Evaluation of the patient undergoing respiratory endoscopic procedures

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Carvalho" "autores" => array:1 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Carvalho" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215911001462?idApp=UINPBA00004E" "url" => "/08732159/0000001800000001/v2_201509041308/S0873215911001462/v2_201509041308/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Evaluation of the patient undergoing respiratory endoscopic procedures" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "48" "paginaFinal" => "53" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "A. Magalhães" "autores" => array:1 [ 0 => array:3 [ "nombre" => "A." "apellidos" => "Magalhães" "email" => array:1 [ 0 => "adrimagalhaes08@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Bronchoscopy Unit, Pulmonology Department, Hospital de São João, Porto, Portugal" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Avaliação do paciente submetido a procedimentos endoscópicos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 712 "Ancho" => 950 "Tamanyo" => 122623 ] ] "descripcion" => array:1 [ "en" => "Operating room and monitoring of vital signs." ] ] ] "textoCompleto" => "IntroductionEndoscopic techniques, flexible, rigid bronchoscopy and thoracoscopy are central tools in the evaluation and treatment of respiratory disorders and their use has been steadily growing.The first rigid bronchoscopy was performed in 1897 when Gustav Killian removed a piece of pork bone from the bronchus of a 63-year-old farmer, thus avoiding a tracheotomy.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> IKEDA<a class="elsevierStyleCrossRef" href="#bib0015">3</a> in the late 60s pioneered fiberoptic bronchoscopy as a tool to enter subsegmental bronchi and obtain specimens for early diagnosis of lung cancer. During the last 30 years the flexible bronchoscope has become the diagnostic instrument of choice for visualization of the bronchial tree as it is less invasive, does not require general anaesthesia and provides much better visualization of the smaller peripheral airways. The introduction of laser technology into the tracheobronchial tree and the advent of airway stents in the early 1990s caused a resurgence of rigid bronchoscopy in the management of both benign and malignant central airway obstruction.<a class="elsevierStyleCrossRefs" href="#bib0020">4–6</a>Thoracoscopy began in 1908 with Jacobeus,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> and was extensively used in the treatment of tuberculosis, for pneumothorax induction and lyses of adhesions. When effective treatment for TB was discovered, interest in this technique disappeared. With technical improvements during the 90s, thoracoscopy regained popularity for dealing with undiagnosed pleural effusion.These techniques can be considered safe since they are widely used and the rate of complications is extremely low.<a class="elsevierStyleCrossRefs" href="#bib0040">8–10</a> A recent retrospective analysis of 23.682 patients undergoing bronchoscopy over a period of 11 years showed a mortality rate of 0.013% with a complication rate of 0.739%.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Mortality from medical thoracoscopy ranges between 0.09 and 0.24%.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Despite these small numbers, complications do occur and in order to avoid them, the evaluation of the patient before and after any intervention, is of utmost importance. Considering that this issue is of major concern, it is surprising that there are very few up to date studies dealing with these areas, the evidence level remains low and most recommendations (European Respiratory Society, American Thoracic Society and national societies) are based on common sense and the very small number of evidence based publications.The aim of this article is to address pre- and post evaluation workup of patients undergoing endoscopic techniques in order to determine the fitness of the patient and the ideal planning and strategy in order to obtain the maximum benefit with the lowest risk.The issues discussed are the preparation of the patient and informed consent, the general assessment – medical history, current medications, physical examination, laboratory tests, radiological evaluation and analysis of the indication and planning. The post intervention evaluation will also be discussed, in order to detect and treat complications and decide on the guidance to be given to the patient after discharge.Pre-operative assessmentPreparation and informed consentThe importance of relevant and comprehensible patient information before diagnostic and therapeutic procedures is increasingly recognized, and improves the patient's tolerance of the procedure.<a class="elsevierStyleCrossRefs" href="#bib0060">12–14</a> There are several ways of helping patients, for example, careful explanation and relaxing music, have been found to calm patients and reduce anxiety.<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> Patients and their relatives may have questions about the procedure and later management and sufficient time should be made available for this. The clinician should be able to explain the procedure, its purpose, the associated risks and possible adverse outcomes and the patient should be able to give consent entirely voluntarily.It is the responsibility of the doctor who performs the examination to ensure that a valid consent form has been signed. An intervention performed without consent may lead to legal proceedings.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>General assessment – history and physical examinationIt is essential to have detailed information about the patient's current and past medical history for formulating diagnostic hypothesis and planning the examination. Relevant information should be obtained about smoking history, occupational exposure, and comorbidities such as asthma, COPD, cardiovascular status (myocardial infarction, arrhythmias, unstable angina, congestive heart failure), bleeding disorders (thrombocytopenia, immunossupression, uremia, impared liver function), allergies and medications (antiagregating agents, anticoagulant therapy).Before any procedure, it is useful to know the basal physical characteristics of the patient. Monitoring of vital signs (heart rate, respiratory rate, blood pressure and O2 saturation) is mandatory (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Visual assessment of the patient is required to detect signs of respiratory distress, superior vena cava syndrome, stridor, hoarseness, anatomic abnormalities of the face and neck (for example wounds, burns and fractures), and spine deformities that could preclude the performance of the examination. Lung auscultation to rule out asymmetries of breath sounds (atelectasis, pneumothorax), abnormal breath sounds (wheezing, crackles) enables the physician to understand whether they had existed previously or are a consequence of the procedure. Performance status evaluation is also needed to prevent the unnecessary performance of invasive techniques in terminally ill patients who may be best treated with comfort measures.