• bronchoscopy;
  • complication;
  • management


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From the humble beginnings as a mere curiosity, the art of bronchoscopy has progressed at a rapid pace. The millennium ushers in new technologies and refinements in established techniques to facilitate early detection of cancer, precise targeting of pulmonary nodules and infiltrates, near-total staging of the mediastinum with combined endoscopic modalities and more effective palliation of inoperable tumours. Bronchoscopists are faced with an increasing myriad of tools and equipment, each promising to carry out better than the previous. It is opportune to review the complications of established bronchoscopic techiques and how to manage them as well as new complications associated with novel technologies. In this article, we provide a concise overview of diagnostic and therapeutic bronchoscopic modalities, discussion of associated complications and their management strategies.


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Bronchoscopy dates back to the early 19th century where rigid illuminating tubes were used to examine the tracheobronchial tree. Its very first indication was for the removal of a foreign body in 1897.1 Chevalier Jackson later reported the first bronchoscopic resection of an endobronchial tumour in 1917,2 and proposed its use to drain retained secretions.3

Since the invention of the flexible bronchoscope (FB) by Shigeto Ikeda and its introduction into clinical practice in 1968, flexible bronchoscopy has revolutionized the practice of pulmonary medicine, enhanced our understanding of pulmonary disease, and has evolved into the most commonly used invasive diagnostic as well as therapeutic procedure. Bronchoscopy is widely carried out today by pulmonologists, thoracic surgeons, critical care specialists, otolaryngologists, anesthesiologists and paediatric pulmonologists. In this article, we provide a review of diagnostic and therapeutic bronchoscopic treatment modalities, associated complications and management strategies.


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Flexible bronchoscopy offers a high diagnostic yield and therapeutic possibility in patients with suspected lung cancer. Bronchial washing, brushing, endobronchial and transbronchial biopsy have variable yields depending on tumour location and accessibility. For endobronchial tumour, forceps biopsy has the highest diagnostic yield (74%) compared with brushing (59%) and washing (48%), and 88% with combined techniques. For peripheral parenchymal lesions, fluoroscopic guided transbronchial brush gives the highest yield (52%) followed by transbronchial biopsy (46%) and washing (43%), and 69% with combined techniques.4

The addition of conventional needle aspiration to routine sampling for endobronchial, submucosal and peribronchial disease increases the yield further by 30% and is exclusively diagnostic in 20%, thereby obviating further need for invasive interventions and unnecessary open-close thoracotomies.5,6

Bronchial washing, endobronchial forceps, brush and needle biopsy

Bronchial washings are usually obtained for cytological diagnosis, mycobacterial, fungal stains and cultures. Bronchial washing is carried out in combination with forceps biopsy and cytological brushings,7,8 and obtained first before biopsy and brush to avoid contamination of the specimen with blood.

The forceps is a useful tool for taking biopsies, and non-disposable alligator forceps (7-gauge) is recommended over its fenestrated counterpart to enhance the yield. When necrotic tumours are encountered especially if they have pale surfaces, multiple biopsies should be carried out until viable tissue is obtained as indicated by surface bleeding. Needle biopsy forceps that allows the operator to fix the forceps into the lesion is useful for abnormalities located on the wall of trachea or main stem bronchi.8

Brushing back and forth 5–10 times and rotating the upper handle over the surface of the endobronchial tumour maximize the brush contact and two sizes (3 mm, 7 mm) have been used without difference in the yield.8 Addition of needle aspiration using histology needle (19-gauge) that allows core biopsy to wash, biopsy and brush further enhances the diagnostic yield.6

Complications associated with flexible bronchoscopy and management

Significant decrease in arterial oxygen tension has been documented if flexible bronchoscopy is carried out on room air especially when the scope is inserted past the carina and during occlusion of a bronchus.9,10 Although most patients recovered to their baseline oxygen levels 2 h after the procedure, some required up to 4 h and cardiac arrhythmias have been shown to occur at the nadir of hypoxemia. It is common practice to administer supplemental oxygen via intranasal route, and to switch to high flow oxygen delivery by mask if patients have low baseline pulse oximetry. Pulse oximetry is monitored continuously during flexible bronchoscopy and oxygen requirements adjusted if necessary.11 During hypoxic episodes, suction is suspended to avoid ‘suction steal’ as 40% and 75% reduction in tidal volume might occur when 12.5-cm H2O and 21-cm H2O of vacuum is applied through the working channel.12 Caution should be exercised regarding high flow oxygen administration to patients with chronic hypercapnia as well as judicious use of sedatives and narcotics that can depress the respiratory centre. In COPD patients with hypoxia and hypercapnia who are otherwise contraindicated for flexible bronchoscopy, investigators have showed safety of the procedure carried out with non-invasive positive pressure.13

Bronchoalveolar lavage

Bronchoalveolar lavage (BAL) is diagnostic for infections because of pneumocystis carinii, toxoplasma gondii, strongyloides, legionella, histoplasma, mycoplasma, influenza, respiratory syncytial virus and mycobacterium tuberculosis. For non-infectious causes, BAL is useful for diagnosis of alveolar proteinosis, pulmonary langerhans histiocytosis and malignancy. By estimating proportion of CD4 to CD8 lymphocytes in lavage fluid, BAL can aid in diagnosis of sarcoidosis and hypersensitivity pneumonitis. While carrying out bronchoscopy for the purpose of diagnosing infectious diseases, merthylparaben-free lidocaine should be used as methylparaben has bacteriostatic property. Suction is also kept to minimum to avoid contamination by oropharyngeal secretions, and avoided until BAL and protected catheter brushing have been completed.14,15

Complications associated with BAL and management

No complications have been documented with bronchial washing as only 15 mL is required for acid-fast bacilli, fungi and cytology. As BAL involves instillation of large fluid volumes, transient hypoxemia as well as declines in forced expiratory volume in 1 s (FEV1), forced expiratory flow (FEF 25–75), vital capacity (VC), total lung capacity (TLC) and residual volume (RV) have been documented.

