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Facing Forward: Science and Arts in

Respiratory Medicine
FABRIKAM RESIDENCES

Bronchoscopy in
Respiratory Intensive Care Unit
 Respiratory Intensive care Unit (RICU)
• The Italian Association of Hospital Pulmonologists (AIPO) took
the lead in this field by defining and establishing good practice
in RICUs as “an area for the monitoring and treatment of
patients with acute respiratory failure due to a primary
respiratory cause and of patients with acute or chronic
respiratory failure.

• Noninvasive monitoring techniques and noninvasive

mechanical ventilation should be principally employed as first
line of treatment; however, when mandatory, invasive
techniques must be used.
Thorax. 2001;56:373–8.
Kondisi Medik Pasien Penyakit Kritis yang Memerlukan Tindakan Bronkoskopi

Penyakit/kondisi Jumlah Pasien (n=172) Persentase (%)

Transplantasi organ 29 17
Trauma/kecelakaan la-lin/luka bakar 28 16
Penyakit gastrointestinal 24 14
Penyakit kardiovaskular 23 13
Keganasan 13 8
Penyakit serebrovaskular 13 8
Anomali kongenital 10 6
Benda asing/aspirasi 9 5
Penyakit infeksi 7 4
Asma 4 2
Lain-lain 12 7
Clin Chest Med. 2001;22:241–61.
 Indikasi Bronkoskopi di ICU (1)
Diagnostik Terapetik
• Sekresi/manajemen atelektasis • Hemoptisis
• Demam / VAP • Benda asing
• Hemoptisis • Intubasi sulit
• Gagal ekstubasi • Percutanenous tracheostomy
guidance
• Perubahan gambaran foto toraks
• Obstruksi jalan napas sentral

Ernst A (Ed). Introduction to Bronchoscopy, Cambridge (2009)

 Indikasi Bronkoskopi di ICU (2)

Diagnostik Primer Terapetik Primer

• Pneumonia • Manajemen jalan napas
(immunocompromised host, VAP / (intubasi sulit, ETT double-lumen, ekstubasi)
nosokomial) • Atelektasis dan hipersekresi
• Penyakit paru difus atau fokal (lesi infiltrat • Aspirasi
atau massa) • Hemoptisis masif
• Trauma jalan napas • Benda asing
(cedera intubasi, cedera tumpul toraks, • Fistula bronkopleural (terapi fibrin glue)
pasca bedah) • Obstruksi endobronkial akibat neoplasma
• Cedera inhalasi akut atau luka bakar (laser fotoreseksi atau cryotherapy)
• Mengi terlokalisir atau stridor • Striktur dan stenosis (dilatasi dan stents)
• Fistel trakeoesofagus

Ann Acad Med Singapore. 1998;27:552-9.

Indikasi Bronkoskopi di ICU (3)

Abbreviations:
ARDS: acute respiratory distress syndrome;
BAL: bronchoalveolar lavage;
BW: bronchial washing;
TBB: transbronchial biopsy.

Expert Rev Respir Med. 2018;12(8):651-63.

 Contraindications of Flexible Bronchoscopy in Critically Ill Patients

Respiratory contraindications
• Severe hypoxemia with a FiO2 need >0.9
• Active airflow limitation with severe dynamic hyperinflation
• Pneumothorax with no chest tube drainage
• Severe pulmonary hypertension (mean PAP >30 mmHg or systolic
PAP >50 mmHg) for TBB

Cardiovascular contraindications
• Severe hemodynamic instability despite vasoactive drug infusion
• Unstable arrhythmia
• Unstable angina or acute myocardial infarction within 4 weeks

Expert Rev Respir Med. 2018;12(8):651-63.

 Contraindications of Flexible Bronchoscopy in Critically Ill Patients
Contraindications due to possible bleeding risk
• Platelet count <20,000/μL for FB and BAL and platelet count
<50,000/μL → TBB
• Elevated PT, increased aPTT (renal failure, hepatic failure)
• Antiplatelet and anticoagulant medications (relative contraindication)

