Bibliographic Source(s)

• American Association for Respiratory Care (AARC). Bronchoscopy assisting--2007 revision & update. Respir Care 2007 Jan;52(1):74-80. [51 references]

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Association for Respiratory Care (AARC). AARC clinical practice guideline. Fiberoptic bronchoscopy assisting. Respir Care 1993 Dec;38(12):1173-8.

Guideline Category

Diagnosis
Evaluation
Management
Treatment

Intended Users

Respiratory Care Practitioners

Guideline Objective(s)

To address the role of the health care professional (HCP) in bronchoscopy assistance (BA)

Target Population

Individuals with inflammatory infectious and malignant diseases of the airway and lungs

Interventions and Practices Considered

Bronchoscopy (fiberoptic or rigid) including

• Indications
• Assessment of need
• Assessment of outcome
• Resources (equipment medications personnel)
• Patient and technical devices monitoring
• Infection control

Major Outcomes Considered

• Patient outcome as determined by clinical physiologic and pathologic assessment
• Procedural outcome as determined by the accomplishment of the procedural goals and by quality assessment indicators
• Hazards and complications

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

Not stated

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Not stated

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review

Description of Method of Guideline Validation

This guideline was approved by the 2006 Clinical Practice Guideline (CPG) Steering Committee

Major Recommendations

Indications

Indications include but are not limited to:

• The presence of lesions of unknown etiology on the chest radiograph film or the need to evaluate recurrent pneumonia persistent atelectasis or pulmonary infiltrates (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992; Prakash Offord & Stubbs 1991; Landa 1978; Green 1991; Zawadzka-Glos et al. 2003; Jain et al. 2004)
• The need to assess patency or mechanical properties of the upper airway (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992; Landa 1978; Zawadzka-Glos al. 2003)
• The need to investigate hemoptysis persistent unexplained cough dyspnea localized wheeze or stridor (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992; Prakash Offord & Stubbs 1991; Landa 1978; Green 1991; Zawadzka-Glos al. 2003; Selecky 1978)
• Suspicious or positive sputum cytology results (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992; Prakash Offord & Stubbs 1991; Landa 1978)
• The need to obtain lower respiratory tract secretions cell washings and biopsies for cytologic histologic and microbiologic evaluation (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992; Green 1991; Jain et al. 2004; Holgate Wilson & Howarth 1992; "Summary and recommendations" 1985)
• The need to determine the location and extent of injury from toxic inhalation or aspiration; (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992; Landa 1978)
• The need to evaluate problems associated with endotracheal or tracheostomy tubes (tracheal damage airway obstruction or tube placement) (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992; Prakash Offord & Stubbs 1991; Landa 1978; Green 1991)
• The need for aid in performing difficult intubations or percutaneous tracheostomies (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992; Landa 1978; Green 1991)
• The suspicion that secretions or mucus plugs are responsible for lobar or segmental atelectasis (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992; Landa 1978)
• The need to remove abnormal endobronchial tissue or foreign material by forceps basket or laser (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003)
• The need to retrieve a foreign body (although under most circumstances rigid bronchoscopy is preferred) (Landa 1978; Green 1991; Cunanan 1978)
• Therapeutic management of endobronchial toilet in ventilator associated pneumonia (Bush 2003)
• Achieving selective intubation of a main stem bronchus (Bush 2003)
• The need to place and/or assess airway stent function (Bush 2003)
• The need for airway balloon dilatation in treatment of tracheobronchial stenosis (Hautmann et al. 2001; Mayse et al. 2004)

Contraindications

Flexible bronchoscopy should be performed only when the relative benefits outweigh the risks.

