Refer to: Yrigoyen E, Fujikawa YF: Flexible fiberoptic bronchoscopy-Anesthesia, technique and results. West J Med 122:117-122, Feb 1975
Flexible Fiberoptic Bronchoscopy Anesthesia, Technique and Results EDMUNDO YRIGOYEN, MD, and Y. F. FUJIKAWA, MD, Long Beach
During a period of three years, 256 diagnostic bronchoscopies were done with flexible fiberoptic bronchoscopes at a Veterans Administration hospital. In all of these procedures, topical cocaine hydrochloride anesthesia was used, and it proved satisfactory and free of any undesirable side effects. The peroral route using an endotracheal tube is preferred for flexible bronchofiberscopy. Fluoroscopic guidance is essential in examining peripheral lung lesions. A 70 percent positive yield was obtained for patients with peripheral carcinoma of the lung as contrasted to a 47 percent yield when the tissue specimens were obtained blindly. THE FLEXIBLE BRONCHOFIBERSCOPE has considerable advantages over the limitations of the rigid
bronchoscopel 2 in the diagnosis of peripheral lung lesions3-9 and has largely replaced the rigid scope since its introduction by Ikeda in 1968. Many of those who use a flexible bronchofiberscope prefer the transnasal route using lidocaine as the topical anesthetic. We propose to re-evaluate the use of cocaine hydrochloride as a topical anesthetic, the advantages of using an endotracheal tube and our results with the flexible bronchofiberscope in the diagnosis of peripheral malignant lesions of the lung.
Materials and Methods We have been using both the 5 mm and 6 mm Machida bronchofiberscopes. The 5 mm model has an upward deflection of 180 degrees and the downward deflection of 10 degrees. In addition, From the Pulmonary Disease Section, Veterans Administration Hospital, Long Beach, California. Submitted, revised, August 22, 1974. Reprint requests to: E. Yrigoyen, MD, Chief, Bronchoscopy Unit, Pulmonary Division, Veterans Administration Hospital, 5901 East Seventh Street, Long Beach, CA 90801.
the flexible tip can be rotated or panned 30 degrees to the right or left; this feature being very useful for guiding the instrument into the subsegments or sub-subsegments, especially in the apices. The disadvantages of the 5 mm instrument are that it is quite fragile and its channel is only 1.4 mm in diameter, which precludes obtaining good specimens with the tiny biopsy forceps. The 6 mm instrument also has an upward and downward deflection of 180 and 10 degrees respectively. In most models, the lateral panning has been eliminated, resulting in a sturdier instrument. The 6 mm bronchofiberscope has a 2.2 mm channel so that suctioning is more effective, and adequate biopsy specimens can be obtained with a larger
biopsy forceps. Premedication In patients with no cardiac, respiratory or liver problems, a barbiturate such as sodium secobarbital (50 to 100 mg) is given approximately an hour and a half before the scheduled time; atropine 0.4 to 0.6 mg and codeine 30 to 60 mg are given hypodermically 45 minutes later. When bronchoTHE WESTERN JOURNAL OF MEDICINE
117
FLEXIBLE FIBEROPTIC BRONCHOSCOPY TABLE 1.-Results of 206 Consecutive Diagnostic Flexible Bronchoscopies in Patients with Suspected Bronchogenic Carcinoma False Percent of Positive Negative Negative Positive
Peripheral (139) with fluoroscopic guidance (93) ........ without fluoroscopic guidance (46) ........ Central (43) ............ Normal (8) ............ TOTAL: 190* .........
28
53
12
70
8 26 0 62
29 7 8 97
9 10 0 31
47 72.2 66.6
*12 patients had two and 2 patients had three fiberoptic bronchoscopies.
TABLE 2.-Results of Flexible Fiberoptic Bronchoscopy in 43 Patients with Suspected Lung Tumors After Negative Results from Previous Rigid Bronchoscopy False Percent of Positive Negative Negative Positive
Peripheral (30) with fluoroscopic guidance (14) ........ without fluoroscopic guidance (16) ........ Central (10) ........... Normal (3) ............ TOTAL: 43 ............
