Interventional Pulmonary Procedures: Guidelines from the American College...

DOI 10.1378/chest.123.5.1693 2003;123;1693-1717 Chest

Armin Ernst, Gerard A. Silvestri and David Johnstone

Chest PhysiciansGuidelines from the American College of Interventional Pulmonary Procedures:

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Interventional Pulmonary Procedures*Guidelines from the American College of ChestPhysicians

Armin Ernst, MD, FCCP; Gerard A. Silvestri, MD, FCCP; andDavid Johnstone, MD, FCCP; for the ACCP Interventional Chest/DiagnosticProcedures Network Steering Committee†

(CHEST 2003; 123:1693–1717)

Key words: airways; bronchoscopy; guidelines; interventionalpulmonology; pleural disease; procedures

Abbreviations: ACCP ! American College of Chest Physicians;APC ! argon plasma coagulation; EBUS ! endobronchial ultra-sound; PDT ! percutaneous dilatational tracheostomy;RN ! registered nurse; TBNA ! transbronchial needle aspira-tion; TPNA ! thoracic percutaneous needle aspiration;TTOT ! transtracheal oxygen therapy; WLB ! white light bron-choscopy

T he ability to perform procedures is one of thedefining characteristics that attracted so many of

us to fellowships in pulmonary medicine, critical caremedicine, and thoracic surgery. In fact, nearly500,000 bronchoscopies are done each year in theUnited States. Additionally, approximately 15,000airway stents are placed yearly worldwide. The num-ber and complexity of procedures that can be per-formed in the bronchoscopy unit is increasing. Forexample, endobronchial electrocautery for tumorablation and the treatment of hemoptysis can beperformed under local anesthesia during a “routine”outpatient bronchoscopy.

Unfortunately, our training and expertise is notuniform. An American College of Chest Physicians(ACCP) survey revealed that " 50% of respondentsbelieved that their training in advanced diagnostictechniques such as transbronchial needle aspiration(TBNA) was inadequate. In another query of seniorpulmonary fellows, Haponik et al found that whilemost fellows reported “adequate” training in bron-

choscopy, only 72% had any instruction in TBNAand 27% in stent placement.

Despite the proliferation in the number and typeof chest procedures currently performed, there arepresently no guidelines that ensure that the basicskills and competency needed to provide these ser-vices have been acquired by the pulmonologist,critical care physician, or thoracic surgeon (dedicat-ed operators). To address this void, the developmentof guidelines for chest procedures was initiatedthrough the Interventional Chest/Diagnostic Proce-dures Network of the ACCP (the “Network”). Therewere several compelling reasons to do so. First, theseprocedures carry inherent risks, and patient safety isof paramount concern. Second, defining the equip-ment and personnel required, indications, contrain-dications, risks, and training requirements of each ofthe procedures may facilitate uniform practicewithin fellowship training programs. In addition,these guidelines could be used as a guide to hospitalnursing, respiratory therapy and administrative de-partments who wish to develop these services. Fi-nally, dedicated operators who display competencyin these individual procedures should have lessdifficulty overcoming the barriers that sometimesexist within local hospital credentialing committees.

The guidelines themselves were developed by agroup of physicians representing a wide range ofinterests within the college. The group was com-prised of pulmonologists and thoracic surgeons, ac-ademics, and private practitioners who reside in theUnited States and abroad. Despite the diversity ofpractice views, consensus was reached on all of theparameters put forth in this document.

For physicians wishing to learn how to performone of these advanced procedures, there are severaldifferent educational approaches. There are intenseshort training programs (1 to 3 days). These areavailable throughout the United States and abroad.More formal mini-sabbaticals (1 to 6 months) areavailable as well. Several fellowship training pro-grams have developed an additional year of fellow-ship training in advanced interventional techniquessimilar to other procedure-intensive internal medi-

*From the Department of Pulmonary Medicine (Dr. Ernst), BethIsrael Deaconess Medical Center, Boston, MA; Division ofPulmonary Medicine (Dr. Silvestri), Medical University of SouthCarolina, Charleston, SC; and Division of Cardiothoracic Surgery(Dr. Johnstone), University of Rochester, Rochester, NY.†A list of participants is given in Appendix 1.Manuscript received November 22, 2002; revision acceptedNovember 25, 2002.Reproduction of this article is prohibited without written permis-sion from the American College of Chest Physicians (e-mail:[email protected]).Correspondence to: Armin Ernst, MD, FCCP, Director, Interven-tional Pulmonology, Beth Israel Deaconess Medical Center, 330Brookline Ave, Boston, MA 02215; e-mail: [email protected]

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cine subspecialties such as cardiology and gastroen-terology. Both of these groups have adopted mini-mum requirements for their trainees to achievecompetence in advanced procedures. Still othershave used novel approaches such as virtual reality-simulated bronchoscopy as a teaching tool for thenovice dedicated operator. Innovative approaches tolearning these techniques will no doubt becomewidely available in the future.

These guidelines clearly have limitations. Al-though we do not have the necessary data on all ofthe procedures outlined in this document to makedefinitive statements on patient outcome and thenecessary number of procedures to achieve compe-tency, that does not mean we should shy away fromcompetency guidelines altogether. Therefore, wehave developed some competency parameters basedon the expertise of our panel members. The ACCPNetwork hopes that fellowship program directorswill use this document to assess the strengths andweaknesses of the procedural training they provideand adopt this working document to develop thehighest level of procedural training. We hope thatthis document will focus interest on the diversity oftechniques now available to our patients. These ACCPguidelines can also be built on as new procedures arebrought out of the laboratory and into practice.

When learning new techniques, the old adage “seeone, do one, teach one” is no longer acceptable. TheACCP Network offers these guidelines as an alter-native. We hope our membership will embrace it.

ReferencesBaillie J, Ravich WJ. On endoscopic training and proceduralcompetence. Ann Intern Med 1993; 118:73–74Cass OW, Freeman ML, Peine CJ, et al. Objective evaluation ofendoscopy skills during training. Ann Intern Med 1993; 118:40–44Centers for Disease Control and Prevention. Vital and healthstatistics: ambulatory and inpatient procedures in the UnitedStates, 1996. Hyattsville, MD: US Department of Health andHuman Services, Centers for Disease Control and Prevention,National Center for Health Statistics, 1998; DHHS publicationNo. 99-1710Colt HG, Crawford SW, Galbraith O. Virtual reality bronchos-copy simulation: a revolution in procedural training. Chest 2001;120:1333–1339Colt HG, Prakash UBS, Offord KP. Bronchoscopy in NorthAmerica: survey by the American Association for Bronchology. JBronchol 2000; 7:8–25Haponik EF, Russell GB, Beamis JF, et al. Bronchoscopytraining: current fellows’ experiences and some concerns for thefuture. Chest 2000; 118:625–630

Flexible BronchoscopyDefinition

Flexible bronchoscopy is an invasive procedurethat is utilized to visualize the nasal passages, phar-

ynx, larynx, vocal cords, and tracheal bronchial tree.It is utilized for both the diagnosis and treatment oflung disorders. The procedure may be performed inan endoscopy suite, the operating room, the emer-gency department, a radiology suite, or at the bed-side in the ICU.

Equipment

At minimum, the equipment needed is a broncho-scope, light source, cytology brushes, biopsy forceps,needle aspiration catheters, suction apparatus, sup-plemental oxygen, fluoroscopy (C-arm), pulse oxim-etry, sphygmomanometer, and equipment for resus-citation including an endotracheal tube. A videomonitor is a useful accessory, but not required.Fluoroscopy may be needed to facilitate certaintransbronchial biopsy procedures.

Personnel

A dedicated operator performs the procedure.Personnel required for this procedure include aregistered nurse (RN) or a respiratory therapist toadminister and monitor conscious sedation, as well asa separate RN or a respiratory therapist to assist thededicated operator with the procedure. All support-ing personnel should be familiar with the procedurebeing performed, as well as the appropriate handlingof the specimens. This will maximize patient com-fort, safety, and yield.

Anesthesia and Monitoring

Flexible bronchoscopy may be performed underlocal anesthesia with or without conscious sedationor under general anesthesia. Specific monitoring anddocumentation guidelines vary from hospital to hos-pital and from state to state. We recommend that thededicated operator inquire about the applicable an-esthesia and monitoring guidelines in their particularpractice environment.

Technique

The patient should be placed in either a semi-recumbent or supine position after IV access has beenobtained. The patient should fast for at least 4 h prior tothe procedure. If the dedicated operator chooses to usethe nose as the orifice of entry, the patient should havea topical anesthetic applied to the pharynx and nasalpassages. After the topical anesthetic has taken effect,the bronchoscope is introduced either through the noseor mouth with a bite block in place. The oropharynx isexamined. After a thorough examination is performedand on reaching the vocal cords, the patient is usuallyagain anesthetized topically. The vocal cords are exam-

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ined for abduction and adduction. The bronchoscope ispassed through the vocal cords, and a complete airwayinspection is performed.

Both therapeutic and diagnostic procedures canbe performed during flexible bronchoscopy. De-pending on the indication, the following diagnosticprocedures can be performed: BAL, endobronchialor transbronchial biopsies, cytologic wash or brush,and TBNA, endobronchial ultrasound (EBUS), andautofluorescence bronchoscopy. Therapeutic proce-dures such as balloon dilatation, endobronchial laserablation, electrocautery, photodynamic therapy,brachytherapy, and selected stent placement can allbe accomplished through flexible bronchoscopy.

Indications

Indications include, but are not limited to, undi-agnosed pulmonary infiltrates, lung masses, medias-tinal lymphadenopathy, hemoptysis, airway disor-ders, endobronchial lesions, therapeutic suctioning,and pediatric bronchoscopy.

Contraindications

Most contraindications to flexible bronchoscopyare relative rather than absolute. Special attentionmust be paid to respiratory and bleeding status. Inunstable patients or prolonged procedures, rigidbronchoscopy may be preferred.

Risks

Diagnostic flexible bronchoscopy is usually anextraordinarily safe procedure. Major complicationssuch as bleeding, respiratory depression, cardiorespi-ratory arrest, arrhythmia, and pneumothorax occurin # 1% of cases. Mortality is rare, with a reporteddeath rate of 0 to 0.04% in " 68,000 procedures.

Training Requirements

Expertise in flexible bronchoscopy for the diagno-sis of lung diseases is absolutely necessary for thepulmonary physician trained in pulmonary and crit-ical care medicine. Trainees should perform at least100 procedures in a supervised setting to establishbasic competency. To maintain competency, dedi-cated operators should perform at least 25 proce-dures per year. In addition to the number of proce-dures, the competency of each trainee should becertified by the program director or the director ofthe bronchoscopy unit. Finally, it is important thattraining include competency in assisting a dedicatedoperator in the performance of the procedure.

ReferencesCredle W, Smiddy J, Elliott R. Complications of fiberopticbronchoscopy. Am Rev Respir Dis 1974; 109:67–72

Dreison RB, Albert RK, Talley PA, et al. Flexible fiberopticbronchoscopy in the teaching hospital. Chest 1978; 74:144–149Honeybourne D, Babb J, Bowie P, et al. British Thoracic Societyguidelines on diagnostic flexible bronchoscopy. Thorax 2001;56:i1–i21Pereira W, Kovnat D, Snider G. A prospective cooperative studyof complications following flexible fiberoptic bronchoscopy.Chest 1978; 73:813–816 Prakash UBS, Offord KP, Stubbs SE.Bronchoscopy in North America: the ACCP survey. Chest 1991;100:1668–1675Prakash Udaya BS. Bronchoscopy unit, expertise, equipment andpersonnel. In: Bolliger CT, Mathur PN, eds. Interventionalbronchoscopy (vol 30). Basel, Switzerland: Karger, 2000; 31–43Simpson FG, Arnold AG, Purvis A, et al. Postal survey ofbronchoscopic practice by physicians in the United Kingdom.Thorax 1986; 41:311–317Suratt P, Smiddy J, Gruber B. Deaths and complications associ-ated with fiberoptic bronchoscopy. Chest 1976; 69:747–751Zavala DC. Diagnostic fiberoptic bronchoscopy: techniques andresults of biopsy in 600 patients. Chest 1975; 68:12–19

Rigid BronchoscopyDefinition

Rigid bronchoscopy is an invasive procedurethat is utilized to visualize the oropharynx, larynx,vocal cords, and tracheal bronchial tree. It isperformed for both the diagnosis and treatmentof lung disorders. The procedure may be per-formed in an endoscopy suite with available anes-thesia, but more appropriately in the operatingroom, and rarely in the ICU. It is frequentlycombined with flexible bronchoscopy to acquireand maintain better distal airway visualization andsuctioning.

