Micheline B Grattan, RN
Stage 0 lung cancer Carcinoma of the lung continues to be the most common and serious tumor in men. The lesion is localized and resectable in only one-third of the cases by the time the growth is visible on chest x-ray. Two-thirds have evidence of either regional or distant metastases.' Only one of every three patients who have lung resections are expected to be alive and well five years after treatment. Overall survival rates in lung cancer are still less than 10%. In some cases, the diagnosis of lung carcinoma can be made early by Micheline B Grattan, R N , is head nurse of the endoscopic department, Memorial Sloan-Kettering Cancer Center (MSKCC), New York, N Y . She received a diploma in nursing from Hospital Notre Dame DE, Bons Secours, Paris, a bachelor$ degree in philosophy from the University of Paris, and RMN (registered mental nurse) from Littlemore Hospital, Oxford, England. She is a member of the board of directors of AORN of New York City. The author acknowledges the assistance of Nael Martini, MD, chief of the thoracic service, and Paul Goldiner, MD, attending anesthesiologist, both at MSKCC.
966
sputum cytology even though chest roentgenograms are normal.2 If treated effectively at this early stage, the five-year survival is expected to be as high as 60% to 80%.3 Early detection of curable lung cancer may be achieved effectively if high risk individuals are provided with periodic checkups including chest x-ray and sputum cytology. High risk groups are cigarette smokers of either sex over the age of 45, uranium miners, asbestos workers, and all patients with prior head and neck cancers. The National Cancer Institute is currently supporting a program for early lung cancer detection in three major medical centers. Participating institutions are the Johns Hopkins University, the Mayo Foundation, and the Memorial Sloan-Kettering Cancer Center. Controlled surveys have been set up in which 30,000 high risk individuals (10,000 at each institution) are screened. Screening includes annual chest roentgenograms and sputum cytology every four months. When sputum cytology is positive, localization of the source of cancer cells becomes necessary. Bronchoscopy and bronchograms are the most successful methods of localization. Precise localization of radiologically occult cancers, also known as Stage 0 can-
AORN Journal, November 1976, Vol24, No 5
Remote parts of the lung are viewed by Nael Martini, MDJhrough a fiberoptic scope that projects the image onto closed-circuit television. Assisting him are A Bell, RN, and V Ruiz, engineer. (Photo by Stuart Smith.)
968
AORN Journal, November 1976, Vol24. No 5
Fig 1. Rigid bronchoscopy setup.
cers, is frequently not possible by conventional bronchoscopy with rigid i n ~ t r u m e n t s .The ~ flexible fiberoptic bronchoscope, however, makes it possible to obtain a more detailed examination of the tracheobronchial tree. Fiberoptic bronchoscopy also enables the physician to obtain selective washings, brushings, and biopsies from peripheral as well as central bronchi. The flexible bronchoscope is an important advance because survival depends on the ease of localization since no treatment is possible until the tumor is identified. When a patient is referred to us with a positive sputum cytology and a negative chest x-ray, a careful and detailed bronchoscopic examination is carried out under general anesthesia. Both rigid and fiberoptic Sronchoscopes are used on all cases. Each bronchus and major pulmonary segment is thoroughly visualized. Washings are meticulously collected and carefully labeled to ensure accurate localization and prevent cross-contamination. Under direct vision, bronchial brushes are guided into each segment. Brushings are obtained and smeared
on slides for cytologic study. This examination is recorded in its entirety on color videotape for documentation. The procedure may take from two to three hours to complete. During this prolonged period of anesthesia, the patient’s airway is kept relatively dry with preoperative administration of scopolamine. Enflurane is the agent of choice during the procedure to provide good dilatation of the bronchial tree.5 The patient is intubated with a standard, but adequate, size endotracheal tube (9 mm or 10 mm diameter) fitted with a T-adapter to allow simultaneous general anesthesia and flexible fiberoptic bronchoscopy. Arterial blood gases are taken regularly to check for respiratory acidosis. The bronchoscopic procedure can be divided into three phases: 1. rigid ventilating bronchoscopy under laryngeal block 2. prolonged flexible fiberoptic bronchoscopy for complete visualization of the bronchial tree, videotape recording, and photographic studies 3. specimen collections of numerous
