The first rigid bronchoscope was developed by Gustav Killian 1–4 in Europe slightly more than a century ago. This technique was further perfected by Chevalier Jackson 1–3 in the United States, who improved the design, created and improved supporting instruments, and developed procedural and safety protocols that are still in use today. In the late 1960s, Ikeda 1,2 created a flexible bronchoscope that, to a large extent, replaced the rigid bronchoscope for both diagnostic and some therapeutic indications because of its simplicity and ease of use. This technique permitted rapid examination of both central and peripheral airways using only local anesthesia. In view of these changes in the bronchology world, rigid bronchoscopy (RB) had to find its place, and in 1981 1 a moderate but significant increase in the use of this technique was seen as a result of interventional pulmonology development.
Rigid bronchoscopy is preferred by many 1,3,5–10 in the field of interventional bronchoscopy for safety reasons, patient and pulmonologist comfort, speed of action, and savings of time and number of procedures. In fact, the wide channel of the rigid scope allows better control of hemorrhage using more effective suction catheters and the wall of the barrel to tamponade. It also permits deeper biopsy specimens and more efficient debridement. Insertion of prostheses, retrieval of foreign bodies, and dilations can be performed while adequately ventilating the patient. At this time, RB is not a dying art, 1–3 but a technique in its renascent period.
Rigid bronchoscopy is a potentially hazardous technique. 1,2,11 Most experts agree that the number of complications is inversely related to operator experience and technical expertise. 2,12 Despite the fact that the majority of patients undergoing this technique have neoplastic disease, and that palliation is the only aim, we must not run unnecessary risks, and the prevention of complications should always be kept in mind. 11 The aim of this study was to identify the main complications of RB and analyze possible existing risk factors for increased complications.
MATERIALS AND METHODS
We retrospectively reviewed data from 775 RBs performed in our department between 1992 and 1999. We routinely performed a preprocedure risk evaluation in all patients and classified them according to 3 performance factors: respiratory, cardiac, and hematologic (Table 1). The risk associated with RB was considered to increase with a lower performance score.
The procedures were performed with Storz bronchoscopes (Fig. 1) (Karl Storz GmbH & Co., Tuttlingen, Germany), including a Shapshay scope model. All patients underwent general anesthesia. Patients were premedicated with 1 mg/kg prednisone intravenously to diminish allergic reactions and the development of airway edema. Anesthesia induction was performed by administering a 2-mg/kg propofol intravenous bolus. To obtain profound but rapidly recoverable muscle relaxation, the patients received 1 mg/kg succinylcholine intravenously. We used lidocaine spray on the vocal cords to reduce the local vagal response and to also reduce the risk of arrhythmias and hypertension resulting from mucosal absorption. 13 The maintenance of anesthesia status was achieved by administering a propofol perfusion of 12 mg/kg per hour in the first 10 minutes, 9 mg/kg per hour from 10 to 30 minutes, and 6 mg/kg per hour from 30 minutes to the end of the procedure.
Because our own preference is to maintain ventilation by means of a jet ventilator, all patients underwent jet manual ventilation during the procedure. This ventilation technique allows the proximal portion of the scope to be open, permitting easy introduction of several instruments as needed without significantly affecting ventilation. 3
In our department, we prefer to use the classic intubation technique without a laryngoscope and telescope. Once the patient is properly relaxed, the head position is adjusted so that the neck is extended, creating a straight line from the oral cavity through the oropharynx to the vocal cords. The bronchoscope is inserted with direct visualization. During this maneuver, a gauze pad is used for teeth protection. After scope insertion, we introduce a telescope linked to a video monitor and the suction catheter inside the metallic barrel. The laser fiber, stent introducer, and biopsy or grasping forceps are inserted according to the technique we decided to perform. The use of a video monitor allows for training of the technique, discussion with the rest of the team about the decisions made during the procedure, and better documentation of the images. For stent insertion, we use a prosthesis introducer specially designed for Dumon stents. To retrieve foreign bodies from the tracheobronchial tree, only grasping forceps are used because we have good results with this technique.
A pulse oximeter is used during the procedure to provide continuous monitoring of oxyhemoglobin saturation. Continuous electrocardiographic monitoring is also performed, and blood pressure is measured periodically using an electronic blood pressure cuff. The rigid bronchoscope is removed only when effective spontaneous ventilation has been established and preferably when the patient gave clear signs of imminent cough.
Bleeding severity was defined according to the amount of blood loss during the procedure: severe, >200 mL; moderate, between 50 and 200 mL; and mild, >50 mL. Transient respiratory failure was defined as the need for ventilatory manual assistance after the procedure for more than 30 minutes without invasive ventilatory support requirement. All patients had a 3-hour postprocedure observational period before they were discharged or transferred.
