The use of bronchoscopy in critically ill patients: considerations and complications

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Abstract

Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.

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A randomized trial of diagnostic techniques for ventilator-associated pneumonia.

(2006)

Critically ill patients who require mechanical ventilation are at risk for ventilator-associated pneumonia. Current data are conflicting as to the optimal diagnostic approach in patients who have suspected ventilator-associated pneumonia. In a multicenter trial, we randomly assigned immunocompetent adults who were receiving mechanical ventilation and who had suspected ventilator-associated pneumonia after 4 days in the intensive care unit (ICU) to undergo either bronchoalveolar lavage with quantitative culture of the bronchoalveolar-lavage fluid or endotracheal aspiration with nonquantitative culture of the aspirate. Patients known to be colonized or infected with pseudomonas species or methicillin-resistant Staphylococcus aureus were excluded. Empirical antibiotic therapy was initiated in all patients until culture results were available, at which point a protocol of targeted therapy was used for discontinuing or reducing the dose or number of antibiotics, or for resuming antibiotic therapy to treat a preenrollment condition if the culture was negative. We enrolled 740 patients in 28 ICUs in Canada and the United States. There was no significant difference in the primary outcome (28-day mortality rate) between the bronchoalveolar-lavage group and the endotracheal-aspiration group (18.9% and 18.4%, respectively; P=0.94). The bronchoalveolar-lavage group and the endotracheal-aspiration group also had similar rates of targeted therapy (74.2% and 74.6%, respectively; P=0.90), days alive without antibiotics (10.4+/-7.5 and 10.6+/-7.9, P=0.86), and maximum organ-dysfunction scores (mean [+/-SD], 8.3+/-3.6 and 8.6+/-4.0; P=0.26). The two groups did not differ significantly in the length of stay in the ICU or hospital. Two diagnostic strategies for ventilator-associated pneumonia--bronchoalveolar lavage with quantitative culture of the bronchoalveolar-lavage fluid and endotracheal aspiration with nonquantitative culture of the aspirate--are associated with similar clinical outcomes and similar overall use of antibiotics. (Current Controlled Trials number, ISRCTN51767272 [controlled-trials.com].). Copyright 2006 Massachusetts Medical Society.

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Utility of early versus late fiberoptic bronchoscopy in the evaluation of new pulmonary infiltrates following hematopoietic stem cell transplantation.

Thomas Shannon, X. Lei, Franklin R. Champlin … (2010)

Pulmonary infiltrates frequently complicate hematopoietic SCT (HSCT). The utility of fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) in the evaluation of new pulmonary infiltrates, particularly as it relates to optimal timing of the procedure, is unclear. Based on this, we retrospectively reviewed 501 consecutive, adult, nonintubated patients who underwent 598 BALs for evaluation of new pulmonary infiltrates during the first 100 days following HSCT to determine whether diagnostic yields for infection, subsequent antimicrobial treatment modifications and patient outcomes differed following early vs late referrals for the procedure. The overall yield of BAL for clinically significant pathogens was 55%. Notably, the yield was 2.5-fold higher among FOBs performed within the first 4 days of presentation (early FOB) compared to those performed late, and highest (75%) when performed within 24 h of clinical presentation. Rates of FOB-guided adjustments in antimicrobial therapy (51%) did not differ significantly between early and late examinations. However, late FOB-related antibiotic adjustments were associated with 30-day pulmonary-associated deaths that were threefold higher (6 vs 18%, P=0.0351). Major FOB-related complications occurred in only three (0.6%) patients. We conclude that early referral for FOB in this patient setting is associated with higher diagnostic yields and may favorably impact survival.

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American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients.

Momen M Wahidi, Prasoon Jain, Michael Jantz … (2011)

Optimal performance of bronchoscopy requires patient's comfort, physician's ease of execution, and minimal risk. There is currently a wide variation in the use of topical anesthesia, analgesia, and sedation during bronchoscopy. A panel of experts was convened by the American College of Chest Physicians Interventional/Chest Diagnostic Network. A literature search was conducted on MEDLINE from 1969 to 2009, and consensus was reached by the panel members after a comprehensive review of the data. Randomized controlled trials and prospective studies were given highest priority in building the consensus. In the absence of contraindications, topical anesthesia, analgesia, and sedation are suggested in all patients undergoing bronchoscopy because of enhanced patient tolerance and satisfaction. Robust data suggest that anticholinergic agents, when administered prebronchoscopy, do not produce a clinically meaningful effect, and their use is discouraged. Lidocaine is the preferred topical anesthetic for bronchoscopy, given its short half life and wide margin of safety. The use of a combination of benzodiazepines and opiates is suggested because of their synergistic effects on patient tolerance during the procedure and the added antitussive properties of opioids. Propofol is an effective agent for sedation in bronchoscopy and can achieve similar sedation, amnesia, and patient tolerance when compared with the combined administration of benzodiazepines and opiates. We suggest that all physicians performing bronchoscopy consider using topical anesthesia, analgesic and sedative agents, when feasible. The existing body of literature supports the safety and effectiveness of this approach when the proper agents are used in an appropriately selected patient population.

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Author and article information

Journal

Title: Expert Review of Respiratory Medicine

Abbreviated Title: Expert Review of Respiratory Medicine

Publisher: Informa UK Limited

ISSN (Print): 1747-6348

ISSN (Electronic): 1747-6356

Publication date Created: July 17 2018

Publication date Created: August 03 2018

Publication date (Electronic): July 12 2018

Publication date (Print): August 03 2018

Volume: 12

Issue: 8

Pages: 651-663

Affiliations

[1 ] Department of Pulmonary and Critical Care, School of Medicine, Dokuz Eylul University, Izmir, Turkey

[2 ] Department of Clinical, Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University, Bologna, Italy

Article

DOI: 10.1080/17476348.2018.1494576

PubMed ID: 29958019

SO-VID: 3bc13049-6af7-4e23-8b47-261bbe4d034a

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The use of bronchoscopy in critically ill patients: considerations and complications

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Most cited references 88

A randomized trial of diagnostic techniques for ventilator-associated pneumonia.

Utility of early versus late fiberoptic bronchoscopy in the evaluation of new pulmonary infiltrates following hematopoietic stem cell transplantation.

American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients.

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