Bronchoscopy

 

so I think I'll just go and start there's a lot of stuff to cover in bronchoscopy but I'm gonna skip over

some of the unnecessary details so at the end of the day if you can remember maybe I don't know 50% of it I think

you'll be fine it's that dense not for Delap alright so bronchoscopy so this is the general

Outline

outline of our talk we'll talk about brief history open-casket it's actually

very interesting talking for me because the history of bronchoscopy is is incredible then we'll talk about the

tracheobronchial tree some points about sedation and anesthesia then diagnostic bronchoscopy and this is where we spend

most of our time the therapeutic bronchoscopy is really like an IP talk I'll introduce this idea of functional

bronchoscopy this is a term and some concepts that are still out there and being tested and then a few things about

how we train and check for bronchoscopy competencies so you probably have seen

History

this picture before I want can you turn the lights down a little bit please thank you so this is dr. Gustav Killian

from Austria who was actually an ENT surgeon and he's the first one who

performed bronchoscopy in in the complete sense of the world there are a lot of people who tried before that

bronchoscopy was always important or people who thought about it because for

decades and centuries diphtheria tuberculosis and foreign body aspiration

were universally fatal so anyone who had any kind of medical inclination was thinking about how to approach the

airway so dr. Gustav Killian did the first bronchoscopy in a patient with

tracheostomy in 1896 and then that led to a lot of other advancements and other

procedures like he did fluoroscopy he used fluoroscopy he you at least tried

putting stents and he pulled out the first foreign body and then he also used

radiotherapy so he's really considered the father of bronchoscopy he trained

dr. Jackson and he's the doctor Jackson who came up with a Jackson trach

Dr Jackson

so dr. Jackson learned from him and then brought bronchoscopy to North America and a lot of things that today we take

for granted like having a dedicated staff having some kind of bee procedure intra procedure post procedure follow-up

having a you know an exception in the bronchoscopy light all those things that

we now take for granted were actually thought of and written by dr. Jackson he

was very you know very nice academician so this is dr. Jackson who's considered

the father of American Bronco II Sophie ology and then dr. Kubo he also learned

Dr Kubo

from dr. Killian and brought bronchoscopy Penh and Japan is important

in bronchoscopy because the first flexible bronchoscopy was invented in Japan so what dr. Jackson did in North

America is more or less what dr. Kubo did in Japan and the bronchoscopy were

done in the Killian chair and I'll show you a picture of the Killian chair basically a chair that had a little bit

of a depressed bottom so that patient had to sit with his neck up and you had to put the scope straight down but he

you know he modified that as well so

it's a little fun fact I didn't want I don't have that clicker that always forget that part but little historical fun fact who

discovered the anesthetic effect of cocaine why is cocaine important it's very

important right from both the doctors and patients standpoint but see when when bronchoscopy was being designed the

three biggest challenges to bronchoscopy was a nasty yeah light and instrument

and the the history of bronchoscopy so interesting because it's all started in

Europe they had to wait an entire year where light was just enough and just right for like 15 minutes in a day and

they would be able to look at you know something for like 15 minutes like the vocal cord there was an opera singer who

actually looked at his vocal cords while singing that was like the first live ENT

procedure so cocaine was important as an anesthetic but who's the first one

who designed or discovered the effects doctor gustaaf killing and dr. Osler Sigmund Freud

dr. Tinsley or the cashier at my local 7-eleven Sigmund Freud yes

the Sigmund Freud was a nobody and he trying to get someone to get married

actually and during that process you know he was actually using cocaine to detox morphine addicts and what during

the process he found out that actually cocaine is a good anesthetic but he didn't take it seriously he's alright

who cares so he told it to one of his friends who was an ophthalmologist and off-model just needed a good topical anesthetic so

that often is presented that work in one of the international societies and became famous for bringing cocaine as an

anesthetic and Sigmund Freud lost his chance but he became famous among the reasons so dr. Sigmund okay these two

Bronchoscopy History

are important people in the history bronchoscopy this was dr. akkada who's the inventor of flexible be 1968 in

Japan and that's dr. Du Monde the guy who the demand stand from France

he started flexible bronchoscopy he started intervention pulmonology in the contemporary sense of the world

okay this is the first flexible bronchoscope by dr. Ikeda so it had a

little eyepiece and this is this is sort of the timeline that tells you the history bronchoscopy so for many many

Bronchoscopy Timeline

many years actually some deck is rigid bronchoscopy was the only thing that and

there were not that many people who were doing it and then in 1966 gave me

none today actually started because flexible Binkowski became on the field

now IBAs and navigation bronchoscopy came around like 2000 2001 since then

things have been slow and a lot of work is being done and sort of fine tweaking this advanced from cost copies this

timeline over here is you know a little bit empty but this just how one

advancement area can just spawn an entire field of inventions this is how

Killian Chair

bronchoscopy was done this the Killian chair I don't know if you can see it this is dr. Gustav Killian this is I

think a medical student or somebody is passing by and then this is the patient

slash volunteer and this is I guess they call him conscious sedation so that's

how it was done I mean a little bit of cocaine and then that's it right nothing else but this is what bronchoscopy has

Bronchoscopy Suite

come so now you have a bronchoscopy suite with obviously all kinds of

advanced equipment your electrocardiogram terapy balloons super d or navigation you have IBAs see

a lot of fluorescence you have stands and APC and you know a lot more so bronchoscopy the history of on cost

could be is actually very very interesting not just from the technologic standpoint but also historical standpoint and I like this

