BTS Guideline for Diagnostic Flexible Bronchoscopy in Adults PDF

August 2013 Volume 68 Supplement 1 Thorax AN INTERNATIONAL JOURNAL OF RESPIRATORY MEDICINE BTS Guideline for diagnostic flexible broncho...

August 2013 Volume 68 Supplement 1 Thorax AN INTERNATIONAL JOURNAL OF RESPIRATORY MEDICINE BTS Guideline for diagnostic flexible bronchoscopy in adults British Thoracic Society BTS Flexible Bronchoscopy Guideline Group thorax.bmj.com thoraxjnl_68_S1_Cover.indd 1 10/07/13 12:53 PM  Thorax AN INTERNATIONAL JOURNAL OF Aims and Scope: Thorax enjoys an enviable and longstanding reputation for publishing RESPIRATORY MEDICINE Journal of the British Thoracic Society clinical and experimental research articles Editorial Board E Abraham (USA) covering many disciplines, including A Agusti (Spain) H Aranibar (Chile) pathology, immunology and surgery E Baraldi (Italy) E Bateman (South Africa) J Bradley (UK) J Britton (UK) Contact Details J de Jongste (Netherlands) Editors N Maskell (UK) Editorial Office O Eickelberg (Germany) S Nathan (USA) BMJ Publishing Group Ltd, BMA House, Tavistock A Bush (UK) J Fahy (USA) JL Pepin (France) Square London, WC1H 9JR, UK I Pavord (UK) M Fitzgerald (Canada) T Sethi (UK) T: +44 (0)20 7383 6373 U Frey (Switzerland) Deputy Editors E: [email protected] M Steiner (UK) J Gauldie (Canada) P Cullinan (UK) D Thickett (UK) M Han (USA) C Lloyd (UK) A Torres (Spain) J Henderson (UK) Associate Editors Z Udwadia (India) Permissions F Holguin (USA) R Beasley (New Zealand) H Zar (South Africa) See http://journals.bmj.com/misc/permissions.dtl R Hubbard (UK) R Buhl (Germany) Statistical Editors I Janahi (Qatar) JC Celedón (USA) J Gibson (UK) Supplement Enquiries R Kalhan (USA) A Custovic (UK) T McKeever (UK) T: +44 (0)20 7383 6057 A Knox (UK) P Gibson (Australia) Statistician E: [email protected] C Kuehni (Switzerland) J Grigg (UK) G Lack (UK) L Szatkowshi (UK) D Halpin (UK) F Maltais (Canada) A Jones (UK) Journal club Editor For ALL subscription enquiries and orders D Mannino (USA) E Lim (UK) J Quint (UK) T: +44 (0)20 7111 1105 F Martinez (USA) E: [email protected] A Morice (UK) http://thorax.bmj.com/site/help/index.xhtml P O’Byrne (Canada) M Peters-Golden (USA) C Pison (France) Advertising E Pizzichini (Canada) Sophie Fitzsimmons A Quittner (USA) T: +44 (0)20 7383 6783 F Ratjen (Canada) E: [email protected] J Scullion (UK) http://group.bmj.com/group/advertising J Simpson (UK) R Stein (Brazil) Display & Online Advertising Sales (USA) R Taylor (New Zealand) Jim Cunningham M Thomas (UK) T: +1 201 767 4170 T Treasure (UK) E: [email protected] T Troosters (Belgium) C Wainwright (Australia) D Warburton (USA) Subscription Information Author Reprints M Whyte (UK) Reprints Administrator A Woodcock (UK) Thorax is published monthly (subscribers receive all supplements) T: +44 (0)20 7383 6305 J Yorke (UK) E: [email protected] President, British Thoracic Institutional Rates Personal Rates Society 2013 2013 Ashley Woodcock Commercial Reprints (except USA & Canada) Print Print (includes online access at Nadia Gurney-Randall Production Editor £600; US$1,170; €810 no additional cost) T: +44 (0)20 8445 5825 Aimee Knight £251; US$490; €339 M: +44 (0)7866 262344 Journal Manager Online E: [email protected] Site licences are priced on FTE Online only Claire Weinberg basis and allow access by the £136; US$266; €184 Publisher whole institution. 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London WC1N 2PL, UK exclusive licence to publish http:// T: +44 (0)20 7831 8778 Residents of some EC countries must pay VAT; for details call us or visit E: [email protected] thorax.bmj.com/ifora/licence.dtl http://group.bmj.com/group/subs-sales/subscriptions/subs-vat http://www.brit-thoracic.org.uk/index.html Impact Factor: 8.376 thoraxjnl_68_S1_EB.indd 1 10/07/13 12:54 PM  IA Du Rand, J Blaikley, R Booton, N Chaudhuri, V Gupta, S Khalid, S Mandal, J Martin, J Mills, N Navani, NM Rahman, JM Wrightson, M Munavvar BTS Flexible Bronchoscopy Guideline Group On behalf of the British Thoracic Society Standards of Care Committee thoraxjnl_68_S1_Title_Page.indd 1 10/07/13 12:55 PM  Healthcare providers need to use clinical judgement, knowledge and expertise when deciding whether it is appropriate to apply recommendations for the management of patients. The recommendations cited here are a guide and may not be appropriate for use in all situations. The guidance provided does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer. thoraxjnl_68_S1_Title_Page.indd 2 10/07/13 12:55 PM  Contents Volume 68 Supplement 1 | THORAX August 2013 Summary of recommendations Decontamination Introduction Staff safety i4 Clinical context and need for a guideline i26 Nursing skill mix and staffing levels i5 Target audience of the guideline i5 Scope of the guideline i26 Patient satisfaction Journal of the British Thoracic Society Methodology i27 Consent Impact Factor: 8.376 Editors i5 Clinical questions and literature search i28 Conclusion A Bush (UK) i5 Appraisal of the literature I Pavord (UK) i6 Considered judgement and grading of the i28 References Deputy Editors evidence P Cullinan (UK) C Lloyd (UK) i6 Drafting of the guideline Appendices Associate Editors i34 Appendix 1 Contributions and declarations of R Beasley (New Zealand) N Maskell (UK) Audit and research recommendations Interest R Buhl (Germany) S Nathan (USA) JC Celedón (USA) JL Pepin (France) i7 Training i35 Appendix 2 Search Strategy (online only) A Custovic (UK) P Gibson (Australia) T Sethi (UK) M Steiner (UK) i7 Audit Standards i35 Appendix 3 Evidence Tables (online only) J Grigg (UK) D Thickett (UK) i35 Appendix 4 List of stakeholders D Halpin (UK) A Jones (UK) A Torres (Spain) Z Udwadia (India) Monitoring, precautions and i36 Appendix 5 Flexible bronchoscopy safety E Lim (UK) H Zar (South Africa) complications checklist Statistical Editors i7 Hypoxaemia i36 Appendix 6 Management approach to J Gibson (UK) T McKeever (UK) i8 Cardiac complications bleeding at bronchoscopy Statistician i8 Arrhythmia i37 Appendix 7 Management