Bronkoskopi L

BRONKOSKOPIBRONKOSKOPI

Lian Lanrika Waidi Lubis


Broncho = batang tenggorokan Scopos = melihat atau menonton

Bronkoskopi : Tindakan medis yang bertujuan untuk melakukan

visualisasi trakea dan bronkus, berfungsi dalam prosedur diagnostik dan terapi penyakit paru.


Bronkoskop kaku = Rigid Bronchoscopy

Bronkoskop fleksibel = Fiber Optic

Bronchoscopy

= Bronkoskopi Serat Optik Lentur

Rigid bronchoscopyRigid bronchoscopy

Tabung lurus stainless steel

Panjang dan lebar bervariasi

Bronkoskopi untuk dewasa :– panjang 40 cm – diameter 9-13,5 mm– tebal dinding bronkoskop

2-3 mm Anestesi umum

Flexible bronchoscopyFlexible bronchoscopy

55cm total panjang bronkoskop ini mengandung serat optik memancarkan cahaya.

Indikasi bronkoskopiIndikasi bronkoskopi

Hemoptisis Batuk kronik Bronchoalveolar lavage

(BAL) Penentuan derajat

karsinoma bronkus Evaluasi pembedahan Obstruksi saluran nafas

besar Pengambilan dahak

yang tertahan/ada gumpalan mukus

Abses paru Mengeluarkan benda

asing dari saluran trakeobronkial

Dilatasi bronkus dengan menggunakan balon

Penanganan stenosis saluran nafas

Pemasangan stent bronkus

Laser bronkoskopi Endobronchial

brachitheraphy

Kontraindikasi BronkoskopiKontraindikasi Bronkoskopi

Penderita kurang kooperatif

Keterampilan operator kurang

Fasilitas kurang memadai

Angina yang tidak stabil Aritmia yang tidak

terkontrol

Asma berat Hiperkarbia berat Koagulopati yang serius Bulla emfisema berat Obstruksi trakea Obstruksi vena cava

superior Hipoksemia ireversibel

( PO2 60 mmHg )

Persiapan BronkoskopiPersiapan Bronkoskopi

Inform consent Pemeriksaan penunjang :

– Foto toraks, CT scan

– Faal hemostasis, CT, BT

– EKG

– Analisa gas darah

– Elektrolit

– Spirometri

– Evaluasi jantung pada penderita penyakit koroner

Persiapan Bronkoskopi (lanjutan)Persiapan Bronkoskopi (lanjutan)

Fasilitas penunjang : – ruangan persiapan, ruangan tindakan, ruangan

pemulihan, ruangan desinfeksi alat– bronkoskopi, kelengkapan televisi, video, foto,

kelengkapan alat diagnostik dan terapi– sarana penunjang (oksigen, mesin penghisap

lender/suction); holter monitoring, pulse oksimetri, nebulizer, resusitator.

Persiapan Bronkoskopi (lanjutan)Persiapan Bronkoskopi (lanjutan)

Medikasi : anti sedatif ringan 30 menit sebelum tindakan. Selama prosedur, anestesi topikal diberikan pada saluran

nafas. Anestesi dengan midazolam IV onset cepat dan masa

paruhnya pendek Anestesi topikal pada traktus respirasi atas, area glottis

dan bronkial dengan pemberian lidokain secara langsung.

Peralatan BronkoskopiPeralatan Bronkoskopi

Sumber O2 dengan aparatusnya

Mouth piece Povidon iodine diencerkan

untuk membersihkan bronkoskop

Kassa steril Kain penutup mata pasien Pulse oxymetri Mucus collector / wadah

penampung cairan bilasan Xylocain jelly

Sulfas atropin ( SA ) 0,25 mg, 1-2 ampul

Diazepam 5 mg, 1 ampul Lidocaine 2 %, 20 ampul @

2 mL Spuit 10, 5 cc, @ 2 buah Spuit 20 cc, 3 buah Cairan NaCl 0,9 % Xylocaine spray 10 % Obat resusitasi: Adrenalin

ampul, dexamethason ampul, SA ampul, bicnat ampul, bronkodilator ampul.

Pengambilan SpesimenPengambilan Spesimen1. Bilasan bronkus (bronchial

washing)2. Sikatan bronkus (bronchial

brushing)3. Biopsi forsep4. Biopsi aspirasi jarum

transbronkial (transbronchial needle aspiration/TBNA)

5. Biopsi paru transbronkial (Transbronchial Lung Biopsy/TBLB)

6. Endobronchial ultrasound (EBUS)

7. Bronkoalveolar lavage (BAL)

Prosedur BronkoskopiProsedur Bronkoskopi

Periksa tanda vital, status paru dan jantung. Premedikasi dengan Sulfas Atropin 0,25 – 0,5 mg IM,

setengah jam sebelum bronkoskopi. Sesaat sebelum tindakan : Diazepam 5 mg IM. Anestesi lokal :

– Inhalasi lidocaine 2% 5 mL lewat kanul inhalasi.– Xylocaine spray 10 % 5 – 7 semprot daerah

laringo-faring dan pita suara tarik lidah dengan bantuan kassa steril pada tangan kiri

• Bila via hidung: semprotkan 30 mg lidocaine 4 % atau 10 % ke ostium nasal.

