HEAT THERAPY IN

BRONCHOSCOPY

Arindam Mukherjee
SR
Pulmonary medicine
 THERMAL EFFECT ON BIOLOGICAL
TISSUES

• 37 -40 c – normal
• >40 c – hyperthermia .
• >60 c- devitalization and coagulation
• >100 c – vaporization of tissue fluid and cutting due to mechanical
tearing of the tissue
• > 150 c – carbonization.
• >300 c –vaporization of the entire tissue.

•
 MODALITIES

• Endobronchial LASER
• Endobronchial electrocautery
• Argon Plasma Coagulation
 ENDOBRONCHIAL LASER THERAPY –
TECHNICAL ASPECTS

• LASER can be considered a form of light energy with 3 distinctive

properties
 Monochromacity –all the photons of laser light has a single
wavelength.
 Coherence –LASER light waves travel in parallel phase in relation to
time and space.
 Collimation – LASER light travel in a same direction with a very narrow
beam of divergence.
PRODUCTION OF LASER
TYPES OF LASER
MECHANISM OF LASER
 DETERMINANT OF LASER EFFICACY

• Three main characteristics determine the suitability of a particular

LASER for therapeutic bronchoscopy
1. Power density rating; Power density depends on laser technology
and on factors such as target tissue and exposure time.
2. Ratio of absorption and scattering coefficients in soft tissue : By
determining the volume of tissue that is heated, absorption and
scattering make the difference between cutting and haemostasis.
Lasers with high absorption as well as high scattering coefficients are
good coagulators.
3. The delivery system.
• .

Bolliger etal Eur Respir J 2006; 27: 1258–1271

Relative depth of CO2, Argon and
Nd:YAG lasers tissue
penetration. Heavy absorption of
the laser beam by either the
water (CO2) or the hemoglobin
content of the tissue (Argon)
limits its penetration and thus
variation in the effect.
 PROCEDURE

• The neodynium:yttrium aluminium garnet (Nd-YAG) equipment is the

most widely used type of laser for bronchoscopic interventions
because it has sufficient power to vaporise tissues and produces an
excellent coagulation effect.
• Its wavelength is1,064 nm, which is in the invisible range; a
pilot light usually in the red colour range is required for the procedure.
• Both contact and noncontact probes are available.
• In the noncontact mode, the tip of the probe is held at about1 cm
proximal to the target.

Bolliger etal Eur Respir J 2006; 27: 1258–1271

• An initial power setting of 20–40 Watts with a pulse duration of
0.5–1 s represents a safe initial setting to obtain devascularisation.
• To carbonise tissue, the tip of the probe is either moved closer to the target at
about 3 mm or several pulses are applied at the same location.
• When treating obstructing lesions of the central airways, the aim is to
devascularise the tumour and subsequently core out the bulk of the tumour
with the tip of the rigid bronchoscope.
• When working with a flexible bronchoscope, the lesion is either devascularised
or carbonised and the remaining tissue removed by forceps, or the whole
lesion is vaporised.
• Protective eyewear is mandatory when the laser beam is activated

Bolliger etal Eur Respir J 2006; 27: 1258–1271

Khemasuwan etal, J Thorac Dis 2015;7(S4):S380-S388
 COMPLICATION OF ENDOBRONCHIAL
LASER THERAPY -INTRAOPERATIVE

• Intraoperative : hypoxia and haemorrhage

Hypoxia due to tracheal obstruction and

operator’s response –cross the obstruction

Hypoxemia due to unilateral obstruction and

operator’s response –ventilate the healthy
lung

Dumon etal chest 1984, august 86.2

Tracheal haemorrhage –operator goes distal
to the bleeding site, producing tamponade.
Laser coagulation can be resumed when
ventilation is satisfactory

Bronchial haemorrhage –operator cleans the

area and continues to coagulate

Haemostasis technique –coagulate

circumferentially and then to come at the
point of bleeding
 INTRA PROCEDURE COMPLICATIONS –
CONTD,

• Tracheobronchial firing is one of the most dreaded complication

of LASER use.
• Air embolism [occurs usually due to coolant system]
 POST OPERATIVE COMPLICATIONS

