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Who needs a bronchoscopy?. Andrew Bush MD FRCP FRCPCH Imperial School of Medicine & Royal Brompton Hospital. Email: a.bush@rbh.nthames.nhs.uk. Who needs a bronchoscopy?. When the necessary information required is best obtained by flexible bronchoscopy Why am I doing this?

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who needs a bronchoscopy

Who needs a bronchoscopy?

Andrew Bush MD FRCP FRCPCH

Imperial School of Medicine &

Royal Brompton Hospital

Email: a.bush@rbh.nthames.nhs.uk

who needs a bronchoscopy2
Who needs a bronchoscopy?
  • When the necessary information required is best obtained by flexible bronchoscopy
      • Why am I doing this?
      • Thus, how should I do it?
  • When the risks are justified
fibreoptic bronchoscopy
Fibreoptic Bronchoscopy

What is the question?

What information do I need?

What is the best bronchoscopic technique?

What is the best anaesthetic technique?

slide5

Sizes (mm):

Paediatric: 4.9, 3.6, 2.7 (BAL, Bx, Brush)

Neonatal: 2.2 (Look only)

bronchofibervideoscopes
Bronchofibervideoscopes
  • Hybrid scope – fibreoptic / electronic imaging, fibres but CCD (charge coupled device) in control section
  • Display larger, brighter & much clearer, lighter instrument
  • 4 mm scope (P260F) – 2 mm biopsy channel
  • 2.8 mm scope (XP260F) – 1.2 mm channel
  • Larger scopes have ‘chip in the tip’
extent of airway obstruction
Extent of Airway Obstruction

Important equations

  • ETT size (mm) = 4 + (age in years)/4
  • % airway occluded = 100(1-r2/R2)

(where r is the radius of the bronchoscope, and R the radius of the airway)

extent of airway obstruction9
Extent of Airway Obstruction

Worked Example

  • Four year old child, 5 mm diameter airway
  • 3.6 mm external diameter bronchoscope

Hence,

  • 52% of the airway is occluded
contraindications
Absolute

No purpose

Airway too small

Foreign body (unless happy to remove)

Massive haemoptysis

Relative

Bleeding problems

Severe airway obstruction

Severe hypoxia

Pulmonary hypertension

Unstable haemodynamics

Contraindications
complications hypoxia
Obstructed airways -

Raw exp>insp, FRC, PEEP, TV, minute vol

Underlying lung disease

IV sedation

Lavage (large volume)

Suction of O2 from airways

Mobilisation of secretions

Complications - Hypoxia
complications others
Hypercapnia - may be masked by oxygen

Cardiac arrhythmias

vagal stimulation, catecholamine release

Laryngospasm

Not if adequate anesthesia

Bronchospasm

asthmatics - rare in practice (steroids)

Complications - others
slide14

Hypoxia and hypercapnia

during bronchoscopy in an

infant (note he was pre-

oxygenated)

complications infective
Complications - infective
  • Cross-infection
  • Fever - 20-30%, 4-6 hours post scope transient bacteraemia
  • Septicaemia – immunocompromised
  • Spill over into unaffected lung
  • Congenital heart disease - prophylaxis
complications mechanical
Pneumothorax - TBB (avoid RML, lingula) wedge & cough, blow down O2

Haemoptysis - rare unless biopsy, contact bleeding common

Epistaxis (esp. sedation bronchs)

Laryngeal trauma

Subglottic oedema

Mucosal oedema - vigorous suction

Complications - mechanical
how to get into the lungs
How to get into the lungs
  • Nose directly or via mask
  • Mouth via ETT or laryngeal mask
  • Tracheostomy
slide20

Posterior

Bronchoscopy via endotracheal tube

bronchoscopy stridor
Bronchoscopy: Stridor!
  • Anaesthetic technique: facemask, spontaneous quiet respiration
  • Instrument: smallest possible
  • Procedure:
      • Sutton’s law
      • Inspect all the airway (multiple pathology)
bronchoscopy focal signs
Bronchoscopy: Focal Signs!
  • Anaesthetic technique: can be any
  • Instrument: large enough to remove secretions if anticipated
  • Procedure:
      • Inspect all the airway (multiple pathology)
      • Proceed carefully, think before you biopsy
slide29

Posterior

Complete cartilage ring at origin of right main bronchus

bronchoscopy immunocompromised host
Bronchoscopy: Immunocompromised Host!
  • Anaesthetic technique: Any depending on state and size of child
  • Instrument: smallest possible (hypoxaemia)
  • Procedure:
      • Inspect all the airway (endobronchial pathology)
      • BAL
      • Timing?
bronchoscopy airway malacia
Bronchoscopy: Airway Malacia?
  • Anaesthetic technique: facemask, spontaneous quiet respiration
  • Instrument: smallest possible
  • Procedure:
      • Inspect airway ?Vascular compression
      • Consider small contrast volume bronchogram
severe tracheomalacia
Severe Tracheomalacia

Inspiration

Expiration

bronchoscopy in picu
Bronchoscopy in PICU?

Specific problems

  • Unstable pulmonary circulation
    • Increased PVR with hypoxia, hypercapnia, acidosis
  • Unstable systemic circulation
    • Fall in cardiac output, raised ICP, HT with inadvertent PEEP
bronchoscopy pild
Bronchoscopy – pILD
  • Generally not useful
  • A few diagnosable conditions
    • LCH
    • IPH
    • PAP
  • Most need lung biopsy
bronchoscopy cf
Bronchoscopy – CF!
  • Negative or unhelpful cultures, not doing well
  • At diagnosis
  • ?Surveillance – trial data awaited
who needs a bronchoscopy40
Who needs a bronchoscopy?
  • When the necessary information required is best obtained by flexible bronchoscopy
      • Why am I doing this?
      • Thus, how should I do it?
  • When the risks are justified