Version May 2024
INTRODUCTION — Both diagnostic sampling and therapeutic interventions can be performed during flexible bronchoscopy. Common diagnostic and therapeutic procedures are reviewed in this topic. An overview of flexible bronchoscopy, indications, contraindications, complications, and technical aspects of the procedure are discussed separately. (See "Flexible bronchoscopy in adults: Overview" and "Flexible bronchoscopy in adults: Indications and contraindications" and "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications".)
PREPARATION — All patients should be consented for bronchoscopic airway inspection and for any pre-planned bronchoscopic procedures. Consent, preparation, and the procedural details of airway inspection are discussed separately. (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications".)
DIAGNOSTIC — Many diagnostic procedures can be performed using a flexible bronchoscope with the aim of establishing a diagnosis of benign or malignant disease involving the airway (figure 1), parenchyma, and/or mediastinum. Typically, airway inspection is coupled with each procedure.
Standard conventional white light bronchoscopy can be used for all of the diagnostic procedures discussed in this section. (See 'Endobronchial brushing' below and 'Bronchoalveolar lavage' below and 'Bronchial washing' below and 'Endobronchial biopsy' below and 'Transbronchial biopsy' below and 'Needle aspiration' below.)
Diagnostic procedures that can be performed with other types of bronchoscopy are provided separately:
●Endobronchial ultrasound (EBUS) – When EBUS is used to biopsy a target lesion, the operator will use both types of equipment. (See "Endobronchial ultrasound: Indications, contraindications, and complications" and "Endobronchial ultrasound: Technical aspects".)
●Fluorescence bronchoscopy or narrow band imaging can provide additional details in the airways mucosa that can suggest malignancy or premalignant lesions. Standard equipment has dual modes (white light and fluorescent light) such that most procedures that can be performed with a regular bronchoscope can be performed with a fluorescence bronchoscope. (See "Detection of early lung cancer: Autofluorescence bronchoscopy and investigational modalities".)
●The ultrathin bronchoscope has a working channel that allows for insertion of small biopsies from targeted sampling. (See "Flexible bronchoscopy in adults: Overview", section on 'Ultrathin bronchoscopy'.)
●Flexible bronchoscopy is commonly used in combination with rigid bronchoscopy to perform a detailed examination of the airways, specifically the upper lobes. (See "Rigid bronchoscopy: Instrumentation".)
Choosing the type of procedure — The appropriate diagnostic procedure should be determined prior to the bronchoscopy. The decision is based upon the clinical history, physical examination, and imaging studies, which determine the type of information that is desired (ie, cytological, histological, microbiological, immunocytochemical, cell counting), and location of the lesion or area of interest (table 1). Multiple diagnostic procedures are often combined to increase the diagnostic yield. When this is done, bronchial washing is generally performed after brushing, endobronchial biopsy, and/or transbronchial biopsy in order to collect any diagnostic material that was dislodged by the brushing or biopsies. (See "Flexible bronchoscopy in adults: Indications and contraindications", section on 'Diagnostic indications'.)
●Desired type of information – With respect to the type of information that is desired, the following should be considered:
•Cytological information can be obtained from bronchoalveolar lavage (BAL), brushing, washings, and either transbronchial or endobronchial needle aspiration. (See "Procedures for tissue biopsy in patients with suspected non-small cell lung cancer", section on 'Bronchoscopic approaches'.)
•Microbiological information can be obtained from BAL, brushing, washings, and either transbronchial or endobronchial needle aspiration. Biopsy is a helpful adjunct if fungal or mycobacterial (AFB) infection is suspected. (See "Basic principles and technique of bronchoalveolar lavage" and "Role of bronchoalveolar lavage in diagnosis of interstitial lung disease".)
•Histological information requires an endobronchial biopsy, transbronchial biopsy, cryobiopsy, or needle core biopsy (obtained by aspirating through a large needle). (See "Procedures for tissue biopsy in patients with suspected non-small cell lung cancer", section on 'Bronchoscopic approaches' and "Bronchoscopy: Transbronchial needle aspiration".)
•Total and differential cell counts can be determined from a BAL specimen.
