Effects of diagnostic procedures during fiberoptic bronchoscopy on heart rate, blood pressure, and blood gases

[Clinical practice guidelines for bronchoalveolar lavage in Chinese children (2024)]

Bronchoalveolar lavage (BAL) has become an important technique in the diagnosis and treatment of respiratory diseases in children. In order to standardize the clinical application of BAL in children, the Branch of Pediatric Critical Care Physicians of Chinese Medical Association, in collaboration with other institutions, has developed the "Clinical practice guidelines for bronchoalveolar lavage in Chinese children (2024)" based on the principles of the World Health Organization guidelines and the formulation/revision principles of the Chinese clinical practice guidelines (2022 edition). This guideline provides 30 recommendations to guide the operational procedures of BAL in children.

Characteristics and financial costs of patients with respiratory failure at bronchoscopy

BACKGROUND

A case-control study was conducted to identify the possible risk factors for acute respiratory failure in patients undergoing bronchoscopy. We also aimed to estimate the financial costs incurred in the care of high-risk patients.

METHODS

All hypoxic respiratory complications that occurred during bronchoscopy between January 2005 and March 2009 were reviewed. Mild hypoxia was defined as the need for up to 6 L of nasal cannula, moderate hypoxia as requiring up to 100% nonrebreather face mask, and severe hypoxia requiring intubation and mechanical ventilation to maintain pulse oximetry above 90%. The Wilcoxon 2-sample test was used to compare continuous groups. Categorical variables were assessed using χ(2), Fischer exact, and Kruskal-Wallis tests. We calculated the cost of medical care for patients admitted to the intensive care unit after bronchoscopy.

RESULTS

During our study period, 26 patients were reported to have hypoxia with bronchoscopy. The mean age for our study group was 66.1 years, and body mass index 26.1 kg/m(2) (SD, 7.6). The study group's mean albumin was 2.9 g/dL (SD, 0.6) compared with 3.3 g/dL (SD, 0.7, P=0.0019), the study group's hematocrit was 32.4% (SD, 5.7) compared with 37.9% (SD, 5.5, P=0.0241), the study group's forced expiratory volume to forced vital capacity ratio ratio was 65.0 (SD, 15.8) compared with 78.0 (SD, 18.8, P=0.0133), and the study group's forced expiratory volume was 59.5% compared with 71.2% (P=0.0606). The study group's mean pCO(2) was 53.7 mm Hg (SD, 18.6). Six patients required intensive care unit admission after bronchoscopy and the total cost of care for this group was $80,353.

CONCLUSIONS

Prescreening of selected patients may reduce respiratory failure and possibly the total cost of medical care.

[Diagnostic flexible bronchoscopy. Recommendations of the Endoscopy Working Group of the French Society of Pulmonary Medicine]

These guidelines on flexible bronchoscopy depict important clues to be known and taken into account while practicing flexible bronchoscopy, in adult, except in emergency situations. This is a practical clarification. Safety conditions, complications, anesthesia, infectious risks, cleaning and disinfection are detailed from a review of the literature. Intensive care practice of bronchoscopy requires more attention due to higher risks patients and is discussed extensively. Standards and performances of the various sampling techniques complete this work. Indications for bronchoscopy, therapeutic and paediatric bronchoscopy are not covered in these guidelines.

[Fiberoptic bronchoscopy during noninvasive positive-pressure ventilation in patients with chronic obstructive lung disease with hypoxemia and hypercapnia]

OBJECTIVES

To assess the feasibility and safety of non invasive positive-pressure ventilation (NIPPV) via a face mask to performing fiberoptic bronchoscopy (FOB) in patients with COPD contraindicating FOB in spontaneous ventilation.

STUDY DESIGN

Clinical, prospective, open, non comparative trial of feasibility.

PATIENTS

Ten consecutive COPD patients (71 +/- 5 year-old, PaO2 = 53 +/- 13 mmHg and PaCO2 = 67 +/- 11 mmHg), without any sign of acute respiratory failure, admitted to the intensive care unit for pneumonia requiring a bronchoalveolar lavage (BAL). Including were: PaO2 < 70 mmHg despite nasal O2 delivered at 3 L.min-1, PaCO2 > 50 mmHg, improvement of SpO2 with NIPPV before FOB.

