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How I flexible bronchoscopy with use of laser therapy to relieve stenosis

How I flexible bronchoscopy with use of laser therapy to relieve stenosis

The CPT code 31641 can be used for flexible bronchoscopy that uses laser,flexible bronchoscopy with use of laser therapy to relieve stenosis INTRODUCTIONBronchoscopic laser therapy is a thermally-ablative technique. It has cutting and coagulant properties which make it a useful tool to treat symptoms associated with airway disease. Its indications, efficacy, contraindications, equipment, and technique are reviewed here. Other bronchoscopic techniques used to manage airway obstruction are described separately. (See “Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults” and “Endobronchial electrocautery” and “Endobronchial photodynamic therapy in the management of airway disease in adults” and “Bronchoscopic argon plasma coagulation in the management of airway disease in adults” and “Airway stents” and “Flexible bronchoscopy balloon dilation” and “Endobronchial brachytherapy” and “Bronchoscopic cryotechniques in adults”.)Management of central airway obstruction is an essential skill for an Interventional Pulmonologist (IP). Thirty percent of lung cancers patients developed central airway involvement during the course of their illness leading to bleeding, post-obstructive pneumonia or respiratory distress (1). Endobronchial therapy of the malignant airway obstruction is considered as a palliative measure or a bridge therapy to the definite treatment of cancer. Several ablative therapies including electrocautery, argon plasma coagulation (APC), cryotherapy and laser photoresection exist in the armamentarium of IP to tackle such presentations. This chapter focuses on the historical perspective, current status, and potentials of lasers in the management of central airway lesions.

flexible bronchoscopy with use of laser therapy to relieve stenosis History and historical perspective

Therapeutic applications of the Light Amplification by Stimulated Emission of Radiation (LASER) have been recognized since 1960. The CO2 was the first laser that was introduced to the field of medicine. Dr. Patel was the first ever to use CO2 lasers in medicine during early 60s. In 1967, Jako et al., were first to use CO2 laser on a cadaveric larynx. It was also the first laser used in the endobronchial tree. However, CO2 laser has several disadvantages, such as a long wavelength of 10,600 nm requiring a rigid delivery system and suboptimal hemostasis due to its shallow depth of penetration. Peter Kiefhaber was first to successfully perform endoscopic argon laser photocoagulation for gastrointestinal bleeding in humans . Similar to the CO2 laser however, Argon laser also has shallow depth of penetration and is too weak to produce tissue vaporization. Thus, it has limited ability to stop bleeding from large-bore vessels and its role remains limited to ophthalmology.

Subsequently, Neodymium-Yttrium, Aluminum, Garnet (Nd:YAG) laser was introduced by Geusic et al. at Bell laboratories in 1964. Peter Kiefhaber is considered as a pioneer of using Nd:YAG laser in Medicine. He used Nd:YAG laser photocoagulation to control gastrointestinal bleeding . In terms of the laser application in the airways, Toty et al. was first to report treatment of tracheobronchial lesions using Nd:YAG laser at hospital Foch, Lille, France. In 1983, Jean-Francois Dumon, also from France expanded the utility of Nd:YAG laser as the preferred modality for palliation for obstructing malignant lesions of the airways. Its instant popularity was based on the fact that the laser light could be delivered to the distal airways using flexible quarts filaments because of its shorter wave length (1,064 nm) . This property of the laser light also made its use possible through a flexible bronchoscope. In subsequent years Nd:YAG laser was also used to treat benign lesions obstructing the large airways. Since that time onwards laser photoresection has become a standard treatment in the management of central airway obstruction.

flexible bronchoscopy with use of laser therapy to relieve stenosis INDICATIONS AND EFFICACY

In general, bronchoscopic laser therapy is an immediate-acting, palliative, or adjunctive therapy used to relieve central airway obstruction (CAO; trachea and main stem bronchi) due to malignant or benign conditions. Ideal lesions are intraluminal and short (ie, <4 cm) such that the region beyond the obstruction can be visualized and the distal lung is functional. It is not suitable for lesions causing CAO from extrinsic compression or distal lesions (ie, beyond the mainstem bronchus). Lesions that extend a long distance in the trachea or mainstem bronchus are generally not suitable for laser debulking but laser may be used to photocoagulate and devascularize tumor tissues prior to mechanical debulking. Less commonly, it is used to treat hemoptysis, and rarely, it is used to treat inoperable radiographic occult lung cancer that is limited to the airway.

