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Bronchoscopy

 
, medical expert
Last reviewed: 04.07.2025
 
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Before reaching its current state, endoscopy has undergone a long path of development associated with the improvement of endoscopic equipment and auxiliary endoscopic instruments.

The birth of clinical bronchology dates back to the end of the 19th century and is associated with the emergence of a new diagnostic and therapeutic method - bronchoscopy. The emergence of bronchoscopy was preceded by the inventions of A. Desormeaux (1853), A. Kussmaul (1868), J. Mikulicz (1881) of a rigid gastroscope and special endoscopic instruments for it. In 1897, a German otolaryngologist from Freiburg G. Killan performed the world's first bronchoscopy and removed a foreign body from the right main bronchus using J. Mikulicz's endoscope. The term "bronchoscopy" was also proposed by G. Killan.

C. Jackson (1903) designed a bronchoscope with proximal illumination, substantiated the use of biopsy, and proposed performing bronchography through a bronchoscope. He also wrote the world's first monograph on bronchoscopy.

G. Killan's student W. Brunings designed a bronchoscope with distal illumination in 1908, which is still used today.

For 50 years, bronchoscopy was used in the practice of otolaryngologists mainly for the removal of foreign bodies. The use of modern anesthesia (Adams, 1945; Bars, 1955) contributed to the further improvement of bronchoscopy. The progress of thoracic surgery, phthisiology and pulmonology created the preconditions for the rapid development of bronchological methods. In 1956, H. Friedel designed a rigid respiratory bronchoscope, which made it possible to perform examinations under anesthesia with artificial ventilation of the lungs.

In Russia, the first bronchoscopy was performed by K. M. Schmidt in 1903. A major role in the establishment and development of bronchoscopy was played by Russian scientists N. A. Schneider (1909), V. I. Voyachek (1911), V. L. Trutnev (1927), G. I. Lukomsky (1963), L. Ts. Ioffe (1969), E. V. Klimanskaya (1972), A. A. Ovchinnikov (1980), and others.

The invention of the fiber bronchoscope by S. Ikeda et al. in 1968 increased the value of both diagnostic and therapeutic bronchoscopy and expanded the range of its application. The resolution capabilities of bronchoscopy expanded: it became possible to examine all fourth-order bronchi, 86% of fifth-order bronchi, and 56% of sixth-order bronchi (G.I. Lukomsky et al., 1973).

The disadvantage of fiber endoscopes is that strong compression of the device, for example with teeth, leads to the destruction of glass fibers, the appearance of black dots in the field of view and deterioration of the image. Video endoscopes do not have this disadvantage.

In 1984, the first video endoscopes EVF-F, EVD-XL, EVC-M were created in the USA. In modern video endoscopes, thanks to the use of highly efficient lenses and precise digital signal processing systems using megapixel CCD matrices, it is possible to obtain a clear, high-quality image, magnified approximately 100 times, while color rendition does not deteriorate.

Video endoscopes are more reliable in operation, as they can be bent at any angle and even tied in a knot without fear of damaging the endoscope. The strain on the endoscopist's eyes has been significantly reduced. Thanks to the use of video endoscopes, it is possible to detect the smallest changes in the mucous membrane of the trachea and bronchi, which allows diagnosing cancer of these organs at an early stage of development.

Bronchoscopy arose from direct laryngoscopy by improving it and reconstructing the directoscope. The first bronchoscopy was performed in 1897 by the German otolaryngologist G. Killian, who supplemented the laryngoscope (directoscope) of Kirstein (1895) with a metal tube, with which he removed a bone from the bronchus of the victim. Later, G. Killian, together with his student W. Brunings, created a bronchoscopic kit, which included an illuminator-electroscope, a set of instruments for biopsy and extraction of a foreign body, a set of endoscopic tubes of different lengths and diameters.

All parameters of the bronchoscope parts were carefully developed during corresponding anthropometric studies. Later, this bronchoscope was improved by V. Brunings and is practically used for its intended purpose even today. The Brunings bronchoesophagoscope set includes tubes of different structures (double, sliding, inserted into each other). Later, other modifications of the Killian bronchoscope were developed. Modern domestic and foreign bronchoscopes are created on the principle of fiber optics or telescopes with image transmission to a television screen. These bronchoscopes are equipped with devices for injection artificial ventilation, various devices for taking swabs and biopsies, suctioning sputum, microsurgeries, removing small foreign bodies, etc.

A distinction is made between upper and lower bronchoscopy. Upper bronchoscopy is performed by inserting a bronchoscope through the mouth, lower bronchoscopy - through a laryngofissure or tracheostomy. The following indications exist for upper bronchoscopy: foreign bodies in the trachea and bronchi; diagnostics of various diseases (cicatricial stenosis, bronchiectasis, tuberculosis, neoplasms, detected radiological changes in the bronchi and lungs); performing certain diagnostic and therapeutic procedures (biopsy, bronchial lavage and suction of secretions from them in severe asthmatic conditions, hemostasis in bronchopulmonary hemorrhages, etc.).

