Bronchoscopy

Introduction

Bronchoscopy is a procedure in which a doctor uses a thin instrument, called a bronchoscope, to look inside the airways and lungs. It is one of the most useful tools in modern lung medicine, both for finding out what is causing a respiratory problem and, in some cases, for treating problems within the airway during the same procedure.

If your doctor has recommended a bronchoscopy, you are most likely either being investigated for a symptom such as a persistent cough, coughing up blood, or an unexplained finding on a chest X-ray or CT scan; or you have a known airway problem that may need direct treatment. Either way, the procedure is usually performed as a day case, with most patients going home the same day.

This article explains what bronchoscopy is, the different types and reasons it is performed, what to expect before, during, and after the procedure, what the risks are, and how to make sense of the results. The two main forms — diagnostic bronchoscopy (looking and taking samples) and therapeutic bronchoscopy (treating a problem in the airway) — are covered in turn.

What Is a Bronchoscopy?

To understand bronchoscopy, it helps to know a little about the anatomy of the airways. The trachea, or windpipe, runs from the back of the throat down into the chest, where it divides into two main bronchi (one for each lung). The bronchi divide again and again into progressively smaller airways, eventually ending at the alveoli, the tiny sacs where oxygen is exchanged.

A bronchoscope is a thin, tube-shaped instrument with a light and a small camera at the tip. Images from the camera are displayed on a monitor so the doctor can see the inside of the airways in real time. The scope also has one or more channels running down its length, through which instruments can be passed — for example, fine forceps to take tissue samples, a needle to take samples through the airway wall, brushes to collect cells, or instruments to deliver treatments.

There are two main kinds of bronchoscope:

• Flexible bronchoscope — a thin, bendable scope that can navigate the curves of the airways. This is the type used in the great majority of bronchoscopies today. The procedure is usually performed with the patient awake and lightly sedated, and the scope is passed in through the nose or mouth.
• Rigid bronchoscope — a straight, hollow metal tube, larger in diameter than a flexible scope. Rigid bronchoscopy is performed in the operating room under general anaesthesia. It is used less often than flexible bronchoscopy but remains important for certain situations, such as removing foreign objects from the airway, treating significant airway bleeding, dilating narrowed airways, and placing airway stents.

Both types may sometimes be used together in the same procedure — for example, a rigid scope to maintain a wide working channel and a flexible scope passed through it to reach smaller airways.

Types of Bronchoscopy

Bronchoscopy is broadly classified by purpose into two types: diagnostic and therapeutic. Many bronchoscopies are both at once — the doctor looks, finds something, and treats it in the same session.

Diagnostic bronchoscopy

Diagnostic bronchoscopy is performed to find out what is causing a respiratory problem, or to investigate an abnormal finding on imaging. The doctor inspects the airways visually and usually takes one or more types of sample for laboratory analysis. Common diagnostic techniques performed during bronchoscopy include:

• Bronchoalveolar lavage (BAL) — a portion of the lung is gently washed with sterile saline solution, which is then suctioned back and sent for analysis. This is useful for detecting infections (including unusual or opportunistic ones), examining inflammatory cells in lung diseases, and looking for cancer cells.
• Endobronchial biopsy — a small tissue sample is taken from the wall of an airway using tiny forceps, usually when the doctor sees a visible abnormality.
• Transbronchial biopsy — a sample of lung tissue is taken from beyond the airway wall, reaching the lung itself. This is used to diagnose interstitial lung diseases and some peripheral lung lesions.
• Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) — an ultrasound probe at the scope tip allows the doctor to see lymph nodes and structures next to the airway. A thin needle is then passed through the airway wall to sample these structures. EBUS-TBNA has become a key tool for diagnosing and staging lung cancer.
• Brushings and washings — cellular samples are collected from the airway surface for cytological examination.
• Cryobiopsy — a probe is briefly frozen to obtain a larger and better-preserved tissue sample than is possible with standard forceps; used particularly in some interstitial lung diseases.

