1. BRONCHOSCOPY Cori Daines, MD Pediatric Pulmonology, Allergy and Immunology University of Arizona

2. BACKGROUND Allows direct visualization of the airways Rigid and flexible instruments Clinical tool –Airway anatomy –Airway sampling –Therapeutic Research tool

3. ORIGINS Until the 1980’s, only rigid instruments were widely used Multiple generations of adult and pediatric flexible bronchoscopes now Widely used in adult and pediatric pulmonary medicine now

4. RIGID BRONCHOSCOPY Generally performed by ENT’s and surgeons Procedure oriented –Foreign body removal –Biopsies –Granuloma/polyp removal –Laser –Stent placement Visualization for future surgery

5. INSTRUMENTS Rigid bronchoscopes –Hollow metal tube –Glass rod telescope Ultimate optics

8. FLEXIBLE BRONCHOCSOPY Examination of the entire respiratory anatomy, nose to bronchi Minor impact on anatomy Able to pass through an endotracheal tube or tracheostomy tube

9. INSTRUMENTS Flexible instruments –Fiberoptic bronchoscopes 2.2mm ultrathin 2.8mm/1.2mm suction channel 3.4mm/1.2mm suction channel 4.4mm/2.0mm suction channel 4.9mm/2.2mm suction channel 5.9mm/3.0mm suction channel

10. INSTRUMENTS Flexible instruments –Video bronchoscopes 2.8mm/1.2mm suction channel (hybrid video scope) 3.8mm/1.2mm suction channel 4.0mm/2.0mm suction channel (hybrid video scope) 4.9mm/2.0mm suction channel 6.0mm/3.0mm suction channel 6.3mm/3.2mm suction channel

11. Fiberoptic bronchoscope 2.8mm diameter

12. Pediatric Videoscope 2.8mm diameter

13. Pediatric videoscope 3.8mm diameter

14. Adult videoscope 4.9 mm diameter

15. INDICATIONS When flexible bronchoscopy is the best, easiest, safest, most efficient way to obtain the information

16. AIRWAY ANATOMY

17. TECHNIQUE

18. Anesthesia –Best accomplished in the operating room –May be performed bedside in an ICU setting –Continuous monitoring –Light anesthesia--allows continued spontaneous breathing –May be done with conscious sedation in older individuals

19. TECHNIQUE Insertion –Nasal –LMA –Endotracheal tube –Tracheostomy tube –Appropriate topical anesthesia and lubrication

20. TECHNIQUE Anatomical survey –Nasal passages –Pharynx –Larynx –Trachea –Bronchi Examine all before any other procedures

21. TECHNIQUE Additional procedures –Bronchoalveolar lavage –Brushings –Bronchial biopsy –Transbronchial biopsy –Laser –Others: cryotherapy, stent placement, foreign body removal, needle biopsy

22. BRONCHOALVEOLAR LAVAGE Small aliquots of sterile normal saline instilled into the airway Removed by suctioning Samples distal bronchial and alveolar surfaces Wedge position to prevent loss of fluid

23. BAL TESTS Microbiology –Bacterial, viral, fungal, AFB, special techniques Pathology –Cell count, differential, special stains

24. MICROBIOLOGIC STUDIES Stains –Gram stain –Acid fast stain (Ziehl-Neelsen) Antibody tests –Rapid tests, DFA tests In-situ PCR

25. SPECIAL STAINS Lipid –Oil Red O –Sudan Hemosiderin –Prussian Blue Alveolar proteinosis –PAS –Electron microscopy

26. SPECIAL STAINS Fungi –Silver (Gomori’s methenamine silver stain) Pneumocystis carinii –Silver stain –Papanicolaou

27. BRONCHOALVEOLAR LAVAGE

28. SPECIFIC INDICATIONS Atelectasis Recurrent pneumonia Chronic cough Persistent/unexplained wheeze Hemoptysis Suspected airway compression/obstruction Stridor Upper airway obstruction Suspected aspiration Evaluation of tracheostomies

29. NORMAL ANATOMY

30. BRONCHOALVEOLAR LAVAGE

31. LARYNGOMALACIA

33. TRACHEOMALACIA

35. SUCTION TRAUMA

36. TRACHEOBRONCHOMEGALY

37. VASCULAR COMPRESSION

38. TECHNIQUES-BIOPSY

39. TECHNIQUES-LASER

40. BRONCHOSCOPY TEAM Pulmonologists Respiratory therapists Anesthesia Nurses Laboratory –Microbiology –Pathology