Bronchoscopy is an important diagnostic tool that can also be used therapeutically. Both rigid ( Fig. 18.1 ) and flexible bronchoscopes ( Fig. 18.2 ) can be used, and both techniques have relative advantages and disadvantages. Although flexible bronchoscopy has largely replaced rigid bronchoscopy for diagnostic procedures, rigid bronchoscopy remains an important modality for therapeutic procedures. The newer technologies of navigational bronchoscopy and endobronchial ultrasound have extended the diagnostic utility of bronchoscopy to include the assessment of peripheral lung nodules and peribronchial lymph nodes.
Bronchoscopy can allow for pathologic diagnosis of endobronchial lesions; peribronchial mediastinal and hilar lymphadenopathy; and now for peripheral lung lesions. It also is an effective tool for diagnosis and management of hemoptysis, airway obstruction, tracheobronchomalacia, and foreign bodies in the airway.
Key Operative Learning Points
Flexible bronchoscopy can be done with local anesthetic and spontaneous respiration and allows evaluation down to the segmental and subsegmental airways. However, the diameter of the working channel for biopsy and suction is small.
Rigid bronchoscopy is stimulating and requires general anesthesia, and the scope can reach down only to the trachea and the main stem bronchi. However, the diameter of the scope is large and allows for better suctioning and doing biopsies and other procedures.
Electromagnetic bronchoscopy allows virtual bronchoscopy and the passage of a directable catheter out in to the lung parenchyma to allow biopsies of peripheral lung lesions to be undertaken.
Endobronchial ultrasound allows visualization and real-time imaging for biopsy of mediastinal and hilar lymph nodes via bronchoscopy ( Fig. 18.3 ).
What is the volume of the blood expectorated?
Is the blood bright red or dark in color?
Is it associated with any pneumonic symptoms or excessive mucous production?
Is the patient taking any anticoagulants?
Where there any preceding episodes?
Is the patient a past or present cigarette smoker?
Does the patient have a history of lung cancer or any risk factors for lung cancer?
The degree of dyspnea present; at rest or only with exertion?
The onset and duration of dyspnea
Is the dyspnea positional?
Any history of airway intervention in the past, such as oral tracheal intubation and mechanical ventilation (and for how long) or tracheostomy
Any history of Wegener disease?
Any history of foreign body aspiration?
The patient’s cardiorespiratory status should be evaluated, including cardiovascular stability and the degree of respiratory insufficiency.
Patient’s body habitus should be evaluated, as well as the patient’s degree of neck extension for oral tracheal intubation.
Evaluate for inspiratory or expiratory stridor, as well as the presence of distal airway wheezing (either unilateral or bilateral).
Evaluate for palpable cervical lymphadenopathy.
Evaluate the patient’s dentition and oral cavity, checking for any loose teeth.
Plain chest radiograph can be useful to evaluate tracheal narrowing, tracheal deviation, and lung parenchymal collapse or infiltrate. Gross mediastinal adenopathy and peripheral lung masses may also be apparent.
Computed tomography (CT) scan of the neck and chest can better evaluate the diameter of the airway, as well as the detection of lesions compressing the airway, either intrinsic airway lesions or lesions causing extrinsic compression. Will also demonstrate the presence and location of an aspirated foreign body. Any potentially pathologic lymph nodes or lesions of the lung parenchyma will be visualized. A CT scan may also show evidence of aspirated blood. If intravenous (IV) contrast is given, one can also evaluate for a potential pseudoaneurysm or the site of active bleeding.
Intraoperative fluoroscopy can be undertaken with bronchoscopic procedures, such as deployment of an airway stent and transbronchial biopsy of the lung.
Evaluation of patients with unexplained cough who do not have an obvious explanation, such as reactive airways disease or respiratory infection
Diagnosis of malignant disease. It could include biopsy of an endobronchial tumor, transbronchial aspiration of a mediastinal or hilar lymph node with the aid or endobronchial ultrasound, or biopsy of a more distal lesion in the lung parenchyma with electromagnetic navigational bronchoscopy.
