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

Application and Reliability Evaluation of Sternal Notch Sagittal Ultrasound Imaging for Endotracheal Tube Positioning in Neonates Under General Anesthesia: A Prospective Study Comparing Electronic Bronchoscopy

OBJECTIVE

To evaluate the accuracy and reliability of sternal notch sagittal ultrasound imaging for neonatal endotracheal tube positioning by comparing the ultrasound-measured distance from the endotracheal tube tip to the right pulmonary artery with the electronic bronchoscopy-measured distance from the endotracheal tube tip to the carina.

DESIGN

A prospective, single-center, observational study using a self-controlled design.

SETTING

Department of Anesthesiology and Perioperative Medicine at Anhui Provincial Children's Hospital, Hefei, China.

PARTICIPANTS

Neonates undergoing endotracheal intubation under general anesthesia for both elective and urgent surgeries were included, with all intubations performed in the operating room.

INTERVENTIONS

Neonates were evaluated for endotracheal tube position using both electronic bronchoscopy and ultrasound in the median sagittal plane at the sternal notch.

MEASUREMENTS AND MAIN RESULTS

The distance from the endotracheal tube tip to the right pulmonary artery was measured using ultrasound imaging. The distance from the endotracheal tube tip to the carina was measured using electronic bronchoscopy. A high linear correlation was found between the two methods (r = 0.899, p < 0.001). The internal consistency of the three ultrasound measurements was high (Cronbach alpha = 0.985, ICC = 0.985). The precision of ultrasound measurements varied with endotracheal tube size, showing improved consistency with larger tube diameters. The mean absolute deviation (MAD) was 0.18 mm for the 2.5-mm ETT, 0.14 mm for the 3.0-mm ETT, and 0.12 mm for the 3.5-mm ETT, with corresponding coefficient of variation values of 5.60%, 4.50%, and 4.20%, respectively. No adverse events were observed during the ultrasound examination, whereas the incidence of hypoxemia during the electronic bronchoscopy examination was 18.4% (p < 0.001). In terms of operation time, the electronic bronchoscopy examination took (15.43 ± 4.34) seconds, while the ultrasound examination took (10.25 ± 4.27) seconds, with a significant difference between the two methods (p < 0.001).

CONCLUSION

Sternal notch sagittal ultrasound imaging shows highly consistent measurement results with electronic bronchoscopy for assessing the position of the endotracheal tube in neonates. Additionally, sternal notch sagittal ultrasound is safer and non-invasive, making it a viable alternative method for endotracheal tube positioning in neonates under general anesthesia, with significant clinical application value.

Size Matters: Endotracheal Tube Sizes and Glottic Stenosis Familiarity Among Intubating Physicians

Objective

Given the prevalence of post-intubation acute laryngeal injury (ALgI) and its association with glottic stenosis, greater attention has been placed on the mitigation of modifiable risk factors in patients requiring intubation, notably endotracheal tube (ETT) size. No widely accepted guidelines for adult ETT sizing exist. To better understand how factors driving ETT sizing may differ across specialties, we conducted a survey of faculty Anesthesiologists, Intensivists, and Emergency Medicine (EM) physicians.

Methods

An anonymous 14-question Qualtrics survey was distributed to relevant faculty employed at a single tertiary care institution. Participants completed questions pertaining to their training, ETT sizing preferences, factors considered in decision-making, and perceived knowledge regarding risk factors of glottic stenosis.

Results

A total of 103 complete responses were included, with a response rate of 55.1%. Standard ETT size was reported by 94 (91.3%) respondents to be 7.5 mm or larger in adult males and by 92 (89.3%) respondents to be 7.0 mm or larger in adult females. All respondents preferred a significantly larger ETT size for males compared to females (all p < 0.001). "Need for bronchoscopy" was the most cited factor precluding both males and females from being intubated with a smaller ETT across all specialties. When queried on posterior glottic stenosis, 64 (62.1%) respondents erroneously identified cuff pressure as a risk factor.

Conclusions

Understanding ETT sizing among intubating physicians is critical to reducing intubation-related ALgI. Future laryngologist-led interventions may be directed toward the adoption of a predominately height-based model for ETT sizing and education on glottic stenosis.

Level of Evidence

5.

Caring for the Patient During Bedside Bronchoscopy in the Critical Care Setting

BACKGROUND

Bedside bronchoscopy is a pivotal diagnostic and therapeutic tool often used with critically ill patients in the critical care setting. Bronchoscopy allows for direct visualization of the airways and lung parenchyma and can be useful in evaluating different bronchopulmonary diseases including foreign bodies, tumors, infectious and inflammatory conditions, airway stenosis, and bronchopulmonary hemorrhage.

OBJECTIVE

This article explores bedside bronchoscopy in critically ill patients. Covering key areas from preprocedure preparation care, it emphasizes the nurse's role, procedural techniques, and adaptations. The focus extends to nurses' roles with emerging bedside bronchoscopy technologies and provides insight on implications for clinical practice.

