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* From the Department of Pulmonary Medicine (Dr. Ernst), Beth Israel Deaconess Medical Center, Boston, MA; Division of Pulmonary Medicine (Dr. Silvestri), Medical University of South Carolina, Charleston, SC; and Division of Cardiothoracic Surgery (Dr. Johnstone), University of Rochester, Rochester, NY.
Correspondence to: Armin Ernst, MD, FCCP, Director, Interventional Pulmonology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215; e-mail: aernst{at}caregroup.harvard.edu
Key Words: airways • bronchoscopy • guidelines • interventional pulmonology • pleural disease • procedures
The ability to perform procedures is one of the defining characteristics that attracted so many of us to fellowships in pulmonary medicine, critical care medicine, and thoracic surgery. In fact, nearly 500,000 bronchoscopies are done each year in the United States. Additionally, approximately 15,000 airway stents are placed yearly worldwide. The number and complexity of procedures that can be performed in the bronchoscopy unit is increasing. For example, endobronchial electrocautery for tumor ablation and the treatment of hemoptysis can be performed under local anesthesia during a "routine" outpatient bronchoscopy.
Unfortunately, our training and expertise is not uniform. An American College of Chest Physicians (ACCP) survey revealed that > 50% of respondents believed that their training in advanced diagnostic techniques such as transbronchial needle aspiration (TBNA) was inadequate. In another query of senior pulmonary fellows, Haponik et al found that while most fellows reported "adequate" training in bronchoscopy, only 72% had any instruction in TBNA and 27% in stent placement.
Despite the proliferation in the number and type of chest procedures currently performed, there are presently no guidelines that ensure that the basic skills and competency needed to provide these services have been acquired by the pulmonologist, critical care physician, or thoracic surgeon (dedicated operators). To address this void, the development of guidelines for chest procedures was initiated through the Interventional Chest/Diagnostic Procedures Network of the ACCP (the "Network"). There were several compelling reasons to do so. First, these procedures carry inherent risks, and patient safety is of paramount concern. Second, defining the equipment and personnel required, indications, contraindications, risks, and training requirements of each of the procedures may facilitate uniform practice within fellowship training programs. In addition, these guidelines could be used as a guide to hospital nursing, respiratory therapy and administrative departments who wish to develop these services. Finally, dedicated operators who display competency in these individual procedures should have less difficulty overcoming the barriers that sometimes exist within local hospital credentialing committees.
The guidelines themselves were developed by a group of physicians representing a wide range of interests within the college. The group was comprised of pulmonologists and thoracic surgeons, academics, and private practitioners who reside in the United States and abroad. Despite the diversity of practice views, consensus was reached on all of the parameters put forth in this document.
For physicians wishing to learn how to perform one of these advanced procedures, there are several different educational approaches. There are intense short training programs (1 to 3 days). These are available throughout the United States and abroad. More formal mini-sabbaticals (1 to 6 months) are available as well. Several fellowship training programs have developed an additional year of fellowship training in advanced interventional techniques similar to other procedure-intensive internal medicine subspecialties such as cardiology and gastroenterology. Both of these groups have adopted minimum requirements for their trainees to achieve competence in advanced procedures. Still others have used novel approaches such as virtual reality-simulated bronchoscopy as a teaching tool for the novice dedicated operator. Innovative approaches to learning these techniques will no doubt become widely available in the future.
These guidelines clearly have limitations. Although we do not have the necessary data on all of the procedures outlined in this document to make definitive statements on patient outcome and the necessary number of procedures to achieve competency, that does not mean we should shy away from competency guidelines altogether. Therefore, we have developed some competency parameters based on the expertise of our panel members. The ACCP Network hopes that fellowship program directors will use this document to assess the strengths and weaknesses of the procedural training they provide and adopt this working document to develop the highest level of procedural training. We hope that this document will focus interest on the diversity of techniques now available to our patients. These ACCP guidelines can also be built on as new procedures are brought out of the laboratory and into practice.
When learning new techniques, the old adage "see one, do one, teach one" is no longer acceptable. The ACCP Network offers these guidelines as an alternative. We hope our membership will embrace it.
Appendix
Contributers include David Johnstone, MD, Thoracic Surgery, Rochester, NY (Chair, ICDP Network); Armin Ernst, MD, Pulmonary Medicine, Boston, MA (Vice-chair, IDCP Network); George Mallory, MD, Pediatric Pulmonology, Houston, TX (Pediatric Network Representative); and the Steering Committee of the IDCP Network, including Atul Mehta, MD, Pulmonary Medicine, Cleveland, OH; John Howington, MD, Thoracic Surgery, Cincinnati, OH; Heinrich Becker, MD, Pulmonary Medicine, Heidelberg, Germany; Gerard Silvestri, MD, Pulmonary Medicine, Charleston, SC; Steven Yang, MD, Thoracic Surgery, Baltimore, MD; David Midthun, MD, Pulmonary Medicine, Rochester, MI; Tim Herrick, MD, Pulmonary Medicine, Hyannis, MA; and Neri Cohen, MD, Thoracic Surgery, Richmond, VA. Invited reviewers were Paul Kvale, MD, Pulmonary Medicine, Detroit, MI; Carolyn Reed, MD, Thoracic Surgery, Charleston, SC; Kevin Kovitz, MD, Pulmonary Medicine, New Orleans, LA; and Richard Irwin, MD, Pulmonary Medicine, Worcester, MA.
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Abbreviations: ACCP = American College of Chest Physicians; APC = argon plasma coagulation; EBUS = endobronchial ultrasound; PDT = percutaneous dilatational tracheostomy; RN = registered nurse; TBNA = transbronchial needle aspiration; TPNA = thoracic percutaneous needle aspiration; TTOT = transtracheal oxygen therapy; WLB = white light bronchoscopy
A list of participants is given in Appendix 1. 
Received for publication November 22, 2002. Accepted for publication November 25, 2002.
