Flexible bronchoscopy in adults: Preparation, procedural technique, and complications

INTRODUCTION — Bronchoscopy is a procedure that visualizes the tracheobronchial tree by placing an optical instrument inside the airways. Flexible bronchoscopy is used for a growing number of diagnostic and therapeutic indications such that the clinician should be aware of the potential value of this procedure for their patient. Flexible bronchoscopy is also used with rigid bronchoscopy to access or evaluate the upper lobe airways as well as the distal lower lobe bronchi.

The general principles of patient preparation, as well as the procedural technique and complications of flexible bronchoscopy are reviewed here. The equipment, indications, contraindications, and procedures that can be performed using a flexible bronchoscope are described separately. (See "Flexible bronchoscopy in adults: Overview" and "Flexible bronchoscopy in adults: Indications and contraindications" and "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures".)

PREPROCEDURAL PREPARATION

Patient selection — Patients should be selected for flexible bronchoscopy after reviewing the history and clinical exam, and carefully weighing the indications and contraindications, which are reviewed in detail separately. (See "Flexible bronchoscopy in adults: Indications and contraindications".)

Patients are generally asked not to eat or drink for at least six hours prior to the procedure and for patients who are intubated, feeding is discontinued for the same period of time. However, an emergent bronchoscopy can be performed when the patient is fasting for less than six hours depending on the indication.

Patients at high risk for infective endocarditis (IE) may be considered for antibiotic prophylaxis (eg, previous IE, prosthetic valves, congenital heart disease, ventricular assist devices) [1]. Further details regarding antibiotic prophylaxis for the prevention of IE are provided separately. (See "Prevention of endocarditis: Antibiotic prophylaxis and other measures".)

Informed consent — Once a patient has been selected for flexible bronchoscopy, the clinician should obtain informed consent from the patient or a designated decision maker. This involves discussing the indications, potential complications, benefits, and alternatives of the planned procedure and the type of sedation (moderate versus general anesthesia). Questions should be answered. Implied consent is acceptable when the bronchoscopy is emergent, the patient is incapable of giving consent due to altered mental status, and a surrogate decision maker is unavailable (eg, removal of a foreign body causing life-threatening airway obstruction or in massive hemoptysis). In such cases, the clinician should carefully document the reason that the informed consent is not possible and indicate why the emergent procedure is medically necessary. Some institutions require a documentation of the need for bronchoscopy by a second attending physician. (See "Informed procedural consent" and "Ethics in the intensive care unit: Informed consent".)

Personnel — Bronchoscopy can be performed in various hospital settings including the bronchoscopy or endoscopy suite, operating room, intensive care unit, postoperative anesthesia care unit, and emergency department. In all settings, an experienced team is essential to perform bronchoscopy safely, efficiently, and successfully.

There is a wide variation in personnel requirement depending upon the institution, clinical setting, and type of bronchoscopy (ie, inspection bronchoscopy versus an advanced diagnostic or interventional procedure). Similar principles apply if the bronchoscopy is scheduled or emergent:

●Ideally, the team should include the bronchoscopist, a nurse, and a technician. The technician or assistant is needed to set up the equipment, assist the bronchoscopist with collection of the specimens or performance of additional procedures, and clean the scope after completion of the procedure. The nurse usually does the preprocedure evaluation including medication review and then will monitor and record the patient's vital signs and each step of procedure as well as administer moderate sedation. At minimum, at least one qualified assistant in addition to the bronchoscopist should be present, especially in an emergent situation.

●For more complex bronchoscopic procedures (eg, interventional procedure requiring laser for tissue debulking or endobronchial ultrasound), additional personnel is often necessary (eg, a respiratory therapist or someone with knowledge of advanced airway management, laser technician to operate the laser equipment or cytology technicians to prepare and evaluate cytology specimen onsite).

Equipment and supplies — All equipment and materials necessary to perform the procedure, administer sedation, and manage the airway should be set up prior to the bronchoscopy. This includes:

●Bronchoscope, image processor with light source and video monitor (for bronchoscopes utilizing video) (figure 1 and figure 2). (See "Flexible bronchoscopy in adults: Overview", section on 'Equipment'.)

●Protection equipment including gloves, nonsterile gowns, masks with plastic shield (N-95 mask if necessary), shoe covers. (See "Flexible bronchoscopy in adults: Overview", section on 'Infection control'.)

●Fluoroscopy equipment, if fluoroscopy is planned. (See "Flexible bronchoscopy in adults: Overview", section on 'Radiation control'.)

●If additional procedures such as biopsy, needle aspiration, laser, or cryosurgery are anticipated, then these should be available in the suite and tested before induction of anesthesia.

●Topical anesthetic including an aerosolized anesthetic (usually a 10 mL vial of 4 percent lidocaine) for administering above the vocal cords, topical anesthetic (usually 20 mL of 1 to 2 percent lidocaine) for administering below the vocal cords, anesthetic gel and long cotton tip swabs (optional for nasal anesthesia). (See 'Topical airway anesthesia' below.)

●Peripheral intravenous catheters or central venous lines for patients in the intensive care unit. (See "Peripheral venous access in adults".)

●Planned sedative agents (eg, midazolam, fentanyl). (See "Procedural sedation in adults in the emergency department: Medication selection, dosing, and discharge criteria", section on 'Medications'.)

●Specimen traps (approximately three) for airway secretions, bronchial washing, and sometimes bronchoalveolar lavage fluid collection. (See "Basic principles and technique of bronchoalveolar lavage".)

