Pulmonary Procedures

Bronchoscopy

Bronchoscopy is a test to view the airways and diagnose lung disease. It may also be used during the treatment of some lung conditions.

 

How the Test is Performed

A bronchoscope is a device used to see the inside of the airways and lungs. The scope can be flexible or rigid. A flexible scope is almost always used. It is a tube less than one half inch (1 centimeter) wide and about 2 feet (60 centimeters) long. In rare cases, a rigid bronchoscope is used.

  • You will likely get medicines through a vein (IV, or intravenously) to help you relax. Or, you may be asleep under general anesthesia, especially if a rigid scope is used.

  • A numbing drug (anesthetic) will be sprayed in your mouth and throat. If bronchoscopy is done through your nose, numbing jelly will be placed in the nostril the tube goes through.

  • The scope is gently inserted. It will likely make you cough at first. The coughing will stop as the numbing drug begins to work.

  • Your health care provider may send saline solution through the tube. This washes the lungs and allows your provider to collect samples of lung cells, fluids, microbes and other materials inside the air sacs. This part of the procedure is called a lavage.

  • Sometimes, tiny brushes, needles, or forceps may be passed through the bronchoscope to take very small tissue samples (biopsies) from your lungs.

  • Your provider can also place a stent in your airway or view your lungs with ultrasound during the procedure. A stent is a small tube-like medical device. Ultrasound is a painless imaging method that allows your provider to see inside your body.

  • Sometimes ultrasound is used to see the lymph nodes and tissues around your airways. 

  • At the end of the procedure, the scope is removed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How to Prepare for the Test

Follow instructions on how to prepare for the test. You will likely be told:

  • Not to eat or drink anything for 6 to 12 hours before your test.

  • Not to take aspirin, ibuprofen, or other blood-thinning drugs before your procedure. Ask the provider who will do your bronchoscopy when to stop taking these drugs.

  • Arrange for a ride to and from the hospital.

  • Arrange for help with work, child care, or other tasks, as you will likely need to rest the next day. 

 

Usually, the test is done as an outpatient procedure and you will go home the same day. Some people may need to stay overnight in the hospital.

 

How the Test Will Feel

Local anesthetic is used to relax and numb your throat muscles. Until this medicine begins to work, you may feel fluid running down the back of your throat. This may cause you to cough or gag.

Once the medicine takes effect, you may feel pressure or mild tugging as the tube moves through your windpipe. Although you may feel like you are not able to breathe when the tube is in your throat, there is no risk of this happening. The medicines you receive to relax will help with these symptoms. You will likely forget most of the procedure. 

When the anesthetic wears off, your throat may be scratchy for several days. After the test, your ability to cough (cough reflex) will return in 1 to 2 hours. You will not be allowed to eat or drink until your cough reflex returns.

Why the Test is Performed

You may have a bronchoscopy to help your provider diagnose lung problems. Your provider will be able to inspect your airways or take a biopsy sample.

Common reasons to do a bronchoscopy for diagnosis are:

  • An imaging test showed abnormal changes of your lung, such as a growth or tumor, changes or scarring of lung tissue, or collapse of one area of your lung.

  • To biopsy lymph nodes near your lungs.

  • To see why you are coughing up blood.

  • To explain shortness of breath or low oxygen levels.

  • To see if there is a foreign object in your airway.

  • You have a cough that has lasted more than 3 months without any clear cause.

  • You have an infection in your lungs and major airways (bronchi) that cannot be diagnosed any other way or need a certain type of diagnosis.

  • You inhaled a toxic gas or chemical.

  • To see if a lung rejection after a lung transplant is occurring. 

 

You may also have a bronchoscopy to treat a lung or airway problem. For example, it may be done to:

  • Remove fluid or mucus plugs from your airways

  • Remove a foreign object from your airways

  • Widen (dilate) an airway that is blocked or narrowed

  • Drain an abscess

  • Treat cancer using a number of different techniques

  • Wash out an airway 

 

Normal Results

Normal results mean normal cells and fluids are found. No foreign substances or blockages are seen.

What Abnormal Results Mean

Many disorders can be diagnosed with bronchoscopy, including:

  • Infections from bacteria, viruses, fungi, parasites, or tuberculosis.

  • Lung damage related to allergic-type reactions.

  • Lung disorders in which the deep lung tissues become inflamed due to the immune system response, and then damaged. For example, changes from sarcoidosis or rheumatoid arthritis may be found.

  • Lung cancer, or cancer in the area between the lungs.

  • Narrowing (stenosis) of the trachea or bronchi.

  • Acute rejection after a lung transplant. 

