ORIGINAL ARTICLE
Rigid Bronchoscopy
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Complications in a University Hospital
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Marta Drummond, MD, Adriana Magalhães, MD, Venceslau Hespanhol, PhD, and
Agostinho Marques, PhD
Abstract: Despite the expansion of flexible bronchoscopy, rigid
bronchoscopy (RB) remains an important tool in respiratory medi-
cine, especially for therapeutic purposes. In this study, we attempted
to identify the main complications associated with RB and analyze
possible risk factors. This retrospective study reviewed data from 775
RBs performed in a tertiary-care university hospital between 1992
and 1999. The majority of patients were men (n=557, 72%) with a
median age of 47 years. Lung cancer was the diagnosis in 414 patients
(53.4%), tracheobronchial stenosis was present in 84 (10.8%), and
foreign bodies were seen in 155 cases (20%). Laser therapy was per-
formed in 346 patients (44.7%), foreign bodies removed in 155
(20%), and only 197 RBs (25.4%) were performed for diagnostic pur-
poses. Complications were seen in 103 patients (13.4%) and the ma-
jority of them were mild. Three deaths occurred (1 patient had respi-
ratory failure and 2 had severe hemorrhage during the procedure).
Sex, age, and the aim of the procedure were not associated with an
increased incidence of complications. RB is an important procedure,
especially for therapeutic bronchoscopic purposes, and is a safe tech-
nique if used properly. Preoperative risk assessment is essential in
preventing complications. In our series, major complications were
rare (mortality rate, 0.4%). Severe initial risk factors related to respi-
ratory, cardiac, and/or hematologic disorders, carinal involvement,
neoplastic disease, or the presence of foreign bodies were associated
with increased complications.
Key Words: rigid bronchoscopy, complications, risk factors, mortal-
ity
(J Bronchol 2003;10:177–182)
T he first rigid bronchoscope was developed by Gustav Kill-
ian1–4 in Europe slightly more than a century ago. This
technique was further perfected by Chevalier Jackson1–3 in the
United States, who improved the design, created and improved
supporting instruments, and developed procedural and safety
protocols that are still in use today. In the late 1960s, Ikeda1,2
From the Pulmonology Department, Hospital de São João, Porto, Portugal
Reprints: Marta Drummond, MD, Serviço de Pneumologia, Hospital de São
João, Av. Hernâni Monteiro, Porto 4202-451, Portugal (e-mail:
marta.drummond@clix.pt).
Copyright © 2003 by Lippincott Williams & Wilkins
J Bronchol • Volume 10, Number 3, July 2003
created a flexible bronchoscope that, to a large extent, replaced
the rigid bronchoscope for both diagnostic and some therapeu-
tic indications because of its simplicity and ease of use. This
technique permitted rapid examination of both central and pe-
ripheral airways using only local anesthesia. In view of these
changes in the bronchology world, rigid bronchoscopy (RB)
had to find its place, and in 19811 a moderate but significant
increase in the use of this technique was seen as a result of
interventional pulmonology development.
Rigid bronchoscopy is preferred by many1,3,5–10 in the
field of interventional bronchoscopy for safety reasons, patient
and pulmonologist comfort, speed of action, and savings of
time and number of procedures. In fact, the wide channel of the
rigid scope allows better control of hemorrhage using more
effective suction catheters and the wall of the barrel to tampon-
ade. It also permits deeper biopsy specimens and more effi-
cient debridement. Insertion of prostheses, retrieval of foreign
bodies, and dilations can be performed while adequately ven-
tilating the patient. At this time, RB is not a dying art,1–3 but a
technique in its renascent period.
Rigid bronchoscopy is a potentially hazardous tech-
nique.1,2,11 Most experts agree that the number of complica-
tions is inversely related to operator experience and technical
expertise.2,12 Despite the fact that the majority of patients un-
dergoing this technique have neoplastic disease, and that pal-
liation is the only aim, we must not run unnecessary risks, and
the prevention of complications should always be kept in
mind.11 The aim of this study was to identify the main compli-
cations of RB and analyze possible existing risk factors for
increased complications.
MATERIALS AND METHODS
We retrospectively reviewed data from 775 RBs per-
formed in our department between 1992 and 1999. We rou-
tinely performed a preprocedure risk evaluation in all patients
and classified them according to 3 performance factors: respi-
ratory, cardiac, and hematologic (Table 1). The risk associated
with RB was considered to increase with a lower performance
score.
