Introduction
Bronchoscopy is a well-developed and essential technique to investigate bronchial and pulmonary structures and to treat its pathologies. Within the past decades, several surveys on methods, usage, medication and complication rates in different countries have been published [1 ]
[2 ]
[3 ]
[4 ]
[5 ]
[6 ]
[7 ]
[8 ]. The “ACCP Survey” 1991 in North America [1 ] and the German Survey in 2000 [3 ] were the largest collections of data, including 871 and 681 institutions respectively. Since its establishment by Killian in the late 19th century [9 ], bronchoscopy has developed immensely. Endobronchial ultrasound (EBUS), stent treatment or thermal recanalisation techniques are true examples of procedures that, in the recent past, have found their way into clinical routine [10 ]. Guidelines [10 ]
[11 ]
[12 ] summarise developments and recent study results to define standards and help bronchoscopists optimise their performance. However, guidelines do not necessarily reflect clinical practice and do not always meet the specific requests, demands and various traditions of the different institutions. Questions as to whether the rigid or the flexible approach is more favourable, or what is the best strategy for sedation and anaesthesia, are still under debate.
This survey is intended to describe the current situation of bronchoscopy in Germany, as well as to focus on the developments that have taken place within the past two decades, by considering previous polls. Furthermore, it investigates the allocation of modern interventional and diagnostic methods and takes a detailed look at the use of sedation strategies which have, so far, not been explored to this extent. In this way, we can better understand how research and development in the field of bronchoscopy are reflected in everyday clinical routine.
Results
Responses
In total, 472 hospitals (response-rate: 29.5 %) and 155 private practitioners (response-rate: 56.0 %) returned 627 questionnaires (overall response-rate: 33.4 %). 92.8 % of the questions in the questionnaire were answered. 28 institutions (nine hospitals, 19 private practices) stated that they did not conduct bronchoscopies. The response rate was significantly higher in hospitals with more than 600 beds (57.3 %). On average, bronchoscopies are performed by 4.2 physicians per hospital and 1.6 physicians per private practice respectively. The survey covers a total number of 2158 physicians.
Bronchoscopy in hospitals
Frequencies
54.7 % of respiratory clinics use dedicated bronchoscopy labs, whereas internal clinics prefer to participate in interdisciplinary facilities (94.9 %). Both equally often serve in-house intensive care units (74.7 % vs. 73.5 %). The frequency of all the examinations are shown in [Table 1 ]. 7.5 % of all bronchoscopies are done in outpatients. 46.3 % of hospitals do not perform outpatient bronchoscopies.
Table 1
Frequencies and distribution of bronchoscopies/year.
Institution
Total bronchoscopies
Flexible bronchoscopies
Rigid bronchoscopies
Outpatient bronchoscopies
n
N
n/N
n
N
n/N
n
N
n/N
n
N
n/N
all hospitals
289 310
451
641
267 222
443
603
20 633
155
133
21 603
195
111
respiratory clinics
231 028
167
1383
210 538
166
1268
19 440
124
157
17 732
121
147
internal clinics
53 892
265
203
52 426
259
202
1131
26
44
3125
69
45
n: number of bronchoscopies, N: number of institutions, n/N: mean number of bronchoscopies per institution.
[Fig. 1 ] displays the proportion of rigid bronchoscopies in reference to the total number of bronchoscopies, today, and in 2000 [3 ], respectively. The proportion of hospitals performing rigid bronchoscopies has increased over time (35.0 % vs. 22.7 %). In 2000, almost three-quarters of these hospitals performed less than 50 rigid bronchoscopies per year. Today, nearly 50 % perform more than 50 rigid bronchoscopies per year. However, the proportion of rigid bronchoscopies as a whole decreased from 10.2 % to 7.3 %. Respiratory clinics perform rigid bronchoscopies more often (8.5 %) than internal clinics (2.1 %).
Fig. 1 Distribution of rigid bronchoscopy frequencies comparing the current survey with the German survey from 2000.
Similar to the distribution of rigid bronchoscopies, the number of flexible bronchoscopies per institution has increased. [Table 2 ] gives an overview of the frequencies in comparison with previous surveys.
Table 2
Comparison of flexible bronchoscopy frequencies across different surveys.
Number of flexible bronchoscopies per institution per year
This survey
(%)
Markus et al. [3 ]
(%)
Smyth et al. [5 ]
(%)
1 – 99
29.2
57.7
12
100 – 299
26.4
23.1
76
> 299
44.4
19.2
12
Numbers are given as percentage of all institutions.
