Bronchoscope Consent Form Updated

Chest & Dr Fiona E Kritzinger Dr Taryn Gray
Allergy MBChB cum laude (US), DCH (SA), FCPaed (SA), MMed
cum laude (US), Cert Pulmonology (SA) Paed
MBChB (UCT), DCH (SA), DA (SA), FCPaed (SA),
MMed cum laude (US), Cert Pulmonology (SA) Paed
Centre Practice no: 0320090366382 | MP 0518107 Practice no: 0320090534390 | MP 0545325

[email protected] [email protected]
S p e ci a l i s t P a e d i a t r i c C a r e
CONSENT FORM FOR LARYNGO-TRACHEO-BRONCHOSCOPY
PATIENT DETAIL
Surname:
Forename:
Date of birth:
Hospital case no:
PROPOSED TREATMENT
The doctor has explained that my child/dependent (name of patient)
has the following possible condition
and that a laryngo-tracheo-bronchoscopy and
is proposed.
1.What is a bronchoscopy and biopsy?

The doctor uses a soft, thin, flexible fibre-optic tube (bronchoscope) to look at the vocal cords and the airways inside the lungs.
The bronchosope is passed through the nose or mouth. Small samples of tissue and cells may be removed (biopsy) and sent for tests.
How are tissue samples taken?

If tissue samples are taken, they are sent to pathology for testing. It may take a week or more before a result is obtained. These are some of the
samples that can be taken:
Endo-bronchial biopsy: A small tissue sample is taken from the inside lining of the airways.
Bronchial brushings: A small brush is passed on the inside lining of the airways.
Broncho-alveolar lavage: Fluid is put into a single small airway and sucked back up into a specimen jar. This collects cells from the air sacs of the lung.
Trans-bronchial needle aspiration: A needle is passed through the wall of the bronchus airway to take samples from outside the bronchial wall.
Trans-tracheal needle aspiration: A needle is passed through the wall of the trachea to take samples from structures outside the lungs, such as
lymph nodes.
Trans-bronchial lung biopsy: A small (< 1 mm) sample of lung tissue is taken from the lung by passing a needle through the bronchus.
3. What are the risks of this specific procedure?

These are the common risks. There may be other unusual risks that have not been listed here. Please ask your doctor about any other specific concerns
you may have.
Common risks (>5%)
1. Fever in first 24 hrs. Usually mild and treated with paracetomol.
2. Low oxygen levels while waking up after procedure. This can last up to 24 hours and will be treated with oxygen.
3. Coughing.
4. Wheezing or noisy breathing.
Uncommon risks (< 5%)
1. There is a theoretical risk of bleeding into the lung and introducing air into the chest causing the lung to collapse (pneumothorax), only if biopsies
are taken. Usually the risk of this complication is less than 1 in 1000. In that event, the air around the lung would have to be removed with a chest
tube. This would mean your child would have to stay longer at the hospital until the hole in the lung is healed, which usually takes 1 to 3 days. Please
ask the doctor if this risk applies to your child.
2. Narrowing of vocal cords (laryngospasm). This is usualy brief and rarely a problem.
T: 021 003 7272 | F: 086 548 3713 | AH: 021 712 6699 | [email protected] | www.chestandallergy.co.za
Suite 1610, Christiaan Barnard Memorial Hospital, 25 D.F. Malan Street, Cape Town City Centre, 8000 | PO Box 914, Cape Town, 8000
Pg 1 of 2
Chest & Dr Fiona E Kritzinger Dr Taryn Gray
Allergy MBChB cum laude (US), DCH (SA), FCPaed (SA), MMed
cum laude (US), Cert Pulmonology (SA) Paed
MBChB (UCT), DCH (SA), DA (SA), FCPaed (SA),
MMed cum laude (US), Cert Pulmonology (SA) Paed
Centre Practice no: 0320090366382 | MP 0518107 Practice no: 0320090534390 | MP 0545325

[email protected] [email protected]
S p e ci a l i s t P a e d i a t r i c C a r e
4. Individual Risks
I understand the following are possible significant risks and complications specific to my child’s individual circumstances, that I
have considered these in deciding my child will have the procedure.
RISKS OF NOT HAVING A BRONCHOSCOPY AND BIOPSY (Doctor to document in space)
5. Details of how procedure is performed

Please read attached information sheet “Flexible Bronchoscopy” and ask the doctor if anything is unclear.
DECLARATION BY PATIENT/PARENT/LEGAL GUARDIAN

• I acknowledge the doctor has informed me about the procedure, alternatives to it and answered my specific queries and
concerns about this matter.
• I acknowledge that I have discussed with the doctor any specific risks and complications specific to my child’s individual
circumstances that I have considered in deciding to have this procedure.
• I agree to any other additional life saving procedures considered necessary in the judgement of my doctor during this
procedure.
• I agree to the disposal by the hospital authorities of any tissues that may be removed during the procedure. I understand that
some tissues or samples may be kept as part of my child’s / dependent’s hospital and practice records.
• I understand that there are risks associated with the anaesthetic. I am aware that I can discuss these risks with the
anaesthetist before the procedure.
• I have received a copy of this form to take home with me.
• I have been given a patient information sheet on flexible bronchoscopy that I have read and I understand the content.
Signature of parent/guardian Date
Name of parent/guardian Relationship to patient
DECLARATION BY DOCTOR
I declare that I have explained to the parent(s) / guardian the nature of the patient’s condition, the procedure to be performed, and
discussed the risks that particularly concern the patient. I have given the parent(s) / guardian an opportunity to ask questions and I
have answered these.
Doctor’s signature Date
Doctor’s name
Print name
INTERPRETER’S DECLARATION
I confirm I have accurately interpreted the contents of this form and the related conversations between the patient and the doctor.
Interpreter’s signature Date
Interpreter’s name
Print name
T: 021 003 7272 | F: 086 548 3713 | AH: 021 712 6699 | [email protected] | www.chestandallergy.co.za
Suite 1610, Christiaan Barnard Memorial Hospital, 25 D.F. Malan Street, Cape Town City Centre, 8000 | PO Box 914, Cape Town, 8000
Pg 2 of 2

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Chest & Dr Fiona E Kritzinger Dr Taryn Gray

Centre Practice no: 0320090366382 | MP 0518107 Practice no: 0320090534390 | MP 0545325

CONSENT FORM FOR LARYNGO-TRACHEO-BRONCHOSCOPY

Hospital case no:

The doctor has explained that my child/dependent (name of patient)

has the following possible condition

and that a laryngo-tracheo-bronchoscopy and

1.What is a bronchoscopy and biopsy?

How are tissue samples taken?

3. What are the risks of this specific procedure?

Centre Practice no: 0320090366382 | MP 0518107 Practice no: 0320090534390 | MP 0545325

RISKS OF NOT HAVING A BRONCHOSCOPY AND BIOPSY (Doctor to document in space)

5. Details of how procedure is performed

DECLARATION BY PATIENT/PARENT/LEGAL GUARDIAN

Signature of parent/guardian Date

Name of parent/guardian Relationship to patient

Doctor’s signature Date

Interpreter’s signature Date

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