From WardWiki - Foundation Doctor Helper
Bronchoscopy is an endoscopic procedure to image the lower respiratory tract, from the trachea to the segmental bronchi. It is invasive but justified for both diagnostic and therapeutic use. Its utility lies in the ability to obtain excellent views of the lower respiratory tract and perform interventions on it. These views allow prompt diagnosis of mucosal inflammation, ulceration and lesions. This is essential for surveillance post lung surgery and removing or palliating bronchial obstruction. Rigid bronchoscopy is used under general aneasthetic to remove foreign bodies and cauterising bleeding points. Flexible bronchoscopy is used under sedation for diagnosis, collection of brochoalveloar fluid, therapeutic washout, transbronchial biospy of lung tissue, and biopsy and stenting of lesion.
Very little preparation is needed for bronchoscopy performed under sedation. Preoperative assessment is required for any patient undergoing general aneastheic, although this need not be extensive for young healthy adults. Patients must be nil by mouth for at least 6 hours prior to bronchosocpy. A patient will be returned to the ward if found not to be fasted. Any patient that requires more oxygen than can be delivered by nasal speculae must be discussed with the bronchoscopist. In patients who are meet preoperative requirements for ECG must have one, as bronchoscopy is very stimulating. Prophylactic antibiotics are only given in unusual circumstances; a mechanical heart valve is classical.
Immediate management for all unwell patients
The emergency preparation for bronchoscopy occurs when an emergency exists and no short cuts can be taken. The timely and careful resusitation of a critically patient should done alongside arranging senior support and transfer to the endoscopy room or theatre. Recognise that this is serious and not manageable by a foundation doctor alone.
Assess the patency and protection of the airway. Take baseline observations, viewing them on a chart using an early warning system.
If evidence of airway compromise, contact anaesthetist and your seniour colleague.
If there is a raised or reduced respiratory rate, listen to the chest and give high flow oxygen via a non-rebeathe mask.
If there is a tachycardia, low blood pressure or evidence of dehydration establish IV access and give a fluid challenge.
Consider now placing a urinary catheter. Send off FBC, U&E, CRP, Group and Save, and any special relevant blood tests. Send of clotting screen if there is jaundice, history of alcohol excess or liver disease.
If there is pyrexia equal to or above 38 or less than or equal to 35 degrees, take blood cultures.
If SIRS is confirmed or sepsis suspected consider the Severe Sepsis Resuscitation Bundle, although sepsis is rare in upper GI bleeds. If patient meets these criteria and does not respond well to initial management contact a senior team member, and a member of critical care who can see the patient or give advice immediately.
Always cross match at least four units for a haemoptysis in extremis. It is time consuming and distressing to attempt(pointlessly so) to rush the blood bank to dispense blood later on. Transfuse without hesitation when GI bleeding is obvious and the patient has a pulse greater than 120, systolic or diastolic hypotension that suggests Class III haemorrhage. Be cautious when other causes of tachycardia exist.
Note a urinary catheter is therapeutic only in cases where an empty bladder is desired (including transfer to theatre for surgery). It is important not to miss out resusitation and diagnostics steps in the first hour in an effort to set up equipment that measures a patient only hourly. Your initial fluid challenges will, by definition, not be affected by your promptly placed urinary catheter.
Continuing from the above, ensure patency of two wide bore cannulae; in practice at least two green cannulae needed. Secure these if patient is agitated with bandaging.
Many trusts offer consent training and one must be familiar with the procedure prior to consenting for it. This article should serve as reminder to those who have consented previously. The benefits depend on the indication, not all will be true for each case. Any procedure for research purposes must be consented by a senior doctor.
Bronchoscopy +/- biopsy +/- dilation and insertion of stent +/- diathermy of point of bleeding +/- brochoalveloar lavage.
Diagnosis of stricture, removal of foreign body, removal of cause of bleeding, diagnosis
Bleeding, sepsis, atelectasis, failure to achieve goals, perforation of bronchus requiring surgery, bleeding, blockage of stent requiring retreatment, pneumonia.
Monitor for effects of sedation and nausea and confusion post analgesia. Most patients recover well and can go home the same evening. Unless stated in the operation notes, all patients can eat and drink as soon as is comfortable.
Follow up with histology if any taken; a normal bronchoscopy needs no routine follow up.
Monitor patient for signs of bleeding post bronchoscopy. Hypotension is usually caused by bleeding or by opioid analgesia (pethidine) or sedatives given periprocedure.
It occurs also in tension pneumothorax.
Obtain a CXR after any biospy and if signs of respiratory distress develops to look for pneumothorax or lobar collapse
Investigate carefully and inform senior if not responsive to immediate treatment.