Basic Instruments of Interventional Bronchoscopy

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Basic Instruments of Interventional Bronchoscopy

• Ass. Prof. Sedat ALTIN
• Pulmonolog, interventional bronchoscopist

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Rigid Bronchoscope

• The newer modifications in the rigid bronchoscope
  have established it as the ideal instrument for
  debulking of large tumors in the major airways,
  dilatation of tracheobronchial strictures, laser
  bronchoscopy, insertion of airway prostheses
  (stents), and extraction of tracheobronchial
  foreign bodies.

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Fiberoptic Bronchoscope

• Flexible bronchoscopes with a larger working
  channel enable the bronchoscopist to insert
  larger biopsy forceps, balloon catheters, laser
  fibers, and other instruments into the airways to
  obtain larger and better-quality biopsy
  specimens.

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Videobronchoscope

• A flexible bronchoscope equipped with a
  charge-coupled device at its distal tip. The
  bronchoscopic images are digitally captured and
  transmitted to a video processor for display on a
  television monitor.
• The advantage is that the excellent images can be
  simultaneously visualized by many, making it an
  excellent tool for teaching purposes. The images
  can also be stored in several digital formats.

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Videobronchoscope

• The disadvantages include the added expense of
  purchasing video equipment and a computer
  terminal, and the larger working and storage
  space required.
• The major drawback is the loss of ability to view
  the image through the headpiece of the flexible
  bronchoscope the bronchoscopist has to depend
  on the video monitor to visualize bronchoscopic
  findings. The image on the monitor is only as
  good as the monitor.

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EndoBronchialUltraSound (EBUS)

• The major advantage of this technique
  is the ability to
  visualize, via ultrasound,
  the extra-airway structures that
  cannot
  be seen through the bronchoscope.
  
  The major technical problem is the
  
  inability to consistently provide the
  
  coupling of the ultrasound probe to
  the
  bronchial wall to generate meaningful
  
  images of the extrabronchial structures. To
  overcome this, flexible bronchoscopes are being
  fitted with water-inflatable balloons. This will
  permit constant 360-degree contact between the
  wall of the airway and the ultrasound probe.
  Preliminary studies have shown the ability to
  identify mediastinal structures including lymph
  nodes, great vessels, and esophagus .The
  identification of lymph nodes and their relation
  to airways may help improve diagnostic techniques
  such as BNA for the diagnosis and staging of
  thoracic tumors.

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Fluorescence Bronchoscopy

• When the normal bronchial mucosa is illuminated
  via the bronchoscope, a higher fluorescence is
  observed. Mucosa containing abnormal or malignant
  cells produces decreased autofluorescence. This
  phenomenon is used to detect mucosal changes
  suggestive of either premalignant or malignant
  lesions in the airway mucosa. Mucosal changes
  observed by routine (white-light) bronchoscopy
  can be compared with those observed via
  green-light bronchoscopy. Early reports show that
  this technique, when used as an adjunct to
  standard bronchoscopy, may enhance the ability to
  localize small neoplastic lesions, especially
  intraepithelial lesions.

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Electromagnetic Guidance System
A novel method for guiding transbronchial
catheters or forceps is electromagnetic
navigation. In comparison to fluoroscopy or CT
scanning, electromagnetic navigation as a method
not only has minimum technical and spatial
requirements, it also indicates the position of
the catheter in three dimensions without
radiation exposure all that it needs is the
availability of a preprocedure CT data set.
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Equipment p e r s o n e l
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Things to Consider

• Personel
• Scope of practice
• Equipment
• Space/unit
• Your financial and practice environment

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Minimal equipments

• Rigid bronchoscopy system
• Fiberoptic bronchoscopes and cold light
  source/video processor
• Picture monitor
• Forceps for biopsy, sitology brushes,
  transbronchial needlles, baskets for foreign
  bodies
• Cleaning/disinfection equipments

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Personel

• A bronchoscopist alone is not enough
• Nursing, ancillary help(minimal 2 nurses)
• Anesthesiolog, technician
• Good relationships with other services such as
  pathology, oncology and thoracic surgery
• Requirements differ..

