What Is a Virtual Bronchoscopy?

Bronchoscopy is to place an elongated bronchoscope into the patient's lower respiratory tract through the mouth or nose, that is, enter the trachea and bronchus through the glottis and more distally, observe the lesions of the trachea and bronchus directly, and perform corresponding inspections and treatment. In a broad sense, it includes transbronchoscopic biopsy, bronchial mucosal biopsy, transbronchial transmural lung biopsy (TBLB), and transbronchial needle aspiration (TBNA). Most lung and airway diseases, such as tumors, interstitial lung disease, granulomatous disease, and certain infectious diseases require a bronchoscopic biopsy to determine the diagnosis. This is the most commonly used test item.

Wang Zhen	(Chief physician)	Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Diseases, Beijing Chaoyang Hospital, Capital Medical University
Xu Lili	(Deputy Chief Physician)	Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Diseases, Beijing Chaoyang Hospital, Capital Medical University
Tong Zhaohui	(Chief physician)	Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Diseases, Beijing Chaoyang Hospital, Capital Medical University

Introduction to Bronchoscopy

Bronchoscopy is to place an elongated bronchoscope into the patient's lower respiratory tract through the mouth or nose, that is, enter the trachea and bronchus through the glottis and more distally, observe the lesions of the trachea and bronchus directly, and perform corresponding inspections and treatment. The endoscopy used in the examination is divided into rigid bronchoscopy and flexible bronchoscopy (also known as flexible bronchoscopy). Flexible bronchoscopes are divided into fiber bronchoscopes and electronic bronchoscopes.

History of bronchoscopy

In 1897, German scientist Killian used an esophagoscope to remove a foreign body from the trachea. This was the first time in history that a rigid bronchoscope was used to enter the tracheobronchi. Since then, rigid bronchoscopy has been used for nearly 70 years. Due to the limited scope of rigid bronchoscopy and the need to operate under general anesthesia, its clinical application is limited.

With the development of optical fibers, flexible endoscopes have gradually appeared. In 1964, Ikeda of Japan's OLYMPUS company designed endoscopes that entered the trachea to make a standard optical fiber bronchoscope. In 1967, it was officially named a flexible bronchofibroscope. It can directly enter the focus of the examination. Site, take lesion tissue and cytological examination. Due to the flexibility of the flexible fiber bronchoscope, the patient can be examined in the supine or sitting position. The patient does not need general anesthesia. The lens body is slender and can reach the tracheobronchi and its farther end, so it has obvious advantages in the diagnosis and treatment of airway diseases .

In the 1980s, with the development of electronic technology, a new type of flexible bronchoscope came into being, namely electronic bronchoscope. It is a charge coupled device (CCD) installed at the front end of the endoscope to replace the original inner lens, and the cable is used to transfer the image instead of the fiber bundle, instead of transmitting through a prism or optical fiber. In February 1987, the world's first electronic flexible bronchoscope was launched. When the electronic bronchoscope is operated, the doctor no longer looks at the eyepiece, but instead looks at the display screen. The image is clearer, the picture is more realistic, and the operation is more convenient. At present, most domestic hospitals have used electronic bronchoscopy for bronchoscopy. Whether it is performed with fiberoptic bronchoscope or electronic bronchoscope, it is collectively called bronchoscopy.

This entry mainly introduces the application of flexible bronchoscopy and related related technologies.

Bronchoscopy examination items and application indications

Bronchoscopy

( Transbronchial Biopsy, TBB ): Broadly includes transbronchial focus biopsy, bronchial mucosal biopsy, transbronchial transmural lung biopsy (Transbronchial LungBiopsy, TBLB) and transbronchial needle aspiration biopsy (Transbronchial Needle Aspiration, TBNA). Most lung and airway diseases such as tumors, interstitial lung diseases, granulomatous diseases, and certain infectious diseases require a bronchoscopic biopsy to determine the diagnosis, which is the most commonly used test item ^[1] .

1. TBB indications

1) Lesions in the trachea and bronchus : such as bronchial cancer, central lung cancer with bronchial wall infiltration, bronchial tuberculosis, bronchial amyloidosis, sarcoidosis, etc. Bronchoscopy can be used to detect lesions and perform biopsy of the lesion.

2) Diffuse lung lesions: Diffuse lesions not visible under bronchoscopy: peri-adenocarcinoma, diffuse interstitial lung lesions, and various inflammatory lesions. The diseased tissue is often obtained through TBLB.

3) Focal lesions in the lung: bronchoscopy, invisible peripheral lung masses or nodules, limited pulmonary infiltrative lesions, such as peripheral lung cancer, metastases, isolated lung nodules, tuberculosis, Inflammatory lesions and fungal nodules. These localized lesions require biopsy of the lesion by means of ultra-bronchoscopy or X-ray or ultrasound guidance.

