Interventional Pulmonology and the practice of pulmonary endoscopy have evolved tremendously in the past decade. Thanks to new technology, the trained pulmonologist can now perform a large array of diagnostic and therapeutic interventions. Importantly, the complexity of these procedures demands training, and national standards should be met before performing them. In addition, it is clear that the success in these procedures depends only partly on the skills of the physician; the skills of the support staff and the adequacy of the facilities and related resources are also indispensable. Regulating agencies such as Departments of Public Health Services, Joint Commission, and The Health Insurance Portability and Accountability (HIPAA) have released rigorous standards affecting work and workflow in endoscopy units in general. Although pulmonologists are frequently in charge of bronchoscopy units, they are generally not prepared during a fellowship to manage these units. In fact, starting or directing a bronchoscopy unit requires substantial knowledge of the necessary staff, equipment, training, procedure, space, and applicable regulations and legislation. To help provide this knowledge, I briefly describe these requirements here and comment on their importance in ensuring the success of bronchoscopic services.
The Intake and Recovery Area
A dedicated intake and recovery area should be available where nurses can receive and prepare patients for procedures and to help them recover after procedures (Figures 7.1a,b and 7.2). Here, patients will have their medical records updated and their medications verified to be sure the procedure can be performed safely. Each patient has his or her own space in the intake and recovery area, with spacers to provide privacy. In each dedicated personal space, the patient can change into the appropriate attire for the procedure, receive an identifying wrist band, have an intravenous line established, and have a place to store personal belongings safely (for example, any loose dental appliances, jewelry, just to name a few). It is important to note that all discussions and interactions between the patient and healthcare providers in the intake/recovery areas are performed with utmost respect and privacy. Each patient space is equipped to monitor vital signs and oxygen saturation. Suction and oxygen outlets are also indispensable. Further, it should be sufficient to allow patients to be placed on the bed or stretcher appropriate for their procedure (for instance, fluoroscopy, electromagnetic navigation, brachytherapy, etc…). The intake and recovery area should have at least one negative-pressure isolation room for patients who require such management. Importantly, the patient’s name, attending physician, and procedures to be performed should be clearly displayed, and the status of the patient and the procedure should be monitored at all times, either electronically or on a schedule board. The latter is performed with the utmost respect to patient’s privacy regulations. Transportation to and from the intake and recovery area, especially to the procedure suites should be direct and without interruption; hallways should be free from clutter and competing foot traffic (Figure 7.3).
Figure 7.2 An individual patient space in an intake and recovery area showing monitors and a mobile workstation. Note that adequate dividers secure privacy.
Figure 7.3 Hallways from the intake and recovery area to procedure rooms should always be kept clear.
The Bronchoscopy Procedure Room
Procedure rooms should be large enough to accommodate the equipment and staff needed to perform a specific procedure. As a general rule, room size ranges between 500 and 800 square feet. Note that rooms dedicated to more complex procedures may require more space than others. In all cases, there must be room for two individuals to stand at the head of the patient’s bed, and the patient must be accessible from all sides at all times. Lighting must be sufficient and easily dimmed to maximize viewing quality during procedures. Because the electrical connections on bronchoscopes are on the left side, the processors and other equipment are usually positioned on the left side of the patient’s bed, to allow easy access and to decrease potential clutter at the work site during procedures. It is advisable that bronchoscopes are stored in a nearby central location easily accessible (Figure 7.4). After use, they should be routed immediately to a disinfection/sterilization room, which is ideally located in the endoscopy suite for easy access. Procedure rooms should also have enough space to store the equipment needed during procedures, such as tubes, slides, special media, stents, balloons, chest tubes, etc…The locations of each item should be clearly labeled for ease of retrieval. Emergency resuscitation equipment and carts should be easily accessible, and their storage locations in the endoscopy suite should be common knowledge to all staff. Viewing monitors are accessible to both the bronchoscopist and the assistant. If possible, monitors should be adjustable, to allow maximum flexibility in lateral direction, height, and rotation. The number of monitors per patient varies among different centers, but each room should have at least two (Figure 7.5). Rooms are also equipped with oxygen outlets, suction devices, sinks, and hand hygiene supplies. In general, procedure rooms should be ventilated with negative-pressure air exchanges, and fluoroscopy rooms (for C-arm biplanar machines) need to be able to store protective coverings for the staff (Figure 7.6).
