Bronchoscopy

Before reaching the modern state, endoscopy has passed a long way of development, related to the improvement of endoscopic instruments and auxiliary endoscopic instruments.

The birth of clinical bronchology dates back to the end of the XIX century and is associated with the emergence of a new diagnostic and therapeutic method - bronchoscopy. The emergence of bronchoscopy was preceded by the inventions of A. Desormeaux (1853), A. Kussmaul (1868), J.Mikulicz (1881) of a rigid gastroscopy and special endoscopic instruments for him. In 1897 the German otolaryngologist from Freiburg G.Killan produced the world's first bronchoscopy and removed a foreign body from the right main bronchus with the help of the J. Mikulicz endoscope. The term "bronchoscopy" was also suggested by G. Killan.

C. Jackson (1903) designed a bronchoscope with proximal lighting, substantiated the use of a biopsy, suggested bronchoscopy through a bronchoscope. He also owns the world's first monograph on bronchoscopy.

The student G. Killan W. Brunings constructed in 1908 a bronchoscope with distal illumination, which has been applied to the present day.

For 50 years, bronchoscopy has been used in the practice of otorhinolaryngologists mainly to remove foreign bodies. The use of modern anesthesia (Adams, 1945, Bars, 1955) contributed to the further improvement of bronchoscopy. The progress of thoracic surgery, phthisiology and pulmonology has created the prerequisites for the rapid development of bronchial methods. In 1956, H. Friedel constructed a rigid respiratory bronchoscope, which allowed performing studies under anesthesia with artificial ventilation.

In Russia, the first bronchoscopy was performed by KM. Schmidt in 1903. A great role in the formation and development of bronchoscopy was played by native scientists NA. Schneider (1909), V.I. Voyachek (1911), V.L. Trutnev (1927), G.I. Lukomsky (1963), L.C. Ioffe (1969), E.V. Klimanskaya (1972), A.A. Ovchinnikov (1980) and others.

Invention in 1968 S. Ikeda et al. Fibrobronhoscope increased the value of both diagnostic and medical bronchoscopy and expanded the range of its application. The resolving possibilities of bronchoscopy were enlarged: it became possible to examine all the bronchi of the fourth order, 86% of the bronchi of the fifth order and 56% of the bronchi of the sixth order (GI Lukomsky et al., 1973).

The disadvantage of fibroendoscopes is that strong compression of the device, for example with teeth, leads to the death of glass fibers, the appearance of black dots in the field of view and deterioration of the image. This disadvantage is deprived of a video endoscope.

In 1984 the first video endoscopes EVF-F, EVD-XL, EVC-M were created in the USA. In modern video endoscopes, thanks to the use of high-performance lenses and precise digital signal processing systems with the help of megapixel CCDs, it is possible to obtain a clear high-quality image, increased approximately 100-fold, and the color rendition does not deteriorate.

Video endoscopes are more reliable in operation, since they can be bent at any angle and even tied with a knot, without fear of damaging the endoscope. Significantly decreased the load on the eyes of an endoscopist. Thanks to the use of video endoscopes, it is possible to detect minute changes in the mucous membrane of the trachea and bronchi, which allows to diagnose the cancer of these organs at an early stage of development.

Bronchoscopy originated from direct laryngoscopy by improving and reconstructing the directory. The first bronchoscopy was carried out in 1897 by the German otolaryngologist G. Killian, who supplemented the laryngoscope (directrix) of Kirshtein (1895) with a metal tube, with which he removed the bone from the patient's bronchial tube. Later, G. Killian, together with his student V. Brunings (W.Brunings), created a bronchoscopic set consisting of an electroscope, a set of tools for biopsy and extraction of a foreign body, a set of endoscopic tubes of different length and diameter.