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Equipment-Diagnostics

• Basics
• Good brochoscopes, at least 2 (videoscope)
• Processors, screens etc.
• Image processing
• Full range of forceps, brushes and TBNA needles

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Equipment-Diagnostics

• Advanced
• AF if lung cancer detection program
• EBUS
• EM guidance system
• Soon
• NBI
• Poss OCT

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Equipment-Therapeutics

• Basics
• Therapeutic and thin flexible scopes
• Choice of thermal ablation
• Laser
• ES/APC
• Cryotherapy
• Different diameter stents

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Equipment-Therapeutics

• Advanced
• Rigid endoscopy with barrels, optics, camera and
  processor
• PDT
• Collection of silicone stents

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interventional bronchoscopic procedures

• Complications,
  cautions,
  essential points

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Procedures

• Mechanical resection with rigid bronchoscopy
• Dilatation
• Laser (Nd-YAG, Nd-YAP),
• Cryotherapy
• Stent insertion
• Photodinamic therapy
• Brachitherapy
• Argon Plasma Coagulation
• Electrocautery

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Conditions Required for Safety Endoscopic
Treatment

• Tumour must be accesible with the bronchoscope
• Tumour must be spread restrictly in the bronchus
  and have to do not lymphangitic invasion
• The lungs and the airways without stenosis must
  be functional
• The performance of the patient must be enough
  good!!

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Description of Common Practical Problems

• Difficult airway management
• Bleeding
• Intubation
• Indications and contraindications
• Anesthesia and risk management

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Which technical for which patient?

• The type and the nature of stenosis
• The localisation of the lesion
• Available equipment must be preferred!
• The experience of the physician
• The condition of distal airways
• The cost of the technics

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Factors reducing the complications

• Adequate equipment
• Educated personnel
• Sufficient sterilization
• Good patient selection
• Enough sedation, premedication and anesthesia
• Follow-up after bronchoscopy and if need be
  therapy

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Rigid Bronchoscopic Procedure-Related Adverse
Events

• poor insertion techniques,
  prolonged trauma of the larynx and vocal cords,
  or failure to heed the warnings of hypercapnia,
  hypoxemia, or hemodynamic instability
• Airway wall perforation
  posterior wall of the trachea, subglottis,
  and median walls of the left and right main
  bronchi just below the carina
  Luxation or laceration of the vocal cords and
  arytenoids

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Rigid Bronchoscopic Procedure-Related Adverse
Events

• Other complications can be avoided by a careful
  inspection of the mouth. Loose teeth should not
  be dislodged. The gums should not be traumatized,
  and the lips should not be injured.
• Spinal cord injuries are possible in patients
  with cervical spine disease and severe
  osteoporosis. In selected instances, these
  diseases are contraindications to rigid
  bronchoscopic intubation.

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Laser Bronchoscopy Attentions

• FIO2 must be kept below 40 because of the risk
  of endobronchial fire
• Avoid curare,pavulon because of post-operative
  respiratory depression.
• Non flammable anaesthetic gases are mandatory.
• An anesthesiologist experienced in the technique
  is important.
• Oximetry monitoring is mandatory.
• All persons in the room must wear protective
  glasses to avoid the risk of laser eye injury.
• Plumbing- increased water for machine cooling
• Electrical- special generator for high power
  needs.
• RN Laser safety nurse
• Laser operation-fiber bundle repair
• Laser- 200,000maintainance- backup?

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Laser Equipment

• Dumon rigid laser bronchoscope with ventilating
  port, laser channel and suction channel.
• Disposable large bore suction catheters.
• Biopsy forceps with telescope.
• Flexible bronchoscope.
• Endobrochial balloon catheters in case of massive
  hemorrhage.

