Bronchoscopy- What is it?

Bronchoscopy is a tool for monitoring and diagnosis of your lungs.  The bronchoscope is a thin long instrument with a light and a camera at the end.

Procedure:

1. The bronchoscopy(bronch) is performed after the patient receives intravenous sedation.  In addition, local anesthesia is applied to the nose and upper airways. (Sedation varies by center and patient).
2. The bronchoscope is passed through the  nose, and the upper airways are closely examined.
3. The vocal cords are then examined and additional local anesthesia is applied to the cords.  This is often the worst part of the procedure for the patient. Bronchoscopy is generally not a painful procedure, but it may be associated with excess coughing from irritation caused by the bronchoscope/instilled fluids.
4. The trachea is entered and both sides of the lung are inspected in detail.  Any secretions that are present are cleared via suctioning through the bronchoscope. Sterile fluid is instilled in into the lung and then is suctioned back into a collection container.
5. The specimens obtained are referred to as bronchial washings or bronchoalveolar lavages. These are routinely sent off to the Microbiology laboratory to check for the presence of any bugs/organisms(viruses, bacteria, fungi) which may potentially need to be treated.
6. Close attention is paid to the bronchial anastomosis (the hook-up between the patient's native bronchus and the donor bronchus for evidence of any scar tissue or stricture formation.
7. In most cases biopsies of the lung will be taken. This involves passing a biopsy forceps through the suction channel of the bronchoscope out into the lung and taking very small pieces of lung tissue by opening and closing the biopsy forceps.  This is done with fluoroscopic(x-ray) guidance to prevent the biopsy forceps from going to far out or close in.
8. Possible complications of taking biopsies include bleeding and a pneumothorax.
9. Bronchs are usually performed by the Transplant Pulmonologist, in the bronch suite.

Surveillance Bronchoscopy

These bronchs are performed on a routine basis, even if the patient is doing well clinically.  Centers vary on the routine bronch schedule.  Many centers perform bronchs in the first year after transplant on a routine basis, and then at one year after surgery only perform them when clinicallly needed.

Clinical-Indicated Bronchoscopy

These bronchs are performed when there is a change in the patient's clinical condition and the physician needs to determine what is happening in the lungs.

Examples of reasons for a bronch include:

• patient symptoms, for example shortness of breath
• a drop in the patient's PFT numbers
• a change seen on the patient's chest x-ray
• unexplained fever

Biopsy Scale

The lung tissue is graded on a scale of 0-4.  0 means no rejection, 4 means severe rejection.

Information you Need to Know:

1. You will be able to return home after the bronch. You may be drowsy, so have someone available to drive. (Centers vary on rules. Some will not allow you to drive for 24 hours. Remember, if you do drive and are the cause of an accident, you will be at fault as you signed papers in the hospital that indiate that driving before 24 hours is not allowed.)
2. Do not eat or drink anything prior to your bronch without first talking with your coordinator. You may take your medication with sips of water.
3. If you take prednisone, blood thinner, blood pressure, diabetic medication, consult with your coordinator about these medicines prior to the bronch.  (Prednisone is hard on the stomach if taken with no food, so may be told to not take it.  Diabetic medications are normally to help your glucose levels due to the food you eat.  If you have not eaten you could put your gluscose levels too low if you take them. Ask your coordinator for the guidelines.)
4. Bring your medicine with you to take after the procedure.

Nature Sights and Sounds Can Ease Pain of Bronchoscopy

Investigators at Johns Hopkins have proven that distracting patients during and after bronchoscopy(bronch) with the gurgle of a brook and colorful panorama of tranquil meadow improves pain control by approximately 43 percent.

The Hopkins researcher emphasizes that sound and sight distraction therapy is not a substitute for pain medication, but a way to enhance pain control.  The Hopkins group of 41 men and women during their 25 minute bronch and three hour recovery periods looked at cloth murals hung by their bedside and listene to nature sounds through headphones and a tape player.   

Patients who listened to the nature sounds and looked at the mural during the bronch were 43 percent more likely to report pain contral was very good or excellent.

To see some of the murals that may possibley be used go to: http://www.bedscapes.com/    or  www.healthdesign.org

