What is the step-by-step procedure for removing a mucous plug via bronchoscopy using forceps and basket tools?

Bronchoscopic Removal of Mucous Plugs: Complete Procedural Guide

Flexible bronchoscopy is the primary method for removing mucous plugs causing atelectasis, with rigid bronchoscopy reserved only for large, resistant plugs that cannot be cleared with flexible techniques. 1

Pre-Procedure Preparation

Patient Assessment and Monitoring

• Ensure continuous multi-modal physiological monitoring including oxygen saturation, electrocardiogram, blood pressure, peak inspiratory pressure, and exhaled tidal volume throughout the procedure 1
• Assess the internal diameter of the endotracheal tube if the patient is intubated—the tube must be at least 1.5 mm larger than the external diameter of the bronchoscope to maintain adequate ventilation 1
• Administer 100% FiO2 and reduce positive end-expiratory pressure as much as tolerated before beginning 1
• Provide adequate sedation with consideration of short-acting paralytic agents to prevent coughing during the procedure 1

Equipment Selection

• Select a bronchoscope with a wide suction channel (preferably ≥2.8mm) for efficient mucus removal 1
• Prepare optical forceps and wire basket retrieval tools for grasping tenacious plugs 2, 3
• Have sterile or bacteria-free saline (autoclaved or filtered through 0.2 μm filters) available for lavage 1
• Consider having acetylcysteine available for instillation to help break down thick secretions 1, 2

Staff Safety Precautions

• All staff must wear protective clothing including gowns or plastic aprons, masks/visors, and non-powdered latex or non-latex gloves 1

Step-by-Step Procedural Technique

Initial Bronchoscope Insertion and Assessment

• In intubated patients, advance the bronchoscope through the endotracheal tube while monitoring for changes in ventilation parameters 1
• Perform systematic inspection of the tracheobronchial tree to identify the location and extent of mucous plugging 1
• The most common location for bronchial casts and mucous plugs is the left main stem bronchus, though bilateral involvement frequently occurs 2

Mucous Plug Removal Techniques

Standard Suctioning Method

• Begin with direct suctioning through the bronchoscope's working channel to remove loose secretions and smaller plugs 1
• Apply suction intermittently rather than continuously to avoid excessive negative pressure that could cause pneumothorax 4
• Monitor oxygen saturation closely during suctioning as transient desaturation commonly occurs 5

Saline Lavage Technique

• Instill 20-50 mL aliquots of sterile saline through the bronchoscope into the affected bronchial segment 1, 6
• For therapeutic bronchoscopic lavage in mechanically ventilated patients, total volumes of approximately 237 mL may be used 6
• Allow brief dwell time (10-20 seconds) before aspirating to help loosen adherent mucus 6
• Expect transient decreases in oxygenation and compliance immediately after lavage, which typically resolve within 8-11 hours 6

Forceps Retrieval Method

• When plugs are too tenacious for suctioning alone, advance optical forceps through the working channel under direct visualization 2, 3
• Grasp the visible edge of the mucous plug firmly with the forceps 2
• Apply steady, gentle traction to extract the plug while maintaining visualization 2
• Be prepared for plug friability and fragmentation—remove fragments systematically to prevent distal migration 2

Basket Tool Technique

• For larger or more cohesive plugs, advance a wire basket retrieval device through the working channel 1
• Position the basket distal to or around the plug under direct visualization 1
• Open the basket to engage the plug, then close it to capture the material 1
• Withdraw the bronchoscope and basket together as a unit to remove the plug 1

Management of Difficult Cases

• If flexible bronchoscopy fails to remove large resistant plugs, rigid bronchoscopy becomes necessary 1
• Rigid bronchoscopy allows use of larger optical forceps and more powerful rigid suction 2, 3
• The barrel of the rigid bronchoscope itself can be used for mechanical removal of obstructing material 1

Post-Procedure Management

Immediate Monitoring

• Continue physiological monitoring for at least 2-4 hours post-procedure 1
• Expect and monitor for transient worsening of oxygenation and compliance that typically improves within 8-11 hours 6
• Obtain chest radiograph to assess for lung re-expansion and rule out pneumothorax 5, 4

Assessment of Success

• Document improvement in atelectasis on post-procedure chest x-ray—in one series, 73% of patients with mucus plug-related atelectasis showed lung re-expansion after bronchoscopic removal 5
• Monitor for improvement in oxygenation (PaO2/PAO2 ratio) within 11 hours and compliance within 8 hours 6

Follow-Up Considerations

• Patients with underlying conditions like asthma or plastic bronchitis may require serial bronchoscopy at intervals of 1-5 months for recurrent mucous plugging 2
• Consider therapeutic bronchoscopy when patients become unresponsive to standard therapy or develop partial/complete airway obstruction 2

Critical Safety Considerations

Complications to Avoid

• Pneumothorax can occur from vigorous suctioning—use gentle, intermittent suction technique rather than continuous forceful aspiration 4
• Transient hypoxemia is common and usually resolves with brief increases in FiO2 6, 5
• Bleeding is uncommon with therapeutic suctioning alone but monitor for this complication 1

High-Risk Patient Populations

• ICU patients should be considered at high risk for complications during bronchoscopy 1
• Patients with clotting abnormalities (elevated PT, APTT, thrombocytopenia) are at higher risk if biopsy is performed, though therapeutic suctioning alone carries lower risk 1
• Neonates and infants require particular attention to sedation, analgesia, and airway monitoring 1

Equipment Decontamination

• Maintain detailed records of which bronchoscope was used on each patient 1
• Clean and disinfect all reusable equipment according to institutional protocols using appropriate disinfectants 1
• Flush bronchoscope channels with 70% alcohol at the end of sessions to destroy non-sporing bacteria including mycobacteria 1