Interventional Pulmonology

Over the last decade, advancements in technology in pulmonary (lung) care have created a shift away from diagnostic thoracic surgery toward the ever-growing specialty of interventional pulmonology (IP).

Interventional pulmonologists are trained to perform advanced diagnostic and therapeutic bronchoscopy and pleura (thin membrane that lines the lungs and chest cavity) procedures. IP physicians have at least an extra year of training beyond what’s required for the general pulmonary and critical care specialists, allowing them to perform these new procedures with fewer complications and better-overall outcomes. Many of the diagnostic procedures performed by these experts are minimally invasive, helping patients recover more quickly.

Justin Thomas, MD, brought his passion for IP to Eisenhower Health in 2013 and has since grown his department, bringing the latest techniques and technology to the Coachella Valley. Read on to learn about the recent developments and procedures on the forefront of the specialty that have saved the lives of many local residents.

The panel includes:

• Justin Thomas, MD, Board Certified in Interventional Pulmonology, Pulmonary Disease, Critical Care Medicine and Internal Medicine. He earned his medical degree from the University of Colorado Health Sciences Center, completed Internal Medicine training at the Mayo Clinic in Rochester, Minnesota, and a Pulmonary and Critical Care fellowship at the University of Pittsburgh, Pennsylvania. He then completed an advanced fellowship training in Interventional Pulmonology at National Jewish Health in Denver, Colorado, and is among the first in the nation to be board certified in this subspecialty.
   
• Sevwandi De Silva, MD, Board Certified in Interventional Pulmonology, Pulmonary Disease, Critical Care Medicine and Internal Medicine,began her medical career through her residency with the Eisenhower Health Internal Medicine Residency Program in 2017. She then completed a Pulmonary and Critical Care fellowship at Loma Linda University and went on to complete an Interventional Pulmonary fellowship at the University of California, San Francisco Medical Center at Mount Zion before returning to Eisenhower in September 2024 to practice IP.
   
• Anil Perumbeti, MD, Board Certified in Internal Medicine, Pulmonary Disease and Critical Care Medicine, moderated the discussion. Dr. Perumbeti earned his medical degree from Northeastern Ohio Medical University, and then completed residency and fellowship programs at the University of Southern California Medical Center[WB1] .

Dr. Perumbeti: Thank you Dr. Thomas and Dr. De Silva for joining our roundtable. Let’s start with how you chose interventional pulmonology and what led you to Eisenhower Health.

Dr. De Silva: Actually, Dr. Thomas and you, Dr. Perumbeti, are both why I pursued pulmonology. I was excited when I saw your work during my residency at Eisenhower. I saw all the cool procedures that Dr. Thomas was doing, and then I decided I wanted to focus on interventional pulmonology.

Dr. Thomas: I became interested in Interventional Pulmonology during my residency at Mayo Clinic, working with pioneers like Dr. Udaya Prakash and Dr. Eric Edell. I was drawn to how IP offers immediate relief to patients with lung disease. At the time, there were only about 12 IP fellowships nationwide -now there are around 50. The field is gaining popularity. I graduated the same year the first IP board exam launched, which I helped write and also took. When I joined Eisenhower in 2013, I had the privilege of building the IP program from the ground up.

Dr. Perumbeti: What is a bronchoscopy?

Dr. De Silva: A traditional bronchoscopy is a procedure in which a thin, flexible tube with a camera is inserted through the mouth or nose. Through this, we can take biopsies and cultures. The standard bronchoscope’s diameter limits how far you can go out into the lungs, whereas the robotic bronchoscope is very tiny and gives us the ability to get to the periphery of the lungs. Wherever that nodule is, we can get there and biopsy, which we couldn’t do with a regular-size tube.

Dr. Thomas: Bronchoscopy began with Gustav Killian (in 1876), an ENT who used a rigid scope to remove a pork bone from a patient’s airway - while the patient was awake and seated. For years, the main purpose was removing foreign objects. In the early 1900s, improvements in scopes and lighting emerged. Then in the 1960s, Dr. Shigeto Ikeda developed the first flexible bronchoscope, revolutionizing the field. Since then, scopes have become smaller, more advanced, and now include high-definition video, specialized imaging and robotic technology.

