Bronchoscopy: how it is performed and when it is prescribed

Bronchoscopy is an endoscopic procedure in which a physician examines the interior of the trachea and bronchi using a flexible or rigid instrument, taking tissue samples as needed, and performing therapeutic procedures. Modern bronchoscopy has become a highly precise technology: it combines video imaging, targeted biopsies, ultrasound navigation, and treatment methods within the airways. This allows for a more precise diagnosis and the elimination of the cause of symptoms, reducing the need for open surgery. [1]

The main advantage of this method is its real-time access to the central and peripheral airways. The physician can visualize the source of hemoptysis, determine the nature of the obstruction, assess the tumor's extent, take a forceps biopsy, or perform bronchoalveolar lavage. For pathologies of the mediastinum and pulmonary roots, endobronchial ultrasound needle aspiration under visual control is used, which has significantly improved the accuracy of tumor staging and the diagnosis of many benign conditions. [2]

Bronchoscopy safety is determined by standardization: mandatory monitoring of vital signs before, during, and after the procedure, patient preparation, appropriate choice of anesthesia and sedation, and team preparedness to manage the airway. Professional guidelines detail these elements, reducing the risk of complications and improving the quality of the examination. [3]

Bronchoscopy can be diagnostic or therapeutic. Diagnostic procedures include examination and sampling using various methods, while therapeutic procedures include stopping bleeding, removing foreign bodies, restoring the lumen in cases of stenosis, installing stents, thermal ablation, and other techniques. The choice of approach depends on the clinical objective, anatomy, associated diseases, and risk assessment. [4]

Table 1. Flexible and rigid bronchoscopy: where what is appropriate

Criterion	Flexible bronchoscopy	Rigid bronchoscopy
Target	Diagnostics, minor interventions	Major medical procedures, massive hemoptysis
Pros	Comfort, access to distal sections	Airway control, wide channel, powerful hemostasis
Cons	Limited instrumental channel	Requires anesthesia and experience
Typical role	First line of diagnosis	Reserve for complex tasks

Indications: When is bronchoscopy really necessary?

Classic indications include suspected central airway tumors, persistent hemoptysis, unclear infiltrates on radiography or CT scan, prolonged cough suggestive of a foreign body, and the need to verify infection or inflammatory disease. In these cases, bronchoscopy allows for rapid tissue collection for morphological analysis and the determination of further management. [5]

Important roles are played by differential diagnosis of stenosis and narrowing, clarification of the causes of segment collapse, assessment of tumor progression after treatment, and monitoring of treatment effectiveness in inflammatory diseases. The procedure allows for local treatment if the cause of the problem is identified during examination, saving time and resources. [6]

Endobronchial ultrasound needle aspiration has become the standard for staging lung tumors and assessing mediastinal lymph nodes. Under visual and ultrasound guidance, the physician obtains material from nodes and parabronchial lesions, improving staging accuracy and helping to select the optimal treatment. [7]

Bronchoscopy is also used in cases of unclear immune deficiency, recurrent infections, for the placement of temporary devices, and for the precise administration of medications into the bronchial tree. In each case, the physician evaluates the benefit-risk ratio, considering alternative imaging and biopsy methods. [8]

Table 2. Typical indications and clinical purposes

Situation	What does a bronchoscopy provide?
Suspected tumor	Visualization of the lesion, biopsy, staging
Hemoptysis	Search for the source, local hemostasis
Unclear infiltrates	Lavage, forceps and brush biopsy
Narrowing of the lumen	Diagnosis of the cause, restoration of the lumen
Lymph node assessment	Ultrasound-guided needle aspiration

Contraindications and risk assessment

Absolute contraindications are few and primarily related to an unstable condition: uncorrected hypoxemia, severe hemodynamic instability, severe arrhythmia, and failure to maintain airway patency. In these situations, the procedure is postponed until stabilization occurs, or an alternative approach is chosen. [9]

Relative contraindications include blood clotting disorders, the need to continue anticoagulant therapy without interruption, recent heart attack, severe exacerbations of bronchial asthma, and chronic obstructive pulmonary disease. In this case, the decision is made on an individual basis, optimizing treatment and choosing gentle techniques with minimal risk of bleeding. [10]

Before bronchoscopy, assessment of respiratory function, blood oxygen levels, heart rate, and blood pressure is mandatory, as well as discussion of the sedation plan. The team should be prepared to provide mechanical ventilation if necessary, especially during therapeutic interventions and in high-risk patients. [11]

A separate section addresses the risk of bleeding and thrombosis when taking anticoagulants and antiplatelet agents. Current guidelines describe algorithms for temporarily discontinuing and reinstating medications, taking into account the type of intervention and individual risk of thrombosis. [12]

