Fig. 28.1
Devices for endoscopic bronchial occlusion. (a) Endobronchial Watanabe spigot is a type of silicone bronchial blocker that is available in three sizes based on diameter. (b) Grasping forceps. (c) Balloon catheter
Fig. 28.2
Endoscopic bronchial occlusion by EWS. (a) Balloon occlusion test. (b–d) EWS insertion using grasping forceps. EWS Endobronchial Watanabe spigot
28.3 Determination of the Affected Bronchi
28.3.1 Balloon Occlusion Test
A chest drainage system is used to assess air leaks. A balloon occlusion test is performed to identify the affected region. After passing a balloon catheter through the working channel of a flexible bronchoscope (Fig. 28.1c), the balloon is inflated to achieve complete occlusion of the lobar, segmental, and subsegmental bronchi (Fig. 28.2). The affected airway is identified if air leak through the chest tube is reduced or stopped 15 s to 1 min after occlusion. When reduction of air leak could not be detected by bronchial occlusion, lung inflation on X-ray fluoroscopy images may be used to identify the affected bronchi.
28.3.2 Chest Computed Tomography Reading
Computed tomography (CT) is useful to identify the responsible bronchus that has continuous communication with the thoracic cavity. It is recommended to refer to a three-dimensional (3D) CT (virtual bronchoscopy) that can be created with 3D workstations (Ziostation, synapse VINCENT, etc.) (Fig. 28.3). From our experience, an extended cyst is less likely a cause of air leakage; rather, a bronchus that leads to the collapsed lesion is more often responsible (Fig. 28.4).
Fig. 28.3
Simulation of Endobronchial Watanabe spigot insertion by virtual bronchoscopy made by a 3D workstation (Ziostation2®, Ziosoft Inc., Tokyo, Japan)
Fig. 28.4
A case of empyema with intractable pneumothorax. The responsible bronchi are identified on thin-slice chest computed tomography (arrow)
28.3.3 Bronchography
Inject 5–10 ml of nonionic contrast agent (twofold dilution) forcefully through a bronchoscope and observe for immediate outflow of the contrast into the chest cavity (Fig. 28.5). In other cases, leakage of contrast agent into the chest cavity can be confirmed by gradual visualization of the pleural surface on X-ray fluoroscopy after a few seconds of instillation.
Fig. 28.5
Bronchography. (a) Prepare a nonionic contrast agent (twofold dilution). (b) Through a bronchoscope, forcefully inject 5–10 ml of the contrast agent into the suspected bronchus (e.g., right B1), and observe for outflow into the chest cavity. (c) Stop the leakage by inserting an Endobronchial Watanabe spigot to the responsible bronchus (in this case, the right B1)
28.3.4 Repositioning
Observation of changes in air leakage due to repositioning is useful. Air leakage is reduced when taking a position that is on the bottom.
28.3.5 Intrathoracic Dye Injection
About 10 ml of indigo carmine, diluted twofold in saline, is injected into the thoracic cavity from the drainage tube, followed by additional instillation of approximately 20 ml of saline solution. The bronchus in which reverse flow of dye is observed is indicated as the responsible bronchus. In cases with open post-thoracoscopy window, apply povidone-iodine on the surface of the lung where air leakage is suspected then check by bronchoscopy the bronchus where the povidone-iodine flows through (Fig. 28.6).
Fig. 28.6
Case of open postsurgical window. (a) Bronchoscopic observation through the open window. (b) Coat the portion where air leakage is suspected (black arrow) with povidone-iodine. (c) Identify the bronchus where the povidone-iodine will flow though; in this case, it was the right B6
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