First Things First (assess & treat for the following)

• Does pt have an indication for ICU bronchoscopy?
  • Indications are the same as for non-ICU bronchoscopy.
  • Diagnostic (most common ICU indications)
    • Hemoptysis/hemostasis
    • Diffuse parenchymal infiltrates of unknown etiology
    • Unresolving infiltrate
    • Acute inhalation injury
    • Chest traumatic airways injuries (exclude fractured airway)
    • Infection/ventilator-associated pneumonia
    • Assessment of ETT placement
    • Undiagnosed lung mass w/ associated respiratory failure
    • Evaluation of bleeding or pneumothorax after lung resection
  • Therapeutic (most common ICU indications)
    • Lobar or segmental atelectasis
      • Retained secretions or mucous plugging
      • Unresponsive to chest physiotherapy
    • Facilitate endotracheal intubation in difficult airways
    • Extract foreign bodies
    • Closure of bronchopleural fistulas
    • Central obstructing lesions
    • Assist w/ percutaneous dilational tracheostomy
• Does pt have a contraindication for ICU bronchoscopy?
  • Unable to obtain informed consent/patient refusal
  • Experienced personnel unavailable
  • Refractory hypoxemia
  • Uncorrectable coagulopathy when biopsies (forceps or brush) are planned
  • Unstable arrhythmias or active ischemia
  • Refractory hypotension
  • Uncontrolled bronchospasm
• Flexible vs. rigid bronchoscopy?
  • Several advantages to flexible bronchoscopy
    • Easier
    • Fewer complications
    • More comfortable for patient
    • Better visualization of entire tracheobronchial tree
    • Does not require general anesthesia
  • Relative indications for rigid bronchoscopy
    • Brisk hemoptysis (>200 mL/24 hrs)
    • Pediatric or large foreign bodies
    • Obstructing lesions of major airways