The procedures were performed with Storz broncho-
scopes (Fig. 1) (Karl Storz GmbH & Co., Tuttlingen, Ger-
177
 Drummond et al
TABLE 1. Criteria for Preoperative Evaluation of Risk in
Patients Undergoing Rigid Bronchoscopy
Moderate Risk Severe Risk
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Respiratory PaO2: 55–60 mm Hg PaO2 <55 mm Hg
FEV1: 50–80% FEV1 <50%
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Cardiac Stable angina Unstable angina
Stable cardiac failure Unstable cardiac failure
Non severe arrhythmia Severe arrhythmia
Myocardial infarction Myocardial infarction
<6 M >6 M
Hematologic Platelet count: Platelet count:
50–125 × 109 20–50 × 109
Normal prothrombin Abnormal prothrombin
time time
many), including a Shapshay scope model. All patients under-
went general anesthesia. Patients were premedicated with 1
mg/kg prednisone intravenously to diminish allergic reactions
and the development of airway edema. Anesthesia induction
was performed by administering a 2-mg/kg propofol intrave-
nous bolus. To obtain profound but rapidly recoverable muscle
relaxation, the patients received 1 mg/kg succinylcholine in-
travenously. We used lidocaine spray on the vocal cords to
reduce the local vagal response and to also reduce the risk of
arrhythmias and hypertension resulting from mucosal absorp-
tion.13 The maintenance of anesthesia status was achieved by
administering a propofol perfusion of 12 mg/kg per hour in the
first 10 minutes, 9 mg/kg per hour from 10 to 30 minutes, and
6 mg/kg per hour from 30 minutes to the end of the procedure.
Because our own preference is to maintain ventilation by
means of a jet ventilator, all patients underwent jet manual
ventilation during the procedure. This ventilation technique al-
lows the proximal portion of the scope to be open, permitting
easy introduction of several instruments as needed without sig-
nificantly affecting ventilation.3
In our department, we prefer to use the classic intubation
technique without a laryngoscope and telescope. Once the pa-
tient is properly relaxed, the head position is adjusted so that
the neck is extended, creating a straight line from the oral cav-
ity through the oropharynx to the vocal cords. The broncho-
scope is inserted with direct visualization. During this maneu-
ver, a gauze pad is used for teeth protection. After scope inser-
tion, we introduce a telescope linked to a video monitor and the
suction catheter inside the metallic barrel. The laser fiber, stent
introducer, and biopsy or grasping forceps are inserted accord-
ing to the technique we decided to perform. The use of a video
monitor allows for training of the technique, discussion with
the rest of the team about the decisions made during the pro-
cedure, and better documentation of the images. For stent in-
sertion, we use a prosthesis introducer specially designed for
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J Bronchol • Volume 10, Number 3, July 2003
Dumon stents. To retrieve foreign bodies from the tracheo-
bronchial tree, only grasping forceps are used because we have
good results with this technique.
A pulse oximeter is used during the procedure to provide
continuous monitoring of oxyhemoglobin saturation. Continu-
ous electrocardiographic monitoring is also performed, and
blood pressure is measured periodically using an electronic
blood pressure cuff. The rigid bronchoscope is removed only
when effective spontaneous ventilation has been established
and preferably when the patient gave clear signs of imminent
cough.
Bleeding severity was defined according to the amount
of blood loss during the procedure: severe, >200 mL; moder-
ate, between 50 and 200 mL; and mild, >50 mL. Transient
respiratory failure was defined as the need for ventilatory
manual assistance after the procedure for more than 30 minutes
without invasive ventilatory support requirement. All patients
had a 3-hour postprocedure observational period before they
were discharged or transferred.
Of the 775 patients in the study, 557 (72%) were men
and 218 (28%) were women. The median age was 47 years. We
observed 2 peaks of incidence: one in children related to the
presence of foreign bodies and another in patients between 60
and 75 years related to neoplastic airway involvement (Fig.2).
Because we are a small department, only 262 patients
(33.8%) came from pulmonology; 314 (40.5%) came from
other departments in our hospital; 122 (15.7%) came from
other hospitals, and 77 (10%) were directly admitted from the
emergency department.
Statistical Analysis
Data were analyzed using ⌶2 comparison of means (n x
2 tables); P values less than 0.05 were considered statistically
significant. A multiple regression model was used to analyze
FIGURE 1. Rigid bronchoscopes with different lengths and di-
ameters, grasping and biopsy forceps, telescopes, aspiration
catheters, and stent introducer.
© 2003 Lippincott Williams & Wilkins
 J Bronchol • Volume 10, Number 3, July 2003 Rigid Bronchoscopy
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FIGURE 2. Age distribution of 775 patients who underwent rigid bronchoscopy.

