Transcript Economic aspects of the Solitary Pulmonary Nodule

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Light
Amplification by
Stimulated
Emission or
Radiation
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Central airways obstruction  Action!
>50% stenosis
No expertise,
Intubate and refer
Anticipate intra –
& extraluminal
Immediate “hot” debulking & stent
JF Dumon et al. Chest 1984; 86:163 & ERS/ATS statement on
Interventional Pulmonology Eur Respir J 2002; 19:356
Extra? Intraluminal?
Lasers
Electro
APC
Cryo, PDT &
brachytherapy
Stent
Immediate: STENT and HOT techniques
Emergency = ready to use facility
Nd-Yag Laser
Argon, KTP,
CO2, PDT
Laser is powerful!
 Coherence, light photons are in step,
monochromatic waves of the same λ
 Collimation of parallel waves, little loss of
intensity (high power density)
  always remember laser – tissue interactions
and tracheobronchial wall – adjacent and
mediastinal anatomy!
NeoDymium-Yttrium Alluminium Garnet
Practical
principles :
1. Coagulation
of tumor basis
(less bloody)
2. Mechanical
debulking
3. Remember
depth effect –
anatomy!
Nd-YAG in practice
 Nd-YAG invisibly penetrates tissue with deep
scattering especially in darker tissue far
beyond the surface
 Temperature rise enhance scattering (crust)
displacement of power density below tissue
surface
 Popcorn: T-rise to boiling point – collection of
steam blowout perforation/massive
hemorrhage
Effects: wavelength, power density, duration
of exposure, pulse intensity & tissue color
Nd-YAG clinical results
Authors
Year
Patients
Resections
Remarks
Dumon
1982
111
205
Landmark work!
Personne
1986
1310
2284
Survival >1 yr 25
Cavaliere
1996
1838
2610
0.4% mortality!
Nd-YAG: photon scattering
 In depth coagulation, powerful
……BUT…..
YDSWYG, not a standard facility,
Coagulation  debulking!
Overview: Palliative (+curative)
Choices
Elec
YAG
Cryo
HDR
PDT
Simple
Yes
+/-
Yes
+/-
No
Safe
Yes
+/-
Yes
+/-
Yes
Immediate
Immediate
Late
Very late
Late
YSWYG!
DEEP
Cost
Low
High
Fair
Very
expensive
Very
expensive
Morbid
Low
Fair
Low
Mortality!
Fractions!
Skin!
Repeat
sessions
Effect
LASER is a powerful and
fashionable tool
&
Bronchoscopy is an artful science
 But interventional pulmonology is not heroism
Which to choose?
Weapon of Mass Destruction found
Bronchoscopist, never imitates a cartoonist!