AtlasofFlexibleBronchoscopy

Iwouldliketodedicatethisbooktomyfamilyforalltheirsupportandencouragementdespitetheendlesseveningsandweekendsspentonthisbook.Aspecialthankstomywife,Malawhocreatedsomeoftheinitialanatomicaldrawingforthisbook.

AtlasofFlexibleBronchoscopy

Pallav Shah md frcpConsultantPhysicianandHonorarySeniorLecturerRoyalBromptonHospital,ChelseaandWestminsterHospitalandImperialCollegeLondon,UK

FirstpublishedinGreatBritainin2012byHodderArnold,animprintofHodderEducation,anHachetteUKcompany,338EustonRoad,LondonNW13BH

http://www.hodderarnold.com

2012PallavShah

Allrightsreserved.ApartfromanyusepermittedunderUKcopyrightlaw,thispublicationmayonlybereproduced,storedortransmitted,inanyform,orbyanymeanswithpriorpermissioninwritingofthepublishersorinthecaseofreprographicproductioninaccordancewiththetermsoflicencesissuedbytheCopyrightLicensingAgency.IntheUnitedKingdomsuchlicencesareissuedbytheCopyrightLicensingAgency:SaffronHouse,610KirbyStreet,LondonEC1N8TS.

Whilsttheadviceandinformationinthisbookarebelievedtobetrueandaccurateatthedateofgoingtopress,neithertheauthornorthepublishercanacceptanylegalresponsibilityorliabilityforanyerrorsoromissionsthatmaybemade.Inparticular,(butwithoutlimitingthegeneralityoftheprecedingdisclaimer)every effort hasbeenmade to checkdrugdosages; however it is still possible that errors havebeenmissed.Furthermore,dosageschedulesareconstantlybeingrevisedandnewsideeffectsrecognized.Forthese reasons the reader is stronglyurged to consult thedrug companiesprinted instructionsbeforeadministeringanyofthedrugsrecommendedinthisbook.

British Library Cataloguing in Publication DataAcataloguerecordforthisbookisavailablefromtheBritishLibrary

Library of Congress Cataloging-in-Publication DataAcatalogrecordforthisbookisavailablefromtheLibraryofCongress

ISBN-13 978-0-340-96832-1

12345678910

Publisher : CarolineMakepeaceEditorialManager: JoannaSilmanProductionController : KateHarrisCoverDesign: HelenTownson

CoverimageKrishnacreations/Fotolia

Typesetin11/13ptGillSansLightbyPhoenixPhotosetting,Chatham,KentPrintedandboundinIndiabyReplicaPress

Whatdoyouthinkaboutthisbook?OranyotherHodderArnoldtitle?Pleasevisitourwebsite:www.hodderarnold.com

vContentsPreface vii

1 Introduction 1

2 Bronchopulmonarysegments 11

3 Normalanatomy(anteriorapproach) 28

4 Normalanatomy(posteriorapproach) 53

5 Vascularrelationshipsandlymphnodestations 78

6 Transbronchialfine-needleaspiration(anteriorapproach) 94

7 Transbronchialfine-needleaspiration(posteriorapproach) 113

8 Endobronchialultrasoundbronchoscopy 133

9 Pathology 158

10 Fluorescence-basedimaging 164

11 Electromagneticnavigation 172

12 Intubationandmanagementofairwayhaemorrhage 189

13 Endobronchialtumourdebulking 202

14 Stents 211

15 Bronchoscopictreatmentforemphysemaandasthma 220

Index 238

This page intentionally left blank

vii

Preface Strivingforexcellenceinthecareofourpatients.

My ambition for this book is to provide a simple step wise approach to flexiblebronchoscopy. I have linked gross anatomywith the radiology and correlated it tothebronchoscopicfindingsandview.Thisapproachshouldassistthebronchoscopistwithbothdiagnosticandtherapeuticprocedures.Safepractice isalsoofparamountimportanceandisakeythemethroughoutthisbook.

This page intentionally left blank

1CHAPTER

1Introduction

Bronchoscopyhasbecomeanessentialtoolfortherespiratoryphysician.Theoriginalfibreopticbronchoscopeswereprimarilyutilized for visualizing theairwaysandalsoforsampling.Themodernvideobronchoscopesprovidehigh-definitionimagesoftheairwayssothatevensubtlelesionsarerecognized.Theprocedurehasalsoexpandedfromsimplediagnosticprocedurestotherapeuticprocedures.Thedevelopmenthasseenthetherapeuticcapabilitiesprogressfrompalliativetreatmentofendobronchialtumourstoasthmaandemphysema.

