The Bronchoscopy Survey

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current status of bronchoscopy The Bronchoscopy Survey* Some Reflections Udllya B. S. Prakash, M.D., F.C.C.P.; and Samuel E. Stubbs, M. D.

This communication is in essence an editorial expressing the views of the authors; it does not represent an official policy statement of the American College of Chest Physicians. The companion report which follows (see page 1668), however; reports the results of an official ACCP survey. Editor (Chest 1991; 100:1660-67) BAL = bronchoalveolar lavage; FFB = 8exible 6beroptic bronchoscope; RB = rigid bronchoscope; TBLB = transbronchial lung biopsy; TBNA = transtracheallbronchial needle aspiration

E

loqu~nt editoria~s have lamented the lack of infor-

matIon regardIng the standards of practice of bronchoscopy. 1-3 The results of the questionnaire survey sponsored by the American College of Chest Physicians (ACCP) and published in this issue (see page 1668) shed light on the "state of the art," if not the "standard," of bronchoscopy as it is currently practiced in North America. The fact that a majority of physicians perform a particular bronchoscopic procedure in an identical fashion does not imply that the method used is the best or preferred one. Keeping in mind the limitations of such surveys, we offer our personal reflections on the findings and interject our own bias in our comments about the "surprise" findings and what constitutes the optimal performance of certain aspects of bronchoscopy. SURVEY PARTICIPANTS

Almost all physicians surveyed were pulmonary specialists. Because of the differences in the patient populations encountered by pulmonary specialists and nonpulmonary physicians, the nature of bronchoscopy practices in these two groups may vary. It would be speculative to extrapolate the results and assume that they represent the bronchoscopy practices of nonpulmonary physicians. If a substantial number of other specialists, such as thoracic surgeons and otolaryngologists, who also perform a significant number of bronchoscopic procedures had been included in the survey, the results may have differed. *From the Division of Thoracic Diseases and the Department of Inte~nal Medicine, Mayo Clinic, Mayo Medical Center, and Mayo MedIcal School, Rochester, Minnesota. Reprint requests: Dr. Prakash, East 18, Mayo Clinic, Rochester; MInnesota 55905

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INDICATIONS FOR BRONCHOSCOPY

It is no surprise that cancer/mass/nodules, hemoptysis, pneumonitis, and diffuse lung disease were the most common indications for bronchoscop)'. What is surprising is the finding that acquired immunodeficiency syndrome and immunosuppression were among the "five most common" indications for bronchoscopy, according to 14.7 percent and 15.4 percent of respondents, respectivel)'. This reflects not only the increasing frequency with which these conditions are encountered in clinical practice, but also the wellestablished value of bronchoscopy in the diagnosis of pulmonary problems in these patients. Considering the high diagnostic yield from bronchoalveolar lavage (BAL) in pulmonary infections in immunosuppressed patients, we expected almost all survey participants to employ this technique, in contrast to the 77 percent who routinely did so in these patients. We stress that bronchoalveolar lavage is safe even in severely thrombocytopenic patients and those requiring mechanical ventilation.4-6 The survey did not investigate, but should have looked into, the prevalence of use of protected catheter brushing for the diagnosis of bacterial infection. 7 ,8 Notwithstanding the documentation that bronchoscopy carries a low diagnostic yield in the evaluation of chronic cough,9-13 nearly a quarter of the survey participants listed it as one of the five most common indications for the procedure. Even though bronchoscopy is presumably aimed at "clearing the airway" in patients with cough and no apparent abnormality on the chest roentgenograph, we believe that bronchoscopy is overused in this group of patients. However, in carefully selected patients with chronic cough and nonlocalizing chest roentgenographic findings, bronchoscopy can be of use .14 It is likely that cough will remain one of the common indications for bronchoscop)'. Hemoptysis was identified as one of the five most common indications for bronchoscopy. The survey questionnaire did not go into more detailed questioning on this important topic. THE RIGID BRONCHOSCOPE

