Gurmeet Singh, MD

 Education
 1990-1997 : General Practitioner, Universitas Kristen Krida Wacana, Jakarta
 1999-2002 : Family Doctor (Member), Public Health, Universitas Indonesia, Jakarta
 2006-2010 : Post Graduate in Internal Medicine, Universitas Indonesia, Jakarta
 2013-2015 : Trainee in Respirology and Critical Illness Division, Internal Medicine, Cipto Mangunkusumo
 April-June 2014 : Trainee, Department of Pulmonary, Critical Care & Sleep Medicine Vardhman Mahavir Medical
College & Safdarjang Hospital, New Delhi (21 th April to 17th June,2014)
 2016 –2017 : Trainee, Interventional Pulmonology, Rajiv Gandhi Cancer Institute and Jaipur Golden Hospital, New Delhi (December
12th, 2016 to January 14th, 2017)
 2017 – now : PhD in Universitas Indonesia
 Dec 2018 : Observership in Department of Medicine, AIIMS, New Delhi (All India Institute of Medical Science)

 Employment:
 2001-2004 : General Practioner, Wamena General Hospital, Wamena, Papua-Indonesia
 2004-2005 : Head of Tiom Public Health Center, Wamena, Papua-Indonesia
 2002-2004 : Teaching Staff, Nursing School, Wamena, Papua-Indonesia
 2012-2014 : Supervisor (Internist) Primary Health Center, Tanah Abang
 2011 - present : Staff of Respirology and Critical Illness Division, Internal Medicine, RSCM
 2014 - present : Honorary Editor Indonesian Journal of Chest Critical and Emergency Medicine
 2014 - 2018 : Board Staff Member of National Health Insurance Regional Central Jakarta
 2015 - 2018 : Head of 24 Hour Executive Clinic RSCM Kencana

 Organization :
 1997 - present : Member of Indonesian Medical Doctor Society (IDI)
 2011 - present : Member of Indonesian Society of Internal Medicine (PAPDI)
 2011 - present : Member of Indonesian Society of Respirology (PERPARI)
 2016 – present : Member of World Association Bronchoscopy and Interventional Pulmonology (WABIP)
 2016 – present : Member of Indonesian Society of Emergency Medicine (PKGDI)
 Introduction of
Interventional Pulmonology
Gurmeet Singh, MD

KONAS PERPARI PADANG 2019

Interventional Pulmonology
•  Relatively new in pulmonary medicine

• respiratory disease  need for these procedures

• Performed by trained cardiothoracic surgeons or pulmonologists

Bolliger et al. Eur Resp J. 2002; 19(2): 356-73

INTERVENTIONAL PULMONOLOGY

Bellinger CR, Prakash B, Chatterjee AB. Clin Pulm Med 2013;20:320-9.

Interventional Pulmonology in Cipto
Mangunkusumo
• Basic procedures  bronchoscopies have been performed since the
1980’s

• Advanced procedures (cryotherapy, EBUS, thoracoscopy)  started in

2014

• Navigational bronchoscopy  5 cases in this year (2019)

Bronchoscopy
Procedure done for either diagnosis or treatment in respirology diseases

Indications:
Therapeutic
Diagnostic
Pneumonia Endotracheal intubation
Hemoptysis Atelectasis
Thoracic trauma Tracheobronchial obstruction
Tracheal obstructive pseudomembrane Percutanaeous tracheostomy
Specimen obtaining Foreign body extraction

Kadabayi et al. BJA edu. 2017; 17(2): 48-56

Bronchoscopy: Contraindications
Absolute Relative
Uncooperative patient Severe hypoxaemia
Team
Team isis unexperienced
unexperienced Acute
Acute coronary
coronary syndrome
syndrome
Insufficient facilities or equipment Arrythmia
Insufficient facilities or equipment Arrythmia
Inability to maintain proper oxygenation during Bronchospasm
Inability to maintain proper oxygenation during
the procedure Bronchospasm
the procedure
Severe pulmonary hypertension
Severe
Severe pulmonary hypertension
lung inflation (auto-PEEP 15 cmH2O)
Intracranial hypertension
Chronic renal
Intracranial failure
hypertension
Immunosuppression
Chronic renal failure
Bleeding diasthesis
Immunosuppression
Pulmonary abcess
Bleeding diasthesis
Pulmonary abcess
Kadabayi et al. BJA edu. 2017; 17(2): 48-56
Bronchoscopy: Complications
Anaesthesia/sedation Bronchoscopy Biopsy or brushing
Respiratory arrest Airway obstruction Pneumothorax
Convulsions Laryngospasm Hemorrhage
Cardiovascular collapse Bronchospasm
Toxicity from local anaesthetics Arrythmia
Hypoxaemia
Hypotension
Pulmonary edema
Hemorrhage

Kadabayi et al. BJA edu. 2017; 17(2): 48-56

Bronchoscopy: Types
Flexible Rigid

Fragoso et al. J Bronch Int Pulm. 2011; 18: 69-83

Electromagnetic Navigational Bronchoscopy
• An image-based newer
technology which helps in
approaching peripheral lung
lesions and mediastinal lymph
nodes

• Common complications:
pneumothorax and hemorrhage

Khan KA et al. Adv Ther. 2016; 33: 580-96

Bronchial Thermoplasty
• Works
  by delivering controlled thermal energy into the airway

• Indications: patients aged 18 years with severe persistent asthma not well
controlled with ICS and LABA

• Contraindications: COPD, bronchiectasis, recurrent respiratory infections

• Done in 3-week intervals where full recovery in between treatments

• Treatment sequences: first session (right lower lobe)  second session (left
lower lobe)  third session (both upper lobes) Dombret MC et al. Eur Resp Rev. 2014; 23: 510-8
Bronchial Thermoplasty