4) Extra-bronchial lesions: Some extra-bronchial lesions that cannot be seen under bronchoscopy or only show external pressure, such as lesions in the mediastinum or hilar region, enlarged lymph nodes, clumps, and nodules Lesions, etc., can be obtained by bronchial needle aspiration, to obtain cytological or histological specimens.

2. Operation method of transbronchoscope biopsy

1) TBB narrowly refers to biopsy performed directly under bronchial lumen, such as bronchial mucosal biopsy and intrabronchial lesion biopsy. It is mainly used for various intrabronchial and mucosal lesions.

2) TBLB is mainly used for diffuse lung lesions and peripheral intrapulmonary focal lesions. Divided into two methods without X-ray guidance and via X-ray guidance.

TBLB without X-ray guidance is usually used. It is mostly used for diffuse lesions of the lung. The lower lobe of the affected side is selected. Generally, the 9th and 10th segments of the lower lobe are selected, and the middle lobe should be avoided. Operation method: Insert the biopsy forceps into the selected section of the bronchus, and pull back the biopsy forceps 1-50px when resistance is encountered. At this time, open the biopsy forceps, instruct the patient to inhale deeply, and advance the biopsy forceps 1- 50px to meet resistance, then instruct the patient to exhale deeply, at the end of deep exhalation, clamp the biopsy forceps and slowly withdraw. During the operation, if the patient feels chest pain, he should withdraw the biopsy forceps and replace the site with another biopsy.

X-ray guided TBLB is mostly used for peripheral lesions in the lung. After the bronchoscope reaches the lung segment or sub-segment where the lesion is located, under X-ray TV perspective, insert biopsy forceps into the selected sub-segment bronchus, wear Cross the bronchial wall to the lesion. For peripheral lung lesions, the positive rate of TBLB under X-ray guidance was higher than that without X-ray guidance.

3) TBNA: mainly puncture a lesion or lymph node outside the cavity in the airway, enter the mediastinum or hilum through the airway wall, and obtain the diseased tissue of the mediastinum or hilum area close to the airway wall through the puncture needle. TBNA is a non-direct biopsy method. It requires the operator to be proficient in the anatomy of the thoracic lymph nodes and the structural relationship of the large blood vessels associated with it, and has strong stereoscopic imagination. This helps the operator to puncture correctly. The needle enters deep lesions through the trachea and bronchial wall and avoids damaging important organs in the mediastinum. Wang's puncture is usually used for blind puncture of mediastinal lymph nodes. At present, Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has been widely used in clinical practice, and its specimen acquisition rate is better than that of ordinary blind TBNA.

Bronchoscopy bronchoalveolar lavage

Bronchial alveolar lavage (BALchoalveolarlavage, BAL) is a non-invasive technique performed by bronchoscopy, which has been widely accepted in the diagnosis of diseases. Bronchoalveolar lavagefluid (BALF) is obtained by injecting a sufficient amount of lavage fluid into the alveoli, and analyzing the following important information at the alveolar level, such as immune cells, inflammatory cells, cytology, and infectious microbial etiology Data to assist in the diagnosis, observation and prognosis of respiratory diseases ^[2] .

Bronchial alveolar lavage is divided into whole lung lavage and pulmonary alveolar lavage. Alveolar lavage is the standard treatment for alveolar proteinosis; pulmonary alveolar lavage is a routine method for the diagnosis of disease.

Indications for BAL

1) For the diagnosis of diffuse parenchymal lung diseases, such as sarcoidosis, allergic pneumonia, cryptogenic organizing pneumonia, and idiopathic pulmonary fibrosis, BALF has certain diagnostic value.

2) Special lung infections: For opportunistic infections in immunosuppressed patients (such as kidney transplants, liver transplants, bone marrow transplants, etc.), BAL can help to obtain pathogens, such as human pneumocystis pneumonia, and its BALF positive rate is superior to ordinary sputum Smear.

3) For some special diseases, it can provide powerful clues, such as: acute eosinophilic pneumonia and diffuse alveolar hemorrhage, alveolar proteinosis, etc., such as the gradually deepening of red BALF indicates diffuse alveolar hemorrhage, and white Cloudy BALF suggests alveolar proteinosis.

4) Judge the course and therapeutic effect of certain diseases. For example, in idiopathic interstitial pneumonia (IIP), changes in BALF of idiopathic pulmonary fibrosis (IPF) and nonspecific interstitial pneumonia (NSIP) are important. The difference. The cell classification of the BALF of NSIP is mainly lymphocytic, with mild neutrophils and eosinophils, and the prognosis is good. IPF's lavage fluid is dominated by neutrophils and often has a poor prognosis.

BAL operation method:

1) Preparation before operation: monitoring of local anesthesia, ECG blood pressure and pulse oximetry.

