AQuIRE Diagnostic Registry Codebook
Revised July 29, 2009
Procedure Form
General Procedure Information
Patient race
Patient sex
Indicate the site of service where the procedure took place
Indicate patient age on the date of the procedure.
Urgency of the procedure
Indicate the following regarding a fellow’s participation with the procedure.
Indicate the first assistant assisting with the procedure.
Other Procedural and Patient Information
Indicate Zubrod score
ASA
Was the ASA score classified as emergent?
Indicate any co-morbidities the patient has
Indicate if the patient using any of the following medications
Bleeding Risk/Labs
Platelets
INR
Has the patient taken clopidogrel within 96 hours?
Is the patient taking a medication other than clopidogrel or does the patient have a disease
that increases risk of bleeding?
Lifestyle
Indicate the patient’s tobacco use in the form of cigarettes
Indicate pack-years of patient’s tobacco use in the form of cigarettes
Indication for Procedure
Indicate mass or nodule size
Procedure indicated for infiltrate (infectious or ILD evaluation)
Procedure indicated for mediastinal LN
Procedure indicated for hilar LN
Procedure indicated for transplant evaluation
Procedure indicated due to prior procedure, which did not yield a diagnosis
Procedure indicated by other (specify)
Indication for Procedure - SPN
Indicate the size of the SPN on the short axis
Indicate the anatomical site of the SPN
Indicate the location of the SPN
Indicate the following regarding the SPN
Indication for Procedure - Mass
Indicate the size of the mass on the short axis
Indicate the anatomical site of the mass
Indicate the location the of the mass
Indicate the following regarding the mass
Indication for Procedure – Multiple peripheral nodules/masses
Indicate the size of the smallest of the multiple peripheral nodules/masses identified on the short axis
Indicate the anatomical site of the smallest of the multiple peripheral nodules/masses identified
Indicate the location the of the smallest of the multiple peripheral nodules/masses identified
Indicate the size of the largest of the multiple peripheral nodules/masses identified on the short axis
Indicate the anatomical site of the largest of the multiple peripheral nodules/masses identified
Indicate the location the of largest of the multiple peripheral nodules/masses identified
Indicate the total number of peripheral nodules/masses
Indication for Procedure - Infiltrate
Indicate the location(s) of infiltrate(s)
Is the infiltrate localized?
Indicate size of infiltrate on the short axis
Indicate anatomical site of the infiltrate
Indicate the following regarding the infiltrate
Procedure Performed
BAL
Transbronchial biopsy
Cytology brushing
Wash
Transbronchial Needle Aspiration (TBNA)
Endobroncial biopsy
Other Procedure
If a procedure was performed that is not listed above, specify here
Was autofluoresence used?
Indicate the total fluoro time for the proceudure in seconds
Was narrow band imaging used?
