Flexible Bronchoscopy and Bronchoalveolar Lavage (BAL)
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Flexible bronchoscopy is a commonly utilized endoscopic procedure allowing for direct visualization of the airways, as well as a variety of therapeutic and diagnostic interventions. Common indications of flexible bronchoscopy include evaluation of pulmonary infiltrates, hemoptysis, airway obstruction, foreign body aspiration, tracheal stenosis, bronchopleural fistula, and post-lung transplant. The procedure involves the insertion of a flexible bronchoscope through the vocal cords and into the lumen of the trachea and bronchi. Direct visualization is provided by fiberoptic video imaging. Bronchoalveolar lavage (BAL) further refers to instillation and subsequent recovery of sterile saline into the airways. In this article, we will detail the technique, considerations, and complications of flexible bronchoscopy and BAL.
Bronchoscopy; bronchoalveolar lavage; pulmonology; interventional pulmonology.
Prior to 1968, direct visualization and intervention of the airways could only be achieved via rigid bronchoscopy, whereby a light source and suction was affixed to a rigid bronchoscope.1 The first flexible bronchoscope became available in 1968 and has largely become the cornerstone of minimally invasive airway intervention.2 Bronchoalveolar lavage (BAL) was further introduced in 1974 and allowed for the procurement of material from the lower respiratory tract.3 While it was originally conceived for the purpose of removing aspirated foreign bodies, modern flexible bronchoscopy serves a wide range of applications.1 The most common diagnostic purposes of basic bronchoscopy are the direct identification of airway abnormalities, including obstruction, endobronchial lesions and masses, sources of bleeding, fistulas and foreign bodies, and collection of airway materials for microbiologic, immunologic, or cytologic analysis.
History of present illness will vary depending on the underlying etiology and purpose of examination. For example, a typical patient undergoing assessment for a suspected lung malignancy are classically older, former or current smokers, and may report cough, hemoptysis, weight loss, fatigue, and chronic dyspnea. This patient evaluated in the corresponding video was undergoing work up for suspected non-tuberculous mycobacterial infection, and reported chronic nonproductive cough, low grade fevers, and night sweats unresponsive to typical antibiotic treatment courses. Particular attention should be given to any personal history or associated symptoms of hematologic malignancy, bleeding disorders, pulmonary hypertension, bullous emphysema, and myocardial ischemia, which may individually increase the risk of procedural complications.
Physical exam findings will vary depending on the underlying indication for bronchoscopy. Preoperative assessment should include vital signs with particular attention to hypoxemia or hemodynamic instability, oropharyngeal inspection, and cardiopulmonary auscultation.
Prior to the procedure, a high-resolution CT scan of the chest should be obtained. Imaging is vital for preliminary evaluation of airway anatomy, including anatomic variants, and identification of target lobes and abnormalities for intervention. Depending on the intervention undertaken, a plain film of the chest may be obtained postoperatively to evaluate for procedural complications.
Special Considerations
Absolute contraindications to flexible bronchoscopy include severe hypoxemia, hemodynamic instability, refractory arrhythmias.7 Coagulopathy, recent myocardial infarction, pulmonary hypertension, and increased intracranial pressure are generally considered relative contraindications, though bronchoscopy can generally be performed safely in these scenarios with proper precautions and expertise.8
Flexible bronchoscopy begins with positioning the patient in the supine position. Though this procedure can be safely performed without sedation, the use of sedation has been associated with improved outcomes and is generally recommended.4 In the above video, we used a combination of moderate sedation and topical anesthesia. A laryngeal mask airway is placed and affixed with a bronchoscope adapter, allowing for simultaneous mechanical ventilation and insertion of the bronchoscope. First, the bronchoscope is inserted and advanced to the vocal cords, and lidocaine is instilled directly to the vocal cords via the working channel. The bronchoscope is then advanced through the vocal cords and into the trachea, at which point additional lidocaine is instilled to the carina. An airway exam is then conducted starting with the right bronchial tree by convention. As shown in the video, the bronchoscope is advanced in the right mainstem bronchus, where the take-off of the right upper lobe bronchus at the first secondary carina is visualized. Once the right upper lobe bronchial segments are inspected, the bronchoscope is then advanced into the bronchus intermedius, where the second secondary carina is visualized. This can be identified by the trifurcation of the right middle lobe bronchus, right lower lobe bronchus, and superior segment of the right lower lobe bronchus. After inspection of each of the above bronchi and their respective segments, the bronchoscope is then retracted to the tracheal carina and advanced into the left mainstem bronchus, where the secondary carina is identified by the bifurcation of the left upper and left lower lobe bronchi. Inspection of the left upper lobe bronchus will also reveal the take-off of the lingular bronchus. After all of the remaining segments are directly visualized, the bronchoscope is directed to the lobe of interest, and “wedged” into the respective bronchus. Sterile saline is instilled into the bronchial segment via the working channel, and then retrieved through the suction port into either the syringe or a specimen trap. It is generally recommended that at least 100 mL of fluid be instilled, though more may be required depending on indication and yield.5 The bronchoscope is then retracted from the patient, and the procedure is concluded.
