Fourth Edition
Edited by
Ko‐Pen Wang, MD
Division of Pulmonary and Critical Care Medicine
Johns Hopkins Bayview Medical Center
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Atul C. Mehta, MD, FACP, FCCP
Lerner College of Medicine
Buoncore Family Endowed Chair in Lung Transplantation
Department of Pulmonary Medicine
Respiratory Institute
Cleveland Clinic
Cleveland, OH, USA
J. Francis Turner, Jr., MD, FACP, FCCP, FCCM
Division of Pulmonary and Critical Care Medicine
University of Tennessee Graduate School of Medicine
Knoxville, TN, USA;
National Supercomputing Institute
University of Nevada, NV, USA
This edition first published 2020 © 2020 by John Wiley & Sons Ltd.
Edition History [3e, 2012]
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Ko‐Pen Wang, Atul C. Mehta, and J. Francis Turner, Jr. be identified as the authors of editorial work has been asserted in accordance with law.
Registered Office(s)
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial Office
9600 Garsington Road, Oxford, OX4 2DQ, UK
For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats.
Limit of Liability/Disclaimer of Warranty
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication Data
Names: Wang, Ko Pen, editor. | Mehta, Atul C., editor. | Turner, J. Francis, Jr., editor.
Title: Flexible bronchoscopy / edited by Ko‐Pen Wang, Atul C. Mehta, J. Francis Turner, Jr.
Description: Fourth edition. | Hoboken, NJ : John Wiley & Sons, 2020. | Includes bibliographical references and index.
Identifiers: LCCN 2019058267 (print) | LCCN 2019058268 (ebook) | ISBN 9781119389057 (hardback) | ISBN 9781119389224 (adobe pdf) | ISBN 9781119389217 (epub)
Subjects: MESH: Bronchoscopy | Bronchial Diseases–diagnosis | Bronchial Diseases–therapy
Classification: LCC RC734.B7 (print) | LCC RC734.B7 (ebook) | NLM WF 500 | DDC 616.2/307545–dc23
LC record available at https://lccn.loc.gov/2019058267
LC ebook record available at https://lccn.loc.gov/2019058268
Cover Design: Wiley
Cover Images: Courtesy of Professors Kurimoto and Miyazawa, Courtesy of J. Francis Turner, Courtesy of Yang Xia, Courtesy of Eric Carlson and Tom Schlieve, © yodiyim/Getty Images
Jason Akulian, MD, MPH
Section of Interventional Pulmonology
Division of Pulmonary and Critical Care Medicine
University of North Carolina at Chapel Hill
Chapel Hill, NC, USA
Chong Bai, MD, PhD
Respiratory and Critical Care Medicine
Changhai Hospital
Second Military Hospital
Shanghai, China
Swati Baveja, MBBS
Division of Pulmonary and Critical Care Medicine
University of Tennessee Graduate School of Medicine
Knoxville, TN, USA
Heinrich D. Becker, MD
Formerly Department of Interdisiplinary Endoscopy
Thoraxclinic at Heidelberg University Heidelberg, Germany
Ben Bevill, MD
Division of Pulmonary and Critical Care Medicine
University of Tennessee Graduate School of Medicine
Knoxville, TN, USA
Semra Bilaceroglu, MD
Izmir Dr Suat Seren Training and Research Hospital for Thoracic Medicine and Surgery
Health Sciences University
Izmir, Turkey
Martina Bonifazi, MD
Department of Biomedical Sciences and Public Health
Università Politecnica delle Marche, Ancona;Pulmonary Diseases Unit
Department of Internal Medicine
Azienda Ospedaliero‐Universitaria ‘Ospedali Riuniti’Ancona, Italy
Robert F. Browning Jr., MD, FACP, FCCP
Interventional Pulmonology
Walter Reed National Military Medical Center, Bethesda;Uniformed Services University of Health Sciences
Bethesda, MD, USA
Eric R. Carlson, DMD, MD, FACS
Department of Oral and Maxillofacial Surgery
University of Tennessee Medical Center University of Tennessee Cancer Institute
Knoxville, TN, USA
Alexander Chen, MD
Division of Pulmonary and Critical Care
Washington University School of Medicine
St Louis, MO, USA
Ara A. Chrissian, MD
Pulmonary and Critical Care
Loma Linda University
Loma Linda, CA, USA
David Feller‐Kopman, MD
Interventional Pulmonology
Division of Pulmonary and Critical Care Medicine
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Erik E. Folch, MD, MSc
Division of Pulmonary and Critical Care Medicine
Massachusetts General Hospital
Boston, MA, USA
Stefano Gasparini, MD, FCCP
Department of Biomedical Sciences and Public Health
Universita Politecnica delle Marche
Ancona; and
Pulmonary Diseases Unit
Department of Internal Medicine
Azienda Ospedaliero‐Universitaria ‘spedali Riuniti’ Ancona, Italy
Thomas R. Gildea, MD, MS, FCCP
Department of Pulmonary Allergy and Critical Care Medicine
Respiratory Institute
Cleveland Clinic
Cleveland, OH, USA
Sarah Hadique, MD
Department of Pulmonary and Critical Care Medicine
West Virginia University
Morgantown, WV, USA
Richard Helmers, MD