References
Definition
Flexible bronchoscopy is an invasive procedure that is utilized to visualize the nasal passages, pharynx, larynx, vocal cords, and tracheal bronchial tree. It is utilized for both the diagnosis and treatment of lung disorders. The procedure may be performed in an endoscopy suite, the operating room, the emergency department, a radiology suite, or at the bedside in the ICU.
Equipment
At minimum, the equipment needed is a bronchoscope, light source, cytology brushes, biopsy forceps, needle aspiration catheters, suction apparatus, supplemental oxygen, fluoroscopy (C-arm), pulse oximetry, sphygmomanometer, and equipment for resuscitation including an endotracheal tube. A video monitor is a useful accessory, but not required. Fluoroscopy may be needed to facilitate certain transbronchial biopsy procedures.
Personnel
A dedicated operator performs the procedure. Personnel required for this procedure include a registered nurse (RN) or a respiratory therapist to administer and monitor conscious sedation, as well as a separate RN or a respiratory therapist to assist the dedicated operator with the procedure. All supporting personnel should be familiar with the procedure being performed, as well as the appropriate handling of the specimens. This will maximize patient comfort, safety, and yield.
Anesthesia and Monitoring
Flexible bronchoscopy may be performed under local anesthesia with or without conscious sedation or under general anesthesia. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment.
Technique
The patient should be placed in either a semi-recumbent or supine position after IV access has been obtained. The patient should fast for at least 4 h prior to the procedure. If the dedicated operator chooses to use the nose as the orifice of entry, the patient should have a topical anesthetic applied to the pharynx and nasal passages. After the topical anesthetic has taken effect, the bronchoscope is introduced either through the nose or mouth with a bite block in place. The oropharynx is examined. After a thorough examination is performed and on reaching the vocal cords, the patient is usually again anesthetized topically. The vocal cords are examined for abduction and adduction. The bronchoscope is passed through the vocal cords, and a complete airway inspection is performed.
Both therapeutic and diagnostic procedures can be performed during flexible bronchoscopy. Depending on the indication, the following diagnostic procedures can be performed: BAL, endobronchial or transbronchial biopsies, cytologic wash or brush, and TBNA, endobronchial ultrasound (EBUS), and autofluorescence bronchoscopy. Therapeutic procedures such as balloon dilatation, endobronchial laser ablation, electrocautery, photodynamic therapy, brachytherapy, and selected stent placement can all be accomplished through flexible bronchoscopy.
Indications
Indications include, but are not limited to, undiagnosed pulmonary infiltrates, lung masses, mediastinal lymphadenopathy, hemoptysis, airway disorders, endobronchial lesions, therapeutic suctioning, and pediatric bronchoscopy.
Contraindications
Most contraindications to flexible bronchoscopy are relative rather than absolute. Special attention must be paid to respiratory and bleeding status. In unstable patients or prolonged procedures, rigid bronchoscopy may be preferred.
Risks
Diagnostic flexible bronchoscopy is usually an extraordinarily safe procedure. Major complications such as bleeding, respiratory depression, cardiorespiratory arrest, arrhythmia, and pneumothorax occur in < 1% of cases. Mortality is rare, with a reported death rate of 0 to 0.04% in > 68,000 procedures.
Training Requirements
Expertise in flexible bronchoscopy for the diagnosis of lung diseases is absolutely necessary for the pulmonary physician trained in pulmonary and critical care medicine. Trainees should perform at least 100 procedures in a supervised setting to establish basic competency. To maintain competency, dedicated operators should perform at least 25 procedures per year. In addition to the number of procedures, the competency of each trainee should be certified by the program director or the director of the bronchoscopy unit. Finally, it is important that training include competency in assisting a dedicated operator in the performance of the procedure.
References
Definition
Rigid bronchoscopy is an invasive procedure that is utilized to visualize the oropharynx, larynx, vocal cords, and tracheal bronchial tree. It is performed for both the diagnosis and treatment of lung disorders. The procedure may be performed in an endoscopy suite with available anesthesia, but more appropriately in the operating room, and rarely in the ICU. It is frequently combined with flexible bronchoscopy to acquire and maintain better distal airway visualization and suctioning.
Equipment
A set of ventilating bronchoscopes should be available in different sizes. A halogenated light provides illumination; 0°, 30°, and 90° telescopes can be placed down the rigid barrel to improve visualization. An array of instruments such as graspers, biopsy forceps, and suction devices should also be readily available. Video capability is desirable but not necessary. Other miscellaneous materials that should be available include normal saline solution, lubricant jelly, syringes, and suction tubing.
Personnel
A dedicated operator performs the procedure. Personnel required for this procedure include a nurse or a respiratory therapist to administer and monitor conscious sedation, as well as a separate RN or a respiratory therapist to assist the dedicated operator with the procedure. All supporting personnel should be familiar with the procedure being performed, as well as the appropriate handling of the specimens. This will maximize patient comfort, safety, and yield.
Additional personnel may be utilized, depending on where the procedure is performed (operating room vs bronchoscopy suite). An anesthesiologist, circulating nurse, and operating room technician are frequently utilized during this procedure.
Anesthesia and Monitoring
This procedure is usually performed under general anesthesia with adequate sedation and muscle relaxants. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment.
Technique
The patient is placed in the supine position. The head should be on a small pillow or foam rest, and positioned on the portion of the table that can be flexed or extended as needed. After introducing the instrument, the epiglottis is gently lifted with the end of the bronchoscope, after which the larynx and vocal cords can be seen. Once the vocal cords have been visualized, the bronchoscope is turned 90° vertically in order to pass through the vocal cords. This offers the least resistance and avoids damage to the vocal cords. After entering the upper trachea, the bronchoscope is turned back to its original neutral position.
Ventilation is initiated via the side port. The bronchoscope is gently advanced toward the carina, and systematically inserted into each mainstem bronchus. Anatomic, airway, and mucosal abnormalities are noted. Telescopes may be inserted into the rigid bronchoscope to visualize the distal segments, requiring the angled 30° and 90° scopes to see particularly the right upper lobe orifice. The head is usually turned to the left to enter into the right mainstem bronchus, and turned to the right to enter into the left mainstream bronchus.
