Pulmonary Medicine

Interventional Bronchoscopy: Endoscopic Palliative Care

General description of procedure, equipment, technique

Endoscopic Palliative Care

Initially defined in 1995 and subsequently described in European Respiratory Society (ERS) and American Thoracic Society (ATS) guidelines, interventional pulmonology is "the art and science of medicine as related to the performance of diagnostic and invasive therapeutic procedures that require additional training and expertise beyond that required in a standard pulmonary medicine training program." Clinical entities encompassed within the discipline include complex airway management, benign and malignant central airway obstruction, pleural diseases, and pulmonary vascular procedures.

Diagnostic and therapeutic procedures pertaining to these areas include rigid bronchoscopy, transbronchial needle aspiration, autofluorescence bronchoscopy, endobronchial ultrasound, transthoracic needle aspiration and biopsy, laser bronchoscopy, endobronchial electrosurgery, argon-plasma coagulation, cryotherapy, airway stent insertion, balloon bronchoplasty and dilatation techniques, endobronchial radiation (brachytherapy), photodynamic therapy, percutaneous dilatational tracheotomy, transtracheal oxygen catheter insertion, medical thoracoscopy, and image-guided thoracic interventions. This presentation focuses on endoscopic palliative care.

Successful palliation results in relief from or improvement in troublesome symptoms for the patient. Dyspnea, cough, pain and hemoptysis are common in advanced lung and metastatic cancers, and those in remission but with complications of treatment. Prior airway surgery or intubation, recurrent pneumonia, or other underlying illnesses that may involve the airways, such as vasculitis, sarcoidosis, histoplasmosis, or tuberculosis are important conditions that may lead to conditions requiring palliation. Additionally, airway stenosis related to inflammatory tissue caused anastomosis granulation tissue following lung transplantation suture-related granulomas, systemic inflammatory conditions caused by collagen vascular diseases such as Wegner's granulomatosis, Bechet’s syndrome, and relapsing polychondritis. In addition, co-morbid conditions such as COPD, interstitial lung disease, and heart disease contribute to the overall well-being of the patient.

Dyspnea is present in the majority of lung cancer patients, often from central airway obstruction (CAO) due to tumor or as a complication of therapy. Benign or malignant tracheobronchial obstructions may lead to acute respiratory distress, asphyxia, or death. If curative resection is not possible, endoscopic methods for palliation including Nd: YAG laser therapy, cryotherapy, electrosurgery, photodynamic therapy (PDT) and Argon Plasma Coagulation (APC), are available. For extraluminal lesions, palliation using balloon dilatation, stent placement, or external beam radiation may be helpful.

Patients presenting with hemoptysis may be a particular challenge since significant hemoptysis can be rapidly life-threatening. Once the patient is stabilized, bronchoscopy for diagnosis is recommended and may be an opportunity to intervene if an endobronchial source of bleeding is discovered.

Pain and cough are further challenges for the interventionalist. There are limited interventional techniques available that will reduce pain and cough, although reduction in these symptoms sometimes occurs when treating CAO or pleural effusions.

Indications and patient selection

The techniques used to accomplish palliation must be applied to disease states and patients in a specific manner. For example, obstructing squamous cell lung cancer may be coagulated and cored using a laser and rigid bronchoscopy, while a post-radiation bronchial stenosis may respond best to dilatation and steroid injections. Lesions that completely obstruct the lumen of the airway may be difficult to laser in a safe manner due to penetration of the laser energy into unseen vital structures beyond the lesion. Cryotherapy may be too slow or ineffective in some situations, and electrosurgery may be limited due to the angle needed to approach the lesion. Extrinsic compression of the airway with essentially normal endoluminal mucosa should never be ablated, but if necessary, stented.

The condition of the patient must be taken into consideration when contemplating any bronchoscopic palliation. Patients with a very short life expectancy should not be burdened with invasive palliation, and patients who are unlikely to benefit for other reasons similarly should not be taken through invasive procedures. Great care must be used to obtain a history and physical examination of the patient, examine available chest imaging and physiologic lung function testing, and to consider the overall impact of interventions and goals of care. Knowledge of vascular and bronchial anatomy is essential when considering palliation, as well as the natural history of the disease and the response of the airway tissues to various treatment techniques.

Contraindications

The use of palliative endobronchial therapy must be carefully balanced between the patient, underlying condition, goals of care, and techniques. If a patient cannot tolerate sedation or anesthesia, endoscopic palliation is less likely to be of benefit. Similarly, if a complete airway obstruction has been present for 6 or more weeks the likelihood of a successful result in opening the airway is very small.

Details of how the procedure is performed

For details of procedures, the reader is referred to specific chapters in this program.

Interpretation of results

Not applicable.

Performance characteristics of the procedure (applies only to diagnostic procedures)

Not applicable.

Outcomes (applies only to therapeutic procedures)

In a cohort of 37 patients with malignant CAO, interventions by experienced operators resulted in significant improvements in 6-minute walk distance, dyspnea scores, FEV1 and FVC at 30 days post-procedure. Quality of life scores improved at day 90 and 180 after treatment. Although the study did not directly compare endoscopic interventions to other palliative therapies such as radiation and chemotherapy, it appears that endoscopic palliation may be superior to these therapies in selected patients.

In nineteen patients with inoperable non-small cell carcinoma and symptomatic bronchial obstruction who underwent Nd: YAG laser therapy with the goal of debulking the airways before conventional external-beam radiation therapy, those with "satisfactory debulking" and subsequent radiation therapy had a significantly better outcome (mean survival, 340 days versus fewer than 100 days) than those with "unsatisfactory" laser therapy. A significant increase in survival was noted among the subset of fifteen patients who underwent emergency palliative photoresection as the initial therapeutic intervention compared with a subset of eleven patients who received palliative radiation alone.

When a group of patients who underwent a combination of Nd: YAG photo-resection and subsequent external-beam radiation therapy was compared with a group that underwent external-beam radiation therapy plus brachytherapy, those in the laser treatment group demonstrated significantly longer survival than those treated with radiation alone.

In a report of a large number of patients treated for malignant airway obstructions using therapy that incorporated Nd:YAG laser, stents, and brachytherapy, 93 percent of those who received laser resection achieved immediate airway patency and improvement in quality of life.

Alternative and/or additional procedures to consider

None

Complications and their management

Complications of interventional bronchoscopy are related to the equipment used, anesthesia, and perioperative developments. Despite the possibility of severe, often fatal, complications, overall risk is low if the operator is experienced.

In a database study, 15 centers that performed 1115 therapeutic bronchoscopic procedures, had an overall complication rate of 3.9% requiring an escalation in care in 61% of these. The risk of complications was higher if using moderate sedation, repeat therapeutic procedures, and ASA 3 or greater. The 30-day mortality was 14.8%.

Additional specific complications are discussed in individual chapters.

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