Bronchoscopy | Johns Hopkins Medicine

What is bronchoscopy?

Bronchoscopy is a procedure to look directly at the airways in the lungs
using a thin, lighted tube (bronchoscope). The bronchoscope is put in the
nose or mouth. It is moved down the throat and windpipe (trachea), and into
the airways. A healthcare provider can then see the voice box (larynx),
trachea, large airways to the lungs (bronchi), and smaller branches of the
bronchi (bronchioles).

There are 2 types of bronchoscope: flexible and rigid. Both types come in
different widths.

A rigid bronchoscope is a straight tube. It’s only used to view the larger
airways. It may be used within the bronchi to:

• Remove a large amount of secretions or blood

• Control bleeding

• Remove foreign objects

• Remove diseased tissue (lesions)

• Do procedures, such as stents and other treatments

A flexible bronchoscope is used more often. Unlike the rigid scope, it can
be moved down into the smaller airways (bronchioles). The flexible
bronchoscope may be used to:

• Place a breathing tube in the airway to help give oxygen

• Suction out secretions

• Take tissue samples (biopsy)

• Put medicine into the lungs

Why might I need bronchoscopy?

A bronchoscopy may be done to diagnose and treat lung problems such as:

• Tumors or bronchial cancer

• Airway blockage (obstruction)

• Narrowed areas in airways (strictures)

• Inflammation and infections such as tuberculosis (TB), pneumonia,
  and fungal or parasitic lung infections

• Interstitial pulmonary disease

• Causes of persistent cough

• Causes of coughing up blood

• Spots seen on chest X-rays

• Vocal cord paralysis

Diagnostic procedures or treatments that are done with bronchoscopy
include:

• Biopsy of tissue

• Collection of sputum

• Fluid put into the lungs and then removed (bronchoalveolar lavage
  or BAL) to diagnose lung disorders

• Removal of secretions, blood, mucus plugs, or growths (polyps) to
  clear airways

• Control of bleeding in the bronchi

• Removing foreign objects or other blockages

• Laser therapy or radiation treatment for bronchial tumors

• Placement of a small tube (stent) to keep an airway open (stent
  placement)

• Draining an area of pus (abscess)

Your healthcare provider may also have other reasons to advise a
bronchoscopy.

What are the risks of bronchoscopy?

In most cases, the flexible bronchoscope is used, not the rigid
bronchoscope. This is because the flexible type has less risk of damaging
the tissue. People can also handle the flexible type better. And it
provides better access to smaller areas of the lung tissue.

All procedures have some risks. The risks of this procedure may include:

• Bleeding

• Infection

• Hole in the airway (bronchial perforation)

• Irritation of the airways (bronchospasm)

• Irritation of the vocal cords (laryngospasm)

• Air in the space between the lung covering (pleural space) that
  causes the lung to collapse (pneumothorax)

Your risks may vary depending on your general health and other factors. Ask
your healthcare provider which risks apply most to you. Talk about any
concerns you have.

In some cases, a person may not be able to have a bronchoscopy. Reasons for
this can include:

• Severe narrowing or blockage of the trachea (tracheal stenosis)

• High blood pressure in the lungs’ blood vessels (pulmonary
  hypertension)

• Severe coughing or gagging

• Low oxygen levels

If you have high levels of carbon dioxide in the blood (hypercapnia) or
severe shortness of breath, you may need to be on a breathing machine
before the procedure. This is done so oxygen can be sent right into your
lungs while the bronchoscope is in place.

How do I get ready for bronchoscopy?

Give your healthcare provider a list of all of the medicines you take. This
includes prescription and over-the-counter medications, vitamins, herbs,
and supplements. You may need to stop certain medicines before the
procedure.

You will be asked to sign an informed consent document. This document
explains the benefits and risks of the procedure. Make sure all of your
questions are answered before you sign it.

If the procedure is being done on an outpatient basis, arrange to have
someone drive you home.

What happens during bronchoscopy?

You may have your procedure as an outpatient. This means you go home the
same day. Or it may be done as part of a longer stay in the hospital. The
way the procedure is done may vary. It depends on your condition and your
healthcare provider’s methods. In most cases, a bronchoscopy will follow
this process:

1. You may be asked to remove your clothes. If so, you will be given a
   hospital gown to wear. You may be asked to remove jewelry or other
   objects.

