future of interventional pulmonology - namdrc today level iv: basic diagnostic: wash, brush, ebb,...
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Future of Interventional Pulmonology
Atul C. Mehta, MBBS, FACP, FCCP Professor of Medicine, Lerner College of Medicine
Staff, Respiratory Institute Cleveland Clinic, Cleveland, Ohio, USA
Editor-in-Chief, Journal of Bronchology &
Interventional Pulmonology
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Conflict of Interest
Participating in Coil Trial; PneumRx ® Corporation
Editor in Chief: Journal of Bronchology and Interventional
Pulmonology
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“Future”
“It is tough to make predictions, especially about the
future!”
Yogi Berra
“The best prophet of the future is the past.”
Lord Byron
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Interventional Pulmonology
Past, Present and Future
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Bronchoscopy
Early Years: Rigid Scope: Foreign Body removal
Day before y’day: Flexible Scope: Curiosity << RB
Yesterday: Diagnostic tool FB>>RB
Today: Diagnostic and Therapeutic Tool
Resurrection of Rigid Scope
Tomorrow: Diagnostic, Therapeutic and Research tool
Technology
FB >>>RB
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History
1807: Philipp Bozzini (German army surgeon): Light conductor, precursor of endoscopes
1828: Benjamin Guy Babington (British physician): “Glottiscope”
1800: Manuel Garcia (Spanish music teacher, singer): First laryngoscopy
1847: Horace Green inserted a gum-elastic catheter through the larynx and into the lower bronchi; expelled from the society
1867: G. Johnson: Extracted a penny impacted in a throat of a child using laryngoscope
Prakash UBS, Bronchoscopy and Interventional Pulmonology: Reflections on the Past, the Present and the Future [In] J.P. Díaz-Jimenez and A.N. Rodriguez (eds.), Interventions in Pulmonary Medicine, Chapter 34: 471 (Springer Science)
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Father of Bronchoscopy: Gustav Killian
1895: Alfred Kirstein (Germany) : first direct visualization of VC using esophagoscope (autoscope)
1897: Gustav Killian, (ENT, Freiburg, Germany) :
Examined trachea and main bronchi of a volunteer using Laryngoscope
Removed a bone from RMB using an esophagoscope
Removed 3 more FB in a similar fashion, same year and coined term “directe bronkoscopie”
1898: Algernon Coolidge (Harvard Medical School) used an open urethroscope, a head-mirror, and reflected sunlight to remove a hard-rubber cannula from RMB
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Father of American Bronchoesophagology
Year: 1913
Cavalier Jackson
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History
1904-20: Chevalier Jackson (ENT surgeon, Professor x 5, Pittsburgh Philadelphia, USA) Modifications of RB, light at the distal end
Bronchoscopy: Hands-on-Courses!
Victor Negus (British, Jackson’s student): Negus bronchoscope
C.L. Jackson, Jr. (Laryngologist)-Founder:
Pan American Association of Otolaryngology
International Bronchoesophagological Society *
Edwin Boyles: Optical Telescope with forward & angle viewing
Paul H. Holinger: Bronchoscopic photography
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History
1922: Yankauer Brachytherapy
1976: Neel & Sanderson Cryotherapy
1976: Laforet: Use of CO2 Laser on the trachea
1985: Hooper & Jackson Endobronchial Electrosurgery
Beamis J, Mathur P, Interventional Pulmonology: Current Status and Future Direction [In] A.C. Mehta and P. Jain (eds.), Interventional Bronchoscopy: A Clinical Guide, Respiratory Medicine (10), Chapter:1; 3-14 Springer Science+Business Media New York 2013
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Major Milestones Fiberoptic Bronchoscope: 1968
Transbronchoscopic Lung Biopsy: 1972
TBNA: 1979
Laser Therapy: 1981
Lung Transplantation: 1982
Endobronchial Stents: 1990
EBUS:
Radial Probe: 1992
Convex probes: 2004
EMN: 2003
Bronchial Thermoplasty: 2006
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Transbronchoscopic Lung Biopsy
Andersen HA et al, TBBx for diffuse pulmonary diseases:
Technique & results in 450 cases. Chest. 1972;62:125
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Major Milestone: Fiberoptics
