- Update May 2007
- Update March 2007
- UPDATE January 2007
Final Report – December 2007
I cannot believe it but my fellowship has finished. When you look back, you always feel that it has been too short but, sincerely, I feel that my time here has been adequate to achieve the objective of the fellowship.
At the beginning, it was not very easy because I was the first fellow in this hospital and appropriate time was needed in order to clarify the objectives of my fellowship, but the assistance from Dr. Freitag (my host supervisor and Chief of the Department), Dr. Reichle (my tutor) and my colleagues and coworkers, has been excellent, allowing me to integrate into the work group.
The principal objective of my fellowship was to learn interventional bronchoscopy. During this year I have acquired a good technique related to rigid bronchoscopy and the use of APC, cryotherapy, EBUS and stent placement and have performed more than 200 procedures. I have also learnt other techniques such as thoracoscopy and thoracic ultrasound. The ERS encourages one to participate in all the activities at the hospital and so I treated and was responsible for the care of some patients (around eight) including on the private ward under Dr. Freitag’s supervision, the oncology department under Dr. Reichle’s supervision and, during the last three months, under Dr. Westhoff’s supervision learning sleep-medicine and ventilation technique.
Under Dr. Freitag’s and Dr. Reichle’s supervision, I have undertaken an interesting research project about a new technique to treat tracheobronchial stenosis. The results were presented in the ERS Congress in Stockholm and I hope that they will be soon published. I have also carried out a second research project using the real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and at present I am writing a second paper. Therefore, I feel the fellowship has contributed to improving my skills as a researcher and has allowed me to see how my tutor and host supervisor have collaborated in the development of different techniques, bronchoscopes and other medical instruments.
In January 2007, I attended the Hemer-Heidelberg bronchoscopy three day course (7th Workshop of thoracic endoscopy) hosted in our hospital. I also had the opportunity to attend the X International Meeting on Respiratory Endoscopy in Barcelona. In both courses, I was introduced to bronchoscopy specialists and it was a great honour to speak with such world famous experts.
The Lungenklinik Hemer is a hospital with a recognised prestige, and as such I had the opportunity to meet a past ERS fellow from Greece, others doctors from Germany and other countries (Holland, Slovenia, China and Spain) who visited the Lungenklinik Hemer to learn interventional bronchoscopy.
Although no beginning is easy and it has been challenging at times, after 12 months of the fellowship, I am really satisfied to have had the opportunity to work with Dr. Freitag and his team.
I want to thank the ERS/ELF, Dr. Freitag, Dr. Reichle and all my colleagues and co-workers of the Lungenklinik Hemer for their help.
I highly recommend the Lungenklinik Hemer to others wishing undertake a similar fellowship.
Update May 2007
During my training as a specialist in Pneumology I received a Fellowship SEPAR 2003: “Learning Rigid Bronchoscopy” for 3 months in the Lungenklinik Hemer (Germany). However, three months were not enough time to learn and practice all the different endoscopic treatment modalities that are now available.
Therefore, I am grateful to the ERS/ELF for awarding me with this fellowship and it is a great honour for my and for my Chief that ERS/ELF selected our project last year. I appreciate this great opportunity to continue my postgraduate training.
I have one supervisor, Dr.Reichle. He is not only a very good physician, but also a most helpful colleague who has taught me many things. Together we are at present involved in a research that we will be presented in the ERS Congress in Stockholm.
In our hospital we use the wolf bronchoscopes that have been developed in cooperation with the Lungenklinik Hemer by Dr. Reichle (my tutor) and Dr. Pobloth (he is the Assistant Medical Director in the Anaesthetic Department).
This particular bronchoscope has four ports: one to insert the telescope lens, a second one to measure the CO2 and pressure in the trachea, a third one that is connected to the jet ventilator and a fourth one that permits spontaneous ventilation. We use the low frequency Venturi jet ventilation, because it is an open system that facilitates endoscopic procedures while maintaining an effective gas exchange. We have 8 different forceps called “Hemeraner forceps”. Their names match with their shape or movement that they do. We have different sizes of bronchoscope with different diameter (it is refer to the inner diameter: from 3 to 14 mm) and different length (from 250 to 430 mm). We have tracheoscopes and bronchoscopes. That is important to select the most appropriate on e.g. in cases of tracheobronchial stenosis. While bronchoscopes have side holes for ventilation the shorter tracheoscopes do not have those.
