Bronchoscopy

Shailendra Das, DO, FAAP

Introduction

•Flexible bronchoscopy allows for examination of the nose, pharynx, larynx, and tracheobronchial tree.

•Bronchoscopic developments, including smaller scope sizes and improvements in picture quality and video technology, have facilitated use in younger children and neonates.

Indications for Bronchoscopy

•Stridor (especially in the setting of failure to thrive or apneic spells)

•Persistent wheezing (especially if asthma therapies do not alleviate symptoms)

•Monophonic wheezing (suspicion of foreign body)

•Persistent wet cough

•Recurrent and/or persistent pneumonia

•Persistent abnormal chest radiographic and/or computed tomographic findings (atelectasis, infiltrate)

•Recurrent aspiration

•Foreign-body aspiration

•Hemoptysis and/or pulmonary hemorrhage

•Respiratory symptoms in an immunocompromised host

•Interstitial lung disease

•Tracheostomy evaluation

•Lung transplant surveillance

•Direct instillation of medications (deoxyribonuclease, hypertonic saline, N-acetylcysteine, sodium bicarbonate) to aid in thinning and removing mucus

Additional Tests

•Bronchoalveolar lavage

—Evaluation of alveolar cells via instillation of saline in a pulmonary lobe to obtain diagnostic information

—Indications

▪Microbial cultures (bacterial, fungal, viral, and mycobacterial) and rapid diagnostic tests

▪Cytologic analysis and cell count

▪Bleeding

▪Aspiration or gastroesophageal reflux

▪Normal: >80% macrophages

▪Inflammation and/or infection: increased numbers of neutrophils

▪Asthma: increased percentage of eosinophils

▪Alveolar or airway hemorrhage: presence of hemosiderin-laden macrophages

▪Aspiration and/or gastroesophageal reflux: presence of lipid-laden macrophages (sensitive, not specific)

▪Interstitial lung disease: increased numbers of lymphocytes, eosinophils, neutrophils

▪Sarcoidosis: increased lymphocyte count (CD4⁺ cells)

▪Hypersensitivity pneumonitis: increased lymphocyte count (CD8⁺ cells)

•Transbronchial biopsies: evaluation for acute cellular rejection in patients who underwent lung transplantation, sarcoidosis

•Endobronchial biopsies: evaluation of airway inflammation, potential malignant lesions, granulation tissue

•Endobronchial brush biopsies: evaluation of ciliary motility and cilia electron microscopy ultrastructure (primary ciliary dyskinesia)

Deciding Between Flexible and Rigid Bronchoscopy

•Flexible bronchoscopy

—Usually performed by pulmonologists

—Can be performed at the bedside (eg, in the pediatric intensive care unit) or in an outpatient procedure suite

—Can be performed with moderate sedation or general anesthesia

•Rigid bronchoscopy

—Usually performed by otolaryngologists or pediatric surgeons

—Usually performed in an operating room

—Requires general anesthesia

•Table 8-1 shows indications for flexible and rigid bronchoscopy.

•In general, flexible bronchoscopy

—Allows for more maneuverability, giving a better view of the lower airways

—Offers a more dynamic view of the airway

—Provides the opportunity for sampling of the lower airways for microbial and cytologic testing

•Direct laryngoscopy (without endotracheal tube)

—Allows for better examination of the posterior glottis

•Rigid bronchoscopy

—Provides for controlled ventilation through the scope