Once the preliminary examination is completed, the purpose for which the procedure was performed should be addressed (eg, dilation, stent insertion, laser ablation, extraction of foreign bodies). Cautery, forceps, and suction should be readily available. If a more detailed examination, washings, laser/photodynamic ablation, or stent insertion is required, a flexible bronchoscope can be inserted through the rigid bronchoscope.
Indications
There are many indications for rigid bronchoscopy, including bleeding or hemorrhage, foreign body extraction, deeper biopsy specimen when fiberoptic specimen is inadequate, dilation of tracheal or bronchial strictures, relief of airway obstruction, insertion of stents, and pediatric bronchoscopy. It is also used for tracheobronchial laser therapy or other mechanical tumor ablation.
Contraindications
Relative contraindications include uncontrolled coagulopathy, extreme ventilatory and oxygenation demands, and tracheal obstruction to the novice operator.
Risks
Most potential complications of rigid bronchoscopy can be avoided. These include injury to the teeth or gums, tracheal or bronchial tears, or severe bleeding. Complication rates should be < 0.1%. Procedure-related mortality is rare.
Training Requirements
Trainees should perform at least 20 procedures in a supervised setting to establish basic competency in patients with normal airways, and to become comfortable with the set-up and intricacies of the procedure. Dedicated operators should perform at least 10 procedures per year to maintain competency. Individual institutional program directors in bronchoscopy and surgery should ultimately decide on the competency of each candidate, and they should also determine where best these procedures should be performed, either in the bronchoscopy or operating suite.
References
Overview
Bronchoscopy has been performed in infants, children, and adolescents by pediatric surgeons and specialists for > 50 years. Until the 1980s, the approach was almost exclusively via the rigid bronchoscope and the operators, at least in the United States, were almost exclusively surgeons. Today, however, pediatric pulmonologists perform flexible bronchoscopy more often on children than rigid bronchoscopy. Due to this preference, this section focuses on flexible bronchoscopy. The equipment, techniques, and indications are quite different than those applied in adult populations. Proficiency in flexible bronchoscopy is a recommended element in pediatric pulmonology fellowship training, but no specific number or type of procedures has been required of trainees.
Equipment
The standard pediatric bronchoscope has an outer diameter of 3.4 to 3.6 mm (depending on the manufacturer) with a suction channel of 1.2 mm. Specific information about the bronchoscopes used in pediatric patients is provided in Appendix 2. The standard pediatric bronchoscope can usually be safely used in healthy infants with mild respiratory difficulties receiving oxygen supplementation. The 2.2-mm, ultrathin, flexible bronchoscope has no suction channel. It has its greatest use in premature and newborn infants who may or may not be intubated. The recently introduced 2.8-mm bronchoscope with a 1.2-suction channel is very fragile and can be used in older infants or newborn infants who are not intubated. In older children, this bronchoscope can be passed through several generations of bronchi and thereby identify abnormalities previously beyond the reach of the bronchoscope. The smallest adult bronchoscopes can be safely used in older children and adolescents, and are particularly useful when purulent secretions are present or transbronchial biopsy specimens are to be obtained.
Standard biopsy forceps cannot be passed through the 1.2-mm suction channel of the 3.4- to 3.6-mm or 2.8-mm bronchoscopes. Olympus Healthcare (Olympus America; Melville, NY) introduced a mini-forceps in the mid-1990s. As expected, the mouth of the forceps is quite small, as are the samples obtained. In order to obtain adequate specimens, multiple passages of the forceps are usually required. Cytology brushes are available that can be passed through the 1.2-suction channel. Recently, the use of urologic baskets and forceps passed through the suction channel has been described to retrieve foreign bodies with the standard pediatric bronchoscope.
Personnel
A dedicated operator must always be present, and is the overseer and supervisor over all aspects of the procedure. A second physician is often present, especially in training contexts, but is not usually required. Two other trained persons are usually present and, in the absence of a second physician, should be present. A nurse provides care and monitoring of the patient and keeps a chronologic record of medications administered and the condition of the patient. A second person, often a respiratory therapist, oversees the bronchoscope, light source, and suction equipment, and manages medications administered through the bronchoscope and collects any specimens obtained during the procedure. All personnel should be trained and skilled in cardiopulmonary resuscitation.
Anesthesia and Monitoring
As a rule, pediatric flexible bronchoscopy is performed with IV sedation due to the lower predictability of cooperation from children during bronchoscopy when compared to adults. Most practitioners use a short-acting benzodiazepine and either a short-acting opiate or ketamine. Continuous monitoring of heart rate, arterial oxyhemoglobin saturation by pulse oximetry, and BP is standard care. The 3.4- to 3.6-mm bronchoscope occupies a greater proportion of the cross-sectional area of the trachea and glottis than do standard adult bronchoscopes within the mature airway, leading to the potential for greater interference with gas exchange in infants and young children. Thus, efficiency during the procedure, minimizing the duration of inspection and instrumentation and an acute and dynamic awareness of the patient’s condition and vital signs, are critical to successful and safe pediatric flexible bronchoscopy. In addition, the potential for hypoventilation due to the use of IV sedating agents adds to the potential for respiratory compromise during pediatric flexible bronchoscopy. Similarly, the use of smaller adult scopes in the 4.8- to 5.2-mm size for school-aged children and younger adolescents will predispose to more gas exchange abnormalities than in most adult procedures.