•Immunological studies and flow-cytometry require BAL fluid, a needle aspirate, or a tissue biopsy.
•Molecular markers or genetic mutations (eg, endothelial growth factors mutations) can be identified on most tissue material obtained during bronchoscopy including needle aspiration and biopsies. If adequate cellular material is present, BAL can also be used.
●Location of the target lesion or area – With respect to the location of the lesion or the area of interest, the following should be considered:
•Endobronchial lesions or areas of interest that are proximal enough to be visualized during the airway inspection can be sampled by brushing, endobronchial biopsy, endobronchial needle aspiration, or washings. Endobronchial biopsy is the preferred sampling procedure for such lesions because it will provide histological information, whereas the other procedures provide only cytological and microbiological information. Cryobiopsy in this situation may provide a larger biopsy sample if available to the operator, with an added risk of bleeding. If the lesion is large or has a necrotic layer, however, the forceps are likely to grasp the necrotic surface and be nondiagnostic. Needle aspiration or needle core biopsy is a reasonable alternative in this situation because it may provide a good sample from deeper tissue. (See "Procedures for tissue biopsy in patients with suspected non-small cell lung cancer", section on 'Bronchoscopic approaches'.)
•Infiltrates, lesions, nodules, or areas of interest that are too distal to be visualized during the airway inspection can be sampled bronchoscopically by BAL, brushing, transbronchial needle aspiration (TBNA), or transbronchial biopsy. BAL, TBNA, and brushing provide cytological and microbiological information, while transbronchial biopsy provides histological information about the lung parenchyma, including the distal airways and alveoli. Newer techniques that utilize imaging or navigational technology to biopsy peripheral nodules enhance the diagnostic yield but are limited to centers with expertise. Transbronchial cryobiopsies can provide a larger sample with an added risk of bleeding, which is beneficial in the diagnosis of interstitial lung diseases (ILDs). (See "Procedures for tissue biopsy in patients with suspected non-small cell lung cancer", section on 'Enhanced, image-guided bronchoscopic techniques' and "Image-guided bronchoscopy for biopsy of peripheral pulmonary lesions" and "Endobronchial ultrasound: Technical aspects", section on 'Parenchymal lesions'.)
•Masses or lymph nodes adjacent to an airway (ie, paratracheal, peribronchial or hilar) can be sampled via transbronchial needle aspiration (TBNA). EBUS guided TBNA is commonly performed to localize and sample mediastinal lymph nodes or peribronchial lesions with real-time ultrasound imaging. Radial ultrasound can be used to guide tissue sampling from parenchymal nodules or masses. (See "Bronchoscopy: Transbronchial needle aspiration" and "Endobronchial ultrasound: Indications, contraindications, and complications" and "Endobronchial ultrasound: Technical aspects".)
●Diagnostic yield for the suspected disorder – The diagnostic utility of samples obtained bronchoscopically depends upon the suspicion for the underlying disorder. As an example, the diagnostic utility for transbronchial biopsy for sarcoidosis is high while the yield is lower for other ILDs and for smaller peripheral lesions suspected to be cancerous. Similarly, bronchoalveolar lavage is helpful in the evaluation of sarcoidosis but not diagnostic; in contrast, it is more helpful for the diagnosis of infection or pneumonia especially in the immunosuppressed patient. (See "Selection of modality for diagnosis and staging of patients with suspected non-small cell lung cancer" and "Role of lung biopsy in the diagnosis of interstitial lung disease" and "Approach to the immunocompromised patient with fever and pulmonary infiltrates", section on 'Lung sampling' and "Clinical manifestations and diagnosis of sarcoidosis", section on 'Invasive diagnostic testing'.)
Endobronchial brushing — Brushing specimens are collected using a special, sterile, single-use brush that is enclosed within a catheter sheath (picture 1). Brushings are more commonly used to obtain cytologic specimens from endobronchial lesions, and rarely from parenchymal lesions . Samples are sent for culture, and for cytologic, and occasionally genomic analysis [1]. They cannot be used to biopsy tissue for pathological analysis.
