10/17/2017 Flexible bronchoscopy: Indications and contraindications

Flexible bronchoscopy: Indications and contraindications

Author Section Deputy

Kevin C Editor Editor
Wilson, MDPraveen N Helen
Mathur, Hollingsworth,
MB, BS MD

Disclosures

Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 | This topic last
updated: Fri Nov 12 00:00:00 GMT 2010 (More)
INTRODUCTION Bronchoscopy is a procedure to visualize the tracheobronchial tree [1]. There are
three types of bronchoscopy: rigid, flexible, and virtual bronchoscopy (table 1):

Rigid bronchoscopy visualizes the proximal airways. It is almost always performed in the
operating room under general anesthesia and is usually performed in situations in which
relatively large amounts of tissue are targeted for removal (eg, laser ablation of tracheal or
mainstem bronchial tumors), since the working channels are significantly larger than those of
flexible bronchoscopes (table 2). The rigid bronchoscope consists of an inflexible tube that
encloses a telescope, light source, and working channels (figure 1) [2]. (See "Rigid
bronchoscopy: Instrumentation".)

Flexible bronchoscopy is the most common type of bronchoscopy. It visualizes the trachea,
proximal airways, and segmental airways out to the third generation of branching and can be
used to sample and treat lesions in those airways. Flexible bronchoscopy is generally performed
in a procedure room with conscious sedation. The flexible bronchoscope consists of a flexible
sheath that contains cables that allow the tip of the bronchoscope to be flexed and extended,
fiberoptic fibers for transmitting endobronchial images, a light source, and a working channel
(figure 2) [3].

Several variants of traditional flexible bronchoscopy exist [4]. Endobronchial ultrasound is

performed using a flexible bronchoscope that has an ultrasound probe built into its distal end. It
provides real-time ultrasound images of tissues adjacent to the airway, facilitating transbronchial
needle aspiration of abnormalities such as enlarged lymph nodes. Electromagnetic navigation
bronchoscopy is performed using a flexible bronchoscope with an electromagnetic guidance
system. This provides an endobronchial map that is used to direct a special biopsy catheter into
the distal airways for more accurate sampling of small peripheral abnormalities. Non-magnetic
navigation systems are also available. (See "Endobronchial ultrasound: Indications, advantages,
and complications" and "Endobronchial ultrasound: Technical aspects".)

Virtual bronchoscopy consists of computer generated pictures of the endobronchial tree, which
are constructed from computed tomography (CT) images of the thorax (figure 3) [5,6]. It has
the advantage of being noninvasive, being able to define the airways out to the seventh
generation of branching, and providing important information about structures outside the
airways (eg, lymph nodes). However, it is not yet widely available and mucosal abnormalities are
not well seen. (See "Virtual bronchoscopy".)

Indications and contraindications for flexible bronchoscopy are reviewed here. The equipment,
procedure, and complications of flexible bronchoscopy are described separately. (See "Flexible
bronchoscopy: Equipment, procedure, and complications".)

INDICATIONS Flexible bronchoscopy is indicated for diagnostic or therapeutic reasons.

Diagnostic indications There are numerous diagnostic indications for flexible bronchoscopy,
including the following (table 3 and table 4):

Suspected pneumonia Specimens for microbiological analysis can be collected by flexible

bronchoscopy. This is helpful when pneumonia is suspected on the basis of an infiltrate on a

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chest radiograph and symptoms or signs of pneumonia (eg, fever, cough), but the patient
cannot produce sputum for collection [7]. The value of bronchoscopic sampling in patients who
can produce sputum for analysis is controversial and uncertain, as discussed separately.
(See "Clinical presentation and diagnosis of ventilator-associated pneumonia", section on
'Sampling methods'.)

Parenchymal nodules or masses Flexible bronchoscopy is a reasonable approach for the

diagnostic evaluation of large central masses [8]. It can assess the degree of extrinsic
compression caused by the mass and specimens can be collected for pathological analysis by
washing or lavaging the airway supplying the lesion, or by direct sampling of peribronchial
lesions with brushings or transbronchial needle aspiration. Flexible bronchoscopy is much less
useful for smaller peripheral nodules. (See "Diagnostic evaluation and management of the
solitary pulmonary nodule", section on 'Bronchoscopy'.)

Mediastinal lymphadenopathy or masses Flexible bronchoscopy with transbronchial needle

aspiration is used to sample enlarged mediastinal lymph nodes or mediastinal masses,
potentially eliminating the need for mediastinoscopy. (See "Transbronchial needle aspiration",
section on 'Mediastinal lymphadenopathy'.)

