![]() ![]() NPO status is required to minimize the risk of aspiration and further compromise to critically ill patients this is less of a concern in patients who already have an endotracheal tube in place. In general patients who are not and will not need to be intubated and require bronchoscopy in the ICU should have had no oral or tube feed intake (NPO) for six hours prior to the procedure. For ICU bronchoscopy routine neuromuscular blockade is not required. When bronchoscopy is to be performed via the nasal route the nares must be adequately anaesthetized with topical gels. ![]() In the intubated patient topical anesthesia down the ETT or tracheostomy tube minimizes airway irritation and cough. In the extubated patient topical anesthesia in the posterior pharynx and airway limits the gag reflex. ![]() Topical sedation for both the intubated and extubated patient cannot be overlooked. Typical sedation involves the use of an analgesic and a sedative, the most common combination is opiates and benzodiazepines but sedation can be individualized to your specific ICU protocol. When performing bronchoscopy on either the intubated or extubated patient in the intensive care unit sedation is required. When performing bronchoscopy on the mechanically ventilated patient an adapter is required on the end of the endotracheal tube to ensure that tidal volume and PEEP are maintained during the procedure ( Figure 12.1). Remember a smaller bronchoscope will have a smaller working channel and considerably less suctioning capability limiting visibility and decreasing suctioning of secretions and specimen acquisition. If the patient has a smaller-diameter ETT limiting bronchoscopy, the intensivist should consider changing the ETT to a larger diameter. The bronchoscope must easily pass through the inner lumen of the ETT and permit exhaled gas to escape to prevent air trapping, Table 12.2 shows common ETT sizes and size appropriate bronchoscopes. Diagnostic scopes are smaller with working channels ≤2.8 mm. Therapeutic bronchoscopes are larger and typically have a suction channel ≥2.8 mm, they are best suited to viscous and larger volume airway secretions. Bronchoscopes are commonly referred to as “diagnostic” and “therapeutic” based on the size of the suction channel and the overall size of the bronchoscope. The most common sizes for endotracheal tubes in adults are: 7.0 mm, 7.5 mm, and 8.0 mm. The endotracheal tube should be placed prior to the procedure if the patient’s respiratory status is felt to be fragile and the information from bronchoscopy is critical to patient care. Performing bronchoscopy through an endotracheal tube (ETT) in the ICU is a common procedure. Common indications for bronchoscopy in the ICU are listed in Table 12.1. The overwhelming number of indications will be for diagnostic questions, all though some therapeutic indications exist. In this chapter I hope to outline the most common consultations and appropriate uses for bronchoscopy in the ICU. Technology is not a substitute for good clinical judgment operators must assess patient safety and perform procedures with attention to patient comfort with knowledge of potential complications and a management plan for complications including respiratory failure, pneumothorax, etc. The ready access of bronchoscopy to intensivists has broadened the pulmonary diagnostic and therapeutic capabilities in critically ill patients, but like many technologies it also raises certain challenges in its appropriate application. The ease, safety, and portability of bronchoscopy make it one of the most commonly requested invasive procedures in the ICU setting. Bronchoscopy is an essential tool in critical care medicine and an increasingly ubiquitous presence in the hospital. ![]()
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