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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3784_Библиотеки_им_академика_М_И_Перельмана
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C O N T E N T S
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1 Introduction, 1
Momen M. Wahidi and David E. Ost
SECTION 1 Advanced Diagnostic
Bronchoscopy Procedures
2 Linear Endobronchial Ultrasound, 5
Kazuhiro Yasufuku, Terunaga Inage,
Alexander Gregor, and Tsukasa Ishiwata
3 Radial Endobronchial Ultrasound, 17
Alexander Chen and Kevin Haas
4 Electromagnetic Navigation Bronchoscopy, 23
Allen Cole Burks and Jason Akulian
5 Transbronchial Cryobiopsy for
Diffuse Lung Diseases, 35
Fabien Maldonado, Otis B. Rickman and
Matthew Aboudara
SECTION 2 Therapeutic Bronchoscopy
Procedures
11 The Endoscopic Application of
Medication to the Airway, 113
Megan Acho, Roy Semaan, and Lonny Yarmus
12 Bronchial Thermoplasty, 127
Waqas Aslam, Ajay Sheshadri, and Carla R. Lamb
13 Bronchoscopic Lung Volume Reduction, 137
Jason Beattie and Adnan Majid
14 Multimodality Approach to Malignant
Airway Obstruction, 147
David E. Ost
15 Multimodality Approach to Benign
Central Airway Obstruction, 157
George Z. Cheng and Momen M. Wahidi
SECTION 3 Pleural Disease
16 Chest Tubes and Indwelling Pleural Catheters, 165
Kevin Ross Davidson and Samira Shojaee
17 Medical Thoracoscopy, 179
Pyng Lee
6 Rigid Bronchoscopy, 51
Coral X. Giovacchini and Kamran Mahmood
7 Mechanical Debridement, 63
Russell Jason Miller and Lakshmi Mudambi
8 Rapid Ablative Techniques, 77
Donald R. Lazarus
9 Delayed Ablation Techniques:
Photodynamic Therapy and Cryotherapy, 89
Michael Dorry and Jasleen Pannu
10 Stent Placement, 101
A. Christine Argento and Sean B. Smith
SECTION 4 Additional IP Topics
18 Percutaneous Tracheostomy, 193
Tenzing Phanthok, Crystal Ann Duran, and Shaheen Islam
19 How to Start an Interventional Pulmonology
Program, 207
Edward Kessler, Neeraj R. Desai, Kim D. French, and
Kevin L. Kovitz
Index, 213
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V I D E O T A B L E O F C O N T E N T S
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Video 6.1: Rigid Bronchoscope Intubation
Video 8.1: Electrocautery Needle Knife
Video 8.2: Electrocautery Snare and APAC
Video 10.1: Tracheobronchial Esophageal Fistula
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Introduction
Momen M. Wahidi and David E. Ost
INTERVENTIONAL PULMONOLOGY
Interventional pulmonology (IP) has evolved over the
past decade to become a recognized discipline oering advanced consultative and procedural services to
patients with thoracic malignancy, anatomic airway disease, and pleural disease. As with many procedurally
oriented medical disciplines, there are not always data to
inform every aspect of how to perform a given IP procedure. Consequently, there exists signicant variation
between physicians in how procedures are performed.
Many publications focus on the evidence of ecacy of IP
interventions but fail to provide practical advice on how
to perform the procedures. Procedural details are oen
relegated to a single paragraph in the methods section of
original research. is leaves trainees and practicing physicians who are learning a new procedure with a paucity
of practical information on how to actually do them.
In this book, we aim to present a practical approach
to IP procedures with a focus on patient selection, preprocedural preparation (including equipment, sta, and
setting), procedural techniques, complications, and a
brief summary of the evidence. e book is organized in
chapters covering diagnostic and therapeutic IP procedures, as well as multimodality approaches to malignant
and benign airway obstruction, and nishes with some
practical advice on how to build and lead an IP program.
We designed the procedural chapters to ow in a similar
fashion and consistently cover the aforementioned practical steps of IP procedures. We further supplemented
the book with colored images and original illustrations.
e goal of this book is to capture the procedure
“cra” of IP practice as well as the science. Procedure
cra in this context really refers to how to do a procedure. It includes tips and tricks from experienced physicians that may not reach the level of evidence necessary
for a guideline but are nonetheless helpful and oen
essential for everyday practice. To achieve this goal, each
chapter is written by experts in the eld who use these
techniques in their everyday practice. Aer all, when
learning to y a plane, who would you rather learn from:
a PhD aerospace engineer or an experienced pilot who
ies the same type of plane you are going to y?
is book covers the most frequently performed IP
procedures, but some rare IP procedures are not included.
