Approach to Common Chief Complaints

Flexible bronchoscopy is an efficient tool for diagnosing common respiratory complaints, including noisy breathing, chronic wheezing, and chronic cough. Accurate diagnosis involves not only recognition of anatomic abnormalities but also assessment of airway dynamics under conditions that can vary from sleep to forced exhalation. Thus, accurate diagnosis requires a recognition of the conditions under which the problem exists and an understanding of how the airways behave under normal and pathologic conditions. The bronchoscopist must understand the physiology of the airways under normal and abnormal conditions, taking into account how both transmural pressure and airways resistance can affect airway cross-sectional area. Aspects of the patient’s history, including timing, persistence, triggers, and predisposing factors for the problem, can all help identify which patient requires airway evaluation and under what conditions the evaluation will be most revealing. Similarly, the physical examination is directed toward the quality and characteristics of the abnormal sound, any associated changes to voice, clinical features that could predispose toward the problem, and the impact of the problem on the patient’s breathing effort and overall growth and development. Together, a careful history and physical examination, as well as an understanding of the conditions under which the respiratory abnormality occurs in a given patient, can enhance the diagnostic yield of the bronchoscopic procedure. Additionally, an understanding of dynamic airway mechanics under passive and dynamic conditions can help the endoscopist distinguish between normal and abnormal phenomena.