• Cardiovascular complications and hypoxemia related to retained

secretions or respiratory depression induced by excessive
anesthesia;
• Secondary hemorrhage stemming from loosened eschar or
coagulation irregularities and leading to hypoxemia;
• Perforation from delayed tissue necrosis with fatal sequelae such
as mediastinitis or esophageal fistula; and,
• Infection and/or pneumonia after atelectasis or from retained
secretions.
SAFETY OF LASER PROCEDURE

Meheta’s rule of four

Dumon’s ten commandments
 Know the anatomical danger zone
 Well trained laser team
 Proper patient selection
 Rigid bronchoscopy only
 Monitor the vitals
 Fire the LASER beam parallel to the wall
 Avoid LASER at >40 watts
 Donot neglect haemorrhage
 Before termination ensure thorough
irradiation of resected areas
 Keep the patient under observation in a
specially outfitted recovery

Folch et al, Semin Respir Crit Care Med 2008;29:441–452

Khemasuwan etal, J Thorac Dis 2015;7(S4):S380-S388
 POPCORN EFFECT DURING LASER
BRONCHOSCOPY

Before procedure
Tumor explosion during
procedure

Post procedure

Petrella etal J Bronchol Intervent Pulmonol Volume 20, Number 2, April 2013
In a retrospective study from ITALY comprising over 12 years,
2610 LASER resection in 1838 patients, following complications
were found with a mortality rate of around 0.4%.
 COMPLICATION IN LPR IN DIFFERENT
PUBLISHED SERIES
Author No of pt (no of Death hemorrhag Fire Respiratory others
(year) procedures) e failure
Dumon 111/205 None None None none none
1982
Dumon 839 (1503) 6 (.4%) 17 (1.06%) None 19 (1.3%) none
1984
Personne 1310(2284) 13(0.8%) 5 (0.3%) None 24 1 fistula
1986 pneumotho
rax
Cavaliere 1838 (2610) 12 (0.4%) 19 (0.7%) None 24 (1%) Not
1996 significant
Moghissi 1559 (2235) 2 (.17%) 36 (3.1%) 2(.2%) 10 (3 N/S
etal (2006) pneumotho
rax)
Moghissi etal,Lasers Med Sci (2006) 21: 186–191
MECHANISM OF ACTION FOR
ELECTROSURGERY

Tissue effects –coagulation at <100c

(continuous mode) and cutting at
>100c (intermittent mode)
 TYPES OF DIATHERMY

Bipolar –current doesnot flow

Monopolar –current flows through the patient –not required in
through the patient EBES
 ELECTROSURGICAL ACCESSORIES

• Probe (Coagulation Electrode): Tumor coagulation and hemostasis

(similar to direct contact laser)
• Electrosurgical Knife: Broad-based surface coagulation and tissue
resection (eg, of webs, scars, and sessile and pedunculated lesions)
in narrow airway lumens
• Electrosurgical Snare: “Lassoing” and removal of polypoid and
pedunculated endobronchial lesions
• Hot Biopsy Forceps: Biopsies and cauterizes simultaneously for tissue
collection and tumor debulking.
 MODES

• Cutting mode
• Coagulation mode
 Soft -Voltage is kept <200 V and no electrical arc is produced between
tissue and the probe. Deeper coagulation.
 Hard –voltage is kept at least 500 V and an electrical arc is produced
between tissue and probe, allowing deeper tissue penetration.
 Spray- it is a type of non contact coagulation where current spark or
jumps from probe to tissue, can cause wider coagulation, good for
tumor surface or hidden bleeder.