AORN Journal, November 1976, Vol24, No 5
969
washings and brushings (30 to 40 specimens). The procedure requires two setup tables: one holds equipment used for rigid bronchoscopy (Fig 1) and the other is for the flexible bronchoscopy setup (Fig 2). The rigid bronchoscopy setup includes the following: bronchoscopy tray towels, 2 towel clips, 2 holder for specimen trap T-adapter straight scissors smooth forceps Petri dish for biopsies basin for saline #8 x 40 bronchoscope and set regular suction tips (1velvet and 1 straight) specimen connector and two suction tips, one for the right lung and one for the left atomizer containing anesthetic spray to control patient’s coughing rubber cuff to slide on the bronchoscope for separation of washings
soaking basin of activated glutaraldehyde for sterilization of telescopes (90’ right-angled telescope, 30” fore oblique telescope, 180” straight vision telescope) additional items Vaseline gauze to cover the patient’s eyes 4” x 4” gauze specimen trap suction tubing fiberoptic cord fiberoptic light source marking pen The flexible bronchoscopy setup includes a cold high-intensity light source and table setup. The table is set up with the following: basin with saline flexible bronchoscope round basin 4” x 4” gauze disposable 10 cc syringe specimen trap holder specimen trap suction tubing suction control connector marking pen T-adapter
Fig 2. Flexible bronchoscopy setup.
AORN Journal, November 1976,Vol24, No 5
971
Diagram for brushing and washing sites Left lung
Right lung
Washings and brushings are systematically collected from each bronchus and major pulmonary segment.
lubricant spray sterile sheet and sterile paper towel biopsy forceps and brushes The rigid bronchoscopy is done under local laryngeal block. The patient is sedated but not asleep and generally needs reassurance. He arrives in a strange room filled with people and equipment. After the laryngeal block, his throat feels numb and he thinks he cannot breathe. This anxiety increases when the bronchoscope is introduced and he cannot speak. He becomes apprehensive and will need vocal support and reassurance and a friendly hand to hold. The circulating nurse should never leave his side during the rigid bronchoscopy procedure. It is usually completed quickly since it is done primarily to
912
collect samples from the left and right bronchial trees for differential bronchial washings. The patient is then intubated under general anesthesia. The anesthetist sits or stands to the left of the patient so the bronchoscopist has full access to the patient’s head. The suction and light cord are connected and the patient is draped in a surgically clean manner. The flexible bronchoscope is connected to the video camera which has been checked just prior to the procedure. Adequate ventilation is ascertained by the anesthetist with the help of arterial blood gas tests. The tracheobronchial tree is then carefully inspected with the fiberoptic bronchoscope. As explained earlier,
AORN Journal, November 1976,Vol 24, No 5
the examination i s recorded on videotape. I f a tumor or suspicious area i s noted, recording i s interrupted and s t i l l photographs of t h e area are taken. Upon completion of the examination, washings and brushings are systematically collected f r o m each bronchus and major pulmonary segment. Washings are mixed with 50% alcohol whereas brushings are smeared o n slides and then fixed in 90% alcohol. Biopsies, when obtained, are fixed in formaldehyde. Careful labeling o f
these numerous specimens i s essential for accurate localization.s
I f initial attempts t o localize t h e tumor are unsuccessful, reexamination i s recommended in one to t w o months and repeated every t w o months until the t u m o r i s found or malignancy i s r u l e d out. It i s hoped t h a t w i t h similar programs, lung cancer may be detected, localized, and treated early enough t o improve overall prognosis.
