Bronchoscopy

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Bronchoscopy
Bronchoscopy.png
A physician performing bronchoscopy.
ICD-9-CM 33.21-33.23
MeSH D001999
OPS-301 code 1-62
MedlinePlus 003857

Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumors, or inflammation. Specimens may be taken from inside the lungs. The construction of bronchoscopes ranges from rigid metal tubes with attached lighting devices to flexible optical fiber instruments with realtime video equipment.

Contents

History

The German laryngologist Gustav Killian is attributed with performing the first bronchoscopy in 1897. [1] Killian used a rigid bronchoscope to remove a pork bone. The procedure was done in an awake patient using topical cocaine as a local anesthetic. [2] From this time until the 1970s, rigid bronchoscopes were used exclusively.

Chevalier Jackson refined the rigid bronchoscope in the 1920s, using this rigid tube to visually inspect the trachea and mainstem bronchi. [3] The British laryngologist Victor Negus, who worked with Jackson, improved the design of his endoscopes, including what came to be called the "Negus bronchoscope".

Shigeto Ikeda invented the flexible bronchoscope in 1966. [4] The flexible scope initially employed fiberoptic bundles requiring an external light source for illumination. These scopes had outside diameters of approximately 5 mm to 6 mm, with an ability to flex 180 degrees and to extend 120 degrees, allowing entry into lobar and segmental bronchi. Fiberoptic scopes have been superseded by bronchoscopes with a charge-coupled device (CCD) video chip located at their distal end. [5]

Types

Rigid

Rigid bronchoscopy. Broncoscopia terapeutica.jpg
Rigid bronchoscopy.

The rigid bronchoscope is a hollow metal tube used for inspecting the lower airway. [6] It can be for either diagnostic or therapeutic reasons. Modern use is almost exclusively for therapeutic indications. Rigid bronchoscopy is used for retrieving foreign objects. [7] Rigid bronchoscopy is useful for recovering inhaled foreign bodies because it allows for protection of the airway and controlling the foreign body during recovery. [8]

Massive hemoptysis, defined as loss of over 600 mL of blood in 24 hours, is a medical emergency and should be addressed with initiation of intravenous fluids and examination with rigid bronchoscopy. The larger lumen of the rigid bronchoscope (versus the narrow lumen of the flexible bronchoscope) allows for therapeutic approaches such as electrocautery to help control the bleeding.

Flexible (fiberoptic)

A flexible bronchoscope is longer and thinner than a rigid bronchoscope. It contains a fiberoptic system that transmits an image from the tip of the instrument to an eyepiece or video camera at the opposite end. Using Bowden cables connected to a lever at the hand piece, the tip of the instrument can be oriented, allowing the practitioner to navigate the instrument into individual lobar or segmental bronchi. Most flexible bronchoscopes also include a channel for suctioning or instrumentation, but these are significantly smaller than those in a rigid bronchoscope.

Flexible bronchoscopy causes less discomfort for the patient than rigid bronchoscopy, and the procedure can be performed easily and safely under moderate sedation. It is the technique of choice nowadays for most bronchoscopic procedures.

Indications

Flexible bronchoscopy plays an important role in the diagnosis, monitoring and therapy of certain pulmonary diseases. [9]

Diagnostic

Diagram of a bronchoscopy being performed Diagram showing a bronchoscopy CRUK 053.svg
Diagram of a bronchoscopy being performed

Therapeutic

Interventional bronchoscopy in chronic obstructive airway inflammatory diseases including asthma and COPD has greatly evolved and show promising results for the clinical management of patients. [10]

Procedure

Video of a bronchoscopy of the right bronchial tree

Bronchoscopy can be performed in a special room designated for such procedures, operating room, intensive care unit, or other location with resources for the management of airway emergencies. [11]

The patient will often be given antianxiety and antisecretory medications (to prevent oral secretions from obstructing the view), generally atropine, and sometimes an analgesic such as morphine. During the procedure, sedatives such as midazolam or propofol may be used. A local anesthetic is often given to anesthetize the mucous membranes of the pharynx, larynx, and trachea. The patient is monitored during the procedure with periodic blood pressure checks, continuous ECG monitoring of the heart, and pulse oximetry.

