Profile of Repeat Fiberoptic Bronchoscopy
T. Balamugesh, A.N. Aggarwal, D. Gupta, D. Behera and S.K. Jindal
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Background. Fiberoptic bronchoscopy (FOB) is invaluable in the diagnosis of a variety of
pulmonary diseases, but in many instances the procedure has to be repeated because of an
inconclusive initial FOB or for reassessment.
Methods. A retrospective analysis of all the fiberoptic bronchoscopic procedures done between
September 2000 and February 2003 was performed and details of patients undergoing repeat
Results. Of the 2,270 bronchoscopies performed on 2114 patients, 132 procedures were repeated,
yielding an over all frequency of repeat FOB of 6.34 percent. Bronchoscopy was done twice in
112 patients, thrice in 16 patients and four times in four patients. The commonest diagnosis in
patients undergoing repeat bronchoscopy was bronchogenic carcinoma, followed by non-
resolving pneumonia or presence of pulmonary infiltrates in immunocompromised host. The
major indications for repeating FOB included obtaining specimens for pathological examination,
pre and postoperative evaluation of airways, localization of site of bleeding in patients with
hemoptysis, and placement of catheters for intraluminal brachytherapy. Of the 88 cases
undergoing repeat bronchoscopy for diagnostic purposes, 41 (46.6%) yielded positive results,
either in form of positive histology or localisation of source of hemoptysis.
Conclusions. The frequency of repeat bronchoscopy was low. Commonest indication for a repeat
procedure was to obtain repeat/additional diagnostic samples. A repeat procedure can yield
positive results even when the initial FOB is nondiagnostic.
Key words: Fiberoptic bronchoscopy, Bronchogenic carcinoma, Bronchial biopsy.
[Indian J Chest Dis Allied Sci 2005; 47: 181-185]
INTRODUCTION comfort of the patient, greater maneuverability
of the bronchoscope, improved diagnostic
Flexible fiberoptic bronchoscopy (FOB), the
accuracy and safety of FOB as an outpatient
most frequently performed invasive procedure
in practice of pulmonary medicine has largely
replaced rigid, open-tube bronchoscopy in the Besides localisation and biopsy of airway
diagnosis and management of inflammatory, tumours, FOB is useful in evaluation of
infectious, and malignant diseases of the interstitial lung diseases, non-resolving pneu-
lungs 1,2 . This has been possible due to the monias (especially in immunocompromised
[Received: July 28, 2003; accepted after revision: December 11, 2003]
Correspondence and reprints request: Dr S.K. Jindal, Professor and Head, Department of Pulmonary Medicine,
Postgraduate Institute of Medical Education and Research, Chandigarh-160 012, India; Tele.: 91-172-2747585-94
Extn 6821; Telefax: 91-172-2745959; E-mail: <email@example.com>.
182 Repeat Bronchoscopy T. Balamugesh et al
patients), and unexplained hemoptysis. FOB is bronchial biopsy, and bronchoalveolar lavage
also useful in the assessment of response to (BAL) were obtained after thorough evaluation
treatment and placement of catheters for of the endobronchial anatomy.
intraluminal brachytherapy for bronchogenic
Depending on clinical, radiologic and
carcinoma, and placement of stents in airway
bronchoscopic findings, patients not diagnosed
after FOB were subjected to either a repeat
Although FOB is invaluable in the diagnosis procedure, or advised other diagnostic tests. The
of a variety of pulmonary diseases, the outcome of these other tests were not available
procedure is required to be repeated in several for most patients. For intraluminal brachy-
situations, either because of an inconclusive therapy, the catheter with its guidewire was
initial study or for reassessment. We have inserted through the working channel of the
analysed the frequency and indications of repeat bronchoscope and placed at the site of tumor.
bronchoscopic procedures performed at our
institute over a two and half year period. Such
an analysis has been infrequent in published RESULTS
literature. The significance of nondiagnostic
bronchoscopies as well as the efficacy of serial Of the 2,270 bronchoscopies performed on
procedures has not been well addressed in the 2114 patients over a period of two and half
past. years, 132 procedures were repeated, yielding
an over all frequency of repeat FOB of 6.34%. Six
patients were known to be seropositive for
MATERIAL AND METHODS human immunodeficiency virus (HIV). None of
these patients underwent a repeat procedure.
We analysed all fiberoptic bronchoscopic Bronchoscopy was done twice in 112 patients,
procedures performed on a nonemergent basis thrice in 16 patients and four times in four
between September 2000 and February 2003. patients. No procedure-related complications
Records of all patients who underwent repeat were observed in any of the repeat
bronchoscopies were identified and analysed. bronchoscopies.
Bronchoscopy was done as an outpatient
The commonest diagnosis in patients
procedure in all instances. Assessment of
undergoing a repeat bronchoscopy was
coagulation profile and pulmonary function
bronchogenic carcinoma (69 patients, 52.3%).
tests was carried out before bronchoscopy in
Forty-three patients underwent repeat proce-
patients where transbronchial lung biopsy was
dures to obtain a repeat (40) or fresh (3) bron-
planned. Electrocardiogram was done in all
chial biopsy specimen. A positive diagnosis was
patients above 35 years of age. Informed
made in 15 instances. Five patients underwent
consent was taken, and was repeated in those
transbronchial biopsies, two of which yielded
requiring repeat bronchoscopy. After
the diagnosis. Ten patients received
premedication with intramuscular atropine (0.6
mg) and promethazine (25 mg), bronchoscopy
was performed with a flexible fiberoptic Sixteen (11.4%) patients had hemoptysis. FOB
bronchoscope (Olympus 1T 20) under topical had to be repeated in 14 of these as the initial
lidocaine anaesthesia. All procedures were assessment did not localise the site of bleeding.
performed by senior residents of the The site of bleeding could be ascertained in
department under supervision of a consultant. seven instances. No active bleeding was noticed
Oxygenation was monitored during and in six patients. In one patient, both the airways
immediately after the procedure with pulse were filled with clots and blood, and it was not
oximetry and oxygen administered wherever possible to localise the site of bleeding. Two
required to maintain a saturation above 90%. other patients underwent repeat FOB as part of
Appropriate samples such as the lung or preoperative assessment.
