Version May 2024
INTRODUCTION — Bronchoscopy is an endoscopic procedure that visualizes the tracheobronchial tree by placing an optical instrument inside the airways. The value of bronchoscopy has grown in its diagnostic and therapeutic capacity such that the clinician needs to be aware of the available technology and the associated clinical applications.
An overview of flexible bronchoscopy and accessory procedures that can be performed during flexible bronchoscopy are reviewed here. The procedure, indications, contraindications, and complications of flexible bronchoscopy are described separately. (See "Flexible bronchoscopy in adults: Indications and contraindications".)
TYPES OF BRONCHOSCOPY — The main types of bronchoscopy are compared in the table (table 1).
●Flexible bronchoscopy – Flexible bronchoscopy is also known as standard white light bronchoscopy. It is typically performed using conscious sedation and is a smaller, more flexible piece of equipment that permits access to the lower airways such as the third order of bronchi (figure 1). Consequently, it is more widely used than rigid bronchoscopy for both diagnostic and therapeutic procedures. (See 'Flexible bronchoscopy' below.)
●Rigid bronchoscopy – Rigid bronchoscopy also uses a white light source to visualize the airways. However, compared with flexible bronchoscopy, it is a larger, more rigid piece of equipment that can only access the proximal airways. It requires general anesthesia and is usually used for interventional procedures for which flexible bronchoscopy cannot be performed. (See 'Rigid bronchoscopy' below.)
●Virtual bronchoscopy – Virtual bronchoscopy is a noninvasive form of bronchoscopy. It is not an endoscopic procedure but rather an imaging modality that reconstructs the airways in a three-dimensional (3D) manner producing images that appear similar to those visualized during invasive bronchoscopy. Unlike flexible and rigid bronchoscopy, it cannot be used to acquire samples. Its use is limited to centers with expertise. (See 'Virtual bronchoscopy' below.)
●Robotic-assisted bronchoscopy – In this technology, a small location-sensing catheter is inserted into the airways and maneuvered with robotic assistance to reach peripheral target lesions, using both direct visual and virtual computer guidance, primarily to obtain tissue diagnosis. (See 'Robotic bronchoscopy' below.)
Flexible bronchoscopy — Several variants of traditional flexible bronchoscopy exist [1]:
Traditional white light bronchoscopy — Standard white light flexible bronchoscopy is the most common type of bronchoscopy. It contains optical fibers or a small camera at the distal end to transmit images, a working channel, and a light source (figure 2 and figure 3), which together allow the operator to visualize the endobronchial tree [2] (see 'Equipment and procedure' below). Unlike the rigid bronchoscope, the flexible bronchoscope has a mechanism to flex or extend its distal end (anteriorly or posteriorly), which facilitates insertion through curved airways and enhances its ability to reach distal airways. All other forms of bronchoscopy listed in the sections below are variants of this form of bronchoscopy. (See 'Endobronchial ultrasound' below and 'Navigation bronchoscopy' below and 'Ultrathin bronchoscopy' below and 'Confocal bronchoscopy' below and 'Fluorescence bronchoscopy' below.)
