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bronchoscopic management


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3 Definition Classification Vascular origin Etiology An approach to a case of hemoptysis Bronchoscopic and airway Management Bronchial Artery Embolization

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4 Definition Classification Vascular origin Etiology An approach to a case of hemoptysis Bronchoscopic and airway Management Bronchial Artery Embolization

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5 Hemoptysis (Gr. haima =blood; ptysis =spitting ) The spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage . (Stedman TL. Stedman’s Medical dictionary. 27th ed. Philidelphia : Lipincott Williams & Wilkins, 2000.)

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Definition Classification Vascular origin Etiology An approach to a case of hemoptysis Bronchoscopic and airway Management Bronchial Artery Embolization 6

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7 GRADE AMOUNT /24 HRS Mild < 50 ml Moderate 50 - 200 ml Severe ** /Major * > 200 ml * 150 ml per 12 hrs or ** >400 ml per 24 hrs Massive > 600 ml Exsanguinating # #1,000 ml total or 150 ml/h Life-threatening 200 ml/h or 50 ml/h in a patient with chronic respiratory failure. * Corey R, Hla KM. Am J Med Sci 1987; 294:301–309 . ** de Gracia J, de la Rosa D, Catal!an E, Alvarez A, Bravo C, Morell F. Respir Med 2003; 97: 790–795 # Garzon AA, Cerruti MM, Golding ME: Exsanguinating hemoptysis . J Thorac Cardiovasc Surg 1982; 84: 829–833 .

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8 Definition Classification Vascular origin Etiology An approach to a case of hemoptysis Bronchoscopic and airway Management Bronchial Artery Embolization

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Bronchial arteries (90%) Pulmonary arteries 9 Source of bleed: * Remy J, Remy-Jardin M, Voisin C: Endovascular management of bronchial bleeding; in Butler J ( ed ): The Bronchial Circulation. New York, Dekker, 1992, pp 667–723.

Bronchial arteries: :

Bronchial arteries : Origin : Thoracic aorta ( T3 to T8 levels ) 80% arise from T5 to T6 level Pressure : Systemic pressure Supply: Bronchi, vagus nerve, posterior mediastinum , and esophagus. Source : ~ 90%* cases 10 2 Left bron.art 1 Rt.bron.art T5 -T6

Bronchial artery branching pattern:

Bronchial artery branching pattern Cauldwell et al - four patterns: 11 Type I Type II Type III Type IV Cauldwell EW, Siekert RG, Lininger RE, Anson BJ.The bronchial arteries: an anatomic study of 105 human cadavers. Surg Gynecol Obstet 1948; 86:395– 412.

Type I:

Type I Incidence: 40.6% Left: 2 Right: 1 { intercostobronchial trunk (ICBT)} 12 Single rt.branch Lt. 2 br.arties Sup.lft.bron.art Inf.Lf . bron.art . Rt.bron.art .

Type II :

Type II Incidence: 21.3% Left: 1 Bron A. Right: 1 ICBT 13 Single Lft.bron.art Single.Rt.ICBT

Type III :

Type III Incidence: 20.6% Left: 2 Right : 2(1 ICBT & 1 bronchial artery) 14 Left sup.& Lft.Inf . bron.art . Rt.ICBT Rt.Bron.art .

Type IV:

Type IV Incidence: 9.7% Left: 1 Right: 2 (one ICBT and one bronchial artery) 15 Single Lft.art . Rt.ICBT Rt.Bron.art .

Pulmonary arterial system::

Pulmonary arterial system: Origin : Base of rt.ventricle Pressure : Low pressure system -25mmHg syst. -8mmHg diast . -15mmHg mean . Source :< 10% of cases. 16

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17 Definition Classification Vascular origin Etiology An approach to a case of hemoptysis Bronchoscopic and airway Management Bronchial Artery Embolization


Infectious Tuberculosis Fungal infections ( including mycetoma ) Necrotizing pneumonia and lung abscess ( Klebsiella pneumoniae , Pseudomonas aeruginosa,Staphylococcus aureus , Streptococcus pneumoniae, other Streptococcus spp. and Actinomyces spp.) Bacterial endocarditis with septic emboli Parasitic ( paragonimiasis , hydatid cyst ) 18 It is the most common cause of hemoptysis worldwide with 2 billion people infected worldwide with 5-10% developing disease ( Public Health Reports. Vol. 3. New York: World Health Organization; 1996: p. 8–9.)


