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Unformatted text preview: INVESTIGATIONS AND PROCEDURES IN PULMONOLOGY PULMONOLOGY BAL AND TBLB Elective and ICU January 14, 2005 History History Originated in 1897: Gustav Kilian of Kilian of Germany used rigid bronchoscope Germany Chevalier Jackson refined rigid bronchoscope bronchoscope 1970: Shigeta Ikeda→ flexible Shigeta flexible bronchoscope INDICATIONS of BRONCHOSCOPY INDICATIONS Bronchoscopy is one of the most common invasive diagnostic & therapeutic procedure in pulmonology. pulmonology Diagnosis of lung cancer Diagnosis Occult CA (Positive sputum cytology) Occult Diagnosis of diffuse lung disease: TBLB Diagnosis Diagnosis of pulmonary infections Diagnosis Surveillance bronchoscopy & TBLB: obliterative Surveillance TBLB: obliterative bronhioitis in lung transplant patients Procedures for FOB Procedures Apart from visual inspection of bronchial tree FOB is accompanied by other diagnostic tests diagnostic BAL BAL Bronchial brushing Bronchial TBLB TBLB TBNA TBNA Endobronchial biopsy Endobronchial Procedure for BAL Procedure FOB acts as a suitable conduit for injection & aspiration of saline aspiration The earliest indication of BAL were therapeutic in the form of removing inspissated secretions in severe asthma inspissated Later this technique was modified and smaller volumes were used volumes When 60 ml or more fluid is used technically the procedure becomes BAL rather than simple bronchial washing simple BAL procedure BAL For obtaining BAL the tip of bronchoscope is wedged in a peripheral small bronchus; either middle lobe/lingula or lower lobe bronchus middle Segment is usually selected on the basis of CXR 20-60 ml of warm buffered saline is injected 20 60 and gently aspirated. and A return of 50-60% is expected in normal return 60% persons and lesser in diseased lung persons BAL fluid obtained and subjected for: TC/DC, special appearance of cells, supernatant analysis, culture analysis, Precautions Precautions Coughing & trauma are kept to minimum to avoid contamination with blood & mucus blood Pre-warmed saline helps in ↓ cough Pre warmed Lowering aspiration pressure ↓ trauma Large introduction volume >300 ml  risk of post lavage pyrexia risk lavage Standardization of BAL Standardization To reduce the problem of variability a standard procedure for BAL is recommended procedure Standard introduction volume>100 ml (240 ml recommended) for adults recommended) Standard no. of input aliquots (4) Standard Standard site of lavage middle lobe of R lung lavage Discarding first 20 ml is not a standard procedure to ↓bronchial contamination If the numbers of ciliated bronchial epithelial cells and squamous epithelial cells present in the BAL samples exceed 5% of the total BAL cells, the lavage sample may be unsatisfactory as a representation of alveoli European Respiratory Society Recommendation SPECIAL APPEARANCE OF CELLS IN BAL IN Haemosiderosis/Haemorrhage: Large no. Haemosiderosis/Haemorrhage Large hemosiderin laden macrophages hemosiderin PAP: amorphous proteinaceous material PAP: amorphous proteinaceous Asbestosis: asbestos disease Asbestosis: Hard metal disease: mutinucleated Hard mutinucleated macrophages CMV: inclusion bodies CMV: Pneumocystis carinii: silver stain Pneumocystis Histiocytosis: >5% CD1a-positive cells is Histiocytosis positive highly specific; Birberk granules on EM Birbe Lymphocytic BAL: granulomatous diseases, Lymphocytic granulomatous diseases, Hypersensitivity pneumonitis (very high pneumonitis (very counts,  mast cells, atypical lymphocytes) drug induced ILDs ILDs Neutrophils and Eosinophils: IPF, CT-ILD, Neutrophils and Eosinophils ILD, asbestosis, ARDS, smokers, contamination asbestosis, Haemorrhagic BAL: cytotoxic medication like Haemorrhagic cytotoxic medication Bleomycin Bleomycin BAL CD4/CD8 ratio can help in differentiating BAL can sarcoidosis from lymphoma: ratio lowest in sarcoidosis from lymphomas lymphomas Atypical BAL counts Atypical Chronic sarcoidosis: BAL lymphocytes sarcoidosis BAL may be normal, neutrophils may be neutrophils may increased (usually without Eosinophils) Eosinophils Some cases of IPF and ILD associated with S. Sc may have  lymphocytes BAL in IIP BAL UIP:  N occasionally E NSIP:  L BOOP:  TC, L, ↓CD4/CD8 TC, AIP:  TC,N,RBCs RB-ILD & DIP:  alveolar pigmented RB ILD alveolar macrophages, N macrophages, LIP:  L BAL as a prognostic indicator BAL IPF with increased numbers