Therapeutic bronchoscopy

Therapeutic bronchoscopy is performed to treat a problem within the airways themselves. The range of treatments that can be delivered through a bronchoscope has expanded considerably over the past two decades. They include:

• Removing foreign objects — particularly important in children, who occasionally inhale small objects, but also performed in adults. Rigid bronchoscopy is often used for this purpose.
• Clearing thick mucus plugs — in critically ill patients, in people with cystic fibrosis, or after severe pneumonia, dense mucus can block an airway and collapse a portion of lung. Suctioning and lavage through a bronchoscope can clear this.
• Treating airway bleeding (haemoptysis) — significant bleeding in the airways can sometimes be located and controlled bronchoscopically using cold saline, certain medications, balloon tamponade, or other techniques.
• Opening blocked airways — tumours, scar tissue, or other obstructions in the central airways can be treated using mechanical debridement, laser, electrocautery, argon plasma coagulation, cryotherapy, microdebrider, or photodynamic therapy, depending on the problem. The 2024 CHEST clinical practice guideline on central airway obstruction emphasises a multi-modality approach tailored to the underlying cause.
• Airway stenting — placing a small metal or silicone tube (a stent) inside a narrowed airway to keep it open. Used for both cancer-related and non-cancer-related strictures.
• Balloon dilation — gently stretching open a narrowed airway using a balloon catheter.
• Bronchial thermoplasty — a treatment used in selected patients with severe asthma, in which controlled heat is applied to the airway walls to reduce the smooth muscle that causes airway constriction.
• Endobronchial valves — small one-way valves placed in specific airways to treat severe emphysema (where they allow trapped air to escape from over-inflated portions of lung) or persistent air leaks after lung surgery or trauma.

Whether a bronchoscopy is purely diagnostic, purely therapeutic, or a combination depends on the clinical situation.

Why Is a Bronchoscopy Performed?

The reasons for bronchoscopy fall broadly into diagnostic and therapeutic indications.

Diagnostic reasons

• Unexplained chronic cough that has not responded to initial assessment and treatment
• Coughing up blood (haemoptysis), particularly when the cause is unclear or when significant
• Abnormal chest X-ray or CT scan findings — masses, nodules, persistent shadows, or unexplained changes
• Suspected lung cancer — both to obtain tissue for diagnosis and to stage the disease via EBUS-TBNA sampling of nearby lymph nodes
• Suspected lung infection, particularly in patients with weakened immune systems where standard sputum tests may not identify the cause
• Investigation of interstitial lung disease when imaging and other tests have not given a clear answer
• Persistent atelectasis (a collapsed portion of lung) of unclear cause
• Inhalation injury following exposure to smoke, fire, or chemical fumes
• Suspected airway abnormalities such as narrowing, fistulas, or congenital problems
• Hoarseness or vocal cord problems seen on imaging

Therapeutic reasons

• Foreign body in the airway — particularly in children, but also in adults
• Severe mucus plugging causing collapse of a portion of lung or worsening respiratory failure in a critically ill patient
• Significant airway bleeding requiring direct treatment
• Central airway obstruction from tumour, scar tissue, or external compression — bronchoscopic treatment can relieve breathlessness, improve quality of life, and in some cases extend survival
• Symptomatic airway narrowing from any cause
• Severe asthma not controlled by standard treatments — bronchial thermoplasty is one option that may be considered in selected patients
• Severe emphysema with specific anatomic features — endobronchial valves are one option considered for selected patients
• Persistent air leak from the lung that has not closed with conservative management

Bronchoscopy is not always the right answer. Some questions are better addressed by imaging alone, by sputum analysis, by a needle biopsy through the chest wall, or by surgery. The choice of approach depends on what the doctor is trying to find or treat.

Preparing for Bronchoscopy

Bronchoscopy is a planned procedure, and preparation usually takes place over a few days.

Before the day of the procedure

• Medication review — blood-thinning medications (such as aspirin, clopidogrel, warfarin, and direct oral anticoagulants) are usually stopped for a period before the procedure, particularly if biopsies are planned. Diabetes and blood pressure medications are usually continued, with specific instructions for the day of the procedure. Always follow the instructions given by the bronchoscopy team.
• Pre-procedure tests — blood tests are typically arranged. Sometimes an ECG, oxygen saturation check, or recent imaging is reviewed.
• Discussion of the procedure — the bronchoscopy team explains what will be done, why, what alternatives exist, and what the risks are. This is the time to ask questions.