2. You will sit on a procedure table with the head raised like a
   chair.

3. An IV (intravenous) line may be put into your arm or hand.

4. You may be given antibiotics before and after the procedure.

5. You will be awake during the procedure. You will be given medicine
   to help you relax (sedative). You will also be given a liquid
   medicine to numb your nose and throat. For a rigid bronchoscopy,
   you will be given general anesthesia. This is medicine that
   prevents pain and lets you sleep through the procedure.

6. You may be given oxygen through a nasal tube or face mask. Your
   heart rate, blood pressure, and breathing will be watched during
   the procedure.

7. Numbing medicine will be sprayed into the back of your throat. This
   is to prevent gagging as the bronchoscope is passed down your
   throat. The spray may have a bitter taste to it. Once the tube
   passes down your throat the gagging feeling will go away.

8. You won’t be able to talk or swallow saliva during the procedure.
   Saliva will be suctioned from your mouth as needed.

9. The healthcare provider will move the bronchoscope down your throat
   and into the airways. You may have some mild pain. Your airway will
   not be blocked. You can breathe around the bronchoscope. You will
   be given extra oxygen if needed.

10. As the bronchoscope is moved down, the lungs will be examined.
    Tissue samples or mucus may be taken for testing. Other procedures
    may be done as needed. This may include giving medicine or stopping
    bleeding.

11. When the exam and other procedures are done, the bronchoscope will
    be taken out.

What happens after bronchoscopy?

After the procedure, you will spend some time in a recovery room. You may
be sleepy and confused when you wake up from general anesthesia or
sedation. Your healthcare team will watch your vital signs, such as your
heart rate and breathing.

A chest X-ray may be done right after the procedure. This is to make sure
your lungs are okay. You may be told to gently cough up and spit your
saliva into a basin. This is so a nurse can check your secretions for
blood.

You may have some mild pain in your throat. You will not be allowed to eat
or drink until your gag reflex has returned. You may notice some throat
soreness and pain with swallowing for a few days. This is normal. Using
throat lozenges or gargle may help.

If you had an outpatient procedure, you will go home when your healthcare
provider says it’s OK. Someone will need to drive you home.

At home, you can go back to your normal diet and activities if instructed
by your healthcare provider. You may need to not do strenuous physical
activity for a few days.

Call your healthcare provider if you have any of the below:

• Fever of 100.4°F (38°C) or higher, or as advised by your provider

• Redness or swelling of the IV site

• Blood or other fluid leaking from the IV site

• Coughing up significant amounts of blood

• Chest pain

• Severe hoarseness

• Trouble breathing

Your healthcare provider may give you other instructions after the
procedure.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure

• Who will do the test or procedure and what that person’s
  qualifications are

• What would happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how will you get the results

• Who to call after the test or procedure if you have questions or
  problems

• How much will you have to pay for the test or procedure

What is a bronchoscopy? | Procedure and Side-Effects

In this series Chest Infection Acute Bronchitis Pneumonia Aspiration Pneumonia Post-operative Chest Infection

A bronchoscopy is a test which can help to diagnose and treat conditions of your breathing. It involves a doctor sliding a flexible camera-tube into your lungs.

Note: The information below is a general guide only. The arrangements and the way tests are performed often vary between different hospitals.

Bronchoscopy

In this article

• What is a bronchoscopy?
• Who has a bronchoscopy?
• What happens during a bronchoscopy?
• What preparation do I need to do?
• What can I expect after a flexible bronchoscopy?
• Are there any side-effects or possible complications?

What is a bronchoscopy?

A bronchoscopy is a test where a doctor looks into your lungs with a thin, plastic camera tube.

Diagram showing how a bronchoscopy is performed

This photo shows a bronchoscope:

Bronchoscope

Håkon Olav Leira (Own work) via Wikimedia Commons

By Håkon Olav Leira (Own work) via Wikimedia Commons

A fibre-optic bronchoscope is the device usually used. This is a thin, flexible, telescope (shown in the diagram). It is about as thin as a pencil. You are usually awake during a bronchoscopy, but usually are sedated and made very sleepy. It is not painful.

