1. Recent Advances in Bronchoscopy
Dr. Ashok S. Bansode
Assistant Professor
Pulmonary Medicine

2. INTRODUCTION
Flexible bronchoscopy in many ways defines the procedural component of pulmonary medicine. Interventional Bronchoscopy (IB) 􀂴 Evolving field within pulmonary medicine that focuses on providing consultative and procedural services to patients with malignant and non malignant airway & parenchymal disorders 􀂴 IB encompasses the following three main areas in pulmonary medicine: malignant ; nonmalignant airway disorders; and artificial airways

3. THE PRE-ENDOSCOPIC ERA
Access to the airways in the living patient was tried already by Hippocrates (460–370 bc), who advised the introduction of a pipe into the larynx of a suffocating patient.
Desault (1744–1795) advised nasotracheal intubation for treatment of suffocation and removal of foreign bodies.

4. THE DEVELOPMENT OF ENDOSCOPY
Although instruments for the inspection of the body cavities such as the mouth, nose, ear, vagina, rectum, urethra, and others had been in use for ages, Porter in 1838 still stated, “There is perhaps no kind of disease covered by greater darkness or posing more difficulties to the practitioner than those of the larynx and the trachea” , because until then the larynx could be only insufficiently inspected by forcible depression of the tongue with a spatula, a so-called “Glossokatochon.”

5. Nobody had ever looked into the living trachea
Nobody had ever looked into the living trachea. It was only after the advent of three major inventions – (i) instruments for inspection, (ii) suitable light sources, and (iii) sufficient anesthesia – that direct inspection of the airways and visually controlled treatment became possible.

6. The First Endoscopes and Light Sources

7. GUSTAV KILLIAN AND THE INVENTION OF BRONCHOSCOPY
G. Killian performing tracheoscopy with Kasper’s electrical handle for illumination attached to his bronchoscope.

8. 1897-Bronchoscopy was born
1897-Bronchoscopy was born. In the same year (1897), he removed the first foreign body via the translaryngeal route on which his coworker Kollofrath reported in his paper “direct bronchoscopy” at the sixth meeting of the Society of South German Laryngologists in Heidelberg on May 29, 1898, and in the same year his first publication on direct bronchoscopy was printed.

9. RIGID BRONCHOSCOPY IN THE 20TH CENTURY
In photographic atlas of bronchoscopy. in Riecker introduced relaxation by curare , Curare was replaced with succinylcholine by M¨undnich and Hoflehner Maassen introduced bronchography via double lumen catheter. Two companies, Storz and Wolf, instrument makers in Germany and introduced new technologies such as the Hopkins telescope and television cameras. 1948–1949 E. Schiepatti of Buenos Aires wrote about transtracheal puncture of the carinal lymph nodes, and Euler reported on pulmonary and aortic angiography by transbronchial puncture in 1948–1949 and later on the technique of rigid transbronchial needle aspiration (TBNA) for mediastinal masses in 1955, which was further perfected by Schießle in 1962

10. Shigeto Ikeda- developed the flexible fiberscope, introduced glasfiber illumination for the rigid bronchoscope in 1962.
S. Ikeda demonstrating the first prototype of the flexible bronchofiberscope
to the author. In the transition from rigid to flexible technology he introduced the fiberscope
via an orotracheal tube that could be fixed in a straight position for introduction
of a rigid optic and forceps if flexible biopsy was insufficient.

14. Interventional Pulmonology
Ashok S. Bansode
Assistant Professor
Pulmonary Medicine

15. Topics Brochoscopy (diagnostic and therapeutic)
Endobronchial USG (EBUS)
Improving TBNA yield
Autofluorescence bronchoscopy
Navigational bronchoscopy
Endobronchial electrosurgery and Argon Plasma Coagulation
Endobronchial cryotherapy
Laser bronchoscopy
Bronchial thermoplasty
Airways
Percutaneous tracheostomy
Airway Stents:
Balloons and tubes for airways and pleura
Laryngo-tracheal stenosis
Tracheomalacia and dynamic airway collapse
Endobronchial valves

