Video of the procedure

Indications

The indications for a bronchoscopy are many. The object in each setting is different.

Diagnostic:

• For Endobronchial Symptoms or Signs
  Symptoms and signs of endobronchial disease are the most common indications for a bronchoscopy.
  • Chronic cough
  • Hemoptysis
  • Atelectasis
  • Obstructive pneumonia
  • Localized wheezing
• Lung Cancer:
  Lung cancer is one of the most common conditions where a bronchoscopy is indicated. It is necessary for:
  • Tissue diagnosis
  • Staging
  • Early diagnosis
• Burn:
  Patients who sustained burns and suspected of having injuries to the respiratory passages are bronchoscoped.
• Assessment of the Endotracheal Tube Position:

Therapeutic

• Removal of Foreign Body:
  In general, foreign body removal is best done with a rigid bronchoscopy under general anesthesia.

  A fiberoptic bronchoscopy may be used as a screening procedure for suspected cases of aspiration. Patients with known or suspected foreign bodies should undergo a rigid bronchoscopy. If the evidence for aspiration is equivocal, patients should undergo a diagnostic flexible bronchoscopy, and then a rigid bronchoscopy if a foreign body is found.

  There have been reports of foreign body extraction using flexible bronchoscopes, but this is poorly suited for such work. I discourage its use for this purpose.

  Let me show you a chest x-ray of a patient who aspirated a tooth. One of my colleagues successfully removed it with a fiberoptic bronchoscopy.

  References:

  1. Hiller, C, et al. Foreign body removal with the flexible fiberoptic bronchoscopy. ________216-22.
  2. Wood, RE, et al. Flexible fiberoptic bronchoscopy in the management of tracheobronchial foreign bodies in children: The value of a combined approach with open tube bronchoscopy. J of Ped Surg 19:693-8, 1984.
  3. Zxavala, DC, et al. Foreign body removal. A new role for the fiberoptic bronchoscope. Ann Otol 84:650-____, 1975.

• Lung Abscess:
  To Rule out Endobronchial Lesion and for Drainage
• Tracheal Stenosis:
  For Dilation
• Refractory Atelectasis: With a Balloon Cuff
• Respiratory Toilette:
  Occasionally, a bronchoscopy will be indicated for respiratory toilette. As a general rule, postural drainage, tapotage, cough and suction of secretions are sufficient. If for some reason these cannot be done, then bronchoscopy can be done for respiratory toilette. Prospective studies have shown that a good intensive respiratory toilette can accomplish good results in the control of atelectasis. However, there are many clinical circumstances when respiratory toilette cannot ideally be accomplished. They are as follows:

• Spine injury
• Balloon pump
• Left lower lobe atelectasis
• Weekends

Blind passage of the catheter to the left lower lobe is difficult. Hence, the poor success rate with respiratory toilette with lower lobe atelectasis.

Staff availability on weekends for providing respiratory toilette is a problem and one is forced to resort to doing a bronchoscopy. While a bronchoscopy is relatively simple, it should not, in any way, replace the general principles of respiratory toilette.

References:

1. Stevens, RP, et al. Fiberoptic bronchoscopy in the intensive care unit. Heart and Lung 10:1037-45, 1981.
2. Barret, R. Flexible bronchoscopy in the critically ill patient. Methodology and Indications 73:746-9, 1978.

Preliminary to Other Procedures

• Pneumonia, Diffuse lung disease
  A bronchoscopy is a preliminary to many other procedures . A bronchoscopy has to be done at times to obtain respiratory secretions for establishing the diagnosis of an infection. The choice of brushing, triple lumen microbiology brush or broncho-alveolar lavage is made appropriate to the clinical situation. After inspection of the tracheobronchial tree, depending on the clinical situation, you can:
  • Brush
  • Biopsy
  • Transbronchial lung or mass biopsy
  • BAL
  • Triple lumen catheter
  • Lase

  
  A bronchoscope acts as a medium through which these accessories are introduced to the desired location to accomplish the task.

• Difficult Intubation:
  If you experience difficulty in intubation, a fiberoptic bronchoscope can be used to help you. The endotracheal tube is passed over the bronchoscope and, under direct vision, can be introduced into the trachea.

  References:

  1. Ovassapian, A, et al. Difficult pediatric intubation: An indication for the fiberoptic bronchoscope. Anesthesiology 56:412- 3, 1982.