of patients L Szatkowski (UK) i9 Myocardial infarction on warfarin or clopidogrel undergoing Journal club Editor i9 Bleeding complications J Quint (UK) bronchoscopy President, British Thoracic Society i10 Pneumothorax i38 Appendix 8 Drugs used in bronchoscopy A Woodcock i10 Fever and infection i39 Appendix 9 Sedation scoring scales Editorial Office which may be used to aid assessment and BMJ Publishing Group Ltd, BMA House, Safety of FB in specific medical documentation of sedation level Tavistock Square, London WC1H 9JR, UK T: +44 (0)20 7383 6373 conditions i40 Appendix 10 BTS Flexible Bronchoscopy – F: +44 (0)20 7383 6668 i11 Patients with asthma Suggested guides on how to perform standard E: [email protected] i11 Patients with COPD procedures ISSN: 0040-6376 (print) i11 Patients with ischaemic heart disease i41 Appendix 11 Recommendations for size of ISSN: 1468-3296 (online) i11 Bronchoscopy for haemoptysis bronchoscope with different airway devices Disclaimer: Thorax is owned and published by the British Thoracic Society and BMJ Publishing Group i12 Bronchoscopy in the older patient i42 Appendix 12 Cleaning and disinfecting Ltd, a wholly owned subsidiary of the British Medical Association. The owners grant editorial freedom to i12 Bronchoscopy in patients who are procedure the Editor of Thorax. immunosuppressed i42 Appendix 13 Patient information leaflet Thorax follows guidelines on editorial independence produced by the World Association of Medical Editors and the code on good Premedication, sedation and topical publication practice of the Committee on Publication Ethics. anaesthesia for FB Thorax is intended for medical professionals and is provided without warranty, express or implied. i12 Premedication Statements in the Journal are there sponsibility of their authors and advertisers and not authors’ i13 Sedation institutions, the BMJ Publishing Group Ltd, the i15 Topical anaesthesia British Thoracic Society or theBMAunless otherwise specified or determined by law. Acceptance of advertising does not imply endorsement. Sampling and diagnostic accuracy To the fullest extent permitted by law, the BMJ Publishing Group Ltd shall not be liable for any loss, i16 Lung cancer This article has been chosen by the Editor to be of special interest injury or damage resulting from the use of Thorax or importance and is freely available online. or any information in it whether based on contract, i17 Interstitial lung disease tort or otherwise. Readers are advised to verify any information they choose to rely on. i18 Diagnosis of infection This article has been made freely available online under the BMJ Journals Open Access scheme. Copyright: © 2013 BMJ Publishing Group Ltd and OPEN ACCESS the British Thoracic Society. All rights reserved; no Bronchoscopy in the ICU See http://thorax.bmj.com/site/about/guidelines.xhtml#open part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or i20 Bronchoscopes used in the ICU by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission i21 Indications for FB in the ICU of Thorax. i22 Precautions and contraindications to This journal is a member of and subscribes to the principles of the Thorax is published by BMJ Publishing Group Ltd, typeset by Techset and printed in the UK on bronchoscopy on the ICU Committee on Publication Ethics acid-free paper. i23 Monitoring www.publicationethics.org.uk Thorax (ISSN No: 0040–6376) is published monthly by BMJ Publishing Group and distributed i23 Ventilator settings in the USA by Air Business Ltd. Periodicals postage paid at Jamaica NY 11431. POSTMASTER: send i24 Sedation and analgesia address changes to Thorax, Air Business Ltd, c/o Worldnet Shipping Inc., 156-15, 146th Avenue, 2nd Floor, Jamaica, NY 11434, USA. thoraxjnl_68_S1_TOC.indd 1 10/07/13 12:56 PM  BTS guidelines British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults I A Du Rand,1 J Blaikley,2 R Booton,3 N Chaudhuri,4 V Gupta,2 S Khalid,5 S Mandal,6 J Martin,4 J Mills,7 N Navani,8 N M Rahman,9 J M Wrightson,9 M Munavvar,7 on behalf of the British Thoracic Society Bronchoscopy Guideline Group ▸ Additional material is SUMMARY OF RECOMMENDATIONS endobronchial biopsy (EBB) or transbronchial lung published online only. To view Monitoring, precautions and complications biopsy (TBLB) is planned. (Grade D) please visit the journal online (http://dx.doi.org/10.1136/ ▸ All patients undergoing bronchoscopy should have ▸ Discontinue clopidogrel 7 days prior to consid- thoraxjnl-2013-203618). heart rate, respiratory rate, blood pressure and eration of EBB and TBLB. Low-dose aspirin 1 oxygen saturation recorded repeatedly, including alone can be continued. (Grade C) Worcestershire Royal Hospital, Worcestershire Acute Hospitals before, during and after the procedure. (Grade D) ▸ Anticoagulants should be managed according NHS Trust, Worcester, UK ▸ All bronchoscopy units should undertake peri- to published guidelines as set out in appendix 7 2 The University of Manchester, odic audit of bronchoscopic performance, of this guideline. (√) Manchester, UK including efficacy, complications and patient sat- ▸ The risk of biopsy needs to be weighed against 3 The University of Manchester, Manchester Academic Health isfaction surveys. (Good practice point (√)) the potential for benefit and appropriate Science Centre, University ▸ All Trusts should have a ‘safe sedation policy’, informed consent obtained. (√) Hospital South Manchester and ensure all bronchoscopy unit staff, including NHS Foundation Trust, trainees, receive appropriate training. (√) Pneumothorax Manchester, UK 4 ▸ A chest radiograph should be obtained if a University Hospital of South Manchester, Manchester, UK patient is symptomatic or there is a clinical sus- 5 Royal Blackburn Hospital, Hypoxaemia picion of possible pneumothorax after TBLB. Lancashire, UK 6 ▸ Patients should be monitored by continuous (Grade D) Lane Fox Unit, St Thomas’ pulse oximetry during bronchoscopy. (Grade C) ▸ Fluoroscopic screening may improve diagnostic Hospital, London, UK 7 Lancashire