Bombay Hospital Journal ReviewsContentsHomeArchivesSearchBooksFeedback


DIAGNOSTIC BRONCHOSCOPY

Darshit D Dalal*, JJ Vyas**

*Senior Resident; **Prof and Head of Thoracic Service, Surgical Oncology, Tata Memorial Hospital, Parel, Mumbai - 400 012.


 

INTRODUCTION

The bronchoscope is quite indispensable in the study of thoracic diseases, for it provides an information that is unattainable in any other way.

INDICATIONS OF BRONCHOSCOPY

In many centres, bronchoscopy is an underused procedure, usually because its diagnostic potential is underrated or supposed danger is greatly exaggerated. But, the modern techniques of anaesthesia and ventilation make the procedure so safe that a patient must be gravely ill, or have quite gross reduction in his respiratory, before bronchoscopy becomes dangerous.

Indications are as follows:

  1. Patientís history
    The patientís symptoms together with the story of his illness are of paramount importance. The clinician should be prepared to undertake bronchoscopy on history alone.
  2. Profuse or repeated haemoptysis (however slight) with or without radiological abnormalities or physical signs.
  3. Cough of recent onset, unexplained and persistent, with or without sputum. Less well recognised, however of significance, is a change in cough habit which is frequently missed in chronic bronchitis, with their already long history of cough and sputum. Bronchial carcinoma quite frequently presents in this way.
  4. Wheeze of recent onset and persistent-
    Of particular significance is a unilateral wheeze which will not disappear on coughing or, if it does, always returns to the same place.
  5. Dyspnoea
  6. Aspiration
    The possibility of an aspirated foreign body, vomit or blood, particularly in children, must never be forgotten while taking the history.
  7. Radiological changes
    • Persistent or recurrent pneumonia
    • Pulmonary collapse
    • Typical enlarged hilar shadow
    • More peripheral shadow, particularly if persistent, enlarging. Much information about the segment or involved bronchus can be obtained without a view of the presumed tumour itself.
  8. Miscellaneous
    • Pleural effusion - to find out its cause
    • Pleuritic pain without effusion
    • Bonchiectasis
    • Severe chest trauma
    • Finding of malignant cells in sputum, even in absence of symptoms, physical signs or radiographic changes
  9. Extrathoracic indications-

    If extrathoracic manifestations are otherwise unexplained, bronchoscopy should be done.

    They are -

    • Lymphadenopathy in neck or axilla
    • Unexplained erythema nodosum
    • Superior vena caval obstruction
    • Hypertrophic pulmonary osteoarthropathy and/or digital clubbing
    • Neuromyopathies
    • Endocrine disturbances
    • Gynaecomastia
    • Voice changes due to left recurrent laryngeal nerve involvement in intrathoracic diseases

EXPLANATION TO THE PATIENTS

Patients should be explained for bronchoscopy by full but simple explanation. This includes explanation about premedication, induction of anaesthesia and after effects of the procedure like irritating cough lasting for a few minutes, occasional expectoration of blood following biopsy, soreness of mouth and throat.

RIGID BRONCHOSCOPY

The head is fully extended after keeping a pillow or a ring beneath it so that the chin points vertically upwards : in fact, the position usually assumed while shaving the chin. Dentures should be removed outside the operating room. The forefinger and thumb of the left hand form a supportive guide for the bronchoscope and protect the teeth or gums from trauma. Under no circumstances should be upper teeth or gum be used as a fulcrum to lever the bronchoscope into position.

The instrument is first introduced almost vertically, either via right side of the mouth or, in an edentulous patient, in the middle. As the scope is inserted further, its proximal end is brought downwards smoothly with slight movement of tip towards the pharynx. By this manoeuvre, the epiglottis can be seen. If this manoeuvre is done too rapidly, sometimes the clinician may enter epiglottic valleculae. Once the epiglottis is passed, laryngeal inlet is entered. Sometimes the clinician may enter the left pyriform fossa or the oesophagus. Once glottis is seen, the scope is advanced in the midline. The vocal cords should be examined. Tracheal walls, carina and bronchial tree must be examined.

Inspection must be carried out methodically. Secretions must be sucked out. Colour and condition of the mucosa must be examined. Any division, distortion of the tracheal/bronchial walls or the lumina and of the carina must be looked for. Right bronchial tree is easier to examine than the left because it is in the direct continuation with the trachea.

