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Interventional Pulmonology - Coggle Diagram
Interventional Pulmonology
Diagnostic
Pre-Op Evaluation
Mallampati
Class 1 - Soft palate, uvulua, tonsillar pillars
Tonsils cannot be seen
Only base of uvula seen
No structures seen - only soft tissues
Comorbidities
COPD
Nebulizers b4 bronch is not routinely recommended
Asthma
Recommended to have nebulized bronchodilator
Morbid Obesity
Prior Anticoagulation
Stop Clopidogrel 5-7 days
No need to stop Aspirin
DOAC - usually 1 to 2 days, unless poor kidney function or high risk of bleeding
ASA -
Completely healthy patient
Mild systemic disease
Severe Systemic Disease [moderate to severe COPD]
Constant threat to life disease [advanced COPD, cardiac failure]
Not expected to live 24 hours w. or w/o surgery [Ruptured aortic aneurysm or massive PE]
E - emergency case
Sedation & Analgesia
Topical Anesthesia
Benzocaine & Tetracaine should be used in extreme caution b/c risk of induced methemoglobinemia
Must get an ABG with coaxometry to detect MethHb
Lidocaine
Preferred topical anesthesia
If someone is seizing during bronchscopy, its usually lidocaine
Do not exceed > 7mg/kg
Can use 1% lidocaine - similar efficacy than 2%
Nebulized lidocaine is NOT better than topical.
Anticholinergic Agents [Atropine & Glycopyrrolate] - DO NOT GIVE
Studied & found no significant improvement
Bleeding Management
No need to check routine coagulation testing
Stablize
Wedge the scope at location of bleeding - bad lung down
Stop the bleeding [iced saline, epi [not preferred]
Intubate then on-bleeding lung
Large Airway Disorders
Central Airway Obstruction & Tracheal Stenosis
Etiology
Tracheal Stenosis
Web-like
Bottle-neck stenosis
Mixed [complex] stenosis
Malignant
Benign
Management
Surgical Management
Best option --. Decreases SOB & Quality of Life. Increase in FEV1
EXCEPT if proximal to vocal cords [<2 cm] or length of stenossi > 4-5 cm
Nonsurgical Management
Debulk & Dilate --> only helps to de-esclaate care
Lsaer, cautery
Balloon dilation, airway stenting
Recurrence is rule rather than an exception
Degree of Airway Obstruction
Lesions must narrow the tracheal lumen to less than 8 mm before abnromalities can be detected
Look at flow volume loop -> extrathoracic [trachea from thoracic outlet to your vocal cords] vs. intrathoracic
Foreign Objects Inhalation
1-2 year olds [children eat stuff] & 51-80 [loss of airway protection]
Imaging Studies
< 20% of FB are radiopaque
CT is more sensitivite than CXR
Surggate Imaging -> CXR with hyperinflation
Management
Airway Control
Flexbile Bronch
Rigid Bronch if needed for sharp or large objects
Tracheobronchomalacia (TBM) & Excessive Dyanamic Airway Collapse (E-DAC)
Workup
Dyanmic CT [inspiratory & expiratory imaging]
PFTS
Bronchscopy
Bronchscopy Findings
Need to do under mild sedation. b/c you want to see airway collapse with inspiration, expiraion, maneuvers, and coughing
Management
Look at Degree of airway collapse with bronch
90% collapse of airway during exhalation
Conservative Treatemnt
Tx coexisting conditions [COPD,asthma,GERD,VCD]
Supportive treatment [abx, airway clering regimen, pulm rehab]
CPAP during daytime
Stents
Temporary to see if trach helps
If it does, then tracheobronchoplasty [3-4 hr. long surgery]
Etiology
TBM - softening of cartilages of the trachea
EDAC - excessive laxity of posterior membranous wall with an intact integrity of cartilagionous support [70% collapse]
Key Points
TBM/EDAC: If you cant explain dyspnea & imaging is clear, consider dynamic [inspiratory & expiratory CT chest]
Confirm TBM/EDAC with awake or light sedation bronchscopy: It will also allow you to evaluate from VCD
Tracheal Stenosis: Surgical treatment is unlikely if the stenosis is less than 2 cm from the cords or if it more than 4-5 cm long
Be aware of foreign object inhalation symptoms as they can be subtle and can mimic other chronic airway disease
Advanced Diagnostic Bronchscopy
Endobronchial Ultrasound
Radial Ultrasound
Navigation Bronchscopy
Robotic Bronchscopy
Staging TNM System
Biopsy the place that gives you the highest stage
