- •Foreword
- •Preface
- •Contents
- •About the Editors
- •Contributors
- •1: Tracheobronchial Anatomy
- •Trachea
- •Introduction
- •External Morphology
- •Internal Morphology
- •Mucous Layer
- •Blood Supply
- •Anatomo-Clinical Relationships
- •Bronchi
- •Main Bronchi
- •Bronchial Division
- •Left Main Bronchus (LMB)
- •Right Main Bronchus (RMB)
- •Blood Supply
- •References
- •2: Flexible Bronchoscopy
- •Introduction
- •History
- •Description
- •Indications and Contraindications
- •Absolute Contraindications
- •Procedure Preparation
- •Technique of FB Procedure
- •Complications of FB Procedure
- •Basic Diagnostic Procedures
- •Bronchoalveolar Lavage (BAL)
- •Transbronchial Lung Biopsy (TBLB)
- •Transbronchial Needle Aspiration (TBNA)
- •Bronchial Brushings
- •Advanced Diagnostic Bronchoscopy
- •EBUS-TBNA
- •Ultrathin Bronchoscopy
- •Transbronchial Lung Cryobiobsy (TBLC)
- •Therapeutic Procedures Via FB
- •LASER Bronchoscopy
- •Electrocautery
- •Argon Plasma Coagulation (APC)
- •Cryotherapy
- •Photodynamic Therapy
- •Airway Stent Placement
- •Endobronchial Valve Placement
- •Conclusion
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •Procedure Description
- •Procedure Planning
- •Target Approximation
- •Sampling
- •Complications
- •Future Directions
- •Summary and Recommendations
- •References
- •4: Rigid Broncoscopy
- •Innovations
- •Ancillary Equipment
- •Rigid Bronchoscopy Applications
- •Laser Bronchoscopy
- •Tracheobronchial Prosthesis
- •Transbronchial Needle Aspiration (TBNA)
- •Rigid Bronchoscope in Other Treatments for Bronchial Obstruction
- •Mechanical Debridement
- •Pediatric Rigid Bronchoscopy
- •Tracheobronchial Dilatation
- •Foreign Bodies Removal
- •Other Indications
- •Complications
- •The Procedure
- •Some Conclusions
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •Preprocedural Evaluation and Preparation
- •Physical Examination
- •Procedure-Related Indications
- •Application of the Technique
- •Topical Anesthesia
- •Anesthesia of the Nasal Mucosa and Nasopharynx
- •Anesthesia of the Mouth and Oropharynx
- •Superior Laryngeal Nerve Block
- •Recurrent Laryngeal Nerve Block (RLN)
- •Conscious Sedation
- •Monitored Anesthesia Care (MAC)
- •General Anesthesia
- •Monitoring the Depth of Anesthesia
- •Interventional Bronchoscopy Suites
- •Airway Devices
- •Laryngeal Mask Airway (LMA)
- •Endotracheal Tube (ETT)
- •Rigid Bronchoscope
- •Modes of Ventilation
- •Spontaneous Ventilation
- •Assisted Ventilation
- •Noninvasive Positive Pressure Ventilation (NIV)
- •Positive Pressure Controlled Mechanical Ventilation
- •Jet Ventilation
- •Electronic Mechanical Jet Ventilation
- •Postprocedure Care
- •Special Consideration
- •Anesthesia for Peripheral Diagnostic and Therapeutic Bronchoscopy
- •Anesthesia for Interventional Bronchoscopic Procedures During the COVID-19 Pandemic
- •Summary and Recommendations
- •Conclusion
- •References
- •Background
- •Curricular Structure and Delivery
- •What Is a Bronchoscopy Curriculum?
