Flexible Bronchoscopy E-Book

Ko-Pen Wang

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1457

Veröffentlichungsjahr: 2020

Beschreibung

In this fourth edition of the popular Flexible Bronchoscopy, which has been revised and updated throughout, the world's leading specialists discuss the technical and procedural aspects of performing diagnostic and therapeutic bronchoscopy. Four new chapters have been added, taking into account new developments in EBUS and electromagnetic navigation.

Leseprobe

Table of Contents

Cover

List of Contributors

Preface

About the Companion Website

1 A Short History of Flexible Bronchoscopy

1.1 Introduction

1.2 Shigeto Ikeda and the Invention of the Flexible Bronchoscope

1.3 Further Development of Flexible Endoscopes

1.4 Further Developments in Flexible Bronchoscopy

1.5 Current Concepts and Strategies in Flexible Bronchoscopy

1.6 Detection and Staging of Early Lung Cancer in the Central Airways

1.7 Diagnosing and Staging of Advanced Lung Cancer

1.8 Tumors of the Central Airways: From Palliation to Cure

1.9 Diagnosis and Treatment of Peripheral Lung Cancer

1.10 Parenchymal Lung Disease

1.11 Treatment of Lung Function Disorders: Emphysema and Asthma

1.12 The Future of Flexible Bronchoscopy

References

2 Professor Ikeda's Genius

2.1 Professor Shigeto Ikeda (1925–2001): The Father of Flexible Bronchoscopy

2.2 Flexible Bronchoscopy Training and Education

2.3 Bronchoscopy Simulation

2.4 Interventional Pulmonology and Bronchoscopy Training

2.5 Conclusion

References

3 Applied Anatomy of the Airways

3.1 The Pharynx and Larynx

3.2 The Tracheobronchial Tree

3.3 The Relationship of Airways to Lymph Nodes and Vessels

References

4 Infection Control and Radiation Safety in the Bronchoscopy Suite

4.1 Infection Control

4.2 Radiation Safety

4.3 Conclusion

References

5 Anesthetic Management for Diagnostic and Therapeutic Bronchoscopy

5.1 Introduction

5.2 Preanesthetic Evaluation

5.3 Monitoring and Equipment

5.4 Anesthetic Agents Commonly Used in Bronchoscopy

5.5 Regional Anesthetic Technique for Airway Anesthesia for Awake Intubation or Flexible Bronchoscopy

5.6 Neuromuscular Blockade

5.7 Sedation Management of Different Bronchoscopic Procedures

5.8 Airway Management

5.9 Special Topics

5.10 Emergencies

5.11 Conclusion

Acknowledgments

References

6 Indications and Contraindications in Flexible Bronchoscopy

6.1 Introduction

6.2 Cough

6.3 Wheezing

6.4 Stridor

6.5 Hoarseness and Vocal Cord Paralysis

6.6 Inhalational Injury

6.7 Hemoptysis

6.8 Superior Vena Cava Syndrome

6.9 Mediastinal Mass

6.10 Interstitial Lung Disease

6.11 Infection

6.12 Lobar Collapse

6.13 Pleural Effusions

6.14 Chest Trauma

6.15 Lung Transplantation

6.16 Bronchography

6.17 Pulmonary Nodules

6.18 Lung Masses and Mediastinal Adenopathy

6.19 Therapeutic Bronchoscopy

6.20 Contraindications

References

7 Radial‐Probe Ultrasonography in Flexible Bronchoscopy

7.1 Introduction

7.2 Step‐by‐Step Procedure of EBUS‐GS

7.3 Advancements in EBUS for Peripheral Pulmonary Lesions

7.4 Future Prospects

References

8 Convex‐Probe Ultrasonography in Flexible Bronchoscopy

8.1 Convex‐Probe Endobronchial Ultrasound

8.2 Future Directions for CP‐EBUS

8.3 Conclusion

References

9 Early Diagnosis of Lung Cancer

9.1 Introduction

9.2 Principles of Photonic Imaging

9.3 Autoflorescence Bronchoscopy

9.4 Narrow‐band Imaging

9.5 Optical Coherence Tomography

9.6 Laser Raman Spectroscopy

9.7 Conclusion

References

10 Electromagnetic Navigation Bronchoscopy

10.1 Introduction

10.2 Historical Aspects

10.3 Technical Components

10.4 Performance

10.5 Complications

10.6 Therapeutic Applications

10.7 Conclusion

References

11 Virtual Bronchoscopic Navigation

11.1 Introduction

11.2 Definition

11.3 History and Development

11.4 Technique

11.5 Discussion

11.6 Conclusion

References

12 Indirect Laryngoscopy

12.1 The Airway History

12.2 Physical Examination: Focused Evaluation of the Airway

12.3 Medical Comorbidity

12.4 Pathological Conditions

12.5 Craniomaxillofacial Trauma

12.6 Pharyngeal Anatomy

12.7 Laryngeal Anatomy

References

13 Bronchoscopy for Airway Lesions

13.1 Introduction

13.2 Prevalence and Endoscopic Appearance of Bronchial Lesions

13.3 Adjuvant Imaging Techniques

13.4 Techniques for Sampling and Preparation of Specimens

13.5 Results of Procedures and Combination of Methods

13.6 Results for Endobronchial Biopsies in Visible Tumors

13.7 Results for Brushing

13.8 Results for Washing

13.9 Results of Combination

13.10 Complications

13.11 Cost‐Effectivenes

13.12 Conclusions and Suggestions for Strategy

References

14 Bronchoalveolar Lavage

14.1 Technique

14.2 Safety and Complications

14.3 Sample Processing

14.4 Clinical Utility

14.5 Conclusion

References

15 Bronchoscopic Lung Biopsy

15.1 Introduction

15.2 Indications for Bronchoscopic Biopsy

15.3 Contraindications

15.4 Preprocedure Evaluation

15.5 Technique

15.6 New Techniques

15.7 Special Patient Groups

References

16 Transbronchial Needle Aspiration for Cytology and Histology Specimens

16.1 Introduction

16.2 Historical Overview

16.3 Instruments

16.4 Relevant Anatomy

16.5 TBNA in Mediastinal Diseases

16.6 Electromagnetic Navigation Bronchoscopy

16.7 Virtual Bronchoscopy

16.8 Bronchoscopic Transparenchymal Nodule Access

16.9 Conclusion

References

17 Staging of Bronchogenic Carcinoma

References

18 The Future of Interventional Pulmonology

18.1 Introduction

18.2 Translational Research Conceptual Framework

18.3 Challenges to Carrying Out Translational Research

18.4 Applying the Translational Research Framework to Interventional Pulmonology

18.5 Conclusion

References

19 Application of Laser, Electrocautery, Argon Plasma Coagulation, and Cryotherapy in Flexible Bronchoscopy

19.1 Introduction

19.2 Types of Laser

19.3 Electrocautery

19.4 Argon Plasma Coagulation

19.5 Cryotherapy

19.6 Highlights and Recommendations for Practice

References

20 Flexible Bronchoscopy and the Application of Endobronchial Brachytherapy, Fiducial Placement, Radiofrequency Ablation, and Microwave Ablation

