8. Bronchoscopy: types, sampling procedures, indications, contraindications, adverse events

Question 1

Types of Bronchoscopy used

Answer 1

Flexible and Rigid

Question 2

Procedure of Bronchoscopy

Answer 2

1. Patient should be given nothing orally for 6 hours before procedure and have IV access, intermittent BP monitoring, continuous pulse oxymetry and cardiac monitoring
2. Patients receive conscious sedation with short acting benzodiazepines, opioids or both before procedure to decrease anxiety, discomfort and cough. General anaesthesia is used when using Rigid bronchoscopy
3. Pharynx and Vocal cords are anaesthesized with nebulized or aerosolized lidocaine, or just sprayed using syringe
4. Bronchoscope lubricated and passed through mouth or artifical airway
5. After inspecting nasopharynx and larynx, passed through vocal cords during inspiration into trachea and then distally into bronchi
6. After procedure typically patients receive supplemental oxygen and observed for 2-4 hours
7. Return of gag reflex and maintanence of O2 saturation without O2 supplementation are the two primary signs of recovery

Question 3

5 Sampling types done through Bronchoscopy

Answer 3

1. Bronchial Washing: Saline is injected through bronchoscope and then aspirated from airways
2. Bronchial Brushing: a brush is introduced through scope and used to brush suspicious lesions to obtain cells
3. Bronchoalveolar Lavage: 50 to 200ml of Sterile Saline is infused in distal bronchoalveolar tree and then suctioned out, retrieving cells, proteins, pathogens located at alveolar level [Local Pulmonary edema caused by lavage may cause transient hypoxemia]
4. Transbronchial Biopsy: Forceps are advanced through scope and samples are obtained from parenchyma. Can be done without Xray but using fluoroscopy has shown better evidence for diagnostic yields. Xray after procedure is recommended
5. Transbronchial Needle Aspiration: a retractable needle is inserted through the scope and can be used to sample enlarged mediastinal lymph nodes or masses. Endobronchial US can be used as a guide

Question 4

Indications for Flexible Bronchoscopy

Answer 4

Dx:
- Abnormal CXR
- Etiology of Pneumonia in immunocompromised patients
- Etiology of recurrent/non resolbing infection in immunocompromised patients
- Patient with paratracheal/mediastinal/hilar/parenchymal mass or nodule
- Persistent Atelectasis
- Eval of transplant rejection
- Eval for airway in burn patients
- Eval of bronchial disruption in chest trauma
- Hemoptysis
- Lung cancer staging

Therapeutic:
- Aspiration of retained secretions
- Laser resection of tumour
- Brachytherapy
- Placement of airway stent
- Removal of foreign body

Question 5

Indications for Rigid Bronchoscopy

Answer 5

Used only when wider aperture and channels are required for
better visualization such as in:
- Investigating Vigorous Pulmonary hemorrhage
- Viewing and removing of aspirated foreign bodies in young children
- Viewing obstructive endobronchial lesions for possible laser debulking or stent placement

Question 6

Contraindications for Bronchoscopy

Answer 6

Absolute:
- Acute respiratory failure with hypercapnia
- High grade tracheal obstruction
- Inability to adequately oxygenate patient before procedure
- Untreatable life threatening Afib or arrhythmias

Relative:
- Recent MI
- Uncooperative patient
- Uncontrollable coagulopathy

Question 7

Adverse events that can happen due to Bronchoscopy

Answer 7

• Minor bleeding after biopsy at site and fever in 10 to 15% patients
• Increase in cough after lavage
• Bronchoscopy itself may cause arrhythmias [PAC, PVC, Brady], hypoxemia [in patients with compromised gas exchange], minor laryngeal edema and transmission of infection
• Mortality ~1-4/10,000 patients. Elderly patients with serious comorbidities are at greatest risk
• Transbronchial biopsy can cause Pneumothorax in 2-5% cases, significant hemorrhage in 1-1,5% cases or death in 0,1% cases
• Can increase risk of bleeding in uremic, SPV obstruction and Pulmonary HTN patients