Patients are typically monitored for a short time postoperatively and discharged home the same day. Significant complications are rare (<1% occurrence), but may include respiratory failure, bronchospasm, bleeding, and pneumothorax.6
Airway exploration by flexible bronchoscopy is generally limited to the extent of the subsegmental airways. Recent innovation in diagnostic bronchoscopy, including ultrathin bronchoscopy and robotic bronchoscopy, have allowed for access to the subsegmental airways and periphery of the lung parenchyma.6
A flexible bronchoscope is the primary tool used for this procedure. As described in the video, the tip of the flexible bronchoscope contains a light source, a video camera, and a working channel. The working channel can be used to instill medications, introduce a variety of instruments, or suction airway material. The bronchoscope tip can be flexed and extended via a lever on the handle, and rotation of the handle is used to guide the bronchoscope directionally.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Becker HD, Marsh BR. Interventional bronchoscopy. In: Anonymous. History of the rigid bronchoscope. Karger Publishers; 2000. p. 2–15.
- Panchabhai TS, Mehta AC. Historical perspectives of bronchoscopy. Connecting the dots. Ann Am Thorac Soc. 2015 May;12(5):631-41. doi:10.1513/AnnalsATS.201502-089PS.
- Reynolds HY, Newball HH. Analysis of proteins and respiratory cells obtained from human lungs by bronchial lavage. J Lab Clin Med. 1974;84(4):559-573.
- Putinati S, Ballerin L, Corbetta L, Trevisani L, Potena A. Patient satisfaction with conscious sedation for bronchoscopy. Chest. 1999 May;115(5):1437-40. doi:10.1378/chest.115.5.1437.
- Haslam PL, Baughman RP. Report of ERS Task Force: guidelines for measurement of acellular components and standardization of BAL. Eur Respir J. 1999 Aug;14(2):245-8. doi:10.1034/j.1399-3003.1999.14b01.x.
- Ninan N, Wahidi MM. Basic bronchoscopy: technology, techniques, and professional fees. Chest. 2019 May;155(5):1067-1074. doi:10.1016/j.chest.2019.02.009.
- Waxman AB. Flexible bronchoscopy: indications, contraindications, and consent. A. Ernst (Ed.), Introduction to bronchoscopy (1st edition), Cambridge University Press, New York. 2009;78-84.
- Miller RJ, Casal RF, Lazarus DR, Ost DE, Eapen GA. Flexible bronchoscopy. Clin Chest Med. 2018 Mar;39(1):1-16. doi:10.1016/j.ccm.2017.09.002.
Cite this article
Alpert MS, Htwe YM. Flexible bronchoscopy and bronchoalveolar lavage (BAL). J Med Insight. 2024;2024(448). doi:10.24296/jomi/448.
