Special Procedures Bronchoscopy

Special Procedures

• Bronchoscopy

• Dr. Abdul-Monim Batiha

Definition and Terminology

• Endoscopy

• Use of instrument to look into various parts of the body to diagnose various diseases or explain certain conditions

• Bronchoscopy

• Procedure that allows visualization of the airways below the larynx

Equipment

• A bronchoscope is an instrument about 3ft long and 0.5 ins or smaller in diameter that combines four narrow chambers into one tube

• One lumen contains a fiber-optic light source so that structures can be viewed effectively
• 2nd chamber lumen is attached to a suction device & airway secretions can be removed
• 3rd chamber has tiny metallic alligator forceps that can be extended past the proximal end for tissue biopsies
• 4th chamber lumen allows passage of a small wire brush that can be passed vigorously over airway structures for collection of tissue cells for microscopic evaluation

Equipment

• Flexible or Rigid

• Adult sizes

• 5.0 mm OD to 6.0 mm OD

• Pediatric sizes

• Most manufacturers provide scopes in sizes 3.5 mm OD or less appropriate for children. No channel outlet may exist for suctioning because of its small size

Indications

• Diagnostic

• Suspected foreign body
• Suspected malignancy
• Bronchial washings
• Hemoptysis
• Persistent problems

Procedure

• Topical anesthetic (lidocaine) is administered to control gag/cough reflex and prevent bronchospasm

• 5 – 10 cc 4% lidocaine aerosolized to upper airway delivered by a mask nebulizer
• Benzocaine nasal sprays
• 2% lidocaine instilled into the hypopharynx in 2 cc incements

• Intubation preferred but not required. Intubation will not allow visualization of the vocal cords

• Scope is inserted and the airways viewed

• O2 needs to be provided to patient via mask or by removing one prong of the nasal cannula from the nose to allow for insertion of the scope

Procedure

• Diagnostic and/or therapeutic procedures are performed

• Intubated patients on vents need special adapters for advancement of the scope. Adapter should allow for:

• No loss of ventilating pressures
• No loss of PEEP

• Continuous monitoring of EKG and O2 saturation by pulse oximeter is recommended

• Equipment is cleaned by decontamination with alkaline glutaraldehyde

Adapter for intubated patients

Rigid bronchoscopy

• Diagnostic use

• Biopsy of tumors within the main airway

• Therapeutic use

• Treatment of massive hemoptysis by cold-saline lavage or placement of Fogarty catheter to occlude the airway
• Removal of foreign bodies in infants and small children
• Aspiration of inspissated secretions

• Limitations

• observing or treating beyond the right or left mainstem bronchus
• Dz or trauma of cervical spine who cannot hyperextend neck
• Dz or trauma of jaw who cannot open their mouth wide

RCP responsibilities

• Inform patient of procedure and obtain consent form. Prepare patient and explain procedure

• Nebulize a topical/local anesthetic

• Check fiberoptic unit for proper functioning

• Set up and monitor patient’s ECG and SpO2

• Administer O2 and monitor vital signs

• Collect suctioned or other specimens for C&S

• Perform biopsies and brushings for cytology

• Operate any photographic equipment

• Tend to patient comfort

• Disinfect the equipment between patients

Hazards and complications

• Most common complication is mild epistaxis

• Bronchospasm or laryngospasm

• From irritation of the airway

• Bleeding

• Hypoxemia

• Arrhythmias

• From vagal stimulation. Monitor ECG and remove scope until cardiac status is stabilized

• Seizures

• Aspiration

• Pneumothorax

• Respiratory depression

Contraindications

• Refractive hypoxemia

• Bleeding disorders

• Cardiovascular instability

• Status asthmaticus

• Marked hypercpanea