Table 3. Contraindications and team actions

Factor	Risk	What to do
Unstable hemodynamics	Exacerbation of conditions	Stabilize, postpone
Severe hypoxemia	Gas exchange disorder	Optimize oxygen therapy, consider alternatives
Coagulopathy	Bleeding	Correction of coagulation parameters
High thrombogenic risk	Thrombosis	Individual plan with the participation of a specialist

Preparation: from consultation to the day of the procedure

Preparation begins with a detailed explanation of the purpose, possible findings, and alternatives. Information about medications, allergies, and previous anesthesia experiences is always collected. The patient is explained how anesthesia and sedation will be administered, what to expect after the procedure, and when they can return to normal activities. Being informed reduces anxiety and improves tolerance. [13]

A few days beforehand, the anticoagulant and antiplatelet therapy strategy will be agreed upon. Temporary discontinuation or dose adjustment is not necessary for everyone; the decision depends on the complexity of the procedure and the thrombogenic risk. For direct oral anticoagulants and vitamin K antagonists, there are clear interval recommendations that help balance safety and efficacy. [14]

Immediately prior to bronchoscopy, a pre-procedure assessment is performed: oxygen saturation, heart rate, blood pressure, and respiratory rate are measured. Oxygen support and venous access are provided if necessary. Monitoring of these parameters continues during and after the procedure until full recovery. [15]

Routine antibiotic prophylaxis is not required for standard diagnostic procedures. Exceptions are rare and are justified by the specific clinical situation, such as a high risk of bacteremia in certain patient groups. [16]

Table 4. Mini-checklist for preparation

Paragraph	For what
Discuss goals and alternatives	Understanding and agreement
Review medications	Management of bleeding and thrombosis
Assess respiration and hemodynamics	Reducing risks during the procedure
Provide monitoring and access	Readiness for urgent action

Anesthesia and sedation: how to make the procedure comfortable and safe

Sedation improves bronchoscopy tolerability and examination quality while maintaining a good safety profile. A stepwise approach is used, from minimal sedation to deep sedation with an anesthesiologist, based on the complexity of the procedure, comorbidities, and patient preferences. The choice of drug and sedation depth is determined by a trained team. [17]

Guidelines recommend offering sedation to most patients unless contraindicated, ensuring routine monitoring of oxygen saturation, heart rate, and blood pressure. Monitoring should begin before the procedure, continue during it, and be maintained afterward until stable. This algorithm reduces the likelihood of respiratory and hemodynamic complications. [18]

For certain situations, such as prolonged therapeutic interventions or severe anxiety, deeper sedation under the supervision of an anesthesiologist is advisable. This increases comfort and facilitates procedures, but requires enhanced monitoring and preparedness for airway management. This decision is made on an individual basis. [19]

It's important to understand that sedation safety is determined not only by the medication itself, but also by protocols: checklists, staff training, and the availability of equipment for immediate respiratory and circulatory support. Ongoing internal audits help maintain a high level of quality and safety. [20]

Table 5. Sedation and monitoring options

Approach	Where appropriate	Monitoring
Minimal sedation	Short diagnostic procedures	Oxygen saturation, pulse, pressure
Moderate sedation	Most procedures	Oxygen saturation, pulse, blood pressure, breathing monitoring
Deep sedation	Long and complex interventions	Advanced monitoring, ventilation readiness
Without sedation on request	Selected patients	Basic monitoring and analgesia of the mucous membranes

How the procedure works: step by step

After local anesthesia of the nasopharyngeal or oropharyngeal mucosa, the bronchoscope is carefully inserted through the nose or mouth into the trachea and bronchi. A systematic examination is performed from the central sections outward, recording visual findings and photographing key areas. If necessary, specimen collection and therapeutic interventions are performed. The duration depends on the objectives and ranges from a few minutes to an hour or more. [21]

Bronchoalveolar lavage is performed to assess cellular composition and detect infection: a sterile solution is injected into a segmental bronchus and then aspirated, sending samples for laboratory testing. Forceps and brush biopsies are taken from suspicious areas of the mucosa. For peripheral lesions, navigation techniques and X-ray monitoring are used as indicated. [22]

If mediastinal lymph node or pulmonary hilar involvement is suspected, a bronchoscope with an ultrasound probe is used. The physician visualizes the node, selects a safe trajectory, and performs a fine-needle aspiration with multiple passes, which increases diagnostic yield and allows for simultaneous molecular testing. [23]

