Bronchoscopy Procedures and Techniques

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Questions and Answers

What is the main purpose of using bronchoscopy?

To enter the bloodstream

To perform heart surgery

To visualize and assess the bronchi (correct)

To administer vaccines

Which type of bronchoscope allows access to very small airways?

Flexible fiberoptic bronchoscope (correct)

Rigid bronchoscope

Transnasal bronchoscope

Metal bronchoscope

What is a significant disadvantage of rigid tube bronchoscopy?

It requires full anesthesia for all patients.

It is uncomfortable for conscious patients. (correct)

It can be performed without an operating room.

It is easy to use in small airways.

How long should a patient refrain from food or drink before the bronchoscopy procedure?

8 hours Signup and view all the answers

What role does a sedative play before performing bronchoscopy?

Helps the patient to follow commands Signup and view all the answers

Which of the following statements about flexible fiberoptic bronchoscopy is true?

It has multiple channels for different functions. Signup and view all the answers

What is one function of grasping forceps used in rigid tube bronchoscopy?

To remove foreign bodies Signup and view all the answers

Which medication is commonly used for conscious sedation before bronchoscopy?

Diazepam Signup and view all the answers

What is a relative contraindication for therapeutic bronchoscopy?

Lack of patient cooperation Signup and view all the answers

Which procedure requires visualization of the vocal cords before advancing the endotracheal tube?

Endotracheal intubation Signup and view all the answers

What complication may occur during bronchoscopy that results from airway irritation?

Bronchospasm Signup and view all the answers

What should be readily available during a bronchoscopy to address laryngospasm?

Bronchodilator Signup and view all the answers

Which of the following is an absolute contraindication to performing bronchoscopy?

Severe refractory hypoxemia Signup and view all the answers

During a bronchoscopy, what is a primary risk associated with hypoxemia?

Decreased O2 saturation Signup and view all the answers

What is a potential risk for patients with recent head injury undergoing bronchoscopy?

Increased intracranial pressures Signup and view all the answers

What approach is taken if bleeding occurs during a bronchoscopy procedure?

Use of epinephrine or iced saline lavage Signup and view all the answers

Which of the following measures can help stop hemorrhage during bronchoscopy?

Direct instillation of racemic epinephrine Signup and view all the answers

What is a potential cause of hypotension during bronchoscopy?

Vagal nerve stimulation Signup and view all the answers

What is the main responsibility of a respiratory therapist during a bronchoscopy?

Monitor the patient continuously Signup and view all the answers

What complication can result from the inadvertent puncture of the lung during a procedure?

Pneumothorax Signup and view all the answers

What medication should be readily available to reverse oversedation during bronchoscopy?

Flumazenil Signup and view all the answers

Which of the following conditions does NOT typically require drainage via a chest tube?

Chronic obstructive pulmonary disease Signup and view all the answers

What is the primary purpose of administering an anticholinergic agent like atropine before a procedure?

To enhance anesthetic deposition and reduce vagal responses Signup and view all the answers

Which substance accumulation is indicated by the term 'pyothorax'?

Pus Signup and view all the answers

What is the recommended sterilization method for bronchoscopes according to CDC guidelines?

Immersion in glutaraldehyde Signup and view all the answers

Which of the following medications is commonly used to reduce pain and diminish laryngeal reflexes during procedures?

Fentanyl or morphine Signup and view all the answers

What is a common method for administering airway anesthesia before a procedure?

Aerosolized lidocaine and nebulizers Signup and view all the answers

What is an indication for diagnostic bronchoscopy related to lung health?

Tumors in the airways and lungs Signup and view all the answers

Which anatomical area is specifically anesthetized by a superior laryngeal nerve block?

Upper larynx only Signup and view all the answers

What is the goal of using topical vasoconstrictors in airway preparation?

To prevent or treat bleeding Signup and view all the answers

What action should be taken if respiratory depression occurs after administering narcotics?

Administer naloxone (Narcan) Signup and view all the answers

Which procedure involves the removal of retained secretions or mucus plugs?

