Basic Instruments of Interventional Bronchoscopy

Ass. Prof. Sedat ALTINPulmonolog, interventional bronchoscopist

Rigid Bronchoscope

The newer modifications in the rigid bronchoscope have established it as the ideal instrument for debulking of large tumors in the major airways, dilatation of tracheobronchial strictures, laser bronchoscopy, insertion of airway prostheses (stents), and extraction of tracheobronchial foreign bodies.

Fiberoptic Bronchoscope

Flexible bronchoscopes with a larger working channel enable the bronchoscopist to insert larger biopsy forceps, balloon catheters, laser fibers, and other instruments into the airways to obtain larger and better-quality biopsy specimens.

Videobronchoscope

A flexible bronchoscope equipped with a charge-coupled device at its distal tip. The bronchoscopic images are digitally captured and transmitted to a video processor for display on a television monitor.

The advantage is that the excellent images can be simultaneously visualized by many, making it an excellent tool for teaching purposes. The images can also be stored in several digital formats.

Videobronchoscope

The disadvantages include the added expense of purchasing video equipment and a computer terminal, and the larger working and storage space required.

The major drawback is the loss of ability to view the image through the headpiece of the flexible bronchoscope; the bronchoscopist has to depend on the video monitor to visualize bronchoscopic findings. The image on the monitor is only as good as the monitor.

                       

                     

                                                                      

      

EndoBronchialUltraSound (EBUS)

The major advantage of this technique is the ability to visualize, via ultrasound, the extra-airway structures that cannot be seen through the bronchoscope. The major technical problem is the inability to consistently provide the coupling of the ultrasound probe to the bronchial wall to generate meaningful images of the extrabronchial structures. To overcome this, flexible bronchoscopes are being fitted with water-inflatable balloons. This will permit constant 360-degree contact between the wall of the airway and the ultrasound probe. Preliminary studies have shown the ability to identify mediastinal structures including lymph nodes, great vessels, and esophagus .The identification of lymph nodes and their relation to airways may help improve diagnostic techniques such as BNA for the diagnosis and staging of thoracic tumors.

Fluorescence Bronchoscopy

When the normal bronchial mucosa is illuminated via the bronchoscope, a higher fluorescence is observed. Mucosa containing abnormal or malignant cells produces decreased autofluorescence. This phenomenon is used to detect mucosal changes suggestive of either premalignant or malignant lesions in the airway mucosa. Mucosal changes observed by routine (white-light) bronchoscopy can be compared with those observed via green-light bronchoscopy. Early reports show that this technique, when used as an adjunct to standard bronchoscopy, may enhance the ability to localize small neoplastic lesions, especially intraepithelial lesions.

Electromagnetic Guidance System

A novel method for guiding transbronchial catheters or forceps is electromagnetic navigation. In comparison to fluoroscopy or CT scanning, electromagnetic navigation as a method not only has minimum technical and spatial requirements, it also indicates the position of the catheter in three dimensions without radiation exposure; all that it needs is the availability of a preprocedure CT data set.

Equipment & p e r s o n e l

Things to Consider

PersonelScope of practiceEquipmentSpace/unitYour financial and practice environment

Minimal equipments

Rigid bronchoscopy systemFiberoptic bronchoscopes and cold light

source/video processorPicture monitorForceps for biopsy, sitology brushes,

transbronchial needlles, baskets for foreign bodies

Cleaning/disinfection equipments

Personel

A bronchoscopist alone is not enoughNursing, ancillary help(minimal 2 nurses)Anesthesiolog, technicianGood relationships with other services

such as pathology, oncology and thoracic surgery

Requirements differ..

Equipment-Diagnostics

BasicsGood brochoscopes, at least 2 (videoscope)Processors, screens etc…. Image processingFull range of forceps, brushes and TBNA

needles

Equipment-Diagnostics

AdvancedAF if lung cancer detection programEBUSEM guidance system

SoonNBIPoss OCT

Equipment-Therapeutics

BasicsTherapeutic and thin flexible scopesChoice of thermal ablation

LaserES/APCCryotherapy

Different diameter stents

Equipment-Therapeutics

AdvancedRigid endoscopy with barrels, optics,

camera and processorPDTCollection of silicone stents

interventional bronchoscopic procedures

Complications, cautions, essential points

Procedures

Mechanical resection with rigid bronchoscopy Dilatation Laser (Nd-YAG, Nd-YAP), Cryotherapy Stent insertion Photodinamic therapy Brachitherapy Argon Plasma Coagulation Electrocautery

Conditions Required for Safety Endoscopic Treatment

Tumour must be accesible with the bronchoscope

Tumour must be spread restrictly in the bronchus and have to do not lymphangitic invasion

The lungs and the airways without stenosis must be functional

The performance of the patient must be enough good!!