Neurologic contraindications
• Severe intracranial hypertension

Other contraindications
• Presence of treatment limiting decisions
• Unwillingness to give consent for bronchoscopy
• Inability to respond adequately for emergency situations due to lack of
expertise or lack of equipment/facilities
Expert Rev Respir Med. 2018;12(8):651-63.
 Faktor-Faktor yang Meningkatkan Risiko Komplikasi Bronkoskopi
Paru
• PaO2 <70 mmHg, FiO2 inspirasi >0,7
• Positive end-expiratory pressure (PEEP) >10 cmH20
• Auto PEEP >15 cmH20
• Bronkospasme
Jantung
• Riwayat infark miokard (<48 jam)
• Unstable arrhythmia
• MAP <65 mmHg dengan terapi vasopresor
Koagulopati
• Trombosit < 20.000/mm3
•  prothrombin time (PT) / partial thromboplastin time (PTT) >1,5 kali kontrol
Susunan saraf pusat
• Peningkatan tekanan intrakranial
Chest. 1992;102:557–64S.
 Bronkoskopi di ICU (1)
Pasien tanpa ETT
→ Oral (bite block) atau transnasal
→ Oksigenasi, tidak ada gagal napas atau NIV (CPAP / BIPAP)
→ Kesadaran baik → sedasi dan analgesia
→ Bronkoskopis, menguasai intubasi (laringoskopi atau bronkoskopi) jika
terjadi gagal napas
→ Kontraindikasi 1) RR > 30/mnt,
2) otot bantu napas,
3) PaO2 <70 mmHg atau SaO2 <90% dengan suplemen O2,
4) membutuhkan ventilasi invasif BIPAP/CPAP, dan
5) perubahan status mental

Ernst A (Ed). Introduction to Bronchoscopy, Cambridge (2009) ; Clin Chest Med 2001;22:241–61.
 Bronkoskopi di ICU (2)
Bronkoskopi pasien terintubasi
• Melalui endotracheal tube (ETT)
• Ø dalam ETT : 7.0 mm, 7.5 mm, 8.0 mm (orang dewasa)
• Ø luar bronkoskop 5 mm
• Bronkoskop harus mudah melalui lumen ETT
→ cegah “air trapping”
• Ø ETT kecil → ganti dengan Ø yang lebih besar
• Jika ETT tidak dapat diganti (stenosis, sebab lain)
→ pediatrik atau bronkoskop Ø kecil
→ bronkoskop (smaller working channel), suction terbatas,
pandangan terbatas

Ernst A (Ed). Introduction to Bronchoscopy, Cambridge (2009) ; Clin Chest Med 2001;22:241–61.
 Rute Bronkoskopi di ICU
• Pasien dengan ventilasi mekanis, diperlukan
adapter (dual-axis swivel) di ujung ETT untuk
memudahkan akses ke jalan napas,
mempertahankan volume tidal dan positive end
expiratory pressure (PEEP) selama tindakan
bronkoskopi.

Ernst A (Ed). Introduction to Bronchoscopy, Cambridge (2009)

Bronchoscopy in Mechanically Ventilated Patients
1) Use an endotracheal tube with an internal diameter of at least 8 mm, if a standard
fiberscope size (5.7 mm diameter) is utilized.
2) Discontinue PEEP or reduce by 50%, or monitor bronchoscope tip pressure.
3) Increase FiO2 to 1.0 starting 15 min before procedure and tidal volume by about
30% during bronchoscopy.
4) Check arterial blood gases before and after procedure. Postpone examination if
SaO2 <90% on FiO2 1.0.
5) Monitor SaO2 by continuous pulse oximetry.
6) Monitor tidal volume.
7) Monitor PetCO2 in selected unstable and/or hypercapnic patients.
8) Monitor pulse and blood pressure.
Intensive Care Med. 1992;18:160-9.
 Bronkoskopi pada Trauma

Trauma jalan napas

1) ekserna → blunt force injuries atau
2) interna (ETT stilet)

Cedera jalan napas → identifikasi dengan bronkoskopi

Cedera traumatik dinding dada

→ konsultasi dengan bedah pasca resusitasi lengkap

Ernst A (Ed). Introduction to Bronchoscopy, Cambridge (2009)

 Ventilator Associated Pneumonia (VAP)
• Pasien dengan VM → suspek VAP → lakukan bronkoskopi
1) VM > 48 jam dengan (foto toraks) infiltrat baru / menetap
dan
2) Salah satu : sekret purulen, febril suhu >38.3℃, leukositosis

• Bronkoskopi dengan BAL

• Bronkoskopi tidak boleh memperlambat antibiotika

→ setting ICU 24 jam tidak tersedia bronkoskopi

• Kultur kuantitatif dari bronkoskopi → “tailor antibiotic therapy”

Ernst A (Ed). Introduction to Bronchoscopy, Cambridge (2009)
Most Widely Used Bronchoscopic Techniques For the Diagnosis of
Nosocomial Pneumonia
Technique Sample analysis/ diagnostic criteria Sensitivity (%) Specificity (%)
Bronchoalveolar lavage >7% Macrophages/PMN's 86 96
(BAL) containing bacteria
Gram stain, cytocentrifuged sample 73 100
≥1 micro-organism/100 x field
Quantitative cultures 74 92
(Bacterial index ≥ 5) 88 100
71 86
Quantitative cultures 100 100
(> 105 CFU/ml+ < % SEC)
Protected specimen brush Gram stain 58 NA
(PSB) Quantitative cultures 100 77
(>103 CFU/ml) 70 100
100 90

Intensive Care Med. 1992;18:160-9.

