A Scientific Basis for Fiberoptic Bronchoscopy

1977) is an excellent contribution to our understanding of Dressler's syndrome. It also casts light on the role or lack of a role for anticoagulant therapy in relation to pericardia} effusions. I noted with some interest that the patient of Tew et al had to have two pericardia} punctures within three hours because, despite immediate relief from the first small tap, he again went into tamponade shortly thereafter. Tew and associates could have avoided this occurrence, including the repeated hazard of puncture by needle, had they routinely used pericardia} catheterization. We have done this for many years,1 -a with the advantages that pericardial catheterization not only permits constant drainage, but also the insertion of a soft catheter, rather than maintaining a sharp needle's tip in the pericardium. Daoid H. Spodick, M.D., D.Sc., F.C.C.P. Profeuor of Cardiovascular Medicine and Medicine University of Massachusetts Medical School and Director, Cardiology Division St. Vincent HO&TJital, Worcester, Masa

1 Spodick DH: Acute Pericarditis. New York, Grune and Stratton, Inc, 1959, p 84 2 Spodick DH: Acute cardiac tamponade: Pathophysiology, diagnosis and management. Prog Cardiovasc Dis 10:64-96, 1967 3 Spodick DH: Electric alternation of the heart: Its relation to the kinetics and physiology of the heart during cardiac tamponade. Am J Cardiol 10:155-165, 1962

A Scientific Basis for Fiberoptic Bronchoscopy To the Editor: The World Conference on Bronchoscopy met on Feb 24 to 26, 1977 in San Francisco. The case reports were voluminous, and the enthusiasm was contagious. When reporting the results of bronchoscopic procedures in patients with carcinoma of the lung, the anatomic location of the lesion and its distance from the pleura and mediastinum must be known. The histologic tumor type, either primary or metastatic, may inBuence diagnostic yield. The types of diagnostic procedures, such as bronchial lavage, suctioning biopsy, curetting, bronchial biopsy, or brushing, need to be documented, with yields for each procedure. The number of bronchoscopic procedures performed in order to establish a diagnosis also is important. Careful reports need to elucidate whether patients had several bronchoscopic procedures, rather than a single procedure. The results of cytologic examinations need to be amplified. "Highly suspicious" cytologic flndings must be distinguished from truly positive cytologic flndings. The percentages of false-negative and false-positive cytologic findings are necessary information for the evaluation of cytologic data from any institution. The accuracy of determining a speciflc cell type is more important than

440 COMMUNICATIONS TO THE EDITOR

whether the cytologic flndings are "positive" or "negative." These data also need to be included in case reports. Also, the method of selection of patients needs to be documented. In some centers, peripheral lesions are diagnosed by aspiration needle biopsy. The reports of bronchoscopic procedures for peripheral lesions are actually skewed toward more central and more easily accessible lesions. Hence, a higher yield would be expected. Unless more information is given by authors, much of their information is uninterpretable. Reports of transbronchoscopic biopsy of the lung were also numerous; however, the question is not whether tissue can be obtained by this method, which by now has been adequately proven, but what is the impact of that biopsy on physicians' performance and the care of the patient. The biopsy from a patient with fibrosing alveolitis will not, in all probability, change the pattern of his care. The presence or absence of a cellular response, intermingled with pulmonary fibrosis, does not reHect the responsiveness to therapy with corticosteroids or immunosuppressive drugs. Hence, it is unlikely that a biopsy will in any way change the patient's care, since he will be treated anyway. The question is not what diseases can be documented by this method, but in what setting is the best method of diagnosis, and how will this diagnosis affect the care of the patient. Therapeutic bronchoscopic procedures for retained secretions also are gaining popularity. Many would like to give all patients with retained secretions an "enema" to the airways. Colonic irrigation is effective for fecal impaction but is not of value for a variety of other abdominal conditions which may similarly cause the symptom of abdominal distention; for example, in pancreatitis, a large amount of stool may be produced by an enema, but this has no effect on the underlying disease. So it is with pulmonary diseases; the very fact that secretions are removed does not necessarily indicate a change in the natural history of a disease process. Careful consideration must be given as to which patients are most likely to benefit from a therapeutic bronchoscopic procedure. There is a potential for overuse and an unnecessary increase in the costs of health care. A change in the natural history of the disease, as compared to aggressive noninvasive therapy, must be documented, and not simply a change in the x-ray film. Reports on fiberoptic bronchoscopic procedures often reflect an attitude of "look, Ma, at what I can do," rather than a critical appraisal of the limitations as well as the value of such procedures. More accurate reporting will help to establish a scientiflc basis for fiberoptic bronchoscopy. Dorsett D. Smith, M.D., F.C.C.P. Assistant Clinical Professor of Medicine and Director of Chest Clinic, University Hospital University of W arhington, Seattle

Reprint requests: Dr. Smith, 908 Grand Avenue, Everett, Washington 98201

CHEST, 73: 3, MARCH, 1978