The Interventional Pulmonology and Bronchology section is the center for innovation in diagnosis and treatment of lung and chest wall diseases. The section is trained in advanced procedures, offering less invasive options compared to traditional surgery.
Interventional Pulmonology (IP) has evolved as a subspecialty of pulmonary medicine and is defined as “the art and science of medicine as related to the performance of diagnostic and invasive therapeutic procedures that require additional training and expertise beyond what is required in standard pulmonary medicine training program.” It is under the Pulmonary, Critical Care, and Sleep Medicine Department and provides a wide range of services.
The section is headed by Dr. Joven Roque Gonong, together with his interventional pulmonology team namely: Dr. Paul Rilhelm Evangelista, Dr. Lawrence Raymond, and Dr. Maria Charisma Laborte. The team aligns itself to the institution’s vision to be a regionally competitive, locally responsive premier institution for lung and other chest diseases, providing quality healthcare through excellent service, training and research.
1. Flexible bronchoscopy and biopsy
Flexible bronchoscopy is a technique that allows a pulmonologist to visualize the airway through an endoscope. It is both diagnostic and therapeutic and is a relatively safe procedure. It is easy to manipulate, simple to use, may be done at the patient’s bedside without anesthesia, and it can access the distal airways.
Basic procedures such as bronchoalveolar lavage, transbronchial lung biopsy, and transbronchial needle aspiration biopsy can be done using this technique. It is generally indicated for the following:
a. Diagnostic indications:
- To Investigate unexplained symptoms
- Hemoptysis, cough, localized wheeze or stridor
- Evaluate lung lesions of unknown etiology
- Density, infiltrate, atelectasis or localized hyperlucency on chest x-ray
- Evaluate unexplained findings
- Paralysis of vocal cords or hemidiaphragm, SVC, chylothorax or pleural effusion
- To search for the origin of suspicious or positive sputum cytology
- To assess airway patency
- Evaluate problems associated with ET tube such as tracheal damage, airway obstruction or tube placement
- Lung cancer diagnosis and staging
- Obtain material for microbiological studies in suspected pulmonary infections
b. Therapeutic indications:
- Remove retained secretions or mucus plugs not mobilized by conventional non invasive techniques
- Removal of foreign bodies
- Removal of abnormal endobronchial tissue or foreign material by use of forceps or laser techniques
- Perform difficult intubation in:
– Cervical spondylosis
– Dental problems
– Full stomach
– Myasthenia Gravis
– Small bowel obstruction
– Trauma to head neck and larynx or trachea
- Atelectasis/Lobar Collapse
- Debridement of necrotic tracheobronchial mucosa
- Dilatation of strictures and stenosis
- Pneumothorax (fibrin glue treatment)
- Percutaneous Tracheostomy
- Drainage of lung abscess/cysts
- Photodynamic therapyElectrocautery/Cryotherapy
2. Endobronchial ultrasound (EBUS) and radial EBUS
Endobronchial ultrasound (EBUS) is a technique that uses ultrasound along with a bronchoscope to visualize the airway wall and structures adjacent to it. EBUS has been incorporated into routine practice in many centers because of its high diagnostic informative value and may replace more invasive methods for staging lung cancer or for evaluating mediastinal lymphadenopathy and lesions in the future. It allows real-time guidance of transbronchial needle aspiration (TBNA) of mediastinal and hilar structures and parabronchial lung masses. Only a few centers in the country offer this procedure and Lung Center of the Philippines is one of them.
A much recent technique adapted by the section of Interventional Pulmonology by LCP is the use of the radial probe EBUS. It employs a flexible catheter housing a rotating ultrasound transducer which produces a 360° (“radial”) ultrasound image and is usually used to guide peripheral lung lesions.
The transducer is passed into bronchial subsegments until the characteristic ultrasound signal indicating the presence of a solid lesion is demonstrated. Transbronchial lung biopsy and other methods of sampling tissue are then performed from this bronchus.
3. Bronchoscopic cryotherapy and electrocautery
The Lung Center of the Philippines is the only center in the Philippines offering bronchoscopic cryotherapy. Cryotherapy is an evolving therapeutic and diagnostic tool used during bronchoscopy.
Through rapid freeze-thaw cycles, cryotherapy causes cell death and tissue necrosis or tissue adherence that can be used via the flexible bronchoscope. It can be used for the treatment of malignant and benign central airway obstruction and low-grade airway malignancy, foreign body removal or cryoextraction, endobronchial biopsy, and transbronchial biopsy.
Electrocautery is a bronchoscopic technique which uses electricity that is used to treat nonmalignant or malignant airway lesions that are intraluminal and involve the central airways. It is most commonly indicated for the treatment of symptomatic airway obstruction caused by bronchogenic carcinoma in patients who are not operative candidates. It can also be used to treat nonmalignant obstructing lesions of the central airways such as granulation tissue, hamartomas, papillomas, and lipomas. In addition, it is also utilized to control bleeding during bronchoscopic procedures.