20.1 Brachytherapy

20.2 Fiducial Marker Implantation

20.3 Radiofrequency Ablation

20.4 Microwave Ablation

References

21 Foreign Body Aspiration and Flexible Bronchoscopy

21.1 Introduction

21.2 Risk Factors

21.3 Clinical Presentation

21.4 Foreign Body Types

21.5 Radiological Evaluation

21.6 Delays in Diagnosis

21.7 Complications of Foreign Body Aspiration

21.8 Therapeutic Approach to the Patient with Foreign Body Aspiration

21.9 Case Presentation

References

22 The Role of Bronchoscopy in Hemoptysis

22.1 Definitions of Massive and Nonmassive Hemoptysis

22.2 Causes of Hemoptysis

22.3 Pathophysiology of Hemoptysis

22.4 Diagnostic Utility of Bronchoscopy in Hemoptysis

22.5 Therapeutic Role of Bronchoscopy in Hemoptysis

22.6 Bronchoscopy‐Induced Massive Hemoptysis

References

23 Endobronchial Stents

23.1 Overview and History

23.2 Engineering and Materials

23.3 Biomechanical Properties

23.4 Physiological Rationale for Airway Stenting

23.5 Indications

23.6 Contraindications to Stent Insertion

23.7 Stent Types and Insertion Requirements

23.8 New Models of Metallic Stents

23.9 Stent‐Related Adverse Events

23.10 Considerations for Stent Removal

23.11 Future Directions

23.12 Special Considerations

23.13 Follow‐Up after Stenting

23.14 Final Considerations

References

24 Balloon Bronchoplasty

24.1 Introduction

24.2 Indications

24.3 Technique

24.4 Other Methods of Dilation

24.5 Complications

24.6 Outcomes

24.7 Conclusion

References

25 Rigid Bronchoscopy

25.1 Introduction

25.2 Equipment

25.3 Indications and Contraindications

25.4 Anesthesia

25.5 Technique

25.6 Complications

25.7 Training Goals

25.8 Conclusion

References

26 Pediatric Flexible Bronchoscopy

26.1 Introduction

26.2 Preprocedural Considerations

26.3 Bronchoscopy Procedure

26.4 The Operation of Bronchoscopy

26.5 Diagnosis and Treatment of Children's Lung Diseases

26.6 Indications and Contraindications of Pediatric Bronchoscopy

26.7 Differential Diagnosis

26.8 Airway Management

26.9 Common Complications and Management of Bronchoscopy

References

27 Bronchoscopy in the Intensive Care Unit

27.1 Introduction

27.2 Flexible Bronchoscopy

27.3 Indications

27.4 Equipment

27.5 Sedation and Anesthesia

27.6 Bronchoscopy in Patients on Mechanical Ventilation

27.7 Complications

27.8 Airway Management

27.9 Diagnostic Bronchoscopy

27.10 Therapeutic Bronchoscopy

27.11 Conclusion

References

28 Bronchial Thermoplasty Management of Asthma

28.1 Introduction

28.2 Pathophysiological Rationale

28.3 Overview and Supporting Clinical Data

28.4 Patient Selection

28.5 Performing the Procedure

28.6 Long‐term Outcomes and Future Directions

28.7 Conclusion

References

29 Endoscopic Management of Emphysema

29.1 Introduction

29.2 Unidirectional Valves

29.3 Coils

29.4 Sclerosing Agents

29.5 Patient Selection and Proposed Algorithm

29.6 Conclusion

References

30 Endoscopic Management of Bronchopleural Fistulas

30.1 Etiology and Incidence

30.2 Clinical Presentation and Diagnosis

30.3 Traditional Treatment

30.4 Bronchoscopic Management

30.5 Conclusion

References

31 Clinical Management of Benign Airway Stenosis and Tracheobronchomalacia

31.1 Epidemiology and Etiology

31.2 Presentation

31.3 Diagnostic Evaluation

31.4 Classification

31.5 Treatment

References

Index

End User License Agreement

List of Tables

Chapter 2

Table 2.1 Flexible fiberbronchoscope specifications (1964)

Chapter 4

Table 4.1 Organisms implicated in bronchoscopy‐related infections

Table 4.2 Levels of disinfection

Table 4.3 Spaulding classification of medical devices

Table 4.4 Mechanism of resistance in biofilm

Table 4.5 Steps in reprocessing of flexible bronchoscopes

Table 4.6 Common agents used for high‐level disinfection of bronchoscopes

Table 4.7 Advantages and disadvantages of manual and automated endoscopic rep...

Table 4.8 Sources of contamination during bronchoscopy

Table 4.9 Common procedures using fluoroscopy

Table 4.10 Adverse health effects of radiation

Table 4.11 Dose limits for occupational radiation exposure

Table 4.12 Measures to reduce radiation exposure during bronchoscopy

Chapter 5

Table 5.1 American Society of Anesthesiologists (ASA) Physical Status classif...

Table 5.2 ASA continuum of depth of sedation: definition of general anesthesi...

Chapter 6

Table 6.1 Indications for diagnostic bronchoscopy

Table 6.2 Indications for therapeutic bronchoscopy

Table 6.3 Contraindications to laser bronchoscopy

Table 6.4 Contraindications to bronchoscopy

Chapter 8

Table 8.1 Convex‐probe endobronchial ultrasound

Table 8.2 EBUS‐TBNA needles available

Chapter 9

Table 9.1 Endoscopic findings of early lung cancer [5]

Table 9.2 Size of lung cancers detected by screening low‐dose computed tomogr...

Table 9.3 Diagnostic yields for screen‐detected cancer via bronchoscopy, CT‐g...

Table 9.4 AFB devices [18–23]

Chapter 10

Table 10.1 Characteristics of the different ENB studies

Chapter 11

Table 11.1 Difference between VBN and EMN [12]

Table 11.2 Diagnostic yield of VBN in different studies

Chapter 12

Table 12.1 Elements of the general medical history and airway history that pr...

Chapter 15

Table 15.1 Pulmonary diseases in which bronchoscopic lung biopsy provides a h...

Table 15.2 Prebronchoscopy checklist

Chapter 16

Table 16.1 Wang transbronchial needles

Table 16.2 Wang TBNA staging system: TBNA site for mediastinum and hilar lymp...

Table 16.3 Wang TBNA staging system: location of mediastinum and hilar lymph ...

Table 16.4 Comparison of Wang's map and the IASLC map

Table 16.5 Diagnostic yield from individual procedures and their combinations

Chapter 19

Table 19.1 Characteristics of medical lasers

Table 19.2 Indications for laser/electrocautery/cryotherapy

Table 19.3 Contraindications for laser/electrocautery/cryotherapy

Table 19.4 Complications of laser airway therapy

Chapter 20

Table 20.1 Descriptive case series studies of HDR brachytherapy

Table 20.2 Complications following HDR brachytherapy

Table 20.3 ABS modified grading of radiation bronchitis and stenosis

Table 20.4 Potential treatments for radiation bronchitis

Chapter 21

Table 21.1 Risk factors for foreign body aspiration in adults

Table 21.2 Signs and symptoms of foreign body aspiration

Table 21.3 Case series of airway foreign body removal by flexible bronchoscop...

Chapter 22

Table 22.1 Defnitions of massive hemoptysis

Table 22.2 A summary of available studies of delayed versus immediate broncho...

Chapter 23

Table 23.1 Stents as a palliative therapeutic option in major airways obstruc...

Table 23.2 Grouping of stenosis

Table 23.3

Numerical assignment of degree of stenosis

Table 23.4 Stenosis scoring system according to location

Table 23.5 Design and data on new metallic stents

Table 23.6 Stent complications and their incidence rates

Chapter 24

Table 24.1 Etiologies of central airway obstruction

Chapter 26

Table 26.1 Laryngeal mask airway (LMA) sizes

Chapter 27

Table 27.1 Major indications for bronchoscopy in the intensive care unit

Table 27.2 Effect of bronchoscope in endotracheal tube on various respiratory...

