Sometimes certain respiratory procedures may be needed for diagnostic and/or therapeutic reasons. Thoracentesis and Bronchoscopy are two of these respiratory procedures.
Thoracentesis
Thoracentesis is a respiratory procedure performed with the aim of removing pleural effusion. A needle is inserted through the back of the chest wall and into the pleural space to extract pleural effusion for diagnostic (where pleural fluid is examined a.k.a. cytological examination) and/or therapeutic (where pleural fluid is removed to provide relief) reasons.
Thoracentesis Complications
- Intercostal Vessels Laceration – leads to Haemothorax if undetected post procedure through ultrasound
- Pneumothorax – lung laceration by needle or plastic catheter during procedure
- Re-expansion Pulmonary Edema (RPE) – uncommon complication following procedure. Symptoms, usually noticed within 24 hours post procedure, include cough, chest discomfort and hypoxaemia. May be fatal.
- Infection – risk can be reduced through correct infection control procedures
- Hypotension – may happen if too much fluid is extracted too quickly
Nursing Responsibilities Prior to Thoracentesis
- Obtain informed consent
- Explain and emphasis the importance of having the procedure done
- Inform patient that mild pain is experienced in situ
- Check patient history with reference to anticoagulation therapy and/or known bleeding disorders
- Area to be punctured may be shaved
- Monitor vital signs
- Ask patient to remove anything that may interfere with the procedure such as jewellery and clothing around insertion site
- Prior to the procedure, a chest x-ray, ultrasound or CT scan may be performed to identify the exact location of pleural fluid that needs to be extracted
- A sedative may be administered to reduce anxiety and help the patient relax during the procedure
- Position patient in a sitting position with arms and head resting supported on an adjustable bedside table. If this is not possible, the patient should be placed in a lying position on the unaffected side and at the edge of the bed (attn patient safety!)
- During needle insertion, teach patient not to cough, breathe deeply or move, as doing any of this may lead to lung puncturing
Nursing Responsibilities During Thoracentesis
- Thoracentesis is performed using a sterile technique
- The thoracentesis needle is usually inserted in the posterolateral aspect of the back, over the diaphragm but under the fluid level
- Clean puncture site with an antiseptic solution
- Local anaesthetic is administered at the area to be punctured
- Monitor vital signs
- Observe for distress signs such as dyspnoea and pallor
- Administer supplemental oxygen if needed
- If being performed for diagnostic purposes, fluid is aspirated; if being performed for therapeutic purposes, chest tube should be well secured
- DO NOT drain more than 1000ml of pleural fluid within the first 30 minutes as this may lead to hypotension
- Cover puncture site with a small sterile dressing
Nursing Responsibilities After Thoracentesis
- Close drain for 4 hours after draining 1000ml of fluid into the Wolves bottle (you can reopen drain after the 4 hours are over…repeat if necessary)
- Elevate head of bed to promote better breathing
- Monitor vital signs
- Observe for changes in patient’s cough, sputum and respiratory rate and for chest pain complaints
- Document procedure including physician name, date and time of performed procedure and the amount and colour of the drained pleural fluid
- Monitor dressing for bleeding or other drainage
- Transport specimen to the lab if it is being evaluated
- Chest x-ray should be performed 6 hours after procedure is done
Bronchoscopy
Bronchoscopy is an invasive procedure that allows direct examination of the larynx, trachea and bronchi either under general or local anaesthetic for diagnostic and/or therapeutic purposes. This is done using a bronchial brush, forceps and/or needle which are passed through the bronchoscope to retrieve tissue samples which can then be tested. This procedure can be done using either a flexible fiberoptic bronchoscope (provides a wider view of the tracheobronchial tree) or a rigid metal bronchoscope (ideal for foreign body removal and massive haemoptysis control a.k.a. blood coughing control.
Local anaesthetic is sprayed in the patient’s throat. Following effect of sedative, a bronchoscope is inserted through the patient’s mouth or nose. Anaesthetic is then sprayed through the scope’s inner channel to the vocal cords surrounding area. The anatomical structure of the trachea and bronchi is then examined; mucosal lining colour is noted, along with inspection for visible tumours or inflammation. Bronchoalveolar lavage may also be performed, where sterile water is injected into a segment of the lung and suctioned back before being sent for further testing.
