Latest bronchoscopy data

                

We have touched  a triple century... Here is the latest bronchoscopy data from our center.

 



Data current as of  15/8/16.

Amritsar bronchoscopy hands on workshop

A workshop was conducted by the Department of Pulmonary Medicine, Government Medical College, Amritsar on Bronchoscopy and Medical thoracoscopy where I was invited to give talks on TBNA, EBUS-TBNA and Medical Thoracoscopy along with hands-on workshop. Thanks to the organizers for inviting me. It was educational interacting with the post graduate students.

Changing scenario of Sarcoidosis in India

There has been a rapid change in recognition and spectrum of sarcoidosis in India in the last decade. This was considered a rare disease almost till the end of the last century even though the disease was recognized and reported from different places. The change is remarkable considering the fact that the number of publications on the subject has suddenly jumped in the last decade. Of 340 total papers which are listed in PubMed since 1980, about two-third (228) have appeared in the last 10 years. There were only rare publications before 1980. The increase can be attributed to several different causes:

1. True increase in incidence
2. Increased awareness of disease among physicians. Many cases of sarcoidosis were dismissed as tuberculosis in the past.
3. Increased availability of diagnostic tests such as chest CT scanning, fiberoptic bronchoscopy and endo-bronchial ultrasound sound guided fine needle aspiration (EBUS-FNA)
4. Insistence of physicians as well as patients in making a confirmed diagnosis than starting anempiric treatment

Clinical spectrum of sarcoidosis: There is also a change in the spectrum of disease and organ involvement described in the reports of the recent past. Previously, it was mostly the pulmonary involvement i.e. hilar and mediastinal lymphadenopathy which was commonly described. Now, there is a greater recognition of extra-pulmonary involvement including that of the liver, spleen, nervous system and other organs. Moreover, atypical pulmonary presentations such as miliary involvement of lung parenchyma and pleural effusions are frequently reported. It is again a moot question whether this finding is a true change in the spectrum or only an increased recognition because of the factors already listed above.

Sarcoidosis tuberculosis enigma continues to bother physicians in India not only because of similar presentations of both diseases but also since the treatments are different for the two diseases. Corticosteroids, which are used for sarcoidosis may in fact precipitate tuberculosis and are necessarily avoided except in a few specific situations. There is no place to start the treatments for both conditions simultaneously as had been a common practice in the past. It is therefore important to make a firm diagnosis before starting treatment for either condition.

The other major shift which has happened relates to the more frequent use of non-steroidal drugs. Drugs such as methotrexate, hydroxy chloroquin and other immunosuppressants are now available for use for relapse and in the presence of co-morbidities with or without corticosteroid therapy, depending upon the clinical condition.  

S.K. Jindal

Medical Director, Jindal Clinics, Chandigarh

Air in the Pleural Cavity - Pneumothorax

Air is normally present in the lungs. On the other hand, the pleural cavities on the two sides (Right and left) formed by the two pleural membranes on the surface of the lungs are empty. The negative pressure in the pleural cavities keeps the lungs expanded with air. In some diseases of the lungs or due to injury to the pleural membrane, the air can enter the pleural cavity on either side. This condition is called ‘pneumothorax’ i.e. air the thorax – pleural cavity. (Pneumothorax is defined as presence of air in the pleural cavity, i.e. between the lung and the chest wall). Presence of air within the pleural space causes collapse of the lung.

 

TYPES OF PNEUMOTHORAX

 Pneumothorax is traditionally divided into primary and secondary varieties.  

1. Spontaneous pneumothorax which occurs in the absence of external trauma.

i)                    Primary spontaneous where the underlying lung is healthy.

ii)            Secondary spontaneous where the pneumothorax occurs as a complication of some underlying disease.