●Additional instruments (eg, tissue sampling with brushes, biopsy forceps, aspiration needles, etc). (See 'Diagnostic and therapeutic procedures' below.)

●Equipment to perform endotracheal intubation if needed (eg, endotracheal tubes [ETTs] and laryngoscope). (See "Direct laryngoscopy and endotracheal intubation in adults".)

●Equipment to monitor and record the blood pressure, cardiac rhythm, heart rate, respiratory rate, and pulse oximetry. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications", section on 'Equipment and medications' and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications", section on 'Monitoring'.)

●Airway adjuncts such as oxygen and oxygen tubing, face mask, a bag valve mask, and a bite block (if the oral route is planned). While low flow oxygen is routinely used during bronchoscopy, case reports describe use of high flow nasal oxygen for high risk patients with acute respiratory failure [2-4]. (See "Heated and humidified high-flow nasal oxygen in adults: Practical considerations and potential applications".)

●Multiple syringes (usually 10, 20, and 60 mL slip-tip).

●Sterile normal saline for flushing, washing, or bronchoalveolar lavage.

●Suction tubing and oral suction catheter; one tubing set for suctioning via the bronchoscope and another for oral suction (to manage and clear vomiting or oral secretions).

●Specimen collection jars with saline or fixative for collecting cytologic and/or histopathologic specimens.

●Ice-cold saline, oxymetazoline, epinephrine in a concentration of 1:10,000, or tranexamic acid to control significant airway bleeding.

●Resuscitation medications, including advanced cardiac life support medications and reversal agents (eg, naloxone and flumazenil) and a code-cart.

●Ice for sample preservation during travel to the laboratory or for cooling saline.

Additional interventional equipment necessary to carry out specific procedures are provided in separate topic reviews that discuss the following interventions:

●Balloon dilatation (see "Flexible bronchoscopy balloon dilation for nonmalignant airway strictures (bronchoplasty)").

●Argon plasma coagulation (see "Bronchoscopic argon plasma coagulation in the management of airway disease in adults").

●Laser therapy (see "Bronchoscopic laser in the management of airway disease in adults").

●Electrocautery (see "Bronchoscopic laser in the management of airway disease in adults").

●Brachytherapy (see "Endobronchial brachytherapy").

●Photodynamic therapy (see "Endobronchial photodynamic therapy in the management of airway disease in adults").

●Cryotherapy and cryobiopsy (see "Bronchoscopic cryotechniques in adults").

●Airway stent placement (see "Airway stents").

●Endobronchial valve or coil placement and endobronchial thermoplasty (see "Bronchoscopic treatment of emphysema", section on 'Endobronchial valves' and "Bronchoscopic treatment of emphysema", section on 'Coil placement' and "Bronchoscopic treatment of emphysema", section on 'Thermal airway ablation' and "Treatment of severe asthma in adolescents and adults", section on 'Bronchial thermoplasty').

●Robotic-assisted bronchoscopy: Flexible bronchoscopy is routinely performed prior to robotic-assisted bronchoscopy.

Occasionally, patients who are mechanically ventilated in the intensive care unit will require a bronchoscopy for simple airway inspection, mucus plug clearance, or to obtain microbiology specimen. These patients usually have an ETT or a tracheostomy tube that is connected to the ventilator. A special adapter is necessary for such procedures to avoid any air leak so that the patients can be adequately mechanically ventilated during the bronchoscopy. The adaptor allows the flexible bronchoscope to be inserted through the ETT or tracheostomy tube while the patient is being ventilated.

Similarly, special masks are available for patients on noninvasive ventilation (NIV) so that continued NIV can be administered while patients are undergoing bronchoscopy to avoid any leak [5-7]. However, bronchoscopy while on NIV is not commonly performed in the United States as these patients are at risk for possible intubation and if indicated patient should be intubated first.

It is important to check and make sure that all equipment are in the room and is functional prior to administering sedation. This check can be done during the "universal time-out" procedure. (See 'Preprocedural universal protocol' below.)

COVID-19 — Precautions for coronavirus disease 2019 (COVID-19) are discussed separately. (See "Flexible bronchoscopy in adults: Overview", section on 'COVID-19'.)

TOPICAL AIRWAY ANESTHESIA

Spontaneously breathing patients — After informed consent has been obtained and the setup complete, the patient is usually brought into the procedure or operating room unless they are in the intensive care unit or emergency department. It should be confirmed that the patient has not had anything to eat or drink during the six hours prior to the administration of topical airway anesthesia. The patient is then placed on continuous cardiac and pulse oximetry monitors, and supplemental oxygen is administered (generally 2 to 6 L/min by nasal cannula), with an ideal target peripheral oxygen saturation (SpO₂) of 100 percent, but an SpO₂ above 96 percent is acceptable in select circumstances. Intravenous access is established. The oropharynx and both nasal passages are generally anesthetized topically which takes 15 to 20 minutes to perform:

●Oropharynx – The upper airway (oropharynx, vocal cords, and trachea) is typically anesthetized by aerosolizing topical anesthetic (usually 1 or 2 percent lidocaine, occasionally 4 percent) so that the gag reflex is inhibited during bronchoscopy. This can be done using a nebulizer and/or manual spray which deposit anesthetic into the posterior oropharynx [8]. In our practice, for all moderate-sedation cases, we use lidocaine nebulizer and one to two sprays of benzocaine in the oropharynx for topical anesthesia prior to introduction of the bronchoscope.