Prosedur Bronkoskopi

Pasien terlentang dengan tubuh bagian bahu disangga bantal, membentuk sudut 45º

Bronkoskopi diinspeksi dan kejernihan gambar diperiksa. Sensor oksimetri ditempelkan pada jari telunjuk pasien. O2 3-4 L/m melalui kanul nasal. Kedua mata pasien ditutup dengan kain penutup untuk

mencegah terkena larutan lidocaine / cairan pembilas. Diletakkan mouth piece di antara gigi atas dan bawah

untuk melindungi bronkoskop. Bronkoskop mulai dimasukkan melalui celah mouth piece.

Cara memegang scopeCara memegang scope

Prosedur BronkoskopiProsedur Bronkoskopi Faring diinspeksi.

Instilasi lidocaine 2% 2 mL ke trakea via pita suara.

Pita suara diinstilasi dengan lidocaine 1-2 mL melalui saluran di bronkoskop. ES : merangsang batuk

Lidocaine yang berlebihan diaspirasi dari sekitar laring

Instrumen bronkoskopi dimasukkan melalui bagian terlebar dari glottis pada saat inspirasi tanpa menyentuh pita suara. – Sebelumnya pasien diberitahu bahwa hal ini dapat

menimbulkan sensasi tercekik yang segera hilang

Prosedur BronkoskopiProsedur Bronkoskopi

Trakea, karina, dan percabangan bronkus dinilai dan dianestesi dengan lidocaine 2% 2 mL, maksimal 6 kali.

Lobus superior paru kanan dan kiri dianestesi dengan instilasi langsung lidocaine.

Inspeksi menyeluruh dilakukan pada semua percabangan bronkus sampai bronkus subsegmental.

Bila pandangan terhalang oleh sekret pada lensa distal, disemprot dengan 5mL NaCl 0,9 % yang diaspirasi kembali saat pasien batuk.– Alternatif adalah memfleksikan ujung bronkoskop dan

dengan hati-hati diusapkan pada mukosa trakea atau bronkus

Prosedur BronkoskopiProsedur BronkoskopiBilasan bronkusBilasan bronkus

Setelah bronkoskop berada pada daerah bronkus yang dicurigai, dimasukkan cairan NaCl 0,9% hangat 5 mL, cairan segera diaspirasi lagi dan ditampung dalam wadah penampung khusus (mucous collector) yang dipasang pada alat bronkoskop.

Tindakan ini diulangi sampai cukup bersih atau didapat spesimen.

Bilasan Bilasan

Prosedur BronkoskopiProsedur BronkoskopiSikatan BronkusSikatan Bronkus

Setelah bronkoskop berada pada daerah bronkus yang dicurigai terdapat kelainan, alat sikat dimasukkan melalui bronkoskop, dilakukan sikatan beberapa kali sampai dirasa cukup.

Setelah selesai melakukan sikatan, alat sikat ditarik ke dalam kanal bronkoskop dan dikeluarkan dari trakeobronkial bersama bronkoskop.

Sesudah berada di luar, sikat dikeluarkan dari ujung bronkoskop sepanjang 5 cm, kemudian sikat dijentikkan pada gelas obyek dan dibuat sediaan apus untuk pemeriksaan sitologi direndam dalam wadah berisi alkohol 96%

Prosedur BronkoskopiProsedur BronkoskopiBiopsiBiopsi

Setelah bronkoskop berada pada daerah bronkus yang dicurigai terdapat kelainan, ujung bronkoskop ditempatkan 4 cm di atas daerah tersebut.

Alat biopsi forsep dimasukkan melalui manouver channel sampai terlihat keluar dari ujung bronkoskop.

Asisten membuka forsep, lalu forsep didorong sampai terbenam di massa, forsep ditutup, lalu ditarik sambil melihat jaringan yang didapat (jaringan nekrotik dihindari)

Sesudah biopsi selesai, forsep bersama material yang didapat ditarik keluar dari bronkoskop

Spesimen direndam dalam wadah berisi cairan formalin 40% Bronkoskop dilanjutkan untuk evaluasi, bila ada perdarahan

harus diatasi. Setelah tidak ada masalah lagi, bronkoskop dikeluarkan.

Evaluasi Pasca tindakanEvaluasi Pasca tindakan

Diterangkan kepada pasien kemungkinan adanya sedikit darah saat batuk, yang akan hilang dalam 48 jam.

Dianjurkan tidak makan atau minum selama 2 jam setelah tindakan karena efek anestesi topikal.