Flexible bronchoscopy has both diagnostic and therapeutic applications:
●Diagnostic – To visualize and sample lesions of the oropharynx, vocal cords, and tracheobronchial tree (to the level of the third order of bronchi) (figure 1). It can also be used to sample lung parenchyma. Sampling procedures include the following and are discussed separately:
•Bronchial brushings (see "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Endobronchial brushing')
•Bronchial washings (see "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Bronchial washing')
•Bronchoalveolar lavage (see "Basic principles and technique of bronchoalveolar lavage" and "Role of bronchoalveolar lavage in diagnosis of interstitial lung disease" and "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Bronchoalveolar lavage')
•Endobronchial biopsy (see "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Endobronchial biopsy')
•Transbronchial biopsy (see "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Transbronchial biopsy')
•Transbronchial needle aspiration (see "Bronchoscopy: Transbronchial needle aspiration" and "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures", section on 'Needle aspiration')
●Therapeutic – Various endoluminal interventions, some of which are performed using rigid bronchoscopy, can also be administered via flexible bronchoscopy. These interventions are discussed separately in the following sections:
•Balloon dilatation (see "Flexible bronchoscopy balloon dilation for nonmalignant airway strictures (bronchoplasty)")
•Argon plasma coagulation (see "Bronchoscopic argon plasma coagulation in the management of airway disease in adults")
•Laser (see "Bronchoscopic laser in the management of airway disease in adults")
•Electrocautery (see "Bronchoscopic laser in the management of airway disease in adults")
•Brachytherapy (see "Endobronchial brachytherapy")
•Photodynamic therapy (see "Endobronchial photodynamic therapy in the management of airway disease in adults")
•Cryotherapy and cryobiopsy (see "Bronchoscopic cryotechniques in adults")
•Airway stent placement (see "Airway stents")
•Endobronchial valve or coil placement and endobronchial thermoplasty (see "Bronchoscopic treatment of emphysema", section on 'Endobronchial valves' and "Bronchoscopic treatment of emphysema", section on 'Coil placement' and "Bronchoscopic treatment of emphysema", section on 'Thermal airway ablation' and "Treatment of severe asthma in adolescents and adults", section on 'Bronchial thermoplasty')
Flexible bronchoscopy is generally performed in a procedure room (ie, a bronchoscopy suite) using moderate sedation or general anesthesia, the details of which are discussed separately (see "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Sedation' and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications"). For extensive procedures, or procedures that require both rigid and flexible bronchoscopy, it can also be performed in the operating room under general anesthesia. (See "Anesthesia for adult bronchoscopy" and "Rigid bronchoscopy: Intubation techniques", section on 'Anesthesia'.)
Endobronchial ultrasound — Endobronchial ultrasound (EBUS) involves a flexible bronchoscopy with an ultrasound probe. Commonly used, the linear EBUS bronchoscope is a hybrid scope that has an ultrasound probe built at the distal end; it allows the airways to be visualized similar to a standard bronchoscope, and additionally allows the structures surrounding the airways to be visualized (eg, lymph nodes, blood vessels, or lung masses). It provides real-time ultrasound images of the tissue adjacent to the airway, facilitating transbronchial needle aspiration of enlarged lymph nodes or masses.
There are also miniature ultrasound probes that can be introduced through a flexible bronchoscope, known as radial EBUS. Detailed discussion of EBUS probes is provided separately. (See "Endobronchial ultrasound: Technical aspects" and "Endobronchial ultrasound: Indications, contraindications, and complications".)
Navigation bronchoscopy — The two types of navigation bronchoscopy (NB) are electromagnetic NB (ENB) and virtual NB (VNB).
●ENB uses a special catheter with a sensor probe that is inserted through the working channel of a regular flexible bronchoscope. The probe is then steered through the distal airways beyond the third generation of airways, guided by an electromagnetic guidance system that is external to the patient.
●In VNB, first an airway path is planned to the target lesion using a computerized 3D reconstruction of the patient's computed tomographic (CT) chest images. An ultrathin bronchoscope (see 'Ultrathin bronchoscopy' below) is then inserted and advanced through the airways following the virtual guidance by matching the airways seen on 3D imaging with the real images obtained through the ultrathin scope. There is no electromagnetic guidance. This allows peripheral lung masses or abnormal areas to be sampled even if they cannot be accessed by a regular bronchoscope directly. (See "Image-guided bronchoscopy for biopsy of peripheral pulmonary lesions".)
Ultrathin bronchoscopy — Ultrathin bronchoscopy is performed with a flexible bronchoscope that has an external diameter of only 2.8 mm (ie, smaller than a regular bronchoscope), thereby allowing examination beyond the third generation of airways (figure 1). It can be used to obtain biopsy material from peripheral pulmonary nodules under VNB guidance [3].
Confocal bronchoscopy — A confocal probe is inserted through the working channel of the bronchoscope to illuminate and examine the microscopic structure of the airways and lung parenchyma in real time. This can be used to identify peripheral lung nodules [4]. It is not commonly used and remains investigational.
Fluorescence bronchoscopy — Autofluorescence bronchoscopy uses technology to detect biologically abnormal tissue such as precancerous lesions of the airway that have lost the fluorescent property. Most of the fluorescent bronchoscopy devices can switch from fluorescent to white light modes such that both modalities can be used in the same session. Further details regarding this modality are reviewed separately. (See "Detection of early lung cancer: Autofluorescence bronchoscopy and investigational modalities".)
