Role the diagnostic value of bronchoscopy.[4] FOB is

Role of Fiberoptic Bronchoscopy in the Diagnosis of Various Lung DiseasesAbstractBackground: Fiberoptic bronchoscopy is a safe and useful diagnostic and therapeutic tool for the management of the pulmonary diseases. Objectives: To assess the role of fiberoptic bronchoscopy in the diagnosis of various lungdiseases.Materials and methods: This study was conducted in the Department of Pulmonary Medicine, Government Medical College, Patiala over a period one year (2010). The study was carried out on 157 patients suspected to have pneumonia, pulmonary tuberculosis, lung cancer or sarcoidosis. All the patients were subjected to fiberoptic bronchoscopy.Results: There were total 157 cases included in the study and subjected to fiberoptic bronchoscopy(FOB).Majority 94 (59.87%) were males and 63 (40.13%) were females, mean age was 50 years with range from 21-80 years. The diagnostic yield of FOB was 29.94%, 15.23%, 5.73% and 1.27% in pulmonary tuberculosis, pneumonia, lung cancer and sarcoidosis respectively. The overall diagnostic yield was 52.23%.Conclusion: Fiberoptic bronchoscopy can be successfully employed for the diagnosis of lung diseases, including malignancies and granulomatous lesions. Routine flexible bronchoscopy technique continues to have a good diagnostic yield in current clinical practice in various lung diseases.Key Words:  Fiberoptic bronchoscopy (FOB), lung disease, Pulmonary Tuberculosis, INTRODUCTION:  In 1965, the advent of flexible fiberoptic bronchoscope revolutionised the practice of pulmonary medicine and proved itself as a safe and useful technique for diagnostic and therapeutic purposes. The fiberoptic bronchoscopy (FOB), has greatly enhanced the diagnosis and understanding of lung diseases and has evolved into the most commonly used diagnostic procedure in pulmonary medicine.1 It is a universally accepted procedure both in the diagnosis and therapy of different pulmonary disorders. FOB can be performed under local anesthesia in various clinic/hospital settings providing maximal visualization of tracheobronchial tree2, and if performed carefully, can be a thoroughly safe procedure.3Samples can be collected by several methods like bronchial biopsy, bronchial brushing, aspiration, transbronchial lung biopsy, transbronchial needle aspiration and these combined advantages enhance the diagnostic value of bronchoscopy.4 FOB is shown to be of diagnostic value in opportunistic pulmonary infections occurring in immunodeficient patients including HIV positive patients, apart from its role in diagnosis of tuberculosis, lung carcinoma, pneumonia, interstitial lung diseases.5 The initial diagnostic approach to suspected cases of pulmonary tuberculosis is to demonstrate Mycobacterium tuberculosis in stained smears of expectorated sputum. In most of the tuberculosis centers, even after meticulous search, the bacteriological positive yield from sputum is around 16 to 50% and large portion remain negative in spite of clinical profile and radiological lesions being consistent with diagnosis of pulmonary tuberculosis.6  FOB has significant role to establish the diagnosis of tuberculosis in such sputum smear negative cases. FOB is immensely useful for making a conclusive diagnosis of lung cancer, especially when there is an endobronchial lesion, providing adequate tissue sample by endobronchial biopsy, bronchoalveolar lavage (BAL) or brush cytology.MATERIALS AND METHODS:  This study approved by institutional ethics committee was conducted in the Department of Pulmonary Medicine, Government Medical College, Patiala over a period one year (2010). The study was carried out on 157 patients suspected to have pneumonia, pulmonary tuberculosis, lung cancer or sarcoidosis.Detailed clinical history, physical examination and routine investigations were carried out in all the participants. All the patients were subjected to sputum examination acid-fast bacilli (AFB) staining, gram staining, culture/sensitivity, KOH staining, malignant cells; haematological examination; coagulation profile. Chest X-rays in both PA and lateral views were obtained in all the patients before the procedure to define the location of the lesion. CT scan thorax was performed in some cases. . All the patients were then subjected to fiberoptic bronchoscopy. Prior to the procedure an informed consent was obtained from the patient. Patients with contraindications to bronchoscopy; such as coagulation disorders, thrombocytopenia, uremia, single lung and severe pulmonary hypertension were excluded. The procedure was carried out effectively with the patient nil per orally for 4 to 6 hours. Nebulisation was done with 2% xylocaine via nebulizer. Bronchoscopy was carried out under local anesthesia (2% lignocaine) via olympus bronchoscope. Oxygenation was monitored throughout the procedure with pulse oximetry. Appropriate samples such as bronchoscopic aspirate, brushing and biopsy were obtained depending on the lesion after thorough