APSR Short-Term Research/Training Scholarship

It is with little doubt that both the popularity and our scientific knowledge of the field of Interventional Pulmonology (IP) has risen dramatically in recent years. We have seen the rise of the Endobronchial Ultrasound (EBUS) as the primary tool in diagnosing lung tumors, largely replacing the conventional fluoroscopy-guided bronchoscopy. EBUS with transbronchial needle aspiration biopsy (EBUS-TBNA) has also unseated traditional mediastinoscopy in the diagnosis of mediastinal lymphadenopathies, and boasts superior yield and better safety profile. The recent years has also ushered new techniques in IP, such as medical pleuroscopy (which can even diagnose pleural effusions with a minimally invasive strategy and no need for general anesthesia), stent insertions (to rescue critical airway obstructions), and even transesophageal biopsies.

The timeline of IP development in CMUH
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CMUH boasts of a large number of IP procedures performed every year

However, we recognize that there is a great gap of knowledge in this very novel and important field in pulmonology worldwide. More developed countries enjoy the convenience of the availability of machines capable of these new technologies, while some countries still struggle. Taiwan is recognized as a developed country in Asia, with a comprehensive health insurance system and good quality healthcare. The Philippines is Taiwan's very close neighbor, and enjoy great political and economic ties. Despite the proximity in location however, Taiwan and the Philippine's IP fields are very much dissimilar, with the latter lagging behind.

I came to China Medical University Hospital (CMUH), under the mentorship of the Chief of the Pulmonary Medicine Division, Dr Chih Yen Tu. CMUH is located in Taichung City, the nation's economic center in Central Taiwan. It is a big academic medical center, with a 2,500 bed capacity and hundreds of patients seek care in this hospital on a daily basis. Undoubtedly, CMUH is the leading IP Center in Taiwan which started development in 2007, and continues to grow until now. The number of procedures in this center is much at par with the rest of the world, with more than 8,000 bronchoscopies, 4,000 EBUS, and hundreds of TBNA, stent insertions and pleuroscopies performed since the center started.

With the faculty and staff of the Division of Pulmonary Medicine in CMUH (to my left is Dr Chich Yeh Tu, and to my left are Dr Wei Chih Liao and Dr Chen Chia Hung)
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With Taiwan's renowned expert in Chest Ultrasound, Dr Hsu Wu Hei

The faculty of the Division of Pulmonary Medicine of CMUH is also very well-trained in IP cases. Dr Tu and his assistant Chief, Dr Chen Chia Hung, are trained extensively in IP and got their training from the National Cancer Center in Japan, and in the MD Anderson Center and Johns Hopkins University Hospital in the US. They have been practicing IP for more than 10 years. They have also authored a large number of internationally peer-reviewed articles, both in IP and other fields of Pulmonary Medicine. The Associate Dean of the University, Dr Hsu Wu Hei, is also a leading figure in the field of Chest Ultrasound in Taiwan.

Apart from the actual experience of the procedure, they had prepared a series of lectures in EBUS, TBNA, pleuroscopy and central airway obstruction. I also participated in multidisciplinary case discussions with the IP team, chest surgeons and pathologists to tackle difficult cases involving IP. This was a very enriching academic experience for me, as well as the other trainees.

One particularly interesting case is a very interesting presentation of a primary pulmonary lymphoma. The patient's condition was only diagnosed with EBUS- cryobiopsy, after a series of non-diagnostic bronchoscopies and CT-guided biopsies. We have written a case report for this patient, since this is the first documented case of primary pulmonary lymphoma which was diagnosed via cryobiopsy, not requiring surgical intervention.

Dr Tu and I discussing a medical pleuroscopy procedure.
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One of the lectures delivered by the faculty.

During my four-month stay in CMUH, we have performed a total of 188 radial probe EBUS, 70 TBNA, fourteen stent insertions, fourteen pleuroscopies, eight balloon dilations, and a number of central airway tumor excisions, foreign body removals, and percutaneous tracheostomy. All these procedures were not associated with significant morbidity. Indeed, CMUH boasts not only of the volume of their procedures, but also of the quality of their procedures and cases. I am very much grateful for CMUH for letting me experience state-of-the-art facilities, and gain technical knowledge on planning, monitoring to the actual execution of the procedures.

As I return to the Philippines after a four-month training in IP, I plan to widen the knowledge base of both general physicians and chest specialists alike in this new and important subspecialty. IP is very underdeveloped in the Philippines, despite a huge number of patients needing interventions. The Philippine College of Chest Physicians (our local society of chest specialists) has already drafted to create a separate council dedicated towards the advancement of this field. It is indeed recognized that IP is continuing to grow, and that every nation should have the benefit of these technology and skills.

Lastly, I thank the APSR for being an instrument for my training, true to its commitment to enhance and improve lung care in the Asia-Pacific Region.