, yes, we should do it with rigid because they're not going to have a rigid first thing, have more ridges than two. We have nine, so we don't usually run into that trouble. Part two is, yeah, the patient had to be managed right away. There's no question. You have to manage the patient. Would I have said that I would have done a complete? No, this is a reasonably unstable patient. We'd go in. We'd manage it. We'd do removes part of the tracheal tumor, stabilize the airway, get their oxygenation ventilation improved, and then use the appropriate tool to manage the case within the next 24 hours. Yes, that's two procedures. But that is two short procedures. You don't want to take a patient like this and subject them to longer. And the bottom line is, it does take longer with a flexible than it does with a rigid. I have done them both ways over the years. And thus, the reason I'm towards rigid. Excellent. All right. So scenario two, 50-year-old, 8-year-old patient presents to the ED with five days after a diagnostic bronchoscopy for a left upper lobe mass. During the procedure, there was a friable endobronchial tumor just distal to the LC2 carinae, sorry, in the left upper lobe. A biopsy resulted in moderate bleeding, which was controlled with some isolein and epi. And he was discharged the same day. Patient, when he came back to the ED, was hemodynamically stable, had an oxygen stat of 95%. She had one episode of large volume hemoptysis prior to presentation, but had no recurrences since she was admitted, since she presented to the ER. And she was simply admitted to the ward for observation. While in the ward, she had a second witness episode of large volume hemoptysis, followed by respiratory stress. She was intubated with an 8-5 ET tube and transferred to the ICU. A bedside bronchoscopy showed active bleeding from the left upper lobe. And an endobronchial tumor was placed. So, ICU day number two. The endobronchial blocker remained inflated overnight without any further bleeding. Patient was oxygenated okay. IP came up for a plan to deflate the balloon and take a look. Prior to the procedure, while the balloon was still inflated, and this is a real case, a column of blood was observed filling the ET tube and beginning to enter the ventilator circuit. The circuit was open, resulting in a large volume of blood being exposed. The patient was positioned with the bleeding side down. Flexible bronch was inserted. It wasn't possible to visualize the blocker, so it was removed. The ET position was positioned in the soil right main stem. Cryotherapy and argon plasma coagulation were brought to the bedside. The patient appeared to have stabilized, but blood's observing slowly leaking past the ET tube cuff into the isolated right side. The question is, do you attempt to manage this patient immediately with the bronchoscope, flexible bronchoscope in the ICU or in your suite, or do you take this, do you set up the OR and attempt to transfer this patient prior to doing any type of intervention? So this is going to be even more brief. This is the architecture of a flexible bronchoscope. It's simple. It has two wires. It has a light source, and it has a channel that is two millimeters to, let's say, three millimeters in average. But look at the proximity between the light source and the camera and this suction port, the place where you're supposed to be therapeutic. So as you suction, you're bringing to your eyes all this blood that is coming down the ET tube. So keep that in mind. And the comparison of the suction has been actually looked at for the different scopes. I don't remember if they told us the size of the ET tube that the patient was intubated, but regardless there's a common thing in the ICU. Some people do double lumen, which makes it even harder to put a flexible. Having said that, this study comparing the suction capabilities of disposable scopes shows you that the ability of the flexible scope is very limited to suction large amount of fluids, particularly a thick fluid like blood. And only one of the scopes in orange there, the Boston Scientific was able to suction any of a gel type fluid in the presence of instrument in your channel. So keep that in mind, we're talking, oh, you can put this and you can put that, well, I can't suction. And if I can't suction, I can't see. This is another study showing you with different negative pressures on different size flexible bronchoscopes and the ability to suction a water or viscous fluid is very, very different and very limited. So with that, whenever you try to remove a foreign object or a blood clot or anything from one side, you run the risk of dropping it in the other and making it even worse. You already have one side that is down or that is not participating of oxygen exchange. You can make this significantly worse if you actually don't have the right tools. And if it's hard to remove a foreign object with a rigid or with poor technique, imagine with a two millimeter or three millimeter channel. Okay, so yes, 58 bleeding, hypoxic in the ICU, eight and a half ET tube is in place. The blocker wasn't working, the patient is still intubated, they're still bleeding, they're not