Juan M. Olazagasti, MD ERS - Spring 2013 UVA Health System.
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Transcript of Juan M. Olazagasti, MD ERS - Spring 2013 UVA Health System.
Juan M. Olazagasti, MDERS - Spring 2013UVA Health System
Objectives:
Procedure basics and things to remember
Cases that have taught and challenged me
New trends in thoracic interventions Thoracic: US why now?
Case 1: Abnormal CXR, Leukocytosis
The thrill of victory
Case #2:Please place drain in LUQ fluid collection
Success!
Same day and 2 days later with new fever..Free empyema
And the agony of defeat..
Inferior border of pleura
BSA motto: always do your best
Would you please biopsy this 4mm nodule?
BSA motto: always do your best
Is the procedure indicated?
Is it going to benefit the patient?
Do benefits outweigh risks?
Approach and planning
Best approach is not necessarily the easiest
Play to your strengths Be aware of immediate and delayed
complications
85 year old gentleman with SCCA of the neck
Approach and planning
Plan ahead: Coagulation factors, team’s experience,
patient’s ability to cooperate
IS A TEAM EFFORT: Nurse, tech, trainee, faculty AND
patient Knowledgeable tech, a good nurse and a
cooperative patient go a LONG way
Dr. Ravenell looking for pluff mud while in San Antonio
Procedures and golf..Too much pride doesn’t get me anywhere good
How comfortable are you with the procedure? Don’t hesitate to ask for help
Ask before you start
Rehearse (beforehand) what is going to happen once the procedure starts
Post right thoracotomy, clinically deteriorating with fluid collection on recent CT
Checklist:
-Indicated?-Informed consent-Approach-Sedation?-Catheter size-Possible complications
Cake walk..
Nurse and tech say, “there is a lot of air coming out into the Pleura VAC”
Trapped lung
Informed consent
Be clear, precise, in lay terms Be prepared to answer questions re
your expertise, how many have you done, etc.
Be honest, caring and appropriate If a complication occurs, address it
immediately With patient and family after patient is
stable
SMOKER WITH INCREASING SIZE OF PULMONARY NODULEPOOR SURGICAL CANDIDATE. NEED TISSUE DIAGNOSIS WITH MARKERSFOR TREATMENT GUIDANCE
Planning scan
Giving local anesthesia..
1. Assess situation2. If pt. is stable, proceed with
biopsy or..3. Evacuate ptx. , then do
procedure
LESSON: don’t let the resident give local anesthesia
Professionalism
Restrict talk to patient’s concerns and procedure Patients can hear and understand while
under sedation, esp. with conscious sedation
Role modeling for trainees, support team
http://www.youtube.com/watch?v=GS2jaqDzkJs
A few cool things we do.. Radionuclide nodule localization US guided thoracic procedures
Radionuclide localization of small lung nodules Prior to surgical resection of non
palpable lesions or GGN Aids surgeon and patient
Decreases OR time and bleeding, other complications
Can decrease amount of tissue resected in patient with poor lung reserve
Surgical Resection of SPN and GGO VATS
Locate the lesion thoracoscopically
Sometimes lesion can’t be seen or palpated
<10mm in size > 5mm deep from
pleura (Suzuki, et al, 2008)
ground glass nodules
Alternatives Thoracoscopic
removal bulk of tissue to increase the likelihood of getting the lesion
Open thoracotomy Increased morbidity
and mortality Increased OR time
Approach
Talk with surgeon first Before and after
procedure
Focused CT or, Pre-procedure full
chest non contrast CT Over 2 month or
questionable appearance Few lesions no longer
present
Technique - when in correct position
Inject 0.1cc of Tc 99m MAA 0.3 millicuries
Macroaggregate with long half life (12hrs.)
Patient goes to NM for orthogonal views of tracer location
Approach
22 gauge needle Coaxial needle or
direct injection ALWAYS
DEEP/CENTRAL TO LESION! More so if
peripheral lesion: BAD: pleural
injection
Technique
Failure of being central: Pleural injection No help to surgeon Have to repeat
Intraoperative Localization
Thoracoscopic localization via specially Thoracoscopic localization via specially designed gamma probe with 30 degree designed gamma probe with 30 degree angled tipangled tip
Guides surgeon towards lesion “activity”Guides surgeon towards lesion “activity”
Wedge resection – pathology at siteWedge resection – pathology at site
NEW OPPORTUNITIES
More biopsies because of tumor markers KRAS, VEGF, etc. Surgeons more accountable
Don’t want to take out benign disease
Oligometastatic disease Colorectal, sarcomas, renal
RFA, microwave ablation
Thoracic UltrasoundGOOD Portable, accessible Images readily available
for evaluation/treatment Unrestricted imaging
planes No ionizing radiation Cost effective
BAD Bones absorb sound
waves Air limits
propagation of sound waves
How and when to use US in the Thorax? Adjunct to CXR and CT to aid in
diagnosis Diaphragm Pleural space and peripheral lung
parenchyma Chest wall and Mediastinum
Critically ill patient cost effective, added flexibility
Peripheral lung lesion
Why Thoracic US?
Great tool for patient care AND: ER and others using it and teaching
it Association of University Radiologists
US national medical student curriculum
Sonographic Air Bronchograms RLL Pneumonia
Ill defined opacity in RLL on CXR
TB pericarditis
Thoracic Procedures with US
Pleural Space Diagnostic &
therapeutic thoracentesis Catheter placement
Pleural biopsy Pleural sclerotherapy
Lung/MediastinumLung/Mediastinum• Biopsy lung massBiopsy lung mass
• Catheter drainage lung abscessCatheter drainage lung abscess
• Biopsy guidanceBiopsy guidance
Tuberculous Effusion - exudate
Pleural Effusions Simple effusion -
transudate
Pleural effusion versus thickening US signs
Effusion
Changes with respiration (mobile)
Moving septations Floating
echodensities
Thickening Solid, >3mm Irregular contour Lung is displaced
Septated effusion with Septated effusion with LymphomaLymphoma
• Complex fluid & nodular Complex fluid & nodular pleural thickening - pleural thickening - mesotheliomamesothelioma
Lymphoma Lymphoma metastasis to metastasis to pleurapleura
Pericardial implant
Pleural Pleural metastasesmetastases
Pneumococcal Empyema1 1/2 year old boy
PneumothoraxUS Signs
Hyperechoic line with reverberation
artifact similar to normal lung but without comet
tail
Absent respiratory movement no sliding pleura sign
Loss of visualized lesion
Another local anesthesia episode
Mediastinal US
Examination Supra/parasternal Infra and
supraclavicular Paravertebral
Guide biopsy Decubitus position can
widen your window
Critically ill patientsProspective study 41 Inpts, ICU, ER Suboptimal CXR
Pleural vs parench. dz?Delay in dx –signif underlying
dz
Chest US helpful in 66%, signif. influenced treatment plans in 41%
More sensitive on small effusion, character & guiding for tap
Cost effective
YU, et al, AJR 159:695-701, Oct, 1992
Summary – thoracic interventions
Remember your checklist:- Indicated? - Approach- Informed consent- Sedation?- Possible complications
Summary
US supplements CXR & CT Diagnoses & characterizes diseases
Pleural space and lung Mediastinum, diaphragm and chest wall
Portable bedside technique – ICU Cost effective
New trends Stay on top or get run over
And remember..
Thanks for the invite!