What is the nursing intervention for patient post bronchoscopy to prevent risk of aspiration?

Post Procedure Management

My routine post bronchoscopy management consists of the following:

• Observation Period Based on Procedure Done:
  Post bronchoscopy management is mainly followed to screen for complications. The complications of routine bronchoscopy are negligible.

  Vital Signs: It is a good idea to observe the patient following the bronchoscopy. I do not keep the patient under observation for longer than a half an our following a routine bronchoscopy. If a transbronchial lung biopsy was done, the period of observation should be two hours.

  I don't obtain a routine chest x-ray following a bronchoscopy. However, it is important to get a chest x-ray following a transbronchial biopsy to rule out pneumothorax. This complication does not occur following a routine bronchoscopy.

• Instructions to the patient
  

  I always give the following instructions to my patients:

  • Not to eat or drink for another two hours. The gag reflex should return before he can resume oral consumption.
  • Someone should drive the patient home if they've been given demerol or valium.
  • Anticipate a sore throat and take a throat lozenge.
  • Call if a fever, shortness of breath or chest pain develops.
  • Anticipate mild hemoptysis.

Post Bronchoscopy Sputum:
Some physicians routinely collect post bronchoscopy sputum for cytology. While it seems logical, a retrospective study failed to confirm its utility.

Digital Edition: Preparing and supporting patients undergoing a bronchoscopy

14 October, 2003

Bronchoscopy is primarily used as a diagnostic tool.

Abstract
VOL: 99, ISSUE: 41, PAGE NO: 52
Julie Martin, BSc, RGN, Dip(Respiratory), is nurse bronchoscopist. South Manchester University Hospital NHS Trust

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Aspiration occurs when food, secretions, fluids, or other substances enter the airways or lungs. When you swallow, the epiglottis should close over the trachea which prevents food or fluids from entering the trachea (often called the windpipe). If this mechanism fails, unintended substances can end up in the lungs which can cause complications such as aspiration pneumonia. Sometimes gastric contents can also reflux which causes stomach contents to regurgitate into the esophagus. Symptoms such as vomiting and belching can cause aspiration in vulnerable patients.

Older adults, those with a compromised airway or impaired gag reflexes, or the presence of oral, nasal, or gastric tubes are at an increased risk. Aspiration causes choking, respiratory complications, infections, and can be fatal if not quickly recognized and treated. Prevention is the first step as the nurse should assess for risk factors prior to feeding or medicating patients and institute aspiration precautions for those with swallowing difficulties.

• Presence of tracheostomy or endotracheal tube 
• Tube feedings 
• Reduced level of consciousness 
• Depressed cough or gag reflex 
• Impaired swallowing 
• Oral/facial/neck trauma or surgery 
• Inability to maintain upright body posture 
• Gastrointestinal disorders: hiatal hernia, delayed gastric emptying, GERD, etc.

Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions are aimed at prevention.

Expected Outcomes

• Patient will not experience aspiration as observed by clear lung sounds, unlabored breathing, and oxygen saturation within normal limits 
• Patient and/or caregiver will demonstrate appropriate techniques to prevent aspiration 
• Patient and/or caregiver will verbalize potential risk factors for aspiration

1. Identify patients at an increased risk for aspiration.
Patients with impaired swallowing (dysphagia) from a stroke, Parkinson’s disease, or spinal cord injury or suffering neurological damage with the inability to clear secretions require assessment and monitoring when providing anything by mouth.

2. Determine level of consciousness.
Patients who are sedated either intentionally or unintentionally are at risk for aspiration. Patients with cognitive delays may not be able to clear secretions themselves.

3. Assess gag reflex and ability to safely swallow.
The nurse can first assess the patient’s speech and any difficulty in speaking which can signal further issues. Assess dentition and the ability to close the lips, control tongue movement, presence of facial symmetry, and the ability to cough. The nurse can assess the gag reflex by touching the back of the patient’s throat with a tongue blade or cotton swab. The patient may cough or initiate swallowing as a positive response. If not, do not provide anything by mouth and request further evaluation.

4. Monitor for signs of aspiration after oral intake.
If a patient is pocketing food in the mouth/cheeks, clearing the throat or coughing while eating, drooling, or displaying any difficulty breathing with eating or drinking these are indicators of possible aspiration.

5. Monitor for tubes that increase aspiration risk.
An overinflated or underinflated tracheostomy or endotracheal cuff can increase the risk of aspiration. A nasogastric tube that is dislodged from the stomach can cause aspiration if gastric contents get into the lungs. Tube feedings with a large amount of residual signal ineffective digestion and increase the risk of reflux and aspiration.

6. Auscultate lung sounds and assess respiratory status.
Adventitious lung sounds such as crackles or rhonchi may be heard with aspiration pneumonia. Any change in respiratory status such as an increased rate, effort, or declining SaO2 level needs immediate attention.

Nursing Interventions for Risk For Aspiration

1. Keep suctioning equipment at the bedside.
Patients at an increased risk for aspirating should have functioning suctioning equipment at the bedside for immediate use.

2. Performing suctioning as necessary.
Patients with a large amount of secretions or who cannot clear them themselves may require frequent suctioning.

3. Keep the head of the bed elevated after feeding.
Whether self-feeding, assisting with feeding, administering medications or tube feedings, the head of the bed should remain elevated for 30 min-1 hour after.

4. Implement other feeding techniques.
Patients who require assistance with feeding should be fed small bites slowly. Some patients may require coaching to remind them to chew and swallow. Allow rest before feeding times as this may decrease the patient’s difficulty with swallowing. Do not distract or allow the patient to talk while chewing or swallowing.

5. Consult with speech therapy.
If swallowing is impaired the patient requires further screening. A speech-language pathologist (SLP) can test swallowing with different foods and liquids. They can also teach the patient techniques to reduce swallowing such as the “chin-tuck” maneuver.

6. Follow diet modifications.
Use thickening agents as ordered and ensure the use of proper diet modifications such as pureed or mechanical soft foods as thicker foods and liquids are less likely to be aspirated.

7. Position properly.
Patients with drooling or uncontrolled secretions should be placed side-lying to allow secretions to drain and not pool in their mouths. Patients on continuous tube feeds should always have the head of the bed elevated at least 30 degrees.

8. Educate about conditions that can cause aspiration.
Esophageal strictures (narrowing of the esophagus) can trap food. Gastroesophageal reflux disease (GERD) which is gastric acid backing up into the esophagus can cause damage and lead to strictures. Delayed gastric emptying doesn’t empty food as quickly as it should which can cause reflux, vomiting, and other problems.

9. Request medication formulation changes.
Patients who cannot swallow pills may need medications in liquid, IV, or powder form. Some pills cannot be crushed and may not come in other forms and the patient may tolerate swallowing by placing the pill in applesauce or pudding.

10. Monitor tube-feeding patients closely.
Check residuals as ordered, often every 4 hours. Facility policy will dictate when residuals are too high. Always alert the provider if residuals are increasing, bowel sounds are hypoactive or absent, any vomiting or frequent diarrhea, and if abdominal distention is observed.

11. Provide mouth care.
Mouth care prior to meals increases the desire to eat while oral care following meals removes any residual food that could cause aspiration.

References and Sources

1. Aspiration from Dysphagia. (n.d.). Cedars-Sinai. Retrieved December 7, 2021, from https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/aspiration-from-dysphagia.html
2. Clark Tippett, D. (n.d.). Dysphagia: What Happens During a Bedside Swallow Exam. Johns Hopkins Medicine. Retrieved December 7, 2021, from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/dysphagia-what-happens-during-a-bedside-swallow-exam
3. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.

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