Hypoxemia is a common complication associated with BAL, and the degree of hypoxia is related to volume of fluid administered.16 Lavage fluid of 100 mL was observed to cause oxygen desaturation up to 7% while 200 mL resulted in 15% fall from baseline. Most patients achieved normal oxygen saturation within 10 min of bronchoscopy, those who experienced significant decline needed 30 min to return to baseline.16 Although supplemental oxygen during BAL reduced the magnitude of oxygen desaturation, volume of lavage fluid and duration of procedure are important factors affecting outcome.17 Our recommendations for preventing arterial hypoxemia during BAL are: measurement of baseline arterial blood gases before BAL in patients with low baseline pulse oximetry; supplemental oxygen and to continue oxygen 1 h after BAL; continuous monitoring of pulse oximetry and electrocardiogram during and 1 h after BAL as cardiac arrhythmias is related to nadir of oxygen saturation as well as limit 200 mL per lavage by using 20 mL fluid aliquots.16

Selection of bronchial segment for lavage in patients with diffuse lung infiltrates is important. Superolateral segment of the right middle lobe and superior segment of the lingual are less dependent lobes. BAL of the right middle lobe can increase fluid return by 20% compared with BAL of the lower lobes.18 Moreover, slow deep inhalation during instillation and prolonged exhalation during aspiration of lavage fluid as well as steady suction with syringe plunger to avoid collapse of segmental bronchial wall have been shown to increase return.19

Changes in spirometry have also been documented with BAL attributable to temperature of the lavage fluid.17 BAL carried out with saline at room temperature resulted in falls in VC, TLC, and FEF25–75 as well as increase in RV. These changes were not observed with saline lavage at body temperature. Asthmatics with increased responsiveness to methacholine PC20 (<4 mg/mL) might wheeze for up to 2 weeks after BAL compared against those with PC20 > 4 mg/mL.20 Bronchoscopy should be postponed if patient has acute bronchospasm, and therapy optimized if BAL is planned for asthmatics with history of status asthmaticus or intensive care admissions. Pre-treatment with steroids and bronchodilators; nebulized beta-2-agonists on standby; and lavage fluid warmed to body temperature are considerations to avoid complications. Transient fever and chills from cytokine release occurs between 2.5% and 50%, and is related to the number of segments lavaged than the total volume used.17,18,21 Incidence of alveolar infiltrates affecting dependent lavaged segments varies between 0.4% and 50%, and they usually resolve within 24 h.18,22,23 We recommend limiting BAL to maximum three different lobar segments at each sitting and 200 mL per lavage, and antibiotics if clinical and radiological suspicion of infection is present or when the fever does not resolve after 24 h. Bleeding is very rare as long as the patient has a platelet count >75 000/mL, normal coagulation, urea and creatinine. In one report, this complication rate is reported as 0.7% and none required intervention.22

Overall, BAL has the same complication rate as routine flexible bronchoscopy (0–3%), and no mortality has been reported. Bronchoscopists should have a high index of suspicion for pneumothorax when carrying out diagnostic BAL in patients with pneumocystis carinii pneumonia and therapeutic BAL for pulmonary alveolar proteinosis (PAP).24,25

Bronchoscopic lung biopsy

Bronchoscopic lung biopsy (BLB) used interchangeably with transbronchial lung biopsy should in strict terminology describe a procedure to procure specimens from abnormal lung parenchyma. Today, BLB is carried out exclusively with the FB.26 BLB complements BAL by improving the yield for diagnosis of sarcoidosis, pulmonary langerhan's cell histiocytosis, pneumocystis carinii pneumonia, PAP and lymphangitic carcinomatosis.27,28 BLB is contraindicated in patients with unstable cardiovascular status, status asthmaticus, severe hypoxemia, and unable to cooperate with the procedure. Relative contraindications include uncontrollable cough, uncorrected bleeding diatheses, uraemia, significant hypoxemia with single lung, as well as extensive bullous disease and vascular malformations adjacent to target sites. High resolution CT might be helpful in deciding which areas should be targeted to improve diagnostic yield and areas that should be avoided, such as bullae or vascular abnormalities.

Biopsy of diffuse infiltrates is more likely to provide diagnosis than small peripheral nodules. Overall yield from BLB was 72%.29 In one study that included 530 BLB in 516 immunocompetent patients with diffuse pulmonary infiltrates, localized peripheral lesions or hilar adenopathies, higher yield was obtained for hypersensitivity pneumonitis (92%), sarcoidosis (75%), lymphangitic carcinomatosis (68%) and pneumoconiosis (54%). Diagnostic accuracy for interstitial pulmonary fibrosis was only 27%,30 the American Thoracic Soceity/European Respiratory Society Consensus recommends BLB not for the diagnosis of idiopathic interstitial pneumonias but for the exclusion of sarcoidosis, infections and lymphangitis carcinomatosis.31

Complications associated with BLB and management

In a postal survey of 231 British bronchoscopists, it was reported that bronchoscopy complication rate increases from 0.12% to 2.7%, and mortality rate from 0.04% to 0.12% if BLB is carried out.32 Similarly in a review of 3572 flexible bronchoscopy procedures carried out by first and second year pulmonary fellows under faculty supervision at the Veterans Affairs Medical Centre where 1408 BLB, 926 endobronchial biopsies, 962 BAL and 376 bronchoscopic needle aspirations were evaluated, BLB was most commonly associated with complications accounting for 41 out of 56 events.33

