Transcript File - Respiratory Therapy Files

BRONCHOSCOPY
BRONCHOSCOPY TEAM
• Pulmonologists (manipulate scope)
• Respiratory therapists (assist with slides and
lavage)
• Anesthesia
• Nurses
• Laboratory
– Microbiology
– Pathology
BACKGROUND
• Can be done at bedside using a portable
machine without picture capabilities
• May be done with picture and visulalization
capabilities in a procedure room or at
bedside
• It is a sterile technique, may require
sedation
• Scope can be inserted in nose, mouth, trach
tube or ETT
BACKGROUND
• Allows direct visualization of the airways
• Basic purposes:
– Therapeutic (lavage and suction)
– Diagnostic (inspect/collect samples for Dx)
– Difficult intubation
• Two types:
– Rigid (under heavy sedation, removal of
FBAO, surgical procedures)
– flexible instruments (common, BAL…)
Bronch Steps
• http://www.youtube.com/watch?v=XafLSo
htOuk&feature=related
• http://www.youtube.com/watch?v=hEA0T
WEw5jU&feature=related
• http://www.youtube.com/watch?v=AHNK_
bs6YZU&feature=related
RIGID BRONCHOSCOPY
• Generally performed by ENT’s and
surgeons
• Procedure oriented
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Foreign body removal
Biopsies
Granuloma/polyp removal
Laser
Stent placement
• Visualization for future surgery
FLEXIBLE BRONCHOCSOPY
• Examination of the entire respiratory
anatomy, nose to bronchi
• Minor impact on anatomy
• Able to pass through an endotracheal tube
or tracheostomy tube
INDICATIONS
• When flexible bronchoscopy is the best,
easiest, safest, most efficient way to obtain
the information
Bronch Assisting
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Obtain the following medications and fluids:
1 bottle of sterile normal saline 250 ml or greater.
Xylocain jelly for the scope
(2) bottles of 1% lidocaine (you will likely use only one)
At least 4 ml of sterile 4% lidocaine
Hurricane spray to numb the throat, may also have patient gargle lidocain, or
inject it into trachea, may also use Cocaine.
1 mg/ml epinephrine for possible bleeding
RN will administer sedative (Ativan or Versed usually)
Bronch Assisting
• Setting up room
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Depending on setting (bedside or in procedure room,
may also be done under fluoroscopy)
Have several 10-12 ml syringes for injection ready
Open saline bottle, have ready for injection and lavage
Open small specimen cups and lable 1% and 2-4%
Lidocaine, have ready for injection
Have slides and specimen container ready for biopsies
Have cytology brush and forceps ready (keep sterile)
Have Leukins trap ready
Bronch Assisting
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Setting up room
Gauze
Towels
Sterile gloves, gowns and masks, face shields
Lead vests if done in Fluoroscopy
Bite block
Suction equipment/tubing
Oxygen and resusitation bag
Bronch Assisting
• When drawing up fluid for injection through the injection
port of the bronchoscope, draw up several cc of air on top
of the fluid. The air will follow the fluid through the
bronchoscope to clear the channel of fluid. Fluid injected
into the airway should be sterile
• Obtain several patient labels to attach to laboratory
specimens (you will need to write the sample type and site
on the label (e.g. "Right upper lobe BAL", "bronchial
washing", etc.) once obtained. Have available any
laboratory forms that might be necessary for proper
specimen processing (pathology, cytology, microbiology,
etc).
Bronch Assisting
• Organize at the bedside at least: 1 sterile biopsy forceps for
bronchoscopy (have formalin available and a separate small container
of sterile NS for rinsing the forceps if it touches the formalin). Assure
smooth functioning of the forceps.
• 1 sterile cytology brush for bronchoscopy (have several slides
available with slide container and fixative – you will need to ask the
physician if the slides should be "fixed" if you obtain a brushing.
• 1 sterile transbronchial aspiration needle for bronchoscopy (have a 2035 ml syringe to apply suction to the needle (assure it is compatible
with the syringe port on the needle) and several slides available).
• Compatibility of the external diameter of all scope accessories with the
internal diameter of the bronchoscope should be verified before the
procedure.
Bronch Assist
• Assure the bronchoscope and other reusable items have
been properly cleaned and disinfected. If the suction valve
is reusable inspect it for possible debris left behind after
cleaning. Plug the bronchoscope into the light source and
"white balance" it (shine the tip at something white and
push the "white balance" button) the look through it and
assure it is in proper working order. Check any cameras
and/or video equipment that may be used. Connect suction
tubing to bronchoscope (during the procedure you will
likely be using full suction vacuum setting) with an in-line
suction trap (have at least 3 more suction traps available).