Equipment

A set of ventilating bronchoscopes should beavailable in different sizes. A halogenated light pro-vides illumination; 0°, 30°, and 90° telescopes can beplaced down the rigid barrel to improve visualiza-tion. An array of instruments such as graspers, biopsyforceps, and suction devices should also be readilyavailable. Video capability is desirable but not nec-essary. Other miscellaneous materials that should beavailable include normal saline solution, lubricantjelly, syringes, and suction tubing.

Personnel

A dedicated operator performs the procedure.Personnel required for this procedure include anurse or a respiratory therapist to administer andmonitor conscious sedation, as well as a separate RNor a respiratory therapist to assist the dedicatedoperator with the procedure. All supporting person-nel should be familiar with the procedure beingperformed, as well as the appropriate handling of thespecimens. This will maximize patient comfort,safety, and yield.




Additional personnel may be utilized, dependingon where the procedure is performed (operatingroom vs bronchoscopy suite). An anesthesiologist,circulating nurse, and operating room technician arefrequently utilized during this procedure.


This procedure is usually performed under gen-eral anesthesia with adequate sedation and musclerelaxants. Specific monitoring and documentationguidelines vary from hospital to hospital and fromstate to state. We recommend that the dedicatedoperator inquire about the applicable anesthesia andmonitoring guidelines in their particular practiceenvironment.

Technique

The patient is placed in the supine position. Thehead should be on a small pillow or foam rest, andpositioned on the portion of the table that can beflexed or extended as needed. After introducing theinstrument, the epiglottis is gently lifted with the endof the bronchoscope, after which the larynx and vocalcords can be seen. Once the vocal cords have beenvisualized, the bronchoscope is turned 90° verticallyin order to pass through the vocal cords. This offersthe least resistance and avoids damage to the vocalcords. After entering the upper trachea, the bron-choscope is turned back to its original neutral posi-tion.

Ventilation is initiated via the side port. Thebronchoscope is gently advanced toward the carina,and systematically inserted into each mainstem bron-chus. Anatomic, airway, and mucosal abnormalitiesare noted. Telescopes may be inserted into the rigidbronchoscope to visualize the distal segments, re-quiring the angled 30° and 90° scopes to see partic-ularly the right upper lobe orifice. The head isusually turned to the left to enter into the rightmainstem bronchus, and turned to the right to enterinto the left mainstream bronchus.

Once the preliminary examination is completed,the purpose for which the procedure was performedshould be addressed (eg, dilation, stent insertion,laser ablation, extraction of foreign bodies). Cautery,forceps, and suction should be readily available. If amore detailed examination, washings, laser/photody-namic ablation, or stent insertion is required, aflexible bronchoscope can be inserted through therigid bronchoscope.

Indications

There are many indications for rigid bronchos-copy, including bleeding or hemorrhage, foreign

body extraction, deeper biopsy specimen when fiber-optic specimen is inadequate, dilation of tracheal orbronchial strictures, relief of airway obstruction,insertion of stents, and pediatric bronchoscopy. It isalso used for tracheobronchial laser therapy or othermechanical tumor ablation.

Contraindications

Relative contraindications include uncontrolledcoagulopathy, extreme ventilatory and oxygenationdemands, and tracheal obstruction to the noviceoperator.

Risks

Most potential complications of rigid bronchos-copy can be avoided. These include injury to theteeth or gums, tracheal or bronchial tears, or severebleeding. Complication rates should be # 0.1%.Procedure-related mortality is rare.


Trainees should perform at least 20 procedures ina supervised setting to establish basic competency inpatients with normal airways, and to become com-fortable with the set-up and intricacies of the proce-dure. Dedicated operators should perform at least10 procedures per year to maintain competency.Individual institutional program directors in bron-choscopy and surgery should ultimately decide onthe competency of each candidate, and they shouldalso determine where best these procedures shouldbe performed, either in the bronchoscopy or oper-ating suite.

ReferencesCooper JD, Pearson FG, Patterson GA, et al. Use of siliconestents in the management of airway problems. Ann Thorac Surg1989; 47:371–378Ehrenwerth J, Brull S. Anesthesia for thoracic diagnostic proce-dures. In: Kaplan JA, ed. Thoracic anesthesia. 2nd ed. New York,NY: Churchill Livingstone, 1991; 321–346Hetzel MR, Smith SG. Endoscopic palliation of tracheobronchialmalignancies. Thorax 1991; 46:325–333Holinder PH, Holinder LD. Use of the open tube bronchoscopein the extraction of foreign bodies. Chest 1978; 73:721–724Miller JI Jr. Rigid bronchoscopy. Chest Surg Clin N Am 1996;6:161–167Sanders RD. The ventilating attachments for bronchoscopy. DelMed J 1967; 39:170–177Wedzicha JA, Pearson MC. Management of massive haemopty-sis. Respir Med 1990; 84:9–12Weissberg D, Schwartz I. Foreign bodies in the tracheobronchialtree. Chest 1987; 91:730–733




Pediatric SectionOverview

Bronchoscopy has been performed in infants, chil-dren, and adolescents by pediatric surgeons andspecialists for " 50 years. Until the 1980s, theapproach was almost exclusively via the rigid bron-choscope and the operators, at least in the UnitedStates, were almost exclusively surgeons. Today,however, pediatric pulmonologists perform flexiblebronchoscopy more often on children than rigidbronchoscopy. Due to this preference, this sectionfocuses on flexible bronchoscopy. The equipment,techniques, and indications are quite different thanthose applied in adult populations. Proficiency inflexible bronchoscopy is a recommended element inpediatric pulmonology fellowship training, but nospecific number or type of procedures has beenrequired of trainees.

Equipment

The standard pediatric bronchoscope has an outerdiameter of 3.4 to 3.6 mm (depending on themanufacturer) with a suction channel of 1.2 mm.Specific information about the bronchoscopes usedin pediatric patients is provided in Appendix 2. Thestandard pediatric bronchoscope can usually besafely used in healthy infants with mild respiratorydifficulties receiving oxygen supplementation. The2.2-mm, ultrathin, flexible bronchoscope has nosuction channel. It has its greatest use in prematureand newborn infants who may or may not be intu-bated. The recently introduced 2.8-mm broncho-scope with a 1.2-suction channel is very fragile andcan be used in older infants or newborn infants whoare not intubated. In older children, this broncho-scope can be passed through several generations ofbronchi and thereby identify abnormalities previ-ously beyond the reach of the bronchoscope. Thesmallest adult bronchoscopes can be safely used inolder children and adolescents, and are particularlyuseful when purulent secretions are present or trans-bronchial biopsy specimens are to be obtained.

Standard biopsy forceps cannot be passed throughthe 1.2-mm suction channel of the 3.4- to 3.6-mm or2.8-mm bronchoscopes. Olympus Healthcare (Olym-pus America; Melville, NY) introduced a mini-forceps in the mid-1990s. As expected, the mouth ofthe forceps is quite small, as are the samples ob-tained. In order to obtain adequate specimens, mul-tiple passages of the forceps are usually required.Cytology brushes are available that can be passedthrough the 1.2-suction channel. Recently, the use ofurologic baskets and forceps passed through the

suction channel has been described to retrieve for-eign bodies with the standard pediatric broncho-scope.

Personnel

A dedicated operator must always be present, andis the overseer and supervisor over all aspects of theprocedure. A second physician is often present,especially in training contexts, but is not usuallyrequired. Two other trained persons are usuallypresent and, in the absence of a second physician,should be present. A nurse provides care and mon-itoring of the patient and keeps a chronologic recordof medications administered and the condition of thepatient. A second person, often a respiratory thera-pist, oversees the bronchoscope, light source, andsuction equipment, and manages medications ad-ministered through the bronchoscope and collectsany specimens obtained during the procedure. Allpersonnel should be trained and skilled in cardiopul-monary resuscitation.


As a rule, pediatric flexible bronchoscopy is per-formed with IV sedation due to the lower pre-dictability of cooperation from children duringbronchoscopy when compared to adults. Most prac-titioners use a short-acting benzodiazepine and ei-ther a short-acting opiate or ketamine. Continuousmonitoring of heart rate, arterial oxyhemoglobinsaturation by pulse oximetry, and BP is standardcare. The 3.4- to 3.6-mm bronchoscope occupies agreater proportion of the cross-sectional area of thetrachea and glottis than do standard adult broncho-scopes within the mature airway, leading to thepotential for greater interference with gas exchangein infants and young children. Thus, efficiency dur-ing the procedure, minimizing the duration of in-spection and instrumentation and an acute anddynamic awareness of the patient’s condition andvital signs, are critical to successful and safe pediatricflexible bronchoscopy. In addition, the potential forhypoventilation due to the use of IV sedating agentsadds to the potential for respiratory compromiseduring pediatric flexible bronchoscopy. Similarly, theuse of smaller adult scopes in the 4.8- to 5.2-mm sizefor school-aged children and younger adolescentswill predispose to more gas exchange abnormalitiesthan in most adult procedures.

The pioneers of pediatric flexible fiberoptic bron-choscopy stressed the importance of carefully ti-trated IV sedation providing conscious to deep levelsof sedation depending on the needs of each individ-ual patient and procedure. In recent years, manypediatric dedicated operators have opted for the




operating room setting with or without general an-esthesia more routinely. This change appears to berelated to at least four different developments. First,pediatric anesthesiologists have established them-selves as the experts in pediatric sedation. Since thelevel of sedation often needed for successful pediat-ric bronchoscopy goes beyond conscious sedation,many institutions have questioned the safety of theprocedure without the presence of the anesthesiol-ogist. Second, more pediatric anesthesiologists havecome to understand the need and ability for flexiblebronchoscopy to be performed safely and effectivelyin spontaneously breathing patients, and have be-come interested in participating in these procedures.In the United States, IV propofol, an ideal sedativefor flexible bronchoscopy when spontaneous breath-ing is necessary, is restricted in most institutions inNorth America for use by anesthesiologists. Third,the development and utilization of the laryngealmask with appropriate pediatric sizes has permittedthe safe use of the standard pediatric bronchoscopein infants with more significant degrees of respira-tory insufficiency, or who require temporary electiveextubation to facilitate the bronchoscopic procedure.In older patients, the laryngeal mask permits the safeuse of the smaller adult bronchoscopes with theability to assist ventilation as needed if transbronchialbiopsies are required. Fourth, the involvement of theanesthesiologist and operating room provides accessto a staffed recovery room with continuous monitor-ing after the bronchoscopy, which may not be readilyavailable to the pulmonologist who performs theprocedure outside the operating room under IVsedation. The excellent safety record documentedover many years with IV sedation should ensure thatthis option remains available to those practitioners inthose institutions who prefer that approach.

Technique

The patient is usually brought into the procedureroom in the company of a parent to provide reassur-ance. Infants are laid in supine position. Childrenmay sit while being hooked up to the monitor. IVaccess is obtained, and the patient is attached to theappropriate monitors. An aerosol of nebulized lido-caine or the application of lidocaine to the posteriororopharynx via atomizer is often used. Initial IVsedation is often administered before topical anes-thetic is applied by cotton tip applicator to the naris.Some endoscopists prefer to add topical nasal decon-gestants routinely.