The bronchoscope is passed through your nose or mouth, down the back of your throat, into your windpipe (trachea), and down into your bronchi. The fibre-optics allow light to shine around bends in the bronchoscope and so the doctor can see clearly inside your airways.

A rigid bronchoscope (not shown in diagram) is used much less often. It is like a thin, straight telescope. It may be needed for some procedures and in children. It requires a general anaesthetic. (A fibre-optic bronchoscopy only requires sedation.)

Both types of bronchoscope have a side channel down which thin instruments can pass. For example, a thin grabbing instrument can pass down to take a small sample (biopsy) from the inside lining of an airway, or from structures next to the airways.

Who has a bronchoscopy?

To help diagnose a problem

There are various reasons for having a bronchoscopy. For example, to help make a diagnosis if you have a persistent cough or cough up blood and the cause is not clear. If you have a shadow on a chest X-ray or the doctor sees a growth or a strange-looking area in a bronchus, the doctor may take a small sample (a biopsy) during a bronchoscopy. The sample is then looked at under the microscope to help decide whether problems such as inflammation, infection or cancer might be responsible for your symptoms. Bronchial lavage (described below) is also sometimes done during a bronchoscopy to help diagnose certain lung conditions.

To treat various problems

As mentioned, thin instruments can be passed down the side channel of a bronchoscope. Different instruments can do different things – for example:

• To remove a small object (such as an inhaled peanut) that has been lodged in an airway.
• To insert a small tube called a stent to open a blocked airway.
• To remove a growth that is blocking an airway.
• To take a small biopsy of a growth to see what it is. 

What happens during a bronchoscopy?

Bronchoscopy using a flexible bronchoscope

This is usually done as an outpatient or day case. The doctor will numb the inside of your nose and the back of your throat by spraying on some local anaesthetic. This may taste a bit unpleasant. Also, you will normally be given a sedative to help you to relax. This is usually given by an injection into a vein in the back of your hand or your arm. The sedative can make you drowsy but it is not a general anaesthetic and does not make you go to sleep. However, you are unlikely to remember anything about the bronchoscopy if you have a sedative.

You may be connected to a monitor to check your heart rate and blood pressure during the procedure. A device called a pulse oximeter may also be put on a finger. This does not hurt. It checks the oxygen content of the blood and will indicate if you need extra oxygen during the bronchoscopy. You may have soft plastic tubes placed just inside your nostrils to give you oxygen during the procedure.

The doctor will insert the tip of the bronchoscope into one of your nostrils and then gently guide it round the back of your throat into your windpipe (trachea). (It is sometimes passed via your mouth rather than via your nose if you have narrow nasal passages.) The bronchoscope may make you cough.

The doctor looks down the bronchoscope and inspects the lining of your trachea and main bronchi (the main airways). Bronchoscopes transmit pictures through a camera attachment on to a TV monitor for the doctor to look at.

The doctor may take one or more samples (biopsies) of parts of the inside lining of the airways – depending on why the test is done and what they see. This is painless. The biopsy samples are sent to the laboratory for testing and to be looked at under the microscope.

Sometimes bronchial lavage is done. This is a procedure where some fluid is squirted into a section of the lung and then syringed back. The fluid is then examined in the laboratory to look for abnormal cells and other particles that may be present in certain diseases.

The bronchoscope is then gently pulled out. Sometimes other procedures are done, as described earlier.

The bronchoscopy itself usually takes about 20-30 minutes. However, you should allow at least two hours for the whole appointment, to prepare, give time for the sedative to work, for the bronchoscopy itself and to recover.

Bronchoscopy using a rigid bronchoscopy

This requires a general anaesthetic, similar to that for minor operations. So, after receiving the anaesthetic, the next thing you know is when you wake up in a recovery room.

What preparation do I need to do?

You may be advised not to take any medicines that affect blood clotting, such as aspirin and warfarin, for one week before the bronchoscopy. (You will need to discuss your medication with your doctor if you take such medicines for other conditions.)

In addition to this, you should receive instructions from the hospital before the test. These usually include:

• That you should not eat or drink for several hours hours before the bronchoscopy. (Small sips of water may be allowed up to two hours before the test.)
• That you will need somebody to accompany you home, as you will be drowsy with the sedative.

