microbiological diagnosis is the main stay for the effective treatment of pulmonary tuberculosis ( pt ) . for obtaining the correct sputum sample ,
patient education is imperative . however , even if the correct sample is expectorated , the bacillary population has to be at least 10000 per milliliter , to get the smear positive for acid fast bacilli ( afb ) .
moreover , it depends on the previous treatment , default behavior , and effective cough .
as such , it opens a pandora 's box in the diagnosis , as there are no authentic radiological diagnosis criteria for pt .
the computed tomography ( ct ) of the chest only increases the guessing probability for the clinician , but does not lead to a photo - finish diagnosis .
however , a fiberscope can reach the pathological site of the bronchopulmonary segments and the lavage , brush smear , and post scopy sputum can reflect the correct collection of the specimen . hence fiberoptic bronchoscopy ( fob ) was done in cases having undiagnosed radiological panorama .
all were sputum smear - negative for afb twice and exfoliative cytology was suggestive of inflammation .
the highlight of this study was the usage of the trans oro pharyngeal spacer ( tops ) , which was a multipurpose one .
this avoided contamination with the nasal and oral flora , and if necessary , respiratory toilet or emergency intubation could be done through this .
the objective of the study was to confirm the presence of afb in the pulmonary lesions in smear - negative pulmonary tuberculosis cases for earlier initiation of the treatment .
this study has been conducted by the department of microbiology and department of respiratory medicine , ganni subba lakshmi ( gsl ) medical college , rajahmundry , from february 2007 to may 2010 . our teaching hospital attached to the medical college
has thousand beds and is a referral center for tb treatment in this area . in this study
we considered patients with suspected pt , that is , cough of more than two weeks .
patients who were not cooperative and children below 14 years were excluded from the study ( getting sputum sample was difficult ) .
first , smears were made with the sputum samples to detect afb as per the revised national tuberculosis control program ( rntcp ) guidelines .
all smears positive for afb cases were referred to the clinician for anti - tuberculosis treatment ( att ) and smears negative for afb cases were preceded by fob , and were then included in the study . written informed consent was taken from all the individuals participating in the study , as also an endorsement from the ethical committee of the institute .
algorithm of the study the fob was done by fujinon - bro yl2 , japan , transorally , tops was used to avoid contamination .
injection atropine 0.01mg / kg i m was given half an hour before the procedure .
bronchodilator , salbutamol 1 ml + 1 ml normal saline was given via a nebulizer to all these subjects as they had bronchospasm earlier .
the subjects were directed to rinse the oral cavity with 2 ml of lidocaine jelly before the procedure and lidocaine 2% was liberally used through the channel of fob , not exceeding 200 mg in total .
bronchial lavage from the affected segment , brush smear , and post scopy sputum were also collected for smear examination to detect afb by ziehl neelsen ( zn ) staining .
the main features of the study design were : 
 the microbiologist picked up the correct portion of the bronchial lavage in the endoscopy room and the samples were examined immediately after zn staining.the total xylocaine used , on an average , was 3 ml from the vocal cords down to the bronchial tree.fob was done through tops , patented by the senior author and manufactured by the pran clinic and co. , rajahmundry , 2004 model .
this was a mechanical devise to deliver the aerosol medicine for the symptomatic treatment of bronchial asthma .
it was 10 cm in length , with a 10 mm internal diameter [ figure 2 ] .
there was a universal adapter in front , which had a straight part and an arched section that bent twice with angles of 110 and 150. as per the mallampati classification , the oropharynx could be classified into classes i , ii , iii , and iv , depending upon the patency of the oropharyngeal lumen .
the tops was much more useful [ figure 3 ] , as it lifted the uvula [ figure 4 ] , and fob or blind intubation could be done easily through tops .
it also snugly fitted into the pharynx , the distal end being just above the epiglottis . the advantage of using this was avoidance of contamination with the oropharyngeal / nasal flora and easy passage of the scope . if there was bleeding , effective toileting could be done and intubation also could be achieved . 
 
the microbiologist picked up the correct portion of the bronchial lavage in the endoscopy room and the samples were examined immediately after zn staining .
the total xylocaine used , on an average , was 3 ml from the vocal cords down to the bronchial tree .
fob was done through tops , patented by the senior author and manufactured by the pran clinic and co. , rajahmundry , 2004 model .
this was a mechanical devise to deliver the aerosol medicine for the symptomatic treatment of bronchial asthma .
it was 10 cm in length , with a 10 mm internal diameter [ figure 2 ] .
there was a universal adapter in front , which had a straight part and an arched section that bent twice with angles of 110 and 150. as per the mallampati classification , the oropharynx could be classified into classes i , ii , iii , and iv , depending upon the patency of the oropharyngeal lumen .
the tops was much more useful [ figure 3 ] , as it lifted the uvula [ figure 4 ] , and fob or blind intubation could be done easily through tops .