Description of Common Practical Problems

Difficult airway managementBleedingIntubationIndications and contraindications Anesthesia and risk management

Which technical for which patient?

The type and the nature of stenosis The localisation of the lesion Available equipment must be preferred! The experience of the physician The condition of distal airways The cost of the technics

Factors reducing the complications

Adequate equipmentEducated personnelSufficient sterilizationGood patient selectionEnough sedation, premedication and

anesthesiaFollow-up after bronchoscopy and if

need be therapy

Rigid Bronchoscopic Procedure-Related Adverse Events

poor insertion techniques, prolonged trauma of the larynx and vocal cords, or failure to heed the warnings of hypercapnia, hypoxemia, or hemodynamic instability

Airway wall perforation posterior wall of the trachea, subglottis, and median walls of the left and right main bronchi just below the carina Luxation or laceration of the vocal cords and arytenoids

Rigid Bronchoscopic Procedure-Related Adverse Events

Other complications can be avoided by a careful inspection of the mouth. Loose teeth should not be dislodged. The gums should not be traumatized, and the lips should not be injured.

Spinal cord injuries are possible in patients with cervical spine disease and severe osteoporosis. In selected instances, these diseases are contraindications to rigid bronchoscopic intubation.

Laser Bronchoscopy Attentions

FIO2 must be kept below 40% because of the risk of endobronchial fire

Avoid curare,pavulon because of post-operative respiratory depression.

Non flammable anaesthetic gases are mandatory. An anesthesiologist experienced in the technique is important. Oximetry monitoring is mandatory. All persons in the room must wear protective glasses to avoid the

risk of laser eye injury. Plumbing- increased water for machine cooling Electrical- special generator for high power needs. RN Laser safety nurse Laser operation-fiber bundle repair Laser- $200,000maintainance- backup?

Laser Equipment

Dumon rigid laser bronchoscope with ventilating port, laser channel and suction channel.

Disposable large bore suction catheters.

Biopsy forceps with telescope.

Flexible bronchoscope. Endobrochial balloon

catheters in case of massive hemorrhage.

Laser Complications:

1. Failure to achieve an adequate airway 2. Hemorrhage usually mild and represents only a

nuisance. 3. Asphyxia 4. Tracheoesophageal fistula can occur in LMB or

tracheal lesions. 5. Mediastinal emphysema, pneumothorax. 6. Delayed hemorrhage (probably results from

necrosis of tumor that had invaded a nearby pulmonary artery)

7. Endobronchial fire 8. Eye injury to the patient or OR staff

Cryo

In addition to the equipment needed for flexible or rigid bronchoscopy, dedicated operators need different probes depending on whether the cryotherapy is delivered through the rigid or flexible bronchoscope. Generally, the area of freezing is larger and the thawing quicker with the rigid probes. The gas most commonly used in cryotherapy and the gas most commercially available is nitrous oxide.

Cryotherapy

This technique is not indicated to achieve immediate debulking of an obstructive tumor.

The tumor will be first cored out mechanically with the tip of bronchoscope after coagulation, after first this step and inthe same session cryotherapy can be applied on the remaining infitrative part of the tumor.

Well vascularized tumor such as bronchial caecinomas, carcinoids,adenoid cystic carcinomas or granulomas

In situ or microinvasive carcinomas CT is useful to remove many foreign bodies from the

airways (pills, foods, clots, peanuts; not bones, metal,or teeth)

CT is not indicated in external compression of the bronchial tree,

CT is not indicated in benign strictures of the trachea or bronchi caused by fibroma, lipomas, or post-intubation stenosis

A transient fever immediately following cryotherapy. This fever can be prevented by corticosteroid administration given during the procedure

Airway sloughing material elimination after CT remains a problem. A bronchial toilet with a flexible fiberoptic bronchoscope is usually necessary 8-10 days after CT

Cryotherapy

Cryotherapy

The equipment is less expensive and easier to use than lasers. Subjective improvements have been observed in > 75% of patients with malignant airway lesions.

Complications are few and minor. One disadvantage is the longer duration of therapy required because of the need for frequent freeze-thaw cycles. Repeat bronchoscopy is needed for continued therapy in many patients.

