Flexible fiberoptic bronchoscopy (rather than rigid bronchoscopy) is used for virtually all diagnostic, and most therapeutic, indications.
Indications for Bronchoscopy
Flexible bronchoscopes facilitate airway visualization and documentation of findings (see table ).
Diagnostically, flexible fiberoptic bronchoscopy allows for
Direct airway visualization down to, and including, subsegmental bronchi
Sampling of respiratory secretions and cells via bronchial washings, brushings, and lavage of peripheral airways and alveoli
Biopsy of endobronchial, parenchymal, and mediastinal structures
Therapeutic uses include
Suctioning of retained secretions
Placing an endobronchial tube, stent, or valve
Removing foreign objects
Using balloon dilation to relieve airway stenoses
Rigid bronchoscopy is used only when a wider aperture and channels are required for better visualization and instrumentation, such as when
Investigating vigorous pulmonary hemorrhage (in which the rigid bronchoscope can better identify the bleeding source and, with its larger suction channel, can better suction the blood and prevent asphyxiation)
Viewing and removing aspirated foreign bodies in young children
Viewing obstructive endobronchial lesions for possible laser debulking or stent placement
Contraindications to Bronchoscopy
Absolute contraindications to bronchoscopy include
Acute respiratory failure with hypercapnia (unless the patient is intubated and ventilated)
High-grade tracheal obstruction
Inability to adequately oxygenate the patient during the procedure
Untreatable life-threatening arrhythmias
Relative contraindications to bronchoscopy include
Recent myocardial infarction
Inability or unwillingness to hold still for the procedure
Transbronchial biopsy should be done with caution in patients with uremia, superior vena cava obstruction, or pulmonary hypertension because of increased risk of bleeding. Inspection of the airways is safe in these patients, however.
Procedure for Bronchoscopy
Bronchoscopy should be done only by a pulmonologist or trained surgeon in a monitored setting, typically a bronchoscopy suite, operating room, or intensive care unit.
Except in true emergencies, patients should receive nothing by mouth for at least 6 hours before bronchoscopy and have IV access, intermittent blood pressure monitoring, continuous pulse oximetry, and cardiac monitoring. Supplemental oxygen should be used.
Patients usually receive conscious sedation with short-acting benzodiazepines, opioids, or both before the procedure to decrease anxiety, discomfort, and cough. In some centers, general anesthesia (eg, deep sedation with propofol and airway control via endotracheal intubation or use of a laryngeal mask airway Laryngeal Mask Airways (LMA) If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more ) is commonly used before bronchoscopy.
The pharynx and vocal cords are anesthetized with nebulized or aerosolized lidocaine (1 or 2%, to a maximum of 250 to 300 mg for a 70-kg patient). The bronchoscope is lubricated and passed either through a nostril, the mouth with use of an oral airway or bite block, or an artificial airway such as an endotracheal tube. After inspecting the nasopharynx and larynx, the clinician passes the bronchoscope through the vocal cords during inspiration, into the trachea, and then further distally into the bronchi.
Several ancillary procedures can be done as needed, with or without fluoroscopic guidance Chest x-ray Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more :
Bronchial washing: Saline is injected through the bronchoscope and subsequently aspirated from the airways.
Bronchial brushing: A brush is advanced through the bronchoscope and used to abrade suspect lesions to obtain cells.
Bronchoalveolar lavage: 50 to 200 mL of sterile saline is infused into the distal bronchoalveolar tree and subsequently suctioned out, retrieving cells, protein, and microorganisms located at the alveolar level. Local areas of pulmonary edema created by lavage may cause transient hypoxemia.
Endobronchial and transbronchial biopsy: Endobronchial biopsy obtains a tissue sample from a lesion that can be seen in the airway lumen. Transbronchial biopsy uses forceps that are advanced through the bronchoscope and airway to obtain samples from one or more sites in the lung parenchyma. Transbronchial biopsy can be done without fluoroscopic guidance, but some evidence supports increased diagnostic yields and lower incidence of pneumothorax when fluoroscopic guidance is used.
Transbronchial needle aspiration: A retractable needle is inserted through the bronchoscope and can be used to sample enlarged mediastinal lymph nodes or masses. Endobronchial ultrasonography Ultrasonography of the Chest Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more (EBUS) can be used to help guide the needle biopsy.
Patients are typically given supplemental oxygen and observed for 2 to 4 hours after the procedure. Return of a gag reflex and maintenance of oxygen saturation when not receiving supplemental oxygen are the two primary indices of recovery.
Standard practice is to obtain a posteroanterior chest x-ray Chest x-ray Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more after transbronchial lung biopsy to exclude pneumothorax Pneumothorax Pneumothorax is air in the pleural space causing partial or complete lung collapse. Pneumothorax can occur spontaneously or result from trauma or medical procedures. Diagnosis is based on clinical... read more .