Traditionally, the rigid bronchoscope (RB) has been used by surgeons. A British survey15 reported that The Bronchoscopy Survey (Prakash, Stubbs)

although only 2 percent of 39,564 bronchoscopic procedures performed between 1974 and 1986 employed the RB, more than 90 percent of the RB procedures were done by surgeons. That·~eport also noted that the flexible fiberoptic bronchoscope (FFB) was used by 81 percent of bronchoscopists, that both the FFB and the RB were used by 9 percent and that the FFB through the RB was used by 8 percent. In our ACCP surve~ only 8 percent of the survey respondents used the RB. The reasons for the diminished use of the RB in the current practice of bronchoscopy include the demonstrated versatility of the FFB, the decreasing number of cases where the RB is indicated, and the increasing frequency with which the surgeons, who traditionally used the RB, utilize the FFB. These factors are also responsible for the rapidly diminishing number of experts available to provide training in use of the RB. In our opinion, an uideal bronchoscopist" should be able to use both the RB and the FFB in adults as well as pediatric patients. However, the present trends in training programs and the status of bronchoscopy revealed by the survey suggest that the number of ideal bronchoscopists will gradually diminish. This is unfortunate because the RB is a very useful and extremely versatile instrument, and its applicability in certain clinical situations remains unsurpassed. The superiority of the RB for the management of massive hemoptysis,16,17 laser procedures,I8-21 removal of tracheobronchial foreign bodies,22-25 dilation of tracheobronchial strictures, and placement of airway stentsi6-30 is well established. Nevertheless, some have questioned thiS. 31-34 The latter viewpoint may re8ect a lack of training in use of the RB and therefore a lack ofappreciation ofthe utility ofthe instrument. Granted that general anesthesia or deep intravenous sedation is required in most cases before RB procedures, the RB is as safe as the FFB in experienced hands. RIGID BRONCHOSCOPE IN LASER THERAPY The bronchoscopy section at the Mayo Clinic has performed approximately 400 laser bronchoscopic procedures; except for the initial 25 percent of the procedures, in which the FFB was used, we and our colleagues have used the RB as the primary instrument in such procedures and feel that the RB is far superior to the FFB. Those with experience in using the RB have realized that Ulaser ablation' of large airway tumors is, to a large extent, readily accomplished via the RB, with removal of large pieces of obstructing tissue by a biopsy forceps and the use of the RB itself as a coring instrument. Most of the tumor mass is indeed removed this way, while the laser is used to coagulate and cauterize vascular lesions and vascular stalks of pedunculated tumors. Additionall~ the RB itself functions as an airway dilator. The RB can open an obstructed airway in a much shorter time than the

FFB can. There is an important and statistically significant difference in the number of laser therapy sessions required to treat an airway obstruction with the RB and the FFB: only one session is necessary with the RB, compared with a mean of two with the FFB.OO,35 In fact, bronchoscopists who use only the FFB for laser resection oflarge airway lesions schedule several sessions because of the long duration involved in removing large tumors with the laser via the FFB. The argument that the FFB is better suited for laser therapy of distal or peripheral airway lesions is rather tenuous because such cases are infrequent and the indications for palliative therapy are questionable. Even in those rare cases, we feel that the RB is superior because a FFB can be passed, if needed, through the RB to apply laser therap~36 This approach combines the safety of the RB with the maneuverability of the FFB. 00 Hence, laser bronchoscopists should be proficient in both FFB and RB techniques. 21 ,36 Kvale37 has recommended suitable guidelines for training and credentialing in laser bronchoscop~ FLEXIBLE VS RIGID BRONCHOSCOPE The increasing numbers of negative comments in the literature on the role of the RB seem unjustified without supporting data and are reminiscent ofsimilar criticisms of the FFB when it was first introduced into clinical practice more than two decades ago.38-40 In fact, the increasing role ofthe RB, as discussed above, in the current practice of pulmonolo~ should not be ignored. Clearly, assertions by some authors41,42 that the FFB will eventually replace the RB seem appropriate. The FFB and the RB should complement, not compete with, each other. The surprising findings from the survey included the significant number of bronchoscopists who routinely required many tests before proceeding with bronchoscop~ At a time when the costs of medical care are of increasing concern, it behooves the bronchoscopist to consider each patient individually and to obtain data preoperatively on the basis of the patient's clinical status and the potential risks of the procedure planned. Obtaining an accurate and pertinent history with special attention to the presence of underlying potential risk factors, a proper cardiopulmonary examination, and a chest roentgenogram are three of the most important prebronchoscopy requirements. In an otherwise healthy patient scheduled to undergo bronchoscopy; a complete blood cell count, a hemostatic survey, blood chemistry evaluation, and urinalysis should not be necessary. Uremia is associated with a clinical bleeding tendency that can be quite severe. Platelet dysfunction is common in patients with renal failure. 43 Even though a 45 percent incidence of pulmonary hemorrhage after transbronchial lung biopsy (TBLB) has been documel)ted in CHEST I 100 I 6 I DECEMBER, 1991