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Laser Complications

• 1. Failure to achieve an adequate airway
• 2. Hemorrhage usually mild and represents only a
  nuisance.
• 3. Asphyxia
• 4. Tracheoesophageal fistula can occur in LMB or
  tracheal lesions.
• 5. Mediastinal emphysema, pneumothorax.
• 6. Delayed hemorrhage (probably results from
  necrosis of tumor that had invaded a nearby
  pulmonary artery)
• 7. Endobronchial fire
• 8. Eye injury to the patient or OR staff

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Cryo

• In addition to the equipment needed for flexible
  or rigid bronchoscopy, dedicated operators need
  different probes depending on whether the
  cryotherapy is delivered through the rigid or
  flexible bronchoscope. Generally, the area of
  freezing is larger and the thawing quicker with
  the rigid probes. The gas most commonly used in
  cryotherapy and the gas most commercially
  available is nitrous oxide.

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Cryotherapy

• This technique is not indicated to achieve
  immediate debulking of an obstructive tumor.
• The tumor will be first cored out mechanically
  with the tip of bronchoscope after coagulation,
  after first this step and inthe same session
  cryotherapy can be applied on the remaining
  infitrative part of the tumor.
• Well vascularized tumor such as bronchial
  caecinomas, carcinoids,adenoid cystic carcinomas
  or granulomas
• In situ or microinvasive carcinomas
• CT is useful to remove many foreign bodies from
  the airways (pills, foods, clots, peanuts not
  bones, metal,or teeth)

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Cryotherapy

• CT is not indicated in external compression of
  the bronchial tree,
• CT is not indicated in benign strictures of the
  trachea or bronchi caused by fibroma, lipomas, or
  post-intubation stenosis
• A transient fever immediately following
  cryotherapy. This fever can be prevented by
  corticosteroid administration given during the
  procedure
• Airway sloughing material elimination after CT
  remains a problem. A bronchial toilet with a
  flexible fiberoptic bronchoscope is usually
  necessary 8-10 days after CT

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Cryotherapy

• The equipment is less expensive and easier to use
  than lasers. Subjective improvements have been
  observed in gt 75 of patients with malignant
  airway lesions.
• Complications are few and minor. One disadvantage
  is the longer duration of therapy required
  because of the need for frequent freeze-thaw
  cycles. Repeat bronchoscopy is needed for
  continued therapy in many patients.

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Advantages of Cryotherapy

• high penetration depth
• no vaporization or carbonization
• no smoke plume
• fixation of liquids or tissue
• can also be used to treat patients with cardiac
  pacemakers
• no electrosurgical interference
• no combustion risk
• mobile unit

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Advantages of Cryotherapy

• Better control of depth effect
• Can also be used in the area of coated stents
• Does not harm cartilages
• Less costs
• approx. 7000 /

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APC EC

• a dedicated operator needs a high-frequency
  electrical generator in combination with
  insulated probes. Different types of probes in
  terms of shape as well as polarity (monopolar vs
  bipolar) are available. For patient and staff
  protection, proper insulation precautions need to
  be observed. Insulated flexible equipment is also
  available. For APC, a dedicated operator needs a
  special catheter allowing for the argon gas and
  the electrical current flow. This catheter is not
  used in electrocautery where there is direct
  tissue contact.

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Rigid and flexible HF-contact coagulation probes
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Flexible APC Probes
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Rigid APC Applicators
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Argon Plasma Coagulation

• The indication of APC is the same as that for
  laser an obstructive endobronchial lesion of
  airway causing symptoms such as dyspnea, cough or
  pneumonia
• The role of APC as a cure for early stage lung
  cancer is not yet fully established
• In addition benign polyp removal and palliative
  care in malignant disease, it can also be used
  for debridement of granulation tissue around
  endobronchial stents.
• APC has no role in removing a foreign body,
  mucous plug or clot.
• Precautions The power setting (lt80W) and the
  application time (lt5 sec)should minimize the
  risks and keeping the argon flow rate (lt2 Lpm)
  should lessen the chance of gas embolism

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Electrocauthery

• Lesions considered suitable for the procedure
  were required to have lt 50 luminal obstruction,
  a visualized size that was lt 2 cm in its greatest
  dimension, limited vascularity, and an estimated
  procedure time of lt 1 h.

