1. 1 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

2. 2 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Chapter 18 Bronchoscopy Assisting

3. 3 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Therapeutic and Diagnostic Bronchoscopy Therapeutic indications: –Secretion removal, foreign body removal, or airway management problems Diagnostic bronchoscopy is performed to identify or rule out pathologic conditions.

4. 4 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Rigid and Flexible Bronchoscopes Rigid bronchoscope –Advantage: has a large channel –Disadvantages: Patient must be under general anesthesia, limited view of tracheobronchial tree Flexible bronchoscope –Advantages: Able to assess areas located distally, easy maneuvering

5. 5 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Types of Instruments Instruments used during flexible bronchoscopy: –Cytology brush –Wang needle –Forceps –Basket

6. 6 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Types of Sample Testing and Analysis Cytological –Study a cell’s structure, function, or origin Histological –Study the structure of cells, their composition, and how they are organized Microbiological –Identify the cause of various pulmonary infections

7. 7 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Solutions Used to Fix or Prepare Samples for Testing Cytological studies –95% alcohol, Saccomanno’s solution Histological testing –Formalin solution Microbiological testing –Physiologic saline (0.9%), Ringer’s lactate

8. 8 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Personal Protective Equipment Waterproof gown Gloves Mask and goggles –or full face shield or mask-shield combination Radiation dosimeter badge

9. 9 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Bronchoscopy Room or Suite Specialized room or suite specifically designed for the procedure –Fluorescent lighting –Irradiation by ultraviolet (UV) lights –Special filtration –Piped oxygen, air, and vacuum services

10. 10 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Medications Employed for Anesthesia and Analgesia Medications for Anesthesia Lidocaine (Xylocaine) 1%, 2%, 4%; 0.5% for pediatric patients Benzocaine spray (Hurricane spray) Benzocaine-tetracaine-butamben (Cetacaine) spray Medications for Secretion or Bleeding Management Atropine Epinephrine (1:20,000 concentration) (continues)

11. 11 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Medications Employed for Anesthesia and Analgesia (continued) Medications for Sedation Diazepam (Valium) Midazolam (Versed) Lorazepam (Ativan)

12. 12 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Patient Monitoring Blood pressure Heart rate and rhythm SPO 2 FIO 2

13. 13 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Hazards and Complications of Bronchoscopy Hypoxemia Wheezing Hypotension Bradycardia Hemoptysis Bleeding Infection

14. 14 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Equipment Preparation Bronchoscope preparation Medication preparation Sample solution preparation Emergency equipment Personal protective equipment Equipment for the patient

15. 15 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Documentation Preparation Informed consent form that must be signed by the patient and a witness –If patient is unable to sign, an immediate family member may sign the form Charting Forms (as required) Laboratory Testing Request Forms (as needed)

16. 16 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Patient Preparation Monitoring –Prepare patient to be adequately monitored Anesthesia/Analgesia –Prepare for application of anesthesia and analgesia

17. 17 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Supplemental Oxygen May be provided using: –Nasal cannula with one prong “clipped off” or plugged –Simple mask with an opening cut for the bronchoscope Monitor the SpO 2 Maintain saturations greater than 90%

18. 18 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Bronchoscopy Assisting Medication Administration Tissue Sampling –Forceps –Brushing –Wang needle –Bleeding control

19. 19 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Specimen Preparation Label with the patient’s name and anatomical location where the samples were taken. Ask the physician to name all lobes and segments sampled. Prepare the sample using the correct solution.

20. 20 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Bronchoalveolar Lavage (BAL) Performed when the area to be sampled is distal to the segmental or subsegmental bronchi in which the bronchoscope is resting –Bronchoscope is “wedged,” occluding the airway. –Instill 30 to 50 ‑ ml of normal saline (0.9%). –Aspirate as much of the instilled saline as possible through the bronchoscope.

21. 21 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Patient Monitoring It is the responsibility of the therapist to: –Report adverse signs or symptoms –Closely monitor level of consciousness –Evaluate for the return of protective reflexes of upper airway as local anesthetic wears off –Note evidence of return of reflexes –Ensure that patient is alert

22. 22 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Bronchoscopy During Mechanical Ventilation Bronchoscopy may be performed on patients who are receiving mechanical ventilation –Ventilator settings will need to be modified Tidal volume Flow rate FIO 2 Respiratory rate

23. 23 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Documentation Documentation should include: –Baseline blood pressure, ECG strip, and SpO 2 –Preparation of the patient –Notation during the procedure –Amount and type of medications administered –Location of samples and types of tests –Recovery data

24. 24 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Cleaning the Bronchoscope Aspirate saline through the suction channel Decontaminate and clean Test for leaks Place in automatic endoscope washer or immerse in disinfection solution Rinse, inject alcohol and aseptically cover

25. 25 © 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Sample Delivery Comply with labeling requirements. Prompt delivery and handling of sample will help ensure an accurate diagnosis.