4. Ultrasound guided interventional pulmonology procedures (thoracentesis, pleural catheter insertion, cervical lymph node biopsy, transthoracic core needle biopsy)
Ultrasound guidance can be used for several procedures that are performed at the bedside including thoracentesis, pleural catheter insertion, needle aspiration biopsy of pleural or subpleural lung masses, cervical lymph node biopsy, and transthoracic biopsy of pleural or mediastinal masses.
a. Ultrasound guided thoracentesis and pleural catheter insertion:
Thoracentesis is a percutaneous procedure where fluid is removed through your chest wall into your lung cavity to remove or collect fluid accumulation. The location for this procedure may be in an inpatient or outpatient setting. Performing ultrasound-guided thoracentesis can be done to provide real-time estimated volume of the pleural effusion prior to evacuation of pleural fluid. For cases of recurrent and symptomatic effusions, particularly malignant pleural effusions, pleural catheter insertion can be done. It is a simple procedure done by the IP team and it can be accomplished as outpatient.
b. Ultrasound guided percutaneous cervical lymph node biopsy and transthoracic needle lung biopsy
Ultrasound-guided percutaneous cervical lymph node biopsy is a cost-effective, safe, and diagnostically effective procedure without radiation exposure. The benefit of real-time visualization of the needle location allows to instantly maneuver the needle trajectory for safe and accurate tissue sampling with short procedural time.
Ultrasound-guided transthoracic needle biopsy is also a safe and rapid method used to achieve definitive diagnosis for most thoracic lesions, whether it’s located in the pleura, the lung parenchyma, or the mediastinum. It allows accurate needle placement into peripheral lesions and may help in the repetitive adjustment of needle position, avoiding the vascular structures and providing adequate specimen for histopathologic diagnosis.
5. Chemical pleurodesis
Pleurodesis is a procedure that removes the space between the lung and the chest wall (pleural space) so that fluid or air no longer builds up between the layers. By instilling a mildly irritant drug on the pleural space via chest tube or pleural catheter, pleurodesis prevents recurrent pleural effusions and pneumothorax. The procedure is relatively quick and can be done as outpatient.
6. Medical Thoracoscopy
Thoracoscopy is a minimally invasive procedure performed to diagnose and/or treat pleural lung disease. Patients with pleural thickening or pleural effusions (pleural fluid) who have lung cancer, chylothorax, lymphoma, mesothelioma, metastatic cancers, or benign conditions such as congestive heart failure, may be eligible for this procedure.
Thoracoscopy increases the ability to diagnose pleural disease and the cause of pleural fluid accumulation.
7. Intrapleural fibrinolysis
Intrapleural fibrinolysis is the instillation of fibrinolytic agents to the pleura via chest tube or pleural catheter. This procedure dissolves fibrinous clots and locules, facilitating improved drainage. This is noted to have a high success rate, decreases the likelihood of surgical intervention (i.e. VATS), and shortens the duration of hospitalization. It is indicated for early management (days to weeks) of loculated pleural effusion, complicated effusion who fail antibiotic therapy and initial drainage, and those who are poor surgical candidates. This procedure is being used by few institutions in the Philippines and LCP-interventional pulmonology intends to provide patients this option for our patients.
8. Navigational bronchoscopy
Navigational bronchoscopy is a type of technology that can be used to help access difficult to reach lesions within the pulmonary parenchyma. It often involves peripheral bronchoscopy that is augmented by a computer-aided system which maps out the anatomy and navigates its way to the lesion of interest.
Navigational bronchoscopy has higher diagnostic yields when compared to conventional bronchoscopy. It is used to obtain tissue from difficult to reach peripheral lung lesions. Lung Center of the Philippines is one of the few centers that offer this type of service in our country.
9. Bronchoscopic Thermal Vapor Ablation (BTVA) – Coming soon
The newest procedure that the section of Interventional Pulmonology and Bronchology is offering is the Bronchoscopic thermal vapor ablation (BTVA). This represents one of the endoscopic lung volume reduction (ELVR) techniques that aims at hyperinflation reduction for patients with COPD to improve respiratory mechanics.
By targeted segmental vapor ablation, an inflammatory response leads to tissue and volume reduction of the most diseased emphysematous segments. Considered to be the first in our country, patients with upper lobe-predominant emphysema may benefit on this procedure.
Interventional Pulmonology Fellowship Training
The Lung Center of the Philippines, as the premier institution that caters to chest and lung diseases, is the first institution to set up their Interventional Pulmonology Fellowship program. The section’s goal is to teach interventional pulmonary medicine through extensive hands on training. Upon graduation, fellows will be trained to provide common procedures offered by interventional pulmonologists.
Requirements for admission:
The program will accept applicants to either a 3-year combined Basic Pulmonary Medicine-Interventional Pulmonology Fellowship Training Program, or a 1-year Interventional Pulmonary Fellowship Training Program. Applicants to a 3-year combined program must be at least a diplomate in Internal Medicine. Applicants to the 1-year program must be a diplomate in Pulmonary Medicine.
All applicants must submit the following:
1. Letter of application addressed to the Department Manager of the Department of Pulmonary, Critical Care and Sleep Medicine through the Section Head of the Bronchoscopy Unit:
VIRGINIA DE LOS REYES, M.D.
Department Manager Ill
Department of Pulmonary, Critical Care and Sleep Medicine
Lung Center of the Philippines
THRU: JOVEN ROQUE V. GONONG, M.D.
Head, Section of Interventional Pulmonology and Bronchology
Lung Center of the Philippines
2. Three (3) letters of recommendation from the list of references: One letter of recommendation must come from the past or current head of the Department or training officer of the program where the applicant completed his/her training.
3. Curriculum vitae with two (2) recent 2×2 photographs
4. Certified true photocopy of transcript of records from the medical school
5. Photocopy of PRC and medical board rating
6. Photocopy of updated PRC ID (front and back)
7. Photocopy of appropriate specialty and subspecialty board certificates.
8. Complete LCP data form (from HRD)
The applicant may be required to undergo an assessment examination and a panel interview during the screening procedure.
For more information and inquiries regarding the Interventional Pulmonology and Bronchology Section, you can contact us at:
LCP Direct line: (02) 8924-6101 local 2017/2018.