Bronchoscopy can be used in patients who have hemoptysis to evaluate for the source of bleeding (either identification of an endobronchial lesion or, if the bleeding source is more distal, evaluation for which lobe or segment the blood is emanating from). Therapy can also be accomplished for hemoptysis with removal of blood clots from the airway, laser ablation of bleeding endobronchial tumors, or placement of balloon catheters to isolate bleeding portions of the lung.
Bronchoscopy can identify the site and degree of airway obstruction (diameter of residual airway and length of obstructing lesion). Interventions include débridement of obstructing endobronchial tumor with forceps or laser ablation and/or placement of endobronchial airway stents.
Bronchoscopy can also be used to evaluate and retrieve foreign bodies from the airway.
Lung washings and random transbronchial biopsies can be performed using bronchoscopy in the evaluation of patients with interstitial lung disease and infiltrates of unclear etiology in immunocompromised patients or patients who have undergone lung transplantation.
For patients with pulmonary abscess, occasionally bronchoscopy can be useful in establishing internal drainage of the abscess cavity to the airway.
Bronchoscopy can be used for clearing secretions for pulmonary toilet in patients with hypoxia and/or lung collapse not responding to more conservative respiratory measures.
Mediastinal lymph nodes can be affected by a spectrum of pathologic conditions, both benign and malignant. Although the overall clinical situation in addition to imaging may be suggestive of a diagnosis, in most cases pathologic confirmation by tissue diagnosis of mediastinal or hilar lymph nodes is usually required for a definitive diagnosis. Real-time bronchoscopic endobronchial ultrasound-guided visualization of intrathoracic lymph nodes can be accompanied by transbronchial needle aspiration for diagnosis. This technique can be useful for diagnosing infectious diseases, sarcoidosis, and lymphoma and for staging lung cancers or other cancers metastatic to the mediastinal lymph nodes (see Fig. 18.3 ).
Peripheral lung nodules located distal to the segmental and subsegmental airways can now also be biopsied bronchoscopically using electromagnetic navigational bronchoscopy. The patient is on a table that emits electromagnetic waves that are detected by a miniature receptor located at the tip of a directable catheter, which is introduced via the bronchoscope. The system is linked to a computer where the patient’s preloaded fine-cut CT scan serves as a virtual roadmap for the procedure. The probe on the end of the catheter can be directed to lesions that have been identified on the CT imaging. After the navigatable catheter has been moved into position the probe is removed, and biopsies can be obtained through the catheter.
Bronchoscopy can be used for placement of endobronchial catheters for brachytherapy.
Bronchoscopy can be used to facilitate placement of oral or nasal endotracheal tubes, particularly in patients with a difficult airway due to upper airway abnormalities or limited neck flexion or in patients who need to undergo an awake intubation. Bronchoscopy is also routinely used to confirm the correct positioning of double-lumen endotracheal tubes.
Patients undergoing rigid bronchoscopy need to be able to tolerate general anesthesia.
Patients with limited neck flexion may not be able to be positioned adequately to allow safe passage of the rigid bronchoscope.
In patient with hypoxia requiring high concentrations of oxygen, laser ablation of endobronchial lesions is contraindicated due to the risk of airway fire.
In patients with massive hemoptysis, flexible bronchoscopy is contraindicated because the capacity for blood aspiration through the small-diameter suction channel of the scope will not allow effective management.
Flexible bronchoscopy is contraindicated in patients with high-grade obstruction due to tracheal lesions, bilateral main stem bronchial lesions, or large extrinsically compressing mediastinal masses for which the surgeon is not confident that one can safely bag ventilate the patient after the induction of anesthesia.
The patient needs to be fluid resuscitated and hemodynamically stable for anesthesia.
Any coagulopathy needs to be treated with vitamin K and blood factors, as appropriate, prior to intervention.
Appropriate imaging needs to be performed and immediately available for review in the operating room during the procedure.
Depending on the diagnosis, the patient and his or her family need to be aware of the gravity of the situation, potential morbidity or mortality associated with the procedure, and potential need for postoperative ventilation.