9
3
2
81.8
6 6 0
7 1 3 14
3 3 0 8
66.6 66.6
21
72.4
fiberscopy is done through a tracheostomy or in an intubated patient, premedication is usually not necessary. In very ill patients, atropine alone may be sufficient. Topical anesthesia The anesthetic is administered with the patient sitting or in a high Fowler's position. In a sterile medicine glass, 2 ml of a 10 percent solution of cocaine hydrochloride is placed; 3 ml of a 10 percent cocaine solution is placed in a second medicine glass and this is diluted with saline to make a 2.5 percent solution. A small cotton pledget affixed to a Jackson cross-action forceps is dipped into the 10 percent cocaine solution and any excess solution is removed by pressing the pledget against the side of the glass. The tongue and posterior oropharynx is swabbed once or twice; then, the pledget is placed in each pyriform sinus for 30 to 60 seconds. The patient or an assistant grasps the tongue with gauze and pulls it out as far as possible. The patient is reminded to relax and breathe slowly and deeply. Using a laryngeal mirror, the epiglottis is then swabbed with the 10 percent cocaine solution. Then the diluted 2.5 118
FEBRUARY 1975 * 122 * 2
percent cocaine solution is instilled directly into the larynx in fractions of 1 to 2 ml. With the patient tilted to the left, the left bronchial tree can be anesthetized. The total amount of cocaine rarely exceeds 300 mg. As soon as the cough reflex is abolished, the examination can be done, instilling small fractions of 2.5 percent cocaine through the channel in the scope as necessary. Procedure for flexible bronchofiberscopy In most cases, a flexible tube such as a 9 or 9.5 mm cuffed endotracheal tube with a wire guide is introduced by indirect laryngoscopy into the trachea. If, for some technical reason this is not possible, the endotracheal tube is slipped over the bronchoscope as a sleeve. The scope is then introduced directly into the trachea with the patient lying supine, and is passed down to the level of the carina. Then, with the patient breathing deeply, the endotracheal tube is slipped into the trachea during inspiration. A mouthpiece is placed about the endotracheal tube for protection. Oxygen can be given through the 2.2 mm channel or through the sidearm of an attachment such as a Rovenstein elbow or a tracheostomy swivel unit. In the case of peripheral lesions, the procedure is done under fluoroscopic guidance. The involved segment is predetermined by a careful study of the posteroanterior, lateral roentgenograms and planigrams when available. Ideally, routine bronchograms of the involved area would be most helpful, but this is not yet possible under our present setup. During fluoroscopy, anteroposterior, oblique and lateral views are obtained to determine the exact position of the brush or curette in relation to the lesion. The diagnosis of peripheral malignant lung lesions This report does not include any therapeutic bronchofiberscopies or the first fifty cases since we consider these early cases a learning experience. Table 1 is a breakdown of the location of lesions examined. Peripheral lesions are determined by their location on x-ray films and by showing no evidence of bronchial involvement by direct visualization with the 5 or 6 mm bronchofiberscope. Central lesions are those visible on direct examination. We have had 139 peripheral lesions from which brush biopsy specimens were obtained. Of these, 93 were secured under fluoroscopic guidance with positive cytology for malignancy in 28 out of 40 proven cases of bronchogenic carcinoma, an incidence of 70 percent. Brush biopsies were
FLEXIBLE FIBEROPTIC BRONCHOSCOPY
done blindly on 46 patients with 47 percent positive findings (eight out of 17 proven cases of bronchogenic carcinoma), clearly demonstrating the superiority of collecting the specimens under fluoroscopic guidance. Flexible fiberoptic bronchoscopies were done on 43 patients with suspected lung tumors in whom results of previous rigid bronchoscopies had been negative. Thirty-nine of these procedures were done within two weeks, and four within two months of the previous rigid bronchoscopies. As shown in Table 2 we were able to make a positive diagnosis in 21 of 29 patients with bronchogenic carcinoma, a yield of 72.4 percent. Of the 29 cases of bronchogenic carcinoma, 20 were peripheral and a diagnosis was made in 15 of these cases, a positive yield of 81.8 percent under fluoroscopic guidance and 66.6 percent without fluoroscopy. This clearly demonstrates the superiority of the flexible bronchofiberscope over the conventional rigid bronchoscope. Examples of brushing under fluoroscopic guidance are shown in Figures 1 through 3. The case illustrated in Figure 4 is that of a 42-year-old man who had pulmonary tuberculosis in 1971 and now has residual bilateral upper lobe cavities. The patient reentered the hospital with complaint of blood streaked sputum for three days. Bronchoscopy was done with the 6 mm bronchofiberscope and, to our surprise, on entering the left upper lobe, we were able to get the scope into the large cavitary lesion shown in the spot film. We are not aware of any similar case reported in the literature.
