Diagnostic Indications for Flexible Bronchoscopy and the Procedures for Tissue Acquisition

There are numerous clinical indications for flexible bronchoscopy. The procedure can be ordered for either diagnostic or therapeutic reasons. The most common diagnostic indications for bronchoscopy that we see at our facility include the evaluation of chest X-ray (CXR) or computed tomography (CT) lesion, unexplained cough, hemoptysis, non-resolving pneumonia, and the staging of lung cancer. This article will cover these diagnostic indications for the use of flexible bronchoscopy as well as the technical procedures that are required of the nurse during the procedure. Finally, patient education will be covered to provide the reader with the knowledge to keep their patients well informed about the procedures that they will experience.

Clinical Findings requiring Diagnostic Bronchoscopy

A 68-year-old (YO) male presents for a general surgery procedure. A preop CXR discovers a questionable shadow in the right middle lobe (RML). CT scan confirms a spiculated 1.3 cm nodule in need of diagnostic evaluation.

An abnormal CXR or CT scan is the most common reason to prompt evaluation by bronchoscopy. Lesions on CXR or CT scan that are accessible by bronchoscopy include mediastinal masses or enlarged lymph nodes, parenchyma lesions of the lung that are not too peripheral, or pleural bases. The differential diagnosis list includes malignancy, infection, scar and inflammatory reaction. Out of these potential diagnoses, malignancy is by far the most common finding. Lung cancer is the most common diagnosis with metastatic malignancies being the second most common. Methods used to obtain tissue diagnosis in these circumstances include transbronchial biopsies, Wang biopsies, wash, brush and even bronchoalveolar lavage (BAL).

A 56-YO female smoker presents to a pulmonologist with complaints of a persistent troublesome chronic cough over the past three months. Her primary care provider (PCP) has treated her for allergies, GERD and postnasal-drip syndrome. She does not take any anti-hypertension medications.

The use of bronchoscopy for the evaluation of cough is controversial but in cases of persistent chronic cough when common causes have been ruled out or treated, clinical evaluation with bronchoscopy is warranted. The cause of cough in this setting is typically an endobronchial lesion from either malignancy or viral infections such as human papilloma virus (HPV).

Sampling methods for chronic cough include a basic airway survey for endobronchial lesions, bronchial wash, brush, BAL and endobronchial biopsies. It is important to know that if no airway lesion is seen on evaluation, a diagnosis from bronchoscopy for chronic cough is low-yield.

A 76-YO male with a 100+ pack/year smoking history presents to the emergency department (ED) after two days of coughing up 15-30 ounces of bright red blood. He is admitted for further evaluation.

The clinical indication for bronchoscopy in the setting of hemoptysis is one of the more straightforward indications. An airway survey will allow the clinician to visualize the area of bleeding and allow for direct sampling of the area. Typical causes for hemoptysis include endobronchial lesions from cancer, severe cases of bronchitis, bronchiectasis, cavitary lesions, granulomas or abscesses. Procedures used in this setting will include endobronchial biopsies, wash, brush and—on occasion—BAL. Radiology evaluation is very helpful in this setting to look for any other lesions in the lungs that could contribute to the hemoptysis.

A 69-YO male is referred to the pulmonologist for the evaluation of a persistent pneumonic process in the lower left lobe (LLL). Repeated sputum samples have been negative, H. flu testing is negative, and despite several rounds of oral antibiotic therapy, the LLL infiltrate persists. The patient has clinically worsened in the past one to two weeks.

The use of bronchoscopy in a non-responding pneumonia will allow for better sampling in the area of concern. Possible etiologies of the pneumonic process could include bacterial infection, fungal infection, chronic eosinophilic pneumonia, post-obstructive process and pulmonary hemorrhage. Procedures used in this setting include BAL, wash, brush, protected brush, and transbronchial biopsies for better tissue sampling. By obtaining these larger samples, clinical diagnosis of the causative organism can be obtained and therapy tailored for effective treatment.

A 71-YO man presents with hemoptysis. CXR notes a questionable 3 cm mass that is new when compared to past films. CT scan confirms the mass in the right upper lobe (RUL) as well as extensive mediastinal adenopathy. There is a 1.5 cm subcarinal node that would be accessible by bronchoscopy. He is referred to pulmonary for evaluation.

When a patient presents not only with a lung mass but also mediastinal lymphadenopathy (LAD), bronchoscopy can be used to aid in the clinical staging of lung cancer. By using transbronchial biopsies (Wang biopsies), tissue samples of the mediastinal LAD can be obtained. If indeed a diagnosis of cancer is obtained from a mediastinal lymph node, there is no clinical reason to proceed with sampling the larger parenchyma mass.

The diagnosis of cancer from a lymph node will aid in the treatment decisions for the patient. Metastatic spread of lung cancer to mediastinal nodes may preclude surgical resection as a treatment option for the patient.

