Bronchoscopy - Nursing Responsibilities

Bronchoscopy is an invasive procedure that directly examines the larynx, trachea, and bronchi using either a flexible fiberoptic bronchoscope or a rigid metal bronchoscope. A trained practitioner (pulmonologist or thoracic surgeon) performs it. A noninvasive option, virtual bronchoscopy, uses a series of computed tomography (CT) scans to visualize the tracheobronchial tree.

The flexible fiberoptic scope is used more often and gives a wider view. The rigid metal scope is the method of choice for foreign body removal, endobronchial lesion excision, and massive hemoptysis control. A bronchial brush, forceps, and needle can be passed through the scope to collect samples for cytology.

Beyond the airway watch, the nurse relieves patient anxiety by explaining what to expect and what to avoid.

Indication

Bronchoscopy is performed for diagnostic or therapeutic purposes.

Diagnostic Bronchoscopy

• Direct visualization of the tracheobronchial tree for abnormalities such as inflammation, tumors, or strictures
• Direct visualization of the larynx to check for vocal cord paralysis
• Aspiration of a specimen for culture and sensitivity and for cytologic examination
• Biopsy of tissue from suspected lesions

Therapeutic Bronchoscopy

• Removal of excessive secretions, mucus plugs, and benign or malignant tumors to clear airways
• Removal of foreign objects or other obstructions
• Control of bleeding in the bronchi
• Palliative laser therapy or radiation therapy for bronchial tumors

Contraindication

Know when not to proceed. Bronchoscopy is contraindicated in:

• Uncooperative patients
• Uncorrectable coagulopathy
• Severe acute respiratory failure with hypercapnia in a patient who cannot tolerate interruption of high flow oxygen (unless intubated and ventilated)
• Severe tracheal obstruction that makes passing the scope difficult
• Recent myocardial infarction or unstable angina
• Recent head trauma with risk of increased intracranial pressure

Interfering Factors

• Failure to place samples in the proper containers

Procedure

Bronchoscopy may use fluoroscopic guidance to evaluate distal lesions for a tracheobronchial biopsy involving alveolar areas. A routine procedure runs as follows.

1. Apply local anesthetic. A local anesthetic is flushed into the patient's throat with the patient sitting upright or lying supine.
2. Insert the bronchoscope. As the sedative takes effect, the scope is inserted through the patient's mouth or nose.
3. Apply additional anesthetic. When the scope reaches above the vocal cords, about 3 to 4 mL of 2% to 4% lidocaine is sprayed through the scope's inner channel onto the vocal cords to anesthetize distal areas.
4. Examine the area. The practitioner inspects the trachea and bronchi, notes the color of the mucosal lining, and looks for tumors or inflamed areas.
5. Collect tissue samples. A bronchial brush collects cells from the surface of a lesion, and a suction apparatus removes foreign material or mucus plugs. Bronchoalveolar lavage may be done to diagnose infectious causes of infiltrates in an immunocompromised patient or to clear copious secretions.

Nursing Responsibilities

Before the procedure

• Secure informed consent. Confirm the signed consent form is on the chart.
• Obtain medical history. Ask about allergies to anesthetic agents and the patient's current medications.
• Check NPO status. Withhold food and fluids before the exam to lower aspiration risk, commonly 6 to 8 hours for solids and about 2 hours for clear liquids per standard preprocedure fasting practice. Follow the facility order and the American Thoracic Society patient guidance, which advises an empty stomach before sedation.
• Monitor vital signs. Get a baseline and report any abnormal findings to the practitioner.
• Provide oral hygiene. Have the patient do oral care and remove dentures if appropriate.
• Administer preoperative medications as ordered. Explain that an IV sedative such as propofol may be given.
• Prepare for local anesthesia. If general anesthesia is not used, tell the patient a topical anesthetic (lidocaine) will be sprayed on the pharynx to prevent coughing and gagging as the scope passes. Warn that the spray may taste bitter.
• Relieve anxiety. Reassure the patient that airway blockage will not occur.
• Stage emergency resuscitation equipment at the bedside. Laryngospasm and respiratory distress can follow the procedure.