2) Complete the observation of tracheobronchial branches, then perform BAL, and finally perform biopsy or brushing. This operation can reduce the effect of iatrogenic bleeding on the cellular and protein components in alveolar lavage fluid.

3) BAL site: usually choose the site with the most significant radiographic manifestations; for those with limited lesions, choose the lesional lung segment BAL; for diffuse lesions, the right middle lobe (B4 or B5) and the left tongue lobe are the best sites.

4) BAL fluid injection: bronchoscope is placed and paused in the selected lung segment. When the bronchoscope is paused in the third or fourth stage of the bronchus, the best recovery of alveolar lavage can be obtained. Inject 37 ° C or room temperature sterile saline. Usually, a lavage solution is injected through a biopsy hole of a bronchoscope with a syringe, 20 to 60 ml each time (conventionally 4 to 5 times), until a total of 100 to 300 ml is perfused. Too little lavage fluid (<100ml) increases the possibility of tracheal and bronchial contamination. For example, inflammatory cells in the airway can bias the classification of lavage cells.

5) BAL absorption: After the first tube of lavage fluid is injected, the lavage fluid should be suctioned and recovered with a negative pressure of 50 to 100 mmHg, and the recovery rate is usually 40 to 60%. Excessive negative pressure can occlude the distal airway or damage the airway mucosa, reduce the amount of reabsorption, or change the properties of the BAL fluid. For patients with suspected alveolar hemorrhage, three tubes of fluid are usually lavaged at the same site. Observe that the recovered 3 tubes of lavage fluid gradually become darker.

6) Qualified BALF specimens: no airway secretions are mixed in BALF; recovery rate is> 40%; surviving cells account for more than 95%; red blood cells <10% (excluding trauma / bleeding factors), epithelial cells <3% to 5%; The smear cells had complete morphology, no deformation, and even distribution.

7) BAL is different from bronchial irrigation and whole lung lavage: the irrigation solution mainly comes from the airway, usually requires the injection of saline volume of 10 ~ 30ml, the purpose is to check the lung segment of the lesion for bacteriological or exfoliated cells. Total lung lavage is a unique treatment method for treating alveolar protein deposits. Under general anesthesia, a large amount of (30-50L) sterile saline is injected through a double-lumen endotracheal tube to clean alveolar protein deposits. The whole lung on one side of the patient.

Bronchoscopy

( Protected Specimen Brush, PSB )

PSB is mainly used for the etiological diagnosis of severe or hospital-acquired pneumonia, especially for the etiological diagnosis of ventilator-associated pneumonia or immunosuppressive host pulmonary infections ^[3] .

1. Indications for PSB

1) Lung infections in immunodeficiency patients;

2) Etiological diagnosis of ventilator-associated pneumonia;

3) Ineffective treatment of pneumonia or delayed absorption of pneumonia, that is, refractory pneumonia with unknown pathogens;

4) Suspected anaerobic infection or obstruction factor;

5) It is difficult to distinguish between lung infections and non-infectious diseases;

6) Those with negative non-invasive test results or difficult to interpret clinically.

2. PSB operating technology

There are two types of brushes for PSB inspection: single sleeve and double sleeve protective brushes. Polyethylene glycol with a molecular weight of 1500 ~ 2000 is often used to make protective plugs. The specific steps are as follows:

1) After bronchoscopy to the bronchial opening of the lung segment where the secretion is seen directly or the lesion is X-ray, a protective brush is inserted through the bronchoscopy biopsy hole;

2) Extend the protective brush 2 ~ 75px from the end of the bronchoscope, then push out the inner tube, and push off the protective plug at the end of the brush. After the inner tube extends from the end of the outer tube 1 ~ 50px, push out the brush and collect the specimen

3) Return the brush or inner sleeve in order, and then pull the entire brush out of the bronchoscope;

4) Wipe the end of the outer tube with 75% alcohol, then cut off the front part of the brush with sterile scissors, extend the brush, cut off the brush head until it is fully oscillated in 1ml physiological saline, and make the specimen in the brush fall off . If you want to reuse the brush, you can directly cut the brush head into the test tube without cutting the brush and shake it fully;

5) Quantitative culture of specimens. PSB quantitative culture generally uses> 10cfu / ml as the positive diagnostic standard.

Bronchoscopy

Intratracheal laser ablation for bronchoscopy

When laser light is irradiated to biological tissues, four biological effects of light absorption, reflection, conduction, and diffusion can occur. When laser light irradiates living tissue, part of it is absorbed by the tissue, and light energy can be converted into heat energy to produce a series of tissue changes, such as cell edema and death, protein coagulation, tissue water boiling, dehydration tissue burning, etc. Post-diffusion effects. The bronchoscopic laser treatment mainly uses the thermal effect of the laser to cause the irradiated tissue to solidify, vaporize or carbonize to achieve the purpose of eliminating lesions.