The patient is then placed in the supine position,and IV sedation is titrated to desired effect. Oxygensupplementation delivered via nasal cannula is virtu-ally always used. The transnasal approach is used in

the majority of circumstances. The patency of thenaris is noted, and the size and position of adenoidaland tonsillar tissue is noted. The bronchoscope isadvanced to a position just above the larynx, andfurther topical lidocaine is sprayed onto the vocalcords and adjacent structures to effect. Supraglotticanatomy in static and dynamic conditions is noted.The bronchoscope is then passed through the vocalcords, and further topical anesthesia is administeredvia the suction channel into the tracheobronchialtree. The bronchoscopist then carries out a thoroughlower airway inspection.

Indications

There are many and diverse clinical indications forflexible bronchoscopy in the pediatric age group.Most common, perhaps, are those related to eitherupper or lower airway obstruction: stridor, noisybreathing, snoring of uncertain anatomic origin, oratypical wheeze. Evaluation of the artificial airway oras an aid to the intubation of the difficult upperairway is another reasonably common indication.Vocal cord dysfunction can often be diagnosed onclinical grounds or via spirometry, but in someindividuals, the visual identification of vocal cordadduction with the patient conscious and viewing thevideo screen can be helpful, both from diagnosticand therapeutic points of view. Suspected aspirationof gastric contents or feedings due to swallowingdysfunction appears to be reasonably common in thepopulation seen by most pediatric pulmonologists.Flexible bronchoscopy is commonly performed aspart of the evaluation to inspect the airway andperform BAL to evaluate for lipid-laden macro-phages. Complicated, severe, or persistent pneumo-nias and pneumonias in immunocompromised pa-tients are other common indications for pediatricflexible bronchoscopy. Hemoptysis, undifferentiatedlesions in the lung on chest radiograph, and nonin-fectious parenchymal lung diseases are all less com-mon in children but still lead to elective fiberopticbronchoscopy at times.

When transbronchial biopsy is added to flexiblebronchoscopy, the most common indications arethose conditions in which histopathology is impor-tant in therapeutic decision making, such as lungtransplantation and rare or unusual parenchymallung diseases. Endobronchial masses are very rare inchildren except for foreign bodies. Foreign bodiesare virtually always indications for rigid bronchos-copy in most institutions, although a recent publica-tion showed an excellent safety and efficacy recordutilizing flexible bronchoscopy with urologic basketsand forceps.




Contraindications

The contraindication to flexible bronchoscopy oc-curs when the risk of the procedure outweighs thepotential benefits, or when respiratory failure in asmall infant will not permit the passage of a flexiblebronchoscope while gas exchange is maintained. Theactual determination of the strength of contraindica-tion will vary depending on the skill and experienceof the dedicated operator and clinical practice andguidelines of the specific institution in which thepatient is hospitalized. With the introduction oflaryngeal mask anesthesia, more young patients maysafely undergo bronchoscopy with ventilation than inthe past. Coagulopathy is a relatively strong contra-indication to transbronchial biopsy.

Risks

The most common complications of flexible bron-choscopy are patient discomfort and transient hypox-emia. With the addition of BAL, fever 4 to 12 h afterthe procedure is also common. More seriouscomplications—pneumonia, respiratory failure, life-threatening hemoptysis, pneumothorax, and death—are rare.


There is no formal quantitative training require-ment for bronchoscopic procedures established bythe American Board of Pediatrics Sub-board forPulmonology. Two formal courses in pediatric flexi-ble bronchoscopy are held annually, one in theUnited States and the other in Europe. Pulmonaryfellows should perform at least 50 pediatric broncho-scopies in a supervised setting to establish basiccompetency. To maintain competency, dedicatedoperators should perform at least 25 procedures peryear. When fellows do not achieve this volume ofbronchoscopic procedures, they should be overseenby more senior members of the faculty or practicewhere they work until such time that they showproficiency in pediatric bronchoscopy.

Ancillary Procedures Applicable to PediatricPatients

Ancillary procedures applicable to pediatric pa-tients include the following: BAL (common); trans-bronchial biopsy and cytology brushing (uncom-mon); laser therapy (rare); airway dilation via ballooninsufflation (rare); airway stenting (rare); bronchog-raphy (rare); segmental instillation of medication(rare); and assessment of lower airways inflammation(research only).

ReferencesBarbato A, Magarotto M, Crivellaro M, et al. Use of the pediatricbronchoscope, flexible and rigid, in 51 European countries. EurRespir J 1997; 10:1761–1766Kurland G, Mpues BE, Jaffe R, et al. Bronchoalveolar lavage andtransbronchial biopsy in children following heart-lung and lungtransplantation. Chest 1993; 104:1043–1048Midulla F, Ratjen F. Special considerations for bronchoalveolarlavage in children. Eur Respir J 1999; 66:38–42Nicolai T. Pediatric bronchoscopy. Pediatr Pulmonol 2001; 31:150–164Picard E, Schlesinger Y, Goldberg S, et al. Fatal pneumococcalsepsis following flexible bronchoscopy in an immunocompro-mised infant. Pediatr Pulmonol 1998; 25:390–392Schellhase DE. Pediatric flexible bronchoscopy. Curr Opin Pe-diatr 2002; 14:327–333Slonim AD, Ognibene FP. Amnestic agents in pediatric bron-choscopy. Chest 1999; 116:1802–1808Smyth AR, Bowhay AR, Heaf LJ, et al. The laryngeal mask airwayin fiberoptic bronchoscopy. Arch Dis Child 1996; 75:344–345Stokes DC, Shenep JL, Parham D, et al. Role of flexiblebronchoscopy in the diagnosis of pulmonary infiltrates in pediat-ric patients with cancer. J Pediatr 1989; 115:561–567Swanson KL, Prakash UB, Midthun DE, et al. Flexible broncho-scopic management of airway foreign bodies in children. Chest2002; 121:1695–1700Wagener JS. Fatality following fiberoptic bronchoscopy in a 2year old child. Pediatr Pulmonol 1987; 3:197–199Wood RE. Spelunking in the pediatric airways: explorations withthe flexible fiberoptic bronchoscope. Pediatr Clin North Am1984; 31:785–799

TBNADefinition

TBNA is a minimally invasive procedure thatprovides a nonsurgical means to diagnose and stagebronchogenic carcinoma by sampling the mediasti-nal lymph nodes. Applications of bronchoscopic nee-dle aspiration have expanded to include not onlysampling of paratracheal or mediastinal lymphnodes, but peripheral, submucosal, and endobron-chial lesions. The procedure allows for samplingtissue through the trachea or bronchial wall, andsampling of tissue beyond the vision of the dedicatedoperator.

Equipment

In addition to the equipment needed for bron-choscopy, the equipment needed specifically forTBNA include TBNA needles, which are designed topass through a bronchoscope without causing dam-age and to be flexible enough to facilitate thepositioning of the bronchoscope, yet rigid enough topenetrate the airway wall. Two types of TBNAneedles, 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 RNor a respiratory therapist to administer and monitorconscious sedation, as well as a separate RN or arespiratory therapist to assist the dedicated operator.All supporting personnel should be familiar with theprocedure being performed, as well as the appropri-ate handling of specimens. This will maximize pa-tient comfort, safety, and yield.


This procedure may be performed under localanesthesia, with or without conscious sedation, orunder general anesthesia. Specific monitoring anddocumentation guidelines vary from hospital to hos-pital and from state to state. We recommend that thededicated operator inquire about the applicable an-esthesia and monitoring guidelines in their particularpractice environment.

Technique

TBNA usually begins with review of the chestradiograph and, in most instances, is greatly facili-tated by a CT scan. Knowledge of the anatomy iscritical for selecting the proper anatomic location forthe needle aspiration or biopsy. This is true forselecting the location of the paratracheal or subcari-nal lymph nodes, or for proper location of a periph-eral lesion that is to be sampled.

Generally, when performing mediastinal lymphnode aspiration for staging bronchogenic carcinoma(either known or suspected), it is critical to performthe needle aspiration prior to general inspection.This will reduce the likelihood of entraining airwaysecretions in the sample and avoid a false-positiveresult. A TBNA needle should be selected accordingto the size and location of the lesion.

Different techniques can be used singularly or incombination to ensure complete penetration of theneedle through the tracheobronchial wall. Whilesuction is applied, the catheter (and consequentlythe needle tip) is agitated back and forth to shear offcells from the node or mass with care not to disen-gage the tip of the needle from the tracheobronchialwall. This agitation is performed for a few seconds.Once the catheter is removed from the broncho-scope, the smears are prepared.

For submucosal lesions, a similar technique isapplied; however, since the goal is to obtain aspecimen from the mucosa, the needle and catheterare kept in a position of slight angulation rather thanthe 90° angle used to obtain lymph node aspirate.For endobronchial lesions that are either necrotic in

appearance or highly vascular, TBNA may be used toobtain a sample by altering the technique in order todirectly place the needle into the endobronchial lesion.

For peripheral lesions, fluoroscopy is used tolocalize the lesion. Once the lesion is localized, theneedle is locked into position, and the needle is usedto shear off cells from the peripheral lesion whilesuction is applied.

Specimen preparation is the same for the submu-cosal, endobronchial, or peripheral lesions as it is forthe nodal aspirations. Multiple nodal aspirations canbe obtained to increase yield.

Indications

Diagnostic and staging information in the pres-ence of malignancy in mediastinal lymph nodes,submucosal, endobronchial, and parenchymalmasses are indications for TBNA. Diagnostic infor-mation may also be obtained in the same locationsfor many benign conditions, including sarcoidosisand fungal disease.

Contraindications

Most contraindications to TBNA are relativerather than absolute. Special attention must be paidto respiratory and bleeding status.

Risks

TBNA is extremely safe and has a very lowincidence of complications. The most common po-tential complications are bleeding, pneumothorax, orpneumomediastinum. Significant bleeding rarely oc-curs even after a major vessel puncture. Fever andbacteremia have been reported following TBNA,although this may be related to the bronchoscopicprocedure itself rather than this specific technique.


In order to protect the bronchoscopy, the needlemust be properly and carefully used. In addition,improper technique will result in an inadequateneedle aspirate. Trainees should perform at least 25needle aspirates in a supervised setting to establishbasic competency. Trainees should also gain experi-ence in the acquisition of needle aspirates from lymphnodes in mostly paratracheal as well as subcarinalregions. To maintain competency, dedicated operatorsshould perform at least 10 procedures per year.

ReferencesBilaceroglu S, Perim K, Gunel O, et al. Combining transbronchialaspiration with endobronchial and transbronchial biopsy in sar-coidosis. Monaldi Arch Chest Dis 1999; 54:217–223




Crymes TP, Fish RG, Smith DE, et al. Complications oftransbronchial left atrial puncture. Am Heart J 1959; 58:46–52Garpestad E, Goldberg S, Herth F, et al. CT fluoroscopyguidance for transbronchial needle aspiration: an experience in35 patients. Chest 2001; 119:329–332Gay PC, Brutinel WM. Transbronchial needle aspiration in thepractice of bronchoscopy. Mayo Clin Proc 1989; 64:158–162Harrow E, Halber M, Hardy S, et al. Bronchoscopic androentgenographic correlates of a positive transbronchial needleaspiration in the staging of lung cancer. Chest 1991; 100:1592–1596Lundgren R, Bligman F, Angstrom T. Comparison of transbron-chial fine needle aspiration biopsy, aspiration of bronchial secre-tion, bronchial washing, brush biopsy, and forceps biopsy in thediagnosis of lung cancer. Eur J Respir Dis 1983; 64:378–385Shure D, Fedullo PF. Transbronchial needle aspiration in thediagnosis of submucosal and peribronchial bronchogenic carci-noma. Chest 1985; 88:49–51Wang KP, Terry PB. Transbronchial needle aspiration in thediagnosis and staging of bronchogenic carcinoma. Am Rev RespirDis 1983; 127:344–347

Autofluorescence BronchoscopyDefinition

Autofluorescence bronchoscopy is a broncho-scopic procedure in which a blue light rather than awhite light is employed for illumination, and prema-lignant and malignant tissue is distinguished by achange in color from normal tissue without the needfor fluorescence-enhancing drugs. Fluorescencetechniques used with bronchoscopy have demon-strated detection of dysplasia, carcinoma in situ, andearly invasive cancers not visible by standard whitelight bronchoscopy (WLB) through a specializedbronchoscope.

