The Role of an Interventional Pulmonologist in Management of Complications of Thoracic Malignancies

Transcription

1 Canadian Association of General Practitioners in Oncology 2015 The Role of an Interventional Pulmonologist in Management of Complications of Thoracic Malignancies Kayvan Amjadi MD, FRCPC Director, Interventional Pulmonology October 2 nd, 2015

2 Disclosures Advisory Committee Carefusion PFM Medical Avantage

3 Objectives Discuss the role of an Interventional Respirologist in management of thoracic oncological emergencies Pleural Disease Parenchymal Disease Central Airway Disease

4 White-out of a hemithorax 70 y.o male with renal cancer Progressive SOBOE Now SOB at rest No infectious, cardiac issues No hemoptysis, hoarseness, pleuritic chest pain

5 Post Right Chronic Indwelling Catheter Insertion (7L)

6 Pleural Physiology Pleural Pressure Ppl Determined by the elastic properties of the lung and the chest wall FRC ( 3 to 5 cmh 2 O) TLC ( 30 cmh 2 O) Vertical pleural pressure gradient Pleural pressure decreases by 0.5 cmh 2 O per centimeter of vertical distance above the lung base (viscous flow theory) Higgins and Doelken Clin Chest Med 2006; 27:

7 When Pleural Fluid Enters Pleural Space There would be a gradual increase in intra pleural pressure Compresses the underlying lung Exerts pressure on chest wall Exerts pressure on the mediastinum Depresses the diaphragm Neuromechanichal dissociation

8 Pleural Physiology Improvement in respiratory status post drainage of the effusion depends on Re expansion of the lung Normalization of intra pleural pressure Functional capacity of the re expanded lung

9 Pleural Physiology Un expandable lung (40%) Endobronchial Obstruction Severe Parenchymal Fibrosis Lymphangitic ca Visceral Pleural Restriction Trapped lung Lung entrapment

10 Pleural Physiology As pleural fluid is drained, the drop in pleural pressure is dependent on whether the lung is Expandable (a/w clinical improvement) Un expandable (rarely improve)

11 Pleural pressure measurements Hepatic hydrothorax PEL 3.0 cm H 2 O/L Trapped lung with ve opening pressure and a steep slope. PEL 216 cm H 2 O/L Entrapped lung. PEL during first 1250 ml is normal, but then the elastance increases to 22 cm H 2 O/L Doelken et al., Chest 2004; 126:

12 Lung Entrapment

13 Entrapped Lung

14 Case of Pleural Effusion 54 y.o male with Adeno ca Diffuse lymphangitic ca C/o progressive SOBOE and now requiring O 2 at rest. Referred for drainage of moderated R pleural effusion

15 CT chest post drainage of effusion

16 Drainage of effusion does not lead to improvement Patient denied any benefit from drainage of 1.2 L of effusion Within 24 hours Progressively more SOB Increased FiO 2 requirements (100% non rebreather) Hypotensive (89/52, HR=104/min, sinus)

17 Pleural Physiology Thoracentesis related complications Procedural Bleeding, nerve injury, infection, PTX Re expansion of the lung Cough Chest tightness Re perfusion of the lung Hypotension Re expansion pulmonary edema (RPE)

18 Re-expansion Pulmonary Edema

19 RPE Clinical syndrome characterized by Development of unilateral (non cardiogenic) pulmonary edema In a lung that has been re inflated rapidly After variable period of collapse Pleural effusion Pneumothorax Clinical picture varies Asymptomatic (radiographic) Variable degree of hypoxia May require mechanical ventilation or Death Pneumothorax (Lancet 1979; 1: )

20 Radiographic appearance of RPE (J Thorac Dis 2014;6: )

21 Radiographic appearance of RPE (J Thorac Dis 2014;6: )

22 RPE Pathophysiology Unclear May be related to Duration of lung collapse Application of excessive ve pleural pressure Miller et al, Am Rev Respir Dis 1973; 108: Pavlin and Cheney. J Appl Physiol 1979; 46: Size of the effusion Re perfusion injury Leaky vessels» Pavlin et al., Am Rev Respir Dis 1981; 124: » Pavlin DJ. Chest 1986; 89:2 3» Pavlin et al., J Appl Physiol 1987; 62: (FiO 2 0.4)» Jackson et al., Amm Rev Respir Dis 1988; 137: (Anti oxidants) Elevated levels of IL 8, leukotriene B4» Nakamura et al., Am J Respir Crit Care Med 1994; 149:

23 Therapy for RPE Therapy Supportive O 2, CPAP, mechanical ventilation? Benefit from Diuretics, albumin infusion

24 CXR 24 hours post catheter insertion

25 CT-PE ve for embolus

26 Sudden Onset Dyspnea 57 year old male presents to Emergency Department Dec/1 st /06 sudden onset of shortness of breath after a coughing spell Past history of RUL NSCLC (SVCO) Chemo/Rads 2005 RA Right hip replacement Recurrent chest infections since therapy October 16 th, 2006

