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Bronchoscopy, thoracoscopy, and tissue biopsy 

Bronchoscopy, thoracoscopy, and tissue biopsy

Bronchoscopy, thoracoscopy, and tissue biopsy

Pallav L. Shah


August 28, 2014: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.


New bronchoscopic techniques—description of fluorescence bronchosopy and narrow band imaging for early detection of lung cancer.

Endobronchial ultrasound techniques—(1) expanded discussion of endobronchial ultrasound-guided transbronchial needle aspiration, now the first line investigation for staging the mediastinum in lung cancer; (2) description of radial ultrasound.

Therapeutic bronchoscopy—updated discussion of usage in emphysema and asthma.

Updated on 30 May 2013. The previous version of this content can be found here.
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date: 24 April 2017

Bronchoscopy, thoracoscopy, and radiologically guided biopsy techniques provide different methods for visualizing and sampling thoracic lesions, the approach chosen in any particular case being based on a number of factors, including the anatomical location of abnormal areas, presence of coexisting pulmonary disease, presence of comorbidities, and local expertise. CT is useful in both selection and planning of the most appropriate sampling method.


Bronchoscopy can be used for sampling central lesions, mediastinal lymph nodes, hilar lymph nodes, and—where magnetic navigation technology or radial ultrasound is available—peripheral nodules. Suspected lung cancer is the commonest indication.

Lung cancer—bronchoscopy is an essential tool in diagnosis and staging, when a combination of techniques such as bronchial washings, brushings, and biopsy improves diagnostic yield, as does review of CT imaging before the procedure. Any abnormal mediastinal lymph nodes should be sampled in the first instance by either transbronchial fine-needle aspiration (TBNA) or endobronchial ultrasound-guided TBNA. In the active palliation of lung cancer in patients with primary tumour or metastases involving the trachea or main bronchi, a variety of bronchoscopic techniques can be used to restore airway patency, including stenting in selected cases.

Diffuse lung disease and focal parenchymal infiltrates—bronchoalveolar lavage provides information on cellular processes involved, transbronchial lung biopsy on the pathological characteristics, and segmental lavage is a useful tool in patients with suspected respiratory infection.

Other indications—the role of therapeutic bronchoscopy is increasing with the development of new endoscopic treatments for respiratory diseases such as emphysema and asthma.


Thoracoscopy allows visual inspection and direct sampling of pleural abnormalities, the commonest indications being (1) evaluation of an exudative pleural effusion when cytological analysis of aspirated fluid does not provide a conclusive diagnosis; and (2) in the treatment of a malignant pleural effusion, when a sclerosing agent such as talc can be evenly applied to the pleural surface, a technique which also has a role in the management of recurrent spontaneous pneumothorax.

Percutaneous biopsy

The role of ‘blind’ (unguided) pleural biopsy is diminishing as it has been superseded by either thoracoscopic or image-guided biopsy. Radiologically guided percutaneous biopsy is usually considered where cancer is suspected and there is no clear indication to proceed to surgical resection.

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