Flexible Fiberoptic Bronchoscopy

Transcription

1 L. Penfield Faber, M.D., David 0. Monson, M.D., Joseph J. Amato, M.D., and Robert J. Jensik, M.D. ABSTRACT The flexible fiberoptic bronchoscope has become an invaluable diagnostic and therapeutic instrument in the management of pulmonary disease. Advantages over the conventional rigid bronchoscope include airway examination to the subsegmental level, increased accuracy of diagnosis in pulmonary malignancy, patient comfort, ease of bedside examination, and atraumatic aspiration of postoperative secretions. Disadvantages include cost, inability to remove foreign bodies, and lack of a satisfactory technique for infant endoscopy. The extended range of diagnostic and therapeutic capabilities of the flexible bronchoscope makes it an important instrument for the thoracic surgeon. 0 channel. f the available flexible fiberoptic bronchoscopes, we use the Olympus BF-5B and BF-5B2." The major differences between the two instruments are in the external diameter and size of the inner The distal end of the 5B is 5 mm. in diameter, while that of the 5B2 is 5.2 mm. The channel of the 5B scope is 1.4 mm. and admits passage of a brush: however, flexible biopsy forceps cannot be inserted, and thick secretions may plug the lumen. The 5B2 instrument with its larger channel of 2.0 mm. permits the easy insertion of biopsy forceps and efficient aspiration of thick secretions. Although construction of the larger channel in the 5B2 instrument decreased the forward field of vision from 83 to 72 degrees, it is the preferred instrument for all-around use. Bright illumination from a cold light supply provides good image resolution and permits 35 mm. photography. A small, easily manipulated handle located at the head of the instrument controls angulation of the tip through an arc of 160 degrees (-30 degrees to +130 degrees). Flexible fiberoptic bronchoscopes with smaller diameters are available, but the lack of an aspirating channel make them less desirable instruments. Instrumentation Techniques Topical anesthesia can be accomplished in a routine fashion. Our technique is to spray the pharynx with 2yo Pontocaine and then instill 3 ml. of 10% cocaine into the tracheobronchial tree. A flexible fiberoptic bronchoscope can be inserted through the nasopharynx, oropharynx, rigid bronchoscope, endotracheal tube, nasopha- From the Section of Thoracic Surgery of the Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Ill. Presented at the Ninth Annual Meeting of The Society of Thoracic Surgcons, Houston, Tex., Jan , Address reprint requests to Dr. Faber, Director, Section of Thoracic Surgery, Rush- Presbyterian-St. Luke's Medical Center, 1753 W. Congress Pkwy., Chicago, Ill. *Olympus Corporation of America, 2 Nevada Dr., Hyde Park, N.Y VOL. 16, NO. 2, AUGUST,

2 FABER ET AL. ryngeal airways, and tracheostomy tube. Our original method of insertion was to pass the instrument through the lumen of a previously introduced rigid bronchoscope. As proficiency with the instrument increased, it was discovered that the flexible scope could be passed through the oropharynx into the trachea with the patient in the supine position. When a brushing or biopsy was performed, the instrument either had to be entirely removed from the tracheobronchial tree or the brush or biopsy forceps had to be withdrawn through the channel, which often dislodged a portion of the specimen and decreased the likelihood of obtaining a positive diagnosis for malignancy. An endotracheal tube inserted to function as a sheath permitting the fiberoptic scope to be withdrawn after the specimen is obtained obviates this problem [4, 61. The distal end of the fiberoptic instrument is guided through the oropharynx and into the trachea under direct vision. A No. 34 endotracheal tube previously passed onto the flexible scope is then inserted over the scope, through the larynx, and into the trachea. This size of endotracheal tube passes easily, and visualization of the larynx is not required for tube insertion. A soft tube is easily tolerated by the patient and allows repeated and rapid passage of the scope. Wanner and co-workers [9, 101 describe the use of a soft latex nasopharyngeal airway to guide the instrument through the nasopharynx to a position just above the larynx. The scope is then inserted into the trachea under direct vision. Multiple brushings and biopsies, however, can he accomplished only by removing and reintroducing the scope. This is neither easily nor comfortably accomplished. Bleeding from the nasopharynx can also be troublesome. The same problems apply to nasopharyngeal introduction of the instrument without the airway. Ikeda [5] originally described the technique of inserting a flexible endotracheal tube to serve as a sleeve through which the scope could be introduced. The standard endotracheal tube has proved adequate, however, and it has not been necessary to use the special flexible tube. Bedside examination and aspiration of secretions are smoothly accomplished using the oropharyngeal route. An endotracheal tube is not required, as only aspiration and inspection are carried out. Clinical Experience A total of 507 patients have been bronchoscoped with the fiberoptic instrument. In 205 patients malignant disease was suspected; while in 240 patients the procedure was done for a variety of problems, such as chronic obstructive pulmonary disease, bronchiectasis, or undiagnosed inflammatory disease. Included in the second group were drug-suppressed patients who were severely ill and in whom selective culture material was obtained. Bedside aspiration for retained secretions and atelectasis was successfully accomplished in 62 persons, the majority of whom were postoperative 164 THE ANNALS OF THORACIC SURGERY

