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, indications.
BronchoscopyANTONIA REEVE/SCIENCE PHOTO LIBRARY
Flexible bronchoscopes facilitate airway visualization and documentation of findings (see table Indications for Flexible Fiberoptic Bronchoscopy ).
Diagnostically, flexible fiberoptic bronchoscopy allows for
Therapeutic uses include
Indications for Flexible Fiberoptic Bronchoscopy
Abnormal chest radiograph: To diagnose the etiology of pneumonia * in a patient who is immunocompromised; in a patient who is immunocompetent and has recurrent or nonresolving disease; or in a patient with a paratracheal/mediastinal/hilar mass, parenchymal mass, or nodule, especially in a proximal lung section
Diffuse lung process (transbronchial lung biopsy)
Evaluation for rejection in a recipient of a lung transplant
Evaluation of airway in a patient with burns
Evaluation for bronchial disruption in a patient with chest trauma
Positive sputum cytology in a patient with a normal chest x-ray*
Suspected tracheoesophageal fistula
Aspiration of retained secretions*, †
Laser resection of tumor‡
Lung volume reduction
Management of bronchopleural fistula
Placement of an airway stent‡
Placement of endotracheal tube in a difficult situation (cervical injury, abnormal anatomy)
Placement of an endobronchial valve
Removal of foreign body‡
* Flexible fiberoptic bronchoscopy is indicated only after failure of less invasive investigations and treatments.
† Flexible fiberoptic bronchoscopy is not a substitute for chest physiotherapy, bronchodilator nebulization, and nasotracheal suctioning; it should be reserved for hypoxemia (in a patient receiving mechanical ventilation) and/or lobar atelectasis secondary to impacted secretions refractory to conventional therapy.
‡ Rigid bronchoscopy provides more control for instrumentation than flexible bronchoscopy.
Rigid bronchoscopy is used only when a wider aperture and channels are required for better visualization and instrumentation, such as when
Absolute contraindications to bronchoscopy include
Relative contraindications to bronchoscopy include
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.
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.
laryngeal mask airway ) is commonly used before bronchoscopy.
Several ancillary procedures can be done as needed, with or without fluoroscopic guidance :
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 after transbronchial lung biopsy to exclude pneumothorax .
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.
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 ).
Serious complications are uncommon; minor bleeding from a biopsy site, fever occurs in 10 to 15% of patients ( 3 ).
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
Mortality is 1 to 4/10,000 patients ( 4 ). Older adults and patients with serious comorbidities (eg, severe chronic obstructive pulmonary disease [COPD], coronary artery disease , pneumonia 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 ( 5 ).