Aims of rehabilitation \200 \200 \200 To reduce disability and handicap in people with chronic lung disease To improve quality of life and restore independence To diminish the health care burden of disease. Early studies measured pulmonary function tests and found there was no improvement after pu lmonary rehabilitation. The \201 rst positive study of pulmonary rehabilitation measured functional status. Meta-analysis of 14 RCTs using a variety of different style programs has con \201 rmed the bene \201 t of rehabilitation, with improvements in functional exercis e. \200 Further UK RCT of patients with severe air \202 ow obstruction showed improvements in exer cise, health status, and health economic advantages Patients who had completed rehabilitati on courses had no fewer hospital admissions for exacerbations than those who had not had re habilitation, but hospital stays were shorter (10 days vs. 21 days) Patients with COPD who have completed rehabilitation courses perform better than controls on walking tests and hav e less subjective dyspnoea Rehabilitation programs containing lower-extremity training are better, when compared with controls, than those using just respiratory muscle training Shor t-term programs achieve overall similar outcome bene \201 ts across the spectrum of patien t disability. A minimum program length of 6 weeks is recommended Decline in exercise tolera nce and health status tends to occur between 6 and 12 months after completion of a course. Sustained improvement with ongoing rehabilitation sessions has yet to be evaluated. Candidates \200 \200 Anyone with chronic lung disease causing functional impairment The majority of candidates w ill have COPD, but also asthma, pulmonary \201 brosis, and bronchiectasis Any stage of a lung disease, when symptoms are affecting a patient \200\231s activity. Ideally receiving o ptimum medical treatment Well-motivated patients seem to bene \201 t most Patients with po or lower limb mobility may bene \201 t from upper limb exercise Oxygen therapy is not a co ntraindication to rehabilitation Stable ischaemic heart disease is not a contraindication t o rehabilitation. \200 \200 Candidates in whom rehabilitation may not be indicated \200 Unstable ischaemic heart disease, severe valvular heart disease, cognitive impairment, loco motor dif \201 culties Poorly motivated people with geographical or transportation problem s making attendance dif \201 cult tend to do less well. This page intentionally left blank CHAPTER 60 Pulmonary rehabilitation 726 Program Programs are usually run on an out-patient basis, but can be done in the community, in the home, or as an in-patient. They are run by a multi- professional team \200\224physi cian, physiotherapist, occupational therapist, dietician, nurse, pharmacist, social worker, and psychologist. A minimum program length of 6 weeks is recommended. Programs should be r egularly audited by the department. \200 Physical training The main component of the program, with aerobic exercise such as walking and cycling 2 \200\2233 times per week, with 2 super- vised/class sessions. May include upp er limb strength exercise with weights. Individually prescribed exercise programs, designed for each patient to work to high intensity. Bene \201 t increases with training intensity . Oxygen supplementation may be required if signi \201 cant desat- uration occurs during e xercise to below 80% Disease education Psychological and social intervention with advice on anxiety and depression, smoking cessation, plus physiotherapy and occupational therapy inp ut Nutritional education to optimize body weight and muscle mass. \200 Pre-rehabilitation assessment \200 \200 \200 Optimize medical treatment Oxygen saturation on exercise ECG may be warranted, especially i f history of cardiac disease. Outcome assessment measures \200 Physical Often with shuttle walk tests (SWT) or 6-min walk test (6MWT) to assess ability an d progress (see box opposite) Health status Disease-speci \201 c questionnaires: \200 Ch ronic Respiratory Questionnaire (CRQ) \200 St George \200\231s Respiratory Questionnaire \200 Generic questionnaires \200 Short Form-36 (SF-36) \200 Hospital Anxiety and Depr ession scores (HADS) are measured, but are insensitive to change during pulmonary rehabilit ation Practical Pulmonary Function Status \200\223Dyspnoea Questionnaire (PFS-DQ) may be us ed to measure performance and satisfaction relating to activities of daily living. program 727 Shuttle walk test (SWT) 10-m course between two points. Walking speed determined by external audio-tape signals ( \200\230beeps \200\231), and the patient should pace their walk to reach each point at a be ep. The patient is required to incrementally increase their speed as the beeps occur more f requently. Test \201 nishes when the patient needs to stop and distance achieved calculat ed. 6-min walk test (6MWT) 30-m course between two points