Discussion Anesthesia In 1924, a special committee of the American Medical Association chaired by Dr. Emil Mayer reported on toxic effects following the use of topical anesthetics. Of the 43 deaths collected, 26 were due to cocaine. In all of them, convulsions were followed by respiratory arrest within a few minutes. The dosage of cocaine and the total amount employed were not stated for 21 of the 26 patients.'0 Since Mayer's report, the use of cocaine as a topical anesthetic has fallen into disrepute except in a few centers. Cocaine is normally detoxified by the liver at the rate of one minimal lethal dose (MLD) per hour. The fatal dose has been stated to be about 1.2 grams. The recommended maximal dosage for
topical anesthesia is 3.3 mg per kg of body weight, (about 225 mg for a 150 lb adult)"' and the anesthesia persists for more than 20 minutes.'2 Serious complications arising from topical anesthesia appear to be related to a more rapid than usual absorption of the drugs used (cocaine, lidocaine, tetracaine).'3 This absorption rate depends on the state of the mucosa, amount of mucus in the airways, rate and depth of respiration, state of the patient's circulation, period of time in which the drug is given and the total dose.'4"5 The clearance rate of these drugs is impaired in patients with heart failure or liver disease.'6 Credle,'7 in a recent review of complications during flexible fiberoptic bronchoscopies in 24,521 collected cases does not mention the use of cocaine topical anesthesia. He reports one death and five serious complications due to tetracaine, which is still used by some. Weisel'8 reported 1,000 consecutive bronchoscopies in which 2 percent tetracaine was used with no fatalities. However, severe reactions occurred in seven patients, in two of whom bronchoscopy was done subsequently without difficulty using 4 percent and 10 percent cocaine solution. Adriani'9 reported 15 deaths due to tetracaine in 1956. At the La Jolla Shores Conference on Flexible Fiberoptic Bronchoscopy held in September 1973, lidocaine was noted to be the most commonly used topical anesthetic agent. In addition to 256 flexible fiberoptic bronchoscopies, we have done 2,040 rigid bronchoscopies in a seven-year span (February 1967 to February 1974) using topical cocaine anesthesia without any complications requiring treatment. In particular we have seen no convulsions, respiratory depression or cardiac or respiratory arrest. We attribute this to the judicious use of the drug following adequate premedication. We have noted occasional patients with transient moderate hypotension, sinus tachycardia, nausea or euphoria; but none of these required therapy. One of us (Y.F.F.) has used cocaine topical anesthesia in over 4,000 bronchoscopies between January 1944 and January 1967. In the earlier period, a DeVillbiss atomizer was used to spray 10 percent cocaine solution repeatedly into the oral cavity and the posterior pharynx until the gag reflex was eliminated and fractional instillation could be done by indirect laryngoscopy until the cough reflex was abolished. In those earlier days when the amount administered was not well controlled, an occasional toxic reaction was observed in which the THE WESTERN JOURNAL OF MEDICINE
119
FLEXIBLE FIBEROPTIC BRONCHOSCOPY
Figure 1.-Small coin lesions are also amenable to brush biopsy.
..
Figure 2.-54-year-old man with recent blood streaked sputum and a right upper lobe infiltrate. Bush biopsy: adenocarcinoma.
120
FEBRUARY 1975 * 122 * 2
FLEXIBLE FIBEROPTIC BRONCHOSCOPY
I ,l.
~r,ii!
Figure 3.-Mass in left apex. Brush biopsy: malignant cells.
L
..
Abil.
-::,l-
A
-,
11
."' lbil. ..
tiiL
Figure 4.-Spot film of the chest showing the 6 mm flexible fiberoptic bronchoscope inside the cavitary lesion located in the left upper lobe .p
THE WESTERN JOURNAL OF
MEDICINE
121
FLEXIBLE FIBEROPTIC BRONCHOSCOPY
patients became extremely restless and began jerking intermittently. These responses were quickly controlled by intravenous administration of a barbiturate such as sodium pentothal or sodium amobarbital with no fatalities. A barbiturate such as sodium secobarbital or, more recently, diazepam20 may be given as a premedication since they may be valuable in protecting against cocaine induced seizures.