What can I expect after a flexible bronchoscopy?

If you have a sedative, you may take an hour or so before you are ready to go home after the bronchoscopy is finished. The sedative will normally make you feel quite pleasant and relaxed. However, you should not drive, operate machinery or drink alcohol for 24 hours after having the sedative. You should not eat or drink anything for two hours after the bronchoscopy because your throat will still be numb. You will need somebody to accompany you home and to stay with you for 24 hours until the effects have fully worn off. Most people feel able to resume normal activities after 24 hours.

The doctor may tell you what they saw before you leave. However, if you have had a sedative you may not remember afterwards what they said. Therefore, you may wish to have a relative or close friend with you who may be able to remember what was said. The result from any sample (biopsy) may take a few days or weeks to come back.

Are there any side-effects or possible complications?

Most are done without any problem. Your nose and throat may be a little sore for a day or so afterwards. You may feel tired or sleepy for several hours, caused by the sedative. There is a slightly increased risk of developing a throat or chest infection following a bronchoscopy.

If you had a biopsy taken, you may cough up a little blood a few times in the following day or so. Rarely, a bronchoscopy can cause damage to the lung. This is more likely to occur if a specialised sample (biopsy) of lung tissue is taken. Serious complications from a bronchoscopy are extremely rare.

• Du Rand IA, Blaikley J, Booton R, et al; British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013 Aug68 Suppl 1:i1-i44. doi: 10.1136/thoraxjnl-2013-203618.

Bronchoscopy

HomeFor patientsDiagnosticsTypes of examinationsEndoscopic examinationsBronchoscopy

Bronchoscopy is a modern diagnostic examination of the mucous membranes of the trachea and bronchi using a special optical device – a bronchoscope. This is the only method that allows you to directly assess the inner surface of the bronchi, study their configuration, the relief of the mucous membrane and its vascular pattern, and if a pathologically altered area of ​​the mucous membrane is detected, a biopsy is performed for subsequent morphological analysis. Bronchoscopy is also the most important and effective way to treat patients with chronic inflammatory and purulent lung diseases.

Laryngoscopy is a visual examination of the larynx. The specialist examines the anterior and posterior parts of the larynx, the folds of the vestibule and the true vocal folds. The study is most often performed by an ENT doctor using a laryngeal mirror (indirect laryngoscopy) or a rigid laryngoscope (direct laryngoscopy). However, with tumor lesions of the larynx, examination using rigid instruments can be difficult due to limited viewing conditions, the threat of tumor damage and bleeding, and also because of the patient’s pain, which inevitably accompanies this study. In the endoscopy department of the National Medical Research Center of Oncology named after N.N. Petrov, a digital video system Olympus EVIS Exera III with a flexible video endoscope, the diameter of which is not more than 5 mm, is used to perform laryngoscopy and bronchoscopy. This allows you to safely perform a full examination of even the most inaccessible parts of the larynx with minimal negative sensations in the patient, as well as to make a targeted biopsy of the tumor, which is necessary for making a diagnosis.

Indications for elective bronchoscopy:

• Suspected tumor of the trachea and bronchi
• Hemoptysis
• Suspicion of a foreign body in the airway lumen
• Burns of the lower respiratory tract
• Chronic pneumonia, recurrent pneumonia
• Destructive/aspiration pneumonia, lung abscess
• Unexplained chronic diseases of the bronchi and lungs
• X-ray signs of disseminated pathological processes (small foci, cysts, cavities)
• Prolonged dyspnea (with exclusion of bronchial asthma and heart failure)
• Unmotivated cough lasting over 1 month

Test contraindications:

Doctors are now reducing the number of contraindications for bronchoscopy. But in some pathologies, the examination can do more harm than good.

