John F Beamis, Jr MD FCCP; Stanley ...

John F Beamis, Jr MD FCCP; Stanley M Shapshay, MD FCCP; Suzanne Setzer BS; and Jean-Francois Dumon MD FCCP

A number of assemblages have demonstrated the efficacy of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser bronchoscopy for treatment of patients with gooded tracheobronchial disorders. This therapy involves a just discovered technology, the laser, and modern adaptations of conventional rigid and flexible bronchoscopy that are unfamiliar to many bronchoscopists. We describe sum of two units teaching models for laser bronchoscopy that have been engageed successfully in our laser courses. Using these protoplasts bronchoscopists can become familiar with laser bronchoscopic equipment and appreciate the interaction of laser and easily moulded tissue in a controlled setting in the laboratory before applying this therapy to patients.

(Chest 1989; 95:1316-18)

In novel years, the use of the Nd:YAG laser within rigid and flexible bronchoscopes for the treatment of patients with benign and malignant obstructing tracheobronchial lesions has become an accepted therapeutic tool for thoracic endoscopists. Several large clinical series[1-6] demonstrating the utility and safety of Nd:YAG laser bronchoscopy have been reported. These[1-6] and other reports[7,8] have also emphasized the potential risks involved with laser therapy within airways.

To render certain the safe delivery of laser bottom and the efficacy of laser therapy, the operator must be an experienced bronchoscopist and posses a working knowledge of laser physics. generally most pulmonary physicians and thoracic surgeon in training receive instruction in flexible fiberoptic bronchoscopy still have little training with the rgid bronchoscope which is preferr for laser treatment of patients with lesions obstructing the central airways.[2,4] Also, scarcely any practicing pulmonary physicians are skilled in the use of the rigid bronchoscope Laser physics and the interaction of laser [i]vis viva[/i] and soft tissue receive little or no attention in medical instruct or in postgraduate training.

Before this strange technology is applied to human beings, the physician should receive formal training at common or more hands-on instructional courses for laser bronchoscopy As instructors in a number of these courses, we have fix that attendees gain a better appreciation of the manner of proceeding when they are permitted to fire the laser at a specific endobronchial lesion. We have used the two living and inanimate animal designs in our courses and believe that our technique provides a useful initial experience in laser bronchoscopy

TECHNIQUE

Living Canine Model

After induction of general intravenous anesthesia with thiopental (Pentothal) sodium and when the animal is breathing spontaneously, the animal's neck is stretch outed shaved, prepared with povidone-iodine (Betadine), and draped. An 8-cm to 10-cm vertical incision is made between the walls of the skin overlying the trachea and is carried [i]or[/i] part of to the other the subcutaneous tissues down to the fascia overlying the strap muscles. The fascia is divided in the vertical midline, and dissection is carried between the strap muscles down to the pretracheal fascia. The strap muscles are retracted laterally upon both sides (Fig 1A). The pretracheal fascia is divided, and the trachea is expos the same of the midtracheal rings is chosen and horizontal incisions are made above and below the ring. The horizontal incisions are have relationed on one side only, permitting the ring to have a pedicle at single lateral aspect. The ring is cause to deviateed into the tracheal lumen and labor fors as an excellent "foreign body" for Nd:YAG laser practice.

To provide additional material of different color and grain one of the strap muscles is dissected clear of surrounding connective tissue. The belly of the muscle is split vertically, and the superior attachment is sculpture producing a long bipedicle of muscle (Fig 1B) The clear end of the muscle belly is inserted into the tracheotomy to provide a impressible tissue "tumor" with intact house supply (Fig 1C). As the endotracheal constituent of the muscle is vaporized by means of the laser, more muscle is f into the stoma. Care must be taken not to hinder the trachea by more than 50 percent to debar interference with ventilation. The endoscopic appearance of the tumor pattern is demonstrated in Figure 2

It is best to intubate the trachea with a rigid bronchoscope to make secure a patent airway that cannot be ignited by the agency of the laser. An optical spyglass a suction catheter, and the laser fiber can be inserted into the rigid bronchoscope in a manner similar to that used in actual conditions in the operating expanse The laser fiber can also be passed by means of the working channel of a flexible fiberoptic bronchoscope which in bend is passed through the rigid instrument.

A video attachment for the bronchoscopic spyglass is highly desirable. This permits the instructor to demonstrate the technique to the participants and to monitor the performance of each trainee.

At the conclusion of the session, the animal's hurt is closed with usual surgical techniques.