Training and experience
71.3 % of the responding physicians have been performing bronchoscopies for more than 10 years. Training is most commonly conducted in-hospital by experienced colleagues. 62.5 % of physicians attended an additional training course. [Table 3 ] displays the experience of bronchoscopists in dedicated skills and techniques.
Table 3
Experience in diagnostic and interventional techniques.
Proportion of bronchoscopists with experience in:
Cryotherapy, APC or laser (%)
EBUS
(%)
Stent implantation (%)
ELVR
(%)
all hospitals
35.4
24.8
18.7
12.5
respiratory clinics
45.4
41.8
31.2
22.7
internal clinics
25.9
6.9
5.8
2.0
APC: argon plasma coagulation, EBUS: endobronchial ultrasound, ELVR: endoscopic lung volume reduction.
On-call service
On-call services for emergencies overnight or on weekends are provided by 56.0 % of all departments (respiratory 73.2 %, internal 46.1 %).
Premedication, local anaesthesia
Atropine as a premedication is applied in 15.4 % of the institutions; opioids (e. g. codeine) in 20.1 %. 15.3 % of the hospitals state that they do not use any premedication. Local anaesthetics are used in 79.4 %.
Sedation
Sedation is nowadays routine during bronchoscopy (88.0 %). General anaesthesia is used in 5.4 % of cases. No sedatives are applied in 6.6 %. When sedation is applied, propofol and midazolam are the preferred drugs ([Table 4 ]). The most common regimen is the combination of propofol and midazolam (41.3 %), followed by the sole application of propofol (28.3 %) or of midazolam (20.8 %) respectively. The use of the opioid-combinations, fentanyl/alfentanil (4.9 %), or other sedative drugs (e. g. diazepam, pethidine) (4.7 %) is rare. The combination of propofol and midazolam has the highest acceptance among bronchoscopists. 73.1 % of them are satisfied with the sedation quality. Satisfaction with propofol or with midazolam as a mono-sedative is slightly less (72.6 % and 65.4 %). Only 31.7 % of those using a propofol/midazolam combination declare that occasionally they would wish to have a “deeper, but equally safe sedation”, especially for interventional procedures.
Infusion systems are used by 7.3 % of the institutions, in 1.6 % with target-controlled infusion (TCI) modes. For special indications (e. g. critical patients, complicated interventions, TBB, EBUS), 48.8 % of institutions make use of dedicated endobronchial tubes.
Table 4
Preferred sedation regimen.
Sedation regimen
Preferred by % of institutions
propofol + midazolam
41.3
propofol mono
28.3
midazolam mono
20.8
combination with fentanyl/alfentanil
4.9
combination with other sedatives[1 ]
4.7
1 other sedatives contain: diazepam, pethidine, etomidate.
Indications and techniques
The most frequent indication for a bronchoscopy is the diagnostic evaluation of a suspected tumour or its follow-up. It is followed by 2) microbiological diagnostics, 3) chronic cough or haemoptysis, 4) bronchial washing and cleaning and 5) interstitial alterations. The practice of the different diagnostic and therapeutic techniques among the respondent institutions are shown in [Table 5 ].
When sedation is considered to be inadequate for specific procedures, general anaesthesia is used. Examples for interventions that mainly take place under general anaesthesia are stent implantation (79.4 %), laser therapy (69.9 %) and ELVR (65.2 %) ([Table 6 ]). For some procedures, the use of general anaesthesia is more or less balanced: cryotherapy, which includes cryorecanalisation (57.1 %), EBUS (50.3 %), cryobiopsy (49.4 %). APC (38.1 %) and brachytherapy (19.8 %) are carried out less frequently under general anaesthesia. For all other bronchoscopic methods, general anaesthesia is rarely used (BAL: 4.4 %, EBB: 4.1 %, TBB: 7.9 %, TBNA: 12.4 %). It can be observed that, for numerous interventional methods (e. g. TBNA, EBUS, laser therapy, cryotherapy, stent implantation), the percentage of general anaesthesia increases, the more bronchoscopies the hospital does. This especially applies to APC, as hospitals with more than 999 bronchoscopies use general anaesthesia in 54.9 % and hospitals with 300 or less bronchoscopies use it in 18.7 % of the cases. Respiratory clinics, compared to internal clinics, often have significantly higher numbers of general anaesthesia usage which applies to the following procedures: TBNA (respiratory: 15.3 %, internal: 8.1 %), laser (respiratory: 75.0 %, internal: 50.0 %), APC (respiratory: 53.8 %, internal: 20.2 %), cryotherapy (respiratory: 61.1 %, internal: 39.1 %) and stent implantation (respiratory: 84.6 %, internal: 60.3 %). Sometimes, the size of the hospital is relevant when considering the usage of general anaesthesia. For example, during EBUS, cryobiopsy and ELVR bronchoscopies, hospitals with more than 600 beds use notably less general anaesthesia than hospitals with less than 600 beds. For APC, the opposite relationship applies.
