fig5 shows a flexible bronchoscope 40 with a working channel 42 into which a needle guide 44 has been inserted . prior to inserting bronchoscope 40 into a patient , a an access accessory such as guide wire 46 is inserted into the distal end 48 of needle guide 44 . guide wire 46 is bent around so that a proximal end 50 lies along the length of bronchoscope 40 . when bronchoscope 40 is inserted into a patient &# 39 ; s lungs , the proximal end 50 of guide wire 46 will remain outside of the patient . guide wire 46 can then be used to deliver diagnostic , therapy or biopsy tools to the distal end of bronchoscope 40 without having to pass such tools through working channel 42 . such tools can be delivered either simultaneously alongside the bronchoscope or after the bronchoscope has been placed at the selected site within the patient &# 39 ; s lung . the guide wire 46 can also be used to position and steer the distal end 41 of the bronchoscope . pulling guide wire 46 in a proximal direction will cause the needle guide 44 and distal end 41 of bronchoscope 40 to bend in that direction , thereby enhancing the user &# 39 ; s control of the distal end of the bronchoscope . in an alternative embodiment , the guide wire can be attached to or made integral with the needle guide . fig6 shows the use of a blunt dilator 52 with the bronchoscope 40 , needle guide 44 and guide wire 46 arrangement of fig5 . dilator 52 can be used to help advance the system without causing trauma to the wall of the bronchi or other lung passage . fig7 and 8 show an embodiment of the invention that omits the use of a needle guide within the working channel 42 of the bronchoscope 40 . in this embodiment , guide wire 46 is placed in the working channel 42 at the distal end 41 of the bronchoscope so that one end 51 extends proximally through the working channel and the other end ( not shown ) extends proximally outside the bronchoscope along its length to the exterior of the patient . when the bronchoscope is inserted into the patient &# 39 ; s lung , guide wire 46 can be used to deliver tools to the treatment site . in the example shown in fig7 a and 7b , guide wire 46 is being used to deliver a needle guide 54 to a biopsy site , either by pushing needle guide 54 distally along guide wire 46 , withdrawing proximal guide wire end 51 proximally while needle guide 54 is on the exterior portion of guide wire 46 , or a combination of both actions . when the distal end 56 of needle guide is at the distal end 41 of the bronchoscope , the needle guide &# 39 ; s distal end 56 follows the curve of guide wire 46 to bend toward the biopsy site . proximal tension on guide wire 46 can be used to control the amount of needle guide bending . a flexible biopsy needle 58 within needle guide 54 may then be used to penetrate the bronchial wall to take the tissue sample . fig9 - 12 show a bronchoscope and guide wire arrangement in which a blunt tipped needle guide 60 with a side port 62 is disposed in working channel 42 of bronchoscope 40 . guide wire 46 is fixed in a guide wire port 64 at the distal end of needle guide 60 prior to inserting bronchoscope 40 into the patient so that guide wire 46 extends along the length of bronchoscope 40 to place a proximal end 50 of guide wire 46 outside the patient . guide wire 46 may be used to rotate and / or bend needle guide 60 to orient side port 62 as desired . as in the other embodiments , after insertion of bronchoscope 40 into a patient &# 39 ; s lung , guide wire 46 may be used to deliver tools ( such as a grasper , light source , tumor fixator , forceps ) to the distal end of bronchoscope without having to pass through the bronchoscope &# 39 ; s limited size working channel . other delivery tools are described in applicant &# 39 ; s applications bearing the attorney docket numbers 30689 . 703 . 201 , 30689 . 703 . 301 , and 30689 . 703 . 304 ; the contents of these applications are incorporated herein by reference in their entirety . for example , fig1 - 12 show the use of the bronchoscope system to deliver a balloon 66 to a biopsy site . the catheter 68 communicating with balloon 66 may be coaxial with guide wire 46 as shown in fig1 ; alternatively , guide wire 46 may exit the balloon &# 39 ; s shaft 66 via a side port 69 as shown in fig1 . the balloon &# 39 ; s inflator 70 is disposed outside of the patient at the proximal end 50 of guide wire 46 . after using guide wire 46 to orient side port 62 , balloon 66 is inflated to move side port 62 toward or against the bronchial wall 72 at the biopsy site and to hold the distal end 60 of the needle guide in this position . a biopsy needle 74 and center wire 76 may then be advanced through needle guide 60 and through side port 64 through the bronchial wall 72 into the biopsy site . the center wire 76 may be used to fix the suspected tumor in place as an aspirating syringe 78 is used to draw a tissue sample into the core biopsy needle 74 . after taking the tissue sample , the needle and center wire are withdrawn , and balloon 66 may be deflated . fig1 shows a bronchoscope system similar to that of fig9 - 12 . the system of fig1 , however , replaces the side port needle guide of fig9 - 12 with a straight channel needle guide 44 . like the system of fig9 - 12 , balloon 66 may be used to orient and support needle guide 44 prior to and during the biopsy procedure . fig1 shows a bronchoscope system in which multiple guide wires 46 a , 46 b , and 46 c are disposed in a needle guide 44 extending through the working channel of bronchoscope 40 . as in