Broncoscopia durante la ventilación mecánica no invasiva: revisión de técnicas y procedimientos

The use of non-invasive respiratory assistance to facilitate bronchofiberoscopy performance in patients with hypoxemic (type one) respiratory failure - Study protocol

PURPOSE

Bronchofiberoscopy (FOB) is a procedure routinely performed for: lung cancer, obstruction, interstitial diseases, foreign bodies' removal, airway clearance, and hemoptysis. It causes acute airway narrowing leading to respiratory and cardiovascular stress. Due to increasing number of ill patients with respiratory failure (RF), conventional oxygen therapy (COT) is frequently insufficient to assure accurate oxygenation and prevent RF in patients requiring FOB. In this clinical scenario, patients may be intubated and supported with invasive mechanical ventilation (IMV) with the specific aim of allowing a safe FOB. However, this invasive strategy is associated with an increased risk of IMV-associated complications.

MATERIALS AND METHODS

Our study is a planned prospective multicenter three-arm randomized controlled trial (RCT). The target number of 300 patients was calculated based on the intubation risk in RF patients, which is 0.2-2%. The patients will be assigned to each arm based on Horowitz index. In each arm, the patients will be randomly assigned to one out of two dedicated respiratory support methods in each group i.e. COT/high flow nasal cannula (HFNC), HFNC/non-invasive ventilation (NIV) and NIV/IMV. In the manuscript the current state of art in the area of respiratory support is discussed. We have underlined knowledge gaps in medical evidence which we are planning to reveal with our results.

RESULTS

The results of our study are clinically crucial, because they address current gaps concerning COT/HFNC/NIV/IMV.

CONCLUSION

The expected findings of this study would allow for careful selection of respiratory support method to safely perform FOB in patients with hypoxemic RF.

Case Report: Case report: Non-invasive mechanical ventilation in combination with bronchoscopy in the treatment of respiratory failure of lung cancer patient

Background: Respiratory failure (RF) is a common medical problem among cancer patients. Particularly active or ex-smokers diagnosed with chronic obstructive pulmonary disease (COPD) or lung cancer may develop severe hypoxemic and hypercapnic respiratory failure. Moreover, pneumonitis as a complication of the currently widely used immunotherapy of various cancers, may cause respiratory disorders requiring ventilation support. Non-invasive ventilation (NIV) is recommended as the first-line treatment for this type of respiratory failure and reduces the need for endotracheal intubation. Case presentation: We present a case report of lung cancer patient, who received NIV in the treatment of RF due to an infectious exacerbation of COPD. In addition, NIV enabled assisted flexible bronchoscopy (NIV-FB) to be performed. During the procedure tumor samples were collected for further molecular diagnosis of lung cancer. Improvement of the patient general condition and quality of life was also achieved. Conclusions: NIV can be used at any stage of oncological management in patients with lung cancer. It can also be implemented during endoscopic procedures of the respiratory system, as well as support in palliative care of patients with lung cancer at the end of life. Further studies should evaluate the use of NIV in conjunction with various oncological treatments and identify the exact contradictions for BF with NIV support in advanced cancer patients with RF.

Use of high-flow nasal cannula and intravenous propofol sedation while performing flexible video bronchoscopy in the intensive care unit: Case reports

Flexible video bronchoscopy is a procedure that plays an important role in diagnosing various types of pulmonary lesions and abnormalities. Case 1 is a 68-year-old male patient with a lesion in the right lung apex of approximately 4 mm × 28 mm with atelectasis bands due to a crash injury. High-flow system with 35 L/min and fraction of inspired oxygen (FiO₂) 0.45 and temperature of 34 °C was installed prior to the video bronchoscopy. SpO₂ was maintained at 98%-100%. The total dose of sedative was 50 mg of propofol. In Case 2, a 64-year-old male patient with bronchiectasis, cystic lesions and pulmonary fibrosis of the left lung field was placed on a high-flow system with 45 L/min and 0.35 FiO₂ at a temperature of 34 °C. SpO₂ was maintained at 100%. The total duration of the procedure was 25 min; SpO₂ of 100% was sustained with oxygenation during maintenance time with the flexible bronchoscope within the airway. The total dose of propofol to reach the degree of desired sedation was 0.5-1 mg/kg. Both patients presented hypotension. For the patient of case 1, a vasopressor (norepinephrine at doses of 0.04 µg/kg/min) was given, and for the patient of case 2, only saline volume expansion was used. The video bronchoscopy with propofol sedation and high-flow nasal cannula allows adequate oxygenation during procedure in the intensive care unit.