Procedure Outline
Table of Contents
Transcription
CHAPTER 1
My name is Dr. Yu Maw Htwe.I am the assistant professorof Intervention Pulmonary Departmentof the Penn State Health.We have an intervention pulmonary fellowship program,and today we will be doing the bronchoscopycalled the bronchoalveolar lavage,and for a patient that is a 56-year-old womanwith the recurrent environmental mycobacterial infection,so she's been a frequent flier to us.She's been treated with a complete treatment for the MAC,but right now she started having cough,shortness of breath again,so our infectious disease specialist want to seethe organism sensitivity.So this is kind of the quick and easy procedurethat we do very often.So for, I say, bronchoalveolar lavage,what we usually do hereis that we use the general anesthesia.But in off-site, if you wanna do moderate anesthesia,you can perform that as well,but here, we do general anesthesia.So after general anesthesiologist gonna place the LMA,I'm gonna put my bronchoscope from the mouth to the airwayand then I do airway inspection.So usually the airway inspection gonna start from the right,and in the right side, there are three lobes, right?Upper lobe, middle, and lower.In the upper lobe,they're gonna be anterior, apical, and posterior segment.We're gonna inspectand to look for any kind of endobronchial lesion,any inflammation, any bleeding, or any mucus plug.That's we're gonna look into.And then we are gonna move to another segmentcalled the middle lobe,and then in the middle lobe, the medial and lateral,the same way we look into all those segment.Then in the lower lobe,they're gonna be superior segment, medial basilarand then anterior, lateral, posterior basilar segment.We're gonna look into all those segmentand then I move to the left bronchial tree.In this case, however, abnormality is more prominentin the left bronchial tree,so I decided to do the BAL,kind of getting the fluid sample from the lungfrom the left side.So in the left side, there is the upper lobe and lower lobe.In the upper lobe, there is the left upper proper.In the left upper proper,they're gonna be apicoposterior segmentand anterior segment,and in lingula is the superior and inferior segment.This case, we decided to do with the lingulabecause in the CAT scan,the lingula is the most prominent abnormalitiesare in the CAT scan that we find.So after the lingula, we're gonna go to lower lobe.In the lower lobe, again, superior segmentand anteromedial, lateral, and posterior basilar segment,we do the airway inspectionand then after airway inspection, we do BAL.BAL, how we do it is we kind of squirt itinto the 60 or 50 cc of the salineand we push it in and then we try to kind of suction back.That's the way how we do it.And then sometime, if you put it out 50 cc,we usually come back 5 or 10 cc.That's the way it is.And then from that fluid sample,we send it to the kind of cell count cultureand also cytology.So procedure can take from 5 to 10 minutesand then after that, patient gonna wake upand she can resume the daily activitywithout any restriction.So the complication is very minimal.
CHAPTER 2
So I want to explain what is the bronchoscope is.So, this is called the therapeutic bronchoscope,and the reason why we call therapeutic bronchoscopeis because of the channel, the inner working channel,which is you can see is right here, 3.2 millimeter.So there is some other scope that is thinner size,and those thinner size does not workfor the diagnostic bronchoscope, okay?So this scope is like 60 centimeter long,and you can see every white linethat is a five-centimeter distance,and then at the tip of the scope,so whatever you see in the biggest holeis called a working channel.So the very big channel is the working channeland we need to know how much diameterwe have working channel.So this scope has 3.2-millimeter working channel.And then at the top, there is a camera,and the other two button right here each sideis a camare and light source, okay?So now I'm gonna turn on the lamp,so that's how you're gonna see.So all of our procedure go through that working channel.If we gonna do biopsy,the biopsy forceps gonna come out of here.If we gonna do bronchoalveolar lavage,the fluid gonna come out of here, okay?That's one thing.And then this is another sourcethat you can give the medication.If you give lidocaine or epinephrine or saline,this gonna go down and come out of this working channel.Okay, so if you're gonna hold it,you have to hold the bronchoscope like that,like three fingers right here, the thumb right here,and then your index finger gonna be, this is a suction.If you press it, you're gonna suction, okay?And then a little button here,button one, two, three, four,some of them work for the white balance,some of them work for the kind of picture,you can set up as you like.And here, I'm gonna focus here,if I thumb down, they look up, okay?They go up to the 190 degree.If you thumb up, it look down.So the bronchoscope have this wide channelthat you can go up and down.If you wanna turn right, you're gonna go this.If you wanna turn left, you're gonna go this.