the other embodiments , one end of each of the guide wires is inserted into the distal end 48 of the needle guide prior to insertion of the bronchoscope into the patient so that the guide wires extend along the length of bronchoscope 40 to place their other ends 50 a , 50 b and 50 c outside of the patient . tools such as side port balloon 66 may be delivered along the guide wires to the distal end of bronchoscope 40 without using the bronchoscope &# 39 ; s working channel . in an alternative embodiment , the guide wire can be attached to or made integral with the needle guide . fig1 shows the use of a guide wire bronchoscope system similar to that of fig5 to deliver a steerable scope and / or camera 80 to a biopsy site via a rail 81 running along guide wire 46 . the directable distal end 82 of scope 80 may penetrate the bronchial wall 83 adjacent the suspected tumor or lymph node 84 to view the tissue to be biopsied . a biopsy needle may be delivered to the biopsy site via needle guide 44 . the scope &# 39 ; s distal end 82 may emit a guide signal ( emf , light , magnetic , sound , radio ) to guide the biopsy needle into the suspected tumor or lymph node 84 . in fig1 and 17 , a needle guide 44 is attached to the distal end 41 of bronchoscope 40 so that biopsy needles or other instruments may be delivered to a treatment site via the guide 44 outside of the bronchoscope &# 39 ; s working channel 42 . in fig1 , needle guide 44 is attached to bronchoscope by a nose clip 90 or other attachment mechanism such as a strap , glue , etc . fig1 shows the use of a clip , hinge or adhesive 92 to create an articulating connection between the bronchoscope 40 and the needle guide 44 . a guide wire 46 extends through the bronchoscope &# 39 ; s working channel 42 to the exterior of the patient and also through a side port ( not shown ) in the needle guide , as in earlier embodiments . the bronchoscope and needle guide are inserted into the lung simultaneously as in the other embodiments , and the guide wire 46 may be used to move , position and hold the distal end 48 of needle guide 44 . this arrangement combines the flexibility and maneuverability of the needle guide with the longitudinal stiffness of the bronchoscope . in fig1 , a needle guide 44 is sewed together or otherwise attached to a tumor fixation device 100 . needle guide 44 is inserted into the working channel 42 at the bronchoscope &# 39 ; s distal end , and the shaft 102 of tumor fixation device 100 extends along the bronchoscope &# 39 ; s length . when the bronchoscope is inserted into the patient &# 39 ; s lung , one or more fixation needles 104 are at a biopsy site at the bronchoscope &# 39 ; s distal end , and a control mechanism 106 is at the device &# 39 ; s proximal end outside the patient . operation of control mechanism 106 inserts needles 104 in and around the tissue to be biopsied . a biopsy needle 74 and center wire 76 may then be used as described above to take a tissue sample . fig1 shows a bronchoscope system with several biopsy needle mechanisms . primary needle guide 44 a is disposed in the distal end of working channel 42 of bronchoscope 40 prior to insertion of bronchoscope 40 into the patient &# 39 ; s lung . the distal ends of secondary needle guides 44 b and 44 c are attached to the distal end of primary needle guide 44 a by sewing or other means . each needle guide has center wires and biopsy needles , as shown , which may be operated in a known manner to take tissue samples . fig2 shows a bronchoscope system in which a balloon catheter 110 , side port needle guide 60 , biopsy needle 74 and center wire 76 are all disposed within the bronchoscope &# 39 ; s working channel . balloon 110 is disposed opposite to the side port 62 of needle guide 60 . syringe 70 may be used to inflate balloon 110 via balloon shaft 112 to push side port 62 against the bronchial wall so that needle 74 and center wire 76 may be pushed firmly into suspected tumor 84 . fig2 shows a biopsy needle for use with bronchoscope systems such as those described above . as shown in fig2 a , a sleeve 120 covers needle 122 and center wire 124 during delivery and positioning of the needle . sleeve 120 extends back proximally exterior of the patient and is advanced along with needle 122 and 124 through a needle guide disposed within a bronchoscope working channel or exterior to the bronchoscope . when the needle is to be used to gather a tissue sample , sleeve 120 is held stationary while needle 122 and center wire 124 are advanced distally ( or sleeve 120 is drawn proximally while needle 122 and center wire 124 are held stationary ) so that needle 122 and center wire 124 perforate sleeve 120 , as shown in fig2 b . needle 122 and center wire 124 are then used to gather a tissue sample . in fig2 , a radially expandable sleeve 126 covers needle 122 and center wire or needle 124 during delivery and positioning via a bronchoscope system , as in the embodiment of fig2 a above . when at the biopsy site , the distal end of sleeve 126 is radially expanded as shown in fig2 to permit needle 122 and center wire or needle 124 to pass through the distal end of sleeve 126 . when the sleeve 126 is open , the radial wings 128 at the sleeve &# 39 ; s distal end can perform several functions . wings 128 provide a registration function when disposed against the bronchial wall so that the needle 122 and center wire or needle 124 can be advanced a controlled distance into and beyond the wall . also , if the radial wings 128 are opened while the sleeve 126 is placed against