Bronchoscopy in intubated and non-intubated intensive care unit patients with respiratory failure

Abstract

Bronchoscopy is one of the important tool for the pulmonary and critical care physicians to diagnose and treat various pulmonary conditions. It is increasingly being used by the intensivist due to its safety and portability. The utilization of bronchoscopy in the intensive care unit (ICU) has made the diagnosis and treatment of many conditions more feasible to intensivists. Sedation, topical or intravenous, usually helps better tolerate the procedure. However, the risks and benefits of bronchoscopy should be carefully considered in critically ill patients. The hypoxic patients in ICU pose a challenge as hypoxemia is one of the known complications of bronchoscopy, and this risk is exacerbated in patients with hypoxic respiratory failure. Bronchoscopy is relatively contraindicated in patients with severe hypoxemia and coagulopathy. However, bronchoscopy in hypoxic patients can have diagnostic as well as therapeutic implications. In patients with hypoxic respiratory failure, the use of non-invasive ventilation (NIV) during bronchoscopy has been shown to reduce the risk of intubation. On the other hand, bronchoscopy in mechanically ventilated patients is not contraindicated and has been widely used. Staying focused, monitoring vital signs closely, limiting the scope time in the airway, and understanding patient's physiology may help decrease risk of complications. In this review, we discuss indications, techniques, complications, and yield associated with bronchoscopy in critically ill hypoxic patients.

Clinical Value of Bronchoscopy in Acute Respiratory Failure

“…The main indications for bronchoscopy in ARF patients are: (1) to support difficult intubation and percutaneous dilatational tracheostomy (PDT) [5][6][7]; (2) to help in the diagnosis of infective and non-infective lung infiltrates in non-ventilated and ventilated patients [1,[8][9][10][11]; (3) to manage acute airway obstruction of different origins, such as mucous plugs, FBs, and benign/malignant trachea-bronchial disorders [3,12]; (4) to manage massive haemoptysis [13] (Figure 1).…”

Safety of Fiberoptic Bronchoscopy in Airway Pressure Release Ventilation Mode in Critically Ill Patients: Are These Results Safe?

“…We have carefully read the recently published study titled, “The Safety of Fiberoptic Bronchoscopy in Airway Pressure Release Ventilation Mode in Critically Ill Patients with Severe Acute Respiratory Distress Syndrome: A Preliminary Study” 2 and have the following concerns regarding the methodology, validity, and recommendations made on the basis of the reported results. 3 …”

“…In daily practice, the use of muscle relaxants in critically ill patients requiring bronchoalveolar lavage (BAL) is generally due to bronchospasm, patient-ventilator maladjustment, or elevated airway pressure. 3 However, these factors should not be at play here as APRV encourages spontaneous breathing efforts to increase the final end-inspiratory transpulmonary pressure much higher than the set P-high of 30 cm H 2 O. 4 …”