Bronkoskopi L

BRONKOSKOPILian Lanrika Waidi Lubis BRONKOSKOPI  Broncho = batang tenggorokan Scopos = melihat atau menonton Bronkoskopi : Tindakan medis yang bertujuan untuk melakukan visualisasi trakea dan bronkus, berfungsi dalam prosedur diagnostik dan terapi penyakit paru.  BRONKOSKOPI  Bronkoskop kaku = Rigid Bronchoscopy  Bronkoskop fleksibel = Fiber Optic Bronchoscopy = Bronkoskopi Serat Optik Lentur Rigid bronchoscopy  Tabung lurus stainless steel  Panjang dan lebar bervariasi  Bronkoskopi untuk dewasa : – panjang 40 cm – diameter 9-13.5 mm – tebal dinding bronkoskop 2-3 mm  Anestesi umum . Flexible bronchoscopy  55cm total panjang bronkoskop ini mengandung serat optik memancarkan cahaya. . Indikasi bronkoskopi    Hemoptisis Batuk kronik Bronchoalveolar lavage (BAL)  Penentuan derajat karsinoma bronkus  Evaluasi pembedahan  Obstruksi saluran nafas besar  Pengambilan dahak yang tertahan/ada gumpalan mukus        Abses paru Mengeluarkan benda asing dari saluran trakeobronkial Dilatasi bronkus dengan menggunakan balon Penanganan stenosis saluran nafas Pemasangan stent bronkus Laser bronkoskopi Endobronchial brachitheraphy . Kontraindikasi Bronkoskopi  Penderita kurang kooperatif  Keterampilan operator kurang  Fasilitas kurang memadai  Angina yang tidak stabil  Aritmia yang tidak terkontrol  Asma berat  Hiperkarbia berat  Koagulopati yang serius  Bulla emfisema berat  Obstruksi trakea  Obstruksi vena cava superior  Hipoksemia ireversibel ( PO2  60 mmHg ) . CT. CT scan – Faal hemostasis.Persiapan Bronkoskopi  Inform consent  Pemeriksaan penunjang : – Foto toraks. BT – EKG – Analisa gas darah – Elektrolit – Spirometri – Evaluasi jantung pada penderita penyakit koroner . video. holter monitoring. kelengkapan televisi. mesin penghisap lender/suction). . foto. ruangan pemulihan.Persiapan Bronkoskopi (lanjutan)  Fasilitas penunjang : – ruangan persiapan. kelengkapan alat diagnostik dan terapi – sarana penunjang (oksigen. pulse oksimetri. ruangan tindakan. resusitator. ruangan desinfeksi alat – bronkoskopi. nebulizer. Persiapan Bronkoskopi (lanjutan)     Medikasi : anti sedatif ringan 30 menit sebelum tindakan. anestesi topikal diberikan pada saluran nafas. Anestesi dengan midazolam IV onset cepat dan masa paruhnya pendek Anestesi topikal pada traktus respirasi atas. . Selama prosedur. area glottis dan bronkial dengan pemberian lidokain secara langsung. 25 Sumber O2 dengan mg. 1 ampul  Mouth piece  Povidon iodine diencerkan  Lidocaine 2 %. 1-2 ampul aparatusnya  Diazepam 5 mg. bicnat  Xylocain jelly ampul. @ 2 buah bronkoskop  Spuit 20 cc. 5 cc. 20 ampul @ 2 mL untuk membersihkan  Spuit 10.Peralatan Bronkoskopi  Sulfas atropin ( SA ) 0. dexamethason penampung cairan bilasan ampul.  . SA ampul.9 %  Xylocaine spray 10 %  Pulse oxymetri  Obat resusitasi: Adrenalin  Mucus collector / wadah ampul. 3 buah  Kassa steril  Kain penutup mata pasien  Cairan NaCl 0. bronkodilator ampul. Pengambilan Spesimen 1. 2. 3. 4. 5. 6. 7. Bilasan bronkus (bronchial washing) Sikatan bronkus (bronchial brushing) Biopsi forsep Biopsi aspirasi jarum transbronkial (transbronchial needle aspiration/TBNA) Biopsi paru transbronkial (Transbronchial Lung Biopsy/TBLB) Endobronchial ultrasound (EBUS) Bronkoalveolar lavage (BAL) Prosedur Bronkoskopi  Periksa tanda vital, status paru dan jantung.  Premedikasi dengan Sulfas Atropin 0,25 – 0,5 mg IM, setengah jam sebelum bronkoskopi.  Sesaat sebelum tindakan : Diazepam 5 mg IM.  Anestesi lokal : – Inhalasi lidocaine 2% 5 mL lewat kanul inhalasi. – Xylocaine spray 10 % 5 – 7 semprot daerah laringo-faring dan pita suara tarik lidah dengan bantuan kassa steril pada tangan kiri • Bila via hidung: semprotkan 30 mg lidocaine 4 % atau 10 % ke ostium nasal. Prosedur Bronkoskopi  Pasien terlentang dengan tubuh bagian bahu disangga bantal, membentuk sudut 45º  Bronkoskopi diinspeksi dan kejernihan gambar diperiksa.  Sensor oksimetri ditempelkan pada jari telunjuk pasien.  O2 3-4 L/m melalui kanul nasal.  Kedua mata pasien ditutup dengan kain penutup untuk mencegah terkena larutan lidocaine / cairan pembilas.  Diletakkan mouth piece di antara gigi atas dan bawah untuk melindungi bronkoskop.  