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Selective Bronchography

Childs, Carter J. H. MD; Kurshid, Imtiaz MD; Downie, Gordon H. MD, PhD

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From the Section of Pulmonary and Critical Care Medicine, The Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA (Drs. Childs, Kurshid, and Downie).

Reprints: Gordon H. Downie, MD, PhD, Pulmonary and Critical Care Medicine, 3E-149 Brody, The Brody School of Medicine at East Carolina University, 600 Moye Blvd., Greenville, NC 27858-4354, USA. (e-mail: downieg@mail.ecu.edu).

Bronchography is a relatively safe diagnostic procedure initially used for the evaluation of tracheobronchial tree anatomy and has been a useful tool in evaluating structural lung abnormality. However, the widespread use of computerized tomography (CT) scanning has substantially reduced the use of bronchography. Another factor for a decline in the use of bronchography was the advent of flexible fiberoptic bronchoscopy. The increasing use of interventional pulmonary procedures has rekindled the interest in using bronchography as a diagnostic adjuvant. 1,2 In past years, bronchography was routinely performed by a radiologist or by a team of radiologists with or without the input of a pulmonologist. Bronchography or selective bronchography now can be easily performed by a pulmonologist in a well-equipped bronchoscopy suite. Given the relatively unfamiliarity of many pulmonologists with the historical development of the technique, we review and discuss this procedure in detail, including its role in the evaluation of neoplastic obstruction with or without postobstructive atelectasis.

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HISTORICAL BACKGROUND

Jackson gave the earliest description of bronchography in 1918; since then, the technique has changed dramatically, which has simplified and made it more tolerable to patients. 3 Bronchography had been extensively used for the diagnosis of bronchiectasis, chronic bronchitis, bronchial tree anomalies, and bronchogenic carcinoma until Ikeda introduced flexible fiberoptic bronchoscopy as an alternative diagnostic technique. 4 Bronchography was still used as an adjunctive diagnostic tool for demonstrating lesions in the peripheral airway, which were not accessible through flexible bronchoscopy. Fennessy reported bronchography in 5 patients by bronchoscopic placement of a catheter over an angiographic guidewire for contrast injection under fluoroscopy; this was an important advancement in the technique of bronchography and the first reported selective variant of the procedure. 5 Several other authors have described the method of selective bronchography combined with bronchoscopy with minor procedural modifications. 6–13 Morcos et al. reported the use of a water-soluble contrast dye (Iotrolan Schering) in 20 patients with minimal side effects and excellent radiographic resolution, making water-soluble dyes the contrast of choice for this procedure. 14

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INDICATIONS

Traditionally, bronchography has been used in the evaluation of hemoptysis, suspected bronchiectasis, chronic bronchitis, broncho-occlusive disease, foreign body aspiration, bronchial fistulas, and airway neoplasm. Presently, other diagnostic modalities like bronchoscopy, CT scan, and magnetic resonance imaging (MRI) have largely replaced the need for bronchography. With the increasing use of pulmonary interventional techniques such as Nd-YAG laser, electrocautery, brachytherapy, cryotherapy, photodynamic therapy, balloon dilatation, and stent placement for occluded tracheobronchial airway, bronchography has reemerged as a method that can provide important information regarding airway status distal to the obstruction. 1,2 Recently, we published our experience using selective bronchography for the prediction of reversal of postobstructive atelectasis. 2 Combined bronchoscopy and selective bronchography can be performed in a single setting by an interventional pulmonologist before an interventional procedure or in a separate setting by a noninterventional pulmonologist at the time of initial bronchoscopy with fluoroscopic pictures for review.

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CONTRAINDICATIONS

History of sensitivity to contrast medium is the most obvious contraindication to the procedure. Allergic reaction to the non-iodinate contrast medium is uncommon compared with iodine-containing contrast agents. Otherwise, contraindications to this procedure are similar to those for standard flexible bronchoscopy. 15

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PREPROCEDURE EVALUATION

Preoperative evaluation is similar as that for standard flexible bronchoscopy. Chest radiograph and CT scan are useful in localizing the area of active pathology for the selective bronchogram. Attempts to examine all old radiographs or CT scans and obtain an extensive history should be made to better pinpoint changes in lung pathophysiology, including onset of atelectasis.