If a narrowing of the lumen or bleeding is detected, immediate treatment options include mechanical removal of the obstruction, administration of adrenaline or coagulation for hemostasis, balloon dilation, stent placement, or thermal ablation. The decision regarding intervention is made based on the patient's condition and the anatomy of the lesion. [24]

Table 6. Diagnostic methods within bronchoscopy

Method	What is it used for?	Peculiarities
Bronchoalveolar lavage	Infection, inflammation	Standardized collection protocols
Punch and brush biopsy	Tumors, inflammatory foci	Sufficient depth and multiplicity are required
Transbronchial lung biopsy	Peripheral foci	Requires planning and control
Ultrasonic needle aspiration	Mediastinal lymph nodes	High staging accuracy

Treatment options: what can be done immediately

In hemoptysis, bronchoscopy allows localization of the source and control of bleeding using local agents and coagulation. This is a key element of emergency care, especially in cases of severe bleeding, when the risk of airway obstruction remains. In some cases, a transition to rigid bronchoscopy is required for more effective hemostasis and ventilation control. [25]

Lumen narrowing due to tumors, granulation, or scarring is treated with mechanical recanalization, balloon dilation, thermal ablation, and stent placement. The choice of method depends on the nature of the obstruction, its length and location, as well as the overall treatment plan for the underlying disease. Combined approaches yield the best results in complex anatomy. [26]

Bronchoscopy is indispensable for removing foreign bodies in adults and children. In most situations, a flexible apparatus and specialized grasping instruments are sufficient; however, for large or firmly fixed objects, a rigid approach is chosen. Timely intervention prevents atelectasis and infectious complications. [27]

For chronic purulent infections and bronchiectasis, bronchoscopy helps remove viscous secretions, take targeted cultures, and assess the need for treatment adjustments. This approach improves symptoms and quality of life in selected patients. [28]

Table 7. Therapeutic techniques in bronchoscopy

Task	Method	Comments
Hemoptysis	Local hemostasis, coagulation	In case of massive - hard access
Narrowing of the lumen	Recanalization, dilatation, stent	Combinations of methods according to indications
Foreign body	Extraction with instruments	Select access by size and fixation
Evacuation of the secret	Aspiration, lavage	Improvement of symptoms in selected subjects

Endobronchial ultrasound needle aspiration: staging standard

Endobronchial ultrasound needle aspiration has become the standard for primary staging of lung tumors and diagnosis of lesions in the hilar and mediastinal regions. At least several passes are made under ultrasound guidance in each target node to increase the likelihood of obtaining representative material suitable for morphological and molecular studies. [29]

The accuracy of the method is high and comparable to surgical selective biopsy methods, but significantly less invasive. Proper sample handling and transportation are just as important as the collection technique, as it determines the scope of subsequent studies, including molecular tests that determine targeted therapy. [30]

Preparation for the procedure follows the general principles of bronchoscopy, with mandatory monitoring and careful sedation. If there is an increased risk of bleeding, smaller-diameter needles and the minimum number of passes are selected without sacrificing diagnostic value. [31]

Lymph node sampling algorithms are based on clinical presentation and imaging data. Biopsies are typically performed sequentially, from higher-numbered nodes to lower-numbered nodes, which helps to more accurately determine the stage and avoid missing micrometastases. [32]

Transbronchial cryobiopsy in interstitial lung diseases

Transbronchial cryobiopsy is a method for obtaining larger fragments of lung tissue using a cryoprobe, which is important for morphological diagnosis in a number of interstitial diseases. Current guidelines describe the indications, technique, safety measures, and requirements for the team's experience. This method is considered an alternative to surgical biopsy in selected cases. [33]

Advantages include a larger, more complete sample compared to standard punch biopsy and lower invasiveness compared to surgery. However, cryobiopsy requires strict measures to prevent bleeding and pneumothorax, as well as a trained team and equipment to quickly stop bleeding. [34]

The choice of segment and probe insertion depth is determined based on imaging and functional testing data. The number of samples and their distribution are agreed upon in advance with a morphologist to increase diagnostic value and reduce the need for repeat procedures. [35]

The decision to perform a cryobiopsy is made by a multidisciplinary team including a pulmonologist, radiologist, and pathologist. This improves the accuracy of the diagnosis and allows for a more rapid determination of the optimal therapeutic strategy. [36]

Table 8. Biopsy techniques: comparison

Technique	Sample size and quality	Risk	Typical tasks
Punch biopsy	A small fragment	Short	Superficial lesions
Ultrasonic needle aspiration	Cellular material and columns	Short	Lymph nodes, parabronchial foci
Transbronchial cryobiopsy	Large fragment of parenchyma	Average	Interstitial diseases
Surgical biopsy	Very large fragment	High	Complex diagnostic cases

