Bronchoscopy

Indications for Bronchoscopy

Diagnostic:

Evaluation of hemoptysis.
Assessment for evidence of endobronchial narrowing (i.e. tracheobronchial Malacia).
Assessment for evidence of endobronchial malignancy.
Acute inhalational injury evaluation.
Evaluation of atelectasis.
Evaluation for causes of diaphragmatic paralysis.
Evaluation of non-resolving pneumonia.
Assessment of trachea in patients with esophageal cancer, to rule in or out, invasion into the airway.
Blunt chest trauma evaluation i.e. for bronchial transection/laceration.
Evaluation of post lung transplant patients i.e. assess suture lines, detecting bronchopleural fistula.
Assessment of intubation-induced injury.
Evaluation of chronic cough (usually for outpatients).
Evaluation of unilateral wheeze (usually for outpatients).

Therapeutic:

Obtaining BAL sample i.e. for opportunistic pathogens in immunocompromised patients or “wash” specimens in non immunocompromised patients who have minimal secretions.
Treatment of massive hemoptysis (insertion of bronchial blocker, instillation of cold saline, epinephrine, TXA, etc).
Foreign body removal.
Removal of impacted secretions.
Facilitating endotracheal intubation (i.e. in challenging anatomic cases).
Management and biopsy of central airway lesions.
Facilitating bronchoscopic guidance during percutaneous tracheostomy.
Facilitating transbronchial lung biopsy i.e. sarcoidosis, eosinophilic pneumonia.
Facilitating advanced therapies i.e. stent placement, balloon dilation, and EBUS.

Relative Contraindications

Poor oxygenation.
- Note: Typically, oxygenation will decrease by 20-30% post bronchoscopy. Non-intubated patients requiring FiO2 of 50% or more need to have a risk/benefit assessment and may need to agree to post procedure intubation if they worsen.
- Note: If patient is intubated on high FiO2 and need the procedure, a skilled bronchoscopist is recommended to limit time and instilled volume to the airways.
Untreated symptomatic asthma.
- Note: For all asthmatics, we generally recommend salbutamol just before the procedure to limit bronchospasm.
Unstable cardiac patient (i.e. acute coronary syndrome).
Severe hemodynamic instability.

Before starting procedure

Ensure that supervision is present for the procedure and who will be performing the procedure.
- The resident is usually not expected to be performing a bronchoscopy alone, unless they are formally trained.
Coordinate time with RT and nurse (if in ICU), or with endoscopy if out of ICU.
- Intubated patients must be placed on 100% oxygen and a controlled mode for at least 15 minutes before starting.
- Non-intubated patients must be on at least 4L NP oxygen.
Oxygen and hemodynamic monitoring.

Equipment Required

PPE: gown, gloves, face shield, N95.
Possible topical anesthetic ((i.e. 1% lidocaine to the posterior pharynx (if not intubated) as well as in the trachea and each bronchial segment, given in 2ml aliquots (20mg)).
1. Note: Avoid giving more than 15 ml topically to avoid lidocaine toxicity.
2. Note: Some intensivists do not use lidocaine but instead paralyze and sedate the patient).
Confirmed functioning peripheral IV access.
Sedative agents (i.e. fentanyl, midazolam), reversal agents (i.e. naloxone, flumazenil), code cart available.
Equipment to monitor vital signs (i.e. continuous cardiac monitoring, pulse oximetry).
1. Sound for the oxygen saturation should be on.
Bite block (must still be used in the intubated patient).
Endotracheal tube adaptor (to enable bronchoscope to be inserted).
Syringes of various sizes (i.e. 10, 20, 50mL).
Sterile normal saline flush.
Suction tubing + suction cannister.
1. One available for bronchoscope suction.
2. One available for direct oropharyngeal suction.
Specimen traps (3 available) +- collection jars.
Hemostatic agents for planned transbronchial biopsies: i.e. diluted epinephrine, ice cold saline, TXA.
Additional personnel to assist (nurse, RT at bedside).
Additional interventional equipment based on indication (i.e. bronchial blocker, APC).
Bronchoscope + bronchoscopy tower.
Lubricant jelly + gauze.
Bronchoscope cleaning equipment.