Role of bronchoscopy in critically ill patients managed in intermediate care units - indications and complications: A narrative review

Flexible bronchoscopy (FB) has become a standard of care for the triad of inspection, sampling, and treatment in critical care patients. It is an invaluable tool for diagnostic and therapeutic purposes in critically ill patients in intensive care unit (ICU). Less is known about its role outside the ICU, particularly in the intermediate care unit (IMCU), a specialized environment, where an intermediate grade of intensive care and monitoring between standard care unit and ICU is provided. In the IMCU, the leading indications for a diagnostic work-up are: To visualize airway system/obstructions, perform investigations to detect respiratory infections, and identify potential sources of hemoptysis. The main procedures for therapeutic purposes are secretion aspiration, mucus plug removal to solve atelectasis (total or lobar), and blood aspiration during hemoptysis. The decision to perform FB might depend on the balance between potential benefits and risks due to frailty of critically ill patients. Serious adverse events related to FB are relatively uncommon, but they may be due to lack of expertise or appropriate precautions. Finally, nowadays, during dramatic recent coronavirus disease 2019 (COVID-19) pandemic, the exact role of FB in COVID-19 patients admitted to IMCU has yet to be clearly defined. Hence, we provide a concise review on the role of FB in an IMCU setting, focusing on its indications, technical aspects and complications.

Clinical Value of Bronchoscopy in Acute Respiratory Failure

Bronchoscopy may be considered the “added value” in the diagnostic and therapeutic pathway of different clinical scenarios occurring in acute respiratory critically ill patients. Rigid bronchoscopy is mainly employed in emergent clinical situations due to central airways obstruction, haemoptysis, and inhaled foreign body. Flexible bronchoscopy (FBO) has larger fields of acute applications. In intensive care settings, FBO is useful to facilitate intubation in difficult airways, guide percutaneous dilatational tracheostomy, and mucous plugs causing lobar/lung atelectasis. FBO plays a central diagnostic role in acute respiratory failure caused by intra-thoracic tumors, interstitial lung diseases, and suspected severe pneumonia. “Bronchoscopic” sampling has to be considered when “non-invasive” techniques are not diagnostic in suspected ventilator-associated pneumonia and in non-ventilated immunosuppressed patients. The combined use of either noninvasive ventilation (NIV) or High-flow nasal cannula (HFNC) with bronchoscopy is useful in different scenarios; the largest body of proven successful evidence has been found for NIV-supported diagnostic FBO in non-ventilated high risk patients to prevent and avoid intubation. The expected diagnostic/therapeutic goals of acute bronchoscopy should be balanced against the potential severe risks (i.e., cardio-pulmonary complications, bleeding, and pneumothorax). Expertise of the team is fundamental to achieve the best rate of success with the lowest rate of complications of diagnostic and therapeutic bronchoscopic procedures in acute clinical circumstances.