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Electrocautery

• The diameter of the working channel of the scope
  is 2.6 mm, which allows the insertion of most
  therapeutic accessories. An electrosurgical unit
  was the power source for the procedure. This unit
  is approximately 1 cubic foot in volume and
  produces the three following current modes cut,
  coagulate, and blend. The endobronchial
  accessories consisted of polypectomy snare,
  coagulation probe, forceps, and a cutting blade

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Complications During Electrosurgery

• Bleeding
• Limited field of bronchoscope view
• Transient desaturation
• Excessive cough
• Endobronchial fire
• Electrical shock

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Brachytherapy

• Major complications include formation of fistulae
  between the airways and other thoracic structures
  in 6 to 8 of patients. Serious hemorrhage has
  been noted to occur more frequently in patients
  who receive high-dose radiation. The risk of
  massive hemoptysis increases dramatically when a
  fraction size of 15 Gy is used.

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PDT

• Complications from photodynamic therapy include
  sunburn involving skin exposed to bright light,
  hemoptysis, and expectoration of thick necrotic
  material.

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Jean-François Dumon, MD, FCCP

• Various types of airway stents available to
  treat airway stenoses. There is no ideal stent.

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Stent indications

• Inoperable, symptomatic lung cancer  Primary
  airway tumours  Oesophageal cancer  Thyroid
  cancer  Head and Neck tumours  Metastases  P
  ostintubation and idiopatic benign tracheal
  stenosis  Inflammatory lesions  Tracheobronch
  ial malacia  Vascular compression

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Stents

• Complications seen with silicone stents include
  migration of stent and inspissation of thick
  mucous within the stent lumen. Metallic stents
  seem to promote growth of granulation tissue,
  which makes it difficult to remove and replace
  the stent. Uncovered metallic stents should not
  be inserted in patients with malignant airway
  lesions because the growth of cancer through the
  wire mesh negates the benefits of stent
  placement.

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Commercial stents
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Bronchoscopic Needle Aspiration

• Complications are rare and include pneumothorax
  and hemomediastinum. Serious bleeding is seldom
  encountered. More commonly, inadvertent passage
  of the needle through the wall of the working
  channel of the flexible bronchoscope leads to
  expensive damage to the inner lining of the
  bronchoscope.

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Hazards Problems
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Areas of Potential Damage to the FOB

• Improper handling
• Procedural
• TBNA
• Nd-YAG laser photoresection
• Electrosurgery
• Radiation
• Use of lubricants
• Patient related
• Cleaning and maintenance
• Ethylene oxide gas sterilization

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Damage of the FOB

• An educational program was effective in
  dramatically decreasing the costs of equipment
  repair after initiating an interventional
  pulmonology program.
• This is the first study to offer budgetary
  guidelines for equipment repair in an IP program
  and to demonstrate that an educational program
  can effectively reduce costs.
• Lunn W et al. Chest 2005127 1382-1387

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Improper Handling

• Care must be taken not to allow the distal end of
  the instrument to strike a hard surface.
• Forced angulation or twisting the body of scope
  may damage its quartz filaments.
• Rotation of the body of the scope should be
  performed by flexing or extending the wrist

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Procedural-TBNA

• Improperly used
• Nonretractable TBAN
• The diameter of the working channel of the FFB
• TBAN should be used only by or under the
  supervision of experienced bronchoscopist

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Procedural-Nd-YAG Laser

• Indications Exophytic, intraluminal, proximal
  airway lesions that cause symptoms such as
  hemoptysis, cough, dyspnea, difficulty clearing
  secretionsor postobstructive pneumonia
• Precautions During laser firing the fraction of
  inspired oxygen should be kept below 40 percent,
• Flammable materials should be kept far away from
  the operating field and silicone stents should be
  removed prior to laser firing
• The laser should always be placed on standby mode
  when tissue is removed from the bronchoscope
• Power settings greater than 40 watts are never
  necessary

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Procedural-Electrocautery

• Airway obstruction caused by bronchogenic
  carcinoma is the most common indication
• Precautions The power setting (lt80W) and the
  application time (lt5 sec)should minimize the
  risks, like APC

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Radiation

• Yellowish discloration and darkening of both the
  fiber bundles and the visual image
• FFB should not be syored in areas where
  fluoroscopy is performed

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Use of Lubricants

• A water-soluble lubricant should be used to
  lubricate
• Petroleum-based products should be avoided,
  because may cause premature wear streching and
  deterioration of the rubber sheath of the FFB.

