R. Duncalf, MD, FCCP
Pulmonary & Critical Care Division
Bronx Lebanon Hospital Center

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Pneumonia- community or nosocomial
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Pulmonary edema- cardiogenic or noncardiogenic
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Pulmonary hemorrhage ± hemoptysis
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Thromboembolic disease
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Primary or metastatic CA
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Interstitial lung disease
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Obstructive airway disease
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Complications of intubation and MV

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Essential diagnostic and therapeutic tool in ICU
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Can be performed via endotracheal tube (ETT) or tracheostomy tube
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Bedside procedure: avoids transport/ OR time

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Abnormal chest X-ray/ suspected pulmonary infection
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Hemoptysis
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Lung carcinoma/ obstructing neoplasm
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Chemical or thermal burns
 intubation/extubation assist, position/ injury evaluation

Feng A, Sy E. A Lung Saddle Tumor. The Internet Journal of Pulmonary
Medicine 2009 : Volume 11 Number 1
Elderly patient admitted with respiratory failure.
Bx= Squamous cell Ca

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Retained secretions/ atelectasis
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Mucous plugs- bronchial asthma, cystic fibrosis
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Hemoptysis/ blood clots
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Drainage lung abscess
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Debridement of necrotic tracheobronchial mucosa
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Dilation airway stenosis/ strictures

198 bronchoscopies:
45% retained secretions
35% specimens for culture
7% airway evaluation
2% hemoptysis
Olapade CS, Prakash U: Bronchoscopy in the critical care unit.
Mayo Clin Proc 64:1255-1263, 1989

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Usually to evaluate infectious process
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Allows directed sampling, identification of pathogens, de-escalation of antibiotics

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BAL 10-50,000 CFU on culture diagnostic protected specimen brush 5-10,000 CFU diagnostic

Potential for identification of noninfectious processes

Middle age patient admitted with RLL pneumonia and DKA.

Cos J, Sy E, Diaz-Fuentes G, Menon L. Foreign body presenting as a persistent lung infiltrate.
The IJPM 2009 : Volume 11 Number 1

Cos J, Sy E, Diaz-Fuentes G, Menon L. Foreign body presenting as a persistent lung infiltrate.
The IJPM 2009 : Volume 11 Number 1
After removal of foreign body


FFB vs. physiotherapy for retained secretions: no superiority demonstrated
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FFB in atelectasis:


 retained secretions and air bronchograms to segmental level only lobar or greater atelectasis not responding to aggressive chest PT life threatening whole lung atelectasis
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Severe hypoxemia not contraindication
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Expect improved A-a gradient, static compliance, radiography (8 hrs)

3/24/10 3/26/10

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27% atelectasis/ retained secretions
17% ARDS/ pulmonary edema
13% airway stenosis/ tracheobronchomalacia
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13% pneumonia/ empyema
8% hemoptysis
8% foreign body

CXR after difficult intubation. Septic shock with MOD and AIDS

Daniel V, DeLaCruz A, Diaz-Fuentes G. Tracheal Laceration Due to
Endobronchial Intubation. Journal of Respiratory diseases. June 2007:15-17

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Premedication/ local anesthesia: respiratory depression/ arrest, methemoglobinemia, death
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Procedure related: hypoxemia, cardiac complications, pneumonia, death
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Ancillary procedures: barotrauma, pulmonary hemorrhage, death

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Common: up to 2 hrs. post procedure: 20-30 mmHg O2 drop in healthy, 30-60 in critically ill
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Reduction in effective tidal volume and FRC
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Suction at 100mmHg via 2mm suction port removes 7L/min
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Saline/lidocaine instillation

J Bronchol Volume 14, Number 3, July 2007
148 ventilated patients with ARDS in ICU underwent FOB-BAL for investigation of VAP
No deaths or major complications occurred in relation to BAL
Only 2 minor episodes of desaturation (fall in SpO2 of
6%) occurred within two hours after BAL, a complication rate of 1.4% (P=0.49)
FFB with BAL in ICU in ventilated ARDS patients (even with extreme hypoxemia ) is safe provided adequate precautions are taken

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Hypoxemia, hypercapnea  increased sympathetic tone  arrhythmias, ischemia, hypotension  death
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Major arrhythmias in 11%
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Unstable angina, severe preexisting hypoxemia risk factors
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Hemodynamics: 30%  MAP, 43%  HR, 28%  CI

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Standard ED 5.7mm scope occludes 10% cross sectional area of trachea, 40% 9mm ID ETT, 51%
8mm ID ETT, 66% 7mm ID ETT
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Hypoventilation, hypoxemia, gas trapping/ high intrinsic PEEP
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8mm ID ETT for standard scope recommended
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Ultrathin bronchoscopes (2.8mm): reduce potential for hypoxemia/hypercapnea, dynamic hyperinflation

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Pulmonary:
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PaO2< 70mmHg with FiO2> 0.7
PEEP> 10 cm H2O autoPEEP > 15 cm H2O active bronchospasm
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Cardiac:
 recent MI (48 hrs.)
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 unstable arrhythmia
MAP < 65mm Hg or vasopressor
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CNS:
 increased intracranial pressure

