Bronchoscopy

Rigid bronchoscopy is also used for airway dilation and some foreign bodies. Bronchoscopy for retained secretions does not replace conservative therapy; the lobar atelectasis is from impacted secretions.

BTS 2013 gives > 20,000 for lavage and says to liaise with hematology before biopsy; the ≥ 50,000 biopsy number is from the 2026 Polish and 2019 Indian guidelines (conditional, low to very low-quality evidence). No current US society number was found. Don't stop dual antiplatelet therapy by default. Involve cardiology if the procedure is needed within 4–6 weeks of an MI. On anticoagulants, inspection and BAL may proceed but biopsy is not advised. If interrupting, stop warfarin 5 days before and check the INR on the procedure day; schedule DOACs at trough; bridging is not routine.

The lidocaine limit is the total across every site

Lidocaine, no single standard: Indian 2019 suggests 8.0 mg/kg; 8.2 mg/kg is the older BTS 2001 figure still widely quoted; CHEST 2011 ties toxicity to > 7 mg/kg. BTS 2013 sets no cap: up to 15.4 mg/kg caused no serious events, but subjective toxicity appeared at ≥ 9.6 mg/kg. Merck limits upper-airway lidocaine to 250–300 mg in a 70-kg patient. The 4.5 mg/kg on the Wound Management sheet is for infiltration, a different route. Sedation doses are on the Procedural Sedation sheet. CHEST 2011 suggests combining a benzodiazepine with an opioid. Merck notes some centers commonly use general anesthesia or propofol deep sedation with airway control, and dexmedetomidine has been studied.

Merck advises using supplemental oxygen during the procedure in general. BAL technique: wedge the scope in the target segment, instill 100–300 mL saline in 3–5 aliquots and retrieve at least 30%; lower return can mislead the differential, and transient hypoxemia may follow. Merck describes 50–200 mL for bronchoalveolar lavage generally; the ATS range is for cellular analysis in interstitial lung disease. On the ventilator: preoxygenate and continue 100% oxygen through recovery, use a mandatory mode, raise the pressure limit, and pass the scope through a swivel connector to preserve PEEP.

Recovery: observe 2–4 hours; recovery means a returned gag reflex and stable saturation off oxygen.

Overall, serious complications are uncommon

Serum lidocaine levels vary widely between patients at the same dose. Post-bronchoscopy fever lasts about 14 hours on average.

Milky fluid with settling sediment suggests pulmonary alveolar proteinosis. 10⁴ CFU/mL is the diagnostic threshold if quantitative bronchoscopic BAL is done. Lymphocytes > 50% particularly suggest hypersensitivity pneumonitis or cellular NSIP; lymphocytosis with a CD4/CD8 ratio > 4 raises confidence in sarcoidosis when clinical features and imaging fit.