Hasil spesimen bronkoskopi ditujukan untuk :– Sitologi spesimen sekret atau jaringan– BTA spesimen sekret atau jaringan– CRP atau hsCRP spesimen sekret atau jaringan– Kultur dan resistensi mikroorganisme (kuman

aerob, kuman anaerob, dan jamur) dari spesimen sekret atau jaringan

KomplikasiKomplikasi

– Premedikasi: depresi pernafasan, hipotensi transien, syncope, hipereksitabilitas.

– Analgesia topikal (lidocaine): henti nafas, konvulsi, kolaps kardiovaskular, laryngospasme, metHemoglobinemia

– Bronkoskopi: laryngospasme, depresi nafas, bronkospasme, demam pasca bronkoskopi, epistaksis (bila via nasal), henti jantung, aritmia, sinkop, pneumonia, infeksi silang

– Biopsi transbronkial: pneumothoraks, perdarahan– Lavage / BAL: demam

TERIMA KASIH

IntroductionIntroduction

Flexible bronchoscopy (FB) optimal management of ICU patients with both diagnostic and therapeutic.

Rigid bronchoscopes (RB) management of massive haemoptysis, tracheobronchial foreign bodies, tracheobronchial strictures and placement of airway stents

FlexiblFlexiblee Bronchoscopy (FB) Bronchoscopy (FB)

Can be performed via endotracheal tube (ETT) or tracheostomy tube

Bedside procedure: avoids transport/OR time

Indications in Critically Ill Indications in Critically Ill Medical PatientsMedical Patients

198 bronchoscopies:

45% retained secretions

35% specimens for culture

7% airway evaluation

2% hemoptysis

Olapade CS, Prakash U. Mayo Clin Proc 64:1255-1263, 1989

Common Therapeutic Common Therapeutic Indications for Indications for BronchoscopyBronchoscopy

Retained secretions/atelectasis – bronchial toilet

Mucous plugs

Hemoptysis/blood clots

Difficult intubation

Dilation airway stenosis/strictures

Bronchoscopy in Patients Bronchoscopy in Patients with Mechanical Ventilatorwith Mechanical Ventilator

Not a contraindicationUsually the same as non-intubated

patientsThe risk for complications are increased

in the prsesence of several factors; – pulmonary, – cardiac, – coagulopathy, and – central nervous system Chest 1992; 102: 557-664

Bronchoscopy in Patients Bronchoscopy in Patients with Mechanical Ventilatorwith Mechanical Ventilator

ETT internal Ø at least 8 mm for standard fiberscope (5,7 – 6,0 mm)

Discontinue PEEP or reduce 50% Increase FiO2 to 1.0, 5-15 minutes prior to

procedureCheck BGA before and after Continuous pulse oximetry Monitoring pulse and BP

Chest 1992; 102: 557-664

Route of Bronchoscopy in the Route of Bronchoscopy in the ICUICU

Non-intubated patients Performed either via oral route using a bite block or

transnasal No respiratory failure or require NIV (CPAP) The bronchoscopist, must be knowledgeable about

intubation and skill in intubation (direct laryngoscopy or over a bronchoscope)

CI: 1) RR > 30 bpm, 2) clinically use of accesory muscles, 3) PaO2 < 70 mmHg or SaO2 < 90 %, 4) requirement for minimally invasive BIPAP/CPAP, and 5) altered mental status

Ernst A (Ed). Introduction to Bronchoscopy,

Cambridge (2009)

Route of Bronchoscopy in the Route of Bronchoscopy in the ICUICU

Intubated patients Bronchoscope through an ETT The bronchoscope must easily pass through the inner lumen

of the ETT and permit gas exhaled If the patients has a smaller Ø ETT, consider changing the ETT

to a larger Ø In case of stenosis or other causes use a pediatric or

smaller Ø bronchoscope Smaller scope smaller working channel & less suctioning

capability

Ernst A (Ed). Introduction to Bronchoscopy,

Cambridge (2009)

The Bronchoscopic TechniqueThe Bronchoscopic Technique

The procedure for preparations and performance of bronchoscopy is similar to that for patients who are not critical ill.

The critical ill patients, however may have to undergo bronchoscopy while receiving mechanical ventilation and may be attached to multiple tubes and other life-sustaining equipments.

The prerequisites for a safe & efficient The prerequisites for a safe & efficient bronchoscopy in ICUbronchoscopy in ICU

Consent Discontinuation of feeds at

least 8 hrs Checking of coagulation

profile Bite block O2, intubation tray, 100%

nonrebreather mask Cardiac monitor & oximetry Topical anesthetics Epinephrine 1:1000 Sedatives Adapter

Secretion trap, specimen jars (alc 70% & 90%, formalin)

Glass slidesSterile needles, disposable

syringeLubrication jelly Intravenous tubing, & fluids Brush & biopsy forceps,

Fogarty ballon cateheter, wire basket

Pneumothorax kitGown, gloves, maskTransbronchial aspiration

needles

Adapter route of bronchoscope

ETT

to mechanicalventilator

One of the most common consultations for bronchoscopy in the ICU

Should not be considered as first line therapy for routine pulmonary toilet and secretions clearance

Severe hypoxemia not contraindication

Retained Secretions and Atelectasis

FFB in atelectasis:– retained secretions and air bronchograms to

segmental level only– lobar or greater atelectasis not responding to

aggressive chest PT– life threatening whole lung atelectasis

More distal mucous plugs BAL Lung segments: room air insufflation by an Ambu

bag connected to the working channel of a bronchoscope.

