FUNDA 2

• Bronchoscopy


  An invasive procedure for visualization of the upper and lower respiratory tract

  
• Bronchoscopy


  • Used for the diagnosis and management of a spectrum of inflammatory, infectious, and malignant diseases of the airway and lungs
  • Used as a diagnostic and therapeutic tool for management of the airway

  
• Bronchoscopy procedure


  Performed by a specially trained physician bronchoscopes and is assisted by a specially trained health care professionals

  
• Purposes of bronchoscopy


  • Retrieval of tissues specimens (bronchial brush, forceps, and needle)
  • Cell washings
  • Bronchoalveolar lavage
  • Coagulation
  • Removal of abnormal tissue by laser
  • Inspect the airway
  • Remove objects from the airway
  • Place devices into the airway

  
• Settings for bronchoscopy


  • Bronchoscopy room or suite
  • Bedside in the intensive care unit (ICU)
  • Operating room

  
• Resources for bronchoscopy

  • Rigid Bronchoscope
  • Flexible Bronchoscope

  
• Advanced bronchoscopy techniques

  • Endobronchial Ultrasound (EBUS) - Convex and Radial
  • Navigational bronchoscopy - Computer assisted and High resolution CT-scan
• Indications for bronchoscopy


  • Investigate hemoptysis, persistent unexplained cough, dyspnea, localized wheeze, or stridor
  • Evaluate lesions of unknown etiology on the chest radiograph film
  • Evaluate recurrent pneumonia, persistent atelectasis or pulmonary infiltrates
  • Suspected or known bronchogenic carcinoma
  • Obtain lower respiratory tract secretions, cell washings, and biopsies for cytologic, histologic, and microbiologic evaluation
  • Determine the location and extent of injury from toxic inhalation or aspiration
  • Evaluate problems associated with endotracheal or tracheostomy tubes
  • Aid in performing difficult intubations or percutaneous tracheostomies
  • Evaluate unexplained lung collapse or secretions/mucus plugs causing atelectasis
  • Evaluate foreign body aspiration, chemical-related, or burn-related injury to the airway
  • Remove abnormal endobronchial tissue or foreign material

  
• Diagnostic indications for standard bronchoscopy

  • Suspected infection
  • Parenchymal nodules or masses
  • Mediastinal lymphadenopathy or masses
  • Hemoptysis
  • Suspected airway obstruction
  • Persistent atelectasis
  • Abnormal or persistent opacities on chest imaging
  • Suspected lung transplantation rejection
  • Suspected trachoebronchomalacia
  • Suspected tracheoesophageal fistula
• Diagnostic indications for bronchoscopy on intubated patients

  • Ventilator associated pneumonia
  • Hemoptysis
  • Airway obstruction
  • Persistent atelectasis
  • Smoke inhalation
  • Tracheoesophageal fistula
  • Bronchopleural fistula
  • Unexplained pulmonary opacities

  
• Indications for therapeutic bronchoscopy

  • Mucus accumulation unresponsive to broncho-pulmonary hygiene
  • Foreign bodies
  • Endotracheal tube management
  • Laser therapy
  • Photodynamic therapy
  • Electrocoagulation
  • Cryotherapy
  • Balloon dilatation
  • Brachytherapy catheters
  • Tracheobronchial stents
  • Bronchial thermoplasty

  
• Absolute contraindications for bronchoscopy

  • Absence of informed consent
  • Profound refractory hypoxemia
  • Severe bleeding uncorrectable before the procedure
  • Malignant cardiac arrhythmias
• Relative contraindications for bronchoscopy

  • Lack of patient cooperation
  • Recent myocardial infarction or angina
  • Respiratory failure
  • Uncontrolled hypertension
• Hazards and complications of bronchoscopy

  • Adverse effects of medication used before and during the bronchoscope procedure
  • Hypoxemia
  • Hypercarbia
  • Bronchospasm
  • Hypotension
  • Laryngospasm, bradycardia
  • Mechanical complications
  • Increased airway resistance
  • Death
  • Infection hazards for health care workers or other patients
  • Cross-contamination of specimens or bronchoscopes
  • Nausea, vomiting
  • Fever and chills
  • Cardiac dysarthythmias
• Medications used for bronchoscopy

  • Topical anesthetic (lidocaine 1%, 2%, 4%, benzocaine 14%)
  • Anticholinergic agent (atropine, glycopyrrolate)
  • Sedative agents (codeine, midazolam, morphine, hydroxyzine)
  • Intravenous sedative (midazolam, propofol, diazepam, fentanyl)
  • Benzodiazepine antagonist (flumazenil), narcotic antagonist (Narcan)
  • Sterile nonbacteriostatic 0.9% NaCl solution
  • Vasoconstrictor for bleeding control (dilute epinephrine, 1:10,000)
  • Inhaled beta agonist (albuterol, metaproterenol, levalbuterol)
  • Water-soluble lubricant or combined lubricant/anesthetic (viscous lidocaine)
  • Nasal decongestant (pseudoephedrine)
  • Mucolytic or mucokinetics (10% or 20% acetylcysteine, 7.5% sodium bicarbonate)
  • Emergency and resuscitation drugs
• Moderate (Conscious) Sedation


