Pulmonary Medicine

Interventional Bronchoscopy: Rigid Bronchoscopy

General description of procedure, equipment, technique

Rigid Bronchoscopy

Initially defined in 1995 and subsequently described in European Respiratory Society (ERS) and American Thoracic Society (ATS) guidelines, interventional pulmonology is "the art and science of medicine as related to the performance of diagnostic and invasive therapeutic procedures that require additional training and expertise beyond that required in a standard pulmonary medicine training program." Clinical entities encompassed within the discipline include complex airway management, benign and malignant central airway obstruction, pleural diseases, and pulmonary vascular procedures.

Diagnostic and therapeutic procedures pertaining to these areas include, but are not limited to, rigid bronchoscopy, transbronchial needle aspiration, autofluorescence bronchoscopy, endobronchial ultrasound, transthoracic needle aspiration and biopsy, laser bronchoscopy, endobronchial electrosurgery, argon-plasma coagulation, cryotherapy, airway stent insertion, balloon bronchoplasty and dilatation techniques, endobronchial radiation (brachytherapy), photodynamic therapy, percutaneous dilatational tracheotomy, transtracheal oxygen catheter insertion, medical thoracoscopy, and image-guided thoracic interventions. This presentation focuses on rigid bronchoscopy; additional procedures are discussed elsewhere.

Rigid bronchoscopy was first performed in 1897 by Gustav Killian to remove a pork bone impacted in the airway of a farmer. Chevalier Jackson was responsible for the development of rigid bronchoscopy in the United States. The procedure has gained usefulness because of its increasing use as a therapeutic tool.

The rigid bronchoscope, also known as the open-tube bronchoscope, is a rigid, straight, hollow metallic tube made of stainless steel. The tube is available in various external diameters, ranging from 2 mm to 14 mm. The scope's diameter is constant from proximal to distal ends, but most have a beveled tip to facilitate lifting of the epiglottis during intubation and to facilitate "coring out" endobronchial lesions.

Scopes are constructed with a variety of angulations to allow visualization of upper and lower lobe bronchi. However, angled scopes are used only on a limited basis, as fiberoptic bronchoscopes must be passed through the rigid scope to achieve a greater range of visibility.

Light sources that use xenon or halogen lamps are currently used. In addition, video technology based on single-chip or three-chip cameras can be easily connected to the proximal aspect or eyepiece of a rigid telescope. Accessory instruments often used during rigid bronchoscopy include biopsy forceps of various lengths and shapes, suction tubing, and specific forceps that may be used for foreign-body removal.

Indications and patient selection

The rigid bronchoscope is used for endoscopic resection of endobronchial masses, placement of stents, and removal of foreign bodies. Some clinicians use either a flexible or a rigid bronchoscope.

Contraindications

The principal contraindication to performing rigid bronchoscopy is cervical spine disease.

Details of how the procedure is performed

Rigid bronchoscopy is performed under general anesthesia. An anesthesiologist provides intravenous general anesthesia and muscle relaxation; paralysis can be avoided. If inhaled anesthetic gases are to be used, the nose and mouth are packed with gauge to avoid gas leakage. Ventilator support may be provided using assisted spontaneous ventilation or closed-circuit positive pressure ventilation. The teeth must be protected with gauze pads or a plastic mouth guard. A rolled blanket placed between the patient's shoulder blades enables anterior movement of the upper trachea.

Direct intubation using a rigid scope is the method of choice for rigid bronchoscopic intubation.

Interpretation of results

Not applicable.

Performance characteristics of the procedure (applies only to diagnostic procedures)

Not applicable.

Outcomes (applies only to therapeutic procedures)

Not applicable.

Alternative and/or additional procedures to consider

The rigid bronchoscope is used for endoscopic resection of endobronchial masses, placement of stents, and removal of foreign bodies.

Complications and their management

Most complications of rigid bronchoscopy are related to poor insertion technique, creating trauma to the gums, teeth, lips, or larynx. In addition, spinal cord injuries are possible in patients with cervical spine disease and/or severe osteoporosis.

What’s the evidence?

Bolliger, CT, Mathur, PN, Beamis, JF. "ERS/ATS statement on interventional pulmonology". Eur Respir J. vol. 19. 2002. pp. 356.

The first published guidelines by European and American investigators on interventional pulmonology.

Jackson, C. "Bronchoscopy: Past, present and future". N Engl J Med. vol. 199. 1928. pp. 758.

The original description of bronchoscopy, a report of historical significance.

Mathur, PN, Beamis, J, Mathur, PN, Beamis, J. "Preface.” page xi- xii". Interventional pulmonology. W.B. Saunders. 1995. pp. xi-xii.

The first paper to define the term "interventional pulmonology."

Tyson, EB. "The development of the bronchoscope". J Med Soc N J. vol. 54. 1957. pp. 26.

Another historically significant report describing the procedure of bronchoscopy.
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