A flexible bronchoscope is inserted with the patient in a sitting or supine position. Once the bronchoscope is inserted into the upper airway, the vocal cords are inspected. The instrument is advanced to the trachea and further down into the bronchial system and each area is inspected as the bronchoscope passes. [11]

If an abnormality is discovered, it may be sampled using a brush, a needle, or forceps. Specimen of lung tissue (transbronchial biopsy) may be sampled using a real-time X-ray (fluoroscopy) or an electromagnetic tracking system. [12] Flexible bronchoscopy can also be performed on intubated patients, such as patients in intensive care. In this case, the instrument is inserted through an adapter connected to the tracheal tube.

Rigid bronchoscopy is performed under general anesthesia. Rigid bronchoscopes are too large to allow parallel placement of other devices in the trachea; therefore the anesthesia apparatus is connected to the bronchoscope and the patient is ventilated through the bronchoscope.

Recovery

Although most patients tolerate bronchoscopy well, a brief period of observation is required after the procedure. Most complications occur early and are readily apparent at the time of the procedure. The patient is assessed for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema, laryngospasm, or bronchospasm). Monitoring continues until the effects of sedative drugs wear off and gag reflex has returned. If the patient has had a transbronchial biopsy, doctors may take a chest X-ray to rule out any air leakage in the lungs (pneumothorax) after the procedure. The patient may need to be hospitalized if any bleeding, pneumothorax, or respiratory distress occurs.

Bronchoscopy in critical care

Bronchoscopy has an important role to play in the management critically ill patients in the Intensive care unit. Fibreoptic bronchoscopy can be applied via an endotracheal tube or tracheotomy in mechanically ventilated patients, or via the native airway in those not requiring ventilation. [13] Indications for bronchoscopy in critically ill patients can be broadly divided into diagnostic and therapeutic categories. [14]

Diagnostic indications

Therapeutic indications

The role of diagnostic bronchoscopy for the identification of pneumonia remains controversial [15] with differing recommendations from learned bodies including the British Thoracic Society, [16] American Thoracic Society/Infectious Disease Society of America, [17] and European Society of Intensive Care Medicine/ European Respiratory Society/European Society of Clinical Microbiology and Infectious Diseases/ Asociación Latinoamericana del Tórax. [18] Although it is accepted that bronchoscopic diagnostic approaches have a lower false positive rate, [19] the effect on patient outcomes is uncertain although there is clear evidence of the ability to safely reduce antibiotic use through this lower false positive rate. [20]

Complications and risks

Figure showing complications of bronchoscopy, from Complications of bronchoscopy.png
Figure showing complications of bronchoscopy, from

Besides the risks associated with the drugs used, there are also specific risks of the procedure. Although a rigid bronchoscope can scratch or tear airways or damage the vocal cords, the risk of bronchoscopy is limited in otherwise well patients. Complications are more frequent in critically ill patients in intensive care. [22] The risk of complications from fiberoptic bronchoscopy are minimized with good training, careful technique and an ongoing dialogue with the anesthesiologist or sedationist. [9] Common complications include excessive bleeding following biopsy. A lung biopsy also may cause leakage of air, called pneumothorax. Pneumothorax occurs in less than 1% of lung biopsy cases. Laryngospasm is a rare complication but may sometimes require tracheal intubation. Patients with tumors or significant bleeding may experience increased difficulty breathing after a bronchoscopic procedure, sometimes due to swelling of the mucous membranes of the airways. Other complications include arrhythmias, bronchospasm, hypoxia, hypercapnia and raised intracranial pressure.

See also

Related Research Articles

<span class="mw-page-title-main">Tracheal intubation</span> Placement of a tube into the trachea

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction.

<span class="mw-page-title-main">Pulmonary aspiration</span> Entry of materials into the larynx (voice box) and lower respiratory tract

Pulmonary aspiration is the entry of solid or liquid material such as pharyngeal secretions, food, drink, or stomach contents from the oropharynx or gastrointestinal tract, into the trachea and lungs. When pulmonary aspiration occurs during eating and drinking, the aspirated material is often colloquially referred to as "going down the wrong pipe".

<span class="mw-page-title-main">Pulmonology</span> Study of respiratory diseases

Pulmonology, pneumology or pneumonology is a medical specialty that deals with diseases involving the respiratory tract. It is also known as respirology, respiratory medicine, or chest medicine in some countries and areas.

