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Policies,Clinical,UWHC Clinical,Department Specific,Respiratory Care Services,Special Procedures

Bronchoscopy (3.57)

Bronchoscopy (3.57) - Policies, Clinical, UWHC Clinical, Department Specific, Respiratory Care Services, Special Procedures

3.57





3.57 Bronchoscopy
Category: UWHC Patient Care Policy
Effective Date: March 1, 2016
Version: Revision
Manual: Respiratory Care Services
Section: Special Procedures

I. PURPOSE
To provide a fiberoptic bronchoscope connected to an appropriate light source allowing for illumination
and visualization of the upper and lower airways of the respiratory system in an invasive procedure. The
procedure allows for the collection of specimens from the tracheobronchial tree for diagnostic analysis.

II. CONTRAINDICATIONS
A. Coagulopathy which cannot be corrected or INR less than 1.5 and platelets less than 50,000.
B. Ingestion of food within 8 hours of bronchoscope
C. Significant dysrhythmias and hemodynamic instability

III. POLICY
A. Respiratory Therapy Assistant (RTA) Respiratory Therapist (RT), Registered Nurse (RN), and
Attending Physician must be present for all bronchoscopy procedures.
B. Universal precautions must be followed throughout all bronchoscopy procedures including
gloves, gown, goggles and hospital approved particulate respirators masks.
C. Emergency airway management equipment and manual resuscitation equipment must be set up
and immediately available at the bedside. Confirm ventilated patient is on 100% oxygen therapy
and non-ventilated patients are on a minimum of 2 liter nasal cannula or oxymask.
D. Patients must be monitored throughout bronchoscopy procedures with a pulse oximeter.
Desaturations below 89% on the pulse oximeter during the bronchoscopy should be treated with
an increase in the FiO2 delivery.
E. Cardiopulmonary instability as manifested by a change in heart rate, rhythm, or blood pressure
should be reported to the MD and RN if noted. Efforts to medicate the patient in cases of vagal
irritation may be indicated.

IV. EQUIPMENT
Bronch Cart will include:
1. One Selection of an appropriate bronchoscope
2. Two In line Leukens traps CS # 1220130
3. Six 60 ml slip-tip syringes
4. Ten 20 ml slip-tip syringes
5. One White Cap Tip for Syringe CS # 1203048
6. Four Mini–Spike Dispensing Pin 412012
7. Four Max Guard extension set ME 1055, CS # 9996035
8. Four BD Insyte Autoguard 381454, CS # 1204003
9. Two 500 ml bottles of 0.9% NaCl (sodium chloride) solution
10. One Buffered 10% Formalin Container
11. One Silicone Spray Bottle
12. Two Blue Bite Block
13. Two Green Bite Block, CS # 1209133
14. One Box of 4x4 gauze pads
15. Ten Cotton Tips
16. Four 10-French Oxygen Catheter 16 inches long, CS # 1203224
17. Four Goggles
18. Two Blue Bowls CS #1202362
19. Four Bronchoscope Portex blue swivel adapter (for intubated patients)





20. One Biopsy forceps each of FG-20P, FG -32C-1, FG-26C-1
21. Two sterile specimen containers CS # 1203495
22. One CV190 Video System, CLV Light Source, MAJ 1925 Memory Stick
23. Four First Step Pre Clean Kits
24. Ten Germicidal Disposable Wipe Pads
25. Ten MAJ 209 Suction Valves
26. Ten MAJ 210 Biopsy Valves
27. Five MAD 700 Laryngo-Tracheal Atomization Devices

II. Procedure
A. Ensure that suction setups are operational. Make sure there is a Yankauer and suction catheters at
the bedside.
B. Determine type of bronchoscope for procedure by referencing chart titled Bronchoscope Sizing
Chart located on Bronch Cart. There must be at least 1.5 mm space left between the scope and
the tube in order to maintain proper oxygenation.

