May 22, 2025 • 40 mins
Centered on Health 5-22-25 - Pulmonary Nodules with Dr. Jewani
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Episode Transcript
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Speaker 1 (00:01):
It's now time for Centered on Health with Baptists Help
on use Radio. Wait forty teledy WYJS.
Speaker 2 (00:07):
Now here's doctor Jeff Tubbler.
Speaker 3 (00:11):
Good evening, everyone, and welcome to tonight's episode of Centered
on Health with Baptist Health here on news radio eight
forty whas. I'm your host, doctor Jeff Tublin, and we
are joined from the studio by our producer, mister Jim Fenn.
He is in the studio ready to take your calls
to talk to our guest this evening. Our number is
five oh two, five seven one eight four eighty four.
(00:32):
If you want to call in and ask a question,
five oh two, five seven one eight four eight four.
Tonight we're talking about pulmonary nodules and we're talking with
doctor Sandeep or Sonny Jowani. Doctor Jowani is a specialist
in pulmonary medicine and an intensive care medicine. One of
his area of expertise is in lung nodules. He received
(00:53):
his medical degree from Wayne State University School of Medicine,
has been practicing for quite a while, and he also
has some advance training that we're going to be talking
about a little bit later on.
Speaker 2 (01:02):
So Welcome to the show. Welcome to Centered on Health.
Speaker 1 (01:06):
Thank you for having me, doctor Tullan.
Speaker 3 (01:09):
You know, I'm excited to have you. I've been I've
been talking to trying to get you on for a while.
I'm glad we finally have the opportunity to hear your expertise.
Speaker 2 (01:17):
But start off starts off by telling us what is
a pomonologist.
Speaker 1 (01:23):
So pomonologist is someone who specializes in disorders of the lung.
So we deal with airways, and we deal with the
lung prank of myself, and we also deal with the
plural that's the lining of the lung and the space
around the lung in essence, and.
Speaker 3 (01:40):
Was there something about this field that drew you to
this field?
Speaker 2 (01:44):
Why were you interested in this?
Speaker 1 (01:46):
So? You know, I think a lot of promonologists are
actually driven to the field because here in the United
States we actually have a humble fellowship with pulmonary and
critical care. So you get trained from both simultaneously, and
I think with intensive care it's exciting. You know, there's
a lot going on, and then the pulmonary aspect fits
(02:08):
in really well because a lot of our ic you
patients end up meeting ventilators or have hypoxic respiratory failure,
and then it's a wide breath of things that you
kind of deal with. You keep your internal medicine training
seeing that you know, you address a lot of different
organ systems while they're in the ICU. You specialize specifically
in pulmonary and you have and you have the capability
(02:31):
of doing different procedures also, so you.
Speaker 3 (02:35):
Mentioned this, You and I see each other mostly in
your role as intensivists at the at the hospital.
Speaker 2 (02:41):
And the intensive care unit.
Speaker 3 (02:42):
But what are the other kinds of things in case
people are listening and want to call in what kind
What are the most common things that you treat in
the outpatient setting and.
Speaker 1 (02:51):
The outpatient setting, most of the common things asthma, COPD,
pulmonary infections like pneumonia, sleep to so on, verus obstructive
sleep apnea is also something that comes under our purview,
prominating nodules, lung cancer usually with the diagnosis aspect of it.
(03:11):
Those are just a few things.
Speaker 2 (03:14):
Yeah, just a few.
Speaker 3 (03:15):
Yeah, we could definitely do the whole series a series
of promonology with you. I mentioned in the introduction that
you have some advanced training as an interventional pullmonologist. I
know that's going to come into play when we talk
a little bit later about the procedures that you do.
But what does that extra training mean and what is
an interventional promonologist.
Speaker 1 (03:35):
So it's the one year fellowship that occurs after our
three years of promary Critical care fellowship, and in essence,
you train for advanced procedures that you can partake in
in the lung. So we continue the training that we
had in primary critical care fellowship with broncoscopy, but we
do more advanced procedures stent placements, different oblation techniques, with
(03:59):
crowd therapies and with peap therapies, more advanced robotic broncoscopies.
We also deal with a lot of plural conditions thors
and pieces or costc apiece. Also, those are a few
different things.
Speaker 2 (04:17):
And when you say plural, you what are you referring to?
Speaker 1 (04:20):
So the plurer the lining of the lung. So if
there's plural effusions, we do thoughts and PCs. We can
also do medical thori costapy, so similar to what the
thoracic surgeons do, we tend to focus on that parietal plura,
while the thoracic surgeons will focus more so on that
visceral pleura, the actual lining that's right along the lunes.
Speaker 2 (04:41):
Fantastic. Well, hopefully we'll have a little.
Speaker 3 (04:43):
Time at the end to pick your brain about some
of that. But so so one of us, one of
our listeners goes to their primary care physician and for
whatever reason, a chest X ray is ordered and they
get their report or it comes back on the my
chart before the provider has a chance to call them,
and they read that they have a pulmonary nodule.
Speaker 2 (05:02):
And of course, you know.
Speaker 3 (05:03):
Nobody likes to see those terms, especially when we don't
know what that means.
Speaker 2 (05:07):
So what is a pulmonary nodule?
Speaker 1 (05:11):
Yeah, so, in essence, a pulmonary nodule is anything that
is a different density in the lung tissue than should
normally be there. Typically, when you're taking a look at
a chest sex rate or a CT scan of the lung,
the air and the lung, which is the predominant factor,
is just all black. So when there's a white, in essence,
solid nodule that's there. It can be anything that is
(05:34):
filling that space which should be occupied by air. It
can be puffed, it can be fluid, it can be
cancer cells, it could be inflammatory cells, it could be
scar tissue, pretty much anything that is not air.
Speaker 3 (05:49):
So I think you mentioned that, But are those the
most common things that a nodule could be? If if
I guess, what we would call these would be incidental
nodules that you know, people get when they're looking for
something else, like you go to the mechanic and they
hear they find something else wrong with your car. But
what are those the most common things that a nodule
would be or should patients be worried when they hear
(06:10):
that or see that on their report?
Speaker 1 (06:12):
So the majority of nodules are benign in nature. The
studies kind of vary, and there's so many different factors
that play into if you have malignant disease and a
malignant nodule, smoking being one of the big risk factors.
But anywhere between one and ten percent of nodules on
average are malignant. The remaining, you know, ninety to ninety
(06:32):
nine percent of them are benign nodules. And there's multiple
different things that can cause that. Like I mentioned, smoking
is one of the biggest risk factors. If you have
a significant smoking history, your chances of developing lung cancer
are much higher than the public. Despite that, most smokers
will still not develop lung cancer, which is very fortunate,
(06:54):
but it is one of the concerns that we always
have living here in Kentucky with the Ohio River Valley.
Of the most common reasons we see pommearing nodules are
just infectious granuloma, so you have Granulomai's lung disease. Most
these nodules are calcified, so they just have a little
bit of calcium deposition, and they're usually just from previous
infections that you've had histoplasmosis, plaster like coss.
Speaker 3 (07:18):
So and those our infections, as you mentioned, that are
pretty common to the area that we live in, so
our listening audience might actually have some of these. And
if that happens, or that's what it's determined to be,
do they have to worry about the infection? Does it
mean that they have an infection that needs to be treated?
Speaker 1 (07:39):
Not necessarily if they're asymptomatic, this could just be remnants
of an infection that they've had in the past. It's
very similar to the skin. When you have a small cut,
sometimes you will develop a scar and sometimes you won't.
It just kind of depends on the severity of the cut.
The lungs are kind of very similar that if you
have a severe pulmary infection, sometimes they can leave a
(08:02):
scar and the tissue and the lungs and that can
manifest as a pulmary nodule.
Speaker 3 (08:09):
And so when this report comes back, and I mean,
thank you for reassuring us that so many of these
are probably benign. But can you tell that by looking
at the X ray? In other words, when do they
have to be worked up more? And is there more
imaging that needs to be done.
Speaker 2 (08:27):
What's the first step.
Speaker 3 (08:28):
With a pulmonary nodule to determine that it's not something
to be worried about.
Speaker 1 (08:33):
Yeah, so one of the easiest ways to tell if
there's calasifications those are benign. We don't recommend further follow
up for those nodules. Otherwise, it depends on multiple different factors.
The three big factors that we kind of take a
look at is the size of the nodule, the morphology
of the nodule, and the distribution of the nodule. Kind
(08:54):
of a little counterintuitive, but most of the time not always.
The more nodules that are there, the less likely it
is to be malignant. It tends to favor that's most
likely an infectious ideology. Sometimes we do see some nodules
which do represent metastatic disease with multiple different areas that
(09:14):
have now gotten disease from somewhere else in the body.
