Bronchoscopy is an

endoscopic An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...

technique of visualizing the inside of the

airway The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to ...

s for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a

tracheostomy Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe). The r ...

. This allows the practitioner to examine the patient's airways for abnormalities such as foreign bodies, bleeding,

tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

s, or

inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...

. 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.

History

The German

laryngologist The larynx (), commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about ...

Gustav Killian Gustav Killian (2 June 1860 – 24 February 1921) was a German laryngologist and founder of the bronchoscopy. Life and death His father Johann Baptist Caesar Killian (1820–1889), the son of a ''städtischen Wegeaufsehers'' an urban way overseer, ...

is attributed with performing the first bronchoscopy in 1897. Killian used a rigid bronchoscope to remove a pork bone. The procedure was done in an awake patient using topical

cocaine Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Ameri ...

as a

local anesthetic A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general a ...

. From this time until the 1970s, rigid bronchoscopes were used exclusively.

Chevalier Jackson Chevalier Quixote Jackson (November 4, 1865 – August 16, 1958) was an American pioneer in laryngology. He is sometimes known as the "father of endoscopy", although Philipp Bozzini (1773–1809) is also often given this sobriquet. Chevalier Q. J ...

, refined the rigid bronchoscope in the 1920s, using this rigid tube to visually inspect the

trachea The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air- breathing animals with lungs. The trachea extends from the ...

and mainstem bronchi. The British laryngologist

Victor Negus Sir Victor Ewings Negus, MS, FRCS (6 February 1887 – 15 July 1974) was a British surgeon who specialised in laryngology and also made fundamental contributions to comparative anatomy with his work on the structure and evolution of the larynx ...

, who worked with Jackson, improved the design of his endoscopes, including what came to be called the "Negus bronchoscope".

Shigeto Ikeda was a Japanese physician, regarded as the "father" of fiberoptic bronchoscopy. He graduated from Keio University , mottoeng = The pen is mightier than the sword , type = Private research coeducational high ...

invented the flexible bronchoscope in 1966. The flexible scope initially employed

fiberoptic An optical fiber, or optical fibre in Commonwealth English, is a flexible, transparent fiber made by drawing glass (silica) or plastic to a diameter slightly thicker than that of a human hair. Optical fibers are used most often as a means t ...

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. More recently, fiberoptic scopes have been replaced by bronchoscopes with a charge coupled device (CCD)

video chip A video display controller or VDC (also called a display engine or display interface) is an integrated circuit which is the main component in a video-signal generator, a device responsible for the production of a TV video signal in a computin ...

located at their distal end.

Types

Rigid

The rigid bronchoscope is a hollow metal tube used for inspecting the lower airway. 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. Rigid bronchoscopy is useful for recovering inhaled foreign bodies because it allows for protection of the airway and controlling the foreign body during recovery. Massive

hemoptysis Hemoptysis is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs. In other words, it is the airway bleeding. This can occur with lung cancer, infections such as tuberculosis, bronchitis, or pneumonia, a ...

, 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 Cauterization (or cauterisation, or cautery) is a medical practice or technique of burning a part of a body to remove or close off a part of it. It destroys some tissue in an attempt to mitigate bleeding and damage, remove an undesired growth, o ...

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 An eyepiece, or ocular lens, is a type of lens that is attached to a variety of optical devices such as telescopes and microscopes. It is named because it is usually the lens that is closest to the eye when someone looks through the device. The ...

or video camera at the opposite end. Using

Bowden cable A Bowden cable ( ) is a type of flexible cable used to transmit mechanical force or energy by the movement of an inner cable relative to a hollow outer cable housing. The housing is generally of composite construction, consisting of an inne ...

s 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 A bronchus is a passage or airway in the lower respiratory tract that conducts air into the lungs. The first or primary bronchi pronounced (BRAN-KAI) to branch from the trachea at the carina are the right main bronchus and the left main bronchus. ...

. 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

Diagnostic

* To view abnormalities of the

* To obtain tissue specimens of the inside the

lungs The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side ...

biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a dise ...

, bronchoalveolar lavage, or endobronchial brushing. * To evaluate a person who has bleeding in the

, possible

lung cancer Lung cancer, also known as lung carcinoma (since about 98–99% of all lung cancers are carcinomas), is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. Lung carcinomas derive from transformed, malign ...

, a chronic

cough A cough is a sudden expulsion of air through the large breathing passages that can help clear them of fluids, irritants, foreign particles and microbes. As a protective reflex, coughing can be repetitive with the cough reflex following three ph ...

, or

sarcoidosis Sarcoidosis (also known as ''Besnier-Boeck-Schaumann disease'') is a disease involving abnormal collections of inflammatory cells that form lumps known as granulomata. The disease usually begins in the lungs, skin, or lymph nodes. Less commonly a ...

Therapeutic

* To remove secretions, blood, or foreign objects lodged in the

Laser A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word "laser" is an acronym for "light amplification by stimulated emission of radiation". The fi ...

resection of

tumors A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

or benign tracheal and bronchial

strictures A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture' ...