Hemoptysis Flexible bronchoscopy may identify the cause of bleeding, which is important for
determining appropriate therapy and prognosis [9]. Even if the source of bleeding cannot be
identified, flexible bronchoscopy may localize the area of bleeding, which will guide
endobronchial balloon tamponade, angiographic embolization, or surgery [10]. (See "Etiology
and evaluation of hemoptysis in adults" and "Massive hemoptysis: Initial management".)

Suspected airway obstruction Airway obstruction may be expected on the basis of history (eg,
aspiration), an abnormal physical exam finding (eg, focal wheezing), an abnormal pulmonary
function test result (eg, flattening of the inspiratory or expiratory limbs of the flow-volume loop),
or an abnormal radiographic finding (eg, focal hyperlucency on a chest radiograph). Flexible
bronchoscopy may be helpful in confirming airway obstruction and identifying the cause.
(See "Diagnosis and management of central airway obstruction", section on
'Diagnosis' and "Airway foreign bodies in adults", section on 'Diagnostic fiberoptic
bronchoscopy'.)

Persistent atelectasis Flexible bronchoscopy is warranted in patients who have persistent

atelectasis that is either of unknown cause or suspected of being due to airway obstruction. The
purpose of bronchoscopy is to identify and remove any obstructing lesion (eg, mucus plug,
foreign body). (See "Airway foreign bodies in adults", section on 'Diagnostic fiberoptic
bronchoscopy'.)

Persistent infiltrate Slow or incomplete resolution of presumed pneumonia despite treatment is

common. Flexible bronchoscopy can obtain specimens as part of the evaluation for an alternative
etiology. The evidence suggests that among the persistent infiltrates that are eventually
definitively diagnosed, most can be diagnosed by bronchoscopy [11]. (See "Nonresolving
pneumonia", section on 'Bronchoscopy'.)

Suspected lung transplantation rejection When a patient who has had a lung transplantation
presents with a clinical syndrome suggestive of rejection or infection, most clinicians perform
flexible bronchoscopy with bronchoalveolar lavage and/or transbronchial biopsies in an attempt
to distinguish rejection and infection [12]. (See "Evaluation and treatment of acute lung
transplant rejection", section on 'Use of fiberoptic bronchoscopy'.)

Suspected tracheobronchomalacia Bronchoscopic visualization of dynamic airway collapse is

the gold standard for diagnosing tracheomalacia and tracheobronchomalacia [13,14].
(See "Tracheomalacia and tracheobronchomalacia in adults", section on 'Bronchoscopy'.)

Smoke inhalation Flexible bronchoscopy is frequently performed in fire victims to diagnose

smoke inhalation. Evidence of smoke inhalation includes carbonaceous debris, mucosal pallor,
mucosal ulceration, and/or mucosal erythema [15]. Patients with smoke inhalation require close
monitoring of their upper airway because obstruction due to edema is common.

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(See "Emergency care of moderate and severe thermal burns in adults", section on 'Diagnostic
tests and monitoring'.)

Chest trauma Blunt or penetrating trauma to the chest or neck can cause a laceration of the
airway, which is generally suspected when a patient develops pneumomediastinum and
pneumothorax following trauma. Airway lacerations that follow blunt chest trauma generally
involve the membranous portion of the distal trachea or proximal mainstem bronchi. Such
injuries can be visualized and their severity determined by flexible bronchoscopy [16]. Small
injuries may be managed conservatively (ie, placing the end of the endotracheal tube distal to
the laceration, minimization of airway pressures), but severe injuries require surgical repair.

Cough Flexible bronchoscopy is usually one of the last diagnostic modalities employed in the
evaluation of patients with subacute or chronic cough, but it may occasionally identify a foreign
body, airways disease, or a tumor as the cause of the cough [17-19]. (See "Evaluation of
subacute and chronic cough in adults", section on 'Diagnostic approach'.)

Suspected tracheoesophageal fistula Tracheoesophageal fistulas can be congenital, due to

malignancy (eg, esophageal or lung cancer), or a complication of prolonged intubation. The
initial diagnostic evaluation of a suspected tracheoesophageal fistula generally involves an upper
gastrointestinal series with thickened water soluble contrast material. However, if this study is
negative and suspicion remains high, flexible bronchoscopy can be performed to look for the
fistula. Administration of a contrast agent (eg, methylene blue) into the esophagus during
bronchoscopy may help identify the tracheoesophageal fistula [20]. (See "Congenital anomalies
of the intrathoracic airways and tracheoesophageal fistula", section on 'Tracheoesophageal
fistula and esophageal atresia'.)

