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Topics in Compan An Med 28 (2013) 97 102

Topical Reviews

Transtrac eal !as and "ronc oalveolar #ava$e


Ma%reen &' (in)e* &+M* &AC+,M
-e.words/ respirator. 0ronc oscop. trac ea c.tolo$. c%lt%re ! eat Rid$e +eterinar. 1pecialists* ! eat Rid$e* C2* 31A
n

7;amination and samplin$ o< t e p%lmonar. airwa.s can 0e o< $reat 0ene9t in patients wit respirator. disease' Transtrac eal and endotrac eal was es are minimall. invasive proced%res t at allow <or 0lind samplin$ o< t e lar$er airwa.s <or c.tolo$ic and c%lt%re anal.sis' (le;i0le trac eo0ronc oscop. allows <or direct vis%ali=ation o< t e trac ea* 0ronc i* and orop ar.n;' "ronc oalveolar lava$e elps to o0tain samples <rom t e small airwa.s and alveoli d%rin$ 0ronc oscop.' T e com0ined %se o< t ese tec ni4%es can elp clinicians dia$nose c allen$in$ respirator. cases' T e <ollowin$ article reviews t e indications and tec ni4%es o< t ese proced%res' > 2013 7lsevier ,nc' All ri$ ts reserved'

Address reprint re4%ests to Ma%reen &' (in)e* &+M* &AC+,M* 1mall Animal ,nternal Medicine* ! eat Rid$e +eterinar. 1pecialists* 3596 -iplin$ 1treet* ! eat Rid$e* C2 80033' 78mail/ m9n)e:wra 'com

,ntrod%ction Transtrac eal !as (TT!)

TT! is a minimall. invasive proced%re %sed to sample t e lar$er airwa.s (e'$'* trac ea and mainstem 0ronc i) o< do$s' ,n case o< lower airwa. or interstitial l%n$ disease* t e res%lts ave 0een s own to 0e in<erior to samples o0tained 0. 0ronc oalveolar lava$e ("A#)'1 TT! as t e 0ene9t o< 0ein$ per<ormed in awa)e patients* 0.passin$ t e need <or anest esia in a patient wit respirator. compromise' "eca%se t e animal is not sedated* t ere is t e additional 0ene9t o< an intact co%$ response* w ic ma. res%lt in some e;pectoration o< samples <rom t e lower airwa.s'

Tec ni4%e TT!s are %s%all. per<ormed %sin$ a t ro%$ 8t e8needle* lon$ intraveno%s cat eter' T ese cat eters are eas. to %se and ave t e advanta$e o< allowin$ removal o< t e needle <rom t e trac ea once t e cat eter is in place' Alternativel.* a 1?8 or 158 $a%$e needle or over8t e8needle cat eter can 0e placed perc%taneo%sl. into t e trac ea and a lon$* red* r%00er or pol.prop.lene cat eter can 0e <ed t ro%$ t e needle and into t e trac ea' 1trict asepsis s o%ld 0e per<ormed t ro%$ o%t t e proced%re' @lace t e patient in eit er sternal rec%m0enc. or in a sittin$ position wit t e nec) e;tended and t e nose elevated' 1 ave and asepticall. scr%0 t e ventral nec) incl%din$ t e lar.n; and cervical trac ea' ,n<%se a local anest etic dr%$ (2A lidocaine) into t e s)in and s%0c%taneo%s (1B) tiss%es' ! ile t e local anest etic is ta)in$ e<<ect* preload several s.rin$es wit 6820 m# o< sterile* non0acteriostatic 0'9A saline' T e operator s o%ld wear sterile $loves and %se aseptic tec ni4%e t ro%$ o%t t e proced%re' @alpate t e cricot .roid li$ament as a trian$%lar depression distal to t e t .roid cartila$e' T e needle can 0e placed eit er t ro%$ t e cricot .roid li$ament or 0etween 2 trac eal rin$s C%st distal to t e lar.n;' !it t e 0evel <acin$ ventrall.* insert t e needle t ro%$ t e s)in and cricot .roid li$ament into t e trac eal l%men' A sli$ t DpopE can 0e <elt as t e li$ament is passed' Retc in$ as 0een reported w en %sin$ t e cricot .roid approac

