Bronchoscopy

Transudative causes of Pleural Effusion

CHF, cirrhosis, renal failure, urinothorax

Bronchial brush

a standard nonprotected bronchial brush is used to collect cytologic samples of abnormalities in the proximal airways under direct visualization as well as peripheral lesions under fluoroscopic guidance; protected bronchial brush collects microbiologic samples to ensure that the bacteria collected represent lower-tract pathogens and not upper airway contaminants

Relative contraindications

active ischemic heart disease, active cardiac arrhythmia, refractory hypoxemia, bleeding diathesis, uncooperative patient, active or uncontrolled bronchospasm

Fiberoptic Bronchoscopy Techniques

airway examination (is it intact?); BAL; bronchoscopic washing; bronchial brushing; endobronchial biopsy; transbronchial lung biopsy; transbronchial needle aspiration

Main factors to consider when selecting a patient for bronchoscopy

asthma and bronchospasm, CV risk, head trauma and elevated IC pressure, anticoagulant and antiplatelet therapy, thrombocytopenia, uremia and renal dysfunction

Diagnostic Bronchoscopy (2)

bronchoscopy helps to evaluate suspected malignancy; it is used in infection to help defined the causative microbiological organism and figure out what antibiotic to treat with; foreign body aspiration is a common (and serious) problem in children, but it can occur in any age group

Key points (1)

bronchoscopy is the most commonly used invasive procedure in pulmonary medicine, it is used both diagnostically and therapeutically; the flexible fiberoptic bronchoscope consists of a control unit and a soft flexible shaft; bronchoscopy is a safe and effective tool for diagnosing and treating pulmonary processes

Diagnostic bronchoscopy

bronchoscopy is the most commonly used invasive procedure in pulmonary medicine; it performs both diagnostic and therapeutic procedures

Introduction of flexible bronchoscope

can be introduced through the nose, mouth, endotracheal tube, or tracheostomy site

Key points (3)

common techniques include airway exam, BAL, bronchoscopic washing, bronchial brushing, endobronchial biopsy, transbronchial lung biopsy, and transbronchial needle aspiration; indications include atelectasis, hemoptysis, cough, suspected malignancy, infection, foreign body aspiration, ILD, lung transplant, and trauma; also if someone is considering a lung transplant

Silicone stents

composed of silicone sleeves fitted with external studs to retard stent migration in the airway

Flexible fiberoptic bronchoscope

consists of a control unit (or head) and a soft, flexible shaft; control unit is attached to a light source and can be fitted with a camera; two types: fiberoptic and video chip

Self-expanding metallic stents

constructed of nitinol, an alloy composed of nickel and titanium that has the properties of being flexible while retaining excellent shape memory

Future directions

endoluminal lung-volume reduction for treatment of advanced emphysema using one-way endobronchial valves; actually take out a patients lobe or an entire lung

Interventional pulmonology

focuses on procedural services provided to patients with airway disorders and pleural diseases

Absolute contraindications

inability to maintain adequate oxygenation, operator inexperience, inadequate facilities, lack of informed consent, status asthmaticus

Bronchoalveolar lavage (BAL)

is the method traditionally used to sample the cellular and microbiologic components of the alveolar space; shoot saline down and suck it back out for cytology

Indications for diagnostic bronchoscopy

lung collapse/atelectasis; hemoptysis; cough; suspected malignancy; infection; foreign body aspiration; interstitial lung disease; lung transplant; trauma

Exudative causes of Pleural Effusion

malignancy, pneumonia, pulmonary embolism, following thoracic surgery, TB, chyle, connective tissue diseases

Causes of central airway obstruction

malignant (carcinomas, tumors, lymphoma); nonmalignant (sarcoidosis, infections, vascular, granulation-forming things)

3 main areas of pulmonary medicine

malignant and nonmalignant airway disorders; pleural diseases; artificial airways

Indications for rigid bronchoscopy

massive hemoptysis, foreign body removal, dilation of airway stenosis (stretch it), airway stent placement, resection of central airway tumor

`Therapeutic bronchoscopy

most commonly employed to treat patients with central airway obstruction due to benign or malignant etiology

Prior to procedure

once appropriate patient has been selected, informed consent can be obtained; all aspects of procedure should then be explained (initial application of topical anesthesia to the introduction of the bronchoscope through the nose or mouth, vocal cords, and distal airways); risk of bronchoscopy and anesthesia should be specifically reviewed

