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Who needs a bronchoscopy?

Who needs a bronchoscopy?. Andrew Bush MD FRCP FRCPCH Imperial School of Medicine & Royal Brompton Hospital. Email: a.bush@rbh.nthames.nhs.uk. Who needs a bronchoscopy?. When the necessary information required is best obtained by flexible bronchoscopy Why am I doing this?

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Who needs a bronchoscopy?

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  1. Who needs a bronchoscopy? Andrew Bush MD FRCP FRCPCH Imperial School of Medicine & Royal Brompton Hospital Email: a.bush@rbh.nthames.nhs.uk

  2. Who needs a bronchoscopy? • When the necessary information required is best obtained by flexible bronchoscopy • Why am I doing this? • Thus, how should I do it? • When the risks are justified

  3. Indications

  4. Fibreoptic Bronchoscopy What is the question? What information do I need? What is the best bronchoscopic technique? What is the best anaesthetic technique?

  5. Sizes (mm): Paediatric: 4.9, 3.6, 2.7 (BAL, Bx, Brush) Neonatal: 2.2 (Look only)

  6. Bronchofibervideoscopes • Hybrid scope – fibreoptic / electronic imaging, fibres but CCD (charge coupled device) in control section • Display larger, brighter & much clearer, lighter instrument • 4 mm scope (P260F) – 2 mm biopsy channel • 2.8 mm scope (XP260F) – 1.2 mm channel • Larger scopes have ‘chip in the tip’

  7. Bronchofibervideoscopes

  8. Extent of Airway Obstruction Important equations • ETT size (mm) = 4 + (age in years)/4 • % airway occluded = 100(1-r2/R2) (where r is the radius of the bronchoscope, and R the radius of the airway)

  9. Extent of Airway Obstruction Worked Example • Four year old child, 5 mm diameter airway • 3.6 mm external diameter bronchoscope Hence, • 52% of the airway is occluded

  10. Absolute No purpose Airway too small Foreign body (unless happy to remove) Massive haemoptysis Relative Bleeding problems Severe airway obstruction Severe hypoxia Pulmonary hypertension Unstable haemodynamics Contraindications

  11. Obstructed airways - Raw exp>insp, FRC, PEEP, TV, minute vol Underlying lung disease IV sedation Lavage (large volume) Suction of O2 from airways Mobilisation of secretions Complications - Hypoxia

  12. CT appearances a few hours after BAL

  13. Hypercapnia - may be masked by oxygen Cardiac arrhythmias vagal stimulation, catecholamine release Laryngospasm Not if adequate anesthesia Bronchospasm asthmatics - rare in practice (steroids) Complications - others

  14. Hypoxia and hypercapnia during bronchoscopy in an infant (note he was pre- oxygenated)

  15. Complications - infective • Cross-infection • Fever - 20-30%, 4-6 hours post scope transient bacteraemia • Septicaemia – immunocompromised • Spill over into unaffected lung • Congenital heart disease - prophylaxis

  16. Pneumothorax - TBB (avoid RML, lingula) wedge & cough, blow down O2 Haemoptysis - rare unless biopsy, contact bleeding common Epistaxis (esp. sedation bronchs) Laryngeal trauma Subglottic oedema Mucosal oedema - vigorous suction Complications - mechanical

  17. How to get into the lungs • Nose directly or via mask • Mouth via ETT or laryngeal mask • Tracheostomy

  18. Normal view through the vocal cords into the subglottis

  19. Vocal cords visible through laryngeal mask

  20. Posterior Bronchoscopy via endotracheal tube

  21. Bronchoscopy: Stridor! • Anaesthetic technique: facemask, spontaneous quiet respiration • Instrument: smallest possible • Procedure: • Sutton’s law • Inspect all the airway (multiple pathology)

  22. Posterior

  23. Flow volume loop – fixed large airway obstruction

  24. Severe post-intubation subglottic stenosis

  25. Bronchoscopy: Focal Signs! • Anaesthetic technique: can be any • Instrument: large enough to remove secretions if anticipated • Procedure: • Inspect all the airway (multiple pathology) • Proceed carefully, think before you biopsy

  26. Hugely overinflated right lung with displacement of the mediastinum

  27. CT – massive over-inflation of right lung

  28. Endobronchial polyp (arrowed)

  29. Posterior Complete cartilage ring at origin of right main bronchus

  30. Bronchoscopy: Immunocompromised Host! • Anaesthetic technique: Any depending on state and size of child • Instrument: smallest possible (hypoxaemia) • Procedure: • Inspect all the airway (endobronchial pathology) • BAL • Timing?

  31. Diffuse bilateral shadowing in an immunocompromised child

  32. Silver stain – Pneumocystis Carinii Pneumonia (PCP)

  33. Tuberculous lymph nodes eroding through the bronchial wall

  34. Bronchoscopy: Airway Malacia? • Anaesthetic technique: facemask, spontaneous quiet respiration • Instrument: smallest possible • Procedure: • Inspect airway ?Vascular compression • Consider small contrast volume bronchogram

  35. Severe Tracheomalacia Inspiration Expiration

  36. Bronchoscopy in PICU? Specific problems • Unstable pulmonary circulation • Increased PVR with hypoxia, hypercapnia, acidosis • Unstable systemic circulation • Fall in cardiac output, raised ICP, HT with inadvertent PEEP

  37. Severe mucus plugging of right bronchus intermedius

  38. Bronchoscopy – pILD • Generally not useful • A few diagnosable conditions • LCH • IPH • PAP • Most need lung biopsy

  39. Bronchoscopy – CF! • Negative or unhelpful cultures, not doing well • At diagnosis • ?Surveillance – trial data awaited

  40. Who needs a bronchoscopy? • When the necessary information required is best obtained by flexible bronchoscopy • Why am I doing this? • Thus, how should I do it? • When the risks are justified

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