Bronchology | Specialists and Information

The bronchial system comprises the airways within the lungs.

The trachea and bronchi transport air, while gas exchange takes place in the alveoli (air sacs). There, the blood absorbs oxygen from the inhaled air and releases carbon dioxide into the exhaled air.

The human lungs consist of two lung lobes. The left lung consists of two lobes, while the right lung consists of three lobes.

Since the lungs have no muscles of their own, inhalation (inspiration) is carried out by the diaphragm and the intercostal muscles. Exhalation (expiration) is usually passive.

Air is drawn in through the mouth or nose and then enters the windpipe (trachea). There, it divides into the two main bronchi.

Each main bronchus is located within a lung lobe. The left lung is smaller than the right and has only two lung lobes. The right lung has three. Therefore, the left main bronchus divides into two, and the right into three smaller bronchi (lobar bronchi).

The lobar bronchi, in turn, branch into even smaller bronchi (segmental bronchi). These branch first into the rami subsegmentales and then further into the bronchioles. They ultimately terminate in the alveoli.

The final, lower portion of the bronchioles and the alveoli are involved in gas exchange. The remaining portion (main bronchus, bronchi, upper section of the bronchioles) merely conducts air (conductive or air-conducting section).

Anatomy of the Human Respiratory Tract @ bilderzwerg/AdobeStock

Among the most well-known lung and bronchial diseases diagnosed and treated by pulmonologists are:

• Bronchial asthma
• Chronic obstructive pulmonary disease (COPD)
• Chronic bronchitis and
• Chronic cough

Other common diseases in bronchology include:

• Pneumonia
• Pulmonary fibrosis
• Sleep-related breathing disorders and
• Allergic respiratory diseases

Pulmonary fibrosis involves the remodeling of lung tissue and a progressive loss of lung function @ Mohwet /AdobeStock

Bronchial asthma

Bronchial asthma, often simply referred to as asthma, is a chronic, inflammatory disease of the bronchi. The inflammation can lead to episodic shortness of breath due to narrowing of the bronchi (bronchial obstruction).

This results in increased mucus production, spasms of the bronchial muscles, and edema of the bronchial mucosa.

An asthma attack can last from a few seconds to several hours. In people with asthma, the airways react to certain harmless triggers (psychological stress, overexertion) with increased sensitivity and constrict spasmodically.

Triggers may include:

• Allergens
• Respiratory tract infections
• Cold
• Medications and
• Polluted air

Asthma can be diagnosed based on medical history, a physical examination, and lung function and allergy tests.

Treatment for allergic asthma involves avoiding the allergen. During an acute asthma attack, an asthma inhaler relieves symptoms. In cases of very severe attacks, the doctor administers the medication directly into a vein.

In Germany, about 3.5 million people suffer from asthma @ Orawan /AdobeStock

Bronchiectasis (bronchiectases)

Bronchiectases are irreversible cylindrical, spindle-shaped, or sac-like dilations of the bronchi that are either congenital or acquired. These dilations are filled with purulent secretions due to a bacterial infection.

Bronchiectases are dilated bronchi, often filled with secretions, that serve as constant foci of inflammation and infection in the body @ joshya /AdobeStock

Bronchiectasis is characterized by coughing and large volumes of sputum with a sweet or foul odor.

If left untreated, various complications can arise, such as:

• pneumonia
• Fungal infection of the lungs
• bacterial infection of other organs
• as well as coughing up blood (hemoptysis) and
• in the long term, cor pulmonale (a condition characterized by a severely dilated right ventricle)

If bronchiectases rupture, this can lead to an accumulation of purulent fluid (known as an empyema) in the chest cavity.

In bronchology, bronchiectasis can be diagnosed based on symptoms (cough, characteristic sputum) or through pulmonary function tests and X-rays. 

Computed tomography can be used to detect bronchiectasis based on the typical dilation of the bronchi. Occasionally, a bronchoscopy is performed to obtain a mucus sample.

In bronchology, loosening the mucus is considered a key component of treating bronchiectasis. This includes daily bronchial hygiene (coughing up mucus in the knee-elbow position). In addition, medications can be used to treat symptoms and discomfort:

Mucolytics thin the secretions in the bronchi or bronchiectases, thereby making it easier to cough them up;

Bronchodilators widen the bronchi, thereby making breathing easier,

Antibiotics fight bacterial infections.

Bronchiectasis requires surgical removal in the following cases:

• The bronchiectasis does not respond to treatment
• There is only unilateral involvement with bronchiectasis
• Life-threatening hemoptysis occurs

Bronchitis

Bronchitis is an inflammation of the lining of the bronchi. It can be acute or chronic. Chronic bronchitis is defined as a cough and phlegm on most days for at least three months in any two-year period.

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

Acute bronchitis, on the other hand, is a newly developed inflammation of the mucous membrane lining the bronchi.