2. Traumatic:  It can result from injury from outside.

CAUSES OF PNEUMOTHORAX

1.      Primary spontaneous pneumothorax: It is caused by the rupture of sub pleural emphysematous blebs which may be congenital or acquired.  Recent studies have demonstrated such small emphysematous changes in up to 80% patients of spontaneous pneumothorax on CT scan.  Some risk factors identified for primary pneumothorax are:

• Tall and thin body habitus
• Smoking.  Risk may be as high as 100 times in heavy smokers (>20 cigarettes/day).
• Genetic and inherited factors like presence of HLA A2, B40 haplotype.
• Marfan’s syndrome
• Mitral valve prolapse
• Broad swings in atmospheric pressure, e.g., going on high altitude etc.
• Bronchial abnormalities like disproportionate bronchial anatomy.

2.      Secondary spontaneous pneumothorax: The incidence of secondary spontaneous pneumothorax is almost the same as that of primary spontaneous.  Tuberculosis and Chronic Obstructive Pulmonary Disease (COPD) are the common causes.  Almost every lung disease is known to be associated with pneumothorax.

Other known causes are:

• Infections.  Necrotizing pneumonias, lung abscess
• Interstitial lung disease.  Rheumatoid arthritis, Wegener’s granulomatosis, idiopathic pulmonary fibrosis etc.
• Occupational disease.  Silicosis, coal workers’ pneumoconiosis
• Neoplastic disorders.  Bronchogenic carcinoma, lymphangioleiomyomatosis
• Rare causes.  Pulmonary infarction, Bronchial asthma, Cystic fibrosis, Eosinophilic granuloma, Post-irradiation, etc.

3.      Traumatic Pneumothorax:  Trauma can result in pneumothorax in the following three ways viz.,

• Blunt injury to chest and abdomen
• Penetrating injuries to chest
• Iatrogenic, following procedures like pleural tap, pleural biopsy, needle aspirations from intrathoracic lesions, bronchoscopy and lung biopsies, endoscopy and sclerotherapy.

CLINICAL FEATURES

Symptoms:  Primary spontaneous pneumothorax usually develops suddenly.  It has no relation to heavy exertion as is usually believed.  Symptoms depend on the amount of air present in the pleural cavity.  If pneumothorax is small there may be no symptom and it may be detected by chance on routine chest x-ray.  Main symptoms are chest pain and dyspnea.  Chest pain is sharp, pleuritic, acute in onset and localized to the side of the pneumothorax.  Dyspnea is proportional to the amount of pneumothorax.  Secondary pneumothorax is usually more symptomatic because of the pre-existing compromised lung functions.

Tension Pneumothorax

This clinical syndrome associated with any sort of pneumothorax is a medical emergency and needs urgent recognition and attention.  It develops due to persistent air leak into the pleural cavity by a communication which opens up only during inspiration when pleural pressures rises, thus acting as a check valve.   Air accumulates with each successive breath and causes rising pressure in the pleural cavity thereby causing shift of mediastinum to the opposite side and pressure on great vessels.  There is decreased venous return to the heart and cardiac output falls leading to hypotension and cyanosis.

It commonly presents with sudden onset of shortness of breath or sudden increase in symptoms in a patient of pneumothorax. In addition, tachypnea, tachycardia, hypotension, cyanosis and pulsus paradoxus are usually present.

DIAGNOSIS

A high index of suspicion is required to diagnose pneumothorax in a given clinical setting.  Chest x-ray usually confirms the suspected pneumothorax.  It is also helpful in quantitating the pneumothorax. 

Chest CT scan is required to confirm a small pneumothorax and to see the condition of the underlying lung. Differentiation from a large bulla is at times very difficult on a plain chest x-ray.

TREATMENT

The treatment of pneumothorax is aimed at:

A.  Removal of air from pleural space, and

B.  Prevention of recurrence.

1. Removing air from pleural space

Pneumothorax needs aspiration if it is symptomatic, more than 20%, and if the underlying lung is diseased. Secondary spontaneous pneumothorax is better managed with intercostal tube drainage.

Intercostal tube drainage (ICTD) is required for all cases of:

       i)          Tension pneumothorax

ii)                  Secondary pneumothorax

iii)                Failed aspiration in primary pneumothorax

The tube should be kept under water seal or one way valve if available, should be used.  Once the lung expands, the tube should be clamped for 12-24 hours and a check x-ray should be done to exclude the recurrence before removing the tube.  Chest tube should be kept in situ for at least 24 hours after the lung has expanded and the air leak has ceased.  This is known to be associated with lesser recurrence rates than when ICTD is removed earlier.