Equipment

In addition to the equipment needed for bron-choscopy, a dedicated endoscopic system allowingfor blue light imaging is required. Several differentsystems for autofluorescence bronchoscopy havebeen developed. Two images of different wave-lengths (red and green) are captured. Images areprocessed such that the image on the video monitorallows for normal tissue to be visualized as green andabnormal tissue to be visualized as reddish-brown incolor. Inspection is then performed using a standardbronchoscopic technique.

Personnel

A dedicated operator performs the procedure.Personnel required for this procedure include an RNor a respiratory therapist to administer and monitorconscious sedation, as well as a separate RN or arespiratory therapist to assist the dedicated operator.All supporting personnel should be familiar with the

procedure being performed, as well as the appropri-ate handling of specimens. This will maximize pa-tient comfort, safety, and yield.


This procedure may be performed under localanesthesia with or without conscious sedation orunder general anesthesia. Specific monitoring anddocumentation guidelines vary from hospital to hos-pital and from state to state. We recommend that thededicated operator inquire about the applicable an-esthesia and monitoring guidelines in their particularpractice environment.

Technique

Initial bronchoscopic examination is performedusing conventional WLB. Trauma to the mucosa,either by the bronchoscope tip or by suctioning,needs to be avoided, as this can obscure the imagingunder the autofluorescence system. For this reason,biopsy specimens are not obtained from abnormali-ties until after (or during) autofluorescence inspec-tion. Following white light inspection, a detailedautofluorescence examination is performed and allabnormalities are graded. Biopsies are then per-formed either under white light settings of the areasdetermined to be abnormal, or after (or during)autofluorescence bronchoscopic inspection of theareas determined to be abnormal.

Indications

Indications include known or suspected lung can-cer by abnormal sputum cytology findings, inspec-tion for synchronous tumors, surveillance followingcancer resection, and primary screening among high-risk patients.

Contraindications

Most contraindications to autofluorescence bron-choscopy are relative rather than absolute and do notdiffer from routine bronchoscopy.

Risks

There have been no untoward risks reported in theseries utilizing autofluorescence bronchoscopy. Con-sidering that fluorescence inspection simply useslight of a different wavelength and that bronchialbiopsy attainment is the same as in conventionalbronchoscopy, there is no increase in risk to thepatient over a standard WLB flexible bronchoscopytechnique. Autofluorescence inspection followingWLB generally adds 5 to 10 min to the overallbronchoscopic procedure.





Trainees should perform at least 20 autofluores-cence bronchoscopies in a supervised setting toestablish basic competency. To maintain compe-tency, dedicated operators should perform at least10 procedures per year.

ReferencesKuri JM, Lee JS, Morice RC, et al. Autofluorescence bronchos-copy in the detection of squamous metaplasis and dysplasia incurrent and former smokers. J Natl Cancer Inst 1998; 90:991–995Lam S, MacAulay C, Hung J, et al. Detection of dysplasia andcarcinoma in situ with the lung imaging fluorescence endoscopedevice. J Thorac Cardiovasc Surg 1993; 105:1035–1040Lam S, MacAulay C, Palcic B. Detection and localization of earlylung cancer by imaging techniques. Chest 1993; 103:12S–14SSato M, Sakurada A, Sagawa M, et al. Diagnostic tests before andafter introduction of autofluorescence bronchoscopy in patientssuspected of having lung cancer detected by sputum cytology andlung cancer mass screening. Lung Cancer 2001; 32:247–253Shibuya K, Fujisawa T, Hoshino H, et al. Fluorescence bron-choscopy in the detection of preinvasive bronchial lesions inpatients with sputum cytology suspicious or positive for malig-nancy. Lung Cancer 2001; 32:19–25Van Rens MT, Schramel FM, Ebbers JR, et al. The clinical valueof lung imaging fluorescence endoscopy for detecting synchro-nous lung cancer. Lung Cancer 2001; 32:13–18Weigel TL, Yousem S, Tacic, et al. Fluorescence bronchoscopicsurveillance after curative surgical resection for non-small celllung cancer. Ann Surg Oncol 2000; 7:176–180

EBUSDefinition

EBUS is an invasive procedure in which physi-cians use ultrasound devices inside the airways andthe lung for exploration of the structures of airwaywalls, the surrounding mediastinum, and the lungs.

Equipment

In addition to the equipment needed for flexiblebronchoscopy, the most widely applied device cur-rently used is a miniaturized catheter probe bearinga 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 completecircular contact. Another device that is used whenperforming EBUS is a dedicated ultrasonic endo-scope with an electronic curvilinear scanner at its tip,which provides a sectorial view into the bronchialwall and the mediastinal structures. Prototypes ofthis system are still under investigation and are notyet commercially available.

Personnel

A dedicated operator performs the procedure.Personnel required for this procedure include a RN

or a respiratory therapist to administer and monitorconscious sedation, as well as a separate RN or arespiratory therapist to assist the dedicated operator.All supporting personnel should be familiar with theprocedure being performed, as well as the appropri-ate handling of specimens. This will maximize pa-tient comfort, safety, and yield.



Technique

Techniques using both devices can be appliedduring routine bronchoscopy under general and localanesthesia. The miniaturized probe is insertedthrough a regular flexible bronchoscope with a bi-opsy channel of at least 2.8 mm. Inside the airways,the balloon is inflated until complete circular contactis achieved and the structures of the wall and thesurrounding mediastinum become visible. In orderto add the longitudinal dimension to the cross-sectional image, the probe has to be moved along theaxis of the airways.

When using a dedicated ultrasonic endoscope, itshould be placed with its tip against the tracheobron-chial wall. In order to add the circular and thelongitudinal dimension to the sectorial view, theinstrument has to be rotated and moved alongthe axis of the airways.

Indications

These two techniques are indicated for visualiza-tion, tumor invasion, TBNA guidance, and differen-tiating of vascular from nonvascular structures.EBUS may be helpful in guiding therapeutic proce-dures such as curative photodynamic and brachy-therapy by assessing tumor volume and other inter-ventions such as airway recanalization.

Contraindications

Most contraindications to EBUS are relativerather than absolute and do not differ from standardbronchoscopy. Special attention must be paid torespiratory and bleeding status.

Risks

EBUS is usually an extraordinarily safe procedure.It adds 5 to 10 min to a standard procedure.





EBUS requires intensified training and practicalexperience in interpreting sonographic images, sincethe anatomic structures of the mediastinum arecomparatively complex, and the planes of EBUSimages may be oblique and very different from theusual images by conventional radiology. Accordingly,trainees should perform at least 50 procedures in asupervised setting to establish basic competency inanalyzing anatomic structures and handling the in-strument. To maintain competency, dedicated oper-ators should perform at least 20 examinations peryear.

ReferencesHerth F, Becker HD. Endobronchial ultrasound of the airwaysand the mediastinum. Monaldi Arch Chest Dis 2000; 55:36–44Hurter T, Hanrath P. Endobronchial sonography: feasibility andpreliminary results. Thorax 1992; 47:565–567Lam S, Becker HD. Future diagnostic procedures. In: Fines RH,ed. Thoracic endoscopy: chest surgery clinics of North America(vol 30). Philadelphia, PA: WB Saunders, 1996; 366–380Shannon JJ, Bude RO, Orens JB, et al. Endobronchial ultra-sound-guided needle aspiration of mediastinal adenopathy. Am JRespir Crit Care Med 1996; 153:1424–1430

Laser TherapyDefinition

The word laser is an acronym for light amplifica-tion of stimulated emission of radiation. The wave-length of the laser determines the characteristics ofeach type. Tissues absorb the intense light of thelaser, and energy is dissipated, mainly in the form ofheat. This tissue/light interaction is used for tissuedestruction and coagulation.

Equipment

Laser therapy may be performed with either flex-ible or rigid bronchoscopic instruments. In additionto the equipment needed for bronchoscopy, thereare four major medical lasers currently being usedfor bronchoscopic resection (laser therapy). Each hasspecific characteristics that provide advantages forcertain situations. The Nd-YAG laser is the mostcommonly used laser. The wavelength is 1064 nm,yielding invisible light in the infrared range. Otherlasers include the potassium titanyl phosphate laser,the carbon dioxide laser, and diode lasers. Thespecific laser fibers are usually accompanied with theappropriate power generator and specific protectiveeyewear.

Personnel

A dedicated operator performs the procedure.Personnel required for this procedure include an RN

or a respiratory therapist to administer and monitorconscious sedation, as well as a separate RN or arespiratory therapist to assist the dedicated operator.All supporting personnel should be familiar with theprocedure being performed, as well as the appropri-ate handling of the specimens. This will maximizepatient comfort, safety, and yield. If the procedure isperformed under general anesthetic, an anesthesiol-ogist should also be present.


Laser therapy may be performed under localanesthesia with or without conscious sedation orunder general anesthesia. Specific monitoring anddocumentation guidelines vary from hospital to hos-pital and from state to state. We recommend that thededicated operator inquire about the applicable an-esthesia and monitoring guidelines in their particularpractice environment; however, it is recommendedto keep the percentage concentration of oxygenwithin the airways as low as possible (! 40%) inorder to prevent airway fires. The patient and per-sonnel must be protected from the laser light bystandard laser precautions.

Technique

Laser therapy can be used alone or in associationwith other ablative techniques or stenting. Laserfiring can result in the photocoagulation of superfi-cial and deep blood vessels, thermal necrosis, andscatter to adjacent tissues. Excessive laser applicationcan, however, result in substantial tissue damage,necrosis, and airway wall penetration.

Rigid bronchoscopy is usually preferred over theflexible technique as a delivery mechanism for lasertherapy. This provides easy access for suction andgrasping of large debris. The rigid scope can be usedto tamponade bleeding. Airway strictures can bedilated using rigid bronchoscopes of increasing di-ameter. All personnel in the operating room shouldwear protective eyewear. Flammable material shouldbe kept away from the operating field. After intuba-tion, a suction catheter and the laser fiber areinserted. While the laser is fired, the fraction ofinspired oxygen should be kept at # 40% to avoidcombustion. Whether performed via rigid or flexiblebronchoscopy, continuous suction should be applied.This is more important if gaseous anesthesia is beingdelivered. Once a certain amount of charring hasoccurred and tissues become softer, direct mechan-ical debulking should be done to expedite the pro-cedure.

Following completion of the operation, the patientshould be observed for bronchospasm or laryngo-spasm. The recovery room staff should be closely




monitoring the patient and should be adept in themanagement of acute airway obstruction.

Indications

The primary indication for bronchoscopic laserresection is the relief of central airway obstructionusually from benign or malignant tissue. There aremany potential dangers involved with the use of thistechnique; therefore, the indications must beweighed carefully, even in patients with terminalcancer. Note that laser therapy cannot be utilized fortreatment of extrabronchial disease. The specificindications include relief of obstruction by tumor orbenign exophytic lesion, and intraluminal diseaseinvolving the central airways. Central or segmentalairway strictures or scarring from tuberculosis, priorlung resection, trauma, radiation therapy, tracheot-omy, tracheostomy, inhalation injury, endotrachealintubation, previous laser surgery, or foreign bodyobstruction causing intractable cough, hemoptysis,severe dyspnea, or postobstruction pneumonia arealso indications. Additionally, treatment of in situbronchogenic carcinoma or in conjunction with pho-todynamic therapy is an indication.

Contraindications

Potential contraindications include, but are notlimited to the following: tracheoesophageal fistula,uncorrected coagulopathy, total airway obstructionwith little if any functional distal airway open, andlittle or no exophytic lesion visible. Laser firing canresult in the photocoagulation of superficial anddeep blood vessels, thermal necrosis, and scatter toadjacent tissues. Excessive laser application can,however, result in substantial tissue damage, necro-sis, and airway wall penetration.