The night before and the day of the procedure

• Fasting — typically no food for 6–8 hours and no clear liquids for 2 hours before the procedure, but exact instructions are given by the team.
• Transport — because sedation is usually used, you will not be able to drive yourself home. Arranging a relative, friend, or escort is essential.
• Clothing and comfort — loose, comfortable clothing; remove glasses, contact lenses, jewellery, and dentures before the procedure as advised.
• Questions worth asking the doctor in advance — will I be awake? Will biopsies be taken? When will I get results? When can I return to normal activities? Are there particular signs I should watch for at home?

What Happens During the Procedure

The exact experience varies depending on whether flexible or rigid bronchoscopy is being performed, whether sedation or general anaesthesia is used, and what is being done. The following describes a typical flexible bronchoscopy, the most common form.

Arrival and preparation

You change into a hospital gown. Vital signs are checked. An intravenous (IV) line is placed for medications. Monitoring equipment — oxygen saturation probe, heart rhythm leads, blood pressure cuff — is connected. Supplemental oxygen is given through a nasal tube.

Anaesthesia and sedation

Most flexible bronchoscopies are performed under moderate sedation — medications given through the IV that make you drowsy, relaxed, and less aware, while you can still breathe on your own and respond to simple instructions. Local anaesthetic is sprayed or instilled into the nose and throat to numb the airway and reduce coughing. For some procedures — particularly therapeutic bronchoscopies and rigid bronchoscopies — general anaesthesia is used, and you will be fully asleep.

Insertion and inspection

The bronchoscope is passed gently, usually through the nose (sometimes through the mouth, or through a breathing tube if you are already on a ventilator). It moves down through the throat, past the vocal cords (this may cause coughing despite the anaesthetic; the team manages this with extra local anaesthetic), and into the trachea. The doctor then systematically inspects the airways, advancing the scope through the main bronchi and into the smaller branches.

Sampling and treatment

If samples are needed, the doctor passes appropriate instruments through the working channel of the scope. Tissue biopsies, brushings, washings, needle aspiration through the airway wall, or other techniques may be used, depending on what is being investigated. For therapeutic procedures, the relevant instrument or device — suction, balloon catheter, laser fibre, stent delivery system, or other — is passed through the scope.

Duration

Most diagnostic bronchoscopies take 20 to 45 minutes. Therapeutic procedures, particularly those involving stenting or treatment of central airway obstruction, may take longer.

What you might feel

With moderate sedation, most patients remember little or nothing of the procedure. You may feel some pressure, coughing during scope insertion, and a sensation of fluid in the chest during BAL. Pain is uncommon. The team monitors comfort throughout and can give additional sedation or anaesthetic if needed.

Recovery and Aftercare

Recovery from bronchoscopy is usually straightforward, but knowing what to expect helps.

In the recovery area

After the scope is removed, you are moved to a recovery area where vital signs and oxygen saturation are monitored as the sedation wears off. The gag reflex must return before you can eat or drink — usually within an hour or two of the procedure — because the throat is still numb. Most patients are awake, alert, and ready for discharge within a few hours.

Going home

For an outpatient bronchoscopy, you can usually go home the same day. Because of the sedation, you will not be able to drive, operate machinery, sign legal documents, or make important decisions for the rest of the day. An escort is essential. Plan to rest at home for the remainder of the day.

The first 24 to 48 hours

• Sore throat or hoarseness for one to two days
• Mild cough
• Small amounts of blood-tinged sputum, particularly if biopsies were taken — this is usually minor and resolves within a day
• A mild fever in the evening after the procedure — particularly after BAL — usually settles within 24 hours
• Drowsiness and mild memory gaps for the day of the procedure (effects of sedation)

Most patients can return to their usual activities, including work, the day after the procedure. For more involved therapeutic bronchoscopies or after significant biopsies, a longer recovery may be advised.

When to contact the doctor

Although serious problems are uncommon, you should contact the bronchoscopy team or seek medical care promptly if you experience:

• Significant or persistent coughing up of blood (more than streaks)
• Worsening shortness of breath
• Sharp chest pain, particularly with breathing
• Persistent or high fever lasting more than 24 hours after the procedure
• Severe or persistent throat pain

Understanding the Results

What you can learn from a bronchoscopy — and how soon — depends on what was done.

