A new frontier in lung health: the rise of interventional pulmonology

Episode Transcript

Behind every case, there’s a story. Behind every story, there’s a lesson. And behind every lesson learned, there’s a trusted mentor. This is Prepped & Draped with Dr. John Kaufman, where candid conversations, actual cases, and bold new professionals shape medicine.

Hello, everybody. Welcome to Prepped & Draped. This is John Kaufman, chief medical officer at Cook Medical, and I’m delighted today to have as my guest, Dr. Fayez Kheir, who’s associate professor of pulmonary critical care at Harvard Medical School, MGH. And he is the director of interventional pulmonology research. And I’m really looking forward to having a discussion with him about this exciting area of procedural medicine.

And Fayez, why don’t we start by just having you introduce yourself and how you got into IP and what attracted you to that?

Thank you very much, Dr. Kaufman, for the invitation. My name, as I said, Fayez Kheir. I work at Mass General. As a background, I have done internal medicine, then moved to do my pulmonary and the critical care at Tulane University in New Orleans, where also I did my master’s in clinical research and minor in medical education, as well as a certificate with ATS, or American Thoracic Society, for guideline methodology training.

After that, I did my interventional pulmonary fellowship in the combined fellowship at Mass General, as well as Beth Israel Deaconess. That was back in 2016, almost now 10-plus years ago. Eventually, I joined the MGH four years ago, and this is my fifth year at Mass General Hospital.

Thank you. I once, many, many decades ago, worked at MGH. It’s a fabulous place to work. But at that time, I don’t think we really had an IP program, as I remember. So, curious for those of us who are new to understanding interventional pulmonology, tell us what your average day is like as a proceduralist in that specialty.

So, interventional pulmonary is a relatively new specialty, it has been probably there from early 2000. And Boston was one of the first programs to establish intervention pulmonary in the US. Our day, usually, it’s mainly focused about interventional procedures in the lung, including tracheostomies, as well as some PEG tubes with tracheostomies, including diagnostic, as well as therapeutic evaluation for lung nodules, lung masses, airway narrowing, stents, also including pleural diseases, pleural infection, pneumothorax, and also pleural biopsies. We also deal with patients with interstitial lung disease where we get a biopsy to establish their management as well treatment by their ILD experts. We also do sometimes manage patients with emphysema or COPD where we place a valve to help them breathe better and improve their quality of life.

I always say in interventional pulmonary our schedule every day is unexpected. We start with four or five scheduled procedures, but we know that during the day that we’re going to run into more emergent or urgent procedures where we have to deal with and add on for our cases. So, at least I can tell you most of our procedures are scheduled, but during the day we run out into emergency procedures, bronchoscopies or airway bleeding that we have to deal with on an urgent basis.

Yeah. I think all of us proceduralists live in a world of being predictably unpredictable. One thing you can count on is that emergency coming up right in the middle of your day.

It sounds like a really exciting emerging field, and that’s one of the things that I’ve observed that it’s just growing rapidly and the applications are growing. What are some of the tools that are allowing you to grow like this?

So, mainly it’s, honestly, the growth of industry over the years, where most of the industry, at least in our field, are being focused on mainly oncology and interventional oncology. We know now that lung cancer studies, as well as lung cancer management, has evolved over the years, including now targeted or precision therapy for lung cancer. But sometimes some patients are not eligible for these targeted therapy, or they have some of their nodules and lymph nodes that has grew despite having being treated by some mutation analysis treatment.

So, for us as interventionalists, we always have a close relationship with oncology where we help them get more tissues to see whether there’s any mutations and also sometimes discuss if we are able to approach an airway that has a tumor where we are able to ablate the tumor. And eventually, over the next one to two years, I think we are planning to do more ablation to peripheral lung nodules as a multidisciplinary discussion with intervention radiology, thoracic surgery, as well as radiation oncology and oncology.

Yeah. I think your point about multidisciplinary is important. We’re seeing that across all the procedural specialties, these complex patients and everyone brings something a little different to the table, so that’s always important. You’ve published on the importance of robotics in these procedures. And I’m wondering, as you’re talking about extending the capabilities of the specialty of the proceduralists, what role the robotics might have. And you may have to describe a little bit what robotics means for IP because not everyone may understand what the tools actually are that you use.

Robotic bronchoscopy have evolved over the last five to six years. So, robotic— It’s mainly like— What we do is you have a lung nodules. In order to approach it, there’s two ways, either transcutaneous approach or we go from inside the airways through a guided approach by a robot. I always tell patients that robot is similar to the GPS of a car where we can drive it under anesthesia and we can go inside your airways, go to, and manipulate until we reach the nodule. However, reaching the nodule will not guarantee that we have a successful biopsy because as you know that the lung has respiratory gating and the lung move and does the target move.

