Continuous positive airway pressure during fiberoptic bronchoscopy in hypoxemic patients. A randomized double-blind study using a new device

High-Flow Nasal Cannula Therapy as an Adjuvant Therapy for Respiratory Support during Endoscopic Techniques: A Narrative Review

High-flow nasal cannula (HFNC) is a respiratory support technique that delivers a controlled concentration of oxygen with high flow, heat, and humidity via the nasal pathway. As it has many physiological effects, its use has increased for a variety of clinical indications; however, there is limited guidance on using HFNC as a respiratory support tool during endoscopic procedures. We conducted a narrative review to evaluate the effect of HFNC as an adjuvant tool during fiberoptic bronchoscopy (FOB), upper gastrointestinal tract endoscopy, and surgical procedures in adults. A search of the PubMed and Cochrane databases were performed. Approximately 384 publications were retrieved, and 99 were selected (93 original works and 6 case reports with a literature review). In patients who underwent FOB, HFNC appears to be superior to conventional oxygen therapy (COT) in preventing hypoxaemia. In contrast, for gastrointestinal endoscopy, the current evidence is insufficient to recommend HFNC over COT in a cost-effective manner. Finally, in surgical procedures such as laryngeal microsurgery or thoracic surgery, HFNC has been shown to be a safe and effective alternative to orotracheal intubation. As the results are heterogeneous, we advocate for the need for more quality studies to understand the effectiveness of HFNC during endoscopic procedures.

Efficacy of different respiratory supports to prevent hypoxia during flexible bronchoscopy in patients of COPD: a triple-arm, randomised controlled trial

BACKGROUND

Patients with chronic-obstructive-pulmonary-disease (COPD) undergo bronchoscopy for various reasons, and are at relatively higher risk of complications. This study evaluated the efficacy of non-invasive ventilation (NIV) and high-flow-oxygen-therapy (HFOT) compared with conventional-oxygen-therapy (COT) in patients with COPD undergoing bronchoscopy, to prevent hypoxia.

METHODS

It was a triple-arm, open-label, randomised controlled trial. Ninety patients with COPD were randomly assigned into three intervention arms in 1:1:1 ratio. The incidence of hypoxia, lowest recorded oxygen saturation measured by plethysmography (SpO2), ECG, patient vitals and comfort levels were assessed.

RESULTS

Mean age of the study population was 61.71±7.5 years. Out of 90 cases enrolled, 51, 34 and 5 were moderate, severe and very-severe COPD, respectively, as per GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification. Rest of the baseline characteristics were similar. SpO2 during flexible bronchoscopy (FB) was lowest in COT group (COT: 87.03±5.7% vs HFOT: 95.57±5.0% vs NIV: 97.40±1.6%, p<0.001). Secondary objectives were similar except respiratory-rate (breaths-per-minute) which was highest in COT group (COT: 20.23±3.1 vs HFOT: 18.57±4.1 vs NIV: 16.80±1.9, p<0.001). Whereas post FB partial of oxygen in arterial blood was highest in NIV group (NIV: 84.27±21.6 mm Hg vs HFOT: 69.03±13.6 mm Hg vs COT: 69.30±11.9 mm Hg, p<0.001). Post FB partial pressure of carbon dioxide in arterial blood was similar in the three arms. Operator's ease-of-performing-procedure was least in the NIV group as assessed with Visual Analogue Scale (p<0.01). A higher number of NIV group participants reported nasal pain as compared with the other two arms (p<0.01).

CONCLUSION

NIV and HFOT are superior to COT in preventing hypoxia during bronchoscopy, but NIV is associated with poor patient-tolerance and inferior operator's ease of doing procedure.

TRIAL REGISTRATION NUMBER

CTRI/2021/03/032190.

[The perioperative role of high-flow cannula oxygen (HFNO)]

High-flow nasal cannula oxygen (HFNO) is commonly used during the perioperative period. Its numerous physiological benefits, satisfactory tolerance and ease of use have led to its widespread application in intensive care and post-anesthesia care units. HFNO is also used in the operating theater in multiple indications: as oxygen supplementation (associated with pressurization) prior to orotracheal intubation; in digestive and bronchial endoscopies, especially in patients at risk of hypoxemia; and in intraoperative surgery requiring spontaneous ventilation (ENT, thoracic surgery…). During the postoperative period, HFNO can be used in a curative strategy for respiratory failure or in a prophylactic strategy to prevent reintubation. In a curative approach, HFNO seems of interest following cardiac or thoracic surgery but has not been evaluated in respiratory failure subsequent to abdominal surgery, in which case noninvasive ventilation remains the gold standard. The risk of respiratory complications depends on type of surgery and on patient comorbidities. As prophylaxis, HFNO is currently preferred to conventional oxygen therapy after cardiac or thoracic surgery, especially in patients at high risk of respiratory complications. For the clinician, it is important to acknowledge the limits of HFNO and to closely monitor patients receiving HFNO, the objective being to avoid delays in intubation that could lead to increased mortality.

Incidence, management, and outcome of lung cancer in patients with long-term oxygen therapy

BACKGROUND

Here, we aimed to assess the specific features of lung cancer in patients with long-term oxygen therapy (LTOT), and compare their outcomes with patients suffering from lung cancer without LTOT.

METHODS

This retrospective, case-controlled study included patients with LTOT and an incident diagnosis of lung cancer treated at Rouen University Hospital.

