Bronchoscopy: To visualize and assess the bronchial structure for diseases such as cancer and infection. The procedure has both diagnostic and therapeutic implications.
PATIENT PREPARATION for Bronchoscopy
There are no activity restrictions unless by medical direction. Instruct the patient that to reduce the risk of aspiration related to nausea and vomiting, solid food and milk or milk products are restricted for at least 6 hr, and clear liquids are restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The patient may be required to be NPO at midnight. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status.
Patients on beta-blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulants, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. The number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
NORMAL FINDINGS of Bronchoscopy
Normal larynx, trachea, bronchi, bronchioles, and alveoli.
CRITICAL FINDINGS AND POTENTIAL INTERVENTIONS of Bronchoscopy
OVERVIEW: This procedure provides direct visualization of the larynx, trachea, and bronchial tree by means of either a rigid or more commonly, a flexible bronchoscope. A bronchoscope with a light incorporated is guided into the tracheobronchial tree. A local anesthetic may be used to allow the scope to be inserted through the mouth or nose into the trachea and into the bronchi. The patient must breathe during insertion and with the scope in place.
The rigid bronchoscope is used under general anesthesia and 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, large foreign bodies are to be removed, or large-sized biopsy specimens are to be obtained. The flexible 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 drugs and medications, and to obtain specimens with brushes for cytological examination. In general, flexible bronchoscopy is less traumatic to the surrounding tissues than the larger rigid bronchoscopes. Flexible bronchoscopy is performed under local anesthesia; patient tolerance is better for flexible bronchoscopy than for rigid bronchoscopy.
INDICATIONS of Bronchoscopy
• 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 anomalies.
• Identify and, as appropriate, cauterize bleeding sites, and remove clots within the tracheobronchial tree.
• Identify hemorrhagic and inflammatory changes in Kaposi sarcoma.
• Intubate patients with cervical spine injuries or massive upper airway edema.
• Remove foreign body.
• Treat lung cancer through instillation of chemotherapeutic drugs, implantation of radioisotopes, or laser palliative therapy.
Contraindications of Bronchoscopy
A: Patients with bleeding disorders, especially those associated with uremia and cytotoxic chemotherapy.
B: Patients with pulmonary hypertension.
C: Patients with cardiac conditions or dysrhythmias.
D: Patients with disorders that limit extension of the neck.
E: Patients with severe obstructive tracheal conditions.
F: Patients with or having the potential for respiratory failure.
Factors that may alter the results of the study of Bronchoscopy
• Metallic objects within the examination field (e.g., jewelry, earrings, and/or dental amalgams), which may inhibit organ visualization and can produce unclear images.
Other Considerations
• Hypoxemic or hypercapnic states require continuous oxygen administration.
POTENTIAL MEDICAL DIAGNOSIS of Bronchoscopy
CLINICAL SIGNIFICANCE OF RESULTS
Abnormal Bronchoscopy findings related to
• Abscess
• Bronchial diverticulum
• Bronchial stenosis
• Bronchogenic cancer
• Coccidioidomycosis, histoplasmosis, blastomycosis, phycomycosis
• Foreign bodies
• Inflammation
• Interstitial pulmonary disease
• Opportunistic lung infections
(e.g., pneumocystitis, Nocardia, cytomegalovirus)
• Strictures
• Tuberculosis
• Tumors
NURSING IMPLICATIONS of Bronchoscopy
POTENTIAL NURSING PROBLEMS: ASSESSMENT & NURSING DIAGNOSIS
| PROBLEM | Signs and Symptoms |
| Activity (related to ineffective oxygenation secondary to obstruction, infection, inflammation, tumor, trauma, fistula, edema, hemorrhage, foreign body) | Weakness, fatigue, chest pain with exertion, anxiety, shortness of breath, cyanosis, increased work of breathing, decreasing oxygen saturation, increased heart rate |
| Breathing (related to obstruction, infection, inflammation, tumor, trauma, fistula, edema, hemorrhage, foreign body). | Shortness of breath; cool, clammy skin; cyanosis; anxiety; pleuritic chest pain; decreased oxygenation; abnormal blood gas; increased work of breathing (use of accessory muscles); increased respiratory rate. |
| Gas exchange (related to obstruction, infection, inflammation, tumor, trauma, fistula, edema, hemorrhage, foreign body). | Dyspnea; chest pain (pleuritic); diminished oxygenation, cyanosis; increased heart rate, respiratory rate, work of breathing; restlessness, anxiety, fear; adventitious breath sounds (rales, crackles); sense of impending death and doom; hemoptysis; abnormal arterial blood gas. |
BEFORE THE STUDY: PLANNING AND IMPLEMENTATION
➧ Inform the patient this procedure can assess the lungs and respiratory system.
➧ Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort or pain experienced when the IV line or catheter is inserted to allow infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
➧ Baseline vital signs will be recorded and monitored throughout the procedure. Protocols may vary among facilities.