16. Diagnostic and therapeutic
Bronchoscopy
Diagnostic and therapeutic

17. IDEAL INTERVENTIONAL BRONCHOSCOPY SUITE
BASIC SUITE ADVANCED SUITE
Airway examination EBUS
BAL Autofluorescence
Cytologic brushing External Navigation
Endobronchial Biopsy Electrocautery / APC
Transbronchial biopsy Cryotherapy & PDT
TBNA Laser & Stenting
Thoracoscopy

18. SPECTRUM OF INTERVENTIONAL BRONCHOSCOPY

19. Regional Lymph Node Classification for Lung Cancer Staging
Mountain and Dresler 1997

20. Areas accessible by technique2 3 4 5 6 7 8 9
TBNA ●
EUS/FNA
Mediastinoscopy
Thoracoscopy

21. Endobronchial ultrasound (EBUS)
Radial probe (not real-time): for peripheral lesion
Linear probe (real-time): for central lesion
Stations 2, 4, 5, 6, 7
+ doppler function

22. Radial probe

25. Wahidi, M. M. et al. Chest 2007;131:261-274
Image of a transbronchial needle puncture of a small lymph node in the 10R position
Wahidi, M. M. et al. Chest 2007;131:

26. Autofluorescence systems

27. Autofluorescence bronchoscopy

31. A patient with a small endobronchial carcinoma in situ
Wahidi, M. M. et al. Chest 2007;131:

32. Local indications for autofluorescence bronchoscopy examination (QMH)
Sputum cytology atypia but normal white light bronchoscopy and non-localizing radiological examination i.e. normal CXR/CT
Operable lung cancer patients but synchronous lung cancer suspected.
Preoperative assessment of lung cancer to delineate endobronchial extension.

33. Follow up plan for patients who had autofluorescence bronchoscopy performed (QMH)
For patients confirmed to have invasive lung cancer, they will be staged and managed according to the current recommendations.
For patients with intraepithelial neoplasm, i.e. severe dysplasia or carcinoma in situ, local treatment will be offered (e.g. cryotherapy) unless refused by patients.
For patients with moderate dysplasia, they would be followed up with autofluorescence bronchoscopy at 6 monthly interval till histology reported as mild dysplasia or less
For remaining patients who had non-diagnostic autofluorescence bronchoscopy, they should have CT thorax if not done yet to look for peripheral lesions. If still non-diagnostic, these patients should be followed up regularly at referring unit and repeat sputum cytology at 6 monthly intervals. They should be referred for repeating autofluorescence bronchoscopy examination if sputum atypia persisted.

34. Navigational bronchoscopy

35. Wahidi, M. M. et al. Chest 2007;131:261-274
Typical images of an electromagnetically guided (superDimension) transbronchial lung biopsy
Wahidi, M. M. et al. Chest 2007;131:

36. Electrosurgery Electrocautery with Argon Plasma Coagulation
Nd:YAG Laser
Cryotherapy

37. Electrocautery via the flexible or rigid bronchoscope
Relies on direct tissue contact
Can be done through rigid or flexible scopes.

39. Argon plasma coagulation (APC)
A high voltage spark is delivered at the tip of the probe, which ionizes the argon gas as it is sprayed from the probe tip in the direction of the target tissue.
via the flexible or rigid bronchoscope
Non-contact

40. Wahidi, M. M. et al. Chest 2007;131:261-274
Granulation tissue is visible at the proximal end of a tracheal stent (top left)
Wahidi, M. M. et al. Chest 2007;131:

41. Nd:YAG laser via the flexible or rigid bronchoscope Non-tissue contact
Low tissue absorption
High coagulation
Low cutting effect
Perforation, airway fire, air embolism

42. Cryotherapay via the flexible or rigid bronchoscope Tissue contact
safe, with no danger of bronchial wall perforation
delayed results and the requirement for multiple endoscopies to remove debris or to retreat.
(A) Cryotherapy can be applied to tissue using either the probe tip or side. (B) Reapplication to the same area after thawing allows a deeper freeze and tissue destruction.

