Reprinted from Respiratory Care (Respir Care 1993;38:1173-1178)
AARC Clinical Practice Guideline
Fiberoptic Bronchoscopy Assisting
FBA 1.0 PROCEDURE:
The role of the assistant in flexible fiberoptic bronchoscopy (FFB)
FBA 2.0 DESCRIPTION/DEFINITION:
FFB involves direct visualization of the upper and lower respiratory tract for the diagnosis and management of a spectrum of inflammatory, infectious, and malignant diseases of the chest.(1) FFB may include retrieval of tissue specimens (bronchial brush, forceps, needle), cell washings via bronchoalveolar lavage, or removal of abnormal tissue by laser. FFB is performed by a specially trained physician and assisted by a specially trained health-care professional (HCP). This guideline addresses the role of the HCP in FFB (Section 10.3).
FBA 3.0 SETTINGS:
The preferred location for FFB is determined by the available equipment, the medical condition of the patient, and the specific procedures to be performed.(2) A designated bronchoscopy room or suite is the preferred location for outpatients or inpatients who are not critically ill. The procedure may be safely performed at the bedside in the intensive care unit, the operating room, an appropriately equipped outpatient facility, or other suitably equipped clinical area.(2)
FBA 4.0 INDICATIONS:
Indications include but are not limited to
- 4.1 The presence of lesions of unknown etiology on the chest x-ray film or the need to evaluate recurrent or persistent atelectasis or pulmonary infiltrates;(1-5)
- 4.2 The need to assess patency or mechanical properties of the upper airway;(1,2,4)
- 4.3 The need to investigate hemoptysis, persistent unexplained cough, localized wheeze, or strider;(1-6)
- 4.4 Suspicious or positive sputum cytology results;(1-4)
- 4.5 The need to obtain lower respiratory tract secretions, cell washings, and biopsies for cytologic, histologic, and microbiologic evaluation;(1,2,5,7,8)
- 4.6 The need to determine the location and extent of injury from toxic inhalation or aspiration;(1,2,4)
- 4.7 The need to evaluate problems associated with endotracheal or tracheostomy tubes (tracheal damage, airway obstruction, or tube placement);(1-5)
- 4.8 The need for aid in performing difficult intubations;(1,2,4,5)
- 4.9 The suspicion that secretions or mucus plugs are responsible for lobar or segmental atelectasis;(1-4)
- 4.10 The need to remove abnormal endobronchial tissue or foreign material by forceps, basket, or laser;(1)
- 4.11 The need to retrieve a foreign body (although under most circumstances, rigid bronchoscopy is preferred).(4,5,9)
FBA 5.0 CONTRAINDICATIONS:
Flexible bronchoscopy should be performed only when the relative benefits outweigh the risks.
- 5.1 Absolute contraindications include
- 5.1.1 Absence of consent from the patient or his/her representative unless a medical emergency exists and patient is not competent to give permission;(1)
- 5.1.2 Absence of an experienced bronchoscopist to perform or closely and directly supervise the procedure;(1,2)
- 5.1.3 Lack of adequate facilities and personnel to care for such emergencies as car
diopulmonary arrest, pneumothorax, or bleeding;(1,2)
- 5.1.4 Inability to adequately oxygenate the patient during the procedure.(1)
- 5.2 The danger of a serious complication from bronchoscopy is especially high in patients with the disorders listed, and these conditions are usually considered absolute contraindications unless the risk-benefit assessment warrants the procedure:(1,2)
- 5.2.1 Coagulopathy or bleeding diathesis that cannot be corrected,(1,2)
- 5.2.2 Severe obstructive airways disease,(1,2)
- 5.2.3 Severe refractory hypoxemia,(1,2)
- 5.2.4 Unstable hemodynamic status including dysrhythmias.(1,2)
- 5.3 Relative contraindications (or conditions involving increased risk), according to the American Thoracic Society Guidelines for Fiberoptic Bronchoscopy in adults,(1) include
- 5.3.1 Lack of patient cooperation;
- 5.3.2 Recent myocardial infarction or unstable angina;
- 5.3.3 Partial tracheal obstruction;
- 5.3.4 Moderate-to-severe hypoxemia or any degree of hypercarbia;
- 5.3.5 Uremia and pulmonary hypertension (possible serious hemorrhage after biopsy);
- 5.3.6 Lung abscess (danger of flooding the airway with purulent material);
- 5.3.7 Obstruction of the superior vena cava (possibility of bleeding and laryngeal edema);
- 5.3.8 Debility, advanced age, and malnutrition;
- 5.3.9 Respiratory failure requiring mechanical ventilation;
- 5.3.10 Disorders requiring laser therapy, biopsy of lesions obstructing large airways, or multiple transbronchial lung biopsies;
- 5.3.11 Known or suspected pregnancy because of radiation exposure.
