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 Limitation 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: Whole procedure is quick and safe 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 EBEC: poor man’s laser APC: 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 Unfavorable 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 Balloon dilatation
Stent Silicon stent (by Rigid bronchoscopy) SEMT: (RB or FB) Dumon stent Y stent T tube SEMT: (RB or FB) Ultraflex stent
Silicone or Metal? Silicone stent Metal stents 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 Brachytherapy 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: Endoscopic: 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”