Bronchoscopy & IP Flashcards
Sedations for bronchoscopy:
1) Midazolam
- dose
- SE
- reversal agent
- onset of action
- duration of action
2) Fentanyl
- dose
- SE
- reversal agent
- onset of action
- duration of action
1) Midazolam
- Dose:
Initial: 2–2.5 mg
(0.5–1 mg in the
elderly)
Supplemental: 1 mg
(0.5–1 mg in the
elderly) at 2–5 min
intervals
Max dose: 3.5-7mg
- SE: Respiratory depression, hypotension
- Reversal agent: Flumazenil 200mcg stat, then 100mcg every min until conscious (max 3mg)
- onset of action: 30-60s
- duration of action: 30-60min
2) Fentanyl
- Dose:
Initial: 25–50 mcg
Supplemental: 25 mcg
Max dose: 50mcg
- SE: Respiratory depression,
nausea and vomiting
- Reversal agent: Naloxone 200 mcg with supplemental
doses of 100 mcg every 2 min until reversal occurs
- onset of action: 3-5min
- duration of action: 1-2h
How to do BAL?
50cc aliquot is flushed to total of 120-180mls. The first 20cc is discarded to reduce contamination
What is the burns inhalation bronchoscopic grading system?
Grade 0: no inhalation injury
Grade I: mild injury
Grade II: moderate injury
Grade III: severe injury
Grade IV: massive injury
What are the intrathoracic lymph nodes?
1: Lower cervical
2: Upper paratracheal
3: Ant - prevascular, Post - retrotracheal
4: Lower paratracheal
5: Subaortic
6: Paraaortic
7: Subcarinal
8: Paraesophageal
9: Pulmonary ligament
10: Hilar
11: Interlobar
12: Lobar
13: Segmental
14: Subsegmental
What are the benefits of minimally invasive endosonographic technique of biopsy vs mediastinoscopy?
Minimally invasive endosonographic technique = combining EBUS/EUS/ EUS-B FNA
#EUS-B is using bronchoscope to take transoesophageal Bx
Benefits compared to mediastinoscopy:
- less invasive
- daycare procedure done under conscious sedation
- less morbidity & cost
- able to Bx multiple stations, distant mets and structure below diaphragm
(mediastinoscopy able to access: 2R, 2L, 4R, 4L,7)
(EBUS able to access: 1,2,4,7,10,11,12)
(EUS able to access: 2,3p,4L,5,6,7,8,9)
Sensitivity of EBUS-TBNA: 88-93%
Sensitivity of EUS-FNA: 88%
Sensitivity EBUS/EUS-B: 96%
Sensitivity of mediastinoscopy: 79-93%
Risk of mediastinoscopy (haematoma & wound infection): 2.6%
How to do EBUS-TBNA for staging?
Ax
1) N3 (contralateral hilum/mediastinum, then
2) N2 (ipsilateral mediastinal nodes), then
3) N1 (ipsilateral hilum)
What are the types of navigational bronchoscopy?
Radial EBUS
Virtual bronch
Electromagnetic navigation
Radial EBUS:
normal lung: whitish snow-storm like
solid tumour: bright border, grey, homogenous
trapped air: sharp white spots with a comet tail sign
#no doppler for radial EBUS - look for vascular pulsation
Sens: 73%, Spec: 100%
Rate of complications:
1) Pneumothorax (1% vs >25% in CT-guided) and need for ICD (0.4% vs 69% for CT-guided)- resource from
Virtual bronch:
Uses CT scan data to generate 3-D visual representation –> simplifies navigation to the peripheries even for less experienced operators
Disadvantages:
- need CT thickness of <1mm
- breathing artefact/ excessive secretions shorten the visual pathway
Sens: 82%
Electromagnetic navigation:
-imaged based bronch with electromagnetic sensor
- diagnostic yield: 65%
EBUS-TBNA
- role and sens/spec in Dx
Reference:
2011 BTS for advanced diagnostic and therapeutic flex bronch in adults
EBUS-TBNA can be used to Dx:
1) Malignancy (sens 85-100%, spec 100%)
2) Sarcoidosis (sens 88-93%, can also do TBLB & BAL to Dx)
3) Lymphoma - but usu not used as larger tissue Bx for HPE is required
Preparation for bronchoscopy
1) FBC/RP/LFT/Coagulation profile
- Plt ≥20000 for BAL,
- ≥50000 for EBB/TBLB
2) If asthma/COPD: routine neb before procedure
3) NBM
- 6 hours for food,
- 2 hours clear fluid
4) Explain the indications to the patient for bronchoscopy
- Written &
- verbal consent from patient
5) Clarify allergies, comorbidities & drug history
Indications for bronchoscopy
- Diagnostic
- Therapeutic
Diagnostic:
1) Infection:
- pneumonia of unknown cause