0
Care of the bronchoscope The flexible bronchoscope is a delicate and expensive instrument made of flexible glass fiber bundles. It requires specific care. These are some of the “don’ts.’’ Do not bend. Do not handle roughly. Do not place under heavy instruments. Do not steam autoclave. The scope can be gas sterilized if aerated for 36 hours before use. It has a temperature tolerance of 135 F (57 C)at a pressure of 10 psi and at 50% humidity. Therefore, do not aerate in temperatures over 135 F (57 C). Do not immerse the control system or allow it to be splashed with liquids. The cost of repair for this particular piece may be as high as $1,000. The instrument should be cleaned as soon as possible after use. To provide a mar-free surface, cover working area with linen so the bronchoscope will not lie on a rough, hard surface. Put gloves on and wipe the scope from the control unit to the distal end with a 4” x 4” gauze flat wet with soapy water (one drop of Microbac to a cup of water). Rinse by wiping with flat moistened by distilled water. Connect suction channel of scope to vacuum, dip distal end of scope into cup containing soapy water, and suction. Rinse by dipping the scope’s distal end into a cup
974
containing distilled water. Suction. Third, dip the distal end into a cup containing povidone-iodine solution and suction. This solution contains two parts povidone-iodine to one part each of 70% alcohol and distilled water. Wipe the entire scope with 4 ’ x 4” gauze wet with 70% alcohol. Wipe the lens of the distal end with a cotton applicator wet with soapy water, followed by a cotton applicator wet with distilled water. Do not scratch or bend the distal end of the scope during this maneuver. After 30 minutes, dip the distal end in a cup containing 70% alcohol and suction until alcohol is clear. To dry the apparatus, air is forced through every opening with a 10 cc syringe. Again, wipe the entire scope with 70% alcohol and place it gently in container lined with clean towels. The scope is now ready for gas sterilization. Biopsy forceps and brushes are delicately cleaned with soft brushes in soapy water and rinsed with distilled water. They are checked and oiled if necessary and then steam sterilized. The video-stereo equipment is maintained by an electronic and medical physics engineer who is present at each procedure and helps in editing of tapes.
AORN Journal, November 1976, V o l 2 4 , No 5
I
System Composition
ramera rahle
control unit d-1
"I.. " . . " . . . I . . . _
coaxial cable I
The flexible bronchoscopeis connected to the video camera and the examination is recorded in its entirety for documentation.
Notes 1. N Martini, M R Melamed, E E Cliffton, "Occult lung cancer diagnosed by cytology," Cinical B u l b tin, Memorial Sloan-Kettering Cancer Center 1 (1971) 107-110. 2. M R Melamed. L G Koss. E E Cliffton, "Roentgenobgically occult lung cancer diagnosed by cytology," Cancer 16 (1963) 1537-1551. 3. N Martini, et al, "Radiologically occult lung cancer: Report of 26 cases," The Surgical Clinics of North America 54 (1974) 81 1-823; L B Woolner, et at, "In situ and early invasive bronchogenic carcinoma: Report of 28 cases with postoperative survival data," Journal of Thorecic and Cardiovascular Surgery 60 (1970) 275-290. 4. B R Marsh, et at, "Occult bronchogenic carcinoma: Endoscopic localization and television documentation," Cancer 30 (1972) 1348-1352. 5. L B Perry, D R Sanderson, "Anesthesia for prolonged bronchoscopy," Annals of Thoracic Surgery 19 (March 1975) 248-253. 6. Martini, et at, "Radiologically occult lung cancer."
976
Fund for graduate nursing education ends The National Fund for Graduate Nursing Education (NFGNE) formally dissolved on July 15, 1976, ending its 15-year history of awarding grants to graduate nursing programs accredited by the National League for Nursing (NLN). The League had been affiliated with the Fund since 1973 in a joint program to promote improvement of graduate education. The decision to terminate NFGNE was attributed by Fund president Robert J Dixson to the recent economic situation and the corresponding decline in support from key contributors. In announcing the Fund's final awards-$52,046 to 16 accredited graduate nursing programs for the 1976-77 academic year, Dixson noted that almost $2 million in grants had been awarded to NLN-accredited graduate programs during NFGNE's years of operation. In a recent letter to contributors, Dixson stressed that "a crisis in nursing still exists. . . . Schools preparing students for administrative and teaching positions are desperately in need of financial help."
