Bronchoscopy

Definition
Purpose
Demographics
Description
Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Bronchoscopy is a procedure in which a hollow, flexible tube called a bronchoscope is inserted into the airways through the nose or mouth to provide a view of the tracheobronchial tree. It can also be used to collect bronchial and/or lung secretions and to perform tissue biopsy.

Purpose

During a bronchoscopy, the physician can visually examine the lower airways, including the larynx, trachea, bronchi, and bronchioles. The procedure is used to examine the mucosal surface of the airways for abnormalities that might be associated with a variety of lung diseases. Its use may be diagnostic or therapeutic.

Bronchoscopy may be used to examine and help diagnose all of the following:

• diseases of the lung, such as cancer or tuberculosis
• congenital deformity of the lungs
• suspected tumor, obstruction, secretion, bleeding, or foreign body in the airways
• airway abnormalities, such as tracheal stenoses
• persistent cough, or hemoptysis, that includes blood in the sputum

Bronchoscopy may also be used for the following therapeutic purposes:

• remove a foreign body in the lungs
• remove excessive secretions
• remove tumors in the airway
• treat stenosis (narrowing) of the airways, by using balloon dilatation or placing a stent

Bronchoscopy can also be used to collect the following biopsy specimens:

• sputum
• tissue samples from the bronchi or bronchioles
• cells collected from washing the lining of the bronchi or bronchioles

If the purpose of the bronchoscopy is to take tissue samples, or biopsy, a forceps or bronchial brush are used to obtain cells. Alternatively, if the purpose is to identify an infectious agent, a bronchoal-veolar lavage can be performed to gather fluid for culture purposes. If any foreign matter is found in the airways, it can be removed as well. Tumors can be debulked (made smaller) through the use of laser, electrocautery, or cryotherapy during the bronchoscopy. A balloon can be passed into a narrowed area of the airway and inflated in order to treat stenosis. A stent (tiny artificial tube) can be placed during bronchoscopy, in order to keep a portion of the airway open.

The instrument used in bronchoscopy, a bronchoscope, is a slender, flexible tube less than 0.5 in (2.5 cm)

wide and approximately 2 ft (0.3 m) long that uses fiber-optic technology (very fine filaments that can bend and carry light). There are two types of bronchoscopes: a standard tube that is more rigid and a fiber-optic tube that is more flexible. The rigid instrument does not bend, does not see as far down into the lungs as the flexible one, and may carry a greater risk of causing injury to nearby structures. Because a standard tube can cause more discomfort than the flexible bronchoscope, it usually requires general anesthesia. However, it is useful for taking large samples of tissue and for removing foreign bodies from the airways. During the procedure, the airway is not blocked since oxygen can be supplied through the bronchoscope.

Demographics

Nearly 500,000 bronchoscopies are performed annually in the United States. According to the National Cancer Institute, cancer of the lung and bronchi is the second most common cancer among both men and women and is the leading cause of cancer death in both sexes in the United States. Among men, lung cancer incidence rates per 100,000 people range from a low of approximately 14 among American Indians to a high of 117 among African Americans. Between these two extremes, rates fall into two groups ranging from 42 to 53 for Hispanics, Japanese, Chinese, Filipinos, and Koreans, and from

71 to 89 for Vietnamese, Caucasians, Alaska Natives, and Hawaiians. The range among women is much narrower, from a rate of about 15 among Japanese to nearly 51 among Alaska Natives, only a three-fold difference. Rates for the remaining female populations fall roughly into two groups with low rates of 16-25 for Korean, Filipino, Hispanic, and Chinese women, and rates of 31-44 among Vietnamese, Caucasian, Hawaiian, and African American women. The rates among men are about two to three times greater than the rates among women in each of the racial/ethnic groups.

KEY TERMS

Anesthetic— A drug that causes loss of sensation. It is used to lessen the pain of surgery and medical procedures.

Biopsy— Procedure that involves obtaining a tissue specimen for microscopic analysis to establish a precise diagnosis.

Bronchi— The network of tubular passages that carry air to the lungs and allow air to be expelled from the lungs.

Bronchioles— Small airways extending from the bronchi into the lobes of the lungs.

Bronchoalveolar lavage— Washing cells from the air sacs at the end of the bronchioles.

Computed tomography (CT)— A special radiographic imaging technique that uses a computer to acquire multiple x rays into a two-dimensional sectional image.

Emesis basin— A basin used to collect sputum or vomit.

Endoscope— A highly flexible viewing instrument.

Endoscopy— The visual inspection of any cavity of the body using an endoscope.

Hemoptysis— The expectoration of blood or of blood containing sputum.

Larynx— The voice box.

Lavage— Washing out.

Neoplasm— A new growth or tumor.

Sputum— Matter ejected from the lungs, bronchi, and trachea through the mouth.

Stenosis— Narrowing of a duct or canal.

Trachea— The windpipe.

Tracheobronchial— Pertaining both to the tracheal and bronchial tubes or to their junction.

Description

Bronchoscopy is usually performed in an endoscopy room, but may also be performed at the bedside. The patient is placed on the back or sits upright. A pulmonologist, a specialist trained to perform the procedure, sprays an anesthetic into the patient’s mouth or throat. When anesthesia has taken effect and the area is numb, the bronchoscope is inserted into the mouth and passed into the throat. If the bronchoscope is passed through the nose, an anesthetic jelly is inserted into one nostril. While the bronchoscope is

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

The test is usually performed in a hospital or clinic by a pulmonologist, a physician specializing in diseases of the lungs. Nursing staff assist by providing education, monitoring the patient, and conducting tests, including checking blood pressure, pulse, and respiratory rate prior to the patient’s discharge.

moving down the throat, additional anesthetic is put into the bronchoscope to anesthetize the lower airways. The physician observes the trachea, bronchi, and the mucosal lining of these passageways looking for any abnormalities that may be present. If samples are needed, a bronchial lavage may be performed, meaning that a saline solution is used to flush the area prior to collecting cells for laboratory analysis. Very small brushes, needles, or forceps may also be introduced through the bronchoscope to collect tissue samples from the lungs. If the procedure is therapeutic in nature, laser, electrocautery, cryotherapeutic, or balloon dilatation instruments may be passed through the bronchoscope, as well as a stent may be placed.

Preparation

The patient should fast for six to 12 hours prior to the procedure and refrain from drinking any liquids the day of the procedure. Smoking should be avoided for 24 hours prior to the procedure, and patients should also avoid taking any aspirin or ibuprofen-type medications. The bronchoscopy itself takes about 45–60 minutes. Prior to the bronchoscopy, several tests are usually done, including a chest x ray and blood work. Sometimes a bronchoscopy is done under general anesthesia, in which case the patient will have an intravenous (IV) line in the arm. More commonly, the procedure is performed under local anesthesia, which is sprayed into the nose or mouth. This is necessary to inhibit the gag reflex. A sedative may also be given. A signed consent form is necessary for this procedure.