Seeing that the lungs get one hundred percent of the
blood supply coming to them as they pass through the
right heart into the lungs, So it's very commonplace of
metastatic disease. But like I said, most times when there's
multiple nodules that are in the lungs, it's usually some
kind of infectious ideology that's going on. The size of
(09:36):
the nodules make a big difference. Most primary nodules end
up being what's called micro nodules, or less than six
millimeters in size, and we kind of assess based on
risk factors if we need further screening or not if
we have an isolated nodule that's above six millimeters. Now
we have a step white fashion in air for screening.
Speaker 3 (09:59):
I'm going to want to hear all about that. I
know our listeners will too. We are talking about pulmonary
nodules and all things pulmonary tonight with doctor Sanji Jowani,
We are going to take a short break, and I
want to remind everybody that you are listening to send
it on Health with Baptists Help here on news radio
eight forty whs our phone number five oh two, five
seven one, eight four eighty four if you want to
(10:21):
call in and ask a question to our guests tonight.
Speaker 2 (10:24):
And we'll be right back.
Speaker 3 (10:42):
Welcome back to send it on Health with Baptist Help
here on news radio eight forty WHAS. I'm your host,
doctor Jeff Tumblin, and we're talking tonight with doctor Sonny Jowani,
who's a pullmonologist, and he's talking to us tonight about
pulmonary nodules, common thing we find in incidentally and when
we're looking for them in patients with risk factors. Phone
(11:04):
numbers five oh two, five seven one, eight four eight four.
Our producer message in fen is ready on standby to
take your calls, so doctor Jowanni. While we were on
the break, a couple of questions did come through. One
of the questions came from one of our listeners who
lives not in the city of Louisville, but out in
distant in Kentucky and was wondering about environmental exposures and
(11:30):
access to care in those areas. If pulmonary nodules are
a result of getting exposed to environmental factors.
Speaker 1 (11:39):
Yeah, there's definitely environmental factors. One thing you have to
consider is, unlike several of the other organs which are
isolated in a sterile environment, the lungs are exposed to everything.
You know, when we live in these bigger cities, we
definitely have a lot of exposure to pollution with our cars,
with you know, factories, with power plants, breathe those in
(12:00):
and the body does the best job they possibly can
to try to filter these out and get rid of
these particles. But some of the smaller particles will in
essence get lodged into the pulmonary parankoma further out and
stay there. So sometimes when we do bronz cost to
peace and patients who have been long term smokers or
have been exposed to coal mines or grown up in
(12:21):
you know, polluted cities a little less so here in
the United States, where where pollution standards are a little
better than some areas of Asia, you do see black
blackening or anthracosis of the airway walls. You can see
that exposure sometimes these Sometimes these exposures will result in
(12:43):
very small nodules that are seen diffusely. The distribution again
depends on you know what the exposure is. A lot
of these smaller particulates UH will in essence go to
the top of the lungs where most of the air
will go. It's just based off of simple gravity. So
the distribution pattern is very important to identify what's causing it.
Speaker 2 (13:05):
And have you seen any creative ways?
Speaker 3 (13:09):
Are you a part of any ways to reach some
of these areas of Kentucky where probably the environmental and
the smoking and things are a real problem, but the
access to care easily is also.
Speaker 1 (13:21):
A problem, you know, here in Kentucky. I have not
had a chance to do this thus far, especially with
COVID and with the pivot that we've had to Tally health.
I think it has been a great asset in getting
care to those remote communities. When I did my training
out in Colorado, Colorado is you know, surprisingly enough, doesn't
(13:46):
have the greatest access to healthcare because most of it
is most of it is related to the Denver area
and the western part of the state is pretty isolated.
So what we ended up doing was we set up
up to a virtual clinic in a few of those
smaller towns out there, So the patients would come into
the clinic there, this was just a primary care clinic,
(14:08):
and we would connect them with us out in Denver
and we would go over the imaging. All that can
be done pretty much anywhere, so we would just have
access to that. We would do the interview, and these
permanent inagos don't really require a lung evan and if
anything were to change, or if there was anything concerning
and they did need a procedure, then they could make
(14:29):
that trek out the four or five six hours that
they needed to and I think that that would be
a reasonable opportunity here in Kentucky also where unfortunately, our
smoking rate is one of the higher higher rates in
the country. We're at about twenty percent through the entire population.
And again this is a little better than it was
a few years ago, and we do have some discrepancies where,
(14:51):
you know, the younger generation eighteen and below is less
likely to smoke, and now the older generation sixty five
and above has decreased. But that chunk in the middle
between eighteen and sixty five, you know, is greater than
twenty percent. It's closer to twenty five to twenty eight percent.
Speaker 2 (15:08):
That's a lot.
Speaker 3 (15:09):
And sticking with the tobacco question for just a moment,
what is a pack here? I know that's kind of
often used to measure, you know, how much somebody smokes.
Speaker 2 (15:20):
So what does the term pack here mean? And how
is it sort of used?
Speaker 1 (15:24):
It's just to give us a general idea of how
much exposure you've had total in your life, and a
pack here means that you've smoked one pack per day
for a year duration.
Speaker 2 (15:35):
Got okay, great, thank you.
Speaker 3 (15:37):
And the other question that came in somebody was saying
that their doctor and I am going to want to
ask you about this here at Baptists, but that they
are in a program where they get regular X rays
because of their risk factors. But they were wondering how
much radiation they're getting exposed to with either a test
X ray or a CT scan very often during a
(15:58):
screening program.
Speaker 1 (16:00):
Yeah. Yeah, So that's actually a really good question because
a lot of patients are always concerned because there is
radiation exposure to chest X rays and CT scans, and
typically for imaging of the chess, we do not use MRI,
so a typical chess TEXT ray amounts to approximately approximately
about a month to a month and a half of
(16:22):
baseline radiation that we're all exposed to any given time.
This is closer to sea level, you know, when you're
in places like Denver or a higher altitude, clearly you're
exposed to more. But a simple way to think of
it from a chest X ray standpoint is if you
take a two hour flight or you get a chests
dex rate, they're the equivalent in radiation exposure. ST skins definitely, Yeah,
(16:44):
CT skins definitely have significantly more exposure. A just regular
CT scan of the chest is about fifty to seventy
times as much as a chest X ray. And what
we typically do when we're monitoring patients who qualify, we
get a low top skin and that tends to be
about twenty times twenty five times a typical chest X ray.
Speaker 3 (17:07):
And so these are being done oftentimes to monitor patients
with risk factors. Talk to us a little bit about
who is the type of patient that should be in
a screening program and how does a screening program work.
Speaker 1 (17:23):
Yeah, so there are set guidelines on who should be screened.
Anyone over the age, anyone between the age fifty and
eighty years, who has had at least a twenty pack,
your smoking history, and who is an active smoker or
has quit within the past fifteen years qualifies for LOTOS
lung cancer screening per national guidelines. So when we initiate
(17:47):
people on this lo those screening in the clinic, we
kind of go over the different risks and benefits of
the procedure of the imaging. In essence, the benefits are,
if there is a lung cancer or a nodule, we
can catch it early and hopefully we can intervene on
it early before there are complications that arise and before
(18:07):
the stage goes higher. There are again negatives associated with screening.
Also kind of similar to what we just talked about.
There is radiation exposure which is not denign, but again
not tremendous either most of the time. The other aspect
is when you do these lung cancer screening cetis, it
is very common to find a permanenty nodule, and like
(18:30):
I mentioned before, most permanenty nodules are benign, but it
may take you down that path of having more CT
scans done or at an increased frequency to monitor that
nodule and possibly undergoing procedures, and all these procedures do
come with their potential for complications.
Speaker 3 (18:49):
And how are we doing with our primary care offices
and providers recognizing the need for screening. Are we taking
advantage of this screening program enough? Or how are we
doing in Kentucky?
Speaker 1 (19:03):
I think I think in Kentucky we're still below the
national average, so we still have room to improve. And
there are different pockets where pockets of Kentucky where we
tend to do better. Again, the bigger cities tend tend
to do better overall, just from an education standpoint, Lovell
does better up closer to Cincinnati. They also have a
(19:23):
very robust screening program that's set up there. And especially
as we get into eastern Kentucky with the cool mine
and with the higher rates of smoking, that is that
is where we want the screening program to be quite ubiquitous.
Speaker 3 (19:39):
And we've had the privilege of having on our show
before nurse navigators, especially with when it comes to the
lung nodule clinics.
Speaker 2 (19:52):
Are you a part of that?
Speaker 3 (19:53):
Do you do you utilize the nurse navigators and how
have you fit that into your practice?