Procedure Performed - BAL
Indicate the volume instilled for the BAL in milliliters
Indicate the volume returned from the BAL in milliliters
Indicate anatomical site where BAL was performed
Procedure Performed - Transbronchial Biopsy
Indicate number of anatomical locations where a transbronchial biopsy was performed
Transbronchial Biopsy Site 1
Indicate the first anatomical location where a specimen was acquired during the transbronchial biopsy (biopsy site 1)
Indicate the number of specimens acquired at biopsy site 1
Indicate all of the techniques utilized to localize the SPN/mass/infiltrate at biopsy site 1
Transbronchial Biopsy Site 2
Indicate the second anatomical location where a specimen was acquired during the transbronchial biopsy (biopsy site 2)
Indicate number of specimens acquired at biopsy site 2
Indicate all of the following techniques utilized to localize the SPN/mass/infiltrate at biopsy site 2
Transbronchial Biopsy Site 3
Indicate the third anatomical location where a specimen was acquired during the transbronchial biopsy (biopsy site 3)
Indicate number of specimens acquired at biopsy site 3
Indicate all of the following techniques utilized to localize the SPN/mass/infiltrate at biopsy site 3
Procedure Performed - Cytology Brushing
Indicate number of anatomical locations where a cytology brushing was performed
Cytology Brushing Site 1
Indicate the first anatomical location where a specimen was acquired during the cytology brushing (brush site 1)
Indicate how the brush site 1 specimen was processed
Indicate all of the techniques utilized to localize the SPN/mass/infiltrate at cytology brush site 1
Cytology Brushing Site 2
Indicate the second anatomical location where a specimen was acquired during the cytology brushing (brush site 2)
Indicate how the brush site 2 specimen was processed
Indicate all of the techniques utilized to localize the SPN/mass/infiltrate at cytology brush site 2
Cytology Brushing Site 3
Indicate the third anatomical location where a specimen was acquired during the cytology brushing (brush site 3)
Indicate how the brush site 3 specimen was processed
Indicate all of the techniques utilized to localize the SPN/mass/infiltrate at cytology brush site 3
Procedure Performed - Wash
Indicate the amount of saline instilled for the wash
Procedure Performed - Transbronchial Needle Aspiration (TBNA)
Indicate number of anatomical locations where a unique combination of technology was used for the transbronchial needle aspiration (TBNA)
TBNA Site 1
Indicate the first anatomical location where a unique combination of technology was used during the TBNA (TBNA site 1)
Indicate number of passes made at TBNA site 1
Indicate the guidance used to perform the TBNA site 1
Based on the EBUS image, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 1
Was on-site cytology performed on the specimen acquired at TBNA site 1?
Was adequate tissue obtained to either confirm a diagnosis or placement in a lymph node at TBNA site 1?
Based on the CT scan, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 1
Based on the PET scan indicate the size of the lymph node targeted for TBNA site 1 was metabolically active
Indicate needle gauge used for TBNA site 1
TBNA Site 2
Indicate the second anatomical location where a unique combination of technology was used during the TBNA (TBNA site 2)
Indicate number of passes made at TBNA site 2
Indicate the guidance used to perform TBNA site 2
Based on the EBUS image, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 2
Was on-site cytology performed on the specimen acquired at TBNA site 2?
Was adequate tissue obtained to either confirm a diagnosis or placement in a lymph node at TBNA site 2?
Based on the CT scan, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 2
Based on the PET scan indicate if the lymph node targeted for TBNA site 2 was metabolically active
Indicate needle gauge used for TBNA site 2
TBNA Site 3
Indicate the third anatomical location where a unique combination of technology was used during the TBNA (TBNA site 3)
Indicate number of passes made at TBNA site 3
Indicate the guidance used to perform TBNA site 3
Based on the EBUS image, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 3
Was on-site cytology performed on the specimen acquired at TBNA site 3?
Was adequate tissue obtained to either confirm a diagnosis or placement in a lymph node at TBNA site 3?
Based on the CT scan, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 3
Based on the PET scan indicate if the lymph node targeted for TBNA site 3 was metabolically active
Indicate needle gauge used for TBNA site 3
TBNA Site 4
Indicate the fourth anatomical location where a unique combination of technology was used during the TBNA (TBNA site 4)
Indicate number of passes made at TBNA site 4
Indicate the guidance used to perform TBNA site 4
Based on the EBUS image, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 4
Was on-site cytology performed on the specimen acquired at TBNA site 4?
Based on the CT scan, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 4
Based on the PET scan indicate if the lymph node targeted for TBNA site 4 was metabolically active
Indicate needle gauge used for TBNA site 4
TBNA Site 5
Indicate the fifth anatomical location where a unique combination of technology was used during the TBNA (TBNA site 5)
Indicate number of passes made at TBNA site 5
Indicate the guidance used to perform TBNA site 5
Based on the EBUS image, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 5
Was on-site cytology performed on the specimen acquired at TBNA site 5?