Aftercare

After the bronchoscopy, the vital signs (heart rate, blood pressure, and breathing) are monitored. Sometimes patients have an abnormal reaction to anesthesia. Any sputum should be collected in an emesis basin

QUESTIONS TO ASK THE DOCTOR

• What will happen during the procedure?
• Will it hurt?
• How long will the test take to perform?
• How many bronchoscopies do you perform each year?
• Are there any risks associated with the procedure?

so that it can be examined for the presence of blood. If a biopsy was taken, the patient should not cough or clear the throat as this might dislodge any blood clot that has formed and cause bleeding. No food or drink should be consumed for about two hours after the procedure or until the anesthesia wears off. There is a significant risk for choking if anything (including water) is ingested before the anesthetic wears off, and the gag reflex has returned. To test if the gag reflex has returned, a spoon is placed on the back of the tongue for a few seconds with light pressure. If there is no gagging, the process is repeated after 15 minutes. The gag reflex should return in one or two hours. Ice chips or clear liquids should be taken before the patient attempts to eat solid food. Patients should be informed that the throat may be irritated for several days.

Patients should notify their healthcare provider if they develop any of these symptoms:

• hemoptysis (coughing up blood)
• shortness of breath, wheezing, or any trouble breathing
• chest pain
• fever, with or without breathing problems

Risks

Use of the bronchoscope mildly irritates the lining of the airways, resulting in some swelling and inflammation, as well as hoarseness caused from abrading the vocal cords. If this abrasion is more serious, it can lead to respiratory difficulty or bleeding of the lining of the airways.

The bronchoscopy procedure is also associated with a small risk of disordered heart rhythm (arrhythmia), heart attacks, low blood oxygen (hypoxemia), and pneumothorax (a puncture of the lungs that allows air to escape into the space between the lung and the chest wall). These risks are greater with the use of a rigid bronchoscope than with a fiberoptic bronchoscope. If a rigid tube is used, there is also a risk of chipped teeth. The risk of transmitting infectious disease from one patient to another by the bronchoscope is also present. The Centers for Disease Control (CDC) reported cases of patient-to-patient transmission of infections following bronchoscopic procedures using bronchoscopes that were inadequately reprocessed by the automated endoscope reprocessing (AER) system. Investigation of the incidents revealed inconsistencies between the reprocessing instructions provided by the manufacturer of the bronchoscope and the manufacturer of the AER; or that the bronchoscopes were inadequately reprocessed.

Normal results

If the results of the bronchoscopy are normal, the windpipe (trachea) appears as smooth muscle with C-shaped rings of cartilage at regular intervals. There are no abnormalities either in the trachea or in the bronchi of the lungs.

Bronchoscopy results may also confirm a suspected diagnosis. This may include swelling, ulceration, or deformity in the bronchial wall, such as inflammation, stenosis, or compression of the trachea, neoplasm, and foreign bodies. The bronchoscopy may also reveal the presence of atypical substances in the trachea and bronchi. If samples are taken, the results could indicate cancer, disease-causing agents, or other lung diseases. Other findings may include constriction or narrowing (stenosis), compression, dilation of vessels, or abnormal branching of the bronchi. Abnormal substances that might be found in the airways include blood, secretions, or mucous plugs.

Morbidity and mortality rates

Bronchoscopy belongs to the group of procedures associated with highest inpatient mortality with a 12.7% mortality rate.

Alternatives

Depending upon the purpose of the bronchoscopy, alternatives may include a chest x ray or a computed tomography (CT) scan. If the purpose is to obtain biopsy specimens, one option is to perform surgery, which carries greater risks. Another option is percutaneous biopsy guided by CT.

Resources

BOOKS

Abeloff, M. D., et al. Clinical Oncology. 3rd ed. Philadelphia: Elsevier, 2004.

Cummings, C. W., et al. Otolayrngology: Head and Neck Surgery. 4th ed. St. Louis: Mosby, 2005.

Khatri, V. P., and J. A. Asensio. Operative Surgery Manual. 1st ed. Philadelphia: Saunders, 2003.

Koppen, W., J. F. Turner, and A. C. Mehta, eds. Flexible Bronchoscopy. 2nd ed. Oxford: Blackwell Publishers, 2004.

Mason, R. J., et al. Murray & Nadel’s Textbook of Respiratory Medicine. 4th ed. Philadelphia: Saunders, 2007.

Townsend, C. M., et al. Sabiston Textbook of Surgery. 17th ed. Philadelphia: Saunders, 2004.

PERIODICALS

Diette, G. B., N. Lechtzin, E. Haponik, A. Devrotes, and H. R. Rubin. “Distraction Therapy with Nature Sights and Sounds Reduces Pain during Flexible Bronchoscopy: A Complementary Approach to Routine Analgesia.” Chest 123 (March 2003): 941–948.

Starobin, D., G. Fink, D. Shitrit, G. Izbicki, D. Bendayan, I. Bakal, and M. R. Kramer. “The Role of Fiberoptic Bronchoscopy Evaluating Transplant Recipients with Suspected Pulmonary Infections: Analysis of 168 Cases in a Multi-organ Transplantation Center.” Transplantation Proceedings 35 (March 2003): 659–660.

Wu, K. H., T. T. Man, K. L. Wong, C. F. Lin, C. C. Chen, and C. R. Cheng. “Bronchoscopy and Anesthesia for Preschool-aged Patients: A Review of 228 Cases.” Internal Surgery 87 (October–December 2002): 252–255.

Yang, C. C., and K. S. Lee. “Comparison of Direct Vision and Video Imaging during Bronchoscopy for Pediatric Airway Foreign Bodies.” Ear, Nose, and Throat Journal 82 (February 2003): 129–133.

ORGANIZATIONS

American College of Chest Physicians. 3300 Dundee Road, Northbrook, IL 60062. (800) 343–2227.

The Association of Perioperative Registered Nurses, Inc. (AORN). 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711. (800) 755-2676. http://www.aorn.org (accessed March 8, 2008).

OTHER

“Bronchoscopy.” Medline Plus. [cited April 2003]. http://www.nlm.nih.gov/medlineplus/ency/article/003857.htm (accessed March 8, 2008).

“Public Health Advisory: Infections from Endoscopes Inadequately Reprocessed by an Automated Endoscope Reprocessing System.” U. S. Food and Drug Administration, Center for Devices and Radiological Health. September 1999 [cited April 2003]. http://www.fda.gov/cdrh/safety/endoreprocess.html (accessed March 8, 2008).

Maggie Boleyn, RN, BSN

Monique Laberge, PhD

Rosalyn Carson-DeWitt, MD

Bronchoscopy

Definition

Bronchoscopy is a procedure in which a hollow, flexible tube called a bronchoscope is inserted into the airways through the nose or mouth to provide a view of the tracheobronchial tree. It can also be used to collect bronchial and/or lung secretions and to perform tissue biopsy.

