🩺 Interventional Pulmonology Procedures Bronchoscopy · Pleural Interventions · Tracheostomy for Medical Students

1. Overview of Interventional Pulmonology

Interventional pulmonology (IP) focuses on minimally invasive diagnostic and therapeutic procedures for central airway obstruction, lung cancer diagnosis/staging, pleural diseases, and complex airway management.

2. Bronchoscopy: Flexible vs. Rigid

Feature	Flexible Bronchoscopy	Rigid Bronchoscopy
Anesthesia	Moderate sedation (conscious) or general	General anesthesia (requires paralysis)
Airway Management	Through ETT, LMA, or nasal/oral with spontaneous breathing	Ventilation through bronchoscope (jet ventilation or closed circuit)
Indications	Diagnostic sampling (BAL, brush, biopsy, TBNA), inspection, minor bleeding, difficult intubation	Therapeutic: massive hemoptysis, foreign body removal, tumor debulking, stent placement, airway dilation
Advantages	Widely available, less invasive, can be performed at bedside	Larger working channel, better suction, simultaneous ventilation, safer for massive bleeding
Contraindications	Refractory hypoxemia, unstable arrhythmias, uncorrected coagulopathy	Unstable cervical spine, inability to open mouth widely, severe oropharyngeal stenosis

Flexible Bronchoscopy Techniques & Sampling

Technique	Description	Diagnostic Yield
Bronchoalveolar Lavage (BAL)	Instill and aspirate saline in distal airway; analyzes cellular and microbiologic content	High for infection (PJP, TB), alveolar hemorrhage, eosinophilic pneumonia
Endobronchial Biopsy (EBB)	Forceps biopsy of visible endobronchial lesion	High for central tumors; low for peripheral nodules
Transbronchial Biopsy (TBBx)	Biopsy of lung parenchyma under fluoroscopic guidance	Moderate for diffuse lung disease, peripheral nodules; risk of pneumothorax
Transbronchial Needle Aspiration (TBNA)	Needle aspiration of submucosal or peribronchial lesions / lymph nodes	Improved with EBUS guidance
Cryobiopsy	Freezing probe obtains larger tissue sample	Higher yield for ILD; higher bleeding/pneumothorax risk

3. Endobronchial Ultrasound (EBUS)

EBUS‑TBNA (Convex Probe)

• Ultrasound transducer at tip of bronchoscope → real‑time visualization of structures adjacent to airway.
• Allows sampling of mediastinal and hilar lymph nodes (stations 2, 4, 7, 10, 11) and central masses.
• Indications: Lung cancer staging, diagnosis of sarcoidosis, lymphoma, TB, metastatic disease.
• Advantages: Minimally invasive, high diagnostic yield (~90‑95% for malignancy), lower complication rate than mediastinoscopy.

Radial EBUS (Peripheral Lesions)

• Radial probe passed through working channel into peripheral airways to localize nodules.
• Guides transbronchial biopsy of peripheral lung lesions; often combined with navigational bronchoscopy or fluoroscopy.

Navigational Bronchoscopy

• Electromagnetic or robotic guidance to reach peripheral nodules. Often combined with radial EBUS for confirmation before biopsy.

4. Therapeutic Bronchoscopic Interventions

Procedure	Indication	Technique
Airway Stent Placement	Malignant or benign central airway obstruction (trachea, mainstem bronchi)	Silicone (requires rigid bronchoscopy) or self‑expanding metallic stents. Palliative for dyspnea.
Tumor Debulking / Ablation	Endobronchial tumor causing obstruction	Laser (Nd:YAG), argon plasma coagulation (APC), electrocautery, cryotherapy
Balloon Dilation	Benign airway stenosis (post‑intubation, post‑transplant, TB)	High‑pressure balloon inflation to dilate stricture; often combined with steroid injection or mitomycin C
Bronchial Thermoplasty	Severe persistent asthma	Radiofrequency energy applied to airways → reduces smooth muscle mass
Endobronchial Valve Placement	Severe emphysema with hyperinflation, persistent air leak	One‑way valves inserted bronchoscopically to collapse target lobe; requires intact fissures

5. Pleural Interventions: Thoracentesis

Indications

• Diagnostic: New pleural effusion of unknown etiology.
• Therapeutic: Relief of dyspnea due to large effusion.

Contraindications

• Uncorrected coagulopathy (INR >1.5, platelets <50k) — relative; can be corrected.
• Small or loculated effusion without image guidance.
• Active skin infection at puncture site.

Procedure & Safety

• Ultrasound guidance strongly recommended — reduces pneumothorax risk and identifies safe puncture site.
• Site: 1‑2 interspaces below fluid meniscus, superior border of rib (avoid neurovascular bundle at inferior border).
• Maximum drainage: No strict limit, but stop if patient develops cough, chest pain, or re‑expansion pulmonary edema risk (usually <1.5 L at one time).
• Complications: Pneumothorax (3‑5% with US guidance), hemothorax, re‑expansion pulmonary edema, vasovagal reaction, infection.

Pleural Fluid Analysis (Light's Criteria)

• Exudate if ≥1 of: Pleural protein/serum protein >0.5; Pleural LDH/serum LDH >0.6; Pleural LDH >⅔ upper limit of normal serum LDH.
• Send: Cell count/diff, protein, LDH, glucose, pH, cytology, culture, AFB, fungal, ADA (if TB suspected).

