Interventional Pulmonology | Pulmonary Medicine | Dartmouth-Hitchcock
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Interventional Pulmonology

Image of lung and bronchiolesInterventional pulmonology offers minimally invasive care for chest and lung diseases.

If you have a medical condition that impacts your ability to breathe, then you know how important it is to receive care from doctors who specialize in respiratory disorders.

Whether you need further evaluation of a lung mass or ongoing care for pleural effusion, we can help. As one of the few health systems in the United States to offer interventional pulmonology services, Dartmouth-Hitchcock (D-H) doctors diagnose and treat lung cancer, complex airway disorders and pleural diseases using highly specialized, minimally invasive techniques.

What is interventional pulmonology?

Numerous medical conditions can affect your respiratory system, resulting in symptoms such as shortness of breath, wheezing, chest pain or chronic cough. Doctors who treat these conditions are called pulmonary medicine specialists, or pulmonologists. Interventional pulmonology is a branch of pulmonary medicine that has produced important new techniques allowing doctors to diagnose and treat chest and lung diseases less invasively. Interventional pulmonology techniques often reduce the number of procedures needed to treat illness as well as their associated risk of complications.

Interventional pulmonology services offered at Dartmouth-Hitchcock

D-H is proud to be one of the few medical centers in the United States to offer interventional pulmonology services.

The techniques our doctors use are less invasive than many traditional procedures used to diagnose or treat chest and lung disorders. These techniques have helped transform pulmonary care by making it easier, faster and often safer to access the lungs and other hard-to-reach parts of the respiratory system.

The procedures we offer allow us to:

  • Biopsy, diagnose and stage lung cancer all in one procedure.
  • Diagnose and treat complex medical conditions that cause narrowed or blocked airways.
  • Diagnose and treat pleural diseases, which are conditions that affect the space around the lungs (sometimes referred to as the pleural cavity).
  • Provide palliative therapies that help relieve pain, reduce symptoms and improve quality of life through the duration of an illness.
  • Obtain tissue samples that allow doctors and researchers to genetically profile tumors, a vital step in creating targeted new therapies for lung cancer.

Respiratory diseases managed at Dartmouth-Hitchcock

D-H interventional pulmonologists have extensive experience diagnosing and treating adults with a variety of medical conditions that impact the respiratory system, including:

  • Asthma: a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe.
  • Bronchial stenosis: narrowing of one of the bronchi, or special tubes that help air flow in and out of the lungs.
  • Lung cancer, including non-small cell lung cancer, small cell lung cancer and lung carcinoid tumors.
  • Lung metastases: cancer that begins in another organ and spreads to the lungs.
  • Mediastinal lymphadenopathy: enlarged lymph nodes within a portion of the chest known as the mediastinum. This is usually a symptom of another disease such as tuberculosis, a fungal infection or lung cancer.
  • Pleural effusion: a condition that occurs when excess fluid builds up in the space around the lungs, increasing the risk of lung collapse.
  • Pneumothorax: commonly known as collapsed lung, this occurs when air leaks out of a lung and builds up in the space around it. This prevents the lung from expanding, thus causing it to collapse.
  • Pulmonary alveolar proteinosis (PAP): a rare disorder in which a type of protein builds up inside the alveoli (air sacs) within the lungs, preventing them from absorbing adequate oxygen.
  • Pulmonary (lung) nodules: small round or oval-shaped growths that occur, for many different reasons, in the lungs. Although most are benign (non-cancerous), it is important to have them evaluated because some may be an early sign of cancer.
  • Sarcoidosis: an inflammatory disease that can affect many organs including the lungs.
  • Tracheal stenosis: occurs when the trachea (main windpipe) begins to narrow and restrict breathing.

Diagnostic procedures

Bronchoscopy

Bronchoscopy allows doctors to see inside the airway using a small tube, called a bronchoscope, which is fitted with a tiny camera. During flexible bronchoscopy, doctors use a long, flexible, lighted tube to examine the airways and collect small tissue samples. During rigid bronchoscopy, which requires general anesthesia, a straight metal tube is used to look at the airways, remove objects blocking the airway or collect large tissue samples.

