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Bronchoscopy in the Sitting Position
Bronchoscopy in the Sitting Position ROBERT K. BROWN, M.D.* JOSEPH L. KOVARIK, M.D. **
While elective diagnostic bronchoscopic examination is usually performed by a trained endoscopist, there are occasions when emergency bronchoscopy can, and should, be undertaken by the "occasional endoscopist." Bronchoscopy in cases of intrabronchial obstruction from foreign bodies, hemorrhage, or retained secretions is therapeutic as well as diagnostic. These conditions usually constitute a clinical emergency and bronchoscopy may be life-saving. The establishment and maintainence of an adequate airway is the primary concern of the physician in treating a patient with respiratory distress or insufficiency. Effective ventilation by any means requires a clear, unobstructed bronchial passage. Many practitioners are familiar with the techniques of endotracheal intubation and tracheostomy, and should not hesitate to perform emergency bronchoscopy as well. Contrary to the general opinion of most patients, and many physicians, bronchoscopy need not be a terrifying or inordinately unpleasant experience. Properly performed, it can be a rewarding procedure for both patient and surgeon. With these considerations in mind, we are prompted to review our experience and technique, with special emphasis on the advantages of bronchoscopic examination in the sitting position. On the Thoracic Surgical Service of the Veterans Administration Hospital in Denver during the past 22 years, approximately 5000 bronchoscopies have been performed by the surgical resident staff, under the direct supervision of one of us (R.K.B.). Most of these procedures were done using the sitting position. We feel that this position simplifies passage of the bronchoscope through the glottis and shortens the "novice" phase of the resident's training. Most patients who previously experienced bronchoscopy in the supine position express a preference for the sitting position.
*Associate Clinical Professor of Surgery, University of Colorado School of Medicine, Denver,
Colorado
"'* Assistant Clinical Professor of Surgery, University of Colorado School of Medicine, Denver, Colorado Surgical Clinics of North America- Vol. 49, No.6, December, 1969
1421
1422
ROBERT
K.
BROWN, JOSEPH
L.
KOVARIK
TECHNIQUE Premedication should include a barbiturate to complement whatever topical agent is used, plus codeine for suppression of cough and atropine for drying. We prefer to use topical anesthesia for most bronchoscopies, as we feel that the procedure is simpler and safer with a conscious patient, less postanesthetic nursing care is needed, and the procedure can often be done on an outpatient basis. This conservation of professional personnel and facilities is a significant factor. Obviously, when general anesthesia is required (for infants, small children, and some adults), the supine position is used. In an extreme emergency, bronchoscopy may be performed without premedication or anesthesia. Our choice for the topical anesthetic agent is cocaine (4 per cent solution, freshly made up), applied first with small cotton pled gets or a nebulizer spray to the pharynx and pyriform sinuses to block the superior laryngeal nerves and eliminate the gag reflex. Then a few milliliters of the cocaine solution is dripped on and through the vocal cords, using a laryngeal cannula and indirect visualization with a laryngeal mirror. In our hands, this has been more satisfactory than transtracheal injection via needle puncture or percutaneous nerve block. The patient is seated in a straight-backed chair which gives support to his hips and shoulders. A towel is draped turban-wise over his head and eyes, leaving the nose and mouth exposed. The operator stands behind the chair, using a small platform if needed (Fig. 1). The patient is instructed to thrust his chin directly upwards (not to tip his head back)
Figure 1. Elective bronchoscopy: sitting position.
BRONCHOSCOPY IN THE SITTING POSITION
1423
and to open his mouth. While the operator's left fingers hold a moist gauze pad to the patient's upper gum or teeth, his left thumb guides the bronchoscope over the base of the tongue, elevating the epiglottis and directing the tip of the scope through the vocal cords into the trachea. It is important to not use the upper gum or teeth as the fulcrum of a lever. A headholder is not needed, as the operator can easily assist the patient in flexion and extension of his neck, as well as any desired lateral or rotary manipulation. The tracheobronchial tree is then systematically inspected, insuring that all bronchial orifices are seen and cleared. If necessary, a laryngoscope may be used to aid in inserting the bronchoscope through the glottis into the trachea. A variation of the chair position is useful in emergency bronchoscopy performed on patients with postoperative atelectasis, hemorrhage, or aspirated foreign bodies (food, dentures, etc.) The head of the bed is elevated and the patient's shoulders are raised on a pillow so that his head hangs free, while the operator stands on the bed frame and introduces the bronchoscope from above (Fig. 2). In such emergency situations, a discussion of the various types of instruments is academic, because the available bronchoscope is the "instrument of choice." Following bronchoscopy, the patient should not eat or drink for at least one hour. Further medication is not usually necessary. It is advisable to collect three consecutive 24-hour sputum specimens following
Figure 2.
Emergency bronchoscopy: patient upright in bed.
1424
ROBERT
K.
BROWN, JOSEPH
L.