- atelectasis
- unexplained cough
2) Malignancy
- centrally located mass
3) Haemoptysis - bleeding source
4) Airway evaluation
- Suspected airway obstruction
- Evaluation of stridor
- Tracheomalacia
- Tracheoesophageal fistula
5) Others
- Toxic inhalation
- Burn injury
Therapeutic:
1) Airway clearance
- Foreign body removal
- Mucous plugging
2) Balloon dilatation
3) Brachytherapy
4) APC
5) Laser
Relative contraindication for bronchoscopy (list 10)
1) No informed consent
2) SpO2 <90% RA
2) PaO2 <60mmHg
3) FEV1 <40%
4) Plt <50000
5) Uremia, Pulm HTN, SVCO, liver disease
6) Recent MI <4w
7) Haemodynamic instability
8) If AVM, need to do MDT
9) Intubated
10) Uncooperative pt
Risks of bronchoscopy
1) Bleeding (overall): 0.7%
2) Bleeding with brushing/EBBx: 2%
3) Bleeding with TBBx: 4.4%
4) Pneumothorax: up to 6% (need CXR 1h post TBBx)
5) Overall mortality: 0.1%
6) Others:
- Bronchospasm
- Vasovagal
- Arrhythmia/ cardiac arrest
- Airway obstruction
- Nausea/ vomiting
- Respi depression
- Fever/ pneumonia
Mortality: 0.01%
Major complication: 0.08-2%
ECG changes: 15%
Major bleeding: 1:500 - 1000
Bronchoscopy lignocaine dosage
- solution
- nasal spray
- gel
and complications
Lignocaine solution:
- Total lignocaine solution dose: 7mg/kg (max 8.2mg/kg)
- Common lignocaine solution concentration: 2% (=20mg/ml)
- e.g. 60kg pt –> 420mg. Therefore (420mg/20mg), the pt could receive total of 21mls
- To be given at least 6 times (21/6 = 3.5mls each site):
2x vocal cord
1x trachea
1x carina
1x RMB
1xLMB
Nasal spray
- Concentration: 10% (10mg/actuation)
- Dose: 3-5 sprays
Gel
- common concentration: 2%
- Dose: 5mls of 2%
- Apply to nose as lubricant
Complications of lignocaine:
i) CNS: confusion, blurred vision, euphoria, dizziness, myoclonus, seizure
ii) CVS: arrhythmia, cardiac arrest
Warfarin & Clopidogrel Mx in bronchoscopies - low vs high risk pt groups
Mx of anticoagulation in interventional procedures
How to clean the bronchoscope?
1) Wear appropriate, protective clothing: gloves, aprons, goggles, face mask and forearm cover
2) Before removing bronchoscope from light source, suction with enzymatic detergent, then air for 10s. This will remove blood, mucus and
debris from internal channels. 3) Wipe the external surface of the scope with a soft lint free cloth soaked in detergent.
4) Check scope for damage.
5) Remove, flush and wipe
biopsy and suction ports.
6) Discard single use valves.
7) Transport bronchoscope to the decontamination area in an appropriately sized and covered receptacle.
8) Leak test bronchoscope according to manufacturer’s recommendations.
9) Manual cleaning of bronchoscope to be performed in a dedicated sink filled with water and detergent according to manufacturer’s recommendations. Water and
detergent to be discarded after each use.
10) Brush suction and biopsy channels and ports with a single-use brush, according to manufacturer’s guidelines. Ensure the brush is visibly clean at the end of the process.
11) Clean the external surface of the scope, around the angulation control and distal tip of the bronchoscope.
12) Brush the biopsy and suction channel ports with a single-use short brush.
13) Irrigate the channels with an enzymatic detergent followed by water, then air.
14) Transfer the bronchoscope to a separate sink for rinsing, to remove residual detergent.
15) Transfer bronchoscope to AER in an appropriately sized receptacle.
16) Disinfect in Automated Endoscope Reprocessor alongside reusable valves. Ensure all channels are exposed to disinfectant process.
17) Store hanging in cupboard or drying cabinet following manufacturers recommendations.
18) Maintain record of decontamination process for bronchoscope and accessories.
Advantages & disadvantages of flexible vs rigid bronchoscopy
Endobronchial interventions:
- Electrocautery
- Cryotherapy
- Laser
- Argon Plasma Coagulation (APC)
Stenting
Modalities of tissue biopsy
- advantages & disadvantages