Speaker 1 (19:58):
If you do yeah, yeah, So we do work with
the lung clinic here at Baptist. That involves as perminologists,
and then that also involves the two thoracic surgeons, doctor
Mayheon and doctor Gol. So, in essence, we have a
new software it's been out for about a year year
(20:18):
and a half now called Eon EO N and what
in essence is an AI driven software where any single
mention of Pomeray nodule and any of the imaging that
is done at Baptist gets flagged and from there we
do a screening process where we check the size of
the nodule, We assess if the station is already being
(20:40):
followed by a pominologist or biothoracic surgeon who we're monitoring,
and any of the higher risk nodules usually above about
six to eight millimeters, we triage to the front so
we can intervene early.
Speaker 3 (20:55):
Well, that is a great segue into kind of delving
into one of the areas of expertise, which is getting
at these nodules for us. So we're going to take
a break and we're going to jump into that conversation
when we come back and you are listening to center
it on health with Baptist Health here on news radio
eight forty whas. I'm your host, doctor Jeff Tublin, and
(21:16):
tonight we're talking with doctor Sunny Jowani about pulmonary nodules
and here at Baptists five five oh two, five seven one,
eight four eighty four. Please call us if you have
any questions or you want to talk to doctor Juwanis.
Speaker 2 (21:28):
We'll be right back.
Speaker 3 (21:43):
Well, welcome back to Senate on Health with Baptist Health
here on news radio eight forty whas. I'm your host,
doctor Jeff Tublin, And if you're just joining us, we're
talking tonight about pulmonary nodules with doctor Sunny Joanni and
he has been telling us all about what they might
be and how we're going to treat them. So, doctor Juani,
(22:04):
I know that you've been trained and you're bringing some
pretty exciting stuff to Baptists. So give us a little
bit a picture of the landscape of how were we
addressing these nodules once they've been determined that they need
to be biapsed for some reason. What were we doing
and what are you doing now that's improving it?
Speaker 1 (22:25):
Yeah, So as of you know, the last four or
five years, we've had a new technology called robotic bronchoscopy.
There are two predominant systems that are available on the
market right now, Ion and Monarch, and the one that
we have here is the Ion broncoscope. Prior to this,
you know, we were quite limited with our with our
(22:45):
bronchoscopic technology on how far we could get out into
the lung tissue. Usually even our smallest pediatric broncoscopes would
go out maybe three or four generations of ailways, so
you can make it probably about fifty percent into the perferiate,
but lung, the Ion broncoscopy is a much thiner scope,
and in essence, the way that they're able to decrease
(23:08):
that size is you have a camera that's in there
and then nothing else, and once you want to actually intervene,
you have to take out that camera and then you
intervene with with whatever tool that you're using. But the
benefit that this has done is it's allowed us to
reach nodules even all the way up to the flura itself,
so pretty much in most areas is a long we
(23:28):
can access it. So when you.
Speaker 2 (23:32):
Yeah, go ahead, now go please.
Speaker 1 (23:34):
Go continue, So you know, the in essence, the steps
that we take is we find a pomeary nodule, we
assess if it needs to be biopsyeed based on the
risk factors, and based on the risk the probability that
this is a malignant or not, if you know, we
do pursue a biops seed, then we get what's called
(23:54):
an Ion planning CT. It's slightly different than the other
cts we get where the cuts are thinner. But what
this allows us to do is is we can take
that CT and put it into our planning software and
it helps to recreate that airway tree. This serves almost
like a Google Maps kind of situation, where you know,
in the software we can mark exactly where we want
(24:16):
to go in this case the pomary nodule, and the
software will figure out a route based on which airways
it take. So we can get to that PASI and
then as a result, we can bio see that.
Speaker 2 (24:29):
What is the Ion part of the Ion broncoscopy? What
is that?
Speaker 1 (24:34):
I so Ion is the company that makes the roboty.
So this is a brand name in.
Speaker 3 (24:40):
Essence that we're saying perfect okay, And now just to
kind of give our listeners a sense of why this
is such an advancement before. If I'm understanding it correctly,
sometimes you had to put a needle from the outside
of the body, and did that increase the risk of
the procedure? Is that why this is so benef or
(25:00):
is it an access issue or is it both.
Speaker 1 (25:04):
Both? So significantly so when we would when we would
pursue transtutaneous biopses, your risk of a pneumothorax or collapsed
with the lung is significantly higher. The data shows anywhere
between fifteen and twenty five percent of patients will delet
up a neumothorax. You know, you do not need to
intervene in every single neumothorax. Sometimes most of the time
(25:26):
they will just resolve on their own. But it does
lead to increased morbidity, and it does lead to increased
optialization with the ion. Typically the studies have shown that
it's less than five percent chance of pneumothorax and more
of the recent studies are shown up three and a
half percent or less risk of neumoto.
Speaker 3 (25:44):
X and walk us through the procedure. Is it an
inpatient procedure an outpatient procedure? What's the what's the experience
to get this done? Through the patient lens.
Speaker 1 (25:57):
Yes, so it's an outpatient procedure seen in clinic. Once
that decision is made that we will pursue an ion vonkoscopy,
we get that ion planning CT. If there is a
high suspicion that this nodule or lesion will get figger.
Usually that power up CT is immediately planned as an
ion planning CT. But once that's Once that's done, it's
(26:19):
like pretty much any other typical outpatient procedure NPO before
midnight from the procedure, if you're at any blood dinner's
anti platelet agents, those need to be held for a
few days. You come in for the procedure or an
hour hour and a half before it's scheduled. The procedure
itself depends on how difficult of a location it is
(26:40):
to get to, but typically ranges about an hour hour
and a half. And after the procedure, they're usually monitored
for about forty five minutes to an hour, and as
long as there's no complications meaning hemoposess where you're coughing
up significant quantities of blood or pneumoporax, they go home
the same day.
Speaker 3 (27:00):
And we know that it takes an hour and a
half because your GI colleagues are waiting for the room,
right for sure?
Speaker 1 (27:08):
For sure, yeah, exactly where we're not as skills as
the GI colleagues where we can get a procedure done
in ten minutes. So there with.
Speaker 2 (27:15):
Us, you know, we'll be very patient. So obviously this
is very anxiety.
Speaker 3 (27:21):
And produce inducing for the patient because you're going into
biopsy and nodule that they are at this point aware
that you have some suspicion of how quickly do you
get a result or do you work with the pathologists
right away?
Speaker 2 (27:34):
How quickly is there an answer?
Speaker 1 (27:37):
Final pathology takes about three to five days to come back,
but we do have rapid on site evaluation that's done
by a cytotechnologist in the room, so sometimes we are
able to get a confirmation that this is malignant. Usually
the final confirmation of what kind of malignancy it is
(27:57):
takes a few days when all the staining is done
by the pathologist and that final diagnosis comes out. But
it is quite often that I will tell the family
or the family member that this is malignant and we
need to pursue all of the other avenues, meaning get
a pet skin, get an mrim the brain and get
them in with oncology in the meantime while we're waiting
(28:18):
for that final diagnosis.
Speaker 3 (28:21):
Eda, And you answered this nicely already about what comes next,
which is kind of that work up. And I know
that you do some some interesting stuff that we'll try
and touch on a little bit. But in general, when
does a CT surgeon a cardiothoracic surgeon need to get involved?
Speaker 1 (28:37):
Yeah, yeah, So a cardiothoracic surgeon will often get involved
depending on the stage of the lung cancer and the
tolerability of the patient to in essence tolerate surgery. A
lot of the times, especially with these ion robotic broncostrophies
and the lung cancer screening, we're able to find quite
small lesions that are there and that can be completely
(29:00):
freed in by resection. Sometimes it's a segment tectomy, so
just a small portion of the lungs. Sometimes it does
require a more involved intervention where they're taking out an
entirely low bectomy. And this has to be evaluated from
the setting of will the cancer be treated, will the
patient tolerate it? From a pulmonary function standpoint, will the
(29:21):
patient tolerate it? From just an overall clinical standpoint, Do
they have any other contraindications to that? And that's where
the thoracic surgeons evaluate the patient.
Speaker 3 (29:31):
Fantastic, and of course we want diagnosis and we want
all of these things rapidly. But you know, obviously one
of the other reasons we're doing all of this, the
screening and the access, is to change outcomes. Do we
have any evidence yet? Is it too early to know
if by getting to these peripheral lesions or these smaller
lesions that were previously unaccessible, are we changing changing the
(29:53):
outcomes yet?
Speaker 1 (29:55):
Yeah? Yes, So you know, when you look at when
you look at the outcomes based on stage, there's a drastic,
drastic survival benefit that you have. If you're catching these
patients within stage one disease, there are chances of five
year survival or anywhere between seventy and ninety percent. As
(30:17):
soon as you get into stage two disease, you've dropped
another ten to twenty percent in survival benefit survival chances,
and then it precipitously drops after that. Stage three and
stage four one cancer are still extraordinarily difficult to treat
and survival is quite limited at five years.
