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Fiberoptic Bronchoscopy in the ICU. R. Duncalf, MD, FCCP Pulmonary & Critical Care Division Bronx Lebanon Hospital Center. Introduction: Spectrum of Pulmonary Disease in the ICU . Pneumonia- community or nosocomial Pulmonary edema- cardiogenic or noncardiogenic

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fiberoptic bronchoscopy in the icu
Fiberoptic Bronchoscopy in the ICU

R. Duncalf, MD, FCCP

Pulmonary & Critical Care Division

Bronx Lebanon Hospital Center

introduction spectrum of pulmonary disease in the icu
Introduction: Spectrum of Pulmonary Disease in the ICU
  • Pneumonia- community or nosocomial
  • Pulmonary edema- cardiogenic or noncardiogenic
  • Pulmonary hemorrhage ± hemoptysis
  • Thromboembolic disease
  • Primary or metastatic CA
  • Interstitial lung disease
  • Obstructive airway disease
  • Respiratory failure in any of above requiring intubation and mechanical ventilation (MV)
  • Complications of intubation and MV
introduction flexible fiberoptic bronchoscopy ffb
Introduction: Flexible Fiberoptic Bronchoscopy (FFB)
  • Essential diagnostic and therapeutic tool in ICU
  • Can be performed via endotracheal tube (ETT) or tracheostomy tube
  • Bedside procedure: avoids transport/ OR time
common diagnostic icu indications for ffb
Common Diagnostic ICU Indications for FFB
  • Inspection, bronchoalveolar lavage (BAL), transbronchial lung biopsy (TBBx)
  • Abnormal chest X-ray/ suspected pulmonary infection
  • Hemoptysis
  • Lung carcinoma/ obstructing neoplasm
  • Chemical or thermal burns
  • ETT assessment/ management: intubation/extubation assist, position/ injury evaluation
slide5

Feng A, Sy E. A Lung Saddle Tumor. The Internet Journal of Pulmonary Medicine 2009 : Volume 11 Number 1

Elderly patient admitted with respiratory failure.

Bx= Squamous cell Ca

common therapeutic icu indications for ffb
Common Therapeutic ICU Indications for FFB
  • Retained secretions/ atelectasis
  • Mucous plugs- bronchial asthma, cystic fibrosis
  • Hemoptysis/ blood clots
  • Drainage lung abscess
  • Debridement of necrotic tracheobronchial mucosa
  • Dilation airway stenosis/ strictures
indications in critically ill medical patients
Indications in Critically Ill Medical Patients

198 bronchoscopies:

45% retained secretions

35% specimens for culture

7% airway evaluation

2% hemoptysis

Olapade CS, Prakash U: Bronchoscopy in the critical care unit. Mayo Clin Proc 64:1255-1263, 1989

ffb in pulmonary infiltrates
FFB in Pulmonary Infiltrates
  • Usually to evaluate infectious process
  • Allows directed sampling, identification of pathogens, de-escalation of antibiotics
    • BAL 10-50,000 CFU on culture diagnostic
    • protected specimen brush 5-10,000 CFU diagnostic
  • Potential for identification of noninfectious processes
slide11

Cos J, Sy E, Diaz-Fuentes G, Menon L. Foreign body presenting as a persistent lung infiltrate. The IJPM 2009 : Volume 11 Number 1

slide12

Cos J, Sy E, Diaz-Fuentes G, Menon L. Foreign body presenting as a persistent lung infiltrate. The IJPM 2009 : Volume 11 Number 1

After removal of foreign body

ffb in retained secretions and atelectasis
FFB in Retained Secretions and Atelectasis
  • FFB vs. physiotherapy for retained secretions: no superiority demonstrated
  • FFB in atelectasis:
    • retained secretions and air bronchograms to segmental level only
    • lobar or greater atelectasis not responding to aggressive chest PT
    • life threatening whole lung atelectasis
  • Severe hypoxemia not contraindication
  • Expect improved A-a gradient, static compliance, radiography (8 hrs)
slide14

3/24/10

3/26/10

emergent ffb in the icu
Emergent FFB in the ICU
  • 27% atelectasis/ retained secretions
  • 17% ARDS/ pulmonary edema
  • 13% airway stenosis/ tracheobronchomalacia
  • 13% pneumonia/ empyema
  • 8% hemoptysis
  • 8% foreign body

Hasegawa S, Terada Y, Murakawa M, et al: Emergency bronchoscopy. Journal of bronchology 5: 284-287, 1998

slide20

Daniel V, DeLaCruz A, Diaz-Fuentes G. Tracheal Laceration Due to Endobronchial Intubation. Journal of Respiratory diseases. June 2007:15-17

ffb complications
FFB: Complications
  • Premedication/ local anesthesia: respiratory depression/ arrest, methemoglobinemia, death
  • Procedure related: hypoxemia, cardiac complications, pneumonia, death
  • Ancillary procedures: barotrauma, pulmonary hemorrhage, death
complications hypoxemia
Complications: Hypoxemia
  • Common: up to 2 hrs. post procedure: 20-30 mmHg O2 drop in healthy, 30-60 in critically ill
  • Reduction in effective tidal volume and FRC
  • Suction at 100mmHg via 2mm suction port removes 7L/min
  • Saline/lidocaine instillation
slide23

