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![Flexible Bronchoscopy
• Topical anesthesia preferred but general anesthesia may be considered
particularly for prolonged examination.
• Most commonly used are tidocaine [2% and 4%]. Tetracaine [0.5%, 1% and 2%].
• Using nasotracheal route, nasopharynx is anesthetized using an atomized
topical agent, flexible bronchoscope passed through the nares to a level just
proximal to false vocal cords,
• when larynx is in clear view additional anesthetic is administered directly onto
vocal cords and into trachea. Bronchoscope is then passsed through glottis and
topical anesthesia instilled further down the tracheobronchial tree](https://image.slidesharecdn.com/bronchoscopy1-241027103529-7575d273/75/BRONCHOSCOPY-vjfhfhcghdgdgdhfdgddgdgfhghjgd-28-2048.jpg)
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- 5. The first illuminatedlaryngoscope introduced by Chevalier Jackson
- 13. Types of Bronchoscope •Rigid • Flexible
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- 21. INDICATIONS Diagnostic • To findout the cause for wheezing, hemoptysis or unexplained cough persisting for more than 4 weeks. • When X-ray chest shows: (a) Atelectasis of a segment, lobe or entire lung. (b) Opacity localized to a segment or lobe of lung. (c) Obstructive emphysema—to exclude foreign body. (d) Hilar or mediastinal shadows. • Vocal cord palsy.
- 22. • Collection ofbronchial secretions for culture and sensitivity tests, acid fast bacilli, fungus and malignant cells. • Mass in neck thought to be of metastatic carcinoma • Auscultatory evidence of some pathology
- 23. Therapeutic • Removal offoreign bodies. • Removal of retained secretions or mucus • Atelectasis for aspiration of tracheobronchial secretions that cannot be handled by the patient • Lung abscess • Stricture excision with laser • Removal of benign endobronchial neoplasms such as papillomas, osteochondromas/lipomas, and neurofibromas.
- 24. Other indications • Difficultintubation • Gastric aspiration • Lobar gas sampling. • When using laser photoablation, rigid bronchoscopes permit photoablation and rapid debridement of obstructing lesion while simultaneously maintaining control of airway.
- 25. Procedure Anesthesia Rigid Bronchoscopy • Performedunder general anesthesia • Anesthesia can be given using the ventilation port on the side of the bronchoscope. • Loss of tidal volume can be minimized by packing the hypopharynx with gauze or by compression of the supraglottic area by the fingers of the assistant. • Method is safe for procedures lasting not more than 20 minutes.
- 26. Position • Patient liessupine. • Head is elevated by 10–15 cm by placing a pillow under the occiput or by raising head flap of the operation table. Neck is flexed on thorax and the head extended on atlanto-occipital joint (barking-dog position)
- 27. Introduction and advancementof rigid bronchoscope
- 28. Flexible Bronchoscopy • Topicalanesthesia preferred but general anesthesia may be considered particularly for prolonged examination. • Most commonly used are tidocaine [2% and 4%]. Tetracaine [0.5%, 1% and 2%]. • Using nasotracheal route, nasopharynx is anesthetized using an atomized topical agent, flexible bronchoscope passed through the nares to a level just proximal to false vocal cords, • when larynx is in clear view additional anesthetic is administered directly onto vocal cords and into trachea. Bronchoscope is then passsed through glottis and topical anesthesia instilled further down the tracheobronchial tree
- 29. Introduction and advancementof flexible bronchoscope
- 30. Monitoring during procedure •Level of consciousness • Heart rhythm, blood pressure and other cardiac status • Oxygen saturation • Lavage volume delivered and retrived
- 31. Contraindications • inability toadequately oxygenate the patient during procedure. • Coagulopathy or bleeding diathesis that cannot be corrected. • Rigid bronchoscopy-aneurysm, marked kyphosis. • It should not be performed in patient with bilateral vocal cord paralysis, as the passage of bronchoscope through the glottis can lead to edema causing life-threatening airway obstruction. • Recent MI or unstable angina.
- 32. • Respiratory failurerequiring mechanical ventilation. • Lack of patient cooperation. • Bronchoscopy should be avoided in acute respiratory infection • Cardiac arrhythmias. • Despite the relatively low risk the benefits of performing the bronchoscopy must be weighed against the potential for complication in each patient.
- 33. Advantages of rigidbronchoscopy • Foreign body removal • Massive hemoptysis • Infant endoscopy • Dilate strictures • Tracheal obstruction • Laser bronchoscopy.