the influence of age, sex, aim of the procedure, initial risk, nostic purposes. Removal of a foreign body was performed in
previous diagnosis, and lesion location on outcome with re- 155 cases (20%) (Fig. 3). Dilation, laser therapy, and stenting
spect to complications. were performed in 422 cases (54.6%) (Figs. 4, 5, and 6); one or
more of these procedures were performed in each patient as
RESULTS needed. The majority of patients (n = 672, 86.7%) had no com-
Sixty percent of the patients (n = 465) had a basal initial plications related to the technique. Only 51 patients (6.6%)
risk for the procedure, established according to the criteria in hemorrhaged during the procedure, with 27 being moderate
Table 1. Only 8.6% (n = 67) had severe initial risk for RB. The cases and 4 severe cases. Forty-one patients (5.3%) developed
majority of patients (n = 414, 53.4%) had a previous diagnosis transient respiratory failure, but it was easily reversible and
of tumor: 2 patients had laryngeal neoplasm with subglottic seldom life-threatening. Postoperative reintubation in the re-
involvement; 14 patients had benign tumors, the majority lo- covery room was necessary in one patient who was then ad-
cated in the trachea; and 50 patients had metastatic involve- mitted to an intensive-care unit.
ment of the lungs secondary to various neoplasms, the most Three deaths occurred (mortality rate, 0.4%); 1 patient
frequent being the esophagus. Tracheobronchial foreign bod- died because of respiratory failure and 2 died as a result of
ies were present in 155 (20%) patients and 84 (10.8%) had severe and uncontrollable hemorrhage during the procedure.
tracheobronchial stenosis as a previous diagnosis, of which 56
of them were secondary to tracheal intubation. One hundred
twenty-two patients (15.7%) had other diagnoses, the most fre-
quent being tuberculosis, hemoptysis, and fistulae.
Endoscopic findings were classified according to the
following criteria: airway tumor, mucosal infiltration, mucosal
inflammation, and absence of endoscopic lesions. Airway tu-
mor was visualized in 418 cases (53.9%); 31 patients (4%)
presented signs of mucosal infiltration; 120 (15.5%) showed
signs of mucosal inflammation; and in 153 cases (19.7%), no
endoscopic alterations were found. All of the latter cases cor-
responded to the presence of foreign bodies. In 53 patients
(6.8%), there was no record of the endoscopic findings.
Lesions located in the trachea were seen in 207 patients
(26.7%). The right bronchial tree and left bronchial tree were
affected in 183 (23.6%) and 156 patients (20.1%), respec-
tively. The most rare location of the lesions was the carina (n =
20, 2.6%). Multiple lesions were seen in 84 cases (10.8%) and
9 patients (1.2%) had diffuse involvement of the tracheobron- FIGURE 3. Use of grasping forceps to remove a vegetal foreign
chial tree. RB was performed in 197 cases (25.4%) for diag- body (pignut) from the right main bronchus.

© 2003 Lippincott Williams & Wilkins 179

 Drummond et al
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FIGURE 4. Mucosal-sparing technique. Combined use of laser
and mechanical dilation to achieve an increased tracheal lu-
men.
Five patients (0.6%) developed severe cough after the proce-
dure. Arrhythmia complicated the procedure in 2 cases (0.3%).
There was one case of pneumothorax and one case of a broken
tooth during the scope insertion.
In this study, we also analyzed the presence of possible
existing risk factors in patients with complications after RB.
We found that sex, age (categorized as <1 y, 1-5, 5-15, 15-65,
>65), and the aim of the procedure was not associated with
complications (Fisher exact test 1.000, 0.259, and 0.770, re-
spectively). The initial risk (basal, moderate, or severe) was
associated with the development of complications (P = 0.000).
Patients with severe initial risk experienced more problems
(Table 2). In addition, previous diagnosis was significantly as-
sociated with complications (P = 0.023), with patients having
airway tumors or foreign bodies experiencing more complica-
tions. Patients who underwent RB to treat stenosis had fewer
complications. Patients with carinal involvement were more
likely to have complications than any other group (Table 2).
DISCUSSION
Rigid bronchoscopy is generally used for 2 different ap-
plications1,2,11: for neoplastic patients in whom palliation is
the only aim and for patients with benign tracheobronchial pa-
thology, including foreign body presence. If our goal is to
avoid unnecessary risks11 in any situation, we must be particu-
larly careful in the nonneoplastic cases because RB is a poten-
tially hazardous technique1,2,7,11 and complications can occur.