History of Bronchoscopy

dr. Becker from Jeremy wrote a very nice book chapter on the history of endoscopy and bronchoscopy and there's some

interesting quotes from how bronchoscopy was first perceived when the for idea of

bronchoscopy was presented at the New York Academy of Sciences by dr. Horace green in 1846 this is this is what the

reviewers said monstrous assumption the ludicrously absurd and physically

impossible and anatomic impossibility and unwarrantable innovation in practical

medicine see reviewers used to be so subtle in those days you know now it's just like and then dr. Gerstein who was

actually a gastroenterologist he was trying to do a an EGD and accidentally ended up in the trachea and so he was

the first one accidentally see live tricky and I like the word is this almost like you know

he's an O because he saw the trachea and a live patient he said I convinced myself that one can pass the vocal cords

intentionally with a middle-sized saw he so fingers come into the coconut trachea and right down to the bifurcation but

the region of the low trachea is a very dangerous place the rhythmic protrusions of its wall is

a regular and all inspiring phenomenon so sometimes I remember these because it tells you know how far we have come we

just go through the vocal cord and boom boom boom right laughs you know but for someone who did it for the first time it

was just like you know Neil Armstrong landing on moon and this is from I think

somebody wrote a comment and I don't know if this is serious or not but it looked pretty serious to me because it's in this book he said these robots might

undergo an evolution from mirror machine to transcendent mind and therefore run out of control and he said I advise to

refrain completely from their development or at least perform some elements in outer space far from our

planet anyway anyway so that's just a little history so it's important to know

Vocal Cords

these structure most of the time when we go in and we look at the vocal cord we just look at the vocal cords put some

lidocaine sometimes there can be pathology right and left and you have the false vocal cords or the you know

the vestibular fold and then you have the true vocal cords so looking at the vocal cords how they're moving or their trophic or not sometimes you'll see

glottic webs which are basically thin strands between the the vocal cords those can be important but most of the

time we don't pay a lot of attention here because most of the pathology that you find here cannot really be treated

by us we can't really biopsy them and I generally advise even say you have a mass or a Polock here do not biopsy it

because if you end up bleeding in the upper airway and you are nowhere to control it you can end up in a lot of

trouble so if you find some major pathology you take some pictures it'd be a good description and then move on all

tracheobronchial tree

right a little bit about the tracheobronchial tree and this is important for patients to know or

for us to describe to the patient and I'll tell you why so the tracheobronchial trees are 23 generation

airway like the trachea as of generation 0 then right left bronchi which is first generation then lobar bronchus second

and segmental bronchi third generations three main landmarks in the bronchi as you know one is the crown are the most

prominent landmark one is the right minor karana also called RC one and then the left minor karana also called LC

bond why is it important because say you have a patient coming in with hemoptysis

and has an unremarkable chest CT and you say we're gonna do when cause could be on you right so this trachea bronchial

tree is a pretty extensive 23 generations and with the normal scope

you can only examine up to a third of it Thanks so you have ultra thin

bronchoscope that can take you a lot further but the optics and the suction starts to suffer so you can't really see

much so it's important for us to describe to the patient that we're going to look in your major Airways but if we

don't find anything it does not mean there is nothing there because there could be something in the 8 9 10 to 12

generation bronchus that we did not see the good thing is that if you can see

the central Airways which are the areas that you are able to look at with the scope and you don't see anything major

the chances that you actually miss this significant pathology are pretty low but still it's important for patients to

know that there could be something pretty distal I'm gonna skip this now this is just to let you know that

there's this Japanese classification of the tracheobronchial tree they go over b1 b2 I have not found any reason so far

to know this and there was a time when I knew this and then I honestly forgot it

because I never had to use this so I honestly don't think that you really need to worry about it I cannot remember

any any physician calling me or any surgeon telling me hey there's a problem the b1 a you know it's always right

upper lobe right lower lobe right middle oh so I will want you to just you know forget it just know that it's there

trachea

sometimes when we put valves in that becomes a little bit more important this is mainly for people who do

they're appearing interventions but just to let you know that the

trachea is about 10 to 12 centimeter long in an average male the trach

emitter close to 20 in an average female close to 50 and it's important because

if you see tracheal stenosis you need to have an idea of how bad it is usually patients start having symptoms when the

tracheal diameter is less than 50 percent of normal so if you see something that's really tight you need

to have an idea what the normal diameter was we know that the right mainstem bronchus is much shorter and it's a more

in line with the right of it the trachea that's why food generally aspirated food generally goes to the right side the

left mainstem bronchus is much longer and then the other segmental airways are much smaller so this is what I was

referring to this your regular bronchoscope I think most of the olympus scopes in diameter are close to about

five point eight to six millimeter so they can only take you up to maybe the

fourth and fifth generation scope and then with your camera you can see another one or one two three generations

so you cannot really see about a third of the tracheobronchial tree with the ultra thin scope you can go much farther

but then your optics start to get smaller your suction channel starts to get smaller so vision does suffer this

anatomic variations

is also important not because it's of any major you know like pathologic

significance but sometimes you see a lot of anatomic variations and you almost

wonder if this is some kind of an abnormality now these are some studies most of them were done in the

