What therapeutic interventions can be done with bronchoscopy in an adult patient with no prior medical history, who was involved in a burning building incident, presenting with severe metabolic acidosis, respiratory compromise, and is currently intubated (invasive mechanical ventilation) and stabilized?

Therapeutic Bronchoscopy in Intubated Burn Patients

In your intubated burn patient with severe metabolic acidosis, bronchoscopy can therapeutically remove retained secretions and mucus plugs, clear debris from thermal airway injury, obtain microbiological samples to guide antibiotic therapy, and manage lobar atelectasis—all critical interventions beyond simple inspection in this clinical scenario. 1, 2

Primary Therapeutic Interventions

Airway Clearance and Debris Removal

• Directed suctioning using a wide-channel bronchoscope combined with saline or acetylcysteine instillation is highly effective for removing retained secretions and mucus plugs that commonly obstruct major airways in burn patients. 1, 2
• Remove soot, particulate matter, and carbonaceous debris from thermal airway injury that occurred during the burning building exposure. 3
• Clear any residual embers or burning materials if airway fire occurred, using saline irrigation through the bronchoscope. 3

Management of Atelectasis

• Lobar collapse unresponsive to physiotherapy represents the most common therapeutic indication for ICU bronchoscopy, with documented effectiveness in resolving atelectasis through targeted secretion removal. 1, 2, 4
• Address ventilator-associated complications, as lobar collapse is frequent and multifactorial in critically ill mechanically ventilated patients. 1

Foreign Body Retrieval

• Remove tooth fragments, food material, or other aspirated foreign bodies using wire baskets or bronchoscopy forceps. 1, 2

Hemorrhage Management

• If persistent or excessive endotracheal bleeding develops, bronchoscopy can identify the source and extent of hemorrhage to guide your management plan, though massive hemorrhage requires rigid bronchoscopy instead. 1, 2

Diagnostic Applications with Therapeutic Implications

Microbiological Sampling

• Obtain bronchoscopically-directed lavage or brushing for microbiological specimens to diagnose ventilator-associated pneumonia, which occurs in up to 30% of critically ill ventilated patients, and guide targeted antibiotic therapy. 1, 2
• Bacterial, viral, and fungal co-infections should not be neglected in this population. 1
• Use minimal lavage volumes (2-3 mL recovered fluid is sufficient) in hypoxemic patients to reduce physiological stress. 1

Airway Assessment

• Grade the severity of thermal inhalation injury through direct visualization to determine the extent of mucosal damage and predict risk of progressive airway edema. 3
• Assess for signs of severe inhalation injury including mucosal erythema, edema, ulceration, and carbonaceous deposits. 5, 3

Critical Pre-Procedural Protocols for Your Intubated Patient

Ventilator Management

• Pre-oxygenate with 100% FiO2 and maintain throughout the procedure and immediate recovery period. 2
• Switch to mandatory ventilation mode (volume control, pressure-limited is preferable) as triggered modes like pressure support or assist control fail to maintain adequate ventilation during bronchoscopy. 1, 2
• Keep PEEP at the same level during the procedure, making dynamic adjustments only after assessing anticipated risks like lung derecruitment, desaturation, arrhythmias, or pneumothorax. 1, 2
• Increase ventilator pressure limits to ensure adequate tidal volumes are delivered despite bronchoscope obstruction. 2

Airway Circuit Management

• Clamp the ventilation circuit immediately before bronchoscope introduction and repeat immediately before withdrawal to avoid aerosol dispersion. 1, 2
• Verify cuff pressure is maintained at 25-30 cmH2O to minimize aerosol generation and prevent endotracheal tube displacement. 1, 2
• Avoid bronchoscope removal and reinsertion during the procedure to minimize circuit disruption. 1

Sedation and Anesthesia

• Use general anesthesia with muscle relaxants to reduce aerosol production and minimize cough reflex, which is particularly important given the aerosol-generating nature of bronchoscopy. 1, 2

Physiological Monitoring

• Continuous multi-modal monitoring is mandatory including ECG, arterial blood pressure (continuous intra-arterial preferred), and pulse oximetry with appropriate alarm limits. 2
• Withdraw the bronchoscope immediately if adverse events occur, perform resuscitation, then reassess whether to proceed. 2

Special Considerations for Burn Patients

Coagulopathy Assessment

• Check coagulation parameters before any biopsy procedures, as coagulopathy (elevated PT, increased APTT, reduced fibrinogen, thrombocytopenia) makes tissue sampling hazardous; use brushing or lavage as safer alternatives if coagulopathy is present. 2

Metabolic Acidosis Context

• Your patient's severe metabolic acidosis may reflect cyanide or carbon monoxide poisoning from smoke inhalation, tissue hypoperfusion from burn shock, or acute kidney injury—bronchoscopy findings can help differentiate inhalational injury severity and guide systemic management. 5, 3

Common Pitfalls to Avoid

• Do not perform bronchoscopy outside a burn center if it will delay transfer for definitive management. 5
• Do not use bronchoscopy under high-flow nasal oxygen due to excessive aerosol generation risk (not applicable to your intubated patient but relevant for future management). 1, 2
• Recognize that approximately 10% pneumothorax risk and 5% hemorrhage risk exist in ventilated patients undergoing bronchoscopy. 2
• Avoid nebulized medications before or after the procedure due to aerosol generation concerns. 1