Risks

In experienced hands, laser therapy is safe andeffective and rarely associated with morbidity andmortality. Hypoxemia can occur both intraopera-tively and postoperatively. Hemorrhage can occurimmediately after laser ablation. Other complica-tions include perforation and fistulae formation, firein the airway, and pneumothorax.

Training Requirement

Safe laser resection requires training, thoroughknowledge of laser/tissue interactions, and an expe-rienced team consisting of a dedicated operator,nurses, respiratory therapists and anesthesiologists.Most institutions require that potential dedicatedoperators fulfill both an outside and hospital-based

laser therapy course before privileges are permitted.Dedicated operators performing laser therapyshould have extensive experience in flexible bron-choscopy, management of central airway lesions, andendotracheal intubation. Dedicated operators shouldalso have a comfortable familiarity with rigid bron-choscopy. Trainees should perform at least 15 pro-cedures in a supervised setting to establish compe-tency. To maintain competency, dedicated operatorsshould perform at least 10 procedures annually.

ReferencesBrutinel WM, Corese DA, McDougall JC, et al. A two-yearexperience with neodymium-YAG laser in endobronchial ob-struction. Chest 1987; 91:159–165Hetzel MR, Nixon C, Edmondstone WM, et al. Laser therapy in100 tracheobronchial tumors. Thorax 1985; 40:341–345Joyner LR Jr, Maran AG, Sarama R, et al. Neodymium-YAG lasertreatment of intrabronchial lesions: a new mapping technique viathe flexible fiberoptic bronchoscope. Chest 1985; 87:418–427Laforet EG, Berger RL, Vaughn CW. Carcinoma obstructing thetrachea: treatment by laser resection. N Engl J Med 1976;294:941Ross DJ, Mohsenifar Z, Koerner SK. Survival characteristics afterneodymium:YAG laser photoresection in advanced stage lungcancer. Chest 1990; 98:581–585Simpson GT, Strong MS, Healy GB, et al. Predictive factors ofsuccess or failure in the endoscopic management of laryngeal andtracheal stenosis. Ann Otol Rhinol Laryngol 1982; 91:384–388Unger M. Neodymium:YAG laser therapy for malignant andbenign endobronchial lesion. Clin Chest Med 1985; 6:277–290

Electrocautery and Argon PlasmaCoagulation

Definition

Endobronchial electrocautery and argon plasmacoagulation (APC) are modes of thermal tissue de-struction that may be used via the flexible or rigidbronchoscope. Similar to laser tissue destruction, theeffect of both endobronchial electrocautery and APCis determined by heat and tissue interaction, and isfairly rapid. Heat is created through the applicationof high-frequency electric currents to coagulate orvaporize tissue. The difference between the twoprocedures centers on the fact that APC is a non-contact mode of tissue coagulation. Dedicated oper-ators use argon plasma as the medium to conduct theelectric current in APC rather than using the contactprobe as a medium to conduct the electric current aselectrocautery does.

Equipment

In addition to the equipment needed for theflexible or rigid bronchoscopy, a dedicated operatorneeds a high-frequency electrical generator in com-




bination with insulated probes. Different types ofprobes in terms of shape as well as polarity (monopo-lar vs bipolar) are available. For patient and staffprotection, proper insulation precautions need to beobserved. Insulated flexible equipment is also avail-able. For APC, a dedicated operator needs a specialcatheter allowing for the argon gas and the electricalcurrent flow. This catheter is not used in electrocau-tery where there is direct tissue contact.

Personnel




Technique

Endobronchial electrocautery and APC are ther-mal tissue-destructive modalities that use electricityto generate heat. They differ in the fact that APCdoes not make contact with the tissues it destroysand has a penetration depth of just a few millimeters.For these reasons, it is more suitable for the treat-ment of superficial and spreading lesions. Once gas isreleased through the catheter tip, it is ignitedthrough electrical current; an arc is formed if theprobe is close enough to the mucosal surface, caus-ing heat destruction and desiccation of the tissue.The arc can be moved back and forth (painting) andcan even be aimed around bends, making it verysuitable for hard to reach lesions.

Endobronchial electrocautery, however, relies ondirect tissue contact. The set power output deter-mines the type of tissue destruction (coagulation vsvaporization). Different probes and snares are avail-able for different indications. Energy delivery inboth modalities is terminated once the desired effecthas been achieved.

Indications

Endobronchial electrocautery is frequently seen asa less expensive alternative to laser therapy withsimilar effects and as such similar indications. Similarto laser, electrocautery cannot be used for extrabron-chial disease. APC and electrocautery are indicatedfor any benign or malignant tissue destruction re-sponsive to heat delivery. These indications includeendobronchial malignancy, benign tumors, and reliefof postintubation stenosis, and, in the case of APC,treatment of stent-induced granuloma.

Contraindications

In addition to the contraindications for rigid orflexible bronchoscopy, the only absolute contraindi-cation is the presence of a pacemaker susceptible toelectrical interference.

Risks

In addition to the risks associated with the rigid orflexible bronchoscopy, potential complications aresimilar to other thermal therapies and include airwayfires (need to keep oxygen levels as low as possible,preferably # 40%), hemorrhage, airway perforation,and stenosis.


Dedicated operators performing endobronchialelectrocautery and APC should have extensive expe-rience in flexible bronchoscopy and management ofcentral airway lesions. Trainees should perform atleast 15 procedures in a supervised setting to estab-lish basic competency in endobronchial electrocau-tery and APC. To maintain competency, dedicatedoperators should perform at least 10 procedures peryear.

ReferencesHomasson JP. Endobronchial electrocautery. Semin Respir CritCare Med 1997; 18:535–543Hooper RG, Jackson FN. Endobronchial electrocautery. Chest1985; 87:712–714Sheski FD, Mathur PN. Cryotherapy, electrocautery, and brachy-therapy. Clin Chest Med 1999; 20:123–138van Boxem T, Muller M, Venmans B, et al. Nd-YAG laser vsbronchoscopic electrocautery for palliation of symptomatic air-way obstruction: a cost-effectiveness study. Chest 1999; 116:1108–1112van Boxem TJ, Westerga J, Venmans BJ, et al. Tissue effects ofbronchoscopic electrocautery: bronchoscopic appearance andhistologic changes of bronchial wall after electrocautery. Chest2000; 117:887–891




CryotherapyDefinition

Cryotherapy is a form of thermal tissue ablation.In contrast to the use of heat, it is the application ofrepetitive freeze/thaw cycles that cause tissue dam-age and destruction. Due to the particular action ofcryotherapy, results are not immediate and may bedelayed for several days.

Equipment

In addition to the equipment needed for flexibleor rigid bronchoscopy, dedicated operators needdifferent probes depending on whether the cryother-apy is delivered through the rigid or flexible bron-choscope. Generally, the area of freezing is largerand the thawing quicker with the rigid probes. Thegas most commonly used in cryotherapy and the gasmost commercially available is nitrous oxide.

Personnel




Technique

Tissue destruction is achieved through repetitivefreeze/thaw cycles. The cooling probe is directlyattached or inserted into the lesion to be treated.The same area has to be frozen several times beforetreating the next part of the lesion. There should beoverlap between all regions in order to not leave anyarea untreated. As the effects are delayed and ne-crotic tissue frequently cannot be expectorated, fol-low-up therapeutic bronchoscopy should be per-formed.

Indications

Cryotherapy is indicated for the treatment ofintrinsic airway lesions. Due to the delayed effects, itis not the first choice in high-grade lesions needingimmediate intervention. Some tissues are not re-sponsive to cryotherapy (eg, fibrotic scarring). Theuse of cryotherapy may be helpful in the removal offoreign bodies.

Contraindications

In addition to the contraindications for rigid orflexible bronchoscopy, cryotherapy is contraindi-cated in patients with life-threatening airway ob-struction.

Risks

Besides the risks associated with the rigid orflexible bronchoscopy, complications are rare, espe-cially since cartilage is resistant to cryotherapy. Mostside effects are associated with the use of bronchos-copy itself. There is no risk of airway fire.


Dedicated operators performing cryotherapyshould have extensive experience in flexible bron-choscopy and management of central airway lesions.Trainees should perform at least 10 procedures in asupervised setting to establish competency. To main-tain competency, dedicated operators should per-form at least five procedures per year.

ReferencesHomasson JP, Thiery JP, Angebault M, et al. The operation andefficacy of cryosurgical, nitrous oxide driven cryoprobe. Cryobi-ology 1994; 31:290–304Maiwand MO. Cryotherapy for advanced carcinoma of thetrachea and bronchi. BMJ 1986; 293:181–182Marasso A, Gallo E, Massaglia GM, et al. Cryosurgery inbronchoscopic treatment of tracheobronchial stenosis. Chest1993; 103:472–474Vergnon JM, Schmitt T, Alamartine E. Initial combined cryo-therapy and irradiation for unresectable non-small lung cancer.Chest 1992; 102:1436–1440Walsh DA, Maiwand MO, Nath AR, et al. Bronchoscopic cryo-therapy for advanced bronchial carcinoma. Thorax 1990; 45:509–513

BrachytherapyDefinition

Brachytherapy is a minimally invasive procedurethat allows localized delivery of radiation therapywithin the body. Methods of brachytherapy delivery




include direct implantation of radioactive seeds intothe tumor area; image-guided implantation of radio-active sources; transbronchial source implantationwith a bronchoscope; and, most commonly, deliveryof a radioactive source through a transnasal catheterplaced via the lumen of a bronchoscope. This sectionapplies only to the last, most commonly utilizedmethod of delivery.

Equipment

Placement of the delivery catheter requires per-sonnel and equipment for flexible bronchoscopy,including a flexible bronchoscope with adequatechannel size for the delivery catheter. Afterloadingcatheters and radioactive sources are required. Flu-oroscopy is needed to confirm correct catheterplacement. A treatment room must have appropriateshielding and, for high-dose-rate treatment, a remoteafterloading device. 192Ir is the preferred radiationsource at this time.

Personnel

A dedicated operator performs the procedure.Personnel required for this procedure include an RNor a respiratory therapist to administer and monitorconscious sedation, as well as a separate RN or arespiratory therapist to assist the dedicated operator.All supporting personnel should be familiar with theprocedure being performed, as well as the appropri-ate handling of specimens. This will maximize pa-tient comfort, safety, and yield. A radiation oncolo-gist and the appropriate support staff are responsiblefor the delivery of the therapeutic radiation.



Technique

After establishing satisfactory topical analgesia andappropriate monitoring, flexible bronchoscopy isperformed. The involved portion of the airwayshould have a visible lumen through which to passthe catheter. If the bronchus is occluded, a passagemust be established with a variety of means, includ-ing mechanical debridement or laser ablation. This isusually done in a separate setting and may require

rigid bronchoscopy. The afterloading catheter isadvanced distal to the tumor area. If additionalcatheters are needed, the procedure is repeated.Catheter position is confirmed radiographically. Theradioactive source is then afterloaded in a shieldedroom using a remote device in the case of high-dose-rate treatment. Dwell stations and times are deter-mined by radiation oncology and radiation physicspersonnel. Several treatments at weekly intervals areusually required for maximal response, but there isno consensus on optimal dose or frequency.

Indications

Brachytherapy is mainly used for palliation ofsymptomatic malignant airway obstruction, but mayalso be a curative modality in some patients withcarcinoma in situ or very limited early stage lungcancer within the central airways. Improvement inpostobstructive symptoms and hemoptysis isachieved in most patients.

Contraindications

In addition to the contraindications for rigid orflexible bronchoscopy, brachytherapy is contraindi-cated as primary treatment for malignant tracheo-esophageal fistula, and for patients who have hadprior brachytherapy in the same area.

Risks

In addition to the risks associated with rigid orflexible bronchoscopy, complications related to therisks of the procedure itself are rare and are mostcommonly related to the risks of the bronchoscopyitself. The catheter may get displaced and evenpenetrate the airway wall and cause pneumomedias-tinum and pneumothorax. Complications due to theactual radiation effects include fatal hemoptysis,bronchial necrosis, airway fistulas to neighboringstructures, fibrotic stenosis, and radiation bronchitis.