• Absolute contraindications include:
  1. Absence of consent from the patient or his/her representative unless a medical emergency exists and patient is not competent to give permission (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003)
  2. Absence of an experienced bronchoscopist to perform or closely and directly supervise the procedure (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992)
  3. Lack of adequate facilities and personnel to care for such emergencies as cardiopulmonary arrest pneumothorax or bleeding (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992)
  4. Inability to adequately oxygenate the patient during the procedure (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003)
• The danger of a serious complication from bronchoscopy is especially high in patients with the disorders listed and these conditions are usually considered absolute contraindications unless the risk-benefit assessment warrants the procedure (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992)
  1. Coagulopathy or bleeding diathesis that cannot be corrected (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992)
  2. Severe refractory hypoxemia (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992)
  3. Unstable hemodynamic status including dysrhythmias (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992)
• Relative contraindications (or conditions involving increased risk) according to the American Thoracic Society Guidelines for Fiberoptic Bronchoscopy in adults (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003) include:
  1. Lack of patient cooperation
  2. Recent (within 6 weeks) myocardial infarction or unstable angina (British Thoracic Society Bronchoscopy Guidelines Committee 2001)
  3. Partial tracheal obstruction
  4. Moderate-to-severe hypoxemia or any degree of hypercarbia
  5. Uremia and pulmonary hypertension (possible serious hemorrhage after biopsy)
  6. Lung abscess (danger of flooding the airway with purulent material)
  7. Obstruction of the superior vena cava (possibility of bleeding and laryngeal edema)
  8. Debility and malnutrition
  9. Disorders requiring laser therapy biopsy of lesions obstructing large airways or multiple transbronchial lung biopsies
  10. Known or suspected pregnancy (safety concern of possible radiation exposure
• The safety of bronchoscopic procedures in asthmatic patients is a concern but the presence of asthma does not preclude the use of these procedures (Holgate Wilson & Howarth 1992; Smith & Deshazo 1993)
• Recent head injury patients susceptible to increased intracranial pressures (Kerwin et al. 2000)
• Inability to sedate (including time constraints of oral ingestion of solids or liquids) (British Thoracic Society Bronchoscopy Guidelines Committee 2001)

Hazards/Complications

Refer to the Potential Harms field for information on hazards and complications of bronchoscopy.

Limitations/Validation of Results

• Bronchoscopy should not be performed in patients who have a contraindication (listed in "Contraindications" section) unless the potential benefit outweighs the risk as determined by the physician bronchoscopist.
• Poor or inadequate training of the bronchoscopy assistant or bronchoscopist in:
  1. The techniques of premedication for bronchoscopic examination
  2. Function and preparation of bronchoscope and related equipment
  3. Physical and physiologic monitoring during the procedure
  4. Specimen retrieval (biopsies and washings) preparation of specimens and site documentation
  5. Post-procedure care of the patient

Assessment of Need

Need is determined by bronchoscopist assessment of the patient and treatment plan in addition to the presence of clinical indicators and by the absence of contraindications. (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992)

Assessment of Outcome

Patient outcome is determined by clinical physiologic and pathologic assessment. Procedural outcome is determined by the accomplishment of the procedural goals as indicated in the "Indications" section and by quality assessment indicators listed in the "Monitoring" section.

