Flexible Bronchoscopy and Bronchoalveolar Lavage (BAL)

CHAPTER 1

My name is Dr. Yu Maw Htwe. I am the assistant professor of Intervention Pulmonary Department of the Penn State Health. We have an intervention pulmonary fellowship program, and today we will be doing the bronchoscopy called the bronchoalveolar lavage, and for a patient that is a 56-year-old woman with the recurrent environmental mycobacterial infection, so she's been a frequent flier to us. She's been treated with a complete treatment for the MAC, but right now she started having cough, shortness of breath again, so our infectious disease specialist want to see the organism sensitivity. So this is kind of the quick and easy procedure that we do very often. So for, I say, bronchoalveolar lavage, what we usually do here is that we use the general anesthesia. But in off-site, if you wanna do moderate anesthesia, you can perform that as well, but here, we do general anesthesia. So after general anesthesiologist gonna place the LMA, I'm gonna put my bronchoscope from the mouth to the airway and then I do airway inspection. So usually the airway inspection gonna start from the right, and in the right side, there are three lobes, right? Upper lobe, middle, and lower. In the upper lobe, they're gonna be anterior, apical, and posterior segment. We're gonna inspect and to look for any kind of endobronchial lesion, any inflammation, any bleeding, or any mucus plug. That's we're gonna look into. And then we are gonna move to another segment called the middle lobe, and then in the middle lobe, the medial and lateral, the same way we look into all those segment. Then in the lower lobe, they're gonna be superior segment, medial basilar and then anterior, lateral, posterior basilar segment. We're gonna look into all those segment and then I move to the left bronchial tree. In this case, however, abnormality is more prominent in the left bronchial tree, so I decided to do the BAL, kind of getting the fluid sample from the lung from the left side. So in the left side, there is the upper lobe and lower lobe. In the upper lobe, there is the left upper proper. In the left upper proper, they're gonna be apicoposterior segment and anterior segment, and in lingula is the superior and inferior segment. This case, we decided to do with the lingula because in the CAT scan, the lingula is the most prominent abnormalities are in the CAT scan that we find. So after the lingula, we're gonna go to lower lobe. In the lower lobe, again, superior segment and anteromedial, lateral, and posterior basilar segment, we do the airway inspection and then after airway inspection, we do BAL. BAL, how we do it is we kind of squirt it into the 60 or 50 cc of the saline and we push it in and then we try to kind of suction back. That's the way how we do it. And then sometime, if you put it out 50 cc, we usually come back 5 or 10 cc. That's the way it is. And then from that fluid sample, we send it to the kind of cell count culture and also cytology. So procedure can take from 5 to 10 minutes and then after that, patient gonna wake up and she can resume the daily activity without any restriction. So the complication is very minimal.

CHAPTER 2

So I want to explain what is the bronchoscope is. So, this is called the therapeutic bronchoscope, and the reason why we call therapeutic bronchoscope is because of the channel, the inner working channel, which is you can see is right here, 3.2 millimeter. So there is some other scope that is thinner size, and those thinner size does not work for the diagnostic bronchoscope, okay? So this scope is like 60 centimeter long, and you can see every white line that is a five-centimeter distance, and then at the tip of the scope, so whatever you see in the biggest hole is called a working channel. So the very big channel is the working channel and we need to know how much diameter we have working channel. So this scope has 3.2-millimeter working channel. And then at the top, there is a camera, and the other two button right here each side is a camare and light source, okay? So now I'm gonna turn on the lamp, so that's how you're gonna see. So all of our procedure go through that working channel. If we gonna do biopsy, the biopsy forceps gonna come out of here. If we gonna do bronchoalveolar lavage, the fluid gonna come out of here, okay? That's one thing. And then this is another source that you can give the medication. If you give lidocaine or epinephrine or saline, this gonna go down and come out of this working channel. Okay, so if you're gonna hold it, you have to hold the bronchoscope like that, like three fingers right here, the thumb right here, and then your index finger gonna be, this is a suction. If you press it, you're gonna suction, okay? And then a little button here, button one, two, three, four, some of them work for the white balance, some of them work for the kind of picture, you can set up as you like. And here, I'm gonna focus here, if I thumb down, they look up, okay? They go up to the 190 degree. If you thumb up, it look down. So the bronchoscope have this wide channel that you can go up and down. If you wanna turn right, you're gonna go this. If you wanna turn left, you're gonna go this.