RESULTS

Out of 2201 patients with LTOT, 31 were diagnosed with lung cancer. Among 24 patients with proven lung cancer, the most frequent histological type was squamous cell carcinoma (n = 12/24, 50%). Active treatment of any type was given in 19/31 (61%) and 41/62 (66%) of patients in the LTOT and control groups, respectively (p = 0.83). In the LTOT group, median survival was 38 days with best supportive care and 462 days with active treatment (p = 0.003). However, when adjusting on performance status and disease stage, LTOT was not significantly associated with a worse outcome. Hazard ratio (HR): 1.56 (95% confidence interval [CI]: 0.87 to 2.81) (p = 0.137). Administration of any treatment was associated with a better prognostic: HR: 0.35 (95% CI: 0.19 to 0.66). Both groups had a similar treatment safety profile.

CONCLUSION

Incidence of lung cancer in patients with LTOT was comparable to the general population. The proportion of LTOT patients who received active treatment was similar to controls, and overall survival did not differ from controls in a multivariate analysis. Although reaching a histological diagnosis may be challenging in LTOT patients, the efficacy and safety of the management strategies of lung cancer seem preserved.

The right interface for the right patient in noninvasive ventilation: a systematic review

INTRODUCTION

Research in the field of noninvasive ventilation (NIV) has contributed to the development of new NIV interfaces. However, interface tolerance plays a crucial role in determining the beneficial effects of NIV therapy.

AREAS COVERED

This systematic review explores the most significant scientific research on NIV interfaces, with a focus on the potential impact that their design might have on treatment adherence and clinical outcomes. The rationale on the choice of the right interface among the wide variety of devices that are currently available is discussed here.

EXPERT OPINION

The paradigm "The right mask for the right patient" seems to be difficult to achieve in real life. Ranging from acute to chronic settings, the gold standard should include the tailoring of NIV interfaces to patients' needs and preferences. However, such customization may be hampered by issues of economic nature. High production costs and the increasing demand represent consistent burdens and have to be considered when dealing with patient-tailored NIV interfaces. New research focusing on developing advanced and tailored NIV masks should be prioritized; indeed, interfaces should be designed according to the specific patient and clinical setting where they need to be used.

Modified high-flow nasal cannula oxygen therapy versus conventional oxygen therapy in patients undergoing bronchoscopy: a randomized clinical trial

Background

Hypoxemia frequently occurs during bronchoscopy. High-flow nasal cannula (HFNC) oxygen therapy may be a feasible alternative to prevent the deterioration of gas exchange during bronchoscopy. With the convenience of clinical use in mind, we modified an HFNC using a single cannula. This clinical trial was designed to test the hypothesis that a modified HFNC would decrease the proportion of patients with a single moment of peripheral arterial oxygen saturation (SpO₂) < 90% during bronchoscopy.

Methods

In this single-center, prospective randomized controlled trial, hospitalized patients in the respiratory department in need of diagnostic bronchoscopy were randomly assigned to a modified HFNC oxygen therapy group or a conventional oxygen therapy (COT) group. The primary outcome was the proportion of patients with a single moment of SpO₂ < 90% during bronchoscopy.

Results

Eight hundred and twelve patients were randomized to the modified HFNC (n = 406) or COT (n = 406) group. Twenty-four patients were unable to cooperate or comply with bronchoscopy. Thus, 788 patients were included in the analysis. The proportion of patients with a single moment of SpO₂ < 90% during bronchoscopy in the modified HFNC group was significantly lower than that in the COT group (12.5% vs. 28.8%, p < 0.001). There were no significant differences in the fraction of inspired oxygen between the two groups. The lowest SpO₂ during bronchoscopy and 5 min after bronchoscopy in the modified HFNC group was significantly higher than that in the COT group. Multivariate analysis showed that a baseline forced vital capacity (FVC) < 2.7 L (OR, 0.276; 95% CI, 0.083–0.919, p = 0.036) and a volume of fluid instilled > 60 ml (OR, 1.034; 95% CI, 1.002–1.067, p = 0.036) were independent risk factors for hypoxemia during bronchoscopy in the modified HFNC group.

Conclusions

A modified HFNC could decrease the proportion of patients with a single moment of SpO₂ < 90% during bronchoscopy. A lower baseline FVC and large-volume bronchoalveolar lavage may predict desaturation during bronchoscopy when using a modified HFNC.

Trial registration ClinicalTrials. Gov: NCT02606188. Registered 17 November 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01744-8.

Bronchoscopy during COVID-19 pandemic, ventilatory strategies and procedure measures

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has changed bronchoscopy practices worldwide. Bronchoscopy is a high-risk aerosol-generating procedure with a potential for direct SARS-CoV-2 exposure and hospital-acquired infection. Current guidelines about personal protective equipment and environment considerations represent key competencies to minimize droplets dispersion and reduce the risk of transmission. Different measures should be put in field based on setting, patient's clinical characteristics, urgency and indications of bronchoscopy. The use of this technique in SARS-CoV-2 patients is reported primarily for removal of airway plugs and for obtaining microbiological culture samples. In mechanically ventilated patients with SARS-CoV-2, bronchoscopy is commonly used to manage complications such as hemoptysis, atelectasis or lung collapse when prone positioning, physiotherapy or recruitment maneuvers have failed. Further indications are represented by assistance during percutaneous tracheostomy. Continuous positive airway pressure, non-invasive ventilation support and high flow nasal cannula oxygen are frequently used in patient affected by Coronavirus Disease-2019 (COVID-19): management of patients' airways and ventilation strategies differs from bronchoscopy indications, patient's clinical status and in course or required ventilatory support. Sedation is usually administered by the pulmonologist (performing the bronchoscopy) or by the anesthetist depending on the complexity of the procedure and the level of sedation required. Finally, elective bronchoscopy for diagnostic indications during COVID-19 pandemic should be carried on respecting rigid standards which allow to minimize potential viral transmission, independently from patient's COVID-19 status. This narrative review aims to evaluate the indications, procedural measures and ventilatory strategies of bronchoscopy performed in different settings during COVID-19 pandemic.