27 Dec 1 st, 2006

28 Post Chest Tube placement

29 Jan/25/2007 post pleurodesis x 3, 8 weeks of hospitalization and prior to d/c

30 Feb 2 nd, 2007 return to ED

31 Post Insertion of Pleurx Catheter and suction

32 Follow-up as outpatient, Intermittent drainage

33 May 22 nd, 2009 presents with fever, cough, SOB

34 May 25 th, 2009 progresses to ARDS

35 Persistent Fever and Hemoptysis 66 y.o male with metastatic Right NSCLC Completed palliative Radiation therapy 6/52 ago Persistent, productive, foul smelling cough, moderate hemoptysis, fever, 15 lb weight loss, elevated WBC, air fluid level in cavity despite 4/52 of IV Pip/Tazo Meropenem Clindamycin

36 Persistent Fever and Hemoptysis

37 Persistent Fever and Hemoptysis Patient continued to decline despite antibiotics Drainage of the infected cavity was requested Embolization of the feeding bronchial arteries to the RUL was organized Bronchoscopy was performed postembolization

38 Persistent Fever and Hemoptysis Bronchoscopy was performed with the aim to create an opening from the cavity into the central airways Using laser/cautery Facilitate emptying of the cavity Administer intra cavitary antibiotics or antifungal Left a catheter in the cavity Administered Intra cavitary Clindamycin Cultures from the cavity grew Stomatococcus Mucilaginosa No need for Ampho B

39 Post drainage of cavity

40 Drainage of cavity

41 Post Procedure Patient defervesced within 48 hours Was discharged home 4 days later Was able to start chemotherapy 4 months later, no obvious cavity

42 Sudden Onset of Dyspnea 70 y.o male History of metastatic colon ca Respiratory failure

43 Post thoracentesis consult was placed for management of pneumothorax

44

45 Post Tumor debulking and airway stent

46 Central Airway Obstruction Central airway obstruction (CAO), can result from a variety of disease processes and is a cause of significant morbidity and mortality It is estimated that 20 30% of patients with lung cancer will develop complications associated with airway obstruction Atelectasis Pneumonia Dyspnea Up to 40% of lung cancer deaths may be attributed to locoregional disease. Noppen et al., Acta Clin Belg 1997; 52:371

47 Therapeutic Procedures Laser Electrocautery Argon Plasma Coagulation (APC) Cryotherapy Brachytherapy Photodynamic Therapy (PDT) Airway Stents

48 Therapeutic Procedures The choice of intervention is dictated by Nature of the underlying problem Patient s stability Overall prognosis Patient s quality of life Particular expertise of the physician Available technology

49 Therapeutic Procedures: Endoluminal disease

50 Therapeutic Procedures: Extrinsic Compression

51 Therapeutic Procedures

52 Modified Y Stent

53 Training in Interventional Pulmnology

54 When you can t breath, nothing else matters (with permission from patient)

55 Study (N) Stent Results Dumon 1996 (1058) Wood 2003 (143) Saad 2003 (82) Noppen 1999 (46) Eisner 1999 (9) Bollinger 1996 (27) Bollinger 1993 (31) Silicone Silicone 87%, Metal 13% Metal Silicone Metal Metal Silicone 1574 stents, mean stenting 4 mo for malignant and 14 mo for benign, effective (migration) 95% clinical success, 41% required multiple procedures 14/16 (88%) of patients requiring mechanical ventilation were subsequently extubated More migration in benign disease. Effective Improvement (PFTs), 23 mo F/U 36 stents, significant improvement in Karnofsky Index Karnofsky Index improved in 90% of patients

56 Dyspnea Miyazawa et al., Chest 2000; 118:959

57 PFT Miyazawa et al., Chest 2000; 118:959

58 Quality of Life (QoL) EORTC was used for assessment of QoL 20 patients 7 days and 30 days post procedure Dyspnea scores improved in 85% of patients (p = 0.01) 65% of patients had improvement in overall QoL Significant improvement in dyspnea, insomnia, and fatigue scores 35% had stabilization or decline in QoL Significant decline in emotional, pain, and loss of appetite scores Need for multidisciplinary approach to patients with complications from thoracic malignancies Amjadi et al. Respiration 2008; 76:

59 Complications of Stenting Saad et al., Chest 2003; 124:1993 Complications Infection (15.9%) All treated with oral antibiotics, no hospitalizations In stent obstructive granulomas (14.6%) Laser, APC In stent obstructive disease recurrence (6.1%) Laser, APC, re stented Migration in (3.5%) Replaced with new stent Mild Hemoptysis (10%) No therapy required Bronchial perforation (1%) Covered stents No complications in 54%

60 Timely airway stenting improves survival in patients with malignant CAO 50 patients (10 stage III, 40 stage IV) received 72 airway stents Improvement in performance status was seen in 45/50 (90%) However, significant improvement in survival was observed in patients with intermediate performance (MRC < 4, ECOG < 3) compared to a matched group with poor performance status 8 months vs. 3 months; P<0.05 Conclusion Patients with CAO should be treated in timely fashion Razi et al. Ann Thorac Surg 2010; 90:

61 Stenting facilitates extubation 15 consecutive ICU patients with CAO who had multiple failed attempts at extubation Non surgical patients 14/15 (93%) were successfully extubated post stenting Noppen et al. Respiratory Medicine 2007; 101:

62 Conclusion Thoracic malignancies are often associated with unique complications impacting the Pleura Parenchyma Central Airways Endoscopic and minimally invasive modalities are available for patients with limited reserves Therapeutic and palliative options often need to be modified to accommodate patient s specific needs 1) Olden AM, Holloway R. J Palliat Med; 13:59 65.