RCP 330 QUIZ4

- quiz 4

Indications of flexible bronchoscopy: 

• Flexible bronchoscopy is indicated for diagnostic or therapeutic reasons.

- Diagnostic indications

• Radiographic finding suggestive of neoplasia

• Pneumonia

• Hemoptysis

• Persistent atelectasis

• Unexplained persistent pleural effusion

• Unexplained paralysis of a  Hemidiaphragm

• Interstitial lung disease

• Unexplained hoarseness

- Therapeutic indications

• Atelectasis (to remove mucous plugs and secretions)

• Removal of foreign bodies

• Tamponade of a bleeding source

- Miscellaneous indications

• Difficult intubations (like Mallampati)

• Research

divisions of flexible bronchoscopy: 

- Fiberoptic: gathers the images from the distal tip of the instrument that are visualized through the eyepiece

- Video: gathers the images from the endobronchial tree and transmit them to the image processing unit

- Hybrid: uses fiberoptic imaging system but also converts the information in a digital format

Indications for rigid bronchoscopy

• Rigid bronchoscopy is most commonly used for large foreign object retrieval, large volume tissue biopsies

• interventional procedures such as insertion of silicone airway stents or management of massive hemoptysis

• therapies in management of endobronchial obstruction

• its purpose is to provide open access to the airways for interventional procedures

• Rigid bronchoscopy is performed under deep sedation with muscle relaxation

Preparing the patient for bronchoscopy

• Prep

- Patient arrives at facility after 6-h fast (outpatient)

- understand procedure and alternatives prior to signing consent includes risks and complications

- Check vitals 

- Patient in Fowler’s position breathes 5 mL nebulized 4% Xylocaine

- IV started for infusion of conscious sedation

- Nostril is numbed with Xylocaine

- Suction line attached to specimen trap and bronchoscope; 

- Final step is administration of IV drugs (given by RN or MD)

- optimize the length and the size of the ETT, place a bite-block in place

- RT assists bronchoscopist with selection and insertion 

medications used during bronchoscopy

• Local anesthetic agents to the upper and the lower airway

- 10 mL of 2% viscous lidocaine

- Nebulizing 5 mL of 4% lidocaine

- The nasal passage is usually anesthetized using 5 mL of 2% lidocaine jelly

- 1% to 2% lidocaine instilled directly into the lower airways during the procedure (2-mL aliquots)

• moderate sedation 

- benzodiazepines and opioids are commonly use

dangers of lidocaine and what treats it

- Total dose of lidocaine is 5.0-7.0 mg/kg in adults (don’t exceed 7.0mg

- Dangers of lidocaine Avoid Methemoglobinemia (treat with methylene blue IV)

- Added caution in the elderly and in those with liver or cardiac disease

dangers of blood thinners

- if patient on blood thinners use Warfarin it should be stopped 3-5 days prior to the procedure or normalized ratio <1.5

monitoring during bronchoscopy

- Every 5 to 15 min, vital signs and SpO2

- continuous monitoring of oxygenation and hemodynamic stability . Pulse oximetry, heart rate, and blood pressure are monitored throughout the procedure

- monitor depth of sedation.

- Monitor signs of increased discomfort, bleeding, or respiratory distress 

- Monitor patient’s responses to verbal commands or spontaneous movements

- monitor the presence of a patient's slipping into deep sedation with associated hypoventilation, Capnography is highly recommended

stents

• Stents are tubular devices designed for internal splinting of the airway lumen. Airway stents are used to help reduce airway obstruction from malignant or benign processes that compress the airway from the outside. 

• can offer immediate relief of acute respiratory distress, can allow successful extubation, and may prolong survival

- Metallic

- Placed by flexible or ridged

- Self-expanding metallic stents (SEMS). Covered and uncovered forms

- Covered stents prevent growth of granulation tissue into the lumen of the stent

- indications for SEMS placement include (1)  compression of central airways, (2) stabilizing airway patency after endoscopic removal of an intrinsic tumor, (3) sealing fistula between the airways and the gastrointestinal tract, and (4) managing of post–lung transplant 

- Silicone 

- Silicone stents have two major designs, straight and Y-shaped (for disease involving the carina).

- The silicone stent is usually placed through a rigid bronchoscope

- indications are similar to SEMS and include internal splinting for external compression/intraluminal growing cancer, benign strictures, collapsing airways, and tracheoesophageal fistulas. 

lavage locations

- The right middle lobe, lingual or the anterior segment of the right upper lobe is generally used to perform BAL in patients with diffuse diseases.

- Meanwhile, in localized lung diseases, lavage is performed from the area of the focal abnormality (affected lung segment)

- To obtain the lavage fluid, the bronchoscope is wedged at the level of fourth- or fifth-generation bronchu

where BAL is obtained

- obtain specimens from the alveolar level of the lung.

- obtained from the nondependent part of the lung to optimize the fluid return.

where bronchial washings are obtained

- obtained from the large airways 

when endobronchial biopsy is performed

- When you need to obtain a tissue sample from a visible endobronchial lesion

- At least 3 biopsies should be obtained to successfully diagnose malignancy or carcinomas

transbronchial biopsy

- A technique of obtaining a specimen of the lung by using flexible forceps positioned distally through the working channel of the bronchoscope

- alligator forceps is most commonly used to obtain the TBBX 

- Six to ten tissue specimens are obtained, depending on the suspected diagnosis

- can be performed with or without fluoroscopic guidance

- two major complications of TBBx are pneumothorax and bleeding.

roth net and its purpose

- roth net is a retrieval device to help Removal of foreign object, food, securing polyps, tissue sampling, mucus plug removal 

appropriate ETT size for adult bronchoscopy

- bronchoscopy in adults depends on the size of the bronchoscope being used

- The ETT must be large enough to accommodate the bronchoscope while still allowing adequate ventilation during the procedure

- the external diameter of a standard FB is 5.7 mm, but in some situations a smaller (5 mm or less) or larger (6.4 mm) diameter scope may used.

purpose of the Bodai adapter

- bodai adapter is used during fiberoptic bronchoscopy it allows the clinician to perform the procedure without disrupting ventilation or compromising oxygenation.

- Maintains Ventilation

- Prevents Airway Leaks

- improves Patient Safety

- Facilitates Suctioning

dangers of bronchoscopy

- Mechanical complications such as epistaxis, pneumothorax, and hemoptysis

- increased airway resistance

- Death

- Cross-contamination of specimens or bronchoscopes

- Nausea, vomiting, fever, and chills

- Cardiac dysrhythmias

hazards of bronchoscopy

- Adverse effects of associated medications

- Hypoxemia

- Hypercapnia

- Bronchospasm

- Hypotension

- Laryngospasm, bradycardia, or other vagal responses

- Loss of Vt in mechanically ventilated patients leading to hypoxemia

contraindications for bronchoscopy

- If history of bleeding problems

- Refractory hypoxemia

- Lack of patient cooperation

- Lack of skilled personnel

- Lack of appropriate equipment and facilities

- Unstable angina

- Uncontrolled arrhythmias

- Increased intracranial pressure

- Uncorrectable bleeding diathesis

- Uncorrected coagulopathy