• Exacerbation of chronic obstructive pulmonary disease (COPD) and bronchial asthma (carrying out the procedure at this moment can increase bronchospasm and aggravate the patient’s condition).
• Myocardial infarction and stroke less than 4 weeks old (stress and vasospasm and some lack of oxygen during the procedure may cause a second episode of circulatory failure).
• Uncontrolled arrhythmia
• Severe bleeding disorders (thrombocytopenia less than 20,000)
• Aortic aneurysm
• Psychiatric illnesses such as schizophrenia and epilepsy (stress and low oxygen levels in the blood can trigger seizures)

Preparation for the study

• The study is carried out strictly on an empty stomach, food intake is completely excluded for 8-10 hours and liquids for 4-6 hours before the procedure. On the evening before the study (until 18:00) – a light dinner. On the day of the study, you should refrain from smoking.
• Discontinue oral anticoagulants (blood thinners) on the eve of the study, pause s/c heparin administration 4-6 hours before the procedure.
• For examination, you must have an outpatient card, the results of a CT scan of the chest or a description of the x-ray of the lungs, a towel (because short hemoptysis is possible after the procedure). If you suffer from bronchial asthma, then do not forget the inhaler.
• During the initial interview, tell your doctor about any allergies to medications (especially if you are allergic to painkillers) and any chronic illnesses you have (bronchial asthma, heart failure).

How the examination is carried out:

The examination is carried out in a sitting position. In this case, you can not stretch your head forward and arch your chest so that the device does not injure the respiratory mucosa. For the purpose of local anesthesia, immediately before the study, the nasal and oral cavities are treated with 10% Lidocaine spray. It causes numbness of the palate, a feeling of a lump in the throat, slight nasal congestion. Anesthesia helps suppress the cough and gag reflex. During the study, the mucosa of the larynx, vocal cords, trachea and bronchi is gradually irrigated with an anesthetic. Contrary to the alarming expectations of most patients, during bronchoscopy they do not feel any pain at all.

The bronchoscope tube has a very small diameter, so it does not interfere with the patient’s breathing. While moving the tube through the airways, you may feel a slight pressure in them, but you do not experience severe discomfort. To reduce the gag reflex at the time of insertion of the bronchoscope, we recommend that you breathe shallowly and as often as possible.

After the procedure, the feeling of numbness remains for half an hour. It is not recommended to smoke and eat for 2 hours after the completion of the procedure.

The bronchoscopy procedure, performed on modern digital equipment, is accompanied by the fixation of the obtained material in the form of a photo or video recording, which makes it possible to trace changes in the state of the mucous organs in dynamics.

The endoscopist will inform you about the results of the study immediately after the examination, the results of the cytological examination will be ready in 3-4 days, the morphological report will be ready in 8-12 days

Additional diagnostic and therapeutic manipulations during bronchoscopy:

• Mucosal biopsy/neoplasm

Biopsy is an important part of diagnostic bronchoscopy and laryngoscopy. It is performed for morphological verification of the process and determination of its prevalence in the bronchial tree. Taking material for cytological and histological studies is performed in several ways, each of which has its own indications. Most often, a biopsy is performed using biopsy forceps or a scarifier brush (brush biopsy). The material is placed in a disposable labeled container, and in the case of a brush biopsy, on a glass slide. The procedure is painless for the patient.

• Bronchial wall wash

Material for bacteriological and cytological studies (to detect atypical cells in peripheral lung cancer, pathogenic flora in pneumonia and bronchitis, as well as to detect Mycobacterium tuberculosis) is obtained from the walls and lumen of the bronchi. If the contents of the bronchi are poor, then at the beginning a small volume (20-40 ml) of isotonic sodium chloride solution is injected through the endoscope channel into the lumen of the bronchi, and then the solution mixed with the bronchial contents is aspirated into a disposable sterile container.

• Bronchoalveolar lavage

Bronchoalveolar lavage is an additional study to establish the nature of lung disease, in which a significant volume of isotonic sodium chloride solution (about 120-240 ml) is injected into the lumen of small caliber bronchi. At the same time, in the lavage fluid obtained during aspiration, there are cells not only from the lumen of the smallest bronchi, but also from the alveoli. Diagnostic bronchoalveolar lavage is indicated for patients who have vague changes in the lungs, as well as diffuse changes, on chest x-ray. Diffuse interstitial lung diseases (sarcoidosis, allergic alveolitis, idiopathic fibrosis, histiocytosis X, pneumoconiosis, collagenosis, bronchiolitis obliterans) present the greatest difficulty for clinicians, as their etiology is often unknown.