METHODS

Topical anaesthesia of the nose and pharynx was obtained with a 5% lidocaine spray. NIPPV was administered using a ventilatory support system Evita 4 (Dräger) applied through a full facial mask secured to the patient with elastic straps. Patients were first allowed to acclimate for 5 min with NIPPV (IPAP = 16 cmH2O, EPAP = 0 and trigger of 0.3 cm H2O while a FIO2 kept at 0.7). A T-adapter Medisize (Péters) was attached to the facial mask. The tip of the FOB was inserted through the nose. Topical anaesthesia of the vocal cords was obtained with 1% lidocaine solution (3 mL). The FOB was inserted into the trachea up to a bronchial sub-segment. BAL was performed by instillation of 100 mL of saline solution. After FOB, the NIPPV was maintained for 5 min. Heart rate, SpO2 were measured continuously and arterial pressure at 2 min intervals. Arterial blood gas values were obtained just prior NIPPV and after 15 min and 60 min NIPPV disconnection.

RESULTS

FOB duration was 11 +/- 4 min. SpO2 significantly improved during FOB (from de 91 +/- 4.7% to 97% +/- 1.7) without decrease of oxygen saturation lower than 90%. There were no changes in PaCO2 and PaO2 during the hour following the end of procedure. FOB under NIPPV was performed in all patients without complications and was very well tolerated in eight patients. After NPPV disconnecting, one patient required again NIPPV for 15 min. No patient required endotracheal intubation within 24 hours. All patients survived.

CONCLUSION

Application of NIPPV during FOB is a safe technic for maintaining adequate gas exchange in hypoxaemic and hypercapnic COPD patients not in acute respiratory failure. After the end of the procedure a close surveillance in the intensive care unit is essential.

Right ventricular function and plasma atrial natriuretic peptide levels during fiberbronchoscopic alveolar lavage in critically ill, mechanically ventilated patients

STUDY OBJECTIVE

To assess the influence of fiberbronchoscopic alveolar lavage on hemodynamics, right ventricular function, and plasma atrial natriuretic peptide (ANP) concentrations in critically ill, mechanically ventilated patients.

DESIGN

Prospective investigation.

SETTING

Eight-bed ICU of a university hospital.

PATIENTS

Fourteen patients with cardiovascular instability due to a systemic inflammatory response syndrome who were mechanically ventilated.

INTERVENTIONS

Fiberbronchoscopic alveolar lavage after fluid replacement, deep sedation, and paralyzation. Intervention time: 10 min. After inspection of the endobronchial system, one lavage of 40 mL sterile saline solution was instilled in each lung and recovered.

MEASUREMENTS AND RESULTS

The fiberbronchoscopic procedure induced a prompt increase in mean pulmonary arterial pressure after 3 min (median[range]: 25 [13 to 39] to 30 [19 to 45] mm Hg, p < 0.05), which increased further after 6 min (34 [17 to 46] mm Hg, p < 0.01). Cardiac index increased simultaneously (4.25 [3.1 to 5.7] to 4.85 [4.3 to 6.9] L/min.m2 after 6 min, p < 0.01), whereas mean arterial pressure and heart rate remained unchanged. Central venous pressure rose from 12 (3 to 18) mm Hg before procedure to 14 (4 to 20) mm Hg after 6 min (p < 0.01). The right ventricular function was measured using a "fast response" ejection fraction thermodilution catheter: end-diastolic volume increased (238 [137 to 358] to 280 [150 to 4ll] mL after 9 min, p < 0.05), as well as stroke volume (88 [54 to 113] to 103 [67 to 153] mL after 9 min, p < 0.01). Right ventricular ejection fraction (37 [25 to 50] %) did not change significantly during the procedure, but the stroke work index was reinforced (8.2 [4.7 to 15.7] to 13.3 [2.4 to 41.3] gm.M/M2 after 6 min, p < 0.01). Plasma c-ANP concentration rose from 135 (24 to 350) to 196.5 (44 to 830 pg/ml after 20 min (p < 0.05). Systemic vascular resistance decreased from 533 (390 to 1,042) to 429 (281 to 684) dynes.s/cm5 after removal of the bronchoscope (p < 0.01).

CONCLUSIONS

Although acute pulmonary hypertension was observed during the fiberbronchoscopic procedure, the right ventricular performance did not deteriorate in hemodynamically unstable patients. To maintain a "hyperdynamic cardiovascular state," the right ventricular stroke work was reinforced, presumably by the "Frank-Starling mechanism." We assume that the acute distention of the right side of the heart resulted in elevated ANP concentrations. The marked decrease in systemic vascular resistance might be due to high ANP levels.