Bronchoscopy

What do I need to know if I am having a bronchoscopy?

This information leaflet has been prepared to help you and your relatives understand more about what a Bronchoscopy is and how to prepare for it.

It is really important that you read all of the information. It will help put your mind at ease about some worries you may have. It will also help you avoid any simple mistakes which might stop you being able to have the procedure on the day.

We want to hear from you before the day of your test if you have any questions. There aren’t any “silly” questions you can ask. If you are worried or concerned, please ask us and we will do our best to help.

There is a lot of information in this leaflet. It has been written to cover as many different situations and problems people who are coming for the test may have. Don’t worry if some of the information doesn’t apply to you.

What is a bronchoscopy?

A Bronchoscopy is a procedure where a flexible camera (known as a bronchoscope) is passed through your mouth and vocal cords into your windpipe and airways. This camera allows the team to look at your airways.

This test is used to look inside your lungs and take samples from your airways or from areas of your lung.

Why do I need a bronchoscopy?

You will have been offered a Bronchoscopy usually after you have gone through other tests by the chest team.

Most often you will have had a CT scan of your chest (a detailed 3-dimensional X-ray scan). The CT scan may have shown abnormal areas in your lung tissue such as shadows, areas of infection or inflammation or problems with your airways.

To help understand what has caused these problems a Bronchoscopy can be used to take samples.

Less commonly, some patients have a Bronchoscopy if they have been coughing up blood, even if they have had a CT scan and it is normal. This is because very occasionally CT scans can miss very small problems. We are more likely to do this if you are or have been a smoker.

Your team will talk to you before the test to explain why they are doing the test.

How do I get ready for a bronchoscopy?

Don’t worry, it isn’t complicated. However, it is important that you follow these instructions carefully and ask us any questions you may have regarding preparation as problems could lead to a delay or even cancellation of your procedure.

The most important things to know are when to fast (go without food) and what adjustments you may need to make in taking your regular medicines.

Fasting

We ask you to fast before the procedure to make sure that your stomach is empty. This reduces the chance of you being sick during the procedure, which is very dangerous and could damage your lungs.

You should not eat anything for 6 hours before your appointment time. You can have clear fluid up until 2 hours before your appointment time.

Your procedure may be done in the morning or afternoon.

Morning appointments

If your appointment for your Bronchoscopy is in the morning, we ask you to fast from midnight on the day of your procedure.

You can have morning medications (except diabetes medications and medications to thin the blood – we explain what to do with these below), providing they are taken with a small sip of water before 6:30am.

Afternoon appointments

If your appointment is in the afternoon then you can have a light breakfast, such as a slice of toast around 7:30am. You can have clear fluids up till 11:00am.

You can take your morning medications (except diabetes medications and medications to thin the blood- we explain what to do with these below) with your breakfast.

Will any of my usual medicines change?

We may need to change some of your medicines in the days leading up to your test or on the day of the test itself. These are the most common medicines we might change:

Diabetes medicine

If you take insulin or medication for diabetes, you will have received advice from the doctor who arranged your Bronchoscopy so that appropriate arrangements can be made and advice given about your preparations. Some patients will not be suitable for the procedure to be done as a day case and an overnight stay may be necessary. The following are the guidelines for each of the different medications

What should I do with my diabetes TABLETS before my test?

Acarbose

Day before going to hospital: take as normal.

Day of the test:

If your test is in the morning: omit morning dose if you have been told to fast from midnight.

If your test is in the afternoon: take your morning dose if eating breakfast. Do not take your lunchtime dose.

Repaglinide or Nateglinide

Day before going to hospital: take as normal.

Day of the test:

If your test is in the morning: omit morning dose if you have been told to fast from midnight.

If your test is in the afternoon: take your morning dose if eating breakfast. Do not take your lunchtime dose.

Metformin

Day before going to hospital: take as normal.

