The fibrobronchoscope

1. Paraclinical investigations in pneumology: bronchoscopy, thoracentesis, pleural biopsy, thoracoscopy

2. Bronchial endoscopy (flexible or rigid) aims to explore (directly) the bronchial tree reffering to topographic, morphologically and functionally aspects.

3. The fibrobronchoscope • Exploit the transmission of light through glass fibers, both for lighting and for the image acquisition of the bronchi. • Fibrobronchoscope components: • the handle • the insertion tube • the connection to light source

4. Indications and limits in bronchoscopy Indications for diagnosis: • Clinical type: • Hemoptysis after excluding haematemesis, with or without radiological changes - (cancer, tuberculosis, bronchiectasis) • Chronic cough with or without sputum, recent unexplained cough, persistent bronchial lesions, foreign body, changing in cough character - chronic bronchitis, bronchial carcinomas • Localized wheezing, unilateral, persistent - bronchial stenosis • Dyspnea of unknown etiology, sometimes bronchial or tracheal tumors as benign or malignant

5. 2. Radiological type: • Atelectasis; • Opaque/non-parenchymal infiltrates without response to antibiotic treatment; • Diffuse interstitial diseases; • Localized or diffuse pulmonary hyper transparency; • Intrathoracic lymph nodes; • Widening of mediastinum; • Paralysis of diaphragm. • Pleural effusion of unknown etiology / chilotorax.

6. 3. Laboratory • sputum cytology positive or suspicious for lung cancer • microbiological confirmation of certain pathogens when other less invasive procedures failed; • suspicion of bronchial tuberculosis especially, including atypical mycobacteria; • microbiological investigations to immunocompromised patients (Pneumocystis, Cytomegalovirus)

7. Preoperative and postoperative- diagnosis and evaluation of bronchopulmonary tumors;- preoperative tumor staging;- regular monitoring of patients with lung resection (fistula, recurrence). Therapeutic indication • extraction of tracheobronchial foreign bodies; • aspiration of airway secretions; • difficult intubation in anesthesia; • treatment of bronchial fistulas; • bronchoalveolar lavage in therapy practice (eg. alveolar proteinosis); • bronchial instillation of various drugs; • local administration of thrombin solutions in hemoptysis; • palliative tumor resection and palliative release of endobronchial obstruction (lasertherapy, cryotherapy, brachytherapy, electrocautery, stent implantation);

8. Absolute contraindications: • Patient without his consent or his legal representatives consent; • Performing bronchoscopy by an inexperienced person without competent supervision; • Performing bronchoscopy in a not qualified service or personnel with no possibility to do it in emergency situations (possibility of oxygen therapy during surgery, anesthesia and intensive careservice immediately available, etc).

9. Absolute contraindications in terms of risk/benefit - severe obstructive ventilatory dysfunction (unstable asthma with FEV1 values below 30% of predicted) - shortness of breath with moderate to severe hypoxemia or hypercapnia - severe, refractory hypoxemia (PO2 less than 65 mmHg after oxigen therapy) - instability, malignant arrhythmias - severe bleeding diathesis

10. Relative contraindications: • Uncooperative patients; • Myocardial infarction (less than 6 weeks) or unstable angina pectoris; • Aortic aneurysm. • Partial tracheal stenosis and laryngeal obstruction (may exacerbate the spasm); • Mechanical ventilation; • Uremia and pulmonary hypertension (risk of major bleeding); • Obstruction of superior cave vein; • Debility, advanced age, malnutrition, terminally ill • Allergy or contraindications to local anesthetic drug administration. • Coma • Cerebral circulatory insufficiency.

11. Sampling techniques in fibrobronchoscopy • Bronchial aspirate • Bronchial brushing • Bronchial biopsy            Endobronchial biopsy            Peripheral transbronchial biopsy • Transtracheal/transbronchial needle aspiration • Bronchoalveolar lavage

12. Conclusions Fibrobronchoscopy - safe procedure with broad applicability; The indications for bronchoscopy are many and varied; Nearly every lung disease could be considered for this investigation; Contraindications are few, some morbid conditions are only relative contraindications only if associated different sampling techniques; http://www.bronchoscopy.org/education/BiEducStep_.asp

13. Diagnostic approach to pleural effusions thoracentesis etiology ? closed pleural biopsy etiology ? medical thoracoscopy etiology ? surgicalbiopsy follow-up

14. Thoracentesis • Useful in diagnosis of pleural effusion (which was confirmed by radiological and clinical exams); • Biochemical, cytological and bacteriological balance; • Evacuatory purpose and for drug introductions (antibiotics, chemotherapy);

15. Thorancetesis technique • Patient in sitting position with arms folded over the back, head resting on the forearms, the back curved • Puncture is made in full dullness, preferably 8 intercostal space posterior axillary line • Clean the skin with iodine • We palpatory set with the index the upper edge of the lower coast of the intercostal space chosen for puncture