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uremic patients,44.45 only 25 percent of the survey participants routinely required evaluation of the creatinine level before bronchoscop~ A blood urea nitrogen level of ~30 mgldl is considered a contraindication to TBLB.45.46 Zavala has stated that u any biopsy procedure is avoided, if at aU possible, on a uremic patient because of hemorrhage."45 In our practice, a serum creatinine level of >3 mgldl is considered a relative contraindication to TBLB. Bronchoscopists are frequently confronted with immuno-suppressed patients with thrombocytopenia. Patients with platelet counts <50,000 dl should receive six to ten packs ofplatelet transfusion before TBLB. ".45 No single test can predict bleeding during surge~ Bleeding-time measurement as a routine screening test is not warranted at the present time because of the inability of this test to predict the risk of hemorrhage in individual patients. 47.48 Likewise, measurement of prothrombin time and the activated partial thromboplastin time should not be used on a routine basis to screen for potential bleeding problems. The tests to determine the risk of bleeding should be individualized, depending on the underlying clinical condition. Prebronchoscopy coagulation screening should be limited to patients with active bleeding, known or clinically suspected bleeding disorders, liver disease, renal dysfunction, malabsorption, malnutrition, or other conditions associated with acquired coagulopathies. 49 Although prebronchoscopy determination ofarterial blood gas levels has been recommended, 50 we do not feel that it is required before aU bronchoscopic procedures. Noninvasive measures such as sphygmomanome~ electrocardiographic monitoring, and pulse oximetry should provide adequate information during the procedure in most cases. Prebronchoscopy pulmonary function tests are also unnecessary. Even the severe respiratory function impairment encountered in immunosuppressed patients with diffuse pulmonary infiltrates is only a relative contraindication to bronchoscop~4 However, if a patient is scheduled to undergo both bronchoscopy and pulmonary function testing within a period of 72 h, it is advisable to perform the latter first, since bronchoscopy can produce bronchial mucosal edema and cause falsely abnormal pulmonary function test results. 51 -53 Grouping of blood type and cross-matching, obtained by 22 percent of British bronchoscopists prior to bronchoscop~ 15 is seldom required. PREMEDICATION

A small number of our survey participants and 6

percent of bronchoscopists in a British survey15 used no premedication. Bronchoscopy without any premedication has been advocated by some. 54 In our opinion, routine avoidance of premedication is unjustified. Prior to bronchoscopy, many patients are more afraid 1882

of the possible diagnosis of cancer than of dyspnea and asphyxiation. 55 Preoperative medication to allay anxiety should be considered for most patients with the proviso that the medication and dosage must be individualized for each patient. Routine use of an anticholinergic drug, such as atropine or glycopyrrolate, is generally recommended to reduce secretions and to prevent bradycardia. 15.56-60 In addition to an anticholinergic, a drug capable of producing sedation or anxiolysis (eg, codeine, meperidine, morphine, or a barbiturate) should be administered approximately 30 to 45 min before the procedure. The wide variety of premedications used by the bronchoscopists in our survey is surprising. The survey did not include questions on the use of topical anesthetics and the method oftheir use. Many publications have discussed the types of topical anesthetic agents available; the majority of bronchoscopists use lidocaine. 15.61-64 SEDATION

