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flexible bronchoscopyPulmonology Examination of the airways using a flexible bronchoscope, often performed at the bedside of critically ill Pts who may be too unstable to move to the OR or bronchoscopy suite; FB is used to visualize distal airways; generally, conscious sedation is sufficient for the procedure. Cf Rigid bronchoscopy.
Area of applicationBronchial tree, larynx, trachea.
The rigid bronchoscope allows visualization of the larger airways, including the lobar, segmental, and subsegmental bronchi, while maintaining effective gas exchange. Rigid bronchoscopy is preferred when large volumes of blood or secretions need to be aspirated, foreign bodies are to be removed, large-sized biopsy specimens are to be obtained, and for most bronchoscopies in children.The flexible fiber-optic bronchoscope has a smaller lumen that is designed to allow for visualization of all segments of the bronchial tree.The accessory lumen of the bronchoscope is used for tissue biopsy, bronchial washings, instillation of anesthetic agents and medications, and to obtain specimens with brushes for cytological examination. In general, fiber-optic bronchoscopy is less traumatic to the surrounding tissues than the larger rigid bronchoscopes. Fiber-optic bronchoscopy is performed under local anesthesia; patient tolerance is better for fiber-optic bronchoscopy than for rigid bronchoscopy.
This procedure is contraindicated for
- Patients with bleeding disorders, especially those associated with uremia and cytotoxic chemotherapy.
- Patients with pulmonary hypertension.
- Patients with cardiac conditions or dysrhythmias.
- Patients with disorders that limit extension of the neck.
- Patients with severe obstructive tracheal conditions.
- o2) Patients with or having the potential for respiratory failure; (introduction of the bronchoscope alone may cause a 10 to 20 mm Hg drop in Pa
- Detect end-stage bronchogenic cancer
- Detect lung infections and inflammation
- Determine etiology of persistent cough, hemoptysis, hoarseness, unexplained chest x-ray abnormalities, and/or abnormal cytological findings in sputum
- Determine extent of smoke-inhalation or other traumatic injury
- Evaluate airway patency; aspirate deep or retained secretions
- Evaluate endotracheal tube placement or possible adverse sequelae to tube placement
- Evaluate possible airway obstruction in patients with known or suspected sleep apnea
- Evaluate respiratory distress and tachypnea in an infant to rule out tracheoesophageal fistula or other congenital anomaly
- Identify bleeding sites and remove clots within the tracheobronchial tree
- Identify hemorrhagic and inflammatory changes in Kaposi’s sarcoma
- Intubate patients with cervical spine injuries or massive upper airway edema
- Remove foreign body
- Treat lung cancer through instillation of chemotherapeutic agents, implantation of radioisotopes, or laser palliative therapy
- Normal larynx, trachea, bronchi, bronchioles, and alveoli
Abnormal findings related to
- Bronchial diverticulum
- Bronchial stenosis
- Bronchogenic cancer
- Coccidioidomycosis, histoplasmosis, blastomycosis, phycomycosis
- Foreign bodies
- Interstitial pulmonary disease
- Opportunistic lung infections (e.g., pneumocystitis, nocardia, cytomegalovirus)
Factors that may impair the results of the examination
- Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
- Metallic objects within the examination field (e.g., jewelry, earrings, and/or dental amalgams), which may inhibit organ visualization and can produce unclear images.
- Hypoxemic or hypercapnic states require continuous oxygen administration.
- Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.
Nursing Implications and Procedure
- Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
- Patient Teaching: Inform the patient this procedure can assess the lungs and respiratory system.
- Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, sedatives, or anesthetics.
- Obtain a history of the patient’s immune and respiratory systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
- Note any recent procedures that can interfere with test results. Ensure that this procedure is performed before an upper gastrointestinal study or barium swallow.
- Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
- Obtain a list of the patient’s current medications including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure. Note the last time and dose of medication taken.
- Review the procedure with the patient. Instruct that prophylactic antibiotics may be administered prior to the procedure. Address concerns about pain related to the procedure and explain that some pain may be experienced during the test, and there may be moments of discomfort. Explain that a sedative and/or analgesia may be administered to promote relaxation and reduce discomfort prior to the bronchoscopy. Atropine is usually given before bronchoscopy examinations to reduce bronchial secretions and prevent vagally induced bradycardia. Meperidine (Demerol) or morphine may be given as a sedative. Lidocaine is sprayed in the patient’s throat to reduce discomfort caused by the presence of the tube. Inform the patient that the procedure is performed in a gastrointestinal laboratory or radiology department, under sterile conditions, by a health-care provider (HCP) specializing in this procedure. The procedure usually takes about 30 to 60 min to complete.
- Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
- Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, antibiotics, anesthetics, analgesics, sedatives, or emergency medications.
- Instruct the patient that to reduce the risk of nausea and vomiting, solid food and milk or milk products have been restricted for at least 8 hr, and clear liquids have been restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.
- Instruct the patient to avoid taking anticoagulant medication or to reduce dosage as ordered prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Protocols may vary among facilities.
- Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
- Potential complications:
Complications from the procedure are rare but may include infection (related to the use of an endoscope), hypoxemia, pneumothorax, or bleeding, (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners).
Establishing an IV site is an invasive procedure. Complications are rare but do include risk for bleeding from the puncture site (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners), hematoma (related to blood leakage into the tissue following needle insertion), infection (that might occur if bacteria from the skin surface is introduced at the puncture site), or nerve injury (that might occur if the needle strikes a nerve).