 Indikasi Bronkoskopi pada Atelektasis dan
Hipersekresi Jalan Napas

1. Keadaan mengancam jiwa

2. Mucous plugs
3. Penyakit neuromuskular → bersihan tidak efektif
4. Trauma dada, luka bakar, fraktur spinal, cedera kepala berat →
suctioning dan fisioterapi dada tidak berhasil.
5. Fibrosis kistik, bronkiektasis
6. Asma akut berat (status asmatikus) dan penyapihan sulit
7. Transplantasi paru

Ann Acad Med Singapore. 1998;27:552-9.

Toilet Bronchoscopy Indication

(a) Chest radiograph of a tracheostomized critically-ill patient who was admitted for acute exacerbation
of COPD the radiograph depicts extensive left lung atelectasis with no evidence of air-bronchograms.
(b) Following unsuccessful chest physiotherapy, toilet bronchoscopy showed full obstruction of the left
main bronchus by copious airways secretions.

Oxford Textbook of Critical Care (2nd Ed)

 Batuk Darah (Hemoptisis)
Tujuan penatalaksanaan hemoptisis masif :
1. Membebaskan jalan napas,
2. Identifikasi sumber perdarahan,
3. Isolasi daerah perdarahan → cegah kerusakan paru sehat
4. Menghentikan perdarahan

Bronkoskopi dan pemeriksaan radiologi

→ tentukan sebab dan sumber perdarahan

“Timing” → “crucial” dalam melokalisir perdarahan

Ernst A (Ed). Introduction to Bronchoscopy, Cambridge (2009)
Algoritma Tatalaksana Hemoptisis Masif

Ernst A (Ed). Introduction to Bronchoscopy, Cambridge (2009)

 Gagal Ekstubasi

• Gagal penyapihan dari VM

→ masalah di ICU
→ masalah kritis persisten dan gagal napas

• Gagal ekstubasi → masalah mekanik →WOB meningkat

• Masalah mekanik spesifik dapat diagnosis oleh BC

1) granulasi jaringan → obstruksi jalan napas
2) stenosis trakea
3) trakealbronkialmalasia

Ernst A (Ed). Introduction to Bronchoscopy, Cambridge (2009)

Intubasi Tuntunan Bronkoskopi
 Komplikasi Bronkoskopi (1)

Premedikasi Depresi pernapasan

Hipotensi / pingsan
Topikal anetesi Henti napas
Henti jantung Appropriate care
Bronkoskopi Laringospasme → BC extremely safe procedure
Bronkospasme
Hipoksemia Insidens komplikasi mayor 0,08– 0,15%
Aritmia jantung Mortalitas 0,01 – 0,04%.
Hipotensi
Reaksi vasovagal
Pneumonia Komplikasi Minor 6,5%.
Demam
Biopsi / sikatan Perdarahan
Pneumotoraks

Ann Acad Med Singapore. 1998;27:552-9. ; Chest. 1978; 73: 813–6. ; Chest. 1991; 100: 1668–75.
 Komplikasi Bronkoskopi (2)
Bronkoskopi fleksibel Bronkoskopi Kaku
- Depresi pernapasan / henti napas
- Takikardi - Risiko anestesi umum
- Hipotensi - Leakage of general anesthetic in
- Syok bronchoscopy
- Pingsan - Cedera (bibir, gusi, gigi, tenggorok)
- Kejang - Edema laring
- Laringospasme - Nyeri tenggorok
- Mual dan muntah - Kaku leher
- Hipotonia, gangguan psikomotor - Kerusakan dinding trakea posterior
- Anafilaksis - Pneumotoraks
- Bradikardi
- Methemoglobinemia
- Henti jantung
Clin Chest Med. 2001;22:241–61.
Diagnostics (Basel). 2022 Jan;12(1): 174.
Recommended indications for Single Use FB and Reuseable FB

Diagnostics (Basel). 2022 Jan;12(1): 174.

