Relative Contraindications

(Risk–Beneft Assessment)

•\ Bleeding diathesis: Platelet count less than 50,000/mm3, uremic platelet dysfunction, and international normalized ratio (INR) > 1.5 are relevant when brushing or biopsies are considered [16, 17]. Papin and colleagues demonstrated a signifcant incidence of bleeding in 24 patients who underwent transbronchial lung biopsy (TBLB) with a mean platelet count of 30,000/mm3 [18]. Ernest and colleagues concluded that Clopidogrel use greatly increases the risk of bleeding after TBLB in humans and, therefore, should be discontinued fve days before bronchoscopy with planned biopsies [19]. On the other hand, Herth et al. found that Aspirin does not increase bleeding complications after TBLB [20]. A small case series by Stather concluded that proceeding to EBUS-­ transbronchial needle aspiration (TBNA) without frst withdrawing Clopidogrel should only be performed in situations where the risk of short-term thrombosis is believed to outweigh the (theoretical) risk of bleeding [21].

•\ Recent myocardial infarction or unstable angina: Most experts will postpone elective bronchoscopies for six weeks post-acute coronary syndrome [22].

•\ Lack of patient cooperation •\ Pregnancy

•\ Asthma attack

•\ Increased intracranial pressure •\ Inability to sedate

Procedure Preparation

Flexible bronchoscopy can be performed in the endoscopy suite, operating room, intensive care unit, or even emergency room.

1. Equipment

The basic equipment needed is a bronchoscope and its accessories, light source and a video monitor, bronchoalveolar lavage (BAL) container, cytology brushes, biopsy forceps, needle aspiration catheters, syringes, normal

Fig. 2.5  The bronchoscopy team in the procedure suite

saline aliquots, specimen containers, bronchoscope lubricant, bite block, suction apparatus, supplemental oxygen, continuous pulse oximetry, hemodynamic monitoring, and equipment for resuscitation including an endotracheal tube, laryngoscope, and chest tube insertion kit. Fluoroscopy can be valuable when performing TBLB, or advanced diagnostic or therapeutic FB (Fig. 2.5).

2. Personnel

The bronchoscopist, registered nurse, endoscopy technician or respiratory therapist (RT), and the anesthesiologist or certifed registered nurse anesthetist should all be familiar with the patient’s condition and the procedure being performed and appropriate handling of the specimens. This will maximize patient experience and outcome.

3. Patient Preparation

A consent form must be obtained after explaining the procedure, indication, risks, and benefts.

The bronchoscopist must perform a thorough history and physical exam before pro-

ceeding. Chest imaging and diagnostic tests should be reviewed carefully.

A few important concerns to mention:

\(a)\ Nil per os (NPO): Indicated for 2 h for clear liquids and 6–8 h for solids before FB [23].

\(b)\ Electrocardiograms are generally indicated for patients with suspected or known cardiac history.

\(c)\ Spirometry is not indicated before proceeding with bronchoscopy [24].

\(d)\ Premedication with atropine or glycopyrrolate is not benefcial in reducing bronchoscopy-­related cough or secretions [13, 14].

\(e)\ Prophylactic antibiotics: FB is a rare cause of bacteremia and endocarditis [25]. Prophylactic antibiotics are indicated in patients with mechanical valves and a history of endocarditis.

\(f)\ Chest X-ray is indicated 1-h post transbronchial lung biopsy (TBLB) to rule out pneumothorax [26]. Alternatively, a thoracic ultrasound (US) exam documenting sliding lung sign will rule out pneumothorax post TBLB. Kumar and colleagues performed a total of 379 FB and 113 TBLB. Lung US exam detected all cases

Fig. 2.6  A bronchoscopy procedure in progress using ENB and radial EBUS through a laryngeal mask airway with general anesthesia

of pneumothorax (PTX), whereas chest X ray (CXR) missed one PTX. The sensitivity, specifcity, and overall accuracy for ultrasound were 100% as compared with a sensitivity of 87.5% and an accuracy of 99.6% for the CXR group [27].

