Bronchoscopy For The New Endoscopy Nurse

As healthcare continues to evolve, healthcare workers (HCWs) must learn to be multi-skilled and diverse. It is probable that hospitals will combine endoscopy units into one large suite, only adding to the necessity of diversity.

What is a Bron-koss'ko-pee?

bronchoscopy is the endoscopic direct examination and visualization of the trachea and the tracheobronchial tree. Using a fiberoptic bronchoscope (a slender flexible tube with a light on the distal end) structures and abnormalities can be located and identified.¹

Bronchoscopy was developed for the removal of foreign bodies in 1895 in Freiburg, Germany. Gustav Killian succeeded in the removal of a piece of bone from the right mainstem bronchus of a 36-year-old man. Since then, Chevlier Jackson wrote a textbook on endoscopy, Shigeto Ikeda introduced flexible fiberoptic bronchoscopy for clinical use in 1968 and flexible fiberoptic bronchoscopy became available in the United States in 1972. Bronchoscopy has made a dramatic impact on the approach and management of the pulmonary patient.²

Flexible fiberoptic bronchoscopy offers a variety of features and capabilities:

• Easily performed in a procedure room or at the patient's bedside.
• Associated with few complications.
• Flexible fiberoptic bronchoscopy is much more comfortable and safer than a rigid bronchoscopy.
• Flexible fiberoptic bronchoscopy exposes a greater portion of the tracheobronchial tree.
• Flexible bronchoscopy does not require general anesthesia or the use of the operating room (OR).
• Excellent patient tolerance.
• No endotracheal intubation needed.³

A standard flexible fiberoptic bronchoscope consists of a proximal control section with a distal light source attachment connected by a flexible insertion tube. The outer diameter is approximately 4.8 mm to 5.9 mm. The control section has an eyepiece at its most proximal end and an angle lever that allows distal end to flex up and down. There is an inner channel for instillation or aspiration of liquids or insertion of cytology brushes, needles or biopsy forceps.⁴

Fiberoptic bronchoscopes are available in various external diameters, types of channels, degrees of flexion and extensions of the tip. Instrument choice is determined by the specific purpose for which the fiberoptic bronchoscope is to be used and physician preference.⁵

Why Do a Bronchoscopy?

Bronchoscopy offers several procedures to treat and diagnose pulmonary disorders. Goals of the procedures include:

• To visually examine airways for tumors, obstructions, secretions or foreign bodies.
• To diagnose disease processes such as interstitial pulmonary diseases.
• To therapeutically remove foreign bodies, mucous plugs or excessive secretions.
• To locate the site and cause of hemoptysis.
• To treat malignant airway obstruction.⁶

Types of Bronchoscope Procedures

Bronchoalveolar lavage (BAL): The technique is not standardized. For focal infiltrates on the chest X-ray, the segmental bronchus chosen for BAL should be in the area of new or progressive radiologic abnormalities. A BAL is commonly done in patients with diffuse infiltrates, cavitary lesions or suspected chemical injury. A lavage done in the right middle lobe or lingula can yield up to 20 times more fluid when compared to the lower lobes. The tip of the fiberoptic bronchoscope is wedged into a bronchial segment. Five aliquots of 25 cc of sterile normal saline is placed into the specified bronchial segment, then withdrawn immediately. The fluid is sent to the laboratory for viral, bacterial and fungal cultures and cytology.

Endobronchial forceps biopsy: This procedure is used for visual lesions and lesions that can only be seen with a fluoroscope. Small nodules, diffuse infiltrates and toxic injury can be biopsied. Biopsy forceps are used to obtain pieces of the bronchial mucosa, bronchial wall, lung parenchyma or lesions.

Transbronchial biopsy: Biopsy forceps are advanced through the fiberoptic bronchoscope using fluoroscopy and several lung tissue samples are obtained.

No special forceps are designed for endobronchial or transbronchial forceps biopsy. Two main types of forceps are the cup forceps (without teeth) and the alligator forceps (saw-toothed). It has been noted that the alligator forcep is being used less because the tearing action of the forcep has been associated with hemorrhage.

Transbronchial needle aspiration (TBNA): Extends the diagnostic capabilities of the flexible fiberoptic bronchoscope by allowing the retrieval of specimens beyond the confines of the tracheobronchial mucosa.

A (Wang) transbronchial needle is inserted through the working channel of the fiberoptic bronchoscope into a segment of lung tissue with a noted abnormality. The needle aspirates material from masses and/or enlarged lymph nodes.

Once removed from the bronchoscope, the needle is used to expel a sample of the aspirated material onto a glass slide. Placing the two slides together and pulling them apart make a mirror image smear. One slide is immediately stained (diff quick) and evaluated for diagnostic adequacy. The second slide is taken to the cytology lab for additional staining. The transbronchial needle is flushed and the rinse (specimen) is processed by a concentration technique for later staining and evaluation.

In The Procedure Room

When the patient arrives in the procedure room, the endoscopy nurse will:

• Review patient's chart for informed consent.
• Assess compliance with NPO requirements.
• Review chart and ask patient about known allergies.
• Place patient on cardiac monitor, automatic blood pressure cuff and oxygen saturation monitor.

