HIGH RISK BLEEDING:

Brushing, biopsy or needle Patient on antiplatelet agents (clopidogrel), oral or

aspiration increases the risk. parental anticoagulant therapy.

Patient with thrombocytopenia,

Chronic renal insufficiency.
coagulopathy.

 Non-emergent bronchoscopy should be preferably avoided in following patients.:

i. Consumed anti-platelet agent within 4 to 5 days.
ii. Sc LMWH in past 12 hrs.
iii. P/c<=50,000/mm3.
iv. INR>1.5 sec .Partial thromboplastin time x >1.5 times of baseline value
 WAYS TO MINIMISE THE RISK OF
BLEEDING:
1.HOLD PRIOR TO THE PROCEDURE:
Growing evidence
suggests that ASPIRIN
WARFARIN - CLOPIDOGREL IV HEPARIN - is safe and does not
3 TO 5 DAYS LMWH-24 HRS.
-5 TO 7 DAYS 2 TO 4 HRS. increase bleeding
during bronchoscopy

2.ADMINISTRATION OF PLATELETS IN THOSE WITH THROMBOCYTOPENIA.

Superior Vena Caval syndrome Collateral vessel formation

Increases chance of bleeding.

Ref: Houssein A. Youness , et al : Management of oral antiplatelet agents and anticoagulation therapy before
bronchoscopy;Department of Medicine ,Section of Pulmonary disease, Critical care and Sleep Medicine, Oklahoma ,
USA-Journal of Thoracic Disease-(Suppl 10):S1022-S1033:March 20, 2017.
IN CASE OF RENAL INSUFFICIENCY:
o Risk of bleeding can increase because of dysfunctional platelets.

o If BUN>30 mg/dl or serum creatinine>2mg/dl,

Administer desmopressin (DDAVP) approximately 30 min before

the procedure.
  Minimum person needed in bronchoscopy:

C. At minimum ,at
A.The technician B.The nurse least one qualified
assistant.

Performance of the bronchoscopy.

 PATIENT PREPARATION
Patients should be given a full explanation of the procedure accompanied by written
information. (INFORMED CONSENT)
PRE-PROCEDURE CHECK
LIST:
Full blood count and clotting – before transbronchial lung biopsy
ECG if history of cardiac disease
Ensure patients do not eat or drink for at least 4–6 h before the procedure
Ensure patients have someone to take them home following the procedure , if they
receive sedation
Patients are advised not to drive or operate machinery for at least 24 h after any sedation
Patients are monitored by continuous oximetry throughout the procedure.
Those with pre-existing cardiac disease or hypoxia that is not fully corrected by
oxygen therapy should undergo continuous ECG monitoring.
 PROCEDURE:
 Rule out contraindications.

 Informed consent is essential.

10 ml vial of 4% and
Topical anaesthesia:
20 ml of 1 to 2 %
lidocaine.
 Be gentle and slow and keep scope at the center

 Ice cold saline or epinephrine in a conc. of

1:20000 to control significant bleeding
Image obtained through
the videobronchoscope.
 ROUTES OF BRONCHOSCOPY:
NASAL- ORAL- ENDOTRACHEAL – LARYNGEAL MASK
Most In case of I. Patient on AIRWAYS (LMA)-
Preferable coagulopathy, renal ventilator and Used during
failure, II. The size of the ET flexible
thrombocytopenia should be 7.5 cm) bronchoscopy
III. Increase the FiO2
to 100
IV. Decrease the PEEP
LARYNGEAL MASK AIRWAYS (LMA)-
PROCEDURE: Oxygen administered at 5to 15 l/min via mask with hole cut to
accommodate bronchoscope.

Bronchoscope lubricated with 2 % lidocaine jelly.

Bronchoscope needs to be advanced through nose and pharynx

until epiglottis and vocal cords are visualized.

1% lidocaine is sprayed on the epiglottis and cords .

Once the vocal cords are seen , 1 to 2 ml of 1%to 2% lidocaine is

sprayed through the working channel onto the vocal cords.
 • The maximum amount of allowable topical lidocaine is 200 to 400 mg.
• 4% lidocaine is not used below the vocal cords.