- 34. Disadvantages of RigidBronchoscopy • General anesthesia • • Cannot visualize upper lobe and distal segments for biopsy. • Peripheral biopsy of upper lobe cannot be taken
- 35. Advantages of FlexibleFiberoptic Bronchoscopy • . Patient comfort • Segmental visualization and Segmental biopsy • Peripheral biopsy • Transbronchial needle aspiration • Bedside aspiration of retained secretions • Patients on ventilator • Can bypass small stenosis and distortion • Photography • Increased cancer diagnosis • Brachytherapy.
- 36. Disadvantages of FlexibleFiberoptic Bronchoscopy • Small channel • Breakdown • Sterilization • Both flexible and rigid bronchoscopes can be used for foreign body retrieval if it is lodged in distal airway or in upper lobe bronchi
- 38. Complications and Treatment •Hypoxemia • Bronchospasm • Laryngospasm • Pneumothorax common in patients undergoing transbronchial lung biopsy
- 39. Bleeding • Topical epinephrinesolution 1: 100000 instilled into segmental bronchus. • Wedging the scope in the segmental bronchus to tamponade the lumen by clot. • Laryngospasm/subglottic edema and bronchospasm, compromise the airway in pediatric patients-humidification of supplemental oxygen and administration of systemic corticosteroids. Most other complications occur due to premedication and topical anesthesia to be used cautiously.
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Editor's Notes
- #2 The German laryngologist Gustav Killian is attributed with performing the first bronchoscopy in 1897.[1] Killian used a rigid bronchoscope to remove a pork bone. The procedure was done in an awake patient using topical cocaine as a local anesthetic.[2] From this time until the 1970s, rigid bronchoscopes were used exclusively. Victor Negus, who worked with Jackson, improved the design of his endoscopes, including what came to be called the "Negus bronchoscope".
- #4 Chevalier Jackson refined the rigid bronchoscope in the 1920s, using this rigid tube to visually inspect the trachea and mainstem bronchi.[3] The British laryngologist
- #6 A, Infant's size, 4 mm. X 30 cm.; B, child's size, 5 mm. X 30 cm.; C, adolescent's size, 7 mm. X 40 cm.; D, adult's size, 9 mm. X 40 cm.; E, aspirating bronchoscope made in all the foregoing sizes, and in a special size, 5 mm. X 45 cm
- #8 Shigeto Ikeda invented the flexible bronchoscope in 1966.[4] The flexible scope initially employed fiberoptic bundles requiring an external light source for illumination. These scopes had outside diameters of approximately 5 mm to 6 mm, with an ability to flex 180 degrees and to extend 120 degrees, allowing entry into lobar and segmental bronchi. Fiberoptic scopes have been superseded by bronchoscopes with a charge-coupled device (CCD) video chip located at their distal end.[5]
- #22 Ronchi-copd asthama cystic fibrosis
- #23 Removal of retained secretions or mucus plug in cases of head injuries, chest trauma, thoracic or abdominal surgery, or comatose patients. .Lung abscess-drainage of lung abscess, passage of brushes and biopsy forceps into abscess cavity can promote bronchial drainage
- #24 • Placement of endobronchial stents. • Inhalation of caustic fumes or smoke-it is a safe way of assessing damage to tracheobronchial tree • Surveillance biopsy in lung transplant recipients to rule out acute rejection and silent CMV pneumonia. • Interventional techniques-YAG and CO2 laser bronchoscopy. • Placement of radioactive brachytherapy.
- #28 Other methods • Topical anaesthesia sprayed into hypopharynx with atomizer. • 5 ml 4% lidocaine injected transtracheally through cricothyroid membrane; care is taken to confirm the position of the needle. • Supplemental 2% lidocaine is then instilled into tracheobronchial tree while advancing the broncho- scope.
- #33 • Massive hemoptysis should be assessed with rigid bronchoscopy immediately (600 ml in 24 hours) Airway control with rapid and repeated suctioning is readily accomplished, major bronchus can be packed with epinephrine-soaked pledget.
- #38 Hypoxemia most severe in patients with underlying lung disease-patient should receive Oxygen before and during procedure. Bronchospasm: Most severe in asthmatics; should be premedicated with corticosteroids and bronchodilators. Laryngospasm: Consequence of inadequate topical anesthesia. Therefore adequate topical anesthesia should be applied on the vocal cords. Pneumothorax common in patients undergoing transbronchial lung biopsy- to perform procedure under fluoroscopic control to prevent lung perforation.