Purpose

During a bronchoscopy, the physician can visually examine the lower airways, including the larynx, trachea, bronchi, and bronchioles. The procedure is used to examine the mucosal surface of the airways for abnormalities that might be associated with a variety of lung diseases. Its use may be diagnostic or therapeutic.

Bronchoscopy may be used to examine and help diagnose all of the following:

• diseases of the lung, such as cancer or tuberculosis
• congenital deformity of the lungs
• suspected tumor, obstruction, secretion, bleeding, or foreign body in the airways
• airway abnormalities, such as tracheal stenoses
• persistent cough, or hemoptysis, that includes blood in the sputum Bronchoscopy may also be used for the following therapeutic purposes:l remove a foreign body in the lungs
• remove excessive secretions
• remove tumors in the airway
• treat stenosis (narrowing) of the airways, by using balloon dilatation or placing a stent Bronchoscopy can also be used to collect the following biopsy specimens:l sputum
• tissue samples from the bronchi or bronchioles
• cells collected from washing the lining of the bronchi or bronchioles

If the purpose of the bronchoscopy is to take tissue samples, or biopsy, a forceps or bronchial brush are used to obtain cells. Alternatively, if the purpose is to identify an infectious agent, a bronchoalveolar lavage can be performed to gather fluid for culture purposes. If any foreign matter is found in the airways, it can be removed as well. Tumors can be debulked (made smaller) through the use of laser, electrocautery, or cryotherapy during the bronchoscopy. A balloon can be passed into a narrowed area of the airway and inflated in order to treat stenosis. A stent (tiny artificial tube) can be placed during bronchoscopy, in order to keep a portion of the airway open.

The instrument used in bronchoscopy, a bronchoscope, is a slender, flexible tube less than 0.5 in (2.5 cm) wide and approximately 2 ft (0.3 m) long that uses fiber-optic technology (very fine filaments that can bend and carry light). There are two types of bronchoscopes: a standard tube that is more rigid and a fiber-optic tube that is more flexible. The rigid instrument does not bend, does not see as far down into the lungs as the flexible one, and may carry a greater risk of causing injury to nearby structures. Because a standard tube can cause more discomfort than the flexible bronchoscope, it usually requires general anesthesia . However, it is useful for taking large samples of tissue and for removing foreign bodies from the airways. During the procedure, the airway is not blocked since oxygen can be supplied through the bronchoscope.

Demographics

Nearly 500,000 bronchoscopies are performed annually in the United States. According to the National Cancer Institute, cancer of the lung and bronchi is the second most common cancer among both men and women and is the leading cause of cancer death in both sexes in the United States. Among men, lung cancer incidence rates per 100,000 people range from a low of approximately 14 among American Indians to a high of 117 among African Americans. Between these two extremes, rates fall into two groups ranging from 42 to 53 for Hispanics, Japanese, Chinese, Filipinos, and Koreans, and from 71 to 89 for Vietnamese, Caucasians, Alaska Natives, and Hawaiians. The range among women is much narrower, from a rate of about 15 among Japanese to nearly 51 among Alaska Natives, only a three-fold difference. Rates for the remaining female populations fall roughly into two groups with low rates of 16–25 for Korean, Filipino, Hispanic, and Chinese women, and rates of 31–44 among Vietnamese, Caucasian, Hawaiian, and African American women. The rates among men are about two to three times greater than the rates among women in each of the racial/ethnic groups.

Description

Bronchoscopy is usually performed in an endoscopy room, but may also be performed at the bedside. The patient is placed on the back or sits upright. A pulmonologist, a specialist trained to perform the procedure, sprays an anesthetic into the patient's mouth or throat. When anesthesia has taken effect and the area is numb, the bronchoscope is inserted into the mouth and passed into the throat. If the bronchoscope is passed through the nose, an anesthetic jelly is inserted into one nostril. While the bronchoscope is moving down the throat, additional anesthetic is put into the bronchoscope to anesthetize the lower airways. The physician observes the trachea, bronchi, and the mucosal lining of these passageways looking for any abnormalities that may be present. If samples are needed, a bronchial lavage may be performed, meaning that a saline solution is used to flush the area prior to collecting cells for laboratory analysis. Very small brushes, needles, or forceps may also be introduced through the bronchoscope to collect tissue samples from the lungs. If the procedure is therapeutic in nature, laser, electrocautery, cryotherapeutic, or balloon dilatation instruments may be passed through the bronchoscope, as well as a stent may be placed.

KEY TERMS

Anesthetic —A drug that causes loss of sensation. It is used to lessen the pain of surgery and medical procedures.

Biopsy —Procedure that involves obtaining a tissue specimen for microscopic analysis to establish a precise diagnosis.

Bronchi —The network of tubular passages that carry air to the lungs and allow air to be expelled from the lungs.

Bronchioles —Small airways extending from the bronchi into the lobes of the lungs.

Bronchoalveolar lavage —Washing cells from the air sacs at the end of the bronchioles.

Computed tomography (CT) —A special radiographic imaging technique that uses a computer to acquire multiple x rays into a two-dimensional sectional image.

Emesis basin —A basin used to collect sputum or vomit.

Endoscope —A highly flexible viewing instrument.

Endoscopy —The visual inspection of any cavity of the body using an endoscope.

Hemoptysis —The expectoration of blood or of blood containing sputum.

Larynx —The voice box.

Lavage —Washing out.

Neoplasm —A new growth or tumor.

Sputum —Matter ejected from the lungs, bronchi, and trachea through the mouth.

Stenosis —Narrowing of a duct or canal.

Trachea —The windpipe.

Tracheobronchial —Pertaining both to the tracheal and bronchial tubes or to their junction.

Preparation

The patient should fast for six to 12 hours prior to the procedure and refrain from drinking any liquids the day of the procedure. Smoking should be avoided for 24 hours prior to the procedure, and patients should also avoid taking any aspirin or ibuprofen-type medications. The bronchoscopy itself takes about 45–60 minutes. Prior to the bronchoscopy, several tests are usually done, including a chest x ray and blood work. Sometimes a bronchoscopy is done under general anesthesia, in which case the patient will have an intravenous (IV) line in the arm. More commonly, the procedure is performed under local anesthesia , which is sprayed into the nose or mouth. This is necessary to inhibit the gag reflex. A sedative may also be given. A signed consent form is necessary for this procedure.

Aftercare

After the bronchoscopy, the vital signs (heart rate, blood pressure , and breathing) are monitored. Sometimes patients have an abnormal reaction to anesthesia. Any sputum should be collected in an emesis basin so that it can be examined for the presence of blood. If a biopsy was taken, the patient should not cough or clear the throat as this might dislodge any blood clot that has formed and cause bleeding. No food or drink should be consumed for about two hours after the procedure or until the an-esthesia wears off. There is a significant risk for choking if anything (including water) is ingested before the anesthetic wears off, and the gag reflex has returned. To test if the gag reflex has returned, a spoon is placed on the back of the tongue for a few seconds with light pressure. If there is no gagging, the process is repeated after 15 minutes. The gag reflex should return in one or two hours. Ice chips or clear liquids should be taken before the patient attempts to eat solid food. Patients should be informed that the throat may be irritated for several days.

