SUBMITTED TO – Resp. Mr.

Somorjit Singh

SUBMITTED BY - Rapinder Kaur

M.SC- 2nd yr. (Medical Surgical )

Bronchoscopy
Inroduction

Bronchoscopy is a technique of visualizing the inside of the airways for diagnostic and
therapeutic purposes. An instrument (bronchoscope) is inserted into the airways,
usually through the nose or mouth, or occasionally through a tracheostomy. This allows
the practitioner to examine the patient's airways for abnormalities such as foreign
bodies, bleeding, tumors, or inflammation. Specimens may be taken from inside the
lungs. The construction of bronchoscopes ranges from rigid metal tubes with attached
lighting devices to flexible optical fiber instruments with realtime video equipment.

Definition-

Bronchoscopy is a diagnostic procedure for examining bronchia, the main airways of

respiratory system with the help of a bronchoscope. It is used for visually examining
abnormalities in the airways such as inflammation, tumors, bleeding and for taking
tissue samples or mucus. Bronchoscopy is also used to remove any objects that block
the passage of the airways.

A bronchoscope is a thin tubular instrument that can be flexible or rigid (metallic) fixed
with a video camera and biopsy equipments on one end. Flexible bronchoscope is more
common than rigid type as there is no need to give anesthesia. It is mostly used for
removing small samples of tissues. Rigid type is carried out with general anesthesia. It is
useful for removing large samples of tissues for biopsy and also for clearing any foreign
objects, for example, presence of food in the airways.

Bronchoscopy is done for various reasons like difficulty in breathing, chronic cough,
coughing up blood and abnormal chest X-ray. It is one of the most effective tests for
diagnosing lung diseases such as pneumonia, tuberculosis, bronchitis and lung cancer.
Usually, a bronchoscope is inserted either in the nose or mouth. However, insertion can
be done by means of tracheotomy; a surgical procedure in which an incision is made in
the trachea on the neck to open an artificial airway.

Rigid bronchoscopy is now used only when a wider aperture and channels are
required for better visualization and instrumentation such as when

 Investigating vigorous pulmonary hemorrhage (in which the rigid bronchoscope

can better identify the bleeding source and, with its larger suction channel, can better
suction the blood and prevent asphyxiation)
 Viewing and removing aspirated foreign bodies in young children
 Viewing obstructive endobronchial lesions (requiring laser debulking or stent
placement)
Flexible bronchoscopes are nearly all color video–compatible, facilitating airway
visualization and documentation of findings.

Diagnostically, flexible fiberoptic bronchoscopy allows for

 Direct airway visualization down to, and including, subsegmental bronchi

 Sampling of respiratory secretions and cells via bronchial washings, brushings,
and lavage of peripheral airways and alveoli
 Biopsy of endobronchial, parenchymal, and mediastinal structures

Purposes

Diagnostic

 To view abnormalities of the airway

 To obtain tissue specimens of the lung in a variety of disorders. Specimens may be
taken from inside the lungs by biopsy, bronchoalveolar lavage, or endobronchial
brushing.
 To evaluate a person who has bleeding in the lungs, possible lung cancer, a
chronic cough, sarcoidosis

Therapeutic

 To remove secretions, blood, or foreign objects lodged in the airway

 Laser resection of tumors or benign tracheal and bronchial strictures
 Stent insertion to palliate extrinsic compression of the tracheobronchial lumen
from either malignant or benign disease processes
 Bronchoscopy is also employed in percutaneous tracheostomy
 Surgical procedures on the airways, such as tracheal reconstruction, often require
the use of bronchoscopy
 Intubation of patients with difficult airways is often performed using a flexible
bronchoscope

Contraindications: Absolute contraindications include

 Untreatable life-threatening arrhythmias
 Inability to adequately oxygenate the patient during the procedure
 Acute respiratory failure with hypercapnia (unless the patient is intubated and
ventilated)
Relative contraindications include

 Uncooperative patient
 Recent MI
 High-grade tracheal obstruction
 Uncorrectable coagulopathy
Transbronchial biopsy should be done with caution in patients with uremia, superior
vena cava obstruction, or pulmonary hypertension because of increased risk of
bleeding. Inspection of the airways is safe in these patients.