1 . Indications for laser treatment of airway lesions

Obstruction caused by new organisms in the airway visible through the bronchoscope can be accurately aligned with optical fibers, and laser-treated areas can be applied for easy operation. Currently, laser treatment is rarely used for airway diseases.

1) Primary and metastatic malignant tumors in the trachea and bronchi: including primary bronchial lung cancer, sarcoma, carcinosarcoma, teratoma, lymphoma, plasmacytoma, carcinoid, and adenoid cystic carcinoma. Generally used for malignant tumors or advanced tumors that have lost the opportunity for surgery. Hyperplasia of airway diseased tissues obstructs the airway and causes difficulty in ventilation. Laser can ablate the obstructed tissue and re-vent, improve ventilation, and alleviate or cure dyspnea.

2) Benign tumors of trachea and bronchus: including hamartoma, papilloma, polyps, chondroma, lipoma, fibroleiomyoma, fibroma, endometriosis, bronchial stones, scleroderma, hemangioma, nerve Sheath tumors and so on. Benign tumors are generally limited. Lasers are easy to remove and rarely recur. Therefore, lasers are very effective in treating benign tumors. They can be used instead of surgery for benign tumors in certain areas.

3) Trachea and bronchial granuloma: mainly include foreign body granulomas, tuberculous granulomas, and inflammatory granulomas caused by surgical sutures and tracheostomy metal sleeves. Laser treatment of foreign body granuloma is very effective, and it is not good for tuberculosis and inflammatory granuloma, but it can at least reopen the airway and improve lung ventilation. The treatment of tuberculosis granuloma is best performed after anti-tuberculosis treatment stabilizes the lesion.

4) Organic tracheal and bronchial stenosis: scarring stenosis mainly caused by tracheotomy or tracheal intubation, diphtheria, trauma, bronchial tuberculosis, etc., especially iatrogenic tracheotomy or intubation. For those who have not damaged the cartilage ring, laser treatment is better, but it is not effective for bottleneck-like and external pressure stenosis.

5) Others: such as trachea-bronchial hemorrhage, trachea-bronchial fistula, atypical hyperplasia of tracheobronchial intima, etc. Because laser has obvious protein coagulation and blood vessel sealing effect, appropriately reducing laser power can be used for hemostasis treatment in the airway.

2 Contraindications and precautions for laser treatment of airway lesions

The contraindications for laser treatment are similar to the contraindications for conventional bronchoscopy, but because they are often performed under general anesthesia, the contraindications are also consistent with the contraindications for general anesthesia. However, in terms of endoscopic laser technology, the contraindications are mainly:

1) Tracheo-bronchial extraluminal stenosis is mainly caused by mediastinal tumors, lymphadenopathy, and atrophy of the lung lobe. Ablation treatment will cause trachea-bronchial wall perforation, which is an absolute contraindication for ablation treatment.

2) When long-distance funnel-shaped stenosis of the airway is accompanied by submucosal infiltration, the effect of ablation treatment is poor.

3) Ablation treatment is also very difficult when the airway is completely occluded, and the path of the obstruction and the condition of the distal end of the obstruction must be evaluated before operation, otherwise the perforation of the tube wall is likely to occur. In cases of incomplete airway occlusion, the function of the obstructed distal lung tissue must be evaluated before ablation treatment. If the distal lung tissue loses gas exchange capacity, ablation treatment is no longer necessary.

4) When the tumor erodes the back wall of the trachea and affects the esophagus, there is a high probability of perforation and sinus formation in ablation treatment. For patients with lung cancer who have been receiving extensive radiotherapy for a long time, since the trachea wall is likely to be twisted and softened during radiotherapy, ablation treatment is also likely to cause perforation at this time.

5) Special care should be taken in the treatment of upper lobe lesions by ablation, because the location is close to large blood vessels, which can cause large bleeding accidentally.

6) Small cell lung cancer and lymphoma are diffuse lesions and often involve the airway. Chemotherapy can achieve good results. You should grasp the timing when choosing ablation treatment.

7) Patients with abnormal coagulation function, electrolyte disorders, hypotension, and severe infections should be considered contraindications.

3 Specific steps and methods of operation

Flexible bronchoscopy can be performed under local or general anesthesia. Preoperative preparations under general anesthesia are the same as general anesthesia surgery. Local anesthesia and preoperative preparations are the same as ordinary bronchoscopy. The laser treatment instrument is preheated first. The laser power is 100 watts and the wavelength is 1064 nanometers. For conventional anesthesia, the anesthesia is as superficial as possible, and the suppression of the patient's breathing is minimized as much as possible. At the same time, 2% lidocaine is used for airway surface anesthesia to reduce the irritation response. Insert the tracheal tube, apply bronchoscopy through the tracheal intubation, insert the bronchoscope to the lesion, insert the optical fiber through the bronchoscope biopsy hole, and extend the distal end of the bronchoscope at least 1 cm. Use visible red light for positioning, alignment and distance The ablation target was 4-10 mm, and Nd: YAG laser was irradiated. The foot switch is controlled by the operator. The power used is generally 20-40 watts, each irradiation (pulse time) is 0.5-1 second, and the interval is 0.1-0.5 second. The energy used depends on the size of the lesion. It is safer to irradiate larger lesions in divided doses, and each interval is 1-2 weeks.

