Bronchoscopy with transbronchial biopsy

Alternative names
Biopsy - lung

Bronchoscopy with transbronchial biopsy is a diagnostic procedure in which a bronchoscope is inserted through the nose or mouth to collect multiple specimens of lung tissue.

How the test is performed

A lung specialist (pulmonologist) trained to perform a bronchoscopy sprays a topical or local anesthetic in your mouth and throat. This will cause coughing at first, which will cease as the anesthetic begins to work. When the area feels “thick,” it is sufficiently numb.

You may be given an intravenous (IV) sedative to help you relax. This medication may make you sleepy and should reduce any anxiety you might have about the procedure. The procedure can also sometimes be performed using general anesthesia, during which you are unconscious and pain-free.

If the bronchoscopy is performed via 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 trachea and bronchi. Usually, a flexible bronchoscope is used. This tool is a tube that is less than 1/2 inch wide and about 2 feet long.

As the bronchoscope is used to examine the airways of your lungs, samples of your lung secretions may be obtained to send for laboratory analysis. Saline fluid may be used to flush the area and to collect cells that may need to be analyzed by a pathologist.

The transbronchial biopsy procedure is performed using a tiny forceps passed through a channel of the bronchoscope into your lungs. You will be instructed to breathe out slowly as the pulmonologist obtains a small sample of lung tissue. This step is usually repeated until several samples of tissue have been obtained for analysis. Occasionally real-time chest x-rays (fluoroscopy) are used during the bronchoscopy to help direct the forceps to the desired area of lung.

How to prepare for the test

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

Fasting is required for 6 to 12 hours before the test. You may be advised to avoid aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen for a period of time before the procedure. Always check with your health care provider before changing or discontinuing 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.

Infants and children:
The preparation you can provide for this test depends on your child’s age, previous experiences, and level of trust. For general information regarding how you can prepare your child, see the following topics:

  • Infant test or procedure preparation (birth to 1 year)  
  • Toddler test or procedure preparation (1 to 3 years)  
  • Preschooler test or procedure preparation (3 to 6 years)  
  • Schoolage test or procedure preparation (6 to 12 years)  
  • Adolescent test or procedure preparation (12 to 18 years)

How the test will feel

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

Despite the anesthesia, you may have sensations of 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 to 2 hours, then normal eating and drinking is allowed.

It is common after a transbronchial biopsy to cough up small amounts of blood-tinged sputum for a day. The pulmonologist will give you instructions on whom to contact should you cough up significant amounts of blood.

Why the test is performed
A transbronchial biopsy is most often performed when there is diffuse infiltrative pulmonary disease, tumors, rejection of a transplanted lung, or severe illness that prevents the use of open lung biopsy.

Normal Values

The trachea and bronchi normally appear pink and smooth and have minimal secretions and no foreign bodies, growths, obstructions, or infections. The sample obtained with a transbronchial biopsy should be normal tissue from the lining of the bronchus and air sacs (alveoli).

What abnormal results mean

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

What the risks are

Pneumothorax occurs in about 2% of transbronchial biopsies. Usually this is followed with repeated chest x-rays unless the pneumothorax is large enough to require insertion of a chest tube to decompress the lung.

Whenever a biopsy is taken, there is a risk of hemorrhage. Some bleeding is common, and a technician or a nurse will monitor the amount of bleeding.

Lung infection may occur after any bronchoscopy.

There is also a small risk of:

  • Disordered heart rhythm (arrhythmias)  
  • Heart attack  
  • Low blood oxygen (hypoxemia)

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

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

There is a significant risk of choking if anything (including water) is ingested before the anesthetic wears off.

Special considerations

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.

Johns Hopkins patient information

Last revised: December 3, 2012
by Levon Ter-Markosyan, D.M.D.

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