Bronchoscopy for atelectasis in the ICU: a case report and review of the literature

Corticosteroid Therapy in Severe Cases of Pneumonia Caused by SARS-CoV-2

We present a case of severe pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a 63-year-old woman needing venous oxygenation by an extracorporeal membrane. Given the difficult clinical resolution with persistent inflammatory parameters, treatment with corticosteroids (methylprednisolone) was prescribed. The clinical evolution observed, namely the improvement of respiratory and imaging parameters, reiterates the recommendations of corticosteroids for moderate to severe disease.

Immediate and long-term effects of manual chest compression and decompression maneuver on patients receiving invasive mechanical ventilation

BACKGROUND

It has been reported that the manual chest compression and decompression (MCCD) maneuver can increase lung volume in patients receiving invasive mechanical ventilation (IMV), but some important questions related to this maneuver require answers: how long the effects of MCCD on lung volume remain, and whether there are effects on other respiratory and hemodynamic variables.

METHODS

Patients receiving IMV support in an intensive care unit (ICU) with signs of hypoventilation, hypoexpansion, or atelectasis were eligible to receive the MCCD maneuver. Immediately before the maneuver, respiratory and hemodynamic parameters were collected. Then, 20 MCCD maneuvers were performed while measured the same parameters. After 10 min, all parameters were measured again. The primary outcome was the tidal volume (Vt ) during the MCCD maneuver and after 10 min compared to the previous Vt .

RESULTS

Of the 255 patients who were mechanically ventilated in the study period, 105 patients composed the final cohort. The MCCD increased inspiratory tidal volume (iVt ), expiratory tidal volume (eVt ), and chest dynamic compliance (Cdyn ) during the application of the maneuver, but after 10 min, these parameters returned to their basal levels. The MCCD maneuver did not change the peak pressure, respiratory rate, peripheral oxygen saturation (SpO2 ), heart rate, or blood pressure. There was no difference in increased iVt in patients with sedation, respiratory comorbidity, or obesity. Further, there was no association between the iVt response to the MCCD and the admission diagnosis, and no correlation with the ICU length of stay, IMV duration, or APACHE II score.

IMPLICATIONS OF PHYSIOTHERAPY PRACTICE

We concluded that MCCD increased iVt , eVt , and Cdyn during the application of the maneuver, but this effect was not observed after 10 min. Randomized controlled trials should be performed in the future to investigate the mechanism involved in increasing Vt and the possible impact of the MCCD maneuver on ICU outcomes.

Portable electronic bronchoscopy for clinical application: a multi-institutional randomized instrument validation study

OBJECTIVE

Electronic bronchoscopy is routinely used for the diagnosis and treatment of lung and bronchial disorders. However, the devices used are normally large and costly. Here, we evaluated the clinical effectiveness of a portable electronic bronchoscope produced by Zhejiang UE Medical Corp., the UE-EB.

METHODS

We conducted a multi-institutional, randomized, single-blind, non-inferiority and parallel-group controlled clinical trial. Participants were randomly assigned 1:1 to the experimental group or control group. The primary indicator was the effectiveness of the device. Safety indicators were assessed from enrollment to 3 days after the operation.

RESULTS

The UE-EB had good consistency between groups during the procedure, and the effective rate was 100.00% in both groups. The difference value (95% confidence interval) between the two groups was 0.00% (-5.45%, 5.45%), and the lower limit was greater than -10% (negative non-inferiority margin). There was also no difference between the two groups in terms safety indicators.

CONCLUSIONS

The portable electronic bronchoscope described in this study showed reliable effectiveness and safety. This device is worth promoting and applying in clinical practice.Research registry number: ZXLB20200295 (Zhejiang Medical Products Administration, China).

Perioperative Pulmonary Atelectasis: Part II. Clinical Implications

The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.

Endobronchial Therapy With Gentamicin and Dexamethasone After Airway Clearance by Bronchoscopy in Exacerbation of Non-Cystic Fibrosis Bronchiectasis: A Real-World Observational Study

Background: The exacerbation of non-cystic fibrosis bronchiectasis (NCFB) may lead to poor prognosis. The objective of this study was to retrospectively analyze the clinical efficacy and safety of endobronchial therapy with gentamicin and dexamethasone after airway clearance by bronchoscopy in the exacerbation of NCFB.