Factors necessary for successful bronchoscopy

patient selection, patient preparation, appropriate sedation; the ideal patient is awake, able to understand and cooperate, and low risk for complications; patient is usually consciously sedated, vitals monitored, EKG, EtCO2, SpO2

Pleural disease

pleural effusions may be caused by CHF, malignancy, pneumonia, and pulmonary embolism; thoracentesis is a sage procedure that may be performed at the bedside and is the first step in the diagnosis of a newly recognized pleural effusion (be careful of flash pulmonary edema)

Complication of bronchoscopy

pneumothorax occurs in 1% to 6% of patients and the symptoms include chest pain, hemoptysis, and shortness of breath after the procedure; significant hemorrhage (defined as more than 50 mL of blood) is observed in 2-9% of patients; transient hypoxemia has been documented in up to 35% of patients undergoing fiberoptic bronchoscopy, but can often be alleviated with the use of supplemental oxygen therapy

Diagnosis of ILD

requires a tissue sample for pathology evaluation; bronchoscopy with transbronchial biopsy is often considered; flexible bronchoscopy with BAL and/or transbronchial biopsy has proven to be a valuable tool for evaluating lung allograft complications; blunt trauma to the chest can be associated with tracheal and bronchial injuries that are life threatening

Key points (4)

rigid bronchoscopy can be used for any bronchoscopic indication but is usually limited due to the fact that general anesthesia is required; airway stenting uses self-expandable metal stents, silicone stents, and hybrid stents; pleural effusions may be caused by a variety of medical conditions

Airway stents

self-expandable metal stents (look like chicken wire), silicone stents, and hybrid metal-silicone stents are available; rigid bronchoscopy is required for silicone stent placement; stents are generally effective in improving airway patency; common complications include stent migration and occlusion by secretions; generally are effective in improving airway patency and are associated with increases in FEV1

Hybrid stents

share some of the characteristics of silicone and metallic stents and are constructed of a polyurethane or silicone sleeve with supporting nitinol struts

Bronchoscopic washing

similar to a lavage but is designed to sample the airway rather than the alveolar space

Rigid Bronschoscope

stainless steel tube with a beveled tip at the distal end while the proximal end contains a series of ports for ventilation, passage of suction catheters, grasping tools, a telescope, or a flexible bronchoscope; prior to bronchoscope insertion, the patient must be adequately sedated with general anesthesia

Key points (2)

successful bronchoscopy depends on patient selection, patient preparation, and appropriate anesthesia; the ideal patient is awake, able to understand and cooperate, and low risk for the procedure; although topical anesthesia alone can be used, many physicians use adjunctive IV sedations

Endobronchial biopsy

the method used to sample abnormalities directly visualized within the airway, including visible tumors or mucosal irregularities

Indications cont.

the use for acute atelectasis, lobar collapse, and clearance of retained secretions is common; indications in hemoptysis include identifying the cause of bleeding, localizing the bleeding source, and evaluating for endobronchial malignancy; asthma, postnasal drip/allergic rhinitis, and GERD are the most common causes of chronic cough

Key points (5)

thoracentesis indications include: diagnosis of new pleural effusion of unknown etiology, relief of dyspnea in a patient with a large pleural effusion; pleural fluid is exudative if the ratio pleural fluid serum protein is 0.5 or greater or if pleural fluid serum LDH is 0.6 or greater (this is for physicians); traditional approach to recurrent pleural effusions is pleurodesis or administering a sclerosing agent

Thoracentesis purpose

to categorize pleural fluid as either transudative, suggesting benign, noninflammatory causes, or exudative, suggesting a malignant, infectious or inflammatory etiology; many pleural effusions are self-limited and resolve with treatment of the underlying etiology of the effusion

Recurrent Pleural effusion

traditional approach is to provide pleurodesis, either with mechanical abrasion during a thoracotomy or thorascopic surgery or by administering a sclerosing agent via tube thoracostomy; an alternative to pleurodesis is the placement of a tunneled pleural catheter, which allows patients to manage their effusion in the outpatient setting

Sedation

use of IV sedation can be important in alleviating anxiety, improving patient comfort and cooperation, providing amnestic effects, and facilitating the bronchoscopic procedure; conscious sedation is generally used in the outpatient setting

Transbronchial biopsy (TBB)

used to collect small samples of lung tissue for histopathologic review; a simple and safe procedure that can provide useful diagnostic information in benign and malignant conditions; the availability of endobronchial ultrasound (EBUS) guidance has significantly increased the diagnostic yield of this procedure