Teaching Hospitals ▸ Oxygen supplementation should be used when yield of TBLB in focal but not diffuse lung NHS Trust, Preston, UK desaturation is significant (pulse oximeter oxygen disease. (Grade D) 8 University College London saturation (SpO2)>4% change, or SpO21 min) to reduce the risk of delayed complications following TBLB and pro- Trials Unit, National Institute hypoxaemia-related complications. (Grade D) vided with written information regarding likely for Health Research University College London Hospitals ▸ The risks of hypoxaemia-related complications symptoms and action required. (Grade D) Biomedical Research Centre, are associated with baseline arterial oxygen sat- London, UK 9 uration (SaO2) and lung function, comorbidity, Fever and infection Oxford Centre for Respiratory sedation and procedural sampling. Fitness for ▸ Patients should receive written information Medicine, NIHR Oxford Biomedical Research Centre, bronchoscopy should incorporate an assessment regarding post-bronchoscopy fever (PBF) and Oxford Respiratory Trials Unit, of these elements, and appropriate monitoring appropriate management advice. (Grade C) University of Oxford, Oxford, and preprocedure optimisation. (Grade D) ▸ Antibiotic prophylaxis is not warranted before UK bronchoscopy for the prevention of endocardi- Cardiac arrhythmias tis, fever or pneumonia. (Grade B) Correspondence to Dr Ingrid Du Rand, ▸ Continuous ECG monitoring should be used Worcestershire Royal Hospital, when there is a high clinical risk of arrhythmia. SAFETY OF FLEXIBLE BRONCHOSCOPY IN Aconbury East, Charles (Grade D) SPECIFIC MEDICAL CONDITIONS Hastings Way, Worcester, ▸ When there is a high risk of arrhythmia, oxygen Asthma WR5 1DD, UK; [email protected] saturations, pulse rate and blood pressure should ▸ Patients’ asthma control should be optimised prior be optimised. Appropriate aftercare monitoring to bronchoscopy, especially when bronchoalveolar and instructions should be given. (Grade D) lavage (BAL) is likely to be performed. (Grade C) ▸ Resuscitation equipment should be readily avail- ▸ Nebulised bronchodilators should be considered able. (√) before bronchoscopy in patients with asthma. ▸ Intravenous access should be established before (√) sedation is given and maintained until discharge. (√) Chronic obstructive pulmonary disease ▸ Chronic obstructive pulmonary disease (COPD) Bleeding complications treatment should be optimised prior to bron- ▸ Perform coagulation studies, platelet count and choscopy when possible. (Grade D) haemoglobin concentration when there are clinical ▸ Bronchoscopists should be cautious when sedat- risk factors for abnormal coagulation. (Grade D) ing patients with COPD. (Grade D) ▸ Bronchoscopy with lavage can be performed with platelet counts >20 000 per μL. Liaise with the Ischaemic heart disease To cite: Du Rand IA, local haematology team regarding the need for ▸ Liaison with cardiologists should be considered Blaikley J, Booton R, et al. Thorax 2013;68:i1–i44. platelet transfusion before bronchoscopy if in high-risk patients with cardiac disease and if Du Rand IA, et al. Thorax 2013;68:i1–i44. doi:10.1136/thoraxjnl-2013-203618 i1  BTS guidelines flexible bronchoscopy (FB) is indicated within 4–6 weeks trained in its administration (eg, anaesthetists) since it has a after myocardial infarction (MI). (Grade D) narrow therapeutic window beyond which general anaesthe- ▸ FB should ideally be delayed for 4 weeks after MI. (Grade D) sia is achieved. (Grade B) Haemoptysis ▸ Consider bronchoscopy after a normal CT if the patient is Opioids high risk for lung carcinoma or if the haemoptysis continues. ▸ Combination opioid and midazolam sedation should be con- (Grade D) sidered in patients to improve bronchoscopic tolerance. (Grade B) Older patients ▸ When opioids are used, short-acting agents (such as fentanyl ▸ Age alone should not be a contraindication for bronchos- or alfentanil) should be used to minimise post-procedural copy. (Grade D) sedation. (Grade D) ▸ The older patient may require reduced doses of benzodiaze- ▸ When combination sedatives are used, opioids should be pines/opioids sedation. (Grade D) administered first and allowed time to become maximally effective before administration of any other agent. (Grade D) Patients who are immunosuppressed ▸ When a diagnosis is not likely to be obtained through non- invasive measures, bronchoscopy with BAL can be consid- Topical anaesthesia ered to provide diagnostic information. (Grade C) ▸ Lidocaine should be used for topical anaesthesia during ▸ TBLB is helpful in lung transplant recipients when rejection bronchoscopy, unless contraindicated. (Grade A) is a possibility. (Grade C) ▸ Nasal topical anaesthesia is most effectively provided using 2% lidocaine gel. (Grade A) SEDATION ▸ Both cricothyroid and spray-as-you-go techniques are effect- Premedication ive in delivering lidocaine to the vocal cords and trachea. ▸ Anticholinergics (glycopyrrolate or atropine) should not rou- (Grade B) tinely be used prior to bronchoscopy due to a lack of clinical ▸ Nebulisation is not recommended as a technique for deliver- benefit and a possible increased risk of haemodynamic ing lidocaine to the airways. (Grade B) changes. (Grade A) ▸ 1% lidocaine solution should be used for spray-as-you-go ▸ Premedication for bronchoscopy is not routinely indicated. administration. (Grade A) (Grade C) ▸ To reduce the risk of lidocaine toxicity, bronchoscopists should use the lowest dose of lidocaine sufficient to prevent Sedation excessive coughing and provide patient comfort. (Grade D) ▸ Intravenous sedation should be offered to patients undergo- ▸ Bronchoscopists should remain vigilant for objective and sub- ing bronchoscopy, provided there are no contraindications. jective symptoms of lidocaine toxicity, particularly given sig- (Grade B) nificant inter-patient variability in lidocaine absorption and ▸ Some patients will tolerate unsedated bronchoscopy well, metabolism. (Grade B) and patient preference should be sought. (Grade B) ▸ Bronchoscopists should monitor and document the total ▸ Sedative drugs should be titrated to provide the desired lidocaine dose delivered at all sites during bronchoscopy. (√) depth of sedation, given significant inter-patient variability in required doses. (Grade B) Sampling and diagnostic accuracy ▸ The desired depth of sedation is one in which verbal contact ▸ Bronchoscopists should maintain a record of their personal is possible at all times. (Grade D) diagnostic accuracy for FB. (√) ▸ Bronchoscopists are encouraged to document an assessment of sedation depth as part of the procedural report. (√) Lung cancer ▸ A diagnostic level of 85% should be attainable when definite Benzodiazepines endobronchial tumour is visible. (Grade B) ▸ Intravenous midazolam is the preferred drug for sedation, ▸ At least five biopsy samples should be taken when endobron- having a rapid onset of action, being titratable to provide the chial tumour is visible to maximise diagnostic yield and the required depth of sedation, and being reversible. (Grade B) volume of biopsy tissue and to allow for tumour phenotyp- ▸ No more than 5 mg midazolam should be initially drawn up ing and genotyping. (Grade D) into any syringe prior to bronchoscopy for patients under the ▸ When endobronchial tumour is visible, brushings and wash- age of 70 (2 mg midazolam for patients over 70) to prevent ings can increase the diagnostic yield of the procedure. potential inadvertent oversedation associated with the practice (Grade D) of routinely drawing up 10 mg midazolam. (Grade D) ▸ A chest CT scan should be performed prior to a diagnostic bron- ▸ Only low-strength midazolam (1 mg/mL) should be available choscopy in patients with suspected lung cancer. (Grade D) within bronchoscopy suites. High-strength midazolam (2 mg/ mL or 5 mg/mL) should be restricted to general anaesthesia, Interstitial lung disease intensive care and other areas where its use has been for- ▸ In suspected sarcoidosis, EBBs should be considered to mally risk assessed. (Grade D) increase the diagnostic yield. (Grade C) ▸ TBLB is recommended for the diagnosis of stage II–IV sar- Propofol coidosis. (Grade C) ▸ While propofol has similar efficacy to midazolam, it should ▸ In patients with diffuse interstitial lung disease (ILD), five to only be used when administered by practitioners formally six TBLBs should be taken from the same lung. (Grade D) i2 Du Rand IA, et al. Thorax 2013;68:i1–i44. doi:10.1136/thoraxjnl-2013-203618  BTS guidelines ▸ Fluoroscopy should be considered for TBLB in patients with ▸ Patients in the ICU should be considered at high risk from localised or focal parenchymal lung disease. (Grade D) complications when undergoing bronchoscopy. (Grade D) ▸ All potential risk factors (ventilator parameters, clotting dys- function) should be corrected as far as possible before under- Diagnosis of infection taking bronchoscopy. (Grade D) Patients who are immunocompromised ▸ The risks and benefits of bronchoscopy should be carefully ▸ In patients with pulmonary infiltrates who are immunocom- considered in mechanically ventilated patients. (√) promised and in whom tuberculosis (TB) is considered ▸ Continuous multimodal physiological monitoring should unlikely, BAL alone is usually sufficient to achieve a diagno- occur during and after bronchoscopy in the ICU setting. sis. In areas or populations with high prevalence of TB, (Grade C) TBLB may be considered in addition. (Grade C) ▸ Patients should be monitored after the procedure for compli- ▸ BAL or bronchial washings should be sent for microscopy for cations, including pneumothorax, even when a biopsy has acid fast bacteria (AFB) and for mycobacterial culture in patients not been taken. (Grade D) with pneumonia who are immunocompromised. (Grade C) ▸ Continuous positive airway pressure (CPAP) plus oxygen ▸ Post-bronchoscopy sputum could be collected in patients support may be considered in patients with hypoxia under- who are immunocompromised and suspected to have TB. going bronchoscopy to prevent desaturation and post- (Grade D) procedure requirement for mechanical ventilation. (Grade B) ▸ TBLB and EBB for invasive aspergillosis may be avoided if ▸ When patients require non-invasive ventilation prior to bron- BAL galactomannan test is available due to the high sensitiv- choscopy, the procedure should be conducted in an environ- ity and specificity of the latter and inherent risks with the ment where intubation and ventilatory support are readily biopsies. (Grade C) accessible. (Grade D) ▸ In patients suspected to have invasive aspergillosis, BAL ▸ Bronchoscopy should be undertaken cautiously in patients should be sent for microscopy for hyphae and fungal with documented or suspected raised intracranial pressure culture; a BAL galactomannan test should be considered to (ICP). (Grade D) further improve diagnostic yield. (Grade C) ▸ Care must be exercised to ensure adequate ventilation and oxygenation is maintained during bronchoscopy in intubated Patients who are immunocompetent patients. (√) ▸ Bronchoscopy may be considered in patients with non-resolving ▸ Adequate sedation and analgesia should be provided for or slowly resolving pneumonia, especially if they are current or patients undergoing bronchoscopy in an intensive care ex smokers and older than 50 years. (Grade C) setting. The risks of these procedures should be carefully ▸ If bronchoscopy is performed for community-acquired pneu- balanced with their potential benefit in ventilated patients. monia, BAL specimens should be sent for legionella PCR (Grade D) and atypical pathogens. (Grade C) ▸ Clinicians administering sedation/anaesthesia/analgesia ▸ Bronchoscopy may be considered if the patient is suspected should be acquainted with the use of these agents, and the to have TB when sputum smear is negative. (Grade C) anaesthetist/intensivist is usually best placed to fulfil this role. ▸ In cases of suspected TB, BAL, bronchial aspirates and post- (Grade D) bronchoscopy sputum appear to be complementary and should