Indications

• Atelectasis.
  
• Large volume aspirate for lavage.
  
• Non‐resolving pneumonia, to collect samples.
  
• Percutaneous tracheostomy placement.
  
• Endotracheal tube (ETT) placement with difficult intubations.
  
• Evaluation of tracheostomy tube or ETT.
  
• Aid to relieve thick secretions/mucus impaction, mostly in spinal cord injury patients (this is done frequently prior to extubation of a ventilated patient).
  
• Hemoptysis.
  
• Small foreign body removal.
  
• Suspected airway obstruction, e.g. tracheal stenosis, endobronchial lesions.

Pre‐procedure

• Obtain informed consent (in ICU this is usually from the health care proxy).
  
• NPO for at least 4–6 hours prior to the procedure if possible in non‐emergent or non‐intubated patients; tube feeds should be held before the procedure.
  
• Perform time out.
  
• Set up: done in a monitored setting with ECG recording, BP monitoring, O₂ saturation monitoring, bronchoscope, accessories for the bronchoscope (e.g. brush, forceps, balloon), bronchoscopic adaptor (ventilator and bronchoscope can both be use at the same time), specimen collecting system, saline (some should be ice cold), alcohol, slides, epinephrine, lidocaine (solution and gel), oxygen, ETT, oral piece, gauzes, port syringes, suctioning system, IV fluid, sedative, analgesics, lubrication, vasopressor agents, and resuscitation medications (e.g. naloxone) available if needed.
  
• Protective wear available.
  
• Personnel: bronchoscopist, bronchoscopist assistant (to help with use of forceps, brush, ETT stabilization, etc.), critical care nurse, and respiratory therapist.
  
• Lab work: generally not needed but PTT and INR in cases of hemoptysis.
  
• In non‐intubated patients, the nares/airways should be anesthetized with aerosolized lidocaine and lidocaine gel.
  
• In intubated patients, the ETT should be at least 7.5–8 mm in diameter for the typical bronchoscope to pass. ETT change may be necessary.
  
• In intubated patients, the airway can be sprayed with lidocaine or the lidocaine can be nebulized before the start of the procedure. About 400–600 mg can be safely used for the entire procedure.
  
• Sedatives should be given for moderate sedation in non‐intubated patients. Typical medications are midazolam (noted to decrease salivation during bronchoscopy) or propofol used with fentanyl (to decrease coughing). For intubated and sedated patients, an increase in the baseline sedative(s) is required.
  
• Generally patients should be placed on 100% oxygen. In the ICU, most patients requiring bronchoscopic procedures are intubated.

Bronchoscopy procedure

• Adjust the height of the bed where your non‐dominant hand can reach the point of entry of the bronchoscope (mouth, nose, ETT, or tracheostomy device) and the other arm can be fairly well extended upright to control the bronchoscope.
  
• Keep the bronchoscope in the center of the airways. If suction is applied while the tip of the bronchoscope is on the airway wall, ecchymosis or erythema will occur.
  
• Examine the lungs by advancing the lubricated bronchoscope through the nares towards the vocal cords, or threading it through an ETT (Video 5.1). It should be advanced slowly, ensuring that there is no resistance. See Figure 5.1 for the segmental and lobar divisions of the lungs.
  
• The anterior larynx should be seen with the cartilaginous rings and the posterior should be seen flat.
  
• The vocal cords should not be seen in an intubated patient since the ETT should be through the vocal cords and the ETT tip sits about 3–4 cm above the main carina. (If the vocal cords are seen, the ETT is above the cords and would need to be advanced.)
  
• The bronchoscope is advanced to the main carina (Video 5.2). The tracheal rings are on the anterior aspect. If the bronchoscopist is doing the procedure from behind the patient, the right main bronchus will be on the right and the left main bronchus will be on the left, as in Figure 5.1.
  
• The bronchoscope can then be advanced to the right mainstem bronchus. At this point the bronchus intermedius will be seen at 3 o’clock and the right upper lobe (RUL) bronchus will also be seen (Figure 5.2). In most patients the RUL will have three orifices: the apical, anterior, and posterior segments (called the Mercedes Benz sign). However, in <3% of patients four orifices will be seen.
  
• Now withdraw the scope from the RUL bronchus and return to the bronchus intermedius. Straight ahead the right lower lobe (RLL) will be seen. The superior segment of the RLL is opposite to the right middle lobe (RML). The RML has the shape of a letter ‘D’ (called the fish mouth sign).
  
• Withdraw the bronchoscope to the main carina before advancing it towards the left bronchus, which is longer than the right main bronchus. Once in the left mainstem bronchus a ‘secondary carina’ can be seen. This can be distinguished from the main carina by the smaller diameter of the lumens and the absence of tracheal rings.
  
• The secondary carina divides the left upper lobe and left lower lobe.
  
• Samples can be collected in the infected lobe/s after visualization of the presumed uninfected lung/lobes/segments. The bronchoscope should be directed to the lobe/segments in question and wedged, then saline squirted in aliquots of 10–15 mL. The saline is then suctioned into the sample containers.
  
• If a lesion is seen, samples can be obtained by using a brush/forceps. Slides can be made from the samples or the brush can be washed and the sample sent for cultures/cytology. Biopsies of lesions are usually deferred to a pulmonologist.
  
• If active intrabronchial hemorrhage (Video 5.3) is noted then the source of bleeding can be controlled by squirting epinephrine or ice‐cold saline at the site and holding the bronchoscope to tamponade the bleeding. A catheter with a small balloon can be inserted and inflated at the end of the bronchoscope that may temporize the bleeding. In cases of massive hemoptysis, the non‐bleeding lung can be intubated allowing the bleeding lung to collapse. Rigid bronchoscopy may be required. Options for the control of bleeding include interventional radiologic procedures, bronchial artery embolization, and surgery.
  
• The flexible bronchoscope fits well in a 7.5 mm ETT and can be used to visualize and be inserted into the trachea for difficult intubation.
  
• Forceps and basket can be inserted through the flexible bronchoscope working port and this can assist with the removal of small foreign objects in the airway.
  
• Bedside tracheostomy can be done in the ICU with the aid of bronchoscopic visualization.

Common complications

Follow‐up

A CXR is generally not required after airway clearance, visualization, and lavage, but is often done to assess the efficacy of treatment for atelectasis.

Reading list

1. Foster WM, Hurewitz AN. Aerosolized lidocaine reduces dose of topical anesthetic for bronchoscopy. Am Rev Respir Dis 1992; 146(2):520–2.
   
2. Gonlugur U, et al. Major anatomical variations of the tracheobronchial tree: bronchoscopic observation. Anat Sci Int 2005; 80:111–15.
   
3. Jin F, MU D, Chu D, et al. Severe complications of bronchoscopy. Respiration 2008; 76:429.
   
4. Jose R, Shaefi S, Navani N. Sedation for flexible bronchoscopy: current and emerging evidence. Eur Respir Rev 2013; 22(128):106–16.
   
5. Langmack EL, Martin RJ, Pak J, Kraft M. Serum lidocaine concentrations in asthmatics undergoing research bronchoscopy. Chest 2000; 117(4):1055–60.