It is characterized by:

• Cough
• Mucus production
• Fever, and
• Other nonspecific symptoms

This bronchial disease is usually caused by viruses; in rare cases, it can also be caused by bacteria. Therefore, acute bronchitis typically resolves on its own without medication. Antibiotics are effective only when the cause is bacterial.

To prevent acute bronchitis from becoming chronic, the patient must avoid the irritants that trigger it (dust, gases, or vapors).

There are several medications that alleviate the symptoms of chronic bronchitis.

Typical symptoms of bronchitis include coughing, coughing up mucus, and a sore throat caused by irritation of the airways @ Africa Studio /AdobeStock

Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia is a chronic disease of the bronchi and lungs in premature infants and newborns.

It is often caused by:

• mechanical ventilation
• respiratory distress syndrome, or
• meconium aspiration syndrome (inhalation of a newborn’s first stool [meconium] leads to severe respiratory distress)

Bronchopulmonary dysplasia is the most common complication in neonatal and premature infant intensive care. It results in a need for supplemental oxygen that extends beyond the neonatal period.

Bronchopulmonary dysplasia is characterized by:

• Increased respiratory rate
• Deep and labored breathing
• Increased mucus production in the bronchi
• Cough
• Growth retardation and
• Bluish skin and mucous membranes

Treatment primarily consists of administering oxygen. Depending on the symptoms, additional medication and conservative therapies may be necessary, such as:

• Diuretics for pulmonary edema Bronchodilators for airway constriction
• Physical therapy

Chronic Cough

A cough is considered chronic if it lasts longer than three to four weeks. A doctor should always evaluate it, as a cough is a symptom of an underlying condition.

Common causes of chronic cough include:

• Recurrent respiratory tract infections
• Years of smoking (smoker’s cough) or
• Damage caused by industrial dust

During the examination, the doctor looks for harmful irritants (cigarette smoke), side effects of medications, and conditions in which a cough is a symptom.

These include, for example:

• Chronic bronchitis
• COPD
• Bronchial asthma
• Pneumonia
• Emphysema (destruction of the alveoli),
• Bronchial carcinoma (bronchial tumor) and
• Allergies
• Chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) encompasses a group of diseases affecting the bronchi and lungs. In this condition, the bronchi are permanently narrowed.

COPD is characterized by:

• Cough
• Increased phlegm and
• Shortness of breath on exertion

These primarily include chronic obstructive bronchitis and pulmonary emphysema. A characteristic feature of both is difficulty exhaling.

The narrowing (obstruction) of the bronchi is usually a result of smoking. However, dust, fumes, and gases can also cause COPD.

COPD is incurable. Medications alleviate the symptoms and reduce the frequency of coughing fits. This prevents the bronchial disease from progressing further.

Physical endurance also improves, helping to prevent relapses and complications. Quality of life and life expectancy increase.

In chronic obstructive pulmonary disease (COPD), the lungs are damaged and the airways are narrowed @ Angelov /AdobeStock

Bronchial Carcinoma

Cancer of the lungs or bronchi is called 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 developing bronchial carcinoma.

Cigarette smoke is the primary cause in 80–90% of male patients and 30–60% of female patients with bronchial carcinoma.

Other risk factors for bronchial carcinoma include:

• inhaled dust and fumes in the workplace (e.g., asbestos, quartz dust, arsenic, chromates, nickel, and aromatic hydrocarbons),
• environmental factors (e.g., the radioactive noble gas radon, high levels of air pollution), and
• to a certain extent, genetic predisposition

Bronchial carcinoma does not become apparent until very late in its development.

Symptoms are often nonspecific, such as:

• Cough
• shortness of breath or
• Weight loss

If a tumor is suspected in the bronchial area, a chest X-ray is performed. This is often followed by a CT scan and a bronchoscopy.

Treatment for bronchial carcinoma consists of:

• Removal of the tumor
• Chemotherapy or
• Radiation therapy

A combination of these options is usually used.

Pulmonary Emphysema

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

As the walls of the alveoli break down due to enzymatic action, large bubbles form in which air becomes trapped.

Although the lungs contain air, shortness of breath occurs. As a result, the body does not receive enough oxygen. Under certain circumstances, this can lead to organ damage.

Smoking is considered the primary cause of pulmonary emphysema.

Other risk factors include:

• Indoor air pollution
• Open fireplaces
• Inhalation of gases and dust in the workplace
• Genetic predisposition and
• Frequent bronchial infections

Pulmonary emphysema can be diagnosed through pulmonary function tests (spirometry), blood gas analysis, and imaging procedures (chest X-ray).

Treatment consists of immediately quitting smoking, avoiding other triggering irritants, and surgery. During surgery, doctors reduce the size of the lungs and remove large air sacs. In extreme cases, a lung or lung lobe transplant may also be necessary.

The therapeutic services offered in bronchology essentially include:

• Bronchoscopy (lung endoscopy)
• Thoracoscopy (chest endoscopy)
• COPD education
• Allergy desensitization and
• Asthma education

Bronchoscopy (examination of the bronchi)

Bronchoscopy is one of the most important diagnostic procedures in bronchology. It is used to detect diseases of the airways, bronchi, and lungs. Bronchoscopy is performed under local anesthesia with light sedation or under general anesthesia.