Dedicated operators performing brachytherapycatheter insertion should have extensive experiencein flexible bronchoscopy and management of centralairway lesions. Trainees should perform at least fiveprocedures in a supervised setting to establish basiccompetency in brachytherapy. To maintain compe-tency, dedicated operators should perform at leastfive procedures per year.

ReferencesChella A, Ambrogi MC, Ribechini A, et al. Combined Nd-YAGlaser/HDR brachytherapy versus Nd-YAG laser only in malignant




central airway involvement: a prospective randomized study.Lung Cancer 2000; 27:169–175Langendijk H, de Jong J, Tjwa M, et al. External irradiationversus external irradiation plus endobronchial brachytherapy ininoperable non-small cell lung cancer: a prospective randomizedstudy. Radiother Oncol 2001; 58:257–268Nag S, Kelly JF, Horton JL, et al. Brachytherapy for carcinoma ofthe lung. Oncology (Huntingt) 2001; 15:371–381Sheski FD, Mathur PN. Cryotherapy, electrocautery, and brachy-therapy. Clin Chest Med 1999; 20:123–138Stout R, Barber P, Burt P, et al. Clinical and quality of lifeoutcomes in the first United Kingdom randomized trial ofendobronchial brachytherapy (intraluminal radiotherapy) vs. ex-ternal beam radiotherapy in the palliative treatment of inoperablenon-small cell lung cancer. Radiother Oncol 2000; 56:323–327Villanueva AG, Lo TC, Beamis JF Jr. Endobronchial brachyther-apy. Clin Chest Med 1995; 16:445–454

Photodynamic TherapyDefinition

Photodynamic therapy is a minimally invasive pro-cedure that is done using a bronchoscope and targetstissue destruction using a selectively retained photo-sensitizer, which, when exposed to the properamount and wavelength of light, produces an acti-vated oxygen species that oxidizes critical parts ofneoplastic cells. The photosensitizer is administeredIV, and the light source, in the case of endobronchialtreatment, is delivered endoscopically via a quartzfiber. Direct interstitial delivery of light energy isalso possible. Repeated injections and treatmentscan be performed.

Equipment

In addition to the equipment needed for flexibleand rigid bronchoscopy, a dedicated operator shouldhave available a photosensitizer, facilities for IVadministration, a laser light source (630 nm withcurrent agents), and an optical fiber. Laser safetyequipment and precautions are also necessary, suchas appropriate eye protection and signage.

Personnel

A dedicated operator performs the procedure andmust be experienced in the use of medical lasers andphotosensitizers. Personnel required for this proce-dure include an RN or a respiratory therapist toadminister and monitor conscious sedation, as well asa separate RN or a respiratory therapist to assist thededicated operator with the procedure. All support-ing personnel should be familiar with the procedurebeing performed, as well as the appropriate handlingof specimens. This will maximize patient comfort,safety, and yield.



Technique

The photosensitizer is administered IV at a doserecommended for the specific agent. After an appro-priate interval (usually 1 to 2 days, but within 7 days),a flexible or rigid bronchoscopy is performed, andthe area of abnormality is illuminated with light ofthe proper wavelength and dose.

The light is delivered in a superficial or interstitialmanner as required for uniform delivery to the targettissue. Penetration is limited to 5 to 10 mm from thetissue surface.

Immediate effects are not seen, but within 48 h,necrosis becomes apparent. Necrotic tissue must bedebrided with repeat bronchoscopy 1 to 2 days aftertreatment. Any residual tumor can be immediatelyretreated.

Indications

Photodynamic therapy has been approved in theUnited States, Japan, and Europe to treat superficialcancers in patients ineligible for surgery or externalbeam radiation. It is also approved for palliation ofmalignant endobronchial obstruction. Photodynamictherapy response is not dependent on the tumor celltype. It can be applied in patients who have alreadyundergone surgery, radiation, or chemotherapy.Photodynamic therapy produces complete responserates in 60 to 80% of early stage mucosal carcinomas,and has been shown to palliate airway obstruction in80% of patients.

Contraindications

In addition to the contraindications for rigid orflexible bronchoscopy, photodynamic therapy is con-traindicated for patients with critical central airwayobstruction (because of the delay in improvement),for tumors invading the esophagus or major vessels,and for patients with porphyria or an allergy tocomponents of the photosensitizer.

Risks

In addition to the risks associated with rigid orflexible bronchoscopy, the most common complica-




tion of photodynamic therapy is skin photosensitivity.This may last for up to 8 weeks after injection of thephotosensitizer. All patients receiving these agentsmust take careful precautions to avoid significantlight exposure during the period of sensitivity.

Local complications from the treatment includeairway edema, necrosis, and stricture. Tumor lysiscan result in bronchovascular fistula or tracheo-esophageal fistula. Fatal hemoptysis has been re-ported, but its relationship to photodynamic therapy,as opposed to progression of disease alone, is notknown.


Dedicated operators performing photodynamictherapy should have extensive experience in flexiblebronchoscopy, management of central airwaylesions, and endotracheal intubation. Familiaritywith rigid bronchoscopy is recommended. Traineesshould perform at least 10 procedures in a super-vised setting to establish basic competency. To main-tain competency, dedicated operators should per-form at least five procedures per year.

ReferencesHayata Y, Kato H, Konaka C, et al. Photodynamic therapy inearly stage lung cancer. Lung Cancer 1993; 9:287–294Henderson B, Dougherty T. How does photodynamic therapywork? Photochem Photobiol 1992; 55:145–157McCaughan JS Jr, Hawley PC, Brown DG, et al. Effect of lightdose on the photodynamic destruction of endobronchial tumors.Ann Thorac Surg 1992; 54:705–711McCaughan JS Jr. Survival after photodynamic therapy to non-pulmonary metastatic endobronchial tumors. Lasers Surg Med1999; 24:194–201McCaughan JS Jr, Williams TE. Photodynamic therapy forendobronchial malignant disease: a prospective fourteen-yearstudy. J Thorac Cardiovasc Surg 1997; 114:940–947Sutedja TG, Posthumus PE. Photodynamic therapy in lungcancer: a review. Photochem Photobiol 1996; 36:199–204

Airway StentsDefinition

Airway stents, similar to vascular stents, are de-vices designed to keep tubular structures open andstable. Airway stents are intended for placement inthe central tracheobronchial tree. Depending on thedesign, they may be placed with either flexible orrigid bronchoscopes.

Equipment

Numerous different stent designs have been de-veloped to allow for adaptation to the individualanatomic requirements and operator preference.

Depending on the manufacturing material (silicone,metal, or hybrid design), flexible or rigid endoscopicequipment is required. Delivery devices specific forthe individual stent are necessary and frequentlyaccompany the actual device (such as delivery cath-eters). Some operators may want fluoroscopic capa-bility to be available.

Personnel

A dedicated operator performs the procedure.Personnel required for this procedure include an RNor a respiratory therapist to administer and monitorconscious sedation, as well as a separate RN or arespiratory therapist to assist the dedicated operatorwith the procedure. All supporting personnel shouldbe familiar with the procedure, as well as theappropriate handling of the specimens. This willmaximize patient comfort, safety, and yield.



Technique

In case of airway obstruction, an appropriatelumen needs to be reestablished before placing astent. This can be achieved by a variety of methodsdepending on the type of obstruction. The choice ofstent depends on the underlying lesion to be treated,dedicated operator preference and resource avail-ability. Proper stent sizing is critical and can beachieved by reviewing CT images, balloon cathetersizing and other methods, including relying on theexperience of the dedicated operator. The stentlength should exceed the length of the lesion to somedegree to ensure patency. If stents are chosen toosmall in diameter, they may migrate; if they arechosen too large, they may not open or may causestress on the airway wall.

Indications

Indications for stents in the central airways areexpanding. Conditions responsive to stenting underthe appropriate circumstances are intrinsic airwayobstruction from benign or malignant diseases, ex-trinsic airway compression such as tumors or otherstructures within the chest, sealing of airway fistulasand, in selected cases, tracheobronchomalacia.




Contraindications

In addition to the contraindications for flexible orrigid bronchoscopy, stent placement, like other en-dobronchial therapeutic interventions, should beavoided if nonviable lung is present beyond theobstruction. As long-term experience with metallicstents is limited compared to silicone prosthesis,many authorities prefer the primary consideration ofremovable stents in benign disorders.

Risks

In addition to the risks associated with rigid orflexible bronchoscopy, stents may migrate and causeinfection. Granuloma formation, breakage of metalfibers, hemoptysis, and airway obstruction due toimpaction or granulomas and pain are potentialresults. Mortality due to stent placement is rare.


Dedicated operators performing airway stentingshould have extensive experience in flexible and rigidbronchoscopy and management of central airway le-sions. Trainees should perform at least 20 supervisedprocedures in a supervised setting to establish basiccompetency. To maintain competency, dedicated op-erators should perform at least 10 procedures per year.In order to make the best choice for the individualpatient, the dedicated operator should be proficient inthe placement of both flexible and silicone stents.

ReferencesBecker HD. Stenting of the central airways. J Bronchol 1995;2:98–106Bolliger CT. Airway stents. Semin Respir Crit Care Med 1997;18:563–570Dasgupta A, Heights C, Dolmatch BL, et al. Self-expandablemetallic airway stent insertion employing flexible bronchoscopy:preliminary outcome. Chest 1998; 114:106–109Dumon JF. A dedicated tracheobronchial stent. Chest 1990;97:328–332Freitag L. Tracheobronchial stents. In: Bolliger CT, Mathur PN,eds. Interventional bronchoscopy (vol 30). Basel, Switzerland:Karger, 2000; 171–186Freitag L, Eicker K, Donovan TJ, et al. Mechanical properties ofairway stents. J Bronchol 1995; 2:270–278Montgomery WW. T-tube tracheal stent. Arch Otolaryngol 1965;82:320–321

Thoracic Percutaneous Needle Aspiration/Core Biopsy

Definition

Thoracic percutaneous needle aspiration (TPNA)and core biopsy are both minimally invasive proce-

dures in which samples are obtained through theskin with a fine-bore hollow needle or coring needle.Lesions of the lung parenchyma, pleura, chest wall,or mediastinum are sampled in this manner, usuallyusing image guidance such as CT or ultrasound.

Equipment

Biopsy needles are typically 15 cm in length and18- to 25-gauge in diameter. They may be aspiratingor core biopsy needles. In addition, “automatic fir-ing” biopsy guns are available. Ultrasound, fluoros-copy, or CT for localizing nonpalpable lesions andconfirming accurate placement of the biopsy needleare also needed. Cytology slides and fixatives alongwith specimen containers for core biopsies andculture samples are needed, as are small-bore (8F to12F) catheters or chest tubes to treat large orsymptomatic pneumothoraces.

Personnel

A dedicated operator performs the procedure.Personnel required for this procedure include an RNor a respiratory therapist to administer and monitorconscious sedation, as well as a separate RN or arespiratory therapist to assist the dedicated operator.All supporting personnel should be familiar with theprocedure being performed, as well as the appropri-ate handling of specimens. This will maximizepatient comfort, safety, and yield. An on-site cyto-pathologist and/or technician should confirm ade-quate tissue samples.


This procedure may be performed under localanesthesia with or without conscious sedation. Spe-cific monitoring and documentation guidelines varyfrom hospital to hospital and from state to state. Werecommend that the dedicated operator inquireabout the applicable anesthesia and monitoringguidelines in their particular practice environment.

Technique

After positioning the patient to provide suitableexposure and reviewing the imaging studies, theappropriate site, angle, and approximate depth ofneedle penetration are determined. Before insertingthe biopsy needle, sufficient local anesthesia shouldbe given. In case of a lesion that cannot be palpated,the needle path is guided through the use of ultra-sound, fluoroscopy, or CT. Cell aspirate or corebiopsy as previously determined is obtained andtransferred to slides or appropriate media. Repeatbiopsy in a separate area, if insufficient or inade-




quate material was obtained, may be performed. Achest radiograph should be obtained to check forpneumothorax.

