What are the Indian bronchoscopy practice guideline recommendations for indications, contraindications, patient preparation, sedation, procedural technique, infection control, and post‑procedure care?

Indian Bronchoscopy Guidelines

The Joint Indian Chest Society/National College of Chest Physicians (I)/Indian Association for Bronchology published comprehensive guidelines in 2019 that provide evidence-based recommendations for diagnostic flexible bronchoscopy, covering indications, patient preparation, sedation, procedural technique, infection control, and post-procedure care. 1

Patient Preparation

Pre-Procedure Fasting

• Patients should have no solid food for 4 hours before bronchoscopy 2, 3
• Clear fluids are permitted up to 2 hours before the procedure 2, 3
• This evidence-based approach balances aspiration risk against patient comfort 3

Pre-Procedure Assessment and Risk Stratification

• Patients with suspected COPD require spirometry before bronchoscopy; if FEV₁ <40% predicted and/or SaO₂ <93%, arterial blood gas measurement is mandatory 2
• Asthmatic patients must receive bronchodilator premedication 2
• Routine coagulation screening (platelet count, PT/INR) is only required in patients with known bleeding risk factors or when transbronchial biopsy is planned 2

Anticoagulation Management

• Stop oral anticoagulants at least 3 days before bronchoscopy if biopsy is anticipated, or reverse with low-dose vitamin K 2, 4
• If anticoagulation must continue, reduce INR to <2.5 and initiate heparin 2, 4
• Check platelet count, PT, and PTT before performing transbronchial biopsies 2

Prophylactic Antibiotics

• Administer prophylactic antibiotics to patients who are asplenic, have prosthetic heart valves, or have a history of endocarditis 2, 4

Contraindications

Absolute Contraindications

• Unstable cervical spine (for rigid bronchoscopy) 4
• Severe maxillofacial trauma preventing safe bronchoscope passage 4
• Obstructing oral or laryngeal disease 4

Relative Contraindications

• Recent myocardial infarction: avoid bronchoscopy within 6 weeks of MI due to increased arrhythmia risk 2, 4
• Severe hypoxemia (SaO₂ <93%) - may proceed with appropriate oxygen supplementation and close monitoring 4
• Elevated pre-procedure arterial CO₂ - sedation must be avoided as it can precipitate respiratory failure 2, 3, 4
• Uncorrected coagulopathy when biopsy is planned 4

Sedation and Anesthesia

Current Indian Practice Patterns

• The 2017 Indian Bronchoscopy Survey revealed that 59% of Indian bronchoscopists perform bronchoscopy without sedation, representing a significant departure from international guidelines 5
• When sedation is used, midazolam with or without fentanyl is the preferred agent 5

Evidence-Based Sedation Recommendations

• Sedation should be offered to patients where there is no contraindication 2
• Use incremental doses to achieve adequate sedation and amnesia 2
• Avoid sedation in patients with elevated baseline CO₂, as both sedation and oxygen supplementation can further increase CO₂ levels 2, 3, 4
• Atropine is not required routinely before bronchoscopy 2
• The survey found that 55% of Indian bronchoscopists use anticholinergic premedication either routinely or occasionally 5

Topical Anesthesia

• Limit total lignocaine (lidocaine) dose to 8.2 mg/kg in adults (approximately 29 ml of 2% solution for a 70 kg patient) 2
• Use 2% lignocaine gel for nasal anesthesia rather than spray 2
• Use the minimum amount of lignocaine necessary when instilled through the bronchoscope 2
• Exercise extra caution in elderly patients or those with liver or cardiac impairment 2
• In Indian practice, 72% use nebulized lignocaine, 24% utilize transtracheal administration, and 75% use 2% concentration 5

Procedural Technique

Monitoring Requirements

• Establish intravenous access before bronchoscopy begins and maintain through the recovery period 2, 3, 4
• Continuous pulse oximetry monitoring is mandatory during the procedure 2, 3, 4
• Provide oxygen supplementation to achieve SaO₂ ≥90% to reduce arrhythmia risk 2, 3, 4
• ECG monitoring is not required routinely but should be considered in patients with severe cardiac disease or hypoxia despite oxygen supplementation 2, 4
• Resuscitation equipment must be readily available 2, 4

