RSPT 2325 Diagnostics: Diagnostic and therapeutic bronchoscopy

Prepared November 2008 by EKB

Notes by Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP

Reading assignments:

• Wilkin’s Assessment Chapter 16
• Egan’s Fundamentals pp. 697-701
• Merck manual http://www.merck.com/mmpe/sec05/ch047/ch047d.html

Bronchoscopy

Bronchoscopy is the use of a bronchoscope to view the central airways in order to diagnosis or treat various disorders of the central airways. This technique is usually done by the MD assisted by RN [for IV drugs] and a RCP [airway management, patient assessment and oxygenation.]

Go here for view of the technique

http://www.sentara.com/NR/rdonlyres/6A6CFB6B-EEDF-4936-863942541692B84A/0/Bronchoscope_web.jpg

Indications for therapeutic bronchoscopy

1. Removal of foreign objects from the central airways by use of various appliances and suction

· See video on this technique

http://www.youtube.com/watch?v=w_N0gQn3kTY

peanut removal

http://www.youtube.com/watch?v=8V_kgCClwtI&NR=1

chicken bone removal

http://www.youtube.com/watch?v=7qpwqd_9Rhs

2. Removal of excessive secretions and mucus plugs in the central airways that have resulted in atelectasis and have failed to respond to normal CPR, adjuncts to CPT or to normal suctioning.
3. Direct visualization during difficult intubation. Bronchoscope is sent between the cords and the ET tube is sent over the bronchoscope which is then carefully withdrawn

· See video on this technique http://video.google.com/videosearch?q=bronchoscopy&hl=en&emb=0&aq=f#

· Another one in Spanish

· http://www.youtube.com/watch?v=kxXDgIxouYY&NR=1

Indications for diagnostic bronchoscope

1. Direct view of abnormal airway structures such as: a tracheal stenosis due to airway compression or FB, or failure to successfully extubation a patient

http://www.youtube.com/watch?v=e7xvhw3YTEU

normal and abnormal airways

http://www.youtube.com/watch?v=oEunQi92fLs&feature=related

2. Biopsy of airway lesions for cytology for lung CA. This is called transbronchial biopsy
3. Diagnosis of pneumonia etiology in immune-compromised patients with unusual pathogens such as Legionella or some fungal infections
1. BAL: broncho-alveolar lavage the end of the bronchoscope is lodged in a distal airway at the site of consolidation and instillation of several 4 or 5 syringes of 20-30ml of sterile non-bacteriostatic saline is used to ‘washout’ the bronchioles and alveolar sac.
2. These washings are sent to the lab to diagnosis such pathogens as TB and PCP and fungal agents that are located deep within the periphery of the lung.
3. Local areas of pulmonary edema created by this lavage may cause transient hypoxemia [Merck manual]

BAL on Horse http://www.youtube.com/watch?v=zJRoYWjVfbk

Some diseases need a transbronchial biopsy for diagnosis such as idiopathic interstitial pneumonitis, sarcodosis, alveolar proteinosis and some collagen vascular disorders

4. Inspection of areas of bleeding for possible lung CA. When there is 200 ml/day of frank bleeding, investigation of the site of bleeding is indicated

Contraindications for bronchoscopy

• Bronchoscopy should not be done in the event there is no one qualified to do the procedure, there are no supplementary 02 set up and inadequate personal to handle side effects, or when there is no informed consent [assuming the patient is alert and able to consent].
• Bronchoscopy should not be done if there is bleeding that cannot be controlled—unless the benefits outweigh the risks
• Bronchoscopy should not be done with persons with severe COPD or with persons who in refractory hypoxemic or are not hemodynamically stable

Hazards of bronchoscope per AARC CPG [Egan’s pp. 698-699]

There is increased risk of hazards in the following persons:

• Recent MI
• Uncooperative patient
• Partial tracheal obstruction [unless you are removing the obstruction]
• Persons with moderate to severe hypoxemia or hypercapnia
• Lung abscess or pulmonary HTN
• Advanced age, debilitated or starved patient
• Known or suspected pregnancy if fluoroscopy is to be used

Equipment

Flexible fiberoptic bronchoscope: [Egan’s pg 697 Fig30-41]

http://images.emedicinehealth.com/images/4453/4453-4492-11603-25135.jpg

A flexible tube that can be passed down the nose or mouth into the central airways. It has an external diameter of about 5.3 mm and with skill is possible to get the tube far enough down to visualize some of the airways at the 5^th and 6^th generation in adults. [Wilkin’s pp. 334]

The last inch or so of the scope has a bendable tip that can move 130 degrees in one direction and 160 degrees in another. [Wilkin’s pp. 334]

Channels

· Light channel: fiberoptic technology sends light that can bend around corners. The fibers can be broken and the final view or picture if using a camera will have gaps in it. Never bend the bronchoscope

· Visualing channel or objective lens: the channel used by the clinician to view the distal end of the scope. With the right adaptors, this can be attached to a still or video camera

· Multipurpose open channel: devices called appliances can be send down the hollow end of this channel

· Suctioning: adaptors to wall suction connectors. A sputum trap can be placed in line to collect sputum from specific lobe or segments of the airway for analysis.

· Passage of appliances: devices used to collect samples or capture foreign objects can be passed through here to operate at the end of the tube

Rigid bronchoscope:

http://images.emedicinehealth.com/images/4453/4453-4492-11603-25133.jpg

Because it doesn’t bend and because it a bigger diameter it cannot go down as low as the flexible ones can. These are used to:

1. remove large central airway obstructions and foreign bodies
2. Remove massive amounts of frank blood during hemoptysis

Appliances

Forceps

Go here for picture of forceps:

http://www.virtualpediatrichospital.org/providers/ElectricAirway/MiscImages/AlligatorForceps.shtml

grasping forceps can be used to collect Foreign bodies while other types of forceps are used to collect biopsy specimens. “W”shaped forceps for collecting coins and pelican-shaped forceps collect food. [Wilkins pp. 335]

Needles: hollow needle attached to thin plastic can be used to obtain tissue samples by puncture. This may be sheathed or unsheathed depending on the need to keep the needle sterile.

