Other forms of treatment
Therapeutic bronchoscopy via a rigid bronchoscope has several indications. It is used for control of bronchial haemorrhage (usually from a tumour), for removal of large mucous plugs or foreign bodies from the airway, and for palliative local tumour resection, dilatation of central airway narrowing and the insertion of stents to maintain patency in patients with obstruction of a central airway (due to malignant or nonmalignant conditions). Localised radiotherapy can be administered bronchoscopically where appropriate (brachytherapy). More experimental bronchoscopic techniques include photodynamic therapy (in which laser treatment is applied bronchoscopically after intravenous administration of a photosensitising agent), gene therapy (e.g. for CF) and the insertion of one-way valves in lobar and segmental airways, with the aim of deflating emphysematous lobes or lung segments.
Pleural aspiration or intubation is a standard treatment for symptomatic pneumothorax, but in many cases of spontaneous pneumothorax, especially in young, otherwise fit individuals, no treatment is needed as the pneumothorax will resolve spontaneously over a few days. Aspiration, or intubation with underwater drainage, may be required for spontaneous or iatrogenic pneumothorax if this is very large (particularly if under tension) or if respiratory function is so poor that even a small collection of air in the pleural space increases breathlessness.
With a pleural effusion, drainage of fluid may be both diagnostic (see chapter 27) and therapeutic; simple needle aspiration may improve breathlessness but with a large volume of fluid, drainage may necessitate intercostal intubation for a few days. Introduction of a sclerosing agent prior to removing the intercostal drain can help to control accumulation of pleural fluid in patients with recurrent effusions. For long-term management of persistent pleural air, fluid or infected material, a semipermanent one-way valve may be used, attached, if necessary, to a drainage bag.
Bronchial artery embolisation is increasingly used to control severe or recurrent haemoptysis, due, for example, to lung cancer or bronchiectasis. Under radiological guidance, a catheter is introduced from the aorta into the relevant bronchial artery (or arteries) and an occluding device (gel foam or small metal coil) is injected. Less commonly, embolisation of the blood vessel supplying a pulmonary arteriovenous malformation may be treated similarly. In patients with recurrent haemoptysis due to widespread bronchiectasis or multiple arteriovenous malformations, the procedure may need to be repeated several times.