Noninvasive Ventilation-assisted Bronchoscopy in High-risk Hypoxemic Patients

Abstract

Background and aims Hypoxemic patients undergoing fiber-optic bronchoscopy (FOB) are at risk of worsening of respiratory failure requiring mechanical ventilation due to FOB procedure itself and its complications. As patients with respiratory failure are frequently managed by non-invasive ventilation (NIV); feasibility of FOB through NIV mask has been evaluated in some studies to avoid intubation. We describe here our own case series. Materials and methods Clinical data of 28 FOB done through NIV mask in 27 intensive care unit (ICU) patients over 6 years period at our center was collected retrospectively and analysed. Results Study comprises 27 (17 male; 52±21.6 years age) hypoxemic (PaO 2 71.3±14.2, on NIV and oxygen supplementation) patients. All FOB were done at bedside, 15 of them were given sedation for the procedure. Twenty four patients had bronchoalveolar lavage (BAL); three underwent bronchial biopsies, four brush cytology and seven transbronchial biopsies. In 10 patients lung or lobar collapse was reversed. There was no significant change between pre and post bronchoscopy ABG parameters except for improved post FOB PaO 2 ( p = 0.0032) and SpO 2 ( p = 0.0046). One patient (3.57%) developed late pneumothorax and 3 patients (10.7%) had bleeding after biopsy. Prior to bronchoscopy 17 (16 BIPAP, 1 CPAP) patients were already on NIV. Two patients required mechanical ventilation 6 hours after FOB due to subsequent clinical deterioration but could be weaned off later. One patient died on third day after FOB from acute myocardial infarction. Conclusion Hypoxemic patients in ICU can safely undergo bedside diagnostic and simple therapeutic bronchoscopy with NIV support while mostly avoiding intubation and with low complication rates. How to cite this article Sircar M, Jha OK, Chabbra GS, Bhattacharya S. Noninvasive Ventilation-assisted Bronchoscopy in High-risk Hypoxemic Patients. Indian J Crit Care Med 2019;23(8):363-367.

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“…Endobronchial brushings or endobronchial biopsies are more rarely reported in critically ill patients ( 36 ). Transbronchial biopsies increase the risk for pneumothorax ( 37 ) and in patients on positive pressure ventilation could lead to tension pneumothorax; thus, they are likely not appropriate for research purposes. Because of the lack of published data with these specimen types, with the exception of protected specimen brushes, the committee focused on the safety and collection of BAL samples.…”

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“…Sircar et al . report on 27 patients with respiratory failure who underwent bronchoscopy with NIV support, without requiring intubation ( 22 ). Baumann et al .…”

“…Hypoxemia is accepted as a risk factor for bronchoscopy-related complications, and especially for worsening hypoxemia and cardiac pathologies ( 22 ). In the present study, the complication group patients showed lower PaO 2 /FiO 2 than the patient group without complications.…”