Day of the test:

If your test is in the morning:

• If taken once a day – do not stop
• If taken twice a day – do not stop
• If taken three times a day – do not stop.

If your test is in the afternoon:

• If taken once a day – do not stop
• If taken twice a day – do not stop If taken three times a day – omit lunchtime dose only.

Glipizide, Gliclazide, Glimeprimide, Gliquidone

Day before going to hospital: take as normal.

Day of the test:

If your test is in the morning:

• If taken once a day in the morning – omit this dose
• If taken twice a day – omit the morning dose.

If your test is in the afternoon:

• If taken once a day in the morning – omit this dose
• If taken twice a day – omit both doses.

Pioglitazone

Day before going to hospital: take as normal.

Day of the test:

If your test is in the morning: take as normal.

If your test is in the afternoon: take as normal.

Sitagliptin, Saxagliptin, Vildagliptin

Day before going to hospital: take as normal.

Day of the test:

If your test is in the morning: omit your morning dose.

If your test is in the afternoon: omit your morning dose.

What should I do with INSULINS before my test?

Once daily (evening)

(Lantus® / Glargine or Levemir / Detemir® Insulatard® or Humulin®)

Day before going into hospital: no dose change.

Day of the test:

If your test is in the morning: no dose change.

If your test is in the afternoon: no dose change.

Once daily (morning)

(Lantus® / Glargine or Levemir / Detemir® Insulatard® or Humulin®)

Day before going into hospital: no dose change.

Day of the test:

If your test is in the morning: Take your normal dose. Your blood glucose will be checked on admission.

If your test is in the afternoon: Take your normal dose. Your blood glucose will be checked on admission.

Twice daily

(Novomix 30® / Humulin M3® / Humalog Mix 25® / Humalog Mix 30®)

Day before going into hospital: no dose change.

Day of the test:

If your test is in the morning:

• Halve the usual dose
• Your blood glucose will be checked on admission
• Resume your normal insulin with your evening meal.

If your test is in the afternoon:

• Halve the usual dose
• Your blood glucose will be checked on admission
• Resume your normal insulin with your evening meal.

3, 4 or 5 injections daily

Day before going into hospital: no dose change.

Day of the test:

If your test is in the morning:

• Do not take your morning dose of short acting insulin if no breakfast is eaten
• If you normally take a long acting basal insulin in the morning you should take your normal dose
• If you normally take a pre-mixed insulin the dose should be halved
• Do not take your lunchtime dose. Resume your normal insulin with your evening meal.

If your test is in the afternoon:

• Take your usual morning insulin dose(s)
• Do not take lunchtime dose
• Your blood glucose will be checked on admission
• Resume your normal insulin with your evening meal.

Blood thinning medications

If you continue to take blood thinning medicine before you have a Bronchoscopy this would increase the chance of you having serious bleeding during the test.

This would put your health at serious risk and make it much harder to get enough biopsies to make a diagnosis. This is why we need to stop your blood thinning medicine before the test.

If you are using Warfarin you should have been told exactly when to stop it and when to have a blood test prior to the procedure. If not please ring the respiratory secretaries.

If you are using Apixiban (Eliquis), Dabigatran (Pradaxa) or Rivaroxaban (Xerelto) you should have been given a stop date by the Consultant referring you for the procedure. If not please ring the respiratory secretaries.

The following is a guide to how long each different blood thinner needs to be stopped before the EBUS.

Warfarin

Stop 5 days prior to Bronchoscopy. You will need an INR test the day before the Bronchoscopy to make sure your INR is below 1.5. Please check with us to see if you need injections to thin the blood whilst your INR is low.

Aspirin

Do not take on the morning of the procedure.

Clopidogrel (Plavix) / Dipyridamole (Persantin) / Prasugrel (Effient) / Ticagrelor (Brilique)

Stop 7 days before the Bronchoscopy. Please contact us and check if your Cardiologist has advised you not to stop these medications as we may need to discuss the risk versus benefit with them.