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EQUIPMENT

We use a standard flexible bronchoscope with a 2.2-mm working channel (Olympus BF-P30; Olympus America, Melville, NY). A therapeutic bronchoscope with a larger working channel, ie, 2.8 mm (Olympus BF-1T40, Olympus America), is optional but is beneficial only if additional interventional procedures like balloon dilatation, cryotherapy, and so on, will be done at the same setting. The guidewire we use is a soft tip Jagwire with a diameter of 0.89 mm and a length of 260 cm (Boston Scientific Corp., Watertown, MA). A multipurpose angiographic catheter (Olympus America) is used for contrast injection; in procedures using balloon dilatation, a balloon catheter, diameter 8 to 14 French, can be used instead (Boston Scientific Corp.). Equipment with similar specifications from other manufacturers can be used. Fluoroscopy and contrast media is needed for the procedure. We use a water-soluble contrast material, iohexol (Omnipaque, Amersham Health, Princeton, NJ), diluted equally with normal saline for contrast injection.

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TECHNIQUE

A conscious sedation protocol for monitoring the patient before, during, and after the procedure is followed. Blood pressure, pulse oximetry, and cardiac rhythm are monitored, and an adequate intravenous line is maintained. Supplemental oxygen is administered as needed (usually 2–5 L/min) to maintain adequate oxygen saturation. Conscious sedation is achieved with an intravenous narcotic agent combined with a benzodiazepine. Additional sedation can be used as needed. Nasal and oral airway mucosal surfaces are well anesthetized with a topical anesthetic agent, usually a lidocaine preparation. Airway anesthesia is achieved by transcricothyroid injection of 1% lidocaine, unless there is a contraindication to this injection in which case airway anesthesia is achieved by instilling lidocaine through the bronchoscope.

After proper patient preparation, initially flexible bronchoscopy is performed in a standard manner with an extensive airway inspection. In the majority of our cases, the airway distal to the lesion could not be directly visualized with even our pediatric bronchoscopes without procedure-limiting bleeding or mucosa injury. After localizing the target bronchial airway, a guidewire is passed through the working channel of the bronchoscope under fluoroscopic guidance. The guidewire's gildex tip should extend well beyond the distal end of bronchoscope and the obstructing lesion into the peripheral airway, but not so far that it curls or extends to the pleura. The wire with the gildex tip is used as a precaution against distal airway perforation. Next, a multipurpose angiographic catheter is passed through the bronchoscope and over the guidewire to the desired location, which can be confirmed by injecting 1 mL of diluted contrast medium through the angiographic catheter. Once the position of the angiographic catheter is ascertained, the guidewire is removed, leaving the catheter in place. Then, while performing fluoroscopy, 5 to 10 mL of diluted contrast medium is injected through the catheter in a steady manner and the bronchogram is obtained (Fig. 1). After visualization of the bronchogram under real-time fluoroscopy, the contrast medium is suctioned either through the catheter or suction channel of the bronchoscope. In over 200 cases of selective studies, our patients have not experienced local contrast reactions of inflammation, cough, or adherent contrast residuals. Performing selective bronchography in the hand of an experienced operator adds approximately 10 to 15 minutes to the total procedure time. Most of the hardware is used independent of the bronchography; only the cost of contrast and the procedure code for bronchography provide additional expense to the patient.

FIGURE 1.

FIGURE 1.

In cases in which bronchography and balloon dilatation are to be performed in the same setting, a balloon dilatation catheter is positioned in the same manner as described previously in place of the angiographic catheter. As a result of the larger size of the balloon catheter, a bronchoscope with an appropriately sized working channel is needed. The diluted contrast material is injected through the distal port of the balloon catheter. Afterward, bronchial airway dilation is performed in the usual fashion. 16 In cases in which the airway is much larger than the collapsed balloon, the balloon can be inflated to the point that it occludes the airway before performing the bronchogram.

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COMPLICATIONS

This procedure inherits the complications associated with flexible bronchoscopy. 15 Complications associated with bronchography, other than discomfort, are quite rare. Allergic reaction to contrast medium is a possibility, like in any other radiographic procedure requiring contrast medium injection. Febrile reaction, pneumonitis, and pneumothorax have been reported in the literature. 11,17 Asphyxia and hypoxia tend to occur in patients with limited lung reserve, but the probability of this occurring with selective bronchography is less than that seen with a complete bronchogram. An acute asthmatic episode can be precipitated by bronchography. Granulomatous changes have been reported in resected lung after bronchography. 17 Occasional occurrence of parotitis has been seen after iodinated contrast medium use and is almost certainly evidence of iodism. 17 There has been a case report of grand mal seizure and transient neurologic deficit resulting from cerebral dye embolism when selective bronchography was combined with transbronchial biopsy. 18