Expect improved A-a gradient & chest radiography.

Difficult IntubationDifficult Intubation

Useful tool for difficult intubation >> size 8 ETT, smaller adult female: size 7 ETT FFB ranges from 1.8 mm (ultrathin) to 6.4 mm

(most adult FFB: 6.0 mm). Most standard FFB will pass through a size 7.5

ETT, and is the preferred FFB for intubation in an adult

Crit Care Clin 1995; 11:97-109.

FFB through an ETT

HemoptysisHemoptysis

In ICU, bronchoscopic evaluation within 12-18 hours highest chance for visualization of bleeding site & may guide therapeutic intervention.

The RB is preferred when bleeding is massive

Direct instillation of iced saline or a combination of saline and 1:1000 epinephrine

Other techniques:

– Direct application of a solution of thrombin or fibrinogen-thrombin combination

– Fogarty ballon catheter

HemoptysisHemoptysis

In extreme life-threatening cases, selective intubation of either the right or left main stem bronchi prevent soiling the unaffected lung

This is the best and most rapidy achieved by placing the ETT over the bronchoscope, advancing the ETT into the selected main stem airway

Using the bronchoscope as a guide wire, inflate the ballon on the ETT to prevent soiling.

StentStent Endobronchial stenting can be performed to

prevent impending resp. failure and facilitate weaning

Indication: obstruction that reduce airway lumen < 50%

Silicon stent (by RB)– Dumon stent– Y stent– T tube

SEMT: (RB or FB)– Ultraflex stent

Silicone or Metal?Silicone or Metal?

Silicone stent– Require RB– Easily removed– Migration– Can be used in

both malignant and benign stenosis

Metal stents– Easy to insert– Difficult to remove– Granulation tissue– Not recommended

for most benign stenosis

Squamous cell cancer in trachea

Primary squamous cell carcinoma in trachea - during laser therapy

Nitinol stent implanted into trachea

FFB: ComplicationsFFB: Complications

Premedication/ local anesthesia: respiratory depression arrest, methemoglobinemia, death

Procedure related: hypoxemia, cardiac complications, pneumonia, death

Ancillary procedures: barotrauma, pulmonary hemorrhage, death

Complications: HypoxemiaComplications: Hypoxemia

Common: up to 2 hrs. post procedure: 20-30 mmHg O2 drop in healthy, 30-60 in critically ill

Reduction in effective tidal volume and FRC

Suction at 100 mmHg via 2mm suction port removes 7L/min

Saline/lidocaine instillation

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FLEXIBLE BRONCHOSCOPY IN FLEXIBLE BRONCHOSCOPY IN (ICU)(ICU)

The internal diameter of the endotracheal tube, through which the bronchoscope is inserted, must be taken into consideration before bronchoscopy.

Intensive care units should have the facility to perform urgent and timely flexible bronchoscopy for a range of therapeutic and diagnostic indications.

Patients in ICU should be considered at high risk from complications when undergoing fibreoptic bronchoscopy.

Continuous multi-modal physiological monitoring must be continued during and after fibreoptic bronchoscopy.

Care must be exercised to ensure adequate ventilation and oxygenation is maintained during fibreoptic bronchoscopy via an endotracheal tube.

More profound levels of sedation/anaesthesia can be achieved in ventilated patients provided the clinician performing the procedure is acquainted with the use of sedative/anaesthetic agents.

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ENDOTRACHEAL TUBE SIZEENDOTRACHEAL TUBE SIZE The internal diameter of the tracheal tube relative to

the external diameter of the bronchoscope is an important consideration.

Bronchoscopes in the non-intubated patient occupy only 10–15% of the cross sectional area of the trachea.

In contrast, a 5.7 mm bronchoscope. occupies 40% of a 9 mm endotracheal tube

and 66% of a 7 mm tracheal tube. Failure to recognise this may lead to inadequate

ventilation of the patient and impaction of or damage to the bronchoscope.

Tracheostomy tubes are also prone to damage the bronchoscope, particularly during withdrawal when the rigid edge of the end of the tracheostomy tube can abrade the covering of the bronchoscope.

Lubrication is essential to facilitate passage of the bronchoscope.

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VENTILATOR SETTINGSVENTILATOR SETTINGS

Pre-oxygenation should be achieved by increasing the inspired oxygen concentration to 100%. 100% oxygen should be given during bronchoscopy and in the immediate recovery period.

The ventilator should be adjusted to a mandatory setting. Triggered modes such as pressure support or assist control will not reliably maintain ventilation during fibreoptic bronchoscopy.