3 patients. On several occasions aspiration took place through a tracheostomy tube while continuous mechanical ventilation was maintained. Advantages of Flexible Fi beroptic Bronchoscopy Visualization of pathological changes at the segmental and subsegmental levels using the fiberoptic bronchoscope with precise placement of the brush or biopsy forceps has significantly increased our ability to make a preoperative diagnosis of pulmonary malignancy (Figs. 1, 2). Our initial series of bronchial brushings was accomplished by selective catheterization of a specific bronchus with a premolded, fixed catheter. Our diagnostic accuracy was below that of other reported series [2, 31, and the technique was somewhat cumbersome and time-consuming as the patient had to be transported to a fluoroscopic unit for catheter placement. Diagnosis was made in 23 of 47 patients subsequently proved to have malignant pulmonary disease. Using the flexible fiberoptic bronchoscope with its more accurate control of brush position, we have obtained a positive diagnosis of malignancy in 129 (76y0) of 170 patients with proved pulmonary carcinoma. Use of the fiberoptic bronchoscope has increased our diagnostic accuracy by 55ojb. This improvement represents instrument technique change only, as cytological preparation and evaluation procedures remained constant. Distortion of the carina or extraluminal obstruction of major bronchi secondary to malignant disease limits accurate assessment and diagnosis when rigid bronchoscopy is carried out. The flexible bronchoscope, however, can usually bypass narrow, rigid areas, thereby permitting more exact appraisal of distal sites. Patient comfort and relaxation are so superior with fiberoptic bronchoscopy that general anesthesia is no longer required in the adult patient. A lengthier examination is possible, airway dynamics can be better FIG. 1. A bronchial brush is readily passed through the fiberoptic bronchoscope into a peripheral lesion. VOL. 16, NO. 2, AUGUST,

4 FABER ET AL. A FIG. 2. (A) The flexible biopsy forceps can obtain an adequate specimen. (B) Note on the lateral projection that the forceps is passed to the periphery of the lung. assessed, and patients with bronchial asthma problems tolerate the procedure with less hypoxia and bronchospasm. The opportunity to directly visualize segmental and subsegmental anatomy is a significant diagnostic advantage for the endoscopist (Fig. 3). Subtle compression or mucosal changes in subsegmental bronchi may further confirm a clinical impression of malignant or inflammatory disease. Selective segmental irrigation and aspiration can render a bacteriological diagnosis when routine sputum analysis has failed to produce the expected results. The expediency with which retained tracheobronchial secretions can be B FIG. 3. Clear visualization of subsegmental anatomy is accomplished with the BF-5B2 flexible bronchoscope. 166 THE ANNALS OF THORACIC SURGERY

5 aspirated at the bedside eliminates the necessity for transport of patients to a bronchoscopic suite. The fiberoptic bronchoscope is less traumatic to already inflamed tracheobronchial mucosa, and if repeated procedures are required, they can be accomplished without jeopardy. This is of special importance in patients who have undergone tracheal or bronchial anastomotic procedures. The need for early postoperative aspiration is well established, and careful placement of a small, flexible instrument minimizes the kind of stress at the suture line that would be caused by use of a more rigid tube. Furthermore, accurate evaluation of the suture line is possible. We have used the instrument immediately after a pulmonary resection when it was thought that excessive secretion or bloody mucus was present in the tracheobronchial tree. Aspiration is accomplished through a side-arm or double-lumen adapter, which permits continuous ventilation during the aspiration. It can also be done directly through the endotracheal tube if care is taken to perform the procedure quickly. Patients with a tracheostomy who are dependent upon respirator support can be easily examined and aspirated while the flexible scope is introduced through the aspirating aperture of a Miirch swivel adapter* or through two-channel adapters [7]. This is done without interrupting respirator support and presents an obvious advantage over rigid instrumentation that requires discontinuation of mechanical ventilation. Evaluation of tracheobronchial mucosal alterations can also be assessed as often as indicated in patients who require long-term intubation [ 13. Occasionally the anesthesiologist may have a difficult problem in placing an endotracheal tube because of cervical spine deformity, cervical arthritis, or immobilization due to spinal cord trauma [9]. Using the technique for intubation described above, it has been possible to intubate patients successfully under such conditions. Disnduantages of Flexible Fi beroptic Bronchoscopy Foreign bodies cannot be removed using this instrument, and the development of various types of forceps presents a challenge to the ingenuity of the manufacturers. The biopsy forceps available for insertion into the BF- 5B2 instrument are totally inadequate for foreign body removal. When a foreign body in the tracheobronchial tree is suspected, it is necessary to use a standard rigid instrument. We have not developed a t.echnique for flexible fiberoptic examination of infants. The smaller instruments do not have aspirating channels, a significant disadvantage in infant bronchoscopy. The solid fiberoptic instrument would also considerably occlude the infant s airway, making ventilation difficult. Successful examination of children 7 years of age and *Manufactured by Pilling Co., Delaware Dr., Fort Washington, Pa VOL. 16, NO. 2, AUGUST,