One trial randomized 1050 patients to receive nebulized lidocaine (2.5 mL 4 percent solution), oropharyngeal spray (10 actuations of 10 percent lidocaine), or nebulized lidocaine (2.5 mL 4 percent solution) and two actuations of 10 percent lidocaine [9]. Patient- and bronchoscopist-rated cough severity was lowest in the patients who received 10 actuations of oropharyngeal lidocaine, which also happened to be the group who received the lowest cumulative dose of lidocaine. While this study is in favor of oropharyngeal spray, in practice, this technique is difficult for patients to tolerate and is operator-dependent. In addition, poor deposition by inexperienced operators may result in poor anesthetic effect when it is deposited on the tongue instead of the oropharynx.

In our practice, we only use glycopyrrolate when we experience increased secretions during a bronchoscopy. While routine anticholinergic premedication is not recommended, in a double-blind randomized trial of 1000 consecutive patients undergoing bronchoscopy, glycopyrrolate 0.005 mg/kg given intramuscularly 20 to 40 minutes prior to bronchoscopy was associated with reduced bronchoscopist-reported airway secretions compared with atropine or placebo [10,11].

When an oral route is planned, a bite block is placed in the mouth to prevent the patient from damaging the bronchoscope by accidental biting, especially if moderate sedation is planned. However, topical anesthesia of the oropharynx is still necessary, and topical anesthesia of the nasal passage is also often performed in case the nasal route becomes necessary if the oral route fails.

●Nasal – The nasal passage is also typically anesthetized by squirting anesthetic gel (usually 1 to 2 percent lidocaine) into the nostril using a 1 or 2 mL slip-tip syringe. Use of lidocaine gel provides both lubrication and topical anesthesia. The patients may be asked to sniff the gel into the nostrils. A cotton tip swab covered with topical anesthetic gel is then gently inserted into the nostril (using a twisting motion) along the floor of the nasal passage until it reaches the back of the nasopharynx. This maneuver also helps identify for the operator whether or not the bronchoscope can easily pass through the nasal passage, which is the preferred route for entering the tracheobronchial tree. It is important during this latter step not to force the swab in order to avoid inducing an episode of epistaxis. Also, the nasal passage should be avoided in patients with thrombocytopenia or those who are at increased risk of bleeding. (See 'Entering the tracheobronchial tree' below.)

Patients with an artificial airway — For patients who are intubated or have a tracheostomy in place, the monitors are typically already in place and the clinician must be assured that enteral feeding has been discontinued for at least six hours. Often, in emergent situations, the stomach contents can be aspirated through the feeding tube prior to the procedure to minimize the risk of aspiration. Some experts administer 1 to 2 mL of topical anesthesia (eg, 1 or 2 percent lidocaine) via the endotracheal tube (ETT), although this practice is variable and not well validated but helps with smooth insertion of the bronchoscope through the ETT and allows topical anesthesia of the trachea. In addition, topical anesthesia to the nasal passages is sometimes done in patients with tracheostomy to evaluate the upper airways, vocal cords, or trachea for stenosis or granulation tissue formation above the tracheostomy tube.

Route of entry — The route of entry is usually preplanned.

●Nasal – The nasal route is preferred in most nonintubated, spontaneously breathing patients. The route permits easier insertion of the bronchoscope through the upper airways and the vocal cords. Adequate lubrication is mandatory to avoid any trauma or bleeding in the nasal passages.

●Oral – Choosing an alternative route depends upon factors including nasal bleeding risk and size or abnormalities of the nasal cavity (eg, presence of polyps, edema, septal deviation). As an example, in patients with thrombocytopenia, coagulopathy, small nasal cavities, or obstructing polyps, the nasal route is generally avoided and the oral route is preferred. The oral route is also used for bronchoscopic intubation or when flexible bronchoscopic assistance is needed during airway stent placement.

●Endotracheal devices – For patients who are intubated with an ETT or have a tracheostomy tube in place, the bronchoscopist enters the tracheobronchial tree via the ETT/tracheostomy device usually at mid-level trachea. Thus, visual inspection of the upper airway or vocal cords is bypassed. Occasionally, when upper airway obstruction or oropharyngeal lesions is suspected in this population, the bronchoscope can be passed through the nose and mouth as for a nonintubated patient.

Both the bronchoscope and ETT/tracheostomy size should be taken into consideration. Typically, an endotracheal device with an inner diameter of 7.5 mm or greater is needed for patients who undergo bronchoscopy with a conventional bronchoscope. If not feasible, an ETT or the tracheostomy tube can be changed to a larger size or a smaller diameter bronchoscope can be used. Depending on the indication (ie, a quick bronchoscopic examination versus intervention) an appropriate size can be chosen.

Ventilator alarm settings and the fraction of inspired oxygen (FiO₂) will need to be increased to accommodate the increased airway pressure and reduction in oxygenation that typically occurs during bronchoscopy. It may be a good idea to oxygenate with 100 percent oxygen prior to the insertion of bronchoscope unless contraindicated (eg, laser use).

●Laryngeal mask airways (LMA) – LMAs are being used more commonly during flexible bronchoscopy. It is not as invasive as an ETT (as it is placed above the vocal cords) and can maintain adequate ventilation during a procedure with longer duration. As an example, endobronchial ultrasound and many interventional bronchoscopic procedures are done with LMAs. Similar to ETTs, the bronchoscope is passed through the LMA and inserted through the vocal cords to the tracheobronchial tree. When LMAs are used, the epiglottic aperture bars (if present) are typically cut prior to LMA insertion to facilitate passage of the bronchoscope, although there are newer LMA devices that do not have epiglottic bars and can be used without a bite block (picture 1).