Rigid bronchoscopy — Rigid bronchoscopy is a procedure in which a large straight metal tube with a beveled distal end is inserted into the trachea through the mouth (or the tracheostomy stoma) (picture 1 and picture 2). Instruments including a telescope with a light source (with or without video monitoring), forceps, suction catheters, and even flexible bronchoscopes can be placed through the beveled tube. Patients can also be simultaneously ventilated through the rigid system (picture 3). It requires general anesthesia and is typically used for tumor debulking, airway dilation, foreign body removal, placement or removal of airway stents, or to control massive hemoptysis. Rigid bronchoscopy is reviewed separately. (See "Rigid bronchoscopy: Instrumentation".)
Virtual bronchoscopy — Virtual bronchoscopy is not widely available and it remains largely investigational [5-8]. Virtual bronchoscopy consists of 3D computer-generated images of the tracheobronchial tree that allow "fly-through" visualization of airways (figure 4). The airways are imaged using imaging hardware, usually helical (spiral) CT hardware, that allows the rapid acquisition of volumetric data of the entire airway in a relatively short time. These data are then analyzed by software to reconstruct 3D and endoluminal views of the airways [9,10].
Compared with rigid and flexible bronchoscopy, virtual bronchoscopy has the advantage of being noninvasive, and being able to define the airways out to the seventh generation (figure 1). As an example, it may be able to provide important information about the condition of the distal airway beyond an obstruction when a flexible bronchoscope cannot pass an obstructing airway lesion. It also provides important information about the location of structures outside of the airways (eg, lymph nodes or blood vessels).
The major limitation of virtual bronchoscopy is its inability to sample lesions such that it can only be used prior to rigid or flexible bronchoscopy in order to plan a procedure.
While most modalities use CT to provide virtual images of the airways, some reports describe virtual positron emission tomography/computed tomography (PET/CT) bronchoscopy as a staging tool for lung cancer [11,12].
VNB is used as a navigational tool to enhance the diagnostic utility of invasive modalities (eg, ultrathin bronchoscopy or EBUS) for the biopsy of peripheral parenchymal lesions [3,13]. Details regarding VNB are provided separately. (See 'Navigation bronchoscopy' above and "Image-guided bronchoscopy for biopsy of peripheral pulmonary lesions", section on 'Virtual bronchoscopic navigation'.)
Robotic bronchoscopy — In this technology, instead of manually driving a bronchoscope in the airway, a robotic articulated arm is used to maneuver a bronchoscope or catheter to reach target lesions in the periphery of the lungs. Radial EBUS, fluoroscopy, or cone-beam CT can be used for secondary confirmation of placement in addition to direct vision.
There are two systems available commercially [14]. The Auris Monarch system was approved by the US Food and Drug Administration (FDA) in 2018 and uses electromagnetic guidance and direct visualization of airways with an ultrathin bronchoscope to pass a lockable 6 mm diameter outer sheath to reach peripheral target lesions. Tissue sampling is obtained under direct vision. The Intuitive ION system, approved by the FDA in 2019, uses a 3.5 mm diameter shape-sensing flexible catheter with a vision probe inside to reach the peripheral lesions. Tissue sampling is performed under virtual and fluoroscopic guidance.
The benefit of the robotic system is that the catheter can be locked in place to avoid distortion or warping during tissue sampling to improve diagnostic yield, which ranges from 69.1 percent with the Monarch system [15] to 79.1 percent with the ION system [16] from preliminary studies.
INDICATIONS AND CONTRAINDICATIONS — Flexible bronchoscopy has a growing number of diagnostic and therapeutic uses, the details of which are discussed in detail separately. (See "Flexible bronchoscopy in adults: Indications and contraindications".)
EQUIPMENT AND PROCEDURE
Equipment — The equipment necessary to perform flexible bronchoscopy consists of the flexible bronchoscope and an image processor with a light source.
Bronchoscope — A common flexible bronchoscope has three parts (figure 2 and figure 3 and picture 4):
●The control handle is held by the operator and contains a lever to flex or extend the distal tip of the bronchoscope (figure 2). It also has a suction port and an opening through which instruments (forceps, brushes, etc) are inserted into the working channel.
