Chapter 17 Flexible Fiberoptic Bronchoscopy

Learning Objectives After reading this chapter you will be able to: Define basic terms used with endoscopy Describe the characteristics and capabilities of the flexible bronchoscope Identify the five most common indications for bronchoscopy and which are diagnostic applications and which are therapeutic applications.

Learning Objectives (cont’d) Explain the uses of bronchoalveolar lavage, brushings (both sterile and nonsterile), and needle biopsies. Discuss the complications of flexible bronchoscopy and the relative risks involved in the procedure Identify contraindications to performing a bronchoscopy

Learning Objectives (cont’d) List the essential equipment needed to perform a bronchoscopy safely Prepare a patient, step-by-step, for an outpatient bronchoscopy

Introduction Endoscopy was first introduced in 1904 with the use of a rigid hollow tube bronchoscope Simple design and limited use

Introduction (cont’d) Modern rigid bronchoscopes have valves that allow: Flow of general anesthesia and oxygen Pathway for suctioning and removal of foreign bodies Passage for biopsy 90% of current bronchoscopies are performed using a flexible fiberoptic scope

Characteristics and Capabilities of a Flexible Fiberoptic Bronchoscope Wide range of sizes and applications Ultrathin scopes can examine and biopsy infant airways Large-diameter adult scopes facilitate suctioning, bronchial washings, brushing, biopsies, and removal of foreign bodies Digital scopes facilitate viewing on large video monitors and provide still and video photos Lasers can be directed from scope tip to obliterate large airway tumors

Indications for Bronchoscopy May be diagnostic or therapeutic Masses Most common diagnostic indication is abnormality on chest roentgenogram Infiltrates, atelectasis, mass Biopsy of mass Most effective when fluoroscopy guides tip of forceps to the lesion

Indications for Bronchoscopy (cont’d) Hemoptysis (therapeutic and diagnostic) Massive hemoptysis may require removal of blood through a large-bore rigid scope Once free of active bleeding a flexible scope should be used to assess for presence of cancer

Indications for Bronchoscopy (cont’d) Pneumonia May identify organism in hard-to-diagnose cases Bronchoalveolar lavage (BAL) fluid is suctioned into specimen container, which is sent for analysis

Indications for Bronchoscopy (cont’d) Interstitial lung diseases Infiltrate small bronchioles and supporting tissues Hard to diagnose; need actual tissue biopsy Can obtain by open lung biopsy or bronchoscope Bronchoscopy less invasive; outpatient procedure BAL may also be obtained to check for malignant cells

Indications for Bronchoscopy (cont’d) Foreign bodies With aspiration of objects airway control and patency of greatest importance Rigid scope used to remove large objects Smaller objects require a flexible scope Complications of removal include: Prolonged suctioning causing hypoxemia and atelectasis Damage to airway when grasping object

Complications Complications few, with mortality <0.01% Contraindicated if patient has history of bleeding problems Possible problems include: Bleeding, pneumothorax, and infection 5% of patients develop transient low-grade fever Prolonged procedure increases risk of hypoxemia and hypercapnia These increase the risks of arrhythmias and side effects of anesthesia

Outpatient Flexible Bronchoscopy Safe inexpensive site for bronchoscopy Room should be equipped with: Adequate suction capability ECG, SpO2, and BP monitoring Oxygen equipment and gas source Bag/valve/mask system, crash cart, defibrillator Appropriate drugs including Narcan and flumazenil

Outpatient Flexible Bronchoscopy (cont’d) Complete patient history and examination determine the appropriateness of procedure

Role of the RT Preparation Patient arrives at facility after 6-hour fast Must understand procedure and its alternatives prior to signing informed consent This includes risks and complications Patient in Fowler’s position breathes 5 ml nebulized 4% Xylocaine IV started for infusion of conscious sedation Nostril is numbed with Xylocaine

Role of the RT (cont’d) Preparation Patient placed on oxygen via nasal cannula Suction line attached to specimen trap and bronchoscope; several traps required Final step is administration of IV drugs (given by RN or MD) Fentanyl and Versed are common choices These achieve conscious sedation Procedure begins when patient goes to sleep

Role of the RT (cont’d) For safety personnel wear gown, mask, goggles, and gloves during the procedure RT assists bronchoscopist with selection and insertion of: 2% and 4% Xylocaine Brushes to obtain cells from abnormal tissues Biopsy forceps Needle aspiration apparatus

Role of the RT (cont’d) Monitor patient’s vital signs every 5 min Specimen handling For lung brushings the RT rubs the brush on the slide, making a dime-sized smear Biopsy specimens placed in formalin-filled bottle If biopsy causes bleeding, wash with epinephrine

Role of the RT (cont’d) 2 or 3 drops of the needle aspiration sample are placed on a slide, with a second slide placed on top For BAL, 20 ml 0.9 NaCl is instilled and then suctioned from lung back into labeled specimen trap

Role of the RT (cont’d) Following the procedure patient requires close monitoring Every 5 to 15 minute vital signs and SpO2 In addition one must be attentive for signs of increased discomfort, bleeding, or respiratory distress Physician is notified of any changes in patient condition

Role of the RT (cont’d) Patient is discharged when: Alert and oriented with gag reflex Vital signs are stable, no bleeding, throat is back to normal Instructed to call clinic if status changes

Role of the RT (cont’d) Sending specimens to the laboratory Biopsies, brushings, needle aspirations, and lung washings must be labeled Patient’s name History and physician numbers Date and site of origin Attach forms specifying tests to be performed  

Role of the RT (cont’d) Complete charting to include: Notes of procedure, indications, medications, specimens collected, and tests requested Note of any complications and postoperative impression

Summary Rigid scopes give better access to large airways and are best to remove aspirated large foreign bodies Flexible scopes are more comfortable, requiring only light sedation for spontaneously breathing patients Flexible scopes have expanded the practice of pulmonary medicine

Summary Most common indication for flexible bronchoscopy is to diagnose the cause of an abnormality seen on a chest roentgenogram RTs normally assist during bronchoscopy procedures