Interventional Pulmonology Lahey Clinic??????

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Interventional Pulmonology Lahey Clinic??????

• ??? ????????
• Lahey Clinic
• Burlington Massachusetts
• March 29- April 1,2006

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Agenda Diagnostic Bronchoscopy

• TBNA
• Autofluorescence Bronchoscopy
• Navigational Bronchoscopy

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Agenda Therapeutic Bronchoscopy

• Ablative therapy
• Laser Bronchoscopy
• Electrocautery
• APC
• Cryotherapy
• Displacement Therapy
• Rigid Bronchoscopy
• Balloon Dilatation
• Stent
• Silicon
• Metallic stent

• Therapeutic Bronchoscopy for emphysema
• PDT
• Brachytherapy

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AgendaInvasive Pulmonology

• Rigid Bronchoscopy
• Percutaneous dilated tracheostomy
• Medical Thoracoscopy

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Current Indication for Rigid Bronchoscopy

• Diagnostic
• Deep and large quantitative biopsy
• Photographic documentation
• Pediatric bronchoscopy

• Therapeutic
• Massive hemoptysis airway control and assessment
• Tumor ablation / foreign body retrieval
• Laser therapy
• Airway dilatation / core out of tumor
• Airway stenting
• Cryotherapy (RB/FB)
• Electrocautery (RB/FB)

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• Benefit of RB
• Airway control / ventilation
• Large working channel
• Improved airway visualization
• Large biopsy size
• Absence of coughing and unwanted motion
• Timely multi-modality intervention
• Limitation of RB
• Limited availability
• Access to only the more central airways

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Percutaneous Tracheostomy

• Procedure Safe and quick
• Cost Controversal
• ????????
• ?????? ??ICU stay
• Contra-indication
• Obesity
• Coagulopathy
• Anatomic Barrier prominent goiter or tumor
• Pediatric patient
• High PEEP/FiO2 requirement
• Emergent airway ? Quick airway at TC menbrane

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Medical Thoracoscopy

• Mini-VATS in simple diagnosis and treatment
  procedure
• Indication
• ????sono-guide?? ????????over ???
• ?indication??pleural biopsy ?pig tail/ chest tube
  drainge ?? indication
• ?????????? multiple loculation

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Medical Thoracoscopy

• Procedure
• Local anesthesia, with/without minimal sedation
• Create Pneumothorax
• Insertion of trocar and thoracoscpy
• Traditional VATS instrument
• Newly Thoracoscopy (Olympus)
• Collection fluid and take biopsy to interesting
  region
• Chest tube replacement
• Whole procedure is quick and safe
• Beware of your limitation ??????

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Hot Therapy

• Laser
• CO2 laser
• Nd-YAG laser
• Most powerful
• ??????
• ???Rigid bronchoscopy??

• EBEC poor mans laser
• ??????
• APC
• ??????
• Smaller lesion, convenient, less expensive,
  flexible brochoscopy

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Laser Bronchoscopy

• Favorable Lesions
• Polypoid
• Short duration
• Endobroncheal
• Visible distal lumen
• Tracheal, Main bronchus, First segment
• Functional distal lung

• Unfavorable Lesions
• External compression
• Total obstruction
• Submucosal infiltration
• Chronic collapse
• Lobar / segmental lesions

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Cold Therapy Cryotherapy

• Cryotherapy
• Balloon dilatation

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Stent

• Silicon stent (by Rigid bronchoscopy)
• Dumon stent
• Y stent
• T tube
• SEMT (RB or FB)
• Ultraflex stent

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Silicone or Metal?

• Silicone stent
• Require RB
• Easily removed
• Migration
• Can be used in both malignant and benign stenosis

• Metal stents
• Easy to insert
• Difficult to remove
• Granulation tissue
• Not recommended for most benign stenosis

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Selection of Therapy for Airway obstruction

• For Urgent Therapy
• Laser, Stent, Rigid Bronchoscopy
• For Semi-urgent Therapy
• Cryotherapy, Electrocautery, APC, PDT, Balloon
• For Prolonged Therapy
• PDT, Stent, Brachytherapy

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PDT and Brachytherapy

• PDT
• Not suggested for palliative ? Very expensive
• For central airway early malignancy
• Highly potential of cure of cancer
• Brachytherapy
• Not available in SKH
• For palliative use
• Beware of fistula with great vessels and
  esophagus

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Management of COPD

• Surgical
• Bullectomy
• LVRS
• Lung transplantation
• Endoscopic
• Endobronchial Volume Reduction
• Endobronchial fenestration

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Why BLVR

• Because LVRS
• High risk patient?
• Invasive procedure
• High morbidity (45-75)
• Underestimation of mortality (2yr 27)
• Cost expensive
• Availability
• Irreversible

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Endobroncheal Valve

• One way valve blocker at airway ? shrinkage of
  emphysematous segment / lobe (50) ? increasing
  FEV1 (50), life quality (most), decreasing O2
  dependent (most)
• Emphasys endobroncheal valve (CE)
• Spiration endobroncheal valve (NA)

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TBNA

• Routine TBNA for mediastinal LNs enlargement
• Improving TBNA yield most important
• Subcarinal / Paratracheal / AP window LNs
• 3 point method
• Good needle, and maneuver
• On-site pathologist
• Endobroncheal ultrasound guide much safe

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Autofluorescence Bronchoscopy

• Evidence in 2006
• Detects dysplasia and CIS better than WLB
• Various system seem to produce similar result
• AFB continues to show advantage over video WLB
• It is a safe procedure

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Autofluorescence Bronchoscopy

• Lacking Evidence in 2005
• Nature history of early lesions
• Do we alter or improve outcomes by performing AFB
• Who do we offer AFB to?
• Lung cancer screening programs
• Can we define the high risk population better?
• Pathologists can agree on biopsies

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Autofluorescence Bronchoscopy

• Future
• Manufactures should combine AF with standard WLB
  system
• Adjunct to WL
• Molecular and gene markers will help the
  pathologists

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Diagnosis of Peripheral Nodules lt 2 cm

• CT guide TTNA
• Pneumothorax
• 20-30
• 3-15 require chest tubes
• CT time slot
• Radiation
• Surgery
• Invasive
• Expensive
• Up to 99 of nodules are non-malignant

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Navigational Bronchoscopy

• CT roadmap
• Real-time location of the tumor
• Application for NB
• TBNA, TBLB
• Minimal invasive cancer therapy
• RF ablation
• Brachytherapy
• Stereotactic radiosurgery
• PDT?

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The Future of a Pulmonologist

• Interventional Pulmonology The next
  interventional cardiology