Bronchoscopy argon plasma coagulation

Argon Plasma Coagulation (APC) has been widely used in the treatment of respiratory diseases and has become an important technical means for the treatment of respiratory diseases.

Argon is an inert gas. The argon gas stream is ionized under the action of high-frequency current. The ionized argon plasma beam is conductive and can direct the current from the high-frequency output electrode to the tissue and focus on the one in contact with it. Point. The argon plasma beam has a tendency to move, and its movement direction is determined by the shortest distance from the nozzle to the tissue, so that the movement impedance of the argon plasma beam is minimized.

Transbronchoscopic argon gas knife treatment is mainly applicable to the trachea and local bronchial hemorrhage in the visible range, growth ridges in the airway cavity, narrowing of the lumen, and foreign bodies such as benign narrowing of the airway (anastomotic scar stenosis), the main airway And cancerous obstruction lesions at the left and right trachea openings, granuloproliferative lesions of the respiratory tract, foreign body fixed sutures in the respiratory tract, food foreign bodies in the respiratory tract, and extensive exfoliative lesions of the respiratory tract mucosa (fungal mucosal infection of the respiratory tract after bone marrow transplantation). People who are not suitable for bronchoscopy, and non-respiratory major hemorrhage (such as bronchiectasis, tumor invasion of large blood vessels in the chest) are absolute contraindications.

Bronchoscopy through bronchoscopy high-frequency electric cutting and electrocoagulation treatment

High-frequency electricity is used for endoscopic treatment using electrocoagulation and cutting. High-frequency electrical energy generates thermal energy that acts on tissues, causing them to solidify, necrotize, carbonize, and vaporize, and at the same time occlude blood vessels. High-frequency electric therapy instruments generally have three treatment modes: electric cutting, electrocoagulation and mixed cutting.

High-frequency electrical therapy is suitable for the palliative treatment of trachea and bronchial cavity malignant tumors that have lost the chance of surgery; the radical treatment of various benign tumors in the tracheobronchial cavity; the removal of various inflammations, surgery, trauma and foreign body granulomas. Patients with pacemakers should not undergo high-frequency electrical therapy to prevent the pacemaker from malfunctioning or causing injuries such as myocardial burns.

Bronchoscopy cryotherapy with bronchoscopy

Cryotherapy was mainly used in the early treatment of various skin diseases. Since then, with the development of various cryotherapy equipment, it has been widely used in clinical treatment of various tumors. Damage caused by freezing can occur at the molecular, cell, tissue and organ levels. The rate of local cooling and dissolution and the lowest temperature that can be reached determine whether cells can survive. The sensitivity of tissues to freezing is usually related to its water content. Tissues with more water content are relatively sensitive to freezing, while tissues with less water content are more sensitive to freezing. Is better tolerated. Generally tumor tissue is more sensitive to freezing than normal cells.

Cryotherapy is suitable for palliative treatment of trachea and bronchial malignant tumors; radical treatment of benign tumors of trachea and bronchus; treatment of restenosis at both ends and in the cavity after stent implantation; trachea, bronchial foreign bodies or blood clots Removal.

After cryotherapy, complete intravascular thrombosis occurred 6-12 h after treatment. In the next few days, cells will degenerate and necrosis, and non-hemorrhagic necrosis of the tissue will occur 8-15 days after treatment. Due to the delayed effect of cryotherapy, it is not suitable for the relief of acute airway obstruction.

Bronchoscopy with bronchoscopy (high pressure) balloon dilation

Transbronchoscopic (high-pressure) balloon dilation is mainly used for the treatment of central airway stenosis. The principle is that the balloon is placed in a narrow airway, and the balloon is pressurized and expanded by a high-pressure gun pump, so that there are multiple longitudinal small lacerations around the trachea in the narrow area, and the laceration is filled with fibrous tissue to reach the narrow area. The purpose of expansion.

1.Indications for balloon dilation

Balloon dilation has no therapeutic effect on the etiology, and is mainly used for main airway stenosis caused by benign scar lesions, and only as an adjuvant treatment for airway stenosis caused by malignant diseases.

1) Tracheal and bronchial tuberculosis stenosis, which is mainly caused by contraction of scars after bronchial tuberculosis is cured.