PREPROCEDURAL UNIVERSAL PROTOCOL — The universal preprocedural and time-out protocol should be performed prior to beginning the procedure.

●The preprocedure verification process requires that the clinician confirm that the correct patient is present and that the correct procedure is about to be performed on the correct site. In addition, the clinician must confirm that all of the relevant documentation (eg, history and physical exam, documentation of allergies, signed consent form) and radiologic studies are available.

●The time-out requires that each member of the procedure team agree that the patient, procedure, and site are correct. Documentation of the time-out is required.

●The bronchoscopist or operator should confirm with the team that all equipment necessary for the procedure is available and functional.

●It is a good practice to communicate any potential risks (eg, fire if laser is used or high risk of bleeding or pneumothorax if transbronchial biopsy is planned) with the team and have the appropriate plan in place and supportive personnel available (eg, anesthesiologist, interventional pulmonologist, or thoracic surgeon) before the "time-out" is performed.

SEDATION — Moderate sedation (previously known as conscious sedation) is generally used during regular flexible bronchoscopy. Sedation should not be initiated until the procedure room is prepared, equipment checked, the time-out is done, the upper airway is anesthetized, and all required personnel are present. It is also important to have a discharge plan in place for outpatients undergoing sedation, as patients are not allowed to drive home by themselves after the procedure. Agents typically used include short-acting benzodiazepines (eg, midazolam) and opioids (eg, fentanyl). The administration of moderate sedation and its complications are discussed separately. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

Some complex bronchoscopic procedures (eg, extensive argon plasma coagulation or procedures that require rigid bronchoscopy or endobronchial ultrasound guided tissue sampling) require deep sedation (low-dose propofol and/or opioid infusions) or general anesthesia with paralytics [12]. Intravenous sedation or total intravenous anesthesia is preferred during bronchoscopy as opposed to gas to avoid any leakage of anesthetic gas during the bronchoscopy. (See "Rigid bronchoscopy: Intubation techniques", section on 'Anesthesia'.)

Patients who are intubated in the intensive care unit are often already receiving sedative infusions (benzodiazepines, opioid, propofol, dexmedetomidine) such that a small amount of supplemental medication given as an intravenous bolus may be all that is required in this population. (See "Sedative-analgesia in ventilated adults: Medication properties, dose regimens, and adverse effects" and "Sedative-analgesia in ventilated adults: Management strategies, agent selection, monitoring, and withdrawal".)

PROCEDURAL TECHNIQUE

Entering the tracheobronchial tree — Following topical anesthesia and sedation, the flexible bronchoscope is usually inserted nasally. Oral and endotracheal/tracheostomy tube routes are additional alternatives and the choice depends upon individual patient characteristics. (See 'Route of entry' above and 'Topical airway anesthesia' above.)

For nasal and oral routes:

●The glottis is entered and inspected for mucosal abnormalities. The vocal cords are identified posterior to the epiglottis.

●Once the vocal cords are visualized, they are inspected for lesions and movement. Vocal cord lesions should be documented and imaged. If moderate sedation is used, movement of both cords is observed during the phases of respiration and during vocalization of the letter "e." The vocal cords should abduct symmetrically during inspiration and adduct symmetrically during expiration and vocalization. A sluggish, or absence of, movement (unilateral or bilateral) or movement in unexpected and opposing directions, may indicate vocal cord paresis, paralysis, or paradoxical motion, respectively. (See "Inducible laryngeal obstruction (paradoxical vocal fold motion)".)

●Once the vocal cords are inspected, 1 to 2 mL of 2 to 4 percent lidocaine is then sprayed through the working channel of the bronchoscope onto the vocal cords. It is important to flush the working channel with air to make sure all the lidocaine is pushed out of the working channel and often requires 8 to 10 mL of air flushed with an empty syringe. This is likely to induce coughing, but it will subsequently facilitate passage of the bronchoscope through the larynx by suppressing the cough reflex. This step is bypassed for intubated patients but may be performed when visualization of the oropharynx and vocal cords is indicated in patients who have a tracheostomy in place.

●Following the administration of lidocaine, the patient is instructed to take a deep breath and the distal tip of the bronchoscope is then passed into the trachea between the vocal cords during inspiration. Forcing the bronchoscope through the vocal cords blindly or during expiration is not advised as it is potentially damaging.

●Passing the bronchoscope through the vocal cords may cause coughing, tachypnea, and anxiety. Spraying additional lidocaine once the bronchoscope is passed through the upper trachea and taking a moment to reassure the patient while the distal tip of bronchoscope is held within the tracheal lumen is generally sufficient for these issues to resolve. A common tendency for the operator is to pass the scope as much distally as possible once vocal cords have been passed and then spray lidocaine at the level of the carina. However, attention should be given to anesthetize the subglottic area immediately distal to the vocal cords and the proximal trachea to obtain sufficient topical anesthesia and control cough.

●Once the patient has settled and the cough reflex is suppressed, the bronchoscopist can gently move forward in the trachea toward the carina, and the remainder of the endobronchial tree can be inspected and planned procedures performed. Topical airway anesthesia is typically administered throughout the airway inspection process via the working channel of the bronchoscope and especially before procedures. We typically administer no more than 20 mL of 1 to 2 percent lidocaine to avoid possible methemoglobinemia. Four percent lidocaine is not used below the vocal cords. (See 'Topical airway anesthesia' above and 'Airway inspection' below.)

