Bronchoscopy is a test used to look inside the lungs to inspect for any abnormalities and to get samples for analysis.

What is a bronchoscopy?

A thin, flexible tube (bronchoscope) with a light and camera on the end is inserted via the nose or mouth in to the windpipe and then in to the lungs. This allows the doctor to inspect the airways for any abnormalities and take any samples as needed.

Why do we do bronchoscopy?

Bronchoscopy can be done for a number of different reasons. These include:

1) Suspected lung cancer: The inside of the airways can be inspected to look for evidence of a tumour and samples taken where indicated.

2) Lung infections: A bronchoscopy is a good way to get samples to send the the laboratory to look for evidence of infections including suspected tuberculosis.

3) Interstitial lung disease: If you have inflammation within your lungs that is suggestive of interstitial lung disease, your doctor may suggest a bronchoscopy to get samples to send off the the laboratory to see which type of immune cells are causing the inflammation.

What will happen before my procedure?

Prior to the bronchoscopy you will have been seen by a doctor, usually a Respiratory Physician. They will have examined you and asked you to have some blood tests and usually a CT scan of the lungs.

They will usually give you some written information about the procedure. This should be read carefully and will include the following advice:

1) The procedure is usually undertaken using intravenous sedation and hence you should come to the appointment with someone who can take you home afterwards .

2) You should not eat or drink anything midnight the night before the procedure. You can have clear fluids up until 6 hours before the procedure.

3) You should let your doctor know if you take any blood thinning medication. This includes:

Antiplatelets such as aspirin, clopidogrel or ticagrelor.

Anticoagulants such a warfarin and the direct oral anticoagulants (DOACS) which include agents such as dabigatran, rivaroxiban, apixiban, edoxaban and others.

You will usually need to stop these agents for a few days before the procedure and this needs to be discussed with your doctor as they will need to know why you take the medications to assess the safety of stopping them.

You will be asked to sign a consent form prior to the procedure after the doctor has explained what the bronchoscopy entails and any potential risks/ complications (see below for more detail).

Technique for procedure

Anaesthesia and sedation

This procedure is usually undertaken under intravenous conscious sedation. Prior to giving any sedation the team will check your blood pressure, pulse rate and oxygen levels. Sedation is injected through a plastic tube (cannula) in to the vein. Different hospitals use different agents but often a benzodiazepine sedative such as midazolam and an opiate analgesic/ cough suppressant such as fentanyl are used. Your consciousness level, blood pressure and oxygen saturations are monitored during the procedure.

Local anaesthesia (gel to nose, spray to throat and further injections through the bronchoscope in to the airways) is used to improve procedure toleration and reduce coughing during the procedure.

What does the procedure involve?

1) The patient is introduced to all the members of staff in the room and their role is explained.

2) Pre procedure safety checks are undertaken

3) Local anaesthetic gel is applied to the nose (if nasal route is chosen for procedure) and spray to the throat.

4) A mouthguard is inserted if the oral route is chosen to prevent damage to teeth and any biting on the bronchoscope

5) Intravenous sedation is then administered to levels required to maintain safe conscious sedation.

6) The bronchoscope is then inserted via the nose or mouth until the vocal cords can be seen on the screen and anaesthetic is applied via the bronchoscope

7) Further anaesthetic is given as the camera passes through the airways.

8) All of the airways are inspected and any abnormalities noted and can be photographed.

9) The following procedures may be performed during the test as required:

a) Bronchial wash: Small amounts of saline (salty water) are injected in to a particular part of the lung and then sucked back out and captured in a sample pot. This is usually done when looking for infective causes such as bacteria, viruses or TB.

b) Bronchoalveolar lavage (BAL). The bronchoscope is advanced as far as possible in to the segmental airways in the area of lung that is most abnormal on the pre procedure CT scan. The bronchoscope is then 'wedged' so that it occludes the airway so fluid does not escape. Larger volumes of saline (150-200ml) are injected and then the returning fluid is sucked in to sample pots. These are sent for microbiology but also for cytological analysis to understand the type of cells that may be causing lung inflammation. This is often done for patients with interstitial lung disease.

c) Bronchial brushings: A small brush is passed through the bronchoscopy channel. opened once it is visible, and then passed over the airway mucosa or a visible lesion/tumour to collect cells for cytological analysis.

d) Endobronchial biopsy: Small crocodile biopsy forceps are passed through the bronchoscope channel and then opened when seen on the camera. They are then advanced to the area of abnormality and closed when in position. At least 5 samples are usually taken to improve the chances of getting a positive result.

e) Transbronchial biopsy: This is performed less often than endobronchial biopsy but can be used to take a sample of the lung itself through the airways. It is sometimes used in conditions such as sarcoidosis.The biopsy forceps are passed through the airway in to the surrounding lung and samples taken.

