Updates in Interventional Pulmonary Medicine

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1 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? 1

Skigeto Ikeda Japan first flexible bronchoscopy 2

2 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 2

3 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 3

4 What are the tools? Traditional Bronchoscopy Anatomic Considerations generations Trachea mm Mainstem mm Segmental 5-8 mm Therapeutic scope 5.8 mm Diagnostic 5.2 mm OD 4

5 Traditional Bronchoscopy Anatomic Considerations generations Trachea mm Mainstem mm Segmental 5-8 mm Therapeutic scope 5.8 mm Diagnostic 5.2 mm OD Traditional Bronchoscopy Anatomic Considerations generations Trachea mm Mainstem mm Segmental 5-8 mm Therapeutic scope 5.8 mm Diagnostic 5.2 mm OD 5

6 But there is so much more LNs But there is so much more nodules 6

7 But there is so much more nodules Endobronchial Ultrasound (EBUS) 7

8 Endobronchial Ultrasound (EBUS) But there is so much more LNs 8

9 But there is so much more LNs EBUS 9

10 EBUS Image with Doppler EBUS Image with Doppler 10

11 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 11

12 EBUS-Therapeutic options. Diagnosis Treat EMN(B) (electromagnetic navigation bronchoscopy) 12

13 Comparable to GPS in the lungs Procedure: navigation views 27 13

symptoms including cough Found to have a 1.

14 Procedure: at the target 28 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 14

15 Nodule-lung windows 15

16 Paragonimus Westermanii Before and after treatment with Praziquantel 16

17 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 17

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.

18 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 18

19 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 19

20 Cryotechnologies Contact Cryoprobe Freezes to -90 Cryogen is NO 2 or CO 2 Adheres to everything Good for: Tumor extraction Foreign body extraction parenchymal lung biopsy? Cryoprobe extraction: Case 20

21 Cryoprobe extraction: Case Before Cryoprobe extraction, cryospray, bronchoplasty Cryoprobe extraction: Case Before After Cryoprobe extraction, cryospray, bronchoplasty 21

Cryotechnologies Non Contact Cryospray Usually via

risk of barotrauma Cools to -196 F Can be combined

tumor ECM resistant to cryo-injury due to lower water

22 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 a Bronchial Thermoplasty (BT) Castro et al AJRCCM

Bronchial Thermoplasty for Severe Asthma - 3 Procedures, 3 weeks apart - Deliver Thermal Energy to airway smooth muscle - Most common side effect is asthma exacerbation -

23 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 23

Lung Volume Reduction for Emphysema LIBERATE TRIAL *

24 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 24

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

25 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 of airway tumors New tools may provide additional options for asthma, emphysema, BPF 25

26 Questions? 26

Learning Objectives. Updates in Interventional Pulmonary Medicine. Brief History of IP. Brief History of IP. Who is an Interventional Pulmonologist?

Learning Objectives. Updates in Interventional Pulmonary Medicine. Brief History of IP. Brief History of IP. Who is an Interventional Pulmonologist? Learning Objectives Who is an Interventional Pulmonologist? Updates in Interventional Pulmonary Medicine Eric J. Seeley, MD, FCCP Director of Bronchoscopy and Interventional Pulmonary Medicine Division