Therapeutic Bronchoscopy Etiology - Benign Stenosis Post - intubation Trauma Post - operative Inflammatory Idiopathic

Transcription

1 Endobronchial Palliation of Airway Disease Douglas E. Wood, MD Professor and Chief Division of Cardiothoracic Surgery Vice-Chair, Department of Surgery Endowed Chair in Lung Cancer Research University of Washington

2 Therapeutic Bronchoscopy Etiology - Benign Stenosis Post - intubation Trauma Post - operative Inflammatory Idiopathic

3 Therapeutic Bronchoscopy Etiology - Malignant Primary Adenoid cystic Squamous Metastatic Renal cell/breast Local extension Lung Esophageal Thyroid Mediastinal tumor Carcinoid Mucoepidermoid

4 Therapeutic Bronchoscopy Primary Management Benign - resection and reconstruction Malignant Primary - resection and reconstruction Metastatic - radiation +/- chemotherapy Local extension - radiation +/- chemo

5 Therapeutic Bronchoscopy Indications Symptomatic stenosis Dyspnea, stridor, obstructive pneumonia Unresectable Extent of airway involvement Metastatic disease Unresectable local invasion Excessive risk of resection

6 Therapeutic Bronchoscopy Anesthesia Nursing Techniques Close airway collaboration and planning Maintain spontaneous ventilation Standard ventilation Extubate at completion of procedure Familiarity with equipment and routines Preparation for variety of interventions Prepared to assist with emergency airway management

7 THERAPEUTIC BRONCHOSCOPY Advantages Ventilation anesthesia Direct manipulation Larger instrumentation Larger suction Techniques Rigid Bronchoscopy Ability to place solid stents Disadvantages General Poor distal view Need to intubate

8 Therapeutic Bronchoscopy Modalities Dilation Core - out Laser Stent Brachytherapy Photodynamic therapy Cryotherapy

9 Therapeutic Bronchoscopy Indications Dilatation Benign stenosis Techniques Esophageal bougies (8-26 F) Rigid bronchoscope ( mm) Hydrostatic balloon (5-18 mm)

10

11

12

13

14

15

16 Therapeutic Bronchoscopy Core - out Indications Endobronchial tumor Endobronchial granulations Techniques Tips of bronchoscope Biopsy forceps

17

18

19

20

21 Therapeutic Bronchoscopy Indications Laser Endobronchial tumor Endobronchial granulations Bleeding or irregular tumor bed Lumen not approachable by rigid bronchoscope Techniques Nd:YAG 2 CO 2 KTP

22

23 Therapeutic Bronchoscopy Brachytherapy Indications Small volume endobronchial tumor Maximized external beam radiation Effect maximal for 1-2 cm diameter Technique Single vs multiple catheters Catheter stabilization Dose

24 Therapeutic Bronchoscopy Indications Stents Recurrent endobronchial tumor Recalcitrant benign stenosis Extrinsic compression Techniques Rigid bronchoscopy Flexible bronchoscopy with fluoroscopy Customization Balloon dilatation

25 AIRWAY STENTING Anatomic Indications Stent as principal therapy Intrinsic tracheobronchial pathology Amyloid, relapsing polychondritis, malacia Extrinsic compression Stent as adjunct to other endoscopic procedures Endoluminal tumor Recalcitrant stricture

26 Therapeutic Bronchoscopy Stents Silicone T and T-Y tubes Endoluminal stents Y-stents Expandable Wallstent Permalume Gianturco Palmaz Ultraflex Polyflex Aero

27 Therapeutic Bronchoscopy Silicone Stents Advantages Adjustable Removable No ingrowth Unreactive Controlled expansion Inexpensive Disadvantages Rigid bronchoscopy Difficult placement Dislodgment inner diameter Distortion

28 Therapeutic Bronchoscopy Expandable Stents Advantages Flexible bronchoscopy Easy delivery Stable placement Conformation Epithelialization Ventilation through interstices Disadvantages Permanent Difficult adjustment Fluoroscopy Granulations Tumor ingrowth Erosion Expensive

29 AIRWAY STENTING Tracheobronchial Malacia

30 AIRWAY STENTING Malacia with 3 stents

31 AIRWAY STENTING NSCLC Right Mainstem

32 AIRWAY STENTING NSCLC after Core-Out and Laser

33 AIRWAY STENTING Right Mainstem Stent Modification of distal stent to prevent obstruction of upper lobe

34 AIRWAY STENTING NSCLC with Tracheal and Bilateral Obstruction

35 AIRWAY STENTING Carinal Y-stent

36 AIRWAY STENTING Bilateral Obstruction from NSCLC

37 AIRWAY STENTING Bilateral Stents for NSCLC

38 AIRWAY STENTING Metastatic Sarcoma

39

40 AIRWAY STENTING Permalume Tracheal Stent

41 AIRWAY STENTING Metastatic Sarcoma with Tracheal Compression

42 AIRWAY STENTING Tracheal Wallstent

43 Therapeutic Bronchoscopy Treatment Algorithm Symptomatic Obstruction Resectable Airway Resection Benign Dilatation Repeated Recurrence Stent Recurrence Unresectable Malignant Endobronchial Tumor Core-out Laser Brachy Recurrence Extrinsic Compression Stent

44 Therapeutic Bronchoscopy University of Washington June 1992 to January 2002 Includes dilatation, core-out, out, laser, stent, brachytherapy, PDT Patients Procedures Stent procedures approximately 200 procedures/yr

45 Therapeutic Bronchoscopy Outcomes Successful airway palliation Mortality Patients 158/165 (95.8%) Procedures 318/325 (97.8%) Operative or procedure related 0% Hospital and 30 day 2/165 (1.2%) Complications - 22 in 19 patients (11%) Bleeding 3 Stent migration 9 Perforation 2 Stent occlusion 7

46 Therapeutic Bronchoscopy Conclusions Excellent airway palliation Improves symptoms, function, quality of life, survival May require multiple interventions Does not replace resection for operable lesions

47