671
Rigid Bronchoscopy Abdul Hamid Alraiyes, MD1
Michael S. Machuzak, MD, FCCP2
1 Division of Interventional Pulmonology, Department of Medicine,
Roswell Park Cancer Institute, Buffalo, New York 2 Department of Pulmonary Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio
Address for correspondence Michael S. Machuzak, MD, FCCP, Department of Pulmonary Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195 (e-mail: [email protected]).
Abstract
Keywords
► ► ► ►
rigid bronchoscopy rigid intubation endobronchial tumor therapeutic rigid bronchoscopy ► foreign body extraction ► massive hemoptysis
The purpose of this article is to provide an introduction to rigid bronchoscopy (RB). We will briefly discuss its history, evolution, and resurgence while we highlight its versatility and usefulness for today’s interventional pulmonologist and thoracic surgeon. Despite being one of the earliest pulmonary procedures described, RB is still an important technique. Advances in thoracic medicine have made this skill critical for a fully functional interventional pulmonary program. If the interventional pulmonologist of this century is to be successful, he or she should be facile in this technique. Despite the availability of RB for decades, the invention of flexible bronchoscopy in 1966 led to a significant downturn in its usage. The growth of the interventional pulmonology field brought RB back into the spot light. Apart from the historic role of RB in treatment of central airway lesions and mechanical debulking of endobronchial lesions, RB is the key instrument that can adapt modern therapeutic tools such as laser, argon plasma coagulation, electrocautery, cryotherapy, and stent deployment. Performing RB requires proper preprocedure preparation, exceptional understanding of upper airway anatomy, specific hand–eye coordination, and open communication between the bronchoscopist and the anesthesiologist. These skills can be primarily learned and maintained with repetition. This article will review information relevant to this technique and lay a foundation to be built upon for years to come.
History of Rigid Bronchoscopy Manuel Rodrigues Garcia, a Spanish singer and music teacher, was the first person reported to perform an “in vivo” evaluation of the airways. He performed this procedure on himself around 1855. The technique for indirect laryngoscopy was later perfected in Germany by Johann Czermak1 in 1858. The first therapeutic rigid bronchoscopy (RB) was performed in 1897 by Professor Gustav Killian at the Department of Otolaryngology, Freiburg University, Germany.2 He used a Mikulicz-Rosenheim rigid esophagoscope with rigid forceps to remove a piece of a pork bone from the right main stem bronchus of a 63-year-old farmer using topical cocaine to locally anesthetize the airway. This was the first documented case of a foreign body (FB) removal; however RB had been
Issue Theme Interventional Pulmonology; Guest Editors: David Feller-Kopman, MD and Lonny Yarmus, DO, FCCP
performed earlier by Professor Killian on tracheotomized patients and volunteers for airway examinations.3,4 In 1920, Chevalier Jackson performed the first RB in the United States. He is regarded as the “Father of American bronchoesophagology” and practiced primarily in Pennsylvania. His career is noteworthy for many reasons, including his avidity for education and innovation. He modified the scope to match the tracheal length, improved upon current instruments, as well as advancing the scope’s optics.2,5,6 The optical telescope manufacturing was advanced in the 1940s to 1950s by Broyles and Hopkins, introducing the telescope optic, optical forceps, and improving lighting and imaging.4 The primary focus of RB in the early years was FB removal, useful though limited in numbers. Later, in the 1950s and beyond, largely due to advances in anesthesia and technology,
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1395500. ISSN 1069-3424.
Downloaded by: University of Florida. Copyrighted material.
Semin Respir Crit Care Med 2014;35:671–680.
Rigid Bronchoscopy
Alraiyes, Machuzak
the rigid scope gained more popularity. Though primarily in the surgical world, RB was recognized as a useful tool for central airway tumor debulking. RB again took a large step forward thanks to Jean-Francois Dumon in the 1980s and beyond, as he continued with innovation, incorporating laser ablation, stenting, as well as publishing and educating. His results, publications, and dissemination of knowledge helped a new burgeoning interest in RB, adding to the formation of a new field in pulmonology.7
Equipment The RB is a simple yet incredibly versatile tool used for airway evaluation, diagnosis, and therapeutics. RB is, in its simplest form, a tool to access the main airways, but if used properly can be much more. Designs vary depending on the manufacturer, but several components are fairly universal including the barrel, head, light source, telescope, and eyepiece/camera attachment. Included in the basic RB assembly are various caps which allow for delivery of instruments or to provide a seal. Because of its large working channel, a multitude of tools such as forceps, dilators, catheters, debulking, or stent deployment devices can be introduced. The RB is a simple device; it is basically a hollow metallic tube of which many styles are available with most incorporating a beveled tip. This bevel can serve several purposes: elevating the epiglottis for insertion/intubation, cutting or coring at a tumor edge, gaining access to a tight luminal stenosis to initiate dilation, or separating an embedded stent from the airway mucosa among others. The multifunctional head also serves many roles, including ventilation and delivery of both devices and the optics. This head allows for attachment to several types of ventilating options (a conventional ventilator, jet ventilator, or hand bagging); insertion of suction catheters, laser, cautery, or other thermal ablation devices; debulking or dilating tools; as well as the visualizing instruments. This can all be accomplished while providing for either an open or closed ventilating system utilizing metal, silicone, glass, or plastic caps. RBs come in several lengths and diameters allowing for both adult and pediatric patients. Lengths vary by manufacturer but typically range from 33 to 43 cm. Diameters range from 3 mm in pediatric sets to as large as 18 mm with most adult scope series ranging from 7 to 14 mm. In general, there are two standard lengths, the bronchial tubes (►Fig. 1) which are longer and have side fenestrations to facilitate the ventilation of the nonintubated main bronchus, and the tracheal tube (►Fig. 2), which is shorter and has
Fig. 1 Long bronchial metallic tubing with side ventilation openings; the colors reflect different diameter. Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
Fig. 2 Short tracheal metallic tubing; the colors reflect different diameter.
no side fenestrations; the ventilation is through the distal opening. The tracheal tube is often used for subglottic or tracheal cases, while the bronchial scope can reach the distal mainstem bronchi bilaterally and into the bronchus intermedius on the right. Telescopes also come with two different lengths to match the length of the individual scope. The various ports enable connection to ventilation systems and insertion of the rigid tools. To minimize air leak and secure the telescope position, silicone caps can be applied to the openings (►Fig. 3).
Rigid Bronchoscopy Indications RB has multiple indications which include gathering tissue for diagnostic purposes, providing a secure airway/working conduit and as a tool for therapeutic intervention. As malignancy has become one of the primary reasons bronchoscopy is performed, both indications are often realized in one procedure. While it is our practice to use both flexible and RB
Fig. 3 The proximal end of the scope. (A) Connecting devices to the ventilation system and working accessory inlets. (B) Silicone capes applied on the working accessory inlets.
Downloaded by: University of Florida. Copyrighted material.
672
Table 1 Rigid bronchoscopy indications & Large biopsies & Massive hemoptysis & Foreign body extraction & Endoluminal obstruction: Mechanical debulking • Coring of tumors • Direct dilation for endobronchial stenosis & Adjunctive Laser, cryotherapy, balloon and bougie dilation, microdebrider Stent placement or removal
concurrently, we focus on RB and discuss several advantages RB offers over flexible bronchoscopy. The presence of a large bore-working channel for both ventilation and delivery of a multitude of instruments simultaneously provided by RB cannot be overstated.8 RB has a unique ability to permit simultaneous procedures without limiting ventilation. One can debulk, ablate, suction, and provide tamponade all while still allowing for ventilation through this large tube. For example, flexible bronchoscopic dilation most commonly occurs with the use of a balloon; however, ventilation is limited when the balloon is inflated particularly in tracheal or subglottic cases. The absolute indications for RB are only limited by current technology and the imagination of the bronchoscopist. RB is particularly useful for most endobronchial pathologies including endobronchial tumors, stricture/ stenosis, hemoptysis, and FB extraction.9–11 In addition to using the RB as the primary tool, many experts favor the use of RB as the conduit to apply current endobronchial therapeutic equipment (►Table 1).12–15
Central Airway Obstruction Primary and metastatic carcinomas of the lung are the most common causes of central airway obstruction (CAO). CAO from malignant disease is reported in as many as 30% of cases11 (►Fig. 4). Other less common causes of CAO include benign airway diseases. Many etiologies can be responsible for benign
Alraiyes, Machuzak
airway CAO, including, but not limited to, autoimmune and/or inflammatory conditions such as granulomatosis with polyangiitis (GPA), sarcoidosis, lung transplantation, postintubation, thermal injury, as well as idiopathic, iatrogenic, or posttraumatic.16,17 Malignant CAO often presents with symptoms of dyspnea and cough or signs such as hemoptysis and is associated with a poor prognosis due to the advanced nature of the disease. As one can imagine, this presentation can be quite disturbing to the patient and their loved ones. RB has been shown to be a safe and reliable method for rapid palliation of symptoms. Primary rigid debulking of the tumor can quickly and dramatically improve their quality of life.18 Endobronchial debulking of CAO with RB can be accomplished solely with the rigid scope or in combination with an adjunctive ablative device, thermal or otherwise. The purely mechanical means can be accomplished quite quickly, safely, and effectively. Coring out of a tumor with the rigid broncho- or tracheoscope has a few advantages over the other means. Utilizing the beveled edge of the RB, one can gently remove endobronchial or endotracheal tumor by placing the beveled edge against the base of tumor and gently rotating with forward pressure to bluntly dissect the tumor away from the wall. Fragments from the primary tumor can be removed with a suction catheter, forceps, cryoprobe, or other device. This technique requires careful attention to details such as visualization of the tumor and airway ensuring the correct axis and course is taken. Bronchial, tracheal, and vascular anatomy can be markedly abnormal in such cases, requiring excellent anatomical understanding and experience to be successful. Careful attention to these details will minimize the chance for perforation (or other injury) to a bronchus or major vessel. This technique highlights several advantages including immediate tamponade at the base of the tumor with the rigid scope. The RB is uniquely qualified for such a maneuver, as its metallic shaft can be manipulated to provide direct pressure in any location over 360 degrees. Additional benefits provided by the rigid scope include the ability to suction large quantities, if needed, while still maintaining a patent lumen for adjunctive instruments. According to many experts, the greatest asset provided by the RB for restoring patency in CAO lies in its ability to provide ventilation throughout this
Fig. 4 Adenocarcinoma of the lung invading the right and left main bronchus treated with Nd:YAP laser and APC.
Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
673
Downloaded by: University of Florida. Copyrighted material.
Rigid Bronchoscopy
Rigid Bronchoscopy
Alraiyes, Machuzak
Fig. 5 Adenocarcinoma of the lung cored using rigid bronchoscopy and suction catheter.
maneuver. This is particularly valuable when the patient presents in respiratory or cardiovascular distress and requires a high level of oxygen delivery to maintain an adequate saturation. A high level of inspired oxygen is a contraindication to using thermal modalities (except cryotherapy), as it increases the risk of an airway fire; this will be covered in detail in other articles in this issue19 (►Fig. 5). Thermal therapeutic treatments such as laser,20–22 electrocautery,20,23 and argon plasma coagulation24 can be applied if lower oxygen levels are tolerated by the patient (►Fig. 4). Now we will shift our focus to the unique benefits RB can apply to patients with benign airway stenosis. These patients typically present similarly with dyspnea, often associated with focal wheezing.16 Many etiologies may be responsible for CAO in benign disease, relating to an underlying autoimmune, inflammatory condition such as GPA, sarcoidosis, inflammatory bowel disease, and others. A benign stricture may also be induced by a traumatic intubation, tracheostomy, as well as a straight-forward endotracheal tube insertion. Cases of benign airway strictures are also seen post–lung transplantation or from an idiopathic cause. Treatment options vary according to the etiology but typically involve a multimodality approach employing electrocautery, cryotherapy, Microdebrider, and rigid, balloon, or bougie dilations.25,26 A rigid bronchoscope or tracheoscope can
accomplish dilations in a safe and effective manner utilizing sequential rigid dilations27 or combining modalities28 (►Fig. 6). RB can accomplish similar results quickly while maintaining a safe airway with continued ventilation that is not possible when using a balloon or bougie for dilation. While most procedures performed by interventional pulmonologists (IP) occur in the trachea and bronchi, occasionally upper tracheal or subglottic obstruction must be addressed and the rigid tracheoscope is well suited for such endeavors. This scope can allow for optimal ventilation, repeated access, and quick dilation in this difficult location. In addition, RB can play a vital role in cases of subglottic and tracheal stenosis in which a T-tube placement is required.29,30 RB can deliver airway support, ventilation, aid in positioning, and endow airway protection while placing the T-Tube. Stent placement is another area where RB can play a major role. Regardless of the stent chosen, RB can offer advantages in stent placement, repositioning, maintenance, and removal.8,31 In regard to stenting, five generally accepted indications for stenting exist32: 1. Extrinsic compression of the airway from tumor or lymph nodes 2. To stabilize an airway after intraluminal removal of tumor
Fig. 6 Benign subglottic stenosis secondary to traumatic intubation treated by sequential rigid dilations.
Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
Downloaded by: University of Florida. Copyrighted material.
674
Rigid Bronchoscopy
Alraiyes, Machuzak
675
3. Restoring patency in benign recurrent strictures 4. To support a symptomatic malacic airway 5. To cover and potentially treat a fistula Discussing the specifics of stenting is beyond the scope of this article and it will be covered in depth elsewhere. RB has much to offer whether the choice of stent is silicone, a selfexpandable metallic stent (SEMS), or a hybrid stent. Benefits of RB include a large working channel, the option for direct visualization during placement of a SEMS, larger forceps in which to grasp the stent for placement, revision or removal, aiding patency by using the RB to stent the airway during placement, and, of course, improved ventilation during placement. Silicone stents are still regarded by many to be the gold standard owing to their long history and experience and have become more popular as RB use has increased. Novel techniques have been described to place silicone stents, but RB is considered the standard of care for placement.15,33 Details of stent placement will be covered elsewhere. Silicone stents are useful in malignant disease but in unusual cases of benign airway diseases requiring stenting, particularly the trachea should be the first stent considered.34 Characteristics of the rigid scope including the large working channel as well as the stiffer forceps allow for the proper method to deploy and remove airway stents (►Fig. 7).35
subglottis, and vocal cords from harm upon removal. This is not to say that successful FB removal can only be accomplished with a rigid scope. In fact, flexible bronchoscopy may be the sole option for removal due to the distal nature of the impaction. Most experts would agree that some combination of both can be incredibly useful depending on the location, size, and type of FB. An aspirated object can be removed using forceps, baskets, snares, or other modalities such as cryotherapy depending on the extrinsic and intrinsic qualities of the FB. For example, one with high water content such as a grape can readily be removed with a cryotherapy probe providing the necessary adhesion, while a larger FB may need rigid forceps due to its girth (►Fig. 8). Neglecting FB removal can cause chronic postobstructive pneumonia and formidable infectious implications. Our ability to remove foreign bodies has led to a significant improvement in patient care. What was once described as a 24% mortality rate has now improved to almost nonexistent rate.39
Massive Hemoptysis Hemoptysis, particularly life-threatening or massive hemoptysis, is another arena in which proper handling of a RB may afford distinct benefits. The ability to provide large volume suction, airway protection, and maintenance of ventilation makes RB a necessary skill in many cases.40,41 During the chaos that can arise during significant airway bleeding, the
Foreign Body Extraction Although FB aspiration is an uncommon event, it is certainly not rare. Although practice patterns vary, it is likely that one will encounter this issue on several occasions during a career in thoracic medicine. FB aspiration is far more common in children than in adults typically involving the young (younger than 3 years) and elderly (adults in their 7th decade and on).36–38 There are no prospective randomized trials which declare whether flexible or rigid bronchoscopy is a superior choice for removal of a FB. In fact, many FB removals employ both flexible and rigid bronchoscopy. However, RB does offer several advantages. A large working channel and a larger scale of instrument are common themes as we discuss the rationale for using RB and both hold true in FB removal. The luminal diameter of the RB allows for not only larger instruments and a wider range of manipulation of those instruments but also multiple instruments to be used simultaneously. The barrel of the RB can be used to protect the uninjured lower airway,
Fig. 8 Foreign body extracted from the trachea aspirated by adult while trying to swallow it. Removed using RB and rigid forceps. Compare the size differences between the rigid and flexible forceps. Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
Downloaded by: University of Florida. Copyrighted material.
Fig. 7 Silicone stent deployment in the airway.
Rigid Bronchoscopy
Alraiyes, Machuzak
rigid bronchoscope can provide isolation of the bleeding and protection of the “healthy” lung by selectively intubating the main stem bronchi of the nonbleeding lung. Isolation of the nonbleeding bronchus will permit both oxygenation and ventilation, while maneuvers can be directed to halt the bleeding. In cases of a proximal hemorrhage, RB can also tamponade the site of bleeding, offering a therapy while safely allowing clot to form.42,43 RB also provides a large conduit to introduce therapeutic measures to address the source of bleeding with thermal techniques or for topical application of epinephrine or ice-cold saline to the bleeding location.44,45 Although RB is a fantastic modality for treatment of hemoptysis, its success depends on proper expertise from an operator and team with the ability to perform RB in a reasonable time frame. Even in the most controlled conditions, establishing an airway with a rigid bronchoscope mandates appropriate experience and preparation that can be difficult to establish in cases of massive hemoptysis.
bronchoscopist communicate throughout the procedure to increase the likelihood of success in each RB case.47 Any alternative or stand-by equipment should be prepared before initiation. Before intubation, preoxygenation and standard anesthetic monitoring should be applied such as electrocardiographic and blood pressure monitoring, pulse oximetry, and end-tidal CO2 monitoring.48 In addition to the usual monitoring, other observations such as chest wall rise with initiation of ventilation should be observed. This technique can be important as end-tidal CO2 may be difficult to assess whether using an open or closed ventilation system. To facilitate intubation, neuromuscular blocking agent is used in most cases after assuring appropriate ventilation. Total intravenous anesthesia (TIVA) is desired over inhalational anesthesia due to significant environmental contamination with the inhalational agent and the inefficiency relating to the substantial leak often seen in RB.49
Ventilation Approach in Rigid Bronchoscopy
Rigid Bronchoscopy Contraindications There are very few absolute contraindications to performing RB. The indications as well as the contraindications should be evaluated based on the need, as for any procedure. Concern for most complications is related to general anesthesia (GA). RB can be accomplished in the absence of GA, but without a high level of sedation the experience of the procedure will certainly be different, both for the bronchoscopist as well as the patient; therefore, most are performed with deep sedation or GA.46 Patients with comorbid diseases making them a concern for GA should be fully evaluated with a risk assessment to determine if and when to proceed. Any preprocedural optimization should be addressed as early as possible, particularly if the indication for RB is related to an airway obstruction or FB. Patients with a coagulopathy or on anticoagulant medication would be another example in which the risks and benefits must be weighed carefully. Anatomic considerations must also be entertained, as a patient with an unstable or fused cervical spine, facial injuries, or abnormalities may not be suitable to position or manipulate as is required for RB. This procedure has potential for complications and so one must consider the risks, benefits, alternatives, and personnel as well as the resources available. A candid conversation should be undertaken with the patient or representative and only if the risks are outweighed by the benefits should RB be performed.
