1 CURRENT PLACE OF BRONCHOSCOPY IN THE DIAGNOSIS OF PULMONARY DISEASES Jana Skřičková Dept. of Pulmonary Diseases and TB Masaryk University Faculty of Medicine University Hospital Brno 2 GUSTAV KILLIAN father of bronchoscopy n1897 – removal of a rabbit bone from the right main bronchus in a Schwarzwald lumberman n''I think I've made an important discovery... bronchoscopy will be essential not only for removal of foreign bodies and evaluation of bronchial disease, but also for diagnosis and treatment of pulmonary diseases.'' - Heidelberg congress, 1898 3 One of the earliest bronchoscopies 4 RIGID BRONCHOSCOPY 5 FLEXIBLE BRONCHOSKOPE with a protruding forceps 6 THE TIP OF THE FLEXIBLE BRONCHOSCOPE with protruding brush 7 VIDEOBRONCHOSCOPE 8 BRONCHIAL BRANCHING 9 DIAGNOSTIC BRONCHOSCOPY nEstablishing diagnosis in primary and secondary tumours, treatment decisions nDiagnosis of infectious complications nDiagnosis of interstitial pulmonary diseases and sarcoidosis nDiagnosis of treatment complications nDifferential diagnosis of COPD and asthma (under certain circumstances) nSymptoms with unknown etiology – cough, dyspnea, unilateral auscultatory finding, hemoptysis... nSuspect trauma or communication 10 CONTRAINDICATIONS of DIAGNOSTIC BRONCHOSCOPY nCritical state of the patient – knowledge of etiology would neither help proper treatment nor delay death nBleeding not manageable with relevant treatment nRecent myocardial infarction nSevere or recent heart rhythm disorders nHypoxemia <6kPa despite oxygen treatment 11 RELATIVE CONTRAINDICATIONS OF BRONCHOSCOPY nBronchial obstruction, bronchial hyperreactivity, unstable angina pectoris, uremia In polymorbid patients, continuity with acute labs, cardiology, ICU, inhalation, monitoring, availability of necessary drugs and tools is essential. 12 Measures recommended when performing bronchoscopy nHeart rhythm monitoring with a cardiac monitor nContinual monitoring of oxygen saturation using pulse oximeter nCoagulation status – prior to therapeutic procedures and biopsy 13 CHOICE OF BRONCHOSCOPE – RIGID x FLEXIBLE nDiagnostic bronchoscopy – mostly flexible nCharacter of the x-ray finding (suspicion of lymph node involvement) – rigid bronchoscopy nA larger sample necessary – rigid nBronchoscopist, nurse, rigid instrument set available, sufficient experience (number of procedures), anaesthetist available, ICU bed available 14 CHOICE OF BRONCHOSCOPE – RIGID x FLEXIBLE nTherapeutic bronchoscopy – rigid nRigid bronchoscopy – patient positioning in recumbent position nFlexible – recumbent or sitting depending on the usage and the planned procedure) Bronchoscopist, nurse, rigid instruments set available, sufficient experience with rigid bronchoscopy (number of procedures), anaesthetist available, ICU bed available 15 MATERIAL SAMPLING DURING RIGID BRONCHOSCOPY nForceps biopsy – larger amount of material nTransbronchial needle aspiration from lymph nodes and lesions outside the airway wall nLavage 16 RIGID BRONCHOSCOPE ADVANCING THROUGH THE GLOTTIS BETWEEN THE VOCAL CORDS 17 SAMPLING OF MATERIAL IN THE COURSE OF FLEXIBLE BRONCHOSCOPY qForceps biopsy (excision) – endobronchial growth, mucosal infiltration qTransbronchial lung biopsy – from the periphery of bronchial tree, under radiography guidance, multiple samples qCryobiopsy qBrush biopsy (brushing, abrasion) qTransbronchial punction – extramural pressure – lymph nodes, other pathologic process qSufficient accessories, mobile x-ray, topical radiographic documentation (electronic...) 