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Gustav Killian reported his experience with the first bronchoscopy in 1898. Technological advances during the next century facilitated development of bronchoscopy as a pivotal diagnostic and therapeutic tool in pulmonary medicine. Although a number of bronchoesophagologists contributed to refinement of the technique based upon use of a rigid instrument, the advent of flexible fiberoptic bronchoscopy, pioneered by Ikeda in 1967, opened new horizons to clinicians. More recently, transthoracic needle biopsy (TTNB) has been added to the pulmonologist's diagnostic armamentarium, although it is now most frequently performed by radiologists under CT guidance.

This chapter comprises an overview of bronchoscopy, TTNB, and related techniques. Following a general discussion of bronchoscopy and associated general instrumentation, indications for the technique and patient preparation are considered. Specific applications of diagnostic bronchoscopy are discussed. Subsequently, safety factors related to bronchoscopy and complications of the technique are reviewed. Finally, TTNB is described.

General Instrumentation

The initial bronchoscope, developed by Killian in Europe and further perfected by Chevalier Jackson in the United States, was a rigid metal tube that permitted either spontaneous or mechanical ventilation. With development of fiberoptic and advanced electronic technology, the flexible bronchoscope has, to a large extent, replaced the rigid bronchoscope for most diagnostic and some therapeutic indications. Therapeutic interventional bronchoscopy, including the use of rigid bronchoscopes, is discussed in Chapter 36.

Flexible Fiberoptic and Videobronchoscopy

Although the optical resolution of early fiberoptic bronchoscopes was inferior to that of rigid devices, their flexibility, ease of manipulation, and simplicity of use, which permit rapid examination under topical anesthesia, have made flexible bronchoscopy the primary endoscopic procedure in pulmonary diseases.

Unlike the larger-bore rigid bronchoscope, the flexible bronchoscope varies from ultrathin – allowing for neonatal endoscopy – to larger, adult size therapeutic devices. The diameter of the working channel permits aspiration of secretions or introduction of accessories required for diagnostic purposes (see Bronchoscopy Technique). With flexible bronchoscopy, the patient's ventilation is assured by airflow around the bronchoscope, between the external wall of the device and the tracheobronchial tree. Thus, the appropriate selection of bronchoscope size is crucial.

Fiberoptic systems have largely been replaced by videobronchoscopes, which utilize a miniaturized CCD camera at the tip of the scope that provides electronic transmission of images to a television monitor. Flexible bronchoscopes are more fragile and more prone to damage than are rigid metal instruments. Appropriate care and adherence to safety techniques during procedures, as well as during routine cleaning and maintenance of the instruments, help assure extended instrument life and reduce repair costs.

Ultrathin Bronchoscopes

Ultrathin bronchoscopes, flexible scopes with external diameters ≤3 mm, were initially developed for pediatric applications; however, these have now incorporated larger working channels, allowing for their use in the diagnosis of peripheral pulmonary lesions in adults.1,2 Ultrathin bronchoscopes can be advanced ...

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