Endoscopic techniques, flexible, rigid bronchoscopy and thoracoscopy are central tools in the evaluation and treatment of respiratory disorders and their use has been steadily growing.The first rigid bronchoscopy was performed in 1897 when Gustav Killian removed a piece of pork bone from the bronchus of a 63-year-old farmer, thus avoiding a tracheotomy.1,2 IKEDA3 in the late 60s pioneered fiberoptic bronchoscopy as a tool to enter subsegmental bronchi and obtain specimens for early diagnosis of lung cancer. During the last 30 years the flexible bronchoscope has become the diagnostic instrument of choice for visualization of the bronchial tree as it is less invasive, does not require general anaesthesia and provides much better visualization of the smaller peripheral airways. The introduction of laser technology into the tracheobronchial tree and the advent of airway stents in the early 1990s caused a resurgence of rigid bronchoscopy in the management of both benign and malignant central airway obstruction.4–6

Thoracoscopy began in 1908 with Jacobeus,7 and was extensively used in the treatment of tuberculosis, for pneumothorax induction and lyses of adhesions. When effective treatment for TB was discovered, interest in this technique disappeared. With technical improvements during the 90s, thoracoscopy regained popularity for dealing with undiagnosed pleural effusion.

These techniques can be considered safe since they are widely used and the rate of complications is extremely low.8–10 A recent retrospective analysis of 23.682 patients undergoing bronchoscopy over a period of 11 years showed a mortality rate of 0.013% with a complication rate of 0.739%.9 Mortality from medical thoracoscopy ranges between 0.09 and 0.24%.11 Despite these small numbers, complications do occur and in order to avoid them, the evaluation of the patient before and after any intervention, is of utmost importance. Considering that this issue is of major concern, it is surprising that there are very few up to date studies dealing with these areas, the evidence level remains low and most recommendations (European Respiratory Society, American Thoracic Society and national societies) are based on common sense and the very small number of evidence based publications.

The aim of this article is to address pre- and post evaluation workup of patients undergoing endoscopic techniques in order to determine the fitness of the patient and the ideal planning and strategy in order to obtain the maximum benefit with the lowest risk.

The issues discussed are the preparation of the patient and informed consent, the general assessment – medical history, current medications, physical examination, laboratory tests, radiological evaluation and analysis of the indication and planning. The post intervention evaluation will also be discussed, in order to detect and treat complications and decide on the guidance to be given to the patient after discharge.

Although bronchoscopy is a safe technique with low rates of morbidity and mortality,8,9 care should be taken in certain situations.

Rigid bronchoscopy is performed under general anaesthesia and so the first thing to do is to evaluate the state of health of the patient. Ventilatory function, cardiac status, hematologic, renal and liver function all must be assessed.

Anatomical features must be taken into consideration. Patients who cannot tolerate hyperextension of the neck or rotation of the neck due to a fused or unstable cervical spine should not be considered for bronchoscopy. Patients with unstable midline facial fractures or deformities of the mouth are not suitable to undergo rigid bronchoscopy.

Rigid bronchoscopy is the preferred option for other endobronchial therapies4,34,35 such as laser, eletrocautery, criotherapy and stent placement. As well as understanding the indications, contraindications and possible complications of RB,10 it is also essential to know about these techniques so as to be able to select the most appropriate for each particular case. Patients undergoing these therapies generally have poor performance status and relevant comorbidities, so it is crucial to analyze the risk/benefit. For a patient undergoing laser therapy it is important to know whether the symptoms are caused by the obstruction, if the lung has been collapsed for more than 4–6 weeks, if there is involvement of the pulmonary artery, if there is functional lung distal to the obstruction.

If a stent is to be placed, the following must be taken into account: type of obstruction (intrinsic/extrinsic), localization (central airways), and patency distal to the obstruction. In order to answer these questions, there should be a careful radiological and endoscopic evaluation prior to any intervention.

