The indications for diagnostic and therapeutic bronchoscopy continue to expand rapidly as the field of bronchoscopy has been revolutionized by advanced technologies. Because of its high accessibility and popularity, there has been high enthusiasm and incentive for performing this procedure even when its value is limited diagnostically, its expected clinical success is low therapeutically, or its risk of complications is high. Bronchoscopy is a relatively safe procedure; however, being able to perform bronchoscopy does not mean and should not lead to the necessity to perform it. This approach can be considered in cases in which a high diagnostic yield or therapeutic clinical success is anticipated, and the benefits of the procedure outweigh the risks. Alternative diagnostic or therapeutic modalities should be used when the pretest probability of diagnostic yield or therapeutic clinical success is low and the risks outweigh the benefits for the patient. The bronchoscopist should be well acquainted with the indications, diagnostic and therapeutic limitations, alternatives, contraindications, risk-benefit ratio, complications, technical and clinical success, and cost of the procedure. Before, during, and after any diagnostic or therapeutic bronchoscopy, a patient-centered practical approach should be exercised by meticulously considering the initial evaluation of the patient, procedural strategies and planning, procedural techniques and results, and long-term management plan.

Interventional pulmonology in Indonesia has experienced significant advancements since its inception, with bronchoscopy being the central focus. The field began with the use of rigid bronchoscopes and rapidly progressed following the introduction of flexible fiberoptic bronchoscopes in the 1970s at Persahabatan Hospital. These advances allowed for less invasive diagnostics and the treatment of complex airway conditions. Over the years, Indonesian pulmonologists have pioneered the adoption of modern techniques, such as endobronchial ultrasound, autofluorescent bronchoscopy, and advanced biopsy methods, thereby enhancing their diagnostic capabilities. Therapeutic interventions, including laser resection, stent placement, and cryotherapy, have become essential for managing complex respiratory diseases. Hosting the 23rd World Congress for Bronchology and Interventional Pulmonology in 2024 underscores Indonesia's growing influence in global respiratory medicine, reflecting its commitment to medical innovation and the continuous improvement of patient outcomes. This review highlights the pivotal role of Indonesian pulmonologists in advancing the field and improving patient outcomes.

With the popularization of low-dose computed tomography scanning technology, the detection rate of pulmonary nodules has significantly increased, and the diagnosis of pulmonary nodules has become a critical issue in the medical field. Close monitoring and early detection of potentially malignant nodules are essential for improving patient survival. Bronchoscopic biopsy has shown remarkable results for the histological diagnosis of pulmonary nodules. Advances in this field have led to several innovative diagnostic tools, including endobronchial ultrasound, ultrathin bronchoscopy, virtual bronchoscopic navigation, electromagnetic navigation bronchoscopy, and robotic-assisted bronchoscopy. The development of these techniques has greatly improved the diagnostic capabilities of bronchoscopy, especially for peripheral pulmonary nodules, thereby providing more effective diagnostic tools. We reviewed recent advances in interventional bronchoscopy for diagnosing and treating pulmonary nodules, with a particular focus on strategies for detecting peripheral pulmonary nodules.

Chronic obstructive pulmonary disease (COPD), which is characterized by emphysema and airflow limitation, is one of the most common diseases worldwide. BTVA ablates emphysematous lung tissue leading to lung volume reduction. This case based narrative review explores BTVA procedure and its impact that has demonstrated improvements in lung function, exercise capacity, and quality of life irrespective of fissure integrity or collateral ventilation. Patient selection and procedure planning are key to successful BTVA. Data on BTVA is promising. More comprehensive research is necessary to provide a well-rounded understanding of BTVA's potential across different emphysema subtypes.

Background: Accurate assessment of the degree of tumor invasion of the tracheobronchial wall in esophageal cancer is a pivotal factor influencing treatment decisions. In addition to radiological modalities, such as computed tomography and magnetic resonance imaging, bronchoscopy is a valuable tool for staging purposes. Due to the increasing availability of convex probe endobronchial ultrasound (CP-EBUS), obtaining esophageal findings has recently become more feasible. This study aimed to evaluate the efficacy of the CP-EBUS sliding sign for predicting tracheobronchial invasion.

