Bronchoscopy is primarily used as a diagnostic tool.
VOL: 99, ISSUE: 41, PAGE NO: 52
Julie Martin, BSc, RGN, Dip(Respiratory), is nurse bronchoscopist. South Manchester University Hospital NHS Trust
It is also useful as a therapeutic tool, for example, for stenting of the airways using interventional bronchoscopic techniques.
Indications for bronchoscopy
The indications for diagnostic and therapeutic bronchoscopy are listed in Boxes 1 and 2. These lists are not exhaustive, as new techniques are constantly developed and evaluated.
Preparation of the patient
This is essential before the patient undergoes a bronchoscopy, because effective preparation will facilitate a safe and successful procedure.
Patient information and consent When a bronchoscopy has been requested, for example, in the outpatient department, the patient must be given a full explanation of the procedure and the preparation required. This will prepare him or her for any possible unpleasant experiences and will help to gain his or her cooperation and confidence.
The bronchoscopist will also need to gain the patient’s informed consent before the examination. The practitioner will therefore need to explain the risks, benefits and alternatives of the procedure followed by a full step-by-step explanation of the intended investigation (Department of Health, 2001).
The unpleasant taste of the local anaesthesia and the numb ‘blocking’ sensation that follows should be described to the patient in advance. The bronchoscopist should also make the patient aware of the cough reflex he or she will experience when the vocal cords and bronchial tree are anaesthetised.
Because patients are sedated for the procedure, it is important to inform them, at the earliest opportunity, that they must make arrangements to be accompanied home after bronchoscopy. Patients also need to be aware that they should not drive or operate machinery for 24 hours after the procedure.
Intake of diet, fluids and drugs The patient must refrain from eating and drinking for four to six hours before the procedure. This reduces the risk of aspiration of gastric contents during the bronchoscopy.
If the patient is taking any medication, this should be taken at the usual time with a minimal amount of fluid. Patients with diabetes should follow their doctor’s instructions regarding their treatment. Any patients on anticoagulant therapy will need to have an international normalised ratio (INR) blood test. The results may indicate that they will need to abstain from taking their medications before the investigation.
Prophylactic antibiotics may be required for patients with prosthetic heart valves or a history of endocarditis.
Assessment before the procedure Blood pressure, respiration rate, pulse rate and oxygen saturations are recorded during the nursing assessment, when any concurrent medical problems, drug therapy and history of allergies are also noted.
Patients with chronic obstructive pulmonary disease should have their lung function assessed using spirometry, to establish whether they are fit to have the procedure. Patients with oxygen saturations of less than 93 per cent on air should also have their arterial blood gases measured (British Thoracic Society, 2001).
Intravenous access is necessary throughout the procedure for administering sedation and related drugs; the cannula remains in place until the patient has recovered.
Care during the procedure
While the procedure is being carried out, the nurse must monitor the patient’s pulse, respirations and oxygen saturation levels using a pulse oximeter. Electrocardiography is not monitored routinely unless the patient has a known history of severe cardiac disease (BTS, 2001). Any fall in oxygen saturation is treated with supplemental oxygen via a nasal cannula.
Lignocaine gel and topical lignocaine are used to anaesthetise the airways. Topical lignocaine is inserted in the main airways via an insertion channel on the bronchoscope. The BTS (2001) recommends using the minimum amount required to facilitate a comfortable investigation. The nurse assisting the bronchoscopist should monitor and record the amounts used.
Intravenous sedation is given in incremental doses until the patient is adequately sedated. A rousable though amnesic effect is optimal, enabling the patient to follow instructions, such as to inhale deeply or produce specific sounds while the vocal cords are examined. The nurse must look for any changes in breathing pattern, chest pain or any other signs of discomfort.
The bronchoscopist is in a position to see any bleeding in the airways and may wish to inject adrenaline on to the affected area to reduce bleeding. Adrenaline 1/1000 diluted in 0.9 per cent saline should be readily available during the procedure.
More advanced interventional techniques require additional, specialised monitoring.