all be analysed. (Grade C) DISINFECTION ▸ In areas with high or intermediate prevalence of TB, patients ▸ All personnel involved in cleaning and decontaminating undergoing bronchoscopy for another indication should have bronchoscopes must receive specific training in infection samples sent routinely for cultures for TB. (Grade C) control practices and decontamination processes. (Grade D) ▸ Decontamination and disinfection should be carried out at INTENSIVE CARE UNITS the beginning and end of each list and after each patient use. ▸ The external diameter of a bronchoscope used in the intensive If drying cabinets or storage chambers are unavailable care unit (ICU) setting should be carefully selected according to bronchoscopes should be decontaminated no more than 3 h the external diameter of the bronchoscope, the size of the before the procedure to eliminate colonisation of pathogens. airway support device (endotracheal tube (ET) or laryngeal (Grade D) mask) and the type of airway device used. (Grade D) ▸ Bronchoscopes should be cleaned in designated cleaning ▸ Prophylactic bronchoscopy and lavage should not be used to areas. Used scopes must be separated from clean scopes to prevent post-lobectomy atelectasis in ventilated patients. prevent cross contamination. (Grade D) (Grade A) ▸ Thorough cleaning, brushing and flushing of all accessible ▸ Bronchoscopy may be considered in specific circumstances channels with enzymatic or low foaming detergent remains for the relief of atelectasis in intubated and ventilated the most important initial stage of the cleaning process. patients. (Grade D) (Grade D) ▸ Bronchoscopy may be considered in ventilated patients with ▸ Single-use suction valves should replace reusable valves wher- haemoptysis if CT imaging has been performed and is ever possible. Single-use valves must be discarded after each unhelpful, or is not possible. (Grade D) procedure. (Grade D) ▸ Directed non-invasive diagnostic strategies (eg, blind catheter ▸ Reusable valves should be used only with one bronchoscope aspiration) should be used first line in preference to bron- and stored alongside the scope for traceability. (Grade D) choscopy in ventilated patients with suspected ventilator- ▸ Single-use accessories should be selected over reusable acces- associated pneumonia. (Grade A) sories wherever possible. (Grade D) ▸ When such non-invasive diagnostic techniques fail to identify a ▸ When it is necessary to use reusable accessories they must be responsible organism, bronchoscopy should be considered for cleaned according to the manufacturer’s recommendations. the diagnosis of ventilator-associated pneumonia. (Grade D) (Grade D) Du Rand IA, et al. Thorax 2013;68:i1–i44. doi:10.1136/thoraxjnl-2013-203618 i3  BTS guidelines ▸ Tracking of patient use of equipment and cleaning processes ▸ Medical histories of staff should be recorded including pre- must be completed after each use. (Grade D) existing asthma, skin and mucosal sensitivities. (Grade D) ▸ On the grounds of staff safety, manual disinfection is no ▸ Pre-employment baseline lung function, such as spirometry, longer recommended. (Grade D) should be measured and recorded. (Grade D) ▸ Bronchoscopes should be processed in automated endoscope ▸ Annual lung function measurements, such as spirometry, reprocessors (AERs). (Grade D) should be performed on all personnel directly exposed to ▸ Aldehyde-based disinfectants are no longer recommended. disinfectants. (Grade D) (Grade C) ▸ Immunisation against hepatitis B and TB should be con- ▸ Alternative, recommended disinfectants should be used in firmed in all bronchoscopy personnel before employment. accordance with the manufacturer’s instructions. (Grade D) Vaccinations should be offered if necessary. (Grade D) ▸ Disinfectant times should be those recommended by disin- ▸ Hypodermic needles or other sharp instruments should not fectant manufacturers. (Grade D) be used to remove tissue samples from biopsy forceps. ▸ Universal decontamination procedures should be performed Blunt-ended needles or sterile plastic toothpicks are prefer- before and after all procedures to avoid transmission of HIV. able. (Grade D) (Grade D) ▸ Reusable spiked forceps are not recommended. (Grade D) ▸ The use of 70% alcohol after final rinse is no longer recom- ▸ A minimum of two qualified nurses are required during mended as it is considered to act as a fixative. (Grade D) bronchoscopy procedures: one assistant nurse and another ▸ Drying cabinets/storage chambers are recommended for dedicated to monitoring the patient’s response to the medica- storing clean bronchoscopes. Compatibility of bronchoscopes tion and procedure. (Grade D) must be confirmed with individual instrument manufacturers. ▸ A qualified nurse is required to recover a patient after bron- (Grade D) choscopy. (Grade D) ▸ Bronchoscopes stored in drying cabinets or storage chambers ▸ Advanced procedures may require additional staff. should be reprocessed in accordance with the manufacturer’s (Grade D) recommendations. (Grade D) ▸ In patients with suspected TB, bronchoscopy should be per- ▸ When drying cabinets or storage chambers are not available, formed in an appropriately engineered and ventilated area, bronchoscopes must be stored in a hanging position, with and the bronchoscopy team should use adequate protection, sufficient space between instruments to avoid cross contamin- including masks. (√) ation. (Grade D) ▸ Valves must not be attached to bronchoscopes during PATIENT SATISFACTION storage. (Grade D) ▸ Verbal and written patient information explaining indications ▸ Bronchoscopes must be cleaned and disinfected before and and what to expect during the procedure, and potential com- after placing in carrying cases as these cases cannot be disin- plications should be provided to improve patient tolerance. fected. Bronchoscopes should not be stored in carrying cases. (Grade C) (Grade D) ▸ Patients should be offered sedation during FB to improve ▸ A record must be kept of each bronchoscope and reusable