Laser probes: to burn out central airway tumors. Because this is a fire hazard we need to keep the Fi02 below 30% for this technique. Hazards include transaction of the airway and cutting into blood vessels

Snares: for capturing foreign bodies [see Wilkins pp. 335 Fig. 16.3 & Fig 16.4]

Baskets: for capturing foreign bodies that might fall apart such as peanuts

Medication during the procedure

*Tranquizers such as Valium or Versed for conscious sedation

*Atropine: to dry out secretions & to prevent reflex bradycardia which could lead to hypotension caused by tactile stimulation of the upper airway- this is controversial now

Lidocaine: local anesthetic – may have methohemoglobin or seizures as a side effect.

Morphine or other systemic narcotic might be necessary, but patient may lose airway protections, even ventilatory drive. In an effort to prevent wheezing, asthmatics are best sedated with Demerol or fentanyl. [Egan’s pp.701]

Narcan to reverse the narcotic if the patient loses his ventilatory drive

It is hard to predict other drug needs during procedures so a CPR cart needs to be close by

Topical vasoconstrictors such as phenylephrine or even cocaine to reduce bleeding

Mucomyst: diluted to about 2% for removal of thick secretions

Sterile saline for removal of secretions, cells for cytology

None-bacteriostatic sterile saline for removal of secretions for microbial cultures

*These need to be given 2 hours prior to procedures

Prep of the patient for bronchoscope

• NPO 8 hours before to prevent vomiting & aspiration during the procedure as we pass the upper airway structures.
• systemic sedation-- 2 hours prior to procedure; usually conscious sedation, rarely we may have a patient completely sedated and intubated for this procedure
• Systemic Atropine-- 2 hours prior to procedure to decrease secretions and to prevent vagal-vagal reflex bradycardia
• Place pulse oximetry on finger, EKG leads on chest, set up and check the function of mask bag system with 02. Because this is usually done as part of conscious sedation, one person needs to be set aside to monitor the patient’s reactions to these procedures
• Set up nasal cannula [or insert nasal catheter for supplementary 02 to one nare; have NRB or bag and mask ready for anoxia. It is possible to set up aerosol mask so that the scope can pass through the larger opening.
• If patient is to get lidocaine by SVN start with 6-8 LPM flow by mask just as you would nebulize any other drug.
• The doctor may want to use lidocaine by atomizer or mouthwash and some like to soak Q-tips in lidocaine to numb the nasal passage
• Set up & test the light source for bronchoscope
• Set up & test suction regulator and connecting tube
• If the bronchoscope is going via oral route, place a bronchoscopy bite-block to protect the ‘scope from the patient’s teeth
• Wear gown, mask and gloves for procedures; have sterile gloves if needed
• Set up multiple labeled 10 cc syringes of non-bacterial sterile saline, diluted Mucomyst or lidocaine for instillation down the tube during the procedure. I always have about 2-3 cc in each 10 cc syringe.
• Set up multiple sputum traps and labels for area and for sample type
• Have sterile scissors and cytology sample cups for brushing and biopsy results

Post-op care

• LOC should be monitored during and after the procedure
• VS, Sp02 & lead II EKG monitor for problems with upper airway occlusion causing hypoxemia or cardiac arrhythmia- we need to keep patient on supplementary 02 for at least 4 hours post-bronch
• BBS for irritation requiring Beta II agonists.
• Patient at risk for aspiration so he should be NPO as long as his mouth and throat are numb.
• If biopsies or lasers were performed, we need a chest film to r/o possible pneumonthorax.
• Therapeutic bronchoscopes to remove excessive secretions can be assessed by post bronchoscopy X-rays

Sampling techniques

Washes: we send non-bacteriostatic sterile water into area and then suction it back up into the sputum trap. The sputum trap is labeled with the lobe or segment and the type of sample: cytology, AFB, or culture and sensitivity

Brushings: May use shielded or unshielded brushes for this.

· Unshielded brushes are used to collect cells for cytology studies

· Shielded brushes are used to collect tissue for culture and sensitivities. The tip of the shield has a wax covering so that the brush is kept sterile until we poke it through and obtain our sample then retract it to return it.

Both types of brushes are rubbed against the tissue to obtain samples, then the entire end of the brush it cut off with sterile scissors and dropped into a sample cup. The sample cup is labeled with type of study required and location of the sample

Biopsies: the alligator Forceps are shoved against the coin lesion and we close the forceps and pull back to obtain a tissue sample [called a bite] that is pulled back and placed in the sample cup.

Generally we will collect multiple samples around the same area. The hazards of biopsies include [1] bleeding and [2] pneumothorax.

This technique is best done with a fluoroscope so that a developing pneumothorax can be diagnosed immediately. The use of fluoroscope with biopsies drastically increases the successful diagnosis of a mass.

Samples prepped for the lab

Cytology: special sample cups are used for these samples will contain formaldehyde-type chemicals to fix the cells

Culture and sensitivities: we may need anaerobic sample cups

Mediastinoscopy

Mediastinoscopy: A short neck incision to allow the surgeon access to the mediastinum by use of a scope behind the breast bone. This technique is used to examine masses found in the mediastinum

http://www.sentara.com/Sentara/Services/Thoracic/Patients/patient_info_procedures.htm

New use for bronchoscope? See this page for a clinical trial

http://www.easetrial.com/airway_bypass.html