Table 27.3 Materials for bronchoalveolar lavage in ventilated patients

Chapter 28

Table 28.1 Summary of prospective, randomized controlled trials evaluating br...

Table 28.2 Key inclusion and exclusion criteria of the AIR‐2 trial

Table 28.3 Summary of mimicking or aggravating disorders of asthma, and sugge...

Chapter 29

Table 29.1 Bronchoscopic lung volume reduction techniques according to mechan...

Chapter 31

Table 31.1 Etiology of benign airway stenosis

Table 31.2 Causes of tracheobronchial malacia

Table 31.3 Types of stenosis

Table 31.4 Location of airway stenosis

Table 31.5 Degree of airway stenosis

Table 31.6 Cotton–Meyer grading system

List of Illustrations

Chapter 1

Figure 1.1 Shigeto Ikeda, 1925–2001.

Figure 1.2 Ikeda demonstrating the first bronchoscope at my first visit to J...

Figure 1.3 Movie clip of the first flexible fiberscope (see video on the w...

Figure 1.4 With Teruomi Miyazawa at Ikeda's tomb. The inscription on the gra...

Figure 1.5 Modern flexible scopes of different diameters and sizes of biopsy...

Figure 1.6 The exponential downsizing of CCD chips for endoscopes.

Figure 1.7 Radial miniature EBUS probe inserted via the channel of a flexibl...

Figure 1.8 J. Rojas‐Solano with the Monarch robotic bronchoscope.

Figure 1.9 Live transmission of an EBUS procedure from Heidelberg, Germany, ...

Figure 1.10 Early lung cancer. The slight discoloration on white light becom...

Figure 1.11 Extensive squamous cell cancer at the bifurcation extending into...

Figure 1.12 Dumon silicone stent (a) and covered Ultraflex Nitinol stent (b)...

Figure 1.13 The Monarch

robotic endoscope

system (

RES

). The proximal control...

Figure 1.14 Diagnosis and treatment of peripheral lesions. Conventional navi...

Figure 1.15 Transbronchial cryobiopsy. With EMN, a catheter is inserted into...

Figure 1.16 Visions of future technologies. Head‐mounted device with two mon...

Chapter 2

Figure 2.1 Dr Shigeto Ikeda.

Figure 2.2 Zavala lung model. An early lung model developed to train physici...

Chapter 3

Figure 3.1 Representation of normal anatomic relationships at the level of t...

Figure 3.2 Representation of the normal anatomic relationships at the level ...

Figure 3.3 Representation of normal anatomic relationships at the level of t...

Figure 3.4 Representation of normal anatomic relationships at the level of t...

Figure 3.5 Representation of normal anatomic relationships at the level of t...

Figure 3.6 Representation of normal anatomic relationships at the level of t...

Figure 3.7 Representation of normal anatomic relationships at the level of t...

Figure 3.8 Representation of normal anatomic relationships at the level of t...

Chapter 4

Figure 4.1 Biofilms arise when microorganisms adhere to solid surfaces, form...

Figure 4.2 Electron micrograph of a biofilm.

Figure 4.3 Steris system automated endoscope reprocessor (SterisCorp, Mentor...

Figure 4.4 High‐efficiency particle exchanger, such as the HEPA‐Care (Abatem...

Figure 4.5 Essential components of C‐arm type fluoroscopy units.

Chapter 5

Figure 5.1 Mallampati score.

Figure 5.2 Schematic flow‐volume loops depicting (a) variable intrathoracic ...

Figure 5.3 The ASA Difficult Airway Algorithm.

Figure 5.4 Manual jet ventilator attached to rigid bronchoscope. The red arr...

Figure 5.5 (a) During right‐sided bleeding, a cuffed ETT in the left main br...

Chapter 7

Figure 7.1 Branch reading diagram. In the case of bronchoscopy to the right ...

Figure 7.2 Representative case. (

Top

) This lesion was located in right S

3

b. ...

Figure 7.3 Confirmation of the location of GS. To clarify the positional rel...

Chapter 8

Figure 8.1 Convex‐probe endobronchial ultrasound. Three different types of C...

Figure 8.2 Important steps for performing a successful EBUS‐TBNA are outline...

Figure 8.3 Regional lymph node mapping by EBUS‐TBNA.

Chapter 9

Figure 9.1 Normal terminal bronchiole with adjacent alveoli (a) and more pro...

Figure 9.2 AF‐OCT (a,f) and corresponding Doppler OCT to illustrate size of ...

Figure 9.3 OCT image of an adenocarcinoma (a) with a solid (b) and lepidic (...

Chapter 10

Figure 10.1 Historical timeline of ENB.

Figure 10.2 (a) Electromagnetic board. (b) Electromagnetic board placed unde...

Figure 10.3 Locatable guide (current version).

Figure 10.4 Extended working channel catheters (current version, all angle t...

Figure 10.5 EMN system planning software.

Figure 10.6 (a) Registration planning. (b) Registration phase.

Figure 10.7 Performing the navigation phase.

Figure 10.8 Different diagnostic yield of published ENB studies.

Figure 10.9 (a) Veran Spin system navigated bronchoscopy. (b) Veran Spin sys...

Figure 10.10 Fiducial marker.

Chapter 11

Figure 11.1 (

Left

) Peripheral target on CT images acquired by VBN. (

Right

) P...

Chapter 12

Figure 12.1 The modified airway Mallampati classification.

Figure 12.2 Neutral (a), flexion (b), and extension (c) lateral cervical spi...

Figure 12.3 (a–d) CT of the C‐spine in a 73‐year‐old woman with CT angiogram...

Figure 12.4 A 27‐year‐old woman (a–c) with an eight‐year history of submenta...

Figure 12.5 A 51‐year‐old man (a) with upper neck infection and swelling and...

Figure 12.6 Axial CT scans of the neck (a,b) of a 60‐year‐old woman with an ...

Figure 12.7 A 59‐year‐old man with severe soft and hard tissue injuries asso...

Figure 12.8 Indirect laryngoscopy view with anatomical landmarks identified....

Chapter 14

Figure 14.1 Milky and cloudy appearance of BALF.

Figure 14.2 Periodic acid–Schiff positive staining of BALF.

Figure 14.3 Whole‐lung lavage of PAP.

Figure 14.4 Foamy cells in BALF.

Figure 14.5 Liquid‐based cytology smear demonstrating squamous cell carcinom...

Figure 14.6 Liquid‐based cytology smear demonstrating adenocarcinoma.

Figure 14.7 Liquid‐based cytology smear demonstrating small cell carcinoma....

Figure 14.8 BALF in bacterial pneumonia.

Figure 14.9

Pneumocystis jiroveci

in BALF (

red arrow

).

Figure 14.10 Mycelia of

Aspergillus

in BALF.

Figure 14.11 Bronchoalveolar specimen microcopy. Oil red O stain showing mai...

Figure 14.12 Alveolar macrophage with multiple membrane‐bound vacuoles with ...

Chapter 15

Figure 15.1 Fluoroscopic guidance used to obtain bronchoscopic lung biopsy f...

Chapter 16

Figure 16.1 (a) MW‐222 transbronchial needle. The most proximal part, the “g...

Figure 16.2 (a) Schematic diagram of the distal end of a transbronchial aspi...