Antegrade amnesia, relaxation, and cooperation, not anesthesia, should be the clinical end points when using intravenous sedatives for bronchoscop~ It is our bias that most patients should be given the benefit of an intraoperative sedative. The choice and dosage of sedation should be individualized for each patient, while recognizing the potential for complications with oversedation. The overwhelming superiority of midazolam over diazepam in endoscopic procedures is well established.6S-74 Currently, midazolam is the drug of choice for almost all endoscopic procedures. 69•73 Yet only 48 percent of the survey participants listed midazolam as the sedative of their choice. In contrast to diazepam, midazolam has a shorter half-life, a larger volume of distribution, and faster total body clearance and achieves significant antegrade amnesia in twice as many patients and at lighter levels of sedation. 61 ,66-68,73;15-77 The recommended dose of midazolam for conscious sedation is 0.07 mglkg, but careful titration is required. The dose requirement for midazolam is sex-dependent, with males requiring about 1.0 mg more than females. 78 Elderly patients are particularly sensitive to midazolam; extreme caution is advised in this group of patients. 57,78.79 The wide assortment of intravenous sedative drugs and the drug combinations used by the survey bronchoscopists were also surprising. It is illogical on pharmacologic grounds to use combinations of two or more opiates or more than one benzodiazepine. Since no single agent provides amnesia, anxiolysis, and analgesia, a combination of two drugs (a benzodiazepine and an opiate) may be necessary in many patients. However, combination of three or more sedatives not only seems unnecessary but also increases the risk of respiratory depression. While judicious use of sedatives will allow smoother bronchoscopy, it should be noted that up to half of the life-threatening complicaThe Bronchoscopy Survey (Prakash, Stubbs)

tions have been attributed to sedative use. 61 A disadvantage of sedative use, from the bronchoscopist's viewpoint, is suppression of the patient's ability to cooperate and respond to commands s~.ch.~ ~ose to make a special effort to control coughing and to signal the perception of chest pain during TBLB, the latter indicating close proximity of the biopsy forceps to the pleura.

the use of 8uoroscopy should obviate routine chest roentgenography after TBLB.91-93 Routine hospitalization after TBLB, as recorded by 12 percent of survey participants, is not justified unless complications such as signficant post-TBLB bleeding, pneumothorax, and respiratory distress are encountered.87.89.91.94.95

GENERAL ANESTHESIA

Oral versus nasal insertion of the FFB, once a topic of debate, has become dependent on one's initial training and subsequent confidence in the use of either route.96-102 One third of the survey participants used only the nasal route, and 6 percent used only the oral route. Although we use the oral route in the majority of our patients, the training of our bronchoscopists encompasses both nasal and oral routes. 99•1OO Even though only 43 percent of the surveyed bronchoscopists reported using both routes, we stress that every bronchoscopist should be able to perform bronchoscopy by both routes, since each method has its own distinct advantages. The oral route of introduction of the FFB using an endotracheal tube permits one to readily remove and reinsert the FFB to clean the lens and to remove mucus plugs from the channel. An endotracheal tube adapter provides a convenient method for oxygen supplementation. Furthermore, the FFB can be removed and reinserted quickly if bleeding and clots become a problem; with bleeding, one has control of the airway from the outset if an endotracheal tube is used. The nasal route for insertion of the FFB is easy to learn. The nasal passage functions as a stent for the passage of the FFB, permitting leisurely inspection of the upper airways and observation of the glottis and trachea under dynamic or static conditions. We find the nasal approach ideal for a brief inspection when manipulation of the airway is not anticipated, such as for postoperative inspection after a bronchoplasty procedure, placement ofbrachytherapy catheters, and evaluation of the results of therapy for major airway obstruction.

Anesthesiology assistance is not required for most routine FFB procedures. The number of bronchoscopists who routinely use general anesthesia (16.5 percent in the ACCP survey and 12 percent in a British surveyl5) is startling, since the majority of adult patients can undergo an FFB procedure under topical anesthesia. Technically difficult procedures, most RB procedures, most time-consuming laser bronchoscopic procedures, and extreme patient apprehension are circumstances in which general anesthesia may be desirable. Almost all RB procedures in pediatric patients will necessitate general anesthesia. SUPPLEMENTAL OXYGEN

