You get a bronchoscopy, you get a bronchoscopy, everyone gets a bronchoscopy! Edward Fong, MD Kapi olani Medical Specialists

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Yu get a brnchscpy, yu get a brnchscpy, everyne gets a brnchscpy! Edward Fng, MD Kapi lani Medical Specialists Financial Disclsure Just like this guy I have nthing t disclse financially. What is it?

1 Yu get a brnchscpy, yu get a brnchscpy, everyne gets a brnchscpy! Edward Fng, MD Kapi lani Medical Specialists Financial Disclsure Just like this guy I have nthing t disclse financially. What is it? Why d it? Objectives Histrical Perspective 1 st brnchsscpy dne: 1876 by Gustave Killian, German ENT Cnsidered Father f brnchscpy Hw is it dne? Are there alternatives? Remved prk bne frm a farmer s airway Vide Disclsure The patient identifiers in the vide clips were unable t be remved/bscured fr this presentatin. Panchabi TS, Mehta AC. Histrical Perspectives f Brnchscpy Cnnecting the Dts. An Am ThracSc 2015; 12(5): Father f American brnchscpy Chevalier Jacksn, American ENT Father f American pediatric brnchscpy Rbert E. Wd, Pediatric Pulmnlgist Intrduced 1 st illuminated rigid brnchscpe Prlific freign bdy remver: 2374 bjects ver 75 yr career Hlds annual brnchscpy curse t teach fellws, pulmnlgists, and intensivists. Perfrms brnchscpies annually. Panchabi TS, Mehta AC. Histrical Perspectives f Brnchscpy Cnnecting the Dts. An Am ThracSc 2015; 12(5):

Rigid Brnchscpy 1 st type perfrmed Swrd Swallwing Requires specific subspecialized training Typically all ENT get training; nt all Pediatric Surgens; very few Pediatric Pulmnlgists.

Panchabi TS, Mehta AC. Histrical Perspectives f Brnchscpy Cnnecting the Dts. An Am ThracSc 2015; 12(5): 631-41.

Pediatric Surgens Flexible brnchscpes Diagnstic Minimal therapeutic Differences f Instruments Requires separate airway cntrl Rigid brnchscpes Therapeutic Minimal diagnstic Cntrl f airway Hllw metal

cm/en/prduct.php?id=114&cat=2 Rle f brnchscpy DIAGNOSTIC Airway structure Nares, Nas-/Or-/Hyppharynx, Larynx, Vcal crds, Extra-/Intra-thracic airways.

secretins, freign bdy, granulatin tissue Reductin f lung tissue INDICATIONS Stridr Chrnic cugh Persistent wheeze Recurrent crup Hemptysis Chrnic/recurrent atelectasis Cmplicated pneumnia Aspiratin

