A bronchoscopy is a procedure that permits visualization of the trachea, bronchi, and select bronchioles. This procedure is performed to diagnose tumors, coin lesions, or granulomatous lesions; to find hemorrhage sites; to evaluate trauma or nerve paralysis; to obtain biopsy specimens; to take brushings for cytologic examinations; to improve drainage of secretions; to identify inflammatory infiltrates; to lavage; and to remove foreign bodies. Bronchoscopy can determine resectability of a lesion as well as provide the means to diagnose bronchogenic carcinoma. There are two types of bronchoscopy: flexible (Figure 12.1), which is almost always used for diagnostic purposes, and rigid, which is less frequently used. A transbronchial needle biopsy may be performed during a bronchoscopy, thus obviating the need for diagnostic open-lung biopsy. A flexible needle is passed through the trachea or bronchus and is used to aspirate cells from the lung. This procedure is performed on patients with suspected sarcoidosis or pulmonary infection.
Diagnostic:
Staging of bronchogenic carcinoma
Differential diagnosis in recurrent unresolved pneumonia
Evaluation of cavitary lesions, mediastinal masses, and interstitial lung disease
Localization of bleeding and occult sites of cancer
Evaluate immunocompromised patients (e.g., HIV-positive patients, bone marrow or lung transplant recipients)
Differentiate rejection from infection in lung transplantation
Assess airway damage in thoracic trauma
Evaluate underlying etiology of nonspecific symptoms of pulmonary disease such as chronic cough (>6 months), hemoptysis, or unilateral wheezing
Therapeutic:
Removal of mucus plugs and polyps
Removal of an aspirated foreign body and to relieve endobronchial obstruction
Brachytherapy (radioactive treatment of malignant endobronchial tumors)
Placement of a stent to maintain airway patency
Drainage of lung abscess
Decompression of bronchogenic cysts
Laser photoresection of endotracheal lesions
Bronchoalveolar lavage (BAL) to remove intra-alveolar proteinaceous material
Alternative to difficult endotracheal intubations
Control bleeding and airway hemorrhage in the presence of massive hemoptysis
The examination is usually done under local anesthesia combined with some form of sedation in an outpatient setting, diagnostic center, or operating room. It also can be done in a critical care unit, in which case the patient may be unresponsive or ventilator-dependent.
The following data must be available before the procedure: history and physical examination, recent chest x-ray film, recent arterial blood gas values, and if the patient is older than 40 years or has heart disease, an ECG. Appropriate blood work (coagulation), urinalysis, pulmonary function tests, and sputum studies (especially for acid-fast bacilli) must be done as well. Bronchoscopy is often done as an ambulatory surgical procedure.
Spray and swab topical anesthetic (e.g., 4% lidocaine) onto the back of the nose, the tongue, the pharynx, and the epiglottis. Give an antisialagogue (e.g., atropine) to reduce secretions. If the patient has a history of bronchospasms, administer a bronchodilator (e.g., albuterol) through a handheld nebulizer. Morphine sulfate is contraindicated in patients who have problems with bronchospasm or asthma because it can cause bronchospasm. Analgesic agents, barbiturates, tranquilizer-sedatives, and atropine may be ordered and administered 30 minutes to 1 hour before bronchoscopy. The patient should be as relaxed as possible before and during the procedure but also needs to know that anxiety is normal.
Insert the flexible or rigid bronchoscope carefully through the mouth or nose into the pharynx and the trachea (Figure 12.2). The scope also can be inserted through an endotracheal tube or tracheostomy. Suctioning, oxygen delivery, and biopsies are accomplished through bronchoscope ports designed for these purposes.
Be advised that because of sedation, usually with diazepam or midazolam, the patient is usually comfortable when a state of conscious sedation is achieved. However, when the bronchoscope is advanced, some patients may feel as if they cannot breathe or are suffocating.
Arterial blood gas measurement during and after bronchoscopy may be ordered, and arterial blood oxygen may remain altered for several hours after the procedure (see Chapter 14). Sputum specimens taken during and after bronchoscopy may be sent for cytologic examination or culture and sensitivity testing. These specimens must be handled and preserved according to institutional protocols.
Continuous monitoring of cardiac rhythm, blood pressure, pulse oximetry, and respirations is routinely performed during and after the procedure. Monitoring of pulse oximetry is especially important to indicate levels of oxygen saturation before, during, and after the procedure.
The right lung is usually examined before the left lung.
Bronchoscopic procedures include any one or a combination of the following:
Bronchial washings for cytology and staining for fungi and mycobacteria
BAL for infectious diseases (e.g., alveolar proteinosis, eosinophilic granuloma)
Bronchial brushings of both visible and peripheral (under fluoroscopy) endobronchial lesions or transbronchial biopsies, both visible and peripheral
Follow guidelines in Chapter 1 for safe, effective, informed intratest care.