So ,what we do in addition to a robot, which is a GPS of the car, we have additional tools to improve our diagnostic yields. Mainly we add a cone beam CAT scan, which confirm lesions during the procedure, and also we use multimodality tools in order to increase our diagnostic yield for the nodules. In addition to that, we always say because we are doing it intrabronchially, we can do two things in one. We can diagnose, but we can also do a chest evaluation or mediastinal staging for the patient. So, two in one. So, this is according to the diagnostic entity or side from robotic bronchoscopy.

In the last one to two years, there had been more interest in ablation techniques or approaching these modules for ablation. However, I always caution people is: As an interventionist or proceduralist, you should not be doing that alone. As we discussed before, it should always be under the multidisciplinary discussion. And thus what we did at Mass General here, we have an ablation clinic where a radiation oncologist, intervention radiologist, thoracic surgeon, oncology, and intervention pulmonary. We meet every single week in order to discuss cases and see how the patient is best served by which service, whether radiation oncology or radiation, whether intervention radiology, or whether intervention pulmonary. And as we discussed, it’s very important to have all these within the clinical context of a multidisciplinary team.

And you mentioned cone beam CT as part of this, that’s a pretty big piece of equipment, pretty expensive. It’s very different than just a C-arm. So I’m curious where you’re doing the procedures and are you doing these sometimes as a multidisciplinary, having someone from radiology there or IR as you’re doing it, if you’re using cone beam?

So, we introduced cone beam CT at Mass General three years ago. So, there is fixed and mobile cone beam. We have both, but mainly in intervention pulmonary, we use the mobile cone beam scan. We do all these procedures in the operating room. Other institutions, they have the capability of doing that in a procedure unit under anesthesia. So, we have anesthesia team and also we have a radiation tech where our RTs, or radiation technologists, were trained by the company in order to see how they are able to run the cone beam scan.

So, it sounds like a hybrid room in the OR, which is probably shared with some other services. For people listening, if they’re not familiar, cone beam CT is when you take a standard C-arm, but it spins around the patient in a reconstruction image. It looks like very much like a CT. It’s not the highest-level CT, but good enough for a lot of diagnostic and therapeutic work.

When you’re staging the mediastinum, are you staging that with endobronchial ultrasound or is it a combination of the cone beam and ultrasound?

No. For the staging of the mediastinum, we use an endobronchial ultrasound, but also we use sometimes an EUSB, which is endoscopic ultrasound. So, in interventional pulmonary, we are trained to do mediastinal staging with the EBUS or endobronchial, but also if needed for stations that are not reachable by endobronchial ultrasound, we use also an EUS to reach the lymph nodes that are not reachable. And that’s why we can do both in the same situation rather than consulting other services to do that.

Are you biopsying the lymph nodes at the time or just imaging them?

No, we are imaging them and we are biopsying the nodes that looks suspicious on the ultrasound.

Yeah. There is just so much coming our way in terms of lung cancer. I’m just trying to imagine what the training pipeline’s going to have to look like for IP. People say about 18% of people who should be screened are getting screened, and the numbers are in the 12, 13 million people are eligible for screening. So, if everyone starts getting screened, there’s going to be a lot of work to do. Can you talk a little bit about the IP training pathway? And I’m only asking, I’m pretty excited about what you’re telling me. I’m considering, I don’t know, should I go back and get some IP training? Sounds pretty cool.

So, in order to be eligible to apply to intervention pulmonary, people should have done internal medicine, pulmonary critical care, which is four years, and then they are eligible to apply for an interventional pulmonary fellowship. Around the US nowadays, there’s probably 20 to 25 intervention pulmonary programs that have a high volume in order to train the next generation of interventional pulmonologists. For example, here at Mass General, we are one of the largest training sites along with Beth Israel Deaconess, we have a combined fellowship, and we recruit the highest number of interventional pulmonologist in the US. We recruit four interventional pulmonary fellows every year.

And is that a one-year program?

It is a one-year program. Yeah.

And so my guess is the output nationally between 60 and 80, if everyone is about your size or is it—?

No, no. Most of the programs only recruit one. So that’s why I’ll say on average, probably they graduate maybe around 35 every year.

Yeah. And IP fellowships are a standardized program. I’m only asking because I just don’t know. But for those that listening, you might be thinking, “Oh, well, Kaufman can’t do it because he’s an interventional radiologist, he can’t go retrain in medicine and stuff, but maybe I can do that.”

No, now intervention pulmonary is going through the process of being ACGME approved by the accreditation of medicine to be a fellowship under internal medicine. It’ll probably going to take one to two years to be fully approved, but it is within the process of doing that. Yes.

Yeah, that is a huge step forward for specialty. I congratulate you and everyone else in the specialty who’s making that happen. When you unify training and you have a singular output, everyone who trains comes out basically as close to the same as possible instead of coming out of little different schools of training, it allows the specialty to really thrive. Patients get sort of uniform better care and changes are much easier to implement because everyone is under the same rules, so you have to advance training. So, that’s great. Right now, if someone completes the training, what does their certification pathway look like?

