Melanie Cole (Host): Medical Thoracoscopy offers Pulmonologists an invaluable tool for understanding and treating pleural diseases. My guest today is Dr. Hitesh Batra. He’s the Director of Interventional Pulmonology and Pleural Diseases Program at UAB Medicine. Welcome to the show, Dr. Batra. Tell us a little bit about the history of Interventional Pulmonology.

Dr. Hitesh Batra (Guest): Thank you, Melanie. Interventional Pulmonology has been around for decades, and as Interventional Pulmonologists, we deal with advanced diagnostic bronchoscopy, complex airway disease, and pleural diseases. The formalization of Interventional Pulmonology Programs has really happened over the past couple of decades with the first few fellowship programs that started in Massachusetts at Lahey Clinic and Beth Israel Deaconess Medical Center. Over the past 15 years or so, several other fellowship programs have started as well, and we now have over 20 programs in the country. At UAB, we recently started our Interventional Pulmonology program in August 2016.

Melanie: Are all Pulmonologists skilled in Interventional Techniques?

Dr. Batra: Most Pulmonologists do get training in bronchoscopy during their training, but in today’s day and age, interventional procedures such as advanced diagnostic bronchoscopy, which includes endobronchial ultrasound and interventional bronchoscopy. Other procedures that deal with complex airway diseases, such as rigid bronchoscopy use thermal techniques, such as a laser, airway stenting and advanced oral procedures, such as medical bronchoscopy, all of those procedures that I just mentioned are not the usual part of training for a General Pulmonary/Critical Care Fellowship.

Melanie: So what are some indications for a medical thoracoscopy or a pleuroscopy? What would send somebody to see you?

Dr. Batra: The most common reason we do medical thoracoscopy is an evaluation for a suspected malignant effusion. Other indications are undiagnosed pleural effusions and staging of cancer -- sometimes we already know a patient has lung cancer or breast cancer for example, but we need to do medical thoracoscopy just to get more tissue, for targeted therapy. Those are the diagnostic indications. There are a couple of therapeutic indications too for medical thoracoscopy, and sometimes medical thoracoscopy is also used for early empyema.

Melanie: Is it also used in the management of pleural effusions?

Dr. Batra: Yes, like I was saying, the therapeutic part of medical thoracoscopy is achieving pleurodesis. We also most commonly do that using talc, but some centers also use some other agents such as doxycycline, which can achieve --.

Melanie: What are some of the complications of the procedure, and the breathing and the movement of the lungs, explain to other physicians what complications they should be aware of when performing this procedure.

Dr. Batra: Right, so there are complications to this procedure like any other procedure, but generally, it is pretty well-tolerated, and the risk of complications is low. Medical thoracoscopy -- as opposed to VATS, which is Video-Assisted Thoracoscopic Surgery -- in contrast to that, medical thoracoscopy is done under conscious sedation and local anesthesia, so our patients are awake and easily arousable and can talk to us during the procedure. The complications that can happen are one, hypoxemia during the procedure. Re-expansion pulmonary edema can certainly happen. You can also get bleeding during the procedure. These are complications during the procedure. Of course, afterward we can have re-expansion pulmonary edema, we can get infections, and those are the common complications that can happen. Again, the chance of these is low. Death due to medical thoracoscopy or having serious complications is extremely rare.

Melanie: And the patient is not intubated, correct? Explain a little more about the difference between a thoracoscopy and a Video-Assisted Thoracic Surgery.

Dr. Batra: Right, yes, you’re correct. When we do medical thoracoscopy, we do it in our bronchoscopy suite, and the patients are not intubated, they are under conscious sedation. Conscious sedation means that the patients are either awake or easily arousable. Typically we use a small dose of medications such as medalozam or fentanyl, and we use local anesthesia during this procedure, so yes, the patients are awake. The fact that the patient is not intubated and compared to VATS where patients often get intubated and often get double-lumen tubes, which can allow the collapse of one lung that does make the examination of the pleural space a little bit easier in the case of thoracic surgery. With VATS, the surgeon can also do a lot more things than we are capable of doing with medical thoracoscopy such as doing lung biopsies, or lymph node dissection and so on and so forth. Having said that, with medical thoracoscopy, we are able to do pleural biopsies; we can inspect the pleural space, we can achieve pleurodesis. Most importantly, the patients don’t have to undergo general anesthesia. It’s a pretty straightforward procedure. It can potentially be done in an outpatient setting -- we don’t need an Anesthesiologist with us in the room. It is really great for cost saving as well.

Melanie: What would you like patients to know about searching for a physician performing these types of procedures?

Dr. Batra: For most centers, medical thoracoscopy is performed by Interventional Pulmonologists. That is one way to look for somebody who performs medical thoracoscopy is to look for an Interventional Pulmonology Program that are in your area.

Melanie: And Dr. Batra, what would you like to tell other physicians about performing this procedure?

Dr. Batra: One good thing about medical thoracoscopy is that it is very easy to learn. It is easier than learning flexible bronchoscopy. Having said that, there is a learning curve to this procedure, and of course, it’s hard to put a fixed number on any procedure to guarantee competence. It is generally recommended that one should do at least 20 procedures under the supervision of a trained Thoracoscopist before adequate competence in this procedure can be achieved. Beyond that, doing beyond 10 to 12 procedures a year is usually adequate to maintain competency. When a procedure – when a physician is evaluating a patient for medical thoracoscopy of course it’s really important to get a really good history and physical, carefully review their imaging, carefully think about the etiology of the diagnosis, management of pleural effusions – what I’m trying to get at is we all need to aspire to be more than just an expert with instruments in the pleural space, we need to always keep in mind the big picture of why we’re doing something.

Melanie: And how can a community physician refer a patient to UAB Medicine?

Dr. Batra: The best way to refer a patient to us is through the MIST Line is 1-800-UAB-MIST.

Melanie: And tell us about your team, Dr. Batra. Why is UAB so great to work with?

Dr. Batra: For one, we are proud that we are the only Interventional Pulmonology Program in the whole state of Alabama. We are able to handle all the broad range of pulmonary and pleural diseases including central airway obstruction, evaluation of nodules, mediastinoscopy, suspected, or progressed malignant effusions, and undiagnosed effusions. We have all of the equipment that any Interventional Pulmonology Program needs. We really have a very experienced team of physicians here including – and of course, I’m here -- but my colleague Dr. Thachuthara-George, he trained at the Interventional Oncology Program at Memorial Sloan-Kettering in New York. We have Dr. Mark Dransfield -- a lot of experience in COPD and lung cancer and advanced bronchoscopic techniques. We have Dr. Veena Antony here who is a Professor in the Division, and she has extensive experience in pleural effusions. Then we have Dr. Belopolsky and Dr. Trevor who has a special interest in interventional techniques for asthma, such as bronchial thermoplasty, but most importantly we also have really great relationships with our Thoracic Surgeons and with our Oncologists, and Radiation Oncologists and also our Hematologist. What we do here at UAB is a truly multidisciplinary approach to treating these diseases.

Melanie: Thank you, so much, for being with us today. You’re listening to UAB Medcast, and for more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician. This is Melanie Cole. Thanks, so much, for listening.