CAUTION! THE POWER SWITCH OF BOTH THE LIGHT SOURCE AND THE VIDEO
SYSTEM CENTER MUST BE 'OFF' WHILE ATTACHING OR REMOVING INTERFACE
CABLES. THE CABLES OR BRONCHOSCOPES MAY BE DESTROYED IF THE POWER
SWITCH IS ON.
C. To attach the bronchoscope to the Light Source CLV190. Align the dot on the light source
with the white dot on the bronchoscope head.
D. Plug in main power cord located at the rear of the cart.
E. Turn on Light Source and CV 190 Video System
F. Confirm that scope is White Balanced to the light source. If you need to use a loaner scope or
one from another cart you may need to White Balance the scope.
1. If screen at lower left corner states scope is not White Balanced, then follow steps 2 and 3
below.
2. Insert scope tip into White Balance Cap located on side of processor.
3. Push White Balance button on light source until screen states White Balanced
Complete.
G. Apply a medical grad water soluble lubricant to bronchoscope section to be inserted.
H. Universal precautions must be followed throughout all bronchoscope procedures including
gloves, gown, goggles and hospital approved particulate respirators masks.
I. Emergency airway management equipment and manual resuscitation equipment must be set up
and immediately available at bedside for all ventilated patients.
J. Assist with attachment of the suction tubing to the bronchoscope.
K. If required, ensure that all persons in the room are wearing lead aprons.
L. Air button should be set at medium and Brightness level at middle range. To rest all settings to
factory settings press Reset button on light source keyboard and then wait 5 minutes. Pressing
Menu button two times on keyboard will show you specifications of scope that is installed.
M. Do not enter patients name and ID on Video System Center.
N. If screen comes up stating “Call Olympus” or no image appears. You will need to do the
following.
1. Do not call Olympus but confirm that scope is pushed all the way into the light source.
Image will appear if scope was not pushed in all the way.
2. Turn off video system center and light source.
3. Remove bronchoscope from light source and clean copper tabs on scope with alcohol
wipe. Let dry for 15 seconds before reinstalling scope.
4. Turn video system center and light source back on.
O. RT to enter Patient and Bronchoscope Information into Health Link and manage airway






for all inpatients. Bronchoscope charting will be done in the RT Bronch flowsheet.
P. Taking Photographs
1. Photographs can be taken by physician directly from the head of the bronchoscope or
through the video system center.
2. Remote switches on bronchoscopy will have the following functions
Button 1 – Freeze
Button 2 – Band Image
Button 3 – Magnification
Button 4 – Capture
3. Button 4 will capture picture to memory stick MAJ 1925 with date and time.
4. Capture picture can be emailed to MD’s UW email address. Picture cannot have
patient’s name or MR number.
The process to place photos in Health Link are still being defined by Enterprise Imaging
(Lexmark MDR Image Capture device)
NOTE: Have Clinical Engineering replace lamp when Lamp Usage Indicator reaches 500 hours
on Light Source.

Q. Performing Bronchoscopy for non-ventilated patients.
1. Confirm with RN that Xylocaine and lidocaine orders are entered.
2. Prepare two cotton tips coated with xylocaine jelly. MD will insert cotton tips in nare for a
period of 5 minutes before inserting oxygen catheter by MD.
3. Confirm that patient is on oxygen via oxygen catheter or OxyMask.
4. Select bronchoscopy by referencing Bronchoscopy Sizing Chart and attach scope to video
system center before turning on.
5. Select bronchoscopy and attach to video system center before turning on. Reference
paragraphs A, B, C, D, and E above for assembly process.
6. Coat bronchoscopy tip with 2% Xylocaine jelly or silicone spray per MD’s preference.
7. Assemble five to ten 20 ml syringes with 2 ml of 1% lidocaine in each syringe. Use Mini –
Spike Dispensing Pin, number 412012 to fill syringes. Each syringe should be labeled 1%
lidocaine.
8. Assemble Max Guard extension set ME 1055 and modified BD Insyte Autoguard to scope
and lidocaine filled syringes if MD requests extension set. Syringes can be attached directly
to the black biopsy valve.
9. Direction of administering lidocaine and epinephrine will be provided by MD.
10. Three to four 60 ml syringes filled with 40 ml of 0.9% NaCl normal saline will be instilled to
achieve a sample size directed by MD. Each syringe should be labeled .9% Sodium Chloride.
11. Assist with photography.
12. Assist with the collection of biopsy specimens by operating the fluoroscopy unit as directed
by the bronchoscopist.
13. Perform oral suctioning as needed to maintain a patent airway and prevent aspiration.