The 2 major complications of BLB are haemorrhage and pneumothorax. In a study of 438 patients who underwent BLB, mild to severe haemorrhage was observed in 9% (45% in uraemic patients), and one death.34 The authors are of the opinion that if a test is to be carried out, estimation of serum creatinine is most important because platelet dysfunction caused by renal failure is associated with clinically significant haemorrhagic tendency. If a low platelet count is documented, BLB should be postponed until the platelet count is greater than 50 000/mm3 with normal coagulation profile. However, if BLB is a necessity, platelet transfusion for thrombocytopenia, correction of coagulation indices and administration of deamino-8D-arginine-vasopressin at 0.3 mcg/kg for uraemia associated platelet dysfunction are steps towards minimizing risk for haemorrhage. Temporary cessation of antiplatelet and anticoagulant therapy for a week before BLB is advised,35 and choosing peripheral areas to target can minimize risk for haemorrhage as the bronchial arteries are smaller distally.

The technique of BLB is also important to avoid complications. Cough suppression is particularly important to reduce the risk of pneumothorax arising from cough-induced barotrauma, adequate sedation as well as pre-operative cough-suppressive therapy might be necessary. If procedures, such as BAL, endobronchial biopsy, transbronchial needle aspiration (TBNA) are required, BLB should be carried out last, and fluoroscopy should be used routinely. There are several advantages for fluoroscopic guided BLB, the most important is to minimize the incidence of pneumothorax, the second is to guide instruments towards localized lung infiltrates to improve diagnostic yield, and the third is to screen for pneumothorax post BLB thereby obviating need for post-procedure CXR.32 BLB can be carried out in patients who are mechanically ventilated although the incidence of pneumothorax is three times higher compared with non-mechanically ventilated patients. All who developed pneumothoraces required tube thoracostomy but no deaths were documented.36,37 Before BLB, FiO2 was increased to one and the ventilator to assist-control mode. PEEP was decreased wherever possible to 5-cm H2O before insertion of bronchoscope into the endotracheal tube. All patients received intravenous sedation and topical anaesthesia while some required short-acting neuromuscular-blocking agent before BLB. BLB was carried out with C-arm fluoroscopy unit in the patient's room. As the risk of tension pneumothorax is high, tube thoracostomy should be readily available.

After ascertaining the appropriate site for biopsy, the bronchoscope is advanced and wedged in the bronchial subsegment, while the forceps is advanced to the target under fluoroscopic guidance. The forceps is opened 5–6 mm proximal to target, advanced and closed. The patient is then asked if pain is experienced before the forceps is withdrawn. If there is pain or if the pleura is pulled back during retraction of forceps, the forceps are open, withdrawn proximally and another area is attempted. Wedging the bronchoscope is advantageous as more biopsies can be obtained once an optimal position is achieved, and even when post BLB bleeding occurs, wedging limits bleeding to subsegment of the lung and confers a ‘tamponade’ effect. If significant bleeding is encountered (>50 mL) the wedge position is maintained, 10–15 mL of iced saline is instilled through the bronchoscope, and allowed to flood the lung subsegment before suction is resumed. Iced saline produces vasoconstriction and another aliquot can be attempted if bleeding persists. The authors have found the addition of 1 mL epinephrine (1 : 1000) to the aliquot of ice saline aids in controlling haemorrhage from distal areas. Bleeding usually stops with these manoeuvres in most patients, however, if persistent, balloon tamponade, fibrin glue application, isolation of bronchial tree with double lumen endotracheal tubes, and surgical resection of the bleeding segment are considerations.

Type of forceps and number of biopsies are factors affecting diagnostic yield. Although alligator (toothed) forceps were alleged to cause more haemorrhage due to its tearing action than cup (without tooth) forceps, a later prospective study of 43 patients who underwent 170 BLBs concluded that tissue specimens obtained with toothed forceps were superior and there was no excessive bleeding observed with either accessory.38 Risk of pneumothorax is directly proportional to number of BLB attempts, thus the least number of biopsies required to establish diagnosis should be carried out. In 530 BLB procedures evaluated, 38% and 69% yields were achieved with 1–3, and 6–10 specimens, respectively.30 The authors' recommendations for BLB are: selection of peripheral sites in diffuse parenchymal disease for biopsy, use of toothed forceps, carry out 6 biopsies, and with fluoroscopy.


The main indication for TBNA is for staging of lung cancer. TBNA has variable yield of 20–74%.39 The site for puncture of enlarged lymph node is first determined by CT images but due to fear of inadvertent puncture of neighbouring vascular structures, damage to the bronchoscope, technical difficulties with needle, inadequate specimen for diagnosis, and discrepancy between reported yield and individual operator's experience, TBNA is not routinely practiced.40 There are different TBNA techniques, namely jabbing, piggyback, hub-against-the-wall and the cough methods. In the authors' opinions flipping the CT images aids the bronchoscopist in achieving better correlation of various lymph node stations with the endoscopic view, use of histology needle,41 at least three passes per lymph node station,42 dry smear for specimen preparation43 and rapid onsite cytology evaluation44 are steps towards improving TBNA yield.