evaluation of endobronchial tree. Samples were subjected to cytology and histopathology depending upon the clinical diagnosis and bronchoscopic findings. The sputum sample after bronchoscopy (Post FOB sputum) was also collected and sent for analysis. After the procedure , patient was observed for development of pneumothorax, haemorrhage, infection and cardiac arrhythmias for 24-48 hours. Proper disinfection of the bronchoscope in between use was mandatory. RESULTS: There were total 157 cases included in the study and subjected to fiberoptic bronchoscopy (FOB). Majority 94 (59.87%) were males and 63 (40.13%) were females, mean age was 50 years with range from 21 to 80 years. Out of 82 diagnosed patients, 2 patients were having both pulmonary tuberculosis and lung cancer and 1 patient was having pulmonary tuberculosis along with fungal pneumonia.Table 1: Clinical Presentation of PatientsClinical Feature% Cough 84Hemoptysis 26Wheeze 20Shortness of breath 58Fever 40 Chest pain 58Table 2: Diagnostic yield of fiberoptic bronchoscopy (FOB)DiseaseDiagnosis by FOBTuberculosis       47(29.94)Pneumonia       24 (15.23)Cancer                             9(5.73)Sarcoidosis         2(1.27) Total          82 (52.23)DISCUSSION: Of the total 157 patients who had undergone fiberoptic bronchoscopy, majority 94 (59.87%) were males and 63 (40.13%) were females. Mean age was 50 years with range from 21 to 80 years.In the present study, Cough was the commonest indication (84%) for bronchoscopy, which is similar to a study conducted by Prakash UB et al 7. Epidemiological studies suggest majority of patients with bronchogenic carcinoma have signs and symptoms of COPD.8, 9 In the present study it was observed that the diagnostic yield of FOB is 52.23%. Foos et al 10 analyzed the retrospective data of 616 bronchoscopy procedures and reported a diagnostic yield of 57%. The diagnostic yield of bronchoscopy for detection of malignancy was 66.6%. Foos et al 10 reported the highest diagnostic yield of 92% in the cases with a macroscopically visible tumor, while another study 11 reported a diagnostic yield of 51% for peripheral lesions.Recently, Anandan et al 12 also reported the highest yield in the diagnosis of malignancy by endobronchial biopsy (85%) followed by bronchial brushings (34%) and washings (12%). Wong and colleagues evaluated biopsy, brushings and washings in the diagnosis of lung cancer and the overall diagnostic yield of FOB were 98.1%, 61.5% and 58.5% for the endoscopically visible, endoscopically not visible and endoscopically not visible fluoroscopic guidance cases respectively.13On histopathological analysis, non-neoplastic lesions constituted the majority in 73 patients (46.5%) and neoplastic in 9 patients (5.73%) cases. In other studies, Hansen et al 14 reported 31% cases of neoplastic category and 62% as non-neoplastic, Abdul Aziz et al 15 found 28% neoplasm and 72% cases were non-neoplastic disease. Gupta et al 16 reported granulomatous diseases in 33% cases followed by interstitial lung disease in 28% cases and non-specific inflammation in 25% cases. Kalra et al 17 in their study of parenchymal lung diseases diagnosed interstitial fibrosis in 76% cases and granulomatous lesions in 32% cases.Bronchoscopy plays an important role in the diagnosis of smear negative pulmonary tuberculosis. In thepresent study the diagnosis of pulmonary tuberculosis was obtained in 37.7% of the cases. Foos et al 10 found the diagnostic yield of 27% for the diagnosis of pulmonary tuberculosis by FOB. Another prospective study by Conde 18 which was conducted in Brazil reported positivity of 56% in the diagnosis of tuberculosis by fiberoptic bronchoscopy. The reason for high diagnostic yield in this study was that most of these patients were unable to produce sputum and with the concomitant HIV infection, sputum production is negligible. In such type of patients it was observed that bronchoscope plays an important role in the diagnosis of pulmonary tuberculosis. Bronchoscopy is a safe and useful tool for making the diagnosis of a variety of pulmonary diseases like bronchogenic carcinoma, pulmonary tuberculosis and some interstitial lung diseases.  CONCLUSION:  Fiberoptic bronchoscopy can be successfully employed for the diagnosis of lung diseases, including malignancies and granulomatous lesions. Routine flexible bronchoscopy technique continues to have a good diagnostic yield in current clinical practice in various lung diseases.ABBREVIATIONS: Fiberoptic bronchoscopy (FOB), bronchoalveolar lavage (BAL), acid-fast bacilli (AFB), computed tomography (CT), chronic obstructive pulmonary disease (COPD).REFERENCES: Joos, N. Patuto, P.N. Chhajed, M. Tamm, Diagnostic yield of flexible bronchoscopy in current clinical practice, Swiss Med. Wkly. 136 (2006) 155–159. Kdvenat DM, Rath GS, Anderson WM, Snider GL. Maximal extent of visualization of bronchial tree by flexible fiberoptic bronchoscopy. Am Rev Repair Dis 1984; 110: 88-90. 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