AARC GUIDELINE: BRONCHOSCOPY ASSISTING AARC Clinical Practice Guideline Bronchoscopy Assisting—2007 Revision & Update BA 1.0 PROCEDURE properties of the upper airway1,2,4,6,8 The role of the assistant in Bronchoscopy Assisting 4.3 The need to investigate hemoptysis, persis- (BA) tent unexplained cough, dyspnea, localized wheeze, or stridor1,2,4-8,10 BA 2.0 DESCRIPTION/DEFINITION 4.4 Suspicious or positive sputum cytology re- Bronchoscopy, fiberoptic or rigid, is an invasive sults1,2,4-6 procedure for visualization of the upper and lower 4.5 The need to obtain lower respiratory tract respiratory tract for the diagnosis and management secretions, cell washings, and biopsies for cyto- of a spectrum of inflammatory, infectious, and ma- logic, histologic, and microbiologic evalua- lignant diseases of the airway and lungs.1,2 Bron- tion1,2,4,7,9,11,12 choscopy may include retrieval of tissue specimens 4.6 The need to determine the location and ex- (bronchial brush, forceps, and needle), cell wash- tent of injury from toxic inhalation or aspira- ings, bronchoalveolar lavage, coagulation, or re- tion1,2,4,6 moval of abnormal tissue by laser. Bronchoscopy is 4.7 The need to evaluate problems associated widely used as a diagnostic and therapeutic tool for with endotracheal or tracheostomy tubes (tra- management of the airway.3 Bronchoscopy is per- cheal damage, airway obstruction, or tube formed by a specially trained physician broncho- placement)1,2,4-7 scopist and is assisted by a specially trained health- 4.8 The need for aid in performing difficult in- care professional (HCP). This guideline addresses tubations or percutaneous tracheostomies1,2,4,6,7 the role of the HCP in bronchoscopy assistance 4.9 The suspicion that secretions or mucus (BA)4 (Section 10.3). plugs are responsible for lobar or segmental at- electasis1,2,4-6 BA 3.0 SETTINGS 4.10 The need to remove abnormal endo- The preferred location for bronchoscopy is deter- bronchial tissue or foreign material by forceps, mined by the available equipment, the medical con- basket, or laser1,2 dition and age of the patient, and the specific proce- 4.11 The need to retrieve a foreign body (al- dures to be performed.1,2,4 A designated bron- though under most circumstances, rigid bron- choscopy room or suite is the preferred location for choscopy is preferred)6,7,13 outpatients or inpatients who are not critically ill. 4.12 Therapeutic management of endo- The procedure may be safely performed at the bed- bronchial toilet in ventilator associated pneu- side in the intensive care unit, the operating room, monia14 an appropriately equipped outpatient facility, or 4.13 Achieving selective intubation of a main other suitably equipped clinical area.1,2,4 stem bronchus14 4.14 The need to place and/or assess airway BA 4.0 INDICATIONS stent function14 Indications include but are not limited to 4.15 The need for airway balloon dilatation in 4.1 The presence of lesions of unknown etiolo- treatment of tracheobronchial stenosis15,16 gy on the chest radiograph film or the need to evaluate recurrent pneumonia, persistent at- BA 5.0 CONTRAINDICATIONS electasis or pulmonary infiltrates1,2,4-9 Flexible bronchoscopy should be performed only 4.2 The need to assess patency or mechanical when the relative benefits outweigh the risks. 74 RESPIRATORY CARE • JANUARY 2007 VOL 52 NO 1 AARC GUIDELINE: BRONCHOSCOPY ASSISTING 5.1 Absolute contraindications include 5.4 The safety of bronchoscopic procedures in 5.1.1 Absence of consent from the patient asthmatic patients is a concern, but the presence or his/her representative unless a medical of asthma does not preclude the use of these emergency exists and patient is not com- procedures11,18 petent to give permission1,2 5.5 Recent head injury patients susceptible to 5.1.2 Absence of an experienced broncho- increased intracranial pressures19 scopist to perform or closely and directly 5.6 Inability to sedate (including time con- supervise the procedure1,2,4 straints of oral ingestion of solids or liquids17 5.1.3 Lack of adequate facilities and per- sonnel to care for such emergencies such BA 6.0 HAZARDS/COMPLICATIONS as cardiopulmonary arrest, pneumotho- 6.1 Adverse effects of medication used before rax, or bleeding1,2,4 and during the bronchoscopic procedure4,7,20,21 5.1.4 Inability to adequately oxygenate 6.2 Hypoxemia4,22 the patient during the procedure1,2 6.3 Hypercarbia 5.2 The danger of a serious complication from 6.4 Bronchospasm23 bronchoscopy is especially high in patients 6.5 Hypotension24 with the disorders listed, and these conditions 6.6 Laryngospasm, bradycardia, or other vagal- are usually considered absolute contraindica- ly mediated phenomena4,7,20 tions unless the risk-benefit assessment war- 6.7 Mechanical complications such as epis- rants the procedure1,2,4 taxis, pneumothorax, and hemoptysis7,20,23,25 5.2.1 Coagulopathy or bleeding diathesis 6.8 