The pioneers of pediatric flexible fiberoptic bronchoscopy stressed the importance of carefully titrated IV sedation providing conscious to deep levels of sedation depending on the needs of each individual patient and procedure. In recent years, many pediatric dedicated operators have opted for the operating room setting with or without general anesthesia more routinely. This change appears to be related to at least four different developments. First, pediatric anesthesiologists have established themselves as the experts in pediatric sedation. Since the level of sedation often needed for successful pediatric bronchoscopy goes beyond conscious sedation, many institutions have questioned the safety of the procedure without the presence of the anesthesiologist. Second, more pediatric anesthesiologists have come to understand the need and ability for flexible bronchoscopy to be performed safely and effectively in spontaneously breathing patients, and have become interested in participating in these procedures. In the United States, IV propofol, an ideal sedative for flexible bronchoscopy when spontaneous breathing is necessary, is restricted in most institutions in North America for use by anesthesiologists. Third, the development and utilization of the laryngeal mask with appropriate pediatric sizes has permitted the safe use of the standard pediatric bronchoscope in infants with more significant degrees of respiratory insufficiency, or who require temporary elective extubation to facilitate the bronchoscopic procedure. In older patients, the laryngeal mask permits the safe use of the smaller adult bronchoscopes with the ability to assist ventilation as needed if transbronchial biopsies are required. Fourth, the involvement of the anesthesiologist and operating room provides access to a staffed recovery room with continuous monitoring after the bronchoscopy, which may not be readily available to the pulmonologist who performs the procedure outside the operating room under IV sedation. The excellent safety record documented over many years with IV sedation should ensure that this option remains available to those practitioners in those institutions who prefer that approach.
Technique
The patient is usually brought into the procedure room in the company of a parent to provide reassurance. Infants are laid in supine position. Children may sit while being hooked up to the monitor. IV access is obtained, and the patient is attached to the appropriate monitors. An aerosol of nebulized lidocaine or the application of lidocaine to the posterior oropharynx via atomizer is often used. Initial IV sedation is often administered before topical anesthetic is applied by cotton tip applicator to the naris. Some endoscopists prefer to add topical nasal decongestants routinely.
The patient is then placed in the supine position, and IV sedation is titrated to desired effect. Oxygen supplementation delivered via nasal cannula is virtually always used. The transnasal approach is used in the majority of circumstances. The patency of the naris is noted, and the size and position of adenoidal and tonsillar tissue is noted. The bronchoscope is advanced to a position just above the larynx, and further topical lidocaine is sprayed onto the vocal cords and adjacent structures to effect. Supraglottic anatomy in static and dynamic conditions is noted. The bronchoscope is then passed through the vocal cords, and further topical anesthesia is administered via the suction channel into the tracheobronchial tree. The bronchoscopist then carries out a thorough lower airway inspection.
Indications
There are many and diverse clinical indications for flexible bronchoscopy in the pediatric age group. Most common, perhaps, are those related to either upper or lower airway obstruction: stridor, noisy breathing, snoring of uncertain anatomic origin, or atypical wheeze. Evaluation of the artificial airway or as an aid to the intubation of the difficult upper airway is another reasonably common indication. Vocal cord dysfunction can often be diagnosed on clinical grounds or via spirometry, but in some individuals, the visual identification of vocal cord adduction with the patient conscious and viewing the video screen can be helpful, both from diagnostic and therapeutic points of view. Suspected aspiration of gastric contents or feedings due to swallowing dysfunction appears to be reasonably common in the population seen by most pediatric pulmonologists. Flexible bronchoscopy is commonly performed as part of the evaluation to inspect the airway and perform BAL to evaluate for lipid-laden macrophages. Complicated, severe, or persistent pneumonias and pneumonias in immunocompromised patients are other common indications for pediatric flexible bronchoscopy. Hemoptysis, undifferentiated lesions in the lung on chest radiograph, and noninfectious parenchymal lung diseases are all less common in children but still lead to elective fiberoptic bronchoscopy at times.
When transbronchial biopsy is added to flexible bronchoscopy, the most common indications are those conditions in which histopathology is important in therapeutic decision making, such as lung transplantation and rare or unusual parenchymal lung diseases. Endobronchial masses are very rare in children except for foreign bodies. Foreign bodies are virtually always indications for rigid bronchoscopy in most institutions, although a recent publication showed an excellent safety and efficacy record utilizing flexible bronchoscopy with urologic baskets and forceps.
Contraindications
The contraindication to flexible bronchoscopy occurs when the risk of the procedure outweighs the potential benefits, or when respiratory failure in a small infant will not permit the passage of a flexible bronchoscope while gas exchange is maintained. The actual determination of the strength of contraindication will vary depending on the skill and experience of the dedicated operator and clinical practice and guidelines of the specific institution in which the patient is hospitalized. With the introduction of laryngeal mask anesthesia, more young patients may safely undergo bronchoscopy with ventilation than in the past. Coagulopathy is a relatively strong contraindication to transbronchial biopsy.
Risks
The most common complications of flexible bronchoscopy are patient discomfort and transient hypoxemia. With the addition of BAL, fever 4 to 12 h after the procedure is also common. More serious complications—pneumonia, respiratory failure, life-threatening hemoptysis, pneumothorax, and death—are rare.
Training Requirements
There is no formal quantitative training requirement for bronchoscopic procedures established by the American Board of Pediatrics Sub-board for Pulmonology. Two formal courses in pediatric flexible bronchoscopy are held annually, one in the United States and the other in Europe. Pulmonary fellows should perform at least 50 pediatric bronchoscopies in a supervised setting to establish basic competency. To maintain competency, dedicated operators should perform at least 25 procedures per year. When fellows do not achieve this volume of bronchoscopic procedures, they should be overseen by more senior members of the faculty or practice where they work until such time that they show proficiency in pediatric bronchoscopy.
Ancillary Procedures Applicable to Pediatric Patients
Ancillary procedures applicable to pediatric patients include the following: BAL (common); transbronchial biopsy and cytology brushing (uncommon); laser therapy (rare); airway dilation via balloon insufflation (rare); airway stenting (rare); bronchography (rare); segmental instillation of medication (rare); and assessment of lower airways inflammation (research only).