Tension Pneumothorax needs immediate relief of tension.  It can be achieved by simply inserting a small needle (16G) into the pleural space even without any under water seal to relieve the tension till an ICTD can be put in place.

2. Preventing Recurrence

About 20-25% patients with primary spontaneous pneumothorax have recurrence in the first year.  Risk for second and third recurrence is even higher reaching up to 80% after the third episode.  The recurrence rates for secondary spontaneous pneumothorax are a little higher.

Pleurodesis:  Pleurodesis involves instillation of talc or other adhesive material into the pleural cavity before removal of ICTD. The resultant fusion of pleural membranes prevents recurrence of pneumothorax in future. Some people advocate instillation of sclerosing agent after the first episode of primary spontaneous pneumothorax while others believe it to be necessary only after the second episode on the same side. 

Role of Thoracoscopy: Thoracoscopy is a useful method to examine the pleural cavity from within, remove the air/fluid and produce pleurodesis. One can also look for the cause of recurrent of persistent air leaks, if any. Indications for thoracoscopy in a case of pneumothorax are:

 a) Poor expansion of lung after 5 days of ICTD.

 b) Persistent air leak after 5 days of ICTD.

 c) Failed chemical pleurodesis.

RE-EXPANSION PULMONARY EDEMA can rarely occur following drain of a massive pneumothorax in a short span of time. It occurs more frequently if the lung has remained collapsed for longer period and if negative pressure is applied.  Preventive steps include slow removal of fluid/air, avoidance of negative pressures in draining pneumothorax and careful monitoring.

 SUMMARY

• Pneumothorax is a medical emergency which needs to be recognized with a high index of suspicion and should be treated promptly.
• It can occur in previously healthy lungs or in a patient with a pre-existing lung disease.
• Symptoms will depend on the amount of air present in the pleural cavity and if under tension, it can be life threatening.
• Treatment lies in the drainage of air from the pleural space which can be achieved with the help of inter-costal tube insertion.
• Chances of recurrence are prevented by pleurodesis done through instillation of sclerosing agents within the pleural cavity.
• Thoracoscopy is important to do especially in cases of persistent and/or recurrent pneumothorax both to examine the source of air leak and to produce pleurodesis.

150 bronchoscopies completed

We have completed 150 bronchoscopies in just over 1 year.  We were able to diagnose 63 new cases of sarcoidosis out which 56 were EBUS procedures. 18 malignancies were also diagnosed.
The current EBUS number is about to touch 100.

The data is as follows:

100 bronchoscopies completed

Our centre for interventional pulmonology has completed one year and alongside --> 100 bronchoscopies. Thanks to God and patients who made this possible.

What is bronchoscopy?

The lungs are host to many diseases, like tuberculosis, cancer, pneumonia, asthma, etc. In order to treat them properly, specialized diagnostic tests are required – bronchoscopy is one such test. It involves the insertion of a flexible endoscope or bronchoscope through either the mouth or the nose into the lungs and the respiratory system. The bronchoscope is connected to a camera and monitor to visualize the interior of the lungs. One can see various abnormalities like cancer growths, bleeding spots, foreign bodies, etc. Additionally, the bronchoscope is hollow – like a pipe – through which special instruments can be passed in order to take pieces (called biopsies) from abnormal areas seen inside. These pieces or biopsies are then studied under the microscope for proper and accurate diagnosis of various diseases.

Various types and sizes of bronchoscopes are available for all ages and diseases. One of the new type is called an Endo bronchial ultrasound bronchoscope or an EBUS scope. The EBUS scope has an ultrasound transducer built-in into the tip of the scope – which is the end that goes into the lungs. With the help of the ultrasound the internal structures can be accurately imaged and all biopsies taken directly under guidance of the ultrasound. This increases the safety, accuracy and yield of the procedure.

The diseases which usually need bronchoscopy for diagnosis include lung cancer, sarcoidosis, some types of tuberculosis, interstitial lung disease (lung shrinkage), etc. Another important use is the removal of foreign bodies especially in children.