- 5.4 The safety of bronchoscopic procedures in asthmatic patients is a concern, but the presence of asthma does not preclude the use of these procedures.(7,10)
FBA 6.0 HAZARDS/COMPLICATIONS:
- 6.1 Adverse effects of medication used before and during the bronchoscopic procedure(2,5,11,12)
- 6.2 Hypoxemia(2,13)
- 6.3 Hypercarbia
- 6.4 Wheezing(14)
- 6.5 Hypotension(14)
- 6.6 Laryngospasm, bradycardia, or other vagally mediated phenomena(2,5,11)
- 6.7 Mechanical complications such as epistaxis, pneumothorax, and hemoptysis(5,11,15)
- 6.8 Increased airway resistance(2,16)
- 6.9 Death(17)
- 6.10 Infection hazard for health-care workers or other patients(18-21) (see also Section 13)
- 6.11 Cross-contamination of specimens or bronchoscopes(18-21)
FBA 7.0 LIMITATIONS/VALIDATION OF RESULTS:
- 7.1 Bronchoscopy should not be performed in patients who have a contraindication listed in Section 5.0 of this Guideline, unless the potential benefit outweighs the risk, as determined by the physician bronchoscopist.
- 7.2 Poor or inadequate training of the bronchoscopy assistant in
- 7.2.1 The techniques of premedication for bronchoscopic examination
- 7.2.2 Function and preparation of bronchoscope and related equipment
- 7.2.3 Physical and physiologic monitoring during the procedure
- 7.2.4 Specimen retrieval (biopsies and washings), preparation of specimens, and site documentation
- 7.2.5 Postprocedure care of the patient
FBA 8.0 ASSESSMENT OF NEED:
Need is determined by the presence of clinical indicators as previously described in Section 4.0, and by the presence of contraindications as described in Section 5.0.
FBA 9.0 ASSESSMENT OF OUTCOME:
Patient outcome is determined by clinical, physiologic, and pathologic assessment. Procedural outcome is determined by the accomplishment of the procedural goals as indicated in Section 4.0, and by quality assessment indicators listed in Section l l.0.
FBA 10.0 RESOURCES:
- 10.1.1 Bronchoscopic devices
- 10.1.1.1 The appropriate scope size is determined by the bronchoscopist, based on the patient and procedures to be performed.(5)
- 10.1.1.2 Bronchoscopic light source, and any related video or photographic equipment, if applicable
- 10.1.1.3 Cytology brushes, flexible forceps, transbronchial aspiration needles, retrieval baskets (Compatibility of the external diameter of all scope accessories with the internal diameter of the bronchoscope should be verified before the procedure.)