Appendix
References
Definition
TBNA is a minimally invasive procedure that provides a nonsurgical means to diagnose and stage bronchogenic carcinoma by sampling the mediastinal lymph nodes. Applications of bronchoscopic needle aspiration have expanded to include not only sampling of paratracheal or mediastinal lymph nodes, but peripheral, submucosal, and endobronchial lesions. The procedure allows for sampling tissue through the trachea or bronchial wall, and sampling of tissue beyond the vision of the dedicated operator.
Equipment
In addition to the equipment needed for bronchoscopy, the equipment needed specifically for TBNA include TBNA needles, which are designed to pass through a bronchoscope without causing damage and to be flexible enough to facilitate the positioning of the bronchoscope, yet rigid enough to penetrate the airway wall. Two types of TBNA needles, cytology needles and histology needles, should be available for the procedure.
Personnel
A dedicated operator performs the procedure. Personnel required for this procedure include an RN or a respiratory therapist to administer and monitor conscious sedation, as well as a separate RN or a respiratory therapist to assist the dedicated operator. All supporting personnel should be familiar with the procedure being performed, as well as the appropriate handling of specimens. This will maximize patient comfort, safety, and yield.
Anesthesia and Monitoring
This procedure may be performed under local anesthesia, with or without conscious sedation, or under general anesthesia. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment.
Technique
TBNA usually begins with review of the chest radiograph and, in most instances, is greatly facilitated by a CT scan. Knowledge of the anatomy is critical for selecting the proper anatomic location for the needle aspiration or biopsy. This is true for selecting the location of the paratracheal or subcarinal lymph nodes, or for proper location of a peripheral lesion that is to be sampled.
Generally, when performing mediastinal lymph node aspiration for staging bronchogenic carcinoma (either known or suspected), it is critical to perform the needle aspiration prior to general inspection. This will reduce the likelihood of entraining airway secretions in the sample and avoid a false-positive result. A TBNA needle should be selected according to the size and location of the lesion.
Different techniques can be used singularly or in combination to ensure complete penetration of the needle through the tracheobronchial wall. While suction is applied, the catheter (and consequently the needle tip) is agitated back and forth to shear off cells from the node or mass with care not to disengage the tip of the needle from the tracheobronchial wall. This agitation is performed for a few seconds. Once the catheter is removed from the bronchoscope, the smears are prepared.
For submucosal lesions, a similar technique is applied; however, since the goal is to obtain a specimen from the mucosa, the needle and catheter are kept in a position of slight angulation rather than the 90° angle used to obtain lymph node aspirate. For endobronchial lesions that are either necrotic in appearance or highly vascular, TBNA may be used to obtain a sample by altering the technique in order to directly place the needle into the endobronchial lesion.
For peripheral lesions, fluoroscopy is used to localize the lesion. Once the lesion is localized, the needle is locked into position, and the needle is used to shear off cells from the peripheral lesion while suction is applied.
Specimen preparation is the same for the submucosal, endobronchial, or peripheral lesions as it is for the nodal aspirations. Multiple nodal aspirations can be obtained to increase yield.
Indications
Diagnostic and staging information in the presence of malignancy in mediastinal lymph nodes, submucosal, endobronchial, and parenchymal masses are indications for TBNA. Diagnostic information may also be obtained in the same locations for many benign conditions, including sarcoidosis and fungal disease.
Contraindications
Most contraindications to TBNA are relative rather than absolute. Special attention must be paid to respiratory and bleeding status.
Risks
TBNA is extremely safe and has a very low incidence of complications. The most common potential complications are bleeding, pneumothorax, or pneumomediastinum. Significant bleeding rarely occurs even after a major vessel puncture. Fever and bacteremia have been reported following TBNA, although this may be related to the bronchoscopic procedure itself rather than this specific technique.
Training Requirements
In order to protect the bronchoscopy, the needle must be properly and carefully used. In addition, improper technique will result in an inadequate needle aspirate. Trainees should perform at least 25 needle aspirates in a supervised setting to establish basic competency. Trainees should also gain experience in the acquisition of needle aspirates from lymph nodes in mostly paratracheal as well as subcarinal regions. To maintain competency, dedicated operators should perform at least 10 procedures per year.
References
Definition
Autofluorescence bronchoscopy is a bronchoscopic procedure in which a blue light rather than a white light is employed for illumination, and premalignant and malignant tissue is distinguished by a change in color from normal tissue without the need for fluorescence-enhancing drugs. Fluorescence techniques used with bronchoscopy have demonstrated detection of dysplasia, carcinoma in situ, and early invasive cancers not visible by standard white light bronchoscopy (WLB) through a specialized bronchoscope.
Equipment
In addition to the equipment needed for bronchoscopy, a dedicated endoscopic system allowing for blue light imaging is required. Several different systems for autofluorescence bronchoscopy have been developed. Two images of different wavelengths (red and green) are captured. Images are processed such that the image on the video monitor allows for normal tissue to be visualized as green and abnormal tissue to be visualized as reddish-brown in color. Inspection is then performed using a standard bronchoscopic technique.
Personnel
A dedicated operator performs the procedure. Personnel required for this procedure include an RN or a respiratory therapist to administer and monitor conscious sedation, as well as a separate RN or a respiratory therapist to assist the dedicated operator. All supporting personnel should be familiar with the procedure being performed, as well as the appropriate handling of specimens. This will maximize patient comfort, safety, and yield.
Anesthesia and Monitoring
This procedure may be performed under local anesthesia with or without conscious sedation or under general anesthesia. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment.
Technique
Initial bronchoscopic examination is performed using conventional WLB. Trauma to the mucosa, either by the bronchoscope tip or by suctioning, needs to be avoided, as this can obscure the imaging under the autofluorescence system. For this reason, biopsy specimens are not obtained from abnormalities until after (or during) autofluorescence inspection. Following white light inspection, a detailed autofluorescence examination is performed and all abnormalities are graded. Biopsies are then performed either under white light settings of the areas determined to be abnormal, or after (or during) autofluorescence bronchoscopic inspection of the areas determined to be abnormal.