In our study, all deaths occurred in terminal neoplastic patients
during laser therapy in which we were trying to obtain airway
patency. An overall mortality of 0.4% might be acceptable in
these patients with advanced malignant disease and poor respi-
ratory function, and this value was similar or inferior to that
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J Bronchol • Volume 10, Number 3, July 2003
found in other series.5-8,12,14–16,22,26–29 Obviously, the risk
for laser therapy was considerable for these patients, but
we considered it justified by the lack of alternative treat-
ment.15,17,23,27,28 We found that the high initial risk, as ex-
pected, was related to increased complications and was similar
to that in other series.12 Lesion location was also associated
with increased problems, a finding that was also in agreement
with other series.5,6 Carinal involvement was the most prob-
lematic location, perhaps because these lesions affect both
bronchi. When these lesions bleed, bleeding into both right and
left lungs simultaneously will impair ventilation to both lungs.
Neoplastic diseases and foreign bodies were related to in-
creased complications. In patients with neoplasms, poor ven-
tilatory and general performance status increases the risk of
complications12 as well as the inherent risk of laser therapy.8
With respect to foreign bodies, the unexpected and unknown
nature of the body and the local mucosal response could ex-
plain the incidence of complications. Some fatal cases are de-
scribed in the literature,30 and there are series31 showing a con-
siderable incidence of complications associated with bron-
choscopic removal of foreign bodies. Like in other procedures,
choosing the appropriate technique and the experience of the
bronchoscopist has a crucial role in minimizing complications.
We confirmed that patients with tracheal strictures had
fewer complications. This finding is easily understandable in
view of the benign nature of the majority of these lesions. Nev-
ertheless, problems occurring during mechanical tracheal or
bronchial dilation are not negligible. Posterior tracheal wall
laceration and bronchial perforation are the most disturbing
ones.32,33
We had one case of pneumothorax. This case was not
related to barotrauma but to laser therapy performed to achieve
airway patency in a patient with neoplastic involvement of the
distal tracheal third and right main bronchus. After the laser
treatment, an attempt to debride the remaining neoplastic tis-
sue using the bronchoscope led to bronchial laceration and iat-
rogenic pneumothorax that was solved with external drainage
and bronchial stent insertion. In our series, there were no cases
of barotrauma, which is probably the result of the use of
manual jet ventilation instead of high-frequency ventilation.34
Not only might technical procedures be harmful, but also
anesthesia could cause problems.1,2,12,18,24 The ideal anesthe-
sia for RB should provide rapid induction, minimal hemody-
namic instability, satisfactory ventilation, rapid recovery, and
minimal complications in the postoperative period .12,19–21
Propofol is the drug of choice as a result of its rapid onset of
action, short half-life, and high body clearance.12,19,20 Propo-
fol also has inconveniences. The tendency for hemodynamic
depression is the most feared. Elderly patients are especially at
risk for hemodynamic depression12,20 and deserve particular
attention. Unlike other authors,12 we did not find age to be a
risk factor for complications in this study, but caution regard-
ing this patient group should always be present.
© 2003 Lippincott Williams & Wilkins
 J Bronchol • Volume 10, Number 3, July 2003 Rigid Bronchoscopy
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FIGURE 5. Combined used of laser therapy and stents in a patient with neoplastic involvement of carina and both main bronchi.
Laser therapy was performed to reduce neoplastic tissue (A), then 2 stents were introduced in both bronchi because they allowed
greater lumen increase than a bifurcated stent (B).

In this study, minor problems related to anesthesia status Endoscopic treatment of locally advanced tumors of the
were found (hypoxemia, arrhythmia). In fact, a comparison lung with laser and stents, removal of foreign bodies, and ste-
made in the early 1990s about complication incidence between nosis dilation are therapeutic options that should be available
patients under local versus general anesthesia for interven- in the armamentarium of institutions with major experience.5
tional bronchoscopic proceedings favors the latter in view of These procedures can be life-saving and improve the quality of
mortality and morbidity.14,25 life. Hazards should never be forgotten.
We also had one case of a broken tooth in an elderly
patient who lacked many dental pieces. The tooth was recov- CONCLUSIONS
ered in the mouth, avoiding further problems. Rigid bronchoscopy is a safe procedure if performed by
expert hands, and many physicians have established RB as the
procedure of choice in interventional pulmonology. In our se-
ries, major complications were rare and the overall mortality
TABLE 2. Risk Factors in Patients With Complications After
Rigid Bronchoscopy rate was 0.4%. The majority (86.7%) of patients did not de-
velop complications related to this technique.
No. of No. of Special attention must be given to patients with severe
Patients With Patients With initial risk for the procedure, neoplastic disease, presence of
Risk Factor Complications
Risk Factor (n = 775) (%)
foreign body, and carinal involvement because these factors
were found to be associated with increased complications.
Initial risk (P = 0.000) This study reinforces the point that RB is a powerful clinical
Basal 465 27 (5.8) tool that should be used with caution.
Moderate 243 51 (21)
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