PROCEDURE: Bronchoscopy with bronchoalveolar lavage and transbronchial biopsies under fluoroscopic guidance.
REASON FOR PROCEDURE: Bilateral persistent lower lobe infiltrates.
MEDICATIONS: Local anesthesia with 10 mL of 2% lidocaine and sedation with 3 mg of Versed and 50 mcg of fentanyl.
CONSENT: Informed consent was obtained after the procedure, alternatives, risks, and benefits were explained to Mrs. Kame. She gave me informed consent.
DESCRIPTION OF PROCEDURE: Continuous monitoring of oxygen saturation and EKG was done. The blood pressure was monitored every 5 minutes throughout the procedure. After adequate local anesthesia was obtained with 2% lidocaine and viscous lidocaine through the nostrils, the bronchoscope was advanced through the right nostril, and the vocal cords were evaluated. The patient received systemic sedation with Versed and fentanyl. The vocal cords appeared normal, and they moved adequately with phonation.
Bronchoscope was passed through the vocal cords, and the tracheobronchial tree was examined. The trachea appeared normal. The carina was sharp. There were no lesions noted. The mucosa appeared normal. The left mainstem bronchus, left upper lobe, and left lower lobe were examined to the subsegmental levels. No abnormalities were noted. There were no intrabronchial lesions. Mucosa appeared normal. The bronchoscope was then withdrawn, and the right side was imaged. Right mainstem, right upper lobe bronchus intermedius, right middle lobe bronchus, and right lower lobe bronchus were all normal down to the subsegmental levels.
The bronchoscope was again advanced in the left lower lobe bronchus, and bronchoalveolar lavage was performed with a total of 90 mL of normal saline. A return of approximately 50 mL was obtained and was sent for microbiology including bacterial cultures, fungal cultures, AFB, also for cytology, flow cytometry, and silver staining. After the bronchoalveolar lavage was performed, the forceps were advanced through the bronchoscope in the left lower lobe bronchus, and under fluoroscopic guidance, 3 biopsies were obtained from the posterior and lateral basal segment of the left lower lobe. Minimal bleeding was noted with the biopsy.
The patient remained stable throughout the procedure. After the biopsies were performed and observation was done to ensure stability and lack of significant bleeding, the bronchoscope was then slowly withdrawn and removed. The left apex was imaged, and no evidence of pneumothorax was noted immediately after the procedure by fluoroscopy.
The patient tolerated the procedure well. There was only minimal cough. Chest x-ray 1 hour after the procedure was ordered to rule out right pneumothorax.