I. Subject: Therapeutic Bronchoscopy and Bronchoscope Assisted Intubation II. Policy: Therapeutic flexible fiberoptic bronchoscopy procedures and bronchoscope assisted intubations will be performed by a physician approved to perform this procedure, assisted by Respiratory Therapy department personnel. The patient will be monitored continuously with EKG, pulse oximetry, and non-invasive blood pressure monitors. Therapeutic bronchoscopy procedures may be performed at bedside on the nursing unit as long as moderate sedation is not employed. If moderate sedation is administered, the procedure must be performed in the bronchoscopy suite, the operating room, the intensive care unit, or the emergency room and guidelines for moderate sedation will be followed. Post procedure monitored recovery is not required unless moderate sedation is employed, or loss of protective reflex occurs. III. Indications: A. Local infiltrates B. Diffuse infiltrates C. Lobar or segmental atelectasis from airway secretions or mucous plug D. Pleural effusion E. Upper airway obstruction F. Specimen collection for microbiology G. Difficult intubations H. Foreign body I. Aspiration J. Verification of artificial airway placement 1
K. Mucous clearance IV. Contraindications: A. Absolute- 1) Inability to adequately oxygenate or ventilate the patient during the procedure. B. Relative- V. Rationale: 1) Coagulopathy or bleeding diathesis that cannot be corrected. 2) Unstable severe hypoxemia. 3) Recent myocardial infarction. 4) Unstable hemodynamic status including life threatening dysrhythmia. 5) Severe obstructive airways disease. 6) Partial tracheal obstruction. 7) Recent large volume solid food ingestion. Therapeutic bronchoscopy facilitates the removal of foreign bodies, or localized lesions from tracheobronchial tree, removal of mucous plugs from lower airways, prevention or treatment of atelectasis, improvement of bronchial drainage of abscesses, instillation of chemotherapeutic agents, and removal of foreign bodies from the lower airway. The fiberoptic bronchoscopy may be performed at bedside with the patient requiring minimal or no sedation. Few areas of the lung are inaccessible to the fiberscope, as it can be inserted into the lobar bronchi, which permits the segmental bronchi to be visualized. Intubation may be assisted with the use of fiberoptic bronchoscope. With this 2
method, the distal end of the bronchoscope is passed through the endotracheal tube and directed into the trachea. Once placement is assured, the endotracheal tube slides down over the bronchoscope into its position in the trachea. VI. Materials: Therapeutic bronchoscope (permanent or disposable) Light source Non-invasive blood pressure monitor (NIBP) Pulse oximeter O2 flowmeter EKG monitor Green bronchoscope procedure pack Bronchoscopy supplies to include: 2-20 mls leur slip syringes 1-portex swivel airway adaptor 2-10 mls leur slip syringes 1-atomizer 1-O2 cannula 1-O2 tubing 1-40 mls mucous trap 1-12 ft. suction tubing 1-250 ml IV bag 0.9% NaCl 3
gloves, masks, eye wear and protective apron silicone spray bite block 1-Bronchoscopy Report Sheet 1-Label 1-Bacteriology slip Cotton tipped applicators 5 mls 4% viscous xylocaine 2% viscous xylocaine Endotracheal tube of appropriate size (for bronchoscopy assisted intubation) Emergency supplies and medications including bag-valve-mask resuscitator available on unit outside patient room. VII. Procedure: Therapeutic bronchoscopy is performed as a clean procedure- A. Check physician's order. 1) Review the patient's chart. Identify and record on the Bronchoscopy procedure record any allergies, blood gas values, chest X-ray results, pertinent history, and possible contraindications to procedure. Make sure that consent has been signed unless a medical emergency exists and the patient is not competent to give permission. Confirm that risk vs. benefit and alternatives discussed with the patient by physician. 2) Verify current H&P present in record. Reviewed current medications. B. Assemble all equipment using clean technique. 4
1) Open bronchoscopy pack onto cart. 2) Fill large bowl with NaCl. Fill the 20 ml syringes from this bowl. Label bowl and syringes. 3) Fill 1-10 ml syringe with 2% viscous xylocaine. Label syringe 4) Place 5 mls 4% xylocaine in atomizer. Label syringe. 5) Connect O2 tubing to scope, the other end to the specimen trap, the specimen trap to the suction tubing, and finally, the tubing to the suction cannister. Turn on suction apparatus. 6) Attach permanent bronchoscope to light source or disposable video display. C. Patient preparation 1) Identify patient, introduce self to patient, and explain procedure to patient. 2) Wash hands before procedure and don personal protective equipment. NOTE: Procedures performed on known or suspected TB patients must be performed in bronchoscopy suite, isolation room, or room using portable hepa filtration system. N-95 respirator must be worn. 3) Connect patient to EKG monitor, O2 at 3 L/min per nasal cannula, NIBP (if no A-line) and pulse oximeter. If patient is on a ventilator, increase FIO2 to 100% prior to procedure. 4) Obtain baseline vital signs and record. 5) Atomize 5 mls 4% xylocaine into right nare. 6) Instill 1-4 mls 2% viscous xylocaine into right nare. 7) Check right nare for patency by advancing a cotton tipped applicator to nasopharynx. If any resistance is met, repeat steps 5 and 6 to left nare and check. Use the nare that is most patent. 5
