Clinical practice guidelines in adult diagnostic flexible bronchoscopy: systematic review of the literature and quality appraisal with AGREE II

Introduction

Flexible bronchoscope (FB) is a safe surgical tool commonly used to evaluate, diagnose, and treat respiratory diseases. As FB has the characteristics of small invasiveness, strong ability to explore bronchial trees, and fast learning curve (1,2), it has become an indispensable tool in respiratory medicine. In pulmonary diseases, we can collect specimens through a variety of ways, such as bronchoalveolar lavage, bronchoscopic lung cryobiopsy, and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) (2,3). However, these operations may lead to a higher risk of complications in some conditions, such as hypoxemia, hemodynamic instability, and bleeding (4). Therefore, clinicians need to strictly grasp the surgical indications and contraindications, and master the treatment of complications in order to balance the potential risks and benefits. High-quality clinical practice guidelines provide an important reference. Relevant clinical practice guidelines have been developed by different professional associations to guide clinical decision-making and management of bronchoscopy. However, there is still a lack of comprehensive evaluation and summary analysis of industry guidelines and expert consensuses on the clinical practice of adult diagnostic FB. Therefore, this study searched the guidelines and expert consensuses published worldwide, used the Appraisal of Guidelines for Research & Evaluation Instrument II (AGREE II) (5,6) to evaluate the quality of existing authoritative guidelines, and the scores of the guidelines in various fields at home and abroad were compared, so as to provide reference for the work focus of the guidelines development team in China. At the same time, the main recommendations in the adult diagnostic FB examination guidelines were summarized to assist clinical professionals. We present this article in accordance with the PRISMA reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-773/rc).

Methods

Literature search and selection criteria

A systematic review of the literature in China National Knowledge Infrastructure (CNKI), Wanfang database, SinoMed, and PubMed was conducted. At the same time, Guidelines International Network (GIN), National Institute for Health and Care Excellence (NICE), Ovid Technologies (OVID), World Health Organization (WHO), Scottish Intercollegiate Guidelines Network (SIGN), and other databases and related websites were supplemented (7). The retrieval time was from the establishment of the database to April 2024; the following search terms were used: ([“bronchoscop*”] AND [“guideline” OR “guide” OR “consensus” OR “common understanding” OR “common view” OR “shared understanding” OR “best practice”]).

Guidelines that addressed the FB were included. We excluded the following: guidelines on pediatric bronchoscopy, guidelines on rigid bronchoscope, guidelines on interventional therapy as the main purpose of bronchoscopy, and guidelines for patients with novel coronavirus infection. If a practice development group or processional society had published multiple guidelines, the most recent guideline was used. Systematic reviews, editorials, short summaries, retrospective reviews, textbook chapters, and other literature reviews evaluating or explaining guidelines were excluded.

Guideline screening and data extraction

According to the established search strategy, the guidelines were screened according to the inclusion and exclusion criteria, and the remaining guidelines were further screened by reading the full text. The following data were simultaneously extracted from each clinical practice guideline during the guideline screening: guideline name, publication year, development institution, source country, number of references, and so on.

Quality appraisal

In order to evaluate the quality of the included guidelines, three researchers (W.H., L.T., C.X.) conducted an independent evaluation using the AGREE II guideline evaluation tool. Prior to the assessment, all researchers completed the free online training provided on the AGREE website (www.agreetrust.org). The AGREE II tool contains 23 items, which are divided into the following six domains: (I) scope and purpose; (II) participants; (III) rigor; (IV) clarity; (V) application; (VI) independence (8,9). Each entry was rated on seven levels, from 1 (strongly disagreed) to 7 (strongly agreed). If there was a big difference in the scores of the three researchers, the group will give a final evaluation after discussion. According to AGREE II, the percentage score of each field was calculated according to the proportion, and the calculation formula was as follows: standardized percentage score of each field = (obtained score-possible minimum score)/(possible maximum score-possible minimum score) ×100%. The higher the score, the higher the methodological quality of the guideline, which is recommended (10). Scores of 60% and 30% were considered to be the thresholds for measuring the quality of clinical practice guidelines (11,12). After completing the evaluation of the six domains, the researchers made an accurate comprehensive judgment on the quality of each guide, and determined the quality level of the guide and whether to recommend the use of the guide according to the number of domains that reached a certain standardized percentage score (Table 1) (13).