Of the 775 patients in the study, 557 (72%) were men and 218 (28%) were women. The median age was 47 years. We observed 2 peaks of incidence: one in children related to the presence of foreign bodies and another in patients between 60 and 75 years related to neoplastic airway involvement (Fig.2).
Because we are a small department, only 262 patients (33.8%) came from pulmonology; 314 (40.5%) came from other departments in our hospital; 122 (15.7%) came from other hospitals, and 77 (10%) were directly admitted from the emergency department.
Data were analyzed using Ξ2 comparison of means (n x 2 tables); P values less than 0.05 were considered statistically significant. A multiple regression model was used to analyze the influence of age, sex, aim of the procedure, initial risk, previous diagnosis, and lesion location on outcome with respect to complications.
Sixty percent of the patients (n = 465) had a basal initial risk for the procedure, established according to the criteria in Table 1. Only 8.6% (n = 67) had severe initial risk for RB. The majority of patients (n = 414, 53.4%) had a previous diagnosis of tumor: 2 patients had laryngeal neoplasm with subglottic involvement; 14 patients had benign tumors, the majority located in the trachea; and 50 patients had metastatic involvement of the lungs secondary to various neoplasms, the most frequent being the esophagus. Tracheobronchial foreign bodies were present in 155 (20%) patients and 84 (10.8%) had tracheobronchial stenosis as a previous diagnosis, of which 56 of them were secondary to tracheal intubation. One hundred twenty-two patients (15.7%) had other diagnoses, the most frequent being tuberculosis, hemoptysis, and fistulae.
Endoscopic findings were classified according to the following criteria: airway tumor, mucosal infiltration, mucosal inflammation, and absence of endoscopic lesions. Airway tumor was visualized in 418 cases (53.9%); 31 patients (4%) presented signs of mucosal infiltration; 120 (15.5%) showed signs of mucosal inflammation; and in 153 cases (19.7%), no endoscopic alterations were found. All of the latter cases corresponded to the presence of foreign bodies. In 53 patients (6.8%), there was no record of the endoscopic findings.
Lesions located in the trachea were seen in 207 patients (26.7%). The right bronchial tree and left bronchial tree were affected in 183 (23.6%) and 156 patients (20.1%), respectively. The most rare location of the lesions was the carina (n = 20, 2.6%). Multiple lesions were seen in 84 cases (10.8%) and 9 patients (1.2%) had diffuse involvement of the tracheobronchial tree. RB was performed in 197 cases (25.4%) for diagnostic purposes. Removal of a foreign body was performed in 155 cases (20%) (Fig. 3). Dilation, laser therapy, and stenting were performed in 422 cases (54.6%) (Figs. 4, 5, and 6); one or more of these procedures were performed in each patient as needed. The majority of patients (n = 672, 86.7%) had no complications related to the technique. Only 51 patients (6.6%) hemorrhaged during the procedure, with 27 being moderate cases and 4 severe cases. Forty-one patients (5.3%) developed transient respiratory failure, but it was easily reversible and seldom life-threatening. Postoperative reintubation in the recovery room was necessary in one patient who was then admitted to an intensive-care unit.
Three deaths occurred (mortality rate, 0.4%); 1 patient died because of respiratory failure and 2 died as a result of severe and uncontrollable hemorrhage during the procedure. Five patients (0.6%) developed severe cough after the procedure. Arrhythmia complicated the procedure in 2 cases (0.3%). There was one case of pneumothorax and one case of a broken tooth during the scope insertion.
In this study, we also analyzed the presence of possible existing risk factors in patients with complications after RB. We found that sex, age (categorized as <1 y, 1-5, 5-15, 15-65, >65), and the aim of the procedure was not associated with complications (Fisher exact test 1.000, 0.259, and 0.770, respectively). The initial risk (basal, moderate, or severe) was associated with the development of complications (P = 0.000). Patients with severe initial risk experienced more problems (Table 2). In addition, previous diagnosis was significantly associated with complications (P = 0.023), with patients having airway tumors or foreign bodies experiencing more complications. Patients who underwent RB to treat stenosis had fewer complications. Patients with carinal involvement were more likely to have complications than any other group (Table 2).