Anesthesia and Ventilation Anesthesia for Rigid Bronchoscopy Like any other procedure, preparation for effective and open communication is crucial to the success of RB. Airway assessment for endotracheal intubation such as Mallampati classification should be performed and appropriate equipment available for cases deemed challenging. A thorough discussion of the initial plan as well as any potential alternatives should be covered before induction. All team members should be involved, but it is critical that the anesthesiologist and Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
Ventilation during RB may be challenging, as leakage around the scope can influence the typical measures of adequate ventilation. As the RB has no balloon, assessment of end-tidal CO2 and tidal volume can be difficult. Ventilation through an open circuit as is done with jet ventilation is a technique many anesthesiologists are unfamiliar with. The mode of ventilation is institution dependent and typically determined by the experience and comfort level of the anesthesiologist and bronchoscopist. As described earlier, considerable collaboration between the anesthesiologist and the bronchoscopist is required. Multiple ventilation modes can be considered including assist spontaneous ventilation (ASV), controlled ventilation (CV), or jet ventilation.47 ASV is typically applied with TIVA; the ventilation depends on the patient’s effort as well as manual assistance. For CV, neuromuscular blockade is commonly used while the patient is ventilated with a pressure or volume control mode. A semiclosed circuit can be achieved by placement of the silicone caps on the multifunctional head as well as packing the oropharynx with moist gauze to minimize the air leak. Neuromuscular blockade is not an absolute requirement and the procedure can still be successful if the patient is breathing spontaneously. Anterior mediastinal masses are a particular concern and NM blockade may need to be avoided to prevent loss of the airway. Dexmedetomidine is one agent that has been described in such circumstances.50 Jet ventilation is another option in which the patient is typically paralyzed during the procedure; either manual jet ventilation or high-frequency jet ventilation (HFJV) can be used. Manual jet ventilation utilizes a respiratory rate of 10 to 14 breaths/minute at a pressure of 50 psi or less with the lowest pressure possible preferred. During this mode, appropriate ventilation is assessed by adequate chest rise.46,51 HFJV differs in that the respiratory rate can be set between 60 and 300 breaths/minute with 12 to 18 psi while maintaining the peak pressures < 35 cm H2O.52 The advantage of HFJV is a motionless operative field. PaCO2 can be monitored by frequent arterial blood gas measurement or by transcutaneous capnographic monitoring.53 Many variations and styles exist
Downloaded by: University of Florida. Copyrighted material.
676
Alraiyes, Machuzak
Fig. 9 Direct method rigid intubation. (A) Mouth opened by scissors technique and the bronchoscope is advanced perpendicularly to the patient in the midline. The base of the tongue is observed and gently raised. (B) The epiglottis observed. (C) Epiglottis raised by the bevel of the bronchoscope and vocal cords seen. (D) The bronchoscope is turned 90 degrees and advanced through the vocal cords. (E) The bronchoscope is turned another 90 degrees to bring the bevel anteriorly. (F) The bronchoscope advanced into the trachea.
and no single mode of ventilation has been shown to be superior, the best choice is one the operator and anesthesiologist are most comfortable with while realizing any one mode may be best for an individual patient.
Rigid Bronchoscopy Intubation The three classic ways of rigid bronchoscopic intubation are direct method, laryngoscope method, and intubation over or alongside an endobronchial tube (ETT).7,18
Direct Method This method is most commonly used and has the most extensive publication and hands-on teaching experience. In the direct method, the bronchoscope is the primary instrument for intubation. The patient is positioned in the sniffing position; this is accomplished by tilting the head and hyperextending the neck (►Fig. 9). Proper positioning will elevate
the larynx and create a more linear route to the vocal cords. As the RB is by definition inflexible, an axis must be created between the mouth, pharynx, and larynx. The mouth is opened using the scissors technique by placing the left thumb over the upper teeth and the left index finger over the lower teeth. Care must be taken to avoid trauma to the patient’s teeth and lips and protection with a tooth guard, moist gauze, or the bronchoscopist’s fingers is recommended. The bronchoscope is then introduced with the right hand holding the bevel anteriorly. Variations do exist and certainly a lefthanded bronchoscopist may use his or her left hand. It is important to mention that the bronchoscope should only be advanced under direct and complete vision. The bronchoscope is advanced perpendicularly into the patient following the midline. The soft palate will be observed first, followed by the uvula, at that point the right hand is lowered and the base of the tongue is gently raised. The epiglottis should now be seen, being elevated by the bevel of the bronchoscope. This Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
677
Downloaded by: University of Florida. Copyrighted material.
Rigid Bronchoscopy
Rigid Bronchoscopy
Alraiyes, Machuzak
action will bring the vocal cords into view. At this point, the bronchoscope is turned 90 degrees and advanced through the vocal cords. Once the trachea is entered, the scope will be rotated 90 degrees again and the trachea is entered.2 If the intubation is with a bronchial scope, one must be aware to advance the scope distal enough to allow all the lateral fenestrations to sit inside the trachea to ensure adequate ventilation. The most common errors occurring with this method are allowing the scope to veer from midline or advancing too far past the epiglottis, underneath the larynx; in this instance the scope would then expose the esophagus upon lifting.
Laryngoscope Method In this method, a straight blade (Miller) laryngoscope is typically held in the left hand and used to visualize the epiglottis. Once visualized, the base of the tongue and the epiglottis are elevated using the laryngoscope allowing for a direct view of the vocal cords. The rigid bronchoscope is then introduced into the mouth with the right hand directly to the vocal cords and the scope is advanced with the same rotation technique described in the direct method.
Rigid Bronchoscopy Training and Future
Intubation over Endobronchial Tube In this scenario, the patient either presented to the procedure room intubated or has been intubated for bronchoscopy. The RB is advanced over the ETT with the same technique as the direct intubation to the epiglottis, then the ETT balloon is deflated and pulled out while maintaining the same position at the level of vocal cords with the RB. The RB is advanced with the same rotation technique described in the direct method intubation. A similar technique has been described alongside the endotracheal tube.
Rigid Bronchoscopy Complications Complications associated with RB are usually uncommon, provided the procedure is performed with the correct indication by a well-trained person.2,31 The most common complaint is a sore throat after the procedure; however, more serious complications are described. Complications related to a rigid bronchoscopic procedure may be classified as preoperative, anesthesia-associated or due to the procedure itself (i.e., the rigid bronchoscope).54 Hypoxemia-induced cardiac ischemia and arrhythmias are the most dangerous complications. Patients with difficult airway are more prone to teeth, gums, and larynx injury. Tracheal or bronchial wall rupture has been reported in some cases.55,56 The key point of avoiding these complications is proper preoperative assessment, appropriate instrument preparation, and anesthesiologist and bronchoscopist communication.57 Data relating to RB complications are sparse but do exist. In a retrospective study between 1992 and 1999, a total of 775 RBs were reviewed retrospectively in a tertiary-care hospital. Complications were seen in 103 patients (13.4%); though most were mild, 3 deaths did occur (1 due to respiratory failure and 2 from severe hemorrhage). The overall mortality rate was low at 0.4% in an ill population predominantly Seminars in Respiratory and Critical Care Medicine
Vol. 35
encompassing advanced lung cancer. Risk factors for severe complications were related to respiratory, cardiac and/or hematologic disease, carinal involvement, neoplastic disease, and foreign bodies. Unfortunately, the population identified is typical for RB. In another large series, only 2 deaths were recorded in 11,000 rigid bronchoscopies.58 While the common belief is that RB leads to more complications than flexible bronchoscopy, there are few publications that compare both head to head. One prospective study looked at 1,146 flexible bronchoscopies compared to 3,449 RB and and found complications were less common with RB. The majority of complications associated with flexible bronchoscopy were related to tetracaine, while RB complications were related to GA. However, the risk of major complications induced by the RB was significantly higher than those caused by flexible bronchoscopy.59 Complication rates vary, likely related to patient factors, experience, and a nonuniform practice of reporting. Standardization and publications relating to complications will be critical for the advancement of this procedure in a scientific manner.
No. 6/2014
RB remains an important tool for the interventional pulmonologist and thoracic surgeon for both diagnosis and therapeutics. Despite advances in flexible bronchoscopy, RB continues to be an indispensable component in the armamentarium of thoracic medicine. Though modifications have occurred, much of RB is remarkably similar to the procedure first performed in the 19th century. RB provides distinct advantages over flexible bronchoscopy but optimal use is with combination. Primary tumor debulking or dilation, adjunctive technologies, stent placement, removal, revision, FB removal, as well as management of massive hemoptysis can all be performed through this simple yet elegant medical device while providing airway management, ventilation, and oxygenation. Surprisingly, this procedure is still underutilized, particularly in the United States, as RB training is offered in only 4.4% of all pulmonary medicine programs and in 31.3% of pulmonary programs that has an interventional pulmonology program.60 However, the increased interest in IP is leading to renaissance of this simple and efficient technique. Simulation-based training has been shown to be effective in transfer of knowledge and skills for a variety of tasks including RB. Based on a recent meta-analysis, simulator training has shown to be effective, though the optimal design is less clear. Longer, more structured training clearly adds value. Animal models may be superior to virtual reality-based simulators because of potentially being less expensive.61
Conclusion Despite the expansion of flexible bronchoscopy, RB remains a vital tool for diagnosis and therapeutics in thoracic medicine. Identifying knowledge gaps, advances in technology and education will propel RB into the next century bringing this once almost forgotten technology back into the spotlight.
Downloaded by: University of Florida. Copyrighted material.
