Overview
Definition:
Rigid bronchoscopy is an endoscopic procedure utilizing a rigid, hollow tube with an integrated light source and port for instruments, inserted through the oral or nasal cavity to visualize and intervene in the central airways (trachea and main bronchi)
It is distinct from flexible bronchoscopy in its larger diameter, enabling more aggressive therapeutic interventions.
Epidemiology:
Central airway obstruction (CAO) can result from intrinsic (endobronchial) or extrinsic (extratracheal) causes
Intrinsic CAO is commonly due to malignant tumors (primary lung cancer, metastases, post-radiation stenosis), benign tumors, inflammatory conditions (e.g., tracheobronchomalacia, sarcoidosis), foreign bodies, or mucus plugging
Extrinsic CAO may be caused by enlarged lymph nodes, vascular anomalies, or mediastinal masses
Incidence varies by etiology
malignant CAO is prevalent in oncological patient populations.
Clinical Significance:
CAO poses a significant threat to patient survival and quality of life due to severe dyspnea, hypoxia, and potential for complete airway collapse
Rigid bronchoscopy offers a direct, therapeutic approach to relieve obstruction, diagnose underlying pathology, obtain tissue biopsies, and manage complications, making it a critical skill for thoracic surgeons and interventional pulmonologists preparing for DNB and NEET SS examinations.
Indications
Primary Indications:
Diagnosis of unexplained central airway lesions
direct visualization and tissue sampling of suspected endobronchial tumors or strictures
therapeutic intervention for life-threatening central airway obstruction causing severe dyspnea or hypoxia
removal of large endobronchial foreign bodies
management of post-surgical or post-intubation tracheal stenosis
airway stenting
control of endobronchial hemorrhage.
Contraindications:
Absolute contraindications are rare and typically involve unstable hemodynamic status or severe coagulopathy that cannot be corrected
Relative contraindications include severe cervical spine instability, recent myocardial infarction, severe respiratory failure requiring mechanical ventilation (though it can be a reason for the procedure), or known difficult airway anatomy where intubation is impossible.
Decision Making:
The decision to proceed with rigid bronchoscopy is based on the severity of obstruction, patient's clinical status, suspected etiology, and the need for immediate therapeutic intervention
CT imaging is crucial for pre-procedural assessment of airway anatomy, lesion extent, and surrounding structures.
Preoperative Preparation
Patient Assessment:
Thorough cardiopulmonary assessment, including evaluation of respiratory function (spirometry, arterial blood gases), cardiac status, and coagulation profile
Review of imaging studies (CT scan, MRI) to understand lesion location, size, relationship to adjacent structures, and vascularity.
Anesthesia Considerations:
Usually performed under general anesthesia with a rigid bronchoscope acting as an endotracheal tube
Anesthesia may be administered by an anesthesiologist experienced in airway procedures, often involving spontaneous ventilation, jet ventilation, or controlled ventilation with apneic periods
Adequate muscle relaxation is essential.
Equipment Setup:
Sterile setup including a rigid bronchoscope of appropriate size, light source, video imaging system, suction, biopsy forceps, cytology brushes, snares, laser fibers, cautery devices, stent delivery systems, and foreign body retrieval instruments
A dedicated surgical team, including scrub nurse and anesthesiologist, is vital.
Procedure Steps
Access And Insertion:
The patient is positioned supine
Oral or nasal intubation with the rigid bronchoscope is performed
A bite block is used to protect the scope and teeth
The bronchoscope is advanced under direct visualization, ensuring no trauma to the laryngeal structures or airway mucosa.
Visualization And Diagnosis:
The entire tracheobronchial tree is systematically inspected
Biopsies are obtained from suspicious lesions using forceps, brushes, or during debulking procedures
Endobronchial ultrasound (EBUS) may be coupled with rigid bronchoscopy for lymph node sampling.
Therapeutic Interventions:
Debulking of endobronchial tumors using forceps, electrocautery, or laser ablation
Foreign body removal using grasping forceps, snares, or baskets
Placement of rigid or flexible stents (e.g., silicone, metallic) to maintain airway patency
Balloon dilation of benign strictures
Hemostasis achieved with cautery, argon plasma coagulation, or local hemostatic agents.
Completion:
After intervention, the airway is re-inspected to ensure patency and control of bleeding
The bronchoscope is carefully withdrawn
Post-procedure chest X-ray may be obtained.
Postoperative Care
Immediate Monitoring:
Close monitoring of vital signs, oxygen saturation, and respiratory status
Assessment for signs of airway edema, bleeding, pneumothorax, or infection
Pain management is crucial.
Airway Management:
Depending on the procedure, the patient may require supplemental oxygen, humidified air, or racemic epinephrine
In cases of significant airway manipulation or edema, a temporary tracheostomy or airway support may be necessary
Early mobilization is encouraged if feasible.
Discharge Criteria:
Stable vital signs, adequate oxygenation, absence of significant bleeding or air leak, tolerable pain, and ability to manage secretions
Follow-up appointments for further management, repeat bronchoscopy, or adjuvant therapy are scheduled as needed.
Complications
Early Complications:
Hemorrhage (acute or delayed), pneumothorax, laryngeal or pharyngeal trauma, dental injury, vocal cord injury, laryngospasm, bronchospasm, hypoxemia, fever, infection, aspiration pneumonia, mediastinitis, tracheal perforation.
Late Complications:
Tracheal stenosis (due to thermal injury or scarring), tracheoesophageal fistula, granuloma formation, stent migration or occlusion, chronic dysphonia, impaired mucociliary clearance.
Prevention Strategies:
Meticulous technique by experienced operators, appropriate patient selection, adequate pre-procedural assessment, skilled anesthesia management, use of appropriate instruments and energy devices, prompt recognition and management of bleeding, and meticulous post-operative care.
Key Points
Exam Focus:
Rigid bronchoscopy is indicated for significant central airway obstruction requiring immediate intervention, tissue diagnosis, or complex procedures like stenting
It offers superior lumenal control and therapeutic capability compared to flexible bronchoscopy
Anesthesia is typically general, with the scope acting as the endotracheal tube.
Clinical Pearls:
Always perform a thorough CT scan before rigid bronchoscopy to assess the extent and nature of the obstruction and relationships with adjacent structures
Have a full armamentarium of interventional tools readily available
Adequate suction and light are paramount
Be prepared for bleeding and have hemostatic agents at hand
Communicate clearly with the anesthesia team and the entire surgical staff.
Common Mistakes:
Inadequate pre-procedural imaging, incorrect bronchoscope size selection, aggressive manipulation leading to mucosal injury or perforation, failure to control bleeding, neglecting post-operative airway monitoring, and suboptimal management of complications
Overlooking extrinsic compression as a cause of obstruction that may require different management strategies.