AORN JOURNAL NOVEMBER 1987, VOL. 46, NO 5

Pediatric Bronchoscopy SPECIAL CONSIDERATIONS

Susan Welsh, RN; Laura Myre, MD; Gayle Gatch, RN

emoving a foreign body from a child's airway presents a special challenge R because the child's airway is small and

easily occluded by an object. In addition, the inflammation and edema caused by the object and the bronchoscopy instruments can decrease the lumen even farther. Ventilatory compromise in children can lead to hypoxia very quickly, and thus the OR nurse must be prepared to administer care in a situation that can change rapidly.

A child who has recently aspirated a foreign body is usually coughing, choking, OJ wheezing. Often, the patient has a history of playing with or eating small objects or pieces of food. If the child is not in acute respiratory distress, diagnostic studies are done.

Inspiratory and expiratory chest radiographs are often the first diagnostic studies done. Some surgeons, however, prefer to use fluoroscopy because it has the advantage of being able to show trapped air distal to the foreign body site. Even if the child has normal radiographs and/or a fluoroscopy, positive symptoms or history are often enough to warrant examining the airway by a bronchoscop y .

Preoperutive Care

n preparing the operating room for a child requiring a bronchoscopy, the OR nurse will I need to know the child's age, height, and

weight to determine the size of the scopes and other necessary equipment. The child's respiratory status will determine the urgency of the procedure.

The OR nurse must be sure that the appropriate

laryngoscopes, bronchoscopes, telescopes, suction catheters, light cords, light sources, eyepieces, telescope adaptors, and ventilation connectors are available and in working order. An assortment of grasping forceps are needed for each scope (Fig

Susan Welsh

Susan Welsh, RN, BSN, is a clinical specialist, Pediatric Surgical Associates, Primary Children 's Medical Center, Salt Lake City. She received her diploma in nursing from Johns Hopkins Hospital School of Nursing, Baltimore, and her bachelor of science in nursing from Westminster College, Salt Lake City,

Laura Myre, MD, is a general surgery resident, University of Utah Medical Center, Salt Luke City. She is coauthor of the preceding article.

Gayle Gatch, RN, is a clinical research and education associate, Pediam'c Surgical Associates, Primary Children S Medical Center, Salt Lake City. She ir coauthor of the preceding article.

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1). Special attention must be given to the equipment to ensure that all parts are the correct size and length and fit together.

An assortment of telescopes (0 degree, 30 degrees) are needed to view the various angles in the bronchial anatomy. Some method of defogging the lens, either with hot water or commercial agents, is also recommended. Nurses must have all equipment assembled and ready before the child is brought into the operating room.

Children with foreign bodies in their airways require general anesthesia for laryngoscopy and bronchoscopy . The anesthetic induction technique will depend on the degree of airway obstruction, the child’s age, and when the child has last eaten. If the child has eaten in the previous eight hours but is not in acute respiratory distress, the anesthesiologist can usually induce anesthesia after an eight-hour fast.

If the child is experiencing respiratory distress and there is a need to proceed despite the NPO status, the risk to the child obviously increases. Induction of anesthesia in a patient with a full stomach is generally done in two phases: (1) obtaining protection of the airway, and (2) emptying the stomach with a nasogastnc tube. Once the two phases are complete, the anesthe- siolopt induces anesthesia with an inhalation anesthetic (usually nitrous oxide or halothane) through a flavored mask. Often, the vocal cords are sprayed with a 4% topical lidocaine to help eliminate a vocal cord spasm. Blood pressure cuffs, electrocardiogram leads, pulse oximeter, and a temperature probe are used to monitor the patient.

Procedure for a Bronchoscopy

he patient is placed in a supine position with his or her head at the very top of T the OR bed. The OR bed is turned so

that the surgeon is at the head, the anesthesiologist is at the surgeon’s left side, and the scrub nurse is on the right side.

Using a laryngoscope, the surgeon passes the bronchoscope under direct vision into the upper trachea airway. The surgeon frequently uses a 30- degree telescope to locate the foreign body. After locating the foreign body, the surgeon leaves the

Fig 1. Grasping forceps used in a bronchoscope. Flexible four-prong grasping forcep (top), grasp- ing optical forcep (center), and embolectomy catheter (bottom).

bronchoscope in place, removes the 30-degree telescope, and inserts the optical forcep.

At Primary Children’s Medical Center, Salt Lake City, we use a rigid 3.5 mm x 30 cm ventilating bronchoscope, a 30-degree 2.7 mm x 30 cm rod lens telescope, and an optical grasping forcep that has its own 0-degree 35 cm telescope (Fig 2). Surgeons at the medical center have found that using the 0-degree telescope with the optical

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Fig 2. Bronchoscope, telescope, and optical forcep.

Fig 3. Grasping an aspirated peanut with an optical forcep.

forcep is the most efficient for direct vision of the object.

Because narrow lumen equipment is used, it is impossible to bring the object out through the sheath. To remove an object, the surgeon first grasps the object with the optical forcep (Fig 3). The surgeon then brings out the bronchoscope and the optical forcep together.

Once the bronchoscope is removed, the anesthesiologist ventilates the child via a mask until the surgeon is ready to reinsert the bronchoscope to look for any fragments and to clean out the bronchus. Often purulent material collects behind the foreign body.

