Bronchoscopy and Lung Biopsy, Lung Scan, CT Pulmonary Angiography

Pulmonary Embolism (V is normal - air getting into lung Q is low - not perfused bc of blockage)

A mismatch of V (ventilation) and Q (perfusion) is characteristic of ____

Hilar Adenopathy

An super common early finding of Sarcoidosis on CXR is ________. This disappears later in the disease

Nightshade

Atropine comes from the _____ plant

Use a balloon to apply pressure to airway to stop bleeding Can also use epinephrine and other local vasoconstrictures to stop bleeding

Balloon tamponade:

Little rods that go into the body and give off radioactivity, killing local cancer cells Commonly used for prostate cancer (into perineum) Can also be used for lung therapy

Brachytherapy:

Endoscopy within the lugns

Bronchoscopy is:

Helical CT done in a single breath hold after patient is injected with IV contrast material. Can 'reconstruct' pulmonary vasculature to form a 3D image

CT Pulmonary Angiography (CT-PA or CTA)

Inserting a flexible tube

Cannulation definition?

Uncooperative patient Patients with hypercapnia and severe shortness of breath (not an absolute contraindication...) Baseline COPD patients Severe tracheal stenosis Can't get the scope past it - epiglottitis, large goiter, etc. Uncorrected bleeding disorder or on antiplatelet/anticoagulant agent Recent myocardial infarction bronchoscopy can cause reflex tachycardia, bronchospasm, hypoxemia)

Contraindications of Bronchoscopy

Patients with bullae or cysts of lung (Popping may cause pnuemothroax) Suspected vascular anomalies - AVM* (*AVM - Arterial venous malformation - abnormal connection that bypasses capillaries - usually congenital) Bleeding disorders Pulmonary hypertension ***The last 3 are due to bleeding risk

Contraindications to lung biopsy:

Serology assesses thrombin and plasmin activity. A fibrin degradation fragment Uses: Screening for DVT/PE, DIC sensitivity of 95% and a specificity of only 45% Can be elevated in MANY other states as well

D-dimer Serum Test

True

DVT patients can be sent home if they are responsible and you trust them to take their medications. True or false?

looking at the inside of something with a camera, can also intervene

Endoscopy definition:

MOST COMMON Does not require general anesthesia Used much more often to obtain biopsies, bronchial washing. Can see down to the 3rd degree of bronchioles

Flexible Bronchoscopy

Bronchoscopy

Fluoroscopy is done with ______ as well. It provides real time x-ray of the lungs

Transbronchial lung biopsy Transbronchial brushing Transbronchial needle aspiration

For central lung lesions, what methods of lung biopsy would you use?

Percutaneous needle biopsy Thorascopic lung biopsy Open Lung biopsy

For distal lung lesions, what methods of lung biopsy would you use?

FLEXIBLE bronchoscopy

How is a closed lung biopsy collected?

VATS (minimally invasive) or full on open thoracotomy (invasive)

How is an open lung biopsy collected?

30 min

How long is a normal flexible fiberoptic bronchoscopy?

Hyperinflation of the ventilated lung Atelectasis of the other lung

If the ET is improperly placed too far down, what can happen?

Pneumonia

If you had a low Q finding on a V/Q Test, but see infiltrates on CXR - what is more likely a diagnosis than PE?

LOW or abnormal Ventilation result

In a V/Q Test, what result would you find with pneumonia, bullae, TB, tumor?

Rigid

Large stints are placed with Rigid or Flexible Bronchoscopy?

Invasive procedure used to obtain pulmonary tissue for histologic exam

Lung Biopsy

Check for biopsy results in 24-48 hours Observe serial sets of vitals and have an explanation for any changes These are concerning Drop of BP Drop of O2 levels Assess breath sounds Obtain chest x-ray if concern over possible pneumothorax

Lung Biopsy Post-Procedure Care

Normal - no evidence of pathology Abnormal - carcinoma, granuloma (sarcoidosis), infiltrative lung disease, infection

Lung Biopsy Results

True

Lung Scan (V/Q Scan) is a type of nuclear medicine study - true or false?

Technetium (Tc)

Lung Scan (V/Q Scan) uses which chemical to attach to different substrates based on where it needs to go?