Bronchoscopy in intubated and non-intubated intensive care unit patients with respiratory failure

Bronchoscopy is one of the important tool for the pulmonary and critical care physicians to diagnose and treat various pulmonary conditions. It is increasingly being used by the intensivist due to its safety and portability. The utilization of bronchoscopy in the intensive care unit (ICU) has made the diagnosis and treatment of many conditions more feasible to intensivists. Sedation, topical or intravenous, usually helps better tolerate the procedure. However, the risks and benefits of bronchoscopy should be carefully considered in critically ill patients. The hypoxic patients in ICU pose a challenge as hypoxemia is one of the known complications of bronchoscopy, and this risk is exacerbated in patients with hypoxic respiratory failure. Bronchoscopy is relatively contraindicated in patients with severe hypoxemia and coagulopathy. However, bronchoscopy in hypoxic patients can have diagnostic as well as therapeutic implications. In patients with hypoxic respiratory failure, the use of non-invasive ventilation (NIV) during bronchoscopy has been shown to reduce the risk of intubation. On the other hand, bronchoscopy in mechanically ventilated patients is not contraindicated and has been widely used. Staying focused, monitoring vital signs closely, limiting the scope time in the airway, and understanding patient’s physiology may help decrease risk of complications. In this review, we discuss indications, techniques, complications, and yield associated with bronchoscopy in critically ill hypoxic patients.

Risk factors of complications during noninvasive mechanical ventilation -assisted flexible bronchoscopy

PURPOSE

Flexible bronchoscopy (FB) causes airway narrowing and may cause respiratory failure (RF). Noninvasive mechanical ventilation (NIV) is used to treat RF. Until recently, little was known about noninvasive mechanical ventilation assisted flexible bronchoscopy (NIV-FB) risk and complications.

MATERIALS AND METHODS

A retrospective analysis of NIV-FB performed in 20 consecutive months (July 1, 2018-February 29, 2020) was performed. Indications for: FB and NIV, as well as impact of comorbidities, blood gas results, pulmonary function test results and sedation depth, were analyzed to reveal NIV-FB risk. Out of a total of 713 FBs, NIV-FB was performed in 50 patients with multiple comorbidities, acute or chronic RF, substantial tracheal narrowing, or after previously unsuccessful FB attempt.

RESULTS

In three cases, reversible complications were observed. Additionally, due to the severity of underlining disease, two patients were transferred to the ICU where they passed away after >48h. In a single variable analysis, PaO₂ 69 ​± ​18.5 and 49 ​± ​9.0 [mmHg] (p ​< ​0.05) and white blood count (WBC) 10.0 ​± ​4.81 and 14.4 ​± ​3.10 (p ​< ​0.05) were found predictive for complications. Left heart disease indicated unfavorable NIV-FB outcome (p ​= ​0.046).

CONCLUSIONS

NIV-FB is safe in severely ill patients, however procedure-related risk should be further defined and verified in prospective studies.

High-flow nasal cannula oxygen therapy for outpatients undergoing flexible bronchoscopy: a randomised controlled trial

INTRODUCTION

High-flow nasal cannula (HFNC) provides benefits to patients undergoing flexible bronchoscopy (FOB). We compared the effects of HFNC versus standard therapy (ST) on gas exchange, lung volume and diaphragm function in patients undergoing FOB for bronchoalveolar lavage (BAL).

METHODS

36 outpatients were randomised to ST or HFNC. Arterial blood gases, episodes of severe desaturation, changes of end-expiratory lung impedance (ΔEELI), diaphragm ultrasound were recorded. Measurements were done at baseline (T0), after bronchoscope insertion (T1), at the end of the procedure (T2) and 10 min afterwards (T3).

RESULTS

Arterial partial oxygen pressure (PaO₂) was not different between T0 (10.8 (95% CI 8.7 to 12.0) kPa and T2 (11.1 (95% CI 10.4 to 12.0) kPa) with HFNC, while decreased from 11.1 (95% CI 10.5 to 12.1) to 9.1 (95% CI 8.4 to 9.8) kPa with ST. At T2, PaO₂ was significantly higher with HFNC than with ST (p<0.001). Also, with HFNC, compared with ST, fewer desaturations occurred (11% vs 56%; p<0.01). ΔEELI was no different at the different time points with HFNC, while with ST there was a significant decrease at T1 (-170 (95% CI -382 to -32) mL, p=0.003), T2 (-211 (95% CI -425 to -148) mL, p<0.001) and T3 (-213 (95% CI -398 to -81) mL, p<0.001), as opposed to T0. EELI was lower with ST than HFNC at T1 (p=0.006), T2 (p=0.001) and T3 (p=0.002). Diaphragm displacement was no different between groups (p=0.748), while the thickening fraction significantly increased at T1 and T2 with ST only (p<0.01).

