atlas of flexible bronchoscopy

of 252 /252

Author: dennisza-kosa

Post on 29-Nov-2015

1.182 views

Category:

Documents


49 download

Embed Size (px)

DESCRIPTION

Pallav Shah md frcpConsultant Physician and Honorary Senior LecturerRoyal Brompton Hospital, Chelsea and WestminsterHospital and Imperial College London, UK

TRANSCRIPT

  • 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