Dr. Perumbeti: Dr. De Silva, what is the difference between a robotic bronchoscopy and a traditional flexible bronchoscopy?

Dr. De Silva: Traditional bronchoscopy uses a larger scope, about 5 to 7 millimeters, but we can only go so far. Our airways get smaller and smaller as we travel farther into our lungs. Our trachea is about 12 millimeters, but by the time you get out to about three to four branches, or generations, into the lungs, the airways narrow down to about 4 millimeters or even less. The catheter in robotic bronchoscopy is about 3 millimeters, giving us the ability to drive the catheter out to eight or nine generations of airways - all the way to the edge of the lung to access a peripheral pulmonary nodule.

Dr. Perumbeti: How does the computer system help physicians navigate the end of the scope farther than what may be seen by sight?

Dr. De Silva: It’s shape-sensing technology. The patient gets a CT scan of the chest and we upload it to the Ion™ robot. Then, the robot technology does 3D reconstruction of the lung. Somewhat like Google maps, we mark the target and the robot technology will show us a pathway to get to that spot, which we can follow as we drive out to the lesion.

Dr. Perumbeti: Even though you can’’t see it, how small of a target can you reach?

Dr. Thomas: I’’ve biopsied nodules as small as 4 millimeters, or a 1/4 inch. It’’s incredible technology and it’’s down to the millimeter as far as precision with the newer scopes. The robotic scope, as opposed to a standard bronchoscope, is stable and when we park it in a spot, it stays there and won’’t move. There are about a thousand different points of reference on the scope so that it knows exactly where it is in space in relation to where the nodule and the patient’s airways are based on the CT scan that was done just prior to the procedure. So, if the scope moves, it knows exactly how far it moved away from its previous position. This technology was developed by NASA and it’’s incredibly precise.

The robot also integrates with a cone beam CT unit, which essentially is a mobile CT scanner that we place around the patient during the procedure and can update the target position in real time. Because the CT that was done on the patient prior to the procedure is performed with the patient taking a deep breath in and holding it, the airways and nodule/mass can be a bit off in position when the patient is under general anesthesia and taking much smaller breaths. So not only does the shape-sensing technology eliminate this CT-to-body divergence, but the ability to do a cone beam CT and integrate that data with the system allows for incredible precision - down to the millimeter. This precision is important when trying to target a specific part of a nodule/mass or if that nodule is only 5 millimeters.

Unfortunately, most lung nodules are located in the periphery, beyond the airways. In only 5 to 10% of cases does the nodule bulge into or break through the airway, making it directly visible and easier to biopsy. Most require precise targeting since they’’re outside the airway, highlighting the importance of accurate scope positioning.

Dr. Perumbeti: How many institutions in Southern California have comparable technological capabilities?

Dr. Thomas: Roughly about 50; however, in 2019, Eisenhower Health was one of the first of about 15 hospital systems in the country to acquire a robotic bronchoscope, the Monarch™, which was FDA approved in 2018. The Ion robot was approved in 2019. The Monarch™ was different in that it’’s not shape sensing - it uses electromagnetic navigation (EMN). A field generator around the patient or next to the patient creates an electromagnetic field and three little positioning spots on the patient sync up to the device. The tip of the scope has a positioning sensor as well. After registering the airways, the robot knows relatively where it is in the airway and where that nodule should be. The problem with EMN is it doesn’’t take into account the CT-to-body divergence I spoke about earlier and there can be interference from metal around the device and the fluoroscope we use to see positioning of tools with an X-ray. In terms of accuracy, shape-sensing technology is a lot better.

Dr. Perumbeti: Before this technology was developed, were we not able to take biopsies of the nodules or were there other methods?

Dr. De Silva: There are other methods we used through interventional radiology. A transthoracic needle aspiration (TTNA) is performed by entering the lung from outside the body through the chest wall. Unfortunately, this technique carries more risks than a robotic bronchoscopy. With robotic bronchoscopy, we can find even the tiniest airway that leads to the nodule, eliminating the need to cut through any of the lung or chest. Whereas when you’’re coming from outside - let’’s say the nodule is 2 to 3 centimeters away from the pleura or edge of the lung - the radiologist has to stick a needle through a lot of lung tissue to get to the nodule.

