The Rigid Bronchoscope: A Pulmonologist’s ‘Forgotten Tool’?

Since its first reported use to remove a foreign body from the airways by Gustav Killian in 1897, rigid bronchoscopy (RB) has been used successfully for other airway diseases. Airway visualization by bronchoscopy was a technique initially performed almost exclusively by surgeons until the introduction of the flexible bronchoscope in 1966. The flexible bronchoscope replaced the use of rigid bronchoscopes and defined the modern era of pulmonary medicine. In the early 1980s, physicians realized that there were advantages to rigid bronchoscopy for interventional procedures, such as the endobronchial management of lung cancer, critical airway obstruction, and other airway diseases. Furthermore, new indications and modalities are still being developed. Despite the advantages of rigid bronchoscopy, only 4% of pulmonologists who responded to a survey reported that they used a rigid bronchoscope in their practice (Colt et al. J Bronchol. 2000;7:8), though interventional pulmonologists, thoracic surgeons, and otolaryngologists use rigid bronchoscopes on a regular basis. Unfortunately, many pulmonologists finish their training with insufficient knowledge about the indications and uses of rigid bronchoscopes. Different interventional pulmonology programs and bronchoscopy organizations are trying to encourage the use of rigid bronchoscopes by creating fellowships and sponsoring hands-on courses. However, due to the complexity of this procedure and the methods of teaching needed, some will not gain this proficiency. It is the goal of this article to heighten the interest of the pulmonary community to explore and learn more about this “old” instrument.

History and Equipment
Manuel Rodriguez Garcia, a Spanish singer and music teacher, was the first to perform an “in vivo” visualization of the airways by studying his own larynx in 1855. Johann Czermak perfected the technique for indirect laryngoscopy in Germany in 1858. The first use in America was by Horace Green, the “father of laryngology,” to make laryngeal applications of silver nitrate (Bryce et al. The American Laryngological Association 1878-1978: A centennial history. Washington, DC: The Association; 1978).

It was not until 1895 in Germany that Alfred Kirstein performed the first direct examination of the larynx by using a rubber tube with an electric bulb. One of his pupils, Gustav Killian, subsequently performed the first rigid bronchoscopy to remove a foreign body from a patient who had aspirated a bone into his right main bronchus (Zollner F. Arch Otolaryngol 1965;82[6]:656). Later, Killian was named the “father of bronchoscopy.” Around the same time, Chevalier Jackson, an American laryngologist from Pennsylvania, started to develop his own endoscopes with distal illumination; he used them initially with dogs and inanimate models. He published his book, Tracheobronchoscopy, Esophagology and Bronchoscopy, in 1907; later, he was considered the “father of American bronchoesophagology” (Jackson. The life of Chevalier Jackson: an autobiography. New York, NY: MacMillan; 1938).

E. Broyles introduced the telescope optic for bronchoscopy in Baltimore in 1940, followed by the optical forceps (1948). Shigeto Ikeda from Japan, who later developed the flexible fiberscope, introduced glass fiber illumination for the rigid bronchoscope in 1962.

Hopkins, in England, developed a rod-lens telescope system that considerably improved the lighting and imaging through the rigid bronchoscope (1954). This technology was adopted by K. Storz as a cold light illumination source for his rigid bronchoscopes in 1963 (Bolliger et al. Interventional bronchoscopy. Basel, Switzerland: S Karger Publishers; 2000).

Though minor adjustments have been made to the equipment since then, today’s rigid bronchoscopes are similar to those used in the days of Jackson. They are stainless steel, tapered tubes with a flared and beveled distal tip. The proximal end of the bronchoscope consists of a central opening and several side ports that are used for ventilation tubes and instrumentation. The typical “light carrier” is a thin glass rod (telescope) connected to a proximal light source through a fiberoptic cable. Bronchoscopes have slit-like openings in the distal end that allow ventilation to the contralateral lung, while tracheoscopes lack these side holes and are shorter. The diameter of rigid bronchoscopes ranges from 9 to 14 mm, which allows the passage of multiple instruments simultaneously, such as suction catheters, laser fibers, forceps, and flexible bronchoscopes, among others (Figs 1-3).

Anesthesia
Preoperative patient preparation for RB includes restricted oral intake for at least 6 hours before the procedure and correction of coagulopathies. The use of agents to decrease bronchial secretions is not routinely required.

Even though the technique for RB has remained almost the same since the late 19th century, the anesthetic technique has changed considerably. Jackson described the use of hypodermic morphine sulfate combined with topical cocaine as adequate to perform RB (Jackson. Bronchoscopy and esophagoscopy. Philadelphia, PA: J B Saunders Company; 1927).

