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Bronchoscopes, Flexible Video
Bronchoscopes, Flexible Video
Purpose
Flexible bronchoscopes are used to view the interior of the respiratory tract, particularly the trachea and the
bronchi of the lungs. Flexible bronchoscopes are introduced at the nose or mouth to observe distal branches of the
bronchi, most of which cannot be reached with rigid bronchoscopes. Through working channels in the
bronchoscope, the physician can sample lung tissue (e.g., when pulmonary malignancies are suspected), instill
radiographic media for bronchographic studies, perform laser therapy, remove foreign objects, suction sputum
for microbiological culturing, insert catheters, and perform difficult intubations.
Principles of operation
Flexible bronchoscopes consist of a proximal housing, a flexible insertion tube ranging from 0.5 to 7.0 mm in
diameter, and an “umbilical cord” connecting the light source and the
proximal housing. The proximal housing, which is designed to be held in
one hand, typically includes the eyepiece (fiberoptic models only), UMDNS Information
controls for distal tip (bending section) angulation and suction, and the
This Product Comparison covers the
working channel port. The image and light bundles are sealed within a following device terms and product codes
single flexible sheath. The bending section can be flexed up or down from as listed in ECRI Institute’s Universal
the insertion tube’s central axis by using hand-activated controls on the Medical Device Nomenclature System™
(UMDNS™):
proximal housing; this allows the physician to direct the scope into most Bronchoscopes, Flexible [15-073]
branches of the bronchi. The viewing aperture is located at the distal end Bronchoscopes, Flexible, Video [17-662]
of the insertion tube and provides forward (0°) viewing. Focusing is
5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA Tel +1 (610) 825-6000 Fax +1 (610) 834-1275 Web www.ecri.org E-mail hpcs@ecri.org
Bronchoscopes, Flexible; Video
Video Bronchoscopy
Video bronchoscopy is the transmission of electronic image data through the bronchoscope to an external
video processing unit. A video bronchoscope uses a charge-coupled device (CCD) located at the distal tip of the
scope to sense and transmit the images, replacing the image guide and eyepiece (see Figure 2). The images
transmitted to the screen can be recorded, printed using
a video printer, stored on digital media, or transmitted
to another location for simultaneous viewing. Video
bronchoscopes may include image enhancements, such
as hue and resolution adjustments, as well as motion
blur compensation.
Working Channels
Most flexible bronchoscopes have one or two hollow
working channels for suction and for insertion of
accessory instruments such as biopsy needles or forceps
(see Figures 1 and 2). Suction is used to aspirate excess
anesthetic and mucus or to clear the lens surface and
working channel. In some units, suction line-channel
bronchoscopes permit stronger suction through a
separate channel during the procedure. With
fluoroscopic imaging, biopsy instruments can be guided
beyond the bronchoscope’s biopsy channel to obtain
specimens of peripheral lung tissue for histologic or
bacteriologic study. Cytology brushes can be used to
collect cell samples, which are often helpful in locating
pulmonary malignancies before positive shadows
Figure 2. Schematic of a typical video endoscope
appear on x-rays.
Recent developments in bronchoscopy include the increased application of transbronchial needle aspiration
(TBNA), new tracheobronchial stents for airway obstructions, autofluorescence bronchoscopy as a guide for
endobronchial biopsy for the localization of intraepithelial neoplasia, and direct endobronchial ultrasound
(EBUS). Most of these techniques utilize a bronchoscope’s
working channels.
There are currently two approaches to performing EBUS: radial
probe EBUS and linear (also known as convex probe) EBUS. A
radial probe is typically placed through a guide sheath in the
working channel of a standard bronchoscope. The radial probe
has a rotating transducer that produces a 360° image to the long
axis of the scope. After the lesion is visualized, the probe is
removed for a biopsy instrument to be inserted into the sheath.
For linear EBUS, a special bronchoscope that has the ultrasound
transducer incorporated into the distal end of the scope is utilized;
this bronchoscope is listed in the accompanying chart. The linear transducer has a scanning range of 50° parallel
to the long axis of the bronchoscope, and images are obtained by direct contact against the airway wall. A 22-
gauge biopsy needle can be placed in the working channel and extended at an angle of approximately 20° from
the direct view. The main advantage of linear EBUS is that it offers real-time ultrasound-guided TBNA
capabilities.
