Interventional pulmonology

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Interventional pulmonology (IP, also called interventional pulmonary medicine) is a maturing medical sub-specialty from its parent specialty of pulmonary medicine. It deals specifically with minimally invasive endoscopic and percutaneous procedures for diagnosis and treatment of neoplastic as well as non-neoplastic diseases of the airways, lungs, and pleura. Many IP procedures constitute efficacious yet less invasive alternatives to thoracic surgery.

Contents

History

Before the advent of optical fibers and advances in anesthesiology, interventional pulmonary procedures were mostly limited to foreign body retrieval via rigid bronchoscopy. Gustav Killian (June 2, 1860 – February 24, 1921), a German laryngologist, performed foreign body retrievals from bronchial passages using a rigid laryngoscope/bronchoscope whereas in the United States, Chevalier Jackson (1865 – 1958) was the first to use the rigid bronchoscope. [1] Later, Swedish internist Hans-Christian Jacobaeus first introduced thoracoscopy in a 1910 paper published in the journal Münch med Wochenschr, before Japanese thoracic surgeon Shiketo Ikeda (1925 – 2001) introduced the fiberoptic bronchoscope in the late 20th century. [2] [3] Jean-Francois Dumon from France is credited with modernizing rigid bronchoscopy in the late 20th century by introducing a novel non-metallic airway stent made of silicone, appropriately named the Dumon stent. [4] Together, these developments laid the foundation for most of today’s interventional pulmonary techniques.

In 1978, Kopen Wang and colleagues at Johns Hopkins Hospital described the use of transbronchial needle aspiration (TBNA) through a rigid bronchoscope to diagnose a paratracheal mediastinal mass. [5] Following the advent of endobronchial ultrasound (EBUS), which first became available in the early 21st century, EBUS-TBNA swiftly replaced mediastinoscopy as the first-line in mediastinal staging for lung cancer. [6] With these developments, interventional pulmonology became much more firmly established on the map of distinct subspecialties.

In 1992, the Association for Bronchology and Interventional Pulmonology (AABIP) was formed as a representative society of interventional pulmonologists based in North America. [7] This organization also publishes a journal, namely the Journal of Bronchology and Interventional Pulmonology. [8] The World Association for Bronchology was founded by Dr. Ikeda in 1978 and renamed as the World Association for Bronchology and Interventional Pulmonology (WABIP) in 2010. [9] It holds a biennial scientific meeting known as the World Congress for Bronchology and Interventional Pulmonology. The Association for Interventional Pulmonology Program Directors (AIPPD), dedicated to the advancement of IP education in the United States, was created in 2012. [10]

Procedures

In addition to basic bronchoscopic and pleural procedures that are performed by a general pulmonologist, an interventional pulmonologist may perform the following advanced procedures:

Advanced diagnostic procedures

Advanced therapeutic procedures

Training and certification

For purposes of formal training in interventional pulmonology, dedicated training programs only became available in the early 21st century. The first dedicated program was a 12-month advanced fellowship offered by Dr. Beamis at Lahey Clinic in Boston. [11] Currently, there are over 30 IP fellowship programs across the country. [10] However, training programs have varied considerably in terms of the breadth and depth of procedural training that they offer. [12]

To address the issue of inconsistent IP training across fellowship programs, representative members from five professional organizations (AABIP, AIPPD, ACCP, ATS, and APCCMPD) jointly published a list of minimum standards required by July 2019 in order for IP fellowship programs to receive formal accreditation from the AABIP and AIPPD. [13]

To be eligible for this fellowship, applicants must first complete a three-year fellowship in pulmonary & critical care medicine. Most of these programs select one to two fellow(s) per year, applying though the Interventional Pulmonary Fellow Application Service (IPFAS©). As with most other medical specialties and subspecialties across the United States, applicants are matched to programs through the National Resident Matching Program (NRMP, or the “Match”). [10]

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<span class="mw-page-title-main">Pleural cavity</span> Thin fluid-filled space between the two pulmonary pleurae (visceral and parietal) of each lung

The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication between the membranes, and also to create a pressure gradient.

<span class="mw-page-title-main">Pulmonology</span> Study of respiratory diseases

Pulmonology, pneumology or pneumonology is a medical specialty that deals with diseases involving the respiratory tract. It is also known as respirology, respiratory medicine, or chest medicine in some countries and areas.

<span class="mw-page-title-main">Cardiac catheterization</span> Insertion of a catheter into a chamber or vessel of the heart

Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes.

<span class="mw-page-title-main">Hemothorax</span> Blood accumulation in the pleural cavity

A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to Pneumothorax, or rarely in association with other conditions.

<span class="mw-page-title-main">Chylothorax</span> Medical condition

A chylothorax is an abnormal accumulation of chyle, a type of lipid-rich lymph, in the space surrounding the lung. The lymphatics of the digestive system normally returns lipids absorbed from the small bowel via the thoracic duct, which ascends behind the esophagus to drain into the left brachiocephalic vein. If normal thoracic duct drainage is disrupted, either due to obstruction or rupture, chyle can leak and accumulate within the negative-pressured pleural space. In people on a normal diet, this fluid collection can sometimes be identified by its turbid, milky white appearance, since chyle contains emulsified triglycerides.