6 FABER ET AL. older can be carried out under general anesthesia with intubation and appropriate side-arm attachments. We have successfully examined adolescents with the flexible bronchoscope using appropriate premedications and topical anesthesia. The flexible instrument does not permit assessment of carinal fixation or bronchial rigidity as an indication of possible malignant disease or even an inoperable state. Originally it was our belief that loss of this information was a disadvantage. As our experience has increased, however, we have come to believe that the more exact evaluation of mucosal change is a more important criterion of operability. Sterilization is a concern when several patients are being examined during one endoscopic session. Glutaraldehyde, Betadine, and 50% alcohol have all been used to flush the inner channel and cleanse the outer surface. Despite less than ideal sterilization techniques in performing a large number of procedures, culture of the channel and instrument have failed to reveal pathological organisms thus far. A still unanswered question is how to proceed with training residents in endoscopy techniques [l 11. House staff can become quite versatile with the flexible instrument, but when required to insert a rigid bronchoscope, residents and interns may be unable to perform the procedure adequately. Is it appropriate to ask a patient to suffer the discomfort of rigid bronchoscopy when a technique is available that permits a more comfortable examination and also affords added diagnostic capability? If flexible instruments are developed to perform foreign body removal and infant endoscopy, then rigid endoscopy will no longer be necessary. For the present, however, it may be necessary to pass a rigid bronchoscope on alternate patients to give residents and fellows adequate training in both types of bronchoscopy. References 1. Amikam, B., Landa, J., West, J., and Sackner, M. A. Bronchofiberscopic observations of the tracheobronchial tree during intubation. Am. Rev. Resp. Dis. 105:747, Fennessy, J. J. Bronchial brushing. Ann. Otol. Rhinol. Laryngol. 79:924, Fry, W. A., and Manalo-Estrella, P. The technical details of bronchial brushing. J. Thorac. Cardiouasc. Surg. 60:636, Harken, A. H., Schonmetzler, H. K., Rosenkaimer, S. W., and Barsamian, E. M. Improved oxygenation during bronchoscopy. Ann. Thorac. Surg. 14:683, Ikeda, S. Flexible bronchofiberscope. Ann. Otol. Rhinol. Laryngol. 79:916, Richardson, R. H. Endotracheal tube bronchoscopy. Ann. Intern. Med. 76:512, Tahir, A. H. Ventilation during bronchofiberscopy. Ann. Thorac. Surg. 14:680, Taylor, P. A., and Towey, R. M. The broncho-fiberscope as an aid to endotracheal intubation. Br. J. Anaesth. 44:611, 1972, 9. Wanner, A., Amikan, B., and Sackner, M. A. A technique for bedside bronchofiberoscopy. Chest 61 :287, THE ANNALS OF THORACIC SURGERY