Bronchoscopy can be done using navigation toward suspect peripherally located lesions for biopsy. Navigation can be electromagnetic or virtual. In both types, thin-slice CT images are used to prepare a virtual bronchoscopic pathway to the lesion using software and before the biopsy.
Virtual guidance: Bronchoscopic images are combined with the virtual images to help direct bronchoscopy in real time.
Electromagnetic guidance: An electromagnetic field placed under the patient provides additional information to help guide bronchoscopy in real time (1 References Bronchoscopy is the introduction of an endoscope into the airways. Flexible fiberoptic bronchoscopy (rather than rigid bronchoscopy) is used for virtually all diagnostic, and most therapeutic... read more ). This procedure is done more commonly than virtual bronchoscopy.
The benefit of navigational bronchoscopy compared to traditional flexible bronchoscopy or endobronchial ultrasound is still being established, although one study did not show additional diagnostic benefit (2 References Bronchoscopy is the introduction of an endoscope into the airways. Flexible fiberoptic bronchoscopy (rather than rigid bronchoscopy) is used for virtually all diagnostic, and most therapeutic... read more ).
Complications of Bronchoscopy
Serious complications are uncommon; minor bleeding from a biopsy site, fever occurs in 10 to 15% of patients (3 References Bronchoscopy is the introduction of an endoscope into the airways. Flexible fiberoptic bronchoscopy (rather than rigid bronchoscopy) is used for virtually all diagnostic, and most therapeutic... read more ).
Patients may have an increase in cough after bronchoalveolar lavage.
Rarely, topical anesthesia causes laryngospasm, bronchospasm, seizures, or cardiac arrhythmias or arrest.
Bronchoscopy itself may cause
Arrhythmias Overview of Arrhythmias The normal heart beats in a regular, coordinated way because electrical impulses generated and spread by myocytes with unique electrical properties trigger a sequence of organized myocardial... read more (most commonly premature atrial contractions, ventricular premature beats, or bradycardia)
Hypoxemia in patients with compromised gas exchange
Minor laryngeal edema or injury with hoarseness
Transmission of infection from suboptimally sterilized equipment (very rare)
Mortality is 1 to 4/10,000 patients (4 References Bronchoscopy is the introduction of an endoscope into the airways. Flexible fiberoptic bronchoscopy (rather than rigid bronchoscopy) is used for virtually all diagnostic, and most therapeutic... read more ). Older adults and patients with serious comorbidities (eg, severe chronic obstructive pulmonary disease Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational... read more [COPD], coronary artery disease Overview of Coronary Artery Disease Coronary artery disease (CAD) involves impairment of blood flow through the coronary arteries, most commonly by atheromas. Clinical presentations include silent ischemia, angina pectoris, acute... read more , pneumonia Overview of Pneumonia Pneumonia is acute inflammation of the lungs caused by infection. Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and... read more with hypoxemia, advanced cancers ) are at greatest risk.
Transbronchial biopsy can cause pneumothorax (2 to 5%), significant hemorrhage (1 to 3.0%), but doing the procedure can often avoid the need for thoracotomy Thoracotomy Thoracotomy is surgical opening of the chest. It is done to evaluate and treat pulmonary problems when noninvasive procedures are nondiagnostic or unlikely to be definitive. The principal indications... read more (5 References Bronchoscopy is the introduction of an endoscope into the airways. Flexible fiberoptic bronchoscopy (rather than rigid bronchoscopy) is used for virtually all diagnostic, and most therapeutic... read more ).
1. Folch EE, Pritchett MA, Nead MA, et al. Electromagnetic Navigation Bronchoscopy for Peripheral Pulmonary Lesions: One-Year Results of the Prospective, Multicenter NAVIGATE Study. J Thorac Oncol 2019 Mar;14(3):445-458. doi: 10.1016/j.jtho.2018.11.013
2. Ost DE, Ernst A, Lei X, et al. Diagnostic Yield and Complications of Bronchoscopy for Peripheral Lung Lesions. Results of the AQuIRE Registry. Am J Respir Crit Care Med 2016;193(1):68-77. doi:10.1164/rccm.201507-1332OC
3. Hackner K, Riegler W, Handzhiev S, et al. Fever after bronchoscopy: serum procalcitonin enables early diagnosis of post-interventional bacterial infection. BMC Pulm Med 2017;17(1):156. doi:10.1186/s12890-017-0508-1
4. Jin F, Mu D, Chu D, Fu E, Xie Y, Liu T. Severe complications of bronchoscopy. Respiration 2008;76(4):429-433. doi:10.1159/000151656
5. Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest 1995;107(2):430-432. doi:10.1378/chest.107.2.430
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