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Unformatted text preview: INTERVENTIONAL BRONCHOSCOPY BRONCHOSCOPY Dr. SACHIN KUMAR SENIOR RESIDENT PULMONARY & CRITICAL CARE PGIMER INTRODUCTION Interventional Bronchoscopy (IB) Evolving field within pulmonary medicine that focuses on providing consultative and procedural services to patients with malignant and non malignant airway & parenchymal disorders IB encompasses the following three main areas in pulmonary medicine: malignant ; nonmalignant airway disorders; and artificial airways airways IDEAL INTERVENTIONAL BRONCHOSCOPY SUITE BASIC SUITE ADVANCED SUITE ADVANCED SUITE EBUS Airway examination BAL Autofluorescence Cytologic brushing External Navigation Endobronchial Biopsy El Electrocautery / APC APC Transbronchial biopsy Cryotherapy & PDT PDT TBNA Laser & Stenting Thoracoscopy SPECTRUM OF INTERVENTIONAL BRONCHOSCOPY INTERVENTIONAL BRONCHOSCOPY DIAGNOSTIC BRONCHOSCOPY US FDA approved innovations in diagnostic di bronchoscopy available to interventional Pulmonologist : Autofluorescence bronchoscopy (AFB) EBUS Future Future modalities Navigational bronchoscopy by electromagnetic guidance Narrow band imaging Optical coherence tomography AUTOFLUORESCENCE AUTOFLUORESCENCE BRONCHOSCOPY AFB endoscopic tool identify precancerous lesions predominantly preinvasive squamous cell carcinoma in respiratory tract based on tissue fluorescence S. Lam et al (1990s) applied Auto Fluorescence (AF) concept to development of diagnostic Bronchoscopy Even when the sputum shows atypia or carcinoma, 40% - 71% may not be detected during during routine white light bronchoscopy J Thorac Cardiovasc Surg 1993 PRINCIPLES PRINCIPLES OF AUTOFLUORESCENCE Normal respiratory tissue fluoresces green when exposed to light in the violet–blue spectrum (400–450 nm). As mucosal and submucosal disease progresses from normal, to metaplasia, to dysplasia, to CIS : progressive loss of the green AF, causing a redbrown brown appearance of the tissue CHEST 2007; 131:261–274 AUTOFLUORESCENCE AUTOFLUORESCENCE BRONCHOSCOPY CLINICAL CLINICAL APPLICATIONS Studies have shown superiority of AFB over whitelight bronchoscopy in detection of cancerous lesions Impact on survival has not been elucidated AFB is not yet recommended as a screening tool for lung cancer Published data in more than 1 ,400 patients suggest that WLB alone detects on average only 40% of highgrade grade dysplasia and CIS, whereas AFB increases the whereas detection rate up to 88% Ann Thorac Surg 2005;80:2395– 401 LIFE STUDY TOTAL +VE BX 379 Chest 2000;118:1776 –82 AFB: LIMITATIONS Cost of autofluorescence unit Lack of specificity( False +ve 34% vs 10% WL) Ann Thorac Surg 2005 Follow-up of any detected abnormality, as currently no no standards exist No accepted standard on who should undergo procedure and no widely accepted algorithm on management of lesions exists Future studies may investigate utility of routine AF examinations prior to surgery in patients with resectable lung cancer ENDOBRONCHIAL ULTRASOUND EBUS allows visualization of tracheobronchial tree with real-time ultrasound and permits visualization of internal structure of pulmonary lesions Hur ter and Hanrath initially repor ted EBUS to diagnose pulmonary and mediastinal tumors Dtsch Med Wochenschr 1990 EBUS term used for two distinct devices ,radial probe EBUS and recently introduced convex probe probe EBUS RADIAL RADIAL PROBE EBUS Radial probe EBUS catheter-based device currently available in frequencies ranging from 12 to 30 MHz Balloon sheath model (20 MHz, external external diameter 2.5 mm,UM-BS20–26R, Olympus, Tokyo), used for evaluating central airways ultraminiature model (20-MHz, external diameter 1.4 mm, UM-S20–20R,OlympusTokyo) used used for peripheral lung lesions LAYERS LAYERS OF THE AIRWAY WALL Mucosa - hyperechoic Submucosa - hypoechoic Car tilage has three layers th a. Endochondrium - hyperechoic b. Internal layer - hypoechoic Internal hypoechoic c. Perichondrium - hyperechoic Supporting connective tissue outside cartilage - hypoechoic Adventitia surrounding supporting connective tissue - hyperechoic Semin Respir Crit Care Med 2004;25:425–431 INDICATIONS INDICATIONS (1) Determine depth of tumor invasion of tracheobronchial lesions (2) (2) Define positional relationships with pulmonary artery and veins and hilar structures (3) Visualize paratracheal and peribronchial lymph nodes and metastases and allow EBUSguided TBNA (4) Localize and diagnose peripheral pulmonary lesions (benign or malignant) Semin Respir Crit Care Med 2008;29:453–464 BIOPSY BIOPSY OF EARLY-STAGE LUNG CANCER Radial probe EBUS useful in assessing depth of EBUS tumor invasion and guiding treatment (endobronchial intervention vs resection) ti In a study of 18 patients with centrally located lung cancer, all nine patients who underwent all PDT therapy after intracartilaginous tumor identified identified by radial probe EBUS remained without evidence of remission for a median follow follow-up of 32 months Am J Respir Crit Care Med 2002 MEDIASTINAL LYMPH NODE EVALUATION AND BIOPSY Regions inaccessible to mediastinoscopy : posterior subcarinal and hilar nodes Overall success rate of 86%, regardless of lymph node size or location Chest 2004;125:322–325 Combining radial probe EBUS and EUS improved diagnostic yield (94%) over either modality alone Am J Respir CritCareMed2005 EVALUATION AND BIOPSY OF PERIPHERAL LUNG NODULES Radial-probe EBUS enables ultrasonic visualization EBUS of peripheral lung nodules beyond the visual range of the bronchoscope of Diagnostic yield of radial probe EBUS for biopsy of peripheral lung nodules is 58 to 80% 58 80% Am J RespirCrit Care Med 2007;176:36–41 Ultraminiature probe with guide sheath left in place following localization of the target lesion allows for repeated coaxial biopsies at the same site Chest2004;126:959–965 RADIAL PROBE: OTHER APPLICATIONS Well suited to distinguish between malignant di central airway compression and infiltration Chest 2003;123:458–462 Far superior to CT and MRI with sensitivity and specificity of 92 % and 83% in comparison with 59% and 56%(CT) and 75% and 73% (MRI) respectively Respiration 2006;73:651–657 In lung transplant recipients,used to evaluate anastomotic site and useful in differentiating acute lung rejection from graft infection Chest 2006;129:349–355 CONVEX CONVEX PROBE EBUS Convex probe endobronchial ultrasound. (XBF-UC 160F, Olympus, Tokyo) Utrasound-guided real-time needle aspiration (N) of an enlarged (1.43 cm) right paratracheal lymph node (4R) with underlying SVC Semin Respir Crit Care Med 2008;29:453–464 CONVEX CONVEX PROBE : MAJOR APPLICATIONS Mediastinal Lymph Node Evaluation and Biopsy Ability to accurately biopsy lymph nodes under realtime image guidance CP EBUS-TBNA lymph node sampling compared with surgically resected specimens or clinical follow-up : EBUS-TBNA accurate (diagnostic accuracy 93 to 97%, sensitivity of 94 to 95.7%, and specificity of sensitivity and 100%) and safe technique Thorax 2006 ;61:795–798 Sensitivity Sensitivity and specificity of convex probe EBUS for malignancy 84.3% and 100% and for benign di disease 75% and 100%, respectivel 75% ly Chest 2007;132:S591 CONVEX CONVEX PROBE MAJOR APPLICATIONS Lung Cancer Staging NSCLC undergoing initial staging because of adenopathy on CT scan, CP EBUS-TBNA had a CP sensitivity and specificity of 94.6% and 100% with no complications. As a result,eight thoracotomies, 29 mediastinoscopies, four thoracoscopies, and nine nine CT-guided biopsies avoided Lung Cancer 2005;50:347–354 2005 A statistically significant improvement in diagnostic accuracy accuracy when using convex probe EBUS-TBNA (sensitivity 