Transcript Bronchial Tuberculosis

Bronchial Tuberculosis
CATCH IT
CURE IT
Dr. Sandhya Nanjundiah
Endobronchial Tuberculosis
• 1698 - Morton
1810 - Cayol
• 10 - 40 % of Pulmonary TB have EBTB
• Primary infection or Reactivation
Endobronchial Tuberculosis
AIRWAY
OBSTRUCTION
POTENTIAL AIRWAY STENOSIS
Early diagnosis & management
Predisposing factors for stenosis
Age > 45 years > 65 yrs
? Female preponderance
Time to treatment > 3 month
Fibrostenotic /combined type
at presentation
Anthracosis ± biomass smoke , silica
suppress mucosal / alveolar macrophages
Endobronchial infection-sources
SPUTUM
Direct from
parenchymal lesion
Lymph node Erosion
Lymphatic drain to
peri-bronchial
region from
parenchymal lesion
Hematogenous
Acid fast bacilli (+)
• Sputum smear
13.6 - 53.3 %
10.5 % (tumourous)
• Sputum culture 73.6 %
• Mantoux test
59 %
• M.Kansasii / Atypical mycobacteria
possible
• NO
multi-drug resistant strains
Chest x ray findings
Normal
10 - 20%
Partial / total lobe collapse
Cavity
5 - 28 %
Destroyed lung 3 - 4 %
Effusion
Patchy infiltrates
Bronchiectasis (traction)
25 - 35 %
Chest x ray findings
hilar nodes 7 - 18%
bronchial narrowing
Chest x ray findings
consolidation 42 - 52%
C.T. scan findings
shaded surface
display image
2 - 10 mm nodules
tree in bud - endobronchial spread
Indications for bronchoscopy
Unexplained dyspnoea
Hemoptysis
Localized wheeze
AFB smear / culture (-) + CXR findings
AFB positive and CXR Normal
Suspected tumour , uncontrolled asthma
Acid fast bacilli (+)
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B.L. smear
26 %
B.L. culture
39 - 94 %
Bronchial Brush 10 - 85 %
Bronchial Biopsy 30 - 84 %
NO multi-drug resistant strains noted
• Histopathology diagnostic
Host factors for stenosis
• IMMUNE STATUS
•  TGF β , IFN γ levels in bronchial washings
• Serum level TGF  lower in stenotic outcome
than non-stenotic after therapy.
• Matrix metalloproteinase (MMP 1)
with IG genotype - 9.86 fold risk of stenosis
(up-regulation of MMP1 activity )
Pathogenesis -- 7 types
nonspecific edema / hyperemia
bronchitis
actively caseating
ulcerative
granular
tumourous
fibrostenosis
Nonspecific bronchitis
Incidence 7.9 - 44%
Mild mucosal hyperemia
or swelling
B.L. smear AFB (+)
B.L. culture AFB(+)
Excellent prognosis
Edema-hyperemic
Incidence 3 - 34.7%
Severe mucosal swelling
hyperemia
No caseous material
initially
B.L. smear AFB (+) 75%
B.L. culture AFB (+) 75%
Upto 64% resulted stenosis
Bad prognosis
Granular
Incidence 1.3 - 31.8%
Scattered white spots
Mucosal inflammation
B.L. smear AFB (+) 20%
B.L. culture AFB (+) 40%
Upto 18% stenotic
outcome
Good prognosis
Active caseating
Incidence 17- 43%
Mucosa swollen covered
with cheese like material
Luminal narrowing
Granulation tissue
presence suggests
stenotic outcome
B.L. smear AFB (+) 12.5%
B.L. culture AFB (+) 25%
Bad prognosis
Ulcerative
Incidence 1.2 - 4.5%
Mucosal ulceration
No luminal narrowing
Sputum smear (+) 53.3%
Sputum culture (+) 73.6%
B.L. smear AFB (+) 50%
B.L. culture AFB(+) 50%
Good prognosis
Tumourous
Incidence 3 – 62 %
Endobronchial mass
occluding lumen R/O CA
New lesions during
treatment
B.L. smear AFB(+) 25%
B.L. culture AFB(+) 50%
Unpredictable prognosis
Fibrostenotic
Incidence 9 - 18.1%
Initial stenosis 90%
some mucosal sparing
(site of biopsy)
B.L. smear AFB (+) 0%
B.L. culture AFB(+) 0%
Heal with stenosis
Bad Prognosis
CRITICAL
Degree of bronchial stenosis
1 - 33 % of luminal narrowing
34 - 66%
67 - 99%
NO lumen 100% stenosis
Treatment goals
• Treatment of tuberculosis
• Early diagnosis / treatment of potential
stenosis
• Treatment of established stenosis
• Maintenance of bronchial lumen
patency
• Long-term follow up needed
Anti-tubercular therapy
First line drugs
• INH Rifampicin Ethambutol PZA
• Streptomycin Fluoroquinolones
• No
M.D.R. strains
• Duration : 6 months -- 12 months
up to 18 months with co-morbid disease
• D.O.T.S. therapy not adequately studied
Oral steroid CONTROVERSIAL
Dose : 0.75 – 1 mg / kg for 2 – 6 weeks then taper
over 4 - 6 weeks -----PREDNISOLONE
• Hypersensitivity reaction after few wk of ATT –
tuberculo - protein release from cell wall.
