BRONCHOSCOPY

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BRONCHOSCOPY

• Cori Daines, MD
• Pediatric Pulmonology, Allergy and Immunology
• University of Arizona

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BACKGROUND

• Allows direct visualization of the airways
• Rigid and flexible instruments
• Clinical tool
• Airway anatomy
• Airway sampling
• Therapeutic
• Research tool

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ORIGINS

• Until the 1980s, only rigid instruments were
  widely used
• Multiple generations of adult and pediatric
  flexible bronchoscopes now
• Widely used in adult and pediatric pulmonary
  medicine now

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RIGID BRONCHOSCOPY

• Generally performed by ENTs and surgeons
• Procedure oriented
• Foreign body removal
• Biopsies
• Granuloma/polyp removal
• Laser
• Stent placement
• Visualization for future surgery

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INSTRUMENTS

• Rigid bronchoscopes
• Hollow metal tube
• Glass rod telescope
• Ultimate optics

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FLEXIBLE BRONCHOCSOPY

• Examination of the entire respiratory anatomy,
  nose to bronchi
• Minor impact on anatomy
• Able to pass through an endotracheal tube or
  tracheostomy tube

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INSTRUMENTS

• Flexible instruments
• Fiberoptic bronchoscopes
• 2.2mm ultrathin
• 2.8mm/1.2mm suction channel
• 3.4mm/1.2mm suction channel
• 4.4mm/2.0mm suction channel
• 4.9mm/2.2mm suction channel
• 5.9mm/3.0mm suction channel

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INSTRUMENTS

• Flexible instruments
• Video bronchoscopes
• 2.8mm/1.2mm suction channel (hybrid video scope)
• 3.8mm/1.2mm suction channel
• 4.0mm/2.0mm suction channel (hybrid video scope)
• 4.9mm/2.0mm suction channel
• 6.0mm/3.0mm suction channel
• 6.3mm/3.2mm suction channel

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Fiberoptic bronchoscope 2.8mm diameter
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Pediatric Videoscope 2.8mm diameter
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Pediatric videoscope 3.8mm diameter
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Adult videoscope 4.9 mm diameter
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INDICATIONS

• When flexible bronchoscopy is the best, easiest,
  safest, most efficient way to obtain the
  information

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AIRWAY ANATOMY
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TECHNIQUE
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TECHNIQUE

• Anesthesia
• Best accomplished in the operating room
• May be performed bedside in an ICU setting
• Continuous monitoring
• Light anesthesia--allows continued spontaneous
  breathing
• May be done with conscious sedation in older
  individuals

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TECHNIQUE

• Insertion
• Nasal
• LMA
• Endotracheal tube
• Tracheostomy tube
• Appropriate topical anesthesia and lubrication

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TECHNIQUE

• Anatomical survey
• Nasal passages
• Pharynx
• Larynx
• Trachea
• Bronchi
• Examine all before any other procedures

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TECHNIQUE

• Additional procedures
• Bronchoalveolar lavage
• Brushings
• Bronchial biopsy
• Transbronchial biopsy
• Laser
• Others cryotherapy, stent placement, foreign
  body removal, needle biopsy

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BRONCHOALVEOLAR LAVAGE

• Small aliquots of sterile normal saline instilled
  into the airway
• Removed by suctioning
• Samples distal bronchial and alveolar surfaces
• Wedge position to prevent loss of fluid

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BAL TESTS

• Microbiology
• Bacterial, viral, fungal, AFB, special techniques
• Pathology
• Cell count, differential, special stains

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MICROBIOLOGIC STUDIES

• Stains
• Gram stain
• Acid fast stain (Ziehl-Neelsen)
• Antibody tests
• Rapid tests, DFA tests
• In-situ
• PCR

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SPECIAL STAINS

• Lipid
• Oil Red O
• Sudan
• Hemosiderin
• Prussian Blue
• Alveolar proteinosis
• PAS
• Electron microscopy

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SPECIAL STAINS

• Fungi
• Silver (Gomoris methenamine silver stain)
• Pneumocystis carinii
• Silver stain
• Papanicolaou

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BRONCHOALVEOLAR LAVAGE
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SPECIFIC INDICATIONS

• Atelectasis
• Recurrent pneumonia
• Chronic cough
• Persistent/unexplained wheeze
• Hemoptysis
• Suspected airway compression/obstruction
• Stridor
• Upper airway obstruction
• Suspected aspiration
• Evaluation of tracheostomies

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NORMAL ANATOMY
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BRONCHOALVEOLAR LAVAGE
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LARYNGOMALACIA
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LARYNGOMALACIA
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TRACHEOMALACIA
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TRACHEOMALACIA
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SUCTION TRAUMA
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TRACHEOBRONCHOMEGALY
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VASCULAR COMPRESSION
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TECHNIQUES-BIOPSY
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TECHNIQUES-LASER
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BRONCHOSCOPY TEAM

• Pulmonologists
• Respiratory therapists
• Anesthesia
• Nurses
• Laboratory
• Microbiology
• Pathology