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Fiberoptic and Rigid Bronchoscopy: The State of the Art

1974; Elsevier BV; Volume: 65; Issue: 6 Linguagem: Inglês

10.1378/chest.65.6.605

1931-3543

Donald C. Zavala, Mitchell L. Rhodes, Robert H. Richardson, George N. Bedell,

Lung Cancer Diagnosis and Treatment

The editorial in the August 1973 issue of Chest, by Tucker, Olsen, Andrews, and Pool, has prompted this communication. These authors gave indications for use of the flexible bronchofiberscope and the conventional rigid instrument. Selection should not be a question of one method against the other but of a solid knowledge of the uses and limitations of each instrument.There is no argument that bronchoscopy by rigid or fiberoptic instruments should be done only by qualified, well trained physicians who are able to maintain their expertise by frequent practice. The bronchoscopist, aided by appropriately instructed personnel, should perform his art in well-equipped surroundings such as an intensive care unit or a hospital biopsy room where resuscitation and fluoroscopic facilities are available. A poorly performed bronchoscopy without adequate safeguards may not only do great physical harm to the patient, but also subtle or more obvious lesions may be missed and the patient given false reassurance that “everything is all right.” These foregoing statements apply to both the rigid and fiberoptic bronchoscopes.Because of inability to control the airway, we cannot support the technique of transnasal insertion without an endotracheal tube.1Smiddy J Ruth WE Kerby GR et al.Flexible fiberoptic bronchoscope.Ann Intern Med. 1971; 75: 971Crossref PubMed Scopus (30) Google Scholar The obvious advantage of passing the fiberscope through a previously inserted endotracheal tube is that an airway is established for resuscitation if needed. In addition, the instrument may be rapidly withdrawn and reinserted with ease for multiple biopsies or clearing of the distal lens. The methods of tube insertion are many and varied, although we prefer the oral route using the technique described by us or passing the tube over the shaft of the preinserted fiberscope.2Zavala DC Richardson RH Mukerjee PK et al.Use of the bronchofiberscope for bronchial brush biopsy.Chest. 1973; 63: 889Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 3Richardson RH, Zavala DC, Mukerjee PK, et al: The use of fiberoptic bronchoscopy and bronchial brush biopsy in the diagnosis of suspected pulmonary malignancy. Am Rev Resp Dis (in press)Google Scholar Laryngeal trauma or post-bronchoscopy laryngospasm has not been encountered.Fiberoptic bronchoscopy is the preferred initial approach in diagnosing a lung density. With few exceptions and when properly used, the fiberoptic instrument is superior to a rigid scope because of increased visual and biopsy range, with minimal discomfort and negligible risk to the patient. The implication that central lesions in major airways can be adequately visualized and biopsied through a modern, rigid bronschoscope and not with a flexible fiberscope is false. The amount of time taken to bronchoscope with either instrument is relative. With practice, the operator of the flexible bronchoscope can become extremely fast in routine examination of the tracheobronchial tree including all segments (B1 through B10) and subsegments, although biopsy of peripheral lesions under fluoroscopic control does require more time. In addition to its major role in diagnosis, fiberoptic bronchoscopy has many therapeutic applications, especially for use in patients on mechanical ventilation. The flexible shaft of the fiberscope also is ideally suited for patients with cervical or cranial pathology where insertion of a rigid tube would be ill-advised. The larynx may be examined with either instrument, but inspection of the nasopharynx can be performed only with the flexible scope.The rigid bronchoscope is an excellent instrument for removal of a foreign body or broncholith, pediatric bronchoscopy, transbronchoscopic lung biopsy, aspiration of massive hemorrhage or retained thick secretions, and for use in patients whose tracheal diameter is significantly decreased by scarring, external compression or intra-luminal tumor. If the trachea is small, such as normally occurs in a child or abnormally occurs in an adult with tracheal pathology, insertion of a hollow, rigid instrument will insure an adequate airway whereas passage of a fiberscope will further occlude the airway.Mild or moderate hemoptysis does not preclude fiberoptic bronchoscopy as a valuable primary technique to determine the cause of bleeding. The newer models of Olympus, Machida or ACMI fiberscopes which have larger suction channels of approximately 2 mm in diameter, have proved to be super sleuths in tracking down the source of bleeding. Three of our patients with hemoptysis and normal chest x-ray films had small bronchogenic carcinomas located in segmental bronchi, visible through the flexible fiberoptic instrument but not the rigid bronchoscope. Brush biopsy through the channel of the bronchofiberscope confirmed the diagnosis of malignancy prior to surgery.For control of brisk lung hemorrhage by application of epinephrine and packing, the ventilating scope is mandatory. Also, at the present time, it is best to employ the rigid bronchoscope to remove foreign bodies. Nevertheless, new instruments are being developed now which look promising for extraction of a variety of foreign bodies from the tracheobronchial tree with the fiberoptic scope.The controversy keeps surfacing whether or not one should learn fiberoptic bronchoscopy without being trained in open tube bronchoscopy. The reasoning is that only then can the bronchoscopist be “a man for all seasons.” Such a position is theoretically sound but not necessary in practice. Our diagnostic chest unit has performed approximately 1000 fiberoptic bronchoscopies, and in only three instances was it necessary to terminate the procedure and insert a rigid tube. Specifically, these instances were as follows: (1) excessive hemorrhage, (2) marked bronchorrhea with tenaceous, thick