AIRWAY INSPECTION:
Mucosal appearance and integrity-erythema/edema ,may indicate infection or inhalational injury.
Thrombi / petechiae may be due to recent bleeding..
Irregularity may indicate malignancy/ granulomatous disease.
Size, stability , patency –of the airway lumen( narrowing may indicate benign or malignant stricture.)
Tracheal and bronchial collapse – may indicate tracheobronchomalacia.
Anatomic or congenital variants –due to prior surgery or fistulous communication.
Endobronchial lesions or foreign bodies .(mucous plug, thick secretion).

A friable ,polypoid lesions –malignancy/granulomatous tissue.

Bleeding- if blood clot or active bleeding is seen, identify the source.

Transbronchial lung biopsy
(TBB) Transbronchial lung biopsy is used to obtain
parenchymal lung tissue for the evaluation of selected diffuse lung diseases.
• Particularly useful when a bronchocentric component is visible on CT scans.
• Samples are obtained from the periphery of the lung.
• PROCEDURE: The closed biopsy forceps are advanced into
a specific bronchial segment until they meet with resistance

The forceps are then withdrawn a short distance and the jaws opened.

The patient is asked to take a deep breath

Open forceps are advanced further

When there is further resistance, the patient is asked to breathe out and a biopsy
sample is taken during expiration.
 •
Transbronchial fine-needle aspiration
(TBNA)
• TBNA is a low-risk procedure with a good yield.
• Mediastinal and hilar lymph nodes can be sampled
by transbronchial fine-needle aspiration (TBNA).
• PROCEDURE: The site of aspiration is planned on the basis of a cross-sectional CT.

The needle is inserted at the desired point perpendicular to the airway wall.

The needle is moved back and forth after penetration of the airway wall and suction
applied with a 20-mL syringe.

Samples collected can then be used to prepare slides, or be placed in cytofix or

saline solution for cytological analysis.
• This is useful in the staging and diagnosis of suspected lung cancer.

• This should be performed prior to any other aspects of bronchoscopy so as not to

carry over cells from endobronchial lesions into TBNA specimens and, hence,
falsely up-stage the patient.

• Needle aspiration of submucosal lesions may also improve diagnostic yield.

• However, there has been a dramatic shift towards endobronchial ultrasound

(EBUS)-guided TBNA in the majority of centres.
BRONCHOALVEOLAR
LAVAGE (BAL)
• Bronchoalveolar lavage (BAL) has gained widespread acceptance
as a powerful investigative tool in pulmonary medicine and has
become a standard diagnostic procedure in patients with interstitial lung diseases (ILDs).
• BAL is regarded as providing complementary information to histopathology from
biopsies, but nevertheless has several advantages over biopsy procedures.
• It is safer and associated with virtually no morbidity and no absolute contraindications.
• BAL collects samples from a much larger area of the lungs than can be obtained by the
small tissue fragments of transbronchial biopsy or even by surgical biopsy specimen,
therefore giving a more representative view of inflammatory and immunological
changes.
 The bronchoscope is wedged into the segment of interest

50–60-mL aliquots of warm saline are injected into the segment.

Total of 150–250 mL is
instilled and aspirated.
The fluid is then slowly aspirated using low-pressure suction or direct hand suction.

BAL is generally well tolerated, except for:

• Increased risk of minor post-BAL fever, which can be minimized by Both of which
are self-
keeping the total BAL instillation volume below 150 mL limiting and
• A transient decrease in lung function parameters resolve within
24 h.
Risk factors for developing side-effects are:
• PaO2 <8.0 kPa (<60 mmHg), oxygen saturation below 90%,
FEV1 below 1.0 L,
Prothrombin time <50 s, platelet count <20 000 mL–1,
Significant comorbidity,
Bronchial hyperreactivity.

