Bronchoscopy Flashcards
What are the clinical indications for a bronchoscopy?
Assessment of hemoptysis to including determining the site of bleeding
Removal of foreign bodies in the airway
Assessment of various pulmonary problems
Infection
Lung mass or nodule
Describe hemoptysis
Coughing up blood
When would it be necessary to perform a bronchoscopy on a patient with pneumonia
If they are unable to produce a sputum sample
Describe massive hemoptysis
Massive blood loss from the bronchopulmonary tree of approximately 200-600 ml of blood within a 12 to 24 hour time frame
What is usually ordered when a patient is experiencing hemoptysis?
CBC and assessment of coagulation factors
Bronchoscopy to establish cause of bleeding
What risk do aspirated foreign bodies pose to patients?
Can cause PNAs that do not resolve
Can cause significant SOB
Why are bronchoscopies used to sample tissues in the transbronchial region?
Safer
More accurate
What is an option for the removal of foreign bodies from the tracheobronchial tree?
Flexible bronchoscopy examination evaluate the foreign body and potentially remove it
Have rigid bronchoscope on hand in case foreign body cannot be successfully removed
What is interstitial lung disease?
An abnormality of the lung parenchyma involving the space between the alveoli
What is a risk associated with removing foreign bodies via bronchoscopy?
Foreign body may move further down the tracheobronchial tree
What is needed to diagnose ILD?
High resolution CT scan
How can a bronchoscopy be useful when evaluating ILD?
Can be used for biopsies of lung tissue for testing
Describe a diagnostic bronchoscopy
A procedure that involves using a bronchoscope to visualize the major airways and obtain tissue, secretion or fluid samples
Describe a flexible bronchoscopy
Comprised of a flexible sheath containing the necessary cables to allow flexion and extension of the tip of the scope
List some uses for the flexible bronchoscopy
Sampling of parenchymal masses and nodules suspicious for cancer
Obtaining brinchoalveolar samples to diagnose infection
Diagnostic sampling of mediastinal lymphadenopathy
Assessing endobronchial tissue for an obstrucint lesion
Sampling of both endobronchial and parenchymal tissues to asses for conditions
Removal of foreign bodies and suctioning of the airway to clear an obstruction
What is included in the prebronchoscopy assessment?
Evaluate the patients airway
See if the patient uses dentures or other oral appliances
Check recent medical history
Patients vital signs
What are relative contraindications for bronchoscopies?
Recent myocardial infarction
Unstable arrhythmias
Unstable bronchial asthma
Respiratory insufficiency with hypoxia or hypercarbia
Coagulopathy
Uremia
Hypo-hypertension
When should a flexible bronchoscopy not be performed
Without formal patient consent
Without adequate support
Bronchoscopist is inexperienced
What is the order of anatomical features that are bypassed/examined in a bronchoscopy?
Advanced through oropharynx
Past epiglottis and through vocal cords (lidocaine applied to vocal cords)
Right upper, right middle, and right lower lobe and subsegmental bronchi are inspected
Left upper and left lower lobes and subsegmental bronchi are examined
What should be monitored during a bronchoscopy?
Patient vitals
Patient oxygenation
What are the options for insertion of a flexible bronchoscope?
Nasal passages
Oropharnx
Oral insertion of the bronchoscope requires what?
A bite block
What are the methods that a bronchoscopist has at their disposal to gather samples?
Sterile brush
Cytologic brush
TBBx
What is the sterile brush on the bronchoscope used to sample?
Microbiology
What is the cytologic brush used to sample?
Assess for malignant cells
What is the TBBx used for?
Tissue sampling to assess for infection or malignancy
What is the BAL used for?
Sample collection from the alveoli looking for malignant cells
What instruments are used to collect samples?
Smooth or serrated forceps
Sterile brush
Cytology brush
When are serrated forceps used?