- •Tradition, Teaching Styles, and Beliefs
- •Using Assessment Tools to Guide the Educational Process
- •The Ethics of Teaching
- •When Learners Teach: The Journey from Novice to Mastery and Back Again
- •The Future Is Now
- •References
- •Interventional Procedure
- •Assessment of Flow–Volume Curve
- •Dyspnea
- •Analysis of Pressure–Pressure Curve
- •Conclusions
- •References
- •Introduction
- •Adaptations of the IP Department
- •Environmental Control
- •Personal Protective Equipment
- •Procedure Performance
- •Bronchoscopy in Intubated Patients
- •Other Procedures in IP Unit
- •References
- •Introduction
- •Safety
- •Patient Safety
- •Provider Safety
- •Patient Selection and Screening
- •Lung Cancer Diagnosis and Staging
- •Inpatients
- •COVID-19 Clearance
- •COVID Clearance: A Role for Bronchoscopy
- •Long COVID: A Role for Bronchoscopy
- •Preparing for the Next Pandemic
- •References
- •Historical Perspective
- •Indications and Contraindications
- •Evidence-Based Review
- •Summary and Recommendations
- •References
- •Introduction
- •Clinical Presentation
- •Diagnosis
- •Treatment
- •History and Historical Perspectives
- •Indications and Contraindications
- •Benign and Malignant Tumors
- •Tumors with Uncertain Prognosis
- •Application of the Technique
- •Evidence Based Review
- •Summary and Recommendations
- •References
- •12: Cryotherapy and Cryospray
- •Introduction
- •Historical Perspective
- •Equipment
- •Cryoadhesion
- •Indications
- •Cryorecanalization
- •Cryoadhesion and Foreign Body Removal
- •Cryoadhesion and Mucus Plugs/Blood Clot Retrieval
- •Endobronchial Cryobiopsy
- •Transbronchial Cryobiopsy for Lung Cancer
- •Safety Concerns and Contraindications
- •Cryoablation
- •Indications
- •Evidence
- •Safety Concerns and Contraindications
- •Cryospray
- •Indications
- •Evidence
- •Safety Concerns and Contraindications
- •Advantages of Cryotherapy
- •Limitations
- •Future Research Directions
- •References
- •13: Brachytherapy
- •History and Historical Perspective
- •Indications and Contraindications
- •Application of the Technique
- •Evidence-Based Review
- •Adjuvant Treatment
- •Palliative Treatment
- •Complications
- •Summary and Recommendations
- •References
- •14: Photodynamic Therapy
- •Introduction
- •Photosensitizers
- •First-Generation Photosensitizers
- •M-Tetrahidroxofenil Cloro (mTHPC) (Foscan®)
- •PDT Reaction
- •Tumor Damage Process
- •Procedure
- •Indications
- •Curative PDT Indications
- •Palliative PDT Indications
- •Contraindications
- •Rationale for Use in Early-Stage Lung Cancer
- •Rationale
- •PDT in Combination with Other Techniques for Advanced-Stage Non-small Cell Lung Cancer
- •Commentary
- •Complementary Endoscopic Methods for PDT Applications
- •New Perspectives
- •Other PDT Applications
- •Conclusions
- •References
- •15: Benign Airways Stenosis
- •Etiology
- •Congenital Tracheal Stenosis
- •Iatrogenic
- •Infectious
- •Idiopathic Tracheal Stenosis
- •Distal Bronchial Stenosis
- •Diagnosis Methods
- •Patient History
- •Imaging Techniques
- •Bronchoscopy
- •Pulmonary Function Test
- •Treatment
- •Endoscopic Treatment
- •Dilatation
- •Laser Therapy
- •Stents
- •How to Proceed
- •Stent Placement
- •Placing a Montgomery T Tube
- •The Rule of Twos for Benign Tracheal Stenosis (Fig. 15.23)
- •Surgery
- •Summary and Recommendations
- •References
- •16: Endobronchial Prostheses
- •Introduction
- •Indications
- •Extrinsic Compression
- •Intraluminal Obstruction
- •Stump Fistulas
- •Esophago-respiratory Fistulas (ERF)
- •Expiratory Central Airway Collapse
- •Physiologic Rationale for Airway Stent Insertion
- •Stent Selection Criteria
- •Stent-Related Complications
- •Granulation Tissue
- •Stent Fracture
- •Migration
- •Contraindications
- •Follow-Up and Patient Education
- •References
- •Introduction
- •Overdiagnosis
- •False Positives
- •Radiation
- •Risk of Complications
