Chapter 30. Bronchoscopy

Introduction

Bronchoscopy is frequently performed both as a diagnostic and therapeutic maneuver in the intensive care unit (ICU), wherein a flexible endoscope is threaded into the airways. The bronchoscope has a fiberoptic light source and suction channels as well as cables allowing the tip of the device to be flexed and retroflexed in one plane (Figure 30-1).

Definitions and Terms

• ▪  Fiberoptic bronchoscope (FOB): Commonly used in the ICU.
• ▪  Rigid bronchoscope: Inflexible variant bronchoscope not typically used in the ICU.
• ▪  Fiberoptic intubation: Endotracheal intubation in which the bronchoscope is advanced through the nose or mouth and into the proximal trachea, after which an endotracheal tube is threaded over it into the airway.
• ▪  Diagnostic bronchoscopy: May be performed to evaluate the character of the airways (ie, for edema, bleeding source), to obtain selected pathological specimens (ie, cultures, or tissue).
• ▪  Therapeutic bronchoscopy: May be performed to remove secretions, clots, or foreign bodies from the airways.

Techniques

• ▪  Prior to performance of bronchoscopy, consent and the universal protocol should be performed as in Section I.
• ▪  The operator should determine the approach to bronchoscopy.
  • —Awake-sedated bronchoscopy: This approach may be selected for patients in whom there is no need for an endotracheal tube and involves topical anesthesia of the proximal airway as well as sedation.
  • —Endotracheal: This approach is more common in patients in the ICU in whom bronchoscopy is performed through an existing artificial airway (ie, endotracheal tube or tracheostomy) as in Figure 30-2.
• ▪  The operator should be familiar with proximal airway anatomy (Figure 30-3).
• ▪  The bronchoscope can be advanced and withdrawn and the tip can be flexed with a thumb control to navigate the airways (Figure 30-4)—the index finger is used to control suction.
• ▪  Airway bifurcations should be identified and may be off-axis depending on the operator’s location relative to the patient and the rotation of the tip of the bronchoscope relative to the hand control (Figures 30-5 and 30-6).
• ▪  Secretions (Figure 30-7), blood, pus, or foreign bodies may be identified in the airway and should be removed to prevent atelectasis.
• ▪  Suctioned material can be captured from the suction line and sent for culture or pathologic identification (Figure 30-8).