There was a time when the only type of bronchoscope available was a rigid bronchoscope. The first “bronchoscope” that was inserted into the lower airways was an esophagoscope, and Gustav Killian in Germany used it in 1897. In the United States, bronchoscopy was begun in 1898 with a urethroscope that was adapted for use in the airways. Chevalier Jackson became the American father of bronchoscopy by virtue of his work that began in 1899, and by 1912 bronchoscopy with rigid instruments was an accepted practice for the removal of foreign bodies from the airway. Jackson developed many different rigid bronchoscopes and retrieval instruments, and as time went on, new indications for rigid bronchoscopes included infectious diseases such as tuberculosis and pneumonia. Foreign body retrieval and dilation of strictures (often the result of diphtheria) continued to be primary indications. A few physicians who were truly experts in bronchoscopy practiced rigid bronchoscopy. Most bronchoscopists were otolaryngologists or thoracic surgeons. Lung cancer was not a common disease until 20 years after cigarette smoking became epidemic in the middle of the 1900s, heralding a change in the indications for bronchoscopy. As recently as the 1960s, it was stated that the best specimen to diagnose lung cancer was a coughed sputum sample that was collected after performing rigid bronchoscopy. Obviously, this is no longer the case with flexible bronchoscopes, in which the peripheral reach of the flexible bronchoscope allows retrieval of specimens that provide a diagnosis in most patients with lung cancer.
Pulmonary medicine as a subspecialty came about because of the occupational risk to internists and family physicians who cared for patients with tuberculosis. Such physicians, spending months or years in tuberculosis sanitaria, would often develop added interest in diseases of the lungs. Bronchoscopes were used to manage some of the complications of pulmonary tuberculosis such as strictures and suppuration or ulceration of the mucosa. The coincidence of antituberculous drug development and the rising prevalence of lung cancer in the 1950s and 1960s served to create a unique opportunity for the use of bronchoscopes.
Dr. Shigeto Ikeda's interest in the early diagnosis of lung cancer led him to develop and introduce a flexible bronchoscope in 1967. Pulmonary physicians quickly adopted this new instrument into their practices; some surgeons complained that they let this operation “get away from them.” Skills in using rigid bronchoscopes quickly began to decline. There seemed to be little need to learn how to use a rigid bronchoscope when flexible bronchoscopes became an integral part of nearly every pulmonary physician's skills. Moreover, almost all things for which a bronchoscope was needed could be accomplished with a flexible bronchoscope. Pulmonary physicians did not mind allowing otolaryngologists and thoracic surgeons to perform rigid bronchoscopy on those few patients who needed rigid bronchoscopy.
This seemed to be a fine arrangement. However, there were problems with the phenomenon caused by new technology and the natural forces just described. For one, most thoracic surgeons became cardiothoracic surgeons (with an emphasis on the cardiac component), and not many of them continued to have large-volume bronchoscopy practices. Most otolaryngologists continued to have reasonable skills in using rigid bronchoscopes, but the indications and frequency of performing rigid bronchoscopy waned.
Training younger physicians how to use a rigid bronchoscope became much more difficult, simply because so few people needed their bronchoscopy to be done with a rigid bronchoscope. Like any technical skill, repetition is needed to become more facile in doing rigid bronchoscopy. Not many pulmonary physicians cared to learn about how to perform rigid bronchoscopy, and the number of cases that were done by otolaryngologists and cardiac (or cardiothoracic) surgeons became fewer. Furthermore, the one-on-one tutelage that is required for rigid bronchoscopy is much more intense than is true in learning how to perform flexible bronchoscopy. As might be expected, the potential for complications when performing rigid bronchoscopy was almost assuredly going to rise.
In the late 1970s and early 1980s, European physicians introduced laser technology, followed by the development of stents, and a new “discipline” of interventional bronchoscopy was born. In Europe, it is not uncommon for bronchoscopy to be practiced by a select few pulmonary physicians (or otolaryngology or thoracic surgery physicians) and with more than 4000 bronchoscopy procedures per year. Rigid bronchoscopy is typically a skill that is part of European bronchoscopy practices. In the United States, almost all pulmonary physicians perform flexible bronchoscopy, but the volume of bronchoscopy procedures per practicing bronchoscopist is far fewer than in a comparable European bronchoscopy physician's practice. Bronchoscopy in the United States is merely one part of a practice that also includes much time spent in the intensive-care unit or with an office practice. Pulmonary physicians began to do some interventional (ie, laser) bronchoscopy with flexible bronchoscopes in the United States, but it quickly became apparent to most interventional bronchoscopists that this type of procedure could be done faster and more efficiently with a rigid bronchoscope. There was a new demand to learn how to use rigid bronchoscopes efficiently and safely.