Mediterranean population aya Greece Turkey and they found that there are 20

different anatomic variations of the tracheobronchial tree and based on the population some of them would have you

know 43% of the population will have some variant of the tracheobronchial

tree the most common site I think most of you who have done because copy you'll see that the right upper lobe is anytime

you go in most of the time it's you know two segments are fused together there you know maybe an extra segment we have

a patient who actually has almost like a separate right upper lobe that basically - right upper lobes left upper

lobe is another common site of anatomic variation right middle ohm and lingula almost never have any what is the

significance of it probably resection is one so if somebody's doing a sleeve

resection for lung cancer and then the say the right mainstem bronchus is very

short it can be difficult long transplant is also important then people who do therapy ring and dimensions like

you're putting a brachytherapy catheter for lung cancer if the segment is very short very distorted it can come into

play but generally it's just an interesting finding I will just want you to know that you'll encounter it every

common findings

now and then part about some of the findings that you see in the central air

base during bronchoscopy what is this saber sheath trachea a very common

finding of little to no clinical significance but I can I cannot tell you

how many patients get referred to me for this because somebody out there did AB

wrong because there was a COPD patient and it's some kind of respiratory problem and they did a blog and they saw this and they refer the patient for

stent placement because you know there's tracheal stenosis this is basically patients who are old who are very frail

who have been smoking who've been on steroids their lateral wall of the cartilage becomes weak so every time

they breathe out or cough the lateral walls come in and it looks like you know an troposphere slit that's called a

sabre sheet trachea or a sable sable trachea really of no clinical significance this is another one of

those things that you'll see quite commonly it was a finding that was generally ignored but now there's a lot

of literature on it excessive dynamic airway collapse where the posterior wall of the trachea bulges in with coughing

and forced expression and again this is a situation where they'll send patients

for stent placement most of the time this is because of small Airways disease

or obesity so you don't generally treat it unless you've ruled out all of the

causes this is a little difficult to see but this is you can think of it as an advanced

edik this is tricky bronchial Malaysia where you have weakening of the tracheal

cartilage along with weakening of the posterior wall so there's concentric

constriction of the trachea so these are common observations and are now more commonly described you will see these

two and COPD patients or patients with have small Airways disease like asthma and you will see this in patients who

have primary cartilage problems so this is a little picture that describes different kinds of what's called central

central airway collapse

airway collapse which includes edik and trachea bronchi Malaysia together so this is normal trachea postie membranous

wall with the C shaped cartilage edik or dynamic airway collapse which is normal with when the posterior membrane bulges

in if it bulges in more than usual and what is more than usual is again debated some people say more than 50 percent

some people say up to 90 percent but clearly if it's it's if it's very obvious you'll see it

that's called eid AK and then you have different types of tracheobronchial Malaysia we talk about the stable sheath

trachea where the lateral walls are weak then this is the interior where it's

just the anterior wall and then concentric if this is if something like

this is found during bronchoscopy the question arises are the patient's bistec

because of this or is this just a finding from the small Airways disease and that's all question to answer

sometimes you have to put a stent in and relieve these kinds of central airway obstruction if patients feel better it

means that the obstruction was partly because of it a little about sedation

sedation and anesthesia

and anesthesia and honestly it is not my favorite topic but studies keep coming out on this nobody lets go of this

subject so I feel obligated to at least touch on it what do you use for sedation

a lot of people have used all kinds of medicines the most common and if you

look at the ACCP garden and they'll say some kind of benzodiazepine and some kind of narcotic most Pithom is fentanyl

and midazolam which is what we use here there are studies with etomidate their studies if ketamine

their studies did propofol I don't think anybody uses cocaine but you know we

generally use lidocaine there are other other medicines that have been trialed

most of them are expensive difficult to administer but does it even matter which

sedation you use you would think that if patients were better sedated we would be

sedation studies

able to do better bronchoscopy that's that's what you know we think having

said that none of the studies that have been done have actually shown it these

studies have not been done in basic philosophy most of these were done in advanced bronchoscopy like IBAs and

navigation because over there you generally tend to spend more time than basic than cost appear so there was a

study in 2009 where model sedation was tried against deep sedation this was

retrospective and again there was no difference in Eavis there was a nun study 2010 again looking at IBAs good

patient satisfaction there was this one study from this is from Johns Hopkins 2013 where there was

a little higher yield eighty percent versus sixty-six percent and more lymph

nodes could be sampled with deep sedation versus model sedation there was a lot of criticism on this study and

even Lonnie Ormus who did the study wasn't very satisfied with the results Roberto Casal from UT Houston this is

the only prospective study in bronchoscopy that has looked at sedation

so they randomized patients to IBAs and a patient's either got moderate sedation

with fentanyl versus versed versus general anesthesia and they found that

there was no difference in either diagnostic yield or major complication or patient tolerance I think the only

important point about this is that there were no innies involved in this study and I think below is actually looking at

our data in at the VA because we do general anaesthesia or model sedation

and I think if we get some data that will be the first time this will be

looked at in a training set right there was another study in 2016

which again looked at IBAs smarter sedation versus deep sedation there was

no difference so I think honestly when it comes to sedation general anesthesia

is better because it allows more time for the trainees to you know learn

bronchoscopy having said that from the patient's perspective it doesn't make a difference all right so I briefly

