BRONCHOSCOPY Cori Daines, MD Pediatric Pulmonology, Allergy and Immunology University of Arizona

BACKGROUND Allows direct visualization of the airways Rigid and flexible instruments Clinical tool –Airway anatomy –Airway sampling –Therapeutic Research tool

ORIGINS Until the 1980’s, only rigid instruments were widely used Multiple generations of adult and pediatric flexible bronchoscopes now Widely used in adult and pediatric pulmonary medicine now

RIGID BRONCHOSCOPY Generally performed by ENT’s and surgeons Procedure oriented –Foreign body removal –Biopsies –Granuloma/polyp removal –Laser –Stent placement Visualization for future surgery

INSTRUMENTS Rigid bronchoscopes –Hollow metal tube –Glass rod telescope Ultimate optics

FLEXIBLE BRONCHOCSOPY Examination of the entire respiratory anatomy, nose to bronchi Minor impact on anatomy Able to pass through an endotracheal tube or tracheostomy tube

INSTRUMENTS Flexible instruments –Fiberoptic bronchoscopes 2.2mm ultrathin 2.8mm/1.2mm suction channel 3.4mm/1.2mm suction channel 4.4mm/2.0mm suction channel 4.9mm/2.2mm suction channel 5.9mm/3.0mm suction channel

INSTRUMENTS Flexible instruments –Video bronchoscopes 2.8mm/1.2mm suction channel (hybrid video scope) 3.8mm/1.2mm suction channel 4.0mm/2.0mm suction channel (hybrid video scope) 4.9mm/2.0mm suction channel 6.0mm/3.0mm suction channel 6.3mm/3.2mm suction channel

Fiberoptic bronchoscope 2.8mm diameter

Pediatric Videoscope 2.8mm diameter

Pediatric videoscope 3.8mm diameter

Adult videoscope 4.9 mm diameter

INDICATIONS When flexible bronchoscopy is the best, easiest, safest, most efficient way to obtain the information

AIRWAY ANATOMY

TECHNIQUE

Anesthesia –Best accomplished in the operating room –May be performed bedside in an ICU setting –Continuous monitoring –Light anesthesia--allows continued spontaneous breathing –May be done with conscious sedation in older individuals

TECHNIQUE Insertion –Nasal –LMA –Endotracheal tube –Tracheostomy tube –Appropriate topical anesthesia and lubrication

TECHNIQUE Anatomical survey –Nasal passages –Pharynx –Larynx –Trachea –Bronchi Examine all before any other procedures

TECHNIQUE Additional procedures –Bronchoalveolar lavage –Brushings –Bronchial biopsy –Transbronchial biopsy –Laser –Others: cryotherapy, stent placement, foreign body removal, needle biopsy

BRONCHOALVEOLAR LAVAGE Small aliquots of sterile normal saline instilled into the airway Removed by suctioning Samples distal bronchial and alveolar surfaces Wedge position to prevent loss of fluid

BAL TESTS Microbiology –Bacterial, viral, fungal, AFB, special techniques Pathology –Cell count, differential, special stains

MICROBIOLOGIC STUDIES Stains –Gram stain –Acid fast stain (Ziehl-Neelsen) Antibody tests –Rapid tests, DFA tests In-situ PCR

SPECIAL STAINS Lipid –Oil Red O –Sudan Hemosiderin –Prussian Blue Alveolar proteinosis –PAS –Electron microscopy

SPECIAL STAINS Fungi –Silver (Gomori’s methenamine silver stain) Pneumocystis carinii –Silver stain –Papanicolaou

BRONCHOALVEOLAR LAVAGE

SPECIFIC INDICATIONS Atelectasis Recurrent pneumonia Chronic cough Persistent/unexplained wheeze Hemoptysis Suspected airway compression/obstruction Stridor Upper airway obstruction Suspected aspiration Evaluation of tracheostomies

NORMAL ANATOMY

BRONCHOALVEOLAR LAVAGE

LARYNGOMALACIA

TRACHEOMALACIA

SUCTION TRAUMA

TRACHEOBRONCHOMEGALY

VASCULAR COMPRESSION

TECHNIQUES-BIOPSY

TECHNIQUES-LASER

BRONCHOSCOPY TEAM Pulmonologists Respiratory therapists Anesthesia Nurses Laboratory –Microbiology –Pathology