Patients should notify their healthcare provider if they develop any of these symptoms:

• hemoptysis (coughing up blood)
• shortness of breath, wheezing, or any trouble breathing
• chest pain
• fever, with or without breathing problems

Risks

Use of the bronchoscope mildly irritates the lining of the airways, resulting in some swelling and inflammation, as well as hoarseness caused from abrading the vocal cords. If this abrasion is more serious, it can lead to respiratory difficulty or bleeding of the lining of the airways.

The bronchoscopy procedure is also associated with a small risk of disordered heart rhythm (arrhythmia), heart attacks, low blood oxygen (hypoxemia), and pneumothorax (a puncture of the lungs that allows air to escape into the space between the lung and the chest wall). These risks are greater with the use of a rigid bronchoscope than with a fiberoptic bronchoscope. If a rigid tube is used, there is also a risk of chipped teeth. The risk of transmitting infectious disease from one patient to another by the bronchoscope is also present. The Centers for Disease Control (CDC) reported cases of patient-to-patient transmission of infections following bronchoscopic procedures using bronchoscopes that were inadequately reprocessed by the automated endoscope reprocessing (AER) system. Investigation of the incidents revealed inconsistencies between the reprocessing instructions provided by the manufacturer of the bronchoscope and the manufacturer of the AER; or that the bronchoscopes were in-adequately reprocessed.

Results

If the results of the bronchoscopy are normal, the windpipe (trachea) appears as smooth muscle with C-shaped rings of cartilage at regular intervals. There are no abnormalities either in the trachea or in the bronchi of the lungs.

Bronchoscopy results may also confirm a suspected diagnosis. This may include swelling, ulceration, or deformity in the bronchial wall, such as inflammation, stenosis, or compression of the trachea, neoplasm, and foreign bodies. The bronchoscopy may also reveal the presence of atypical substances in the trachea and bronchi. If samples are taken, the results could indicate cancer, disease-causing agents, or other lung diseases. Other findings may include constriction

QUESTIONS TO ASK THE DOCTOR

• What will happen during the procedure?
• Will it hurt?
• How long will the test take to perform?
• How many bronchoscopies do you perform each year?
• Are there any risks associated with the procedure?

or narrowing (stenosis), compression, dilation of vessels, or abnormal branching of the bronchi. Abnormal substances that might be found in the airways include blood, secretions, or mucous plugs.

Morbidity and mortality rates

Bronchoscopy belongs to the group of procedures associated with highest inpatient mortality with a 12.7% mortality rate.

Alternatives

Depending upon the purpose of the bronchoscopy, alternatives may include a chest x ray or a computed tomography (CT) scan. If the purpose is to obtain biopsy specimens, one option is to perform surgery, which carries greater risks. Another option is percutaneous biopsy guided by CT.

Resources

BOOKS

Abeloff, M. D., et al. Clinical Oncology. 3rd ed. Philadelphia: Elsevier, 2004.

Cummings, C. W., et al. Otolayrngology: Head and Neck Surgery. 4th ed. St. Louis: Mosby, 2005.

Khatri, V. P., and J. A. Asensio. Operative Surgery Manual. 1st ed. Philadelphia: Saunders, 2003.

Koppen, W., J. F. Turner, and A. C. Mehta, eds. Flexible Bronchoscopy. 2nd ed. Oxford: Blackwell Publishers, 2004.

Mason, R. J., et al. Murray & Nadel's Textbook of Respiratory Medicine. 4th ed. Philadelphia: Saunders, 2007.

Townsend, C. M., et al. Sabiston Textbook of Surgery. 17th ed. Philadelphia: Saunders, 2004.

PERIODICALS

Diette, G. B., N. Lechtzin, E. Haponik, A. Devrotes, and H. R. Rubin. “Distraction Therapy with Nature Sights and Sounds Reduces Pain during Flexible Bronchoscopy: A Complementary Approach to Routine-Analgesia.

” Chest 123 (March 2003): 941–948.

Starobin, D., G. Fink, D. Shitrit, G. Izbicki, D. Bendayan, I. Bakal, and M. R. Kramer. “The Role of Fiberoptic Bronchoscopy Evaluating Transplant Recipients with Suspected Pulmonary Infections: Analysis of 168 Cases in a Multi-organ Transplantation Center.” Transplantation Proceedings 35 (March 2003): 659–660.

Wu, K. H., T. T. Man, K. L. Wong, C. F. Lin, C. C. Chen, and C. R. Cheng. “Bronchoscopy and Anesthesia for Preschool-aged Patients: A Review of 228 Cases.” Internal Surgery 87 (October–December 2002): 252–255.

Yang, C. C., and K. S. Lee. “Comparison of Direct Vision and Video Imaging during Bronchoscopy for Pediatric Airway Foreign Bodies.” Ear, Nose, and Throat Journal 82 (February 2003): 129–133.

ORGANIZATIONS

American College of Chest Physicians. 3300 Dundee Road, Northbrook, IL 60062. (800) 343-2227.

The Association of Perioperative Registered Nurses, Inc. (AORN). 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711. (800) 755-2676. http://www.aorn.org (accessed March 8, 2008).

OTHER

“Bronchoscopy.” Medline Plus. [cited April 2003]. http://www.nlm.nih.gov/medlineplus/ency/article/003857.htm (accessed March 8, 2008).

“Public Health Advisory: Infections from Endoscopes Inadequately-Reprocessed by an Automated Endoscope Reprocessing System.” U. S. Food and Drug Administration, Center for Devices and Radiological Health. September 1999 [cited April 2003]. http://www.fda.gov/cdrh/safety/endoreprocess.html (accessed March 8, 2008).

Maggie Boleyn RN, BSN

Monique Laberge Ph.D.

Rosalyn Carson-DeWitt MD

Bronchoscopy

Definition

Bronchoscopy is a procedure in which a hollow, flexible tube called a bronchoscope is inserted into the airways through the nose or mouth to provide a view of the tracheobronchial tree. It can also be used to collect bronchial and/or lung secretions and to perform tissue biopsy.

Purpose

During a bronchoscopy, the physician can visually examine the lower airways, including the larynx, trachea, bronchi, and bronchioles. The procedure is used to examine the mucosal surface of the airways for abnormalities that might be associated with a variety of lung diseases. Its use may be diagnostic or therapeutic.