therapeutic bronchoscopy

discussed the diagnostic therapeutic and functional part of bronchoscopy so these

are important terms you know you you want to know if you're doing mainly diagnostic on cost could be diagnostic

plus therapeutic or just reputed and then we'll talk about functional bronchoscopy what's the simplest

therapeutic bronchoscopy that you can do yeah suck out a mucus plug we don't

think of it as therapeutic and cost to be because most of it's so effortless you know it's just like routine you go

and you see some goo you suck it out done right but that is really therapeutic bronchoscopy right but then

you can expand that concept to a lot of things that that are done in the IP world okay I put these pictures because

biopsy

this is important what is this fellow's

biopsy forceps what is this or a needle right what is

this brush the reason I'm bringing this up is because I cannot tell you how many

times when I go in in G gastro editing the the note that the fellow has put in

they if he did an F na they say FN a biopsy was done or brush biopsy was done

right and then I get a call from billing and they say did you do an F an A or a

biopsy right so biopsy is a separate

procedure this is not a biopsy this is an F and a not a biopsy

brush dr. Saad will tell you three one six two eight three one six two five

three one six two nine and three one six two three okay so please if if you see

Amy takes something out like this not a biopsy brush if you do something like

this not a biopsy needle fna TB na if you do

something like this if you're using fluoroscopy it's trash rocky o if you're biting something that you can see it's

endo bronchial alright okay so let's go

diagnostic techniques

through these some of these basic diagnostic techniques this is really what's important for this lecture right the diagnostic part of bronchoscopy so

we know for central endo bronchial again you can do a lot of different things you can do an FN a bronco wash brush for

self or peripheral lesions you can again use biopsy Force a brush curette which nobody really use it I think the

Japanese somehow our you know foreign of it pls and then you can do key BNA and

then the hilar lymph nodes and mediastinal structures you can use either the psychology needle which is

you 21 22 gauge or the histology needle which is using 19 gauge so I'm not going

to go through all of this but you know some of the important points are highlighted for central endo bronchial lesion what is an endo bronchial lesion

something you can see right if it's in the central area if you can see it on

your scope that's an endo bronchial lesion and generally you can either biopsied with force and there are all

kinds of forceps usually at the VA Susie will ask you do you want alligator or

alligator with a spike or cut you know and depending on my mood I will say whatever right why because there's no

study that is shown that one is better than the other way as far as diagnostic yield is concerned if it's something

that you think you really need to bite hard then you know choose something with the spike or with an alligator jaw

larger forceps can give you larger tissue but that doesn't translate into better yield and also with things like

small cells sometimes larger forces will give you a bigger crush artifact which at the VA

is a big deal cause you can send them 36 pieces and those sisters tell you not enough tissue okay so if you think it's

smoke sale just be a little gentle okay do not crush to you sensitivity for

biopsy in central lesions is pretty good 90% you want to take at least four biopsies the data will tell you there's

no increase afterwards the problem is most of this data comes from the pre molecular studies you know they weren't

looking at immunohistochemical stains they weren't doing their EGFR they weren't doing foundation bond so if it's

easy to buy it it doesn't bleed just get as many pieces as you want then remember

that if you're doing biopsies of renal cell carcinoma in the lungs or Kappa C's or carcinoid you want to be a little

careful because they can bleed a lot of people do brushing for central and

brush

abroad collisions and data will tell you that you can get up to 72 percent on the

the what the problem is brush we brush it's just like you're rubbing on the lesion and lot of endo bronchial lesions

have a thick coat of necrotic tissue so if you just go in and brush right away

you're all you're getting is the superficial necrotic tissue so just be just be careful the best thing to do is

to do a brush after you actually dug into the lesion and expose the underlying tissue if you're gonna do a

brush bronc wash is really the next to worthless when it comes to endo

bronc wash

bronchial Asians I gently get washes after I've done everything and there's a lot of you know blood and secretions and

potentially cancer cells in the airway because again it's about getting more tissue and bronk wash it's generally a

very easy and harmless thing to do so if you want to get a bronc wall just put

like 30 40 50 whatever cc's of water on it after you have done everything and then you can send it TBN a that's the

needle part right what's the good thing about TB na in endo bronchial lesions

they and pierced the lesion right so you can get to the core of an endo broccoli

tumor and get tissue from underneath that's why the the heal is pretty good

about ninety-one percent plus potentially potentially it is less

traumatic to lesion so if you have renal cell carcinoma or Kappa C's or Carson or that you think is going to bleed it's

good to do a needle aspirate first so say you do a bronchoscopy on a patient

bronchoscopy

is they actually one of the patients who referred to us for Center labeled obstruction so you do a bronchoscopy you

put a scope in you're looking down the trachea got this huge big mass just blocking the left mainstem you can see a

little bit of the right mainstem what do you think I this is again it's not hard and fast but new generally this is you

know what I want you to remember what is the most appropriate sequence of tissue sampling for the mass seen in this

picture you'll do a brush first then endo broccoli boxes and fna or fna with

endo Bronco biopsy then brush or in the broccoli biopsy F and a brush wash brush transmog Popsy dr. price

so it's - its - I told you with a brush if you rub the brush on it what are you

gonna get this mucus and junk right and at the VA we already struggle with large

tumors to get a diagnosis you don't want to send the mucus and junk and tell them there was a tumor so the the get the

best thing will be you go and you don't know if this thing is gonna bleed it could or it may not right so the best thing is you stick a