Medical thoracoscopy is generally performed under local anaesthesia and conscious sedation and is considered a safe procedure.11 Besides knowing the indications, contraindications and complications, a detailed medical history, drug history, physical examination and imaging, chest X-ray and chest CT, are crucial to any preoperative evaluation. Although an ultrasound prior to the procedure is not mandatory, it increases safety and should be used whenever possible.36

Patient general health status is assessed by a total blood count, blood chemistry and coagulation study. Depending on age (>65 years) and the presence of certain comorborbidities, ECG, ABG analyses and spirometry (severe COPD patients) may be added to the screening.

Dyspnea in a patient with a pleural effusion is not a concern since it will improve with effusion drainage, during thoracoscopy.

The procedure involves intravenous sedation/analgesia and so a reasonable level of oxygenation should be assured (>90% with supplemental oxygen during the procedure).36 Visual inspection of the point of entry is important in deciding where to insert the thoracoscope, avoiding skin infection or other abnormalities like sequelae of previous radiotherapy.

Patients must be able to tolerate lateral decubitus during the whole of the procedure.

Like other invasive techniques performed through surgically scrubbed skin, thoracoscopy is not likely to produce significant bacteriemia and so profilactic antibiotics are not recommended.29 When there is pleural space infection it is advisable to give profilactic antibiotics in patients at risk of endocarditis.29

If pleurodesis is a possibility, it is important to analyze the patient performance status, namely life expectancy (superior to 3 months) and to rule out a trapped lung.

All patients should be observed for at least 30–60min after bronchoscopy or for 2h after rigid bronchoscopy or intervention. Observation can take place in the operating room or in a recovery room.

The monitoring of ventilation features, such as SaO2, the respiratory rate and pattern (visible signs of bronchial obstruction and respiratory distress), ABG when required and hemodynamic features, such as blood pressure, heart rate and ECG, is of paramount importance.

Post-operative care should focus on the most common complications, such as acute airway obstruction, bleeding, mucus retention, pneumothorax, respiratory failure and cardiac dysfunction. Hypoxic events subsequent to bronchoscopic procedures can occur in as many as 80% of the patients; oxygen supplementation after the procedure successfully reduces such hypoxic episodes, particularly in subjects with impaired lung function.37

Discharge from the recovery room can be performed when the patient is conscious, when all aspects of the ventilatory and airway reflexes have been restored, and when the patient is able to take deep breaths and to cough effectively without signs of obstruction.

Where patients have been sedated they must be advised after discharge not to drive or operate machinery or sign legal documents in the following 24h.8

Patients should be discharged in the presence of a relative capable of reporting complications and written information about the procedure and its complications should be provided (Table 2).

As medical thoracoscopy is performed with conscious sedation, monitoring of vital signs is essential until patient is fully recovered and is no longer at risk of cardiac and respiratory depression. Chest tube functioning should be checked for bleeding and air leaks. A chest X-ray should be performed to monitor lung reexpansion. Proper analgesia should be supplied especially if a talc pleurodesis has been performed. Two hours later, the chest tube should be connected to active suctioning to promote lung reexpansion. Removal of the chest tube should be considered when production of pleural fluid is less than 100–200ml/day and the lung is fully expanded.11 In mesothelioma it is common practice to perform radiotherapy within 2 weeks at the trocar site of entry to avoid seeding, but there are studies that do not agree with this.39

A thorough evaluation performed prior to any intervention, including medical history, drug history, physical examination, blood tests and imaging, is critical to avoid unnecessary risks and to achieve a successful outcome. Diagnostic procedures must always impact on patient management and therapeutic interventions must take into account patient performance status and life expectancy. Post operatively it is important to be aware of the possible complications and provide adequate surveillance and monitoring to guarantee patient safety and make appropriate decisions for the future. It does not matter how many technological innovations and skills there are in the field of endoscopic techniques, this process of decision making before and after any intervention will remain the key point.

The authors have no conflicts of interest to declare.