Bronchoscopy may be used to examine and help diagnose:

• diseases of the lung, such as cancer or tuberculosis
• congenital deformity of the lungs
• suspected tumor, obstruction, secretion, bleeding, or foreign body in the airways
• airway abnormalities, such as tracheal stenoses
• persistent cough, or hemoptysis, that includes blood in the sputum

Bronchoscopy may also be used for the following therapeutic purposes:

• to remove a foreign body in the lungs
• to remove excessive secretions

Bronchoscopy can also be used to collect the following biopsy specimens:

• sputum
• tissue samples from the bronchi or bronchioles
• cells collected from washing the lining of the bronchi or bronchioles

If the purpose of the bronchoscopy is to take tissue samples or biopsy, a forceps or bronchial brush are used to obtain cells. Alternatively, if the purpose is to identify an infectious agent, a bronchoalveolar lavage can be performed to gather fluid for culture purposes. If any foreign matter is found in the airways, it can be removed as well.

The instrument used in bronchoscopy, a bronchoscope, is a slender, flexible tube less than 0.5 in (2.5 cm) wide and approximately 2 ft (0.3 m) long that uses fiberoptic technology (very fine filaments that can bend and carry light). There are two types of bronchoscopes, a standard tube that is more rigid and a fiberoptic tube that is more flexible. The rigid instrument does not bend, does not see as far down into the lungs as the flexible one, and may carry a greater risk of causing injury to nearby structures. Because it can cause more discomfort than the flexible bronchoscope, it usually requires general anesthesia. However, it is useful for taking large samples of tissue and for removing foreign bodies from the airways. During the procedure, the airway is never blocked since oxygen can be supplied through the bronchoscope.

Demographics

In 2000, the National Hospital Discharge Survey and the National Survey of Ambulatory Surgery Reports outlined the following rates for bronchoscopy with or without biopsy at short-stay hospitals in the United States:

• Both sexes: 8.9 per 10,000 population
• Males: 10.6 per 10,000 population
• Females: 7.3 per 10,000 population

According to the National Cancer Institute, cancer of the lung and bronchi is the second most common cancer among both men and women and is the leading cause of cancer death in both sexes in the United States. Among men, lung cancer incidence rates per 100,000 people range from a low of approximately 14 among American Indians to a high of 117 among African Americans. Between these two extremes, rates fall into two groups ranging from 42 to 53 for Hispanics, Japanese, Chinese, Filipinos, and Koreans and from 71 to 89 for Vietnamese, Caucasians, Alaska natives, and Hawaiians. The range among women is much narrower, from a rate of about 15 among Japanese to nearly 51 among Alaska Natives, only a three-fold difference. Rates for the remaining female populations fall roughly into two groups with low rates of 16–25 for Korean, Filipino, Hispanic, and Chinese women, and rates of 31–44 among Vietnamese, Caucasian, Hawaiian, and African American women. The rates among men are about two to three times greater than the rates among women in each of the racial/ethnic groups.

Description

Bronchoscopy is usually performed in an endoscopy room, but may also be performed at the bedside. The patient is placed on his back or sits upright. A pulmonologist, a specialist trained to perform the procedure, sprays an anesthetic into the patient's mouth or throat. When anesthesia has taken effect and the area is numb, the bronchoscope is inserted into the patient's mouth and passed into the throat. If the bronchoscope is passed through the nose, an anesthetic jelly is inserted into one nostril. While the bronchoscope is moving down the throat, additional anesthetic is put into the bronchoscope to anesthetize the lower airways. The physician observes the trachea, bronchi, and the mucosal lining of these passageways looking for any abnormalities that may be present. If samples are needed, a bronchial lavage may be performed, meaning that a saline solution is introduced to flush the area prior to collecting cells for laboratory analysis. Very small brushes, needles, or forceps may also be introduced through the bronchoscope to collect tissue samples from the lungs.

Preparation

The patient should fast for six to 12 hours prior to the procedure and refrain from drinking any liquids the day of the procedure. Smoking should be avoided for 24 hours prior to the procedure and patients should also avoid taking any aspirin or ibuprofen-type medications. The bronchoscopy itself takes about 45–60 minutes. Prior to the bronchoscopy, several tests are usually done, including a chest x ray and blood work. Sometimes a bronchoscopy is done under general anesthesia, in which case the patient will have an intravenous (IV) line in the arm. More commonly, the procedure is performed under local anesthesia, which is sprayed into the nose or mouth. This is necessary to inhibit the gag reflex. A sedative also may be given. A signed consent form is necessary for this procedure.

Aftercare

After the bronchoscopy, the vital signs (heart rate, blood pressure, and breathing) are monitored. Sometimes patients have an abnormal reaction to anesthesia. Any sputum should be collected in an emesis basin so that it can be examined for the presence of blood. If a biopsy was taken, the patient should not cough or clear the throat as this might dislodge any blood clot that has formed and cause bleeding. No food or drink should be consumed for about two hours after the procedure or until the anesthesia wears off. There is a significant risk for choking if anything (including water) is ingested before the anesthetic wears off, and the gag reflex has returned. To test if the gag reflex has returned, a spoon is placed on the back of the tongue for a few seconds with light pressure. If there is no gagging, the process is repeated after 15 minutes. The gag reflex should return in one to two hours. Ice chips or clear liquids should be taken before the patient attempts to eat solid food.

Patients are informed that after the anesthetic wears off the throat may be irritated for several days.

Patients should notify their health care provider if they develop any of these symptoms:

• hemoptysis (coughing up blood)
• shortness of breath, wheezing, or any trouble breathing
• chest pain
• fever, with or without breathing problems

Risks

Use of the bronchoscope mildly irritates the lining of the airways, resulting in some swelling and inflammation, as well as hoarseness caused from abrading the vocal cords. If this abrasion is more serious, it can lead to respiratory difficulty or bleeding of the lining of the airways.

The bronchoscopy procedure is also associated with a small risk of disordered heart rhythm (arrhythmia), heart attacks, low blood oxygen (hypoxemia), and pneumothorax (a puncture of the lungs that allows air to escape into the space between the lung and the chest wall). These risks are greater with the use of a rigid bronchoscope than with a fiberoptic bronchoscope. If a rigid tube is used, there is also a risk of chipped teeth. The risk of transmitting infectious disease from one patient to another by the bronchoscope is also present. There is also a risk of infection from endoscopes inadequately reprocessed by the automated endoscope reprocessing (AER) system. The Centers for Disease Control (CDC) reported cases of patient-to-patient transmission of infections following bronchoscopic procedures using bronchoscopes that were inadequately reprocessed by AERs. Investigation of the incidents revealed inconsistencies between the reprocessing instructions provided by the manufacturer of the bronchoscope and the manufacturer of the AER; or that the bronchoscopes were inadequately reprocessed.

Normal results

If the results of the bronchoscopy are normal, the windpipe (trachea) appears as smooth muscle with C-shaped rings of cartilage at regular intervals. There are no abnormalities either in the trachea or in the bronchi of the lungs.