- •Lung Cancer Screening Around the World
- •Incidental Lung Nodules
- •Management of Lung Nodules
- •References
- •Introduction
- •Minimally Invasive Procedures
- •Mediastinoscopy
- •CT-Guided Transthoracic Biopsy
- •Fluoroscopy-Guided Transthoracic Biopsies
- •US-Guided Transthoracic Biopsy
- •Thoracentesis and Pleural Biopsy
- •Thoracentesis
- •Pleural Biopsy
- •Surgical or Medical Thoracoscopy
- •Image-Guided Pleural Biopsy
- •Closed Pleural Biopsy
- •Image-Guided Biopsies for Extrathoracic Metastases
- •Tissue Acquisition, Handling and Processing
- •Implications of Tissue Acquisition
- •Guideline Recommendations for Tissue Acquisition in Mediastinal Staging
- •Methods to Overcome Challenges in Tissue Acquisition and Genotyping
- •Rapid on-Site Evaluation (ROSE)
- •Sensitive Genotyping Assays
- •Liquid Biopsy
- •Summary, Recommendations and Highlights
- •References
- •History
- •Data Source and Methodology
- •Tumor Size
- •Involvement of the Main Bronchus
- •Atelectasis/Pneumonitis
- •Nodal Staging
- •Proposal for the Revision of Stage Groupings
- •Small Cell Lung Cancer (SCLC)
- •Discussion
- •Methodology
- •T Descriptors
- •N Descriptors
- •M Descriptors
- •Summary
- •References
- •Introduction
- •Historical Perspective
- •Fluoroscopy
- •Radial EBUS Mini Probe (rEBUS)
- •Ultrasound Bronchoscope (EBUS)
- •Virtual Bronchoscopy
- •Trans-Parenchymal Access
- •Cone Beam CT (CBCT)
- •Lung Vision
- •Sampling Instruments
- •Conclusions
- •References
- •History and Historical Perspective
- •Narrow Band Imaging (NBI)
- •Dual Red Imaging (DRI)
- •Endobronchial Ultrasound (EBUS)
- •Optical Coherence Tomography (OCT)
- •Indications and Contraindications
- •Confocal Laser Endomicroscopy and Endocytoscopy
- •Raman Spectrophotometry
- •Application of the Technique
- •Supplemental Technology for Diagnostic Bronchoscopy
- •Evidence-Based Review
- •Summary and Recommendations, Highlight of the Developments During the Last Three Years (2013 on)
- •References
- •Introduction
- •History and Historical Perspective
- •Endoscopic AF-OCT System
- •Preclinical Studies
- •Clinical Studies
- •Lung Cancer
- •Asthma
- •Airway and Lumen Calibration
- •Obstructive Sleep Apnea
- •Future Applications
- •Summary
- •References
- •23: Endobronchial Ultrasound
- •History and Historical Perspective
- •Equipment
- •Technique
- •Indication, Application, and Evidence
- •Convex Probe Ultrasound
- •Equipment
- •Technique
- •Indication, Application, and Evidence
- •CP-EBUS for Malignant Mediastinal or Hilar Adenopathy
- •CP-EBUS for the Staging of Non-small Cell Lung Cancer
- •CP-EBUS for Restaging NSCLC After Neoadjuvant Chemotherapy
- •Complications
- •Summary
- •References
- •Introduction
- •What Is Electromagnetic Navigation?
- •SuperDimension Navigation System (EMN-SD)
- •Computerized Tomography
- •Computer Interphase
- •The Edge Catheter: Extended Working Channel (EWC)
- •Procedural Steps
- •Planning
- •Detecting Anatomical Landmarks
- •Pathway Planning
- •Saving the Plan and Exiting
- •Registration
- •Real-Time Navigation
- •SPiN System Veran Medical Technologies (EMN-VM)
- •Procedure
- •Planning
- •Navigation
- •Biopsy
- •Complications
- •Limitations
- •Summary
- •References
- •Introduction
- •Image Acquisition
- •Hardware
- •Practical Considerations
- •Radiation Dose
- •Mobile CT Studies
- •Future Directions
- •Conclusion
- •References
- •26: Robotic Assisted Bronchoscopy
- •Historical Perspective
- •Evidence-Based Review
- •Diagnostic Yield
- •Monarch RAB
- •Ion Endoluminal Robotic System
- •Summary
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •General
- •Application of the Technique
- •Preoperative Care
- •Patient’s Position and Operative Field
- •Incision and Initial Dissection
- •Palpation
- •Biopsy
- •Control of Haemostasis and Closure
- •Postoperative Care
- •Complications
- •Technical Variants
