Bronchoscopy

(Flexible Bronchoscopy, Fiberoptic Bronchoscopy, FOB, Rigid Bronchoscopy)

Procedure Overview

What is bronchoscopy?

Bronchoscopy is a procedure that allows the physician to directly visualize the interior passageways of the lower respiratory tract through a bronchoscope (a long, narrow, fiberoptic, lighted tube inserted through the nose or mouth). With the bronchoscope, the physician can see the larynx (voice box), trachea (windpipe), bronchi (large airways to the lungs), and bronchioles (smaller branches of the bronchi).

There are two types of bronchoscopies, characterized by the type of bronchoscope used: flexible or rigid. The type of bronchoscope used will determine the extent to which the bronchioles of the lung are visualized.

With a flexible bronchoscope, the physician is able to visualize not only the tissue of the larger airways (trachea and bronchi), but also that of the smaller sections (bronchioles) as well. The design of the flexible bronchoscope is advantageous because it can be maneuvered into the smaller bronchioles, yielding more information about their condition than can be determined with a rigid bronchoscope.

In addition, the flexible, fiberoptic bronchoscope has interior channels which increase the capabilities of treatment options, such as delivering oxygen, suctioning secretions, obtaining tissue samples (biopsy), instilling medications, and laser therapy.

A rigid bronchoscope is a straight, metal, lighted tube capable of visualizing only the larger airways, thus limiting the diagnostic and therapeutic options available. However, certain conditions may warrant its use, such as aspiration of a large amount of secretions and/or blood, controlling significant bleeding, or removal of foreign objects and/or lesions (diseased tissue) within the bronchi. Generally, the rigid bronchoscope has been replaced by the flexible bronchoscope because it has less risk of traumatizing the tissue, improved patient tolerance, and provides better access to smaller areas of the lung tissue.

Other related procedures that may be used to diagnose lung problems include chest x-ray, computed tomography (CT scan) of the chest, bronchography, chest fluoroscopy, chest ultrasound, lung scan, lung biopsy, mediastinoscopy, positron emission tomography (PET scan) of the chest, and pulmonary angiogram. Please see these procedures for additional information.

Anatomy of the respiratory system:

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The respiratory system is made up of the organs involved in the interchanges of gases, and consists of the:

• nose
• pharynx
• larynx
• trachea
• bronchi
• lungs

The upper respiratory tract includes the:

• nose
• nasal cavity
• ethmoidal air cells
• frontal sinuses
• maxillary sinus
• larynx
• trachea

The lower respiratory tract includes the lungs, bronchi, and alveoli.

What are the functions of the lungs?

The lungs take in oxygen, which cells need to live and carry out their normal functions. The lungs also get rid of carbon dioxide, a waste product of the body's cells

The lungs are a pair of cone-shaped organs made up of spongy, pinkish-gray tissue. They take up most of the space in the chest, or the thorax (the part of the body between the base of the neck and diaphragm).

The lungs are enveloped in a membrane called the pleura.

The lungs are separated from each other by the mediastinum, an area that contains the following:

• the heart and its large vessels
• trachea (windpipe)
• esophagus
• thymus
• lymph nodes

The right lung has three sections, called lobes. The left lung has two lobes. When you breathe, the air enters the body through the nose or the mouth. It then travels down the throat through the larynx (voice box) and trachea (windpipe) and goes into the lungs through tubes called main-stem bronchi.

One main-stem bronchus leads to the right lung and one to the left lung. In the lungs, the main-stem bronchi divide into smaller bronchi and then into even smaller tubes called bronchioles. Bronchioles end in tiny air sacs called alveoli.

Reasons for the Procedure

A bronchoscopy may be performed for diagnostic and/or therapeutic reasons. Diagnostic indications may include, but are not limited to, the following:

• tumors or bronchial cancer
• airway obstructions and/or strictures (narrowed areas)
• inflammation and infections such as tuberculosis, pneumonia, or fungal or parasitic lung infections
• interstitial pulmonary disease
• persistent cough or hemoptysis (coughing up blood)
• abnormal chest x-rays
• biopsy of tissue or collection of other specimens, such as sputum
• vocal cord paralysis
• bronchoalveolar lavage, or BAL (instilling fluid through the bronchoscope to aid in the diagnosis of certain lung disorders)

Therapeutic uses of bronchoscopy may include, but are not limited to, the following:

• removal of secretions, blood, mucus plugs, or polyps (growths) to clear airways
• control bleeding in the bronchi
• removal of foreign objects or other obstructions
• laser therapy or brachytherapy (radiation treatment) for bronchial tumors
• stent placement (a device used to keep the airway open)
• draining of an abscess

There may be other reasons for your physician to recommend a bronchoscopy.

