Bronchology | Specialists and information

Structure of the bronchial system with its bronchi

The bronchial system combines the airways within the lungs.

The trachea and bronchi are used to transport air, while gas exchange takes place in the alveoli (air sacs). There, the blood absorbs the oxygen from the air we breathe and releases the carbon dioxide back into the air we breathe out.

The human lung consists of two lobes. The left lung consists of two lobes, the right lung of three lobes. As the lungs themselves have no muscles, air is inhaled (inspiration) into the lungs with the help of the diaphragm and rib muscles. Exhalation (expiration) is usually passive.

The air is taken in through the mouth or nose and enters the windpipe (trachea), which is then divided into the two main bronchi. Each main bronchus is located within a lung. As the left lung is smaller than the right and only has two lobes and not three like the right lung, the left main bronchus is divided into two and the right into three smaller bronchi (so-called lobar bronchi).

The lobular bronchi in turn divide into even smaller bronchi (so-called segmental bronchi), which first divide into the subsegmental rami and then into the bronchioles and finally end in the alveoli.

Only the last, lower part of the bronchioles and the alveoli are involved in gas exchange. In contrast to this respiratory section, the remaining part (main bronchus, bronchi, upper section of the bronchioles) only serves to conduct air (conductive or air-conducting section).

Selected diseases in the bronchial area

The most well-known lung and bronchial diseases that are diagnosed and treated in pulmonary and bronchial medicine include bronchial asthma, chronic obstructive pulmonary disease (COPD), chronic bronchitis and chronic cough. Other common diseases in bronchology are pneumonia, pulmonary fibrosis, sleep-related breathing disorders and allergic diseases of the respiratory tract.

Bronchial asthma

Bronchial asthma, which is often simply referred to as asthma, is a chronic, inflammatory disease of the bronchial tubes. The inflammation can lead to attacks of breathlessness due to constriction of the bronchial tubes (bronchial obstruction). This leads to increased mucus production, cramping of the bronchial muscles and edema of the bronchial mucosa.

An asthma attack can last from a few seconds to several hours. The bronchial tubes of asthmatics react to certain, otherwise mostly harmless stimuli (e.g. mental stress, overexertion) with increasing sensitivity and constrict like spasms.

• Triggers can also be
• Allergens,
• respiratory tract infections,
• cold,
• medicines and
• polluted air

can be the cause.

Asthma can be diagnosed on the basis of a medical history, a physical examination and with the help of lung function tests and allergy tests.

The treatment for allergic asthma is to avoid the allergen. In the case of an acute asthma attack, an asthma spray usually alleviates the symptoms; in the case of very severe attacks, the doctor injects the medication directly into the vein.

Bronchiectasis (bronchiectasis)

Bronchiectasis are irreversible cylindrical, spindle-shaped or sac-shaped dilatations of the bronchi, which can be either congenital or acquired. The dilations are filled with purulent secretions due to a bacterial infection.

Bronchiectasis is characterized by coughing and large-volume, sweet-smelling or foul-smelling sputum. If left untreated, various complications can occur, e.g.

• Pneumonia,
• Fungal infestation of the lungs,
• bacterial infestation of other organs,
• but also coughing up blood (haemoptysis) and
• cor pulmonale in the long term (so-called pulmonary heart with severely dilated right ventricle).

If bronchiectasis burst, this can lead to an accumulation of purulent fluid (empyema) in the thorax.

In bronchology, bronchiectasis can be diagnosed on the basis of symptoms (cough, typical sputum), by means of a lung function test and an X-ray. Bronchiectasis can be detected using computer tomography on the basis of the typical enlargement of the bronchi. Occasionally, a bronchoscopy is performed to take a mucus sample.

An important component of bronchology in the treatment of bronchiectasis is the loosening of mucus. This also includes the daily bronchial toilet (coughing up the mucus in a knee-elbow position). Medication can also be used to treat the symptoms and discomfort:

• Mucolytics thin the secretions in the bronchi or bronchiectasis, making it easier to cough up,
• Bronchodilators dilate the bronchi and thus make breathing easier,
• Antibiotics fight the bacterial infection.

If the bronchiectasis does not respond sufficiently to these therapeutic measures, and if there is only a one-sided infestation with bronchiectasis or if there is threatening hemoptysis, the bronchiectasis can also be surgically removed.

Bronchitis

Bronchitis is the inflammation of the mucous membrane in the bronchi. It can be acute or chronic. Chronic bronchitis is the form of bronchitis in which coughing and sputum production occur on most days for at least three months in two consecutive years.

Chronic bronchitis is not caused by pathogens, but by cigarette smoke (or its ingredients) or other inhaled irritants.

In contrast, a new inflammation of the bronchial mucosa with coughing, mucus production, fever and other unspecific symptoms is called acute bronchitis.

This bronchial disease is usually triggered by viruses and, in rare cases, bacteria. Acute bronchitis therefore usually heals without medication; antibiotics are only effective if the cause is bacterial.

