BRONCHOSCOPY AND INTERVENTIONAL PULMONOLOGY

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BRONCHOSCOPY AND INTERVENTIONAL PULMONOLOGY

• VASSILIKI FILADITAKI MD
• PULMONARY DEPARTMENT EVANGELISMOS HOSPITAL
• ATHENS GREECE

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Bronchoscopy

• Objectives
• Description of Rigid and Flexible bronchoscopy
• Diagnostic bronchoscopy (indications
  contraindications)
• Therapeutic bronchoscopy (indications)
• Procedures and yield
• Complications

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Which is the main profit of using a rigid
bronchoscope

• Resection of large tumors?
• Dilatation?
• Insertion of a stent?
• Extraction of large foreign bodies?
• Ventilation?
• All of them?

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Which is the main profit of using a rigid
bronchoscope

• Resection of large tumors?
• Dilatation?
• Insertion of a stent?
• Extraction of large foreign bodies?
• Ventilation?
• All of them?

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Rigid Bronchoscopy

• Advantages over flexible
• Larger working channel (clear airway)
• Mechanical ventilation (safety in patients
  oxygenation)
• Debulking large tumors in the major airways
• Dilatation of tracheobronchial strictures
• Insertion of prosthesis (stent)
• Extraction of large foreign bodies

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Disadvantages of the Rigid Bronchoscopy

• Limited access to the small airways
• General anesthesia in most patients
• Unstable neck
• Ankylosed cervical spines or
• Restricted temporomandibular joints

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Advantages of the Flexible Bronchoscopy

• Examination of the central and peripheral airways
• Ultrathin bronchoscope suitable for infants and
  children and for the small airways for the adults
  (10th-12th generation)
• Insertion via nose, mouth or tracheostomy
• Light sedation topical anesthesia

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Which from the following is an indication for FOB

• Intrathoracic Malignancy?
• Diffuse lung disease?
• Pulmonary infections?
• All of them?
• None of them?

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Which from the following is an indication for FOB

• Intrathoracic Malignancy?
• Diffuse lung disease?
• Pulmonary infections?
• All of them?
• None of them?

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Indications for Diagnostic Bronchoscopy

• Malignancy
• Diagnosis of bronchogenic carcinoma
• Staging of bronchogenic carcinoma
• Abnormal sputum cytology
• Follow up after treatment of carcinoma
• Evaluation of patients with head and neck
  malignancy
• Metastatic carcinoma
• Esophageal malignancy
• Mediastinal mass or lymphadenopathy
• Infection
• Recurrent or unresolved pneumonia
• Diffuse infiltrates
• Cavitary lesion
• Immunocompromised patients (HIV non HIV)
• Diffuse interstitial lung disease
• No indication for IPF with typical clinical and
  HRCT presentation

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Which of the following symptoms is not an
indication for FOB?

• Chronic unexplained cough?
• Repetitive hemoptysis?
• Localized wheezing?
• Stridor?
• Hoarseness (vocal cord paralysis)?
• Dyspnea?

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Which of the following symptoms is not an
indication for FOB?

• Chronic unexplained cough?
• Repetitive hemoptysis?
• Localized wheezing?
• Stridor?
• Hoarseness (vocal cord paralysis)?
• Dyspnea?

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Symptoms indicative for FOB

• Chronic unexplained cough
• Persistent hemoptysis
• Localized wheezing
• Stridor
• Hoarseness (or vocal cord paralysis)
• Superior vena cava syndrome
• Clinical suspicion of foreign body aspiration

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Other indications for Diagnostic Bronchoscopy

• Abnormal chest X-ray
• Atelectasis, Nodule(s), Mass, Cavitary lesion,
  Localized air trapping
• Chest trauma
• Blunting, Penetrating, Chemical, Thermal
• Postoperative assessment of tracheal or bronchial
  anastomoses
• After lung transpantation
• Pleural effusion with parenchymal lesion
• Persistent Pneumothorax

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Other indications for Diagnostic Bronchoscopy

• Endotracheal Intubation
• Confirm tube position
• Evaluation tube related injury
• Transtracheal oxygen catheter
• Tracheal stenosis
• Fistulas
• Bronchopleural
• Tracheo-Bronchoesophageal
• Treacheo-Bronchoaortic

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Which of the following causes are related to the
decreased patency of
the airways

• Secretions, mucous plugs, clots, necrotic debris
  ?
• Foreign bodies ?
• Neoplasms of the tracheobronchial tree ?
• Strictures and stenosis ?
• All of the above ?

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Which of the following causes are related to the
decreased patency of
the airways

• Secretions, mucous plugs, clots, necrotic debris
  ?
• Foreign bodies ?
• Neoplasms of the tracheobronchial tree ?
• Strictures and stenosis ?
• All of the above ?

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Indications for Therapeutic Bronchoscopy

• Pulmonary toilet
• Removal of foreign bodies
• Removal of obstructive endobronchial tissue
• Malignant
• Nonmalignant
• Stent placement
• Bronchoalveolar lavage (Alveolar proteinosis)
• Aspiration of cysts
• Mediastinal
• Brochogenic cysts
• Drainage of abscesses
• Pneumothorax
• Lobar collapse
• Intralesional injection
• Thoracic trauma
• Intubation (Respiratory distress)
• Airway maintence (tamponade for bleeding)

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Contraindications

• FOB is considered a safe procedure
• Which of these contraindications are guidelines
  of ATS
• Absence of informed consent?
• Inexperienced operator?
• Inadequate facilities?
• Inadequate oxygenation for the procedure?
• All of them?

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Contraindications

• FOB is considered a safe procedure
• Which of these contraindications are guidelines
  of ATS
• Absence of informed consent?
• Inexperienced operator?
• Inadequate facilities?
• Inadequate oxygenation for the procedure?
• All of them?