Risks of the Procedure

As with any invasive procedure, complications may occur. Complications related to bronchoscopy may include, but are not limited to, the following:

• bleeding
• infection
• bronchial perforation
• bronchospasm or laryngospasm
• pneumothorax - air becomes trapped in the pleural space causing the lung to collapse

Contraindications for bronchoscopy may include severe tracheal stenosis (narrowing or obstruction of the trachea) and pulmonary hypertension (elevated blood pressure in the lungs’ blood vessels). Patients with hypercapnia (elevated carbon dioxide level in the blood) and/or severe shortness of breath may require intubation prior to the procedure, so that oxygen can be delivered directly into the lungs while the bronchoscope is in place.

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Severe coughing and/or gagging may interfere with a bronchoscopy.

Before the Procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.
• Notify your physician if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).
• You will be asked to fast for a certain period of time before the procedure. Your physician will notify you how long to fast, whether for a few hours or overnight.
• If you are pregnant or suspect that you are pregnant, you should notify your physician.
• Notify your physician of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
• Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
• You will be awake during the procedure, but a sedative will be given before the procedure. You will need someone to drive you home afterwards.
• If you are to have a rigid bronchoscopy, your procedure may be performed in the operating room under general anesthesia.
• Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

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A bronchoscopy may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your physician’s practices. A rigid bronchoscopy is usually performed in the operating room under general anesthesia.

Generally, a fiberoptic bronchoscopy procedure follows this process:

1. You will be asked to remove any clothing, jewelry, or other objects that may interfere with the procedure.
2. If you are asked to remove clothing, you will be given a gown to wear.
3. An intravenous (IV) line may be inserted in your arm or hand.
4. Your heart rate, blood pressure, respiratory rate, and oxygen level may be monitored during the procedure.
5. You will be positioned in a sitting position or lying on your back.
6. You may receive oxygen through a nasal cannula (tube) or face mask during the procedure.
7. You may be given a sedative to make you sleepy but arousable.
8. Numbing medication will be sprayed into the back of your throat to prevent gagging as the bronchoscope is passed down your trachea into the bronchi. The spray may have a bitter taste to it. Holding your breath while the physician sprays your throat may decrease the taste.
9. You will not be able to swallow the saliva that may collect in your mouth during the procedure due to the bronchoscope in your throat. The saliva will be suctioned from your mouth from time to time.
10. The physician will advance the bronchoscope down your throat and into the airways. As the bronchoscope is advanced, the tissues and structures will be examined.
11. You may experience some discomfort when the bronchoscope is advanced. Your airway will not be blocked.
12. The physician may obtain tissue samples for biopsy or other specimens for testing during the procedure. Other procedures may be performed as necessary.
13. Once the examination and any other procedures have been completed, the bronchoscope will be removed.

After the Procedure

After the procedure, you will be taken to the recovery room for observation. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room or discharged to your home. If this procedure was performed on an outpatient basis, you should plan to have another person drive you home.

You will not be allowed to eat or drink anything until your gag reflex has returned. You may notice some soreness of your throat and pain with swallowing for a few days. This soreness is normal.

You may be instructed to gently cough up and spit your saliva into a basin. The nurse will monitor your secretions. Your secretions may be blood tinged.

You may have a chest x-ray performed after the procedure.

You may resume your usual diet and activities after the procedure, unless your physician decides otherwise. You may be advised to wait 24 hours before returning to your normal activities.

Your throat may feel hoarse after the procedure. Your physician may recommend a throat lozenge or spray.

Notify your physician to report any of the following:

• fever and/or chills
• redness, swelling, or bleeding or other drainage from the IV site
• extreme hoarseness or difficulty breathing

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.