Standardized Guidelines for Surveillance Bronchoscopy

Introduction

Respiratory physicians commonly perform bronchoscopy for diagnostic and therapeutic purposes, but practices vary globally. Three leading respiratory organizations collaborated to establish national-level guidelines through an expert group. These guidelines offer bronchoscopists a scientifically robust and practical approach, achieved through a thorough review of the evidence, formulating of relevant questions, and critical evaluation the literature. They encompass essential aspects of basic bronchoscopies, such as indications, patient preparation, ICU preparation, sampling techniques, equipment maintenance, and training considerations.

What Is Bronchoscopy?

Since its introduction in 1968, fiber-optic bronchoscopy has been the preferred method for managing tracheobronchial issues and remains essential for monitoring lung transplant recipients. It enables direct visualization of the airways and facilitates diagnostic sampling from the lower respiratory tract. Fiber-optic bronchoscopy is necessary for conducting transbronchial biopsies (TBBs), established since their initial reports, to diagnose suspected acute rejection or infection in lung transplant patients.

Interventional fiber-optic bronchoscopy is increasingly important in addressing post-transplant airway complications. Flexible bronchoscopy is crucial for diagnosis and treatment, with bronchoalveolar lavage (BAL) playing a key role in identifying infections and routine TBB, enabling early detection of acute rejection, and facilitating prompt treatment initiation and follow-up assessments.

What Are the Indications and Contraindications of Bronchoscopy?

Bronchoscopy is crucial in pulmonary medicine and serves various diagnostic and therapeutic purposes. Common indications include suspected infections, malignancies, hemoptysis evaluation, and interstitial lung disease. Therapeutic bronchoscopy often removes retained secretions and foreign bodies, with complication rates below one percent, including laryngospasm, hemorrhage, and pneumothorax. While the literature on contraindications is limited, individual risk-benefit assessments are crucial. Avoid bronchoscopy in conditions like arrhythmia, recent heart events, uremia, bleeding disorders, and uncontrolled hypertension.

Generally, they are well-tolerated and mostly performed outpatiently, but serious adverse events are rare. Complication risks depend on patient characteristics, sedation methods, and sampling techniques. Adverse events include tachycardia, bleeding, bronchospasm, cough, sore throat, desaturation, pneumothorax, and pulmonary edema. Bleeding complications are reported in a few cases. Assessing bleeding volume and hemostasis interventions is crucial for accurate bleeding severity grading.

What Are the Guidelines for Surveillance Bronchoscopy?

The guidelines for surveillance bronchoscopy include:

Setting up a Bronchoscopy Suite:

• Ensure that bronchoscopy is conducted in a dedicated suite or room.

• The suite should have designated areas for patient preparation, procedure performance, and post-procedure monitoring.

• Equip the suite with all the necessary equipment for patient monitoring and resuscitation.

• Provide dedicated spaces for bronchoscope disinfection and equipment storage.

• Ideally, a bronchoscopy should be performed in a room with a negative pressure design.

• Ensure the bronchoscopy room has at least 12 to 15 fresh air exchanges per hour, with airflow directed from the entrance to the outside.

• If air recirculation is necessary, exhaust air should be directed away from patient-care areas, and high-efficiency particulate air (HEPA) filters must be used.

Staff Protection:

• All healthcare personnel in the bronchoscopy suite should wear personal protective equipment (PPE).

• N95 masks are recommended for suspected mycobacterial infections or high-risk droplet infection scenarios.

• Health personnel near the patient during bronchoscopy should ideally wear an eye shield.

• Avoid using needles to remove biopsy specimens from forceps.

• Ensure all staff are vaccinated against hepatitis B and receive annual influenza vaccines.

• Bronchoscopists and nearby health personnel should wear impermeable surgical gowns during the procedure.

• The bronchoscope cleaning and disinfection staff should wear appropriate PPE, including gloves, gowns, masks, and eye shields.

• Preferably, use latex or nitrile, powder-free gloves for disinfecting bronchoscopes.

• Follow hand hygiene practices before and after removing PPR.

• All healthcare workers exposed to disinfectants in the bronchoscopy unit should undergo baseline clinical evaluations.

• If required, ensure periodic clinical assessments and spirometry for all staff engaged in bronchoscope disinfection.