●To obtain a specimen from an endobronchial lesion, the tip of the bronchoscope is placed near the lesion and then the catheter sheath (which contains the brush) is advanced through the working channel of the bronchoscope until its tip is adjacent to the lesion and can be visualized by the operator. The brush is pushed out from the sheath and briskly rubbed against the lesion multiple times in order to trap any cells or micro-organisms within its bristles. Finally, the brush is retracted within its sheath and both the brush and sheath are withdrawn from the bronchoscope. The sample is prepared by placing the brush in saline or cytological fixative, or by smearing the brush onto a microscope slide. The airway is inspected for bleeding, which is usually minor.
●To obtain a specimen from a parenchymal lesion that is beyond the bronchoscopic visualization field, the bronchoscope is placed in or near the bronchus that leads to the lesion, as determined from prior imaging studies. The catheter sheath is then advanced toward the expected location of the lesion, the brush is pushed out from the sheath, and the specimen is collected by gently moving the brush as described above. Fluoroscopy, if available, can guide accurate placement of the brush before the specimen is collected.
The purpose of the catheter sheath is to prevent contamination of the brush with oropharyngeal flora that may remain inside the working channel of the bronchoscope, as well as to protect the inside of the working channel from damage by the brush. The value of protected specimen brushing in the diagnosis of ventilator-associated pneumonia and sensitivity of brushings for the diagnosis of lung cancer are described separately. (See "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia", section on 'Noninvasive respiratory sampling' and "Procedures for tissue biopsy in patients with suspected non-small cell lung cancer", section on 'Conventional bronchoscopy'.)
Brushes come in different sizes, length, and stiffness.
Bronchoalveolar lavage — Bronchoalveolar lavage (BAL) is a procedure that can be used to obtain samples for microbiologic and cytologic analysis only. BAL cannot be used to obtain tissue for histologic analysis, although rarely architectural features or other features that are diagnostic of some conditions (eg, alveolar hemorrhage, glandular formation in adenocarcinoma) can be appreciated.
It involves the instillation of sequential aliquots of sterile saline in to a bronchoalveolar segment from a bronchoscope that is wedged into the second or third order of bronchi (figure 1). After instillation of each aliquot, saline is aspirated from the distal space using a specimen trap attached to the suction port (picture 2) or directly into the syringe from which the saline was originally infused. A BAL typically recovers less than half of the instilled saline. (See "Basic principles and technique of bronchoalveolar lavage" and "Role of bronchoalveolar lavage in diagnosis of interstitial lung disease".)
Bronchial washing — Bronchial washings are obtained by advancing the bronchoscope into an airway, instilling about 5 to 20 mL of sterile saline, and then quickly aspirating the instilled saline into a specimen trap. Bronchial washings are similar to BAL, except washings do not require that the bronchoscope be wedged and they require a smaller volume of sterile saline. They are usually contaminated by oral flora and do not provide a good specimen for determining the differential cell count. Washings and suctioning thick secretions may be therapeutic for patients with lobar collapse or atelectasis causing hypoxemia.
Endobronchial biopsy — Endobronchial biopsy is used to obtain tissue under direct visual guidance from the tracheobronchial tree for histologic analysis. It cannot be used to biopsy lesions that cannot be seen using the bronchoscope.
For endobronchial biopsy, the tip of the bronchoscope is placed 2 or 3 cm proximal to the lesion or tracheobronchial area of interest:
●Endobronchial biopsy specimens are obtained by advancing the bronchoscopic forceps through the working channel until they are seen adjacent to the target lesion or area (picture 3).
●Using clear instructions to the assistant, the forceps are opened, advanced onto the target under direct visual guidance, and the assistant is then asked to close the forceps. Closing the forceps grips the target tissue.
●The forceps are briskly pulled back, taking a 2 to 4 mm sample of endobronchial tissue with them (the operator will feel a slight "pull" during this maneuver).
●The forceps and biopsy specimen are then pulled out through the working channel and handed to the assistant.
●In intubated patients, we frequently pull the whole bronchoscope after the forceps are closed without pulling the biopsy forceps through the working channel to avoid losing additional tissue in the working channel and to obtain a larger specimen.