Daltaparin / Tinzaparin / Enoxaparin

Stop one full day before the procedure.

Apixaban (Eliquis) / Dabigatran (Pradaxa) / Rivaroxaban (Xerelto)

Usually stopped 2 to 4 full days before the procedure but please check with us as your kidney function (determined by blood test) will determine when this should be stopped.

Medication for Parkinson’s Disease

Medicines for Parkinson’s disease need to be taken at very precise times. We advise you to take your normal medicine with a small sip of water up to two hours before the test. We will normally make sure you are first on the list for the test.

We may ask you to bring a supply of your medicine to hospital so that you can take it as soon as you are able to eat and drink, if your next dose is at this time. If you have a very complicated combination of medicines, we may discuss your case with your supervising consultant before you have the test.

Addison’s Disease and other conditions needing long-term steroid use

The treatment for Addison’s disease is daily use of steroids. Some patients with other conditions such as asthma, rheumatoid arthritis and bowel problems may also take long term steroid treatment (specifically 5mg or more of prednisolone a day).

If this applies to you, we will give you an injection of Hydrocortisone into a muscle before you have the test. We will also ask you to double your normal dose of Hydrocortisone or Prednisolone tablets for 24 hours after the test. After this, providing you are well, you can go back to your normal dose.

How exactly is a bronchoscopy done?

You will probably have some worries about exactly how the test is done. You may have had relatives or friends who’ve had other types of camera test done and this has made you worried.

On the day:

If you are having sedation: you will need a friend or relative to bring you, collect you and stay with you overnight after you’ve been discharged. If you don’t have anyone available to stay with for the night after the test, then you will be admitted to hospital overnight.

Please wear comfortable clothing and ensure you remove nail varnish as this can interfere with the monitor we use to monitor your oxygen levels. If you smoke please try to avoid doing so on the day of the procedure as it can lower your oxygen levels during the procedure.

Bring all of your medication (including over the counter remedies) and a list of any allergies.

You must tell us of any Latex allergy, as it is used during the procedure. We can still do the procedure without latex, but it requires special arrangements to be made in advance of your test.

Please come to the Endoscopy department on the lower ground floor of the South Wing at University Hospital North Tees.

After booking in at reception you will be taken through to the Endoscopy department to go through a check list with a nurse.  A relative or friend may be able to sit with you during this conversation, but they won’t be able to accompany you into the procedure room while you’re having your test.

The nurse will ask you questions about your medical history, what medicines you take and what allergies you have. They will also do some simple checks of your pulse, blood pressure, oxygen level and temperature.

You may have answered some of these questions before you came for the test, but we ask you to be patient. These questions are to make sure that we do the test as safely as possible.

You will then be offered a seat in the Endoscopy waiting area. If you wish, you may bring a book or some music and headphones to keep you relaxed.

While we ask you to attend at your appointment time, the time of your actual procedure depends upon a number of different factors such as the number and type of cases to be done.

We know how worrying it is sitting and waiting to have a procedure but sometimes some cases take longer than expected. We will do our best to keep you informed on the day.

The Doctor will go through a consent form to ensure you understand the risks and benefits of having the procedure. You will have the chance to ask any questions you have at this time.

Having the bronchoscopy

When you are ready, you will be taken through to the Bronchoscopy room where you will be made comfortable on a patient trolley.

The nurses will go through some simple checks, including checking your name and allergies. You will then be attached to different monitors to allow the team to read your pulse, blood pressure and oxygen levels during the procedure.

A thick needle (cannula) will be inserted into your arm/hand so that we can give you sedation.

You do not have to have sedation if you don’t want to, we generally recommend it as it makes you more comfortable. However, many people are able to have the test without sedation.

If you don’t want sedation, we still insert the cannula in case you change your mind during the procedure to avoid any delay in giving it to you.