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Which of the followings are Absolute
Contraindications

• Unstable cardiovascular status?
• Life threatening cardiac arrhythmias?
• Severe refractory hypoxemia?
• Uncooperative patient?
• All of them?

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Which of the followings are Absolute
Contraindications

• Unstable cardiovascular status?
• Life threatening cardiac arrhythmias?
• Severe refractory hypoxemia?
• Uncooperative patient?
• All of them?

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Diagnostic Techniques of FOB and yield

• Bronchial washing (central lesions 62-79)
• Cytology brushing (62-78)
• Endobronchial biopsy (central lesions 55-85)
• Transbronchial Lung Biopsy (peripheral lesions
  lt2cm 10-30, gt4cm 40-80)
• Transbronchial Needle Aspiration TBNA
• 50 sensitivity
• 96 specificity
• 78 accuracy
• Bronchoalveolar Lavage (BAL)
• Protected catheter lavage
• Protected catheter brushing

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Therapeutic Techniques of FOB

• Bronchial Toilet
• Mechanical debulking of obstructive endobronchial
  tumor with biopsy forceps
• Balloon catheter dilatation of endobronchial
  stenosis
• Laser photoresection
• Electrocautery
• Argon plasma coagulation
• Cryosurgery
• Photodynamic therapy
• Brachytherapy

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Complications

• Bronchoscopy is a safe procedure with low
  morbidity and low mortality (lt0.01)
• Hypontilation Hypotention Syncope (use of
  sedatives and other medications)
• Laryngospasm, bronchospasm, seizures,
  cardiorespiratory arrest (topical anesthetics)
• Transient fever (1/3 patients)
• Bacteremia is very uncommon
• Pneumothorax lt1
• Bleeding (62 no intervention)
• Hypoxemia (mild recovering in 2-4 hours)

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Interventional Pulmonology

• Interventional Pulmonology is an evolving new
  field of Pulmonary medicine that encompass new
  technologies in bronchoscopy and thoracoscopy in
  order to diagnose, palliate or treat malignant
  and benign airway and pleural disorders

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Objectives

• Services that Interventional pulmonology can
  provide
• Indications and limitations of the interventional
  procedures
• Selection of the most appropriate modalities to
  treat patient with airway obstruction

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Spectrum of Procedures Commonly offered by IP
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Which is the main indication for therapeutic
Bronchoscopy

• Small Hemoptysis?
• Central airway obstruction (trachea main stem
  bronchi bronchus intermedius)?
• Central and peripheral airway obstruction?
• Hypoxemia?
• Dyspnea?

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Which is the main indication for therapeutic
Bronchoscopy

• Small Hemoptysis?
• Central airway obstruction (trachea main stem
  bronchi bronchus intermedius)?
• Central and peripheral airway obstruction?
• Hypoxemia?
• Dyspnea?

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Which is the indication to use RB for central
airway Obstruction

• Ventilate the patient while intervening in the
  airways?
• Large suction catheters to aspirate the blood in
  case of Massive Hemoptysis?
• Coring out tumor tissue?
• Dilating the tight airway stenosis?
• Inserting a stent?
• All of them?

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Which is the indication to use RB for central
airway Obstruction

• Ventilate the patient while intervening in the
  airways?
• Large suction catheters to aspirate the blood in
  case of Massive Hemoptysis?
• Coring out tumor tissue?
• Dilating the tight airway stenosis?
• Inserting a stent?
• All of them?

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• RB is the ideal tool for massive hemoptysis,
  tight airway stenosis and a moderate-to-large
  tumor tissue burden in the airway
• Flex B is not optimal in these instances due to
  the small size of its lens and working channel
  and the possibility of life threatening
  respiratory emergency. It should be utilized for
  these indications after an airway is secured with
  endotracheal intubation

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Which modality is indicative for immediate
ablation of tracheobronchial Obstruction

• Nd YAG Laser?
• Electrocautery?
• Cryotherapy?
• Brachytherapy?
• Photodynamic therapy?
• 12

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Which modality is indicative for immediate
ablation of tracheobronchial Obstruction

• Nd YAG Laser?
• Electrocautery?
• Cryotherapy?
• Brachytherapy?
• Photodynamic therapy?
• 12

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In a benign tracheal stenosis which stent would
you prefer

• Silicone one?
• Metallic one?
• Both of them?
• None of them?

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In a benign tracheal stenosis which stent would
you prefer

• Silicone one?
• Metallic one?
• Both of them?
• None of them?

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In a Malignant central (tracheal) airway
obstruction including extrinsic compression,
which palliative treatment would you choose?

• Endoscopic Intervention (ablation stenting)?
• Chemotherapy?
• External beam radiation ?
• 13
• All of them?
• Unknown?

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In a Malignant central (tracheal) airway
obstruction including extrinsic compression,
which palliative treatment would you choose?

• Endoscopic Intervention (ablation stenting)?
• Chemotherapy?
• External beam radiation ?
• 13
• All of them?
• Unknown?

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• The body of evidence supporting the
  effectiveness of therapeutic bronchoscopy is
  still limited. The data come from retrospective
  studies with very few comparative or randomized
  trials.
• More research is needed to compare the effects
  of various therapeutic modalities the role of
  combined therapy maximizing benefit while
  reducing risk.

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Other therapeutic Modalities

• FOB assisted percutaneus dilatational
  tracheotomies
• Placement of transtracheal oxygen catheters
• Lung volume reduction bronchoscopy by placing
  one-way valves that would allow exhalation but
  preventing inspiration

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Newer Diagnostic interventional Modalities

• Autofluerescence bronchoscopy (AFB)
• EBUS bronchoscopy
• Electromagnetic navigation bronchoscopy

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Thank you