●The sample is generally inspected for size and adequacy by the assistant and collected in saline (eg, for microbiologic analysis or flow cytometry) or a fixative (eg, formalin for biopsy material, cytologic fixative for cellular material). In suspected cases of malignancy, the sample is placed in formalin. Additional immunohistochemical (IHC) staining or mutation studies for genetic biomarkers can be done from this sample by pathologists. Some experts rinse the biopsy forceps in saline or cytologic fixative to enhance the potential diagnostic yield. Importantly, forceps that have come in contact with fixative cannot be used to obtain additional biopsy material unless they are rinsed in sterile saline or exchanged.
●The biopsied area should be inspected for bleeding while the assistant is handling the specimen. Additional biopsies are usually taken if bleeding is minimal or the biopsy attempt was unsuccessful. Bleeding is managed as described separately. (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Complications'.)
There are a variety of forceps available (serrated edge [alligator], smooth edge with fenestrated or unfenestrated cups, and spiked [needle between the cups). The blades of the forceps may be round (shorter) or oval (longer). None are superior such that choosing one type over another is usually operator-dependent.
Transbronchial biopsy — Transbronchial biopsy (TBB) specimens can be obtained blindly, with fluoroscopic guidance, or with ultrasound or other navigational (eg, virtual or electromagnetic) guidance [2]. Guidance procedures confirm proper placement of the forceps, which is particularly helpful if the lesion or area of interest is small and peripheral. It is associated with an improved diagnostic yield, although it does not appear to reduce the incidence of pneumothorax [3-5]. In contrast, the blind approach is sufficient for a diffuse process because the area of interest is widespread (eg, sarcoidosis). (See "Image-guided bronchoscopy for biopsy of peripheral pulmonary lesions" and "Endobronchial ultrasound: Technical aspects", section on 'RP-EBUS-guided transbronchial biopsy'.)
There are a variety of forceps available, none of which are superior such that choosing one type over another is usually operator-dependent. The distal tip of the bronchoscope is placed near or in the airway leading to the lesion or area of interest, as determined from imaging studies. Biopsy forceps are then advanced through the working channel of the bronchoscope until the tip is seen emerging for the distal end of the bronchoscope (picture 3).
●Anatomy-guided TBB – In anatomy-guided or blind technique, the forceps are advanced slowly into the airway of the lung parenchyma until resistance is encountered (resistance signifies that the tip of the forceps has probably reached the pleura; the tip of the forceps will be out of view).
•The forceps are then pulled back approximately 2 cm. The assistant is instructed to open the forceps and the forceps are advanced less than 1 cm and then the assistant is instructed to close the forceps.
•If the patient is undergoing the procedure under moderate sedation, the patient is instructed using a clear, loud voice command to take a deep breath in and asked whether he or she is having any chest pain while the forceps are closed.
-If no pain is reported, the forceps are briskly pulled back, taking a 2 to 4 mm parenchymal tissue sample with them (the operator will feel a slight "pull").
-If the patient reports pain (signifies that the forceps are too far out against the pleura), the forceps are opened and no sample is taken; instead, the forceps are retracted about 1 to 2 cm and the whole process is repeated again.
•The forceps and the biopsy specimen are pulled out through the working channel of the bronchoscope, and the tissue sample is inspected, removed from the forceps tip and collected in saline (eg, for microbiologic analysis) or a fixative (eg, formalin for histologic analysis). Before reinserting the forceps through the scope, it is important to make sure that the forceps are properly rinsed in sterile normal saline to remove any formalin residues from the forceps. This avoids potential damage to the lung parenchyma.
•Pain while the forceps are closed indicates that the forceps may have grasped the pleura, since pleural tissue, not alveolar tissue, has the highest concentration of pain receptors, thereby increasing the risk of pneumothorax. If pneumothorax is suspected, no further biopsy specimens should be taken.
•After each biopsy, the bronchial segment where the forceps were inserted should be inspected for bleeding while the assistant is preparing the sample. When bleeding is noted, suction is applied on the bronchial segment for at least two minutes to keep the specific bronchial segment collapsed to control bleeding. Additional biopsies are usually taken provided bleeding is minimal. We prefer to collect at least two to three good-sized biopsy specimens for pathologic examination and one to two specimens for tissue culture or flow cytometry. Details on how bleeding is managed is described separately. (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Complications'.)
