What are the guidelines for a rigid bronchoscope?

From the Guidelines

Rigid bronchoscopy is recommended for patients with symptomatic malignant or nonmalignant central airway obstruction as a therapeutic intervention, with the suggestion to use rigid bronchoscopy over flexible bronchoscopy for these interventions. This recommendation is based on the most recent guidelines from the American College of Chest Physicians, as outlined in the study published in Chest in 2025 1. The guidelines suggest that for patients with symptomatic malignant or nonmalignant central airway obstruction, therapeutic bronchoscopy should be considered as an adjunct to systemic medical therapy and/or local radiation, with a preference for rigid bronchoscopy over flexible bronchoscopy for therapeutic interventions.

Key Considerations for Rigid Bronchoscopy

• The procedure should be performed by trained pulmonologists or thoracic surgeons in a controlled setting with appropriate anesthesia support, as suggested by the European Respiratory Society/American Thoracic Society statement on interventional pulmonology 1.
• Patients should undergo thorough evaluation prior to the procedure, including imaging studies, pulmonary function tests when possible, and coagulation studies.
• Standard monitoring during the procedure should include continuous ECG, pulse oximetry, blood pressure monitoring, and end-tidal CO2.
• The rigid bronchoscope comes in various sizes (typically 6-14 mm in diameter) and should be selected based on the patient's anatomy and procedural goals.
• Common indications for rigid bronchoscopy include foreign body removal, management of massive hemoptysis, therapeutic interventions for central airway obstruction, and stent placement.

Training and Competency

• Training in rigid bronchoscopy should be reserved for physicians who have had extensive experience with flexible bronchoscopy and endotracheal intubation, as outlined in the European Respiratory Society/American Thoracic Society statement on interventional pulmonology 1.
• Trainees should first practice on mannequins or animal models and should perform at least 20 supervised rigid bronchoscopy procedures before attempting this procedure alone.
• To maintain competency, the procedure should be performed at least 10–15 times/year.

Potential Complications

• Complications may include hypoxemia, bleeding, pneumothorax, and airway trauma, so emergency equipment should be readily available.
• Post-procedure, patients require close monitoring for respiratory compromise, with particular attention to stridor or decreasing oxygen saturation which may indicate laryngeal edema or bronchospasm.

From the Research

Guidelines for Rigid Bronchoscope

• The use of sedatives such as fentanyl and midazolam during bronchoscopy is recommended by the American College of Chest Physician due to its favorable drug profile, as it improves patient comfort and tolerance 2.
• A study found that sedation with midazolam in flexible bronchoscopy improved patient's comfort and decreased complaints, without significant hemodynamic changes, and should be offered to the patient on a routine basis 3.
• The application of muscle relaxants and traditional low-frequency ventilation during rigid bronchoscopy in patients with central airway obstruction can be safely used, with a high usage rate of muscle relaxants (96.5% in total) and no significant carbon dioxide accumulation and hypoxemia occurred 4.
• Combined sedation with midazolam, fentanyl, and propofol (MFP) during flexible bronchoscopy has been shown to be safe and effective, with a reduced dosage of midazolam and propofol compared to sedation with midazolam and fentanyl (MF) or midazolam and propofol (MP) 5.
• A randomized, double-blind, placebo-controlled study found that conscious sedation with fentanyl and midazolam combination resulted in better patient and operator satisfaction when compared with midazolam alone during flexible bronchoscopy 6.

Key Considerations

• The dosage of skeletal muscle relaxants used was higher in rigid bronchoscopy compared with flexible bronchoscopy therapy 4.
• The occurrence of adverse events and severe adverse events was similar in all groups, including MFP, MF, and MP 5.
• Patient-reported tolerance and satisfaction composite scores were higher in the fentanyl-midazolam group compared to the midazolam group and placebo group 6.