I. GENERAL CONSIDERATIONS

A. Indications

1. Diagnostic uses

a. To evaluate the upper and lower airways to confirm that they are normal, or that there is an abnormality present

b. If an abnormality is present on examination of the airway: to obtain appropriate biopsy samples to enable pathologic confirmation of the abnormality where it is clinically appropriate to do so

c. In interstitial lung disorders: to evaluate the airways and to obtain appropriate peripheral lung samples by using bronchoalveolar lavage (BAL), by peripheral brush samples, or by transbronchial lung biopsy

d. In patients with known or suspected lung tumors: to provide staging information by assessment of the airways and by sampling mediastinal and hilar lymph nodes using transbronchial needle aspiration or core biopsy samples

e. To provide objective assessment of airway tumor response to therapy by direct examination of the tumor site after therapy

f. To aid in the investigation of unexplained hemoptysis, localized wheeze or stridor, and, in some instances, to evaluate cough

g. To search for the origin of positive sputum cytology

h. To evaluate diaphragmatic paralysis

i. To evaluate potential tracheal trauma associated with prolonged mechanical ventilation

j. To obtain selective cultures or microbiologic specimens

k. To evaluate thoracic trauma and suspected tracheoesophageal (TE) fistulae

2. Therapeutic uses

a To remove retained airway secretions or plugs not removed by less invasive techniques

b. To aid in the performance of difficult intubations

c. To aid in the placement of brachytherapy catheters

d. To aid in the performance of stent placement, balloon bronchoplasty, and laser resection of benign and malignant airway stenoses

e. To evaluate and extract airway foreign bodies; most often performed using rigid bronchoscopy

B. Contraindications

1. Absolute

a. Patient refusal or absence of trained personnel

b. Severe uncorrectable hypoxemia

2. Relative contraindications, constituting a higher risk for the patient

a. Recent acute myocardial infarction (MI) (ie, within the previous 6 weeks)

b. Partial tracheal obstruction

c. Unstable asthma or angina

d. Cardiac arrhythmia

e. Severe hypoxemia

f. Uremia or coagulation disorders

g. Lung abscess

h. Superior vena cava (SVC) obstruction

i. Respiratory failure on mechanical ventilation

j. Hypoxemia or hypercarbia

3. Current best practice considerations

a. Patients on nonsteroidal anti-inflammatory drug (NSAID) need a bleeding time, if the surgeon anticipates biopsy.

b. Patients on beta-blockers present a special problem, because epinephrine has both alpha-activity and beta-activity; therefore, using epinephrine in the setting of beta-blockage yields unopposed alpha-activity that could result in hypertensive crisis. It is advisable for patients to stop beta-blockers before the procedure, if epinephrine is to be used.

II. PREOPERATIVE PREPARATION

A. Evaluation

1. History and physical examination by the bronchoscopy team, with informed consent for the procedure documented; the patient findings and the explanations about the procedure given to the patient need to be documented in the chart prior to the procedure. The physical examination and history need to rule out other potentially serious diseases, as well as evaluate the primary lung problem.

2. Chest x-ray and oxygen saturation are done prior to the procedure.

B. Patients in whom biopsy procedures other than BAL are expected need, in addition, CBC with platelets, PT, PTT, electrolytes with creatinine, BUN, ABG and simple spirometry.

C. Selected patients need

1. EKG, age over 40, history of cardiac disease

2. Bleeding time

3. Other laboratory studies, as dictated by the clinical setting

III. NURSING CONSIDERATIONS

A. As per pulmonary medicine division

IV. ANESTHESIA CONSIDERATIONS

A. Preoperative Medications

1. Atropine, 0.6 to 1.0 mg, IM, 30 minutes before procedure; dries secretions and blocks vasovagal responses

2. Morphine sulfate, 7.5 to 15 mg, IM, 30 minutes before procedure; anxiolytic, antitussive, and reduces pulmonary artery pressure

a. Alternative, Demerol, 25 to 100 mg, IM

3. Tranquilizers will be offered to patients after they arrive in the bronchoscopy laboratory, and their use should be considered usual rather than exceptional. Respiratory depression can be a major problem with these agents. The agent of choice is midazolam, titrated to effect (0.5 to 2.0 mg, IV, slowly). Reversal of the midazolam effect should be considered in high-risk patients at the completion of the procedure.