Increased airway resistance4,26 that cannot be corrected1,2,4 6.9 Death27 5.2.2 Severe refractory hypoxemia1,2,4 6.10 Infection hazard for health-care workers 5.2.3 Unstable hemodynamic status in- or other patients28-31 (see also Section 13) cluding dysrhythmias1,2,4 6.11 Cross-contamination of specimens or 5.3 Relative contraindications (or conditions bronchoscopes28-31 involving increased risk), according to the 6.12 Nausea, vomiting23 American Thoracic Society Guidelines for 6.13 Fever and chills23 Fiberoptic Bronchoscopy in adults,1,2 include 6.14 Cardiac dysrhythmias32 5.3.1 Lack of patient cooperation 5.3.2 Recent (within 6 weeks) myocardial BA 7.0 LIMITATIONS/VALIDATION OF RE- infarction or unstable angina17 SULTS 5.3.3 Partial tracheal obstruction 7.1 Bronchoscopy should not be performed in 5.3.4 Moderate-to-severe hypoxemia or patients who have a contraindication listed in any degree of hypercarbia Section 5.0 of this Guideline, unless the poten- 5.3.5 Uremia and pulmonary hyperten- tial benefit outweighs the risk, as determined by sion (possible serious hemorrhage after the physician bronchoscopist. biopsy) 7.2 Poor or inadequate training of the bron- 5.3.6 Lung abscess (danger of flooding choscopy assistant or bronchoscopist the airway with purulent material) 7.2.1 The techniques of premedication for 5.3.7 Obstruction of the superior vena bronchoscopic examination cava (possibility of bleeding and laryn- 7.2.2 Function and preparation of bron- geal edema) choscope and related equipment 5.3.8 Debility and malnutrition 7.2.3 Physical and physiologic monitor- 5.3.9 Disorders requiring laser therapy, ing during the procedure biopsy of lesions obstructing large airways, 7.2.4 Specimen retrieval (biopsies and or multiple transbronchial lung biopsies washings), preparation of specimens, and 5.3.10 Known or suspected pregnancy site documentation (safety concern of possible radiation ex- 7.2.5 Post-procedure care of the patient posure) RESPIRATORY CARE • JANUARY 2007 VOL 52 NO 1 75 AARC GUIDELINE: BRONCHOSCOPY ASSISTING BA 8.0 ASSESSMENT OF NEED: tently clearing tip of bronchoscope dur- Need is determined by bronchoscopist assessment ing procedure of the patient and treatment plan in addition to the 10.1.1.14 Appropriate procedure docu- presence of clinical indicators as described in Sec- mentation paperwork, including labo- tion 4.0, and by the absence of contraindications as ratory requisitions described in Section 5.0.1,2,4 10.1.1.15 Water-soluble lubricant or lu- bricating jelly BA 9.0 ASSESSMENT OF OUTCOME: 10.1.2 Monitoring devices Patient outcome is determined by clinical, physio- 10.1.2.1 Pulse oximeter logic, and pathologic assessment. Procedural out- 10.1.2.2 Electrocardiographic monitor- come is determined by the accomplishment of the ing equipment procedural goals as indicated in Section 4.0, and by 10.1.2.3 Sphygmomanometer quality assessment indicators listed in Section 11.0. 10.1.2.4 Whole-body radiation badge for personnel if fluoroscopy is used BA 10.0 RESOURCES 10.1.2.5 Capnograph 10.1 Equipment 10.1.3 Procedure room equipment 10.1.1 Bronchoscopic devices 10.1.3.1 Oxygen and related delivery 10.1.1.1 The appropriate bronchoscope equipment size is determined by the broncho- 10.1.3.2 Resuscitation equipment scopist, based on the patient age7; this 10.1.3.3 Medical vacuum systems includes selecting appropriate suction (wall or portable) and related suction and biopsy valves supplies for scope or mouth 10.1.1.2 Bronchoscopic light source, 10.1.3.4 Infection control devices as and any related video or photographic listed in Section 13.0 equipment, if applicable 10.1.3.5 Fluoroscopy equipment in- 10.1.1.3 Cytology brushes, flexible for- cluding personal protection devices if ceps, transbronchial aspiration needles, warranted retrieval baskets (Compatibility of the 10.1.3.6 Laser equipment if applicable external diameter of all scope acces- 10.1.3.7 Adequate ventilation and sories with the internal diameter of the other measures to prevent transmission bronchoscope should be verified before of tuberculosis34 the procedure.) 10.1.4 Decontamination area equipment 10.1.1.4 Specimen-collection devices, 10.1.4.1 Protease enzymatic agent (eg, fixatives, and as determined by institu- Protozyme) for cleaning and removal tional policies of blood and protein before disinfec- 10.1.1.5 Syringes for medication deliv- tion or sterilization, or other detergent ery, normal saline lavage, and needle capable of removing these substances35 aspiration 10.1.4.2 High-level disinfection or 10.1.1.6 Bite block sterilization agent: 2% alkaline glu- 10.1.1.7 Laryngoscope taraldehyde (eg, Cidex, Metracide, 10.1.1.8 Endotracheal tubes in various Sonacide, Glutarex), ethylene sizes oxide,30,36 or peracetic acid37 10.1.1.9 Thoracostomy set/tray 10.1.4.3 Sterile water is preferred, if 10.1.1.10 Venous access equipment feasible, for rinsing bronchoscopes.