Bronchoscopy: Bronchoscopy is a technique of visualizing the inside of the airways for diagnostic and therapeutic purposes.

An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumors, or inflammation. Specimens may be taken from inside the lungs.

The diagnostic procedures of bronchoalveolar lavage, transbronchial needle aspiration (TBNA), and transbronchial biopsy can be performed during a bronchoscopy. Therapeutic Bronchoscopy Bronchoscopy can also play a therapeutic role. For example, bronchoscopy can be used in the treatment of airway obstruction by tumors or foreign bodies, during the removal of secretions

A bronchoscope is a soft (flexible) tube with an outer diameter as small as 2.2 mm and there are larger sizes for use with larger children and adults, with a tiny camera on the end which is inserted through the nose (or mouth) into the lungs. During a bronchoscopy procedure, a scope will be inserted through the nostril until it passes through the throat into the trachea and bronchi. The scope also allows the doctor to collect lung secretions and lung tissue for biopsy for tissue specimens. There are two types of bronchoscopy: 1) Flexible bronchoscopy uses a long, thin, lighted tube to look at your airway. The flexible bronchoscope is used more often than the rigid bronchoscope because it usually DOES NOT require general anesthesia, is more comfortable for the person, and offers a better view of the smaller airways. It also allows the doctor to remove small samples of tissue (biopsy). The flexible tube actually contains a fiber-optic system which attaches to a video camera and a source of light. The light travels through the scope and lights up the inside of the airway. The image seen at the tip of the scope is transmitted back again through the fiber-optic system to the video camera. Flexible bronchoscopy causes less discomfort for the patient than rigid bronchoscopy and the procedure can be performed easily and safely under moderate sedation. It is the technique of choice nowadays for most bronchoscopic procedures.

 Using Bowden cables connected to a lever at the hand piece, the tip of the instrument can be oriented, allowing the practitioner to navigate the instrument into individual lobe or segment bronchi. Most flexible bronchoscopes also include a channel for suctioning or instrumentation, but these are significantly smaller than those in a rigid bronchoscope.

2) Rigid bronchoscopy is usually done with general anesthesia and uses a straight, hollow metal tube. So it is done in the OR. It is used: When there is bleeding in the airway that could block the flexible scope's view. To remove large tissue samples for biopsy. To clear the airway of objects (such as a piece of food) that cannot be removed using a flexible bronchoscope. Fiberoptic bronchoscopy Better visualization Ability to navigate smaller segments @ bedside in ICU Poor ability to suction blood Less interventions Rigid bronchoscopy Better blood Suctioning More therapeutic interventions Needs OR Needs More Skills

Massive hemoptysis, defined as loss of >600 mL of blood in 24 hours (many different sources say different numbers) , is a

medical emergency and should be addressed with initiation of intravenous fluids and examination with rigid bronchoscopy. The larger lumen of the rigid bronchoscope versus the narrow lumen of the flexible bronchoscope allows for therapeutic approaches such as electrocautery to help control the bleeding. Fibreoptic bronchoscopy Under local anaesthesia and sedation, the central airways can be visualized down to subsegmental level and biopsies can be taken for histology. More distal lesions may be sampled by washing or blind brushing. Diffuse inflammatory and infective lung processes may be sampled by bronchoalveolar lavage and transbronchial biopsy.

Indications Lesions requiring biopsy seen on chest X-ray. Hemoptysis. Stridor. Positive sputum cytology for malignant cells with no chest X-ray abnormality. Collection of bronchial secretions for bacteriology, especially Tuberculosis.

