Flexible Bronchoscopy

What is Flexible Bronchoscopy?

Bronchoscopy is an investigative procedure used to diagnose lung conditions.
This involves a small, flexible camera being inserted through your nose or mouth into your windpipes to have a look and visualise internal abnormalities.

What conditions is Flexible Bronchoscopy used for?

•  Common symptoms and conditions that require a flexible bronchoscopy include persistent coughing, shortness of breath, pneumonia, fungal or parasitic lung infections, lung cancer, COPD, or lung inflammation caused by tuberculosis or sarcoidosis.
• It may also be used if X-rays or other tests show something unusual.
• A Flexible Bronchoscopy can detect infection, lung blockages, tumours, excess mucus and bleeding.
• Samples can also be taken during the procedure.
• Samples include brushing of airway walls, biopsy of abnormal areas and washout of the lungs using sterile saline to detect abnormal cells.
• Difficult to diagnosed lung conditions like atypical infections and fungal infections can be diagnosed using flexible bronchoscopy.

Am I asleep for the procedure? Where can I have it done?

• This depends on whether you are privately insured or not.
• For privately insured patients this procedure is performed under general anaesthetic; therefore, you will not be aware of the procedure.
• The procedure can be booked at Macquarie University Hospital or Northern Beaches Hospital as per your preference. Urgent procedures can be booked at short notice.
• If you do not have private health insurance the procedure will be booked at Northern Beaches Hospital and the procedure will be done under conscious sedation.
• The procedure under sedation is not painful but of course not as comfortable as having it under anaesthesia.

What is the wait period to get a flexible bronchoscopy?

• There is no wait period for bronchoscopy with Dr Herath.
• Dr Herath is a an advanced bronchoscopist and thereby has her own lists in both public and private sector
• The procedure will be done as urgently as possible as per the medical condition of the patient.
• You do not need to be referred to another doctor to do your procedure which reduces the wait times and cost to you as the patient markedly.

How long does it take? How long will I stay in Hospital?

• A Flexible Bronchoscopy with a lavage generally only takes 8-10 minutes for the procedure.
• This is a day procedure and you can go home 1-2 hours after the procedure.
• You will be monitored for two hours after your procedure.
• You will be given a sip of water in 1 hour after the procedure, called a “sip test”.
• This is to check that the local anaesthetic effect on your mouth has worn off and you can swallow without a risk of aspiration.
• If you pass the test you will be given a light snack and discharged home.

What is the item number for this procedure?

• The MBS item number for your health fund for this procedure is 38420.

What should I do in preparation for bronchoscopy?

• Fast for 6 hours prior to the procedure for both food and fluid
• If you are undergoing a biopsy stop blood-thinning tablet agents for 5 days pre procedure. Dr Herath will discuss this with you. (These include but not limited to Xeralto, Eliquis, Warfarin, Clopidogrel, Ticaglore)
• You may continue aspirin even if you have a biopsy.
• Dr Herath will contact your cardiologist or your referring respiratory physician to discuss if it is OK for you to stop blood thinners or if you require a “bridging agent” called Clexane or Heparin leading up to the procedure.
• You should not take diabetic medication the morning of the procedure
• You should take all other medications with a sip of clear water.
• You need someone to drive you home and stay with you for one night. If this is not possible, we can organise for you to stay overnight in the hospital.
• If you are a current smoker, stopping smoking for a period will immensely help in reducing airway discomfort and irritation. This will make the cough much better post procedure

What are the side effects of a flexible Bronchoscopy and lavage?

Flexible Bronchoscopy is a non-complicated safe procedure.
We do these procedures on daily basis and are prepared for types of adverse events during procedure and equipped to handle emergencies. Most side effects occur whilst you are in hospital and will be attended to with monitoring.
The rare side effects that may occur after discharge are listed so that you can watch out for them and act immediately.

• Although not mentioned above in the chart due to extreme rarity, adverse events due to anaesthesia, drug allergies, heart attacks, asthma exacerbations and even death can occur post procedures.
• The more medical issues you have the higher the chance of an adverse events the above chart is a general guide only.
• If you have multiple medical issues Dr Herath will discuss your individual risk and you will be referred to the pre-admission clinic for an anaesthetist to view your medical history and decide on the best level of anaesthesia for you.
• We will take extra precautions like booking an Intensive Care bed post procedure if you have underlying medical issues.