All parameters of the bronchoscope parts were carefully developed with appropriate anthropometric studies. In the future, this bronchoscope was perfected by V. Brunings and is practically used as intended in our time. In the set of bronchodiagnoscopes Brunings there are tubes of different structures (double, sliding, inserted one into the other). Later, other modifications of the Killian bronchoscope were developed. Modern domestic and foreign bronchoscopes are created on the principle of fiber optics or telescopes with the transfer of images to the television screen. These bronchoscopes are equipped with devices for injection ventilation, various devices for taking rinses and biopsies, sputum evacuation, micro-operations, removal of small foreign bodies, etc.

Distinguish between upper and lower bronchoscopy. Upper bronchoscopy is performed by inserting the bronchoscope through the mouth, the lower one through the laryngophyssura or tracheostomy. For upper bronchoscopy, there are the following indications: foreign bodies of the trachea and bronchi; diagnostics of various diseases (cicatricial stenosis, bronchiectatic disease, tuberculosis, neoplasms, revealed radiographic changes in the bronchi and lungs); carrying out some diagnostic and medical procedures (biopsy, flushing of the bronchi and sucking secret from them in severe asthmatic conditions, hemostasis with bronchopulmonary bleeding, etc.).

Bronchoscopy is performed in specially equipped bronchoscopy rooms. Most often, a flexible bronchoscope is used, the use of which requires only local anesthesia. The technique is relatively simple: the subject is usually in a sitting position; in the prone position, the examination is carried out only in seriously ill patients. The endoscope is guided through the nose or mouth. The modern fibroscope consists of a flexible tube with optical fibers packed in it, handles with controls, an eyepiece with a special set of lenses. Fibroscope is equipped with devices that allow to bend the distal end of the tube for more detailed examination of hard-to-reach places, change the focal length and magnify the image, transfer the image to a video monitor, perform video and image capture, for biopsy, removal of a foreign body, coagulation, administration of medications, etc.

Due to the elasticity, small diameter and considerable maneuverability of the distal end of the tube, the bronchic fibroscope, in comparison with the rigid bronchoscope, has considerably wider diagnostic and manipulation capabilities. However, there are contraindications to the use of this gentle tool: profuse bleeding, severe asthmatic status, intolerance of application anesthesia, oxygen deficiency manifested by hypercapnia, in which the partial pressure (tension) of carbon dioxide in the blood is above 50 mm Hg. Art.

Bronchoscopy with a hard bronchoscope is performed under anesthesia in the position of the patient lying on his back. The modern hard bronchoscope is a metal tube 43 cm long, equipped with a lighting system provided by a flexible light guide from a separate light source, an adapter for connecting the ventilator system, a channel for the introduction of various instruments and an eyepiece for the optical system for remote inspection. For the introduction of a bronchoscopic tube into the main bronchi, the head and the trunk of the patient should be diverted to the opposite side of the bronchus that is being examined, thus straightening the angle of the passage of the bronchus from the trachea. Contraindications to "hard" bronchoscopy are the same as for bronchoscopy using a fibroscope, as well as damage to the cervical spine, lower jaw, temporomandibular joint contracture, trisus and inexpediency due to the danger of general anesthesia. With "hard" bronchoscopy, complications such as injury and perforation of the bronchial tube, internal pneumothorax, bleeding, swelling of the lining space, especially in children under 3 years of age, are possible.

At the upper bronchoscopy, the first stage of the procedure of the procedure corresponds to the method of laryngoscopy. A bronchoscopic tube is inserted into the backbone space through the posterior section of the glottis during inspiration. When conducting a bronchoscope in the trachea, pulsation and respiratory movements of its walls are seen. The first (mechanical) is due to the transfer of pressure pulse wave traveling through adjacent arteries (on the right - anonymous, on the left - the carotid and the arch of the aorta). The respiratory movements of the trachea (reflex) are associated with the expansion of the trachea during inspiration, these movements are particularly noticeable in children. The keel of the trachea is slightly deflected to the right, it has the appearance of an arc that is concave in the lumen of the trachea. Normally, the mucous membrane covering the keel is paler than the mucosa of the major bronchi, and differs in a pale pink color; she performs spontaneous movements, synchronous with the acts of inspiration and expiration - respectively, forward-up and back-down. Any deviation of the keel from the norm requires a thorough X-ray examination of the lungs and mediastinum. After examining the trachea and keel, the procedure for the sequential insertion of the tube into the main bronchi and the examination of the bronchi of the left and right lungs should be done.

