covered important procedure

1. Therapeutic Bronchoscopy
Dr Narendra Tengli
Junior resident
Department of Pulmonary Medicine

2. Learning Objectives
• Introduction-history
• Instruments required
• Rigid Bronchoscopy
• Intubation/insertion- procedure
• Preparation, Sedation,
and Monitering
• Indications
• Various Interventional modalities
• Emerging novel technology

3. History
Gustav Killian
 Gustav Killian (1860-1921)
a German laryngologist and
founder of the bronchoscopy
 He removed a pork bone from a
farmer's airway, using an
esophagoscope
 Father of bronchoscopy

4. Dr chevalier Jackson
father of American
bronchoscopy
Designed a first illuminated
Rigid bronchoscopy in 1904
Dr chevalier Jackson

5. Shigeto Ikeda ( 1925 - 2001) was a
Japanese physician, regarded as the
"father" of fiberoptic bronchoscopy.
He developed the first flexible
bronchoscope 1968
Shigeto Ikeda
( 1925 – 2001)

6.  Designed newer type of rigid
bronchoscopy
 First reported use of nd-yag/ na-
yap laser, Silicon stents and stent
insertion instruments
 The Father of Interventional
Pulmonology
Dr jean francois
dumon- (1930-2020)

7. Instruments required for interventional
bronchoscopy
• Rigid/flexible bronchoscopy
• Optics
• Bronchoscopy accessories ( forceps ,suction)
• Ventilator – jet ventilation
• Hot and cold therapy devices

8. Rigid bronchoscopy instrument
• Straight , hollow metal tube available in different sizes
• External diameters and lengths vary
• External diameter varies from 5 to 16mm, wall thickness 2
to 3mm
• Distal end:is bevelled, facilitates intubation by lifting of
the epiglottis and also helps in coring
• Proximal end: accommodate attachments side ports for
ventilation, suction and working port

9. An Efer-Dumon rigid bronchoscope set with the 'universal
head' , several bronchoscope barrels of varying lengths
and diameters, a rigid 0° telescope, a pair of optic
forceps
Efer-Dumon Storz
Different rigid bronchoscopy
instruments

11. Classical method

12. SPECIAL CONSIDERATIONS FOR PATIENT
PREPARATION, SEDATION,
AND MONITORING
• All patients undergoing bronchoscopy should undergo a complete pre-bronchoscopy
evaluation, including a medical history, physical examination, and chest imaging.
• Similar to diagnostic bronchoscopy, if a patient is stable for moderate sedation, topical
analgesia of the oropharynx and airways should be achieved with lidocaine, followed by
administration of a combination of a short-acting benzodiazepine (e.g., midazolam) and
a narcotic (e.g., fentanyl).
• Rigid bronchoscopy is most safely performed with a patient receiving general
anesthesia and breathing spontaneously or being ventilated with a jet ventilator.
• General anesthesia with inhaled anesthetics (e.g., sevoflurane) should be avoided in
favor of total intravenous anesthesia in order to avoid exposure of the bronchoscopist to
inhaled anesthetics when the ventilator circuit is open.
• With appropriate planning and monitoring, the vast majority of patients can undergo
interventional bronchoscopy with low complication rates

13. 1Pre-procedure evaluation
• Patient information
• Informed consent
• Fasting
• Venous access
• History and physical
examination
• Laboratory tests
• Total blood count
• Platelet count
• BUN
• Liver function test
• Ionogram
• Coagulation study
• ABG
• ECG, ecocardiogram, spirometry
• Imaging
Chest X-ray
Chest CT
• Planning and strategy

14. Post procedure evaluation
• Surveillance 30---60 min (respiratory distress signs, consciousness)
2 h if general anaesthesia
• Vital signs monitoring (heart rate, respiratory rate, blood
pressure, saturation) O2 supplementation
• Chest X-ray (1 h later if any intervention)
• ABG, ECG, If cardiac or respiratory complications.