• Conduct bronchoscopy on patients suspected of tuberculosis who cannot produce sputum or when sputum analysis is inconclusive.

Patient Evaluation and Safety Considerations During Flexible Bronchoscopy:

• Routine pre-bronchoscopy hematology evaluation, including coagulation studies, platelet counts, and hemoglobin levels, is not recommended.

• However, coagulation studies, platelet counts, and hemoglobin levels should be performed before bronchoscopy in patients with clinical risk factors for bleeding, such as ongoing anticoagulation, bleeding diathesis, and chronic liver and kidney disease.

• Ensure a platelet count of at least 20,000 per mm for bronchoalveolar lavage (BAL) and at least 50,000 per mm for endobronchial biopsy (EBB) or transbronchial lung biopsy (TBLB).

• BAL can be considered in patients with platelet counts less than 20000 per mm if clinically necessary, after careful risk-benefit analysis, preferably via the oral route in patients with thrombocytopenia.

Antiplatelet and Anticoagulation Agents:

• Discontinue Clopidogrel, Prasugrel, or Ticagrelor at least five days before EBB and TBLB.

• Consult with the appropriate specialist for modifying antiplatelet therapy in patients on dual-antiplatelet agents and at high risk of thrombosis.

• Stop Warfarin five days before transbronchial needle aspiration (TBNA) or bronchoscopy biopsy, ensuring a pre-procedure international normalization ratio (INR) of less than 1.5.

• Discontinue newer oral anticoagulants at least two days before TBNA or bronchoscopic biopsy.

• Perform BAL on patients on therapeutic anticoagulation after careful risk-benefit analysis, preferably via the oral route.

Bronchoscopy in Asthma and COPD (Chronic Obstructive Pulmonary Disease):

• Bronchoscopy is safe for patients with asthma and COPD.

• Optimize asthma treatment before bronchoscopy, especially when bronchoalveolar lavage is planned.

• Ensure COPD treatment optimization before bronchoscopy.

• Avoid routine administration of bronchodilators before bronchoscopy in appropriately controlled asthma or COPD patients.

Antibiotic Prophylaxis and Good Clinical Practice Guidelines:

• Avoid routine prophylactic antibiotics before flexible bronchoscopy to prevent procedure-related infections.

• Provide patients with counseling and written advice on managing post-bronchoscopy fever.

• Fast for at least two hours for clear liquids and four hours for light meals before bronchoscopy.

• Obtain written, informed consent from every patient.

• Inquire about known allergies, comorbidities, and drug history, including anticoagulants or antiplatelets.

• Confirm the fasting duration.

• Obtain and maintain intravenous (IV) access in all patients until discharge.

• Record routine vital signs, including blood pressure (BP), heart rate, oxygen saturation (SPO2), and respiratory rate, for all patients.

Patient Monitoring During and After Bronchoscopy:

• Bronchoscopy should be performed with the patient in the supine position.

• Both nasal and oral routes are suitable for bronchoscopy,

• Use the oral route for larger bronchoscopes, therapeutic procedures like foreign body removal, or patients with thrombocytopenia.

• Provide routine oxygen supplementation for patients at risk of desaturation or low baseline oxygen saturation.

• Monitor continuous or repeated noninvasive blood pressure (BP) during bronchoscopy.

• Perform continuous or repeated electrocardiography (ECG) monitoring during bronchoscopy in patients with known cardiac disease or arrhythmias.

• Monitor patients for symptoms like dyspnea, chest pain, and hemoptysis after bronchoscopy.

• Record vital parameters like heart rate, consciousness, respiratory rate, SpO2, and BP (blood pressure) immediately after bronchoscopy and repeat as needed.

• Keep patients under observation until they regain pre-procedure consciousness and achieve vital parameters.

Conclusion

These bronchoscopy guidelines provide comprehensive recommendations for flexible bronchoscopy's safe and effective performance in various clinical scenarios. These guidelines emphasize patient safety, optimal outcomes, and adherence to best practices, from patient evaluation and preparation to procedural techniques and post-procedure cases. By following these guidelines, healthcare professionals can ensure standardized and high-quality bronchoscopy procedures, ultimately enhancing patient care and improving clinical outcomes.