Oxygenation strategies during flexible bronchoscopy: a review of the literature

During flexible fiberoptic bronchoscopy (FOB) the arterial partial pressure of oxygen can drop, increasing the risk for respiratory failure. To avoid desaturation episodes during the procedure several oxygenation strategies have been proposed, including conventional oxygen therapy (COT), high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV). By a review of the current literature, we merely describe the clinical practice of oxygen therapies during FOB. We also conducted a pooled data analysis with respect to oxygenation outcomes, comparing HFNC with COT and NIV, separately. COT showed its benefits in patients undergoing FOB for broncho-alveolar lavage (BAL) or brushing for cytology, in those with peripheral arterial oxyhemoglobin saturation < 93% prior to the procedure or affected by obstructive disorder. HFNC is preferable over COT in patients with mild to moderate acute respiratory failure (ARF) undergoing FOB, by improving oxygen saturation and decreasing the episodes of desaturation. On the opposite, CPAP and NIV guarantee improved oxygenation outcomes as compared to HFNC, and they should be preferred in patients with more severe hypoxemic ARF during FOB.

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.

Safety and harms of bronchoalveolar lavage for acute respiratory failure: A systematic review and meta-analysis

BACKGROUND

This review aimed to investigate whether bronchoalveolar lavage (BAL) is safe in patients with severe acute respiratory failure (ARF).

METHODS

We searched the MEDLINE, CENTRAL, and other databases up to June 2, 2021 for studies that examined BAL for severe ARF. We included all cohort studies and randomized or non-randomized trials, while we excluded case-control studies, case reports, and case series. We evaluated the quality of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

We included 17 studies (1085 patients) in the meta-analysis. The integrated frequency of death was 0.000% (95% confidence interval [CI]: 0.000-0.045%, I² = 0.0%). The pooled risk of severe complications of respiratory system, cardiovascular system, and major bleeding was 1.32% (95% CI: 0.000-4.41%, I² = 84.8%), 0.040% (95% CI: 0.000-0.71%, I² = 9.3%), and 0.000% (95% CI: 0.000-0.27%, I² = 0.0%), respectively. In the subgroup analysis with mechanical ventilation during BAL, there were few severe complications of the respiratory system (3/717 patients in 13 studies) and almost no heterogeneity (I² = 0.0%).

CONCLUSIONS

Our study suggests that severe complications of BAL for severe ARF are probably rare, particularly in patients receiving mechanical ventilation. After considering the risks and benefits, it would be worthwhile to consider performing BAL in patients with severe ARF of unknown etiology to pursue its cause.

TRIAL REGISTRATION

The protocol was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000040600).

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.

The effect of Oxygen application with nCPAP for the prevention of desaturation during EBUS-TBNA

PURPOSE

EBUS-TBNA is a frequently used diagnostic method for mediastinal/hilar lymphadenopathies and masses. This procedure is performed with intravenous sedation (IVS). During IVS, patients often develop hypoxemia and nasal oxygen delivery is insufficient in some patients. The aim of this study was to investigate the effect of oxygen application with nCPAP on hypoxemia during EBUS-TBNA.

METHODS

Patients with EBUS-TBNA indication who did not have any serious heart-lung disease were randomly divided into two groups. One group received only oxygen and the other group received nCPAP+oxygen. Patient characteristics, arterial oxygen saturations, anesthetic agents, CPAP pressures, oxygen concentrations and processing times were recorded during the procedure. Practitioner satisfaction was evaluated at the end.

RESULTS

29 nCPAP+oxygen, 31 oxygen patients were included in the study. There were no significant differences in terms of age, sex, smoking history and presence of additional diseases in two groups. Neck circumference, BMI and STOP BANG questionnaire values were similar. Desaturation time was significantly longer in oxygen group than nCPAP+oxygen group (316±390 sec, 12±118 sec, respectively, p=0,019). Snoring was detected during the procedure in 22 patients in the oxygen group and in 11 patients in the nCPAP group (p=0,01). There were no serious complications in both groups. Practitioner satisfaction was higher in the nCPAP group but this was not statistically significant (p=0,052).

CONCLUSION

Oxygen application by nCPAP during EBUS-TBNA under IVS, significantly reduces desaturation time. Oxygen delivery with nCPAP seems to be a better choice especially for the patients with high Mallampati index.

Risk Factors for Predicting Hypoxia in Adult Patients Undergoing Bronchoscopy under Sedation

BACKGROUND

Flexible bronchoscopy is one of the essential procedures for the diagnosis and treatment of pulmonary diseases. The purpose of this study was to identify the risk factors associated with the occurrence of hypoxia in adults undergoing flexible bronchoscopy under sedation.

METHODS

We retrospectively analyzed 2,520 patients who underwent flexible bronchoscopy under sedation at our tertiary care university hospital in South Korea January 1, 2013-December 31, 2014. Hypoxia was defined as more than 5%-point reduction in the baseline percutaneous oxygen saturation (SpO2) or SpO2 <90% for >1 minute during the procedure.