- 10.1.1.4 Specimen-collection devices and fixatives (as determined by institutional policies)
- 10.1.1.5 Syringes for bronchoalveolar lavage, needle aspiration, and drug delivery
- 10.1.1.6 Bite block
- 10.1.1.7 Laryngoscope
- 10.1.1.8 Endotracheal tubes in various sizes
- 10.1.1.9 Thoracostomy set/tray
- 10.1.1.10 Venous access equipment (I.V. supplies)
- 10.1.2 Monitoring Devices
- 10.1.2.1 Pulse oximeter
- 10.1.2.2 Electrocardiographic monitoring equipment
- 10.1.2.3 Sphygmomanometer
- 10.1.2.4 Whole-body radiation badge for personnel
- 10.1.3 Procedure Room Equipment
- 10.1.3.1 Oxygen and related delivery equipment
- 10.1.3.2 Resuscitation equipment
- 10.1.3.3 Medical vacuum systems (wall or portable) and related suction supplies for scope or mouth
- 10.1.3.4 Infection control devices as listed in Section 13.0
- 10.1.3.5 Fluoroscopy equipment including personal protection
- 10.1.3.6 Laser equipment if applicable
- 10.1.3.7 Protease enzymatic agent (eg, Protozyme) for cleaning and removal of blood and protein before disinfection or sterilization, or other detergent capable of removing these substances(22)
- 10.1.3.8 High-level disinfection or sterilization agent: 2% alkaline glutaraldehyde (eg, Cidex, Sonacide, Glutarex), ethylene oxide,(20,23) or peracetic acid(24)
- 10.1.3.9 Adequate ventilation and other measures to prevent transmission of tuberculosis(25)
- 10.2 Medications: Institutional policies and personal preferences of the bronchoscopist vary greatly regarding the type and method of premedication for bronchoscopic examination. Administration of these medications by intravenous or intramuscular routes is limited to nurses, physicians, or other trained personnel. (The training and certification of "other personnel" is institution specific, should be consistent with institutional policies, and may include the respiratory therapist.) Aerosolized or atomized drugs, or drugs instilled through the bronchoscope, may be delivered by the respiratory therapist or other trained assistants.
- 10.2.1 Topical anesthetic (lidocaine 1%, 2%, 4%)(3,5,26,27)
- 10.2.2 Anticholinergic agent to reduce secretions and minimize vaso-vagal reflexes (atropine, glycopyrrolate)(3,26)
- 10.2.3 Sedative agent 30-45 min prior to the procedure (eg, codeine, meperidine, midazolam, morphine, hydroxyzine)(3,26)
- 10.2.4 Intravenous sedative immediately prior to and/or during the procedure (mid-
azolam, diazepam, meperidine, fentanyl)(3,5,26)
- 10.2.5 Benzodiazepine antagonist (flumazenil),(2) narcotic antagonist (Narcan)
- 10.2.6 Sterile nonbacteriostatic physiologic (isotonic) saline solution(13)
- 10.2.7 Vasoconstrictor for bleeding control (dilute epinephrine, usually 1:10,000)(28,29)
- 10.2.8 Inhaled beta agonist (albuterol, metaproterenol)(27)
- 10.2.9 Water-soluble lubricant, or combined lubricant/anesthetic (viscous lidocaine)(5,23,26)
- 10.2.10 Emergency and resuscitation drugs as deemed appropriate by institutional policies
- 10.3 Personnel: The precise role of the bronchoscopy assistant varies among institutions;(2,3,5,30) however, the prime responsibilities include preparation and monitoring of the patient, assisting with the procedure, handling specimens, postprocedure care of the patient, maintenance of the bronchoscopy equipment, and recordkeeping.
- 10.3.1 Bronchoscopy assisting should occur only under the direction of a physician who has been trained in bronchoscopy according to the Guidelines endorsed by the American Thoracic Society.(1,2)
- 10.3.2 Bronchoscopy assisting should be limited to Level II personnel who possess the skills necessary to determine adverse reactions and to undertake the appropriate remedial action.
- 10.3.3 The bronchoscopy assistant must be trained in the setup, handling, cleaning, and care of bronchoscopy equipment and related supplies; specimen retrieval and preparation for commonly ordered laboratory studies on bronchoscopy specimens; biopsy labeling; delivery of aerosolized drugs; and mechanical ventilation. The assistant must also be trained in monitoring and evaluating the patient's clinical condition as reflected by pulse oximetry, electrocardiogram, and stability of or changes in mechanical ventilation parameters, and be capable of relating changes in clinical condition to disease state, procedure, or drugs administered for the procedure. Assistants should be versed in CDC ventilation requirements for control of tuberculosis transmission. Bronchoscopy assistants should hold one of the following credentials: Certified Respiratory Therapy Technician (CRTT), Registered Respiratory Therapist (RRT), Certified Pulmonary Function Technologist (CPFT), Registered Pulmonary Function Technologist (RPFT), Registered Nurse (RN), Licensed Practical Nurse (LPN), physician (MD or DO), or operating room technician.
FBA 11.0 MONITORING:
The following should be monitored before, during, and/or after bronchoscopy, continuously, until the patient returns to his pre-sedation level of consciousness.