Table 5
Implementation of different bronchoscopic techniques within institutions. Impact of hospital size and specialisation.
Specialisation
Hospital size
Bronchoscopies/year
Technique
All hospitals
(%)
Respiratory
(%)
Internal
(%)
≤ 600 beds
(%)
> 600 beds
(%)
≤ 300
(%)
> 300
(%)
BAL
98.7
100.0
98.1
98.3
100.0
98.4
99.5
EBB
89.3
93.5
88.8
87.3
96.6
84.7
96.8
TBB
71.8
96.4
59.9
65.6
95.5
52.2
98.4
TBNA
57.8
91.2
38.2
50.4
85.4
33.3
91.6
EBUS
36.3
79.2
11.2
25.3
77.5
4.7
79.5
EBUS MP
10.1
25.0
1.1
8.0
16.9
0.4
23.7
electromagnetic navigation
2.6
6.5
0.4
2.2
4.5
0
6.3
laser
16.8
36.3
5.9
9.6
44.9
2.4
36.8
APC
59.3
82.7
47.6
53.2
82.0
37.6
88.9
cryotherapy
28.2
63.7
8.2
19.8
60.7
4.3
61.1
cryobiopsy
17.3
38.7
5.2
12.1
37.1
0.8
40.0
stent implantation
34.8
75.6
11.9
24.2
74.2
6.7
73.2
brachytherapy
14.4
35.1
2.6
6.9
44.9
0.4
34.2
foreign-body
79.6
94.6
72.1
76.0
93.3
68.6
96.3
thoracoscopy
20.1
42.3
7.1
16.0
37.1
4.7
41.1
Numbers represent the application of the described technique in percent. BAL: bronchoalveolar lavage, EBB: endobronchial biopsy, TBB: transbronchial biopsy, TBNA: transbronchial needle aspiration, EBUS: endobronchial ultrasound, EBUS MP: endobronchial ultrasound with miniprobe, APC: argon plasma coagulation, foreign-body: foreign-body removal.
Table 6
Use of general anesthesia within diagnostic and therapeutic modalities.
Modality
General anesthesia applied in (%)
stent implantation
79.4
laser therapy
69.9
ELVR
65.2
cryotherapy
57.1
EBUS
50.3
cryobiopsy
49.4
APC
38.1
brachytherapy
19.8
TBNA
12.4
TBB
7.9
BAL
4.4
EBB
4.1
BAL: broncho alveolar lavage, EBB: endobronchial biopsy, TBB: transbronchial biopsy, TBNA: transbronchial needle aspiration, EBUS: endobronchial ultrasound, ELVR: endoscopic lung volume reduction, APC: argon plasma coagulation.
TBB and anti-platelet therapy
In some situations, TBBs under anti-platelet therapy are rejected to prevent bleeding. However, 74.4 % of the institutions perform TBB despite aspirin therapy. 8.1 % accept dual anti-platelet therapy. 25.1 % refuse TBB under any type of anti-platelet therapy.
EBUS and ELVR
This survey counts 23,125 EBUS bronchoscopies and 4008 EBUS with mini-probes conducted by 158 hospitals, which represents a mean of 171 EBUS bronchoscopies/year. Together, this adds up to 9.4 % of all bronchoscopies. It can also be observed that the more bronchoscopies a hospital performs, the higher the relative proportion of EBUS procedures. In hospitals with less than 300 bronchoscopies/year, the percentage of EBUS is 0.7 %; in hospitals with 300 to 999 bronchoscopies/year, it is 8.2 % and in hospitals with more than 999 bronchoscopies/year, 10.2 %. Furthermore, 72.7 % of EBUS is performed in institutions with 999 bronchoscopies/year. Respiratory clinics perform more EBUS (195 per year) than other clinics (58 per year).
ELVR is conducted by 23.5 % of institutions. The preferred method for ELVR is the implantation of airway valves (84.7 %) followed by coils (14.4 %). In contrast, steam or tissue glue is rarely used. This order is evenly distributed across institutions, irrespective of specialty, hospital size or examination frequency.