Indications

Indications are an undiagnosed chest wall lesion,as well as undiagnosed pleural masses. An undiag-nosed lung lesion may be an indication for TPNA;however, most central lung lesions will be ap-proached with a bronchoscopy as the first attempt ata diagnosis. Patients eligible for surgical therapy withsignificant risk for lung cancer and peripheral lunglesions often proceed directly to appropriate surgicaltherapy. Presumed metastatic mediastinal massesare appropriate for TPNA. The diagnostic accuracyof cytology for thymoma, lymphoma, and germ-celltumors is low. Some authors report good diagnosticsuccess using 16- to 20-gauge core biopsy needles toobtain adequate tissue from nonmetastatic mediasti-nal masses.

Contraindications

Contraindications for TPNA and core biopsy in-clude uncontrolled bleeding disorders and coagu-lopathies, as well as the inability to tolerate a pneu-mothorax.

Risks

Most series report a 20 to 25% incidence ofpneumothorax after TPNA of the lung, with higherrates when patients have moderate-to-severe emphy-sema or with core biopsy. A minority of patients, 2 to5%, will require a chest tube or catheter for drainageof the pneumothorax. Hemoptysis is reported in 5 to15% of cases, with most patients having minimalhemoptysis. Fewer than 1% of patients experiencesignificant (30 to 50 mL) hemoptysis. Pleuritic chestpain without a pneumothorax is also seen 2 to 5% ofpatients. Fewer than 1% of patients will experience avasovagal reaction. Tension pneumothorax and deathare rare complications of TPNA.


Trainees should perform at least 10 TPNA proce-dures and 10 core biopsies in a supervised setting toestablish basic competency. To maintain compe-tency, dedicated operators should perform at least 10procedures per year.

ReferencesDennie CJ, Matzinger FR, Mariner JR, et al. Transthoracicneedle biopsy of the lung: results of early discharge in 506outpatients. Radiology 2001; 219:247–251

Kahn BG, Healy JC, Bishop JW. The cost of diagnosis: acomparison of four different strategies in the work-up of solitaryradiographic lung lesions. Chest 1997; 111:870–876Khouri NF, Stitik FP, Erozan YS, et al. Transthoracic needleaspiration biopsy of benign and malignant lung lesions. AJR Am JRoentgenol 1985; 144:281–288Larsheid RC, Thorpe PE, Scott WJ. Percutaneous transthoracicneedle aspiration biopsy: a comprehensive review of its currentrole in the diagnosis and treatment of lung tumors. Chest 1997;114:704–709Li H, Boiselle PM, Shepard JO, et al. Diagnostic accuracy andsafety of CT-guided percutaneous needle aspiration biopsy of thelung: comparison of small and large pulmonary nodules. AJRAm J Roentgenol 1996; 167:105–109Protopapas Z, Westcott JL. Transthoracic hilar and mediastinalbiopsy. Radiol Clin North Am 2000; 38:281–291Screaton NJ, Flower CD. Percutaneous needle biopsy of thepleura. Radiol Clin North Am 2000; 38:293–301Westcott JL, Rao N, Colley DP. Transthoracic needle biopsy ofsmall pulmonary nodules. Radiology 1997; 202:97–103Yang PC. Ultrasound-guided transthoracic biopsy of the chest.Radiol Clin North Am 2000; 38:323–343

Tube ThoracostomyDefinition

Tube thoracostomy is a minimally invasive proce-dure in which a drainage catheter is placed percuta-neously into the pleural space.

Equipment

Equipment consists of a sterile set of instruments,local anesthetic, suture material to fix the tube, achest tube or catheter, a collection device, whichincludes a water seal (or dry equivalent), and dress-ings. No monitoring, oxygen, specialized personnel,or dedicated space is necessary, unless required forother aspects of the patient’s condition.

Personnel

The only required personnel is the dedicatedoperator placing the tube. An RN or nurse assistantmay be useful to set up the sterile field, position thepatient, and prepare the collection device.



Technique

The desired entry position of the tube is deter-mined from radiology studies and physical examina-




tion. The patient is positioned to provide suitableexposure. After sterile preparation, local anesthetic isadministered from the skin to the pleura. The ded-icated operator then aspirates the pleural contents toverify the presence of fluid or air. A small skinincision is made. Blunt dissection is carried throughthe inferior portion of the selected interspace (toavoid injury to intercostal vessels) into the pleuralspace. The chest tube is passed into the pleural spaceand secured with all drainage holes within thepleural space. A collection device with water seal isconnected. Wall suction may be applied to thecollection device if desired. A chest radiograph isobtained to verify correct tube position and resolu-tion of the intrapleural process.

Indications

Tube thoracostomy is indicated for pneumothorax,hemothorax, pleural effusion, empyema, and chylo-thorax. Timing, position, and relative indications willvary with each patient and must be individualized.

Contraindications

Tube thoracostomy is contraindicated in the ab-sence of a pleural space (pleural symphysis). Coagu-lopathy is a relative contraindication in electivesettings.

Risks

Complications of tube thoracostomy include hem-orrhage, pulmonary laceration, air leak, and pain.Tube thoracostomy is usually a safe, relatively pain-less, and reliable bedside procedure. Complications,as outlined above, should be uncommon (approxi-mately # 10%).


Dedicated operators performing this procedureshould have ample experience, excellent knowledgeof pleural and thoracic anatomy, mature judgment ininterpreting radiographic images related to pleuraldisease, and sufficient surgical skill. In this setting,complications should be minor and uncommon.Trainees should perform at least 10 procedures in asupervised setting to establish basic competency. Tomaintain competency, dedicated operators shouldperform at least five procedures per year.

ReferencesGilbert TB, McGrath BJ, Soberman M. Chest tubes: indications,placement, management, and complications. J Intensive CareMed 1993; 8:73–86

Iberti TJ, Stern PM. Chest tube thoracostomy. Crit Care Clin1992; 8:879–895Quigley RL. Thoracentesis and chest tube drainage. Crit CareClin 1995; 11:111–126

Medical Thoracoscopy/PleuroscopyDefinition

Medical thoracoscopy/pleuroscopy is a minimallyinvasive procedure that allows access to the pleuralspace using a combination of viewing and workinginstruments. It also allows for basic diagnostic (un-diagnosed pleural fluid or pleural thickening) andtherapeutic procedures (pleurodesis) to be per-formed safely. This procedure is distinct from video-assisted thoracoscopic surgery, an invasive procedurethat uses sophisticated access platform and multipleports for separate viewing and working instrumentsto access pleural space. It requires one-lung ventila-tion for adequate creation of a working space in thehemithorax. Complete visualization of the entirehemithorax, multiple angles of attack to pleural,pulmonary (parenchymal), and mediastinal pathol-ogy with the ability to introduce multiple instru-ments into the operative field allows for both basicand advanced procedures to be performed safely.

Equipment

Sterile equipment for visualization, exposure, ma-nipulation, and biopsy is required. A high-resolutionvideo imaging system, which includes the pleuro-scope, that allows all members of the team to viewand participate in the procedure is beneficial tofacilitate maximum assistance to the dedicated oper-ator and safety for the patient. The procedure can beeither performed in the operating room or in adedicated environment for invasive procedures.

Personnel



This procedure may be performed under localanesthesia with or without conscious sedation orunder general anesthesia. Specific monitoring anddocumentation guidelines vary from hospital to hos-




pital and from state to state. We recommend that thededicated operator inquire about the applicable an-esthesia and monitoring guidelines in their particularpractice environment.

Technique

After adequate sedation is achieved, the patient ispositioned in the full lateral decubitus with thehemithorax up, padded comfortably, and secured tothe table. The site for pleuroscope entry into thepleural space is determined by surface anatomylandmarks, preoperative imaging studies, and physi-cal examination to maximize visualization of theexpected pathology. Standard sterile skin prepara-tion and draping to create an adequate field areperformed while the skin is anesthetized with localinfiltration anesthesia. After ensuring adequate seda-tion, the hemithorax is entered bluntly with a clamppassed over the rib and through the pleura (see chesttube insertion technique). With an adequate accessspace created, the pleural space immediately subja-cent to the entry site is digitally inspected to ensurean adequate pleural space (freedom from pleuraladhesions) to safely insert the pleuroscope. Thepleuroscope is inserted under direct vision into thepleural space. Once the surveillance panoramic ex-amination is completed, the specific purpose of theprocedure (eg, evacuation of pleural fluid, pleuralbiopsy, or pleurodesis) is addressed. Fluid is evacu-ated using suction catheters passed through theworking channel under direct vision. Parietal pleuralbiopsy is performed with biopsy forceps passedthrough the working channel under direct vision.Once the examination and procedure are completed,the pleuroscope is withdrawn, a chest drain is placed,and the pneumothorax is evacuated.

Indications

Indications for medical thoracoscopy/pleuroscopyinclude indeterminate pleural fluid, abnormalpleura, and need for pleurodesis.

Contraindications

Lack of a pleural space, uncorrected coagulopathy,and hemodynamic instability are contraindications tothe procedure.

Risks

Complications of medical thoracoscopy/pleuros-copy are uncommon. They include bleeding, infec-tion of the pleural space, and injury to intrathoracicorgans, atelectasis, and respiratory failure.


Physicians performing this procedure should haveample experience, excellent knowledge of pleuraland thoracic anatomy, mature judgment in interpret-ing radiographic images related to pleural disease,and sufficient surgical skill. Trainees should performat least 20 procedures in a supervised setting toestablish basic competency. To maintain compe-tency, dedicated operators should perform at least 10procedures per year.

ReferencesChen LE, Langer JC, Dillon PA, et al. Management of late-stageparapneumonic empyema. J Pediatr Surg 2002; 37:371–374Danby CA, Adebonojo SA, Moritz DM. Video-assisted talcpleurodesis for malignant pleural effusions utilizing local anes-thesia and IV sedation. Chest 1998; 113:739–742de Campos JR, Vargas FS, de Campos Werebe E, et al.Thoracoscopy talc poudrage: a 15-year experience. Chest 2001;119:801–806Loddenkemper R, Schonfeld N. Medical thoracoscopy. CurrOpin Pulm Med 1998; 4:235–238Petrakis I, Katsamouris A, Drossitis I, et al. Video-assistedthoracoscopic surgery in the diagnosis and treatment of chestdiseases. Surg Laparosc Endosc Percutan Tech 1999; 9:409–413Ronson RS, Miller JI Jr. Video-assisted thoracoscopy for pleuraldisease. Chest Surg Clin N Am 1998; 8:919–932Ross RT, Burnett CM. Talc pleurodesis: a new technique. AmSurg 2001; 67:467–468Seijo LM, Sterman DH. Interventional pulmonology. N EnglJ Med 2001; 344:740–749Wilsher ML, Veale AG. Medical thoracoscopy in the diagnosis ofunexplained pleural effusion. Respirology 1998; 3:77–80

Percutaneous Pleural BiopsyDefinition

Percutaneous pleural biopsy is a minimally inva-sive procedure performed to obtain pleural tissueusing a pleural biopsy needle. This may be per-formed untargeted for pleural effusions, or usingimage guidance for pleural masses.

Equipment

The equipment needed for percutaneous pleuralbiopsy include pleural biopsy needles and a facility toperform an aseptic procedure under local anesthetic.

Personnel

The personnel required are the dedicated opera-tor performing the pleural biopsy, and usually an RNor a physician’s assistant to monitor the patient, helpwith positioning, provide sterile supplies as needed,and process the specimen(s).


Local anesthetic is sufficient for performing apercutaneous pleural biopsy and does not differ from




that provided for a standard thoracentesis. Initialvital signs are obtained, but continuous monitoring isnot required.