15. Approach to ventilation
Several ventilation strategies are commonly used during
rigid bronchoscopy to provide adequate oxygenation and
ventilation while maintaining appropriate sedation to
minimize cough and movement and ensure patient
comfort
1. Apneic oxygenation.
2. Spontaneous assisted ventilation
3. Controlled ventilation (closed system)
4. Manual jet ventilation
5. High-frequency jet ventilation (HFJV)
Rigid bronchoscope with silastic caps on the ports of the
rigid scope.

16. Indication of interventional Bronchoscopy
1. Foreign body retrieval
2. Removing blood clots, thick mucus plugs
3. Relieving airway obstruction from tumour or stenosis
4. Lung lavage(pulmonary alveolar proteinosis)
5. Bronchoscopic drainage – lung abscess
6. Endotracheal tube and percutaneous tracheostomy placement
7. Treatment of persistent air leak
8. Evolving therapies of emphysema
9. Bronchial thermoplasty in severe asthma

17. Foreign body removal
• Its most common indication
• Peaking in children(1-2y) and adult(>70y)
• History of aspiration obtained in less than 50% of
patient
• Visible foreign body in chest radiography is <10%
• The removal of foreign body by flexible
bronchoscopy is 86-91% and by rigid bronchoscopy
its 99.9%

18. Site of foreign body
• The sites of foreign body were as follows
Larynx -3%
Trachea/carina -13%
Right lung 60 %
Left lung 23%
Bilateral 2%

19. Foreign body removal steps
• First dislodge the foreign body
• Grasping or securing the objects
• Finally removing it along with flexible
bronchoscopy as a single unit
• The instrument of choice depends on FB
composition size, shape and location

20. rat tooth forceps, basket forceps, tripod forceps, five-
prong forceps. B, Schematic representation
of the use of a balloon catheter for dislodging a foreign
body by a retrograde pull

25. complication
• Bleeding
• Central airway obstruction
• Hypoxemia
• Bronchospasm
• Objects can also migrate and fragments can impact in distal
airway

26. Different therapeutic modalities
• MECHANICAL DEBULKING
• ELECTROCAUTERY
• ARGON PLASMA COAGULATION
• LASER PHOTORESECTION
• MICRODEBRIDER
• CRYOTHERAPY
• PHOTODYNAMIC THERAPY
• BRACHYTHERAPY
• STENT

27. Mechanical debulking
• Abnormal tissue of both malignant and benign origin can
be removed directly with forceps or by pushing the distal
bevelled edge of the rigid bronchoscope against the
base of the lesion and coring it out under direct
visualization
• In order to avoid excessive bleeding following the coring
out of the lesion, it is advisable to first
coagulate/devascularise the lesion using thermal
ablation techniques
• After resection, the barrel of the rigid bronchoscope is
advanced distally so that haemostasis is effectuated by
the radial compression that is exerted on the airway wall
by the rigid tube
Mechanical debulking
with the tip of the rigid
bronchoscope

28. Microdebrider
• The microdebrider is a form of “powered
instrumentation” that uses a spinning blade
contained within a rigid suction catheter to
cut tissue while providing suction to remove
blood and tumor/granulation tissue.
• Advantages of the microdebrider are that it
can be used in high-FIO2 environments, and,
because it does not vaporize tissue, a
specimen trap can be connected in line so
that tissue can undergo pathologic analysis
The rotating tip tracheal microdebrider.

29. ELECTROCAUTERY
• Endobronchial electrocautery is the application of heat
produced by high-frequency electrical current to treat
tumor tissue
• The degree of tissue destruction depends on the power
used, duration of contact, surface area of contact, and
water content of the tissue
• To avoid endobronchial ignition, the fractional
concentration of oxygen in inspired gas (FIO2) should be
kept below 0.4
• Coagulation is achieved by gently touching the tumor
tissue and applying 1- to 2-second . Additional contact
time can result in vaporization of the tissue as desired.

30. ELECTROCAUTERY
• The tumor area should be kept free of
blood or mucus by continuous suctioning,
or the electrical current will be dissipated
through these liquids.
• The coagulated tissue can then be
removed using biopsy forceps or suction.
• The use of electrocautery is
contraindicated in patients with
pacemakers and/or defibrillators to avoid
electrical interference with these
devices.

