Procedures & Techniques

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Contents:

  • Bronchoscopy
  • EMLA Cream for Painless Needle Sticks
  • Blood Gases and Oximetry – What’s the Difference?
  • Sinus Surgery Procedures
  • Combination Antibiotic Therapy for P. Aeruginosa
  • Nasal Potential
  • Bronchoscopy

    Bronchoscopies are “looks at the bronchi” via a tube inserted through the nostril and down the trachea (or through a tracheotomy if one is present). The device has two fibers in it. One is transmitting light and the other is recieving images which can be displayed on a monitor and recorded on a VCR. Optionally the bronchioscope can also have a tube which can be used to dispense medicine (used to numb the passageways) and to retrieve tissue or mucus samples. The procedure only takes about 1/2 an hour and is generally reported to be virtually painless due to the use of local pain killers, tranquillizers, and anesthesia as needed. Two procedures that may be combined with a bronchoscopy are bronchial lavage (washing the mucus out of the lungs with saline) and directly instilling an antibiotic (e.g., Tobra or Colistin). Bronchial lavage is considered safe and effective by some, and life-threatening by others.

    First-person reports:

    I had several bronchs as a child, for bronchial lavage and directly instilling Tobra or Colistin. If I remember correctly from the last one (years ago, so I’ll do my best), I would go into a procedure room in GI, and be given a little demerol and valium if need be. Then I would “snort” lidocaine jelly up one nostril, followed by (I definitely remember this :*) cocaine nosedrops. The bronchoscope (a tiny tiny flexible neonatal one with a camera) would be put up the nostril that’s been numbed. Through the bronchoscope, lidocaine is squirted ahead of the scope, so there is never any pain. As the tube goes through the windpipe there is sometimes the feeling of needing to cough, but depending on the lidocaine efficacy, I don’t think this always occurred. Then, they would install saline through the tube, while suctioning, so your lungs will never be “filled” with water or anything. This induces very effective coughing, and you will be holding a little suctioner at your mouth, to suck gunk outta your mouth. Also you’ll be on like 15L blow-by, so your sats probably won’t even dip. Then when a great deal has been cleared and you feel like everything is up, either Tobra or Colistin can be instilled through the tube, thus reaching the newly cleared deep parts of the lung. Tobra feels the same as the saline, but colistin foams and you sound and feel like a washing machine for a few minutes. Then the tube comes right out, you sit up and finish coughing, and you should be able to walk back to your room a few minutes later. Have them show you what they suck out — it’s amazing — definitely never would’ve got it up on your own. It’s like a giant clean out, real quick, and is *extremely* effective. The only later effect is hoarseness, and I’m sure your docs will check a cxr to make sure there is no pneumo from the tube. I had them bronchs done at my sickest point before DNase came out, every few months. My best friend, who had severe CF, started having them done weekly, and it really truly kept her at home (she would just come in for a few hours, then go home). I definitely would recommend giving it a try, if DNase/mucomyst doesn’t seem to be thinning your mucus. Sometimes, even with it, nasty plugs accumulate that just need some help getting out.

    I’m not sure if during my Bronchoscopy this past summer the doctor “suctioned and washed” my lungs with antibiotics. I know he looked around in there to see if I had any infections and I seem to remember something about cleaning the gunk out. But the reason I decided to reply was to tell you the procedure I went through was NOT painful, a little uncomfortable. I was under twilight, it’s somewhere between awake and asleep. They did that so they could talk to me throughout the procedure and I could still respond. Anyway–I understand you being nervous. I get near anxiety attacks when I get i.v.’s. And as a matter of fact I almost  fainted before the bronchoscopy when they were taking x-rays. It was weird. I tend to get a little panicky and during the procedure, when I woke up, I freaked out. Then they just gave me a little more of the anaesthetic to knock me back out. I remember them telling me they were going to stick the tube up my nose but I couldn’t feel it because they numb your nose. Afterwards my throat was a little sore and that night I got a fever. The normal side effects. I hope it goes well and you get all cleaned out. I guess these things are always a bit scary even if we know they aren’t going to hurt, but I hope what I’ve said has comforted you regardless.