Bronkoskop mulai dimasukkan melalui celah mouth piece. Cara memegang scope . Prosedur Bronkoskopi    Faring diinspeksi. ES : merangsang batuk Lidocaine yang berlebihan diaspirasi dari sekitar laring   Instrumen bronkoskopi dimasukkan melalui bagian terlebar dari glottis pada saat inspirasi tanpa menyentuh pita suara. Instilasi lidocaine 2% 2 mL ke trakea via pita suara. Pita suara diinstilasi dengan lidocaine 1-2 mL melalui saluran di bronkoskop. – Sebelumnya pasien diberitahu bahwa hal ini dapat menimbulkan sensasi tercekik yang segera hilang . maksimal 6 kali.  Lobus superior paru kanan dan kiri dianestesi dengan instilasi langsung lidocaine. – Alternatif adalah memfleksikan ujung bronkoskop dan dengan hati-hati diusapkan pada mukosa trakea atau bronkus . disemprot dengan 5mL NaCl 0.  Bila pandangan terhalang oleh sekret pada lensa distal.  Inspeksi menyeluruh dilakukan pada semua percabangan bronkus sampai bronkus subsegmental. dan percabangan bronkus dinilai dan dianestesi dengan lidocaine 2% 2 mL.9 % yang diaspirasi kembali saat pasien batuk.Prosedur Bronkoskopi  Trakea. karina. . .Prosedur Bronkoskopi Bilasan bronkus   Setelah bronkoskop berada pada daerah bronkus yang dicurigai. Tindakan ini diulangi sampai cukup bersih atau didapat spesimen. cairan segera diaspirasi lagi dan ditampung dalam wadah penampung khusus (mucous collector) yang dipasang pada alat bronkoskop.9% hangat 5 mL. dimasukkan cairan NaCl 0. Bilasan . alat sikat ditarik ke dalam kanal bronkoskop dan dikeluarkan dari trakeobronkial bersama bronkoskop. dilakukan sikatan beberapa kali sampai dirasa cukup. sikat dikeluarkan dari ujung bronkoskop sepanjang  5 cm.  Setelah selesai melakukan sikatan. kemudian sikat dijentikkan pada gelas obyek dan dibuat sediaan apus untuk pemeriksaan sitologi direndam dalam wadah berisi alkohol 96% .Prosedur Bronkoskopi Sikatan Bronkus  Setelah bronkoskop berada pada daerah bronkus yang dicurigai terdapat kelainan.  Sesudah berada di luar. alat sikat dimasukkan melalui bronkoskop. bila ada perdarahan harus diatasi. . Alat biopsi forsep dimasukkan melalui manouver channel sampai terlihat keluar dari ujung bronkoskop. forsep ditutup. bronkoskop dikeluarkan. lalu forsep didorong sampai terbenam di massa. lalu ditarik sambil melihat jaringan yang didapat (jaringan nekrotik dihindari) Sesudah biopsi selesai. Asisten membuka forsep. ujung bronkoskop ditempatkan  4 cm di atas daerah tersebut.Prosedur Bronkoskopi Biopsi       Setelah bronkoskop berada pada daerah bronkus yang dicurigai terdapat kelainan. Setelah tidak ada masalah lagi. forsep bersama material yang didapat ditarik keluar dari bronkoskop Spesimen direndam dalam wadah berisi cairan formalin 40% Bronkoskop dilanjutkan untuk evaluasi. . yang akan hilang dalam 48 jam. Dianjurkan tidak makan atau minum selama 2 jam setelah tindakan karena efek anestesi topikal.Evaluasi Pasca tindakan    Diterangkan kepada pasien kemungkinan adanya sedikit darah saat batuk. Hasil spesimen bronkoskopi ditujukan untuk : – Sitologi spesimen sekret atau jaringan – BTA spesimen sekret atau jaringan – CRP atau hsCRP spesimen sekret atau jaringan – Kultur dan resistensi mikroorganisme (kuman aerob. dan jamur) dari spesimen sekret atau jaringan . kuman anaerob. hipereksitabilitas. metHemoglobinemia Bronkoskopi: laryngospasme. depresi nafas. demam pasca bronkoskopi. kolaps kardiovaskular. bronkospasme. perdarahan Lavage / BAL: demam .Komplikasi – – – – – Premedikasi: depresi pernafasan. laryngospasme. infeksi silang Biopsi transbronkial: pneumothoraks. konvulsi. Analgesia topikal (lidocaine): henti nafas. syncope. hipotensi transien. epistaksis (bila via nasal). sinkop. pneumonia. henti jantung. aritmia. TERIMA KASIH . . tracheobronchial strictures and placement of airway stents  .  