During the procedure

• Position the patient. Sitting or supine, with supplemental oxygen as ordered.
• Assist with the procedure. Help with specimen collection and any added work: foreign body removal, bronchoalveolar lavage, bronchial stent placement, aspiration of retained secretions.
• Secure the specimen. Send the properly labeled specimen to the lab immediately.

After the procedure

• Assess for bleeding. Watch the sputum and report excessive bleeding. A minimal blood streak for a few hours after the procedure is expected and normal.
• Assess respiratory status. Watch for bronchial spasm or perforation: facial crepitus, hypoxemia, hemorrhage, chest tightness.
• Monitor vital signs. Changes or new discomfort may signal a complication.
• Position the patient. Semi-Fowler's if conscious. If unconscious, side-lying with the head of the bed slightly raised.
• Reinforce diet. Keep NPO until the anesthesia wears off and the gag reflex returns, then resume the normal diet starting with sips of water or ice chips.
• Prevent aspiration. Give an emesis basin and have the patient spit out saliva rather than swallow it.
• Provide comfort. Reassure the patient that hoarseness, loss of voice, and sore throat are temporary. Offer lozenges or a soothing gargle once the gag reflex returns.

Normal Results

• Bronchi structurally consistent with the trachea
• Right bronchus more vertical than the left and slightly larger
• Smaller segmental bronchi branching off the main bronchi

Abnormal Results

• Pulmonary disease: tuberculosis (TB), interstitial pulmonary disease, bronchogenic carcinoma, other fungal or parasitic lung infections
• Foreign substances in the trachea or bronchi (mucus plugs, blood, stones, foreign objects)
• Endotracheal abnormalities: narrowing (stenosis), compression, ectasia (distention of a tubular structure), irregular bronchial branching, abnormal bifurcation from a diverticulum
• Bronchial wall abnormalities: swelling, inflammation, ulceration, tumors, protruding cartilage, mucous gland orifice or submucosal lymph node enlargement

Possible Complications

Bronchoscopy is usually safe, but the risks include:

• Bleeding from the biopsy site. Happens when tissue specimens are taken.
• Fever. A low-grade fever is common and not always a sign of infection.
• Hypoxemia. Low blood oxygen occurs during the procedure and usually returns to normal without intervention.
• Laryngospasm. Irritation or spasm of the larynx (vocal cords).
• Pneumothorax. A collapsed lung from puncture during the procedure.

Frequently Asked Questions

Why does the patient have to be NPO before a bronchoscopy? An empty stomach lowers the risk of aspiration once the throat is anesthetized and sedation blunts the gag reflex. Standard practice is roughly 6 to 8 hours without solids and about 2 hours without clear liquids, but always follow the specific order and MedlinePlus preparation guidance.

Why can't the patient eat or drink right after the procedure? The topical anesthetic sprayed on the throat suppresses the gag reflex, so swallowing is unsafe until it wears off. Keep the patient NPO until the gag reflex returns, then start with sips of water or ice chips.

Is a little blood in the sputum after bronchoscopy normal? Yes. A minimal blood streak for a few hours is expected, especially after a biopsy. Report excessive or increasing bleeding to the practitioner right away.

What is the difference between a flexible and a rigid bronchoscope? The flexible fiberoptic scope is used more often and gives a wider view of the airways. The rigid metal scope is preferred for foreign body removal, endobronchial lesion excision, and controlling massive hemoptysis.

What complications should the nurse watch for afterward? Laryngospasm, bronchospasm, hypoxemia, fever, and pneumothorax. Keep emergency resuscitation equipment at the bedside and watch respiratory status closely, since laryngospasm and distress can follow the procedure.

What is virtual bronchoscopy? A noninvasive alternative that uses a series of computed tomography scans to visualize the tracheobronchial tree without inserting a scope. It does not allow tissue sampling or therapeutic clearing of the airway.