 

Risks

Main risks of bronchoscopy are:

  • Bleeding from biopsy sites

  • Infection 

 

There is also a small risk for:

  • Abnormal heart rhythms

  • Breathing difficulties

  • Fever

  • Heart attack, in people with existing heart disease

  • Low blood oxygen

  • Collapsed lung

  • Sore throat 

 

Risks when general anesthesia is used include:

  • Muscle pain

  • Change in blood pressure

  • Slower heart rate

  • Nausea and vomiting 

 

Alternative Names

Fiberoptic bronchoscopy; Lung cancer - bronchoscopy; Pneumonia - bronchoscopy; Chronic lung disease - bronchoscopy

Thoracentesis

Thoracentesis is a procedure to remove fluid from the space between the lining of the outside of the lungs (pleura) and the wall of the chest.

How the Test is Performed

The test is done in the following way:

  • You sit on a bed or on the edge of a chair or bed. Your head and arms rest on a table.

  • The skin around the procedure site is cleaned. A local numbing medicine (anesthetic) is injected into the skin.

  • A needle is placed through the skin and muscles of the chest wall into the space around the lungs, called the pleural space. The health care provider may use ultrasound to find the best spot to insert the needle.

  • Fluid is drawn out with the needle.

  • The fluid may be sent to a laboratory for testing (pleural fluid analysis).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How to Prepare for the Test

No special preparation is needed before the test. A chest x-ray or ultrasound will be done before and after the test.

DO NOT cough, breathe deeply, or move during the test to avoid injury to the lung.

 

How the Test Will Feel

You will feel a stinging sensation when the local anesthetic is injected. You may feel pain or pressure when the needle is inserted into the pleural space.

Tell your provider if you feel short of breath or have chest pain.

 

Why the Test is Performed

Normally, very little fluid is in the pleural space. A buildup of too much fluid between the layers of the pleura is called a pleural effusion.

The test is performed to determine the cause of the extra fluid, or to relieve symptoms from the fluid buildup.

Normal Results

Normally the pleural cavity contains only a very small amount of fluid.

 

What Abnormal Results Mean

Testing the fluid will help your provider determine the cause of pleural effusion. Possible causes include:

  • Cancer

  • Liver failure

  • Heart failure

  • Low protein levels

  • Kidney disease

  • Trauma or post-surgery

  • Asbestos-related pleural effusion

  • Collagen vascular disease (class of diseases in which the body's immune system attacks its own tissues)

  • Drug reactions

  • Collection of blood in the pleural space (hemothorax)

  • Lung cancer 

  • Swelling and inflammation of the pancreas (pancreatitis)

  • Pneumonia

  • Blockage of an artery in the lungs (pulmonary embolism)

  • Severely underactive thyroid gland

 

If your provider suspects that you have an infection, a culture of the fluid may be done to test for bacteria.

Risks

Risks may include any of the following:

  • Bleeding

  • Infection

  • Pneumothorax

  • Respiratory distress 

 

Considerations

A chest x-ray is commonly done after the procedure to detect possible complications.

 

Alternative Names

Pleural fluid aspiration; Pleural tap

Content provided by MedlinePlus.

Endobronchial Ultrasound (EBUS)

What Is It

Endobronchial ultrasound-guided transbronchial needle aspiration is a special technique used to take samples of body tissue from inside the chest. It is also known as EBUS TBNA for short. The procedure is carried out using a special kind of bronchoscope. This is a thin flexible kind of 'telescope' which passes through the mouth and into the airways. The bronchoscope (often shortened to 'scope') allows doctors to see inside the lungs and carry out the procedure.

Endobronchial means from inside or within the bronchus. The bronchi (the plural of bronchus) are large tube-like airways. They take air from the windpipe (trachea) to the smaller airways, called the bronchioles. During the procedure ultrasound is used to help the doctor doing the test see the structures just outside the airways. This gives the test the first part of its name. The scope also contains a very fine needle. This needle is used to take samples of body tissue by pushing through the bronchus to the tissue on the other side. The needle holds the sample of tissue; this is called aspiration. Transbronchial means across the bronchus, giving the name transbronchial needle aspiration.

 

 

What Is It Used For

EBUS TBNA allows doctors to take samples of tissue without having to do an operation. It is used to take tissue samples from an area of the body called the mediastinum. The mediastinum is part of the chest and contains the heart, thymus, esophagus, windpipe (trachea) and various nerves and lymph nodes. This area of the body is normally very difficult to reach, which is why EBUS TBNA is such a useful procedure.

It may be used to:

  • Investigate enlarged lymph nodes in the mediastinum.

  • Diagnose conditions such as sarcoidosis or tuberculosis.

  • Diagnose cancer outside the bronchi.

