Importance of Pre-Procedure Counselling in Patients Undergoing Flexible Bronchoscopy

Abstract

Flexible fiberoptic bronchoscopy is performed very frequently in pulmonology and cardiothoracic services where the patients are most critically ill. This study aims to assess the degree of satisfaction, duration, and level of cooperativeness among patients undergoing flexible bronchoscopy. A quasi-experimental study with 128 flexible bronchoscopy patients was carried out with two groups of patients (control and study group). All the steps of the procedure were discussed with the patient. The anxiety level score, patient satisfaction, cooperation, and duration of the procedure were assessed in both groups. A total of 128 patients were included. They were divided into two groups (study group and control group). In both groups, the majority were illiterate: study group 40 (62.5%), and control group 41 (64.1%). The hospital anxiety scale was statistically better in the study group than in the control group (p-value of 0.0001). The patients’ satisfaction rate in the study groups was significantly higher (p-value 0.001, chi-square test 120.508). The duration of the procedure was significantly shorter in the study group (Mean ± SD 4.45, 1.381 min). Patients with better knowledge of bronchoscopy were more comfortable with the procedure and the duration of the procedure was significantly shorter.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03767-5.

Introduction

Flexible fiberoptic bronchoscopy is commonly used for diagnostic and therapeutic indications of respiratory pathologies [1]. Patient cooperation is fundamental for the success of the procedure and to avoid repeating it [2]. The factors positively affect the rate of success and outcome in flexible bronchoscopy are the comfort of the patient, due to better knowledge and preparation for the procedure, and proper upper airway anesthesia before the procedure [3, 4]. Our study aimed to apply an educational program to increase patients’ knowledge regarding the bronchoscopic procedure, thus minimizing the levels of anxiety and improving the tolerability of the patients. It was thought this program could lead to better implementation of the procedure and reduce the peri-procedural complications.

Patients and Methods

A total of 128 adult patients who required flexible bronchoscopy were consecutively included in the study. They attended the bronchoscopy unit of Shar hospital/ cardiothoracic department. The patients were randomly divided into two groups: 64 patients were given the designed educational program about the bronchoscopy procedure (Study group) and another 64 patients did not receive any educational program about the procedure, apart from basic consent and a simple explanation (Control group). All patients were alert and were able to communicate verbally. Child patients and un-cooperated patients, such as those who were suffering from a neuropsychiatric disorder, were excluded from the study. A trained professional nurse under supervision explained the educational program to the patients.

The Ethical Committee of the College of the Medicine / University of Sulaimani approved the study; signed informed consent was obtained from all the patients who were candidates for flexible bronchoscopy.

Both groups were subject to the followings:

1. Sociodemographic data, associated comorbidity, previous history of bronchoscopy, and any experience of intervention concerning the procedure were noted.

2. The hospital anxiety scale (HAS) was used to assess the degree of procedure-related anxiety, the score ranging from 0 to 21. Items were ranked on a four-point Likert-type scale ranging from 0 to 3. Scores from 0 to 7 indicated normal levels of anxiety, and then the borderline of anxiety showed from 8 to 10. The scores for abnormal levels of anxiety ranged from 11 to 21. [5].

3. The educational program of the study was composed of three parts. The design of the first part was a leaflet containing detailed information, with photos, about the procedure in the patient’s mother language. The patient’s level of education and understanding was considered during the assessment. A description and structure of the respiratory system, and a definition and indication of bronchoscopy, were mentioned clearly and briefly. Further, the patient’s preparation before bronchoscopy, and the precautions that should be taken during and after the bronchoscopy, were included.

The second and third parts of the educational program were the recorded audio-visual information. The technique and route of administration of the anesthetics that are given to the patient. All this information was clarified in the first record. Moreover, the technique and practice of the procedure were explained in the second record, which included and highlighted the position of the patient, the technique of inserting a flexible tube through the mouth or nose, and how it went down to the trachea and different lobar bronchi.

For the study group, instructions were given to the patients the day before the procedure; an individual face-to-face interview was performed with each patient. The first interview was about 45 min. All information considering the bronchoscopy was illustrated. The second interview was done on the day of the procedure. At this time, the vital signs, hospital anxiety scale, and personal characteristics of the studied patients were assessed. This was done in approximately 20 min. This assessment began 1 to 2 h before the procedure. During this time, the patients looked at the video records. The duration of each video was around 2 to 4 min.

For the control group, an interview was done on the day of the procedure. Detailed instructions concerning the bronchoscopy were not given to them.

Personal characteristics, vital signs, and the hospital anxiety scale were recorded at least 60 to 90 min before the procedure in both groups.