Speaker 3 (30:38):
So this is like a very important linkage of finding
the patients at risk factors, getting them into these screening programs,
finding these nodules, and getting these diagnoses early.
Speaker 1 (30:49):
Very much.
Speaker 2 (30:50):
So, yes, fantastic.
Speaker 3 (30:52):
Well, we're going to take our final break here, and
I want to remind everybody that you are listening to
Centered on Health with Baptist Health here on news Radio
whas our guest tonight, doctor Sunny Jewanni, telling us about
pulmonary nodules and all the.
Speaker 2 (31:05):
Great things we're doing here at Baptist Hospital.
Speaker 3 (31:08):
If you missed any of tonight's show, you can download
the iHeartRadio app. It's free, it's easy to use, and
give you access to the entire show and all our
previous shows.
Speaker 2 (31:16):
We'll be right back.
Speaker 3 (31:31):
Welcome back to Senate on Health with Baptist Health here
on News Radio eight forty whas. I'm your host, Doctor
Jeff Toblin, and we've been talking tonight with doctor Sonny
Jowani about pulmonary nodules. Remember to download the iHeartRadio app
to re listen to this or any of our previous
segments and to have access to all the other features
that the app has to offer. So doctor Jowani. Before
(31:54):
we went on break, you were telling us all about
this new technology, and one of the things you mentioned was,
and I think that automatically, you know, raises an image
of all this you know, high tech advanced stuff. Tell
us a little bit about what the robot is, and
and it's not doing the procedure, and you're just sort
(32:15):
of telling it what to do. It's tell us how
that works.
Speaker 1 (32:19):
So no, it's definitely not doing the procedure. We still
have a few years I think, until we get to
that point and I'm put out of a job. So
in essence of sorry, no.
Speaker 2 (32:29):
I was agreeing with you.
Speaker 1 (32:30):
Yes, yeah, So in essence, the ion robot is made
by Intuitive and it's similar or it's a it's it's
a similar product to the Da Vinci robot that's been
used quite for quite some time with general surgery, with
ractic surgery, et cetera. So the robot is just a
(32:50):
long flexible scope in addition to the machine which involves
a screen and all of the software and all the
hardware that's associated with it. So when the patient is
finally intubated, we actually connect to the patient to this
robot with that small flexible scope that goes into the
end of tracheal two, and then we in essence have
(33:11):
we in essence have a remote control that we're playing
with almost like one of those old Atari video games,
where we have a scroll wheel that we're able to
use to navigate this broncoscope in through the patient's airways
and guide it to which airways we want. This allows
us to get further in and this allows for stability also,
so when we are in the location that we would
(33:33):
like to be, we can keep it parked there without
significant discrepancy or significant movement because again a lot of
these lesions are a decent size one centimeter, one and
a half two centimeters, but we are going for nodules
that are smaller than that. The smallest that I've had
a chance to go for and actually have a diagnosis
(33:54):
is six millimeters. So you know, if you want to
put that into perspective, a cheerio is about a sentime,
So this is, you know, almost half the size of
a cheerio, and this is also in three D space.
We need it. So we need stability as much as
we're able to get.
Speaker 3 (34:13):
And are there are there people that wouldn't be appropriate
for a procedure like this or is this sort of
the standard now that is for everybody?
Speaker 1 (34:23):
So the majority of patients can tolerate a robotic bronchoscope,
we still do have some people who have lesions that
are extremely peripheral, especially when we're considering patients who have
perpole legiance in the complete upper load near the apex
or in the lower lobes. Sometimes those areas are very
(34:43):
difficult to get to even with this technology. And we
still do utilize interventional radiology with the percutaneous biopsy when
when we have these when we have these patients.
Speaker 3 (34:56):
Well, we're lucky to have you here to do these.
And one of the things I love to highlight with
our guests are things that you're doing that are really unique.
And so I wanted to talk to you a little
bit about your role as an interventional pomonologist. And you
mentioned some of the things earlier that you do, and
you mentioned a stent, and so tell us a little
(35:20):
bit about what a stent is and why somebody might
need one.
Speaker 1 (35:25):
Yeah, so very similar to the stents that are placed
in the coordinary arteries by the interventional cardiologists or any
blockagest it's very similar Again, these are much bigger stents
than what we put in the arteries, and they can
be placed for a number of different reasons. Some people
will have some kind of a pollution or some kind
of narrowing within their airway. It could be an extrinsic
(35:47):
compression that's happening. If they have a big tumor that's
causing this airway to compress down, and now they're having
difficulty breathing and significant symptoms. You can place a scent
and open up that airway and in that and offer
them a palliative option. Additionally, there are a number of
different diseases, most of them benign, which can cause the
(36:09):
remodeling in the airway and can cast stenosis. One of
the most common things is when we have these patients
who are in the ITU who are intubated. Some patients
will require multiple intubations, especially if they have severe coopd
or any other prominent problems. When we inflate that balloon
in the airway to for the endotradeo too, sometimes it
(36:31):
can cast some pressure on that airway mucosa and it
can cost some tissue death and then some remodeling, and
and then asen scars down and causes us toenosis, So
we can go in there and sometimes we can use
stems to keep those open. Sometimes we can just use
a simple balloon and in essence priv open. Those are
(36:53):
pretty predominantly the reasons why we place these stems.
Speaker 3 (36:58):
And are they typically that you put in and they
stay in forever? Do they have to be changed or
when you put it in, is it like you're putting
it in and you leave it in?
Speaker 1 (37:09):
And typically we take them out and their palliation until
the underlying disease process has been addressed. There are some
patients who do require long term stents. The concern for
these stents is sometimes you can cause scarring around the stent,
so we have to take that into account and often
we'll have to replace them every year or so, especially
(37:29):
in these long term patients. The other concerning aspect of
them is that we need most of these stents. You know,
they're either metal or some kind of silicone basis, and
they're very They're at much increased risk of getting clogged
up with mucus that you just naturally produce in the airways,
so we need to make sure that these patients are
(37:51):
an extremely aggressive airway clearance therapies, because if that stent
gets secluded, then often that stent actually needs to move
ruled because it's extremely difficult to clean out all that
new gifts.
Speaker 3 (38:05):
And it's interesting that you were going in that direction
because I was going to ask you about problems with
the stent, because you know, my mind goes to the
stents we put in like the heart and stuff like that.
Is there do patients who get stents in the pulmonary
system do they need to be on blood thinners like
patients who get them in the heart.
Speaker 1 (38:24):
No, No, blood sinners, usually just nebulize medications to keep
those secretions minimal and allow them to be cleared.
Speaker 3 (38:34):
Fantastic, and we have about a minute left, But I
would love to just hear your perspective on when you
said that you do tumor ablations. Where do you see
the role of that and when would somebody get an
ablation of a tumor as opposed to getting it removed surgically.
Speaker 1 (38:52):
Yeah. Yeah, So a lot of the times these patients
are not surgical candidates just because if you're seeing the
tumor in the airway, it's usually quite proximal and that
would entail removing a big portion of the lung, either
a lobe or the entire lung. And a lot of
our patients who do end up with lung cancer already
have underlying chronic obstructive pulmary disease or other pulmary processes
(39:14):
where it makes it very difficult for them to tolerate
a surgery of that magnitude. So tumor ablations usually are
in conjugation with radiation therapy or chemotherapy that they're getting
through their oncologists. So this is an essence for valiation
purposes where if they have a tumor in the airway
and it's blocking off some airway and causing recurrent pneumonias
(39:37):
or shortness of breath or causing tomopthesis, you can address
that and help symptomatically manage them well.
Speaker 3 (39:45):
Doctor Juwana, you know how long I've been anxious to
get you on our show, and it was worth every
minute of waiting. Thank you so much for providing us
with all this information that is going to do it
for another episode of Centered on Health with Baptist Health.
I'm your host, doctor Jeff Dublin. I want to thank
our guests, Doctor Sunny, Jowani Burd you're talking to us
about pulmonary nodules. I want to thank our producer mister
(40:06):
Jimpenn and of course you the listener. Next week we
are going to be talking about breast surgery at new
updates with doctor Thomas Nol.
Speaker 2 (40:14):
Make sure you join us next week. Have a great weekend.
This program is for informational purposes only and should not
be relied upon as medical advice. The content of this
program is not intended to be a substitute for professional
medical advice, diagnosis, or treatment.
Speaker 1 (40:30):
This show is not designed to replace a physician's medical
assessment and medical judgment.
Speaker 2 (40:35):
Always seek the advice of your physician with any questions
or concerns you may have related to your personal health
or regarding specific medical conditions. To find a Baptist health provider,
please visit Baptist Heealth dot com.