- 11.1 Patient
- 11.1.1 Level of consciousness(30)
- 11.1.2 Medications administered, dosage, route, and time of delivery(30)
- 11.1.3 Subjective response to procedure (eg, pain, discomfort, dyspnea)(30)
- 11.1.4 Blood pressure, heart rate, rhythm, and changes in cardiac status
- 11.1.5 SpO2 and FIO2(30,3l)
- 11.1.6 Tidal volume, peak inspiratory pressure, adequacy of inspiratory flow, and other ventilation parameters if subject is being mechanically ventilated
- 11.1.7 Lavage volumes (delivered and retrieved)
- 11.1.8 Documentation of site of biopsies and washings and tests requested on each sample
- 11.1.9 Periodic postprocedure follow-up monitoring of patient condition is advisable for 24-48 hours for inpatients. Outpatients should be instructed to contact the bronchoscopist regarding fever, chest pain or discomfort, dyspnea, wheezing, hemoptysis, or any new findings presenting after the procedure has been completed. Oral instructions should be reinforced by written instructions that include names and phone numbers of persons to be contacted in emergency.
- 11.2 Technical Devices
- 11.2.1 Bronchoscope integrity (fiberoptic or channel damage, passage of leak test)(23)
- 11.2.2 Strict adherence to the recommended procedures for cleaning, disinfection, and sterilization of the devices, and the integrity of disinfection or sterilization packaging(22,23)
- 11.2.3 Smooth, unhampered operation of biopsy devices (forceps, needles)
- 11.3 Recordkeeping
- 11.3.1 Quality assessment indicators as determined appropriate by the institution's quality assessment committee
- 11.3.2 Documentation of monitors indicated in Sections 11.1 and 11.2.
- 11.3.3 Identification of bronchoscope used for each patient
- 11.3.4 Annual assessment of the institutional or departmental bronchoscopy procedure, including an evaluation of
- 22.214.171.124 adequacy of bronchoscopic specimens (size or volume for accurate analysis, sample integrity)
- 126.96.36.199 review of infection control procedures and compliance with the current guidelines for semicritical patient-care objects(22,25)
- 188.8.131.52 synopsis of complications
- 184.108.40.206 control washings to assure that infection control and disinfection/sterilization procedures are adequate, and that cross-contamination of specimens does not occur
- 220.127.116.11 annual review of the bronchoscopy service and all of the above listed records with the physician bronchoscopists
FBA 12.0 FREQUENCY:
The frequency with which bronchoscopy is repeated on a given patient should be determined by the physician bronchoscopist based on indications.
FBA 13.0 INFECTION CONTROL:
Cardiopulmonary Diagnostics Guidelines Committee:
- 13.1 Universal Precautions(32,33)
- 13.2 CDC Guideline for Handwashing and Hospital Environmental Control-Section 2: Cleaning, disinfecting, and sterilizing patient care equipment(22)
- 13.3 CDC Guideline for preventing tuberculosis transmission(25)
- 13.4 Hepatitis B vaccination for personnel
- 13.5 Establishment of and conformance to written protocol for infection control.
Kevin Shrake MA RRT; Chairman, Springfield IL
Sue Blonshine RRT, Lansing MI
Bob Brown RRT, Madison WI
Michael Kochansky RPFT CRTT, Lancaster PA
Gregg Ruppel MEd RRT, St Louis MO
Jack Wanger MBA RPFT RRT, Denver CO
Interested persons may copy these Guidelines for noncommercial purposes of scientific or educational advancement. Please credit AARC and Respiratory Care Journal.
- American Thoracic Society. Medical Section of the American Lung Association. Guidelines for fiberoptic bronchoscopy in adults. Am Rev Respir Dis 1987;136: 1066.
- Green CG, Eisenberg J, Leong A, Nathanson I, Schnapf BM, Wood RE. Flexible endoscopy of the pediatric airway. Am Rev Respir Dis 1992;145:233-235.
- Prakash UBS, Offord KP, Stubbs SE. Bronchoscopy in North America: the ACCP survey. Chest 1991;100(6): 1668-1675.
- Landa JF. Indications for bronchoscopy. Chest 1978; 73(5, Suppl):686-690.
- Green CG. Assessment of the pediatric airway by flexible bronchoscopy. Respir Care 1991;36(6):555-568.