➧ 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. A local anesthetic such as 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 respiratory or gastrointestinal laboratory or radiology department, under sterile conditions, by a healthcare provider (HCP) specializing in this procedure. The procedure usually takes about 30 to 60 min to complete. Tissue samples are placed in properly labeled specimen containers containing formalin solution and promptly transported to the laboratory for processing and analysis.
Rigid Bronchoscopy
➧ Inform the patient that he or she will be placed in the supine position using a pillow underneath the head and a shoulder roll to align the pharynx, larynx, and trachea, after which 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.
Flexible Bronchoscopy
➧ Explain to the patient that he or she will be placed in a sitting or supine position while the tongue and oropharynx are sprayed or swabbed with local anesthetic. An emesis basin will be provided for the increased saliva. 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 flexible 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, maybe intubated before the bronchoscopy. Additional local anesthetic is applied through the scope as it approaches the vocal cords and the carina, eliminating reflexes (e.g., cough) in these sensitive areas. The flexible bronchoscopy 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.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
➧ Provide mouth care to reduce oral bacterial flora.
Safety Considerations
➧ The use of morphine for sedation in patients with asthma or other pulmonary disease should be avoided. This drug can further exacerbate bronchospasms and respiratory impairment.
➧ Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure where bleeding is a potential complication.
AFTER THE STUDY: POTENTIAL NURSING ACTIONS
Avoiding Complications
➧ Bleeding (related to a bleeding disorder or the effects of natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties), bronchospasm, hemoptysis, hypoxemia, infection (related to the use of an endoscope), or pneumothorax. Monitor the patient for complications related to the procedure (e.g., bleeding, bronchospasm, infection, pneumothorax). Immediately report to the appropriate HCP symptoms such as absent breathing sounds, air hunger, excessive coughing, or dyspnea (indications of hemoptysis); elevated white blood cell count, fever, malaise, or tachycardia (indications of infection); dyspnea, tachypnea, anxiety, decreased breathing sounds, or restlessness (symptoms of developing pneumothorax). A chest x-ray may be ordered to check for the presence of pneumothorax. Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation. Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction. The use of morphine sulfate in those with asthma or other pulmonary disease should be avoided. This drug can further exacerbate bronchospasms and respiratory impairment. Emergency resuscitation equipment should be readily available in the case of respiratory impairment or laryngospasm after intubation or after the procedure.
Establishing an IV site is an invasive procedure. Complications are rare but include risk for bleeding from the puncture site (related to a bleeding disorder or the effects of natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties), 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).
Treatment Considerations of Bronchoscopy
➧ After the bronchoscopy procedure and the bronchoscope is removed, the patient is placed in a semi-Fowler position (lying on the back, knees slightly bent, with head elevated to 45 degrees) to maximize ventilation during recovery.
➧ 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. Protocols very among facilities.
➧ 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.
➧ Inform the patient that some throat soreness and hoarseness may be experienced. Instruct the patient to treat throat discomfort with lozenges and warm gargles when the gag reflex returns. Inform the patient of smoking cessation programs as appropriate.
➧ Activity: Identify the patient’s normal activity patterns. He or she may need to remain on bed rest to rest the heart and conserve oxygen. Administer ordered oxygen and have the patient wear oxygen with activity. Prioritize, pace, and bundle activities and increase as tolerated. Monitor and trend vital signs.
➧ Breathing: Assess and trend breath sounds, work of breathing, respiratory rate, and arterial blood gases. Use coping mechanisms to decrease anxiety. Position patient to facilitate breathing, elevate the head of the bed or bedrest as appropriate. Administer ordered analgesics. Encourage the patient to cough and deep breathe, prepare for intubation, and administer
ordered oxygen.
➧ Gas Exchange: Assess respiratory status to establish a baseline (rate, rhythm, depth). Administer ordered oxygen and assess saturation with pulse oximetry. Elevate the head of the bed to facilitate breathing and encourage drainage. Monitor and trend arterial blood gas results. Assess for cyanosis and work of breathing. Administer ordered medications, anticoagulants, antibiotics, bronchodilators, steroids, and diuretics.
Safety Considerations of bronchoscopy
➧ Assess the patient’s ability to swallow before allowing the patient to attempt liquids or solid foods.
Nutritional Considerations
➧ Malnutrition is commonly seen in patients with the 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.
Follow-Up, Evaluation, and Desired Outcomes
➧ Correctly describes the pathophysiology behind diminished oxygenation and disease process. Understand that a healthcare specialist may need to be consulted to assist in managing the disease.
➧ Demonstrates techniques for controlled breathing to improve breathing patterns. Recognizes the value in identifying strategies to bundle and pace activities to improve activity tolerance.
➧ Correctly describes reportable signs and symptoms of poor oxygenation and recognizes the importance of keeping oxygen on at all times.
➧ Agrees to make required lifestyle changes to support positive health.