<span class="mw-page-title-main">Interstitial lung disease</span> Diseases of the space or tissue between the alveoli of the lungs

Interstitial lung disease (ILD), or diffuse parenchymal lung disease (DPLD), is a group of respiratory diseases affecting the interstitium and space around the alveoli of the lungs. It concerns alveolar epithelium, pulmonary capillary endothelium, basement membrane, and perivascular and perilymphatic tissues. It may occur when an injury to the lungs triggers an abnormal healing response. Ordinarily, the body generates just the right amount of tissue to repair damage, but in interstitial lung disease, the repair process is disrupted, and the tissue around the air sacs (alveoli) becomes scarred and thickened. This makes it more difficult for oxygen to pass into the bloodstream. The disease presents itself with the following symptoms: shortness of breath, nonproductive coughing, fatigue, and weight loss, which tend to develop slowly, over several months. The average rate of survival for someone with this disease is between three and five years. The term ILD is used to distinguish these diseases from obstructive airways diseases.

<span class="mw-page-title-main">Laryngeal papillomatosis</span> Medical condition

Laryngeal papillomatosis, also known as recurrent respiratory papillomatosis (RRP) or glottal papillomatosis, is a rare medical condition in which benign tumors (papilloma) form along the aerodigestive tract. There are two variants based on the age of onset: juvenile and adult laryngeal papillomatosis. The tumors are caused by human papillomavirus (HPV) infection of the throat. The tumors may lead to narrowing of the airway, which may cause vocal changes or airway obstruction. Laryngeal papillomatosis is initially diagnosed through indirect laryngoscopy upon observation of growths on the larynx and can be confirmed through a biopsy. Treatment for laryngeal papillomatosis aims to remove the papillomas and limit their recurrence. Due to the recurrent nature of the virus, repeated treatments usually are needed. Laryngeal papillomatosis is primarily treated surgically, though supplemental nonsurgical and/or medical treatments may be considered in some cases. The evolution of laryngeal papillomatosis is highly variable. Though total recovery may be observed, it is often persistent despite treatment. The number of new cases of laryngeal papillomatosis cases is approximately 4.3 cases per 100,000 children and 1.8 cases per 100,000 adults annually.

<span class="mw-page-title-main">Hypersensitivity pneumonitis</span> Medical condition

Hypersensitivity pneumonitis (HP) or extrinsic allergic alveolitis (EAA) is a syndrome caused by the repetitive inhalation of antigens from the environment in susceptible or sensitized people. Common antigens include molds, bacteria, bird droppings, bird feathers, agricultural dusts, bioaerosols and chemicals from paints or plastics. People affected by this type of lung inflammation (pneumonitis) are commonly exposed to the antigens by their occupations, hobbies, the environment and animals. The inhaled antigens produce a hypersensitivity immune reaction causing inflammation of the airspaces (alveoli) and small airways (bronchioles) within the lung. Hypersensitivity pneumonitis may eventually lead to interstitial lung disease.

<span class="mw-page-title-main">Pneumonitis</span> General inflammation of lung tissue

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Community-acquired pneumonia (CAP) refers to pneumonia contracted by a person outside of the healthcare system. In contrast, hospital-acquired pneumonia (HAP) is seen in patients who have recently visited a hospital or who live in long-term care facilities. CAP is common, affecting people of all ages, and its symptoms occur as a result of oxygen-absorbing areas of the lung (alveoli) filling with fluid. This inhibits lung function, causing dyspnea, fever, chest pains and cough.

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<span class="mw-page-title-main">Ventilator-associated pneumonia</span> Pneumonia due to use of ventilator

Ventilator-associated pneumonia (VAP) is a type of lung infection that occurs in people who are on mechanical ventilation breathing machines in hospitals. As such, VAP typically affects critically ill persons that are in an intensive care unit (ICU) and have been on a mechanical ventilator for at least 48 hours. VAP is a major source of increased illness and death. Persons with VAP have increased lengths of ICU hospitalization and have up to a 20–30% death rate. The diagnosis of VAP varies among hospitals and providers but usually requires a new infiltrate on chest x-ray plus two or more other factors. These factors include temperatures of >38 °C or <36 °C, a white blood cell count of >12 × 109/ml, purulent secretions from the airways in the lung, and/or reduction in gas exchange.

Bronchoalveolar lavage (BAL), also known as bronchoalveolar washing, is a diagnostic method of the lower respiratory system in which a bronchoscope is passed through the mouth or nose into an appropriate airway in the lungs, with a measured amount of fluid introduced and then collected for examination. This method is typically performed to diagnose pathogenic infections of the lower respiratory airways, though it also has been shown to have utility in diagnosing interstitial lung disease. Bronchoalveolar lavage can be a more sensitive method of detection than nasal swabs in respiratory molecular diagnostics, as has been the case with SARS-CoV-2 where bronchoalveolar lavage samples detect copies of viral RNA after negative nasal swab testing.

