Bronchoscopy

What is bronchoscopy?

Bronchoscopy is a procedure during which an examiner uses a viewing tube to evaluate a patient's lung and airways including the voice box and vocal cord, trachea, and many branches of bronchi. Bronchoscopy is usually performed by a pulmonologist or a thoracic surgeon. Although a bronchoscope does not allow for direct viewing and inspection of the lung tissue itself, samples of the lung tissue can be biopsied through the bronchoscope for examination in the laboratory.

There are two types of bronchoscopes:

• a flexible fiber optic bronchoscope and
• a rigid bronchoscope

Since the 1960s, the fiber optic bronchoscope has progressively outsmarted the rigid bronchoscope because of overall ease of use. In some patients, flexible fiber optic bronchoscopy can be performed without anesthesia, but in most cases, conscious sedation "twilight sleep") is utilized. However, rigid bronchoscopy requires general anesthesia and the services of an anesthesiologist. During the bronchoscopy, the examiner can see the tissues of the airways either directly by looking through the instrument or by viewing on a TV monitor.

Depending on the indication the examiner will choose between the flexible fiber optic bronchoscope and the rigid bronchoscope. For example, if a patient were coughing up large amounts of blood, a rigid bronchoscope is used since it has a large suction channel and allows for the use of instruments that can better control bleeding. The vast majority of bronchoscopies are performed using the flexible fiber optic scope because of the improved patient comfort and reduced use of anesthesia.

What are the indications for bronchoscopy?

Bronchoscopy can be used for diagnosis or treatment. Bronchoscopy is used to make a diagnosis most commonly for these conditions:

• blood in the sputum (coughed up mucus material from the lungs);
• evaluation of a possible lung infection;
• persistent or unexplained cough; or
• abnormal chest x-ray such as a mass, nodule, or inflammation in the lung

Bronchoscopy is used for treatment:

• to remove foreign bodies in the airway;
• to remove a mass or growth that is blocking the airway; or
• to place a stent (a tiny tube) to open a collapsed airway due to pressure by a mass or tumor

What are the potential complications of bronchoscopy?

Complications of bronchoscopy are relatively rare and most often minor. It is important to realize that all procedures may involve risk or complications from both known and unforeseen causes, because individual patients vary in their anatomy and response to medications. Therefore, there is no guarantee that a procedure can be free of complications. The following is a list of potential complications:

• Irregular heart beats
• Nose bleeding (epistaxis)
• Bleeding from the site of biopsy
• Damage to teeth (from rigid bronchoscopy)
• Vocal cord injury
• Lack of oxygen to the body's tissues
• Heart injury due to medications or lack of oxygen
• Punctured lung (pneumothorax)
• Complications from pre-medications or general anesthesia

How does a patient prepare for bronchoscopy?

Usually, prior to the procedure patients undergoing bronchoscopy should take nothing by mouth after midnight. Routine medications should be taken with sips of water except for those drugs that can enhance the risk of bleeding. These medications are aspirin products, blood thinners such as warfarin (Coumadin), and non-steroidal anti-inflammatory products such as ibuprofen. (Depending on the medication, these drugs must be discontinued at varying numbers of days before the procedure. Patients must consult their doctors for the appropriate schedule in their particular situation.) The doctor will also want to know of any drug allergies or major drug reactions that the patient may have experienced.

What is the expectation of a patient during bronchoscopy?

As the patient arrives in the bronchoscopy suite (or if the patient is already in the hospital), an intravenous catheter (IV) will be started for administration of medication and fluid. The patient is then connected to a monitor for continuous monitoring of:

• the heart rate,
• blood pressure, and
• oxygen level in the blood

If needed, supplemental oxygen will be supplied either through a ½ inch tube inserted into the nostrils (cannula) or a facemask. Medication is then given through the IV to make the patient feel relaxed and sleepy for the flexible fiber optic bronchoscopy. If rigid bronchoscopy is to be performed, an anesthesiologist will be present to induce and monitor the general anesthesia.

Patients will be lying on their back with oxygen supplemented through the mouth or the nose. Prior to the insertion of the flexible bronchoscope, a local anesthesia with topical lidocaine is given in the nose and to the back of the throat. The flexible bronchoscope can be introduced either through the mouth or the nose. Some patients may require a special tube called an endotracheal tube to be inserted through the mouth, passing the vocal cord, and into the trachea to protect and secure the airway. Once the bronchoscope is in the airway, an additional topical anesthetic will be sprayed into the airway for local anesthesia to minimize discomfort and coughing spells. The rigid bronchoscope is inserted by mouth only. This is usually done after the patient is under general anesthesia.

Flexible bronchoscopy rarely causes any discomfort or pain. Patients may feel the urge to cough because of the sensation of a foreign object in the "windpipe." Again, this feeling can be minimized by pre-procedural medication given for relaxation and local anesthesia with lidocaine. The procedure usually takes between 15 to 60 minutes. If a specific area needs to be more thoroughly evaluated or an abnormality is detected during the procedure, samples can be collected by several methods listed below:

• Washing - Squirts of salt water (saline) are injected through the bronchoscope into the area of interest and the fluid is then suctioned back. This process is repeated several times to obtain adequate samples, which are then submitted to the laboratory for analysis. Brushing - A soft brush is inserted through the bronchoscope to the area of interest. Cells around the airway are collected by brushing up and down the airway. The samples are also sent to the laboratory for analysis.
• Needle aspiration - A small needle is inserted into the airway and through the wall of the airway to obtain samples outside of the airway for analysis under a microscope.
• Forceps biopsy - Forceps may be used to biopsy either a visible lesion in the airway or a lung lesion. Abnormal tissue that is visible in the airway is usually easily biopsied. However, a mass that is in the lung tissue is deep within the lung and usually requires a biopsy using special x-ray guidance (fluoroscopy). Specimens obtained are sent to a pathologist for inspection under a microscope.

What can a patient expect after a bronchoscopy?

Patients are taken to an observation area for monitoring for one to two hours until any medication given adequately wears off and patients are able to swallow safely. A family member or a friend must take the patient home after the outpatient procedure. Patients are not allowed to drive or operate heavy machinery for the rest of the day because their reflexes and judgement may be impaired. Some patients may cough up dark-brown blood for the next one to two days after the procedure. This is expected and should not be alarming. However, if there is persistent bright red blood in the sputum, the doctor must be consulted immediately. A follow-up visit with the doctor is scheduled to review the laboratory results, which are typically available within one week.

What's new in bronchoscopy?

The bronchoscope is now being used with lasers to help remove and destroy tumor in the lungs. Sometimes, probes can be passed through the scope to freeze bleeding sites or to shrink tumors. Some newer technologies are on the horizon and may play a future role in the management of asthma and emphysema. Warming the linings of the airways can reduce asthma attacks.

Bronchoscopy at a Glance

• Bronchoscopy is a procedure that is performed by lung specialists (pulmonologists or thoracic surgeons) to diagnose or treat a variety of lung-related diseases.
• There are two types of bronchoscopes - flexible fiber optic and rigid.
• Bronchoscopy is relatively safe.
• Bronchoscopy is performed in various settings, including same-day outpatient bronchoscopy suite, operating room, hospital ward, and/or intensive care unit.