Presentation on theme: "Basic Instruments of Interventional Bronchoscopy"— Presentation transcript:
1Basic Instruments of Interventional Bronchoscopy Ass. Prof. Sedat ALTINPulmonolog, interventional bronchoscopist
2Rigid BronchoscopeThe newer modifications in the rigid bronchoscope have established it as the ideal instrument for debulking of large tumors in the major airways, dilatation of tracheobronchial strictures, laser bronchoscopy, insertion of airway prostheses (stents), and extraction of tracheobronchial foreign bodies.
3Fiberoptic Bronchoscope Flexible bronchoscopes with a larger working channel enable the bronchoscopist to insert larger biopsy forceps, balloon catheters, laser fibers, and other instruments into the airways to obtain larger and better-quality biopsy specimens.
4VideobronchoscopeA flexible bronchoscope equipped with a charge-coupled device at its distal tip. The bronchoscopic images are digitally captured and transmitted to a video processor for display on a television monitor.The advantage is that the excellent images can be simultaneously visualized by many, making it an excellent tool for teaching purposes. The images can also be stored in several digital formats.
5VideobronchoscopeThe disadvantages include the added expense of purchasing video equipment and a computer terminal, and the larger working and storage space required.The major drawback is the loss of ability to view the image through the headpiece of the flexible bronchoscope; the bronchoscopist has to depend on the video monitor to visualize bronchoscopic findings. The image on the monitor is only as good as the monitor.
6EndoBronchialUltraSound (EBUS) The major advantage of this technique is the ability to visualize, via ultrasound, the extra-airway structures that cannot be seen through the bronchoscope The major technical problem is the inability to consistently provide the coupling of the ultrasound probe to the bronchial wall to generate meaningful images of the extrabronchial structures. To overcome this, flexible bronchoscopes are being fitted with water-inflatable balloons. This will permit constant 360-degree contact between the wall of the airway and the ultrasound probe. Preliminary studies have shown the ability to identify mediastinal structures including lymph nodes, great vessels, and esophagus .The identification of lymph nodes and their relation to airways may help improve diagnostic techniques such as BNA for the diagnosis and staging of thoracic tumors.
7Fluorescence Bronchoscopy When the normal bronchial mucosa is illuminated via the bronchoscope, a higher fluorescence is observed. Mucosa containing abnormal or malignant cells produces decreased autofluorescence. This phenomenon is used to detect mucosal changes suggestive of either premalignant or malignant lesions in the airway mucosa. Mucosal changes observed by routine (white-light) bronchoscopy can be compared with those observed via green-light bronchoscopy. Early reports show that this technique, when used as an adjunct to standard bronchoscopy, may enhance the ability to localize small neoplastic lesions, especially intraepithelial lesions.
8Electromagnetic Guidance System A novel method for guiding transbronchial catheters or forceps is electromagnetic navigation. In comparison to fluoroscopy or CT scanning, electromagnetic navigation as a method not only has minimum technical and spatial requirements, it also indicates the position of the catheter in three dimensions without radiation exposure; all that it needs is the availability of a preprocedure CT data set.
10Things to Consider Personel Scope of practice Equipment Space/unit Your financial and practice environment
11Minimal equipments Rigid bronchoscopy system Fiberoptic bronchoscopes and cold light source/video processorPicture monitorForceps for biopsy, sitology brushes, transbronchial needlles, baskets for foreign bodiesCleaning/disinfection equipments
12Personel A bronchoscopist alone is not enough Nursing, ancillary help(minimal 2 nurses)Anesthesiolog, technicianGood relationships with other services such as pathology, oncology and thoracic surgeryRequirements differ..
13Equipment-Diagnostics BasicsGood brochoscopes, at least 2 (videoscope)Processors, screens etc….Image processingFull range of forceps, brushes and TBNA needles
14Equipment-Diagnostics AdvancedAF if lung cancer detection programEBUSEM guidance systemSoonNBIPoss OCT
15Equipment-Therapeutics BasicsTherapeutic and thin flexible scopesChoice of thermal ablationLaserES/APCCryotherapyDifferent diameter stents
16Equipment-Therapeutics AdvancedRigid endoscopy with barrels, optics, camera and processorPDTCollection of silicone stents
21Conditions Required for Safety Endoscopic Treatment Tumour must be accesible with the bronchoscopeTumour must be spread restrictly in the bronchus and have to do not lymphangitic invasionThe lungs and the airways without stenosis must be functionalThe performance of the patient must be enough good!!