patient tolerance. (Grade B) accessory used on each individual patient. Tracking each step ▸ It is sufficient for patients to have no food by mouth for 4 h of the decontamination cycle and personnel involved should and to allow clear fluids by mouth up to 2 h before bron- also be recorded. This will facilitate tracing if an increase in choscopy. (Grade D) contamination by organisms is identified amongst bronchos- ▸ Patients who had sedation should be advised not to drive, copy patients. (Grade D) sign legally binding documents or operate machinery for ▸ AERs should be self-disinfected at the beginning of each day. 24 h after the procedure. (√) (Grade D) ▸ AERs must be validated on instillation and following intro- duction of new disinfectants according to Health Technical CONSENT Memorandum 01 (HTM-01). (Grade D) ▸ Practitioners undertaking FB should be familiar with, and ▸ Sterile water or filtered water should be used for the final adhere to the national and local guidance for obtaining rinse. Tap water is not recommended. (Grade D) informed consent. (√) ▸ Regular testing of AERs and final rinse water for mycobac- teria must be carried out according to HTM-01. (Grade D) ▸ Compatibility of bronchoscopes with disinfectant and AER INTRODUCTION manufacturers’ instruction should be checked. (√) Clinical context and need for a guideline ▸ A record of which bronchoscope and other reusable equip- Flexible bronchoscopy (FB) is a safe and frequently performed ment are used on an individual patient should be kept and procedure for the assessment, diagnosis, and treatment of also of the decontamination procedure. (√) patients with respiratory disease. The procedure and applica- ▸ There is currently no known decontamination method that tions of FB have progressively evolved and expanded since it prevents transmission of variant Creutzfeldt–Jakob disease was first introduced in 1968.1 FB is now established as an essen- (vCJD). Record keeping and identification of high-risk cases tial diagnostic and therapeutic tool in respiratory medicine. are advised. (√) The British Thoracic Society (BTS) published the 2001 guide- lines on diagnostic FB.2 This document is well respected, used STAFFING and referenced in the UK and beyond. Literature searches for ▸ Open troughs of disinfectant are not recommended. (Grade D) the 2001 guideline were completed in 1999, but numerous ▸ Staff handling disinfectants should always wear full personal studies have been published in this field since, providing protective equipment in line with COSHH (control of sub- adequate information to revise and update the evidenced-based stances hazardous to health) risk assessment. (Grade D) recommendations. i4 Du Rand IA, et al. Thorax 2013;68:i1–i44. doi:10.1136/thoraxjnl-2013-203618  BTS guidelines In August 2007 the Standards of Care Committee (SOCC) of Clinical questions and literature search the BTS invited the interventional pulmonology specialist advis- Clinical questions were gathered in the PICOT (Patient, ory group of the BTS to produce evidence-based guidelines for Intervention, Control, Outcome and Time) format to define the advanced diagnostic and therapeutic FB and to update and scope of the guideline and inform the literature search. revise the 2001 BTS guideline on diagnostic FB.2 The working Systematic electronic database searches were conducted to party decided to start with the new guideline on advanced diag- identify potentially relevant studies for inclusion in the guide- nostic and therapeutic FB which was published in November line. For each topic area the following databases were searched: 2011.3 The proposal to update and revise the BTS guideline on Ovid MEDLINE (from 1988) (including MEDLINE In Process), diagnostic FB was approved by the BTS SOCC in November Ovid EMBASE (from 1988), Ovid CINAHL (from 1982) and 2010 and work on the guideline started in February 2011. the Cochrane Library (from 1992) (including the Cochrane Appendix 1 of this guideline lists the members of the BTS Database of Systematic Reviews, the Database of Abstracts of Bronchoscopy Guideline Group. Reviews of Effects, the Cochrane Central Register of Controlled Trials, the Health Technology Assessment database and the NHS Target audience of the guideline Economic Evaluation Database). The search strategies are avail- This guideline is aimed primarily at respiratory practitioners in able in appendix 2. the UK but may be of relevance to other healthcare systems The searches were first run in January 2011 and were around the world. It is intended to inform those who undertake updated in January 2012 and June 2012. Searches were saved or intend to undertake FB and procedures described within the and alerts sent via email on a monthly basis to identify newly guideline, and to inform other healthcare professionals as to published literature to date. Searches included a combination of what may be the indications, procedures, likely response and indexed terms and free text terms, and were limited to English complications of FB in adults. Practitioners using this guideline language publications only. The initial search identified 22 865 need to ensure that they follow safe practices and keep patient potential papers. safety paramount at all times. Appraisal of the literature Scope of the guideline Appraisal was performed using the criteria stipulated by the This guideline was formulated following consultation with sta- AGREE collaboration. One individual (IDR) read the title and keholders from the medical and nursing professions, patient abstract of each article retrieved by the literature searches and groups and healthcare management. Basic diagnostic procedures decided whether the paper was (1) definitely relevant, (2) pos- in adults using a flexible bronchoscope are included in the sibly relevant or (3) not relevant to the project. A total of 9121 guideline. papers were identified to review for inclusion of the guideline. Criteria formulated for initial screening of the abstracts into Topics covered