Bronchoscopy

Important information

Before your appointment

• If you are taking warfarin please read the ‘Alert for patients on warfarin’ below, as you may need to have an international normalised ratio test ('INR') seven days before the appointment.
• If you take any other blood thinning medication (anticoagulants) or antiplatelet (eg clopidogrel or aspirin) please contact your referring doctor for advice regarding when to stop taking this medication prior to the procedure.
• All other medication should be taken as normal.
• If you have diabetes, please read the diabetic advice below.
• If you have any questions about the procedure or find that you cannot keep this appointment, please contact the endoscopy office between 09:00 (9am) and 17:00 (5pm) Monday to Friday on 01223 257080 or contact the pleural service on 01223 349189.

On the day

• Have nothing to eat or drink for four hours before your appointment.
• Please ensure you are accompanied. We cannot sedate you if you come to the department alone.

At the hospital

• Please come to the Endoscopy Department on Level 3 of the Addenbrooke’s Treatment Centre (ATC).
• Use Car Park 2. Take your parking ticket and appointment letter to the customer service desk in the car park to obtain discounted parking.
• Please note that the appointment time is for your pre-procedure check; it is not the time of your examination. The length of time you will be here will vary enormously but may be anything from two to four hours or more. Please ask your admitting nurse for further information during your admission check.

Alert for endoscopy patients on warfarin, clopidogrel or other anticoagulant medication

You must read this guidance before your procedure.

If you have any questions or do not know whether to stop your medication before your endoscopy please call 01223 216515 or 01223 349189 for the pleural service.

Please note: the operator on the day has the option to not perform the procedure if they perceive an elevated risk of major bleeding/ haemorrhage.

Warfarin: for patients advised to CONTINUE medication

You must contact the referring doctor and the interventional team (01223 349189) for advice.

Warfarin: for patients advised to STOP medication

• You should stop warfarin five days before the endoscopy.
• After the endoscopy, go back to your usual daily dose as soon as you are eating again (that will usually be the same evening).

You should have your INR checked one week later to ensure you are adequately anticoagulated again.

If you have metal mitral valve, metal valve + previous stroke/ thrombosis, valvular heart disease you may need heparin injections instead of warfarin. Ask your local anticoagulant service for advice.

Clopidogrel: for patients advised to CONTINUE medication

Continue with your usual dose.

Clopidogrel: for patients advised to STOP medication

You should stop clopidogrel seven days before the endoscopy.

Direct oral anticoagulation – rivaroxaban, apixaban, dabigatran, betrixaban: for patients advised to CONTINUE medication

Continue with your usual dose.

Direct oral anticoagulation – rivaroxaban, apixaban, dabigatran, betrixaban: for patients advised to STOP medication

You should stop these one day before the endoscopy.

What is a bronchoscopy?

Your doctor has requested this procedure to help investigate and manage your medical condition.

Bronchoscopy is a procedure that allows the endoscopist to look directly at the passages that take air into your lungs. These airways include the trachea (windpipe) and the bronchi (branches of the airways). The bronchoscope is a long flexible tube, about the width of a thin pencil, with a light at the end. It is passed either through your nose or through your mouth, past your larynx (voice box) down your trachea and into the bronchi. The lining in these areas can be checked to see if there are any problems in your respiratory (breathing) system. The procedure can take between 15 and 20 minutes.

Sometimes it is helpful to take a biopsy – a sample of the lining. This is done by passing a small instrument through the bronchoscope to pinch out a tiny bit of the lining (about the size of a pinhead) which is sent to the laboratory for analysis. Occasionally, the area we need to biopsy is difficult to reach, in which case we might need to use x-ray equipment to help us identify it. This is called a transbronchial biopsy.

It may also be necessary to wash out your lower airways with sterile saline. This is a safe and effective method of gathering samples during the intervention. This is referred to as a bronchial lavage. The bronchoscope used can administer liquid and then suction it back out into sample containers leaving only a very small residual amount of fluid within the airway.

Getting ready for the procedure

Wear loose fitting washable clothing and leave valuables at home.

On arrival at the department we will explain the procedure to you and ask you to sign a consent form. You can change your mind about having the procedure at any time.

Most patients who have a bronchoscopy will be given a local anaesthetic to the nose and back of the throat. You will also be given an intravenous sedative (an injection into a vein) to make you feel relaxed and sleepy (this is not a general anaesthetic) and may mean that you are not aware of the procedure. The sedative will continue to have a mild sedative effect for up to 24 hours and may leave you unsteady on your feet for a while.

You must arrange for a responsible adult to come with you and wait to take you home. You will not be able to drive yourself. If you come without an escort, we will have to cancel the procedure. If you are entitled to use hospital transport, an escort is not required; however, someone should be available to monitor you at home when you return there and, ideally, stay with you overnight. This applies to all patients receiving sedation medication.

COVID-19 testing requirements

If you are experiencing COVID symptoms (fever, persistent new cough, loss of taste or smell, flu-like symptoms, new gastric disturbances) it is advised that you perform a lateral flow test (LFT) before you attend for the procedure and call the Endoscopy Department for advice on 01223 257080.

During the procedure

For your comfort and reassurance, a trained nurse will stay with you throughout. In the procedure room, you will be asked to remove false teeth and glasses and will be made comfortable on a couch in a sitting or lying position.