Airway recanalisation
62.4 % of institutions declare their performance of airway recanalisation. The ranking of the preferred methods is displayed in [Table 7 ]. High frequency units favour cryotherapy, whereas smaller units prefer APC. Stent implantation and balloon-dilatation is also mentioned, but are performed less frequently.
Table 7
Popularity of different recanalisation methods in numerical order among institutions performing airway recanalisation.
All institutions
Institutions w/bronchoscopies/year
method
< 300
> = 300
APC
1
1
2
cryotherapy
2
3
1
mechanical debulking
3
2
3
laser therapy
4
4
4
brachytherapy
5
5
5
1: most popular and 5: least popular, APC: argon plasma coagulation,
Patient monitoring and surveillance
All bronchoscopists measure oxygen-saturation by means of pulse oximetry; 95.2 % use oxygen supplementation during examinations and 93.9 % institute an IV line. Intermittent non-invasive blood pressure monitoring is conducted in 84.1 %, and ECG monitoring in 76.3 % of cases. Capnography is applied by 15.9 % of institutions on selected patients. In outpatients, the average monitoring time before discharge is 132 minutes. Respiratory clinics observe patients longer than internal clinics (difference 11 minutes).
Personal comments
Institutions were asked to specify the next desirable development in the field of bronchoscopy. 135 respondents made additional comments. Advancements in diagnostic instruments and techniques are the major requests, next to improvements in sedation strategies and questions of cost. The five most frequent comments are displayed in [Table 8 ].
Table 8
The five most frequent comments regarding requests for future developments in the field of bronchoscopy.
1.
improved diagnostic possibilities in solitary pulmonary nodules
2.
implementation of biopsy forceps for EBUS
3.
improved EBUS TBNA-needles
4.
less acquisition cost for navigation systems
5.
improvement in sedation strategies
Bronchoscopy by private practitioners
Private practitioners performed 12,655 flexible bronchoscopies, which results in an average of 97 bronchoscopies per private practice. 31.5 % of the responding practitioners do less than 25 flexible bronchoscopies/year and 50.8 % do less than 50 bronchoscopies. However, private practitioners have longer bronchoscopy experience than hospital physicians. 63.0 % of the bronchoscopies are performed in private practice, and 37.0 % in hospitals respectively. 84.1 % of bronchoscopies are outpatient procedures. 91.1 % of private practitioners use local anaesthetics, 21.5 % use Atropine and 11.1 % use opioids (e. g. codeine), whereas only 4.4 % state that they do not use any premedication. 71.3 % of the bronchoscopies are performed with sedation. Midazolam as a monotherapy is preferred by 50.6 % of private practitioners. 19.8 % use propofol only, 13.6 % use propofol and midazolam in combination and 8.6 % use combinations with diazepam. The majority of physicians are satisfied with the combination of propofol and midazolam (90.9 %), while physicians using monotherapies are satisfied to a lesser extent (propofol-only: 57.1 %, midazolam-only 51.2 %).
Endotracheal tubes are rarely used (14.5 %). Chronic cough or haemoptysis are the most common indications, followed by suspected tumour or tumour follow-up. Private practitioners mostly perform BAL (97.0 %) or EBB (83.3 %). TBB (38.6 %), foreign body removal (37.1 %) or TBNA (25.8 %) are done less frequently. APC (6.8 %), EBUS (4.5 %) and stent implantations (3.0 %) are rare. 50.9 % of all private practitioners do TBB under aspirin, 5.7 % accept dual platelet inhibition. 49.1 % of them avoid TBB under any kind of anti-platelet therapy. Private practitioners use less monitoring measures than hospitals. The average surveillance time before discharge is 92 minutes. A major concern for private practitioners is the inadequate reimbursement of bronchoscopic activity.
Discussion
This survey addresses the current situation of bronchoscopy in Germany. It covers more than 300,000 examinations, which makes it numerically the largest investigation on this subject [1 ]
[2 ]
[3 ]
[4 ]
[5 ]. It was also designed to identify changes in clinical practice when compared to the preceding German survey which had been completed in 2000 by Markus et al. [3 ].
The response rate was lower than in the previous surveys. In contrast to Markus et al. [3 ], we addressed a considerably higher number of institutions, whereas the number of returned questionnaires was identical. The most likely reason for this is, that in our mailing list, we frequently addressed different institutions within the same hospital, (e. g. anaesthesiologic and pulmonary clinics), and only one of these institutions responded. In addition, our database covered a large number of very small institutions, suggesting that some of these institutions did not respond because they presently do not perform bronchoscopy or did not feel significant enough to complete such a complex questionnaire. Nevertheless, the absolute number of responses can be interpreted as an indication for a representative cross-section of bronchoscopy in Germany.