Assure proper resuscitation equipment is in the
bronchoscopy area.
Patient Prep
• Obtain and review patient chart and x-rays then
make them available for the physician performing
the procedure. Patients typically are assessed for
potential bleeding problems, etc - obtain any preprocedure laboratory results (coagulation
assessment, ECG, spirometry, etc). Record how
long the patient has been NPO. Assess the ability
to adequately oxygenate the patient during the
procedure. Assess the patient for tuberculosis risk,
as procedure may need to take place in specially
ventilated room.
Patient Prep
• Assure proper consent has been obtained. Obtain
medication allergy and hypersensitivity
information. Explain procedure to patient. Obtain
and record baseline room air oximetry (if patient
normally uses oxygen, obtain oximetry reading on
their normal level of supplemental oxygen).
Obtain and record baseline pulse reading. Obtain
and record baseline blood pressure reading.
Connect patient to ECG monitor.
Post Procedure
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Monitor the following and record items as significant and vital signs on a
regular basis:
Level of consciousness.
Medications administered, dosage, route, and time of delivery.
Subjective responses (e.g., pain, discomfort, dyspnea).
Blood pressure, heart rate, rhythm, and changes in cardiac status
SpO2 and supplemental oxygen use.
Patient should be observed until stable.
Patient should remain NPO for 2 hours and after this period has expired begin
by trying small sips of water to assure the ability to effectively swallow.
Outpatients should be instructed to contact the bronchoscopist regarding fever,
chest pain or discomfort, dyspnea, wheezing, hemoptysis, or any new findings
presenting after the procedure has been completed. Oral instructions should be
reinforced by written instructions that include names and phone numbers of
persons to be contacted in emergency
AIRWAY ANATOMY
TECHNIQUE
TECHNIQUE
• Anesthesia
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Best accomplished in the operating room
May be performed bedside in an ICU setting
Continuous monitoring
Light anesthesia--allows continued spontaneous
breathing
– May be done with conscious sedation in older
individuals
TECHNIQUE
• Insertion
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Nasal
LMA
Endotracheal tube
Tracheostomy tube
Appropriate topical anesthesia and lubrication
TECHNIQUE
• Anatomical survey
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Nasal passages
Pharynx
Larynx
Trachea
Bronchi
• Examine all before any other procedures
TECHNIQUE
• Additional procedures
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Bronchoalveolar lavage
Brushings
Bronchial biopsy
Transbronchial biopsy
Laser
Others: cryotherapy, stent placement, foreign
body removal, needle biopsy
BRONCHOALVEOLAR
LAVAGE
• Small aliquots of sterile normal saline
instilled into the airway
• Removed by suctioning
• Samples distal bronchial and alveolar
surfaces
• Wedge position to prevent loss of fluid
BAL TESTS
• Microbiology
– Bacterial, viral, fungal, AFB, special techniques
• Pathology
– Cell count, differential, special stains
MICROBIOLOGIC STUDIES
• Stains
– Gram stain
– Acid fast stain (Ziehl-Neelsen)
• Antibody tests
– Rapid tests, DFA tests (direct fluorescent
antibody (DFA) testing) Ex: RSV
• In-situ (tumors)
• PCR (polymerase chain reaction) DNA
SPECIAL STAINS
• Fungi
– Silver (Gomori’s methenamine silver stain)
• Pneumocystis carinii
– Silver stain
– Papanicolaou
SPECIFIC INDICATIONS
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Atelectasis
Recurrent pneumonia
Chronic cough
Persistent/unexplained wheeze
Hemoptysis
Suspected airway compression/obstruction
Stridor
Upper airway obstruction
Suspected aspiration
Evaluation of tracheostomies
Inflammation
Banding
Notched Epiglottis
Abnormal Epiglottis shape
Mucus Plug in Trachea
Left mainstem mucus
Fistula
Pneumoectomy
Lung Cancer in Bronchus
http://www.youtube.com/watch?v=ezsD0OjqbH8
Tumor in Left mainstem
Stenosis
Post Laser Surgery
Stent Placement
Granuloma from trach tube
Tracheal Cleft
http://www.youtube.com/watch?v=Po
208uGAeww
tracheal clefts and congenitally short
tracheas