Fibreoptic bronchoscopy

Indications

Diagnostic

• Collection of microbiological 9 cytological specimens (by bronchoalveolar lavage, protected brush specimen, biopsy).

• Cause of bronchial obstruction (e.g. clot, foreign body, neoplasm).

• Extent of inhalation injury.

• Diagnosis of ruptured trachea/bronchus.

Therapeutic

• Clearance of secretions, inhaled vomitus, etc.

• Removal of obstructing matter (e.g. mucus plug, blood clot, food, tooth). Proximal obstruction rather than consolidation is suggested by the X-ray appearance of a collapsed lung/lobe and no air bronchogram.

• Cleansing/removing soot or other toxic materials, irrigation with saline.

• Directed physiotherapy 9 saline to loosen secretions.

• Directed placement of balloon catheter to arrest pulmonary bleeding.

• To aid difficult endotracheal intubation.

Contraindications/cautions

• Coagulopathy.

• Severe hypoxaemia.

Procedure

It is difficult to perform bronchoscopy in a nasally intubated patient. A narrow lumen scope can be used but suction is limited.

1 Pre-oxygenate with FIO2 1.0. Monitor with pulse oximetry.

2 Increase pressure alarm limit on ventilator.

3 Lubricate scope with lubricant gel/saline.

4 If unintubated, apply lidocaine gel to nares 9 spray to pharynx.

5 Consider short-term IV sedation 9 paralysis.

6 Insert scope nasally in a non-intubated patient or via the catheter mount port if intubated. An assistant should support the ET tube

during the procedure to minimise trauma to trachea and/or scope.

7 Inject 2% lidocaine into trachea to prevent coughing and haemodynamic effects from tracheal/carinal stimulation.

8 Perform thorough inspection and any necessary procedures. If SpO2 ≤85% or haemodynamic disturbance occurs, remove scope and allow re-oxygenation before continuing.

9 Bronchoalveolar lavage is performed by instillation of at least 60mL of (preferably warm) isotonic saline into affected lung area without suction, followed by aspiration into a sterile catheter trap. All bronchoscopic samples should be sent promptly to the lab.

10 After procedure, reset ventilator as appropriate.

Complications

• Hypoxaemia: from suction, loss of PEEP, partial obstruction of endotracheal tube, and non-delivery of tidal volume.

• Haemodynamic disturbance, including hypertension and tachycardia (related to hypoxaemia, agitation, tracheal stimulation, etc.).

• Bleeding.

• Perforation (unusual though more common if biopsy taken).