The approach to and choice of modality used to treat patients with central airway obstruction as well as a comparison between the locally ablative bronchoscopic techniques are discussed separately. (See “Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults”.)

flexible bronchoscopy with use of laser therapy to relieve stenosis Malignant central airway obstruction

Patient or tumor characteristics — CAO from bronchogenic carcinoma is the most common indication for laser resection . In general, it is a palliative therapy used in patients for whom other first-line treatment modalities are not feasible (eg, surgery or radiation therapy), and/or in patients who require immediate relief from serious life-threatening obstruction. Occasionally, it is used adjunctively before salvage chemotherapy, radiation (eg, external beam radiation or brachytherapy), or surgical resection. Ideal lesions that are suited to laser resection are short tumors (ie, <4 cm) with a significant intraluminal component with or without concomitant bleeding. Its effects are not generally long lasting such that it is either combined with other bronchoscopic therapies (eg, electrocautery, cryotherapy, stenting, dilation, and brachytherapy) or repeated (usually for palliative purposes). (See “Endobronchial electrocautery” and “Airway stents” and “Flexible bronchoscopy balloon dilation” and “Endobronchial brachytherapy” and “Clinical presentation, diagnostic evaluation, and management of central airway obstruction in adults” and “Bronchoscopic cryotechniques in adults”.)Non-small cell lung cancer (NSCLC), particularly squamous cell carcinoma, is the most common malignancy subjected to laser resection. However, case reports of successful management of other types of malignancy have been described including carcinoid, cystic carcinoma, mucoepidermoid carcinoma, and endobronchial metastases from melanoma, colon, kidney, and breast cancer.

flexible bronchoscopy with use of laser therapy to relieve stenosis Technical aspect of lasers

Laser light emission is created by application of a stimulus to the lasing medium. The stimulus that can excite the medium can be any form of energy such as an electrical current or even another laser. The excited electrons of the medium attain a higher level of energy and emit a photon beam as they fall back to the ground energy level. These photons beams are reflected back and forth within the medium by the mirrors placed at the either end, exciting more and more electrons and creating a more powerful light source. Making one of the mirrors partially refractive a fraction of the light is allowed to escape in form of a laser beam.

The laser light thus created has three distinct properties:

Monochromaticity: all the photons of the laser light have a single wavelength;
Coherence: laser light waves travel in parallel phase in relation to space and time;
Collimation: laser light travels in the same direction and with a very narrow beam of divergence allowing persistence of energy over a long distance.
The selection of an appropriate laser for its medical application requires an understanding of laser-tissue interaction. Once the laser light is applied to the tissue it could go either through reflection, absorption, scattering or transmission.Reflection is when the radiation is returned back by the tissue surface;
Absorption is the transfer of the photon energy to the molecules within the tissue that is to be altered. Absorption of the laser light depends on the wavelength of the beam and the color of the tissue. In general darker tissue absorbs more laser light than the paler one. This is especially true for the Nd:YAG laser;
Scattering occurs when radiation is dispersed in different directions within the tissue without causing desired tissue effect;
Transmission is the passage of the radiation through the medium without scattering and causing reduced tissue effect. It is governed by the law of inverse absorption; paler the tissue, the greater is the depth of penetration.
The tissue effect of laser also depends on the power and the duration of exposure. This tissue interaction may lead to either thermal, photochemical or electrodynamic effects of the laser beam.
The thermal effect of the laser beam is based on the principles of molecular agitation. Presently, it is the thermal effect of the Nd:YAG that is most commonly used in interventional pulmonology. The laser medium is neodymium, a pinked-colored rare earth, doped into crystal structure of an yttrium, aluminum and garnet. The wavelength of YAG is 1,064 nm. Interestingly, laser light of this wave length is poorly absorbed by both, the water and the hemoglobin contents of the tissue allowing it penetrate deeply (up to 15 mm), affecting larger area of the tissue creating most appropriate power density for effective coagulation . However, occasionally the depth of penetration is difficult to predict. Hence the laser beam is always fired in the direction of the visible lumen. The Nd:YAG laser wavelength is not visible to human eyes. Thus, a laser light of a visible wavelength is added for the operator to visualize laser beam. Nd:YAG laser is a powerful laser and could produce over 100 Watts. However the devise is relatively bulky, inefficient and expensive.Potassium titanyl phosphate (KTP) laser emits green light at 532 nm. The wavelength which exactly half of the Nd:YAG laser obtained by placing KTP crystal in the path of the laser beam. This double the frequency of the light while halving its wavelength and bringing it in to the visible to the visible green spectrum. In comparison to Nd:YAG, KTP laser light has less depth of penetration and less coagulative property. Thus, it plays an important role in the management of tracheal hemangiomas and tracheoesophageal fistula in pediatric population and in urological procedures. It is rarely used in adult with large bulky endobronchial lesions where significant debulking is required.
Neodymium: Yttrium-Aluminum-Perovskite (Nd:YAP) laser: in recent years, a more efficient and portable form of thermal laser has been introduced to the medical arena. Nd:YAP laser emits light at 1,340 nm. It has an absorption coefficient in water of 20 times more than Nd:YAG. Theoretically, Nd:YAP has slightly higher wavelength which may provide better coagulation and devascularization than Nd:YAG. In a retrospective review, the use of Nd:YAP laser can effectively restore airway patency without major complications .