Once the procedure is complete, the bronchoscopist will inspect to ensure that any bleeding that has occured has settled and then will remove the scope.

How long does the procedure take?

The procedure usually takes 20-30 minutes, but can take longer in individual cases.

Potential complications:

Bronchoscopy is considered a safe procedure and serious complications from this procedure are very rare. Common and potentially serious complications are listed below:

1) Cough, Sore throat/ hoarse voice: These are very common (>10%) and may last 48-72 hours after the procedure. They occur due to the passing of the bronchoscope through the vocal cords and airways.

2) Low oxygen levels: Due to a combination of sedation, the passage of the bronchoscope through the airways and the instillation of fluids/ performing of procedures, it is common to get low oxygen levels during a bronchoscopy procedure. This is why continuous oxygen saturation monitoring is mandatory during the procedure. Most low oxygen levels are transient and if they persist, respond to the use of supplemental oxygen during the procedure. Significant respiratory failure (ongoing low oxygen levels with adverse effects) occurs in less than 1% (1 in 100) cases. The risk of developing low oxygen levels is higher with underlying lung disease and each individual patient's risk should be discussed with their referring physician.

3) Abnormal heart rhythms or heart attack: Significant heart complications are rare and occur in less than 1% (1 in 100) of cases. Bronchoscopy increases heart rate and blood pressure. This can put patients at risk of arrhythmias or heart attacks, particularly if their oxygen levels are low during the procedure. Bronchoscopy is not usually recommended in anyone with untreated ischaemic heart disease or within 30 days of a heart attack.

4) Fever/ infection. Fever occurs in approximately 10% (1in 10) of patients who undergo a bronchoscopy and occurs at about 8 hours (range 4-24 hours) post procedure. It is more common if the procedure included a bronchoalveolar lavage. It is usually self limiting and does not require antibiotic therapy. If fevers persist at 48 hours or later then it is recommended that medical attention be sought as this may represent post procedure infection. This occurs in less than 1% of cases.

5) Bleeding: Minor bleeding and haemoptysis (coughing of blood) is common after a bronchoscopy, particularly if you have a biopsy procedure. Severe bleeding occurs in less than 0.3% (1 in 3000) occasions. The bleeding risk may be higher if the patient has abnormal blood platelet or clotting levels.

6) Pneumothorax (collapsed lung): This is rare and occurs in only 0.1% (1 in 1000) procedures. If a transbronchial biopsy has been performed, the pneumothorax rate is significantly higher at 1-6%. Sometimes a procedure to drain the air and reinflate the lung is required.

7) Death: This is extremely rare in bronchoscopy and is reported at 0-0.04% risk (less than 1 in 2500 cases).

How long will I stay in hospital?

You will be asked to not eat and drink anything for 2 hours after the procedure as your throat will be numb. You will be allowed to go home once you are alert and your oxygen levels, pulse and blood pressure are within normal limits and you have an accompanying adult to go with you.

What will happen afterwards? Will I need someone to stay with me?

We usually recommend that someone is with you for the first 24 hours afterwards until you are sure the effects of the sedation are warn off.

It is rare to have any significant problems after the procedure and most feel back to normal by the next day.

It is common to have a sore throat and hoarse voice after the procedure for 2-3 days. It is also common to get a fever on the day of the procedure. You will have been advised to take paracetamol and increase your fluid intake. It is also common to cough up a little bit of blood afterwards, especially if you have had a biopsy taken.

You will have been advised by your doctor reasons why you should seek medical assistance after the procedure. These may include:

Coughing up large amounts of blood

Sudden onset of worsening shortness of breath or chest pain

Persistent fevers at 2-3 days post procedure

What follow up will you need?

The doctor who requested your test will have arranged appropriate post procedure follow up with the results.