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ORIGINAL ARTICLE - INTERVENTION PULMONOLOGY
Year : 2020  |  Volume : 69  |  Issue : 2  |  Page : 352-357

Diagnostic experience of flexible fiberoptic bronchoscopy in al-azhar university hospital


Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission01-Jan-2019
Date of Decision17-Apr-2019
Date of Acceptance24-Apr-2019
Date of Web Publication14-May-2020

Correspondence Address:
MD Chest Degree Sameh F Makled
Department of Chest Diseases, Al-Azhar University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejcdt.ejcdt_22_18

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  Abstract 


Background Fiberoptic bronchoscopy (FB) is an endoscopic technique for visualizing the inside of the airway for diagnostic and therapeutic purposes. FB is a simple, useful examination suitable for investigation without general anesthesia.
Aim We aimed to report our 5-year experience with the diagnostic yield of FB at the Al-Azhar University Hospital.
Patients and methods A retrospective review of bronchoscopy reports was performed at the Chest Department, El-Hussein University Hospital, Al-Azhar University, during the 5 years from January 2012 to December 2016. Data collected were encoded into MS Excel 2017 for windows XP professional. Age was presented as mean. Due to the descriptive nature of this study; all other data were presented as percentage. The calculation was done using Excel.
Results Bronchoscopy was successful for giving a final diagnosis in 275 (78.6%) patients out of 350 patients. Of these, 190 patients were men and 160 patients were women. Malignancies were diagnosed in 66.3% of cases; tuberculosis was diagnosed in 2.8%; and interstitial lung diseases were diagnosed in 3.7% of cases.
Conclusion FB can be performed easily in hospitals with appropriate preparation, observation, and attachment to protocol. This study confirms that FB is a valuable diagnostic tool, with low cost and low rates of complication, particularly in patients with lung cancer. Bronchoscopists face many challenges to reach the correct diagnosis of peripheral lung diseases. Some diagnostic bronchoscopies fail to reach the diagnosis, so bronchoscopy can be repeated or search for other diagnostic modalities. Bronchoscopy, performed under local anesthesia in the endoscopy suite, gives a solution in most cases with minimal complications.
Recommendation Every pulmonologist should be aware and well trained in bronchoscopy.

Keywords: biopsy, bronchoscope, diagnosis, endobronchial, fiberoptic, flexible, radiology and histopathology


How to cite this article:
Halima KM, Makled SF, Basiony FS. Diagnostic experience of flexible fiberoptic bronchoscopy in al-azhar university hospital. Egypt J Chest Dis Tuberc 2020;69:352-7

How to cite this URL:
Halima KM, Makled SF, Basiony FS. Diagnostic experience of flexible fiberoptic bronchoscopy in al-azhar university hospital. Egypt J Chest Dis Tuberc [serial online] 2020 [cited 2020 Aug 3];69:352-7. Available from: http://www.ejcdt.eg.net/text.asp?2020/69/2/352/284329




  Introduction Top


Bronchoscopy is an endoscopic technique of visualizing the inside of the airway for diagnostic and therapeutic purposes. This allows the practitioner to examine the patient’s airway for abnormalities such as foreign body, bleeding, tumor, and inflammation [1]. The flexible fiberoptic bronchoscopy (FB) has been and still a useful tool used for the diagnosis and understanding of lung diseases since its introduction by Ikeda et al. [2]. FBs have different sizes to allow the observation of the bronchial tree to the level of the fifth generation of bronchi [3].


  Patients and methods Top


This is a retrospective study conducted on 350 patients from the Chest Department, El-Hussein University Hospital, Al-Azhar University during 5 years from January 2012 to December 2016. The study was approved by the hospital ethics committee and a written consent was obtained from each patient prior to the procedure. All patients were subjected to the following − full history taking and physical examination, plain chest radiography (posteroanterior and lateral views). Computed tomography (CT) scanning of the chest, complete blood picture, liver and kidney function tests, coagulation profile (prothrombin time and concentration), erythrocyte sedimentation rate, and arterial blood gases to prepare the patients for the procedures. Tuberculin skin test using five tuberculin units injected intradermally and interpreted after 48–72 h, sputum smear examination for the presence of acid fast bacilli (AFB) on 3 successive days in cases with sputum production or sputum analysis for malignancy and ECG were done followed by FB.

Exclusion criteria

The following patients were excluded from the study: those with uncorrectable hypoxemia in which the PaO2 is less than 70 mmHg and if it cannot be safely corrected to this figure by supplemental oxygen, acute myocardial infarction, unstable angina, serious cardiac dysrhythmia, uncorrectable bleeding tendency, and uncooperative patients.