Complications associated with TBNA and management

Successful TBNA requires not only familiarity of instrumentation, technique and preparation of slides for cytology, but also knowledge of the relationship between the tracheobronchial tree and associated mediastinal and vascular structures. In fact, the major complication of TBNA is perforating the working channel of the bronchoscope,45 which can be avoided by first retracting the needle into the sheath and straightening bronchoscope as the needle is withdrawn. Fever has been documented after TBNA although blood cultures at 5 and 30 min were reportedly negative for bacteraemia.46 There were isolated reports of purulent pericarditis occurring following TBNA of subcarinal mass in a patient with multiple myeloma,47 pneumothorax after TBNA of peripheral lung lesion and hemomediastinum.48 If puncture of mediastinal blood vessels has occurred and blood is aspirated into the sheath, TBNA of the site should be aborted. The needle is then retracted slowly to allow clotting of the needle tract. Puncture of the mediastinal vessels does not lead to significant haemorrhage.

A major advance in mediastinal staging is notably the incorporation of curvilinear ultrasound to the tip of the bronchoscope that produces sectorial imaging of the lymph nodes. Coupled with colour flow Doppler, endobronchial ultrasonography (EBUS) allows safe real-time aspiration of mediastinal lymph nodes by avoiding surrounding vascular structures. Accuracy with this technique is 89–97%.49–51 In fact, EBUS combined with endoscopic ultrasound trans-oesophageal sampling of enlarged lymph nodes in the mediastinum achieves a diagnostic accuracy of 94%, a figure comparable with mediastinoscopy but carried out in a non-invasive manner.50 Both techniques provide access to hilar, pulmonary ligament and para-oesophageal lymph nodes as well as the adrenal that would otherwise be inaccessible with the mediastinoscope.51


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Rigid bronchoscopy

Rigid bronchoscopy was carried out in the 19th century by Gustav Killian to remove a pork bone from the right main bronchus.52 For 70 years, the rigid bronchoscope provided the only access to the airways. After 1970, flexible bronchoscopy has supplanted rigid bronchoscopy for most diagnostic and therapeutic procedures in adults. A survey by Colt and Prakash reported that 99% of all bronchoscopies in the USA were carried out with the FB. Only 4% of respondents had experience in rigid bronchoscopy.40 Notwithstanding that the FB has replaced its rigid counterpart in many indications rigid bronchoscope remains an invaluable tool for better control of the compromised airway, massive haemoptysis, silicone stent placement and removal of large foreign bodies.

Complications associated with rigid bronchoscopy intubation and managment

The rigid bronchoscope of today is no different from the hollow, straight and stainless steel tube used by Chevalier Jackson; and the procedure is carried out using deep conscious sedation with spontaneous ventilation or general anaesthesia. The combination of intravenous general anaesthesia with propofol and assisted spontaneous ventilation is currently the most frequently used anaesthesia technique for rigid bronchoscopy.53 Muscle relaxation and paralysis can be avoided with the use of assisted spontaneous ventilation, and wake-up time shortened. When general anaesthesia with inhaled gases is used or ventilating via conventional circuit, it is essential to pack the nose, mouth, and proximal end of the rigid scope to avoid gas leakage. Some bronchoscopists prefer the jet ventilator, which delivers tidal volume ventilation to the distal trachea thereby keeping the proximal end of the rigid instrument open for accessories. Contraindications to rigid bronchoscopy include patients who are at high risk for general anaesthesia with active cardiac ischemia or are haemodynamically unstable; unstable cervical spine that makes passage of rigid scope a challenge and lack of adequately trained personnel.

Complications are usually related to the underlying pathology, however, forcibly or blindly introducing the instrument could lead to dental trauma; laryngeal oedema; laceration of uvula, epiglottis, arytenoids and vocal cords, and perforation of the upper airway, trachea and oesophagus. Therefore, proper positioning of the patient with the neck extended is important to ensure that a straight line is created from the oral cavity to the vocal cords. The rigid scope is held with the right hand with the distal flared tip or bevel in the anterior position. The telescope is inserted into the rigid tube, and the image obtained must be adjusted to ensure that the bevel is clearly visualized and positioned at 12 o'clock, which must be maintained throughout intubation. Losing the view and orientation of the sharp bevel as well as forcibly pushing the rigid scope are main causes of injury to the upper airway, trachea and oesophagus. The left hand of the operator is placed such that the thumb and the first finger serve as guide through which the rigid scope is inserted; the forefinger protects the patient's lower teeth and lip from direct contact with the rigid tube while the thumb protects the upper lip and teeth.

The rigid scope is inserted at 90 degrees to the opening of the mouth until the uvula is visualized the scope is then angled downwards with the thumb acting as a fulcrum against which the scope moves. The operator must take great care to avoid pivoting the rigid scope on the upper teeth and lips as this can cause lip trauma or fractured teeth. Once the rigid scope has identified the epiglottis, the bevel is used to lift the epiglottis and rotated 90 degrees clockwise to assure easy passage of the distal tip through the vocal cords. Occasionally, the tip of the bevel is used to gently push the vocal cord aside to allow intubation of the rigid scope; however, force should be not be used to push the rigid tube through the cords especially when the glottic opening is not large enough. In this case, a smaller diameter rigid tube should be used. Once the distal tip has past beyond the vocal cords, the rigid bronchoscope is rotated another 90 degrees clockwise to rest the bevel at 6 o'clock of the trachea. The proximal part of the tube should lie along the orobuccal fold, and the teeth and gums cushioned with wet gauze or rubber protectors. If difficulty in navigating the upper airway is envisaged, such as previous surgery or radiotherapy, the laryngoscope can be used to locate the vocal cords and the rigid scope is inserted into the subglottic space akin to endotracheal intubation.