Figure 16.3 The transbronchial or transesophageal needle aspiration system (...

Figure 16.4 Dedicated ultrasound processor from Olympus, Japan. (a) EU‐M1 an...

Figure 16.5 Commercial available EBUS‐TBNA needles. (a) EchoTip from Cook Me...

Figure 16.6 Wang transbronchial needle (MW‐319): (a) position for insertion;...

Figure 16.7 Different techniques used for tracheobronchial wall penetration ...

Figure 16.8 The Wang transbronchial needle is advanced into the aortopulmona...

Figure 16.9 The TBNA technique for histology specimens: (step 1) hub is visi...

Figure 16.10 Histology specimen retrieved by 19 gauge transbronchial needle ...

Figure 16.11 Nomenclature of mediastinum and hilar lymph nodes for transbron...

Figure 16.12 Comparison of IASLC lymph node map (a) and Wang's lymph node ma...

Figure 16.13 Location of mediastinum and hilar lymph nodes for transbronchia...

Figure 16.14 (a) Subcarinal adenopathy (station 8) on CT scan. Smear from st...

Figure 16.15 (a) Endobronchial polypoid lesion obstructing the right main br...

Figure 16.16 (a) A right paratracheal mass with CT features of benign medias...

Figure 16.17 (a) CT scan demonstrated mediastinal adenopathy at stations 4R ...

Figure 16.18 (a) Chest X‐ray demonstrating left upper lobe nodule with TBNA ...

Figure 16.19 Tumor–bronchial relationship.

Chapter 17

Figure 17.1 Wang's lymph node map and the puncture sites for transbronchial ...

Figure 17.2 The correlation of the right lymph nodes between Wang's and IASL...

Figure 17.3 The correlation between subcarinal lymph nodes on the IASLC maps...

Figure 17.4 Vessel location can vary in relation to the airway (a–c). The ly...

Figure 17.5 Revised ESTS guidelines for primary mediastinal staging..

Chapter 18

Figure 18.1 Conceptual framework for translational research.

Figure 18.2 Translational science. The evolution of c‐EBUS for mediastinal s...

Figure 18.3 Translational science. The evolution of EMN and RP‐EBUS for diag...

Chapter 19

Figure 19.1 Endobronchial lesion. Postintubation web‐like stenosis causing m...

Figure 19.2 Use of

argon plasma coagulation

(

APC

) in postintubation web‐like...

Figure 19.3 Cryotherapy application: one to three freeze–thaw cycles, each l...

Figure 19.4 Cryotherapy. (a) Freezing of the endotracheal malignant tumor wi...

Chapter 20

Figure 20.1 Brachytherapy catheter placement. (a) Tumor recurrence at end of...

Figure 20.2 Treatment planning. (a,b) Planning chest X‐ray with two catheter...

Figure 20.3 (a) Fiducial gold seed loaded on wax tip at end of microbiology ...

Figure 20.4 Visicoil fiducial marker.

Figure 20.5 SuperLock fiducial marker.

Figure 20.6 Civco fiducial markers.

Figure 20.7 (a) Flattened platinum coil spring fiducial marker loaded in tip...

Figure 20.8 Radiopaque fiducial markers identified in and around right lung ...

Figure 20.9 Alpha‐Omega fiducial marker (model SMG0242‐025, Alpha‐Omega Serv...

Figure 20.10 Placement of fiducial marker in hilar mass. (a) Fiducial marker...

Figure 20.11 Placement of fiducial markers around peripheral nodule. (a) End...

Figure 20.12 Internally cooled radiofrequency ablation (RFA) electrodes. The...

Figure 20.13 Expandable tine‐type of RFA catheter.

Chapter 21

Figure 21.1 Broncholith due to chronic histoplasmosis found on rigid broncho...

Figure 21.2 Cryoprobe and application in benign airway disease.

Figure 21.3 Balloon catheter (Fogarty) used as an aid to move a foreign body...

Figure 21.4 (a) Posteroanterior and lateral chest radiograph showing radiopa...

Chapter 22

Figure 22.1 Diagram of the systemic blood supply to the lung. Note that flow...

Figure 22.2 Flexible bronchoscopic insertion of the double‐lumen endobronchi...

Figure 22.3 (a) Fogarty balloon embolectomy catheter with balloon inflated. ...

Figure 22.4 (a) During right‐sided bleeding, a cuffed ETT in the left main b...

Figure 22.5 Effect of different positions on airway blood and ventilation du...

Figure 22.6 An elongated endobronchial tube for treatment of bronchoscopy‐in...

Figure 22.7 Model procedure of inserting the elongated endobronchial tube vi...

Figure 22.8 Chest CT shows patchy consolidation of the right lower lung with...

Figure 22.9 After removing large amount of blood clots in the mouth and nose...

Figure 22.10 Thoracotomy was performed. We could see that the distal interme...

Chapter 23

Figure 23.1 Selection of currently used airway stents. (1) Montgomery T‐tube...

Figure 23.2 Flow limitation theory and choke point physiology. (a) Alveolar ...

Figure 23.3 Clinical examples of the degrees of stenosis. (a) Intraluminar t...

Figure 23.4 Lateral chest X‐ray with Nitinol (Ultraflex) stent in place for ...

Figure 23.5 Montgomery T‐tube. (a) Introduction of Montgomery T‐tube through...

Figure 23.6 CT of the neck showing T‐limb of Montgomery T‐tube. Patient T‐li...

Figure 23.7 An Ultraflex stent is seen partially constrained on the delivery...

Figure 23.8 A fully expanded Ultraflex stent. This stent was deployed in the...

Figure 23.9 Multiple polypoid endotracheal metastasis with intrinsic, extrin...

Figure 23.10 After argon plasma coagulation, a covered Ultraflex stent was p...

Figure 23.11 Left bronchial arm of a Dynamic stent being shortened.

Figure 23.12 Rigid biopsy forceps seen with a Dynamic stent in view.

Figure 23.13 Rigid forceps have been inserted through the Dynamic stent with...

Figure 23.14 PA and lateral films from a barium swallow from a patient prese...

Figure 23.15 The patient's bronchoscopy demonstrated a tracheoesophageal and...

Figure 23.16 A Dynamic stent has been placed, sealing both the tracheal and ...

Figure 23.17 Pictured is a metallic stent that needed to be removed. The for...

Figure 23.18 A tracheal stent is seen to have been compressed and overgrown ...

Figure 23.19 A metallic stent is seen protruding from a tracheocavitary fist...

Figure 23.20 CT images immediately after the accident (a,d,g), on presentati...

Chapter 24

Figure 24.1 Benign web‐like tracheal stenosis seen via rigid bronchoscope.

Figure 24.2 Malignant (mixed intraluminal and extraluminal) airway stenosis ...

Figure 24.3 Steps to balloon bronchoplasty in sequence. (a) Severe web‐like ...

Figure 24.4 High‐pressure syringe (Boston Scientific, Marlborough, MA).

Figure 24.5 CRE single‐use pulmonary balloon dilator (Boston Scientific, Mar...

Chapter 25

Figure 25.1 Gustav Killian positioning a rigid bronchoscope on a cadaver....

Figure 25.2 (

Top to bottom

) Tracheoscope, two sizes of ventilating rigid bro...

Figure 25.3 The ventilating bronchoscope with a Hopkins telescope, biopsy fo...

Figure 25.4 Additional biopsy forceps available for use with the bronchoscop...

Figure 25.5 Clockwise: a portable light source, a “FLUVOG” adapter which may...