and ma. ma)e t e proced%re more di<9c%lt' Alternativel.* t e needle can 0e passed 0etween 2 trac eal rin$s on midline* C%st ventral to t e lar.n;' 2nce t e needle is in t e trac eal l%men* an$le t e needle down appro;imatel. ?61 and <eed t e cat eter into t e trac eal l%men' ,< t e needle is properl. placed* t ere s o%ld 0e minimal resistance as t e cat eter is advanced' ,< resistance is enco%ntered* t is ma. 0e owin$ to t e needle 0ein$ a$ainst t e <ar (dorsal) wall o< t e trac ea* in w ic case t e needle can 0e p%lled 0ac) sli$ tl. and t e cat eter is reinserted wit o%t resistance' ,< resistance is persistent* t e needle is li)el. in s%rro%ndin$ tiss%e and not wit in t e trac eal l%men' ,< t is is t e case* remove t e needle and re8direct' As t e cat eter is passed down t e trac eal l%men* t e do$ ma. co%$ and ma. 0ecome sli$ tl. a$itated' 2nce t e cat eter is in place* t e needle is removed <rom t e trac ea' ,< it is a t ro%$ 8 t e8needle cat eter* place t e $%ard over t e needle' ,< a 158$a%$e needle or an over8 t e8needle cat eter was %sed* p%ll t e needle 0ac) o%t o< t e trac ea and over t e cat eter' Attac t e preloaded s.rin$e to t e cat eter and in<%se t e sterile saline into t e trac ea' ,t ma. 0e elp<%l to ave an assistant per<orm co%pa$e d%rin$ instillation o< t e F%id so as to promote co%$ in$' Aspirate t e in<%sed saline 0ac) into t e s.rin$e' ,< e;cess air is aspirated* t e s.rin$e ma. need to 0e detac ed <rom t e cat eter and t e e;cess air e;pelled so as to aspirate as m%c F%id 0ac) as possi0le' ,t is common to recover onl. 10A or less o< t e in<%sed vol%me' ,< desired* t e proced%re can 0e repeated wit a second preloaded s.rin$e' 2nce an ade4%ate sample as 0een o0tained* remove t e s.rin$e and cat eter <rom t e nec) in a smoot motion' @lace a so<t* padded 0anda$e over t e cat eter site <or appro;imatel. 1 o%r to minimi=e t e <ormation o< 1B emp .sema'

7ndotrac eal !as (7T!) 7T! samplin$ is recommended in smaller patients (cats and do$s o 10 )$) as t eir smaller trac eal l%men diameter precl%des placement o< a lar$e needle 0etween trac eal rin$s' 7T! s o%ld also 0e considered in lar$er do$s t at are <ractio%s or resistant to

162783359GH 8 see <ront matter > 2013 Topics in Companion Animal Medicine' @%0lis ed 0. 7lsevier ,nc' ttp/GGd;'doi'or$G10'1063GC'tcam'2013'05'003

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M'&' (in)e G Topics in Companion An Med 28 (2013) 97102

