bronchoscopy Flashcards
List diagnostic (8) and therapeutic (4) indications for bronchoscopy
diagnostic: infection, abnormal CXR markings (lesions, nodules, masses, infiltrates, atelectasis), airway obstruction, lung/chest trauma, hemoptysis, chronic cough + unexplained resp symptoms, lung disease severity, TE fistula/other bronchial abnormalities
therapeutic: bronchial hygiene, foreign body removal, ETT management (insert difficult airway, confirm position), interventional not performed in bronch suite (laser therapy, cryotherapy, thermoplasty, balloon dilatation of airways, tracheobronchial stents (OR))
absolute contraindications
no Pt consent, no available staff to perform/assist with procedure, not NPO for at least 8 hours, allergies to substances used during procedure
relative contraindications (8)
high O2 requirements, current/recent MI, life-threatening cardiac arrhythmias, hemorrhage risks (low platelets, increased INR or PTT, anticoagulants, thrombocytopenia, elevated creatinine or BUN), compromised upper airway (vc edema), endotracheal lesions (e.g. mass, granuloma), active asthma or COPD exacerbation, immunosuppressed Pt
complications & risks
complications: tachycardia, hypotension, bronchospasm, hypoxemia
risks: pneumothorax, bleeding, aspiration, hypercapnia, infection, vagal response, laryngospasm, cough/irritation
alternative substance used if lidocaine allergy present
Chloroprocaine (Nesacaine) (now); benzocaine (previously but not safe due to MetHb)
NPO restriction pre vs. post bronchoscopy
PRE: NPO 4 - 6hrs prior to procedure to reduce risk of aspiration
POST: NPO for at least 2 hrs to allow local anesthetic to wear off + prevent aspiration
medication doses midazolam & fentanyl
Midazolam = (benzodiazepine) 1-4mg IV to produce amnesia + sleep
Fentanyl (opioid) = 25 - 100mcg IV = analgesia
emergency med anaphylactic shock kit supplies (3)
ampule epinephrine, 1ml diphenhydramine (benadryl H1 antihistamine), 4mg/ml dexamethasone (CS)
seizure kit emergency med
midazolam (versed)
narcotic overdose emergency kit meds
2 ampules narcan (0.4mg/ml); half life 20 minutes
kit D emergency kit meds
hypoglycemia treatment: dextrose, D10W
Reversal agent for Midazolam
Flumazenil (0.1mg/ml); give 0.2mg over 15sec IV, wait 45sec then repeat up to 1mg
dimenhydrinate
gravol (for nausea)
advantages of flexible bronchoscopy (4)
widely available, most respirologists trained in flexible bronchoscopy, does not require general anesthesia, provides more access to more distal airways + good access to upper lobe bronchi
advantages of rigid bronchoscopy (7)
general anaesthesia more comfortable for Pt, allows control of ventilation + oxygenation during interventional procedures, permits removal of large tumour, more control over massive hemoptysis, insertion of silicon airway stents, removes obstructing airway lesions, removes large centrally-located foreign bodies
purpose of TBNA (transbronchial needle aspiration)
samples lymph nodes for diagnosing/staging lung cancer
Versed (midazolam)
BZ: hypnotic, sedative, anxiolytic used in conscious sedation, GABA receptor agonist (Cl- channel). Strong amnesia, little hangover, minimal cardiopulmonary depression. Can cause nausea/emesis, coughing, apnea. onset <5min, duration 20mins. dose 1-4mg IV. Reversal agent = Flumazenil (Ativan). Used with fentanyl or morphine as it is not an analgesic
Sublimaze (fentanyl)
Analgesic, opioid u receptor agonist = decreased nociceptive substance release, dose 25-100mcg for bronchoscopy, rapid onset and offset. Lower side effects than morphine and 100x more potent. Risks still for hypotension, resp depressionm vasodilation, dulled cough reflex. Reversal = Naloxone/Narcan
morphine
Opioid u receptor agonist analgesic, highest release of histamine. Risk of resp depression, vasodilation, hypotension, nausea, dulled cough reflex
Reversal = Naloxone
Dilaudid (Hydromorphone)
opioid u receptor analgesic, 10x more potent than morphine and less risk of dependency/addiction. Minimal histamine release. Same risks as other opioid analgesics
propofol (diprivan)
IV anesthetic sedative and hypnotic; GABA receptor involvement. Benefits = decreased ICP, rapid emergence, anti-nausea. Risk: RESP/CVS depression, PRIS (bradycardia + asystole), pain at site of administration. Onset 15-30sec, duration 5-10min; dose 1-2.5mg/kg
Etomidate (Amidate)
IV anesthetic/sedative/hypnotic, GABA involvement used for head injuries and cardiac complications, no significant CVS effects + decreases metabolism. Note: no analgesia properties. onset 30 sec, duration 10 min, dose 0.3-0.6mg/kg IV
ketamar (ketamine)
IV dissociative anesthetic via NMDA receptor blocker. Benefit: minimal resp depression, increases BP, bronchodilates. Risks: vivid hallucinations on emergence. Onset 30 sec, duration 30 min dose 3-5mg/kg IV
Precedex (Dexmedetomidine)
sedative, short acting alpha 2 adrenergic agonist blocks NE. Adverse: lacks resp depression and can affect BP