Methods: We retrospectively reviewed 2,156 patients with NCFB between January 2015 and June 2016 and 367 consecutive patients with exacerbation of bronchiectasis who had complete data and underwent airway clearance (AC) by bronchoscopy. The final cohort included 181 cases of intratracheal instillation with gentamicin and dexamethasone after AC (a group with airway drugs named the drug group) and 186 cases of AC only (a group without airway drugs named the control group). The last follow-up was on June 30, 2017.

Results: The total cough score and the total symptom score in the drug group were improved compared to those in the control group during 3 months after discharge (p < 0.001). Re-examination of chest HRCT within 4–6 months after discharge revealed that the improvements of peribronchial thickening, the extent of mucous plugging, and the Bhalla score were all significantly improved in the drug group. Moreover, the re-exacerbations in the drug group were significantly decreased within 1 year after discharge. Univariate analysis showed a highly significant prolongation of the time to first re-exacerbation in bronchiectasis due to treatment with airway drugs compared with that of the control group. Multivariate Cox regression analysis showed that the risk of first re-exacerbation in the drug group decreased by 29.7% compared with that of the control group.

Conclusion: Endobronchial therapy with gentamicin and dexamethasone after AC by bronchoscopy is a safe and effective method for treating NCFB.

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.

A Before-and-After Study of Evidence-Based Recommendations for On-Call Bronchoscopy

BACKGROUND

Bronchoscopy is widely used and regarded as standard of care in most intensive care units (ICUs). Data concerning recommendations for on-call bronchoscopy are lacking.

OBJECTIVES

Evaluation of recommendations, complications, and outcome of on-call bronchoscopies.

METHOD

A retrospective single-centre analysis was conducted in a large university hospital. All on-call bronchoscopies performed outside normal working hours in the year before (period 1) and after (period 2) establishing a catalogue of recommendations for indications of on-call bronchoscopy on November 1, 2016, were included.

RESULTS

Overall, 924 bronchoscopies in 538 patients were analysed. A relative reduction of 83.6% from 794 bronchoscopies in 432 patients (1.84 per patient) during period 1 to 130 in 107 patients (1.21 per patient) during period 2 was observed. Most bronchoscopies (812/924, 87.9%) were performed in ICUs, and 416 patients (77.3%) were intubated. Bronchoscopies for excessive secretions decreased significantly during period 2. Fifty-three of 130 bronchoscopies (40.8%) fulfilled the specified recommendations during period 2, in comparison with 16.8% in period 1 (p < 0.001). Complications were recorded in 58 of 924 procedures (6.3%) and were more frequent in period 2, especially moderate bleeding. In-hospital mortality of patients undergoing on-call bronchoscopy did not differ between periods and was 28.7 and 30.2% in periods 1 and 2, respectively.

CONCLUSION

The introduction of recommendations for on-call bronchoscopy led to a significant decline of on-call bronchoscopies without negatively affecting outcome. More evidence is needed in on-call bronchoscopy, especially for ICU patients with intrinsic higher complication rates.

Comparative outcomes of inpatients with lung collapse managed by bronchoscopic or conservative means

Background

Although the incidence and prevalence of atelectatic lung collapse is unknown, such events are common among inpatients, and there are no guidelines for optimally instituting bronchoscopic techniques. The aim of this study was to evaluate the outcomes of patients with complete or near-complete lung collapse managed via interventional flexible fibreoptic bronchoscopy or a conservative approach.

Methods

Retrospective analysis of all adult patients admitted to BronxCare Health System between January 2011 and October 2017 with a diagnosis of lung collapse/atelectasis. The primary outcome was radiological resolution. Timing of bronchoscopy relative to radiological resolution and mortality served as secondary outcomes.

Results

Of the 177 patients meeting inclusion criteria, 149 (84%) underwent bronchoscopy and 28 (16%) were managed through conservative measures only. A significantly greater number of patients in the bronchoscopy group achieved complete or near-complete resolution on chest X-ray, compared with the conservative group (p=0.007). Timing of bronchoscopy had no impact on the rate of radiological resolution, and mortality in the two groups was similar. New endobronchial malignancies were identified in 21 patients (14%).

Conclusions

Our data support the central role of bronchoscopy in instances of complete or near-complete lung collapse, ensuring better radiological outcomes. Judicious use of conservative management is warranted to avoid missing significant pathology. A prime consideration in this setting is obstructive malignancy.

