What are the steps for a bronchoscopy procedure?

Bronchoscopy Procedure Steps

A complete bronchoscopy procedure follows a standardized sequence of pre-procedural preparation, procedural steps, and post-procedural care to ensure patient safety and optimal diagnostic yield. 1

Pre-Procedure Preparation

Patient Preparation

• Obtain informed consent after explaining the procedure to the patient in appropriate terms 1
• Ensure patient fasting: no food for 4 hours and clear fluids allowed up to 2 hours before the procedure 1
• Establish intravenous access before commencing the procedure 1
• Perform pre-procedure assessment:
  • Check spirometry in COPD patients (if FEV₁ <40% predicted and/or SaO₂ <93%, arterial blood gases should be measured) 1
  • Review anticoagulation status (oral anticoagulants should be stopped at least 3 days before or reversed with vitamin K if biopsy is anticipated) 1
  • Check platelet count and coagulation studies if transbronchial biopsy is planned 1

Equipment Preparation

• Select appropriate bronchoscope size (adult bronchoscopes: 4.5-6.0 mm external diameter) 2
• Ensure all necessary sampling equipment is available (brushes, biopsy forceps, needles) 2
• Prepare monitoring equipment (pulse oximeter, ECG monitor for high-risk cardiac patients) 1
• Have resuscitation equipment readily available 1

Procedure Steps

Sedation and Anesthesia

1. Administer sedation in incremental doses (midazolam is commonly used) 1, 3
2. Apply topical anesthesia:
   • Apply 2% lignocaine gel to the nose (preferred over spray) 1
   • Apply spray to the throat 3
   • Use "spray as you go" technique for additional anesthesia during the procedure 1, 3
   • Limit total lignocaine dose to 8.2 mg/kg in adults 1

Bronchoscope Insertion and Airway Examination

1. Insert the bronchoscope via the nose, mouth, tracheostomy, or endotracheal tube 1
2. Systematically examine the airways in sequence:
   • Vocal cords and larynx
   • Trachea
   • Main carina
   • Right main bronchus and its divisions
   • Left main bronchus and its divisions
   • Examine all segmental bronchi 2

Diagnostic Sampling

1. Perform appropriate sampling techniques based on the indication:
   • Bronchial washing
   • Bronchial brushing
   • Endobronchial biopsy (at least five specimens for suspected malignancy) 2
   • Transbronchial biopsy (consider fluoroscopic guidance for localized lesions) 1
   • Transbronchial needle aspiration
   • Bronchoalveolar lavage 2
2. Document precise location of each sample collection 2

Management During Procedure

• Monitor oxygen saturation continuously 1, 4
• Provide oxygen supplementation to maintain saturation ≥90% 1
• Manage complications as they arise (bleeding, hypoxemia, bronchospasm) 1

Post-Procedure Care

1. Continue oxygen supplementation if needed, particularly in patients with impaired lung function 1
2. Obtain chest radiograph at least 1 hour after transbronchial biopsy to exclude pneumothorax 1
3. Monitor for return of gag reflex and ability to swallow safely (typically 60-90 minutes) before discharge 1
4. Provide verbal and written instructions:
   • Not to drive, sign legal documents, or operate machinery for 24 hours if sedated 1
   • Information about possible complications (hemoptysis, pneumothorax) and when to seek medical attention 1
5. Ensure high-risk patients (elderly, those who had transbronchial biopsies) have someone to accompany them home and stay with them overnight 1

Special Considerations

• For intubated patients, use a swivel connector with perforated diaphragm to maintain ventilation 2, 5
• Ensure the bronchoscope occupies no more than 50-60% of the endotracheal tube's internal diameter 2
• For patients with suspected tuberculosis, perform bronchoscopy at the end of the list 1
• Patients with severe respiratory compromise may require smaller bronchoscopes 2

Common Pitfalls to Avoid

• Inadequate sedation assessment (most centers rely on patient observation alone rather than formal sedation scores) 3
• Routine use of atropine (not recommended in guidelines but still used by some practitioners) 1, 3
• Inadequate ventilation during the procedure, which can lead to hypoxemia and hemodynamic instability 2
• Insufficient sampling (at least five bronchial biopsy specimens should be taken for suspected malignancy) 2
• Inadequate decontamination of equipment between patients (thorough cleaning with detergent is the most important initial stage) 1

Following these standardized steps ensures a safe and effective bronchoscopy procedure with optimal diagnostic yield while minimizing complications.