of lymphocytes in the BAL fluid, with or without granulocytes, are more likely to respond to steroids In a study by Haslam et al  granulocytes Haslam et granulocytes without lymphocytes suggested a better responsiveness to cyclophosphamide than to cyclophosphamide than prednisolone prednisolone serial BAL cell counts as a monitor of disease are clinically unhelpful BAL neutrophilia and/or eosinophilia iis neutrophilia and/or eosinophilia s associated with more extensive disease and a poor prognosis BAL in Pneumonia BAL 40-60% of CAP, HAP & VAP are without etiologic 40 60% diagnosis diagnosis BAL is used in VAP, pneumonia in immunocompromised, severe CAP & non resolving immunocompromised severe pneumonia Sensitivity 72-93% specificity 65-100% Sensitivity Results of BAL can help in guiding change of therapy. In studies by Fagon et al and Heyland et al found a Fagon et Heyland et lower mortality for pts with VAP who underwent bronchoscopy for BAL. Both groups were similar in duration of ICU stay and mechanical ventilation. Autopsy studies have indicated that VAP frequently involves posterior portion of right lower lobe this area should be sampled first lower BAL collects 1ml of pulmonary secretions so 104 bacteria in BAL represent 105 cfu/ml in 10 bacteria cfu/ml pulmonary secretions Variables which may affect BAL: Variables Delay in performance of procedure Delay Presence of antibiotics may affect growth of fastidious organism fastidious BAL in HIV BAL Study by Taylor et al (1956 newly diagnosed HIV patients): Study newly 30% underwent bronchoscopy Pneumocystis carinii was the most commonly detected Pneumocystis was organism organism Bacteria : Staphylococcus aureus, Streptoccus aureus Streptoccus pneumoniae, Pseudomonas spp & Haemophilus influezae Pseudomonas spp Haemophilus -Mycobacteria in 8%. Most common: M. tuberculosis Viral isolates (mainly CMV): 31% Viral Endobronchial Kaposi’s sarcoma:15% Endobronchial detection of HHV8 DNA in BAL is sensitive and specific pulmonary involvement of Kaposi's sarcoma). In a recent study bronhoscopies iin HIV are ↓ing. This ↓ bronhoscopies n This correlates with the start of HAART TBLB TBLB Carried out for bilateral disease Carried Tip of bronchoscpe iis wedged into laterally placed bronchoscpe s peripheral segmental bronchus of lower lobe. peripheral Largest possible toothed biopsy forceps are passed. Largest When forceps are seen out, they are opened and advanced till resistance is felt advanced Forceps are closed and withdrawn Forceps An elastic tug followed by a feeling of give is an indication of satisfactory biopsy. Additionally the lung tissue may be seen to coil backwards. tissue Good piece:A pale fluffy specimen that floats piece:A pale Transbronchial llung biopsy in diffuse or Transbronchial ung peripherally located lung disease without endobronchial llesions is endobronchial esions diagnostic in 72%. In the same study 3% of samples were inadequate for daignosis. daignosis UIP, DIP, BOOP, pulmonary angiitis and angiitis and granulomatosis may not be diagnosed granulomatosis may Role of FOB in Immunocompromised Immunocompromised Indications of FOB & BAL in neutropenic patients: Indications neutropenic Patients with extensive pneumonia even after addition Patients of Vancomycin & Amphotericin Vancomycin Amphotericin Non resolving pneumonia even after recovery of counts Yield in immunocompromised of various samples Yield immunocompromised of Sputum: 14% Sputum: Brochial lavage: 30% Brochial Bronchial brushing: 38% Bronchial TBLB: 73% TBLB: antigen detection in BAL: for Aspergillus spp, Aspergillus Cryptococcus neoformans, or Histoplasma neoformans or Histoplasma capsulatum Kiwor et al; Thorax 2001 Role of FOB in Immunocompromised Immunocompromised BAL has a definite role in diagnosis of invasive aspergillosis. A single positive BAL culture should aspergillosis single be regarded as an indication to start amphotericin amphotericin MOTT in BAL are not regaded as contaminant in regaded as BAL BAL Pathogens cultured from BAL are resistant to standard broad spectrum antibiotics in 43% of cases and change of treatment is required in 18% of cases Bronchoscopy in critically ill Bronchoscopy Bronchoscopy is a valuable invasive procedure in critically ill patients who present with a predominantly pulmonary problem and uncertain diagnosis. diagnosis. TBLB adds to additional risk but significantly increases diagnostic yield (60%). (60%). The