Selective Recruitment of Large Lower Lobe Atelectasis on Donor Back Table in Rejected Donor Lungs

Background

Large atelectatic areas in donor lungs are frequently resistant to standard recruitment maneuvers, producing a tenaciously low PO₂/FiO₂ ratio. The aim of this study is to investigate the optimal protocol for the recruitment of large atelectatic areas in the context of ex vivo lung perfusion (EVLP).

Methods

Seventeen rejected lungs with large lower lobe atelectasis (≥40%) were divided into 2 groups: manual resuscitation (n = 5) and selective recruitment (n = 12). Transplant suitability was then evaluated in cellular EVLP. In the manual resuscitation group, following bronchoscopy, if the conventional recruitment maneuver was not successful, a bagging technique was utilized to resolve atelectasis in EVLP. In the selective recruitment group, a pediatric endotracheal tube was introduced to the lower lobe bronchus on the back table of the donor hospital. Selective recruitment of the lower lobe was accomplished while keeping peak inspiratory pressure <30 cm H₂O for 30 seconds.

Results

The average atelectasis size and lung weight in 17 donor lungs was 75.4 ± 20.6% and 960 ± 221 g, respectively. There were no significant differences between the 2 groups in all donor variables, except cold ischemic time (P = 0.001, 5.2 ± 0.5 versus 6.4 ± 0.7 hours). The selective recruitment group was associated with better transplant suitability (P = 0.035, 75% versus 20%), better PO₂/FiO₂ ratio (P = 0.186, 324 ± 89 versus 258 ± 87 mm Hg), lower lung weight (P = 0.057, 997.9 ± 229.2 versus 1377.2 ± 452.9 g), and better pathological score (P < 0.05, 1.0 ± 1.3 versus 2.8 ± 0.8) than the manual resuscitation group.

Conclusion

A selective recruitment procedure is a safe and effective method of eliminating large atelectasis before EVLP.

Independent predictors for longer radiographic resolution in patients with refractory Mycoplasma pneumoniae pneumonia: a prospective cohort study

OBJECTIVES

To examine prospectively the radiographic clearance of refractory Mycoplasma pneumoniae pneumonia (RMPP) in immunocompetent children, and to identify independent predictors of time to complete radiographic resolution in patients with RMPP.

DESIGN

A prospective cohort study.

SETTING

Children's Hospital of Soochow University, China.

PARTICIPANTS

A total of 187 patients with RMPP treated with bronchoscopy were prospectively enrolled in the study between January 2012 and December 2015.

METHODS

Serial chest radiographs were obtained after discharge every 4 weeks up to a maximum of 24 weeks after diagnosis or until large infiltration on chest radiographs had resolved. Multivariate logistic regression was performed to identify independent predictors of time to complete radiographic resolution.

RESULTS

Of the 187 patients with RMPP, bronchial mucus plug formation was detected in 73 (39.0%). C reactive protein (CRP) ≥50 mg/L, lactate dehydrogenase (LDH) ≥480 U/L, total fever duration ≥10 days and presence of mucus plugs were associated with longer time to radiographic clearance (all p<0.01). Compared with children without mucus plugs, those with mucus plugs were significantly more likely to have longer time to radiographic clearance (adjusted OR: 11.5; 95% CI 2.5 to 45.7; p<0.01).

CONCLUSION

Clinicians might use duration of fever, CRP, LDH and presence of mucus plugs as parameters to identify children at a longer time to radiographic clearance in patients with RMPP.

Effect of Bronchoscopy on Gas Exchange and Respiratory Mechanics in Critically Ill Patients With Atelectasis: An Observational Cohort Study

Background: Atelectasis frequently develops in critically ill patients and may result in impaired gas exchange among other complications. The long-term effects of bronchoscopy on gas exchange and the effects on respiratory mechanics are largely unknown.

Objective: To evaluate the effect of bronchoscopy on gas exchange and respiratory mechanics in intensive care unit (ICU) patients with atelectasis.

Methods: A retrospective, single-center cohort study of patients with clinical indication for bronchoscopy because of atelectasis diagnosed on chest X-ray (CXR).