The rigid bronchoscope is slowly advanced from the subglottic space to the trachea and main carina. The patient's head is rotated to the left and right to allow examination of right and left main bronchi and their distal segments, respectively. The FB can now be used to facilitate inspection of upper lobar subsegments and carry out biopsy. On completion of the procedure, the rigid bronchoscope is removed under visualization, rotating the bevel as the vocal cords are passed. Notably, the most important step towards avoidance of complications would be adequate training and competency in rigid bronchoscopy.54,55


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Malignant central airway obstruction is a significant cause of morbidity and mortality. Approximately 30% of patients with lung cancer will present with airway obstruction, and 35% of this group will die of complications, such as haemoptysis, postobstuctive pneumonia and asphyxia.56 Although imminent asphyxiation could be temporarily relieved by endotracheal intubation and mechanical ventilation, recanalization of the airway by bronchoscopic methods and stent placement result in rapid relief of symptoms and allow time for chemo(radio)therapy to achieve sustained palliation, improved quality of life and prolonged survival.57 Therefore, selection of a therapeutic strategy depends on the type of lesion, acuity of presentation, the patient's general health status and physician's expertise (Fig. 1).


Figure 1. Management of malignant central airway obstruction. *To be followed by chemotherapy and/or XRT; **Can be used singly or in combination. EBES, endobronchial electrosurgery; LPR, laser photoresection; PDT, photodynamic therapy; XRT, external beam irradiation.

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The most widely used laser for treatment of malignant tracheobronchial tumours is the Neodymium-Yttrium-Aluminium-Garnet (Nd-YAG) laser. The Nd-YAG laser causes tissue coagulation at low power, and vaporization at high power. The ideal lesion is an endobronchial tumour that measures less than 4 cm, arises from one wall of the trachea or main stem bronchus, visible distal lumen and distal lung collapse of less than 6 weeks. Lesions not amenable to laser are submucosal, arise from lobar or segmental bronchi, compress the airway extrinsically or segment of pulmonary artery and involve the oesophagus. Other contraindications to laser include unstable cardiovascular status and high oxygen requirement (Table 1). We practice the ‘Rule of Four’, an algorithm aimed at reducing risks of endobronchial ignition (Table 2).

Table 1.  Factors that influence outcome of Neodymium-Yttrium-Aluminium-Garnet Laser
LocationTrachea, main bronchiLobar and segmental
Type of lesionEndobronchialExtrinsic
AppearancePolypoid, exophytic, pedunculatedSubmucosal
Extent of involvementLocalized (1 wall)Extensive (>1 wall)
Length of lesion<4 cm>4 cm
Distal lumenVisibleNot visible
Duration of collapse<4–6 weeks>4–6 weeks
Clinical status  
 Oxygen requirement<40% FiO2>40% FiO2
 Coagulation profileNormalAbnormal
Pulmonary vascular supplyIntactCompromised
Table 2.  ‘Rule of Four’
  1. FB, flexible bronchoscope; LPR, laser photoresection.

Maximum length of lesion4 cm
Duration of collapse<4 weeks
Initial settings 
 Power (W) 
  Noncontact40 W
  Contact4 W
  Pulse duration0.4 s
  Endotracheal tube to lesion>4 cm
  Fiber tip to lesion4 mm
  FB to tip4 mm
FiO2 during LPR<40%
Number of pulses between cleaning<40
Procedure time<4 h
Toral number of repeat laser treatments<4
Life expectancy>4 weeks
Laser team individuals4

Laser therapy improves airway patency in 79–92% of patients,58–60 while its coagulative property palliates those with haemorrhagic endobronchial tumours. Laser is very effective in relieving symptoms of cough, dyspnoea and haemoptysis as well as in achieving endoscopic,61 radiographic,61,62 spirometric63 and quality-of-life improvements.64 It also might obviate the need for endotracheal intubation in, patients with respiratory distress as well as facilitate weaning from mechanical ventilation.65

Improving survival is controversial and is not the best parameter given its palliative role. In fact, immediate relief of dyspnoea and better quality of life justify its use and should be considered complementary to chemo(radio)therapy, stenting or surgery as it provides the necessary time window, and in certain situations represents the only option for patients who have had previous therapy.

Complications associated with laser therapy and management

Laser therapy is a relatively safe procedure. Complication rates range from 0 to 2.2,61–66 and the most serious of which is perforation of major intrathoracic blood vessel.67 To avoid this fatal complication, the operator must be adept in the knowledge of airway anatomy, and keep the laser beam parallel to the bronchial wall at all times. Endobronchial ignition is another serious complication,68 which can be prevented by setting the laser to single pulse mode and keeping the fibre clean; avoid combustible anaesthetic agents and firing at inflammable materials (bronchoscope sheath, suction catheter, endotracheal tube) as well as keeping FiO2 at 40% or less. Haemorrhage from a vascular tumour during laser is often easily controlled. Only on rare occasion when bleeding becomes excessive is the rigid bronchoscope required for suction and tamponade of the site. Pneumothorax or pneumomediastinium attendant to laser-induced perforation of the tracheobronchial tree can be avoided by keeping the laser beam parallel to the bronchial wall, while risks for cerebral air embolism arising from coaxial cooling of sheathed fibres and retinal damage from reflected laser light can be minimized by the use of CO2 instead of air as coolant and protective eye-goggles.69

The composition of laser plume came under investigation with reports showing intact human papillomavirus DNA in the vapors of laser-treated verrucae,70 and subsequent infection in treating physicians.71 Similarly, the DNA of human immunodeficiency virus has been detected in laser smoke but viability of virus in cell culture did not occur.72 We therefore recommend use of smoke evacuator and special protective masks for high risk cases pending results on risks of viral transmission and infection.


