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Thoracic Interventions

Juan M. Olazagasti, MD ERS - Spring 2013 UVA Health System. Thoracic Interventions. No finanacial disclosures. That is why I will keep working until I die. Objectives :. Procedure basics and things to remember Cases that have taught and challenged me New trends in thoracic interventions

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Thoracic Interventions

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  1. Juan M. Olazagasti, MD ERS - Spring 2013 UVA Health System Thoracic Interventions

  2. No finanacial disclosures

  3. That is why I will keep working until I die..

  4. Objectives: • Procedure basics and things to remember • Cases that have taught and challenged me • New trends in thoracic interventions • Thoracic: US why now?

  5. Case 1: Abnormal CXR, Leukocytosis

  6. The thrill of victory

  7. Case #2:Please place drain in LUQ fluid collection

  8. Success!

  9. Same day and 2 days later with new fever..Free empyema

  10. And the agony of defeat..

  11. Inferior border of pleura

  12. BSA motto: always do your best • Would you please biopsy this 4mm nodule?

  13. BSA motto: always do your best • Is the procedure indicated? • Is it going to benefit the patient? • Do benefits outweigh risks?

  14. Approach and planning • Best approach is not necessarily the easiest • Play to your strengths • Be aware of immediate and delayed complications

  15. 85 year old gentleman with SCCA of the neck

  16. Approach and planning • Plan ahead: • Coagulation factors, team’s experience, patient’s ability to cooperate • IS A TEAMEFFORT: • Nurse, tech, trainee, faculty AND patient • Knowledgeable tech, a good nurse and a cooperative patient go a LONG way

  17. Dr. Ravenell looking for pluff mud while in San Antonio

  18. 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 beforeyou start • Rehearse (beforehand) what is going to happen once the procedure starts

  19. Post right thoracotomy, clinically deteriorating with fluid collection on recent CT

  20. Checklist: • Indicated? • Informed consent • Approach • Sedation? • Catheter size • Possible complications

  21. Cake walk..

  22. Nurse and tech say, “there is a lot of air coming out into the Pleura VAC”

  23. Trapped lung

  24. 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

  25. SMOKER WITH INCREASING SIZE OF PULMONARY NODULE POOR SURGICAL CANDIDATE. NEED TISSUE DIAGNOSIS WITH MARKERS FOR TREATMENT GUIDANCE

  26. Planning scan

  27. Giving local anesthesia..

  28. Assess situation • If pt. is stable, proceed with biopsy or.. • Evacuate ptx. , then do procedure

  29. LESSON: don’t let the resident give local anesthesia

  30. 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

  31. http://www.youtube.com/watch?v=GS2jaqDzkJs http://www.youtube.com/watch?v=DQBkMtukCPw

  32. A few cool things we do.. • Radionuclide nodule localization • US guided thoracic procedures

  33. 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

  34. 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

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