Materials and Methods: In this observational, single-center cohort study, we examined 12 cases in which CP-EBUS was used during bronchoscopy to evaluate tracheobronchial invasion. Movement of the tracheobronchial membranous portion and esophageal cancer was observed, and gaps in the movement indicated a positive sliding sign. The movement was quantified using particle image velocimetry. Patients who underwent surgical resection were subjected to postoperative pathological examinations and subsequent comparisons.

Results: Sliding sign was positive in eight cases suggesting no invasion from CP-EBUS findings. Of the eight patients assessed without tracheobronchial invasion, six without distant metastases underwent surgical intervention. In each case, postoperative pathological examination confirmed the absence of invasion. Sliding sign was negative in four cases with evident tracheal invasion. All four cases were inoperable, and pathological confirmation was not possible, but in one case, esophageal cancer protruding into the trachea was visible, and tracheal invasion was evident.

Conclusions: CP-EBUS showed that a sliding sign can be used to evaluate real-time visualization of changes in tracheobronchial invasion. This sliding sign is valuable for the accurate staging of esophageal cancer.

Background: Although bronchoalveolar lavage (BAL) is widely used in clinical practice in Japan, the methods of saline injection and BAL sample analysis differ among institutions.

Materials and Methods: We conducted a questionnaire survey at 915 facilities accredited by the Japan Respiratory Society to examine the differences in the implementation methods of BAL among facilities. During the survey period from May 15, 2019, to July 30, 2019, we received responses from 442 facilities (48.3%).

Results: A total of 364 facilities (86.5%) reported that BAL was performed in less than 30% of bronchoscopy procedures. The saline volume used in BAL was 50 mL× 3 times at 377 facilities (90.7%). At 380 facilities (88.6%), BAL was performed on sites with strong imaging lesions. Overall, 244 facilities (56.9%) did not perform BAL for acute exacerbation of interstitial pneumonia.

Conclusions: As each aspect of the BAL procedure was found to differ across facilities, standardization of the BAL procedures is desirable.

An 18-year-old man was referred to our hospital by his family doctor after noticing an abnormal shadow on chest radiography during a health checkup. He did not report respiratory complaints during his first visit to our hospital. Computed tomography of the chest revealed a highly absorptive, club-shaped, bifurcated shadow in the right upper lobe and surrounding granular shadows, indicating a mucus plug. Bronchoscopy revealed edematous changes in the bronchial epithelium of the right upper lobe and viscous white sputum in the right B³ bronchus. When a sputum sample was collected using biopsy forceps, a mass of the mucus plug was suspected. A filamentous fungus was detected in the culture test, and an identification test performed at Chiba University Mycological Medical Research Center identified it as Curvularia mebaldsii. On the basis of the new diagnostic criteria proposed by the Japanese allergic bronchopulmonary mycosis (ABPM) research team in 2019, we diagnosed the condition as ABPM caused by this fungus. This is the first report of ABPM caused by C. mebaldsii in Japan within the scope of our search. The new diagnostic criteria proposed by the ABPM research team were useful for diagnosing this case.

In this report, we present a case of granular cell tumor (GCT) of the mediastinum diagnosed using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy. A 60-year-old woman was referred for the evaluation of a superior mediastinal mass (30 × 40 mm) at the level of the aortic arch with abnormal uptake on 18F-fluorodeoxyglucose positron emission tomography-computed tomography. Upper gastrointestinal endoscopy revealed no tumor; however, stricture was found in the upper esophagus, 20 cm from the incisors. Although a transnasal endoscope (GIF-XP290N; outer diameter at the distal end 5.4 mm, Olympus Medical System, Tokyo, Japan) could be advanced beyond the stricture, endoscopic ultrasound-guided fine-needle aspiration could not be conducted because the scope (FUJINON EG530UT2; outer diameter at the distal end 13.9 mm, Fujifilm Co., Tokyo, Japan) could not be advanced beyond the stricture. Thus, the mediastinal mass was biopsied under EBUS-TBNA, and nests of cells with granular eosinophilic cytoplasm were found, in which pathologically and immunohistochemically, GCT was suggested. The case points out that EBUS-TBNA can be useful for GCT diagnosis in the mediastinum, which is challenging to diagnose via gastroscopy.

