Bronchoscopy is a diagnostic method that allows the doctor to examine the airways. This procedure is performed by introducing a special endoscopic instrument of the bronchoscope through the nose or mouth down the throat to reach the lungs. There are many different methods for diagnosing the respiratory system, such as bronchography, chest x-ray, chest CT, spirography - all of them are widely used, including bronchoscopy, which, in some cases, is vital.
Bronchoscopy first received clinical use in 1897, when Killian removed the pig bone from the German farmer's right main bronchus. Early clinical applications of bronchoscopy were limited to the removal of foreign bodies. With the improvement of lighting and optical technologies, in particular the Hopkins rod and lens system, bronchoscopy has become more widely used. Wood and Flink first described the use of a flexible bronchoscope in children in 1978. In 1981, fibrooptic bronchoscopes became small enough to be small enough for use in children. Since then, the use of flexible bronchoscopy has been rapidly increasing, as well as its improvement.
Types of bronchoscopy
Flexible bronchoscopy is done using a long, thin, lighted tube that is designed to look at the airways. A flexible bronchoscope is used more often than a rigid bronchoscope because it usually does not require general anesthesia, is more convenient for humans and offers a better view of the smaller airways. It also allows the doctor to remove small tissue samples (biopsy).
Solid bronchoscopy is usually performed with general anesthesia, and a straight metal tube is used during the procedure. It is used in the presence of bleeding, which can block the view for a flexible bronchoscope, also if you need to take large tissue samples for a biopsy, to remove foreign bodies in the airways that a flexible bronchoscope cannot handle.
Indications for bronchoscopy
Bronchoscopy is most often a diagnostic procedure that is done to diagnose: lung diseases, tumors, chronic cough, infections. Depending on the patient’s condition and disease, during bronchoscopy you can find: blood, mucus, signs of an infectious process, swelling, swelling, the presence of a foreign body, and a tumor.
Indications for bronchoscopy:
- to detect the cause of the problem (e.g., bleeding, chronic cough, shortness of breath);
- for taking tissue samples when other tests, such as a chest x-ray or CT scan, show problems with the lungs or lymph nodes in the chest;
- to diagnose lung disease by collecting tissue or mucus (sputum);
- to determine the degree of lung cancer;
- to remove foreign bodies that block the airways;
- for brachytherapy;
- for the diagnosis of bronchial tuberculosis (bronchoscopy is performed for differential diagnosis with other diseases).
Preparation for the procedure
Before starting the procedure, the patient needs to remove dentures, glasses, contact lenses, hearing aids, if any of the above is available. When bronchoscopy, a spray is used for local anesthesia, which is applied to the throat and nasal cavity. The patient may also be given a sedative to help him relax.
A patient who is prescribed bronchoscopy should not eat and drink 6-12 hours before the procedure, so it is worth undergoing bronchoscopy in the morning. It is worth consulting with a doctor about what medicines should be stopped before taking the procedure.
Before the procedure, the bladder should be emptied. It is necessary to take off all, or most of the clothes. The procedure is carried out by a pulmonologist and assistant. During the procedure, heart rate, blood pressure and blood saturation level will be checked. Before the procedure, a chest x-ray must be performed.
Before conducting a bronchoscopy, the doctor may prescribe other studies, such as: a general blood test, a coagulogram, functional lung tests.
Algorithm for conducting bronchoscopy
Flexible bronchoscopy algorithm
The patient lies on a table on his back with a pillow under his shoulders and neck, or leaning back in a special chair. Before the procedure, the doctor usually sprays a local anesthetic in the nose and mouth; anesthesia is usually not used. This reduces the gag reflex during the procedure. If a bronchoscope needs to be inserted through the nose, the doctor can also place an anesthetic ointment in the nose. The doctor carefully and slowly inserts a thin bronchoscope through the mouth (or nose) and advances it to the vocal cords. Then more anesthetic is sprayed through the bronchoscope to anesthetize the vocal cords. The patient is asked to take a deep breath, it is important not to try to talk while the bronchoscope is in the airways. The bronchoscope then moves down to examine the lower airways. If the procedure is to collect sputum samples, or tissue for biopsy, a special tiny tool or brush will be used. If there are indications, then the airways are washed with saline and the samples are sent to the laboratory.
Rigid bronchoscopy algorithm
This procedure is performed under general anesthesia. The patient lies on a table on his back, neck and shoulders supported by a pillow. The patient is connected to an artificial respiration apparatus. After that, a bronchoscope is inserted slowly and carefully through the mouth. And then the procedure is carried out as well as flexible bronchoscopy.