A special swivel connector (Portex, Hythe, UK) with a perforated diaphragm, through which the bronchoscope can be inserted and allows continued ventilation.

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TRAINING(1)TRAINING(1) Flexible bronchoscopy is a complex and potentially

hazardous procedure requiring trained personnel (medical, nursing, and paramedical) to minimise the risk to both patient and staff.

The optimal number of procedures which should be undertaken under direct supervision (trainer in bronchoscopy unit) and indirect supervision (trainer able to assist if called) before undertaking bronchoscopy alone will vary, depending on the competency of the trainee and the complexity of the procedure being undertaken.

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TRAINING(2)TRAINING(2)

It would seem reasonable to undertake a minimum of 50 procedures under direct supervision and a further 50 under indirect supervision, although the trainer or other competent bronchoscopist should be available to give advice if needed for any trainee bronchoscopist

Selection of Therapy for Selection of Therapy for Airway obstructionAirway obstructionFor Urgent Therapy

– Laser, Stent, Rigid BronchoscopyFor Semi-urgent Therapy

– Cryotherapy, Electrocautery, APC, PDT, Balloon

For Prolonged Therapy– PDT, Stent, Brachytherapy

PDT and BrachytherapyPDT and Brachytherapy

PDT– Not suggested for palliative Very expensive– For central airway early malignancy– Highly potential of “cure of cancer”

Brachytherapy– Not available in SKH– For palliative use– Beware of fistula with great vessels and esophagus

SEJARAHSEJARAH

Bronkoskopi rigid 1897 Awalnya untuk obstruksi saluraan

napas karena benda asing dan stenosis trakhea karena infeksi

Diagnosis kanker paru 1950-anBronkoskopi fiberoptic fleksibel

1967Sekarang sebagai modalitas

diagnostik kelainan paru

Bronkoskopi rigid 1897 Awalnya untuk obstruksi saluraan

napas karena benda asing dan stenosis trakhea karena infeksi

Diagnosis kanker paru 1950-anBronkoskopi fiberoptic fleksibel

1967Sekarang sebagai modalitas

diagnostik kelainan paru

Indikasi bronkoskopiIndikasi bronkoskopi Evaluasi kelainan foto

toraks Batuk Hemoptysis Wheeze lokal Suspek fistula

trakheoesofageal Trauma dada atau injuri

inhalasi Atelektasis persisten Fistula bronkhopleural

terlokalisir

Aspirasi benda asing Pembawa brachytherapy Evaluasi penolakan pada

penerima transplantasi paru Evaluasi hiperlusensi

unilateral Penempatan atau

kepastian slang endobronkhial

Serak tidak jelas sebabnya atau paralisis pita suara

Penelitian

Kontraindikasi Kontraindikasi

Hipoksia yang tidak dapat dikoreksi (Pao2 < 60 mmHg)

Penyakit jantung tidak stabil dan penyakit jantung berat

Trombosit < 50.000/mm³ bila akan melakukan biopsi

Peninggian tekanan intrakranial

Hipoksia yang tidak dapat dikoreksi (Pao2 < 60 mmHg)

Penyakit jantung tidak stabil dan penyakit jantung berat

Trombosit < 50.000/mm³ bila akan melakukan biopsi

Peninggian tekanan intrakranial

KomplikasiKomplikasi

Angka morbiditas 0.08% - 0.8%Angka kematian 0% - 0.04%Komplikasi utama:

– Hipoksia,

– Aspirasi,

– Demam,

– Bakteremia, dan

– Perdarahan

Persiapan bronkoskopiPersiapan bronkoskopiPuasa 4 – 12 jam untuk mengurangi

aspirasiPasien COPD sebaiknya sudah ada

hasil spirometri, bila COPD berat lakukan BGA

Suplemen O2 dan/atau sedasi iv akan meningkatkan kadar CO2 arterial hindari sedasi berlebih bila CO2 arterial pre-bronchoscopy meningkat dan suplementasi O2 diberikan sangat hati-hati

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Persiapan bronkoskopi Persiapan bronkoskopi Antibiotik profilaktik sebaiknya diberikan

pre-bronkoskopi pada pasien asplenik, katup jantung buatan, atau sebelumnya ada riwayat endokarditis

Hindari tindakan bronchoscopy bila dalam 6 minggu mengalami infak miokard

Berikan informasi secara verbal dan tertulis untuk meningkatkan toleransi pasien terhadap prosedur bronkoskopi