  • 'Stage' cancer by taking tissue samples from the lymph nodes.

 

Your doctor should tell you why the procedure is being done.

EBUS and Staging

One of the main uses for EBUS TBNA is in the staging of cancer. The stage of a cancer is a measure of how much the cancer has grown and spread. Depending on the type of cancer, there may be several different tests used to 'stage' the cancer. By accurately determining the stage, doctors can decide which treatment may be best and give a better idea of what might happen next. One of the ways doctors assess the stage of a cancer is to see if it has spread to structures called lymph nodes.

Lymph nodes are part of the lymphatic system. This is a network of channels and vessels that carry a fluid called lymph. Lymph nodes act like a filter for lymph. They contain white blood cells which can recognize germs (bacteria and pathogens) which have entered the lymph via the bloodstream. When foreign material is detected, other dedicated immune cells are recruited to the node to deal with the infection. This is why lymph nodes may become swollen when you have an infection. Lymph nodes can also become swollen in some forms of cancer. Cancer cells can break off from the main tumor and enter the lymph. These cells may then collect in the lymph nodes. By checking the lymph nodes for signs of cancerous cells, doctors can see if cancer has spread within the body. 

How Does It Work

By using the flexible scope doctors can gain access to the airways of the lungs. The scope has a special ultrasound probe on the end. This provides ultrasound images that are transmitted to a TV monitor for the doctor to see.

Ultrasound is a high-frequency sound that you cannot hear but it can be emitted and detected by the probe on the end of the scope. Ultrasound travels freely through fluid and soft tissues. However, ultrasound is reflected back (it bounces back as 'echoes') when it hits a more solid (dense) surface. For example, the ultrasound will travel freely though blood in a heart chamber. However, when it hits a solid valve, a lot of the ultrasound echoes back.

So, as ultrasound 'hits' different structures of different density in the body, it sends back echoes of varying strength.

The probe is connected to the ultrasound machine and monitor. Pulses of ultrasound are sent from the probe into your body. The ultrasound waves then 'bounce back' (echo) from the various structures surrounding the bronchus.

The echoes are detected by the probe and are sent to the ultrasound machine. They are displayed as a picture on the monitor. The picture is constantly updated so the scan can show movement as well as structure.

In effect, the ultrasound allows the doctor to see through the airways by showing what is on the other side. This allows the doctor to find the lymph node or tissue they want to sample. Then they can use the needle to take a sample of that tissue, while avoiding other structures such as blood vessels. This makes EBUS TBNA an extremely useful method of taking samples from tissue just outside the airways.

What Happens on Procedure Day

This is usually done as an outpatient or day case. Some hospitals may do the procedure under general anesthetic; the following is a description of the outpatient procedure. The doctor will usually numb the back of your throat by spraying on some local anesthetic. This may taste a bit unpleasant. Also, you will be given a sedative to help you to relax. This is usually given by an injection into a vein in the back of your hand. The sedative can make you drowsy but it is not a general anesthetic and does not 'put you to sleep'. However, you are unlikely to remember anything about the procedure if you have a sedative. You may also receive some pain relief into the back of your hand to make you more comfortable.  If general anesthesia is used for the procedure, then you will be put completely asleep until the procedure is over.  You will be carefully monitored and taken care of by a trained anesthesiology provider if this is the case.

You will be connected to a monitor to check your heart rate and blood pressure during the procedure. A device called a pulse oximeter will be put on a finger. This does not hurt. It checks the oxygen content of the blood and will indicate if you need extra oxygen during the EBUS TBNA. You may have a soft plastic tube placed just inside your nostril to give you oxygen during the procedure.  If general anesthesia is used, then a trained anesthesiology provider will insert a laryngeal mask airway (breathing tube above your vocal cords) or endotracheal tube (breathing tube that passes through vocal cords).

The doctor will insert the tip of the scope into your mouth and then gently guide it around the back of your throat into your windpipe (trachea).  If general anesthesia is used, the scope will be inserted through the breathing tube and guided into your windpipe (trachea).  The scope transmits pictures through a camera attachment on to a TV monitor for the doctor to look at. The bronchoscope may make you cough if general anesthesia is not used.

Once the scope is in position, the doctor uses the ultrasound pictures to take the samples of tissue (called biopsy samples). This is painless. The biopsy samples are sent to the laboratory for testing and to look at under the microscope.  If a pathologist is available, he or she may be able to view the biopsy samples under a microscope during the procedure.  The pathologist mat then be able to provide a preliminary result on the day of procedure. The bronchoscope is then gently pulled out. The procedure itself usually takes about 30 to 60 minutes. However, it may take up to four hours for the whole appointment - to prepare, give time for the sedative to work, for the EBUS TBNA itself and to recover.