Dr. Thomas: Unfortunately, this caries a high risk of pneumothorax, or lung collapse - about 20 to 40%. In addition, when the interventional radiologist collapses the lung, they are often not able to get enough tissue to make a diagnosis. Before robotic bronchoscopy, our previous methods were nowhere as accurate as TTNA, so TTNA was used more frequently. There are several recent journals that have published data showing robotic bronchoscopy is as accurate or even more accurate than TTNA and carries a significantly lower risk - only about 1% chance of lung collapse and lower risk of bleeding. When you have the expertise at your hospital like we do at Eisenhower, robotic bronchoscopy is the preferred method.

Dr. Perumbeti: In other words, the biopsy is of the same nodule with less risk. Are there any other advantages of doing the procedure bronchoscopically?

Dr. De Silva: Yes, especially if it’’s cancer. We can stage cancers at the same time as the biopsy. Traditionally, to diagnose lung cancer, there would be a referral to interventional radiology for a biopsy. Then, the patient may be referred to a pulmonologist to undergo another bronchoscopic procedure to sample lymph nodes in the chest to determine the stage of the patient’s cancer. If this is cancer, working bronchoscopically, we can do all of that at the same time under one anesthesia event - biopsy the mass and sample the lymph nodes. Also, as pulmonologists, when we go in and identify any inflammatory cells or findings that are not consistent with cancer, the pathologist can help confirm, and we can send additional biopsies for cultures to guide further workup as needed.

Dr. Thomas: Yes, as pulmonologists we know what to order for different types of cultures and how to follow up on malignant and non-malignant nodules. We’’re connected to oncologists, thoracic surgeons and radiation oncologists. Our patients are referred to them quickly with a phone call or secure messaging. Studies have shown that patients who are referred for a TTNA have a much longer and delayed process to treatment than patients who are referred directly to an interventional pulmonary group. 

Another advantage is that we can biopsy more than one nodule using the robotic scope, which cannot be done with TTNA.  I’’ve biopsied three to four different nodules in different lobes of the lung and found cancer in each one of them, and sometimes even different types of cancers. This is important for staging and treatment. One patient comes to mind fairly recently where a gentleman had an aggressive left upper lobe large cell neuroendocrine carcinoma, and a concurrent right middle lobe adenocarcinoma - a completely different kind of cancer. That was a case where a patient underwent a lung cancer screening CT and the testing caught the nodules.

Dr. Perumbeti: What’’s the advantage of a patient going through the Eisenhower Lung Cancer Screening Program? Why do patients need to know if they have lung nodules?

Dr. Thomas: The Eisenhower Lung Cancer Screening Program was created in 2022 for primary care physicians, cardiologists and other specialists to refer patients who may qualify. The clinic explains the process with the patient, orders the scan and follows up, expediting the patient’’s time to a diagnosis.

The traditional patient who qualifies for lung cancer screening is aged 50 to 80, has a 20-pack-a-year history of smoking (one pack a day for 20 years or half-a-pack a day for 40 years) and has quit in the last 15 years or is currently smoking. Patients may qualify for lung cancer screening with other risk factors, for example, family history or personal history of cancers. The lung cancer screening clinic helps alleviate the burden on primary care providers. If a nodule is found, we as pulmonologists determine what is the best next step and expedite those steps through our clinic.

Dr. Perumbeti: Are all nodules cancerous?

Dr. De Silva: No. That is our job as pulmonologists to risk stratify the nodules. We look at its structure, where it is and factors such as family history and/or smoking history. The lung cancer screening is important because the goal is to catch nodules at an earlier stage - Stage 1 or Stage 2 - when the nodules can be cured with surgery. After resection, patients have a higher risk of recurrent lung cancer, but they are designated as cured. At Stage 3 or Stage 4, that’’s where chemotherapy and radiation are introduced and cure is less likely. As pulmonologists, we look at the lung nodule and figure out if this is something that needs to be biopsied right away or if this is something that we can repeat a CAT scan in three months. Or, is this something we don’’t need to worry about at all?