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Persiapan bronkoskopi Persiapan bronkoskopi Pasien asma sebaiknya dipremedikasi

dengan bronkodilator sebelum bronkoskopi Pemeriksaan rutin terhadap platelet

dan/atau waktu protrombin preoperatif Stop pemakaian antikoagulan 3 hari

prebronkoskopi bila kemungkinan dilakukan sampel biopsi

Bila antikoagulan harus tetap dipakai INR < 2,5

Persiapan bronkoskopi Persiapan bronkoskopi Pasang infus pada semua pasien

prebronkoskopi saampai periode recovery Atropine tidak diperlukan secara rutin

prebronkoskopi Pasien sebaiknya dimonitor dengan

oximetry Berikan O2 untuk mencapai saturasi

minimal 90% Lidocaine 2% untuk anestesi

Selama bronkoskopiSelama bronkoskopi

Ada dua pembantu bronkoskopi, satu adalah perawat telah terlatih

Tidak perlu monitor EKG rutin, kecuali pasien dengan riwayat penyakit jantung berat dan hipoksia meskipun telah diberi O2

Alat resusitasi sebaiknya ada

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Setelah bronkoskopiSetelah bronkoskopi Mungkin masih butuh O2 pada pasien

denganngangguan fungsi paru dan dilakukan sedasi

Dilakukan foto torak bila dicurigai terjadi pneumotorak paling tidak 1 jam setelah transbronkhial biopsi

Pasien yang dilakukan transbronkhial biopsi sebaiknya dijelaskan kemungkinan terjadinya pneumotorak setelah pulang dari RS

Pasien yang dilakukan sedasi dianjurkan untuk tidak mengendarai kendaraan bermotor dalam waktu 24 jam setelah bronkoskopi

DIGNOSIS KANKERDIGNOSIS KANKER

Karsinoma bronkogenik dapat dibagi menjadi sentral (endobronkhial):– Batuk,– Hemoptysis,– Pneumonia, atau– Atelektasis

Atau lesi perifer

Lesi sentralLesi sentralBiopsi forsep,Brushing,Washing, danJarum aspirasi

ForcepForcep Forcep harus dikerjakan dengan teknik

legeartis untuk meminimalkan perdarahan Penarikan forcep pada ujung forcep dapat

menyebabkan merusak bronkoskopi bila forcep secara mendadak dikeluarkan dari jaringan

Untuk mendapatkan cakupan diagnostik yang paling tinggi pada lesi sentral paling tidak 3 sampel biopsi didapatkan apakah dengan brushing atau washing.

BrushingBrushing Setelah brushing lesi, brush dapat ditarik dari

kanal bronkoskopi (teknik withdrawn), atau ditarik bersama dengan bronkoskopi sebagai suatu unit untuk menghindari hilangnya sampel

Walaupun tidak ada penelitian menunjukkan superioritas satu teknik dengan teknik lainnya, bukti sampel dari teknik nonwithdrawn lebih baik

Sampel segera diaplikasikan ke kaca slide dalam gerakan melingkar dan segera taruh pada larutan pengawet untuk mencegah pengeringan

WashingWashing Metode lain untuk prosesing sampel brush

seperti menggoyang dalam larutan salin atau cairan pengawet, setelah itu preparasi blok-sel untuk analisa sitologi.

Washing bronkhial (memasukkan sejumlah kecil salin) kemudian menyedot cairan

Washing cocok untuk tumor lesi sentral

BALBAL Dapat dikerjakan untuk lesi perifer (invisibel

endoskopi) Aliquot 20 mL normal salin 0,9% dimasukan

ke segmen, dan kemudian dengan tekanan negatif 50 – 80 mmHg cairan lavage disuction kembali ke dalam botol suction

Bila tekana suction terlalu tinggi, saluran napas bisa kolap dan menghambat lavage

Biasanya kembali sekitar 40 – 60% dari lavage yang dimasukkan

Jarum aspirasiJarum aspirasi Bila menginginkan penetrasi lebih dalam

untuk menghindari nekrosis permukaan, Bila dicurigai karsinoma sel kecil, Bila lesi kemungkinan besar dapat

menyebabkan perdarahan, Jadi, pada lesi sentral untuk mendapatkan

diagnostik tertinggi bagi tiga sampel biopsi sebaiknya didapatkan dengan cara brushing atau washing

Lesi periferLesi perifer Cara yang dipakai untuk diagnostik lesi

perifer: Biopsi forcepTtansbronkhial, Brushing, Washing, dan Transbronchial needle aspiration (TBNA), Penuntun fluoroscopic imaging dan CT scan

imaging untuk memastikan lokasi biopsi yang lebih tepat,

Disarankan mengambil 5 – 6 sampel biopsi

Optimalisasi diagnosis kankerOptimalisasi diagnosis kanker Presentasi kanker pada stadium lanjut

prognosis jelek, Saat diagnosis tegak inoperabel, 5 year survival tinggal 13% - 15%, Modalitas baru untuk deteksi kanker lebih

dini bronkoskopi autofluorescence, Bronkoskopi autofluorescence untuk

deteksi kanker in situ atau displasia grade-tinggi pada lesi sentral,

Bronkoskopi fluorescence memiliki sinar absorbsi yang berbeda untuk jaringan normal dan malignansi

Penyinaran oleh sinar violet atau sinar biru: Jaringan normal jaringan normal berwarna

fluorescence hijau kuat, Jaringan displastik absorbsinya menurun

warna fluorescence coklat, ungu, atau merah Dengan teknik ini deteksi kanker meningkat

1,5 – 6,3 kali

Optimalisasi diagnosis kanker

Optimalisasi diagnosis kanker

Optimalisasi diagnosis kankerOptimalisasi diagnosis kanker Spesimen kombinasi untuk meningkatkan

diagnostik, Karsinoma sentral visibel tiga biopsi plus

satu tambahan spesimen (brushing, washing, atau aspirasi jarum pada kasus tumor submukosa atau tumor nekrosis)

Tumor perifer: 6 biopsi plus brushing and washing atau BAL, perlu penuntun fluoroskopi untuk memastikan lokasi alat.

