R. Duncalf, MD, FCCPPulmonary & Critical Care DivisionBronx Lebanon Hospital Center

Fiberoptic Bronchoscopy in the ICU

Introduction: Spectrum of Pulmonary Disease in the ICU Pneumonia- community or nosocomialPulmonary edema- cardiogenic or noncardiogenicPulmonary hemorrhage hemoptysisThromboembolic diseasePrimary or metastatic CAInterstitial lung diseaseObstructive airway diseaseRespiratory failure in any of above requiring intubation and mechanical ventilation (MV)Complications of intubation and MV

Introduction: Flexible Fiberoptic Bronchoscopy (FFB)Essential diagnostic and therapeutic tool in ICUCan be performed via endotracheal tube (ETT) or tracheostomy tubeBedside procedure: avoids transport/ OR time

Common Diagnostic ICU Indications for FFB Inspection, bronchoalveolar lavage (BAL), transbronchial lung biopsy (TBBx)Abnormal chest X-ray/ suspected pulmonary infectionHemoptysisLung carcinoma/ obstructing neoplasmChemical or thermal burnsETT assessment/ management: intubation/extubation assist, position/ injury evaluation

Feng A, Sy E. A Lung Saddle Tumor. The Internet Journal of Pulmonary Medicine 2009 : Volume 11 Number 1Elderly patient admitted with respiratory failure. Bx= Squamous cell Ca

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 Patients198 bronchoscopies:45% retained secretions35% specimens for culture7% airway evaluation2% hemoptysis

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

FFB in Pulmonary InfiltratesUsually to evaluate infectious processAllows directed sampling, identification of pathogens, de-escalation of antibioticsBAL 10-50,000 CFU on culture diagnosticprotected specimen brush 5-10,000 CFU diagnostic Potential for identification of noninfectious processes

Middle age patient admitted with RLL pneumonia and DKA.

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

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

FFB in Retained Secretions and AtelectasisFFB vs. physiotherapy for retained secretions: no superiority demonstratedFFB in atelectasis:retained secretions and air bronchograms to segmental level onlylobar or greater atelectasis not responding to aggressive chest PTlife threatening whole lung atelectasisSevere hypoxemia not contraindicationExpect improved A-a gradient, static compliance, radiography (8 hrs)

3/24/103/26/10

Emergent FFB in the ICU27% atelectasis/ retained secretions17% ARDS/ pulmonary edema13% airway stenosis/ tracheobronchomalacia13% pneumonia/ empyema8% hemoptysis8% foreign body

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

CXR after difficult intubation. Septic shock with MOD and AIDS

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

FFB: ComplicationsPremedication/ local anesthesia: respiratory depression/ arrest, methemoglobinemia, deathProcedure related: hypoxemia, cardiac complications, pneumonia, deathAncillary procedures: barotrauma, pulmonary hemorrhage, death

Complications: HypoxemiaCommon: up to 2 hrs. post procedure: 20-30 mmHg O2 drop in healthy, 30-60 in critically illReduction in effective tidal volume and FRCSuction at 100mmHg via 2mm suction port removes 7L/minSaline/lidocaine instillation

Safety of BAL in Ventilated Patients With ARDSJ Bronchol Volume 14, Number 3, July 2007148 ventilated patients with ARDS in ICU underwent FOB-BAL for investigation of VAPNo 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, acomplication 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: CardiacHypoxemia, hypercapnea increased sympathetic tone arrhythmias, ischemia, hypotension deathMajor arrhythmias in 11%Unstable angina, severe preexisting hypoxemia risk factorsHemodynamics: 30% MAP, 43%HR, 28% CI

FFB in MV: PhysiologyStandard ED 5.7mm scope occludes 10% cross sectional area of trachea, 40% 9mm ID ETT, 51% 8mm ID ETT, 66% 7mm ID ETTHypoventilation, hypoxemia, gas trapping/ high intrinsic PEEP8mm ID ETT for standard scope recommendedUltrathin bronchoscopes (2.8mm): reduce potential for hypoxemia/hypercapnea, dynamic hyperinflation

FFB in MV: Increased Complication Risk Pulmonary:PaO2< 70mmHg with FiO2> 0.7PEEP> 10 cm H2OautoPEEP > 15 cm H2Oactive bronchospasmCardiac:recent MI (48 hrs.)unstable arrhythmiaMAP < 65mm Hg or vasopressorCNS:increased intracranial pressure

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 TBBxStudy of 83 lung biopsies:14.3% pneumothorax8.4% hypoxemia < 90%7.2% hypotension (MAP < 60mm Hg)6% hemorrhage > 30 cc3.6% tachycardia >140/min.

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

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

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

Demographics132 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

BAL N= 92BAL + TBBxN= 40Mean age in yrs ( + SD)57 (+15.9)50 (+11.9)Gender FemaleMale54381822Race African-American Hispanic Others4447123152

Overall Yield of FFB

BALN= 92BAL + TBBxN= 40P valueMalignancy05 Infection

PCP Fungi Viral Bacteria50

2024619

7309Total54% 60%0.55

Comparison of yield between HIV and Non HIV groupP value= 0.04P value= 0.9

BAL N=92BAL+ TBBx N=40HIV (25)Non HIV (67)HIV(23)Non HIV (17)Malignancy0014Infection PCP Fungi Viral Bacterial1820115320013113720460105Total72%48%61%59%

Analysis of positive yield in the BAL with TBBx group

N= 24BAL non diagnosticTBBx diagnosticBAL diagnosticTBBx non diagnosticBAL diagnosticTBBx diagnosticMalignancy (5)104PCP (7)124Fungi (3)201Bacterial (9)009Total4 (17%)2 (8%)18 (75%)

Analysis of the yield for the BAL with TBBx positive in the Non-HIV patients

N= 10BAL non diagnosticTBBx diagnosticBAL diagnosticTBBx non diagnosticBAL diagnosticTBBx diagnosticMalignancy (4)103Fungi (1)001Bacterial (5)005Total 1 (10%)9 (90%)

Analysis of yield for the BAL with TBBx positive in HIV patients

N= 14BAL non diagnosticTBBx diagnosticBAL diagnosticTBBx non diagnosticBAL diagnosticTBBx diagnosticMalignancy (1)001PCP (7)124Fungi (2)200Bacterial (4)004 Total 3 (21%)2 (14%)9 (65%)

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

Results

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

Conclusions

Thanks

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