22Description of Common Practical Problems Difficult airway managementBleedingIntubationIndications and contraindicationsAnesthesia and risk management
23Which technical for which patient? The type and the nature of stenosisThe localisation of the lesionAvailable equipment must be preferred!The experience of the physicianThe condition of distal airwaysThe cost of the technics
24Factors reducing the complications Adequate equipmentEducated personnelSufficient sterilizationGood patient selectionEnough sedation, premedication and anesthesiaFollow-up after bronchoscopy and if need be therapy
25Rigid Bronchoscopic Procedure-Related Adverse Events poor insertion techniques, prolonged trauma of the larynx and vocal cords, or failure to heed the warnings of hypercapnia, hypoxemia, or hemodynamic instabilityAirway wall perforation posterior wall of the trachea, subglottis, and median walls of the left and right main bronchi just below the carina Luxation or laceration of the vocal cords and arytenoids
26Rigid Bronchoscopic Procedure-Related Adverse Events Other complications can be avoided by a careful inspection of the mouth. Loose teeth should not be dislodged. The gums should not be traumatized, and the lips should not be injured.Spinal cord injuries are possible in patients with cervical spine disease and severe osteoporosis. In selected instances, these diseases are contraindications to rigid bronchoscopic intubation.
27Laser Bronchoscopy Attentions FIO2 must be kept below 40% because of the risk of endobronchial fireAvoid curare,pavulon because of post-operative respiratory depression.Non flammable anaesthetic gases are mandatory.An anesthesiologist experienced in the technique is important.Oximetry monitoring is mandatory.All persons in the room must wear protective glasses to avoid the risk of laser eye injury.Plumbing- increased water for machine coolingElectrical- special generator for high power needs.RN Laser safety nurseLaser operation-fiber bundle repairLaser- $200,000maintainance- backup?
28Laser EquipmentDumon rigid laser bronchoscope with ventilating port, laser channel and suction channel.Disposable large bore suction catheters.Biopsy forceps with telescope.Flexible bronchoscope.Endobrochial balloon catheters in case of massive hemorrhage.
29Laser Complications: 1. Failure to achieve an adequate airway 2. Hemorrhage usually mild and represents only a nuisance.3. Asphyxia4. Tracheoesophageal fistula can occur in LMB or tracheal lesions.5. Mediastinal emphysema, pneumothorax.6. Delayed hemorrhage (probably results from necrosis of tumor that had invaded a nearby pulmonary artery)7. Endobronchial fire8. Eye injury to the patient or OR staff
30CryoIn addition to the equipment needed for flexible or rigid bronchoscopy, dedicated operators need different probes depending on whether the cryotherapy is delivered through the rigid or flexible bronchoscope. Generally, the area of freezing is larger and the thawing quicker with the rigid probes. The gas most commonly used in cryotherapy and the gas most commercially available is nitrous oxide.
31CryotherapyThis technique is not indicated to achieve immediate debulking of an obstructive tumor.The tumor will be first cored out mechanically with the tip of bronchoscope after coagulation, after first this step and inthe same session cryotherapy can be applied on the remaining infitrative part of the tumor.Well vascularized tumor such as bronchial caecinomas, carcinoids,adenoid cystic carcinomas or granulomasIn situ or microinvasive carcinomasCT is useful to remove many foreign bodies from the airways (pills, foods, clots, peanuts; not bones, metal,or teeth)
32CryotherapyCT is not indicated in external compression of the bronchial tree,CT is not indicated in benign strictures of the trachea or bronchi caused by fibroma, lipomas, or post-intubation stenosisA transient fever immediately following cryotherapy. This fever can be prevented by corticosteroid administration given during the procedureAirway sloughing material elimination after CT remains a problem. A bronchial toilet with a flexible fiberoptic bronchoscope is usually necessary 8-10 days after CT
33CryotherapyThe equipment is less expensive and easier to use than lasers. Subjective improvements have been observed in > 75% of patients with malignant airway lesions.Complications are few and minor. One disadvantage is the longer duration of therapy required because of the need for frequent freeze-thaw cycles. Repeat bronchoscopy is needed for continued therapy in many patients.
