Endoscopic Procedures - Diagnostic Evaluation

ENDOSCOPIC PROCEDURES

Bronchoscopy

Bronchoscopy is the direct inspection and examination of thelarynx, trachea, and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope. The fiberoptic scope is used more frequently in current practice.

The purposes of diagnostic bronchoscopy are: (1) to examine tissues or collect secretions, (2) to determine the location and ex-tent of the pathologic process and to obtain a tissue sample for di-agnosis (by biting or cutting forceps, curettage, or brush biopsy),to determine if a tumor can be resected surgically, and (4) to diagnose bleeding sites (source of hemoptysis).

Therapeutic bronchoscopy is used to: (1) remove foreign bod-ies from the tracheobronchial tree, (2) remove secretions ob-structing the tracheobronchial tree when the patient cannot clear them, (3) treat postoperative atelectasis, and (4) destroy and ex-cise lesions.

The fiberoptic bronchoscope is a thin, flexible bronchoscope that can be directed into the segmental bronchi (Fig. 21-15). Be-cause of its small size, its flexibility, and its excellent optical system, it allows increased visualization of the peripheral airways and is ideal for diagnosing pulmonary lesions. Fiberoptic bronchoscopy allows biopsy of previously inaccessible tumors and can be per-formed at the bedside. It also can be performed through endotra-cheal or tracheostomy tubes of patients on ventilators. Cytologic examinations can be performed without surgical intervention.

The rigid bronchoscope is a hollow metal tube with a light at its end. It is used mainly for removing foreign substances, inves-tigating the source of massive hemoptysis, or performing endo-bronchial surgical procedures. Rigid bronchoscopy is performed in the operating room, not at the bedside.

Possible complications of bronchoscopy include a reaction to the local anesthetic, infection, aspiration, bronchospasm, hyp-oxemia (low blood oxygen level), pneumothorax, bleeding, andperforation.

NURSING INTERVENTIONS

Before the procedure, a signed consent form is obtained from the patient, and food and fluids are withheld for 6 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. The nurse explains the procedure to the patient to reduce fear and decrease anxiety and administers pre-operative medications (usually atropine and a sedative or opioid) as prescribed to inhibit vagal stimulation (thereby guarding against bradycardia, dysrhythmias, and hypotension), suppress the cough reflex, sedate the patient, and relieve anxiety.

The patient must remove dentures and other oral prostheses. The examination is usually performed under local anesthesia, but general anesthesia may be needed for rigid bronchoscopy. A top-ical anesthetic such as lidocaine (Xylocaine) may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discom-fort. Sedatives or opioids are administered intravenously as pre-scribed to provide moderate sedation.

After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns, because the pre-operative sedation and local anesthesia impair the protective la-ryngeal reflex and swallowing for several hours. Once the patient demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The nurse assesses for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine given during the procedure. 

The nurse also monitors the patient’s respiratory status and observes for hypoxia, hypotension, tachycar-dia, dysrhythmias, hemoptysis, and dyspnea. Any abnormality is reported promptly. The patient is not discharged from the re-covery area until adequate cough reflex and respiratory status are present. The nurse instructs the patient and family caregivers to report any shortness of breath or bleeding immediately.

Thoracoscopy

Thoracoscopy is a diagnostic procedure in which the pleural cav-ity is examined with an endoscope (Fig. 21-16). Small incisions are made into the pleural cavity in an intercostal space; the loca-tion of the incision depends on the clinical and diagnostic find-ings. After any fluid present in the pleural cavity is aspirated, the fiberoptic mediastinoscope is inserted into the pleural cavity, and its surface is inspected through the instrument. After the proce-dure, a chest tube may be inserted, and the pleural cavity is drained by negative-pressure water-seal drainage.

Thoracoscopy is primarily indicated in the diagnostic evalua-tion of pleural effusions, pleural disease, and tumor staging. Biop-sies of the lesions can be performed under visualization for diagnosis.

Thoracoscopic procedures have expanded with the availabil-ity of video monitoring, which permits improved visualization of the lung. Such procedures also have been used with the carbon dioxide laser in the removal of pulmonary blebs and bullae and in the treatment of spontaneous pneumothorax. 

Lasers have also been used in the excision of peripheral pulmonary nodules. Al-though the laser does not replace the need for thoracotomy in the treatment of some lung cancers, its use continues to expand be-cause it is less invasive.

NURSING INTERVENTIONS

Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath (which might in-dicate a pneumothorax), and minor activity restrictions, which vary depending on the intensity of the procedure. If a chest tube is in place, monitoring the chest drainage system and chest tube insertion site is essential.