Dr. Thomas: Another caveat is the specifics regarding patients. Were they a smoker or not a smoker? Was it caught incidentally? Was it caught as a lung cancer screening test? Patients who have a 9-millimeter nodule and do not smoke have only about a 3% chance of that nodule being lung cancer vs. a current smoker, who has 11%. We risk stratify patients based on their history, what the nodule looks like and where it is located. This helps us know when to biopsy the nodule vs. just watching for growth with serial CT scans. If the patient has a certain pretest probability of lung cancer, we can also use blood tests to help risk stratify.

Unfortunately, about 80% of lung cancers are diagnosed at a late stage because symptoms often don’t appear until then. A persistent cough might be the first sign - by then, it’s often Stage 3 or 4. That’s why lung cancer screening is so important: it catches cancer early - at Stage 1 - when patients are still asymptomatic.

Since Eisenhower Health acquired the new Ion robotic bronchoscope in February 2024, Dr. De Silva and I have seen a stage shift of lung cancer diagnoses. With the prior technology, I was diagnosing about 40% of lung cancers with Stage 1, which is good, considering the national average is about 20%; however, with the new technology, about 79% of patients [were diagnosing] are in Stage 1.

There are many high-risk patients with lung nodules in the Coachella Valley. I’ve been performing robotic bronchoscopy about two days a week since 2019. After transitioning to the Ion system, my case volume doubled - 350 cases in the first year - due to better access to small, hard-to-reach nodules. Our lung cancer screening program and increased CT imaging have also identified more nodules. Eisenhower was the first institution (in the valley? In the state?) to have three Ion systems and to run flip rooms for robotic bronchoscopy - running two bronchoscopy suits simultaneously and marking nodules for resection in the operating room, improving access and outcomes. Timely intervention matters: for Stage 1 lung cancer, each week of delay increases the risk of upstaging by up to 4%. So, getting patients answers quickly and off to treatment promptly is key to their overall survival.

Dr. Perumbeti: Could you speak about a patient who came in for lung cancer screening and was subsequently diagnosed and treated?

Dr. De Silva: I’’ve seen many Stage 1 lung cancers recently. One was about 6 millimeters in the left lower lobe and after the biopsy, diagnosed as Stage 1 lung cancer. In the span of three weeks, the patient moved from a biopsy to a lobectomy (surgery to remove one or more lobes of the lung) by Joseph Wilson, MD, FACS, Board Certified in Cardiothoracic Surgery and General Surgery. That is a great success story because Eisenhower Health physicians all worked together to move the patient forward through the steps for the best possible treatment plan.

Dr. Perumbeti: Something we as physicians don’t have the opportunity to speak about often is the rate of curing cancer. What is this patient’’s diagnosis after the treatment?

Dr. De Silva: This patient, it’s 100%, because she underwent the lobectomy. She was at a high risk having smoked for more than 50 years, and quitting about 20 years ago. While we diagnose her as cured, she has a higher risk of recurrent lung cancer. I will monitor her through surveillance for at least two years, but for now, she’’s cancer-free.

Dr. Thomas: Stage IA1 lung cancer (lung cancer 1 centimeter or smaller) has a five-year survival rate of about 97% after resection. I recently diagnosed a 6-millimeter nodule in a 42 year old with prior thymic carcinoma and chest radiation. At Eisenhower, we now perform single anesthesia bronchoscopy and resection events (SABRE). Using the robotic bronchoscope, we biopsy the nodule, confirm cancer on-site, mark it, and then Dr. Wilson resects it immediately using the da Vinci robotic surgical system - all in one procedure. Patients receive diagnosis, treatment and potential cure under a single anesthesia event.

Dr. Perumbeti: What are the patient’’s options if a more advanced stage of cancer is diagnosed?

