fiberoptic bronchoscopy - airway securing FOI

fiberoptic bronchoscopy - airway securing FOI

1. Dr.zikrullah mallick Fiberoptic Bronchoscopy

2. Endoscopy Procedures that look into the body’s tubes and cavities Colonoscopy Esophagoscopy/Gastroscopy Bronchoscopy Used to diagnose various diseases and explain conditions

3. Bronchoscopy Allows visualization of the airways (tracheobronchial tree) Performed to diagnose problems with the airway or treat problems such as an object or growth in the airway

4. Equipment A bronchoscope is an instrument about 3ft long and 0.5 ins or smaller in diameter that combines four narrow chambers into one tube One lumen contains a fiber-optic light source so that structures can be viewed effectively 2 nd chamber lumen is attached to a suction device & airway secretions can be removed 3 rd chamber has tiny metallic alligator forceps that can be extended past the proximal end for tissue biopsies 4 th chamber lumen allows passage of a small wire brush that can be passed vigorously over airway structures for collection of tissue cells for microscopic evaluation

5. Figure 4-4 Flexible fiberoptic bronchoscope. The four channels consist of two that provide a light source, one vision channel, and one open channel that accommodates instruments or allows administration of an anesthetic or oxygen.

6. TYPES Flexible or Rigid Adult sizes 5.0 mm OD to 6.0 mm OD Pediatric sizes Most manufacturers provide scopes in sizes 3.5 mm OD or less appropriate for children. No channel outlet may exist for suctioning because of its small size

7. Scopes Rigid bronchoscope Flexible Fiberoptic Scopes

8. Procedure Topical anesthetic (lidocaine) is administered to control gag/cough reflex and prevent bronchospasm 5 – 10 cc 4% lidocaine aerosolized to upper airway delivered by a mask nebulizer Benzocaine nasal sprays 2% lidocaine instilled into the hypopharynx in 2 cc incements Intubation preferred but not required. Intubation will not allow visualization of the vocal cords Scope is inserted and the airways viewed O2 needs to be provided to patient via mask or by removing one prong of the nasal cannula from the nose to allow for insertion of the scope

9. Procedure Diagnostic and/or therapeutic procedures are performed Intubated patients on vents need special adapters for advancement of the scope. Adapter should allow for: No loss of ventilating pressures No loss of PEEP Continuous monitoring of EKG and O2 saturation by pulse oximeter is recommended Equipment is cleaned by decontamination with alkaline glutaraldehyde

10. Rigid bronchoscopy Diagnostic use Biopsy of tumors within the main airway Therapeutic use Treatment of massive hemoptysis by cold-saline lavage or placement of Fogarty catheter to occlude the airway Removal of foreign bodies in infants and small children Aspiration of inspissated secretions Limitations observing or treating beyond the right or left mainstem bronchus trauma of cervical spine who cannot hyperextend neck trauma of jaw who cannot open their mouth wide

11. Indications Diagnostic Suspected foreign body Suspected malignancy Bronchial washings Hemoptysis Persistent problems Therapeutic Foreign-body obstruction Secretion removal Bronchial lavage Stenosis atelectasis

12. Other indications Abnormal CXR Excessive bronchial secretions Acute smoke inhalation injuries Hemoptysis Pneumonia Unexplained Cough Tracheal disease, stridor and localized wheezing Intubation damage Atelectasis Laser excision Removal of foreign bodies Lung lavage Difficult intubations Suctioning of excessive secretions, mucus plugs Selective lavage Management of life threatening hemoptysis

13. USES Direct visualization of the tracheobronchial tree for abnormalities (e.g., tumors, inflammation, strictures) Biopsy of tissue from observed lesions Aspiration of “deep” sputum for culture and sensitivity and for cytologic determinations Direct visualization of the larynx for identification of vocal cord paralysis, if present. With pronunciation of “eeee” the cords should move toward the midline. Aspiration of retained secretions in patients with airway obstruction or postoperative atelectasis Control of bleeding within the bronchus Removal of foreign bodies that have been aspirated Brachytherapy, which is endobronchial radiation therapy using an iridium wire placed via the bronchoscope Palliative laser obliteration of bronchial neoplastic