The Doctor will give you a numbing local anaesthetic (throat spray). This can taste a little unpleasant, but this passes quickly. It is common to feel a lump in your throat as it is numbing, your mouth and throat will then go completely numb and feel strange. These are all normal sensations and nothing to worry about.

A small plastic mouth guard will be placed in your mouth to protect your teeth and the bronchoscope.

If you are having sedation, the team will then give you this through the cannula. This is usually a medicine called Midazolam. This is to relax you and make you feel sleepy.

You will usually receive oxygen through a soft sponge into one of your nostrils.

The procedure can be done while you are sitting up or lying flat. Most patients do prefer to sit up. The team will explain which position they feel would be best, but will be guided by your preference.

The Doctor performing the test will stand in front of you if you are sitting up or behind you if you are lying flat. The other team members will stand around the bed to assist.

The camera is then passed in through either your nose (this is usually better for the patient as it generally causes less irritation at the back of your throat) or your mouth. After spraying your vocal cords with more local anaesthetic, the camera is passed into your windpipe and then your airways.

At each stage the team spray more local anaesthetic to make sure everything is comfortable. It is normal to cough and to have a sensation of narrowing of your throat while this is happening. It passes and the team will be there to reassure you. There is always plenty of room to breathe.

The doctor will then use the camera to have a detailed look through all of your airways. They will focus on areas that were abnormal on your previous CT scan. If they see anything abnormal or if they are wanting to investigate a particular area of your lung, they will take samples. These samples may include some or all of the following:

• Biopsies: a small tool can be passed through the camera to take small bites of tissue from any lumps or bumps in your airways, or for taking samples of your lung tissue. If biopsies are needed, it’s usual for 5 to 10 samples to be taken.

• Brushings: a small, flexible plastic brush can be passed through the camera and rubbed over an abnormal area in your airways or more deeply into the lung. This picks up cells which can be looked at under a microscope to help give more information.

• Washings: a solution of salty water can be passed through the camera over an abnormal area in your airway, or to wash out a particular area in your lung. This is used to pick up cells and secretions from these areas. This can be sent to the laboratory and can be helpful in diagnosing infections in your lungs.

The biopsies and other samples should not cause you any pain, but you will probably cough while they are being taken.

You might hear or remember lots of unusual words being spoken during the test. This might sound odd, but this is the team noting exactly where they are taking samples from.

At least 2 nurses will look after you during the test. The procedure will be performed by a Consultant who may be assisted by a senior doctor who is training in this procedure. The procedure takes an average of 20 to 30 minutes.

When the Bronchoscopy is finished you will be taken to the recovery area.

Will I be awake during the procedure?

As mentioned previously, a Bronchoscopy can be performed without sedation. This is perfectly safe. You may hear the Doctor explaining the procedure as it happens. Some patients find that this helps.

We usually recommend sedation to make you more relaxed and comfortable. However, a general anaesthetic isn’t used, so you will not be unconscious. You may remember some or all of the procedure.

Will I be able to go home on the same day of the bronchoscopy?

Yes. If you have not had sedation, you will normally spend approximately 20 to 30 minutes in recovery while the effects of the local anaesthetic wear off. You will then be given something to eat and drink, providing there are no problems you can leave at this point.

If you have had sedation, you will be monitored in the recovery area for up to 2 hours while the local anaesthetic wears off. You will be offered something to eat and drink.

Important: The sedation medication can affect your judgement and behaviour for up to 24 hours after the procedure. Because of this, for the first 24 hours you must not:

• Drive
• Drink alcohol
• Sign any legal documents
• Work
• Operate machinery
• Be responsible for small children.

If you have had sedation, it will be necessary for someone to collect you from the Endoscopy Unit and stay with you for 24 hours following the procedure.

If we have had to adjust or stop any of your normal medicines, we will tell you and the person collecting you when to restart them before you leave the department.

What risks or side effects should I know about?

It is important to remember that having a Bronchoscopy is a common, safe procedure. If you have been asked to have a Bronchoscopy, then your team feel that the possible benefits outweigh any risks.