Statistical analysis

The software SPSS 27.0 (IBM Corp., Armonk, NY, USA) was used to test the consistency of the evaluation results of the guidelines. The intraclass correlation coefficient (ICC) was used to test whether the evaluation results of different researchers were consistent, and the two-way random model was selected to calculate the absolute consistency (14,15). According to the classification criteria of previous literature, ICC was divided into poor (≤0.20), general (0.21–0.40), moderate (0.41–0.60), good (0.61–0.80), and very good (0.81–1.00) (16,17). The included guidelines were grouped according to whether the first author’s nationality was Chinese, divided into Chinese and international groups, and independent sample t-test was used to compare the differences between the two groups.

Results

Guideline characteristics

A total of 4,504 articles were obtained through major databases and other search methods, leaving 3,864 documents after identifying and removing duplicates using Endnote (Clarivate, Philadelphia, PA, USA). According to the inclusion and exclusion criteria, 11 articles were finally selected by reading the title, abstract and full text (Figure 1). Among them, the first authors of five guidelines were from China, whereas the first authors of six guidelines were from countries other than China. Table 2 summarizes the basic characteristics of each guideline.

Figure 1 Literature screening and process.

Appraisal of guidelines

The AGREE II domain scores for the guidelines are shown in Table 3. The average score of domain 1 (scope and purpose) was the highest (60.6%, range, 46.3–74.1%), and the score of each guideline was greater than 30%. The average scores of domain 2 (participants) and domain 3 (rigor) were 50.5% and 51.8% (range, 18.5–79.6%, 21.8–75.8%), respectively. The average scores of domain 4 (clarity) and domain 6 (independence) were 49.4% and 41.7%, respectively (range, 31.5–59.3% and 2.8–75.0%, respectively). The average score of domain 5 (application) was the lowest, and only one guideline had a score of more than 30% (27), with a score of 24.5% (range, 14.3–33.3%). A total of 11 guidelines were included; among them, the quality grade of 10 articles was rated as grade B, which can be recommended after slight modification and improvement. The quality grade of one article was rated as C, so it was not recommended.

Compared with non-Chinese guidelines, the average scores of the six areas of Chinese guidelines were lower, and the differences in domain 3 (rigor) (P=0.001) and domain 5 (applicability) (P=0.04) were statistically significant. Five domestic guidelines were included, of which four were rated as grade B and one was rated as grade C. Of the six foreign guidelines included, six were rated as grade B (Table 4).

Intraclass reliability

In this study, three researchers participated in the evaluation of the guidelines. The three independent appraisers achieved a score of “very good” intraclass reliability or higher, indicating that the scores of the researchers on the six domains were almost identical (29,30).

Summary of recommendations

Indication of FB

Bronchoscopy is a basic examination in interventional respiratory disease, which has been basically popularized in China and internationally. According to published guidelines and expert consensuses (18,20,22,23,25,26), the indications for bronchoscopy are very broad and can be summarized as follows: (I) symptom assessment (hemoptysis, localized wheezing, unexplained cough); (II) evaluation of endobronchial diseases (tumor, foreign body, stenosis, fistula, mucus obstruction, thermal injury; (III) evaluation of abnormal chest radiographs (lung mass, focal or diffuse pulmonary infiltration, atelectasis, pleural effusion); (IV) evaluation of mediastinal and hilar lymph nodes by ultrasound bronchoscopy. Bronchoscopic lung cryobiopsy should be considered for all patients with diffuse parenchymal lung disease, because clinical and radiological features alone cannot reliably diagnose a specific subtype of diffuse parenchymal lung disease (28). For patients with peripulmonary lesions larger than 8 mm in diameter, or patients who need to obtain tissue samples or microbial evidence to determine the diagnosis and treatment plan, electromagnetic navigation bronchoscopy can be considered (22).

