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BRONCHOSCOPY

BRONCHOSCOPY. Cori Daines, MD Pediatric Pulmonology, Allergy and Immunology University of Arizona. BACKGROUND. Allows direct visualization of the airways Rigid and flexible instruments Clinical tool Airway anatomy Airway sampling Therapeutic Research tool. ORIGINS.

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BRONCHOSCOPY

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  1. BRONCHOSCOPY Cori Daines, MD Pediatric Pulmonology, Allergy and Immunology University of Arizona

  2. BACKGROUND • Allows direct visualization of the airways • Rigid and flexible instruments • Clinical tool • Airway anatomy • Airway sampling • Therapeutic • Research tool

  3. ORIGINS • Until the 1980’s, only rigid instruments were widely used • Multiple generations of adult and pediatric flexible bronchoscopes now • Widely used in adult and pediatric pulmonary medicine now

  4. RIGID BRONCHOSCOPY • Generally performed by ENT’s and surgeons • Procedure oriented • Foreign body removal • Biopsies • Granuloma/polyp removal • Laser • Stent placement • Visualization for future surgery

  5. INSTRUMENTS • Rigid bronchoscopes • Hollow metal tube • Glass rod telescope • Ultimate optics

  6. FLEXIBLE BRONCHOCSOPY • Examination of the entire respiratory anatomy, nose to bronchi • Minor impact on anatomy • Able to pass through an endotracheal tube or tracheostomy tube

  7. INSTRUMENTS • Flexible instruments • Fiberoptic bronchoscopes • 2.2mm ultrathin • 2.8mm/1.2mm suction channel • 3.4mm/1.2mm suction channel • 4.4mm/2.0mm suction channel • 4.9mm/2.2mm suction channel • 5.9mm/3.0mm suction channel

  8. INSTRUMENTS • Flexible instruments • Video bronchoscopes • 2.8mm/1.2mm suction channel (hybrid video scope) • 3.8mm/1.2mm suction channel • 4.0mm/2.0mm suction channel (hybrid video scope) • 4.9mm/2.0mm suction channel • 6.0mm/3.0mm suction channel • 6.3mm/3.2mm suction channel

  9. Fiberoptic bronchoscope 2.8mm diameter

  10. Pediatric Videoscope 2.8mm diameter

  11. Pediatric videoscope 3.8mm diameter

  12. Adult videoscope 4.9 mm diameter

  13. INDICATIONS • When flexible bronchoscopy is the best, easiest, safest, most efficient way to obtain the information

  14. AIRWAY ANATOMY

  15. TECHNIQUE

  16. TECHNIQUE • Anesthesia • Best accomplished in the operating room • May be performed bedside in an ICU setting • Continuous monitoring • Light anesthesia--allows continued spontaneous breathing • May be done with conscious sedation in older individuals

  17. TECHNIQUE • Insertion • Nasal • LMA • Endotracheal tube • Tracheostomy tube • Appropriate topical anesthesia and lubrication

  18. TECHNIQUE • Anatomical survey • Nasal passages • Pharynx • Larynx • Trachea • Bronchi • Examine all before any other procedures

  19. TECHNIQUE • Additional procedures • Bronchoalveolar lavage • Brushings • Bronchial biopsy • Transbronchial biopsy • Laser • Others: cryotherapy, stent placement, foreign body removal, needle biopsy

  20. BRONCHOALVEOLAR LAVAGE • Small aliquots of sterile normal saline instilled into the airway • Removed by suctioning • Samples distal bronchial and alveolar surfaces • Wedge position to prevent loss of fluid

  21. BAL TESTS • Microbiology • Bacterial, viral, fungal, AFB, special techniques • Pathology • Cell count, differential, special stains

  22. MICROBIOLOGIC STUDIES • Stains • Gram stain • Acid fast stain (Ziehl-Neelsen) • Antibody tests • Rapid tests, DFA tests • In-situ • PCR

  23. SPECIAL STAINS • Lipid • Oil Red O • Sudan • Hemosiderin • Prussian Blue • Alveolar proteinosis • PAS • Electron microscopy

  24. SPECIAL STAINS • Fungi • Silver (Gomori’s methenamine silver stain) • Pneumocystis carinii • Silver stain • Papanicolaou

  25. BRONCHOALVEOLAR LAVAGE

  26. SPECIFIC INDICATIONS • Atelectasis • Recurrent pneumonia • Chronic cough • Persistent/unexplained wheeze • Hemoptysis • Suspected airway compression/obstruction • Stridor • Upper airway obstruction • Suspected aspiration • Evaluation of tracheostomies

  27. NORMAL ANATOMY

  28. BRONCHOALVEOLAR LAVAGE

  29. LARYNGOMALACIA

  30. LARYNGOMALACIA

  31. TRACHEOMALACIA

  32. TRACHEOMALACIA

  33. SUCTION TRAUMA

  34. TRACHEOBRONCHOMEGALY

  35. VASCULAR COMPRESSION

  36. TECHNIQUES-BIOPSY

  37. TECHNIQUES-LASER

  38. BRONCHOSCOPY TEAM • Pulmonologists • Respiratory therapists • Anesthesia • Nurses • Laboratory • Microbiology • Pathology

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