• Blending
• Carbonization mode (usually not recommended)
COMPARISON OF DIFFERENT MODES
AVAILABLE MODES
CHOICE OF MODES
 TISSUE EFFECT OF BRONCHOSCOPIC
ELECTROCAUTERY

Study Prospective (Amsterdam 1999)

Population In 6 patients with NSCLC BE procedure was done
immediately before surgery
Method BE was graduated from 1-5 seconds; Bronchoscopic
appearance was documented photographically and
compared with histological appearance.
Outcome Superficial damage was obtained by short duration of
BE (< 2 s), and longer duration of coagulation (3 s or 5
s) caused damage to the underlying cartilage.
Bronchoscopic appearance after endobronchial
electrocautery corresponded with the histologic
changes

Van Boxem et al, chest 2000; 117:887– 891

ARGON PLASMA COAGULATION
MECHANISM

APC is a monopolar electrosurgical

procedure in which electrical
energy is transferred to the target
tissue using ionized and, thus,
conductive argon gas (argon
plasma), without the electrode
coming into direct contact with the
tissue
APC ACCESSORIES
 APC MODES

• FORCED APC -continuous mode with current flow varying with

output setting and distance. .
• PULSED APC Effect 1 & 2 – pulsed but constant energy output.
• PRECISE APC – output is automatically controlled with effect size,
does not need the mandatory distance of 5 mm from the target.
 CHARACTERISTIC OF DIFFERENT
MODES

Seski etal Seminars in Respiratory and Critical Care Medicine, volume 25, number 4, 2004.
 PROCEDURE

• A grounding pad is placed on the patient’s lower back or flank,

utilizing highly vascularized anatomy that is optimally close to the
operative site.
• Power settings from 30 to 80 W and application times of < 2 to 3
seconds have been utilized.
• The argon flow rate is kept between 0.3 and 2 L/min.
• The flexible probes are 1.5 or 2.3 mm in diameter and 220 cm
in length and pass through the instrument channel.

Seksi etal Seminars in Respiratory and Critical Care Medicine, volume 25, number 4, 2004
• With the probe extended beyond the bronchoscope by several
centimeters to prevent burning the bronchoscope, the probe tip
is placed within 1 cm of the target. but not in contact with it.
• The argon plasma is applied to the surface in 1- to 3-second bursts
• When debulking tissue, the eschar is removed and the APC is
applied to fresh tissue. This process is repeated until the tumor is
debulked sufficiently.
• Increasing the power and the application time allows deeper
current penetration and tissue damage.
• With brisk bleeding, increasing the argon flow rate may allow
better visualization of the source and the chance to control it, by
blowing the blood off the lesion.
The APC probe and
white coagulam are
shown
 COMPLICATIONS OF APC

• Airway perforation leading to pneumomediastinum,

subcutaneous emphysema, and pneumothorax; airway
fire; and ‘‘burned’’ bronchoscope are reported complications of
APC but <1%.
• Ignition of nonmetallic stent material, electric shock, and gas
embolism are theoretical complications,
• Massive bleeding may occur as in other modalities due to
excessive removal of the tissue.
• Limiting the inspired oxygen concentration, the power setting (< 80
W), and the application time (<5 sec) should minimize the risk of
airway perforation or fire.
• Keeping the probe tip several cm from the bronchoscope or any
combustible material should limit damaging equipment or airway fire.
• Grounding the patient and keeping the probe tip away
from the bronchoscope tip should minimize the chance
of electric shock.
• Lastly, keeping the argon flow rate (<2 Lpm) should lessen the chance
of gas embolism.
• No deaths directly related to APC have been reported so far
 USER’S GUIDE FOR APC

• To prevent any damage to the instrument channel and/or the tip of

the endoscope, the APC probe must extend at least 10 mm beyond
the end of the scope.
• Activate only when tissue being treated is within field of vision.
• Use of lowest possible setting to achieve the desired thermal effect.
• A distance of 1-5 mm to be maintained with targeted tissue when
being fired en face.
• Avoid APC activation in close proximity to any metal object unless
manipulation of such a device is intended.
• APC should work in an environment with <40% oxygen
 INDICATIONS FOR
LASER/ELECTROSURGERY

• Malignant disorders
1. Primary lung cancer
2. Endobronchial metastasis (from breast, colon, kidney,
thyroid gland, oesophagus)
3. In situ carcinoma
4. Typical carcinoid
• Benign tumours: Papilloma, fibroma, lipoma, hamartochondroma,
leiomyoma etc.