The common occurrence of hypoxia during bronchoscopy, seen even in patients without significant preexisting hypoxemia, is well documented.80-84 The newer FFBs with larger suction channels have the potential to aspirate large volumes of gas from the lungs. Because of these reasons and the fact that more bronchoscopic procedures are being performed on patients with hypoxia associated with diffuse lung disease, administration ofsupplemental oxygen during bronchoscopy is warranted. 85 •86 This is done routinely by the majority of our survey participants. The suggestion that virtually all patients be given supplemental oxygen during bronchoscopy should be tempered with the counsel that each individual must be carefully assessed before bronchoscop~ Pulse oximetry can be quite useful in assessing adequacy of oxygenation whether or not supplemental oxygen is given. In contrast to our survey respondents, only 18 percent of the bronchoscopists in the British survey routinely provided supplemental oxygen. 15 FLUOROSCOPY

Despite several reports that 8uoroscopy is unnecessary in TBLB,87-89 analysis of responses to a mail survey of231 bronchoscopists in the United Kingdom 15 showed that the incidence of pneumothorax after TBLB was 1.8 percent when fluoroscopy was used and was significantly increased to 2.9 percent when fluoroscopy was not used. We highly recommend the use of fluoroscopy because of the level of confidence it provides the bronchoscopist in selecting the maximally abnormal areas for biopsy. Also, 8uoroscopic guidance permits precise placement of the forceps in the periphery of the lung for TBLB near the pleura. Routine chest roentgenography following bronchoscopy is not cost-effective. 90 Except in unusual cases,

ORAL VS NASAL ROUTE

BRONCHOALVEOLAR LAVAGE

The clinical role of BAL to study the alveolar cells in nonimmunosuppressed patients with diffuse lung

disease is yet to be clearly defined. Routine use of BAL in all nonimmunosuppressed patients is unwarranted. We feel that even the small percentage (24 percent) of bronchoscopists in the survey who performed BAL on a routine basis in nonimmunosuppressed patients is too high. However, it is evident that BAL may be diagnostic in certain diseases, such as pulmonary eosinophilic granuloma, eosinophilic pneumonia, pulmonary alveolar proteinosis, and primary or secondary pulmonary malignancies. 103-lI1 Nearly 70 percent of the bronchoscopists surveyed CHEST 1100 161 DECEMBER, 1991

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performed TBLB routinely in diffuse lung disease in nonimmunosuppressed patients. Until further studies are performed to better elucidate the clinical role of BAL, their approach is appropriate. To provide proper comparisons, the survey should have included a question on the role of TBLB in immunosuppressed patients. TRANSTRACHEAI.ffRANsBRONCHIAL NEEDLE ASPIRAnONlBlOPSY The low rates of routine use of the transtracheaV bronchial needle aspiration (TBNA) in malignant and nonmalignant diseases and the large number of negative comments regarding this procedure suggest that TBNA has not gained popularity among the bronchoscopists who participated in the surve}': This is in spite of several publications that have reported on the clinical usefulness ofthis procedure. 112-115 Nonetheless, as noted by many survey participants, we too find the performance of the TBNA needles to be too often unreliable. Irrespective of which manufacturer produces the needles, we have noted several technical difficulties. It is not uncommon to use two or more needles in one patient because of the failure of the needle to function properl}': Another major problem is the well-documented high rate of needle-induced damage to the inner lining of the FFB. 116 As noted in an earlier editorial,117 the current role ofTBNA in the diagnosis of pulmonary diseases seems unclear to man}': Clearly one can sample malignant nodules, masses, or lymph nodes. This can be very useful in preoperative staging of lung cancer in a patient who is a poor surgical risk. The finding of small cell cancer may obviate surgical intervention. In an otherwise healthy individual without evidence of metastatic disease, however, one must weigh the experience of the bronchoscopist, pathologist, and surgeon acting as a team in their desire to offer the patient the best chance for good results. in many cases, a direct surgical approach seems appropriate. FROZEN SECTION ANALYSIS The advantage of immediate frozen-section biopsy analysis is obvious. If the first biopsy can provide the diagnosis (eg, carcinoma or noncaseous granuloma), further biopsies may be unnecessar)'. This may considerably decrease the risk ofpneumothorax and bleeding with the taking of multiple samples. An inherent problem is the possibility of having the diagnosis change when permanent sections are available because of crush artifacts and problems associated with the processing of tiny specimens. BRONCHOSCOPY FEES In 1990, the average prevailing weighted reimbursement (professional fee) from third-party payers for bronchoscopy in the United States was $333, and the average allowable fee was $287. In the same year, the 1884