Resources

• Equipment
  1. Bronchoscopic devices
     1. The appropriate bronchoscope size is determined by the bronchoscopist based on the patient age (Green 1991); this includes selecting appropriate suction and biopsy valves
     2. Bronchoscopic light source and any related video or photographic equipment if applicable
     3. Cytology brushes flexible forceps transbronchial aspiration needles retrieval baskets (Compatibility of the external diameter of all scope accessories with the internal diameter of the bronchoscope should be verified before the procedure.)
     4. Specimen-collection devices fixatives and as determined by institutional policies
     5. Syringes for medication delivery normal saline lavage and needle aspiration
     6. Bite block
     7. Laryngoscope
     8. Endotracheal tubes in various sizes
     9. Thoracostomy set/tray
     10. Venous access equipment (I.V. supplies)
     11. Laryngeal mask airway (Yazbeck-Karam Aouad & Baraka 2003)
     12. Adaptor with ability to connect mechanical ventilator and bronchoscope simultaneously
     13. Sterile gauze for intermittently clearing tip of bronchoscope during procedure
     14. Appropriate procedure documentation paperwork including laboratory requisitions
     15. Water-soluble lubricant or lubricating jelly
  2. Monitoring devices
     1. Pulse oximeter
     2. Electrocardiographic monitoring equipment
     3. Sphygmomanometer
     4. Whole-body radiation badge for personnel if fluoroscopy is used
     5. Capnograph
  3. Procedure room equipment
     1. Oxygen and related delivery equipment
     2. Resuscitation equipment
     3. Medical vacuum systems (wall or portable) and related suction supplies for scope or mouth
     4. Infection control devices (see "Infection Control" section)
     5. Fluoroscopy equipment including personal protection devices if warranted
     6. Laser equipment if applicable
     7. Adequate ventilation and other measures to prevent transmission of tuberculosis (Dooley et al. 1990)
  4. Decontamination area equipment
     1. Protease enzymatic agent (e.g. Protozyme) for cleaning and removal of blood and protein before disinfection or sterilization or other detergent capable of removing these substances (Culver Gordon & Mehta 2003)
     2. High-level disinfection or sterilization agent: 2% alkaline glutaraldehyde (e.g. Cidex Metracide Sonacide Glutarex) ethylene oxide or peracetic acid (Prakash 1993)
     3. Sterile water is preferred if feasible for rinsing bronchoscopes. Following this rinsing with isopropyl alcohol (Tablan et al. 2004)

• Medications:

  Institutional policies and personal preferences of the bronchoscopist vary greatly regarding the type and method of premedication for bronchoscopic examination. Administration of these medications by intravenous or intramuscular routes is limited to nurses physicians or other trained personnel. (The training and certification of "other personnel" is institution specific should be consistent with institutional policies and may include the respiratory therapist.) Aerosolized or atomized drugs or drugs instilled through the bronchoscope may be delivered by the respiratory therapist or other trained assistants.

  1. Topical anesthetic (lidocaine 1% 2% 4% benzocaine 14%) (Prakash Offord & Stubbs 1991; Green 1991; Prakash & Stubbs 1991; Kirkpatrick 1989)
  2. Anticholinergic agent to reduce secretions and minimize vaso-vagal reflexes (atropine glycopyrrolate) (Prakash Offord & Stubbs 1991; Prakash & Stubbs 1991)
  3. Sedative agent 30-45 min prior to the procedure (e.g. codeine midazolam morphine hydroxyzine) (Prakash Offord & Stubbs 1991; Prakash & Stubbs 1991)
  4. Intravenous sedative immediately prior to and/or during the procedure (midazolam propofol diazepam fentanyl) (Prakash Offord & Stubbs 1991; Landa 1978; Prakash & Stubbs 1991; Pickles et al. 2003; Chhajed & Glanville 2003)
  5. Benzodiazepine antagonist (flumazenil) (Green et al. 1992) narcotic antagonist (Narcan) (Pickles et al. 2003)
  6. Sterile nonbacteriostatic 0.9% NaCl solution for bronchial washings or lavage (Schnapf 1991)
  7. Vasoconstrictor for bleeding control (dilute epinephrine usually 1:10000) (Zavala 1976; Hanson et al. 1976)
  8. Inhaled beta agonist (albuterol metaproterenol levalbuterol) (Kirkpatrick 1989)
  9. Water-soluble lubricant or combined lubricant/anesthetic (viscous lidocaine) (Green 1991; Mehta et al. 1990; Prakash & Stubbs 1991)
  10. Nasal decongestants (pseudoephedrine) (Ernst Silvestri & Johnstone 2003)
  11. Mucolytics or mucokininetics (10% or 20% acetylcysteine 75% sodium bicarbonate rhDNAse) (Durwand Forte & Shemie 2000)
  12. Emergency and resuscitation drugs as deemed appropriate by institutional policies

• Personnel:

  The precise role of the bronchoscopy assistant varies among institutions (Green et al. 1992; Prakash Offord & Stubbs 1991; Green 1991; American Academy of Pediatrics [AAP] 1992); however the prime responsibilities include preparation and monitoring of the patient assisting with the procedure handling specimens post-procedure care of the patient maintenance of the bronchoscopy equipment and recordkeeping.