Mayo Clinic Health System
Eau Claire, WI, USA
Wolfgang Hohenforst‐Schmidt, MD
Sana Clinic Group Franken
Department of Cardiology/Pulmonology/Intensive Care/Nephrology
“Hof” Clinics
University of Erlangen
Hof, Germany
Hai‐dong Huang, MD
Respiratory and Critical Care Medicine
Second Military Medical University
Shanghai;Interventional Pulmonology Center of SMMURespiratory and Critical Care Medicine
Changhai Hospital
Second Military Medical University (SMMU)Shanghai;International Training Center for Interventional
Pulmonology
Henry Ford Hospital
Shanghai, China
Yi Huang, MD
Shanghai Changhai Hospital
Shanghai, China
Takeo Inoue, MD
Division of Respiratory Medicine
Department of Internal Medicine
St Marianna University School of Medicine
Kawasaki, Japan
Takeshi Isobe, MD
Division of Medical Oncology and Respiratory Medicine
Department of Internal Medicine
Shimane University Hospital
Izumo, Japan
Prasoon Jain, MD, FCCP
Louis A. Johnson VA Medical Center
Clarksburg, WV, USA
Michael A. Jantz, MD
Division of Pulmonary, Critical Care, and Sleep Medicine
University of Florida
Gainesville, FL, USA
Mani S. Kavuru, MD
Division of Pulmonary and Critical Care Medicine
Jefferson Center for Critical Care
Thomas Jefferson University and Hospital Philadelphia, PA, USA
Ming‐yao Ke, MD
Department of the Respiratory Centre
Second Affiliated Hospital of Xia
Men Medical College
Xiamen, Fujian, China
Danai Khemasuwan, MD, MBA
Tufts University School of Medicine and
St Elizabeth’s Medical Center
Boston, MA, USA
Noriaki Kurimoto, MD
Division of Medical Oncology and Respiratory Medicine
Department of Internal Medicine
Shimane University Hospital
Izumo, Japan
Jonathan S. Kurman, MD
Division of Pulmonary and Critical Care
Department of Medicine
Medical College of Wisconsin Milwaukee, WI, USA
Stephen C.T. Lam, MD, FCCP
Department of Integrative Oncology
British Columbia Cancer Agency
Vancouver, British Columbia; Cancer Imaging Department and Department of Medicine
University of British Columbia
Vancouver, British Columbia, Canada
Carlos Aravena Leon, MD
Department of Pulmonary
Allergy and Critical Care Medicine
Respiratory Institute
Cleveland Clinic
Cleveland, OH, USA;Department of Respiratory Diseases
Faculty of Medicine
Pontificia Universidad Catolica de Chile
Santiago, Chile
Qiang Li, MD
Department of Respiratory and Critical Care Medicine
Shanghai East Hospital
Tongji University School of Medicine
Shanghai, China
Xicheng Liu, MD
Department of Interventional Pulmonology
Beijing Children’s Hospital
Capital University of Medicine
Beijing, China
Jing Ma, MD
Department of Interventional Pulmonology
Qilu Children’s Hospital of Shandong University
Jinan, China
Samir Makani, MD
Division of Pulmonary and Critical Care Medicine
Henry Ford Hospital
Detroit, MI, USA
Sean McKay, MD
Interventional Pulmonology
Walter Reed National Military Medical Center
Uniformed Services University of Health Sciences
Bethesda, MD, USA
Atul C. Mehta, MD, FACP, FCCP
Professor of Medicine Lerner College of Medicine Buoncore Family Endowed Chair in Lung Transplantation
Department of Pulmonary Medicine
Respiratory Institute
Cleveland Clinic
Cleveland, OH, USA
Chen Meng, MD
Department of Interventional Pulmonology
Qilu Children’s Hospital of Shandong University
Jinan, China
Teruomi Miyazawa, MD, PhD, FCCP
Division of Respiratory Medicine
Department of Internal Medicine
St Marianna University School of Medicine
Kawasaki, Japan
Blake A. Moore, MD
Section on Cardiothoracic Anesthesia
University of Tennessee Graduate School of Medicine
Knoxville, TN, USA
Septimiu D. Murgu, MD
Department of Medicine
Section of Pulmonary and Critical Care
University of Chicago
Chicago, IL, USA
Renelle Myers, MD, FRCPC
Department of Integrative Oncology
British Columbia Cancer Agency
Vancouver, British Columbia;Department of Medicine
University of British Columbia
Vancouver, British Columbia, Canada
David E. Ost, MD, MPH, FACP
Division of Internal Medicine
Department of Pulmonary Medicine
MD Anderson Cancer Center
University of Texas
Houston, TX, USA
Luca Paoletti, MD
Division of Pulmonary and Critical Care Medicine
Medical University of South Carolina
Charleston, SC, USA
Nicholas J. Pastis Jr., MD, FCCP
Division of Pulmonary and Critical Care Medicine
Medical University of South Carolina
Charleston, SC, USA
Sunit R. Patel, MD
Medical Group
Trulock, CA, USA
Andrew Pattison, MD
Division of Thoracic Surgery
Toronto General Hospital
University Health Network
University of Toronto
Toronto, Ontario, Canada
Alexander S. Rabin, MD
Department of Pulmonary and Critical Care Medicine
Massachusetts General Hospital
Boston, MA, USA