92.3% and specificity 100%) in comparison with PET (80% and 70.1%) and CT (76.9% and 55.3%) was reported Chest2006;130:710-718 ELECTROMAGNETIC NAVIGATION BRONCHOSCOPY ENB utilizes a steerable sensor probe within an electromagnetic field map superimposed on a virtual bronchoscopy image to navigate to lesions lesions beyond visual range of bronchoscope Chest 2007; 131:261–274 NARROW BAND IMAGING Narrow band imaging : New bronchoscopic system equipped with filters that illuminates target tissue at narrower red/green/blue bands of light spectrum with delineation of the details of Thorax 2003;58:989–995 microvascular network NBI: PRACTICAL APPLICATIONS Characterization of vascular pattern of bronchial epithelial surface Understanding of angiogenesis in early phases of carcinogenesis of lung tissue and diagnosis of premalignant lesions Used to determine what areas to study with Optical Coherence Tomography and con-focal microendoscopes to achieve in-vivo biopsies High magnification bronchovideoscopy combined with NBI useful in detection of capillary blood vessels in ASD lesions at sites of abnormal Thorax. 2003 November; 58(11): 989–995 fluorescence OPTICAL OPTICAL COHERENCE TOMOGRAPHY (OCT) OCT evolving technology that brings capability of a pathologist’s microscope into flexible bronchoscope bronchoscope Analogous to ultrasound, but uses light waves instead instead of sound waves Light backscattered from within a sample processed to develop high-resolution, depthresolved image suitable for analyzing internal microstructure, in vivo, without physical contact With appropriate lateral scanning, 2 D and 3 D images with resolution better than 10 micrometers acquired acquired rapidly and non-invasively. Chest 2007; 131:261–274 OCT OCT : PRACTICAL APPLICATIONS When compared to HE stained histologic samples of animal and excised human tracheas, OCT images displayed with precision microstructures such as epithelium, lamina propria, glands, and cartilage Future clinical application of OCT would be detection and follow-up of submucosal in situ histologic changes without need to obtain a Respiration 2005;72:537–541 biopsy INTERVENTIONAL THERAPEUTIC BRONCHOSCOPY Gustav Killian performed first documented bronchoscopic removal of foreign body Munchener Medizinische Wochenschrift Indications for ITB: 1897;38:1038–1039 1897;38:1038 Life-threatening obstruction of central airways (i.e. trachea trachea, mainstem bronchi and bronchus intermedius) Central airway obstruction (CAO) causing symptoms (dyspnea, atelectasis, postobstructive pneumonia, hemoptysis or airway lumen >50%) Inoperable early lung cancer amenable to bronchoscopic bronchoscopic treatment Semin Respir Crit Care Med 2008;29:441–452 TREATMENT TREATMENT PRINCIPLES Techniques enabling rapid removal of obstruction (Mechanical debulking/resection: laser resection, electrocautery) : life-threatening obstruction Techniques enabling delayed removal of obstruction (cryotherapy, endobronchial irradiation photodynamic therapy) : non-critical stenosis Techniques enabling maintenance of airway patency (stenting) Techniques enabling symptom control such as hemoptysis (electrocautery, argon plasma coagulation, laser therapy, .. SPECTRUM SPECTRUM OF ITB Chest 2007; 131:261–274 RESURGENCE OF RIGID BRONCHOSCOPY (RB) Ability to ventilate patient while intervening in the airways, Capability of using largesuction catheters to aspirate Ideal for massive hemoptysis hemoptysis Tight airway stenosis: Dilatation Dilatation Moderate-to-large tumor tissue burden in airway: Mechanical debridement Chest 2007; 131:261–274 TRACHEOBRONCHIAL FOREIGN BODIES Semin Respir Crit Care Med 2008;29:441–452 Chest. 