Figure 25.6 The distal end of the rigid scope is seen immediately above an a...

Figure 25.7 A 56‐year‐old white male presented with greater than 80% obstruc...

Figure 25.8 Laser photoablation technique is applied through the rigid bronc...

Figure 25.9 Selection of currently used airway stents. (1) Montgomery T‐tube...

Figure 25.10 Bronchoscopy team, University of Tennessee Medical Center, Knox...

Figure 25.11 The rigid scope is held in the right hand at the proximal porti...

Figure 25.12 The ventilating bronchoscope is aimed vertically at a 90° angle...

Figure 25.13 The bronchoscope is slowly advanced forward until the epiglotti...

Figure 25.14 The proximal portion of the tube is allowed to rest along the o...

Figure 25.15 The laryngoscope is used to visualize the vocal cords and the p...

Figure 25.16 A GlideScope is utilized to visualize the vocal cords with intu...

Figure 25.17 The rigid bronchoscope is inserted along the endotracheal tube,...

Chapter 26

Figure 26.1 Laryngomalacia in a 5‐month‐old boy with stridor.

Figure 26.2 Paralyzed vocal cord in a 2‐month‐old girl with stridor.

Figure 26.3 Supraglottic cyst in a 3‐month‐old boy.

Figure 26.4 Subglottic stenosis in a 6‐month‐old girl after intubation.

Figure 26.5 Bronchomalacia in a 5‐month‐old boy with persistent wheezing.

Figure 26.6 Complete tracheal rings in a 13‐month‐old boy with persistent wh...

Figure 26.7 Subglottic hemangioma in a 12‐year‐old boy with chronic cough an...

Figure 26.8 Right mainstem bronchus tumor in a 4‐year‐old boy with cough and...

Figure 26.9 Peanut debris in a small airway of lower lobe in a 1.5‐year‐old ...

Figure 26.10 Bronchial tuberculosis in a 1‐year‐old boy with pulmonary hilar...

Chapter 27

Figure 27.1 Apparatus used to perform bronchoalveolar lavage.

Figure 27.2 Algorithm for bronchoalveolar lavage in ventilator‐associated pn...

Figure 27.3 Improved tracheal caliber following balloon dilation and metalli...

Chapter 28

Figure 28.1 Bronchial thermoplasty: delivery of radiofrequency energy to the...

Figure 28.2 Histological specimens of an untreated control airway wall (a) a...

Figure 28.3 Disposable Alair™ radiofrequency catheter, which houses a four‐a...

Figure 28.4 The expanded electrode array with all four arms contacting the a...

Figure 28.5 Suggested sequence of performing contiguous activations during b...

Chapter 29

Figure 29.1 Zephyr valves (a) and IBV (b).

Figure 29.2 Radiographic evidence of left lower lobe atelectasis and hemidia...

Figure 29.3 Radiographic appearance of bilateral coils in upper (a) and lowe...

Figure 29.4 Radiological evidence of induced segmental sclerosis at one mont...

Figure 29.5 Proposed algorithm for BLVR treatment.

Chapter 30

Figure 30.1 The various Amplatzer devices used in clinical practice.

Figure 30.2 An Amplatzer septal occlusion device and a sheared silicone stri...

Figure 30.3 The stents commonly used for BPF include metallic and silicone m...

Figure 30.4 A metallic stent was used to seal the fistula in a postoperative...

Figure 30.5 The combination of modified Dumon stent and gelatin sponge was a...

Chapter 31

Figure 31.1 Tracheal stenosis due to percutaneous tracheostomy. (a,b) Bronch...

Figure 31.2 Secondary right main bronchus obstruction to tuberculosis (bT2L4...

Figure 31.3 Morphological types of benign tracheal strictures at bronchoscop...

Figure 31.4 Tracheal rupture caused by car accident (bT3L1D4L2.5). (a) Pneum...

Figure 31.5 Postsurgery views of left sternoclavicular abscess (bT1L2D5L2). ...

Figure 31.6 Type 3 upper airway stenosis caused by thyromegaly (bT3L2D5L3). ...

Figure 31.7 (a–c) Deployment of hourglass metal stent in L1 (bT3L1D4L1). (d)...

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Flexible Bronchoscopy

Fourth Edition

Edited by

Ko‐Pen Wang, MD

Division of Pulmonary and Critical Care MedicineJohns Hopkins Bayview Medical CenterJohns Hopkins University School of MedicineBaltimore, MD, USA

Atul C. Mehta, MD, FACP, FCCP

Lerner College of MedicineBuoncore Family Endowed Chair in Lung TransplantationDepartment of Pulmonary MedicineRespiratory InstituteCleveland ClinicCleveland, OH, USA

J. Francis Turner, Jr., MD, FACP, FCCP, FCCM

Division of Pulmonary and Critical Care MedicineUniversity of Tennessee Graduate School of MedicineKnoxville, TN, USA;National Supercomputing InstituteUniversity of Nevada, NV, USA

This edition first published 2020 © 2020 by John Wiley & Sons Ltd.Edition History [3e, 2012]

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Ko‐Pen Wang, Atul C. Mehta, and J. Francis Turner, Jr. be identified as the authors of editorial work has been asserted in accordance with law.

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Library of Congress Cataloging‐in‐Publication Data

Names: Wang, Ko Pen, editor. | Mehta, Atul C., editor. | Turner, J. Francis, Jr., editor.Title: Flexible bronchoscopy / edited by Ko‐Pen Wang, Atul C. Mehta, J. Francis Turner, Jr.Description: Fourth edition. | Hoboken, NJ : John Wiley & Sons, 2020. | Includes bibliographical references and index.Identifiers: LCCN 2019058267 (print) | LCCN 2019058268 (ebook) | ISBN 9781119389057 (hardback) | ISBN 9781119389224 (adobe pdf) | ISBN 9781119389217 (epub)Subjects: MESH: Bronchoscopy | Bronchial Diseases–diagnosis | Bronchial Diseases–therapyClassification: LCC RC734.B7 (print) | LCC RC734.B7 (ebook) | NLM WF 500 | DDC 616.2/307545–dc23LC record available at https://lccn.loc.gov/2019058267LC ebook record available at https://lccn.loc.gov/2019058268

Cover Design: WileyCover Images: Courtesy of Professors Kurimoto and Miyazawa, Courtesy of J. Francis Turner, Courtesy of Yang Xia, Courtesy of Eric Carlson and Tom Schlieve, © yodiyim/Getty Images

List of Contributors

Jason Akulian, MD, MPHSection of Interventional PulmonologyDivision of Pulmonary and Critical Care MedicineUniversity of North Carolina at Chapel HillChapel Hill, NC, USA

Chong Bai, MD, PhDRespiratory and Critical Care MedicineChanghai HospitalSecond Military HospitalShanghai, China

Swati Baveja, MBBSDivision of Pulmonary and Critical Care MedicineUniversity of Tennessee Graduate School of MedicineKnoxville, TN, USA

Heinrich D. Becker, MDFormerly Department of Interdisiplinary EndoscopyThoraxclinic at Heidelberg University Heidelberg, Germany

Ben Bevill, MDDivision of Pulmonary and Critical Care MedicineUniversity of Tennessee Graduate School of MedicineKnoxville, TN, USA

Semra Bilaceroglu, MDIzmir Dr Suat Seren Training and Research Hospital for Thoracic Medicine and SurgeryHealth Sciences UniversityIzmir, Turkey