Endobronchial ultrasound (EBUS)

Endobronchial ultrasound (EBUS) is a highly effective tool used to diagnose a variety of disorders that affect the chest, including infections, inflammatory diseases, lung cancer, lymphoma and other cancers that have spread to the chest. In fact, EBUS has helped revolutionize the ways in which lung cancer is diagnosed — and subsequently treated.

When lung cancer spreads, it may involve lymph nodes in a portion of the chest called the mediastinum. Previously, patients would often undergo two separate procedures to diagnose and then stage their lung cancer (determining the stage of the disease is a very important step, because it dictates how a patient will be treated). In most cases, EBUS allows physicians to diagnose and stage their disease all in one procedure. This expedites their care and eliminates the need for more invasive and risky diagnostic procedures to stage their disease.

And as the field of cancer care continues to evolve, with targeted new ways of treating lung cancer at the genetic level, EBUS is quickly becoming the tool of choice for doctors who need to determine the genetic make-up of a tumor. That's because EBUS is a safe and effective method for collecting numerous tissue samples from the lungs or lymph nodes, all at one time.

Electromagnetic navigation bronchoscopy (ENB)

Electromagnetic navigation bronchoscopy (ENB) uses specialized software — similar to a global positioning (GPS) system found in many vehicles or smart phones — that helps doctors first identify the location of a lung mass, and then guide a bronchoscope to that location so a tissue sample can be taken.

Ultrasound-guided biopsy

As the name implies, ultrasound-guided biopsy uses ultrasound technology to help physicians take tissue samples from the lungs or fluid samples from either the pleural cavity or lymph nodes.

Medical thoracoscopy (available soon)

Medical thoracoscopy allows doctors to examine the pleura, which is the large, thin sheet of tissue that wraps around the outside of the lungs and lines the inside of the chest cavity. The procedure is used to diagnose the cause of pleural thickening or fluid build-up around the lungs (a condition known as pleural effusion), and to obtain pleural biopsies.

Closed pleural biopsy

Closed pleural biopsy, also known as pleural needle biopsy, allows doctors to remove a small piece of pleural tissue from the chest using a hollow needle injected through the skin and into the chest cavity. Despite being minimally invasive, it provides a larger sample of tissue than other biopsy techniques.

Therapeutic pulmonary treatment procedures

Bronchoscopy

Bronchoscopy allows doctors to see inside the airway using a small tube, called a bronchoscope, which is fitted with a tiny camera. During flexible bronchoscopy, doctors use a long, flexible, lighted tube to examine the airways and collect small tissue samples. During rigid bronchoscopy, which requires general anesthesia, a straight metal tube is used to look at the airways, remove objects blocking the airway or collect large tissue samples.

Tracheobronchial (airway) stenting

Tracheobronchial (airway) stenting allows physicians to temporarily or permanently prop open an airway that has become narrowed due to cancer, infection or other diseases. Small devices called stents are customized to the patient's airway and placed inside by specially trained pulmonologists during bronchoscopy.

Fiducial marker placement

During fiducial marker placement, doctors may use special guidance software, such as electromagnetic navigation bronchoscopy, to place tiny metal markers (called fiducial markers) in or near a tumor. These markers allow radiation oncologists to more precisely target radiation, so it destroys the tumor while preserving the surrounding healthy tissue.

Balloon dilation

Balloon dilation is used to help widen an airway that has become narrowed. During the procedure, a tiny balloon is threaded into the airway via flexible or rigid bronchoscopy. Pressure from the balloon, once inflated, helps expand the narrowed airway. Balloon dilation is sometimes used in combination with airway stent placement.

Bronchial Thermoplasty (BT)

Bronchial Thermoplasty (BT), A novel therapy in which radiofrequency energy is used to decrease bronchoconstriction by a reduction in airway smooth muscle. Current clinical evidence suggests that bronchial thermoplasty may be effective in reducing asthma exacerbations and improving asthma symptoms.

