Bronchoscopy

BRONCHOSCOPY

1. BRONCHOSCOPY DR FIROZ A HAKKIM DR GANGAI AMARAN PG 1 ST YEAR CHEST MEDICINE

2. Bronchoscopy  is a  technique  of visualizing the inside of the  airways  for diagnostic and therapeutic purposes

3. Bronchoscope is inserted into the airways, usually through the nose or mouth, or occasionally through a  tracheostomy . This allows the practitioner to examine the patient's airways for abnormalities such as foreign bodies, bleeding,  tumors , or  inflammation . Specimens may be taken from inside the lungs. The construction of bronchoscopes ranges from rigid metal tubes with attached lighting devices to flexible optical fiber instruments with realtime video equipment.

4. A German,  Gustav Killian , performed the first bronchoscopy in 1897. From then until the 1970s, rigid bronchoscopes were used exclusively. Killian used rigid bronchoscopy to remove a pork bone. The procedure was done in an awake patient using topical cocaine as a local anesthetic . HISTORY

5. Killian demonstrates the rigid bronchoscopy in a cadaver specimen

6. An American,  Chevalier Jackson , refined the rigid bronchoscope in the 1920s, using this rigid tube to visually inspect the trachea and mainstem bronchi. The British laryngologist Victor Negus , who worked with Jackson, improved the design of his endoscopes, including what came to be called the 'Negus bronchoscope' He is sometimes known as the "father of  endoscopy ", although  Philipp Bozzini  (1773–1809) is also often given this  sobriquet .

7. A Japanese,  Shigeto Ikeda , invented the flexible bronchoscope in 1966. The flexible scope initially employed fiberoptic bundles requiring an external light source for illumination. These scopes had outside diameters of approximately 5 mm to 6 mm, with an ability to flex 180 degrees and to extend 120 degrees, allowing entry into lobar and segmental bronchi. More recently, fiberoptic scopes have been replaced by bronchoscopes with a charge coupled device (CCD) video chip located at their distal extremity.

8. Shigeto Ikeda regarded as the "father" of fiberoptic   bronchoscopy . he developed the first flexible bronchoscope in conjunction with Machida Endoscope Co. Ltd (later taken over by  Pentax ) and  Olympus Optical Co., Ltd.  This allowed better visualisation of the upper lobe  bronchi  than is possible with the rigid bronchoscope. Successive improvements under his supervision included the development of video- bronchoscopy . His motto was "there is more hope with the bronchoscope".

9. TYPES RIGID FLEXIBLE FIBEROPTIC AND VIDEO BRONCHOSCOPY

10. RIGID BRONCHOSCOPE

11. INDICATIONS - RIGID SURGICAL ASSESMENT OF LUNG CANCER OPERABILITY FOREIGN BODY SUSPECTED AND REMOVAL INSPECTION OF TRACHEAL STENOSIS EMERGENCY CONTROL OF PROFUSE ENDOBRONCHIAL BLEEDING(HEMOPTYSIS) BY PACKING/ TAMPONADE BY BALOON CATHETER PAEDIATRIC BRONCHOSCOPY

12. IN TREATMENT OF LARGE AIRWAY TUMOURS BY LASER INSPECTION OF SERIOUS CAUSES OF TRACHEAL NARROWING, WHEREIN A TRACHEAL DILATOR OR STENTING CAN BE DONE

13. ADVANTAGES WIDE CHANNEL THROUGH WHICH LARGE BIOPSIES AND FORIGN BODIES CAN BE MORE EASILY GRASPED AND REMOVED SUPERIOR SUCTION CAPABILITY

14. DISADVANTAGE LACK OF MANOEUVRABILITY REQUIREMENT OF A ANAESTHETIST

15. FIBREOPTIC BRONCHOSCOPY The bronchoscope is longer and thinner than a rigid bronchoscope. It contains a  fiberoptic  system that transmits an image from the tip of the instrument to an  eyepiece  or video camera at the opposite end. Using  Bowden cables  connected to a lever at the hand piece, the tip of the instrument can be oriented, allowing the practitioner to navigate the instrument into individual  lobe  or  segment bronchi . Most flexible bronchoscopes also include a channel for suctioning or instrumentation, but these are significantly smaller than those in a rigid bronchoscope.