AORN Journal, November 1976, Vol24, No 5
Stage 0 lung cancer Carcinoma of the lung continues to be the most common and serious tumor in men. The lesion is localized and resectable in only one-third of the cases by the time the growth is visible on chest x-ray. Two-thirds have evidence of either regional or distant metastases.' Only one of every three patients who have lung resections are expected to be alive and well five years after treatment. Overall survival rates in lung cancer are still less than 10%. In some cases, the diagnosis of lung carcinoma can be made early by Micheline B Grattan, R N , is head nurse of the endoscopic department, Memorial Sloan-Kettering Cancer Center (MSKCC), New York, N Y . She received a diploma in nursing from Hospital Notre Dame DE, Bons Secours, Paris, a bachelor$ degree in philosophy from the University of Paris, and RMN (registered mental nurse) from Littlemore Hospital, Oxford, England. She is a member of the board of directors of AORN of New York City. The author acknowledges the assistance of Nael Martini, MD, chief of the thoracic service, and Paul Goldiner, MD, attending anesthesiologist, both at MSKCC.
966
sputum cytology even though chest roentgenograms are normal.2 If treated effectively at this early stage, the five-year survival is expected to be as high as 60% to 80%.3 Early detection of curable lung cancer may be achieved effectively if high risk individuals are provided with periodic checkups including chest x-ray and sputum cytology. High risk groups are cigarette smokers of either sex over the age of 45, uranium miners, asbestos workers, and all patients with prior head and neck cancers. The National Cancer Institute is currently supporting a program for early lung cancer detection in three major medical centers. Participating institutions are the Johns Hopkins University, the Mayo Foundation, and the Memorial Sloan-Kettering Cancer Center. Controlled surveys have been set up in which 30,000 high risk individuals (10,000 at each institution) are screened. Screening includes annual chest roentgenograms and sputum cytology every four months. When sputum cytology is positive, localization of the source of cancer cells becomes necessary. Bronchoscopy and bronchograms are the most successful methods of localization. Precise localization of radiologically occult cancers, also known as Stage 0 can-
AORN Journal, November 1976, Vol24, No 5
Remote parts of the lung are viewed by Nael Martini, MDJhrough a fiberoptic scope that projects the image onto closed-circuit television. Assisting him are A Bell, RN, and V Ruiz, engineer. (Photo by Stuart Smith.)
968
AORN Journal, November 1976, Vol24. No 5
Fig 1. Rigid bronchoscopy setup.
cers, is frequently not possible by conventional bronchoscopy with rigid i n ~ t r u m e n t s .The ~ flexible fiberoptic bronchoscope, however, makes it possible to obtain a more detailed examination of the tracheobronchial tree. Fiberoptic bronchoscopy also enables the physician to obtain selective washings, brushings, and biopsies from peripheral as well as central bronchi. The flexible bronchoscope is an important advance because survival depends on the ease of localization since no treatment is possible until the tumor is identified. When a patient is referred to us with a positive sputum cytology and a negative chest x-ray, a careful and detailed bronchoscopic examination is carried out under general anesthesia. Both rigid and fiberoptic Sronchoscopes are used on all cases. Each bronchus and major pulmonary segment is thoroughly visualized. Washings are meticulously collected and carefully labeled to ensure accurate localization and prevent cross-contamination. Under direct vision, bronchial brushes are guided into each segment. Brushings are obtained and smeared
on slides for cytologic study. This examination is recorded in its entirety on color videotape for documentation. The procedure may take from two to three hours to complete. During this prolonged period of anesthesia, the patient’s airway is kept relatively dry with preoperative administration of scopolamine. Enflurane is the agent of choice during the procedure to provide good dilatation of the bronchial tree.5 The patient is intubated with a standard, but adequate, size endotracheal tube (9 mm or 10 mm diameter) fitted with a T-adapter to allow simultaneous general anesthesia and flexible fiberoptic bronchoscopy. Arterial blood gases are taken regularly to check for respiratory acidosis. The bronchoscopic procedure can be divided into three phases: 1. rigid ventilating bronchoscopy under laryngeal block 2. prolonged flexible fiberoptic bronchoscopy for complete visualization of the bronchial tree, videotape recording, and photographic studies 3. specimen collections of numerous