To prevent chronic bronchitis from developing into chronic obstructive bronchitis or even emphysema, the patient must ensure that the triggering irritants (dust, gases or vapors) are avoided. There are some medicines that alleviate the symptoms of chronic bronchitis.

Bronchopulmonary dysplasia

Bronchopulmonary dysplasia is a chronic disease of the bronchi and lungs of premature infants and newborns, which is often caused by

• artificial respiration,
• respiratory distress syndrome or
• meconium aspiration syndrome (inhalation of a newborn's first stool [meconium] leads to severe respiratory distress)

is caused. Bronchopulmonary dysplasia is defined as additional oxygen requirements that extend beyond the neonatal period and is considered one of the most common complications of preterm and neonatal intensive care.

Bronchopulmonary dysplasia is characterized by

• an increased respiratory rate,
• deepened and strained breathing,
• increased mucus production in the bronchi,
• coughing,
• growth retardation and
• bluish skin and mucous membranes.

Treatment consists primarily of administering oxygen. Depending on the symptoms, further medication and conservative therapies (e.g. dehydrating medication for pulmonary oedema, bronchospasmolytics for narrowing of the airways, physiotherapy) may be necessary.

Chronic cough

A cough is considered chronic if it lasts longer than three to four weeks. It should always be clarified by a doctor, as a cough is a symptom of an underlying illness.

Common causes of chronic coughs are, for example

• Repeated respiratory tract infections,
• years of smoking (smoker's cough) or
• damage caused by industrial dust.

During the medical examination, in addition to recognizing harmful stimuli (e.g. cigarette smoke), drug side effects and foreign bodies in the airways, attention is also paid to diseases in which coughing occurs as a symptom, such as

chronic bronchitis,

• COPD,
• bronchial asthma,
• pneumonia,
• pulmonary emphysema (destruction of the alveoli),
• bronchial carcinoma (bronchial tumor) and
• allergies.

Chronic obstructive pulmonary disease (COPD)

In bronchology, chronic obstructive pulmonary disease (COPD) is a group of diseases of the bronchi and lungs in which the bronchi are permanently constricted and which are characterized by coughing, increased sputum production and shortness of breath on exertion.

These include chronic obstructive bronchitis and pulmonary emphysema, which are mainly characterized by difficult exhalation. The narrowing (obstruction) of the bronchial tubes is usually the result of smoking, but dust, vapors and gases can also cause COPD.

COPD cannot be cured. However, medication can be used to alleviate the symptoms, reduce the number of coughing fits and prevent the bronchial disease from progressing. In addition, physical resilience can be improved, relapses and complications prevented, thereby increasing quality of life and life expectancy.

Bronchial carcinoma

Cancer of the lungs or bronchi is referred to as lung cancer(lung carcinoma) or bronchial carcinoma (bronchial cancer).

Bronchial carcinoma is the third most common cancer in Germany. Smoking is the main risk factor for the development of bronchial carcinoma. Cigarette smoking can be assumed to be the main cause in 80-90% of male and 30-60% of female patients with bronchial carcinoma.

Other risk factors for bronchial carcinoma are

• Inhaled dusts and vapors at the workplace (e.g. asbestos, quartz dusts, arsenic, chromates, nickel and aromatic hydrocarbons),
• environmental influences (e.g. the radioactive noble gas radon, high levels of pollutants in the air) and
• hereditary predisposition to a certain extent.

A bronchial carcinoma only becomes noticeable very late; symptoms are often of a general nature, such as coughing, shortness of breath or weight loss. If a tumor is suspected in the area of the bronchial tubes, an X-ray is taken. This is often followed by computer tomography and a bronchoscopy.

In principle, the treatment of bronchial carcinoma consists of removal of the tumor, chemotherapy or radiotherapy, or a combination of these options.

Pulmonary emphysema

Pulmonary emphysema is usually regarded as a form of chronic obstructive pulmonary disease in which the alveoli are irreversibly dilated and destroyed.

As the dividing walls of the alveoli are enzymatically dissolved, large bubbles form in which the air we breathe becomes trapped. Although the lungs contain air, shortness of breath occurs. As a result, the body is not supplied with sufficient oxygen and damage to the organs can occur under certain circumstances.

Smoking is the main cause of emphysema. Other risk factors are polluted indoor air, open fires, inhalation of gases and dust at work and possibly genetic predisposition and frequent bronchial infections.

Pulmonary emphysema can be diagnosed using lung function tests (e.g. spirometry), blood gas analysis and imaging procedures (e.g. X-ray of the lungs).

In addition to stopping smoking immediately or avoiding other triggering stimuli, the lungs can be reduced in size and particularly large air sacs removed by surgery; in extreme cases, a transplant of the lung or a lung lobe may also be necessary.

Common methods in the area of the bronchi

The therapeutic range of bronchology services essentially includes

• Bronchoscopy (lung endoscopy),
• thoracoscopy (examination of the chest),
• Training for COPD,
• hyposensitization for allergies and
• asthma training.

Bronchoscopy (endoscopy of the bronchi)

Bronchoscopy is one of the most important examination methods in bronchology for detecting diseases of the airways, bronchi and lungs. Bronchoscopy is performed under local anesthesia with light sedation or under general anesthesia.

