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”

http://www.teetimes.info/golf-related/golf-books-11-lost-balls-great-holes-tough-shots-and-bad-lies/attachment/lost-balls/

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!