needle in there with an F na get the core of it put it on a slide give it to your psychopathologies which is right

there he gives your diagnosis you can maybe do another one or two and then you can biopsy it so with endo bronchial

lesions the first thing that you want to do if you'd really suspecting malignancy

which matter time we are with endo brach to be here you want to go with an F na first okay it's less traumatic gets you

the core you can put it on a slide get a rapid on site cytology you can even

check if it's gonna be it or not and then go with the biopsy and like I said the brush if you're going to do it for

endo broccoli and just make sure there's a lot of you know blood and secretions in their way because potential there will be cancer cells then but brush is

really less important but always remember fna before endo broccoli box

and this is generally you know this is emphasizing the fat for benign lesions and overarching lesions generally are

approached as malignant we're very rarely use you know find that there have been i've benign tumors of the airway

are very uncommon so with benign lesion you can really follow any sequence we generally just go

straight for forceps but if it's the malignantly and if it's a tumor you stick a needle in first and then forceps

okay what about peripheral lesions like out in the periphery you can either use IBAs like radially burrs or navigation

or fluoroscopy so with peripheral lesions as you have noticed there's a

lot of difficulty getting to the lesion and if you have gotten to the lesion getting biopsy why is that because

obviously you're dealing with a 23 generation tracheobronchial tree and fluoroscopy is

to the image so it cannot tell you if you're in front of the légion behind the

Delian or in the legion it can tell you that you know you're in terms of

superior inferior and median lateral it can tell you where you are but cannot tell you here in front of it or behind

it unless you rotate the fluoroscope so size of peripheral pommy lesions and the

distance from the hilum is something that really determines if you're gonna be able to biopsy just remember if it's

a 2 centimeter or smaller lesion in the outer third of the lung on fluoroscopy

the chances of getting a biopsy with fluoroscopy alone is about 20% or less

and this based on studies I think published in 2001 and she has very nice study now with navigation and guided

bronchoscopy we have been able to increase this number to about 70 75 %

all the guided bronchoscopy in a very well-done meta-analysis whether you use

radial IBAs radially bus with navigation navigation alone really leave us with distance what they call a relievers with

God God sheath or any combination of those Jen Lee gets you to about 70

percent so that's the number that you should remember when I talk to patients about these peripheral visions I say I

we have about a 70 75 percent chance of getting the diagnosis so that means

about 1/3 of the times we may not get the no diagnosis so talking about

non-diagnostic bronch is it's very important because no test gives you 100%

result pbn a 4-perf Allegiant I can if you can get to it has a very good yield

and most people will say go with the key DNA first why is that doctor do you why

do you think a TB na at least in theory will give you a better diagnostic yield

than a force biopsy for a peripheral pulmonary lesion so this is what we have found remember

that timeline where we were you know we were going on this path of innovation and AD right mm it just sort

of stopped well what happened so in 2000 radiant 2000 1999 ready Libas came out

them were designed to take us to the lesion right and all of all of the

people who are working on in this area were thinking if we can get to the lesion we will get the diagnosis while

what they realize in by late 2000 after all these studies that come out is that getting to the lesion was half of the

problem because what really determines whether you will be able to get a diagnosis at that point when you're

there close to the lesion is the relationship of the lesion with the airway so if the lesion is in in series

like right you know the arrow is going right into it then your diagnosis

diagnostic yield is higher you can put the forceps it's going to follow that guy teeth and they go right at the lesion but if the lesion is parallel to

the airway well with your radial EBUS you're going to be seeing through the airway and you'll feel like you're there

but when you put the four step your four step is in the airway while your lesion is right next to it so that's the that's

the biggest explanation perhaps for the 70 percent yield along with the fact

that you're you have respiratory motion so what the needle can give you potentially is a way to traverse the

airway at that point so it can go through the airway and get you to the lesion whereas a forceps cannot so all

most of the innovation that has been done in guided bronchoscopy since that

time is basically working in that part trying to come up with instruments that

can somehow take you to the lesion or you can tell you if with respiration the

lesion is moving or not bl4 for peripheral Palmilla lesions is if you're

looking at malignancies practically worthless unless unless you have

lymphocytic carcinomatosis or one of those minimally invasive and no carcinoma so if you have what looks like

minimally invasive adenocarcinoma or lymphatic carcinomatosis

and patients are pretty sick they cannot tolerate a biopsy just go ahead and do a BL and you'll be surprised how many

times it will actually come back positive so in that case BL can be helpful

there's something called a bronchus sign where on a CT you can see an airway

going to a lesion with navigation bronchoscopy there's one study at least

that showed that if you can see something like this it increases the of your biopsy with radial Eva's there is

no such study but intuitively you would think that if there's an airway going to the lesion that's pretty good so if you

can see something like this and again this is a situation but you want to decide if bronchoscopy is the right

route to get to it or is it a transthoracic biopsy so if you see something like this and patient is a

decent candidate for from Koska B then you have a good chance of getting to the

lesion because trans lassie barks you although it's relatively simple straightforward does carry a much higher risk for pneumothorax about 15% as

opposed to about five six percent for bronchoscopy again with peripheral pommy

lesions if you're suspecting cancer go with a TB na first if you can this is based on some weak data so whether the

the lesion is endo bronchial or peripheral and you're suspecting cancer try to go with the needle first and then

the forceps this is something that I think I'm gonna skip you generally learn

it this is the mediastinal lymph node staging you generally learn it when you're doing EBUS so the cause of this

talk is not to make you a good bronchoscopy is but a smart bronchoscopy so this bronchoscopy is not something

you're going to learn on this table but a few things about the hilar mediastinal lymph node they used to call this blind