Martina Bonifazi, MDDepartment of Biomedical Sciences and Public HealthUniversità Politecnica delle Marche, Ancona;Pulmonary Diseases UnitDepartment of Internal MedicineAzienda Ospedaliero‐Universitaria ‘Ospedali Riuniti’Ancona, Italy

Robert F. Browning Jr., MD, FACP, FCCPInterventional PulmonologyWalter Reed National Military Medical Center, Bethesda;Uniformed Services University of Health SciencesBethesda, MD, USA

Eric R. Carlson, DMD, MD, FACSDepartment of Oral and Maxillofacial SurgeryUniversity of Tennessee Medical Center University of Tennessee Cancer InstituteKnoxville, TN, USA

Alexander Chen, MDDivision of Pulmonary and Critical CareWashington University School of MedicineSt Louis, MO, USA

Ara A. Chrissian, MDPulmonary and Critical CareLoma Linda UniversityLoma Linda, CA, USA

David Feller‐Kopman, MDInterventional PulmonologyDivision of Pulmonary and Critical Care MedicineJohns Hopkins University School of MedicineBaltimore, MD, USA

Erik E. Folch, MD, MScDivision of Pulmonary and Critical Care MedicineMassachusetts General HospitalBoston, MA, USA

Stefano Gasparini, MD, FCCPDepartment of Biomedical Sciences and Public HealthUniversita Politecnica delle MarcheAncona; andPulmonary Diseases UnitDepartment of Internal MedicineAzienda Ospedaliero‐Universitaria ‘spedali Riuniti’ Ancona, Italy

Thomas R. Gildea, MD, MS, FCCPDepartment of Pulmonary Allergy and Critical Care MedicineRespiratory InstituteCleveland ClinicCleveland, OH, USA

Sarah Hadique, MDDepartment of Pulmonary and Critical Care MedicineWest Virginia UniversityMorgantown, WV, USA

Richard Helmers, MDMayo Clinic Health SystemEau Claire, WI, USA

Wolfgang Hohenforst‐Schmidt, MDSana Clinic Group FrankenDepartment of Cardiology/Pulmonology/Intensive Care/Nephrology“Hof” ClinicsUniversity of ErlangenHof, Germany

Hai‐dong Huang, MDRespiratory and Critical Care MedicineSecond Military Medical UniversityShanghai;Interventional Pulmonology Center of SMMURespiratory and Critical Care MedicineChanghai HospitalSecond Military Medical University (SMMU)Shanghai;International Training Center for InterventionalPulmonologyHenry Ford HospitalShanghai, China

Yi Huang, MDShanghai Changhai HospitalShanghai, China

Takeo Inoue, MDDivision of Respiratory MedicineDepartment of Internal MedicineSt Marianna University School of MedicineKawasaki, Japan

Takeshi Isobe, MDDivision of Medical Oncology and Respiratory MedicineDepartment of Internal MedicineShimane University HospitalIzumo, Japan

Prasoon Jain, MD, FCCPLouis A. Johnson VA Medical CenterClarksburg, WV, USA

Michael A. Jantz, MDDivision of Pulmonary, Critical Care, and Sleep MedicineUniversity of FloridaGainesville, FL, USA

Mani S. Kavuru, MDDivision of Pulmonary and Critical Care MedicineJefferson Center for Critical CareThomas Jefferson University and Hospital Philadelphia, PA, USA

Ming‐yao Ke, MDDepartment of the Respiratory CentreSecond Affiliated Hospital of XiaMen Medical CollegeXiamen, Fujian, China

Danai Khemasuwan, MD, MBATufts University School of Medicine andSt Elizabeth’s Medical CenterBoston, MA, USA

Noriaki Kurimoto, MDDivision of Medical Oncology and Respiratory MedicineDepartment of Internal MedicineShimane University HospitalIzumo, Japan

Jonathan S. Kurman, MDDivision of Pulmonary and Critical CareDepartment of MedicineMedical College of Wisconsin Milwaukee, WI, USA

Stephen C.T. Lam, MD, FCCPDepartment of Integrative OncologyBritish Columbia Cancer AgencyVancouver, British Columbia; Cancer Imaging Department and Department of MedicineUniversity of British ColumbiaVancouver, British Columbia, Canada

Carlos Aravena Leon, MDDepartment of PulmonaryAllergy and Critical Care MedicineRespiratory InstituteCleveland ClinicCleveland, OH, USA;Department of Respiratory DiseasesFaculty of MedicinePontificia Universidad Catolica de ChileSantiago, Chile

Qiang Li, MDDepartment of Respiratory and Critical Care MedicineShanghai East HospitalTongji University School of MedicineShanghai, China

Xicheng Liu, MDDepartment of Interventional PulmonologyBeijing Children’s HospitalCapital University of MedicineBeijing, China

Jing Ma, MDDepartment of Interventional PulmonologyQilu Children’s Hospital of Shandong UniversityJinan, China

Samir Makani, MDDivision of Pulmonary and Critical Care MedicineHenry Ford HospitalDetroit, MI, USA

Sean McKay, MDInterventional PulmonologyWalter Reed National Military Medical CenterUniformed Services University of Health SciencesBethesda, MD, USA

Atul C. Mehta, MD, FACP, FCCPProfessor of Medicine Lerner College of Medicine Buoncore Family Endowed Chair in Lung TransplantationDepartment of Pulmonary MedicineRespiratory InstituteCleveland ClinicCleveland, OH, USA

Chen Meng, MDDepartment of Interventional PulmonologyQilu Children’s Hospital of Shandong UniversityJinan, China

Teruomi Miyazawa, MD, PhD, FCCPDivision of Respiratory MedicineDepartment of Internal MedicineSt Marianna University School of MedicineKawasaki, Japan

Blake A. Moore, MDSection on Cardiothoracic AnesthesiaUniversity of Tennessee Graduate School of MedicineKnoxville, TN, USA

Septimiu D. Murgu, MDDepartment of MedicineSection of Pulmonary and Critical CareUniversity of ChicagoChicago, IL, USA

Renelle Myers, MD, FRCPCDepartment of Integrative OncologyBritish Columbia Cancer AgencyVancouver, British Columbia;Department of MedicineUniversity of British ColumbiaVancouver, British Columbia, Canada

David E. Ost, MD, MPH, FACPDivision of Internal MedicineDepartment of Pulmonary MedicineMD Anderson Cancer CenterUniversity of TexasHouston, TX, USA

Luca Paoletti, MDDivision of Pulmonary and Critical Care MedicineMedical University of South CarolinaCharleston, SC, USA

Nicholas J. Pastis Jr., MD, FCCPDivision of Pulmonary and Critical Care MedicineMedical University of South CarolinaCharleston, SC, USA

Sunit R. Patel, MDMedical GroupTrulock, CA, USA

Andrew Pattison, MDDivision of Thoracic SurgeryToronto General HospitalUniversity Health NetworkUniversity of TorontoToronto, Ontario, Canada

Alexander S. Rabin, MDDepartment of Pulmonary and Critical Care MedicineMassachusetts General HospitalBoston, MA, USA

Ali Sadoughi, MDDivision of Pulmonary and Critical CareAlbert Einstein College of Medicine/Montefiore Medical CenterNew York, USA

Ala Eddin Sagar, MDBanner MD Anderson Cancer CenterPhoenix, AZ, USA

Thomas Schlieve, DDS, MDDivision of Oral and Maxillofacial SurgeryUniversity of Texas Southwestern Medical SchoolParkland Memorial HospitalDallas, TX, USA