For those who are intubated or have tracheostomy in place, the upper or midlevel trachea is entered via the endotracheal tube (ETT), or tracheostomy tube, and the process is similar, however, one must be attentive to the fact that the vocal cords or proximal trachea including the subglottic trachea is bypassed and not examined when ETT or tracheostomy tube is in place. A laryngeal mask airway, on the other hand, allows anatomical examination of the vocal cords (except for vocal cord movement because of deep sedation or general anesthesia) and proximal trachea.

Most patients cough during bronchoscopy. It can be managed with additional topical anesthesia, increased sedation, systemic paralytics, and/or removal of blood. (See 'Topical airway anesthesia' above and 'Sedation' above.)

Airway inspection — Visual examination of the trachea, mainstem bronchi, and segmental bronchi should be a component of every bronchoscopy, except for rare clinical circumstances that dictate a brief procedure or for those in whom a complication has occurred or patient is hypoxemic and the procedure needs to be terminated. The inspection should include examination of the following:

●Mucosal appearance and integrity – Erythema and/or edema of the mucosa may indicate infection or an inhalational injury, thrombi or petechiae may be due to recent bleeding, and irregularity may indicate malignancy or granulomatous disease (eg, sarcoidosis). (See "Clinical manifestations and diagnosis of sarcoidosis".)

●Size, stability, and patency of the airway lumen – Luminal narrowing may indicate a benign or malignant stricture (intraluminal or extraluminal); tracheal and bronchial collapse may indicate tracheobronchomalacia. (See "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults" and "Tracheomalacia in adults: Clinical features and diagnostic evaluation".)

●Anatomic or congenital variants or variants due to prior surgery or fistulous communications may be noted. (See "Congenital anomalies of the intrathoracic airways and tracheoesophageal fistula".)

●Endobronchial lesions or foreign bodies – The presence of any mucus plug, thick secretions, or any foreign body is routinely examined. A friable, polypoid lesion usually indicates malignancy or granulation tissue. Often malignant endobronchial lesions are covered with a patch of yellow-white mucus and the lesion is revealed after the airway is cleaned. (See "Airway foreign bodies in adults".)

●Bleeding – If a blood clot or active bleeding is seen, the location should be noted and an attempt should be made to identify the source with bronchoscopy, if possible after the airway is secured. The most efficient way to identify a bleeding segment or to locate a bleeding lesion in the airway is to suction and wash with saline. (See "Evaluation of nonlife-threatening hemoptysis in adults" and "Evaluation and management of life-threatening hemoptysis".)

Diagnostic and therapeutic procedures — Both diagnostic sampling and therapeutic interventions can be performed during flexible bronchoscopy. However, no intervention should be performed during bronchoscopy without previous consent unless it is considered immediately life-saving.

●Diagnostic – Detailed discussion of common diagnostic procedures performed during flexible bronchoscopy are found in the following topics:

•Brushing (see "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Endobronchial brushing')

•Bronchoalveolar lavage (see "Basic principles and technique of bronchoalveolar lavage" and "Role of bronchoalveolar lavage in diagnosis of interstitial lung disease" and "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Bronchoalveolar lavage')

•Bronchial washings (see "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Bronchial washing')

•Endobronchial biopsy (see "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Endobronchial brushing')

•Transbronchial biopsy (TBB; including blind TBB and TBB with radiographic or navigational guidance) (see "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Transbronchial biopsy' and "Endobronchial ultrasound: Technical aspects", section on 'RP-EBUS-guided transbronchial biopsy' and "Image-guided bronchoscopy for biopsy of peripheral pulmonary lesions")

•Needle aspiration or biopsy (see "Bronchoscopy: Transbronchial needle aspiration" and "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Needle aspiration')

●Therapeutic – Many therapeutic procedures can be performed with a flexible bronchoscope, although some require rigid bronchoscopy, the details of which are found in the following topics:

•Endobronchial ultrasound guided biopsy (see "Endobronchial ultrasound: Indications, contraindications, and complications" and "Endobronchial ultrasound: Technical aspects")

•Laser resection or tumor debulking (see "Bronchoscopic laser in the management of airway disease in adults")

•Argon plasma coagulation (see "Bronchoscopic argon plasma coagulation in the management of airway disease in adults")

•Photodynamic therapy (see "Endobronchial photodynamic therapy in the management of airway disease in adults")

•Electrocautery (see "Endobronchial electrocautery")

•Cryosurgery (see "Bronchoscopic cryotechniques in adults")

•Balloon dilatation (see "Flexible bronchoscopy balloon dilation for nonmalignant airway strictures (bronchoplasty)")

•Brachytherapy (see "Endobronchial brachytherapy")

•Airway stenting (see "Airway stents")

•Valve placement (see "Bronchoscopic treatment of emphysema", section on 'Endobronchial valves')

•Bronchial thermoplasty (see "Treatment of severe asthma in adolescents and adults", section on 'Bronchial thermoplasty')

DOCUMENTATION AND REPORTING — All bronchoscopic procedures should include a complete report detailing the airways examined, any pathologic or anatomic abnormality visualized, procedures performed, and any complications that occurred. Drug doses and route of administration as well as vital signs are also documented. Photo (still or video images) documentation greatly enhances the quality of documentation and should be included when possible.

COMPLICATIONS — Flexible bronchoscopy is a safe procedure with reported complication rates ranging from 0.08 to 6.8 percent [10,13-18]. The likelihood of a complication is minimized by appropriate patient selection, careful evaluation of the risk-benefit ratio in high risk patients, and adherence to patient safety protocols.

