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Flexible bronchoscopy in adults: Indications and contraindications

Shaheen Islam, MD, MPH, FCCP
Section Editor
Praveen N Mathur, MB;BS
Deputy Editor
Geraldine Finlay, MD


Flexible bronchoscopy is a procedure that visualizes the lumen and mucosa of the trachea, proximal airways, and segmental airways to the third generation of branching. It can be used to diagnose or treat abnormalities within or adjacent to these airways.

The indications and contraindications of flexible bronchoscopy are discussed in this topic. The equipment, procedure and complications of flexible, fluorescence, and rigid bronchoscopy as well as endobronchial ultrasound and transbronchial needle aspiration techniques are discussed in detail elsewhere. (See "Flexible bronchoscopy in adults: Overview" and "Flexible bronchoscopy balloon dilation" and "Fluorescence bronchoscopy" and "Bronchoscopic laser in the management of airway disease in adults" and "Rigid bronchoscopy: Instrumentation" and "Transbronchial needle aspiration" and "Endobronchial ultrasound: Indications, contraindications, and complications".)


Flexible bronchoscopy is indicated for diagnostic or therapeutic reasons. These are discussed in the followings sections. Guidelines on the indications and contraindications of flexible bronchoscopy can be found at the British Thoracic Society.

Diagnostic indications — There are several diagnostic indications for flexible bronchoscopy. Following is a discussion of the common indications (table 1):

Evaluation of pneumonia or infiltrate of unclear etiology – Flexible bronchoscopy can obtain specimens as part of the evaluation for an infectious, opportunistic, or alternative etiology.