14. Flexible bronchoscopic view of a large foreign body (a Lite-Brite peg) lodged in the right main bronchus of a 7-year-old boy (left, A) Swanson K. L. et.al. Chest 2002;121:1695-1700 ©2002 by American College of Chest Physicians

15. BAL Tip of the scope is wedged into the bronchus Aliquots of sterile saline are instilled in to flood the alveoli A little more than half of the lavage is suctioned back to into a collection chamber Fluid contains cellular debris, microorganisms used for diagnosis

16. Interventional Bronchoscopy Laser Therapy Thermal tissue damage to destroy obstructing lesions Saline lavage to clean debris Cryotherapy Tissue destruction via intracellular freezing Bronchogenic carcinomas Stents Tracheobronchial prostheses May require opening the airway with other techniques prior to placement

17. Fiberoptic Bronchoscopy in the ICU

18. Introduction: Spectrum of Pulmonary Disease in the ICU Pneumonia- community or nosocomial Pulmonary edema- cardiogenic or noncardiogenic Pulmonary hemorrhage ± hemoptysis Thromboembolic disease Primary or metastatic CA Interstitial lung disease Obstructive airway disease Respiratory failure in any of above requiring intubation and mechanical ventilation (MV) Complications of intubation and MV

19. Introduction: Flexible Fiberoptic Bronchoscopy (FFB) Essential diagnostic and therapeutic tool in ICU Can be performed via endotracheal tube (ETT) or tracheostomy tube Bedside procedure: avoids transport/ OR time

20. Common Diagnostic ICU Indications for FFB Inspection, bronchoalveolar lavage (BAL), transbronchial lung biopsy (TBBx) Abnormal chest X-ray/ suspected pulmonary infection Hemoptysis Lung carcinoma/ obstructing neoplasm Chemical or thermal burns ETT assessment/ management: intubation/extubation assist, position/ injury evaluation

21. Feng A, Sy E. A Lung Saddle Tumor. The Internet Journal of Pulmonary Medicine 2009 : Volume 11 Number 1 Elderly patient admitted with respiratory failure. Bx = Squamous cell Ca

22. Common Therapeutic ICU Indications for FFB Retained secretions/ atelectasis Mucous plugs- bronchial asthma, cystic fibrosis Hemoptysis/ blood clots Drainage lung abscess Debridement of necrotic tracheobronchial mucosa Dilation airway stenosis/ strictures

23. FFB in Pulmonary Infiltrates Usually to evaluate infectious process Allows directed sampling, identification of pathogens, de-escalation of antibiotics BAL 10-50,000 CFU on culture diagnostic protected specimen brush 5-10,000 CFU diagnostic Potential for identification of noninfectious processes

24. Cos J, Sy E, Diaz-Fuentes G, Menon L. Foreign body presenting as a persistent lung infiltrate. The IJPM 2009 : Volume 11 Number 1 After removal of foreign body

25. FFB in Retained Secretions and Atelectasis FFB vs. physiotherapy for retained secretions: no superiority demonstrated FFB in atelectasis: retained secretions and air bronchograms to segmental level only lobar or greater atelectasis not responding to aggressive chest PT life threatening whole lung atelectasis Severe hypoxemia not contraindication Expect improved A-a gradient, static compliance

26. FFB: Complications Premedication/ local anesthesia: respiratory depression/ arrest, methemoglobinemia, death Procedure related: hypoxemia, cardiac complications, pneumonia, death Ancillary procedures: barotrauma, pulmonary hemorrhage, death