Dr. De Silva: Stage 3 means the cancer has spread to more than one lymph node or a lymph node in the middle of the chest. In that case, chemotherapy, radiation and immunotherapy comes into play. As soon as I receive a biopsy confirming higher-stage cancer, I’’ve already talked to an oncologist before sharing the diagnosis with the patient. We move fast and some patients start chemotherapy as soon as the week after the diagnosis.

Dr. Perumbeti: Does the bronchoscopy aid other aspects of cancer care?

Dr. De Silva: We are not just putting one needle in and getting one biopsy. We do get a lot of tissue for genetic analysis. The tissues are sent to a different lab to identify any mutations that assists in coming up with a treatment plan and immunotherapy, or targetable therapy.

Dr. Thomas: Often, when patients have already been diagnosed, they’’re being treated and respond well to the targeted treatment. About a year later, the cancer may start progressing. The next step is to return for robotic bronchoscopy, take more biopsies and run more molecular studies to see if there are new mutations that could be targeted by immunotherapy.

Dr. Perumbeti: So, the Ion can help with downstream treatment. Can the robotic bronchoscope be a treatment tool as well?

Dr. Thomas: As of January 2024, Eisenhower Health acquired pulsed electric field (PEF) ablation technology. A needle (either using CT-guided techniques by interventional radiology or with the Ion by an interventional pulmonologist) gets inserted into the tumor and delivers high-voltage, rapid-alternating current through the tumor. This leads to destabilization of the tumor cells, which causes them to undergo programmed cell death. The cells then release intact tumor antigens into the microenvironment and little spots in and around the tumor develop so-called tertiary lymphoid structures, which essentially serve as lymph nodes harboring immune-fighting cells that attack the tumor.

Off-target effects - treating one tumor and other tumors shrink - occurs about 30% with PEF. I’’ve treated about 50 patients with PEF. We reassess the response with repeat CT or PET CT imaging about three months after the treatment. So far, I have had about an 80% disease control rate, meaning we have stabilized the cancer, or caused a partial (30% or more shrinkage) or complete response (tumor goes completely away). This is fairly comparable to radiation therapy.

This is a technology that is providing more hope for patients who otherwise would’’ve been put on hospice or died from their cancer, and my colleagues around the country report similar results. It’’s a promising option for advanced-cancer patients, those failing therapy, or even early-stage patients who can’’t undergo surgery or radiation.

Dr. Perumbeti: Is Eisenhower Health and its interventional pulmonology team contributing to the research body involved with both PEF and robotic bronchoscopy?

Dr. Thomas: I’’ve been part of several studies and with this particular technology, Eisenhower Health was one of five facilities to be recently approved to participate in the national registry called Galvanize Prospective/Retrospective Pulsed Electric Field Device Registry (PROPEL). I am the principal investigator for that study.

Dr. Perumbeti: Both of you perform procedures other than PEF or the robotic bronchoscopy to treat your patients. Dr. De Silva, tell us more about the rigid bronchoscopy, especially when a patient has a tumor that’’s blocking the bronchial tubes.

Dr. De Silva: Rigid bronchoscopy, or regular bronchoscopy, places a rigid metal tube into the airway. That tube facilitates more stability and space with which to work. If there’’s also bleeding, it’’s easier to manage with larger suction catheters, tools or forceps. We can use the scope itself to core out and debulk the airway tumor and we can place airway stents to keep the airway open, helping patients who are short of breath due to the tumor blocking their larger airways. It is essentially surgery from the inside, removing the tumor with the different tools we have. Through the rigid scope or even with the flexible bronchoscope we use tools like argon plasma coagulation, laser, and what we call cryo, which is basically a probe that we can freeze tissue to grab it and take it out.

Dr. Perumbeti: And how fast is the patient’’s recovery after a rigid bronchoscopy?

Dr. De Silva: If we place an airway stent, patients stay in the hospital overnight for observation. If we are debulking and clearing an airway, patients may go home the same day. Most of our patients go home the same day with no complications.

Dr. Thomas: Patients who undergo the debulking procedures have almost immediate relief of their breathing concerns. It is rewarding as a provider to be able see the effects of performing a surgery and helping our patients so quickly.