T V na or conventional TB na which is now rarely done so I feel like this

slide has become somewhat redundant it's just of historical importance

the diagnostic heal as you can see is 15% to 80% like all over the place and

the reason is that a lot of it depends on the the skill of the operator a lot

of it depends on how big the lymph nodes are this is where IBAs has really made a

huge difference basically kicked this thing out of the you know the practical medicine if you're gonna do a lymph node

aspirate the main question is how many times should you ask for the lesion based on many studies up to four passes

maximizes the yield beyond that there's very little increase in in your yield so try to do about

three to four passes if you can with EBUS it's a really different picture but if you're if for whatever reason you end

up doing a conventional or blind pbn a try to get at least four passes and then

when you're doing a sampling of the lymph node what is most important is to

number one sample the lymph node before you sample the cancer and always go for

the lesion that is going to give you the highest stage if it were positive so say

that that tumor that we found if you go straight for it now you spit cancer

cells in the airways and now if you go and biopsy a lymph node and comes back positive the bigger question will be

well is it positive because the airways were contaminated or is it possibly because the lymph node is positive so I

always try to go for the lymph nodes before you sample the air the D tube

little I guess this is my least favorite procedure to do in Akasaka B the BL and

and then I'll tell you the reason because I feel like you have no control

as a bronchoscopy on how much you're gonna get out with everything else there

are things you can do you can try even tweak things up and down and try to get

a better yield with BL it's like you're the victim of circumstances right you

pull it in and you suck out and then you realize how bad you suck

so but there is one study this is important so they've done this digital subtraction radiography to see how much

water you actually need really get the added part of it and this was interesting for me because you need

about 120 cc's to really get to the alveoli otherwise if you put about 60

CCS which is generally what we do because you know at the VA our patients are old and frail BL is really

controlled drowning that's what it is so how much how much drowning can a patient take depends on who the patient is right

you've got a 25 year old otherwise healthy patient you can't pour like 200 300 cc's in as long and he'll do fine

but you got one of those 87 year old on two liters oxygen bad long than you

email it's not do well after 40 cc's so really you have to judge yourself but

you do have to remember that you do need to pour close to hundred cc's you're really gonna get the alveolar part of it

and then we've seen this all all the fellows know it all those collapsible Airways will you suck it a little bit

and it just closes down on you there's really no there is no way you can get a good B L on it if you are doing a BL for

a diffused lung disease plot the right middle lobe and the lingual are just because the orientation of those

segments is such that you actually pour it in and you suck it up so you get a better return otherwise if it's a focal

lesion you'll have to go in that segment this is something that I always tell

patients because you will be surprised how many times patients will call you back and say I have a little fever so BA

L can actually cause a low-grade inflammatory reaction in the lungs and it's very common for patients who have

low-grade fever so when you're getting consent for patients always tell them that in low-grade fever after

bronchoscopy does not that you have a pneumonia and they can take tylenol for

usually about 24-48 hours it's it's gone yield in bronchoscopy in BL for

fungal infections

bacterial pneumonias can be up to 75% TB up to 70% but loan in malaria TB

one study looked at BL yield in bacterial pneumonias on patients who were already on antibiotics and they

found about 40% which was a little a surprise for me and then fungal infections anywhere from fifteen to

eighty percent depending on many factors including the fungus some fungus his you

know easy to grow others are not so I generally remember about fifty percent I tell the patients there's about fifty

percent chance of finding the organism and if you look at pneumonia data generally about 50% of the pneumonias

our culture negative what is the normal composition of the elbe no it's more

like mostly macrophages and it's larger in smokers some may have inclusion bodies and then

the cd4 cd8 ratio is important which disease causes the reversal of cd4 cd8

ratio Arjun sarcoid so sarcoidosis cd4

cd8 ratio the cd4 cells will be much higher cd8 to the little in in HP it's

the reverse that's why it helped because both of them can be granulomatous both of them can have lymphocytes at the BL

and at the hospital I've worked with the Hema

they have a special order for us now so if you're suspecting I'll D of any sort

and you want to actually just specifically check cd4 cd8 ratio the nurses down there know to put the flow

cytometry order on the BL two to eight and they'll send it and you get the results within 24 hours so it helps

again this is not something I'm gonna go into but just remember that sarcoidosis

and hypersensitive pneumonitis both have high lymphocytes in the BL which one of

these these diseases has the highest lymphocyte count sarcoid is actually second it's actually