So, after finishing your training, usually they have to apply for a diploma in interventional pulmonary. Now it has been done through the AABIP, which is the American Association of Bronchology and Interventional Pulmonary. Before doing that, they have to confirm that you was able to attain a certain level of competency in each procedure that is listed under intervention pulmonary, including but not limited to a flexible bronchoscopy, ablation techniques, a medical thoracoscopy, endobronchial ultrasound valve. So, multiple procedures that you have to achieve competency in before sitting for the exam. And then usually you do the written exam, and then after that, you’ll be certified to practice intervention pulmonary by the AABIP.

And it just sounds like a lot of fun. You go to work and you work hard, but it’s a great specialty and a lot of fun. So, the fellowships are new, or are going to be new. When did the application date for the fellowships open up?

So, usually they open around the summertime between July to August. We start the interview process between September until end of say November, early December. And then by January, we know who are going to be the incoming fellows for the July year.

Right. Well, hopefully that’ll give people are listening some guidance. So, you are the director of research in interventional pulmonology. I’m curious, is there something out there that’s coming that you’re really excited about? Maybe it’s not here yet or just getting started, but something out there that you have your eye on as you think is going to be impactful to the specialty in patient care?

Yeah. So, I think now the field is trying to move from diagnostic procedures to therapeutic procedures, and I’m talking mainly in the lung nodule or lung cancer field. So, more and more studies now is evaluating multiple ablative techniques, safety, feasibility, and efficacy for patients who has a lung nodule that are not a surgical candidate and that are not candidates for SBRT. So there are many studies evaluating intratumoral therapy with multiple immunotherapy. Also, there are multiple studies evaluating different ablative technique, whether it’s a radiofrequency ablation, microwave ablation, or photodynamic therapy technique for such lung nodules. Also, non-ablative therapy such as cold therapy for these nodules.

Again, because the patients who are going to be eligible for these are not the usual population, so they are a very highly selective population. So, the first, I think in the next few years, we are trying to evaluate the safety and feasibility of establishing these ablative technique for eventually moving to the efficacy of these technique. I always say, from ablation perspective, for example, we always have to look back at as the SBRT, where over the at least 10 to 20 years, it became eventually an established acceptable modality and standard of care for patients with lung nodules. So, I think it’s going to hopefully take shorter time, but it has to take its natural course before having ablation technique established as a accepted modality for patients with lung modules.

Yeah. And I think we’ve seen this, the adoption rates are faster as time goes on with the new technologies, but still takes a while. And the steps you pointed out, you still have to go through those steps. You have to prove safety, you have to prove efficacy in order to really get the adoption. And that, always, there’s just a certain amount of time. You can’t rush the biology of diseases and cancers.

Yes.

You mentioned that only a certain subset of patients are going to be eligible for these. Could you just give me a little more information as about what that subset is?

Yeah. Nowadays, as you know, the standard of care of anybody who has a lung nodule proven to be malignant is surgery and SBRT or radiation therapy. Now, there are subset of patients who are not candidates for surgery and are not able to do SBRT because of interstitial lung disease or other lung diseases that will prohibit them from having radiation therapy. And this has become an important to discuss what is the best approach for these patients, either from bronchoscopic or interventional pulmonary perspective or from the percutaneous approach for ablative techniques. And that becomes an important, not only offering these patients the type of modality, however, it should be, as we discussed before, a multidisciplinary discussion about the best and safest way in order to treat these patients, whether percutaneously or intrabronchoscopically for these patients.

Fayez, it’s been a delight talking with you. And I’m even more excited about the future of interventional pulmonology than I was before, I think it’s just a great field and has a great future ahead of it. And as in a lot of procedural specialties, you start with the edge cases and once things are proven to be efficacious— and those are often the hardest cases, things kind of move into the more mainstream.

Before we close, I always like to just offer my guests the opportunity that if there’s something you really want to communicate to anybody, maybe it’s somebody thinking about interventional pulmonology, maybe it’s referring clinicians or your peers and other specialties. If there’s any message you want to leave them with, and before we close out, this is your chance.

Thank you. So, I’m going to just close by saying what I always advise my fellows is number one, you have to be passionate about what you do. If you enjoy what you’re doing, you’re going to do it every day and you will not be complaining that you have to leave home, you cannot do it, because this is your passion. So you’ll be happy doing whatever you choose to do, like in my case, interventional pulmonary.

But beside passion, it’s very important to have a work-life balance. You don’t want to get burned out because you have been working a lot. So, I always say between work, between life, and when I say life, it’s mainly family, as well as spiritual and physical health for the physician. These are important to balance them, and we know then when the work out-balance your life, then problems will occur in your life. And that’s always an advice I give it to fellows as they graduate.

Well, those are such wise words. I can’t add anything to that. So, at this point, I think we’ll just wrap this up. And thank you again, Dr. Kheir, this has been a great visit, and I hope to run into you at maybe one of the meetings in the near future. And I really appreciate your joining Prepped & Draped today.

Thank you very much. Thank you.