●The flexible shaft contains cables enclosed within a sheath that allow flexion and extension of the distal tip of the bronchoscope by moving the lever on the handle. It also contains lighting cables, imaging cables, and a working channel through which airway contents are aspirated (eg, mucus or blood) and catheters or other instruments are passed.
●The distal tip (ie, working tip) is the part of the bronchoscope that guides the operator through the patient's airway. It contains an image-retrieval element (ie, camera), an illumination component (ie, light), and the opening of the working channel (figure 3).
Variations exist:
●Most commonly, the image processor and light source are connected to the left side of the control handle or the handpiece of the bronchoscope by a cord (figure 2 and figure 3 and figure 5 and figure 6).
●Small portable flexible bronchoscopes are also available, which differ from a standard bronchoscope in that the light source is located on the bronchoscope and an eyepiece on the handle is used to visualize the airway directly, without any separate video monitor (figure 2).
●A newer single-unit portable system is available that has a built-in small display monitor at the proximal end of the bronchoscope, eliminating the need for any cables or attachment to an image processor (picture 5).
●Some newer single-use disposable bronchoscopes have video chips at the end of the scope, and the video processor along with the light source are all incorporated in the reusable video monitor to make it a compact unit (picture 6). They come in different sizes and can be used for airway examination, intubation, or to obtain a bronchoalveolar lavage specimen.
●Another flexible bronchoscope system is commercially available that uses a sterile single-use disposable sheath with a built-in working channel which is loaded onto a bronchoscope [17]. It eliminates the need for disinfection between procedures thereby reducing the turn-around time. (See 'Cleaning the bronchoscope' below.)
Light source — The light source of the conventional flexible bronchoscope typically transmits a broad-spectrum white light from the working tip. The image processor can adjust the intensity, color, and brightness of the light and/or the acquired image, as well as store images or videos.
Narrow-spectrum light sources are available, which improve the detection of mucosal variations (principle of confocal bronchoscopy) and can activate native fluorochromes (principle of fluorescence bronchoscopy) or dyes (principle of photodynamic therapy) that destroy malignant cells. (See "Detection of early lung cancer: Autofluorescence bronchoscopy and investigational modalities" and "Endobronchial photodynamic therapy in the management of airway disease in adults".)
Image processor — Images are processed in real time so that the operator can appreciate their location and appropriately target lesions for biopsy or therapy. The image of the illuminated airway is transmitted to the operator in one of two ways, fiberoptic transmission or digitized video transmission:
●Most bronchoscopes utilize a miniature charge-coupled device camera located at the working tip, which captures real-time images and then transmits them to a video processor for presentation on video monitors. Compared with older fiberoptic bronchoscopes, the resulting image is of high resolution, sharper, and magnified, with a wider field of vision.
●Older bronchoscopes used fiberoptic transmission which is why flexible bronchoscopy is sometimes called fiberoptic bronchoscopy. The image of the airway is viewed by an operator peering directly into an eyepiece at the proximal end of the scope, located on the control handle. Image quality is related to the number and condition of the fragile fiberoptic bundle, which is prone to damage with use. Attachments are available that can transmit the image from the eyepiece to a video monitor via the image processor.
Procedure — Flexible bronchoscopy should be performed in a monitored setting where, at minimum, procedural sedation can be administered (eg, bronchoscopy or endoscopy suite, operating room, intensive care unit, emergency department). Procedural details regarding the performance of bronchoscopy are reviewed separately. (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications" and "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)
COMPLICATIONS — The complications of bronchoscopy are largely those associated with procedural sedation and the interventions associated with bronchoscopy (eg, biopsy), all of which are described separately. (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Complications'.)
FOLLOW-UP — Since bronchoscopy is performed in a monitored setting, all patients need to be recovered from sedation (or anesthesia). Patients also need to be followed for complications of specific procedures performed during bronchoscopy, the details of which are discussed separately. (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Postprocedure monitoring'.)
INFECTION AND RADIATION ISSUES
Infection control
Health care workers — Health care workers are at risk of being exposed to infectious organisms from the patient during bronchoscopy. Universal barrier protection including gown, gloves, masks, and eye shields during bronchoscopy is routine. Full barrier protection should also be used by personnel cleaning the scopes. (See 'Cleaning the bronchoscope' below.)
