Bronchoscopy and the chest x-ray.

An increasing number of diagnostic X-ray departments are opening their doors for direct referral of patients from general practitioners without the intervention of a clinical consultant before the patient is radiographed. Communication between diagnostic radiologist and practitioner is direct and hence increased responsibility falls upon both. With this in mind we are concerned with two associated factors: (1) The delay in referral for brochoscopy when an opacity of doubtful aetiology is found to be present on the X-ray film. (2) The proper value of bronchoscopy in its relationship to the X-ray appearances. We wish to emphasize that the two investigations are rarely mutually exclusive but most often complementary. Linked with the X-ray film, bronchoscopy is the most important single method of reaching a positive diagnosis in neoplasms of the bronchial tree and it is regrettable that many clinicians are so reluctant to refer patients for this simple investigation when an unsuspected opacity is discovered on the X-ray film. The bronchoscope covers a wide area of vision in the proximal bronchial tree (Fig. 1) and diagnosis is often immediate and absolute. On occasion, however, malignant bronchogenic tumours lie in the vicinity of the major bronchi (as judged by the X-ray film) and yet are not visible at bronchoscopy. Such a negative bronchoscopy will not deter the chest physician from making a diagnosis of malignant disease, but to those unused to the limitations of this otherwise invaluable diagnostic procedure there is a tendency to assume that a negative bronchoscopy renders suspicious X-ray findings less sinister and final diagnosis is corre-