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 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)

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

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

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

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

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

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

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 1

After removal of foreign body

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)

3/24/10 3/26/10

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

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: Complications

Premedication/ local anesthesia: respiratory depression/ arrest, methemoglobinemia, death

Procedure related: hypoxemia, cardiac complications, pneumonia, death

Ancillary procedures: barotrauma, pulmonary hemorrhage, death

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

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, 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: 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

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

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

< 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 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

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

BAL N= 92

BAL + TBBxN= 40

Mean age in yrs ( + SD) 57 (+15.9) 50 (+11.9)

Gender Female

Male5438

1822

Race African-American Hispanic

Others

44471

23152

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

Overall Yield of FFB

BALN= 92

BAL + TBBxN= 40

P value

Malignancy 0 5

Infection

PCP Fungi Viral

Bacteria

50

202

46

19

7309

Total 54% 60% 0.55

Comparison of yield between HIV and Non HIV group

BAL N=92

BAL+ TBBx N=40

HIV (25)

Non HIV (67)

HIV(23)

Non HIV (17)

Malignancy 0 0 1 4

Infection PCP

Fungi Viral

Bacterial

18201

15

32001

31

137204

60105

Total 72% 48% 61% 59%

P value= 0.04

P value= 0.9

Analysis of positive yield in the BAL with TBBx group

N= 24 BAL non diagnostic

TBBx diagnostic

BAL diagnosticTBBx non diagnostic

BAL diagnosticTBBx

diagnostic

Malignancy (5) 1 0 4

PCP (7) 1 2 4

Fungi (3) 2 0 1

Bacterial (9)

0 0 9

Total 4 (17%) 2 (8%) 18 (75%)

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

N= 10 BAL non diagnostic

TBBx diagnostic

BAL diagnosticTBBx non diagnostic

BAL diagnosticTBBx

diagnostic

Malignancy (4)

1 0 3

Fungi (1)

0 0 1

Bacterial (5)

0 0 5

Total 1 (10%) 9 (90%)

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

N= 14 BAL non diagnostic

TBBx diagnostic

BAL diagnosticTBBx non diagnostic

BAL diagnosticTBBx diagnostic

Malignancy (1) 0 0 1

PCP (7) 1 2 4

Fungi (2) 2 0 0

Bacterial (4) 0 0 4

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