Bronchoscopy is used for investigating symptoms, assessing lung infiltrates and masses, staging lung cancer, obtaining samples for diagnosis, and treating conditions like infections, tumors and collapsed airways. It involves inserting a flexible tube with a camera through the mouth or nose into the lungs. Risks include low oxygen, bleeding, collapsed lung, heart problems and death. Patients are prepared with scans, tests and fasting beforehand. Sedation is usually used and monitoring during and after the procedure is important. Informed consent discusses the patient's condition, procedure details, risks and alternatives.

1. BRONCHOSCOPY BASICS
Dr.RAJASEKHAR THOTTADI
Pulmonary medicine
Rmc kakinada

2. Indications
• Investigations of symptoms
• haemoptysis
• persistent cough
• recurrent infection
• Infection
• assessment of pulmonary infiltrates
• identification of organisms
• evaluate airways if recurrent or persistent infection
• clinical or radiological features of environmental
mycobacterial infection

3. • Diffuse lung disease
• differential cell counts and cytology
• transbronchial lung biopsy
• Suspected neoplasia
• unexplained paralysis of vocal cords
• stridor
• localized monophonic wheeze
• segmental or lobar collapse
• assessment of nodules or masses identified on radiology
• unexplained paralysis of hemi-diaphragm or raised right hemi-
diaphragm
• mediastinal tissue diagnosis and staging
• staging of lung cancer

4. • Therapeutic
• clearance of airway secretions
• recurrent mucous plugging causing lobar collapse and atelectasis in
patients on mechanical ventilators
• foreign body removal
• endobronchial ablation of tumour (cryotherapy, electrocautery, laser)
• insertion of airway stents
• insertion of fiducial markers for the gamma/cyberknife
• bronchoscopic lung volume reduction
• bronchial thermoplasty for asthma
• treatment of bronchopleural fistula

5. Preparation of patient
• All patients need to provide informed consent
prior to the procedure.
• They should be provided with written
information in advance of the procedure and
the key aspects, such as risks of the procedure
and alternative approaches, should be
discussed before final consent.

6. • The procedure is usually performed on an
outpatient basis with conscious sedation.
• Patients should be advised not to eat for at
least 6 hours before the procedure but they
may be allowed to drink water for up to 2
hours before the procedure.

7. checklist
• Patient information – verbal and written
• Full blood count and clotting prior to transbronchial lung
biopsy and interventional procedures such as tumour ablation
• Informed consent
• Spirometry if oxygen saturations < 95 per cent
• Arterial blood gases if oxygen saturations < 92 per cent
• Baseline electrocardiogram (ECG) if there is a history of
cardiac diseases

8. checklist
• If patients are to have any sedation, ensure that someone is
going to accompany them home after the procedure.
• Remind patients that if they are sedated they will be unable
to drive or operate machinery for at least 24 hours.
• Intravenous access.
• Consider bronchodilators if there is evidence of
bronchospasm.
• Consider prophylactic antibiotics if at very high risk of
endocarditis: asplenia, heart valve prosthesis.

9. • Computed tomography (CT) scan should be performed
prior to bronchoscopy and there is good evidence that
reviewing CT scans of the thorax before flexible
bronchoscopy significantly improves the yield from the
procedure. It allows the bronchoscopist to select more
accurately the segment of the lung that should be
sampled and hence improve the diagnostic accuracy of
the investigation.

10. • CT scan may also demonstrate the presence of
mediastinal lymph nodes and hence allow additional
procedures such as transbronchial fine-needle aspiration
to be performed at the same time as the diagnostic
bronchoscopy.

11. • All patients undergoing bronchoscopy should have heart rate,
blood pressure and oxygen saturation recorded repeatedly,
including before, during and after the procedure.
• Acute MI is considered a contraindication to bronchoscopy
within 4–6 weeks.
• Continuous ECG monitoring should be used when there is a
high clinical risk of arrhythmia and oxygen saturations , pulse
rate and blood pressure should be optimised.

