The effectiveness of interventional bronchoscopic treatment for immediate palliation of central airway obstruction has been established, often being the only treatment alternative left. Conceptually, the use of EC and APC is no different than applying Nd:YAG laser as described earlier. Easy logistics allow practical management in the daily practice of a bronchoscopy unit (2–4). As extensive investigations, e.g., CT scan, lung function measurements, and blood gas analysis, prior to intervention in patients with imminent respiratory failures are unfeasible, clinical findings of stridor and severe dyspnea justify immediate action. EC and APC can then be applied more easily for tumor coagulation prior to mechanical debulking and stenting.

EC and APC can better safeguard unexpected bleeding after taking biopsy as increasing number of patients at risk have cardiovascular comorbidities and are routinely taking aspirin and clopidogrel. Many educational workshops are now dealing with competency skill training that better prepare operator and team members to act properly and decisively in case of adverse events during bronchoscopy.

By either using the rigid scope or working through the endotracheal (ET) tube, the interventional pulmonologist can perform tissue coagulation with EC or APC probe and recanalize the central airways more effectively. The rigid scope with its larger working channel obviously better provides access for safer manipulation and primarily in safeguarding ventilation. Despite the wider acceptance of using only devices that suite the flexible bronchoscope, the blocking effect of the flexible bronchoscope can jeopardize safety. The proper execution of any interventional technique depends on the readiness and expertise of the team that is familiar with various procedures, including proficiency in using the rigid instruments. Therefore, one should always realize that technique per se is not the only factor that determines success regardless of the use of intraluminal tumor debulking that is easier to be applied.

Interventional pulmonologists can also provide alternative treatment strategies after diligent consultation within the thoracic multidisciplinary team, for other intraluminally located tissue abnormalities.

Apart from lung cancer, involvement of central airways by tumor metastasis, benign lesions, and slow-growing lesions such as typical carcinoid, even malignant fibrosarcoma, does warrant a proactive role for the interventional pulmonologists to be involved in the care of these patients. The argument that a potential delay in surgery will jeopardize patients’ outcome has not been proven in our longitudinal study with regard to bronchoscopic treatment of bronchial carcinoid. Given current knowledge on neuroendocrine tumors, this is in retrospect not surprising. Even after years of postponement, surgical resection would not have been different regarding extent of resection or outcome in the several cases that there was residual tumor or local recurrence in the bronchial wall. The various bronchoscopic techniques for benign processes must be seen in the same conceptual line as foreign body removal, in which surgical resection should remain the last resort. Any minimally invasive technique that can be first commenced in trying to solve the problem before performing major surgery is preferable rather than an immediate and hasty surgical approach.

Indeed, disease management has become a concerted effort between various disciplines by fully exploiting the different input from expert team members, including interventional pulmonologists. Increasing understanding about tumor behavior and clonal cell growth and behavior in current era of molecular biology and also in dealing with early-stage nonsmall-cell lung cancer is of paramount importance. The involvement of interventional pulmonologists in pulmonary medicine and medical oncology can be very supportive regarding early detection, staging, and treatment strategies, both for central airway and lung parenchymal abnormalities.