Interventional Pulmonary Case Based Discussions (ATS) Ali Imran Saeed, MD University of New Mexico

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1 Interventional Pulmonary Case Based Discussions (ATS) Ali Imran Saeed, MD University of New Mexico

2 Objectives Interventional Pulmonary in New Mexico Interventional Pulmonary and Advanced Diagnostic Cases Tunneled Pleural Catheter: Insertion and Management Pleuroscopy: Indications and Follow Up Central Airway Obstruction: Management and Follow Up Miscellaneous Interventional Procedures Endobronchial and Peripheral Ultrasound Techniques

3 Introduction Established sub-specialty >20 years of practicing physicians Meld of many different specialties (ENT, Thoracic Surgery, Interventional Radiology, Vascular Surgery etc.) Emphasis on minimally invasive procedures and multidisciplinary care New technologies & procedures American Association of Bronchology and Interventional Pulmonary Fellowship Training >30 programs recognized by AABIP NRMP match and AABIP board certification

4 New Mexico (SEER registries)

5 First Case Discussion 62 years old female, initially presented to ED on 4/13/2016 with shortness of breath (Presbyterian) CXR in ED revealed a large left pleural effusion Thoracentesis with atypical cells in pleural fluid CT guided biopsy left chest wall mass 5/6/16 with epithelioid mesothelioma She underwent 4 cycles of chemotherapy (Alimta and Cisplatin)

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7 Case Discussion ED visit with left thoracentesis 7/4/2016 Hospitalization for SOB and left thoracentesis 8/10/2016 by IR (SRMC) Hospitalization for SOB 9/1/2016 (UNMH) with large left pleural effusion IP consultation 9/2/2016 Tunneled pleural catheter placement 9/2/2016

8 Introduction Indications: Malignant pleural effusion Pleural effusion refractory to maximal medical therapy Palliation and pleurodesis Contraindications: Ipsilateral mediastinal shift > 2 cm Multiloculated effusion Coagulopathy Infected pleural cavity Chylous effusion

9 Tunneled Pleural Catheter

10 TPC Insertion

11 UNMH Tunneled Pleural Catheter Protocol Education with hands on training of patient and family 7-10 days visit for three suture removal and repeat education in PFT lab 4 weeks visit for anchoring suture removal in the PFT lab (RT s) 4-6 weeks f/u with IP provider (UNM CC) and then every 2-3 months Catheter removal once drainage is less than 50 ml on three separate drainages repeat ultrasound before removal Patient has direct contact with the pleural team ( )

12 Survival with malignant pleural effusion

13 Intervention: preoperative antibiotics, full sterile drapes, limited placement to a single defined place 225 catheters placed in 201 patients Overall infection rate 5.8% Preintervention rate of infection: 8.2% Postintervention rate of infection 2.2% P valve 0.049

14 Patient Education When to remove catheter sutures Drainage technique When to drain How much to drain Change in colour of fluid Fever Life style modifications Travel frequency and timing of drainage Swimming, biking etc Cost When to remove the catheter

15 Clinical Course Patient followed by pleural team NO ED visit or hospitalization TPC removed after 11 weeks on 11/28/2016 Patient now has malignant right pleural effusion s/p two thoracentesis and is considering placement of right TPC

16 Second Case Discussion 62 years old male with PMH of tobacco abuse presented to ED (Mayo Clinic) with acute chest pain EKG revealed PVC s and J point elevation ECHO, 31% EF and small pericardial effusion Troponin <0.01 BNP 682 Autoimmune work up non diagnostic

17 Chest Radiograph

18 CT Chest

19 Re-hospitalization 04/2016 Presents to ED with shortness of breath

20 Thoracentesis 2.4 Liters Cells 2119 N49% L 18% M 24% other 9% ph 7.39 Glucose 105 mg/dl LDH 180 IU/L TP 3.5 g/dl Cytology: negative for malignancy, reactive mesothelial cells, few atypical cells negative for TTF-1 and MOC31

21 Hospital course Significant improvement in shortness of breath CT chest after thoracentesis

22 Chest Radiograph

23 3 rd Hospitalization Thoracentesis: April 19 th Liters Cells 977 N 9%, L 69%, M 10% other 11% Glucose 89 mg/dl LDH 200IU/L TP 3.8 g/dl Cytology: The abnormal groups of cells partially stain for Keratin AE1/AE3, polyclonal CEA, and WT1 D2-40, calretinin, MOC31, TTF-1 (SPT24), and CD45 are negative.

24 Pleuroscopy April 28th 2016

25 Pathology High grade epithelioid angiosarcoma ( ) Patient meets oncologist on May 16 4:00 pm Returns to ED with chest 8:00 pm Cardiac arrest and 11:55 pm

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27 Pleuroscopy (Medical Thoracoscopy) Patient with undiagnosed persistent pleural effusion Patient with malignancy needing more tissue for mutation and genetic analysis i.e. adenocarcinoma Outpatient procedure under conscious sedation Low complication rate

28 Malignant Pleural Effusion Procedural Approach Diagnostic Yield Pleural Fluid Cytology 62% Closed Needle Biopsy 44% Pleural Fluid + Needle Biopsy 74% Medical Thoracoscopy 95% Thoracoscopy + Pleural Fluid cytology Thoracoscopy + Pleural Fluid Cytology + Needle Biopsy 96% 97%

29 CT Chest January 2015

30 CT Chest September 2015

31 Bronchoscopy September 2015

32 CT Chest December 2015

33 CT Chest January 2016

34 Clinical Course Patient admitted on 2/5/2015, to a local hospital in Rapid City SD for 2 weeks of worsening shortness of breath Transferred to Mayo Clinic for continuation of care

35 Bronchoscopy 02/05/2016

36 Clinical Course Patient received radiation and chemotherapy with interval decrease in size of pulmonary metastasis Repeat bronchoscopy with no endobronchial tumor

37 Rigid Bronchoscopy

38 Cryobiopsy for ILD

39 Radial Ultrasound

40 Endobronchial Ultrasound

41 Peripheral Navigation

42 Bronchoscopy Lung Volume Reduction

43 Collaboration Thoracic Surgery Interventional Gastroenterology Interventional Radiology Oncology Radiation Oncology Internal Medicine Rheumatology Infectious Diseases

44 IP Consultation (Order Set)

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