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Patient-Related Damage

• Incooperated patient
• Supine position might lead to grabbing or pulling
  the fiberscope by the patient.
• Mouthpiece must be used the transoral approach.
• The patient teeth with damage to the fiber
  bundles.

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Disinfecting in the morning

• .the safest practice is to terminally disinfect
  (endoscopes) at the end of each days use, and
  again before the first and each subsequent use
  throughout the next day.

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The recommended reprocessing steps include

• Preprocessing and leak testing the endoscope,
• Cleaning the endoscope and each of its components
• Disinfecting and rinsing the endoscope with clean
  water
• Drying the endoscope before storing by rinsing
  its cannnels with 70 alcohol followed by
  forced-air
• Properly handling and storing the endoscope

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Bronchoscope Damage

• Positive leak test result. Air bubbles emitting
  from the surface of the bronchoscope indicate a
  breach in its exterior.

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Cleaning

• Precleaning
• Mechanical Cleaning
• Disinfection
• Postprocessing procedure

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Precleaning

• The three most important rules of any effective
  reprocessing are
• clean it
• clean it
• CLEAN IT!
• If an item cannot be cleaned, it
  cannot be disinfected or sterilised.

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Precleaning

• In the examination room immediately after the
  procedure 1. Wipe the insertion tube with a
  disposable cloth dampened in an enzymatic
  detergent solution.
• 2. Aspirate enzymatic detergent solution through
  the suction/biopsy channels
• 3. Purge air/water channels.
• 4. Detach removable components

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Mechanical Cleaning

• 1. Make up enzymatic solution
• 2. Immerse instrument
• 3. Disassemble removable parts and clean
• 4. Brush and wipe exterior
• 5. Brush all channels

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Cleaning

• ENZYME SOLUTIONS
• DETERGENTS
• ULTRASONIC CLEANING

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Cleaning Maintenance

• Hand antisepsis plays a significant role in
  preventing nosocomial infections. When outbreaks
  of infection occur in the perioperative period,
  careful assesment of the adequacy of hand hygiene
  among operating room personnels recommended.
• Surgical hand antisepsis using either an
  antimicrobial soap or an alcohol-based hand rub
  with persistent activity is recommended before
  donning steril gloves when performing surgical
  procedures.

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Bronchoscope disinfection

• Rigorous procedures should be applied
• Double mechanical washing and brushing before an
  automated washer disinfector cycle
• Duration 40 to 45 minute
• Continuous monitoring at each step
• Glutaraldehyde is replaced now by peracetic acid

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Automatic flexible endoscope reprocessors (AFERs)

• The potential advantages of AFERs include
• Standardisation of endoscope reprocessing.
• Reduced exposure of HCWs to hazardous chemicals.
• Reduction of staff time spent on reprocessing.

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Major Sources of Contamination

• Ineffective cleaning
• Inadequate cleaning
• Damaged internal channel
• Suction channel
• Biopsy port
• Sample collection tubing

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Bronchoscopy-Related Pseudoinfections

• Mycobacterium chelonea, gordonae, abscessus,
  tuberculosis
• Pseudomonas aeruginosa,
• Serratia marcescens
• Fungi (Rhodotorula rubra, etc)

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Bronchoscope storage

• After drying bronchoscopes should be stored in
  special cupboards horizontally or better
  vertically.
• Do not store bronchoscopes in transport luggage
• a new cycle in the automated washer disinfector
  is required after storage before the
  bronchoscopy.

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Staff safety

• During bronchoscopy staff should wear gloves,
  protective clothing, masks and visors
• Bronchoscopes should be disinfected in a
  dedicated, ventilated room.

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Staff safety
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THANK YOU FOR YOUR ATTENTION