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Tracheobronchial Endoscopy


Key Points

  • Flexible and rigid bronchoscopy are essential diagnostic and therapeutic tools for management of thoracic diseases.

  • Diagnostic yields of navigation/guided bronchoscopy increase with (1) experience of the user, (2) the presence of a bronchus sign on CT imaging, and (3) use of fine needle aspiration biopsy.

  • Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) has high sensitivity for both benign and malignant disease and has been shown to be equivalent (or better) than mediastinoscopy for initial lung cancer staging.

  • Therapeutic bronchoscopy with various ablative modalities can improve quality and length of life in patients with central airway obstruction.

  • Patients with central airway obstruction are best served by a multidisciplinary team, including interventional pulmonology, thoracic surgery, head and neck surgery, anesthesiology, and medical/radiation oncology.

Indications

Diagnostic

Indications for diagnostic tracheobronchoscopy include the evaluation of acute or chronic respiratory symptoms, including hemoptysis, chronic cough, and dyspnea that may be accompanied by wheezing, stridor, or fever ( Box 71.1 ). These symptoms may be accompanied by radiographic abnormalities of infiltrates/consolidations, interstitial lung disease, lung nodules/masses, or mediastinal/hilar adenopathy.

Box 71.1
Indications for Tracheobronchoscopy

Diagnostic Evaluation

  • Chronic nonresolving or worsening cough, especially with signs of aspiration

  • Voice change and hoarseness

  • Stridor

  • Wheezing unresponsive to bronchodilator

  • Hemoptysis

  • Pulmonary infections (acute processes unresponsive to empiric therapy or recurrent infections)

  • Progressive dyspnea

  • Radiographic abnormalities:

    • Volume loss with suggestion of central airway obstruction

    • Lung nodules/masses

    • Infiltrate, localized, or diffuse

    • Mediastinal/hilar adenopathy

    • Nonresolving atelectasis

Therapeutic Interventions

  • Assistance in securing the airway

    • Intubation over the bronchoscope, confirmation of position of endotracheal tube, assistance with double-lumen intubation, and guidance for percutaneous tracheostomy

  • Removal of foreign body

  • Therapeutic aspiration of blood clots and mucous plugs

  • Relief of central airways obstruction, both nonmalignant and malignant causes

Therapeutic

A flexible bronchoscope can be used for a variety of therapeutic indications, including therapeutic aspiration of blood clots and mucous plugs, foreign body removal, and securing difficult airways. Notably, therapeutic bronchoscopy (primarily performed with a rigid bronchoscope) has been shown to improve quality and length of life by providing symptomatic relief of central airway obstructions (CAOs) from both malignant and benign etiologies.

Diagnostic Bronchoscopy

General Approaches and Visual Examination

Prior to performing any procedure, the indication, risks, benefits, and alternatives should be discussed with the patient. Bronchoscopy is generally an extremely safe procedure with the risks primarily dependent on the patient's underlying pulmonary disease and other comorbidities. Specific procedures carry additional risks. For example, the risk of pneumothorax associated with transbronchial biopsy (TBBx) is estimated at approximately 5%, and, hence, the physician needs to weigh the diagnostic yield of the procedure with the associated risks. Though TBBx is an excellent modality for diagnosing lymphangitic carcinomatosis, a surgical biopsy (although clearly more invasive) may be required to diagnose certain types of interstitial lung disease.

Starting in the oro- or nasopharynx, careful visual examination of the mucosal integrity and evaluation of vocal cord function are essential. A thorough understanding of airway anatomy is required and all airways should be examined because unexpected pathology can be discovered incidentally. Though deep sedation or general anesthesia may speed recovery and enhance patient satisfaction, moderate sedation is commonly performed and requires adequate topicalization of the airways. Because additional sensory anesthesia is not achieved with higher concentrations of lidocaine, and one can instill twice as much volume (i.e., cover more mucosa) with 1% versus 2% lidocaine before reaching toxic levels (6 to 8 mg/kg); a recent consensus statement recommended 1% lidocaine as the topical anesthetic of choice. The choice of moderate versus deep sedation versus general anesthesia should be made on a case-by-case basis with consideration given to the clinical status of the patient, available resources, duration and invasiveness of the procedure, and the underlying disease in question. For example, if one is performing the bronchoscopy to identify tracheobronchomalacia, the ability of the patient to perform dynamic expiratory breathing maneuvers can be quite beneficial, and, hence, moderate sedation should be used. Likewise, endobronchial ultrasound (EBUS) staging of the mediastinum, investigating all lymph nodes greater than 5 mm in diameter, may be better tolerated with deep sedation.

Evaluation of Infiltrates/Consolidations

Bronchial Wash/Bronchoalveolar Lavage

The widely used technique of bronchial washing or bronchial lavage during routine bronchoscopy is different from bronchoalveolar lavage (BAL). Bronchial washings and bronchial lavage sample material from the central airways, whereas BAL samples from the segmental or subsegmental bronchi and approximately 1 million alveoli with the goal of diagnosing infection, interstitial lung diseases (ILDs), and malignancy.

After identification of the lung region of interest, as identified by chest CT, the tip of the bronchoscope is advanced into a bronchial segment (or subsegment) until a wedge position is reached. Aliquots of sterile saline that range from 20 to 60 mL are gently infused, up to a total volume of 100 to 300 mL and the fluid is recovered by manual aspiration using the attached syringe or via gentle wall suction into a fluid trap. High levels of suction can result in airway collapse and trauma to the airway mucosa, resulting in reduced recovery volume and change in the fluid characterization.

Bronchoalveolar lavage is a minimally invasive technique with a low complication rate (0% to 2.3%) and no associated mortality. The most frequent complications of BAL are transient fever and decreased lung function. Fever, due to release of cytokines, transient bacteremia, and resorption of the fluid, occurs in up to 30% of patients, although it is typically self-limited and resolves within 24 hours. A transient change of lung function with a decreased vital capacity, FEV 1 , and oxygen tension has been reported. Clinically, cough, wheezing, or bronchospasm can occur after BAL. Serious complications can be seen in patients with severe lung or heart disease. Risk factors associated with major complications are extensive pulmonary infiltrates, PaO 2 less than 60 mm Hg, SpO 2 less than 90%, FEV 1 less than 1.0 L bleeding disorders (prothrombin time <50 s, platelet counts <20,000 platelets/mL), significant comorbidity, and bronchial hyperreactivity.

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