Penyakit infeksiPenyakit infeksi CAP dan NP diterapi secara empiris Peranan bronkoskopi pada pneumonia

masih kontroversi Bronkoskopi bermanfaat pada:

– Pneumonia yang tidak membaik,– VAP, atau– Pneumonia pada pasien imunokompromais

Bronkoskopi dengan teknik BAL, dan protected specimen brush yang menggunakan kateter double-sheated

Transbronchial biopsy dan TBNA

HemoptysisHemoptysis Penyebab Hemoptysis: Infeksi: TBC, jamur, abses paruInflamasi: bronkhitis, bronkhiektasiNeoplasma: Karsinoma bronkogenik, adenoma bronkhialKelainan imun: Wegener granulomatosis dan Goodpasture syndromePulmonary vascular disorders: PE, AVM, MVD, fistulaLain-lain: pneumokoniosis, koagulopati, endobronkhial tumor, dll.

04/19/23 BI, All Rights Reserved, 2005 85

Flexible Bronchoscopy Flexible Bronchoscopy Step by Step Step by Step©©

Video exercises to learn bronchoscopy skillsVideo exercises to learn bronchoscopy skills

Prepared By

Bronchoscopy International

Contact us at

[email protected]

Step by Step©

Click anywhere to continue


Main ObjectivesMain Objectives To learn bronchoscopic techniques using an

approach similar to learning to dance, play tennis or play a musical instrument.– To develop “muscle memory”

– To develop a “systematic approach” to bronchoscopic inspection.

To learn how to handle the flexible bronchoscope and to accurately identify and enter lobar and segmental bronchial segments with ease.


Step 8b: Right lower lobe basal pyramidStep 8b: Right lower lobe basal pyramid(D’Artagnan and the three musketeers)(D’Artagnan and the three musketeers)

From the carina advance the scope to the RLL bronchus entrance and then enter the medial-basal segment, pull back and then examine the other three segments of the basal pyramid.

From the frontFrom the front

STAY OFF THE WALLClick to continue

Click HERE to view video


This presentation is part of a This presentation is part of a comprehensive curriculum for comprehensive curriculum for Flexible Bronchoscopy. Our goals Flexible Bronchoscopy. Our goals are to help health care workers are to help health care workers become better at what they do, and become better at what they do, and to decrease the burden of to decrease the burden of procedure-related training on procedure-related training on patients.patients.


A new curriculumA new curriculum

1. Web-based Self-learning study guide.2. Computer-based simulations, didactic lectures, and

image encyclopedia.3. Bronchoscopy step-by-step©: Practical exercises,

skills and tasks, competency testing.4. Guided apprenticeship.5. Learning the art of Bronchoscopy.

DEMOCRATIZATION AND GLOBALIZATION OF

KNOWLEDGE

BRONCHATLAS©

Step by Step©

Assured competency and proficiency


All efforts are made by Bronchoscopy International to maintain currency of online information. All published

multimedia slide shows, streaming videos, and essays can be cited for reference as:

Bronchoscopy International: Bronchoscopy Step-by-Step, an Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/Bronchoscopy Step-by-step/htm. Published 2005 (Please add “Date Accessed”).

Thank you


Group 1 ExercisesGroup 1 Exercises


Step 1: nose to larynxStep 1: nose to larynx

The scope is advanced from the nose to the larynx .

This step includes local anesthesia.

From the head


Click to continue


Step 2: larynx to subglottisStep 2: larynx to subglottis From the larynx the

trachea is entered to the subglottic area.

If from the head: once the vocal cords are passed the scope is slightly flexed downwards.

If from the front: once the vocal cords are passed the scope is slightly flexed upwards. From the front

Click to continue



Step 3: Follow the curve to the carinaStep 3: Follow the curve to the carina

The Trachea is not a “straight pipe”;

It deviates posteriorly and slightly to the right when approaching the main carina.

From the head

Click to continue



Step 4a: Carina to left main bronchusStep 4a: Carina to left main bronchus

From the neutral position the LMB is entered just by twisting the wrist to the left and advancing for 1 -2 cm.

From headFrom head

Click to continue



Step 4b: Carina to right main bronchusStep 4b: Carina to right main bronchus

From the neutral position the RMB is entered just by twisting the wrist to the right and advancing the scope for 1 -2 cm.