 Recurrent laryngeal nerve paralysis of unknown etiology. Infiltrative lung disease (to obtain a transbronchial biopsy). Investigation of collapsed lobes or segments and aspiration of mucus plugs. Procedure The patient is starved overnight. Atropine 0.6 mg IM is given 30 min before the procedure, as an anticholinergic (muscarinic) to decrease the respiratory secretions, and to prevent oral secretions from obstructing the view Topical anesthesia (lidocaine 2% gel) is applied to the nose, nasopharynx and pharynx, to anesthetize the mucous membranes of the pharynx, larynx, and trachea Intravenous sedation (e.g. diazepam 10 mg or midazolam 2.510 mg) is given. The bronchoscope is passed through the nose, nasopharynx and pharynx under direct vision to minimize trauma. Lidocaine (2 mL of 4%) is dropped through the instrument on to the vocal cords. The bronchoscope is passed through the cords into the trachea. All segmental and subsegmental orifices should be identified.

 Biopsies and brushings should be taken of macroscopic abnormalities or occasionally from peripheral lesions under radiographic control.

Disadvantages All patients require sedation to tolerate the procedure (risk of cardiopulmonary arrest) Minor and transient cardiac dysrhythmias occur in up to 40% of patients on passage of the bronchoscope through the larynx. Monitoring is required. Oxygen supplementation is required in patients with PaO2 below 8 kPa. Fibreoptic bronchoscopy should be performed with care in the very sick, and transbronchial biopsies avoided in ventilated patients owing to the increased risk of pneumothorax. Massive bleeding may occur on accidental biopsy of vascular lesions or carcinoid tumors. Rigid bronchoscopy may be required (preferred) to allow adequate access to the bleeding point for hemostasis. Infections, such as pneumonia. These can usually be treated with antibiotics. Ongoing hoarseness. Laryngeal edema , laryngospasm

 You may be asked to take a deep breath so the scope can pass your vocal cords. It is important to avoid trying to talk while the bronchoscope is in your airway. The patient is monitored during the procedure with periodic blood pressure checks, continuous ECG monitoring of the heart, and pulse oximetry. If an abnormality is discovered, it may be sampled, using a brush, a needle, or forceps. Specimen of lung tissue (transbronchial biopsy) may be sampled using a realtime x-ray (fluoroscopy). An X-ray machine (fluoroscope) may be placed above you to provide a picture that helps your doctor see any devices, such as forceps to collect a biopsy sample, that are being moved into your lung. If your doctor collects sputum or tissue samples for biopsy, a tiny biopsy tool or brush will be used through the scope. A salt (saline) fluid may be used to wash your airway, and then the samples are collected and sent to the lab to be studied. Finally, small biopsy forceps may be used to remove a sample of lung tissue. This is called a transbronchial biopsy. Rigid bronchoscopy: This procedure is usually performed under general anesthesia. You will lie on your back on a table with your shoulders and neck supported by a pillow. You will be given a sedative to help you relax. You will have an intravenous line (IV) placed in a vein.

Once you are asleep, your head will be carefully positioned with your neck extended. A tube (endotracheal) will be placed in your windpipe (trachea) and a machine will help you breathe. Your doctor then slowly and gently inserts the bronchoscope through your mouth and into your windpipe. If your doctor collects sputum or tissue samples for biopsy, a tiny biopsy tool or a brush will be inserted through the scope. A salt (saline) fluid may be used to wash your airway, and then the samples are collected and sent to the lab for biopsy. Recovery after bronchoscopy Bronchoscopy by either procedure usually takes between 30 to 60 minutes. You will be in recovery for 1 to 3 hours after the procedure. Following the procedure: Do not eat or drink anything for about 2 hours, until you are able to swallow without choking. After that, you may resume your normal diet, starting with sips of water. Spit out your saliva until you are able to swallow without choking. Do not drive for at least 8 hours after the procedure. Do not smoke for at least 24 hours. Although most patients tolerate bronchoscopy well, a brief period of observation is required after the procedure. Most complications occur early and are readily apparent at the time of the procedure.

The patient is assessed for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema, laryngospasm, or bronchospasm). Monitoring continues until the effects of sedative drugs wear off and gag reflex has returned. If the patient has had a transbronchial biopsy, doctors may take a chest x-ray to rule out any air leakage in the lungs (pneumothorax) after the procedure. The patient will be hospitalized if there occurs any bleeding, air leakage (pneumothorax), or respiratory distress.