Bronchoscopy

Bronchoscopy

Fig.2.15.

Definition

Bronchoscopy is a procedure in which a hollow, flexible tube called a bronchoscope is inserted into the airways through the nose or mouth to provide a view of the tracheobronchial tree. It can also be used to collect bronchial and/or lung secretions and to perform tissue biopsy.

(Fig 2.15.)
Bronchoscopy is a procedure in which a hollow, flexible tube is inserted into the airways, allowing the physician to visually examine the lower airways, including the larynx, trachea,bronchi, and bronchioles. It can also be used to collect specimens for bacteriological culture to diagnose infectious diseases such as tuberculosis.



Purpose

During a bronchoscopy, the physician can visually examine the lower airways, including the larynx, trachea, bronchi, and bronchioles. The procedure is used to examine the mucosal surface of the airways for abnormalities that might be associated with a variety of lung diseases. Its use may be diagnostic or therapeutic.

Bronchoscopy may be used to examine and help diagnose all of the following:

  • diseases of the lung, such as cancer or tuberculosis
  • congenital deformity of the lungs
  • suspected tumor, obstruction, secretion, bleeding, or foreign body in the airways
  • airway abnormalities, such as tracheal stenoses
  • persistent cough, or hemoptysis, that includes blood in the sputum

Bronchoscopy may also be used for the following therapeutic purposes:

  • remove a foreign body in the lungs
  • remove excessive secretions
  • remove tumors in the airway
  • treat stenosis (narrowing) of the airways, by using balloon dilatation or placing a stent

Bronchoscopy can also be used to collect the following biopsy specimens:

  • sputum
  • tissue samples from the bronchi or bronchioles
  • cells collected from washing the lining of the bronchi or bronchioles

If the purpose of the bronchoscopy is to take tissue samples, or biopsy, a forceps or bronchial brush are used to obtain cells. Alternatively, if the purpose is to identify an infectious agent, a bronchoalveolar lavage can be performed to gather fluid for culture purposes. If any foreign matter is found in the airways, it can be removed as well. Tumors can be debulked (made smaller) through the use of laser, electrocautery, or cryotherapy during the bronchoscopy. A balloon can be passed into a narrowed area of the airway and inflated in order to treat stenosis. A stent (tiny artificial tube) can be placed during bronchoscopy, in order to keep a portion of the airway open.

The instrument used in bronchoscopy, a bronchoscope, is a slender, flexible tube less than 0.5 in. (2.5 cm) wide and approximately 2 ft. (0.3 m) long that uses fiberoptic technology (very fine filaments that can bend and carry light). There are two types of bronchoscopes: a standard tube that is more rigid and a fiber-optic tube that is more flexible. The rigid instrument does not bend, does not see as far down into the lungs as the flexible one, and may carry a greater risk of causing injury to nearby structures. Because a standard tube can cause more discomfort than the flexible bronchoscope, it usually requires general anesthesia. However, it is useful for taking large samples of tissue and for removing foreign bodies from the airways. During the procedure, the airway is not blocked since oxygen can be supplied through the bronchoscope.



Description

Bronchoscopy is usually performed in an endoscopy room, but may also be performed at the bedside. The patient is placed on the back or sits upright. A pulmonologist, a specialist trained to perform the procedure, sprays an anesthetic into the patient's mouth or throat. When anesthesia has taken effect and the area is numb, the bronchoscope is inserted into the mouth and passed into the throat. If the bronchoscope is passed through the nose, an anesthetic jelly is inserted into one nostril. While the bronchoscope is moving down the throat, additional anesthetic is put into the bronchoscope to anesthetize the lower airways. The physician observes the trachea, bronchi, and the mucosal lining of these passageways looking for any abnormalities that may be present. If samples are needed, a bronchial lavage may be performed, meaning that a saline solution is used to flush the area prior to collecting cells for laboratory analysis. Very small brushes, needles, or forceps may also be introduced through the bronchoscope to collect tissue samples from the lungs. If the procedure is therapeutic in nature, laser, electrocautery, cryotherapeutic, or balloon dilatation instruments may be passed through the bronchoscope, and a stent may be placed.