Rigid bronchoscopes (RB)  management of massive haemoptysis.Introduction Flexible bronchoscopy (FB)  optimal management of ICU patients with both diagnostic and therapeutic. tracheobronchial foreign bodies. Flexible Bronchoscopy (FB)  Can be performed via endotracheal tube (ETT) or tracheostomy tube Bedside procedure: avoids transport/OR time  . Prakash U. Mayo Clin .Indications in Critically Ill Medical Patients 198 bronchoscopies: 45% retained secretions 35% specimens for culture 7% airway evaluation 2% hemoptysis Olapade CS. Common Therapeutic Indications for Bronchoscopy  Retained secretions/atelectasis – bronchial toilet     Mucous plugs Hemoptysis/blood clots Difficult intubation Dilation airway stenosis/strictures . Bronchoscopy in Patients with Mechanical Ventilator Not a contraindication  Usually the same as non-intubated patients  The risk for complications are increased in the prsesence of several factors. and Chest 1992. – cardiac. 102: 557-6 .  – pulmonary. – coagulopathy. 0 mm)  Discontinue PEEP or reduce  50%  Increase FiO2 to 1.7 – 6. 5-15 minutes prior to procedure  Check BGA before and after   Continuous pulse oximetry  Monitoring pulse and BP Chest 1992.0.Bronchoscopy in Patients with Mechanical Ventilator ETT internal Ø at least 8 mm for standard fiberscope (5. 102: 557-6 . 3) PaO2 < 70 mmHg or SaO2 < 90 %. Introduction to Bronchoscopy. and 5) altered mental status Ernst A (Ed). 4) requirement for minimally invasive BIPAP/CPAP. must be knowledgeable about intubation and skill in intubation (direct laryngoscopy or over a bronchoscope)  CI: 1) RR > 30 bpm.Route of Bronchoscopy in the ICU Non-intubated patients  Performed either via oral route using a bite block or transnasal  No respiratory failure or require NIV (CPAP)  The bronchoscopist. 2) clinically use of accesory muscles. Cambridge (2009) . Cambridge (2009) . Introduction to Bronchoscopy. consider changing the ETT to a larger Ø  In case of stenosis or other causes  use a pediatric or smaller Ø bronchoscope  Smaller scope  smaller working channel & less suctioning capability Ernst A (Ed).Route of Bronchoscopy in the ICU Intubated patients  Bronchoscope through an ETT  The bronchoscope must easily pass through the inner lumen of the ETT and permit gas exhaled  If the patients has a smaller Ø ETT. The Bronchoscopic Technique  The procedure for preparations and performance of bronchoscopy is similar to that for patients who are not critical ill.  The critical ill patients. . however may have to undergo bronchoscopy while receiving mechanical ventilation and may be attached to multiple tubes and other life-sustaining equipments. 100% nonrebreather mask Cardiac monitor & oximetry Topical anesthetics Epinephrine 1:1000  Secretion trap. gloves. wire basket  Pneumothorax kit  Gown.The prerequisites for a safe & efficient bronchoscopy in ICU         Consent Discontinuation of feeds at least 8 hrs Checking of coagulation profile Bite block O2. & fluids Brush & biopsy forceps. formalin) Glass slides Sterile needles. intubation tray. Fogarty ballon cateheter. disposable syringe Lubrication jelly Intravenous tubing. mask  Transbronchial aspiration  Sedatives  Adapter needles . specimen jars (alc      70% & 90%. Adapter route of bronchoscope to mechanical ventilator ETT . Retained Secretions and Atelectasis  One of the most common consultations for bronchoscopy in the ICU  Should not be considered as first line therapy for routine pulmonary toilet and secretions clearance  Severe hypoxemia not contraindication .  Expect improved A-a gradient & chest radiography. . FFB in atelectasis: – retained secretions and air bronchograms to segmental level only – lobar or greater atelectasis not responding to aggressive chest PT – life threatening whole lung atelectasis  More distal mucous plugs  BAL  Lung segments: room air insufflation by an Ambu bag connected to the working channel of a bronchoscope. . 5 ETT.8 mm (ultrathin) to 6.4 mm (most adult FFB: 6.Difficult Intubation  Useful tool for difficult intubation  >> size 8 ETT.0 mm). 11:97-109. and is the preferred FFB for intubation in an adult Crit Care Clin 1995. . smaller adult female: size 7 ETT  FFB ranges from 1.  