AORN Journal, November 1976, Vol24, No 5
969
washings and brushings (30 to 40 specimens). The procedure requires two setup tables: one holds equipment used for rigid bronchoscopy (Fig 1) and the other is for the flexible bronchoscopy setup (Fig 2). The rigid bronchoscopy setup includes the following: bronchoscopy tray towels, 2 towel clips, 2 holder for specimen trap T-adapter straight scissors smooth forceps Petri dish for biopsies basin for saline #8 x 40 bronchoscope and set regular suction tips (1velvet and 1 straight) specimen connector and two suction tips, one for the right lung and one for the left atomizer containing anesthetic spray to control patient’s coughing rubber cuff to slide on the bronchoscope for separation of washings
soaking basin of activated glutaraldehyde for sterilization of telescopes (90’ right-angled telescope, 30” fore oblique telescope, 180” straight vision telescope) additional items Vaseline gauze to cover the patient’s eyes 4” x 4” gauze specimen trap suction tubing fiberoptic cord fiberoptic light source marking pen The flexible bronchoscopy setup includes a cold high-intensity light source and table setup. The table is set up with the following: basin with saline flexible bronchoscope round basin 4” x 4” gauze disposable 10 cc syringe specimen trap holder specimen trap suction tubing suction control connector marking pen T-adapter
Fig 2. Flexible bronchoscopy setup.
AORN Journal, November 1976,Vol24, No 5
971
Diagram for brushing and washing sites Left lung
Right lung
Washings and brushings are systematically collected from each bronchus and major pulmonary segment.
lubricant spray sterile sheet and sterile paper towel biopsy forceps and brushes The rigid bronchoscopy is done under local laryngeal block. The patient is sedated but not asleep and generally needs reassurance. He arrives in a strange room filled with people and equipment. After the laryngeal block, his throat feels numb and he thinks he cannot breathe. This anxiety increases when the bronchoscope is introduced and he cannot speak. He becomes apprehensive and will need vocal support and reassurance and a friendly hand to hold. The circulating nurse should never leave his side during the rigid bronchoscopy procedure. It is usually completed quickly since it is done primarily to
912
collect samples from the left and right bronchial trees for differential bronchial washings. The patient is then intubated under general anesthesia. The anesthetist sits or stands to the left of the patient so the bronchoscopist has full access to the patient’s head. The suction and light cord are connected and the patient is draped in a surgically clean manner. The flexible bronchoscope is connected to the video camera which has been checked just prior to the procedure. Adequate ventilation is ascertained by the anesthetist with the help of arterial blood gas tests. The tracheobronchial tree is then carefully inspected with the fiberoptic bronchoscope. As explained earlier,
AORN Journal, November 1976,Vol 24, No 5
the examination i s recorded on videotape. I f a tumor or suspicious area i s noted, recording i s interrupted and s t i l l photographs of t h e area are taken. Upon completion of the examination, washings and brushings are systematically collected f r o m each bronchus and major pulmonary segment. Washings are mixed with 50% alcohol whereas brushings are smeared o n slides and then fixed in 90% alcohol. Biopsies, when obtained, are fixed in formaldehyde. Careful labeling o f
these numerous specimens i s essential for accurate localization.s
I f initial attempts t o localize t h e tumor are unsuccessful, reexamination i s recommended in one to t w o months and repeated every t w o months until the t u m o r i s found or malignancy i s r u l e d out. It i s hoped t h a t w i t h similar programs, lung cancer may be detected, localized, and treated early enough t o improve overall prognosis.
