What is interventional pulmonology?
Interventional pulmonology is the branch of respiratory medicine that diagnoses and treats disease of the airways, the lungs, the mediastinum and the pleura using minimally invasive techniques rather than open surgery. Instruments are introduced through the natural airway with a bronchoscope, or through a small puncture in the chest wall under ultrasound guidance, so most procedures avoid an incision, a general anaesthetic, or a long hospital stay.
The field exists because many patients with central airway obstruction, malignant pleural disease or complex infection are either unfit for surgery or would gain little from it. A patient who cannot breathe because a tumour has narrowed the main bronchus can be relieved within an hour by debulking and stenting. A patient drowning in recurrent malignant fluid can be freed from repeated hospital visits by pleurodesis or an indwelling catheter. In both cases the intervention treats the symptom immediately while the underlying disease is addressed in parallel.
Dr. Gogineni Ratnakara Rao trained in pulmonary medicine at AIIMS New Delhi and PGIMER Chandigarh and practises the full range of clinical and interventional pulmonary procedures at Apollo Hospitals, Financial District, Hyderabad.
Symptoms and problems addressed
- Breathlessness and noisy breathing from a blocked large airway, caused by tumour, scar tissue, or external compression.
- Stridor, a harsh sound on breathing in, indicating narrowing of the trachea or larynx.
- Coughing up blood requiring localisation of the bleeding site and control.
- Recurrent pleural fluid causing breathlessness that returns within days of drainage.
- Undiagnosed lung masses, nodules and enlarged mediastinal nodes needing tissue.
- Collapsed lung segments from mucus plugging or an inhaled foreign body.
- Persistent air leak after pneumothorax or surgery.
- Severe emphysema with disabling breathlessness despite maximal medical therapy.
- Tracheo-oesophageal fistula causing coughing on swallowing.
Diagnostic procedures
| Procedure | Purpose |
|---|---|
| Flexible bronchoscopy with biopsy and lavage | Direct airway inspection, tissue and microbiological sampling |
| EBUS-TBNA | Ultrasound-guided sampling of mediastinal and hilar lymph nodes for cancer staging, tuberculosis and sarcoidosis |
| Radial EBUS with guide sheath | Localisation and biopsy of peripheral lung nodules that cannot be seen directly |
| Transbronchial lung cryobiopsy | Larger, artefact-free lung tissue for interstitial lung disease |
| Medical thoracoscopy (pleuroscopy) | Direct inspection and targeted biopsy of the pleura in undiagnosed effusions |
| Thoracic ultrasound and image-guided pleural biopsy | Bedside assessment of effusions and safe sampling of thickened pleura |
| Rigid bronchoscopy | Airway control and large-volume sampling in central lesions |
Therapeutic procedures
Restoring a blocked airway
Tumour tissue growing inside the trachea or a main bronchus can be removed mechanically with the rigid bronchoscope or destroyed with cryotherapy, electrocautery, argon plasma coagulation or laser. Relief of breathlessness is often immediate. Where the airway is compressed from outside or the wall has been destroyed, a silicone or self-expanding metallic stent holds the lumen open. Benign strictures, including those following intubation, tracheostomy or tuberculosis, are treated with balloon dilatation, targeted cutting, and stenting where needed.
Foreign body removal
Inhaled objects, most often in children and in elderly patients with impaired swallowing, are retrieved with forceps, baskets, snares or cryoprobe adhesion. Prompt removal prevents distal infection, bronchiectasis and permanent lung damage.
Control of haemoptysis
The bleeding site is localised bronchoscopically and controlled with cold saline, topical vasoconstrictors, tranexamic acid, endobronchial blockers or tamponade, and the airway is protected. Bronchial artery embolisation by an interventional radiologist is arranged when bleeding is arterial and recurrent.
Pleural interventions
Ultrasound-guided aspiration and small-bore intercostal drainage relieve effusion and pneumothorax. Talc pleurodesis, performed at thoracoscopy or through a drain, prevents recurrent malignant effusion. A tunnelled indwelling pleural catheter allows drainage at home and suits patients who prefer to avoid admission. Intrapleural fibrinolytic therapy improves drainage of loculated empyema.
Advanced airway therapies
Endobronchial valves reduce lung volume in selected patients with severe emphysema and can seal a persistent air leak. Airway stents and covered stents close tracheo-oesophageal fistulae. Whole-lung lavage is used in pulmonary alveolar proteinosis. Percutaneous dilatational tracheostomy is performed at the bedside in ventilated intensive care patients.
Safety, anaesthesia and recovery
Procedure choice depends on the target, the urgency and the patient's fitness. Diagnostic work is usually done under conscious or deep sedation as a day-care procedure. Rigid bronchoscopy, stenting, valve placement and major debulking require general anaesthesia in the operating theatre with an anaesthetist experienced in shared airway work, and a short admission. Every case is planned with current imaging, blood counts and clotting results, a review of anticoagulants and antiplatelets, and an anaesthetic assessment where relevant.
Risks vary with the procedure and include bleeding, pneumothorax, infection, airway injury, stent migration or obstruction by secretions, and sedation-related events. These are discussed individually before consent. Complex airway and pleural problems are best managed within a multidisciplinary team that includes thoracic surgery, medical and radiation oncology, radiology, pathology and critical care, so that an intervention fits into an overall treatment plan rather than standing alone.
Frequently asked questions
How does interventional pulmonology differ from thoracic surgery?
Interventional pulmonology works through the natural airway or through a small puncture, usually without an incision and often without general anaesthesia. Thoracic surgery opens the chest or uses surgical ports to remove lung tissue or perform decortication. The two are complementary, and many patients are discussed jointly before a decision is made.
Will an airway stent be permanent?
Not necessarily. Stents used for benign strictures are often removable once the airway has stabilised, while stents placed for malignant compression usually remain in place. Regular follow-up is required to check for secretion crusting, migration or granulation tissue.
How quickly will breathing improve after airway debulking or stenting?
Relief is often immediate or within hours, because the obstruction that limits airflow has been physically removed or bypassed. Improvement in exercise capacity continues over the following days as secretions clear and the collapsed lung re-expands.
Are these procedures suitable for patients unfit for surgery?
Frequently yes. That is one of the main reasons the specialty exists. Many patients with advanced cancer, poor lung function or significant heart disease can safely undergo bronchoscopic or pleural intervention when major surgery would not be tolerated.
Is a hospital stay required?
Most diagnostic procedures are day-care. Therapeutic airway work under general anaesthesia, chest drain insertion, pleurodesis and stent placement usually need a short admission of one to a few days.
Do endobronchial valves cure emphysema?
They do not cure the disease. In carefully selected patients with severe emphysema, intact fissures and no collateral ventilation, valves reduce hyperinflation and improve breathlessness, walking distance and quality of life. Selection requires detailed CT analysis and lung function testing.
What should I bring to the consultation?
Bring all previous chest X-rays and CT or PET-CT images on disc, earlier biopsy and microbiology reports, discharge summaries, a current medication list including blood thinners, and details of any previous anaesthetic problem. Having the actual images rather than only the reports allows the procedure to be planned precisely.
Related conditions and procedures
Consult Dr. Gogineni Ratnakara Rao
Apollo Hospitals, Financial District: Monday to Saturday, 8:30 AM to 5:00 PM. Anything in Lung Clinic, Chanda Nagar: Monday to Saturday (Thursday closed), 6:00 PM to 9:00 PM.