A Prospective Study of Clinical Profile and Role of Fiber Optic
92 Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2
MeThOdOlOgy
Source of data: The source of data for the study is from the patients attending Department of respiratory medicine, J.J.M medical college, both out patients and in patients. The present study was a prospective studyperiod during 2015 -16 with a minimum of 50 cases. The course of study procedure is explained and informed consent taken.
The study is carried out to evaluate the effectiveness of bronchial washings(BW) in the diagnosis of sputum smear for acid fast bacilli(AFB) negative cases of pulmonary tuberculosis and use of BAL & forceps biopsy through FOB in the diagnosis of malignant lesions.
Inclusion Criteria:
1. Patients aged 18 and above.
2. Suspected patients of PTB(as per RNTCP guidelines).
3. Clinic radiological suspicion of malignancy.
4. Hemoptysis with localizing chest radiograph.
5. Chest x-ray showing non resolving pneumonia.
6. Chest x-ray with undiagnosed lung lesion.
exclusion Criteria:
1. Patients who is a known or suspected case of HIV infection.
2. Patients with bleeding diathesis.
3. Patients with history of myocardial infarction, arrhythmias.
4. Patients on anti-tubercular therapy (ATT) for more than 1 month.
Detailed history of patients was taken with physical examination. All patients underwent the investigations;
Complete hemogram,Urine routine, RBS, Chest X-ray, Sputum examination for AFB -2 samples(1-spot sample
& 1-early morning sample) carried out by Ziehl-Neelsen technique ,other bacteria, fungi, malignant cells. ECG, HIV(ICTC), HBSAg, CT-Scan of thorax. Spirometry and Mantoux test.
Fiber Optic bronchoscopy: For this procedure informed consent. Indication, findings, Provisional diagnosis ,reports& final diagnosis are noted. FOB will
be used to examine bronchial tree and obtain Broncho-alveolar lavage(BAL)
endobronchial biopsy: Post bronchoscopy sputum for smear microscopy for AFB using Ziehl- Nelson staining method will be collected in all patients after bronchoscopy procedure.
Relevant specimens will be sent for culture of Mycobacterium tuberculosis on Lowenstein-Jensen medium &histopathological examination for evidence of malignant cells.
PROCeduRe
Bronchoscopies may be performed in endoscopy suites, operating rooms, radiology departments, or at the patient’s bedside. Pre-procedure preparation is done.
Patientsare nil oral with IV line. Blood pressure, oxygen saturation, and electrocardiogram should be monitored and oxygen administered to maintain oxygen saturation greater than 90%.
Anesthesia: Local anesthesia with Lidocaine is safest topical agent and is applied to the nares, oropharynx, vocal cords, and tracheobronchial tree4
Insertion Techniques
The patient should be placed in either a semi-recumbent or supine position. Topical anesthetic agent isapplied. The flexible bronchoscope can be introduced through the nose, mouth, tracheostomy, or endotracheal tube.The oral route is preferred for flexible bronchoscopy if frequent removal and reinsertion of the bronchoscope is anticipated or if endotracheal intubation is to be performed.
The nasal route avoids the possible complication of damage to the bronchoscope if the patient bites down in the absence of a bite block. In the intensive care unit (ICU), a patient requiring bronchoscopy may already have an endotracheal tube in place. This can pose problems if the tube is too small to accommodate an average bronchoscope. A size 8.0 or greater endotracheal tube is recommended for ease of passage of the bronchoscope and for adequate ventilation.
The bronchoscope is introduced either through the nose or mouth with a bite block in place. The oropharynx is examined. After a thorough examination is performed and on reaching the vocal cords, the patient is usually again anesthetized topically. The vocal
Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 93 cords are examined for abduction and adduction. The
bronchoscope is passed through the vocal cords, and a complete airway inspection is performed5,6.
Both therapeutic and diagnostic procedures can be performed during flexible bronchoscopy. Depending on the indications7, the following diagnostic procedures can be performed: BAL, endobronchial or transbronchial biopsies, cytological wash or brush, and TBNA, endobronchial ultrasound (EBUS).
endobronchial lung biopsy: Bronchoscopy is often the only technique by which material from the endo-bronchial tumor can be taken and sent to the pathologist for histological or cytological classification of the tumor. Different types of forceps are used for biopsy.
The material obtained is sent for cytology or after fixing with 10% formalin for histopathological examination.
Upto 3 to 5 biopsies are sufficient. If it is anticipated that biopsy specimens may be required at bronchoscopy, oral anticoagulants should be stopped at least 3 days before bronchoscopy or they should be reversed with low dose vitamin K.
