SUBJECT: Bronchoscopy assisting

PURPOSE:

Fiberoptic bronchoscopy may involve direct visualization of the upper and lower respiratory tract for the diagnosis and management of a spectrum of inflammatory, infectious, and malignant diseases of the chest. Bronchoscopy may include retrieval of tissue specimens (bronchial brush, forceps, needle), cell washings via bronchoalveolar lavage, or removal of abnormal tissue. Bronchoscopy may also be used to remove aspirated objects from the respiratory tract or to assist with difficult intubations.

This procedure deals with typical full fiberoptic bronchoscopy in the spontaneously breathing non-intubated adult. Modifications may be necessary for its application in specific circumstances. Bronchoscopy is also used in intubated mechanically ventilated patients. It has been used while ventilating patients non-invasively, while using a laryngeal mask airway, and while many other conditions exist.

The bronchoscopy assistants must be trained in the setup, handling, cleaning, and care of bronchoscopy equipment and related supplies; specimen retrieval and preparation for commonly ordered laboratory studies on bronchoscopy specimens; biopsy labeling; delivery of aerosolized drugs; and mechanical ventilation. The assistant must also be trained in monitoring and evaluating the patient's clinical condition as reflected by pulse oximetry, electrocardiogram, and stability of or changes in mechanical ventilation parameters, and be capable of relating changes in clinical condition to disease state, procedure, or drugs administered for the procedure.

At least 1 credentialed Respiratory Care Practitioner (RCP) experienced in bronchoscopy, 1 credentialed Nurse experienced in bronchoscopy and 1 Physician experienced in bronchoscopy will staff the procedure. Nurse alone may staff post-procedure care if there is ability to contact the Physician and RCP.

• 1 bottle of sterile normal saline 250 ml or greater.
• 2 30-50 ml bottles of sterile 1% lidocaine (you will likely use only one).
• At least 4 ml of sterile 4% lidocaine.
• Viscous 2% lidocaine (at least 10 ml).
• 1 mg/ml epinephrine (you may need 1-4 ml) (the endoscopy nurse may have this on hand).
• Albuterol (you will likely need at least 2.5 mg).
• 1 bottle nasal decongestant spray (you may not use this).
• Ipratropium bromide – unit dose 0.5 mg (you may not use this).
• Mucomyst 20% (you may not use this).
• Racemic epinephrine (you may not use this).
• Some physicians request up to 2 mg atropine to be delivered via nebulizer.

1. Assure the fluoroscopy room is available if there is a possibility of needing to do the bronchoscopy under fluoroscopy (to obtain specimens from the proper site). Whole body radiation badges may be necessary for certain personnel.
2. Obtain thoracostomy set/tray and chest tube set-up and have it available (for treatment of potential pneumothorax). Assure staff familiar with its use is available during the procedure.
3. The physician may request certain equipment available to deal with specific situations (balloons or topical thrombin, etc for bleeding, special forceps for object retrieval, etc).
4. 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).
5. Check all syringes to be used for injecting fluid into the bronchoscope for compatibility with the bronchoscope injection port.
6. Pour sterile normal saline (NS) into a sterile cup to fill syringes from label the cup "NS" with permanent marker (pour more NS as needed into the cup to maintain a reservoir as you draw from it to fill your syringes).
7. Draw up 35 ml NS into three or four 35 cc syringes. Place the syringes back in their plastic watertight sleeves, and label the top of the syringe plunger "NS" with a permanent marker. Place them vertical in a container of warm water assuring the water does not enter the syringe sleeves (the warm water bath will help to warm the sterile NS for potential broncho-alveolar lavage (BAL)).
8. Draw up 5 ml and 10 ml sterile NS into 12 ml syringes and place the syringes back in their sleeves and label the top of the syringe plunger "NS" with a permanent marker (these will be used for bronchial washing, etc).
10. Draw up 2 ml of sterile 4% lidocaine into a 12 ml syringe and place the syringe back in its sleeve and label the top of the syringe plunger "4%" with a permanent marker (this will be injected through the bronchoscope as directed by the physician while proceeding through the upper airway).
11. Pour 1 of the bottles of 1% lidocaine into sterile cup. Label to cup "1%" with permanent marker. Draw up 2-3 ml of sterile 1% lidocaine into two 12 ml syringes. Place the syringes back in their plastic sleeves, and label the top of each syringe plunger "1%" with a permanent marker (these will likely be injected several times through the bronchoscope during the procedure). Refill them with 2-3 ml sterile 1% lidocaine from the sterile cup as needed during the procedure.
12. Into a 12 ml syringe draw up 5 ml NS then 1 ml of 1mg/ml epinephrine (this will possibly be injected through the bronchoscope to control bleeding (with vasoconstriction) during the procedure.
13. Draw up 5 ml of viscous 2% lidocaine into a syringe (for injection into the nares). Place the syringe back in its plastic sleeve, and label the top of the syringe plunger "visc. 2%" with a permanent marker. Keep the remaining viscous 2% lidocaine at the bedside with a 4X4 gauze for bronchoscope exterior lubrication.
14. Organize at the bedside at least:
1. 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.
2. 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.
3. 1 sterile transbronchial aspiration needle for bronchoscopy (have a 20-35 ml syringe to apply suction to the needle (assure it is compatible with the syringe port on the needle) and several slides available). Sometimes the physician may desire a Pathologist/Cytologist at the bedside during the procedure to examine the specimens.
4. Compatibility of the external diameter of all scope accessories with the internal diameter of the bronchoscope should be verified before the procedure.
15. 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.
16. 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.
17. 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).
18. Assure proper resuscitation equipment is in the bronchoscopy area.
19. Assure a nasal decongestant spray is at the bedside.
20. The nurse, physician, or anesthetist will start IV access, etc and administer medications as needed (typically using meds such as atropine, Versed and Fentanyl they will also have naloxone, flumazenil and resuscitation meds, etc available).
21. Obtain gown, gloves, mask, and eye protection for staff and use them during the procedure.