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<span class="mw-page-title-main">Tracheobronchial injury</span> Damage to the tracheobronchial tree

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<span class="mw-page-title-main">Foreign body aspiration</span> Medical condition

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<span class="mw-page-title-main">Double-lumen endobronchial tube</span> Tube for one-sided lung ventilation

A double-lumen endotracheal tube is a type of endotracheal tube which is used in tracheal intubation during thoracic surgery and other medical conditions to achieve selective, one-sided ventilation of either the right or the left lung.

<span class="mw-page-title-main">Advanced airway management</span>

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Acute eosinophilic pneumonia (AEP) is an uncommon, acute-onset form of eosinophilic lung disease which varies in severity. Though poorly understood, the pathogenesis of AEP likely varies depending on the underlying cause which may include smoking, inhalation exposure, medication, and infection. In most patients, AEP is idiopathic, or has no known cause.

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References

  1. ↑ Hormann, Karl (1999). "Gustav Killian and His Work-A Dawn of Endoscopy". J. Jpn. Bronchoesophagol. Soc. 50 (1): 31–36. doi:10.2468/jbes.50.31.
  2. ↑ Kollofrath O. Entfernung Eines Knochenstucks Aus Dem Rechten Bronchus Auf Naturlichem Wege Und Unter Anwendung Der Directen Laryngoskopie. Munch Med Wochenschr 1897;38:1038-1039.
  3. ↑ "Tracheo-bronchoscopy, esophagoscopy, and gastroscopy". St. Louis, Laryngoscope. 1907.
  4. ↑ Ikeda S, Tobayashi K, Sunakura M, Hatakeyama T, Ono R (August 1969). "[Diagnosis using a fiberscope--the respiratory organs]". Naika (in Japanese). 24 (2): 284–91. PMID   5352887.
  5. ↑ Kobayashi T, Koshiishi H, Kawate N, A dela Cruz CM, Kato H (1994). "The Performance of Prototype Videobronchoscopes: The Pentax Eb-Tm1830 and Eb-Tm1530". Journal of Bronchology & Interventional Pulmonology. 1 (2): 160–167.
  6. ↑ Paradis TJ, Dixon J, Tieu BH (Dec 2016). "The role of bronchoscopy in the diagnosis of airway disease". Journal of Thoracic Disease. 8 (12): 3826–3837. doi: 10.21037/jtd.2016.12.68 . PMC   5227188 . PMID   28149583.
  7. ↑ Daniels R (15 June 2009). Delmar's Guide to Laboratory and Diagnostic Tests. Cengage Learning. pp. 163–. ISBN   978-1-4180-2067-5 . Retrieved 30 May 2010.
  8. ↑ Rosbe KW, Burke K (2012). "Chapter 39. Foreign Bodies". In Lalwani A (ed.). CURRENT Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery (3rd ed.). New York, NY: The McGraw-Hill Companies. Retrieved July 16, 2012.
  9. 1 2 Yonker LM, Fracchia MS (2012). "Flexible bronchoscopy". Adv Otorhinolaryngol. Advances in Oto-Rhino-Laryngology. 73: 12–8. doi:10.1159/000334110. ISBN   978-3-8055-9931-3. PMID   22472222.
  10. ↑ Perotin JM, Dewolf M, Launois C, Dormoy V, Deslee G (March 2021). "Bronchoscopic management of asthma, COPD and emphysema". Eur Respir Rev. 30 (159): 200029. doi: 10.1183/16000617.0029-2020 . PMC   9488643 . PMID   33650526.
  11. 1 2 Alpert, Marcus; Htwe, Yu Maw (2024). "Flexible bronchoscopy and bronchoalveolar lavage (BAL)". J Med Insight. 2024 (448). doi:10.24296/jomi/448.
  12. ↑ Reynisson PJ, Leira HO, Hernes TN, Hofstad EF, Scali M, Sorger H, Amundsen T, Lindseth F, Langø T (July 2014). "Navigated bronchoscopy: a technical review". J Bronchology Interv Pulmonol. 21 (3): 242–64. doi: 10.1097/LBR.0000000000000064 . PMID   24992135.