Bronchoscopic procedure

Prebronchoscopy assessment

Before bronchoscopy, radiological evaluation should routinely include plain chest radiography, CT scanning of the chest, and ABG analysis to evaluate the respiratory status. An ECG was done to exclude recent myocardial infarction or arrhythmia. Other investigations include coagulation profile, blood glucose, blood group, platelet count, liver and kidney function tests; also informed consent must be obtained from the patient and the procedure was explained to each patient.

Bronchoscopic procedure

Patients were fasting for at least 6 h before the procedure. The patient was placed on the operating table and prepared for the bronchoscopy procedure in the endoscopy unit. The patient was made to lie down in the supine position and connected with a monitoring system; ECG, respiratory rate, and pulse oximetry were performed.

The procedure was performed using a FB (pentex) under local anesthesia, via nasal or oral route with the patient lying in the supine position. Patients were premedicated with intramuscular atropine 0.4 mg for 10–30 min before the procedure to reduce secretions and minimize vasovagal reflexes except patients with contraindication, followed by topical anesthesia with 2 ml of lidocaine spray 4% applied nasally or orally and short-term sedation with intravenous midazolam 0.07 mg/kg to create a drowsy state before starting the procedure and after the insertion of the bronchoscope.

All patients were supplemented with oxygen through nasal cannula and were monitored with pulse oximetry and ECG. Liquid xylocaine 2% was administered through the bronchoscope directly to the vocal cords and the bronchial tree as needed. During the bronchoscopic procedure, diagnostic samples were obtained as bronchial washing, bronchoalveolar lavage (BAL), transbronchial needle aspiration (TBNA), endobronchial biopsy, or transbronchial biopsy (TBB) according to each case.

For patients with suspected lung cancer, BAL was performed in the involved segment and in cases with no endobronchial lesion, it was performed in the involved segment detected by CT.

For patients with suspected benign lung diseases, BAL was performed in the middle or lingular lobes in disseminated diseases or in the involved segment detected by CT. For healthy patients, BAL was performed in the middle or lingular lobes.

Bronchial secretion or washing was obtained during most procedures by injecting about 10 ml or more of NaCl solution into the bronchus that contains the lesion followed by immediate aspiration into a trap. Specimen was sent to the laboratory microbiological and cytological examinations.

As regards BAL, after the bronchoscope was introduced to the target segment, 80 ml of sterile normal saline (0.9%) was given in aliquots, each containing 20 ml. Suction was applied after each instillation. The recovered fluid by suction or gravity was immediately passed through two layers of sterile gauze to remove mucus. The filtrates were centrifuged at 3500 rpm for 10 min to remove cells. The supernatants were obtained and stored at −20°C.

TBB was performed blindly and as per the international recommendation chest radiography should routinely be done after TBB by about 4 h. In situation TBNA has to be performed. TBNA was performed prior to other procedures such as brushing, BW, and TBB to avoid contamination. A 13-mm 21-G cytology needle was used for TBNA.

Post-bronchoscopy

All patients were kept under close observation for at least 4 h after bronchoscopy.


  Results Top


This study included 350 patients, 190 (54.3%) men and (45.7%) 160 women with an age range of 15–80 and a mean age of 65 years. The number of bronchoscopies performed each year increase gradually from 50 patients in 2012 to 90 patients in 2016. Cigarette smokers accounted for 170 (49%) patients of the studied patients. About 180 (51%) patients were living in urban areas as shown in [Table 1].
Table 1 General characteristic of the studied sample

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The most common symptoms of the patient of the studied group was hemoptysis in 120 (34.2%) patients followed by cough in 80 (22.8%) patients, loss of weight and fever in 56 (16%) patients, dyspnea in 60 (17%) patients, chest pain in 20 (6%) patients, unilateral wheeze in six (1.8%) patients, and lastly hoarseness of voice in eight (2.2%) patients as shown in [Table 2].
Table 2 Clinical presentation of the studied sample

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The most common indications for performing FB were suspected malignancy in 150 (42.85%) patients, followed by suspected infection in 80 (22.85%) patients, others such as persistent cough, elevated paralyzed hemidiaphragm, and pleural effusion with endobronchial lesion in 43 (12.2%) patients. Patients who underwent bronchoscopy due to hemoptysis (n=50; 14.2%) were confirmed to have existing pathology such as malignancy, pneumonia, chronic bronchitis, tuberculosis (TB), and nonspecific inflammation, while FB performed for abnormal radiological finding (n=27; 7.7%), 15 had interstitial lung disease (ILD) whereas 12 had atelectasis. FB confirmed the diagnosis of ILD in patients via the use of TBB were reported for patients with usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia, bronchiolitis obliterans organizing pneumonia, hypersensitivity pneumonitis, and sarcoidosis. For those patients with atelectasis were confirmed to have existing pathology such as malignancy in five cases, mucus plug or impacted secretion in five cases and granulomatous disease in two cases as shown in [Table 3].
Table 3 Diagnostic indication of flexible fiberoptic bronchoscopy