Transbronchial lung biopsy: This is done in situations where the lesion is beyond the bronchoscopic vision or in bilateral diffuse lung diseases. In lesions outside bronchoscopic vision, biopsy under fluoroscopic vision will increase yield as well as decrease complications.
In diffuse lung diseases biopsy is usually taken from either of lower lobes; middle lobe is generally avoided. Platelet count, prothrombin time, and partial thromboplastin time should be checked before performing transbronchial biopsies.
bronchial Washing & bal: Bronchoalveolar lavage is an important extension to the diagnostic usefulness of fiberoptic bronchoscopy; It provided viable cells, intact proteins and enzymes for analysis, which can give a dynamic and kinetic impression of the disease process8. 20ml aliquots of 0.9 % normal saline solution, devoid of any bacteriostatic material at 37° C is instilled in to the distal air spaces through the wedged bronchoscope and then aspirated through the instrument’s suction channel.
This fluid may be subjected to a variety of tests depending on the clinical situation: microbiologic testing, specific cytological analysis and cell count, immunologic parameters, presence of various biochemical mediators related to pathologic processes, tissue markers,
polymerase chain reaction, electron microscopy, flow cytometry and DNA probes.
For quantitative BAL, 120 ml aliquot of saline is adequate for sampling a pulmonary sub segment. For this, a threshold of 104 cfu per milliliter is used for the diagnosis of pneumonia, reflecting a concentration of 105-106 bacteria per milliliter of the original sample.
When the volume of saline is small (i.e., 10-20 ml) and is sprayed in to the vicinity of the lesion, the procedure is described as bronchial washing.
Quantitative BAL may be superior to protected specimen brush (PSB) in ventilator associated pneumonia (VAP), since BAL samples much larger proportion of lung parenchyma and is estimated to recover 5-10 times as many organisms as PSB.
yield of diagnostic Procedures lung Cancer
a. Visible endobronchial tumour: The diagnostic yield from biopsy of visible endobronchial tumour is over 90%. There is good evidence that the positive yield is increased if specimens are sent for both cytology and biopsy. False positives may occur with cytology, but are rare.
b. Peripheral tumor: The diagnostic yield in case of peripheral tumour beyond bronchoscopic vision is bound to be less and variable.
c. Pulmonary infections: In Mycobacterium tuberculosis the positive yield was 63% in direct smear and 37% only on culture. Transbronchial lung biopsy was positive in 30-50%. Military tuberculosis can be diagnosed bronchoscopically, the highest yield coming from transbronchial lung biopsy followed by bronchial lavage.
Fungal infections, especially, in Pneumocystis sensitivity for BAL was 89%, compared with 97%
for transbronchial lung biopsy. Bronchoscopy is not ordinarily used to diagnose the microbial cause of pneumonia in immunocompromised patients.
COMlICATIONS
Hypoxemia, Bronchospasm, Cardiovascular events, Pneumothorax, Bleeding, Fever, Pneumonitis, and complications related to anesthesia.
94 Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 Statistical Analysis: Data was analyzed using paired T
test and chi-square test.
ReSulTS
Of the 50 patients 36 (72%) were males and 14(28%) were females.Analysis of symptoms among patients, who were included in the study Showed that cough was the most common symptom occurring in 45 patients (90%) and hemoptysis occurred in 10 patients (36%). Shortness of breath, fever and chest pain were seen in decreasing frequency in that order in 32 (64%) 30 (60%), 4(8%) respectively.
TAble 1: RAdIOlOgICAl FINdINgS Sl. No. Symptom Number Percent
1. Hilar
adenopathy 2 4%
2. Collapse 4 8%
3. Fiberocavity 7 14%
4. Mass 10 20%
5. Normal 9 18%
6. Pneumonia/
Unresolved pneumonia
18 36%
Analysis of radiological findings among the 50 patients studied showed that pneumonia or unresolved pneumonia was the most common finding occurring in 18 (36%) patients. it was followed by radiological mass lesion in 10(10%) patients and 9 (18%) of patients had a normal or unremarkable chest X-ray, however fibrocavitary changes secondary Koch’s were seen in 7(14%) patients, 4(8%) patients presented with collapse on chest X-ray and 2(4%) patients had Hilar adenopathy on presentation(Table 1).
TAble 2 : PRebRONChOSCOPIC dIAgNOSIS Prebronchoscopic diagnosis Number Percent
Chronic cough 3 6%
Hemoptysis 6 12%
Sputum negative Kochs 20 40%
Malignancy 21 42%
42% of the bronchoscopies were done to confirm or rule out diagnosis of malignancy.40% for sputum negative pulmonary Koch’s for obtaining samples for
acid fast bacilli stain and mycobacterial culture.. Other indications included Hemoptysis (12%) andchornic cough (6%) with normal chest x-ray, which was refractory in nature to medical line of management.