16. Thorancetesis technique • Insert the needle grazing the upper edge of the coast • Optional local anesthesia, • Mandrel is pulled quickly and closes the valve of the puncture system • Adapt a 10-20 ml syringe to the trocar and check for fluid aspiration • Take a fluid sample for laboratory determinations and then the fluid evacuation is made • At the end, the needle is withdrawn with a sudden movement and iodine is pellet

17. Incidents • White puncture = not extracting liquid puncture • Puncturing the lung - extract a small amount of blood, hemoptysis • Puncturing the liver, spleen or diaphragm • Stick to ribs • Minor bleeding - intercostal arteries minor damage • Needle-puncture obstruction by false membrane, fibrin or by the lung

18. Complications • Vagotonic disorders: cold sweats, pallor, bradycardia, hypotension, syncope sometimes • Superinfection with a germ piogen • Pneumothorax - high risk patients with emphysema and malignant pleurisy • Fluid remove intolerance syndrome (too fast) - stricture feeling chest, oppressive cough, dyspnea and general malaise, acute unilateral pulmonary edema

19. Pleural biopsy • It represents an invasive method of sampling a portion of parietal pleurafor histopathological processing and identifying the specific nature of injuries • The results may be relevant to specific diseases: tuberculosis follicle, sarcoidotic granuloma, collagen damage, amyloidosis, malignant proliferation

20. Pleural biopsy • Cope's Pleural Biopsy Punch

21. Indications • Pleural TB, malignant pleurisy • All repetitive pleurisy > 4 weeks, relapsing after discharge and remained resistant to treatments, without etiologic diagnosis • Not indicated in transudative pleurisy in case of extra pulmonary origin (cardiogenic, hepatic, renal), pulmonary infarction, nonspecific inflammatory pleurisy (Para pneumonic) Pneumology I- Instrumental techniques of investigationTraian Mihaescu, Antigona Trofor

22. Thoracoscopy • allows viewing the pleural space • can explore and other structures: the diaphragm, mediastinum, pericardium, ribs, thoracic spine, and the lung parenchyma itself through visceral pleura • you get a panoramic view of intrathoracic structures

23. Small skin incision Local Anesthesia Trocar technique mod. from Netter Atlas

24. Semi-rigid (semi-flexible) Pleuroscope (Olympus) Ernst A et al. A Novel Instrument for the Evaluation of the Pleural Space. Chest 2002;122:1530-1534

25. Direct inspection by thoracoscope Video-assisted thoracoscopy

26. Induction of pneumothorax, thoracentesis is performed by introducing airafter the fluid is evacuated, and lung collapse obtained is radiologically controlled Local Anesthesia Trocar introduction(patient lying on healthy side) - incision of dermis with scalpel, opening of subcutaneous tissues and biting whith blunt tips scissors - trocar is inserted through the gap – 6-th intercostal space, anterior axillary line for neoplastic lesions, a possible secondary perforation ThoracoscopyTechnique • Exploration of the pleural cavity - parietal pleura, diaphragmatic, visceral • Pleural biopsy using spoon forceps, for lung -sharp forceps are used • Pleural drainage - pulmonary expansion, blood loss assessment • Pleural talcage - spontaneous pneumothorax, malignant and recurrent pleurisy

27. Indications • Diagnostic indications: • Chronic pleurisy - for diagnosis of cancer or TB, staging lung cancer and mesothelioma • Pleural masses without pleural effusion • Spontaneous pneumothorax • Mediastinal tumors • Diffuse lung disease and peripheral location opacities • Therapeutic indications • Evacuation of fibrin deposits, piogene membranes, clots, lysis of adhesions, opening encysted pleurisy, chemical pleurodesis, extraction of pleural foreign bodies, etc.

28. Contraindications • Severe pulmonary fibrosis • Pulmonary arterio-venous aneurysms • Suspected hydatic cyst • Pulmonary Hypertension • Lung injury highly vascularized • Coagulation Disorders • Dyspnea at rest, heart and severe respiratory failure

29. Complications • Empyema (especially those with thoracic drainage) • Massive bleeding - rarelyNeoplastic dissemination along the path of parietal thoracic incision • Subcutaneous emphysema • Mediastinal emphysema– rarely • Cardiac complications - anesthesia is not enough • Gaseous embolism • Bronchopleural fistula • Lung perforation

30. References - Pneumology I - Instrumental techniques of investigation- Traian Mihaescu, Antigona Trofor, 1998 • http://www.vulgarismedical.com/images/pneumologie-16/tumeur-bronchique-94.html#image • http://www.vugarismedical.com/images/pneumologie-16/bronchoscopie-normale-163.html#image • Workshop-bronchial endoscopy– Clinic of Pulmonary Diseases, 3-4 october 2006