RESULTS

The mean age was 64.7±13.5, and 565 patients developed hypoxia during the procedure. The mean sedation duration and midazolam dose for sedation were 31.1 minutes and 3.9 mg, respectively. The bivariate analysis showed that older age, a low forced expiratory volume in one second (FEV1), use of endobronchial ultrasound, the duration of sedation, and the midazolam dose were associated with the occurrence of hypoxia during the procedure, while the multivariate analysis found that age >60 (odds ratio [OR], 1.32), a low FEV1 (OR, 0.99), and a longer duration of sedation (>40 minutes; OR, 1.33) were significant risk factors.

CONCLUSION

The findings suggest that patients older than age 60 and those with a low FEV1 tend to develop hypoxia during the bronchoscopy under sedation. Also, longer duration of sedation (>40 minutes) was a significant risk factor for hypoxia.

Noninvasive respiratory support in the hypoxaemic peri-operative/periprocedural patient: a joint ESA/ESICM guideline

Hypoxaemia is a potential life-threatening yet common complication in the peri-operative and periprocedural patient (e.g. during an invasive procedure at risk of deterioration of gas exchange, such as bronchoscopy). The European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM) developed guidelines for the use of noninvasive respiratory support techniques in the hypoxaemic patient in the peri-operative and periprocedural period. The panel outlined five clinical questions regarding treatment with noninvasive respiratory support techniques [conventional oxygen therapy (COT), high flow nasal cannula, noninvasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP)] for hypoxaemic patients with acute peri-operative/periprocedural respiratory failure. The goal was to assess the available literature on the various noninvasive respiratory support techniques, specifically studies that included adult participants with hypoxaemia in the peri-operative/periprocedural period. The literature search strategy was developed by a Cochrane Anaesthesia and Intensive Care trial search specialist in close collaboration with the panel members and the ESA group methodologist. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final process was then validated by both ESA and ESICM scientific committees. Among 19 recommendations, the two grade 1B recommendations state that: in the peri-operative/periprocedural hypoxaemic patient, the use of either NIPPV or CPAP (based on local expertise) is preferred to COT for improvement of oxygenation; and that the panel suggests using NIPPV or CPAP immediately post-extubation for hypoxaemic patients at risk of developing acute respiratory failure after abdominal surgery.

Benefit-to-risk balance of bronchoalveolar lavage in the critically ill. A prospective, multicenter cohort study

Purpose

To assess the benefit-to-risk balance of bronchoalveolar lavage (BAL) in intensive care unit (ICU) patients.

Methods

In 16 ICUs, we prospectively collected adverse events during or within 24 h after BAL and assessed the BAL input for decision making in consecutive adult patients. The occurrence of a clinical adverse event at least of grade 3, i.e., sufficiently severe to need therapeutic action(s), including modification(s) in respiratory support, defined poor BAL tolerance. The BAL input for decision making was declared satisfactory if it allowed to interrupt or initiate one or several treatments.

Results

We included 483 BAL in 483 patients [age 63 years (interquartile range (IQR) 53–72); female gender: 162 (33.5%); simplified acute physiology score II: 48 (IQR 37-61); immunosuppression 244 (50.5%)]. BAL was begun in non-intubated patients in 105 (21.7%) cases. Sixty-seven (13.9%) patients reached the grade 3 of adverse event or higher. Logistic regression showed that a BAL performed by a non-experienced physician (non-pulmonologist, or intensivist with less than 10 years in the specialty or less than 50 BAL performed) was the main predictor of poor BAL tolerance in non-intubated patients [OR: 3.57 (95% confidence interval 1.04–12.35); P = 0.04]. A satisfactory BAL input for decision making was observed in 227 (47.0%) cases and was not predictable using logistic regression.

Conclusions

Adverse events related to BAL in ICU patients are not infrequent nor necessarily benign. Our findings call for an extreme caution, when envisaging a BAL in ICU patients and for a mandatory accompaniment of the less experienced physicians.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05896-4) contains supplementary material, which is available to authorized users.

Noninvasive ventilation support during fiberoptic bronchoscopy-guided nasotracheal intubation effectively prevents severe hypoxemia

Purpose

This study investigated the feasibility and efficacy of continuous noninvasive ventilation (NIV) support with 100% oxygen using a specially designed face mask, for reducing desaturation during fiberoptic bronchoscopy (FOB)-guided intubation in critically ill patients with respiratory failure.

Materials and methods

This was a single-center prospective randomized study. All patients undergoing FOB-guided nasal tracheal intubation were randomized to bag-valve-mask ventilation or NIV for preoxygenation followed by intubation. The NIV group were intubated through a sealed hole in a specially designed face mask during continuous NIV support with 100% oxygen. Control patients were intubated with removal of the mask and no ventilatory support.

Results

We enrolled 106 patients, including 53 in each group. Pulse oxygen saturation (SpO₂) after preoxygenation (99% (96%–100%) vs. 96% (90%–99%), p = .001) and minimum SpO₂ during intubation (95% (87%–100%) vs. 83% (74%–91%), p < .01) were both significantly higher in the NIV compared with the control group. Severe hypoxemic events (SpO₂ < 80%) occurred less frequently in the NIV group than in controls (7.4% vs. 37.7%, respectively; p < .01).

Conclusions

Continuous NIV support during FOB-guided nasal intubation can prevent severe desaturation during intubation in critically ill patients with respiratory failure.

Trial registration: ClinicalTrials.gov, NCT02462668. Registered on 25 May 2015, https://www.clinicaltrials.gov/ct2/results?term=NCT02462668.

•

Our study is the first to evaluate NIV during FOB-guided nasotracheal intubation.