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Laboratory tests and imagingTotal blood count and platelet count, to eliminate anaemia and thrombocytopenia, blood chemistry to detect electrolytic imbalances, impaired renal and liver function that may impact on blood clotting and drug metabolism (namely anaesthetics and sedatives often used during procedures) are considered routine workup. In specific situations, like elderly patients, or patients with a past history of heart disease, electrocardiogram (EEG) and echocardiogram might also be necessary. In patients with COPD and respiratory insufficiency, arterial blood gas (ABG) analyses and lung function tests might be helpful.Imaging studies such as chest X-ray, chest CT and chest ultrasound should be carefully analyzed prior to any intervention, since they can provide valuable information for the planning of the technique.Evaluation of the indication and planningIt is mandatory that for every invasive technique the clinician be aware of the indications, contraindications and possible complications. After following the steps addressed above regarding patient fitness for the procedure, it is crucial to go through the indication, bearing in mind that diagnostic procedures of any kind should only be performed on patients for whom a diagnosis is going to alter management and where the benefit outweighs the risks.In addition, careful planning helps in the choice of the right diagnostic techniques – biopsy, brushings, transbronchial needle aspiration biopsy (TBNA), bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) – in order to get the most out of the procedure.In relation to therapeutic techniques, it is important to consider patient performance status and life expectancy and only perform therapies that will impact on quality of life. Also the choice of the right therapy – laser, mechanical debulking, eletrocautery, criotherapy, photodynamic therapy, stents – is crucial to ensure a successful outcome (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Special considerations on bronchoscopyAlthough bronchoscopy is a safe technique with low rates of morbidity and mortality,<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> care should be taken in certain situations.RespiratoryPatients with severe COPD (FEV1<40% or less than 1L) should have an ABG measurement before bronchoscopy, sedation should be avoided and supplementary O2 should be given with caution.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> In the presence of a highly hypoxemic patient, bronchoscopy can be performed with noninvasive pressure ventilation via a face mask, which solves this specific problem.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> If it is not possible to ensure adequate oxygenation, bronchoscopy should not take place. Arterial oxygen tension (PaO2)>60mmHg at rest or a saturation >90%, with O2 supplements would be considered acceptable safety thresholds.<a class="elsevierStyleCrossRefs" href="#bib0100">20–22</a>Asthmatic patients are more prone to develop bronchospasm and so a bronchodilator should be given prior to bronchoscopy.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>CardiovascularIf there is a history of recent myocardial infarction, fibreoptic bronchoscopy must be postponed for at least 6 weeks,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> if possible. Unstable angina and poorly controlled congestive heart failure should also lead to postponement of an elective procedure.Anticoagulation and antiplatelet agentsIn order to prevent bleeding complications, anticoagulant therapy should be suspended 3 days earlier or be reverted with vitamin K.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> If it is absolutely necessary to maintain hipocoagulation, heparin should be started and the INR<1.5. Regarding antiplatelet agents, a study<a class="elsevierStyleCrossRef" href="#bib0115">23</a> concluded that clopidogrel increases risk of bleeding and should be interrupted 5 days before bronchoscopy with transbronchial biopsies. Aspirin, on the other hand, is considered to be safe.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> If transbronchial lung biopsies (TBLB) are to be performed it is essential to check platelet count, protrombine time and tromboplastin time. There is no evidence in relation to “safe” levels of coagulation parameters or platelet counts, but a platelet count of 50,000mL−1 and a prothrombin and partial thromboplastin time within 1–2s of the control value is generally regarded as safe.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>AgeElderly patients are prone to comorbidity and a decreased metabolism of some drugs, namely topic anaesthetics and midazolam. However, several studies have shown that they tolerate the procedure well and age per se is not a contraindication.<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a>Bronchoscopy in the ICUPatients in the ICU are high risk patients and benefits must outweigh the risks. Pre-oxygenation must be ensured by increasing the inspired fraction of O2 (FIO2) to 100% and the exam should be performed with a swivel connector with a perforated diaphragm, through which the bronchoscope is inserted, allowing simultaneous ventilation.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> Endotracheal tube size and external diameter of the bronchoscope have to be checked prior to the exam to avoid damage to the scope of vision and impaired ventilation.Head trauma patients should be monitored for intracranial pressure and have complete anaesthesia with neuromuscular blockage during bronchoscopy.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>Prophylaxis of endocarditisAntibiotic prophylaxis before bronchoscopy is not recommended, unless the procedure involves incision of the respiratory mucosa.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>Pre medicationAtropine to dry the airways is no longer recommended because several studies have shown that there is no benefit compared to placebo and it has side effects like tachycardia.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Although the routine use of sedation is not a prerequisite before bronchoscopy it should be offered whenever there is no contraindication<a class="elsevierStyleCrossRefs" href="#bib0155">31,32</a>FastingPatients undergoing bronchoscopy should have no food by mouth for 4h before procedure or clear fluids by mouth 2h before,<a class="elsevierStyleCrossRef" href="#bib0165">33</a> patients should be allowed to take their regular medication, except for any that have to be suspended.An intravenous access should always be provided.Rigid bronchoscopy (RB)Rigid bronchoscopy is performed under general anaesthesia and so the first thing to do is to evaluate the state of health of the patient. Ventilatory function, cardiac status, hematologic, renal and liver function all must be assessed.Anatomical features must be taken into consideration. Patients who cannot tolerate hyperextension of the neck or rotation of the neck due to a fused or unstable cervical spine should not be considered for bronchoscopy. Patients with unstable midline facial fractures or deformities of the mouth are not suitable to undergo rigid bronchoscopy.Rigid bronchoscopy is the preferred option for other endobronchial therapies<a class="elsevierStyleCrossRefs" href="#bib0020">4,34,35</a> such as laser, eletrocautery, criotherapy and stent placement. As well as understanding the indications, contraindications and possible complications of RB,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> it is also essential to know about these techniques so as to be able to select the most appropriate for each particular case. Patients undergoing these therapies generally have poor performance status and relevant comorbidities, so it is crucial to analyze the risk/benefit. For a patient undergoing laser therapy it is important to know whether the symptoms are caused by the obstruction, if the lung has been collapsed for more than 4–6 weeks, if there is involvement of the pulmonary artery, if there is functional lung distal to the obstruction.If a stent is to be placed, the following must be taken into account: type of obstruction (intrinsic/extrinsic), localization (central airways), and patency distal to the obstruction. In order to answer these questions, there should be a careful radiological and endoscopic evaluation prior to any intervention.ThoracoscopyMedical thoracoscopy is generally performed under local anaesthesia and conscious sedation and is considered a safe procedure.