doing well. So I think the obvious points here are that this patient is too unstable to move. Who is gonna move this patient with blood shooting to the ceiling down to an OR? No one's gonna do that. This patient may not tolerate rigid anyway and it can be safely done by flexible. So death in these cases is by asphyxiation. So they're clotting off all of this blood that's in their airways. You've siphoned off it into the good airway and now you need to get the blood out of that airway. And you can easily do that with an ET tube and a flexible bronchoscope. That's obviously a terrible case on that side. This is what it looks like on the inside. You're not gonna be pulling that out with forceps. Do you see how gelatinously gooey, ooey? This isn't a tooth. This is something that you're gonna have to use a suction catheter for, a larger bronchoscope with a larger therapeutic channel, maybe cryo to freeze this, which are all things done with flexible bronchoscopy. This is what it looks like with a flexible bronchoscope and a cryoprobe. So that's what that clot looks like coming out of that patient. These are airways afterwards that are nice and clean, all done through an ET tube. This is what the clots look like coming out on both sides. All again done, flexible ET tube in the ICU cryoprobe. If you're worried about bleeding when you pull this clot out, you can already put a blocker in place. And we're not talking about the Arndt Endobronchial Blocker that's taking up your ET tube channel so then you can't put the scope in or a big scope. Nope, you just slip the Fogarty beside the ET tube. You place it in with your flexible scope. And so now if you've pulled that clot out and it rebleeds, you just inflate the balloon and no harm, no foul. You haven't moved the patient out of the ICU. You've cleared out the side that's working so that they're gonna ventilate better. And you can block off the side that's bleeding while you figure out what you wanna do. There are all these things that aren't really gonna help a lot, but you can consider doing these all through a flexible. You can do argon plasma coagulation. You can do cryo-debulking. All of this you do through a flexible scope through an intratracheal tube. There are other things that if they're still not, if the bleeding has still not stopped and you don't wanna leave the blocker up, you can pack with Surgicel. I'm showing this again through a flexible scope and an intratracheal tube. You can see the lines of the ET tube there. So I'm not faking you out and really did it with RIDGID. You put this here after you've sort of contained whenever that bleed is, but it's still oozing. And then you pack it up there while you're waiting for your next move. Sometimes these things need definitive treatment. You know, you're doing correcting coagulopathy. Maybe they need BAE, surgery, not so much. But you know, while you're trying to figure out what's happening, you're stabilizing the patient. And then if they do need to go to IR, they're not down in the OR with a RIDGID scope in. Are you gonna send them to IR with a RIDGID scope in hooked to jet ventilation? No. No. Maybe the one-off, right? But for most people, that's not gonna be the case. They're not gonna take it and you're gonna have to put an ET tube back in. So. All right, so we're gonna hold rebuttals for this one. And for the last case, we're gonna have to go a little, wait, you'll get your chance. Actually, I take it back. I would like to give you one minute. All right, I'll take 30 seconds. First off, there were a lot of things that she said that are true, but unfortunately, this is an active bleeding patient. So you're not gonna be able to manage that ET tube and do a lot of the things. It's an unstable patient that's being positioned. So sure, you could do a clodectomy with cryo or something to preserve, un-preserve the good lung, but you're doing nothing about the, you can't do anything about the active bleeding. The problem is that they're flexible. You have to pull that ET tube up and you now have, you've exposed the airway. With a rigid, you can go in and you can still place the balloon. Again, placing a Fogarty next to endotracheal tube, absolutely, not that complicated, except in the fact that you have a patient who's decompensating at that point in time. So this is a patient that, yeah, you wanna get stable. Can you get them to an emergency room? I mean, to an OR? If you deal with complex airways all the time, your teams are accustomed to moving complex patients. Any trauma center, you move people who have gunshot wounds and everything else, let alone bleeding airways. So I feel pretty confident that we could get it to, you can get it to an operating room with that. The assumption of going to IR is great, but if it's an endobronchial, if it's an endobronchial tumor that's bleeding because of probably the proximity to the descending pulmonary artery, then the likelihood of IR doing anything for that is gonna be minimal. It's not a peripheral thing. We're pretty focused on something that is central airways, which means that we really need to get there, get control, and remove a lot. Short. No, I think this patient needs a