It's now time for Centered on Health with Baptists Help
on use Radio. Wait forty teledy WYJS.
Speaker 2 (00:07):
Now here's doctor Jeff Tubbler.
Speaker 3 (00:11):
Good evening, everyone, and welcome to tonight's episode of Centered
on Health with Baptist Health here on news radio eight
forty whas. I'm your host, doctor Jeff Tublin, and we
are joined from the studio by our producer, mister Jim Fenn.
He is in the studio ready to take your calls
to talk to our guest this evening. Our number is
five oh two, five seven one eight four eighty four.
(00:32):
If you want to call in and ask a question,
five oh two, five seven one eight four eight four.
Tonight we're talking about pulmonary nodules and we're talking with
doctor Sandeep or Sonny Jowani. Doctor Jowani is a specialist
in pulmonary medicine and an intensive care medicine. One of
his area of expertise is in lung nodules. He received
(00:53):
his medical degree from Wayne State University School of Medicine,
has been practicing for quite a while, and he also
has some advance training that we're going to be talking
about a little bit later on.
Speaker 2 (01:02):
So Welcome to the show. Welcome to Centered on Health.
Speaker 1 (01:06):
Thank you for having me, doctor Tullan.
Speaker 3 (01:09):
You know, I'm excited to have you. I've been I've
been talking to trying to get you on for a while.
I'm glad we finally have the opportunity to hear your expertise.
Speaker 2 (01:17):
But start off starts off by telling us what is
a pomonologist.
Speaker 1 (01:23):
So pomonologist is someone who specializes in disorders of the lung.
So we deal with airways, and we deal with the
lung prank of myself, and we also deal with the
plural that's the lining of the lung and the space
around the lung in essence, and.
Speaker 3 (01:40):
Was there something about this field that drew you to
this field?
Speaker 2 (01:44):
Why were you interested in this?
Speaker 1 (01:46):
So? You know, I think a lot of promonologists are
actually driven to the field because here in the United
States we actually have a humble fellowship with pulmonary and
critical care. So you get trained from both simultaneously, and
I think with intensive care it's exciting. You know, there's
a lot going on, and then the pulmonary aspect fits
(02:08):
in really well because a lot of our ic you
patients end up meeting ventilators or have hypoxic respiratory failure,
and then it's a wide breath of things that you
kind of deal with. You keep your internal medicine training
seeing that you know, you address a lot of different
organ systems while they're in the ICU. You specialize specifically
in pulmonary and you have and you have the capability
(02:31):
of doing different procedures also, so you.
Speaker 3 (02:35):
Mentioned this, You and I see each other mostly in
your role as intensivists at the at the hospital.
Speaker 2 (02:41):
And the intensive care unit.
Speaker 3 (02:42):
But what are the other kinds of things in case
people are listening and want to call in what kind
What are the most common things that you treat in
the outpatient setting and.
Speaker 1 (02:51):
The outpatient setting, most of the common things asthma, COPD,
pulmonary infections like pneumonia, sleep to so on, verus obstructive
sleep apnea is also something that comes under our purview,
prominating nodules, lung cancer usually with the diagnosis aspect of it.
(03:11):
Those are just a few things.
Speaker 2 (03:14):
Yeah, just a few.
Speaker 3 (03:15):
Yeah, we could definitely do the whole series a series
of promonology with you. I mentioned in the introduction that
you have some advanced training as an interventional pullmonologist. I
know that's going to come into play when we talk
a little bit later about the procedures that you do.
But what does that extra training mean and what is
an interventional promonologist.
Speaker 1 (03:35):
So it's the one year fellowship that occurs after our
three years of promary Critical care fellowship, and in essence,
you train for advanced procedures that you can partake in
in the lung. So we continue the training that we
had in primary critical care fellowship with broncoscopy, but we
do more advanced procedures stent placements, different oblation techniques, with
(03:59):
crowd therapies and with peap therapies, more advanced robotic broncoscopies.
We also deal with a lot of plural conditions thors
and pieces or costc apiece. Also, those are a few
different things.
Speaker 2 (04:17):
And when you say plural, you what are you referring to?
Speaker 1 (04:20):
So the plurer the lining of the lung. So if
there's plural effusions, we do thoughts and PCs. We can
also do medical thori costapy, so similar to what the
thoracic surgeons do, we tend to focus on that parietal plura,
while the thoracic surgeons will focus more so on that
visceral pleura, the actual lining that's right along the lunes.
Speaker 2 (04:41):
Fantastic. Well, hopefully we'll have a little.
Speaker 3 (04:43):
Time at the end to pick your brain about some
of that. But so so one of us, one of
our listeners goes to their primary care physician and for
whatever reason, a chest X ray is ordered and they
get their report or it comes back on the my
chart before the provider has a chance to call them,
and they read that they have a pulmonary nodule.
Speaker 2 (05:02):
And of course, you know.
Speaker 3 (05:03):
Nobody likes to see those terms, especially when we don't
know what that means.
Speaker 2 (05:07):
So what is a pulmonary nodule?
Speaker 1 (05:11):
Yeah, so, in essence, a pulmonary nodule is anything that
is a different density in the lung tissue than should
normally be there. Typically, when you're taking a look at
a chest sex rate or a CT scan of the lung,
the air and the lung, which is the predominant factor,
is just all black. So when there's a white, in essence,
solid nodule that's there. It can be anything that is
(05:34):
filling that space which should be occupied by air. It
can be puffed, it can be fluid, it can be
cancer cells, it could be inflammatory cells, it could be
scar tissue, pretty much anything that is not air.
Speaker 3 (05:49):
So I think you mentioned that, But are those the
most common things that a nodule could be? If if
I guess, what we would call these would be incidental
nodules that you know, people get when they're looking for
something else, like you go to the mechanic and they
hear they find something else wrong with your car. But
what are those the most common things that a nodule
would be or should patients be worried when they hear
(06:10):
that or see that on their report?
Speaker 1 (06:12):
So the majority of nodules are benign in nature. The
studies kind of vary, and there's so many different factors
that play into if you have malignant disease and a
malignant nodule, smoking being one of the big risk factors.
But anywhere between one and ten percent of nodules on
average are malignant. The remaining, you know, ninety to ninety
(06:32):
nine percent of them are benign nodules. And there's multiple
different things that can cause that. Like I mentioned, smoking
is one of the biggest risk factors. If you have
a significant smoking history, your chances of developing lung cancer
are much higher than the public. Despite that, most smokers
will still not develop lung cancer, which is very fortunate,
(06:54):
but it is one of the concerns that we always
have living here in Kentucky with the Ohio River Valley.
Of the most common reasons we see pommearing nodules are
just infectious granuloma, so you have Granulomai's lung disease. Most
these nodules are calcified, so they just have a little
bit of calcium deposition, and they're usually just from previous
infections that you've had histoplasmosis, plaster like coss.
Speaker 3 (07:18):
So and those our infections, as you mentioned, that are
pretty common to the area that we live in, so
our listening audience might actually have some of these. And
if that happens, or that's what it's determined to be,
do they have to worry about the infection? Does it
mean that they have an infection that needs to be treated?
Speaker 1 (07:39):
Not necessarily if they're asymptomatic, this could just be remnants
of an infection that they've had in the past. It's
very similar to the skin. When you have a small cut,
sometimes you will develop a scar and sometimes you won't.
It just kind of depends on the severity of the cut.
The lungs are kind of very similar that if you
have a severe pulmary infection, sometimes they can leave a
(08:02):
scar and the tissue and the lungs and that can
manifest as a pulmary nodule.
Speaker 3 (08:09):
And so when this report comes back, and I mean,
thank you for reassuring us that so many of these
are probably benign. But can you tell that by looking
at the X ray? In other words, when do they
have to be worked up more? And is there more
imaging that needs to be done.
Speaker 2 (08:27):
What's the first step.
Speaker 3 (08:28):
With a pulmonary nodule to determine that it's not something
to be worried about.
Speaker 1 (08:33):
Yeah, so one of the easiest ways to tell if
there's calasifications those are benign. We don't recommend further follow
up for those nodules. Otherwise, it depends on multiple different factors.
The three big factors that we kind of take a
look at is the size of the nodule, the morphology
of the nodule, and the distribution of the nodule. Kind
(08:54):
of a little counterintuitive, but most of the time not always.
The more nodules that are there, the less likely it
is to be malignant. It tends to favor that's most
likely an infectious ideology. Sometimes we do see some nodules
which do represent metastatic disease with multiple different areas that
(09:14):
have now gotten disease from somewhere else in the body.