678
Rigid Bronchoscopy
24 Morice RC, Ece T, Ece F, Keus L. Endobronchial argon plasma
1 Bryce DP, Nunis DB. The American Laryngological Association,
2 3
4 5
6 7 8
9
10
11
12
13
14
15
16 17
18
19 20 21
22
23
1878–1978: A Centennial History. Washington: American Laryngological Association; 1978 Ayers ML, Beamis JF Jr. Rigid bronchoscopy in the twenty-first century. Clin Chest Med 2001;22(2):355–364 Becker HD, Marsh BR. History of the rigid bronchoscope. In: Bollinger CT, Mathur PN, editors. Interventional bronchoscopy, vol 30. Basel (Switzerland): Karger, Prog Respir Res; 2000:2–15 Bolliger CT, Mathur PN. Interventional Bronchoscopy. Basel; New York: Karger; 2000 Beamis JF Jr. Interventional pulmonology techniques for treating malignant large airway obstruction: an update. Curr Opin Pulm Med 2005;11(4):292–295 Jackson C. The Life of Chevalier Jackson, An Autobiography. New York: The Macmillan Company; 1938 Helmers RA, Sanderson DR. Rigid bronchoscopy. The forgotten art. Clin Chest Med 1995;16(3):393–399 Jeon K, Kim H, Yu CM, et al. Rigid bronchoscopic intervention in patients with respiratory failure caused by malignant central airway obstruction. J Thorac Oncol 2006;1(4):319–323 Marel M, Pekarek Z, Spasova I, et al. Management of benign stenoses of the large airways in the university hospital in Prague, Czech Republic, in 1998-2003. Respiration 2005;72(6):622–628 McMahon CC, Rainey L, Fulton B, Conacher ID. Central airway compression. Anaesthetic and intensive care consequences. Anaesthesia 1997;52(2):158–162 Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004;169(12): 1278–1297 Hujala K, Sipilä J, Grenman R. Endotracheal and bronchial laser surgery in the treatment of malign and benign lower airway obstructions. Eur Arch Otorhinolaryngol 2003;260(4): 219–222 Freitag L, Ernst A, Thomas M, Prenzel R, Wahlers B, Macha HN. Sequential photodynamic therapy (PDT) and high dose brachytherapy for endobronchial tumour control in patients with limited bronchogenic carcinoma. Thorax 2004;59(9):790–793 Han CC, Prasetyo D, Wright GM. Endobronchial palliation using Nd:YAG laser is associated with improved survival when combined with multimodal adjuvant treatments. J Thorac Oncol 2007; 2(1):59–64 Gompelmann D, Eberhardt R, Schuhmann M, Heussel CP, Herth FJ. Self-expanding Y stents in the treatment of central airway stenosis: a retrospective analysis. Ther Adv Respir Dis 2013;7(5):255–263 Hollingsworth HM. Wheezing and stridor. Clin Chest Med 1987; 8(2):231–240 Honings J, Gaissert HA, van der Heijden HF, Verhagen AF, Kaanders JH, Marres HA. Clinical aspects and treatment of primary tracheal malignancies. Acta Otolaryngol 2010;130(7):763–772 Colt HG, Harrell JH. Therapeutic rigid bronchoscopy allows level of care changes in patients with acute respiratory failure from central airways obstruction. Chest 1997;112(1):202–206 Mathisen DJ, Grillo HC. Endoscopic relief of malignant airway obstruction. Ann Thorac Surg 1989;48(4):469–473, discussion 473–475 Ost D. Photodynamic therapy in lung cancer. A review. Methods Mol Med 2003;75:507–526 Kvale PA, Eichenhorn MS, Radke JR, Miks V. YAG laser photoresection of lesions obstructing the central airways. Chest 1985; 87(3):283–288 Chella A, Ambrogi MC, Ribechini A, et al. Combined Nd-YAG laser/ HDR brachytherapy versus Nd-YAG laser only in malignant central airway involvement: a prospective randomized study. Lung Cancer 2000;27(3):169–175 Coulter TD, Mehta AC. The heat is on: impact of endobronchial electrosurgery on the need for Nd-YAG laser photoresection. Chest 2000;118(2):516–521
679
25
26
27
28 29
30
31 32
33 34
35
36 37
38
39 40
41 42
43 44
45
46 47
coagulation for treatment of hemoptysis and neoplastic airway obstruction. Chest 2001;119(3):781–787 Chhajed PN, Malouf MA, Glanville AR. Bronchoscopic dilatation in the management of benign (non-transplant) tracheobronchial stenosis. Intern Med J 2001;31(9):512–516 De Gracia J, Culebras M, Alvarez A, et al. Bronchoscopic balloon dilatation in the management of bronchial stenosis following lung transplantation. Respir Med 2007;101(1):27–33 Madan K, Agarwal R, Aggarwal AN, Gupta D. Utility of rigid bronchoscopic dilatation and mitomycin C application in the management of postintubation tracheal stenosis: case series and systematic review of literature. J Bronchology Interv Pulmonol 2012;19(4):304–310 Pearson FG. Technique of management of subglottic stenosis. Chest Surg Clin N Am 1996;6(4):683–692 Goto T, Akanabe K, Oyamada Y, Kato R. A new technique for T tube insertion in severe subglottic stenosis. Interact Cardiovasc Thorac Surg 2011;12(6):895–898 Tedde ML, Rodrigues A, Scordamaglio PR, Monteiro JS. A new technique for T-tube insertion in patients with subglottic stenosis. Eur J Cardiothorac Surg 2011;39(1):130–131 Folch E, Mehta AC. Airway interventions in the tracheobronchial tree. Semin Respir Crit Care Med 2008;29(4):441–452 Wood DE, Liu YH, Vallières E, Karmy-Jones R, Mulligan MS. Airway stenting for malignant and benign tracheobronchial stenosis. Ann Thorac Surg 2003;76(1):167–172, discussion 173–174 Casal RF. Update in airway stents. Curr Opin Pulm Med 2010;16(4): 321–328 Noppen M, Stratakos G, Amjadi K, et al. Stenting allows weaning and extubation in ventilator- or tracheostomy dependency secondary to benign airway disease. Respir Med 2007;101(1):139–145 Miyazawa T, Miyazu Y, Iwamoto Y, et al. Stenting at the flowlimiting segment in tracheobronchial stenosis due to lung cancer. Am J Respir Crit Care Med 2004;169(10):1096–1102 Nicolai T. Foreign body aspiration in children [in German]. MMW Fortschr Med 2013;155(16):36–37 Ghaffarlou M, Golzari SE, Nezami N. A large asymptomatic foreign body in larynx and trachea. Quant Imaging Med Surg 2014;4(3): 210–211 Johns S, Sellon R, Spencer E, Tucker M. Tracheal Foreign Body and Pneumonia in a Cat: A Near Missed Diagnosis. J Am Anim Hosp Assoc 2014;50(4):273–277 Rafanan AL, Mehta AC. Adult airway foreign body removal. What’s new? Clin Chest Med 2001;22(2):319–330 Conlan AA, Hurwitz SS. Management of massive haemoptysis with the rigid bronchoscope and cold saline lavage. Thorax 1980; 35(12):901–904 Colchen A, Fischler M. Emergency interventional bronchoscopies [in French]. Rev Pneumol Clin 2011;67(4):209–213 Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC. Bronchoscopy-guided topical hemostatic tamponade therapy for the management of life-threatening hemoptysis. Chest 2005; 127(6):2113–2118 Reisz G. Topical hemostatic tamponade: another tool in the treatment of massive hemoptysis. Chest 2005;127(6):1888–1889 Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration 2010; 80(1):38–58 Solomonov A, Fruchter O, Zuckerman T, Brenner B, Yigla M. Pulmonary hemorrhage: A novel mode of therapy. Respir Med 2009;103(8):1196–1200 Plummer S, Hartley M, Vaughan RS. Anaesthesia for telescopic procedures in the thorax. Br J Anaesth 1998;80(2):223–234 Pathak V, Welsby I, Mahmood K, Wahidi M, MacIntyre N, Shofer S. Ventilation and anesthetic approaches for rigid bronchoscopy. Ann Am Thorac Soc 2014;11(4):628–634
Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
Downloaded by: University of Florida. Copyrighted material.
References
Alraiyes, Machuzak
Rigid Bronchoscopy
Alraiyes, Machuzak
48 Biro P, Layer M, Wiedemann K, Seifert B, Spahn DR. Carbon dioxide
55 Kim JH, Shin JH, Shim TS, Oh YM, Song HY. Deep tracheal laceration
elimination during high-frequency jet ventilation for rigid bronchoscopy. Br J Anaesth 2000;84(5):635–637 Perrin G, Colt HG, Martin C, Mak MA, Dumon JF, Gouin F. Safety of interventional rigid bronchoscopy using intravenous anesthesia and spontaneous assisted ventilation. A prospective study. Chest 1992;102(5):1526–1530 Abdelmalak B, Marcanthony N, Abdelmalak J, Machuzak MS, Gildea TR, Doyle DJ. Dexmedetomidine for anesthetic management of anterior mediastinal mass. J Anesth 2010;24(4):607–610 Sarkiss M. Anesthesia for bronchoscopy and interventional pulmonology: from moderate sedation to jet ventilation. Curr Opin Pulm Med 2011;17(4):274–278 Fernandez-Bustamante A, Ibañez V, Alfaro JJ, et al. High-frequency jet ventilation in interventional bronchoscopy: factors with predictive value on high-frequency jet ventilation complications. J Clin Anesth 2006;18(5):349–356 Eberhard P. Comparison of transcutaneous and end-tidal CO2monitoring for rigid bronchoscopy during high-frequency jet ventilation. Acta Anaesthesiol Scand 2004;48(2):260, author reply 261 Neyman K, Sundset A, Espinoza A, Kongerud J, Fosse E. Survival and complications after interventional bronchoscopy in malignant central airway obstruction: a single-center experience. J Bronchology Interv Pulmonol 2011;18(3):233–238
after balloon dilation for benign tracheobronchial stenosis: case reports of two patients. Br J Radiol 2006;79(942):529–535 Kim JH, Shin JH, Song HY, et al. Tracheobronchial laceration after balloon dilation for benign strictures: incidence and clinical significance. Chest 2007;131(4):1114–1117 Gompelmann D, Eberhardt R, Herth FJ. Interventional pulmonology procedures: an update. Panminerva Med 2013;55(2):121–129 Caputi M, Bellissimo U, Di Matteo L, Aliberti M, Perna B, Speranza A. Complications during bronchofiberscopy and rigid bronchoscopy. Panminerva Med 1986;28(3):271–277 Lukomsky GI, Ovchinnikov AA, Bilal A. Complications of bronchoscopy: comparison of rigid bronchoscopy under general anesthesia and flexible fiberoptic bronchoscopy under topical anesthesia. Chest 1981;79(3):316–321 Pastis NJ, Nietert PJ, Silvestri GA; American College of Chest Physicians Interventional Chest/Diagnostic Procedures Network Steering Committee. Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships: a survey of fellowship directors. Chest 2005;127(5): 1614–1621 Kennedy CC, Maldonado F, Cook DA. Simulation-based bronchoscopy training: systematic review and meta-analysis. Chest 2013; 144(1):183–192
49
50
51
52
53
54
Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
56
57 58
59
60
61
Downloaded by: University of Florida. Copyrighted material.
