Tuberculosis - I.T. Pyatnochka 2005

Methods of examination of tuberculosis patients
Instrumental methods of research and treatment

For the Diagnosis and Cytology/practical/136.html">Differential diagnosis OF tuberculosis, specialists employ laryngoscopy, mediastinoscopy, thoracoscopy, laparoscopy, puncture biopsy of peripheral Lymph Nodes, Pleura, and Lungs, and above all, bronchoscopy, which is performed for both diagnostic and therapeutic purposes. In certain cases, thoracotomy serves as The final stage of the diagnostic process.

Within the general diagnostic and differential diagnostic framework for pulmonary diseases, tracheobronchoscopy holds a prominent position. It allows for a direct visual examination of various segments of the Trachea and Bronchi, as well as the execution of necessary diagnostic studies and therapeutic Procedures.

Naturally, bronchological examination cannot and should not replace or rule out other standard diagnostic Methods. Modern diagnosis of pulmonary conditions relies on three core modalities—clinical, radiological, and endoscopic—which are complemented by bacteriological, myological, cytological, and histological analyses of biological material obtained from the bronchi via biopsy (Fig. 11). This comprehensive approach ensures the most accurate diagnosis of pulmonary pathology and the Selection of optimal Treatment.

Indications for bronchoscopy include pulmonary and respiratory tract diseases or unexplained pathological findings detected on radiographs. Fiberoptic bronchoscopy under local anesthesia is commonly utilized (Fig. 12). Rigid bronchoscopy under general anesthesia is indicated in pediatric practice, in cases of massive or imminent Pulmonary Hemorrhage, for bougienage in stenoses, laser recanalization, and the extraction of large, hard foreign bodies. Rigid bronchoscopy under local anesthesia has not entirely lost its clinical value today; it remains advisable for patients with a depressed cough reflex, the removal of foreign bodies from the tracheobronchial tree, the tamponade of specific bronchi during pulmonary hemorrhage or Spontaneous pneumothorax, and occasionally for the selective placement of a catheter for bronchography and other procedures.

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Fig. 11. Types of biopsies

Contraindications to bronchoscopy using rigid (metal) bronchoscopes:

1. severe cardiovascular diseases (aortic aneurysm, decompensated Heart disease, recent myocardial infarction within the past 6 months, stage III Hypertension);

2. injuries and ankylosis of the Mandible, Skull, and cervical vertebrae, Oral Cavity diseases, tracheal deviation with marked mediastinal displacement in kyphoscoliosis or mediastinal disorders;

3. active laryngeal tuberculosis;

4. acute and subacute intercurrent diseases;

5. menstruation and the second half of Pregnancy;

6. thromboembolic disease.

Contraindications to fiberoptic bronchoscopy under local anesthesia:

massive pulmonary hemorrhage, Epilepsy, severe status asthmaticus, a large foreign body that is ballotable or fixed in the trachea, passive aspiration of gastric contents containing food particles, respiratory failure accompanied by hypercapnia exceeding 50 mm Hg and refractory hypoxemia (below 70 mm Hg), pronounced laryngeal and tracheal stenoses, inability to communicate with the patient, hypersensitivity to local anesthetics, and severe General condition of the patient.

Thoracoscopy (pleuroscopy) is the examination of the pleural cavity using a thoracoscope or, less commonly, a bronchofiberscope. Diagnostic thoracoscopy is indicated for Pleurisy and other pleural diseases, spontaneous pneumothorax, and diffuse lung diseases. Prior to thoracoscopy, artificial pneumothorax is induced, collapsing the lung to 1/2–1/3 of its volume. In tuberculous lesions, the pleura appears hyperemic with pronounced edema and multiple miliary eruptions. In some cases, tubercles reach 2–3 mm in size and are distributed along the intercostal spaces resembling sago grains. After inspecting the pleural membranes and the lung, a forceps or needle biopsy is performed as indicated. Technical complications of thoracoscopy may include hemorrhage and subcutaneous emphysema.

Mediastinoscopy is performed for the differential diagnosis of intrathoracic lymph node tuberculosis versus sarcoidosis, lymphogranulomatosis, and primary or metastatic mediastinal tumors. Mediastinoscopy is carried out under general anesthesia through a small incision made above the suprasternal notch, with tissue dissection along the trachea down to the tracheal bifurcation. Subsequently, a mediastinoscope is used to perform a puncture or biopsy of affected lymph nodes for subsequent histological examination. Potential complications of mediastinoscopy include hemorrhage, pneumothorax, and injury to the recurrent laryngeal nerve.

Fig. 12. Fiberoptic bronchoscope

Prescalene (transcervical) biopsy involves the surgical excision of subcutaneous adipose tissue and lymph nodes located on the anterior surface of the anterior scalene Muscle. It is performed under local anesthesia through an incision 4–6 cm long situated above or parallel to the clavicle.

Transthoracic needle biopsy is used to obtain tissue samples from the pleura and lungs for histological and Cytological examination using a needle-syringe apparatus along with various technical modifications. Fine needles are used for aspiration biopsy, whereas thick or specialized needles are employed for core (trephine) biopsy. These biopsy methods are indicated for lesions located in the peripheral (subcortical) Regions of the lung. The puncture site on the chest wall is selected to ensure the shortest distance to the target lesion. Diagnostic verification via transthoracic needle biopsy is achieved in 80–90 % of cases.

Open biopsy involves obtaining tissue samples from the lung, pleura, or lymph nodes via conventional surgery under direct visual control. It is indicated for diffuse and disseminated pulmonary diseases, as well as when other biopsy methods have yielded inconclusive results. Thoracotomy is performed under general anesthesia, followed by the open biopsy Procedure. The primary advantage of this approach is The ability to obtain large tissue samples from one or multiple sites.

Puncture biopsy of peripheral lymph nodes can be performed as an aspiration or core biopsy. To aspirate lymph node tissue, a standard syringe with a needle is used. After puncturing the lymph node, 2–3 aspiration strokes are performed, disconnecting the syringe from the needle after each aspiration. Before withdrawing the needle from the node, the syringe must be detached to prevent aspiration of the material back into the syringe barrel. Afterward, the collected material is expelled from the needle onto a Microscope Glass slide using the syringe, processed, and sent for cytological evaluation. Core biopsy is performed using a specialized needle that yields a tissue core suitable for histological examination.