6. Chest Tube (Tube Thoracostomy) Placement

Indications

• Pneumothorax: Large (>2‑3 cm), tension, symptomatic, or recurrent.
• Pleural Effusion: Empyema, complicated parapneumonic effusion, hemothorax, chylothorax.
• Post‑operative: After thoracic surgery.

Technique

• Site for pneumothorax: 4th‑5th intercostal space, anterior axillary line (triangle of safety: lateral border of pectoralis major, anterior border of latissimus dorsi, horizontal line at nipple level).
• Site for effusion: Mid‑axillary line, 5th‑6th intercostal space, guided by ultrasound.
• Tube size: Smaller bore (8‑14 Fr) for pneumothorax/effusion; larger bore (24‑32 Fr) for hemothorax, empyema.
• Seldinger technique (small bore) vs. blunt dissection (large bore).

Management & Removal

• Connect to water seal or suction (−20 cm H₂O).
• Air leak: Bubbling in water seal chamber indicates ongoing pneumothorax or bronchopleural fistula.
• Removal: When lung fully expanded, no air leak for 24h, and drainage <200‑300 mL/day. Remove at end‑inspiration or with Valsalva.
• Complications: Bleeding, infection, malposition, re‑expansion pulmonary edema, injury to lung/diaphragm/spleen/liver.

7. Indwelling Pleural Catheter (IPC) & Pleurodesis

8. Tracheostomy

Indications

• Prolonged mechanical ventilation (>7‑14 days).
• Upper airway obstruction (tumor, stenosis, bilateral vocal cord paralysis).
• Inability to protect airway (neurologic injury, secretions).
• Facilitate weaning and pulmonary toilet.

Types

• Percutaneous Dilatational Tracheostomy (PDT): Bedside, bronchoscopy‑guided. Preferred for ICU patients.
• Surgical Tracheostomy: OR, for difficult anatomy, obesity, coagulopathy, or need for permanent stoma.

Timing of Tracheostomy in Critically Ill Patients

• No mortality benefit over prolonged translaryngeal intubation, but may reduce ICU length of stay, sedation requirements, and ventilator‑associated pneumonia.
• Typically performed after 7‑14 days of intubation if prolonged ventilation anticipated.

Tracheostomy Tube Selection

Type	Features	Indication
Cuffed	Inflatable cuff seals airway	Mechanical ventilation, aspiration risk
Uncuffed	No cuff; allows air passage around tube	Long‑term airway, patient can phonate, swallow evaluation
Fenestrated	Opening in posterior wall allows airflow through vocal cords	Facilitates speech, weaning
Adjustable Flange	Variable length from skin to tip	Obesity, neck edema, unusual anatomy

Complications of Tracheostomy

Decannulation (Tracheostomy Removal)

• Patient no longer requires mechanical ventilation, can protect airway, and manage secretions.
• Cuff deflated, tube capped; patient breathes through upper airway. Monitor for stridor, dyspnea.
• Downsize tube progressively before removal.
• Stoma usually closes spontaneously within days to weeks.

9. Other Interventional Pulmonology Procedures

Procedure	Indication	Notes
Whole Lung Lavage	Pulmonary alveolar proteinosis (PAP)	Large‑volume saline lavage of one lung at a time under general anesthesia
Medical Thoracoscopy (Pleuroscopy)	Undiagnosed exudative effusion, pleural biopsy, talc poudrage	Single‑port access; direct visualization of pleural space
Bronchial Artery Embolization (BAE)	Massive or recurrent hemoptysis	Performed by interventional radiology; bronchoscopy may localize bleeding site
Transbronchial Cryobiopsy	Diagnosis of ILD (especially when HRCT non‑diagnostic)	Higher diagnostic yield than conventional TBBx, but higher bleeding/pneumothorax risk
Endobronchial Ultrasound‑Guided Transbronchial Needle Injection (EBUS‑TBNI)	Research / palliative intratumoral therapy	Emerging technique for drug delivery

10. Common Complications & Safety Pearls

• Bronchoscopy: Hypoxemia (most common), bleeding, pneumothorax (1‑3% for TBBx), fever, arrhythmias.
• Thoracentesis: Use ultrasound, avoid rapid large‑volume drainage, monitor for re‑expansion pulmonary edema.
• Chest Tube: Always confirm placement with CXR; never clamp chest tube with ongoing air leak (risk of tension pneumothorax).
• Tracheostomy: First tube change at 5‑7 days (tract mature). Always have spare tube and obturator at bedside.
• Coagulopathy Management: For bronchoscopy with biopsy: Plt >50k, INR <1.5. Hold antiplatelets/anticoagulants per guidelines.

11. Quick Reference: Procedure Selection by Indication

Clinical Scenario	Preferred Procedure
Mediastinal/hilar lymphadenopathy	EBUS‑TBNA
Peripheral lung nodule	Navigational bronchoscopy + radial EBUS, or CT‑guided transthoracic needle biopsy
Central airway obstruction	Rigid bronchoscopy + debulking/stenting
Undiagnosed exudative pleural effusion	Thoracentesis → if nondiagnostic, medical thoracoscopy with pleural biopsy
Recurrent malignant pleural effusion	Indwelling pleural catheter OR talc pleurodesis
Massive hemoptysis	Bronchoscopy (localize) + bronchial artery embolization
Prolonged mechanical ventilation	Percutaneous tracheostomy (if no contraindications)

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