Rigid bronchoscopy is generally used for 2 different applications 1,2,11: for neoplastic patients in whom palliation is the only aim and for patients with benign tracheobronchial pathology, including foreign body presence. If our goal is to avoid unnecessary risks 11 in any situation, we must be particularly careful in the nonneoplastic cases because RB is a potentially hazardous technique 1,2,7,11 and complications can occur. In our study, all deaths occurred in terminal neoplastic patients during laser therapy in which we were trying to obtain airway patency. An overall mortality of 0.4% might be acceptable in these patients with advanced malignant disease and poor respiratory function, and this value was similar or inferior to that found in other series. 5–8,12,14–16,22,26–29 Obviously, the risk for laser therapy was considerable for these patients, but we considered it justified by the lack of alternative treatment. 15,17,23,27,28 We found that the high initial risk, as expected, was related to increased complications and was similar to that in other series. 12 Lesion location was also associated with increased problems, a finding that was also in agreement with other series. 5,6 Carinal involvement was the most problematic location, perhaps because these lesions affect both bronchi. When these lesions bleed, bleeding into both right and left lungs simultaneously will impair ventilation to both lungs. Neoplastic diseases and foreign bodies were related to increased complications. In patients with neoplasms, poor ventilatory and general performance status increases the risk of complications 12 as well as the inherent risk of laser therapy. 8 With respect to foreign bodies, the unexpected and unknown nature of the body and the local mucosal response could explain the incidence of complications. Some fatal cases are described in the literature, 30 and there are series 31 showing a considerable incidence of complications associated with bronchoscopic removal of foreign bodies. Like in other procedures, choosing the appropriate technique and the experience of the bronchoscopist has a crucial role in minimizing complications.
We confirmed that patients with tracheal strictures had fewer complications. This finding is easily understandable in view of the benign nature of the majority of these lesions. Nevertheless, problems occurring during mechanical tracheal or bronchial dilation are not negligible. Posterior tracheal wall laceration and bronchial perforation are the most disturbing ones. 32,33
We had one case of pneumothorax. This case was not related to barotrauma but to laser therapy performed to achieve airway patency in a patient with neoplastic involvement of the distal tracheal third and right main bronchus. After the laser treatment, an attempt to debride the remaining neoplastic tissue using the bronchoscope led to bronchial laceration and iatrogenic pneumothorax that was solved with external drainage and bronchial stent insertion. In our series, there were no cases of barotrauma, which is probably the result of the use of manual jet ventilation instead of high-frequency ventilation. 34
Not only might technical procedures be harmful, but also anesthesia could cause problems. 1,2,12,18,24 The ideal anesthesia for RB should provide rapid induction, minimal hemodynamic instability, satisfactory ventilation, rapid recovery, and minimal complications in the postoperative period. 12,19–21 Propofol is the drug of choice as a result of its rapid onset of action, short half-life, and high body clearance. 12,19,20 Propofol also has inconveniences. The tendency for hemodynamic depression is the most feared. Elderly patients are especially at risk for hemodynamic depression 12,20 and deserve particular attention. Unlike other authors, 12 we did not find age to be a risk factor for complications in this study, but caution regarding this patient group should always be present.
In this study, minor problems related to anesthesia status were found (hypoxemia, arrhythmia). In fact, a comparison made in the early 1990s about complication incidence between patients under local versus general anesthesia for interventional bronchoscopic proceedings favors the latter in view of mortality and morbidity. 14,25
We also had one case of a broken tooth in an elderly patient who lacked many dental pieces. The tooth was recovered in the mouth, avoiding further problems.
Endoscopic treatment of locally advanced tumors of the lung with laser and stents, removal of foreign bodies, and stenosis dilation are therapeutic options that should be available in the armamentarium of institutions with major experience. 5 These procedures can be life-saving and improve the quality of life. Hazards should never be forgotten.
Rigid bronchoscopy is a safe procedure if performed by expert hands, and many physicians have established RB as the procedure of choice in interventional pulmonology. In our series, major complications were rare and the overall mortality rate was 0.4%. The majority (86.7%) of patients did not develop complications related to this technique.
Special attention must be given to patients with severe initial risk for the procedure, neoplastic disease, presence of foreign body, and carinal involvement because these factors were found to be associated with increased complications. This study reinforces the point that RB is a powerful clinical tool that should be used with caution.
1. Beamis JF Jr, Mathur P (eds). Interventional Pulmonology.
New York: McGraw-Hill, 1999:17–28.
2. Fishman A, Elias J, Fishman J, et al. (eds). Fishman's Pulmonary Diseases and Disorders.
New York: McGraw-Hill, 1997:589–602.
3. Turner JF, Ernest A, Becker HD. Rigid bronchoscopy
. Journal of Bronchology. 2000; 7:171–176.
4. Zollner F. Gustav Killian. Father of bronchoscopy. Arch Otolaryngol. 1965; 82:656–659.
5. Cavaliére S, Venuta F, Foccoli P, et al. Endoscopic treatment of malignant airway obstructions in 2008 patients. Chest. 1996; 110:1536–42.
6. Cavaliére S, Foccoli P, Farina PL. Nd-YAG laser bronchoscopy: a five-year experience with 1,396 applications in 1,000 patients. Chest. 1988; 94:15–21.
7. Brutinel WM, Cortese DA, Edell ES, et al. Complications
of Nd-YAG laser therapy. Chest. 1988; 94:902–903.
8. Dumon JF, Shapshay S, Bourcereau J, et al. Principles for safety in application of neodymium-YAG laser in bronchology. Chest. 1984; 86:163–168.