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Literature review current through: Nov 2017. | This topic last updated: Feb 01, 2017.
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  1. van der Eerden MM, Vlaspolder F, de Graaff CS, et al. Value of intensive diagnostic microbiological investigation in low- and high-risk patients with community-acquired pneumonia. Eur J Clin Microbiol Infect Dis 2005; 24:241.
  2. Feinsilver SH, Fein AM, Niederman MS, et al. Utility of fiberoptic bronchoscopy in nonresolving pneumonia. Chest 1990; 98:1322.
  3. Tan BB, Flaherty KR, Kazerooni EA, et al. The solitary pulmonary nodule. Chest 2003; 123:89S.
  4. Oki M, Saka H, Kitagawa C, et al. Novel thin bronchoscope with a 1.7-mm working channel for peripheral pulmonary lesions. Eur Respir J 2008; 32:465.
  5. Adams K, Shah PL, Edmonds L, Lim E. Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis. Thorax 2009; 64:757.
  6. Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e211S.
  7. Gong H Jr, Salvatierra C. Clinical efficacy of early and delayed fiberoptic bronchoscopy in patients with hemoptysis. Am Rev Respir Dis 1981; 124:221.
  8. Karmy-Jones R, Cuschieri J, Vallières E. Role of bronchoscopy in massive hemoptysis. Chest Surg Clin N Am 2001; 11:873.
  9. Nuutinen J. Acquired tracheobronchomalacia. A clinical study with bronchological correlations. Ann Clin Res 1977; 9:350.
  10. Liberman M. Bronchoscopic evaluation of the trachea and dilation of the trachea. Semin Thorac Cardiovasc Surg 2009; 21:255.
  11. Faro A, Visner G. The use of multiple transbronchial biopsies as the standard approach to evaluate lung allograft rejection. Pediatr Transplant 2004; 8:322.
  12. American Burn Association. Inhalation injury: diagnosis. J Am Coll Surg 2003; 196:307.
  13. Chu CP, Chen PP. Tracheobronchial injury secondary to blunt chest trauma: diagnosis and management. Anaesth Intensive Care 2002; 30:145.
  14. Kvale PA, Selecky PA, Prakash UB, American College of Chest Physicians. Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132:368S.
  15. Rank MA, Kelkar P, Oppenheimer JJ. Taming chronic cough. Ann Allergy Asthma Immunol 2007; 98:305.
  16. Brown KK. Chronic cough due to nonbronchiectatic suppurative airway disease (bronchiolitis): ACCP evidence-based clinical practice guidelines. Chest 2006; 129:132S.
  17. Karnak I, Senocak ME, Hiçsönmez A, Büyükpamukçu N. The diagnosis and treatment of H-type tracheoesophageal fistula. J Pediatr Surg 1997; 32:1670.
  18. McManigle JE, Fletcher GL, Tenholder MF. Bronchoscopy in the management of bronchopleural fistula. Chest 1990; 97:1235.
  19. York EL, Lewall DB, Hirji M, et al. Endoscopic diagnosis and treatment of postoperative bronchopleural fistula. Chest 1990; 97:1390.
  20. Islam S, Beamis JF. Autofluorescence bronchoscopy. Minerva Pneumol 2005; 44:1.
  21. Herth FJ, Eberhardt R, Anantham D, et al. Narrow-band imaging bronchoscopy increases the specificity of bronchoscopic early lung cancer detection. J Thorac Oncol 2009; 4:1060.
  22. Thiberville L, Moreno-Swirc S, Vercauteren T, et al. In vivo imaging of the bronchial wall microstructure using fibered confocal fluorescence microscopy. Am J Respir Crit Care Med 2007; 175:22.
  23. Newton RC, Kemp SV, Yang GZ, et al. Imaging parenchymal lung diseases with confocal endomicroscopy. Respir Med 2012; 106:127.
  24. Ussavarungsi K, Kern RM, Roden AC, et al. Transbronchial Cryobiopsy in Diffuse Parenchymal Lung Disease: Retrospective Analysis of 74 Cases. Chest 2017; 151:400.
  25. Sharp C, McCabe M, Adamali H, Medford AR. Use of transbronchial cryobiopsy in the diagnosis of interstitial lung disease-a systematic review and cost analysis. QJM 2017; 110:207.
  26. Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults. Ann Intern Med 1990; 112:604.
  27. Dellinger RP. Fiberoptic bronchoscopy in adult airway management. Crit Care Med 1990; 18:882.
  28. Wahidi MM, Herth FJ, Ernst A. State of the art: interventional pulmonology. Chest 2007; 131:261.
  29. Cox G, Miller JD, McWilliams A, et al. Bronchial thermoplasty for asthma. Am J Respir Crit Care Med 2006; 173:965.
  30. Herth F, Ernst A, Becker HD. Endoscopic drainage of lung abscesses: technique and outcome. Chest 2005; 127:1378.
  31. Unterman A, Fruchter O, Rosengarten D, et al. Bronchoscopic Drainage of Lung Abscesses Using a Pigtail Catheter. Respiration 2017; 93:99.
  32. Twehues A, Islam S. Cystic lesions of the thorax: role of endobronchial ultrasound-guided transbronchial needle aspiration. J Bronchology Interv Pulmonol 2011; 18:265.
  33. Toma TP, Kon OM, Oldfield W, et al. Reduction of persistent air leak with endoscopic valve implants. Thorax 2007; 62:830.
  34. Gillespie CT, Sterman DH, Cerfolio RJ, et al. Endobronchial valve treatment for prolonged air leaks of the lung: a case series. Ann Thorac Surg 2011; 91:270.
  35. Mehta HJ, Malhotra P, Begnaud A, et al. Treatment of alveolar-pleural fistula with endobronchial application of synthetic hydrogel. Chest 2015; 147:695.
  36. Hilbert G, Gruson D, Vargas F, et al. Bronchoscopy with bronchoalveolar lavage via the laryngeal mask airway in high-risk hypoxemic immunosuppressed patients. Crit Care Med 2001; 29:249.
  37. Baumann HJ, Klose H, Simon M, et al. Fiber optic bronchoscopy in patients with acute hypoxemic respiratory failure requiring noninvasive ventilation--a feasibility study. Crit Care 2011; 15:R179.
  38. Diaz-Fuentes G, Bajantri B, Adrish M. Safety of Bronchoscopy in Patients with Echocardiographic Evidence of Pulmonary Hypertension. Respiration 2016; 92:182.
  39. Schulman LL, Smith CR, Drusin R, et al. Utility of airway endoscopy in the diagnosis of respiratory complications of cardiac transplantation. Chest 1988; 93:960.
  40. Diaz-Guzman E, Vadi S, Minai OA, et al. Safety of diagnostic bronchoscopy in patients with pulmonary hypertension. Respiration 2009; 77:292.
  41. Wahidi MM, Rocha AT, Hollingsworth JW, et al. Contraindications and safety of transbronchial lung biopsy via flexible bronchoscopy. A survey of pulmonologists and review of the literature. Respiration 2005; 72:285.
  42. Dunagan DP, Burke HL, Aquino SL, et al. Fiberoptic bronchoscopy in coronary care unit patients: indications, safety, and clinical implications. Chest 1998; 114:1660.
  43. Dweik RA, Mehta AC, Meeker DP, Arroliga AC. Analysis of the safety of bronchoscopy after recent acute myocardial infarction. Chest 1996; 110:825.
  44. 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.
  45. Nandagopal L, Veeraputhiran M, Jain T, et al. Bronchoscopy can be done safely in patients with thrombocytopenia. Transfusion 2016; 56:344.
  46. Herth FJ, Becker HD, Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy. Chest 2002; 122:1461.
  47. Mehta NL, Harkin TJ, Rom WN, et al. Should renal insufficiency be a relative contraindication to bronchoscopic biopsy? J Bronchol 2005; 12:81.
  48. Bigsby R, Greengrass R, Unruh H. Diagnostic algorithm for acute superior vena caval obstruction (SVCO). J Cardiovasc Surg (Torino) 1993; 34:347.
  49. Peerless JR, Snow N, Likavec MJ, et al. The effect of fiberoptic bronchoscopy on cerebral hemodynamics in patients with severe head injury. Chest 1995; 108:962.
  50. Kerwin AJ, Croce MA, Timmons SD, et al. Effects of fiberoptic bronchoscopy on intracranial pressure in patients with brain injury: a prospective clinical study. J Trauma 2000; 48:878.
  51. Grosu HB, Morice RC, Sarkiss M, et al. Safety of flexible bronchoscopy, rigid bronchoscopy, and endobronchial ultrasound-guided transbronchial needle aspiration in patients with malignant space-occupying brain lesions. Chest 2015; 147:1621.
  52. Bulpa PA, Dive AM, Mertens L, et al. Combined bronchoalveolar lavage and transbronchial lung biopsy: safety and yield in ventilated patients. Eur Respir J 2003; 21:489.
  53. Abdelmalak B, Marcanthony N, Abdelmalak J, et al. Dexmedetomidine for anesthetic management of anterior mediastinal mass. J Anesth 2010; 24:607.
  54. Bahhady IJ, Ernst A. Risks of and recommendations for flexible bronchoscopy in pregnancy: a review. Chest 2004; 126:1974.
  55. D'Ippolito R, Foresi A, Castagnetti C, et al. Indications for flexible fiberoptic bronchoscopy and its safety in the very elderly. Monaldi Arch Chest Dis 2007; 67:23.
  56. Du Rand IA, Blaikley J, Booton R, et al. Summary of the British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults. Thorax 2013; 68:786.