Bronchoscopy

Informed consent should be obtained from the patient or the patient’s health care power of attorney. A focused history and physical examination should be obtained to ensure the procedure is clinically indicated and to evaluate for potential contraindications. The patient should fast (nothing by mouth) for six to eight hours before the procedure. Hemodynamic monitoring, pulse oximetry, and intravenous access should be assured before the start of the procedure. Patient’s medication list and allergies, and laboratory results should always be checked. An ECG may be performed if clinically indicated. A ‘time out’ is performed at the start of the procedure. Although bronchoscopy can be done without sedation, most procedures are done under moderate conscious sedation with the use of various sedatives based on the clinician’s preference (e.g., benzodiazepines, opioids, dexmedetomidine). Certain procedures may require more deep sedation or general anesthesia. Regardless of the sedation or anesthesia used the physicians should be aware of the potential side effects and how to manage patients receiving these medications.

The bronchoscope may be introduced into the nasal cavity or the mouth (or through an endotracheal tube or laryngeal mask airway) and advanced to the level of the vocal cords. Assessment of the appearance and movement of the cords is done. As the bronchoscope is advanced beyond the vocal cords, a careful inspection of the entire airway is performed. In particular, abnormal endobronchial lesions or mucosal abnormalities, as well as any evidence of narrowing or dynamic collapse, is assessed. Pictures or videos can be recorded for future reference. Effort should be made to avoid unnecessary contact with the mucosa to avoid trauma. Based on the indication of the procedure, appropriate tools are selected to accomplish specific tasks such as tissue sampling or tumor debulking. At the conclusion of the procedure, a final assessment of the airway should be performed ensure adequate hemostasis. A post-procedural chest x-ray may be needed to evaluate for the presence of a pneumothorax. All patients should be monitored before, during and after the procedure. After uneventful recovery and in the absence of complications the patient may be discharged on the same day. Appropriate follow up is scheduled, and the patient is advised not to drive, operate heavy machinery for the rest of the day, or participate in any activity that requires full consciousness as the effect of the medications may last many hours.

Medication-related complications:[8][9]

• An overdose of local anesthetics can result in central nervous system (CNS)-toxicity like neuropathy, seizures, and coma.
• Methemoglobinemia
• Most sedative medications can result in hemodynamic effects including low blood pressure or low heart rate.
• General anesthetics may result in malignant hyperthermia and prolonged neuromuscular paralysis.

Procedure-related complications:

• Bleeding: In most cases, bleeding is usually self-limited. The pulmonologists should carefully ascertain for hemostasis, and in the event of severe bleeding prompt management should be immediately instituted.
• Pneumothorax: In 1% to 3% of patients, pneumothorax may occur after transbronchial biopsies. Small pneumothoraces may be managed conservatively, while symptomatic and large pneumothorax will require chest tube insertion and hospitalization. A tension pneumothorax results in hemodynamic instability and should be recognized even without imaging studies. Appropriate life-saving measures such as chest tube insertion should be undertaken immediately. Most pneumothoraces after bronchoscopy develop within the first hour of the procedure but can be delayed up to 24 hours. Appropriate instructions to the patient and appropriate follow up should be arranged.
• Cardiac arrhythmias may also occur especially in patients with pre-existing cardiac disease.
• Other potential complications of the procedure include trauma to the vocal cords, pneumomediastinum, hypoxia, and rarely death.

Bronchoscopy is helpful in the diagnosis and management of various airway and lung diseases. With further advances in technology, a bronchoscopy will not only continue its current role in clinical practice but will expand its scope as a minimally invasive advanced diagnostic and therapeutic tool.

an interprofessional team skilled in the care of patients with airways and lung disease and adept in the use of bronchoscopy equipment is essential to performing bronchoscopy safely and manage complications. In addition to a skilled bronchoscopist, personnel includes an endoscopy nurse and respiratory therapist or technician trained in the use of bronchoscopy equipment. If general anesthesia is used for the procedure, additional personnel include anesthesiologist and/or nurse anesthetist. Many bronchoscopy suites also use rapid on-site cytologic evaluation of specimens by a pathologist or cytology technician.[10][11][12]