•

NIV support during FOB-guided nasotracheal intubation was effectively prevented severe desaturation during intubation.

•

We used a specially-designed intubation face mask to ensure that there was no interruption of NIV support during intubation.

Noninvasive Ventilation-assisted Bronchoscopy in High-risk Hypoxemic Patients

BACKGROUND AND AIMS

Hypoxemic patients undergoing fiber-optic bronchoscopy (FOB) are at risk of worsening of respiratory failure requiring mechanical ventilation due to FOB procedure itself and its complications. As patients with respiratory failure are frequently managed by non-invasive ventilation (NIV); feasibility of FOB through NIV mask has been evaluated in some studies to avoid intubation. We describe here our own case series.

MATERIALS AND METHODS

Clinical data of 28 FOB done through NIV mask in 27 intensive care unit (ICU) patients over 6 years period at our center was collected retrospectively and analysed.

RESULTS

Study comprises 27 (17 male; 52±21.6 years age) hypoxemic (PaO2 71.3±14.2, on NIV and oxygen supplementation) patients. All FOB were done at bedside, 15 of them were given sedation for the procedure. Twenty four patients had bronchoalveolar lavage (BAL); three underwent bronchial biopsies, four brush cytology and seven transbronchial biopsies. In 10 patients lung or lobar collapse was reversed. There was no significant change between pre and post bronchoscopy ABG parameters except for improved post FOB PaO2 (p = 0.0032) and SpO2 (p = 0.0046). One patient (3.57%) developed late pneumothorax and 3 patients (10.7%) had bleeding after biopsy. Prior to bronchoscopy 17 (16 BIPAP, 1 CPAP) patients were already on NIV. Two patients required mechanical ventilation 6 hours after FOB due to subsequent clinical deterioration but could be weaned off later. One patient died on third day after FOB from acute myocardial infarction.

CONCLUSION

Hypoxemic patients in ICU can safely undergo bedside diagnostic and simple therapeutic bronchoscopy with NIV support while mostly avoiding intubation and with low complication rates.

HOW TO CITE THIS ARTICLE

Sircar M, Jha OK, Chabbra GS, Bhattacharya S. Noninvasive Ventilation-assisted Bronchoscopy in High-risk Hypoxemic Patients. Indian J Crit Care Med 2019;23(8):363-367.

A prospective randomized comparative study of high-flow nasal cannula oxygen and non-invasive ventilation in hypoxemic patients undergoing diagnostic flexible bronchoscopy

Background

Although oxygen supplementation during bronchoscopy in patients with pre-existing hypoxemia is provided, adequacy of oxygenation may not be achieved, resulting in the occurrence of respiratory failure that requires endotracheal tube intubation. The purpose of this study was to compare high-flow nasal cannula (HFNC) with non-invasive ventilation (NIV) in patients with pre-existing hypoxemia undergoing flexible bronchoscopy (FB) on the ability to maintain oxygen saturation during bronchoscopy.

Methods

A prospective randomized study was conducted in patients who had hypoxemia [defined as partial pressure of arterial oxygen (PaO₂) less than 70 mmHg at room air] and required FB for the diagnosis of abnormal pulmonary lesions. Patients were randomized to receive either HFNC or NIV during FB. The primary outcome was the lowest oxygen saturation level during FB.

Results

Fifty-one patients underwent randomization to HFNC (n=26) or NIV (n=25). Baseline characteristics in terms of age, Simplified Acute Physiologic Score II values, and cardiorespiratory parameters were similar in both groups. After receiving HFNC or NIV, oxygen saturation as measured by pulse oximeter (SpO₂) increased to greater than 90% in all cases. During FB, although the lowest SpO₂ was similar in both groups, the lowest SpO₂ <90% tended to occur more often in the HFNC group (34.6% vs. 12.0%; P=0.057). In patients with baseline PaO₂ <60 mmHg on ambient air, a decrease in PaO₂ from preprocedure to the end of FB was less in the NIV group (-13.7 vs. -57.0 mmHg; P=0.019). After FB, the occurrence of SpO₂ <90% was 15.4% and 4.0% in the HFNC group and NIV group, respectively (P=0.17).

Conclusions

In overall, NIV and HFNC provided the similar effectiveness in prevention of hypoxemia in hypoxemic patients undergoing FB. However, in subgroup analysis, NIV provided greater adequacy and stability of oxygenation than HFNC in patients with baseline PaO₂ <60 mmHg on ambient air.

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.

Noninvasive ventilation in acute respiratory failure: which recipe for success?

Noninvasive positive-pressure ventilation (NPPV) to treat acute respiratory failure has expanded tremendously over the world in terms of the spectrum of diseases that can be successfully managed, the locations of its application and achievable goals.

The turning point for the successful expansion of NPPV is its ability to achieve the same physiological effects as invasive mechanical ventilation with the avoidance of the life-threatening risks correlated with the use of an artificial airway.

Cardiorespiratory arrest, extreme psychomotor agitation, severe haemodynamic instability, nonhypercapnic coma and multiple organ failure are absolute contraindications for NPPV. Moreover, pitfalls of NPPV reduce its rate of success; consistently, a clear plan of what to do in case of NPPV failure should be considered, especially for patients managed in unprotected setting. NPPV failure is likely to be reduced by the application of integrated therapeutic tools in selected patients handled by expert teams.

In conclusion, NPPV has to be considered as a rational art and not just as an application of science, which requires the ability of clinicians to both choose case-by-case the best “ingredients” for a “successful recipe” (i.e.patient selection, interface, ventilator, interface,etc.) and to avoid a delayed intubation if the ventilation attempt fails.