Neoplastic Bronchogenic carcinoma Endobronchial tumors ( carcinoid , adenoid cystic carcinoma) Pulmonary mets . 19 Bronchiectasis (including cystic fibrosis) Chronic bronchitis Alveolar hemorrhage and underlying causes Pulmonary


Vascular Pulmonary artery aneurysm (Rasmussen aneurysm, mycotic , arteritis ) Bronchial artery aneurysm Pulmonary infarct (embolism) Pulmonary hypertension 20 Congenital cardiac or pul . vascular malformations Airway-vascular fistula AV Malformations Mitral stenosis LVF


Vasculitis Wegener’s granulomatosis Goodpasture’s syndrome Behçet’s disease Systemic lupus erythematosus 21 Coagulopathy : Von WilleBrands disease, Hemophilia, Thrombocytopenia Platelet disorders Uremia Platelet dysfunction Anticoagulant therapy Hematological

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22 Definition Classification Vascular origin Etiology An approach to a case of hemoptysis Bronchoscopic and airway Management Bronchial Artery Embolization

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23 Predictors of Mortality 71% in patients who lost =>600 ml of blood in 4 h 22% in patients with =>600 ml within 4–16 h 5% in those with 600 ml of within 16–48 h Life-threatening massive : 5 to 15%. * Crocco JA, Rooney JJ, Fankushen DS, et al:Massive hemoptysis . Arch Intern Med 1968;121: 495–498 .

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Differentiate between true hemoptysis , spurious hemoptysis or hematemesis ????? 24

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25 Hemoptysis Hematemesis 1 Cough + - 2 Sputum Frothy Bright red -pink Liquid or clotted Rarely frothy Brown to black Coffee ground 3 Respiratory symptoms + - 4 Gastric or Hepatic disease - + 5 Vomiting & Nausea - + 6 Melena - + 7 Asphiyxia usual unusual 8 Laboratory Parameters Alkaline pH;Mixed with macrophages and neutrophils Acidic pH;Mixed with food particles

Management and its Difficulties:

Management and its Difficulties Multitude of potential etiologies. Course of bleeding is unpredictable. Frightening to see patients dying from asphyxiation, even in spite of intubation. No consensus regarding the optimal management of these patients. 26

Prognostic factors:

Prognostic factors BAD: -Bleeding rate: ~1,000 ml /24-hrs -Aspiration in to contralateral lung, -Massive bleeding requiring single-lung ventilation - Bronchogenic carcinoma as an underlying etiology 27

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GOALS - three fold : 1)Resuscitation and protecting the airway 2)Localizing the site and cause of bleeding 3) Definitive treatment to prevent recurrence. 28

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29 Air way Breathing circulation Provide suction . Provide O2 crystalloid solutions

Protection of nonbleeding lung :

Protection of nonbleeding lung If bleeding side is known Keep patient at: -Rest -Lateral decubitus - Bleeding side down -Head tilted down. 30 Rt.Main bronchus Left main brochus flooded with blood

Conservative management:

Conservative management Suppressing cough (codeine based) Antibiotics Antifibrinolytics like tranexemic acid. Sedation (Avoid over sedation) Coagulation disorders should be rapidly reversed. 31

Chest radiography :

Chest radiography Site of bleeding in 33–82% * of cases. Underlying cause in 35%**. Tuberculosis or tumors . Rarely normal Is it bronchiectasis ? 32 * Khalil A, Soussan M, Mangiapan G, Fartoukh M, Parrot A, Carette MF: Utility of high-resolution chest CT scan in the emergency management of hemoptysis in the intensive care unit: severity, localization and aetiology. BJR 2007; 80: 21–25 . ** Hirshberg B, Biran I, Glazer M, Kramer MR:Hemoptysis : etiology , evaluation, and outcome in a tertiary referral hospital. Chest 1997; 112: 440–444.


CT SCAN Superior to chest radiography Comparable to bronchoscopy for detecting the site of bleeding. Correct localization in 70–88.5% of cases * Multidetector CT - bronchial and nonbronchial systemic arteries . Better than bronchoscopy for determining the cause of bleeding. 33 * Haponik EF, Britt EJ, Smith PL, Bleecker ER: Computed chest tomography in the evaluation of hemoptysis : impact on diagnosis and treatment. Chest 1987; 91: 80–85.