restraint and in w ic per<ormin$ a transtrac eal was co%ld res%lt in clinician or patient inC%r.' Ieneral anest esia is re4%ired <or 7T! and t ere<ore ma. potentiall. res%lt in more ris) to t e patient' "eca%se anest esia prevents a co%$ reFe;* recovered F%id is more li)el. to represent lar$e airwa. 9ndin$s and t ere8 <ore ma. 0e less dia$nostic' !it t is tec ni4%e* t ere is also more ris) o< contamination <rom t e orop ar.n; "e<ore anest esia* preo;.$enate t e patient <or 6810 min%tes' &%rin$ t is period o< time* preload s.rin$es wit sterile* non8 0acteriostatic 0'9A saline' 2win$ to t e ris) o< 0ronc ospasm d%rin$ t e proced%re* 0ronc odilators are recommended in cats and ma. 0e considered in do$s wit s%spected inFammator. airwa. disease' Ter0%taline (0'01 m$G)$ 1B 4 8 o%rs) can 0e administered 1282? o%rs 0e<ore t e proced%re* wit t e 9nal dose $iven 28? o%rs 0e<ore anest etic ind%ction' 2win$ to t e ina0ilit. to provide o;.$en and in alant anest esia d%rin$ t e proced%re* most patients are ind%ced wit inCecta0le anest etics s%c as propo<ol' T ese s ort8actin$ anest etics also allow <or 4%ic) recover. a<ter t e proced%re' 1imilar to a TT!* aseptic tec ni4%e s o%ld 0e <ollowed <or an endotrac eal lava$e' @lace t e patient in sternal or lateral rec%m8 0enc. wit t e a<<ected side down' Care<%ll. pass a sterile 7T t%0e t ro%$ t e ar.tenoid cartila$es into t e trac ea* ta)in$ care to avoid contaminatin$ t e t%0e wit orop ar.n$eal secretions' &o not attac t e anest esia mac ine t%0in$ to t e 7T t%0e %ntil a<ter t e was as 0een per<ormed' 2nce t e patient is int%0ated* <eed a red r%00er cat eter (8 (r) t ro%$ t e 7T t%0e* 0ein$ care<%l to maintain sterilit.' Attac a preloaded s.rin$e to t e cat eter and in<%se t e contents t ro%$ t e cat eter as previo%sl. descri0ed' T e red r%00er cat eter ma. need to 0e s ortened or a cat eter adapter ma. need to 0e %sed to sec%re t e s.rin$e to t e cat eter' Aspirate t e in<%sed saline 0ac) into t e s.rin$e'