1872: Tyndall Effects
1957: Basil Hirschowitz (U of M): First gastro-fiberscope
1968: Shigeto Ikeda, T/S (Tokyo National Cance Institute, Japan): Flexible Fiberoptic Bronchoscope
1970: First commercial Olympus FB model
Late 1980’s: Video Bronchoscope Ikeda S, Flexible bronchofiberscope. Keio J Med. 1968;17:1
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Flexible Transbronchial Needle Aspiration Wang KP, Teprry P, Marsh B, ARRD, 1978, 118(1): 17
Based on Schipetti and Oho’s concept
designed a needle for its application
through the flexible scope
Cytology and Histology needles
Mediastinal pathology
Peri-bronchial lesions (25% SmCCa)
Peripheral lesions (18%)
Reduction in the number of
mediastinoscopy
Ko Pen Wang, 1978
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Major Milestone: Use of LASER
1981: First reported use of
Nd-YAG Laser in the airways
Designed newer type of rigid
bronchoscope
Silicon Stents and Stent
insertion instrument Toty L, Persone C, Bronchoscopic management of
tracheal lesions using Nd-YAG Laser, Thorax.
1981;36:175
Dumon JF, Treatment of tracheobronchial lesions
with Laser Yag, Minerva Med. 1981;72: 2593
Jean F. Dumon
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Rigid Bronchoscope & Endobronchial Stent
Dumon JF. A dedicated tracheobronchial stent. Chest. 1990;97:328
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Radial Probe-EBUS Becker HD, New Perspective on EBUSm J Ultraschall Med, 1996; 17: 106
Heinrick Becker, MD, Heidelberg, Germany Hunter T, Hanrath P, Endobronchial Sonography, Feasibility & Preliminary Results
Thotax,1992,(47):565
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CP-EBUS
Yasufuku K, Chhajed P, Real-time EBUS-TBNA of mediastinal & hilar lymph nodes
Chest. 2004;126:122
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Electromagnetic Navigation
EMN Diagnostic Bronchoscopy: A Prospective Study. Am J Respir Crit Care Med. 2006; 174(9)982
Yehuda Swrtz, MD, Tel Aviv, IS
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Bronchial Thermoplasty Cox G, AJRCCM, 2006
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Today
Most commonly performed diagnostic procedure
by the pulmonologist
There is no single pulmonary ailment a flexible
bronchoscope can not either diagnose, cure or
palliate! (Asthma, COPD,…..)
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Today
Success of Lung Transplantation cannot be imagined
without the Flexible bronchoscope
E P Trulock; The role of TBBx in Rx of LTx recipients
An analysis of 200 consecutive procedures, Chest. 1992;102(4):1049
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Bronchoscopic Management of Dehiscence
Short-Term Deployment of Self-Expanding Metallic Stent Facilitates Healing
of Bronchial Dehiscence. Amer J of Respir & Critic Care Med 2005; 172:768
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Interventional Pulmonology Well established sub-sub specialty
Fellowship programs
First ever IP Board Exam (# 75)
National & international
organizations:[WABIP,AABIP,
EABIP, IABIP….]
National & International Seminars
[WCBIP]
JOBIP is now Indexed
Guidelines and Consensus statements
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Bronchoscopy Today
Level IV: Basic Diagnostic: Wash, Brush, EBB, TBB, C-TBNA, NBI
Level III: Advanced Diagnostics: Level IV plus EMN, RP-EBUS, CP-EBUS
Level II: Therapeutic bronchoscopy: Level III plus, SEMS, APC, EBES, Laser-PR, Bronchoplasty, Cryo, EBVR, Thermoplasty, FB removal
Level I: Advanced Therapeutics: Level II plus Rigid Bronch, Silicon stent placement, SEM Remova;Staging EBUS, Adrenal Gland Bx, EUS, PEG
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Interventional Pulmonology Fostering Team Approach:
Anesthesiology
Radiation Oncology
Cytopathology
Thoracic surgery
Radiology/Interventional Radiology
Competing Disciplines:
GI: EUS, Adrenal Gland Bx, PEG Tubes
Thoracic Surgery: Pleuroscopy
Otolaryngology: T Tube placement
Pathology Gasparini S, The Role of the Pulmonologist in ROSE Evaluation of TBNA, A Prospective Study CHEST, 2014, 145(1) 60
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Today
What is the largest foreign body a pulmonologist has
ever removed from the endobronchial tree?