- Selecky PA. Evaluation of hemoptysis through the bronchoscope. Chest 1978;73(5, Suppl):741-745.
- Holgate ST, Wilson JR, Howarth PH. New insights into airway inflammation by endobronchial biopsy. Am Rev Respir Dis 1992;145(2, Part 2):S2-S6.
- Summary and recommendations of a workshop on the investigative use of fiberoptic bronchoscopy and bronchoalveolar lavage in asthmatic patients. Chest 1985; 88(1):136-138.
- Cunanan OS. The flexible fiberoptic bronchoscope in foreign body removal: experience in 300 cases. Chest 1978;73(5, Suppl):725-726.
- Smith DL, Deshazo RD. Bronchoalveolar lavage in asthma: an update and perspective. Am Rev Respir Dis 1993; 148:523-532.
- Wood RE. Spelunking in the pediatric airways: explorations with the flexible fiberoptic bronchoscope. Pediatr Clin North Am 1984;31:785-799.
- McAlpine LG, Thomson NC. Lidocaine-induced bronchoconstriction in asthmatic patients: relation to histamine airway responsiveness and effect of preservative. Chest 1989;96:1012-1015.
- Schnapf BM. Oxygen desaturation during fiberoptic bronchoscopy in pediatric patients. Chest 1991;99:591-594.
- Hertz MI, Woodward ME, Gross CR, Swart M, Marcy TW, Bitterman PB. Safety of bronchoalveolar lavage in the critically ill, mechanically ventilated patient. Crit Care Med 1991;19(12):1526-1532.
- Herf SM, Suratt PM. Complications of transbronchial lung biopsies. Chest 1978;73(5, Suppl):759-760.
- Perry LB. Topical anesthesia for bronchoscopy. Chest 1978;73(5, Suppl):691-693.
- Suratt PM, Smiddy JF, Gruber B. Deaths and complications associated with fiberoptic bronchoscopy. Chest 1976;69(6):747-751.
- Webb SF, Vall-Spinosa A. Outbreak of Serratia marcescens associated with the flexible fiberbronchoscope. Chest 1975;68(5):703-708.
- Dawson DJ, Armstrong JG, Blacklock ZM. Mycobacterial crosscontamination of bronchoscopy specimens. Am Rev Respir Dis 1982;126:1095-1097.
- Weinstein HJ, Bone RC, Ruth WE. Contamination of a fiberoptic bronchoscope with Proteus species. Am Rev Respir Dis 1977;116:541-543.
- Hanson PJV, Gor D, Clarke JR, Chadwick MV, Gazzard B, Jeffries DJ, et al. Recovery of the human immunodeficiency virus from fibreoptic bronchoscopes. Thorax 1991;46:410-412.
- Garner JS, Favero MS. CDC guideline for hand-washing and hospital environmental control, 1985. Infect Control 1986;7(4):231-243.
- Mehta AC, Curtis PS, Scalzitti ML, Meeker DP. The high price of bronchoscopy: maintenance and repair of the flexible fiberoptic bronchoscope. Chest 1990;98(2):448-454.
- Prakash UBS. Does the bronchoscope propagate infection? Chest 1993;104:552-559.
- Centers for Disease Control. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues. MMWR 1990; 39(RR-17):1-29.
- Prakash UBS, Stubbs SE. The bronchoscopy survey: some reflections. Chest 1991;100(6):1660-1667.
- Kirkpatrick MB. Lidocaine topical anesthesia for flexible bronchoscopy (editorial). Chest 1989;96(5):965-967.
- Zavala DC. Pulmonary hemorrhage in fiberoptic transbronchial biopsy. Chest 1976;70(5):584-588.
- Hanson RR, Zavala DC, Rhodes ML, Keim LW, Smith JD. Transbronchial biopsy via flexible fiberoptic bronchoscope: results in 164 patients. Am Rev Respir Dis 1976;114:67-72.
- American Academy of Pediatrics, Committee on Drugs. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992;89(6, Part 1):1110-1115.
- American Association for Respiratory Care. Clinical practice guideline: pulse oximetry. Respir Care 1991; 36(12):1406-1409.
- Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other blood-borne pathogens in health-care settings. MMWR 1988;37:377-382,387-388.
- Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens. 29 CFRR Part 1910.1030. Federal Register, Friday December 06, 1991.