it also snugly fitted into the pharynx , the distal end being just above the epiglottis . the advantage of using this was avoidance of contamination with the oropharyngeal / nasal flora and easy passage of the scope .
if there was bleeding , effective toileting could be done and intubation also could be achieved .
tops in class iii oropharynx the highlight of the study is the use of the trans oro pharyngeal spacer ( tops ) , which is an innovative product , by the senior author .
it helps in easy passage of the tube , and bronchoscope bite is avoided . adding to this ,
there have been no complaints of discomfort from the patients while passing the scope . as tops
out of 533 individuals in our study , there were 322 males and 211 females ( mean age was 39.4 years ) .
the radiological profile [ table 1 ] revealed that 291 ( 54.5% ) patients had unilateral minimal radiological extent and the remaining 242 ( 45.5% ) had bilateral moderately advanced disease . in the bilateral disease , the
the samples of lavage , brush smear , plus post scopy sputum were positive for afb , in 241 cases . only post
scopy collection of sputum within 24 hours was positive for afb in 100 cases [ table 2 ] .
thus in 341(64% ) subjects , the bacteriological diagnosis was clinched . in the afb - positive patients the quantitative analysis showed scanty ( 1  9 afb in 100 fields ) results in 260 ( 76% ) and 1 + ( 10  99 afb in 100 fields ) bacillary load in the remaining 81 ( 24% ) patients .
this spectrum of cases , after establishing the cause and effect , were put on effective att .
an editorial quoted that 40% of the cases with initial sputum afb - negative status continued to be sputum negative , while 60% of them had progressive disease later .
previous reports in non - immunocompromised patients with sputum smear - negative tb indicated that bronchoscope specimens and post bronchoscope sputum are helpful in establishing the diagnosis .
as per adelaithi m et al . , diagnostic fob is often performed before the final results of the sputum analysis are available , to exclude other common infections , such as pneumocystis carinii pneumonia , to confirm pt . hence , the present study adumbrated a similar picture helping the clinician to treat the cases immediately not withstanding the radiological shadows .
fiberoptic bronchoscopy through tops ensured ease of procedure and the secretions adhering inside the conduit were useful for microscopic examination .
an immediate diagnosis of pt in smear - negative cases could be established with the bronchoscope , which was 45.3% in our study .
similar results were reported by steve h et al . in a study . however , there was some difference in the afb yield of post scopy sputum . in our study 19% of the post
scopy smears were positive for afb , whereas , it was 32% in the study by steve h et al .
the usage of brush for smear is mandatory when doing bronchoscopy . we have improved over this recommendation by examining the bronchial lavage , brush smear , and post scopy sputum with a stand - by microbiologist .
the specimens were examined and collated by both the pulmonologist and microbiologist , avoiding any false negative reports .
one feature of this study was that the residual 191 ( 36% ) cases ( negative for afb by all means ) were not administered treatment for pt and saved the grace .
it was quite possible that they had treatment elsewhere inadvertently or non - tubercular granulomatous lung disease had to be entertained .
the specimens collected by bronchoalveolar lavage , brush smear , and post scopy sputum , should be evaluated together for afb positivity in a smear negative for afb cases .
they have to be examined immediately avoiding transit delay , contamination , and false reading .
collection of post scopy sputum in the next 24 hours and examining post scopy sputum for afb is also an important aspect of this study . as per the revised national tuberculosis control program ( rntcp ) algorithm , in a symptomatic patient ,
if sputum smear is negative for acid fast bacilli ( afb ) , we have to wait for 10  14 days , with broad spectrum antibiotics . after this time period also , if the sputum sample is negative for afb and if the chest x - ray is suggestive of tb , then the patient will be given anti - tb treatment by categorizing him / her as sputum negative pulmonary tb . in this manner ,
the two - week time period is wasted and without afb patient may have to start att .
 introduction : the tuberculosis control program is based on a felt need  
 oriented basis . 
 the diagnosis is mainly microbiological . 
 however , sputum smear - negative acid fast bacilli ( afb ) cases with suspected radiological findings can be problematic in diagnosis.objectives:to confirm the diagnosis of tuberculosis early , in smear - negative afb cases by using a fiberoptic bronchoscope.materials and methods : we embarked on fiberoptic bronchoscopy ( fob ) and spot scopy smear microscopy ( ssm ) for 533 suspected pulmonary tuberculosis ( pt ) cases ( sputum smear negative and radiologically suggestive ) from february 2007 to may 2010 . 
 fob was performed using a special device , a trans oro pharyngeal spacer ( tops ) , as a conduit.results:the yield for positivity for afb was 341 ( 64% ) out of 533 cases.conclusion and recommendation : the specimens collected by using the fiberoptic bronchoscope confirmed the disease in the smear - negative cases . 
 hence , fob was recommended in smear - negative cases , to avoid delay in the treatment of tuberculosis . 
INTRODUCTION
MATERIALS AND METHODS
OBSERVATIONS
DISCUSSION
CONCLUSION