CONCLUSIONS

During FOB for BAL, HFNC improves gas exchange, avoiding loss of end-expiratory lung volume and preventing increase of diaphragm activation.

TRIAL REGISTRATION NUMBER

NCT04016480.

Ventilator Support and Oxygen Therapy in Palliative and End-of-Life Care in the Elderly

Elderly patients suffering from chronic cardio-pulmonary diseases commonly experience acute respiratory failure. As in younger patients, a well-known therapeutic approach of noninvasive mechanical ventilation is able to prevent orotracheal intubation in a large number of severe scenarios in elderly patients. In addition, this type of ventilation is frequently applied in elderly patients who refuse intubation for invasive mechanical ventilation. The rate of failure of noninvasive ventilation may be reduced by means of the integration of new technological devices (i.e., high-flow nasal cannula, extracorporeal CO₂ removal, cough assistance and high-frequency chest wall oscillation, and fiberoptic bronchoscopy). Ethical issues with end-of-life decisions and the choice of the environment are not clearly defined in the treatment of elderly with acute respiratory insufficiency.

Noninvasive Ventilation-Facilitated Bronchofiberoscopy in Patients with Respiratory Failure

Respiratory failure is one of the most important risk factors for diagnostic bronchofiberoscopy (BF), whereas therapeutic bronchoscopies are typically performed in intubated patients. Only a few published studies analyzed the outcomes of noninvasive mechanical ventilation (NIV)-facilitated BF. In this case series, we present our experiences with NIV-facilitated diagnostic and therapeutic BF performed in patients with respiratory failure that was associated with acute interstitial pulmonary disease, chronic obstructive pulmonary disease, cystic fibrosis exacerbation, foreign body aspiration, tracheal stenosis, pneumonia, and in a patient with a neuromuscular disease. All of the patients were initially hypoxic and some had PaO₂/FiO₂ < 200, which corresponded to moderate-to-acute respiratory distress syndrome (ARDS). NIV-facilitated BF were performed for the diagnostic or therapeutic purposes. The former consisted of bronchoalveolar lavage and bacterial sampling in a patient with impaired cough reflex, airway assessment in otherwise unexplained respiratory failure and hemoptysis, and the latter of mucous plugs resolution, foreign body removal, and assistance in weaning from mechanical ventilation. All procedures were carried out using NIV in the spontaneous timed (ST) or average volume assured pressure support (AVAPS) mode with oxygen supplementation. There were no procedure-related complications noticed during NIV-facilitated BF. We conclude that NIV is a useful and safe tool that facilitates the performance of BF in severe pulmonary diseases. Prospective studies are required to set the recommendations for the procedure and to define the optimum ventilatory modes to be used.

The use of bronchoscopy in critically ill patients: considerations and complications

INTRODUCTION

Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.

Challenges on non-invasive ventilation to treat acute respiratory failure in the elderly

Acute respiratory failure is a frequent complication in elderly patients especially if suffering from chronic cardio-pulmonary diseases. Non-invasive mechanical ventilation constitutes a successful therapeutic tool in the elderly as, like in younger patients, it is able to prevent endotracheal intubation in a wide range of acute conditions; moreover, this ventilator technique is largely applied in the elderly in whom invasive mechanical ventilation is considered not appropriated. Furthermore, the integration of new technological devices, ethical issues and environment of treatment are still largely debated in the treatment of acute respiratory failure in the elderly.