16. USES (DIAGNOSTIC) DIAGNOSIS OF LUNG CANCER CHEST RADIOGRAPHIC ABNORMALITY HAEMOPTYSIS PERSISTENT OR RECURRENT COUGH PARALYSED VOCAL CORD POSITIVE SPUTUM CYTOLOGY

17. STAGING OF LUNG CANCER DIAGNOSIS OF DIFFUSE LUNG DISEASE IDENTIFICATION OF INFECTING AGENTS IMMUNOCOMPRAMISED HOST IMMUNOCOMPETANT HOST

18. COUGH PERSISTENT COUGH , WITHOUT HAEMOPTYSIS, IN A WELL PATIENT WITH CHEST RADIOGRAPHIC FAETURES THAT ARE EITHER NORMAL OR UNSUGGESTIVE OF NEOPLASM( WHERIN CAUSES LIKE SINUSITIS, ASTHMA, BRONCHITIS HAVE BEEN RULED OUT)BY HISTORY, PHYSICAL EXAMINATION, PFTS ETC WHEN NO SATISFACTORY EXPLANATION FOR THE INTRACTABLE COUGH HAS BEEN FOUND OUT , BRONCHOSCOPY IS INDICATED

19. ABNORMAL CHEST RADIOGRAPH CHEST RADIOGRAPH SHOWS A OPACITY CONSISTENT WITH A LUNG TUMOUR OR CHANGES SUGGESTIVE OF BRONCHIAL OBSTRUCTION , SUCH AS APPEARANCE OF EARLY VOLUME LOSS OR UNDOUBTED COLLAPSE, UNRESOLVED PNEUMONIA OR HEMIDIAPHRAGMATIC PARALYSIS , RAISING THE POSSIBILITY OF PHRENIC NERVE INVOLVEMENT BY TUMOUR

20. VOCAL CORD PARALYSIS FINDING OF A PARALYSED VOCAL CORD CALLS FOR A CAREFUL ENDOSCOPIC INSPECTION OF THE BRONCHIAL TREE, WHETHER OR NOT POSTEROANTERIOR AND LATERAL CHEST RADIOGRAPHS ARE NORMAL

21. POSITIVE SPUTUM CYTOLOGY EXPECTORATED SPUTUM MAY CONTAIN NEOPLASTIC CELLS ON CYTOLOGICAL EXAMINATION EVEN THOUGH THE CHEST RADIOGRAPH ITSELF PROVIDES NO CLEAR LOCALIZING FEATURES IF ON EXAMINATION OF THE OROPHARYNX AND LARYNX FOUND TO BE NORMAL , BRONCHOSCOPY MAY FIND TUMOUR (SQUAMOUS CELL CARCINOMA)

22. DIAGNOSIS OF DIFFUSE LUNG DISEASE BY TRANSBRONCHIAL LUNG BIOPSY CARRIED OUT THROUGH FIBREOPTIC BRONCHOSCOPY IN SARCOIDOSIS AND LYMPHANGITIS CARCINOMATOSA ETC.

23. IDENTIFICATION OF INFECTING AGENTS BRONCHOSCOPY MAY BE USED TO OBTAIN MICROBIOLOGICAL EVIDENCE OF LOWER RESPIRATORY TRACT INFECTION BY EXAMINATION OF ASPIRATED BRONCHIAL SECRETIONS, WASHINGS OR LAVAGE FLUID ENDOBRONCHIAL BRUSHINGS TRANSBRONCHIAL LUNG BIOPSY

24. P.CARINI , CYTOMEGALOVIRUS , MYCOBACTERIUM TUBERCULOSIS, ATYPICAL MYCOBACTERIA, ASPERGILLOIS COCCIDIODOMYCOSIS ETC.

25. USES (THERAPEUTIC) INSERTION OF AN ENDOTRACHEAL TUBE FOR GENERAL ANESTHESIA IN PATIENTS IN WHOM EXTENTION OF NECK MAY BE DANGEROUS (ATLANTO –AXIAL SUBLUXATION )

26. TAMPONADE OF ENDOBRONCHIAL BLEEDING, EITHER WITH END OF BRONCHOSCOPE ITSELF OR BY USING A FOGARTY OR OTHER PURPOSE – DESIGNED BALOON CATHETER

27. REMOVAL OF FOREIGN BODIES

28. ASPIRATION OF SECRETIONS IN ACUTE INFLAMATORY LOBAR ATELECTASIS WHERE PHYSIOTHERAPY HAS PROVED UNSUCCESFUL IN ACHIEVING THIS END.

29. RELIEF OF TRACHEOBRONCHIAL NARROWING BY LASER TREATMENT, WHICH MAY BE ADMINISTERED THROUGH THE CHANNEL OF A FIBREOPTIC BRONCHOSCOPE IN THE PALLIATIVE TREATMENT OF LUNG CANCER PLACEMRNT OF STENTS DELIVARY OF ENDOBRONCHIAL RADIOTHERAPY( BRACHYTHERAPY)

30. BIODEGRADABLE STENT

31. PROCEDURE CONSENT/ PROCEDURE EXPLANATION XYLO TEST DOSE BT ,CT ,HIV BLOOD GROUPING , PT ,APTT NPO T. ANXIT 0.5 mg HS PRE PROCEDURE NEBULIZATION