Preliminary research into an airway bypass procedure has led to a possible treatment for advanced
emphysema. For the procedure, a Doppler probe is inserted through the working channel of a flexible
bronchoscope to locate an area away from pulmonary vasculature; then a small needle creates aperture in the
lungs, kept open by a stent, to allow trapped air in the lungs to escape.
Reported problems
Despite the remote location of the light source, some of the heat produced by the lamp is transmitted to the tip
of the bronchoscope. Although ECRI Institute has received no reports of tissue damage, some tissue heating
caused by illumination sources inevitably occurs. Some precautions may be appropriate, such as preventing the
tip from contacting tissue for prolonged periods, particularly during high-intensity illumination (e.g.,
videotaping).
Children’s airways are often too small to permit breathing around a flexible bronchoscope. Some
manufacturers offer small-diameter bronchoscopes that can be used in children; however, some of these
instruments lack biopsy channels and can be used only for diagnostic procedures. Airway stenosis or obstruction
contraindicates flexible bronchoscopy in children.
Bronchospasms and abnormal heartbeats may occur during bronchoscopic procedures, particularly in patients
with respiratory or cardiac disorders. Resuscitation equipment should be close at hand during bronchoscopy.
Bronchial perforations can occur if biopsy brushes or other instruments are forced out of the bronchoscope’s
distal end and meet resistance. Vigorous pressure can also bend the tip of the brush into a hook, lodging it in the
bronchial wall. Dislodging biopsy brushes in these instances may necessitate extending the flexible bronchoscope
over the tip of the brush and then removing the bronchoscope with the brush held inside. Other complications
that have been reported during bronchoscopic procedures include loss of biopsy brushes, breakage of biopsy
forceps, and difficulty withdrawing the bronchoscope from the unit’s covering sleeve.
To prevent costly repairs, hospital personnel should be educated in using, handling, cleaning, and storing
bronchoscopes and other flexible endoscopes. Striking the distal tip against a hard surface or bending or twisting
the scope with excessive force can damage the scope’s lens and glass fibers. If the scope’s delicate exterior sheath
or its working channel is nicked or punctured by endoscopic instruments, fluids can enter the inside of the scope
and come in contact with the light fibers or CCD, as well as with the mechanical components. In fiberoptic scopes,
this can degrade the image quality and angulation capability; in video scopes, this can result in an immediate loss
of the video image. Most fluid damage can be avoided if leaks are detected early by proper leak testing of the
scope during reprocessing.
Patient cross-contamination is a risk associated with bronchoscopy procedures. Known outbreaks of
tuberculosis have occurred due to improperly cleaned bronchoscopes. There has been debate over the need for
high-level disinfection or sterilization of flexible bronchoscopes. Generally, this issue is addressed by each
hospital’s infection control and risk management departments. The decision should be made before purchasing a
bronchoscope because each manufacturer has specific recommended reprocessing guidelines for its equipment,
and germicidal solutions and sterilants have specific exposure times and/or temperature requirements.
Most bronchoscopes are not autoclavable. Ethylene oxide (EtO) sterilization is safe and effective for scopes,
although 10 to 16 hours of aeration time are required before reuse. (For more information, see the Product
Comparison titled Sterilizing Units, Ethylene Oxide.) Germicidal solutions are often used for disinfection, either
as a substitute for, or in conjunction with, EtO sterilization. Some solutions, like glutaraldehyde, contain toxic
residues that can have deleterious effects on patient tissue if the scope is not properly rinsed. Hospital staff must
be aware of the possible risks of such exposure. Orthophthalaldehyde (CIDEX OPA) has mycobacterial activity
and stability over a wide range of pH levels. It is being used as a replacement for glutaraldehyde and is used
primarily as a liquid germicidal agent for scopes.
Hydrogen peroxide is an oxidizing agent used for high-level disinfection. Peracetic acid-, or peroxyacetic acid-
based products are marketed for both sterilization and high-level disinfection by one manufacturer of automated
endoscope reprocessors. Peracetic acid should be handled with caution because it is an oxidizing agent that can
corrode copper, brass, bronze, steel, and galvanized iron; its corrosive effects can be reduced by pH modification.
Failure to rinse scopes after any germicidal solution treatment is hazardous, regardless of the germicidal agent.
