### 1.1 An overview of the ILD guideline

Since the publication of the first BTS guidelines for diffuse lung disease nearly 10 years ago,1 the specialty has seen considerable change. The early discussions of the Guideline Group centred upon whether the revised document might consist of the 1999 document with minor adaptations. However, it was considered that too much change had taken place in the intervening years to justify a simple editorial approach. The last decade had seen the development of a new consensus terminology for the idiopathic interstitial pneumonias (IIP)2 stimulated, in part, by the identification of non-specific interstitial pneumonia (NSIP) as a discrete histological pattern with increasingly recognised clinical correlates.3 The better prognosis seen in fibrotic NSIP than in idiopathic pulmonary fibrosis (IPF)4 5 fuelled a more intense approach to diagnosis in cases of suspected IPF. This in turn has led to a radical change in accepted diagnostic gold standards, which have become increasingly multidisciplinary and dependent equally upon the skills of pathologists, radiologists and clinicians.6 NSIP, as a new entity, has posed particular difficulties. With more detailed studies of outcome specific to individual IIPs, especially IPF and fibrotic NSIP, the prognostic weighting given to pulmonary function impairment has been refined, especially with regard to longitudinal functional trends.7 Most important, with the standardisation of terminology, it became possible to recruit patients into multicentre treatment studies.8–10 With regard to IPF in particular, the last 3 years have seen more studies of treatment than in the previous history of the speciality, yet there is no universally accepted “best current treatment”.

### 1.2 Methodology for constructing guidelines and making recommendations

The overall process for generating BTS guidelines has been addressed in numerous recently published documents (available at http://www.brit-thoracic.org.uk/guidelines.html). The methodology applied herein is broadly similar and is not therefore described in detail. However, there are specific aspects in the …

https://thorax.bmj.com/content/thoraxjnl/63/Suppl_5/v1.full.pdf

Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society.

Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition).

Rationale: Endobronchial ultrasound (EBUS) and electromagnetic navigation bronchoscopy (ENB) have increased the diagnostic yield of bronchoscopic diagnosis of peripheral lung lesions. However, the role of combining these modalities to overcome each individual technique's limitations and, consequently, to further increase the diagnostic yield remains untested.Objectives: A prospective randomized controlled trial involving three diagnostic arms: EBUS only, ENB only, and a combined procedure.Methods: All procedures were performed via flexible bronchoscopy and transbronchial forceps biopsies were obtained without fluoroscopic guidance. In the combined group, after electromagnetic navigation, the ultrasound probe was passed through an extended working channel to visualize the lesion. Biopsies were taken if ultrasound visualization showed that the extended working channel was within the target. Primary outcome was diagnostic yield. The reference “gold standard” was a surgical biopsy if bronchoscopic biopsy did ...

https://www.atsjournals.org/doi/pdf/10.1164/rccm.200612-1866OC

Multimodality bronchoscopic diagnosis of peripheral lung lesions: a randomized controlled trial.

Diagnostic Fiberoptic Bronchoscopy: Techniques and Results of Biopsy in 600 Patients

One hundred and four patients presenting with either massive or repeated hemoptysis were treated by embolization of the bronchial arteries with a resorbable material (Spongel). The procedure was performed via selective catheterization of the abnormal arteries. Forty-nine patients were treated during and 55 after hemoptysis. Of the 49 patients treated during hemoptysis, immediate arrest of bleeding was affected in 41 but 6 of these patients suffered relapse two to seven months after the procedure. There was no recurrence of bleeding in the remaining 35 patients.

Treatment of hemoptysis by embolization of bronchial arteries.

Deaths and complications associated with fiberoptic bronchoscopy.

A survey of the complications of fiberoptic bronchoscopy in 24,521 procedures revealed a low incidence of major complications and mortalities, 0.08 per cent and 0.01 per cent, respectively. Most complications encountered appeared to have been readily preventable. Examination of the patient should always be performed to ensure that he will be in optimal condition before the procedure and that appropriate monitoring will be carried out when indicated. Equipment for cardiovascular and respiratory resuscitation should always be readily available and were lifesaving in several patients in this study. The dosages of both premedication and topical anesthesia must be limited to avoid respiratory depression or systemic toxicity. Of a number of factors to consider in avoiding hypoxemia, maintenance of a patent airway, supplying adequate inspired oxygen, and avoiding oversedation are of utmost importance. Finally, it should be recognized that ancillary procedures, such as blind brushing and transbronchial biopsy, ca...

Complications of fiberoptic bronchoscopy.

A questionnaire was sent to 1,041 owners of fiberoptic bronchoscopes requesting data about complications of bronchoscopic examination; 323 (31 percent) of the questionnaires were returned. From approximately 48,000 procedures, ten deaths were reported and are described. Information about two additional deaths not obtained from data on the questionnaires is also included. All patients who died had either myocardial disease, severe chronic pulmonary disease, serious pneumonia, or cancer. Two deaths were associated with evidence on necropsy of fresh myocardial Infarctions that had been unsuspected prior to the procedure. Two deaths occurred after administration of local anesthesia prior to bronchoscopic examination. Two were patients who previously had slowly hemorrhaging tumors that hemorrhaged massively following, respectively, forceps biopsy and saline lavage. Four brushes broke off in bronchi. Ten cardiac arrests and 41 life-threatening reactions to anesthesia also occurred.

Joseph F. Smiddy

Papers

Deaths and complications associated with fiberoptic bronchoscopy.

Complications of fiberoptic bronchoscopy.

Deaths and complications associated with fiberoptic bronchoscopy

The Evaluation of Hemoptysis with Fiberoptic Bronchoscopy

Comparative in vitro effects of nitrous oxide, halothane, and cyclopropane on rat bone marrow oxygen consumption and anaerobic glycolysis