Black bronchoscopy

1. By
Mahmoud E. Abou El-Magd
BLACK
BRONCHOSCOPY

2. INTRODUCTION
BLACK BRONCHOSCOPY 2

3. INTRODUCTION
BLACK BRONCHOSCOPY 3
• The unusual finding of black pigmentation involving the
airways from occupational exposure has been reported
in the literature since the early 1940s .
• The term black bronchoscopy was introduced in 2003.

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5. MELANOSIS
BLACK BRONCHOSCOPY 5
• The common sites affected are the secondary and the tertiary
carina.
• Men and women are equally affected.
• Melanosis of the larynx and the oropharynx has been
associated with occult malignancy .
• What about TBM ?! .

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7. ALKAPTONURIA (OCHRONOSIS)
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• Alkaptonuria is a rare inborn error of metabolism
involving the degradation of the amino acids
phenylalanine and tyrosine.
• Ochronosis describes the accumulation of
homogentisic acid in collagenous tissues of the body,
resulting in dark gray pigmentation of the connective
tissue and the cartilages .

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• The physical examination may reveal the darkening of
sclera and ear cartilage.
• The bronchoscopic examination reveals
hyperpigmentation of the airways, including the
epiglottis, larynx, bronchial cartilages, and mucosa.
• Hyperpigmentation of the bronchial mucosa extends
distally from the trachea to the small bronchioles, and
the involved bronchial mucosa is typically covered with
dry black secretions .

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12. ASPERGILLUS NIGER
BLACK BRONCHOSCOPY 12
• It predominantly affects the immunocompromised population.
• black pigmentation has been reported on FOB.
• In addition to the black pigmentation, white masses of oxalate
crystals are also seen .
• The treatment of endobronchial aspergillosis follows the
treatment guidelines for invasive aspergillosis.

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14. OCHROCONIS GALLOPAVA
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• Dematiaceous fungi (dark-pigmented fungi) are characterized by
the presence of melanin or melanin-like pigments.
• the genus Ochroconis which include species Gallopava,
Constricta, and Humicola .
• O gallopava infections generally involve the lung with
extrapulmonary involvement especially of CNS and skin .

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• There has been an increase in the incidence of
infections caused by these fungi, particularly in solid-
organ transplant recipients. lung transplant recipients
have the highest incidence of O gallopava infections.
• Common pulmonary presentations include nodules
and non-resolving infiltrates with upper and middle lung
predominance.
• Diagnosis is made by transbronchial biopsies and
fungal culture.

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17. HEALED ENDOBRONCHIAL TB
BLACK BRONCHOSCOPY 17
• Healed endobronchial Mycobacterium tuberculosis (MTB) often
leaves black pigmentation within the airways.
• Multiple areas of dense peribronchial fibrosis and the deposition
of black pigment are observed during bronchoscopy.

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• multiple calcified intrathoracic lymph nodes on CT scan of the
chest raise suspicion for a past history of MTB .
• The proposed pathophysiology of black pigmentation associated
with MTB could be explained by possible intrabronchial
perforation involving infected lymph nodes burdened with
pigment-laden macrophages into the adjacent bronchial
mucosa.
• Hyperpigmentation is considered irreversible.

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22. ANTHRACOSIS AND ANTHRACOFIBROSIS
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• Anthracosis refers to the deposition of carbon particles in the
airways and the lung parenchyma.
• The fibrotic aspect of anthracofibrosis is associated with
occupational exposure to silica . High risk occupations include
coal mining, and those with exposure to wood smoke.
• woodsmoke exposure is usually found in nonsmoking elderly
women using natural fuels for indoor cooking.

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• Common manifestations of anthracofibrosis are chronic cough,
dyspnea, and wheezing.
• COPD of the chronic bronchitis type with a minimal response to
bronchodilators is the usual manifestation .
• Characteristic CT scan findings include peribronchial thickening
and obliteration, leading to lobar atelectasis, predominantly
involving the right upper and middle lobes, surrounded by
enlarged and/or calcified peribronchial, hilar, or mediastinal
lymph nodes.

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• The mechanism is similar to that described in MTB-
associated fibrosis.
• The gold standard for the diagnosis is based on
mineralogic analysis by transmission electron
microscopy (TEM) showing high percentages of
crystalline silica and non-fibrous silicates, such as mica
and kaolin particles, in lung tissue and BAL fluid.
• No definitive treatment exists for anthracofibrosis.

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26. SOOT INHALATION
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• Currently, inhalation injury is the most frequent cause of death
in burn patients.
• The mortality rate from soot inhalation alone is approximately
10%. A combination of smoke inhalation and skin burns
increases this rate to 30% to 90%.
• The combination of inhalation injury and pneumonia results in
a 60% increase in mortality from burns.

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• Bronchoscopic findings are characterized by multiple, focal,
large black-and-gray edematous plaques involving the
tracheobronchial mucosa, extending distally to the small
bronchioles .
• The fundamental concept in managing smoke inhalation is
secretion clearance .
• FOB is very effective for secretion and cell debris removal. If left
untreated, airways could become completely obstructed .