Bronchial artery (BA) aneurysms (BAAs) are often treated with BA embolization (BAE) or surgical procedures; accordingly, there are few reports of treatment with intra-aortic stent grafting (SG).

A 66-year-old woman, a Jehovah's Witness, visited an otorhinolaryngologist due to bloody sputum. Nasopharyngoscopy revealed no bleeding in the examined area. However, she visited again due to hemoptysis. She was referred to us. CT revealed that showed the left BA branched off caudally from the proximal descending aorta, and a BAA with a diameter of 27 mm was observed 5 mm away from the origin of the artery, as well as two 10-mm-diameter BAAs further down the artery. Bronchoscopy revealed no bleeding. As the BAAs were large and consecutive, BAE was considered difficult. We recommended surgical procedures, but she refused because of the risk of needing blood transfusion. Then, she agreed to undergo SG. Treatment was performed under general anesthesia. A sheath was inserted through the right common femoral artery, and a stent graft was inserted into the descending aorta to cover the BA branch. She had a good postoperative course without perioperative complications. After 13 years, CT revealed no endoleak, migration, or re-enlargement of the BAAs.

Wedge resection of lung cancer using a radiofrequency identification (RFID) marking system was first reported in 2020 and has been increasingly used since. The case described here involved a 67-year-old female patient with Parkinson's disease with an Eastern Cooperative Oncology Group performance status of 3. Chest computed tomography showed an irregular 21-mm nodule in the left lung S¹⁺², contacting the interlobar pleura. During bronchoscopic lung biopsy, the guide sheath tip was slipped into the end of the left B¹⁺²ciiα. The broken tip was 15 mm ventrally to the nodule and was judged difficult to palpate intraoperatively because it was 20 mm from the visceral pleura. To obtain accurate positional information during surgery, an RFID tag was placed near the guide sheath tip on the mediastinal side of B¹⁺²ciiβ. After localization using a detection probe, wedge pulmonary resection was performed including both the cancer nodule and guide sheath tip. In short, using an RFID marking system, we could accurately remove a broken guide sheath tip and a lung cancer nodule.

Idiopathic tracheal stenosis is an extremely rare disease that can constrict the airway, with no established therapeutic strategy. We herein present our experience with a patient with recurrent idiopathic tracheal stenosis treated with sequential endoscopic tracheoplasty using different modalities. A 41-year-old woman presented with dyspnea and wheezing 6 years ago, which gradually worsened over time. Chest computed tomography revealed tracheal stenosis caused by fold-like structures 15 mm below the glottis. Spirometry results indicate central airway stenosis. Bronchoscopy revealed significant tracheal stenosis due to a circumferentially protruding web-like structure. Pathological tissue biopsy revealed nonspecific inflammation and granulation. The patient was diagnosed with idiopathic tracheal stenosis in the absence of any obvious alternative causes. Argon plasma coagulation (APC) therapy was performed because of severe dyspnea and decreased peak flow. Her dyspnea and pulmonary function improved immediately after treatment. Follow-up bronchoscopy after 6 months revealed significant improvement in the stenosis; however, the lesion recurred 10 months after treatment. Therefore, tracheoplasty using a cryoprobe and balloon dilatation was performed as a second treatment, resulting in another successful improvement. Endoscopic tracheoplasty using APC or cryoprobe is effective for idiopathic tracheal stenosis, thereby enabling the selection of treatment strategies at each facility.