7 10. Wanner, A., Zighellioim, A., and Sackner, M. A. Nasopharyngeal airway: A facilitated access to the trachea. Ann. Intern. Med. 75:593, Wilson, J. A. S. The flexible fiberoptic bronchoscope (editorial). Ann. Thol-ac. Surg. 14:686, Discussion DR. FREDERICK C. KITTLE (Chicago, Ill.): I would like to review our experiences with bronchial brushing at the University of Chicago, where Dr. John Fennessey has been interested in this since The patient material now encompasses approximately 700 patients. In our present procedure we investigate centrally placed lesions first by rigid bronchoscopy and then by bronchial catheters placed under fluoroscopic guidance into the midpart or periphery of the lung. There is more of an advantage in taking biopsy material using this technique because the bronchial catheters are larger in diameter than the flexible bronchoscope. Because of this, multiple biopsies can be taken using small steel brushes, nylon bristles, and the usual small, miniature bronchial biopsy forceps. From these bronchial catheters we then can secure numerous cultures for bacteria, fungus, virus, and cytology as well as a bronchogram if so indicated. In reviewing our experience we have asked ourselves what we have learned, and certain conclusions become evident. First, there is no question about the diagnostic efficacy of our technique when the patient is believed to have a tumor. About 76% of these patients were diagnosed preoperatively. Second, we are now asking ourselves what the indications are for this technique and whether or not information gained from it actually allows decision-making. In other words, when do we need this technique, and when should the patient have a thoracotomy? From reviewing our experience, we have decided that there are three positive indications for the use of the bronchial brush: (1) when the patient s general condition is such that you would like to avoid a thoracotomy and institute a method other than surgical treatment for his disease; (2) when the lesions are multiple; and (3) probably most important, when the possibility of an inflammatory lesion exists as evidenced by the patient s symptoms or the roentgenographic appearance, or as may occur in patients who are receiving immunosuppressive therapy. In our group of 700 patients we have had 2 fatal complications. One of them was in a woman aged 88 who was admitted with iemoptysis. Probably because of the bronchial brushing techniques, additional bleeding occurred and she died two days later with a massive myocardial infarction. The other fatal complication was in a 27-year-old woman with marked thrombocytopenia; she also died from massive bleeding. All of us are very much indebted to Dr. Faber for such a superb presentation. I would like to ask him specifically about the use of a flexible fiberoptic bronchoscope in patients with acute airway obstruction due to asthma or similar states. DR. GARY M. SILVER (Cleveland, Ohio): During the past three years at the Cleveland Clinic Hospital, bronchoscopy and mediastinoscopy performed concomitantly under general anesthesia has become an important diagnostic procedure. At first, when we were using a rigid bronchoscope, it was somewhat awkward to ventilate the patient, remove the bronchoscope, and then reintubate the patient to perform the mediastinoscopy. With the use of the fiberoptic bronchoscope, however, it has become much simpler, and we have avoided multiple intubations of the patient. Using a relatively large endotracheal tube and a Y-swivel tracheal adapter, the fiberoptic bronchoscope is passed through one arm, using a Teflon cuff to make it fairly airtight, and the patient is ventilated through the other arm. When bronchoscopy is finished after an unhurried view throughout the endobronchial VOL. 16, NO. 2, AUGUST,

8 FABER ET AL. tree, the bronchoscope is removed and that end of the Y-adapter is occluded. The patient is continually ventilated, and mediastinoscopy is performed without having to move the patient at all. There are other ways of handling this problem, I am sure, but this is one that we have found to be quite simple and straightforward. DR. WILLARD A. FRY (Evanston, Ill.): It is interesting how similar techniques and results are reached at different institutions. This speaks for the quality of the procedure. I think that every thoracic surgeon who is doing endoscopy ought to have a flexible scope at his disposal. Those of you who do not will realize this only when you have one. I think its use as a diagnostic tool is important; however, its utilization in postoperative care can avoid a lot of complications. The ease with which flexible fiberoptic bronchoscopy is done is hard to believe until you have done it and can see the patient looking down his own trachea. Dr. Faber, what are you doing about some of the medical types around your hospital who say they can do bronchoscopy? Ace they able to handle all the complications, and do they really appreciate the surgical implications of some of the diseases? Have you had any difficulty with Pa, monitoring? Do you make any provisions to provide extra oxygen within the airway when you are using the flexible fiberoptic bronchoscope? DR. MEREDITH L. SCOTT (New Orleans, La.): At the Ochsner Foundation Hospital we have used this instrument equally to our own satisfaction and to the patient s benefit as compared with the relatively more barbaric rigid bronchoscope. We have also used local anesthesia; however, in a select group of 50 high-risk and overly apprehensive patients we found that controlled, balanced general endotracheal anesthesia is superior to local anesthesia. This is accomplished through a closed-system T-tube adapter on the endotracheal tube. Using the flexible bronchoscope we have been able to avoid the hypoxia and arrhythmias that sometimes occur with local anesthetics. In our 50 patients we found by monitoring the FI,, preoperatively, intraoperatively, and postoperatively that no hypercapnia or hypocapnia and no episodes of hypoxia are produced by the procedure. In conclusion, at Ochsner Foundation Hospital we believe that with selected patients in the high-risk category or with overly apprehensive patients, this method of controlled, balanced general anesthesia is safe, easily accomplished, and well accepted by the patient. DR. FREDERICK H. TAYLOR (Charlotte, N.C.): In the past twenty months we have done 482 bronchoscopies with a flexible scope. One-quarter, or 124 patients, proved to have primary bronchogenic carcinoma. The cancer was visible with the fiberoptic scope in 71 patients, or 57y0. Less than half of these lesions were visible with a straight, rigid scope. One can see well into the sub-subsegmental bronchi with the flexible bronchoscope. The diagnosis of bronchogenic carcinoma was definitely established or highly suspected from bronchoscopic samples in 62y0, 76y0, and even 96% of the patients in three different hospitals. With our technique all patients are examined under local anesthesia by nonbarbaric means. A No. 840 rigid bronchoscope is inserted into the upper trachea. This is relatively comfortable when properly done. The flexible bronchoscope is inserted through the rigid one, and this allows the resident staff to learn both the rigid and the flexible bronchoscopy techniques. It also allows for easy withdrawal and reinsertion of the flexible bronchoscope for irrigation and multiple selective brush biopsies. I have done three lobectomies for cancer in patients with normal chest 170 THE ANNALS OF THORACIC SURGERY