  1. Bronchoscopy assisting should occur only under the direction of a physician who has been trained in bronchoscopy according to the Guidelines endorsed by the American Thoracic Society (Bolliger et al. 2002; Ernst Silvestri & Johnstone 2003; Green et al. 1992)
  2. Bronchoscopy assisting should be limited to personnel who possess the skills necessary to determine adverse reactions and to undertake the appropriate remedial action.
  3. The bronchoscopy assistant must be trained in the setup handling cleaning and care of bronchoscopy equipment and related supplies; specimen retrieval and preparation for commonly ordered laboratory studies on bronchoscopy specimens; biopsy labeling; delivery of aerosolized drugs; and mechanical ventilation. The assistant must also be trained in monitoring and evaluating the patient's clinical condition as reflected by pulse oximetry capnography electrocardiogram and stability of or changes in mechanical ventilation parameters and be capable of relating changes in clinical condition to disease state procedure or drugs administered for the procedure. Assistants should be versed in the Centers for Disease Control and Prevention (CDC) ventilation requirements for control of tuberculosis transmission. Bronchoscopy assistants should hold one of the following credentials: Certified Respiratory Therapist (CRT) Registered Respiratory Therapist (RRT) Certified Pulmonary Function Technologist (CPFT) Registered Pulmonary Function Technologist (RPFT) Registered Nurse (RN) Licensed Practical Nurse (LPN) physician (MD or DO) or Certified Surgical Technologist (CST).

Monitoring

Patient monitoring should be done before at regular intervals during and after bronchoscopy until the patient meets appropriate discharge criteria. For no or minimal sedation less monitoring is necessary. For moderate and deep sedation more monitoring should be done (American Society of Anesthesiologists 2002). The following should be monitored before during and/or after bronchoscopy continuously until the patient returns to his pre-sedation level of consciousness.

• Patient
  1. Level of consciousness (AAP 1992)
  2. Medications administered dosage route and time of delivery (AAP 1992)
  3. Subjective response to procedure (e.g. pain discomfort dyspnea) (AAP 1992)
  4. Blood pressure breath sounds heart rate rhythm and changes in cardiac status
  5. Pulse oximetry (SpO₂ fraction of inspired oxygen (FI_O2) and end tidal carbon dioxide (ETCO₂) (British Thoracic Society Bronchoscopy Guidelines Committee 2001; AAP 1992; American Association for Respiratory Care [AARC] 1991)
  6. Tidal volume peak inspiratory pressure adequacy of inspiratory flow and other ventilation parameters if subject is being mechanically ventilated
  7. Lavage volumes (delivered and retrieved)
  8. Monitor and document site of biopsies and washings. Record which lab tests were requested on each sample
  9. Periodic post-procedure follow-up monitoring of patient condition is advisable for 24-48 hours for inpatients. Outpatients should be instructed to contact the bronchoscopist regarding fever chest pain or discomfort dyspnea wheezing hemoptysis or any new findings presenting after the procedure has been completed. Oral instructions should be reinforced by written instructions that include names and phone numbers of persons to be contacted in emergency.
  10. Chest radiograph one hour after transbronchial biopsy to exclude pneumothorax (Zavala 1976)

• Technical Devices
  1. Bronchoscope integrity (fiberoptic or channel damage passage of leak test) (Mehta et al. 1990)
  2. Strict adherence to the manufacturer's and institutional recommended procedures for cleaning disinfection and sterilization of the devices and the integrity of disinfection or sterilization packaging (Culver Gordon & Mehta 2003; Mehta et al. 1990)
  3. Smooth unhampered operation of biopsy devices (forceps needles brushes)

