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Oct 24, 2023 359 likes •642 views

5/22/2015 Updates in Interventional Pulmonary Medicine Eric J. Seeley, MD, FCCP Director of Bronchoscopy and Interventional Pulmonary Medicine Division of Pulmonary/CCM Department of Internal Medicine UCSF School of Medicine Learning

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Updates in Interventional Pulmonary Medicine

Eric J. Seeley, MD, FCCP Director of Bronchoscopy and Interventional Pulmonary Medicine Division of Pulmonary/CCM Department of Internal Medicine UCSF School of Medicine

Learning Objectives

Who is an Interventional Pulmonologist?
What are the tools?
What can we diagnose?
What can we treat?

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Brief History of IP

1897 – Dr. Gustave Killian performs a rigid

bronchoscopy to remove a bone from the mainstem bronchus of a patient

Brief History of IP

1897 – Dr. Gustave Killian performs a rigid

bronchoscopy to remove a bone from the mainstem bronchus of a patient

1966 – Dr. Skigeto Ikeda – Japan

–first flexible bronchoscopy

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Who becomes an Interventional Pulmonologist?

Most did a residency in internal medicine
Then a fellowship in Pulmonary CCM
And then a formal or informal fellowship in

Interventional Pulmonary Medicine

This is a non-ACGME fellowship
Evolving board exam, but not required

What does an Interventional Pulmonologist do?

It depends on their tools
In general involved in the work-up and

diagnosis of thoracic malignancies

Also involved in therapy

– Airway Recanalization – Tumor Ablation – Fiducial placement

Tools offer access to:

– Pleural Space, Airways, Lung Parenchyma

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What are the tools? Traditional Bronchoscopy

Anatomic Considerations 17-25 generations Trachea 20-25 mm Mainstem 12-16 mm Segmental 5-8 mm Therapeutic scope 5.8 mm Diagnostic 5.2 mm OD

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Traditional Bronchoscopy

Anatomic Considerations 17-25 generations Trachea 20-25 mm Mainstem 12-16 mm Segmental 5-8 mm Therapeutic scope 5.8 mm Diagnostic 5.2 mm OD

Traditional Bronchoscopy

Anatomic Considerations 17-25 generations Trachea 20-25 mm Mainstem 12-16 mm Segmental 5-8 mm Therapeutic scope 5.8 mm Diagnostic 5.2 mm OD

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But there is so much more…LNs

But there is so much more…nodules

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But there is so much more…nodules

Endobronchial Ultrasound (EBUS)

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Endobronchial Ultrasound (EBUS) But there is so much more…LNs

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But there is so much more…LNs EBUS

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EBUS – Image with Doppler EBUS – Image with Doppler

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Mediastinoscopy? What LNs are accessible?

Endobronchial Ultrasound

– Obtain tissue from enlarged LNs

cancer, sarcoid, lymphoma, granulomatous infections

– Allows for LN staging for lung cancer – Can place fiducials for XRT – Can be performed at the same time as EMN – Come and go procedure – Can deliver Ampho to Aspergillomas – Can obtain enough tissue for molecular diagnostics

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EBUS-Therapeutic options.

Diagnosis Treat

EMN(B)

(electromagnetic navigation bronchoscopy)

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Comparable to GPS in the lungs Procedure: navigation views

27 |

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28 |

Procedure: at the target

EMN- case illustration

57 yo man of Japanese ancestry
Presented with respiratory symptoms

including cough

Found to have a 1.2 cm nodule in lung
Mildly PET positive
Recommended lobectomy
Small hilar lymph nodes

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Nodule-lung windows

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Paragonimus Westermanii

Before and after treatment with

Praziquantel

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EMN (electromagnetic navigation bronchoscopy)

– Performed through ETT (fluoro vs. OR) – Can biopsy lesions almost anywhere in the lung down to 5 mm in size – Can biopsy, place fiducials, dye for localization – Easily combined with EBUS for full staging – Overlap with CT-FNA, if touching pleura or no “easy airway” would send for CT-FNA – Faster diagnosis and staging with combined EMN/EBUS

Once procedure…comprehensive diagnosis and treatment

68 yo smoker with severe emphysema High risk TTNA Not a surgical candidate

1. Tissue DX with EMN

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Once procedure…comprehensive diagnosis and treatment

68 yo smoker with severe emphysema High risk TTNA Not a surgical candidate

1. Tissue DX with EMN
2. Staging with EBUS

Once procedure…comprehensive diagnosis and treatment

68 yo smoker with severe emphysema High risk TTNA Not a surgical candidate

1. Tissue DX with EMN
2. Staging with EBUS
3. If EBUS is negative

fiducials could be placed for XRT

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Rigid Bronchoscopy

Rigid Bronchoscopy- Why would we do this?

Requires Jet Ventilation
Allows more stable

access to distal trachea

Allows access for larger

tools

Provides opportunity to

remove large objects (tumor, foreign body)

Provides access for

advanced airway tools

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Cryotechnologies

Contact
Cryoprobe
Freezes to -90
Cryogen is NO2 or CO2
Adheres to everything
Good for:

– Tumor extraction – Foreign body extraction – parenchymal lung biopsy?

Cryoprobe extraction: Case

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Cryoprobe extraction: Case

Before Cryoprobe extraction, cryospray, bronchoplasty

Cryoprobe extraction: Case

Before After

Cryoprobe extraction, cryospray, bronchoplasty

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Cryotechnologies

Non Contact

– Cryospray – Usually via Rigid Bronch – Obviates need for stent – Gas expands 700 x

risk of barotrauma

– Cools to -196 F – Can be combined with bronchoplasty or cryoprobe extraction of airway tumor – ECM resistant to cryo-injury due to lower water content

Bronchial Thermoplasty (BT)

Castro et al AJRCCM 2010

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Bronchial Thermoplasty for Severe Asthma

3 Procedures, 3 weeks apart
Deliver Thermal Energy to

airway smooth muscle

Most common side effect is

asthma exacerbation

Unclear which population

might benefit most

Trials in IP

Endobronchial Lung Volume Reduction

– Lung volume reduction coils – Lung volume reduction valves

Endobronchial Valves for BPF

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RePneu Trial for Emphysema

PneumRx – coils for

LVRC in emphysema

RCT finished
Now entering cross over

PulmonX – Lung Volume Reduction for Emphysema – LIBERATE TRIAL

* Requires screen for colateral ventilation before insertion of valve

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Spiration trial for BPF (VAST)

Compassionate use for BPF

Conclusions

IP allows for access to lung beyond the optical

reach of a traditional bronchoscopy

Can be used for the diagnosis, staging and

therapy in lung cancer

Advanced tools allow for extraction/ablation
f airway tumors
New tools may provide additional options for

asthma, emphysema, BPF

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