The Pulse | Thursday, August 6, 2020
Exploring Interventional Pulmonology Part 2: Procedures, Techniques and Complications
In part one of the Exploring Interventional Pulmonology series, Laura Clark, MSN RN CCRN, focused on the treatment tools, procedural locations, choice of bronchoscope and the need for education reform for interventional pulmonology.
In part two, Clark and Edmund Moon, MD, go into detail on advanced interventional pulmonary procedures, techniques and complications that nursing staff should be aware of to ensure patients are receiving the care they need.
Electrocautery (EC) is an ablative therapy which utilizes alternating electrical current to generate heat through a probe to cauterize, coagulate and vaporize targeted tissue. (Sachdeva, Pickering & Lee 2015). The electrical current circuit consists of the electrosurgical unit (voltage source), the electrode (probe), the patient and the patient return electrode (Ellsworth & Iverson 2006).
EC is an effective way to directly cauterize tissue, relieve central airway obstructions and treat airway stenosis in transplanted lungs. There is a variety of flexible tip probes/tools that may be utilized for EC, including round tipped probes, needle knives and snares. Understanding the goal of treatment and communication with the proceduralist will ensure accurate tool selection and patient safety. The power settings on the EC unit also need to be selected according to the manufacture’s recommendations and verified with the performing physician.
When setting up for electrocautery use, the patient needs to be grounded with a grounding pad, commonly placed on the thigh. The skin should be inspected prior to pad placement and after treatment to asses for injury or burn. The patient should remove any jewelry or metal that could cause a conductive current.
Complications from EC use during bronchoscopy include hemorrhage, airway fire, perforation and stenosis. An airway fire is a serious, life-threatening complication to the patient and staff. An airway fire requires the following three items to take place: an oxidizer (oxygen or nitrous oxide), an ignition source (EC, laser, APC) and a fuel (stent, endotracheal tubes, bronchoscope) (Sachedeva et al. 2015). Caution must be used with EC due to its increased risk of airway fire and thermal injury to the patient. The FiO2 should be <40% during application of EC to mitigate the risk of fire. Nursing staff should remind the team of the fire risk and confirm proper safety precautions before utilizing cautery.
In the event of hemorrhage or unforeseen bleeding, epinephrine 1:20,000 and iced saline should be readily available to administer via the bronchoscope. Fogarty balloon catheters and endobronchial blockers are also utilized to tamponade any significant airway bleeding. Fogarty balloons vary in size. All sizes should be kept in multiple quantities to ensure adequate emergency supplies. Complications that arise during bronchoscopy are time sensitive. Thus, familiarizing oneself with rescue equipment and its intended use prior to any procedure is crucial.
In the event of a pneumothorax, which is when air leaks from the lung into the pleural space, a chest tube may be indicated to re-expand the lung. A chest tube insertion may be needed urgently depending on size of pneumothorax and patient’s clinical condition. Diagnosis of a pneumothorax is typically seen on radiographic imaging such as a portable ultrasound, chest X-ray or CT scan. Common supplies and equipment needed for a chest tube insertion include a chest tube, a chest tube insertion kit, pleurovac collection container and wall suction. A post-bronchoscopy chest tube may be done intra-operatively in the procedural area, or post-operatively in the recovery bay. Anticipated patient needs include supplemental oxygenation, pain management and patient education.
Argon Plasma Coagulation
Argon plasma coagulation (APC) is an electrosurgical technique similar to electrocautery, but uses argon gas indirectly to ablate and destroy central airway tumors, control hemoptysis, desiccate tissue and treat a variety of other pulmonary disorders (Wahidi, Herth, Chen, Chang & Yarmus 2020). APC can utilize straight tip or circumferential tip probes. When utilizing flexible tip probes with the APC unit, probes should be purged/primed prior to use.
Safety measures for APC use are the same as EC. The patient needs to be grounded, fire safety maintained and closed-loop communication with all team members must take place. There are risks of hemorrhage and perforation with use, therefore emergency tools such as fogarty balloon catheter, endobronchial blocker, epinephrine and iced saline should be commonly available for APC use and all other therapeutic bronchoscopies.
Light amplification of stimulated emission of radiation (LASER) is a treatment modality that utilizes non-contact light energy to treat central airway obstructions (Sachdeva et al. 2015). LASER is able to debulk lesions via a combination of two methods: coagulation (allows for control of hemorrhage from a lesion likely to bleed) and vaporization. Thin, flexible fiber probes are able to be placed in the airway by means of a rigid or flexible bronchoscope. Laser is more favorable when there is a need to cut or vaporize tissue with improved bleeding control. There are different types of lasers, however. The Nd:YAG laser is most commonly used in bronchoscopy.
There is a risk for airway fire; precautions to reduce fire in the airway should also be implemented by decreasing FiO2 <40%, using fire retardant drapes and gowns, and appropriate anesthetic. A fire extinguisher and saline/sterile water should be readily available.
Cryotherapy allows for tissue destruction by a cold ablative therapy technique. Standard cryotherapy consists of using decompressed nitrous oxide with direct probe contact to destroy tissue in repeated freeze-thaw cycles. Pressurized gas is released from the probe tip to allow for rapid cooling and crystallization of the tissue. Multiple cycles may be required for necrotic tissue to detach (Pasricha, DiBardino, & Ma 2020). The process can be tedious; however, the risks are relativity low.
Complications of cryotherapy include bleeding and perforation. Emergency hemorrhage or bleeding management precautions (such as those described above) need to be available for cryotherapy. The checklist for any procedure that utilizes cryotherapy include adequate nitrous oxide, probe size and confirmation of intact probe.
Therapeutic intervention that can be utilized during flexible and rigid bronchoscopy continue to grow and expand. Little or no knowledge of the enhancements and developments may lead to staff being in the dark and jeopardizing patient safety during the cases.
A call to action is needed for increasing awareness of the treatment tools, techniques and functionality in order to improve patient outcomes and interprofessional collaboration. Education is essential and should be ongoing to stay informed and up to date with the latest advancements in interventional pulmonary.
Ellsworth,W.A., & Iverson, R.E. (2006). Patient safety in the operating room. Seminars in Plastic Surgery, 20(4), 214-218. doi:10.1055/s-2006-951578
Pasricha, V. G., DiBardino, D. M., Ma, K.C. (2019). Management of malignant central airway obstruction. Shanghai Chest, 1-12. doi:10.21037/shc.2019.11.09
Sachdeva, A., Pickering, E. M., & Lee, H. J. (2015). From electrocautery, balloon dilatation, neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) laser to argon plasma coagulation and cryotherapy. Journal of Thoracic Disease, 7(4), S363-3379. doi: 10.3978/j.issn.2072-1439.2015.12.12
Wahidi, M.M., Herth, F.J., Chen, A., Cheng, G., & Yarmus, L. (2020). State of the art interventional pulmonology. CHEST, 157(3), 724-736.