Compared to 2000, the number of flexible bronchoscopies per institution increased by 80.6 % to 484. Even if the number of examinations cannot be directly compared between the two studies, as we do not know what proportion of institutions participated in both surveys, a growing number of indications and growing technical possibilities may explain the increase. Previous surveys in the UK [2 ], and in the United States [1 ], counted 171 and 115 bronchoscopies per institution respectively. In contrast, the number of rigid bronchoscopies decreased slightly ([Fig. 1 ]). It is particularly interesting to see that the proportion of institutions with a low number of rigid bronchoscopies has declined, indicating that more invasive procedures are concentrated in larger centres.
Guidelines promote a structured education [10 ]
[11 ]. However, most bronchoscopists are still trained exclusively within their institution. Today, two-thirds of institution heads have more than 10 years of experience in bronchoscopy. In the US study from 1991, this proportion was 58 % [1 ]. Interventional skills among bronchoscopists are now widely scattered. In respiratory clinics, nearly half of the examiners are able to perform, e. g. airway recanalisation or EBUS, whilst one-third are able to place bronchial stents. Even recent and complex developments, like ELVR, are already applied by every fourth institution. This reflects the high technical standards and capabilities, as well as the constant desire to quickly offer new and innovative therapies to patients – and, not least, the ambition to obtain the generally attractive reimbursements for the most recent devices.
Premedication and sedation regimen have changed noticeably over time [13 ]. Atropine has always been widely used; in 83 % of patients [1 ]
[2 ]
[14 ] in 1991. In this survey, it was only applied in one of six institutions, recognising the fact that atropine has few beneficial effects to justify routine use [15 ]. The same applies to opioids as antitussive agents. It is now generally accepted that sedation is beneficial during bronchoscopic procedures, both for the patient and for the bronchoscopist [10 ]
[12 ]. In Germany, only 7 % of examinations are performed without sedatives or intravenous anaesthetics. In the past decades, the application of general anaesthesia dropped significantly from 16.5 % (US survey, 1991) and 12 % (UK survey, 1986) to 5.4 %, which corresponds well with a recent Japanese survey [4 ]. Most interventional procedures today can be performed under sedation, only a few techniques require general anaesthesia [16 ]. The most popular regimen for sedation is now a combination of midazolam and propofol, followed by propofol alone ([Table 4 ]). The increasing acceptance of propofol results from the fact that a growing number of studies have proven the feasibility and safety of the drug when administered by the bronchoscopist [17 ]
[18 ], which had been a major concern when propofol was first introduced. In particular the significantly faster sedation, as well as the shorter recovery time, are often very advantageous for patient-handling, when compared to midazolam or other benzodiazepines [19 ] which, in former surveys, have been the most commonly used substances. A few institutions additionally use perfusors for propofol administration (7.3 %). Opioids, however, are rarely given for sedation purposes (4.9 %).
Transbronchial biopsy and transbronchial needle aspiration is now very widely used and its application has further increased over time. Currently, 75 % of institutions even perform TBB under aspirin, which recognises and supports results from a clinical trial on this issue [20 ]. However, in patients with dual platelet inhibition, bronchoscopists are much more cautious, which is also backed up by clinical studies [21 ]
[22 ]. Only 8 % perform TBB in such circumstances. Endobronchial ultrasound (EBUS) has now become a standard for diagnosing mediastinal lymph nodes. It is recommended by various guidelines [23 ]
[24 ] which have clearly led to the wide diffusion of this method. For obstructed airways, the classic method of laser therapy has been mostly replaced by APC and the cryoprobe which have since become the most popular means of airway recanalisation. The reasons for that may vary, but we assume that APC and cryotherapy are relatively uncomplicated to use and more cost-effective [25 ]. Cryobiopsy, a novel diagnostic modality, especially for diffuse lung disease [26 ], is already utilised by a significant number of institutions. Navigation technology, such as electromagnetic navigation [27 ], is effective and wanted by many bronchoscopists, but it has been expressed that the financial cost is a critical issue – this may be one of the factors why it has still not been widely adopted.
To summarise; bronchoscopy has developed in many respects within the past 20 years. When compared with previous surveys, new achievements containing dedicated interventional techniques, as well as a set of diagnostic innovations, have been introduced into clinical practice. Endobronchial ultrasound is certainly one of the most important developments which is now implemented in many institutions. Furthermore, a number of new guidelines and recommendations provide precise instructions and directives for the bronchoscopist, e. g. on how to manage sedation, which have found their way into the daily routine.
