Special Procedures

1. Special Procedures Bronchoscopy Dr. Abdul-Monim Batiha

2. Definition and Terminology • Endoscopy • Use of instrument to look into various parts of the body to diagnose various diseases or explain certain conditions • Bronchoscopy • Procedure that allows visualization of the airways below the larynx

3. Equipment • A bronchoscope is an instrument about 3ft long and 0.5 ins or smaller in diameter that combines four narrow chambers into one tube • One lumen contains a fiber-optic light source so that structures can be viewed effectively • 2nd chamber lumen is attached to a suction device & airway secretions can be removed • 3rd chamber has tiny metallic alligator forceps that can be extended past the proximal end for tissue biopsies • 4th chamber lumen allows passage of a small wire brush that can be passed vigorously over airway structures for collection of tissue cells for microscopic evaluation

6. Equipment • Flexible or Rigid • Adult sizes • 5.0 mm OD to 6.0 mm OD • Pediatric sizes • Most manufacturers provide scopes in sizes 3.5 mm OD or less appropriate for children. No channel outlet may exist for suctioning because of its small size

7. Diagnostic Suspected foreign body Suspected malignancy Bronchial washings Hemoptysis Persistent problems Therapeutic Foreign-body obstruction Secretion removal Bronchial lavage Stenosis atelectasis Indications

11. Procedure • Topical anesthetic (lidocaine) is administered to control gag/cough reflex and prevent bronchospasm • 5 – 10 cc 4% lidocaine aerosolized to upper airway delivered by a mask nebulizer • Benzocaine nasal sprays • 2% lidocaine instilled into the hypopharynx in 2 cc incements • Intubation preferred but not required. Intubation will not allow visualization of the vocal cords • Scope is inserted and the airways viewed • O2 needs to be provided to patient via mask or by removing one prong of the nasal cannula from the nose to allow for insertion of the scope

12. Procedure • Diagnostic and/or therapeutic procedures are performed • Intubated patients on vents need special adapters for advancement of the scope. Adapter should allow for: • No loss of ventilating pressures • No loss of PEEP • Continuous monitoring of EKG and O2 saturation by pulse oximeter is recommended • Equipment is cleaned by decontamination with alkaline glutaraldehyde

14. Adapter for intubated patients

15. Rigid bronchoscopy • Diagnostic use • Biopsy of tumors within the main airway • Therapeutic use • Treatment of massive hemoptysis by cold-saline lavage or placement of Fogarty catheter to occlude the airway • Removal of foreign bodies in infants and small children • Aspiration of inspissated secretions • Limitations • observing or treating beyond the right or left mainstem bronchus • Dz or trauma of cervical spine who cannot hyperextend neck • Dz or trauma of jaw who cannot open their mouth wide

18. RCP responsibilities • Inform patient of procedure and obtain consent form. Prepare patient and explain procedure • Nebulize a topical/local anesthetic • Check fiberoptic unit for proper functioning • Set up and monitor patient’s ECG and SpO2 • Administer O2 and monitor vital signs • Collect suctioned or other specimens for C&S • Perform biopsies and brushings for cytology • Operate any photographic equipment • Tend to patient comfort • Disinfect the equipment between patients

20. Hazards and complications • Most common complication is mild epistaxis • Bronchospasm or laryngospasm • From irritation of the airway • Bleeding • Hypoxemia • Arrhythmias • From vagal stimulation. Monitor ECG and remove scope until cardiac status is stabilized • Seizures • Aspiration • Pneumothorax • Respiratory depression

24. Contraindications • Refractive hypoxemia • Bleeding disorders • Cardiovascular instability • Status asthmaticus • Marked hypercpanea