Preparation

The patient should fast for six to 12 hours prior to the procedure and refrain from
drinking any liquids the day of the procedure. Smoking should be avoided for 24 hours
prior to the procedure and patients should also avoid taking any aspirin or ibuprofen-
type medications. The bronchoscopy itself takes about 45–60 minutes. Prior to the
bronchoscopy, several tests are usually done, including a chest x ray and blood work.
Sometimes a bronchoscopy is done under general anesthesia, in which case the patient
will have an intravenous (IV) line in the arm. More commonly, the procedure is
performed under local anesthesia, which is sprayed into the nose or mouth. This is
necessary to inhibit the gag reflex. A sedative also may be given. A signed consent form
is necessary for this procedure.

Procedure:

 Bronchoscopy should be done only by a pulmonologist or trained surgeon in a

monitored setting, typically a bronchoscopy suite, operating room, or ICU (for
ventilated patients).

Patients should receive nothing by mouth for at least 4 h before bronchoscopy and have
IV access, intermittent BP monitoring, continuous pulse oximetry, and cardiac
monitoring. Supplemental O2 should be available. Premedication with atropine SOME
TRADE NAMES
ATROPEN
ATROPINE-CARE
SAL-TROPINE
0.01 mg/kg IM or IV to decrease secretions and vagal tone is common, although this
practice has been called into question by recent studies. Short-acting benzodiazepines,
opioids, or both are generally given to patients before the procedure to decrease
anxiety, discomfort, and cough.

The pharynx and vocal cords are anesthetized with nebulized or aerosolized lidocaine
SOME TRADE NAMES
XYLOCAINE
(1 or 2%, to a maximum of 250 to 300 mg for a 70-kg patient). The bronchoscope is
lubricated with lidocaine SOME TRADE NAMES
XYLOCAINE
jelly and passed through the nostril or through the mouth with use of an oral airway or
bite block. After inspecting the nasopharynx and larynx, the clinician passes the
bronchoscope through the vocal cords during inspiration, into the trachea and then
further distally into the bronchi.

Several ancillary procedures can be done as needed, with or without fluoroscopic

guidance:

 Bronchial washing: Saline is injected through the bronchoscope and

subsequently aspirated from the airways.
 Bronchial brushing: A brush is advanced through the bronchoscope and used to
abrade suspicious lesions to obtain cells.
 Bronchoalveolar lavage: 50 to 200 mL of sterile saline is infused into the distal
bronchoalveolar tree and subsequently suctioned out, retrieving cells, protein, and
microorganisms located at the alveolar level. Local areas of pulmonary edema
created by lavage may cause transient hypoxemia.
 Transbronchial biopsy: Forceps are advanced through the bronchoscope and
airway to obtain samples from one or more sites in the lung parenchyma.
Transbronchial biopsy can be done without x-ray guidance, but evidence supports
increased diagnostic yields and lower incidence of pneumothorax when fluoroscopic
guidance is used.
 Transbronchial needle aspiration: A retractable needle is inserted through the
bronchoscope and can be used to sample enlarged mediastinal lymph nodes or
masses.
Patients are typically given supplemental O2 and observed for 2 to 4 h after the
procedure. Return of a gag reflex and maintenance of O2 saturation when not receiving
O2 are the two primary indices of recovery. Standard practice is to obtain a
posteroanterior chest x-ray after transbronchial lung biopsy to exclude pneumothorax.
Complications: Serious complications are uncommon; minor bleeding from a biopsy
site and fever occur in 10 to 15% of patients. Premedication can cause oversedation
with respiratory depression, hypotension, and cardiac arrhythmias. Rarely, topical
anesthesia causes laryngospasm, bronchospasm, seizures, methemoglobinemia with
refractory cyanosis, or cardiac arrhythmias or arrest.