HP HP has a very high lymphocyte count is that right that's right right yes HP has the

highest lymphocyte count sarcoidosis is a close second okay so you're asked to

Bronchoscopy in aneutropenic patient

perform bronchoscopy in a neutropenic patient with diffuse forming infiltrate dr. C says I want it done today

right he's suspected of having pneumonia which of the following modalities

provides the highest yield in this patient BL alone be ultra plus trans

bronchial BL flex transport give us brush dbx alone rush alone tbh bx+ brush this

is important too it's far too often be missing dr. de Lappe - very good so this

is this is based on this study published in chess 2004 non HIV immunocompromised patient with prominent infiltrate so

they looked at all these combinations and they were trying to find out which one of these combinations gives you the

highest diagnostic yield no this is patients with with suspected infection and so they found out that BL press

trans molecule box he gave you about a 70 percent yield what was important to know is that adding a brush really

didn't make any difference so doing brush you know out in the lung when you're suspecting pneumonia is really

not needed so if you're suspecting infection in a non EMU in an

immunocompromised patient and you can do a biopsy patients can tolerate it you don't have to tank them up with several

you know units of platelets then go ahead and do it said that it also

depends on your pretest probability so you have a bone marrow transplant patient who has some chronic

institutional capacities and there's really no evidence of infection you

don't have to do above C because Bob C does come with a certain risk of Nemeth oh yeah for CMV you needed because T MV

can be in the BL but unless you see the cytopathic effect you can't really make diagnoses Aspergillus is another one

because Aspergillus can colonize the airways but unless you see it invading into the tissue you can't really technically call it a

basement you look sis now this is another one of those issues where

patients are intubated in the ICU they need a biopsy and people don't want to do a biopsy because it will draw up their long it's not supported by

evidence this study 1997 that's long time alone you didn't even have high forms back

there so retrospective study of these patients who are interbedded and they

did a biopsies bleeding of more than 30 milliliters was only found in 6% pneumothorax this was about

fifteen percent which probably is a little higher than non intubated

patients which is generally ten percent but it is still acceptable mean 15 percent is with transverse eco-city

guided biopsy is so if there is a if patients are not on enormous amounts of

peeve like fifteen or twenty I think you can you can do biopsies if it's clinically indicated the thing is that

most of time and patience are intubated in the ICU on the ventilator with respiratory failure the chances that a

biopsy will change management is miniscule so that's a better reason not

to do a biopsy than to say I'm gonna drop their lung if there's a reason you want to do a biopsy and you think the

biopsy can change management go ahead and do it for me hypertension dr. L

curse you just walked out he actually brought up a good point the other day that this a an area that where research can be done and any one

of the fellows was looking for a research project there is this only one study that has looked at risk of

bleeding the trance bronchial biopsy in patients with pH I think this was from Cleveland Clinic and these were patients

they read they looked retrospectively 45 patients of pas 45 control they have

significant pH and were on oxygen there was no difference in bleeding risk but

this is a retrospective studies VA has an enormous data and you can actually tap into the national VA database and

look at all those patients say who have echo cardiogram and had pH and then

ended up having that's that it's now

common knowledge but when it came out it made big news should be stopped plavix before biopsy or not so they looked at

plavix alone aspen alone on aspirin plus plavix and the bottom line is that if

patients are on plavix and you are doing a trance bronchial biopsy you have to stop it

aspirin by itself is not a problem so stop it about five to seven days before

Hemoptysis

just a few words about this this will happen probably every now and then patients come with hemoptysis they have

a chest x-ray that looks normal they get a CT scan in the ER that looks normal and the question is if you do a bronchoscopy which most

likely you will what are the chances that you'll find something scary with a normal x-ray and a normal CT scan

there's several studies that have looked at it but these are more important so it wouldn't normally percent you'll find

something right and then lung cancer in this study with the normal chest CT with

less than 3% okay but you still do it because we have lawyers therapeutic and

Lung Cancer

koski bombs can escape I think most people know so let me just introduce

Functional Bronchoscopy

this term again it's sort of out there people are working on it it's not really mainstream what is functional

bronchoscopy it's a bronchoscopic way to test function of the airways right so we see

if we see endo bronchial obstruction like tracheal stenosis or we see central air vehicle AB do we want do we know if

it's actually functionally or physiologically important or not so

functional bronchoscopy this is a way to you know basically see if patients can

be improved by improving that area obstruction so you do bronchoscopy on

patients who are actively on CPAP and then you raise the pressure until the

air start to open and then you say okay you know add 15 centimeters of water your central air buds are open and then

you can send home on 15 centimeters of water CPAP even for a few hours if they use

its air just at night sometimes you feel better if they feel better sometimes there's an indication that actually this

central area obstruction may be maybe you know causative and not just a at

finding we are actually able to do it down here and I think even at the VA we haven't tried it but we have the ability to do

it yeah they're just lightly sedated with

with these kinds of bronchoscopy we generally like to keep patients a little awake because you want them to call if

we want them to turn their head because the area dynamics can change so we keep them little lightly sedated we'd put a

CPAP mask on and if you have a special CPAP mask for it we can put the scope through and then first we do

bronchoscopy without CPAP if they're already on CPAP or sleep apnea and they use a pressure for like 12 centimeter we

put them on 12 and see what their neighbors look like and sometimes with center ever collapse as you increase the

pressure you can actually see their elbows open up and then you say you know this is where your Airways or is stay

open because one of the problems with central air vehicle abs is not just shortness of breath it's retained secretions wheezing and coughing I can

definitely get better this is another

Morphometric Bronchoscopy

form of functional bronchoscopy called morphometric bronchoscopy in one of the meetings hypee meetings they showed a

lot of these pictures of central area obstruction from trickiest noses and

they asked the crowd how much obstruction do you think there is somebody said 30% 50% 100% you know like

all kinds of numbers because it was all subjective so this is a way you can actually find this program on the NIH

website uncoded you can take the bronchoscopic pictures and put it in there and we'll

give you a actually a way to subject to objectively measure what's called the stenosis index and you can actually

track it so say you do intervention you v's you improve this Knossos index from

better than just subjective assessment this is another form of functional bronchoscopy called ybn response imaging