18 SAMPLING OF MATERIAL IN THE COURSE OF FLEXIBLE BRONCHOSCOPY qPunction of the tumour qAspiration with plastic catheter qBronchial lavage (10 - 20 ml) – optionally after brush abrasion qBronchoalveolar lavage – optionally following brush abrasion (150 ml and more) qAccessories, laboratory background, knowledge of the procedure and interpretation 19 SAMPLING OF MATERIAL IN THE COURSE OF FLEXIBLE BRONCHOSCOPY IN A SETTING OF SUSPICION OF CANCER 20 THE TIP OF FLEXIBLE BRONCHOSCOPE with ACCESSORIES (FORCEPS, LOOP SNARE) 21 INDICATION OF DIAGNOSTIC BRONCHOSCOPY ON SUSPICION OF LUNG CANCER nPersistent cough, change in the character of cough nStridor nUnexplained unilateral auscultatory finding nPathological finding on chest radiograph nPersistent pneumothorax Cooperating pulmonologist, general practioner, internist, surgeon, intensivist... 22 INDICATION OF DIAGNOSTIC BRONCHOSCOPY ON SUSPICION OF LUNG CANCER nElevated diaphragm nHemoptysis nPresence of malignant cells in sputum (chest radiograph being negative) nRecurrent pneumonia in the same area Cooperating pulmonologist, general practioner, internist, surgeon, intensivist... 23 INDICATION OF DIAGNOSTIC BRONCHOSCOPY ON SUSPICION OF LUNG CANCER nSuperior vena cava syndrome nPersistent hoarseness nPersistent pain radiating into the upper extremity and neck nNew pulmonary symptomatology in the course of treatment nCooperating pulmonologist, general practioner, internist, surgeon, intensivist... 24 > Spiculation MALIGNANCY PERIPHERAL TUMOUR 25 BRONCHIAL BRANCHING – NORMAL FINDING 26 SAMPLING OF MATERIAL IN CASE OF NORMAL ENDOSCOPIC FINDING IN A SETTING OF URGENT RADIOLOGIC SUSPICION OF CANCER nBrush abrasion from the suspect area according to chest radiograh (lateral film indispensable, CT) nAspiration nLavage nBAL nRadiologically guided transbronchial lung biopsy nTransbrochial cryobiopsy nEBUS nRadial EBUS nAcute radiodiagnostic examination (mobile x-ray) 27 NSCLC (squamous cell carcinoma) of right lung's upper lobe 28 NSCLC (squamous cell carcinoma) of left lung's upper lobe 29 SMALL CELL CARCINOMA OF THE LEFT LUNG 30 BRONCHOSCOPIC SIGNS OF TUMOUR nTumour formation – punction, excision, brushing, aspiration, lavage nTumour granulation – punction, excision, brushing, aspiration, lavage nCircular, slot- or funnel-shaped bronchial stenosis – punction, attempt at excision, brushing, aspiration, lavage nExtramural compression of the airway – transbronchial punction nNormal bronchoscopic finding 31 GRANULATION OF TUMOROUS ORIGIN 32 FORCEPS BIOPSY FOR HISTOLOGIC EVALUATION 33 MOSTLY INDIRECT SIGNS OF TUMOUR 34 DIRECT AND INDIRECT SIGNS OF TUMOUR 35 DIRECT SIGNS OF TUMOUR 36 DIRECT SIGNS OF TUMOUR 37 DIRECT SIGNS OF TUMOUR 38 CARCINOID 39 METASTASIS OF MELANOMA IN THE TRACHEA 40 TUMOUR SIGNS ABOVE VOCAL CORDS 41 SEWING MATERIAL 42 SEWING MATERIAL 43 ASSESSMENT OF THE MATERIAL OBTAINED BY BRONCHOSCOPY IN PATIENTS WITH A SUSPICION OF MALIGNANCY nHistologic evaluation – sample as large as possible, multiple samples nCytologic evaluation nMolecular genetic testing nComplex microbiologic assessment in case of infectious complications nBronchologist, laboratory background, clinical cytology Further methods to assess tumour's size and morphologic type nCT guided transparietal needle biopsy nThoracoscopy (mostly VATS), mediastinoscopy, pleural fluid analysis, open thoracic surgery nSputum cytology – morphologic diagnosis is essential for further course of action – to treat or not to treat? 