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34 Definition Classification Vascular origin Etiology An approach to a case of hemoptysis Bronchoscopic and airway Management Bronchial Artery Embolization

Bronchoscopic and Airway management:

Bronchoscopic and Airway management 35

Selective Intubation :

Selective Intubation SINGLE LUMEN ETT Selectively intubate the non bleeding lung. 36 Selective intubation of Lft Main bronchus in Rt sided massive hemoptysis

Selective Intubation:

Selective Intubation DOUBLE LUMEN ETT Specially designed for selective intubation of the right or left main bronchi Last option in an asphyxiating pt. 37

FOB - diagnostic:

FOB - diagnostic Normal or non localizing CXR To rule out endobronchial growth Identifies the site of bleeding in 73–93%* Early versus delayed . (<24 hrs) 38 * Hsiao EI, Kirsch CM, Kagawa FT, Wehner JH, Jensen WA, Baxter RB: Utility of fiberoptic bronchoscopy before bronchial artery embolization for massive hemoptysis . AJR Am J Roentgenol 2001; 177: 861–867.

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In massive & life-threatening hemoptysis : -Not to rely on FOB. Rigid bronchoscope:important tool both as 1)Diagnostic 2)Therapeutic purposes 39

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41 RIGID ADVANTAGES Improved suctioning Better clearance Improved visualization Continuous airway Larger lumen- packing/clearing clots FLEXIBLE ADVANTAGES Performed at bedside Access:UL /distal orifices Methodically Lavage U sed with the rigid scope Topical anaesthesia

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DISADVANTAGES Poor visibility of peripheral lesions and UL General anesthesia DISADVANTAGES Poor suction Air way patency is not good 42 RIGID FLEXIBLE

Bronchoscopic measures:

Bronchoscopic measures Bronchial irrigation Vasoconstrictive agents Topical agents Lasers Endobronchial >Balloon tamponade >Unilateral lung vent. >Double-lumen ETT 43

Cold-Saline Lavage:

44 Cold-Saline Lavage Reported in 1980. * by Conlan et al. Lavage : Normal saline at 4 ° C in 50-ml aliquots Stopped the bleeding with massive hemoptysis ( 600 ml/24 h), obviating the need for emergency thoracotomy.* Rigid scope is better over FOB * Conlan AA, Hurwitz SS, Krige L, Nicolaou N, Pool R: Massive hemoptysis : review of 123 cases. J Thorac Cardiovasc Surg 1983; 85: 120–124.

Topical Vasoconstrictive Agents:

Topical Vasoconstrictive Agents Local instillation Topical epinephrine (1: 20,000) Effective : mild to moderate. Not useful: massive bleeding* Endobronchial epinephrine-side effects - Tachyarrythmias - HTN Newer agents: ADH derivative - ornipressin 45 * Cahill BC, Ingbar DH: Massive hemoptysis . Assessment and management. Clin Chest Med 1994; 15: 147–167.

Tranexamic Acid(TA):

Tranexamic Acid(TA) Antifibrinolytic drug Route : PO ,IV & Topical (recently) Endobronchial :* DOSE: 500–1,000 mg Response time: stops bleeding within seconds * Solomonov A, Fruchter O, Zuckerman T, Brenner B, Yigla M: Pulmonary hemorrhage : a novel mode of therapy. Respir Med 2009; 103: 1196–1200. 46


Fibrinogen/Thrombin Local application Immediate arrest of bleeding. Initial strategy before BAE.* Alternative treatment when endovascular procedures cannot be performed. * Wong LT, Lillquist YP, Culham G, DeJong BP, Davidson AG: Treatment of recurrent hemoptysis in a child with cystic fibrosis by repeated bronchial artery embolizations and long-term tranexamic acid. Pediatr Pulmonol 1996; 22: 275–279 47

Balloon Tamponade:

Balloon Tamponade Described: 1974* Life threatening hemoptysis . 4 Fr 100 cm Fogarthy balloon catheter by FOB. Inflated for 24-48 hrs 48 * Hiebert C: Balloon catheter control of lifethreatening hemoptysis . Chest 1974; 66: 308– 309 .