Endobronchial radiation therapy

Endobronchial radiation therapy, also known as brachytherapy, is a type of high-dose radiation therapy used to treat cancer in the trachea and lungs. During the procedure, a catheter is placed via bronchoscopy and then tiny radiation seeds are placed directly into the catheter. This type of targeted treatment helps destroy the tumor while preserving the surrounding healthy tissue.

Argon plasma coagulation (APC)

Electrocautery and argon plasma coagulation (APC) are procedures that use heat to burn and remove diseased, damaged or bleeding tissue from the airway. During electrocautery, a small amount of electricity is applied to the damaged tissue via a flexible or rigid bronchoscope. During APC, argon gas is ignited to produce a plasma beam, which burns away the damaged tissue.

Large volume pulmonary lavage (whole lung lavage)

Large volume pulmonary lavage, or whole lung lavage, is reserved for patients who have a condition called pulmonary alveolar proteinosis (PAP), which causes a type of protein to build up inside the lungs. During the procedure, several liters of saline fluid are pumped into the lungs and then eventually suctioned out. This process helps flush away the excess proteins that make it difficult for the lungs to absorb oxygen.

Nd:YAG laser treatment

A specific type of laser treatment utilizing the Nd:YAG laser is used to treat cancers, abnormal tissue growth or bleeding within the airway. This specific type of laser, comprised of neodymium, yttrium, aluminum and garnet, is often used to treat airway diseases.

Percutaneous tracheostomy

Percutaneous tracheostomy is a minimally invasive procedure that provides physicians access to the trachea via a small incision in the neck. Doctors often perform tracheostomies in patients with chronic neuromuscular weakness in order to remove secretions from the trachea, or to assist with mechanical ventilation. This procedure is also commonly performed in the intensive care unit when a patient has required prolonged mechanical ventilation.

Photodynamic therapy (available soon)

Photodynamic therapy is a unique form of airway cancer treatment that combines a drug, called Photophrin, with laser light energy. After Photophrin has been injected intravenously, the tumor begins to absorb the medication. Two to three days later, laser light energy applied to the airway "activates" the medication. This chemical interaction between the drug and the laser destroys the tumor cells.

Rigid bronchoscopy

Rigid bronchoscopy, which can only be performed by doctors with advanced training, provides access to the airway via a straight metal tube. Because the tube is rigid, with a larger diameter than a flexible bronchoscope, other devices can be threaded through the tube — allowing a physician better access to remove tumors or foreign objects blocking the airway, to treat tracheal stenosis using stents or other devices and to stop internal bleeding within the airway.

Transtracheal oxygen therapy

Compared to traditional methods of oxygen therapy, which deliver oxygen through a special device fitted into the nose, transtracheal oxygen therapy is a more efficient (and often more comfortable) way of providing oxygen to patients with COPD and other chronic lung conditions. Scripps interventional pulmonologists can place a small, thin tube called a catheter in the trachea, allowing oxygen to skip the "dead space" in the mouth and upper airways and pass directly into the trachea. This helps reduce the overall volume of oxygen needed during rest and exercise.

Thoracentesis

Thoracentesis removes excess fluid from the pleural cavity (the space between the lungs and the chest wall), alleviating symptoms such as shortness of breath or discomfort caused by the presence of the fluid.

Tunneled or indwelling pleural catheters

Tunneled or indwelling pleural catheters are used to treat patients who have chronic fluid build-up in their pleural cavity or pleural effusion. Patients who elect to have a catheter placed in their chest can drain the fluid themselves in the comfort of their home — reducing or eliminating the need for frequent trips to their doctor's office.

Medical thoracoscopy (available soon)

In addition to helping doctors examine the pleura and diagnose pleural diseases, medical thoracoscopy can be used to apply medication that helps prevent further pleural fluid build-up (a procedure called pleurodesis).

Our interventional pulmonologists are also actively engaged in clinical research that allows them to continue providing our patients the latest, evidence-based care – even before it's available at other top medical institutions.


Page reviewed on: Oct 23, 2017

Page reviewed by: Farhad Mazdisnian, MD

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