Inclusion Criteria:  severe uncorrected hypoxemia despite supplemental oxygen treatment unstable angina uncontrolled arrhythmias, severe hypercarbia, unstable cervical spine. Coagulopathy that cannot be reversed Chronic obstructive pulmonary disease (COPD) exacerbation Severe Illness old age malnutrition Patient who refused to have a bronchoscopy performed  Exclusion Criteria:  Patients' histories, including age, sex, and smoking status, were documented for all participants in the trial Clinical examination and medical history Complete blood count, serum creatinine, liver enzymes, INR, bleeding time, and clotting time are all routine laboratory tests Plain chest X-ray and chest computed tomography were used in the radiological workup* Arterial blood gas on room air. bronchoscopy and biopsy taking with forceps and cryobiopsy  -