Dr. Perumbeti: After a debulking surgery or stenting, what goes into patient follow-up?

Dr. De Silva: Usually, I request a four-week follow-up, and depending on how they’’re feeling, I would do another inspection bronchoscopy with a flexible bronchoscopy to evaluate the status of the stent. Also, I may order a CT scan to assess the extent of their cancer and airway obstruction and stent positioning.

Dr. Perumbeti: There’’s a newer procedure that has had a strong impact on certain patients who have chronic obstructive pulmonary disease and emphysema. Can you describe the bronchoscopic lung volume reduction (BLVR) procedure?

Dr. De Silva: The most common BLVR device is the Zephyr^® Valve. The easiest way to explain emphysema is that your lungs go from being a balloon, which naturally pushes out air, to a shopping bag, where it’’ll just keep filling and filling and cannot get rid of that air. When we place a one-way valve, air can come out of the valve, but there’’s no air going back into that lobe, essentially cutting off supply to that lobe and causing it to collapse in on itself without actually physically taking that lobe out. This effectively removes the extra volume that builds up in the lungs of patients with emphysema.

Dr. Thomas: The problem with COPD and emphysema is that generally in the beginning, patients have difficulty exhaling; however, as patients lose that elasticity of their lungs and exhibit the balloon effect that Dr. De Silva described, patients develop hyperinflation of their lungs to the point where their diaphragms become dysfunctional and it also becomes difficult to inhale. A diaphragm that’’s normally dome-shaped is able to contract and become flat and act like a bellows to pull air in; however, when the lung is hyperinflated, the diaphragms become flat and have to work even harder to become flatter. In fact, patients expend so much energy just to breathe from breath to breath that they start to waste away, developing pulmonary cachexia [significant weight loss and loss of appetite].

Initially, a surgical procedure called surgical lung volume reduction was developed that would cut out parts of the upper lobes of the lung in order to reduce the amount of volume and hyperinflation. The problem with that surgery is it carried about a 5% mortality rate and a lot of complications. Pulmonologists needed to come up with less-invasive techniques, which is where the endobronchial valves come in.

Dr. Perumbeti: What should the patient expect if they’’re able to get the valve procedure?

Dr. De Silva: The procedure is straightforward. We go into the lung, choose what lobe to block off based on a quantitative CT analysis of the lung, take some measurements and place the valves. Patients stay in the hospital for three nights for observation to monitor for complications and then are released home.

Dr. Perumbeti: What effect does the valve surgery have on the patient’s life?

Dr. De Silva: Results have shown improvement in symptoms, better lung function, increased exercise capacity, and a better quality of life.

Dr. Thomas: I’’ve had patients come off of oxygen and some of their medications. I never guarantee that for anybody, but it happens and it’’s great when it does. Patients come back and give you a big hug and say, “My life has totally changed.” There are some who don’’t benefit and unfortunately, there are potential problems with the valves. They can rotate or move or become dysfunctional. We may have to repeat the procedure or replace a valve.

Dr. Perumbeti: It is incredible work you two have been doing over the last few years with cutting-edge technology at Eisenhower. What do you two foresee in the future?

Dr. Thomas: SABRE is a game-changer. It lowers costs, speeds up treatment and eases patient anxiety. Beyond surgery, we’re now exploring ways to diagnose and treat cancer in one setting using ablation or targeted drug delivery.

Dr. Perumbeti: Your field is evolving rapidly. Thank you, Dr. Thomas and Dr. De Silva. We’re excited about the innovations Eisenhower’s interventional pulmonology team is bringing to the Coachella Valley.  Any final thoughts?

Dr. Thomas: Yes. If you’ve ever smoked, talk to your doctor about lung cancer screening. Lung cancer is the leading cause of cancer death in both men and women - more than colon, breast and prostate cancers combined. Screening can detect cancer early and save lives - more than mammograms and colonoscopies combined. And, quitting smoking is still the best way to reduce your risk. We offer both screening and smoking cessation support at Eisenhower.

For more information about the Eisenhower Lung Cancer Screening Program, 
visit EisenhowerHealth.org/Lung or call 760.837.8880.