Seeing that the lungs get one hundred percent of the
blood supply coming to them as they pass through the
right heart into the lungs, So it's very commonplace of
metastatic disease. But like I said, most times when there's
multiple nodules that are in the lungs, it's usually some
kind of infectious ideology that's going on. The size of
(09:36):
the nodules make a big difference. Most primary nodules end
up being what's called micro nodules, or less than six
millimeters in size, and we kind of assess based on
risk factors if we need further screening or not if
we have an isolated nodule that's above six millimeters. Now
we have a step white fashion in air for screening.
Speaker 3 (09:59):
I'm going to want to hear all about that. I
know our listeners will too. We are talking about pulmonary
nodules and all things pulmonary tonight with doctor Sanji Jowani,
We are going to take a short break, and I
want to remind everybody that you are listening to send
it on Health with Baptists Help here on news radio
eight forty whs our phone number five oh two, five
seven one, eight four eighty four if you want to
(10:21):
call in and ask a question to our guests tonight.
Speaker 2 (10:24):
And we'll be right back.
Speaker 3 (10:42):
Welcome back to send it on Health with Baptist Help
here on news radio eight forty WHAS. I'm your host,
doctor Jeff Tumblin, and we're talking tonight with doctor Sonny Jowani,
who's a pullmonologist, and he's talking to us tonight about
pulmonary nodules, common thing we find in incidentally and when
we're looking for them in patients with risk factors. Phone
(11:04):
numbers five oh two, five seven one, eight four eight four.
Our producer message in fen is ready on standby to
take your calls, so doctor Jowanni. While we were on
the break, a couple of questions did come through. One
of the questions came from one of our listeners who
lives not in the city of Louisville, but out in
distant in Kentucky and was wondering about environmental exposures and
(11:30):
access to care in those areas. If pulmonary nodules are
a result of getting exposed to environmental factors.
Speaker 1 (11:39):
Yeah, there's definitely environmental factors. One thing you have to
consider is, unlike several of the other organs which are
isolated in a sterile environment, the lungs are exposed to everything.
You know, when we live in these bigger cities, we
definitely have a lot of exposure to pollution with our cars,
with you know, factories, with power plants, breathe those in
(12:00):
and the body does the best job they possibly can
to try to filter these out and get rid of
these particles. But some of the smaller particles will in
essence get lodged into the pulmonary parankoma further out and
stay there. So sometimes when we do bronz cost to
peace and patients who have been long term smokers or
have been exposed to coal mines or grown up in
(12:21):
you know, polluted cities a little less so here in
the United States, where where pollution standards are a little
better than some areas of Asia, you do see black
blackening or anthracosis of the airway walls. You can see
that exposure sometimes these Sometimes these exposures will result in
(12:43):
very small nodules that are seen diffusely. The distribution again
depends on you know what the exposure is. A lot
of these smaller particulates UH will in essence go to
the top of the lungs where most of the air
will go. It's just based off of simple gravity. So
the distribution pattern is very important to identify what's causing it.
Speaker 2 (13:05):
And have you seen any creative ways?
Speaker 3 (13:09):
Are you a part of any ways to reach some
of these areas of Kentucky where probably the environmental and
the smoking and things are a real problem, but the
access to care easily is also.
Speaker 1 (13:21):
A problem, you know, here in Kentucky. I have not
had a chance to do this thus far, especially with
COVID and with the pivot that we've had to Tally health.
I think it has been a great asset in getting
care to those remote communities. When I did my training
out in Colorado, Colorado is you know, surprisingly enough, doesn't
(13:46):
have the greatest access to healthcare because most of it
is most of it is related to the Denver area
and the western part of the state is pretty isolated.
So what we ended up doing was we set up
up to a virtual clinic in a few of those
smaller towns out there, So the patients would come into
the clinic there, this was just a primary care clinic,
(14:08):
and we would connect them with us out in Denver
and we would go over the imaging. All that can
be done pretty much anywhere, so we would just have
access to that. We would do the interview, and these
permanent inagos don't really require a lung evan and if
anything were to change, or if there was anything concerning
and they did need a procedure, then they could make
(14:29):
that trek out the four or five six hours that
they needed to and I think that that would be
a reasonable opportunity here in Kentucky also where unfortunately, our
smoking rate is one of the higher higher rates in
the country. We're at about twenty percent through the entire population.
And again this is a little better than it was
a few years ago, and we do have some discrepancies where,
(14:51):
you know, the younger generation eighteen and below is less
likely to smoke, and now the older generation sixty five
and above has decreased. But that chunk in the middle
between eighteen and sixty five, you know, is greater than
twenty percent. It's closer to twenty five to twenty eight percent.
Speaker 2 (15:08):
That's a lot.
Speaker 3 (15:09):
And sticking with the tobacco question for just a moment,
what is a pack here? I know that's kind of
often used to measure, you know, how much somebody smokes.
Speaker 2 (15:20):
So what does the term pack here mean? And how
is it sort of used?
Speaker 1 (15:24):
It's just to give us a general idea of how
much exposure you've had total in your life, and a
pack here means that you've smoked one pack per day
for a year duration.
Speaker 2 (15:35):
Got okay, great, thank you.
Speaker 3 (15:37):
And the other question that came in somebody was saying
that their doctor and I am going to want to
ask you about this here at Baptists, but that they
are in a program where they get regular X rays
because of their risk factors. But they were wondering how
much radiation they're getting exposed to with either a test
X ray or a CT scan very often during a
(15:58):
screening program.
Speaker 1 (16:00):
Yeah. Yeah, So that's actually a really good question because
a lot of patients are always concerned because there is
radiation exposure to chest X rays and CT scans, and
typically for imaging of the chess, we do not use MRI,
so a typical chess TEXT ray amounts to approximately approximately
about a month to a month and a half of
(16:22):
baseline radiation that we're all exposed to any given time.
This is closer to sea level, you know, when you're
in places like Denver or a higher altitude, clearly you're
exposed to more. But a simple way to think of
it from a chest X ray standpoint is if you
take a two hour flight or you get a chests
dex rate, they're the equivalent in radiation exposure. ST skins definitely, Yeah,
(16:44):
CT skins definitely have significantly more exposure. A just regular
CT scan of the chest is about fifty to seventy
times as much as a chest X ray. And what
we typically do when we're monitoring patients who qualify, we
get a low top skin and that tends to be
about twenty times twenty five times a typical chest X ray.
Speaker 3 (17:07):
And so these are being done oftentimes to monitor patients
with risk factors. Talk to us a little bit about
who is the type of patient that should be in
a screening program and how does a screening program work.
Speaker 1 (17:23):
Yeah, so there are set guidelines on who should be screened.
Anyone over the age, anyone between the age fifty and
eighty years, who has had at least a twenty pack,
your smoking history, and who is an active smoker or
has quit within the past fifteen years qualifies for LOTOS
lung cancer screening per national guidelines. So when we initiate
(17:47):
people on this lo those screening in the clinic, we
kind of go over the different risks and benefits of
the procedure of the imaging. In essence, the benefits are,
if there is a lung cancer or a nodule, we
can catch it early and hopefully we can intervene on
it early before there are complications that arise and before
(18:07):
the stage goes higher. There are again negatives associated with screening.
Also kind of similar to what we just talked about.
There is radiation exposure which is not denign, but again
not tremendous either most of the time. The other aspect
is when you do these lung cancer screening cetis, it
is very common to find a permanenty nodule, and like
(18:30):
I mentioned before, most permanenty nodules are benign, but it
may take you down that path of having more CT
scans done or at an increased frequency to monitor that
nodule and possibly undergoing procedures, and all these procedures do
come with their potential for complications.
Speaker 3 (18:49):
And how are we doing with our primary care offices
and providers recognizing the need for screening. Are we taking
advantage of this screening program enough? Or how are we
doing in Kentucky?
Speaker 1 (19:03):
I think I think in Kentucky we're still below the
national average, so we still have room to improve. And
there are different pockets where pockets of Kentucky where we
tend to do better. Again, the bigger cities tend tend
to do better overall, just from an education standpoint, Lovell
does better up closer to Cincinnati. They also have a
(19:23):
very robust screening program that's set up there. And especially
as we get into eastern Kentucky with the cool mine
and with the higher rates of smoking, that is that
is where we want the screening program to be quite ubiquitous.
Speaker 3 (19:39):
And we've had the privilege of having on our show
before nurse navigators, especially with when it comes to the
lung nodule clinics.
Speaker 2 (19:52):
Are you a part of that?
Speaker 3 (19:53):
Do you do you utilize the nurse navigators and how
have you fit that into your practice?