Preparation

The patient should fast for 6 to 12 hours prior to the procedure and refrain fromdrinking any liquids the day of the procedure. Smoking should be avoided for 24 hours prior to the procedure, and patients should also avoid taking any aspirin or ibuprofen-type medications. The bronchoscopy itself takes about 45-60 minutes. Prior to the bronchoscopy, several tests are usually done, including a chest x ray and blood work. Sometimes a bronchoscopy is done under general anesthesia, in which case the patient will have an intravenous (IV) line in the arm. More commonly, the procedure is performed under local anesthesia, which is sprayed into the nose or mouth. This is necessary to inhibit the gag reflex. A sedative may also be given. A signed consent form is necessary for this procedure.

Aftercare

After the bronchoscopy, the vital signs (heart rate, blood pressure, and breathing) are monitored. Sometimes patients have an abnormal reaction to anesthesia. Any sputum should be collected in an emesis basin so that it can be examined for the presence of blood. If a biopsy was taken, the patient should not cough or clear the throat as this might dislodge any blood clot that has formed and cause bleeding. No food or drink should be consumed for about two hours after the procedure or until the anesthesia wears off. There is a significant risk for choking if anything (including water) is ingested before the anesthetic wears off and the gag reflex has returned. To test if the gag reflex has returned, a spoon is placed on the back of the tongue for a few seconds with light pressure. If there is no gagging, the process is repeated after 15 minutes. The gag reflex should return in one or two hours. Ice chips or clear liquids should be taken before the patient attempts to eat solid food. Patients should be informed that the throat may be irritated for several days.

Patients should notify their healthcare provider if they develop any of these symptoms:

  • hemoptysis (coughing up blood)
  • shortness of breath, wheezing, or any trouble breathing
  • chest pain
  • fever, with or without breathing problems

Risks

Use of the bronchoscope mildly irritates the lining of the airways, resulting in some swelling and inflammation, as well as hoarseness caused from abrading the vocal cords. If this abrasion is more serious, it can lead to respiratory difficulty or bleeding of the lining of the airways.

The bronchoscopy procedure is also associated with a small risk of disordered heart rhythm (arrhythmia), heart attacks, low blood oxygen (hypoxemia), and pneumothorax (a puncture of the lungs that allows air to escape into the space between the lung and the chest wall). These risks are greater with the use of a rigid bronchoscope than with a fiber-optic bronchoscope. If a rigid tube is used, there is also a risk of chipped teeth. The risk of transmitting infectious disease from one patient to another by the bronchoscope is also present. The Centers for Disease Control (CDC) reported cases of patient-to-patient transmission of infections following bronchoscopic procedures using bronchoscopes that were inadequately reprocessed by the automated endoscope reprocessing (AER) system. Investigation of the incidents revealed inconsistencies between the reprocessing instructions provided by the manufacturer of the bronchoscope and the manufacturer of the AER; or that the bronchoscopes were inadequately reprocessed.

Normal results

If the results of the bronchoscopy are normal, the windpipe (trachea) appears as smooth muscle with C-shaped rings of cartilage at regular intervals. There are no abnormalities either in the trachea or in the bronchi of the lungs.

Bronchoscopy results may also confirm a suspected diagnosis. This may include swelling, ulceration, or deformity in the bronchial wall, such as inflammation, stenosis, or compression of the trachea, neoplasm, and foreign bodies. The bronchoscopy may also reveal the presence of atypical substances in the trachea and bronchi. If samples are taken, the results could indicate cancer, disease-causing agents, or other lung diseases. Other findings may include constriction or narrowing (stenosis), compression, dilation of vessels, or abnormal branching of the bronchi. Abnormal substances that might be found in the airways include blood, secretions, or mucous plugs.