The flexible bronchoscope is made up primarily of fiberoptic bundles that carry illuminating light into the bronchus and reflected light back to the lens, which allows direct visualization of the airways. The tip of the bronchoscope can be manipulated with a series of levers. Parallel channels of the bronchoscope can carry irrigating fluid and flexible biopsy forceps and can be used for suctioning at the end of the instrument. The rigid bronchoscope is a long, straight metal tube with a light at the tip. The rigid bronchoscope can be used to manipulate the wall of the trachea and bronchi; the large lumen allows suctioning of large particles, but vision is limited. The rigid bronchoscope is used if large particles (such as inhaled food, coins, other objects) must be cleared from the airways. It is also used to help control massive bleeding from the airway, and is generally done in the operating room.For this procedure there is the doctor, nurse, respiratory therapist and radiology tech generally present. The patient has an IV started for sedation, placed on a cardiac monitor so that the heart rhythm, blood pressure, and oxygenation may be monitored during the procedure. The patient is then given an inhaled breathing treatment with medications to numb the airways which depresses the gag and cough reflexes. Oxygen is also placed on the patient to ensure adequate oxygenation during the procedure. Once this is completed, the patients nose, throat and upper airways are anesthetized with topical anesthetic. Sedation is given through the IV, which relaxes the patient.

Pleural biopsy is a procedure whereby samples of the pleural tissue (the lining around the chest wall) are removed and examined under a microscope as well as sent for cultures. Pleural biopsies are generally performed when a patient has a pleural effusion that, after a thoracentesis, has the characteristics of cancer or tuberculosis but there are no identifiable cancer cells or TB bacteria on stain or culture. This tissue is used to look for granulomas of tuberculosis or implants of tumor cells from a malignant process. The biopsy helps distinguish between cancerous and non-cancerous disease. It also helps detect whether a viral, fungal or parasitic disease is present. Blood tests and chest x-rays may be done prior to the procedure. The procedure is generally done on an outpatient basis, and only requires local anesthesia. The pleura is a membrane that lines the inside of the chest cavity. The patient can either be sitting up or lying down. The biopsy site is cleansed and then a local anesthetic is given. The patient may feel a brief prick of a needle and some burning sensation, but this will numb the skin. A needle is then inserted sterilely through the skin so that a biopsy can be taken. The needle is rotated and tissue samples are withdrawn. Once this is done the biopsy site requires only a small bandage and the patient is monitored for a short time.

A thoracic needle biopsy is a procedure used to biopsy lung nodules and masses. The physician sterilizes the skin in the area of interest and anesthetizes this area with a local anesthetic agent. A "fine" needle is inserted through the skin and the soft tissue between the ribs. Next, the needle is guided by fluoroscopy (motion picture x-rays) or CT scan towards the region of abnormality and biopsies are taken. The most common complication of this procedure is pneumothorax, which occurs between 15 and 30% of the time. Small pneumothoraces or pneumothoraces not associated with symptoms may be observed with chest x-rays every few hours. Larger or symptomatic pneumothoraces may require insertion of a small caliber chest tube.

A thoracentesis is performed to remove fluid or air from the chest. This space usually contains a very small amount of fluid to help lubricate the lining between the lung and chest wall. Generally a thoracentesis is done to determine why an abnormal amount of fluid has collected, and also to help relieve the symptoms of shortness of breath when the fluid is causing compression of the normal lung. Removal of fluid is done with the patient in a sitting position. A needle is inserted one or two rib spaces below the area of the fluid. The skin, rib periosteum (fibrous membrane which forms the covering of bone), and parietal pleura (membrane that lines the chest wall), which are the only pain-sensitive structures in the chest wall, are anesthetized with local anesthetic. A thoracentesis needle (on a syringe) is advanced into the pleural space and a tube is inserted into the fluid between the chest wall and lung. The fluid is removed manually using a two way stop-cock, or with a vacuum bottle. This should be a painless procedure, although some may have some discomfort around their shoulder blades.


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