31. ARGON PLASMA COAGULATION
• Argon plasma coagulation (APC) is a
noncontact form of electrocautery that uses
ionized argon gas (plasma) to conduct
electrical current from the probe to the tissue
• Because positively charged argon gas flows
toward the negatively charged tissue,
treatment can be directed in an axial or
tangential fashion.
• As the tissue becomes desiccated, it offers
more resistance to the electrical current,
limiting its penetration to approximately 2 to 3
mm.
Arrow shows the tungsten
carbide electrode. Positively
charged argon gas automatically
flows radially to the negatively
charged bleeding tissue

32. ARGON PLASMA COAGULATION
• The most important advantages of this technique are the ability to
treat lesions at sharp angles from the tip of the electrode, to
treat lesions in close proximity to airway stents, and to achieve
superior hemostasis.
• Its major limitation is the depth of penetration of less than 3 mm;
however, this also may reduce the risk for airway perforation. Its
only absolute contraindication is the presence of a pacemaker or
implantable defibrillator susceptible to electrical interference

33. LASER PHOTORESECTION
• Laser light causes thermal, photodynamic, and
electromagnetic changes in living tissue. Laser
energy can cut, coagulate, or vaporize endobronchial
lesions in a predictable manner, depending on the
wavelength used.
• Although many types of laser systems exist,
(Nd:YAG) and (Nd:YAP) lasers are most commonly
used in the airways because of their ability to
coagulate and vaporize tissue, with a depth of
penetration of 5 to 10 mm.

34. PHOTODYNAMIC THERAPY
Photodynamic therapy (PDT) is a unique biopharmaceutical modality where an injectable
photosensitising drug delivered prior to the procedure is selectively retained in tumour cells and is
subsequently activated by specific wavelength light .
PDT is a three-step process On day 1, a photosensitizing agent is administered intravenously. Forty-
eight hours after injection, the drug is preferentially retained by tumor cells and cleared from most
healthy tissues, and the tumor is then exposed to a nonthermal laser light introduced via a flexible
bronchoscope. Exposure of the drug to light of specific wavelength results in a photochemical
reaction, including generation of oxygen radical species, direct damage to cells and organelles,
indirect ischemic effects, apoptosis, and inflammatory effects. One to two days later, a cleanup
bronchoscopy is then necessary to remove the devitalized tissue, which is difficult to expectorate
and can cause complications such as post obstructive pneumonia, respiratory distress, or respiratory
failure.

35. CRYOTHERAPY
• Cryotherapy relies on repeated freeze-thaw cycles to cause tissue damage.
Maximal cellular damage results from rapid and deep cooling . The most
commonly used cooling agents (cryogens) available are nitrous oxide and
carbon dioxide.
• The cryoprobe can be used through rigid or flexible bronchoscopes.
• When nitrous oxide is used, the temperature at the tip of the probe falls to
−89° C within several seconds. freezing and recrystallization depend on
cellular water content,
• cartilage and fibrous tissue are relatively cryoresistant, making it more
difficult to damage the normal airway with this therapy than with other
forms of thermal energy. Tissue necrosis and sloughing takes place within 24
to 48 hours, and a “cleanup” bronchoscopy is usually required to remove
necrotic tissue. This delayed tissue effect is one of the shortcomings of
cryotherapy.

36. BRACHYTHERAPY
• Brachytherapy refers to a technique in which the
radiation source is placed within or in close proximity to
the target to deliver the maximum dose of radiation to
the tumor while sparing the normal surrounding tissues.
• Thus this mode of radiation therapy allows the tumor to
receive significantly higher radiation doses than the
surrounding healthy tissues such as lung parenchyma and
mediastinal vasculature.
• Brachytherapy requires close collaboration between the
bronchoscopist and the radiation oncologist. The role of
the bronchoscopist is to identify appropriate patients and
place a catheter into the tracheobronchial tree, whereas
the radiation oncologist calculates the radiation dose and
guides the actual delivery of radiation to the tumor

37. Central airway obstruction
The principal indications for therapeutic bronchoscopy in
central airway obstruction include intrinsic obstruction, extrinsic
compression or their combination (mixed) due to benign or
malignant disease
Different techniques are used to restore
airway patency, either by ablation,
debulking or by dilation according the type
of stenosis. In any case, it is important to
confirm the presence of a potentially patent
airway and viable lung tissue distally of the
stenosis, without which the intervention is
both dangerous and meaningless.

