What is Bronchoscopy?
Bronchoscopy allows a doctor to examine the inside of a person's airway and lungs for any abnormality such as foreign bodies, bleeding, tumors, or inflammation. The doctor uses either a rigid bronchoscope or flexible bronchoscope.
- Gustav Killian, a German laryngologist, performed the first bronchoscopy in 1897. From then until the 1970s, doctors evaluated people's airways using a rigid bronchoscope.
- In the early 1970s, Ikeda introduced the flexible fiberoptic bronchoscope, which greatly enhanced the potential for the procedure. Since then, bronchoscopy has become an increasingly important diagnostic and therapeutic tool for the management of chest diseases. It is now perhaps the most common invasive procedure in the study and care of lungs. Doctors use it to:
- see abnormalities of the airway
- obtain samples of an abnormality or specimens in undiagnosed infections
- obtain tissue specimens of the lung in a variety of disorders
- evaluate a person who has bleeding in the lungs, possible lung cancer, a chronic cough, or a collapsed lung
- remove foreign objects lodged in the airway
- open the spaces of a blocked airway
- treat asthma and emphysema
- treat post-operative air leaks in the lung
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 material and for several other treatments. Rigid bronchoscopy also becomes useful when bleeding interferes with seeing the area.
Flexible bronchoscopy: A flexible bronchoscope is a long thin tube that contains small clear fibers that transmit light images as the tube bends. Its flexibility allows this instrument to reach further points in an airway than rigid bronchoscopy. The procedure can be performed easily and safely under local anesthesia.
Although the rigid bronchoscope can scratch or tear the airway or damage the vocal cords, the risk for bronchoscopy is limited. The main risks relate to the anesthesia necessary for performing the procedure. These risks depend on the health of the patient at the time of surgery. These risks usually can include a drop in blood pressure, cardiac events, stroke, and even death.
Complications from fiber optic bronchoscopy remain extremely low.
- Common complications may include shortness of breath, a drop in oxygen level during the procedure, chest pain, and cough.
- In addition, if a lung biopsy is necessary, it may cause leakage of air called a pneumothorax and/or bleeding from the lung. Pneumothorax occurs in less than 1% of cases requiring lung biopsy. The vast majority of bleeding stops with local therapy such as wedging the bronchoscope into the airway that is bleeding and waiting for it to stop. It is an extremely rare event for a patient to need surgery following persistent bleeding and even less common for death.
- Often mild anesthesia referred to as conscious sedation is used to help make the procedure more comfortable. This form of anesthesia also has risks such as a drop in blood pressure or a decrease in breathing. The bronchoscopist or anesthesiologist must have the skill sets to overcome these issues to assure that the procedure is safe.
- It is important to note that lung tissue has no pain fibers, therefore biopsy and examination is usually painless and often only involves coughing. The outer surface of the lung is known as the pleura and this does contain pain fibers. When this area is inflamed or damaged, a sharp chest pain known as pleurisy develops. This may be a sign of air leaking from the lung, the pneumothorax.
Prior to the procedure, the doctor will discuss the following with the patient:
- The need to do a bronchoscopy
- What doctors hope to achieve (take biopsy and visualize an area)
- The risks of the procedure
- Potential complications
The doctor also will do the following:
- Create an accurate medical history
- Examine the patient's lungs and heart
- Take a chest X-ray
- Perform appropriate blood tests if the patient has a high risk of bleeding or have significant medical problems.
The patient will be asked to fast for at least 6 hours before the procedure.
During the Bronchoscopy
- The bronchoscopy is performed in one of three areas:
- A special room designated for bronchoscopies and similar procedures
- An operating room
- An intensive care unit
- During the procedure, doctors provide an agent to sedate the patient (such as midazolam (Versed) and /or a narcotic (for example, fentanyl), although the patient remains conscious (so-called conscious sedation "twilight sleep"). Recently, propofol (a short acting , intravenous hypnotic agent) has become more commonly used as an anesthetic agent for bronchoscopies. Lidocaine also can be used to anesthetize the patient's upper airways.
- The patient will be monitored during the procedure with periodic blood pressure checks, respiratory rate, continuous electrocardiogram (ECG, EKG) monitoring of heart and oxygen measurement. Monitoring is extremely important in all forms of anesthesia.
- The doctor can insert a flexible bronchoscope through either the nose or mouth. The patient can be either sitting or lying down.
- Once the bronchoscope is inserted into the patient's upper airway, the doctor will examine the vocal cords. The doctor continues to advance the instrument to the trachea and on down, examining each area as the bronchoscope passes.
- If doctors discover an abnormality, they may sample it, using a brush, a needle, or forceps.
- Doctors can obtain a specimen of lung tissue (transbronchial biopsy) often using a real-time X-ray (fluoroscopy). This specimen contains actual lung tissue which may include samples of the air sacs, airways, blood vessels, and supporting membranes of the lungs.
After the Bronchoscopy
Although most adults tolerate bronchoscopy well, doctors require that the patient remain for a brief period of observation.
- Nurses will monitor the patient closely for 2 to 4 hours following the procedure.
- Most complications occur early and are readily apparent at the time of the procedure.
- The patient will be monitored until the effects of sedative drugs wear off and the 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 after the procedure.
- The patient may be hospitalized if he or she shows persistent bleeding, air leakage, or respiratory distress. Quite often any bleeding stops on its own and air leaks often seal quickly.
- Once the patient is released to go home, they should not drive. Effects of the sedative medications may be lingering.
Bronchoscopy Next Steps
The doctor will ask the patient return to the office to discuss the results of the procedure and to plan more tests or treatment if necessary.
Newer Bronchoscopy Techniques
Volume reduction for emphysema: small one way valves are place in the airways of damaged lung in an attempt to reduce the volume of that portion of lung and leave space for the remaining lung to function
Repair of air leaks following lung resection: the same one way valves are used to slow down air leaks at lung suture lines. With the slowing of airflow, these leaks may heal faster and prevent the need for further surgery.
When to Seek Medical Care after Bronchoscopy
Call a doctor if any of the following occur:
- You become increasingly short of breath.
- You develop increasing bleeding with a cough or chest pain.
- You feel ill or develop any other symptom.
When to go to the hospital
Go to the hospital's emergency department if you cannot reach your doctor and you develop sudden shortness of breath or bleeding with cough or severe chest pain.
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Medically reviewed by James E Gerace, MD; American Board of Internal Medicine with subspecialty in Pulmonary Disease
Cox, MB, et al. Asthma control during the year after bronchial thermoplasty. LaN Engl J Med 2007; 356:1327-1337
Ernst A, Anantham D. Review article; Bronchoscopic Lung Volume Reduction. Pulmonary Medicine. Volume 2011 (2011), Article ID 610802.
FDA.gov Press Release. FDA approves lung valve to control some air leaks after surgery. Oct 24,2008.
Gillespie CT, Sterman DH, Cerfolio RJ, Nader D, Mulligan MS, Mularski RA, Musani AI, Kucharczuk JC, Gonzalez X, Springmeyer SC. Endobronchial valve treatment for prolonged air leaks of the lung: a case series. Ann Thorac Surg. 2011. 91:270–273