\4.\ Anesthesia and Monitoring

The current guidelines do not address the type of anesthesia needed for each procedure but suggest that simple diagnostic FB procedures can be performed under local anesthesia or moderate conscious sedation. On the other hand, complex diagnostic and therapeutic bronchoscopy usually requires general anesthesia like total intra venous anesthesia (TIVA) [28].

The most used local/topical anesthetic for FB is lidocaine. Its plasma level of 5 μg/mL or dose greater than 8.2 mg/kg instilled in the airways can result in central nervous system (CNS) toxicity (restlessness, slurred speech, seizure), cardiovascular toxicity (atrioventricular block, hypotension), and methemoglobinemia.

Common sedative and opioid combinations used during conscious sedation are midazolam and fentanyl. Propofol, and to a lesser extent, ketamine, or dexmedetomidine coupled with fentanyl or remifentanil are also used in TIVA (Fig. 2.6).

After the FB procedure, patients are observed in the recovery unit until they meet discharge criteria. Written discharge instructions and contact information are provided to the patient.

Technique of FB Procedure

•\ Insertion route: According to an American College of Chest Physicians (ACCP) survey done in 1991, 33.8% of the total 871 responders/bronchoscopists preferred the nasal FB route, compared to 6.4% who preferred oral route only, and 42.6% had no preference [16]. Choi and colleagues in 2005 randomly assigned 307 patients to nasal vs. oral insertion route. They concluded that oral insertion of a exible bronchoscope was associated with less discomfort for patients than nasal insertion, although the insertion route had no signifcant effect on outcome [29]. Beaudoin and colleagues assessed the feasibility of using the nasal route for linear endobronchial ultrasound performed on 196 patients, where in 73.5% of patients, nasal insertion was possible. The author concluded that linear EBUS could be performed safely and accurately via the nasal route [30].

•\ When ready to proceed with FB, the patient should be placed in either a semirecumbent or supine position after obtaining intravenous (IV) access. A topical anesthetic should be applied to the nasal passages and pharynx in case of nasal route insertion and only the pharynx if the oral route is chosen. Then, the bronchoscope is introduced either through the nose or mouth with a bite block in place to protect the bronchoscope. The oropharynx is examined, reaching the vocal cords, which are re-­ anesthetized topically. The vocal cords are examined for abduction and adduction. The bronchoscope is passed through the vocal cords to examine the tracheobronchial tree. We prefer to start with an inspection of normal airways, leaving the diseased area of interest to the end. A thorough, systematic approach to examining the airways is recommended. Description of airway confguration, mucosal membranes, secretions, location, extent, and

size of the abnormality is very valuable. Luminal narrowing/obstruction, whether intrinsic, extrinsic, combined, or dynamic, should be described; its length and distance from the closest carina should be documented in the report since it is very valuable if a surgical intervention may become an option.

•\ Both diagnostic and therapeutic bronchoscopic procedures can be performed duringexible bronchoscopy. Lengthy, complex diagnostic and therapeutic procedures are better performed under IV general anesthesia.

•\ Depending on the indication, the following diagnostic procedures can be performed: BAL, endobronchial or transbronchial biopsies, cytological washes or brushings, and conventional TBNA, endobronchial ultrasound (EBUS) TBNA, radial probe EBUS, cryobiopsy, navigational bronchoscopy, and narrow-band imaging (NBI) bronchoscopy. Therapeutic procedures including balloon dilatation, endobronchial LASER ablation/coagulation, electrocautery, photodynamic therapy, brachytherapy, self-expandable stent placement, and endobronchial valve placement can all be accomplished through exible bronchoscopy [13, 15].

Complications of FB Procedure

Flexible bronchoscopy, in general, has a great safety profle [1, 2, 31]. Major complications such as bleeding, respiratory depression, cardiorespiratory arrest, arrhythmia, and pneumothorax occur in less than 1% of cases [16]. Mortality is rare, with a reported death rate of 0–0.04% in more than 68,000 procedures [13].

It is important to mention that transient hypoxemia during and after bronchoscopy is the most common complication, especially when performing BAL in a patient with borderline cardiopulmonary reserve [2, 32]. Cardiac arrhythmia and risk of myocardial infarction are increased in elderly patients with cardiovascular comorbidities [33, 34].

Other complications of FB are adverse events of sedatives and narcotics, hypercapnia, hypoten-