CONCLUSION

Bedside bronchoscopy serves as a vital tool in critical care, enabling both diagnosis and treatment of various pulmonary conditions. Nurses play a pivotal role in ensuring procedural success and patient safety, from preprocedure preparation to postprocedure monitoring. As technology evolves, nurses must adapt, embracing opportunities for ongoing learning and interdisciplinary collaboration, while also advocating for patient-centered care and ethical considerations in the integration of advanced technologies.

The Uncommon Suspect: Pseudomonas aeruginosa and Cavitary Lung Lesions in an Immunocompetent Patient

Cavitary lung lesions pose a formidable diagnostic challenge due to their multifaceted etiologies. While tuberculosis and other prevalent pathogens typically dominate discussions, instances of community-acquired Pseudomonas aeruginosa (P. aeruginosa) pneumonia leading to cavitation in immunocompetent individuals remain exceptionally rare. Herein, we present a compelling case of such pneumonia in a 61-year-old man with a past medical history of hypertension and coronary artery disease who presented with cough, chest pain, and subjective fever. Chest imaging revealed cavitary lung lesions, which is atypical for community-acquired pneumonia (CAP). Initial workup excluded common CAP pathogens, following which bronchoscopy with bronchoalveolar lavage (BAL) definitively diagnosed P. aeruginosa, prompting targeted antibiotic therapy. Treatment led to clinical and radiographic improvement. P. aeruginosa rarely causes CAP, especially in immunocompetent patients, and cavitary lesions further complicate diagnosis. This case highlights the importance of considering P. aeruginosa in CAP with unusual features and emphasizes the utility of bronchoscopy with BAL for diagnosis and guiding management.

The Role of Bronchoscopy and Chest Physiotherapy in Postoperative Patients With Acute Lung Atelectasis Due to Airway Mucus Plugging: A Case Series and Review of Entity

Mechanical ventilation and endotracheal intubation can cause airway damage and inflammation resulting in excessive mucus secretions, thereby increasing the risk of respiratory failure post extubation. An abundance of secretions may result in bronchial obstruction and lung collapse distant from the site of obstruction. If lung collapse is diagnosed, extra support, including oxygen and, rarely, reintubation, can be necessary. The combination of chest wall percussion and vibrations, patient positioning to facilitate mucus drainage, coughing, and breathing exercises was the chest physiotherapy method employed for airway clearance in this study. Since the late 20th century, pulmonary rehabilitation strategies have been a standard aspect of care to prevent lung collapse in postoperative cases. Bronchoscopic aspiration and lavage are the common techniques used to remove retained secretions or mucus plugs. Large-volume saline instillation in aliquots and repeated suctioning are required during the procedure. Thus, the current case series emphasizes the role of bronchoscopy and pulmonary rehabilitation in the management of acute lung atelectasis during the postoperative period.

European Network for ICU-Related Respiratory Infections (ENIRRIs): a multinational, prospective, cohort study of nosocomial LRTI

PURPOSE

Lower respiratory tract infections (LRTI) are the most frequent infectious complication in patients admitted to the intensive care unit (ICU). We aim to report the clinical characteristics of ICU-admitted patients due to nosocomial LRTI and to describe their microbiology and clinical outcomes.

METHODS

A prospective observational study was conducted in 13 countries over two continents from 9th May 2016 until 16th August 2019. Characteristics and outcomes of ventilator-associated pneumonia (VAP), ventilator-associated tracheobronchitis (VAT), ICU hospital-acquired pneumonia (ICU-HAP), HAP that required invasive ventilation (VHAP), and HAP in patients transferred to the ICU without invasive mechanical ventilation were collected. The clinical diagnosis and treatments were per clinical practice and not per protocol. Descriptive statistics were used to compare the study groups.

RESULTS

1060 patients with LRTI (72.5% male sex, median age 64 [50-74] years) were included in the study; 160 (15.1%) developed VAT, 556 (52.5%) VAP, 98 (9.2%) ICU-HAP, 152 (14.3%) HAP, and 94 (8.9%) VHAP. Patients with VHAP had higher serum procalcitonin (PCT) and Sequential Organ Failure Assessment (SOFA) scores. Patients with VAP or VHAP developed acute kidney injury, acute respiratory distress syndrome, multiple organ failure, or septic shock more often. One thousand eight patients had microbiological samples, and 711 (70.5%) had etiological microbiology identified. The most common microorganisms were Pseudomonas aeruginosa (18.4%) and Klebsiella spp (14.4%). In 382 patients (36%), the causative pathogen shows some antimicrobial resistance pattern. ICU, hospital and 28-day mortality were 30.8%, 37.5% and 27.5%, respectively. Patients with VHAP had the highest ICU, in-hospital and 28-day mortality rates.

CONCLUSION

VHAP patients presented the highest mortality among those admitted to the ICU. Multidrug-resistant pathogens frequently cause nosocomial LRTI in this multinational cohort study.