Endobronchial electrosurgery (EBES) is the application of electrical current to coagulate or vaporize tissue in the tracheobronchial tree. With development of grounded bronchoscopes, better probes, electrodes and high frequency electrical generators, there is a resurgence of interest in EBES. Moreover, equipment and maintenance costs are very much lower compared with the Nd-YAG laser. EBES is carried out with the probe in contact with the target tissue, and the electrical current set to ‘coagulate’ at high amperage/low voltage, ‘cut’ at low amperage/high voltage, or ‘blend’ at midway between ‘cut’ and ‘coagulate’. By applying electrical current via foot pedal, it passes from the probe to tissue, and finally to a grounded neutral plate attached to the patient. Two main techniques of EBES have been described: (i) tumour debulking by cutting the stalk of polypoid lesion with cutting loop and; and (ii) electrodestruction of tumour by direct contact of the probe.73 Optimal results are achieved if the treated area is kept free of blood or mucus. The authors prefer blend mode as it ‘cuts and coagulates’ at the same time. Indications include small endobronchial tumours, fibrotic strictures and webs, and curative treatment of radiographically occult lung cancer. Massive haemoptysis, near-total obstructing tracheal masses, lesions adjacent to endotracheal tube, radio-opaque silicone stent or vocal cords, and patients requiring FiO2 > 40% or have pacemakers that cannot be turned off temporarily are contraindications to the procedure.74

Complications associated with electrosurgery and management

Laser complications such as perforation of intrathoracic blood vessels causing haemorrhage, and airway fire can also be found with EBES. Thus knowledge of the airway anatomy and its relationship to mediastinal structures is of paramount importance, and before EBES is applied, FiO2 should be adjusted to 40% and below.74

Argon plasma coagulation

The argon plasma coagulator (APC) is an example of non-contact EBES, and uses ionized argon gas as a conductor for electrical current between the electrode and tissue. It is ideal for coagulation of superficial haemorrhagic lesions, tumours of the upper lobe segmental or superior basal lobar bronchi as well as stent-related obstructive granuloma.75,76 The in-depth tissue necrosis achieved with APC is less compared with laser, EBES, brachytherapy and photodynamic therapy (PDT). Recently air embolism has been reported with APC and might be related to gas flow exiting from the tip of the probe. The ideal gas flow rate for APC in airways is unknown, and current recommendations are to set the flow to 0.8 L/min or lower.77


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These modalities are indicated for airway lesions that do not require immediate restoration of airway patency and are used singly or in combination.


Endobronchial brachytherapy is a form of local radiation treatment, which involves temporary placement of encapsulated radioactive sources within or near the tumour. The advantages of brachytherapy over external beam radiation include: (i) delivery of a higher dose of radiation directly to tumour; (ii) rapid fall of radiation outside treatment region; (iii) precise dose localization; and (iv) adaptability to tumour shape.

Patients with endobronchial tumours from primary lung cancer or cancers metastatic to the airways and residual tumour following surgery are candidates for brachytherapy. However, the lesion to be treated must be visible on bronchoscopy, permit the passage and distal placement of catheter and located in the trachea, mainstem or lower bronchi.

Complications associated with brachytherapy and management

Respiratory compromise, massive haemoptysis, fistula formation, radiation bronchitis, airway stenosis and erosion of the pulmonary artery have been reported with brachytherapy.78,79 The risk of massive haemorrhage is related to proximity of pulmonary arteries to the mainstem and upper lobe bronchi, CT, MRI or digital subtraction angiography is suggested to exclude tumours in close proximity to major arteries before brachytherapy. Radiation-induced bronchitis and stenosis consequent to brachytherapy occurred in 8.7%, and are observed more commonly with high radiation dose administered for curative intent, and tumours involving trachea and mainstem bronchi.79


Cryotherapy causes local tissue destruction by the application of extremely low temperatures (below −20 to −40 degree Celsius). A liquid cryogen or coolant (usually nitrous oxide or nitrogen) is delivered under pressure to a specially designed cryoprobe that might be rigid, semi-rigid or flexible. Rigid and semi-rigid cryoprobes are used with rigid bronchoscope while the flexible cryoprobe can be used with both instruments.

Complications associated with cryotherapy and management

Cryotherapy has a success rate of 50–86% for the relief of airway obstruction.80,81 The ideal lesion is a small polypoid tumour that is accessible to the cryoprobe, with visible lumen and functioning lung distally. If the patient has impending respiratory failure from tracheobronchial obstruction, laser, EBES or a combination of modalities is the treatment of choice as cryotherapy is ineffective in removing tissue rapidly. Cryotherapy is used to treat early lung cancer, granulation tissue, web-like stenosis as well as for the removal of foreign bodies, mucus plugs and blood clots.82–84 Complications associated with endobronchial cryotherapy are few and minor, although haemoptysis, pneumothorax, tracheoesophageal fistula, dysrrthymia and bronchospasm have been reported.80–86 These can be avoided by placing the metallic tip of the cryoprobe in contact with the tumour. Three freeze/thaw cycles are carried out at each site with freezing time between 30 and 60 s until the entire visible part of the tumour is frozen. Several days are required for tumour necrosis to occur, and bronchoscopy is carried out 8–10 days later to clean up sloughed tissue as well as for repeat treatment of large lesions.