Contraindications of FB

The contraindications of FB examination can be summarized as follows: (I) acute myocardial infarction within 4 weeks; (II) active hemoptysis; (III) platelet count <20×10⁹/L or uncorrected coagulation dysfunction; (IV) hemodynamic instability; (V) severe respiratory failure; (VI) pregnancy; (VII) severe mental illness.

Preoperative preparation of FB

Before completing the bronchoscope examination, patients need to be informed of the possible situations in the operation process and provided guidance to improve patient compliance and tolerance, and they need to be made aware their risks and sign informed consent (26). In addition, for patients under local anesthesia, it is necessary to start fasting 4 hours before the operation and two hours before the operation; for patients under general anesthesia, it is necessary to start fasting 8 hours before the operation and two hours before the operation (18). Before the operation, it is necessary complete chest film examination to evaluate the patient’s condition, to conduct blood routine and routine coagulation to assess the risk of bleeding, infectious disease examination to reduce the risk of surgery, and electrocardiogram to reduce the occurrence of surgical complications. In order to reduce the risk of bleeding, antiplatelet drugs and anticoagulants should be discontinued or adjusted according to the actual situation before surgery. Pulmonary function test and arterial blood gas analysis are not necessary, but patients with suspected chronic obstructive pulmonary disease need to undergo a pulmonary function test. If the FEV1/FVC is less than 40%, blood gas analysis should be performed.

Sedation and anesthesia of FB

Bronchoscopy should not be an uncomfortable experience for patients. Various measures must be taken to ensure the comfort of patients. Sedation and anesthesia are the most important methods. Sedation does not reduce the safety of bronchoscopy, but can significantly improve patient satisfaction and surgical tolerance. If there is no contraindication, intravenous sedation should be routinely given to patients undergoing FB examination (24,26). Anesthesia needs to be individualized, and sedative drugs need to be titrated to provide the required depth of sedation. The ideal depth of sedation is verbal contact without pain during bronchoscopy (26). On the basis of topical anesthesia, sedation and appropriate analgesic drugs are given to keep the patient at a mild to moderate sedation level, so as to avoid some patients experiencing asphyxia, dyspnea, and other discomfort due to tension and fear, such as patients undergoing EBUS-TBNA and transbronchial frozen lung biopsy (25,28). Lidocaine is the most commonly used surface anesthetic in bronchoscopy. According to the actual situation, it can be administered by spray or aerosol inhalation, endotracheal instillation, gargle, cricothyroid membrane puncture, and so on. Commonly used sedative and analgesic drugs include benzodiazepines (such as midazolam), opioids (such as fentanyl), and propofol. The main advantage of using opioids in bronchoscopy is that they can better inhibit cough than benzodiazepines. However, opioids are not as good as benzodiazepines in amnesia. The combination of benzodiazepines and opioids can improve the comfort and tolerance of patients more than benzodiazepines alone. Propofol is an intravenous anesthetic with sedative, anxiolytic, and amnesia effects, but it has no direct analgesic effect. Due to its narrow therapeutic window, it requires close monitoring by professional anesthesiologists, and is not as commonly used as other sedatives in clinical applications. The characteristics of commonly used anesthetics are detailed in Table 5.

