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A bronchoscope is a thin camera passed through the nose or mouth into the airways. It is used to look, to take samples, and increasingly to treat — clearing a blockage, placing a stent or fitting valves. An ultrasound probe on the tip allows the doctor to see and sample lymph nodes just outside the airway wall, which is how lung cancer is staged.
Diagnostic bronchoscopy
Flexible bronchoscopy is performed under sedation with topical anaesthesia, usually as a day case. Standard sampling includes bronchial washings, brushings, endobronchial biopsy, bronchoalveolar lavage and transbronchial lung biopsy.1
Rigid bronchoscopy, performed under general anaesthesia, remains the tool for massive haemoptysis, foreign body removal, stent placement and airway debulking, because it maintains ventilation and allows large instruments.2
Endobronchial ultrasound
An ultrasound transducer at the bronchoscope tip allows structures beyond the airway wall to be seen and sampled.
- Convex-probe endobronchial ultrasound with transbronchial needle aspiration samples mediastinal and hilar lymph nodes in real time. Combined with oesophageal endosonography it has largely replaced mediastinoscopy for nodal staging of lung cancer, with high sensitivity and far lower morbidity.3,4
- Radial-probe endobronchial ultrasound, usually with navigational or robotic bronchoscopy, is used to reach peripheral nodules that a conventional scope cannot see.
Accurate staging matters to physiotherapy because it determines whether the patient is heading for resection, for chemoradiotherapy, or for palliative treatment — three very different rehabilitation conversations. See Lung Cancer and Lung Resection & Lobectomy.
Therapeutic bronchoscopy
| Intervention | Purpose |
|---|---|
| Secretion and mucus plug removal | Clearing lobar or whole-lung collapse where clearance techniques have failed or cannot be applied |
| Foreign body removal | Usually rigid bronchoscopy |
| Airway stenting | Malignant or benign central airway obstruction; relieves breathlessness and stridor |
| Tumour debulking | Laser, argon plasma coagulation, cryotherapy or mechanical coring |
| Balloon dilatation | Benign airway stenosis, including post-tracheostomy stenosis |
| Endobronchial valve placement | Emphysema and persistent air leak — see Zephyr Valves & Lung Volume Reduction |
| Bronchial thermoplasty | Radiofrequency energy to airway smooth muscle in severe asthma5 |
Patients with a stent have permanently impaired mucociliary clearance through the stented segment and are prone to secretion retention, granulation tissue and stent migration — humidification and regular clearance matter, and a new change in breathing after stenting warrants bronchoscopic review rather than escalating physiotherapy.
The lobar collapse question
Marini and colleagues prospectively compared fibreoptic bronchoscopy with a respiratory therapy regimen of deep breathing, positioning and percussion in acute lobar atelectasis and found no difference in radiographic or clinical resolution at 24 and 48 hours.6 The trial is old and small, but it remains the reference point, and it establishes that a collapsed lobe is not automatically a bronchoscopy referral.
The practical position: where the patient can cooperate and clearance techniques and mobilisation can be applied properly, try them first. Bronchoscopy is reserved for failure of those measures, for patients who cannot cooperate or generate an effective cough, and for suspected obstructing lesion or foreign body. Bronchoscopy is not a substitute for treating the cause — and it does not stop the lobe collapsing again if the reason it collapsed is unaddressed. See Atelectasis and Principles of Airway Clearance.
Around the procedure
Before
Patients are fasted and usually sedated. Anticoagulants and antiplatelets are managed according to the sampling planned. Anxiety about the procedure is common and briefly addressing it is worthwhile.
After
- Sore throat, cough and small-volume haemoptysis are expected after biopsy and settle.
- Nil by mouth until the topical anaesthetic has worn off and swallowing is safe.
- Sedation means the patient is not a reliable historian and is a falls risk for several hours.
- Transient fever after bronchoalveolar lavage is common and usually self-limiting.
Transbronchial biopsy carries a real risk of pneumothorax, which may be delayed. New breathlessness, pleuritic pain or desaturation after bronchoscopy is a pneumothorax until excluded. Where a transbronchial biopsy has been taken, confirm with the respiratory team before applying non-invasive ventilation, intermittent positive pressure breathing or high-pressure positive expiratory pressure devices — unit protocols commonly impose a delay. See Pneumothorax.
Role of the physiotherapist
Know what the procedure was for, because a diagnostic staging procedure and a therapeutic debulking imply completely different trajectories. Treat a collapsed lobe with clearance and mobilisation before assuming bronchoscopy is required, and say so when a referral is being made reflexively. After transbronchial biopsy, treat new breathlessness as a pneumothorax and hold positive pressure until cleared. And for patients with stents, build humidification and routine clearance into the long-term plan.
Evidence summary
Framing. Bronchoscopy sits behind a large share of the procedures in this section — staging before resection, valve placement, stenting and debulking — and it is also the intervention most often requested when a lobe collapses. Physiotherapy has a direct interest in both roles: understanding what the procedure established, and knowing that clearance techniques were shown four decades ago to be an adequate first-line alternative for lobar collapse.6
Evidence — stagingEndobronchial ultrasound with transbronchial needle aspiration, particularly combined with oesophageal endosonography, achieves nodal staging sensitivity approaching surgical staging with substantially lower morbidity, and is the recommended first test for mediastinal staging in guidelines from the ACCP and the joint European societies.3,4
Evidence — lobar collapseMarini's prospective comparison found no advantage of bronchoscopy over a structured respiratory therapy regimen for acute lobar atelectasis at 24 or 48 hours.6 It is a small, old trial and has not been repeated, but no subsequent evidence has displaced it, and it remains the basis for treating bronchoscopy as second-line in the cooperative patient.
Physiotherapy implicationsEstablish the indication and the sampling performed. Withhold positive-pressure interventions after transbronchial biopsy until cleared locally, and treat post-procedure breathlessness as pneumothorax until excluded. Advocate for clearance and mobilisation before bronchoscopy in lobar collapse where the patient can participate. Plan long-term humidification and clearance for stented airways.
Evidence gapsThe lobar collapse comparison has not been repeated in a modern population with contemporary techniques, non-invasive ventilation and high-flow therapy available. There is no evidence guiding airway clearance regimens in patients with airway stents, and no physiotherapy evidence base around navigational or robotic bronchoscopy pathways.
References & evidence base
- Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults. Thorax 2013;68(Suppl 1):i1–i44.
- Du Rand IA, Barber PV, Goldring J, et al. British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax 2011;66(Suppl 3):iii1–iii21.
- Vilmann P, Clementsen PF, Colella S, et al. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy guideline, in cooperation with the European Respiratory Society and the European Society of Thoracic Surgeons. Endoscopy 2015;47(6):545–559.
- Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed. ACCP evidence-based clinical practice guidelines. Chest 2013;143(5 Suppl):e211S–e250S.
- Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma (AIR2): a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med 2010;181(2):116–124.
- Marini JJ, Pierson DJ, Hudson LD. Acute lobar atelectasis: a prospective comparison of fiberoptic bronchoscopy and respiratory therapy. Am Rev Respir Dis 1979;119(6):971–978.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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