38. Benign causes
1. Endotracheal intubation
2. Tracheostomy tube
3. Tuberculosis
4. Thermal injury from fire exposure
5. Lung transplantation
6. Post resection or airway repair
7. Trauma
8. Recurrent stenosis after prior stenosis
resection
9. Sleeve resection
10. high dose-rate brachytherapy
11. Photodynamic therapy
12. Idiopathic

39. Electrocautery incisions were made into the benign stenotic lesion (A). Following
incision, balloon bronchoplasty dilatation was performed (B)

40. Benign tracheal stenosis a) before and b) after silicone
stent placement.

41. Malignant causes
• More than one-third of patients with nonsmall cell lung cancer develop clinically significant
central airway obstruction at presentation or during the course of the disease.
• Primary tracheal tumors, as well as metastatic tumours of any histology from distant sites,
can grow in the central airways. Symptoms include inspiratory or expiratory stridor,
exertional dyspnea, post-obstructive pneumonia, hemoptysis and atelectasis of varying
degrees depending on their size and location. Extrinsic compression from mediastinal
nodes, lymphomas, thyroid, or esophageal cancer can also produce stenosis and/or
fistulae.
• Imaging and endoscopic assessment are required to classify the obstruction as
endoluminal, extraluminal, causing extrinsic compression or mixed and treat it accordingly.
Interventional management in malignant central airway obstruction is warranted in
symptomatic patients and when distal airways are potentially patent. If the disease invades
peripheral airways and lung parenchyma entirely, there is no indication for interventional
management

42. Airway obstruction by malignant lesion
• Purely intrinsic, Purely Extrinsic or both

43. Airway obstruction
• Preprocedural CT scan allows accurate assement and plan an
approach
• For purely intrinsic direct bronchoscopic debulking with rigid
bronchoscopy, with or without stent placement
• For purely extrinsic ballon bronchoplastic dilatation and stent
placement

44. Tracheal invasion from an esophageal cancer a) before and b) after
mechanical debulking and fully covered SEMS placement.

45. Airway Stents
• Stents are devices used for the internal
splinting of luminal structures.
• The first stents that were used in the
trachea were the T tubes developed by
Montgomery.
• Though they require a tracheostomy for
their placement, these silicone stents are
still widely used, primarily in patients with
high tracheal stenosis and/or malacia.
• later modified this stent and designed a T-Y
prosthesis, which enabled splinting of the
distal trachea and carina.

46. • Dumon later developed the first stents that
could be inserted through a bronchoscope
without a tracheostomy.
• self-expanding metallic stents can be placed
with flexible bronchoscopy,
• silicone stents require rigid bronchoscopy

48. Complication of Stents
• Retained secretions,
• bacterial colonization,
• migration,
• stent fractures and
• development of granulation tissue are frequent complications, and
all can be seen with any type of stent. Silicone stents tend to have
a higher incidence of migration, whereas covered metallic stents
are more prone to infection.

49. MANAGEMENT OF HEMOPTYSIS
• Bronchoscopy helps to identify site of bleeding, to provide endobronchial therapy to
reduce or stop bleeding, to clear blood clots that might impair gas exchange, or to place
an endoluminal blocking device to prevent further airway occlusion with blood.
• To cease bleeding, iced saline or an epinephrine solution can be instilled into a bleeding
airway or applied topically onto a proximal bleeding site in attempt to induce
vasoconstriction. In addition, balloon catheters can be placed into the bleeding airway to
tamponade bleeding and prevent proximal airway soilage
• Other effective methods for control of proximal visible bleeding sources, particularly from
endobronchial neoplasms, are thermal modalities, such as Nd:YAG laser or APC
photocoagulation
• These procedures are temporizing, while definitive management with surgery or
bronchial artery embolization is considered.