Purchase considerations
ECRI Institute recommendations
Included in the accompanying comparison chart are ECRI Institute’s recommendations for minimum
performance requirements for bronchoscopes; recommended specifications have been categorized into one group
that includes all flexible fiberoptic and video bronchoscopes.
The two most important selection factors for bronchoscopes are image quality and ease of use. Since both
factors are highly subjective, hospitals should use each system on a trial basis before purchase to allow physicians
to offer their input. In general, controls should be clearly marked and easy to operate. While assessing the
instrument, physicians should consider optical quality of the bronchoscope’s image brightness and resolution,
depth of field, magnification, color differentiation, angle of vision, and field of view.
Scope dimensions may vary, especially between adult and pediatric models. However, all scopes should be
clearly marked with depth-of-insertion markers. Consecutive markers should be no more than 10 cm apart, and
their marked position should be accurate to within 1 cm to aid the physician in estimating the location of the
structures under view.
Large depths of field, tip deflections, and angles of view improve visualization of internal structures.
Scopes should be compatible with a variety of video processors and light sources. This can help the hospital
reduce expenses when replacing a component in the endoscope/processor/light source chain. Scopes should also
be compatible with as wide a range of reprocessing agents and devices as possible. Before purchasing a
bronchoscope, users should confirm compatibility between the endoscope and an automatic endoscope
reprocessor.
Other specifications
Hospitals need to assess the cleaning requirements of the bronchoscope and must review their scope
reprocessing protocol to be sure that it coincides with the scope manufacturer’s reprocessing recommendations.
Some scopes have channels that can be cleaned with a brush. If EtO gas sterilization is the preferred reprocessing
procedure, the purchase of additional bronchoscopes may be needed to fulfill daily caseload requirements. Some
hospitals choose to automate part of their reprocessing with liquid disinfecting or sterilizing units.
When reviewing high-level disinfection or sterilization, users should consult the operator’s manual, as well as
the hospital’s infection control and risk management departments. When selecting a bronchoscope, the following
should be considered: sensitivity of the device to heat, required rinse time and temperature, reuse life of the
cleaning solution (e.g., single use, 21 days), and whether manual or automatic processing will be used. The
cleaning solution’s shelf life, minimum effective concentration, and associated disposal restrictions; safety issues
(e.g., eye or respiratory irritation, skin staining); and cost per cycle should also be considered.
Hospitals also need to consider the educational options provided by the manufacturer. Preventive
maintenance training can help in avoiding costly repairs to delicate components.
Most suppliers offer additional video hardware, such as camera adapters, image processors, monitors, and
image-archiving equipment (see the related Product Comparison titled Video Endoscopy Systems).
Cost containment
Service contracts for bronchoscopes became available in the early 1990s. These contracts vary greatly among
suppliers and can cost anywhere from 8% to 15% of the scope’s list price per year, depending on the age, type,
and condition of the scope. In addition, some suppliers offer different levels of coverage depending on whether
accidental damage will be covered in the contract. Service contract options should be discussed with each
supplier being considered to determine their cost-effectiveness.
Costs for liquid disinfectants or sterilants should be taken into consideration as part of the ongoing operational
cost of the scope. (For more information, see the Product Comparison titled Flexible Endoscope Reprocessors,
Automatic.)
Other costs associated with bronchoscopes include those for hand instruments (disposable or reusable) and
disposables (e.g., biopsy port covers).
Stage of development
Over the years, bronchoscopes have become smaller in diameter because fiberoptic bundles have become
smaller, which is especially important in pediatric bronchoscopy. More recent bronchoscope developments have
concentrated on the maneuverability of the distal end, the convenience and utility of the hand controls, the
durability of the glass fibers, and the improvement of technologies for the various biopsy and surgical procedures
performed through flexible bronchoscopes. Fully immersible bronchoscopes are now available for complete
cleaning and disinfection. Laser techniques allow the use of procedures that previously required invasive surgery
such as endoscopic removal of neoplastic bronchial obstructions.
Surgical and diagnostic bronchoscopic procedures have become more common, partly due to the prevalence of
many AIDS-related lung diseases, such as Pneumocystis carinii pneumonia. In addition, flexible bronchoscopy has
proven to be more useful than percutaneous fine-needle aspiration in certain biopsy cases.