Suspected bronchopleural fistula When a post-lobectomy or post-pneumonectomy patient

develops a bronchopleural fistula, flexible bronchoscopy may be used to evaluate the integrity of
the surgical stump [21,22]. In contrast, bronchoscopy is not helpful in identifying the location of
a bronchopleural fistula following lung biopsy, thoracentesis, or attempted central venous
catheter insertion because the bronchoscope cannot visualize the peripheral airways or lung.

Therapeutic indications There are also numerous therapeutic indications for flexible
bronchoscopy, including the following (table 3 and table 4):

Mucus accumulation Mucus accumulation in the airways may be severe enough to interfere
with ventilation and/or oxygenation, or to precipitate recurrent atelectasis. Flexible bronchoscopy
to suction mucus through the working channel (ie, pulmonary toilet) may be helpful in this
situation.

Foreign bodies Foreign objects can be removed from the tracheobronchial tree using a large
variety of retrieval devices on the distal end of catheters passed through the working channel of
a flexible bronchoscope (eg, grasping forceps and baskets) (figure 4) [23]. (See "Airway foreign
bodies in adults", section on 'Flexible bronchoscopy'.)

Endotracheal tube management Flexible bronchoscopy may be used to guide the insertion of
an endotracheal tube or to confirm the position of an endotracheal tube [24].

Laser therapy Lasers can be used during flexible bronchoscopy to ablate endobronchial lesions
[25]. The most common is the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser, which
directly burns and desiccates abnormal tissues occluding large airways. (See "Bronchoscopic
laser resection".)

Photodynamic therapy Photodynamic therapy is a variation of laser therapy [25]. First, a

fluorescent dye (usually a hematoporphyrin derivative) is administered into the airway, which
accumulates within neoplastic tissue. Then, during flexible bronchoscopy, light of a certain
wavelength is used to activate the fluorescent dye, leading to the death of the neoplastic tissue.
(See "Photodynamic therapy of lung cancer".)

Electrocoagulation During electrocoagulation, a catheter containing an electrically heated tip is

passed through the working channel of a flexible bronchoscope and used to burn away targeted
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tissue within the airways [25]. Some of the catheters are designed with metal snares heated by
electrical current that can snare and burn through tissue for removal. (See "Endobronchial
electrocautery".)

Cryotherapy During cryotherapy, a catheter containing a metallic tip that is cooled by liquid
nitrogen is passed through the working channel of a flexible bronchoscope and placed onto the
targeted tissue [25]. This causes a low temperature thermal injury that kills the tissue.
(See "Bronchoscopic cryosurgery: Principles and technique".)

Balloon dilatation Catheters analogous to those used for endovascular angioplasty can be
passed through the working channel of a flexible bronchoscope, placed adjacent to abnormal
airway narrowing, and inflated to a controlled pressure to expand the airway [25]. This is
generally followed by endobronchial stent placement to maintain the enlarged airway lumen.
(See "Flexible fiberoptic bronchoscopy balloon dilation".)

Brachytherapy catheters Brachytherapy involves passing a catheter with a radioactive pellet

through the working channel of a flexible bronchoscope and placing the radioactive pellet next to
the targeted malignant tissue [25]. The radioactive pellets emit short range radiotherapy.
(See "Endobronchial brachytherapy".)

Tracheobronchial stents Expandable stents are wrapped around catheters that can be passed
through the working channel of a flexible bronchoscope into the airways obstructed by tumor or
stricture [25]. The stents are most commonly placed in conjunction with ablative therapies or
bronchoplasty. The operator positions the stent-catheter complex at the desired site, after which
the cord wrapping the stent is unwound, allowing the stent to expand and slide off the catheter.
(See "Airway stents".)

Bronchial thermoplasty Bronchial thermoplasty uses a special catheter with a heated coiled at
the distal end. The catheter is passed through the working channel of a flexible bronchoscope
and the coil is placed in direct contact with the airway wall. The coil is slowly moved along the
airway with the intent of using heat to weaken smooth muscle. This procedure is directed
towards severe asthmatics with the goal of limiting bronchospasm by permanently weakening
the smooth muscles of the airway [26]. (See "Alternative and experimental agents for the
treatment of asthma", section on 'Bronchial thermoplasty'.)