9 roentgenograms, normal gross findings at bronchoscopy, and normal gross findings at the operating table. The correct lobe was identified in all 3 patients by selective brush biopsies taken through the flexible bronchoscope. This technique has thus proved helpful in patients with cancer cells in their sputum and negative chest roentgenograms. DR. JURO J. WADA (Sapporo, Japan, and Nashville, Tenn.): The speaker and discussants talked about the value of the fiberoptic bronchoscope in making preoperative diagnoses. I have taken advantage of this visualization instrument for navigational guidance during surgical procedures by leaving the tip of the scope in the organ canal or body cavity. For example, during an esophageal procedure, if the scope is left inside you can see what is going on in the esophagus while you do the operation. Its introduction by some smart Japanese engineer-not me-permits us to enter into so-called two-directional surgery. In the past we have been trained to see and guide our technique in surgery by one-directional visualization. Now, by having this flexible scope on hand during an operation and by leaving it inside the gastrointestinal tract or cavity, we have a view with our eyes along with another view, in color on a TV screen, that we could not previously have had during the operation. We may have a multidimensional operation. I would very much like to share my thoughts with you in this regard. The last speaker mentioned the cost. So many members are here at this big successful society meeting; I am sure this will make the cost much less in time. All the discussions about the clinical usefulness of the fiberoptic bronchoscope are, to me, something like the discussions in this country some twenty years ago about the manual versus the automatic gear shift. DR. FABER: In response to Dr. Kittle s remarks, I think any time you can establish a diagnosis prior to thoracotomy with a procedure that carries minimal morbidity, it is worthwhile. Resection can be accomplished without an open biopsy procedure that is time-consuming and could possibly spill tumor cells. The asthmatic patient seems to tolerate endoscopic examination more readily with a flexible instrument than when a rigid bronchoscope is used. We have successfully aspirated thick secretions causing - airway obstruction in asthmatic patients. Several types of adapters exist that permit flexible fiberoptic bronchoscopy while continuous ventilation is maintained. The flexible scope is easily pas& through any side-arm adapter and readily permits endoscopic evaluation without interruption of ventilatory support. You can easily construct your own adapter or use the commercially available two-channel adapter. In response to Dr. Fry s questions, the problem of internists performing bronchoscopy can be a significant one. It may be necessary to establish peer review groups to be certain that people performing this procedure have had appropriate experience and training. Personally, I believe that we just have to do the procedure better and give a more complete assessment of the tracheobronchial tree than can our medical confreres. In urgent situations, oxygen can be passed through the channel of the fiberscope or through a small channel in an endotracheal tube when such a tube is in place. I would have to disagree with Dr. Scott, as I do not think general anesthesia is needed during this procedure; we have yet to use general anesthesia for fiberoptic bronchoscopy. Although oxygen levels have not been monitored we have not had problems of arrhythmia while the procedure was being performed. The elderly patient who is already hypoxic tolerates fiberoptic bronchoscopy very comfortably. I think general anesthesia is an added risk. Dr. Taylor is to be complimented on his results. I consider the flexible bronchoscope a superb instrument that offers an extended range of diagnostic capabilities, and I certainly recommend it for your use. VOL. 16, NO. 2, AUGUST,