Figure 7.5 A basic bronchoscopy suite showing two endoscopy monitors.
Figure 7.6 A C-arm fluoroscope with an appropriate bed in a bronchoscopy suite.
In rooms where specimens are prepared for rapid on-site evaluation, the work area should be free of clutter and be equipped to allow specimens to be processed promptly during the procedure. The latter includes a microscope, slides, and appropriate preparation solutions. In some facilities, advanced surgical procedures are performed in bronchoscopy rooms; therefore, they need adequate overhead surgical lighting and sterile equipment (Figure 7.7). Measures to maintain the sterility of the surgical field should also be easily implemented. In such rooms, space for general anesthesia equipment must also be available. All procedure rooms should have easy access to resuscitation equipment, including airway boxes for endotracheal intubations. Cardiac defibrillators should be located in each room or in a nearby central location. In procedure rooms, access to medical records and radiographic records is crucial. Proceduralist should have capacity to display this information in monitors prior and during their procedures. The experience that a patient has from a procedure is largely dictated by external factors, rather than the endoscopic intervention. Proper sedation, a generally pleasant atmosphere, and minimized chatter and loud noises during procedures are signs of a professional endoscopy unit.
Figure 7.7 Advanced bronchoscopy room includes surgical light, adequate monitors, and anesthesia equipment.
Workstations
Proper documentation, by dictation and image, is important both for patient management and communication, and for accurate billing. Thus, endoscopy suites should have dedicated workstations separate from the procedure rooms. These stations should include computers, special forms, dictation equipment, monitors, printers, and so on, and are important for completing procedure-related paperwork. Patient-related endoscopic information should be easily available at each workstation.
Endoscopy Assistants
Endoscopy assistants have important duties before, during, and after every procedure. In fact, they are very important persons in the suite: The success of the procedures depends greatly on their training, skill, and dedication. They are responsible for preparing the room, the equipment, and patients for each procedure and for handling the specimens and used equipment after the procedure.
Bronchoscopy Equipment
Bronchoscopy requires a variety of equipment for performing specific diagnostic and therapeutic interventions. Equipment acquisition should thus be determined by the kind, extent, and complexity of the procedures to be undertaken in the unit. Diagnostic airway procedures and, occasionally, minimally invasive pleural procedures are common, and require the resources described further. Several manufacturers make several different kinds of flexible bronchoscopes. Generally, all these scopes are adequate for examining the tracheobronchial tree. They range in size from ultrathin and pediatric scopes, to those with diameters of 5.3 mm and working channels of 2.0 mm for adults, to therapeutic scopes with working channels of 3.2 mm. Other equipment include endoscopic ultrasonography (linear and radial), peripheral navigation systems, just to name a few. In some endoscopy suite Cone Beam Computerized Tomography equipment is utilized for accurate localization of targets during peripheral navigation procedures. All equipment must be stored in identified areas, and not placed in hallways. Importantly, some rooms have to be electromagnetically mapped prior to procedures. In units where gastrointestinal endoscopies are also performed, gastrointestinal endoscopes must be separated from bronchoscopes at all times, especially during processing, cleaning, and storage. In addition, labeling each scope and keeping accurate records of each are essential.
Fluoroscopy
Fluoroscopy is often useful in performing bronchoscopic procedures, including transbronchial biopsies, electromagnetic navigation, and a variety of routine pleural interventions. Radiation exposure from the recently introduced digital pulse fluoroscope is substantially lower than that from traditional fluoroscopes. When choosing a fluoroscopic system, remember that biplanar systems are more accurate than single-planar systems. Computed tomographic fluoroscopy is also available. In any case, all personnel in the fluoroscopy suite must wear dosimetry badges, and in many institutions, nonradiologists must pass a basic examination on fluoroscopic safety.
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