ROLE OF BRONCHOSCOPY IN MODERN MEDICAL INTENSIVE CARE UNIT
Section snippets
INDICATIONS FOR BRONCHOSCOPY
Hasegawa et al108 reported the frequency of performing bronchoscopy in ICU patients with different medical conditions (Table 1). Olapade et al86 reported the frequency of use of the FB for different indications in critically ill patients with various medical disorders. Of a total of 198 bronchoscopies, 45% were performed for removal of retained secretions, 35% for obtaining specimens for culture, 7% for airway evaluation, 2% for hemoptysis, and 0.5% each for facilitation of endotracheal
Hemoptysis
Bronchoscopy plays an important therapeutic role in hemoptysis. Bleeding may be managed by endobronchial tamponade or hemostasis achieved by application of fibrin precursors.13, 55, 105, 109 In the ICU, urgent bronchoscopic evaluation within 12 to 18 hours renders the highest chance for visualization of the active bleeding site and may guide therapeutic interventions.104 The type of intervention depends on the most likely cause of bleeding.
An initial attempt at visualization of the bleeding
Retained Secretions and Atelectasis
For the most part, FOB is aimed at clearing thick mucous secretions and plugs, especially when other methods such as tracheal suctioning, inhaled bronchodilators, and chest physiotherapy fail. Immediate performance of bronchoscopy at times becomes necessary to clear out thick mucous plugs, especially in patients with underlying pulmonary diseases. Stevens and associates116 reported that 69% of 297 FOBs performed in 223 patients in the ICU were for therapeutic reasons. Similarly, 75% of FOBs
DIAGNOSTIC BRONCHOSCOPY
The major indications for diagnostic bronchoscopy were listed earlier. The overall diagnostic yield of diagnostic FOB depends on the indication and varies from 55% to 75%.86 The most common indication for diagnostic bronchoscopy in the ICU is the presence of lung infiltrates.
BRONCHOSCOPY IN MECHANICALLY VENTILATED PATIENTS
Mechanical ventilation is not a contraindication for therapeutic or diagnostic bronchoscopy. The indications for performing FOB are usually the same as in nonintubated patients. Among the 297 FOBs performed in 223 patients in the critical care unit reported by Stevens and colleagues,116 65% were performed in patients on mechanical ventilation. Approximately 66% of the FOBs described by Lindholm et al,71 75% by Olapade et al81, and 79% by Turner et al126 were performed in patients while on
THE BRONCHOSCOPIC TECHNIQUE
The procedure for preparation and performance of bronchoscopy in critically ill patients is similar to that for patients who are not critically ill. The critically ill patient, however may have to undergo bronchoscopy while receiving mechanical ventilation and may be attached to multiple tubes and other life-sustaining equipment. The prerequisites for performing a safe and efficient bronchoscopy in ICU are:
Consent
Discontinuation of feeds at least 8 hours before the procedure
Checking of
Battery Bronchoscope
With the recent development of the battery bronchoscopes (Fig. 1), FOB has become much quicker and easy to perform. The main advantages of using battery bronchoscopes include no or minimal requirement of accessories such as light source, bronchoscopy cart, and assistant nurse. It may offer the ability to determine rapidly and reliably the position of the ET. It has been well documented that an ET tip can move by about 4 cm as the head position changes from full flexion to extension.27, 28 In
RISKS AND CONTRAINDICATIONS
There are only a few absolute contraindications to bronchoscopy in the ICU. The most important are inability to keep the patient adequately oxygenated and patient refusal for the operative procedure.114 Absence of adequately trained personnel, inadequate facilities, and uncooperative patients are also contraindications to bronchoscopy.114 Knowledge of situations involving increased risk can help the bronchoscopist avoid complications. The American Thoracic Society guidelines114 divide
COMPLICATIONS
With appropriate care, FOB is an extremely safe procedure. The overall incidence rate of major complications ranges from 0.08% to 0.15% and the mortality rate from 0.01% to 0.04%. Minor complications occur in 6.5% of the patients.89, 96 Lukomsky et al74 prospectively compared the complications of the RB and FB. Of the 4595 procedures, 1146 were performed with an FB and the remainder were with RB. Complications occurred in 235 procedures (5.1%). Major complications requiring intensive medical
COMPLICATIONS OF BRONCHOSCOPIC PROCEDURES IN MECHANICALLY VENTILATED PATIENTS
Complications of FOB in patients on mechanical ventilation are mild and occur in fewer than 10% of FOBs performed in the ICU. Hertz et al50 assessed the safety of BAL in 99 critically ill, mechanically ventilated patients. They found no complications that required premature termination of BAL. Two patients had hypotension, and wheezing was observed in one immediately after BAL, all of which resolved promptly with treatment. No statistically significant changes were observed in the variables of
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Address reprint requests to Suhail Raoof, MD Division of Pulmonary and Critical Care Medicine, Nassau County Medical Center, 2201 Hempstead Turnpike–10th Floor, East Meadow, NY 11554