An initial baseline patient assessment is completed and documented.

Final Preparations Before the Bronchoscopy Procedure

Nebulized lidocaine: Nebulized lidocaine is one of the most effective methods to anesthetize the upper airway. The 5 cc of 4-percent lidocaine (200 mg) is placed in a nebulizer and the patient is instructed to breath deeply. Nebulization of lidocaine takes approximately 20 minutes. Once completed the patient is placed in a supine position.

Oxygenation: Oxygenation throughout the entire bronchoscopy is extremely important. The patient's oxygen flow rate will be adjusted based on the patient's pulse oximetry. It should not drop below 90 percent.

The suction port of the fiberoptic bronchoscope can aspirate up to 14 liters of oxygen, stealing not only administered oxygen, but alveolar oxygen. Suctioning-induced hypoxia can be diminished by the bronchoscopist limiting suctioning for brief periods.⁷

Viscous lidocaine: The pulmonologist applies 2-percent viscous lidocaine to the maximal nasal aperture with a cotton-tipped applicator to minimize discomfort during insertion of the bronchoscope. Typically the left naris is noted to be larger than the right.

Intravenous conscious sedation: The pulmonary clinical nurse gives intravenous (IV) conscious sedation to the patient when the pulmonologist is ready to begin. The goals of IV conscious sedation include:

• Maintenance of spontaneous respirations.
• Adequate oxygenation.
• Patient ability to inspire and expire on command (deep breaths help align the vocal cords, larynx and fiberoptic bronchoscope).
• An amnesic effect to help decrease the patients psychological stressors and increase cooperation.

Regardless of the type of IV sedation used, small doses should be administered until patient is sedated, yet able to follow instructions and demonstrate reflex responsiveness.⁸ The interval between repeated doses should be at least the maximum onset time of the drug. Repeated dosing may cause the patient to become uncooperative or oversedated and may lead to respiratory and/or cardiac arrest.

An emergency resuscitation cart appropriate to the patient's age should be readily available in the bronchoscopy room.

If the patient decompensates during the bronchoscopy, the pulmonologist will maintain ventilation with the assistance of an Ambu bag or may intubate the patient with an endotracheal tube.

IV conscious sedated patients are at risk for oversedation.

The Bronchoscopy Begins

With the patient adequately sedated, the insertion of the flexible fiberoptic bronchoscopy begins with the examination of the nasal fossa, nasal pharynx and larynx. The transnasal approach to bronchoscopy is better tolerated by the patient and allows for better leverage of the scope. The anatomy and mobility of the vocal cords are evaluated visually as the patient verbalizes an "e" sound and the entire circumference of the trachea is viewed.

The fiberoptic bronchoscope is passed to the carina, which is examined for sharpness, position and texture. The bronchial orifice is systematically identified, evaluated and suctioned free of secretions and close attention is paid to color, texture, position size and patency.

Post-Bronchoscopy Laboratory Standards

The pulmonologist sends all specimens to the laboratory. Patients who are not immunosuppressed will have microbiology specimens sent to the laboratory. Immunosuppressed patients (transplant, cancer and HIV patients) will have bronchoscopy specimens sent for microbiology and virology. Cytology specimens are sent for cancer, viral changes and fungal elements.

The following are the standard microbiology specimens sent:

• Bacteriology -- gram smear
• Bacteriology -- routine culture
• Mycobacteriology -- AFB smear
• Mycobacteriology -- AFB culture
• Mycology -- fungus culture
• Mycology -- wet mount prep

The following are the standard microbiology and virology specimens sent:

• Respiratory virus panel -- isolation in culture
• Respiratory virus panel -- direct detection
• Cytomegalovirus (CMV) -- isolation in culture
• CMV -- direct detection

After the Bronchoscopy

When the examination is complete, the patient is placed into a Fowler's position. Close monitoring of the patient's oxygen saturation, vital signs and level of consciousness are documented every five minutes. When oxygen saturations are greater than 92 percent, the patient is weaned off the oxygen therapy.

The patient is monitored in the procedure room for approximately 30 minutes past the last dose of IV sedation. When the patient has returned to his or her assessment, the pulmonary clinical nurse updates the receiving floor nurse.

Special procedure and nurses notes, the fiberoptic bronchoscopy report and the post-bronchoscopy order sheet are placed in the patient's chart and the patient is transported to his or her unit.

If transbronchial biopsies were performed, the patient needs a chest X-ray before returning to his or her floor. The pulmonologist reads the chest X-ray and notifies the medical team with any problems.

The Patient Returns

The post-bronchoscopy order sheet specifies NPO status, vital sign frequency, oxygen delivery and the contact number for the pulmonologist.

The patient must remain NPO for a minimum of one hour after the bronchoscopy due to the lidocaine inhibiting gag reflex. Vital signs and pulse oximetry are monitored q 1 hour X 2, then q 4 hours X 2. Notify the pulmonologist for any sudden shortness of breath, chest pain or hemoptysis. Some hemoptysis may be expected if biopsies were obtained.