Photodynamic therapy is a two-step process that involves the intravenous administration of a photosensitizing agent known as dihematoporphyrin ether/ester (DHE, Photofrin II) and exposure to argon pump-dye laser. DHE is preferentially retained by tumour, and exposure of DHE to 630 nm laser light results in tumour necrosis from cellular destruction by superoxide and hydroxyl radicals as well as vascular occlusions from thromboxane A2 release. Clean-up bronchoscopy is often necessary 2–4 days after the procedure.87

Complications associated with PDT and managment

The main indication for PDT is in treatment of early lung cancer when the squamous cell carcinoma involves the central airway, is roentgenographically occult, and measures <2 cm2 in surface area and ≤1 mm in depth. PDT can also be used to treat synchronous lung cancer where PDT applied pre-operatively could reduce extent of surgical resection in selected patients.88 In some reports, PDT has been administered for the palliation of advanced obstructing cancers of the tracheobronchial tree, and appears to be effective for polypoid tumours, and hazardous for submucosal and peribronchial disease.89,90 The main advantage of PDT over laser is technical ease and safety, and distal lobar obstructions not amenable to laser can be treated with PDT under local anaesthesia. Disadvantages include slow onset of action and is not useful for patients with acute respiratory distress; avoidance of sunlight for 4–6 weeks and frequent clean-up bronchoscopies.87

Complications associated with PDT and management

Complications are infrequently found however patients can develop dyspnoea from airway obstruction due to tissue swelling and necrosis that necessitates clean-up bronchoscopy or repeat intervention as well as haemoptysis.88–90


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Techniques described can also be used to relieve airway obstruction because of benign tumour, obstructive granuloma and stenosis. Subglottic or tracheal stenosis, however, poses a challenge to the pulmonolgist as non-surgical endoscopic attempts at bougie dilatation, EBES, cryosurgery and laser can result in mucosal trauma, unpredictable healing and high rate of restenosis. Laryngotracheal resection or reconstruction, although successful, can cause damage to vocal cords and recurrent laryngeal nerve.91 Our approach to subglottic and tracheal stenosis is to carry out mucosal-sparing radial cuts using Nd-YAG laser followed by gentle dilatation with a single-size RB, and stenting if tracheomalacia is observed.92 With careful patient selection (Fig. 2) and meticulous post-operative care, our success rate is 67% (Table 3). The number of repeat treatments is usually limited to three and if stenosis recurs after the third treatment, the patient is referred for definitive surgical intervention.


Figure 2. Management of benign tracheal stenosis. APC, argon plasma coagulator; EBES, endobronchial electrosurgery.

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Table 3.  Anatomic features of stenosis that predict outcome
Favourable outcomeUnfavourable outcome
Concentric webCircumferential scarring with cicatricial contracture
Scarring <1 cm in vertical lengthScarring >1 cm vertical length
Absence of tracheomalaciaTracheomalacia
History of bacterial infection a/w tracheotomy
Carinal involvement by stenosis
Combined laryngeal and tracheal stenosis

Balloon dilation of benign tracheobronchial stenosis

Instead of using increasing sizes of RB, balloon dilation can be carried out for tracheobronchial stenosis.93,94. Choice of balloon depends on the length and diameter of stenosis as well as target diameter to be achieved.

Complications associated with balloon dilatation and management

Complications include chest pain, bronchospasm and atelectasis, while excessive dilation might lead to laceration or rupture airway causing haemorrhage, pneumothorax, pneumomediastinum and mediastinitis.93,94. An important step to avoid these is to ensure optimal placement of balloon over the stenosis, our practice is to use dilute contrast medium to inflate the balloon for better imaging and continuous fluoroscopy. The balloon is kept inflated for 60 s followed by deflation. The cycle is repeated until target airway diameter is achieved.

Airway stents

Airway stenting complements other treatment modalities for the palliation of inoperable tracheobronchial tumours (Table 4). Stent insertion following laser or electrosurgery for malignant tracheobronchial obstruction results in immediate relief of acute respiratory distress, successful extubation and prolonged survival.95–97

Table 4.  Indications for stent placement in lung cancer
1. Airway obstruction from extrinsic bronchial compression or submucosal disease.
2. Obstruction from endobronchial tumour when patency is <50% after laser therapy.
3. Aggressive endobronchial tumour growth and recurrence despite repetitive laser treatments.
4. Loss of cartilaginous support from tumour destruction.
5. Sequential insertion of airway and oesophageal stents for tracheoesophageal fistulas.
Complications associated with airway stent and management

At present there is no ideal stent, and the evaluation of stent performance is not dependent on the immediate therapeutic response but rather on its ability to maintain long-term patency and associated complications. Moreover, the ease of insertion of a particular stent should not result in its erroneous preference and selection over another that is better suited for a given condition. Stents are classified as tube and metal (Table 5).

Table 5.  Comparison of dumon (tube) stent and (metal) covered ultraflex sent
CharacteristicsDumon stentCovered ultraflex stent
  1. −, poor; +, fair; ++, good; +++, best.

  2. FB, flexible bronchoscope.

Mechanical considerations  
 High internal to external diameter ratio+++
 Resistant to recompression when deployed+++
 Radial force exerted uniformly across stent+++
 Absence of migration++
 Flexible for use in tortuous airways+++
 Dynamic expansion++
 Can be customized+++
Tissue-stent interaction  
 Biologically inert++++
 Devoid of granulation tissue+
 Tumour in growth+++
Ease of use  
 Can be deployed with FB+++
 Deployed under local anaesthesia with conscious sedation++
 Radiopaque for position evaluation+++
 Can be easily repositioned++
Complications associated with airway stent and management

Tube stents are indicated for benign and malignant lesions.95,96 The main advantage of a tube stent is the ease with which it can be repositioned and removed, but requires rigid bronchoscopy for insertion. Other disadvantages include migration, granuloma formation, mucus obstruction and lack of flexibility in conforming to airway tortuosity.95,96

Metallic stents on the other hand can be carried out with flexible bronchoscopy, at an outpatient setting, and with the patient under local anaesthesia.97,98 Advantages are ease of placement, greater airway cross-sectional diameter, better conformity to tortuous airways, maintenance of mucociliary clearance and ventilation across a lobar bronchial orifice. However, disadvantages include granuloma formation and difficulty in removal and repositioning after 6 weeks due to stent epithelialization.97,98 Because of the latter, metallic stents are not recommended for benign airway disease.