• Record keeping
  1. Quality assessment indicators as determined appropriate by the institution's quality assessment committee
  2. Documentation of monitors indicated in "Patient" and "Technical Devices" sections
  3. Identification of bronchoscope used for each patient
  4. Annual assessment of the institutional or departmental bronchoscopy procedure including an evaluation of quality assurance issues
     • Adequacy of bronchoscopic specimens (size or volume for accurate analysis sample integrity)
     • Review of infection control procedures and compliance with the current guidelines for semicritical patient-care objects (Dooley et al. 1990; Culver Gordon & Mehta 2003)
     • Synopsis of complications
     • Control washings to assure that infection control and disinfection/sterilization procedures are adequate and that cross-contamination of specimens does not occur
     • Annual review of the bronchoscopy service and all of the above listed records with the physician bronchoscopists

Frequency

The frequency with which bronchoscopy is repeated on a given patient should be determined by the physician bronchoscopist based on indications.

Infection Control

• Standard Precautions (Bolyard et al. 1998)
• CDC Guideline for Handwashing and Hospital Environmental Control-Section 2: Cleaning disinfecting and sterilizing patient care equipment (Tablan et al. 2004; Boyce & Pittet 2002; Sehulster & Chinn 2003)
• CDC Guideline for preventing tuberculosis transmission (Dooley et al. 1990)
• Hepatitis B vaccination for personnel
• Establishment of and conformance to written protocol for infection control

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• AARC (American Association for Respiratory Care) clinical practice guideline. Pulse oximetry. Respir Care 1991 Dec;36(12):1406-9. PubMed



• American Academy of Pediatrics (AAP). Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992 Jun;89(6 Pt 1):1110-5. [44 references] PubMed



• American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002 Apr;96(4):1004-17. [2 references] PubMed



• Bolliger CT Mathur PN Beamis JF Becker HD Cavaliere S Colt H Diaz-Jimenez JP Dumon JF Edell E Kovitz KL Macha HN Mehta AC Marel M Noppen M Strausz J Sutedja TG European Respiratory Society/American Thoracic Society. ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society. Eur Respir J 2002 Feb;19(2):356-73. PubMed



• Bolyard EA Tablan OC Williams WW Pearson ML Shapiro CN Deitchmann SD. Guideline for infection control in healthcare personnel 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1998 Jun;19(6):407-63. PubMed



• Boyce JM Pittet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations . MMWR Recomm Rep 2002 Oct 25;51(RR-16):1-45 quiz CE1-4. PubMed



• British Thoracic Society Bronchoscopy Guidelines Committee a Subcommittee. British Thoracic Society guidelines on diagnostic flexible bronchoscopy. Thorax 2001 Mar;56 Suppl 1:i1-21. PubMed



• Bush A. Bronchoscopy in paediatric intensive care. Paediatr Respir Rev 2003 Mar;4(1):67-73. [37 references] PubMed



• Chhajed PN Glanville AR. Management of hypoxemia during flexible bronchoscopy. Clin Chest Med 2003 Sep;24(3):511-6. [37 references] PubMed



• Culver DA Gordon SM Mehta AC. Infection control in the bronchoscopy suite: a review of outbreaks and guidelines for prevention. Am J Respir Crit Care Med 2003 Apr 15;167(8):1050-6. [50 references] PubMed



• Cunanan OS. The flexible fiberoptic bronchoscope in foreign body removal. Experience in 300 cases. Chest 1978 May;73(5 Suppl):725-6. PubMed



• Dooley SW Jr Castro KG Hutton MD Mullan RJ Polder JA Snider DE Jr. Guidelines for preventing the transmission of tuberculosis in health-care settings with special focus on HIV-related issues. MMWR Recomm Rep 1990 Dec 7;39(RR-17):1-29. PubMed



• Durward A Forte V Shemie SD. Resolution of mucus plugging and atelectasis after intratracheal rhDNase therapy in a mechanically ventilated child with refractory status asthmaticus. Crit Care Med 2000 Feb;28(2):560-2. PubMed



• Ernst A Silvestri GA Johnstone D American College of Chest Physicians. Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians. Chest 2003 May;123(5):1693-717. PubMed



• Green CG Eisenberg J Leong A Nathanson I Schnapf BM Wood RE. Flexible endoscopy of the pediatric airway. Am Rev Respir Dis 1992 Jan;145(1):233-5. PubMed



• Green CG. Assessment of the pediatric airway by flexible bronchoscopy. Respir Care 1991;36(6):555-68.