Processing of flexible endoscopes

All flexible endoscopes contact intact mucosa and are classified as semi-critical. They should not contain any microorganisms, but may contain spores of certain bacteria. According to statistics, most often with bronchoscopy, gram-negative bacteria and mycobacteria are transmitted.

Disinfection and sterilization of endoscopes

Indications and contraindications to bronchoscopy

Bronchoscopy is one of the most informative instrumental methods of studying the tracheobronchial tree.

Indications for bronchoscopy are: suspected central or peripheral benign or malignant lung tumor, bronchoconstriction and atelectasis of unclear etiology, chronic inflammatory and suppurative lung diseases, hemoptysis and pulmonary hemorrhage, foreign bodies of tracheobronchial tree, tracheal stenosis, disseminated lung diseases, tuberculosis, pleurisy of unclear etiology, mediastinal tumor, bronchial fistula.

Indications and contraindications to bronchoscopy

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Method of bronchoscopy

30 minutes before the local anesthesia, 1 ml of 0.1% solution of atropine sulfate is injected subcutaneously (to remove the vagal effect). Patients with glaucoma are examined without prior atropinization. Patients with a tendency to bronchospasm 15 minutes prior to the study, 10 ml of a 2.4% solution of euphyllin per 10 ml of physiological saline are injected intravenously, and 1-2 drops of aerosol used by the patient immediately after the local anesthesia is given.

Method of bronchoscopy

[10], [11], [12], [13], [14], [15], [16], [17], [18]

Methods of biopsy during bronchoscopy

An important part of diagnostic bronchoscopy is biopsy. It is performed to establish the diagnosis and determine the prevalence of the bronchial process.

During bronchoscopy, the collection of material for cytological and histological studies is performed in several ways, each of which has its own indications.

Methods of biopsy during bronchoscopy

[19], [20], [21], [22], [23], [24], [25], [26], [27]

Diagnostic bronchoalveolar lavage (BAL)

The idea of flushing the bronchus for emptying of the contents belongs to Klin and Winternitz (1915), who conducted BAL in experimental pneumonia. In the clinic, bronchoalveolar lavage was first performed by Yale in 1922 as a therapeutic manipulation, namely for the treatment of phosgene poisoning in order to remove a profuse secretion. Vincente Garcia in 1929 used from 500 ml to 2 liters of fluid with bronchiectasis, gangrene of the lung, foreign bodies of the respiratory tract. Galmay in 1958 applied massive lavage in postoperative atelectasis, aspiration of gastric contents and presence of blood in the respiratory tract. Broom in 1960 made a flushing of the bronchi through the intubation tube. Then, double-lumen tubes began to be used.

Diagnostic bronchoalveolar lavage

[28], [29], [30], [31], [32], [33], [34], [35], [36], [37]

Treatment of bronchoalveolar fluid

The main task of BAL is the production of cells, extracellular proteins and lipids that are present on the epithelial surface of the alveoli and the terminal sections of the respiratory tract. The obtained cells can be evaluated using the cytological method as well as in biochemical, immunohistochemical, microbiological and electron microscopic studies. The routine procedure involves the analysis of the total count and each cell count individually, and if possible, the detection of lymphocytes by staining with monoclonal antibodies.

Treatment of bronchoalveolar fluid

Complications of bronchoscopy and measures for their prevention

According to most authors, bronchoscopy represents a minimal risk to the patient. The largest summary statistics, generalizing 24 521 bronchoscopy, indicates a small number of complications. All complications were divided into three groups: lungs - 68 cases (0.2%), severe cases - 22 cases (0.08%) requiring resuscitation, and fatal - 3 cases (0.01%).

