Procedure

If an abnormality is present, you may choose to proceed with brushing, biopsy or lavage. Let me provide you a choice.

• Brushing:
  The cytology brush can be passed through the bronchoscope to the desired site and the lesion can be brushed. The brush resides inside a protective sheath. Retract the brush into the sheath after brushing. This procedure will avoid the loss of the specimen during withdrawal of the brush.
• Biopsy:
  Advance the biopsy forceps to the abnormal site. Familiarize yourself with opening and closing the forceps. Moving the handle forward opens the forceps. Do not use force to close the forceps, as you will break the springs. Under direct vision, advance the opened forceps to the selected site and close it to take a bite of the lesion.
• Lavage:
  Lavage: The indications for diagnostic lavage are:
  • Sarcoidosis
  • Diffuse interstitial fibrosis
  • Opportunistic infections

  Lavage returns and more frequently with the middle lobe and anterior segments. Wedge the bronchoscope into the selected segment. Slowly instill 20 cc's of saline and apply suction intermittently to collect the secretions. If you are lavaging for determining the cellular content of alveoli, start with an empty trap. Change the trap if it should overflow.

• Transbronchial Lung Biopsy:
  For peripheral lesions and diffuse lung disease, a transbronchial biopsy is indicated. I strongly recommend fluoroscopic guidance for this procedure. The following lists the value of fluoroscope:
  • It is absolutely necessary for placement of the forceps into peripheral lesions that are not visible endobronchially.
  • It ensures that the forceps are open.
  • It minimizes the risk of a pneumothorax.

  For diffuse lung diseases, I usually select the lateral segment of the right lower lobe. It is easier to identify the periphery of the lung in relation to the forceps against the lateral chest wall. Instruct the patient to give a sign if any pleuritic pain is felt.

  Place the bronchoscope in the lower lobe bronchus and identify the lateral basal segment. Instil 2 cc's of 2% xylocaine and 2 cc's of 1 in 1,000 solution of adrenaline. Adrenaline controls bleeding and is also found to yield better specimens!

  Advance the forceps into the segment to about 3 cms near the rib cage. Open the forceps and confirm the fluoroscopy. Instruct the patient to take a deep breath while you simultaneously advance the forceps. Advance the forceps until either it wedges, is close to the chest wall or the patient develops pleuritic pain.

  If the patient complains of pleuritic pain, withdraw the forceps slightly until there is no pain. Ask the patient to expire slowly. Close the forceps at the completion of expiration. Gently withdraw the forceps. You will note a tug on the lung.

  Advancement during inspiration enables the forceps to go as fare as possible into the lung. The end expiration will provide you with the most lung tissue for the biopsy.

  I take multiple biopsies (5-6) if there is no significant bleeding. Depending on the indication, the specimen should be sent for the following:

  • Histology in formalin
  • AFB and fungal cultures in saline
  • Immunofluorescent stains in saline immediately

  References:

  1. Cortese, DA, et al. Biopsy and brushing of peripheral lung lesions with fluoroscopic guidance. Chest 75:141-45, 1979.
  • Transbronchial Needle Aspiration:
    Transbronchial needle aspiration: The indications for transbronchial needle aspiration are:
    • Transcarinal: For purposes of lung cancer staging or for undiagnosed mediastinal nodes.
    • For peripheral pulmonary nodules.
    • At times, even for endobronchial lesions, it is particularly useful for a submucosal process where the standard biopsy forceps may fail to provide adequate tissue.

    The Wang double lumen retractable disposable needle is used for this purpose. The entire needle apparatus consists of a 120 cm long double lumen retractable needle system. An inner steel stylet is surrounded by two semitranslucent polyethylene sheaths. The inner sheath is tipped with a 22 gauge, 13 mm long needle.

    References:

    1. Wang, K, et al. Peripheral pulmonary nodules. Chest 86:819-23, 1984.
    2. Shure, D, et al. The role of transcarinal needle aspiration in the staging of bronchogenic carcinoma. Chest 86:693-6, 19__.
    3. Rosenthal, DL, et al. Fine needle aspiration of pulmonary lesions via fiberoptic bronchoscopy. Acta Cytological 28:203-10, 1984.
  • Triple Lumen Catheter:
    The development of the plugged, double sheathed, telescoping microbiology brush catheter offers a satisfactory method of sampling lower respiratory tract secretions without contamination from the inner channel of the bronchoscope.

    The bronchoscope should be positioned in the orifice of the affected pneumonic segmental bronchus. Under direct vision, the sterile catheter is advanced 1-2 cm beyond the tip of the bronchoscope. The inner telescoping cannula containing the sterile brush is advanced, thereby ejection the polyethylene glyco plug.

    The brush is further advanced beyond the inner cannula to enable sampling of secretions. It is then withdrawn into the inner cannula, prior to removing the catheter from the bronchoscope. The distal portion is then clipped with sterile scissors into the culture medium.

    References:

    1. Bordelon, JY, et al. The telescoping plugged catheter in suspected anaerobic infections. Am Rev Resp Dis 128:465-68, 1983.
    2. Prospective evaluation of the protracted specimen brush for the diagnosis of pulmonary infections in ventilated patients. Amer Rev Resp Dis 130:924-29, 1984.
    3. Glanville, AR, et al. The use of fiberoptic bronchoscopy with sterile catheter in the diagnosis of pneumonia. Austr NZ J Med 15:309-19, 1985.
  • Proceed with Bronchoscopy:
    There are various options we have in obtaining material from a bronchoscopy. The choice of the procedure depends upon the circumstances involved.
    • Endobronchial lesion: Brush and/or biopsy
    • Peripheral lesions and diffuse lung disease: Transbronchial biopsy
    • Diffuse lung disease: Lavage
    • Mediastinal nodes and peripheral nodules: Transbronchial needle
    • Pneumonia: Triple lumen sterile brush