Speaker 1 (19:58):
If you do yeah, yeah, So we do work with
the lung clinic here at Baptist. That involves as perminologists,
and then that also involves the two thoracic surgeons, doctor
Mayheon and doctor Gol. So, in essence, we have a
new software it's been out for about a year year
(20:18):
and a half now called Eon EO N and what
in essence is an AI driven software where any single
mention of Pomeray nodule and any of the imaging that
is done at Baptist gets flagged and from there we
do a screening process where we check the size of
the nodule, We assess if the station is already being
(20:40):
followed by a pominologist or biothoracic surgeon who we're monitoring,
and any of the higher risk nodules usually above about
six to eight millimeters, we triage to the front so
we can intervene early.
Speaker 3 (20:55):
Well, that is a great segue into kind of delving
into one of the areas of expertise, which is getting
at these nodules for us. So we're going to take
a break and we're going to jump into that conversation
when we come back and you are listening to center
it on health with Baptist Health here on news radio
eight forty whas. I'm your host, doctor Jeff Tublin, and
(21:16):
tonight we're talking with doctor Sunny Jowani about pulmonary nodules
and here at Baptists five five oh two, five seven one,
eight four eighty four. Please call us if you have
any questions or you want to talk to doctor Juwanis.
Speaker 2 (21:28):
We'll be right back.
Speaker 3 (21:43):
Well, welcome back to Senate on Health with Baptist Health
here on news radio eight forty whas. I'm your host,
doctor Jeff Tublin, And if you're just joining us, we're
talking tonight about pulmonary nodules with doctor Sunny Joanni and
he has been telling us all about what they might
be and how we're going to treat them. So, doctor Juani,
(22:04):
I know that you've been trained and you're bringing some
pretty exciting stuff to Baptists. So give us a little
bit a picture of the landscape of how were we
addressing these nodules once they've been determined that they need
to be biapsed for some reason. What were we doing
and what are you doing now that's improving it?
Speaker 1 (22:25):
Yeah, So as of you know, the last four or
five years, we've had a new technology called robotic bronchoscopy.
There are two predominant systems that are available on the
market right now, Ion and Monarch, and the one that
we have here is the Ion broncoscope. Prior to this,
you know, we were quite limited with our with our
(22:45):
bronchoscopic technology on how far we could get out into
the lung tissue. Usually even our smallest pediatric broncoscopes would
go out maybe three or four generations of ailways, so
you can make it probably about fifty percent into the perferiate,
but lung, the Ion broncoscopy is a much thiner scope,
and in essence, the way that they're able to decrease
(23:08):
that size is you have a camera that's in there
and then nothing else, and once you want to actually intervene,
you have to take out that camera and then you
intervene with with whatever tool that you're using. But the
benefit that this has done is it's allowed us to
reach nodules even all the way up to the flura itself,
so pretty much in most areas is a long we
(23:28):
can access it. So when you.
Speaker 2 (23:32):
Yeah, go ahead, now go please.
Speaker 1 (23:34):
Go continue, So you know, the in essence, the steps
that we take is we find a pomeary nodule, we
assess if it needs to be biopsyeed based on the
risk factors, and based on the risk the probability that
this is a malignant or not, if you know, we
do pursue a biops seed, then we get what's called
(23:54):
an Ion planning CT. It's slightly different than the other
cts we get where the cuts are thinner. But what
this allows us to do is is we can take
that CT and put it into our planning software and
it helps to recreate that airway tree. This serves almost
like a Google Maps kind of situation, where you know,
in the software we can mark exactly where we want
(24:16):
to go in this case the pomary nodule, and the
software will figure out a route based on which airways
it take. So we can get to that PASI and
then as a result, we can bio see that.
Speaker 2 (24:29):
What is the Ion part of the Ion broncoscopy? What
is that?
Speaker 1 (24:34):
I so Ion is the company that makes the roboty.
So this is a brand name in.
Speaker 3 (24:40):
Essence that we're saying perfect okay, And now just to
kind of give our listeners a sense of why this
is such an advancement before. If I'm understanding it correctly,
sometimes you had to put a needle from the outside
of the body, and did that increase the risk of
the procedure? Is that why this is so benef or
(25:00):
is it an access issue or is it both.
Speaker 1 (25:04):
Both? So significantly so when we would when we would
pursue transtutaneous biopses, your risk of a pneumothorax or collapsed
with the lung is significantly higher. The data shows anywhere
between fifteen and twenty five percent of patients will delet
up a neumothorax. You know, you do not need to
intervene in every single neumothorax. Sometimes most of the time
(25:26):
they will just resolve on their own. But it does
lead to increased morbidity, and it does lead to increased
optialization with the ion. Typically the studies have shown that
it's less than five percent chance of pneumothorax and more
of the recent studies are shown up three and a
half percent or less risk of neumoto.
Speaker 3 (25:44):
X and walk us through the procedure. Is it an
inpatient procedure an outpatient procedure? What's the what's the experience
to get this done? Through the patient lens.
Speaker 1 (25:57):
Yes, so it's an outpatient procedure seen in clinic. Once
that decision is made that we will pursue an ion vonkoscopy,
we get that ion planning CT. If there is a
high suspicion that this nodule or lesion will get figger.
Usually that power up CT is immediately planned as an
ion planning CT. But once that's Once that's done, it's
(26:19):
like pretty much any other typical outpatient procedure NPO before
midnight from the procedure, if you're at any blood dinner's
anti platelet agents, those need to be held for a
few days. You come in for the procedure or an
hour hour and a half before it's scheduled. The procedure
itself depends on how difficult of a location it is
(26:40):
to get to, but typically ranges about an hour hour
and a half. And after the procedure, they're usually monitored
for about forty five minutes to an hour, and as
long as there's no complications meaning hemoposess where you're coughing
up significant quantities of blood or pneumoporax, they go home
the same day.
Speaker 3 (27:00):
And we know that it takes an hour and a
half because your GI colleagues are waiting for the room,
right for sure?
Speaker 1 (27:08):
For sure, yeah, exactly where we're not as skills as
the GI colleagues where we can get a procedure done
in ten minutes. So there with.
Speaker 2 (27:15):
Us, you know, we'll be very patient. So obviously this
is very anxiety.
Speaker 3 (27:21):
And produce inducing for the patient because you're going into
biopsy and nodule that they are at this point aware
that you have some suspicion of how quickly do you
get a result or do you work with the pathologists
right away?
Speaker 2 (27:34):
How quickly is there an answer?
Speaker 1 (27:37):
Final pathology takes about three to five days to come back,
but we do have rapid on site evaluation that's done
by a cytotechnologist in the room, so sometimes we are
able to get a confirmation that this is malignant. Usually
the final confirmation of what kind of malignancy it is
(27:57):
takes a few days when all the staining is done
by the pathologist and that final diagnosis comes out. But
it is quite often that I will tell the family
or the family member that this is malignant and we
need to pursue all of the other avenues, meaning get
a pet skin, get an mrim the brain and get
them in with oncology in the meantime while we're waiting
(28:18):
for that final diagnosis.
Speaker 3 (28:21):
Eda, And you answered this nicely already about what comes next,
which is kind of that work up. And I know
that you do some some interesting stuff that we'll try
and touch on a little bit. But in general, when
does a CT surgeon a cardiothoracic surgeon need to get involved?
Speaker 1 (28:37):
Yeah, yeah, So a cardiothoracic surgeon will often get involved
depending on the stage of the lung cancer and the
tolerability of the patient to in essence tolerate surgery. A
lot of the times, especially with these ion robotic broncostrophies
and the lung cancer screening, we're able to find quite
small lesions that are there and that can be completely
(29:00):
freed in by resection. Sometimes it's a segment tectomy, so
just a small portion of the lungs. Sometimes it does
require a more involved intervention where they're taking out an
entirely low bectomy. And this has to be evaluated from
the setting of will the cancer be treated, will the
patient tolerate it? From a pulmonary function standpoint, will the
(29:21):
patient tolerate it? From just an overall clinical standpoint, Do
they have any other contraindications to that? And that's where
the thoracic surgeons evaluate the patient.
Speaker 3 (29:31):
Fantastic, and of course we want diagnosis and we want
all of these things rapidly. But you know, obviously one
of the other reasons we're doing all of this, the
screening and the access, is to change outcomes. Do we
have any evidence yet? Is it too early to know
if by getting to these peripheral lesions or these smaller
lesions that were previously unaccessible, are we changing changing the
(29:53):
outcomes yet?
Speaker 1 (29:55):
Yeah? Yes, So you know, when you look at when
you look at the outcomes based on stage, there's a drastic,
drastic survival benefit that you have. If you're catching these
patients within stage one disease, there are chances of five
year survival or anywhere between seventy and ninety percent. As
(30:17):
soon as you get into stage two disease, you've dropped
another ten to twenty percent in survival benefit survival chances,
and then it precipitously drops after that. Stage three and
stage four one cancer are still extraordinarily difficult to treat
and survival is quite limited at five years.