on a hard \202 at surface. Patients do as many 60-m laps as they can around the 2 points in 6 min. They deter- mine their pace and intensity of exercise. They are allowed to rest in the time if they need to. Total dis tance walked in 6 min is counted. Results vary according to mood and encouragement. Future developments \200 Determining which components of rehabilitation are the most valuable to improvements in exe rcise: intensity of exercise program, type of exercise How to optimally maintain the improv ements following a rehabilitation program Performance enhancement using oxygen, steroids, n utrition, creatine, heliox, non-invasive ventilation. Further information Nici L et al. ATS/ERS statement on pulmonary rehabilitation. Am J Respi r Crit Care Med 2006; 173: 1390 \200\223413 Troosters T et al. Pulmonary rehabilitation in COPD. Am J Respir Crit Care Med 2005; 172: 19 \200\22338 Lacasse Y, et al. Pulmonary rehabi litation for COPD (Cochrane Review). CD003793 Salman et al. Rehabilitation for patients with COPD: meta-analysis of RCTs. J Gen Int Med 2 003; 18(3): 213 \200\22321 BTS Statement on Pulmonary Rehabilitation. Thorax 2001; 56: 827 \200\22334 Grif \201 ths TL et al. Results at one year of outpatient multidisciplinary pul monary rehabilitation: a randomized controlled trial. Lancet 2000; 355: 362 \200\22368 Laca sse Y et al. Meta-analysis of pulmonary rehabilitation in COPD. Lancet 1996; 348: 1115 \200 \22319 This page intentionally left blank 729 Chapter 61 Smoking cessation Aims and nicotine replacement therapy 730 Non-nicotine replacement therapy 732 CHAPTER 61 Smoking cessation 730 Aims and nicotine replacement therapy Smoking is the main cause of chronic obstructive pulm onary disease and lung cancer. The NHS spends 1.7 billion per year caring for people with smoking-related conditions. Government targets have been set to reduce the number of smoke rs in the UK and health authorities have been allo- cated funding for smoking cessation ser vices. \200 Approximately 31% of men and 29% of women in the UK smoke and 82% of smokers start as teena gers The incidence of smoking is increasing in developing countries Smoking is also associa ted with bladder, oesophageal, cervical, and renal cancers, as well as cardiovascular and c erebrovascular disease Nicotine exerts its effects on the CNS and is very addictive Peak ni cotine withdrawal time is 2 \200\2233 days 0.4% of smokers manage to stop each year Stoppin g smoking is associated with an average weight gain of 2 kg Government legislation in the U K banned smoking in the workplace and public places from 1st July 2007 and increased the ag e for sale of tobacco from 16 to 18 on 1st October 2007. \200 \200 \200 \200 \200 Aims of smoking cessation interventions In order to achieve the goal of sustained abstinenc e, the aim is to reduce short-term cravings for nicotine (nicotine and non-nicotine replace ment therapy) and in the long term to modify behavior (counseling, telephone or group suppo rt (buddy systems)). It is vital that the smoker is motivated to stop or attempts will fail . It is important as a health professional to address smoking cessation at all opportunitie s. Health professionals can trigger quit attempts by giving brief advice to all smokers. Th is can lead to 1 \200\2233 out of 100 people stop- ping smoking for 6 months. Doctor advice often has the strongest impact. People may be more receptive to smoking cessation advice d uring times of concern for their own or their families health. A guide to approaching the t opic is: \200 \200 \200 \200 \200 Ask how much a person smokes and document pack-years Advise on risks of continued smoking. Assess commitment to quitting Assist by offering behavioral therapy pharmacotherapy Prov ide self-help material and refer to stop smoking services Arrange follow-up. Some hospitals or primary care trusts have smoking cessation counselors. The best results i n terms of quit rates are achieved by combining counsel- ling with nicotine replacement the rapy (NRT), bupropion, or varenicline, with regular support and follow-up. These can improv e quit rates to around 25%. The National Institute of Health and Clinical Excellence has is sued guidance on the use of nicotine replacement therapy, bupropion, and varenicline for sm oking cessation. This advises pharmacotherapy should only be for a smoker committed to a ta rget stop date. Choice of therapy is based on a patient \200\231s likely compliance, availa bility of counseling, previous experience of therapies, contraindications, and patient pref erence. Prescribe 2 weeks of NRT or 3 \200\2234 weeks of bupropion/varenicline and only giv e further prescription if individuals show a continuing attempt to quit. If they fail to qu it, a second attempt within 6 months should not be funded. AIMS AND NICOTINE REPLACEMENT THERAPY 731 Nicotine replacement therapy (NRT) allows short- and medium- term nicotine withdrawal