Additional protection is warranted when patients who are at high risk of tuberculosis or have active tuberculosis are undergoing bronchoscopy [18]. In suspected cases of mycobacterial infection or possible airborne transmission, fit-tested N-95 masks should be worn by everyone present in the room during the procedure. It is a common practice to obtain three sets of negative sputum culture for acid-fast bacilli prior to doing a bronchoscopy in a suspected case of tuberculosis. (See "Tuberculosis transmission and control in health care settings".)
Similar precautions are needed during bronchoscopy in coronavirus 2019 (COVID-19) infection. (See 'COVID-19' below.)
Cleaning the bronchoscope — Proper cleaning and disinfection is the single most important aspect of bronchoscope reprocessing and maintenance [19-21]. An appropriate protocol and experienced technicians play key roles in preventing a potential infectious outbreak (eg, mycobacterial, fungal, Pseudomonas aeruginosa, or other bacteria) [22].
The four important steps in reprocessing a bronchoscope include:
●Mechanical cleaning of the lumen and the ports with an enzymatic solution
●Leak testing
●Soaking in disinfectant solution
●Rinsing and drying
Immediately after the completion of the procedure in the bronchoscopy suite, it is a good practice for the operator to suction saline through the bronchoscope to prevent sludge from forming in the working channel. Cleaning begins as soon as the bronchoscopy is completed. In the cleaning area, the bronchoscope should then be inspected for damage, since breaches on the surface of the bronchoscope may develop concretions of debris that cannot be disinfected [19]. All suction ports and attachments should be removed and attachments that cannot be properly cleaned (eg, suction port cap) should be either sterilized or disposed. The internal channels should be thoroughly brushed, since sludge and concretions can develop within the channels. A leak test is routinely performed to determine the integrity of the working channel (movie 1).
The bronchoscope can be disinfected manually or with an automated endoscope reprocessor (picture 7). It is usually soaked for about 20 to 30 minutes in disinfectant solution. Common disinfectants include glutaraldehyde, peracetic acid, ortho-phthalaldehyde, or a hydrogen peroxide formulation. Following disinfection, the bronchoscope is thoroughly rinsed with sterile water or filtered tap water and 70 percent alcohol, since any retained disinfectants may cause mucositis in subsequent patients. The inner channel can be dried by insufflating air into the working ports. After cleaning, the bronchoscopes are hung upright to prevent the accumulation of moisture (picture 8). It is a good practice to transport them inside a bag or sleeve to avoid any contamination prior to use on a patient.
Some institutions use single-use bronchoscopes, particularly for cases with high infection rates.
COVID-19 — Guidance regarding performing bronchoscopy in patients with high-risk infections such as coronavirus disease 2019 (COVID-19) has been published by several societies including the American College of Chest Physicians and the Society for Advanced Bronchoscopy [23-25]. In brief, guidelines are focused on protection of staff and patients.
Since bronchoscopy is an aerosol-generating procedure, precautions must be taken to optimize the safety of health care workers with strict barrier techniques (eg, personal protective equipment [PPE] with impermeable gown, N-95 mask, eye cover, cap, gloves, shoe covers). A powered air-purifying respirator (PAPR) is not mandatory.
Elective procedures can be delayed for two to three weeks since the onset of symptoms or confirmation of COVID-19 infection. A negative test is not mandatory after three weeks. However, urgent time-sensitive bronchoscopies (eg, airway management, control of hemoptysis, or diagnosis and staging of lung cancer) can be performed using strict barrier techniques without any untoward effects on the operators.
While bronchoscopy suites are equipped with negative airflow, bronchoscopies on COVID-19-infected patients can be performed at bedside in the intensive care unit or COVID units in intubated patients, where negative airflow is not available. A simple diagnostic bronchoalveolar lavage can be performed on mechanically ventilated patients by one operator [26]. (See "COVID-19: Management of the intubated adult", section on 'Bronchoscopy'.)
Other recommendations include limiting the number of staff participating in bronchoscopy, use of disposable bronchoscopes when feasible, donning appropriate PPE for an aerosol-generating procedure, and performance in an airborne isolation room [23].
Standard recommendations for infection prevention for patients who remain infectious with COVID-19 are provided in detail separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection" and "COVID-19: Management of the intubated adult", section on 'Bronchoscopy'.)