The endoscopist will give you an intravenous injection and throat spray. If the tube is being inserted into your nose, local anaesthetic jelly will be used to numb your nasal passage. If the tube is being inserted into your mouth, a plastic mouth guard will be placed gently between your teeth. This is to keep your mouth open so that you do not bite the bronchoscope. We will also put a plastic 'peg' on your finger to monitor your pulse and oxygen levels.

As the bronchoscope is gently inserted, more local anaesthetic will be given to numb the larynx (voice box); this may make you cough a little. As the local anaesthetic takes effect, your throat will relax. We will give you extra oxygen by putting a soft plastic tube just inside your nose.

Minimal restraint (hand holding) may be appropriate during the procedure. However, if you make it clear that you are too uncomfortable the procedure will be stopped.

When the procedure is finished, the bronchoscope is removed quickly and easily.

Potential problems

Bronchoscopy procedures carry a small risk; less than one in 1000 of major haemorrhage (bleeding).

If you had a transbronchial biopsy, there is a risk of leakage of air from the lung (one in 30) which may cause the lung to collapse. These leaks often seal up quickly on their own; however, in a small proportion of these cases, we might need to insert a chest drain (a small tube) to remove the unwanted air in the chest area. In order to detect a leak you will have a chest x-ray about an hour after your procedure, and if a leak is detected you will be admitted to hospital.

There may be a slight risk to teeth, crowns or dental bridgework; you should tell the nurse if you have any of these.

Other rare complications of this procedure include aspiration pneumonia (inflammation of the lungs caused by inhaling or choking on vomit) and adverse reactions to the intravenous sedative drugs.

As with all medical investigations, this procedure will not always show up all abnormalities and, on very rare occasions, a significant abnormality may not be identified. If you have any questions about this please ask either at the time of the procedure or the person who referred you.

After the procedure

After the bronchoscopy, you will be taken to a recovery area while the sedation wears off. When you are sufficiently awake, you can go home. We advise you not to eat or drink for about two hours as it is not safe until full sensation has returned. You are also advised not to drive, operate machinery, return to work, drink alcohol or sign any legally binding documents for the next 24 hours. You are advised to have a responsible adult stay with you for the next 12 hours.

You may have a sore throat and/or hoarse voice and a slight nosebleed. If we take some biopsies, you might find some streaks of blood in your phlegm. These are quite normal and usually stop within 24 hours.

If you have any of the following you should contact your GP, the Endoscopy Department or the Accident and Emergency Department:

• pain when breathing, either in your chest or shoulder
• difficulty breathing or expanding your lungs
• persistent or increased bleeding

When will I know the result?

The endoscopist will give you information about the procedure at the bedside in the recovery area (if you would like more privacy, we will take you to a separate room). If you had sedation, it is a good idea to have someone with you when you talk to the endoscopist because the sedation can affect your ability to remember the discussion.

Final results from biopsies will be given to you either by the healthcare professional who requested the procedure at a clinic appointment or by letter. These results can take several weeks to come through. You should discuss details of these results and any further treatment with that person.

Alternatives to bronchoscopy

There are no real alternatives to having a bronchoscopy. In some cases, depending on individual factors such as the symptoms present and the condition being investigated, a CT (computed tomography) scan may be appropriate.

Diabetic advice

Please follow these instructions if you have diabetes which is controlled with insulin or tablets. If you have any questions related to your diabetes during this preparation, please contact your GP or the diabetes specialist nurse on 01223 245151 bleep 152078.

Food and drink

• Do not eat for four hours before your appointment.
• Do not drink for three hours before your appointment.
• Test your blood glucose regularly. If it drops below four, please treat with a sugary drink such as Lucozade 100ml, apple or grape juice 200ml, until your level is five.
• After your procedure, you may eat and drink normally unless specifically told otherwise.

Insulin and tablets

Please adjust your normal insulin and tablet doses as instructed below depending on whether your appointment is in the morning or the afternoon.

*Morning* appointment

If you take insulin once daily

• No change to insulin dose necessary.

If you take insulin twice daily

• Do not have your morning insulin. Bring it with you, plus something to eat.
• If you are able to eat before 11:00 (11am), have your normal dose with food.
• If you are able to eat after 11:00 (11am), have half your normal morning dose with food.
• Have your normal evening dose.

If you take insulin four times daily

• Do not have your morning insulin. Bring it with you, plus something to eat.
• If you are able to eat before 11:00 (11am), have your normal dose with food.
• If you are able to eat after 11:00 (11am), omit your breakfast dose and have your normal lunchtime dose with food.
• Have your normal teatime and bedtime evening doses.

If you take tablets for diabetes

• Do not have your morning diabetic tablets.
• After your procedure, re-start your tablets at the next dose time.

*Afternoon* appointment

If you take insulin once daily

• No change to insulin dose necessary.

If you take insulin twice daily

• Have your normal morning insulin dose unless your breakfast is smaller than usual, in which case reduce your normal dose by half.
• Have your normal evening dose.

If you take insulin four times daily

• Have your normal morning insulin dose.
• Do not have your lunchtime insulin dose.
• Have your normal teatime and bedtime evening doses.

If you take tablets for diabetes

• Do not have your morning diabetic tablets.
• After your procedure, re-start your tablets at the next dose time.

For more information

Contact the endoscopy office between 09:00 (9am) and 17:00 (5pm) on 01223 257080.

References

www.brit-thoracic.org.uk