1. Bronchoscopy and Endobronchial Ultrasound Dr. Brent Toney Pulmonary/Critical Care St. Vincent Hospital, Indianapolis

2. Case Presentation 71yo WM with a cough since September – Smoker for 18 years – No other symptoms – 20lb weight loss over 6 months

3. CT chest

7. Bronchoscopy Akin to the endoscope, a camera in the tracheobronchial tree. Types: – Rigid – Flexible

11. Flexible bronchoscopy Types – Diagnostic/Therapeutic – Endobronchial Ultrasound Convex probe ultrasound Radial probe ultrasound – Navigational bronchoscopy 3D reconstruction for guidance

12. Bronchoscopy

13. Diagnostic Indications – Evaluation of pneumonia or infiltrate – Persistent atelectasis – Lung nodules/masses – Mediastinal lymphadenopathy – Hemoptysis – Airway obstruction (stenosis, mass, foreign object) – Tracheobronchomalacia – Lung transplant eval/rejection – Burn injury – Chest trauma – Cough – Tracheoesophogeal fistula

14. Bronchoscopy Therapeutic indications – Mucous removal (snot bronch) – Foreign body removal – Interventional

15. Bronchoscopy Contraindications – Patients at high risk for pulmonary or cardiovascular decompensation – High risk of bleeding – Unable to tolerate sedation

16. Bronchoscopy Diagnostic – Brushing – Forceps – Wang needle biopsy – Bronchoalveolar lavage Interventional – Cryo/YAG – Endobronchial stenting – Basket retrieval – Balloon dilatation – Bronchial thermoplasty

17. Bronchoalveolar Lavage

19. Bronchoscopy Preparation – NPO 6 hours before procedure – Continuous pulse oximeter, blood pressure cuff – Viscous lidocaine to nares Or bite block if oral – Lidocaine nebulizer – IV access – +/- platelet, PT/INR Time Out

20. Bronchoscopy Entry – Nasal – Oral – Endotracheal intubation Need 7.5 ET tube for diagnostic 8.0 ET tube for EBUS – Cut down to reduce resistance – Tracheostomy

21. Bronchoscopy Personnel – Bronchoscopist – Bronch nurse Medication, IV, monitoring – Respiratory therapist Assists with all procedural aspects For EBUS – Cytopathologist Indicates if adequate sample acquired – Anesthesiologist Keeps patient from coughing, moving, awakening

22. Bronch Complications Generally safe – Complication rate of 0.08-6% Common – Transient hypoxemia – Transient hypotension – Minor bleeding/hemoptysis – Cough – Sore throat – dysphonia Uncommon – Severe bleeding – Pneumothorax – Bronchospasm – Infection – Methemoglobinemia Lidocaine – Cardiac arrhythmia – Vasovagal syncope – Respiratory failure – Death

23. Bronchoscopy Bleeding control – Ice cold saline – Wedge pressure – Epinephrine solution (1:20,000) Cough – Medication - local/systemic

24. Endobronchial Ultrasound Indication – Mediastinal lymphadenopathy – Mediastinal masses – Endobronchial lesions Diagnosis – Most useful with non-small cell lung cancer – Allow diagnosis and staging at the same time.

26. Causes of mediastinal LAD Malignant – Lymphoma – Leukemia – Metastatic from other sites – Lymphagitic spread – Kaposi Sarcoma Benign – Infectious Mycobacterial Fungal Infectious mononucleosis HIV Anthrax Tularemia – Inflammation Sarcoidosis RA Systemic sclerosis Lupus Whipple’s disease CF HSP Pneumoconiosis

27. Endobronchial Ultrasound NSCLC – TNM Staging Tumor – T1 - <3cm – T2 - >3cm to <7cm – T3 - >7cm – T4 – Any tumor invading mediastinum, heart, vessels, trachea, esophagus, bones Nodes – N0 – no regional lymph node metastases – N1 – same side peribronchial or hilar lymph nodes – N2 – same side mediastinal or subcarinal lymph node – N3 – opposite side mediastinal, hilar or supraclavicular node Metastasis – M0 – no mets – M1 – distant mets

28. TNM Staging N1 – automatic stage IIA at best N2 – IIIA N3 – IIIB

29. International Association For the Study Of Lung Cancer (IASLC)

30. Endobronchial Ultrasound Notable differences – Often performed under anesthesia – No pre-procedure lidocaine nebulizer – Longer procedure

31. Endobronchial Ultrasound Preparation – Sheath setting – Stylet insertion – Balloon placement

34. EBUS Complications – Bleeding (1%) – Pneumothorax (4%) – Cough – infection

35. Back to our patient with the lung mass

36. Next Step: EBUS

40. Diagnosis Biopsy of tracheal lesion – Negative for cancer, just bronchial epithelium Biopsy of the 10L lesion – Negative for cancer, just lymph tissue Biopsy of 4R lymph node – NSCLC

41. Post Procedure Monitoring Vitals while patient is recovering from anesthetic – Blood pressure, cardiac rhythm, heart rate, respiratory rate, oxyhemoglobin saturation Gag return – Can eat generally 2-4 hours afterward Alert and oriented +/- Chest X-ray

42. Patient instructions Expect commonly – Sore throat, nasal discomfort – Low grade fever – Mild hemoptysis

43. Special topic request

44. Sarcoidosis Some would say is the last holy grail of medicine. Features: – Lymphadenopathy – Multiple systems involved (30%) – Noncaseating granulomas on biopsy

45. Sarcoidosis Unknown etiology but has features characterized by accumulation of T lymphocytes, mononuclear phagocytes and noncaseating granulomas Lungs involved in 90% – Skin (16%) – Eyes (12%) – Lymph nodes (15%) – Liver (12%)

46. Symptoms Nonspecific – Cough – Dyspnea – Chest pain – Fatigue – Malaise – Weight loss

47. Pulmonary manifestiations Bilateral hilar lymphadenopathy Pulmonary reticular opacities fibrosis

48. Risk factors African American (2.4% vs 0.85%) Genetic link possible

49. Evaluation Other causes need ruled out and biopsy to confirm needs to be performed – History and physical, lab evaluation, pulmonary function testing, EKG, ophthalologic exam

50. Chest Radiograph Stage I – Bilateral hilar adenopathy Stage II – Bilateral hilar adenopathy – Reticular opacities Stage III – reticular opacities with shrinking LAD Stage IV – Reticular opacities worsening – Volume loss – fibrosis

51. HRCT possible findings Hilar and mediastinal LAD Beaded or thickening of bronchovascular bundles Nodules Ground glass opacities Parenchymal masses, possible cavitation Cysts Fibrosis

52. Diagnosis 1.Clinical picture 2.Exclusion of other diseases 3.Biopsy with noncaseating granulomas

53. Biopsy Most accessible site – Skin – Lymph nodes – Conjunctiva – Lung biopsy Bronch with bronchoalveolar lavage and transbronchial biopsies

54. Bronch BAL – Lymphocytic CD4:CD8 ratio elevated – Not confirmatory Transbronchial biopsy – Fairly high yield (50-75%) Endoscopic ultrasound guided needle aspiration – High yield up to 90%

55. Thank you!