• Active caseating / Edema-hyperemia / Tumourous
types with initial bronchial narrowing
• Tracheal involvement
follow up bronchoscopy q. month 2 - 3 times as
needed
Steroid - submucosal injection
1 ml. dexamethasone
40 mg. methyprednisolone
40 mg triamcinolone
At base of lesion
Endobronchial needle
TBNA cytology needle
Inhalation therapy plus ATT
Less stenosis
• Inhalation TGF  1 antibody reduces
scar formation
• INH 200 mg / day
• Ulcerative type : streptomycin 100mg ,
dexamethasone 0 . 5 mg, naphazoline
0.1mg nebs. bid ( till ulcer healed )
(serum conc. SM < 3 γ units)
Repeat bronchoscopy
Every month –
2 to 3 times needed
Assess lesion
Response to therapy
Need for intervention
Virtual bronchoscopy
assess lumen size and distal lesions
follow up degree of stenosis
follow up for pts. unfit for bronchoscopy
Endobronchial interventions
Cryotherapy
Granular lesions at diagnosis
Prior to balloon dilatation
2.4 mm probe, liquid CO2 (- 70º)
½ - 1 min freeze - thaw cycles
Every 2 weeks after diagnosis
Stopped when no lesion seen
100% diameter -- no stenosis
Endobronchial interventions
Argon Plasma Coagulation
Tumourous lesions
No stenosis
30 - 40 W
argon flow 1.6 L / min
Monopolar probe 220
cm
Endobronchial interventions
Nd : Yag Laser
Cicatrical stenosis
Increased risk
Intermittent
low pulse 0. 4 sec
40 W
Immediate relief
Endobronchial interventions
Electrocautery
Stenotic lesions
Balloon dilatation of stenosis
4 F Fogarty balloon via
bronchoscope
10 F Gruentzig under fluoroscopy
Laser + Angioplasty
4 mm balloon catheter
7 F 15 mm Esophageal balloon
--- 20 sec as needed
2 – 3 insufflations : 5 to 180 seconds
Repeat for restenosis
Balloon dilatation
Recurrence
3 months
9 months
18 months
32 months
92 % patency
45 % patency
20 % patency
20 % patency
secondary relapse
Deep mucosal lacerations
Disruption of supportive tissue
- acquired bronchomalacia
- expiratory airway collapse
Re - stenosis
Worsening resp. symptoms
Airway volume loss
Post obstructive pneumonia
in active inflammatory TB
low baseline FEV1, long segment
upper trachea lesion
Long term follow up required
Stent insertion
Gianturco , Palmaz,
Covered expandable Nitinol stent
L.A.
Easy insertion via bronchoscope
Granulation tissue may occur
Stent migration
cough
Metal fatigue -- removal difficult
Expandable metal stents NOT recommended
Stent insertion
Migration
51 - 70 %
Mucostasis 17 - 19 %
Granulation 49 - 76 %
Topical Mitomycin - C
0.5 mg / ml pledget 2 min
over obstructive granulation
Staged stenting
Silicone stents recommended
Guides for stent removal
EBUS
Radial transducer
Cartilage status
Airway Patency
12-18 months healed patent airway
Air pockets - quadrants with air 0 - 4 score
Air Length 2 cm – 68 % success
Failure ----- bronchomalacia
Survey of bronchoscopy
35
2011
33.8%
25.8%
30
25
20
15
8.3%
10
4.6%
5
0
LASER
STENT
A.P.C.
Balloon
Surgical treatment
Parenchymal sparing - main bronchus
sleeve resection
Sleeve lobectomy
Bronchoplasty
Tracheal segment resection
Carinoplasty with anastomosis
• A.T.T. 9 -12 months given peri-operatively
Conclusion
CATCH IT
• Early diagnosis and treatment
• Interventional procedures as needed
• Close follow up
MAINTAIN AIRWAY PATENCY
CURE IT
THANK
YOU