prevailing low and high fees among ten states in the United States were $234 and $500, respectively (E Porter, oral communication, Aug 23, 1991). Therefore, the physician fee of $300 to $450 charged by more than half the survey participants seems reasonable. However, many ofthe survey respondents commented that the third-party reimbursement for bronchoscopy is inadequate. Emotional arguments can be elicited in favor of fees on both sides of any dollar figure suggested. While more uniform structuring of the professional fee for bronchoscopy seems desirable on the surface, it may be inappropriate due to the complexity ofeconomic influences in different regions of the United States. COMPLICATIONS While it is convenient to have a dedicated operating room or other facility, bronchoscopy can be performed safely in other areas provided trained personnel and equipment are available to deal with complications, should they develop. The safety of bronchoscopy has been documented by several earlier multicenter studies. I18-120 Since those studies were published, many new bronchoscopic applications and wide variations in the techniques have evolved. lienee, the potential for new complications has arisen. In spite of this, the finding of very low rates of both minor and major complications among the survey participants is heartening. Nevertheless, a word ofcaution seems in order: the proven safety of bronchoscopy should not lead to complacency and indiscriminate use ofthe procedure. Life-threatening complications can be horrifying experiences for both the patient and the bronchoscopist. These experiences should be infrequent, however, for the skilled and experienced bronchoscopist who appreciates the potential risks and is prepared to deal with them. PROFICIENCY To become proficient, performance of 50 to 100 bronchoscopic procedures (FFB and RB) has been suggested. IJI An individual who completed a training program in pulmonary diseases reported that at least 100 bronchoscopic procedures were needed to become proficient. 122 The eligibility requirements to appear for pulmonary certification by the American Board of Internal Medicine do not specify a number of bronchoscopic procedures that must have been performed during training. l23 The American Board of Thoracic Surgery, on the other hand, requires its candidates to have performed at least 25 bronchoscopy and esophagoscopy procedures. l24 We surmise that at least 50 bronchoscopy procedures may be necessary to become competent in routine FFB use. This should include biopsy of visible tracheobronchial lesions, BAL, and therapeutic bronchoscop)'. In addition, the performance of at least ten TBLBs, ten laser procedures, and 10 RB procedures may be needed to become proficient The 8rOI dloecopy SUrvey (Prakash, Stubbs)

in these specialized techniques. Indisputabl~ some physicians, in spite of performing many more than 50 bronchoscopic pr~~dures, may remain inept and lack confidenc~'.·iri·kchievlng pr06cienc~ Therefore, the decision whether someone is competent to peform bronchoscopy should not be made solely on the basis of the number of procedures performed. The program director or the director of bronchoscopy at the training institution should judge and certify the competence of each candidate and recommend and provide remedial training if necessary. Several studies have reported on various techniques of training to strengthen bronchoscopy skills. 121,125-127 COMPETENCE

At least 50 bronchoscopic procedures per year may be necessary to remain competent. We hasten to stress that the peformance of the procedure on a regular basis is far more important than the numbers alone. The issue of the number ofbronchoscopic procedures needed to remain competent is somewhat threatening to bronchoscopists because of its implications regarding credentials and related matters. As noted in the survey, many participants felt that the question on the number of procedures was unfair. Nevertheless, as physicians, we have always been subject to sometimes seemingly arbitrary numeric grading systems from undergraduate through postdoctoral training programs. Like it or not, the "numbers game" is an integral part of our system for evaluation in many areas. GUIDELINES

The survey suggests that bronchoscopists are divided on whether rigid guidelines for bronchoscopy should be established. When guidelines for a procedure are broad or nonexistent, the incidence of improper use increases. One study observed the inappropriate use of upper gastrointestinal endoscopy among 17 percent of gastroenterologists. l28 In an increasingly complex society which demands and deserves quality and cost-effective medical care, welldefined guidelines for bronchoscopy may help prevent inappropriate and perhaps unnecessary procedures. The results of the ACCP survey and similar surveys may help form the foundation for establishing specific guidelines for the standards of practice of bronchoscopy and documentation ofcompetence as a bronchoscopist. REFERENCES 1 Hazards of bronchoscopy [editorial]. BMJ 1986; 293:286-87

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