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Today
Removal of the endobronchial foreign body and the mediastinal
staging of NSCCA, no longer remain in the domain of the
thoracic surgeons.
Answer: Thoracic Surgeon
Annema, J, Mediastinoscopy vs Endosonography for Mediastinal Nodal
Staging of Lung Cancer: A Randomized Trial, JAMA,2010, 304 (20): 2245
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Future
Future belongs to ideas and innovations.
Yet!
People who don’t remember the past are
condemned to repeat it!
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“All Innovations are History Forgotten!”
Lord Ganesha:
First case of:
Solid organ transplantation
Facial transplantation
Xenotransplantation
(?) Cushing’s Syndrome
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“All Innovations are History Forgotten!”
Laser Photoresection
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Future
Future belongs to the Innovations Endobronchial Volume Reduction: Patient selection
Virtual Bronchoscopic Navigation
Bio-absorbable Stents
3-D Printing
Tracheal Transplantation
Stem Cell Therapy
Confocal Bronchoscopy
OCT (?)
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Endobronchial Volume Reduction: Valves
Use of EBV for Emphysema remains investigational
in USA
EBV are routinely used in select European and Middle
Eastern “Center(s) of Excellence”
EBV have been approved in the compassionate
management of prolonged air leak in the USA
Trials on “Biochemical” agents Thermal Vapor have
been abandoned in USA
Newer modalities for EBVR are emerging:
Coils
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A Randomized Study of Endobronchial Valves for
Advanced Emphysema (Zephyr Valve®) N Engl J Med 2010;363:1233
VENT Trial
N=321, 2:1 randomization (220:101)
Centers: 31
Dec 2004-April 2006
Age: 40-75
Upper lobe Heterogeneous disease
FEV1: 15-45%, TLC: >100%, RV: 150%
Unilateral Upper lobe Rx
EX
IN
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Euro VENT Trial Euro Respi J 2012, 39 1334
23 sites
N=171 111 EBV
60 Control
Overall results Modest benefit in overall cohort
Consistent with findings in US VENT
Complete fissures Greater clinical benefit compared to whole cohort
Complete fissures + lobar occlusion Highest benefit
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Complete Fissure (N=56)
(N) Lobar
Occlusion (20)
No Lobar
Occlusion (17)
P Control
(19)
6 months
Target Lobe VR
-80% -29% <0.0001 0
>55% Reduction 79 % 18% 0.0002 0
FEV1 Change 26 6 0.004 3
>15% Change 67% 8% 0.002 6%
6 MWD 22 -2 0.03 19
>35 meter 56% 25% 0.1 38
SGRQ -10 -2 0.02 3
>4 points 67% 40 0.4 17%
Euro Respi J 2012, 39 1334
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Survival Advantage
N=19 N=40
Eur Respir J 2011;37:1346. Eur Respir J 2012;39:1084
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Lung Volume Reduction Coil System
CE Mark: 2010
> 600 pts Rxed (total)
French MOH:
2013 Cost effectiveness &
reimbursement study
Approved for a US IDE Pivotal
Clinical Trial:
Pts are being recruited
Shape memory Nitinol implant CHEST 2012; 142(3):574–582
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Lung Volume Reduction Coil System
Compresses diseased tissue in
emphysematous lung
Restore elastic recoil
Improve lung compliance
Shift preferential filling of air from diseased
to healthier tissue
Reduce hyperinflation
Radially suspends & tethers airways open to
reduce air trapping
Maintain airway patency
Preserve distal access & flow
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N 180 Days (N=113) p-value N 360 Days (N=75) p-value
FEV1, L 106 0.11L ±0.16 < 0.0001 73 0.10L ±0.22 0.0003
RV, L 112 -0.59L ±0.76 < 0.0001 74 -0.52L ±0.77 <0.0001
6MWT, m 110 43.9m ±66.7 < 0.0001 71 50.6m ±62.4 <0.0001
SGRQ, points 111 -11.2pts ±11.6 < 0.0001 74 -10.1pts ±12.2 <0.0001