Advantages of Cryotherapy

high penetration depth no vaporization or

carbonization no smoke plume fixation of liquids or

tissue can also be used to treat

patients with cardiac pacemakers

no electrosurgical interference

no combustion risk mobile unit

Advantages of Cryotherapy

Better control of depth effect

Can also be used in the area of coated stents

Does not harm cartilages

Less costs approx. 7000 € /

APC & EC

a dedicated operator needs a high-frequency electrical generator in combination with insulated probes. Different types of probes in terms of shape as well as polarity (monopolar vs bipolar) are available. For patient and staff protection, proper insulation precautions need to be observed. Insulated flexible equipment is also available. For APC, a dedicated operator needs a special catheter allowing for the argon gas and the electrical current flow. This catheter is not used in electrocautery where there is direct tissue contact.

Rigid and flexible HF-contact coagulation probes

Flexible APC Probes

Rigid APC Applicators

Argon Plasma Coagulation

The indication of APC is the same as that for laser: an obstructive endobronchial lesion of airway causing symptoms such as dyspnea, cough or pneumonia

The role of APC as a cure for early stage lung cancer is not yet fully established

In addition benign polyp removal and palliative care in malignant disease, it can also be used for debridement of granulation tissue around endobronchial stents.

APC has no role in removing a foreign body, mucous plug or clot. Precautions: The power setting (<80W) and the application time

(<5 sec)should minimize the risks and keeping the argon flow rate (<2 Lpm) should lessen the chance of gas embolism

Electrocauthery

Lesions considered suitable for the procedure were required to have < 50% luminal obstruction, a visualized size that was < 2 cm in its greatest dimension, limited vascularity, and an estimated procedure time of < 1 h.

Electrocautery

The diameter of the working channel of the scope is 2.6 mm, which allows the insertion of most therapeutic accessories. An electrosurgical unit was the power source for the procedure. This unit is approximately 1 cubic foot in volume and produces the three following current modes: cut, coagulate, and blend. The endobronchial accessories consisted of polypectomy snare, coagulation probe, forceps, and a cutting blade

Complications During Electrosurgery

Bleeding Limited field of

bronchoscope view Transient

desaturation Excessive cough Endobronchial fire Electrical shock

Brachytherapy

Major complications include formation of fistulae between the airways and other thoracic structures in 6 to 8% of patients. Serious hemorrhage has been noted to occur more frequently in patients who receive high-dose radiation. The risk of massive hemoptysis increases dramatically when a fraction size of 15 Gy is used.

PDT

Complications from photodynamic therapy include sunburn involving skin exposed to bright light, hemoptysis, and expectoration of thick necrotic material.

Jean-François Dumon, MD, FCCP

‘’Various types of airway stents available to treat airway stenoses. There is no ideal stent.’’

Stent indications

Inoperable, symptomatic lung cancer•  Primary airway tumours•  Oesophageal cancer•  Thyroid cancer•  Head and Neck tumours•  Metastases•  Postintubation and idiopatic benign tracheal stenosis•  Inflammatory lesions•  Tracheobronchial malacia•  Vascular compression

Stents

Complications seen with silicone stents include migration of stent and inspissation of thick mucous within the stent lumen. Metallic stents seem to promote growth of granulation tissue, which makes it difficult to remove and replace the stent. Uncovered metallic stents should not be inserted in patients with malignant airway lesions because the growth of cancer through the wire mesh negates the benefits of stent placement.

Commercial stents

Stent Type

Manufacturer 

Construction Sizes (mm) 

Dumon  Novatech Molded silicon rubber  9 x 20 – 18 x 70 +

Y 

Hood   Hood Corp. Molded silicon rubber  6 x 13 – 18 x 70 +

Y 

Wallstent  Boston

Scientific 

Woven cobalt/chrome alloy monofilament coated with silicone 

8 x 20 – 24 x 60 

Polyflex   Rush Inc.  Polyester mesh covered with

silicone  6 x 20 – 22 x 80 

Ultraflex  Boston

Scientific 

Single strand woven nitilol With/without silicone coating

8 x 20 – 20 x 80 

Dynamic  Rush Inc.  Silicone with anterolateal

steel struts  13, 15, 17

(trachea) 

Bronchoscopic Needle Aspiration

Complications are rare and include pneumothorax and hemomediastinum. Serious bleeding is seldom encountered. More commonly, inadvertent passage of the needle through the wall of the working channel of the flexible bronchoscope leads to expensive damage to the inner lining of the bronchoscope.

Hazards & Problems

Areas of Potential Damage to the FOB

Improper handling Procedural

TBNA Nd-YAG laser photoresection Electrosurgery Radiation Use of lubricants

Patient related Cleaning and maintenance

Ethylene oxide gas sterilization

Damage of the FOB

An educational program was effective in dramatically decreasing the costs of equipment repair after initiating an interventional pulmonology program.

This is the first study to offer budgetary guidelines for equipment repair in an IP program and to demonstrate that an educational program can effectively reduce costs.

