BRONKOSKOPI

Lian Lanrika Waidi Lubis

BRONKOSKOPI

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.

BRONKOSKOPI

Bronkoskop kaku
= Rigid Bronchoscopy

Bronkoskop fleksibel
= Fiber Optic Bronchoscopy = Bronkoskopi Serat Optik Lentur

Rigid 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 bronchoscopy

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

Indikasi 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 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 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)

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)

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 Bronkoskopi
Sulfas atropin ( SA ) 0,25 Sumber O2 dengan mg, 1-2 ampul aparatusnya Diazepam 5 mg, 1 ampul Mouth piece Povidon iodine diencerkan Lidocaine 2 %, 20 ampul @ 2 mL untuk membersihkan Spuit 10, 5 cc, @ 2 buah bronkoskop Spuit 20 cc, 3 buah Kassa steril Kain penutup mata pasien Cairan NaCl 0,9 % Xylocaine spray 10 % Pulse oxymetri Obat resusitasi: Adrenalin Mucus collector / wadah ampul, dexamethason penampung cairan bilasan ampul, SA ampul, bicnat Xylocain jelly ampul, bronkodilator ampul.

Pengambilan Spesimen
1. 2. 3. 4.

5.

6. 7.

Bilasan bronkus (bronchial washing) Sikatan bronkus (bronchial brushing) Biopsi forsep Biopsi aspirasi jarum transbronkial (transbronchial needle aspiration/TBNA) Biopsi paru transbronkial (Transbronchial Lung Biopsy/TBLB) Endobronchial ultrasound (EBUS) Bronkoalveolar lavage (BAL)

Prosedur 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 45 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 scope

Prosedur 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 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 Bronkoskopi Bilasan 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

Prosedur Bronkoskopi Sikatan 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 Bronkoskopi Biopsi

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 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

Komplikasi

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

Introduction
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

Flexible Bronchoscopy (FB)

Can be performed via endotracheal tube (ETT) or tracheostomy tube Bedside procedure: avoids transport/OR time

Indications in Critically Ill Medical Patients

198 bronchoscopies:
45% retained secretions 35% specimens for culture 7% airway evaluation 2% hemoptysis
Olapade CS, Prakash U. Mayo Clin

Common Therapeutic Indications for Bronchoscopy

Retained secretions/atelectasis bronchial

toilet

Mucous plugs Hemoptysis/blood clots Difficult intubation Dilation airway stenosis/strictures

Bronchoscopy in Patients with Mechanical Ventilator

Not a contraindication Usually the same as non-intubated patients The risk for complications are increased in the prsesence of several factors;

pulmonary, cardiac, coagulopathy, and

Chest 1992; 102: 557-6

Bronchoscopy in Patients with Mechanical Ventilator

ETT internal 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 procedure Check BGA before and after

Continuous pulse oximetry Monitoring pulse and BP

Chest 1992; 102: 557-6

Route of Bronchoscopy in the ICU

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 ICU

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 ETT, consider changing the ETT to a larger In case of stenosis or other causes use a pediatric or smaller bronchoscope Smaller scope smaller working channel & less suctioning capability
Ernst A (Ed). Introduction to Bronchoscopy, Cambridge (2009)

The 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 bronchoscopy 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

Secretion trap, specimen jars (alc

70% & 90%, formalin) Glass slides Sterile needles, disposable syringe Lubrication jelly Intravenous tubing, & fluids Brush & biopsy forceps, Fogarty ballon cateheter, wire basket

Pneumothorax kit

Gown, gloves, mask

Transbronchial aspiration

Sedatives Adapter

needles

Adapter

route of bronchoscope to mechanical ventilator

ETT

Retained Secretions and Atelectasis

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

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 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

Hemoptysis

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

Hemoptysis

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.

Stent

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 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: Complications

Premedication/ local anesthesia: respiratory depression arrest, methemoglobinemia, death Procedure related: hypoxemia, cardiac complications, pneumonia, death
Ancillary procedures: barotrauma, pulmonary hemorrhage, death

Complications: 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

FLEXIBLE BRONCHOSCOPY IN

(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.
55

ENDOTRACHEAL 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 1015% 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.
56

VENTILATOR 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.

57

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.

58

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

59

Selection of Therapy for Airway obstruction

For Urgent Therapy

Laser, Stent, Rigid Bronchoscopy

For Semi-urgent Therapy

Cryotherapy, Electrocautery, APC, PDT, Balloon

For Prolonged Therapy

PDT, Stent, Brachytherapy

PDT 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

SEJARAH
Bronkoskopi rigid 1897 Awalnya untuk obstruksi saluraan napas karena benda asing dan stenosis trakhea karena infeksi Diagnosis kanker paru 1950-an Bronkoskopi fiberoptic fleksibel 1967 Sekarang sebagai modalitas diagnostik kelainan paru

Indikasi 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
Hipoksia yang tidak dapat dikoreksi (Pao2 < 60 mmHg) Penyakit jantung tidak stabil dan penyakit jantung berat Trombosit < 50.000/mm bila akan melakukan biopsi Peninggian tekanan intrakranial

Komplikasi
Angka morbiditas 0.08% - 0.8% Angka kematian 0% - 0.04% Komplikasi utama: Hipoksia, Aspirasi, Demam, Bakteremia, dan Perdarahan

Persiapan bronkoskopi
Puasa 4 12 jam untuk mengurangi aspirasi Pasien 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 hatihati

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
67

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
68

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 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

Setelah 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
71

DIGNOSIS KANKER

Karsinoma bronkogenik dapat dibagi menjadi sentral (endobronkhial):

Batuk, Hemoptysis, Pneumonia, atau Atelektasis

Atau lesi perifer

Lesi sentral
Biopsi forsep, Brushing, Washing, dan Jarum aspirasi

Forcep

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.