anest esia ind%ction' "ronc odilator t erap. as previo%sl. men8 tioned is recommended in <eline patients 0e<ore 0ronc oscop.* "A#* and 7T!' ,n alant anest esia is almost alwa.s %tili=ed e;cept in cats and ver. small do$s' ,n t ese patients* endotrac eal int%0ation is not possi0le* as t e 0ronc oscope wo%ld not 9t t ro%$ a small 7T t%0e' ,n t ose patients* inCecta0le propo<ol anest esia is titrated to e<<ect' A small diameter pol.prop.lene cat eter can 0e passed down t e trac ea to provide o;.$en' Alternativel.* some clinicians pre<er to provide o;.$en via Cet ventilation or t ro%$ t e wor)in$ c annel o< t e scope'687 ,t is important to reali=e t at t e trac eal l%men ma. 0e completel. occl%ded 0. t e 0ronc oscope in small patients and .po;ia and .percapnia ma. occ%r' ,t is recommended to per<orm airwa. e;amination and dia$nostic samplin$ at several 0rie< periods in t ese patients' T e %se o< topical lidocaine and sterile l%0ricant can 0e %sed to prevent lar.n$ospasm and ar.tenoid tra%ma as t e scope is passed t ro%$ t e lar.n; m%ltiple times' ,n patients t at are lar$e eno%$ to allow in alant anest esia* place a sterile 7T t%0e and ta)e care to not contaminate t e t%0e wit orop ar.n$eal secretions d%rin$ placement' A sterile J8 or T8s aped 7T t%0e adapter can 0e %sed to allow passa$e o< t e endoscope into t e 7T t%0e w ile sim%ltaneo%sl. allowin$ <or o;.$en and $as anest esia deliver.' 3se a mo%t $a$ to protect t e 0ronc oscope <rom tra%ma in t e %n<oreseen event o< t e patient awa)enin$ 0eca%se o< an ins%<9cient plane o< anest esia' Anatom. Canine trac eo0ronc ial anatom. as 0een well descri0ed and 8 a s.stematic nomenclat%re sc eme as 0een developed ((i$ 1)' T e anatom. o< t e cat is not as well descri0ed* 0%t most clinicians %se t e same nomenclat%re in t is species alt o%$ di<<erences do e;ist' T e %se o< a standardi=ed nomenclat%re sc eme elps clinicians descri0e t e location o< airwa. samplin$ or o< lesions acc%ratel. and serves as a map t at elps )eep t e operator aware o< t e scopeKs location in t e airwa.s t ro%$ o%t t e proced%re' T e airwa.s 0ranc 4%ic)l. and it is eas. to 0ecome lost' ,< t is appens* it is elp<%l to ret%rn t e scope to t e carina to orient t e operator to location and t en $o directl. 0ac) to t e area o< interest' @roced%re @ass t e 0ronc oscope eit er t ro%$ t e 7T t%0e in lar$er patients or directl. t ro%$ t e lar.n; in small patients as noted earlier' ,t is important to reali=e t at t e trac eo0ronc ial airwa.s are ri$id and %nd%e <orce wit t e scope can dama$e t e airwa. m%cosa res%ltin$ in emorr a$e or even tearin$ o< t e airwa. wall' (or t is reason* advance t e scope care<%ll. wit o%t <orce' (irst e;amine t e trac ea* t en t e carina' Le;t* eval%ate t e 0ronc i in a s.stemic consistent manner' T e a%t or e;amines t e ri$ t mainstem 0ronc %s 9rst* <ollowin$ t e se$mental 0ronc i into t e ri$ t cranial lo0e %ntil t e scope reac es its limit' Le;t* ret%rn t e scope to t e carina <or orientation and t en e;amine t e se$mental 0ronc i o< t e ri$ t middle lo0e' Repeat t ese steps %ntil all l%n$ lo0es ave 0een e;amined' Complete t e vis%al e;amination 0e<ore per<ormin$ an. samplin$ proced%res' Lormal trac eo0ronc ial m%cosa is smoot and pin) wit minimal secretions ((i$ 2)' 7r.t ema indicates inFammation and e;cessive m%c%s can 0e seen wit man. inFammator. conditions s%c as 0ronc itis' Jellow or $reenis m%cop%r%lent e;%date ma. 0e seen in cases o< pne%monia or eosinop ilic pne%monopat .9 ((i$ 3)' T e trac ea s o%ld 0e ro%nd and patent wit easil. visi0le trac eal rin$s' Trac eal collapse can 0e identi9ed and t e 10 e;tent o< l%men occl%sion %sed to classi<. t e $rade o< collapse ((i$ ?)' T e dorsal trac eal mem0rane can 0e vis%ali=ed as a

"ronc oscop. 7ndoscopic e;amination o< t e respirator. s.stem is %se<%l in t e dia$nosis o< airwa. disease in do$s and cats' Trac eo0ronc o8 scop. s o%ld 0e considered in patients wit ac%te or c ronic co%$ * stridor* emopt.sis* or respirator. distress* w en ot er dia$nostics ave not identi9ed an %nderl.in$ ca%se' 7ndoscop. allows <or direct vis%ali=ation o< t e l%men o< lar$er airwa. and allows <or samplin$ o< cells* F%id* and in<ectio%s or$anisms <rom t e airwa.s 0. %sin$ "A#* 0ronc ial 0r%s in$* or 0iops.' "ronc o8 scop. is most elp<%l in patients wit airwa. disease and ma. 0e less dia$nostic in patients t at ave interstitial or isolated <ocal parenc .mal p%lmonar. lesions' 74%ipment "ot ri$id and Fe;i0le endoscopes can 0e %sed to e;amine t e respirator. s.stem' &escriptions o< e4%ipment availa0le <or %se in veterinar. trac eo0ronc oscop. ave 0een disc%ssed else8 3*? w ere' "rieF.* t e %se o< ri$id scopes is more limited 0%t allows e;amination o< t e lar.n;* trac ea* and carina' A Fe;i0le endo8 scope is re4%ired <or e;amination o< t e se$mental 0ronc i' T e 0ronc oscope s o%ld contain an instr%ment c annel (<or 0iops. and 0r%s <orceps and to o0tain "A# samples)* s%ction* and a li$ t so%rce and ave t e a0ilit. to per<orm 0ilateral tip deFection to direct t e scope into appropriate airwa.s' Anest esia Ieneral anest esia is re4%ired to per<orm 0ronc oscop.' All patients s o%ld 0e preo;.$enated <or at least 6810 min%tes 0e<ore