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Besides knowing the indications, contraindications and complications, a detailed medical history, drug history, physical examination and imaging, chest X-ray and chest CT, are crucial to any preoperative evaluation. Although an ultrasound prior to the procedure is not mandatory, it increases safety and should be used whenever possible.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>Patient general health status is assessed by a total blood count, blood chemistry and coagulation study. Depending on age (>65 years) and the presence of certain comorborbidities, ECG, ABG analyses and spirometry (severe COPD patients) may be added to the screening.Dyspnea in a patient with a pleural effusion is not a concern since it will improve with effusion drainage, during thoracoscopy.The procedure involves intravenous sedation/analgesia and so a reasonable level of oxygenation should be assured (>90% with supplemental oxygen during the procedure).<a class="elsevierStyleCrossRef" href="#bib0180">36</a> Visual inspection of the point of entry is important in deciding where to insert the thoracoscope, avoiding skin infection or other abnormalities like sequelae of previous radiotherapy.Patients must be able to tolerate lateral decubitus during the whole of the procedure.Like other invasive techniques performed through surgically scrubbed skin, thoracoscopy is not likely to produce significant bacteriemia and so profilactic antibiotics are not recommended.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> When there is pleural space infection it is advisable to give profilactic antibiotics in patients at risk of endocarditis.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>If pleurodesis is a possibility, it is important to analyze the patient performance status, namely life expectancy (superior to 3 months) and to rule out a trapped lung.Post intervention evaluationAll patients should be observed for at least 30–60min after bronchoscopy or for 2h after rigid bronchoscopy or intervention. Observation can take place in the operating room or in a recovery room.The monitoring of ventilation features, such as SaO2, the respiratory rate and pattern (visible signs of bronchial obstruction and respiratory distress), ABG when required and hemodynamic features, such as blood pressure, heart rate and ECG, is of paramount importance.Post-operative care should focus on the most common complications, such as acute airway obstruction, bleeding, mucus retention, pneumothorax, respiratory failure and cardiac dysfunction. Hypoxic events subsequent to bronchoscopic procedures can occur in as many as 80% of the patients; oxygen supplementation after the procedure successfully reduces such hypoxic episodes, particularly in subjects with impaired lung function.<a class="elsevierStyleCrossRef" href="#bib0185">37</a>Discharge from the recovery room can be performed when the patient is conscious, when all aspects of the ventilatory and airway reflexes have been restored, and when the patient is able to take deep breaths and to cough effectively without signs of obstruction.Where patients have been sedated they must be advised after discharge not to drive or operate machinery or sign legal documents in the following 24h.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>Patients should be discharged in the presence of a relative capable of reporting complications and written information about the procedure and its complications should be provided (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Post bronchoscopyIf the patient was submitted to transbronchial biopsy, a chest X-ray should be performed 1h later to rule out pneumothorax. Verbal and written information about the procedure should be provided with instructions to go to the emergency department in case of dyspnea or chest pain. Fever after BAL is a possible complication and patients should also be warned about this.If a stent has been placed, the patient should be given a card identifying the type, the size and location of the stent and a contact phone number. A follow up visit should be scheduled; this is generally between 4 and 6 weeks but this may vary between centres. A study addressing this issue concluded that routine follow up bronchoscopies were not justified.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> Nebulizations and mucolitycs may be recommended but there are no controlled studies.Post thoracoscopyAs medical thoracoscopy is performed with conscious sedation, monitoring of vital signs is essential until patient is fully recovered and is no longer at risk of cardiac and respiratory depression. Chest tube functioning should be checked for bleeding and air leaks. A chest X-ray should be performed to monitor lung reexpansion. Proper analgesia should be supplied especially if a talc pleurodesis has been performed. Two hours later, the chest tube should be connected to active suctioning to promote lung reexpansion. Removal of the chest tube should be considered when production of pleural fluid is less than 100–200ml/day and the lung is fully expanded.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> In mesothelioma it is common practice to perform radiotherapy within 2 weeks at the trocar site of entry to avoid seeding, but there are studies that do not agree with this.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>ConclusionA thorough evaluation performed prior to any intervention, including medical history, drug history, physical examination, blood tests and imaging, is critical to avoid unnecessary risks and to achieve a successful outcome. Diagnostic procedures must always impact on patient management and therapeutic interventions must take into account patient performance status and life expectancy. Post operatively it is important to be aware of the possible complications and provide adequate surveillance and monitoring to guarantee patient safety and make appropriate decisions for the future. It does not matter how many technological innovations and skills there are in the field of endoscopic techniques, this process of decision making before and after any intervention will remain the key point.