EquipmentThebronchoscopeisessentiallyaflexibletubeconsistingoffibreopticbundles,channelsfor instrumentsandanumberofwires formanipulating thedistalend.Thebundlesofoptical fibres carry light to thedistal end inorder to illuminate theairways, andfurtherbundlestransmittheimagebacktotheeyepiece(Fig.1.1).Themodernvideobronchoscopes have a charge-coupled device (CCD) chip at the distal endwhichcaptures the image and is subsequently transmitted to the monitor (Figs 1.21.4).Theresolutionoftheimageisexcellentandcontinuestoimprove,withsomescopesprovidingveryhigh-definitionimageswithdigitalmagnificationoptions.Therearealsohybriddevicesforspecialcircumstances,whichusethefibreopticbundletotransmittheimagebacktowardstheheadofthebronchoscope.Inthiscase,theCCDislocatedat the head of the bronchoscope,which then transmits the image to themonitor.The hybrid setup allows the space of the chip at the distal end to be utilized for

Fig.1.1Fibreoptic bronchoscope with eyepiece.

Fig.1.2Video bronchoscope.

2otherpurposes,i.e.largerinstrumentchannels,dualchannelsorsimplytofacilitatethemanufactureofslimmerbronchoscopes.

Thedistalendof thebronchoscopecanberotatedthrough160bya leverat theendofthescope.This,incombinationwithmanualrotationofthescope,allowsittobemanipulatedduring examinationof the airways.Thenew rangeof scopes beingdevelopedalsohavearotatingfunctionwiththeabilitytolockthedegreeofrotationin a specific position.This development increases the range of movement of thebronchoscopeandfacilitatesaccesstosomeoftheareasinthelung.

Awiderangevarietyofbronchoscopesareavailablewithdifferentexternaldiametersrangingfrom2.2to6.3mm(Fig.1.5).Theinstrumentchannelsandthequalityofthevideochipandimagesalsovaryaccordingly(Fig.1.6).Astandardbronchoscopeshouldbeabletoundertakethemajorityoftasks(goodCCD,instrumentchannelofatleast2.2mmandexternaldiameterofabout4.6mm).Slimmerbronchoscopescanallowforsmallerairwaystobeinspectedandsampled.Anultra-finebronchoscopecanexaminemuchsmallerairwaysbutcanalsofacilitateotherproceduressuchasinsertionofstentsetc.underdirectvision.Alargerbronchoscopewithalargeinstrumentchannelwouldbemoreappropriateforinterventionalprocedureswherealargechannelforsuctionandintroductionofinstrumentsisrequired.Bronchoscopeswithabuilt-inlineararrayultrasound probe are also availablewhich allow sampling of lymph nodes and lungmassesadjacenttothecentralairways(Fig.1.7).

Fig.1.3Distal tip of a video bronchoscope showing the instrument channel, fibreoptics and charge-coupled device video chip.

Fig.1.4Video bronchoscope with connections to image processor and light source.

3DisinfectionManualcleaningofthebronchoscopeisanessentialstep,asanybiologicaldebrisleftbehindwouldnotbeadequatelysterilizedbyanydisinfectantliquid.Thesuctionpartsand instrumentchannelsaresusceptibleareaswheredebrismaynotbecompletelyremovedandcanthenbecomecolonizedbybacteria.Manualcleaningwithabrushisthemostimportantfirststepandthisisusuallyfollowedbyautomaticdisinfection.Instrumentsareplaced inspecializedwashersandcleanedwithdisinfectionsolutionsuchas0.2percentpara-aceticacid.Themethodofdisinfectinginstrumentsbyhandandplacingtheminadisinfectionsolutionsuchas2percentalkalineglutaraldehydeisbeingphasedoutduetotheriskstostafffromoccupationalexposuretothefumesfromthecleaningliquids.Mostmodernsystemscancleanseveralscopesinonecycleandawashcycleusuallylasts40minutes.

Cross-infectionhasbeenobservedwithorganismssuchasenvironmentalMycobacteriumandPseudomonasspecies.Henceprocessesshouldbeinplacetoensurethatrecordsofdisinfectionbeforeuseinapatientandtheserialnumbersofbronchoscopesusedinindividualpatientsaremaintained.Thisisessentialfortracingpatientsintheeventofsuspectedcross-infection.Again,inthemajorityofcases,inadequatemanualcleaningofthebronchoscopes,particularlyofthesuctionportshasbeenakeyfactor.

