ROLE OF BRONCHOSCOPY IN MODERN MEDICAL INTENSIVE CARE UNIT

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Gustav Killian,60 known as the “father of bronchoscopy,” was the first to perform bronchoscopy in 1897 to examine the airways and remove a foreign body. He used a rigid endoscope to remove an aspirated pork bone from the right main bronchus. Chevalier Jackson of Philadelphia later modified the rigid bronchoscope (RB) in 1904 by adding a direct ocular mechanism, suction tube, and tip illumination.100 The RB was the only available instrument to examine the airways until the late 1960s, when Shigeto Ikeda54 introduced the flexible fiberoptic bronchoscope for clinical use. Since its introduction in 1967, the use of the flexible bronchoscope (FB) rapidly has become widespread for various pulmonary disorders, and presently it is considered one of the most useful modalities, primarily for diagnostic and, to a lesser extent, therapeutic purposes.

A critically ill patient can be defined as one whose vital bodily functions are compromised seriously from pathologic injury to one or more organ systems. Critically ill patients therefore require close monitoring by specially trained medical and paramedical personnel. Involvement of the respiratory system is common, whatever the underlying cause of disease that precipitates the critical illness. The common causes of pulmonary disease in the intensive care unit (ICU) include pneumonia (community-acquired and nosocomial), pulmonary edema (cardiogenic and noncardiogenic), pulmonary hemorrhage, thromboembolic disease, primary and metastatic lung cancer, drug- and radiation-induced lung injury, and others, including connective tissue disorders.

Because critically ill patients may be too unstable to move safely, diagnostic procedures that can be performed in the ICU at beside are preferable to those that involve transport to remote sites. The versatility and the easy portability of the FB enable the performance of FOB easily and safely at the bedside. In addition, in contrast to RB, FOB offers enhanced visualization of the distal bronchi and averts the need for general anesthesia and operating room resources. The FB therefore is considered an essential diagnostic and therapeutic instrument in the care of patients admitted to the ICU.28, 71 According to the estimation of Tobin et al,121 as many as 98% of all bronchoscopic procedures are performed using the FB, and most bronchoscopists have never been trained in the technique of RB.

Despite the many advantages of FBs, the RB sometimes is preferred especially as the primary therapeutic and diagnostic tool in massive hemoptysis and large foreign body aspiration. With the advent of new therapeutic modalities such as the neodymium yttrium-aluminium-garnet (Nd–YAG) laser, endobronchial stenting, cryotherapy, and so forth, the RB increasingly is being used in patients with respiratory failure secondary to endobronchial obstruction or extrinsic compression of the bronchus. Rigid bronchoscopy, when used in the ICU, is limited to situations in which an FB is unavailable or when a mature tracheal stoma is present in a spontaneously breathing patient. High-risk patients and those who require bronchoscopic lung biopsies (BLB) probably still should undergo the procedure in the operating room because of the risk for bleeding and tension pneumothorax (especially with positive-pressure ventilation.)

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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