CONTRAINDICATIONS Most contraindications to flexible bronchoscopy are related to the potential

for bronchoscopy to cause tachycardia, bronchospasm, or hypoxemia. Contraindications include
current or recent myocardial ischemia; poorly controlled heart failure; significant hypotension,
hypertension, bradycardia, or tachycardia; exacerbation of asthma or chronic obstructive pulmonary
disease; severe hypoxemia; and life-threatening cardiac arrhythmias. Additional contraindications exist
when brushing, biopsy, or needle aspiration is planned, which are related to bleeding risk. They include
recent anti-platelet agents (eg, aspirin, clopidogrel), anticoagulant therapy, thrombocytopenia,
coagulopathy, elevated blood urea nitrogen (BUN), or elevated serum creatinine.

The following describes our approach for handling these contraindications. We recognize that other
reasonable approaches also exist:

We postpone non-emergent bronchoscopy in patients who are currently having or have had any
of the following events within the past six weeks: myocardial ischemia (ie, unstable angina,
myocardial infarction), decompensated heart failure, an exacerbation of asthma or chronic
obstructive pulmonary disease, or life-threatening cardiac arrhythmias [27].

We avoid non-emergent bronchoscopy in patients with severe hypoxemia, which we define as a

resting arterial oxygen tension (PaO2) <60 mmHg or an oxyhemoglobin saturation (SpO2) <90
percent while receiving a fraction of inspired oxygen [FiO2] 50 percent [27].

We avoid non-emergent brushing, biopsy, or needle aspiration in patients who have taken an
antiplatelet agent within the past five days or subcutaneous low molecular weight heparin in the
past 12 hours, or who have a platelet count of 50,000 platelets/mm3 or lower, an international
normalized ratio (INR) of 1.3 or greater, or an elevated partial thromboplastin time (PTT)
[27,28]. For patients who receive platelets or fresh frozen plasma to correct the abnormality, we
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repeat the relevant laboratory study to confirm that the abnormality has been corrected, before
proceeding with the procedure.

Among patients whose BUN >30 or whose serum creatinine is >2 mg/dL, we generally
administer desmopressin (DDAVP) approximately 30 minutes before the procedure if brushing,
biopsy, or needle aspiration is anticipated [27].

These thresholds are based upon clinical experience, since the reduction of bronchoscopy-related
complications has been scarcely studied. However, we have found that these criteria significantly
reduce the frequency of bronchoscopy complications, which was largely attributable to a reduction in
the incidence of minor bleeding [29].

The recommendation to hold antiplatelet agents prior to bronchoscopy is supported by a prospective

cohort study of 604 patients who underwent flexible bronchoscopy with transbronchial biopsy [30].
The study found that the risk of bleeding was significantly higher among patients
taking clopidogrel alone (89 percent) and clopidogrel plus aspirin (100 percent), compared to control
patients (3.4 percent). However, the possibility that the bleeding risk associated with antiplatelet
medications is agent-specific cannot be excluded, since another study found no increased risk of
bleeding among patients taking aspirin [31].

Other contraindications include an inability to cooperate with the procedure, an unstable cervical spine,
an immobile cervical spine, and limited motion of the temporomandibular joint.

SUMMARY AND RECOMMENDATIONS

Flexible bronchoscopy is a procedure that visualizes the lumen and mucosa of the trachea,
proximal airways, and segmental airways to the third generation of branching. It can be used to
diagnose or treat abnormalities within or adjacent to these airways. (See 'Introduction' above.)

There are numerous indications for flexible bronchoscopy, which can be categorized as diagnostic
or therapeutic indications. Common diagnostic uses include sampling in patients with suspected
pneumonia who cannot produce sputum for collection and microbiological analysis, inspection for
the site and source of hemoptysis, and sampling nodules, masses, or lymph nodes that are
within or adjacent to the airways. Common therapeutic uses include the removal of excess
mucus or foreign bodies, the treatment of endobronchial abnormalities, and the deployment of
endobronchial stents. (See 'Diagnostic indications' above and 'Therapeutic indications' above.)

Most contraindications to flexible bronchoscopy are related to the potential of bronchoscopy to

cause tachycardia or bronchospasm. They include current or recent myocardial ischemia, poorly
controlled heart failure, asthma exacerbation, chronic obstructive pulmonary disease
exacerbation, severe hypoxemia, and life-threatening cardiac arrhythmias. Additional
contraindications exist when brushing or biopsy is planned, which are related to bleeding risk.
They include recent anti-platelet agents, anticoagulant therapy, thrombocytopenia,
coagulopathy, elevated blood urea nitrogen, and elevated serum creatinine.
(See 'Contraindications' above.)

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