Endotracheal tube If an adequate topical anesthetic has been administered, the endotracheal tube can be passed either by indirect laryngoscopy or by the method mentioned previously quite easily. The patients tolerate this with little or no discomfort. The endotracheal tube is routinely used even for bedside bronchofiberscopy. Good topical anesthesia is the key to successful intubation. The advantages of using an endotracheal tube are many: * It facilitates repeated removal and reinsertion of the bronchofiberscope for suction and introduction of brushes, curettes or biopsy forceps. * It probably minimizes or prevents contamination of the bronchial tree by nasopharyngeal secretions. * Very ill patients can be bronchoscoped without interruption of their ventilatory support. * For excessive secretions or moderate hemorrhage, a suction tube can be introduced to keep the airway clear. * In the event of severe hemorrhage, the scope would be introduced into the nonbleeding bronchus and the endotracheal tube advanced into that bronchus, thereby assuring an adequate airway to that lung. In such instances, the cuff can be inflated and the patient placed on his side with the bleeding site dependent. The patient can be placed in the Trendelenburg position in order to drain the blood, at the same time delivering oxygen to the good lung until the situation has resolved.21 Although we have not had to resort to
122
FEBRUARY 1975 * 122 * 2
this tactic, with an endotracheal tube in place, we are prepared for such emergencies.
Results This limited study reveals the safety of cocaine topical anesthesia when used as described above. The advantage of using the fluoroscopic image intensifier for peripheral lesions as well as the advantage of the flexible fiberoptic bronchoscope over the conventional rigid bronchoscope in diagnosing lung cancer is clearly evident. REFERENCES 1. Somner AR, Hibbs BR, Douglas AC, et al: Value of bronchoscopy in clinical practice-A review of 1109 examinations. Br Med J 1:1079-1084, 1958 2. Steele JD: The solitary pulmonary nodule. J Thorac Cardiovasc Surg 46:21-36, 1963 3. Ikeda S: Flexible bronchofiberscope. Ann Otol Rhinol Laryngol 79:916-923, 1970 4. Hattori S, Matsuda M, Sugiyama T, et al: Cytologic diagnosis of early lung cancer-Brushing method under x-ray television fluoroscopy. Chest 45:129-142, 1964 5. Rath GS, Schaff JT, Snider GL: Flexible fiberoptic bronchoscopy. Chest 63:689-693, 1973 6. Valaitis J, McGrew EA, Chomet B, et al: Bronchogenic carcinoma in situ in asymptomatic high-risk population of smokers. J Thorac Cardiovasc Surg 57:325-332, 1969 7. Richardson RH, Zavala DC, Mukerjee PK, et al: The use of fiberoptic bronchoscopy and brush biopsy in the diagnosis of suspected pulmonary malignancy. Am Rev Resp Dis 109:63-66, 1974 8. Smith GH, Warrach AJN: An evaluation of brush biopsy in the diagnosis of peripheral pulmonary lesions. Thorax 27:631-635, 1972 9. Kerby GR: Newer diagnostic techniques in pulmonary disease. Clin Notes on Resp Dis 12:3-6, 1974 10. Mayer E: The toxic effects following the use of local anesthetics. JAMA 82:876-885, 1924 11. Ritchie JM, Cohen PJ, Dripps RD: Cocaine, procaine and other synthetic anesthetics, chap 20, In Goodman LS, Gilman A (Eds): The Pharmacologic Basis of Therapeutics. New York City, The Macmillan Co., 1970, pp 372-382 12. Osol A, Pratt R, Altschule MD: Cocaine, In The United States Dispensatory and Physicians' Pharmacology. Philadelphia, J. B. Lippincott Company, 1967, pp 310-312 13. Steinhaus JE: A comparative study of *the experimental toxicity of local anesthetic agents. Anesthesiology 13:577-586, 1952 14. Campbell D, Adriani J: Absorption of local anesthetics. JAMA 168:873-877, 1958 15. Adriani J, Zepernick R: Some recent studies on the clinical pharmacology of local anesthetics of practical significance. Ann Surg 158:666-671, 1963 16. Thomson PD, Melmon KL, Richardson JA, et al: Lidocaine pharmacokinetics in advanced heart failure, liver disease, and renal failure in humans. Ann Intern Med 78:499-508, 1973 17. Credle WF, Smiddy JF, Elliot RC: Complications of fiberoptic bronchoscopy. Am Rev Resp Dis 109:67-72, 1974 18. Weisel W, Tella RA: Reaction to tetracaine used as topical anesthetic in bronchoscopy. JAMA 147:218-222, 1951 19. Adriani J, Campbell D: Fatalities following topical application of local anepthetics to mucous membranes. JAMA 162: 1527-1530, 1956 20. de Jong RH, Heavner JE: Local anesthetic seizure prevention. Anesthesiology 36:449-457, 1972 21. Ikeda S: Personal communication. Sep 1973
