1. Chapter 17 Flexible Fiberoptic Bronchoscopy

2. 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.

3. 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

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

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

15. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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