Diagnostic and interventional bronchoscopy Bronchoscopy Bronchoscopy is one

Diagnostic and interventional bronchoscopy

Bronchoscopy • Bronchoscopy is one of the most obvious invasive examination in pneumology. • Diagnostic bronchoscopy: development of sofisticated technology allowe to perform some diagnostic procedures to make a diagnosis • Therapeutic (interventional) bronchoscopy is a method to perform some treatment modalities in tracheobronchial tree.

Rigid/flexible Bronchoscopy

History • G. Killian - 1897 S. Ikeda - 1966

Indication of Bronchoscopy • Patients whose chest radiographs reveal abnormal shadows. The most common are cases of lung cancer • Aspiration of foreign body • Hemoptysis • Diffuse intersticial lesions (with bronchoalveolar lavage) • Terapeutic bronchoscopy

Contraindication Generally there are only few contraindications to bronchoscopy: Severe cardiac conditions Acute myocardial infarction Agina pectoris Hypoxemia less than 60 Torr Poor pulmonary function Severe laryngeal or tracheal stenosis

Complication of bronchoscopic procedures • • Hemorrhage – more than 300 ml Pneumothorax Lignocain intoxication Laryngospasm , Bronchospasm High fever > than 38 degree C Extrasystole on ECG record Myocardial infarction Hypoxemia

Anaesthesia • • • General anaesthesia (rigid bronchoscopy) include Intravenous anesthesia (propofol) Analgesia Neuromuscular relaxation Ventilatory support during rigid bronchoscopy • Local anaesthesia with local anaesthetic agents (lignocain, cocain, tetracain, lidocain) most common during flexible bronchoscopy. In Slovakia about 98% of bronchoscopic procedure are performed in local anaesthesia.

Bronchoscopic procedures • We can perform the following procedures with bronchocopy: • Observation of intratracheal and intrabronchial lesions

Bronchial biopsy • Biopsy of tumours visible in trachea or bronchi

Transbronchial biopsy • Peripheral pulmonary lesions • Diffuse parenchymal lessions • Under fluoroscopic guidence

Bronchial brushing • We can collect some specimens to cytologic examination

Transbronchial needle biopsy • To cytologic and/or histologic examination • EBUS TBNA – endobronchial ultrasound needle biopsy/aspiration

Collection of bronchoalveolar lavage fluid To microbiologic, cytologic and imunocytologic examinations. The main causes are various opacities in chest radiograph (interstitial lung diseases). Instilation of 100 ml saline solution

Intervantional bronchoscopy • Therapeutic bronchoscopy – Foreign bodies

Foreign body • 66 years old man

Therapeutic bronchoscopy Includes: • Electrocauthery • Laser therapy • Cryotherapy • Aplication of various stents to airways, • Baloon dilatation of tracheal stenosis • Brachytherapy

Electrocauthery • Heat is generated by a high frequency electrical current passing through the tissue with high resistence and can be applied to coagulate, vaporise or cut tumour tissue using a probe or a snare.

Electrocauthery • The high frequency generator is activated with the pedal and the tissues are heated to 100° degrees C. It is immediately destroyed by vaporization and cut by heat higher than 100° C.

Case report • 59 –years old man ex-smoker presented with cough , shortness of breath and sputum expectoration of four months in duration before he was admitted to hospital. • He was treated for recurrent pneumonia on the left site of lungs. Finally he was admitted to our department as a not verified bronchogenic carcinoma.

Case report • Thoracic computed tomographic scans showed dystelectasis of the basal segments of the left lower lobe. In the left main bronchus we can see a small tumor.

Case report • Flexible bronchoscopic examination revealed almost total obstruction of lower part of the left main bronchus by smooth ovalshaped polypoid tumor. • Five biopsy specimens had been taken. Findings of histological examination was the endobronchial lipoma.

Case report • We have decided for endobronchial treatment by electocauthery using the wire snare. On the polypoid tumor the snare was applied.

Case report • The procedure was performed under the general anesthesia • The duration of the procedure was about 30 minutes.

Case report • Macroscopic view of the polypoid tumor • Histologic result: Endobronchial lipoma without atypia

Case report • Bronchoscopic findings after the procedure one day one mounth

Case report • Computed tomography one mounth after the procedure

Conclusion • Endobronchial lipomas are rare benign tumors. • Bronchoscopic examination can be used to provide both diagnosis and treatment. • In our opinion electrocauthery is an effective modality for treatment of these findings and is not associated with disease recurrence. • Surgical treatment is not required any more.

Electrocauthery of benign tracheal stenosis • 64 years old women

Electrocauthery of carcinoma in situ or microinvasive carcinoma • Diagnosis used by autofluorescence bronchoscopy

Microinvasive carcinoma • Histologic finding – squamous cell carcinoma

Case report • Malignant obturation of right main bronchus

Solution of central malignant obturation • Paliative treatment – destruction of endobronchial tumour + endoluminal brachytherapy with Iridium 192. • Dose 7 – 10 Gy per fraction

Stents Indication: stenosis, obturation of the trachea and main bronchi

Stents • Various kind of stent are aplicated to trachea and bronchi, proximal or distal release, covered, and uncovered

Balloon dilatation

Argon Plasma Coagulation • APC is non-contact coagulation of surface of the tissue (indication is: Ca in situ, bleeding etc. )

Massive hemoptysis • Volume of tracheobronchial tree is 150 ml • Baloon tamponade:

Laser therapy • Indication are the same as electrocauthery, the most common are any obstruction in the main airway (trachea and/or main bronchi). • Carbon dioxid CO 2 laser, used in otolaryngology • Nd: Ya. G Neodynium: ytrium-aluminiumgarnet laser which provides deeper penetration to tissue (3 -5 mm).

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