Although the content may be viewed as ideal for beginners in IP procedures, such as trainees in pulmonary
medicine, interventional pulmonology, and thoracic
surgery, it is truly a fantastic review for clinicians already
performing these procedures. It is an opportunity to
evaluate whether there are dierent styles of performing
certain procedures or just a refresher on the entire spectrum of IP procedures: old and new. Grab that cup of
coee or tea this Sunday morning and immerse yourself
in easy-to-read rich content with tips and tricks from
experts in the eld.
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S E C T I O N 1
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Advanced Diagnostic
Bronchoscopy Procedures
2. Linear Endobronchial Ultrasound 5
Kazuhiro Yasufuku, Terunaga Inage, Alexander Gregor, and Tsukasa Ishiwata
3. Radial Endobronchial Ultrasound 17
Alexander Chen and Kevin Haas
4. Electromagnetic Navigation Bronchoscopy 23
Allen Cole Burks and Jason Akulian
5. Transbronchial Cryobiopsy for Diuse Lung Diseases 35
Fabien Maldonado, Otis B. Rickman and Matthew Aboudara
3
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Linear Endobronchial Ultrasound
Kazuhiro Yasufuku, Terunaga Inage,
Alexander Gregor, and Tsukasa Ishiwata
INTRODUCTION
In 2002, a new bronchoscope was developed by integrating
a convex-type ultrasound probe on its tip and introduced
into clinical practice.
ultrasound (CP-EBUS), also known as linear EBUS, can
be combined with a dedicated biopsy needle for real-time
endobronchial ultrasound-guided transbronchial needle
aspiration (EBUS-TBNA) of centrally located peribronchial lung lesions, mediastinal lymph nodes, and hilar
lymph nodes. EBUS-TBNA using a linear transducer is
a well-established minimally invasive modality for diagnosis and staging of lung cancer. Lung cancer guidelines
recommend combined EBUS-TBNA with endoscopic
ultrasound-ne-needle aspiration (EUS-FNA, also called
EUS-B-FNA if an EBUS bronchoscope is used in the combined procedure) as the best rst test for mediastinal nodal
staging in lung cancer. Over the past 20 years, the role of this
minimally invasive modality has been expanding to include
restaging aer neoadjuvant therapy and additional sample
acquisition for biomarker testing. Advances in ultrasonography image analysis have expanded the capabilities of linear EBUS. As such, EBUS-TBNA has now also become a
minimally invasive diagnostic tool for lymphoma, sarcoidosis, tuberculosis, mediastinal cysts, and other intrathoracic
malignancies. New biopsy needles will further expand the
potential capabilities of EBUS-TBNA in pulmonary medicine. Use of linear EBUS as a therapeutic modality, via
transbronchial injection, has likewise seen growing interest
and evidence. Linear EBUS continues to play an essential
role in disease diagnosis but is taking on novel indications
with potentially signicant clinical implications.
1
e convex probe endobronchial
PREPROCEDURE PREPARATION
Indications for Linear Endobronchial
Ultrasound
e initial indication for linear EBUS is diagnosis and nodal staging of lung cancer.
other intrathoracic malignancies, such as lymphoma,
sarcoma,
metastases,
coidosis,
also be considered as indications for biopsy by EBUSTBNA. EBUS-guided therapeutic interventions
under investigation. Several EBUS bronchoscopes
exist. However, in general, the size and exibility of
currently available EBUS bronchoscopes most reliably provide access to central lesions and in many
circumstances the mid-lung of the lower lobes. e
accessibility of current EBUS bronchoscopes to specic bronchi is more limited than that of regular bronchoscopes, especially when a biopsy needle is inserted
into the working channel. Acce ss to the upper lobes,
particularly the peripheral upper lobe, can be more
challenging. More exible EBUS bronchoscopes and
needles with improved access to the periphery are
under development.