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ADVANTAGES

Selective bronchography boasts several advantages over non-real-time radiographic techniques or the use of whole-lung bronchography. The major advantage with this technique is that it gives the operator a glimpse of the real-time physiology of the airway being studied. Diseased airways can affect lung distal to their pathology by several different mechanisms that might not be elucidated by still radiographic representation. CT scan slices of an airway neoplasm with postobstructive atelectasis usually cannot differentiate between post obstruction mucous impaction, plain airway collapse, and neoplastic destruction of the airway, whereas selective bronchography under real-time fluoroscopic observation can suggest which of these mechanisms is causing the atelectasis. Bronchographic visualization of an intact poststenotic airway can predict the outcome of subsequent interventional procedures. 2 The interventionist could then plan or abort procedures based on a better understanding of the process. Another major advantage is that selective bronchography can be performed in the same setting as either the initial diagnostic bronchoscopy or the initial therapeutic bronchoscopy. By performing bronchography in the same setting and using the same instruments, time and cost are saved. Patient comfort and safety are also improved by requiring fewer visits to procedural suites, thereby requiring fewer applications of moderate sedation. Using the small lumen catheters under fluoroscopic guidance rather than direct contact of the area with the bronchoscope attenuates the risk of significant trauma with potential bleeding or perforation to the involved airway. Selective bronchography has an added advantage over whole-lung bronchography in patients with limited respiratory reserve by limiting contrast burden and exposure of the contrast to unaffected lung areas.

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DISADVANTAGES

In our experience, the images seen during real-time fluoroscopic bronchographic imaging give more information concerning the airway than the still shots from the fluoroscope; the learning curve to accurately read both the real-time and still images is operator-dependent and can affect use of the procedure. Additionally, interpretation would be problematic if the reading physician is different than the performing bronchoscopist. 2

This procedure requires additional training of physicians and bronchoscopy technicians. Optical fiberglass changes, causing a decrease in light transmission and color changes, have been reported as a result of exposure of flexible bronchoscope to the x-ray radiation. 19 These changes are proportional to the radiation dose. These fiberglass changes can be avoided by minimizing the fluoroscopy use after contrast instillation and by suctioning excessive dye present in the airway. 19

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SUMMARY

Bronchoscopy combined with bronchography is a relatively simple and effective technique, which can provide important information regarding tracheobronchial airways. Although the use of bronchography for traditional indications has largely been replaced by other diagnostic modalities, we feel with the increasing use of interventional pulmonary procedures, there will be a need for selective bronchography. Interventional and noninterventional pulmonologists should be familiar with the technique.

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REFERENCES

1. George PJM, Pearson MC, Edwards D, et al. Bronchography in the assessment of patients with lung collapse for endoscopic laser therapy. Thorax. 1990; 45:503–508.
2. Downie GH, Childs CJ, Landucci DL, et al. The use of selective bronchography in predicting reversal of neoplastic obstructive atelectasis. Chest. 2003; 123:828–834.
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13. Koval JC, Joseph SG, Schaefer PS, et al. Fiberoptic bronchoscopy combined with selective bronchography. Chest. 1984; 91:776–778.
14. Morcos SK, Andersen PB, Baudouin SV, et al. Suitability of and tolerance to Iotrolan 300 in bronchography via fiberoptic bronchoscope. Thorax. 1990; 45:628–629.
15. Golden JA, Wang KP, Keith FM. Bronchoscopy, lung biopsy and other diagnostic procedures. In: Murray JF, Nadel JA (eds). Textbook of Respiratory Medicine, 2nd ed. Philadelphia: Saunders, 1994:711–781.
16. Sheski FD, Mathur PN. Balloon bronchoplasty using the flexible bronchoscope. Journal of Bronchology. 1998; 5:242–246.
17. American College of Chest Physicians. Bronchography; a report of the committee on bronchoesophagology. Chest. 1967; 51:663–668.
18. Oldenburg Jr, FA Newhouse MT. Cerebral dye embolism: a complication of selective bronchography following transbronchial biopsy. Chest. 1978; 73:872–873.
19. Kato H, Suzuki T, Ito A, et al. Changes in optical glass-fibers due to x-ray irradiation. Chest. 1979; 76:672–677.
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