Bronchoscopy results may also confirm a suspected diagnosis. This may include swelling, ulceration, or deformity in the bronchial wall, such as inflammation, stenosis, or compression of the trachea, neoplasm, and foreign bodies. The bronchoscopy may also reveal the presence of atypical substances in the trachea and bronchi. If samples are taken, the results could indicate cancer, disease-causing agents, or other lung diseases. Other findings may include constriction or narrowing (stenosis), compression, dilation of vessels, or abnormal branching of the bronchi. Abnormal substances that might be found in the airways include blood, secretions, or mucous plugs.

Morbidity and mortality rates

Bronchoscopy belongs to the group of procedures associated with highest inpatient mortality with a 12.7% mortality rate.

Alternatives

Depending upon the purpose of the bronchoscopy, alternatives may include a chest x ray or a computed tomography (CT) scan. If the purpose is to obtain biopsy specimens, one option is to perform surgery, which carries greater risks. Another option is percutaneous biopsy guided by CT.

Resources

books

Bolliger, C. T., and P. N. Mathur, eds. Interventional Bronchoscopy. (Progress in Respiratory Research, Vol. 30). Basel: S. Karger Publishing, 1999.

Koppen, W., J. F. Turner, and A. C. Mehta, eds. Flexible Bronchoscopy. 2nd ed. Oxford: Blackwell Publishers, 2004.

Loeb, S., ed. Illustrated Guide to Diagnostic Tests. Springhouse, PA: Springhouse Corporation, 1994.

Pagana, Kathleen D., and Timothy J. Pagana. Diagnostic Testing and Nursing Implications. 5th ed. St. Louis: Mosby, 1999.

periodicals

Diette, G. B., N. Lechtzin, E. Haponik, A. Devrotes, and H. R. Rubin. "Distraction Therapy with Nature Sights and Sounds Reduces Pain during Flexible Bronchoscopy: A Complementary Approach to Routine Analgesia." Chest 123 (March 2003): 941–948.

Nakamura, C. T., J. F. Ripka, K. McVeigh, N. Kapoor, and T. G. Keens. "Bronchoscopic Instillation of Surfactant in Acute Respiratory Distress Syndrome." Pediatric Pulmonology 31, no. 4 (April 2001): 317–320.

Starobin, D., G. Fink, D. Shitrit, G. Izbicki, D. Bendayan, I. Bakal, and M. R. Kramer. "The Role of Fiberoptic Bronchoscopy Evaluating Transplant Recipients with Suspected Pulmonary Infections: Analysis of 168 Cases in a Multi-organ Transplantation Center." Transplantation Proceedings 35 (March 2003): 659–660.

Wu, K. H., T. T. Man, K. L. Wong, C. F. Lin, C. C. Chen, and C. R. Cheng. "Bronchoscopy and Anesthesia for Preschool-aged Patients: A Review of 228 Cases." Internal Surgery 87 (October-December 2002): 252–255.

Yang, C. C., and K. S. Lee. "Comparison of Direct Vision and Video Imaging during Bronchoscopy for Pediatric Airway Foreign Bodies." Ear, Nose, and Throat Journal 82 (February 2003): 129–133.

organizations

American College of Chest Physicians. 3300 Dundee Road, Northbrook, IL 60062. (800) 343-2227.

The Association of Perioperative Registered Nurses, Inc. (AORN). 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711. (800) 755-2676. <http://www.aorn.org/>.

other

"Bronchoscopy." Medline Plus. [cited April 2003]. <http://www.nlm.nih.gov/medlineplus/ency/article/003857.htm>.

Public Health Advisory: Infections from Endoscopes Inadequately Reprocessed by an Automated Endoscope Reprocessing System. U. S. Food and Drug Administration, Center for Devices and Radiological Health. September 1999 [cited April 2003]. <http://www.fda.gov/cdrh/safety/endoreprocess.html>.

Maggie Boleyn, RN, BSN Monique Laberge, Ph D

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

The test is usually performed in a hospital or clinic by a pulmonologist, a physician specializing in diseases of the lungs. Nursing staff assist by providing education, monitoring the patient, and conducting tests, including checking blood pressure, pulse, and respiratory rate prior to the patient's discharge.

QUESTIONS TO ASK THE DOCTOR

• What will happen during the procedure?
• Will it hurt?
• How long will the test last?
• How many bronchoscopies do you perform each year?
• Are there any risks associated with the procedure?

Bronchoscopy

Definition

Bronchoscopy is a procedure in which a cylindrical fiberoptic scope is inserted into the airways. This scope contains a viewing device that allows the visual examination of the lower airways.

Purpose

During a bronchoscopy, a physician can visually examine the lower airways, including the larynx, trachea, bronchi, and bronchioles. The procedure is used to examine the mucosal surface of the airways for abnormalities that might be associated with a variety of lung diseases. Its use includes the visualization of airway obstructions such as a tumor, or the collection of specimens for the diagnosis of cancer originating in the bronchi of the lungs (bronchogenic cancer). It can also be used to collect specimens for culture to diagnose infectious diseases such as tuberculosis. The type of specimens collected can include sputum (composed of saliva and discharges from the respiratory passages), tissue samples from the bronchi or bronchioles, or cells collected from washing the lining of the bronchi or bronchioles. The instrument used in bronchoscopy, a bronchoscope, is a slender cylindrical instrument containing a light and an eyepiece. There are two types of bronchoscopes, a rigid tube that is sometimes referred to as an open-tube or ventilating bronchoscope, and a more flexible fiberoptic tube. This tube contains four smaller passages—two for light to pass through, one for seeing through and one that can accommodate medical instruments that may be used for biopsy or suctioning, or that medication can be passed through.

Bronchoscopy may be used for the following purposes:

• to diagnose cancer, tuberculosis, lung infection, or other lung disease
• to examine an inherited deformity of the lungs
• to remove a foreign body in the lungs, such as a mucus plug, tumor, or excessive secretions
• to remove tissue samples, also known as biopsy, to test for cancer cells, help with staging the advancement of the lung cancer, or to treat a tumor with laser therapy
• to allow examination of a suspected tumor, obstruction, secretion, bleeding, or foreign body in the airways
• to determine the cause of a persistent cough, wheezing, or a cough that includes blood in the sputum
• to evaluate the effectiveness of lung cancer treatments

Precautions

Patients not breathing adequately on their own due to severe respiratory failure may require mechanical ventilation prior to bronchoscopy. It may not be appropriate to perform bronchoscopy on patients with an unstable heart condition. All patients must be constantly monitored while undergoing a bronchoscopy so that any abnormal reactions can be dealt with immediately.

