Improvements in technology and expansion in the pool of experts trained in the use of a technology will not surprisingly lead to growth and spread of its use. It is no different in the case of the flexible bronchoscope. Introduction of instruments of different caliber sizes and innovations in image processing, coupled with advances in simulated bronchoscopic navigation, have expanded the scope of diagnostic and interventional bronchoscopy to encompass broader territories of the lung for investigation, including visiting the lung peripheral that had earlier been felt to be a low-yield and riskier territory.
Therefore, surprisingly, even as the bronchoscopes' portability and optics have improved, less has been written about expanding the bronchoscope's operation beyond the standard bronchoscopy settings in hospital endoscopy units, operating rooms, intensive care units, and outpatient endoscopy centers. The article by Samolski and Duré in the July 2010 issue of the Journal reports on the role of out-of-hospital bronchoscopy in a cohort of patients with chronic medical conditions.1 It shows the practicality and safety of performing flexible bronchoscopy (FB) in a carefully screened population of patients, most of whom are in long-term health care facilities, but a significant percentage (25% of 33) were home hospitalized.1 The indications for this series of out-of-hospital bronchoscopies were limited to the structural and functional assessment of the airways, aspiration of mucus, bronchial sampling through lavage, and tracheostomy tube exchange or adjustment in a population that is 2/3 tracheostomized. The researchers acknowledged the limitations of a pilot study in which the patients and the chosen studies were carefully selected, and a critical reading could suggest that bronchoscopy may not be necessary for many of the cases with tracheostomy when simpler maneuvers, such as tracheal aspirates and blind bronchoalveolar lavage, may suffice. The importance of this report lies, however, in the researchers' cautious consideration of what may be best for the patients (less transportation that by itself carries economic costs and medical risks) and the appropriate use of resources. The researchers should be applauded for their dedication to their patients, as the limitation of the procedures to “simple” bronchoscopies, the emphasis and attention to preprocedural preparation, need to prepare for emergencies and postprocedure recovery, and handling of specimens and equipment with a lean 2-person team means more rather than less work.
The out-of-hospital use of endoscopic instruments for airway assessment and management is nothing new, and the paucity of the literature in this area from the pulmonary community should spark an appreciation of potentials, which are not explored. Otolaryngologists routinely use rigid and flexible laryngoscopes to examine the nasopharynx, posterior, and hypopharynx in the out-patient clinic setting.2 Emergency medical personnel have successfully incorporated the use of simple fiberoptic bronchoscopes in securing the airway.3,4 Observations made using a nondirectable fiberbronchoscope as the sole method of confirming an artificial airway's position altered management in 22% of cases in 1 series.3 In relatively untrained hands of air evacuation transport nurses, a portable bronchoscope (87% accuracy) was slightly less effective than end-tidal CO2, but is better than endotracheal tube misting, and all 3 techniques are complementary in verifying tube placement.4 One major difference between the laryngoscope used in the clinic or in securing an airway is the simpler design and/or its disposable nature; conversely, infection control concerns regarding endoscopes with a working channel adds a significant level of complexity to the maintenance of instruments with strict cleaning guidelines that are challenging enough to attain in a hospital, when these are assigned for use outside a hospital setting.5 This is in fact 1 aspect of the practice of FB outside the hospital that was not addressed by Samolski and Duré.1 Fortunately, the development and refinement of disposable sterile endoscopic sheaths for nasopharyngoscopes and for bronchoscopes may make this issue a moot one.6,7 Although these instruments were designed for in-hospital use in locations where nosocomial infections may be most prevalent, their portability and ease of maintenance can ideally be adapted for out-of-hospital use.
Expanding the availability of bronchoscopy to more remote “off-hospital” sites is another logical extension of the current bronchoscopy practice. The concept of real-time image-guided telemedicine is not new, but initial forays in the 1960s and 1970s into this area were limited by slow data transmission. More recently, real-time teleendoscopy demonstration projects are undertaken to improve nonexperts' endoscopic diagnosis,8 or again to secure the airway in critical situations.9,10 Increasing the worldwide availability of high bandwidth digital communication and simpler devices7 should enable the bronchsopic community to assist our colleagues in remote, less developed countries to improve their diagnosis of pulmonary infections in high HIV-prevalent regions and to enhance educational feedback of airway bronchoscopic diagnosis and interventions.
The terrestrial needs for better and more available bronchoscopic services are great, but there is at least 1 more out-of-hospital frontier to consider: space. Endoscopy in the weightless environment poses unique challenges, but preliminary animal studies have been conducted under zero gravity.11,12 The distances from an advanced hospital setting and limitations in the on-board personnel's skills will require greater support in remote robotic steering and control, but these are technical issues that are being actively pursued for other aspects of endoscopy and should be available for bronchoscopic application in time.13 Musings on pushing the bronchoscopic envelope beyond our current comfort zone into remote undeveloped realms may seem irrelevant to improve our everyday practice or to necessarily help patients who would benefit from these technologies, but it was not so long ago (barely a quarter century) when 1 of our pediatric bronchoscopy pioneers was felt to be diving into the abyss by proposing the usefulness of flexible bronchoscopy in the pediatric airway.14 We should be grounded in the recognition that much preliminary work remains to be completed, including developing the clear guidelines of when and how out-of-hospital bronchoscopies should be performed, and by whom, and checklists to ensure safety and to maximize benefit for the patients. In the meantime, we shall encourage more prospective clinical studies on this practice and look to incorporate technological advances in navigation and feedback to spread the beneficial use of bronchoscopic interventions, in the finite confines and comforts of our hospitals and in less familiar or hospitable environments beyond.
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4. Angelotti T, Weiss EL, Lemmens HJ, et al. Verification of endotracheal tube placement by prehospital providers: is a portable fiberoptic bronchoscope of value? Air Med J. 2006;25:74–78.
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