Back to Topics
Interventional
Flexible Bronchoscopy: Indications, Technique & Complications
Added by Dr. Andrew · Last updated 2024-01-15
Overview
Flexible bronchoscopy is the most commonly performed interventional pulmonary procedure. It allows direct visualization of the airways to the subsegmental level and enables diagnostic sampling (BAL, brushings, biopsies) and therapeutic interventions.
Key Points
- 1Indications: hemoptysis workup, airway evaluation, BAL for infection/ILD, endobronchial biopsy, foreign body removal, mucus plug clearance
- 2BAL: instill 100–300 ml saline in 20–60 ml aliquots; discard first aliquot (bronchial washings)
- 3Transbronchial biopsy (TBB): for diffuse parenchymal disease; 4–6 biopsies recommended
- 4Endobronchial biopsy: for visible endobronchial lesions; 3–5 biopsies
- 5Contraindications: severe hypoxemia (SpO₂ <90% on supplemental O₂), coagulopathy (INR >1.5, platelets <50K for biopsy), hemodynamic instability
- 6Complications: hypoxemia (most common), bronchospasm, bleeding, pneumothorax (post-TBB ~2–5%)
Clinical Pearls
- Cryobiopsy: larger, better-preserved specimens than forceps TBB — higher diagnostic yield for ILD
- BAL differential: normal <3% neutrophils, <15% lymphocytes, <1% eosinophils
- Eosinophilic BAL (>25%): eosinophilic pneumonia, drug reaction, ABPA, parasites
- Lymphocytic BAL (>15%): HP, sarcoidosis, NSIP, drug-induced ILD
Board High-Yield
Exam Focus- BAL lymphocytosis >20% argues against IPF — favors HP or sarcoidosis
- Cryobiopsy yield for ILD: ~80% vs ~50% for forceps TBB
- Post-TBB pneumothorax: CXR 1–2 hours post-procedure; most are small and self-limited
- Massive hemoptysis during bronchoscopy: isolate bleeding lobe, cold saline lavage, epinephrine, rigid bronchoscopy
- BAL in immunocompromised: PCP (GMS stain), CMV (viral culture/PCR), Aspergillus (galactomannan)
ABIM Exam Weight
5%
Interventional Pulmonology represents approximately 5% of the PCCM certification exam.