Type of test

Endoscopy

Normal findings

 Normal larynx, trachea, bronchi, and alveoli

Test explanation and related physiology

Bronchoscopy permits endoscopic visualization of the larynx, trachea, and bronchi by either a flexible fiberoptic bronchoscope or a rigid bronchoscope. There are many diagnostic and therapeutic uses for bronchoscopy.

Diagnostic uses of bronchoscopy include:

 • Direct visualization of the tracheobronchial tree for abnormalities (e.g., tumors, inflammation, strictures)

• Biopsy of tissue from observed lesions

 • Aspiration of deep sputum for culture, sensitivity, and cytology determinations

• Direct visualization of the larynx for identification of vocal cord paralysis if present Therapeutic uses of bronchoscopy include:

• Aspiration of retained secretions in patients with airway obstruction or postoperative atelectasis

• Control of bleeding within the bronchus

• Removal of foreign bodies that have been aspirated

• Brachytherapy, which is endobronchial radiation therapy using an iridium wire placed via the bronchoscope

 • Palliative laser obliteration of bronchial neoplastic obstruction

• Access for ultrasound

The flexible fiberoptic bronchoscope has accessory lumens through which cable-activated instruments can be used for removing biopsy specimens of pathologic lesions. Also, the col lection of bronchial washings (obtained by flushing the airways with saline solution), pulmonary toilet, and the instillation of anesthetic agents can be carried out through these extra lumens. Double-sheathed, plugged-protected brushes also can be passed through this accessory lumen. Specimens for cytology and bacteriology can be obtained with these brushes.

Needles can be placed through the scope to obtain biopsies from tissue immediately adjacent to the bronchi. Transbronchial needle aspiration can be directed by the use of endobronchial ultrasound. This technique is particularly helpful in staging lung cancers and identifying sarcoidosis, lymphomas, and infections.

Laser therapy to burn out endotracheal lesions can now be per formed through the bronchoscope.

Laryngoscopy is often performed through a short broncho scope to allow inspection of the larynx and paralaryngeal structures. This is most commonly performed by an ENT (ear, nose, and throat) surgeon. Cancers, polyps, inflammation, and infections of these structures can be identified. The vocal cord motion can be evaluated also. Anesthesiologists use laryngoscopy to visualize the vocal cord structures on patients who are difficult to intubate for general anesthesia.

Contraindications

• Patients with hypercapnia and severe shortness of breath who cannot tolerate interruption of high-flow oxygen •

 Severe tracheal stenosis may make it difficult to pass the scope.

Potential complications

 • Fever • Hypoxemia • Laryngospasm • Bronchospasm • Pneumothorax • Aspiration
• Hemorrhage (after biopsy)

Procedure and patient care

Before

* Explain the procedure to the patient. Allay any fears and allow the patient to verbalize any concerns.

 • Obtain informed consent for this procedure.

 • Keep the patient NPO for 4 to 8 hours before the test to reduce the risk of aspiration.

* Instruct the patient to perform good mouth care to minimize the risk of introducing bacteria into the lungs.

• Remove and safely store the patient’s dentures, glasses, or contacts before administering the preprocedure medications.

 • Administer the preprocedure medications as ordered.

* Reassure the patient that he or she will be able to breathe during this procedure.

* Instruct the patient not to swallow the local anesthetic sprayed into the throat. Provide a basin for expectoration of the lidocaine.

• Have emergency resuscitation equipment available.

During

• Note the following procedural steps for fiberoptic bronchoscopy:

1. This test is performed by a pulmonary specialist or a sur geon at the bedside or in an appropriately equipped room.

 2. The patient’s nasopharynx and oropharynx are anesthetized topically with lidocaine spray before insertion of the bronchoscope.

3. The patient is placed in a sitting or supine position, and the tube is inserted through the nose or mouth and into the pharynx (Figure 1).

4. After the tube is passed into the larynx and through the glottis, more lidocaine is sprayed into the trachea to pre vent the cough reflex.

5. The tube is passed farther, well into the trachea, bronchi, and first- and second-generation bronchioles, for systematic examination of the bronchial tree.

 6. Biopsy specimens and washings are taken if pathology is suspected.

 • Note that this procedure is performed by a physician in approximately 30 to 45 minutes.  * Tell the patient that because of sedation, no discomfort is usually felt.

Fig1. Bronchoscopy. A bronchoscope is inserted through the trachea and into the bronchus.

After

* Instruct the patient not to eat or drink anything until the tracheobronchial anesthesia has worn off and the gag reflex has returned, usually in approximately 2 hours.

• Observe the patient’s sputum for hemorrhage if biopsy specimens were removed. A small amount of blood streaking may be expected and is normal for several hours after the procedure. Large amounts of bleeding can cause a chemical pneumonitis.

• Observe the patient closely for evidence of impaired respiration or laryngospasm. The vocal cords may go into spasms after intubation.

* Inform the patient that postbronchoscopy fever often devel ops within the first 24 hours. High, persistent fever should be reported immediately.

• If a tumor is suspected, collect a postbronchoscopy sputum sample for a cytology determination.

* Inform the patient that warm saline gargles and lozenges may be helpful if a sore throat develops.

* Inform the patient that biopsy or culture reports will be available in 2 to 7 days.

 Abnormal findings

- Inflammation

 - Strictures

- Tuberculosis

- Cancer

- Hemorrhage

- Foreign body

- Abscess

 - Infection