Bronchoscopy includes rigid bronchoscopy and bendable bronchoscopy, the former is mainly done by surgeons and the latter is mostly operated by respiratory doctors. With the progress of science and technology, fiberoptic bronchoscopy has been popularized and transitioned to electronic bronchoscopy, and the following is mainly about bendable bronchoscopy.
Indications for bronchoscopy: both diagnostic and therapeutic aspects
1.Diagnosis
(1) Unexplained hemoptysis or blood in sputum
2）Chronic unexplained cough or restricted croup
3) Unexplained pulmonary atelectasis or obstructive pneumonia
4）Pulmonary or bronchial infectious disease pathogenic diagnosis
(5) Pleural effusion of unknown origin
6）Diffuse pulmonary disease of unknown diagnosis
7) suspected tracheo-esophageal fistula
8) Need for bronchoalveolar lavage, transbronchoscopic lung biopsy or transbronchoscopic needle aspiration biopsy
9) observation of toxic gas damage to the airway, burns
10）Selective bronchography and alveolar angiography
11）Suspected tracheobronchial laceration or rupture
12) tracheobronchial softening, granulation tissue growth in the airway
13）Suspected tracheal stenosis after tracheotomy or tracheal intubation
14）Cancer cells found in sputum cytology and negative chest imaging
15）Unexplained hoarseness, paralysis of the recurrent laryngeal nerve or phrenic nerve
2.Treatment
(1) Removal of tracheobronchial foreign body
(2) Removal of abnormal secretions in the tracheobronchus
(3) Tracheal intubation guided by bronchoscopy
4）Stopping hemorrhage for small amount of hemoptysis
5）Treatment of local tumor lesions of bronchial lung cancer – radiotherapy and local chemotherapy
6）Laser, microwave, freezing, high-frequency electric knife and other treatments for local lesions via bronchoscopy
(7) Transbronchoscopic placement of airway stents
8）Pulmonary catheter placement via bronchoscopy
9）Irrigation treatment of severe infection of bronchial dilatation or pus cavity of pulmonary sepsis
Contraindications: With the wide development of bendable bronchoscopy, the scope of application is expanding, and the experience is getting richer, the scope of contraindications in the application is getting narrower, and certain contraindications, when clinically necessary, become relatively contraindicated.
(1) massive hemoptysis, hemoptysis can be carried out after 2 weeks of cessation
(2) Severe cardiac and pulmonary dysfunction, unable to tolerate the examination
3）Severe cardiac arrhythmia
4）Recent myocardial infarction and unstable angina pectoris
5）Incorrectable bleeding tendency
6）Severe pulmonary hypertension
(7) Diagnosed aortic aneurysm with risk of rupture
Complications of bronchoscopy: In general, the complication rate of bendable bronchoscopy is relatively low, but when complications occur, they are sometimes serious and even life-threatening. Therefore, it is important to be fully aware of the complications and to be ready to respond and prevent them in a timely manner.
1) Bleeding
2) Cardiac arrhythmia or cardiac arrest
3) Severe laryngeal or bronchospasm
4) Hypoxia
5) Pneumothorax, mostly occurring during peripheral lung biopsy
6) Fever
Operation methods and steps
1.Pre-operative examination
1）Detailed medical history, blood pressure measurement and cardiac and pulmonary physical examination.
2）Take X-ray frontal and lateral chest radiographs and, if necessary, CT chest radiographs to determine the site of the lesion.
(3) Examination of coagulation mechanism and platelet count, etc.
4）Electrocardiogram examination.
5）Pulmonary function tests and blood gas analysis are feasible for suspected pulmonary insufficiency.
(6) Liver function and hepatitis B surface antigen and core antigen examination can be performed.
2.Patient preparation
(1) Explain in detail to the patient the purpose and significance of the examination and the method of cooperation with the examination, understand the patient’s drug allergy history, and sign the written informed consent.
2）Fast for 6 hours before surgery.
(3) A small amount of sedative and/or cholinergic receptor blocking drugs, such as diazepam and/or atropine, may be administered 30 min before surgery as needed.
4) Some patients (e.g., elderly, mild hypoxia) may be examined under nasal cannula administration of oxygen and oxygen saturation testing. Asthmatic patients should be given β2 agonists to prevent airway spasm before the examination.
3.Anesthesia
In addition, 2% lidocaine can be injected through the cricothyroid membrane as endotracheal anesthesia.
