Cardiothoracic
Dr.Waleed
Surgery
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chest
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Dr. Waleed
Lecture
#2
Total Lec: 30
Dr.Waleed
lecture: 2
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Bronchoscopy
2016
3
BRONCHOSCOPY (V. IMP.)
Bronchoscopy:
looking into the living lungs (Chevalier Jackson 1928).
Today with the major advance in technology:
- View the fine details of the end bronchial anatomy.
- Diagnosis of the disease.
- Treating diseases.
It is the visualization of the airway using either rigid bronchoscope (under GA) or the
flexible (Fiber-optic bronchoscope, under LA) or both simultaneously. Through which
we can remove FB, take BAL, brushing lesions and Trans bronchial Biopsy.
HISTORY
Gustav Killian (The father of bronchoscopy), was appointed professor of ENT
at the university of Freiburg in 1892. Gustav Killian in 1897 succeeded in removing
aspirated pork bone from the bronchus of a 63 year old farmer under cocaine
anesthesia. He used external light source, a head mirror, esophagoscope and forceps
to remove the bone. He became famous & his clinic attracted patients from far and
wide for his expertise in removing different kind of (FB) such as bones, beans,
buttons, coins & tin whistle.
Gustav Killian Bronchoscope with external light source
Bronchoscopy rapidly developed into a science (with the creation of a better instruments
and techniques).
Chevalier Jackson Founded philadelphia school of bronchoesophalogology.
Jackson‘s monograph first published in 1950.
Chevalier Jackson’s Bronchoscope with a small distal bulb & built-in suction tube
Early in the 1960s Shigeto Ikeda devised a means to replace the small electric
bulb with glass fibers capable of transmitting brighter light from an outside
source.
He presented the first flexible bronchoscope
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at the 1966 International Congress on Diseasesof the Chest in Copenhagen.
H.H.Hopkins, English physicist developed the rod-lens optical telescopes which
could be used with the rigid bronchoscope
At the end of the 1980s, Asahi Pentax replaced the fiberoptic bundle with a
charge-coupled sensor at the tip of the scope. This videobronchoscope allowed
the bronchoscopist to look at a monitor screen instead of through the eyepiece of
the scope
Rigid Bronchoscopes:
o Hollow metal tubes, of variables sizes down to (3 mm-9.5 mm) and variable
length (20-40 cm).
o These instruments usually have illumination at their tips as well as side holes
near the tip to facilitate ventilation.
o They are always inserted trans-orally.
o General anesthesiais recommended for its introduction.
INDICATIONS FOR RIGID BRONCHOSCOPY: IMP.
(DIAGNOSTIC AND THERAPEUTIC)
1. Hemoptysis
2. Tracheal stenosis.
3. Foreign body removal.
4. All bronchological interventions such as bougienage, removal of threads and post
intervention hemoptysis.
5. Confirmation of cell type in case of previous, non-diagnostic fiber-optic bronchoscopy.
6. Laser treatment.
7. Removal of tumor.
8. Removal of excess fibrin, mucous plug.
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9. Bronchography.
10. Autofluorescence and photodynamic diagnosis.
Rigid Bronchoscopy (Adult Set)
Flexible Bronchoscopy (fiber-optic bronchoscopy):
It consists of control section, a flexible insertion tube & a bending tip .The
control section contains the eye piece, control lever and a channel for aspiration
or for introduction of solution and instruments.
These flexible bronchoscopes have variable outside diameter (1.8-6 mm)
with inner channel ranging from (1.8-2.6 mm).
Highly maneuverable and can reach areas in the endobronchial tree not
accessible to the rigid bronchoscopes.
Can be inserted either transorallyor transnasallyor through the rigid
bronchoscope.
We have the Infantile, Pediatric, adult types and the Video–Bronchoscopes.
It can be introduced under local anesthesia.
INDICATIONS FOR RIGID BRONCHOSCOPY: IMP.