- •Extended Cervical Mediastinoscopy
- •Mediastinoscopic Biopsy of Scalene Lymph Nodes
- •Inferior Mediastinoscopy
- •Mediastino-Thoracoscopy
- •Video-Assisted Mediastinoscopic Lymphadenectomy
- •Transcervical Extended Mediastinal Lymphadenectomy
- •Evidence-Based Review
- •Summary and Recommendations
- •References
- •Introduction
- •Case 1
- •Adrenal and Hepatic Metastases
- •Brain
- •Bone
- •Case 1 Continued
- •Biomarkers
- •Case 1 Concluded
- •Case 2
- •Chest X-Ray
- •Computerized Tomography
- •Positive Emission Tomography
- •Magnetic Resonance Imaging
- •Endobronchial Ultrasound with Transbronchial Needle Aspiration
- •Transthoracic Needle Aspiration
- •Transbronchial Needle Aspiration
- •Endoscopic Ultrasound with Needle Aspiration
- •Combined EUS-FNA and EBUS-TBNA
- •Case 2 Concluded
- •Case 3
- •Standard Cervical Mediastinoscopy
- •Extended Cervical Mediastinoscopy
- •Anterior Mediastinoscopy
- •Video-Assisted Thoracic Surgery
- •Case 3 Concluded
- •Case 4
- •Summary
- •References
- •29: Pleural Anatomy
- •Pleural Embryonic Development
- •Pleural Histology
- •Cytological Characteristics
- •Mesothelial Cells Functions
- •Pleural Space Defense Mechanism
- •Pleura Macroscopic Anatomy
- •Visceral Pleura (Pleura Visceralis or Pulmonalis)
- •Parietal Pleura (Pleura Parietalis)
- •Costal Parietal Pleura (Costalis)
- •Pleural Cavity (Cavitas Thoracis)
- •Pleural Apex or Superior Pleural Sinus [12–15]
- •Anterior Costal-Phrenic Sinus or Cardio-Phrenic Sinus
- •Posterior Costal-Phrenic Sinus
- •Cost-Diaphragmatic Sinus or Lateral Cost-Phrenic Sinus
- •Fissures18
- •Pleural Vascularization
- •Parietal Pleura Lymphatic Drainage
- •Visceral Pleura Lymphatic Drainage
- •Pleural Innervation
- •References
- •30: Chest Ultrasound
- •Introduction
- •The Technique
- •The Normal Thorax
- •Chest Wall Pathology
- •Pleural Pathology
- •Pleural Thickening
- •Pneumothorax
- •Pulmonary Pathology
- •Extrathoracic Lymph Nodes
- •COVID and Chest Ultrasound
- •Conclusions
- •References
- •Introduction
- •History of Chest Tubes
- •Overview of Chest Tubes
- •Contraindications for Chest Tube Placement
- •Chest Tube Procedural Technique
- •Special Considerations
- •Pneumothorax
- •Empyema
- •Hemothorax
- •Chest Tube Size Considerations
- •Pleural Drainage Systems
- •History of and Introduction to Indwelling Pleural Catheters
- •Indications and Contraindications for IPC Placement
- •Special Considerations
- •Non-expandable Lung
- •Chylothorax
- •Pleurodesis
- •Follow-Up and IPC Removal
- •IPC-Related Complications and Management
- •Competency and Training
- •Summary
- •References
- •32: Empyema Thoracis
- •Historical Perspectives
- •Incidence
- •Epidemiology
- •Pathogenesis
- •Clinical Presentation
- •Radiologic Evaluation
- •Biochemical Analysis
- •Microbiology
- •Non-operative Management
- •Prognostication
- •Surgical Management
- •Survivorship
- •Summary and Recommendations
- •References
- •Evaluation
- •Initial Intervention
- •Pleural Interventions for Recurrent Symptomatic MPE
- •Especial Circumstances
- •References
- •34: Medical Thoracoscopy
- •Introduction
- •Diagnostic Indications for Medical Thoracoscopy
- •Lung Cancer
- •Mesothelioma
- •Other Tumors
- •Tuberculosis
- •Therapeutic Indications
- •Pleurodesis of Pneumothorax
- •Thoracoscopic Drainage
- •Drug Delivery
- •Procedural Safety and Contraindications
- •Equipment
- •Procedure
- •Pre-procedural Preparations and Considerations
- •Procedural Technique [32]
- •Medical Thoracoscopy Versus VATS
- •Conclusion
- •References
- •Historical Perspective
- •Indications and Contraindications
- •Evidence-Based Review
- •Endobronchial Valves
- •Airway Bypass Tracts
- •Coils
- •Other Methods of ELVR
- •Summary and Recommendations
- •References
- •36: Bronchial Thermoplasty
- •Introduction
- •Mechanism of Action
- •Trials
- •Long Term: Ten-Year Study
- •Patient Selection
