Index
Also known as bronchoscopy is an endoscopic technique to visualize the inside of the respiratory tract for diagnostic and therapeutic purposes.
An instrument ( bronchoscope ) is inserted into the airways, usually through the nose or mouth and very rarely through a tracheotomy.
This allows the doctor to examine the patient’s airways for abnormalities such as foreign bodies, bleeding, tumors or inflammation.
Samples can be taken from inside the lungs.
The construction of bronchoscopes ranges from rigid metal tubes with lighting devices connected to flexible fiber optic instruments with video equipment in real time.
History
The first bronchoscopy was performed by the German, Gustav Killian. Killian used a rigid bronchoscope to extract a pig bone.
The procedure was performed on an awake patient using topical cocaine as a local anesthetic.
From this time until the 1970s, rigid bronchoscopes were used exclusively.
An American, Chevalier Jackson, refined the rigid bronchoscope in the 1920s, using this rigid tube to visually inspect the trachea and the main bronchi.
British laryngologist Victor Negus, who worked with Jackson, improved the design of his endoscopes, including what was called the “Negus bronchoscope.”
In 1966 the flexible bronchoscope was invented by the Japanese Shigeto Ikeda.
The flexible scope initially employed fiber optic bundles that require an external light source for illumination.
These scopes had outer diameters of approximately 5 mm to 6 mm, with a capacity to flex 180 degrees and extend 120 degrees, which allows entry to the lobar and segmental bronchi.
More recently, fiber optic telescopes have been replaced by bronchoscopes with a video-coupled charge device (CCD) chip located at its distal extremity.
Types of bronchoscope
Hard:
Rigid bronchoscopy is used to remove foreign objects.
The massive hemoptysis , defined as the greatest loss to 600 ml blood in 24 hours, is a medical emergency and should be approached with the start 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 bleeding.
Rigid bronchoscopy is preferred for recovery and aspiration of foreign body because it allows the protection of the respiratory tract and the control of the foreign body during recovery.
Flexible (fiber optic):
A flexible bronchoscope is longer and thinner than a rigid bronchoscope.
It contains a fiber optic system that transmits an image from the tip of the instrument to an eyepiece or a video camera at the opposite end.
Using Bowden cables connected to a lever on the handpiece, the tip of the instrument can be oriented, allowing the practitioner to navigate the instrument in individual lobes or bronchi in segments.
Most flexible bronchoscopes also include a suction channel or instrumentation, but these are significantly smaller than those of a rigid bronchoscope.
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 today for most bronchoscopic procedures.
Purposes of fiberoptic bronchoscopy
Diagnosis:
- To see abnormalities of the airway.
- To obtain tissue samples from the lung in a variety of disorders. Samples can be taken from inside the lungs by biopsy, bronchoalveolar lavage or endobronchial brushing.
- To evaluate a person who has bleeding in the lungs, possible lung cancer , chronic cough or sarcoidosis .
Therapeutic:
- To eliminate secretions, blood or foreign objects lodged in the respiratory tract.
- Laser resection of tumors or benign tracheal and bronchial stenosis.
- Stent insertion: to alleviate the extrinsic compression of the tracheobronchial lumen of malignant or benign processes generated by diseases.
- Bronchoscopy is also used in percutaneous tracheostomy.
- Tracheal intubation: of patients with difficult airways.
Preparation for fiberoptic bronchoscopy
A local anesthetic spray is applied to the nose and throat during a bronchoscopy. You will probably get a sedative to help you relax.
This means that you will be awake but asleep during the procedure.
Oxygen is usually given during a bronchoscopy. General anesthesia is very rarely used in this procedure.
You will have to avoid eating or drinking anything for 6 to 12 hours before the bronchoscopy. Before the procedure, ask your doctor if you should stop taking:
- Aspirin.
- Ibuprofeno (Advil).
- Warfarin .
- Other anticoagulants.
Bring someone to your appointment to take you home later or arrange transportation.
Process
The bronchoscopy can be performed in a special room designated for such procedures, operating room, intensive care unit or other location with resources for emergency management of the respiratory tract.