sympt oms to be minimized, by replacing nico- tine. Should not be used whilst still smoking, as i t is possible to overdose on nicotine (symptoms: agitation, confusion, restlessness, palpit ations, hypertension, dilated pupils, SOB, abdominal cramps, vomiting). Can be bought over the counter or be prescribed by general practitioner, and is cheaper than cigarettes. Most NRT products are contraindicated in preg- nancy, breast-feeding mothers, and children under 18, but are used under supervision. \200 Patches Give small amounts of nicotine via transdermal patch to decrease cravings before th ey occur. Different strength patches (15, 10, 5 mg) according to how much is smoked. Use hi gher dose patch if 10+ cigarettes per day smoked. Convenient. Worn continuously throughout day, but removed at night due to vivid nature of dreams. Can get localized irritation at pa tch site. Patches should be used for 6 \200\2238 weeks at the higher dose, then weaned to a lower dose for 2 \200\2234 weeks. Available to buy over the counter Chewing gum Different strengths of gum that release nicotine as they are chewed. (Smoke <20/day - chew one 2-mg p iece slowly for 30 min when urge to smoke occurs. Smoke >20/day or needing >15 pieces of 2- mg gum daily \200\224use 4-mg strength gum. Max 15 4-mg pieces/day). Relieves cravings as t hey occur. When mouth tingles and has peppery taste, should stop chewing and \200\230park \200\231 the gum inside the cheek. Nicotine is then absorbed through the lining of the mout h. Should not chew continuously or may become nauseated. Nicotine needs to be absorbed thro ugh mouth and not swallowed in saliva. Therefore don \200\231t drink with gum. Physical act of chewing can relieve craving. Can taste unpleasant and may need to use several packs of gum a day. Use for 3 months, then reduce the strength and the amount of gum used. Available to buy over the counter Sublingual tablets used on demand to help with cravings. Useful fo r smokers wanting a discreet form of treatment. 1 \200\2232 tablets should be placed under the tongue every hour when needed. Dissolve over 30 min. Licensed for use in pregnancy (1 t ablet only). Use for 3 months and then gradually reduce the number of tablets used a day. A vailable on prescription Lozenges Available to buy over the counter Inhalator Cigarette sty le appliance giving small amounts of nicotine when used. Useful for people who are habitual or ritualistic in when they have a cigarette and want the \200\230hand to mouth \200\231 routine. Nicotine is absorbed through the lining of the mouth, not via the lungs. Use for 2 months, and then gradually reduce. Available on prescription Nasal spray provides rapid re lief of craving. Faster absorption than other forms of NRT. May cause local irritation. Use for 2 months; then reduce. Available on prescription. \200 CHAPTER 61 Smoking cessation 732 Non-nicotine replacement therapy Drugs Bupropion (Zyban ) is promoted as an aid to smoking cessation in combi- nation with motiva tional support. It is an antidepressant that was found to reduce the desire to smoke, regar dless of whether people were depressed or not. It weakly inhibits dopamine, serotonin, and noradrenaline reuptake in the CNS. It counteracts nicotine withdrawal symptoms by increasin g these levels in the brain. It is suitable if people smoke 10 or more cigarettes a day. Li ver metabolism and 20 h half-life. Smokers start taking bupropion 1 \200\2232 weeks before their intended \200\230quit day \200\231. Continue taking it for 7 \200\2239 weeks after. Leads to improved abstinence rates compared with placebo or nicotine patch if associated wi th counseling (30% 12-month absti- nence rate with bupropion, 16% with nicotine patch, 15% with placebo, 35% with patch and bupropion). (NEJM 1999; 340: 685 \200\22391) Also thought to lessen weight gain associated with stopping smoking. Contraindicated in patients with ep ilepsy or at risk of \201 ts, those with a CNS tumor, those acutely withdrawing from alco hol or benzodiazepines, pregnancy, those with eating disorders and those on monoamine oxida se inhibitors. Reduce dose if elderly or hepatic or renal impairment. Recognized adverse ef fects include dry mouth, hypersensitivity, insomnia, seizures (1 in 1000 users) and death. Prescription only. Varenicline (Champix /Chantix ) is a new drug, also promoted as an aid to smoking cessation in combination with motivational support. It binds to the A4B2-nicoti nic acetylcholine receptor and acts as a partial agonist. Its binding alleviates symptoms o f craving and withdrawal, and reduces the rewarding and reinforcing effects of smoking by p reventing nicotine binding to the A4B2 receptors. Smokers start taking varenicline 1 \200 \2232 weeks before their intended \200\230quit day \200\231 and continue for 12 \200\22324 weeks. Starting dose is 500 g od for 3 days, 500 g bd for 4 days, then 1 mg bd for 11 weeks, if