• The normal ranges for differential cell counts in BAL of a healthy non-smokers are:

MACROPHAG LYMPHOCY NEUTROPH MAST

EOSINOPHI PLASMA
ES >80% TES ≤15% ILS ≤3% CELLS
LS ≤0.5% CELLS 0%
≤0.5%
• Cigarette smoking is a strong confounding factor with significant effects on BAL
samples.
• The alveolar macrophages from smokers are much larger than those in nonsmokers and
contain cytoplasmic inclusion bodies (smoker’s inclusion bodies).
• On gross examination:
o the recovered BAL fluid has a light to dark
brown and turbid appearance caused by the
colour of the tar-laden macrophages.
o The total cell yield is three- to five-fold higher
in smokers, due to a three- to five-fold NON-SMOKER SMOKER

numerical increase in the number of

macrophages, leading to a relative decrease in the percentage of lymphocytes.
 BAL FINDING DIAGNOSIS:
Pneumocystis jirovecii, fungi, cytomegalovirus transformed cells Opportunistic infections

Milky effluent, PAS-positive noncellular corpuscles, amorphous Alveolar proteinosis

debris, foamy macrophages

Haemosiderin-laden macrophages, intracytosplasmic fragments Alveolar haemorrhage syndrome

of red blood cells in macrophages, free red blood cells

Malignant cells of solid tumours, lymphoma, leukaemia Malignant infiltrates

Dust particles in macrophages, quantifying asbestos bodies Dust exposure

Eosinophils >25% Eosinophilic lung disease

Positive lymphocyte transformation test to beryllium Chronic beryllium disease

CD1-positive Langerhans cells increased Langerhans cell histiocytosis

Atypical hyperplastic type II pneumocytes Diffuse alveolar damage, drug toxicity

 BAL FINDING DIAGNOSIS:
Lymphocytic EAA , Chronic beryllium disease , Sarcoidosis , TB , NSIP (mainly cellular
type)
Lymphocytic interstitial pneumonia , Connective-tissue disorders
Drug-induced pneumonitis , Malignant infiltrates , Silicosis , Crohn’s disease
Primary biliary cholangitis , HIV infection , Viral pneumonia
Neutrophilic (± IPF , Desquamative interstitial pneumonia , Fibrotic NSIP , Acute interstitial
eosinophilic) pneumonia , Acute respiratory distress syndrome , Bacterial pneumonia
Connective tissue disorders , Asbestosis , Granulomatosis with polyangiitis
Diffuse panbronchiolitis , Transplant bronchiolitis obliterans
Idiopathic bronchiolitis obliterans , Drug-induced reaction
Eosinophilic Eosinophilic pneumonia , Eosinophilic granulomatosis with polyangiitis
Hyper-eosinophilic syndrome , Allergic bronchopulmonary aspergillosis
Desquamative interstitial pneumonia , Drug-induced reaction
Mixed cellularity COP , Connective-tissue disorders , NSIP
Drug-induced reaction , Inorganic dust disease

NSIP: nonspecific interstitial pneumonia; IPF: idiopathic pulmonary fibrosis; COP: cryptogenic
organising pneumonia , EAA- Extrinsic Allergic Alveolitis/Hypersensitivity pneumonitis.
 BAL CD4/CD8 ratio in diseases with a
lymphocytic pattern
CD4/CD8 increased CD4/CD8 normal (0.9-2.5) CD4/CD8 decreased
Sarcoidosis TB EAA
Chronic beryllium disease Lymphangitic carcinomatosis Drug-induced pneumonitis

Asbestos-induced alveolitis COP

Alveolar proteinosis Silicosis
Crohn’s disease HIV infection
Connective-tissue disorders

Ref: Kleth C. Meyer , et al: An official American Thoracic Society Clinical Practice ,Guideline: The clinical utility of
Bronchoalveolar lavage cellular analysis in Intersitial Lung Disease:American Thotacic Society Documents-Am J Respir
Crit Care Med Vol 185,Iss 9 pp 1004-1014, May 1, 2012
 Diagnostic yield of BAL in
ILD
RB-)

BAL without biopsy usually sufficient Alveolar proteinosis , Pneumocystis pneumonia