Used when a mass is visualized and a larger piece of tissue is required
Capable of cutting tissue and are preferred if a larger sample is needed
Describe a shielded brush
Shielded brushes have an inner layer with a plastic outer layer to protect the sterile brush from contamination
Describe unshielded brushes
Unshielded brushes are not protected by an outer sterile plastic sheath and are primarily used to obtain samples of masses or suspicious parenchymal tissues to send for cytologic analysis
What are the risks associated with bronchoscopy
Infection
Bleeding
Pneumothorax
Describe the procedure for a BAL
Bronchoscopist locates subsegment of the lung of interest with the tip of the scope wedged in the subsegment of the lung
20-40 mL of saline is instilled into the side port of the scope and into small airway
Fluid is flushed down airway and suction back into a trap that is attached to scope
What is special about EBUS (endobronchial ultrasound)
Has an ultrasound probe at the end with doppler capability
What is a thoracentesis performed for?
Remove pleural fluid
Reduce respiratory distress in patients with large pleural effusions
What conditions can produce exudative pleural effusions
Infection
Cancer
Pulmonary embolism
What is a rigid bronchoscopy?
Long hollow straight metal tube with light source, telescopes and viewing monitor
Allows for access to the trachea and proximal airways to remove large foreign bodies
What conditions can cause transudative pleural fluid?
Left ventricular failure
Renal failure
Liver failure/cirrhosis
What is used to locate areas for thoracentesis?
Ultrasound is used to locate deep pockets of pleural fluid located away from structures
What are potential complications of a thoracentesis?
Pneumothorax (rare)
Pain, coughing, localized infection
Hemothorax
Intra-abdominal organ injury
Air embolism
Post expansion pulmonary edema
When is a surgical lung biopsy indicated?
Indicated in patients who have clinical findings suggestive of interstitial lung disease
Chest imaging consistent suggestive of ILD
Exclusion of infectious processes and cancer
Evaluating of unexplained hypoxia, hemoptysis or signs of an inflammatory lung process
When is a surgical lung biopsy not indicated?
In cases of ILD if the complications outweigh the benefits
What are complications associated with open lung biopsy
Infection
Bleeding
Creation of bronchopleural fistula
Post procedure PNA
Post op atelectasis
During a BAL, the RT inserts approximately how much normal saline into the side port of the scope?
20-40 ml
What solution anesthetizes the vocal cords?
lidocaine
Describe the VATS procedure
Patient is mechanically ventilated via double lumen ETT
Non dependent lung is collapsed by suction or by positive pressure in pleural cavity
Requires 3 incision points
Chest tubes places for drainage
What is the gold standard for obtaining lung tissue samples
Open lung biopsy
What is used to sample malignant cells during a bronchoscopy?
cytologic brush
BAL
transbronchial biospy
what is the least invasive test which may determine the causative agent for PNA patients?
sputum sample
What can foreign bodies aspirated into the lung cause
significant dyspnea
PNA
When is a thoracentesis performed?
To drain large pleural effusions
T/F: Transbronchial biopsies via flexible bronchoscopy can diagnose both central lesions and peripheral lesions
true
What can be an indication for a bronchoscopy
Sudden oxygen desaturation
Hemoptysis
Chest xrays with complete opacifications
T/F: Bronchoscopy is necessary for every PNA patient
False
Where are rigid bronchoscopies usually performed?
the operating room
Clinical indications for a bronchoscopy include
Removal of foreign bodies
Assessment of various pulmonary problems
Assessment of hemoptysis
When are rigid bronchoscopies usually performed?
usually performed on patients with large foreign bodies in their airways
Flexible bronchoscopy should not be performed without
Formal patient consent
Adequate facilities
An experienced bronchoscopist
In order to sample microbiology during a bronchoscopy, you need a
sterile brush
What do open lung biopsies allow us to do?
Visualize the pleural space
Repair damaged structures
Visualize anatomical structures
Risks associated with bronchoscopies include
Bleeding
Pneumothorax
Infection
What are unshielded brushes used for during a bronchoscopy?
collect samples of masses or suspicious tissue
What would cause an transudative pleural effusion?
left ventricular failure
What are relative contraindications for bronchoscopies?
Hypoxia
Hypercarbia
Unstable arrythmias
Myocardial infarction less than 6 weeks ago
Unstable bronchial asthma
What are serrated forceps used for during a bronchoscopy?
to cut tissue for large tissue samples
ILD can be diagnosed with
A transbronchial biopsy
Specific antibodies
A high resolution cat scan
An autoimmune panel
What could cause an exudative pleural effusion?
Cancer