Flexible Fiberoptic Bronchoscopy Anesthesia, Technique and Results EDMUNDO YRIGOYEN, MD, and Y. F. FUJIKAWA, MD, Long Beach
During a period of three years, 256 diagnostic bronchoscopies were done with flexible fiberoptic bronchoscopes at a Veterans Administration hospital. In all of these procedures, topical cocaine hydrochloride anesthesia was used, and it proved satisfactory and free of any undesirable side effects. The peroral route using an endotracheal tube is preferred for flexible bronchofiberscopy. Fluoroscopic guidance is essential in examining peripheral lung lesions. A 70 percent positive yield was obtained for patients with peripheral carcinoma of the lung as contrasted to a 47 percent yield when the tissue specimens were obtained blindly. THE FLEXIBLE BRONCHOFIBERSCOPE has considerable advantages over the limitations of the rigid
bronchoscopel 2 in the diagnosis of peripheral lung lesions3-9 and has largely replaced the rigid scope since its introduction by Ikeda in 1968. Many of those who use a flexible bronchofiberscope prefer the transnasal route using lidocaine as the topical anesthetic. We propose to re-evaluate the use of cocaine hydrochloride as a topical anesthetic, the advantages of using an endotracheal tube and our results with the flexible bronchofiberscope in the diagnosis of peripheral malignant lesions of the lung.
Materials and Methods We have been using both the 5 mm and 6 mm Machida bronchofiberscopes. The 5 mm model has an upward deflection of 180 degrees and the downward deflection of 10 degrees. In addition, From the Pulmonary Disease Section, Veterans Administration Hospital, Long Beach, California. Submitted, revised, August 22, 1974. Reprint requests to: E. Yrigoyen, MD, Chief, Bronchoscopy Unit, Pulmonary Division, Veterans Administration Hospital, 5901 East Seventh Street, Long Beach, CA 90801.
the flexible tip can be rotated or panned 30 degrees to the right or left; this feature being very useful for guiding the instrument into the subsegments or sub-subsegments, especially in the apices. The disadvantages of the 5 mm instrument are that it is quite fragile and its channel is only 1.4 mm in diameter, which precludes obtaining good specimens with the tiny biopsy forceps. The 6 mm instrument also has an upward and downward deflection of 180 and 10 degrees respectively. In most models, the lateral panning has been eliminated, resulting in a sturdier instrument. The 6 mm bronchofiberscope has a 2.2 mm channel so that suctioning is more effective, and adequate biopsy specimens can be obtained with a larger
biopsy forceps. Premedication In patients with no cardiac, respiratory or liver problems, a barbiturate such as sodium secobarbital (50 to 100 mg) is given approximately an hour and a half before the scheduled time; atropine 0.4 to 0.6 mg and codeine 30 to 60 mg are given hypodermically 45 minutes later. When bronchoTHE WESTERN JOURNAL OF MEDICINE
117
FLEXIBLE FIBEROPTIC BRONCHOSCOPY TABLE 1.-Results of 206 Consecutive Diagnostic Flexible Bronchoscopies in Patients with Suspected Bronchogenic Carcinoma False Percent of Positive Negative Negative Positive
Peripheral (139) with fluoroscopic guidance (93) ........ without fluoroscopic guidance (46) ........ Central (43) ............ Normal (8) ............ TOTAL: 190* .........
28
53
12
70
8 26 0 62
29 7 8 97
9 10 0 31
47 72.2 66.6
*12 patients had two and 2 patients had three fiberoptic bronchoscopies.
TABLE 2.-Results of Flexible Fiberoptic Bronchoscopy in 43 Patients with Suspected Lung Tumors After Negative Results from Previous Rigid Bronchoscopy False Percent of Positive Negative Negative Positive
Peripheral (30) with fluoroscopic guidance (14) ........ without fluoroscopic guidance (16) ........ Central (10) ........... Normal (3) ............ TOTAL: 43 ............