Standardized guidelines for surveillance bronchoscopy reduce complications in lung transplant recipients (ADDED 9/23/04)
The role of surveillance bronchoscopy in the care of lung transplant recipie nts remains controversial. Although there are no controlled studies to suggest a survival advantage, many transplant physicians support the practice. The procedure is generally safe but is associated with some complications. In an effort to minimize these differences and potentially improve outcomes, a standard set of procedural guidelines for all bronchoscopies was adopted in January 2000.Reports from 1,028 surveillance bronchoscopies performed in our outpatient facility from January 1999 to December 2001 were reviewed. The incidence of complications after the introduction of the guidelines  (2000 and 2001) was significantly lower than in the year prior (1999)(1.95% vs 6.45%, p < 0.001). The lower rate of adverse events was mainly a result of a reduction in the incidence of minor bleeding (0.28% vs 2.26% p = 0.006) and of sedation-related complications (0.97% vs 2.90%, p = 0.04). Conclusions The use of a standardized set of guidelines for surveillance fiber-optic bronchoscopy reduces complication rates. Similar guidelines should be  considered by transplant centers performing the procedure. The role of surveillance fiber-optic bronchoscopy (FOB) with transbronchial biopsy (TBBx) in lung transplant recipients remains controversial. Although the early diagnosis of asymptomatic acute rejection and cytomegalovirus (CMV) infection may lead to improved mortality, some investigators have shown comparable survival rates without performing surveillance procedures In addition, although FOB with TBBx is generally viewed as a safe procedure, it is associated with a defined set of complications, including bleeding, pneumonia, hypoxia and pneumothorax. Prior studies have reported that these complications occur in 4.4% to 10.8% of patients undergoing the procedure. Although serious complications are rare, major adverse events have been reported, including respiratory failure and death.In reviewing previous studies, there are clearly significant variations in the manner in which patients are prepared for surveillance FOB, in how the procedure is performed, in how complications are recorded, and the method by which quality control is maintained. At our institution, a review of FOB methods revealed disparat e practices among various bronchoscopy specialists. Variations were noted in the administration of conscious sedation, pre-procedure evaluation and risk stratification, and intra-procedure use of topical lidocaine. In an effort to minimize these differences in practice style and to reduce complication rates, a standard set of bronchoscopy guidelines was adopted in January 2000. In this study, we report the effect standardized FOB guidelines had on the procedure-related complication rate. The study involved 1,028 consecutive surveillance bronchoscopy procedures in lung transplant patients performed at our outpatient bronchoscopy facility during the years 1999, 2000 and 2001. At our institution, a surveillance bronchoscopy involves a bronchoalveolar lavage (BAL) with four 25-ml aliquots of sterile saline and at least 6  ransbronchial biopsies (TBBx) from a lower lobe segment. Patients were observed in the recovery room for a minimum of 1 hour following the procedure, and post-procedure chest radiographs were obtained for all  patients.Reports from the 1,028 consecutive surveillance FOBs performed in them outpatient facility from January 1999 to December 2001 were reviewed.  The characteristics of the patients before and after the guidelines were established were comparable The number of patients with complications was higher in the group having
undergone FOB before the standardized guidelines were adopted (20 of 310 [6.45%] vs 14 of 718 [1.95%]; p < 0.001) The overall complication rate over the 3-year period was 3.3% with 34 of the 1,028 patients suffering adverse events.   Complications of bronchoscopy  Examination of individual complications demonstrated a significant reduction in the number of episodes of minor bleeding (0.28% vs 2.26%) and a trend toward a reduction in the frequency of oversedation (0.56% vs 1.94%) in the group undergoing FOB after the guidelines were instituted. If the occurrence of oversedation requiring a reversal agent and the need for prolonged supplemental oxygen are combined and viewed as a singlemeasure of the safety of conscious sedation (discussed later), the incidence of sedation-related complications was also significantly reduced (0.97% vs 2.90%) There were no significant differences in the rates of other complications.  The data from this study show that a standardized set of guidelines for surveillance FOB is associated with a significantly reduced incidence of complications. .The lower rate of complications in the post-guideline period was largely the result of a reduction in the incidence of minor bleeding and in the rate of  sedation-related complications. .Prior studies have shown that desaturation is not uncommon during a variety of upper endoscopic procedures, including fiber-optic bronchoscopy, and has been associated with alveolar hypoventilation that occurs following the administration of benzodiazepines and narcotics.  It has also been shown that the incidence of post-bronchoscopy desaturation in sedated patients can be reduced by the prophylactic administration of supplemental oxygen,  and this practice is supported by published guidelines for bronchoscopy. These data suggest that the need for prolonged supplemental oxygen following bronchoscopy is closely tied to the amount of sedation administered before and during the procedure. The other key factor leading to a reduced rate of complications after the introduction of the guidelines was a reduction in the incidence of bleeding. A variety of risk factors have been associated with the risk of bleeding during bronchoscopy, including bleeding diatheses, thrombocytopenia, uremia, immunosuppression and pulmonary hypertension The reduced incidence of bleeding complications after January 2000 is likely the result of the guidelines having led to improved awareness of bleeding risk and to modulation of these risks in several ways. First, desmopressin was routinely administered to almost all patients with a blood urea nitrogen (BUN) of>30 mg/dl in the years 2000 and 2001. This agent has been shown to shorten the bleeding time in uremic patients, making minor surgical procedures safer. Second, biopsies were not performed in patients who had taken anti-platelet agents within 24 hours and those procedures were re-scheduled.  Last, transbronchial biopsies were avoided in patients who had known pulmonary hypertension The risk of major bleeding associated with bronchoscopy is very low. (Source: The Journal of Heart and Lung Transplantation   January 2004)