Pulmonary Medicine

Interventional Bronchoscopy: Electrocautery

General description of procedure, equipment, technique

Electrosurgery (Electrocautery)

Initially defined in 1995 and subsequently described in European Respiratory Society (ERS) and American Thoracic Society (ATS) guidelines, interventional pulmonology is "the art and science of medicine as related to the performance of diagnostic and invasive therapeutic procedures that require additional training and expertise beyond that required in a standard pulmonary medicine training program. Clinical entities encompassed within the discipline include complex airway management, benign and malignant central airway obstruction, pleural diseases, and pulmonary vascular procedures.

Diagnostic and therapeutic procedures pertaining to these areas include rigid bronchoscopy, transbronchial needle aspiration, autofluorescence bronchoscopy, endobronchial ultrasound, transthoracic needle aspiration and biopsy, laser bronchoscopy, endobronchial electrosurgery, argon-plasma coagulation, cryotherapy, airway stent insertion, balloon bronchoplasty and dilatation techniques, endobronchial radiation (brachytherapy), photodynamic therapy, percutaneous dilatational tracheotomy, transtracheal oxygen catheter insertion, medical thoracoscopy, and image-guided thoracic interventions. This presentation focuses on electrosurgery (electrocautery).

Electrocautery uses alternating current at a high frequency (105 to 107 Hz) to generate heat that coagulates, vaporizes, or cuts tissue, depending on the power setting. The power applied to the electrocautery device (measured in watts) corresponds to the heat generated in the tissue [as related in the equation, Power = (Current)2 X Resistance]. Coagulation involves high amperage and low voltage, whereas vaporization uses high voltage and low amperage. Cutting tissue with the ability to coagulate blends these two settings. At a temperature of approximately 70°C, tissue coagulates; over 200°C, tissue carbonizes. The degree of destruction depends on the applied power, electrical properties of the tissue, device-tissue contact time, and the contact surface area.

When a tissue is heated sufficiently, cellular water evaporates, destroying cells. Heating to higher temperatures leads to chemical breakdown of the cell constituents and eventual vaporization or carbonization. Electrocautery devices are monopolar; that is, they require the bronchoscope, the generator, and the patient to be grounded to complete the circuit; otherwise, shocks or burns may occur.

Indications and patient selection

Indications for electrocautery are similar to those for use of the Nd: YAG laser. Similar to laser therapy, electrocautery produces rapid debulking of tumor, but at a lower procedure cost. Electrocautery is an effective method for palliation and is a less expensive alternative than laser therapy.

Contraindications

Contraindications to electrocautery are similar to those for Nd: YAG laser therapy.

Details of how the procedure is performed

Insulated flexible bronchoscopes with working channels of 2.0 or 2.6 mm are used. Electrocautery blunt-tip probes are compatible with the flexible bronchoscopes that are usually used. The power generator regulates the high-frequency current, and the operator adjusts the settings based on the target tissue and the intention to cut, cut and coagulate, or vaporize.

The operator may use either a closed forceps or the blunt electrocautery probe to manipulate the lesion, assess its size, mobility, friability, and bleeding potential, and locate any attachments to the airway. Polypoid lesions may be amenable to use of the snare, which is used to cut and remove tissue. A "blended" current is used to cut and coagulate, but not vaporize, tissue.

Interpretation of results

Not applicable.

Performance characteristics of the procedure (applies only to diagnostic procedures)

Not applicable.

Outcomes (applies only to therapeutic procedures)

In one reported series, hemoptysis was controlled in 75 percent of cases and dyspnea alleviated in 67 percent; cough or stridor was relieved in 55 percent. In another series, twenty-eight of twenty-nine patients treated had symptomatic improvement following removal of a lesion using a snare. Finally, in one series of seventeen patients, fifteen had immediate restoration of a patent airway, eight had relief of dyspnea, and four had control of hemoptysis.

Alternative and/or additional procedures to consider

Other procedures to consider include Nd:yag laser, argon plasma coagualtion, and cryotherapy.

Complications and their management

Endobronchial fires have been reported during the electrocautery procedure. In the two cases, a high concentration of inspired oxygen was used; in one case, a silicon stent ignited. Several investigators have reported hemorrhage, usually minor. One death secondary to hemorrhage has been reported. Operator and patient burns and electrical shocks are noted in the literature as possible complications; however, published data are scant. Use of electrocautery in patients with pacemakers or automatic implantable defibrillators (AICDs) should be avoided because the devices may malfunction.

What’s the evidence?

Homasson, JP. "Endobronchial electrocautery". Semin Respir Crit Care Med. vol. 8. 1997. pp. 535-543.

An early report and large review of the use of endobronchial electrocautery.

Hooper, RG, Jackson, FN. "Endobronchial electrocautery". Chest. vol. 87. 1995. pp. 712-714.

An early report on the use of electrocautery in the lung for palliation.

Lavandier, M, Carre, T, Rivoire, B. "High frequency electrocautery in the management of tracheobronchial disorders". Respir Crit Care Med. vol. 75. 1996. pp. A477.

Report describing the role of palliative endobronchial electrocautery.

Petrou, M, Kaptan, D, Goldstraw, P. "Bronchoscopic diathermy resection and stent insertion: A cost effective treatment for tracheobronchial obstruction". Thorax. vol. 48. 1993. pp. 1156-59.

A study that confirms the cost effectiveness of electrocautery and airway stent placement.

Sutedja, C, Schramel, PMNH, Smit, HJF. "Bronchoscopic electrocautery as an alternative for Nd: YAG laser in patients with intraluminal tumor". Eur Resp. vol. 9. 1996. pp. 258-259s.

An analysis that confirms the low cost of electrocautery.

Sutedja, C, Van Kralingen, K, Schramet, FMNH. "Fiberoptic bronchoscopic electrosurgery under local anesthesia for rapid palliation in patients with central airway malignancies: A preliminary report". Thorax. vol. 9. 41994. pp. 1243-1246.

Report addressing the feasibility of electrocautery as an outpatient procedure.
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