8) Page physician to notify that the patient is ready for the procedure. D. Procedure 9) Conduct time out procedure when patient, physician and all assistants are present, verifying correct patient, correct procedure, correct site, patient consent, properly labeled images and diagnostic results, and all safety precautions and appropriate monitoring is in place. 10) Assist physician with procedure. a. Physician will lubricate bronchoscope with Silko spray before insertion into endotracheal tube. b. The physician will insert bronchoscope into nare down to vocal cords the into lungs. (Some physicians will instill 4% xylocaine on vocal cords, most will not during a therapeutic procedure as not to decrease cough reflex). c. Assist physician may instill 0.9% NaCl for washing mucosa. d. Retain washing for bacteriologic studies and other laboratory studies. e. Reassure patient frequently during procedure. f. Observe vital signs and pulse oximetry frequently. g. Record post-procedural vital signs. h. Document bronchoscopy in electronic chart in Bronch intra op notes. 11. Post-procedure a. Reposition the patient. Return the patient to previous O2 therapy if any. b. Place specimen in a plastic bag with a biohazard label, and take specimens to the lab and log in. Physician will enter lab orders in 6
electronic chart. c. If a permanent scope is used, rinse saline through scope immediately following procedure, wipe exterior of scope with a wet enzymatic cleaning sponge, wrap up scope and wet sponge in green bag supplied with kit, affix patient label and biohazard stickers to outside of bag, and deliver to soiled scope area in GI lab. d. Complete bronchoscopy critique and charge. u. Transport patient to recovery room if moderate sedation was used, or if loss of protective reflex has occurred. Bronchoscope assisted intubation is performed as an aseptic procedure- A. Check physician's order including the size of endotracheal tube to be placed. 1) Review the patient's chart. Identify and record on the Bronchoscopy procedure record any allergies, blood gas values, chest X-ray results, pertinent history, and possible contraindications to procedure. Make sure that consent has been signed unless a medical emergency exists and the patient is not competent to give permission. B. Assemble all equipment using clean technique. 1) Open bronchoscopy tray on cart. 2) Fill large bowl with NaCl. Fill two 20 cc syringes from this bowl. Label bowl and syringes. 3) Connect O2 tubing to scope, the other end to the specimen trap, the specimen trap to the suction tubing, and finally, the tubing to the suction catheter. Turn on suction apparatus. 4) Remove the endotracheal tube airway adapter and pass the endotracheal tube up the bronchoscope to the proximal end. 5) Identify patient, introduce self to patient, and explain procedure to patient. Wash hands before procedure and don personal protective equipment. 7
6) Connect patient to EKG monitor, O2 at 3 L/min per nasal cannula, NIBP (if no A-line) and pulse oximeter. 7) Obtain baseline vital signs and record. 8) Page physician to notify that the patient is ready for the procedure. 9) For nasal intubation: a. Atomize 2 cc 4% xylocaine into right nare. b. Instill 1-4 cc 2% viscous xylocaine into right nare. c. Check right nare for patency by advancing a cotton tipped applicator to nasopharynx. If any resistance is met, repeat steps a and b to left nare and check. Use the nare that is most patent. 10. Assist physician with procedure. a. Physician will lubricate bronchoscope with Silko spray before insertion into endotracheal tube. b. The physician will insert the bronchoscope into the nare and through the vocal cords into the trachea. c. Once the bronchoscope tip is in the correct position, the physician will pass the endotracheal tube down along the bronchoscope and into the lower airway. Visualization of the correct position of the endotracheal tube is performed by the physician. d. The physician will now remove the bronchoscope while holding the endo-tracheal tube in place. Quickly replace the airway connector and secure the endotracheal tube. e. Provide supplemental oxygen and ventilatory support as needed and as ordered by the physician. 8
11. Record post-procedure vital signs. 12. Complete the Bronch Inter-op report in electronic chart VIII. Complications: COMPLICATIONS- Respiratory Compromise A. Hypoxemia B. Hypercarbia Bronchospasm Transient hypotension Mechanical complications such as Epistaxis and Hemoptysis Bradycardia Ventricular tachycardia Ventricular tachycardia PVC's Laryngospasm Infection Respiratory Arrest and Cardiac Arrest PRECAUTIONS/ACTIONS- Increase O2 or ventilate Increase O2, Bronchodilators Trendelenburg, increase IV fluids, increase O2 Pressure, or atomized or instilled lidocaine with epinephrine, not to exceed 30 cc of 1% lidocaine with epinephrine Increased O2, Atropine Lidocaine, Defibrillation Defibrillation Evaluate oxygenation, lidocaine Withdraw bronchoscope to above cords and inject 4% Xylocaine on cords. Apply positive pressure with bag and mask. Use aseptic technique. Use proper infection control procedures in care of equipment, antibiotics. Have emergency supplies immediately available. Call ICU for defibrillator. Intubate, ventilate, defibrillate, pharmacologic resuscitation. Pneumothorax O2, support ventilation, prepare for chest tube insertion. 9
Seizure Reaction to local anesthetic medications X. Documentation: Airway management, pharmacologic management. Notify physician if xylocaine administration exceeds 300 mg. The bronchoscopy procedure is documented in the electronic chart in Bronch intra-op. Included on this report are date, time, the chief compliant and past history, indications for procedure,current medications, brief physical exam results, allergies, local anesthetic record, pre-medication, and post-medication record, vital signs record, and laboratory tests requested. All medications used are documented in the EMAR. 10