Technical Procedures used during a Bronchoscopy

There, procedures are used to retrieve small pieces of abnormal tissue from the airways when the patient has either a non-responding pneumonia or a nodule or lesion suspicious for malignancy. The equipment used in this setting has the appearance of forceps that pinch the tissue that requires sampling. Common side effects include localized bleeding and possible pneumothorax in the case of some transbronchial biopsies. The forceps are threaded through a port in the side of the scope and advanced by the clinician to the area of concern.

There, techniques are used to obtain samples of the area by brushing and agitating across the pulmonary mucosa. The brush is indicated when the patient has a diagnosis of respiratory infection or endobronchial mass. A small cytology brush is inserted through a port in the side of the scope and, just as the forceps biopsy, advanced by the clinician to the area of concern.

The protected brush is used to obtain samples that will be sent for microbiology and must be protected for contamination after being collected. The brush is advanced through a side port of the bronchoscope while in the sheath and covered by the wax plug. Once in the proper position, the protected brush is advanced to collect the sample and retracted into the protective sheath and removed from the port. Clinical indications include pulmonary infection, immunosuppression, or non-responding pneumonia.

Bronchoalveolar lavage (BAL) is a sampling technique that involves flushing the distal airways with sterile saline and aspirating the fluid back into syringes to be sent for analysis. The average amount that is used to irrigate the lungs during lavage is 200-240 cc of sterile non-bacteriostatic saline. Washing has the same purpose as the BAL except much less fluid is used. BAL and washings are indicated when the patient has been diagnosed with: pneumonia, interstitial lung disease and alveolar hemorrhage. In certain circumstances, pulmonary malignancies can be diagnosed from BAL or wash.

Transbronchial needle aspirations are used to sample tissue from beyond the bronchial tree by using a technique of needle aspiration. The needle is covered be a sheath and passed through the side port of the bronchoscope. Once in the proper position, the needle is advanced through the bronchial wall into the area desired. This can be a mass or lymph node that is suspected of being abnormal. The most common use of the Wang needle biopsy is when a patient has mediastinal LAD.

Patient Teaching

The goal of the nurse should be to explain the procedure and assess the patient’s ability to comprehend what is to take place. Communication during the procedure will require the nurse to explain the use of hand signals during the procedure should the patient require suction or need to alert the team they are experiencing discomfort. Reassuring the patient that they will be able to breathe and that the staff will be continually assessing them during the procedure is indeed one of the most important roles of the nurse. Other important teaching points include but are not limited to the following:

1. Explain the medications that you will be using;
2. Explain that supplemental oxygen will be used as well;
3. Explain all of the types of samples that are planned for his procedure;
4. Explain the type of equipment that you will be using and
5. Explain the approximate length of time the procedure will take.

When the procedure is complete and the patient has recovered, the nurse should explain the discharge instructions. There, include all restrictions related to sedation, that the patient should expect to cough up a small amount of blood if a biopsy was done, and that a low-grade fever is not unusual for the next 24-48 hours. If the patient experiences hemoptysis or fever that lasts longer than 48 hours, they should contact the provider for evaluation. The patient should be given a number where they or their family can call with concerns after being discharged.

Summary

There are numerous indications for diagnostic bronchoscopy. The major indications for bronchoscopy include — but are not limited to — the evaluation of CXR or CT lesion, unexplained cough, hemoptysis, non-resolving pneumonia, and the staging of lung cancer. The most common diagnosis obtained through bronchoscopy is primary lung cancer with metastatic cancer and infection following close behind. When patients are faced with a potentially serious diagnosis, it is important for the nurse to have a firm understanding of all elements of the procedure as well as the clinical indications. The nurse has the most direct contact with the patient and, therefore, the role for education is clearly vital to patient comfort and satisfaction.

1. Felix, J. F., Eberhardt, R.; & Ernst, A. (2006). The future of bronchoscopy in diagnosing, staging and treatment of lung cancer. Respiration, 73(4), 339-409.
2. Ernst, A., Silverstri, G. A., & Johnsone, D. (2003). Interventional pulmonary procedures guidelines from the American College of Chest Physicians. Chest, 123(5).
3. Kvale, P. A. (2006). Chronic cough due to lung tumors: ACCP evidence-based clinical practice guidelines. Chest, 129; 147-153.
4. Irwin, R. S. & Madison, J. M. (2000). The diagnosis and treatment of cough. The New England Journal of Medicine, 343(23), 1715-1721.
5. Landa, J. F. (1978). Indications for bronchoscopy. Chest, 73. 686-690.
6. Mandell, L. A., Wunderink, R. G., Anzueto, A., Bartlett, J. G., Campbell, G. D., Dean, N. C., et al. (2007). Infectious Disease Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clinical Infectious Disease, 44, S27-72.
7. Kennedy, J. I. (2006). Overview of bronchoscopy. Up to Date. Literature review version 15.1 current through August 2007. www.uptodate.com.

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