Safety of BAL in Ventilated Patients With ARDS

J Bronchol Volume 14, Number 3, July 2007

148 ventilated patients with ARDS in ICU underwent FOB-BAL for investigation of VAP

No deaths or major complications occurred in relation to BAL

Only 2 minor episodes of desaturation (fall in SpO2 of 6%) occurred within two hours after BAL, a

complication rate of 1.4% (P=0.49)

FFB with BAL in ICU in ventilated ARDS patients (even with extreme hypoxemia ) is safe provided adequate precautions are taken

complications cardiac
Complications: Cardiac
  • Hypoxemia, hypercapnea increased sympathetic tone arrhythmias, ischemia, hypotension death
  • Major arrhythmias in 11%
  • Unstable angina, severe preexisting hypoxemia risk factors
  • Hemodynamics: 30% MAP, 43%HR, 28% CI
ffb in mv physiology
FFB in MV: Physiology
  • Standard ED 5.7mm scope occludes 10% cross sectional area of trachea, 40% 9mm ID ETT, 51% 8mm ID ETT, 66% 7mm ID ETT
  • Hypoventilation, hypoxemia, gas trapping/ high intrinsic PEEP
  • 8mm ID ETT for standard scope recommended
  • Ultrathin bronchoscopes (2.8mm): reduce potential for hypoxemia/hypercapnea, dynamic hyperinflation
ffb in mv increased complication risk
FFB in MV: Increased Complication Risk
  • Pulmonary:
    • PaO2< 70mmHg with FiO2> 0.7
    • PEEP> 10 cm H2O
    • autoPEEP > 15 cm H2O
    • active bronchospasm
  • Cardiac:
    • recent MI (48 hrs.)
    • unstable arrhythmia
    • MAP < 65mm Hg or vasopressor
  • CNS:
    • increased intracranial pressure
ffb in mv complication rates
FFB in MV: Complication Rates
  • < 10 %
  • Minor complications: 6.5%
  • Major complications: 0.08-0.15%
  • Mortality: 0.01-0.04%
  • Raoof S, Mehrishi S, Prakash U. Role of bronchoscopy in the modern medical intensive care unit. Clin Chest Med 2001; 22: 241-261
ffb in mv complications of tbbx
FFB in MV: Complications of TBBx
  • Study of 83 lung biopsies:
    • 14.3% pneumothorax
    • 8.4% hypoxemia < 90%
    • 7.2% hypotension (MAP < 60mm Hg)
    • 6% hemorrhage > 30 cc
    • 3.6% tachycardia >140/min.

O’Brien JD, Ettinger NA, Shevlin D et al: Safety yield of transbronchial lung biopsy in mechanically ventilated patients. Crit Care Med 25: 440-446 1997

slide29

Yield and Safety of FFB and TBBX on patients on Mechanical Ventilation in the ICU

Division of Pulmonary and Critical Care Medicine,

Bronx- Lebanon Hospital Center, Bronx, NY

slide30

There is limited information on the usefulness and safety of TBBx in ICU patients on MV

  • The goals of the study were to evaluate the yield, safety and efficacy of FFB with BAL and TBBx compared to FFB-BAL only
  • Retrospective review of ICU patients on MV who underwent diagnostic FFB from January 2006 to December 2007
  • TBBx was done at the bedside and without fluoroscopic guidance
  • The average number of biopsies per patient were 2 (range 1-3)
  • Patients who underwent FFB for inspection and / or therapeutic bronchoscopy were excluded
slide31

Demographics

  • 132 patients were identified: 92 in the BAL and 40 in the BAL with TBBx group
  • 48 (36%) of patients were HIV positive, all had AIDS
  • The main indications for FFB were evaluation of lung infiltrates (99%) and lung masses
results
Results
  • There was no statistical difference in the yield from BAL when compared to BAL with TBBx for patients on MV
  • BAL alone showed a higher yield in patients with HIV as compared to non- HIV patients
  • More patients in the HIV positive group had BAL with TBBx compared with the non-HIV group ( 48% vs 20 % respectively)
  • TBBx revealed additional diagnosis in 4 patients: PCP (1), malignancy (1), and fungal infection (2)
  • There were no complications in either group
conclusions
Conclusions
  • The overall yield of diagnostic BAL with TBBx was 60%; this lower than reported yield could be due to inadequate biopsy sampling due to the non-fluoroscopic technique and/or to the fewer number of biopsies done
  • TBBx is a useful alternative for the diagnosis of infections in critically ill patients who are too ill for surgical biopsies; especially in HIV+/AIDS patients where fungal infection is often a consideration
  • We recommend considering BAL with TBBx in selected patients on MV, especially in HIV+/ AIDS patients, where opportunistic infections are suspected
  • FFB with BAL with TBBx seems to be a safe diagnostic tool in ICU patients on MV