narrow 0and o< tiss%e' ,t s o%ld 0e ti$ tl. ad ered to t e dorsal trac eal wall and

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(i$' 1' "ronc oscopic anatom. o< t e do$' ((rom Amis TC* Mc-iernan "C' 1.stematic identi9cation o< endo0ronc ial anatom. d%rin$ 0ronc oscop. in t e do$' Am M +et Res 1985N?7(12)/2566N wit permission')

s o%ld not droop or occl%de t e l%men in an. wa.' T e carina s o%ld 0e a s arpl. demarcated division into ri$ t and le<t mainstem 0ronc i' 7dema and inFammation can ca%se widenin$ o< t e carina and narrowin$ or irre$%larit. o< t e airwa. l%men' "ronc i s o%ld alwa.s 0e ro%nd* patent d%rin$ all p ases o< respiration and well de9ned' "ronc omalacia* wea)ness o< t e 0ronc i t at res%lts in collapse o< t e airwa. d%rin$ respiration* is o<ten seen in conC%nction wit trac eal collapse11*12 ((i$ 6)' "ronc iectasis* a0normal dilation o< t e 0ronc i* ma. 0e seen secondar. to c ronic inFammator. disorders s%c as c ronic 0ronc itis or eosinop ilic pne%monopat . and can also 0e secon8 13 dar. to con$enital anatomic de<ects ((i$ 5)' @%lmonar. s%0m%8 cosal vessels are easil. vis%ali=ed and s o%ld not 0e enlar$ed* distended* or tort%o%s'3*7*1? Trac eal <orei$n 0odies and t%mors ma. also 0e vis%ali=ed ((i$s 7 and 8)' ! en a0normalities are noted* record t eir location* severit.* and description' Ta)e di$ital p oto$rap s o< an. area o< interest'

&i$ital video$rap . can 0e %sed to doc%ment d.namic lesions s%c as trac eal or 0ronc ial collapse' 2nce t e vis%al e;amination is complete* samplin$ o< t e airwa.s via "A# can 0e per<ormed'

"A# "A# s o%ld alwa.s 0e per<ormed a<ter a t oro%$ and s.stem8 atic e;amination o< t e airwa.s' A<ter 0ronc oscopic e;amination o< t e l%n$ lo0es* t e endoscope s o%ld 0e removed <rom t e airwa.s and t e 0iops. c annel F%s ed wit sterile saline' T e scope can also 0e wiped down wit sterile saline at t is time' To $et a representative sample* an ade4%ate vol%me o< F%id m%st 0e in<%sed' T e proper amo%nt o< saline to 0e in<%sed is controversial wit man. di<<erent p%0lis ed recommendations' "ot wei$ t8 adC%sted and 9;ed amo%nts o< "A# vol%mes ave 0een s%$$ested'

(i$' 2' Lormal canine carina' (i$' 3' T ic) $reenis e;%date in a canine patient wit c ronic 0ronc opne%monia' Lotice t e irre$%lar proli<eration o< t e 0ronc ial wall'

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