benefit are stopping unnecessary and potentially toxic empirical therapies BRONCHOSCOPY IN ICU BRONCHOSCOPY Bronchoscopy in ICU commonly involves intubated patients who are on mechanical ventilation. patients Internal diameter of endotracheal tube restricts the size endotracheal tube of bronchoscope while a larger bronchoscope with wider channel is required for proper suctioning. Bronchoscope in non intubated patients occupy 10-15% of crossin sectional area of trachea. A 5.7 mm bronchoscope sectional occupies 40% of cross-sectional area of 9mm and 60% occupies sectional of 7mm endotracheal tube. endotracheal Tracheostomy tubes are more prone to damage the Tracheostomy tubes brochoscopes especially during withdrawl brochoscopes especially withdrawl Brochoscopy iis indicated most commonly in Brochoscopy s diagnosis and treatment of collapse due to retained secretions. In Mayo clinic ICUs 50% bronhoscpies were performed for atelectasis bronhoscpies were atelectasis Locally directed suctioning combined with local instillation of saline and acetyl-choline iis very s instillation effective in removing these secretions. Bronchoscopy may also be used for obtaining microbiologic specimens for diagnosis of pneumonia pneumonia TBLB in mechanically ventilated: more risk of pneumothorax (10%) and hge (5%). Yield of hge (5%). histologic diagnosis is only in one-third histologic Pre-oxygenation should be achieved by giving Pre oxygenation 100%. 100% O2 should be given throughout 100%. bronchoscopy Mode: mandatory (other modes are not reliable) Mode: TV: to be  TV: Rate: may be  Rate: ARDS: a special perforated diaphragm is required ARDS: for maintainence of PEEP maintainence Sarcoidosis & TBLB Sarcoidosis Sarcoidosis with diffuse infiltrates on CXR:75Sarcoidosis 89% Diagnosis less likely when parenchymal disease parenchymal disease not visible on CXR: 44-66% not Endobronchial biopsy: 45-75%. Any additional Endobronchial 75%. advantage over TBLB is not clear advantage In sarcoidosis granuloma are usually diffuse, so sarcoidosis are 4 bx are sufficient. Endobronchial biopsies bx are Endobronchial biopsies should be obtained if the lesion is visible should Stage II & III sarcoidosis: 75% sarcoidosis Stage I sarcoidosis: 58% sarcoidosis TUBERCULOSIS TUBERCULOSIS Andersen et al (101 pts with positive active TB): 77% were culture positive on induced sputum sample and 95% on BAL 95% In a study done in Kuwait by Balkrishnan et al: AFB was Balkrishnan et identified in BAL, either by smear or culture, in 73.3% patients with suspected pulmonary TB and in 54.5%patients with miliary shadows. miliary In a Turkish study done in suspected TB patients who were smear negative FOB provided diagnosis of TB in 50%. HPE provided diagnosis in 40% Culture of BAL (34%) is better than gastric washing (21%) in diagnosis of smear negative TB (21%) Bronchoscopy is an important tool in the diagnosis & assessment of response to ENDOBRONCHIALTB assessment Pulmonary alveolar proteinosis iis usually proteinosis s diagnosed by BAL & TBLB (characteristic PAS +ve material in most) IPF: Histology of these ds iis sufficiently variable ds s that the larger sampling capability of OLB is required. Bronchoscopy is not definitive; yield varies upto 27% upto For diffuse lung disease 4-6 TBLB specimens For TBLB should be obtained from one lung (for localized lung ds 7-8) ds LUNG CANCER LUNG 80% if malignancies can be judged from bronchoscopic bronchoscopic appearance In a visible tumor yield of EBB is >90% If bronchial biopsy is combined with bronchial washing & brushing:  TBNA is more sensitive if submucosal iinfiltration is submucosal nfiltration present. Otherwise yield is similar to forceps biopsy present. helpful in friable masses which tend to bleed TBNA can be used to sample hilar glands if they are TBNA hilar glands adjacent to airways (yield: 38% if radiological e/o gland e/o gland enlargement) enlargement) BAL in CA Lung: sensitivity 27-90%; not an exclusive BAL 90%; tool for diagnosis tool PERIPHERAL LESION PERIPHERAL Visible on CXR but not on bronchoscopy Visible For diagnosis of peripheral lesions a thin bronchoscope is required. But thinner bronchoscope cannot accommodate biopsy forceps so brushing has to be used forceps Lowest yield with lesions <2 cm Lowest Mayo Clinic Lung Project Protocol for diagnosis of occult CA: repeated, selective segmental brushings until the tumor is detected. Solitary pulmonary nodule Solitary