• Hanson RR Zavala DC Rhodes ML Keim LW Smith JD. Transbronchial biopsy via flexible fiberoptic bronchoscope; results in 164 patients. Am Rev Respir Dis 1976 Jul;114(1):67-72. PubMed



• Hautmann H Gamarra F Pfeifer KJ Huber RM. Fiberoptic bronchoscopic balloon dilatation in malignant tracheobronchial disease: indications and results. Chest 2001 Jul;120(1):43-9. PubMed



• Holgate ST Wilson JR Howarth PH. New insights into airway inflammation by endobronchial biopsy. Am Rev Respir Dis 1992 Feb;145(2 Pt 2):S2-6. [41 references] PubMed



• Jain P Sandur S Meli Y Arroliga AC Stoller JK Mehta AC. Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates. Chest 2004 Feb;125(2):712-22. PubMed



• Kerwin AJ Croce MA Timmons SD Maxwell RA Malhotra AK Fabian TC. Effects of fiberoptic bronchoscopy on intracranial pressure in patients with brain injury: a prospective clinical study. J Trauma 2000 May;48(5):878-82; discussion 882-3. PubMed



• Kirkpatrick MB. Lidocaine topical anesthesia for flexible bronchoscopy. Chest 1989 Nov;96(5):965-7. PubMed



• Landa JF. Indications for bronchoscopy. Chest 1978 May;73(5 Suppl):686-90. PubMed



• Mayse ML Greenheck J Friedman M Kovitz KL. Successful bronchoscopic balloon dilation of nonmalignant tracheobronchial obstruction without fluoroscopy. Chest 2004 Aug;126(2):634-7. PubMed



• Mehta AC Curtis PS Scalzitti ML Meeker DP. The high price of bronchoscopy. Maintenance and repair of the flexible fiberoptic bronchoscope. Chest 1990 Aug;98(2):448-54. PubMed



• Pickles J Jeffrey M Datta A Jeffrey AA. Is preparation for bronchoscopy optimal. Eur Respir J 2003 Aug;22(2):203-6. PubMed



• Prakash UB Offord KP Stubbs SE. Bronchoscopy in North America: the ACCP survey. Chest 1991 Dec;100(6):1668-75. PubMed



• Prakash UB Stubbs SE. The bronchoscopy survey. Some reflections. Chest 1991 Dec;100(6):1660-7. [128 references] PubMed



• Prakash UB. Does the bronchoscope propagate infection. Chest 1993 Aug;104(2):552-9. PubMed



• Schnapf BM. Oxygen desaturation during fiberoptic bronchoscopy in pediatric patients. Chest 1991 Mar;99(3):591-4. PubMed



• Sehulster L Chinn RY. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) [Published errata appear in MMWR Recomm Rep 2003 Oct 24;52(42):1025-6]. MMWR Recomm Rep 2003 Jun 6;52(RR-10):1-42. [419 references] PubMed



• Selecky PA. Evaluation of hemoptysis through the bronchoscope. Chest 1978 May;73(5 Suppl):741-5. PubMed



• Smith DL Deshazo RD. Bronchoalveolar lavage in asthma. An update and perspective. Am Rev Respir Dis 1993 Aug;148(2):523-32. [112 references] PubMed



• Summary and recommendations of a workshop on the investigative use of fiberoptic bronchoscopy and bronchoalveolar lavage in asthmatic patients. Chest 1985 Jul;88(1):136-8. PubMed