9. Brodsky JB. Anesthetic considerations for bronchoscopic procedures in patients with central-airway obstruction. Journal of Bronchology. 2001; 8:36–43.
10. George PJ, Garrett CP, Nixon C, et al. Laser treatment for tracheobronchial tumours: local or general anaesthesia? Thorax. 1987; 42:656–660.
11. Ramon P, Brichet A. Complications
of interventional bronchoscopy [in French]. Rev Mal Respir. 1999; 16:693–698.
12. Perrin G, Colt HG, Martin C, et al. Safety of interventional rigid bronchoscopy
using intravenous anesthesia and spontaneous assisted ventilation: a prospective study. Chest. 1992; 102:1526–1530.
13. Gold SJ, Duthie JR. Anaesthesia for adult bronchoscopy. Royal Coll Anaesthetists Bull. 2000; 3:110–113.
14. Hetzel MR, Smith SGT. Endoscopic palliation of tracheobronchial malignancies. Thorax. 1991; 46:325–333.
15. Hetzel MR, Nixon C, Edmondstone WM, et al. Laser therapy in 100 tracheobronchial tumours. Thorax. 1985; 40:341–345.
16. Brutinel WM, Cortese DA, McDougall JC, et al. A two-year experience with the neodymium-YAG laser in endobronchial obstruction. Chest. 1987; 91:159–165.
17. Petrou M, Goldstraw P. The management of tracheobronchial obstruction: a review of endoscopic techniques. Eur J Cardiothorac Surg. 1994; 8:436–441.
18. Hanowell LH, Martin WR, Savelle JE, et al. Complications
of general anesthesia for Nd:YAG laser resection of endobronchial tumors. Chest. 1991; 99:72–76.
19. Cockshott ID. Propofol (`Diprivan') pharmacokinetics and metabolism: an overview. Postgrad Med J. 1985; 61(suppl 3):45–50.
20. Milligan KR, Howe JP, O'Toole DP, et al. Outpatient anesthesia: recovery after propofol, methohexital, and thiopental [Abstract]. Anesth Analg. 1987; 66:S118.
21. de Grood PMRM, Ruys AH, van Egmond J, et al. Propofol (`Diprivan') emulsion for total intravenous anaesthesia. Postgrad Med J. 1985; 61(suppl 3):65–69.
22. Cavaliere S, Foccoli P, Tonilelli C. Nd:YAG laser therapy in lung cancer: an 11-year experience with 2,253 applications in 1,585 patients. Journal of Bronchology. 1994; 1:105–111.
23. McDougall JC, Cortese DA. Neodymium YAG laser therapy of malignant airway obstruction: a preliminary report. Mayo Clin Proc. 1983; 58:35–39.
24. Dumon JF, Shapshay SM, Bourcereau J, et al. Principles for safety in application of neodymium-YAG laser in bronchology. Chest. 1984; 86:163–168.
25. Smith SGT, Hetzel MR, George PJM. Morbidity and mortality
associated with endoscopic laser resection for endobronchial lesions. Thorax. 1989; 44:839.
26. Hetzel MR, Millard FJC, Ayesh R, et al. Laser treatment for carcinoma of the bronchus. BMJ. 1983; 286:12–16.
27. Toty L, Personne C, Colchen A, et al. Bronchoscopic management of tracheal lesions using the neodymium yttrium-aluminium garnet laser. Thorax. 1981; 36:175–178.
28. Dumon JF, Reboud E, Garbe L, et al. Treatment of tracheobronchial lesions by laser photoresection. Chest. 1982; 81:278–284.
29. Freitag L, Tekilf E, Eicker R. Four years of palliation with airways stents: results of 263 stent placements in 179 patients [Abstract]. Eur Respir J. 1993; 17:A1548.
30. Brkic F, Delibegovic-Dedic S, Hajdarovic D. Bronchoscopic removal of foreign bodies from children in Bosnia and Herzegovina: experience with 230 patients. Int J Pediatr Otorhinolaryngol. 2001; 60:193–196.
31. Emir H, Tekant G, Besik C, et al. Bronchoscopic removal of tracheobronchial foreign bodies: value of patient history and timing. Pediatr Surg Int. 2001; 17:85–87.
32. Mehta AC, Harris RJ, De Boer GE. Endoscopic management of benign airway stenosis. Clin Chest Med. 1995; 16:401–413.
33. Mehta AC, Lee FY, Cordasco EM, et al. Concentric tracheal and subglottic stenosis: management using the Nd:YAG laser for mucosal sparing followed by gentle dilatation. Chest. 1993; 104:673–677.
34. Williams H, Gothard J. Jet ventilation via a Univent tube for sleeve pneumonectomy. Eur J Anaesthesiol. 2001; 18:407–409.