more definitive treatment. I agree that it should be started, bronchial artery embolization. That is what this patient needed. I don't know what's the outcome. I actually just put a stem from the left main stem into the left lower lobe and blocked off the left upper. But if it were a bronchial artery bleed, and you ridged it in, how would you go about transporting them to IR? I'd go in and put an ET tube in. I'd go in and control the bleed. I could pack that area, put a stem across that area, any number of things so that I'm ventilating the vast majority of the lung. I'll pack them up and send them to IR. With an ET tube in, though? Oh, with an ET tube, yeah. But we have, have we taken people with a rigid bronchoscopy to IR? Yes, we have. I mean, it has occurred, and the reasons, I don't even wanna go there. But. So we only have five minutes, but the next session doesn't start till three, and I could get yelled at, but I'm okay with this. So last case, 35-year-old male comes for evaluation of subglottic stenosis. Approximately one year earlier, he had a prolonged ICU stay with rotor appendicitis. During his ICU, he had a trach, was decannulated one month post-discharge, and initially resumed near baseline functional status over the last six months. He was at increasing dyspnea, misdiagnosed with asthma. After failing to respond, he had a CT, which subsequently got him referred to interventional pulmonology. During his clinic exam, he exhibited mild conversational dyspnea, no noticeable stridor. Despite these symptoms, he does not appear to be in acute distress, and is maintaining a SAT of 98% on room air. You do an awake nasal endoscopy in clinic, and this is what you see. The patient consents for bronchoscopic treatment. Do you, in your clinic or in your bronch suite today, do you manage this with flexible bronchoscopy, or do you schedule him for the OR to do a case either tomorrow or sometime soon with the RIDGID? Who's next? Me? No, sorry. So this is going to be Kat. Okay, my favorite case from my flexible side. 35, intubated the past for a non-respiratory problem. So presumably healthy lungs, and just intubated for another reason. Subglottic stenosis that's symptomatic, has stridor. Not in acute distress, but you all saw that picture. That's not something that you're gonna wanna wait on. So number one is RIDGID bronchoscopy makes this harder. RIDGID dilation, there's some thought that this can be harmful in cases with stenosis. And this can easily be safely done with a flexible bronchoscope. So this is my lovely partner, Dr. Ranaghi, who let me take some photos of him. If you have a lesion that's down here at the trachea, or the main stem, or something like that, and you put this RIDGID bronchoscope in, it's really secure, you know? Over half of it's inside the airway, a little less than half of it's hanging outside of the mouth but you're not tripping over the cords from the jet or anything like that. This is what that would look like if the lesion was down here in this area, and this is the exact airway from the stenosis. But that's not what we have. We have a lesion that's up here. And so now if you're using this scope, you've got about a teeny tiny bit of it that's inside and the rest of it's outside, and it's moving around and it's unsafe, and this is not the ideal way to be doing this. Even if you introduce the tracheoscope, because someone's gonna talk about a tracheoscope, it's still not that much shorter. So in general, RIDGID is already making your life harder dealing with this. Not that you can't do it, but it's just the cumbersome way to do it. When you look at the angles at reaching this, which is just below the cords, it's a subglottic stenosis, you can see that in this picture, putting it in LMA, putting the flexible through the LMA, gives you a lot of angulation that you can do with that flexible scope so that you're more agile, more nimble when you're dealing with managing the stenosis. It's a nice closeup there of the angles that you can get when you have a little runway for your flexible scope. There's some thought that RIDGID dilation, especially for really inflammatory, you know, GPA and other things that cause tracheal stenosis, that the shearing forces themselves may cause more injury and tissue inflammation, and they may promote re-stenosis down the road. It's less precise. And if you're doing this RIDGID dilation, oftentimes you have limited or no vision. So now, thankfully, we have flexible balloons that have controlled radial forces. They're easier on the stenosis. They cause less injury and inflammation. They're more precise. You maintain your vision. You can see exactly what's going on. There are all sorts of things that you can do about the stenosis that are all done through flexible. If you wanna make thermal cuts with your cautery knife and then dilate, if you wanna use cryospray, if you wanna use mitomycin C, I'm not gonna get in the weeds here because we're not arguing about the proper management of subglottic, but the point is is that you have all of these options that you will use through your flexible scope depending on what the lesion is. So again, seeing is believing. So this is