Anticoagulants and antiplatelet agents: practical guidelines

The strategy depends on the planned procedure and the individual's risk of thrombosis. For low-risk diagnostic procedures, individual antiplatelet agents may be maintained, while for interventions with a high risk of bleeding, such as large biopsies or cryobiopsies, temporary discontinuation of the medications is considered. For direct oral anticoagulants and vitamin K antagonists, there are recommendations on the timing of interruption and resumption. [37]

Decisions are made in consultation with the treating cardiovascular specialist or hematologist, particularly in patients with mechanical valves, recent thrombosis, or high-risk conditions. In selected cases, bridging therapy with short-acting anticoagulants is considered. [38]

After interventions, the strategy for reintroducing medications takes into account the balance between the risk of rebleeding and the risk of thrombosis. Detailed plans and timing depend on the medication, renal function, and the extent of the intervention. Documentation of this decision is mandatory in the protocol. [39]

Given the diversity of clinical situations, best practice remains adherence to current, regularly updated guidelines and departmental protocols. This reduces variability and improves safety. [40]

Table 9. Approximate risk stratification and actions

Category	Examples	Tactics
Low risk of bleeding	Examination, lavage, brush biopsy	Often without discontinuing individual antiplatelet agents
Medium risk	Punch biopsy of the mucosa, needle aspiration	Individual therapy adjustment
High risk	Large biopsy, cryobiopsy, extensive hemostasis	Temporary cancellation according to the algorithm, resumption plan

Complications: how often and how to prevent them

Most bronchoscopies are performed without serious complications. The most significant risks are hypoxemia, bronchospasm, bleeding, and, very rarely, perforation or severe cardiovascular events. Prevention includes adequate oxygenation, proper sedation, predictors of difficult respiratory support, and established emergency care protocols. [41]

The incidence of complications depends on the type of procedure, comorbidities, and the experience of the team. With diagnostic procedures without large biopsies, serious complications are rare. With cryobiopsies and extensive therapeutic interventions, the risk is higher and requires enhanced safety measures and preparedness to control bleeding. [42]

Risk management begins at the patient selection and preparation stage, continues during the procedure, and into the early postoperative period. Internal audits and incident analysis are essential for continuous process improvement. [43]

The patient is instructed about the signs of late complications: increasing shortness of breath, severe hemoptysis, fever, chest pain. If these occur, immediate contact with a medical professional is necessary. [44]

Table 10. Common risks and prevention

Risk	Prevention
Hypoxemia	Oxygen support, monitoring, ventilation readiness
Bronchospasm	Prediction, preparation with bronchodilators
Bleeding	Antithrombotic management, technique, hemostatic agents
Pneumothorax after biopsy	Control of technique and volume, observation after
Cardiovascular events	Risk assessment, protocol sedation, monitoring

What happens after a bronchoscopy and when to seek help

After the procedure, the patient is observed until their vital signs stabilize. Their level of consciousness and respiration are assessed, and the absence of significant hemoptysis is checked. If sedation is used, it is recommended to limit activity on the day of the procedure and provide an escort. The doctor provides a reminder with signs requiring attention and a communication plan. [45]

Final treatment decisions are made after laboratory and morphological results are received. If treatment is performed during bronchoscopy, a follow-up visit is scheduled to assess the effect and, if necessary, adjust therapy. This step-by-step approach ensures continuity and predictability of management. [46]

If severe throat discomfort, minor bloody mucus discharge, or coughing persists for 24 hours, observation and fluid intake are usually sufficient. Worsening symptoms, high fever, or increasing hemoptysis require medical attention. [47]

If the patient is taking anticoagulants, the time of drug resumption is recorded in the discharge summary, and for interventions with a high risk of bleeding, an individual monitoring schedule is prescribed. This reduces the likelihood of late complications. [48]

Short answers to frequently asked questions

Is it painful? Sedation and local anesthesia make the procedure tolerable for the vast majority of patients. Discomfort and a sore throat are usually short-lived. [49]

How long does a bronchoscopy take? A diagnostic examination can take 10-30 minutes, while more complex procedures take longer. The hospital stay is longer due to preparation and observation. [50]

Are antibiotics necessary? With standard diagnostics, routine prophylaxis is not required and is decided on an individual basis in rare cases. [51]

How accurate are lymph node biopsies? Endobronchial ultrasound-guided needle aspiration provides high staging accuracy with less invasiveness than surgery, and proper sample processing is critical for molecular testing.[52]