How to Prepare for the Procedure

Your doctor will give you specific information about what you need to do to prepare for the EBUS TBNA. You may have a blood test, done shortly before the procedure, to check how well your blood will clot. This is to make sure that you are not likely to bleed following the procedure. You may be advised not to take any medicines that affect blood clotting, such as aspirin and warfarin, for one week before the test. It is important that you let your doctor know what medications you are taking and why you take them.

In addition to this, you should receive instructions from the doctor before the test. These usually include:

  • That you should not eat or drink for several hours before the procedure. (Small sips of water may be allowed up to two hours before the test.)

  • That you will need somebody to accompany you home, as you will be drowsy with the sedative.

What to Expect After the Procedure

After you have the sedative you may take an hour or so before you are ready to go home after the procedure has finished. The sedative will normally make you feel quite pleasant and relaxed. However, you should not drive, operate machinery or drink alcohol for 24 hours after having the sedative. You should not eat or drink anything for two hours after the bronchoscopy because your throat will still be numb. You will need somebody to accompany you home and to stay with you for 24 hours until the effects have fully worn off. Most people feel able to resume normal activities after 24 hours.

What Are the Side Effects of Complications

Most are done without any problem. Your throat may be a little sore for a day or so afterwards. You may feel tired or sleepy for several hours, caused by the sedative. You may also cough up a little blood for a couple of days following the test. You should consult your doctor if:

  • You have chest pain that doesn't settle after a couple of days.

  • You continue to cough up blood.

 

EBUS TBNA is considered to be a very safe test. Very rarely, an EBUS TBNA can cause damage to the lung. This can sometimes allow air to enter the mediastinum or even more infrequently 'collapse' a lung. It is also possible, although very uncommon, for the procedure to cause an infection or bleeding in the lung. Your doctor should explain the usual risks and possible side-effects before carrying out the procedure.

Adapted from content provided by Patient.info .

Electromagnetic Navigation Bronchoscopy (ENB)

What Is It

An Electromagnetic Navigation Bronchoscopy (ENB) procedure is used when a CT scan reveals a spot in your lung that is in a location difficult to reach with traditional bronchoscopy. Many times, lung lesions are beyond the reach of the bronchoscope. ENB procedures use a navigation catheter that extends the reach of a bronchoscope. Doctors use ENB procedures to access the very farthest areas of your lung, where they will gather tissue from your lung to make a diagnosis and consider treatment options. To date, more than 70,000 patients worldwide have had an ENB procedure.

 

 

 

 

 

 

What to Expect During Procedure

During the ENB procedure, your doctor will insert a bronchoscope through your airways and into your lungs. A bronchoscope is a lighted tube that’s about the width of a pencil. Once the tube is in place, your doctor will insert specially designed tools to take a tissue sample for testing. The procedure takes, on the average, between 30 minutes and one hour to complete and, for many people, can be performed on an outpatient basis with no overnight stay.  On occasion, the procedure may take up to 90 minutes depending on location of the target lesion and if additional procedures are performed in conjunction with ENB (for example, if endobronchial ultrasound (EBUS) is used to biopsy additionap lymph nodes). 

How Is This Different from Traditional Bronchoscopy

Traditional bronchoscopy has helped many doctors aid in the diagnosis of lung cancer; however, this procedure only allows doctors to reach the center regions of the lung. The superDimension™ navigation system allows physicians access to the outermost areas of the lung while still minimizing the invasiveness and recovery time needed for a surgical diagnostic procedure.

How Does the Technology Work

It works much like the Global Positioning System (GPS) in your car or phone. Using a CT scan, the superDimension™ navigation system creates a three-dimensional map of the lungs. Your doctor uses their technology and the 3D map it generates to access your lung lesion, where they can use tiny biopsy tools to take samples and prepare for any additional procedures, giving you personalized treatment options tailored to your specific case.

What Is a Fiducial Marker

In addition to collecting lung tissue samples during your ENB procedure, your doctor may also decide to place fiducial markers. These extremely tiny markers are placed in the lung tissue around the lesion in order to help easily locate the lesion again in case any additional procedures are necessary.

What Are the Risks of the Procedure

The most common risk is pneumothorax (collapsed lung). However, the risk is lower compared to other conventional diagnostic procedures such as needle biopsies (including a transthoracic needle aspiration [TTNA], a CT-guided fine-needle aspiration biopsy [CTFNA], or a Transthoracic Needle Biopsy [TTNB]) and invasive procedures.

When Lung Biopsy Results Are Available

Sometimes there may be experts in the room during the ENB procedure so they can test the sample right away; other times they will send the sample to a lab and give you your results at a later time.

 

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