Flexible bronchoscopy: Equipment, procedure, and complications
- Shaheen Islam, MD, MPH, FCCP
Shaheen Islam, MD, MPH, FCCP
- Associate Professor
- Ohio State University Medical Center
Bronchoscopy is a procedure that visualizes the tracheobronchial tree by placing an instrument inside the airways. The types of bronchoscopy are reviewed here. The equipment, technique, and complications of flexible bronchoscopy are also discussed. The indications and contraindications of flexible bronchoscopy are described separately. (See "Flexible bronchoscopy: Indications and contraindications".)
TYPES OF BRONCHOSCOPY
There are two main types of bronchoscopy: rigid and flexible. Virtual bronchoscopy is also available, but it is not common (table 1).
Rigid bronchoscopy — Rigid bronchoscopy is a procedure in which a straight metal tube with a beveled distal end is inserted into the trachea through the mouth (or the tracheostomy stoma) (picture 1 and picture 2), which facilitates the debulking of large tracheal or endobronchial tumors, the management of massive hemoptysis, and the insertion or removal of airway stents (table 2). The rigid bronchoscopy system consists of the rigid bronchoscope, a telescope, a light source, and a monitor to view the images (picture 3). Rigid bronchoscopy is reviewed separately. (See "Rigid bronchoscopy: Instrumentation".)
Flexible bronchoscopy — Flexible bronchoscopy is the most common type of bronchoscopy. The flexible bronchoscope is an instrument that is inserted through the mouth, a nasal orifice, an endotracheal tube, a tracheostomy tube, or a tracheostomy stoma and then used to visualize the vocal cords or tracheobronchial tree, and segmental airways out to the third generation of airways. It can also be used to sample lesions within the airways, adjacent to the airways, or in the lung parenchyma. Various endoluminal interventions to ablate tracheobronchial lesions can be administered via flexible bronchoscopy. Flexible bronchoscopy is generally performed in a procedure room (ie, a bronchoscopy suite) using moderate sedation. The flexible bronchoscope has a mechanism to flex or extend its distal end, which facilitates insertion through the curved airways. It also contains optical fibers or a small camera at the distal end to transmit images, a working channel, and a light source (figure 1 and figure 2) .
Variants — Several variants of traditional flexible bronchoscopy exist :
- Textbook of bronchoscopy, Feinsilver, SJ, Fein, AM (Eds), William & Wilkens, Baltimore 1995.
- Thoracic endoscopy: advances in interventional pulmonology, Simoff, MJ, Sterman, DH, Ernst, A (Eds), Oxford:Blackwell/Futura, Malden, MA 2006.
- Vining DJ, Liu K, Choplin RH, Haponik EF. Virtual bronchoscopy. Relationships of virtual reality endobronchial simulations to actual bronchoscopic findings. Chest 1996; 109:549.
- Boiselle PM, Ernst A. Recent advances in central airway imaging. Chest 2002; 121:1651.
- Ernst A, Silvestri GA, Johnstone D, American College of Chest Physicians. Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians. Chest 2003; 123:1693.
- Johnston AM, Batchelor NK, Wilson D. Evaluation of a disposable sheath bronchoscope system for use in the deployed field hospital. J R Army Med Corps 2014; 160:217.
- Wahidi MM, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients. Chest 2011; 140:1342.
- Grendelmeier P, Tamm M, Pflimlin E, Stolz D. Propofol sedation for flexible bronchoscopy: a randomised, noninferiority trial. Eur Respir J 2014; 43:591.
- Hautmann H, Henke MO, Bitterling H. High diagnostic yield from transbronchial biopsy of solitary pulmonary nodules using low-dose CT-guidance. Respirology 2010; 15:677.
- Rittirak W, Sompradeekul S. Diagnostic yield of fluoroscopy-guided transbronchial lung biopsy in non-endobronchial lung lesion. J Med Assoc Thai 2007; 90 Suppl 2:68.
- Gershman E, Fruchter O, Benjamin F, et al. Safety of Cryo-Transbronchial Biopsy in Diffuse Lung Diseases: Analysis of Three Hundred Cases. Respiration 2015; 90:40.
- Hernández-González F, Lucena CM, Ramírez J, et al. Cryobiopsy in the diagnosis of diffuse interstitial lung disease: yield and cost-effectiveness analysis. Arch Bronconeumol 2015; 51:261.
- Griff S, Schönfeld N, Ammenwerth W, et al. Diagnostic yield of transbronchial cryobiopsy in non-neoplastic lung disease: a retrospective case series. BMC Pulm Med 2014; 14:171.
- Pajares V, Puzo C, Castillo D, et al. Diagnostic yield of transbronchial cryobiopsy in interstitial lung disease: a randomized trial. Respirology 2014; 19:900.
- Mehta AC, Prakash UB, Garland R, et al. American College of Chest Physicians and American Association for Bronchology [corrected] consensus statement: prevention of flexible bronchoscopy-associated infection. Chest 2005; 128:1742.
- Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest 1995; 107:430.
- Jin F, Mu D, Chu D, et al. Severe complications of bronchoscopy. Respiration 2008; 76:429.
- Facciolongo N, Patelli M, Gasparini S, et al. Incidence of complications in bronchoscopy. Multicentre prospective study of 20,986 bronchoscopies. Monaldi Arch Chest Dis 2009; 71:8.
- Carr IM, Koegelenberg CF, von Groote-Bidlingmaier F, et al. Blood loss during flexible bronchoscopy: a prospective observational study. Respiration 2012; 84:312.
- Tukey MH, Wiener RS. Population-based estimates of transbronchial lung biopsy utilization and complications. Respir Med 2012; 106:1559.
- Ernst A, Eberhardt R, Wahidi M, et al. Effect of routine clopidogrel use on bleeding complications after transbronchial biopsy in humans. Chest 2006; 129:734.
- de Blic J, Marchac V, Scheinmann P. Complications of flexible bronchoscopy in children: prospective study of 1,328 procedures. Eur Respir J 2002; 20:1271.
- Culver DA, Gordon SM, Mehta AC. Infection control in the bronchoscopy suite: a review of outbreaks and guidelines for prevention. Am J Respir Crit Care Med 2003; 167:1050.
- Ramsey AH, Oemig TV, Davis JP, et al. An outbreak of bronchoscopy-related Mycobacterium tuberculosis infections due to lack of bronchoscope leak testing. Chest 2002; 121:976.
- TYPES OF BRONCHOSCOPY
- Rigid bronchoscopy
- Flexible bronchoscopy
- - Variants
- Virtual bronchoscopy
- TRAINING AND COMPETENCY
- Light source
- Image processor
- PATIENT SELECTION
- Informed consent
- Equipment and supplies
- Universal protocol
- ENTERING THE TRACHEOBRONCHIAL TREE
- AIRWAY INSPECTION
- Choosing the type of procedure
- Bronchoalveolar lavage
- Bronchial washing
- Endobronchial biopsy
- Transbronchial biopsy
- Needle aspiration
- OPERATOR HEALTH RISK
- POST-PROCEDURE MONITORING
- CLEANING THE BRONCHOSCOPE
- SUMMARY AND RECOMMENDATIONS