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Patient Having a Bronchoscopy

Definition

Bronchoscopy is the direct visualization of the upper and lower respiratory tract for the diagnosis and management of inflammatory, infectious, and malignant diseases of the chest. The flexible bronchoscope may be passed transnasally, transorally, or through an endotracheal or nasotracheal tube, tracheostomy or stoma.

A Bronchoscopy is carried out:

1. To obtain specimens for microbiology and for histology.

2. To assess hemoptysis.

3. To assess unresolved lung abscess, pneumonia or atelectasis.

4. To assess airway involvement in a burn patient.

5. To evaluate bronchial abnormalities.

6. To remove foreign bodies.

7. To evaluate trachea and or lungs prior to surgery.

8. To evaluate trachea and or lungs post surgery, post radiation, or post chemotherapy.

9. To place a brachy therapy catheter prior to radiation.

10. To treat strictures and insert stents.

Contraindications

1. Acute asthmatic episode.

2. Patient not NPO for 6 hours.

3. Hypoxia, unless patient is intubated.

4. Uncooperative patient.

5. Respiratory failure requiring high FIO2

6. Bleeding diathesis-severe thrombocytopenia or coagulopathy.

Pre procedure
The RN will...

1. Complete the nursing history and assessment including allergies.

2. Notify the physician if patient is currently on anticoagulation therapy, ASA, or nonsteroidal anti-inflammatory products and if laboratory results are abnormal.

3. Obtain CXR or CT scan.

4. Ensure informed consent is obtained.

5. If conscious sedation is used, inform the patient of restrictions related to driving or using equipment requiring clear judgment or quick physical responses. It is advised not to drive for 24 hours or to ingest alcohol.

6. Verify the patient has made discharge arrangements according to hospital policy.

7. Obtain baseline vital signs and oximetry. Establish baseline cardiac rhythm as per hospital policy.

8. Verify length of NPO status, 6-8 hours.

9. Establish patent IV line as ordered.

10. Explain the use of premedication to be used.

11. Administer pre medication as ordered: Aerosol mask, atropine, sedative or narcotic analgesic.

12. Document patient teaching and patient comprehension of teaching.

Intra procedure
The RN will...

1. Assist and support the patient during the procedure.

2. Ensure resuscitation equipment and suction is readily available.

3. Attach the monitoring devices such as ECG leads and pulse oximetry as per institutional policy.

4. Assist the Bronchoscopy team with the procedure including sedation, anesthesia, suctioning and specimen handling.

5. Monitor and maintain the patient’s cardiopulmonary status, which may include titrating O2 therapy or maintaining the patient ventilation system when required.

6. Assess color, warmth and dryness of skin.

7. Assess level of consciousness and mental status.

8. Administer medication as ordered, including aerosol delivery, medication via the bronchoscope or IV medication.

9. Assist and support the patient during the procedure.

10. Provide and document the minimal monitoring of all patients including BP, pulse, respiration, O2 sat, level of consciousness and pain tolerance.

11. Label all specimens taken with pertinent patient information and site of biopsy. Send specimens to the appropriate laboratory.

Post procedure
The RN will:

1. Post procedure O2 supplementation may be required in some patients, Particularly those with impaired lung function and those who have been sedated.

2. Assess BP, heart rate, respiratory rate, depth and effort. O2 saturation and level of consciousness on admission to recovery area, after 15 minutes, until stable and at discharge. Post procedure oximetry must be performed until the patient’s respiratory status is stable or returned to pre-procedure state.

3. Assess and document unexplained events and post procedure complications.

4. Keep patient NPO until gag reflex returns.

5. Remove IV access prior to discharge, assess site and document.

6. Reinforce pre-procedure teaching regarding driving, equipment operation and making decisions requiring judgement. The teaching provided should be in written form and a copy given to the patient prior to discharge.

7. Reassure the patient it is common to have some bleeding after a biopsy is done, however coughing up more than 2 tsp of blood requires that the patient contact the physician.

Potential complications post Bronchoscopy

1. Bleeding
2. Pneumothorax
3. Hypoxemia
4. Bronchospasm
5. Cardiac arrhythmias
6. Respiratory or cardiac arrest
7. Pulmonary hypertension
8. Laryngospasm
9. Reaction to topical anaesthesia
10. Hypoventilation
11. Myocardial Infarction
12. Post Bronchoscopy fever/infection
13. Aspiration pneumonia

The registered nurse functions within the limitations of the provincial licensing body and institutional policies.

Disclaimer

The CSGNA assumes no responsibility for the practices or recommendations of any member or other practitioner or for the policies and practices of any Endoscopy unit.

Bibliography

------- 1996. Practice Guidelines for Sedation and Analgesia by Non- Anesthesiologists.  A report by the American Society of Anesthesiologists Task force on Sedation. Anesthesiology 84; 459-471.
------- Fiberoptic Bronchoscopy Assisting. 1993.  Clinical Practice Guideline. Respiratory Care.38:1173-1178.
Association of Operating Room Nurses Inc. 1995.  Standards of Recommended Practices.163-210.
Association of Operating Room Nurses 1996. Recommended practices for monitoring the patient receiving IV conscious sedation. Standards and Recommended practices. AORN.
Berkowitz, C. 1997. Conscious sedation a primer. RN. 32-35.
Honeybourne, D, Babb, J, Bowie, P, Brewin, A, Fraise, A. Garrard, C, Harvey, J, Lewis, R, Neumann, C, Wathen, C, Williams T. 2001. British Thoracic Society Guidelines on diagnostic Flexible Bronchoscopy. British Thoracic Society. Thorax; 56, 1-21.
Holzman, R, Cullen,D.1994. Guidelines for sedation by non-anesthesiologists during diagnostic and therapeutic procedures.  Journal Clinical Anesthesia. 6; 265-276.
Jones, A., O’Driscoll, R. 2001. Do all patients require supplemental Oxygen during Flexible Bronchoscopy?  Chest 119(6). 1906-1909.
Lesser, S. 1998. Building a Bronchoscopy Teaching Module. Nursing Spectrum 8(13): 6-7.
Murphy, E. 1993. Monitoring IV Conscious sedation, the legal scope of practice. AORN 57(2); 512.
Standards of practice. 1994. College of Respiratory Therapists of Ontario.
SGNA  1991. Manual of Gastroenterology  Procedures -Pulmonary supplement.
SGNA 2001. Manual of Pulmonary procedures for Endoscopy Nurses.
Stoller, J. 2001. Evolving roles of Non-physician Respiratory Care providers.   Clinical Pulmonary Medicine; 8(5) 279-283.

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