9
3
2
81.8
6 6 0
7 1 3 14
3 3 0 8
66.6 66.6
21
72.4
fiberscopy is done through a tracheostomy or in an intubated patient, premedication is usually not necessary. In very ill patients, atropine alone may be sufficient. Topical anesthesia The anesthetic is administered with the patient sitting or in a high Fowler's position. In a sterile medicine glass, 2 ml of a 10 percent solution of cocaine hydrochloride is placed; 3 ml of a 10 percent cocaine solution is placed in a second medicine glass and this is diluted with saline to make a 2.5 percent solution. A small cotton pledget affixed to a Jackson cross-action forceps is dipped into the 10 percent cocaine solution and any excess solution is removed by pressing the pledget against the side of the glass. The tongue and posterior oropharynx is swabbed once or twice; then, the pledget is placed in each pyriform sinus for 30 to 60 seconds. The patient or an assistant grasps the tongue with gauze and pulls it out as far as possible. The patient is reminded to relax and breathe slowly and deeply. Using a laryngeal mirror, the epiglottis is then swabbed with the 10 percent cocaine solution. Then the diluted 2.5 118
FEBRUARY 1975 * 122 * 2
percent cocaine solution is instilled directly into the larynx in fractions of 1 to 2 ml. With the patient tilted to the left, the left bronchial tree can be anesthetized. The total amount of cocaine rarely exceeds 300 mg. As soon as the cough reflex is abolished, the examination can be done, instilling small fractions of 2.5 percent cocaine through the channel in the scope as necessary. Procedure for flexible bronchofiberscopy In most cases, a flexible tube such as a 9 or 9.5 mm cuffed endotracheal tube with a wire guide is introduced by indirect laryngoscopy into the trachea. If, for some technical reason this is not possible, the endotracheal tube is slipped over the bronchoscope as a sleeve. The scope is then introduced directly into the trachea with the patient lying supine, and is passed down to the level of the carina. Then, with the patient breathing deeply, the endotracheal tube is slipped into the trachea during inspiration. A mouthpiece is placed about the endotracheal tube for protection. Oxygen can be given through the 2.2 mm channel or through the sidearm of an attachment such as a Rovenstein elbow or a tracheostomy swivel unit. In the case of peripheral lesions, the procedure is done under fluoroscopic guidance. The involved segment is predetermined by a careful study of the posteroanterior, lateral roentgenograms and planigrams when available. Ideally, routine bronchograms of the involved area would be most helpful, but this is not yet possible under our present setup. During fluoroscopy, anteroposterior, oblique and lateral views are obtained to determine the exact position of the brush or curette in relation to the lesion. The diagnosis of peripheral malignant lung lesions This report does not include any therapeutic bronchofiberscopies or the first fifty cases since we consider these early cases a learning experience. Table 1 is a breakdown of the location of lesions examined. Peripheral lesions are determined by their location on x-ray films and by showing no evidence of bronchial involvement by direct visualization with the 5 or 6 mm bronchofiberscope. Central lesions are those visible on direct examination. We have had 139 peripheral lesions from which brush biopsy specimens were obtained. Of these, 93 were secured under fluoroscopic guidance with positive cytology for malignancy in 28 out of 40 proven cases of bronchogenic carcinoma, an incidence of 70 percent. Brush biopsies were
FLEXIBLE FIBEROPTIC BRONCHOSCOPY
done blindly on 46 patients with 47 percent positive findings (eight out of 17 proven cases of bronchogenic carcinoma), clearly demonstrating the superiority of collecting the specimens under fluoroscopic guidance. Flexible fiberoptic bronchoscopies were done on 43 patients with suspected lung tumors in whom results of previous rigid bronchoscopies had been negative. Thirty-nine of these procedures were done within two weeks, and four within two months of the previous rigid bronchoscopies. As shown in Table 2 we were able to make a positive diagnosis in 21 of 29 patients with bronchogenic carcinoma, a yield of 72.4 percent. Of the 29 cases of bronchogenic carcinoma, 20 were peripheral and a diagnosis was made in 15 of these cases, a positive yield of 81.8 percent under fluoroscopic guidance and 66.6 percent without fluoroscopy. This clearly demonstrates the superiority of the flexible bronchofiberscope over the conventional rigid bronchoscope. Examples of brushing under fluoroscopic guidance are shown in Figures 1 through 3. The case illustrated in Figure 4 is that of a 42-year-old man who had pulmonary tuberculosis in 1971 and now has residual bilateral upper lobe cavities. The patient reentered the hospital with complaint of blood streaked sputum for three days. Bronchoscopy was done with the 6 mm bronchofiberscope and, to our surprise, on entering the left upper lobe, we were able to get the scope into the large cavitary lesion shown in the spot film. We are not aware of any similar case reported in the literature.