CHAPTER 3
Okay.So, the scope is in.So this is the bronchoscope going in.My goal is I have to keep it straight.If I bend it, they don't kind of,it's very hard to manipulate,so our goal is keep the scope straight all the time.And then, we're gonna give the 1% lido to the vocal cordto anesthetize.So, the maximum dose of the lidocaineis a 4.4 milligram by kilogram.So if your anesthesia is also using lidocaine,you have to communicate with the anesthesiology team.So that's how she give the medication, with that channel,and if you look at that cameraand then they gonna come out from the working channel.Three. Okay.So now, I go into the airway.Oh, it came out again.So she is having little bit of spasm,so I'm gonna wait.Okay.Now I am in the airwayand then my goal is to keep it in the center.Okay, she is coughing.I'm gonna give her a little bit morepropofol here. Okay.Thank you.So this is the anterior wall and then posterior walland then you see that when she breathes,the posterior wall kind of contractingand the airway narrow.And right now I'm on the main carina.I'm gonna clean out the secretion first,so I go all the way down and I suction.And then I go to the left main.I go all the way down and suck it up.Now I'm gonna give another 1% lido to each main airway.Okay.And then I point it to the left main.Another one.Thank you.
CHAPTER 4
Now I'm gonna do the airway inspection.You can start from either right or left side,but I always try to start from the right sideso that it become organized.And I'm gonna go to the right mainand then from the right main,this is the right upper lobe takeoff.So this is kind of a beautiful anatomy.In the right upper lobe, there is the anterior segment,an apical, and the posterior segment,that's how you do the airway inspection.So you have to check that any mucosal abnormalities,any bleeding, or any foreign bodyor any endobronchial lesion,if you find those abnormalities,then you can take care of it during the procedure.Now I'm gonna come out from the right upper lobe,I go to the bronchus intermedius,and then this is the right middle lobe.And I go into the right middle lobe,there is a medial and lateral.So that's how I do the airway inspection,and I don't see any.And then, I came out to the bronchus intermediusand then this is the right lower lobe.So in the right lower lobe,the first takeout is on superior segmentof the right lower lobe,so I go in.Sometimes, very hard to go into that superior segment.There is nothing here.And then, the second takeoutusually gonna be the medial basilar.Those are the basilar segment.So there is nothing that I can see.And then, I used to memorize it like ALP,so this is anterior, this is lateral, this is posterior.They all are basilar segments.So this patient has a really good anatomy.
CHAPTER 5
Then I'm gonna go to the left side.So usually, the left bronchial tree is very friable,and this patient has a recent infection,so her airways are inflamed on the left side.And then around the carina,left upper lobe and left lower lobe takeoutis the most friable area,you can cause bleeding just by suction.This is a bleeding from my airways clearancethat I did before.And I'm gonna go to the left upper lobe proper.Can I get a saline, iced saline?Iced? Mm-hmm.So if you have a little bit bleeding,you can control it using the iced salineor iced epinephrine.It depend on the proceduralist's preference.So what it does is if you give the iced saline,they gonna cause a vasoconstrictionand those mucosal bleeding can stop.Give like 10 or 20 cc from the channel,like maybe 10, 20 cc.Mm-hmm.Good now, uh-huh.Thank you, uh-huh.This is kind of, iced saline application.I did not suction out.I want to let it sit for a little bitbecause I have to do my airway exam, right?So then I slowly go in.So now this is the left upper lobe proper.So this is the lingula.I'm gonna go to left upper lobe proper.This is the apicoposterior segment.I don't see anything.And this is the anterior segment of the left upper lobe.Now I'm gonna go to the lingula.Lingula have a superior and inferior segment.In her CAT scan,the lingula is the most prominent abnormality,so I'm gonna do the BAL here,and I'm ready to start BAL.Mm-hmm.So - lingula.Uh-huh.So what Emily is doingis she is hooking up with the Lukens trap,and then, yeah.Uh-huh.And then it has to maintain kind of upside down,so I kind of try to use it with my, kind of pinky fingers.And - you wanna do the BAL?Uh-huh.So this is a procedure called bronchoalveolar lavage.I want it cold. I want cold saline, yeah,because she has a little bit of bleeding.So she gonna squirt out with the salineand what it does is now I have to aim to the airway.So this is a kind of a good BAL.So our theory is that those fluidsgonna go all the way to the end of the airwayand then go to the alveoli,and once she pulled back,she have to apply certain pressure.So yes, she has applied the,you have to apply negative pressure.Yeah, like this.She have to