purulent material, and (3) a large tracheal tumor. In each case there was no danger to the patient because of a short delay in performing rigid bronchoscopy. The editorial in the August 1973 issue of Chest, by Tucker, Olsen, Andrews, and Pool, has prompted this communication. These authors gave indications for use of the flexible bronchofiberscope and the conventional rigid instrument. Selection should not be a question of one method against the other but of a solid knowledge of the uses and limitations of each instrument. There is no argument that bronchoscopy by rigid or fiberoptic instruments should be done only by qualified, well trained physicians who are able to maintain their expertise by frequent practice. The bronchoscopist, aided by appropriately instructed personnel, should perform his art in well-equipped surroundings such as an intensive care unit or a hospital biopsy room where resuscitation and fluoroscopic facilities are available. A poorly performed bronchoscopy without adequate safeguards may not only do great physical harm to the patient, but also subtle or more obvious lesions may be missed and the patient given false reassurance that “everything is all right.” These foregoing statements apply to both the rigid and fiberoptic bronchoscopes. Because of inability to control the airway, we cannot support the technique of transnasal insertion without an endotracheal tube.1Smiddy J Ruth WE Kerby GR et al.Flexible fiberoptic bronchoscope.Ann Intern Med. 1971; 75: 971Crossref PubMed Scopus (30) Google Scholar The obvious advantage of passing the fiberscope through a previously inserted endotracheal tube is that an airway is established for resuscitation if needed. In addition, the instrument may be rapidly withdrawn and reinserted with ease for multiple biopsies or clearing of the distal lens. The methods of tube insertion are many and varied, although we prefer the oral route using the technique described by us or passing the tube over the shaft of the preinserted fiberscope.2Zavala DC Richardson RH Mukerjee PK et al.Use of the bronchofiberscope for bronchial brush biopsy.Chest. 1973; 63: 889Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 3Richardson RH, Zavala DC, Mukerjee PK, et al: The use of fiberoptic bronchoscopy and bronchial brush biopsy in the diagnosis of suspected pulmonary malignancy. Am Rev Resp Dis (in press)Google Scholar Laryngeal trauma or post-bronchoscopy laryngospasm has not been encountered. Fiberoptic bronchoscopy is the preferred initial approach in diagnosing a lung density. With few exceptions and when properly used, the fiberoptic instrument is superior to a rigid scope because of increased visual and biopsy range, with minimal discomfort and negligible risk to the patient. The implication that central lesions in major airways can be adequately visualized and biopsied through a modern, rigid bronschoscope and not with a flexible fiberscope is false. The amount of time taken to bronchoscope with either instrument is relative. With practice, the operator of the flexible bronchoscope can become extremely fast in routine examination of the tracheobronchial tree including all segments (B1 through B10) and subsegments, although biopsy of peripheral lesions under fluoroscopic control does require more time. In addition to its major role in diagnosis, fiberoptic bronchoscopy has many therapeutic applications, especially for use in patients on mechanical ventilation. The flexible shaft of the fiberscope also is ideally suited for patients with cervical or cranial pathology where insertion of a rigid tube would be ill-advised. The larynx may be examined with either instrument, but inspection of the nasopharynx can be performed only with the flexible scope. The rigid bronchoscope is an excellent instrument for removal of a foreign body or broncholith, pediatric bronchoscopy, transbronchoscopic lung biopsy, aspiration of massive hemorrhage or retained thick secretions, and for use in patients whose tracheal diameter is significantly decreased by scarring, external compression or intra-luminal tumor. If the trachea is small, such as normally occurs in a child or abnormally occurs in an adult with tracheal pathology, insertion of a hollow, rigid instrument will insure an adequate airway whereas passage of a fiberscope will further occlude the airway. Mild or moderate hemoptysis does not preclude fiberoptic bronchoscopy as a valuable primary technique to determine the cause of bleeding. The newer models of Olympus, Machida or ACMI fiberscopes which have larger suction channels of approximately 2 mm in diameter, have proved to be super sleuths in tracking down the source of bleeding. Three of our patients with hemoptysis and normal chest x-ray films had small bronchogenic carcinomas located in segmental bronchi, visible through the flexible fiberoptic instrument but not the rigid bronchoscope. Brush biopsy through the channel of the bronchofiberscope confirmed the diagnosis of malignancy prior to surgery. For control of brisk lung hemorrhage by application of epinephrine and packing, the ventilating scope is mandatory. Also, at the present time, it is best to employ the rigid bronchoscope to remove foreign bodies. Nevertheless, new instruments are being developed now which look promising for extraction of a variety of foreign bodies from the tracheobronchial tree with the fiberoptic scope. The controversy keeps surfacing whether or not one should learn fiberoptic bronchoscopy without being trained in open tube bronchoscopy. The reasoning is that only then can the bronchoscopist be “a man for all seasons.” Such a position is theoretically sound but not necessary in practice. Our diagnostic chest unit has performed approximately 1000 fiberoptic bronchoscopies, and in only three instances was it necessary to terminate the procedure and insert a rigid tube. Specifically, these instances were as follows: (1) excessive hemorrhage, (2) marked bronchorrhea with tenaceous, thick purulent material, and (3) a large tracheal tumor. In each case there was no danger to the patient because of a short delay in performing rigid bronchoscopy.