Most standard FFB will pass through a size 7. FFB through an ETT . The RB is preferred when bleeding is massive Direct instillation of iced saline or a combination of saline and 1:1000 epinephrine Other techniques: – Direct application of a solution of thrombin or fibrinogen-thrombin combination – Fogarty ballon catheter    . bronchoscopic evaluation within 12-18 hours  highest chance for visualization of bleeding site & may guide therapeutic intervention.Hemoptysis  In ICU. selective intubation of either the right or left main stem bronchi  prevent soiling the unaffected lung This is the best and most rapidy achieved by placing the ETT over the bronchoscope.Hemoptysis  In extreme life-threatening cases. inflate the ballon on the ETT to prevent soiling.   . advancing the ETT into the selected main stem airway Using the bronchoscope as a guide wire. failure and facilitate weaning  Indication: obstruction that reduce airway lumen < 50%  Silicon stent (by RB) – Dumon stent – Y stent – T tube  SEMT: (RB or FB) – Ultraflex stent .Stent  Endobronchial stenting can be performed to prevent impending resp. Silicone or Metal?  Silicone stent – Require RB – Easily removed – Migration – Can be used in both malignant and benign stenosis  Metal stents – Easy to insert – Difficult to remove – Granulation tissue – Not recommended for most benign stenosis . Squamous cell cancer in trachea . Primary squamous cell carcinoma in trachea .during laser therapy . Nitinol stent implanted into trachea . cardiac complications. death Ancillary procedures: barotrauma. methemoglobinemia. pulmonary hemorrhage. death   . death Procedure related: hypoxemia.FFB: Complications  Premedication/ local anesthesia: respiratory depression arrest. pneumonia. post procedure: 20-30 mmHg O2 drop in healthy. 30-60 in critically ill Reduction in effective tidal volume and FRC Suction at 100 mmHg via 2mm suction port removes 7L/min Saline/lidocaine instillation    .Complications: Hypoxemia  Common: up to 2 hrs. . . Continuous multi-modal physiological monitoring must be continued during and after fibreoptic bronchoscopy. 55 . Patients in ICU should be considered at high risk from complications when undergoing fibreoptic bronchoscopy. Care must be exercised to ensure adequate ventilation and oxygenation is maintained during fibreoptic bronchoscopy via an endotracheal tube. More profound levels of sedation/anaesthesia can be achieved in ventilated patients provided the clinician performing the procedure is acquainted with the use of sedative/anaesthetic agents.FLEXIBLE BRONCHOSCOPY IN (ICU)       The internal diameter of the endotracheal tube. must be taken into consideration before bronchoscopy. Intensive care units should have the facility to perform urgent and timely flexible bronchoscopy for a range of therapeutic and diagnostic indications. through which the bronchoscope is inserted. 7 mm bronchoscope. particularly during withdrawal when the rigid edge of the end of the tracheostomy tube can abrade the covering of the bronchoscope. 56 . Tracheostomy tubes are also prone to damage the bronchoscope. occupies 40% of a 9 mm endotracheal tube and 66% of a 7 mm tracheal tube. Failure to recognise this may lead to inadequate ventilation of the patient and impaction of or damage to the bronchoscope. a 5. In contrast. Lubrication is essential to facilitate passage of the bronchoscope. Bronchoscopes in the non-intubated patient occupy only 10–15% of the cross sectional area of the trachea.ENDOTRACHEAL TUBE SIZE        The internal diameter of the tracheal tube relative to the external diameter of the bronchoscope is an important consideration. 100% oxygen should be given during bronchoscopy and in the immediate recovery period. through which the bronchoscope can be inserted and allows continued ventilation. Hythe. The ventilator should be adjusted to a mandatory setting.VENTILATOR SETTINGS    Pre-oxygenation should be achieved by increasing the inspired oxygen concentration to 100%. UK) with a perforated diaphragm. 57 . A special swivel connector (Portex. Triggered modes such as pressure support or assist control will not reliably maintain ventilation during fibreoptic bronchoscopy. 