Fever out in order to collect cells Laryngospasm Bronchospasm Aspiration Hemorrhage (after biopsy) Severe complications like pneumothorax, respiratory failure, bacteremia, serious hemorrhage are uncommon

Potential Complications of Bronchoscopy (its generally a very safe procedure)

Pneumothorax Pulmonary hemorrhage Empyema (pic) - pus buildup (doesn't have meniscus sign of pleural effusion)

Potential Complications of Lung Biopsy

Diabetics on metformin and risk for lactic acidosis with contrast Risk of cardiac arrhythmias when you catheterize the R heart to get to the main pulmonary artery

Potential Complications of Pulmonary Angiography

Explain procedure to patient Informed consent required NPO past midnight

Preparation for Lung Biopsy

Explain procedure to the patient Informed consent required (unless implied consent in emergency situations) Pt must be NPO (nothing by mouth) 4-8 hours prior to test to prevent aspirations Remove dentures, glasses, contact lenses Premedicate: Local anesthetic is applied to throat Atropine 0.01 mg/kg IV

Preparation of Procedure

Lung produces too much surfactant Can use bronchoscope to lavage - remove some of the fluid

Pulmonary Alveolar Proteinosis:

Patients with allergies to iodinated dye or shellfish Pregnancy Bleeding disorders

Pulmonary Angiogram Contraindications

Observe catheter site for inflammation, hematoma, and/or hemorrhage Apply cold compress to stop swelling if needed Assess vital signs for trends

Pulmonary Angiogram Post-Procedure Care

'Gold Standard' for PE but...... invasive, labor intensive (1 hour), expensive

Pulmonary Angiography

Less common Can't see very far Has to be anesthetized Visualizes PROXIMAL airways Indicated when large amounts of tissue need to be removed (has bigger working channels) Can be used to place large stints

Rigid Bronchoscopy

"Noncaseating Granulomatous disease..." 25% of sarcoid patients have facial eruptions

Sarcoidosis

Has reticular and nodular signs on CXR Beaded nodular signs on CT No air bronchograms

Sarcoidosis (interstitial - infiltrative - lung disease)

Cytology - looking for cancer Gram stain and culture Positive - purple Negative - red

Specimens collected via bronchoscopy are sent to the lab for:

Mydriasis Tachycardia Other sympathetic stimulant type situations

Symptoms of atropine toxicity

~5 cm

The ET tube should be ____ cm above the carina to ensure both lungs are aerated

Proximal Distal

Thrombosis in the ______ lower extremity is way more concerning for potential PE than _____ lower extremities

Pregnant Unstable patients

V/Q Contraindications

Detection of Pulmonary emboli Assessment of regional lung function (often before surgery)

V/Q Indications

Explain procedure Obtain informed consent Obtain a recent CXR to compare results to

V/Q Patient Preparation

If negative for PE, you will see diffuse homogenous uptake of nuclear material by the lungs Can also be: Low Probability for PE Moderate Probability PE (need more tests) High Probability for PE or Positive for PE

V/Q Scan findings:

Sensitive Specific

V/Q is very _____ (98%) but not very _____ (10%)

Q - Perfusion - think bloodflow patency test V - Ventilation - think airway patency test

V/Q test - how can you think of the V and Q?

Completely computer generated 3D pictures which are reconstructed based on the CT images of the thorax Win: Non-invasive, can define airways down to 7th generation of branching! Lose: not available! Diagnostic only

Virtual Bronchoscopy

Rigid Flexible

What are the two main types of Bronchoscopy?

Video-assisted thoracoscopic surgery

What does VATS stand for?

Atropine (anticholinergic) - 0.01 mg/kg IV

What drug can you give before performing bronchoscopy to help dry up airways?

Pulmonary Embolism

What is CT-PA used to diagnose?

Nuclear Medicine Imaging of the Lung using radiotracers (technetium) Two Tests are performed: V (ventilation test) and Q (perfusion test)

What is a Lung Scan (V/Q Scan)?

walled off section of inflammatory cells (done by the immune system)

What is a granuloma?

To determine the pathology of pulmonary parenchymal disease Can diagnose: Carcinomas (cancer) Granulomas (Sarcoidosis) Infections

What is a lung biopsy used to test for?

Shows pulmonary arteries more directly and is more specific

What is an advantage of CT-PA (CTA) over V/Q perfusion scanning?

20 mL of saline inserted and then re-suctioned out in order to collect cells Bacteria culture collection

What is brochoalveolar lavage and what is it used for?

Prednisone (high dose steroid)

What is the best treatment for sarcoidosis?

Caseating - 'cheese-like' infections, necrosing - dead cells Noncaseating - Not necrosing, no dead cells

What is the difference between caseating and noncaseating?

CT-PA (CTA)

What is used considerably more than pulmonary angiography in the clinic?

lidacaine 1-2%

What type of topical anesthetic is given before bronchoscopy?

Negative CTA, but very convincing clinical picture and equivocal VQ scan

When would you order pulmonary angiography when testing for PE?

Age <50 Pulse Ox>94% on RA HR<100 No hx of previous venous thromboembolism No recent surgery or trauma (requiring hospitalization, intubation, or epidural anesthesia within 4 weeks prior) No hemoptysis No estrogen use (birth control, HRT) No unilateral leg swelling

Who do you image for suspected pulmonary embolism?

PA and Lateral CXR

You MUST have a _____ and _____ before ordering a V/Q Scan?