2007;131:261–74. LASER LASER PHOTORESECTION Monochromatic, coherent light induce tissue vaporization, coagulation, hemostasis,and necrosis Destruction of granulation tissue, fibrous bands, and exophytic lesions associated with WG ,C.diphtheriae, tuberculosis, and postradiation fibrosis Nd:YAG laser 1% complication rate: hemorrhage, perforation of major blood vessel, endobronchial ignition, arrythmias arrythmias, myocardial infarction, and stroke Absolute contraindication : isolated extrinsic compression of airways Largest study of 1838 patients reported achieving 93% airway patency and associated improvement in quality of life Semin Respir Crit Care Med 2008;29:441–452 ENDOBRONCHIAL ENDOBRONCHIAL ELECTROSURGERY Application of heat produced by electrical current to cut, coagulate, or vaporize tissue in airways Palliation of unresectable malignant airway tumors Management of benign airway obstruction, and recently in curative intent for carcinoma in situ tl Contraindicated in extrinsic compression of airway and in patients with pacemakers Risk of significant bleeding (2 to 5%),endobronchial ignition while using high FiO2, and electrical shock Semin Respir Crit Care Med 2008;29:441–452 Eur Respir J 2006; 27: 1258–1271 ARGON ARGON-PLASMA COAGULATION Ionized argon gas to conduct electrical current between delivery probe and tissue Noncontact method more desirable over electrosurgery Drawback is shallow depth of penetration, thus thus limiting its use in large bulky tumors obstructing obstructing central airway Palliation of malignant obstruction as part of multimodality treatment, and also in benign conditions, like excess granulation tissue, papillomatosis,postinfectious airway stenosis Semin Respir Crit Care Med 2004;25:367–374 PHOTODYNAMIC THERAPY Delayed tumor destruction method based on lightactivated chemical compounds that cause cell death act co cause ce deat Early lung cancer not extending beyond the airway wall in patients not candidates for surgery or external beam radiation therapy Palliative treatment for endobronchial obstruction with no acute dyspnea Eur Respir J 2002;19:356–373 Most common complications of PDT using photosensitizer DHE include skin photosensitivity up to 4 to 6 weeks after procedure Local airway edema, strictures, hemorrhage, and fistula formation. Overall operative mortality 0% CRYOTHERAPY CRYOTHERAPY Joule-Thompson principle to cause thermal tissue destruction by direct contact : N2,N2O,CO2 Little immediate effect, and most of its effect occurs hours later later Excellent results in removing foreign objects, blood clots, Chest Chest 1996;110:718–723 and and polypoid lesions Safe to use, even in a high oxygen environment. limited bronchial bronchial wall damage, under local anesthesia , lack of pain Most common side-effects : airway sloughing requiring a ost co repeat bronchoscopy , and post procedure fever Combination of cryotherapy and chemotherapy to enhance apoptosis and necrosis in mouse model Lung Cancer 2006;54:79–86 BALLOON BALLOON BRONCHOPLASTY Use of balloons for symptomatic airway stenosis resulting from intubation, infection, radiation, malignancy, sarcoidosis ,WG, or inhalational injury Final desired diameter usually diameter immediately proximal or distal to stenosis Recurrence of stenosis , pain, and, albeit rarely, lb airway tear or rupture Published results of balloon dilation in non malignant stenosis : 70 -100% immediate results Semin Respir Crit Care Med 2008;29:441–452 BRACHYTHERAPY Direct placement of radioactive seeds (iridium-192) into airway tumor or in close proximity by use of flexible bronchoscope: Delayed response Palliation of symptoms related to malignant airway obstruction and curative intent after surgical resection with microscopically positive resection margins margins Overall improvement and palliation of symptoms in 65 65 to 95% of cases Benign lesions of stent related granulomatosis Complications: hemorrhage, fistula formation, arrythmias, hypotension, bronchospasm, bronchial stenosis