The patient should be placed on fall precautions post-bronchoscopy due to the IV sedation.

Fever of up to 101 degrees Fahrenheit.can be expected after a bronchoscopy. Although anticipated, it should be reported to the pulmonologist for evaluation. A transplant patient with a temperature greater than 99.6 F should be reported to the pulmonologist or the transplant physician for evaluation.

Outpatient Bronchoscopy

An outpatient bronchoscopy is slightly different than an inpatient bronchoscopy. The pulmonologist identifies that a patient needs a bronchoscopy. The pulmonary clinical nurse contacts the patient and family to:

• Obtain patient information and schedule the bronchoscopy.
• Give the patient and family instructions on dietary restrictions.
• Inform the patient and family that the patient cannot drive after a bronchoscopy procedure. Arrangements for transportation need to be made in advance.

After consultation with the physician, the nurse tells the patients who take Coumadin® to stop their prescription for approximately three to four days prior to the bronchoscopy. Patients who stop their Coumadin may experience a medical risk and special arrangements are made for them. Aspirin should be held for several days before the procedure as well. A prothrombin time (PT) should be checked prior to the procedure.

The patient is instructed to arrive at the hospital one hour before the bronchoscopy.

After checking with the clerk in the outpatient area, the patient comes to the pulmonary diagnostic laboratory where the pulmonologist reviews the procedure with the patient and family and obtains informed consent. Physician orders are completed and placed in the chart.

The pulmonary clinical nurse starts a peripheral IV line. The patient is given the 4-percent 5 cc lidocaine nebulizer. The recovery period is approximately 30-60 minutes.

Before Discharge:

• IV will be removed.
• Discharge instructions will be reviewed with patient and family.
• Written instructions are provided since the medications used for conscious sedation may cause difficulty in remembering instructions.
• If the patient requires a post-procedure chest X-ray, he or she is escorted to radiology to wait for the pulmonologist to read the X-ray before final discharge.

All of the outpatient's records from the bronchoscopy are sent immediately to medical records for placement in the patient's chart.

Potential Complications and Risks

Hypoxia: Hypoxia is the most common complication of bronchoscopy. Interventions include:

• Supplemental oxygen is always given during the procedure.
• Pulse oximetry, respiratory rate, cardiac rhythm and level of consciousness are monitored continuously.
• Patients with underlying lung disease are monitored closely due to increased risk of complications.
• The pulmonologist is notified immediately for any and all changes in the patient's respiratory status. (i.e., dyspnea, decreased oxygen saturation, laryngeal stridor, wheezing).

Drug reaction: Allergies are checked and noted before the procedure. If the patient has never had a medication before, the chance for an allergic reaction exists.

Death: Although death is extremely rare during a bronchoscopy, intervention includes:

• Emergency resuscitative equipment is readily available in the procedure room.
• All staff should have conscious sedation training.
• All staff should have advanced cardiac life support (ACLS) training.

Pneumothorax: Interventions include:

• Pulse oximetry, respiratory rate, vital signs, cardiac rhythm and level of consciousness are monitored continuously.
• Assess for signs and symptoms of dyspnea.
• Assess breath sounds in all lung fields.
• Chest X-ray performed for transbronchial biopsies and transbronchial needle aspirations.
• Chest tube or a Tru-Close thoracic vent will be inserted for lung re-expansion if necessary.

Infection: Transient fever may occur due to the irritation of the tissue or, rarely, by introduction of a contaminant. Interventions include:

• Notify the pulmonologist for a temperature greater than 101 F. For transplant patients, notify the physicians of a temperature of greater than 99.6 F.

Irregular heart beat: Vasovagal stimulation can occur as the fiberoptic bronchoscope passes through the vocal cords. Intervention includes:

• The patient is cardiac monitored continuously.
• Atropine 1 mg is given to prevent a vasovagal response.
• Emergency equipment should be readily available in the procedure area.

Bleeding: Interventions include:

• PT/PTT, CBC and platelet count are obtained before the procedure.
• Platelets can be given during the bronchoscopy to help control bleeding if necessary.
• The fiberoptic bronchoscope can be placed at the site of bleeding to perform rapid suctioning if necessary.
• Epinephrine can be applied topically via the fiberoptic bronchoscope in order to control the bleeding. Epinephrine 1:1,000 (1 mg/ml) is mixed with 9 cc of normal saline and administered to the site in 1-2 cc aliquots. (Epinephrine is a very potent vasoconstrictor and can increase the heart rate.)
• The patient can be placed on the a affected side in order to minimize aspiration of blood into the non-affected lung.
• The patient may be intubated in order to protect the airway with a massive hemoptysis.

Sharon Lesser, RN, is a pulmonary clinical nurse in the Department of Pulmonary and Critical Care Medicine at the University of Maryland Hospital in Baltimore, Md. She is an SGNA member and the pulmonary special interest group chair.

For a complete list of references, log on to: www.endonurse.com.

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