    First, the bronch. I had one done when I was “asleep” for my port surgery. Needless to say, I didn’t feel a thing! They “sucked” all the gunk out of my lungs, and it seemed to do me some good. Since I have had my tx (the first time was before tx) I’ve had a few bronchs. Before I had my tx, having bronchs was one of my fears. But, (You’ll be happy to hear this), now I know that is not that big a deal! I had two done with the trachea tube in which were fairly easy because they just went in through the tube, no gagging! I have had about 3 without the trachea tube. Here anyway, they give you something to knock you out. I go in (they usually put in an IV to administer the drugs), they swab the back of my throat with freezing (I am awake for this, a little bit of gagging), I lie back…..I wake up in the recovery room! I have no recollection of what just happened. My last experience though, I was a little bit sick from the morphine they gave me beforehand. I think I will skip it this time coming up (I think I am due for one in Feb. sometime). Oh, yeah, I think I should mention that the bronch they did before my tx was to suction some of the junk out. Now (because there isn’t any more of that junk:) they take samples of the tissue (I’m not totally sure about that…) to check for infection, signs of rejection.

    The bronchiowash is done with a saline solution. There is two types of procedures that I know of, one where they isolate one lung at a time and start washing each bronchial passage. The other is they isolate each bronchial passage with a small balloon and wash each passage by itself. Both procedures are dangerous, the first one can cause asphyxiation due to drowning (which has happened to a few patients), as for the other procedure due to them blocking off a bronchial passage with a balloon to do the wash, too much pressure can cause a rupture. By the way this whole procedure of washing the lung’s is called a Lavage. Lavage’s were done in extreme case that I know of in the olden days, though I do believe they still do them in eastern Canada on occasion. I being from the west, the doctors here frown on them big time do to the inherent  dangers the patient is put into.

    I’m not quite sure who’s doing the asking, but I just had a bronchoscopy done in December. I had it done in order to rule out any infections that your typical sputum culture can’t cultivate that deep inside the lungs. I was “out” for most of the procedure, but I do remember it not being pleasant once I awoke. That is when I experienced some pain. Recovery was slow, but everything came out ok! Don’t be scared. It is not a major procedure and is performed quite frequently with great success!!

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    EMLA Cream for Painless Needle Sticks

    EMLA is a cream that is applied to the skin under a tegaderm for 1-2 hours prior to a painful procedure. EMLA (Eutectic Mixture of Local Anaesthetics, with Eutectic meaning that the resultant mixture has greater effect than the mere sum of its parts) is available by prescription only. It is a combination of lidocaine (2.5%) and prilocaine (2.5%).

    So why isn’t EMLA used routinely for all sticks? A first- person account: “I use EMLA for all blood draws, ABGs, port-accesses, IVs – everything involving a needle. It is wonderful for children, and *completely* eliminates the pain of blood draws, IVs, accesses, and significantly reduces the pain of blood gasses. It is simple to use – I keep a bottle at home at all times, and apply it before going to the hospital, or before my home care nurse comes. My personal opinion is that IV teams do not use EMLA as it is disruptive to their schedule (having to place it 1 hr. before). But as far as the physiology goes, here’s what I know: 1% lidocaine injected subcutaneously is often reported to cause local vasoconstriction, making it more difficult to place a line. However, for every person who uses this excuse to avoid proper pain control, another professional will say that lidocaine is an excellent way to numb the skin for an IV. EMLA has been shown to have a vasoconstrictive effect at 1.5 hrs., but vasodilation effect after 3 hrs. A couple things you may want to try would be to have the line put in after 30-45 min., which is long enough to be numb and have blanched skin, but not long enough to have a major vasoconstrictive response. Alternatively, I believe that EMLA can be left on for up to 4 hours for major procedures (please check this in the insert.) You could try leaving it on for 3 hours, in which case you’d have vasodilation, which may ease the whole procedure”.

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    Blood Gases and Oximetry – What’s the Difference?

    The differences between blood gases and oximetry are: The blood gas is a direct measurement of the pH, Carbon Dioxide, and Oxygen levels in your arterial blood. It is extremely accurate, but not the most enjoyable procedure for a patient. Make sure anyone who does one on you performs an Allen test before they puncture your artery. An Allen test makes sure that circulation to the hand. The person doing the blood gas should occlude the circulation to your hand (they usually use a radial artery) using their hand as a tourniquet. Your hand will turn white. The person then releases the tension from the ulnar artery to see if your hand pinks up. If it doesn’t, they shouldn’t use that artery.