When can you return to work?

You can return to work and start all your normal medications including blood thinners the next day.

When will the results be available?

Results will be available within one week.
Please book an appointment with Dr Herath one week after your procedure to discuss results and start treatment.
If you were referred to Dr Herath by your Respiratory Physician or other specialist, please make an appointment with your specialist only.
The results will be copied to the referring specialist.

EBUS

What is EBUS? (Endobronchial Ultrasound Guided Biopsy)

• EBUS is a minimally invasive advanced bronchoscopy procedure and the success of this procedure heavily relies on the training and expertise of the proceduralist.
• Dr Herath has completed an international fellowship in interventional bronchoscopy and EBUS in McGill University in Canada in 2013 and has completed over a 1000 EBUS procedures with excellent success rates.
• The procedure involves a small flexible camera that also has an USS (ultrasound scan) at the end of the bronchoscope.
• Therefore, EBUS is an internal scan of your windpipes and identifies abnormal masses and glands around your windpipes. These glands are situated near large blood vessels in the chest.
• Once an abnormal area is identified a needle is inserted under direct vision to the abnormal area to take a sample.
• There are two types of EBUS – Linear EBUS and Radial EBUS
• Linear EBUS is used to diagnose glands and abnormal masses around large windpipes and Radial EBUS is used to diagnose lung nodules around the smaller windpipes which are usually more peripherally located.

What conditions is Linear EBUS used for?

• This procedure is used mainly to diagnose and decide the spread of lung cancer.
• It can also be used to diagnose infections and other diseases causing enlarged chest lymph nodes like sarcoidosis and tuberculosis.
• EBUS is less invasive than the conventional surgical treatment to remove lymph node samples (mediastinoscopy) and is most often used to biopsy lymph nodes in patients with lung cancer.
• EBUS can also be used to assist in staging a range of other conditions from sarcoidosis and blood disorders like lymphomas that start in the lymphatic system.
• Linear EBUS using a “core biopsy” or larger biopsy needle is sometimes required to obtain repeat samples of tumours during treatment to test for various immunomarkers.

Am I asleep for the procedure? Where can I have it done?

• This depends on whether you are privately insured or not.
• For privately insured patients this procedure is performed under general anaesthetic; therefore, you will not be aware of the procedure.
• The procedure can be booked at Macquarie University Hospital and Northern Beaches Hospital as per your preference.
• Urgent procedures can be booked at very short notice.
• If you do not have private health insurance the procedure will be booked at Northern Beaches Hospital and the procedure will be done under conscious sedation.
• The procedure performed under sedation is not painful but of course not as comfortable as having it under anaesthesia.

What is the wait period to get a Linear EBUS?

• Dr Herath is a an advanced bronchoscopist and thereby has her own lists in both public and private sector
• The procedure will be done as urgently as possible as per the medical condition of the patient.
• You do not need to be referred to another doctor to do your procedure which reduced the wait times and cost to you as the patient markedly.
• If you were referred by another Respiratory Physician for Linear EBUS and your Respiratory physician has already discussed the procedure with you and had taken your consent, you will be given a booking immediately.
• Dr Herath will discuss this procedure with you on the day of the procedure.
• However, if you are anxious about the procedure, we will organise a clinic appointment with Dr Herath to discuss your concerns and meet Dr Herath beforehand.

How long does it take? How long will I stay in Hospital?

• A Linear EBUS takes 30-45 minutes for the procedure.
• This is a day procedure and you can go home 1-2 hours after the procedure.
• You will be monitored for two hours after your procedure.
• You will be given a sip of water in 1 hour after the procedure called a “sip test”.
• This is to check that the local anaesthetic effect on your mouth has worn off and you can swallow without a risk of aspiration. If you pass the test you will be given a light snack and discharged home.

What is the item number for this procedure?

• The MBS item number for your health fund for this procedure is 38417.

What should I do in preparation for Linear EBUS?