Technique

In most patients, no focal pleural abnormality ispresent; in those with a focal abnormality, thatlocation should be marked using CT or ultrasound(preferably in the same position as will be used forthe biopsy). After selecting the site for biopsy, usingaseptic technique, local anesthetic is administered tothe pleural level. A small incision is made to accom-modate the biopsy needle, which is then insertedinto the pleural space at the lower side of theselected interspace (to minimize risk of intercostalneurovascular injury). The cutting edge of the needleis seated in the pleura and the biopsy taken.

Diagnostic yield is increased with multiple passes.Pleural brushings can also be obtained through thepleural needle.

Indications

Indications for percutaneous pleural biopsy in-clude undiagnosed pleural effusions and pleuralthickening or pleural masses. Diagnostic thoracente-sis should precede pleural biopsy for pleural effu-sions. The role and relative yield of diagnostic tho-racoscopy should also be considered when selectingclosed pleural biopsy.

Contraindications

An uncorrectable coagulopathy is a contraindica-tion. The risk of pneumothorax may be increased ifno free-flowing pleural fluid is present.

Risks

Complications occur in # 1% of pleural biopsies,and include pneumothorax, hemothorax, and lacera-tion of diaphragm, lung, liver, and spleen. Tumorseeding along the needle tract has rarely beenreported.


Physicians performing percutaneous pleural bi-opsy should be competent in thoracentesis, familiarwith the mechanism and technique of the biopsyneedle being used, and competent to recognize andtreat the common complications. Trainees shouldperform at least five procedures in a supervisedsetting to establish basic competency. To maintaincompetency, dedicated operators should perform atleast five procedures per year.

ReferencesAbrams LD. A pleural-biopsy punch. Lancet 1958; 1:30–31Cope C, Bernhardt H. New pleural biopsy needle: preliminarystudy. JAMA 1958; 167:1107–1108Poe RH, Israel RH, Utell MJ, et al. Sensitivity, specificity, andpredictive values of closed pleural biopsy. Arch Intern Med 1984;144:325–328Prakash UB, Reiman HM. Comparison of needle biopsy withcytologic analysis for the evaluation of pleural effusion: analysis of414 cases. Mayo Clin Proc 1985; 60:158–164Screaton NJ, Flower CD. Percutaneous needle biopsy of thepleura. Radiol Clin North Am 2000; 38:293–301

Percutaneous Dilatational TracheostomyDefinition

Percutaneous dilatational tracheostomy (PDT) isan invasive procedure in which the placement of atracheostomy tube is achieved after establishing atracheal stoma through dilation, rather than surgicalcreation of a stoma.

Equipment

The procedure may be performed in the operatingroom or at the bedside. Dedicated procedure kitsincluding needles, guidewire, and dilators are avail-able. Easy access to bronchoscopy and airway man-agement equipment is necessary.

Personnel

Two dedicated operators need to be present forthis procedure; one dedicated operator performs theprocedure, and the other manages the airway andendotracheal tube. This second dedicated operatorshould be prepared to perform bronchoscopy ifnecessary. Additional personnel required for thisprocedure include a nurse with the ability to admin-ister and monitor conscious sedation.


The procedure may be performed under localanesthesia, conscious sedation, or general anesthesia.Specific monitoring and documentation guidelinesvary from hospital to hospital and from state to state.We recommend that the dedicated operator inquireabout the applicable anesthesia and monitoringguidelines in their particular practice environment.

Technique

Several techniques with slight variations from oneanother are described herein. Generally, the patient




is in supine position with the neck slightly extended.Ventilation should be controlled and the fraction ofinspired oxygen changed to 1.0. Landmarks such asthe tracheal cartilages are identified, and the area isthen prepared and draped. A 1.0- to 1.5-cm super-ficial incision is made over the intended entry site,which usually is below the first and above the thirdtracheal ring. Depending on the neck anatomy,higher or lower entry points may need to be chosen.The endotracheal tube may be pulled back at thistime, but the cuff should stay below the vocal cords.Alternatively, the endotracheal tube may stay inplace during the procedure. A needle is introducedinto the chosen interspace in the midline and aguidewire inserted. Once the needle is removed, thespace is sequentially dilated to a size appropriate forthe desired tracheostomy tube. The tracheostomytube is then placed over the guidewire on an obtu-rator. Once placement is confirmed, the endotra-cheal tube is removed. Bronchoscopic guidance maybe beneficial for the novice and in complicated cases,and therefore should be readily available. It is notrequired for routine use.

Indications

Indications for PDT do not differ from acceptedindications for placement of a surgical tracheostomy.The main indications are a need for a long-termartificial airway for prolonged ventilator dependenceor management of secretions.

Contraindications

Absolute contraindications are uncontrollablecoagulopathy, infection over the site, extreme ven-tilatory and oxygenation demands, and trachealobstruction. Relative contraindications pertain tounfavorable neck anatomy and emergency airwaymanagement.

Risks

The complication rate is low. Airway injury, respi-ratory depression, pneumothorax, bleeding, cardio-respiratory arrest, arrhythmia, infection, and deathare potential complications. Several studies haveshown comparable outcomes between conventionaland dilatational tracheostomy. An advantage of PDTseems to be a lesser incidence of bleeding andinfection. If performed as a bedside procedure, therisk of patient transportation and operating roomcosts are foregone.


Dedicated operators need to be experienced inemergent airway management before performing

PDT. Trainees should perform at least 20 proce-dures in a supervised setting to establish basiccompetency. To maintain competency, dedicatedoperators should perform at least 10 procedures peryear. Surgeons competent in conventional tracheos-tomy still need to acquire the necessary exper-tise with this procedure, but the required numberof procedures could be less for such dedicatedoperators.

ReferencesCiaglia P, Firsching R, Syniec C. Elective percutaneous dilata-tional tracheostomy: a new simple bedside procedure; prelimi-nary report. Chest 1985; 87:715–719Ernst A, Garland R, Zibrak J. Percutaneous tracheostomy.J Bronchol 1998; 5:247–250Freeman BD, Isabella K, Lin N, et al. A meta-analysis ofprospective trials comparing percutaneous and surgical tracheos-tomy in critically ill patients. Chest 2000; 118:1412–1418Hazard P, Jones C, Benitone J. Comparative clinical trial ofstandard operative with percutaneous tracheotomy. Crit CareMed 1991; 19:1018–1023

Transtracheal Oxygen TherapyDefinition

Transtracheal oxygen therapy (TTOT) is a mini-mally invasive procedure that is achieved throughpercutaneously placed devices that allow for long-term oxygen use. This procedure only deals withmethods not employing surgically created stomas,and is usually a multistep procedure.

Equipment

The procedure is usually performed on an outpa-tient basis. Dedicated procedure kits including nee-dles, guidewire, dilators, stents, and oxygen deliverycatheters are available.

Personnel

A dedicated operator performs the procedure.Personnel required for this procedure include an RNor a respiratory therapist to administer and monitorconscious sedation if required, as well as a separateRN or a respiratory therapist to assist the dedicatedoperator. All supporting personnel should be familiarwith the procedure being performed. This will max-imize patient comfort and safety. As the long-termsuccess of a TTOT procedure depends on carefulteaching and follow-up and instructions on self-care,it is highly recommended to have a process in placededicated to providing adequate patient educationon the care of the device.






Technique

Before establishing TTOT, patients and theircaregivers need to undergo appropriate teachingand preparation and demonstrate motivation toreturn for multiple postprocedure visits. The firststep for the procedure is placement of the percu-taneous stent. A small, 1.0- to 1.5-cm verticalincision is made over the insertion site and aguidewire introduced via Seldinger technique.The opening is then dilated and a stent is placed.After 1 week of tract maturation, the stent isremoved and the oxygen delivery catheter placed.Until the tract is completely mature, all exchangeshave to occur over the wire. Regular frequentfollow-up is needed for several weeks postproce-dure to allow for patient teaching and early rec-ognition of complications.

Indications

Long-term oxygen has been shown to be beneficialin a variety of disorders. TTOT provides an addi-tional means of delivering oxygen. Advantages arelonger life of oxygen sources and cosmetic issues.Additionally, there is some evidence that patientsexperience improvement of dyspnea and exercisetolerance. TTOT can be considered for any patientreceiving long-term oxygen. It is a good option in thepatient intolerant of nasal cannula oxygen delivery,refractory hypoxemia, and limited mobility due tohigh oxygen demands.

Contraindications

Contraindications are uncorrectable coagulopathy,terminal illnesses, lack of motivation or support,inability to return for follow-up, pleural herniationover the trachea, and upper airway obstruction.

Risks

Complications of TTOT placement are very un-common and include mucous ball formation, pneu-

mothorax, and subcutaneous emphysema. Mortalityis exceedingly low, and the most common morbidityis catheter-induced coughing.


Trainees should perform at least 10 proceduresin a supervised setting to establish basic compe-tency. To maintain competency, dedicated opera-tors should perform at least five procedures peryear.

ReferencesChristopher KL, Spofford BT, Petrun MD, et al. A program fortranstracheal oxygen delivery: assessment of safety and efficacy.Ann Intern Med 1987; 107:802–808Couser JL, Make BJ. Transtracheal oxygen decreases inspiredminute ventilation. Am Rev Respir Dis 1989; 139:627–631Kampelmacher MJ, Deenstra M, van Kasteren RG, et al. Tran-stracheal oxygen therapy: an effective and safe alternative to nasaloxygen administration. Eur Respir J 1997; 10:828–833Wesmiller SW, Hoffman LA, Sciurba FC, et al. Exercise toler-ance during nasal cannula and transtracheal oxygen delivery. AmRev Respir Dis 1990; 141:789–791

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The material in this article is furnished for generalinformational purposes and does not constitute thepractice of medicine, nor should it be relied on fordealing with a specific medical or health condition.You should consult a qualified care professional foradvice about a specific condition. The ACCP dis-claims any liability to any party for the accuracy,completeness, or availability of the Guidelines, or forany damages arising out of the use or nonuse of thematerial and any information contained therein.

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following the posting of any such modifications shallbe subject to such modified disclaimer.

Appendix 1

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 Committeeof the IDCP Network, including Atul Mehta, MD, PulmonaryMedicine, Cleveland, OH; John Howington, MD, Thoracic Sur-gery, Cincinnati, OH; Heinrich Becker, MD, Pulmonary Medi-cine, Heidelberg, Germany; Gerard Silvestri, MD, PulmonaryMedicine, 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, Rich-mond, VA. Invited reviewers were Paul Kvale, MD, Pulmo-nary Medicine, Detroit, MI; Carolyn Reed, MD, ThoracicSurgery, Charleston, SC; Kevin Kovitz, MD, Pulmonary Med-icine, New Orleans, LA; and Richard Irwin, MD, PulmonaryMedicine, Worcester, MA.

Appendix 2: Bronchoscopes Used in Pediatric Patients

Scope DesignationOuter Diameter,

mmWorking Length,

cmSuction Channel,

mm

SmallestEndotrachealTube Size*

Olympus pediatric fiberoptic andvideo bronchoscopes†

BF-N20 2.2 55 None 3.0BF-XP40 2.8 60 1.2 3.5BF-3C40 3.6 60 1.2 4.5BF-3C160 (video) 3.8 60 1.2 5.0

Pentax pediatric fiberoptic bronchoscope‡FB-7P 2.4 60 None 3.0–3.5FB-10V 3.4 60 1.2 4.5

*Tube sizes are the smallest possible with each instrument. Utilizing these bronchoscopes with these sizes often leads to limited ability to ventilate,and the distinct possibility of the scope meeting significant frictional resistance as it is passed through the tube. It will always be safer andpreferable to use 0.5 size larger than those listed or a laryngeal mask of larger caliber, especially in patients with significant intrinsic lung disease.

†Olympus; Tokyo, Japan.‡Pentax; Asahi Optical; Tokyo, Japan.




DOI 10.1378/chest.123.5.1693 2003;123;1693-1717 Chest

Armin Ernst, Gerard A. Silvestri and David Johnstone College of Chest Physicians

Interventional Pulmonary Procedures: Guidelines from the American

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