  13. ↑ Patolia, Setu; Farhat, Rania; Subramaniyam, Rajamurugan (August 2021). "Bronchoscopy in intubated and non-intubated intensive care unit patients with respiratory failure". Journal of Thoracic Disease. 13 (8): 5125–5134. doi: 10.21037/jtd-19-3709 . PMC   8411155 . PMID   34527353.
  14. ↑ Singh, Suveer (2023-10-13), Singh, Suveer; Pelosi, Paolo; Conway Morris, Andrew (eds.), "Bronchoscopy in Critical Care", Oxford Textbook of Respiratory Critical Care, Oxford University PressOxford, pp. 183–194, doi:10.1093/med/9780198766438.003.0019, ISBN   978-0-19-876643-8 , retrieved 2024-10-17
  15. ↑ Röder, Maire; Ng, Anthony Yong Kheng Cordero; Conway Morris, Andrew (2024-10-09). "Bronchoscopic Diagnosis of Severe Respiratory Infections". Journal of Clinical Medicine. 13 (19): 6020. doi: 10.3390/jcm13196020 . ISSN   2077-0383. PMC   11477651 .
  16. ↑ Du Rand, I A; Blaikley, J; Booton, R; Chaudhuri, N; Gupta, V; Khalid, S; Mandal, S; Martin, J; Mills, J; Navani, N; Rahman, N M; Wrightson, J M; Munavvar, M; on behalf of the British Thoracic Society Bronchoscopy Guideline Group (August 2013). "British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE". Thorax. 68 (Suppl 1): i1–i44. doi:10.1136/thoraxjnl-2013-203618. ISSN   0040-6376. PMID   23860341.
  17. ↑ Kalil, Andre C.; Metersky, Mark L.; Klompas, Michael; Muscedere, John; Sweeney, Daniel A.; Palmer, Lucy B.; Napolitano, Lena M.; O'Grady, Naomi P.; Bartlett, John G.; Carratalà, Jordi; El Solh, Ali A.; Ewig, Santiago; Fey, Paul D.; File, Thomas M.; Restrepo, Marcos I. (2016-09-01). "Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society". Clinical Infectious Diseases. 63 (5): e61–e111. doi:10.1093/cid/ciw353. ISSN   1537-6591. PMC   4981759 . PMID   27418577.
  18. ↑ Torres, Antoni; Niederman, Michael S.; Chastre, Jean; Ewig, Santiago; Fernandez-Vandellos, Patricia; Hanberger, Hakan; Kollef, Marin; Li Bassi, Gianluigi; Luna, Carlos M.; Martin-Loeches, Ignacio; Paiva, J. Artur; Read, Robert C.; Rigau, David; Timsit, Jean François; Welte, Tobias (September 2017). "International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT)". European Respiratory Journal. 50 (3): 1700582. doi:10.1183/13993003.00582-2017. ISSN   0903-1936. PMID   28890434.
  19. ↑ Morris, A C.; Kefala, K; Simpson, A J; Wilkinson, T S; Everingham, K; Kerslake, D; Raby, S; Laurenson, I F; Swann, D G; Walsh, T S (2009-06-01). "Evaluation of the effect of diagnostic methodology on the reported incidence of ventilator-associated pneumonia". Thorax. 64 (6): 516–522. doi:10.1136/thx.2008.110239. ISSN   0040-6376. PMID   19213771.
  20. ↑ Zhang, Luming; Li, Shaojin; Yuan, Shiqi; Lu, Xuehao; Li, Jieyao; Liu, Yu; Huang, Tao; Lyu, Jun; Yin, Haiyan (2022-06-08). "The Association Between Bronchoscopy and the Prognoses of Patients With Ventilator-Associated Pneumonia in Intensive Care Units: A Retrospective Study Based on the MIMIC-IV Database". Frontiers in Pharmacology. 13. doi: 10.3389/fphar.2022.868920 . ISSN   1663-9812. PMC   9214225 . PMID   35754471.
  21. ↑ Röder, Maire; Ng, Anthony Yong Kheng Cordero; Conway Morris, Andrew (2024-10-09). "Bronchoscopic Diagnosis of Severe Respiratory Infections". Journal of Clinical Medicine. 13 (19): 6020. doi: 10.3390/jcm13196020 . ISSN   2077-0383. PMC   11477651 .
  22. ↑ Schnabel, R M; van der Velden, K; Osinski, A; Rohde, G; Roekaerts, P M H J; Bergmans, D C J J (December 2015). "Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients". BMC Pulmonary Medicine. 15 (1): 107. doi: 10.1186/s12890-015-0104-1 . ISSN   1471-2466. PMC   4588466 . PMID   26420333.
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