a case of mine. You can see in that first photo the LMA is in. You can see that this is the tracheal stenosis, which of course is terrifying. And you can see us using the cautery knife and the balloon dilation, and afterwards it looks like this. PFT's before, PFT's after. This was done in a very controlled, easy way, and it was a quick case. This is what it looks like with that cautery knife inside. You can see it's at an angle. And what I mean by at an angle is if your lesion is where this blue circle is, then you want to be able to put the instrument diagonally to be able to cut into that stenosis. And if you have a rigid scope that's not allowing you this angulation to get at the side, it can actually be more difficult. And you're not gonna be able to pull it back a lot because then it's just gonna be dangling in the vocal cords. So this is what that patient looked like afterwards. Thank you. Wait, I'm just gonna go back. Can I go back to one of your first slides? I think that's an endoscope. Are you suggesting we should use a gastroscope for these cases? Ha ha ha. Okay, scenario three. That image I think should tell you what you need to know. That usually stenosis or tumor yields to steel. If you have to secure the airway and you push forward, guess what, it moves out of the way. So if you're really in an emergency, the rigid is your friend if you know what you're doing. This is a very pronounced tracheal stenosis case I had. Try fixing that with a flexible. And that quote from a publication by Dr. Mina and his group, while balloon dilation can be done via either flexible or rigid, the rigid provides better control of the airway along with proper ventilation of the patient. And the stenotic segment can be dilated. And all of you know Dr. Mina and his incredible group in Arkansas. What does that bottom line say of that, though, that you don't have that? Thank you very much. What does that say? Ha ha ha. I'm pretty sure it said, however flexible is the safer preferred approach or something like that that wasn't highlighted. I have more questions. Can I make a response in the closing statement? Yes, yes, please. I have to go back to, I have a response here. Okay. You made response slides? Yes, I made response slides because I know what Eric was gonna tell. I knew exactly what mistakes he was gonna make. All right, so this is the case we are talking about, all right? He's 35 years of age, all right? So the most definitive treatment for this patient is tracheal reconstruction. We are not gonna mess around with dilatation or any of those things. Nevertheless, if that's not possible, the alternative acceptable treatment is T2 placement. And as it has been mentioned, the less acceptable treatment is dilatation and the least acceptable treatment for this thing is stent placement. I'm sure all of you will agree with me. Now Tom Gilday is here, in all respect to him, he say, I would put a 3D custom-made stent, but there are some anecdotes we need to prove more in that particular fashion. Repeated dilatation. Why did this stenosis started in first place? Because there was trauma. And if you dilate it with the rigid bronchoscope, you are going to cause more trauma. And this is gonna come back in less than four weeks. So that's not a good idea at all. More trauma you cause to this area, the frequent would be the recurrence. So therefore, you can minimize the trauma by placing radial incisions, which you already saw, followed by gentle dilatation, that is the balloon you saw. Single balloon dilatation or single insertion of the rigid bronchoscope. And then the myth of mitomycin C or steroid injection should be considered. And let's give proper credit to Stan Shapshade who came up with this idea many, many years ago. And he showed that when you do this mucosal sparing technique which is shown here, he was using CO2 laser because there was no Yager laser at that time, or there was no endobronchial electrosurgery. So what he's trying to do is minimize the trauma, save as much normal mucosa as possible, and then dilate this area. And he had 75 success rate. And you have seen other articles referenced as well that you have 75 success rate. And this is an artist's rendition how you do this thing. And I'm showing you at the bottom, there is dilatation of the stenotic area, and then there is mitomycin placement or application to this particular area. It's a very interesting study. Now, we did not touch upon it, but I did see Eric's picture or slide, which he showed a silicone stent placement in this location. So let me show you what I'm talking about. There was an article which clearly showed the subglottic stenosis patients experience high recurrence rate with endoscopic dilatation than with the resection itself. There is also external fixation of the silicone stent in this particular situation, which substitutes migration with infection. Now, there is no migration of the stent, but that site gets infected. Now, uncovered or partially covered metallic stents are not ideal for managing subglottic stenosis. All of us know about that. However, fully covered metallic stents have also been used. The data is insufficient to support the selection