tolerated. If smokers are abstinent after 12 weeks, they should continue for anot her 12 weeks to avoid relapse. Avoid abrupt withdrawal. Side-effects include nausea, vomiti ng, appetite change, change in taste, headache, dif \201 culty sleeping, abnormal dreams, dry mouth, tiredness. Use with caution if breast feeding, history of psychiatric disease, r enal impair- ment. RCTs have shown signi \201 cantly higher quit rates with varenicline th an with bupropion or placebo. Quit rates are higher with higher doses (e.g. continuous quit rate for any 4 weeks: 48% with 1 mg bd (p = 0.01 vs. placebo), 37% with 1 mg od (p = 0.01) , 33% with bupropion (p = 0.02, 17% with placebo), Drug-side effects leading to stopping tr eatment were lower than with bupropion (Arch Int Med 2006; 166: 1561 \200\2238). Prescripti on only. Hypnosis aims to improve will power in the subconscious state with therapeutic sug gestion. Anecdotal success, but Cochrane review of trials showed no greater abstinence rate with hypnosis than with any other treatment or placebo treatment. Acupuncture/acupressure No evidence in favor of it over placebo acupuncture. NON-NICOTINE REPLACEMENT THERAPY 733 Future developments \200 Increasing and improving hospital-based smoking cessation services with links to community- based services Nicotine immunotherapy. Laboratory-based models to create a \200\230nico- t ine vaccine \200\231 to try and prevent abstinent smokers from re-starting are in progress. Induce speci \201 c nicotine antibodies to prevent inhaled nicotine from binding to nicot ine receptors and causing neurological stimulation. Further information BTS powerpoint \200\230toolkit \200\231 for smoking cessation www.brit -thoracic.org.uk/cessationcompetencies Brief interventions and referral for smoking cessation in primary care and other settings. March 2006. www.nice.org.uk ABC of smoking cessation series. BMJ Feb-April 2004 Riemsma RP et al. Systematic review of the effectiveness of stage based interventions to pr omote smoking cessation. BMJ 2003; 326: 1175 West R et al. Smoking cessation guidelines for health professionals. Thorax 2000; 55: 987 \200\22399 www.doh.gov.uk/tobacco www.nosmokingday.org.uk Quitline 0800 002200 This page intentionally left blank 735 Chapter 62 Tracheostomy CHAPTER 62 Tracheostomy 736 Temporary tracheostomy is most often performed as an adjunct to assisted ventilation. Such patients are now often returned to respiratory wards for \200\230decannulation \200\231. I ndications for tracheostomy on the ICU (no uniform agreement) \200 Usually performed after a period of time following intubation with an endotracheal tube Imp roved patient communication (with appropriate cuff de \202 ation and/ or tube fenestration ) Possible reduction in laryngeal damage. The evidence for this is very limited Nursing car e potentially easier Facilitation of weaning. \200 (There is no evidence for a reduced incidence of aspiration or pneumonia with tracheostomy versus endotracheal tube.) The usual practice is to convert from endotracheal tube to trache- ostomy at 7 days if vent ilation is likely to be needed beyond 14 days. Conversion beyond 14 days is considered best practice and certainly by 21 days. Percutaneous versus surgical tracheostomy Percutane ous trache- ostomy (PT) can be performed on the ICU immediately once the deci- sion is made an d is quicker than conventional tracheostomy. There are a variety of PT techniques: Griggs \200\231 guidewire with dilating forceps, and the Ciaglia multiple or single (Blue Rhino) d ilator approach, preferably with endoscopic veri \201 cation of placement. In the Blue Rhi no system a curved, cone-shaped dilator is slid over a guidewire and introduced into the tr acheal lumen between the 2nd and 3rd tracheal rings until the hole is large enough to accep t the required tracheostomy tube. This technique requires controlled force and there is sig ni \201 cant potential for traumatic damage. The \201 t of the tracheostomy tube is tigh ter, with less stomal infec- tion, less post-operative hemorrhage, but the long-term compli cations of the two techniques are similar. However, units with prompt access to surgical tr acheostomy tend to use this whenever possible, due to the potential traumatic damage from t he PT approach. Humidi \201 cation of the inspired gas is always required to prevent the b uild-up of thick viscid mucus. Humidi \201 cation can only be withdrawn in long-term trach eostomy patients after several weeks or months. Decannulation Tracheostomy may still be req uired to administer inter- mittent ventilation, reduce ventilatory deadspace, aid respirato ry secre- tion clearance, limit aspiration (when cuffed), and bypass any upper airway obstr uction. This is weighed against the consequences of a tracheostomy: increased tendency to a spirate (because of a reduced ability to swallow), reduced ability to talk, and the increas ed infection brought