This review aims at reporting and critically analyzing the peculiarities in the management of acute respiratory failure in elderly people, the role of noninvasive mechanical ventilation, the potential advantages of applying alternative or integrated therapeutic tools (i.e. high-flow nasal cannula oxygen therapy, non-invasive and invasive cough assist devices and low-flow carbon-dioxide extracorporeal systems), drawbacks in physician’s communication and “end of life” decisions. As several areas of this topic are not supported by evidence-based data, this report takes in account also “real-life” data as well as author’s experience.

The choice of the setting and of the timing of non-invasive mechanical ventilation in elderly people with advanced cardiopulmonary disease should be carefully evaluated together with the chance of using integrated or alternative supportive devices. Last but not least, economic and ethical issues may often challenges the behavior of the physicians towards elderly people who are hospitalized for acute respiratory failure at the end stage of their cardiopulmonary and neoplastic diseases.

8th International conference on management and rehabilitation of chronic respiratory failure: the long summaries – Part 3

This paper summarizes the Part 3 of the proceedings of the 8^th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and chronic respiratory failure. The outline follows the temporal sequence of presentations.

This paper (Part 3) presents a section regarding Moving Across the Spectrum of Care for Long-Term Ventilation (Moving Across the Spectrum of Care for Long-Term Ventilation, New Indications for Non-Invasive Ventilation, Elective Ventilation in Respiratory Failure - Can you Prevent ICU Care in Patients with COPD?, Weaning in Long-Term Acute Care Hospitals in the United States, The Difficult-to-Wean Patient: Comprehensive management, Telemonitoring in Ventilator-Dependent Patients, Ethics and Palliative Care in Critically-Ill Respiratory Patients, and Ethics and Palliative Care in Ventilator-Dependent Patients).

Pathophysiological Basis of Acute Respiratory Failure on Non-Invasive Mechanical Ventilation

Noninvasive mechanical ventilation (NIMV) was created for patients who needed noninvasive ventilator support, this procedure decreases the complications associated with the use of endotracheal intubation (ETT). The application of NIMV has acquired major relevance in the last few years in the management of acute respiratory failure (ARF), in patients with hypoxemic and hypercapnic failure. The main advantage of NIMV as compared to invasive mechanical ventilation (IMV) is that it can be used earlier outside intensive care units (ICUs). The evidence strongly supports its use in patients with COPD exacerbation, support in weaning process in chronic obstructive pulmonary disease (COPD) patients, patients with acute cardiogenic pulmonary edema (ACPE), and Immunosuppressed patients. On the other hand, there is poor evidence that supports the use of NIMV in other pathologies such as pneumonia, acute respiratory distress syndrome (ARDS), and during procedures as bronchoscopy, where its use is still controversial because the results of these studies are inconclusive against the decrease in the rate of intubation or mortality.

A novel technique of non-invasive ventilation: Pharyngeal oxygen with nose-closure and abdominal-compression--Aid for pediatric flexible bronchoscopy

OBJECTIVE

To evaluate the safety, feasibility and efficacy of a novel non-invasive ventilation (NIV) technique--pharyngeal oxygen with nose-closure and abdominal-compression (PhO2 -NC-AC)--to aid pediatric flexible bronchoscopy (FB).

DESIGN

A prospective 1 year study of patients who received FB. A basic PhO2 flow (0.5-1.0 L/kg/min, maximal 5.0 L/min) was routinely applied. Active NIV was initiated when the heart rate dropped <80 beats/min or desaturation was <80% for >10 sec. It was performed as follows: NC 1 sec for inspiration then released, followed by AC 1 sec for active expiration at a rate of 20-30 cycles/min until vital signs returned to acceptable levels for >10 sec. When the patients were stable, supplementary NIV was optionally given. Cardiopulmonary parameters were collected and analyzed.

MEASUREMENTS AND MAIN RESULTS

Three hundred thirty-seven FBs, including 188 therapeutic, were conducted in 286 patients with a mean age of 18.3 months (± 14.4, 10 min to 12 years) and a mean body weight of 13.5 kg (± 6.7, 0.5-35 kg). Three hundred thirty-three active NIVs were executed with a mean duration of 87.8 sec (± 40.4, 28-190 sec). A significantly longer FB duration (33.2 ± 16.7 min vs. 7.2 ± 2.8 min, P < 0.001) and a higher application rate of active NIV (1.44/FB vs. 0.42/FB) were noted in the therapeutic compared to the diagnostic group. Vital signs and blood gases (35 cases) improved rapidly and returned to baseline within 3 min. All FBs were safely and successfully completed without significant complications.

