Telescopic Bronchoscopy via Laryngoscope

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1 Telescopic Bronchoscopy via Laryngoscope New Technique By Amr Hegab MS,FRCS,MD Head of Department of Otolaryngology,Head/Neck & Skull Base Surgery Maadi Armed Forces Hospital Cairo - Egypt Silver Jubilee of Annual International Congress - ENT Department Faculty of Medicine Alexandria University - Egypt (April 18-20,2007)

3 Bronchoscopy was developed by ENT surgeons & still practiced by them Bronchoscopy Brief History In Gustav Killian performed the first rigid bronchoscopy to remove a piece of bone impacted in the Rt. main bronchus.

4 Bronchoscopy Brief History In early 1900s Thomas Edison overcome the hurdle of distal visualization using small lamps attached to the rigid bronchoscopes. This allowed Chevalier Jackson ( ) to popularize the procedure by several training courses & lectures. Bronchoscopy Brief History Later rigid Bronchoscopy faded away & flexible bronchoscopes took the upper hand for a while ( some decades ). By the early 1980s the Renaissance of rigid Bronchoscopy came once y y g py more from Europe by the prominent French bronchoscopist Jean Francois Dumon whose father trained with Chevalier Jackson.

5 Bronchoscopy Brief History Additional advances were possible with the invention of optical telescopes by Boyles & the introduction of solid rod lens optical systems by Hopkins Pertinent Anatomy The Trachea is attached superiorly to the cricoid cartilage at level of C7. It is cm long in the adult &its lumen is held open by horseshoe shaped cartilaginous rings. The posterior part is membranous & lies in contact with the anterior oesophageal wall.

6 Pertinent Anatomy The carina, the origin of the 2 principal bronchi lies at the level of D6 The RMB,wider, shorter & more vertical than the LMB is about 2.5cm long & lies at an angle of 17 to the midline while the left is at 35 and 5cm long. Pertinent Anatomy The 2 principal bronchi further subdivides to give 10 segmental bronchi on each side. The tracheo-bronchial tree is lined with respiratory epithelium which flattens towards the periphery.

7 Indications for Bronchoscopy Diagnostic Therapeutic Haemoptysis of uncertain cause. FB removal. Obtaining biopsies. Arrest of bleeding in trachea Unexplained persistent attacks or bronchi. of coughing & wheezing. Laser photocoagulation. Bronchial lavage. Laser resection of obstructing Suspicion of bronchial trauma. malignant lesions. Laser evaporation of benign tracheo-bronchial strictures. Stent insertion. Preparation & Instrumentation Even the most experienced bronchoscopist would agree that dealing with a young child with a history of FB inhalation is a very challenging task. This is because of the unpredictability of the degree of difficulty of the procedure which depends on a number of factors as : 1. age of the patient 2. type of the inhaled FB 3. site of the inhaled FB 4. time elapsed between inhalation & removal 5. equipment available 6. skill of the anaesthatist.

8 Preparation & Instrumentation So ideally bronchoscopy should be done as an elective procedure which means the Surgical-Anaesthetic-Nursing team knows each other and are able to perform their tasks in harmony, efficiency & above all peacefully. Complete set of rod lens telescopes ( variable degrees of Complete set of rod lens telescopes ( variable degrees of viewing ) and different types of optical forceps & suction tips should be available along with the standard ENT laryngoscopy instruments & documentation system.

10 Preparation & Instrumentation Immediate pre-op CXR is mandatory as occasional coughing of FB & re-ingestion in GIT occurs. In this case conservation is the rule with repeated abdomen & pelvic plain X rays & gastroenterologist consultation until it passes out. Before commencing, the surgeon must be satisfied that ALL his gear is in working order especially for patency and length of suction tips as well as non jamming of the forceps jaws. Technique Surgeon & Anaethatist should not work in opposite directions

11 They should share the same field & go in the same direction The New Technique The patient is placed in a supine position with the head & neck hyper extended dalong with adequate venous access & monitoring i BP,HR, ECG and O² saturation

12 The New Technique Standardlaryngoscope d is inserted and after obtaining good view of the laryngeal inlet, it is self suspended by the chest piece to maintain that view ( as in laryngoscopy ).

13 The New Technique Now the anaesthatist is asked to withdraw the endotracheal tube slowly outwards till its beveled tip rests posteriorly between both arytenoids at the level of the vocal folds Glottic Anaesthesia Tip of anaesthetic tube at posterior glottis

14 The New Technique Next a rigid Hopkins 0 telescope size 5.5 or 2.9 mm in diameter ( according to age) with the camera head attached to it, is advanced via the laryngoscope, passing between the vocal folds & down the trachea and main bronchi.

15 The New Technique Once the FB is identified, a suitable forceps (preferably an optical one) is introduced under visual control to grasp it and pull it out gently.

16 The New Technique Following removal, it is extremely important while the patient is still under GA to take a Second Look to ensure that : 1) A 2 nd FB is not missed. 2) Removal of any residual small fragments in case of organic FB. 3) Aspiration of pus & mucus thus speeding the resolution of atelectasis & pneumonia. 4) Assess and treat any complications that might have happened during the procedure.

18 Post- operative Protocol Plain XR chest as a routine to assess the patient. Patient is observed on the ward for 24 hours before discharge. Short course of prophylactic antibiotics & efficient physiotherapy are recommended in cases of organic FB inhalation.

19 Discussion

20 Discussion In our series, we performed 32 bronchoscopic procedures mostly for FB removal with this new technique over the past 2 years ( ) 9 males 23 females 19 adults 13 children 23 in RMB 9 in LMB &Trachea i.e. FB inhalation in our series is more common in adult females in RMB Discussion Types of FB ranged from organic ( eg water millon seeds, peanuts, garlic cotyledon etc..) to non organic as hair pins, toy parts etc.. No complications were encountered in the whole series. One failure occurred where the FB could not be removed as it was covered by granulations being neglected in place for 4 months!! This required thoracotomy by the Cardiothoracic team to retrieve the FB.

21 Take Home Points Take Home points FB inhalation is a significant health hazard which may occur in all age groups. Accidental inhalation of FB is almost entirely preventable. Adults should set a good example by never placing pins and inedible objects in their mouths. Children under the age of 2 should not be allowed to eat peanuts & their play rooms should be cleaned of small objects that could be inhaled

22 Take Home points This new technique assures a comfortable quick removal of FB from the tracheobronchial tree, where Glottic Anaesthesia provides a smooth continuous & safe route for adequate ventilation. No interference with the anaesthatist job and no interruption of the procedure. Take Home points In this technique accidental displacement of the FB & possible injury of the trachea or bronchi by insertion of the classic bronchoscopes are minimized. Last but not least, by virtue of their supreme illumination and optics, using the rigid telescopes allows for : 1. Better viewing i ofthe operative field. 2. Accurate localization & better control of the FB. 3. Documentation using the attached camera.(used for medico legal purposes as well as teaching ) 4. Attracting all OR staff attention!

23 Everyone is watching Thank you for your Thank you for your attention

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