open lung biopsy
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open lung biopsyPulmonology A procedure in which the chest cavity is opened to allow visually directed biopsy of lung tissue Indications Diagnose bronchiolitis, chronic interstitial lung disease, lung CA, eosinophilic granuloma, honeycomb lung, lymphoma, pulmonary HTN, sarcoidosis Pros Greater diagnostic yield than transbronchial Bx Cons ↑ complications Complications Pneumothorax, hemorrhage, air embolism. Cf Cf Bronchoalveolar lavage, Transbronchial biopsy.
SpecimenLung tissue or cells.
This procedure is contraindicated for
- Patients with bleeding disorders (related to the potential for prolonged bleeding from the biopsy site)
- Assist in the diagnosis of lung cancer
- Assist in the diagnosis of fibrosis and degenerative or inflammatory diseases of the lung
- Assist in the diagnosis of sarcoidosis
Abnormal findings related to
- Infections caused by Blastomyces, Histoplasma, Legionella spp., and Pneumocystis jiroveci (formerly P. carinii)
- Systemic lupus erythematosus
- Any postprocedural decrease in breath sounds noted at the biopsy site should be reported immediately.
- Assessment of clear margins after tissue excision
- Classification or grading of tumor
- Identification of malignancy
- Shortness of breath, cyanosis, or rapid pulse during the procedure must be reported immediately
It is essential that critical findings be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.
Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. The notification processes will vary among facilities. Upon receipt of the critical finding the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical finding, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.
- Conditions such as vascular anomalies of the lung, bleeding abnormalities, or pulmonary hypertension may increase the risk of bleeding.
- Conditions such as bullae or cysts and respiratory insufficiency increase the risk of pneumothorax.
- 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 assist in establishing a diagnosis of lung disease.
- Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex or anesthetics.
- Obtain a history of the patient’s immune and respiratory systems, any bleeding disorders or other symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
- Note any recent procedures that can interfere with test results.
- 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.
- Review the procedure with the patient. Inform the patient that it may be necessary to remove hair from the site before the procedure. Instruct the patient that prophylactic antibiotics may be administered before the procedure. Address concerns about pain and explain that a sedative and/or analgesia will be administered before the percutaneous biopsy to promote relaxation and reduce discomfort; general anesthesia will be administered before the open biopsy. Explain to the patient that no pain will be experienced during the test when general anesthesia is used but that any discomfort with a needle biopsy will be minimized with local anesthetics and systemic analgesics. 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 biopsy is performed under sterile conditions by an HCP specializing in this procedure. The surgical procedure usually takes about 30 min to complete, and sutures may be necessary to close the site. A needle biopsy usually takes about 15 to 30 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 will be inserted to allow infusion of IV fluids, antibiotics, anesthetics, and analgesics.
- 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.
- Have the patient void before the procedure.
- Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
- Potential complications:
Bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners), pneumothorax (increased risk for pneumothorax is related to the presence of bullae or cysts and respiratory insufficiency), hemoptysis, air embolism, or seeding of the biopsy tract with tumor cells
- Ensure that the patient has complied with dietary restrictions.
- Ensure that anticoagulant therapy has been withheld for the appropriate number of days prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Notify the HCP if patient anticoagulant therapy has not been withheld. Ensure that patients on beta-blocker therapy have continued their medication regimen as ordered.
- Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
- Have emergency equipment readily available. Keep resuscitation equipment on hand in the case of respiratory impairment or laryngospasm after the procedure.
- 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 containers 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.
- Have patient remove dentures and notify the HCP if the patient has permanent crowns on teeth. Have the patient remove clothing and change into a gown for the procedure.
- Assist the patient to a comfortable position and direct the patient to breathe normally during the beginning of the general anesthetic. Instruct the patient to cooperate fully and to follow directions. For the patient undergoing local anesthesia, direct him or her to breathe normally and to avoid unnecessary movement during the procedure.
- Record baseline vital signs and continue to monitor throughout the procedure. Protocols may vary among facilities.
- After the administration of general or local anesthesia, use clippers to remove hair from the surgical site if appropriate, cleanse the site with an antiseptic solution, and drape the area with sterile towels.
- Adhere to Surgical Care Improvement Project (SCIP) quality measures. Administer ordered prophylactic antibiotics 1 hr before incision, and use antibiotics that are consistent with current guidelines specific to the procedure.
- The patient is prepared for thoracotomy under general anesthesia in the operating room. Tissue specimens are collected from suspicious sites. Place specimen from needle aspiration or brushing on clean glass microscope slides. Place tissue or aspirate specimens in appropriate sterile container for culture or appropriate fixative container for histological studies.
- Carefully observe/assess the patient for any signs of respiratory distress during the procedure.
- A chest tube is inserted after the procedure.
- Instruct the patient to take slow, deep breaths when the local anesthetic is injected. Protect the site with sterile drapes. Assist patient to a sitting position with arms on a pillow over a bed table. Instruct patient to avoid coughing during the procedure. The needle is inserted through the posterior chest wall and into the intercostal space. The needle is rotated to obtain the sample and then withdrawn. Pressure is applied to the site with a petroleum jelly gauze, and a pressure dressing is applied over the petroleum jelly gauze.
- Provide mouth care to reduce oral bacterial flora.
- After administration of general anesthesia, position the patient in a supine position with the neck hyperextended. If local anesthesia is used, the patient is seated while the tongue and oropharynx are sprayed and swabbed with 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 is elevated. Discontinue prophylactic antibiotics within 24 hr after the conclusion of the procedure. Protocols may vary among facilities.
- Emergency resuscitation equipment should be readily available if the vocal cords become spastic after intubation.
- Observe/assess for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
- Observe/assess the biopsy site for bleeding, inflammation, or hematoma formation.
- Instruct the patient in the care and assessment of the biopsy site.
- Instruct the patient to report any redness, edema, bleeding, or pain at the biopsy site.
- Observe/assess the patient for hemoptysis, difficulty breathing, cough, air hunger, excessive coughing, pain, or absent breath sounds over the affected area. Monitor chest tube patency and drainage after a thoracotomy.
- 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/assess 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.
- Instruct the patient to remain in a semi-Fowler’s position after bronchoscopy or fine-needle aspiration to maximize ventilation. Semi-Fowler’s position is a semisitting position with the knees flexed and supported by pillows on the bed or examination table. Instruct the patient to stay in bed lying on the affected side for at least 2 hr with a pillow or rolled towel under the site to prevent bleeding. The patient will also need to remain on bedrest for 24 hr.
- 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.
- Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. 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 are 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. Answer any questions or address any concerns voiced by the patient or family.
- Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage him or her to review corresponding literature provided by a pharmacist.
- Depending on the results of this procedure, additional testing may be performed 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 antiglomerular basement membrane, blood gases, bronchoscopy, chest x-ray, CBC, CT thoracic, culture sputum, cytology sputum, gallium scan, gram/acid fast stain, lung perfusion scan, lung ventilation scan, MRI chest, mediastinoscopy, pleural fluid analysis, PFT, and TB skin tests.
- Refer to the Immune and Respiratory systems tables at the end of the book for related tests by body system.