Guideline Summary for Diagnostic Flexible Bronchoscopy

Patient Preparation

Patients should abstain from solid food for 4 hours before bronchoscopy and may ingest clear fluids up to 2 hours prior to the procedure. [@1]
Individuals with suspected COPD require spirometry; if FEV₁ < 40 % predicted or SaO₂ < 93 %, an arterial blood gas measurement is mandatory. [@1]
Asthmatic patients must receive a bronchodilator before the procedure. [@1]
Routine coagulation screening (platelet count, PT/INR) is indicated only for patients with known bleeding risk factors or when a transbronchial biopsy is planned. [@1]

Oral anticoagulants should be stopped ≥ 3 days before bronchoscopy if a biopsy is anticipated, or reversed with low‑dose vitamin K. [@1]
When anticoagulation must be continued, the INR should be reduced to < 2.5 and heparin initiated. [@1]
Prior to transbronchial biopsies, verify platelet count, PT and PTT. [@1]

Administer prophylactic antibiotics to patients who are asplenic, have prosthetic heart valves, or a history of endocarditis. [@1]

Recent myocardial infarction: avoid bronchoscopy within 6 weeks due to increased arrhythmia risk. [@1]
Elevated pre‑procedure arterial CO₂: avoid sedation because it may precipitate respiratory failure. [@1]

Sedation should be offered to all patients without contraindications. [@1]
Use incremental dosing to achieve adequate sedation and amnesia. [@1]
Avoid sedation in patients with elevated baseline CO₂. [@1]
Atropine is not required routinely before bronchoscopy. [@1]
Limit total lidocaine dose to 8.2 mg/kg (≈ 29 ml of 2 % solution for a 70 kg adult). [@1]
Prefer 2 % lidocaine gel for nasal anesthesia rather than spray. [@1]
Apply the minimum necessary lidocaine when instilled through the bronchoscope and exercise extra caution in elderly or patients with hepatic or cardiac impairment. [@1]

Establish intravenous access before bronchoscopy and maintain it through recovery. [@1]
Continuous pulse‑oximetry is mandatory throughout the procedure. [@1]
Provide oxygen supplementation to maintain SaO₂ ≥ 90 %, reducing arrhythmia risk. [@1]
ECG monitoring is not routine but should be considered in patients with severe cardiac disease or persistent hypoxia despite oxygen. [@1]
Resuscitation equipment must be readily available. [@1]
Ensure at least two assistants, with one qualified nurse, are present. [@1]

For suspected endobronchial malignancy, obtain ≥ 5 bronchial biopsy specimens plus brushings and washings. [@1]
Aim for a diagnostic yield of ≥ 80 % from the combined biopsies, brushings, and washings in endoscopically visible malignancy. [@1]
In diffuse lung disease, perform 4–6 transbronchial lung biopsy samples from a single lung. [@1]

All staff must be vaccinated against hepatitis B and tuberculosis, with immunity and tuberculin status verified. [@5]
Staff should wear protective clothing (gowns or plastic aprons, masks/visors, gloves) during bronchoscopy. [@5]
When bronchoscopy is performed on patients with multidrug‑resistant tuberculosis, wear high‑grade particulate respirators and conduct the procedure in a negative‑pressure environment. [@5]
Use non‑powdered latex or non‑latex gloves. [@5]
Bronchoscopes must be disinfected in a dedicated room using automated, well‑ventilated systems, preferably inside a fume cabinet. [@5]
During cleaning, staff should wear nitrile gloves, plastic aprons, and eye/respiratory protection. [@5]
Do not re‑sheath injection needles; spiked biopsy forceps require meticulous cleaning. [@5]
Prefer disposable or autoclavable accessories to reduce infection risk. [@5]
Staff require training in patient care, infection control, instrument decontamination, and safe aldehyde handling. [@5]
Pre‑employment health checks for aldehyde exposure should follow COSHH recommendations. [@5]
Conduct periodic lung‑function screening and symptom monitoring for bronchoscopy personnel. [@5]

Oxygen supplementation may be needed after the procedure, especially in patients with impaired lung function or who received sedation. [@1]
Continue monitoring until the patient is stable and alert. [@1]
Maintain intravenous access throughout the recovery period. [@1]
Obtain a chest radiograph ≥ 1 hour after transbronchial biopsy to exclude pneumothorax. [@1]
Patients who were sedated should avoid driving, signing legal documents, or operating machinery for 24 hours. [@1]
Provide verbal and written instructions to improve patient tolerance and understanding. [@1]

Prior to bronchoscope insertion, assess the internal diameter of the endotracheal tube. [@5]
ICU patients are high‑risk for complications during fiberoptic bronchoscopy. [@5]
Maintain continuous multimodal physiological monitoring during and after the procedure. [@5]
Ensure adequate ventilation and oxygenation throughout bronchoscopy via the endotracheal tube. [@5]
More profound sedation or anesthesia can be administered in ventilated patients when the clinician is experienced with such agents. [@5]
ICUs should have the capability to perform urgent flexible bronchoscopy for therapeutic and diagnostic indications. [@5]

When guideline‑adherent practice is followed, mortality rates range from 0.01 % to 0.04 % and major complication rates are ≈ 0.08 %. [@4][@6]