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres547628" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec565508" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres547629" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec565509" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Pre-operative assessment" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Preparation and informed consent" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "General assessment – history and physical examination" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Laboratory tests and imaging" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Evaluation of the indication and planning" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Special considerations on bronchoscopy" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Respiratory" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Cardiovascular" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Anticoagulation and antiplatelet agents" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Age" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Bronchoscopy in the ICU" ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "Prophylaxis of endocarditis" ] 6 => array:2 [ "identificador" => "sec0070" "titulo" => "Pre medication" ] 7 => array:2 [ "identificador" => "sec0075" "titulo" => "Fasting" ] ] ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Rigid bronchoscopy (RB)" ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Thoracoscopy" ] 9 => array:3 [ "identificador" => "sec0090" "titulo" => "Post intervention evaluation" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Post bronchoscopy" ] ] ] 10 => array:2 [ "identificador" => "sec0100" "titulo" => "Post thoracoscopy" ] 11 => array:2 [ "identificador" => "sec0105" "titulo" => "Conclusion" ] 12 => array:2 [ "identificador" => "sec0110" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-09-15" "fechaAceptado" => "2011-10-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec565508" "palabras" => array:5 [ 0 => "Endoscopic techniques" 1 => "Bronchoscopy" 2 => "Thoracoscopy" 3 => "Pre-evaluation" 4 => "Post-evaluation" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec565509" "palabras" => array:5 [ 0 => "Técnicas endoscópicas" 1 => "Broncoscopia" 2 => "Toracoscopia" 3 => "Pré-avaliação" 4 => "Pós-avaliação" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Endoscopic techniques can be considered reasonably safe since they are widely used and the rate of complications is extremely low. Still complications do occur and in order to avoid them, the evaluation of the patient before and after any intervention is of the utmost importance. In this article, issues concerning the preparation of the patient and informed consent, the general assessment – medical history, current medications, physical examination, laboratory tests, radiological evaluation and analysis of the indication and planning will be addressed. The post intervention evaluation will also be discussed, in order to detect and treat complications and decide on the final guidance for the patient after discharge.There are very few up-to-date studies or publications dealing with these areas, the evidence level remains low and most recommendations are based on common sense and expert opinion." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "As técnicas endoscópicas podem ser consideradas razoavelmente seguras dado que são amplamente utilizadas e o índice de complicações é extremamente reduzido. Ainda assim, ocorrem complicações e, para as evitar, a avaliação do paciente antes e depois de qualquer intervenção, é da maior importância. Neste artigo, serão abordadas as questões relacionadas com a preparação do paciente e o consentimento esclarecido, a avaliação geral – historial médico, medicação actual, exame físico, testes de laboratório, avaliação radiológica e análise da indicação e planeamento. A avaliação após a intervenção também será discutida, para detectar e tratar complicações e determinar a orientação final para o paciente, após a alta.Existem muito poucos estudos ou publicações actualizados que abordem estas áreas, o nível de evidência permanece baixo e a maioria das recomendações baseiam-se no bom senso e na opinião de peritos." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 712 "Ancho" => 950 "Tamanyo" => 122623 ] ] "descripcion" => array:1 [ "en" => "Operating room and monitoring of vital signs." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patient information \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Informed consent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Fasting \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Venous access \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">History and physical examination \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Laboratory tests \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr 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Evaluation of the patient undergoing respiratory endoscopic procedures

Avaliação do paciente submetido a procedimentos endoscópicos

A. Magalhães

Bronchoscopy Unit, Pulmonology Department, Hospital de São João, Porto, Portugal

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Endoscopic techniques&#44; flexible&#44; rigid bronchoscopy and thoracoscopy are central tools in the evaluation and treatment of respiratory disorders and their use has been steadily growing&#46;The first rigid bronchoscopy was performed in 1897 when Gustav Killian removed a piece of pork bone from the bronchus of a 63-year-old farmer&#44; thus avoiding a tracheotomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> IKEDA<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> in the late 60s pioneered fiberoptic bronchoscopy as a tool to enter subsegmental bronchi and obtain specimens for early diagnosis of lung cancer&#46; During the last 30 years the flexible bronchoscope has become the diagnostic instrument of choice for visualization of the bronchial tree as it is less invasive&#44; does not require general anaesthesia and provides much better visualization of the smaller peripheral airways&#46; The introduction of laser technology into the tracheobronchial tree and the advent of airway stents in the early 1990s caused a resurgence of rigid bronchoscopy in the management of both benign and malignant central airway obstruction&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Thoracoscopy began in 1908 with Jacobeus&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and was extensively used in the treatment of tuberculosis&#44; for pneumothorax induction and lyses of adhesions&#46; When effective treatment for TB was discovered&#44; interest in this technique disappeared&#46; With technical improvements during the 90s&#44; thoracoscopy regained popularity for dealing with undiagnosed pleural effusion&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">These techniques can be considered safe since they are widely used and the rate of complications is extremely low&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> A recent retrospective analysis of 23&#46;682 patients undergoing bronchoscopy over a period of 11 years showed a mortality rate of 0&#46;013&#37; with a complication rate of 0&#46;739&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Mortality from medical thoracoscopy ranges between 0&#46;09 and 0&#46;24&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Despite these small numbers&#44; complications do occur and in order to avoid them&#44; the evaluation of the patient before and after any intervention&#44; is of utmost importance&#46; Considering that this issue is of major concern&#44; it is surprising that there are very few up to date studies dealing with these areas&#44; the evidence level remains low and most recommendations &#40;European Respiratory Society&#44; American Thoracic Society and national societies&#41; are based on common sense and the very small number of evidence based publications&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this article is to address pre- and post evaluation workup of patients undergoing