Chest Lectures Pr. Dr.Waleed Mustafa Consultant Thoracic & Vascular Surgeon

Major disadvantage of the flexible Bronchoscope is that it is a closed system that does not provide an airway, and the relatively small inner channel is considered to be incapable of allowing adequate suction when confronted with copious secretions or massive haemoptysis. It is not so much effective in the removal of foreign bodies. Indications for flexible Bronchoscopy 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.

Tracheo-Bronchial Trainer

Sample collection (BAL) Saline for irrigation Lever Suction Lecture scope

Rigid Bronchoscopy Is best avoided in the presence of Cervical spine injury thoracic to prevent hyperextension of the neck & in patient with Aneurysm of the aorta Flexible Bronchoscopy Best avoided in patient with Massive Haemoptysis & patients with air way problems Contra indications In cases of doubt as to whether bronchoscopy should be done or not, bronchoscopy should always be done ( Jackson ’ s 1915 statement ). In suspected cases of F.B inhalation it is better to have a negative bronchoscopy rather than to miss a F.B inside with all its pathological consequences.

Normal Bronchoscopic Findings

Abnormal Bronchoscopic Findings

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 & tension pneumothorax ), Subglottic edema, Uncontrolled bleeding, Infections Arrhythmias rarely ( Cardiopulmonary arrest ) 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 have worn off. 3-Some may advise routine CXR after performing a biopsy to check for signs of pneumothorax. 3-Those patients develop complications may need to stay in the hospital for additional time. 4-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 (Air way prosthesis ) 3-PDD & AF Bronchoscopy. 4-Bronchoscopic Laser therapy. 5-Bronchoscopic Electro Cautery 6-Cryo therapy 7-Brachy therapy 8-Photo therapy

Bronchoscopy need cooperation and mutual understanding Between 1-A well trained endoscopist 2-a qualified staff 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 endobronchial malignancy.

Pleural Tumors Classified as primary and secondary tumors. Primary Pleural tumors are Mesotheiloma which may be 1-Localized benign 2- Diffuse Malignant Malignant Mesothelioma causes chest pain, bloody pleural effusion and chest X-Ray findings of diffused pleural thickening with nodularity and limited pleural effusion.There is a possible relationship with asbestos exposure. Metastases are uncommon.Death usually occurs within 1-2 years.It has a poor response to surgery, radiotherapy and chemotherapy. Pleural involvement by metastatic diseases is more common than primary tumor and usually comes from lung, breast and stomach.

Benign Tumors of Trachea and Bronchi Are rare,more in males.They are slowly growing.Their presentation is is as a result of luminal obstruction or mucosal irritation.Patients may present with dyspnea, cough and haemoptysis.A sub glottic tumor presents with stridor,The diagnosis is by bronchoscopy and treatment is surgical excision.E.g Papilloma, Haemangioma,Chondroma and Fibroma

Bronchial Adenomas 1-Bronchial Carcinod 2-Muco epidermoid Tumors 3-Adenoid Cystic Carcinomas (Cylindromas ) 4-Mucous Gland Adenomas The first three are potentially malignant,the 4 th. Is benign The first three are slowly growing, invade locally and surgical excision is the treatment of choice. Bronchial Carcinoid Tumors Resemble intestinal carcinoid as the cytoplasm as the cytoplasm of their cells contains neurosecretory granules.In the bronchus these tumors arise from the neuro endocrine argentafin cells of bronchial mucosa (Kultchitsky ‘s cells ).They are grouped among APUD tumors (Amine Percursor Uptake Decaboxylation). They are capable of producing a number of hormones like Serotonin, histamine and gastrin.They are slowly growing tumors, but sometime they are aggresaive termed (atypical carcinoid ).They present with cough, haemoptysis and dyspnea ). Carcinoid Syndrome is a rare,presents with episodes of flushing, diarrhea and in addition to the systemic manifestations,there may be cardiac manifestations.Elavated 5-HIAA may be detected in the urine,which may be diagnostic.Bronchoscopic appearance is diagnostic and severe bleeding may follow a biopsy.Surgical excision is the treatment of choice.

Carcinoma of the lung

Affects both sexes, It is however commoner in men It has poor prognosis. The incidence has shown a marked rise during recent years partly because of improved methods of diagnosis and partly due to 1-Ecessive cigarette smoking,both active & passive smoking are implicated 2-Inhalation of irritants, such as silica,cobalt dust.

Pathology :- A-Central type is the commonest (75%).It arises in one of the main bronchi or their primary division leading to bronchial obstruction with secondary changes in the lung such as atelectasis. B-Peripheral type (25%) arises from the smaller bronchi and remains symptom less for long time.

Histologically Squamous cell Ca (SCC) 60%, smoker, centrally located,metastasizes to mediastinal & supraclavicular LN. Adenocarcinoma (15% ), located peripherally, more in women.Tends to metastasizes to the liver, brain,bone & adrenals in addition to the LN Undifferentiated carcinoma (oat) cell carcinoma and large cell carcino(20-30%) which includes small ma Alveolar cell carcinoma, located peripherally,metastasizes to the liver and adrenals Recent classification..Non small & small cell carcinoma

Superior sulcus tumor of Pancoast It is a low grade epidermoid carcinoma that grows slowly and metastasize late, infiltrates and involves lower root of Brachial plexus, intercostal nerves, Cervical sympathetic nerves & eroding the upper ribs,producing pain in the shoulder & Horner's syndrome.

Clinical features :- 1- cough dry or productive 2-Haemoptysis 3-Chest pain 4-Dyspnea 5-Pleural effusion 6-Anorexia & loss of weight 7-Clubbing of the fingers 8-Hoarseness of the voice (recurrent LN) 9-Dysphagia involvement of the esophagus 10-Hormonal syndromes..ectopic ACTH, ADH, hypercalcaemia,carcinoid syndrome Diagnosis Clinical, sputum cytology Chest X-ray,CT chest.. Bronchoscopy,BAL,bronchial brush &biopsy FNAC….or Trucut biopsy, pleural fluid aspiration & cytology Diagnostic Thoracoscopy & mediastinoscopy TNM classification for staging

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