Discussion Anesthesia In 1924, a special committee of the American Medical Association chaired by Dr. Emil Mayer reported on toxic effects following the use of topical anesthetics. Of the 43 deaths collected, 26 were due to cocaine. In all of them, convulsions were followed by respiratory arrest within a few minutes. The dosage of cocaine and the total amount employed were not stated for 21 of the 26 patients.'0 Since Mayer's report, the use of cocaine as a topical anesthetic has fallen into disrepute except in a few centers. Cocaine is normally detoxified by the liver at the rate of one minimal lethal dose (MLD) per hour. The fatal dose has been stated to be about 1.2 grams. The recommended maximal dosage for
topical anesthesia is 3.3 mg per kg of body weight, (about 225 mg for a 150 lb adult)"' and the anesthesia persists for more than 20 minutes.'2 Serious complications arising from topical anesthesia appear to be related to a more rapid than usual absorption of the drugs used (cocaine, lidocaine, tetracaine).'3 This absorption rate depends on the state of the mucosa, amount of mucus in the airways, rate and depth of respiration, state of the patient's circulation, period of time in which the drug is given and the total dose.'4"5 The clearance rate of these drugs is impaired in patients with heart failure or liver disease.'6 Credle,'7 in a recent review of complications during flexible fiberoptic bronchoscopies in 24,521 collected cases does not mention the use of cocaine topical anesthesia. He reports one death and five serious complications due to tetracaine, which is still used by some. Weisel'8 reported 1,000 consecutive bronchoscopies in which 2 percent tetracaine was used with no fatalities. However, severe reactions occurred in seven patients, in two of whom bronchoscopy was done subsequently without difficulty using 4 percent and 10 percent cocaine solution. Adriani'9 reported 15 deaths due to tetracaine in 1956. At the La Jolla Shores Conference on Flexible Fiberoptic Bronchoscopy held in September 1973, lidocaine was noted to be the most commonly used topical anesthetic agent. In addition to 256 flexible fiberoptic bronchoscopies, we have done 2,040 rigid bronchoscopies in a seven-year span (February 1967 to February 1974) using topical cocaine anesthesia without any complications requiring treatment. In particular we have seen no convulsions, respiratory depression or cardiac or respiratory arrest. We attribute this to the judicious use of the drug following adequate premedication. We have noted occasional patients with transient moderate hypotension, sinus tachycardia, nausea or euphoria; but none of these required therapy. One of us (Y.F.F.) has used cocaine topical anesthesia in over 4,000 bronchoscopies between January 1944 and January 1967. In the earlier period, a DeVillbiss atomizer was used to spray 10 percent cocaine solution repeatedly into the oral cavity and the posterior pharynx until the gag reflex was eliminated and fractional instillation could be done by indirect laryngoscopy until the cough reflex was abolished. In those earlier days when the amount administered was not well controlled, an occasional toxic reaction was observed in which the THE WESTERN JOURNAL OF MEDICINE
119
FLEXIBLE FIBEROPTIC BRONCHOSCOPY
Figure 1.-Small coin lesions are also amenable to brush biopsy.
..
Figure 2.-54-year-old man with recent blood streaked sputum and a right upper lobe infiltrate. Bush biopsy: adenocarcinoma.
120
FEBRUARY 1975 * 122 * 2
FLEXIBLE FIBEROPTIC BRONCHOSCOPY
I ,l.
~r,ii!
Figure 3.-Mass in left apex. Brush biopsy: malignant cells.
L
..
Abil.
-::,l-
A
-,
11
."' lbil. ..
tiiL
Figure 4.-Spot film of the chest showing the 6 mm flexible fiberoptic bronchoscope inside the cavitary lesion located in the left upper lobe .p
THE WESTERN JOURNAL OF
MEDICINE
121
FLEXIBLE FIBEROPTIC BRONCHOSCOPY
patients became extremely restless and began jerking intermittently. These responses were quickly controlled by intravenous administration of a barbiturate such as sodium pentothal or sodium amobarbital with no fatalities. A barbiturate such as sodium secobarbital or, more recently, diazepam20 may be given as a premedication since they may be valuable in protecting against cocaine induced seizures.