Results: In total, 101 bronchoscopies were performed in 88 ICU patients. Bronchoscopy improved oxygenation (defined as an increase of PaO₂/FiO₂ ratio > 20 mmHg) and ventilation (defined as a decrease of > 2 mmHg in partial pressure of CO₂ in arterial blood) in 76 and 59% of procedures, respectively, for at least 24 h. Patients with a low baseline value of PaO₂/FiO₂ ratio and a high baseline value of PaCO₂ were most likely to benefit from bronchoscopy. In addition, in intubated and pressure control ventilated patients, respiratory mechanics improved after bronchoscopy for up to 24 h. Mild complications, and in particular desaturation between 80 and 90%, were reported in 13% of the patients.

Conclusions: In selected critically ill patients with atelectasis, bronchoscopy improves oxygenation, ventilation, and respiratory mechanics for at least 24 h.

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.

Adverse outcomes after percutaneous dilatational tracheostomy versus surgical tracheostomy in intensive care patients: case series and literature review

Tracheostomy is a routinely done procedure in the setting of intensive care unit (ICU) in patients requiring prolonged mechanical ventilation. There are two ways of making a tracheostomy: an open surgical tracheostomy and percutaneous dilatational tracheostomy. Percutaneous dilatational tracheostomy is associated with fewer complications than open tracheostomy. In this study, we would like to compare both techniques of performing a tracheostomy in ICU patients and to present possible complications, methods of diagnosing and treating and minimizing their risk.

Interventions during Donor Care before Lung Transplantation

Improvement in the ratio of PaO2 to the fraction of inspired oxygen and treatment of pulmonary infections in donors have been cited as important goals for improving lungs before implantation and restoring marginal lungs to the donor pool. Likewise, improving donor PaO2 is often critical for other organs during donor care. The common physiological mechanisms responsible for hypoxemia are ventilation/perfusion mismatching, abnormal oxygen diffusion, and hypoventilation. These mechanisms are discussed and treatment options are considered.

Complications of bronchoscopy: A concise synopsis

Flexible and rigid bronchoscopes are used in diagnosis, therapeutics, and palliation. While their use is widespread, effective, and generally safe; there are numerous potential complications that can occur. Mechanical complications of bronchoscopy are primarily related to airway manipulations or bleeding. Systemic complications arise from the procedure itself, medication administration (primarily sedation), or patient comorbidities. Attributable mortality rates remain low at < 0.1% for fiberoptic and rigid bronchoscopy. Here we review the complications (classified as mechanical or systemic) of both rigid and flexible bronchoscopy in hope of making practitioners who are operators of these tools, and those who consult others for interventions, aware of potential problems, and pitfalls in order to enhance patient safety and comfort.

Pulmonary lobectomies for patients with cognitive impairment: the importance of postoperative respiratory care

BACKGROUND

Patients with cognitive impairment (CI) may have an increased risk of complications after major thoracic surgery. However, little is known about this risk and the corresponding management.

METHODS

Clinical data of patients who underwent pulmonary lobectomy via open thoracotomy between January 2006 and December 2008 in our institution were retrospectively reviewed.

RESULTS

Overall, 1,325 patients who underwent pulmonary lobectomy via open thoracotomy were analyzed retrospectively, in which five patients were diagnosed with CI. Sputum retention was common and led to significant hypoxemia in all five patients. Four patients were re-intubated due to severe respiratory dysfunction, and three underwent tracheotomy 7 days after intubation due to respiratory infection. Regarding to duration of chest tube placement, length of hospital stay, morbidity rate, and hospital cost, CI patients were significant higher compared with cognitively normal patients undergoing lobectomy via open thoracotomy.

CONCLUSIONS

Patients with CI may have difficulties in expectoration after pulmonary lobectomy, and develop multiple respiratory complications, thus increasing hospital stay. Efficacious sputum and airway clearance is critical in these patients.

Intensive care unit imaging

Chest radiography serves a crucial role in imaging of the critically ill. It is essential in ensuring the proper positioning of support and monitoring equipment, and in evaluating for potential complications of this equipment. The radiograph is useful in diagnosing and evaluating the progression of atelectasis, aspiration, pulmonary edema, pneumonia, and pleural fluid collections. Computed tomography can be useful when the clinical and radiologic presentations are discrepant, the patient is not responding to therapy, or in further defining the pattern and distribution of a radiographic abnormality.

