From the Guidelines
Bronchoscopic tracheal toilet should be performed by inserting a flexible bronchoscope through the mouth, nose, or artificial airway to remove secretions from the trachea and bronchi, with careful consideration of patient preparation, sedation, and monitoring to minimize risks and ensure effective clearance of secretions. When performing bronchoscopic tracheal toilet, it is essential to prepare the patient with appropriate sedation (such as midazolam 1-5mg IV or fentanyl 25-100mcg IV) and topical anesthesia (lidocaine 1-2% spray or gel for the upper airway, and 1% solution instilled through the bronchoscope for the lower airway, not exceeding 8mg/kg total dose) 1. The patient should be positioned supine with the neck slightly extended, and the bronchoscope should be inserted through the chosen route and advanced past the vocal cords into the trachea. Some key points to consider when performing this procedure include:
- Systematically examining the airways while applying suction to remove secretions
- Instilling 3-5ml of normal saline if secretions are thick
- Advancing the bronchoscope into the affected bronchi and applying suction for deeper secretions
- Maintaining oxygen supplementation and monitoring vital signs, oxygen saturation, and ECG throughout the procedure 1. It is crucial to ensure the patient is stable and recovering from sedation after completing the procedure. This procedure is particularly effective in clearing airway secretions when conventional methods like suctioning or chest physiotherapy are inadequate, especially in intubated patients or those with neuromuscular weakness who cannot clear secretions effectively. The equipment needed for this procedure includes a bronchoscope, light source, suction apparatus, supplemental oxygen, and equipment for resuscitation, including an endotracheal tube 1. Personnel required for this procedure include a dedicated operator, a registered nurse (RN) or a respiratory therapist to administer and monitor conscious sedation, and a separate RN or a respiratory therapist to assist the dedicated operator with the procedure 1.
From the Research
Bronchoscopic Tracheal Toilet Procedure
To perform a bronchoscopic tracheal toilet, the following steps can be considered:
- Preparation: Sedation is usually necessary for flexible bronchoscopy, and a combination of midazolam and fentanyl or midazolam, fentanyl, and propofol can be used 2, 3.
- Monitoring: Standard monitoring should include non-invasive blood pressure and pulse oximetry, and an electrocardiogram for cardiac patients 4.
- Bronchoscopy: A flexible bronchoscope can be used for the procedure, and it can be performed under spontaneous ventilation and sedation with midazolam and fentanyl 5.
- Tracheal toilet: The procedure may involve transtracheal oxygen therapy and bronchial toileting using minitracheostomy in patients with advanced respiratory failure 6.
Sedation and Monitoring
- Sedation: Midazolam combined with an opioid is a preferred sedation method for bronchoscopy 4.
- Monitoring: Capnometry and recovery time lack evidence, and more primary research is needed in these fields 4.
- Complications: Cough, decrease in transient oxygen saturation, and difficult progression of the cannula through the larynx are potential complications, but these factors do not necessarily prevent intubation 5.
Special Considerations
- Patients with advanced respiratory failure may require transtracheal oxygen therapy and bronchial toileting using minitracheostomy 6.
- Patients with difficult airway can undergo flexible bronchoscopy intubation under spontaneous ventilation and sedation with midazolam and fentanyl 5.
- Lung-diseased patients are not well-represented by current guidelines, and more research is needed to address their specific needs 4.