Bronchoscopy Enough or Too Much?

Abstract

Hippocrates's caveat, primum non nocere, or “do no harm,” applies to fiberoptic bronchoscopy (FFB). We support Robin's1Robin ED Iatroepedemics: a Probe to examine systematic preventable errors in (chest) medicine.Am Rev Respir Dis. 1987; 135: 1152-1156PubMed Google Scholar analysis of iatroepidemics, the plagues caused by physicians. Dr. Robin cited a probable iatroepidemic of excess diagnostic fiberoptic bronchoscopy in many patients in whom “no firm indication exists that any therapeutically useful information will emerge.” The American Thoracic Society2American Thoracic Society. Guidelines for fiberoptic bronchoscopy in adults. Am Rev Respir Dis 1987; 136:1066Google Scholar has published guidelines for fiberoptic bronchoscopy in adults, urging “experience and sound clinical judgment in individual cases.” Fiberoptic bronchoscopy quickly achieved widespread use in chest medicine because of its diagnostic utility, minimal morbidity, and patient acceptance. Sackner3Sackner MA Bronchofiberscopy: state of the art.Am Rev Respir Dis. 1975; 111: 62-88PubMed Google Scholar reinforced Jackson's sentiments of 1915 concerning indications for bronchoscopy: “In case of doubt as to whether bronchoscopy should be done or not, bronchoscopy should always be done.” FFB should not replace thought in clinical problem solving. Detailed medical histories, physical examination, and review of prior roentgenograms may obviate invasive diagnostic techniques. Nevertheless, FFB may provide information previously obtainable only through potentially more harmful or expensive procedures, such as mediastinoscopy or thoracotomy, and permit additional insight into pulmonary immunopathology and pathologic bronchial anatomy. Generally, physicians perform FFB for evaluation of symptoms, focal or diffuse lung disease, or therapeutically for atelectasis or foreign body removal. Available data substantiate the poor yield of diagnostic bronchoscopy for hemoptysis with nonlocalizing chest films. No fewer than ten studies address this issue.4Adelman M Haponik EF Bleecker ER Britt EJ Cryptogenic Hemoptysis.Ann Intern Med. 1985; 102: 829-834Crossref PubMed Scopus (65) Google Scholar In our institution, using standard indications,5Snider GL Editorial. When not to use the bronchoscope for hemoptysis.Chest. 1979; 76: 1-2Crossref PubMed Scopus (11) Google Scholar only two of the last 100 bronchoscopies performed for hemoptysis with normal roentgenograms have demonstrated neoplasms, both carcinoid tumors (unpublished data). Patient enthusiasm for diagnostic study and fear of “delayed diagnosis” of malignancy may promote these studies.6Spiro HM Delayed diagnosis of disease.JAMA. 1985; 253: 2258Crossref Scopus (8) Google Scholar Poe et al7Poe RH Israel RH Utell MJ Hall WJ Chronic cough: bronchoscopy or pulmonary function testing?.Am Rev Respir Dis. 1982; 126: 160-162PubMed Google Scholar and Irwin et al8Irwin RS Corrao WM Pratter MR Chronic persistent cough in the adult: the spectrum and frequency of causes and successful outcome of specific therapy.Am Rev Respir Dis. 1981; 123: 413-417PubMed Google Scholar reported a 2- to 4-percent yield of FFB for unexplained cough, reflecting the low incidence of bronchial abnormalities seen in patients with rhinitis and/or unsuspected asthma. Our primary use of FFB occurs in the diagnosis and staging of lung cancer. FFB has a role in the patient with the solitary pulmonary nodule (in establishing both benign and malignant diagnosis), in staging the mediastinum, and detecting synchronous primaries.9Rohwedder JJ The solitary pulmonary nodule [Editorial].Chest. 1988; 93: 1124-1125Crossref PubMed Scopus (3) Google Scholar FFB for assessment of localized disease (eg, right middle lobe syndrome) and bronchography prior to surgical resection of bronchiectasis are accepted. Routine bronchoscopy for lung abscess and slowly resolving pneumonia with clinical evidence of a patent bronchus is unnecessary. Patients with bronchogenic carcinoma and lung abscess have a lower incidence of systemic symptoms, less predisposition to aspiration, lower white cell count, less fever, and smaller infiltrates.10Sosenko A Glassroth J Fiberoptic bronchoscopy in the evaluation of lung abscesses.Chest. 