2) Iatrogenic airway stenosis: Anastomotic stenosis after tracheotomy, long-term tracheal intubation, radiation therapy, and lung surgery (such as lung transplantation, sleeve resection, and tracheectomy).

3) Inflammatory diseases involve the airways, such as sarcoidosis and Wegner's granulomatosis.

4) Airway stenosis after trauma.

5) Congenital airway stenosis.

6) Malignant airway stenosis: External pressure or combined external pressure airway stenosis, which assists in dilating the airway, facilitates the expansion of the airway stent and assists in the placement of a therapeutic airway catheter.

2.Contraindications of balloon dilation

1) Lung function is lost at the distal end of the stenosis. Although the trachea is open, there is no improvement in lung function.

2) Severe coagulopathy.

3) Severe cardiopulmonary insufficiency, patients can not tolerate and lose treatment opportunities; however, if cardiopulmonary insufficiency caused by main tracheal stenosis, active treatment should be sought to resolve the cause as soon as possible to achieve the purpose of treatment.

4) After surgical sleeve anastomosis, the tension of the trachea has been inconsistent, and it is easy to cause laceration of the anastomosis during dilation treatment. Dilation treatment needs to be careful.

5) Tracheal softening is not an indication for balloon dilatation treatment. Bronchial cartilage is damaged and the support of the tracheal wall disappears. The balloon can be expanded during balloon dilation treatment, but the balloon will be retracted as soon as the balloon is relaxed. .

3. Timing and precautions for treatment

For bronchial stenosis caused by tuberculosis, antituberculosis treatment should be fully performed before surgery. It is recommended to adhere to regular anti-tuberculosis treatment for 9 months after operation; there is no obvious active tuberculosis in the bronchus during treatment; do not use heat treatment or stent in the treatment of bronchial tuberculosis; if obvious infection or active tuberculosis is found after expansion, it should be immediately Stop dilation therapy and switch to anti-inflammatory or anti-tuberculosis therapy. Dilatation therapy should be performed after the inflammation is absorbed. Those who have obvious tracheal contraction in anti-tuberculosis therapy should be closely observed, and the lumen must not be occluded to obtain the opportunity for dilatation therapy.

4. Specific steps and precautions for operation

1) Anesthesia: General anesthesia is selected for patients with main tracheal lesions and severe stenosis for a long time; the lesion is located in the main bronchus but the contralateral lung function is poor, and local anesthesia may not complete the expansion operation. General anesthesia is recommended.

2) Choose the right balloon catheter: understand the diameter and length of normal trachea and bronchus: trachea diameter 16-20mm, length 10-325px; right main bronchus diameter 12-15mm, length 1-50px; right middle bronchus diameter 12mm, 75px in length; the left main bronchus is 10-14mm in diameter and 125px in length. At present, the balloon produced by Boston Scientific Corporation is commonly used, and the appropriate balloon catheter is selected according to the inner diameter of the working channel of the therapeutic bronchoscope and the diameter and length of the balloon.

3) Catheter placement and expansion: At present, the balloon catheter is usually inserted through the working channel under the guidance of a bronchoscope. The expansion position is determined under direct vision. Water is injected into the balloon with a pressure gun pump. The pressure can be selected from 3-8 atmospheres. To achieve different expansion diameters, the pressure needs to increase in order from low to high. Each expansion operation is about 30-60 seconds. Observe the effect. If it is invalid, use frozen treatment to re-expand. If it still fails, use high-frequency electroacupuncture to cut the scar and expand again. Be careful not to cut the tracheal membrane. Depending on the degree of expansion, each operation can be repeated 1-10 times. In the absence of a therapeutic bronchoscope, a combination of fluoroscopy and bronchoscopy can be used. First insert the guidewire and balloon catheter under the perspective to determine the position corresponding to the stenosis, and insert a bronchoscope to observe the balloon catheter and the stenosis. This will help the operator to observe the process of direct balloon expansion.

4) Precautions: For the narrow expansion of the upper trachea, pay attention to protecting the vocal cords; gradually increase the pressure during operation to avoid tracheal wall lacerations; the balloon must fully enter the airway to avoid damage to the bronchoscope; Be careful not to insert it too far, as it may damage the normal airway at the distal end.

5, common complications

1) Tube wall bleeding: Bleeding is the most common complication. However, under normal circumstances, there is not much bleeding and no treatment is needed; after a long time, the bleeding can be diluted by thrombin or epinephrine (1: 10000 topical), and the bleeding point can be treated with APC local electrocoagulation.

2) Bronchial rupture: After treatment, the patient developed emphysema of the mediastinum or neck, which was caused by rupture of the trachea during dilation. Most people can heal themselves after a break. At this time, care should be taken to minimize the cough and to prevent infections.