- •Bronchial Thermoplasty Procedure
- •Equipment
- •Pre-procedure
- •Bronchoscopy
- •Post-procedure
- •Conclusion
- •References
- •Introduction
- •Bronchoalveolar Lavage (BAL)
- •Technical Aspects of BAL Procedure
- •ILD Cell Patterns and Diagnosis from BAL
- •Technical Advises for Conventional TLB and TLB-C in ILD
- •Future Directions
- •References
- •Introduction
- •The Pediatric Airway
- •Advanced Diagnostic Procedures
- •Endobronchial Ultrasound
- •Virtual Navigational Bronchoscopy
- •Cryobiopsy
- •Therapeutic Procedures
- •Dilation Procedures
- •Thermal Techniques
- •Mechanical Debridement
- •Endobronchial Airway Stents
- •Metallic Stents
- •Silastic Stents
- •Novel Stents
- •Endobronchial Valves
- •Bronchial Thermoplasty
- •Discussion
- •References
- •Introduction
- •Etiology
- •Congenital ADF
- •Malignant ADF
- •Cancer Treatment-Related ADF
- •Benign ADF
- •Iatrogenic ADF
- •Diagnosis
- •Treatment Options
- •Endoscopic Techniques
- •Stents
- •Clinical Results
- •Stent Complications
- •Other Available Stents
- •Other Endoscopic Methods
- •References
- •Introduction
- •Anatomy and Physiology of Swallowing
- •Functional Physiology of Swallowing
- •Epidemiology and Risk Factors
- •Types of Foreign Bodies
- •Organic
- •Inorganic
- •Mineral
- •Miscellaneous
- •Clinical Presentation
- •Acute FB
- •Retained FB
- •Radiologic Findings
- •Bronchoscopy
- •Airway Management
- •Rigid Vs. Flexible Bronchoscopy
- •Retrieval Procedure
- •Instruments
- •Grasping Forceps
- •Baskets
- •Balloons
- •Suction Instruments
- •Ablative Therapies
- •Cryotherapy
- •Laser Therapy
- •Electrocautery and APC
- •Surgical Management
- •Complications
- •Bleeding and Hemoptysis
- •Distal Airway Impaction
- •Iron Pill Aspiration
- •Follow-Up and Sequelae
- •Conclusion
- •References
- •Vascular Origin of Hemoptysis
- •History and Historical Perspective
- •Diagnostic Bronchoscopy
- •Therapeutic Bronchoscopy
- •General Measures
- •Therapeutic Bronchoscopy
- •Evidence-Based Review
- •Summary
- •Recommendations
- •References
- •History
- •“The Glottiscope” (1807)
- •“The Esophagoscope” (1895)
- •The Rigid Bronchoscope (1897–)
- •The Flexible Bronchoscope (1968–)
- •Transbronchial Lung Biopsy (1972) (Fig. 42.7)
- •Laser Therapy (1981–)
- •Endobronchial Stents (1990–)
- •Electromagnetic Navigation (2003–)
- •Bronchial Thermoplasty (2006–)
- •Endobronchial Microwave Therapy (2004–)
- •American Association for Bronchology and Interventional Pulmonology (AABIP) and Journal of Bronchology and Interventional Pulmonology (JOBIP) (1992–)
- •References
- •Index
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ated the feasibility of using an ultrathin bronchoscope, VBN, and 2Duoroscopy with the addition of CBCT in 40 patients. The target was unable to be localized with conventional C-Armuoroscopy, but it was seen in all 40 patients with CBCT. They categorized the biopsy location into three categories: inside lesion, outside lesion, and indeterminate with goals of a CBCT target-forceps sign. The overall diagnostic yield was 90.0%. Diagnostic yield for CBCT targetforceps sign was 100%, 0%, and 75%, respectively [98]. Park et al. concluded that the only contributing factor that increases diagnostic yield is the forceps’ position assessed by CBCT [94].
Therapeutic Procedures Via FB
Therapeutic bronchoscopy refers mainly to managing central airway obstruction (CAO), which may be intrinsic, extrinsic, or combined. This entitles mechanical and non-mechanical tumor debulking in malignant and benign diseases, tracheobronchial dilatation of stenosis, deployment of airway stents, extraction and removal of foreign bodies, and management of hemoptysis. It also includes newer therapeutic applications like endobronchial valve placement for prolonged air leak post lobectomy or endoscopic lung volume reduction interventions in selected emphysema patients.