• Visual findings — what the doctor sees during the procedure is often available immediately. The bronchoscopy report typically describes whether the airways looked normal, where any abnormalities were found, and what samples or treatments were taken.
• Microbiology results — from BAL or other samples sent for infection testing. Routine results often take 24–72 hours; cultures for slower-growing organisms (mycobacteria, fungi) may take days to weeks.
• Cytology and histology — results from biopsies, brushings, or washings examined under a microscope. These typically take several working days to two weeks, depending on the type of sample and the laboratory.
• Molecular and genetic tests — if performed (for example, on lung cancer samples), results may take an additional one to several weeks.

A follow-up consultation with the pulmonologist or other treating doctor is usually arranged to discuss all the findings together once they are available. Not getting results on the day of the procedure does not mean nothing was found — the most important results often take time.

Risks and Complications

Bronchoscopy is a well-established procedure and is generally safe. Major complications are uncommon. As with any procedure, however, there are risks, and they should be understood.

Common, usually minor

• Sore throat and hoarseness
• Cough
• Small amounts of blood in sputum, especially after biopsy
• Low-grade fever in the hours after the procedure (especially after BAL)
• Drowsiness from sedation
• Brief, transient drop in oxygen levels during the procedure, managed by the team
• Mild nausea

Less common but more serious

• Significant bleeding — small bleeds after biopsy are common; major bleeding is uncommon. Risk is higher in patients on blood thinners, with bleeding disorders, or undergoing larger biopsies such as transbronchial biopsy.
• Pneumothorax (collapsed lung) — air leaks from the lung into the chest cavity, requiring observation or a chest drain. Mainly a risk after transbronchial biopsy; uncommon after most diagnostic bronchoscopies.
• Infection — new infection introduced or pre-existing infection worsened. Uncommon.
• Reaction to sedation or anaesthesia — uncommon but possible.
• Worsening of pre-existing breathing problems — particularly in patients with severe COPD, asthma, or other lung disease; manageable in most cases but a real consideration.
• Cardiac complications — in patients with underlying heart disease; uncommon.
• Damage to teeth, gums, or vocal cords — uncommon, more associated with rigid bronchoscopy.

Higher-risk situations

Risk is generally higher in patients who are critically ill, on blood-thinning medication, have severe underlying lung disease, or are undergoing more complex therapeutic procedures. These risks are weighed against the expected benefit when deciding whether and how to proceed.

Bronchoscopy in Children

Paediatric bronchoscopy is performed in dedicated centres by paediatric pulmonologists, paediatric otolaryngologists, or paediatric surgeons. The principles are similar to adult bronchoscopy but the practical aspects differ in important ways.

Common reasons for paediatric bronchoscopy

• Foreign body removal — one of the most frequent indications. Small children sometimes inhale small objects (food fragments, small toy parts). Rigid bronchoscopy under general anaesthesia is the usual approach.
• Recurrent or persistent respiratory symptoms — chronic cough, recurrent pneumonia in the same area, persistent wheeze of unclear cause.
• Suspected congenital airway abnormalities — tracheomalacia, laryngomalacia, vascular rings, airway stenosis, fistulas.
• Investigation of stridor — noisy breathing that suggests upper airway narrowing.
• Assessment after surgery — for example, after repair of certain congenital conditions.

Practical differences in children

• Children are almost always under general anaesthesia during bronchoscopy.
• Smaller bronchoscopes are used; the choice of scope depends on the child’s age and size.
• Rigid bronchoscopy is used more often in children than in adults, particularly for foreign body removal.
• The paediatric team usually includes a paediatric anaesthetist experienced with managing children’s airways.
• Family are usually allowed to be with the child during preparation and recovery, even if not during the procedure itself.

Alternatives to Bronchoscopy

Bronchoscopy is one of several ways to investigate or treat airway and lung problems. Depending on the clinical question, other approaches may be more suitable or may be tried first.

