What is the comprehensive checklist for a bronchoscopy procedure?

Bronchoscopy Checklist

A comprehensive bronchoscopy checklist must address pre-procedure preparation, intra-procedure monitoring, post-procedure care, equipment decontamination, and staff safety to minimize morbidity and mortality. 1

Pre-Procedure Preparation

Patient Assessment and Optimization

• Check coagulation studies (platelet count, PT, PTT) before any biopsy procedure, though routine testing is only required for patients with known bleeding risk factors 2
• Stop oral anticoagulants at least 3 days before the procedure or reverse with low-dose vitamin K; if anticoagulation must continue, reduce INR to <2.5 and bridge with heparin 2
• Perform respiratory function testing including spirometry for suspected COPD patients; obtain arterial blood gas if FEV1 <40% predicted and/or SaO2 <93% 2
• Premedicate asthmatic patients with bronchodilators 2
• Avoid bronchoscopy within 6 weeks of myocardial infarction when possible 2
• Administer prophylactic antibiotics to asplenic patients, those with heart valve prostheses, or previous endocarditis history 2

Patient Preparation

• Ensure NPO status for 4 hours; clear fluids permitted up to 2 hours before procedure 2
• Establish intravenous access before procedure and maintain until end of recovery period 2
• Obtain written informed consent after explaining advantages and disadvantages 3

Staffing and Equipment

• Ensure at least two endoscopy assistants are available, with at least one qualified nurse 1
• Have resuscitation equipment readily available 1
• Verify immediate availability of resuscitative drugs and age/size-appropriate equipment with personnel trained in airway management 4

Intra-Procedure Monitoring and Safety

Monitoring Requirements

• Continuous pulse oximetry is mandatory 1, 2
• Maintain oxygen saturation ≥90% with supplemental oxygen to reduce arrhythmia risk 2
• Consider ECG monitoring for patients with severe cardiac disease or hypoxia despite oxygen supplementation 1, 2

Anesthesia and Sedation

• Limit lignocaine dosing to 8.2 mg/kg in adults (approximately 29 ml of 2% solution for 70 kg patient); use extra care in elderly or those with liver/cardiac impairment 1, 2
• Use lignocaine gel (2%) rather than spray for nasal anesthesia 1
• Administer sedatives in incremental doses to achieve adequate sedation and amnesia 1, 2
• For midazolam in healthy adults <60 years: titrate slowly over at least 2 minutes, starting with no more than 2.5 mg; wait additional 2+ minutes between doses; total dose rarely exceeds 5 mg 4
• For patients ≥60 years or debilitated: start with no more than 1.5 mg over 2 minutes; wait 2+ minutes between doses; total dose rarely exceeds 3.5 mg 4

Procedure-Specific Considerations

• Use fluoroscopic screening for transbronchial biopsy in patients with localized lung lesions (not required for diffuse disease) 1
• Take at least five bronchial biopsy specimens in cases of suspected bronchial malignancy 1
• Schedule patients with suspected tuberculosis at the end of the list 1

ICU-Specific Considerations

• Consider the internal diameter of the endotracheal tube before inserting the bronchoscope 1
• Recognize ICU patients as high risk from complications 1
• Continue continuous multi-modal physiological monitoring during and after the procedure 1
• Ensure adequate ventilation and oxygenation is maintained during bronchoscopy via endotracheal tube 1

Staff Safety During Procedure

• All staff must be vaccinated against hepatitis B and tuberculosis; verify immunity and tuberculin status 1
• Staff must wear protective clothing: gowns or plastic aprons, masks/visors, and non-powdered latex or non-latex gloves 1
• Wear high-grade particulate masks when patients have multidrug-resistant tuberculosis; perform procedure in negative pressure facility 1
• Never re-sheath injection needles; handle spiked biopsy forceps with care during cleaning 1

Post-Procedure Care

Immediate Monitoring

• Provide postoperative oxygen supplementation as needed, particularly for patients with impaired lung function or who received sedation 1, 2
• Obtain chest radiograph at least 1 hour after transbronchial biopsy to exclude pneumothorax 1, 2

Patient Instructions

• Provide verbal and written advice about the possibility of delayed pneumothorax development after transbronchial biopsy 1, 2
• Advise sedated patients verbally and in writing not to drive, sign legally binding documents, or operate machinery for 24 hours 1, 2
• Ensure day case patients who received sedation are accompanied home; high-risk patients (elderly, post-transbronchial biopsy) should have someone stay with them overnight 1, 2

Equipment Decontamination and Disinfection

Cleaning Protocol

• Perform decontamination at the beginning and end of the list and between patients 1, 2
• Thorough cleaning with detergent is the most critical initial step 1, 2
• Use trained staff in a dedicated room for cleaning and disinfection 1, 2

Disinfection Standards

• Immerse in 2% glutaraldehyde for 20 minutes for routine cases at beginning/end of session and between patients 1, 2
• Extend immersion to 60 minutes for known/suspected atypical mycobacterial infections and HIV-positive patients with respiratory symptoms 1, 2
• Use automated washer disinfectors to minimize staff contact with disinfectants and fumes 1
• Ensure automated systems have facilities for disinfecting tanks, immersion trays, and all fluid pathways 1

Water Quality and Rinsing

• Use only sterile or bacteria-free water for rinsing: autoclaved or filtered water (0.2 μm filters) 1, 2
• Ensure all rinse water pathways (tanks, filters, pipework) are accessible for regular, preferably sessional, cleaning and disinfection 1, 2
• Use chlorine-releasing agent or peracetic acid via water filters for water-borne mycobacteria like M. chelonae that are extremely resistant to glutaraldehyde 1, 2
• If rinse water quality is uncertain, wipe external surfaces and flush lumen with 70% alcohol; this destroys non-sporing bacteria including mycobacteria and rapidly evaporates 1

Documentation

• Keep a record of which bronchoscope and reusable equipment are used on each patient and the decontamination procedure performed 1, 2

Staff Safety During Decontamination

• Perform pre-employment health checks on all staff working with aldehydes per COSHH recommendations; conduct regular periodic screening for lung function and symptoms via occupational health 1
• Disinfect bronchoscopes in a dedicated room using well-ventilated automated systems, preferably inside a fume cabinet 1
• Staff must wear protective clothing during cleaning: nitrile gloves, plastic aprons, eye and respiratory protection as appropriate 1
• Use disposable accessories, especially injection needles, to reduce infection risk during equipment cleaning 1
• Use autoclavable or disposable accessories wherever possible to prevent unnecessary disinfectant exposure 1
• Ensure all bronchoscopy staff are trained in patient care, infection control, instrument decontamination, safe aldehyde use, and potential health risks 1

Critical Pitfalls to Avoid

• Inadequate coagulation assessment can lead to serious bleeding complications even in short procedures requiring biopsy 2
• Failure to optimize respiratory status (uncontrolled asthma, unassessed severe COPD) significantly increases complication rates 2
• Delayed pneumothorax recognition is preventable with mandatory post-procedure chest radiograph after transbronchial biopsy 2
• Inadequate disinfection times (35% of units in UK audit failed to meet minimum standards) increases infection transmission risk 5
• Using non-sterile rinse water (43% of UK units) can transmit water-borne mycobacteria 5
• Inadequate room ventilation and glutaraldehyde use in patient examination rooms (31% of UK units) exposes staff and patients to unnecessary chemical hazards 5