44 Other bronchoscopic diagnostic methods nEBUS (endobronchial ultrasound) nAutofluorescence bronchoscopy nNBI (narrow band imaging) nMultidimensional bronchoscopy nVideobronchoscope with full HD (full high definition) nConfocal microscopy (Cellvizio) 45 EBUS 46 NBI 47 Autofluorescence bronchoscopy 48 CT-guided bronchoscopy 49 TUMOUR MARKERS IN LUNG CANCER and their significance nDetermining and monitoring of tumour markers plays a role in treated patients (dynamics), rarely in differential diagnosis. nCEA – NSCLC nTPA – tissue polypeptide antigen – NSCLC nCYFRA – 21 – 1 – NSCLC nSCC Ag – NSCLC nNSE – SCLC nPro GRP – SCLC 50 51 BRONCHOALVEOLAR LAVAGE nTechnique for the acquisition of bronchoalveolar lavage fluid (BALF) and its cellular and non-cellular elements from lower airways and alveoli nUnlike the instillation of saline with reverse aspiration of a small portion of the instilled fluid into large airways 52 BRONCHOALVEOLAR LAVAGE nValuable examination technique for determination of etiology in a number of pulmonary diseases nSafe, repeatable, suitable for monitoring of disease activity and response to treatment nAdequate treatment can be initiated based on timely BAL and complex BALF analysis 53 BRONCHOALVEOLAR LAVAGE nGeneral indications: interstitial processes or diffuse pulmonary processes (their diagnosis, monitoring of the course of disease and treatment) nInflammatory lung diseases, peripheral pulmonary lesions, lesions of unknown etiology, diagnosis of lung disease in immunocompromised patients (AIDS patients, post-transplant patients, patients treated with corticosteroids and immunosuppressants, oncologic patients on intensive chemotherapy and radiotherapy) 54 BRONCHOALVEOLAR LAVAGE nSpecial indication: suspicion of pulmonary lesion in immunocompromised patients nIn these patients, determining the etiology of the pulmonary lesion and initiation of adequate treatment can be life saving Saline instillation (lavage, one of the portions of bronchoalveolar lavage) 55 Obrázek1 Saline instillation https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcROF9CtlDhVhoW9OP3zfs0KmLi2Gs3GstxoraJrfAMeMvJ WmCYVgQ 56 57 INTERSTITIAL PULMONARY FIBROSIS 58 POSTRADIATION FIBROSIS 59 MATERIAL SAMPLING IN SUSPECT INFECTIOUS COMPLICATION nBronchoalveolar lavage and complex microbiologic examination of the bronchoalveolar lavage fluid (bacteria, mycobacteria, yeasts and fungi, viruses, Pneumocystis jirovecii) nCytology of BALF including the differential count nX-ray guided transbronchial lung biopsy, transbronchial cryobiopsy nTimely delivery to the lab, range of diagnostic methods (availability of molecular diagnostics), knowledge of diagnostic options, interpretation of results 60 PNEUMOCOCCAL PNEUMONIA 61 PNEUMOCYSTIS PNEUMONIA 62 LEGIONELLA PNEUMONIA IN IMMUNOCOMPROMISED HOST 63 LEGIONELLA PNEUMONIA 64 Aims of endobronchial treatment (Bartoň, Endobronchiální léčba laserem, in Kolek a kol., 2002) nVentilatory function improvement nIrritant cough alleviation/supression nRepeat hemoptysis suppression nCreating options for other therapeutic procedures nQuality of life improvement nLife prolongation 65 Indications to endobronchial treatment (symptoms) (Freitag et al., Interventional bronchoscopic procedures, ERS, 2001) nDyspnea at rest nExercise dyspnea nCough nHemoptysis nRecurrent pneumonia 66 Endobronchial lesions and indication for the use of different types of procedures (Freitag et al., Interventional bronchoscopic procedures, ERS, 2001) 67 Location of endobronchial lesions and the success rate after the first proceeding (Cavaliere et al., CHEST, 1988) 68 Endobronchial options nUsing the flexible bronchoscope (in analgosedation) nUsing the rigid instrument set (in general anesthesia or very deep analgosedation) nRigid instrument set and flexible bronchoscope combined (in general anesthesia or very deep analgosedation) 69 FLEXIBLE BRONCHOCOPY ASSETS (Cavaliere et al., CHEST, 1988) nWidely used technique ('everybody can do it') nOutpatient option possible nCheaper 70 FLEXIBLE BRONCHOSCOPY DRAWBACKS (Cavaliere et al., CHEST, 1988) nDiscomfort for the patient nDilation impossible with the tip of the bronchoscope, larger forceps cannot be used nThin working channel to