Therapeutic bronchoscopic interventions, to a certain degree, can be accomplished via the exible bronchoscope (Fig. 2.10a–c).
However, the bronchoscopist must be competent and experienced with the use of rigid bronchoscopy and ready to use it when intervening on complex central airway obstruction. The rigid bronchoscope remains the tool of choice recommended by most experts in the feld when treating CAO [15, 99].
In this chapter, we will outline a brief summary of some available interventional therapeutic
modalities that can be implemented for use withexible bronchoscopy.
LASER Bronchoscopy
The majority of publications on LASER bronchoscopy report the use of neodymium-doped yttrium aluminum garnet (Nd:YAG) LASER [100, 101]. Other LASERs like CO2, Nd:YAP neodymium doped yttrium aluminum perovskite (Nd:YAP), Holmium:YAG, and diode LASERs are utilized in bronchoscopic interventions.
In LASER therapy, the heat energy from the LASER light is used to coagulate and vaporize the endobronchial lesion.
It is recommended to set LASER at low power (40 W) to coagulate the target lesion in anticipation to prevent bleeding.
The LASER fber is introduced through the working channel of the FB. The LASER fber tip should be at least 4 mm away from both the target lesion and the bronchoscope distal end. The inspired FiO2 should be lowered to 40% or less, and frequent suctioning should be used to minimize the risk of endobronchial fre [102].
Then coagulation followed by mechanical resection with the exible forceps can occur. In general, LASER treatments performed using aexible bronchoscope are long and require a signifcant amount of patience. The exible bronchoscope is not useful in severe obstruction or critical situations; they are better handled with the rigid bronchoscope [17]. Small lesions such as granulomas are easily treated with LASER application via exible bronchoscopy.
LASER is very effective in restoring airway patency, with symptomatic improvement in around 70–80% of patients [100, 101, 103]. Complications related to LASER application include massive hemoptysis (1%), pneumothorax (0.4%), pneumomediastinum (0.2%), and endobronchial fre and peri-procedural death (2–3%) [101, 103, 104].
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c
Fig. 2.10 (a) Right main stem obstruction with squamous cell carcinoma causing post-obstructive pneumonia and severe hypoxemia. (b) The endobronchial component
of the tumor resected via a exible bronchoscope in an already intubated patient. (c) The resected tumor
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Electrocautery
Electrocautery is used to treat central airway obstructions from benign or malignant tumors of the airway [105]. It also acts through coagulation and vaporization. The electrical probe can be used to treat superfcial lesions, while the snare can be applied to polypoid tumors protruding into the airway lumen. Similar to LASER, electrocautery is contraindicated when the obstruction arises from extrinsic compression without an intraluminal component [106].
Palliation of malignant obstructions using electrocautery is effective, with a rate of restoration of airway patency and symptomatic relief similar to LASER debulking (69–94%) [107–109].
Complications are similar to those of LASER application, with massive hemoptysis being the most concerning. Suggested settings to avoid fre during the procedure are: FiO2 equal to or less than 40% and low power (20–30 W).
Argon Plasma Coagulation (APC)
APC is a non-contact mode of electrocautery that causes coagulation and vaporization. It is performed to treat exophytic endobronchial tumors and has good results treating bleeding tumors. APC can also be applied to other benign lesions compromising the airway, such as granulomas resulting from airway stents.
APC shows good results in central airway obstruction, with a partial or complete restoration of airway patency in 66% of patients. It has a reported success rate of 99% when treating hemoptysis [110].
Complications related to APC are airway perforation and gas embolism [35].
Cryotherapy
Cryotherapy refers to the use of extreme cold to destroy abnormal or diseased tissue. The cryoprobe is inserted through the working channel of the exible bronchoscope, and cycles of freezing and thawing are applied to the target, causing
delayed necrosis. Repeat bronchoscopy is performed three to seven days after the application to remove necrotic tissue. Cryotherapy does not open the airway rapidly, and it is not utilized in critical airway obstruction since its application generates edema that may worsen the degree of the obstruction.
Conventional cryotherapy is indicated in malignant airway obstruction as a palliative method. A success rate of 61% has been reported in airway restoration and signifcant improvement of symptoms such as hemoptysis, cough, and dyspnea [111, 112]. Complications related to cryotherapy are hemoptysis, bronchospasm, cardiac arrhythmia, and death [113].