endoscopic techniques in order to determine the fitness of the patient and the ideal planning and strategy in order to obtain the maximum benefit with the lowest risk&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The issues discussed are the preparation of the patient and informed consent&#44; the general assessment &#8211; medical history&#44; current medications&#44; physical examination&#44; laboratory tests&#44; radiological evaluation and analysis of the indication and planning&#46; The post intervention evaluation will also be discussed&#44; in order to detect and treat complications and decide on the guidance to be given to the patient after discharge&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pre-operative assessment</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Preparation and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The importance of relevant and comprehensible patient information before diagnostic and therapeutic procedures is increasingly recognized&#44; and improves the patient&#39;s tolerance of the procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> There are several ways of helping patients&#44; for example&#44; careful explanation and relaxing music&#44; have been found to calm patients and reduce anxiety&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> Patients and their relatives may have questions about the procedure and later management and sufficient time should be made available for this&#46; The clinician should be able to explain the procedure&#44; its purpose&#44; the associated risks and possible adverse outcomes and the patient should be able to give consent entirely voluntarily&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is the responsibility of the doctor who performs the examination to ensure that a valid consent form has been signed&#46; An intervention performed without consent may lead to legal proceedings&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">General assessment &#8211; history and physical examination</span><p id="par0040" class="elsevierStylePara elsevierViewall">It is essential to have detailed information about the patient&#39;s current and past medical history for formulating diagnostic hypothesis and planning the examination&#46; Relevant information should be obtained about smoking history&#44; occupational exposure&#44; and comorbidities such as asthma&#44; COPD&#44; cardiovascular status &#40;myocardial infarction&#44; arrhythmias&#44; unstable angina&#44; congestive heart failure&#41;&#44; bleeding disorders &#40;thrombocytopenia&#44; immunossupression&#44; uremia&#44; impared liver function&#41;&#44; allergies and medications &#40;antiagregating agents&#44; anticoagulant therapy&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Before any procedure&#44; it is useful to know the basal physical characteristics of the patient&#46; Monitoring of vital signs &#40;heart rate&#44; respiratory rate&#44; blood pressure and O<span class="elsevierStyleInf">2</span> saturation&#41; is mandatory &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Visual assessment of the patient is required to detect signs of respiratory distress&#44; superior vena cava syndrome&#44; stridor&#44; hoarseness&#44; anatomic abnormalities of the face and neck &#40;for example wounds&#44; burns and fractures&#41;&#44; and spine deformities that could preclude the performance of the examination&#46; Lung auscultation to rule out asymmetries of breath sounds &#40;atelectasis&#44; pneumothorax&#41;&#44; abnormal breath sounds &#40;wheezing&#44; crackles&#41; enables the physician to understand whether they had existed previously or are a consequence of the procedure&#46; Performance status evaluation is also needed to prevent the unnecessary performance of invasive techniques in terminally ill patients who may be best treated with comfort measures&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Laboratory tests and imaging</span><p id="par0050" class="elsevierStylePara elsevierViewall">Total blood count and platelet count&#44; to eliminate anaemia and thrombocytopenia&#44; blood chemistry to detect electrolytic imbalances&#44; impaired renal and liver function that may impact on blood clotting and drug metabolism &#40;namely anaesthetics and sedatives often used during procedures&#41; are considered routine workup&#46; In specific situations&#44; like elderly patients&#44; or patients with a past history of heart disease&#44; electrocardiogram &#40;EEG&#41; and echocardiogram might also be necessary&#46; In patients with COPD and respiratory insufficiency&#44; arterial blood gas &#40;ABG&#41; analyses and lung function tests might be helpful&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Imaging studies such as chest X-ray&#44; chest CT and chest ultrasound should be carefully analyzed prior to any intervention&#44; since they can provide valuable information for the planning of the technique&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Evaluation of the indication and planning</span><p id="par0060" class="elsevierStylePara elsevierViewall">It is mandatory that for every invasive technique the clinician be aware of the indications&#44; contraindications and possible complications&#46; After following the steps addressed above regarding patient fitness for the procedure&#44; it is crucial to go through the indication&#44; bearing in mind that diagnostic procedures of any kind should only be performed on patients for whom a diagnosis is going to alter management and where the benefit outweighs the risks&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In addition&#44; careful planning helps in the choice of the right diagnostic techniques &#8211; biopsy&#44; brushings&#44; transbronchial needle aspiration biopsy &#40;TBNA&#41;&#44; bronchoalveolar lavage &#40;BAL&#41; and transbronchial lung biopsy &#40;TBLB&#41; &#8211; in order to get the most out of the procedure&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In relation to therapeutic techniques&#44; it is important to consider patient performance status and life expectancy and only perform therapies that will impact on quality of life&#46; Also the choice of the right therapy &#8211; laser&#44; mechanical debulking&#44; eletrocautery&#44; criotherapy&#44; photodynamic therapy&#44; stents &#8211; is crucial to ensure a successful outcome &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Special considerations on bronchoscopy</span><p id="par0075" class="elsevierStylePara elsevierViewall">Although bronchoscopy is a safe technique with low rates of morbidity and mortality&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> care should be taken in certain situations&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Respiratory</span><p id="par0080" class="elsevierStylePara elsevierViewall">Patients with severe COPD &#40;FEV1<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#37; or less than 1<span class="elsevierStyleHsp" style=""></span>L&#41; should have an ABG measurement before bronchoscopy&#44; sedation should be avoided and supplementary O<span class="elsevierStyleInf">2</span> should be given with caution&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In the presence of a highly hypoxemic patient&#44; bronchoscopy can be performed with noninvasive pressure ventilation via a face mask&#44; which solves this specific problem&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> If it is not possible to ensure adequate oxygenation&#44; bronchoscopy should not