YBN Response

studies were done like her or 2,000 or so in Germany mainly so when you take a

deep breath in air goes through your Airways in pure lungs then sort of vibrates your chest wall and you can

feel those vibrations right so all these are sensors on a vest and they turn the

vibrations into a picture that's the normal picture so your Airways and your lungs are nice and open

as you can see there's uniform distribution but today if dips and airway obstructions is the left mainstem

bronchus you know or airway obstruction now you can see the obstruction but how do you know how bad it is so you do a

vibration response imaging before so there's you know less airflow here less

vibrations and then you do your laser or whatever you're gonna do and you improve

it so this is almost like a te EB Doppler you know you see a valve that's obstructed now you want to see how bad

is this erotic obstruction so this is a way to objectively check the only

problem is that because of secretion you can get a lot of vibration all right

Training and Education

just maybe one minute or two minutes on one Kostka p training i like this when i

think about training and education they said the belief that all genuine education comes about to it it does not

mean and all experiences are genuinely or equally as you care if right they say

practice makes perfect it actually does not practice just makes you permanent so if you're making the same mistake over

and over again you could do it for 30 years that doesn't mean you're better you just now you know permanently

I guess disabled all right so when it comes to bronchoscopy training we know

Bronchoscopy Training

that there are two main kinds of similary you have the electronic similar to high-fidelity simulator which we have

here and we have the low fidelity simulator which doesn't always look like this but more or less the plastic model

which we have at the VA right so they did this very nice study this was like a multicenter study by dr. host where

they'd wanted to see how do fellows perform and you give them these simulators you know so they first took

these three groups of people experts intermediates and novices based on how many bronchoscopy they have done more

than 500 was expert 25 to 500 was the intermediate and novices were like these

guys when they're gonna start right so then they first gave them the brach simulator just to kind of see how they

do this you know like a dry run and they took some parameters that they're going to follow then they took the new pommy

fellows day one and they they randomized them to either conventional method which

was like okay here's the patient go ahead put the force up in and bite what you can you know that was a conventional

method versus okay you're gonna do certain number of them cost appease on the simulator before you touch the

patient that's like when the fighter pilot scream huh so overall this is not a surprise

Results

experts did better than intermediates and novices okay no surprises if they found out that after about 20

simulations on the simulator the the fellow started to look like okay they

were learning something 20 is actually a lot on a simulator you know so I don't

know but 20 simulation they started to improve in their speed they could identify the segments fell time and read

out where you just can't see anything except just the wall that's read out and the collisions with the wall so after

they had sort of gone through this early phase then they looked at these three different parameters compared the

fellows who were trained on bronchoscopy simulator versus the conventional ones

to see how they did in their first bronchoscopy and they had the procedure time then also the bronc tech was

basically had a form that he or she was filling out that yes this fellow's good that this fellow sucks you know versus

there was another bronc quality score and all these three they generally performed better okay so the moral of

the lesson or the lesson of from the story is that Brock simulators work and

this is what I recommend to all fellows who start you're not going to really learn the skill and procedural aspects

of bronchoscopy on the patient you really are not you're going to learn it on the simulator because once you start

it on the patient you have in conscious sedation you have about fifteen to twenty minutes beyond that patient start

coughing and whatnot so you really need to be you know sort of in your stride when you put the scope in the in the

patient so if you have free time during the early part of your fellowship go down there and just practice it that's

what I did in my first month of fellowship which was the sleep months I actually spend more time in the Bronx

and later than the sleep lab and it actually worked alright so we've gone through this these

Websites

are two good websites for bronchoscopy education sensual bronchoscopies and IBAs

Realworld bronchoscopy

bronchoscopies let's have one slide about the real-world bronchoscopy this is somewhat disappointing so what's

happening in the real world with bronchoscopy this is a little bit old but I don't think it's that hold so more

than 50% of the practicing pulmonologists felt that there is inadequate training and advanced

diagnostic technique including TB na okay more than 70% of the bronchoscopy

is out there practicing perform less than 100 will cost apiece per year

seventy percent felt that additional training should be provided to those who

are mainly interested and only 25% of the practicing pulmonologist were

actually doing all the procedures that are needed for board certification so

it's strange that a lot of people come to pull money because of the procedure as people out in the real world this is

the picture there was a study published in chest where they found that less than 15% of the practicing pulmonologist were

actually doing conventional TV na and less than 25% or so of the fellowship

programs were teaching conventional TV and this is early 2000s and this is conventional TV na and that study was

done because Ebers was starting to come up and a lot of those people who really didn't care about TB na but you know

they started to feel like oh let's just make sure this doesn't go away so that's that's really what it is and there are

sedation

many different validated scores so anyway just to kind of emphasize sedation really doesn't matter but can

use sedation based on what you're going to do for malignant lesions whether they're out in the lung or in the

Airways go with the needle first if you can followed by the brush do your biopsies in immunocompromised patient

itami infiltrates if you can and you're suspecting infection stop your plavix seven days before and use your free time

on the Bronx emulator especially in the early part of fellowship I think that's it

questions [Applause]