Bronchoscopic Evaluation of the Lungs and Tracheobronchial Tree

Rigid Bronchoscopy

Most commonly in adult: ID 6,7,8 mm, 40 cm in length

♦ Supine position, assistant positioning the head, neck is slightly fixed, chin extended ♦ Risks: injury to gums, tooth dislodgement, hypoventilation, airway bleeding, direct injury to larynx, rupture of the tracheobronchial tree

Flexible Bronchoscopy In the early 1970s, fiberoptic bronchoscopy was introduced, revolutionizing examination.

Most commonly used: OD 5.9mm, 2.2 mm working channel, reach to the 4-5order bronchi.

Anesthetic Consideration ♦ Pulse oximeter, cuff BP, ECG monitor, O2, topical anesthesia, IV sedation ♦ 50% of severe complication: oversedation, hypoxia, hypercapnia, respiratory depression ♦ Pre-op opiates: Meperidine ♦ Midazolam: 0.07mg/kg, half life 2 hours, liver disease→prolonged sedation liver disease→prolonged sedation

♦ Topical anesthesia: lidocaine (1%, 2%), tetracaine(0.5, 1, 2 %) lidocaine (1%, 2%), tetracaine(0.5, 1, 2 %) ♦ Spraying of hypopharynx, additional to vocal cord, trachea, tracheobronchial tree ♦ Injected through cricothyroid membrane

♦ Nasal route: avoid chewing instrument ♦ Mouth route: ♦ Through oral endotracheal tube, laryngeal madk

Bronchia Biopsy and Brushing ♦ Mucosal change of malignance ♦ Bleeding: 1/100,000 epinephrine, Nd:YAG laser photoablation, Nd:YAG laser photoablation,

Transbronchial Biopsy and Brushing

Transbronchial Needle Aspiration ♦ Transbronchial needle aspiration before brushing, lavage ♦ At least 15% false-negative rate ♦ Endobronchial ultrasonography(EUS): assess, localize paratracheal, peribronchial pathology assess, localize paratracheal, peribronchial pathology

Bronchoalveolar lavage (BAL) ♦ Material from terminal bronchial, alveolar sacs ♦ ml saline, 40-60% is recovered. ♦ Useful in microbiological specimens, especially in immunosuppressed, fungal, bacterial, viral culture specimens

Complication ♦ Bronchospasm, hypoxia, fever, transient decline in pulmonary function ♦ Careful evaluation and preparation ♦ General anesthesia ♦ Pneumothorax: 3% in transbronchial bx

Foreign Body Retrieval

Autofluorescence Bronchoscopy ♦ Helium cadmium laser: severe dysplasia and carcinoma can be easily recognized

Massive Hemoptysis ♦ 600 ml in 24 hours ♦ Rigid bronchoscope ♦ Airway control, suction, packing with epinephrine soaked pledget, fogarty ballon ♦ The site of massive hemoptysis must be localized: Sugical excision Sugical excision Nd:YAG laser photoablation Nd:YAG laser photoablation Endobronchial tamponade Endobronchial tamponade Bronchial artery embolization Bronchial artery embolization

Interventional Bronchoscopy ♦ Endobronchial electrocaudery ♦ Nd:YAG laser photoablation ♦ Cryoablation ♦ Photodynamic therapy ♦ Placement of radioactive brachytherapy ♦ Placement of endobronchial stent: silicone stent, self-expanding metal stent silicone stent, self-expanding metal stent