• Tablan OC Anderson LJ Besser R Bridges C Hajjeh R. Guidelines for preventing health-care--associated pneumonia 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36. [433 references] PubMed



• Yazbeck-Karam VG Aouad MT Baraka AS. Laryngeal mask airway for ventilation during diagnostic and interventional fibreoptic bronchoscopy in children. Paediatr Anaesth 2003 Oct;13(8):691-4. PubMed



• Zavala DC. Pulmonary hemorrhage in fiberoptic transbronchial biopsy. Chest 1976 Nov;70(5):584-8. PubMed



• Zawadzka-Glos L Chmielik M Gabryszewska A Zajac B. Analysis of indications for bronchoscopy in the department of paediatric otolaryngology in Warsaw from 1998-2003. N Med 2003;6(2):4-11.

Type of Evidence supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

The guideline is developed from a thorough review of the literature surveys of current practice and the expertise of the members of the Working Group.

Potential Benefits

Appropriate bronchoscopy assistance by health care professionals

Potential Harms

• Adverse effects of medication used before and during the bronchoscopic procedure
• Hypoxemia
• Hypercarbia
• Bronchospasm
• Hypotension
• Laryngospasm bradycardia or other vagally mediated phenomena
• Mechanical complications such as epistaxis pneumothorax and hemoptysis
• Increased airway resistance
• Death
• Infection hazard for health-care workers or other patients
• Cross-contamination of specimens or bronchoscopes
• Nausea vomiting
• Fever and chills
• Cardiac dysrhythmias

Contraindications

• Absolute contraindications to bronchoscopy include:
  1. Absence of consent from the patient or his/her representative unless a medical emergency exists and patient is not competent to give permission
  2. Absence of an experienced bronchoscopist to perform or closely and directly supervise the procedure
  3. Lack of adequate facilities and personnel to care for such emergencies as cardiopulmonary arrest pneumothorax or bleeding
  4. Inability to adequately oxygenate the patient during the procedure
  5. Coagulopathy or bleeding diathesis that cannot be corrected
  6. Severe refractory hypoxemia
  7. Unstable hemodynamic status including dysrhythmias

• Relative contraindications include
  1. Lack of patient cooperation
  2. Recent (within 6 weeks) myocardial infarction or unstable angina
  3. Partial tracheal obstruction
  4. Moderate-to-severe hypoxemia or any degree of hypercarbia
  5. Uremia and pulmonary hypertension (possible serious hemorrhage after biopsy)
  6. Lung abscess (danger of flooding the airway with purulent material)
  7. Obstruction of the superior vena cava (possibility of bleeding and laryngeal edema)
  8. Debility and malnutrition
  9. Disorders requiring laser therapy biopsy of lesions obstructing large airways or multiple transbronchial lung biopsies
  10. Known or suspected pregnancy (safety concern of possible radiation exposure)
  11. Recent head injury
  12. Inability to sedate

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Safety

Bibliographic Source(s)

• American Association for Respiratory Care (AARC). Bronchoscopy assisting--2007 revision & update. Respir Care 2007 Jan;52(1):74-80. [51 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American Association for Respiratory Care (AARC)

Guideline Committee

Not stated

Composition of Group that Authored the Guideline

Revised by Shelly Clifton RRT CPFT University of Michigan Hospitals Ann Arbor Michigan

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Association for Respiratory Care (AARC). AARC clinical practice guideline. Fiberoptic bronchoscopy assisting. Respir Care 1993 Dec;38(12):1173-8.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American Association for Respiratory Care (AARC) Web site.

Print copies: Available from the American Association for Respiratory Care (AARC) CPG Desk 11030 Ables Ln Dallas TX 75229-4593; Web site: www.aarc.org.

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

This summary was completed by ECRI on November 30 1998. The information was verified by the guideline developer on December 15 1998. This NGC summary was updated by ECRI Institute on June 11 2007. This summary was updated by ECRI Institute on March 10 2009 following the U.S. Food and Drug Administration advisory on Topical Anesthetics.

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