stenosis, and chronic bronchitis Int J Radiat Oncol Biol Phys 2008;70:701–706 BRONCHIAL THERMOPLASTY Controlled application of radiotherapy to generate local heat and decrease smooth muscle mass in distal airways ( ≥3 mm) of asthmatics Decreased airway hyperresponsiveness, and persistence of benefit for at least 2 years Am J Respir Crit Care Med 2006;173:965–969 AIR Trial: moderate or severe-persistent asthma : decrease in frequency of mild exacerbations and an increase in symptom-free days, subjective symptom improvement persisted for 12 months N Engl J Med2007;356:1327–1337 Symptomatic, severe asthma : significant decrease in use of rescue medications ,improvement in FEV1, di FEV1 and ACQ scores Am J Respir Crit Care Med 2007;176:1185–1191 BRONCHIAL BRONCHIAL THERMOPLASTY Bronchial thermoplasty : stages Semin Respir Crit Care Med 2008;29:441–452. AIRWAY AIRWAY STENTING 1. 2. 3. 4. 4. 5. 6. Airway stents are hollow tubular devices designed to maintain the patency of tracheobronchial tree th An ideal stent : Easy to insert and remove Be available in different sizes to match obstruction Once placed, should maintain its position without should migration Be firm enough to resist compressive forces, sufficient elasticity to conform to airway contours Be made of inert material, not to irritate airway, precipitate infection, or promote granulation tissue Should exhibit same characteristics of normal airway so so that mobilization of secretions is not impaired Semin Respir Crit Care Med 2004;25:375–380 INDICATIONS INDICATIONS FOR AIRWAY STENTING Malignant tracheobronchial obstruction With extrinsic compression of large airways Despite laser resection and dilatation Patients undergoing external beam radiation Postintubation subglottic stenosis after failure of laser resection or or dilatation Benign, complex tracheobronchial stenosis nonsurgical candidates after failure of laser resection or dilatation Inflamatory or infectious processes while waiting for response to systemic therapy Anastomotic strictures after lung and heart–lung transplantation Tracheo- or bronchoesophageal fistula Semin Respir Crit Care Med 2008;29:441–452 SILICONE STENTS Montgomery T tube ; Relief of subglottic stenosis Dumon stent : Molded silicone with external studs to prevent dislodgment Dynamic stent : Silicone Y stent with anterolateral walls reinforced with metal hoops and non reinforced collapsible silicone posterior wall METALLIC METALLIC STENTS First generation : simple stents Gianturco stent & Palmaz stent Second generation :metallic expandable stents Wallstent : cobalt-based super alloy tubular mesh inserted through flexible fiberoptic bronchoscope under under fluoroscopic guidance Third generation ; ‘‘shape memory’’ Ult Ultraflex stent:nitinol (nickel-titanium alloy) stent Fourth generation : bioabsorable stents PLLA (poly-l-lactic acid ) : extraction of device unnecessary, and normal airway preserved after stent stent resorption Semin Respir Crit Care Med 2004;25:375–380 AIRWAY STENTING : CURRENT STATUS Complications :migration, obstruction with secretions or granulation tissue, airway wall erosion, halitosis, infection,hemoptysis, pain, halitosis cough, and stent rupture No No clear advantage of one stent over the other Palliative nature of the procedure is not amenable to randomized, controlled trials frequently Performed in conjunction with ablative techniques in case of endobronchial tumors and with dilatational dilatational techniques Semin Respir Crit Care Med 2008;29:441–452 LUNG LUNG ISOLATION Isolation: avoid spillage / contamination massive hemorrhage infection Control the distribution of ventilation unilateral bronchopulmonary lavage Unilateral lung disease requiring differential lung ventilation / PEEP strategies Surgical exposure: Pneumonectomy / lobectomy / segmentectomy / sleeve resections / BPF repair Thoracoscopy Transplantation LVRS Pulmonary embolectomy DOUBLE DOUBLE-LUMEN TUBES Have high-volume, lowhi pressure cuffs Available in right or lef tsided varieties Di Distal bronchial cuff and a proximal tracheal cuff bronchial cuff separates the lungs from each other tracheal cuff separates the lungs from atmosphere T YPES OF DLT LEFT DLT RIGHT DLT Campos, Thorac Surg Clin 2005; 15: 71 UNIVENT UNIVENT TUBES Silicone tube with similar shape as conventional ETT Advanced into the mainstem bronchi under bronchoscopic visualization Includes a movable endobronchial blocker ENDOBRONCHIAL LUNG VOLUME REDUCTION Poorly functioning lung, usually at apices surgically reduced with aim of improving respiratory mechanics by better fitting of lungs to rib cage LVRS associated with significant morbidity, mortality, and cost, nonsurgical alternatives for and nonsurgical achieving volume reduction have been developed Proc Am Thorac Soc. 2008 May 1;5(4):454-60 Sabaratnam Sabanathan: first person to perform an endoscopic treatment for emphysema Cardiovasc Surg (Torino) 2003;44:101–108 RATIONALE : ELVR Concept I: Closing Anatomical Airways silicone plugs Emphasys valve Umbrella valve fibrin-based alveolar glue Biomodulators: ECMs and PCPs Am Am J Respir Crit Care Med 2003;167:771–778 Concept II: Opening Extra-anatomical Passages Broncus Technologies : Exhale Emphysema Treatment System designed to create bronchial holes using a radiofrequency probe Proc Am Thorac Soc. 2008 May 1;5(4):454-60 BLVRS : CURRENT STATUS All current clinical evidence is at best from case series and late stages of clinical trials Efficacy signals have been substantially smaller and less durable than those observed after LVRS Biological lung volume reduction (BLVR) using biological reagents to remodel and shrink damaged regions of lung : 3-month follow-up in humans Chest. 2007 Apr;131(4):1108-13 BRONCHOSCOPIC INTRATUMORAL CHEMOTHERAPY Intratumoral injection of one or several conventional cytotoxic drugs directly into tumor tissue through a flexible bronchoscope Precise delivery of cancer drugs to and within tumor Dramaticall higher Dramatically higher intratumor drug concentrations than possible by systemic drug delivery, Virtually none of toxic side effects which normally occur with conventional systemic chemotherapy Reported to achieve broader tumor-specific systemic immune response in addition to local act action Lung Cancer (2008) 61, 1—12 (2008) BRONCHOSCOPIC INTRATUMORAL CHEMOTHERAPY Nonsystemic loco-regional chemotherapy Life threatening obstruction of the central airways airways Symptomatic obstruction of central airways (dyspnea, atelectasis, pneumonia) Asymptomatic obstruction with luminal diameter reduced to less than 50% of normal; Inoperable or operable early lung cancer amenable to potentially curative endoscopic treatment treatment. Eur Respir J 2002;19:356—73. MULTIMODALITY TREATMENT FOR CAO (A) Pretreatment (B) Laser photoresection (C) (C) Argon-plasma coagulation debulking (D) Postmechanical debulking (E) Balloon dilatation (F) Stent placement. Semin Respir Crit Care Med 2008;29:453–464 MULTIMODALITY MULTIMODALITY TREATMENT : OUTCOMES Eur Respir J 2006; 28: 200–218 CONCLUSIONS Evolving field focusing on application of advanced bronchoscopic techniques for treatment of various malignant and nonmalignant airway disorders First-line endoscopic interventions should now be strongly considered due to more immediate results and a favorable safety profile Territorial battles with other disciplines, financial financial concerns, training, verification of competency and lack of rigorous scientific research in this field are main challenges and future directions facing IB Broader clinical application in near future to manage patients in a better way ...
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