3) Recurrence of stenosis: It is necessary to distinguish between recurrence caused by uncontrolled tuberculosis infection and restenosis caused by hyperplasia of the scar due to scar constitution and contracture. The first case is active anti-TB treatment. The second case requires repeated expansion and freezing. Some patients can be treated with radiation to suppress the hyperplasia of scars. Even after the above treatment, some patients still cannot control the stenosis and need to take other treatments.

Bronchoscopy airway support

Airway stents can be divided into silicone tube stents and metal mesh stents (coated or uncoated) according to their materials, each with advantages and disadvantages.

Compared with the metal mesh stent, the silicone tubular stent is cheap; its position adjustment and removal are relatively easy during the stent placement process, but the stent placement needs to be performed with a rigid bronchoscope under general anesthesia, which affects the mucous cilia Clearing function is more likely to cause secretions to block the lumen and stent displacement, especially for short conical airway stenosis and poor adherence. It is not suitable for stenosis with irregular airways or uneven surfaces. At present, there is no silicone stent in China.

Compared with the silicone tubular stent, the metal mesh stent is more convenient to insert. Most patients can be placed with a flexible bronchoscope under local anesthesia. The metal mesh stent has good elasticity, so it is displaced after placement. The incidence is relatively low; the stent itself is thinner and has a higher inner / outer diameter ratio, while retaining the mucus removal function of the airway to a certain extent. The disadvantage of the metal mesh stent is that (without a membrane) the metal mesh stent has a higher rate of restenosis in the stent cavity due to tumors or granulation tissue passing through the mesh. Since metal mesh stents are difficult to remove after implantation, for patients with benign airway stenosis, especially in patients with diseased areas that are still in the acute inflammation phase, metal mesh stents should be placed with caution. At present, the use of removable metal stents (such as Lee's stent) ).

The indications for tracheal and bronchial stent implantation mainly include three aspects: Lumen reconstruction of the central airway (including trachea and bronchus above segment) with organic narrowness. Support of weak cartilage in trachea and bronchial softening. Blocking of trachea, bronchial fistula or fissure.

The etiology of organic stenosis of the central airway includes both malignant tumors and benign lesions. For the airway stenosis caused by malignant tumors, if the time for surgical treatment has been lost, in most cases, laser, argon, high-frequency electric cautery or cryotherapy under bronchoscope is required to clear the tumor tissue in the cavity. If the patient has airway obstruction and dyspnea due to extensive invasion of the wall tumor or compression of extracavity tumors and metastatic lymph nodes at this time, temporary stent placement in the airway obstruction site can be performed. Malignant airway stenosis is currently considered to be an indication for stent placement in the airway. The etiology of benign airway stenosis is relatively complicated. In China, the most common cause is tracheal, bronchial tuberculosis, and tracheal intubation or intubation due to excessive balloon pressure. For benign airway stenosis, the stent placement should be cautious. The principle of implantation should be that after the use of laser, high-frequency electric cauterization or freezing and balloon dilatation, the effect is difficult to maintain, only the airway stent placement is considered. Apply removable bracket.

Bronchial tuberculosis, relapsing polychondritis, and other inflammatory or mechanical stress caused by the damage and defects of the trachea, bronchial cartilage, often cause abnormal movement of the airway wall at the cartilage defect. For these patients, stent placement is sometimes the only alternative.

The fistula between the esophagus and the trachea or bronchus can be congenital, but the vast majority of clinical findings are caused by malignant tumors. The clinical symptoms of tracheoesophageal fistula are mainly cough, dyspnea and aspiration pneumonia when drinking and eating. Tracheoesophageal fistula caused by esophageal tumor infiltrates the airway. The placement of esophageal stent can improve the quality of life of patients, but generally cannot completely close the fistula. The placement of double membrane stent in the esophagus and airway can achieve more ideal clinical results. .

Bronchial stump and bronchial anastomotic fistula or fissure are common complications of lobectomy and sleeve resection of central lung cancer. In addition to the local sealing of gelatin sponges, celluloses, and medical adhesives used in the bronchoscope in the past, the membrane stent is placed in or filled with gelatin sponge and then fixed with an ordinary metal stent. It is also a trachea, bronchial fistula or cleft seal in recent years. Common and effective ways to block.

Application of bronchoscopy in the establishment of artificial airways

The establishment of artificial airways is generally done by anesthesiologists, but tracheal intubation is often encountered in some patients, such as cervical spondylitis, myasthenia gravis, acromegaly, and severe head trauma. Using bronchoscopy to guide intubation is the only option. In addition, due to the intuitive visibility of the bronchoscope, the damage caused by conventional blind intubation can be avoided, especially for patients who may have upper airway abnormalities and difficulty in intubation. When bilateral pulmonary mechanical ventilation is required, double-lumen endotracheal intubation must be performed. Guidance with bronchoscope is a good method. For determining the position of double-lumen endotracheal intubation, bronchoscope is the most reliable tool.