Treatment of intraoperative and postoperative complications of FB

The patient’s physical condition should be evaluated before bronchoscopy, and routine monitoring should be performed during the examination to reduce the risk of complications. Heart rate, heart rhythm, blood pressure, oxygen saturation, respiratory rate, and electrocardiogram should be monitored during the operation to identify the occurrence of complications as early as possible (18,22,23,26). Although the incidence of complications of bronchoscope examination is low, there are still many complications due to the large population base of bronchoscope examination (Table 6). At present, the included guidelines all have a certain description of surgical complications, but the treatment measures are not clear.

Discussion

This study is the first to evaluate the current adult diagnostic FB guidelines using the AGREE II. Overall, the quality of the included guidelines was moderate. The average score of each guideline in domain 1 (scope and purpose) was the highest, with a score of 60.6%; the average score of domain 5 (applications) was the lowest, with a score of 24.5%. The average scores for domain 2 (participants), domain 3 (rigor), domain 4 (clarity), and domain 6 (independence) were 50.5%, 51.8%, 49.4%, and 41.7%, respectively. Compared with the scores of other guidelines in the previous literature, the scores of the guidelines included in this study were lower (6,16,17). In addition, compared with non-Chinese guidelines, Chinese FB guidelines scored lower in domain 3 (rigor) (P=0.001) and domain 5 (applications) (P=0.04). Therefore, the guideline development team, especially the Chinese guideline development team, should pay special attention to the methodological quality of the guidelines when formulating the guidelines.

In this study, domain 1 (scope and purpose) addresses the overall purpose of the guidelines, the health issues covered, and the target population. This was the domain with the highest score of each guideline, and the Chinese and international guidelines generally had higher scores in this domain, which more clearly described the overall purpose and users of the guidelines. However, since the item 2 evaluations included target populations, interventions or exposure factors, controls, outcomes, health care facilities, and the environment, evidence-based guidelines scored higher in this item (25-28). In contrast, the expert consensus had a lower score in this item.

In domain 2 (participants), we aimed to investigate whether the professionals developing the guidelines did so appropriately and comprehensively, and whether they represented the views and preferences of the target population. For the specific situation of bronchoscope examination, the main stakeholders are respiratory physicians. However, the indications for bronchoscopy cover many common diseases or symptoms, such as unexplained hemoptysis, cough, tumor, lung infection, and people with these symptoms or diseases may not visit the respiratory department in the first place. Therefore, primary care physicians, general practitioners, infectious disease physicians, emergency physicians, and thoracic surgeons can also benefit from high-quality bronchoscope practice guidelines. In each guide, the average score was not less than 50%. This was because most of the guidelines provided information such as the name, organization, and geographical location of the guide development team members (18-28), and the three researchers consistently gave a high score after discussion. However, it should be noted that the staff comprising each guideline development team was relatively simple, and almost all of them were respiratory clinicians. In contrast, there was relatively little involvement from physicians of other fields, medical statistics, evidence-based medicine, epidemiology, and other methodological experts. In addition, when developing guidelines, less consideration was given to the willingness of the target population, which might reduce patient compliance. Therefore, we suggest that in the development of bronchoscope practice guidelines, the participation of doctors and methodological experts in other disciplines should be increased, and more attention should be paid to the willingness of the target population to improve the quality of the guidelines and patient compliance.

Domain 3 (rigor) involves the process of synthesizing evidence, assessing the quality of reports collected and synthesized in the development of clinical practice guidelines, and the methods used to develop and update recommendations. This field is an important indicator for measuring the reliability and transparency of the guidelines, and it is also one of the most critical domains in AGREE II (31). Compared with non-Chinese guidelines, Chinese guidelines scored significantly lower in this field (P=0.001). Specifically, the average scores of Chinese and international guidelines in domain 3 (rigor) were 36.8% and 64.4%, respectively. In the five domestic guidelines, there was no systematic search of evidence, no clear description of the criteria for selecting evidence, and no steps for updating the guidelines or processes reviewed by external experts. Although only one non-Chinese guideline clearly stated that it had been reviewed by external experts before publication (25), six foreign guidelines all provided detailed evidence retrieval strategies (23-28). Only two guidelines were vague in the criteria for selecting evidence (23,28), which might be the main reason why non-Chinese guidelines scored higher than Chinese ones. The rigor of the method can ensure that the recommendations implemented by the guide users are fair and accurately reflect the current high-quality evidence. In view of the importance of domain 3 (rigor) in the development of the guidelines, future guidelines, in particular Chinese guidelines, should provide detailed information on the development process of the guidelines, such as search terms, databases searched, search processes, and methodologies for selecting evidence and developing recommendations. This is also one of the reasons for the high score of evidence-based guidelines. By raising the Chinese guide’s score domain 3, we can increase the reliability and transparency of the guide and ensure that recommendations are based on sufficient and high-quality evidence.