27. Complications: Hypoxemia Common: up to 2 hrs. post procedure: 20-30 mmHg O2 drop in healthy, 30-60 in critically ill Reduction in effective tidal volume and FRC Suction at 100mmHg via 2mm suction port removes 7L/min Saline/lidocaine instillation

28. Complications: Cardiac Hypoxemia, hypercapnea  increased sympathetic tone  arrhythmias, ischemia, hypotension  death Major arrhythmias in 11% Unstable angina, severe preexisting hypoxemia risk factors Hemodynamics: 30%  MAP, 43%  HR, 28%  CI

29. CXR after difficult intubation. Septic shock with MOD and AIDS

30. Daniel V, DeLaCruz A, Diaz-Fuentes G. Tracheal Laceration Due to Endobronchial Intubation. Journal of Respiratory diseases. June 2007:15-17

31. FFB in MV: Physiology Standard ED 5.7mm scope occludes 10% cross sectional area of trachea, 40% 9mm ID ETT, 51% 8mm ID ETT, 66% 7mm ID ETT Hypoventilation, hypoxemia, gas trapping/ high intrinsic PEEP 8mm ID ETT for standard scope recommended Ultrathin bronchoscopes (2.8mm): reduce potential for hypoxemia/hypercapnea, dynamic hyperinflation

32. FFB in MV: Increased Complication Risk Pulmonary: PaO2< 70mmHg with FiO2> 0.7 PEEP> 10 cm H2O autoPEEP > 15 cm H2O active bronchospasm Cardiac: recent MI (48 hrs.) unstable arrhythmia MAP < 65mm Hg or vasopressor CNS: increased intracranial pressure

33. Potential Complications Fever Bronchospasm Hemorrhage (after biopsy) Hypoxemia Pneumothorax Infection Laryngospasm Aspiration Cardiac arrest – arrhythmias Respiratory depression Hypotension Age-Related Concerns Children have a smaller bronchus. The bronchoscope can significantly decrease the available space for them to breathe. They are at higher risk of hypoxemia than adults.

34. REFERANCES 1 Ahmad M. Bronchoscopy: current status and future prospects. In: Wang KP, Mehta AC, eds. Flexible bronchoscopy. Cambridge, MA: Blackwell Science, 1995:3–5 2 Torrington KC, Kern JD. The utility of fiberoptic bronchoscopy in the evaluation of the solitary pulmonary nodule. Chest 1993; 104:1021–1024 3 Naidich DP, Sussman R, Kutcher WL, et al. Solitary pulmonary nodules: CT- bronchoscopic correlation. Chest 1988; 93:595–597 4 Wallace JM, Deutsch AL. Flexible fiberoptic bronchoscopy and percutaneous needle lung aspiration for evaluating the solitary pulmonary nodule. Chest 1982; 81:665– 670 5 Gaeta M, Pandolfa I, Volta S, et al. Bronchus sign on CT in peripheral carcinoma of the lung: value in predicting results of transbronchial biopsy. AJR Am J Roentgenol 1991; 157: 1181–1185 6 Ellis JH. Transbronchial lung biopsy via the fiberoptic bronchoscope. Chest 1975; 68:524 –531 7 Hanson RR, Zavala DC, Rhodes M, et al. Transbronchial biopsy via flexible fiberoptic bronchoscope: results in 164 patients. Am Rev Respir Dis 1976; 114:67–72 8 Stringfield JT, Markowitz DJ, Bentz RR, et al. The effect of tumor size and location on diagnosis by fiberoptic bronchoscopy. Chest 1977; 72:474 – 476 9 Cortese DA, McDougall JC. Biopsy and brushing of peripheral lung cancer with fluoroscopic guidance. Chest 1979; 75:141–145 10 Radke JR, Conway WA, Eyler WR, et al. Diagnostic accuracy in peripheral lung lesions. Chest 1979; 76:176 –179 11 Fletcher EC, Levin DC. Flexible fiberoptic bronchoscopya

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