Interventional Pulmonology

Lahey 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

Agenda Diagnostic Bronchoscopy  TBNA  Autofluorescence Bronchoscopy  Navigational Bronchoscopy

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

Agenda: Invasive Pulmonology  Rigid Bronchoscopy  Percutaneous dilated tracheostomy  Medical Thoracoscopy

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)

 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

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

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

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

Hot Therapy  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

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

Cold Therapy: Cryotherapy  Cryotherapy  Balloon dilatation

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

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

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

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

Management of COPD  Surgical: – Bullectomy – LVRS – Lung transplantation  Endoscopic: – Endobronchial Volume Reduction – Endobronchial fenestration

Why BLVR  Because LVRS: – High risk patient?

– Invasive procedure – High morbidity (45-75%) – Underestimation of mortality (2yr: 27%) – Cost expensive – Availability – Irreversible

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)

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

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

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

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

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

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?

The Future of a Pulmonologist

Interventional Pulmonology: “ The next interventional cardiology ”