Therapeutic bronchoscopy Signup and view all the answers

What are the three essential elements required for the transmission of infection within a health care setting?

Source of pathogens, susceptible host, route of transmission Signup and view all the answers

Which type of infection occurs when an individual serves as their own source of infection through their flora?

Autogenous infection Signup and view all the answers

Which of the following host factors can enhance susceptibility to infections?

Diabetes mellitus Signup and view all the answers

What is considered the primary source for infectious agents in health care settings?

Humans, including patients and personnel Signup and view all the answers

Which routes are associated with the transmission of pathogens in health care environments?

Contact, respiratory droplets, and airborne droplet nuclei Signup and view all the answers

What indicates that an obstruction may be present in the chest tube system?

Absence of drainage in the collection bottle Signup and view all the answers

What is the recommended action to maintain tube patency?

Strip or milk the tube every 1 to 2 hours Signup and view all the answers

What could excessive bubbling in the water-seal bottle suggest?

Possible air leaks in the system Signup and view all the answers

What is the maximum negative pressure recommended when attaching a suction source?

15 cm H2O Signup and view all the answers

What is the appropriate action if an air leak is suspected in the chest tube system?

Clamping the chest tube to identify the leak Signup and view all the answers

Why must the drainage and collection bottles be kept at a level below the chest?

To prevent backflow of fluids Signup and view all the answers

What dressing should be applied after the chest tube is removed?

Sterile petroleum jelly dressing Signup and view all the answers

What defines a health care-associated infection (HAI)?

Infections that develop during treatment Signup and view all the answers

Study Notes

Respiratory Care Procedures

Bronchoscopy is a procedure used for both therapeutic and diagnostic purposes. It involves inserting a visualization instrument (endoscope) into the bronchi.

Purposes of Bronchoscopy

Inspect the airway
Remove objects from the airway
Collect samples from the airway
Place devices into the airway

Types of Bronchoscopes

Rigid tube bronchoscope
Flexible fiberoptic bronchoscope

Rigid Tube Bronchoscopy

Passed through the mouth, down into the trachea, and into the bronchi
A telescoping tube with mirrors to view and advance to segmental bronchi
Suctioning is done via an internal diameter metal tube passed through the scope to remove foreign objects.
Grasping instruments (forceps) passed through the scope remove foreign bodies and biopsied airway tumors.

Rigid Tube Bronchoscopy - Disadvantages

Very uncomfortable for conscious patients
Usually requires an anesthesiologist and operating room
Cannot access smaller airways

Flexible Fiberoptic Bronchoscopy

Consists of thin, threadlike glass strands (fiberoptic filaments) with a light source at the distal end for visualization
Allows access to very small airways
Has light transmission channel, visualizing channel, and multipurpose open channel (for aspiration, tissue sampling or O2 administration)
The control section allows directing the scope tip to desired location.
Most often used by pulmonologists, often with the assistance of the Respiratory Therapist.

Preparatory Regimen

Refrain from food or drink for at least 8 hours before the procedure.
Vascular access should be available.

Medications - Conscious Sedation

The patient should be calm, but alert enough to follow commands (e.g., taking a deep breath).
Mild sedative (e.g., Diazepam or Midazolam) administered 1 to 2 hours before the procedure, to allow patient to follow commands and remain comfortable.

Medications - Dry the Patient's Airway

Promotes anesthetic deposition, aids visibility, and can reduce procedure time.
Anticholinergic agent (e.g., Atropine) may be given 1 to 2 hours before the procedure to decrease vagal responses.

Medications - Narcotic Analgesics

Morphine or fentanyl may be given to reduce pain and decrease laryngeal reflexes
Caution must be exercised to avoid respiratory depression. Naloxone (Narcan) must be available in the event of respiratory depression.

Medications

Water-soluble jelly (e.g., Xylocaine) is used as a lubricant and anesthetic for easier nasal insertion.
Lidocaine (1%, 2%, or 4%) is often used, aerosolized via the nose, mouthwash to oropharynx, and via nebulizer. This limits the need for lidocaine instillations into the lower airways making the procedure less unpleasant.