Bronchoscopy is performed in specially equipped bronchoscopic rooms. Most often, a flexible bronchoscope is used for this, the use of which requires only local anesthesia. The technique is relatively simple: the patient is usually in a sitting position; the examination is only performed in seriously ill patients in a lying position. The endoscope is inserted through the nose or mouth. A modern fibroscope consists of a flexible tube with light guides packed in it, a handle with controls, an eyepiece with a special set of lenses. The fibroscope is equipped with devices that allow bending the distal end of the tube for a more detailed examination of hard-to-reach places, changing the focal length and magnifying the image, transmitting the image to a video monitor, video and photographing the image, using an additional channel to wash the bronchi, aspirate their contents, insert flexible instruments for biopsy, removal of a foreign body, coagulation, administration of drugs, etc.

Due to its elasticity, small diameter and significant maneuverability of the distal end of the tube, the bronchofibroscope has significantly broader diagnostic and manipulation capabilities compared to a rigid bronchoscope. However, there are contraindications to the use of this gentle instrument: profuse bleeding, severe asthmatic status, intolerance to application anesthesia, oxygen deficiency manifested by hypercapnia, in which the partial pressure (tension) of carbon dioxide in the blood is above 50 mm Hg. Art.

Bronchoscopy with a rigid bronchoscope is performed under general anesthesia with the patient lying on his back. A modern rigid bronchoscope is a 43 cm long metal tube equipped with a lighting system provided by a flexible light guide from a separate light source, an adapter for connecting a ventilator system, a channel for introducing various instruments and an eyepiece of the optical system for remote examination. To insert the bronchoscopic tube into the main bronchi, the patient's head and body should be tilted to the side opposite the bronchus being examined, thereby straightening the angle of the bronchus from the trachea. Contraindications to "rigid" bronchoscopy are the same as for bronchoscopy using a fiberscope, as well as damage to the cervical spine, lower jaw, contracture of the temporomandibular joint, trismus and the inappropriateness of general anesthesia due to the danger. With “rigid” bronchoscopy, complications such as injury and perforation of the bronchus, internal pneumothorax, bleeding, and swelling of the subglottic space are possible, especially in children under 3 years of age.

In upper bronchoscopy, the first stage of the examination procedure corresponds to the laryngoscopy technique. The bronchoscopic tube is inserted into the subglottic space through the posterior glottis during inhalation. When the bronchoscope is inserted into the trachea, pulsating and respiratory movements of its walls are visible. The former (mechanical) are caused by the transmission of pressure of the pulse wave running through the adjacent arteries (on the right - the innominate, on the left - the carotid and the aortic arch). Respiratory movements of the trachea (reflex) are associated with its expansion during inhalation; these movements are especially noticeable in children. The carina of the trachea is slightly deviated to the right, has the appearance of an arch with its concavity facing the lumen of the trachea. Normally, the mucous membrane covering the carina is paler than the mucous membrane of the main bronchi, and is pale pink; it makes spontaneous movements synchronous with the acts of inhalation and exhalation - forward and upward and backward and downward, respectively. Any deviation of the carina from the norm requires a thorough X-ray examination of the lungs and mediastinum. After examining the trachea and carina, the actual procedure of alternately inserting the tube into the main bronchi and examining the bronchi of the left and right lungs follows.

Processing of flexible endoscopes

All flexible endoscopes come into contact with intact mucous membranes and are classified as semi-critical. They should not contain any microorganisms, but may contain spores of some bacteria. According to statistics, gram-negative bacteria and mycobacteria are most often transmitted during bronchoscopy.

Disinfection and sterilization of endoscopes

Indications and contraindications for bronchoscopy

Bronchoscopy is one of the most informative instrumental methods for examining the tracheobronchial tree.

Indications for bronchoscopy are: suspected central or peripheral benign or malignant lung tumor, bronchostenosis and atelectasis of unknown etiology, chronic inflammatory and suppurative lung diseases, hemoptysis and pulmonary hemorrhage, foreign bodies in the tracheobronchial tree, tracheal stenosis, disseminated lung diseases, tuberculosis, pleurisy of unknown etiology, mediastinal tumors, bronchial fistula.

Indications and contraindications for bronchoscopy

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Bronchoscopy technique

Thirty minutes before the start of local anesthesia, the patient is given 1 ml of 0.1% atropine sulfate solution subcutaneously (to remove the vagal effect). Patients with glaucoma are examined without preliminary atropinization. Patients with a tendency to bronchospasm are given 10 ml of 2.4% euphyllin solution per 10 ml of physiological solution intravenously 15 minutes before the examination, and immediately before the start of local anesthesia, the patient is given 1-2 doses of the aerosol used by the patient to inhale.

Bronchoscopy technique

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Methods of biopsy during bronchoscopy

An important component of diagnostic bronchoscopy is biopsy. It is performed to establish a diagnosis and determine the extent of the process in the bronchus.

During bronchoscopy, material for cytological and histological examination is collected in several ways, each of which has its own indications.