12. Identify Clinical risk factors for abnormal
coagulation
• Anticoagulant therapy,
• Evidence of liver disease,
• History, family history or physical evidence of bleeding
tendency,
• Active bleeding or pre-procedure transfusion.

13. • Perform coagulation studies, platelet count and haemoglobin
concentration when there are clinical risk factors for abnormal
coagulation.
• Bronchoscopy with lavage can be performed with platelet
counts >20 000 per μL.
• Discontinue clopidogrel for 7 days prior to consideration of
EBB and TBLB. Low-dose aspirin alone can be continued.

14. SAFETY OF FOB IN SPECIFIC MEDICAL CONDITIONS
• Patients with asthma
• Patients’ asthma control should be optimised prior to bronchoscopy,
especially when BAL is likely to be performed.
• Nebulised bronchodilators should be considered before
bronchoscopy in patients with asthma.
• Patients with COPD
• COPD treatment should be optimised prior to bronchoscopy when
possible.
• Bronchoscopists should be cautious when sedating patients with
COPD

15. • Patients with ischaemic heart disease
• cardiologists should be considered in high-risk patients
with cardiac disease and if FB is indicated within 4–6
weeks after MI.
• FB should ideally be delayed for 4 weeks after MI.
• Bronchoscopy in the older patient
• Age alone should not be a contraindication for
bronchoscopy.
• The older patient may require reduced doses of
benzodiazepines/opioids for sedation

16. Consent
• Name age sex
• Diagnosis
• Condition and treatment
• The doctor has explained that you have the following condition: (Doctor
to document in patient’s own words)
• .........................................................................................................................
...........................................
• This condition requires the following procedure. (Doctor to document -
include site and/or side where relevant to the procedure)
•
.........................................................................................................................
........................................

17. • The following will be performed
• Doctor to tick which samples may be taken:
 Endo-bronchial biopsy:
Bronchial brushings:
Bronchial washings:
Trans-bronchial lung biopsy:
Trans-bronchial needle aspiration:
Trans-tracheal needle aspiration:
Broncho-alveolar lavage:

18. • Risks of a bronchoscopy +/- biopsy
• There are risks and complications with this procedure.
They include but are not limited to the following
– low oxygen levels
– Bleeding
– Pneumothorax
– Heart problems
– Fever
– Arrythmias
– Death.

19. • Risks of not having this procedure
• Anaesthetic

20. • Patient consent
• I acknowledge that the doctor has explained;
• my medical condition and the proposed procedure, including additional
treatment if the doctor finds something unexpected. I understand the risks,
including the risks that are specific to me.
• the anaesthetic required for this procedure. I understand the risks, including
the risks that are specific to me.
• other relevant procedure/treatment options and their associated risks.
• my prognosis and the risks of not having the procedure.
• that no guarantee has been made that the procedure will improve my
condition even though it has been carried out with due professional care.
• the procedure may include a blood transfusion. tissues and blood may be
removed and could be used for diagnosis or management of my condition,
stored and disposed of sensitively by the hospital.
• if immediate life-threatening events happen during the procedure, they will
be treated based on my discussions with the doctor or my Acute
Resuscitation Plan.
• a doctor other than the Consultant may conduct the procedure. I
understand this could be a doctor undergoing further training.

21. • I have been given the following Patient Information Sheet/s:
– About Your Anaesthetic
– Bronchoscopy +/- Biopsy
• I was able to ask questions and raise concerns with the doctor about my
condition, the proposed procedure and its risks, and my treatment options. My
questions and concerns have been discussed and answered to my satisfaction.
• I understand I have the right to change my mind at any time, including after I have
signed this form but, preferably following a discussion with my doctor.
• I understand that image/s or video footage may be recorded as part of and during
my procedure and that these image/s or video/s will assist the doctor to provide
appropriate treatment.
Signature of the patient