Complications are usually minor and are procedure-related and/or sedation related:

●Common complications include mild transient hypotension and hypoxia related to sedation as well as bleeding and pneumothorax, which are most likely to occur in the context of adjunct procedures, usually transbronchial biopsy (bleeding from brushing is rare). Nasal discomfort, a sore throat, and mild hemoptysis are not unusual for a day or two after bronchoscopy. (See 'Bleeding' below and 'Pneumothorax' below.)

●Less common complications that occur during or immediately following bronchoscopy include bronchospasm, hypoxemia, epistaxis due to nasal trauma, nausea, vomiting, cardiac arrhythmias, infection, vasovagal syncope, laryngospasm, seizure, bacteremia, methemoglobinemia (from lidocaine), laryngeal edema, laryngeal injury, and fractured equipment. Unusual but late complications include fever and pneumonia. (See 'Hypotension and cardiac arrhythmias' below and 'Hypoxemia and respiratory failure' below and 'Others' below.)

●Other more serious adverse effects are rare and are often related to advanced procedures or the underlying disease for which the bronchoscopy is indicated; these include tension pneumothorax, cardiorespiratory arrest, respiratory failure requiring intubation and mechanical ventilation, airway perforation, airway fire.

●Procedure-related mortality is extremely rare (0.013 percent in one study) and associated with organic heart disease or severe airway obstruction [14]. Cardiopulmonary arrest was reported in 0.03 percent of patients in a single center retrospective study of 3473 patients [19].

Most complications occur during or in the first few hours following bronchoscopy.

Bronchoscopy does not in general need to be terminated for minor bleeding when hemostasis is easily achieved, or for transient mild hypotension or hypoxemia that easily resolve with an increased rate of intravenous fluids or increasing supplemental oxygen, respectively. However, the development of serious complications, other than these, during the procedure necessitates that the clinician administer therapy immediately and terminate the procedure.

Bleeding — In a retrospective study of more than 4000 bronchoscopies, transbronchial biopsy was associated with a bleeding rate of 2.8 percent [13]. In a registry-based study, the rate of bleeding requiring intervention was only 0.2 percent in patients who underwent transbronchial needle aspiration using endobronchial ultrasound bronchoscopic guidance [10].

The risk of bleeding during transbronchial biopsy appears to be particularly high in patients receiving clopidogrel alone or clopidogrel plus aspirin, according to a prospective cohort study of 604 patients [20].

In theory, the risk of bleeding can be minimized by avoiding transbronchial biopsy in patients who have an uncorrected coagulopathy and thrombocytopenia (≤50,000/mm³), patients who have recently taken antiplatelet medications, and patients with lesions that are likely to bleed (eg, vascular tumors, pulmonary hypertension). (See "Flexible bronchoscopy in adults: Indications and contraindications", section on 'Contraindications'.)

Most bleeding events are minor and resolve spontaneously with natural hemostasis. Reflecting this observation, in one retrospective study of more than 4000 bronchoscopies, 3 percent of whom had an associated bleeding event, almost all of the bleeding events resolved with conservative measures [13]. Thus, most minor bleeding events are generally treated expectantly.

For those in whom bleeding continues, ice-cold saline, oxymetazoline, epinephrine, or tranexamic acid (TXA), can be sprayed onto the bleeding lesion (these agents induce vasoconstriction). There are limited data comparing these agents. We usually start with ice-cold saline and then escalate to other options if bleeding is not controlled.

One double-blinded randomized study of 130 patients with bleeding during bronchoscopy compared the topical application of epinephrine (up to three applications; maximum 0.2 mg in 2 mL [1:10,000]) with TXA (up to three applications; maximum of 100 mg in 2 mL) after the bleeding could not be controlled with ice-cold saline alone [21]. Cross over was allowed for up to three more doses of the other agent if bleeding needed further control. There was no difference in the rate of hemostasis between the groups (83 percent), and both agents were more successful in controlling moderate bleeding (87 [epinephrine] versus 89 [TXA] percent) than severe bleeding (40 [epinephrine] versus 58 [TXA] percent). There were no drug-related adverse events in either group. Another randomized trial reported that prophylactic administration of epinephrine (1:10,000-diluted topical epinephrine) in a post-lung transplant population reduced the incidence of severe hemorrhage compared with saline placebo (4 versus 24 percent) [22].

Recombinant factor VIIa, originally developed for hemostasis in hemophilia, has also been used topically during bronchoscopy to control bleeding, especially diffuse alveolar hemorrhage [23-25]. Fifty mcg/kg of activated recombinant factor VIIa (rFVIIa) in 50 mL of 0.9 percent sodium chloride can be administered through the working channel of the bronchoscope [25].

Serious life-threatening bleeding that fails these conservative measures may be treated with several options including local ablative therapies, such as argon plasma coagulation (APC) or neodymium-doped yttrium aluminum garnet (Nd:YAG) laser; the choice among these options depends on the source of bleeding, availability, or local expertise. APC or Nd:YAG laser ablative therapies work best if the source of bleeding is from the luminal walls of larger airways. For parenchymal bleeding, embolization or surgery are better definitive treatment options when above treatment options fail.

An endobronchial balloon blocker (picture 2) can be placed to isolate the bleeding lung and to maintain ventilation with the normal lung. (See "Evaluation and management of life-threatening hemoptysis".)