58 . nursing. The optimal number of procedures which should be undertaken under direct supervision (trainer in bronchoscopy unit) and indirect supervision (trainer able to assist if called) before undertaking bronchoscopy alone will vary. and paramedical) to minimise the risk to both patient and staff.TRAINING(1)   Flexible bronchoscopy is a complex and potentially hazardous procedure requiring trained personnel (medical. depending on the competency of the trainee and the complexity of the procedure being undertaken. although the trainer or other competent bronchoscopist should be available to give advice if needed for any trainee bronchoscopist 59 .TRAINING(2)  It would seem reasonable to undertake a minimum of 50 procedures under direct supervision and a further 50 under indirect supervision. Stent. Rigid Bronchoscopy For Semi-urgent Therapy – Cryotherapy. Stent. Balloon  For Prolonged Therapy – PDT. APC. Brachytherapy . PDT. Electrocautery.Selection of Therapy for Airway obstruction   For Urgent Therapy – Laser. PDT and Brachytherapy  PDT – Not suggested for palliative  Very expensive – For central airway early malignancy – Highly potential of “cure of cancer”  Brachytherapy – Not available in SKH – For palliative use – Beware of fistula with great vessels and esophagus . SEJARAH Bronkoskopi rigid  1897  Awalnya untuk obstruksi saluraan napas karena benda asing dan stenosis trakhea karena infeksi  Diagnosis kanker paru  1950-an  Bronkoskopi fiberoptic fleksibel  1967  Sekarang sebagai modalitas diagnostik kelainan paru  . Indikasi bronkoskopi  Evaluasi kelainan foto toraks  Batuk  Hemoptysis  Wheeze lokal  Suspek fistula trakheoesofageal  Trauma dada atau injuri inhalasi  Atelektasis persisten  Fistula bronkhopleural terlokalisir  Aspirasi benda asing  Pembawa brachytherapy  Evaluasi penolakan pada penerima transplantasi paru  Evaluasi hiperlusensi unilateral  Penempatan atau kepastian slang endobronkhial  Serak tidak jelas sebabnya atau paralisis pita suara  Penelitian . 000/mm³ bila akan melakukan biopsi  Peninggian tekanan intrakranial  .Kontraindikasi Hipoksia yang tidak dapat dikoreksi (Pao2 < 60 mmHg)  Penyakit jantung tidak stabil dan penyakit jantung berat  Trombosit < 50. 04%  Komplikasi utama: – Hipoksia. – Bakteremia. dan – Perdarahan  .0. – Demam.Komplikasi Angka morbiditas 0. – Aspirasi.08% .8%  Angka kematian 0% .0. Persiapan bronkoskopi Puasa 4 – 12 jam  untuk mengurangi aspirasi  Pasien COPD sebaiknya sudah ada hasil spirometri. bila COPD berat  lakukan BGA  Suplemen O2 dan/atau sedasi iv akan meningkatkan kadar CO2 arterial  hindari sedasi berlebih bila CO2 arterial pre-bronchoscopy meningkat dan suplementasi O2 diberikan sangat hatihati  . katup jantung buatan. atau sebelumnya ada riwayat endokarditis  Hindari tindakan bronchoscopy bila dalam 6 minggu mengalami infak miokard  Berikan informasi secara verbal dan tertulis untuk meningkatkan toleransi pasien terhadap prosedur bronkoskopi 67 .Persiapan bronkoskopi  Antibiotik profilaktik sebaiknya diberikan pre-bronkoskopi pada pasien asplenik. 5 68 .Persiapan bronkoskopi  Pasien asma sebaiknya dipremedikasi dengan bronkodilator sebelum bronkoskopi  Pemeriksaan rutin terhadap platelet dan/atau waktu protrombin preoperatif  Stop pemakaian antikoagulan 3 hari prebronkoskopi bila kemungkinan dilakukan sampel biopsi  Bila antikoagulan harus tetap dipakai  INR < 2. Persiapan bronkoskopi  Pasang infus pada semua pasien prebronkoskopi saampai periode recovery  Atropine tidak diperlukan secara rutin prebronkoskopi  Pasien sebaiknya dimonitor dengan oximetry  Berikan O2 untuk mencapai saturasi minimal 90%  Lidocaine 2% untuk anestesi . Selama bronkoskopi Ada dua pembantu bronkoskopi, satu adalah perawat telah terlatih  Tidak perlu monitor EKG rutin, kecuali pasien dengan riwayat penyakit jantung berat dan hipoksia meskipun telah diberi O2  Alat resusitasi sebaiknya ada  Setelah bronkoskopi  Mungkin masih butuh O2 pada pasien denganngangguan fungsi paru dan dilakukan sedasi  Dilakukan foto torak bila dicurigai terjadi pneumotorak paling tidak 1 jam setelah transbronkhial biopsi  Pasien yang dilakukan transbronkhial biopsi sebaiknya dijelaskan kemungkinan terjadinya pneumotorak setelah pulang dari RS  Pasien yang dilakukan sedasi dianjurkan untuk tidak mengendarai kendaraan bermotor dalam waktu 24 jam setelah bronkoskopi 71 DIGNOSIS KANKER  Karsinoma bronkogenik dapat dibagi menjadi sentral (endobronkhial): – Batuk, – Hemoptysis, – Pneumonia, atau – Atelektasis  Atau lesi perifer  Washing. dan  Jarum aspirasi  .  