KOVARIK
bronchoscopy. These often yield bacteriologic or cytologic evidence of disease when the initial specimen is negative. The sitting position for bronchoscopy, as described, allows greater comfort and less respiratory effort on the part of the patient, requires one less member of the "team" by eliminating the headholder, aids bronchial lavage by gravity, and is easier technically for the "occasional endoscopist" or the neophyte surgical resident. While pooling of blood or secretions in the lower lobe bronchi, or migration of foreign bodies into the distal air passages, may be mentioned as possible disadvantages, these are more theoretical than real, and have not been a problem in our experience. For the reasons mentioned above, we feel that the sitting position for bronchoscopy facilitates a rapid and complete examination and clearing of the tracheobronchial tree. 1727 Gilpin Street Denver, Colorado 80218
While elective diagnostic bronchoscopic examination is usually performed by a trained endoscopist, there are occasions when emergency bronchoscopy can, and should, be undertaken by the "occasional endoscopist." Bronchoscopy in cases of intrabronchial obstruction from foreign bodies, hemorrhage, or retained secretions is therapeutic as well as diagnostic. These conditions usually constitute a clinical emergency and bronchoscopy may be life-saving. The establishment and maintainence of an adequate airway is the primary concern of the physician in treating a patient with respiratory distress or insufficiency. Effective ventilation by any means requires a clear, unobstructed bronchial passage. Many practitioners are familiar with the techniques of endotracheal intubation and tracheostomy, and should not hesitate to perform emergency bronchoscopy as well. Contrary to the general opinion of most patients, and many physicians, bronchoscopy need not be a terrifying or inordinately unpleasant experience. Properly performed, it can be a rewarding procedure for both patient and surgeon. With these considerations in mind, we are prompted to review our experience and technique, with special emphasis on the advantages of bronchoscopic examination in the sitting position. On the Thoracic Surgical Service of the Veterans Administration Hospital in Denver during the past 22 years, approximately 5000 bronchoscopies have been performed by the surgical resident staff, under the direct supervision of one of us (R.K.B.). Most of these procedures were done using the sitting position. We feel that this position simplifies passage of the bronchoscope through the glottis and shortens the "novice" phase of the resident's training. Most patients who previously experienced bronchoscopy in the supine position express a preference for the sitting position.
*Associate Clinical Professor of Surgery, University of Colorado School of Medicine, Denver,
Colorado
"'* Assistant Clinical Professor of Surgery, University of Colorado School of Medicine, Denver, Colorado Surgical Clinics of North America- Vol. 49, No.6, December, 1969
1421
1422
ROBERT
K.
BROWN, JOSEPH
L.
KOVARIK
TECHNIQUE Premedication should include a barbiturate to complement whatever topical agent is used, plus codeine for suppression of cough and atropine for drying. We prefer to use topical anesthesia for most bronchoscopies, as we feel that the procedure is simpler and safer with a conscious patient, less postanesthetic nursing care is needed, and the procedure can often be done on an outpatient basis. This conservation of professional personnel and facilities is a significant factor. Obviously, when general anesthesia is required (for infants, small children, and some adults), the supine position is used. In an extreme emergency, bronchoscopy may be performed without premedication or anesthesia. Our choice for the topical anesthetic agent is cocaine (4 per cent solution, freshly made up), applied first with small cotton pled gets or a nebulizer spray to the pharynx and pyriform sinuses to block the superior laryngeal nerves and eliminate the gag reflex. Then a few milliliters of the cocaine solution is dripped on and through the vocal cords, using a laryngeal cannula and indirect visualization with a laryngeal mirror. In our hands, this has been more satisfactory than transtracheal injection via needle puncture or percutaneous nerve block. The patient is seated in a straight-backed chair which gives support to his hips and shoulders. A towel is draped turban-wise over his head and eyes, leaving the nose and mouth exposed. The operator stands behind the chair, using a small platform if needed (Fig. 1). The patient is instructed to thrust his chin directly upwards (not to tip his head back)
Figure 1. Elective bronchoscopy: sitting position.
BRONCHOSCOPY IN THE SITTING POSITION
1423
and to open his mouth. While the operator's left fingers hold a moist gauze pad to the patient's upper gum or teeth, his left thumb guides the bronchoscope over the base of the tongue, elevating the epiglottis and directing the tip of the scope through the vocal cords into the trachea. It is important to not use the upper gum or teeth as the fulcrum of a lever. A headholder is not needed, as the operator can easily assist the patient in flexion and extension of his neck, as well as any desired lateral or rotary manipulation. The tracheobronchial tree is then systematically inspected, insuring that all bronchial orifices are seen and cleared. If necessary, a laryngoscope may be used to aid in inserting the bronchoscope through the glottis into the trachea. A variation of the chair position is useful in emergency bronchoscopy performed on patients with postoperative atelectasis, hemorrhage, or aspirated foreign bodies (food, dentures, etc.) The head of the bed is elevated and the patient's shoulders are raised on a pillow so that his head hangs free, while the operator stands on the bed frame and introduces the bronchoscope from above (Fig. 2). In such emergency situations, a discussion of the various types of instruments is academic, because the available bronchoscope is the "instrument of choice." Following bronchoscopy, the patient should not eat or drink for at least one hour. Further medication is not usually necessary. It is advisable to collect three consecutive 24-hour sputum specimens following
Figure 2.
Emergency bronchoscopy: patient upright in bed.
1424
ROBERT
K.
BROWN, JOSEPH
L.
KOVARIK
bronchoscopy. These often yield bacteriologic or cytologic evidence of disease when the initial specimen is negative. The sitting position for bronchoscopy, as described, allows greater comfort and less respiratory effort on the part of the patient, requires one less member of the "team" by eliminating the headholder, aids bronchial lavage by gravity, and is easier technically for the "occasional endoscopist" or the neophyte surgical resident. While pooling of blood or secretions in the lower lobe bronchi, or migration of foreign bodies into the distal air passages, may be mentioned as possible disadvantages, these are more theoretical than real, and have not been a problem in our experience. For the reasons mentioned above, we feel that the sitting position for bronchoscopy facilitates a rapid and complete examination and clearing of the tracheobronchial tree. 1727 Gilpin Street Denver, Colorado 80218