B. Local Anesthesia

1. Transoral

a. Dentures are out.

b. Electrocardiogram (EKG) monitor and nasal oxygen are on; liter flows recommended by the bronchoscopist; standard flow is 5 LPM per nasal prongs, unless physician orders otherwise.

c. One to two sprays of 20% benzocaine may be used, per bronchoscopist assistant’s discretion.

d. Spray: oropharynx is sprayed with approximately 5 to 20 cc of 4% xylocaine from a #15 or #16 DeVilbiss atomizer. Spray on inspiration to aid distribution of the anesthetic. More or less of the spray may be used, depending on the patient.

e. Piriform sinus anesthesia: piriform sinuses are blocked by applying cotton balls soaked with 4% xylocaine via Jackson cross-action forceps to each side for 1 minute. This effectively blocks the internal branch of the superior laryngeal nerve by transmucosal absorption, knocking out the gag reflex.

f. Anesthesia can be checked by inserting fingers into the patient’s mouth to the back of the tongue to check for gag reflux. If anesthesia is effective, the patient is ready for the initial insertion of the bronchoscope.

g. With the patient sitting, the flexible bronchoscope can be placed orally and gently slide over the back of the tongue to view the vocal cords. In this position, 2 ml of 1% lidocaine can be instilled through the bronchoscope channel to pass by gravity through the vocal cords. This works best with the patient making panting respirations.

h. Glassware and metalware should be cleaned in the scope washer.

i. CAUTION: Total xylocaine dosage during the entire fiber optic bronchoscopy procedure is NOT TO EXCEED 600 mg. Overdose is manifested by CNS symptoms (tremor, shivering, weakness). Use 4% xylocaine for anesthesia above the vocal cords, 1% xylocaine below the vocal cords.

2. Transnasal

a. Proceed as with transoral fiber optic bronchoscopy (FOB), with the following additions:

(1) After patient is anesthetized, nasally spray 4% lidocaine via atomizer at least 4 times in each nares, up to 8 times. Spray by pointing atomizer tip straight back, not up the nares. The patient is often uncomfortable until some anesthesia has been accomplished.

(2) Have the patient lie back on the table and squirt 0.5 cc of 0.25% phenylephrine hydrochloride into each nares.

(3) Have the patient sniff through each nostril to determine which is the most patent.

(4) Apply 3 to 5 cc of topical 2% lidocaine via a 10 cc syringe into and around the side of the nose that will be intubated with FOB. Let anesthesia take effect (5 minutes) before proceeding. Carefully insert cotton tip swab into most of the patient’s nares to ensure patency. Additional epinephrine can be applied on cotton tip swabs.

(5) Place the scope while the patient is lying down.

(6) Note: The piriform sinus anesthesia is also performed routinely for the transnasal approach.

V. OPERATIVE PROCEDURE

A. Procedure

1. Examination of the normal airway

a. After the patient is adequately anesthetized (see procedure for anesthesia), the bronchoscopist will do an upper airway examination. This includes the postnasal space, pharynx, and larynx. Once the bronchoscope has passed through the cords, the trachea is examined. It is important to examine for the presence of tracheal rings and for the presence of normal respiratory movement of the posterior tracheal wall where there are no rings present. Following instillation of any further local anesthesia that might be required into the left or right upper lobe regions, and occasionally into the right middle lobe, the excess local anesthetic is aspirated, and the rest of the bronchial tree is examined. This should be done in a systematic manner, so as not to miss any of the airway branches.

b. The most commonly used nomenclature system is a numbering system that has been accepted on an international basis for describing the tracheobronchial tree. Start with finding the right upper lobe and making sure that there are 3 segments in the right upper lobe nominated as RB1, 2, and 3. Their subsegments are RB1a and b, RB2a and b, and RB3a and b, respectively. Then the bronchoscope can be inserted into the right middle lobe where there are 2 main segments, RB4 and 5 which, again, have a and b subsegments. The next portion to be examined is the right lower lobe, and this has a medial segment or RB7 which, again, has a and b subsegments, and then the segments RB8, which is the anterior segment of the right lower lobe; RB9, which is the lateral segment of the right lower lobe; and RB10. RB10 is the posterior segment of the right lower lobe. RB8 and RB9 have a and b subsegments, and RB10 has a, b, and c subsegments. The bronchoscope should also examine the posterior apical segment of the right lower lobe that is RB6. This orifice normally comes off opposite the right middle lobe orifice, sometimes a little lower, and the RB6 segment should have three subsegments called RB6a, b, and c.

c. The left main bronchus can then be entered to examine the left lung in which similar anatomy applies with some differences. The left upper lobe now contains the equivalent of the right middle lobe as the lingular segment. Here, it is rotated through about 90°. Usually in the left upper lobe, the apical segment is combined with the posterior segment. Nevertheless, these can be identified as LB1 and 2, and again they have a and b subsegments. The anterior segment of the left upper lobe is usually quite separate, and again has 2 subsegments labeled LB3a and b. The lingular is now part of the upper lobe and contains segments 4 and 5 with 2 subsegments in each of these, 4a and b and 5a and b. The bronchoscope can then go into the left lower lobe. Here, the apical posterior segment is LB6, which has 3 subsegments, a, b, and c. There is no LB7 on the left side. LB8, 9, and 10 replicate the 8, 9, and 10 on the right, with LB8a and b, LB9a and b, and LB10a, b, and c.

