Bronchoscopy

Identify the five most common indications for bronchoscopy and which indications are diagnostic applications and which are therapeutic applications.

1) Evalulate for lung cancer - Diagnosis, staging, directing therapy (chemotherapy? radiation? surgery?) - Diagnostic application of bronchoscopy 2) Airway inspection (e.g. hemoptysis, trauma, burns) 3) Infectious illnesses (pneumonia) - Certain patients with suppressed immune systems or with subacute or chronic symptoms) may be unable to cough up sputum for a sputum testing. 4) Interstitial lung disease - Bronchoscopies are used in ILD to gather samples of the pt's lungs from random regions for lab testing to confirm the type of ILD. - BAL may be used to assess for CA, alveolar bleeding, or infection. 5) Therapeutic treatment - To remove a foreign body or suction out mucus plugs after failed attempts from CPT, mucolytics, suctioning, etc.

List the essential equipment needed to perform a bronchoscopy safely.

1) Prebronchoscopy assessment 2) Conscious sedation administration to ensure pt is comfortable but can be aroused easily after the procedure. 3) Supplemental O2 via nasal cannula at 2 to 6 L/min to prevent hypoxemia. - Intubation may be used to keep airways open and clear at 100% O2. 4) Vital signs are continuously monitored to note heart rate, BP, and ability to oxygenate and ventilate (oximetry w/ or w/o capnography). 5) Flexible bronchoscope, sterile/cytology brush, 20-40 mL saline vial, specimen container/trap. 6) Benzodiazepines (Versad, Ativan to keep the patient calm or have the pt forget the procedure) - Narcotics (therapists can push these meds) - Anticholinergics-purported to reduce: secretions, cough, vagal reflexes.

Identify the contraindications to performing a bronchoscopy.

Absolute contraindications - Unstable cardiovascular status - Uncorrectable gas exchange abnormalities (ventilator pts) Relative contraindications - Recent unstable coronary syndrome (acute MI) - Unstable asthma - Uncooperative patients

Explain the uses of bronchoalveolar lavage (BAL), brushings, and needle biopsies.

Bronchoalveolar lavage (BAL) - Performed to obtain a lung tissue sample from airways too small for the bronchoscope cath tip to enter. - BAL samples are sent to lab to diagnose infection, determine total and differential cell counts, assess cytology (cancer), or perform immunologic studies. BAL procedure: 1) RT or RN assistance needed 2) Doctor locates the subsegment of the lung of interest. 3) The RT inserts approx 20 to 40 mL of saline into the side port of the scope and out into the small airway. 4) The doctor will then suction the fluid back into a collection container or trap that the RT attaches to the outside of the scope. Brushings (sterile, cytology) - Sterile brush can be inserted along with the bronchoscope to retrieve microbiology sample or a cytology brush for cytology specimen collection. - Inserted through the hollow working channel of the standard bronchoscope. Needle biopsies - A TBBx or transbronchial biopsy is performed for tissue sampling when a solitary pulmonary nodule (SPN) or lung mass is seen on CXR or computer tomography (CT) scan. - Valuable for diagnosis of the central lesions as well as peripheral lesions.

Define the terms used with endoscopy

Bronchoscopy - Procedure to examine the bronchial tree. Bronchoscope - Invasive tool for diagnosis (r/o tumors, lung CA) and treatment (suction mucus plugs in the airways) of disorders of the lung. Catheter - A thin, tube like instrument inserted into the lungs with a small light and camera on the tip which transmits images.

Describe the characteristics and capabilities of the flexible bronchoscope.

Flexible bronchoscope characteristics and capabilities: - Less than 0.5 inches wide and is about 2 feet long. - Composed of a flexible sheath containing the necessary cables to allow flexion and extension of the tip of the scope (ranging from 130 degrees in one direction and 160 degrees in the opposite direction). - Holds encapsulated fibers that transmit the endobronchial images from a small camera at the tip onto a video screen or to a camera. - Light source - Working channel to allow the use of forceps, sterile brush, cytology brush, fine-needle aspiration, and suctioning of bronchoalveolar samples. - Allow for visualization of the vocal cords, larynx, trachea, and tracheobronchial tree down to the segmental airways (forth or fith generation in most patients).

Discuss the complications of flexible bronchoscopy and relative risks involved in the procedure.

Major risks - Death (0.01-0.1%) - Significant bleeding (0.01-0.05%) (higher risk if sicker, more complicated procedure) - Respiratory failure - Nosocomial infection (caused by inadequate sterilization of scopes) Minor risks - Pneumothorax (1-4%) - Lidocaine toxicity - Temporary hypoxemia