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Critical Care
Published in: Critical Care 1/2018

Open Access 01-12-2018 | Letter

Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position

Authors: Or Kalchiem-Dekel, Carl B. Shanholtz, Jean Jeudy, Ashutosh Sachdeva, Edward M. Pickering

Published in: Critical Care | Issue 1/2018

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Excerpt

Prone positioning (PP) was shown to reduce mortality in mechanically ventilated (MV) patients with severe ARDS [1]. Despite its common use, safety concerns inhibit use of flexible bronchoscopy (FB) in patients with ARDS, and there are few reports of FB performed in PP [2]. We reviewed all adults receiving FB in PP in one institution between April 2016 and September 2017. The study was approved by the institutional review board. Four men and three women were identified (Table 1). In five patients, FB was indicated for clearance of thick secretions, and in two patients for microbial analysis. The mode of mechanical ventilation was not changed for FB, but FIO2 was universally set to 100%. All subjects had invasive hemodynamic and pulse oximetry monitoring. End-tidal carbon dioxide (EtCO2) was monitored in 3/7 subjects. With the subject’s head tilted to the side, the bronchoscope was advanced into the airways, repeatedly, and in short cycles, allowing time for oxygenation, ventilation, and lung recruitment between insertions. Therapeutic aspiration was performed in 6/7 subjects. Bronchoalveolar lavage was performed in two subjects. No significant hemodynamic compromise was observed during any of the procedures. Significant oxygen desaturation and rising EtCO2 were observed in one case (patient 4). Both derangements resolved with withdrawal of the bronchoscope and recruitment. No additional complications were documented. Figure 1 illustrates evolution of the PaO2:FIO2 ratio over time for each subject. Six subjects had antibiotics modified based on FB-obtained cultures. Consistent with previous data [3], 4/7 subjects survived 30 days following discharge from the ICU.
Table 1
Individual patient parameters, flexible bronchoscopy performance, and outcomes (n = 7)
Variable
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
Age (years)
63
18
44
79
53
23
61
Sex
Female
Female
Male
Male
Male
Female
Male
Ethnicity
Black
Caucasian
Caucasian
Asian
Caucasian
Black
Caucasian
Etiology of ARDS
MRSA sepsis
Massive pulmonary embolism
Fulminant hepatic failure, Klebsiella sepsis
Pneumonia
Massive aspiration
Massive aspiration
Pneumonia
Total ICU LOS (days)/day of FB
27/9
30/13
97/32
35/29
9/2
49/11
16/1
Prone-positioning protocol (total hours)
28
18
16
236
20
133
18
30-day survival post ICU discharge
No
Yes
Yes
No
Yes
Yes
No
Ventilator-related parameters at FBa
 Mode
PRVC
PC/AC
VC/AC
PRVC
VC/AC
PC/AC
PC/AC
 Peak pressure (cmH2O)
32
29
24
37
30
20
32
 Plateau pressure (cmH2O)
27
NA
NA
30
26
NA
27
 PEEP (cmH2O)
11
12
15
8
10
10
14
 FIO2 (%)
100
100
100
100
100
100
100
FB-related data
 Δ-diameter ETT to bronchoscope (mm)
1.7
2.0
1.7
2.0
2.0
4.0
3.1
 Therapeutic aspiration
Yes
Yes
Yes
No
Yes
Yes
Yes
 Bronchial washings / BAL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Monitoring data
 MAP
  Baselinea
69
67
87
68
72
67
80
  Trough during FB
69
64
72
66
71
67
68
 SpO2
  Baselinea
94
98
97
100
100
100
100
  Trough during FB
94
92
97
87
99
99
100
 EtCO2
  Baselinea
48
30
NA
43
NA
NA
NA
  Trough during FB
49
30
NA
51
NA
NA
NA
Change in antibiotic regimen based on culture results
De-escalation
De-escalation
No
Additional coverage
De-escalation
De-escalation
De-escalation
ARDS adult respiratory distress syndrome, ICU intensive care unit, LOS length of stay, FB flexible bronchoscopy, MRSA methicillin-resistant Staphylococcus aureus, PRVC pressure-regulated volume control, PC/AC pressure-cycled assist-controlled, VC/AC volume-cycled assist-controlled, PEEP positive end-expiratory pressure, ETT endotracheal tube, BAL bronchoalveolar lavage, MAP mean arterial pressure as measured with an arterial line, NA not available, SpO 2 oxygen saturation as measured with pulse oximetry, EtCO 2 end-tidal carbon dioxide,FIO 2 fractional concentration of inspired oxygen
aAs documented prior to first bronchoscope insertion
…
Literature
1.
Guerin C, Reignier J, Richard J-C, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–68.CrossRefPubMed
2.
Guarracino F, Bertini P, Bortolotti U, Stefani M, Ambrosino N. Flexible bronchoscopy during mechanical ventilation in the prone position to treat acute lung injury. Rev Port Pneumol. 2013;19(1):42–4.CrossRefPubMed
3.
Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, Gattinoni L, van Haren F, Larsson A, McAuley DF, Ranieri M, Rubenfeld G, Thompson BT, Wrigge H, Slutsky AS, Pesenti A. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788–800.CrossRefPubMed
4.
Graf J, Marini JJ. Do airway secretions play an underappreciated role in acute respiratory distress syndrome? Curr Opin Crit Care. 2008;14(1):44–9.CrossRefPubMed
5.
Steinberg KP, Mitchell DR, Maunder RJ, Milberg JA, Whitcomb ME, Hudson LD. Safety of bronchoalveolar lavage in patients with adult respiratory distress syndrome. Am Rev Respir Dis. 1993;148(3):556–61.CrossRefPubMed
Metadata
Title
Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position
Authors
Or Kalchiem-Dekel
Carl B. Shanholtz
Jean Jeudy
Ashutosh Sachdeva
Edward M. Pickering
Publication date
01-12-2018
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2018
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-018-1983-3

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