Fogarthy balloon catheter of various sizes:

Fogarthy balloon catheter of various sizes 49 Inflated fogarthy catheter bronchoscopically

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Advantages: Air way protection Allows gas exchange Supports patient before embolization or surgery Disadvantages: Ischemic mucosal injury Post obstructive pneumonia. 50

Endobronchial Airway Blockade(Silicone Spigot):

Endobronchial Airway Blockade(Silicone Spigot) Dutau et al.* reported first case. Temporary management. Silicone spigot is placed endobronchially . Stabilizes patient before endovascular embolization . * Dutau H , Palot A, Haas A, Decamps I, Durieux O: Endobronchial embolization with a silicone spigot as a temporary treatment for massive hemoptysis . Respiration 2006; 73: 830–832. 51

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52 A rigid bronchoscope initially allowed aspiration of blood and removal of clots followed by cold saline and topical vaso active agents ,clearing the vision to place spigot posterior segment of the right upper lobe Silicon spigots of various sizes

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53 Distal end of flexibe biopsy forceps with Spigot in place 6-mm silicone spigot posterior segment of the right upper lobe A rigid bronchoscope initially allowed aspiration of blood and removal of clots followed by cold saline and topical vaso active agents ,clearing the vision to place spigot

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54 Following this procedure, the patient underwent BAE, and the spigot was removed 2 h later. 6-mm silicone spigot in place posterior segment of the right upper lobe

Bronchoscopy-Guided Topical Hemostatic Tamponade(THT):

Bronchoscopy -Guided Topical Hemostatic Tamponade (THT) Oxidized regenerated cellulose mesh , a sterile kitted fabric is used. * Saturates with blood- swells-brownish or black gelatinous mass -clot. Successful in life threatening hemoptysis . Immediate arrest of bleed: 98% (56 of 57) 55 * Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC: Bronchoscopy -guided topical hemostatic tamponade therapy for the Management of life-threatening hemoptysis . Chest 2005; 127: 2113–2118.

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57 Endobronchial view of a bleeding subsegmental bronchus before THT During bronchoscopy guided THT

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Disavantages : Not suitable for proximal sites, trachea. Patients who cannot tolerate occlusion. Recurrence of hemoptysis 58

Endobronchial Sealing with Biocompatible Glue:

Endobronchial Sealing with Biocompatible Glue Parthasarathi Bhattacharyya et al,* 2002 Material : n-butyl cyanoacrylate (adhesive) Injected into the bleeding airway through a catheter via a flexible FOB. Used in mild hemoptysis . * *From the EKO Bronchoscopy Centre, Calcutta, India (CHEST 2002; 121:2066–2069) 59

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Laser Photocoagulation:

Laser Photocoagulation First introduced by Dumon et al. * Nd -YAG laser: employed since 1982. Effective in: Bronchoscopically visible source. MECHANISM : Photocoagulation of the bleeding mucosa with resulting hemostasis . Achieves photoresection and vaporization 61 * Dumon JF, Reboud E, Garbe L, Aucomte F, Meric B: Treatment of tracheobronchial lesions by laser photoresection . Chest 1982; 81: 278–284.


62 Flooding of the bron.intermed . Suctioning airway clearance visualization Coagulation and devascularization of tissues Carbonization of the bleeding site

Argon Plasma Coagulation(APC):

Argon Plasma Coagulation(APC) TYPE : Thermal tissue destruction Non contact electrocoagulation tool*. Used: In bronchoscopically visible areas of sources of bleed 63 * Keller CA, Hinerman R, Singh A, Alvarez F: The use of endoscopic argon plasma coagulation In airway complications after solid organ transplantation. Chest 2001; 119: 1968–1975. APC machine

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Once desired dessication is done ,deeper penetration of current is stopped and damage to further tissue is stopped.* Used for superficial and spreading lesions. Advantages of APC over YAG laser.: It provides easy access to lesions. Allows homogeneous tissue dessication . 64

Endobronchial Electrocautery:

Endobronchial Electrocautery TYPE: Thermal tissue destruction Coagulation mode: contact Readily available in most of the OT with gastroenterology colleagues . 65 Contact probes Electro cautery machine Probe through working channel

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Indications : - Bleeding endobronchial growth & benign tumors Less expensive alternative to laser. Control of hemoptysis using endobronchial electrocautery was achieved in 75%* of the cases * Homasson JP: Endobronchial electrocautery . Semin Respir Crit Care 1997; 18: 535– 543 66

Bronchial Artery Embolization:

Bronchial Artery Embolization First by Remy et al. in 1973 .* Temporary or definitive Immediate control: 57–100% of patients** Embolization : bronchial and nonbronchial Long-term control: 70%-88% 67 * Remy J, Voisin C, Dupuis C, et al: Traitement des hémoptysies par embolisation de la circulation systémique. Ann Radiol (Paris) 1974; 17: 5–16. ** Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977; 122: 33–37.

