Interventional Pulmonology Approach to Central Airway ... · SuperDimension iLogic System •Uses...
Transcript of Interventional Pulmonology Approach to Central Airway ... · SuperDimension iLogic System •Uses...
Navigational Bronchoscopy
Christine Argento, MD, FCCP
Interventional Pulmonology
Northwestern University
Disclosures
• Consultant to:
Biodesix
Olympus
Outline
• Peripheral Pulmonary Nodules
• Navigational Platforms
– EMN
– VBN
– Radial EBUS
– Cone Beam CT
– Robotic
• Clinical Realities
Peripheral Pulmonary Nodules
• Pulmonary nodules are an increasingly common
finding
• 4.5-14 million CT chest yearly
• NLST by NCI
– > 25% of the low dose CT group had positive finding
– 96.4% false positive
– 20% RRR in mortality from lung cancer
• MANY more CT scans will be ordered
N Engl J Med 2011; 365:395-409
Kardiochirurgia i Torakochirurgia Polska 2014; 11 (4): 397-403
Approach
• Does the patient need a biopsy?
– Malignant or benign
– Operative?
• Safety vs Efficacy
• Efficiency
– get all the information you need in one setting
ACCP Guidelines 2013
• In patients with peripheral lung lesions difficult to reach with conventional bronchoscopy, electromagnetic navigation guidance is recommended if the equipment and the expertise are available (Grade 1C).
• Remark: The procedure can be performed with or without fluoroscopic guidance and it has been found complementary to radial probe ultrasound
• Remark: If electromagnetic navigation is not available, TTNA is recommended.
CHEST May 2013Volume 143, Issue 5,
Supplement, Pages 7S–37S
GPS for the lung?
Electromagnetic Navigation
• Acquires spatial navigation in virtual time
– based on reconstruction of previously acquired
images
Planning• 3D reconstruction from
dedicated CT of the
chest w/ thin slices
• Slice thickness < 1.25
mm
• Slice spacing < 0.625
mm
– The thinner the
better
• Select Target(s)
Planning • 3D-Airway Tree View
• Automatic calculation
of airway paths to
target(s)
• Review Virtual
Bronchoscopy
– Three paths generated• Path 1: Ends closest to the
target
• Path 2: Potentially provides
(better) angle to target
• Path 3: Utilizes different
branch of airway
YieldHigher• Size > 2cm
• Bronchus sign
• Closer to the hilum
• Further from the diaphragm
• Obstructive lung disease
• Multiple modality procedure
Electromagnetic Navigation
SuperDimension iLogic System
• Uses previously performed thin cut non-contrast CT.
• Tip-tracked locatable guide (LG) through a catheter system.
• LG removed and biopsies are done through thecatheter working channel.
• Longest tenure/track record of navigation systems.
Lamptrcht et al Respir Med 2012
Karnak et al Ann Thor Med 2013
Gildea et al Am J Respir Crit Care Med 2006
Ebhardt et al Am J Respir Crit Care Med 2
Screen Shot
Evidence for SuperDimension
Veran
• Same day scan with expiratory
planning
– Can use a historical CT scan if needed
• No room mapping limitations
• ‘Always on instrumentation’
• tip tracked steerable working
channels, needles, brushes, forceps
and guidewires
Always-On Tip Tracked Instruments
Screen Shot
SPIN perc
Virtual Bronchoscopy• Direct Path, Cybernet system
Broncus- Lung Point
• Pattern Recognition Software
VBN – Does it Work?
Respiration 2014; 88:430-440
3.0 mm OD/1.7 mm WC 4.0 mm OD/2.0 mm WC
AJRCCM 2015. 192(4): 468-476
Thorax 2011.66(12):1072
VBN Pro/Con
• Pro– Easy to use software
– Requires no proprietary hardware
– System DOES NOT require specialized, disposable instruments
– Complements other technologies well
– Case cost is likely less than other navigation platforms
• Con– Variable CT quality
– “Prisoner” of airway
– Confirmation of biopsy instruments at target not synchronized
– Dependence on additional infrastructure
Transparenchymal Nodule Access
(TPNA)
Radial EBUS
• Ultrasound used in the periphery of the lung
– Introduced through the working channel of the
bronchoscope
• Frequency 20 MHz
Remember to breathe!
CHEST 2015; 147(5):1275-1281
Multi-Modality
Multi-Modality
Eberhardt et al, AJRCCM 2007; 176: 36
Robotic
Collaborative Efforts
• Pleural dye marking
• Localization for VATS/RATS
• EMN guided wedge resections
• Fiducial placement
J Thorac Dis. 2017 Mar;9(3):802-808.
Ann Thorac Surg 2008;85:S797–801
Ann Thorac Surg 2014;98:471–6
Sem Thorac and Cardio Surg Vol 22 (3):262-265
Journal of Community Hospital Internal Medicine Perspectives 2014, 4:
Summary
• Navigational bronchoscopy platforms are useful
to diagnose peripheral pulmonary lesions
• Often performed as multi-modality
– That increases yield
• New technology for navigational bronchoscopy
is being developed
• Collaboration efforts with Thoracic Surgery are
an important use of navigational bronchoscopic
platforms
Thank YouQuestions?