BRONCHOSCOPY IN THE ICU

 

Indications

1. Intubations

2. Atelectasis/retained secretions (45%)

3. Hempotysis

4. Dx of pneumonia (35%)

5. Airway evaluation/trauma

6. Foreign body removal

 

Contraindications (relative)

1. hypoxia/hypercarbia

2. recent MI

3. asthma

 

Complications

1. Fever (15-20%)

2. Arrhythmia (3-11%)

3. PTX (7-14% if TBBx)

4. Other: bleeding(.6-5.4%), mediastinal emphysema, increased ICP, death(.02-.1%)

5. Anaesthesia- resp depression, seizures

6. Hypercapnea- pCO2 inc 25-30% (dec TV)

7. Hypoxia- pO2 dec 40%, lasts 15min-2hrs post procedure (atelectasis)

 

Practical aspects

1. ETT- size matters

ETT size

Effective size (5.5mm scope)

Inc R

8.5

7

120%

8.0

6

215%

7.5

5.5

250%

7.0

5

280%

Results- inc PIP, tracheal pressure, autopeep

 

2. Topical anesthesia- lidocaine

a. 20-50% absorbed

b. metabolized by liver but inc effect in CHF and RF

c. peak serum level 1hr post, t1/2 90min

d. toxic dose 4-6mg/kg _28cc 1% in 70kg male

e. 1% = 10mg/ml

f. seizures

 

Specific applications

1. Atelectasis/retained secretions

a. Several case series 70s-80s, 30-1000 pts

i. GBS, SCI appears benficial

ii. asthma w/ mucous plugging

iii. generally 40-80% show improvement by CXR or oxygen

iv. MOST BENEFIT: 1)lobar or > collapse, 2)no air bronchograms

a. RCT- Marini et al 79: 31 pts w/ lobar atelectasis, bronch plus PT vs PT, CXR f/u _38% better with bronch, 37% with PT

1. Dx nosocomial pneumonia

a. Clinical and radiographic assessment of nosoc pneumonia very bad

b. Endotracheal aspirates sensitive but not specific_quantitative cx methods and invasive sampling techniques

c. Histologic data show 100,000 organisms/cc = pneumonia

d. PSB samples .001cc_1:100dil_1000CFU/cc cutoff for dx

e. BAL samples .01cc_1:100dil_ 10,000CFU/cc cutoff

f. Fagan AIM 2000: RCT 413pts PSB/BAL vs EA

Group

14d mort

AbxFD

PSB/

BAL

16.2%

11.5

EA

25.8%

7.5

?due to dec abx, inc ID of other sources of infection, *no improvement in 28d mortality