4
mesothelioma,
6,7
as well as benign conditions, such as sar-
8
tuberculosis,
5
and other mediastinal
9
and mediastinal cysts,
Equipment
• Linear endobronchial ultrasound bronchoscope
• Universal ultrasound processor
• EBUS-TBNA needle (19-gauge [G], 21-G, 22-G, and/
or 25-G)
2
Suspicion for
10
can
11
are
3
5
6
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SECTION 1 Advanced Diagnostic Bronchoscopy Procedures
Staff
• Bronchoscopist
• Endoscopy/respiratory technician
• Sedation nurse or anesthesia team
• Cytopathologist (optional)
• Cytopathology technician (optional)
Setting
e procedure can be performed in an endoscopy suite
or operating room, with either moderate/conscious
sedation or general anesthesia. e linear endobronchial
ultrasound bronchoscope may be inserted into the airway via the oral route. An endotracheal tube or laryngeal mask airway can be selected optionally.
PROCEDURAL TECHNIQUES
General Linear EBUS/EBUS-TBNA
Preparation
A dedicated latex balloon is attached to the probe tip of
the EBUS bronchoscope using the balloon applicator
and inated with normal saline during EBUS-TBNA. A
20-mL syringe and extension tube lled with saline is
connected to the balloon channel. Approximately 0.3 to
0.5 mL of saline is needed to achieve appropriate balloon
ination. Because the balloon is made of latex, it cannot
be used in patients with allergy to latex.
EBUS-TBNA can be performed under either local
anesthesia with mild conscious sedation or general
anesthesia. With local anesthesia, the EBUS scope is
inserted orally and 1% lidocaine (a 2-mL bolus dose) is
gently administered into the airway through the instrument channel. With general anesthesia, an endotracheal
tube (at least 8.0 mm in internal diameter) or a laryngeal
mask airway (#4) is generally used. General anesthesia
with these airway devices provides some advantages
such as easier EBUS scope insertion and reduced coughing. is must be balanced against the logistic and safety
considerations of general anesthesia.
Aer sedation or induction of anesthesia, a regular exible bronchoscope is rst inserted into the airway. e initial diagnostic bronchoscopy facilitates safe
EBUS through clearance of secretions, identication of
airway lesions, verication of bronchial tree anatomy,
and administration of additional local anesthetic, if
required. Once complete, the exible bronchoscope is
removed, and EBUS-guided biopsy can begin. Insertion
and manipulation of the EBUS bronchoscope can be
more challenging than a conventional exible bronchoscope. e EBUS bronchoscope optical system is limited
by the forward oblique angle relative to the scope neutral position and ultrasound probe. Flexing the bronchoscope downward to provide a traditional “end-on”
view during EBUS scope advancement can result in
inadvertent injury from forceful dragging of the ultrasound probe. Rather, the EBUS bronchoscope should
be advanced in a neutral position, with intermittent
pausing and downward exion to conrm position, if
needed.
EBUS/EBUS-TBNA of Specic Lesions
If EBUS is being performed to acquire tissue from a specic lung or mediastinal lesion, the EBUS bronchoscope
is navigated to the planned area identied on preprocedural imaging review. e ultrasound balloon should
be gently inated and the bronchoscope upward exed
to maximize contact with the bronchial wall. Once the
lesion is centered on the ultrasound image, the EBUS
needle sheath is advanced beyond the working channel,
followed by the biopsy needle. Care should be made
to monitor both the white-light and ultrasound image
during advancement, as the bronchoscope may move
as the needle is pushed forward. Ideally, for mediastinal lesions, the needle should be deployed in the gaps
between cartilage rings.
EBUS/EBUS-TBNA of Lymph Nodes for Lung
Cancer Staging
Lymph node staging should be performed in a consistent,
systematic fashion to promote accurate staging. Lymph
nodes are examined by EBUS for documentation of their
station, size, and other ultrasound features (see later),
in accordance with the American Joint Committee on
Cancer (AJCC)/Union for International Cancer Control
(UICC) staging systems. EBUS-TBNA has limited
access to lymph nodes far from the central airways such
as the prevascular nodes (station 3a), subaortic/paraaortic nodes (stations 5 and 6), and paraesophageal/pulmonary ligament nodes (stations 8 and 9). However, both
transbronchial and transesophageal endosonographic
procedures can be performed with a single EBUS scope,
oen referred to as EUS-B-FNA, which can facilitate
access to stations 8 and 9 as well as alternative access
routes for other stations.
12,13
EUS-B-FNA oers potential
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