I have learnt to use Argon Plasma Coagulation (APC). Dr. Reichle has developed this technique of APC during the last two decades and has gained a reputation around the world. I had the privilege to help him in developing the different algorithms with different programmes to achieve the desired effects in patients. I have managed stop tumour bleedings with APC and could remove large tumour pieces with the rigid forceps.
Regarding to pleural procedures I performed fifteen medical thoracoscopies under guided supervision of Prof. Freitag and Dr. Reichle. We performed the procedures under local anaesthesia and conscious sedation without intubating the patient. During the procedure he is breathing spontaneously. Another advantage is that we perform it in an endoscopy suite and it is cheaper than video-assisted-thoracoscopy surgery.
Update March 2007
In the Lungenklinik-Hemer we start work at 7:30am. We perform approximately 20-25 flexible bronchoscopies and 6-8 rigid bronchoscopies every day. Between eight and ten thoracoscopies are performed every month.
In our hospital we use the wolf bronchoscopes that have been developed in cooperation with the Lungenklinik Hemer by Dr. Reichle (my tutor) and Dr. Pobloth (the Assistant Medical Director in the Anaesthetic Department).
Over the last five months I performed more than 50 rigid intubations and now I am very confident with this technique. I really enjoyed doing these bronchoscopic interventions under the supervision of Dr. Reichle.
With regard to other techniques of interventional bronchoscopy, the Lungenklinik Hemer is taking part in a multi-centre trial testing the feasibility of endobronchial cryobiopsy. The hypothesis is that biopsy specimen taken with a freezing probe will increase the diagnostic yield compared to conventional forceps biopsies. Within this study I performed several cryobiopsies obtaining relatively large tumour biopsies.
Furthermore I was permitted to perform two endobronchial cryotherapies in patients with obstructing tumours under the supervision of Dr. Reichle.
We guide all pleural procedures (pleura punctures, pleura drainage and thoracoscopy) with ultrasound. I had not been able to use sonography before I came to Germany and I learnt to appreciate it as a most useful technique. It provides a lot of information and helps to detect even small pleural effusions. It allows also to distinguish pleural fluid from pleural thickening.
I have performed more than 50 pleural ultrasound examinations and I can highly recommended learning this technique. The ultrasound also permits you to look for the appropriate location for a transthoracic puncture. I think it is very useful for example in countries like Spain because using a CT scanner for puncture procedures is often blocked by radiologists and the limited accessability results in inacceptably long waiting times. I experienced that using the ultrasound in patients with peripheral masses transthoracical needle aspiration became easy. This is not only fast and efficient but also cost saving.
In January 2007, I attended for three days the Hemer-Heidelberg bronchoscopy course (7. Workshop of thoracic endoscopy) in our hospital. For me it was a wonderful opportunity to learn not just the theory but also to practice actively the different procedures of interventional bronchoscopy during the hands-on course. It is also very nice and helpful to speak with such these world famous experts. The message was that everybody had been struggling first but that everything can be accomplished with enthusiasm and effort.
UPDATE January 2007
I started my ERS training fellowship on 01.11.2006.
The aim of my fellowship is to learn how and when I should use a technique called rigid bronchoscopy.
Rigid bronchoscopy is a very important instrument in the diagnosis and treatment of many lung diseases. For the last two or three decades, we have seen the revival of rigid bronchoscopy.
The problem is that apprenticeships in rigid bronchoscopy are not possible in all hospitals. Also, it is not part of the current program in the pneumology speciality in many countries, including my country, Spain.
For this reason I have come to the Lungenklinik Hemer, a lung hospital in Germany.
I chose the Lungenklinik Hemer because I worked in this hospital for three months in 2004. It is a hospital with a recognised prestige in the diagnosis and treatment of lung diseases. It has more than 50 years experience. This hospital contains 240 beds: 135 belong to the pneumology department, 85 to the thorax surgery and 20 to radiotherapy. They perform approximately 6,950 bronchoscopies each year.
Now I am learning when to use rigid bronchoscopy, acquiring knowledge and becoming familiar with the use of rigid bronchoscopy. I am practising rigid bronchoscopy in different situations, both diagnostic and therapeutic. I am also learning the technique and indications of the medical thoracoscopy.
For example, I have met different patients with an endobronchial tumour with an obstruction in the main right/left bronchus. This obstruction causes an obstructive pneumonitis.
With the use of rigid bronchoscopy, we can remove the tumour, we can help the patients to relieve their symptoms and perhaps to improve their survival.
In the next update, I will provide more details about how we perform the technique.
In the next week I will start a scientific project with my chief, Dr. Freitag.