2005; Vol. 47 The Indian Journal of Chest Diseases & Allied Sciences 183
Twenty (15.2%) patients undergoing repeat repeat bronchial biopsy, 11 (73.3%) were positive
FOB had nonresolving pneumonia. Fifteen of on second biopsy, 4 (26.7%) on third biopsy and
these underwent repeat (11) or fresh (4) none on fourth biopsy. Patients not diagnosed
transbronchial biopsies, of which seven yielded on bronchoscopy were subjected to other
a positive diagnosis. Twelve (9.1%) had inter- diagnostic tests as indicated. Details of these are
stitial lung diseases. Nine patients underwent a not available.
transbronchial biopsy, which was a repeat
procedure in all except one patient. A positive DISCUSSION
histological diagnosis could be made in five of
these. Fifteen other patients underwent repeat We found that 6.34% of patients subjected to
FOB for other indicatons. FOB had to undergo a repeat procedure due to
Overall, the major indications for repeating a variety of reasons. This is comparable to the
FOB included obtaining specimens for frequency of 6.1-10.1% reported from a tertiary
pathological examination (bronchial or lung care hospital from United States3. In another
biopsy, 34.6% and 23.5% respectively), pre and series of patients with acquired immuno-
postoperative evaluation of airways (6.8%) deficiency syndrome (AIDS), 23% of patients
localisation of site of bleeding in patients with had repeat bronchoscopies, and a diagnosis was
hemoptysis (10.6%), and placement of catheters established in 59% of cases if the repeat
for intraluminal brachytherapy (7.6%). Other procedure was performed within a month of the
infrequent indications included the suspicion of initial FOB 4 . This high frequency could be
a problem other than the initial disease, to attributed to increased frequency of pulmonary
document response to therapy of endobronchial infections in HIV positive patients. The overall
lesions or an inadequate initial evaluation in an diagnostic yield of repeat bronchoscopy was
uncooperative patient. 46.59% in our study, although none of these
patients was HIV seropositive.
Of the 88 cases undergoing repeat bronchos-
copy for diagnostic purposes, 41 (46.59%) The commonest indication for a repeat
yielded positive results, either in form of a bronchoscopy was to obtain a second bronchial
positive histology or localisation of source of biopsy specimens in cases of bronchogenic
hemoptysis (Table 1). The yield of repeat carcinoma (31.1%). In such cases the overall
bronchial biopsy was significantly higher in yield in obtaining positive histology was 36.6%.
those with a visible growth (12 of 23 patients, The yield was significantly greater in cases with
52.2%) than in those with mucosal infiltration (3 visible intraluminal growth than in cases with
of 18 patients, 16.7%, p<0.05). Among the 26 mucosal or submucosal infiltration. This is
cases with negative repeat biopsy, four consistent with most reports on FOB yield in
specimens showed necrosis and one specimen bronchogenic carcinoma5. Usually the diagnos-
was inadequate. In the remaining cases, no tic yield of endoscopically visible carcinoma is
definite opinion could be given despite over 90 percent. Greater the number of biopsies,
adequate biopsy material. Of the 15 cases in the higher is the yield. Five direct forceps biopsy
whom a positive histology could be obtained on specimens allow a greater than 90% probability
Table 1. Yield of repeat diagnostic bronchoscopic procedures
Positive Negative Total Yield (%)
Repeat bronchial biopsy 15 26 41 36.6
Repeat transbronchial lung biopsy 7 7 14 50.0
Fresh bronchial biopsy 2 0 2 100
Fresh transbronchial lung biopsy 9 8 17 52.9
Localise bleeding 8 6 14 57.1
Total 41 47 88 46.6
184 Repeat Bronchoscopy T. Balamugesh et al
of obtaining at least one positive sample. But introduced into the catheter and positioned.
forceps biopsy of a tumor causing extrinsic Single large fractions have been associated with
compression is positive in only about one fourth a large risk of massive hemoptysis and,
of cases because the device does not reach the therefore, frequently 2-4 fractions are given11-14.
tumour6-8. Other reasons for a negative biopsy
To summarize, the frequency of repeat
include the presence of necrosis in the tumour
bronchoscopy is low at our institute and is at
mass. This was an important reason for a
par with the Western reports. Commonest
negative result even on repeat sampling.
indication for a repeat procedure is to obtain
In cases where a repeat FOB was done for repeat/additional diagnostic samples. A repeat
obtaining a transbronchial lung biopsy (TBLB) procedure may yield positive results even when
which was not done during the first procedure, the initial FOB is nondiagnostic. Therefore, a
a positive diagnosis could be obtained in 50% of repeat FOB should be considered if the likeli-
cases. Transbronchial biopsy provides a hood of a positive bronchoscopic yield is high.
significantly higher diagnostic yield than that
obtained by BAL in all categories of diffuse lung
diseases, and it has been suggested that TBLB
should be routinely carried out in these
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