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The most common radiological finding present in chest radiography and CT chest was lung mass in 189 (54%) patients, complete opacification of one lung in 60 (17%) patients, Hilar shadow and mediastinal lymphadenopathy in 50 (14%) patients, and other findings as shown in [Table 4].
Table 4 Radiological findings of the studied sample

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The most common malignancy was confirmed by FFB (Pentax SB 15; Pentax, Japan) as squamous cell carcinoma in 120 (34.2%) patients, followed by adenocarcinoma in 60 (17%) patients, small-cell lung cancer in 10 (2.8%) patients, large-cell lung cancer in 30 (8.4%) patients, lymphoma in 10 (3%) patients, carcinoid in two (0.57%) patients, bacterial pneumonia in 10 (2.8%) patients, and pulmonary TB in 10 (2.8%) patients. ILD was diagnosed in 13 (3.7%) cases, impacted secretion in five (1.4%) patients, while nonspecific inflammation in 75 (22%) patients as shown in [Table 5].
Table 5 Final results of FFB

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  Discussion Top


The present study, a retrospective analysis of 350 diagnostic bronchoscopies, was performed at the Chest Department, El-Hussein University Hospital, Al-Azhar University during 5 years from January 2012 to December 2016. Although the indication for diagnostic bronchoscopy remained the same, different regions may have different priorities. Suspected malignancy, the most common indication for FB in our records, can be explained by the observation that 54.3 and 48.6% of our cohorts were men and cigarette smokers, respectively; urban area and age of the studied sample are the major risk factors of malignancy. Our study agree with that done by Smyth and Stead [4], where the malignancy was the most common indication for bronchoscopy. On the contrary, our results disagree with those of Alzeer et al. [5] where infection was the most common indication for bronchoscopy followed by malignancy.

This is also consistent with previous studies in which bronchogenic carcinoma formed the commonest indication for FB. In one study of 429 patients, bronchogenic carcinoma was an indication in about 45.5% of cases undergoing FB [6]. There has been an increase in the incidence of lung cancer in India in the last few decades. In a sporadic review from various hospitals across the country, the incidence of lung cancer increased from 27.4 per million in 1950 to 78.6 per million in 1959. There are 47 000 men and 11 000 women diagnosed as having lung cancer every year according to the global burden of lung cancer data in India [7].

Among benign diseases, sarcoidosis, pulmonary infections, evaluation for hemoptysis, and preoperative and postoperative assessment were the common indications. Foreign body inhalation was a rare indication for performing FB. FB is widely used to identify the etiology and localize the site of bleeding. In this study hemoptysis as an indication for FB constituted 14.2% (n=50) of all the bronchoscopies performed.

ILD was an indication in 4.2% (n=15) of all bronchoscopic procedures performed. Sarcoidosis was the commonest disease, whereas others such as nonspecific interstitial pneumonia, idiopathic pulmonary fibrosis, hypersensitivity pneumonia, and eosinophilic lung diseases were an indication for FB in only a minority of cases. While sarcoidosis as an indication for bronchoscopy had increased over time, other ILDs have remained fairly constant as an indication for the diagnosis. The diagnosis of interstitial lung disorders such as idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia is primarily clinicoradiological (or requires surgical lung biopsy), and generally obviates the need for FB.

Gupta et al. [8] performed a retrospective analysis of all FB procedures performed between September 1979 and November 2013; the total number involved was 24814 patients: they found that the most common clinical indication for performing FB during the study period was bronchogenic carcinoma constituting almost one-third of all the bronchoscopies performed. Among benign diseases, sarcoidosis, pulmonary infections, evaluation for hemoptysis, and preoperative and postoperative assessment were the common indications. Foreign body inhalation was a rare indication for performing FB. FB is widely used to identify the etiology and localize the site of bleeding. In their series, hemoptysis as an indication for FB constituted 11% (n=2734) of all the bronchoscopies performed. Nonresolving pneumonia as an indication was seen in ∼20% of all bronchoscopies performed. ILD was an indication in 13% (n=3244) of all bronchoscopic procedures performed.