Route and Equipment

• The nasal route is most commonly used (94% in Indian practice) 5
• Video bronchoscopes are widely used (80.8% in India) 5
• At least two endoscopy assistants should be available, with at least one being a qualified nurse 2

Diagnostic Sampling Techniques

• For suspected endobronchial malignancy: obtain at least 5 bronchial biopsy specimens plus brushings and washings 2
• Achieve a minimum diagnostic yield of 80% from the combination of biopsies, brushings, and washings in endoscopically visible malignancy 2
• For transbronchial lung biopsy in diffuse lung disease: obtain 4-6 samples from one lung 2
• Fluoroscopic screening is not required routinely during transbronchial biopsy in diffuse lung disease, but should be considered for localized lesions 2
• In Indian practice, 74% perform conventional TBNA, 92% perform endobronchial biopsy, and 78% perform transbronchial lung biopsy 5

Advanced Procedures

• EBUS-TBNA is performed by 27% of Indian bronchoscopists 5
• Therapeutic airway interventions (stents, electrocautery, cryotherapy) are performed by 30% 5
• Rigid bronchoscopy is performed by only 19.5% of practitioners, highlighting a training gap 5, 6

Infection Control and Staff Safety

Staff Protection

• All staff should be vaccinated against hepatitis B and tuberculosis, with immunity and tuberculin status checked 2
• During bronchoscopy, staff must wear protective clothing: gowns or plastic aprons, masks/visors, and gloves 2
• Wear high-grade particulate masks when patients with multidrug-resistant tuberculosis undergo bronchoscopy, and perform the procedure in a negative pressure facility 2
• Use non-powdered latex or non-latex gloves instead of powdered latex gloves 2

Equipment Disinfection

• Bronchoscopes should be disinfected in a dedicated room using well-ventilated automated systems, preferably inside a fume cabinet 2
• During cleaning and disinfection, staff need protective clothing including nitrile gloves, plastic aprons, and eye/respiratory protection 2
• Do not re-sheath injection needles; spiked biopsy forceps require careful cleaning 2
• Use disposable or autoclavable accessories wherever possible to reduce infection risk and disinfectant exposure 2

Staff Training and Health Monitoring

• Bronchoscopy staff require training in patient care, infection control, and instrument decontamination including safe aldehyde use 2
• Pre-employment health checks should be performed on all staff working with aldehydes per COSHH recommendations 2
• Regular periodic screening of lung function and symptom occurrence should be conducted by occupational health 2

Post-Procedure Care

Immediate Recovery

• Postoperative oxygen supplementation may be required, particularly in patients with impaired lung function and those who have been sedated 2
• Continue monitoring until the patient is stable and alert 2
• Maintain intravenous access through the recovery period 2, 3

Chest Radiography

• Obtain a chest radiograph at least 1 hour after transbronchial biopsy to exclude pneumothorax 2

Patient Instructions

• Patients who have been sedated should be advised not to drive, sign legally binding documents, or operate machinery for 24 hours after the procedure 2
• Provide verbal and written patient information, which improves tolerance and understanding 2

Bronchoscopy in the Intensive Care Unit

Special Considerations

• Consider the internal diameter of the endotracheal tube before inserting the bronchoscope 2
• ICU patients should be considered at high risk from complications during fibreoptic bronchoscopy 2
• Continuous multi-modal physiological monitoring must be continued during and after the procedure 2
• Exercise care to ensure adequate ventilation and oxygenation is maintained during bronchoscopy via an endotracheal tube 2
• More profound sedation/anesthesia can be achieved in ventilated patients if the clinician is experienced with sedative/anesthetic agents 2
• ICUs should have the facility to perform urgent and timely flexible bronchoscopy for therapeutic and diagnostic indications 2

Training and Quality Considerations

Training Gaps in India

• 45% of Indian bronchoscopists learned the procedure outside of their fellowship training, indicating significant training gaps 5
• There is a dire need for rigid bronchoscopy training at teaching hospitals in India 6
• The 2019 Indian guidelines aim to standardize practices and serve as a complete reference guide for pulmonary physicians 1

Quality Metrics

• Flexible bronchoscopy is extremely safe when practice guidelines are followed, with mortality rates of 0.01-0.04% and major complication rates of 0.08% 2
• The wide national variation in bronchoscopy practices in India highlights the need for guideline adherence 5, 1