Pneumothorax — Pneumothorax or pneumomediastinum are most likely to occur in the context of adjunct procedures including transbronchial biopsy, needle aspiration, or other more advanced procedures [10,13,18]. Most cases are minor with tension pneumothorax being rare. In a retrospective study of more than 4000 bronchoscopies, transbronchial biopsy was associated with pneumothorax rate of 4 percent [13]. It is not clear whether imaging or navigational guidance reduces this rate. However, a registry-based study that included 312 patients who had a diagnostic biopsy for peripheral lung lesions, some of whom had imaging or navigational guidance, reported a pneumothorax rate of almost 2 percent [18]. The same registry reported a pneumothorax rate of 3 percent when EBUS-guided procedures were performed [10]. In robotic-assisted bronchoscopies, 1.5 to 3.7 percent pneumothorax is reported [26,27].

Pneumothorax can also rarely occur from bronchoscopy alone (without an associated advanced procedure) when performed during mechanical ventilation, presumably from increased airway pressure. (See "Diagnosis, management, and prevention of pulmonary barotrauma during invasive mechanical ventilation in adults".)

While most cases occur within minutes or hours after the intervention and are detected on routine chest radiography following bronchoscopy, some cases are delayed and can occur up to 24 hours later. A routine chest radiograph after a high risk procedure or if a patient is symptomatic, is a common practice to rule out pneumothorax.

Many cases are managed conservatively while the remainder require drainage of air, often with a chest tube. In a large retrospective study less than half of patients with transbronchial biopsy-associated pneumothorax required a chest tube [13]. It is rare that patients who develop pneumomediastinum require thoracostomy tubes placed, but they should be monitored radiographically either in the inpatient or outpatient setting. (See "Treatment of secondary spontaneous pneumothorax in adults".)

Hypotension and cardiac arrhythmias — Transient hypotension or vasovagal syncope usually responds to an intravenous bolus of normal saline. Hypotension is mostly due to sedation and rarely due to tension pneumothorax or hemorrhage. Cardiac arrhythmias (eg, bradycardia) are also generally transient and self-resolving. Vasopressors and advanced cardiac life support for life-threatening arrhythmias are rarely needed. (See "Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock" and "Advanced cardiac life support (ACLS) in adults".)

Hypoxemia and respiratory failure — Hypoxemia is usually mild and transient. It usually responds to increasing supplemental oxygen whether under moderate sedation or monitored anesthesia care. Some cases are due to atelectasis from blood or mucus, in which case, repeated bronchial washes and suctioning may be needed to resolve the issue. Respiratory depression from sedation is unusual. Reversal of sedatives is unproven but often performed; mechanical ventilation is rarely needed.

Most advanced diagnostic and therapeutic bronchoscopies are usually performed under general anesthesia with an airway in place; hypoxia may still occur during the procedure after extubation, or during recovery.

A retrospective study on 164 patients who underwent a bronchoalveolar lavage (BAL) while on mechanical ventilation found that procedure-related hypoxia (peripheral oxygen saturation ≤88 percent) and bronchospasm in 9 percent of patients, and a decrease of >25 percent in the partial pressure of oxygen/fraction of inspired oxygen (PaO₂/FiO₂) ratio was found in 29 percent of patients [28]. (See "Overview of initiating invasive mechanical ventilation in adults in the intensive care unit" and "The evaluation, diagnosis, and treatment of the adult patient with acute hypercapnic respiratory failure" and "The evaluation, diagnosis, and treatment of the adult patient with acute hypercapnic respiratory failure", section on 'Reversal and avoidance of sedatives'.)

Others

●Less common complications include nausea and vomiting as well as aspiration. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

●Airway injury that induces bronchospasm, epistaxis, laryngospasm, laryngeal edema, and/or laryngeal injury should be treated accordingly and fractured equipment should be removed. (See "Evaluation of wheezing illnesses other than asthma in adults" and "Approach to the adult with epistaxis" and "An overview of angioedema: Clinical features, diagnosis, and management" and "Airway foreign bodies in adults" and "Airway foreign bodies in adults", section on 'Management'.)

●Late complications include bacteremia, fever, and pneumonia. Fever is most likely if a bronchoalveolar lavage (BAL) was performed during the bronchoscopy. The fever is not associated with the bacterial colony count on BAL [29], is generally self-limited, and can be treated with acetaminophen. Antibiotics may be prescribed if the fever continues for more than 24 hours since bacterial infection can complicate bronchoscopy. Chest radiography may not be helpful in distinguishing transient fever from that due to infection since radiographic abnormalities are common following bronchoscopy especially when BAL has been performed. Prophylactic antibiotics are not routinely required except for patients with a prosthetic valve or history of endocarditis, and asplenic patients. (See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures".)

●Complications of topical anesthetic use (eg, benzocaine, lidocaine) are uncommon, but may include seizure, tachycardia, methemoglobinemia, hypoxemia, cyanosis, confusion, anxiety, lethargy, and dizziness. (See "Methemoglobinemia", section on 'Topical anesthetics'.)

●Other adverse effects specific to advanced interventional procedures are reviewed separately. (See "Bronchoscopic laser in the management of airway disease in adults" and "Bronchoscopic argon plasma coagulation in the management of airway disease in adults" and "Endobronchial photodynamic therapy in the management of airway disease in adults" and "Endobronchial electrocautery" and "Bronchoscopic cryotechniques in adults" and "Flexible bronchoscopy balloon dilation for nonmalignant airway strictures (bronchoplasty)" and "Endobronchial brachytherapy" and "Airway stents" and "Bronchoscopic treatment of emphysema", section on 'Endobronchial valves' and "Treatment of severe asthma in adolescents and adults", section on 'Bronchial thermoplasty'.)