The following are the risks which you should be aware of:

• Sore throat and hoarse voice

• Cough: it is common to cough during the procedure. We try to reduce this as much as possible by using local anaesthetic spray as we insert the camera. You may cough more often than normal for a few days after the test.

• Bruising in your eye: very rarely the cough can result in a bruising to the white of your eye. This is known as a subconjunctival haemorrhage. It can look worrying but is harmless and does not affect your eyesight. It usually gets better in 7 to 14 days.

• Damage to existing teeth or any dental work: this is rare and minimised by the removal of any dentures before the test and the use of a mouth guard.

• Breathing problems: rarely, the airways can be irritated by the test and go into spasm. This is more likely in patients with pre-existing lung disease such as asthma or COPD. You may require a nebuliser. Some patients may take a longer time to recover after the procedure and you may need to be admitted to hospital for observation or further treatment.

• Heart Problems: in up to 5 out of every 100 patients having this procedure, a brief minor strain may be put on the heart. This can cause abnormal beating of the heart. It can very rarely cause fluid to collect in the lungs or a heart attack.

• Fever: fever can be common after this procedure. It usually settles within 24 to 48 hours and can be treated by paracetamol. Always stick to the recommended daily dose advice on the packet.

• Infection: less than 1 in 500 patients develop an infection in their chest. Please contact your GP or Specialist Nurse if you have symptoms such as breathlessness, a cough that isn’t going away or is getting worse and new sputum (phlegm), or if you simply just don’t “feel right.”

• Bleeding: usually any bleeding is minor and settles quickly. About 1 in 1000 patients may develop significant bleeding. This may require the team to give medicine into your airways to control the bleeding. It is very rare for any bleeding to be life threatening.

• Allergic reactions to sedative medicine or local anaesthetic spray.

• Failure to achieve a diagnosis: in about 1 in 10 patients, the samples don’t give enough information to be confident about the diagnosis. This may mean that the team ask you either to undergo a repeat or alternative biopsy test.

• Death: less than 1 in 1000 patients will not survive the procedure. The risks are higher in patients who have very severe heart or breathing problems. Your team will have carefully weighed up the risk to your health before recommending this test to you.

It’s normal to feel quite anxious about the test after reading all of the possible risks and side effects. However, please be assured that the vast majority of patients have no problems during or after the test.

When will I get my test results?

The team will tell you on the day if they have been able to get the samples they needed. However, they won’t be able to tell you the results of these samples on the day of the test.

After the samples have been taken they go to the laboratory. In the laboratory they are prepared with different chemicals before they are ready to be looked at. This is a complex and precise process and takes a certain amount of time.

The results are usually available within 7 days. However, it can take longer for the results if it is a particularly difficult biopsy to come to an answer with, or if extra tests are needed on the samples. Some tests looking for slow growing bacteria or other bugs can take up to 6 weeks to run to completion.

You will be contacted after the results are available to arrange when and where you will have a consultation.

If you have come from another hospital to have the test, you will receive the results from the team at the referral hospital. If you are worried about lack of follow up arrangements, please let us know.

Is there an alternative test to having a bronchoscopy?

This depends on why you are having the Bronchoscopy. If you have a shadow or mass in your lung, alternative tests are possible, such as using a CT scanner to guide a needle through your chest wall into the area of concern.

A Bronchoscopy is generally used in this setting to investigate shadows or lumps in or near your airways which are generally less amenable to this other type of biopsy.

If the Bronchoscopy is being used to investigate areas of lung inflammation or infection, other tests such as sputum (phlegm) testing will usually have been tried before this test.

Your team will have carefully considered this before recommending a Bronchoscopy to you. They will be more than happy to go through any other possible tests and the final decision is always yours.

References

British Thoracic Society guideline for diagnostic flexible Bronchoscopy in adults, Du Rand IA, Blaikley J, Booton R, et al. Thorax 2013; 68: i1–i44.

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