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“The Black Bronchoscopy”: A Case of Airway Soot Deposition

Ribeiro, Carla MD; Guimarães, Miguel MD; Antunes, Ana MD; Oliveira, Ana MD; Neves, Sofia MD; Almeida, José MD; Moura e Sá, João MD

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Journal of Bronchology & Interventional Pulmonology: July 2013 - Volume 20 - Issue 3 - p 271-273
doi: 10.1097/LBR.0b013e31829add96
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The term “black bronchoscopy” was introduced by Packham et al1 to describe endobronchial metastasis from melanoma and is used to describe the black pigmentation of the airways. It is a rare and usually benign condition that can have many causes such as anthracosis, alkaptonuria, argyrosis, iron overload, amiodarone toxicity, charcoal aspiration, and tracheobronchial melanosis but may appear in malignant conditions such as metastasis from melanoma.2 Soot deposition is not usually described in this group of conditions.

Any burn patient highly suspicious for inhalation injury should undergo an early bronchoscopy for diagnostic, staging, and appropriate treatment.3 If the results are positive, prompt and aggressive measures, including prophylactic mechanical ventilation, could be undertaken. Flexible bronchoscopy is a safe, effective, and economical procedure for the early diagnosis of inhalation injury as it enables the prediction of acute lung injury and improves the patients’ prognosis.3,4 It has been proven to be superior to history or clinical examination for this diagnosis. Recent studies demonstrated that using routine bronchoscopy to evaluate the airways for soot, charring, mucosal necrosis, airway edema, and inflammation led to a 2-fold increase in the diagnosis of inhalational airway injury.5 The bronchoscopy findings have shown to have a positive correlation with mortality and length of mechanical ventilation3 in patients with inhalation injury. Carr et al6 demonstrated that the systematic use of bronchoscopy reduces the duration of mechanical ventilation, intensive care unit (ICU) stay, and overall hospital cost.

Despite major progress in resuscitation and critical care medicine, inhalation airway injury remains the leading cause of fire-related mortality in patients admitted to the ICU.3


The 71-year-old woman presented to the emergency department with hoarseness, blurred vision, and acute dyspnea after smoke inhalation in a domestic fire the same day.

Her history was significant for controlled hypertension, high cholesterol, and atrial fibrillation.

On physical examination, the patient had face and upper body covered with soot, nostril edema, and hoarseness without respiratory distress at admittance.

The chest x-ray was unremarkable. Laryngoscopy revealed severe right arytenoid edema, right vocal cord bleeding, and narrowing of the glottic chinch. The ophthalmological examination revealed corneal burn. She underwent flexible bronchoscopy that revealed right nostril edema and soot plaques and severe edema of the laryngeal structures including the vocal cords and the entire endobronchial tree, up to the level of segmental bronchi, completely covered with soot (Figs. 1, 2). Bronchoscopy helped partial removal of this soot coverage by washing it with normal saline and repeated aspiration, leaving the entire bronchial tree patent but with severe inflammatory changes (Fig. 3).

Full coverage of the trachea with soot.
Soot present beyond the carina to lobar and segmental level.
Partial removal of the soot after saline lavage and aspiration.

Within the first few hours in the emergency room, the patient’s condition worsened and she developed respiratory failure. The patient was admitted to the ICU needing mechanical ventilation. The patient was placed on intravenous corticoid and antimicrobial therapy with broad spectrum coverage.

On day 7 in the ICU with clinical improvement, she underwent a reevaluation with a rigid bronchoscope. She had developed fibrous synechia involving the anterior commissure of the vocal cords with a small granuloma formation; the latter was removed with a biopsy forceps. Purulent secretions and necrotic debris involved both the endobronchial trees. Overall, there was an improvement of the inflammatory process, and there was no evidence of soot fragments (Fig. 4).

Trachea with necrotic debris and mucosal edema, without any evidence of soot.

The patient experienced progressive clinical improvement and was released after 25 days of inpatient treatment, 11 of these in the ICU. At the follow-up visit, the patient complained only of slight hoarseness without any respiratory symptoms.


Early flexible bronchoscopy is essential in a patient exposed to fire with suspected inhalation injury. It allows the direct visualization and grading of endobronchial lesions that directly correlate with morbidity and mortality of the patient. Moreover, in these patients, the flexible bronchoscope can be an asset in the insertion and management of endotracheal tubes as the patients usually suffer with upper airway edema, making it more difficult for conventional intubation through laryngoscopy.

Bronchoscopy may be used for treatment purposes through lavage and aspiration of soot and for preventing further damage, as these patients usually present with difficulty to expectorate secretions. It can also play an important role for the early diagnosis of associated pneumonia, which is highly prevalent in these patients regardless of the severity of the cutaneous burns.

Although our patient had a very severe case of soot deposition, the early bronchoscopy and lavage proved to be very helpful for the good clinical outcome.


1. Packham S, Jaiswal P, Kuo K, et al..Black bronchoscopy.Respiration.2003;70:206.
2. Teo YK, Kor AC.Black bronchoscopy—a case of endobronchial metastases from melanoma.J Bronchology Interv Pulmonol.2010;17:146–148.
3. Ikonomidis C, Lang F, Radu A, et al..Standardizing the diagnosis of inhalation injury using a descriptive score based on mucosal injury criteria.Burns.2012;38:513–519.
4. Chou SH, Lin S-D, Chuang H-Y, et al..Fiber-optic bronchoscopic classification of inhalation injury: prediction of acute lung injury.Surg Endosc.2004;18:1377–1379.
5. Mlack RP, Suman OE, Herndon DN.Respiratory management of inhalation injury.Burns.2007;33:2–13.
6. Carr JA, Phillips BD, Bowling WM.The utility of bronchoscopy after inhalation injury complicated by pneumonia in burn patients: results from the National Burn Repository.J Burn Care Rehab.2009;30:967–974.

black bronchoscopy; smoke inhalation; airway soot deposition

© 2013 by Lippincott Williams & Wilkins.