Pre-procedural nasal oxygen was administered for 10 min in both groups at a rate of 5 L/min. Oxygen supplement was given to the control group during the procedure and afterward for at least 30 min. However, oxygen was only delivered before the procedure for the case group. Intra-procedural assessments were done for both groups; for example, difficulties during bronchoscopy, hemodynamic parameters (heart rate, oxygen saturation, and blood pressure), any abnormal movement, complications, and duration of the procedure. The duration started from the insertion of a flexible tube into the nose until retrieving the scope from the nose. One hour after the procedure, both groups were re-assessed for vital signs, patient satisfaction with the procedure, and any discomfort they had experienced during the procedure. Fiberoptic flexible bronchoscopy (Olympus® EXERA II BF-P180 Video Bronchoscope) was used for all patients.

Statistics

The collected data has been organized, categorized, and tabulated and SPSS (Statistical Package for the Social Science Inc., Chicago, IL, USA) version 25 has been used. The data has been tested for normality using the Anderson-Darling test and for homogeneity variance before further statically analysis. Number and percentage were used for categorical variables, however, the continuous variable was designated by mean and SD. Categorical variables were compared by using Chi-square and Fisher’s exact test, though the continuous variables were associated using the t-test. A two-tailed p-value of less than 0.05 was measured statically significantly.

Results

A total of 128 patients were included in the study. They were divided into 2 sub-groups (study group and control group). The number of patients included in the educational program study group was 64. In the study group, 44 (68.8%) were males and the females were 20 (31.3%). In the control group, the males numbered 38 (59.4%) and females numbered 26 (40.6%). The rate of illiterate patients in both groups was high. The age range was between 61to 90 years, the study group patient was 38 cases (59.4%), however, the control group was 44 (68.8%). About one-third of all participants were smokers (32.8%) (Table 1 shows sociodemographic information).

Table 1.

clarifies the socio-demographic characteristics of participants in both groups

Socio demographic Characteristics	Group				P. value
	Case		Control
	No.	%	No.	%
Age < 30 years 31–60 years 61–90 years Total	6 20 38 64	9.4 31.3 59.4 100	2 18 44 64	3.1 28.1 68.8 100	0.884* N. Sig
Mean ± SD	59.1 ± 16.4		62.0 ± 14.1		0.038† Sig
Gender Male Female Total	44 20 64	68.7 31.3 100	38 26 64	59.4 40.6 100	0.584* N. Sig
Education Illiterate Secondary High school University graduated Other Total	40 17 5 1 1 64	62.5 26.6 7.8 1.6 1.6 100	41 14 5 3 1 64	64.1 21.9 7.8 4.7 1.6 100	0.793** N. Sig
How many relatives came with the patient One person More than one Total	11 53 64	17.2 82.8 100	15 49 64	23.4 76.6 100	0.505* N. Sig

** Fisher-exact test *Chi-square † t-test

Tables 2 and 3 illustrate the hemodynamic parameter of patients as oxygen saturation (Mean 95.42 94.47 95.14), heart rate, blood pressure, and respiratory rate. Table Two shows that the case group was more comfortable than the control group; this is because the mean of oxygen saturation before, during, and after the procedure was slightly higher than in the control group. Tachycardia was not evident in the study group, but it was very problematic in the control group. The mean range is illustrated in Table 3. Further, the duration of the procedure was statistically significantly shorter (p-value ˂ 0.001) in the study group (Fig. 1).

Table 2.

Highlights the initial information and the worst moment during the procedure

Have you done the test previously
	Valid	Case group	Control Group	Chi-square	df	P value
Have you done the test before	Yes	4 (6.3%)	3 (4.7%)	1.51	1	0.697  N. Sig*
	No	60 (93.8%)	61 (95.3%)
	Total	64	64
What was the worst moment during the procedure
What was the worst moment during the exam?	Waiting period	0	0	0.321	1	0.782  N. Sig*
	Topical anaesthesia of nose and oropharynx	6 (9.4%)	8 (12.5%)
	Passage of bronchoscope through the nose	0	0
	Passage of bronchoscope through vocal cords	58 (90.6%)	56 (87.5%)
	Total	64	64

Chi-square test N. Sig* No significant

Table 3.

