Advanced Techniques in Interventional Pulmonology at Lahey Clinic: Insights and Learnings

1. Interventional PulmonologyLahey Clinic進修心得報告 謝義山 胸腔外科主治醫師 Lahey Clinic Burlington Massachusetts March 29- April 1,2006

2. Agenda Diagnostic Bronchoscopy • TBNA • Autofluorescence Bronchoscopy • Navigational Bronchoscopy

3. Ablative therapy Laser Bronchoscopy Electrocautery APC Cryotherapy Displacement Therapy Rigid Bronchoscopy Balloon Dilatation Stent Silicon Metallic stent Therapeutic Bronchoscopy for emphysema PDT Brachytherapy Agenda Therapeutic Bronchoscopy

4. Agenda:Invasive Pulmonology • Rigid Bronchoscopy • Percutaneous dilated tracheostomy • Medical Thoracoscopy

5. 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) Current Indication for Rigid Bronchoscopy

6. 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

7. Percutaneous Tracheostomy • Procedure: Safe and quick • Cost: Controversal • 不須外科及麻醉科 • 減少等待時間 減少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

8. Medical Thoracoscopy • Mini-VATS in simple diagnosis and treatment procedure • Indication: • 覺得光是sono-guide不夠 而給外科開刀又太over 的情形 • 有indication進行pleural biopsy 及pig tail/ chest tube drainge 就有 indication • 不要選看起來就太粘黏 multiple loculation

9. 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 千萬不要逞強

10. Laser CO2 laser Nd-YAG laser Most powerful 無法控制深度 最好用Rigid bronchoscopy操作 EBEC: poor man’s laser 深度無法控制 APC: 可以控制深度 Smaller lesion, convenient, less expensive, flexible brochoscopy Hot Therapy

11. 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 Laser Bronchoscopy

12. Cold Therapy: Cryotherapy • Cryotherapy • Balloon dilatation

13. Silicon stent (by Rigid bronchoscopy) Dumon stent Y stent T tube SEMT: (RB or FB) Ultraflex stent Stent

14. 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 Silicone or Metal?

15. 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

16. 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

17. Management of COPD • Surgical: • Bullectomy • LVRS • Lung transplantation • Endoscopic: • Endobronchial Volume Reduction • Endobronchial fenestration

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

19. 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)

20. 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

21. 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

22. 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

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

24. Diagnosis of Peripheral Nodules < 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

25. 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?

26. The Future of a Pulmonologist Interventional Pulmonology: “The next interventional cardiology”