Based on the CT scan, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 5
Based on the PET scan indicate if the lymph node targeted for TBNA site 5 was metabolically active
Indicate needle gauge used for TBNA site 5
TBNA Site 6
Indicate the sixth anatomical location where a unique combination of technology was used during the TBNA (TBNA site 6)
Indicate number of passes made at TBNA site 6
Indicate the guidance used to perform TBNA site 6
Based on the EBUS image, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 6
Was on-site cytology performed on the specimen acquired at TBNA site 6?
Based on the CT scan, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 6
Based on the PET scan indicate if the lymph node targeted for TBNA site 6 was metabolically active
Indicate needle gauge used for TBNA site 6
TBNA Site 7
Indicate the seventh anatomical location where a unique combination of technology was used during the TBNA (TBNA site 7)
Indicate number of passes made at TBNA site 7
Indicate the guidance used to perform TBNA site 7
Based on the EBUS image, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 7
Was on-site cytology performed on the specimen acquired at TBNA site 7?
Based on the CT scan, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 7
Based on the PET scan indicate if the lymph node targeted for TBNA site 7 was metabolically active
Indicate needle gauge used for TBNA site 7
TBNA Site 8
Indicate the eighth anatomical location where a unique combination of technology was used during the TBNA (TBNA site 8)
Indicate number of passes made at TBNA site 8
Indicate the guidance used to perform TBNA site 8
Based on the EBUS image, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 8
Was on-site cytology performed on the specimen acquired at TBNA site 8?
Based on the CT scan, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 8
Based on the PET scan indicate if the lymph node targeted for TBNA site 8 was metabolically active
Indicate needle gauge used for TBNA site 8
TBNA Site 9
Indicate the ninth anatomical location where a unique combination of technology was used during the TBNA (TBNA site 9)
Indicate number of passes made at TBNA site 9
Indicate the guidance used to perform TBNA site 9Based on the EBUS image, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 9
Was on-site cytology performed on the specimen acquired at TBNA site 9?
Based on the CT scan, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 9
Based on the PET scan indicate if the lymph node targeted for TBNA site 9 was metabolically active
Indicate needle gauge used for TBNA site 9
TBNA Site 10
Indicate the tenth anatomical location where a unique combination of technology was used during the TBNA (TBNA site 10)
Indicate number of passes made at TBNA site 10
Indicate the guidance used to perform TBNA site 10
Based on the EBUS image, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 10
Based on the CT scan, indicate the size of the lymph node or mass on the short axis sampled at TBNA site 10
Based on the PET scan indicate if the lymph node targeted for TBNA site 10 was metabolically active
Indicate needle gauge used for TBNA site 10
Procedure Performed- Endobronchail Forceps Biopsy
Indicate the number of anatomical locations where a endobronchial forceps biopsy was performed
Endobronchial Forceps Biopsy Site 1
Indicate the first anatomical location where a specimen was acquired during the endobronchial forceps biopsy.
Endobronchial Forceps Biopsy Site 2
Indicate the second anatomical location where a specimen was acquired during the endobronchial forceps biopsy.
Endobronchial Forceps Biopsy Site 3
Indicate the third anatomical location where a specimen was acquired during the endobronchial forceps biopsy.
Anesthesia
Who administered the sedation to the patient?
Indicate the deepest level of anesthesia performed
Was ventilation used?
Indicate method of ventilation
Indicate type of bronchoscope used
Indicate approach used
Procedure Time
Indicate time of induction
Indicate time of scope insertion
Indicate time of scope removal
Indicate time the patient was removed from the procedure room after the bronchoscopy
Periprocedural Morbidity
Did complications occur within 1 hour of the procedure?
Bleeding (requiring intervention)
Pneumothorax
Indicate intervention for pneumothorax
Indicate where patient was admitted for pneumothorax.
Clinically significant airway injury occurred
Sustained hypoxia (>1 min, less than 90% saturation)
Unexpected hypotension (requiring pressors)
Cardiac arrest
Arrhythmia
Indicate type of arrhythmia