Unclear changes may be infectious, non-infectious, malignant etiology. Even in cases where lavage is not diagnostic, its results can suggest a diagnosis, and then the doctor’s attention will be focused on the necessary further studies. For example, even in a normal lavage fluid, there is a high probability of detecting various disturbances. In the future, bronchoalveolar lavage is potentially used to determine the degree of disease activity, to determine the prognosis and the necessary therapy.

• Sanitation of the tracheobronchial tree

Sanitation of the tracheobronchial tree is a therapeutic measure to eliminate the accumulation of mucus on the affected bronchi. The main tasks of sanitation bronchoscopy are to influence the nature of the secretion of the mucous glands, improve the drainage function of the bronchi by removing the secret, and conduct anti-inflammatory therapy. Single courses of therapeutic sanation bronchoscopy are effective for pneumonia, festering lung cyst, lung abscess, and for chronic obstructive pulmonary disease, chronic obstructive bronchitis, bronchiectasis, cystic fibrosis, multiple course treatment is necessary.

What are the possible complications?

This examination is generally well tolerated by patients, but sometimes there is loss or hoarseness of the voice, sore throat, and in the case of a biopsy, hemoptysis may be observed. These phenomena are temporary. You should be alerted by prolonged hemoptysis, intense unrelenting chest pain, swelling on the face and around the neck, nausea and vomiting, as well as fever and chills. If these symptoms appear, consult a doctor immediately.

Bronchoscopy and laryngoscopy procedures in our center are possible only after prior registration in the registration register (see the Contacts section), if you have the results of a chest CT scan or a description of a lung radiograph.

Bronchoscopy and laryngoscopy are performed EXCLUSIVELY under local anesthesia.

At the outpatient stage, the procedure is performed on a fee basis. You can pay for the study at the reception desk of the center’s polyclinic on the 1st floor.

No referral from other specialists is required for the examination.

Using bronchoscopy specimens to make treatment decisions for lung infections in people with cystic fibrosis

Survey Question

We reviewed the evidence about whether bronchoscopy specimens should be used when deciding how to treat lung infections in people with cystic fibrosis.

Relevance

Breathing problems in people with cystic fibrosis are mainly due to recurring lung infections. Growth of pathogens in mucus/sputum samples from the lower respiratory tract obtained by coughing often allows doctors to quickly identify the infectious agent causing the infection and start treatment earlier. If people cannot cough up mucus/sputum, swabs are taken from their upper throat to look for the pathogen causing the lower respiratory tract infection, but this method can be unreliable.

During a bronchoscopy, doctors look at the lower airways using a long, thin, flexible tube with light and a camera at the end; this device can also collect sputum/mucus for examination. A person who needs to have a bronchoscopy needs sedation or general anesthesia [general anesthesia]. We do not know whether treatment based on analysis of samples taken during bronchoscopy is better than treatment based on analysis of throat swabs. This is an update of a previously published review.

Search date

Evidence current to: 10 April 2018.

Study profile

We searched for studies in people of all ages, but this review included only one study in 170 children with cystic fibrosis less than six months of age who were randomly assigned to two groups. In one group, study participants received antibiotics based on bronchoscopy specimens, and in the other group, on throat specimens. Investigators measured/evaluated outcomes in study participants at five years of age. A total of 157 children completed the study.

Main results

This study found no between-group differences in lung function, weight, body mass index, or lung CT values ​​in children at five years of age. There were no differences in the number of children (in each group) with  Pseudomonas aeruginosa,  infection at five years of age or for each year of follow-up, nor in the rate of deterioration in children with exacerbation of respiratory symptoms. Children in the bronchoscopy group were admitted to the hospital more often, although usually for shorter periods, than children in the other group. There were no differences in total health care costs between the two groups.

Side effects reported during and after bronchoscopy were not serious; the most common side effect was increased coughing (in one third of the children).

There is currently insufficient evidence to support routine use of bronchoscopy for the diagnosis and treatment of lung infections in children with cystic fibrosis.

Quality of evidence

Evidence was limited to only one well-designed study. Overall, the quality of the evidence was low (for most outcomes) to moderate (for indicators calculated from high-resolution computed tomography and health care cost analysis).