OT notes · ENT

Rigid bronchoscopy (diagnostic / foreign-body removal)

Usual anaesthesia
General anaesthesia with muscle relaxation, ventilation through the side port of a ventilating bronchoscope or by Venturi (jet) ventilation. Spontaneous ventilation, with relaxants withheld until the airway is secured, is kept for a large mediastinal mass or near-complete tracheal obstruction
Position
Supine, head on a pillow in the sniffing position, head end raised; neck extended once the scope is in the trachea
Setting
emergency

Operative note template for rigid bronchoscopy, with a filled example for removal of an inhaled groundnut from the right main bronchus of a 3-year-old child under general anaesthesia.

Download printable PDFFree. Just log in with your Google (Gmail) account.

Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • damage to lips, teeth or gums; loose teeth may be lost
  • injury to the vocal cords and hoarseness
  • laryngeal or subglottic swelling, breathing difficulty
  • need for a tracheostomy
  • pneumothorax or pneumomediastinum
  • bleeding, especially after biopsy
  • foreign body not removed, or a repeat bronchoscopy
  • pneumonia after the procedure
  • cardiac or respiratory arrest

Pre-operative details for this operation

  1. IndicationSuspected foreign bodyHaemoptysisStridor / airway stenosisBiopsy of lesionBronchial toiletfor foreign body: what, when inhaled, choking episode witnessed
  2. Chest X-ray / CT findingsside, hyperinflation, collapse, radio-opaque object
  3. Teethloose teeth, dentures or bridges removed before OT
  4. Neck and mouth openingcervical spine problem, trismus
  5. Bleeding tendency checked if biopsy planned
  6. Instruments checked before inductionbronchoscope sizes, light source, telescopes, forceps that fit the object, suction

Anaesthesia and position

  1. AnaesthesiaGA with muscle relaxant, ventilation via bronchoscope side portGA with muscle relaxant, Venturi / jet ventilationGA, spontaneous ventilation assisted, relaxant withheld until airway secured (critical airway obstruction)names of all anaesthetists; relaxant given or withheld
  2. Oxygenation before the scope is passedventilated with oxygen by mask for at least 3 minutes before insertion; lowest SpO2 during the procedure
  3. PositionSupine, sniffing position, head end raised
  4. Mouth guardPlaced

Operative findings

  1. Larynx and vocal cordsnormal / oedema / injury
  2. Trachea and carinasecretions, mucosa, carina sharp or widened
  3. Right bronchial treemain bronchus, upper lobe, middle lobe, lower lobe openings
  4. Left bronchial treemain bronchus, upper and lower lobe openings
  5. Foreign bodywhat, size, exact site, impacted or loose, granulations around it
  6. Mucosa after removaloedema, granulations, bleeding, pus distal to the object

Procedure (steps)

  1. Bronchoscopetype (ventilating, Jackson), length and diameter, e.g. 30 cm x 5 mm child
  2. Pharynx suctioned, mouth guard in
  3. Larynx exposedLaryngoscope bladeScope tip under epiglottis, lifted by left thumbteeth not used as a fulcrum
  4. Glottis passedscope turned 90 degrees to pass between the cords, then turned back
  5. Ventilation connectedSide port to circuitVenturibreaks for ventilation during work
  6. Right side examinedhead turned to the left; telescopes used (0, 30, 90 degree)
  7. Left side examinedscope withdrawn above the carina, head turned to the right
  8. Secretions suctionedsent for culture / cytology / AFB; saline lavage
  9. Foreign body removalOptical peanut forcepsAlligator forcepsOthernumber of attempts; removed whole or in pieces
  10. Biopsy (if done)site, number of bites, bleeding control
  11. Re-inspection of both sides after removalresidual fragments, bleeding
  12. Bronchoscope withdrawn under visionturned 90 degrees at the glottis; mask ventilation after

Closure, drains and dressing

  1. Airway at endMask ventilation, extubated / awakeEndotracheal tube placedTracheostomy
  2. Steroid for laryngeal oedemaGiven by anaesthetist: drug, doseNot given
  3. Teeth and lips checked at endNo injuryInjury: describe

Specimens and implants

  1. Foreign bodyShown to parents and discardedKept / handed over (medicolegal case)
  2. Bronchial secretions / lavageCulture and sensitivityCytologyAFBNot sent
  3. Biopsy for HPESentNot applicable

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Breathing watchrespiratory rate, SpO2, stridor, chest retraction; frequency
  2. Oxygenmask or prongs; wean to room air as SpO2 allows
  3. Positionpropped up
  4. Steroidif prescribed for laryngeal oedema: drug, dose, number of doses
  5. Chest X-rayafter therapeutic bronchoscopy, or if breath sounds remain reduced
  6. Oral intakesips when fully awake and swallowing
  7. Antibioticsonly if prescribed: drug, dose, reason (e.g. pneumonia distal to the object)
  8. Call ENTstridor, falling SpO2, cyanosis, surgical emphysema

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Master A.R., 3 years, 13 kg, choked on groundnuts 2 days ago, now cough and wheeze with reduced air entry on the right; chest X-ray shows right-sided air trapping.

Case details

Date: 04/02/2026. Emergency rigid bronchoscopy. OT 3.

In OT 10:05. Induction 10:12. Scope in 10:18. Foreign body out 10:31. Scope out 10:36.

Surgeon: Dr A. (3rd-year resident, ENT). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present and scrubbed.

Anaesthetists: Dr D. (consultant) and Dr F. (resident). Scrub nurse: Sr E.

