Bronchoscopic Observations in Tuberculous Tracheobronchitis — Clinical and Pathological Correlation * *

1) Tuberculous bronchitis is a frequent and serious complication of pulmonary tuberculosis. It occurs in 10 to 15 percent of (all patients admitted to sanatoria. 2) The study of surgical pathology indicates that the earliest bronchial lesions are submucosal in type. The second stage is represented by hyperplastic changes and ulceration, and the third stage by healing. In the third stage a fibrous stenosis may result. The predilection for stenotic lesions to involve the left main bronchus and the right upper lobe bronchus has been suggested. 3) The indications for bronchoscopy in tuberculous patients have been outlined. If these are followed in selecting patients, about 50 percent of the bronchoscopies will reveal endobronchial disease. /[See figure in the PDF file/] All patients presenting these indications should be bronchoscoped. 4) The existence of the preclinical phase of tuberculous bronchitis is emphasized. This can be diagnosed only by bronchoscopy performed routinely. 5) When clinical and x-ray evidence of tuberculous bronchitis is present, a negative bronchoscopy does not rule out involvement of the branch bronchi and repetition of the examination is indicated at a future date. 6) The importance of technique in performing bronchoscopy in tuberculous patients is emphasized. The following safeguards are indicated: (1) careful and complete anesthesia; (2) the avoidance of trauma to any bronchial lesions during the procedure; (3) the careful aspiration of all secretions in the tracheobronchial tree during the bronchoscopy and just before the bronchoscope is withdrawn. It is important to withdraw the bronchoscope slowly so that all tracheal secretions which have collected around the scope will be aspirated. (4) Place the patient on his affected side for three hours after returning him to his bed. This is done to protect him against spilling secretions to his good lung during a period when his cough reflexes have been abolished by the anesthesia. 7) The pathological physiology as seen through the bronchoscope is discussed and the importance of the bronchial lesion in determining the type of parenchymal lesion is presented. The stagnation and "backfiring" of secretions are described as the pathogenetic factors in producing the opaque lesions, basal tuberculosis, "hilar flares," and disseminated infiltration so commonly seen in the ipsolateral lung. An "atomizer" effect is described as the cause of the nodular spreads frequently seen in the contralateral lung. 8) Local therapy of the endobronchial lesion with 30 percent silver nitrate has been found to be effective in lesions considered to be suitable for treatment. These are the ulcerative and ulcerophperplastic types. This represents only one phase of the treatment of these patients. Their general condition and the therapy of the parenchymal lesion are factors of extreme importance, neither of which should be neglected. 9) The presence of a marked fibrous stenosis contraindicates local therapy except for the cauterization of any associated ulceration or granulation tissue. Complete thoracoplasty or pneumonectomy is indicated in such cases. In my opinion, dilatation as a form of treatment does more harm than good and leads to procrastination in applying surgery. It is indicated only to alleviate distressing symptoms, either as a temporary measure or in the hopeless case. 10) An evaluation of the bronchial system is as important as that of the parenchyma. Without it an intelligent approach to a therapeutic program is impossible. No patient with any of the symptoms, signs, or roentgenological evidence of tuberculous bronchitis should be given any type of collapse therapy without preliminary bronchoscopy. 11) The type of collapse therapy to be used in controlling the parenchymal lesion is governed by two factors: (1) the type of parenchymal disease; and (2) the type of endobronchial lesion present. The bronchoscopic findings should be considered prior to instituting collapse therapy, especially pneumothorax, in order to avoid serious complications. 12) In the light of present knowledge it would seem ideal to bronchoscope every patient on admission to the sanatorium. However, this seems to be impossible in most institutions and for this reason careful selection of patients by history, physical examination and review of x-ray findings is advised in preference to selecting any one group of patients, such as the pre-thoracoplasty patients, for examination. 13) The concept is presented that we are treating a patient with pulmonary tuberculosis with tuberculous bronchitis as a complication, not treating tuberculous endobronchial disease as an isolated pathological process. This demands consideration of the patient's general condition, the parenchymal disease, and the type of endobronchial lesion. It also requires the complete cooperation of the clinician, surgeon and bronchoscopist to arrive at the most effective program in the treatment of each individual case.