Bronchoscopy

Techniques

Direct airway visualisation plus tissue acquisition; in thoracic oncology its role is diagnosis, staging and palliation in a single procedure

Technique	Use
Flexible bronchoscopy + endobronchial biopsy/brush/washings	Visible central endobronchial tumour
EBUS-TBNA	Mediastinal and hilar node sampling - the workhorse of lung cancer staging
EUS-FNA (oesophageal)	Stations 8, 9, left adrenal - complements EBUS
Radial EBUS / navigational (electromagnetic, robotic) bronchoscopy	Peripheral nodules
Transbronchial lung biopsy / cryobiopsy	Diffuse parenchymal disease, lymphangitis
BAL	Infection, and to exclude it in suspected drug-induced pneumonitis
Rigid bronchoscopy	Massive haemoptysis, stenting, debulking, foreign body

EBUS-TBNA is first-line for mediastinal staging in Australia and has largely replaced mediastinoscopy
Complication rates are low: pneumothorax <1-2% (higher with transbronchial biopsy), significant bleeding <1%, mortality <0.05%

Accessible disease is central and peribronchial - SCLC and squamous cell carcinoma are typically central and endobronchial
Adenocarcinoma is peripheral -> lower flexible bronchoscopy yield; needs radial EBUS, navigational bronchoscopy or CT-guided core biopsy
EBUS uses real-time ultrasound through the airway wall to sample paratracheal and peribronchial nodes (stations 2R/L, 4R/L, 7, 10, 11)
- Stations 5, 6, 8, 9 are not reachable by EBUS - use EUS, mediastinoscopy or VATS

Sensitivity ~93%, specificity ~100% for malignant mediastinal nodes
*Negative predictive value falls to ~60% when the node is PET-positive*
- -> a negative EBUS in a PET-positive node does NOT exclude nodal disease
- -> proceed to mediastinoscopy or surgical staging if the result would change treatment intent
The general principle: a positive result is definitive, a negative result must be interpreted against pre-test probability

Sample the site that gives the highest stage - a supraclavicular node or a metastasis gives diagnosis and stage in one biopsy
Get enough tissue for molecular testing and PD-L1, not just a diagnosis
- Cytology alone is often insufficient for a full NGS panel - discuss with the pathologist and take extra passes; rapid on-site evaluation (ROSE) improves adequacy
Also assess: airway invasion, distance from carina, vocal cord function (hoarseness = recurrent laryngeal palsy = mediastinal invasion)

Haemoptysis, suspected infection (TB, PJP, fungal, non-resolving pneumonia), ILD, foreign body, atelectasis, transplant surveillance, airway assessment before surgery

Coagulation status; withhold antiplatelets and anticoagulants per local protocol (clopidogrel 5-7 days; DOAC by renal function)
Fasting; consent covering bleeding, pneumothorax, infection, sedation risk, arrhythmia
Assess hypoxia and hypercapnia - severe respiratory failure and unstable cardiac disease are relative contraindications
*Uncorrected coagulopathy, severe pulmonary hypertension and an unstable airway are the main contraindications to biopsy*

Central airway obstruction -> rigid bronchoscopy with debulking, laser/electrocautery/argon plasma/cryotherapy, airway stent
- Can produce immediate relief of stridor and dyspnoea
Massive haemoptysis -> rigid bronchoscopy for airway control; also bronchial artery embolisation
- Position the bleeding side down to protect the good lung
Endobronchial brachytherapy, photodynamic therapy for selected obstructing tumours

Bleeding (higher with transbronchial biopsy, pulmonary hypertension, uraemia, thrombocytopenia)
Pneumothorax (transbronchial and cryobiopsy) - post-procedure CXR if biopsy taken
Hypoxia, arrhythmia, sedation-related events, laryngospasm, bronchospasm
Post-bronchoscopy fever (~5%, usually transient), infection

Lung cancer diagnosis and staging; mediastinal lymphadenopathy of any cause
Sarcoidosis - EBUS-TBNA has high yield for non-caseating granulomas and has replaced blind transbronchial biopsy
Lymphoma - EBUS cytology is often insufficient; needs a core or excisional node
Tuberculosis, PJP, invasive fungal disease, non-resolving pneumonia
Interstitial lung disease - transbronchial cryobiopsy as an alternative to surgical lung biopsy
Drug-induced and immune checkpoint inhibitor pneumonitis - BAL to exclude infection
Lung transplant surveillance for rejection and infection
Central airway obstruction, tracheo-oesophageal fistula, massive haemoptysis

A negative bronchoscopy never excludes lung cancer - proceed to CT-guided biopsy, navigational bronchoscopy, or surgical biopsy if suspicion remains
Diagnostic yield: >90% for visible endobronchial lesions; ~35-70% for peripheral nodules (size- and technique-dependent, improving with robotic navigation)
Insufficient tissue for molecular testing is a common and consequential failure - it delays targeted therapy by weeks
Airway stenting relieves symptoms but does not alter survival; stents obstruct with granulation tissue and secretions over time

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