in the guideline these three groups were: ▸ Monitoring of a patient during the procedure. ▸ Whether the study addressed the clinical question. ▸ Specific precautions, contraindications and complications. ▸ Whether the appropriate study type was used to produce the ▸ Sedation, premedication and topical anaesthesia. best evidence to answer the clinical question. ▸ FB in specific patient groups. ▸ Abstract was in English. ▸ Role of bronchoscopy in infections. ▸ Studies in which exclusively rigid bronchoscopy was used ▸ FB in the ICU. were not evaluated. ▸ Cleaning and disinfection of equipment. ▸ Abstracts were not rejected on the basis of the journal of ▸ Staffing and staff safety. publication, country in which the research was performed or ▸ Diagnostic accuracy and specific procedures. published or the date of publication. ▸ Patient satisfaction and patient care. The full paper was obtained for all relevant or possibly rele- vant abstracts and allocated to the relevant section(s): Topics not covered in the guideline ▸ Sedation, premedication and topical anaesthesia. ▸ Training in bronchoscopy (The BTS is producing separate ▸ Monitoring, precautions, contraindications and complications. guidance on training). ▸ Specific conditions. ▸ Advanced diagnostic and therapeutic FB.3 ▸ Bronchoscopy in the ICU. ▸ Rigid bronchoscopy. ▸ Infections. ▸ FB used for intubation, percutaneous tracheostomy place- ▸ Cleaning, disinfecting and staff safety. ments and intraoperative complications. ▸ Diagnostic accuracy. ▸ Paediatric FB. ▸ Patient satisfaction and consent. ▸ FB performed under general anaesthetic. The first screening process identified 9121 abstracts to be reviewed, 1824 abstracts did not meet the criteria as set out above, 1504 studies used FB to collect samples for research pur- METHODOLOGY poses and 1731 case reports in FB were identified. Two guide- This guideline is based on the best available evidence and is a line reviewers independently reviewed the abstracts of the revised update of the BTS guideline on diagnostic FB2 published remaining 4062 studies to identify 2197 papers to be appraised in 2001. The methodology used to write the guideline adheres for the guideline. The two leads for each section independently strictly to the criteria as set by the BTS guideline production appraised each paper assigned to them using the Scottish manual and the Appraisal of Guidelines for Research and Intercollegiate Guidelines Network (SIGN) critical appraisal Evaluation (AGREE) collaboration in the document ‘The checklists. A web-based guideline development tool (http://www. AGREE Instrument’, which is available online: http://www. bronchoscopy-guideline.org, designed by IDR) was used for agreecollaboration.org/1/agreeguide/ 1505 critical appraisals of 522 studies. The website enabled Du Rand IA, et al. Thorax 2013;68:i1–i44. doi:10.1136/thoraxjnl-2013-203618 i5  BTS guidelines each pair of reviewers to collaborate online and produce evi- Table 2 Grades of recommendations used for this guideline dence tables electronically. The reliability of the evidence in each individual study was graded using the SIGN critical Grade Type of evidence appraisal checklists and is shown in the evidence tables (++, + A At least one meta-analysis, systematic review or RCT rated as 1++ and or −). The body of evidence for each recommendation was sum- directly applicable to the target population or marised into evidence statements and graded using the SIGN A systematic review of RCTs or a body of evidence consisting principally grading system (see table 1). Disagreements were resolved by of studies rated as 1+ directly applicable to the target population and discussion with the section partner and the Guideline Group. demonstrating overall consistency of results B A body of evidence including studies rated as 2++ directly applicable to the target population and demonstrating overall consistency of results or Considered judgement and grading of the evidence Extrapolated evidence from studies rated as 1++ or 1+ The Guideline Group used the online derived evidence tables to C A body of evidence including studies rated as 2+ directly applicable to judge the body of evidence and grade recommendations for this the target population and demonstrating overall consistency of results or Extrapolated evidence from studies rated as 2++ guideline. The evidence tables are available in appendix 3 for D Evidence level 3 or 4 or review and are published electronically on the BTS website. Extrapolated evidence from studies rated as 2+ When evidence was lacking to answer the formulated clinical √ An important practical point for which there is no research evidence, nor questions, expert opinions were obtained for formal consensus is there likely to be any research evidence. The guideline group wishes statements using the Delphi method. to emphasise these as good practice points The following were considered in grading the recommendations: RCT, randomised controlled trial. ▸ The available volume of the body of evidence. ▸ How applicable the obtained evidence was in making recom- mendations for the defined target audience of this guideline. the use of different grading systems rather than a change in the ▸ Whether the evidence was generalisable to the target popula- recommendation itself. tion for the guideline. ▸ Whether there was a clear consistency in the evidence Drafting of the guideline obtained to support recommendations. The Guideline Group corresponded regularly by email and ▸ What the implications of recommendations will be on clin- meetings of the full group were held in February 2011, ical practice in terms of recourses and skilled expertise. September 2011, December 2011, March 2012, May 2012 and ▸ Cost effectiveness was not reviewed in detail as in-depth eco- June 2012. The guideline was discussed at an open session at nomic analysis of recommendations falls beyond the scope of the BTS Summer Meeting in July 2012. A revised draft guide- this guideline. line document was circulated