R. Performing the Bronchoscopy Procedure on a ventilated patient
1. Confirm with RN that Xylocaine and lidocaine orders are entered.
2. Confirm patient is on 100% oxygen therapy and position the patient flat with pillow removed
if directed by MD.
3. Review Bronchoscopy Sizing Chart to confirm that the correct size scope is used with
endotracheal tube.
4. Select bronchoscopy and attach to video system center before turning on.
5. Select bronchoscopy and attach to video system center before turning on. Reference
paragraphs A, B, C, D, and E above for assembly process.
6. Insert a bronchoscope blue adapter and in line specimen container to the ventilator circuit.
7. If directed by MD. Assemble 20 ml syringes with 2 ml of 1% lidocaine in each syringe. Use
Mini –Spike Dispensing Pin, number 412012 to fill syringes. Each syringe should be labeled





1% lidocaine.
8. Assemble Max Guard extension set ME 1055 and modified BD Insyte Autoguard to scope
and lidocaine filled syringes
9. Assist with the instillation of lidocaine and normal saline and the collection of specimens as
requested by MD.
10. Three to four 60 ml syringes filled with 40 ml of normal saline will be instilled to achieve a
sample size directed by MD. Each syringe should be labeled .9% Sodium Chloride.
11. Assist photography.
12. Assist with the collection of biopsy specimens by operating the fluoroscopy unit as directed
by the MD.
13. RT to perform oral suctioning as needed to maintain a patent airway and prevent aspiration.

S. Performing the Bronchoscopy Procedure for Research.
1. Research Bronchoscopies will be perform in room K4/965
2. Use BF –H190 for all procedures
2. Attach Suction Valve and Biopsy Valve
3. Do not apply a medical grade water soluble lubricant to bronchoscope section to be inserted.
4. MD and RN will be responsible for all other duties involved in the Research Bronchoscopy
Procedure

T. Performing Bronchoscopy for Biopsy
1. Follow all steps for non-ventilated or ventilated patients outlined above.
2. Obtain MD requested biopsy forceps, formalin solution 10% biopsy sample container, and
.9% sodium chloride saline for rinse.
3. RTA will control the open and close function of the forceps. Forceps must always be closed
when being introduced in the instrument channel or being withdrawn.
4. RTA will operate the forceps per MD’s direction.
5. Samples will be placed in 10% formalin solution container and then rinse forceps with
normal saline before gathering another sample.
6. Sample will be labeled, placed in bag with printed order and then sent to lab by RT or RN.

III. Post Procedure Performed by RTA
IMPORTANT: Prior to cleaning the bronchoscope, the Reprocessing Center will attach
the water-resistant cap to the bronchoscope. Do not immerse the bronchoscope unless the water-
resistant cap is attached to the bronchoscope.
Failure to comply with these instructions may result in permanent damage to the bronchoscope.
Do not inappropriately bend or hyperflex the bronchoscope at any time as this may cause
extensive damage and contribute to costly repairs.

A. Decontamination procedure for Bronchoscope:
1. Immediately following the use of the bronchoscope, insert the tip of the bronchoscope
into the First Step Endoscopic Pre-Clean Kit solution mixed with water and apply suction
for 10 to 15 seconds. Then run air suction for 15 seconds and wipe outer portion of scope
with cleaning pad included with kit.
2. Write bronchoscope ID number on patient label and attach to bronchoscopy for
processing.
3. Place scope with patient label in plastic bag The Central Services Reprocessing Request
form will be left at the reprocessing drop off container. All other equipment to be
reprocessed should be rinsed and sent to CS in a separate bag (biopsy forceps).
4. The Central Services Reprocessing form must have all blanks filled out. Customer Name
will be RTA’s Name, Customer Phone is Pager 9000, Account name is Respiratory Care,





and Account Number is 3501. Circle High Level Disinfection and fill in Item
Description and Quantity.
5. Take scope to Central Services for reprocessing. Scopes and Biopsy equipment are not to
be left at Dirty Reprocessing Drop Off door E 5/150. You must push button for service.
If reprocessing request is after hours call 263-7069.

WARNING: After cleaning the forceps, do not inappropriately bend the forceps. Evaluate
the operation of the forceps making sure that the teeth on the forceps open and close with
ease. Package the forceps with large loops in a large envelope to avoid excessive bending.
B. Processing Damaged bronchoscope:
1. Contact Peter Rusch or Willian Backes to initiate the return of damaged item.
2. Olympus will provide us with pre-paid and pre-printed next day P.M. freight stamps to
send the equipment to Olympus for repair service.
3. If Olympus is unable to return scope the next day a loaner will be provided.

VI. REFERENCES

A. Bronchoscopy Sizing Chart
B. Bronchoscopy Procedure
C. Central Services Reprocessing Request form


Approved by Director and Medical Director of Respiratory Care:
A copy of this Policy & Procedure is available in the Respiratory Care Office [E5/489].