Radiation control — All personnel should wear lead aprons with neck shields if fluoroscopy is planned during the procedure to minimize radiation exposure. The suite may be locked or a clear sign posted on the door to indicate the use of fluoroscopy to prevent exposure to health care workers. The bronchoscopist and the assistants should complete an operational training prior to using fluoroscopy per the institutional policy, and always wear a radiation dosimeter badge to measure the amount of exposed radiation. (See "Radiation-related risks of imaging".)
TRAINING AND COMPETENCY — Flexible bronchoscopy should be performed by experienced operators because this maximizes the quality of the bronchoscopic examination, the quality of sample collection, and patient safety. It is typically performed by pulmonologists, thoracic surgeons, critical care clinicians, anesthesiologists, and otolaryngologists.
In addition to the dexterity and skills, the operator needs to have thorough knowledge of the indications, contraindications, alternate options, risks, potential complications, and their immediate management. Basic maneuvers can be learned from an expert by training on a simulator or by practicing on an airway model [27-29]. The operator must be familiar with the bronchial tree and able to identify all the lobar bronchi and its subsegments before performing it independently (figure 1) [30]. The American College of Chest Physicians suggests a minimum of 100 supervised procedures for training and 25 procedures per year to maintain competence [31]. We believe that competency cannot be determined by the number of procedures alone, but also depends upon performing the specific types of bronchoscopic procedures that the specialty requires.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here is the patient education article that is relevant to this topic. We encourage you to print or e-mail this topic to give to your patient. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topic (See "Patient education: Flexible bronchoscopy (Beyond the Basics)".)
SUMMARY AND RECOMMENDATIONS
●Bronchoscopy is an endoscopic procedure that visualizes the tracheobronchial tree by placing an optical instrument inside the airways. There are many types of bronchoscopy (flexible, rigid, robotic, or virtual), among which flexible bronchoscopy is the most common (table 1). (See 'Introduction' above and 'Types of bronchoscopy' above.)
●Unlike the rigid bronchoscope, the flexible bronchoscope has a mechanism to flex or extend its distal end, which facilitates insertion through curved airways (figure 2 and figure 3). The traditional white light flexible bronchoscope can examine the oropharynx, vocal cords, and trachea, and airways to the third order of bronchi can be visualized (figure 1). Diagnostic samples may be obtained (from airways and lung parenchyma) and airway lesions can be treated with a variety of accessory equipment that can be used with the flexible bronchoscope. Other variants of the flexible bronchoscope exist, each with their own unique features for visualization and sampling of the tracheobronchial tree (eg, endobronchial ultrasound). (See 'Flexible bronchoscopy' above.)
●Patients should be selected for flexible bronchoscopy only after carefully weighing the indications and contraindications. (See "Flexible bronchoscopy in adults: Indications and contraindications".)
●Standard bronchoscopy equipment typically consists of the bronchoscope and an image processor with a light source. The bronchoscope contains optical fibers or a small camera at the distal end, to transmit images, and a working channel. Images are processed in real time so that the operator can appropriately target lesions for biopsy or therapy. The working channel can be used to insert diagnostic and therapeutic instruments or to apply suction to remove secretions from the airways. (See 'Equipment and procedure' above and "Flexible bronchoscopy in adults: Associated diagnostic and therapeutic procedures".)
●The complications of bronchoscopy are largely those associated with procedural sedation and the interventions associated with bronchoscopy (eg, biopsy). Since bronchoscopy is performed in a monitored setting, all patients need to be recovered from sedation (or anesthesia) and followed for complications. (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Complications' and "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Postprocedure monitoring'.)
●Full protection barrier (masks, gloves, gown, and eye-shields) should be worn by all personnel. The bronchoscope should be cleaned and disinfected after each procedure to prevent the transmission of infection and a leak test should be routinely performed to determine the integrity of the working channel. All personnel should wear lead aprons with neck shields if fluoroscopy is planned during the procedure. Additional precaution is needed to perform bronchoscopy in patients with coronavirus 2019 (COVID-19) infection. (See 'Infection and radiation issues' above.)
●Flexible bronchoscopy should be performed by experienced operators to maximize the quality of the procedure and to assure patient safety. (See 'Training and competency' above.)
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