4, position: mostly use supine position, the condition requires can also choose semi-recumbent or sitting position.
5, insertion route: generally inserted through the nose or mouth, tracheotomy can be from the incision into the mirror.
6, operation: before entering the mirror must check whether the field of view of the lens is clear, the principle of inspection is first healthy side after the affected side. The left hand holds the operating part, the right hand assists in entering the mirror and biopsy, etc.
(1) transnasal entry: after the local anesthetic has taken effect, the tip of the bronchoscope can be flexed and sent into the nostril of one side, generally taking the nostril of the opposite side of the affected side of the chest is better. The lens and mirror body are coated with an appropriate amount of lidocaine gel or paraffin oil to play a lubricating role. When feeding the flexable bronchoscope, the direction is directly backward and can enter along the lower nasal passage. When reaching the posterior wall of the nasopharynx, the tip of the bendable bronchoscope is kept curved enough to enter, and the vocal fold can be found.
(2) Transoral access examination: Ask the patient to hold the disposable mouthpiece and let the assistant assist in fixing the mouthpiece so that it will not come out and bite the bronchoscope. The bronchoscope is fed through the mouthpiece until it reaches the posterior part of the tongue, and the tip is bent upward to reveal the voice box.
(3) For beginners, routine bendable bronchoscopy can be performed in the following order: vocal hilum subglottis and tracheal ramus right main bronchus right upper lobe bronchus right upper lobe apical segment bronchus right upper lobe posterior segment bronchus right upper lobe anterior segment bronchus right middle lobe bronchus right lower lobe bronchus right lower lobe anterior basal segment bronchus right lower lobe lateral basal segment bronchus right lower lobe posterior basal segment Right lower lobe dorsal segment bronchus Left main bronchus Left upper lobe bronchus Left lingual segment bronchus Left upper lobe anterior segment bronchus Left upper lobe posterior apical segment bronchus Left lower lobe bronchus Left lower lobe bronchus Left lower lobe bronchus Left lower lobe medial anterior segment bronchus
Left lower lobe lateral basal segment bronchus Left lower lobe posterior basal segment bronchus Left lower lobe dorsal segment bronchus.
7.Related examination by bendable bronchoscopy
(1) Endobronchial biopsy: After observing the lesion site, the bendable bronchoscope is fixed at an appropriate distance from the lesion, and the biopsy forceps are fed in from the biopsy hole, and the jaws of the biopsy forceps are fully opened near the lesion site and clamped against the target and then quickly withdrawn. Generally clamp 4~6 specimens to obtain a more desirable positive rate.
(2) Brush inspection: mostly performed after the lesion biopsy. The brush is sent through the biopsy hole to the lesion, slightly pressurized, rotated and brushed several times, and then the brush is retired to the end of the mirror (not to the biopsy hole at the end of the mirror to avoid losing the specimen) and then pulled out together with the bronchoscope. The extracted brush is immediately stained on a slide for 3~4 smears, and the smears for cytological examination are fixed in 95% alcohol and sent for pathological examination.
(3) Transbronchoscopic lung biopsy: After the bendable bronchoscope enters the airway, the visible extent should be examined in the usual order. For confined lesions, biopsy forceps are inserted from the selected bronchial opening according to the positioning before the examination, and the biopsy forceps are sent to the lesion site under fluoroscopic X-ray inspection and clamped at the end of the patient’s expiration. For diffuse lung lesions, the specimen may also be taken “blindly” without X-ray inspection. The biopsy site is usually chosen from the posterior basal segment or the outer basal segment of the lower lobe. Biopsies are not performed in the middle lobe of the right lung or the lingual lobe of the left lung because of the tendency to pneumothorax. Biopsies should not be performed in both lungs at the same time. When the biopsy forceps are delivered to the periphery of the lung, the pleura is stimulated to produce pain, and the patient needs to be instructed to indicate this in advance. At this point, the biopsy forceps are backed off by 1~2 cm and clamped at the end of the patient’s expiration. In addition, in the process of feeding the biopsy forceps, sometimes resistance may be encountered before reaching the peripheral lung, suggesting that the biopsy forceps are pushing against the small bronchial ridge. At this point, no force should be applied, and the biopsy forceps can be turned slightly to fine-tune the direction, and each can be fed smoothly. It is generally recommended to take 3~4 biopsy specimens from the same side of the lung.