Brushing.Lesi sentral Biopsi forsep. .Forcep  Forcep harus dikerjakan dengan teknik legeartis untuk meminimalkan perdarahan  Penarikan forcep pada ujung forcep dapat menyebabkan merusak bronkoskopi bila forcep secara mendadak dikeluarkan dari jaringan  Untuk mendapatkan cakupan diagnostik yang paling tinggi pada lesi sentral paling tidak 3 sampel biopsi didapatkan apakah dengan brushing atau washing. brush dapat ditarik dari kanal bronkoskopi (teknik withdrawn). bukti sampel dari teknik nonwithdrawn lebih baik  Sampel segera diaplikasikan ke kaca slide dalam gerakan melingkar dan segera taruh pada larutan pengawet untuk mencegah pengeringan .Brushing  Setelah brushing lesi. atau ditarik bersama dengan bronkoskopi sebagai suatu unit untuk menghindari hilangnya sampel  Walaupun tidak ada penelitian menunjukkan superioritas satu teknik dengan teknik lainnya. setelah itu preparasi blok-sel untuk analisa sitologi.  Washing bronkhial (memasukkan sejumlah kecil salin) kemudian menyedot cairan  Washing cocok untuk tumor lesi sentral .Washing  Metode lain untuk prosesing sampel brush seperti menggoyang dalam larutan salin atau cairan pengawet. saluran napas bisa kolap dan menghambat lavage  Biasanya kembali sekitar 40 – 60% dari lavage yang dimasukkan .9% dimasukan ke segmen. dan kemudian dengan tekanan negatif 50 – 80 mmHg cairan lavage disuction kembali ke dalam botol suction  Bila tekana suction terlalu tinggi.BAL  Dapat dikerjakan untuk lesi perifer (invisibel endoskopi)  Aliquot 20 mL normal salin 0. pada lesi sentral untuk mendapatkan diagnostik tertinggi bagi tiga sampel biopsi sebaiknya didapatkan dengan cara brushing atau washing .  Bila lesi kemungkinan besar dapat menyebabkan perdarahan.  Bila dicurigai karsinoma sel kecil.Jarum aspirasi  Bila menginginkan penetrasi lebih dalam untuk menghindari nekrosis permukaan.  Jadi. Brushing. Disarankan mengambil 5 – 6 sampel biopsi . Washing. dan Transbronchial needle aspiration (TBNA).Lesi perifer        Cara yang dipakai untuk diagnostik lesi perifer: Biopsi forcepTtansbronkhial. Penuntun fluoroscopic imaging dan CT scan imaging untuk memastikan lokasi biopsi yang lebih tepat. Bronkoskopi autofluorescence untuk deteksi kanker in situ atau displasia gradetinggi pada lesi sentral. . Saat diagnosis tegak  inoperabel.Optimalisasi diagnosis kanker      Presentasi kanker pada stadium lanjut  prognosis jelek.15%. Modalitas baru untuk deteksi kanker lebih dini  bronkoskopi autofluorescence. 5 year survival tinggal 13% . Jaringan displastik absorbsinya menurun  warna fluorescence coklat.5 – 6.3 kali .Optimalisasi diagnosis kanker      Bronkoskopi fluorescence memiliki sinar absorbsi yang berbeda untuk jaringan normal dan malignansi Penyinaran oleh sinar violet atau sinar biru: Jaringan normal jaringan normal berwarna fluorescence hijau kuat. atau merah Dengan teknik ini deteksi kanker meningkat 1. ungu. . washing. atau aspirasi jarum pada kasus tumor submukosa atau tumor nekrosis)  Tumor perifer: 6 biopsi plus brushing and washing atau BAL.Optimalisasi diagnosis kanker  Spesimen kombinasi untuk meningkatkan diagnostik.  Karsinoma sentral visibel tiga biopsi plus satu tambahan spesimen (brushing. perlu penuntun fluoroskopi untuk memastikan lokasi alat. dan protected specimen brush yang menggunakan kateter double-sheated  Transbronchial biopsy dan TBNA . atau – Pneumonia pada pasien imunokompromais  Bronkoskopi dengan teknik BAL. – VAP.Penyakit infeksi  CAP dan NP diterapi secara empiris  Peranan bronkoskopi pada pneumonia masih kontroversi  Bronkoskopi bermanfaat pada: – Pneumonia yang tidak membaik. fistula  Lain-lain: pneumokoniosis. bronkhiektasi  Neoplasma: Karsinoma bronkogenik. dll. MVD. endobronkhial tumor. adenoma bronkhial  Kelainan imun: Wegener granulomatosis dan Goodpasture syndrome  Pulmonary vascular disorders: PE. jamur. AVM. koagulopati. abses paru  Inflamasi: bronkhitis. .Hemoptysis Penyebab Hemoptysis:  Infeksi: TBC. Step by Step© Flexible Bronchoscopy Step by Step© Video exercises to learn bronchoscopy skills Prepared By Bronchoscopy International Contact us at [email protected] Click anywhere to continue 4/10/2014 BI. All Rights Reserved. 