What are the updated guidelines for using bronchoscopy in critically ill patients requiring intensive care, particularly those with severe respiratory failure, hemodynamic instability, or coagulopathy, and suspected or confirmed COVID-19?

Updated Guidelines for Bronchoscopy in Critical Care

Bronchoscopy in critically ill patients should be performed with strict aerosol mitigation protocols, prioritizing cuffed endotracheal intubation with general anesthesia whenever possible, maintaining cuff pressures of 25-30 cmH2O, and clamping ventilation circuits immediately before scope insertion and withdrawal to minimize viral transmission and hemodynamic complications. 1

Procedural Stratification and Timing

Risk-benefit assessment must be individualized based on local COVID-19 prevalence, ICU capacity, and clinical urgency. The Portuguese Pulmonology Society recommends step-wise reopening of elective interventional pulmonology procedures according to:

• Number of new confirmed COVID-19 cases 1
• Hospital ward and ICU admission rates 1
• Equipment and healthcare staff availability 1
• Backlog of postponed cases 1

Urgent Indications (Cannot Be Delayed)

• Massive hemoptysis when embolization is not feasible 1
• Acute foreign body aspiration 1
• Severe symptomatic central airway obstruction 1
• Migrated airway stents 1
• Ventilator-associated pneumonia in mechanically ventilated patients (occurs in up to 30% of critically ill patients) 1
• Lobar collapse refractory to standard therapy 1

Bronchoscopy in Mechanically Ventilated ICU Patients

Pre-Procedure Ventilator Settings

Volume control, pressure-limited mode is preferable with PEEP maintained at baseline levels throughout the procedure. 1, 2

• Cuffed endotracheal tube is mandatory over supraglottic devices (laryngeal mask) 1
• Cuff pressure: 25-30 cmH2O (must be at least 5 cmH2O above peak inspiratory pressure if using high airway pressures) 1
• FiO2: Increase to 100% before and during procedure 1, 2
• General anesthesia with muscle relaxant to reduce aerosol production 1
• PEEP: Maintain at same level during procedure; adjustments require assessment of derecruitment risk, desaturation, arrhythmias, and pneumothorax 1

Critical Aerosol Mitigation Technique

The single most important safety maneuver is clamping the ventilation circuit immediately before bronchoscope introduction and again before withdrawal. 1 This simple step prevents aerosol dispersion during the highest-risk moments.

Procedural Execution

• Minimize scope removal and reinsertion during the procedure 1
• Reduce bronchoalveolar lavage volume to minimum necessary in hypoxemic patients (2-3 mL is sufficient for SARS-CoV-2 diagnosis) 1
• Collect deep tracheal sample via closed suction for COVID-19 testing if status unknown (upper airway samples have higher false-negative rates) 1
• Pass nasogastric tube after intubation is complete to minimize need for later interventions 1

Post-Procedure Monitoring

• Use HME filter close to patient instead of heated humidified circuit, monitoring for wetness and blockage 1
• Monitor cuff pressure at every shift to prevent displacement 1
• Record tube depth prominently and verify at each shift change 1
• Document difficult airway prominently and communicate at handoffs 1

Bronchoscopy Under Spontaneous Ventilation

General anesthesia with orotracheal intubation is safer for elective procedures when clinical conditions permit. 1 If spontaneous ventilation is necessary:

Operator Positioning and Oxygen Delivery

• Operator stands behind patient's head to reduce direct exposure 1
• Oxygen without humidification via nasal cannula or oxygen mask with bronchoscope entrance 1
• Transnasal approach preferred for flexible bronchoscopy 1
• Surgical mask over patient's mouth to minimize droplet emission 1

Hypoxemic Patients Requiring Support

Bronchoscopy can be performed under NIV using closed circuit ventilation with double-circuit viral filters and non-ventilated masks with dedicated bronchoscope entrance. 1

• High-performance NIV ventilators with FiO2 regulation are preferable 1
• Continue NIV for 1-2 hours post-procedure, titrating FiO2 to SpO2 94-95% 1
• Bronchoscopy under high-flow nasal oxygen is NOT recommended and should be avoided 1, 2

Additional Safety Measures

• Avoid nebulized medications before or after procedure 1
• Proper sedation to minimize cough reflex and increase cooperation 1
• Oral aspiration cannula available during procedure 1
• Transparent protective box over patient's head may contain droplet particles 1

Rigid Bronchoscopy Considerations

Urgent rigid bronchoscopy should be avoided in suspected/confirmed COVID-19 except for life-threatening scenarios. 1 Manual jet ventilation and high-frequency jet ventilation create open systems releasing aerosols into the room, making this extremely high-risk. 1

Limited Acceptable Indications

• Acute foreign body aspiration (consider non-contrast CT first to confirm presence in stable patients) 1
• Massive hemoptysis when embolization unavailable 1
• Severe symptomatic central airway obstruction 1
• Migrated stents 1

Complications and Risk Mitigation

Serious adverse events from bronchoscopy in critically ill patients are relatively uncommon but increase with lack of expertise or inadequate precautions. 3, 4, 5

Common Pitfalls to Avoid

• Inadequate cuff pressure leading to aerosol leak during ventilation 1
• Failure to clamp circuit before scope insertion/withdrawal 1
• Chest auscultation is difficult with PPE and risks contamination—use visual chest expansion instead 1
• Excessive BAL volume in hypoxemic patients causing further desaturation 1
• Multiple scope reinsertions increasing aerosol exposure 1

Monitoring for Deterioration

• Cardiopulmonary complications (desaturation, arrhythmias) 3, 5
• Pneumothorax risk with high PEEP or recruitment maneuvers 1
• Bleeding complications 3
• Lung derecruitment requiring re-recruitment 1

COVID-19 Specific Modifications

All bronchoscopy procedures in suspected or confirmed COVID-19 patients are aerosol-generating and require enhanced PPE with airborne precautions. 1, 2

• 5% of COVID-19 patients develop respiratory failure requiring ventilatory support 1
• Bacterial, viral, and fungal co-infections must not be neglected 1
• Flexible bronchoscopy techniques (alone or via SGA conduit) are aerosol-generating and unlikely to be first choice for difficult airways 1