The doctor will report the results of bronchoscopy immediately, after the procedure, the doctor will give an opinion, or in a few days if tissue samples were taken for further research.
What does the patient feel during the procedure?
If general anesthesia was performed, then during the procedure the patient will not feel anything. There may be a feeling of pressure in the airways when the bronchoscope moves from one place to another. During bronchoscopy, the patient may experience a cough. After the procedure, a feeling of fatigue during the day is possible, a bitter taste in the mouth may be felt if local anesthesia was used. It is also possible a feeling of dry mouth, sore throat, difficulty swallowing after the procedure. If a biopsy was performed during bronchoscopy, the patient may spit out small blood clots, which is normal.
Contraindications to the procedure
Absolute contraindications include:
- uncontrolled, life-threatening arrhythmias;
- the inability to adequately oxygenate the patient during the procedure;
- acute respiratory failure with hypercapnia (if the patient is not intubated and ventilated);
- tracheal obstruction;
Relative contraindications include:
- non-contact patient;
- recent myocardial infarction;
- uncorrectable coagulopathy.
A transbronchial biopsy should be performed with caution in patients with uremia, obstruction of the superior vena cava, or pulmonary hypertension due to an increased risk of bleeding. However, airway examination is safe in these patients.
Extended and modified methods
Extended forms of visualization can sometimes be used, as they can provide more complete visualization. There are methods:
- Virtual bronchoscopy. During virtual bronchoscopy, computed tomography is used to see the airways in more detail, a bronchoscope is not used for this procedure, that is, it is not endoscopic, but a type of computed tomography.
- Endobronchial ultrasonography. During endobronchial ultrasonography, an ultrasound probe is used that attaches to the bronchoscope to see the airways.
- Fluorescence bronchoscopy. During fluorescence bronchoscopy, fluorescent light, which is attached to the bronchoscope, is additionally used, this allows you to see the inside of the lungs.
New methods of bronchoscopy:
- Bronchial thermoplasty: This new method is being developed to gently warm the airways in some patients with asthma. This reduces episodes of exacerbation of asthma.
- Reducing the volume of emphysema: small one-way valves are located in the airways of the damaged lung, they reduce the volume of this part and leave room for the functioning of the remnants of a normal lung.
- Resolving air leaks after resection of the lungs: One-way valves are used to slow air leakage along the seam lines of the lungs. With slower airflow, these leaks can heal faster and prevent the need for further surgery.
- Sanitation bronchoscopy, which is performed for therapeutic purposes.
Recovery after bronchoscopy
Bronchoscopy is performed relatively quickly, lasts about 30 minutes. Since after the procedure, the patient needs to recover and calm down, he will rest in the hospital for a couple of hours until he feels awake and the numbness in his throat disappears. Respiratory function and blood pressure should be monitored during recovery.
Immediately after the procedure, you can’t eat or drink anything until the sensation of numbness in the throat has completely passed, usually it takes from one to two hours. The patient will have to spit out saliva until he can swallow it without breathing, it is also contraindicated to drive for 8 hours after the procedure and smoke for a day.
It is also possible to preserve pain and discomfort in the throat for several days, the voice may hoarse. All these symptoms are normal, do not last long and go away on their own, without additional treatment.
Complications of the procedure
Bronchoscopy is a safe procedure, its implementation rarely causes complications. Complications that may occur include: bronchospasm, which may impair breathing; irregular heart rhythms (arrhythmias); infections such as pneumonia (usually they can be treated with antibiotics); persistent hoarseness.
If a biopsy was performed during bronchoscopy, the following complications may occur: partial collapse of the lung (pneumothorax), bleeding caused by biopsy forceps used to collect tissue, infection from the biopsy procedure.
Bronchoscopy in children
In pediatric practice, there is both rigid and flexible bronchoscopy, but still flexible is more widely used.
Bronchoscopy in children is used to diagnose abnormalities in the development of the respiratory system, to examine the nasal cavity, nasopharynx, larynx, trachea, bronchi and esophagus, and to diagnose the presence of inhalation of a foreign body. Flexible bronchoscopy, due to its small size, can even be used in newborns.
The procedure in children is carried out using anesthetics, sometimes using anesthesia, often during the procedure, children are injected with additional oxygen using face masks. The consequences in children are very rare, but they may include: excessive cough, fever, pneumothorax, excessive gag reflex with cough, transient laryngospasm, nosebleeds. The total frequency of complications in children, according to one study, is 6.7%.