Bronchoscopy with transbronchial biopsy is a procedure in which a thin, lighted tube (bronchoscope) is inserted through the nose or mouth to collect several pieces of lung tissue.

A lung specialist (pulmonologist) sprays a numbing medicine (anesthetic) in your mouth and throat. This will cause you to cough at first. The coughing should stop as the anesthetic begins to work.

You may be given a sedative medicine through a vein (IV) to help you relax. This medication may make you sleepy and should reduce any anxiety you have about the procedure. The procedure can also sometimes be done using general anesthesia, during which you are asleep and pain-free.

If the bronchoscopy is done through the nose, an anesthetic jelly will be inserted into one nostril. When the nostril is numb, the scope will be inserted through the nostril until it passes through the throat into the windpipe (trachea) and air passages of the lungs (bronchi). Usually, a long, thin flexible tool called a bronchoscope is used.

Samples of lung fluids may be taken through the bronchoscope. Salt water (saline) may be used to flush the area and collect cells for examination.

The transbronchial biopsy procedure is performed using a tiny forceps passed through the bronchoscope into your lungs. You will be asked to breathe out slowly as a small sample of lung tissue is taken. This step is usually repeated until several samples of tissue have been collected. Sometimes chest x-rays (fluoroscopy) are used during the bronchoscopy to help direct the forceps to the correct area of the lung.

This test may require an overnight stay in the hospital. You must sign an informed consent form.

You should not eat for 6 - 12 hours before the test. You may be told to avoid the following medications before the procedure:

• Aspirin
• Blood thinniners such as warfarin
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen

Always check with your health care provider before changing or stopping any medications.

Arrange for transportation to and from the hospital. Many people want to rest the following day, so make arrangements for work, child care, or other obligations.

Local numbing medicine (anesthesia) is used to relax your throat muscles. You may feel fluid running down the back of your throat, and the need to cough or gag until the anesthetic takes effect.

Even with the anesthesia, you may feel pressure or mild tugging as the tube moves through the trachea. Many patients experience a feeling of suffocation when the tube is in the throat, but there is no risk of suffocation. Try to remain calm. If you cough during the test, more anesthetic will be added.

An x-ray is often taken after the bronchoscope is removed. When the anesthetic wears off, your throat may be scratchy for several days. After the test, your cough reflex will return in 1 - 2 hours. Once that happens, you can eat and drink normally.

It is common after a transbronchial biopsy to cough up small amounts of bloody phlegm (sputum) for a day. The health care provider will tell you who to contact if you cough up large amounts of blood.

A transbronchial biopsy is most often performed for:

• Diffuse infiltrative pulmonary disease
• Rejection of a transplanted lung
• Tumors

The trachea and bronchi are normally pink and smooth. There are no foreign bodies, growths, blockages, or infections.

The sample taken with a transbronchial biopsy should be normal tissue from the lining of the bronchus and air sacs (alveoli).

• Adenoma (tumor)
• Alveolar abnormalities such as alveolar proteinosis
• Bronchial abnormalities, tumors
• Endobronchial mass
• Granulomas
  • Caseating granulomas
  • Necrotizing granuloma (granular tumor)
  • Non-necrotizing granulomatous inflammation
  • Peribronchial granulomas
  • Sarcoidosis
• Infection such as:
  • Actinomycosis
  • Anaerobic bacterial infections
  • Aspergillosis
  • CMV pneumonia
  • Coccidiomycosis
  • Fungus infections
  • Histoplasmosis infections
  • Pneumocystis carinii pneumonia (PCP)
  • Tuberculosis or mycobacteria
• Inflammation of the lungs related to allergy-type reactions (hypersensitivity pneumonitis)
• Rheumatoid lung disease
• Vasculitis

A popped lung or pneumothorax occurs in a very small number of transbronchial biopsies. Usually chest x-rays are done, unless the pneumothorax is large enough to need a chest tube to be inserted to expand (decompress) the lung. In rare cases this can be life threatening if air escapes from the lung, gets trapped in the chest, and presses on (compresses) the lungs and heart.

Whenever a biopsy is taken, there is a risk of excess bleeding (hemorrhage). Some bleeding is common, and a health care provider will monitor the amount of bleeding. In very rare cases, major and life threatening bleeding may occur.

Lung infection may occur after any bronchoscopy.

There is also a small risk of:

• Heart attack
• Irregular heart rhythm (arrhythmia)
• Low blood oxygen (hypoxemia)

If general anesthesia is used, there is also some risk of:

• Breathing difficulties
• Change in blood pressure
• Kidney damage
• Muscle pain
• Nausea and vomiting
• Slow heart rate
• Sore throat

There is a significant risk of choking if you eat or drink anything (including water) before the anesthesia wears off.

To test whether your gag reflex has returned, place a spoon on the back of your tongue for a few seconds with light pressure. If you do not gag, wait 15 minutes and try again.

Do not use small or sharp objects to test your gag reflex. Call your health care provider or go to an emergency room immediately if you have shortness of breath or chest pain after this procedure.

Prakash, UBS. Bronchoscopy. In: Mason RJ, Murray JF, Broaddus VC, Nadel JA, eds. Murray & Nadel's Textbook of Respiratory Medicine. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2005:chap 22.