Biopsyforcepsandneedlesaremoreinvasiveandhenceneedtobesterilizedratherthansimplydisinfected.Thepotentialriskofinfectionwithvirusesandprionshasdriven

Fig.1.5Distal portion of a number of bronchoscopes showing the variety of instruments available with differing external diameters and functional characteristics.

Fig.1.6Two bronchoscopes with different sizes of the charge-coupled device video chip, and instrument channel.

Fig.1.7Distal tip of the linear array ultrasound bronchoscope.

4thedevelopmentofsingle-usedisposableinstruments.Hence,inmostbronchoscopyunits,thebiopsyforceps,transbronchialaspirationneedlesandsoonarenowdisposablesingle-useinstruments.Bronchoscopesthatcanbesterilizedratherthandisinfectedarealsoindevelopment,whichwouldfurtherreducetheriskfromprions,butthesewouldrequiremostbronchoscopyunitstosignificantlyincreasethenumberofinstrumentstheyhaveinordertomanageabronchoscopylist.Single-usebronchoscopesarealsoindevelopmentwhichemployLEDlightsourcesandsmalldistalchipswithinasimpleplastictubing.However,thusfartheyhavelimitedfunctionality.

IndicationsThemain indications forflexiblebronchoscopyare listed inBox1.1.Suspected lungcanceristhemajorindicationforbronchoscopyfollowedbytheassessmentofpulmonaryinfiltratesformicrobiologicalsampling.Traditionallybronchoscopywasconductedfordiagnosticpurposesbuttheroleof therapeuticbronchoscopy is increasingwiththedevelopmentofnewendoscopictreatmentsforrespiratorydiseases.

BOX1.1Indications for bronchoscopy

Investigationsofsymptoms haemoptysis persistentcough recurrentinfection

Suspectedneoplasia unexplainedparalysisofvocalcords stridor localizedmonophonicwheeze segmentalorlobarcollapse assessmentofnodulesormassesidentifiedonradiology unexplainedparalysisofhemi-diaphragmorraisedrighthemi-diaphragm suspicioussputumcytology unexplainedpleuraleffusions mediastinaltissuediagnosisandstaging assesssuitabilityforsurgery stagingoflungcancer

Infection assessmentofpulmonaryinfiltrates identificationoforganisms evaluateairwaysifrecurrentorpersistentinfection clinicalorradiologicalfeaturesofenvironmentalmycobacterialinfection

Diffuselungdisease differentialcellcountsandcytology transbronchiallungbiopsy

Therapeutic clearanceofairwaysecretions recurrentmucouspluggingcausinglobarcollapseandatelectasisinpatientsonmechanicalventilators

foreignbodyremoval palliationofneoplasm endobronchialablationoftumour(cryotherapy,electrocautery,laser) insertionofairwaystents insertionofbrachytherapycatheters insertionoffiducialmarkersforthegamma/cyberknife bronchoscopiclungvolumereduction bronchialthermoplastyforasthma treatmentofbronchopleuralfistula

5ContraindicationsFailure of the patient or their representative (in special circumstances) to provideconsent isacontraindication,andwrittenconsent isrequiredbeforetheprocedure.Themaincontraindicationsforbronchoscopyarehypoxiathatcannotbeadequatelycorrectedbyoxygensupplementationandableedingdiathesis.However,eveninthesecircumstances, firm cut-offs are not given as the riskbenefit should be evaluatedon an individual-patient basis. Full resuscitation equipment should be available inthebronchoscopy suite and the staff should have the appropriate level of skill andexperiencetodealwithanypotentialcomplications.Theseincluderespiratoryfailure,cardiacarrhythmias,haemorrhageandintercostaldraininsertion.

PatientpreparationAllpatientsneedtoprovideinformedconsentpriortotheprocedure.Theyshouldbeprovidedwithwritteninformationinadvanceoftheprocedureandthekeyaspects,such as risks of the procedure and alternative approaches, should be discussedbeforefinalconsent.Theprocedureisusuallyperformedonanoutpatientbasiswithconscioussedation.Patientsshouldbeadvisednottoeatforatleast6hoursbeforetheprocedurebuttheymaybeallowedtodrinkwaterforupto2hoursbeforetheprocedure.Box1.2providesasimplechecklist forpatientpreparationprior totheprocedure.

BOX1.2Preparation for bronchoscopy

Patientinformationverbalandwritten Fullbloodcountandclottingpriortotransbronchiallungbiopsyandinterventionalproceduressuchastumourablation

Informedconsent Spirometryifoxygensaturations