1. 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

2. Agenda Diagnostic Bronchoscopy
TBNA
Autofluorescence Bronchoscopy
Navigational Bronchoscopy

3. 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

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

5. 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)

6. 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

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: 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

10. 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

11. 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

12. Cold Therapy: Cryotherapy
Balloon dilatation

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

14. 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

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 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

17. Management of COPD Surgical: Endoscopic: 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”