fiberoptic bronchoscopy - airway securing FOI

1.  Dr.zikrullah mallick

Fiberoptic
Bronchoscopy

2. Endoscopy
 Procedures that look into the body’s tubes and
cavities
 Colonoscopy
 Esophagoscopy/Gastroscopy
 Bronchoscopy
 Used to diagnose various diseases and explain
conditions

3. Bronchoscopy
 Allows visualization of the airways (tracheobronchial
tree)
 Performed to diagnose problems with the airway or
treat problems such as an object or growth in the
airway

4. Equipment
 A bronchoscope is an instrument about 3ft long and 0.5
ins or smaller in diameter that combines four narrow
chambers into one tube
 One lumen contains a fiber-optic light source so that structures can
be viewed effectively
 2nd chamber lumen is attached to a suction device & airway
secretions can be removed
 3rd chamber has tiny metallic alligator forceps that can be extended
past the proximal end for tissue biopsies
 4th chamber lumen allows passage of a small wire brush that can be
passed vigorously over airway structures for collection of tissue
cells for microscopic evaluation

5. Figure 4-4 Flexible fiberoptic bronchoscope. The four channels consist of two that
provide a light source, one vision channel, and one open channel that
accommodates instruments or allows administration of an anesthetic or oxygen.

9. TYPES
 Flexible or Rigid
 Adult sizes
 5.0 mm OD to 6.0 mm OD
 Pediatric sizes
 Most manufacturers provide scopes in sizes 3.5 mm OD
or less appropriate for children. No channel outlet may
exist for suctioning because of its small size

10. Scopes
 Rigid bronchoscope  Flexible Fiberoptic
Scopes

11. Procedure
 Topical anesthetic (lidocaine) is administered to control
gag/cough reflex and prevent bronchospasm
 5 – 10 cc 4% lidocaine aerosolized to upper airway
delivered by a mask nebulizer
 Benzocaine nasal sprays
 2% lidocaine instilled into the hypopharynx in 2 cc
incements
 Intubation preferred but not required. Intubation will not
allow visualization of the vocal cords
 Scope is inserted and the airways viewed
 O2 needs to be provided to patient via mask or by
removing one prong of the nasal cannula from the nose to
allow for insertion of the scope

12. Procedure
 Diagnostic and/or therapeutic procedures are performed
 Intubated patients on vents need special adapters for
advancement of the scope. Adapter should allow for:
 No loss of ventilating pressures
 No loss of PEEP
 Continuous monitoring of EKG and O2 saturation by
pulse oximeter is recommended
 Equipment is cleaned by decontamination with alkaline
glutaraldehyde

14. Rigid bronchoscopy
 Diagnostic use
 Biopsy of tumors within the main airway
 Therapeutic use
 Treatment of massive hemoptysis by cold-saline lavage or placement
of Fogarty catheter to occlude the airway
 Removal of foreign bodies in infants and small children
 Aspiration of inspissated secretions
 Limitations
 observing or treating beyond the right or left mainstem bronchus
trauma of cervical spine who cannot hyperextend neck
 trauma of jaw who cannot open their mouth wide

17. Indications
 Diagnostic
 Suspected foreign body
 Suspected malignancy
 Bronchial washings
 Hemoptysis
 Persistent problems
 Therapeutic
 Foreign-body obstruction
 Secretion removal
 Bronchial lavage
 Stenosis
 atelectasis

18. Other indications
 Abnormal CXR
 Excessive bronchial
secretions
 Acute smoke inhalation
injuries
 Hemoptysis
 Pneumonia
 Unexplained Cough
 Tracheal disease, stridor
and localized wheezing
 Intubation damage
 Atelectasis
 Laser excision
 Removal of foreign
bodies
 Lung lavage
 Difficult intubations
 Suctioning of excessive
secretions, mucus
plugs
 Selective lavage
 Management of life
threatening hemoptysis

19. USES
 Direct visualization of the
tracheobronchial tree for
abnormalities (e.g., tumors,
inflammation, strictures)
 Biopsy of tissue from
observed lesions
 Aspiration of “deep” sputum
for culture and sensitivity
and for cytologic
determinations
 Direct visualization of the
larynx for identification of
vocal cord paralysis, if
present. With pronunciation
of “eeee” the cords should
move toward the midline.
 Aspiration of retained
secretions in patients with
airway obstruction or
postoperative atelectasis
 Control of bleeding within
the bronchus
 Removal of foreign bodies
that have been aspirated
 Brachytherapy, which is
endobronchial radiation
therapy using an iridium
wire placed via the
bronchoscope
 Palliative laser
obliteration of bronchial
neoplastic

20. Flexible bronchoscopic view of a large foreign body (a Lite-Brite peg) lodged in the right main
bronchus of a 7-year-old boy (left, A)
Swanson K. L. et.al. Chest 2002;121:1695-1700
©2002 by American College of Chest Physicians

21. BAL
 Tip of the scope is wedged into the bronchus
 Aliquots of sterile saline are instilled in to flood the
alveoli
 A little more than half of the lavage is suctioned back
to into a collection chamber
 Fluid contains cellular debris, microorganisms used
for diagnosis

22. Interventional Bronchoscopy
 Laser Therapy
 Thermal tissue damage to
destroy obstructing
lesions
 Saline lavage to clean
debris
 Cryotherapy
 Tissue destruction via
intracellular freezing
 Bronchogenic carcinomas
 Stents
 Tracheobronchial
prostheses
 May require opening the
airway with other
techniques prior to
placement