Procedural Alert
Bronchoscopy instruments can decrease an already small airway lumen even more by causing inflammation and edema. Resuscitation, oxygen administration equipment, and drugs must be readily accessible when this procedure is performed. Close monitoring of respiratory and cardiac status is imperative during and after the procedure. The same precautions and treatment apply to children and adults
Abnormalities revealed through bronchoscopy may identify the following conditions:
Abscesses
Bronchitis
Carcinoma of the bronchial tree (occurs in the right lung more often than the left)
Tumors (usually appear more often in larger bronchi)
Tuberculosis
Alveolitis
Evidence of surgical nonresectability (e.g., involvement of tracheal wall by tumor growth, immobility of a main stem bronchus, widening and fixation of the carina)
P. carinii infection
Inflammatory processes
Cytomegalovirus infection
Aspergillosis
Idiopathic nonspecific pulmonary fibrosis
Cryptococcus neoformans infection
Coccidioidomycosis
Histoplasmosis (disease caused by the fungus H. capsulatum)
Blastomycosis (fungal infection caused by inhalation of Blastomyces dermatitidis)
Phycomycosis (group of fungal diseases caused by Phycomycetes)
Pretest Patient Care
Reinforce information related to the purpose, procedure, benefits, and risks of the test. Record signs and symptoms (e.g., dyspnea, bloody sputum, coughing, hoarseness).
Emphasize that pain is not usually experienced because lungs do not have pain fibers, but they may experience some discomfort.
Explain that the local anesthetic may taste bitter, but numbness will occur in a few minutes. Feelings of a thickened tongue and the sensation of something in the back of the throat that cannot be coughed out or swallowed are not unusual. These sensations will pass within a few hours following the procedure as the anesthetic wears off.
Ensure that an informed consent form must be properly signed and witnessed and in the patient’s medical record (see Chapter 1).
Confirm that the patient has fasted for at least 6 hours before the procedure to reduce the risk for aspiration. Gag, cough, and swallowing reflexes will be blocked during and for a few hours after surgery.
Ensure that the patient removes wigs, nail polish, makeup, dentures, jewelry, and contact lenses before the examination.
Use techniques to help the patient relax and breathe more normally during the procedure. The more relaxed the patient is, the easier it is to complete the procedure.
Follow guidelines in Chapter 1 for safe, effective, informed pretest care.
Clinical Alert
Contraindications to bronchoscopy include the following conditions:
Severe hypoxemia
Severe hypercapnia (carbon dioxide retention)
Certain cardiac arrhythmias, cardiac states
History of being hepatitis B carrier
Bleeding or coagulation disorders
Severe tracheal stenosis
Posttest Patient Care
Ensure that swallowing, gagging, and coughing reflexes are present before allowing food or liquids to be ingested orally.
Provide gargles to relieve mild pharyngitis. Monitor cardiac rhythm, blood pressure, temperature, pulse, pulse oximeter readings, skin and nail bed color, lung sounds, and respiratory rate and patterns according to institution protocols. Document observations.
Check medical orders, which may include:
Oxygen by mask or nasal cannula: Humidified oxygen at specific concentrations up to 100% by mask may be necessary.
A chest x-ray film: This will check for pneumothorax or to evaluate the lungs.
Sputum specimen: These must be preserved in the proper medium or solution.
Elevate the head of the bed for comfort.
Review test results; report and record findings. Modify the nursing care plan as needed. Monitor patient appropriately and explain need for other tests or treatment. Follow-up procedures may be necessary. CT-guided fine-needle cytology aspiration may be done when bronchoscopy is not diagnostic.
Do not allow the patient to drive or sign legal documents for 24 hours because of the effects of anesthetics and sedation.
Refer to IV sedation precautions in Chapter 1.
Follow guidelines in Chapter 1 for safe, effective, informed posttest care.
Clinical Alert
Observe for possible complications of traditional bronchoscopy, which may include the following conditions:
Shock
Bleeding following biopsy (rare, but can occur if there is excessive friability of airways or massive lesions, or if patient is uremic or has a hematologic disorder)
Hypoxemia
Partial or complete laryngospasm (inspiratory stridor) that produces a “crowing” sound; may be necessary to intubate
Bronchospasm (pallor and increasing dyspnea are signs)
Infection or Gram-negative bacterial sepsis
Pneumothorax
Respiratory failure
Cardiac arrhythmias
Anaphylactic reactions to drugs
Seizures
Febrile state
Hypoxia, respiratory distress
Empyema (accumulation of pus in the lung pleura)
Aspiration
Virtual noninvasive bronchoscopy using spiral CT technology requires no sedation or analgesic agents. Indications include pulmonary embolism and staging of lung cancer.