A 53-year-old woman who smokes was admitted to the neurologic intensive care unit (NeuroICU) after warfarin-associated lobar intracerebral hemorrhage (ICH). Her Glasgow Coma Scale in the field was 7, and her ICH score was 2. She was intubated for airway protection on admission. After extubation on hospital day 4, she began to cough up a large quantity of red blood and required reintubation. Her coagulopathy had been reversed on admission, and the INR was normal on day 2. Chest radiograph performed prior to intubation showed complete opacification of the right hemithorax, with rightward tracheal deviation (Figure 46-1).
Chest radiograph performed prior to intubation showing complete opacification of the right hemithorax, with rightward tracheal deviation.
Is bronchoscopy indicated? What preparations should be made prior to bronchoscopy?
Although atelectasis can often be successfully managed with chest physiotherapy and airway clearance techniques, hemoptysis requires airway inspection to localize the source of bleeding. Coagulation parameters should be checked, and flexible bronchoscopy (FB) with diagnostic and therapeutic intent performed. FB may allow for the visualization of the source of bleeding, identification of the reason for right lung atelectasis, therapeutic suctioning of blood clots from the airway, foreign body removal, placement of endobronchial blocker balloon, or selective intubation of one lung (Table 46-1).
Table 46-1.Indication for Flexible Bronchoscopy in the Intensive Care Unit ||Download (.pdf) Table 46-1. Indication for Flexible Bronchoscopy in the Intensive Care Unit
|Airway management |
|Bronchoscopy-assisted intubation or tube exchange, visualization of airway during percutaneous tracheostomy, assessment of airway edema |
|Diagnostic role |
|Airway inspection, suspected infection, mucus plugging, mechanical trauma, smoke inhalation, localization of hemoptysis, alveolar hemorrhage, biopsies |
|Therapeutic role |
|Mucus plug aspiration, treatment of hemoptysis, foreign body removal, atelectasis, isolation of a single lung, debridement of endobronchial obstruction |
|Advanced bronchoscopy |
|Tumor destruction, endobronchial stent placement or adjustment, cryotherapy, argon plasma coagulation, and laser |
Prior to bronchoscopy, reversal of any coagulopathy should be initiated, and hypoxia should be corrected to the maximal degree possible using increased fraction of inspired oxygen (Fio2) and end-expiratory pressure. There should be consideration of chest physiotherapy and blind endobronchial suctioning; the lumen of a Ballard suction catheter is much larger than the working channel of a bronchoscope, so it may be easier to remove a large occluding central mucus plug or blood clot with a directional suction catheter than with a bronchoscope.
Bronchoscopy, especially when a large therapeutic bronchoscope is used, impairs ventilation. For this reason it is crucial to monitor the end-tidal CO2 level during the procedure in any patient with a CNS mass lesion or elevated intracranial pressure (ICP). Airway occlusion will frequently result in low lung volumes when pressure-limited modes of ventilation are employed, leading to hypoventilation, cerebral ...