From the Guidelines
Bronchoscopy is primarily used for diagnostic purposes in patients with fungal ball indication, with limited therapeutic effectiveness. The role of bronchoscopy in patients with fungal ball indication is mainly to obtain samples for microbiological confirmation when the diagnosis is uncertain based on imaging alone, as recommended by the 2017 ESCMID-ECMM-ERS guideline 1. During bronchoscopy, physicians can visualize the airways and collect bronchoalveolar lavage fluid, bronchial washings, or tissue samples for fungal culture and histopathological examination. Some key points to consider when using bronchoscopy in this context include:
- The use of chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) is strongly recommended 1
- Direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended for diagnosis 1
- Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA 1 Therapeutically, bronchoscopy has minimal effectiveness for fungal ball treatment as these lesions are typically located within cavities that may not communicate well with airways. In cases where hemoptysis occurs, bronchoscopy can help localize bleeding sites and occasionally allow for temporary management through instillation of antifungal agents directly into the cavity. However, this approach provides only temporary relief and is not curative. Definitive treatment of symptomatic fungal balls generally requires surgical resection, particularly for recurrent hemoptysis. Bronchoscopy is most valuable as part of the initial evaluation process to confirm diagnosis and rule out other conditions, but its therapeutic limitations should be recognized when planning comprehensive management for patients with fungal balls.
From the Research
Role of Bronchoscopy in Fungal Ball Indication
- Bronchoscopy plays a crucial role in the management of fungal ball indication, particularly in patients who are poor surgical candidates or prefer a less invasive treatment modality 2.
- The procedure can be used for intracavitary instillation or endobronchial administration of antifungal medication, as well as direct transbronchial aspergilloma removal 2, 3.
- Bronchoscopic debulking, combined with antifungal therapy, has been shown to be an effective approach in managing complex fungal balls, with a high success rate and relatively low complication rate 3.
Bronchoscopy in Hemoptysis Management
- Bronchoscopy is also used in the management of hemoptysis, a common complication of fungal ball indication, to protect the airway and determine the site and etiology of bleeding 4, 5.
- Topical hemostatic tamponade therapy (THT) using oxidized regenerated cellulose (ORC) mesh has been shown to be a safe and effective technique in controlling life-threatening hemoptysis 4.
- Bronchial artery embolization is used to treat massive hemoptysis, particularly when an involved artery is noted on computed tomography angiography, and surgery is reserved for patients whose medical treatment and embolization are not effective 5.
Antifungal Therapy and Bronchoscopy
- Systemic antifungal therapy, such as azoles, has been shown to be effective in approximately 50-80% of patients with fungal ball indication, and can be used in combination with bronchoscopic debulking 2, 3.
- Topical antifungal therapy, such as Amphotericin B, can also be administered through bronchoscopy, and has been shown to be effective in improving antifungal effects and clinical symptoms in patients with chronic pulmonary aspergillosis 6.