apply this...Not too much.If you apply to much, it's gonna close.But that's fine.You can give another one.Not good.We're gonna give her another...I want cold because she has a little bleeding.Usually the first one, you chase it.So did you see, look at the airway.When you suction, applying the negative pressure,you should not look at here,you should look at there. I'm sorry.Kind of align with this, yeah.And then...Okay, and wait, it's a little bit of bleeding, that's why.How much do I have?Yeah, yeah, pull more, pull more.It's coming out.Okay, fine.So now, I'm gonna do suction and pull backwhatever the left over.How much do I have?Six total.Only six? Then I need more.This is called, the procedure called bronchoalveolar lavage.We use it for the infection workup and cancer workupand pneumonitis,and sometime a thing called the bronchoalveolar lavage,and we do the serial of those BAL process.Okay, push it down.I think it's because of the blood.No, I want total like 30,not 40, yes.20 would not be enough.Maybe at least 25 and 30.They went - I know.How much?Total of nine.None?Nine total. Oh, nine.Nine total.One second, let me get you more.I mean, I gave like 150.Okay, I think I should be okay, right?It's okay if I don't get it...How much it is?This is 15.Almost 15.Oh, 15 and 9, okay, okay.So 10 for cyto and the rest for micro.So when you take out,you have to take out this one first, okay.If you accidentally take out everything,whatever we collected can accidentally go to there.Okay.Good, okay.So then, now I'm gonna continue my airway inspection.We almost done.She has bleeding, so it was bad.Now can I get a little bit of saline?Saline? Iced saline.Mm-hmm.More.Okay, that's good enough.So she have a little bit of bleeding.Sometimes BAL can also induce the bleeding.So I'm gonna be just left it there.And so I'm gonna go to lower lobeand I want all the way down.So that's a good bronchoscopy.Sometimes, you need to know where you areeven though you don't see anything.So this is a basilar segment.She have a very kind of atelectatic lungthat's caused from the smoking historyand also from the anesthesia as well.So this is the anterior basilar segmentand this is a lateral and posterior.So now, there is nothing here.And then, this is a superior segment,so, yeah.It look good,and it's just a little bit bleeding,so what I'm gonna do,I'm gonna just sit there and see if the bleedingis eventually gonna stop.There is no way that we can suture the airway or anything.So usually, those kind of mucosal tear is gonna stopon its own andwe don't have to do anything.So I'm kind of wait herefor, like, at least three to five breathing cycleand see any blood coming toward me.If that's the case, then I'm in trouble.So now, she is doing fine,so I'm gonna slowly come outand then clean out the other airway.
CHAPTER 6
Again, this is in the right side.Okay, so now I'm gonna come out.So she has a little bit of saber-sheath tracheathat we can see in the COPD and also smoker lungs.Okay.On the way back, I look at my vocal cord.It's doing fine.It is done. Thank you.
CHAPTER 7
So now that I finished the procedure,and I did the BAL on the lingula,but if you see, there we see a lot of bleedingcame from the lingula airwaybecause she has a chronic mycobacterial infection,so her airways are very inflamed,so even a little bit of pressure,they can cause the mucosal bleeding.That's what has happened there.So I use the two technique.One technique is that I use the cold saline.For the airway bleeding,there is the step 1, 2, 3, 4, up to 10,and then the first step is to kind of iced saline.Iced saline, what it doesis it's gonna cause the vasoconstrictionof the airway capillariesand that gonna cause sparcer bleeding.And then the second thing that I didis after I clean out the airway,I kind of stay there and watchbecause if there is active bleeding or not.Because once you are in the airway, the very narrow lumen,and you're looking from the very small camera,everything is not very clear.Then if you use, you can, sometimes can be mixedwith airway inflammation or bleeding,and like kind of iced saline mixed with the bloodcan be confused with the active bleeding,so what I did is I stayed therein the distal part of the left mainand then I look for any blood coming toward me.If that is active bleeding,you're gonna start seeing that - it's kind of a well -it's gonna be filling up with the blood over time.If the bleeding is stopped,and if it is just a mucosal edema or old bleeding,they're gonna stay the same.They're gonna move with the patient breathing,they're gonna come in, go out, come in, go out,depend on the patient breathing, breathe out pattern,but they should not be coming toward your camera.So that is the teaching pointthat I have experienced in this case.So the bottom line is BAL can be very simplebut it can cause the massive bleeding as well,so you always have to keep back of in your mindand to prepare if you encounter bleeding.