Currently, general anesthesia is preferred for the comfort and safety of the patient. Communication and coordination between the bronchoscopist and the anesthesiologist is crucial before, during, and after the procedure. Anesthesia induction can be done via inhaled sevoflurane (usually in critical airway stenosis) or by administration of IV agents like ramifentanyl and propofol (Perrin et al. Chest. 1992;102[5]:1526). Muscle relaxants, like succinylcholine, are commonly used during the initial bronchoscope insertion. Ventilation can be spontaneous-assisted ventilation, in which the anesthesiologist provides frequent assisted breaths and works to synchronize breathing with the bronchoscopist’s maneuvers. Venturi jet ventilation is another modality adopted by many centers, due to its advantages for oxygenation and to overcome the increased airway resistance that occurs with telescope use (Godden et al. Thorax. 1982;37[7]:532). Postprocedure care is done in a recovery room under strict monitoring. Most rigid bronchoscopic procedures are ambulatory.

Intubation Technique
The position of the patient is very important in order to achieve successful intubation with the rigid bronchoscope. The patient should be positioned supine with extension of the neck, allowing alignment of the pharynx, larynx, and trachea. Some techniques use a laryngoscope as an aide for intubation, others use an initial placement of an endotracheal tube that then is used as a guide for intubation, and others use only the rigid bronchoscope with or without the use of a Hopkins telescope.

Once the bronchoscope is passed into the trachea, the central airways can be visualized. Segmental airways are difficult to evaluate unless an angled telescope or a flexible bronchoscope is used through the rigid bronchoscope.

Indications and Contraindications
Even though flexible bronchoscopy is indicated in the diagnosis and management of different pulmonary diseases, there are still multiple conditions in which RB is preferred over flexible bronchoscopy, ie, the management of massive hemoptysis, removal of foreign bodies, and malignant airway obstruction. Moreover, some therapeutic techniques, like the placement of silicone stents for tracheal stenosis, tracheobronchomalacia, and malignant airway obstruction, can only be performed with a rigid bronchoscope.

Since general anesthesia is typically needed, contraindications for RB are related to comorbid diseases that increase the risk of anesthesia. An absolute contraindication includes cervical spine disease, which prevents positioning of the neck (Wain. Chest Surg Clin N Am. 2001;11[4]:691).

Indications for Rigid Bronchoscopy

Diagnostic
•Massive hemoptysis
•Endobronchial biopsies (large specimens)

Therapeutic
•Foreign body removal
•Airway obstruction: malignant and benign
•Ablative techniques: mechanical, laser, electrocautery, argon plasma coagulation, cryotherapy
•Airway stenting: airway obstruction, tracheomalacia, tracheoesophageal fistula
•Tracheobronchoplasty with balloon

Complications
In experienced hands, the complications of RB are rare. The most common ones are related to trauma of the upper airways, including the oropharynx and teeth (Ayers and Beamis. Clin Chest Med. 2001;22[2]:355). Massive hemoptysis is very rare. Cardiac arrhythmias and respiratory depression can be seen due to anesthesia. Only two deaths were reported after 11,000 rigid bronchoscopies (Caputi et al. Panminerva Med. 1986;28[3]:271).

Conclusion
The use of RB decreased after the introduction of flexible bronchoscopy. Despite being a safe procedure and having solid indications in the management of pulmonary diseases, most pulmonologists do not perform RB; furthermore, many of them have no exposure to RB during their training. It is important to stimulate the interest of pulmonologists to prevent RB from becoming a “forgotten tool.”

Dr. Javier I. Diaz-Mendoza
Senior Staff Physician
Interventional Pulmonology
and
Dr. Paul A. Kvale, FCCP
Senior Staff Physician
Pulmonary and Critical Care Medicine
Henry Ford Health System
Detroit, MI

Editor’s Insight
This article provides a historical review of rigid bronchoscopy and highlights its importance in the future of pulmonary medicine. The introduction of flexible bronchoscopy brought about a rapid decline in the number of physicians performing and teaching the technique of rigid bronchoscopy. Over the past 20 years, however, the growing field of interventional pulmonary medicine has brought the rigid bronchoscopist back from the “brink of extinction” by defining the criteria for certification and indications for use (Ernst et al. Chest. 2003;123[5]:1693; and Bolliger et al. Eur Respir J. 2002;19[2]:356). This review should serve as a call to action to incorporate rigid bronchoscopy into the basic training of a bronchoscopist, especially at those institutions where high-grade airway obstruction, massive hemoptysis, and stent deployment and removal are commonplace.

Dr. Eric L. Flenaugh, FCCP
Georgia Cancer Coalition’s Distinguished
Cancer Clinician & Scholar,
Director of Advanced Diagnostic and
Interventional Pulmonary Medicine,
Georgia Cancer Center of Excellence and
Morehouse School of Medicine,
Atlanta, GA

Editor’s note: Because I was not trained in rigid bronchoscopy and RB is not performed by thoracic surgery at my institution, commentary for this article was invited and provided by a guest editor.