• Imaging alone — in some situations, a high-quality CT scan or other imaging is sufficient to answer the clinical question, and bronchoscopy adds little.
• Sputum tests — for some infections, examining sputum that the patient coughs up (or induces with nebulised saline) is enough to make a diagnosis without bronchoscopy.
• CT-guided needle biopsy — for lesions in the outer (peripheral) parts of the lung, a needle biopsy through the chest wall under CT guidance may be a better choice than bronchoscopy, which struggles to reach these areas.
• Navigation bronchoscopy and robotic-assisted bronchoscopy — newer technologies that use electromagnetic navigation, virtual three-dimensional maps, or robotic platforms to reach peripheral lung nodules that traditional bronchoscopy cannot.
• Surgical biopsy — in some cases, when less invasive tests have not given an answer, a surgical lung biopsy (open or video-assisted) is the next step.
• Bronchial artery embolization — for some causes of significant haemoptysis, blocking specific bleeding arteries (performed by an interventional radiologist) may be the preferred or complementary approach.

The choice between bronchoscopy and an alternative is a clinical decision based on the suspected diagnosis, the location of the problem, the patient’s overall condition, and what facilities are available.

Frequently Asked Questions

Will I be awake during the procedure?

Most flexible bronchoscopies are performed under moderate sedation. You are sleepy and relaxed but not unconscious; you can breathe on your own and respond to simple instructions. Most patients remember little of the procedure afterwards. Rigid bronchoscopies, longer therapeutic procedures, and most paediatric bronchoscopies are performed under general anaesthesia, where you are fully asleep.

Will it hurt?

Bronchoscopy is generally not painful, although it can be uncomfortable. The throat and airway are numbed with local anaesthetic, which controls most of the sensation. Coughing during scope insertion is common but is managed by the team. You may feel pressure or a sensation of fluid in the chest during washings.

When can I eat and drink afterwards?

You will be asked to wait until the local anaesthetic in your throat has worn off and your gag reflex has returned — usually about one to two hours after the procedure. Starting with small sips of water is wise. Once you are tolerating fluids, you can return to normal eating.

When will I get the results?

Visual findings and the doctor’s initial impression are often known straight away. Microbiology results usually take 24–72 hours, with cultures for slower-growing organisms taking longer. Biopsy results typically take several working days to two weeks. Additional molecular tests, if needed, may take longer.

Can I go to work the next day?

Most patients can return to their usual activities the day after a routine diagnostic bronchoscopy. After more involved procedures, or if significant biopsies were taken, the team may advise a slightly longer recovery.

Why do I need a bronchoscopy rather than just a CT scan?

CT scans show what something looks like; bronchoscopy can directly inspect the airway and obtain a tissue sample. A scan can show that there is a lump or shadow, but in most cases only a tissue sample — obtained by bronchoscopy, needle biopsy, or surgery — can definitively tell you what it is. The doctor chooses the most appropriate test for the specific question.

Is bronchoscopy safe if I have asthma or COPD?

Bronchoscopy can be performed safely in most patients with asthma or COPD, with appropriate preparation. Inhaler use and breathing optimisation before the procedure are common. Severe, unstable disease may increase risk, and the team will weigh the benefits against the risks individually.

How safe is it really?

Bronchoscopy is one of the most commonly performed procedures in lung medicine, and modern flexible bronchoscopy has an excellent safety record. Major complications are uncommon. Risks are higher for certain patients (critically ill, on blood thinners, severe lung disease) and for certain procedures (transbronchial biopsy, complex therapeutic interventions). These risks are discussed individually as part of consent.

Is bronchoscopy done as a day case or do I need to be admitted?

Most diagnostic bronchoscopies are done as day-case procedures — you arrive in the morning, have the procedure, recover for a few hours, and go home the same day. Complex therapeutic procedures, rigid bronchoscopies, and bronchoscopies in particularly unwell patients may require an overnight stay.

Conclusion

Bronchoscopy is a well-established procedure that combines two roles in lung medicine: finding out what is wrong, and in many cases treating problems in the airway during the same session. Modern flexible bronchoscopy is generally safe, can be performed as a day case in most patients, and provides information and treatments that would otherwise require more invasive surgery.

The exact form of bronchoscopy — flexible or rigid, awake-sedated or under general anaesthesia, diagnostic or therapeutic — depends on what the doctor is trying to find or treat. Knowing why it is being recommended, what will be done, what risks apply to your situation, and what to expect during recovery is the foundation of an informed decision. Those details are best worked out with the pulmonologist or other doctor who knows your case.