about from a foreign body in the trachea and bypassing the upper airwa y. Thus, decan- nulation should be carried out as soon as: \200 \200 Adequate clearance of secretions, i.e. good cough and thin secretions No upper airway obstr uction TRACHEOSTOMY 737 No signi \201 cant aspiration (can be checked by drinking methylene blue and then suctioni ng), although a small amount is not an absolute contraindication No need to continue ventil ation for maintenance of gas exchange Conversion to non-invasive ventilation is possible, a nd has been dem- onstrated to work adequately. \200 The ability to cope adequately without the tracheostomy can be repeat- edly determined (and for increasing periods) by capping the tube with the cuff fully de \202 ated and preferab ly with a fenestrated tube. Once a tube has been removed, the stoma can close over very quickly and make reinsertion di f \201 cult. Introducing a \200\230guidewire \200\231, over which the old tube is removed and the new can be inserted, is often useful (a suction tube, with the connector cut off, will suf \201 ce). The \201 nal decision to decannulate is often delayed unnecessarily. Sooner rather than later is usually better. Available tube options Tracheostomy tubes can be cuffe d or uncuffed. If ventilation is not necessary, and aspiration is not a problem, cuffs are not required. Some patients can be adequately ventilated even with the cuff down (or no cuf f at all): this is usually in patients with normal lungs where the compliance is good and i n \202 ation pressures therefore low. Tracheostomy tubes can be either single or double (i.e. with an inner and outer tube). Doub le tubes allow better cleaning and therefore reduce the chance of the lumen obstructing, bu t the diameter of the lumen is of course less for a similar sized external diameter. Tracheostomy tubes can be fenestrated to allow exhalation via the larynx to aid talking. Th e fenestration can be closed off with a non-fenestrated inner tube, should intermittent ven tilation still be required. Speaking valves are available that \201 t on the tracheostomy, allowing inspiration via t he tracheostomy, but close and allow expiration via the larynx (if cuff down and/or fenestr ation open). They effectively maintain a reduced deadspace, maintain access for suctioning, but allow talking. Further information Commercial video of Blue Rhino insertion, http://www.cookmedical.com/cc /educationMedia. do?mediaId=1558 This page intentionally left blank Part 00 Part 4 Practical procedures 63 Airway management 64 Bronchoscopy 65 Chest drains 66 Cricothyroidotomy 67 Miscellaneous diagnostic tests 68 Pleural biopsy 69 Pleurodesis 70 Pneumothorax aspiration 71 Thoracentes is 72 Thoracoscopy (medical) 741 745 757 763 767 771 775 779 781 785 This page intentionally left blank 741 Chapter 63 Airway management Simple airway 742 CHAPTER 63 Airway management 742 Simple airway 3 Call for anesthetic help early Patients may require support of their airway and ventilation/oxygena- tion in situations when they are unable to adequately maintain th ese. Such situations may be related to a Glasgow Coma Score of <8, which can cause dif \201 culties with airway maintenance, or related to respiratory compromise or arrest in the critically ill patient. Simple airway adjuncts are used to overcome backward tongue dis- placement in an unconsciou s patient. Oropharyngeal airway (Guedel) A curved plastic tube with a \202 anged end that is inserted into the mouth. Size is estimated by holding it at the side of the patient \200\231s face and estimating required length from angle of the mouth to angle of the jaw. Ensure the mouth is clear, then insert the airway \200\230upside down \200\231, with the c urved side towards the tongue. When it is in as far as the soft palate, turn it around by 1 80 and push it in further, so the \202 ange is at the patient \200\231s mouth. If the p atient has a gag re \202 ex, remove the airway. Suction can be performed through the airwa y and oxygen administered via a mask. Nasopharyngeal airway A soft plastic tube with a beve led end and a \202 ange at the other end. Better tolerated in the semi-conscious, and sho uld not be used in those with base of skull fractures. Sizes 6 \200\2237mm are suitable for adults. If necessary, insert a safety pin through the \202 ange. Lubricate it with water -soluble jelly and insert the beveled end into a nostril and gently push back with a twisti ng action. Do not force if obstruction is encountered, but remove and try in the other nost ril. Nasal bleeding can be caused if the mucosa is damaged. The safety pin ensures the airw ay is not dislodged into lung. Oxygen can be administered through a mask. Intubation Endotr acheal tube The optimal method of managing a patient \200\231s airway and providing airway protection from aspiration of gastric contents. Requires training in tube insertion. The tu be is beveled