Indication and pre-op

Witnessed choking on groundnut 2 days ago. Cough, wheeze, reduced breath sounds on the right. Chest X-ray: right lung hyperinflated on expiration, mediastinum shifted to the left.

No loose teeth. Neck movement normal.

Consent: general, procedure-specific and anaesthesia consent from father in Hindi. Risks explained: teeth and lip injury, cord injury, airway swelling, possible tracheostomy, pneumothorax, repeat procedure, cardiac arrest.

Bronchoscopes (child 30 cm x 5 mm and infant 25 cm x 3.5 mm), telescopes, optical peanut forceps and suction checked before induction.

WHO checklist sign in and time out done.

Anaesthesia and position

General anaesthesia with muscle relaxant. Ventilated with oxygen by mask for 3 minutes before the scope was passed, then through the side port of the ventilating bronchoscope.

Supine, head on a small pillow in the sniffing position. Mouth guard placed. Pharynx suctioned.

Procedure and findings

Ventilating rigid bronchoscope, child size 30 cm x 5 mm. Introduced from the right side of the mouth, tip placed under the epiglottis and lifted with the left thumb; teeth not used as a fulcrum.

Scope turned 90 degrees to pass the glottis, then turned back. Cords normal. Circuit connected to the side port.

Trachea: moderate mucoid secretions, suctioned. Carina sharp.

Head turned to the left, scope passed into the right main bronchus. Half groundnut kernel about 8 mm impacted in the right main bronchus just above the upper lobe opening, with mild mucosal oedema and pus distal to it.

Foreign body grasped with optical peanut forceps and removed whole at the first attempt. Pus distal to it suctioned; sample sent for culture.

Right bronchial tree re-inspected with 0 and 30 degree telescopes: no residual fragment, upper, middle and lower lobe openings clear. Scope withdrawn above the carina, head turned to the right: left bronchial tree normal, no foreign body.

Two breaks for ventilation during the procedure; SpO2 lowest 91%.

Scope withdrawn under vision, turned 90 degrees at the glottis. Cords normal on withdrawal.

End of procedure

Mask ventilation, then extubated awake by anaesthetist. IV dexamethasone given by anaesthetist, recorded in the anaesthesia chart.

Teeth and lips checked: no injury. Blood loss nil.

Instrument check: forceps and telescopes complete and intact. No antibiotic prophylaxis given in OT; antibiotic to be decided with the culture report.

Specimens: bronchial pus for culture and sensitivity. Groundnut shown to father and discarded.

No complications. Shifted to recovery awake, crying, no stridor. SpO2 97% on 2 L oxygen by mask, respiratory rate 30/min.

Post-op orders

Propped up. Oxygen by mask, weaned to room air as SpO2 allows.

Pulse oximetry in recovery, then observe in the ward overnight: respiratory rate, SpO2, stridor and chest retraction charted by the nurse.

Sips of water when fully awake, then normal diet.

Chest X-ray this evening.

Call ENT resident on call for stridor, chest retraction, falling SpO2 or neck swelling.

Signature

Dr A., JR-3, ENT. Reg. no. ________. 04/02/2026, 10:55.

Must document for this operation

  • Size and type of bronchoscope, and every instrument used for removal. If the object breaks or a repeat is needed, the next team knows what failed and what fitted.
  • Exact site of the foreign body and whether it came out whole. A fragment left behind is the main reason for persistent symptoms, and the note must show that both sides were re-inspected.
  • Names of all anaesthetists and how ventilation was maintained. The airway is shared during rigid bronchoscopy, and Indian courts have faulted op notes that left out an anaesthetist's name.
  • State of cords, trachea and bronchial mucosa after removal. Oedema or granulations explain later stridor or cough and decide the need for steroids or a repeat look.
  • Teeth and lips checked at the end. Dental injury is a known complication and is a common complaint after rigid endoscopy.
  • What was done with the foreign body and any samples. Parents often ask for the object, and in a medicolegal case it may be needed as evidence.

Common mistakes in these notes

  • Writing 'FB removed' with no site, size or type of object.
  • Not recording that the other bronchus was examined.
  • Leaving out the bronchoscope size and the forceps used.
  • Naming only one anaesthetist when two were present.
  • No post-op airway plan for a small child with airway oedema.

Indian practice and paperwork

  • The type of anaesthesia and the drugs used must be recorded, and an operative note must be written before the patient leaves recovery. (NABH 5th ed., COP.13(h) and COP.14(e))
  • A hospital was held negligent because the operation notes did not name the anaesthetist when two anaesthetists had given anaesthesia. Name everyone who managed the airway. (Thomas J. Indian J Urol 2009;25(3):384-8 (PMID 19881136))
  • Consent must be in a language the parents understand and must say who will do the procedure. (NABH 5th ed., PRE.4(c))

Sources

  • Theissing J, Rettinger G, Werner JA. ENT-Head and Neck Surgery: Essential Procedures. Thieme; 2011, Ch 10, Tracheobronchoscopy with a rigid bronchoscope, pp. 230-231.
  • Kaiser LR, Jamieson GG, eds. Operative Thoracic Surgery (Rob & Smith's Operative Surgery). 5th ed. Hodder Arnold; 2006, Ch 7, Bronchoscopy (Kucharczuk JC), pp. 63-71.
  • Tuli BS, Tuli IP, Singh A, Tuli NK. Textbook of Ear, Nose and Throat. 2nd ed. Jaypee Brothers; 2013, Ch 80, Bronchoscopy, pp. 494-496.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

This page cannot be printed from the browser. Use the Download printable PDF button on the page.