Bronchoscopy Guidelines in Intensive Care Settings
Intensive care units should have the facility to perform urgent and timely flexible bronchoscopy for a range of therapeutic and diagnostic indications, as patients in ICU should be considered high-risk for complications during the procedure. 1
Indications for Bronchoscopy in ICU
Therapeutic Indications
- Removal of retained secretions and mucus plugs that obstruct major airways
- Management of lobar collapse unresponsive to physiotherapy 1
- Removal of foreign bodies (food material, tooth fragments) using wire basket or forceps
- Identification and management of endotracheal bleeding sources
Diagnostic Indications
- Collection of microbiological samples in patients with pneumonia
- Evaluation of airways in cases of persistent hypoxemia
- Assessment of tube position and patency
- Evaluation of stridor post-extubation
Pre-Procedure Risk Assessment
Patient Evaluation
- Assess for hypoxia, electrolyte disturbances, clotting abnormalities, and arrhythmias 1
- Check coagulation parameters before biopsy procedures:
- Elevated prothrombin time
- Increased activated partial thromboplastin time (APTT)
- Reduced fibrinogen titre
- Thrombocytopenia
Anticoagulation Management
- Stop oral anticoagulants at least 3 days before bronchoscopy when biopsy specimens may be required 2
- For high thromboembolic risk patients:
- Reduce INR to <2.5
- Consider bridging with heparin
- Consult cardiology/hematology for individualized protocol 2
Procedural Considerations
Equipment Selection
- Choose appropriate bronchoscope size based on endotracheal tube internal diameter
- For efficient suctioning, use larger bronchoscope with wide suction channel 1
Ventilator Adjustments
- Pre-oxygenate with 100% oxygen
- Switch to mandatory ventilation mode (avoid triggered modes like pressure support)
- Increase ventilator pressure limit to ensure adequate tidal volumes
- Increase ventilator rate if necessary 1
Sedation Protocol
- For bronchoscopic procedures, narcotic premedication is recommended 3
- Midazolam dosing:
- Titrate slowly over at least 2 minutes
- Allow 2+ minutes between doses to evaluate sedative effect
- For healthy adults <60 years: Start with 1 mg, maximum 2.5 mg initially
- For patients ≥60 years or debilitated: Start with 1 mg, maximum 1.5 mg initially 3
- More profound sedation/anesthesia can be achieved in ventilated patients 1
- For patients with head injury, profound anesthesia with neuromuscular blockade is required 1
Monitoring Requirements
During Procedure
- Continuous multi-modal physiological monitoring is mandatory 1
- ECG for heart rate and rhythm
- Continuous intra-arterial blood pressure or intermittent cuff measurements
- Pulse oximetry (SpO₂)
- End-tidal CO₂ monitoring, especially in head injury patients 1
- Set appropriate alarm limits and have staff monitor physiological variables
Safety Measures
- Establish intravenous access before starting the procedure
- Have resuscitation equipment readily available
- Ensure immediate availability of resuscitative drugs and age-appropriate equipment 3
- Have personnel trained in airway management present 3
Post-Procedure Care
- Continue 100% oxygen in the immediate recovery period 1
- If transbronchial biopsy was performed, obtain chest radiograph at least 1 hour after to exclude pneumothorax 2
- Provide verbal and written instructions about potential delayed complications 2
- Resume oral anticoagulants only after confirming absence of bleeding 2
Complications and Risk Mitigation
Major Risks in ICU Setting
- Pneumothorax (approximately 10% risk with transbronchial biopsy) 1
- Hemorrhage (approximately 5% risk with biopsy procedures) 1
- Hypoxemia due to bronchoscope obstruction of endotracheal tube
- Increased intracranial pressure in head-injured patients
Risk Mitigation
- For patients with clotting dysfunction, consider brushing or lavage instead of biopsy 1
- In patients with renal failure, be aware of potential platelet dysfunction 1
- For massive hemorrhage, rigid bronchoscopy is generally preferred over flexible bronchoscopy 1
- Monitor intracranial pressure in head-injured patients 1
Bronchoscopy in the ICU setting is a valuable diagnostic and therapeutic tool when performed with appropriate precautions and monitoring. The benefits must clearly outweigh the risks, particularly in critically ill patients who represent a high-risk group for invasive procedures.