Understanding the basics of rigid bronchoscopy

In the assessment of central airway obstruction and disease, no imaging technique is an adequate substitute for bronchoscopy. The indications for rigid bronchoscopy include multiple malignant and benign disorders, with most interventions performed for treatment of complications of lung cancer. The rigid bronchoscope is a useful tool for managing most types of airway stenoses, and it facilitates other endobronchial therapies, including stent placement, argon plasma coagulation, balloon dilatation, electrocautery probes, and laser therapy. Certain patients with benign lesions or postintubation or post-tracheostomy stenosis may benefit from rigid bronchoscopic techniques instead of surgery. Although use of the rigid bronchoscope requires general anesthesia, it provides a stable airway and often results in fast removal of foreign bodies. (J Respir Dis. 2006;27(3):100-113) For over 100 years, rigid bronchoscopy has been used to view the lower respiratory tract, and today this procedure has new applications in the emerging area of interventional bronchoscopy.Although bronchoscopes are simply designed, their use requires an experienced operator who is familiar with airway disease and the technical aspects of the procedure (Figure 1). Because rigid bronchoscopy requires the use of general anesthesia in the operating room, an experienced anesthesiologist who understands sedation and control of ventilation during airway procedures is also essential. In this setting, rigid bronchoscopy is performed safely with infrequent complications. The rigid bronchoscope is a useful tool for treating patients with most types of airway stenoses, and it facilitates other endobronchial therapies, including stent placement, argon plasma coagulation (APC), balloon dilatation, electrocautery probes, and laser therapy. Because lung cancer remains a common problem, pulmonologists and primary care physicians will increasingly recognize treatable airway complications. In this article, we will review the indications and contraindications for rigid bronchoscopy. We will describe the procedure, associated complications, and use in central airway obstruction.Background Rigid bronchoscopy was first performed by German otolaryngologist Gustav Killian in 1897 to remove an aspirated pork bone.1,2 Killian, who is often referred to as the "father of bronchoscopy," continued to develop new bronchoscopes and techniques.3 Around this time, American laryngologist Chevalier Jackson made significant advances in the field of endoscopy; these included designing new equipment, teaching bronchoesophagology, and establishing safety techniques.3 In the 1960s, the development of the flexible bronchoscope by Shigeto Ikeda in Japan revolutionized the field of bronchoscopy and helped expand the procedure beyond the realm of the surgeon to that of the pulmonologist. Over the next 10 years, flexible bronchoscopy replaced rigid bronchoscopy as an easier procedure for the patient and the physician. As a result, few modern pulmonologists have significant training or proficiency in rigid bronchoscopy. In 1991, an American College of Chest Physicians (ACCP) bronchoscopy survey revealed that 8% of pulmonologists in North America were performing rigid broncoscopy.4 By 1999, only 5% of surveyed pulmonologists had performed this procedure in the previous year.5 Renewed interest in rigid bronchoscopy is largely a result of an evolving arsenal of tools to treat the airway manifestations of lung cancer. Worldwide, the mortality rate for lung cancer is higher than the combined rates for breast, colorectal, and cervical cancers. One million deaths were attributed to lung cancer in 2001, with the global incidence increasing 0.5% per year.6 Survival continues to be poor, and a significant percentage of cases of lung cancer involve endotracheal or endobronchial disease. Thus, we can expect to see a continued need for rigid bronchoscopic techniques for years to come.Indications The indications for rigid bronchoscopy include multiple malignant and benign disorders, with most interventions performed for the treatment of lung cancer involving the airway.Malignant airway stenosis and obstruction About 20% of patients with lung cancer may have central airway obstruction as the initial manifestation of disease, and most patients will have airway obstruction at some point during the