d. In the usual bronchoscopy, all of these segments need to be identified and examined. If they are normal, the bronchial tree can be described as normal to the subsegmental level. With smaller bronchoscopes, further segments can be examined in a more peripheral manner, as required. For the routine bronchoscopy, the examination to the subsegmental level is adequate.

e. With bronchoscopy, as well as with determining normal anatomy, there are frequently abnormal anatomic changes. These usually do not cause disease and are asymptomatic. The most common abnormality is the loss of the 3 divisions of LB10 and RB10. These may have only 2 divisions. A B6 subsegment may be present on either the left or right side or, sometimes, on both sides. This additional segment is usually seen clearly just adjacent to the RB7 on the right and just below the LB6 on the left. Another anatomic anomaly that may occur is the right upper lobe coming from the trachea and not from the bronchus. This so-called “porpoise” lobe replicates the lung anatomy of porpoises and sheep. Occasionally, the apical segment of the right upper lobe only (RB1) will come from the trachea with the anterior and posterior segments (RB2 and RB3) coming from their normal positions.

f. In addition to the anatomic variance, there is also a need to observe the movement of the airways with normal respiration, looking for airway collapse and closure, and to examine the mucosa for signs of acute or chronic inflammation. Chronic inflammation may be indicated either by the presence of airway pitting or the presence of increased circumferential or vertical muscle bands. In severe acute inflammation, the airway mucosa is swollen, red, and has contact bleeding.

2. Transbronchial biopsies

a. The operator identifies the preselected segmental bronchus through which the forceps are to be passed, and a 2 to 3 ml bolus of epinephrine (1:10,000) is injected into the airway. The local drug effect is that of vasoconstriction and bronchodilation. Hemorrhage may be reduced in this manner. Because of the potential danger of bilateral pneumothoraces, biopsies are taken on one side only. When the pulmonary infiltrates are localized, the appropriate segmental bronchus is entered with the forceps.

b. As soon as the forceps disappear from endoscopic view, the operator relies on fluoroscopic control to pass the biopsy tool to the desired area.

c. In diffuse disease, a peripheral biopsy is taken. The bronchial arteries are smaller at the periphery of the lung; therefore the danger of significant bleeding is less. One should keep in mind, however, the risk of bleeding from pulmonary arterioles and capillaries may be increased by pulmonary hypertension. Care is taken to see that the forceps do not penetrate the visceral pleura. If the patient experiences pain during the insertion of the forceps, the biopsy instrument is immediately withdrawn and repositioned. Upon arrival at the periphery, the forceps are retracted 1 to 2 cm, and the following commands are given in fairly rapid order.

(1) To the patient, “Take a deep breath.”

(2) To the assistant, “Open the forceps.”

(3) To the patient, “Breathe all the way out.”

At this point during expiration, the bronchoscopist gently advances the forceps forward 1 cm, thus entrapping a small portion of the bronchial wall, together with the surrounding alveolar tissue.

(4) To the assistant, “Close the forceps.”

d. This last command, “Close the forceps,” is given at the end of an expiration, whereupon the endoscopist completely withdraws the forceps, leaving the tip of the broncho-fiberscope wedged into the bronchial segment to tamponade any possible bleeding. While retracting the biopsy, the operator can feel the pulling of lung tissue and can also see it on the fluoroscopy monitor.

e. As soon as the forceps are removed through the fiber optic bronchoscope, the operator inserts it into a sterile tube or Petri dish filled with saline. While opening and closing the forceps, the assistant taps on the distal end of the flexible shaft to dislodge the biopsy material. Rarely, the tissue has to be teased from the jaws of the forceps with a needle. Fluffy, floating tissue is indicative of lung, whereas bronchial tissue is dense and sinks.

f. Routinely, 4 or 5 segments (occasionally as many as 8) are taken.