For lesions ≤2 cm outer 1/3: 14% For lesions ≤2 cm outer 1/3: 31% Thus routine biopsy of lesions< 2 cm is not always justifiable HRCT can help in assessing the need of bronchoscopy in diagnosing peripheral lung lesions. lesions. Bronchus sign: bronchus transiting the lesion Calcification: better delineated on HRCT BAL is beneficial in adding to diagnostic yield BAL METASTASIS METASTASIS Metastatic masses present in 3 waysEndobronhial masses: breast & RCC Endobronhial Yield is similar to lung CA by EBB Lymphangitis carcinomatosa: Lymphangitis bronchoscopy with TBLB is the diagnostic procedure of choice yield 66% procedure Hematogenous: same as solitary Hematogenous same pulmonary nodule pulmonary PRE PROCEDURE WORKUP PRE Suspected COPD: spirometry spirometry Severe COPD FEV1< 40%: ABG Severe Prophylactic antibiotics: asplenic, heart valve asplenic heart prosthesis, or a previous H/O endocarditis endocarditis Avoid bronchoscopy within 6 wks of MI Asthmatic patients should be given bronchodilator prior to the procedure bronchodilator Clear fluids may be allowed 2 hrs prior Clear NPO for 4 hrs after bronchoscopy NPO Complications Recent retrospective study 4000 procedures: no death major complication:0.5%, minor complication: 0.8% complication: Major complications: respiratory depression, Major respiratory pneumonia, pneumothorax, cardiorespiratory cardiorespiratory arrest, arrythmias, pulmonary edema arrest, arrythmias Minor complication: vasovagal, fever, Minor vasovagal fever, haemorrhage, airway obstruction, haemorrhage airway Complication following Transbronchial biopsy: Transbronchial pneumothorax 1-5%, haemorrhage pneumothorax 5%, haemorrhage 9%(uremic and immunosupressed 9%(uremic immunosupressed patients).Hospitalization iis not required for s TBLB TBLB Complications of lidocaine: seizures & cardiac lidocaine seizures depression; caution in patients with malignancies involving liver. Recommended maximum dose 8.2 mg/kg maximum Arrythmia: occurs commonly in patients who Arrythmia occurs develop hypoxia(40% in pts with hypoxia) develop ECG monitoring is recommended in patients who have abnormal preoperative ECG (in patients with severe cardiac disease) and if hypoxia is refractory to O2 refractory PNEUMOTHORAX PNEUMOTHORAX Pneumothorax requiring drainage: 3.5% after TBLB. 50% of pneumothorax after TBLB require drainage. The risk is higher if mechanically ventilated(14%) Pneumothorax most commonly develops within 1 hr. develops Role of fluroscopy iin preventing fluroscopy n pneumothorax is not very clear pneumothorax BLEEDING BLEEDING Routine checkup of platelet count and PTI and aPTT iis required in patients aPTT s with impaired liver function test. Routine checkup of these is required before TBLB before If TBLB is planned oral anticoagulants should be stopped 3 days prior or they should be reversed with low dose warfarin warfarin Anticoagulation can be continued in form of heparin if very necessary INFECTION/FEVER INFECTION/FEVER Fever may occur in bronchoscopy without lavage iin 1.2%; with lavage (10-30%); lavage n lavage 30%); after TBLB 15%; TBNA 10% fever is caused by release of proinflammatory cytokines from alveolar proinflammatory cytokines macrophages macrophages Bacteremia is rare Bacteremia Prophylactic antibiotics are not required routinely routinely HYPOXEMIA HYPOXEMIA Hypoxia is more common if BAL is done Hypoxia Monitoring by oximetry should be done in all oximetry should patients patients O2 supplementation is beneficial in patients with impaired lung funtion funtion Oxygen should be given through nasal cannulae Oxygen cannulae @ atleast 2 lpm atleast lpm In high risk hypoxemic patients requiring In bronchoscopy & lavage noninvasive lavage noninvasive ventilation via face mask can be used ventilation SPECIFIC SITUATIONS SPECIFIC ISCHEMIA: more common in pts> 60 yrs ISCHEMIA more Continuous ECG monitoring, prevention of hypoxia and adequate sedation should be used if ongoing ischemia is present used ASTHMA: asthmatic undergoing ASTHMA asthmatic bronchoscopy→8% develop bronchospasm bronchoscopy 8% bronchospasm Lignocaine exacerbates brochospasm exacerbates brochospasm Preoperative bronchodilator beneficial and Preoperative should be used routinely should COPD: Complication rate increases to 5%(cf COPD: Complication to normal 0.6%) when FEV1/FVC <50% or to <50% FEV1<1L & FEV1/FVC <69% FEV THANK YOU THANK ...
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