• Fasting for 6 hours prior to the procedure for both food and fluid
• If you are undergoing a biopsy stop blood-thinning tablet agents for 5 days pre procedure.
• Dr Herath will discuss this with you. These include but not limited to Xeralto, Eliquis, Warfarin, Clopidogrel, Ticaglore
• You may continue aspirin even if you have a biopsy.
• Dr Herath will contact your cardiologist or your referring respiratory physician to discuss if it is OK for you to stop blood thinners or if you require a “bridging agent” called Clexane or Heparin leading up to the procedure.
• You should not take diabetic medication the morning of the procedure.
• You should take all other medications with a sip of clear water.
• You need someone to drive you home and stay with you for one night.
• If this is not possible, we can organise for you to stay overnight in the hospital.
• If you are a current smoker, stopping smoking for a period will help immensely in reducing airway discomfort and irritation. This will make the cough much better post procedure

What are the side effects of a Linear EBUS?

• Linear EBUS is a non-complicated, advanced but safe procedure.
• We do these procedures on daily basis and are prepared for types of adverse events during procedure and equipped to handle emergencies. Most side effects occur whilst you are in hospital and will be attended to with monitoring.
• The rare side effects that may occur after discharge are listed so that you can watch out for them and take immediate action.
• The success of the procedure relies heavily on the training and expertise of the proceduralist.

• Although not mentioned above in the chart due to extreme rarity, adverse events due to anaesthesia, drug allergies, heart attacks, asthma exacerbations and even death can occur post procedures.
• The more medical issues you have the higher the chance of an adverse events the above chart is a general guide only.
• If you have multiple medical issues Dr Herath will discuss your individual risk and you will be referred to the pre-admission clinic for an anaesthetist to view your medical history and decide on the best level of anaesthesia for you.
• We will take extra precautions like booking an Intensive Care bed post procedure if you have underlying medical issues.

When can you return to work?

You can return to work and start all your normal medications including blood thinners the next day.

When will the results be available?

• Preliminary results will be available as soon as the procedure is completed on the same day.
• There is a cytologist working with Dr Herath during the procedure who will look at the samples as they are being taken to give a diagnosis and feedback to see if more tissue is required. You will have a preliminary result at the end of the procedure.
• Please book an appointment with Dr Herath one week after your procedure to discuss management and obtain referrals.
• On some occasions when the diagnosis is an aggressive tumour you may be sent to the oncologist on the same day.
• If you were referred to Dr Herath by your respiratory physician or other specialist, please make an appointment with your specialist only. The results will be copied to the referring specialist.

Combined Linear and Radial EBUS

What is a combined linear Radial EBUS?

• This is carrying out both radial EBUS and linear EBUS procedures in the same patient at the same time.
• This saves time and fast tracks treatment and the patient undergoes only a single procedure.

Why do I need a combined procedure?

• A combined procedure is needed for patients who have suspected lung cancer or a lung nodule.
• 75% of lung cancer at presentation has already spread to the lymph nodes in the middle of the chest.
• It is extremely important to diagnose this spread as patients who have this spread cannot undergo surgery.
• This also means they have lesser chance of survival.
• Therefore, if you have an abnormal area in your lung suspected of lung cancer, just a biopsy of that lung lesion via Radial EBUS (or CT guided biopsy) is not adequate. Before you start treatment, you will need a linear EBUS as well.
• Therefore instead of going for two separate procedures performing both procedures at the same time improves the time, financial involvement, patient safety and side effects markedly.

Cryobiopsy

What is Cryobiopsy or “cold biopsy” for lung cancer and lung nodules?

• Cryobiopsy is a game-changing, minimally invasive procedure used during a lung biopsy for suspected lung cancer.
• This is used in combination with Radial EBUS bronchoscopy (see above)
• Instead of traditional biopsy, a cold biopsy probe is deployed through the bronchoscope and placed exactly in the lesion.
• The probe is cooled for 4 seconds, freezing and causing the lung tissue around it to stick to the probe and pulled back.
• This procedure requires advanced skills in both Radial EBUS biopsy as well as using Cryobiopsy probes.
• Therefore, experience and skill level are required to identify suitable patients, perform the procedure safely and obtain a suitable biopsy as well.
• Once you are asleep you will need an endotracheal tube or a rigid type of bronchoscopy to keep your airway safe.

What conditions is Cryobiopsy used for?