shows pain, cough and breathing status between both groups

	Valid	Case group	Control group	chi-square	df	p-value
Feeling pain during FB	Very painful	0	8 (12.5%)	124.675	3	< 0.001  H. Sig*
	Somewhat painful	0	38 (59.4%)
	Not so painful	9 (14.1%)	17 (26.6%)
	Not painful at all	55 (85.9%)	1 (1.6%)
	I don’t know	0	0
	Total	64	64
Cough during FB	Very severe	0	14 (21.9%)	98.655	3	< 0.001* H. Sig
	Intermittent	9 (14.1%)	40 (62.5%)
	Not much	4 (6.3%)	9 (14.1%)
	Rarely	51 (79.7%)	1 (1.6%)
	I don’t know	0	0
	Total	64	64
Breathing during FB	Very difficult	0	30 (46.9%)	85.457	3	< 0.001 * H. Sig
	Somewhat difficult	15 (23.4%)	30 (46.9%)
	Not so difficult	44 (68.8%)	4 (6.2%)
	Not difficult at all	5 (7.8%)	0
	I don’t know	0	0
	Total	64	64

H sig * high significant

Fig. 1.

Correlation between procedure time in the two groups

Table 4 highlights the hospital anxiety scale, as it was statistically significantly higher among members of the control group (p-value 0.0001). Willingness to return to the procedure and patients’ satisfaction are shown in Table 4. Patient satisfaction and readiness to repeat the procedure if necessary was statistically significant among members of the case group (p-value 0.001; highlighted in Table 5).

Table 4.

Explain the overall anxiety in both groups

Overall anxiety	Control		Case		P-value (Independent t-test)
	F**	%	F**	%
Normal	17	26.6	64	100	< 0.0001  H. Sig*
Borderline abnormal	41	64.1	0	0
Abnormal	6	9.4	0	0

 F ** frequency % percentages H. Sig * high significant

Discussion

Flexible bronchoscopy is one of the most stressful procedures in medical practice, as it creates a sensation of asphyxia, and many papers have demonstrated that hypoxia is the main cause of periprocedural complications among patients [6, 7]. Nevertheless, this procedure is safe, and it has increasing importance, for therapeutic and diagnostic purposes, and respiratory pathologies [7, 8].

Approximately one-fifth of the participants are workers in the construction domains. This is a risk factor for many pulmonary diseases, such as pneumoconiosis, lung cancer, and chronic obstructive pulmonary disease [9, 10]. Additionally, some of them have worked outside, as farmers. This kind of work prescribes as dusty work. More studies approved the idea and agreed with this finding [11, 12].

In our study group, all the patients were comfortable and they were not reluctant to repeat the procedure if required. In the study group, about 55% were willing to return. The study discovered that satisfaction among the study group patients was statistically significant (p-value 0.001, chi-square test 124.364). A study mentioned that a minority of patients would repeat the procedure if needed, although the majority of them were satisfied during the procedure [13]. Other authors have stated that the degree of patient cooperation depends on the level of comfort after undergoing initial bronchoscopy [3]. Based on the results of our study, some patients were comfortable and felt safe to a point where they were ready to re-do the examination whenever necessary [14]. The study argues that well-explained instructions to patients were associated with a definite willingness to return. Another point that affects patients’ discomfort is the duration of the procedure; some papers have argued that longer examination time is associated with patient discomfort [15, 16].

In our study group, the anxiety scale was significantly low. Sun et al. stated that talking with the patients before the procedure minimizes anxiety levels among them significantly [4, 17]. Hasan et al. mentioned that using an educational program for patients raises tolerability, and easiness and minimizes procedure-related complications [4]. Many other researchers have also highlighted that a significant factor that affects tolerability for patients is patients’ comfort during the procedure [3, 4]. Moreover, one piece of research describes how the assessment of anxiety levels before the procedure can help the examiner to anticipate the anxiety levels of patients [18]. Further research mentioned that the predominant factor for patient tolerance is anxiety [19]. Coughing is distressing to the patient and bronchoscopist equally. This disturbing symptom was lower in our study group. This is because a positive correlation was found between coughing and patient discomfort [20].

In conclusion, our study shows that when patients were fully informed about the flexible bronchoscopy, tolerability and comfort were improved during the procedure. In addition, the shorter duration of the procedure is another significant point that affects the patient’s comfort. Further study of the patient assessments for the bronchoscopy procedure is recommended.

Electronic Supplementary Material

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Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declarations

Conflict of Interest

There is no conflict of interest.

Ethics Approval

The Ethical Committee of the College of Medicine / University of Sulaimani approved the study; (Approval number: 60 / 07.03.2021).

Ethics, consent, and permissions

Signed informed consent was obtained from all patients who were candidates for flexible bronchoscopy and their procedure’s photos, images may be used for scientific publications only.

Consent to publish

Written consent was obtained from all participants that their operation photos and images may be used for scientific publications only.