take place&#46; Arterial oxygen tension &#40;PaO<span class="elsevierStyleInf">2</span>&#41;<span class="elsevierStyleHsp" style=""></span>&#62;60<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg at rest or a saturation &#62;90&#37;&#44; with O<span class="elsevierStyleInf">2</span> supplements would be considered acceptable safety thresholds&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;22</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Asthmatic patients are more prone to develop bronchospasm and so a bronchodilator should be given prior to bronchoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cardiovascular</span><p id="par0090" class="elsevierStylePara elsevierViewall">If there is a history of recent myocardial infarction&#44; fibreoptic bronchoscopy must be postponed for at least 6 weeks&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> if possible&#46; Unstable angina and poorly controlled congestive heart failure should also lead to postponement of an elective procedure&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Anticoagulation and antiplatelet agents</span><p id="par0095" class="elsevierStylePara elsevierViewall">In order to prevent bleeding complications&#44; anticoagulant therapy should be suspended 3 days earlier or be reverted with vitamin K&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> If it is absolutely necessary to maintain hipocoagulation&#44; heparin should be started and the INR<span class="elsevierStyleHsp" style=""></span>&#60;1&#46;5&#46; Regarding antiplatelet agents&#44; a study<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> concluded that clopidogrel increases risk of bleeding and should be interrupted 5 days before bronchoscopy with transbronchial biopsies&#46; Aspirin&#44; on the other hand&#44; is considered to be safe&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> If transbronchial lung biopsies &#40;TBLB&#41; are to be performed it is essential to check platelet count&#44; protrombine time and tromboplastin time&#46; There is no evidence in relation to &#8220;safe&#8221; levels of coagulation parameters or platelet counts&#44; but a platelet count of 50&#44;000<span class="elsevierStyleHsp" style=""></span>mL<span class="elsevierStyleSup">&#8722;1</span> and a prothrombin and partial thromboplastin time within 1&#8211;2<span class="elsevierStyleHsp" style=""></span>s of the control value is generally regarded as safe&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Age</span><p id="par0100" class="elsevierStylePara elsevierViewall">Elderly patients are prone to comorbidity and a decreased metabolism of some drugs&#44; namely topic anaesthetics and midazolam&#46; However&#44; several studies have shown that they tolerate the procedure well and age per se is not a contraindication&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Bronchoscopy in the ICU</span><p id="par0105" class="elsevierStylePara elsevierViewall">Patients in the ICU are high risk patients and benefits must outweigh the risks&#46; Pre-oxygenation must be ensured by increasing the inspired fraction of O<span class="elsevierStyleInf">2</span> &#40;FIO<span class="elsevierStyleInf">2</span>&#41; to 100&#37; and the exam should be performed with a swivel connector with a perforated diaphragm&#44; through which the bronchoscope is inserted&#44; allowing simultaneous ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Endotracheal tube size and external diameter of the bronchoscope have to be checked prior to the exam to avoid damage to the scope of vision and impaired ventilation&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Head trauma patients should be monitored for intracranial pressure and have complete anaesthesia with neuromuscular blockage during bronchoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prophylaxis of endocarditis</span><p id="par0115" class="elsevierStylePara elsevierViewall">Antibiotic prophylaxis before bronchoscopy is not recommended&#44; unless the procedure involves incision of the respiratory mucosa&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pre medication</span><p id="par0120" class="elsevierStylePara elsevierViewall">Atropine to dry the airways is no longer recommended because several studies have shown that there is no benefit compared to placebo and it has side effects like tachycardia&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Although the routine use of sedation is not a prerequisite before bronchoscopy it should be offered whenever there is no contraindication<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Fasting</span><p id="par0125" class="elsevierStylePara elsevierViewall">Patients undergoing bronchoscopy should have no food by mouth for 4<span class="elsevierStyleHsp" style=""></span>h before procedure or clear fluids by mouth 2<span class="elsevierStyleHsp" style=""></span>h before&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> patients should be allowed to take their regular medication&#44; except for any that have to be suspended&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">An intravenous access should always be provided&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Rigid bronchoscopy &#40;RB&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Rigid bronchoscopy is performed under general anaesthesia and so the first thing to do is to evaluate the state of health of the patient&#46; Ventilatory function&#44; cardiac status&#44; hematologic&#44; renal and liver function all must be assessed&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Anatomical features must be taken into consideration&#46; Patients who cannot tolerate hyperextension of the neck or rotation of the neck due to a fused or unstable cervical spine should not be considered for bronchoscopy&#46; Patients with unstable midline facial fractures or deformities of the mouth are not suitable to undergo rigid bronchoscopy&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Rigid bronchoscopy is the preferred option for other endobronchial therapies<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;34&#44;35</span></a> such as laser&#44; eletrocautery&#44; criotherapy and stent placement&#46; As well as understanding the indications&#44; contraindications and possible complications of RB&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> it is also essential to know about these techniques so as to be able to select the most appropriate for each particular case&#46; Patients undergoing these therapies generally have poor performance status and relevant comorbidities&#44; so it is crucial to analyze the risk&#47;benefit&#46; For a patient undergoing laser therapy it is important to know whether the symptoms are caused by the obstruction&#44; if the lung has been collapsed for more than 4&#8211;6 weeks&#44; if there is involvement of the pulmonary artery&#44; if there is functional lung distal to the obstruction&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">If a stent is to be placed&#44; the following must be taken into account&#58; type of obstruction &#40;intrinsic&#47;extrinsic&#41;&#44; localization &#40;central airways&#41;&#44; and patency distal to the obstruction&#46; In order to answer these questions&#44; there should be a careful radiological and endoscopic evaluation prior to any intervention&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Thoracoscopy</span><p id="par0155" class="elsevierStylePara elsevierViewall">Medical thoracoscopy is generally performed under local anaesthesia