Endotracheal tube If an adequate topical anesthetic has been administered, the endotracheal tube can be passed either by indirect laryngoscopy or by the method mentioned previously quite easily. The patients tolerate this with little or no discomfort. The endotracheal tube is routinely used even for bedside bronchofiberscopy. Good topical anesthesia is the key to successful intubation. The advantages of using an endotracheal tube are many: * It facilitates repeated removal and reinsertion of the bronchofiberscope for suction and introduction of brushes, curettes or biopsy forceps. * It probably minimizes or prevents contamination of the bronchial tree by nasopharyngeal secretions. * Very ill patients can be bronchoscoped without interruption of their ventilatory support. * For excessive secretions or moderate hemorrhage, a suction tube can be introduced to keep the airway clear. * In the event of severe hemorrhage, the scope would be introduced into the nonbleeding bronchus and the endotracheal tube advanced into that bronchus, thereby assuring an adequate airway to that lung. In such instances, the cuff can be inflated and the patient placed on his side with the bleeding site dependent. The patient can be placed in the Trendelenburg position in order to drain the blood, at the same time delivering oxygen to the good lung until the situation has resolved.21 Although we have not had to resort to
122
FEBRUARY 1975 * 122 * 2
this tactic, with an endotracheal tube in place, we are prepared for such emergencies.
Results This limited study reveals the safety of cocaine topical anesthesia when used as described above. The advantage of using the fluoroscopic image intensifier for peripheral lesions as well as the advantage of the flexible fiberoptic bronchoscope over the conventional rigid bronchoscope in diagnosing lung cancer is clearly evident. REFERENCES 1. Somner AR, Hibbs BR, Douglas AC, et al: Value of bronchoscopy in clinical practice-A review of 1109 examinations. Br Med J 1:1079-1084, 1958 2. Steele JD: The solitary pulmonary nodule. J Thorac Cardiovasc Surg 46:21-36, 1963 3. Ikeda S: Flexible bronchofiberscope. Ann Otol Rhinol Laryngol 79:916-923, 1970 4. Hattori S, Matsuda M, Sugiyama T, et al: Cytologic diagnosis of early lung cancer-Brushing method under x-ray television fluoroscopy. Chest 45:129-142, 1964 5. Rath GS, Schaff JT, Snider GL: Flexible fiberoptic bronchoscopy. Chest 63:689-693, 1973 6. Valaitis J, McGrew EA, Chomet B, et al: Bronchogenic carcinoma in situ in asymptomatic high-risk population of smokers. J Thorac Cardiovasc Surg 57:325-332, 1969 7. Richardson RH, Zavala DC, Mukerjee PK, et al: The use of fiberoptic bronchoscopy and brush biopsy in the diagnosis of suspected pulmonary malignancy. Am Rev Resp Dis 109:63-66, 1974 8. Smith GH, Warrach AJN: An evaluation of brush biopsy in the diagnosis of peripheral pulmonary lesions. Thorax 27:631-635, 1972 9. Kerby GR: Newer diagnostic techniques in pulmonary disease. Clin Notes on Resp Dis 12:3-6, 1974 10. Mayer E: The toxic effects following the use of local anesthetics. JAMA 82:876-885, 1924 11. Ritchie JM, Cohen PJ, Dripps RD: Cocaine, procaine and other synthetic anesthetics, chap 20, In Goodman LS, Gilman A (Eds): The Pharmacologic Basis of Therapeutics. New York City, The Macmillan Co., 1970, pp 372-382 12. Osol A, Pratt R, Altschule MD: Cocaine, In The United States Dispensatory and Physicians' Pharmacology. Philadelphia, J. B. Lippincott Company, 1967, pp 310-312 13. Steinhaus JE: A comparative study of *the experimental toxicity of local anesthetic agents. Anesthesiology 13:577-586, 1952 14. Campbell D, Adriani J: Absorption of local anesthetics. JAMA 168:873-877, 1958 15. Adriani J, Zepernick R: Some recent studies on the clinical pharmacology of local anesthetics of practical significance. Ann Surg 158:666-671, 1963 16. Thomson PD, Melmon KL, Richardson JA, et al: Lidocaine pharmacokinetics in advanced heart failure, liver disease, and renal failure in humans. Ann Intern Med 78:499-508, 1973 17. Credle WF, Smiddy JF, Elliot RC: Complications of fiberoptic bronchoscopy. Am Rev Resp Dis 109:67-72, 1974 18. Weisel W, Tella RA: Reaction to tetracaine used as topical anesthetic in bronchoscopy. JAMA 147:218-222, 1951 19. Adriani J, Campbell D: Fatalities following topical application of local anepthetics to mucous membranes. JAMA 162: 1527-1530, 1956 20. de Jong RH, Heavner JE: Local anesthetic seizure prevention. Anesthesiology 36:449-457, 1972 21. Ikeda S: Personal communication. Sep 1973
