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