Withdrawal of bronchoscope also requires care. This should be done visually until the tip reaches the tongue. Vocal cord movements should be seen at this time.

FIBREOPTIC BRONCHOSCOPY

The introduction of the flexible bronchoscope, in the late 1960s, not only led to a remarkable increase of the diagnostic potential of the bronchoscopy, but to a revolution in the practice of thoracic medicine.

Advantages

Disadvantages

Method of introduction

The lens of the fibrescope must be treated with an antifogging agent.
  1. Normality

    The clinician should have a sound knowledge of bronchial anatomy. Fig. 1 shows branching, as encountered during passage of the bronchoscope.

    Fig 1
    Fig. 1 : Shows main branching of the bronchial tree, as visualised by the bronchoscopist operating at the head of the supine patient.

  2. Inflammatory and associated changes

    Inflammatory changes may be generalized (e.g. chronic bronchitis: Fig. 2) or localized (e.g. round a foreign body). They may be acute (e.g. associated with segmental pneumonia) or chronic (e.g. tuberculosis : Fig. 3).

    The inflammatory changes include:
    i. endobronchial inflammation
    ii. luminal distortion of trachea/bronchus due to extrabronchial
    .... lymphadenopathy.

Tumours

Bronchoscopically, tumours, or metastatic lymph node enlargement therefrom, may produce visible changes of 3 main types.

Tumour Bronchoscopic characteristics
i. Carcinoma Fleshy, lobulated or necrotic and white/creamy coloured. Presence of blood streaking and engorged vessels on the surface.
ii. Carcinoid Cherry red in colour, rounded, bleeds readily.
iii. Chondromata Smooth, pale surface. Hard consistency.
  1. Miscellaneous conditions

TAKING SPECIMENS

Obtaining specimens from the bronchial tree during endoscopy is a vital part of diagnosis. Specimens can be taken as follows:

  1. Secretions

    They are sucked gently with a sucker and sent for routine microscopy, culture/antibiotic sensitivity, cytology and other specific investigations.

  2. Bronchial lavage

    If secretions are not of adequate quantity or very thick to be sucked directly, the area can be lavaged with little quantity of normal saline and suckings are obtained.

  3. Scrappings

    Specimens are obtained by using swabs, sponges, brushes or curettes from the suspicious areas; especially when no visible growth is present.

  4. Endobronchial biopsy

    The lesion should be close to the bronchoscope tip and well within the visual field. Biopsy can be taken with punch or cut forceps.

  5. Needle aspiration

    A wide bore needle, sufficiently long to project beyond the bronchoscope tube is used to obtain material from the enlarged lymph nodes.

  6. Transbronchial lung biopsy

    This is one of the safest ways to obtain biopsies of the lung parenchyma. The procedure can be particularly helpful in elucidating diffuse diseases which have defied diagnosis by other means. e.g. possible pneumocystis carinii infection in immunosuppressed patients.

    Pneumothorax and haemorrhage are the possible complications. Pneumothorax may require drainage. Haemorrhage is not usually severe and stops by plugging the bronchus by the scope.

  7. Biopsy of peripheral lesions

    It is done under general anaesthesia. With advent of fibrescope and delicate instruments, this procedure has become more acceptable and safer.

CONTROL OF HAEMORRHAGE

Haemorrhage is usually due to biopsies, but sometimes follows sucking only. If mild to moderate, sucking only is required awaiting the natural clotting process. A small swab soaked in 1/1000 adrenaline is applied at the bleeding point for 2-3 minutes if needed.

Profuse haemorrhage such that the blood flows up the bronchoscope in a steady stream, or is clearly of arterial origin is rare. This may lead to asphyxia, cardiac arrest and death. Following are the cardinal rules to tackle this situation. *

The bronchoscope tube, the orifice of which should have been as near the point of biopsy as possible, must not be moved until the bleeding has stopped.

CONCLUSION

Diagnostic bronchoscopy has its own merits. Though associated with some complications (even major), it is safe in the expert hands. Claim is sometimes made by many that the flexible scope completely replaces the conventional rigid scopes; but this is not agreeable. The two instruments are complementary : the disadvantages of one reflect the advantages of the other.


      To Section TOC
      Sponsor-Dr. Reddy's Lab