Time Out

Procedure + Team Preparation

Confirm correct patient, procedure, and correct site (have radiology studies available if needed) + confirm allergies + consent.
Confirm all equipment needed is available and functioning.
Ask regarding any team concerns and discuss any anticipated complications/risks.
Fasting guidelines: For the non-intubated patient ensure patient has been fasting for 6 hours (or NG feeds stopped) if possible. For the intubated patient, you can just stop the feeds and no need to wait.
For planned biopsies, ensure consent has been obtained.

Hemodynamics + ET Size Assessment

Confirm ET size tube and if standard bronchoscopy is feasible.
1. Standard = Q190 (but smaller and larger bronchoscopes are available).
2. The smallest ETT used should be 2mm greater than the outer bronchoscope diameter. So for a standard bronchoscope this would be 7mm (with a lot and frequent lubrication to avoid damage to the outer layer).Ensure coagulation and hemodynamics are optimized prior to procedure.
Ventilator inspired oxygen concentration can be increased to facilitate bronchoscopy. Ventilator pressure alarms may need to also be adjusted by RT.

Procedure Steps

Probe Introduction

Deliver sedative (i.e. fentanyl, midazolam).
Wait for desired effect and consider additional doses based on response.
Generously lubricate the bronchoscope.
Open adaptor + insert bronchoscope into ET tube.
1. Take hold of bronchoscope at the tip to ensure it remains straight as going through the adaptor/ET tube and prevent damaging the bronchoscope.
2. If there is resistance the plastic securing the ETT in place may be too tight and the RT will need to loosen it (do not force the bronchoscope past).

Airway Assessment

Trachea and Carina Assessment:

Inspect the trachea for narrowing, ulcerations, etc.
1. Make note that the muscular wall is posterior and the tracheal rings are seen anterior.
2. Note: You may need to reorient the bronchoscope if you are upside down.
Inspect carina, take note of position of ET tube relative to carina.
1. 3mL of lidocaine 1% can be instilled at carina.
Enter airways sequentially
1. Examine for mucosal appearance/integrity, patency of lumen, lesions or foreign bodies, secretions/mucus plugs, and bleeding.

Right side: right mainstem bronchus:

Right upper lobe bronchus

Trifurcation: apical, anterior, posterior (3 orifices)

Bronchus intermedius
- Right middle lobe bronchus:
  - Medial
  - Lateral
- Right lower lobe bronchus
  1. Superior (apical) segment
  2. Basal segments:
  - Medial (Note: often found on the left, just below RML entrance.)
  - Anterior
  - Lateral
  - Posterior
  - Note: ‘ALP’ are usually seen in that order with anterior being upper and posterior being the lowest subsegment.

Left side: left mainstem bronchus:

Left Upper Lobe bronchus
- Superior
  - Apicoposterior
  - Anterior
- Lingular
  - Superior
  - Inferior
Left Lower lobe
- Superior (Apical) segment
- Basal
  - Anterior
  - Lateral
  - Posterior

Bronchoalveolar Lavage

Request the RT to lower the suction to 100 mmHg.
Without suctioning (to avoid contamination with upper airway secretions) advance bronchoscope until the tip wedges into a distal subsegmental bronchus in area of greatest clinical interest.
1. Note: If there is diffuse disease typically target RML or lingula.
2. Note: In a good wedge position there will be slight airway collapse when gentle suction is applied. Whereas a bad wedge position will have leaking of lavage fluid around the bronchoscope.
3. Be careful the collection trap does not spill over and lose your specimen.
50mL sterile saline is instilled in the wedge position and is then aspirated with gentle suction, this is done sequentially 2-3 times into the specimen trap. The effluent collected should be at least 10ml for general culture. More advanced testing will need 30-40 mL.
1. Note: If there is little fluid being collected into the trap, do not withdraw the bronchoscope. If you do that, it no longer becomes a BAL.
Remove bronchoscope slowly from airway, taking note of any additional scope trauma.
Remove bronchoscope entirely, close ET tube adaptor.
Hand the bronchoscope to the RT, who will then start the cleaning process for the bronchoscope.
Document procedure (include indication, date and start-stop time, and anesthetics administered and vitals following procedure, and any complications).

Document written by: Muraile Vignarajah MD

Staff Reviewed by: Dr. Christine D'Arsigny (Internal Medicine, Respirology, Critical Care)

Bronchoscopy for Intubated Patients