Dombret MC et al. Eur Resp Rev. 2014; 23: 510-8

Bronchoscopic Laser Coagulation
• A fast-acting, palliative, or
adjunctive thermally-ablative
therapy for central airway
obstruction
• Indicated in short intraluminal
lesions where first-line
treatment methods are not
doable
• Not suitable in lesions from
extrinsic compressions
Airway Stenting
Metal stenting Silicone stenting
• Inserted with topical anesthesia • A uniform length stent which can
and moderate sedation through be adjusted at time of insertion
flexible bronchoscopy
• Management of benign central
• Used in benign airway disorders airway obstruction due to
only if other treatments are not intubation trauma,
doable tracheostomy, connective tissue,
and collapsing airway
stabilization
Semaan R et al. T Thorac Dis. 2015; 7(4): 253-62
Airway Stenting
Metal stent Silicone stent
Thoracoscopy
• A common procedure utilizing a flexible-ended semi-rigid scope
inserted to the thoracic cavity

Shojaee S et al. J thorac Dis. 2015; 7(4): 339-51

Thoracoscopy: Two Types
Medical Thoracoscopy (MT) Video-Assisted Thoracoscopy Surgery (VATS)
Setting Procedure room Operation room
Sedation Local anaesthesia and mild to medium General anaesthesia
sedation
Ventilation Spontaneous ventilation One-lung ventilation
Purpose Diagnostic (biopsy) and therapeutic Minimally invasive surgery (lobectomy,
(pleurodesis, adenolysis) pneumonectomy)
Operator Respirology consultant, pulmonologist, Thoracic surgeon
or pediatrician
Process Minimally invasive, less expensive Invasive

Shojaee S et al. J thorac Dis. 2015; 7(4): 339-51

Medical Thoracoscopy
• The second most common procedure after bronchoscopy
Indications:
Diagnostic Therapeutic
Pleural effusions of unclear etiologies Talc poudrage (pneumothorax, malignant and
chronic recurrent non-malignant pleural
effusions)
Lung cancer staging with pleural effusion Parapneumonic effusions
Staging of diffuse malignant mesothelioma Empyema
Pneumothorax staging
Diffuse lung diseases
Localized chest wall lesions
Tuberculosis pleurisy culture
Breast cancer hormone receptor

Alraiyes AH et al. SAGE J. 2016: 3

Medical Thoracoscopy: Contraindications
Absolut Relative
Advanced empyema causing lack of pleural space Unstable cardiovascular or haemodynamic status
Pleural thickening (unknown causes) Patient cannot remain on lateral decubitus
position
Suspected mesothelioma (with fused visceral and Untreatable hypoxaemia
parietal surfaces)
Previous pleurodesis Bleeding diasthesis
Pulmonary arterial hypertension
Refractory cough
Drug hypersensitivity
Low life expectance

Alraiyes AH et al. SAGE J. 2016: 3

Medical Thoracoscopy: Procedure
Endobronchial Ultrasound (EBUS)
• A bronchoscope guided by ultrasound to provide visualization of the
airway wall and the adjacent structures

• Types: radial probe endobronchial ultrasound and convex probe

endobronchial ultrasound (EBUS-TBNA)

Balamugesh T et al. Lung Ind. 2009; 26(1): 17-21

EBUS: Indications and Contraindications
Indication Contraindications
Staging on non-small cell lung cancer (NSCLC) Life-threatening arrhythmias
Mediastinal lesions evaluation Myocardial ischemia (previous or current)
Intrapulmonary nodules assessment Poorly controlled heart failure
Endobronchial lesions evaluation Severe hypoxaemia
Airway integrity assessment Uncooperative patient
Endobronchial treatment guide Anti-platelets or anticoagulation consumption
Peripheral lesions Thrombocytopenia
Increased blood urea nitrogen or serum
creatinine levels

Balamugesh T et al. Lung Ind. 2009; 26(1): 17-21

Balamugesh T et al. Lung Ind. 2009; 26(1): 17-21
Cryotherapy
• Usage of extreme cold to destroy tissues with rapid freeze-thaw cycles

• Induces cell death and tissue adherence

• Probes: rigid, semi-rigid, and flexible

DiBardino DM et al. Ann An Thorac Soc. 2016; 13(8): 1405-15

Cryotherapy
Indications Contraindications
Palliative treatment of non-critical endobronchial Extraluminal occlusions
obstructive lesions
Foreign body removal Life-threatening obstructions
Blood clots
Mucus plugs
Management of low-grade malignant lesions and
early cancer

DiBardino DM et al. Ann An Thorac Soc. 2016; 13(8): 1405-15

Cryotherapy
Benefits Risk
Low risk of perforation Transient increase in airway obstruction
Low risk of air fire Bleeding
No hypoxaemia risk

 Risks do not manifest immediately  should not be performed in

severe acute airway obstruction

DiBardino DM et al. Ann An Thorac Soc. 2016; 13(8): 1405-15

Argon plasma coagulation
• An electrosurgical procedure used during bronchoscopy to induce
coagulative necrosis

Dumot JA et al. Endoscopy. 2008; 40(12): 1026-32

Argon Plasma Coagulation
Indications Contraindications
Hemorrhage Exclusive extraluminal obstruction of the airway
Airway granulomatous lesions Presence of pacemaker
Presence of metallic objects adjacent to either
electrode

Dumot JA et al. Endoscopy. 2008; 40(12): 1026-32

EBUS
Cryotherapy