Bolliger etal Eur Respir J 2006; 27: 1258–1271

 INDICATION -CONTD

• Stenosis Due to the following:

1) Anastomosis (lung transplantation, surgical resection)
2) Intubation, Tracheotomy, tracheostomy

3) Tuberculosis
4) Sarcoidosis
5) Wegener’s granulomatosis
6) Trauma
7) Inhalation injury
8) Radiation therapy
9) Granulation tissue

Bolliger etal Eur Respir J 2006; 27: 1258–1271

 INDICATION -CONTD

• Miscellaneous
1) Reduction of bleeding
2) Amyloidosis
3) Endometriosis
4) Closure of oesophago-bronchial fistulas
5) Foreign body removal (lithotripsy)

Bolliger etal Eur Respir J 2006; 27: 1258–1271

 CONTRAINDICATIONS FOR
LASER/ELECTRO SURGERY

• Anatomical contraindications
I. Extrinsic obstruction without endobronchial lesion.
II. Lesions incursion into bordering major vascular structure.
III. Lesion incursion into bordering oesophagus with potential for fistula
formation
IV. Lesion incursion into bordering mediastinal structure with potential for
fistula formation.

Mathur etal Flexible Bronchoscopy, Third Edition.

 CONTRAINDICATION -CONTD

• Clinical contraindications
I. Candidate for surgical resection.
II. Unfavourable short time prognosis.
III. Coagulation disorder.
IV. Total obstruction for more than 4/6 weeks
 COMPARISON BETWEEN ELECTRO
SURGERY AND LPR
Electrosurgery LASER photo resection
During Electrosurgey electrons collide with the tissue to generate It causes tissue destruction by LASER, a form
heat for desired effect, hence it follow the rules of of light energy, hence follow the rules of
electromagnetism OPTICS.
EC /APC can burn/destroy the tissue but usually donot With sufficient energy LASER can vaporizes
vaporizes, hence mechanical debulking is required tissue
Wet surfaces eg blood with higher electrical conductance can LASER has no such problem.
significantly attenuate effectivity, of electrosurgery.
Its effect is much superficial than LASER (2-3mm for APC) Too deep necrosis (upto 10mm) with LASER
may endanger great vessels
Probes delivering electrical current/ or ionized Argon gas can be LASER beams cannot be directed to
steered to different corners of tracheobronchial tree. such angles
Cost of electrosurgical equipments are cheaper, hence LASER is a costly affair.
also known as poor man’s LASER
 IMPACT OF ENDOBRONCHIAL ELECTRO
SURGERY ON THE NEED FOR LPR

Study Prospective observational study (Cleveland ,2000)

Population 118 patients who were evaluated for LPR at
bronchoscopy unit.
Method Patients who were having <50% luminal obstruction
and <2cm growth were considered for EBES instead of
LPR
Outcome Of the 47 procedures, 42 (89%) were successful in
alleviating the obstruction, thus eliminating the need
for LPR. No major complications were encountered

Coulter etal chest 2000; 118:516–521

 THERAPEUTIC BRONCHOSCOPY
INDICATIONS –MALIGNANT AIRWAY
OBSTRUCTION

• More than 20% to 30% of patients with lung cancer will

experience central airway obstruction
• Symptoms related to the endobronchial progression of lung
cancer
are often associated with a major reduction in quality of life and
a short-term prognosis (1 to 2 months median survival)
• Surgery is often contraindicated in very proximal lesions, and
chemotherapy has uncertain and delayed benefits, whereas
radiation therapy solves atelectasis in 54.2% of cases, but the
result is also delayed (median, 24 days)

Guibert etal, Ann Thorac Surg 2014;97:253–9

CHOICE OF PROCEDURE

Bollinger etal Eur Respir J 2002; 19: 356–373

 ALGORITHM FOR MALIGNANT
OBSTRUCTION OF CENTRAL AIRWAY

Bollinger etal, Eur Respir J 2002; 19: 356–373

COMPARISON OF ENDOBRONCHIAL LASER
THERAPY AND EXTERNAL BEAM RADIATION
FOR CAO
Study Retrospectively matched case control study
(Germany 1994)
Population 75 patients who underwent endobronchial LASER
therapy for malignant airway obstruction along with
external radiation.
Method Comparison with a matched historic cohort in
respect to age, sex, TNM staging, external radiation
dose etc
Outcome LASER resection did not influence overall survival,
But in patients who had a complete reopening of
the airway time from treatment to death increased
by 4 months.