Ali Sadoughi, MD
Division of Pulmonary and Critical Care
Albert Einstein College of Medicine/Montefiore Medical Center
New York, USA
Ala Eddin Sagar, MD
Banner MD Anderson Cancer Center
Phoenix, AZ, USA
Thomas Schlieve, DDS, MD
Division of Oral and Maxillofacial Surgery
University of Texas Southwestern Medical School
Parkland Memorial Hospital
Dallas, TX, USA
Michael J. Simoff, MD, FCCP
Division of Pulmonary and Critical Care Medicine
Henry Ford Hospital
Detroit, MI, USA
J. Francis Turner, Jr., MD, FACP, FCCP, FCCM
Division of Pulmonary and Critical Care Medicine
University of Tennessee Graduate School of Medicine
Knoxville, TN;
National Supercomputing Institute
University of Nevada
Las Vegas, NV, USA
Ko‐Pen Wang, MD
Division of Pulmonary and Critical Care Medicine
Johns Hopkins Bayview Medical Center
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Wei Zhang, MD
Shanghai Changhai Hospital
Shanghai, China
Yang Xia, MD
Division of Pulmonary and Critical Care Medicine
Second Affiliated Hospital of Zhejiang University School of Medicine
Hangzhou, China
Kazuhiro Yasufuku, MD, PhD
Division of Thoracic Surgery
Toronto General Hospital
University Health Network
University of Toronto
Toronto, Ontario, Canada
Shunying Zhao, MD
Department of Interventional Pulmonology
Beijing Children’s Hospital
Capital University of Medicine
Beijing, China
Guo‐wu Zhou, MD, PhD
Respiratory and Critical Care Medicine
Changhai Hospital
Second Military Hospital
Shanghai;Respiratory and Critical Care Medicine
China‐Japan Friendship Hospital
Beijing, China
We are honored to be the editors of the fourth edition of Flexible Bronchoscopy. In this role, we wish to recognize that this book is the collaborative efforts of many experts in the art and science of bronchoscopy, as reflected by the contributions of our eminent authors.
The art of bronchoscopy is now recognized as a critical skill not only in the technical performance of obtaining necessary tissue and a variety of therapeutics, but also to ensuring the best application of our rapidly expanding technology.
Modern bronchoscopy was born over 100 years ago when Professor Gustav Killian began utilizing the rigid bronchoscope in 1897. This was followed by the genius of Professor Shigeto Ikeda in developing the flexible bronchoscope in 1964. Since these early years, technology has enhanced our capabilities at a steady pace with intermittent brilliant leaps forward with the insight of modern thought leaders and inventors since the 1970s. These developments are well known to the field of bronchoscopy and interventional pulmonology. They include the development of the flexible transbronchial needle for nodal aspiration and bronchoscopic lung cancer staging, followed by Professors Heinrich Becker, Teruomi Miyazawa, Kazuhiro Yasufuku, and others shepherding the application of ultrasound in the tracheobronchial tree. Also, we acknowledge the seminal work of Professor François Dumon and the development of silicone stents in 1990, and other advances as detailed by the authors in this textbook.
In this book, our authors delineate the bedrock techniques of bronchoscopy, such as anesthesia for bronchoscopy, rigid bronchoscopy, and bronchoscopic lung biopsy. Also covered are the history and applications of the more recent developments of linear and radial‐probe ultrasound, navigational bronchoscopy for localization and sampling of peripheral pulmonary nodules, as well as authoritative information on therapeutic procedures such as ablative therapy utilizing “hot” instruments with laser, electrocautery, and argon plasma coagulation or “cold” interventions utilizing spray cryotherapy.
As bronchoscopy and interventional pulmonology mature as a specialty, the challenge will be to explore how we might best apply this burgeoning technology in an effective, safe, and economically prudent manner. Optimal application of many standard techniques still yields substantial benefit in the diagnosis and staging of benign and malignant disease while new techniques need to be carefully judged against the established ones.
This is an exciting time for those of us privileged to be helping patients with diseases of the chest through our interest in the art and science of bronchoscopy. We hope that the wisdom and enthusiasm shared by our authors will allow you to excel in your chosen profession and improve the welfare of our patients.
Don't forget to visit the companion website for this book:
www.wiley.com/go/wang4e 
There you will find valuable video material designed to enhance your learning.
Scan this QR code to visit the companion website.