bronchoscopy

Question 1

List diagnostic (8) and therapeutic (4) indications for bronchoscopy

Answer 1

diagnostic: infection, abnormal CXR markings (lesions, nodules, masses, infiltrates, atelectasis), airway obstruction, lung/chest trauma, hemoptysis, chronic cough + unexplained resp symptoms, lung disease severity, TE fistula/other bronchial abnormalities
therapeutic: bronchial hygiene, foreign body removal, ETT management (insert difficult airway, confirm position), interventional not performed in bronch suite (laser therapy, cryotherapy, thermoplasty, balloon dilatation of airways, tracheobronchial stents (OR))

Question 2

absolute contraindications

Answer 2

no Pt consent, no available staff to perform/assist with procedure, not NPO for at least 8 hours, allergies to substances used during procedure

Question 3

relative contraindications (8)

Answer 3

high O2 requirements, current/recent MI, life-threatening cardiac arrhythmias, hemorrhage risks (low platelets, increased INR or PTT, anticoagulants, thrombocytopenia, elevated creatinine or BUN), compromised upper airway (vc edema), endotracheal lesions (e.g. mass, granuloma), active asthma or COPD exacerbation, immunosuppressed Pt

Question 4

complications & risks

Answer 4

complications: tachycardia, hypotension, bronchospasm, hypoxemia
risks: pneumothorax, bleeding, aspiration, hypercapnia, infection, vagal response, laryngospasm, cough/irritation

Question 5

alternative substance used if lidocaine allergy present

Answer 5

Chloroprocaine (Nesacaine) (now); benzocaine (previously but not safe due to MetHb)

Question 6

NPO restriction pre vs. post bronchoscopy

Answer 6

PRE: NPO 4 - 6hrs prior to procedure to reduce risk of aspiration
POST: NPO for at least 2 hrs to allow local anesthetic to wear off + prevent aspiration

Question 7

medication doses midazolam & fentanyl

Answer 7

Midazolam = (benzodiazepine) 1-4mg IV to produce amnesia + sleep
Fentanyl (opioid) = 25 - 100mcg IV = analgesia

Question 8

emergency med anaphylactic shock kit supplies (3)

Answer 8

ampule epinephrine, 1ml diphenhydramine (benadryl H1 antihistamine), 4mg/ml dexamethasone (CS)

Question 9

seizure kit emergency med

Answer 9

midazolam (versed)

Question 10

narcotic overdose emergency kit meds

Answer 10

2 ampules narcan (0.4mg/ml); half life 20 minutes

Question 11

kit D emergency kit meds

Answer 11

hypoglycemia treatment: dextrose, D10W

Question 12

Reversal agent for Midazolam

Answer 12

Flumazenil (0.1mg/ml); give 0.2mg over 15sec IV, wait 45sec then repeat up to 1mg

Question 13

dimenhydrinate

Answer 13

gravol (for nausea)

Question 14

advantages of flexible bronchoscopy (4)

Answer 14

widely available, most respirologists trained in flexible bronchoscopy, does not require general anesthesia, provides more access to more distal airways + good access to upper lobe bronchi

Question 15

advantages of rigid bronchoscopy (7)

Answer 15

general anaesthesia more comfortable for Pt, allows control of ventilation + oxygenation during interventional procedures, permits removal of large tumour, more control over massive hemoptysis, insertion of silicon airway stents, removes obstructing airway lesions, removes large centrally-located foreign bodies

Question 16

purpose of TBNA (transbronchial needle aspiration)

Answer 16

samples lymph nodes for diagnosing/staging lung cancer

Question 17

Versed (midazolam)

Answer 17

BZ: hypnotic, sedative, anxiolytic used in conscious sedation, GABA receptor agonist (Cl- channel). Strong amnesia, little hangover, minimal cardiopulmonary depression. Can cause nausea/emesis, coughing, apnea. onset <5min, duration 20mins. dose 1-4mg IV. Reversal agent = Flumazenil (Ativan). Used with fentanyl or morphine as it is not an analgesic

Question 18

Sublimaze (fentanyl)

Answer 18

Analgesic, opioid u receptor agonist = decreased nociceptive substance release, dose 25-100mcg for bronchoscopy, rapid onset and offset. Lower side effects than morphine and 100x more potent. Risks still for hypotension, resp depressionm vasodilation, dulled cough reflex. Reversal = Naloxone/Narcan

Question 19

morphine

Answer 19

Opioid u receptor agonist analgesic, highest release of histamine. Risk of resp depression, vasodilation, hypotension, nausea, dulled cough reflex
Reversal = Naloxone

Question 20

Dilaudid (Hydromorphone)

Answer 20

opioid u receptor analgesic, 10x more potent than morphine and less risk of dependency/addiction. Minimal histamine release. Same risks as other opioid analgesics

Question 21

propofol (diprivan)

Answer 21

IV anesthetic sedative and hypnotic; GABA receptor involvement. Benefits = decreased ICP, rapid emergence, anti-nausea. Risk: RESP/CVS depression, PRIS (bradycardia + asystole), pain at site of administration. Onset 15-30sec, duration 5-10min; dose 1-2.5mg/kg

Question 22

Etomidate (Amidate)

Answer 22

IV anesthetic/sedative/hypnotic, GABA involvement used for head injuries and cardiac complications, no significant CVS effects + decreases metabolism. Note: no analgesia properties. onset 30 sec, duration 10 min, dose 0.3-0.6mg/kg IV

Question 23

ketamar (ketamine)

Answer 23

IV dissociative anesthetic via NMDA receptor blocker. Benefit: minimal resp depression, increases BP, bronchodilates. Risks: vivid hallucinations on emergence. Onset 30 sec, duration 30 min dose 3-5mg/kg IV

Question 24

Precedex (Dexmedetomidine)

Answer 24

sedative, short acting alpha 2 adrenergic agonist blocks NE. Adverse: lacks resp depression and can affect BP