of one over the other, and this is what I want to show you. This is the article which has been published in Respiration because Eric showed that silicone stent in that position. My friend, Arvind Atta, now he is using SilMet stent in the same location in a similar fashion with the flexible bronchoscope, and he has got equal results. Either you use the silicone stent or you use fully covered self-expanding metallic stents. So these are the options for this particular thing. However, for me, this particular patient requires tracheal reconstruction. Thank you. Thank you very much, and I appreciate your attention. Thank you. Thank you again. Thank you very much. I agree. The patient, 35-year-old, tracheal reconstruction is the best thing. One, we can get in. You could technically do this with a flexible. I find it much easier, much more straightforward, much faster to be done with a rigid very smoothly. We do a laser, and we use laser incision. I'm not a fan of electrocautery. Completely different discussion. Two, once we do sequential balloon dilatation, rapid balloon dilatation, particularly in a single stage like that, causes a lot more microtrauma, thereby leading to more fibroblast activity, i.e. recurrent stenosis to occur. Three, along those lines, then once the rigid, once we have done dilatation, so you can simply place the rigid down through the airway. The big problem for these tracheal stenosis patients isn't just the work of breathing due to that, but they've been retaining secretions, et cetera, which can lead to a lot of complications. You can easily stabilize the airway for that part of the procedure. In terms of silastic versus fully covered stents, I won't disagree. You can use fully covered stents, but I can tell you from the use of fully covered stents, they have just as many complications as silicone stents. Retention of secretions, the biocapacity, the risk for infection, the migration rates, et cetera, because they don't have, the uncovered stents didn't see that much because they had all the radial force, and then the tissue reaction with the endothelialization that occurred with the uncovered portions of stents and or uncovered stents. The whole reason that that article was written, the thing, and I was part of the committee that proposed that, is that metallic stents were being placed, uncovered metallic stents were being placed in the trachea for benign or other benign disease. Once placed, they almost eliminated the opportunity for a very appropriate cases going for tracheal resection, which we agree upon. In terms of using a Montgomery T, a Montgomery T most certainly can be used, but that means you're placing a tracheostomy into a patient who's already developed tracheostenosis. They didn't just develop tracheostenosis because they have some other underlying reasons. We don't understand them all. We know that diabetes has microvascular disease, et cetera, that's gonna put those patients at a higher risk for re-endothelialization, stenosis, granulation tissue, and other complications. We don't know exactly from this story why this person developed tracheostenosis, but as soon as I introduce another procedure, i.e. a tracheostomy, Montgomery T-tube, and let's just put it there that with a Montgomery T-tube, you still have to do a laser insertion, you have to do the laser insertion, balloon dilatation to place them confidently. So in terms of the argument, you can go back and forth a lot, but the bottom line comes in is that you can do things with a rigid that you can't do with a flexible. You can't do a rigid without the combination of flexible. Therapeutic bronchoscopy is a mandatory aspect of what we do, and in the bottom line, if you don't feel confident that your facility and or your patients or your skill sets and or whatever your team can't do it, always know who outside facilities are that you can relate to, call, get referrals to, and or transfer a patient when it's necessary. All right, real quick, there isn't anything after, we'll take a couple questions if the panel's okay with it, but before that, we're gonna answer the question. So Team RIDGID, please stand up. Oh, come on. No, I'm sorry, the question is. He already said the question. Now it's Team Flexible. Who stands up for Team Flexible? All right, Team Flexible. Please stand up. Wow. Yay! Okay, all of you standing up, I have a picture. Your RIDGID privileges have been rescinded. Enjoy your six-hour cases. We'll take a couple questions if you have. Listen, he said about six-hour cases, and I have to tell you a story. When we started doing lasers with a flexible scope, and of course, this big central lesion would take three to four hours to do it because we were new at it. We didn't have cryo, and it took four hours. So I wrote a table which says that rule of four, that you don't go extend beyond the four hours, and then they laughed at me and said, who does four-hours bronchoscopy, and now he is six-hours bronchoscopy doing those robot cases, okay? So don't laugh at somebody. You know, it may come back to you someday. Yeah, he goes after every little notch. Are we getting kicked out? Only five, only five, I'm sorry. Okay, question.