- Ensure that the patient has complied with food, fluid, and medication restrictions for 8 hr prior to the procedure.
- Ensure that the patient has removed dentures, jewelry, and external metallic objects in the area to be examined prior to the procedure.
- Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
- Have emergency equipment readily available.
- Instruct the patient to void prior to the procedure and change into the gown, robe, and foot coverings provided.
- Avoid using morphine sulfate in those with asthma or other pulmonary disease. This drug can further exacerbate bronchospasms and respiratory impairment.
- Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date and time of collection, and site location, especially right or left lung.
- Assist the patient to a comfortable position, and direct the patient to breathe normally during the beginning of the general anesthesia. Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement during the local anesthetic and the procedure.
- Record baseline vital signs and continue to monitor throughout the procedure. Protocols may vary among facilities.
- Establish an IV fluid line for the injection of saline, antibiotics, anesthetics, analgesics, sedatives, or emergency medications.
- The patient is placed in the supine position and a general anesthetic is administered. The patient’s neck is hyperextended, and the lightly lubricated bronchoscope is inserted orally and passed through the glottis. The patient’s head is turned or repositioned to aid visualization of various segments.
- After inspection, the bronchial brush, suction catheter, biopsy forceps, laser, and electrocautery devices are introduced to obtain specimens for cytological or microbiological study or for therapeutic procedures.
- If a bronchial washing is performed, small amounts of solution are instilled into the airways and removed.
- After the procedure, the bronchoscope is removed and the patient is placed in a side-lying position with the head slightly elevated to promote recovery.
- Provide mouth care to reduce oral bacterial flora.
- The patient is placed in a sitting position while the tongue and oropharynx are sprayed or swabbed with local anesthetic. Provide an emesis basin for the increased saliva and encourage the patient to spit out the saliva because the gag reflex may be impaired. When loss of sensation is adequate, the patient is placed in a supine or side-lying position. The fiberoptic scope can be introduced through the nose, the mouth, an endotracheal tube, a tracheostomy tube, or a rigid bronchoscope. Most common insertion is through the nose. Patients with copious secretions or massive hemoptysis, or in whom airway complications are more likely, may be intubated before the bronchoscopy. Additional local anesthetic is applied through the scope as it approaches the vocal cords and the carina, eliminating reflexes in these sensitive areas. The fiberoptic approach allows visualization of airway segments without having to move the patient’s head through various positions.
- After visual inspection of the lungs, tissue samples are collected from suspicious sites by bronchial brush or biopsy forceps to be used for cytological and microbiological studies.
- After the procedure, the bronchoscope is removed. Patients who had local anesthesia are placed in a semi-Fowler’s position to recover.
- Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis).
- Place tissue samples in properly labeled specimen containers containing formalin solution, and promptly transport the specimen to the laboratory for processing and analysis.
- Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
- Instruct the patient to resume preoperative diet, as directed by the HCP. Assess the patient’s ability to swallow before allowing the patient to attempt liquids or solid foods.
- Inform the patient that he or she may experience some throat soreness and hoarseness. Instruct patient to treat throat discomfort with lozenges and warm gargles when the gag reflex returns.
- Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature changes. Protocols may vary among facilities.
- Emergency resuscitation equipment should be readily available if the vocal cords become spastic after intubation.
- Observe for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
- Observe the patient for hemoptysis, difficulty breathing, cough, air hunger, excessive coughing, pain, or absent breathing sounds over the affected area. Immediately report symptoms to the appropriate HCP.
- Evaluate the patient for symptoms indicating the development of pneumothorax, such as dyspnea, tachypnea, anxiety, decreased breathing sounds, or restlessness. A chest x-ray may be ordered to check for the presence of this complication.
- Evaluate the patient for symptoms of empyema, such as fever, tachycardia, malaise, or elevated white blood cell count.
- Observe the patient’s sputum for blood if a biopsy was taken, because large amounts of blood may indicate the development of a problem; a small amount of streaking is expected. Evaluate the patient for signs of bleeding such as tachycardia, hypotension, or restlessness.
- Assess for nausea and pain. Administer antiemetic and analgesic medications as needed and as directed by the HCP.
- Administer antibiotic therapy if ordered. Remind the patient of the importance of completing the entire course of antibiotic therapy even if signs and symptoms disappear before completion of therapy.
- Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services.
- Instruct the patient to use lozenges or gargle for throat discomfort. Inform the patient of smoking cessation programs as appropriate. Malnutrition is commonly seen in patients with severe respiratory disease for numerous reasons, including fatigue, lack of appetite, and gastrointestinal distress. Adequate intake of vitamins A and C is also important to prevent pulmonary infection and to decrease the extent of lung tissue damage. The importance of following the prescribed diet should be stressed to the patient/caregiver. Educate the patient regarding access to counseling services, as appropriate.
- Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
- Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.
- Related tests include arterial/alveolar oxygen ratio, antibodies, anti-glomerular basement membrane, biopsy lung, blood gases, chest x-ray, complete blood count, CT thorax, culture and smear mycobacteria, culture sputum, culture viral, cytology sputum, Gram stain, lung perfusion scan, lung ventilation scan, MRI chest, mediastinoscopy, and pulse oximetry.
- Refer to the Immune and Respiratory systems tables at the end of the book for related tests by body system.