1. For routine examinations.
2. Treatment of acute respiratory problems in the ICU.
3. Suction under visual control.
4. Use of catheter and brushes for cytology.
5. For obtaining secretions for bacteriological tests.
6. Localization of the bleeding site in case of hemoptysis.
7. Theraputic suction & irrigation.
8. Transbronchial lung biopsy.
9. Selective bronchography.
10. Autofluorescence& photodynamic diagnosis.
MAJOR DISADVANTAGE OF THE FLEXIBLE BRONCHOSCOPE IS THAT
1. it is a closed system that does not provide an airway,
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2. and the relatively small inner channel is considered to be incapable of allowing
adequate suction when confronted with copious secretions or massive
haemoptysis.
3. It is not so much effective in the removal of foreign bodies.
CONTRAINDICATIONS:
RIGID BRONCHOSCOPY:
is best avoided in the presence of cervical spine injury to prevent hyperextension of the
neck and in patient with aneurysm of the aorta.
FLEXIBLE BRONCHOSCOPY:
is best avoided in patient with Massive Haemoptysisand patients with air way problems.
Note: we choose the type of bronchoscopy according to the patient or his problem, for
example in case of:
- Patient couldn't undergo GA → flexible bronchoscopy.
- Patient with cervical spine problem → flexible bronchoscopy.
- Patient with aortic aneurysm → flexible bronchoscopy.
- Peripheral lesion → flexible bronchoscopy.
- Selective wash → flexible bronchoscopy.
- Patients need ventilation (airway problem) → rigid bronchoscopy.
- Massive hemoptysis → rigid bronchoscopy.
- Foreign body → rigid bronchoscopy.
- Tracheal stenosis → rigid bronchoscopy.
COMPLICATIONS:
When bronchoscopy performed by properly trained individuals it is a safe procedure.
However a variety of other problems have been reported including:
pneumothorax ○ bronchospasm ○ Bronchial perforation (Surgical emphysema
and tension pneumothorax)
Subglottic edema ○ Uncontrolled bleeding ○ Infections
Arrhythmias rarely (Cardiopulmonary arrest)
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Hypoventilation (Hypoxia &hypercapnia)
Majority related to a biopsy procedure, so explorative thoracotomy may be safer than
(injudicious biopsy).
Some minor complications: ○ damage of teeth ○ injuries to lips or mouth
Post bronchoscopy care:
1. Close monitoring for 2-4 hours after the procedure.
2. Eating and drinking is not allowed until the effect of anesthesia has worn off.
3. Some may advise routine CXR after performing a biopsy to check for signs of
pneumothorax.
4. Those patients develop complications may need to stay in the hospital for additional
time.
5. The patients may have sore throat, hoarseness, cough or muscle ache .
Fever up to temperature 38 c is common after bronchoscopy but usually for only 24
hours.
Advances in Bronchoscopy:
1. Brochoscopic ultra-sound.
2. Bronchoscopic stenting (airway prosthesis).
3. Photodynamic diagnosis (PDD) and autofluorescence (AF) bronchoscopy.
4. Bronchoscopic laser therapy.
5. Bronchoscopic electro cautery.
6. Cryotherapy.
7. Brachytherapy.
8. Phototherapy.
Bronchoscopy needs cooperation and mutual understanding between:
1. A well trained endoscopist.
2. A qualified staff.
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3. Expert and well trained anesthetist.
Bronchoscopy is now an integral part of respiratory medicine.
Diagnostic indications include
tissue diagnosis, detection and staging of lung malignancy, evaluation of diffuse lung
diseases like sarcoidosis and idiopathic interstitial pneumonias, pulmonary inspection of
burn patients, identification of organisms infecting the respiratory tract and lungs.
As a therapeutic modality
, bronchoscopy is used to place stents to protect airways vulnerable to collapse or
occlusion, to remove foreign bodies or masses, to treat early stage
endobronchialmalignancy .
Done by : Sally Saeed