Methods of biopsy during bronchoscopy

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Diagnostic bronchoalveolar lavage (BAL)

The idea of washing the bronchi to empty their contents belongs to Klin and Winternitz (1915), who performed BAL in experimental pneumonia. In the clinic, bronchoalveolar lavage was first performed by Yale in 1922 as a therapeutic manipulation, namely for the treatment of phosgene poisoning in order to remove abundant secretions. Vincente Garcia in 1929 used from 500 ml to 2 liters of fluid for bronchiectasis, pulmonary gangrene, foreign bodies in the respiratory tract. Galmay in 1958 used massive lavage for postoperative atelectasis, aspiration of gastric contents and the presence of blood in the respiratory tract. Broom in 1960 performed bronchial lavage through an endotracheal tube. Then double-lumen tubes began to be used.

Diagnostic bronchoalveolar lavage

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Bronchoalveolar fluid processing

The primary objective of BAL is to obtain cells, extracellular proteins, and lipids present on the epithelial surfaces of the alveoli and terminal airways. The cells obtained can be evaluated cytologically as well as biochemically, immunohistochemically, microbiologically, and electron microscopically. Routine procedures include total and cell counts and, if possible, detection of lymphocytes by monoclonal antibody staining.

Bronchoalveolar fluid processing

Complications of bronchoscopy and measures to prevent them

According to most authors, bronchoscopy poses minimal risk to the patient. The largest summary statistics, summarizing 24,521 bronchoscopies, indicate a small number of complications. The authors divided all complications into three groups: mild - 68 cases (0.2%), severe - 22 cases (0.08%), requiring resuscitation, and fatal - 3 cases (0.01%).

Complications of bronchoscopy and measures to prevent them

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Diagnostic manipulations used in bronchoscopy

Obtaining diagnostic material and its examination (microbiological, cytological and histological) are mandatory components of a bronchoscopic examination.

Smears taken from the bronchi are important for diagnosing tumors. In non-specific endobronchitis, cytological examination of smears can be recommended as one of the methods for determining the nature of inflammation.

Washing from the bronchial walls is of great importance for the detection of tuberculosis mycobacteria, non-specific microflora, and fungi. To obtain a wash, 10-20 ml of sterile isotonic sodium chloride solution is introduced through the working channel of the fiber bronchoscope, which is then aspirated into a sterile bottle.

Bronchoalveolar lavage (BAL) is performed during fibrobronchoscopy performed under local anesthesia, or during combined RBS. The fibrobronchoscope is installed in the subsegmental bronchus, 40-100 ml of warm sterile isotonic sodium chloride solution is introduced in portions (20 ml) through the working channel under pressure. The lavage fluid is immediately aspirated into a sterile container, its biochemical and immunological parameters, as well as cellular composition, are studied. This is important for the differential diagnosis of tuberculosis.

Direct biopsy is performed using special forceps. Indications for forceps biopsy:

  • active tuberculosis of the trachea or bronchus, especially when complicated by granulation;
  • non-specific endobronchitis;
  • unspecified etiology of the process (suspected neoplasm, sarcoidosis, etc.).

When lymph nodes are enlarged, a puncture biopsy is performed through the wall of the trachea or bronchi. Most authors prefer to examine bifurcation lymph nodes by puncturing the inner wall of the mouth of the right main bronchus (on the right slope of the tracheal spur). Puncture of this area is the safest: the probability of the needle hitting a large blood vessel is very small. The results of cytological examination of punctures from the spur of the right upper lobe bronchus have high diagnostic significance.

Catheterization and brush biopsies are very close in significance and capabilities. The main indication for examination is changes in the lungs of unclear genesis (peripheral round formations, disseminated processes, cavitary changes).

During fibrobronchoscopy or combined bronchoscopy, the fibrobronchoscope is inserted into the corresponding segmental bronchus and a special brush enclosed in a catheter is inserted through the working channel. The brush is removed from the catheter and advanced further into the bronchus, several light forward movements are made and then pulled back into the catheter, which is removed from the fibrobronchoscope. The brush is used to make smears on slides. Similarly, a catheter is inserted into the corresponding bronchus through the working channel of the fibrobronchoscope. The bronchial contents are aspirated through it with a syringe, which are then extracted onto a slide.

Transbronchial lung biopsy (TBLB) is used mainly for disseminated lung lesions. Successful transbronchial lung biopsy requires a highly qualified endoscopic diagnostics physician, the ability to provide emergency care in the event of complications (bleeding or pneumothorax), and a modern X-ray machine that allows monitoring manipulations on the screen. Experienced endoscopic diagnostics physicians can perform transbronchial lung biopsy without X-ray control.

A biopsy during fibrobronchoscopy is performed under local anesthesia on one side only (to exclude the development of bilateral pneumothorax). The fibroscope is brought to the mouth of a segmental or subsegmental bronchus, and biopsy forceps are advanced through the working channel of the fibrobronchoscope. The forceps are moved under X-ray control (or blindly) until a feeling of slight resistance and a slight tingling in the patient's chest appears. Then they step back 1-2 cm, open the branches and, slightly moving the forceps forward at the moment of inhalation, gently close them and remove them from the fibrobronchoscope channel. The biopsy is placed in a bottle with formalin, sometimes imprints are made from it on a glass slide beforehand.

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