1	Laser Resection Right Main Bronchus Tumor Learning Objectives Explain the principle of Power Density. Describe anatomic dangers during the right main bronchial tumor resection. Describe expected survival after successful restoration of airway patency.
2	Case Description (Practical Approach # 3) CC is a 69 year male with 30 pound weight loss, dyspnea and diagnosis of squamous cell carcinoma with complete obstruction right bronchial tree one month earlier. Positive tobacco use. Works in a factory. Divorced and lives with his two adult children. No advance directives.
3	The Practical Approach
4	Initial Evaluation HPI: 69 y/o male (Mr. P) with shortness of breath and cough due to squamous cell carcinoma. Physical exam: decreased breath sounds on the right. Comorbidities: ex-smoker; otherwise none. Support system: divorced; lives with children. Patient’s expectations: relief of symptoms; palliative control of primary disease.
5	Procedure Strategies Indications: complete right main bronchial obstruction with altered anatomy (mediastinal shift). Contraindications: possibility of non-functioning lung distal to obstruction. High-risk procedure. Expected results: resection, dilatation, and stent insertion in the right main bronchus with restoration of ventilation to distal airways. Beware postobstructive pneumonia Operator experience: excellent Risk-benefits: Risks: Aspiration to contra lateral lung. May improve ventilatory function and decrease risk of postobstructive pneumonia. Risk of bleeding and perforation, risk of respiratory failure. Benefits: prolonged life expectancy and quality of life. Respect for persons: informed patient and family of potential failure to restore airway patency, also risk for bleeding, ,perforation, respiratory failure, temporary and prolonged mechanical ventilation, and death.
6	Alternative procedures External beam radiation therapy Less than 20% response in case of atelectasis. This patient has complete atelectasis. Brachytherapy Extensive tumor with substantial extrabronchial component Photodynamic therapy Phototoxicity, no distal lumen visible Balloon dilatation Severe extrinsic compression and no distal lumen visible Cryotherapy Not pure intraluminal disease Electrocautery-APC Superficial cauterization may not suffice to stop bleeding Covered metal stent insertion No distal lumen visible, more costly than silicone
7	Procedure Techniques Anesthesia and other perioperative care: general anesthesia and spontaneous assisted ventilation; preparedness for selective LMB intubation in case of massive hemoptysis, prepare to pack mouth in case of inability to oxygenate through open system. Technology and instrumentation: 10 to 12 mm EFER-Dumon rigid ventilating bronchoscope, Nd-YAG laser low power density; dilation and silicone stent insertion. Anatomical dangers and other risks: right pulmonary artery (at 12-3h) and right pulmonary vein (at 6-9h). Results and procedure-related complications: successful stent insertion; no complications
8	Equipment Flexible bronchoscope Working channel Rigid bronchoscope Diameter, length, model Accessory instruments Fibers Balloon catheters Forceps Suction capability
9	Anatomic considerations
10	Anatomic dangers
11	Effects of Nd:YAG laser energy on living tissues Conversion of radiant energy into Heat Vaporization of water content in tissues Creation of steam-disruption of tissues Creation of pressure waves: rupture tissues or creation of plasma (hot gas of electrons and positive ions).
12	Wavelength Considerations
13	Displacement of maximum power density Nd:YAG beam penetrates tissue without visible effect Energy is absorbed by darker tissues beyond surface tissue Temperature rises during irradiation, causing scattering and displacement of maximum power density to a point below the tissue surface here temperature rises to boiling point of water, and pocket of steam collects until it explodes.
14	Procedure technique-patient safety Video: lateral decubitus position Slight right lateral decubitus position Protects contra-lateral airway from flooding with blood or purulent secretions. Facilitates clot formation in gravity dependent regions.
15	Video: Equipment EFER Rigid ventilating bronchoscope Racine adaptor for anesthesia-assisted ventilation. Swivel adaptors allow repositioning of laser fiber, suction, and ventilation ports. 5 mm rigid telescope. Laser-safety eye shield Tooth protection-mouth guard
16	Procedure technique Flexible bronchoscopy to clean LMB and trachea. Avoid traumatizing airway abnormality Gentle dilation with rigid tube. No preliminary flexible exploration of RMB because of bleeding risk. As dilation proceeds, rigid tube maintains proximal airway patency and tamponades bleeding airway wall. Flexible bronchoscopy through rigid tube removes pus and blood from now visible distal airways. Extubate and reintubate with rigid tube of greater diameter for large airway stent insertion, if possible. Bronchial toilet, specimens for microbiology, begin intravenous antibiotics. Extubate and move to Intensive Care Unit overnight for observation.
17	Procedure technique-results
18	Video: procedure (Practical Approach # 3)
19	Long term Management Plan Outcome assessment: Resection and dilatation of right main bronchus tumor with stent insertion Squamous cell CA stage IV Restored the airway patency Improved aeration on post-op CXR Stable status post procedure Discharged within 24 hours
20	Long term Management Plan Follow-up tests, visits, procedures: Medical alert and outpatient visits Referrals to medical, surgical, or palliative/end of life subspecialty care: referral for palliative radiation therapy. Quality improvement and team evaluation of clinical encounter: successful restoration of airway patency.
21	Quality of life and complications of treatment Quality of life* Karnofsky Performance scores increase from 40 to 60. Stent-related complications** 13% overall (172 stents, mostly expanding covered metal) placed in 140 patients with cancer) Migration Restenosis Granulation tissue formation
22	Survival Median survival after metal stenting 3.4 months* 1-year survival of 15% (21/140 patients) ≠ from Wood et al, Ann Thorac Surg 2003;76:167-174) with 41% complications. Increased disease free survival for those patients receiving post stent external beam radiation therapy, but no overall survival benefit.
23	Case analysis using The Practical Approach Strategy and planning Operative risk Informed consent issues Ethics of care issues Indications-contraindications-alternatives Execution and performance Techniques and instrumentation Anesthesia Bronchoscopy Results Survival Quality of life Disease process Team dynamics and team performance (quality improvement) Response to complications and follow-up care Instrumentation Ancillary care Additional procedures and consultations
24	All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide shows, streaming videos, and essays can be cited for reference as: Bronchoscopy International: Practical Approach^©, an Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/PracticalApproach/htm. Published 2007 (Please add “Date Accessed”).
25	Prepared with the assistance of Young-Jae Cho M.D. (Korea)