1985; 87: 489-494Crossref PubMed Scopus (36) Google Scholar Fein and others11Fein AM Feinsilver SH Niederman MS Fiel S Pai PB When the pneumonia doesn't get better.Clin Chest Med. 1987; 8: 529-541PubMed Google Scholar review the natural history of commonly occurring pneumonias and data on bronchogenic carcinoma, reiterating the frequency of host defects and infrequency of bronchogenic carcinoma (0 to 8 percent). Murray et al12Murray JF Felton CP Garay SM et al.Report of a National Heart, Lung, and Blood Workshop: pulmonary complications of the acquired immunodeficiency syndrome.N Engl J Med. 1984; 310: 1682-1688Crossref PubMed Scopus (465) Google Scholar and Stover and colleagues13Stover DE Zaman MB Hajdu SI Lange M Gold J Armstrong D Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host.Ann Intern Med. 1984; 101: 1-7Crossref PubMed Scopus (357) Google Scholar have validated the use of bronchoalveolar lavage (BAL) in immunocompromised patients. Despite Luce's14Luce JM Sputum induction in the acquired immunodeficiency syndrome [Editorial].Am Rev Respir Dis. 1986; 133: 515-518Google Scholar promising review of sputum induction in acquired immunodeficiency syndrome, we have limited success with this technique and rarely avoid FFB with symptomatic HIV human immunodeficienty virus-infected patients. Wall et al15Wall CP Gaensler EA Carrington CB Hayes JA Comparison of transbronchial and open lung biopsies in chronic infiltrative lung diseases.Am Rev Respir Dis. 1981; 123: 280-285PubMed Google Scholar demonstrated the superiority of open lung biopsy for diffuse lung disease without suspected sarcoidosis or cancer, limiting the utility of FFB in these settings. A basis for use of BAL for assessment of interstitial lung disease is emerging,16Crystal RG Reynolds HY Kalica AR Bronchoalveolar lavage: the report of an international conference.Chest. 1986; 90: 122-131Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar although we agree with Whitcomb and Dixon17Whitcomb ME Dixon GF Gallium scanning, bronchoalveolar lavage, and the national debt [Editorial].Chest. 1984; 85: 719-721Crossref Scopus (7) Google Scholar and Davis18Davis GS Bronchoalveolar lavage and the technological dilemma [Editorial].Am Rev Respir Dis. 1986; 133: 181-183PubMed Google Scholar that its routine clinical use is premature. Reynolds'19Reynolds HY Bronchoalveolar lavage.Am Rev Respir Dis. 1987; 135: 250-263PubMed Google Scholar concept of the “patient-volunteer” for BAL research is appealing. In our practice, we receive no reimbursement for bronchoscopy, are not concerned with loss of our referral base when we decide against bronchoscopy, and we may be less concerned about malpractice. Factors that might increase our use of FFB are our training program, absence of cost concerns for patients, and the need to establish a rapid final diagnosis so as to return some of our patients to worldwide duty. We suspect that unneeded FFB is most likely to occur in the evaluation of symptoms (cough, hemoptysis) and in overzealous therapy, particularly for atelectasis. Approaches that we employ that restrict our use of FFB are: making a clinical rather than pathologic diagnosis of type I sarcoidosis in selected patients,20Winterbauer RH Belic N Moores KD A clinical interpretation of bilateral hilar adenopathy.Ann Intern Med. 1973; 78: 65-71Crossref PubMed Scopus (192) Google Scholar CT with phantom density comparison for solitary pulmonary nodules,21Zerhouni EA Boukadoum M Siddiky MA et al.A standard phantom for quantitative CT analysis of pulmonary nodules.Radiology. 1983; 149: 767-773Crossref PubMed Scopus (88) Google Scholar avoiding transbronchial biopsy in patients with diffuse interstitial lung disease in whom sarcoid, malignancy, or infection are not among the leading diagnoses, and restriction of therapeutic bronchoscopy virtually to patients with refractory lobar atelectasis or foreign body aspiration. We do not bronchoscope low-risk, nonsmoking, postsurgical patients with slowly resolving atelectasis. Marini and others22Marini JJ Pierson DJ Hudson LD Acute lobar atelectasis: a prospective comparison of fiberoptic bronchoscopy and respiratory therapy.Am Rev Respir Dis. 1979; 119: 971-978PubMed Google Scholar demonstrated that no significant difference exists in restoration of postoperative volume loss between bronchoscopy and chest physical therapy. We rarely employ FFB to diagnose acute pneumonia in the previously normal host and avoid FFB for at least six to eight weeks for slowly resolving pneumonia (radiographically) in a patient who is clinically recovering. FFB expands our diagnostic capabilities in many benign and malignant diseases, as well as broadens our understanding of pulmonary immunopathology. Its clinical uses expand continually, and yields should increase with newer technology. However, bronchoscopists should ask themselves, “If I were the patient, would bronchoscopy be necessary?” and “If the patient had no resources, would I perform bronchoscopy at no cost?” More data are needed examining the use and effect of FFB in contemporary practice to confirm or refute Dr. Robin's analysis. Bronchoscopy is more than a procedure, it is a science; it also is a means to an end, not an end in itself.