●Fluoroscopy-guided TBB – Fluoroscopic guidance is typically used when biopsy is planned from a specific segment, lung mass, or lung nodule so the location of the target lesion and the placement of the forceps can be confirmed in real-time. It is often used in diffuse processes to ensure that the tip of the forceps is not placed against the pleura to avoid pneumothorax.
Transbronchial biopsy with fluoroscopic guidance is similar to blind-TBB. The forceps are advanced into the distal airways under fluoroscopic guidance and, prior to attempting the biopsy, the location of the forceps is confirmed fluoroscopically to verify that it is in the target area and not against the pleura (to minimize the risk of pneumothorax). Some fluoroscopes are planar and can only determine how lateral the forceps are while others can rotate in different planes to provide more accurate three-dimension information regarding the location of the forceps tip.
Fluoroscopic guidance is not mandatory for transbronchial biopsies. Comparison studies of transbronchial biopsies with or without fluoroscopic guidance report similar rates of complications including pneumothorax and diagnostic yields [6,7]. Transbronchial biopsies performed without fluoroscopic guidance to diagnose sarcoidosis or ILDs report 70 to 88 percent diagnostic yield with 0 to 0.75 percent pneumothorax [8,9].
●TBB using other guidance tools – Radial probe ultrasound can be used to confirm placement of the forceps in a peripheral lung nodule or mass to increase diagnostic yield [10]. (See "Endobronchial ultrasound: Technical aspects".)
Additional guidance tools including computed tomography and positron emission tomography have been described to improve access to peripheral lesions, thereby potentially enhancing the diagnostic yield of biopsy. However, these methods are less well validated and not widely available [11-15]. (See "Image-guided bronchoscopy for biopsy of peripheral pulmonary lesions".)
TBB with navigational tools or robotic bronchoscopies is similar to obtaining TBB under fluoroscopic guidance and is generally performed for biopsy of target nodules/masses and not for diffuse lesions. (See "Image-guided bronchoscopy for biopsy of peripheral pulmonary lesions".)
●Cryobiopsy – The use of cryoprobes to obtain alveolar material during bronchoscopy is a newer technique of obtaining TBB. Although the size of the specimen is usually much larger than that obtained with a biopsy forceps, the risk of bleeding is reported to be higher [16-19]. Use of occlusion balloon catheter [20] or 2-scope technique has been used to control excessive bleeding from cryobiopsy [21]. (See "Bronchoscopic cryotechniques in adults", section on 'Cryobiopsy'.)
Needle aspiration — Needle aspiration is performed with a catheter sheath that contains a needle at its distal end (picture 4). Needle aspiration techniques are used to obtain cellular aspirate (for cytologic analysis) or small "core" biopsy specimens (for histologic analysis) from endobronchial lesions (endobronchial needle aspirate), and from paratracheal or peribronchial masses or lymph nodes, or peripheral nodules (transbronchial needle aspiration).
●Endobronchial needle aspiration – Endobronchial lesions are aspirated under direct visual guidance.
●Transbronchial needle aspiration – Paratracheal and peribronchial lesions can be sampled blindly or under ultrasound guidance, and peripheral lesions are typically sampled using some form of navigational guidance, most often computed tomography.
The technique and diagnostic yield of needle aspiration techniques are reviewed separately. (See "Bronchoscopy: Transbronchial needle aspiration".)
THERAPEUTIC — Many therapeutic procedures can be performed using a flexible bronchoscope, although some require rigid bronchoscopy. Therapeutic bronchoscopic procedures are typically targeted at relieving central airway obstruction. Even when the rigid bronchoscope is primarily used, the flexible bronchoscope is often used as an adjunct to inspect the airway following the procedure (eg, to examine the airway for residual for debris after ablative resection or residual foreign bodies after removal).
Choosing the therapeutic procedure — Choosing a bronchoscopic therapeutic procedure is dependent upon the nature of the underlying disorder. Flexible bronchoscopy is all that is necessary for suctioning secretions but technically complex equipment is necessary for foreign body removal, cyst aspiration, and locally ablative techniques. (See "Flexible bronchoscopy in adults: Indications and contraindications", section on 'Therapeutic indications'.)