at one end with an in \202 at- able cuff and has a connector at the other en d. The connector can be removed if the tube needs to be cut, but can be replaced. - Patient lies \202 at, with neck \202 exed and head extended (the \200\230snif \201 ng the mo rning air \200\231 position). A pillow is placed under the head, not the neck, to aid this Pre-oxygenate with bag and mask ventilation - Using the laryngoscope in left hand and stand ing behind the head, the mouth is opened, and the laryngoscope placed over the right side o f the tongue and advanced It may be necessary to apply suction to clear the mouth of secretions - When the epiglottis is seen, the laryngoscope is advanced into the val- lecula, between the root of the epiglo ttis and the base of the tongue Upward pressure in the direction of the laryngoscope handle is applied to lift the jaw slightly and the cords should come into view, taking care not t o damage the teeth Slide the tube through the cords and then withdraw the laryngoscope - In \202 ate the cuff AIRWAY MANAGEMENT 743 Con \201 rm adequate tube position by auscultating for breath sounds over the chest bilaterally End tidal CO2 measurement should be used if available; 5 breaths showing CO2 con \201 rm an adequate tube position If the tube is not in position, usually because it has been passed into the esophagus or th e right main bronchus, de \202 ate the cuff, remove the tube, and re-oxygenate with the ba g and mask, before trying again. Pull the tube back slightly if the breath sounds are only on the right as this suggests the tube is in the right main bronchus Secure the tube - Administer oxygen with a self-in \202 ating bag with oxygen and reservoi r bag CXR to con \201 rm correct tube position 2 \200\2233 cm above the carina - Suction can be performed through the tube Laryngeal mask airway An alternative to formal intubation. A wid e-bore tube with an in \202 ated cuff at one end, which is positioned over the larynx and in \202 ated, hence forming a seal; thus aspiration of gastric contents and gastric in \202 ation are minimized. It is easy to insert, and is used in anesthetic practice and also used in emergencies. Requires minimal head tilt, so is ideal for use in patients with poss ible cervical spine injuries. Not suitable for patients with high airway resistance, such a s pulmonary oedema, bronchospasm, or COPD. Select a size 4 or 5 tube and, after ensuring th e cuff works, de \202 ate it. Put water- soluble lubricating jelly over the cuff. The pati ent should be lying \202 at, with head extension if possible. Hold the tube like a pen an d insert from behind the patient \200\231s head, with the point of the cuff positioned to t he back of the mouth. Advance along the roof of the mouth and then press it downwards and b ackwards until resistance is felt. In \202 ate the cuff, which will cause the tube to lift out of the mouth a little. Con \201 rm adequate airway position by auscultating for breat h sounds over the chest bilaterally. Secure the tube. Larynx Trachea Esophagus Fig. 63.1 Diagram of laryngeal mask insertion. This page intentionally left blank 745 Chapter 64 Bronchoscopy Indications and risks 746 Patient preparation and procedure 748 Sampling techniques 750 Cen tral airway obstruction 752 Interventional bronchoscopy 754 CHAPTER 64 Bronchoscopy 746 Indications and risks Bronchoscopy is the procedure of passing a telescope or camera into t he trachea to inspect the large and medium-sized airways. It may be per- formed with a \202 exible scope using local anesthetic sedation, favored by physicians, or under a gen eral anesthetic with a rigid scope, used mostly by surgeons. Airways can be visually inspec ted, samples taken, and therapeutic procedures can be performed. This chapter focuses on \202 ex- ible bronchoscopy. Indications for bronchoscopy \200 Suspected lung cancer Patients who have a central mass <4 cm from the origin of the nearest lobar bronchus, which is likely to be accessible for biopsy at bronchoscopy Suspected pulm onary infection such as TB in a patient who is unable to produce sputum, or in immunocompro mised patients, with fever, cough, hypoxia, or CXR changes (induced sputum with hypertonic saline may be an alternative; see p 769) Suspected interstitial lung disease if a transbron chial biopsy will provide an adequate sample for diagnostic purposes, such as in sarcoid. O nly indicated in a limited number of interstitial lung diseases, as more adequate biopsies are often obtained through open lung biopsy, which may be preferable Foreign body removal i f this is located proximally Therapeutic indications include central airway obstruction, sp utum plugging, and possibly emphysema (endobronchial lung volume reduc- tion, see p 180) an d asthma (bronchial thermoplasty, see p 137). \200 Relative contraindications/take care \200 If a patient has saturations below 90% on air at rest, or PaO2 less than 8 kPa, the