3. Transbronchial needle aspiration

a. After proper anesthesia and insertion of the flexible bronchoscope, the position to place the needle is determined by review of the relevant bronchial anatomy, together with the relevant radiology (CT scan).

b. The aspiration needle is placed through the channel of the bronchoscope with the bronchoscope straight in the major airways. The distal end of the aspiration needle is extended out of the bronchoscope and remains under direct view.

c. The needle is then extended. If the needle tip is always out of the bronchoscope channel (ie, distal to), there is almost no likelihood of perforating the bronchoscope channel.

d. With the needle tip always under view, the aspiration needle assembly can be withdrawn slightly into the bronchoscope channel. The needle tip is then placed into the mucosa of the airway and pushed through the airway wall. The position of the needle in relation to the mass/nodes to be biopsied can be checked using fluoroscopy at this time.

e. Suction is applied to the needle. If the needle jacket fills with blood, the needle can be withdrawn, washed, and replaced into another site. If there is a good seal (ie, no leak), the needle, under direct bronchoscopic vision, is slowly moved back and forth into the airway wall, never completely removing the needle and breaking the air seal.

f. The needle tip is then retracted into the jacket (this is confirmed visually) and the needle withdrawn from the bronchoscope. If the needle tip does not fully retract, the needle must not be withdrawn through the channel. Under these circumstances, if the needle cannot be withdrawn completely, the bronchoscope is removed from the patient, the needle specimen handled appropriately, and the needle withdrawn through the distal end of the bronchoscope.

g. Air-dried smears are made, and the remainder of the needle sample is washed into a small quantity (1 cc) of physiologic saline.

4. Brush biopsy for distal lung disease

a. Whereas the brush has a good record in diagnosing bronchogenic carcinoma, mediocre to poor results are obtained in diagnosing diseases confined chiefly to the alveoli (alveolar cell carcinoma, pneumocystic carinii pneumonia) or to the lung parenchyma (metastatic carcinoma, lymphoma, fungal infections without cavitations). Lung tissue obtained by transbronchial forceps biopsy (TBB) is required to diagnose any of the parenchymal diseases that are not associated with endobronchial lesions.

b. The biopsy is taken by moving the brush back and forth in short strokes, thus entrapping bronchial tissue between and on the bristles. After each biopsy, the brush is drawn back just to its exit porthole, and the entire bronchoscope is withdrawn. The brush is then advanced from the bronchoscope into a tube of sterile normal saline solution and manually agitated to remove bits of tissue. Removing the brush through the channel of the broncho-fiberscope would result in needless loss of biopsy material. Examination of brush biopsy material requires cytologic approach, utilizing smears, Millipore filters, and cell blocks. Generally, bronchial brush biopsy carries the lowest risk of any pulmonary biopsy technique. The one exception is when biopsying high-risk patients who are prone to bleed.

5. Wash samples

A long procedure may require 2 to 3 new trap reservoirs. It is vital to collect good wash samples (specimens), which means changing the trap reservoir before a biopsy is taken, so the sample collection will not be contaminated with blood. A collected specimen must always be protected from any spillover and should be kept in the specimen tray holder.

6. Wedge technique

Currently, hemorrhage is controlled in all TBB by the wedge method. The procedure consists of securely lodging the tip of the fiberoptic bronchoscope into the selected distal bronchus before, during, and after TBB. Following biopsy, the forceps are withdrawn through the channel and suction is applied, but the fiber optic bronchoscope is left firmly in place to prevent blood from flooding the tracheobronchial tree. If, within 1 minute, no red wall of blood is seen at the top of the bronchoscope, the instrument is withdrawn, and other areas can be chosen for additional biopsies. If hemorrhage occurs, the bronchoscope is kept in the wedge position for 4 or 5 minutes to allow time for a clot to form. It is not unusual for the suction channel to become filled with blood, and occasionally, a clotted-blood cast of the segmental airway is retrieved. Unfortunately, the wedge technique cannot be used to tamponade severe bleeding if the fiber optic bronchoscope already has been removed from the patient. In such a situation, vision is obscured by blood flooding the airway, which precludes reinserting and repositioning the fiber optic instrument. This can be helped by saving the fluoroscopy picture of the bronchoscopic position and then replacing the bronchoscope in this position, using the fluoroscope rather than direct bronchoscopic vision.

VI. POSTOPERATIVE CARE

A. All patients are observed for 2 to 4 hours and/or until gag returns.

B. Patients undergoing transbronchial biopsies do not need a routine chest x-ray post-bronchoscopy.

C. Bronchoscopy staff will be notified of any dyspnea, pain, or hemoptysis. The patient is evaluated promptly for these developments.

D. Many patients develop a postbronchoscopy fever. This usually occurs 6 to 12 hours after the procedure and requires only symptomatic treatment. If fever persists, the patient should be reevaluated.

E. Complications

1. Significant reactions to medications

2. Significant coughing

3. Significant bronchospasm

4. Significant hypoventilation (drug-related)

5. Significant pneumothorax (1 to 3% of transbronchial biopsies)

6. Significant hemorrhage

7. Significant cardiac arrhythmia

8. Myocardial infarction

9. Ruptured lung abscess with flooding of the airways

10. Significant hypoxemia

VII. CPT CODING

A. 31322, Adult flexible bronchoscopy