Diagnostic Bronchoscopy allows:
- Visualisation of the tracheobronchial tree to detect any abnormalities, including but not limited to inflammation, tumours or strictures
- Visualisation of the larynx to detect vocal cord paralysis presence
- Aspiration of sputum specimen for microscopy, culture and sensitivity
- Biopsy of tissue from suspected tumours
- Identification of bleeding site in haemoptysis (blood coughing)
Therapeutic Bronchoscopy allows:
- Removal of excessive secretions and mucus plugs
- Removal of foreign objects
- Bleeding control
- Resection of benign or malignant tumours
Bronchoscopy Contraindications
- Uncooperative patients
- Patients with coagulopathy problems
- Patients with severe acute respiratory failure
- Recent head trauma prone to developing an increase in intracranial pressure
- Severe tracheal obstruction
Nursing Responsibilities Prior To Bronchoscopy
- Withhold food and fluids for 6 to 12 hours prior to bronchoscopy to reduce aspiration risk
- Obtain baseline vital signs and inform physician regarding any abnormal findings
- Provide oral hygiene
- Instruct patient to remove any dentures if present
- If local anaesthesia is being administered, inform patient of its use and that it may have a bitter taste
- Reassure patient that airway blockage doesn’t happen with the procedure to relieve associated anxiety
- Prepare emergency resuscitation equipment at bedside to be prepared to resuscitate in case of bronchospasms and hypoxaemia during or following the procedure
Nursing Responsibilities During Bronchoscopy
- Position patient in a sitting or supine position
- Provide supplemental oxygen as required (usually via nasal cannula)
- Assist in tissue specimen collection, removal of foreign body, bronchoalveolar lavage and aspiration of retained secretions
- Send specimen to the lab with proper labelling
- Monitor parameters repeatedly to detect any significant decrease in oxygen saturation during bronchoscopy
Nursing Responsibilities Following Bronchoscopy
- Place patient in a semi-fowlers position
- Reassure patient that hoareseness, loss of voice and sore throat may happen temporarily. This helps provide comfort and relieve anxiety
- Maintain NBM (nil by mouth) until anaesthesia wears off and cough reflex is returned; resume normal diet gradually, starting with sips of water or ice chips
- Observe patient sputum and report any excessive bleeding (minimum blood streak is expected and is considered normal for a few hours post procedure
- Instruct patient to spit out any saliva in a provided emesis basin instead of swallowing it so as to prevent aspiration
- Assess respiratory status to detect any signs of bronchospasm or bronchial perforation (hypoxaemia, haemorrhage and chest tightness)
- Monitor vital signs (changes or discomforts may indicate possible complications)
Complications following Bronchoscopy
- Bleeding from biopsy site
- Fever – low grade fever (<38°C) is common due to an acute inflammatory response, high white blood cell count, elevated C-reactive protein and absence of infection
- Bronchospasm
- Pneumothorax – happens if lung is punctured during the procedure
- Infection
- Hypoxaemia – low blood oxygen saturation; common during the procedure, but is usually restored without any intervention; a higher risk of hypoxaemia is associated with the patient being in a sitting position, patients with chronic obstructive disorders and patients requiring supplemental oxygen prior to the procedure (suctioning can exacerbate hypoxaemia)
- In patients with significant desaturation (>4% decrease or <90% saturation), oxygen supplementation should be administered to reduce complications related to hypoxaemia
Findings Following Bronchoscopy
- Lung Disease eg. TB, Carcinoma or fungal infection
- Foreign Substances eg. mucus plugs, blood and foreign objects
- Endotracheal Abnormalities eg. narrowing or compression in the trachea
- Bronchial Wall Abnormalities eg. swelling, inflammation or ulceration
Below you can find a collection of videos that can help provide a more visual approach to Thoracentesis and Bronchoscopy.
Thoracentesis
Thoracentesis Using Thoracic Ultrasonography
Bronchoscopy
https://www.youtube.com/watch?v=XTC3AKmtrcs
Bronchoscopy Segmental Anatomy
Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Pulmonary Resident Essentials, UW Wish, Nucleus Medical Media and HansDaniels.
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Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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