1. 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 pre-procedure laboratory results (coagulation assessment, ECG, spirometry, etc).
2. Record how long the patient has been NPO.
3. Assess the ability to adequately oxygenate the patient during the procedure.
4. Assess the patient for tuberculosis risk, as procedure may need to take place in specially ventilated room.
5. Assess the possibility of pregnancy.
6. Assure proper consent has been obtained.
7. Obtain medication allergy and hypersensitivity information.
8. Explain procedure to patient.
9. Obtain and record baseline room air oximetry (if patient normally uses oxygen, obtain oximetry reading on their normal level of supplemental oxygen).
10. Obtain and record baseline pulse reading.
11. Obtain and record baseline blood pressure reading.
12. Connect patient to ECG monitor.
13. 2 ml 4% lidocaine (80mg) is diluted with 1.5 ml of normal saline and 2.5 mg albuterol and delivered to the airway via small volume neb approximately 20 minutes before the start of the procedure.
14. Five sprays of 4% lidocaine are delivered to each nare via atomizer approximately 20 minutes before the start of the procedure. Repeat this step two more times prior to the procedure.
15. 5 ml viscous 2% lidocaine is divided between each nare (delivered by syringe).
16. Place towel or chux on patient’s chest and a towel behind the patient’s head.
17. Remove any dentures and/or eyeglasses from the patient prior to the procedure unless directed not to do so by the physician.
18. Cut one prong off a nasal cannula and tape closed the opening where prong was. Place the cannula on the patient (run the oxygen liter flow at the level the physician desires – maintain an SpO2 of 91% during the procedure). Certain patients may need oxygen by mask – in this case cut an opening in the mask for insertion of the bronchoscope.

1. Physician reviews chart, test results, and assesses/interacts with the patient and staff as necessary.
2. Staff uses protective barriers.
3. Light source is turned on.
4. Suction is turned on at the direction of the physician (some physicians avoid suctioning anything through the bronchoscope channel until a specimen is obtained from a specific site).
5. Inject lidocaine, NS, etc through the bronchoscope at the direction of the physician (notify the physician if you use up the first bottle of 1% lidocaine as you may be nearing the maximum dose).
6. Obtain specimens at the direction of the physician.
7. Medications via other routes are given by authorized personnel at the direction of the physician.
8. Monitor the following and record items as significant and vital signs on a regular basis:
1. Level of consciousness.
2. Medications administered, dosage, route, and time of delivery.
3. Subjective response to procedure (e.g., pain, discomfort, dyspnea).
4. Blood pressure, heart rate, rhythm, and changes in cardiac status.
5. SpO2 and supplemental oxygen use.
6. Lavage volumes (delivered and retrieved).
7. Documentation of site of biopsies and washings and tests requested on each sample.
8. Tidal volume, peak inspiratory pressure, adequacy of inspiratory flow, and other ventilation parameters if subject is being mechanically ventilated
9. Record the bronchoscope used for the procedure.

1. Monitor the following and record items as significant and vital signs on a regular basis:
2. Level of consciousness.
3. Medications administered, dosage, route, and time of delivery.
4. Subjective responses (e.g., pain, discomfort, dyspnea).
5. Blood pressure, heart rate, rhythm, and changes in cardiac status
6. SpO2 and supplemental oxygen use.
7. Patient should be observed until stable.
8. 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.
9. 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.

AARC Clinical Practice Guideline – Bronchoscopy Assisting

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