The first known bronchoscopy was performed by Gustav Killian in 1897 when he removed a pork bone from the right mainstem bronchus of a patient. For the subsequent 70 years, bronchoscopy was predominantly a therapeutic procedure performed for foreign body extraction. Two events shifted the landscape of bronchoscopy—the lung cancer epidemic and the development of flexible bronchoscopy by Shigeto Ikeda in 1967. Following an escalation in lung cancer incidence, malignant airway obstruction requiring therapeutic intervention became much more common than foreign body extraction. As a result, new tools were developed to address malignant airway obstruction based upon a minimally-invasive bronchoscopic approach. In addition, bronchoscopy-based technology has been developed to treat asthma, as well as select chronic obstructive pulmonary disease (COPD) phenotypes. This chapter presents an overview of interventional bronchoscopy and related modalities that can be utilized for benign and malignant airway obstruction, COPD, and asthma.
INDICATIONS FOR INTERVENTIONAL BRONCHOSCOPY
Many potential indications for interventional bronchoscopy have been recognized, including malignant airway obstruction, benign airway obstruction, and foreign body extraction, among others (Table 34-1). The majority of therapeutic bronchoscopies performed today are undertaken for management of malignant airway obstruction, most commonly from lung cancer. It is estimated that up to 40% of patients with lung cancer develop symptomatic airway obstruction at some point during their disease process. Although lung cancer is the most common source of malignant airway obstruction, any primary thoracic malignancy or pulmonary metastases may result in symptomatic airway obstruction. Regaining airway patency to palliate symptomatic dyspnea and other respiratory symptoms can significantly improve the quality of life for patients with advanced malignancy.
TABLE 34-1Indications for Interventional Bronchoscopy ||Download (.pdf) TABLE 34-1 Indications for Interventional Bronchoscopy
Atelectasis from inspissated secretions
Foreign body removal
Tracheobronchial tree neoplasms (primary or metastatic)
Direct bronchoscopic debulking
Electrocautery/argon plasma coagulation
Airway strictures and stenoses
Rigid bronchoscopic dilation
Balloon tracheobronchoplasty dilation
Lung lavage (pulmonary alveolar proteinosis)
Bronchoscopic drainage—lung abscess
Endotracheal tube and percutaneous tracheostomy placement
Treatment of persistent air leak
Evolving therapies for emphysema
Bronchial thermoplasty in severe asthma
Benign airway obstruction etiologies are listed in Table 34-2 and consist of a variety of localized inflammatory and systemic conditions. Although the etiologic airway process is benign and not malignant, the interventions and management of these complex processes are far from benign to the patient. Interventional bronchoscopy techniques can often improve the presenting symptoms; however, symptomatic stenosis often recurs, and patients may require repeat procedures to maintain airway patency. Selected patients may need to proceed with airway resection of the benign stenotic airway segment.1
TABLE 34-2Etiologies of Benign Tracheobronchial Stenosis ||Download (.pdf) TABLE 34-2 Etiologies of Benign Tracheobronchial Stenosis
Granulomatosis with polyangiitis (formerly known ...