Indications
Indications include known or suspected lung cancer by abnormal sputum cytology findings, inspection for synchronous tumors, surveillance following cancer resection, and primary screening among high-risk patients.
Contraindications
Most contraindications to autofluorescence bronchoscopy are relative rather than absolute and do not differ from routine bronchoscopy.
Risks
There have been no untoward risks reported in the series utilizing autofluorescence bronchoscopy. Considering that fluorescence inspection simply uses light of a different wavelength and that bronchial biopsy attainment is the same as in conventional bronchoscopy, there is no increase in risk to the patient over a standard WLB flexible bronchoscopy technique. Autofluorescence inspection following WLB generally adds 5 to 10 min to the overall bronchoscopic procedure.
Training Requirements
Trainees should perform at least 20 autofluorescence bronchoscopies in a supervised setting to establish basic competency. To maintain competency, dedicated operators should perform at least 10 procedures per year.
References
Definition
EBUS is an invasive procedure in which physicians use ultrasound devices inside the airways and the lung for exploration of the structures of airway walls, the surrounding mediastinum, and the lungs.
Equipment
In addition to the equipment needed for flexible bronchoscopy, the most widely applied device currently used is a miniaturized catheter probe bearing a mechanical transducer at its tip that rotates 360°. For complete contact with the tracheobronchial wall, the catheter is inserted with a balloon at the tip that, after being filled with water, provides complete circular contact. Another device that is used when performing EBUS is a dedicated ultrasonic endoscope with an electronic curvilinear scanner at its tip, which provides a sectorial view into the bronchial wall and the mediastinal structures. Prototypes of this system are still under investigation and are not yet commercially available.
Personnel
A dedicated operator performs the procedure. Personnel required for this procedure include a RN or a respiratory therapist to administer and monitor conscious sedation, as well as a separate RN or a respiratory therapist to assist the dedicated operator. All supporting personnel should be familiar with the procedure being performed, as well as the appropriate handling of specimens. This will maximize patient comfort, safety, and yield.
Anesthesia and Monitoring
This procedure may be performed under local anesthesia with or without conscious sedation or under general anesthesia. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment.
Technique
Techniques using both devices can be applied during routine bronchoscopy under general and local anesthesia. The miniaturized probe is inserted through a regular flexible bronchoscope with a biopsy channel of at least 2.8 mm. Inside the airways, the balloon is inflated until complete circular contact is achieved and the structures of the wall and the surrounding mediastinum become visible. In order to add the longitudinal dimension to the cross-sectional image, the probe has to be moved along the axis of the airways.
When using a dedicated ultrasonic endoscope, it should be placed with its tip against the tracheobronchial wall. In order to add the circular and the longitudinal dimension to the sectorial view, the instrument has to be rotated and moved along the axis of the airways.
Indications
These two techniques are indicated for visualization, tumor invasion, TBNA guidance, and differentiating of vascular from nonvascular structures. EBUS may be helpful in guiding therapeutic procedures such as curative photodynamic and brachytherapy by assessing tumor volume and other interventions such as airway recanalization.
Contraindications
Most contraindications to EBUS are relative rather than absolute and do not differ from standard bronchoscopy. Special attention must be paid to respiratory and bleeding status.
Risks
EBUS is usually an extraordinarily safe procedure. It adds 5 to 10 min to a standard procedure.
Training Requirements
EBUS requires intensified training and practical experience in interpreting sonographic images, since the anatomic structures of the mediastinum are comparatively complex, and the planes of EBUS images may be oblique and very different from the usual images by conventional radiology. Accordingly, trainees should perform at least 50 procedures in a supervised setting to establish basic competency in analyzing anatomic structures and handling the instrument. To maintain competency, dedicated operators should perform at least 20 examinations per year.
References
Definition
The word laser is an acronym for light amplification of stimulated emission of radiation. The wavelength of the laser determines the characteristics of each type. Tissues absorb the intense light of the laser, and energy is dissipated, mainly in the form of heat. This tissue/light interaction is used for tissue destruction and coagulation.
Equipment
Laser therapy may be performed with either flexible or rigid bronchoscopic instruments. In addition to the equipment needed for bronchoscopy, there are four major medical lasers currently being used for bronchoscopic resection (laser therapy). Each has specific characteristics that provide advantages for certain situations. The Nd-YAG laser is the most commonly used laser. The wavelength is 1064 nm, yielding invisible light in the infrared range. Other lasers include the potassium titanyl phosphate laser, the carbon dioxide laser, and diode lasers. The specific laser fibers are usually accompanied with the appropriate power generator and specific protective eyewear.
Personnel
A dedicated operator performs the procedure. Personnel required for this procedure include an RN or a respiratory therapist to administer and monitor conscious sedation, as well as a separate RN or a respiratory therapist to assist the dedicated operator. All supporting personnel should be familiar with the procedure being performed, as well as the appropriate handling of the specimens. This will maximize patient comfort, safety, and yield. If the procedure is performed under general anesthetic, an anesthesiologist should also be present.
Anesthesia and Monitoring
Laser therapy may be performed under local anesthesia with or without conscious sedation or under general anesthesia. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment; however, it is recommended to keep the percentage concentration of oxygen within the airways as low as possible (
40%) in order to prevent airway fires. The patient and personnel must be protected from the laser light by standard laser precautions.
Technique
Laser therapy can be used alone or in association with other ablative techniques or stenting. Laser firing can result in the photocoagulation of superficial and deep blood vessels, thermal necrosis, and scatter to adjacent tissues. Excessive laser application can, however, result in substantial tissue damage, necrosis, and airway wall penetration.
Rigid bronchoscopy is usually preferred over the flexible technique as a delivery mechanism for laser therapy. This provides easy access for suction and grasping of large debris. The rigid scope can be used to tamponade bleeding. Airway strictures can be dilated using rigid bronchoscopes of increasing diameter. All personnel in the operating room should wear protective eyewear. Flammable material should be kept away from the operating field. After intubation, a suction catheter and the laser fiber are inserted. While the laser is fired, the fraction of inspired oxygen should be kept at < 40% to avoid combustion. Whether performed via rigid or flexible bronchoscopy, continuous suction should be applied. This is more important if gaseous anesthesia is being delivered. Once a certain amount of charring has occurred and tissues become softer, direct mechanical debulking should be done to expedite the procedure.