Effectiveness and Safety of High-Flow Nasal Cannula Oxygen Delivery during Bronchoalveolar Lavage in Acute Respiratory Failure Patients

Background

Bronchoalveolar lavage (BAL) is a necessary procedure for diagnosis of various lung diseases. High-flow nasal cannula (HFNC) oxygen delivery was recently introduced. This study aimed to investigate the safety and effectiveness of HFNC oxygen supply during BAL procedure in patients with acute respiratory failure (ARF).

Methods

Patients who underwent BAL while using HFNC at a partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO₂/FiO₂; PF) ratio of 300 or below among patients who had been admitted from March 2013 to May 2017 were retrospectively investigated.

Results

Thirty-three BAL procedures were confirmed. Their baseline PF ratio was 166.1±46.7. FiO₂ values before, during, and after BAL were 0.45±0.12, 0.74±0.19, and 0.57±0.14, respectively. Flow (L/min) values before, during, and after BAL were 26.5±20.3, 49.0±7.2, and 40.8±14.2, respectively. Both FiO₂ and flow during and after the procedure were significantly different from those before the procedure (both p<0.001). Oxygen saturation levels before, during, and after BAL measured by pulse oximeter were 94.8±2.9, 94.6±3.5, and 95.2±2.8%, respectively. There were no significant differences in oxygen saturation among the three groups. Complications of BAL procedure included transient hypoxemia, hypotension, and fever. However, there was no endotracheal intubation within 24 hours. Baseline PF ratio in “without HFNC” group was significantly higher than that in “with HFNC” group. There were no differences in complications between the two groups.

Conclusion

The use of HFNC during BAL procedure in ARF patients was effective and safe. However, there were no significant differences in oxygen saturation level and complications comparing “without HFNC” group in mild ARF. More studies are needed for moderate to severe ARF patients.

Nasal high flow therapy: a novel treatment rather than a more expensive oxygen device

Nasal high flow is a promising novel oxygen delivery device, whose mechanisms of action offer some beneficial effects over conventional oxygen systems. The administration of a high flow of heated and humidified gas mixture promotes higher and more stable inspiratory oxygen fraction values, decreases anatomical dead space and generates a positive airway pressure that can reduce the work of breathing and enhance patient comfort and tolerance. Nasal high flow has been used as a prophylactic tool or as a treatment device mostly in patients with acute hypoxaemic respiratory failure, with the majority of studies showing positive results. Recently, its clinical indications have been expanded to post-extubated patients in intensive care or following surgery, for pre- and peri-oxygenation during intubation, during bronchoscopy, in immunocompromised patients and in patients with “do not intubate” status. In the present review, we differentiate studies that suggest an advantage (benefit) from other studies that do not suggest an advantage (no benefit) compared to conventional oxygen devices or noninvasive ventilation, and propose an algorithm in cases of nasal high flow application in patients with acute hypoxaemic respiratory failure of almost any cause.

Can fiberoptic bronchoscopy be applied to critically ill patients treated with noninvasive ventilation for acute respiratory distress syndrome? Prospective observational study

Background

Noninvasive ventilation (NIV) is a cornerstone for the treatment of acute respiratory failure of various etiologies. Using NIV is discussed in mild-to-moderate acute respiratory distress syndrome (ARDS) patients (PaO₂/FiO₂ > 150). These patients often have comorbidities that increase the risk for bronchoscopy related complications. The primary outcome of this prospective observational study was to evaluate the feasibility, safety and contribution in diagnosis and/or modification of the ongoing treatment of fiberoptic bronchoscopy (FOB) in patients with ARDS treated with NIV.

Methods

ARDS patients treated with NIV and who require FOB as the diagnostic or therapeutic procedure were included the study. Intensive care ventilators or other dedicated NIV ventilators were used. NIV was applied via simple oro-nasal mask or full-face mask. Pressure support or inspiratory positive airway pressure (IPAP), external positive end expiratory pressure (PEEP) or expiratory positive airway pressure (EPAP) levels were titrated to achieve an expiratory tidal volume of 8 to 10 ml/kg according to ideal body weight, SpO₂ > 90 % and respiratory rate below 25/min.

Results

Twenty eight subjects (mean age 63.3 ± 15.9 years, 15 men, 13 women, PaO₂/FiO₂ rate 145 ± 50.1 at admission) were included the study. Overall the procedure was well tolerated with only 5 (17.9 %) patients showing minor complications. There was no impairment in arterial blood gas and cardiopulmonary parameters after FOB. PaO₂/FiO₂ rate increased from 132.2 ± 49.8 to 172.9 ± 63.2 (p = 0.001). No patient was intubated within 2 h after the bronchoscopy. 10.7, 32.1 and 39.3 % of the patients required invasive mechanical ventilation after 8 h, 24 h and 48 h, respectively. Bronchoscopy provided diagnosis in 27 (96.4 %) patients. Appropriate treatment was decided according to the results of the bronchoscopic sampling in 20 (71.4 %) patients.

Conclusion

FOB under NIV could be considered as a feasible tool for diagnosis and guide for treatment of patients with ARDS treated via NIV in intensive care units. However, FOB-correlated life-treathening complications in severe hypoxemia should not be forgotten. Furthermore, further controlled studies involving a larger series of homogeneous ARDS patients undergoing FOB under NIV are needed to confirm these preliminary findings.

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).

[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.