34Advantages of Cryotherapy high penetration depthno vaporization or carbonizationno smoke plumefixation of liquids or tissuecan also be used to treat patients with cardiac pacemakersno electrosurgical interferenceno combustion riskmobile unit
35Advantages of Cryotherapy Better control of depth effectCan also be used in the area of coated stentsDoes not harm cartilagesLess costsapprox € /
36APC & ECa dedicated operator needs a high-frequency electrical generator in combination with insulated probes. Different types of probes in terms of shape as well as polarity (monopolar vs bipolar) are available. For patient and staff protection, proper insulation precautions need to be observed. Insulated flexible equipment is also available. For APC, a dedicated operator needs a special catheter allowing for the argon gas and the electrical current flow. This catheter is not used in electrocautery where there is direct tissue contact.
37Rigid and flexible HF-contact coagulation probes
40Argon Plasma Coagulation The indication of APC is the same as that for laser: an obstructive endobronchial lesion of airway causing symptoms such as dyspnea, cough or pneumoniaThe role of APC as a cure for early stage lung cancer is not yet fully establishedIn addition benign polyp removal and palliative care in malignant disease, it can also be used for debridement of granulation tissue around endobronchial stents.APC has no role in removing a foreign body, mucous plug or clot.Precautions: The power setting (<80W) and the application time (<5 sec)should minimize the risks and keeping the argon flow rate (<2 Lpm) should lessen the chance of gas embolism
41ElectrocautheryLesions considered suitable for the procedure were required to have < 50% luminal obstruction, a visualized size that was < 2 cm in its greatest dimension, limited vascularity, and an estimated procedure time of < 1 h.
42ElectrocauteryThe diameter of the working channel of the scope is 2.6 mm, which allows the insertion of most therapeutic accessories. An electrosurgical unit was the power source for the procedure. This unit is approximately 1 cubic foot in volume and produces the three following current modes: cut, coagulate, and blend. The endobronchial accessories consisted of polypectomy snare, coagulation probe, forceps, and a cutting blade
43Complications During Electrosurgery BleedingLimited field of bronchoscope viewTransient desaturationExcessive coughEndobronchial fireElectrical shock
44BrachytherapyMajor complications include formation of fistulae between the airways and other thoracic structures in 6 to 8% of patients. Serious hemorrhage has been noted to occur more frequently in patients who receive high-dose radiation. The risk of massive hemoptysis increases dramatically when a fraction size of 15 Gy is used.
45PDTComplications from photodynamic therapy include sunburn involving skin exposed to bright light, hemoptysis, and expectoration of thick necrotic material.
46Jean-François Dumon, MD, FCCP ‘’Various types of airway stents available to treat airway stenoses. There is no ideal stent.’’
47Stent indicationsInoperable, symptomatic lung cancer • Primary airway tumours • Oesophageal cancer • Thyroid cancer • Head and Neck tumours • Metastases • Postintubation and idiopatic benign tracheal stenosis • Inflammatory lesions • Tracheobronchial malacia • Vascular compression
48StentsComplications seen with silicone stents include migration of stent and inspissation of thick mucous within the stent lumen. Metallic stents seem to promote growth of granulation tissue, which makes it difficult to remove and replace the stent. Uncovered metallic stents should not be inserted in patients with malignant airway lesions because the growth of cancer through the wire mesh negates the benefits of stent placement.
49Commercial stents Stent Type Manufacturer Construction Sizes (mm) Dumon NovatechMolded silicon rubber 9 x 20 – 18 x 70 + Y Hood Hood Corp.6 x 13 – 18 x 70 + Y Wallstent Boston Scientific Woven cobalt/chrome alloy monofilament coated with silicone 8 x 20 – 24 x 60 Polyflex Rush Inc. Polyester mesh covered with silicone 6 x 20 – 22 x 80 Ultraflex Single strand woven nitilol With/without silicone coating8 x 20 – 20 x 80 Dynamic Silicone with anterolateal steel struts 13, 15, 17 (trachea)
50Bronchoscopic Needle Aspiration Complications are rare and include pneumothorax and hemomediastinum. Serious bleeding is seldom encountered. More commonly, inadvertent passage of the needle through the wall of the working channel of the flexible bronchoscope leads to expensive damage to the inner lining of the bronchoscope.