Lunn W et al. Chest 2005;127: 1382-1387

Improper Handling

Care must be taken not to allow the distal end of the instrument to strike a hard surface.

Forced angulation or twisting the body of scope may damage its quartz filaments.

Rotation of the body of the scope should be performed by flexing or extending the wrist

Procedural-TBNA

Improperly usedNonretractable TBANThe diameter of the working channel of

the FFBTBAN should be used only by or under

the supervision of experienced bronchoscopist

Procedural-Nd-YAG Laser

Indications: Exophytic, intraluminal, proximal airway lesions that cause symptoms such as hemoptysis, cough, dyspnea, difficulty clearing secretionsor postobstructive pneumonia

Precautions: During laser firing the fraction of inspired oxygen should be kept below 40 percent,

Flammable materials should be kept far away from the operating field and silicone stents should be removed prior to laser firing

The laser should always be placed on standby mode when tissue is removed from the bronchoscope

Power settings greater than 40 watts are never necessary

Procedural-Electrocautery

Airway obstruction caused by bronchogenic carcinoma is the most common indication

Precautions: The power setting (<80W) and the application time (<5 sec)should minimize the risks, like APC

Radiation

Yellowish discloration and darkening of both the fiber bundles and the visual image

FFB should not be syored in areas where fluoroscopy is performed

Use of Lubricants

A water-soluble lubricant should be used to lubricate

Petroleum-based products should be avoided, because may cause premature wear streching and deterioration of the rubber sheath of the FFB.

Patient-Related Damage

Incooperated patientSupine position might lead to grabbing or

pulling the fiberscope by the patient.Mouthpiece must be used the transoral

approach.The patient’ teeth with damage to the

fiber bundles.

Disinfecting in the morning

….the safest practice is to terminally disinfect (endoscopes) at the end of each day’s use, and again before the first and each subsequent use throughout the next day.

The recommended reprocessing steps include

Preprocessing and leak testing the endoscope,

Cleaning the endoscope and each of its components

Disinfecting and rinsing the endoscope with clean water

Drying the endoscope before storing by rinsing its cannnels with 70% alcohol followed by forced-air

Properly handling and storing the endoscope

Bronchoscope Damage

Positive leak test result. Air bubbles emitting from the surface of the bronchoscope indicate a breach in its exterior.

Cleaning

PrecleaningMechanical CleaningDisinfectionPostprocessing procedure

Precleaning

The three most important rules of any effective reprocessing are: clean it clean it CLEAN IT!

If an item cannot be cleaned, it cannot be disinfected or sterilised.

Precleaning

In the examination room immediately after the procedure:

1. Wipe the insertion tube with a disposable cloth dampened in an enzymatic detergent solution.

2. Aspirate enzymatic detergent solution through the suction/biopsy channels

3. Purge air/water channels. 4. Detach removable components

Mechanical Cleaning

1. Make up enzymatic solution 2. Immerse instrument 3. Disassemble removable parts and

clean 4. Brush and wipe exterior 5. Brush all channels

Cleaning

ENZYME SOLUTIONS DETERGENTSULTRASONIC CLEANING

Cleaning & Maintenance

Hand antisepsis plays a significant role in preventing nosocomial infections. When outbreaks of infection occur in the perioperative period, careful assesment of the adequacy of hand hygiene among operating room personnels recommended.

Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with persistent activity is recommended before donning steril gloves when performing surgical procedures.

Bronchoscope disinfection

Rigorous procedures should be applied

Double mechanical washing and brushing before an automated washer disinfector cycle

Duration: 40 to 45 minute Continuous monitoring at

each step Glutaraldehyde is replaced

now by peracetic acid

Automatic flexible endoscope reprocessors (AFERs)

The potential advantages of AFERs include:

Standardisation of endoscope reprocessing.

Reduced exposure of HCWs to hazardous chemicals.

Reduction of staff time spent on reprocessing.

Major Sources of Contamination

Ineffective cleaningInadequate cleaningDamaged internal channelSuction channelBiopsy port Sample collection tubing

Bronchoscopy-Related Pseudoinfections

Mycobacterium chelonea, gordonae, abscessus, tuberculosis

Pseudomonas aeruginosa, Serratia marcescensFungi (Rhodotorula rubra, etc)

Bronchoscope storage

After drying bronchoscopes should be stored in special cupboards horizontally or better vertically.

Do not store bronchoscopes in transport luggage

a new cycle in the automated washer disinfector is required after storage before the bronchoscopy.

Staff safety

During bronchoscopy staff should wear gloves, protective clothing, masks and visors

Bronchoscopes should be disinfected in a dedicated, ventilated room.

Staff safety

THANK YOU FOR YOUR ATTENTION