Airway Preparation

Goals of airway preparation are: prevent bleeding, decrease coughing and gagging, decrease pain.
Topical vasoconstrictors (e.g., pseudoephedrine or dilute epinephrine) may be used to prevent or treat bleeding.
Airway anesthesia achieved via topical anesthetics or nerve block.

Airway Preparation - Nerve Block

Superior laryngeal nerve block provides anesthesia in the upper larynx, but it does not affect the vocal cords.
Transtracheal block through the cricoid membrane anesthetizes both the vocal cords and trachea.

Medication (Route) Dosage (Route) and Purpose

Lidocaine (5 - 10 mL of 1-4% solution (aerosol)): administered 30-90 minutes before procedure for reducing mucosal membrane irritation
Atropine sulfate (0.5-1.0 mg (IM)): administered before procedure for reducing vagal response, oral secretions, and bronchospasm
Morphine sulfate (1.5- 10 mg (IM)): administered before procedure; for pain relief and cough suppression
Diazepam* (2.5- 10 mg (IV bolus) or 10-15 mg (oral)): administered before and during procedure, as needed for sedation.

Indications for diagnostic bronchoscopy

Tumors in the airways and lungs
Airway obstruction
Hemoptysis, inflammation and infection
Interstitial pulmonary disease
Staging of lung cancer before surgery
Vocal cord paralysis
Tissue or fluid samples collected from the airways or lungs

Indications for therapeutic bronchoscopy

Removal of retained secretions, mucus plugs, or polyps
Removal of foreign bodies (common in pediatric patients)
Removal of endobronchial tissues
Drainage of an abscess;
Pulmonary hemorrhage (a. To locate area of bleeding; b. To control bleeding by instillation of epinephrine or iced saline lavage)

Absolute Contraindications

Absence of consent (unless medical emergency and patient is incompetent).
Absence of an experienced bronchoscopist.
Lack of adequate facilities and personnel for emergencies (e.g., cardiopulmonary arrest, pneumothorax, or bleeding).
Coagulopathy or bleeding diathesis that cannot be corrected.
Severe refractory hypoxemia
Unstable hemodynamic status including dysrhythmias.

Relative Contraindications

Lack of patient cooperation
Recent myocardial infarction or unstable angina (within 6 weeks)
Partial tracheal obstruction
Moderate to severe hypoxemia or hypercarbia
Uremia and pulmonary hypertension (possible serious hemorrhage after biopsy)
Lung abscess (danger of flooding airway with purulent material)
Obstruction of superior vena cava (possibility of bleeding)
Disorders requiring laser therapy, biopsy of lesions obstructing large airways, or multiple transbronchial lung biopsies
Known or suspected pregnancy
Safety of the bronchoscopic procedures in asthmatic patient

Complications of Bronchoscopy

Hypoxemia (monitor O2 saturation, increase O2%)
Laryngospasm (bronchodilators should be readily available)
Bronchospasm (bronchodilator should be readily available)
Arrhythmias (monitor ECG, remove bronchoscope)
Hemorrhage (direct instillation of epinephrine, racemic epinephrine, or cold saline)
Respiratory Depression (monitor respiratory status closely, flumazenil readily available)
Hypotension (results from vagal or sedative stimulation)
Pneumothorax (monitor respiratory status closely)

Hazards and Complications

Adverse effects of medication used before and during the bronchoscopic procedure
Hypercarbia
Increased airway resistance
Cross-contamination of specimens or bronchoscopes
Nausea, vomiting
Fever and chills
Cardiac dysrhythmias
Death
Infection hazard for health care workers or other patients.

Respiratory Therapist's Responsibilities During Bronchoscopy

Prepare and explain the procedure
Administer aerosolized local anesthetic to the patient's upper airway
Conduct patient monitoring throughout the procedure (pulse, blood pressure, respiratory rate, ECG, O2 saturation, level of consciousness)
Collect and prepare sputum and tissue samples for laboratory analysis
Clean the bronchoscope properly after procedure (immersion in glutaraldehyde (Cidex) for 3 to 10 hours).