    An oximetry probe bounces a light source through a capillary bed (usually in your fingertip) and using logarithms, derives a percentage of oxygen in your blood (saturation). O2 sat probes don’t allow for the potential of Carbon Monoxide being in your system. The probe is usually placed on a digit, if a person has poor circulation, you will have an erroneous reading. The Sat probes are great for a general idea of how someone is doing and are great over long term when watching for trends, but I certainly don’t rely on them. I get a better indication from how a patient looks. I’ve seen too many patients with “great sats” who were sick as stink, but no one looked at the patient. Sorry, I’m soapboxing. If I want absolute accuracy, I get a blood gas. If it doesn’t matter, oxygen sat probes are great tools in the right hands.

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    Sinus Surgery Procedures

    TWO STEP LASER

    This procedure consisted of an initial surgery using a laser to clean out the sinus cavities. there are no actual incisions and the operation is performed using a scope for visual access. After the polyps are cut and the openings to the sinus cavities enlarged they are flushed and vacuumed to remove as much of the mucus build up. After this stents “sp?” are inserted, which, as I understand it, are designed to keep the fresh cut surfaces / wounds from binding to each other and closing up the cuts. They are of a plastic of some sort and the healing areas do not attach themselves to the material. About a week later, there was a second surgery in which the doctor mainly just looked at the area and removed the stents (still under a general anesthesia).

    ONE STEP LASER

    Basically the same process as the first step of the two step procedure. The stents were removed in the doctor’s office using a short scope and long tweezers.

    CALDWELL LUC

    In this procedure there is an actual incision made through the gums above the front teeth. After this incision, the doctor has access to the front sinus cavities (ethnoid?) through the bottom of the cavity.

    This was the older procedure and is “messier” due to the incision and patient basis while there was a “short stay” for the Caldwell Luc (overnight).

    PROS and CONS

    TWO STEP LASER – can’t think of many pros, the biggest con is having to go under a general anesthesia a second time (higher risk for PWCF due to the lung condition). also was more expensive because of the second operating room, etc. Also had more swelling and pain due to the second assault on the sinuses.

    ONE STEP LASER – Pro was only one time in the operating room. Con was the swelling, pain, etc. We had short and longer times (min 6 mo., max 12 mo.) between surgeries for both the one step and two step methods.

    CALDWELL LUC – This is supposed to be the worst one for the patient but Steve actually had less pain and swelling. It did take a few weeks before one of the holes in his gum closed completely but he actually had us stop at MacDonalds on the way home some 18 hours after the surgery. Apparently this method also gives the doctor better access to some areas since they are coming in lower in the sinus cavity. It also is easier to flush out all the mucus, etc. By the time he gets to surgery (my son’s) mucus is about the consistency of cheese cake so being able to flush or suck from the bottom helps.

    Apparently using the endoscope and laser does not give access to all areas of some sinus cavities since there is a limit to how much the scope will bend. The result is that there are blind spots which get missed. We think this is why some of the surgeries had to be repeated so soon for (our son).

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    Combination Antibiotic Therapy for P. Aeruginosa

    Simultaneous combinations of different antibiotics to treat P. aeruginosa especially when the organism is proving obdurate, is a well established treatment approach. It have even been claimed that the antibiotics act synergistically – that is the overall effect is better than the forecast sum of individually monotherapies.

    As far as I know, staggered combination therapy is not used. Two groups have investigated combination versus staggered therapy but in both cases used laboratory (non-animal) models with reference strains of P. aeruginosa. One group, a Swiss/ US co-operation (1991) found simultaneous combination to be more effective. However more recently, a group from New Zealand (1995) found staggered therapy to be a little more effective. However quite frankly how well one can extrapolate to the human situation with clinical P. aeruginosa from these experiments is beyond me. One final aspect concerning staggered combination therapy that occurs to me, is that it maybe more difficult to get consistent patient compliance.

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    Nasal Potential

    This is a method that measures the electrical potential across the nasal mucosa. It is a technique that has been pioneered by Dr. Duncan Geddes and is thought to be more reliable than the sweat test which it could possibly replace one day. However as far as I know it still needs relatively elaborate equipment and in consequent is still an experimental technique and used in limited sites in the UK and USA. Its most recent claim to fame has been its use in monitoring the effectiveness of gene transfer to the nasal mucosa.

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