Impact of bedside bronchoscopy in critically ill lung transplant recipients

BACKGROUND

Over 32,000 lung transplants have been performed worldwide for a variety of end-stage lung diseases (http://www.ishlt.org/). Flexible bronchoscopy (FB) is frequently used as a bedside-tool for diagnosis and management of respiratory failure among critically ill lung transplant recipients (LTRs). We study the indications, results, therapeutic impact, and complications of FB in LTRs admitted to medical intensive care unit (MICU).

METHODS

Retrospective chart review was performed for all critically ill LTRs undergoing FB while admitted to MICU at the Cleveland Clinic Foundation between 2009 and 2011. ICD-9 codes for bronchoscopy were used to identify patients. The procedures were categorized as: (i) airway examination and interventions, (ii) microbiological, and (iii) histopathologic diagnosis. SAS version 9.2 was used for analysis.

RESULTS

A cohort of 76 LTRs accounted for 93 hospital admissions, 101 MICU admissions, and 129 bronchoscopies. FB was helpful in evaluation and management of airway complications [secretion clearance (18% bronchoscopy procedures), stenosis/dehiscence (8% patients)] and optimizing management of lower respiratory tract infections. Isolation of resistant gram-negative organisms, community-acquired respiratory viruses, and fungi commonly led to modification in antimicrobial therapy (35% microbiological samples). Nonspecific finding of acute lung injury was the most commonly seen histopathology (70%) on transbronchial biopsy. Twenty percent (4/20) of transbronchial biopsies showed acute cellular rejection, with 1 episode contributing to respiratory failure. Occasional hypoxia and hypotension, but no deaths, were noted due to FB during the ICU admission.

CONCLUSIONS

Use of FB modified clinical management in one third of airway evaluation and microbiological sampling procedures for critically ill LTRs. No fatalities were attributed to bronchoscopy in this critically ill population.

Frequency of hypoxic events in patients on a mechanical ventilator

Background:

Mechanical ventilation is an important tool in the management of respiratory failure in the critically ill patient. Although mechanical ventilation can be a life-saving intervention, it is also known to carry several side-effects and risks. Adequate oxygenation is one of the primary goals of mechanical ventilation. However, while on mechanical ventilation, patients frequently experience hypoxic events resulting from various causes, which need to be properly evaluated and treated.

Materials and Methods:

Data were obtained by prospectively reviewing all intensive care admissions during the period from March 2009 to March 2010 at a 651-bed urban medical center. Patients who developed hypoxemia (oxygen saturation ≤88% and a PaO₂≤60 torrs) while on mechanical ventilation were investigated for the cause of hypoxic event.

Results:

During the study period, 955 patients required mechanical ventilation from which 79 developed acute hypoxia. The causes of acute hypoxia in decreasing order of occurrences were pulmonary edema, atelectasis, pneumothorax, pneumonia, ARDS, endotracheal tube malfunction, airway bleeding, and pulmonary embolism.

Conclusions:

Appropriate evaluation of all hypoxic events must begin at the bedside. A step-by-step approach must include a thorough physical examination. Evaluation of the endotracheal tube can immediately reveal dislodgement, bleeding, and secretions. Correlation of physical examination findings with those on chest radiograph is essential. Each hypoxic event requires a different intervention depending on its etiology. Instead of simply increasing the fraction of oxygen in the inspired air to overcome hypoxia, a concerted effort in appropriate problem solving can reduce the likelihood of an incorrect diagnosis and management response.

Transbronchoscopic oxygen insufflation-induced barotrauma during endobronchial silicon spigot removal

While transbronchoscopic air insufflation has been described in refractory atelectasis as a therapy without any serious complications, 3 cases of gastric rupture during the same procedure have been reported when it was used to support tracheal intubation by employing the jet of oxygen from the wall pipeline. Here, we report a 66-year-old woman who underwent transbronchoscopic oxygen insufflation using a flexible fiberscope to clear away secretions during an endobronchial silicon spigot removal procedure. She suffered a sudden drop of blood pressure with pneumomediastinum, subpleural and subcutaneous emphysema, and bilateral pneumothorax. Blood pressure recovered rapidly when we stopped the insufflation. Tube thoracostomy was initiated, and she recovered well without systemic air embolism. We conclude that transbronchoscopic oxygen insufflation using the wall pipeline does carry a potential risk of serious barotrauma, and is not to be recommended except with the use of a pressure monitor or pop-off valve.

