Bronchoscopy

This test allows direct visualization of the larynx, trachea, and bronchi through a flexible fiber-optic bronchoscope or a rigid metal bronchoscope. Although a flexible fiber-optic bronchoscope allows a wider view and is used more often, the rigid metal bronchoscope is required to remove foreign objects, excise endobronchial lesions, and control massive hemoptysis. A brush, biopsy forceps, or catheter may be passed through the bronchoscope to obtain specimens for cytologic examination.

Purpose

• To visually examine a tumor, an obstruction, secretions, bleeding, or a foreign body in the tracheobronchial tree
• To help diagnose bronchogenic carcinoma, tuberculosis, interstitial pulmonary disease, and fungal or parasitic pulmonary infection by obtaining a specimen for bacteriologic and cytologic examination
• To remove foreign bodies, malignant or benign tumors, mucus plugs, and excessive secretions from the tracheobronchial tree

Patient preparation

• Explain to the patient that this test is used to examine the lower airways.
• Describe the procedure, and instruct the patient to fast for 6 to 12 hours before the test.
• Tell him who will perform the test and where and that the procedure takes 45 to 60 minutes.
• Tell the patient that a chest X-ray and blood studies will be performed before the bronchoscopy and afterward, if appropriate.
• Advise him that he may receive a sedative I.V. to help him relax.
• If the procedure isn't being performed under general anesthesia, inform the patient that a local anesthetic will be sprayed into his nose and mouth to suppress the gag reflex. Warn him that the spray has an unpleasant taste and that he may experience discomfort during the procedure.
• Reassure him that his airway won't be blocked during the procedure and that oxygen will be administered through the bronchoscope.
• Make sure the patient or a responsible family member has signed a consent form.
• Check the patient's history for hypersensitivity to the anesthetic.
• Obtain baseline vital signs.
• Administer the preoperative sedative.
• If the patient is wearing dentures, have him remove them before he receives the sedative.

Equipment

Flexible fiber-optic bronchoscope, sedative, local anesthetic (spray, jelly, or liquid), sterile gloves, sterile container for microbiology specimen, container with 10% formaldehyde solution for histology specimen, Coplin jar with 95% ethyl alcohol for cytology smears, six glass slides (frosted, if possible, or with frosted tips), emesis basin, handheld resuscitation bag with face mask, oral and endotracheal airways, continuous suction equipment, laryngoscope, oxygen delivery equipment, ventilating bronchoscope for a patient requiring controlled mechanical ventilation

Procedure and posttest care

• Place the patient in the supine position, or have him sit upright in a chair.
• Tell him to remain relaxed with his arms at his sides and to breathe through his nose.
• Provide supplemental oxygen by nasal cannula, if necessary.
• After the local anesthetic is sprayed into the patient's throat and takes effect, a bronchoscope is introduced; it's used to inspect the anatomic structure of the trachea and bronchi, observe the color of the mucosal lining, and note masses or inflamed areas.
• Biopsy forceps may be used to remove a tissue specimen from a suspect area, a bronchial brush may be used to obtain cells from the surface of a lesion, and a suction apparatus may be used to remove foreign bodies or mucus plugs.
• After collection, place the specimens in their respective, properly labeled containers and send them to the laboratory at once.
• Check vital signs every 15 minutes until the patient is stable and then every 30 minutes for 4 hours, every hour for the next 4 hours, and then every 4 hours for 24 hours. Immediately notify the doctor of any adverse reactions to the anesthetic or sedative.
• Place the conscious patient in semi-Fowler's position; place the unconscious patient on his side with his head slightly elevated to prevent aspiration.
• Provide an emesis basin, and instruct the patient to spit out saliva rather than swallow it. Observe sputum for blood, and report excessive bleeding immediutely.
• Tell the patient who has had a biopsy to refrain from clearing his throat and coughing, which may dislodge the clot at the biopsy site and cause hemorrhaging.
• Immediately report subcutaneous crepitus around the patient's face and neck because this may indicate tracheal or bronchial perforation.

Clinical Alert Watch, listen for, and immediately report symptoms of respiratory difficulty resulting from laryngeal edema or laryngospasm, such as laryngeal stridor and dyspnea. Observe for signs of hypoxemia, pneumothorax, bronchospasm, and bleeding.

• Restrict food and fluids to avoid aspiration until the gag reflex returns (usually in 1 to 2 hours). Then the patient may resume his usual diet, beginning with sips of clear liquid or ice chips.
• Reassure the patient that hoarseness, loss of voice, and sore throat are temporary. Provide lozenges or a soothing liquid gargle to ease discomfort when his gag reflex returns.

Precautions

• A patient with respiratory failure who can't breathe adequately by himself should be placed on a ventilator before bronchoscopy.
• Send the specimens to the laboratory immediately.

Normal Findings

The trachea normally consists of smooth muscle containing C-shaped rings of cartilage at regular intervals, and it's lined with ciliated mucosa. The bronchi appear structurally similar to the trachea; the right bronchus is slightly larger and more vertical than the left. Smaller segmental bronchi branch off the main bronchi.

Abnormal findings

Bronchial wall abnormalities include inflammation, swelling, and tumors. Endotracheal abnormalities include stenosis, compression, and abnormal bifurcation due to diverticulum.

Abnormal substances in the trachea or bronchi include blood, secretions, and foreign bodies. They'll be removed and sent for culture and cytologic examination.

Results of tissue and cell studies may indicate interstitial pulmonary disease, bronchogenic carcinoma, tuberculosis, or other pulmonary infections, such as Pneumocystis carinii pneumonia and aspergillosis. Correlation of radiographic, bronchoscopic, and cytologic findings with clinical signs and symptoms is essential.

Interfering factors

• Failure to observe pretest restrictions
• Failure to place specimens in the appropriate containers or to send them to the laboratory immediately
• Patient's inability to cooperate if the procedure is done under local anesthesia