In this issue of the Journal of Bronchology, Drummond and her colleagues describe an 8-year consecutive case series of 775 rigid bronchoscopies at one university hospital. Using stringent criteria, these authors report that 13.4% of patients experienced a complication of the procedure, noting that the great majority of complications were mild. Risk stratification was done as part of the analysis, and patients with abnormal lung function or baseline hypoxemia, those with known cardiac disease, and those with abnormal prothrombin times or thrombocytopenia were more likely to experience complications than patients who did not have these comorbid disorders. Severe preoperative risk (PaO2 <55 mm Hg, FEV1 <50% predicted; unstable angina or cardiac failure, a severe arrhythmia, or myocardial infarction <6 months; and thrombocytopenia <50 × 109 or abnormal prothrombin time) was associated with a 37% likelihood of a complication at the time of rigid bronchoscopy. The group of patients most likely to experience a complication of rigid bronchoscopy were those who had neoplasms that involved the main carina of the trachea and who underwent palliative resection of their tumor in an attempt to relieve airway obstruction. There were only 3 deaths (0.4%) in this series; 2 patients died of hemorrhage and another from respiratory failure.
We have not systematically analyzed the incidence of complications while performing rigid bronchoscopy at our institution. If we were to do so, using the same stringent criteria in this report, I suspect our complication rate might be about the same. Deaths at the time of bronchoscopy seem to etch themselves into the operator's memory bank; I can only recall 3 deaths in our series over the last 21 years of performing interventional bronchoscopy in approximately 2000 procedures. Like the current series, 2 were from massive bleeding in patients with advanced neoplasms and another was from an intraoperative myocardial infarct with a cardiac arrhythmia. Two of these deaths (one from bleeding, the other cardiac) occurred at a time before we had made the decision to perform interventional bronchoscopy with rigid bronchoscopes.
Some bleeding is expected when a palliative resection of a tumor is done through a bronchoscope. Although we always estimate the volume of blood loss, I do not normally consider bleeding <100 mL to be a complication of the procedure. It is just a phenomenon that happens when performing tumor resections, much of which is done by coring out the tumor with the rigid bronchoscope or with forceps in piecemeal fashion. A laser, electrocautery, or argon plasma coagulator device is simply an adjunct to help manage the bleeding that is expected with these procedures. When bleeding occurs with palliative resection of an airway tumor, it is much easier to manage efficiently with a rigid bronchoscope than with a flexible bronchoscope.
Respiratory depression for a short time after rigid bronchoscopy was seen in 5.3% of the patients in the series reported by Drummond and her colleagues. Interventional procedures can be lengthy, particularly in a university setting where residents and fellows are learning how to perform these complex procedures. Reversing a general anesthetic (and muscle paralysis, which we routinely use) could occasionally take more than 30 minutes. This is especially true when underlying intrinsic lung diseases like emphysema are commonplace, as is usually the case for patients who undergo resections of malignant neoplasms by way of rigid bronchoscopy. Again, I hardly consider this to be a complication, so the frequency of complications that are reported in this series by Drummond and her colleagues seems quite reasonable.
Complications of rigid bronchoscopy were less frequent for patients who underwent foreign body removal and for those with benign diseases like stenosis. Generally, such patients do not have as many comorbid disorders and would be expected to have fewer complications, much as was the case in this report. Other authors have reported success in removing foreign bodies with flexible bronchoscopes, even in pediatric populations. However, most practicing flexible bronchoscopists have only occasional chances to attempt removing foreign bodies. The time spent attempting such foreign body removal with a flexible bronchoscope might be as long as 2 hours or more. In contrast, removing a foreign body with a rigid bronchoscope rarely takes more than a few minutes in the hands of a well-trained and highly experienced rigid bronchoscopist.
There are some complications of bronchoscopy that are relatively unique to the use of a rigid bronchoscope. Breaking or dislodging teeth, lacerating the mucosa of the upper aerodigestive tract, and lacerating the wall of a bronchus are not likely to occur with a flexible bronchoscope. Even with an experienced rigid bronchoscopist, such complications do occasionally occur. Despite bleeding up to 100 mL, and despite some delays in reversing general anesthesia, almost all of our interventional (rigid) bronchoscopies are done on an ambulatory basis without the need to hospitalize our patients.
These and other complications of rigid bronchoscopy are less likely when the early phase of the “learning curve” phenomenon has been passed. I am pleased that university programs exist that can report a 13.4% complication rate of rigid bronchoscopy, because that is the only way we can preserve this valuable practice and train the rigid bronchoscopists of the future.