2005 85 .  To learn how to handle the flexible bronchoscope and to accurately identify and enter lobar and segmental bronchial segments with ease.Main Objectives  To learn bronchoscopic techniques using an approach similar to learning to dance. play tennis or play a musical instrument. – To develop “muscle memory” – To develop a “systematic approach” to bronchoscopic inspection. 4/10/2014 BI. All Rights Reserved. 2005 86 . pull back and then examine the other three segments of the basal pyramid.Step 8b: Right lower lobe basal pyramid (D’Artagnan and the three musketeers)  From the carina advance the scope to the RLL bronchus entrance and then enter the medialbasal segment. Click HERE to view video From the front Click to 4/10/2014 continue STAY OFF THE WALL BI. All Rights Reserved. 2005 87 . All Rights Reserved. 2005 88 . and to decrease the burden of procedure-related training on patients.This presentation is part of a comprehensive curriculum for Flexible Bronchoscopy. Our goals are to help health care workers become better at what they do. 4/10/2014 BI. Step by Step© A new curriculum Assured competency and proficiency 1. 2. 3. 4. 5. Web-based Self-learning study guide. Computer-based simulations, didactic lectures, and image encyclopedia. Bronchoscopy step-by-step©: Practical exercises, skills and tasks, competency testing. Guided apprenticeship. Learning the art of Bronchoscopy. BRONCHATLAS© 4/10/2014 DEMOCRATIZATION AND GLOBALIZATION OF BI, All Rights Reserved, 2005 KNOWLEDGE 89 All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide shows, streaming videos, and essays can be cited for reference as: Bronchoscopy International: Bronchoscopy Step-by-Step, an Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/Bronchoscopy Step-by-step/htm. Published 2005 (Please add “Date Accessed”). Thank you 4/10/2014 BI, All Rights Reserved, 2005 90 Group 1 Exercises 4/10/2014 BI, All Rights Reserved, 2005 91 Click HERE to view video  This step includes local anesthesia.Step 1: nose to larynx  The scope is advanced from the nose to the larynx . From the head Click to continue 4/10/2014 BI. All Rights Reserved. 2005 92 . . 2005 Click to 4/10/2014 93 continue upwards.  If from the front: once the vocal cords are From the front passed the scope is slightly flexed BI.Step 2: larynx to subglottis  From the larynx the trachea is entered to the subglottic area. All Rights Reserved.  If from the head: once Click HERE to view video the vocal cords are passed the scope is slightly flexed downwards. 2005 94 . Click to continue 4/10/2014 Click HERE to view video From the head BI. All Rights Reserved.Step 3: Follow the curve to the carina  The Trachea is not a “straight pipe”.  It deviates posteriorly and slightly to the right when approaching the main carina. Click HERE to view video From head 4/10/2014 Click to continue BI. All Rights Reserved.Step 4a: Carina to left main bronchus  From the neutral position the LMB is entered just by twisting the wrist to the left and advancing for 1 -2 cm. 2005 95 . From head Click HERE to view video 4/10/2014 Click to continue BI.Step 4b: Carina to right main bronchus  From the neutral position the RMB is entered just by twisting the wrist to the right and advancing the scope for 1 -2 cm. 2005 96 . All Rights Reserved. All Rights Reserved. Click to continue From head Click HERE to view video 4/10/2014 BI.Step 4c: Left-right-neutral  From the neutral position the left and right main bronchi are entered alternatively just by twisting the wrist and advancing the scope for few cm. 2005 97 . Step 5a: Down-up-left main bronchus  The scope is slowly advanced the pulled back up the LMB while always keeping it in the middle of the airway lumen. From the front Click HERE to view video 4/10/2014 BI. All Rights Reserved. 2005 Click to continue 98 . All Rights Reserved.Step 5b: Down-up right main bronchus  The scope is slowly advanced down the RMB to RLL and pulled back upwards while always keeping it in the middle of the airway lumen. Click HERE to view video From the front Click to continue 4/10/2014 BI. 2005 99 . All Rights Reserved. 