General description of procedure, equipment, technique
The definition of interventional pulmonology, originally published in European Respiratory Society (ERS) and American Thoracic Society (ATS) guidelines is “the art and science of medicine as related to the performance of diagnostic and invasive therapeutic procedures that require additional training and expertise beyond that required in a standard pulmonary medicine training program.” Clinical entities encompassed in this discipline include complex airway management, benign and malignant central airway obstruction, and pleural disease.
Diagnostic and therapeutic procedures in interventional pulmonology include rigid bronchoscopy, transbronchial needle aspiration, autofluorescence bronchoscopy, endobronchial ultrasound, transthoracic needle aspiration and biopsy, laser bronchoscopy, endobronchial electrosurgery, argon plasma coagulation, cryotherapy, airway stent insertion, balloon bronchoplasty and dilatation techniques, endobronchial radiation (brachytherapy), photodynamic therapy, percutaneous dilatational tracheotomy, transtracheal oxygen catheter insertion, medical thoracoscopy, and image-guided thoracic interventions. The following section will discuss rigid bronchoscopy; additional procedures are discussed elsewhere.
Rigid bronchoscopy was first performed in 1897 by Gustav Killian to remove a pork bone impacted in the airway of a farmer. Chevalier Jackson was responsible for the development of rigid bronchoscopy in the United States. As the field of interventional pulmonology has evolved, rigid bronchoscopy has gained increased popularity as a tool to manage benign and malignant disease of the central airways. Many endobronchial therapies including endobronchial stent placement, balloon dilation, tumor debulking, foreign body removal, laser photo resection, electrocautery, argon plasma coagulation, and cryotherapy can be performed safely and efficiently with rigid bronchoscopy.
The design of the rigid bronchoscope has changed little over the last hundred years. The design of this scope includes a rigid, straight, hollow metallic tube made of stainless steel. The tube is available in various external diameters, ranging from 3 mm to 14 mm. The scope’s diameter is constant from the proximal to distal end, with a beveled tip to facilitate lifting of the epiglottis during intubation and to facilitate “coring out” endobronchial lesions. The shorter rigid bronchoscope, or tracheoscope, is used primarily to manage diseases of the trachea. The longer rigid bronchoscope can reach down to the mainstem bronchi and has side ventilation holes at the distal end to allow ventilation of the contralateral lung during the procedure.
Rigid telescopes provide a magnified view of the airway and are constructed with a variety of angulations to allow visualization of upper and lower lobe bronchi. However, angled telescopes are used only on a limited basis, as fiberoptic bronchoscopes can be passed through the rigid scope to achieve a greater range of access and visibility.
Lighting systems, which use xenon or halogen lamps, project light out of the distal end of the scope. While rigid bronchoscopy can be performed under direct visualization, video cameras can be easily connected to the proximal aspect, or eyepiece, of the rigid telescope to allow the image to be viewed on a display screen. Accessory instruments often used during rigid bronchoscopy include biopsy forceps of various lengths and shapes, suction tubing, and specific forceps that may be used for foreign-body removal.
While the majority of bronchoscopies are performed with the flexible bronchoscope, the rigid bronchoscope remains an essential tool for many therapeutic indications. The advantages of the rigid bronchoscope including optimal airway control, increased inside diameter allowing use of larger-sized and multiple accessories, and greater ability to remove blood, secretions, and tissue from airway. Some of the disadvantages of rigid bronchoscopy include the need for general anesthesia, an increased risk of airway trauma, and the inability to access upper lobes and segmental bronchi.
Indications and patient selection
The rigid bronchoscope is used diagnostically and therapeutically for a number of purposes including resection of benign and malignant endobronchial tumors, placement of stents, dilation of tracheobronchial stenosis, and removal of foreign bodies. Rigid bronchoscopy is an important tool to manage massive hemoptysis as it can help to tamponade the source of bleeding (both directly and through the use of endotherapy instruments) and allow the use of a larger suction catheters and forceps to help remove obstructing thrombi.
Contraindication to performing rigid bronchoscopy include any contraindication to general anesthesia, an unstable cervical spine, a limited range of motion of the cervical spine, a restricted mouth opening, and any maxillofacial trauma that prevents safe insertion of the rigid scope.
Details of how the procedure is performed
Rigid bronchoscopy is typically performed under general anesthesia in an operating room setting. An anesthesiologist provides intravenous or inhalational anesthesia. Muscle relation may be used to allow for safe passage of the rigid bronchoscope through the airway and to provide adequate ventilation. If inhaled anesthetic gases are to be used, the nose and mouth are packed with gauze to avoid gas leakage. Ventilator support may be provided using spontaneous ventilation, spontaneous-assisted ventilation, high-frequency jet ventilation, or closed-circuit positive pressure ventilation. The teeth must be protected with gauze pads or a plastic mouth guard. The neck may be partially extended by lowering the head of the bed or placing a rolled blanket between the patient’s shoulder blades to provide anterior positioning of the upper trachea, which helps to facilitate intubation with the rigid bronchoscope.
Three rigid bronchoscopic intubation techniques can be used including direct intubation using a rigid scope, the use of a straight laryngoscope to improve view of the vocal cords and facilitate proper advancement of the scope, and advancing the rigid scope along the side of an endotracheal tube.
The direct intubation technique involves advancing the rigid bronchoscope midline through the oropharynx, with the bevel of the scope positioned anteriorly (12 o’clock position). The bronchoscope is advanced under the epiglottis and then rotated 90 degrees before passing through the vocal cords to prevent injury. After the trachea has been entered the scope is rotated back 90 degrees with the bevel of the scope located anteriorly. The scope is then advanced through the airways and an inspection is performed.
Interpretation of results
Performance characteristics of the procedure (applies only to diagnostic procedures)
Outcomes (applies only to therapeutic procedures)
Alternative and/or additional procedures to consider
The rigid bronchoscope is used for endoscopic resection of endobronchial masses, placement of stents, and removal of foreign bodies.
Complications and their management
When performed by an experienced operator and team, the rate of complications from rigid bronchoscopy is low. Most complications of rigid bronchoscopy are related to poor insertion technique, creating trauma to the gums, teeth, lips, pharynx or larynx. Other potential complications include avulsion of an arytenoid cartilage or vocal cord, tear of the trachea or bronchus, and injury to the neck or cervical spinal cord during intubation due to hyperextension of the neck.
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- General description of procedure, equipment, technique
- Indications and patient selection
- Details of how the procedure is performed
- Interpretation of results
- Performance characteristics of the procedure (applies only to diagnostic procedures)
- Outcomes (applies only to therapeutic procedures)
- Alternative and/or additional procedures to consider
- Complications and their management