A bronchoscope is also a very useful tool in changing endotracheal tubes. In the ICU ward, it is often necessary to replace the endotracheal tube due to ruptured airbags and too small models of tracheal intubation, or when the oral intubation needs to be replaced by nasal intubation, the use of a bronchoscope to assist in the replacement of the endotracheal tube can be observed. The situation of tracheal intubation and airway is convenient to find abnormal conditions in time, and artificial airway can be re-established in the shortest time to reduce the impact of hypoxia on critically ill patients.

Clinically, some patients experience respiratory distress suddenly after tracheal intubation, partly because of Upper Airway Obstruction (UAO). This UAO mostly occurs under the glottis or at the glottis. In the event of UAO, the artificial airway must be reconstructed. Although the patient's respiratory distress symptoms were relieved soon after reintubation, the cause of UAO has not been understood. For patients who may have UAO, insert a bronchoscope before withdrawal, and then withdraw the bronchoscope and tracheal intubation. This can discover the cause of UAO, and at the same time, re-enter the intubation to avoid UAO. Impact of the patient. Then look for a solution based on what happened. The occurrence of UAO is generally related to patients who have been intubated before, difficulty in intubation, repeated repeated intubation attempts, and long mechanical ventilation.

Treatment of severe lung infections and atelectasis with bronchoscopy

Acute and chronic lung abscesses, pneumonia, and bronchial infectious diseases often cause poor systemic effects due to blood-bronchial barriers, tissue wrapping, and physiochemical properties of pus. Bronchoscopic drainage and administration can increase local drug concentrations. Generally, a bronchoscope is inserted into the directional lung segment and the bronchi of the lung lobe, and the sputum is fully attracted, and then it is rinsed with a small amount of physiological saline. After the irrigation solution is cleaned, it is injected with antibiotics that are sensitive and non-irritating to the respiratory tract, such as: Amikacin and cephalosporins were dissolved in 10 ml of normal saline and injected into the lesions as retention treatments. The total lavage volume should not exceed 100ml. If the condition is critical, the operation time should be limited to 15 minutes without flushing.

Patients with chronic obstructive pulmonary disease (COPD) with respiratory failure or other critically ill patients often block large airways due to thick sputum or blood clots, resulting in atelectasis of segments, leaves, or sides. At this time, the patient's condition is often exacerbated. It can be life threatening. When the measures such as cough stimulation, deep breathing exercise, back pat and body drainage are still ineffective, bronchoscopy can be used for suction and lavage to effectively relieve atelectasis and save the patient's life. Some patients, such as patients with fractured ribs, hemothorax, pneumothorax, and after surgery, cannot cough back by patting the back, and bronchoscopy has become the only effective tool to relieve atelectasis. Most of the atelectasis can be relieved after bronchoscopic suction and irrigation.

Bronchoscopy contraindications

The contraindications of bronchoscopy include: active hemoptysis, blood in sputum is allowed to be tested, and easy to obtain positive results; severe cardiopulmonary dysfunction; severe arrhythmia; extreme systemic condition; uncorrectable bleeding tendency; severe upper cavity Venous occlusion syndrome; recent myocardial infarction, unstable angina pectoris; suspected aortic aneurysm; partial tracheal stenosis, which is estimated to be impossible to pass through bronchoscopy; severe pulmonary hypertension, severe bleeding during biopsy, etc.

Bronchoscopy complications

Common complications of bronchoscopy include:

1) Allergies to anesthetics, nosebleeds, hemoptysis, fever, infection, etc .;

2) Laryngeal edema: Forcible insertion may cause laryngeal edema. In severe cases, breathing difficulties may occur, and tracheotomy should be performed immediately if necessary;

3) Hypoxemia: arterial blood oxygen partial pressure drops by 10-20 mmHg. For patients with resting arterial blood oxygen partial pressure equal to or less than 60-70 mmHg, before bronchoscopy, oxygen should be given and continued until examination End;

4) Wheezing and airway spasm, bronchoscopy may cause extensive bronchospasm. Therefore, for patients with bronchial asthma, aminophylline should be treated with or without symptoms;

5) Asphyxia: Patients with pulmonary insufficiency may have a small amount of bleeding or secondary bronchospasm after the biopsy, and asphyxia within minutes after the examination;

6) cardiac arrest: strong stimulation may cause reflex cardiac arrest;

7) Tumor trachea and bronchial implant metastasis;

8) Spontaneous pneumothorax and mediastinal emphysema;

9) Esophageal-tracheal fistula, tracheal perforation, airway obstruction, asphyxia, etc. These complications are mostly related to therapeutic bronchoscopy operations, such as laser treatment, APC ablation treatment, etc.

10) Rupture of other aortic aneurysms.