(high sensitivity and high specificity)
BAL in combination with clinical and
HRCT features frequently sufficient
(high sensitivity, low specificity)
BAL typical in only 50% of patients,
biopsy often needed (if CT atypical)
(moderate sensitivity, high specificity)
BAL mostly not diagnostic, biopsy
required (low sensitivity ± low
specificity)
Bronchoalveolar carcinoma , Malignant non-Hodgkin lymphoma
Alveolar haemorrhage , Eosinophilic pneumonia
IPF (neutrophils ± eosinophil) , EAA (lymphocytes, plasma cells,
foamy macrophages) , RB-ILD (smokers’ macrophages)
COP (mixed cellularity, decreased CD4/CD8 ratio)
Lymphangioleiomyomatosis (alveolar haemorrhage)
Sarcoidosis (increased CD4/CD8 ratio)
Langerhans cell histiocytosis (CD1a >3%)
Hodgkin disease
Invasive aspergillosis

RB-ILD: respiratory bronchiolitis-associated interstitial lung disease. Reproduced and modified

from Bonella et al. (2010).
STUDIES TO BE SENT:
STUDIES OF BRONCHIAL WASH , BAL, BRONCHIAL BRUSH AND ENDOBRONCHIAL BIOPSY
BRONCHIAL WASH/BAL BRUSH ENDOBRONCHIAL BIOPSY
AFB/ MODIFIED AFB(KINYOUN) AFB AFB
FUNGAL STAIN/CULTURE. FUNGAL FUNGAL
BACTERIAL(QUANTITATIVE) BACTERIAL (QUANTITATIVE) BACTERIAL(QUANTITATIVE)
VIRAL VIRAL VIRAL
LEGIONELLA(Direct Fluorescent Antibody)
SILVER STAIN FOR PNEUMOCYSTIS
PCR FOR TB
PCR FOR PNEUMOCYSTIS
GALACTOMANNAN FOR ASPERGILLOSIS.
CELL COUNT AND DIFFERENTIAL CD4-CD8 RATIO
CYTOLOGY CYTOLOGY CYTOLOGYPATHOLOGY
FLOW CYTOMETRY (CELL MARKERS) FLOW CYTOMETRY( FOR LYMPHOMA)
 COMPLICATIONS:
• Usually minor and procedure or sedation related .
 Procedure related mortality is 0.013%-associated with organic heart disease or
severe airway obstruction.

BAL- 0-2.3%
COMPLICATION RATE: TBB- 7% Surgical lung biopsy- 13%

(Avoid trans-bronchial in a bullous lung disease ,as the chance of pneumothorax

becomes higher than usual. )
 Common complication of sedation: Upper airway Central respiratory
obstruction depression

 Upper airway obstruction is the most important cause of acute hypoxemia during FB. This is
effectively treated with a nasopharyngeal tube. One must watch for central respiratory
depression.
 Stepwise approach to manage hypoxemia during fibrobronchoscopy:
o Increase O2 to 6 lit/min & jaw support.
o Nasopharyngeal tube insertion .
o Additional oxygen via catheter.
o Withdraw bronchoscope.
o Bag and mask ventilation.
o Sedation reversal medication
o Rarely endotracheal intubation
o Rule out pneumothorax if there is persistent hypoxemia
COMMON COMPLICATIONS:
Nasal discomfort , a sore throat.

Mild transient hypotension related to sedation.(Propofol)

Mild hypoxemia.

Bleeding(2.8% in TBB)

Pneumothorax / pneumomediastinum( m/c in TBB)-4%, some cases are delayed

and can occur upto 24 hrs later.

Mild hemoptysis(for 1 to 2 days)

LESS COMMON COMPLICATIONS:
Bronchospasm, laryngospasm Syncope

Hypoxemia Seizure

Epistaxis due to nasal trauma Bacteremia

Nausea, vomiting Methemoglobinemia (from lidocaine)

Cardiac arrythmia Laryngeal edema, injury and

fractured equipment.
Infection, vasovagal.
RARE COMPLICATIONS:
Tension pneumothorax

Cardiorespiratory arrest

Respiratory failure requiring intubation and mechanical ventilation

Airway perforation

Airway fire.

LATE COMPLICATION:
Bacteremia, fever and pneumonia
POST PROCEDURE MONITORING:
Nil orally for a minimum to 1 to 4 hrs after the procedure.
(Gag reflex returns after 2to 3 hrs).

Chest X-RAY .