A foreign body tightly impacted in a bronchus can be difficult to remove. Food objects can cause

an inflammatory reaction in the bronchial wall, which prevents the surgeon from getting a firm grasp on the object with a forcep. It may be necessary to dislodge the object with a balloon catheter and then grasp it with a forcep. The four- prong wire grasping forcep will sometimes hold onto a soft friable object better than a hinged forcep, which may slice through the object. The balloon catheter and the four-prong wire forcep will fit through the instrument channel of the bronchoscope.

Sharp objects may need to be turned before being removed to avoid abraiding the bronchial wall. Occasionally, an object has swelled so much that it will not pass through the vocal cords and can cause total airway obstruction. If that happens,

AORN JOURNAL

the surgeon pushes the object back down into the bronchus and ventilation is restored. The object is then fractured and the pieces removed one at a time-a difficult and timeconsuming process that requires intense concentration.

Postoperative Care

he anesthesiologist ventilates patients with a bag and mask before and after the T bronchoscopy. Patients who have had

respiratory distress or have significant pulmonary injury may experience some degree of postoper- ative laryngospasm or bronchospasm. The anesthesiologist will intubate these patients at the conclusion of the procedure. They will either be extubated in the ,postanesthesia care unit (PACU) when fully awake or be taken to the intensive care unit for overnight observation. These children are often treated in the PACU with broncho- dilators, such as an aerosol racemic epinephrine.

Children with evidence of pulmonary infection, such as preoperative fevers, pulmonary infiltrates on chest radiographs, or purulent bronchial secretions, are placed on systemic antibiotics. Some patients may be kept in the hospital for a few days to receive additional respiratory therapy. The patients without a significant laryngospasm or bronchospasm often recover from the procedure quickly and are sent home after eight to 12 hours of observation.

A child who has aspirated a foreign body and requires a bronchoscopy poses a difficult problem for the perioperative nurse. To ensure safe and effective surgical intervention, the nurse must determine the needs of the child, prepare and equip the OR accordingly, and coordinate the efforts of the surgical and postanesthesia teams. A well- designed perioperative nursing care plan will improve the quality of care and hasten the recovery of the child. 0

Suggested reading Black, R E, et al. “Bronchoscopic removal of aspirated

foreign bodies in children.” American Journal of Surgery 148 (December 1984) 778-78 1.

Roberts, L S, et al. “A unique method for the anesthetic management of laryngeal foreign bodies.” AneJfhe- siofogy 56 (June 1982) 480-482.

NOVEMBER 1987, VOL. 46, NO 5

Teglovic Joins Continuing Education Staff

Mary Teglovic

Mary Teglovic, RN, MA, joined the AORN staff in August as a continuing education specialist. She is working part-time until she completes her bachelor of science in nursing in March, at which time she will begin working full-time. She has a master of arts degree in health education from the University of Northern Colorado, Greeley.

Teglovic has several years of experience both in perioperative nursing and teaching OR issues. She worked as an OR staff nurse at North Colo- rado Medical Center, Greeley, intermittently dur- ing the last 20 years while raising her family.

She also worked as an instructor from 1982 to 1983 with the Centennial Area Health Education Center in northeastern Colorado, which was administered by the University of Colorado Health Sciences Medical Center, Denver. Her responsibilities included bringing updated medi- cal information to those professionals working in rural areas. She concentrated on teaching OR nursing and infection control issues.

responsibilities include updating the AORN Stana’arh and Recommended Practices for Peri- operative Nursing and a Modular Independent Learning Systems (MILS’“) on the nursing pro- cess. She will also teach education seminars when she becomes a full-time employee.

Teglovic is excited about working at AORN. She said the hope of being employed by AORN was the “driving force” for her to seek her BSN at the University of Northern Colorado.

As a continuing education specialist, Teglovic’s

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Demand for Latex Gloves Increases Greater use of latex gloves during routine medi- cal examinations is the latest consequence of the acquired immune deficiency syndrome (AIDS) crisis, according to the Sept 7 issue of American Hospital Association News.

The top three glove makers in the United States have increased production of gloves from 30% to 35% in the past year. Although the manu- facturers admit that hospitals may have trouble getting gloves quickly, they do not say that there will be a national glove shortage.

The manufacturers cited tougher AIDS-safety guidelines issued by the Centers for Disease Con- trol, Atlanta, as one reason for the increased demand, according to the article. The guidelines advise that all hospital staff wear medical gloves-and in some cases use additional protec- tive equipment-any time there is a chance of exposure to a patient’s blood or other body

fluids, regardless of whether the patient is infected with the AIDS virus.

The manufacturers are trying to keep up with the increased demand for gloves. One producer is planning to increase its manufacturing capacity to boost the number of its shipments by 60% within the next year. Another manufacturer is building a new plant in Malaysia solely to make medical gloves. The plant is scheduled to be completed in March 1988.

accurate surgical & scientific instruments corporation 300 S H A M E S DRIVE WESTBURY. N Y 11590, PHONE (516) 333-2570. WEST COAST SALES SAN DIEGO, CA (619) 235-9400 TO ORDER CALL (Except N Y Slate TOLL FREE 1-800-645-3569 call 516-333-2570

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