[Current status of fibreoptic bronchoscopy in intensive care medicine]

Flexible bronchoscopy (FB) has been of great help in the management of critically ill patients. Its safety and usefulness in the hands of experienced professionals, with the required measures of caution, has resulted in the increasingly widespread use of the technique even in unstable critical patients subjected to mechanical ventilation and with high oxygen demands. The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), through its Acute Respiratory Failure (GT-IRA) and Infectious Diseases (GT-EI) Work Groups, aims to promote knowledge and standards of quality in the use of FB among all specialists in Intensive Care Medicine. Through an expert committee, the SEMICYUC has established the objective of accrediting such training, with the preparation of a curriculum and definition of those Units qualified for providing training in the different techniques and levels. The accreditation process seeks to stimulate good learning practice and quality in training. Both specialists in Intensive Care Medicine and other specialists, and the patients, will benefit from the commitment and control afforded by such accreditation, and from the learning and training which the mentioned process entails.

Update on interventional bronchoscopy for the thoracic radiologist

Interventional bronchoscopy, together with other domains of interventional pulmonology, has experienced tremendous technological advances. Diagnostic applications include endobronchial ultrasound, which enables endoscopists to see through airway walls. White light videobronchoscopy, autofluorescence imaging, and narrow band imaging have enhanced the ability to detect early lung cancer at a preinvasive stage. Electromagnetic navigational bronchoscopy, ultrathin bronchoscopy, and virtual bronchoscopy increase the diagnostic yield of biopsy of small peripheral lung lesions. The options that are currently available for the relief of central airway obstruction are also numerous, with both flexible and rigid bronchoscopic applications. Stents, although dichotomized to silicone and metal, come in various sizes and shapes to suit the requirements of the pathology being treated. Ablative techniques are categorized into those with an immediate effect and those with a delayed effect. Laser, electrocautery, and argon plasma coagulation can immediately relieve obstruction and control hemoptysis, whereas cryosurgery, brachytherapy, and photodynamic therapy have established roles in subacute airway obstruction and in the treatment of early lung cancer. Microdebriders have recently been added to the armamentarium of modalities for mechanical debulking of tumor. Distal airway obstruction has also been targeted with bronchial thermoplasty treatment of refractory asthma and with bronchoscopic lung volume reduction for the management of severe emphysema. This array of new technology has fostered collaborative work with a wide range of other medical specialties to deliver safer, more effective, minimally invasive treatment.

[Analysis of 208 flexible bronchoscopies performed in an intensive care unit]

OBJECTIVE

To describe the main indications, clinical results and complications associated with fibrobronchoscopy in the Intensive Care Unit (ICU).

DESIGN

A retrospective, single-center observational study was carried out. Setting. Seventeen beds in a medical/surgical ICU. Patients. Consecutive patients undergoing fibrobronchoscopy during their stay in the ICU over a period of 5 years.

INTERVENTIONS

Flexible bronchoscopy performed by an intensivist. Main variables of interest. Flexible bronchoscopy indications and complications derived from the procedure.

RESULTS

A total of 208 flexible bronchoscopies were carried out in 192 patients admitted to the ICU. Most of the procedures (193 [92.8%]) were performed in mechanically ventilated patients. The average patient age was 58 ± 16 years, with an APACHE II score at admission of 19 ± 7. The most frequent indication for flexible bronchoscopy was diagnostic confirmation of initially suspected pneumonia (148 procedures), with positive bronchoalveolar lavage findings in 46%. The most frequent therapeutic indication was the resolution of atelectasis (28 procedures). Other indications were the diagnosis and treatment of pulmonary hemorrhage, the aspiration of secretions, control of percutaneous tracheotomy, and difficult airway management. The complications described during the procedures were supraventricular tachycardia (3.8%), transient hypoxemia (6.7%), and slight bleeding of the bronchial mucosal membrane (2.4%).

CONCLUSIONS

A microbiological diagnosis of pneumonia and the resolution of atelectasis are the most frequent indications for flexible bronchoscopy in critically ill patients. Flexible bronchoscopy performed by an intensivist in ICU is a safe procedure.