Description

There are two types of bronchoscopes, a rigid tube and a fiberoptic tube. Because of its flexibility, the fiberoptic tube is usually preferred. However, if the purpose of the procedure is to remove a foreign body caught in the windpipe or lungs of a child, the more rigid tube must be used because of its larger size. The patient will either lie face-up on his/her back or sit upright in a chair. Medication to decrease secretions, lessen anxiety, and relax the patient are often given prior to the procedure. While breathing through the nose, anesthesia is sprayed into the mouth or nose to numb it. It will take one to two minutes for the anesthesia to take effect. Once this happens, the bronchoscope will be put into the patient's mouth or nose and moved down into the throat. While the bronchoscope is moving down the throat, additional anesthesia is put into the bronchoscope to numb the lower parts of the airways. Using the eyepiece, the physician then observes the trachea and bronchi, and the mucosal lining of these passageways, looking for any abnormalities that may be present.

If the purpose of the bronchoscopy is to take tissue samples or biopsy, forceps or a bronchial brush are used to obtain cells. If the purpose is to identify an infectious agent, a bronchoalveolar lavage (BAL) can be used to gather fluid for culture purposes. Also, if any foreign matter is found in the airways, it can be removed.

Another procedure using bronchoscopy is called fluorescence bronchoscopy. This can be used to detect precancerous cells present in the airways. By using a fluorescent light in the bronchoscope, precancerous tissue will appear dark red, while healthy tissue will appear green. This technique can help detect lung cancer at an early stage, so that treatment can be started early.

KEY TERMS

Anesthesia— A drug used to loss of sensation. It is used to lessen the pain of surgery and medical procedures.

Bronchi— The network of tubular passages that carry air to the lungs and allow air to be expelled from the lungs.

Bronchioles— Small airways extending from the bronchi into the lobes of the lungs.

Bronchoalveolar lavage— Washing cells from the air sacs at the end of the bronchioles.

Trachea— The windpipe.

Alternative procedures

Depending upon the purpose of the bronchoscopy, alternatives might include a computed tomography scan (CT) or no procedure at all. Bronchoscopy is often performed to investigate an abnormality that shows up on a chest x ray or CT scan. If the purpose is to obtain biopsy specimens, one option is to perform surgery, which carries greater risks. Another option is percutaneous (through the skin) biopsy guided by computed tomography.

Preparation

The doctor should be informed of any allergies and all the medications that the patient is currently taking. The doctor may instruct the patient not to take medications like aspirin or anti-inflammatory drugs, which interfere with clotting, for a period of time prior to the procedure. The patient needs to fast for 6 to 12 hours prior to the procedure and refrain from drinking any liquids the day of the procedure. The bronchoscopy takes about 45 to 60 minutes, with results usually available in one day. Prior to the bronchoscopy, several tests may be done, including a chest x ray and blood work. Sometimes a bronchoscopy is done under general anesthesia. Patients usually have an intravenous (IV) line in the arm. Most likely, the procedure will be done under local anesthesia, which is sprayed into the nose or mouth. This is necessary to decrease the gag reflex. A sedative may also be used to help the patient relax. It is important that the patient understands that at no time will the airway be blocked and that oxygen can be supplied through the bronchoscope. A signed consent form is necessary for this procedure.

Aftercare

After the bronchoscopy, the patient will be monitored for vital signs such as heart rate, blood pressure, and breathing, while resting in bed. Sometimes patients have an abnormal reaction to anesthesia. All saliva should be spit into a basin so that it can be examined for the presence of blood. If a biopsy was taken, the patient should not cough or clear the throat as this might dislodge any blood clot that has formed and cause bleeding. No food or drink should be consumed for about two hours after the procedure or until the anesthesia wears off. Diet is gradually progressed from ice chips and clear liquids to the patient's regular diet. There will also be a temporary sore throat and hoarseness that may last for a few days.

Risks

Minor side effects arise from the bronchoscope causing abrasion of the lining of the airways. This results in some swelling and inflammation, as well as hoarseness caused from abrading the vocal cords. If this abrasion is more serious, it can lead to respiratory difficulty or bleeding of the airway lining. A more serious risk involved in having a bronchoscopy performed is the occurrence of a pneumothorax, due to puncturing of the lungs, which allows air to escape into the space between the lung and the chest wall. These risks are greater with the use of a rigid bronchoscope than with a fiberoptic bronchoscope. If a rigid tube is used, there is also a risk of chipped teeth.

Normal results

Normal tracheal appearance consists of smooth muscle with C-shaped rings of cartilage at regular intervals. The trachea and the bronchi are lined with a mucous membrane.

Abnormal results

Abnormal bronchoscopy findings may involve abnormalities of the bronchial wall such as inflammation, swelling, ulceration, or anatomical abnormalities. The bronchoscopy may also reveal the presence of abnormal substances in the trachea and bronchi. If samples are taken, the results could indicate cancer, disease-causing agents or other lung disease. Other abnormalities include constriction or narrowing (stenosis), compression, dilation of vessels, or abnormal branching of the bronchi. Abnormal substances that might be found in the airways include blood, secretions, or mucous plugs. Any abnormalities are discussed with the patient.

Bronchoscopy

Definition

Bronchoscopy is a procedure in which a hollow, flexible tube is inserted into the airways (nose or mouth). The bronchoscope is inserted through the nose (or mouth) provides a view of the tracheobronchial tree and can be used to collect bronchial and/or lung secretions. Tissue biopsy may also be performed via the bronchoscope.

Purpose

During a bronchoscopy, the physician can visually examine the lower airways, including the larynx, trachea, bronchi, and bronchioles. The procedure is used to examine the mucosal surface of the airways for abnormalities that might be associated with a variety of lung diseases. Its use may be diagnostic or therapeutic.

Bronchoscopy may be used to examine and help diagnose:

• diseases of the lung, such as cancer or tuberculosis
• a congenital deformity of the lungs
• a suspected tumor, obstruction, secretion, bleeding or foreign body in the airways
• airway abnormalities, such as tracheal stenoses
• a persistent cough, or hemoptysis, a cough that includes blood in the sputum

Bronchoscopy may be used for the following therapeutic purposes:

• to remove a foreign body in the lungs
• to remove excessive secretions

Bronchoscopy can also be used to collect the following specimens:

• sputum
• tissue samples from the bronchi or bronchioles
• cells collected from washing the lining of the bronchi or bronchioles

If the purpose of the bronchoscopy is to take tissue samples or biopsy, a forceps or bronchial brush are used to obtain cells. Alternatively, if the purpose is to identify an infectious agent, a bronchoalveolar lavage can be used to gather fluid for culture purposes. If any foreign matter is found in the airways, it can be removed as well.

The instrument used in bronchoscopy, a bronchoscope, is a slender flexible tube that uses fiberoptic technology (very fine filaments that can bend and carry light). There are two types of bronchoscopes, a standard tube which is more rigid and a fiberoptic tube which is more flexible. The rigid instrument doesn't bend, doesn't see as far down into the lungs as the flexible one, and may carry a greater risk of causing injury to nearby structures. Because it can cause more discomfort than the flexible bronchoscope, it requires stronger anesthesia. However, it is useful for taking large samples of tissue and for removing foreign bodies from the airways.