680
Rigid Bronchoscopy Abdul Hamid Alraiyes, MD1
Michael S. Machuzak, MD, FCCP2
1 Division of Interventional Pulmonology, Department of Medicine,
Roswell Park Cancer Institute, Buffalo, New York 2 Department of Pulmonary Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio
Address for correspondence Michael S. Machuzak, MD, FCCP, Department of Pulmonary Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195 (e-mail: [email protected]).
Abstract
Keywords
► ► ► ►
rigid bronchoscopy rigid intubation endobronchial tumor therapeutic rigid bronchoscopy ► foreign body extraction ► massive hemoptysis
The purpose of this article is to provide an introduction to rigid bronchoscopy (RB). We will briefly discuss its history, evolution, and resurgence while we highlight its versatility and usefulness for today’s interventional pulmonologist and thoracic surgeon. Despite being one of the earliest pulmonary procedures described, RB is still an important technique. Advances in thoracic medicine have made this skill critical for a fully functional interventional pulmonary program. If the interventional pulmonologist of this century is to be successful, he or she should be facile in this technique. Despite the availability of RB for decades, the invention of flexible bronchoscopy in 1966 led to a significant downturn in its usage. The growth of the interventional pulmonology field brought RB back into the spot light. Apart from the historic role of RB in treatment of central airway lesions and mechanical debulking of endobronchial lesions, RB is the key instrument that can adapt modern therapeutic tools such as laser, argon plasma coagulation, electrocautery, cryotherapy, and stent deployment. Performing RB requires proper preprocedure preparation, exceptional understanding of upper airway anatomy, specific hand–eye coordination, and open communication between the bronchoscopist and the anesthesiologist. These skills can be primarily learned and maintained with repetition. This article will review information relevant to this technique and lay a foundation to be built upon for years to come.
History of Rigid Bronchoscopy Manuel Rodrigues Garcia, a Spanish singer and music teacher, was the first person reported to perform an “in vivo” evaluation of the airways. He performed this procedure on himself around 1855. The technique for indirect laryngoscopy was later perfected in Germany by Johann Czermak1 in 1858. The first therapeutic rigid bronchoscopy (RB) was performed in 1897 by Professor Gustav Killian at the Department of Otolaryngology, Freiburg University, Germany.2 He used a Mikulicz-Rosenheim rigid esophagoscope with rigid forceps to remove a piece of a pork bone from the right main stem bronchus of a 63-year-old farmer using topical cocaine to locally anesthetize the airway. This was the first documented case of a foreign body (FB) removal; however RB had been
Issue Theme Interventional Pulmonology; Guest Editors: David Feller-Kopman, MD and Lonny Yarmus, DO, FCCP
performed earlier by Professor Killian on tracheotomized patients and volunteers for airway examinations.3,4 In 1920, Chevalier Jackson performed the first RB in the United States. He is regarded as the “Father of American bronchoesophagology” and practiced primarily in Pennsylvania. His career is noteworthy for many reasons, including his avidity for education and innovation. He modified the scope to match the tracheal length, improved upon current instruments, as well as advancing the scope’s optics.2,5,6 The optical telescope manufacturing was advanced in the 1940s to 1950s by Broyles and Hopkins, introducing the telescope optic, optical forceps, and improving lighting and imaging.4 The primary focus of RB in the early years was FB removal, useful though limited in numbers. Later, in the 1950s and beyond, largely due to advances in anesthesia and technology,
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1395500. ISSN 1069-3424.
Downloaded by: University of Florida. Copyrighted material.
Semin Respir Crit Care Med 2014;35:671–680.
Rigid Bronchoscopy
Alraiyes, Machuzak
the rigid scope gained more popularity. Though primarily in the surgical world, RB was recognized as a useful tool for central airway tumor debulking. RB again took a large step forward thanks to Jean-Francois Dumon in the 1980s and beyond, as he continued with innovation, incorporating laser ablation, stenting, as well as publishing and educating. His results, publications, and dissemination of knowledge helped a new burgeoning interest in RB, adding to the formation of a new field in pulmonology.7
Equipment The RB is a simple yet incredibly versatile tool used for airway evaluation, diagnosis, and therapeutics. RB is, in its simplest form, a tool to access the main airways, but if used properly can be much more. Designs vary depending on the manufacturer, but several components are fairly universal including the barrel, head, light source, telescope, and eyepiece/camera attachment. Included in the basic RB assembly are various caps which allow for delivery of instruments or to provide a seal. Because of its large working channel, a multitude of tools such as forceps, dilators, catheters, debulking, or stent deployment devices can be introduced. The RB is a simple device; it is basically a hollow metallic tube of which many styles are available with most incorporating a beveled tip. This bevel can serve several purposes: elevating the epiglottis for insertion/intubation, cutting or coring at a tumor edge, gaining access to a tight luminal stenosis to initiate dilation, or separating an embedded stent from the airway mucosa among others. The multifunctional head also serves many roles, including ventilation and delivery of both devices and the optics. This head allows for attachment to several types of ventilating options (a conventional ventilator, jet ventilator, or hand bagging); insertion of suction catheters, laser, cautery, or other thermal ablation devices; debulking or dilating tools; as well as the visualizing instruments. This can all be accomplished while providing for either an open or closed ventilating system utilizing metal, silicone, glass, or plastic caps. RBs come in several lengths and diameters allowing for both adult and pediatric patients. Lengths vary by manufacturer but typically range from 33 to 43 cm. Diameters range from 3 mm in pediatric sets to as large as 18 mm with most adult scope series ranging from 7 to 14 mm. In general, there are two standard lengths, the bronchial tubes (►Fig. 1) which are longer and have side fenestrations to facilitate the ventilation of the nonintubated main bronchus, and the tracheal tube (►Fig. 2), which is shorter and has
Fig. 1 Long bronchial metallic tubing with side ventilation openings; the colors reflect different diameter. Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
Fig. 2 Short tracheal metallic tubing; the colors reflect different diameter.
no side fenestrations; the ventilation is through the distal opening. The tracheal tube is often used for subglottic or tracheal cases, while the bronchial scope can reach the distal mainstem bronchi bilaterally and into the bronchus intermedius on the right. Telescopes also come with two different lengths to match the length of the individual scope. The various ports enable connection to ventilation systems and insertion of the rigid tools. To minimize air leak and secure the telescope position, silicone caps can be applied to the openings (►Fig. 3).
Rigid Bronchoscopy Indications RB has multiple indications which include gathering tissue for diagnostic purposes, providing a secure airway/working conduit and as a tool for therapeutic intervention. As malignancy has become one of the primary reasons bronchoscopy is performed, both indications are often realized in one procedure. While it is our practice to use both flexible and RB
Fig. 3 The proximal end of the scope. (A) Connecting devices to the ventilation system and working accessory inlets. (B) Silicone capes applied on the working accessory inlets.
Downloaded by: University of Florida. Copyrighted material.
672
Table 1 Rigid bronchoscopy indications & Large biopsies & Massive hemoptysis & Foreign body extraction & Endoluminal obstruction: Mechanical debulking • Coring of tumors • Direct dilation for endobronchial stenosis & Adjunctive Laser, cryotherapy, balloon and bougie dilation, microdebrider Stent placement or removal
concurrently, we focus on RB and discuss several advantages RB offers over flexible bronchoscopy. The presence of a large bore-working channel for both ventilation and delivery of a multitude of instruments simultaneously provided by RB cannot be overstated.8 RB has a unique ability to permit simultaneous procedures without limiting ventilation. One can debulk, ablate, suction, and provide tamponade all while still allowing for ventilation through this large tube. For example, flexible bronchoscopic dilation most commonly occurs with the use of a balloon; however, ventilation is limited when the balloon is inflated particularly in tracheal or subglottic cases. The absolute indications for RB are only limited by current technology and the imagination of the bronchoscopist. RB is particularly useful for most endobronchial pathologies including endobronchial tumors, stricture/ stenosis, hemoptysis, and FB extraction.9–11 In addition to using the RB as the primary tool, many experts favor the use of RB as the conduit to apply current endobronchial therapeutic equipment (►Table 1).12–15
Central Airway Obstruction Primary and metastatic carcinomas of the lung are the most common causes of central airway obstruction (CAO). CAO from malignant disease is reported in as many as 30% of cases11 (►Fig. 4). Other less common causes of CAO include benign airway diseases. Many etiologies can be responsible for benign
Alraiyes, Machuzak
airway CAO, including, but not limited to, autoimmune and/or inflammatory conditions such as granulomatosis with polyangiitis (GPA), sarcoidosis, lung transplantation, postintubation, thermal injury, as well as idiopathic, iatrogenic, or posttraumatic.16,17 Malignant CAO often presents with symptoms of dyspnea and cough or signs such as hemoptysis and is associated with a poor prognosis due to the advanced nature of the disease. As one can imagine, this presentation can be quite disturbing to the patient and their loved ones. RB has been shown to be a safe and reliable method for rapid palliation of symptoms. Primary rigid debulking of the tumor can quickly and dramatically improve their quality of life.18 Endobronchial debulking of CAO with RB can be accomplished solely with the rigid scope or in combination with an adjunctive ablative device, thermal or otherwise. The purely mechanical means can be accomplished quite quickly, safely, and effectively. Coring out of a tumor with the rigid broncho- or tracheoscope has a few advantages over the other means. Utilizing the beveled edge of the RB, one can gently remove endobronchial or endotracheal tumor by placing the beveled edge against the base of tumor and gently rotating with forward pressure to bluntly dissect the tumor away from the wall. Fragments from the primary tumor can be removed with a suction catheter, forceps, cryoprobe, or other device. This technique requires careful attention to details such as visualization of the tumor and airway ensuring the correct axis and course is taken. Bronchial, tracheal, and vascular anatomy can be markedly abnormal in such cases, requiring excellent anatomical understanding and experience to be successful. Careful attention to these details will minimize the chance for perforation (or other injury) to a bronchus or major vessel. This technique highlights several advantages including immediate tamponade at the base of the tumor with the rigid scope. The RB is uniquely qualified for such a maneuver, as its metallic shaft can be manipulated to provide direct pressure in any location over 360 degrees. Additional benefits provided by the rigid scope include the ability to suction large quantities, if needed, while still maintaining a patent lumen for adjunctive instruments. According to many experts, the greatest asset provided by the RB for restoring patency in CAO lies in its ability to provide ventilation throughout this
Fig. 4 Adenocarcinoma of the lung invading the right and left main bronchus treated with Nd:YAP laser and APC.
Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
673
Downloaded by: University of Florida. Copyrighted material.
Rigid Bronchoscopy
Rigid Bronchoscopy
Alraiyes, Machuzak
Fig. 5 Adenocarcinoma of the lung cored using rigid bronchoscopy and suction catheter.
maneuver. This is particularly valuable when the patient presents in respiratory or cardiovascular distress and requires a high level of oxygen delivery to maintain an adequate saturation. A high level of inspired oxygen is a contraindication to using thermal modalities (except cryotherapy), as it increases the risk of an airway fire; this will be covered in detail in other articles in this issue19 (►Fig. 5). Thermal therapeutic treatments such as laser,20–22 electrocautery,20,23 and argon plasma coagulation24 can be applied if lower oxygen levels are tolerated by the patient (►Fig. 4). Now we will shift our focus to the unique benefits RB can apply to patients with benign airway stenosis. These patients typically present similarly with dyspnea, often associated with focal wheezing.16 Many etiologies may be responsible for CAO in benign disease, relating to an underlying autoimmune, inflammatory condition such as GPA, sarcoidosis, inflammatory bowel disease, and others. A benign stricture may also be induced by a traumatic intubation, tracheostomy, as well as a straight-forward endotracheal tube insertion. Cases of benign airway strictures are also seen post–lung transplantation or from an idiopathic cause. Treatment options vary according to the etiology but typically involve a multimodality approach employing electrocautery, cryotherapy, Microdebrider, and rigid, balloon, or bougie dilations.25,26 A rigid bronchoscope or tracheoscope can
accomplish dilations in a safe and effective manner utilizing sequential rigid dilations27 or combining modalities28 (►Fig. 6). RB can accomplish similar results quickly while maintaining a safe airway with continued ventilation that is not possible when using a balloon or bougie for dilation. While most procedures performed by interventional pulmonologists (IP) occur in the trachea and bronchi, occasionally upper tracheal or subglottic obstruction must be addressed and the rigid tracheoscope is well suited for such endeavors. This scope can allow for optimal ventilation, repeated access, and quick dilation in this difficult location. In addition, RB can play a vital role in cases of subglottic and tracheal stenosis in which a T-tube placement is required.29,30 RB can deliver airway support, ventilation, aid in positioning, and endow airway protection while placing the T-Tube. Stent placement is another area where RB can play a major role. Regardless of the stent chosen, RB can offer advantages in stent placement, repositioning, maintenance, and removal.8,31 In regard to stenting, five generally accepted indications for stenting exist32: 1. Extrinsic compression of the airway from tumor or lymph nodes 2. To stabilize an airway after intraluminal removal of tumor
Fig. 6 Benign subglottic stenosis secondary to traumatic intubation treated by sequential rigid dilations.
Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
Downloaded by: University of Florida. Copyrighted material.
674
Rigid Bronchoscopy
Alraiyes, Machuzak
675
3. Restoring patency in benign recurrent strictures 4. To support a symptomatic malacic airway 5. To cover and potentially treat a fistula Discussing the specifics of stenting is beyond the scope of this article and it will be covered in depth elsewhere. RB has much to offer whether the choice of stent is silicone, a selfexpandable metallic stent (SEMS), or a hybrid stent. Benefits of RB include a large working channel, the option for direct visualization during placement of a SEMS, larger forceps in which to grasp the stent for placement, revision or removal, aiding patency by using the RB to stent the airway during placement, and, of course, improved ventilation during placement. Silicone stents are still regarded by many to be the gold standard owing to their long history and experience and have become more popular as RB use has increased. Novel techniques have been described to place silicone stents, but RB is considered the standard of care for placement.15,33 Details of stent placement will be covered elsewhere. Silicone stents are useful in malignant disease but in unusual cases of benign airway diseases requiring stenting, particularly the trachea should be the first stent considered.34 Characteristics of the rigid scope including the large working channel as well as the stiffer forceps allow for the proper method to deploy and remove airway stents (►Fig. 7).35
subglottis, and vocal cords from harm upon removal. This is not to say that successful FB removal can only be accomplished with a rigid scope. In fact, flexible bronchoscopy may be the sole option for removal due to the distal nature of the impaction. Most experts would agree that some combination of both can be incredibly useful depending on the location, size, and type of FB. An aspirated object can be removed using forceps, baskets, snares, or other modalities such as cryotherapy depending on the extrinsic and intrinsic qualities of the FB. For example, one with high water content such as a grape can readily be removed with a cryotherapy probe providing the necessary adhesion, while a larger FB may need rigid forceps due to its girth (►Fig. 8). Neglecting FB removal can cause chronic postobstructive pneumonia and formidable infectious implications. Our ability to remove foreign bodies has led to a significant improvement in patient care. What was once described as a 24% mortality rate has now improved to almost nonexistent rate.39
Massive Hemoptysis Hemoptysis, particularly life-threatening or massive hemoptysis, is another arena in which proper handling of a RB may afford distinct benefits. The ability to provide large volume suction, airway protection, and maintenance of ventilation makes RB a necessary skill in many cases.40,41 During the chaos that can arise during significant airway bleeding, the
Foreign Body Extraction Although FB aspiration is an uncommon event, it is certainly not rare. Although practice patterns vary, it is likely that one will encounter this issue on several occasions during a career in thoracic medicine. FB aspiration is far more common in children than in adults typically involving the young (younger than 3 years) and elderly (adults in their 7th decade and on).36–38 There are no prospective randomized trials which declare whether flexible or rigid bronchoscopy is a superior choice for removal of a FB. In fact, many FB removals employ both flexible and rigid bronchoscopy. However, RB does offer several advantages. A large working channel and a larger scale of instrument are common themes as we discuss the rationale for using RB and both hold true in FB removal. The luminal diameter of the RB allows for not only larger instruments and a wider range of manipulation of those instruments but also multiple instruments to be used simultaneously. The barrel of the RB can be used to protect the uninjured lower airway,
Fig. 8 Foreign body extracted from the trachea aspirated by adult while trying to swallow it. Removed using RB and rigid forceps. Compare the size differences between the rigid and flexible forceps. Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
Downloaded by: University of Florida. Copyrighted material.
Fig. 7 Silicone stent deployment in the airway.
Rigid Bronchoscopy
Alraiyes, Machuzak
rigid bronchoscope can provide isolation of the bleeding and protection of the “healthy” lung by selectively intubating the main stem bronchi of the nonbleeding lung. Isolation of the nonbleeding bronchus will permit both oxygenation and ventilation, while maneuvers can be directed to halt the bleeding. In cases of a proximal hemorrhage, RB can also tamponade the site of bleeding, offering a therapy while safely allowing clot to form.42,43 RB also provides a large conduit to introduce therapeutic measures to address the source of bleeding with thermal techniques or for topical application of epinephrine or ice-cold saline to the bleeding location.44,45 Although RB is a fantastic modality for treatment of hemoptysis, its success depends on proper expertise from an operator and team with the ability to perform RB in a reasonable time frame. Even in the most controlled conditions, establishing an airway with a rigid bronchoscope mandates appropriate experience and preparation that can be difficult to establish in cases of massive hemoptysis.
bronchoscopist communicate throughout the procedure to increase the likelihood of success in each RB case.47 Any alternative or stand-by equipment should be prepared before initiation. Before intubation, preoxygenation and standard anesthetic monitoring should be applied such as electrocardiographic and blood pressure monitoring, pulse oximetry, and end-tidal CO2 monitoring.48 In addition to the usual monitoring, other observations such as chest wall rise with initiation of ventilation should be observed. This technique can be important as end-tidal CO2 may be difficult to assess whether using an open or closed ventilation system. To facilitate intubation, neuromuscular blocking agent is used in most cases after assuring appropriate ventilation. Total intravenous anesthesia (TIVA) is desired over inhalational anesthesia due to significant environmental contamination with the inhalational agent and the inefficiency relating to the substantial leak often seen in RB.49
Ventilation Approach in Rigid Bronchoscopy
Rigid Bronchoscopy Contraindications There are very few absolute contraindications to performing RB. The indications as well as the contraindications should be evaluated based on the need, as for any procedure. Concern for most complications is related to general anesthesia (GA). RB can be accomplished in the absence of GA, but without a high level of sedation the experience of the procedure will certainly be different, both for the bronchoscopist as well as the patient; therefore, most are performed with deep sedation or GA.46 Patients with comorbid diseases making them a concern for GA should be fully evaluated with a risk assessment to determine if and when to proceed. Any preprocedural optimization should be addressed as early as possible, particularly if the indication for RB is related to an airway obstruction or FB. Patients with a coagulopathy or on anticoagulant medication would be another example in which the risks and benefits must be weighed carefully. Anatomic considerations must also be entertained, as a patient with an unstable or fused cervical spine, facial injuries, or abnormalities may not be suitable to position or manipulate as is required for RB. This procedure has potential for complications and so one must consider the risks, benefits, alternatives, and personnel as well as the resources available. A candid conversation should be undertaken with the patient or representative and only if the risks are outweighed by the benefits should RB be performed.