Michael J. Simoff, MD, FCCPDivision of Pulmonary and Critical Care MedicineHenry Ford HospitalDetroit, MI, USA

J. Francis Turner, Jr., MD, FACP, FCCP, FCCMDivision of Pulmonary and Critical Care MedicineUniversity of Tennessee Graduate School of MedicineKnoxville, TN;National Supercomputing InstituteUniversity of NevadaLas Vegas, NV, USA

Ko‐Pen Wang, MDDivision of Pulmonary and Critical Care MedicineJohns Hopkins Bayview Medical CenterJohns Hopkins University School of MedicineBaltimore, MD, USA

Wei Zhang, MDShanghai Changhai HospitalShanghai, China

Yang Xia, MDDivision of Pulmonary and Critical Care MedicineSecond Affiliated Hospital of Zhejiang University School of MedicineHangzhou, China

Kazuhiro Yasufuku, MD, PhDDivision of Thoracic SurgeryToronto General HospitalUniversity Health NetworkUniversity of TorontoToronto, Ontario, Canada

Shunying Zhao, MDDepartment of Interventional PulmonologyBeijing Children’s HospitalCapital University of MedicineBeijing, China

Guo‐wu Zhou, MD, PhDRespiratory and Critical Care MedicineChanghai HospitalSecond Military HospitalShanghai;Respiratory and Critical Care MedicineChina‐Japan Friendship HospitalBeijing, China

Preface

We are honored to be the editors of the fourth edition of Flexible Bronchoscopy. In this role, we wish to recognize that this book is the collaborative efforts of many experts in the art and science of bronchoscopy, as reflected by the contributions of our eminent authors.

The art of bronchoscopy is now recognized as a critical skill not only in the technical performance of obtaining necessary tissue and a variety of therapeutics, but also to ensuring the best application of our rapidly expanding technology.

Modern bronchoscopy was born over 100 years ago when Professor Gustav Killian began utilizing the rigid bronchoscope in 1897. This was followed by the genius of Professor Shigeto Ikeda in developing the flexible bronchoscope in 1964. Since these early years, technology has enhanced our capabilities at a steady pace with intermittent brilliant leaps forward with the insight of modern thought leaders and inventors since the 1970s. These developments are well known to the field of bronchoscopy and interventional pulmonology. They include the development of the flexible transbronchial needle for nodal aspiration and bronchoscopic lung cancer staging, followed by Professors Heinrich Becker, Teruomi Miyazawa, Kazuhiro Yasufuku, and others shepherding the application of ultrasound in the tracheobronchial tree. Also, we acknowledge the seminal work of Professor François Dumon and the development of silicone stents in 1990, and other advances as detailed by the authors in this textbook.

In this book, our authors delineate the bedrock techniques of bronchoscopy, such as anesthesia for bronchoscopy, rigid bronchoscopy, and bronchoscopic lung biopsy. Also covered are the history and applications of the more recent developments of linear and radial‐probe ultrasound, navigational bronchoscopy for localization and sampling of peripheral pulmonary nodules, as well as authoritative information on therapeutic procedures such as ablative therapy utilizing “hot” instruments with laser, electrocautery, and argon plasma coagulation or “cold” interventions utilizing spray cryotherapy.

As bronchoscopy and interventional pulmonology mature as a specialty, the challenge will be to explore how we might best apply this burgeoning technology in an effective, safe, and economically prudent manner. Optimal application of many standard techniques still yields substantial benefit in the diagnosis and staging of benign and malignant disease while new techniques need to be carefully judged against the established ones.

This is an exciting time for those of us privileged to be helping patients with diseases of the chest through our interest in the art and science of bronchoscopy. We hope that the wisdom and enthusiasm shared by our authors will allow you to excel in your chosen profession and improve the welfare of our patients.

Ko‐Pen WangAtul C. MehtaJ. Francis Turner, Jr.

About the Companion Website

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1A Short History of Flexible Bronchoscopy: From Fiberoptics to Robotics

Heinrich D. Becker

Department of Interdisiplinary Endoscopy, Thoraxclinic at Heidelberg University, Heidelberg, Germany

It is already 70 years since the beginning of bronchoscopic examination and the appearance of the flexible bronchofiberscope represents the opening of a new page in bronchoscopic examination. Future bronchoscopic examinations should make further progress on this milestone of the flexible bronchofiberscope.

(Shigeto Ikeda [1])

1.1 Introduction

There is ample literature about the history of bronchoscopy in general. In this chapter, I will describe the steps that led to the development of the first flexible bronchoscope from prototype to the final device and the crucial steps of further evolution from fiberscopes to videoscopes, endobronchial ultrasound (EBUS) scopes, and the latest robotic flexible bronchoscope. The introduction of adjuvant technologies created a wide range of diagnostic and therapeutic applications for flexible bronchoscopy that has made it the central indispensible tool in pulmonary medicine today. I will describe how, driven by changing concepts, planned search for technical solutions or chance detection, new technologies were added to existing ones, leading to new concepts and strategies in a logical pattern. The examples given are early and advanced lung cancer, central airway obstruction, solitary pulmonary nodules (SPN), diseases of lung tissue, emphysema, and asthma. And finally, based on current developments I will take a look at the future of flexible bronchoscopy.

1.2 Shigeto Ikeda and the Invention of the Flexible Bronchoscope

From its introduction by Gustav Killian in 1897, the rigid bronchoscope remained the standard instrument for inspection of the airways during the following 70 years. Due to the comparatively complicated procedure, requiring special skills and in many cases additional general anesthesia, application of rigid bronchsocopy was mainly restricted to ENT departments, thoracic surgery, and specialized pulmonology centers. Only after Shigeto Ikeda introduced the flexible bronchoscope in 1967 did the art of bronchoscopy spread to many medical disciplines worldwide.

Ikeda was born in 1925 (Figure 1.1). After graduating from high school, he began studying medicine at Keio University in 1944. However, he had to interrupt his studies for one year as he suffered from specific pleuritis and underwent thoracoplasty. After recovery, he graduated in 1952 but in the same year, he had to have lung resection for a tuberculous mass during his internship in the Division of Tuberculous Surgery. Here he began studies on bronchial anatomy, including bronchography and motion pictures. As he found illumination by electric bulbs at the tip of rigid telescopes unsatisfactory, in 1962 he designed a telescope with “cold light.” A glass fiber bundle, connected to a 500 W xenon light source, was attached to the telescope and provided sufficient illumination for obtaining photographs and taking movies, for which he constructed special cameras.

Figure 1.1 Shigeto Ikeda, 1925–2001.

However, visualization of the bronchi in both upper lobes was often difficult due to the anatomical structures. Thus the need for a flexible bronchoscope, based on the concept of the gastrointestinal fiberscope presented by Basil Hirshowitz in 1961, was apparent [2,3]. As Machida Co. and Olympus Optical Co. had produced the first gastrofiberscopes in Japan from 1962, Ikeda approached Machida in 1964 and Olympus in 1965 for the construction of prototypes for bronchoscopy. He formulated specific requirements regarding diameter, more and smaller optical fibers, flexible light guide, fixed tip <1 cm, length 1 m, fixed focus 0.5–3 cm, visual angle 80°, and tip flexion of 60°. For ease of introduction, a special semiflexible orotracheal tube was constructed, that could be straightened in case specimens had to be obtained by a rigid forceps (Figure 1.2).