CHAPTER 3

Okay. So, the scope is in. So this is the bronchoscope going in. My goal is I have to keep it straight. If I bend it, they don't kind of, it's very hard to manipulate, so our goal is keep the scope straight all the time. And then, we're gonna give the 1% lido to the vocal cord to anesthetize. So, the maximum dose of the lidocaine is a 4.4 milligram by kilogram. So if your anesthesia is also using lidocaine, you have to communicate with the anesthesiology team. So that's how she give the medication, with that channel, and if you look at that camera and then they gonna come out from the working channel. Three. Okay. So now, I go into the airway. Oh, it came out again. So she is having little bit of spasm, so I'm gonna wait. Okay. Now I am in the airway and then my goal is to keep it in the center. Okay, she is coughing. I'm gonna give her a little bit more propofol here. Okay. Thank you. So this is the anterior wall and then posterior wall and then you see that when she breathes, the posterior wall kind of contracting and the airway narrow. And right now I'm on the main carina. I'm gonna clean out the secretion first, so I go all the way down and I suction. And then I go to the left main. I go all the way down and suck it up. Now I'm gonna give another 1% lido to each main airway. Okay. And then I point it to the left main. Another one. Thank you.

CHAPTER 4

Now I'm gonna do the airway inspection. You can start from either right or left side, but I always try to start from the right side so that it become organized. And I'm gonna go to the right main and then from the right main, this is the right upper lobe takeoff. So this is kind of a beautiful anatomy. In the right upper lobe, there is the anterior segment, an apical, and the posterior segment, that's how you do the airway inspection. So you have to check that any mucosal abnormalities, any bleeding, or any foreign body or any endobronchial lesion, if you find those abnormalities, then you can take care of it during the procedure. Now I'm gonna come out from the right upper lobe, I go to the bronchus intermedius, and then this is the right middle lobe. And I go into the right middle lobe, there is a medial and lateral. So that's how I do the airway inspection, and I don't see any. And then, I came out to the bronchus intermedius and then this is the right lower lobe. So in the right lower lobe, the first takeout is on superior segment of the right lower lobe, so I go in. Sometimes, very hard to go into that superior segment. There is nothing here. And then, the second takeout usually gonna be the medial basilar. Those are the basilar segment. So there is nothing that I can see. And then, I used to memorize it like ALP, so this is anterior, this is lateral, this is posterior. They all are basilar segments. So this patient has a really good anatomy.