During bronchoscopy, doctors insert a thin tube equipped with a camera and light through the mouth or nose into the bronchi.

The bronchoscope allows the doctor to view only the larger airways (trachea and large bronchi). The doctor can assess the smaller bronchi, the bronchioles, the alveoli, and the lung tissue only indirectly.

Using the camera, the doctor can examine the patient’s airways on a monitor. In addition, very small forceps can be advanced through the bronchoscope. This allows the doctor to take tissue samples (biopsies) or remove foreign objects, as well as to inject and suction fluid (e.g., thick mucus).

A very small ultrasound transducer can be used to visualize the area surrounding the airways on an ultrasound image.

Bronchoscopy is used for the diagnosis and treatment of bronchial diseases.

Especially in cases of:

• Unclear abnormalities on a chest X-ray
• Bronchial tumors
• Respiratory tract infections and
• Inflammation (e.g., bronchitis, bronchiectasis) as well as
• A persistent, unexplained cough or coughing up blood

Bronchoscopic diagnostics (examples): Various specialized bronchoscopic diagnostic procedures are used in bronchology.

Autofluorescence bronchoscopy is used for the early detection of tumors in the bronchi (bronchial carcinoma). Under light of a specific wavelength, even the smallest tumors in the bronchi can be detected.

The NBI (narrow-band imaging) technique is also used for early bronchoscopic tumor detection. Suspicious lesions can be better highlighted by filtering 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 abnormal lymph nodes and tumors, for example, in the space between the two pleural cavities (mediastinum).

Bronchoscopic Treatment (Examples): Bronchoscopy is frequently used in bronchology to dilate narrowed airways.

For example, doctors can use a laser to remove a bronchial carcinoma that is obstructing the airways or bronchi.

Another application in bronchology is the placement of stents (elastic tubes) in the airways. This is performed using bronchoscopy. This helps keep the bronchi open, allowing for unobstructed breathing once again.

In endobronchial brachytherapy, doctors insert a very small radiation source during bronchoscopy. This allows for the targeted irradiation of specific malignant tumors in a small area.

Bronchoalveolar Lavage (Bronchial Lavage)

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

Both procedures are used for:

• Collecting mucus and cytological samples from the bronchi and lungs
• Removing mucus plugs

Bronchoalveolar lavage is performed in the alveoli and is used for cytological and immunohistochemical examination.

Bronchial lavage, on the other hand, is performed in the trachea and is used for bacteriological or cytological diagnosis. It is also suitable for clearing the airways and bronchi and for irrigation with isotonic saline solution. This is often necessary when mucus is very thick.

Bronchial clearance

Bronchial clearance refers to measures taken to keep the airways and bronchi clear. Bronchial clearance is always used when the self-cleaning mechanisms are impaired. This is the case in intubated, tracheostomized, unconscious, and generally weakened patients.

A catheter suctions out the mucus during a bronchoscopy. A special technique enables the patient to cough up the mucus. If the mucus is thick, doctors flush it with isotonic saline solution (bronchial lavage) before suctioning.

Bronchoscopy is an endoscopic method for examining the lower respiratory tract @ Andrey Zhernovoy /AdobeStock

Spiroergometry

Spiroergometry (ergospirometry or ergospirography) is a procedure used in bronchology to diagnose diseases of the bronchi and lungs.

During the test, doctors first measure respiratory gases at rest and then during physical exertion. This allows them to assess the function of the heart, circulatory system, respiratory system, and muscular metabolism, as well as physical performance.

During the examination, the patient stands on a treadmill ergometer or sits on a bicycle ergometer and wears a tight-fitting mask equipped with a flowmeter.

Doctors determine the following:

• Respiratory volumes
• Oxygen and carbon dioxide concentrations
• Heart rate
• Blood pressure

Doctors often use spiroergometry to investigate exercise-induced shortness of breath.

Spirometry (lung function test)

The pulmonary function test (“Lufu,” spirometry, spirography, pulmonary function diagnostics) is a central component of bronchology and a pulmonology examination. The goal of the pulmonary function test is to assess the functional status of the airways and lungs as accurately as possible.

Even minor changes in the airways and bronchi can be detected this way. This allows doctors to identify bronchial disease at an early stage and treat it accordingly.

Spirometry measures:

• Lung and respiratory volumes (e.g., vital capacity, tidal volume, inspiratory and expiratory reserve volumes)
• Airflow parameters (one-second capacity, peak flow)

During the examination, the patient wears a nose clip and breathes into a closed container through a mouthpiece.

Specialists in Pulmonary and Bronchial Medicine possess not only surgical expertise but also knowledge of diagnostic procedures as well as pre- and post-treatment care related to specific conditions.

To become a specialist in pulmonary and bronchial medicine, a physician must complete several years of advanced training.