CONCLUSIONS

PhO2 -NC-AC is a simple, safe and effective NIV technique for respiratory support and rescue during various pediatric FB procedures.

Lights and shadows of non-invasive mechanical ventilation for chronic obstructive pulmonary disease (COPD) exacerbations

Despite the overwhelming evidence justifying the use of non-invasive ventilation (NIV) for providing ventilatory support in chronic obstructive pulmonary disease (COPD) exacerbations, recent studies demonstrated that its application in real-life settings remains suboptimal. European clinical audits have shown that 1) NIV is not invariably available, 2) its availability depends on countries and hospital sizes, and 3) numerous centers declare their inability to provide NIV to all of the eligible patients presenting throughout the year. Even with an established indication, the use of NIV in acute respiratory failure due to COPD exacerbations faces important challenges. First, the location and personnel using NIV should be carefully selected. Second, the use of NIV is not straightforward despite the availability of technologically advanced ventilators. Third, NIV therapy of critically ill patients requires a thorough knowledge of both respiratory physiology and existing ventilatory devices. Accordingly, an optimal team-training experience, the careful selection of patients, and special attention to the selection of devices are critical for optimizing NIV outcomes. Additionally, when applied, NIV should be closely monitored, and endotracheal intubation should be promptly available in the case of failure. Another topic that merits careful consideration is the use of NIV in the elderly. This patient population is particularly fragile, with several physiological and social characteristics requiring specific attention in relation to NIV. Several other novel indications should also be critically examined, including the use of NIV during fiberoptic bronchoscopy or transesophageal echocardiography, as well as in interventional cardiology and pulmonology. The present narrative review aims to provide updated information on the use of NIV in acute settings to improve the clinical outcomes of patients hospitalized for COPD exacerbations.

[Non-invasive mechanical ventilation in the pre- and intraoperative period and difficult airway]

Non-invasive mechanical ventilation is a method of ventilatory assistance aimed at increasing alveolar ventilation, thus achieving, in selected subjects, the avoidance of endotracheal intubation and invasive mechanical ventilation, with the consequent improvement in survival. There has been a systematic review and study of the technical, clinical experiences, and recommendations concerning the application of non-invasive mechanical ventilation in the pre- and intraoperative period. The use of prophylactic non-invasive mechanical ventilation before surgery that involves significant alterations in the ventilatory function may decrease the incidence of postoperative respiratory complications. Its intraoperative use will mainly depend on the type of surgery, type of anaesthetic technique, and the clinical status of the patient. Its use allows greater anaesthetic depth without deterioration of oxygenation and ventilation of patients.

Complementary home mechanical ventilation techniques. SEPAR Year 2014

This is a review of the different complementary techniques that are useful for optimizing home mechanical ventilation (HMV). Airway clearance is very important in patients with HMV and many patients, particularly those with reduced peak cough flow, require airway clearance (manual or assisted) or assisted cough techniques (manual or mechanical) and suctioning procedures, in addition to ventilation. In the case of invasive HMV, good tracheostomy cannula management is essential for success. HMV patients may have sleep disturbances that must be taken into account. Sleep studies including complete polysomnography or respiratory polygraphy are helpful for identifying patient-ventilator asynchrony. Other techniques, such as bronchoscopy or nutritional support, may be required in patients on HMV, particularly if percutaneous gastrostomy is required. Information on treatment efficacy can be obtained from HMV monitoring, using methods such as pulse oximetry, capnography or the internal programs of the ventilators themselves. Finally, the importance of the patient's subjective perception is reviewed, as this may potentially affect the success of the HMV.