Stent In medicine, a stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open, and stenting is the placement of a stent. A wide variety of stents are used for different purposes, from expandab ...

insertion to palliate extrinsic compression of the tracheobronchial lumen from either malignant or benign disease processes * For percutaneous

Tracheal intubation 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 frequentl ...

of patients with difficult airways is often performed using a flexible bronchoscope Interventional bronchoscopy in chronic obstructive airway inflammatory diseases including

asthma Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, co ...

and

COPD Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce ...

has greatly evolved and show promising results for the clinical management of patients.

Procedure

Bronchoscopy can be performed in a special room designated for such procedures, operating room,

intensive care unit 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensi ...

, or other location with resources for the management of airway emergencies. The patient will often be given

antianxiety An anxiolytic (; also antipanic or antianxiety agent) is a medication or other intervention that reduces anxiety (mood), anxiety. This effect is in contrast to anxiogenic agents which increase anxiety. Anxiolytic medications are used for the tre ...

and antisecretory medications (to prevent oral secretions from obstructing the view), generally atropine, and sometimes an analgesic such as

morphine Morphine is a strong opiate that is found naturally in opium, a dark brown resin in poppies (''Papaver somniferum''). It is mainly used as a pain medication, and is also commonly used recreationally, or to make other illicit opioids. T ...

. During the procedure, sedatives such as

midazolam Midazolam, sold under the brand name Versed among others, is a benzodiazepine medication used for anesthesia and procedural sedation, and to treat severe agitation. It works by inducing sleepiness, decreasing anxiety, and causing a loss of ...

or propofol may be used. A

is often given to anesthetize the

mucous membrane A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It i ...

s of the

pharynx The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus and trachea (the tubes going down to the stomach and the lungs). It is found in vertebrates and invertebrates, though its st ...

, larynx, and trachea. The patient is monitored during the procedure with periodic blood pressure checks, continuous

ECG Electrocardiography is the process of producing an electrocardiogram (ECG or EKG), a recording of the heart's electrical activity. It is an electrogram of the heart which is a graph of voltage versus time of the electrical activity of the hear ...

monitoring of the heart, and

pulse oximetry Pulse oximetry is a noninvasive method for monitoring a person's oxygen saturation. Peripheral oxygen saturation (SpO2) readings are typically within 2% accuracy (within 4% accuracy in 95% of cases) of the more accurate (and invasive) reading o ...

. A flexible bronchoscope is inserted with the patient in a sitting or

supine position The supine position ( or ) means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it grants access to the peritoneal, thoracic and pericardium, pericardi ...

. Once the bronchoscope is inserted into the upper airway, the

vocal cords In humans, vocal cords, also known as vocal folds or voice reeds, are folds of throat tissues that are key in creating sounds through vocalization. The size of vocal cords affects the pitch of voice. Open when breathing and vibrating for speec ...

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. If an abnormality is discovered, it may be

sampled Sample or samples may refer to: Base meaning * Sample (statistics), a subset of a population – complete data set * Sample (signal), a digital discrete sample of a continuous analog signal * Sample (material), a specimen or small quantity of so ...

using a brush, a needle, or forceps. Specimen of lung tissue (transbronchial

) may be sampled using a real-time

X-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...

(

fluoroscopy Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and function ...

) or an electromagnetic tracking system.Pall J. Reynisson et al. (2014). Navigated Bronchoscopy - A Technical Review. ''Interv Pulmonol.'' 21(3):242-264 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 Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing di ...

resulting from

laryngeal edema Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels tight, the area ma ...

laryngospasm Laryngospasm is an uncontrolled or involuntary muscular contraction (spasm) of the vocal folds. The condition typically lasts less than 60 seconds, but in cases partial blocking it may last 20 to 30 minutes and hinder inspiration, while exhala ...

, or

bronchospasm Bronchospasm or a bronchial spasm is a sudden constriction of the muscles in the walls of the bronchioles. It is caused by the release (degranulation) of substances from mast cells or basophils under the influence of anaphylatoxins. It causes di ...

). Monitoring continues until the effects of sedative drugs wear off and

gag reflex The pharyngeal reflex or gag reflex is a reflex muscular contraction of the back of the throat, evoked by touching the roof of the mouth, the back of the tongue, the area around the tonsils, the uvula, and the back of the throat. It, along with ot ...

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 A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...

) after the procedure. The patient will be hospitalized if there occurs any bleeding, pneumothorax, or

respiratory distress Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing di ...

Complications and risks

Besides the risks associated with the drugs used, there are also specific risks of the procedure. Although a rigid bronchoscope can scratch or tear

s or damage the vocal cords, the risk of bronchoscopy is limited. Complications from fiberoptic bronchoscopy remain extremely low. 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.

References

External links

Medical Encyclopedia - Bronchoscopy
{{Authority control Endoscopy Respiratory system procedures Veterinary diagnosis Articles containing video clips