2 Rigid Brnchscpy 1 st type perfrmed Swrd Swallwing Requires specific subspecialized training Typically all ENT get training; nt all Pediatric Surgens; very few Pediatric Pulmnlgists. Flexible Brnchscpy Easier t perfrm Adjusts t patient Requires specific specialized training All Pediatric Pulmnlgists; all ENT; sme Pediatric Surgens; few Pediatric Intensivists. Panchabi TS, Mehta AC. Histrical Perspectives f Brnchscpy Cnnecting the Dts. An Am ThracSc 2015; 12(5): Laryngscpy Easiest t perfrm, but mst limited infrmatin Direct (swrd swallwing) All physicians receive training Flexible (adjusts t pt) All ENT; mst Pediatric Pulmnlgists; sme Anesthesilgists; sme Pediatric Surgens Flexible brnchscpes Diagnstic Minimal therapeutic Differences f Instruments Requires separate airway cntrl Rigid brnchscpes Therapeutic Minimal diagnstic Cntrl f airway Hllw metal tube Optics Fiberptic Vide (similar t rigid) Ultimate ptics Glass rd telescpe Increased risk fr cmplicatins Rle f brnchscpy DIAGNOSTIC Airway structure Nares, Nas-/Or-/Hyppharynx, Larynx, Vcal crds, Extra-/Intra-thracic airways. Airway dynamics Malacia, Narrwing, Stensis, Cllapse, Cmpressin, Ballning Airway functin Ciliary mtility, infectin, bleeding, cytlgy, bipsy THERAPEUTIC Crrect placement f artificial airways Remval f secretins, freign bdy, granulatin tissue Reductin f lung tissue INDICATIONS Stridr Chrnic cugh Persistent wheeze Recurrent crup Hemptysis Chrnic/recurrent atelectasis Cmplicated pneumnia Aspiratin (chemical/freign bdy) Trachestmy tube PEEP study Immundeficiency Nn-sputum expectratr Abnrmal CXR Why d it? DIAGNOSES Laryng-/Trache-/Brnchmalacia Laryngeal cleft/web Vcal crd dysfunctin/paralysis vs. paresis Subglttic stensis Cmplete tracheal rings TEF Freign bdy Brnchiectasis Pulmnary hemrrhage Alvelar prteinsis GER/Direct aspiratin Infectin Cancer (hematlgic/slid rgan) 2

Perfrming brnchscpy APPROACH Nares Upper airway, functinal studies Can g t lwer airways LMA Avid intubatin Distrts larynx ETT Already intubated Samples/therapeutic SEDATION Lcal

viceandswallwing.cm/imagegal_image_laryxnrmal.htm Nrmal Subglttic Space, Trachea, and Carina Nrmal-ish Airway Subglttic space Carina Trachea www.emedicine.cm/ped/tpic2167.

jpg Stridr One f mst cmmn reasns fr brnchscpy Nt all striduluspatients require airway evaluatin Biphasic, FTT, simulating CPR, slppy eater, Dc, I gtta knw Mst cmmn etilgy:

flexible brnchscpy Sedatin required/desired Assciated lwer airway anmalies means flexible laryngscpy is an incmplete examinatin = false negative It s Just Stridr Right?

3 Perfrming brnchscpy APPROACH Nares Upper airway, functinal studies Can g t lwer airways LMA Avid intubatin Distrts larynx ETT Already intubated Samples/therapeutic SEDATION Lcal Exercise Laryngscpy Functinal study Brutane and lcal Nenates Upper airway studies Prcedural r GA BAL; ciliary brushing N cncern fr upper airway dynamics r Nrmal Larynx Nrmal Subglttic Space, Trachea, and Carina Nrmal-ish Airway Subglttic space Carina Trachea nes_digitales/imagenes/laringe/traquea.jpg Stridr One f mst cmmn reasns fr brnchscpy Nt all striduluspatients require airway evaluatin Biphasic, FTT, simulating CPR, slppy eater, Dc, I gtta knw Mst cmmn etilgy: laryngmalacia Laryngmalacia is a diagnsis f visualizatin Flexible laryngscpy vs. flexible brnchscpy Sedatin required/desired Assciated lwer airway anmalies means flexible laryngscpy is an incmplete examinatin = false negative It s Just Stridr Right? Diagnsis # f Patients Percent (%) Cngenital Laryngeal Anmalies Cngenital Tracheal Anmalies Cngenital Brnchial Anmalies 11 5 Infectius Cnditins 12 5 Internal Laryngeal Trauma 12 5 Other 17 7 Ttal Cngenital airway anmalies are present in >85% f all infants/children.abut 10% f children with laryngmalacia have assciated cngenital anmaly. 3

4 Laryngmalacia Effects f Reflux Granulma ing.cm/imagegal_image_ref _edema3.htm _ref_granulmas.htm Why Reflux Matters in Laryngmalacia Vcal Crd Paralysis Piseuille s Law R = 8nl πr 4 Unilateral Paralysis Bilateral Paralysis Vcal Crd Ndules Laryngeal Web Papillmatsis Ndules Web (abve vcal crds) Vcal Crds Respiratry_papillmatsis.jpg 4