  A level of sedation where the patient is responsive to verbal commands
• Drugs used for moderate (conscious) sedation

  • Midazolam (Benzodiazepine)
  • Lorazipam (Ativan) (Benzodiazepine)
  • Diazepam (Valium) (Benzodiazepine)
  • Propofol (Diprivan) (Sedative)
  • Fentanyl (Opiod/Narcotic)
  • Mederidine (Demerol) (Opiod/Narcotic)
• Lidocaine


  A class 1b anti-arrhythmic drug used for topical anesthesia, with a peak concentration in 20-30 minutes, and a goal of less than 8mg/kg total dose
• Lidocaine dosing routes

  • Gargle: 2.5 of 2% = 50mg
  • Atomizer: 10mL of 1% = 100mg, 10mL of 2% = 200mg
  • Nebulizer: 3mL of 1% = 60mg, 3mL of 2% = 120mg, 3mL of 4% = 240mg
  • Jelly: 5mL of 2% = 100mg
  • Syringes: 1mL of 2% = 20mg
• Lidocaine dosing example

  For a 70kg man: 50mg gargle, 200mg atomizer, 100mg lidocaine jelly, total 560mg (70kg x 8mg/kg)
• Levels of sedation

  • Light sedation (anxiolytics)
  • Moderate (conscious) sedation
  • Deep sedation -general anesthesia
• Patient monitoring during bronchoscopy

  • Level of consciousness
  • Medications administered, dosage, route, and time of delivery
  • Subjective response to procedure (eg. Pain, discomfort, dyspnea)
  • Blood pressure, breath sounds, heart rate, rhythm, and changes in cardiac status
  • Spo2, FiO2 and ETCO2
  • Tidal volume, peak inspiratory pressure, adequacy of inspiratory flow, and other ventilation parameters if subjects is being mechanically ventilated
  • Lavage volume (delivered and retrieved)
  • Site of biopsies and washings
  • Lab tests requested on each sample
• Post-procedure monitoring


  • Periodic follow-up monitoring of patient condition for 24-48 hours for inpatients
  • Outpatients should be instructed to contact the bronchoscopist regarding fever, chest pain or discomfort, dyspnea, wheezing, hemoptysis, or any new findings presenting after the procedure
  • Oral and written instructions with contact information should be provided
• Physiologic and mechanical alterations associated with flexible bronchoscopy in intubated patients

  • Transient hypoxemia
  • Tension Pneumothorax
  • Bronchial hemorrhage greater than 30 mL (6%)
  • Hypotension with mean arterial pressure less than 60mmHg
  • Tachycardia greater than 140
• Bronchoalveolar Lavage (BAL)


  A diagnostic technique where normal saline is instilled into the large airways or bronchial tubes and then aspirated/suctioned back to obtain specimens from the alveolar level of the lungs for analysis

  
• Uses and role of BAL

  • Identify microbiologic or cellular abnormalities to diagnose infection, pulmonary hemorrhage, malignancy, pulmonary alveolar proteinosis, eosinophilic lung disease, Langerhans cell histocytosis, lipoid pneumonia, diffuse alveolar hemorrhage
• Bronchial Washings


  Obtained from the large airways for cytologic examination for cancer and microbiologic analysis to diagnose mycobacterial or fungal infections

  
• Bronchial Brushings


  An adjunct diagnostic test to obtain cells from the surface of a suspicious lesion for cytology examination
• Endobronchial Biopsy


  A technique using flexible forceps to obtain a tissue sample from a visible end-bronchial lesion
• At least five biopsies are usually performed to obtain an adequate sample
• Brushing technique


  1. Insert bronchoscope

  2. Direct to target site

  3. Assistant advances brush 3cm from bronchoscope

  4. Brush retracted into sheath

  5. Brush pulled back through working channel
• Specimen collection


  1. Cells smeared onto slide

  2. Brush end cut off and placed in fixative solution
• Brushing is usually performed after obtaining all the other specimens to avoid bleeding or cellular degradation
• Endobronchial biopsy


  1. Insert flexible forceps through operating channel

  2. Forceps tip in neutral position

  3. Forceps fully opened and rotated for best approach

  4. Forceps pushed against lesion
• At least five biopsies should be taken at the same location to maximize the chance of obtaining histological evidence of neoplasia
• Endobronchial biopsy sensitivity


  • Highest for central cancer lesions (0.74)
  • Followed by brushings (0.59)
  • Followed by washings (0.48)
• Tracheobronchial biopsy


  1. Insert fenestrated alligator forceps through working channel

  2. Forceps gently pushed to lung periphery and opened 5-6mm proximal to area to be biopsied

  3. Forceps advanced to lesion and closed
• If the patient feels pain during tracheobronchial biopsy, it is preferable to withdraw the forceps and choose another point to biopsy
• After tracheobronchial biopsy, the bronchoscope must be maintained in the wedge position to detect or control any bleeding and keep the best position for the next biopsy
• Tracheobronchial biopsy is performed in the diagnostic work-up of diffuse lung infiltrates, with a yield in the order of 75%