Disposable bronchoscopy. Face mask for NIV with diaphragm
for the entry of the bronchoscope;
oral insertion through the
mouthpiece.

Monaldi Arch Chest Dis. 2021;91:1744. ; World J Crit Care Med. 2021;10(6):334-44.
Key issues while performing flexible bronchoscopy in different
ventilation supports (Invasive ventilation)

• The diameters of the artificial airway and bronchoscope should be checked for at least a 2
mm difference
• Preoxygenation with FiO2 of 1.0 for 15 min
• Controlled modes are preferred over spontaneous breathing modes
• Volume targeted modes preferred over pressure targeted modes
• Peak inspiratory pressure limit should be increased in order to ensure delivery of adequate
tidal volume
• Decrease PEEP to zero or at least decrease by 50% if possible
• Set FiO2 to 0.5–1.0 throughout the procedure and at least half an hour afterwards to keep
SpO2 > 90%
• Application of suctioning for short periods when needed
• Monitoring of vital signs (heart rate, blood pressure, O2 saturation) and ECG
• Monitoring ventilator waveforms (pressure, flow, volume)
• Consider monitoring end-tidal CO2 in case of hypercapnia, increased intracranial pressure

Expert Rev Respir Med. 2018;12(8):651-63.

Key issues while performing flexible bronchoscopy in different
ventilation supports (Noninvasive ventilation)
• The interface and connector for bronchoscope insertion should be
checked
• NIV should be initiated 15–20 min prior to procedure
• Preoxygenation with FiO2 of 1.0 for 15 min
• Set FiO2 to 0.5–1.0 throughout the procedure and at least half an hour
afterwards to keep SpO2 > 90%
• PEEP/EPAP should be started at 5 cmH2O and increased until SpO2 > 90%
• A pressure support of 10 cmH2O is usually enough for most of the patients
• Monitoring of exhaled tidal volume (at least 8–10 ml/kg for IBW must be
ensured)
• Monitoring of vital signs (respiratory rate, heart rate, blood pressure, O2
saturation) and ECG
• Monitoring ventilator waveforms (pressure, flow) and leaks
Expert Rev Respir Med. 2018;12(8):651-63.
 The Fffects of Flexible
Bronchoscopy on Gas
Exchange in the Critically
Ill

Expert Rev Respir Med. 2018;12(8):651-63.

Bronchoscopy in COVID-19 ICU Patients
• Working in the coronavirus disease 2019 (COVID-19) era has changed the
habits of bronchoscopists who perform bronchoscopies.

• The safety of healthcare workers (HCW), through personal protective

equipment (PPE) and an adapted environment, has become the priority
when bronchoscopy is required, as it is considered to be an aerosol-
generating procedure, with the risk of personal contamination.

• The present study shows that bronchoscopy in ICU COVID-19 patients,

performed with disposable devices and the best PPE, is a safe procedure
for HCW and seems useful in these severe patients mainly for two
indications: removing of bronchial plugs and adaptation of antimicrobial
agents.
Respirology. 2020 Aug 25 : 10.1111/resp.13932.
Summary of Bronchoscopic Procedures

Respirology. 2020 Aug 25 : 10.1111/resp.13932.

Practical Strategies to Reduce Aerosol Transmission During Bronchoscopy of
Patients with COVID-19
A B C D

Bronchoscope insertion:
A) via the nose in spontaneously breathing patients wearing a surgical
mask and a negative pressure suction device into the oral cavity
B) via a non-vented non-invasive ventilation mask with examination port
C) via the endotracheal tube with a swivel connector
D) via transparent airway box

Panminerva Med. 2021;63:529-38.

A B C D

Measures to reduce environmental transmission during bronchoscopy of spontaneous

breathing patients with non-invasive ventilation support:
A) tools used: antiviral-antibacterial filter, single-use oronasal mask, catheter mount, single-
use headgear
B) placement of oro-nasal mask with connection of catheter mount and then to the circuit
of the flow generator
C) passage of the bronchoscope through the dedicated membrane of the catheter mount
or through the swivel connector
D) nasal or oral approach to the patient
Panminerva Med. 2021;63:529-38.
 CONCLUSION

• Pada pasien kritis, bronkoskopi merupakan tindakan

yang aman.

• Penggunaan bronkoskopi di ICU membutuhkan

keputusan klinik dan kemampuan klinik yang tepat serta
dukungan (kerjasama) tim.
 FR
FABRIKAM RESIDENCES
Thank You
Prasenohadi
0811997xxx
praseno@gmail.com