In this study, the most common laser power setting was 20 W/30 Hz.
Homium: Neodymium-Yttrium, Aluminum, Garnet (Ho:YAG) laser: the Ho:YAG operates at the wavelength of 2,100 nm and is absorbed by water approximately 100 times more than Nd:YAG laser. Thus, Ho:YAG laser cuts through the tissue and limits thermal necrosis to the nearby tissue in a similar manner to CO2 laser. Interestingly, Ho:YAG maintains coagulative property similar to Nd:YAG laser. This laser has been used in both malignant and benign endobronchial conditions with minimal postoperative morbidity and mortality . Ho:YAG laser fiber can be placed several millimeters from target tissues for rapid vaporization. Alternatively, the laser fiber can be inserted into target tissue. The laser fiber emits photons which are trapped into tissue, providing coagulative effect. In addition to its application in Interventional bronchoscopy, Ho:YAG is widely used for lithotripsy in urologic procedure.
Diode laser has been reported to be used in bronchoscopic procedure. Diode laser has operational wavelength at 808 nm. Tissue absorption of Diode laser is greater than Nd:YAG, the coagulation effect is similar to argon laser, and the cutting effect is comparable to CO2 laser.

flexible bronchoscopy with use of laser therapy to relieve stenosis Present status

It needs to be pointed out that in recent years the armamentarium of the IP has expanded with addition of electro-cautery, APC, cryotherapy, microdebrider, brachytherapy as well as stent placement. Most patients are managed in a multimodality fashion for the optimal outcome. In this regard advantages or disadvantages of a specific modality remain difficult to evaluate. This is further compounded by the fact that selection of a specific modality remains operator and institution specific. In absence of well controlled randomized trails even in 2015, experts’ opinion continues to guide the therapeutic approaches.We believe that the use of laser photoresection in the management of central airway obstruction is at its peak at present. It has maintained its status with the increasing popularity of the subspecialty of interventional pulmonology. However it is likely that, at least in the developed world, number of patients presenting with large endobronchial lesion will decline in the future. Increasing reliance on the CT scan of the chest and lung cancer screening programs will lead to earlier detection of lung cancer as well as central airway lesions before they become symptomatic. Widespread use of flexible bronchoscopy also will help in early detection of airway lesions before they become critical requiring emergent intervention. It is not too optimistic to accept that reducing popularity of smoking will also reduce in the incidences of lung cancer curtailing the need for laser photoresection.Additionally, recent advancement in personalized treatment for lung cancer using tyrosin kinase inhibitors and monoclonal antibodies is likely to improve the welfare of lung transplant patients by reducing the need for invasive palliative procedures.Intuitively, as the cost of healthcare continues to escalate future of palliative modalities may heavily depend upon the cost effectiveness of the procedure. In this regard use of reusable tools such as endobronchial electrocautery might be favored over expensive disposable accessories.While the incidence of lung cancer, benefits of lung cancer screening trials and advances in personalized treatment readjust, the skill of invasive palliative modalities will mainly concentrate at the centers of excellences. But until then, thermal ablative therapy with laser will remain an important tool in the armamentarium of every IP.Laser photoresection of central airway obstruction is a useful tool in the hands of an experience operator. It is considered as an adjunct to other endobronchial therapeutic modalities. Nd:YAG laser is the most commonly used laser for this indication. In absence of randomized control trials experts’ opining continue to guide its selection and application. “Ten commandments” established by Dr. Dumon are the beacon of light for the IP to attain optimal outcome form the laser photoresection.


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