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• A retrospective study has revealed that
patients with a 30% to 60% surface-area
burn and pneumonia who underwent at
least one bronchoscopy : -
• shorter duration mechanical ventilation
(21 days vs 28 days) .
• ICU stay (35 vs 39 days,).
• overall hospital stay (45 days vs 49 days)
than otherwise.
• mortality rate was reduced by 18% in the
bronchoscopy group.
Carr and Phillips ,The utility of bronchoscopy after inhalation injury
complicated by pneumonia in burn patients: National Burn Repository . J 2009.

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30. ARGYRIA AND ARGYROSIS
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• Argyria is a term which describes chronic silver exposure which
causes an irreversible, blue-gray discoloration of the skin
(argyria) and sclera (argyrosis).
• Chronic inhalation of silver vapors could result in the
discoloration of bronchial mucosa and alveoli. However, no
reports of significant clinical consequences, except for chronic
cough, mild bronchitis, emphysematous change, and reduction
in lung volumes .

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34. ENDOBRONCHIAL MELANOMA
BLACK BRONCHOSCOPY 34
• Primary melanoma of the lung is a rare tumor involving
0.01% of all lung tumors.
• FOB exhibiting a black, sticky endobronchial lesion
raises a possibility of either a primary or a metastatic
melanoma .
• Occasionally, the metastatic lesion may lose its
pigmentary characteristic and be labeled as amelanotic
melanoma.

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36. TERATOMAS
BLACK BRONCHOSCOPY 36
• A mature teratoma may rupture and release its contents into
airways, resulting in a recurrent cough, hemoptysis, and
tricoptysis.
• The term tricoptysis refers to the expectoration of hairs in the
sputum. seen in 15% of the cases of intrapulmonary teratoma.
• Excision of the tumor is the treatment of choice for a mature
teratoma even though the tumor is benign. A benign teratoma
may potentially transform into a malignancy.

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39. CHARCOAL ASPIRATION
BLACK BRONCHOSCOPY 39
• Activated charcoal is considered an effective GI decontaminant
for acute intoxication with select drugs.
• Aspiration is reported in 1.7% of patients who receive charcoal
alone and 2.3% of those who also undergo gastric emptying.
• The aspiration of gastric contents occurs concomitantly with
charcoal aspiration, which frequently results in severe
pulmonary complications.

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• Acute complications of charcoal aspiration include
airway obstruction, bronchospasm, hypoxemia, and
pneumonia. Late complications include ARDS,
bronchiolitis obliterans, bronchopleural fistula, and
even death.
• If FOB demonstrates charcoal in the endobronchial
tree,washings are performed to mitigate the severity of
complications. repeated bronchoscopy to facilitate
clearance.

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42. AMIODARONE
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• Amiodarone and its metabolite accumulate in lung
tissue at levels 100- to 500-fold higher than serum.
• Pulmonary complications develop in 5% to 15% of
patients on 500 mg or more daily and in 0.1% to 0.5%
of patients on doses up to 200 mg daily.

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• Patients may present with: interstitial pneumonia,
organizing pneumonia, ARDS, alveolar hemorrhage,
and pulmonary fibrosis.
• Hyperpigmentation of the airway .The possible
mechanism may be the chronic accumulation of
amiodarone in the submucosal tissue from its long term
use.
• Discontinuation of the drug results in the resolution of
bronchial pigmentation .

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45. TRICOPTYSIS
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• In a single case report, the patient presented with a
gradual onset of shortness of breath, hoarseness,
wheezing, and coughing of hair. This patient had
undergone reconstruction surgery for a benign
laryngeal tumor, which used a mucosal flap.

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47. ENDOBRONCHIAL IGNITION
BLACK BRONCHOSCOPY 47
• An endobronchial ignition during the thermal ablation of
an airway lesion resulting in black discoloration has
been reported on several occasions.
• Such complications can occur during the use of a laser,
electrocautery, or argon plasma coagulation.

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• A step by-step protocol should be established. When a
flash fire is detected:
• all anesthetic agents should be immediately discontinued,
followed by endotracheal tube removal and extinguishing the
fire with saline.
• The patient should receive pure oxygen ventilation by mask
prior to reintubation.
• The tracheobronchial tree should be re-evaluated for the
removal of any foreign particles.
• Daily FOB should be performed to detect complications and
delineate the extent of injury.

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• Steroids should be initiated with a gradual tapering as the
patient improves.
• Daily tracheal cultures should be obtained for the early
detection of changing microbiology .
• Prophylactic antibiotics, such as penicillin and cephalosporin,
should be initiated and later adjusted, based on bacteriologic
findings .
• A high-humidity nebulizer will facilitate the clearing of secretions
because burned airways with impaired mucociliary function are
prone to form mucus plugs, resulting in postobstructive
pneumonia.
• In severe laryngopharyngeal injury, tracheostomy is necessary
to prevent airway obstruction.

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