Speaker 3 (30:38):
So this is like a very important linkage of finding
the patients at risk factors, getting them into these screening programs,
finding these nodules, and getting these diagnoses early.
Speaker 1 (30:49):
Very much.
Speaker 2 (30:50):
So, yes, fantastic.
Speaker 3 (30:52):
Well, we're going to take our final break here, and
I want to remind everybody that you are listening to
Centered on Health with Baptist Health here on news Radio
whas our guest tonight, doctor Sunny Jewanni, telling us about
pulmonary nodules and all the.
Speaker 2 (31:05):
Great things we're doing here at Baptist Hospital.
Speaker 3 (31:08):
If you missed any of tonight's show, you can download
the iHeartRadio app. It's free, it's easy to use, and
give you access to the entire show and all our
previous shows.
Speaker 2 (31:16):
We'll be right back.
Speaker 3 (31:31):
Welcome back to Senate on Health with Baptist Health here
on News Radio eight forty whas. I'm your host, Doctor
Jeff Toblin, and we've been talking tonight with doctor Sonny
Jowani about pulmonary nodules. Remember to download the iHeartRadio app
to re listen to this or any of our previous
segments and to have access to all the other features
that the app has to offer. So doctor Jowani. Before
(31:54):
we went on break, you were telling us all about
this new technology, and one of the things you mentioned was,
and I think that automatically, you know, raises an image
of all this you know, high tech advanced stuff. Tell
us a little bit about what the robot is, and
and it's not doing the procedure, and you're just sort
(32:15):
of telling it what to do. It's tell us how
that works.
Speaker 1 (32:19):
So no, it's definitely not doing the procedure. We still
have a few years I think, until we get to
that point and I'm put out of a job. So
in essence of sorry, no.
Speaker 2 (32:29):
I was agreeing with you.
Speaker 1 (32:30):
Yes, yeah, So in essence, the ion robot is made
by Intuitive and it's similar or it's a it's it's
a similar product to the Da Vinci robot that's been
used quite for quite some time with general surgery, with
ractic surgery, et cetera. So the robot is just a
(32:50):
long flexible scope in addition to the machine which involves
a screen and all of the software and all the
hardware that's associated with it. So when the patient is
finally intubated, we actually connect to the patient to this
robot with that small flexible scope that goes into the
end of tracheal two, and then we in essence have
(33:11):
we in essence have a remote control that we're playing
with almost like one of those old Atari video games,
where we have a scroll wheel that we're able to
use to navigate this broncoscope in through the patient's airways
and guide it to which airways we want. This allows
us to get further in and this allows for stability also,
so when we are in the location that we would
(33:33):
like to be, we can keep it parked there without
significant discrepancy or significant movement because again a lot of
these lesions are a decent size one centimeter, one and
a half two centimeters, but we are going for nodules
that are smaller than that. The smallest that I've had
a chance to go for and actually have a diagnosis
(33:54):
is six millimeters. So you know, if you want to
put that into perspective, a cheerio is about a sentime,
So this is, you know, almost half the size of
a cheerio, and this is also in three D space.
We need it. So we need stability as much as
we're able to get.
Speaker 3 (34:13):
And are there are there people that wouldn't be appropriate
for a procedure like this or is this sort of
the standard now that is for everybody?
Speaker 1 (34:23):
So the majority of patients can tolerate a robotic bronchoscope,
we still do have some people who have lesions that
are extremely peripheral, especially when we're considering patients who have
perpole legiance in the complete upper load near the apex
or in the lower lobes. Sometimes those areas are very
(34:43):
difficult to get to even with this technology. And we
still do utilize interventional radiology with the percutaneous biopsy when
when we have these when we have these patients.
Speaker 3 (34:56):
Well, we're lucky to have you here to do these.
And one of the things I love to highlight with
our guests are things that you're doing that are really unique.
And so I wanted to talk to you a little
bit about your role as an interventional pomonologist. And you
mentioned some of the things earlier that you do, and
you mentioned a stent, and so tell us a little
(35:20):
bit about what a stent is and why somebody might
need one.
Speaker 1 (35:25):
Yeah, so very similar to the stents that are placed
in the coordinary arteries by the interventional cardiologists or any
blockagest it's very similar Again, these are much bigger stents
than what we put in the arteries, and they can
be placed for a number of different reasons. Some people
will have some kind of a pollution or some kind
of narrowing within their airway. It could be an extrinsic
(35:47):
compression that's happening. If they have a big tumor that's
causing this airway to compress down, and now they're having
difficulty breathing and significant symptoms. You can place a scent
and open up that airway and in that and offer
them a palliative option. Additionally, there are a number of
different diseases, most of them benign, which can cause the
(36:09):
remodeling in the airway and can cast stenosis. One of
the most common things is when we have these patients
who are in the ITU who are intubated. Some patients
will require multiple intubations, especially if they have severe coopd
or any other prominent problems. When we inflate that balloon
in the airway to for the endotradeo too, sometimes it
(36:31):
can cast some pressure on that airway mucosa and it
can cost some tissue death and then some remodeling, and
and then asen scars down and causes us toenosis, So
we can go in there and sometimes we can use
stems to keep those open. Sometimes we can just use
a simple balloon and in essence priv open. Those are
(36:53):
pretty predominantly the reasons why we place these stems.
Speaker 3 (36:58):
And are they typically that you put in and they
stay in forever? Do they have to be changed or
when you put it in, is it like you're putting
it in and you leave it in?
Speaker 1 (37:09):
And typically we take them out and their palliation until
the underlying disease process has been addressed. There are some
patients who do require long term stents. The concern for
these stents is sometimes you can cause scarring around the stent,
so we have to take that into account and often
we'll have to replace them every year or so, especially
(37:29):
in these long term patients. The other concerning aspect of
them is that we need most of these stents. You know,
they're either metal or some kind of silicone basis, and
they're very They're at much increased risk of getting clogged
up with mucus that you just naturally produce in the airways,
so we need to make sure that these patients are
(37:51):
an extremely aggressive airway clearance therapies, because if that stent
gets secluded, then often that stent actually needs to move
ruled because it's extremely difficult to clean out all that
new gifts.
Speaker 3 (38:05):
And it's interesting that you were going in that direction
because I was going to ask you about problems with
the stent, because you know, my mind goes to the
stents we put in like the heart and stuff like that.
Is there do patients who get stents in the pulmonary
system do they need to be on blood thinners like
patients who get them in the heart.
Speaker 1 (38:24):
No, No, blood sinners, usually just nebulize medications to keep
those secretions minimal and allow them to be cleared.
Speaker 3 (38:34):
Fantastic, and we have about a minute left, But I
would love to just hear your perspective on when you
said that you do tumor ablations. Where do you see
the role of that and when would somebody get an
ablation of a tumor as opposed to getting it removed surgically.
Speaker 1 (38:52):
Yeah. Yeah, So a lot of the times these patients
are not surgical candidates just because if you're seeing the
tumor in the airway, it's usually quite proximal and that
would entail removing a big portion of the lung, either
a lobe or the entire lung. And a lot of
our patients who do end up with lung cancer already
have underlying chronic obstructive pulmary disease or other pulmary processes
(39:14):
where it makes it very difficult for them to tolerate
a surgery of that magnitude. So tumor ablations usually are
in conjugation with radiation therapy or chemotherapy that they're getting
through their oncologists. So this is an essence for valiation
purposes where if they have a tumor in the airway
and it's blocking off some airway and causing recurrent pneumonias
(39:37):
or shortness of breath or causing tomopthesis, you can address
that and help symptomatically manage them well.
Speaker 3 (39:45):
Doctor Juwana, you know how long I've been anxious to
get you on our show, and it was worth every
minute of waiting. Thank you so much for providing us
with all this information that is going to do it
for another episode of Centered on Health with Baptist Health.
I'm your host, doctor Jeff Dublin. I want to thank
our guests, Doctor Sunny, Jowani Burd you're talking to us
about pulmonary nodules. I want to thank our producer mister
(40:06):
Jimpenn and of course you the listener. Next week we
are going to be talking about breast surgery at new
updates with doctor Thomas Nol.
Speaker 2 (40:14):
Make sure you join us next week. Have a great weekend.
This program is for informational purposes only and should not
be relied upon as medical advice. The content of this
program is not intended to be a substitute for professional
medical advice, diagnosis, or treatment.
Speaker 1 (40:30):
This show is not designed to replace a physician's medical
assessment and medical judgment.
Speaker 2 (40:35):
Always seek the advice of your physician with any questions
or concerns you may have related to your personal health
or regarding specific medical conditions. To find a Baptist health provider,
please visit Baptist Heealth dot com.
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