risk of signi \201 cant hypoxia during bronchoscopy is increased FEV1 <40% predicted Blood clotti ng abnormalities, particularly platelet level <50 000/mm3 Uraemia, pulmonary hypertension, SVCO, liver disease, and immuno- suppression predispose to hemorrhage Recent myocardial inf arction may be associated with cardiac ischaemia during bronchoscopy. Wait until 4 \200\223 6 weeks after. \200 \200 Risks associated with bronchoscopy Flexible bronchoscopy is a safe procedure, with reported mortality rates in large series being 0.01 \200\2230.04% and major complications of 0.08 \200\2230.12%. Complications include respiratory depression, pneumonia, pneumothorax, airwa y obstruction, laryngospasm, cardiorespiratory arrest, arrhythmias, pulmonary oedema, vasov agal epi- sodes, fever (especially following BAL), septicaemia, hemorrhage, nausea, and vom iting. INDICATIONS AND RISKS 747 Bleeding and bronchoscopy \200 Bleeding occurs in approximately 0.7% of patients due to mechanical trauma from the scope, suctioning, brushing, or biopsy, but is more common with transbronchial biopsy (1.6 \200 \2234.4%). Patients with malig- nancy, immunocompromise, or uraemia have an increased bleed ing tendency If bleeding does not stop spontaneously, the bronchoscope should be wedged to tamponade the bleeding in the segmental bronchus. Use minimal suction, to allow clot format ion. 1 mL aliquots of 1:10 000 adrenaline solution are administered via the bronchoscope as near to the bleeding point as possible, until it stops. Iced saline may be useful If massi ve hemorrhage occurs, the patient should be turned on to the side of the bleeding to protec t the other lung. Balloon tipped vascular catheter may be used to tamponade the bleeding po int. If bleeding con- tinues, emergency or thoracic surgery may be indicated. Further information Lee P et al. Therapeutic bronchoscopy in lung cancer. Clin Chest Med 20 02; 23: 241 \200\22356 BTS Bronchoscopy guidelines. Thorax 2001; 56(suppl. 1) Bungay HK et al. An evaluation of CT as an aid to diagnosing patients undergoing bronchosco py for suspected bronchial carcinoma. Clin Radiol 2000; 55(7): 554 \200\22360 Laroche C et al. Role of CT scanning of the thorax prior to bronchoscopy in the investigati on of suspected lung cancer. Thorax 2000; 55(5): 359 \200\22363 Ernst A et al. Effect of routine clopidogrel use on bleeding complications after TBB in hum ans. Chest 2006; 129: 734 \200\2237. CHAPTER 64 Bronchoscopy 748 Patient preparation and procedure Patient preparation \200 Information Patients should be given written information about the procedure ideally more t han 24 h prior to the procedure. Provide an information sheet for the patient to take home following the bronchos- copy, with advice about the effects of any sedation and possible co mpli- cations, as well as telephone numbers in case help is needed Consent The physician pe rforming the bronchoscopy should obtain written consent, with a description of the procedur e and its associated risks Nil by mouth Patients should have no food for 4 h beforehand and clear \202 uids only until 2 h beforehand Blood tests Patients do not need routine pre-p rocedure blood tests, unless there are speci \201 c concerns (uraemia, deranged LFTs, low plate- lets). Many physicians check platelet counts and clotting times prior to transbronch ial biopsy (platelets >75 000/mm3, PT, and APTT within 1 \200\2232 s of control) and warfar in/heparin/low molecular weight heparin may be temporarily stopped Bedside tests Consider p erforming an ECG in patients with a history of cardiac disease. Check blood sugar in patien ts with diabetes Prophylactic antibiotics recommended in those at risk of endocarditis, i.e . asplenic, heart valve prosthesis, previous infective endocarditis: amoxicillin 3 g PO 1 h pre-bronchoscopy, or if penicillin allergic, clindamycin 600 mg PO or azithromycin 200 mg PO. Recent guidelines, however, from British Society of Antimicrobial Chemotherapy suggest this is not necessary (Gould FK et al. J Antimicrob Chemother 2006; 57: 1035 \200\22342) In those with asthma, a nebulized bronchodilator should be given before the bronchoscopy Thos e at high risk of infection (TB) should be last on the list. Procedure \200 Practices vary between centers. Some perform bronchoscopy with the patient sitting up facin g the operator; some from behind with the patient lying \202 at IV access should be prese nt in all patients Nasal oxygen should be administered and oximetry measured throughout Pre medication may be given in addition for mild sedation, anxiolysis, and anterograde amnesia. A benzodiazepine such as midazolam 2 mg, with 1 mg increments as necessary, may be used wi th fentanyl. Some patients and operators prefer not to use sedation, due to concerns partic ularly in elderly patients, those with COPD, or those with cardiac disease. Midazolam can m ake some patients more agitated. Premedication