A newer modality of cryotherapy called cryoextraction or cryorecanalization can be considered a rapid airway restoration method since tumor pieces attached to the cryoprobe are removed immediately [14].
Photodynamic Therapy
It involves the administration of a photosensitizer substance (most commonly porfmer sodium) followed by its activation with LASER light of a given wavelength. This generates a photodynamic reaction that produces oxygen radicals that damage tumor cells, ultimately resulting in cellular death. Photodynamic therapy can be applied to early and advanced malignant lesions with good results [114].
Complications related to this procedure are photosensitivity (can last up to six weeks) and hemoptysis.
Airway Stent Placement
The exible bronchoscope can be used to deploy self-expandable metallic stents (SEMS) in the airway. Both bare and fully covered SEMS are commercially available.
The bare SEMS’ application is limited to malignant conditions. Long-term permanence inside the airway has been linked to severe complications such as erosion and perforation of the airway wall, excessive granulation tis-
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sue, bacterial colonization, stent disruption, and fracture [115].
The Food and Drug Administration (FDA) released very clear recommendations regarding the use of metallic airway stents in 2005 [116]. Experts recommend avoiding bare metallic stents and considering other therapeutic strategies. Placement of a silicon stent can be performed in most patients via rigid bronchoscopy and represents a safer alternative [117].
However, post-surgical stenosis that follows lung transplant or tracheal resection can be an indication for metallic stents. Bronchial dehiscence after lung transplantation can present as a lifethreatening respiratory insuffciency, and deployment of a metallic stent can be life-saving and can favor healing, taking advantage of granulation tissue formation secondary to stent placement [118]. This indication is left to the team of experts managing lung-transplanted patients, not applicable to the general interventional bronchoscopy practice.
It is crucial to note that when bronchoscopists deploy a stent via exible bronchoscopy approach, they must be skilled and ready to perform rigid bronchoscopy if needed.
Endobronchial Valve Placement
Currently, two commercially FDA-approved valves for the treatment of emphysema exist.
•\ Zephyr Valve: This is a one-way silicone duckbill endobronchial valve attached to Nitinol self-expandable frame.
•\ Spiration Valve: This is an umbrella-shaped self-expanding one-way valve made of various metals, including a nickel-titanium frame. Distal anchors secure the valve against bronchial walls, with proximal struts keeping contact with the airway.
These valves can range in sizes, and depending on target airway size, they can be passed through a exible bronchoscope with a channel > 2.6 mm.
The uses for endobronchial valve (EBV) are growing but most commonly limited to severe
emphysema and a non-surgical alternative to persistent air leaks.
Criner et al. studied patients with forced expiratory volume in the frst second (FEV1) between 15 and 45% of predicted, TLC greater than 100% predicted, residual volume (RV) equal or greater than 175% predicted, and diffusion capacity of carbon monoxide (DLCO) equal or greater than 20% predicted in the lung function improvement after bronchoscopic lung volume reduction with pulmonx endobronchial valves used in the treatment of emphysema (LIBERATE) study, and demonstrated that the Zephyr EBV provides meaningful benefts in the lung function where FEV1 improved 0.106 L, and 6-min-walk distance +39.31 m. Also, the study demonstrated improvement in quality of life for these severe emphysema patients with intact fssure or lack of collateral ventilation of the target lobe [119].
The effectiveness and safety of the Spiration valves were evaluated in a multicenter, open- label, randomized controlled trial evaluation of the spiration valve system for emphysema to improve lung function (EMPROVE), including patients with severe heterogeneous emphysema with somewhat similar inclusion criteria to the LIBERATE study.
The primary effectiveness endpoint was a mean change in FEV1 post-bronchodilator from baseline to 6 months between treatment and control groups; 12-month results were also reported.
Mean FEV1 showed statistically signifcant improvements in the treatment group at 6 and 12 months, respectively, of 0.10 and 0.099 L and in health status quality of life questionnaires [120].
Pneumothorax is the most common complication, with rates ranging 12–34% without affecting survival rates [121, 122].
EBV can be used for patients with air leaks who are refractory to conventional treatments and not good surgical candidates. A balloon occlusion device is often placed in the airway to assess if the air leak has improved. If it does improve, an EBV can be considered for placement. Fiorelli et al. and Gilbert et al. both showed improvement in air leaks with EBV placement [123, 124].
Large prospective trials are ongoing to continue to evaluate effcacy and safety profle.