Ablative therapies are mostly indicated as second line therapies for central airway obstruction (CAO) (table 2). Choosing among such ablative interventions is dependent upon factors including the cause of the lesion, predicted response to therapy, operator experience, available expertise, patient prognosis or health status, patient preference, and the ability of the patient to tolerate a selected procedure. Procedural interventions for managing CAO are discussed separately. (See "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults", section on 'Diagnostic evaluation and initial management'.)
General — The flexible bronchoscope may be used for the following:
●Lobar or lung collapse from mucus plug – Suctioning thick secretions may be therapeutic for patients with lobar collapse or atelectasis causing hypoxemia. In general, larger bore therapeutic bronchoscopes are more effective than smaller bronchoscopes at suctioning thick secretions. (See "Atelectasis: Types and pathogenesis in adults" and "Radiologic patterns of lobar atelectasis".)
●Drainage of peribronchial or paratracheal cysts or parenchymal abscesses – Needle aspiration is anecdotally therapeutic for the aspiration of peribronchial or paratracheal cysts. Flexible bronchoscopy has also rarely been used to place pigtail catheters to drain parenchymal abscess or to administer antibiotics locally, when other treatment measures have failed. (See "Bronchoscopy: Transbronchial needle aspiration" and "Approach to the adult patient with a mediastinal mass" and "Flexible bronchoscopy in adults: Indications and contraindications", section on 'Therapeutic indications'.)
●Foreign body removal – Flexible bronchoscopy is often the initial procedure of choice in non-life threatening cases of foreign body aspiration, although rigid bronchoscopy may be required for the extraction of large, more complex, severe, life-threatening cases. (See "Airway foreign bodies in adults", section on 'Foreign body removal'.)
●Endotracheal tube placement – Flexible bronchoscopy can be used to place an endotracheal tube (ETT) in patients with difficult airways who are in respiratory distress or to selectively place an ETT in the right or left mainstem bronchus for selective lung ventilation (eg, patients with hemoptysis or undergoing thoracic surgery). Similarly, flexible bronchoscopy is often used during percutaneous tracheostomy placement to confirm the position of the tracheostomy tube within the trachea and avoid paratracheal placement. (See "Lung isolation techniques" and "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients".)
Specific — Flexible bronchoscopy can be used to administer locally ablative and other types of therapies (eg, stents, dilation, or laser ablation) that treat central airway obstruction from benign and malignant disease as well as in interventional therapies such as valve placement and bronchial thermoplasty. These are discussed in the topics listed in the sections below.
Laser resection — (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'.)
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 5th to 6th 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 10th to 12th 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
●Types of diagnostic procedures that can be performed using a flexible bronchoscope include airway examination, bronchial brushing, bronchoalveolar lavage, bronchial washings, endobronchial biopsy, transbronchial biopsy, and needle aspiration. Conventional white light bronchoscopy can be used for all of these diagnostic procedures. (See 'Diagnostic' above.)
●Choosing a diagnostic procedure is dependent upon the type of information (ie, cytological, histological, microbiological, immunocytochemical, cell counting) that is desired, the location of the lesion or area of interest, and diagnostic yield of lung sampling for the suspected disorder (table 1). (See 'Choosing the type of procedure' above.)
●General and advanced therapeutic procedures can also be performed using a flexible bronchoscope. General procedures include suctioning for lobar collapse, aspiration of peribronchial/tracheal cysts, and foreign body removal. More advanced procedures include laser resection, argon plasma coagulation, photodynamic therapy, electrocautery, cryosurgery, balloon dilatation, brachytherapy, stenting, valve placement, and bronchial thermoplasty. (See 'Therapeutic' above.)
●Choosing a bronchoscopic therapeutic procedure is dependent upon the nature of the underlying disorder. Flexible bronchoscopy is all that is necessary for suctioning secretions but technically complex equipment is necessary for foreign body removal, cyst aspiration, and locally ablative techniques for central airway obstruction (table 2), (See 'Choosing the therapeutic procedure' above and "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults", section on 'Choosing among modalities'.)
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