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In a recent study conducted in China,mortality has come down from 15 % (1995-1999) * to 0 % (2000-2005) with BAE. 68 * Shigemura N, Wan IY, Yu SCH: Multidisciplinary management of life-threatening massive hemoptysis : a 10-year experience Ann Thorac Surg 2009; 87: 849–853 .


INDICATIONS 69 To Stabilize patients before surgical resection or medical treatment As a definitive therapeutic approach in patients : Who refuse surgery Who are not candidates for surgery Where surgery is contraindicated

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PROCEDURE Identification of the bleeding vessel by selective bronchial artery cannulation . Injection of particles in to the feeding vessel. 70 MATERIALS USED Catheters Embolizing materials or particles


Catheters : Reverse-curved catheters ( Mikaelson , Simmons I, SOS Omni) Forward-looking catheters ( Cobra , HIH,RC) Sizes: 4, 5, or 5.5 Fr are routinely used. 71 Mikaelson catheter

Cobra type: curved catheter :

Cobra type: curved catheter Most commonly used Microcatheter Superselective catherization Less complications 72 Cobra type catheter

Embolizing materials: :

Embolizing materials : Absorbable gelatin sponge Gelfoam Pledgets (1 to 2 mm) Thrombin Glue Recently approved - Embospheres , -Spherical Poly vinyl alcohol(PVA) particles 73

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PVA particles (350-500 mic ) Most common & Safe Liquid embolic agents -ischemic necrosis Stainless steel platinum coils -occlude more proximal vessels. Particles > 200 to 250 micr.m should be used 74

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Distal embolization : ideal Proximal occlusion: temporary relief particles < 200 micr.m :avoided -Tissue infarction 75

Clues to bronchial artery as the source of bleeding: :

Clues to bronchial artery as the source of bleeding: 76 Parenchymal hypervascularity Vascular hypertrophy aneurysm

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77 The identification of extravasated dye --INFREQUENT Bronchopulmonary shunting Neovasculirization -Capillary stasis -Thrombosis of vessel

Left upper lobe bronchial artery:

Left upper lobe bronchial artery 78 After embolization Decreased vascularity & hypertrophy Tortous and hypertrophied vessel Before embolization

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79 Right Left Abnormal circulation Pre- embolisation bronchial angiogram No abnormal circulation Post embolisation

Bronchial artery aneurysm:

Bronchial artery aneurysm 80 Hypervascular lesion with aneurysm Pre embolisation Post embolisation PVA particles No hypervascular lesion & aneurysm

Super selective Embolization of intercostal artery:

Super selective Embolization of intercostal artery 81 Hypervascular areas and a small amount of pulmonary arterial shunting Decreased vasularity POST EMBOLIZATION PRE EMBOLIZATION Radicular arteries INTERCOSTAL ARTERY Micro catheter passed beyond radicular artery

Bronchial Artery Embolisation:

Bronchial Artery Embolisation 82

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Success rates : 64% to 100%. Recurrent non-massive bleeding : 16–46% BAE :Useful in CF with hemoptysis Technical failure: 13% 83

Complications of BAE:

Complications of BAE Transversemyelitis Neurological (Para paresis) Intimal tears Chest pain Pyrexia Haemoptysis Systemic embolisation Vessel perforation 84


SURGICAL MANAGEMENT BAE unavailable Uncontrolled bleed with BAE. Localised lesions Mortality : 1% to 50% Mortality :7.1-18.2% (massive hemoptysis ) Mortality : upto 40% (emergency procedure) 85

Indications of surgery:

Indications of surgery Procedure of choice in : Bronchial adenoma Aspergilloma Hydatid cyst Iatrogenic pulmonary rupture Chest trauma AV malformations 86

Contra indications for surgery:

Contra indications for surgery Unresectable carcinoma Inability to lateralize the bleeding site Diffuse disease Multiple AVM Cystic fibrosis Arterial hypoxia Co2 retention Marginal pulm . Reserve Dyspnea at rest Non-localizing bronchiectasis 87

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88 Life Threatening hemoptysis Pulmonary isolation & identification of bleeding source (Radiological/ Bronchoscopic means:CT Thorax,Balloon bronchial blockers) Rigid Bronchoscopy Surgery BAE (Delayed TREATMENT) Follow up at OPD SUCCESS FAILURE

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