0
Care of the bronchoscope The flexible bronchoscope is a delicate and expensive instrument made of flexible glass fiber bundles. It requires specific care. These are some of the “don’ts.’’ Do not bend. Do not handle roughly. Do not place under heavy instruments. Do not steam autoclave. The scope can be gas sterilized if aerated for 36 hours before use. It has a temperature tolerance of 135 F (57 C)at a pressure of 10 psi and at 50% humidity. Therefore, do not aerate in temperatures over 135 F (57 C). Do not immerse the control system or allow it to be splashed with liquids. The cost of repair for this particular piece may be as high as $1,000. The instrument should be cleaned as soon as possible after use. To provide a mar-free surface, cover working area with linen so the bronchoscope will not lie on a rough, hard surface. Put gloves on and wipe the scope from the control unit to the distal end with a 4” x 4” gauze flat wet with soapy water (one drop of Microbac to a cup of water). Rinse by wiping with flat moistened by distilled water. Connect suction channel of scope to vacuum, dip distal end of scope into cup containing soapy water, and suction. Rinse by dipping the scope’s distal end into a cup
974
containing distilled water. Suction. Third, dip the distal end into a cup containing povidone-iodine solution and suction. This solution contains two parts povidone-iodine to one part each of 70% alcohol and distilled water. Wipe the entire scope with 4 ’ x 4” gauze wet with 70% alcohol. Wipe the lens of the distal end with a cotton applicator wet with soapy water, followed by a cotton applicator wet with distilled water. Do not scratch or bend the distal end of the scope during this maneuver. After 30 minutes, dip the distal end in a cup containing 70% alcohol and suction until alcohol is clear. To dry the apparatus, air is forced through every opening with a 10 cc syringe. Again, wipe the entire scope with 70% alcohol and place it gently in container lined with clean towels. The scope is now ready for gas sterilization. Biopsy forceps and brushes are delicately cleaned with soft brushes in soapy water and rinsed with distilled water. They are checked and oiled if necessary and then steam sterilized. The video-stereo equipment is maintained by an electronic and medical physics engineer who is present at each procedure and helps in editing of tapes.
AORN Journal, November 1976, V o l 2 4 , No 5
I
System Composition
ramera rahle
control unit d-1
"I.. " . . " . . . I . . . _
coaxial cable I
The flexible bronchoscopeis connected to the video camera and the examination is recorded in its entirety for documentation.
Notes 1. N Martini, M R Melamed, E E Cliffton, "Occult lung cancer diagnosed by cytology," Cinical B u l b tin, Memorial Sloan-Kettering Cancer Center 1 (1971) 107-110. 2. M R Melamed. L G Koss. E E Cliffton, "Roentgenobgically occult lung cancer diagnosed by cytology," Cancer 16 (1963) 1537-1551. 3. N Martini, et al, "Radiologically occult lung cancer: Report of 26 cases," The Surgical Clinics of North America 54 (1974) 81 1-823; L B Woolner, et at, "In situ and early invasive bronchogenic carcinoma: Report of 28 cases with postoperative survival data," Journal of Thorecic and Cardiovascular Surgery 60 (1970) 275-290. 4. B R Marsh, et at, "Occult bronchogenic carcinoma: Endoscopic localization and television documentation," Cancer 30 (1972) 1348-1352. 5. L B Perry, D R Sanderson, "Anesthesia for prolonged bronchoscopy," Annals of Thoracic Surgery 19 (March 1975) 248-253. 6. Martini, et at, "Radiologically occult lung cancer."
976
Fund for graduate nursing education ends The National Fund for Graduate Nursing Education (NFGNE) formally dissolved on July 15, 1976, ending its 15-year history of awarding grants to graduate nursing programs accredited by the National League for Nursing (NLN). The League had been affiliated with the Fund since 1973 in a joint program to promote improvement of graduate education. The decision to terminate NFGNE was attributed by Fund president Robert J Dixson to the recent economic situation and the corresponding decline in support from key contributors. In announcing the Fund's final awards-$52,046 to 16 accredited graduate nursing programs for the 1976-77 academic year, Dixson noted that almost $2 million in grants had been awarded to NLN-accredited graduate programs during NFGNE's years of operation. In a recent letter to contributors, Dixson stressed that "a crisis in nursing still exists. . . . Schools preparing students for administrative and teaching positions are desperately in need of financial help."
AORN Journal, November 1976, Vol24, No 5