Precautions

If the patient has severe respiratory failure and cannot breathe adequately one his or her own, the patient should be placed on a ventilator prior to bronchoscopy. It may not be appropriate to perform bronchoscopy on patients who have congestive heart failure or have experienced a recent heart attack. All patients must be constantly monitored while undergoing a bronchoscopy so that any abnormal reactions can be dealt with immediately.

Description

The procedure is ideally performed in an endoscopy room, but may be performed at the bedside. Follow institutional procedures for preoperative medications. The patient is placed in a supine position or sits upright. A pulmonologist trained to perform a bronchoscopy will spray anesthesia into the patient's mouth or nose. When the anesthetic has taken effect, the bronchoscope will be put into the patient's mouth or nose and passed into the throat. While the bronchoscope is moving down the throat, additional anesthesia is put into the bronchoscope to anesthetize the lower airways. The physician observes the trachea, bronchi, and the mucosal lining of these passageways looking for any abnormalities that may be present.

Alternative procedures

Depending upon the purpose of the bronchoscopy, alternatives may include a chest x ray or a computed tomography (CT) scan. If the purpose is to obtain biopsy specimens, one option is to perform surgery, which carries greater risks. Another option is percutaneous biopsy guided by CT.

Preparation

The patient should fast for six to twelve hours prior to the procedure and refrain from drinking any liquids the day of the procedure. Smokers should refrain from smoking for 24 hours prior to the procedure. The bronchoscopy itself takes about 45-60 minutes. Prior to the bronchoscopy, several tests will be done, including chest x ray and blood work. Sometimes a bronchoscopy is done under general anesthesia, in which case the patient will have an intravenous (i.v.) line in the arm. More commonly, the procedure is performed under local anesthesia, which is sprayed into the nose or mouth. This is necessary to inhibit the gag reflex. A sedative may be given. It is important that the patient understands that at no time will the airway be blocked and that oxygen can be supplied through the bronchoscope. A signed consent form is necessary for this procedure.

Aftercare

After the bronchoscopy, the vital signs (heart rate, blood pressure, and breathing) are monitored. Sometimes patients have an abnormal reaction to anesthesia. Any sputum should be collected in an emesis basin so that it can be examined for the presence of blood. If a biopsy was taken, the patient should not cough or clear the throat as this might dislodge any blood clot that has formed and cause bleeding. No food or drink should be consumed for about two hours after the procedure or until the anesthesia wears off. There is a significant risk for choking if anything (including water) is ingested before the anesthetic wears off, and the gag reflex has returned. To test if the gag reflex has returned, a spoon is placed on the back of the tongue for a few seconds with light pressure. If there is no gagging, the process is repeated after 15 minutes. No small or sharp objects are used to test this reflex. The gag reflex should return in one to two hours. Ice chips or clear liquids should be taken before the patient attempts to eat solid food.

The patient should be instructed that after the anesthetic wears off the throat may be irritated for several days.

Patients should notify their health care provider if they develop any of these symptoms:

• hemoptysis (coughing up blood)
• shortness of breath, wheezing or any trouble breathing
• chest pain
• fever, with or without breathing problems

Complications

Minor side effects arise from the bronchoscope causing abrasion of the lining of the airways. This results in some swelling and inflammation, as well as hoarseness caused from abrading the vocal cords. If this abrasion is more serious, it can lead to respiratory difficulty or bleeding of the lining of the airways. A more serious risk involved in having a bronchoscopy performed is the occurrence of a pneumothorax, due to puncturing of the lungs, which allows air to escape into the space between the lung and the chest wall. These risks are greater with the use of a rigid bronchoscope than with a fiberoptic bronchoscope. If a rigid tube is used, there is also a risk of chipped teeth. The risk of transmitting infectious disease from one patient to another by the bronchoscope is also present. There is potential for infection from endoscopes inadequately reprocessed by an automated endoscope reprocessing (AER) system. The Centers for Disease Control (CDC) reported apparent patient-to-patient transmission of infections following bronchoscopic procedures that used bronchoscopes that were inadequately reprocessed by AERs. Investigation of the incidents revealed inconsistencies between the reprocessing instructions provided by the manufacturer of the bronchoscope and the manufacturer of the AER; or that the bronchoscopes were inadequately reprocessed.

Results

Normal tracheal appearance consists of smooth muscle with C-shaped rings of cartilage at regular intervals. The trachea and the bronchi are lined with a mucous membrane.

KEY TERMS

Anesthesia— A drug used which causes loss of sensation. It is used to lessen the pain of surgery and medical procedures.

Bronchi— The network of tubular passages that carry air to the lungs and allow air to be expelled from the lungs.

Bronchioles— Small airways extending from the bronchi into the lobes of the lungs.

Bronchoalveolar lavage— Washing cells from the air sacs at the end of the bronchioles.

Emesis basin— A basin used to collect a patient's sputum or vomit.

Neoplasm— A new growth or tumor.

Trachea— The windpipe.

Abnormal bronchoscopy findings include deformity in the bronchial wall, such as inflammation, stenosis or compression of the trachea, neoplasm, and foreign bodies. Findings of swelling, or ulceration are abnormal. The bronchoscopy may also reveal the presence of atypical substances in the trachea and bronchi. If samples are taken, the results could indicate cancer, disease-causing agents or other lung disease. Other abnormalities include constriction or narrowing (stenosis), compression, dilation of vessels, or abnormal branching of the bronchi. Abnormal substances that might be found in the airways include blood, secretions, or mucous plugs. Any abnormalities are discussed with the patient.

Health care team roles

The test is usually performed by a pulmonologist, a physician specializing in diseases of the lungs. Nursing staff assist with providing education, monitoring the patient, and conducting tests, including checking blood pressure, pulse, and respiratory rate prior to the patient's discharge.

Resources

BOOKS

Loeb, S., ed. Illustrated Guide to Diagnostic Tests. Springhouse, PA: Springhouse Corporation, 1994.

Pagana, Kathleen D., and Timothy J. Pagana. Diagnostic Testing and Nursing Implications, 5th ed. St. Louis: Mosby, 1999.

PERIODICALS

Nakamura, C.T., Ripka, J.F., McVeigh, K., Kapoor, N., Keens, T.G. "Bronchoscopic instillation of surfactant in acute respiratory distress syndrome." Pediatric Pulmonology 31, no. 4 (April 2001): 317-320.

ORGANIZATIONS

American College of Chest Physicians. 3300 Dundee Road, Northbrook, IL 60062. (800) 343-2227.

The Association of Perioperative Registered Nurses, Inc. (AORN). 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711. (800) 755-2676. 〈http://www.aorn.org/〉.

OTHER

Public Health Advisory: Infections From Endoscopes Inadequately Reprocessed By An Automated Endoscope Reprocessing System. U.S. Food and Drug Administration, Center for Devices and Radiological Health. September 1999. 〈http://www.fda.gov/cdrh/safety/endoreprocess.html〉.