Complications of bronchoscopy and measures for their prevention

[38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53]

Diagnostic manipulations used in bronchoscopy

The acquisition of a diagnostic material and its investigation (microbiological, cytological and histological) are mandatory components of bronchoscopy.

Smears taken from the bronchi are important for the diagnosis of tumors. With nonspecific endobronchitis, cytological examination of smears can be recommended as one of the methods for determining the nature of inflammation.

Flushing from the walls of the bronchi is of great importance for the detection of mycobacteria tuberculosis, nonspecific microflora, fungi. To obtain flushing through the working channel of the fibroblochoscope, 10-20 ml of sterile isotonic sodium chloride solution is injected, which is then aspirated into a sterile vial.

Bronchoalveolar lavage (BAL) is performed during fibrobronchoscopy. Conducted under local anesthesia, or during combined RBS. Fibrobronhoscope is installed in the subsegmental bronchus, 40-100 ml of a warm sterile isotonic sodium chloride solution is injected through the working channel under pressure (20 ml each). The lavage liquid is immediately aspirated into a sterile container, its biochemical and immunological parameters as well as its cellular composition are examined. This is important for the differential diagnosis of tuberculosis.

A direct biopsy is performed using special forceps. Indications for gingival biopsy:

• active tuberculosis of the trachea or bronchus, especially when complicating its granulation;
• nonspecific endobronchitis;
• Unspecified etiology of the process (suspected neoplasm, sarcoidosis, etc.).

With increasing lymph nodes, a puncture biopsy is performed through the wall of the trachea or bronchi. Most authors prefer to investigate bifurcation lymph nodes, puncturing the inner wall of the mouth of the right main bronchus (on the right side of the spur of the trachea). The puncture of this site is most safe: the probability of getting a needle into a large blood vessel is very small. The results of a cytological study of spines from the spur of the right upper lobe bronchus have high diagnostic significance.

The catheterization and brushing biopsies are very close in importance and capacity. The main indication for research - changes in the lungs of an unclear genesis (peripheral rounded formations, disseminated processes, cavitary changes).

During the fibrobronchoscopy or combined bronchoscopy, the fibrobronchoscope is placed in the appropriate segmental bronchus and a special brush inserted into the catheter is inserted through the working channel. The brush is removed from the catheter and advanced further into the interior of the bronchus, several light translational movements are made and re-drawn into the catheter, which is removed from the fibroblochoscope. Brushes are made with brush on object glasses. Similarly, through the working channel of the fibrobronchoscope, a catheter is inserted into the corresponding bronchus. Through it, a syringe aspirates the contents of the bronchus, which is then removed onto a slide.

Transbronchial lung biopsy (TBBL) is used mainly for disseminated lung lesions. For a successful transbronchial lung biopsy, a high qualification of a physician for endoscopic diagnostics, the ability to provide emergency assistance in the event of complications (bleeding or pneumothorax), the presence of a modern radiology device that allows you to monitor the manipulations on the screen is necessary. Experienced doctors of endoscopic diagnostics can conduct a transbronchial lung biopsy without X-ray control.

Biopsy with fibrobronchoscopy is performed under local anesthesia only on one side (to exclude the development of bilateral pneumothorax). The fibroscope is brought to the mouth of the segmental or subsegmental bronchus, the biopsy forceps are pushed forward through the working channel of the fibroblochoscope. The forceps move under X-ray control (or blindly) until a feeling of slight resistance and a slight tingling in the patient's chest. Then they retreat back 1-2 cm. They open the jaws and, slightly pushing the forceps forward at the moment of inspiration, gently close them and remove them from the fibroblochoscope canal. The biopsy is placed in a vial of formalin, and sometimes fingerprints are made from it on the slide.

[54], [55], [56], [57], [58], [59], [60]