Figure 1.2 Ikeda demonstrating the first bronchoscope at my first visit to Japan. (Note: he was left handed, which is why the line to the light source and the suction of flexible bronchoscopes are running to the left so that the control section of the scope rests easily in your left hand and the lines are not pulling.) On the left is the first scope with the special orotracheal tube that could be straightened for taking rigid biopsies.

In 1966, when Ikeda presented the first prototype at the 9th International Congress on Diseases of the Chest in Copenhagen, Denmark, he created huge excitement and the story was even published in the New York Times. Further improvements were made on the following prototypes: control mechanisms for lengthwise rotation and bending of the tip were built into the control section, improved imaging was achieved by regular arrangement of smaller glass fibers, and a lens was mounted on the tip (Figure 1.3, movie). Finally, in the seventh prototype a channel was integrated into the scope for the introduction of sampling devices; Ikeda was confident that the instrument was ready for commercialization and introduced and popularized flexible fiberbronchoscopy throughout the world.

Figure 1.3 Movie clip of the first flexible fiberscope (see video on the website: function with flexion and rotation).

Source: Courtesy of T. Shirakawa.

In the following years, more and more experience was gained in clinical application and by 1980 flexible fiber bronchoscopy had become a routine procedure and spread worldwide. In 1980, after visiting Dumon in Marseille, Ikeda's group began Nd:YAG laser treatment and photodynamic therapy (PDT) of malignant lesions. For better image resolution and processing, together with Asahi Pentax Co. he introduced charge‐coupled device (CCD) chip technology to build the first videoscope which was later adopted by Machida‐Toshiba and Olympus. On his mission to promote the art of flexible fiberbronchoscopy, Ikeda traveled extensively all over the world and in 1978 founded the World Association for Bronchology (WAB) within which nowadays, as the World Association for Bronchology and Interventional Pulmonology (WABIP), national and continental assocations are united.

In recognition of his outstanding achievements, Ikeda received many national and international awards. After resignation from his clinical and academic positions in 1991, he preserved a keen interest in the development of bronchoscopy and stayed closely connected to the scientifc societies. Despite his fragile health due to several strokes and heart attacks, according to his lifelong motto “Never give up,” he attended all the meetings until the year 2000 before he died in 2001 [14–8] (Figure 1.4).

1.3 Further Development of Flexible Endoscopes

In the beginning, Machida and Olympus were the only manufacturers of flexible fiberbronchoscopes but soon other companies in Japan, the US and Europe began entering the market and today there are around 20 in business. As Olympus had the widest distribution network, it remains the main player in the market. With growing experience in fiberbrochoscopy, there was an increasing demand for different types of bronchoscopes for special diagnostic and therapeutic applications and also for other disciplines in medicine that realized the value of the new technology, such as anesthesia, pediatrics, and ICU medicine.

Figure 1.4 With Teruomi Miyazawa at Ikeda's tomb. The inscription on the gravestone beneath the emblem of the WAB reads: “Invention.”

Figure 1.5 Modern flexible scopes of different diameters and sizes of biopsy channels.

The development of new imaging and therapeutic technologies that could be applied via flexible bronchoscopes drove new advances. Improved fiberbronchoscopes were brought to the market in comparatively quick succession. Different diameters from 6 mm down to 2.2 mm for peripheral airways and pediatric use became available (Figure 1.5). Recently, miniaturized bronchoscopes with an outer diameter of less than 1 mm have been constructed for laboratory research in small animals. A variety of bronchoscopes with wide channels of 3 mm for interventional procedures and 1.2 mm for peripheral use are now available. Improvement of fiberoptics is allowing better analysis of small structures and photodocumentation. For observation by trainees, a teaching attachment (lecture scope) can be mounted onto the control section of the bronchoscope. Fiberscopes with battery illumination and integrated monitor are useful for the ICU, sleep laboratory, on wards and in the outpatient department.

The next big step was the introduction of videobronchoscopy by Pentax in 1987, which became possible due to miniaturization of CCD chips, that could be integrated into the tip of flexible bronchoscopes instead of optical fibers [9] (Figure 1.6). Via a video processor, moving images can be followed on a monitor, stored on film and data banks, and printed. They can be directly integrated into the report or transmitted online to other departments. The biggest advantage is that images can be processed according to colors, contour enhancement, magnification, and different light sources. The CCDs have become so efficient that today videbronchoscopes with high‐definition television (HDTV) with superior image quality are available. In very small endoscopes, the CCD is integrated into the control section and transmits the fiberoptic image to the processor (hybrid scope).

The next technological revolution was the introduction of EBUS in 1996, adding a new dimension to flexible bronchoscopy by widening the view of the bronchoscopist beyond the airway. In 1999, the miniaturized radial probe was launched, that could be introduced via the biopsy channel of the flexible bronchoscope [10]. As there was an increasing demand for real‐time transbronchial needle aspiration of mediastinal lymph nodes (TBNA), a dedicated ultrasonic endoscope was added in 2002 [11] (Figure 1.7) Today, EBUS‐TBNA has become the standard for mediastinal staging and the radial probe for approach to peripheral lesions. “Endobronchial ultrasound (EBUS) is the single most useful pulmonary procedure in decades and should be available to all patients with thoracic adenopathy requiring evaluation” (Kevin L. Kovitz).

Figure 1.6 The exponential downsizing of CCD chips for endoscopes.

Figure 1.7 Radial miniature EBUS probe inserted via the channel of a flexible bronchoscope and ultrasonic bronchoscope, so‐called convex probe (cP) bronchoscope.

The latest revolution in flexible bronchoscopy is the introduction of robotic bronchoscopy. In the attempt to become more independent from the bronchoscopist's individual skills in handling and accuracy, robotic surgery has been developed. It is expected to improve access to peripheral airways by flexibility in all directions in order to place tools with precision consistently in the desired location and maintain stability in position under vision and by active remote robotic control. In 2018, a paper on clinical application of the first robotic bronchoscope (Monarch®, Auris Surgical Robotics Inc.) was published by my former coworker Jose Rojas‐Solano [12] (Figure 1.8) A second upcoming robotic platform is the Ion™ endoluminal system by Intuitive Surgical, Inc., which currently is waiting for 510(k) clearance.

A general problem with flexible bronchoscopes is disinfection because of the small channels with risk of cross‐contamination [13]. As few optical systems can withstand the autoclaving procedure, disposable videobronchoscopes have been developed [14]. The costs of reusable bronchosopes have been assessed for application in the ICU which, albeit with many imponderables, seemed favorable. However, due to the many different diagnostic and therapeutic applications of flexible bronchoscopy as illustrated below, it is highly improbable that disposable flexible bronchoscopes will be taking over more than the current approximately 30% of the market. So far, the only practical solution is high‐level disinfection of instruments and strict observation of hygienic guidelines.

Figure 1.8 J. Rojas‐Solano with the Monarch robotic bronchoscope.

With all these technical improvements, bronchoscopy has become an essential part of pulmonary medicine. The bronchoscope market is driven by increasing prevalence of pulmonary diseases that can be diagnosed and treated by minimal invasive procedures with the bronchoscope, improved reimbursement, and technological advancements. The global market was valued at US$15.4 billion in 2017 and is expected to have increased 8.3% annually by the year 2025. Thus it can be expected that this will be an important incentive for manufacturers to research and invest in innovations [15].

1.4 Further Developments in Flexible Bronchoscopy

The ease of application and access beyond the central airways opened vast opportunities for the introduction of new optical, diagnostic, and therapeutic techniques [16], starting with transbronchial lung biopsy (TBLB