During bronchoscopy, a bronchoscope (endoscope) - a soft, flexible, very thin tube with a camera and a light source at the front end (so-called flexible video bronchoscopy) - is inserted through the trachea into the bronchi via the mouth or nose.

Only the larger airways (trachea and large bronchi up to the first or second bifurcation) can be viewed with the bronchoscope. The smaller bronchi, the bronchioles, the alveoli and the lung tissue can only be assessed indirectly.

Using the camera, the doctor can examine the patient's airways on a monitor. In addition, very small forceps can be advanced via the bronchoscope and used to remove tissue samples (biopsies) or foreign bodies as well as inject and aspirate fluid (e.g. thick mucus).

With the help of a very small ultrasound probe, the area surrounding the airways can be visualized in the ultrasound image. Bronchoscopy is used in the diagnosis and treatment of bronchial disease, e.g. for unclear changes in the X-ray image of the lungs, bronchial tumors, respiratory tract infections and inflammations (e.g. bronchitis, bronchiectasis) as well as long-lasting, unclear coughs or haemoptysis.

Bronchoscopic diagnostics (examples): Various special bronchoscopic diagnostic procedures are used in bronchology. Autofluorescence bronchoscopy, for example, is used for the early detection of tumors in the bronchi (bronchial carcinoma). Even the smallest tumors in the bronchi can be detected in the light of a special wavelength.

The NBI method (narrow band imaging) is also used in early bronchoscopic tumor detection; suspicious changes are better highlighted by filtering part of the visible light.

Bronchoscopic ultrasound is used to diagnose peripheral lung lesions and to visualize lymph nodes outside the bronchi.

Endobronchial ultrasound can be used to visualize conspicuous lymph nodes and tumours, e.g. in the space between the two pleural cavities (mediastinum).

Bronchoscopic treatment (examples): Bronchoscopy is often used in bronchology to widen narrowed airways. For example, a bronchial carcinoma that is obstructing the airways or bronchi can be removed with a laser or by coagulation.

Another application in bronchology is the insertion of stents (elastic tubes) into the airways using bronchoscopy, which keeps the bronchi open and allows the patient to breathe freely again.

In endobronchial brachytherapy, a very small radiation source is introduced during a bronchoscopy, making it possible to irradiate specific malignant tumors in a small space.

Bronchoalveolar lavage (bronchial lavage)

Bronchoalveolar lavage and bronchial lavage are diagnostic and therapeutic procedures in bronchology.

Both procedures are used as part of a bronchoscopy to remove mucus and cytological samples from the bronchi and lungs and to remove mucus plugs.

While bronchoalveolar lavage is performed in the alveoli and is used for cytological and immunohistochemical examination, bronchial lavage is performed in the trachea and bronchi and is used for bacteriological or cytological diagnostics and for cleaning the airways or bronchi. bronchi, if necessary by rinsing with isotonic saline solution to improve removal of the often viscous secretions.

Bronchial toilet

Bronchial toilet is the term used in bronchology to describe measures used to keep the airways and bronchi clear. Bronchial toilet is always used when self-cleaning mechanisms are impaired, which is the case, for example, in intubated, tracheotomized, unconscious and generally weakened patients.

The mucus can be aspirated using a catheter or during a bronchoscopy or coughed up using a special technique. If the mucus is viscous, it may be rinsed with isotonic saline solution before suctioning (bronchial lavage).

Spiroergometry

Spiroergometry (ergospirometry or ergospirography) is a procedure used in bronchology to diagnose diseases of the bronchi and lungs, with which the respiratory gases are first measured at rest and then under physical exertion, thereby assessing the function of the heart, circulation, respiration and muscle metabolism as well as physical performance.

During the examination, the patient is placed on a treadmill or bicycle ergometer and wears a tight-fitting breathing mask fitted with a flow meter. The respiratory volumes and the oxygen and carbon dioxide concentrations are determined and the heart rate is recorded via the exercise ECG and, if necessary, the blood pressure value is measured.

In the field of bronchology, spiroergometry is often used to clarify exercise-induced breathlessness.

Spirometry (lung function test)

The lung function test ("Lufu", spirometry, spirography, lung function diagnostics) is a central component of bronchology and a pneumological examination. The aim of lung function testing is to record the functional state of the airways and lungs as accurately as possible.

Even minor changes in the airways and bronchi can be detected. In this way, bronchial disease can be detected at an early stage and treated accordingly.

In bronchology, spirometry is used to measure lung and respiratory volumes (e.g. vital capacity, tidal volume, inspiratory and expiratory reserve volume) and airflow parameters (e.g. one-second capacity, peak flow) to assess lung function. During the examination, the patient wears a nose clip and breathes through a mouthpiece into a closed container.

Specialist in pulmonary and bronchial medicine

Specialists in pulmonary and bronchial medicine have specialist surgical knowledge as well as knowledge of diagnostic procedures and disease-related pre- and post-treatment. To become a specialist in pulmonary and bronchial medicine, a doctor must complete several years of further training.