Lung USG.
 JACKSON-HUBER CLASSIFICATION FOR
SEGMENT NOMENCLATURE
NOMENCLATURE AND ANATOMIC VARIATIONS:
ANATOMICAL NOMENCLATURE NUMERIC SYSTEM SUBSEQUENT DIVISION<
RIGHT LUNG
UPPER LOBE
APICAL B1 a AND b
POSTERIOR B2 a AND b
ANTERIOR B3 a AND b
MIDDLE LOBE
LATERAL B4 a AND b
MEDIAL B5 a AND b
LOWER LOBE
BASAL APICAL B6 a ,b AND c
BASAL MEDIAL B7 a AND b
BASAL ANTERIOR B8 a AND b
BASAL LATERAL B9 a AND b
BASAL POSTERIOR B10 a , b AND c
NOMENCLATURE AND ANATOMIC VARIATIONS:
LEFT LUNG
UPPER LOBE
APICAL-POSTERIOR B1+B2 a , b AND c
ANTERIOR B3 a , b AND c
SUPERIOR LINGULAR B4 a AND b
INFERIOR LINGULAR B5 a AND b
LOWER LOBE
BASAL APICAL B6 a , b AND c
BASAL ANTEROMEDIAL B8 a AND b
BASAL LATERAL B9 a AND b
BASAL POSTERIOR B10 a AND b
 Bifurcation of carina is at T5.

C1- primary
carina;

 The right bronchus is more vertically placed at

an angle of 90degree or less with the trachea ,
it is shorter. While the left bronchus is more
horizontal and is longer .
(5 cm in men and 4.5 cm in women)

 The right main bronchus right upper lobe(RUL)

continues as the bronchus intermedius
  Right upper lobe (at C3 carina):

RB1(apical segment) @ 11’o clock RB3(ant. Segment ) @6 ‘o clock

RB2(post. Segment ) @1’o clock

 Longitudinal striations are present in the posterior part (the membranous part.)
 At intermediate bronchus:
o Right middle lobe @12’o clock ;
o Central bronchus @center
o RB6 (apical basal of right lower lobe)@ 6 ‘o clock .
Right middle lobe(RML)
 At C3 secondary bronchus
Right lower lobe (RLL)
 and At C4 right lower lobe bronchus into apical
basal and rest.
 Right middle lobe:

RB4(Rt. Lateral segment) RB5(Rt. Medial segment)

@ 3’o clock @9 ‘o clock

Right lower lobe:

RB6 RB7 (medial basal RB8(ant. Basal RB9 (lateral RB10 (post.
(basal apical) segment)@8,9,10 ‘o segment)@1’o basal Basal
clock-common variant clock ; segment)@3 segment)@
,: that RB7 is missing ‘o clock; 5 ‘o clock;
in many patients)
 Left main bronchus

Left Upper Lobe(LUL) Left Lower Lobe(LLL)

C3 carina
Left Upper Lingula
division • LB4(superior
• LB1 & LB2 lingula)@ 9’o
(bigger clock LB3 (smaller
segment)-apico- segment )- ant.
posterior Segment @5 ‘o
segment @ 11 ‘o clock
clock. • LB5 (inferior
• LB3 (smaller lingular )@ 3’o
segment )- ant. clock;.
Segment @5 ‘o
clock
 Left lower segment:

LB6(apical basal)-@ 11’o clock; LB8,9,10(ant. Basal; lateral basal ;

post basal)-@ 5’o clock

LB8@ 12 ‘o clock

o On going down LB9 @ center

LB10 @ 6’o clock

RIGID BRONCHOSCOPY: It was first introduced in the late 1890s, but its use declined in
the 1960s with the development of flexible bronchoscopy.
However, due to its many new applications and indications, it has seen a revival in recent
years.(often used in combination with a flexible bronchoscope) :
• Management of severe haemoptysis,
• Stent placement and recanalization.
Its main disadvantages are the need for general anaesthesia

