clinic进修心得报告【共享精品-ppt】

Interventional Pulmonology Lahey Clinic進修心得報告,謝義山 胸腔外科主治醫師Lahey ClinicBurlington MassachusettsMarch 29- April 1,2006,Agenda Diagnostic Bronchoscopy,TBNAAutofluorescence BronchoscopyNavigational Bronchoscopy,Agenda Therapeutic Bronchoscopy,Ablative therapyLaser BronchoscopyElectrocautery APCCryotherapyDisplacement TherapyRigid BronchoscopyBalloon DilatationStentSiliconMetallic stent,Therapeutic Bronchoscopy for emphysemaPDTBrachytherapy,Agenda:Invasive Pulmonology,Rigid BronchoscopyPercutaneous dilated tracheostomyMedical Thoracoscopy,Current Indication for Rigid Bronchoscopy,DiagnosticDeep and large quantitative biopsyPhotographic documentationPediatric bronchoscopy,TherapeuticMassive hemoptysis: airway control and assessmentTumor ablation / foreign body retrievalLaser therapyAirway dilatation / “core out” of tumorAirway stenting Cryotherapy (RB/FB)Electrocautery (RB/FB),Benefit of RBAirway control / ventilationLarge working channelImproved airway visualizationLarge biopsy sizeAbsence of coughing and unwanted motionTimely multi-modality interventionLimitation of RBLimited availabilityAccess to only the more central airways,Percutaneous Tracheostomy,Procedure: Safe and quickCost: Controversal不須外科及麻醉科減少等待時間 減少ICU stayContra-indication:ObesityCoagulopathyAnatomic Barrier: prominent goiter or tumorPediatric patientHigh PEEP/FiO2 requirementEmergent airway Quick airway at TC menbrane,Medical Thoracoscopy,Mini-VATS in simple diagnosis and treatment procedureIndication: 覺得光是sono-guide不夠 而給外科開刀又太over 的情形有indication進行pleural biopsy 及pig tail/ chest tube drainge 就有 indication不要選看起來就太粘黏 multiple loculation,Medical Thoracoscopy,Procedure:Local anesthesia, with/without minimal sedationCreate PneumothoraxInsertion of trocar and thoracoscpyTraditional VATS instrumentNewly Thoracoscopy (Olympus)Collection fluid and take biopsy to interesting regionChest tube replacement Whole procedure is quick and safe Beware of your limitation 千萬不要逞強,Hot Therapy,LaserCO2 laserNd-YAG laserMost powerful無法控制深度最好用Rigid bronchoscopy操作,EBEC: poor mans laser深度無法控制APC:可以控制深度Smaller lesion, convenient, less expensive, flexible brochoscopy,Laser Bronchoscopy,Favorable LesionsPolypoidShort durationEndobronchealVisible distal lumenTracheal, Main bronchus, First segmentFunctional distal lung,Unfavorable LesionsExternal compressionTotal obstructionSubmucosal infiltrationChronic collapseLobar / segmental lesions,Cold Therapy: Cryotherapy,Cryotherapy Balloon dilatation,Stent,Silicon stent (by Rigid bronchoscopy)Dumon stentY stentT tubeSEMT: (RB or FB)Ultraflex stent,Silicone or Metal?,Silicone stentRequire RBEasily removedMigrationCan be used in both malignant and benign stenosis,Metal stentsEasy to insertDifficult to removeGranulation tissueNot recommended for most benign stenosis,Selection of Therapy for Airway obstruction,For Urgent TherapyLaser, Stent, Rigid BronchoscopyFor Semi-urgent TherapyCryotherapy, Electrocautery, APC, PDT, Balloon For Prolonged TherapyPDT, Stent, Brachytherapy,PDT and Brachytherapy,PDTNot suggested for palliative Very expensiveFor central airway early malignancyHighly potential of “cure of cancer”BrachytherapyNot available in SKHFor palliative useBeware of fistula with great vessels and esophagus,Management of COPD,Surgical:BullectomyLVRSLung transplantationEndoscopic:Endobronchial Volume ReductionEndobronchial fenestration,Why BLVR,Because LVRS:High risk patient?Invasive procedureHigh morbidity (45-75%)Underestimation of mortality (2yr: 27%)Cost expensiveAvailabilityIrreversible,Endobroncheal Valve,One way valve blocker at airway shrinkage of emphysematous segment / lobe (50%) increasing FEV1 (50%), life quality (most), decreasing O2 dependent (most)Emphasys endobroncheal valve (CE)Spiration endobroncheal valve (NA),TBNA,Routine TBNA for mediastinal LNs enlargementImproving TBNA yield: most important Subcarinal / Paratracheal / AP window LNs3 point method Good needle, and maneuverOn-site pathologistEndobroncheal ultrasound guide: much safe,Autofluorescence Bronchoscopy,Evidence in 2006Detects dysplasia and CIS better than WLBVarious system seem to produce similar resultAFB continues to show advantage over video WLBIt is a safe procedure,Autofluorescence Bronchoscopy,Lacking Evidence in 2005Nature history of early lesionsDo we alter or improve outcomes by performing AFBWho do we offer AFB to?Lung cancer screening programsCan we define the high risk population better?Pathologists can agree on biopsies,Autofluorescence Bronchoscopy,FutureManufactures should combine AF with standard WLB systemAdjunct to WLMolecular and gene markers will help the pathologists,Diagnosis of Peripheral Nodules 2 cm,CT guide TTNAPneumothorax20-30%3-15% require chest tubesCT time slotRadiationSurgeryInvasiveExpensiveUp to 99% of nodules are non-malignant,Navigational Bronchosco