Following completion of the operation, the patient should be observed for bronchospasm or laryngospasm. The recovery room staff should be closely monitoring the patient and should be adept in the management of acute airway obstruction.
Indications
The primary indication for bronchoscopic laser resection is the relief of central airway obstruction usually from benign or malignant tissue. There are many potential dangers involved with the use of this technique; therefore, the indications must be weighed carefully, even in patients with terminal cancer. Note that laser therapy cannot be utilized for treatment of extrabronchial disease. The specific indications include relief of obstruction by tumor or benign exophytic lesion, and intraluminal disease involving the central airways. Central or segmental airway strictures or scarring from tuberculosis, prior lung resection, trauma, radiation therapy, tracheotomy, tracheostomy, inhalation injury, endotracheal intubation, previous laser surgery, or foreign body obstruction causing intractable cough, hemoptysis, severe dyspnea, or postobstruction pneumonia are also indications. Additionally, treatment of in situ bronchogenic carcinoma or in conjunction with photodynamic therapy is an indication.
Contraindications
Potential contraindications include, but are not limited to the following: tracheoesophageal fistula, uncorrected coagulopathy, total airway obstruction with little if any functional distal airway open, and little or no exophytic lesion visible. Laser firing can result in the photocoagulation of superficial and deep blood vessels, thermal necrosis, and scatter to adjacent tissues. Excessive laser application can, however, result in substantial tissue damage, necrosis, and airway wall penetration.
Risks
In experienced hands, laser therapy is safe and effective and rarely associated with morbidity and mortality. Hypoxemia can occur both intraoperatively and postoperatively. Hemorrhage can occur immediately after laser ablation. Other complications include perforation and fistulae formation, fire in the airway, and pneumothorax.
Training Requirement
Safe laser resection requires training, thorough knowledge of laser/tissue interactions, and an experienced team consisting of a dedicated operator, nurses, respiratory therapists and anesthesiologists. Most institutions require that potential dedicated operators fulfill both an outside and hospital-based laser therapy course before privileges are permitted. Dedicated operators performing laser therapy should have extensive experience in flexible bronchoscopy, management of central airway lesions, and endotracheal intubation. Dedicated operators should also have a comfortable familiarity with rigid bronchoscopy. Trainees should perform at least 15 procedures in a supervised setting to establish competency. To maintain competency, dedicated operators should perform at least 10 procedures annually.
References
Definition
Endobronchial electrocautery and argon plasma coagulation (APC) are modes of thermal tissue destruction that may be used via the flexible or rigid bronchoscope. Similar to laser tissue destruction, the effect of both endobronchial electrocautery and APC is determined by heat and tissue interaction, and is fairly rapid. Heat is created through the application of high-frequency electric currents to coagulate or vaporize tissue. The difference between the two procedures centers on the fact that APC is a noncontact mode of tissue coagulation. Dedicated operators use argon plasma as the medium to conduct the electric current in APC rather than using the contact probe as a medium to conduct the electric current as electrocautery does.
Equipment
In addition to the equipment needed for the flexible or rigid bronchoscopy, a dedicated operator needs a high-frequency electrical generator in combination with insulated probes. Different types of probes in terms of shape as well as polarity (monopolar vs bipolar) are available. For patient and staff protection, proper insulation precautions need to be observed. Insulated flexible equipment is also available. For APC, a dedicated operator needs a special catheter allowing for the argon gas and the electrical current flow. This catheter is not used in electrocautery where there is direct tissue contact.
Personnel
A dedicated operator performs the procedure. Personnel required for this procedure include an RN or a respiratory therapist to administer and monitor conscious sedation, as well as a separate RN or a respiratory therapist to assist the dedicated operator. All supporting personnel should be familiar with the procedure being performed, as well as the appropriate handling of specimens. This will maximize patient comfort, safety, and yield.
Anesthesia and Monitoring
This procedure may be performed under local anesthesia with or without conscious sedation or under general anesthesia. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment.
Technique
Endobronchial electrocautery and APC are thermal tissue-destructive modalities that use electricity to generate heat. They differ in the fact that APC does not make contact with the tissues it destroys and has a penetration depth of just a few millimeters. For these reasons, it is more suitable for the treatment of superficial and spreading lesions. Once gas is released through the catheter tip, it is ignited through electrical current; an arc is formed if the probe is close enough to the mucosal surface, causing heat destruction and desiccation of the tissue. The arc can be moved back and forth (painting) and can even be aimed around bends, making it very suitable for hard to reach lesions.
Endobronchial electrocautery, however, relies on direct tissue contact. The set power output determines the type of tissue destruction (coagulation vs vaporization). Different probes and snares are available for different indications. Energy delivery in both modalities is terminated once the desired effect has been achieved.
Indications
Endobronchial electrocautery is frequently seen as a less expensive alternative to laser therapy with similar effects and as such similar indications. Similar to laser, electrocautery cannot be used for extrabronchial disease. APC and electrocautery are indicated for any benign or malignant tissue destruction responsive to heat delivery. These indications include endobronchial malignancy, benign tumors, and relief of postintubation stenosis, and, in the case of APC, treatment of stent-induced granuloma.
Contraindications
In addition to the contraindications for rigid or flexible bronchoscopy, the only absolute contraindication is the presence of a pacemaker susceptible to electrical interference.
Risks
In addition to the risks associated with the rigid or flexible bronchoscopy, potential complications are similar to other thermal therapies and include airway fires (need to keep oxygen levels as low as possible, preferably < 40%), hemorrhage, airway perforation, and stenosis.