FEV1, L 106 14.92% ±22.01 < 0.0001 73 13.16% ±27.07 <0.0001
RV, L 112 -10.49% ±13.02 < 0.0001 74 -9.2% ±13.55 <0.0001
6MWT, m 110 17.9% ±27.9 < 0.0001 71 19.0% ±25.9 <0.0001
SGRQ, points 111 -18.9% ±21.2 < 0.0001 74 -17.9% ±24.8 <0.0001
Change vs. Baseline, Actual Value
% Change vs. Baseline
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-15
-10
-5
0
Baseline 6month 12month
%
ELVR – Lessons learned - SGRQ
LVRS
Valves
Valve
Coils
Vapor
Med
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Virtual Bronchoscopy Navigation
McLennan G, Ferguson JS, Use of MDCT-based computer aided pathway finding
mediastinal & perihilar LN Biopsy: A randomized controlled prospective trial,
Respiration 2007;74:423
Weiner GM, Ebhardt R, CT bronchoscopic simulation for guiding TBNA of extramural
mediastinal and hilar lesions. Initial clinical results. Radiology 2009;250:923
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Carinal Replacement with Fresh Aortic Grafts
Seguin. Ann Thorac Surg 2006
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Carinal Replacement
Continuous mucociliary
epithelium:
Ciliated cells
Goblet cells
Seguin. Ann Thorac Surg 2006
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Tracheal Transplantation (Tissue Engineering)
At 5 months
BCA
RUL
Bronchus
intermedius
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Tissue Engineering Distant Future or Tomorrow’s Treatment?
1. Synthetic scaffold
cultured with autologous
human bone marrow
mononuclear cells
2. Bronchoscopy at 1 week
3: Histology at 2 months:
Respiratory epithelium
Mucus-secreting cells
AJRCCM 2013, (187) : 468-475
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Endobronchial Stent: 3D Printing: Silicon Stent
Cleveland Clinic
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Bioabsorbable Airway Splint Created with 3-D Printer Zopf et al, NEJM 2013
2 month old child with severe TBM
3-D printing using polycaprolactone
Normal airways at 1 year follow up
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Tracheal Replacement in Humans Using
Autologous Tissues: An 8-Year Experience Fabre et.al., Ann Thorac Surg 2013; 96:1146
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Tracheal Replacement in Humans Using
Autologous Tissues: An 8-Year Experience Fabre et.al., Ann Thorac Surg 2013; 96:1146
Trachéal substitution with tube made up of forearm fascio-cutaneous flap vascularized by radial vessels, re-anastomosed to internal mammary vessels, reinforced by rib cartilage implanted into the subcutaneous tissue
No immunosuppression
No synthetic materials
N=12 (8 years)
Tracheal neoplasms: 8
7 –12 cm resection
All extubated on POD 1
8 are alive at a mean of 36 months, 2 with trach
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2009 ACM 55
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ACM 56
Endoscopic Microscope
Colon
“Future of Bronchoscopy lies in the
Colon of the patient!”
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Challenges of the Future
“The future ain’t what it used to be!” Yogi Berra
Radiology: HRCT
Cost vs Reimbursement
Education: Training, Credentialing
Overenthusiasm
Maldistribution between needs and resources
Innovations: Electronic nose, Molecular Radiology, Serology
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Editorial Comments Interventional Pulmonology is more than just interventions
[EBTB, EB Sarcoid, GPA, IBD, Infections]
You have to be a good bronchoscopist to be an interventionalist; interventions don’t make you a better bronchoscopist
Because it could be done that doesn’t mean it should be done
One has to be larger than his or her abilities
Pt’s welfare >> self gratification, “Adrenalizing”
A good bronchoscopist is the one who knows when not to perform the procedure
Reducing health care cost is a civic responsibility
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ACM 59