Domain 4 (clarity) deals with the language, structure, and overall usability of the guidelines. Among them, four guidelines adopted the method of sub-point discussion (24,25,27,28), which was conducive to user identification of main recommendations, so they scored higher in the evaluation of researchers. On the contrary, the rest of the guidelines did not use any method to emphasize important recommendations, so the score was low. However, since the recommendations of each guideline are clear, none of the guidelines scored less than 30% in this field.

Domain 5 (applications) deals with facilitators and disincentives to the application of the guideline, the mode of dissemination, and potential resources for the practical application of the guidelines. The Chinese and non-Chinese guidelines generally scored low, with an average score of only 24.5%. In this field, the score of Chinese guidelines was lower than that of international guidelines (20.8% vs. 27.6%, P=0.04). Only one guide scored higher than 30% (27), because the guide provides oversight and auditing standards. None of the guideline clearly described the promotion and hindrance factors in the application, nor did they provide opinions or tools for the application of recommendations, and the potential related resources for the application of recommendations have not been mentioned.

Domain 6 (independence) assesses whether the recommendations in the guidelines are affected by the source of funding. Six guidelines indicated external sponsorship (18,20,21,24,25,27), whereas only one guideline clearly indicated no external sponsorship (28). However, none of the guidelines clearly stated whether the final recommendations of the guidelines were influenced by the views or interests of the sponsors, which was the main reason for the low score. Lack of transparent funding sources and unspecified conflicts of interest can lead to potential guideline users and patients refusing to use them.

In addition to conventional bronchial examination, a series of new technologies have emerged, such as electromagnetic navigation bronchoscopy, EBUS-TBNA, and bronchoscopic lung cryobiopsy. After comprehensive analysis of authoritative guidelines in China and internationally, it was found that the indications, contraindications, sedation and anesthesia, and treatment of complications were relatively consistent, but there were few high-level evidence-based recommendations. The quality of Chinese and international guidelines included in this study is low. It is recommended that the Chinese and international guideline development team should pay attention to the following clinical issues in addition to improving the methodological quality: (I) how to increase the diagnostic accuracy and reduce the risk of surgery under relative contraindications; (II) detailed treatment measures for intraoperative complications; (III) emphasize the additional precautions of the new bronchoscopy technique compared with conventional bronchoscopy.

The purpose of this study was to evaluate the quality of adult diagnostic FB practice guidelines published worldwide, and to summarize and analyze the main recommendations. At the same time, it highlighted the methodological deficiencies and clinical issues that need attention in the formulation of guidelines, so as to provide reference for the members of the guideline development team in the formulation of high-quality guidelines and better serve the clinical practice. However, this study also had the following limitations: (I) each researcher may have had a certain degree of subjectivity, and may have a higher score on guidelines issued by authoritative agencies, and a lower score on guidelines issued by immature agencies; (II) this study only included Chinese or English guidelines, and may have missed high-quality guidelines in other languages; (III) the quality of the guidelines is mainly reflected in domain 3 (rigor), but the AGREE II score places this key domain on the same weight as other domains, thus limiting the accuracy of the score; (IV) AGREE II is a methodological tool that does not assess the content and clinical significance of the guidelines, and mainly focuses on the development of guidelines. Therefore, even if the guidelines are based on low-quality evidence, AGREE II can still give high scores to the guidelines if they meet the AGREE II standard.