Medical treatment of lung collapse in children

This study was aimed to establish non-invasive (medical) treatment of lung collapse for children who are admitted to PICU of Tabriz Children's Hospital. During a period of 48 months (from March 2004 to February 2008), an interventional pre-experimental study carried out on 90 children suffering from lung collapse who received non-invasive treatment; which mainly consists of postural drainage, chest physiotherapy and inhalation of aerosols (fluid as floating droplets in air) and bronchodilators. Eighty six out of 90 studied patients (94.5%) with the average age of 22 months, responded to this treatment within the average duration of 3.4 days, as collapsed area of lung reexpanded. Because of simplicity and easy availability of this method of treatment and also its efficacy and scientific base; it can substitute bronchoscopic treatment and its usage be generalized to small hospitals.

Evaluation of a 24-hour emergency bronchoscopy service in a tertiary care hospital

BACKGROUND

Flexible bronchoscopy has become an important diagnostic and therapeutic tool for the management of patients with various diseases of the chest. Availability of a 24-hour bronchoscopy service equipped with experienced personnel is becoming increasingly important especially for intensive care patients. However, such services have been implemented only in a few medical centres. The aim of this study was to evaluate the usage of a 24-hour emergency service in a large university hospital with a 1 year prospective analysis of emergency bronchoscopy service in a tertiary care centre.

METHODS

Frequencies, indications and efficiency of therapeutic interventions were evaluated after each bronchoscopy using a specially designed questionnaire. All bronchoscopies were performed as emergency procedures out of operational schedule. A total of 614 emergency bronchoscopies were performed, 88% of them in intensive care units.

RESULTS

The vast majority (84.5%) of the procedures were necessary for therapeutic interventions; that is, atelectasis, airway secretion, aspiration or bronchopulmonary bleeding. According to prespecified criteria, 37.6% (n = 195) of therapeutic procedures were assessed as 'very helpful' and 3.9% (n = 20) as 'life saving'. Diagnostic bronchoscopies were performed mainly to collect airway material for microbiological evaluations in immunocompromised patients. In these cases, the diagnostic yield was approximately 50%.

CONCLUSION

The availability of a 24-hour bronchoscopy service has been found to improve patient care and was occasionally considered life saving. Thus, comparable services should be made more widely available.

Predictors of atelectasis after pulmonary lobectomy

PURPOSE

To define the incidence of and factors predisposing to postlobectomy atelectasis (PLA).

METHODS

The subjects were 412 patients who underwent pulmonary lobectomy at our hospital between January 2004 and April 2007. This study was performed as a retrospective analysis of our prospective database. Postlobectomy atelectasis was defined as ipsilateral opacification of the involved lobe or segment with an ipsilateral shift of the mediastinum on chest radiograph, requiring bronchoscopy.

RESULTS

Postlobectomy atelectasis developed in 27 patients (6.6%), accounting for 29% of all postoperative pulmonary complications. There were no significant differences between the PLA and no-PLA groups in age, sex, American Society of Anesthesiology performance status, cardiovascular comorbidity, or operation time. Chronic obstructive pulmonary disease (COPD) was the only preoperative variable predictive of PLA (P<0.05). Right upper lobectomy (RUL), either alone or in combination with right middle lobectomy, was associated with a significantly higher incidence of PLA than any other type of resection (P<0.05).

CONCLUSIONS

Postlobectomy atelectasis is an important postoperative complication. Patients with COPD and those undergoing RUL are at higher risk of this complication. Although often isolated, PLA is associated with longer hospital stay.

ICU imaging

Chest radiography serves a crucial role in imaging of the critically ill. Its uses include diagnosis and monitoring of commonly encountered pulmonary parenchymal and pleural space abnormalities. It is also important in evaluating monitoring and support devices and associated complications. CT, another useful imaging modality in select patients, can better characterize pulmonary parenchymal and pleural space disease.

Clinical review: airway hygiene in the intensive care unit

Maintenance of airway secretion clearance, or airway hygiene, is important for the preservation of airway patency and the prevention of respiratory tract infection. Impaired airway clearance often prompts admission to the intensive care unit (ICU) and can be a cause and/or contributor to acute respiratory failure. Physical methods to augment airway clearance are often used in the ICU but few are substantiated by clinical data. This review focuses on the impact of oral hygiene, tracheal suctioning, bronchoscopy, mucus-controlling agents, and kinetic therapy on the incidence of hospital-acquired respiratory infections, length of stay in the hospital and the ICU, and mortality in critically ill patients. Available data are distilled into recommendations for the maintenance of airway hygiene in ICU patients.