43. Chest. 2007;131:

44. Bronchial thermoplasty
The Alair® System - which is manufactured by Asthmatx, Inc. - consists of a single-use device and a controller that delivers thermal energy to the bronchial wall during an outpatient bronchoscopic procedure known as Bronchial Thermoplasty™.

46. The Asthma Intervention Research (AIR) Trial
Cox G et al. NEJM 2007; 356:

47. Summary Bronchial thermoplasty to moderate to severe asthma
55 BT vs 54 control
The mean rate of mild exacerbations, as compared with baseline, was reduced in the bronchial-thermoplasty group but was unchanged in the control group (change in frequency per subject per week, –0.16±0.37 vs. 0.04±0.29; P=0.005).
At 12 months, there were significantly greater improvements in the bronchial-thermoplasty group than in the control group in the
morning peak expiratory flow (39.3±48.7 vs. 8.5±44.2 liters per minute)
scores on the AQLQ (1.3±1.0 vs. 0.6±1.1)
ACQ (reduction, 1.2±1.0 vs. 0.5±1.0)
the percentage of symptom-free days (40.6±39.7 vs. 17.0±37.9), and
symptom scores (reduction, 1.9±2.1 vs. 0.7±2.5)
while fewer puffs of rescue medication were required.
Adverse events immediately after treatment were more common in the bronchial-thermoplasty group than in the control group but were similar during the period from 6 weeks to 12 months after treatment.

48. Airways

49. Percutaneous tracheostomy
Human cadaver available for practice

50. Airway stents Silicone stents Metallic stents Cheaper easily removed
higher incidence of migration
require rigid bronchoscopy for placement
Metallic stents
can be placed via flexible bronchoscopy or rigid bronchoscopy, with or without fluoroscopy.
Ultraflex® stent

51. Wahidi, M. M. et al. Chest 2007;131:261-274
Top, A: a proximal view of a silicone stent within the right mainstem bronchus
Wahidi, M. M. et al. Chest 2007;131:

52. Wahidi, M. M. et al. Chest 2007;131:261-274
Top, A: squamous cell carcinoma with near complete occlusion of the left mainstem bronchus
Wahidi, M. M. et al. Chest 2007;131:

53. Stent Type
Manufacturer 
Construction
Dumon 
Novatech
Molded silicon rubber 
Hood  
Hood Corp.
Wallstent 
Boston Scientific 
Woven cobalt/chrome alloy monofilament coated with silicone 
Polyflex  
Rush Inc. 
Polyester mesh covered with silicone 
Ultraflex 
Single strand woven nitilol With/without silicone coating
Dynamic 
Silicone with anterolateal steel struts 

54. Bronchoscopic lung volume reduction
Placement of one-way endobronchial valves in segmental and/or sub-segmental airways
General inclusion and exclusion criteria (extrapolated from NETT)
Inclusion: severe, UL emphysema
Exclusion: diffuse emphysema, FEV1<20%, DLCO<20%

55. Endobronchial valves Emphasys Med Inc: Spiration Inc:
Emphasys Zephyr™ Endobronchial Valve* (EBV) is a one-way, silicone valve supported by a Nitinol retainer
Endobronchial Valve for Emphysema PalliatioN Trial (VENT)
Spiration Inc:
IBV valve
IBV Valve Trial
An older model

56. Balloon bronchoplasty
Ballon bronchoplasty can be performed with a flexible or a rigid bronchoscope
Serial bougie dilatation can only be done by rigid bronchoscope
Mayse, M. L. et al. Chest 2004;126:

57. Microdebrider

58. CONCLUSIONS
Evolving field focusing on application of advanced bronchoscopic techniques for treatment of various malignant and nonmalignant airway disorders.
First-line endoscopic interventions should now be strongly considered due to more immediate results and a favorable safety profile.
Territorial battles with other disciplines, financial concerns, training, verification of competency and lack of rigorous scientific research in this field are main challenges and future directions facing IB.
Broader clinical application in near future to manage patients in a better way.

59. Thankyou