Chest Tube Drainage Systems

Chest Tubes (thoracostomy tube) drain substances that accumulate in the pleural space.

Substances that may accumulate in the pleural space

Air (pneumothorax)
Blood (hemothorax)
Lymph (chylothorax)
Serous fluids (pleural effusion)
Pus (pyothorax/empyema)

Chest Tube Insertion

For pneumothorax, chest tube typically inserted in the second, third, or fourth intercostal space anteriorly along the midclavicular line or midaxillary line.
For fluid drainage, chest tube typically placed lower, in the sixth or seventh intercostal space.

Chest Tube Placement

Size (16 - 20 Fr) for pneumothorax, usually at the 2nd-3rd intercostal space.
For pleural fluids, typically a larger size (28-40 Fr)
Insertion point: 4th to 6th intercostal space at the mid-axillary line.
Chest tubes: straight, curved, trocar, or nontrocar. A trocar is a sharp instrument for incision.

Chest Tube Selection

Large Adults: 36 to 40 French
Small Adults/Teens: 28 to 32 French
Children: 18 French
Neonates: 12 to 14 French

Chest Tube Drainage Systems (Bottle Systems)

One-bottle system
Two-bottle system
Three-bottle system

Important Points Concerning Chest Tube Drainage

Water level fluctuation in water-seal bottle is normal with changes in pleural pressure.
Obstructed chest tubes from blood clots or kinks may result in tension pneumothorax.
"Strip" or "Milk" the tube every 1-2 hours to ensure adequate drainage and patency.
Occasional bubbling in the water-seal bottle is normal air.
Excessive bubbling may indicate air leak. Absence of bubbling indicates improvement.
Clamp chest tube if air leak suspected to identify leak source.
Drainage and collection bottles kept at a level below the chest to prevent backflow.
Clamping required when changing drainage bottles (caution with pleural air leaks to prevent tension pneumothorax).
Drainage and collection system must be airtight.
If suction source connected and the tubing vent, a negative pressure (not to exceed 15 cm H2O) is necessary.
After lung re-expands, chest tube should remain in place for another 1-2 days, and covered with sterile petroleum jelly dressing after removal to prevent air from entering pleural space.

Equipment Decontamination and Infection Control

Health care-associated infection (HAI) refers to infections that develop in a patient during medical treatment.
Three elements for infection transmission: source of pathogens, susceptible host, and route of transmission.

Sources of Infectious Agents

Humans (patients, personnel, or visitors) are the primary source of infectious agents.
Inanimate objects (e.g., contaminated medical equipment, linen, medications) also implicated in transmission.
People can be their own source (autogenous infection) via endogenous flora.

Susceptible Hosts

Host factors (e.g., diabetes, extreme age, immunodeficiency) enhance infection susceptibility.
Surgical incisions, radiation therapy impair skin and organ defenses.
Medical devices (e.g., urinary catheters, central venous catheters, endotracheal tubes) increase infection risk.

Modes of Transmission

Contact (direct and indirect)
Respiratory droplets
Airborne droplet nuclei (respirable particles <5µm)

Organisms in active growth

Pose greatest hazard for infection via respiratory therapy equipment.
Most common equipment contaminants (spore forming bacteria).

Spores

Resting, resistant stage of organisms.
Very difficult to kill.

Disinfection

Killing vegetative forms of organisms, but not spores.
Agents that disinfect equipment are called disinfectants.

Sterilization

Killing all organisms (both vegetative forms and spores).
Agents that sterilize equipment are called sterilants.

###-cidal and -static

Suffix -cidal means to kill.
Suffix -static means to prevent growth.

Gram/Gram Staining Methods

Gramstain is used for differential staining of bacteria. Gram-positive stain purple-black; gram-negative stain pink.

Nosocomial Infection

Hospital-acquired infection. Commonly caused by Pseudomonas, Staphylococcus, Candida albicans, or E. coli.