Anesthesia and Ventilation Anesthesia for Rigid Bronchoscopy Like any other procedure, preparation for effective and open communication is crucial to the success of RB. Airway assessment for endotracheal intubation such as Mallampati classification should be performed and appropriate equipment available for cases deemed challenging. A thorough discussion of the initial plan as well as any potential alternatives should be covered before induction. All team members should be involved, but it is critical that the anesthesiologist and Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
Ventilation during RB may be challenging, as leakage around the scope can influence the typical measures of adequate ventilation. As the RB has no balloon, assessment of end-tidal CO2 and tidal volume can be difficult. Ventilation through an open circuit as is done with jet ventilation is a technique many anesthesiologists are unfamiliar with. The mode of ventilation is institution dependent and typically determined by the experience and comfort level of the anesthesiologist and bronchoscopist. As described earlier, considerable collaboration between the anesthesiologist and the bronchoscopist is required. Multiple ventilation modes can be considered including assist spontaneous ventilation (ASV), controlled ventilation (CV), or jet ventilation.47 ASV is typically applied with TIVA; the ventilation depends on the patient’s effort as well as manual assistance. For CV, neuromuscular blockade is commonly used while the patient is ventilated with a pressure or volume control mode. A semiclosed circuit can be achieved by placement of the silicone caps on the multifunctional head as well as packing the oropharynx with moist gauze to minimize the air leak. Neuromuscular blockade is not an absolute requirement and the procedure can still be successful if the patient is breathing spontaneously. Anterior mediastinal masses are a particular concern and NM blockade may need to be avoided to prevent loss of the airway. Dexmedetomidine is one agent that has been described in such circumstances.50 Jet ventilation is another option in which the patient is typically paralyzed during the procedure; either manual jet ventilation or high-frequency jet ventilation (HFJV) can be used. Manual jet ventilation utilizes a respiratory rate of 10 to 14 breaths/minute at a pressure of 50 psi or less with the lowest pressure possible preferred. During this mode, appropriate ventilation is assessed by adequate chest rise.46,51 HFJV differs in that the respiratory rate can be set between 60 and 300 breaths/minute with 12 to 18 psi while maintaining the peak pressures < 35 cm H2O.52 The advantage of HFJV is a motionless operative field. PaCO2 can be monitored by frequent arterial blood gas measurement or by transcutaneous capnographic monitoring.53 Many variations and styles exist
Downloaded by: University of Florida. Copyrighted material.
676
Alraiyes, Machuzak
Fig. 9 Direct method rigid intubation. (A) Mouth opened by scissors technique and the bronchoscope is advanced perpendicularly to the patient in the midline. The base of the tongue is observed and gently raised. (B) The epiglottis observed. (C) Epiglottis raised by the bevel of the bronchoscope and vocal cords seen. (D) The bronchoscope is turned 90 degrees and advanced through the vocal cords. (E) The bronchoscope is turned another 90 degrees to bring the bevel anteriorly. (F) The bronchoscope advanced into the trachea.
and no single mode of ventilation has been shown to be superior, the best choice is one the operator and anesthesiologist are most comfortable with while realizing any one mode may be best for an individual patient.
Rigid Bronchoscopy Intubation The three classic ways of rigid bronchoscopic intubation are direct method, laryngoscope method, and intubation over or alongside an endobronchial tube (ETT).7,18
Direct Method This method is most commonly used and has the most extensive publication and hands-on teaching experience. In the direct method, the bronchoscope is the primary instrument for intubation. The patient is positioned in the sniffing position; this is accomplished by tilting the head and hyperextending the neck (►Fig. 9). Proper positioning will elevate
the larynx and create a more linear route to the vocal cords. As the RB is by definition inflexible, an axis must be created between the mouth, pharynx, and larynx. The mouth is opened using the scissors technique by placing the left thumb over the upper teeth and the left index finger over the lower teeth. Care must be taken to avoid trauma to the patient’s teeth and lips and protection with a tooth guard, moist gauze, or the bronchoscopist’s fingers is recommended. The bronchoscope is then introduced with the right hand holding the bevel anteriorly. Variations do exist and certainly a lefthanded bronchoscopist may use his or her left hand. It is important to mention that the bronchoscope should only be advanced under direct and complete vision. The bronchoscope is advanced perpendicularly into the patient following the midline. The soft palate will be observed first, followed by the uvula, at that point the right hand is lowered and the base of the tongue is gently raised. The epiglottis should now be seen, being elevated by the bevel of the bronchoscope. This Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
677
Downloaded by: University of Florida. Copyrighted material.
Rigid Bronchoscopy
Rigid Bronchoscopy
Alraiyes, Machuzak
action will bring the vocal cords into view. At this point, the bronchoscope is turned 90 degrees and advanced through the vocal cords. Once the trachea is entered, the scope will be rotated 90 degrees again and the trachea is entered.2 If the intubation is with a bronchial scope, one must be aware to advance the scope distal enough to allow all the lateral fenestrations to sit inside the trachea to ensure adequate ventilation. The most common errors occurring with this method are allowing the scope to veer from midline or advancing too far past the epiglottis, underneath the larynx; in this instance the scope would then expose the esophagus upon lifting.
Laryngoscope Method In this method, a straight blade (Miller) laryngoscope is typically held in the left hand and used to visualize the epiglottis. Once visualized, the base of the tongue and the epiglottis are elevated using the laryngoscope allowing for a direct view of the vocal cords. The rigid bronchoscope is then introduced into the mouth with the right hand directly to the vocal cords and the scope is advanced with the same rotation technique described in the direct method.
Rigid Bronchoscopy Training and Future
Intubation over Endobronchial Tube In this scenario, the patient either presented to the procedure room intubated or has been intubated for bronchoscopy. The RB is advanced over the ETT with the same technique as the direct intubation to the epiglottis, then the ETT balloon is deflated and pulled out while maintaining the same position at the level of vocal cords with the RB. The RB is advanced with the same rotation technique described in the direct method intubation. A similar technique has been described alongside the endotracheal tube.
Rigid Bronchoscopy Complications Complications associated with RB are usually uncommon, provided the procedure is performed with the correct indication by a well-trained person.2,31 The most common complaint is a sore throat after the procedure; however, more serious complications are described. Complications related to a rigid bronchoscopic procedure may be classified as preoperative, anesthesia-associated or due to the procedure itself (i.e., the rigid bronchoscope).54 Hypoxemia-induced cardiac ischemia and arrhythmias are the most dangerous complications. Patients with difficult airway are more prone to teeth, gums, and larynx injury. Tracheal or bronchial wall rupture has been reported in some cases.55,56 The key point of avoiding these complications is proper preoperative assessment, appropriate instrument preparation, and anesthesiologist and bronchoscopist communication.57 Data relating to RB complications are sparse but do exist. In a retrospective study between 1992 and 1999, a total of 775 RBs were reviewed retrospectively in a tertiary-care hospital. Complications were seen in 103 patients (13.4%); though most were mild, 3 deaths did occur (1 due to respiratory failure and 2 from severe hemorrhage). The overall mortality rate was low at 0.4% in an ill population predominantly Seminars in Respiratory and Critical Care Medicine
Vol. 35
encompassing advanced lung cancer. Risk factors for severe complications were related to respiratory, cardiac and/or hematologic disease, carinal involvement, neoplastic disease, and foreign bodies. Unfortunately, the population identified is typical for RB. In another large series, only 2 deaths were recorded in 11,000 rigid bronchoscopies.58 While the common belief is that RB leads to more complications than flexible bronchoscopy, there are few publications that compare both head to head. One prospective study looked at 1,146 flexible bronchoscopies compared to 3,449 RB and and found complications were less common with RB. The majority of complications associated with flexible bronchoscopy were related to tetracaine, while RB complications were related to GA. However, the risk of major complications induced by the RB was significantly higher than those caused by flexible bronchoscopy.59 Complication rates vary, likely related to patient factors, experience, and a nonuniform practice of reporting. Standardization and publications relating to complications will be critical for the advancement of this procedure in a scientific manner.
No. 6/2014
RB remains an important tool for the interventional pulmonologist and thoracic surgeon for both diagnosis and therapeutics. Despite advances in flexible bronchoscopy, RB continues to be an indispensable component in the armamentarium of thoracic medicine. Though modifications have occurred, much of RB is remarkably similar to the procedure first performed in the 19th century. RB provides distinct advantages over flexible bronchoscopy but optimal use is with combination. Primary tumor debulking or dilation, adjunctive technologies, stent placement, removal, revision, FB removal, as well as management of massive hemoptysis can all be performed through this simple yet elegant medical device while providing airway management, ventilation, and oxygenation. Surprisingly, this procedure is still underutilized, particularly in the United States, as RB training is offered in only 4.4% of all pulmonary medicine programs and in 31.3% of pulmonary programs that has an interventional pulmonology program.60 However, the increased interest in IP is leading to renaissance of this simple and efficient technique. Simulation-based training has been shown to be effective in transfer of knowledge and skills for a variety of tasks including RB. Based on a recent meta-analysis, simulator training has shown to be effective, though the optimal design is less clear. Longer, more structured training clearly adds value. Animal models may be superior to virtual reality-based simulators because of potentially being less expensive.61
Conclusion Despite the expansion of flexible bronchoscopy, RB remains a vital tool for diagnosis and therapeutics in thoracic medicine. Identifying knowledge gaps, advances in technology and education will propel RB into the next century bringing this once almost forgotten technology back into the spotlight.
Downloaded by: University of Florida. Copyrighted material.