Safety and efficacy of bronchoalveolar lavage using a laryngeal mask airway in cases of acute hypoxaemic respiratory failure with diffuse lung infiltrates

Objective Fibre-optic bronchoscopy with bronchoalveolar lavage (FOB-BAL) is an important tool for diagnosing and selecting treatment for acutely hypoxaemic patients with diffuse lung infiltrates. However, FOB-BAL carries a risk of significant hypoxaemia and subsequent tracheal intubation during and after the procedure. The application of FOB-BAL using a laryngeal mask airway (LMA) in combination with continuous positive airway pressure (CPAP) may minimize the incidence of hypoxaemia; however, the safety and efficacy of this procedure have not been investigated. Methods A retrospective chart review was performed from April to September 2013. Data regarding the recovered volume of BAL fluid, incidence of tracheal intubation within eight hours after the completion of FOB-BAL, respiratory and haemodynamic parameters and treatment modifications were collected for the evaluation. Results Ten trials of FOB-BAL using an LMA and CPAP were performed in nine patients with severe acute hypoxaemia associated with diffuse lung infiltrates. The BAL fluid recovery rate was 56%, and the procedure was completed without subsequent complications. In addition, the percutaneous arterial oxygen saturation decreased to 95.7%±3.8%, although it was never lower than 90.0% during the procedure, and no patients required intubation. Furthermore, the arterial blood pressure significantly but transiently decreased due to sedation, and the procedure yielded diagnostic information in all nine patients. Conclusion FOB-BAL using LMA and CPAP appears to be safe and effective in patients who develop severe acute hypoxaemia.

High-flow nasal cannula oxygen versus non-invasive ventilation in patients with acute hypoxaemic respiratory failure undergoing flexible bronchoscopy--a prospective randomised trial

Introduction

Critically ill patients with respiratory failure undergoing bronchoscopy have an increased risk of hypoxaemia-related complications. Previous studies have shown that in awake, hypoxaemic patients non-invasive ventilation (NIV) is helpful in preventing gas exchange deterioration during bronchoscopy. An alternative and increasingly used means of oxygen delivery is its application via high-flow nasal cannula (HFNC). This study was conducted to compare HFNC with NIV in patients with acute hypoxaemic respiratory failure undergoing flexible bronchoscopy.

Methods

Prospective randomised trial randomising 40 critically ill patients with hypoxaemic respiratory failure to receive either NIV or HFNC during bronchoscopy in the intensive care unit.

Results

After the initiation of NIV and HFNC, oxygen levels were significantly higher in the NIV group compared to the HFNC group. Two patients were unable to proceed to bronchoscopy after the institution of HFNC due to progressive hypoxaemia. During bronchoscopy, one patient on HFNC deteriorated due to intravenous sedation requiring non-invasive ventilatory support. Bronchoscopy was well tolerated in all other patients. There were no significant differences between the two groups regarding heart rate, mean arterial pressure and respiratory rate. Three patients in the NIV group and one patient in the HFNC group were intubated within 24 hours after the end of bronchoscopy (P = 0.29).

Conclusions

The application of NIV was superior to HFNC with regard to oxygenation before, during and after bronchoscopy in patients with moderate to severe hypoxaemia. In patients with stable oxygenation under HFNC, subsequent bronchoscopy was well tolerated.

Trial registration

ClinicalTrials.gov NCT01870765. Registered 30 May 2013.

Fiber-optic bronchoscopy and volume-cycled mouthpiece ventilation for a patient with multiple sclerosis and ventilatory failure

Fiber-optic bronchoscopy supported by continuous or bilevel positive airway pressure has helped patients with hypoxemic or hypercapnic respiratory failure avoid respiratory complications. The authors describe a case of a 57-yr-old man with multiple sclerosis with a vital capacity of 250 ml (5% of predicted normal) who was using continuous noninvasive intermittent positive pressure ventilatory support when he underwent bronchoscopy while receiving continuous noninvasive intermittent positive pressure ventilatory support via a 15-mm angled mouthpiece interface. He was switched from a nasal to a 15-mm angled mouthpiece interface for continuous noninvasive intermittent positive pressure ventilatory support for the procedure. Simple mouthpieces may be useful alternatives to other facial interfaces for ventilatory support during bronchoscopy because of patient comfort and operator convenience.

Implementation of bronchoalveolar lavage using a high-flow nasal cannula in five cases of acute respiratory failure

In recent clinical practice, high-flow nasal cannula (HFNC) therapy has been used to improve oxygenation in adults with acute respiratory failure (ARF). However, bronchoscopy using HFNC in ARF has not yet been reported. Herein, we describe 5 cases of ARF where bronchoalveolar lavage (BAL) was employed successfully using an HFNC. We were able to discontinue or reduce the HFNC fraction of inspired oxygen (FiO2) 30 min after completion of the bronchoscopy. Only 1 patient needed non-invasive positive pressure ventilation for 16 h after bronchoscopy. The HFNC may be a useful tool for ARF patients who require bronchoscopy.

Role of bronchoscopy during non invasive ventilation in hypercapnic respiratory failure

Introduction

Non invasive positive pressure ventilation (NIPPV) is the first line treatment for hypercapnic acute respiratory failure (ARF) secondary to COPD exacerbation in selected patients. Limited data exist supporting the use of fiberoptic bronchoscopy (FOB) during this clinical setting. The aim of this study is to assess the role of FOB during NIPPV in patients with decompensated COPD acute exacerbation.