CHAPTER 5

Then I'm gonna go to the left side. So usually, the left bronchial tree is very friable, and this patient has a recent infection, so her airways are inflamed on the left side. And then around the carina, left upper lobe and left lower lobe takeout is the most friable area, you can cause bleeding just by suction. This is a bleeding from my airways clearance that I did before. And I'm gonna go to the left upper lobe proper. Can I get a saline, iced saline? Iced? Mm-hmm. So if you have a little bit bleeding, you can control it using the iced saline or iced epinephrine. It depend on the proceduralist's preference. So what it does is if you give the iced saline, they gonna cause a vasoconstriction and those mucosal bleeding can stop. Give like 10 or 20 cc from the channel, like maybe 10, 20 cc. Mm-hmm. Good now, uh-huh. Thank you, uh-huh. This is kind of, iced saline application. I did not suction out. I want to let it sit for a little bit because I have to do my airway exam, right? So then I slowly go in. So now this is the left upper lobe proper. So this is the lingula. I'm gonna go to left upper lobe proper. This is the apicoposterior segment. I don't see anything. And this is the anterior segment of the left upper lobe. Now I'm gonna go to the lingula. Lingula have a superior and inferior segment. In her CAT scan, the lingula is the most prominent abnormality, so I'm gonna do the BAL here, and I'm ready to start BAL. Mm-hmm. So - lingula. Uh-huh. So what Emily is doing is she is hooking up with the Lukens trap, and then, yeah. Uh-huh. And then it has to maintain kind of upside down, so I kind of try to use it with my, kind of pinky fingers. And - you wanna do the BAL? Uh-huh. So this is a procedure called bronchoalveolar lavage. I want it cold. I want cold saline, yeah, because she has a little bit of bleeding. So she gonna squirt out with the saline and what it does is now I have to aim to the airway. So this is a kind of a good BAL. So our theory is that those fluids gonna go all the way to the end of the airway and then go to the alveoli, and once she pulled back, she have to apply certain pressure. So yes, she has applied the, you have to apply negative pressure. Yeah, like this. She have to apply this... Not too much. If you apply to much, it's gonna close. But that's fine. You can give another one. Not good. We're gonna give her another... I want cold because she has a little bleeding. Usually the first one, you chase it. So did you see, look at the airway. When you suction, applying the negative pressure, you should not look at here, you should look at there. I'm sorry. Kind of align with this, yeah. And then... Okay, and wait, it's a little bit of bleeding, that's why. How much do I have? Yeah, yeah, pull more, pull more. It's coming out. Okay, fine. So now, I'm gonna do suction and pull back whatever the left over. How much do I have? Six total. Only six? Then I need more. This is called, the procedure called bronchoalveolar lavage. We use it for the infection workup and cancer workup and pneumonitis, and sometime a thing called the bronchoalveolar lavage, and we do the serial of those BAL process. Okay, push it down. I think it's because of the blood. No, I want total like 30, not 40, yes. 20 would not be enough. Maybe at least 25 and 30. They went - I know. How much? Total of nine. None? Nine total. Oh, nine. Nine total. One second, let me get you more. I mean, I gave like 150. Okay, I think I should be okay, right? It's okay if I don't get it... How much it is? This is 15. Almost 15. Oh, 15 and 9, okay, okay. So 10 for cyto and the rest for micro. So when you take out, you have to take out this one first, okay. If you accidentally take out everything, whatever we collected can accidentally go to there. Okay. Good, okay. So then, now I'm gonna continue my airway inspection. We almost done. She has bleeding, so it was bad. Now can I get a little bit of saline? Saline? Iced saline. Mm-hmm. More. Okay, that's good enough. So she have a little bit of bleeding. Sometimes BAL can also induce the bleeding. So I'm gonna be just left it there. And so I'm gonna go to lower lobe and I want all the way down. So that's a good bronchoscopy. Sometimes, you need to know where you are even though you don't see anything. So this is a basilar segment. She have a very kind of atelectatic lung that's caused from the smoking history and also from the anesthesia as well. So this is the anterior basilar segment and this is a lateral and posterior. So now, there is nothing here. And then, this is a superior segment, so, yeah. It look good, and it's just a little bit bleeding, so what I'm gonna do, I'm gonna just sit there and see if the bleeding is eventually gonna stop. There is no way that we can suture the airway or anything. So usually, those kind of mucosal tear is gonna stop on its own and we don't have to do anything. So I'm kind of wait here for, like, at least three to five breathing cycle and see any blood coming toward me. If that's the case, then I'm in trouble. So now, she is doing fine, so I'm gonna slowly come out and then clean out the other airway.

CHAPTER 6

Again, this is in the right side. Okay, so now I'm gonna come out. So she has a little bit of saber-sheath trachea that we can see in the COPD and also smoker lungs. Okay. On the way back, I look at my vocal cord. It's doing fine. It is done. Thank you.

CHAPTER 7

So now that I finished the procedure, and I did the BAL on the lingula, but if you see, there we see a lot of bleeding came from the lingula airway because she has a chronic mycobacterial infection, so her airways are very inflamed, so even a little bit of pressure, they can cause the mucosal bleeding. That's what has happened there. So I use the two technique. One technique is that I use the cold saline. For the airway bleeding, there is the step 1, 2, 3, 4, up to 10, and then the first step is to kind of iced saline. Iced saline, what it does is it's gonna cause the vasoconstriction of the airway capillaries and that gonna cause sparcer bleeding. And then the second thing that I did is after I clean out the airway, I kind of stay there and watch because if there is active bleeding or not. Because once you are in the airway, the very narrow lumen, and you're looking from the very small camera, everything is not very clear. Then if you use, you can, sometimes can be mixed with airway inflammation or bleeding, and like kind of iced saline mixed with the blood can be confused with the active bleeding, so what I did is I stayed there in the distal part of the left main and then I look for any blood coming toward me. If that is active bleeding, you're gonna start seeing that - it's kind of a well - it's gonna be filling up with the blood over time. If the bleeding is stopped, and if it is just a mucosal edema or old bleeding, they're gonna stay the same. They're gonna move with the patient breathing, they're gonna come in, go out, come in, go out, depend on the patient breathing, breathe out pattern, but they should not be coming toward your camera. So that is the teaching point that I have experienced in this case. So the bottom line is BAL can be very simple but it can cause the massive bleeding as well, so you always have to keep back of in your mind and to prepare if you encounter bleeding.