Macha et al Chest 1994: 105:1668-72)

 THERAPEUTIC BRONCHOSCOPY FOR
MALIGNANT AIRWAY OBSTRUCTION –
AQUIRE REGISTRY
Study Prospective multicentre registry 2014
Population 947 patients who underwent 1115 procedures for
malignant airway obstruction
Method Technical success (primary outcome), relief of
symptoms as well as complications and prognostic
factors were noted
Outcome Therapeutic bronchoscopy was successful
(defined as restoring >50% lumen) in 93% cases.
Endobronchial obstruction and stent placement
were significantly associated with success whereas
higher ASA score, primary lung cancer, renal
failure, lt main lesion and TEF were associated with
failure

OST etal CHEST 2015; 147(5):1282-1298

 ROLE OF ENDOBRONCHIAL
ELECTROCAUTERY IN CAO
Study (place, Retrospective review (2014, Durham)
year)

Population 94 patients who underwent endobronchial electrocautery in between

2004 -2009.
Method Data on efficacy and safety were collected
Outcome Among 117 electrocautery procedures on 92 malignant and 25 non-
malignant lesions. Endoscopic improvement was seen in 94% of cases, 71%
of patients reported symptomatic improvement. Radiographic studies
demonstrated luminal improvement in 78% of patients on chest CT,
improved aeration on chest CT and chest x-ray in 63% and 43% of patients,
respectively. The rate of major complications was 0.8%, whereas minor
complications occurred in 6.8% of cases. There was no perioperative
mortality.

Wahidi etal, J Thorac Oncol. 2011;6: 1516–1520

 USEFULNESS OF APC

Study Retrospective ( Texas 2001)

Population A total of 60 patients with bronchogenic carcinoma,
metastatic tumors affecting the bronchi or benign
bronchial disease. Indications for intervention were
hemoptysis (n = 31), symptomatic airway obstruction
(n =14), and both (n =25)

Method APC, a noncontact form of electrocoagulation, was

performed via flexible bronchoscopy. 60 patient
received total 70 sessions

Outcome Hemoptysis was controlled immediately and did not

recur during a follow up of >90 days/ there was also
significant improvement in airway lumen

Morice etal CHEST 2001; 119:781–787

 ENDOBRONCHIAL LASER FOR BENIGN
TUMORS

Study Retrospective (France 1993)

Population 185 patients with benign tracheobronchial tumors
who underwent total 317 LASER procedures
Method Charts, video recording of endobronchial
procedure and histology were reviewed
Outcome The LASER resection were very good (i.e. only
single procedure was required) in 115 i.e. 62%
cases whereas good (multiple procedures
required without complication) in 70 1.e. 38%.
Complications were low.

Shah etal chest 1995; 107:1744-51

 ELECTROCAUTERY FOR BENIGN
AIRWAY STENOSIS

Study Retrospective analysis(Boston ,2015)

(place,year)
Population 36 patients who underwent endobronchial electro cautery for benign
airway stenosis (total no of procedure 57)
Method Data were collected for etiology of airway stenosis, stenosis type,
presenting symptoms, endoscopic tracheal diameter, spirometry,
symptom improvement, time to re intervention and complications.
Outcome In 91% procedures patients noted symptomatic improvement, mean
airway diameter and FEV1 was also significantly improved. Complication
rate was 8.8% with no mortality.

Barry etal, Am J Respir Crit Care Med 191;2015:A3724

INTERVENTIONAL BRONCHOSCOPY FOR
POST INTABATION /POST TRACEOSTOMY
STENOSIS

Zias etal BMC Pulmonary Medicine 2008, 8:18

 TAKE HOME MESSAGE

• Endobronchial electrosurgey can be a optimal replacement for

LASER therapy for central airway obstruction.