Methods

This study is a randomized prospective case control pilot study carried out on 50 patients - admitted to critical care units at Alexandria University Hospital, Egypt - suffering from hypercapnic ARF secondary to COPD exacerbation with Kelly Matthay Score from 2 to 4. All patients received NIPPV. Patients were divided randomly into 2 equal groups: group I (cases) (25 patients) was subjected to additional intervention of early FOB during the first 6–12 h from admission while group II (control) (25 patients) received the conventional treatment and NIPPV only. Outcome parameters measured were changes in ABG data, duration of NIPPV, rate of its success, ICU stay and mortality as well as the safety of FOB and possible complications.

Results

No significant difference was detected between the 2 groups regarding the baseline characteristics. No serious complications happened from FOB, and Oxygen desaturation happened in 4/25 patients (16%), Tachycardia in 2/25 patients (8%). In group I, 23 patients (92%) were successfully weaned from NIPPV versus 16 patients (64%) in group II (p = 0.037). Total duration of NIPPV was 28.52 h in group I versus 56.25 h in group II (p = 0.001). Length of ICU stay was 4.84 days in group I versus 8.68 days in group II (p = 0.001). Only 1 patient died in group I versus 3 patients in group II (p = 0.609).

Conclusion

The early application of FOB during NIPPV in patients with ARF due to COPD exacerbation was shown to be safe. Significant improvement in the outcome of patients who underwent FOB was noticed in terms of improved ABG data, shorter duration of NIPPV, higher percentage of success and shorter ICU stay while no significant difference was detected in mortality.

Bronchoscopic intubation during continuous nasal positive pressure ventilation in the treatment of hypoxemic respiratory failure

Endotracheal intubation is difficult in patients with hypoxemic respiratory failure who deteriorate despite treatment with noninvasive positive pressure ventilation (NIPPV). Maintaining NIPPV during intubation may prevent alveolar derecruitment and deterioration in gas exchange. We report a case series of 10 nonconsecutive patients with NIPPV failure who were intubated via a flexible bronchoscope during nasal mask positive pressure ventilation. All 10 patients were intubated in the first attempt. Hypotension was the most frequent complication (33%). Mean decrease in oxyhemoglobin saturation during the procedure was 4.7 ± 3.1. This method of intubation may extend the benefits of preoxygenation throughout the whole process of endotracheal intubation. It requires an experienced operator and partially cooperative patients. A prospective trial is necessary to determine the best intubation method for NIPPV failure.

Evaluation of early mini-bronchoalveolar lavage in the diagnosis of health care-associated pneumonia: a prospective study

Introduction

Health care-associated pneumonia (HCAP) has been proposed as a new category of respiratory infection to identify patients at risk of multidrug-resistant (MDR) pathogens. The American Thoracic Society's recommendation for HCAP treatment is to use broad-spectrum and multiple antibiotics. However, this strategy may be economically expensive and promote antimicrobial resistance when a multisensitive pathogen is not identified.

Methods

We prospectively included all patients presenting with HCAP in the emergency department. Blood cultures and fiberoptic bronchoscope-guided distal protected small volume bronchoalveolar lavage (FODP mini-BAL) were performed in each patient. Empirical antibiotic therapy was adapted when microbiological findings were available. The primary objective was to assess whether FODP mini-BAL is more efficient than blood cultures in identifying pathogens with the ratio of identification between both techniques as principal criteria.

Results

We included 54 patients with HCAP. Pathogens were identified in 46.3% of cases using mini-BAL and in 11.1% of cases using blood cultures (P <0.01). When the patient did not receive antibiotic therapy before the procedure, pathogens were identified in 72.6% of cases using mini-BAL and in 9.5% of cases using blood cultures (P <0.01). We noted multidrug-resistant pathogens in 16% of cases. All bronchoscopic procedures could be performed in patients without complications.

Conclusions

FODP mini-BAL was more efficient than blood cultures for identifying pathogens in patients presenting with HCAP. When bacteriological identification was obtained, antibiotic therapy was adapted in 100% of cases.

See related letter by Sircar et al.,http://ccforum.com/content/17/2/428

Safety of performing fiberoptic bronchoscopy in critically ill hypoxemic patients with acute respiratory failure

BACKGROUND

The safety of fiberoptic bronchoscopy (FOB) in nonintubated critically ill patients with acute respiratory failure has not been extensively evaluated. We aimed to measure the incidence of intubation and the need to increase ventilatory support following FOB and to identify predictive factors for this event.

METHODS

A prospective multicenter observational study was carried out in eight French adult intensive care units. The study included 169 FOB performed in patients with a PaO(2)/FiO(2) ratio ≤ 300. The main end-point was intubation rate. The secondary end-point was rate of increased ventilatory support defined as an increase in oxygen requirement >50 %, the need to start noninvasive positive pressure ventilation (NI-PPV) or increase NI-PPV support.

RESULTS

Within 24 h, an increase in ventilatory support was required following 59 bronchoscopies (35 %), of which 25 (15 %) led to endotracheal intubation. The existence of chronic obstructive pulmonary disease (COPD; OR 5.2, 95 % CI 1.6-17.8; p = 0.007) or immunosuppression (OR 5.4, 95 % CI 1.7-17.2; p = 0.004] were significantly associated with the need for intubation in the multivariable analysis. None of the baseline physiological parameters including the PaO(2)/FiO(2) ratio was associated with intubation.

CONCLUSIONS

Bronchoscopy is often followed by an increase in ventilatory support in hypoxemic critically ill patients, but less frequently by the need for intubation. COPD and immunosuppression are associated with the need for invasive ventilation in the 24 h following bronchoscopy.