After stent placement, the patient should be given a stent alert card with details on type of stent, dimensions, location and instructions for intubation if patient develops respiratory distress. Endotracheal tube placement must be carried out via flexible bronchoscopy, and size 6 tube is recommended to avoid stent displacement.

Although Colt and colleagues have shown that regular bronchoscopic surveillance following tube stent placement is unnecessary,99 advice must be given to seek prompt medical attention when dyspnoea develops. Flexible bronchoscopy is recommended as symptoms can arise as a result of mucus plugging that can be resolved with bronchoscopic toilet, obstructing granuloma with APC, electrocautery or laser and stent repositioning with rigid bronchoscopy if it has migrated. Following metal stenting, bronchoscopic surveillance should be carried out every 2–3 months to manage granulation tissue or tumour recurrence with APC76 as migration is uncommon due to stent epithelialization, which in turn makes removal a challenge.100


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Pulmonary alveolar proteinosis is a rare disease. PAP is characterized by defective alveolar macrophages, abnormal surfactant proteins, cytokine imbalance, autoantibody against granulocyte-macrophage colony stimulating factor (GM-CSF) as well as defective expression of GM-CSF or its receptors on alveolar macrophages and type-II pneumocytes.101 Therapeutic whole-lung lavage (either one lung or sequential two lung lavages per anaesthesia session) is considered the most effective treatment for PAP as it not only mechanically removes the lipoproteinaceous material, anti-GM-CSF antibody, but has immunological effects on alveolar macrophages and type-II pneumocytes.102 However, the technique requires general anaesthesia and an experienced anaesthesiologist competent in placing double-lumen ETT. Hypoxemia and haemodynamic instability can occur during whole-lung lavage.103

Segmental or lobar lavage is reported as a therapeutic alternative, but requires special equipment, such as cuffed bronchoscopic catheter with fluoroscopy104 or modified bronchoscope with inflated tracheostomy cuff105 and trypsin as lavage fluid.106 Chen et al. described a novel approach of multiple lobar lavages using the FB, local anaesthesia and normal saline. In the report, lavage was carried out with local anaesthesia (xylocaine 2%), and no parenteral sedation or anaesthesia. Warm saline, in aliquots of 50 mL, was instilled into the bronchus corresponding to the most severely affected lobe observed on high-resolution computed tomography. Lobar lavages were repeated every 2–3 days and good clinical, physiological and radiological response was demonstrated in patients with less advanced disease.107

Massive haemoptysis or haemorrhage

Massive haemoptysis, defined as the volume of expectorated blood that is life-threatening due to hypoxia from airway obstruction or haemodynamic instability from blood loss, accounts for only 4.8–14% of all patients with haemoptysis.108 Although issues such as optimal timing of bronchoscopy and preferred instrument (rigid or FB) in the initial assessment remain controversial,109,110 our practice is early bronchoscopy with FB as it allows better localization of site of haemorrhage as well as institution-specific protocols to arrest bleeding which include endoscopic modalities, bronchial arterial embolization and surgery.

Technique for bronchoscopic therapy

Topical application of ice-saline lavage or epinephrine (1 : 20 000) via FB is effective in achieving control of haemorrhage.111 Endobronchial tamponade can be carried out by wedging the tip of FB into the bleeding segment, followed by inflation of balloon catheter (4–7 French), which is introduced through the working channel. FB is removed over the catheter and the balloon is left inflated in the bronchus for 24 h. FB is carried out the next day and if no further bleeding is observed after deflation of balloon, the catheter is removed. Although no complications have been reported with this technique, extended use of balloon tamponade catheters might result in mucosal ischemic injury and post-obstructive pneumonia.112,113

Modifications of this technique have also been described. The first involves the placement of an angiographic J-guide wire into the affected bronchial segment via FB. FB is removed over the wire and reinserted into the opposite nostril, thereby allowing better suctioning of blood and visualization of the bleeding site. An appropriate balloon catheter is then inserted over the guide wire into the bleeding segment under direct vision.113 The other modification is the use a double lumen bronchus blocking catheter which has an inner channel for instillation of cold saline, epinephrine and thrombin/thrombin-fibrinogen solutions, an inflatable balloon at the tip and detachable valve. This catheter can be introduced via the working channel of FB and wedged in the bleeding segment for several days without complications, while the patient receives definitive therapy.114,115 Other therapeutic modalities shown to be beneficial in the control of haemorrhagic endobronchial lesions include Nd-YAG laser, EBES and APC.116


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We have provided a concise review of the complications that can occur with diagnostic and therapeutic bronchoscopic techniques as well as management and prevention strategies. With advancing technology aimed at improving diagnostic accuracy and innovative methods that seemingly allow unlimited access to the thoracic cavity, bronchoscopists should continue to push the envelope and yet be cognizant of the complications that might arise as a result of these novel techniques. Rigorous efforts must be maintained to assure that standards in the delivery of care are by no means compromised.


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