23. Fiberoptic Bronchoscopy in the ICU

24. Introduction: Spectrum of Pulmonary
Disease in the ICU
 Pneumonia- community or nosocomial
 Pulmonary edema- cardiogenic or noncardiogenic
 Pulmonary hemorrhage ± hemoptysis
 Thromboembolic disease
 Primary or metastatic CA
 Interstitial lung disease
 Obstructive airway disease
 Respiratory failure in any of above requiring
intubation and mechanical ventilation (MV)
 Complications of intubation and MV

25. Introduction: Flexible Fiberoptic
Bronchoscopy (FFB)
 Essential diagnostic and therapeutic tool in
ICU
 Can be performed via endotracheal tube
(ETT) or tracheostomy tube
 Bedside procedure: avoids transport/ OR
time

26. Common Diagnostic ICU Indications for
FFB
 Inspection, bronchoalveolar lavage (BAL),
transbronchial lung biopsy (TBBx)
 Abnormal chest X-ray/ suspected pulmonary
infection
 Hemoptysis
 Lung carcinoma/ obstructing neoplasm
 Chemical or thermal burns
 ETT assessment/ management:
intubation/extubation assist, position/ injury
evaluation

27. Feng A, Sy E. A Lung Saddle Tumor. The Internet Journal of Pulmonary
Medicine 2009 : Volume 11 Number 1
Elderly patient admitted with respiratory failure.
Bx= Squamous cell Ca

28. Common Therapeutic ICU Indications for
FFB
 Retained secretions/ atelectasis
 Mucous plugs- bronchial asthma, cystic fibrosis
 Hemoptysis/ blood clots
 Drainage lung abscess
 Debridement of necrotic tracheobronchial mucosa
 Dilation airway stenosis/ strictures

29. FFB in Pulmonary Infiltrates
 Usually to evaluate infectious process
 Allows directed sampling, identification of
pathogens, de-escalation of antibiotics
 BAL 10-50,000 CFU on culture diagnostic
 protected specimen brush 5-10,000 CFU diagnostic
 Potential for identification of noninfectious
processes

30. Cos J, Sy E, Diaz-Fuentes G, Menon L. Foreign body presenting as a persistent lung infiltrate. The
IJPM 2009 : Volume 11 Number 1
After removal of foreign body

31. FFB in Retained Secretions and Atelectasis
 FFB vs. physiotherapy for retained secretions: no superiority
demonstrated
 FFB in atelectasis:
 retained secretions and air bronchograms to segmental level only
 lobar or greater atelectasis not responding to aggressive chest PT
 life threatening whole lung atelectasis
 Severe hypoxemia not contraindication
 Expect improved A-a gradient, static compliance

32. FFB: Complications
 Premedication/ local anesthesia: respiratory
depression/ arrest, methemoglobinemia, death
 Procedure related: hypoxemia, cardiac
complications, pneumonia, death
 Ancillary procedures: barotrauma, pulmonary
hemorrhage, death

33. Complications: Hypoxemia
 Common: up to 2 hrs. post procedure: 20-30 mmHg
O2 drop in healthy, 30-60 in critically ill
 Reduction in effective tidal volume and FRC
 Suction at 100mmHg via 2mm suction port removes
7L/min
 Saline/lidocaine instillation

34. Complications: Cardiac
 Hypoxemia, hypercapnea increased sympathetic
tone arrhythmias, ischemia, hypotension death
 Major arrhythmias in 11%
 Unstable angina, severe preexisting hypoxemia risk
factors
 Hemodynamics: 30% MAP, 43%HR, 28% CI

35. CXR after difficult intubation. Septic shock with MOD and AIDS

36. Daniel V, DeLaCruz A, Diaz-Fuentes G. Tracheal Laceration Due to Endobronchial
Intubation. Journal of Respiratory diseases. June 2007:15-17

37. FFB in MV: Physiology
 Standard ED 5.7mm scope occludes 10% cross
sectional area of trachea, 40% 9mm ID ETT, 51%
8mm ID ETT, 66% 7mm ID ETT
 Hypoventilation, hypoxemia, gas trapping/ high
intrinsic PEEP
 8mm ID ETT for standard scope recommended
 Ultrathin bronchoscopes (2.8mm): reduce potential
for hypoxemia/hypercapnea, dynamic hyperinflation

38. FFB in MV: Increased Complication Risk
 Pulmonary:
 PaO2< 70mmHg with FiO2> 0.7
 PEEP> 10 cm H2O
 autoPEEP > 15 cm H2O
 active bronchospasm
 Cardiac:
 recent MI (48 hrs.)
 unstable arrhythmia
 MAP < 65mm Hg or vasopressor
 CNS:
 increased intracranial pressure

39. Potential Complications
 Fever
 Bronchospasm
 Hemorrhage (after
biopsy)
 Hypoxemia
 Pneumothorax
 Infection
 Laryngospasm
 Aspiration
 Cardiac arrest –
arrhythmias
 Respiratory depression
 Hypotension
Age-Related Concerns
 Children have a smaller
bronchus. The
bronchoscope can
significantly decrease
the available space for
them to breathe. They
are at higher risk of
hypoxemia than adults.

40. REFERANCES
1 Ahmad M. Bronchoscopy: current status and future prospects. In: Wang KP, Mehta AC,
eds. Flexible bronchoscopy.
Cambridge, MA: Blackwell Science, 1995:3–5
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531
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8 Stringfield JT, Markowitz DJ, Bentz RR, et al. The effect of
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41.  Thank you