1. Tg.sutedja@vumc.nl

2. L ight A mplification by S timulated E mission or R adiation tg.sutedja@vumc.nl

3. 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

4. Extra? Intraluminal? Immediate: STENT and HOT techniques Stent Lasers Electro APC Cryo, PDT & brachytherapy

5. Emergency = ready to use facility

7. Nd-Yag Laser Argon, KTP, CO2, PDT

9. 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!

11. NeoDymium-Yttrium Alluminium Garnet

13. Practical principles : 1.Coagulation of tumor basis (less bloody) 2.Mechanical debulking 3.Remember depth effect – anatomy!

14. 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 Nd-YAG in practice

16. Effects: wavelength, power density, duration of exposure, pulse intensity & tissue color

17. Nd-YAG clinical results AuthorsYearPatientsResectionsRemarks Dumon 1982111205Landmark work! Personne198613102284Survival >1 yr 25 Cavaliere1996183826100.4% mortality!

18. Nd-YAG: photon scattering  In depth coagulation, powerful ……BUT….. YDSWYG, not a standard facility,  Coagulation  debulking!

19. Overview: Palliative (+curative) Choices ElecYAG CryoHDRPDT Simple Yes+/- Yes+/-No Safe Yes+/- Yes+/-Yes Effect Immediate YSWYG! Immediate DEEP LateVery lateLate Cost LowHigh FairVery expensive Morbid LowFair LowMortality! Fractions! Skin! Repeat sessions

20. LASER is a powerful and fashionable tool & Bronchoscopy is an artful science  But interventional pulmonology is not heroism

21. Which to choose?

22. Weapon of Mass Destruction found

23. Bronchoscopist, never imitates a cartoonist!