50. Whole-lung lavage
• . Whole-lung lavage is a large-volume BAL that is performed mainly in the
treatment of PAP. In brief, it involves the induction of general anesthesia
followed by isolation of the two lungs with a double-lumen endotracheal
tube and performance of single-lung ventilation while large-volume
lavages are performed on the nonventilated lung. Warmed normal saline
solution in 1-L aliquots (total volumes up to 20 L) is instilled into the lung,
chest physiotherapy is performed, then the proteinaceous effluent is
drained with the aid of postural positioning. The sequence of events is
repeated until such time as the effluent, which is initially milky and
opaque, becomes clear. This procedure results in significant clinical and
radiographic improvement secondary to the washing out of the
proteinaceous material from the alveoli.

52. SECRETION ASPIRATION
• According to a survey of bronchoscopists in the United States,
removal of retained secretions as a leading indication for
therapeutic bronchoscopy. Aspiration of bronchoscopic secretions
may be indicated in patients with respiratory muscle weakness
(e.g., due to underlying neuromuscular disease or the
postoperative state) who cannot generate adequate cough for
secretion clearance and even critically ill patients

53. EMERGING TECHNOLOGIES
• BRONCHOSCOPIC LUNG VOLUME REDUCTION
Various devices and chemical agents have been used via
the endobronchial route to reduce lung volumes in a
relatively noninvasive fashion.65-70 The majority of
studies have focused on patients with heterogeneous
(i.e., upper lobe predominant) emphysema
1. Endobronchial Valves
2. Bronchial Lung Volume-Reduction Coils
3. Biologic Sealant
4. Bronchoscopic Thermal Vapor Ablation
The Spiration Valve is an umbrella-shaped, one-way
valve that is placed via a delivery catheter, introduced
through the working channel of a flexible bronchoscope

55. Complications
• Procedures are performed in patients with
severe underlying emphysema, complications
can be expected. The more common
complications include transient reductions in
lung function, flares of bronchitis or
pneumonia, and pneumothorax. Whereas
placement of valves is reversible, the
placement of coils, instillation of sealant, and
ablation via bronchoscopic thermal vapor are
irreversible procedure

56. BRONCHIAL THERMOPLASTY
• Bronchial thermoplasty (BT) is a novel bronchoscopic treatment for
patients with severe asthma aiming to reduce the airway smooth
muscle mass, therefore diminishing bronchial constriction and
improving asthma symptoms
• Delivering controlled heat to the airway walls via a radiofrequency
electrical generator and a disposable catheter with an expandable
four-electrode basket at its distal tip.
• BT is performed in three bronchoscopy sessions, 2 to 3 weeks apart.
The first two sessions treat each lower lobe separately, and the third
session treats both upper lobes (the right middle lobe is not treated,
because it was not included in recent study protocols).

57. Indications and Contraindications
• BT is indicated in adult patients with severe persistent asthma
who remain symptomatic despite maximal medical treatment.
Concomitant medical conditions that can contribute to asthma
symptoms should be sought and treated before resorting to this
treatment. In addition, BT should not be used as a substitute for
medication compliance. Contraindications for BT include the
presence of an implantable electronic device, severe comorbid
conditions that increase the risk of the procedure, and FEV1 of
greater than 65% predicted. In children (age < 18 years), the
procedure has not been studied and is not approved.

59. ENDOBRONCHIAL VALVE PLACEMENT FOR
PROLONGED AIR LEAKS
• The procedure is performed under deep sedation/general anesthesia
and begins with selective balloon occlusion of the suspected airways.
• When the culprit airway is occluded, a significant reduction or
cessation of the leak can be visualized in the water-seal chamber of the
chest drainage system. A calibrated balloon is used to select the
proper-sized valve, which is then placed under bronchoscopic control.
It is common that multiple valves are used in each case because many
patients have a degree of collateral ventilation.
• After 6 weeks the valves are removed. IBV use in this patient
population has been associated with cessation of the air leak in as little
as 1 day following placement and complications can theoretically
include postobstructive pneumonia, hypoxemia, and valve migration,
these seem to be quite rare

62. THANK YOU