handle complications nPlacing stents difficult without previous dilation with the rigid set 71 Advantages of JET VENTILATION (Studer et al., in: Interventional Bronchoscopy, 2000) nGood visibility, ample space for procedures nSmall risk of laser ignition nAirways dilation nEffective ventilation nSupport of mucociliary clearence 72 Drawbacks of JET VENTILATION (Studer et al., in: Interventional Bronchoscopy, 2000) nCO2 removal difficult nCO2 monitoring difficult nBlood gas exchange difficult to predict nRisk of pulmonary barotrauma nRisk of aspiration nExpensive 73 Complications of endobronchial treatment (Studer et al., in: Interventional bronchoscopy, 2000) nHypoxemia (O2 saturation < 90%) nCO2 retention (> 6 kPa) nMajor bleeding nPneumothorax nDeath (0.45 - 3.2%) 74 Postero-anterior chest radiograph before and after repeat laser procedures > > 75 LIMITS OF NOVEL DIAGNOSTIC BRONCHOSCOPIC METHODS qEndobronchial examination using ultrasound (EBUS = endobronchial ultrasound) – mainly in diagnosis of mediastinal lesions adjacent to bronchi qAutofluorescence bronchoscopy – to detect subtle mucosal changes not apparent in 'white-light' bronchoscopy qNBI (narrow-band imaging) to detect early lung cancer, to determine the exact location for bronchoscopic sampling… qVirtual bronchoscopy – radiodiagnostic (CT) technique that produces high-resolution images of the tracheobronchial tree qAdequate equipment, more physicians should master the technique (illness, official journeys, vacation...) 76 LIMITS of THERAPEUTIC BRONCHOSCOPY nBronchial secretion aspiration nHemostasis – iced saline, Remestyp, Exacyl nForeign body extraction Equipment, everyday service (24/7 if possible), sufficient number of bronchoscopists and nurses, sufficiency in bronchoscopes, interdisciplinary cooperation... 77 THERAPEUTIC BRONCHOSCOPY – LIMITS nBrachytherapy – where the bronchial orifice is narrowed by an extramural tumour nBalloon dilation nDilation using the rigid bronchoscope's tubus nElectrocauterization nLaser nCryotherapy nPhotodynamic treatment? nStents nKnowledge of the method, availability, equipment, everyday service (24/7 if possible), sufficient number of bronchoscopists and nurses, a good supply of bronchoscopes, interdisciplinary cooperation... 78 CONCLUSION nBronchoscopy is of crucial importance in diagnosis and therapeutic decisions nDiagnostic bronchoscopy has a central place in intensive medicine, oncology, diagnosis of infections, interstitial lung processes and sarcoidosis nFor bronchoscopy's yield and efficacy, rapid availability of inter-specialty cooperation (pathologist, cytologist, radiologist, anesthetist, microbiologist, molecular geneticist) is essential nThe education of bronchoscopists, sufficient number of bronchoscopists, adequate knowledge of bronchoscopic methods... 79 REFERENCES n1. Bolliger C.T., Mathur P.N.: Interventional Bronchoscopy. Basel, Karger, 2000, 297 s. n2. Bolliger C.T., Mathur P.N. (chairmen): ERS/ATS statement on interventional pulmonology. Eur Respir J 19, 2002, 356-373. n3. Kolek V. a kol.: Bronchologie pro zdravotní sestry. Brno, IDVPZ v Brně, 2002, 212 s. 80 REFERENCES n4. Mayer J., Skřičková J., Vorlíček J.: Plicní postižení u imunokompromitovaných nemocných. Diferenciální diagnostika a využití bronchoalveolární laváže. Brno, IDVPZ Brno, 1995, 511 s. n5. Prakash U.B.S (editor): Bronchoscopy. New York, Raven Press, 1994, 547 s. 81 REFERENCES n6. Strausz J.: Pulmonary Endoscopy and Biopsy Techniques. Sheffield. European Respiratory Society Journals ltd. Publications Office, 1998, 269 s. n7. Zavala D.C.: Bronchoscopy, Lung Biopsy and Other Procedures. In: Murray J.F. and Nadel J.A.: Textbook of Respiratory Medicine. Philadelphia, W.B. Saunders company, 1988, 562-596.