678
Rigid Bronchoscopy
24 Morice RC, Ece T, Ece F, Keus L. Endobronchial argon plasma
1 Bryce DP, Nunis DB. The American Laryngological Association,
2 3
4 5
6 7 8
9
10
11
12
13
14
15
16 17
18
19 20 21
22
23
1878–1978: A Centennial History. Washington: American Laryngological Association; 1978 Ayers ML, Beamis JF Jr. Rigid bronchoscopy in the twenty-first century. Clin Chest Med 2001;22(2):355–364 Becker HD, Marsh BR. History of the rigid bronchoscope. In: Bollinger CT, Mathur PN, editors. Interventional bronchoscopy, vol 30. Basel (Switzerland): Karger, Prog Respir Res; 2000:2–15 Bolliger CT, Mathur PN. Interventional Bronchoscopy. Basel; New York: Karger; 2000 Beamis JF Jr. Interventional pulmonology techniques for treating malignant large airway obstruction: an update. Curr Opin Pulm Med 2005;11(4):292–295 Jackson C. The Life of Chevalier Jackson, An Autobiography. New York: The Macmillan Company; 1938 Helmers RA, Sanderson DR. Rigid bronchoscopy. The forgotten art. Clin Chest Med 1995;16(3):393–399 Jeon K, Kim H, Yu CM, et al. Rigid bronchoscopic intervention in patients with respiratory failure caused by malignant central airway obstruction. J Thorac Oncol 2006;1(4):319–323 Marel M, Pekarek Z, Spasova I, et al. Management of benign stenoses of the large airways in the university hospital in Prague, Czech Republic, in 1998-2003. Respiration 2005;72(6):622–628 McMahon CC, Rainey L, Fulton B, Conacher ID. Central airway compression. Anaesthetic and intensive care consequences. Anaesthesia 1997;52(2):158–162 Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004;169(12): 1278–1297 Hujala K, Sipilä J, Grenman R. Endotracheal and bronchial laser surgery in the treatment of malign and benign lower airway obstructions. Eur Arch Otorhinolaryngol 2003;260(4): 219–222 Freitag L, Ernst A, Thomas M, Prenzel R, Wahlers B, Macha HN. Sequential photodynamic therapy (PDT) and high dose brachytherapy for endobronchial tumour control in patients with limited bronchogenic carcinoma. Thorax 2004;59(9):790–793 Han CC, Prasetyo D, Wright GM. Endobronchial palliation using Nd:YAG laser is associated with improved survival when combined with multimodal adjuvant treatments. J Thorac Oncol 2007; 2(1):59–64 Gompelmann D, Eberhardt R, Schuhmann M, Heussel CP, Herth FJ. Self-expanding Y stents in the treatment of central airway stenosis: a retrospective analysis. Ther Adv Respir Dis 2013;7(5):255–263 Hollingsworth HM. Wheezing and stridor. Clin Chest Med 1987; 8(2):231–240 Honings J, Gaissert HA, van der Heijden HF, Verhagen AF, Kaanders JH, Marres HA. Clinical aspects and treatment of primary tracheal malignancies. Acta Otolaryngol 2010;130(7):763–772 Colt HG, Harrell JH. Therapeutic rigid bronchoscopy allows level of care changes in patients with acute respiratory failure from central airways obstruction. Chest 1997;112(1):202–206 Mathisen DJ, Grillo HC. Endoscopic relief of malignant airway obstruction. Ann Thorac Surg 1989;48(4):469–473, discussion 473–475 Ost D. Photodynamic therapy in lung cancer. A review. Methods Mol Med 2003;75:507–526 Kvale PA, Eichenhorn MS, Radke JR, Miks V. YAG laser photoresection of lesions obstructing the central airways. Chest 1985; 87(3):283–288 Chella A, Ambrogi MC, Ribechini A, et al. Combined Nd-YAG laser/ HDR brachytherapy versus Nd-YAG laser only in malignant central airway involvement: a prospective randomized study. Lung Cancer 2000;27(3):169–175 Coulter TD, Mehta AC. The heat is on: impact of endobronchial electrosurgery on the need for Nd-YAG laser photoresection. Chest 2000;118(2):516–521
679
25
26
27
28 29
30
31 32
33 34
35
36 37
38
39 40
41 42
43 44
45
46 47
coagulation for treatment of hemoptysis and neoplastic airway obstruction. Chest 2001;119(3):781–787 Chhajed PN, Malouf MA, Glanville AR. Bronchoscopic dilatation in the management of benign (non-transplant) tracheobronchial stenosis. Intern Med J 2001;31(9):512–516 De Gracia J, Culebras M, Alvarez A, et al. Bronchoscopic balloon dilatation in the management of bronchial stenosis following lung transplantation. Respir Med 2007;101(1):27–33 Madan K, Agarwal R, Aggarwal AN, Gupta D. Utility of rigid bronchoscopic dilatation and mitomycin C application in the management of postintubation tracheal stenosis: case series and systematic review of literature. J Bronchology Interv Pulmonol 2012;19(4):304–310 Pearson FG. Technique of management of subglottic stenosis. Chest Surg Clin N Am 1996;6(4):683–692 Goto T, Akanabe K, Oyamada Y, Kato R. A new technique for T tube insertion in severe subglottic stenosis. Interact Cardiovasc Thorac Surg 2011;12(6):895–898 Tedde ML, Rodrigues A, Scordamaglio PR, Monteiro JS. A new technique for T-tube insertion in patients with subglottic stenosis. Eur J Cardiothorac Surg 2011;39(1):130–131 Folch E, Mehta AC. Airway interventions in the tracheobronchial tree. Semin Respir Crit Care Med 2008;29(4):441–452 Wood DE, Liu YH, Vallières E, Karmy-Jones R, Mulligan MS. Airway stenting for malignant and benign tracheobronchial stenosis. Ann Thorac Surg 2003;76(1):167–172, discussion 173–174 Casal RF. Update in airway stents. Curr Opin Pulm Med 2010;16(4): 321–328 Noppen M, Stratakos G, Amjadi K, et al. Stenting allows weaning and extubation in ventilator- or tracheostomy dependency secondary to benign airway disease. Respir Med 2007;101(1):139–145 Miyazawa T, Miyazu Y, Iwamoto Y, et al. Stenting at the flowlimiting segment in tracheobronchial stenosis due to lung cancer. Am J Respir Crit Care Med 2004;169(10):1096–1102 Nicolai T. Foreign body aspiration in children [in German]. MMW Fortschr Med 2013;155(16):36–37 Ghaffarlou M, Golzari SE, Nezami N. A large asymptomatic foreign body in larynx and trachea. Quant Imaging Med Surg 2014;4(3): 210–211 Johns S, Sellon R, Spencer E, Tucker M. Tracheal Foreign Body and Pneumonia in a Cat: A Near Missed Diagnosis. J Am Anim Hosp Assoc 2014;50(4):273–277 Rafanan AL, Mehta AC. Adult airway foreign body removal. What’s new? Clin Chest Med 2001;22(2):319–330 Conlan AA, Hurwitz SS. Management of massive haemoptysis with the rigid bronchoscope and cold saline lavage. Thorax 1980; 35(12):901–904 Colchen A, Fischler M. Emergency interventional bronchoscopies [in French]. Rev Pneumol Clin 2011;67(4):209–213 Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC. Bronchoscopy-guided topical hemostatic tamponade therapy for the management of life-threatening hemoptysis. Chest 2005; 127(6):2113–2118 Reisz G. Topical hemostatic tamponade: another tool in the treatment of massive hemoptysis. Chest 2005;127(6):1888–1889 Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration 2010; 80(1):38–58 Solomonov A, Fruchter O, Zuckerman T, Brenner B, Yigla M. Pulmonary hemorrhage: A novel mode of therapy. Respir Med 2009;103(8):1196–1200 Plummer S, Hartley M, Vaughan RS. Anaesthesia for telescopic procedures in the thorax. Br J Anaesth 1998;80(2):223–234 Pathak V, Welsby I, Mahmood K, Wahidi M, MacIntyre N, Shofer S. Ventilation and anesthetic approaches for rigid bronchoscopy. Ann Am Thorac Soc 2014;11(4):628–634
Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
Downloaded by: University of Florida. Copyrighted material.
References
Alraiyes, Machuzak
Rigid Bronchoscopy
Alraiyes, Machuzak
48 Biro P, Layer M, Wiedemann K, Seifert B, Spahn DR. Carbon dioxide
55 Kim JH, Shin JH, Shim TS, Oh YM, Song HY. Deep tracheal laceration
elimination during high-frequency jet ventilation for rigid bronchoscopy. Br J Anaesth 2000;84(5):635–637 Perrin G, Colt HG, Martin C, Mak MA, Dumon JF, Gouin F. Safety of interventional rigid bronchoscopy using intravenous anesthesia and spontaneous assisted ventilation. A prospective study. Chest 1992;102(5):1526–1530 Abdelmalak B, Marcanthony N, Abdelmalak J, Machuzak MS, Gildea TR, Doyle DJ. Dexmedetomidine for anesthetic management of anterior mediastinal mass. J Anesth 2010;24(4):607–610 Sarkiss M. Anesthesia for bronchoscopy and interventional pulmonology: from moderate sedation to jet ventilation. Curr Opin Pulm Med 2011;17(4):274–278 Fernandez-Bustamante A, Ibañez V, Alfaro JJ, et al. High-frequency jet ventilation in interventional bronchoscopy: factors with predictive value on high-frequency jet ventilation complications. J Clin Anesth 2006;18(5):349–356 Eberhard P. Comparison of transcutaneous and end-tidal CO2monitoring for rigid bronchoscopy during high-frequency jet ventilation. Acta Anaesthesiol Scand 2004;48(2):260, author reply 261 Neyman K, Sundset A, Espinoza A, Kongerud J, Fosse E. Survival and complications after interventional bronchoscopy in malignant central airway obstruction: a single-center experience. J Bronchology Interv Pulmonol 2011;18(3):233–238
after balloon dilation for benign tracheobronchial stenosis: case reports of two patients. Br J Radiol 2006;79(942):529–535 Kim JH, Shin JH, Song HY, et al. Tracheobronchial laceration after balloon dilation for benign strictures: incidence and clinical significance. Chest 2007;131(4):1114–1117 Gompelmann D, Eberhardt R, Herth FJ. Interventional pulmonology procedures: an update. Panminerva Med 2013;55(2):121–129 Caputi M, Bellissimo U, Di Matteo L, Aliberti M, Perna B, Speranza A. Complications during bronchofiberscopy and rigid bronchoscopy. Panminerva Med 1986;28(3):271–277 Lukomsky GI, Ovchinnikov AA, Bilal A. Complications of bronchoscopy: comparison of rigid bronchoscopy under general anesthesia and flexible fiberoptic bronchoscopy under topical anesthesia. Chest 1981;79(3):316–321 Pastis NJ, Nietert PJ, Silvestri GA; American College of Chest Physicians Interventional Chest/Diagnostic Procedures Network Steering Committee. Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships: a survey of fellowship directors. Chest 2005;127(5): 1614–1621 Kennedy CC, Maldonado F, Cook DA. Simulation-based bronchoscopy training: systematic review and meta-analysis. Chest 2013; 144(1):183–192
49
50
51
52
53
54
Seminars in Respiratory and Critical Care Medicine
Vol. 35
No. 6/2014
56
57 58
59
60
61
Downloaded by: University of Florida. Copyrighted material.
680