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< 10 %
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Minor complications: 6.5%
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Major complications: 0.08-0.15%
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Mortality: 0.01-0.04%
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Raoof S, Mehrishi S, Prakash U. Role of bronchoscopy in the modern medical intensive care unit. Clin Chest Med 2001; 22:
241-261

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Study of 83 lung biopsies:
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14.3% pneumothorax
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8.4% hypoxemia < 90%
7.2% hypotension (MAP < 60mm Hg)
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6% hemorrhage > 30 cc
3.6% tachycardia >140/min.
O’Brien JD, Ettinger NA, Shevlin D et al: Safety yield of transbronchial lung biopsy in mechanically ventilated patients. Crit Care Med 25: 440-446 1997

Yield and Safety of FFB and TBBX on patients on
Mechanical Ventilation in the ICU
Division of Pulmonary and Critical Care Medicine,
Bronx- Lebanon Hospital Center, Bronx, NY

 There is limited information on the usefulness and safety of TBBx in ICU patients on MV
 The goals of the study were to evaluate the yield, safety and efficacy of FFB with BAL and TBBx compared to FFB-BAL only
 Retrospective review of ICU patients on MV who underwent diagnostic FFB from January 2006 to December 2007
 TBBx was done at the bedside and without fluoroscopic guidance
 The average number of biopsies per patient were 2 (range 1-3)
 Patients who underwent FFB for inspection and / or therapeutic bronchoscopy were excluded

Demographics
Mean age in yrs ( + SD)
Gender
Female
Male
Race
African-American
Hispanic
Others
BAL
N= 92
57 (+15.9)
54
38
44
47
1
BAL + TBBx
N= 40
50 (+11.9)
18
22
23
15
2
 132 patients were identified: 92 in the BAL and 40 in the BAL with TBBx group
 48 (36%) of patients were HIV positive, all had AIDS
 The main indications for FFB were evaluation of lung infiltrates (99%) and lung masses

Malignancy
Infection
PCP
Fungi
Viral
Bacteria
Total
BAL
N= 92
0
50
2
0
2
46
54%
BAL + TBBx
N= 40
5
19
0
9
7
3
60%
P value
0.55

Comparison of yield between HIV and Non HIV group
Malignancy
Infection
PCP
Fungi
Viral
Bacterial
Total
BAL
N=92
HIV
(25)
0
18
2
0
1
15
Non HIV
(67)
0
32
0
0
1
31
72% 48%
P value= 0.04
HIV
(23)
1
13
7
2
0
4
BAL+ TBBx
N=40
Non HIV
(17)
4
1
0
6
0
5
61%
P value= 0.9
59%

Analysis of positive yield in the BAL with TBBx group
N= 24
Malignancy (5)
PCP (7)
Fungi (3)
Bacterial (9)
BAL non diagnostic
TBBx diagnostic
BAL diagnostic
TBBx non diagnostic
1
1
2
0
0
2
0
0
BAL diagnostic
TBBx diagnostic
4
4
1
9
Total 4 (17%) 2 (8%) 18 (75%)

Analysis of the yield for the BAL with TBBx positive in the Non-HIV patients
N= 10
Malignancy
(4)
BAL non diagnostic
TBBx diagnostic
1
Fungi
(1)
0
0 Bacterial
(5)
Total 1 (10%)
BAL diagnostic
TBBx non diagnostic
0
0
0
BAL diagnostic
TBBx diagnostic
3
1
5
9 (90%)

Analysis of yield for the BAL with TBBx positive in HIV patients
N= 14
Malignancy (1)
PCP (7)
Fungi (2)
Bacterial (4)
Total
BAL non diagnostic
TBBx diagnostic
0
BAL diagnostic
TBBx non diagnostic
0
BAL diagnostic
TBBx diagnostic
1
1
2
0
2
0
0
4
0
4
3 (21%) 2 (14%) 9 (65%)

 There was no statistical difference in the yield from
BAL when compared to BAL with TBBx for patients on
MV
 BAL alone showed a higher yield in patients with HIV as compared to non- HIV patients
 More patients in the HIV positive group had BAL with
TBBx compared with the non-HIV group ( 48% vs 20 % respectively)
 TBBx revealed additional diagnosis in 4 patients: PCP
(1), malignancy (1), and fungal infection (2)
 There were no complications in either group

 The overall yield of diagnostic BAL with TBBx was 60%; this lower than reported yield could be due to inadequate biopsy sampling due to the non-fluoroscopic technique and/or to the fewer number of biopsies done
 TBBx is a useful alternative for the diagnosis of infections in critically ill patients who are too ill for surgical biopsies; especially in HIV+/AIDS patients where fungal infection is often a consideration
 We recommend considering BAL with TBBx in selected patients on MV, especially in HIV+/ AIDS patients, where opportunistic infections are suspected
 FFB with BAL with TBBx seems to be a safe diagnostic tool in ICU patients on MV