The patient will often receive anti-anxiety and antisecretory medications (to prevent oral secretions from obstructing vision), usually atropine, and sometimes an analgesic such as morphine.
During the procedure, sedatives such as midazolam or propofol can be used.
A local anesthetic is often administered to anesthetize the mucous membranes of the pharynx, larynx, and trachea.
The patient is monitored during the procedure with regular blood pressure checks, continuous ECG monitoring of the heart and pulse oximetry.
A flexible bronchoscope is inserted with the patient seated or in the supine position.
Once the bronchoscope is inserted into the upper airway, the vocal cords are inspected.
The instrument advances towards the trachea and towards the bronchial system and each area is inspected as the bronchoscope passes.
If an abnormality is discovered, a sample can be taken, using a brush, a needle or tweezers.
The sample of lung tissue (transbronchial biopsy) can be taken with X-rays ( fluoroscopy ) in real time or with an electromagnetic tracking system.
Flexible bronchoscopy can also be performed in intubated patients, such as patients in intensive care.
In this case, the instrument is inserted through an adapter connected to the tracheal tube.
Rigid bronchoscopy is performed under general anesthesia.
The rigid bronchoscopes are too large to allow the parallel placement of other devices in the trachea, therefore, the anesthesia apparatus is connected to the bronchoscope and the patient ventilates through the bronchoscope.
Fiberoptic bronchoscopy recovery
Although most patients tolerate bronchoscopy well, a brief observation period is required after the procedure.
Because fibrobronchoscopy is relatively quick since the patient will be sedated, he should rest in the hospital for a couple of hours until he feels more awake and the numbness in the throat disappears.
Breathing and blood pressure will be monitored during recovery.
You can not eat or drink anything until the throat is no longer numb.
This can take from one to two hours. Your throat may feel pain or itch for a couple of days, and it may be hoarse.
This is normal. It usually does not last long and disappears without medication or treatment.
Most complications occur early and are evident at the time of the procedure.
The patient is evaluated for respiratory distress (stridor and dyspnea as a result of laryngeal edema, laryngospasm or bronchospasm ).
If the patient has had a transbronchial biopsy, doctors can take a chest x-ray to rule out any air leaks in the lungs (pneumothorax) after the procedure.
The patient will be hospitalized if bleeding occurs, air leaks (pneumothorax) or respiratory distress.
Risks and complications
In addition to the risks associated with the medications used, there are also specific risks to the procedure.
Although a rigid bronchoscope can scratch or tear the airways or damage the vocal cords, the risk of bronchoscopy is limited.
The complications of fibrobronchoscopy remain extremely low. Common complications include excessive bleeding after the biopsy.
A lung biopsy can also cause an air leak, called a pneumothorax. Pneumothorax occurs in less than 1% of lung biopsy cases.
Laryngospasm is a rare complication, but sometimes it may require tracheal intubation.
Patients with tumors or significant bleeding may experience greater difficulty breathing after a bronchoscopic procedure, sometimes due to swelling of the mucous membranes of the airways.
Very rare but potentially fatal bronchoscopy risks include heart attack and lung collapse.
A collapsed lung may be due to a pneumothorax or an increase in pressure in the lung due to the release of air into the lung.
This results from a puncture of the lung during the procedure and is more common with a rigid bronchoscope than with a flexible fiber optic scope.
If air builds up around your lung during the procedure, your doctor may use a chest tube to remove the accumulated air.
New bronchoscopy techniques
- Bronchial thermoplasty: this new technique is being developed to gently warm the airways in some asthmatic patients. This decreases episodes of asthmaexacerbations .
- Volume reduction for emphysema: small one-way valves are placed in the airways of the damaged lung in an attempt to reduce the volume of that part of the lung and leave room for the remaining lung to function.
- Repair of air leaks after pulmonary resection: the same one-way valves are used to stop air leaks in the pulmonary suture lines. With the deceleration of the air flow, these leaks can heal faster and avoid the need for more surgeries.