52Areas of Potential Damage to the FOB Improper handlingProceduralTBNANd-YAG laser photoresectionElectrosurgeryRadiationUse of lubricantsPatient relatedCleaning and maintenanceEthylene oxide gas sterilization
53Damage of the FOBAn educational program was effective in dramatically decreasing the costs of equipment repair after initiating an interventional pulmonology program.This is the first study to offer budgetary guidelines for equipment repair in an IP program and to demonstrate that an educational program can effectively reduce costs.Lunn W et al. Chest 2005;127:
54Improper HandlingCare must be taken not to allow the distal end of the instrument to strike a hard surface.Forced angulation or twisting the body of scope may damage its quartz filaments.Rotation of the body of the scope should be performed by flexing or extending the wrist
55Procedural-TBNA Improperly used Nonretractable TBAN The diameter of the working channel of the FFBTBAN should be used only by or under the supervision of experienced bronchoscopist
56Procedural-Nd-YAG Laser Indications: Exophytic, intraluminal, proximal airway lesions that cause symptoms such as hemoptysis, cough, dyspnea, difficulty clearing secretionsor postobstructive pneumoniaPrecautions: During laser firing the fraction of inspired oxygen should be kept below 40 percent,Flammable materials should be kept far away from the operating field and silicone stents should be removed prior to laser firingThe laser should always be placed on standby mode when tissue is removed from the bronchoscopePower settings greater than 40 watts are never necessary
57Procedural-Electrocautery Airway obstruction caused by bronchogenic carcinoma is the most common indicationPrecautions: The power setting (<80W) and the application time (<5 sec)should minimize the risks, like APC
58RadiationYellowish discloration and darkening of both the fiber bundles and the visual imageFFB should not be syored in areas where fluoroscopy is performed
59Use of LubricantsA water-soluble lubricant should be used to lubricatePetroleum-based products should be avoided, because may cause premature wear streching and deterioration of the rubber sheath of the FFB.
60Patient-Related Damage Incooperated patientSupine position might lead to grabbing or pulling the fiberscope by the patient.Mouthpiece must be used the transoral approach.The patient’ teeth with damage to the fiber bundles.
61Disinfecting in the morning ….the safest practice is to terminally disinfect (endoscopes) at the end of each day’s use, and again before the first and each subsequent use throughout the next day.
62The recommended reprocessing steps include Preprocessing and leak testing the endoscope,Cleaning the endoscope and each of its componentsDisinfecting and rinsing the endoscope with clean waterDrying the endoscope before storing by rinsing its cannnels with 70% alcohol followed by forced-airProperly handling and storing the endoscope
63Bronchoscope DamagePositive leak test result. Air bubbles emitting from the surface of the bronchoscope indicate a breach in its exterior.
65PrecleaningThe three most important rules of any effective reprocessing are:clean itCLEAN IT!If an item cannot be cleaned, it cannot be disinfected or sterilised.
66PrecleaningIn the examination room immediately after the procedure: 1. Wipe the insertion tube with a disposable cloth dampened in an enzymatic detergent solution.2. Aspirate enzymatic detergent solution through the suction/biopsy channels3. Purge air/water channels.4. Detach removable components
67Mechanical Cleaning 1. Make up enzymatic solution 2. Immerse instrument3. Disassemble removable parts and clean4. Brush and wipe exterior5. Brush all channels
69Cleaning & Maintenance Hand antisepsis plays a significant role in preventing nosocomial infections. When outbreaks of infection occur in the perioperative period, careful assesment of the adequacy of hand hygiene among operating room personnels recommended.Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with persistent activity is recommended before donning steril gloves when performing surgical procedures.
70Bronchoscope disinfection Rigorous procedures should be appliedDouble mechanical washing and brushing before an automated washer disinfector cycleDuration: 40 to 45 minuteContinuous monitoring at each stepGlutaraldehyde is replaced now by peracetic acid
71Automatic flexible endoscope reprocessors (AFERs) The potential advantages of AFERs include:Standardisation of endoscope reprocessing.Reduced exposure of HCWs to hazardous chemicals.Reduction of staff time spent on reprocessing.
74Bronchoscope storageAfter drying bronchoscopes should be stored in special cupboards horizontally or better vertically.Do not store bronchoscopes in transport luggagea new cycle in the automated washer disinfector is required after storage before the bronchoscopy.
75Staff safetyDuring bronchoscopy staff should wear gloves, protective clothing, masks and visorsBronchoscopes should be disinfected in a dedicated, ventilated room.