with anticholinergics is not bene \201 cial during bronchoscopy \200 PATIENT PREPARATION AND PROCEDURE 749 Lidocaine Local anesthetic spray or gel is applied to the nostrils and the vocal cords are anesthetized by spraying local anesthetic (lido- caine 10 mg/spray) to the back of the thro at and allowing time to work. Peak plasma levels occur after 15 min. \200 Transcricoid injection may be used to administer 4% lidocaine into the trachea, or this may be anesthetized under direct vision through the bronchoscope, when the vocal cords are ope n Aliquots of 1 \200\2232% lidocaine may be administered to right and left main bronchi via the bronchoscope when it is passed through the vocal cords into the trachea. Use the minim al dose required for cough suppression. Peak plasma levels occur after 5 min via the scope. Airway in \202 ammation increases lidocaine absorption Maximum dose of lidocaine is 8 mg/ kg (= 29 mL of 2% solution in 70 kg patient); 5 mg/kg if hepatic or cardiac insuf \201 cie ncy. Toxic effects include seizures and arrhythmias The half-life of lidocaine is 1.5 \200 \2232 h Most access the trachea via the nasal route, as this gives increased sta- bility when takin g biopsies and allows the patient to cough and spit out secretions more easily. If this is not possible, a mouth guard is used and access obtained through the mouth All sections of t he bronchial tree should be visually inspected, including the cords and trachea. CXR or CT may help localize the area of concern so specimen site can then be targeted. This increases the diagnostic yield of bronchoscopy in cases of suspected lung cancer Avoid unnecessary s uction, as this can increase hypoxia. CHAPTER 64 Bronchoscopy 750 Sampling techniques Bronchial washings are taken by instilling about 10 mL of saline and th en collecting it in a pot/trap to obtain super \201 cial airway cells. Bronchial brushings are taken by inserting a covered brush into a bronchial segment, uncovering it, rubbing th e bronchial wall, covering it, removing it, and wiping it on a slide. The slide is then spr ayed with a cell \201 xing solution. Bronchial biopsies are taken with biopsy forceps. 5 \200\2237 should be taken to optimize yield. These may be taken blindly or from a visibly a bnormal area, which gives a higher diagnostic yield than blind biopsies. They can be placed in formalin or saline solution depending on whether they are for histology or microbiology . Bronchoalveolar lavage (BAL) is performed by inserting 50 \200\223100 mL of saline throug h the bronchoscope when it is wedged well in a small airway. Ideally instill \202 uid dur ing inspiration and, after allowing the \202 uid to dwell for 10 \200\22330 s, aspirate b ack into the syringe during expiration or collect in a trap. Best performed in the area of abnormality on CXR or CT, or non-dependent lobes such as the right middle lobe or lingula. Poor return if the patient is coughing excessively or if they have emphysema. Can cause hyp oxia proportional to amount of lavage \202 uid used. Transbronchial biopsy (TBB) Techniqu e of passing transbronchial biopsy forceps down a terminal bronchus until resistance is \201 rst felt and taking a sample of parenchymal tissue. Safe to perform if patient is taki ng aspirin or on subcutaneous heparin, but omit clopidogrel for 5 days before (as well as a spirin if taking both) and, if on warfarin, wait until INR <1.3. Some perform with radiolog ical screening. Associated with a signi \201 cant risk of bleeding in 9% and pneumothorax in 3.5%, but up to 14% if patient is mechanically ventilated. Half of all pneu- mothoraces require chest dr ains. Therefore perform on one side only and minimize risk by performing TBB in the lower l obes, in dependent seg- ments. Perform CXR 1 h after the bronchoscopy. Pneumothorax should be managed according to standard guidelines (p 376). Small pneumo- thoraces often resolve s pontaneously, but the patient may need admission if there are concerns. Transbronchial need le aspiration (TBNA) (see p 286) is used to sample mediastinal and hilar lymph nodes in sus pected malignancy, TB, or sarcoidosis. It is also useful in sampling extrabronchial masses or necrotic endobronchial tumor. When added to other sampling techniques in lung cancer, it increases the diagnostic yield by 18%. When performing bronchoscopy \200 Wear gloves, face mask and eye shields \200 Use parti culate (duck) masks if there are concerns about TB or HIV SAMPLING TECHNIQUES 751 Superior Mediastinal Nodes Brachiocephalic (innominate) a. 1 1 Highest Mediastinal 2 Upper Paratracheal 2R 3 Pre-vascular and Retrotracheal Ao 4R Azygos v. 4 Lower Paratracheal (including Azygos Nodes) N2=single digit, ipsilateral N3=single digit, contralateral or supraclavicular 4L 10R PA 7 11R Aortic Nodes 11L 5 Subaortic (A-P window) 10L 8 6 Para-aortic (ascending aorta or phrenic 9 12,13,14R 12,13,14L Inf.pulm.ligt. Inferior Mediastinal Nodes