From headFrom head

Click to continue



Step 4c: Left-right-neutral Step 4c: Left-right-neutral

From the neutral position the left and right main bronchi are entered alternatively just by twisting the wrist and advancing the scope for few cm.

From headFrom head

Click to continue



Step 5a: Down-up-left main bronchusStep 5a: Down-up-left main bronchus

The scope is slowly advanced the pulled back up the LMB while always keeping it in the middle of the airway lumen.


Click to continue



Step 5b: Down-up right main bronchusStep 5b: Down-up right main bronchus

The scope is slowly advanced down the RMB to RLL and pulled back upwards while always keeping it in the middle of the airway lumen.


Click to continue



Step 6a: Left main to left upper lobe bronchusStep 6a: Left main to left upper lobe bronchus

From the LMB the scope is advanced to the entrance of the LUL bronchus.


Click to continue



Step 6b: Left main to left lower lobe bronchusStep 6b: Left main to left lower lobe bronchus

The scope is advanced down the LMB to the entrance of the LLL bronchus.


Click to continue



Step 6c: Right main to right upper lobe bronchusStep 6c: Right main to right upper lobe bronchus

The scope is advanced down the RMB then with the wrist twisted 60 degrees from midline the scope is flexed up to the entrance of RUL.


Click to continue



Step 6d: Right main to bronchus intermediusStep 6d: Right main to bronchus intermedius

From the carina advance the scope down the RMB to the distal bronchus intermedius and visualize the entrance to RB456 and the basal pyramid.


Click to continue



Step 6e: Right main to right lower lobe bronchusStep 6e: Right main to right lower lobe bronchus

Advance the scope from the carina to the entrance of the RLL while always keeping it in the midline.


Click to continue



Step 7a: Left upper lobe uno dosStep 7a: Left upper lobe uno dos

From the carina, the scope is advanced to LUL entrance; there, just by thumb movement, the lingula and upper division bronchus are visualized.

From the headFrom the head

Click to continue



Step 7b: Left before five six (LB 456)Step 7b: Left before five six (LB 456)

From the LMB, the lingula is entered, then the scope is pulled back into the distal LMB and the scope is advanced into the superior segment of the LLL.

! Wrist movements are “in the mirror” From the headFrom the head

Click to continue



Step 7c: Left B6-8,9,10Step 7c: Left B6-8,9,10

With the scope at the LLL bronchus entrance, the superior segment is entered, then alternately, the antero, lateral and postero-basal segments of the LLL are entered.


Click to continue



Step 7d: Right upper lobe uno-dos-tresStep 7d: Right upper lobe uno-dos-tres From the RMB the scope is

advanced and flexed up into the RUL bronchus where just by wrist and thumb movements the three segments are visualized; then the scope is withdrawn to the main carina.

From the From the headhead

Click to continue



Step 7e: Right before five six (RB 4,5,6)Step 7e: Right before five six (RB 4,5,6)

From the distal bronchus intermedius, the RML and superior segment are entered alternatively;

! Wrist movements are “in the mirror”. From the headFrom the headClick to continue



Step 7f: Right medial basal (RB7) Step 7f: Right medial basal (RB7) (d”Artagnan)(d”Artagnan)

From the distal bronchus intermedius the scope is advanced and the medio-basal segment is entered.

From the frontFrom the frontClick to continue



Step 8a: Left lower lobe basal pyramidStep 8a: Left lower lobe basal pyramid

From the entrance of the LLL bronchus go in and out of the 3 basal segments, then withdraw the scope to the carina.


Pan - Pan - Pan

Click to continue



Art of BronchoscopyArt of Bronchoscopy

04/19/23

8 steps8 steps


Bronchoscopy exercisesBronchoscopy exercises

Group Group 11

Nose/mouth to Nose/mouth to larynxlarynx

Larynx to Larynx to subglottissubglottis

Follow the curve Follow the curve to the carinato the carina

Carina to leftCarina to left

Carina to rightCarina to right

Left right Left right neutralneutral

Down-up rightDown-up right

Down-up leftDown-up left

Group Group 22

LMB to LLLLMB to LLL

LMB to LULLMB to LULRMB to RLLRMB to RLL

RMB to BIRMB to BI

RMB to RULRMB to RUL

Larynx to RLLLarynx to RLL

Larynx to LLLLarynx to LLL

Group Group 33

LLL pan pan panLLL pan pan pan

LUL uno dosLUL uno dos

LLL B6-8910LLL B6-8910

LB456LB456

RB456RB456

RLL medio-RLL medio-basal basal (D’Artagnan)(D’Artagnan)

RLL D’Artagnan RLL D’Artagnan and the three and the three musketeersmusketeers

RUL uno dos tresRUL uno dos tres


Background A: Flexion-ExtensionBackground A: Flexion-Extension

Extension Flexion


Background B: Down-Neutral-Up positionsBackground B: Down-Neutral-Up positions

Lever down

Lever straight (Neutral)

Lever up

Bronkoskopi L

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