and conscious sedation and is considered a safe procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Besides knowing the indications&#44; contraindications and complications&#44; a detailed medical history&#44; drug history&#44; physical examination and imaging&#44; chest X-ray and chest CT&#44; are crucial to any preoperative evaluation&#46; Although an ultrasound prior to the procedure is not mandatory&#44; it increases safety and should be used whenever possible&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Patient general health status is assessed by a total blood count&#44; blood chemistry and coagulation study&#46; Depending on age &#40;&#62;65 years&#41; and the presence of certain comorborbidities&#44; ECG&#44; ABG analyses and spirometry &#40;severe COPD patients&#41; may be added to the screening&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Dyspnea in a patient with a pleural effusion is not a concern since it will improve with effusion drainage&#44; during thoracoscopy&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The procedure involves intravenous sedation&#47;analgesia and so a reasonable level of oxygenation should be assured &#40;&#62;90&#37; with supplemental oxygen during the procedure&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Visual inspection of the point of entry is important in deciding where to insert the thoracoscope&#44; avoiding skin infection or other abnormalities like sequelae of previous radiotherapy&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Patients must be able to tolerate lateral decubitus during the whole of the procedure&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Like other invasive techniques performed through surgically scrubbed skin&#44; thoracoscopy is not likely to produce significant bacteriemia and so profilactic antibiotics are not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> When there is pleural space infection it is advisable to give profilactic antibiotics in patients at risk of endocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">If pleurodesis is a possibility&#44; it is important to analyze the patient performance status&#44; namely life expectancy &#40;superior to 3 months&#41; and to rule out a trapped lung&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Post intervention evaluation</span><p id="par0190" class="elsevierStylePara elsevierViewall">All patients should be observed for at least 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min after bronchoscopy or for 2<span class="elsevierStyleHsp" style=""></span>h after rigid bronchoscopy or intervention&#46; Observation can take place in the operating room or in a recovery room&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The monitoring of ventilation features&#44; such as SaO<span class="elsevierStyleInf">2</span>&#44; the respiratory rate and pattern &#40;visible signs of bronchial obstruction and respiratory distress&#41;&#44; ABG when required and hemodynamic features&#44; such as blood pressure&#44; heart rate and ECG&#44; is of paramount importance&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Post-operative care should focus on the most common complications&#44; such as acute airway obstruction&#44; bleeding&#44; mucus retention&#44; pneumothorax&#44; respiratory failure and cardiac dysfunction&#46; Hypoxic events subsequent to bronchoscopic procedures can occur in as many as 80&#37; of the patients&#59; oxygen supplementation after the procedure successfully reduces such hypoxic episodes&#44; particularly in subjects with impaired lung function&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Discharge from the recovery room can be performed when the patient is conscious&#44; when all aspects of the ventilatory and airway reflexes have been restored&#44; and when the patient is able to take deep breaths and to cough effectively without signs of obstruction&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Where patients have been sedated they must be advised after discharge not to drive or operate machinery or sign legal documents in the following 24<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Patients should be discharged in the presence of a relative capable of reporting complications and written information about the procedure and its complications should be provided &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Post bronchoscopy</span><p id="par0220" class="elsevierStylePara elsevierViewall">If the patient was submitted to transbronchial biopsy&#44; a chest X-ray should be performed 1<span class="elsevierStyleHsp" style=""></span>h later to rule out pneumothorax&#46; Verbal and written information about the procedure should be provided with instructions to go to the emergency department in case of dyspnea or chest pain&#46; Fever after BAL is a possible complication and patients should also be warned about this&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">If a stent has been placed&#44; the patient should be given a card identifying the type&#44; the size and location of the stent and a contact phone number&#46; A follow up visit should be scheduled&#59; this is generally between 4 and 6 weeks but this may vary between centres&#46; A study addressing this issue concluded that routine follow up bronchoscopies were not justified&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Nebulizations and mucolitycs may be recommended but there are no controlled studies&#46;</p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Post thoracoscopy</span><p id="par0230" class="elsevierStylePara elsevierViewall">As medical thoracoscopy is performed with conscious sedation&#44; monitoring of vital signs is essential until patient is fully recovered and is no longer at risk of cardiac and respiratory depression&#46; Chest tube functioning should be checked for bleeding and air leaks&#46; A chest X-ray should be performed to monitor lung reexpansion&#46; Proper analgesia should be supplied especially if a talc pleurodesis has been performed&#46; Two hours later&#44; the chest tube should be connected to active suctioning to promote lung reexpansion&#46; Removal of the chest tube should be considered when production of pleural fluid is less than 100&#8211;200<span class="elsevierStyleHsp" style=""></span>ml&#47;day and the lung is fully expanded&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In mesothelioma it is common practice to perform radiotherapy within 2 weeks at the trocar site of entry to avoid seeding&#44; but there are studies that do not agree with this&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0235" class="elsevierStylePara elsevierViewall">A thorough evaluation performed prior to any intervention&#44; including medical history&#44; drug history&#44; physical examination&#44; blood tests and imaging&#44; is critical to avoid unnecessary risks and to achieve a successful outcome&#46; Diagnostic procedures must always impact on patient management and therapeutic interventions must take into account patient performance status and life expectancy&#46; Post operatively it is important to be aware of the possible complications and provide adequate surveillance and monitoring to guarantee patient safety and make appropriate decisions for the future&#46; It does not matter how many technological innovations and skills there are in the field of endoscopic techniques&#44; this process of decision making before and after any intervention will remain the key point&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "General assessment &#8211; history and physical examination"