VIRTUAL BRONCHOSCOPY: Virtual bronchoscopy is the descriptive term given to

representations of the bronchial tree and surrounding structures created from spatial
information derived from imaging sources other than the bronchoscope itself.
 Endobronchial ultrasound (EBUS)
• EBUS-guided TBNA is performed with an integrated linear array ultrasound bronchoscope.
• It provides excellent ultrasound images of the mediastinum and tissue adjacent to the
airways, and allows ultrasound-guided sampling of mediastinal lymph nodes or
peribronchial tumour masses.
• It has high sensitivity and has significantly reduced the need for mediastinoscopy.
• It is particularly indicated in:
• Staging and diagnosis of lung cancer
• Sampling para tracheal and para bronchial masses
• Diagnosis of sarcoidosis in the presence of hilar and/or mediastinal adenopathy
• Suspected TB
 Radial endobronchial ultrasound
• A radial or mini-probe system can be used for localizing peripheral pulmonary masses.

PROCEDURE:
Probes are passed through the instrument channel of a flexible bronchoscope
into the desired segment with a guide sheath.

Probe is manipulated in the airways with or without radiological guidance

Once the abnormal area is identified
The sheath is maintained in position, the radial ultrasound probe is removed

Washings, brushings and biopsies obtained via the guide sheath.

 Cryobiopsy
• Cryoprobes may be used to obtain better tissue samples
either endobronchially or for transbronchial lung biopsy.
PROCEDURE:
The cryoprobe is passed through the instrument channel of
the bronchoscope and applied to the tissue to be biopsied.
The freezing effects cause the tissue to become adherent
Gentle traction is applied to tear off a piece off the frozen tissue.

The probe and bronchoscope need to be removed from the airway

The piece of tissue thawed and placed in formalin.

• Patients need to be intubated with an endotracheal tube or laryngeal mask.
• It is not possible to remove the probe through the instrument channel of the bronchoscope
when there is tissue adherent to the tip, hence the need to intubate the patient.
 • Prophylactic use of adjuncts, such as blocking balloons, is recommended to minimise the
risk of bleeding.
The balloon should be placed in the segmental orifice where the transbronchial
cryobiopsy is being obtained

Inflated immediately after removing the cryoprobe and bronchoscope as one unit.
• This ensures that the tamponade effect controls any bleeding .
• Importantly reduces the risk of blood overspilling into adjacent airways (the main cause
of asphyxia due to endobronchial bleeding).

• Care is also taken (with fluoroscopic guidance) to obtain the transbronchial lung
biopsies about 1 cm from the pleural edge to further minimise risk of bleeding and a
pneumothorax.
Central biopsies Greater risk of Peripheral Greater risk of
(larger vessels) haemorrhage biopsies pneumothorax
 Bronchoscopic treatment of Asthma and COPD
• More recently, a number of innovations have been developed for the bronchoscopic
treatment of patients with severe emphysema with significant hyperinflation.
• Endobronchial valves, such as zephyr valves and intrabronchial valves, can be used for
bronchoscopic volume reduction. These have been shown to be effective in patients with
severe hyperinflation where the target lobe does not have any collateral ventilation.

• Other developments under evaluation include airway stents, biological polymers,

endobronchial coils and thermal vapour.
• Bronchial thermoplasty, a novel treatment for patients with moderate-to-severe asthma: A
special catheter is used to apply radiofrequency energy to the airways in order to destroy
airway smooth muscle.
• Bronchoscopic treatments for chronic obstructive airways includes : targeted lung
denervation, metered spray cryotherapy treatment and electroporation.
 FEW GLANCES OF PULMONARY INTERVENTIONS:

a. b.

a) Severe obstruction of the upper b) Satisfactory tracheal patency after

trachea by an adenoid cystic laser assisted mechanical debulking.
carcinoma.
a) Post-tracheostomy tracheal stenosis b) After silicone airway stent placement.
a) Nodule visualised by b) Image of virtual bronchoscopy.
radial endobronchial ultrasound.
Talc poudrage at the
surface of a lung
during medical
thoracoscopy.
Endoscopic treatment of emphysema. a) Bilateral coil placement in both upper lobes and
b) one-way valves inserted in segmental bronchi.
SOME CLINICAL CASES,
WHERE
BRONCHOSCOPY CAN
PLAY PIVOTAL ROLE