Conclusions

The quality assessment of guidelines showed that the overall level of adult diagnostic FB guidelines is moderately biased. In addition, this study compared Chinese FB guidelines with international guidelines for the first time, and found that the quality of Chinese guidelines was lower than that of international guidelines. In view of this, clinical professionals should pay special attention to and conduct in-depth review when referring to the recommendations in the guidelines, especially Chinese guidelines. At the same time, in the process of guideline development, the members of the guideline development team should strive to ensure the methodological quality of the evidence-based guidelines and strive to incorporate high-quality evidence to standardize the operation of adult diagnostic FB examination, improve the diagnosis rate of the disease, reduce the risk of adverse reactions, and reduce the operation-related complications.

Acknowledgments

Funding: This work was supported by grants from Natural Science Foundation of Gansu Province (No. 22JR5RA983), Lanzhou University Cui Ying Technology Innovation Program (No. CY2023-BJ-04), Cuiying Scientific Training Program for Undergraduates of The Second Hospital & Clinical Medical School, Lanzhou University (No. CYXZ2024-24), and Natural Science Foundation of Gansu Province (No. 24JRRA371).

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-773/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-773/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-773/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Scala R, Guidelli L. Clinical Value of Bronchoscopy in Acute Respiratory Failure. Diagnostics (Basel) 2021;11:1755. [Crossref] [PubMed]
2. Miller RJ, Casal RF, Lazarus DR, et al. Flexible Bronchoscopy. Clin Chest Med 2018;39:1-16. [Crossref] [PubMed]
3. Diaz-Mendoza J, Peralta AR, Debiane L, et al. Rigid Bronchoscopy. Semin Respir Crit Care Med 2018;39:674-84. [Crossref] [PubMed]
4. Ergan B, Nava S. The use of bronchoscopy in critically ill patients: considerations and complications. Expert Rev Respir Med 2018;12:651-63. [Crossref] [PubMed]
5. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010;182:E839-42. [Crossref] [PubMed]
6. Gavriilidis P, Askari A, Roberts KJ, et al. Appraisal of the current guidelines for management of cholangiocarcinoma-using the Appraisal of Guidelines Research and Evaluation II (AGREE II) Instrument. Hepatobiliary Surg Nutr 2020;9:126-35. [Crossref] [PubMed]
7. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372: [Crossref] [PubMed]
8. Xie X, Wang Y, Li H. AGREE II for TCM: Tailored to evaluate methodological quality of TCM clinical practice guidelines. Front Pharmacol 2022;13:1057920. [Crossref] [PubMed]
9. Dayto DC, Blonski W, Reljic T, et al. A systematic critical appraisal of clinical practice guidelines of antithrombotic agents in gastrointestinal endoscopy using the AGREE II tool. J Gastroenterol Hepatol 2024;39:818-25. [Crossref] [PubMed]
10. Tittlemier BJ, Wittmeier KD, Webber SC. Quality and content analysis of clinical practice guidelines which include nonpharmacological interventions for knee osteoarthritis. J Eval Clin Pract 2021;27:93-102. [Crossref] [PubMed]
11. Qin ZH, Yang X, Zheng YQ, et al. Quality evaluation of metabolic and bariatric surgical guidelines. Front Endocrinol (Lausanne) 2023;14:1118564. [Crossref] [PubMed]
12. Ruiz-Sánchez FJ, Ruiz-Muñoz M, Martín-Martín J, et al. Management and treatment of ankle sprain according to clinical practice guidelines: A PRISMA systematic review. Medicine (Baltimore) 2022;101:e31087. [Crossref] [PubMed]
13. Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg 2011;128:305-10. [Crossref] [PubMed]
14. Zhu XM, Qian SY, Lu GP, et al. Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children. World J Pediatr 2018;14:419-28. [Crossref] [PubMed]
15. Doniselli FM, Zanardo M, Mazon M, et al. A Critical Appraisal of the Quality of Vertigo Practice Guidelines Using the AGREE II Tool: A EuroAIM Initiative. Otol Neurotol 2022;43:1108-15. [Crossref] [PubMed]
16. Barrette LX, Xu K, Suresh N, et al. A systematic quality appraisal of clinical practice guidelines for Ménière's disease using the AGREE II instrument. Eur Arch Otorhinolaryngol 2022;279:3439-47. [Crossref] [PubMed]
17. Luu NN, Chorath KT, May BR, et al. Clinical practice guidelines in idiopathic facial paralysis: systematic review using the appraisal of guidelines for research and evaluation (AGREE II) instrument. J Neurol 2021;268:1847-56. [Crossref] [PubMed]
18. Society CT. Guideline for diagnostic flexible bronchoscopy in adults. Chinese Journal of Tuberculosis and Respiratory Diseases 2019;42:573-90. [Crossref] [PubMed]
19. Society CT. Expert consensus on prevention and treatment of massive hemorrhage related to bronchoscopy diagnosis and treatment. Chinese Journal of Tuberculosis and Respiratory Diseases 2016;39:588-91.
20. Tumors CftPaToS. Consensus of Chinese Experts on Navigation Guided Transbronchial Interventional Diagnosis and Treatment of Pulmonary Nodules. Medical Journal of Chinese People’s Liberation Army 2023;48:993-9.
21. Deng XM, Wang YL, Feng Y, et al. Expert consensus on sedation and anesthesia for bronchoscopy (2020 version). International Journal of Anesthesiology and Resuscitation 2021;42:785-94.
22. Xie F, Yang H, Huang R, et al. Chinese expert consensus on technical specifications of electromagnetic navigation bronchoscopy in diagnosing peripheral pulmonary lesions. J Thorac Dis 2021;13:2087-98. [Crossref] [PubMed]
23. Wood-Baker R, Burdon J, McGregor A, et al. Fibre-optic bronchoscopy in adults: a position paper of The Thoracic Society of Australia and New Zealand. Intern Med J 2001;31:479-87. [Crossref] [PubMed]
24. Wahidi MM, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients. Chest 2011;140:1342-50. [Crossref] [PubMed]
25. Wahidi MM, Herth F, Yasufuku K, et al. Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: CHEST Guideline and Expert Panel Report. Chest 2016;149:816-35. [Crossref] [PubMed]
26. Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax 2013;68:i1-i44. [Crossref] [PubMed]
27. Maldonado F, Danoff SK, Wells AU, et al. Transbronchial Cryobiopsy for the Diagnosis of Interstitial Lung Diseases: CHEST Guideline and Expert Panel Report. Chest 2020;157:1030-42. [Crossref] [PubMed]
28. Dhooria S, Agarwal R, Sehgal IS, et al. Bronchoscopic lung cryobiopsy: An Indian association for bronchology position statement. Lung India 2019;36:48-59. [Crossref] [PubMed]
29. Gibbs AJ, Gray B, Wallis JA, et al. Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines. Osteoarthritis Cartilage 2023;31:1280-92. [Crossref] [PubMed]
30. Chee E, Huang K, Haggie S, et al. Systematic review of clinical practice guidelines on the management of community acquired pneumonia in children. Paediatr Respir Rev 2022;42:59-68. [Crossref] [PubMed]
31. Hoffmann-Eßer W, Siering U, Neugebauer EAM, et al. Guideline appraisal with AGREE II: online survey of the potential influence of AGREE II items on overall assessment of guideline quality and recommendation for use. BMC Health Serv Res 2018;18:143. [Crossref] [PubMed]

(English Language Editor: J. Jones)