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              "titulo" => "Cardiovascular"
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              "titulo" => "Anticoagulation and antiplatelet agents"
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              "identificador" => "sec0055"
              "titulo" => "Age"
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            4 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Bronchoscopy in the ICU"
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            5 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Prophylaxis of endocarditis"
            ]
            6 => array:2 [
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              "titulo" => "Pre medication"
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              "identificador" => "sec0075"
              "titulo" => "Fasting"
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        ]
        7 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Rigid bronchoscopy &#40;RB&#41;"
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        8 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Thoracoscopy"
        ]
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          "identificador" => "sec0090"
          "titulo" => "Post intervention evaluation"
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            0 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Post bronchoscopy"
            ]
          ]
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          "identificador" => "sec0100"
          "titulo" => "Post thoracoscopy"
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          "titulo" => "Conclusion"
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          "identificador" => "sec0110"
          "titulo" => "Conflicts of interest"
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        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
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    "fechaRecibido" => "2011-09-15"
    "fechaAceptado" => "2011-10-07"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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            0 => "Endoscopic techniques"
            1 => "Bronchoscopy"
            2 => "Thoracoscopy"
            3 => "Pre-evaluation"
            4 => "Post-evaluation"
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          "palabras" => array:5 [
            0 => "T&#233;cnicas endosc&#243;picas"
            1 => "Broncoscopia"
            2 => "Toracoscopia"
            3 => "Pr&#233;-avalia&#231;&#227;o"
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        "titulo" => "Abstract"
        "resumen" => "<span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Endoscopic techniques can be considered reasonably safe since they are widely used and the rate of complications is extremely low&#46; Still complications do occur and in order to avoid them&#44; the evaluation of the patient before and after any intervention is of the utmost importance&#46; In this article&#44; issues concerning the preparation of the patient and informed consent&#44; the general assessment &#8211; medical history&#44; current medications&#44; physical examination&#44; laboratory tests&#44; radiological evaluation and analysis of the indication and planning will be addressed&#46; The post intervention evaluation will also be discussed&#44; in order to detect and treat complications and decide on the final guidance for the patient after discharge&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">There are very few up-to-date studies or publications dealing with these areas&#44; the evidence level remains low and most recommendations are based on common sense and expert opinion&#46;</p></span>"
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                      "titulo" => "History of the rigid bronchoscope"
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                            0 => "H&#46;D&#46; Becker"
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Article information

ISSN: 08732159
Original language: English

DOI:10.1016/j.rppneu.2011.10.001

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Year/Month	Html	Pdf	Total

2024 November	8	10	18
2024 October	40	49	89
2024 September	35	57	92
2024 August	45	35	80
2024 July	49	30	79
2024 June	33	26	59
2024 May	49	36	85
2024 April	46	36	82
2024 March	38	19	57
2024 February	30	17	47
2024 January	25	23	48
2023 December	24	22	46
2023 November	32	27	59
2023 October	24	32	56
2023 September	23	34	57
2023 August	33	20	53
2023 July	27	25	52
2023 June	22	13	35
2023 May	41	27	68
2023 April	26	21	47
2023 March	60	17	77
2023 February	41	18	59
2023 January	23	21	44
2022 December	37	19	56
2022 November	58	36	94
2022 October	45	26	71
2022 September	28	23	51
2022 August	39	42	81
2022 July	58	44	102
2022 June	34	27	61
2022 May	48	41	89
2022 April	34	30	64
2022 March	40	47	87
2022 February	44	29	73
2022 January	45	29	74
2021 December	35	34	69
2021 November	61	29	90
2021 October	35	38	73
2021 September	39	34	73
2021 August	21	21	42
2021 July	48	26	74
2021 June	45	19	64
2021 May	30	22	52
2021 April	92	58	150
2021 March	104	16	120
2021 February	85	20	105
2021 January	46	24	70
2020 December	39	15	54
2020 November	70	26	96
2020 October	38	17	55
2020 September	55	26	81
2020 August	67	27	94
2020 July	101	28	129
2020 June	97	17	114
2020 May	85	20	105
2020 April	81	7	88
2020 March	53	15	68
2020 February	85	34	119
2020 January	95	22	117
2019 December	78	19	97
2019 November	71	21	92
2019 October	81	22	103
2019 September	68	11	79
2019 August	225	14	239
2019 July	205	19	224
2019 June	259	17	276
2019 May	313	14	327
2019 April	184	20	204
2019 March	243	11	254
2019 February	200	12	212
2019 January	213	24	237
2018 December	103	5	108
2018 November	38	0	38
2018 October	67	17	84
2018 September	28	5	33
2018 August	91	34	125
2018 July	52	28	80
2018 June	51	14	65
2018 May	93	23	116
2018 April	84	26	110
2018 March	98	19	117
2018 February	33	6	39
2018 January	53	16	69
2017 December	53	19	72
2017 November	62	10	72
2017 October	45	21	66
2017 September	38	17	55
2017 August	35	15	50
2017 July	30	12	42
2017 June	43	24	67
2017 May	60	23	83
2017 April	31	17	48
2017 March	38	7	45
2017 February	54	7	61
2017 January	38	4	42
2016 December	50	19	69
2016 November	102	18	120
2016 October	88	18	106
2016 September	82	11	93
2016 August	51	9	60
2016 July	29	19	48
2016 April	77	6	83
2016 March	111	11	122
2016 February	116	15	131
2016 January	110	12	122
2015 December	85	17	102
2015 November	80	9	89
2015 October	102	14	116
2015 September	118	17	135
2015 August	111	15	126
2015 July	94	4	98
2015 June	73	9	82
2015 May	95	11	106
2015 April	60	9	69
2015 March	103	8	111
2015 February	82	8	90
2015 January	61	11	72
2014 December	83	22	105
2014 November	83	13	96
2014 October	116	22	138
2014 September	107	24	131
2014 August	69	18	87
2014 July	80	9	89
2014 June	57	14	71
2014 May	58	14	72
2014 April	59	10	69
2014 March	63	11	74
2014 February	55	7	62
2014 January	66	10	76
2013 December	63	8	71
2013 November	56	13	69
2013 October	60	12	72
2013 September	47	16	63
2013 August	52	20	72
2013 July	62	20	82
2013 June	49	17	66
2013 May	46	16	62
2013 April	55	32	87
2013 March	51	16	67
2013 February	47	22	69
2013 January	73	34	107
2012 December	43	19	62
2012 November	36	22	58
2012 October	19	15	34
2012 September	13	7	20
2012 January	353	0	353

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