Brushing

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

Washing

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

BAL

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 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 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 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 gradetinggi pada lesi sentral,

Optimalisasi diagnosis kanker

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

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 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

Hemoptysis
Penyebab Hemoptysis: Infeksi: TBC, jamur, abses paru Inflamasi: bronkhitis, bronkhiektasi Neoplasma: Karsinoma bronkogenik, adenoma bronkhial Kelainan imun: Wegener granulomatosis dan Goodpasture syndrome Pulmonary vascular disorders: PE, AVM, MVD, fistula Lain-lain: pneumokoniosis, koagulopati, endobronkhial tumor, dll.

Step by Step

Flexible Bronchoscopy Step by Step

Video exercises to learn bronchoscopy skills

Prepared By Bronchoscopy International

Contact us at BI@bronchoscopy.org Click anywhere to continue
4/10/2014 BI, All Rights Reserved, 2005 85

Main 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.
4/10/2014 BI, All Rights Reserved, 2005 86

Step 8b: Right lower lobe basal pyramid (DArtagnan and the three musketeers)

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

Click HERE to view video

From the front

Click to 4/10/2014 continue

STAY OFF THE WALL

BI, All Rights Reserved, 2005 87

This presentation is part of a comprehensive curriculum for Flexible Bronchoscopy. Our goals are to help health care workers become better at what they do, and to decrease the burden of procedure-related training on patients.
4/10/2014 BI, All Rights Reserved, 2005 88

Step by Step

A new curriculum
Assured competency and proficiency

1. 2. 3. 4. 5.

Web-based Self-learning study guide. Computer-based simulations, didactic lectures, and image encyclopedia. Bronchoscopy step-by-step: Practical exercises, skills and tasks, competency testing. Guided apprenticeship. Learning the art of Bronchoscopy.
BRONCHATLAS

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DEMOCRATIZATION AND GLOBALIZATION OF BI, All Rights Reserved, 2005 KNOWLEDGE

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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

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Group 1 Exercises

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Step 1: nose to larynx

The scope is advanced from the nose to the larynx . Click HERE to view video This step includes local anesthesia.
From the head Click to continue
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Step 2: larynx to subglottis

From the larynx the trachea is entered to the subglottic area. If from the head: once Click HERE to view video the vocal cords are passed the scope is slightly flexed downwards. If from the front: once the vocal cords are From the front passed the scope is slightly flexed BI, All Rights Reserved, 2005 Click to 4/10/2014 93 continue upwards.

Step 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.
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Click HERE to view video

From the head

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Step 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.
Click HERE to view video

From head

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Step 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 head Click HERE to view video

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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.

Click to continue From head Click HERE to view video

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Step 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.

From the front

Click HERE to view video

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Step 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 HERE to view video

From the front Click to continue

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Group 2 Exercises

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Step 6a: Left main to left upper lobe bronchus

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

Click HERE to view video

From the front

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Step 6b: Left main to left lower lobe bronchus

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

Click HERE to view video

From the front

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Step 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 HERE to view video

From the front Click to BI, All Rights Reserved, 2005 continue

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Step 6d: Right main to bronchus intermedius

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

From the front

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Step 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 HERE to view video

From the front

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Group 3 Exercises

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Step 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.

Click HERE to view video

From the head

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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
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Click to continue

Click HERE to view video

From the head

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Step 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 4/10/2014 continue

Click HERE to view video

From the head

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Step 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.

Click to continue From the head

Click HERE to view video

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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.
Click to 4/10/2014 continue

Click HERE to view video

From the head

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Step 7f: Right medial basal (RB7) (dArtagnan)

From the distal bronchus intermedius the scope is advanced and the medio-basal segment is entered.
Click to continue
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Click HERE to view video

From the front

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Step 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.
Click to continue
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Pan - Pan - Pan

Click HERE to view video

From the head

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Art of Bronchoscopy

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8 steps

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Bronchoscopy exercises
Group 1
Nose/mouth to larynx Larynx to subglottis Follow the curve to the carina LMB to LLL LMB to LUL Carina to left Carina to right Left right neutral Down-up right Down-up left

Group 2 Group 3
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RMB to RLL RMB to BI RMB to RUL

Larynx to RLL Larynx to LLL

LLL pan pan pan LUL uno dos LLL B6-8910

LB456 RLL DArtagnan and the three musketeers RB456 RLL medio-basal RUL uno dos tres (DArtagnan)
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Background A: Flexion-Extension

Extension
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Flexion
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Background B: Down-Neutral-Up positions

Lever straight (Neutral) Lever down

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Lever up