tissue , movement of the wings can move aside and hold tissue to open a working area and fixate the device against the tissue . the radial wings can also be moved to a closed position after taking the tissue sample to help capture and contain the tissue sample . fig2 - 25 show other embodiments of space - making devices that can be delivered via a bronchoscope system to provide working space for a biopsy or other procedure performed via a bronchoscope . in fig2 a , an expansion tool 130 is shown disposed in a closed configuration within an open - ended sleeve 132 . after delivery via a bronchoscope system to a treatment site within a lung , expansion tool 132 may be operated to an open configuration to expand the open end 134 of sleeve 132 . in this embodiment , pivoting arms 136 of tool 130 are moved apart against the inside of sleeve 132 , as shown in fig2 b . after expansion of sleeve 132 , expansion tool 130 may be removed to allow other tools to be delivered to the treatment site via sleeve 132 . the expanded sleeve 132 may be used to stabilize the working area at the treatment site , to spread apart anatomical features at the treatment site and / or to help contain tissue samples . fig2 a and 24b show another embodiment of a space - making device . in fig2 a , an expansion tool 140 is being delivered to a treatment site via the working channel 42 of a bronchoscope 40 . expansion tool 140 is formed as a spiral . once it emerges from the distal end of working channel 42 , the spirals of expansion tool 140 unwind , as shown in fig2 b , to form a work space at the tool &# 39 ; s distal end . alternatively , expansion tool 140 may be delivered within a sleeve , and tool 140 may be used to expand the distal end of the sleeve , as in the embodiment of fig2 . fig2 shows yet another embodiment of a space - making device . as in the previous embodiment , expansion tool 150 is delivered to a treatment site via the working channel 42 of a bronchoscope 140 . once outside of the channel , an expansion portion 152 of tool 150 unwinds and expands radially to form a work space at the tool &# 39 ; s distal end . as in the other embodiments , expansion tool 150 may be delivered within a sleeve , and tool 150 may be used to expand the distal end of the sleeve . in fig2 , a bifurcated cannula 160 has been inserted into the distal end of the working channel 42 of a bronchoscope 40 prior to insertion of bronchoscope 40 into the patient . cannula 160 provides two branches 162 and 164 for advancing tools to the same treatment site via distal port 166 . as shown , branch 162 runs proximally along working channel 42 , while branch 164 runs along the length of bronchoscope 40 . the tip 168 surrounding port 166 may be sharp for penetrating tissue . for example , distal tip 168 may be pushed into the bronchial wall while the user observes the cannula &# 39 ; s motion via a scope disposed in one of the lumens . the camera can then be pulled back so that a biopsy instrument can be advanced into that location . a marker can also be placed before , during or after taking the biopsy sample . as an alternative to the use of a biopsy needle with the embodiments described above , a side collecting cutter tool may be used to collect tissue samples . with respect to imaging , most pulmonology labs have real time fluoroscopy that can be quickly turned 90 degrees to confirm direction and depth . alternatively , real time cat scans can be used to image a cross - section of the patient &# 39 ; s lungs and mediastinal region prior to biopsy or other procedures . if the image slice is narrowed to 3 - 5 mm and it cuts a plane transverse across the thorax , the user can visualize when the needle enters the plane and the 2d coordinates relative to the target . unfortunately , real time ct equipment is not common . in another aspect of the invention , therefore , a very small radiopaque dye mark or metallic radiopaque marker may be delivered via a small transthoracic needle so the location can be confirmed and the mark can be used as an obvious landmark to direct a transbronchial needle aspiration system through a bronchoscope . transthoracic delivery is generally much more accurate but the device profile would need to be small to avoid damaging the lung wall . yet another aspect of the invention is the use of endoscopes with access accessories to enter the mediastinal space to , e . g ., obtain a tissue sample . the invention includes the use of glue or a plug ( e . g ., self - expanding stent , collagen plug , polymer plug , cyanoacrylates , glutaraldehyde formulations , polyethylene balloons to contain the glue , etc .) to close any holes in the lung wall or adjacent tissue in the event of pneumothorax . in certain biopsy needle embodiments , the needle guide element or channel has a continuous channel through the center or side port with a constant lumen diameter and a close - fitting port dimension for precise biopsy device delivery . radiopaque marker bands may be added at the port opening to facilitate imaging of the biopsy device with respect to the target tissue .
this invention relates generally to lung access devices and methods of using the devices to gain access to the interior of a lung or to the mediastinal space around the lung . in particular , the invention relates to auxiliary access devices and tools for use with conventional bronchoscopes or other endoscopes to enable the delivery of more and larger devices to a target site than is currently possible through a typical endoscope or bronchoscope .