Bibliography
Agerton T, Valway S, Gore B, et al. Transmission of a highly drug-resistant strain (strain W1) of Mycobacterium
tuberculosis. Community outbreak and nosocomial transmission via a contaminated bronchoscope. JAMA 1997
Oct 1;278(13):1073-7.
Supplier information
FUJINON
Fujinon Corp [451460]
1-324 Uetake Kita-Ku
Saitama City 331-9624
Japan
Phone: 81 (48) 6682153 Fax: 81 (48) 6681570
Internet: http://www.fujinon.co.jp
E-mail: fujinon@fujinon.co.jp
KARL STORZ
KARL STORZ Endoscopy-America Inc [102159]
2151 E Grand Ave
El Segundo, CA 90245-5017
Phone: (424) 218-8100, (800) 421-0837 Fax: (424) 218-8525, (800) 321-1304
Internet: http://www.karlstorz.com
E-mail: info@ksea.com
OLYMPUS
Olympus Medical Systems Europa GmbH [451962]
Wendenstrasse 14-18 Postfach 104908
Hamburg D-20097
Germany
Phone: 49 (40) 237735401 Fax: 49 (40) 237734656
Internet: http://www.olympus-europa.com
E-mail: endointer@olympus-europa.com
PENTAX
PENTAX Corp [417222]
2-36-9 Maeno-cho Itabashi-ku
Tokyo 174-8639
Japan
Phone: 81 (3) 39605155 Fax: 81 (3) 53926724
Internet: http://www.pentax.jp
Internet: http://www.pentax-endoscopy.com
E-mail: info@pentax.co.uk
RICHARD WOLF
Richard Wolf France Sarl [366842]
rue Daniel Berger Zone d'Activites la Neuvillette
Reims F-51100
France
Phone: 33 (3) 26870289 Fax: 33 (3) 26876033
Internet: http://www.richard-wolf.com
E-mail: endoscopes@richardwolf.fr
SHANGHAI
Shanghai Medical Instruments Co Ltd Medical Optical Instruments Factory Div [439528]
No 50 Qixin Road Min-Hang District
Shanghai 201100
People's Republic of China
Phone: 86 (21) 55214994 Fax: 86 (21) 64881487
Internet: http://www.smoif.com
E-mail: smoif@online.sh.cn
Note: The data in the charts derive from suppliers’ specifications and have not been verified through
independent testing by ECRI Institute or any other agency. Because test methods vary, different products’
specifications are not always comparable. Moreover, products and specifications are subject to frequent changes.
ECRI Institute is not responsible for the quality or validity of the information presented or for any adverse
consequences of acting on such information.
When reading the charts, keep in mind that, unless otherwise noted, the list price does not reflect supplier
discounts. And although we try to indicate which features and characteristics are standard and which are not,
some may be optional, at additional cost.
For those models whose prices were supplied to us in currencies other than U.S. dollars, we have also listed the
conversion to U.S. dollars to facilitate comparison among models. However, keep in mind that exchange rates change
often.
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for the medical device industry.
MODEL SHANGHAI
XZ-4
WHERE MARKETED Africa, Asia, Europe
FDA CLEARANCE No
CE MARK (MDD) Yes
TYPE Fiberoptic
INSERTION TUBE
Length, mm 550
Diameter, mm 6
WORKING CHANNELS 1
Diameter, mm 2
OPTICS
Field of view, degrees 85
Depth of field, mm 3-50
Diopter range +3 to -3
Compatible cameras NA
Resolution Not specified
Magnification Not specified
Color differentiation Not specified
TIP DEFLECT RANGE, Up 130, down 90
degrees
DISTAL TIP
DIAMETER, mm 5.8
UMBILICAL CORD 1,500
LENGTH, mm
COMPATIBLE LIGHT Olympus halogen, SMOIF
SOURCES/VIDEO (Shanghai Medical Optical
PROCESSORS Instruments Factory)
RECOMMENDED Glutaraldehyde
REPROCESSING
PURCHASE
INFORMATION
List price $3,560
Warranty 1 year
Delivery time, ARO Not specified
Year first sold Not specified
Fiscal year January to December
GREEN FEATURES None specified
OTHER SPECIFICATIONS Completely immersible.
UMDNS CODE(S) 15073
LAST UPDATED September 2004
Supplier Footnotes
Model Footnotes
Data Footnotes