Endoscopy: Respiratory Endoscopy

Respiratory Endoscopy

Definitions

  • Laryngoscopy: Endoscopic Evaluation of the Upper Respiratory Tract (Larynx)
  • Bronchoscopy: Endoscopic Evaluation of the Lower Respiratory Tract (Bronchi)

Laryngoscopy

  • Direct Laryngoscopy
  • Indirect Laryngoscopy
    • Indirectly Visualize Using Mirrors or Video/Fiberoptic Devices
    • Optimal Positioning: “Sniffing” Position – Sitting Upright, Lean Forward with Atlanto-Occipital Extension

Bronchoscopy

  • Type:
    • Rigid Bronchoscopy – Rigid Straight Hollow Tube
      • Generally Only Used for Removal of Foreign Body – Larger Lumen Facilitates Easier Removal
      • Only Able to Visualize Trachea & Proximal Bronchi
    • Flexible Bronchoscopy – Flexible Tube that Transmits Light/Images Through Fiber Optics
      • Better Tolerated with Decreased Sedation Required
      • Generally the Preferred Option – Improved Manipulation & Navigation
      • Allows Better Access to Lower Airway & More Distal Bronchi
  • Interventions:
    • Diagnostic Interventions:
      • Bronchoalveolar Lavage (BAL)
        • Technique:
          • Place into the Desired Subsegmental Bronchus & Wedge to Fully Occlude the Lumen
          • Do Not Suction Prior to Collecting Sample
          • Inject 20-40 cc NS & Withdraw into the Same Syringe as a Specimen (Variable Fluid Return)
            • Repeat 3-5 Times
          • All Samples are Pooled for the Final Specimen
        • Best Test for Diagnosis of Ventilator Associated Pneumonia (VAP)
        • Send for a Quantitative Culture
      • Endobronchial Ultrasound (EBUS)
      • Transbronchial Biopsy
        • Most Common Cause of Complication During Bronchoscopy
    • Therapeutic Interventions:
      • Suctioning
      • Foreign Body Removal
      • Argon Plasma Coagulation
      • Photodynamic Therapy
      • Balloon Dilation
      • Airway Stenting
      • Brachytherapy
  • Contraindications to Nonemergent Bronchoscopy:
    • Severe Hypoxemia (PaO2 < 60 mmHg or SpO2 < 90% with FiO2 ≥ 60%)
      • Exception: If Procedure is Therapeutic or Will Significantly Guide Hypoxemia Treatment
    • Severe Pulmonary Hypertension
    • Unstable/Severe Obstructive Airway Disease
    • Hemodynamic Instability & Myocardial Infarction

Complications

  • Bleeding
    • Most are Minor & Resolve Spontaneously
    • If Refractory: Spray Epinephrine or Ice-Cold Saline (Induces Vasoconstriction)
    • If Severe & Still Refractory: Argon Plasma Coagulation, Angioembolization or Surgery
  • Pneumothorax (PTX)
  • Cardiac Arrhythmia
  • Respiratory Failure & Hypoxemia
  • Aspiration
  • Airway Injury/Perforation
  • Laryngospasm or Bronchospasm