Staff should wear protective clothing in accordance with local infection-control policies. Patients will cough during the procedure, so steps must be taken to avoid transmission of infections such as HIV and tuberculosis.
Patients with HIV or TB should be scheduled to have their bronchoscopy at the end of the list. Because the injection of topical anaesthesia induces a cough, it will be necessary to nurse such patients in isolation immediately following the procedure.
Trust guidelines on decontaminating clinical areas and equipment must be followed. Bronchoscopy instruments must be thoroughly cleaned and disinfected according to the manufacturer’s and the trust’s guidelines after each examination, to remove any risk of cross-infection.
During and after the procedure, the nurse assisting the bronchoscopist will need to document the patient’s oxygen saturation levels, percentage of oxygen administered during the procedure, administration of sedation and related drugs, and any samples taken
Any adverse events, including bleeding and wheezing, should be documented. This information provides the recovery nurse with a clear picture of the procedure the patient has experienced and gives an indication of the expected recovery.
Care after bronchoscopy
For an hour after the procedure, the patient’s vital signs must be monitored regularly according to their general condition. For example, a frail older person may need closer monitoring than a young healthy adult (Prakash, 1994). Changes in breathing pattern, chest pain or oxygen saturation levels should be reported to medical staff.
When the patient is no longer experiencing the effects of the intravenous sedation, he or she can be allowed to sit up. Similarly, the patient may be offered a drink when the effects of local anaesthesia on the airway have worn off and an adequate swallowing reflex has returned.
Bronchoscopy is a safe procedure for most patients, with a mortality rate of 0.01 per cent (Busick, 2002). However, all procedures carry risks and patients must be informed of these before consent to the procedure is obtained.
- Previously unknown drug reactions may occur during the procedure. Careful monitoring of the patient is important for prompt detection of any reactions; resuscitation equipment must always be available;
- The bronchoscope is passed through the nasal or oral cavity, so the patient may have a sore throat or nose, or a slight nose bleed after the procedure. These effects can be minimised by using local anaesthetic gel and spray, as well as ensuring the patient does not talk once the bronchoscope has passed through the vocal cords. Any discomfort of this nature will usually pass quickly;
- The injection of local anaesthesia will cause coughing. If the patient has been referred because they have a cough, they must be made aware that it will not improve after the examination and may become worse for a few days;
- The patient may wheeze during or after the procedure. This is particularly common in patients with asthma. The injection of saline and local anaesthesia may exacerbate asthma symptoms;
- Oxygen saturations may decrease during the procedure, particularly in patients who have a reduced respiratory reserve. Supplemental oxygen via a nasal catheter usually rectifies this problem. Some bronchoscopists administer oxygen throughout the procedure, although caution is advised for patients with carbon dioxide retention (BTS, 2001);
- A low-grade pyrexia can also occur but any significant fevers must be reported to medical staff;
- The insertion of a bronchoscope can cause trauma to the patient, particularly if the nasal anatomy is difficult to pass. Coughing while the bronchoscope is in the airway can also cause trauma. In such situations, the patient may notice a slight streaking of blood in his or her sputum;
- Bleeding can occur when biopsies, particularly of tumours, are taken. This can sometimes cause significant bleeding and may require the application of adrenaline directly on to the area. When bleeding occurs, the patient should be nursed on the affected side to prevent blood entering the opposite lung. Any uncontrolled bleeding may require further investigation;
- Biopsies taken beyond the field of vision of the bronchoscopist are associated with an increased risk of a pneumothorax (Prakash, 1994). A chest X-ray will reveal the extent of this and may indicate the need for further treatment.
Advice on discharge
Before leaving the department, the patient’s intravenous cannula will be removed and the bronchoscopist must provide an explanation of events. The patient and accompanying relatives or carers will be given discharge instructions advising them of the possible complications.
This should include the contact details of a nurse who can offer support or advice to the patient should they have any concerns. Before the patient leaves the department, a written follow-up appointment should also be given.
Bronchoscopy is a safe procedure for the majority of patients and a useful tool for both diagnostic and therapeutic purposes. Patients will require monitoring before, during and following the procedure.