Our result showed an overall diagnostic yield of 78.6% and a yield of 66.3% for detecting malignancy. So, this study confirms the importance of FB in the diagnosis of different pulmonary lesions especially for detecting malignancies, which increase to 95% for macroscopically visible tumors. Endobronchial biopsies provided the highest sensitivity followed by washing and BAL ([Table 6]). The study done by Mohamed et al. [9] showed an overall diagnostic yield of 67% and a yield of 70% for detecting malignancy. Several authors had reported the diagnostic yield of FFB, with controversial results. Joos et al. [10] and Alzeer et al. [5] reported an yield of 57 and 58%, among 430 and 592 patients, respectively. Whereas, Bhadke et al. [10] and Fein and Feinsilver [11] reported yields of 75 and 86%, among 120 and 14 patients, respectively. These discrepancies might be explained by differences in patient numbers and demographic, methods of laboratory and pathologic diagnosis, and statistical analysis. Our study disagrees with that done by Awotedu et al. [12], which shows the diagnostic yield of FB was 44% in the studied patients and that in 83 patients, 22 patients had primary lung malignancy, four had TB, three had secondary lung malignancy, and three had sarcoidosis. The cytological results have shown that squamous cell carcinoma was the most common type of lung cancer in men by 34.2, then adenocarcinoma in17%, large-cell lung cancer in 8.4%, small-cell lung cancer and lymphoma in 2.8% and lastly carcinoid tumor in 0.57%. The study done by Kaparians et al. [13] showed that the most common type of lung cancer in women is adenocarcinoma followed by squamous cell carcinoma which is common in men followed by small-cell lung cancer. In a study by Knight and Clarke [14] it has been reported that 36% of the studied patients had visible carcinoma, while that done by Zavalo [15] showed that the two diseases most frequently occurred were bronchogenic carcinoma and bacterial infection in 55 and 16%, respectively. Our data have shown that bacterial pneumonia was diagnosed in 3% of patients who underwent bronchoscopy for suspected infection. The study done by Mohammed et al. [9] showed that bacterial pneumonia was diagnosed in 48.5% of patients who underwent bronchoscopy for suspected infection. Other studies reported different results [5],[9],[10], yet with smaller numbers of enrolled patients. The infection due to the Candida species has become more frequent in immunocompromised patients like those with HIV, diabetes mellitus, and those on immunosuppressive drugs and corticosteroid.
Table 6 Diagnostic yield of flexible fiberoptic bronchoscopy in the studied sample

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Our study has shown that the diagnosis of pulmonary TB in 2.8% of reported cases due to a good selection of cases suspect for TB to avoid contamination of the bronchoscope in positive cases. Many studies [5],[9],[16] had established the utility of FB in the diagnosis of pulmonary TB. FB can be particularly useful in patients with smear-negative or absent sputum and in those with endobronchial TB. Shin et al. [16] reported sensitivity, specificity, positive predictive value, and negative predictive value for FB of 75.9, 97.2, 95.3 and 84.3%, respectively, for rapid diagnosis of pulmonary TB. The study by Mohamed et al. [9] found an overall diagnostic yield of 58.5%. BAL samples were positive with AFB stain and culture in 42 and 46.2% patients, respectively. Notably, 30% of positive samples for AFB stain were for patients with smear-negative sputum. FFB confirmed the diagnosis of ILD in 4% patients via the use of TBB and were reported for patients with UIP, nonspecific interstitial pneumonia, bronchitis obliterans organizing pneumonia, hypersensitivity pneumonitis and sarcoidosis. The study done by Mohamed et al. [9] reported that the diagnostic yield of 33, 47, and 55% were reported for patients with UIP, bronchiolitis obliterans organizing pneumonia, and sarcoidosis, respectively. Our data is in disagreement with those reported by several authors [5],[17],[18] and confirm the importance of TBB in diagnosing ILD. Those patients with atelectasis were confirmed to have existing pathology such as malignancy, mucus plug, or impacted secretion in 1.2% of patients.Although cost analysis was not carried out in the current study, our results could have important implications with regard to bronchoscopic management of patients with various respiratory diseases [19]. The optimum use of conventional bronchoscopy and its techniques in the hands of experienced bronchoscopists, with the adherence to the international guidelines for performing these techniques [20] will improve diagnostic outcomes of those patients with the least morbidity and mortality, employing better therapeutic strategies, and thus improving the overall management of those patients.

The possible limitations of this study such as the bias in data selection are related to its retrospective nature. Further prospective studies in the future may be needed to highlight the new diagnostic bronchoscopic interventions.


  Conclusion Top


The results of this study confirm that FB is a valuable diagnostic tool, with low cost and with low rates of complication, particularly in patients with lung cancer. FB can be performed with relative safety in a teaching hospital with appropriate preparation, supervision, and adherence to protocol. Bronchoscopists face numerous challenges to establish the correct diagnosis of peripheral lung diseases. Some diagnostic bronchoscopies fail to achieve the designated goals, so patients have to repeat bronchoscopy or need additional procedures. Bronchoscopy, performed under local anesthesia in the endoscopy suite, gives solution in most cases with minimal complications.

Recommendation

Every pulmonologist should be aware and well trained about bronchoscopy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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