POSTPROCEDURE MONITORING — Patients require continued monitoring after bronchoscopy until the effects of the sedation and upper airway anesthesia have resolved. This includes ongoing assessment and documentation of alertness, blood pressure, cardiac rhythm, heart rate, respiratory rate, and oxyhemoglobin saturation. The patient is not allowed to eat or drink for a minimum of one to four hours after the procedure to prevent aspiration. (See "Procedural sedation in adults in the emergency department: Medication selection, dosing, and discharge criteria", section on 'Discharge criteria'.)

Inpatients should return to their baseline functional and physiological status prior to returning to the inpatient ward. Once they are back on the inpatient ward, personnel should monitor them for return of their gag reflex (assuming that they had a gag reflex prior to the procedure). Eating and drinking can be resumed once the gag reflex returns (up to 1 to 4 hours). The goal is to ensure that the patient is able to eat and drink without aspirating.

Outpatients should be alert and oriented, have stable vital signs, have returned to baseline ambulation status, and have controlled nausea and vomiting before being discharged. We also monitor patients for return of their gag reflex and, once their swallowing reflex returns, we evaluate their eating or drinking prior to discharge. An individual or transportation should be available to take the patient home, since patients are not permitted to drive home by themselves.

For patients who are intubated, vital signs are routinely monitored and ventilator settings should be slowly weaned to the original settings.

Chest radiography is routinely performed in those in whom a transbronchial biopsy was performed (preferably in expiration), after balloon bronchoplasty, stent placement, and rigid bronchoscopy, and in those in whom barotrauma is suspected. The chest radiograph should be reviewed prior to discharge. (See "Clinical presentation and diagnosis of pneumothorax".)

The commonly expected short term effects of bronchoscopy such as sore throat or nose discomfort, low grade fever, and mild hemoptysis (if biopsy is performed) need to be discussed with the patient or their caregiver. The patient or their surrogate is given clear instruction to seek emergency care in case they experience sudden onset of shortness of breath, significant hemoptysis, or chest tightness (indicating a late pneumothorax, if transbronchial biopsy was done) after they are discharged.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here is the patient education article that is relevant to this topic. We encourage you to print or e-mail this topic to give to your patient. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topic (see "Patient education: Flexible bronchoscopy (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Preparation – Patients should be consented for flexible bronchoscopy after carefully weighing the indications and contraindications. Ideally, the bronchoscopy team should include an experienced bronchoscopist, a nurse, and a technician. All equipment and materials necessary to perform the procedure, administer sedation, and manage the airway should be set up and functional prior to the bronchoscopy. (See "Flexible bronchoscopy in adults: Indications and contraindications" and 'Patient selection' above and 'Informed consent' above and 'Equipment and supplies' above.)

●Topical anesthesia – Flexible bronchoscopy must be performed in a monitored setting including an endoscopy suite, operating room, emergency department, postoperative anesthesia care unit or intensive care unit. Intravenous access should be established, cardiorespiratory monitoring started, supplemental oxygen administered, and the upper airway anesthetized. The route of entry is usually preplanned, with the nasal route being the most common. The universal preprocedural and time-out protocol should be performed prior to beginning the procedure. (See 'Topical airway anesthesia' above and 'Route of entry' above and 'Preprocedural universal protocol' above.)

●Sedation – Moderate sedation is generally used during flexible bronchoscopy. Sedation should not be initiated until the procedure room is prepared, equipment checked, the time-out is done, the upper airway is anesthetized, and all required personnel are present. Agents typically used include short-acting benzodiazepines (eg, midazolam) and opioids (eg, fentanyl). However, most advanced bronchoscopies are usually done under general anesthesia. (See 'Sedation' above and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

●Technique

•The flexible bronchoscope is usually inserted nasally. Oral and endotracheal/tracheostomy tube routes are additional alternatives. (See 'Entering the tracheobronchial tree' above.)

•Visual examination of the upper airway, vocal cords, trachea, mainstem bronchi, and segmental bronchi should be a component of every flexible bronchoscopic procedure. Inspection should include examination of the mucosa, airway patency, anatomic variants, endobronchial lesions, foreign bodies, and bleeding. (See 'Airway inspection' above.)

•Types of diagnostic procedures that can be performed using a flexible bronchoscope include bronchial brushing, bronchoalveolar lavage, bronchial washing, endobronchial biopsy, transbronchial biopsy, and needle aspiration. Advanced diagnostic procedures such as endobronchial ultrasound and therapeutic procedures including laser resection, argon plasma coagulation, photodynamic therapy, electrocautery, cryosurgery, balloon dilatation, brachytherapy, stenting, valve placement, and bronchial thermoplasty can also be performed using a flexible bronchoscope. (See "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures" and 'Diagnostic and therapeutic procedures' above.)

●Complications – Flexible bronchoscopy is a safe procedure with reported complication rates ranging from 0.08 to 6.8 percent. Complications are usually minor. They are generally procedure-related (eg, hemorrhage and pneumothorax) and/or sedation related (eg, hypotension, arrhythmias). Most occur during or in the first few hours following bronchoscopy. Serious complications and death are rare. (See "Flexible bronchoscopy in adults: Overview" and 'Complications' above.)

●Postprocedure monitoring – Following flexible bronchoscopy, patients require continued monitoring until the effects of sedation and upper airway anesthesia have resolved. Chest radiography is routinely performed in those in whom a transbronchial biopsy was performed (preferably in expiration) and in those in whom barotrauma is suspected. (See "Flexible bronchoscopy in adults: Overview".)