• Cryobiopsy is the preferred method for lung cancer diagnosis and treatment by Dr Herath.
• This enables a larger biopsy sample which can be used for multitude of immunological testing and preservation for future testing.
• If a large airway is blocked, Cryobiopsy can be used to unblock this.
• Dr Herath will carefully assess your medical condition and perform navigation mapping using the GPS software system and inform you of this procedure only if you are suitable for the procedure and Dr Herath is sure that she can get a sample with minimal side effects for you.

Am I asleep for the procedure? Where can I have it done?

• This procedure is only performed by me at Macquarie University Hospital.
• This procedure requires specially trained staff and equipment that is specially set up at Macquarie University Hospital.
• This procedure is performed under general anaesthetic; therefore, you will not be aware of the procedure.

What is the wait period to get a Cryobiopsy?

• Dr Herath is a an advanced bronchoscopist and thereby has her own lists in both public and private sector
• The procedure will be done as urgently as possible as per the medical condition of the patient.
• You do not need to be referred to another doctor to do your procedure which reduces the wait times and cost to you as the patient markedly.
• If you were referred by another respiratory physician and your respiratory physician has already discussed the procedure with you and has taken your consent, you will be given a booking immediately and Dr Herath will discuss this procedure with you on the day of the procedure. However, if you are anxious about the procedure, we will organise a clinic appointment with Dr Herath to discuss your concerns and meet Dr Herath beforehand.

How long does it take? How long will I stay in Hospital?

• It takes 30-45 minutes for the procedure.
• This is a day procedure and you can go home 1-2 hours after the procedure.
• You will be monitored for two hours after your procedure.
• You will be given a sip of water in 1 hour after the procedure called a “sip test”.
• This is to check that the local anaesthetic effect on your mouth has worn off and you can swallow without a risk of aspiration.
• If you pass the test you will be given a light snack and discharged home.

What is the item number for this procedure?

• The MBS item number for your health fund for this procedure is 30710

What should I do in preparation for Cryobiopsy/Radial EBUS bronchoscopy?

• Fasting for 6 hours prior to the procedure for both food and fluid
• If you are undergoing a biopsy stop blood-thinning tablet agents for 5 days pre procedure.
• Dr Herath will discuss this with you. These include but not limited to Xeralto, Eliquis, Warfarin, Clopidogrel, Ticaglore
• You may continue aspirin even if you have a biopsy.
• Dr Herath will contact your cardiologist or your referring respiratory physician to discuss if it is OK for you to stop blood thinners or if you require a “bridging agent” called Clexane or Heparin leading up to the procedure.
• You should not take diabetic medication the morning of the procedure.
• You should take all other medications with a sip of clear water.
• You need someone to drive you home and stay with you for one night.

What are the side effects of a CryoBiopsy-radial EBUS bronchsocpy?

• Radial EBUS is a non-complicated advanced but safe procedure. Cryobiopsy is a biopsy technique used via the hollow radial EBUS GS.
• We do these procedures on weekly basis and are prepared for types of adverse events during procedure and equipped to handle emergencies. Most side effects occur whilst you are in hospital and will be attended to with monitoring.
• The rare side effects that may occur after discharge are listed so that you can watch out for them and take immediate action.
• The success of the procedure relies excessively on the training of the proceduralist.

• Although not mentioned above in the chart due to extreme rarity, adverse events due to anaesthesia, drug allergies, heart attacks, asthma exacerbations and even death can occur post procedures.
• The more medical issues you have the higher the chance of an adverse events the above chart is a general guide only.
• If you have multiple medical issues Dr Herath will discuss your individual risk and you will be referred to the pre-admission clinic for an anaesthetist to view your medical history and decide on the best level of anaesthesia for you.
• We will take extra precautions like booking an Intensive Care bed post procedure if you have underlying medical issues.

When can you return to work?

You can return to work and start all your normal medications including blood thinners the next day.

When will the results be available?

• Preliminary results will be available as soon as the procedure is completed on the same day.
• There is a cytologist working with Dr Herath during the procedure who will look at the samples as they are being taken to give a diagnosis and feedback to see if more tissue is required. You will have a preliminary result at the end of the procedure.
• Please book an appointment with Dr Herath one week after your procedure to discuss management and obtain referrals.
• On some occasions when the diagnosis is an aggressive tumour you may be sent to the oncologist on the same day.
• If you were referred to Dr Herath by your respiratory physician or other specialist, please make an appointment with your specialist only. The results will be copied to the referring specialist.