Flexible Bronchoscopy Assisted by Noninvasive Positive Pressure Ventilation

Abstract

endotracheal intubation in order to ensure airway patency and minimize risks of procedure-related respiratory insufficiency. [4][5][6][7] In many instances, however, bronchoscopy can be safely performed while the patient receives NPPV, sparing patients the discomfort and risks of refractory hypoxemia, intubation, and mechanical ventilation. The limited available published evidence indicates that NPPVassisted flexible bronchoscopy is used about 3 times per month in tertiary academic centers. 4,7 Critical care nurses have an essential role in the preparation and performance of this procedure, as well as in surveillance after the procedure, and, as part of the multidisciplinary health care team, in patient care decisions. The objectives of this article, therefore, are to review the physiological basis for NPPV-assisted bronchoscopy; describe its indications, contraindications, and techniques; and identify ways in which critical care nurses can further influence patient care before, during, and after this airway procedure. Critically ill patients with the aforementioned comorbid conditions may require diagnostic or therapeutic flexible bronchoscopy to diagnose or treat causes of airway obstruction, atelectasis, and pneumonia. Standard practice in these instances is to recommend bronchoscopy with high-flow supplemental oxygenation via face mask, or to proceed with sedation and N oninvasive positive pressure ventilation (NPPV) is defined as any form of ventilatory support applied without endotracheal intubation. 1An often-used alternative to endotracheal intubation, NPPV reduces the need for invasive mechanical ventilation in patients with hypoxic respiratory failure due to cardiogenic pulmonary edema or immunocompromised state. NPPV is also used to improve postoperative hypoxemia; reduce pulmonary complications after cardiac, upper abdominal, Noninvasive positive pressure ventilation is an alternative to intubation in critically ill patients with respiratory insufficiency or poor gas exchange who may require flexible bronchoscopy for diagnostic or therapeutic purposes. This ventilatory technique might help decrease the risk of bronchoscopy-related complications in patients with refractory hypoxemia, postoperative respiratory distress, severe emphysema, obstructive sleep apnea, and obesity hypoventilation syndrome and allows bronchoscopic assessment of patients with severe dyspnea from expiratory central airway collapse. In this review, the physiological rationale, indications, contraindications, techniques, and monitoring requirements for flexible bronchoscopy assisted by noninvasive positive pressure ventilation are described, with an emphasis on the role of critical care nurses in this procedure. (Critical Care Nurse.

Anesthesia for Advanced Bronchoscopic Procedures: State-of-the-Art Review

“…Patients with significant resistance (airway or chest wall) may have unacceptable leaks at pressures needed to achieve sufficient tidal volumes [45]. Morbid obesity and restrictive lung diseases are some of the examples [46].…”

ISHLT Consensus Statement on adult and pediatric airway complications after lung transplantation: Definitions, grading system, and therapeutics

“…Management strategies range from conservative therapy (pulmonary hygiene and non-invasive positive pressure ventilation [NIPPV]) to invasive therapy (silicone airway stents and tracheobronchoplasty). [88][89][90][91][92][93][94][95][96][97] Because the primary goal of therapy is to improve symptoms and quality of life, asymptomatic malacia should not be treated. Treatment of the underlying cause should be considered first.…”

“…The amount of pressure required can be determined by performing a dynamic bronchoscopy while titrating NIPPV settings. 92 NIPPV can be used at night and intermittently as needed during the day.…”

Anesthesia for interventional pulmonology procedures: a review of advanced diagnostic and therapeutic bronchoscopy

“…Pressure-controlled ventilation with a standard continuous positive end-expiratory pressure (PEEP) between 5 and 10 cmH 2 O as well as positive pressure support ventilation between 15 and 20 cmH 2 O is a reasonable approach. 51,61 Other parameters suggested include a tidal volume close to 10 mL·kg −1 body weight, F I O 2 of 100%, a 1:2 inspiratory to expiratory ratio, and a respiratory rate of 12 cycles·min −1 . When performing electrosurgical procedures, different settings (including low F I O 2 ) are recommended to prevent airway fire (see common complications and special considerations as discussed further it the text).…”