Bronchoscopy itself may cause minor laryngeal edema or injury with hoarseness,
hypoxemia in patients with compromised gas exchange, arrhythmias (most commonly
premature atrial contractions, ventricular premature beats, or bradycardia), and, very
rarely, transmission of infection from suboptimally sterilized equipment. Mortality is 1
to 4/10,000 patients. The elderly and patients with serious comorbidities (severe COPD,
coronary artery disease, pneumonia with hypoxemia, advanced cancers, mental
dysfunction) are at greatest risk.

Transbronchial biopsy can cause pneumothorax (2 to 5%) and significant hemorrhage

(1 to 1.5%); mortality increases to 12/10,000 patients but doing the procedure can
avoid the need for thoracotomy.

Aftercare

After the bronchoscopy, the vital signs (heart rate, blood pressure, and breathing) are
monitored. Sometimes patients have an abnormal reaction to anesthesia. Any sputum
should be collected in an emesis basin so that it can be examined for the presence of
blood. If a biopsy was taken, the patient should not cough or clear the throat as this
might dislodge any blood clot that has formed and cause bleeding. No food or drink
should be consumed for about two hours after the procedure or until the anesthesia
wears off. There is a significant risk for choking if anything (including water) is ingested
before the anesthetic wears off, and the gag reflex has returned. To test if the gag reflex
has returned, a spoon is placed on the back of the tongue for a few seconds with light
pressure. If there is no gagging, the process is repeated after 15 minutes. The gag reflex
should return in one to two hours. Ice chips or clear liquids should be taken before the
patient attempts to eat solid food.

Patients are informed that after the anesthetic wears off the throat may be irritated for
several days.

Patients should notify their health care provider if they develop any of these symptoms:

 hemoptysis (coughing up blood)

  shortness of breath, wheezing, or any trouble breathing

 chest pain

 fever, with or without breathing problems

Risks

Use of the bronchoscope mildly irritates the lining of the airways, resulting in some
swelling and inflammation, as well as hoarseness caused from abrading the vocal cords.
If this abrasion is more serious, it can lead to respiratory difficulty or bleeding of the
lining of the airways.

The bronchoscopy procedure is also associated with a small risk of disordered heart
rhythm (arrhythmia), heart attacks, low blood oxygen (hypoxemia), and pneumothorax
(a puncture of the lungs that allows air to escape into the space between the lung and
the chest wall). These risks are greater with the use of a rigid bronchoscope than with a
fiberoptic bronchoscope. If a rigid tube is used, there is also a risk of chipped teeth. The
risk of transmitting infectious disease from one patient to another by the bronchoscope
is also present. There is also a risk of infection from endoscopes inadequately
reprocessed by the automated endoscope reprocessing (AER) system. The Centers for
Disease Control (CDC) reported cases of patient-to-patient transmission of infections
following bronchoscopic procedures using bronchoscopes that were inadequately
reprocessed by AERs. Investigation of the incidents revealed inconsistencies between
the reprocessing instructions provided by the manufacturer of the bronchoscope and
the manufacturer of the AER; or that the bronchoscopes were inadequately
reprocessed.

Bibliograpy

Bolliger, C. T., and P. N. Mathur, eds. Interventional Bronchoscopy. (Progress in

Respiratory Research, Vol. 30). Basel: S. Karger Publishing, 1999.

Koppen, W., J. F. Turner, and A. C. Mehta, eds. Flexible Bronchoscopy. 2nd ed. Oxford:
Blackwell Publishers, 2004.
Loeb, S., ed. Illustrated Guide to Diagnostic Tests. Springhouse, PA: Springhouse
Corporation, 1994.

Pagana, Kathleen D., and Timothy J. Pagana. Diagnostic Testing and Nursing Implications.
5th ed. St. Louis: Mosby, 1999