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Bronchoscopy

Bronchoscopy is a medical procedure where a tube is inserted into the airways, usually through the nose or mouth. This allows the practitioner to examine inside a patient's airway for abnormalities such as foreign bodies, bleeding, tumors, or inflammation. The practitioner often takes samples from inside the lungs: biopsies, fluid (bronchoalveolar lavage), or endobronchial brushing. The practitioner may use either a rigid bronchoscope or flexible bronchoscope.

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History

A German, Gustav Killian, performed the first bronchoscopy in 1897. From then until the 1970s, doctors evaluated people’s airways using a rigid bronchoscope.

Rigid Bronchoscopy

A rigid bronchoscope is a straight, hollow, metal tube. Doctors perform rigid bronchoscopy less often today, but it remains the procedure of choice for removing foreign materials, as its increased thickness allows instruments to be more easily inserted through it. Rigid bronchoscopy also becomes useful when bleeding interferes with viewing the examining area, and allows for more interventions, such as cautery to stop the bleeding.

Flexible Bronchoscopy

A flexible bronchoscope is a long thin tube that contains small clear optical fibers that transmit light images as the tube bends. Its flexibility allows this instrument to reach further into the airway. The procedure can be performed easily and safely under local anesthesia. As flexible bronchoscopes become more advanced, it is likely that they will replace rigid bronchoscopes for most procedures.

Indications

Diagnostic Procedures

To view abnormalities of the airway
To obtain samples of an abnormality or specimens in undiagnosed infections
To obtain tissue specimens of the lung in a variety of disorders
To evaluate a person who has bleeding in the lungs, possible lung cancer, a chronic cough, or a collapsed lung

Therapeutic Procedures

To remove foreign objects lodged in the airway
Laser photocoagulation, electrocauterization, or argon plasma coagulation of exophytic tumors, granulation tissue, or benign lesions such as papilloma, hamartoma, lipoma, and adenoma
Laser resection of benign tracheal and bronchial strictures
Stent insertion to palliate extrinsic compression of the tracheobronchial lumen from either malignant or benign disease processes

Bronchoscopy - The Procedure

The bronchoscopy is performed in 1 of 3 areas:

A special room designated for such procedures
An operating room
An intensive care unit

The patient will be given antianxiety and antisecretory medications (to prevent oral secretions from obstructing the view), generally atropine (Atropair, I-Tropine) and morphine (Duramorph, Oramorph, Roxanol), half an hour before the procedure.

During the procedure, doctors provide an agent such as midazolam (Versed) to sedate although the patient would remain conscious. Lidocaine may also be used to anesthetize the upper airways.

The patient is monitored during the procedure with periodic blood pressure checks, continuous ECG monitoring of the heart and oxygen measurement. Monitoring is particularly important when the patient remains conscious during the procedure.

The doctor inserts a flexible bronchoscope through either the nose or mouth either in the sitting or lying down position.

Once the bronchoscope is inserted into the upper airway, the doctor examines the vocal cords. The doctor continues to advance the instrument to the trachea and further down into the bronchus, examining each area as the bronchoscope passes.

If doctors discover an abnormality, they may sample it, using a brush, a needle, or forceps.They also may sample a large number of alveoli. Doctors can obtain a specimen of lung tissue (transbronchial biopsy) often using a real-time x-ray (fluoroscopy).

After the procedure

Although most adults tolerate bronchoscopy well, doctors require that the patient remains under a brief period of observation.

Nurses watch closely for 2-4 hours following the procedure, usually every 15 minutes. the patient is kept in semi-fowler position. 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 or laryngospasm). Monitoring continues until the effects of sedative drugs wear off and gag reflex has returned. If the patient has had a transbronchial biopsy, doctors will take a chest x-ray to rule out any air leakage in the lungs (pneumothorax) after the procedure. The patient will be hospitalized if there occurs any bleeding, air leakage (pneumothorax), or respiratory distress.

Risks

Although the rigid bronchoscope can scratch or tear airway or damage the vocal cords, the risk for bronchoscopy is limited. The conditions for which doctors use it are ongoing, life-threatening cardiac problems or severely low oxygen.

Complications from fiberoptic bronchoscopy remain extremely low.

Common complications include either heart and blood vessel problems or excessive bleeding following biopsy. A lung biopsy also may cause leakage of air called pneumothorax. Pneumothorax occurs in less than 1% of cases requiring lung biopsy.

References

Medical Encyclopedia - Bronchoscopy
Aaron's Tracheostomy Page - Bronchoscopy