32. PROCEDURE SUPPLEMENTAL OXYGEN VIA NASAL CANNULAE MONITOR SATURATION PRE MEDICATION INJ ATROPINE 0.6 mg im ( REDUCE SECRETIONS IN AIRWAYS, DIMINISH THE CHANCE OF REFLEX VASOVAGAL PHENOMENON LIKE BRONCHOCONSTRICTION & BRADYCARDIA)

33. SEDATION INJ MORPHINE 10 mg/5mg im 20-40 MIN BEFORE PROCEDURE ( SENSE OF EUPHORIA, REDUCE ANXIETY , SUPRESS COUGHING) INJ MIDAZOLAM 2.5 mg ( 1mg - > 70 YR OLD, 5mg –YOUNG PTS) SLOW IV OVER 30 SEC INJ DIAZEPAM 5 mg IV SLOW ( YOUNG PTS, 2mg IV OLD PTS) OMIT SEDATIVES IF FEV1 < 1L, IF PaCo2 IS RAISED , IF PTS RESPIRATORY FUNCTION GIVES ANY CAUSE FOR CONCERN

34. TOPICAL ANAESTHESIA 10 mg BENZOCAINE LOZENGE GIVEN AT TIME OF PRE MEDICATION 4% LIDOCAINE SOLUTION SPRAYED VIA ATOMIZER INTO PTS MOUTH IN DIRECTION OF THE FAUCES. PT ASKED TO SAY ‘AAH’ TO ELEVATE THE SOFT PALATE TRANSCUTANEOUS CRICOTHYROID INJECTION WITH 5mL OF 4% LIDOCAINE, BY PALPATING CRICOID CARTILAGE USING FOREFINGER IN PTS NECK SLIGHTLY EXTENDED, IT BEING THE FIRST PROMINENCE ABOVE THE CARTILAGENOUS TRACHEAL RING . IMMEDIATELY ABOVE IT AND BELOW THE NEXT PROMINENCE , IS THE THYROID CARTILAGE, WHICH IS A SHALLOW DEPRESSION THAT MARKS THE CRICOTHYROID MEMBRANE

35. THIS AREA IS WIPED WITH A ALCOHOL SWAP, PT ASKED TO LOOK AT THE CEILING AND NOT TO SWALLOW( TO AVOID MOVT OF LARYNX) A 23 GAUGE NEEDLE ATTACHED TO LOADED SYRINGE INSERTED IN MIDLINE, A NO RESISTANCE FELT AND WITHDRAWAL OF THE PLUNGER REWARDED BY BUBBLES OF AIR .LOCAL ANAESTHETIC THEN ADMINISTERED.

36. PT POSITIONED ON TABLE , OPERATOR STANDS BEHIND THE PATIENT, AT HEAD END.

37. BRONCHOSCOPE LUBRICATED WITH 2% LIDOCAINE GEL ADVANCED VIA EITHER NOSTRIL OR MOUTH USING A BITE BLOCK

38. AS INSTRUMENT ADVANCED EPIGLOTTIS AND LARYNX COME TO VIEW POSITION AND MOVEMENT OF VOCAL CORDS WITH RESPIRATION NOTED , PT ASKED TO SAY ‘EEEH’, TO OBSERVE THE FULL APPOSITION OF CORDS WHEN PASSED BEYOND VOCAL CORDS, 2.5 ml LIDOCAINE INSTILLED FOLLOWED BY 5 ml AIR PASSING BEYOND , OBSERVE THE TRACHEA, MAIN CARINA, SUB CARINA, SEGMENTAL BRONCHI

39. SAMPLING THROUGH FIBEROPTIC BRONCHOSCOPE BY ENDOBRONCHIAL BIPOSY TRANSBRONCHIAL LUNG BIOPSY BRONCHIAL WASHINGS AND BRONCHOALVEOLAR LAVAGE

40. COMPLICATIONS PNEUMOTHORAX HAEMORRHAGE COMPLICATIONS OF SEDATION AND TOPICAL ANAESTHESIA ( EPILEPTIC SEIZURES, CARDIAC DYSARRYTHMIAS, HYPOVENTILATION , LARYNGOSPASM) BRONCHOSPASM IN ASTHMATICS CVS – MINOR VASOVAGAL EPISODE TO SERIOUS CARDIAC DYSAARYHTMIAS, MYOCARDIAL INFARCTION, PULMONARY EDEMA HYPOXAEMIA

41. CONTRAINDICATIONS UNCOOPERATIVE PATIENT UNCORRECTABLE HYPOXAEMIA/ HYPERCAPNIA UNSTABLE MYOCARDIUM UNCORRECTABLE BLEEDING TENDENCY TRACHEAL STENOSIS POORLY CONTROLLED ASTHMA

42. INFECTION CONTROL PROTECTION OF INSTRUMENTS PROTECTION OF STAFF PROTECTION OF PATIENTS

43. REFERENCE CROFTON FISHMAN INTERNET