to all the relevant stakeholders for Recommendations were graded from A to D according to the consultation in July 2012 followed by a period of online con- strength of the evidence, as listed in table 2. Important practical sultation. The BTS SOCC reviewed the draft guideline in June points lacking any research evidence were highlighted as ‘good 2012. A list of stakeholders is available for review in appendix 4 practice points’ (√). of this guideline. The grading system used to grade recommendations for this revised guideline differs from the system used to grade the recommendations for the 2001 BTS guideline on diagnostic FB, shown in table 3. Readers of the guideline are therefore advised Table 3 Grading system used in the 2001 British Thoracic Society to review both grading systems and to note that apparent (BTS) guideline on diagnostic flexible bronchoscopy changes in recommendations between guidelines may be due to Level Evidence Ia Evidence obtained from meta-analysis of RCTs Ib Evidence obtained from at least one RCT Table 1 Revised grading system for levels of evidence in IIa Evidence obtained from at least one well designed controlled study evidence-based guidelines without randomisation Grade Evidence IIb Evidence obtained from at least one other type of well designed quasi-experimental study 1++ High-quality meta-analyses, systematic reviews of RCTs or RCTs with a III Evidence obtained from well designed non-experimental descriptive very low risk of bias studies such as comparative studies, correlation studies and case– 1+ Well conducted meta-analyses, systematic reviews of RCTs or RCTs with controlled studies a low risk of bias IV Evidence obtained from expert committee reports of opinions and/ 1− Meta-analyses, systematic reviews or RCTs, or RCTs with a high risk of or clinical experiences of respected authorities bias 2++ High-quality systematic reviews of case–control or cohort studies, or Grade Type of recommendation high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal A (Ia, Ib) Requires at least one RCT as part of a body of literature of overall 2+ Well conducted case–control or cohort studies with a low risk of good quality and consistency addressing the specific confounding, bias or chance and a moderate probability that the recommendation relationship is causal B (IIa, IIb, Requires availability of well conducted clinical studies but no RCTs 2− Case–control or cohort studies with a high risk of confounding, bias or III) on the topic of recommendation chance and a significant risk that the relationship is not causal C (IV) Requires evidence from expert committee reports or opinions and/ 3 Non-analytic studies, for example, case reports, case series or clinical experience of respected authorities. Indicates absence of 4 Expert opinion directly applicable studies of good quality RCT, randomised controlled trial. RCT, randomised controlled trial. i6 Du Rand IA, et al. Thorax 2013;68:i1–i44. doi:10.1136/thoraxjnl-2013-203618  BTS guidelines The Guideline Group members adhered to the BTS policy for studies, included tachycardia/bradycardia, major and minor the Declaration of Interests, and if appropriate, specific interests bleeding, bronchospasm/laryngospasm, cough, dyspnoea, sore are declared in appendix 1. throat, apnoea, seizure, desaturation, pneumothorax and pul- The guideline will be reviewed within 5 years from the date monary oedema. Other smaller studies report complication rates of publication (2018). of 5–32%, and mortality rates of 0–0.8%, but these studies are limited by their retrospective nature, the variable definition of AUDIT AND RESEARCH RECOMMENDATIONS adverse events and limited follow up. Audit: Smaller prospective studies suggest that the rate of adverse ▸ All those undertaking FB are advised to maintain personal events may be higher than previously reported. Hehn et al5 records of each procedure, including indication, outcome demonstrated respiratory complications in 4.3%, non- and complications for audit purposes. respiratory complications in 2.8% and mortality in 0.1%. In ▸ Periodic audit of bronchoscopy practice, including patient addition, Bechara et al6 reported adverse events in 35% of 300 satisfaction surveys. bronchoscopies performed, 60% of which were classified as Research: mild and 8% as severe. Approximately 6% of patients were hos- ▸ Utility of all bronchoscopic samples, including brush and pitalised and procedure-related deaths occurred in 1.4%.6 BAL for phenotyping and genotyping in patients with There is an increased risk of adverse events with increasing advanced non-small cell lung cancer (NSCLC). age but the absolute frequency is low. Chronological age should ▸ Randomised assessment of the utility of bronchoscopy in the not be a contraindication for bronchoscopy.5 7 Patient position relief of lobar collapse/atelectasis in ventilated patients. during the procedure does not influence complication rates, ▸ Further assessment of the use of jet ventilation during bron- with the exception that desaturation >4% is more common in choscopy in mechanically ventilated patients. the sitting position.8 ▸ Further assessment of optimal analgesia and sedation for safe Many factors will influence the risk of complications, includ- bronchoscopy in mechanically ventilated patients. ing patient characteristics and factors related to the broncho- scopic unit (including sedation practice and the sampling procedures employed). Utilisation of a WHO safety Training checklist aids in identifying specific possible complications (see Training in FB does not fall in the scope of this guideline. appendix 5) Complications, particularly serious adverse events (box 1), patient satisfaction and efficacy should be routinely Audit standards monitored by every bronchoscopy unit. The following standards provide criteria which may form the Recommendation basis of future audits: ▸ All patients undergoing bronchoscopy should have heart ▸ A serious adverse event rate of 4% and Box 1 Suggested serious adverse events SpO2