Subglttic Stensis Cngenital subglttic stensis

Mnphnic Structural bstructin Single large caliber

Biphasic Trachemalacia, Mainstem brnchmalacia,

Tracheesphageal Fistula Anterir Plyphnic

caliber airways Failure f medical management

5 Subglttic Stensis Cngenital subglttic stensis Acquired subglttic stensis Laryngmalacia Recurrent/Persistent Wheeze & Chrnic Cugh Mnphnic Structural bstructin Single large caliber airway Uniphasic vs. Biphasic Trachemalacia, Mainstem brnchmalacia, Rings, Slings, and ther Things, Freign bdy, TEF Tracheesphageal Fistula Anterir Plyphnic Structural/dynamic bstructin Multiple varied caliber airways Failure f medical management Brnchmalacia, cardimegaly, infectin TEF Rutter M, Manning P. Internatinal Cngress Series 1254 (2003) Tracheal Rings Shrt segment midtrachea Cmplete whle length Brnchmalacia Rutter M, Manning P. Internatinal Cngress Series 1254 (2003)

exam, imaging = Rigid brnchscpy r Flexible w/ rigid n stand-by Often requires fllw up brnchscpy

Mucus Plug (CF/brnchiectasis) Persistent/recurrent pacity And, there are times, where: It s the

Imaging studies CXR Flurscpy CT scan with 3D recnstructin Alternatives Static, nt dynamic

6 Nasal apprach Surprise! Witnessed aspiratin = Rigid brnchscpy Freign Bdy Unwitnessed aspiratin, but (+) clinical histry, exam, imaging = Rigid brnchscpy r Flexible w/ rigid n stand-by Often requires fllw up brnchscpy White ut Abnrmal CXR Unrespnsive t aggressive ventilatr management using recruitment strategies Mucus Plug (CF/brnchiectasis) Persistent/recurrent pacity And, there are times, where: It s the Heart, nt the Lungs! Imaging studies CXR Flurscpy CT scan with 3D recnstructin Alternatives Static, nt dynamic Supplemental nt a subsitute Withut ging thrugh Wilsn tunnel, yu can t tell me abut the traffic. De Wever W, et al. MultidetectrCT-generated virtual brnchscpy: an illustrated review f the ptential clinical indicatins. Eur Resp Jur 2004; 23):

Suctin Trauma What s wrng with deep suctining? Repetitive suctin trauma will cause granulatin tissue t frm.

trachetmy, airway visualizatin must ccur Cnfirmatin trachetmy required N surprises f airway structure dwn the rad (ie.

7 Suctin Trauma What s wrng with deep suctining? Repetitive suctin trauma will cause granulatin tissue t frm. Repetitive insertin and withdrawal f a tube n matter hw sft will cause trauma t tissue mucsa Trachestmy Tubes Befre trachetmy, airway visualizatin must ccur Cnfirmatin trachetmy required N surprises f airway structure dwn the rad (ie. Rings) Functinal Exam After trachestmy tube placed, annual airway evaluatin required Summary Brnchscpy is an invaluable diagnstic and therapeutic tl. Mahal Nui La A cmplete airway evaluatin frm nse thrugh extrathracic airways and dwn int intrathracic airways may nly be accmplished via brnchscpy. Brnchscpy is the nly way t determine airway dynamics, including having the benefit f real time interventins. 7

IAEM Clinical Guideline 12 Foreign Bodies: The Emergency Department Management of Inhaled and Inserted Objects in Children

IAEM Clinical Guideline 12 Foreign Bodies: The Emergency Department Management of Inhaled and Inserted Objects in Children IAEM Clinical Guideline 12 Freign Bdies: The Emergency Department Management f Inhaled and Inserted Objects in Children Versin 1 August 2018 Authr: Dr Susan Uí Bhrin Adapted with Permissin frm the Jint