(Table 2)
Among the 20 patients who were included under the category of sputum negative pulmonary tuberculosis, BW was done in all the patients and a positive microscopic yield in 4 of 20 patients was obtained.
Mycobacterial culture was positive in 2 of the 5 patients in whom culture was done, hence a BW fluid total yield of 24% endobronchial biopsy was taken in 4 patients with a positive yield in 1 (25%) patients.
Post bronchoscopic sputum for AFB staining was done in half of the patients 10 with a positive yield in the 2 patients (20%)
A preliminary diagnosis of malignancy was made in 21 patients, BW was done in 20 of these patients with a positive yield in 9 (45%) of them. Of the 15 patient in whom endobronchial biopsy was taken. 13(86.66%) turned out to be positive for malignancy.
Among the 15 patients with definite diagnosis of malignancy, most common cell type in our study was of Squamous Cell Carcinoma occurring in 7(46.66%) of patients. the exact cell type could not be identified in 4 (30.77) patients and were managed in the lines of non small lung carcinoma. Adenocarcinoma occurred in about 3 (20%) patients and other malignancies occurred in 1 (6.66%) patients.
The complications following bronchoscopic procedure were very few, minor hemorrahage following forceps biopsy was seen in 2(4%) patients, hypoxia requiring postponement of the procedure to a later date occurred in 1(2%) patient and respiratory distress requiring observation following the procedure occurred in 1(2%) patient
dISCuSSION
Nearly half of the patients 42% included in our study had a suspected diagnosis of malignancy & 40%
had a prebronchoscopic diagnosis of sputum negative pulmonary Koch`s. A pre bronchoscopic diagnosis of hemoptysis with normal chest x ray was done in 12% of our patients. 3(6%) patients with chronic cough with non localizing chest x ray were also included. Our findings are similar to study by Sinha et al.9
FOb Findings: Vocal cords were involved in 2 of 50(4%) patients in our study. Inflammatory lesions were the most common bronchoscopic findings seen in 15(30%) patients
Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 95 followed by intra luminal growth in 11(22%). However
in 8(16%) of bronchoscopies were normal. Structural changes in the form of atrophic mucosa or distorted anatomy or bronchostenosis was seen in 6(12%) & extra luminal compression occurred in 12%, followed by bleeding site, abnormal anatomy & foreign body occurred in 3(6%),1(2%),0% patients respectively.
In sputum smear negative case of pulmonary tuberculosis, the overall diagnostic yield of smear examination and MTB culture from bronchial washing, post bronchoscopy sputum and histopathological studies of forceps biopsy was found to be 35% in our study comparable with the study by Yuksekol I et al10.
Bronchial washing alone showed evidence of pulmonary Koch’s on MTB culture and smear examination in 28% of cases. I n our study the positive yield of lavage fluid smear for AFB was 20.33%
patients,bronchoscopic forceps biopsy was 25% and PBS(20%) which is similar to study by Chawla et al11.
In our study 21 patients were evaluated. Yield of bronchoscopic procedures in diagnosis of lung cancer was 71.42%.
In our study the positive yield from bronchial washings was 45% and forceps biopsy yielded 86.66%
.Combinations of biopsy and brushing or biopsy and washings are usually done. It is well established that combination increases the yield.
Among the complications ,minor hemorrhage following forceps biopsy occurred in 2(4%) patients, hypoxia resulting in postponing the procedure to later date resulted in 2% (1 patient),1 patient(2%) developed respiratory distress requiring observation following the procedure. However there were no other serious complications like arrhythmia or cardiac arrest.
Conflict of Interest: None Source of Support: Self-funding.
ethical Clearance: Taken from Institution Ethics Committee
CONCluSION
The most common symptom in our study was cough followed by breathlessness & fever. Most common indication in our study was malignancy followed by Sputum smears negative pulmonary Koch’s. FOB aids in the confirmation of the diagnosis of pulmonary Koch’s in 35 of sputum negative cases, which otherwise would have been missed.
FOB was extremely useful in the diagnosis of malignancy, with forceps biopsy being the most yielding procedure with an overall yield of 86.66%. Apart from identifying the site of bleeding in few cases, FOB in patients with hemoptysis & normal chest x ray did not add much to diagnosis.Fiber optic bronchoscopy (FOB) is an important investigation in determining the etiology and definitive diagnosis in patients presenting with various respiratory symptoms with undiagnosed lung lesions in the chest x-ray.
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