Conditions Influencing Antimicrobial Action

Chemical Concentration (more concentrated, more rapid action).
Intensity of the physical agent (more intense, more rapid killing).
Time (longer exposure, greater killing achieved).
Temperature (higher temperature, shorter exposure time needed).
Type of Organism (vegetative bacteria more easily killed than spore-forming bacteria; spores more resistant to agents).
Number of Organisms (more organisms, longer exposure time).
Nature of the material bearing the organisms (e.g., blood, sputum provide protection; need to wash equipment thoroughly to reduce potential contamination).

Three Main Classes of Bacteria

Cocci (sphere-shaped)
Spirilla (spiral-shaped)
Bacilli (rod-shaped)

Three Main Classes of Bacilli bacteria

Klebsiella pneumoniae (gram-negative bacillus)
Pseudomonas aeruginosa (gram-negative bacillus)
Legionella species (gram-negative bacilli, secondary invader in respiratory/burn patients)
Serratia marcescens (gram-negative bacillus, secondary invader in respiratory/burn patients)
Haemophilus influenzae (gram-negative bacillus)
Mycobacterium species (gram-positive, causative agent of tuberculosis (TB))

Sterilization and Disinfection Techniques

Physical Agents
- Autoclaving (steam under pressure): 121°C for 15 minutes.
  - Sterilize equipment by coagulating cell proteins.
  - Equipment must be completely dry, wrapped in cloth or paper bag before autoclaving.
- Pasteurization: 60 - 70°C for 20 - 30 minutes, disinfects but does not sterilize equipment.
Chemical Agents
- Ethylene oxide gas sterilization: 800-1000 mg/L and at least 50% relative humidity. Kills all organisms including spores. (Highly flammable - mixed with carbon dioxide or freon).
- Alcohols (ethyl/isopropyl): Bactericidal and fungicidal (but not sporicidal), disinfect equipment by destroying cell protein. Dilutions below 50% have significantly reduced effectiveness.
- Glutaraldehydes (Cidex): normally used to disinfect equipment, may sterilize; bactericidal in 10-15 minutes, sporicidal in 3-10 hours, depending on solution temperature. Equipment must be thoroughly washed in soapy water and rinsed off before placing into the bath.
- Acetic acid (vinegar); disinfectant effective against some bacteria; not recommended for respiratory therapy equipment unless in combination with other cleaning methods).

Important Points Concerning Decontamination of Equipment

Use only sterile solutions in reservoirs
Solutions left in a reservoir should be discarded before adding fresh solution.
Solutions should be dated after opening and discarded within 24 hours to reduce contamination.
Do not drain condensation in the delivery tubing into the reservoir.
Quality control of equipment using various methods such as processing indicator strips/strips (biological & chemical), swab sampling, and culture sampling (to determine effectiveness of process).
Disposable/single-used equipment should not be refilled or reused. The equipment must be completely dry when packaged and stored.

Handling of contaminated equipment

Double bag all equipment and supplies taken from an isolation area in non-porous plastic bags.
A person in isolation attire must place the contaminated equipment into a bag (outside the room, in a second container by second person).
Bag must be properly labeled with isolation area, name and room number of the patient.

Infection Control and Standard Precautions

Standard Precautions (apply to all patients, including: blood, body fluids, secretions, excretions, mucous membranes and non-intact skin.)
- Handwashing (15 seconds before and after patient interaction, including glove use, preferring alcohol-based solutions over soap/water to reduce skin drying)
- Gloves (worn during patient interaction)
- Gown (worn when splashing fluids/blood is possible.)
- Mask, eye goggles, face shield (worn when fluids/blood are possible.
Transmission-Based Precautions (additional to standard precautions, used for contagious diseases):
- Contact precautions (private room, discard gloves and gowns before exiting.)
- Airborne precautions (private room, HEPA masks.)
- Droplet precautions (private room, patient wear mask.)

Cohorting

If private rooms aren't available, patients with the same organism may be placed in shared rooms.

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