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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. Subsequently, transthoracic needle biopsy was 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, transthoracic needle biopsy, 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, transthoracic needle biopsy is described.


The original 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 assisted 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 bronchoscopy is discussed in Chapter 34.

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 with local anesthesia and conscious sedation, have made flexible bronchoscopy the primary endoscopic procedure in pulmonary diseases.

Unlike the larger-bore rigid bronchoscope, the flexible bronchoscope varies from ultra-thin (allowing for greater access to the lung periphery in adults and 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 below). 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 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.

Recently, the advent of a flexible single-use disposable fiberoptic bronchoscope attempts to address rising concerns over the efficacy of endoscope cleaning practices, the burden of repair costs, the size of a modern endoscopy tower, and the challenge of prompt bedside availability.1 Improving image quality ...

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