Training Requirements
Dedicated operators performing endobronchial electrocautery and APC should have extensive experience in flexible bronchoscopy and management of central airway lesions. Trainees should perform at least 15 procedures in a supervised setting to establish basic competency in endobronchial electrocautery and APC. To maintain competency, dedicated operators should perform at least 10 procedures per year.
References
Definition
Cryotherapy is a form of thermal tissue ablation. In contrast to the use of heat, it is the application of repetitive freeze/thaw cycles that cause tissue damage and destruction. Due to the particular action of cryotherapy, results are not immediate and may be delayed for several days.
Equipment
In addition to the equipment needed for flexible or rigid bronchoscopy, dedicated operators need different probes depending on whether the cryotherapy is delivered through the rigid or flexible bronchoscope. Generally, the area of freezing is larger and the thawing quicker with the rigid probes. The gas most commonly used in cryotherapy and the gas most commercially available is nitrous oxide.
Personnel
A dedicated operator performs the procedure. Personnel required for this procedure include an RN or a respiratory therapist to administer and monitor conscious sedation, as well as a separate RN or a respiratory therapist to assist the dedicated operator. All supporting personnel should be familiar with the procedure being performed, as well as the appropriate handling of specimens. This will maximize patient comfort, safety, and yield.
Anesthesia and Monitoring
This procedure may be performed under local anesthesia with or without conscious sedation or under general anesthesia. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment.
Technique
Tissue destruction is achieved through repetitive freeze/thaw cycles. The cooling probe is directly attached or inserted into the lesion to be treated. The same area has to be frozen several times before treating the next part of the lesion. There should be overlap between all regions in order to not leave any area untreated. As the effects are delayed and necrotic tissue frequently cannot be expectorated, follow-up therapeutic bronchoscopy should be performed.
Indications
Cryotherapy is indicated for the treatment of intrinsic airway lesions. Due to the delayed effects, it is not the first choice in high-grade lesions needing immediate intervention. Some tissues are not responsive to cryotherapy (eg, fibrotic scarring). The use of cryotherapy may be helpful in the removal of foreign bodies.
Contraindications
In addition to the contraindications for rigid or flexible bronchoscopy, cryotherapy is contraindicated in patients with life-threatening airway obstruction.
Risks
Besides the risks associated with the rigid or flexible bronchoscopy, complications are rare, especially since cartilage is resistant to cryotherapy. Most side effects are associated with the use of bronchoscopy itself. There is no risk of airway fire.
Training Requirements
Dedicated operators performing cryotherapy should have extensive experience in flexible bronchoscopy and management of central airway lesions. Trainees should perform at least 10 procedures in a supervised setting to establish competency. To maintain competency, dedicated operators should perform at least five procedures per year.
References
Definition
Brachytherapy is a minimally invasive procedure that allows localized delivery of radiation therapy within the body. Methods of brachytherapy delivery include direct implantation of radioactive seeds into the tumor area; image-guided implantation of radioactive sources; transbronchial source implantation with a bronchoscope; and, most commonly, delivery of a radioactive source through a transnasal catheter placed via the lumen of a bronchoscope. This section applies only to the last, most commonly utilized method of delivery.
Equipment
Placement of the delivery catheter requires personnel and equipment for flexible bronchoscopy, including a flexible bronchoscope with adequate channel size for the delivery catheter. Afterloading catheters and radioactive sources are required. Fluoroscopy is needed to confirm correct catheter placement. A treatment room must have appropriate shielding and, for high-dose-rate treatment, a remote afterloading device. 192Ir is the preferred radiation source at this time.
Personnel
A dedicated operator performs the procedure. Personnel required for this procedure include an RN or a respiratory therapist to administer and monitor conscious sedation, as well as a separate RN or a respiratory therapist to assist the dedicated operator. All supporting personnel should be familiar with the procedure being performed, as well as the appropriate handling of specimens. This will maximize patient comfort, safety, and yield. A radiation oncologist and the appropriate support staff are responsible for the delivery of the therapeutic radiation.
Anesthesia and Monitoring
This procedure may be performed under local anesthesia with or without conscious sedation or under general anesthesia. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment.
Technique
After establishing satisfactory topical analgesia and appropriate monitoring, flexible bronchoscopy is performed. The involved portion of the airway should have a visible lumen through which to pass the catheter. If the bronchus is occluded, a passage must be established with a variety of means, including mechanical debridement or laser ablation. This is usually done in a separate setting and may require rigid bronchoscopy. The afterloading catheter is advanced distal to the tumor area. If additional catheters are needed, the procedure is repeated. Catheter position is confirmed radiographically. The radioactive source is then afterloaded in a shielded room using a remote device in the case of high-dose-rate treatment. Dwell stations and times are determined by radiation oncology and radiation physics personnel. Several treatments at weekly intervals are usually required for maximal response, but there is no consensus on optimal dose or frequency.
Indications
Brachytherapy is mainly used for palliation of symptomatic malignant airway obstruction, but may also be a curative modality in some patients with carcinoma in situ or very limited early stage lung cancer within the central airways. Improvement in postobstructive symptoms and hemoptysis is achieved in most patients.
Contraindications
In addition to the contraindications for rigid or flexible bronchoscopy, brachytherapy is contraindicated as primary treatment for malignant tracheoesophageal fistula, and for patients who have had prior brachytherapy in the same area.
Risks
In addition to the risks associated with rigid or flexible bronchoscopy, complications related to the risks of the procedure itself are rare and are most commonly related to the risks of the bronchoscopy itself. The catheter may get displaced and even penetrate the airway wall and cause pneumomediastinum and pneumothorax. Complications due to the actual radiation effects include fatal hemoptysis, bronchial necrosis, airway fistulas to neighboring structures, fibrotic stenosis, and radiation bronchitis.
Training Requirements
Dedicated operators performing brachytherapy catheter insertion should have extensive experience in flexible bronchoscopy and management of central airway lesions. Trainees should perform at least five procedures in a supervised setting to establish basic competency in brachytherapy. To maintain competency, dedicated operators should perform at least five procedures per year.
References