2005 100 .Group 2 Exercises 4/10/2014 BI. 2005 4/10/2014 101 . All Rights Reserved. Click HERE to view video From the front Click to continue BI.Step 6a: Left main to left upper lobe bronchus  From the LMB the scope is advanced to the entrance of the LUL bronchus. 2005 continue 102 . All Rights Reserved. Click HERE to view video From the front 4/10/2014 Click to BI.Step 6b: Left main to left lower lobe bronchus  The scope is advanced down the LMB to the entrance of the LLL bronchus. Step 6c: Right main to right upper lobe bronchus  The scope is advanced down the RMB then with the wrist twisted 60 degrees from midline the scope is flexed up to the entrance of RUL. Click HERE to view video From the front Click to BI. 2005 continue 4/10/2014 103 . All Rights Reserved. 2005 continue 104 .Step 6d: Right main to bronchus intermedius  From the carina advance the scope down the RMB to the distal bronchus intermedius Click HERE to view video and visualize the entrance to RB456 and the basal pyramid. All Rights Reserved. From the front 4/10/2014 Click to BI. All Rights Reserved.Step 6e: Right main to right lower lobe bronchus  Advance the scope from the carina to the entrance of the RLL while always keeping it in the midline. Click HERE to view video From the front 4/10/2014 Click to BI. 2005 continue 105 . All Rights Reserved.Group 3 Exercises 4/10/2014 BI. 2005 106 . the lingula and upper division bronchus are visualized. All Rights Reserved. the scope is advanced to LUL entrance. there.Step 7a: Left upper lobe uno dos  From the carina. Click HERE to view video From the head 4/10/2014 Click to BI. 2005 continue 107 . just by thumb movement. then the scope is pulled back into the distal LMB and the scope is advanced into the superior segment of the LLL.Step 7b: Left before five six (LB 456)  From the LMB.  ! Wrist movements are “in the mirror” 4/10/2014 Click to continue Click HERE to view video From the head 108 BI. All Rights Reserved. the lingula is entered. 2005 . Click to 4/10/2014 continue Click HERE to view video From the head 109 BI. 2005 . lateral and postero-basal segments of the LLL are entered.Step 7c: Left B6-8. the superior segment is entered.9. the antero. then alternately.10  With the scope at the LLL bronchus entrance. All Rights Reserved. All Rights Reserved. Click to continue From the head Click HERE to view video 4/10/2014 BI. 2005 110 . then the scope is withdrawn to the main carina.Step 7d: Right upper lobe uno-dos-tres  From the RMB the scope is advanced and flexed up into the RUL bronchus where just by wrist and thumb movements the three segments are visualized. 2005 .6)  From the distal bronchus intermedius.5.Step 7e: Right before five six (RB 4. Click to 4/10/2014 continue Click HERE to view video From the head 111 BI. the RML and superior segment are entered alternatively. All Rights Reserved.  ! Wrist movements are “in the mirror”. 2005 112 . All Rights Reserved.Step 7f: Right medial basal (RB7) (d”Artagnan)  From the distal bronchus intermedius the scope is advanced and the medio-basal segment is entered. Click to continue 4/10/2014 Click HERE to view video From the front BI. Click to continue 4/10/2014 Pan .Step 8a: Left lower lobe basal pyramid  From the entrance of the LLL bronchus go in and out of the 3 basal segments.Pan Click HERE to view video From the head BI. then withdraw the scope to the carina.Pan . 2005 113 . All Rights Reserved. . All Rights Reserved.Art of Bronchoscopy 4/10/2014 BI. 2005 115 . 8 steps 4/10/2014 . 2005 .Bronchoscopy exercises Group 1 Nose/mouth to larynx Larynx to subglottis Follow the curve to the carina LMB to LLL LMB to LUL Carina to left Carina to right Left right neutral Down-up right Down-up left Group 2 Group 3 4/10/2014 RMB to RLL RMB to BI RMB to RUL Larynx to RLL Larynx to LLL LLL pan pan pan LUL uno dos LLL B6-8910 LB456 RLL D’Artagnan and the three musketeers RB456 RLL medio-basal RUL uno dos tres (D’Artagnan) 117 BI. All Rights Reserved. Background A: Flexion-Extension Extension 4/10/2014 Flexion 118 BI. 2005 . All Rights Reserved. 2005 119 Lever up . All Rights Reserved.Background B: Down-Neutral-Up positions Lever straight (Neutral) Lever down 4/10/2014 BI.