<span class="mw-page-title-main">Thoracentesis</span> Medical procedure

Thoracentesis, also known as thoracocentesis, pleural tap, needle thoracostomy, or needle decompression, is an invasive medical procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia. The procedure was first performed by Morrill Wyman in 1850 and then described by Henry Ingersoll Bowditch in 1852.

<span class="mw-page-title-main">Endoscopic ultrasound</span>

Endoscopic ultrasound (EUS) or echo-endoscopy is a medical procedure in which endoscopy is combined with ultrasound to obtain images of the internal organs in the chest, abdomen and colon. It can be used to visualize the walls of these organs, or to look at adjacent structures. Combined with Doppler imaging, nearby blood vessels can also be evaluated.

<span class="mw-page-title-main">Bronchopulmonary segment</span>

A bronchopulmonary segment is a portion of lung supplied by a specific segmental bronchus and its vessels. These arteries branch from the pulmonary and bronchial arteries, and run together through the center of the segment. Veins and lymphatic vessels drain along the edges of the segment. The segments are separated from each other by layers of connective tissue that forms them into discrete anatomical and functional units. This separation means that a bronchopulmonary segment can be surgically removed without affecting the function of the others.

<span class="mw-page-title-main">Endobronchial valve</span>

An endobronchial valve(EBV), is a small, one-way valve, which may be implanted in an airway feeding the lung or part of lung. The valve allows air to be breathed out of the section of lung supplied, and prevents air from being breathed in. This leaves the rest of the lung to expand more normally and avoid air-trapping. Endobronchial valves are typically implanted using a flexible delivery catheter advanced through a bronchoscope in minimally invasive bronchoscopic lung volume reduction procedures in the treatment of severe emphysema. The valves are also removable if they are not working properly.

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Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumors, or inflammation. Specimens may be taken from inside the lungs. The construction of bronchoscopes ranges from rigid metal tubes with attached lighting devices to flexible optical fiber instruments with realtime video equipment.

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A lung nodule or pulmonary nodule is a relatively small focal density in the lung. A solitary pulmonary nodule (SPN) or coin lesion, is a mass in the lung smaller than three centimeters in diameter. A pulmonary micronodule has a diameter of less than three millimetres. There may also be multiple nodules.

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<span class="mw-page-title-main">Hybrid cardiac surgery</span>

A hybrid cardiac surgical procedure in a narrow sense is defined as a procedure that combines a conventional, more invasive surgical part with an interventional part, using some sort of catheter-based procedure guided by fluoroscopy imaging in a hybrid operating room (OR) without interruption. The hybrid technique has a reduced risk of surgical complications and has shown decreased recovery time. It can be used to treat numerous heart diseases and conditions and with the increasing complexity of each case, the hybrid surgical technique is becoming more common.

<span class="mw-page-title-main">Lung biopsy</span>

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References

  1. ↑ Ernst A.; Herth, F.J.F. Principles and Practice of Interventional Pulmonology. New York, NY: Springer 2013. ISBN   978-1-4614-4291-2.
  2. ↑ Jacobaeus HC. Ueber die Möglichkeit die Zystoskopie bei Untersuchungen seröser Höhlungen anzuwenden. Munch Med Wochenschr. 1910;57:2090–2019.
  3. ↑ Ernst A.; Herth, F.J.F. Principles and Practice of Interventional Pulmonology. New York, NY: Springer 2013. ISBN   978-1-4614-4291-2.
  4. ↑ Dumon, J; et al. Seven-Year Experience with the Dumon Prosthesis. Journal of Bronchology. 1996; 3:6-10.
  5. ↑ Pen Wang, K.; et al. Bronchoscopic needle aspiration biopsy of paratracheal tumors. American Review of Respiratory Disease. 1978. 117: 17-21.
  6. ↑ Silvestri, G. A.; et al. Methods for Staging Non-small Cell Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2013;143(5_suppl):e211S-e250S.
  7. ↑ "AABIP" . Retrieved 30 May 2017.
  8. ↑ "Journal of Bronchology & Interventional Pulmonology" . Retrieved 30 May 2017.
  9. ↑ "World Association for Bronchology and Interventional Pulmonology" . Retrieved 30 May 2017.
  10. 1 2 3 "AIPPD - Association of Interventional Pulmonology Program Directors" . Retrieved 30 May 2017.
  11. ↑ "Lahey Clinic Overview - Interventional Pulmonary Fellowship" . Retrieved 30 May 2017. With Harvard, Penn, & Duke also part of the early Founders of the field.
  12. ↑ Lee, H., L.; Mullon, J. J. Accredited Interventional Pulmonary Fellowships: The Time is Here. Journal of Bronchology & Interventional Pulmonology. 2015. 22: 189–190.
  13. ↑ Mullon, J.J.Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. Chest. 2017. 151:1114-1121.
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